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  3. 1095 (ACA) Form Filing

How do I create Form 1095-C?

Creating Form 1095-C

  1. Click on the Payer List button.
  2. Double click on the payer name.
  3. Highlight the recipient to add the form to.
  4. Click on the Add Form button.
  5. Choose 1095-C from the Form Type drop down menu.
  6. Fill in the necessary fields on the form:
    • 1095 Contact Phone/Ext: the phone number of a person that the 1095 Recipient/Employee may call for additional information.
    • If more than one plan year could apply, select the earliest applicable month.
    • If there is no health plan under which coverage is offered to the employee, select “00”.
    • The Plan Start Month may be left blank.
    • 1A - Qualifying Offer: Minimum essential coverage providing minimum value offered to full-time employee with employee contribution for self-only coverage equal to or less than 9.5% (as adjusted; see Note below) mainland single federal poverty line and at least minimum essential coverage offered to spouse and dependent(s).
    • 1B - Minimum essential coverage providing minimum value offered to employee only.
    • 1C - Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to dependent(s) (not spouse).
    • 1D - Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to spouse (not dependent(s)). Do not use code 1D if the coverage for the spouse was offered conditionally. Instead use code 1J.
    • 1E - Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to dependent(s) and spouse. Do not use code 1E if the coverage for the spouse was offered conditionally. Instead use code 1K.
    • 1F - Minimum essential coverage NOT providing minimum value offered to employee; employee and spouse or dependent(s); or employee, spouse and dependents.
    • 1G - Offer of coverage for at least one month of the calendar year to an individual who was not an employee for any month of the calendar year or to an employee who was not a full-time employee for any month of the calendar year (which may include one or more months in which the individual was not an employee) and who enrolled in self-insured coverage for one or more months of the calendar year.
      • Code 1G applies for the entire year or not at all. Therefore, if code 1G applies, the filer must select 1G in the "All 12 Months" drop-down or in all of the individual month drop-downs.
    • 1H - No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage, which may include one or more months in which the individual was not an employee).
    • 1J - Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage conditionally offered to spouse; minimum essential coverage not offered to dependent(s).
    • 1K - Minimum essential coverage providing minimum value offered to employee; at least minimum essential coverage offered to dependents; and at least minimum essential coverage conditionally offered to spouse.
    • If a code is selected in any of the individual month drop-downs, any code selected in the All 12 Months drop-down is removed. If a code is entered in the All 12 Months drop-down, any code entered in any of the Individual Month drop-downs is removed.
    • If a drop-down contains 1A, 1F, or 1H, then the corresponding line 15 (Employee Share of Lowest Cost Monthly Premium for Self-Only Minimum Value Coverage) will be disabled as it should not be filled out. Any values already entered in Line 15 will be cleared.
    • If a drop-down contains 1G, then the corresponding line 15 (Employee Share of Lowest Cost Monthly Premium for Self-Only Minimum Value Coverage) and Line 16 (Applicable Section 4980H Safe Harbor) drop downs will be disabled as it should not be filled out. Any values already entered in Line 15 and 16 will be cleared.
    • If an employee does not elect coverage, lines 14 and 15 will be completed to reflect the offer that was made to the employee, even though the coverage was waived.
    • Enter the amount of the Employee Required Contribution, which is, generally, the employee share of the monthly cost for the lowest-cost self-only minimum essential coverage providing minimum value that is offered to the employee. If the employee is offered coverage but the Employee Required Contribution is zero, enter “0.00” (do not leave blank).
    • If an amount is entered in the All 12 Months field, any amount entered in the Individual month fields are removed.
    • If an amount is entered in any of the Individual month fields, any amount entered in the All 12 Months field is removed.
    • The employee was not employed or was not a full-time employee.
    • The employee enrolled in the minimum essential coverage offered.
    • The employee was in a Limited Non-Assessment Period.
    • The employer met one of the Section 4980H affordability safe harbors.
    • The employer was eligible for multiemployer interim rule relief.
    • Note: If no code applies, leave Line 16 blank.
    • Drop-down list box containing the following options: 2A, 2B, 2C, 2D, 2E, 2F, 2G, and 2H.
    • Series 2 codes (line 16):
      • 2A - Employee not employed on any day during the month (2A does not display in All 12 Months drop down)
      • 2B - Employee is not a full-time employee.
      • 2C - Employee enrolled in health coverage offered.
      • 2D - Employee is in a Section 4980H limited non-assessment period.
      • 2E - Multiemployer interim rule relief.
      • 2F - Section 4980H affordability Form W-2 safe harbor.
      • 2G - Section 4980H affordability federal poverty line safe harbor.
      • 2H - Section 4980H affordability rate of pay safe harbor.
    • 1095 Contact Phone/Ext:  Enter the following required contact fields on the Manage Payer screen:
    • Corrected:  Check if this box applies.
    • Plan Start Month:  Select the number (01 through 12) to indicate the month in which the health plan's plan year starts.
    • Lines 14-16:  See Greatland’s Online Filing Guide to better understand what codes to enter in Lines 14-16 of Form 1095-C: https://yearli.com/form-1095-c-part-ii
    • Employee Offer of Coverage - Line 14 Offer of Coverage (enter required code):  Drop-down list box contains the following options to describe the type of health coverage offered to an employee, and the employee's spouse and dependents: 1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H,1J, and 1K. A drop-down choice is required in either All 12 Months or one of the individual monthly fields.
    • Employee Offer of Coverage – Line 15 Employee Required Contribution:  An entry on Line 15 is required when code 1B, 1C, 1D, 1E, 1J, or 1K is selected on line 14.
    • Employee Offer of Coverage - Line 16 Section 4980H Safe Harbor and Other Relief (enter code, if applicable):  Enter applicable code to report that one of the following situations applied to the employee:

Note:  References to 9.5% in the Section 4980H affordability safe harbors and Qualifying Offer Method are applied based on the percentage as indexed for purposes of applying the affordability thresholds under section 36B (the premium tax credit). The percentage, as adjusted, is 9.56% for plan years beginning in 2015, and 9.66% for plan years beginning in 2016.

        • If a code is entered in the All 12 Months field, any code selected in the Individual month fields are removed. If a code is entered in any of the Individual Months drop-downs, the All 12 Months field is removed.  
        • If a code is selected in any of the individual month drop-downs, any code selected in the All 12 Months drop-down is removed.
    • Covered Individuals:  If the employer provided self-insured coverage, check the box in Part III.
      • Enter Covered Individuals using the “Cov Ind” button on the right side of the prep screen.
      • At least one covered individual is required on Form 1095-C when the self-insured coverage checkbox is selected.
      • If the form's Recipient (Employee) is enrolled in coverage, include the Recipient as a Covered Individual.
      • Recipients and/or covered individuals who did not enroll in coverage will not be included in the Covered Individuals section.
      • Information about individuals covered under the employer's health plan will be filled from the Covered Individuals Window.
      • Name is filled from the respective fields on the Covered Individuals Window.
      • SSN or other TIN is filled from the SSN or other TIN field on the Covered Individuals Window.
      • Date of Birth is formatted as MM/DD/YYYY.
      • The Months of Coverage (All 12 Months, Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, and Dec) will show an X or blank, as entered on the Covered Individuals Window.

        7. Click Save. 

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