Form 1095 Conflicts & Appeals in the Health Insurance Marketplace - Premium Tax Credit

Q: How should affordability be assessed when comparing Form 1095-A with Form 1095-C?

The materials indicate that ER coverage is treated as affordable when self-only premiums are at or below the stated affordability threshold (using 2016 values shown). Practitioners should review the employer offer and related lines/codes, including conditional offer indicators for a spouse where applicable.

Sep 19, 2026

Upload by Lucas Vance

Materials for the ABA Section of Taxation Low-Income Taxpayer Representation Workshop (Dec. 12, 2016) explain premium tax credit (PTC) eligibility and how to handle conflicts between IRS forms 1095-A, 1095-B, and 1095-C. Focus areas include access to minimum essential coverage (MEC), circumstances that disregard employer-sponsored coverage and other MEC types, and practical representation steps. The guidance covers issues such as reporting errors, brief overlap in coverage, retroactive eligibility, transitions from Marketplace coverage, dual enrollment from Medicaid/CHIP ineligibility, and conditional affordability when employer coverage is offered.

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Coverage Overlap Issues and Form 1095 Conflicts

Premium Tax Credit

PTC Eligibility: Access to MEC

PTC Eligibility: Form 1095 Conflicts

Form 1095-A vs Form 1095-B

Form 1095-A vs Form 1095-C

Form 1095 Conflicts & Appeals in the Health Insurance Marketplace Tara Straw, Center on Budget and Policy Priorities Christine Speidel, Vermont Legal Aid December 12, 2016 ABA Section of Taxation Low-Income Taxpayer Representation Workshop Coverage Overlap Issues and Form 1095 Conflicts Premium Tax Credit PTC Eligibility: Access to MEC • An individual eligible for government or employersponsored insurance (MEC) is not generally eligible for a premium tax credit (PTC) • For which months is your client eligible for a PTC? – Review forms 1095-A, 1095-B, and 1095-C – Client interview is important I.R.C. § 36B(c)(2) PTC Eligibility: Access to MEC • Eligibility for employer-sponsored insurance (ESI) is disregarded if – Individual did not enroll in the ESI; and – The plan does not provide minimum value, or – Premiums for self-only coverage > 9.5% of household income (as indexed), or – Individual is not in the employee’s tax household. Reg. §1.36B-2(c)(3),(c)(4) PTC Eligibility: Access to MEC • Several other types of MEC are disregarded if the individual did not enroll: – Retiree and post-employment COBRA coverage – TRICARE and certain health programs for veterans and related individuals – Medicare, if a Part A premium is required – Self-funded student health plans – See Effectively Representing Your Client Before the IRS p. 29-21 (2016) Notice 2013-41 and Reg. 1.36B-2(c) PTC Eligibility: Form 1095 Conflicts • IRS has posted ACA return preparer best practices for resolving conflicts between forms 1095 –Go to [irs.gov/aca](irs.gov/aca) – click on Tax Professionals – scroll to bottom of page • Form 1095-A vs Form 1095-B • Form 1095-A vs Form 1095-C PTC Eligibility: Form 1095 Conflicts Form 1095-A vs Form 1095-B 1. Reporting errors: Ask for correction as early as possible 2. Change in coverage: <1 month overlap ok Reg. § 1.36B-3(c)(1)(iii); Example 1 3. Retroactive eligibility determinations and enrollmentsin gov’t-sponsored coverage Reg. § 1.36B-2(c)(2)(iv) PTC Eligibility: Form 1095 Conflicts Form 1095-A vs Form 1095-B 4. Transition from Marketplace to gov’t-sponsored MEC – 3 months Reg. § 1.36B-2(c)(2)(ii) 5. Dual enrollment due to determination of Medicaid or CHIP ineligibility Reg. § 1.36B-2(c)(2)(v) 6. Supplemental private insurance coverage I.R.C. § 36B(c)(2) PTC Eligibility: Form 1095 Conflicts Form 1095-A vs Form 1095-C • 1095-A with PTC in months that 1095-C shows affordable coverage? – Must ask the TP about circumstances – Note Questions 13 & 14, Questions and Answers on the Premium Tax Credit, on [irs.gov](irs.gov) • ER coverage is affordable if premiums for self-only coverage ≤ 9.66% HHI (2016) –Any tax family member offered coverage is not eligible for PTC if self-only coverage is affordable PTC Eligibility: Form 1095 Conflicts Form 1095-A vs Form 1095-C • Indicators of affordability of ER offered coverage – Line 15: self-only cost o May need adjustment o Check against 9.66% of HHI – Line 14: 1A – self-only premium ≤ 9.66% of FPL, MV, offer also to spouse and dependents – New for 2016: code for conditional offer to spouse (line 14, code 1J or 1K)

FAQs

How should affordability be assessed when comparing Form 1095-A with Form 1095-C?

The materials indicate that ER coverage is treated as affordable when self-only premiums are at or below the stated affordability threshold (using 2016 values shown). Practitioners should review the employer offer and related lines/codes, including conditional offer indicators for a spouse where applicable.

Sep 19, 2026

Upload by Lucas Vance