Use this screen after you generate 1095-C records through the Create 1094-C and 1095-C Data screen. Thoroughly review the data on this screen before you generate 1094-C information on the Create 1094-C and 1095-C Data screen or create the 1095-C reports on the Print 1095-Cs screen and Create 1094-C and 1095-C Electronic File screen. You can also enter and change 1095-C information on this screen.
Enter, or click 
to select, the employee for which the 1095-C record is being entered. The employee must be linked to the login company and must not be flagged as a Contractor on the Manage Employee Information screen in order to be entered here. The following Mailing Address values must be assigned to the Taxable Entity on the Configure Company Information screen in order to be entered here:
Address Line 1
City
State/Province
Country
Postal Code
Enter the 4-digit calendar year for which the 1095-C was created.
Enter, or click to select, the taxable entity for which the 1095-C record is being entered. This field loads the Taxable Entity assigned to the employee on the Manage Employee Information screen. The value may be edited for a new record. The following address values must be assigned to the taxable Entity on the Configure Company Information screen in order to be entered here:
Address Line 1
City
State/Province
Country
Postal Code
Select this check box to void the 1095-C record.
If correcting information on a Form 1095-C that was previously filed with the IRS, file a fully completed Form 1095-C including the correct information and enter an X in the CORRECTED check box. File a Form 1094-C Transmittal (DO NOT mark the CORRECTED check box on the Form 1094-C) with corrected Form(s) 1095-C. Furnish the employee a copy of the corrected Form 1095-C, unless the employer is eligible to use the Qualifying Offer Method or the Qualifying Offer Method Transition Relief for 2015.
For more information, see Alternative Method of Furnishing Form 1095-C to Employees under the Qualifying Offer Method or Alternative Method of Furnishing Form 1095-C to Employees under the Qualifying Offer Method Transition Relief.
This field displays the sequence number of the 1095-C for the specified Employee / Calendar Year / Taxable Entity combination. If the 1095-C does not yet exist in the Manage 1095-C Data table, then a Sequence Number of 1 (one) will be assigned. The sequence number will be incremented by one for any correcting or voided 1095-Cs entered for the same Employee / Calendar Year / Taxable Entity combination.
This check box displays as selected when you processed this record on the Create 1094-C and 1095-C Electronic File screen using the Confirm Records as Accepted by the IRS processing option. The record is disabled and no longer editable if this check box is selected.
This field displays the XML record ID which is the unique identifying number that designates the 1095-C record’s location in the XML file submitted to the IRS.
This field displays the data file generation key created when an electronic file is generated for 1094-C and 1095-C transmission. This ID is used when you process the record on the Create 1094-C and 1095-C Electronic File screen using the Confirm Records as Accepted by the IRS processing option.
This group box contains employee and applicable large employer member information.
This field displays the name of the employee for which the 1095-C record is being entered. This field loads the Displayed Name assigned to the employee on the Manage Employee Information screen.
This field displays the Social Security Number (SSN) of the employee for which the 1095-C record is being entered. This field loads the SSN assigned to the employee on the Manage Employee Information screen
This field displays the street address (including apartment number) of the employee for which the 1095-C record is being entered. This field loads the Mailing Address-Address Line 1, Address Line 2, and Address Line 3 assigned to the employee on the Manage Employee Information screen.
This field displays the city or town of the employee for which the 1095-C record is being entered. This field loads the Mailing Address City assigned to the employee on the Manage Employee Information screen.
This field displays the State/Province of the employee for which the 1095-C record is being entered. This field loads the Mailing Address State/Province assigned to the employee on the Manage Employee Information screen.
This field displays the Country and Postal Code of the employee for which the 1095-C record is being entered. This field loads the Mailing Address Country and Postal Code assigned to the employee on the Manage Employee Information screen.
This field displays the name of the employer for which the 1095-C record is being entered. This field loads the name assigned to the taxable entity on the Configure Company Information screen.
This field displays the Employer Identification Number (EIN) of the employer for which the 1095-C record is being entered. This field loads the tax ID assigned to the taxable entity on the Configure Company Information screen.
This field displays the Street Address (including room or suite number) of the employer for which the 1095-C record is being entered. This field loads the Address Line 1, Address Line 2, and Address Line 3 assigned to the taxable entity on the Configure Company Information screen.
Enter the Contact Telephone Number of the taxable entity for which the 1095-C record is being entered. This field loads the telephone number assigned to the taxable entity on the Configure Company Information screen.
This field displays the city or town of the taxable entity for which the 1095-C record is being entered. This field loads the city assigned to the taxable entity in the Configure Company Information screen.
This field displays the state/province of the taxable entity for which the 1095-C record is being entered. This field loads the state/province assigned to the taxable entity on the Configure Company Information screen.
This field displays the country and ZIP or foreign postal code of the taxable entity for which the 1095-C record is being entered. This field loads the country and postal Code assigned to the taxable entity on the Configure Company Information screen.
From the drop-down list, select the beginning month of the plan year of the health plan in which is the employee is offered coverage. This may also be the month that the employee would be offered coverage if the employee were eligible to participate in the plan.
If more than one plan year could apply (for instance, if the employer changes the plan year during the year), enter the earliest applicable month. If there is no health plan under which coverage is offered to the employee, enter 00.
Use these fields to enter the offer of coverage that applies all 12 months of the calendar year or you can also enter the offer of coverage that applies to each month.
Valid options are:
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% 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)).
1E - Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to dependent(s) and spouse.
1F - Minimum essential coverage NOT providing minimum value offered to employee, or employee and spouse or dependent(s), or employee, spouse and dependents.
1G - Offer of coverage to employee who was not a full-time employee for any month of the calendar year and who enrolled in self-insured coverage for one or more months of the calendar year. Enter code 1G in the “All 12 Months” box and do not complete the monthly boxes.
1H - No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage).
1I - Qualified Offer Transition Relief 2015: Employee (and spouse or dependents) received no offer of coverage, received an offer that is not a qualified offer, or received a qualified offer for less than 12 months.
If the same Offer of Coverage code applies to the employee for all 12 months of the screen calendar year, enter, or click to select, the Offer of Coverage code which applies to the employee.
Enter a value in this field only if the same Offer of Coverage code applies to the employee for the entire calendar year. If more than one code applies during the Calendar Year, leave this field blank.
If the same Offer of Coverage code does not apply to every month in the year, enter, or click to select, the Offer of Coverage code which applies to the specific month.
Enter a value in this field only if the same Offer of Coverage code does not apply to the employee for the entire calendar year. If the same code applies during the entire calendar year, leave this field blank.
Use these fields to enter the Employee Share of Lowest Cost Monthly Premium amount that applies to all months of the calendar year. If the value does not apply to all months of the calendar year, use the fields for specific months to enter the value.
According to IRS instructions, complete line 15 only if code 1B, 1C, 1D, or 1E is entered on line 14 either in the All 12 Months box or in any of the monthly boxes. Enter the amount of the employee share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that is offered to the employee. Enter the amount including any cents. If the employee is offered coverage but is not required to contribute any amount towards the premium, enter 0.00 (do not leave blank). If the employee share of the lowest-cost monthly premium amount was the same amount for all 12 calendar months, enter that monthly amount in each monthly box or enter that monthly amount in the All 12 Months box and do not complete the monthly boxes. If the employee share of the lowest-cost monthly amount was not the same for all 12 months, enter the amount in each calendar month for which the employee was offered minimum value coverage.
If the Offer of Coverage is 1B, 1C, 1D, or 1E for all 12 months and the same Employee Share of Lowest Cost Monthly Premium applies to all 12 months of the screen calendar year, enter the amount in this field.
Enter a value in this field only if the same Employee Share of Lowest Cost Monthly Premium applies to the employee for the entire Calendar Year. If more than one amount applies during the Calendar Year, leave this field blank.
If the same Employee Share of Lowest Cost Monthly Premium does not apply to every month in the year, enter the amount that applies to the specific month.
Enter a value in this field only if the same Employee Share of Lowest Cost Monthly Premium amount does not apply to the employee for the entire calendar year. If the same amount applies during the entire calendar Year, leave this field blank.
Use these fields to specify a Section 4980H Safe Harbor code that applies to all months of the calendar year. If the codes are not the same for the whole calendar year, specify Section 4980H Safe Harbor codes in the fields for each month.
Valid Section 4980H Safe Harbor codes are as follows:
2A - Employee not employed during the month. Enter code 2A if the employee was not employed on any day of the month. Do not use code 2A for a month if the individual is an employee of the employer on any day of the month. Do not use this code for the month during which an employee terminates employment with the employer.
2B - Employee not a full-time employee. Enter code 2B if the employee is not a full-time employee for the month and did not enroll in minimum essential coverage, if offered for the month.
2C - Employee enrolled in coverage offered. Enter code 2C for any month in which the employee enrolled in health coverage offered by the employer, regardless of whether any other code in Code Series 2 might also apply.
If the employee enrolled in the minimum essential coverage offered for the month, enter code 2C (employee enrolled in coverage offered), and not any other in Code Series 2 that might also apply.
2D - Employee in a section 4980H(b) Limited Non-Assessment Period. Enter code 2D for any month during which an employee is in a Limited Non-Assessment Period for section 4980H(b).
If an employee is in an initial measurement period, enter code 2D (employee in a section 4980H(b) Limited Non-Assessment Period) for the month, and not code 2B (employee not a full-time employee). For an employee in a section 4980H(b) Limited Non-Assessment Period for whom the employer is also eligible for the multiemployer interim rule relief for the month code 2E, enter code 2E (multiemployer interim rule relief) and not code 2D (employee in a Limited Non-Assessment Period).
2E - Multiemployer interim rule relief. Enter code 2E for any month for which the multiemployer interim guidance applies for that employee. This relief is described in the Definitions under Offer of Health Coverage.
Although employers may use the section 4980H affordability safe harbors to determine affordability for purposes of the multiemployer interim guidance, an employer eligible for the relief provided in the multiemployer interim guidance for a month for an employee should enter code 2E (multiemployer interim rule relief), and not a code for the section 4980H affordability safe harbors (codes 2F, 2G, or 2H).
2F - Section 4980H affordability Form W-2 safe harbor. Enter code 2F if the employer used the section 4980H Form W-2 safe harbor to determine affordability for purposes of section 4980H(b) for this employee for the year. If an employer uses this safe harbor for an employee, it must be used for all months of the calendar year for which the employee is offered health coverage.
2G - Section 4980H affordability federal poverty line safe harbor. Enter code 2G if the employer used the section 4980H federal poverty line safe harbor to determine affordability for purposes of section 4980H(b) for this employee for any month(s).
2H - Section 4980H affordability rate of pay safe harbor. Enter code 2H if the employer used the section 4980H rate of pay safe harbor to determine affordability for purposes of section 4980H(b) for this employee for any month(s).
2I - Non-calendar year transition relief applies to this employee. Enter code 2I if non-calendar year transition relief for section 4980H(b) applies to this employee for the month. See the instructions later under Section 4980H Transition Relief for 2015 and 2015 Section 4980H(b) Transition Relief for Employers with Non-Calendar Year Plans (Form 1095-C, line 16, code 2I), for a description of this relief.
If the same Applicable Section 4980H Safe Harbor code applies to the employee for all 12 months of the screen calendar year, enter, or click to select, the Section 4980H Safe Harbor code which applies to the employee.
Enter a value in this field only if the same Section 4980H Safe Harbor code applies to the employee for the entire calendar year. If more than one code applies during the calendar year, leave this field blank.
If the same Section 4980H Safe Harbor code does not apply to every month in the year, enter, or click to select, the Section 4980H Safe Harbor code which applies to the specific month.
Enter a value in this field only if the same Section 4980H Safe Harbor code does not apply to the employee for the entire calendar year. If the same code applies during the entire calendar year, leave this field blank.
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Part III - Covered Individuals |
Select this link to enter Covered Individuals information. |