DEPARTMENT OF HEALTH & HUMAN SERVICES
465 INDUSTRIAL BOULEVARD
LONDON, KENTUCKY 40750-0001
Victoria Cobb Jan 06, 2024
14 Briarwood Drive
Savannah, GA 31408
Application ID: 4866761523
Plan Name: Silver S: Aetna network of doctors hospitals + $0 Walk-in clinic + $0 Telehealth 24/7
You must file a tax return if the IRS Form 1095-A shows that you got advance payments of the premium tax credit.
See Part III, Column C on your form.
Use Form 1095-A to complete “IRS Form 8962, Premium Tax Credit” with your federal income tax return when you
file. If you don’t, you may have to pay back some or all of the tax credits you got last year.
Victoria Cobb:
Enclosed is your tax Form 1095-A about your Health Insurance Marketplace® coverage. You’re getting this form because
you and/or members of your household had Marketplace coverage for all or some part of 2023.
This form has important information you’ll need to fill out your federal income tax return. We also shared this
information with the Internal Revenue Service (IRS). Keep this form for your records.
You must file a tax return
You must file a federal income tax return if you or another member of your household got any advance payments of the
premium tax credit in 2023 to lower premium costs, even if you don’t normally file a return. If you don’t file a tax return:
• You may have to pay back all or some of the advance payments of the premium tax credits you got.
• You won’t qualify for advance payments of the premium tax credit or cost-sharing reductions to help pay for
your Marketplace coverage in future years.
Complete “IRS Form 8962, Premium Tax Credit” when you file your taxes. You’ll use the information on Form 1095-A to
complete Form 8962. The Form 1095-A also states which months of 2023 you and other household members had
coverage. You’ll need that information to complete IRS Form 8962. Get more details on the back of the enclosed form. If
you need IRS Form 8962, visit IRS.gov/aca.
App ID 4866761523 1
Why Form 1095-A is important
Form 1095-A includes information about:
• You and any other members of your household who were enrolled in a Marketplace plan in 2023.
• Your Marketplace plan premium and other information you may need to fill out your federal income tax return
and claim the premium tax credit.
• The amount of any advance payments of the premium tax credit we paid in 2023 to a health plan for your
household.
To learn more about using your form, visit HealthCare.gov/tax-form-1095.
You may need more information to complete your tax return
When you file your 2023 taxes, you’ll need more information about your premium tax credit if:
• You had changes in your household that you didn’t report to the Marketplace – like having a baby, moving,
getting married or divorced, or losing a dependent.
• Your Form 1095-A has zeroes printed in Part III, Column B for the months you had coverage.
Visit HealthCare.gov/tax-tool to get the information you need if either of these apply to you.
Changes to your Form 1095-A information
If you think information on the enclosed Form 1095-A is wrong, call the Marketplace Call Center at 1-800-318-2596 to
find out how to get a corrected Form 1095-A. TTY users should call 1-855-889-4325.
You may receive more than one Form 1095-A. This can happen if different members of your household had different
health plans, you updated your coverage information during 2023, or you switched plans during 2023. Be sure to keep
all Forms 1095-A with your important tax documents.
You also may get IRS Form 1095-B or IRS Form 1095-C
If you or members of your household had coverage in 2023 through other programs or plans outside the Marketplace,
you may also get a “Form 1095-B, Health Coverage” or “Form 1095-C, Employer-Provided Health Insurance Offer and
Coverage.” Follow the instructions on these forms when you fill out your tax return.
NOTE: If you’re enrolled in another type of health coverage that qualifies as minimum essential coverage (for example,
Medicare Part A) and received a Form 1095-B, you may no longer be eligible to get financial assistance for your
Marketplace plan. It’s important to contact the Marketplace and report any changes in your coverage as soon as
possible. For more information, visit HealthCare.gov/taxes/other-health-coverage.
How to get help with your taxes
Many people can get free help to fill out their taxes. Visit IRS.gov/VITA to learn more. You can also visit IRS.gov/FreeFile
for electronic filing options.
If you need more information, visit HealthCare.gov/taxes.
For more help
• Visit IRS.gov if you have questions about your taxes.
• For questions about Marketplace coverage, visit HealthCare.gov, or call the Marketplace Call Center at
1-800-318-2596. TTY users can call 1-855-889-4325. You can also make an appointment with someone in your
area who can help you. Information is available at LocalHelp.HealthCare.gov.
• Get help in a language other than English. Information about how to access these services is included with this
notice and available through the Marketplace Call Center.
• Call the Marketplace Call Center to get this information in an accessible format, like large print, braille, or audio,
at no cost to you.
App ID 4866761523 2
Sincerely,
Health Insurance Marketplace
Department of Health and Human Services
465 Industrial Boulevard
London, Kentucky 40750-0001
Privacy Disclosure: The Health Insurance Marketplace® protects the privacy and security of the personally identifiable information (PII) that you
have provided (see HealthCare.gov/privacy). This notice was generated by the Marketplace based on 45 CFR 155.230 and other provisions of 45
CFR part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace®. The
Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on
your application. If you have questions about this data, contact the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1207.
Nondiscrimination: The Health Insurance Marketplace® doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis
of race, color, national origin, disability, sex (including sexual orientation and gender identity), or age. If you think you’ve been discriminated
against or treated unfairly for any of these reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil
Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S.
Department of Health and Human Services/ 200 Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.
App ID 4866761523 3
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App ID 4866761523 4
Form 1095-A Health Insurance Marketplace Statement VOID OMB No. 1545-2232
Department of the Treasury
Internal Revenue Service ▶
▶ Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095A for instructions and the latest information.
CORRECTED 2023
Part I Recipient Information
1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name
GA 132571408 Aetna CVS Health
4 Recipient's name 5 Recipient's SSN 6 Recipient's date of birth
Victoria N Cobb xxx-xx-6248
7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth
10 Policy start date 11 Policy termination date 12 Street address (including apartment no.)
04/01/2023 06/30/2023 14 Briarwood Drive
13 City or town 14 State or province 15 Country and ZIP or foreign postal code
Savannah GA US 31408
Part II Covered Individuals
A. Covered individual name B. Covered individual SSN C. Covered individual D. Coverage start date E. Coverage termination date
date of birth
16 Victoria N Cobb xxx-xx-6248 04/01/2023 06/30/2023
17
18
19
20
Part III Coverage Information
Month A. Monthly enrollment premiums B. Monthly second lowest cost silver C. Monthly advance payment of
plan (SLCSP) premium premium tax credit
21 January 0.00 0.00 0.00
22 February 0.00 0.00 0.00
23 March 0.00 0.00 0.00
24 April 390.41 387.31 388.00
25 May 390.41 387.31 388.00
26 June 390.41 387.31 388.00
27 July 0.00 0.00 0.00
28 August 0.00 0.00 0.00
29 September 0.00 0.00 0.00
30 October 0.00 0.00 0.00
31 November 0.00 0.00 0.00
32 December 0.00 0.00 0.00
33 Annual Totals 1,171.23 1,161.93 1,164.00
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q Form 1095-A (2023)
Form 1095-A (2023)
Instructions for Recipient If advance credit payments are made, the only individuals listed on
Form 1095-A will be those whom you certified to the Marketplace would
You received this Form 1095-A because you or a family member be in your tax family for the year of coverage (yourself, spouse, and
enrolled in health insurance coverage through the Health Insurance dependents). If you certified to the Marketplace at enrollment that one or
Marketplace. This Form 1095-A provides information you need to more of the individuals who enrolled in the plan aren’t individuals who
complete Form 8962, Premium Tax Credit (PTC). You must complete would be in your tax family for the year of coverage, those individuals
Form 8962 and file it with your tax return (Form 1040, Form won’t be listed on your Form 1095-A. For example, if you indicated to
1040-SR, or Form 1040-NR) if any amount other than zero is shown the Marketplace at enrollment that an individual enrolling in the policy is
in Part III, column C, of this Form 1095-A (meaning that you your adult child who will not be your dependent for the year of coverage,
received premium assistance through advance payments of the that child will receive a separate Form 1095-A and won’t be listed in
premium tax credit (also called advance credit payments)) or if you Part II on your Form 1095-A.
want to take the premium tax credit. The filing requirement applies If advance credit payments are made and you certify that one or more
whether or not you’re otherwise required to file a tax return. If you are enrolled individuals aren’t individuals who would be in your tax family for
filing Form 8962, you cannot file Form 1040-NR-EZ, Form the year of coverage, your Form 1095-A will include coverage
1040-SS, or Form 1040-PR. The Marketplace has also reported the information in Part III that is applicable solely to the individuals listed on
information on this form to the IRS. If you or your family members your Form 1095-A, and separately issued Forms 1095-A will include
enrolled at the Marketplace in more than one qualified health plan coverage information, including dollar amounts, applicable to those
policy, you will receive a Form 1095-A for each policy. Check the individuals not in your tax family.
information on this form carefully. Please contact your Marketplace if If advance credit payments weren’t made and you didn’t identify at
you have questions concerning its accuracy. If you or your family enrollment the individuals who would be in your tax family for the year of
members were enrolled in a Marketplace catastrophic health plan or coverage, Form 1095-A will list all enrolled individuals in Part II on your
separate dental policy, you aren’t entitled to take a premium tax credit Form 1095-A.
for this coverage when you file your return, even if you received a Form
1095-A for this coverage. For additional information related to Form If there are more than 5 individuals covered by a policy, you will
1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and- receive one or more additional Forms 1095-A that continue Part II.
Families/Health-Insurance-Marketplace-Statements. Part III. Coverage Information, lines 21–33. Part III reports information
Additional information. For additional information about the tax about your insurance coverage that you will need to complete Form
provisions of the Affordable Care Act (ACA), including the premium tax 8962 to reconcile advance credit payments or to take the premium tax
credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or credit when you file your return.
call the IRS Healthcare Hotline for ACA questions (800-919-0452). Column A. This column is the monthly premiums for the plan in which
VOID box. If the “VOID” box is checked at the top of the form, you you or family members were enrolled, including premiums that you paid
previously received a Form 1095-A for the policy described in Part I. and premiums that were paid through advance payments of the
That Form 1095-A was sent in error. You shouldn’t have received a premium tax credit. If you or a family member enrolled in a separate
Form 1095-A for this policy. Don’t use the information on this or the dental plan with pediatric benefits, this column includes the portion of
previously received Form 1095-A to figure your premium tax credit on the dental plan premiums for the pediatric benefits. If your plan covered
Form 8962. benefits that aren’t essential health benefits, such as adult dental or
vision benefits, the amount in this column will be reduced by the
CORRECTED box. If the “CORRECTED” box is checked at the top of
premiums for the nonessential benefits. If the policy was terminated by
the form, use the information on this Form 1095-A to figure the premium
your insurance company due to nonpayment of premiums for 1 or more
tax credit and reconcile any advance credit payments on Form 8962.
months, then a -0- will appear in this column for these months
Don’t use the information on the original Form 1095-A you received for
regardless of whether advance credit payments were made for these
this policy.
months. See the instructions for Form 8962, Part II, on how to complete
Part I. Recipient Information, lines 1–15. Part I reports information Form 8962 if -0- is reported for 1 or more months.
about you, the insurance company that issued your policy, and the
Column B. This column is the monthly premium for the second lowest
Marketplace where you enrolled in the coverage.
cost silver plan (SLCSP) that the Marketplace has determined applies to
Line 1. This line identifies the state where you enrolled in coverage members of your family enrolled in the coverage. The applicable SLCSP
through the Marketplace. premium is used to compute your monthly advance credit payments
Line 2. This line is the policy number assigned by the Marketplace to and the premium tax credit you take on your return. See the instructions
identify the policy in which you enrolled. If you are completing Part IV of for Form 8962, Part II, on how to use the information in this column or
Form 8962, enter this number on line 30, 31, 32, or 33, box a. how to complete Form 8962 if there is no information entered, the
information is incorrect, or the information is reported as -0-. If the
Line 3. This is the name of the insurance company that issued your
policy was terminated by your insurance company due to nonpayment
policy.
of premiums for 1 or more months, then a -0- will appear in this column
Line 4. You are the recipient because you are the person the for the months, regardless of whether advance credit payments were
Marketplace identified at enrollment who is expected to file a tax return made for these months.
and who, if qualified, would take the premium tax credit for the year of
Column C. This column is the monthly amount of advance credit
coverage.
payments that were made to your insurance company on your behalf to
Line 5. This is your social security number (SSN). For your protection, pay for all or part of the premiums for your coverage. If this is the only
this form may show only the last four digits. However, the Marketplace column in Part III that is filled in with an amount other than zero for a
has reported your complete SSN to the IRS. month, it means your policy was terminated by your insurance company
Line 6. A date of birth will be entered if there is no SSN on line 5. due to nonpayment of premiums, and you aren’t entitled to take the
premium tax credit for that month when you file your tax return. You
Lines 7, 8, and 9. Information about your spouse will be entered only if
must still reconcile the entire advance payment that was paid on your
advance credit payments were made for your coverage. The date of
behalf for that month using Form 8962. No information will be entered in
birth will be entered on line 9 only if line 8 is blank.
this column if no advance credit payments were made.
Lines 10 and 11. These are the starting and ending dates of the policy.
Lines 21–33. The Marketplace will report the amounts in columns A, B,
Lines 12 through 15. Your address is entered on these lines. and C on lines 21–32 for each month and enter the totals on line 33. Use
Part II. Covered Individuals, lines 16–20. Part II reports information this information to complete Form 8962, line 11 or lines 12–23.
about each individual who is covered under your policy. This information
includes the name, SSN, date of birth, and the starting and ending dates
of coverage for each covered individual. For each line, a date of birth is
reported in column C only if an SSN isn’t entered in column B.
January 2022
Health Insurance Marketplace® is a registered service mark of the
U.S. Department of Health & Human Services. January 2022
