Edit Forms 1095-C screen Field Reference

A reference for completing or changing the field values in the Edit Forms 1095-C screen.

This screen reference describes the following:

Select Employees

Each row in the grid is an employee who had earnings within 30 months of the last day of the tax year. Earnings include Holiday hours.

Most of the fields are display only. The only exception is the checkbox in the Print 1095-C column. Use the remaining fields on the tab to identify the employees for whom you want to create a Form 1095-C.

Tip: Select in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin.
FieldDescription
Print 1095-CSelect the checkbox to indicate that you want to create a Form 1095-C for the employee. Only employees for whom you have selected the checkbox will appear on the remaining tabs on the screen.
Note: The checkbox is automatically selected for employees who have been full-time for at least one day in the specified tax year.

Part I

Each row in the grid is an employee who was selected on the Select Employees tab.

Most of the fields are display only. The only exception is the checkbox in the Enrolled in Employer Provided Self-Insurance Coverage column.

Tip: Select in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin.
FieldDescription

Employee

These values come from the Employee screen.

Enrolled in Employer Provided Self-Insurance CoverageSelect the checkbox to indicate that the employee was enrolled in employer provided self-insurance coverage. You must select this checkbox for the employee to appear on the Part III tab.
First NameThe employee's first name.
InitialThe employee's middle initial.
Last NameThe employee's last name.
SuffixThe employee's suffix.
Social Security NumberThe employee's social security number.
Street Address 1The first line of the employee's street address.
Street Address 2The second line of the employee's street address.
City or townThe city for the employee's address.
State or provinceThe state for the employee's address.
ZIP or foreign postal codeThe ZIP for the employee's address.
Date of Birth The employee's date of birth.

Part II Line 14

FieldDescription
Employee Offer and Coverage, Offer of Coverage (enter required code)
All Employees - Use this area to set the offer of coverage for all employees. This sets the default coverage offered to employees. You can override this information for a specific employee in the Employee Overrides section. Complete either the All 12 Months field or the fields for each month.
Plan Start MonthSelect the default month in which coverage started. This field is required.
All 12 MonthsSelect the indicator that specifies the type of coverage offered to employees for the entire year. Use this field if the coverage offered to employees was the same in every month of the year. If you select a value in the All 12 Months field, the fields for the months are disabled.
  • 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).
    Note: This code may be used to report for specific months for which a Qualifying Offer was made, even if the employee did not receive a Qualifying Offer for all 12 months of the calendar year. However, an employer may not use the Alternative Furnishing Method for an employee who did not receive a Qualifying Offer for all 12 calendar months (except in cases in which the employer is eligible for and reports using the Alternative Method of Furnishing Form 1095-C to Employees Under the Qualifying Offer Method Transition Relief as described in these instructions).
  • 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.
  • 1H - No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage).
  • 1J - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage NOT offered to the employee's dependents.
  • 1K - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage offered to the employee's dependents.
  • 1L - Individual coverage health reimbursement arrangement (HRA) offered to you only wth affordability determined by using employee's primary residence location and zip code.
  • 1M - Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee's primary residence location ZIP code.
  • 1N - Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by using employee's primary residence location ZIP code.
  • 1O - Individual coverage HRA offered to you only using the employee's primary employment site ZIP code affordability safe harbor.
  • 1P - Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1Q - Individual coverage HRA offered to you, spouse and dependent(s) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1R - Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee, spouse, and dependents.
  • 1S - Individual coverage HRA offered to an individual who was not a full-time employee.
  • 1T - Individual coverage HRA offered to employee and spouse (not dependents) with affordability determined using employee's primary residence location ZIP code.
  • 1U - Individual coverage HRA offered to employee and spouse (not dependents) using employee's primary employment site ZIP code affordability safe harbor.

January - December

Select the indicator that specifies the type of coverage offered to employees in each month of the year. Use these fields if the coverage offered to employees was different in different months of the year. If you select a value in a month field, the All 12 Months field is disabled.
  • 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).
    Note: This code may be used to report for specific months for which a Qualifying Offer was made, even if the employee did not receive a Qualifying Offer for all 12 months of the calendar year. However, an employer may not use the Alternative Furnishing Method for an employee who did not receive a Qualifying Offer for all 12 calendar months (except in cases in which the employer is eligible for and reports using the Alternative Method of Furnishing Form 1095-C to Employees Under the Qualifying Offer Method Transition Relief as described in these instructions).
  • 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.
  • 1H - No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage).
  • 1J - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage NOT offered to the employee's dependents.
  • 1K - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage offered to the employee's dependents.
  • 1L - Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using employee's primary residence location ZIP code.
  • 1M - Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee's primary residence location ZIP code.
  • 1N - Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by using employee's primary residence location ZIP code.
  • 1O - Individual coverage HRA offered to you only using the employee's primary employment site ZIP code affordability safe harbor.
  • 1P - Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1Q - Individual coverage HRA offered to you, spouse and dependent(s) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1R - Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee, spouse, and dependents.
  • 1S - Individual coverage HRA offered to an individual who was not a full-time employee.
  • 1T - Individual coverage HRA offered to employee and spouse (not dependents) with affordability determined using employee's primary residence location ZIP code.
  • 1U - Individual coverage HRA offered to employee and spouse (not dependents) using employee's primary employment site ZIP code affordability safe harbor.
Employee Overrides - Each row in the grid is an employee who was selected on the Select Employees tab. Most of the fields are display only. Use the grid to enter offer of coverage information specific to individual employees, which will override the default information entered above.
Tip: Select in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin.
Print FromDefaults to All Employees Section, which will use the default offer of coverage information entered above for the employee. Select the coverage information to print on the Form 1095-C for each employee.
  • All Employees Section - Select this option to print the default offer of coverage information, entered in the All Employees section above, on Form 1095-C for the employee.
  • Every Value From This Row - Select this option to enter coverage information for the employee and print it on Form 1095-C for the employee. This will override the default information for the employee.
Plan Start MonthSelect the month in which coverage started for the employee.
All 12 MonthsSelect the indicator that specifies the type of coverage offered to the employee for the entire year. Use this field if the coverage offered to the employee was the same in every month of the year. If you select a value in the All 12 Months field, the fields for the months are disabled.
  • 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).
    Note: This code may be used to report for specific months for which a Qualifying Offer was made, even if the employee did not receive a Qualifying Offer for all 12 months of the calendar year. However, an employer may not use the Alternative Furnishing Method for an employee who did not receive a Qualifying Offer for all 12 calendar months (except in cases in which the employer is eligible for and reports using the Alternative Method of Furnishing Form 1095-C to Employees Under the Qualifying Offer Method Transition Relief as described in these instructions).
  • 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.
  • 1H - No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage).
  • 1J - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage NOT offered to the employee's dependents.
  • 1K - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage offered to the employee's dependents.
  • 1L - Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using employee's primary residence location ZIP code.
  • 1M - Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee's primary residence location ZIP code.
  • 1N - Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by using employee's primary residence location ZIP code.
  • 1O - Individual coverage HRA offered to you only using the employee's primary employment site ZIP code affordability safe harbor.
  • 1P - Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1Q - Individual coverage HRA offered to you, spouse and dependent(s) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1R - Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee, spouse, and dependents.
  • 1S - Individual coverage HRA offered to an individual who was not a full-time employee.
  • 1T - Individual coverage HRA offered to employee and spouse (not dependents) with affordability determined using employee's primary residence location ZIP code.
  • 1U - Individual coverage HRA offered to employee and spouse (not dependents) using employee's primary employment site ZIP code affordability safe harbor.
Jan - DecSelect the indicator that specifies the type of coverage offered to the employee in each month of the year. Use these fields if the coverage offered to the employee was different in different months of the year. If you select a value in a month field, the All 12 Months field is disabled.
  • 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).
    Note: This code may be used to report for specific months for which a Qualifying Offer was made, even if the employee did not receive a Qualifying Offer for all 12 months of the calendar year. However, an employer may not use the Alternative Furnishing Method for an employee who did not receive a Qualifying Offer for all 12 calendar months (except in cases in which the employer is eligible for and reports using the Alternative Method of Furnishing Form 1095-C to Employees Under the Qualifying Offer Method Transition Relief as described in these instructions).
  • 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.
  • 1H - No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage).
  • 1J - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage NOT offered to the employee's dependents.
  • 1K - Minimum essential coverage providing minimum value offered to the employee; minimum essential coverage conditionally offered to the employee's spouse; and minimum essential coverage offered to the employee's dependents.
  • 1L - Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using employee's primary residence location ZIP code.
  • 1M - Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee's primary residence location ZIP code.
  • 1N - Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by using employee's primary residence location ZIP code.
  • 1O - Individual coverage HRA offered to you only using the employee's primary employment site ZIP code affordability safe harbor.
  • 1P - Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1Q - Individual coverage HRA offered to you, spouse and dependent(s) using the employee's primary employment site ZIP code affordability safe harbor.
  • 1R - Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee, spouse, and dependents.
  • 1S - Individual coverage HRA offered to an individual who was not a full-time employee.
  • 1T - Individual coverage HRA offered to employee and spouse (not dependents) with affordability determined using employee's primary residence location ZIP code.
  • 1U - Individual coverage HRA offered to employee and spouse (not dependents) using employee's primary employment site ZIP code affordability safe harbor.

Part II Line 15

FieldDescription
Employee Offer and Coverage, Employee Share of Lowest Cost Monthly Premium, for Self Only Minimum Value Coverage
All Employees - Use this area to set the employee share for all employees. This sets the default amount for the employee share for employees. You can override this information for a specific employee in the Employee Overrides section. Complete either the All 12 Months field or the fields for each month.
All 12 Months Enter the amount for the employee share of the monthly premium for the lowest cost plan for self only minimum value coverage. Use this field if the employee share was the same in every month of the year. If you enter an amount in the All 12 Months field, the fields for the months are disabled.
January - December Enter the amount for the employee share of the monthly premium for the lowest cost plan for self only minimum value coverage in each month of the year. Use these fields if the employee share was different in different months of the year. If you enter an amount in a month field, the All 12 Months field is disabled.
Employee Overrides - Each row in the grid is an employee who was selected on the Select Employees tab. Most of the fields are display only. Use the grid to enter offer of coverage information specific to individual employees, which will override the default information entered above.
Tip: Select in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin.
Print FromDefaults to All Employees Section, which will use the default employee share information entered above for the employee. Select the coverage information to print on the Form 1095-C for each employee.
  • All Employees Section - Select this option to print the default employee share information, entered in the All Employees section above, on Form 1095-C for the employee.
  • Every Value From This Row - Select this option to enter employee share information for the employee and print it on Form 1095-C for the employee. This will override the default information for the employee.
All 12 MonthsEnter the amount for the employee share of the monthly premium for the lowest cost plan for self only minimum value coverage. Use this field if the employee share was the same in every month of the year. If you enter an amount in the All 12 Months field, the fields for the months are disabled.
Jan - DecEnter the amount for the employee share of the monthly premium for the lowest cost plan for self only minimum value coverage in each month of the year. Use these fields if the employee share was different in different months of the year. If you enter an amount in a month field, the All 12 Months field is disabled.

Part II Line 16

FieldDescription
Employee Offer and Coverage, Applicable Section 4980H Safe Harbor (enter code if applicable)
All Employees - Use this area to set the Code Series 2 for all employees. This sets the default coverage status for employees. You can override this information for a specific employee in the Employee Overrides section. Complete either the All 12 Months field or the fields for each month.
All 12 MonthsSelect the indicator that specifies the default coverage status for employees for the entire year. Use this field if the coverage status for employees was the same in every month of the year. If you select a value in the All 12 Months field, the fields for the months are disabled.
  • 2A - Employee not employed during the month. Select code 2A if the employee was not employed on any day of the calendar month. Do not use code 2A for a month if the individual was an employee of the employer on any day of the calendar month. Do not use code 2A for the month during which an employee terminates employment with the employer.
  • 2B - Employee not a full-time employee. Select 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. Enter code 2B also if the employee is a full-time employee for the month and whose offer of coverage (or coverage if the employee was enrolled) ended before the last day of the month solely because the employee terminated employment during the month (so that the offer of coverage or coverage would have continued if the employee had not terminated employment during the month).
  • 2C - Employee enrolled in coverage offered. Select code 2C for any month in which the employee enrolled in health coverage offered by the employer for each day of the month, regardless of whether any other code in Code Series 2 might also apply (for example, the code for a section 4980H affordability safe harbor).
  • 2D - Employee in a section 4980H(b) Limited Non-Assessment Period. Select 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. Select code 2E for any month for which the multiemployer interim guidance applies for that employee. This relief is described under Offer of Health Coverage in the Definitions section of these instructions.
  • 2F - Section 4980H affordability Form W-2 safe harbor. Select 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. Select 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. Select 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).
    Note: Codes 2F through 2H: 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).
  • 2I - Reserved for future use.
January - DecemberSelect the indicator that specifies the default coverage status for employees for each month of the year. Use these fields if the coverage status for employees was different in different months of the year. If you select a value in a month field, the All 12 Months field is disabled.
  • 2A - Employee not employed during the month. Select code 2A if the employee was not employed on any day of the calendar month. Do not use code 2A for a month if the individual was an employee of the employer on any day of the calendar month. Do not use code 2A for the month during which an employee terminates employment with the employer.
  • 2B - Employee not a full-time employee. Select 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. Enter code 2B also if the employee is a full-time employee for the month and whose offer of coverage (or coverage if the employee was enrolled) ended before the last day of the month solely because the employee terminated employment during the month (so that the offer of coverage or coverage would have continued if the employee had not terminated employment during the month).
  • 2C - Employee enrolled in coverage offered. Select code 2C for any month in which the employee enrolled in health coverage offered by the employer for each day of the month, regardless of whether any other code in Code Series 2 might also apply (for example, the code for a section 4980H affordability safe harbor).
  • 2D - Employee in a section 4980H(b) Limited Non-Assessment Period. Select 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. Select code 2E for any month for which the multiemployer interim guidance applies for that employee. This relief is described under Offer of Health Coverage in the Definitions section of these instructions.
  • 2F - Section 4980H affordability Form W-2 safe harbor. Select 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. Select 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. Select 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).
    Note: Codes 2F through 2H: 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).
  • 2I - Reserved for future use.
Employee Overrides - Each row in the grid is an employee who was selected on the Select Employees tab. Most of the fields are display only. Use the grid to enter offer of coverage information specific to individual employees, which will override the default information entered above.
Tip: Select in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin.
Print FromDefaults to All Employees Section, which will use the default code entered above for the employee. Select the coverage information to print on the Form 1095-C for each employee.
  • All Employees Section - Select this option to print the default employee share information, entered in the All Employees section above, on Form 1095-C for the employee.
  • Every Value From This Row - Select this option to enter employee share information for the employee and print it on Form 1095-C for the employee. This will override the default information for the employee.
All 12 MonthsSelect the indicator that specifies the coverage status for the employee for the entire year. Use this field if the coverage status for the employee was the same in every month of the year. If you select a value in the All 12 Months field, the fields for the months are disabled.
  • 2A - Employee not employed during the month. Select code 2A if the employee was not employed on any day of the calendar month. Do not use code 2A for a month if the individual was an employee of the employer on any day of the calendar month. Do not use code 2A for the month during which an employee terminates employment with the employer.
  • 2B - Employee not a full-time employee. Select 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. Enter code 2B also if the employee is a full-time employee for the month and whose offer of coverage (or coverage if the employee was enrolled) ended before the last day of the month solely because the employee terminated employment during the month (so that the offer of coverage or coverage would have continued if the employee had not terminated employment during the month).
  • 2C - Employee enrolled in coverage offered. Select code 2C for any month in which the employee enrolled in health coverage offered by the employer for each day of the month, regardless of whether any other code in Code Series 2 might also apply (for example, the code for a section 4980H affordability safe harbor).
  • 2D - Employee in a section 4980H(b) Limited Non-Assessment Period. Select 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. Select code 2E for any month for which the multiemployer interim guidance applies for that employee. This relief is described under Offer of Health Coverage in the Definitions section of these instructions.
  • 2F - Section 4980H affordability Form W-2 safe harbor. Select 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. Select 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. Select 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).
    Note: Codes 2F through 2H: 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).
  • 2I - Reserved for future use.
Jan - DecSelect the indicator that specifies the coverage status for the employee for each month of the year. Use these fields if the coverage status for employees was different in different months of the year. If you select a value in a month field, the All 12 Months field is disabled.
  • 2A - Employee not employed during the month. Select code 2A if the employee was not employed on any day of the calendar month. Do not use code 2A for a month if the individual was an employee of the employer on any day of the calendar month. Do not use code 2A for the month during which an employee terminates employment with the employer.
  • 2B - Employee not a full-time employee. Select 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. Enter code 2B also if the employee is a full-time employee for the month and whose offer of coverage (or coverage if the employee was enrolled) ended before the last day of the month solely because the employee terminated employment during the month (so that the offer of coverage or coverage would have continued if the employee had not terminated employment during the month).
  • 2C - Employee enrolled in coverage offered. Select code 2C for any month in which the employee enrolled in health coverage offered by the employer for each day of the month, regardless of whether any other code in Code Series 2 might also apply (for example, the code for a section 4980H affordability safe harbor).
  • 2D - Employee in a section 4980H(b) Limited Non-Assessment Period. Select 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. Select code 2E for any month for which the multiemployer interim guidance applies for that employee. This relief is described under Offer of Health Coverage in the Definitions section of these instructions.

  • 2F - Section 4980H affordability Form W-2 safe harbor. Select 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. Select 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. Select 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).

    Note: Codes 2F through 2H: 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).
  • 2I - Reserved for future use.

Part II Line 17

Select the pin in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin.
FieldDescription
Zip Code

The zip code used to determine affordability for an ICHRA, if one was offered to the employee.

The default value in the All 12 Months field depends on the Series One Offer Code you entered for this employee in Part II Line 14:
  • If you entered code 1L, 1M, or 1N, the default value is the employee's residence zip code from their employee record.
  • If you entered code 1O, 1P, or 1Q the default value is the company's zip code.
  • All other codes cause this field to be disabled and empty.
If needed, override the default value.

Part III

FieldDescription
Covered Individuals - Each row in the grid is an employee who was selected on the Select Employees tab and who has the Enrolled in Employer Provided Self-Insurance Coverage checkbox selected on the Part I tab. Use the grid to specify the dependents for each employee. You can manually add dependents by adding rows under each employee, import dependent information from Excel, or copy dependents from the prior tax year. If needed, select to delete the active dependent row from the grid. You cannot delete employee rows.
Tip: You cannot sort the data in this grid; however, you can copy the data to paste it in Excel. Right-select on the Covered Individuals grid and select Copy Grid to Clipboard. Open Excel and paste the data. You may need to format cells as text before pasting, if the data contains leading zeros. You may need to press Esc to exit the current cell before right-clicking to copy the grid or to paste into to the grid.

Select in the column header to pin a column. A pinned column is moved to the left side of the grid and remains visible when you scroll to the right. Each column has its own pin. Select to unpin a column. When you unpin a column, it will remain in its current location in the grid; it will not return to its original location.

Import Dependents

Select Import Dependents to import dependent information from Excel (XLSX or XLS files). Browse to the file you want to import and select Open.

You can import dependent information more than once. If you import a line with the same employee name and dependent name as an existing line, all other information in the line is overwritten with the information from the imported file. If you import an employee line with the same name as an existing line, only the columns for All 12 Months and Jan-Dec are overwritten with the information from the imported file.

An import template for covered individuals is installed in the following location:

C:\Program Files\Maxwell Systems\ProContractorMX\Import Templates\1095 - Covered Individuals.xlsx

C:\Program Files (x86)\Viewpoint\PCACA\1095 - Covered Individuals.xlsx

  • In order to import data from Microsoft Excel, the file that contains the data to be imported cannot be open in Excel.
  • The import data must be in an import template on a worksheet named Sheet1.
  • If you are using Office 365 Online, you must first download and save a local copy of the Excel file you want to import before you can import it.
  • To ensure that data is imported correctly, the following fields must be formatted correctly in Excel:
    • Employee Code - Format as Text. Set the format for the column to Text, before adding data. This will ensure that Excel does not remove leading zeros from employee codes.
    • Date of Birth - Format as Date. Enter data in the format MM/DD/YYYY, so that Excel will set the format to Date.
    • Social Security Number - Format as General. Enter data in the format 999-99-9999, so that Excel will set the format to General.
Copy Dependents from Prior Tax YearSelect Copy Dependents from Prior Tax Year and Yes on the confirmation message to copy dependent information from the prior tax year for all employees listed in the Part III tab. ProContractor copies dependent information as follows:
  • If the December checkbox or the All 12 Months checkbox is selected for the dependent for the prior year, the All 12 Months checkbox is automatically selected for the dependent for the year that is copied to.
  • If the December checkbox or the All 12 Months checkbox is not selected for the dependent for the prior year, the dependent information is not copied.
Sort NameThe sort name for the employee.
EmployeeThe code that identifies the employee.
Name of Covered IndividualThe full name of the covered individual (employee or dependent).
Add DependentSelect Add to manually enter a dependent for the employee. This button is not available on dependent rows.
First NameFor an employee row, displays the employee's first name. For a dependent row, enter the dependent's first name.
InitialFor an employee row, displays the employee's middle initial. For a dependent row, enter the dependent's middle initial.
Last NameFor an employee row, displays the employee's last name. For a dependent row, enter the dependent's last name.
SuffixFor an employee row, displays the employee's suffix, such as Sr., Jr., or III. For a dependent row, enter the dependent's suffix, such as Sr., Jr., or III.
Social Security NumberFor an employee row, displays the employee's social security number. For a dependent row, enter the dependent's social security number.
Date of BirthFor an employee row, displays the employee's date of birth. For a dependent row, enter the dependent's date of birth.
All 12 MonthsSelect the checkbox to indicate that the individual was covered for all 12 months of the year. Complete either the All 12 Months field or the fields for each month as needed. If you select this checkbox, the fields for each month are disabled.
Jan - DecSelect the checkbox in each month column to indicate in which months the individual was covered. Complete either the All 12 Months field or the fields for each month as needed. If you select a checkbox in a month field, the All 12 Months field is disabled.
Employee/DependentDisplays whether the individual in the row is an employee or a dependent.