This form is for informational purposes only. You may need information provided on this form to assist the IRS in determining whether you are eligible for a premium tax credit for purchasing individual health coverage through the Health Insurance Marketplace, such as Covered California.
Under the ACA’s Employer Shared Responsibility provision (known as the employer mandate), the State of California is required to offer affordable health coverage that provides minimum value to its full-time employees and their dependents to avoid a penalty.
To demonstrate compliance, the state must file annual reports with the IRS and furnish a statement, IRS Form 1095-C, no later than 30 days after January 31 to full-time employees with information about the health coverage that was offered, if any, to the employee, their spouse and dependents.
The IRS will use information reported on this form to determine if the state is complying with the ACA’s employer mandate or subject to a penalty.
You received this form because you were considered a full-time employee for ACA reporting purposes for one or more months during the preceding calendar year.
The ACA defines a full-time employee as any employee who averages 130 or more hours of service per month. The state is using a 6-month measurement period to average an employee’s hours of service to determine their full-time status for ACA reporting purposes.
If you were appointed to a position with a time base of 3/4 or more, you should receive this form. Additionally, if you were appointed to an intermittent time base and averaged 130 or more hours of service per month during one of the state’s 6-month measurement periods, you should receive this form, regardless of whether you were eligible for state-sponsored health coverage.
This form was provided by your employer, the State of California, because you were considered a full-time employee for ACA reporting purposes for one or more months during the preceding calendar year.
Information about the state employer’s offer of health coverage, if any, to you, your spouse and your dependents is reported for each month during the preceding calendar year in Part II of the form. This information will help the IRS determine if the state is complying with the ACA’s employer mandate and if you are eligible for a premium tax credit if you purchase individual health coverage through the Health Insurance Marketplace, such as Covered California.
The codes on Line 14 reflect the type of health coverage offered, if any, to you, your spouse, and dependents for each month during the preceding calendar year. The state will report the following codes on Line 14 of the form to reflect the period in which you were eligible for and offered state-sponsored health or COBRA coverage, regardless of whether you enrolled in coverage:
- 1B—Indicates that minimum essential coverage providing minimum value was offered to you only. (COBRA coverage only).
- 1C—Indicates that minimum essential coverage providing minimum value was offered to you and your dependents (not your spouse). (COBRA coverage only).
- 1D—Indicates that minimum essential coverage providing minimum value was offered to you and your spouse (not your dependents). (COBRA coverage only)
- 1E—Indicates that minimum essential coverage providing minimum value was offered to you, your spouse, and your dependents. (State-sponsored health or COBRA coverage)
- 1H—Indicates that you were not offered an opportunity to enroll in state-sponsored health coverage because you were not appointed to a position eligible for health benefits (e.g., Temporary/Intermittent) or were not eligible for COBRA coverage.
The dollar amounts on Line 15 reflect your share of the lowest cost monthly premium for self-only coverage providing minimum value offered by the state (health premium minus your respective employer health/CoBen contribution for self-only coverage).
This amount may not reflect the amount you actually paid for health coverage if you chose to enroll in more expensive coverage, such as a different plan, two-party or family coverage.
The dollar amounts on Line 15 may also reflect the full premium for self-only COBRA coverage (for the plan in which you were eligible to enroll) for the month(s) you were offered/eligible for COBRA coverage, or the full premium for self-only coverage for the month(s) in which you were eligible for or enrolled in health coverage but were not receiving the employer contribution towards the cost of coverage, for example, if you were on Direct Pay.
The IRS will use information reported on Line 15 to determine if the health coverage offered by the state meets the ACA’s affordability standards.
The codes on Line 16 provide information to the IRS to determine if the state is in compliance with the ACA’s employer mandate or subject to a penalty.
Part III of the form is blank because the state does not provide self-insured health coverage. Instead, you will receive a Form 1095-B from your health coverage provider, if applicable, with information about the individuals who were enrolled in minimum essential coverage for at least one day during the preceding calendar year.
If you did not receive this form, you were not considered a full-time employee for ACA reporting purposes for any month during the preceding calendar year.
You should contact your department's personnel office if you believe you should have received this form and did not. They can verify whether you should have received the form.
You should contact your department's personnel office if any information reported on the form is incorrect.
You should contact your department's personnel office to assist in requesting a duplicate form 1095-C statement from the State Controller’s Office.
You should contact your department's personnel office with questions or visit www.irs.gov/aca.
