Countries and Languages
| Countries | Languages |
|---|---|
| USA | English |
Extracted Fields
Form Information
| Field | Description |
|---|---|
| Year | The reporting fiscal year. |
| Void | Specifies that the processed form should be annulled. |
| Corrected | Specifies that the processed form is being submitted to correct data provided earlier. |
Part I - Recipient Information
| Field | Description |
|---|---|
| Marketplace Identifier | The identifier of the Marketplace where the recipient enrolled in the coverage. |
| Marketplace-Assigned Policy Number | The policy number assigned by the Marketplace to identify the policy in which the recipient enrolled. |
| Policy Issuer’s Name | The name of the insurance company that issued the recipient’s policy. |
| Recipient’s Name | The name of the recipient. |
| Recipient’s SSN | The Social Security Number (SSN) of the recipient. |
| Recipient’s Date of Birth | The date of birth of the recipient. |
| Recipient’s Spouse’s Name | The name of the recipient’s spouse. Information about the recipient’s spouse is entered only if advance credit payments were made for the coverage. |
| Recipient’s Spouse’s SSN | The Social Security Number (SSN) of the recipient’s spouse. |
| Recipient’s Spouse’s Date of Birth | The date of birth of the recipient’s spouse. |
| Policy Start Date | The starting date of the policy. |
| Policy Termination Date | The ending date of the policy. |
| Street Address | The address of the recipient. |
| City or Town | The address of the recipient. |
| State or Province | The address of the recipient. |
| Country and ZIP or Foreign Postal Code | The address of the recipient. |
Part II - Covered Individuals (table)
| Field | Description |
|---|---|
| Covered Individual Name | The name of the individual who is covered under the recipient’s policy. |
| Covered Individual SSN | The Social Security Number (SSN) of the individual. |
| Covered Individual Date of Birth | The date of birth of the individual. |
| Coverage Start Date | The starting date of the coverage. |
| Coverage Termination Date | The ending date of the coverage. |
Part III - Coverage Information (table)
| Field | Description |
|---|---|
| Month | Month of the insurance coverage. |
| Monthly Enrollment Premiums | The monthly premiums for the plan in which the recipient or his family members were enrolled, including premiums that the recipient paid and premiums that were paid through advance payments of the premium tax credit. |
| Monthly Second Lowest Cost Silver Plan (SLCSP) Premium | The monthly premium for the second lowest cost silver plan (SLCSP) that the Marketplace has determined, which applies to members of the recipient’s family enrolled in the coverage. |
| Monthly Advance Payment of Premium Tax Credit | The monthly amount of advance credit payments that were made to the insurance company on behalf of the recipient to pay for all or part of the premiums for his coverage. |
Annual Totals
| Field | Description |
|---|---|
| Monthly Enrollment Premiums - Annual Total | The total amount of the monthly enrollment premiums. |
| Monthly Second Lowest Cost Silver Plan (SLCSP) Premium - Annual Total | The total amount of the monthly SLCSP premiums. |
| Monthly Advance Payment of Premium Tax Credit - Annual Total | The total amount of the monthly advance credit payments. |
Key Fields
- Part I - Recipient Information/Marketplace Identifier
- Part I - Recipient Information/Recipient’s Name
- Part I - Recipient Information/Recipient’s SSN
Validation Rules
| Rule | Description |
|---|---|
| Clean Year | Checks the value in the Year field. It converts a 2-digit year (such as 24) into a 4-digit format (such as 2024). It assumes all 2-digit years are in the 2000s. |