Form 1095-A, Health Insurance Marketplace Statement

The Form 1095-A, Health Insurance Marketplace Statement skill extracts data from Forms 1095-A, which are used to report certain information to the Internal Revenue Service (IRS) about individuals who enroll in a qualified health plan through the Health Insurance Marketplace. It includes information such as the effective date of the coverage, the premium amounts paid monthly, and any advance payments of the premium tax credit or subsidy. The Form 1095-A, Health Insurance Marketplace Statement skill is a preview skill. It has been trained on a limited set of documents and is designed to help you quickly get started with processing Forms 1095-A. For production use, you may need to uptrain the skill with your own document samples. This skill recognizes handwritten text. The option is enabled by default. If you do not import handwritten forms, disable the Handwritten option in the skill settings.

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.

​Countries and Languages

​Extracted Fields

​Form Information

​Part I - Recipient Information

​Part II - Covered Individuals (table)

​Part III - Coverage Information (table)

​Annual Totals

​Key Fields

​Validation Rules