Countries and Languages
| Countries | Languages |
|---|---|
| USA | English |
Basic Form Information
| Field | Description |
|---|---|
| Year | The name of the health insurance carrier. |
| 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 - Employee and Employer Information
Employee Information
| Field | Description |
|---|---|
| Name of Employee | The name of the covered employee. |
| Social Security Number | The Social Security Number (SSN) of the covered employee. |
| Street Address | The address of the covered employee. |
| City or Town | The address of the covered employee. |
| State or Province | The address of the covered employee. |
| Country and ZIP or Foreign Postal Code | The address of the covered employee. |
Employer Information
| Field | Description |
|---|---|
| Name of Employer | The name of the employer sponsoring the coverage. |
| Employer Identification Number | The Employer Identification Number (EIN) of the employer sponsoring the coverage. |
| Street Address | The address and phone number of the employer sponsoring the coverage. |
| Contact Telephone Number | The address and phone number of the employer sponsoring the coverage. |
| City or Town | The address and phone number of the employer sponsoring the coverage. |
| State or Province | The address and phone number of the employer sponsoring the coverage. |
| Country and ZIP or Foreign Postal Code | The address and phone number of the employer sponsoring the coverage. |
Part II - Coverage Information
General Coverage Details
| Field | Description |
|---|---|
| Employee’s Age on January 1 | The age of the employee as of January 1st of the previous calendar year. |
| Plan Start Month | The month in which the employer’s health insurance plan year begins. |
Offer of Coverage Table
Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.| Month | Description |
|---|---|
| All 12 Months | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Jan | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Feb | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Mar | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Apr | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| May | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| June | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| July | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Aug | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Sept | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Oct | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Nov | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Dec | Contains codes from Code Series 1 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
Employee Required Contribution Table
Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount.| Month | Description |
|---|---|
| All 12 Months | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Jan | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Feb | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Mar | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Apr | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| May | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| June | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| July | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Aug | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Sept | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Oct | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Nov | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
| Dec | Contains the amount of the Employee Required Contribution for each month. If the same amount applies for all 12 calendar months, only the All 12 Months column contains the monthly amount. |
Section 4980H Safe Harbor and Other Relief Table
Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.| Month | Description |
|---|---|
| All 12 Months | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Jan | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Feb | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Mar | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Apr | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| May | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| June | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| July | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Aug | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Sept | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Oct | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Nov | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Dec | Contains codes from Code Series 2 for each calendar month. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
ZIP Code Table
Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code.| Month | Description |
|---|---|
| All 12 Months | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Jan | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Feb | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Mar | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Apr | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| May | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| June | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| July | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Aug | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Sept | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Oct | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Nov | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
| Dec | Contains ZIP codes used to identify the lowest cost silver plan. If the same code applies for all 12 calendar months, only the All 12 Months column contains the applicable code. |
Part III - Self-Insured Coverage
General Self-Insured Information
| Field | Description |
|---|---|
| Employer Provided Self-Insured Coverage | Indicates that the health insurance coverage offered by the employer was self-insured. |
Covered Individuals Table
| Field | Description |
|---|---|
| Name | The name of each covered individual, including the employee, if the employee is enrolled in self-insured coverage. |
| SSN or TIN | The Social Security Number (SSN) or Taxpayer Identification Number (TIN) for each covered individual. |
| DOB | The date of birth (YYYY-MM-DD) for the covered individual. |
| Covered All 12 Months | Indicates that the individual was covered for at least one day per month for all 12 months of the calendar year. |
Monthly Coverage Details
| Month | Description |
|---|---|
| Jan | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Feb | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Mar | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Apr | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| May | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| June | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| July | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Aug | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Sept | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Oct | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Nov | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
| Dec | The month(s) in which the individual was covered for at least one day per month for all 12 months of the calendar year. |
Key Fields
- Part I/Employee/Name of Employee
- Part I/Employee/Social Security Number
- Part I/Employer/Name of Employer
- Part I/Employer/Employer Identification Number
Validation Rules
| Rule | Description |
|---|---|
| Clean Name | Checks for unsupported characters such as | and ] in name fields. It also cleans multiple spaces, tabs, and newlines. |
| 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. |