*Greatland Corporation does not provide tax, legal or accounting advice. This document has been prepared for

informational purposes only, and is not intended to provide, and should not be relied on for, tax, legal or accounting

advice. You should consult your own tax, legal and accounting advisors before engaging in any transaction.

Information for Completing Form 1095-C Lines 14–16*

Scenario: Employee Only; Termination; Declines COBRA

The following example describes an employee scenario and indicates the proper entries for Lines 14–16 on

Form 1095-C applicable to that scenario. Filers may find this information useful when completing Form

1095-C for an employee in a similar scenario. This example assumes that the employer offered the employee

minimum essential coverage that provided minimum value. Please replace all data with your employee

data.

Example criteria

Full-time employee is terminated May 8

Employee was enrolled in coverage when employed; premium is $105.00

Employee declines COBRA

All 12

Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec

Line 14 1B 1B 1B 1B 1H 1H 1H 1H 1H 1H 1H 1H

Line 15 $105.00 $105.00 $105.00 $105.00

Line 16 2C 2C 2C 2C 2B 2A 2A 2A 2A 2A 2A 2A

Explanation

Code 1B is entered on Line 14 in January–April, since an offer of coverage was made to the employee

only in these months. Code 1H is entered in May–December, since no offer of coverage should be

reported in any month in which the offer of COBRA applies due to employee termination.

The premium amount of $105.00 is entered on Line 15 in January–April, representing the employee

share of the lowest cost monthly premium for self-only minimum value coverage. Line 15 is left blank

in May–December since no offer of coverage should be reported in any month in which the offer of

COBRA applies due to employee termination.

Code 2C is entered on Line 16 in January–April indicating that the employee enrolled in the coverage

offered. Code 2B is entered in May indicating that the coverage ended before the last day of the

month due to employee termination. Code 2A is entered in June–December indicating that the

employee was not employed during these months.

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*Greatland Corporation does not provide tax, legal or accounting advice. This document has been prepared for

informational purposes only, and is not intended to provide, and should not be relied on for, tax, legal or accounting

advice. You should consult your own tax, legal and accounting advisors before engaging in any transaction.

Frequently Asked Questions

How should information about the offer of coverage for the month in which an employee terminates employment be reported on Form 1095-C? If an employee terminates employment on any day other than the last day of a month and the coverage or offer of coverage expires upon termination of employment, the Applicable Large Employer (ALE) should enter Code 1H on Line 14. If the coverage or offer of coverage would have continued if the employee had not terminated employment during the month, the ALE should enter Code 2B on Line 16 for that month.

How should an Applicable Large Employer (ALE) complete Line 14 of Form 1095-C for a full-time employee who terminates employment during a calendar year and receives an offer of COBRA continuation coverage? An offer of COBRA continuation coverage that is made to a former employee due to termination of employment is not reported as an offer of coverage on Line 14 of Form 1095-C. For a terminated employee, Code 1H (No offer of coverage) should be entered for any month in which the offer of COBRA coverage applies.

How should an Applicable Large Employer (ALE) complete Lines 14–16 of Form 1095-C for an ongoing employee who receives an offer of COBRA continuation coverage due to a reduction in hours? An ALE making an offer of COBRA continuation coverage to an ongoing employee who loses eligibility for non-COBRA coverage due to a reduction in hours (for instance, a change from full-time to part-time status resulting in loss of eligibility under the plan) should report the offer of COBRA coverage as an offer of coverage on Lines 14–16 of Form 1095-C.

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Form 1095-C Lines 14–16 Codes*

Line 14 – Offer of Coverage

Line 14 specifies the type of coverage, if any, offered to an employee, spouse and dependents. The code must indicate

the coverage the employee was offered; however, it may not match the coverage in which the employee is actually

enrolled. For example, if an employee is offered family coverage but enrolls in employee-only coverage, Line 14 must

indicate that the employee was offered family coverage. A code must be entered for each calendar month even if the

employee was not a full-time employee for one or more months. Alternatively, the “All 12 Months” box may be

completed if the same offer applies to all 12 months.

Line 15 – Employee Share of Lowest Cost Monthly Premium for Self-Only Minimum Value Coverage

Enter the amount of the employee share of the lowest cost monthly premium for self-only minimum essential coverage

(MEC) providing minimum value (MV) offered to the employee. This amount may not equal the amount the employee

is actually paying for coverage. For example, an employee enrolls in family coverage with a monthly premium of $200.00.

The monthly premium for employee-only coverage is $100.00 which is the amount that should be entered on Line 15.

Line 14 Code Descriptions Line 15 Entry

1A

Qualifying offer: Minimum Essential Coverage (MEC) providing Minimum Value (MV) offered to ful- time employee, and at least MEC offered to spouse and dependents. Employee contribution for self-only coverage is $93.18 or less (for 2015).

Leave blank

1B MEC providing MV offered to employee only Required

1C MEC providing MV offered to employee and at least MEC offered to dependents (no spouse) Required

1D MEC providing MV offered to employee and at least MEC offered to spouse (no dependents) Required

1E MEC providing MV offered to employee and at least MEC offered to dependents and spouse. (If employee contribution for self-only coverage is more than $93.18 for 2015, use Code 1E.)

Required

1F Offer of MEC NOT providing MV was made to employee, or employee and spouse or dependents, or employee, spouse and dependents

Leave blank

1G Offer of coverage to employee who was not a full- time employee for any month and who enrolled in self-insured coverage for one or more months

Leave blank

1H No offer of coverage to the employee, or the offer was not MEC Leave blank

1I

Qualifying Offer Transition Relief for 2015: Employee (and spouse or dependents) received no offer of coverage, received an offer that is not a qualifying offer, or received a qualifying offer for less than 12 months.

Leave blank

Line 16 – Applicable Section 4980H Safe Harbor

Line 16 provides an opportunity for an employer to indicate an exception to a penalty. Completing this line is optional,

however it is in the employer’s best interest to provide the information if it is applicable.

2A Employee not employed during the month 2F Section 4980H affordability Form W-2 safe harbor 2B Employee is not a full-time employee 2G Section 4980H affordability federal poverty line safe harbor 2C Employee enrolled in coverage offered 2H Section 4980H affordability rate of pay safe harbor 2D Employee is in a limited non-assessment period 2I Non-calendar year transition relief 2E Multiemployer interim rule relief

If more than one code applies to Line 16, use the following guidelines:

If 2E and any other Code series 2 applies, enter 2E

If 2C and any other Code series 2 applies other than Code 2E, enter 2C

If 2B and 2D apply, enter 2D

*Greatland Corporation does not provide tax, legal or accounting advice. This document has been prepared for informational

purposes only, and is not intended to provide, and should not be relied on for, tax, legal or accounting advice. You should consult your

own tax, legal and accounting advisors before engaging in any transaction.

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