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CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 1 of 17
January 9, 2015
Covered California provides an annual notice to Consumers, which includes a cover letter and the
Health Insurance Marketplace Statement (Form 1095-A), to provide the household coverage
information needed for tax filing purposes. The Form 1095-A is generated for each plan that is
effectuated (i.e., the first premium payment has been made) through Covered California during the
previous year, regardless if premium assistance was received. (This notice is not generated for
plans purchased through the Small Business Health Options Program, called SHOP). The cover
letter and the Form are generated in PDF format as a hardcopy (paper) document to mail to the
Consumer, and as an electronic document to be sent to the Secure Mailbox associated with the
Consumer’s account.
This Job Aid reviews functionality to view the notice and provides an overview of documents that
comprise the notice and is intended for Certified Enrollment Counselors (CECs), Certified Insurance
Agents (Agents), County Eligibility Workers (CEWs), Plan Based Enrollers (PBEs), and Service
Center Representatives (SCRs).
Secure Mailbox
Covered California mails a paper copy of the notice to the Consumer and sends the electronic copy
of the notice to the Secure Mailbox associated with the Consumer’s account. To view the notification
online, the Consumer must log into their Covered California account.
Once the Consumer has logged in,
clicking the Secure Mailbox link above
the Global Header navigates the
Consumer to their Inbox where they may
view, download and print their Form
1095-A.
Keep in mind the Consumer’s Secure
Mailbox link does not display for CECs,
CEWs, Agents, PBEs or SCRs viewing a
Consumer’s case.
Note: It may be necessary to download
software (for example, a free Adobe
Acrobat reader) to be able to view,
download, and print the document.
JOB AID: FORM 1095-A
Your destination for affordable,
quality health care, including Medi-Cal
JOB AID: FORM 1095-A
CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 2 of 17
There may also be a popup after the document
link is clicked to prompt the download of a font
package if applicable, to display text other than
English correctly.
Click the OK button to continue, if needed. Click
the Cancel button to cancel.
Documents and Correspondence Page
After the Form 1095-A notice is delivered
to the Consumer’s Secure Mailbox, the
notice can be viewed on the Documents
and Correspondence page for the case.
For SCRs and CEWs:
To view the notice, search and select the
Individual from the Administration Home
page, click the View Case button then
click the Documents & Correspondence
tab to navigate to the Documents and
Correspondence page where the notice
will be listed.
For Consumers, CECs, Agents and
PBEs:
To view the notice from the Consumer’s
case, click Summary on the Individual
Landing page, then click the Documents
and Correspondence tab to navigate to
the Documents and Correspondence
page where the notice will be listed.
CalNOD62A- Health Insurance
Marketplace Statement
The CalNOD62A notice is generated
annually for each Individual policy
purchased through Covered California in
the previous year. The Consumer will
JOB AID: FORM 1095-A
CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 3 of 17
receive a hardcopy (paper) notice in the mail and an electronic PDF copy is also available in the
Consumer’s Secure Mailbox.
The CalNOD62A notice is generated after the close of the tax year and includes the following
documents:
Cover Letter
A Form 1095-A Health Insurance Marketplace Statement for each plan (including plan
and plan level changes)
The notice is addressed to the household Tax Filer (or to the Primary Contact when no tax filer
information is available). The notice explains why the Consumer is receiving the notice, describes
how premium assistance affects tax filing, defines steps to reconcile premium assistance, identifies
ways to get help with tax filing, and includes the Form 1095-A Instructions for Recipient. The notice
advises Consumers to contact Covered California right away if they think there is a mistake on the
Form 1095-A and informs that Covered California cannot provide tax advice.
A draft copy of CalNOD62A is provided on the following pages:
JOB AID: FORM 1095-A
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JOB AID: FORM 1095-A
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JOB AID: FORM 1095-A
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JOB AID: FORM 1095-A
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JOB AID: FORM 1095-A
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JOB AID: FORM 1095-A
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Health Insurance Marketplace Statement (Form 1095-A)
CalHEERS uses all household coverage information for the previous calendar year to generate the
Form 1095-A for each effectuated Individual Covered California health insurance policy. The
information provided on the Form 1095-A is used for tax filing purposes to reconcile premium
assistance and claim tax credits. The information presented is also provided to the Internal Revenue
Service (IRS).
A separate Form 1095-A is generated per policy, including for each plan change or plan level
change (for example, when a bronze plan is changed to a silver plan), during the previous
enrollment year. When multiple Form 1095-As are generated for the same tax filing household, they
are bundled together as one notice.
If multiple families are enrolled in a
single qualified health plan (QHP),
a Form 1095-A is generated to
each Tax Filer (or Primary
Contact). For example, if a single
QHP is shared among two or more
households, each Tax Filer will
receive a separate Form 1095-A
which reports information about
their household’s enrollment in that
policy for tax filing purposes.
Form 1095-A is a two page IRS
document. Page 1 of the Form
provides the household coverage
information in three parts:
Recipient Information, Coverage
Household and Household
Information.
Page 2 provides the Instructions
for Recipient.
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Key Data Fields For Form 1095-A
Form 1095-A Part I Part I of the IRS Form 1095-A is prepopulated with recipient and policy information. Note the
term recipient refers to the Tax Filer or Primary Contact. Only the last four digits of social security
numbers of household members will display for security reasons.
JOB AID: FORM 1095-A
CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 13 of 17
Form 1095-A Part II Part II of the IRS Form 1095-A is prepopulated with information regarding members of the coverage
household. If there are more than five family members in the coverage household, additional pages
will be provided to continue this section.
Part III Part III of the IRS Form 1095-A is prepopulated with the Monthly Premium Amount, the Monthly
Premium Amount of Second Lowest Cost Silver Plan (SLCSP) and the Monthly Advance Payment of
the Premium Tax Credit (APTC), if any, for each month of the coverage year. If the household did
not receive APTC for a month, the field will be blank.
Consumers should be advised that Covered California has determined the Monthly Premium
Amount of SLCSP which applies to the household member’s coverage. The SLCSP was used to
compute the amount of APTC and the premium tax credit. Keep in mind that the notice is generated
regardless if premium assistance was received and that the Form 1095-A is populated with the
SLCSP regardless if the household accepted APTC.
JOB AID: FORM 1095-A
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JOB AID: FORM 1095-A
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Instructions for Recipient Page 2 of Form 1095-A provides instructions for the recipient. Consumers should be aware that the
information on the Form 1095-A is needed to complete IRS Form 8962, Premium Tax Credit (PTC),
for attachment to the Consumer’s IRS Form 1040, Form 1040A or Form 1040NR.
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CalNOD62B – Corrected Health Insurance Marketplace Statement
The CalNOD62B notice is only generated when corrections are made to information on the initial
Form 1095-A, as a result of data changes identified by CalHEERS. If a Consumer reports a mistake
on their Form 1095-A, Report a Change functionality can be used to update the data.
Changes for the previous year submitted via the Report a Change process made after the original
Form 1095-A has been generated may trigger a CalNOD62B. Keep in mind that changes to a
household member’s social security number or date of birth are retroactive to the beginning
coverage date for the member.
Note: If the update cannot be made
using the Report a Change
functionality (for example, Report a
Change for 2014 has ended), refer to
Covered California policy and
procedure for the appropriate process
for making the necessary CalHEERS
data changes so that the corrected
Form 1095-A can be generated for
the Consumer.
CalNOD62B is marked as a revision
and explains the Consumer is
receiving the corrected form because
a correction was made. The notice
advises Consumers that Covered
California cannot provide tax advice.
Note that the Tax Filer (or Primary
Contact) will not receive a
CalNOD62B unless data on their
initial Form 1095-A is corrected.
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Corrected Health Insurance Marketplace Statement (Form 1095-A) When CalNOD62B is generated due to a correction to the initial Form 1095-A, the Corrected
checkbox is marked on the updated Form 1095-A to identify it as a corrected version.
Notice Availability
The CalNOD62A (and the CalNOD62B, if necessary) is available in English, Spanish, Korean,
Vietnamese, or Chinese, and generated in the preferred language documented in the Consumer’s
case.
CalNOD62A is available on or before January 31st of each calendar year, beginning with
2015. The paper document is postmarked no later than January 31.
CalNOD62B, if generated for a correction to the initial Form 1095-A, is generated on a bi-
weekly basis as needed, when changes are identified, beginning in mid-February.
Paper Document Mailing Envelope
Covered California mails the paper copy of the notice to the Household Tax Filer or Primary
Contact’s mailing address. Envelopes used to mail the CalNOD62A and CalNOD62B display a
Covered California image and message in English, Spanish, Chinese, Vietnamese, and Korean
languages on the address side of the envelope, regardless of the notice print language.