Information for Completing Form 1095-C Lines 14–16*
Scenario: Employee, Dependents and Spouse; Hired Mid-Year; No Waiting Period; Qualifying
Offer
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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 with the employee contribution for self-only
coverage equal to or less than $93.18 for 2015, and that the employer offered the employee’s spouse and
dependents minimum essential coverage. Please replace all data with your employee data.
Example criteria
 Employee was hired full time on August 1 and enrolled in coverage for employee, dependents and
spouse upon hire
 There is no waiting period
 The premium is $80.00
Line 14
Jan
Feb
Mar
1H
1H
1H
2A
2A
2A
Line 15
May
June
July
Aug
Sept
Oct
Nov
Dec
1H
1H
1H
1H
1A
1A
1A
1A
1A
2A
2A
2A
2A
2C
2C
2C
2C
2C
at
Line 16
Apr
la
All 12
Months
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Explanation
 Code 1H is entered on Line 14 in January–July, since no offer of coverage was made in these months.
Code 1A is entered in August–December, since a qualifying offer was made to the employee, spouse
and dependents in these months. The employee contribution for self-only minimum value coverage is
$93.18 or less (for 2015).
 Line 15 is left blank in January–July, since there was no offer of coverage and therefore no associated
premium. Line 15 is left blank in August–December since a qualifying offer does not require the
employee contribution to be specified.
 Code 2A is entered on Line 16 in January–July indicating that the employee was not employed during
these months. Code 2C is entered in August–December, indicating that the employee enrolled in the
coverage offered.
*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.
What is the difference between Code 1A and Code 1E on Line 14 of Form 1095-C?
Code 1A Qualifying Offer is minimum essential coverage (MEC) providing minimum value offered to
a full-time employee with the employee contribution for self-only coverage equal to or less than 9.5%
of the mainland single federal poverty line and at least MEC offered to spouse and dependents. Code
1E is MEC providing minimum value offered to employee and at least MEC offered to dependents
and spouse. Code 1A is a subset of Code 1E, but has to be offered at a low price to be designated as
a Qualifying Offer. The employee contribution for self-only coverage must be less than 9.5% of the
mainland single federal poverty line. If MEC providing minimum value is offered to the employee,
and MEC is offered to the spouse and dependents with the employee contribution for self-only
coverage at a higher price, then the offer is not a Qualifying Offer and the Applicable Large Employer
(ALE) would enter Code 1E on Line 14. The ALE does not have to use Code 1A, but if the ALE uses
Code 1E then the ALE must also report the amount of the required employee contribution for the
self-only coverage on Line 15.
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
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Frequently Asked Questions
 How should information about the offer of coverage for the month in which an employee is hired
be reported on Form 1095-C?
Code 1H should be entered on Line 14 in the month the employee was hired, unless the offer of
coverage extended to every day of that month. For example, if an employee starts employment on
the 10th of the month, with the offer of coverage (if accepted) providing coverage also starting on the
10th of the month, the Applicable Large Employer (ALE) should indicate that the employee was not
offered coverage for that first month. The employer may be entitled to penalty relief for that month.
For instance, the first three months after an employee first becomes a full-time employee may be
treated as a limited non-assessment period if all applicable conditions are satisfied. Therefore, the
ALE should enter Code 2D on Line 16.
*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.
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.
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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.
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Line 14 Code Descriptions
Qualifying offer: Minimum Essential Coverage (MEC) providing Minimum Value (MV) offered to
1A 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).
1B MEC providing MV offered to employee only
1C MEC providing MV offered to employee and at least MEC offered to dependents (no spouse)
1D MEC providing MV offered to employee and at least MEC offered to spouse (no dependents)
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.)
1F Offer of MEC NOT providing MV was made to employee, or employee and spouse or
dependents, or employee, spouse and dependents
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
1H No offer of coverage to the employee, or the offer was not MEC
Qualifying Offer Transition Relief for 2015: Employee (and spouse or dependents) received no
1I offer of coverage, received an offer that is not a qualifying offer, or received a qualifying offer
for less than 12 months.
Line 15 Entry
Leave blank
Required
Required
Required
Required
Leave blank
Leave blank
Leave blank
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
2B
2C
2D
2E
Employee not employed during the month
Employee is not a full-time employee
Employee enrolled in coverage offered
Employee is in a limited non-assessment period
Multiemployer interim rule relief
2F
2G
2H
2I
Section 4980H affordability Form W-2 safe harbor
Section 4980H affordability federal poverty line safe harbor
Section 4980H affordability rate of pay safe harbor
Non-calendar year transition 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.