Information for Completing Form 1095-C Lines 14–16*
Scenario: Employee and Dependents (no spouse); 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, and offered the employee’s dependents
minimum essential coverage. Please replace all data with your employee data.
All 12
Months
nd
Example criteria
 Full-time employee is terminated on May 8
 Employee was enrolled in coverage for employee and dependents (no spouse) when employed;
premium is $105.00
 Employee declines COBRA
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Line 14
1C
1C
1C
1C
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
la
Jan
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Explanation
 Code 1C is entered on Line 14 in January–April, since an offer of coverage was made to the employee
and dependents (no spouse) 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 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.
*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 parttime 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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
*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.
nd
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.