Tax Credit Income

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Cape Coral, FL, 33990

Posted:

December 06, 2023

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DEPARTMENT OF HEALTH & HUMAN SERVICES

*** ********** *********

LONDON, KENTUCKY 40750-0001

App ID 416******* 1

NICHOLAS ULSCH Jan 04, 2023

***** ******* **** **

Fort Myers, FL 33905-6262

Application ID: 416*******

Plan Name: myBlue Bronze 2146

You must file a tax return if the enclosed Form 1095-A shows that you got advance payments of the premium tax credit. See Part III, Column C on your form.

Use Form 1095-A to complete “IRS Form 8962, Premium Tax Credit” with your federal income tax return when you file. If you don’t complete this step, you may have to pay back some or all of the advance premium tax credits you used last year.

Dear NICHOLAS ULSCH:

Because you and/or members of your household had Health Insurance Marketplace® coverage for all or some part of 2022, we’re required to provide you with the enclosed IRS Form 1095-A from the Marketplace. The form includes important information you’ll need to correctly fill out your federal income tax return for that year. This information also has been given to the Internal Revenue Service (IRS). After using this information for tax filing, please keep this form for your records.

You must file a tax return

You must file a federal income tax return if you or another member of your household received any advance payments of the premium tax credit in 2022 to lower premium costs, even if you don’t normally file a return. If advance payments are made on behalf of you or an individual in your family and you don’t file a tax return:

• You may have to pay back all or some of the advance payments of the premium tax credits you used.

• You won’t be eligible for advance payments of the premium tax credit or cost-sharing reductions to help pay for your Marketplace health coverage in future years.

When you file your tax return electronically or by mail, you must complete and file “Form 8962, Premium Tax Credit.” Use the information on the included Form 1095-A to complete Form 8962. The Form 1095-A also indicates which months of 2022 you and other members of your household had health coverage. You’ll need that information to complete your tax return. More information about Form 1095-A can be found in the “Instructions for Recipient” section on the back of the enclosed form. If you need Form 8962, visit IRS.gov/aca. Many people who signed up for Marketplace coverage can get free assistance with filling out their taxes. This may include free access to tax software programs, or free in-person assistance. For more information, visit IRS.gov/freefile or IRS.gov/VITA.

App ID 416******* 2

Why Form 1095-A is important

Form 1095-A includes:

• Information about you and any other members of your household who were enrolled in a Marketplace plan during 2022.

• Information about your Marketplace plan premium and other information you may need to fill out your federal income tax return and claim the Premium Tax Credit.

• The amount of any advance payments of the premium tax credit that we paid in 2022 to a health plan on your behalf or on behalf of other members of your household. To learn more about using your form, visit HealthCare.gov/tax-form-1095. You may need more information to complete your tax return Visit HealthCare.gov/tax-tool to get the additional information you need to figure out your premium tax credit if:

• You had changes in your household that you didn’t report to the Marketplace – like having a baby, moving, getting married or divorced, or losing a dependent.

• Your Form 1095-A has zeroes printed in Part III, column B for the months you had coverage. You can also visit IRS.gov to find more details in the Instructions for Form 8962. Changes to your Form 1095-A information

If you think information on the attached Form 1095-A is incorrect, call the Marketplace Call Center at 1-800-***-**** to find out how to get a corrected Form 1095-A. TTY users should call 1-855-***-****. It’s important to note that you may receive more than one Form 1095-A. This may happen if different members of your household had different health plans, you updated your coverage information during 2022, or you switched plans during 2022. Be sure to keep all Forms 1095-A with your important tax documents. You also may get Form 1095-B or Form 1095-C

If you or members of your household had coverage in 2022 through other programs or plans outside of the Marketplace, you may also get a “Form 1095-B, Health Coverage” or “Form 1095-C, Employer-Provided Health Insurance Offer and Coverage.” It’s important to follow the instructions on these forms, so you fill out your federal income tax return correctly.

NOTE: If you’re enrolled in another type of health coverage that qualifies as minimum essential coverage (for example, Medicare Part A) and received a Form 1095-B, you may no longer be eligible to receive financial assistance for your Marketplace plan. It’s important to contact the Marketplace and report any changes in your coverage as soon as possible.

For more information, visit HealthCare.gov/taxes/other-health-coverage. How to get help with your taxes

Many people can get free help to fill out their taxes. Visit IRS.gov/Individuals/Free-Tax-Return-Preparation-for-You-by-Volunteers to learn more about getting help. Using tax preparation software is the best and simplest way to file a complete and accurate tax return, as it guides individuals and tax preparers through the process and does all the math. Electronic filing options include IRS Free File for taxpayers who qualify, free volunteer assistance, commercial software, and professional assistance. If you need more information, visit HealthCare.gov/taxes or call the Marketplace Call Center. App ID 416******* 3

For more help

• Visit IRS.gov if you have questions about your taxes. Free tax help is available if you qualify through Free File or Volunteer Income Tax Assistance.

• Visit HealthCare.gov, or call the Marketplace Call Center at 1-800-***-**** for questions about the Marketplace. TTY users can call 1-855-***-****. You can also make an appointment with someone in your area who can help you. Information is available at LocalHelp.HealthCare.gov.

• Get help in a language other than English. Information about how to access these services is included with this notice and available through the Marketplace Call Center.

• Call the Marketplace Call Center to get this information in an accessible format, like large print, braille, or audio, at no cost to you.

Sincerely,

Health Insurance Marketplace

Department of Health and Human Services

465 Industrial Boulevard

London, Kentucky 40750-0001

Privacy Disclosure: The Health Insurance Marketplace® protects the privacy and security of the personally identifiable information (PII) that you have provided (see HealthCare.gov/privacy). This notice was generated by the Marketplace based on 45 CFR 155.230 and other provisions of 45 CFR part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace®. The Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on your application. If you have questions about this data, contact the Marketplace at 1-800-***-**** (TTY: 1-855-***-****). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1207. Nondiscrimination: The Health Insurance Marketplace® doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex (including sexual orientation and gender identity), or age. If you think you’ve been discriminated against or treated unfairly for any of these reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil Rights by calling 1-800-***-**** (TTY: 1-800-***-****), visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S. Department of Health and Human Services/ 200 Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201. Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services. App ID 416******* 4

This page is intentionally left blank.

CORRECTED

VOID

Form 1095-A

Department of the Treasury 20 22

Internal Revenue Service

Health Insurance Marketplace Statement

Do not attach to your tax return. Keep for your records.

Go to www.irs.gov/Form1095A for instructions and the latest information. OMB No. 1545-2232

Part I Recipient Information

1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name 4 Recipient's name 5 Recipient's SSN 6 Recipient's date of birth 7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth 10 Policy start date 11 Policy termination date 12 Street address (including apartment no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code Part II Covered Individuals

A. Covered individual name B. Covered individual SSN C. Covered individual date of birth

D. Coverage start date E. Coverage termination date 16

Part III Coverage Information

Month A. Monthly enrollment premiums B. Monthly second lowest cost silver plan (SLCSP) premium

C. Monthly advance payment of

premium tax credit

21 January

22 February

23 March

24 April

25 May

26 June

27 July

28 August

29 September

30 October

31 November

32 December

33 Annual Totals

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q Form 1095-A (2022) 718.98 859.23 718.98

718.98 859.23 718.98

8,627.76 10,310.76 8,627.76

FL 108266576 Florida Blue HMO (a BlueCross BlueShield FL compan NICHOLAS ULSCH xxx-xx-2380

01/01/2022 12/31/2022 11990 Bramble Cove Dr

Fort Myers FL US 33905

NICHOLAS ULSCH xxx-xx-2380 01/01/2022 12/31/2022

Form 1095-A (2022)

Instructions for Recipient

You received this Form 1095-A because you or a family member enrolled in health insurance coverage through the Health Insurance Marketplace. This Form 1095-A provides information you need to complete Form 8962, Premium Tax Credit (PTC). You must complete Form 8962 and file it with your tax return (Form 1040, Form 1040-SR, or Form 1040-NR) if any amount other than zero is shown in Part III, column C, of this Form 1095-A (meaning that you received premium assistance through advance payments of the premium tax credit (also called advance credit payments)) or if you want to take the premium tax credit. The filing requirement applies whether or not you’re otherwise required to file a tax return. If you are filing Form 8962, you cannot file Form 1040-NR-EZ, Form 1040-SS, or Form 1040-PR. The Marketplace has also reported the information on this form to the IRS. If you or your family members enrolled at the Marketplace in more than one qualified health plan policy, you will receive a Form 1095-A for each policy. Check the information on this form carefully. Please contact your Marketplace if you have questions concerning its accuracy. If you or your family members were enrolled in a Marketplace catastrophic health plan or separate dental policy, you aren’t entitled to take a premium tax credit for this coverage when you file your return, even if you received a Form 1095-A for this coverage. For additional information related to Form 1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and- Families/Health-Insurance-Marketplace-Statements.

Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), including the premium tax credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or call the IRS Healthcare Hotline for ACA questions 800-***-****). VOID box. If the “VOID” box is checked at the top of the form, you previously received a Form 1095-A for the policy described in Part I. That Form 1095-A was sent in error. You shouldn’t have received a Form 1095-A for this policy. Don’t use the information on this or the previously received Form 1095-A to figure your premium tax credit on Form 8962.

CORRECTED box. If the “CORRECTED” box is checked at the top of the form, use the information on this Form 1095-A to figure the premium tax credit and reconcile any advance credit payments on Form 8962. Don’t use the information on the original Form 1095-A you received for this policy.

Part I. Recipient Information, lines 1–15. Part I reports information about you, the insurance company that issued your policy, and the Marketplace where you enrolled in the coverage.

Line 1. This line identifies the state where you enrolled in coverage through the Marketplace.

Line 2. This line is the policy number assigned by the Marketplace to identify the policy in which you enrolled. If you are completing Part IV of Form 8962, enter this number on line 30, 31, 32, or 33, box a. Line 3. This is the name of the insurance company that issued your policy.

Line 4. You are the recipient because you are the person the Marketplace identified at enrollment who is expected to file a tax return and who, if qualified, would take the premium tax credit for the year of coverage.

Line 5. This is your social security number (SSN). For your protection, this form may show only the last four digits. However, the Marketplace has reported your complete SSN to the IRS.

Line 6. A date of birth will be entered if there is no SSN on line 5. Lines 7, 8, and 9. Information about your spouse will be entered only if advance credit payments were made for your coverage. The date of birth will be entered on line 9 only if line 8 is blank. Lines 10 and 11. These are the starting and ending dates of the policy. Lines 12 through 15. Your address is entered on these lines. Part II. Covered Individuals, lines 16–20. Part II reports information about each individual who is covered under your policy. This information includes the name, SSN, date of birth, and the starting and ending dates of coverage for each covered individual. For each line, a date of birth is reported in column C only if an SSN isn’t entered in column B. If advance credit payments are made, the only individuals listed on Form 1095-A will be those whom you certified to the Marketplace would be in your tax family for the year of coverage (yourself, spouse, and dependents). If you certified to the Marketplace at enrollment that one or more of the individuals who enrolled in the plan aren’t individuals who would be in your tax family for the year of coverage, those individuals won’t be listed on your Form 1095-A. For example, if you indicated to the Marketplace at enrollment that an individual enrolling in the policy is your adult child who will not be your dependent for the year of coverage, that child will receive a separate Form 1095-A and won’t be listed in Part II on your Form 1095-A.

If advance credit payments are made and you certify that one or more enrolled individuals aren’t individuals who would be in your tax family for the year of coverage, your Form 1095-A will include coverage information in Part III that is applicable solely to the individuals listed on your Form 1095-A, and separately issued Forms 1095-A will include coverage information, including dollar amounts, applicable to those individuals not in your tax family.

If advance credit payments weren’t made and you didn’t identify at enrollment the individuals who would be in your tax family for the year of coverage, Form 1095-A will list all enrolled individuals in Part II on your Form 1095-A.

If there are more than 5 individuals covered by a policy, you will receive one or more additional Forms 1095-A that continue Part II. Part III. Coverage Information, lines 21–33. Part III reports information about your insurance coverage that you will need to complete Form 8962 to reconcile advance credit payments or to take the premium tax credit when you file your return.

Column A. This column is the monthly premiums for the plan in which you or family members were enrolled, including premiums that you paid and premiums that were paid through advance payments of the premium tax credit. If you or a family member enrolled in a separate dental plan with pediatric benefits, this column includes the portion of the dental plan premiums for the pediatric benefits. If your plan covered benefits that aren’t essential health benefits, such as adult dental or vision benefits, the amount in this column will be reduced by the premiums for the non-essential benefits. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.

Column B. This column is the monthly premium for the second lowest cost silver plan (SLCSP) that the Marketplace has determined applies to members of your family enrolled in the coverage. The applicable SLCSP premium is used to compute your monthly advance credit payments and the premium tax credit you take on your return. See the instructions for Form 8962, Part II, on how to use the information in this column or how to complete Form 8962 if there is no information entered. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for the months, regardless of whether advance credit payments were made for these months.

Column C. This column is the monthly amount of advance credit payments that were made to your insurance company on your behalf to pay for all or part of the premiums for your coverage. If this is the only column in Part III that is filled in with an amount other than zero for a month, it means your policy was terminated by your insurance company due to nonpayment of premiums, and you aren’t entitled to take the premium tax credit for that month when you file your tax return. You must still reconcile the entire advance payment that was paid on your behalf for that month using Form 8962. No information will be entered in this column if no advance credit payments were made. Lines 21–33. The Marketplace will report the amounts in columns A, B, and C on lines 21–32 for each month and enter the totals on line 33. Use this information to complete Form 8962, line 11 or lines 12–23. January 2022

January 2022

Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.

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