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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



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



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:

















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.



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.



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.





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.



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.



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.

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