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Dispute Form 1095-A for Covered California
Consumer
If you need help in Spanish, or would like this form in Spanish, you can call 1-800-300-0213. If you
need help in a language other than English or Spanish, please see the final page of this document
for language-specific telephone numbers.
If you would like more information about Form 1095-A, please visit: www.coveredca.com.
If you would like more information about filing your taxes, please visit: www.irs.gov/aca.
Free tax advice is also available through Volunteer Income Tax Assistance at 1-800-906-9887 or if
you are over 60 years old there is free Tax Counseling for the Elderly at 1-800-906-9887.
Instructions:
You may use this form to dispute the information on the Form 1095-A or request a Form 1095-A if you did not
receive one. Based on any corrections you show on this form, Covered California will review and check the
new information you report. If, after review, Covered California determines that the updated information you
provided is correct, we will send you a new, corrected Form 1095-A. To help with our review, please include
any supporting documents with this form. Supporting documents could include invoices from your health plan
that show the amount of premium assistance (tax credits or APTC) you received and monthly premium you
paid, or Covered California notices that show how much premium assistance you were eligible for.
Do I have to use this form to make all changes to information on my Form 1095-A?
No. If you would like to correct any of the following information on your Form 1095-A, you may do so by calling
Covered California’s Service Center or contacting your local County Social Services office. You do not need
to complete this form for the following types of changes.
The information a Service Center Representative or local County Social Services official can change is:
Your name
Your date of birth
Your social security number
Your address
Why do I need to ensure the information is correct on my Form 1095-A?
Form 1095-A is used to report important information to the Internal Revenue Service (IRS) about your health
insurance bought through Covered California. The Form 1095-A also tells you how much premium assistance
(tax credits or APTC) your health plan got on your behalf during 2014. If you enrolled in a health plan through
Covered California but did not receive premium assistance, you will still receive a Form 1095-A from Covered
California to show you what months you had health insurance (this rule does not apply to individuals who
purchased Minimum Coverage Plans or health plans through Covered California’s Small Business Health
Options Program (SHOP)). All Covered California health plan consumers must use the information on the
Form 1095-A to complete IRS Form 8962: Premium Tax Credit. If you disagree with any of the information
shown on the Form 1095-A, you must report it to Covered California and you must send a corrected Form
8962 to the IRS if you already filed your taxes.
What is IRS Form 8962?
Form 8962 is a new IRS form that you will use to “reconcile” the premium assistance (tax credit or APTC)
amount your health insurance plan got (or how much you may get, if you did not get premium assistance in
advance) based on your estimated income for 2014 along with the amount that is determined based on your
actual income for 2014, as reported on your federal tax return. People who received premium assistance will
have to “reconcile” the premium amount they got based on their estimated income (this will be listed in their
Form 1095-A) with the amount that is determined based on their actual income as reported on their federal tax
return. For more information on IRS Form 8962, please visit: www.irs.gov/aca.