“WHICH CODE APPLIES TO THIS EMPLOYEE?”ACA Reporting

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EMPLOYEE TYPE

NOFORM

NOFORM

CURRENT YEAR

PRIOR YEAR

EMPLOYEETERMED IN

PLAN OFFERED METSTANDARDS OF MINIMUMESSENTIAL COVERAGE

OFFERED ATMINIMUM

VALUE?

2015 TRANSITION RELIEF

NO COVERAGE

EMPLOYEE’S MONTHLYCONTRIBUTION TOWARDSSELF-ONLY COVERAGE -IN RELATION TO THE FEDERALPOVERTY LINE:

> 9.5% ($93.18)

≤ 9.5% ($93.18)

ANY CODES A-E DETERMINED BY THE COBRACOVERAGE ELECTED

WHO WASOFFEREDCOVERAGE?

EMPLOYEEELECTEDCOBRA?

NO

YES

WAS EMPLOYEEELIGIBLE FORCOVERAGE?

More info on Series 1 Codes at bit.ly/how-to-1095-c