IRS Form 1095-B

The Internal Revenue Service (IRS) Form 1095-B is provided to each MC client who receives Minimum Essential Coverage (MEC) from the Department of Health Care Services (DHCS) for any month during the tax year. The form should be mailed out by DHCS no later than January 31 of each year.

According to Senate Bill 78, California residents must enroll and maintain MEC beginning January 01, 2020. If an individual does not have MEC and does not meet the requirements for exemption, they will be penalized. California Franchise Tax Board (FTB) is responsible for collecting penalties through the state tax filing process.

Clients will use Form 1095-B as proof of MEC under both the state and federal mandates when they file their state and federal taxes, but are not required to have the form as proof, as long as they self-attest to having MEC that year. MEC information is stored in IN95 screens in MEDS. A Form 1095-B in alternate formats such as large print, data CD, Braille and audio CD are available upon the client’s request.

The Department of Health Care Services (DHCS) stops mailing Form 1095-B to MEDS known deceased individuals starting in 2019 Tax Year. However, minimum essential coverage (MEC) data for the deceased individual will still be stored in MEDS and reported to the Internal Revenue Service (IRS).

Form 1095-B for deceased individuals can be requested through the existing 1095-B reprint process that is outlined in MEDS Handbook Chapter 1.

Note: Form 1095-B is sent to each person enrolled in an MC program that meets MEC, so households may receive more than one Form 1095-B.

Clients enrolled in MC programs that do not meet MEC or clients who have alien indicator codes that are excluded from MEC will not receive the Form 1095-B.

Form 1095-B MEC Aid Codes

MEC Aid Code	Description
03	AAP - Federal
04	AAP/AAC - Non-Federal
06	AAP Title IV-E Federal Medi-Cal
07	Federal EFC AAP/FFP Medi-Cal
08	Entrant Cash Assistance
0A	RCA (Exempt)
0D	Medi-Cal Access Program (MCAP) Pregnant Woman
0M	BCCTP Accelerated Enrollment 2 Mo.
0N	BCCTP Accelerated Enrollment
0P	BCCTP Federal Program
0W	BCCTP Transitional Medi-Cal (Post 0P)
10	Aged - SSI/SSP
14	Aged - MN No SOC
16	Aged - Pickle Eligible
1E	Craig v. Bonta -Aged
1H	Aged FPL - Full Scope
1X	MSSP Waiver., Spousal Impov., No SOC
20	Blind - SSI/SSP Cash
23	Blind - Long Term Care
24	Blind - MN No SOC
26	Blind - Pickle Eligible
2A	Abandoned Baby Program
2E	Craig v. Bonta - Blind
2H	Blind FPL - Full Scope
2P	ARC Funding only (State general fund)
2R	ARC Funding only for non-minor dependent (State general fund)
2S	ARC Funding Option + Federal CalWORKS (DSS)
2T	ARC Funding Option + State CalWORKS (DSS)
2U	ARC Funding Option + State CalWORKS for non-minor dependents
30	CalWORKs-AF
32	TANF Timed-Out (Federal)
33	CalWORKS-ZP
34	CalWORKs-MN
35	CalWORKs-U
36	Disabled Widow/ers
38	Edwards v. Kizer
39	Transitional Medi-Cal (TMC)
3A	CalWORKS Safety Net -Timed-Out - All Other Families
3C	CalWORKs Safety Net - Timed-Out - Two Parent Families
3D	CalWORKs Pending - MC eligible
3E	CalWORKs Legal Immig-Family Group - Mixed
3F	CalWORKs Two Parent Safety Net & Drug/Fleeing Felon Family
3G	CalWORKs - Zero Parent (ZP)- Exempt - State Only
3H	CalWORKs - ZP - Mixed
3L	CalWORKs Legal Immig.- Family Group - State
3M	CalWORKs Legal Immig.- Unemployed - State
3N	AFDC 1931(b) Non-CalWORKs
3P	CalWORKs - All Family - exempt
3R	CalWORKs - ZP - Exempt
3U	CalWORKs Legal Immig.- Unemployed Mixed
3W	TANF Timed-Out, Mixed Case (Federal)
40	AFDC - FC Non-Federal
42	AFDC - FC Federal
43	State EFC/FFP Medi-Cal
44	200% Pregnant
45	Foster Care Children - Public Funds
46	Out-of-State Foster Care Children
47	200% Infant Citizen
49	Federal EFC FC/FFP Medi-Cal
4A	AAP - Other State
4E	Hospital Presumptive Eligibility for Former FC Children up to age 26
4F	Kin-GAP Cash Assistance - Federal
4G	Kin-GAP Cash Assistance - State
4H	Foster Care Children in CalWORKs
4K	Emergency Assistance Foster Care - Probation
4L	Foster Care Children in 1931 (b)
4M	Extended MC Former Foster Care
4N	State CalWORKs Non-Minor Dependent (NMD)
4S	KinGAP NMD Title IV-E Federal/FFP Medi-Cal
4T	Federal KinGAP
4U	Former Foster Care - Optional Coverage Group
4W	KinGAP NMD State Cash/FFP Medi-Cal
54	Four Month Continuing
59	Additional TMC
5C	HFP to Medi-Cal Transitional PE - No Premium Age 1 to 19 100%-150%
5D	HFP to Medi-Cal Transitional PE - Premium Age 1 to 19 150%-250%
5E	HF AER Medi-Cal PE Under Age 19
5K	EA - FC Child Welfare
60	Disabled - SSI/SSP
63	Disabled - Long Term Care
63	Disabled - Long Term Care
64	Disabled - MN No SOC
66	Disabled - Pickle Eligible
6A	DAC - Blind
6C	DAC - Disabled
6E	Craig v. Bonta - Disabled
6G	250% Working Disabled
6H	Disabled FPL
6J	SB 87 Pending Disability No SOC
6N	NOT Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), No Longer Disabled (NLD) in SSI Appeal Status
6P	PRWORA NLD Children in SSI Appeal Status
6V	DDS Waiver No SOC - Disabled
6X	IHO Waivers No SOC - Disabled
72	133% Citizen Child 1through 5 Yrs.
76	60-Day Postpartum
7A	Citizen Child, Age 6 - 19, FPL 100% and below.
7J	CEC
7S	Express Lane Enrollment for Parent Caretaker Relatives
7U	Express Lane Enrollment For Adults
7W	Express Lane Enrollment For Children
7X	Medi-Cal to HF Bridge
82	MI - Children No SOC
86	MI - CP No SOC
8E	Accelerated Enrollment of Children or Temporary Placement of Pending MAGI Medi-Cal (01/2014)
8G	QSIWI (Qualified Severely Impaired Working Individual) Program
8P	Property Disregard - Citizen, Age 1 to 6, FPL 133% and below
8R	Property Disregard - Citizen, Age 6 to 19, FPL100% and below
8U	CHDP Deemed Infant - No SOC
8W	MI-AE-CHDP Gateway for Medi-Cal
8X	MI-AE-CHDP Gateway for Healthy Families.
E6	Medi-Cal Access Infant Program 0-2 Yrs >213% thru 266%
E7	Medi-Cal Access Infant Program 0-2 Yrs >266% Premium
G0	State Parolee Inmate
H0	Children's Hospital Presumptive (HP) Eligibility (60 days) FPL > 133% to 266% (6-19)
H1	MC Targeted Low Income FPL >200% up to 250% (Infants)
H2	MC Targeted Low Income FPL >133% up to 150% (Age 1-6)
H3	MC Targeted Low Income FPL >150% up to 250% (Age 1-6)
H4	MC Targeted Low Income FPL >100% up to 150% (Age 6-19)
H5	MC Targeted Low Income FPL >150% up to 250% (Age 6-19)
H6	Children's HP Eligibility (60 days) FPL >208% up to 266% (0-1)
H7	Children's HP Eligibility (60 days) FPL at or below 142% (1-6)
H8	Children's HP Eligibility (60 days) FPL at or below 133% (6-19)
H9	Children's HP Eligibility (60 days) FPL > 142%-266% (1-6)
J1	Compassionate Release County Full scope no SOC
J5	Compassionate Release County LTC Aged
J7	Compassionate Release County LTC Disabled
K1	CalWORKs One Parent Safety Net & Drug/Fleeing Felon Family
K2	State Medical Parole MAGI Adult 19-64, 0-138% FPL Citizen
K4	State Medical Parole MAGI Adult 19-64, 0-128% FPL, Disabled/Blind, Citizen
K6	County Compassionate Release MAGI Adult 19-64, <138% FPL,
K8	County Compassionate Release MAGI Adult 19-64, <128% FPL, Disabled/Blind, Citizen
L1	LIHP Transition
L6	ACA Adult 19 to 65 at or below 128% FPL, Citizen (CZ)
M1	Adult 19 to 65 Yrs at or below 138% FPL, CZ/Lawfully Present
M3	Parent/Caretaker Relative at or below 109% FPL: CZ/Lawfully Present
M5	Expansion Child from 6 to 19 Yrs 108% through 133% FPL, CZ/Lawfully Present
M7	Pregnant Women 0% through 138% FPL, CZ/Lawfully Present
M9	Pregnant Women >138 through 213% FPL CZ/Lawfully Present
P1	Hospital PE for Infant age 0-1 through 208% FPL
P2	Hospital Presumptive Eligibility Parent-Caretaker
P3	Hospital PE Adults (19 to 65 Yrs) at or below 138%
P5	ACA Child 6-19 yrs 0-108% FPL, CZ
P7	ACA Child 1-6 yrs 0-142% FPL, CZ
P9	ACA Infants 0-1 Yrs 0-208% FPL, CZ
T1	MAGI OTLIC Ages 6-19 Citizen 160-266% FPL, Premium
T2	MAGI OTLIC Ages 6-19 Citizen >133-160% FPL
T3	MAGI OTLIC Ages 1-6 Citizen 160-266% FPL, Premium
T4	MAGI OTLIC Ages 1-6 Citizen >142-160% FPL
T5	Medi-Cal OTLIC Infant Citizen >208-266% FPL

Form 1095-B Non-MEC Aid Codes

Non-MEC Aid Code	Description
01	Refugee Cash Assistance
02	Refugee/Entrant Medical Assistance
05	SED Children
09	Food Stamps
0F	Transitional FS (Food Stamps)
0L	BCCTP Trans. Medi-Cal Undocs (Post 0U/0V)
0R	BCCTP OHC/St Only 18 mo./24 mo.
0T	BCCTP State Only 18 mo./24 mo.
0U	BCCTP Undocs 18 mo./24 mo.
0V	Post BCCTP 0U Undocs
0X	BCCTP Trans. Medi-Cal Undocs due to OHC
0Y	BCCTP Trans. Medi-Cal Undocs due to age
11	Aged - Social Serv. Only
12	Aged - Spec. Circumstance
13	Aged - Long Term Care
17	Aged - MN SOC
1A	Aged - CAPI - Qualified Aliens
1U	Aged FPL - Restricted (Undoc.)
1V	TCVAP
1Y	MSSP Waiver, Spousal Impov., SOC
21	Blind - Social Serv. Only
22	Blind - Spec. Circumstance
27	Blind - MN SOC
2C	County Children’s Health Insurance Program (C-CHIP) >266 thru 322% 0-19 years old
2F	Blind-PCSP--Other Public Assist
2K	CFCO
2L	IHSS Plus Waiver
2M	IHSS Personal Care Services Program
2N	IHSS Residual
2V	TCVAP
31	CalWORKs-FG-Social Srvcs. Only
37	AFDC - MN SOC
3S	CalWORKs RegDP
3T	Transitional Medi-Cal Undoc
3V	Section 1931(b) Medi-Cal Undocs
41	AFDC - FC Social Serv. Only
48	200% Pregnant OBRA
4C	Supportive Trans. Emancipation Prog. (STEP)
4D	Automated District Attorney Match
4P	CalWORKs Family Reunif.-All Families
4R	CalWORKs Family Reunif. 2 Parents
4V	TCVAP-RMA
50	CMSP Undoc. Alien
51	MIA - Long Term Care
55	Undoc. Aliens - LTC
58	OBRA Alien
5F	Undoc. Alien Preg. Women
5J	SB 87 Pending Disab. No SOC Undoc
5R	SB 87 Pending Disability SOC Undoc
5T	Addl. Trans. Medi-Cal Undoc
5V	TCVAP
5W	Four Month Continuing Undoc
61	Disabled - Social Serv. Only
62	Disabled - Spec. Circum.
65	Hurricane Katrina Evacuees
67	Disabled - MN SOC
68	Inactive
69	200% Infant OBRA
6K	CAPI - Non-Qualified Aliens
6L	RMA 133% - 200% FPL- Not Implemented
6M	CAPI - Sponsored Aliens
6R	SB 87 Pending Disability SOC
6S	Disabled - SGA/ABD-MN (IHSS) - SOC/NO SOC
6T	CAPI - Limited Term Qualified Aliens
6U	Disabled FPL - Restricted (Undoc.)
6W	Disabled - DDS Waiver SOC
6Y	Disabled - IHO Waivers SOC
71	Dialysis & Supplemental
73	TPN & Supplemental
74	133% Undoc. Child 1through 5 Yrs.
77	Organ Transplant-Anti-rejection meds
7C	100% Undoc. Child 6-18 Yrs.
7D	RCA to MAGI Bridge
7F	Presumptive Elig. Preg. Neg.
7G	Presumptive Elig. Preg. Pos.
7H	Tuberculosis Program
7K	CEC - Restricted (Undocs)
7L	ELE Disabled Adults at or below 128% FPL, No Medicare
7M	Minor Consent Restricted Svcs - Sexually Trans. Disease, Drug/Alcohol Abuse
7N	Minor Consent (MC) (under age 21) - All Preg. Related Services
7P	Minor Consent (MC) (age 12-21) - Outpatient Mental Health
7R	Minor Consent (MC) (under age 12) - Family Planning, Sexual Assault
7T	TCVAP
7V	Express Lane Enrollment - Do Not Use Until Further Research
80	QMB
81	MIA - Aid Paid Pending
83	MI - Children SOC
84	MI - Adult No SOC
85	MI - Adult SOC
87	MI - CP SOC
88	MI - A - Disabl. Pend. No SOC
89	MI - A - Disabl. Pend. SOC
8A	QDWI
8C	SLMB
8D	Qualifying Individual-1
8F	CMSP Companion A/C for A/C 53
8H	Family PACT 1115 Federal Waiver
8N	Property Disregard 133% Undoc. Age 1 through 5
8T	Property Disregard 100% Undoc. Age 6 through18
8V	CHDP Deemed Infant - SOC
8Y	CHDP State Only - Undoc.
90s	Aid Codes 90-99 (GR/GA for county use)
9A	Breast Cancer Early Detection
9C	Expanded Access to Primary Care
9D	CCS Only Child Targeted for HCP Enrollment
9E	Limits IEVS match to EDD
9F	Limits IEVS match to FTB
9G	GR/GA (for county use)
9H	Healthy Families Child
9J	GHPP Eligible
9K	CCS Health Access Program (HAP)
9M	CCS Medical Therapy Program
9N	CCS Case Management
9R	CCS Eligible HF Child
9S	Limits IEVS match to SSA
9T	Healthy Families Adult
9U	CCS Eligible HF Child - NPSA
9V	HAP PPCW Participant not eligible for CCS
9W	HAP PPCW Participant eligible for CCS
9X	FC Ineligible
C1	Aged Limited
C2	Aged Limited SOC
C3	Blind Limited
C4	Blind Limited SOC
C5	AFDC Limited
C6	AFDC Limited SOC
C7	Disabled Limited
C8	Disabled Limited SOC
C9	MI Child Limited
D1	MI Limited Child SOC
D2	Aged LTC Limited
D3	Aged LTC Limited SOC
D4	Blind LTC Limited
D5	Blind LTC Limited SOC
D6	Disabled LTC Limited
D7	Disabled LTC Limited SOC
D8	MI Pregnant Limited
D9	MI Pregnant Limited SOC
E1	Medi-Cal t/HF Bridge- Unverified Citizen To Be Deactivated
F0	HCCI New
F1	Medi-Cal State Inmate Inpatient Hospital Only
F2	Medi-Cal State Inmate Undoc Inpatient Hospital Pregnancy + ESO
F3	Medi-Cal County Inmate Inpatient Hospital Only
F4	Medi-Cal County Inmate Undoc Inpatient Hospital Pregnancy + ESO
F5	MCE State Inmates Inpatient Hospital Only
F6	MCE County Inmates Inpatient Hospital Only
F7	MCE Existing
F8	MCE New
F9	HCCI Existing
G1	State Juvenile Inmate Inpatient Hospital & Inpatient MH
G2	State Juvenile Inmate ESO Inpatient Hospital MH & Pregnancy
G3	Medi-Cal County Inmate SOC Inpatient Hospital Only
G4	Medi-Cal County Inmate Undoc SOC Inpatient Hospital Only Pregnancy + ESO
G5	County Juvenile Inmate Inpatient Hospital & Inpatient MH
G6	County Juvenile Inmate Undoc ESO Inpatient Hospital MH & Pregnancy
G7	County Juvenile Inmate SOC Inpatient Hospital & Inpatient MH
G8	County Juvenile Inmate Undoc SOC ESO Inpatient Hospital, MH & Pregnancy
G9	State Medical Parolee Undoc Pregnancy & ESO
IE	Ineligible Designation for County ID Only
J2	Compassionate Release Full scope SOC
J3	County Medical Probation Restricted no SOC
J4	County Medical Probation Restricted SOC
J6	Compassionate Release County Restricted LTC Aged
J8	Compassionate Release County Restricted LTC Disabled
K3	State Medical Parole MAGI Adult 19-64, 0-138% FPL Undoc
K5	State Medical Parole MAGI Adult 19-64, 0-128% FPL, Disabled/Blind Undoc
K7	County Compassionate Release MAGI Adult 19-64, 0-138% FPL, Undoc
K9	County Compassionate Release MAGI Adult 19-64, 0-128% FPL, Disabled/Blind Undoc
L0	TBD: Hold for Pregnant NQI - Cancelled
L3	Deduction when IHSS SOC exceeds IHSS need
L7	ACA Adult 19 to 65 at or below 128% FPL, Undocumented
M0	Pregnant Women >138 through 213% FPL, Undocumented
M2	Adult 19 to 65 Yrs at or below 138% FPL, Undocumented
M4	Parent/Caretaker Relative at or below 109% FPL: Undocumented
M6	Expansion Child from 6 to 19 Yrs 108% through133% FPL, Undocumented
M8	Pregnant Women 0% through 138% FPL, Undocumented
N0	LIHP Transition - County Inmate
N5	Limited Scope Medi-Cal No SOC State Adult Inmate (19 to 64 yrs old)
N6	Restricted Scope Medi-Cal No SOC State Adult Inmate (19 to 64 yrs old)
N7	Limited Scope Medi-Cal No SOC Cty Adult Inmate (19 to 64 yrs old)
N8	Restricted Scope Medi-Cal No SOC Cty Adult Inmate (19 to 64 yrs old)
N9	LIHP Transition - State Inmate
P0	ACA Infants 0-1 Yrs 0-208% FPL, Undocumented
P4	Hospital PE Pregnant Women at or below 213%
P6	ACA Child 6-19 0-108% FPL Undocumented
P8	ACA Child 1 to 6 Yrs 0%-142% FPL Undocumented
R1	CalWORKS TCVAP Trafficking Victims
R2	F/S TCVAP
R3	F/S S/O CFAP Food Stamps
R4	WINS-1P CalFresh Plus PA $10 Supplement Benefit
R5	WINS-2P CalFresh Plus PA $10 Supplement Benefit
R6	WINS-CFAP CalFresh Plus PA $10 Supplement Benefit
R7	WINS TCF non-2 parent/caretaker family
R8	WINS TCF 2 parent/caretaker family
R9	WINS TCF CFAP
RR	Responsible Relative Designation for County ID Only
T0	Medi-Cal OTLIC Infant Undoc >208-266% FPL
T6	Medi-Cal OTLIC Ages 6-19 Undoc 160-266% FPL Prem
T7	Medi-Cal OTLIC Ages 6 -19 Undoc >133-160% FPL
T8	Medi-Cal OTLIC Ages 1-6 Undoc 160-266% FPL Prem
T9	Medi-Cal OTLIC Ages 1-6 Undoc >142-160% FPL Prem
X1	Covered CA - Subsidized Coverage (250-400 FPL)
X2	Covered CA - Subsidized Coverage (100 to 150 FPL)
X3	Covered California Subsidized Cov. (151-200 FPL)
X4	Covered California Subsidized Cov. (201-250 FPL)
X5	Covered CA - Cost Sharing Waiver (100-300 FPL)
X6	Covered CA - AI/AN CSR Only No Income Test
X7	Covered CA – Unsubsidized Coverage (above 400 FPL)
X8	Covered CA - Lawful Present/MC ineligible <100% FPL
X9	Covered CA - “Narrow Bridge” Program < 200% FPL

Refer to MEDS Chapter 1.11.6 for alien indicator codes with a description displayed on the Alien Indicator Exclusion Table

These programs include:

Restricted-scope MC.
MC with a SOC.
Limited coverage programs including:
- Tuberculosis,
- Minor Consent,
- Dialysis,
- Family Planning, Access, Care, and Treatment (Family PACT), and
- Parenteral Hyperalimentation.

Correcting Form 1095-B

If the information on the 1095-B is incorrect, the EW should make any necessary changes in CalSAWS, CalHEERS, and/or MEDS. After making the changes or corrections, the corrected Form 1095-B is automatically generated and sent to the client, and the corrected data is transmitted to the IRS and FTB.

Changes within a MEDS record that qualify as a correction are:

A new or corrected SSN (pseudo to SSN, update incorrect SSN to correct SSN)
Any change in aid codes for any given month that will add or remove MEC status (i.e., IE to aid code M1)
A name change if the change occurred after an original Form 1095-B was reported to IRS. In some instances, the client may have the correct name in MEDS, but not in IRS data file (i.e., married and changed last name)

Note: Corrections of names and addresses made, directly, to IN9D screen only will not be updated on MEDS screens (i.e., INQM, INQ1)

Request Reprints

When there is a pending reprint on IN95 record in MEDS, the EW should cancel the pending reprint prior to request another reprint.

A beneficiary who requests to have their Form 1095-B reprint with an Address Override the current MEDS address (Reprint Type ‘T’) in [IN9D] screen, mailed to someone other than themselves, their parents, legal guardians or Authorized Representatives, must submit a written authorization. Written requests can be made by regular mail or other forms of written communications (i.e., email, fax, scanned, etc.), or over the phone via telephonic signatures to authorize the release of the Form1095-B to a designated individual.

If there is no 1095-B form generated for the selected tax year, the EW should check for a MEC aid code, an alien indicator code on INQE screen, or IRS transmission status on INDS screen.

Social Security Administration (SSA)

Individuals on SSI/SSP may end up calling us instead of the SSA. If there is incorrect information on the Form 1095-B, these clients should contact SSA at:

SSA Toll-Free Contact Number: 1-800-772-1213
SSA County Office Locator website

Client Questions

EWs should answer any questions related to the Form 1095-B. However, THE EW MUST NOT PROVIDE ANY TAX ADVICE OR HELP CLIENTS COMPLETE ANY TAX FORMS. There are several resources available to assist clients with tax information:

DHCS 1095-B Website and Help Desk

DHCS 1095-B Website
Phone: 1-844-253-0883 (MC Helpdesk for clients)

IRS

IRS ACA Website
1-800-829-1040

Volunteer Income Tax Assistance (VITA)

1-800-906-9887

Tax Counseling for the Elderly (TCE)

1-800-906-9887

The Federal Healthcare Exchange

www.healthcare.gov