Governor Chris Christie • Lt. Governor Kim Guadagno  
The Official Web Site For The State of New Jersey - Department of Treasury
Global Navigation
FAQs Departments/ Agencies Services A to Z NJ Home Page
Disclaimer
Twitter YouTube Facebook
Pensions and Benefits
FORM 1095-C
EXAMPLE AND EXPLANATION

In March 2010, Congress passed the Health Care and Education Reconciliation Act (HCERA) of 2010 and the Patient Protection and Affordable Care Act (PPACA) – collectively referred to as the Affordable Care Act. The Affordable Care Act requires certain employers to offer health insurance coverage to full-time employees and their dependents. Those employers must send an annual statement to all employees eligible for coverage describing the insurance offered to them, beginning this year. The Internal Revenue Service (IRS) created Form 1095-C to serve as that statement.

By February 1, all State employees enrolled in the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP) for coverage year 2016 should receive personalized 1095-C statements from Centralized Payroll. A sample 1095-C form is below.

State employees can log on to myNewJersey to access digital copies of their 1095-C forms and answers to ACA/1095-C FAQs at Employee Self Service – NJ. The IRS also offers extensive information on both the 1095-C form and the Affordable Care Act online at www.irs.gov State employees with further questions about their 1095-C statement or the Affordable Care Act benefit disclosure requirement should contact their agency payroll representatives.

Local employees enrolled in SHBP or SEHBP will receive 1095-C forms from their employer, not Centralized Payroll.  Local employees should direct any questions on their 1095-C statement or the Affordable Care Act benefit disclosure requirement to their employer certifying officer.

When you receive your Form 1095-C, please check the information carefully. Listed below is an example of Form 1095-C.


Click on an area of the form to view information about that part of the form.

payer copy information box 4

Part I. Employee, lines 1–13: reports information about the member carrying the coverage.

 

Part II. Employee Offer and Coverage, lines 14–16: provides information for employer-sponsored the coverage

 

Part III. Covered Individuals, lines 17–22: lists the name and information for each covered individual during the tax year.

  • For each covered individual there is a box that will be checked if the person was covered by the SHBP/SEHBP for all 12 months of the year.
  • If an individual's SHBP/SEHBP coverage ended or was no longer the primary coverage for the full year (i.e., Medicare became the primary coverage mid-year), there is a box for each month; the months the person was covered by the SHBP/SEHBP only will be checked.

 

IRS 1095-C Instructions for Recipient

Return to Top

 

 
spacer

Pensions and Benefits: Home | Employer Manual | Health Benefits | Forms and Publications | Counseling Appointments
Treasury: Home | ServicesPeopleBusinesses | Divisions/AgenciesFormsContact Us
Statewide:
NJ Home | Services A to Z | Departments/Agencies | FAQs
Copyright © State of New Jersey, 1996 -
This site is maintained by the Division of Pensions and Benefits.
 

Reports Accessibility Statement Legal Statement Privacy Notice Contact Us Open Public Records Act Proposed Rules and Amendments Comment or Petition for new Rule Division/Ageny Statutes and Rules Electronic Notification Twitter YouTube Facebook