Q. What is the 1095-B form and why does it matter to me?

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1 FAQ This tax season, certain Medicaid members will receive Form 1095-B from the Georgia Medicaid/ PeachCare for Kids program. Select members who receive their healthcare coverage through Fee-for-Service Medicaid or any one of the three Care Management Organizations (Amerigroup, Peach State, or WellCare) including Georgia Families 360, will receive this form from the Georgia Medicaid/PeachCare for Kids program. This form is required by the Internal Revenue Service (IRS) as a result of the Affordable Care Act (ACA). The following information is being provided to our members: The 1095-B form is an information form. Just like a W-2 form, it contains information that is required for completing your taxes. Also, like a W-2 form, the 1095-B form will be provided to the IRS to show the months you had healthcare coverage through the Georgia Medicaid/PeachCare for Kids program. In order to avoid possible delays with filing your taxes or with receiving your refund, it is extremely important for each member to make sure that the Division of Family and Children Services (DFCS) or the Social Security Administration (SSA), if you receive SSI, has his or her current address on file. The 1095-B form will be sent to the address on file as of December 31, If your address is not correct, this could result in a delay in filing your taxes or with receiving your refund. Q. What is the 1095-B form and why does it matter to me? A. The 1095-B form is an information form that lets you know which months during the previous calendar year you had healthcare coverage. Individuals who show proof that they had the required coverage are not liable for the penalty/fee imposed on those without such coverage. This information is also provided to the IRS. You will need this form beginning in Q. When will I receive my 1095-B form? A. The forms will be mailed out beginning the month of January The last forms will be mailed no later than January 31, Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

2 Q. May I receive the form electronically? A. Yes. You will have the option to download the form from the Georgia Medicaid/PeachCare for Kids website or from selecting the appropriate link on your Care Management Organization s (CMO) website. You will need to provide your consent to do so. You will be able to provide this consent from December 1, 2015 December 30, It is very important to update your address with DFCS as soon as possible. This will allow the Georgia Medicaid/PeachCare for Kids program to send you additional information concerning the 1095-B form and how to receive the form electronically. Q. What happens if I file my taxes without including the form? A. The 1095-B form does not have to be submitted at the same time you file your taxes. However, you must send the 1095-B form to the IRS as proof of healthcare coverage. If you do not show that you had the healthcare coverage required by the Affordable Care Act (ACA), you may be assessed a penalty/fee by the IRS. Q. What should I do to make sure I am not charged a penalty /fee by the IRS? A. You should do 3 things: 1. Make sure you have updated your address with the Division of Family and Children Services (DFCS) or the Social Security Administration (SSA), if you have SSI. If your address is not updated, you could experience a delay in receiving the 1095-B form and in filing your taxes. 2. Give the 1095-B form to your tax preparer. The tax preparer will use the form to prepare your taxes. 3. If you do not use a tax preparer, send in the form to the IRS. Q. Is this the only year I will receive this form? A. No. This form is a requirement of the Affordable Care Act (ACA). Each year, you will be required to show that you have the required healthcare coverage or you could be liable for a penalty/fee assessed by the IRS. Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

3 Q. Who will receive the 1095-B form? A. Each person who has received certain types of healthcare coverage through the Georgia Medicaid/PeachCare for Kids program during the previous calendar year. This includes persons who received their healthcare coverage through any one of the Care Management Organizations (Amerigroup, Peach State, or WellCare) including Georgia Families 360, and also individuals who received Supplemental Security Income (SSI). Q. Will my child receive Form 1095-B? A. Yes, if your child received healthcare insurance coverage through Georgia Medicaid/PeachCare for Kids, or any one of the Care Management Organizations (Amerigroup, Peach State, or WellCare), including Georgia Families 360, that child will receive a form. Q. What if I was only insured for part of the year? Will I still receive a 1095-B form? A. Yes. Anyone who was insured for any time during the previous calendar year will receive a 1095-B form. If you had healthcare coverage for even one day during the previous calendar year, you will receive Form 1095-B. Q. What is included on the form? A. So that you can see what the form will look like, a copy of the form is included at the end of these questions. The form will include: 1. Your name, the last four digits of your Social Security Number, and/or your date of birth; 2. The name, address, Employer Identification Number (EIN), and phone number for the Georgia Department of Community Health, 3. The months you had healthcare coverage through the Georgia Medicaid/PeachCare for Kids program during the previous calendar year. Q. Will Form 1095-B be made available in languages other than English? A. Currently, Form 1095-B will only be made available in English. For assistance in Spanish, please see your tax preparer or visit irs.gov/freefile or irs.gov. Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

4 Q. What do I do if I have not received a Form 1095-B? A. Certain member categories will not receive a 1095-B form. Those categories are: Medically Needy/ Spenddown Qualified Medicare Beneficiaries (QMB) Specified Low Income Medicare Beneficiaries (SLMB) Qualifying Individuals (QI1) Planning for Healthy Babies (P4HB) Presumptive Pregnant Woman Emergency Medical Assistance (EMA) Other Presumptively eligible categories If your situation does not fit any on this list, please call Georgia Medicaid/PeachCare for Kids at or your Care Management Organization (Amerigroup, Peach State, or WellCare). The phone numbers are listed below: WellCare: Q. What do I do if I lose my Form 1095-B? A. Please contact Georgia Medicaid/PeachCare for Kids at If you received your healthcare coverage through Amerigroup, Peach State, WellCare or Georgia Families 360, please contact your specific CMO. The phone numbers are listed below: WellCare: Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

5 Q. How can I get my 1095-B form mailed to my new address if I have recently moved? A. You must contact the Division of Family and Children Services (DFCS) at or if you receive SSI, please contact the Social Security Administration at to update your address. Q. If Form 1095-B is incorrect, will I receive a corrected form? A. If your name, social security number, or other demographic information is incorrect, you will need to contact DFCS at or Social Security at (TTY ). For other corrections, members should contact the Department of Community Health s Georgia Medicaid/PeachCare for Kids program at The representative will research your issue. If a correction is required, Georgia Medicaid/PeachCare for Kids program will make the update and send a corrected 1095-B form to you and the IRS. If there are changes to your healthcare coverage, you will automatically receive a corrected form. Final Tip: To avoid a delay in receiving your tax refund, update your address with your local county DFCS as soon as possible. This will ensure that you receive your form and all communications related to the form without delay. Contact information you may need: Social Security: DFCS: Georgia Medicaid/PeachCare for Kids : WellCare: Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

6 FAQ Esta temporada de impuestos, ciertos miembros de Medicaid recibirán el Formulario 1095-B del programa Georgia Medicaid/ PeachCare for Kids. Miembros selectos que reciben su cobertura de cuidado de la salud a través de Medicaid de pago por servicios o de cualquiera de las tres Organizaciones de administración de cuidado (Amerigroup, Peach State o WellCare) incluyendo Georgia Families 360, recibirán este formulario del programa Georgia Medicaid/PeachCare for Kids. Este formulario es requerido por el Internal Revenue Service (IRS) como resultado de la Ley del cuidado asequible (Affordable Care Act (ACA)). La siguiente información está siendo proporcionada a nuestros miembros: El formulario 1095-B es un formulario de información. Igual que un formulario W-2, este contiene información que se requiere para completar sus impuestos. Además, igual que un formulario W-2, el formulario 1095-B será proporcionado al IRS para mostrar los meses que usted tuvo cobertura de cuidado de la salud a través del programa Georgia Medicaid/PeachCare for Kids. Con el fin de evitar posibles retrasos con la presentación de su declaración de impuestos o con el recibo de su reembolso, es extremadamente importante que cada miembro se asegure de que la Division of Family and Children Services (DFCS) o la Social Security Administration (SSA), si usted recibe SSI, tenga su dirección actual en archivos. El formulario 1095-B será enviado a la dirección que está en archivos al 31 de diciembre de Si su dirección no es correcta, esto podría resultar en un retraso en la presentación de sus impuestos o el recibo de su reembolso. P. Qué es el formulario 1095-B y por qué tiene importancia para mí? R. El formulario 1095-B es un formulario de información que le permite saber cuáles meses durante el año calendario anterior usted tuvo cobertura de cuidado de la salud. Las personas que muestran prueba de que han tenido la cobertura requerida no son responsables por la penalidad/el cargo impuesto en las personas sin dicha cobertura. Esta información también es proporcionada al IRS. Usted necesitará este formulario a partir de P. Cuándo recibiré mi formulario 1095-B? R. Los formularios serán enviados por correo a principios del mes de enero de Los últimos formularios serán enviados por correo a más tardar el 31 de enero de Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

7 P. Puedo recibir el formulario por vía electrónica? R. Sí. Usted tendrá la opción de descargar el formulario desde el sitio web de Georgia Medicaid/PeachCare for Kids o al seleccionar el enlace apropiado en el sitio web de su Organización de administración de cuidado (Care Management Organization (CMO)). Deberá proporcionar su consentimiento para hacerlo. Podrá proporcionar este consentimiento desde el 1 de diciembre de 2015 hasta el 30 de diciembre de Es muy importante actualizar su dirección el DFCS lo más pronto posible. Esto permitirá que el programa Georgia Medicaid/PeachCare for Kids envíe su información adicional con respecto al formulario 1095-B y cómo recibir el formulario por vía electrónica. P. Qué pasa si hago mi declaración de impuestos sin incluir el formulario? R. El formulario 1095-B no tiene que ser presentado al IRS al mismo tiempo en que hace su declaración de impuestos. Sin embargo, debe enviar el formulario 1095-B al IRS como prueba de cobertura de cuidado de la salud. Si usted no demuestra que ha tenido la cobertura de cuidado de la salud requerida por la Ley de cuidado asequible (ACA), el IRS le puede cobrar una penalización/un cargo. P. Qué debo hacer para asegurarme de que el IRS no me cobre una penalización/un cargo? R. Debe hacer 3 cosas: 1. Asegúrese de haber actualizado su dirección con la Division of Family and Children Services (DFCS) o la Social Security Administration (SSA), si usted tiene SSI. Si su dirección no está actualizada, usted podría experimentar un retraso en el recibo del formulario 1095-B y la presentación de sus impuestos. 2. Entregue el formulario 1095-B a la persona que prepara sus impuestos. Esa persona usará el formulario para preparar sus impuestos. 3. Si no usa una persona que prepara sus impuestos, envíe el formulario al IRS. P. Es este el único año en que recibiré este formulario? R. No. Este formulario es un requisito de la Ley de cuidado asequible (ACA). Cada año, usted deberá mostrar que tiene la cobertura de cuidado de la salud requerida o podría ser responsable por una penalización/un cargo cobrado por el IRS. Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

8 P. Quién recibirá el formulario 1095-B? R. Cada persona que haya recibido ciertos tipos de cobertura de cuidado de la salud a través del programa Georgia Medicaid/PeachCare for Kids durante el año calendario anterior. Esto incluye personas que recibieron su cobertura de cuidado de la salud a través de cualquier de las Organizaciones de administración de cuidado (Amerigroup, Peach State o WellCare) incluyendo Georgia Families 360 y también personas que recibieron Supplemental Security Income (SSI). P. Recibirá mi hijo el Formulario 1095-B? R. Sí, si su hijo recibió cobertura de seguro de cuidado de la salud a través de Georgia Medicaid/PeachCare for Kids o cualquiera de las Organizaciones de administración de cuidado (Amerigroup, Peach State o WellCare), incluyendo Georgia Families 360, ese niño recibirá un formulario. P. Qué pasa si solo estuve asegurado parte del año? Aún recibiré un formulario 1095-B? R. Sí. Cualquier persona que estuvo asegurada por cualquier tiempo durante el año calendario anterior recibirá un formulario 1095-B. Si usted tuvo cobertura por incluso un día durante el año calendario anterior, recibirá el Formulario 1095-B. P. Qué está incluido en el formulario? R. Para que usted pueda observar cómo se verá el formulario, al final de estas preguntas se incluye una copia del formulario. El formulario incluirá: 1. Su nombre, los últimos cuatro dígitos de su número de Seguro Social y/o su fecha de nacimiento; 2. El nombre, la dirección del número de identificación de empleador (Employer Identification Number (EIN)) y el número telefónico del Georgia Department of Community Health, 3. Los meses que usted tuvo cobertura de cuidado de la salud a través del programa Georgia Medicaid/PeachCare for Kids durante el año calendario anterior. P. Estará disponible el Formulario 1095-B es idiomas distintos al inglés? R. Actualmente, el Formulario 1095-B solo estará disponible en inglés. Si necesita asistencia en español, consulte a la persona que prepara sus impuestos o visite irs.gov/freefile o irs.gov. Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

9 P. Qué debo hacer si no recibo un Formulario 1095-B? R. Ciertas categorías de miembros no recibirán un formulario 1095-B. Esas categorías son: Medically Needy/Spenddown Qualified Medicare Beneficiaries (QMB) Specified Low Income Medicare Beneficiaries (SLMB) Qualifying Individuals (QI1) Planning for Healthy Babies (P4HB) Presumptive Pregnant Woman Emergency Medical Assistance (EMA) Otras categorías presuntamente elegibles Si su situación no se ajusta a alguna en esta lista, llame a Georgia Medicaid/PeachCare for Kids al o a su Organización de administración de cuidado (Amerigroup, Peach State o WellCare). Los números telefónicos están listados a continuación: WellCare: P. Qué debo hacer si pierdo mi Formulario 1095-B? R. Póngase en contacto con Georgia Medicaid/PeachCare for Kids al Si usted recibió su cobertura de cuidado de la salud a través de Amerigroup, Peach State, WellCare o Georgia Families 360, póngase en contacto con su CMO específica. Los números telefónicos están listados a continuación: WellCare: Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

10 P. Cómo puedo recibir por correo mi formulario 1095-B en mi nueva dirección si me he mudado recientemente? R. Debe ponerse en contacto con la Division of Family and Children Services (DFCS) al o si recibe SSI, póngase en contacto con la Social Security Administration al para actualizar su dirección. P. Si el Formulario 1095-B está incorrecto, recibiré un formulario corregido? R. Si su nombre, número de seguro social u otra información demográfica está incorrecta, deberá ponerse en contacto con la DFCS al o el Seguro Social al (TTY ). Para otras correcciones, los miembros deben ponerse en contacto con el programa Georgia Medicaid/PeachCare for Kids del Department of Community Health al El representante investigará su problema. Si se requiere una corrección, el programa Georgia Medicaid/PeachCare for Kids hará la actualización y le enviará un formulario 1095-B corregido a usted y al IRS. Si hay cambios a su cobertura de cuidado de la salud, usted recibirá automáticamente un formulario corregido. Consejo final: Para evitar un retraso en el recibo de su reembolso de impuestos, actualice su dirección con su oficina local del condado de la DFCS lo más pronto posible. Esto garantizará que usted reciba su formulario y todas las comunicaciones relacionadas con el formulario sin retraso. Información de contacto que puede necesitar: Seguro Social: DFCS: Georgia Medicaid/PeachCare for Kids : WellCare: Georgia Department of Community Health 2 Peachtree Street NW, Atlanta, GA

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