Form 1095-B – Important Health Coverage Information for Your 2015 Taxes

Under the Affordable Care Act (ACA), you are required to verify on your federal income tax return that you, and your spouse and/or individuals you claim as dependents, had qualifying health coverage (referred to as "minimum essential coverage") for some or all months during the tax year. Individuals who did not have minimum essential coverage and do not qualify for an exemption may have to pay a penalty known as the "individual shared responsibility payment." You must verify your qualifying health coverage or report your shared responsibility payment on line 61 of Form 1040, line 38 of Form 1040A or line 11 of Form 1040EZ. What is Form 1095-B? Form 1095-B provides information about your Horizon Blue Cross Blue Shield of New Jersey health insurance coverage to help you properly prepare your tax return for the Internal Revenue Service (IRS). Form 1095-B reports the names, addresses and Social Security Numbers (SSNs) of individuals covered under a fully-insured health plan and the number of months each member had coverage from January 1, 2015 through December 31, 2015. You do not need to attach Form 1095-B to your federal income tax return. Why are You Receiving this Form? You received Form 1095-B because either you bought your coverage directly from Horizon BCBSNJ and not through Healthcare.gov OR you have Horizon BCBSNJ coverage through your fully-insured employer. Form 1095-B includes the following information for you and, if applicable, your covered dependents:

• Name(s)
• Last four digits of the SSNs
• Date(s) of birth (if SSNs not available)
• Months of health insurance coverage with Horizon BCBSNJ

If you had Horizon BCBSNJ coverage through your employer during the tax year, see the Employer-Sponsored Coverage section (Part II) for information about your employer-sponsored coverage in 2015 on the form. Part III on the form, Issuer or Other Coverage Provider, reports information about Horizon BCBSNJ. Horizon BCBSNJ will report to the IRS the months that you and your covered dependents had qualifying health coverage through Horizon BCBSNJ. Horizon BCBSNJ can only provide you with the months that you and your qualified dependents had Horizon BCBSNJ coverage. What You Need to Do

• Talk to your tax professional, if you have one, for information on how to complete your tax return.
• Review the information contained in Form 1095-B for accuracy when you receive it.
• If your information is incorrect, please call Member Services at the number on the back of your member ID card.
• You do not need to attach Form 1095-B to your federal income tax return.

For More Information For more information about the shared responsibility payment under the ACA, visit irs.gov/Affordable-Care-Act/Individuals-and-Families/Individual-Shared-Responsibility-Provision. You may also visit HorizonBlue.com/faqs and click the Social Security Number Solicitation and Reporting link on the left side of the page. Horizon BCBSNJ cannot provide tax advice; if you need help, please contact your tax advisor or consult the IRS with specific questions.