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<h1><img width="151" height="57" style="width:1.5694in;height:.5972in" id="Picture_x0020_1" src="cid:image004.png@01D81854.1D5EEF30"><o:p></o:p></h1>
<p class="MsoNormal"> <o:p></o:p></p>
<p class="MsoNormal"><o:p> </o:p></p>
<p class="MsoNormal"><span style="font-family:"Arial",sans-serif">February 2, 2022<o:p></o:p></span></p>
<p class="MsoNormal"><o:p> </o:p></p>
<table class="MsoNormalTable" border="0" cellspacing="0" cellpadding="0" width="642" style="width:481.5pt;margin-left:-4.5pt;border-collapse:collapse">
<tbody>
<tr>
<td width="91" valign="top" style="width:68.3pt;padding:0in 5.4pt 0in 5.4pt">
<p class="MsoNormal" style="mso-margin-top-alt:3.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in">
<span style="font-family:"Arial",sans-serif">To:<o:p></o:p></span></p>
</td>
<td width="551" valign="top" style="width:413.2pt;padding:0in 0in 0in 0in">
<p class="MsoNormal" style="mso-margin-top-alt:3.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:5.3pt">
<span style="font-family:"Arial",sans-serif">Department Benefits Representatives (DBRs)<o:p></o:p></span></p>
</td>
</tr>
<tr>
<td width="91" valign="top" style="width:68.3pt;padding:0in 5.4pt 0in 5.4pt">
<p class="MsoNormal" style="mso-margin-top-alt:3.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in">
<span style="font-family:"Arial",sans-serif">From:<o:p></o:p></span></p>
</td>
<td width="551" valign="top" style="width:413.2pt;padding:0in 0in 0in 0in">
<p class="MsoNormal" style="mso-margin-top-alt:3.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:5.3pt">
<span style="font-family:"Arial",sans-serif">HR Benefits Office on behalf of the UC Office of the President<o:p></o:p></span></p>
</td>
</tr>
<tr>
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<p class="MsoNormal" style="mso-margin-top-alt:3.0pt;margin-right:0in;margin-bottom:3.0pt;margin-left:0in">
<span style="font-family:"Arial",sans-serif">Re:<o:p></o:p></span></p>
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<b><span style="font-family:"Arial",sans-serif;color:#002060">Availability of 1095 Employer Benefits Enrollment Tax Forms for 2021</span></b><span style="font-family:"Arial",sans-serif"><o:p></o:p></span></p>
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<p class="MsoNormal" style="text-autospace:none"><b><span style="font-family:"Arial",sans-serif"> </span></b><span style="font-family:"Arial",sans-serif"><o:p></o:p></span></p>
<p class="MsoNormal" style="text-autospace:none"><span style="font-family:"Arial",sans-serif">In accordance with requirements of the Affordable Care Act (ACA) and various reporting requirements of other jurisdictions, UC employees will receive 1095-B and/or
1095-C forms verifying their health coverage for 2021. The forms are for employees’ information and records only; the forms are not filed with tax returns.<o:p></o:p></span></p>
<p><b><span style="font-family:"Arial",sans-serif;color:#002060">General Reminders regarding 1095-Cs and 1095-Bs</span></b><b><span style="font-family:"Arial",sans-serif;color:#002060">:
</span></b><span style="font-family:"Arial",sans-serif;color:#002060"><o:p></o:p></span></p>
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<li class="MsoNormal" style="margin-bottom:6.0pt;mso-list:l2 level1 lfo2"><span style="font-family:"Arial",sans-serif">Employees defined as full-time under the ACA (those who work 75% time or more) will receive the 1095-C from UC. Parts I and II of the 1095-C
will be populated for all employees; only those enrolled in UC’s self-insured plans (Core, Health Savings Plan, UC Care, the Resident program administered by UC Health) will have Part III populated.<o:p></o:p></span></li></ul>
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<span style="font-family:"Arial",sans-serif"> <o:p></o:p></span></p>
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<li class="MsoNormal" style="margin-bottom:6.0pt;mso-list:l2 level1 lfo2"><span style="font-family:"Arial",sans-serif">Employees defined as not full-time under the ACA who are plan members of UC’s self-insured plans (Core, Health Savings Plan, UC Care, the
Resident program administered by UC Health) will receive Form 1095-B.<o:p></o:p></span></li><li style="mso-list:l2 level1 lfo2"><span style="font-family:"Arial",sans-serif">All plan members of UC’s fully insured plans (Health Net and Kaiser Permanente) will receive Form 1095-B directly from the plan. <o:p></o:p></span></li></ul>
<p><b><span style="font-family:"Arial",sans-serif;color:#002060">Below is the current status (as of 1/21/22) for Form 1095s issued by UC:</span></b><span style="font-family:"Arial",sans-serif;color:#002060"><o:p></o:p></span></p>
<p><b><span style="font-family:"Arial",sans-serif;color:#002060">For 2021 Active Employees:</span></b><span style="font-family:"Arial",sans-serif;color:#002060"><o:p></o:p></span></p>
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<span style="font-family:"Arial",sans-serif">All forms will be sent via paper copy – no electronic copies will be available for the 2021 tax year. Employees should expect to receive their 1095s over the next few weeks (USPS delays notwithstanding).<o:p></o:p></span></li></ul>
<p><b><span style="font-family:"Arial",sans-serif;color:#002060">For COBRA Members:</span></b><span style="font-family:"Arial",sans-serif;color:#002060"><o:p></o:p></span></p>
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<span style="font-family:"Arial",sans-serif">UC Care, Core and HSP: COBRA members in self-insured plans will be sent via paper copy – no electronic copies will be available for the 2021 tax year. Employees should expect to receive their 1095s over the next
few weeks (USPS delays notwithstanding).<o:p></o:p></span></li><li class="MsoNormal" style="mso-margin-top-alt:auto;mso-margin-bottom-alt:auto;mso-list:l4 level1 lfo4">
<span style="font-family:"Arial",sans-serif">Kaiser Permanente, UC Blue & Gold: COBRA members in fully-insured plans will receive paper copies directly from the carriers.<o:p></o:p></span></li></ul>
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<b><span style="font-family:"Arial",sans-serif;color:#002060">Other Jurisdiction Reporting:</span></b><span style="font-family:"Arial",sans-serif;color:#002060"><o:p></o:p></span></p>
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<li class="MsoNormal" style="margin-bottom:6.0pt;mso-list:l1 level1 lfo5"><span style="font-family:"Arial",sans-serif">In addition to filing with the IRS, UC is required to submit a separate filing to California, Massachusetts, New Jersey, District of Columbia,
and Rhode Island, verifying their residents’ health insurance status. Residents of Massachusetts will receive a Form 1099-HC. Residents of the other jurisdictions do not receive any additional forms.
<o:p></o:p></span></li></ul>
<p><b><span style="font-family:"Arial",sans-serif;color:#002060">Corrections, Reprints, and Questions:</span></b><span style="font-family:"Arial",sans-serif;color:#002060"><o:p></o:p></span></p>
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<li class="MsoNormal" style="margin-bottom:6.0pt;mso-list:l0 level1 lfo6"><span style="font-family:"Arial",sans-serif">Requests for duplicate copies:<o:p></o:p></span></li><ul style="margin-top:0in" type="circle">
<li class="MsoNormal" style="margin-bottom:6.0pt;mso-list:l0 level2 lfo6"><span style="font-family:"Arial",sans-serif">Employees: Requests may be submitted for duplicate 1095s after February 14. This allows for adequate time for delivery from USPS. To request
a duplicate copy, employees should log on to the UCPath portal, scroll down to the Forms Library, and click on “Records” to complete a Benefits record request. <s><span style="background:yellow;mso-highlight:yellow">
</span></s><o:p></o:p></span></li></ul>
<li class="MsoNormal" style="margin-bottom:6.0pt;mso-list:l0 level1 lfo6"><span style="font-family:"Arial",sans-serif">Employees with general questions about the 1095 Forms should be referred to
<span style="color:#4472C4"><a href="https://www.irs.gov/affordable-care-act/questions-and-answers-about-health-care-information-forms-for-individuals"><span style="color:#4472C4">Internal Revenue Service (IRS) website/Affordable Care Act/Questions and Answers
about Health Care Information Forms for Individuals</span></a></span>. <o:p></o:p></span></li></ul>
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<p class="MsoNormal" style="margin-bottom:6.0pt"><b><span style="font-family:"Arial",sans-serif;color:#002060">Related Links<o:p></o:p></span></b></p>
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<span style="font-family:"Arial",sans-serif"><a href="https://ucnet.universityofcalifornia.edu/compensation-and-benefits/health-plans/medical/affordable-care-act/1095-faq-2017.html"><span style="color:#002060">FAQ: IRS Form 1095</span></a><o:p></o:p></span></li></ul>
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