The document is a Covered California notice addressed to Valerie Vess Jimenez that delivers the 2020 California Health Insurance Marketplace Statement (Form FTB 3895). It explains why the form is required for filing California state taxes, how to use it together with Form FTB 3849 to report the California premium assistance subsidy, and provides a detailed breakdown of monthly enrollment premiums, second‑lowest‑cost silver‑plan (SLCSP) premiums, and advance subsidy payments for the entire year. The letter includes step‑by‑step instructions for completing the tax forms, information about the 2020 individual mandate, penalties, and exemptions, as well as a comprehensive FAQ covering the subsidy, multiple forms, and reporting nuances. It lists contact information for tax help, Covered California support, and civil‑rights/translation services in many languages, and outlines how to obtain digital copies. The document also contains legal notices, a VOID/CORRECTED disclaimer, and a table of covered individuals. Overall, it serves as both a tax‑filing guide and an informational resource for California health‑insurance subsidy recipients.
Topics
Purpose and Use of Form FTB 3895 for California State Tax Filing
Explains that Form FTB 3895 is required to report the California premium assistance subsidy and proof of coverage when filing a California state tax return.
Monthly Premium and Subsidy Details for 2020 Coverage
Provides a month‑by‑month table of enrollment premiums, SLCSP premiums, and advance subsidy payments, plus annual totals.
How to Complete Form FTB 3849 Using Information from Form 3895
Step‑by‑step guidance on transferring data from the 3895 (columns a‑c) to the appropriate lines on Form 3849, and attaching it to the state tax return.
Frequently Asked Questions About the California Premium Subsidy and Tax Forms
A Q&A section addressing why the form is sent, how the advance subsidy affects taxes, multiple‑form scenarios, and interpretation of zeros or –0– entries.
Multilingual Accessibility and Civil‑Rights Services
Details the availability of translation, large‑print, TTY, and sign‑language services, plus civil‑rights grievance procedures for discrimination.
Contact Information and Resources for Tax Assistance
Lists phone numbers, websites, and organizations (VITA, FTB, Covered California) that can help with tax preparation and subsidy questions.
Questions this document answers
Beginning in 2020, Covered California offered a new type of financial help. The California premium subsidy lowers the premium (monthly cost) of a qualified health plan through Covered California. Covered California uses the information on your application to decide if you qualify.
When you file state taxes at the end of the year, the Franchise Tax Board uses the final income and family size that you report on your state tax return to determine the amount of subsidy you were entitled to for the tax year. Based on your specific situation, you may have to pay back some or all of the subsidy you got during the year. Or you may qualify for more subsidy and get the rest as a refund. If you owe other state taxes, your unused subsidy may lower the amount you owe.
We send Form FTB 3895 to everyone who got health insurance through Covered California in 2020. You need this form to file your state taxes. We also send Form FTB 3895 to the Franchise Tax Board. It shows who was enrolled and how many months they had health insurance, how much was paid in monthly premiums, and how much California premium subsidy was paid to the health insurance company.
This could happen if members of your household were enrolled in different health plans. This could also happen if someone changed health plans or benefit levels during the year, such as changing from a Silver to a Gold plan.
Use your Form FTB 3895 to fill out Form FTB 3849, Premium Assistance Subsidy. You must file this with your state tax return. You can get a blank copy on the Franchise Tax Board's website at www.ftb.ca.gov/forms/index.html. Your tax preparer or online tax service should also have the form.