State Tax Filing

If you received a state subsidy to help pay for your health insurance:

Form FTB 3895

Covered California will send Form FTB 3895 California Health Insurance Marketplace Statement to all enrolled members. It is used to fill out Form FTB 3849, Premium Assistance Subsidy, as part of your state tax return. Use the California Franchise Tax Board forms finder to view these forms.

Form FTB 3849 or Publication 3849A

Some individuals may have been instructed in the following form or publication to go to Covered California for information on determining the applicable "second lowest-cost Silver plan premium (SLCSP)":

• Form FTB 3849, Premium Assistance Subsidy
• Publication 3849A, Premium Assistance Subsidy

To find this amount, follow the steps below: 

Step 1: Go to Covered California’s Shop and Compare Tool

Step 2: From the dropdown menu:

• Select coverage year 2020 (or the tax year in which you need information)
• Enter ZIP code (and county, if prompted)
• Enter total household income for the tax filing year
• Enter the number of people in the tax household
• Enter the age of the head of household and select “Needs Coverage”
  • Note: do not select the boxes for pregnant or blind or disabled for purposes of completing Form FTB 3849.

Step 3: Select "See My Results" after entering the information

Step 4: Select "Continue" after the pop up appears

Step 5: Select "Preview Plans"

Step 6: Skip the next two screens, “Tell us about your health care needs,” by selecting "Next"

Step 7: Select "View Plans"

Step 8: Find the second lowest-cost Silver plan premium:

• Use the "Sort By" menu and sort by Monthly Premium (low to high).
• Use "Filter By" and scroll to "Metal Tier"; then select "Silver."
• When sorted low to high, find the second Silver plan on the top row.
• Add together the monthly premium (the dollar amount in large black font) and the “after $[x] monthly savings” (the dollar amount in bold blue font). The sum of these amounts is the gross monthly premium for the second lowest-cost Silver plan.
• Enter this number on the appropriate line in Form FTB 3849.

If you need help, please contact the Covered California Service Center. Representatives can help you calculate the second lowest cost Silver plan premium amount but cannot provide tax advice.

If you claim an exemption:

Form FTB 3853

Some individuals may have been instructed in Form FTB 3853, Health Coverage Exemptions and Individual Shared Responsibility Penalty, to complete the Marketplace Coverage Affordability Worksheet and need to find their lowest-cost Bronze plan and second lowest-cost Silver plan premiums. To find these amounts, click the following link:

FTB Form 3853 Health Coverage Exemptions and Individual Shared Responsibility Penalty