California Form FTB 3895: Health Insurance Marketplace Statement

Form FTB 3895 is the California Health Insurance Marketplace Statement that Covered California sends to everyone who enrolled in a marketplace health plan during the year. You use it for two things on your California return: reconciling any advance Premium Assistance Subsidy on Form FTB 3849, and confirming your months of coverage on Form FTB 3853 for the state’s individual mandate.¹

When You Get It and Where to Find It

Covered California must deliver FTB 3895 by January 31 of the year after the coverage year. If your communication preference is email, you’ll get a notice to sign in at CoveredCA.com and pull the form from your secured mailbox. If your preference is mail or phone, a paper copy arrives in the post.²

You can download it from your online account before the paper copy shows up. The online version carries the same data the Franchise Tax Board already has on file.³

You’ll receive a form whether or not you took any financial help, because it also documents your enrollment for the state mandate. If you bought a plan directly from a carrier outside Covered California, you won’t get an FTB 3895; your insurer sends separate proof of minimum essential coverage, and you won’t have a subsidy to reconcile.

What’s on the Form

FTB 3895 has two parts. Part I lists up to five covered individuals with their names, Social Security numbers, dates of birth, and coverage start and end dates. Households larger than five on the same policy get additional forms.¹

Part II is the part that drives your tax calculations. It breaks the year into monthly rows (lines 6 through 17, with line 18 as the annual total) across three financial columns:⁴

Column (a), monthly enrollment premiums: the full premium charged before any financial help.
Column (b), monthly SLCSP premium: the cost of the second-lowest-cost Silver plan in your area, used to size your subsidy.
Column (c), monthly advance payment of PAS: the subsidy Covered California already paid to your insurer each month.

If any amount appears in column (c), you received advance subsidy payments and must file FTB 3849 with your return.⁵

Reconciling the Subsidy on Form FTB 3849

FTB 3849 compares what Covered California advanced to your insurer with the subsidy you actually qualify for once your final income is known. The form calculates your household income as a percentage of the federal poverty line, then applies that percentage against the SLCSP figures from your FTB 3895 to produce your allowed Premium Assistance Subsidy.⁵

Transfer the monthly numbers from FTB 3895 straight across:

Column (a) on FTB 3895 goes to column (a) of FTB 3849, lines 12–23.
Column (b) on FTB 3895 goes to column (b) of FTB 3849, lines 12–23.
Column (c) on FTB 3895 goes to column (g) of FTB 3849, lines 12–23.

If your advance payments came in below the subsidy you earned, the difference becomes a credit that increases your refund or cuts your tax. If your actual income was higher than what you estimated when you applied, you may owe some of the subsidy back.

Repayment Caps for 2025

California limits how much excess advance subsidy you have to repay, based on where your household income lands on the federal poverty level. For the 2025 tax year:⁶

Below 200% FPL: $375 single, $750 all other filers.
200% to below 300% FPL: $975 single, $1,950 other.
300% to below 400% FPL: $1,625 single, $3,250 other.
400% FPL or above: no cap; you repay the full excess.

The jump from a capped repayment to no cap at 400% FPL catches people whose income lands just above the threshold. Check the income number carefully if you’re close.

Using FTB 3895 with the Coverage Mandate

California requires residents and their dependents to carry minimum essential coverage every month of the year. The months shown on your FTB 3895 are the months you can claim marketplace coverage on Form FTB 3853. For any gap without coverage or an exemption, FTB 3853 calculates a penalty.⁷

For the 2025 tax year, the flat penalty is $950 per adult and $475 per dependent child under 18, prorated by month.⁸ A percentage-of-income calculation runs alongside the flat amount, and FTB 3853 applies whichever is greater.

Some exemptions you claim directly on FTB 3853, including income below the filing threshold, a short coverage gap of less than three consecutive months, and residence outside the United States. Hardship, affordability, and religious conscience exemptions have to be applied for through Covered California first; if approved, you enter the Exemption Certificate Number on FTB 3853.⁹

Filing Your Return

Before you file, have your FTB 3895 in hand, along with FTB 3849 if any advance subsidy was paid and FTB 3853 if you’re reporting an exemption or a penalty. Finish your federal return first; the California subsidy reconciliation builds on the figures used for the federal Premium Tax Credit.

Tax software will prompt you to enter the data from FTB 3895 and generate FTB 3849 and FTB 3853 for you. If you file on paper, attach FTB 3853 (and FTB 3849 when it applies) behind Form 540. Don’t mail FTB 3895 itself; the Franchise Tax Board already receives that data directly from Covered California.

Hold on to your FTB 3895 and related coverage records for at least four years from the return’s due date or filing date, whichever is later. That’s the standard window the FTB has to examine your return.¹⁰

Fixing an Error on the Form

If something on your FTB 3895 doesn’t match your records, there are two correction routes:³

Call Covered California at 800-300-1506 for personal details: name, date of birth, Social Security number, or mailing address.
File a dispute online at CoveredCA.com/3895 for coverage start or end dates, monthly premium amounts, monthly subsidy figures, or adding or removing household members.

If Covered California agrees a change is needed, they mail a corrected form. Don’t file your return with numbers you know are wrong, because the FTB has the same data and a mismatch can trigger a notice. If the filing deadline is near and the corrected form hasn’t arrived, request an extension with Form FTB 3519.¹¹

One wrinkle for mixed households: if some members are on Medi-Cal, corrections to personal information like names, dates of birth, and Social Security numbers have to go through a county eligibility worker rather than Covered California’s standard process.

1
Franchise Tax Board. California Instructions for Form FTB 3895
2
Covered California. Find Your Tax Forms
3
Covered California. Form FTB 3895 Quick Guide Certified Enrollers
4
Franchise Tax Board. 2025 Form 3895 California Health Insurance Marketplace Statement
5
Franchise Tax Board. 2021 Instructions for Form FTB 3849 Premium Assistance Subsidy
6
Covered California. Financial Help Repayment Limits
7
Franchise Tax Board. 2021 Recipient Instructions for Form FTB 3895 California Health Insurance Marketplace Statement
8
Franchise Tax Board. Personal Health Care Mandate
9
Covered California. Exemptions
10
Franchise Tax Board. Keeping Your Tax Records
11
Covered California. California Health Insurance Marketplace Statement