Form 116M PDF Details

Navigating the intricacies of health insurance within the employer-employee context can often feel daunting. The State of Utah’s Department of Health provides a comprehensive solution to this through the DOH Form 116M, a pivotal document designed to streamline the collection of employer-provided health insurance information. This form serves a multifaceted purpose: it aids employed household members in reporting their health insurance details succinctly. Employers play a crucial role in completing this form, especially the Human Resources representatives or those in charge of employee benefits, ensuring the information is accurate and up-to-date. The form meticulously covers several critical aspects: it ascertains whether the company offers health insurance and delves into the specifics of such plans, including coverage details like deductibles, inpatient stay coverage percentages, and the inclusion of essential services such as physician visits and prescription drugs. Notably, it addresses how these plans cover abortion services, a topic of significant relevance. Furthermore, it elucidates the cost-sharing dynamics between the employee and employer for the least expensive plans available, thereby offering a transparent view of the financial obligations on both sides. By also touching upon eligibility for enrollment and providing a section for those not currently enrolled in a health plan to state their reasons, the DOH Form 116M stands as a crucial tool for ensuring that employees are well-informed and adequately covered in terms of health insurance.

QuestionAnswer
Form NameForm 116M
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesutah employer insurance, 116m form, 116m employer health insurance information, 116m

Form Preview Example

DOH Form 116M 02/21

State of Utah

Department of Health

EMPLOYER'S HEALTH INSURANCE INFORMATION

Complete this form for each employed household member. Your employer‘s Human Resources representative or department who manages employee benefits must complete it.

Employee’s Name:

 

 

 

(first, m.i., last)

eREP Case #:

 

 

D02921900040102

SSN (optional) or DOB:

 

 

 

Employer Name:

 

 

 

 

EIN #:

 

 

 

Yes No

1. Does your company offer health insurance?

 

 

 

If no, skip to section E, sign, and return the form.

 

 

2. When does your company's enrollment period begin? (mm/dd/yy)

Section A – Access to a Qualified Health Plan:

Yes No

Check one:

3.Does your company offer any health plan that meets all of the following?

•The network deductible is $4,000 or less per person

•The plan pays at least 70% of an inpatient stay after employee meets in-network deductible

•The plan covers physician's visits, inpatient and outpatient hospital care, prescription drugs, laboratory services, preventative and wellness services, pregnancy, and childbirth

•Employer pays at least 50% of the employee's premium

•Lifetime maximum benefit is $1,000,000 or more, or the plan has no maximum

4.How do those plans cover abortion services? This can typically be found in the maternity/pregnancy or exclusion sections of your policy.

Does not cover abortion in any circumstances Plan covers elective abortion

Covers abortion only in the case where the life of the mother would be endangered if the fetus were carried to term, or in the case of incest or rape (plan lists this exact language)

Other, or if multiple plans offer differing coverages, please describe:

Section B - Least Expensive Plan

Complete the chart below for the plan that would cost the employee the least. Do not include the cost of dental, vision or other coverage if it is not included in the medical insurance premium amount.

 

 

Monthly Premium

 

 

 

 

Employee’s Portion

Company’s Portion

 

 

 

 

 

 

 

Employee

$

$

 

 

 

 

 

 

 

Employee + Spouse

$

 

 

 

 

 

 

 

 

Employee + Child

$

 

 

 

 

 

 

 

 

Family

$

 

 

 

 

 

 

 

Yes No

5. Is this health insurance plan a state employee benefit plan?

Yearly Health Plan Deductible

Individual Amount

$

 

 

Family Amount

$

 

 

If the employee is enrolled in health insurance skip to section D

Section C – Employee Not Enrolled in Health Plan:

Yes No

6. Is this employee eligible to enroll in a health insurance plan?

 

If no, why not?

 

Yes No Yes No

7.Was the employee eligible to enroll in the last open enrollment period?

8.Has this employee or any family member dropped or reduced coverage in the last 90 days? If yes, name(s):

If yes, when did coverage end/change? (mm/dd/yy)

Section D - Employee's Health Plan Information:

Yes No

Yes No

Check one:

9.Is this employee or any family member enrolled in any insurance plan offered? If no, skip to section E

If yes, name(s) of person(s) enrolled:

When did coverage begin? (mm/dd/yy)

Insurance company and plan name:

 

 

 

 

 

D02921900040202

 

 

 

 

 

Policy number:

 

 

Group number:

 

 

 

 

 

 

 

 

What is the check date for the first premium deduction?

10.Does the employee's chosen health plan meet all of the following?

•The network deductible is $4,000 or less per person

•The plan pays at least 70% of an inpatient stay after employee meets in-network deductible

•The plan covers physician's visits, inpatient and outpatient hospital care, prescription drugs, laboratory services, preventative and wellness services, pregnancy, and childbirth

•Employer pays at least 50% of the employee's premium

•Lifetime maximum is $1,000,000 or more, or the plan has no maximum

11.How does the plan cover abortion services? This can typically be found in the maternity/pregnancy or exclusion sections of your policy

Does not cover abortion in any circumstances

Plan covers elective abortion

Covers abortion only in the case where the life of the mother would be endangered if the fetus were carried to term, or in the case of incest or rape (plan lists this exact language)

Other, please describe:

12. What is the monthly premium cost of this plan for a single employee, not including any family members?

This plan's monthly premium cost for just a single employee

Employee Cost

Employer Cost

$

$

 

 

13.Complete this chart for the benefits the employee is enrolled in. Fill out all applicable boxes

Premium deducted from this employee's check:

How often is the premium deducted?

 

 

 

 

 

 

 

Weekly Every 2 Weeks Twice a month

Monthly Other (Specify:)

 

 

 

 

 

 

 

 

 

 

 

 

Medical (Required)

 

Dental (Optional)

Vision (Optional)

Employee

$

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

Employee + Spouse

$

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

Employee + Child

$

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

Family

$

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yearly Health Plan Deductible

 

 

 

 

 

Individual Amount

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family Amount

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Please list any children who have dental coverage

Section E - Signature:

Name (please print):

 

 

Title:

 

Phone #:

 

 

Email Address:

 

Signature

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

Please Return Completed Form To:

Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245

Fax: 1-801-526-9500 Toll-Free Fax: 1-877-313-4717

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How one can complete 116m employer health insurance information step 1

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Filling out section 3 in 116m employer health insurance information

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The way to fill in 116m employer health insurance information part 4

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Ways to complete 116m employer health insurance information stage 5

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