New Health Marketplace Coverage Form – Fill Out and Use

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer name			4.	Employer I dentification Number (EI N)
5. Employer address			6.	Employer phone number
7. City		8. Stat e			9. ZI P code
10. Who can w e contact about employee health coverage at this job?
11. Phone number (if different from above)	12. Email address

Here is some basic information about health coverage offered by this employer:

•As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

•With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

**Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.

13. I s t he employee current ly eligible for coverage offered by t his employer, or w ill t he employee be eligible in t he next 3 mont hs?

Yes (Continue)

13a. I f the employee is not eligible today, including as a result of a waiting or probationary period, when is the

employee eligible for coverage?		(mm/ dd/ yyyy) (Continue)

No (STOP and return this form to employee)

14. Does the employer offer a health plan that meets t he minimum value standard* ?

Yes (Go to question 15)

No ( STOP and return form to employee)

15.For the lowest -cost plan that meets the minimum value standard* offered only t o t he employee (don't include family plans): I f the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $
b. How often?	Weekly	Every 2 weeks	Twice a month	Monthly	Quarterly	Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee.

16.What change will the employer make for the new plan year?

Employer won't offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest -cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)

a. How much would the employee have to pay in premiums for this plan? $
b. How often?	Weekly	Every 2 weeks	Twice a month	Monthly	Quarterly	Yearly

•A employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)