Health Insurance Marketplace Coverage Options and Your Health Coverage at a glance
What it is: Health Insurance Marketplace Coverage Options and Your Health Coverage is a notice that provides some basic information about the Health Insurance Marketplace and health coverage offered through your employment.
Only the last section of Part B corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.
A filled-in Health Insurance Marketplace Coverage Options and Your Health Coverage example: an employer completes Part B for its employees
How to fill out Health Insurance Marketplace Coverage Options and Your Health Coverage, box by box
3. Employer name, 4. Employer Identification Number (EIN), 5. Employer address, 6. Employer phone number, 7. City, 8. State and 9. ZIP code
Enter the 3. Employer name, 4. Employer Identification Number (EIN), 5. Employer address, 6. Employer phone number, 7. City, 8. State and 9. ZIP code.
10. Who can we contact about employee health coverage at this job?, 11. Phone number (if different from above) and 12. Email address
Enter 10. Who to contact about employee health coverage at this job, 11. Phone number (if different from the employer phone number) and 12. Email address.
As your employer, we offer a health plan to
The employer offers a health plan to: All employees. Eligible employees are: or Some employees. Eligible employees are:
With respect to dependents
With respect to dependents: Coverage is offered. Eligible dependents are: or Coverage is not offered.
If checked, this coverage meets the minimum value standard
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.
13. Is the employee currently eligible for coverage offered by this employer
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? Yes (Continue)
If 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 the minimum value standard
14. Does the employer offer a health plan that meets the minimum value standard? Yes (Go to question 15) No (STOP and return form to employee)
An 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)
15. How much would the employee have to pay in premiums for this plan and How often
15. For the lowest-cost plan that meets the minimum value standard offered only to the employee (don't include family plans): If 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
16. What change will the employer make for the new plan year? Employer won't offer health coverage or 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.)
More rules for Health Insurance Marketplace Coverage Options and Your Health Coverage
You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer does not offer coverage, or offers coverage that is not considered affordable for you and doesn't meet certain minimum value standards. The savings that you're eligible for depends on your household income.
You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period.
Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment Period. In general, you qualify for a Special Enrollment Period if you've had certain qualifying life events, such as getting married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a Marketplace plan.
To learn more, visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325.
Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace or applying directly through your state Medicaid agency. Visit https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/ for more details.
Part B 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.
Common questions about Health Insurance Marketplace Coverage Options and Your Health Coverage
Is there a deadline?
Open Enrollment varies by state but generally starts November 1 and continues through at least December 15.
Sources
[1] Health Insurance Marketplace Coverage Options and Your Health Coverage, Form Approved OMB No. 1210-0149 (expires 12-31-2026), U.S. Department of Labor (the Official source link on this page).
