Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to:
X
All Employees. Eligible employees are:
All Full Time Employees working at least 30 hours.
Some employees. Eligible employees are:
With respect to dependents:
•
X
We do offer coverage. Eligible Dependents are:
Your Legal Spouse. Your married or unmarried natural children, step-children living with you, legally adopted children and any other children for whom you have legal guardianship, who are under 26 years of age. A dependent who is older than 26 years of age, but less than 30 years of age may be eligible for medical benefits if the dependent is: • unmarried and not have dependents of his or her own; AND • Be a resident of Florida or a student; AND • Not have coverage of their own, or covered under any other plan; AND • Not entitled to benefits under Medicare
We do not offer coverage.
X 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. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
X
Yes (Continue)
13a. 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*?
X
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 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?
$ 12.00
b. How often?
X
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
1 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 36(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
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