LEGAL NOTICES
The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coveragechoices.
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3months? □ Yes (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligiblefor coverage? (mm/dd/yyyy) (Continue) □ No (STOP and return this form toemployee)
14.
Does the employer offer a health plan that meets the minimumvaluestandard*? Yes (Go toquestion15) No (STOP and return formto 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 wellnessprograms. a.How much would the employee have to pay in premiums for thisplan? $ b. How often? Weekly Every 2 weeks Twicea month 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. Ifyou don't know, STOP and return form toemployee.
16. What change will the employer make for the new plan year? □ Employer won't offer healthcoverage □
Employer will start offering health coverage to employees or change the premium for the lowest-costplan available only to the employee that meets the minimum value standard.* (Premium should reflectthe discount for wellness programs. See question15.)
a.How much would the employee have to pay in premiums for thisplan? $ b. How often? Weekly Every 2 weeks Twicea month month Monthly Quarterly Yearly
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PRIVATE PREP BENEFITS GUIDE
LEGAL NOTICES
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