Notice to Employees of Coverage Options Under FLSA Section 18B (State and Local Gov't)




New Health Insurance Marketplace Coverage
Options and Your Health Coverage

Form Approved
OMB No. 1210-0149
H[SLUHV5312020

PART A: General Information
ΈΙΖΟ͑ΜΖΪ͑ΡΒΣΥΤ͑ΠΗ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΔΒΣΖ͑ΝΒΨ͑ΥΒΜΖ͑ΖΗΗΖΔΥ͑ΚΟ͑ͣͥ͑͢͡͝ΥΙΖΣΖ͑ΨΚΝΝ͑ΓΖ͑Β͑ΟΖΨ͑ΨΒΪ͑ΥΠ͑ΓΦΪ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ:͑ΥΙΖ͑͹ΖΒΝΥΙ͑
ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅Π͑ΒΤΤΚΤΥ͑ΪΠΦ͑ΒΤ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΠΡΥΚΠΟΤ͑ΗΠΣ͑ΪΠΦ͑ΒΟΕ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͑͝ΥΙΚΤ͑ΟΠΥΚΔΖ͑ΡΣΠΧΚΕΖΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑
ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΥΙΖ͑ΟΖΨ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΖΞΡΝΠΪΞΖΟΥνΓΒΤΖΕ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟
͑

What is the Health Insurance Marketplace?
΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΤ͑ΕΖΤΚΘΟΖΕ͑ΥΠ͑ΙΖΝΡ͑ΪΠΦ͑ΗΚΟΕ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΪΠΦΣ͑ΟΖΖΕΤ͑ΒΟΕ͑ΗΚΥΤ͑ΪΠΦΣ͑ΓΦΕΘΖΥ͑͟΅ΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΠΗΗΖΣΤ͓͑ΠΟΖ͞ΤΥΠΡ͑ΤΙΠΡΡΚΟΘ͓͑ΥΠ͑ΗΚΟΕ͑ΒΟΕ͑ΔΠΞΡΒΣΖ͑ΡΣΚΧΒΥΖ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑ΠΡΥΚΠΟΤ͑͟ΊΠΦ͑ΞΒΪ͑ΒΝΤΠ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΟΖΨ͑ΜΚΟΕ͑ΠΗ͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑ΣΚΘΙΥ͑ΒΨΒΪ͑͟΀ΡΖΟ͑ΖΟΣΠΝΝΞΖΟΥ͑ΗΠΣ͑ΙΖΒΝΥΙ͑ΚΟΤΦΣΒΟΔΖ͑
ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΓΖΘΚΟΤ͑ΚΟ͑΀ΔΥΠΓΖΣ͑ͣͤ͑͢͡ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΤΥΒΣΥΚΟΘ͑ΒΤ͑ΖΒΣΝΪ͑ΒΤ͑ͻΒΟΦΒΣΪ͑͑ͣͥ͑͢͢͟͝͡

Can I Save Money on my Health Insurance Premiums in the Marketplace?
ΊΠΦ͑ΞΒΪ͑΢ΦΒΝΚΗΪ͑ΥΠ͑ΤΒΧΖ͑ΞΠΟΖΪ͑ΒΟΕ͑ΝΠΨΖΣ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΓΦΥ͑ΠΟΝΪ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͝ΠΣ͑
ΠΗΗΖΣΤ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΕΠΖΤΟ͘Υ͑ΞΖΖΥ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟΅ΙΖ͑ΤΒΧΚΟΘΤ͑ΠΟ͑ΪΠΦΣ͑ΡΣΖΞΚΦΞ͑ΥΙΒΥ͑ΪΠΦ͘ΣΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑ΕΖΡΖΟΕΤ͑ΠΟ͑
ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͟

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?
ΊΖΤ͑͟ͺΗ͑ΪΠΦ͑ΙΒΧΖ͑ΒΟ͑ΠΗΗΖΣ͑ΠΗ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΗΣΠΞ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͝ΪΠΦ͑ΨΚΝΝ͑ΟΠΥ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑
ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΞΒΪ͑ΨΚΤΙ͑ΥΠ͑ΖΟΣΠΝΝ͑ΚΟ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͘Τ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑͟͹ΠΨΖΧΖΣ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑
ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΙΒΥ͑ΝΠΨΖΣΤ͑ΪΠΦΣ͑ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞ͑͝ΠΣ͑Β͑ΣΖΕΦΔΥΚΠΟ͑ΚΟ͑ΔΖΣΥΒΚΟ͑ΔΠΤΥ͞ΤΙΒΣΚΟΘ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΕΠΖΤ͑
ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΒΥ͑ΒΝΝ͑ΠΣ͑ΕΠΖΤ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΒΥ͑ΞΖΖΥΤ͑ΔΖΣΥΒΚΟ͑ΤΥΒΟΕΒΣΕΤ͑͟ͺΗ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑Β͑ΡΝΒΟ͑ΗΣΠΞ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑ΥΙΒΥ͑ΨΠΦΝΕ͑ΔΠΧΖΣ͑ΪΠΦ͙͑ΒΟΕ͑ΟΠΥ͑ΒΟΪ͑ΠΥΙΖΣ͑ΞΖΞΓΖΣΤ͑ΠΗ͑ΪΠΦΣ͑ΗΒΞΚΝΪ͚͑ΚΤ͑ΞΠΣΖ͑ΥΙΒΟ͖͑ͪͦ͑͟ΠΗ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑
ΚΟΔΠΞΖ͑ΗΠΣ͑ΥΙΖ͑ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΥΙΖ͑ΔΠΧΖΣΒΘΖ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΡΣΠΧΚΕΖΤ͑ΕΠΖΤ͑ΟΠΥ͑ΞΖΖΥ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͓͑ΤΥΒΟΕΒΣΕ͑ΤΖΥ͑ΓΪ͑ΥΙΖ͑
ͲΗΗΠΣΕΒΓΝΖ͑ʹΒΣΖ͑ͲΔΥ͑͝ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑͟͢
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ͿΠΥΖͫ͑ͺΗ͑ΪΠΦ͑ΡΦΣΔΙΒΤΖ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟΤΥΖΒΕ͑ΠΗ͑ΒΔΔΖΡΥΚΟΘ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑
ΖΞΡΝΠΪΖΣ͑͝ΥΙΖΟ͑ΪΠΦ͑ΞΒΪ͑ΝΠΤΖ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͙͑ΚΗ͑ΒΟΪ͚͑ΥΠ͑ΥΙΖ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͟ͲΝΤΠ͑͝ΥΙΚΤ͑ΖΞΡΝΠΪΖΣ͑
ΔΠΟΥΣΚΓΦΥΚΠΟ͑͞ΒΤ͑ΨΖΝΝ͑ΒΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΖ͑ΔΠΟΥΣΚΓΦΥΚΠΟ͑ΥΠ͑ΖΞΡΝΠΪΖΣ͞ΠΗΗΖΣΖΕ͑ΔΠΧΖΣΒΘΖ͑͞ΚΤ͑ΠΗΥΖΟ͑ΖΩΔΝΦΕΖΕ͑ΗΣΠΞ͑ΚΟΔΠΞΖ͑ΗΠΣ͑
ͷΖΕΖΣΒΝ͑ΒΟΕ͑΄ΥΒΥΖ͑ΚΟΔΠΞΖ͑ΥΒΩ͑ΡΦΣΡΠΤΖΤ͑͟ΊΠΦΣ͑ΡΒΪΞΖΟΥΤ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΣΖ͑ΞΒΕΖ͑ΠΟ͑ΒΟ͑ΒΗΥΖΣ͞
ΥΒΩ͑ΓΒΤΚΤ͑͟

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How Can I Get More Information?
ͷΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΡΝΖΒΤΖ͑ΔΙΖΔΜ͑ΪΠΦΣ͑ΤΦΞΞΒΣΪ͑ΡΝΒΟ͑ΕΖΤΔΣΚΡΥΚΠΟ͑ΠΣ͑
ΔΠΟΥΒΔΥ͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͑͟
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΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΔΒΟ͑ΙΖΝΡ͑ΪΠΦ͑ΖΧΒΝΦΒΥΖ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΠΡΥΚΠΟΤ͑͝ΚΟΔΝΦΕΚΟΘ͑ΪΠΦΣ͑ΖΝΚΘΚΓΚΝΚΥΪ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑
;ΒΣΜΖΥΡΝΒΔΖ͑ΒΟΕ͑ΚΥΤ͑ΔΠΤΥ͑͟΁ΝΖΒΤΖ͑ΧΚΤΚΥ͑͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΗΠΣ͑ΞΠΣΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͝ΚΟΔΝΦΕΚΟΘ͑ΒΟ͑ΠΟΝΚΟΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΙΖΒΝΥΙ͑
ΚΟΤΦΣΒΟΔΖ͑ΔΠΧΖΣΒΘΖ͑ΒΟΕ͑ΔΠΟΥΒΔΥ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΗΠΣ͑Β͑͹ΖΒΝΥΙ͑ͺΟΤΦΣΒΟΔΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΚΟ͑ΪΠΦΣ͑ΒΣΖΒ͑͟

͑͢ͲΟ͑ ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͑ ͓ΞΚΟΚΞΦΞ͑ ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ ΚΗ͑ ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑
ΓΪ͑ ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ ΟΠ͑ ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ ΤΦΔΙ͑ΔΠΤΥΤ͑͟

PART B: Information About Health Coverage Offered by Your Employer
΅ΙΚΤ͑ΤΖΔΥΚΠΟ͑ΔΠΟΥΒΚΟΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΒΟΪ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͟ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΔΠΞΡΝΖΥΖ͑ΒΟ͑
ΒΡΡΝΚΔΒΥΚΠΟ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝ΪΠΦ͑ΨΚΝΝ͑ΓΖ͑ΒΤΜΖΕ͑ΥΠ͑ΡΣΠΧΚΕΖ͑ΥΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑͟΅ΙΚΤ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΚΤ͑ΟΦΞΓΖΣΖΕ͑
ΥΠ͑ΔΠΣΣΖΤΡΠΟΕ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΒΡΡΝΚΔΒΥΚΠΟ͑͟
3. Employer name

4. Employer Identification Number (EIN)

5. Employer address

6. Employer phone number

7. City

8. State

9. ZIP code

10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)

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12. Email address

͹ΖΣΖ͑ΚΤ͑ΤΠΞΖ͑ΓΒΤΚΔ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΒΓΠΦΥ͑ΙΖΒΝΥΙ͑ΔΠΧΖΣΒΘΖ͑ΠΗΗΖΣΖΕ͑ΓΪ͑ΥΙΚΤ͑ΖΞΡΝΠΪΖΣͫ͑
x ͲΤ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑͝ΨΖ͑ΠΗΗΖΣ͑Β͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΥΠͫ͑
… ͲΝΝ͑ΖΞΡΝΠΪΖΖΤ͑͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑
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… ΄ΠΞΖ͑ΖΞΡΝΠΪΖΖΤ͑͟ͶΝΚΘΚΓΝΖ͑ΖΞΡΝΠΪΖΖΤ͑ΒΣΖͫ͑͑
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x ΈΚΥΙ͑ΣΖΤΡΖΔΥ͑ΥΠ͑ΕΖΡΖΟΕΖΟΥΤͫ͑
… ΈΖ͑ΕΠ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟ͶΝΚΘΚΓΝΖ͑ΕΖΡΖΟΕΖΟΥΤ͑ΒΣΖͫ͑
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… ΈΖ͑ΕΠ͑ΟΠΥ͑ΠΗΗΖΣ͑ΔΠΧΖΣΒΘΖ͑͟
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… ͺΗ͑ΔΙΖΔΜΖΕ͑͝ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΞΖΖΥΤ͑ΥΙΖ͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͑͝ΒΟΕ͑ΥΙΖ͑ΔΠΤΥ͑ΠΗ͑ΥΙΚΤ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΪΠΦ͑ΚΤ͑ΚΟΥΖΟΕΖΕ͑
ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΓΒΤΖΕ͑ΠΟ͑ΖΞΡΝΠΪΖΖ͑ΨΒΘΖΤ͑͟
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͛͛͑ ͶΧΖΟ͑ΚΗ͑ΪΠΦΣ͑ΖΞΡΝΠΪΖΣ͑ΚΟΥΖΟΕΤ͑ΪΠΦΣ͑ΔΠΧΖΣΒΘΖ͑ΥΠ͑ΓΖ͑ΒΗΗΠΣΕΒΓΝΖ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑
ΕΚΤΔΠΦΟΥ͑ΥΙΣΠΦΘΙ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͟΅ΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ΨΚΝΝ͑ΦΤΖ͑ΪΠΦΣ͑ΙΠΦΤΖΙΠΝΕ͑ΚΟΔΠΞΖ͑͝ΒΝΠΟΘ͑ΨΚΥΙ͑ΠΥΙΖΣ͑ΗΒΔΥΠΣΤ͑͝
ΥΠ͑ΕΖΥΖΣΞΚΟΖ͑ΨΙΖΥΙΖΣ͑ΪΠΦ͑ΞΒΪ͑ΓΖ͑ΖΝΚΘΚΓΝΖ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟ͺΗ͑͝ΗΠΣ͑ΖΩΒΞΡΝΖ͑͝ΪΠΦΣ͑ΨΒΘΖΤ͑ΧΒΣΪ͑ΗΣΠΞ͑
ΨΖΖΜ͑ΥΠ͑ΨΖΖΜ͙͑ΡΖΣΙΒΡΤ͑ΪΠΦ͑ΒΣΖ͑ΒΟ͑ΙΠΦΣΝΪ͑ΖΞΡΝΠΪΖΖ͑ΠΣ͑ΪΠΦ͑ΨΠΣΜ͑ΠΟ͑Β͑ΔΠΞΞΚΤΤΚΠΟ͑ΓΒΤΚΤ͚͑͝ΚΗ͑ΪΠΦ͑ΒΣΖ͑ΟΖΨΝΪ͑
ΖΞΡΝΠΪΖΕ͑ΞΚΕ͞ΪΖΒΣ͑͝ΠΣ͑ΚΗ͑ΪΠΦ͑ΙΒΧΖ͑ΠΥΙΖΣ͑ΚΟΔΠΞΖ͑ΝΠΤΤΖΤ͑͝ΪΠΦ͑ΞΒΪ͑ΤΥΚΝΝ͑΢ΦΒΝΚΗΪ͑ΗΠΣ͑Β͑ΡΣΖΞΚΦΞ͑ΕΚΤΔΠΦΟΥ͑͟
͑
ͺΗ͑ΪΠΦ͑ΕΖΔΚΕΖ͑ΥΠ͑ΤΙΠΡ͑ΗΠΣ͑ΔΠΧΖΣΒΘΖ͑ΚΟ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑͝͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ ΨΚΝΝ͑ΘΦΚΕΖ͑ΪΠΦ͑ΥΙΣΠΦΘΙ͑ΥΙΖ ΡΣΠΔΖΤΤ͑͟͹ΖΣΖ͘Τ͑ΥΙΖ͑
ΖΞΡΝΠΪΖΣ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΪΠΦ͘ΝΝ͑ΖΟΥΖΣ͑ΨΙΖΟ͑ΪΠΦ͑ΧΚΤΚΥ͑͹ΖΒΝΥΙʹΒΣΖ͟ΘΠΧ͑ΥΠ͑ΗΚΟΕ͑ΠΦΥ͑ΚΗ͑ΪΠΦ͑ΔΒΟ͑ΘΖΥ͑Β͑ΥΒΩ͑ΔΣΖΕΚΥ͑ΥΠ͑ΝΠΨΖΣ͑ΪΠΦΣ͑
ΞΠΟΥΙΝΪ͑ΡΣΖΞΚΦΞΤ͑͟
͑

΅ΙΖ͑ΚΟΗΠΣΞΒΥΚΠΟ͑ΓΖΝΠΨ͑ΔΠΣΣΖΤΡΠΟΕΤ͑ΥΠ͑ΥΙΖ͑;ΒΣΜΖΥΡΝΒΔΖ͑ͶΞΡΝΠΪΖΣ͑ʹΠΧΖΣΒΘΖ͑΅ΠΠΝ͑͑͟ʹΠΞΡΝΖΥΚΟΘ͑ΥΙΚΤ͑ΤΖΔΥΚΠΟ͑ΚΤ͑ΠΡΥΚΠΟΒΝ͑ΗΠΣ͑
ΖΞΡΝΠΪΖΣΤ͑͝ΓΦΥ͑ΨΚΝΝ͑ΙΖΝΡ͑ΖΟΤΦΣΖ͑ΖΞΡΝΠΪΖΖΤ͑ΦΟΕΖΣΤΥΒΟΕ͑ΥΙΖΚΣ͑ΔΠΧΖΣΒΘΖ͑ΔΙΠΚΔΖΤ͑͟
͑
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)
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*?
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? $
b. How often?
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly
ͺΗ͑ΥΙΖ͑ΡΝΒΟ͑ΪΖΒΣ͑ΨΚΝΝ͑ΖΟΕ͑ΤΠΠΟ͑ΒΟΕ͑ΪΠΦ͑ΜΟΠΨ͑ΥΙΒΥ͑ΥΙΖ͑ΙΖΒΝΥΙ͑ΡΝΒΟΤ͑ΠΗΗΖΣΖΕ͑ΨΚΝΝ͑ΔΙΒΟΘΖ͑͝ΘΠ͑ΥΠ͑΢ΦΖΤΥΚΠΟ͑ͧ͑͢͟ͺΗ͑ΪΠΦ͑ΕΠΟ͘Υ͑
ΜΟΠΨ͑͝΄΅΀΁͑ΒΟΕ͑ΣΖΥΦΣΟ͑ΗΠΣΞ͑ΥΠ͑ΖΞΡΝΠΪΖΖ͑͟
͑
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

‫Ͳ͑ח‬Ο͑ΖΞΡΝΠΪΖΣ͞ΤΡΠΟΤΠΣΖΕ͑ΙΖΒΝΥΙ͑ΡΝΒΟ͑ΞΖΖΥΤ͑ΥΙΖ͓͑ΞΚΟΚΞΦΞ͑ΧΒΝΦΖ͑ΤΥΒΟΕΒΣΕ͓͑ΚΗ͑ΥΙΖ͑ΡΝΒΟ͘Τ͑ΤΙΒΣΖ͑ΠΗ͑ΥΙΖ͑ΥΠΥΒΝ͑ΒΝΝΠΨΖΕ͑ΓΖΟΖΗΚΥ͑ΔΠΤΥΤ͑ΔΠΧΖΣΖΕ͑ΓΪ͑
ΥΙΖ͑ΡΝΒΟ͑ΚΤ͑ΟΠ͑ΝΖΤΤ͑ΥΙΒΟ͑ͧ͑͡ΡΖΣΔΖΟΥ͑ΠΗ͑ΤΦΔΙ͑ΔΠΤΥΤ͙͑΄ΖΔΥΚΠΟ͑ͤͧͳ͙Δ͚͙͚͙ͣʹ͚͙ΚΚ͚͑ΠΗ͑ΥΙΖ͑ͺΟΥΖΣΟΒΝ͑΃ΖΧΖΟΦΖ͑ʹΠΕΖ͑ΠΗ͚͑ͪͩͧ͑͢