Proof Of Other Group Health Insurance Form
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1Broward County Human Resources Division
Employee Benefit Services Section
115 S Andrews Avenue, Ste. 514, Fort Lauderdale FL 33301
Office: 954-357-6700 | Secured Facsimile: 954-728-2777
Email: | Website:
PROOF OF OTHER GROUP HEALTH INSURANCE - 2016
Employees receiving health insurance coverage through an Exchange, the individual insurance marketplace, OR
Medicare are not eligible to receive the 2016 Waiver Credit per guidelines issued by the United States Departments of
Labor (DOL), Health and Human Services (HHS), the Treasury, and the Centers for Medicare and Medicaid Services
(CMS).
The Patient Protection and Affordable Care Act (PPACA), states that most U.S. citizens must have health coverage or pay an
annual penalty. Broward County requires that all employees who wish to waive the County-offered health insurance coverage
show proof of other group health insurance coverage in order to receive the Waiver Credit (full-time employees: $119.23 per
pay period).
In order to qualify for the Waiver Credit, you must show proof of coverage that specifically demonstrates PPACA-compliant group
health insurance coverage in 2016. Examples of proof of 2016 health coverage:
A copy of your insurance card (must show a date proving coverage in 2016);
Insurance coverage letter from your group insurance carrier specifying coverage in 2016;
A letter from your spouse/domestic partner’s employer that states you are enrolled for the 2016 Benefit year;
An open enrollment confirmation statement for group health insurance specifying elections for 2016;
Veterans can provide a letter or other documentation from Veterans Services;
Tricare members can provide a copy of their uniformed service ID card.
Employees who take no action during open enrollment and/or
do not show proof of other health coverage by 01/15/16 will not receive the Waiver Credit.
SECTION 1: BROWARD COUNTY EMPLOYEE INFORMATION
EMPLOYEE NAME: _______________________________________ EMPLOYEE ID: _____________________________
INSURED UNDER (IF APPLICABLE; E.G. SPOUSE’S NAME) _________________________________________________
AUTHORIZATION
By signing this document, you agree to allow your group health insurance plan sponsor to provide your name and detailed information about
your health insurance benefit plan to Broward County, Employee Benefit Services, for the purpose of determining eligibility for the Waiver
Credit. If you would like to revoke this authorization at any time, written notice must be provided to the Broward County Employee Benefits
Office. However, any actions taken by the Broward County, Employee Benefit Services Section in reliance on your authorization before you
revoked it will not be affected by the revocation.
EMPLOYEE SIGNATURE: _____________________________________________________________________________
INSURER’S SIGNATURE (IF APPLICABLE): _______________________________________________________________
SECTION 2: GROUP HEALTH INSURANCE
HEALTH INSURANCE CARRIER: _______________________________________________________________________
PLAN SPONSOR: ____________________________________________________________________________________
EFFECTIVE DATE: _________________________________ EXPIRATION DATE: ________________________________
DOES THIS PLAN OFFER PPACA-COMPLIANT MINIMUM ESSENTIAL COVERAGE: YES ___________ NO __________
OFFICE USE ONLY
ENTERED: ________________________________________ AUDITED: ________________________________________
RETURN INSTRUCTIONS:
Please return this form directly to:
Broward County Employee Benefit Services | Fax: 954-728-2777 | Email:
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