Doh-Form 116m 05 - Employer Health Insurance Information

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DOH/Form 116M 05/2014
Case#:_______________
Employer's Health Insurance Information
l This form MUST be completed by your employer or your company’s Human Resources
representative. Any blanks left on this form may delay the process.
l A form must be completed for each employed household member. You may copy this form.
l If you have general questions about this form or the medical programs, please call
1-866-435-7414.
A
General Information
Employee Information
Employee name _______________________________________
Employee SSN#_________________
(first, m.i., last)
Employer Information
Employer Name: ___________________________________________________________________________________________
EIN#:___________________________________________________
Phone #:________________________________________
Address:__________________________________________________________________________________________________
street
apt.#
city
state
zip
Who can we contact about employee health coverage at this job?
Contact Name:_____________________________________________________________________________________________
Phone #:_________________________________________________
Email address:__________________________________
oYes oNo
1. Does your company offer health insurance? If no, skip to section D. Sign and return the form.
oYes oNo
2. Is your health insurance a state employee benefit plan?
oYes oNo
3. Is your health insurance offered through Avenue H?
oYes oNo
4. Is the employee eligible to enroll in any insurance plan offered?
If no, please explain: ________________________________________________________________________
If yes, when is/was the employee eligible to enroll? (mm/dd/yy)_____________________________________
oYes oNo
5. Is the employee or any family member enrolled in any insurance plan offered?
If yes, name(s) of person(s) enrolled:___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
oYes oNo
6. Has this employee or any family member dropped/changed coverage in the last six months?
If yes, name(s): ____________________________________________________________________________
If yes, when did coverage end/change? (mm/dd/yy) ______________________________________________
Does the employer offer a health plan that meets the * minimum value standard?
oYes oNo
7.
8. For the lowest-cost plan that meets the * minimum value standard offered only to 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 did not receive any other
discounts based on the wellness programs:
a. How much would the employee have to pay in premiums for that plan? $__________________________
b. How often?
o weekly
o every 2 weeks
o twice a month o quarterly o yearly
oYes oNo
9. Do you know what change the employer will make for the new plan year?
If yes, complete the following:
o Employer won’t offer health insurance
o 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 not reflect the discount for wellness programs. See question 8.
a. How much will the employee have to pay in premiums for that plan?
$____________________
b. How often?
o weekly
o every 2 weeks
o twice a month o quarterly o yearly
*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% of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

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