Form Fa-001 - Application For Benefits - Arizona Department Of Economic Security (Page 24 of 31) in pdf

Do you need help with this application? Visit

or call 1-855-HEA-PLUS (432-7587).

Health Insurance Tax Credits:

If you are not eligible for help with health insurance cost, you may be eligible for federal tax credits to help with your health insurance

premiums

If you are not eligible for any programs through AHCCCS, we will send your information to the federal Health Insurance

Marketplace to see about health insurance tax credits.

Tell us about health insurance that may be offered through a job.

Insurance from Jobs:

 I do not know

 Yes

 No

Is anyone eligible for health insurance coverage offered by an employer, or

If YES: answer the questions below.

will you become eligible for coverage in the next 60 days?

If NO or I DO NOT KNOW: go to the next section.

Tell us about the job that offers health insurance coverage. If there are plans offered by more than one employer and you need more

space, please attach additional pages. If you need help with the information, contact the employer.

Employee Name: ___________________________________________ Employee Social Security Number: ______________________

Employer Name: ___________________________________________ Employer Identification Number (EIN):____________________

Employer Address: __________________________________ City: __________________ State: __________ Zip Code: ___________

Whom may we contact about employment health insurance coverage at this job?____________________________________________

If you are in a waiting or probationary period for insurance offered by an employer, when can you enroll in coverage?

_________________________________________________________________________

Who is eligible for coverage from this job? __________________________________________________________________________

Does the employer offer a health plan that meets the minimum value standard*?

 Yes

 No

 I do not know

If YES: answer the questions below. If NO or I DO NOT KNOW: go to the next section.

*An employer-sponsored health plan meets “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.

For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not 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 wellness programs:

How much will the employee have to pay in premiums for that plan? $ __________________________________  I do not know

How often will the employee have to pay the premium?

 Weekly

 Twice a month

 Every 2 Weeks

 Monthly

 Quarterly

 Yearly

 I do not know

 Other: _________

What changes will the employer make for the new plan year (if known)?

 Employer will not 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*.

How much will the employee have to pay in premiums for that plan? $ __________________________________  I do not know

How often will the employee have to pay the premium?

 Weekly

 Twice a month

 Every 2 Weeks

 Monthly

 Quarterly

 Yearly

 I do not know

 Other: _________

Renewal of Tax Credit Coverage in Future Years:

To make it easier for the Federal Facilitated Marketplace to determine my eligibility for help paying for health coverage in future years, I

agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let

me make changes, and I can opt out at any time.

Yes, renew my eligibility for the next:

 5 years

 4 years

 3 years

 2 years

 1 year

No, do not use information from tax returns to renew my coverage



Go to the next page to sign the application.

FA-001 (10-2017)

Page 15

Form Fa-001 - Application For Benefits - Arizona Department Of Economic Security Page 24

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