Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 14
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16APPENDIX A
Health Coverage from Jobs
You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this
page for each job that offers coverage.
Tell us about the job that offers coverage.
Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need
to include this page when you send in your application, not the Employer Coverage Tool.
EMPLOYEE information
1. Employee name (First, Middle, Last)
2. Employee Social Security number
EMPLOYER information
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)
12. Email address
(
)
13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
YES. If YES, continue below.
NO. If NO, stop here and go to Step 3 on the application.
13a. If you’re in a waiting or probationary period, when can you enroll in coverage?
(mm/dd/yyyy)
List the names of anyone else who is eligible for coverage from this job.
Name:
Name:
Name:
Tell us about the health plan offered by this employer.
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes
No
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 cessa-
tion programs, and did not 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
Yearly
16. What change will the employer make for the new plan year (if known)?
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
Yearly
Date of change (mm/dd/yyyy):
* 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 percent of such costs [Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986]
NEED HELP WITH YOUR APPLICATION?
SCDHHS.gov
or call us at 1-888-549-0820. Para obtener una copia de este formulario
Visit
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 - Appendix A (January 2014)
Page 1 of 2
DW
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