Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 15
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16EMPLOYER COVERAGE TOOL
Health Coverage from Jobs
Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even if it’s from another
person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes on Appendix A. For example, the answer
to question 14 on this page should match question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form.
Complete one tool for each employer that offers health coverage.
EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last)
2. Employee Social Security number
EMPLOYER Information
The employer needs to fill out this section.
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. Is the employee currently eligible for coverage offered by this employer, or will the employee 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 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)
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 2 of 2
DW
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