Application For Health Coverage & Help Paying Costs Page 12

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Tell us about the health coverage offered by this employer.

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

YES (Go to question 15.)

NO (STOP and return this form to employee.)

15. How much would the employee have to pay for the lowest cost plan offered to the employee only that meets the minimum value standard*? Don’t

include family plans. NOTE: If the employer offers wellness programs, enter the premium that the employee would pay if the employee got the maximum

discount for any tobacco cessation programs and didn’t get any other discounts based on wellness programs.

a. Employee would pay this premium:

NOTE: Enter the lowest amount the employee could pay for health coverage.

b. Employee would pay this amount:

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

(Go to next question.)

16. What changes will the employer make for the new plan year?

Employer won’t offer health coverage as of this date: (mm/dd/yyyy)

The premium amount will change for the lowest-cost plan that meets the minimum value standard and is available to the employee only. (Premium

should only reflect discounts for tobacco cessation programs. See question 15.)

a. Employee would pay this premium:

b. How often?

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

c. Date of change: (mm/dd/yyyy)

I don’t know if the employer will make changes.

Employer won’t make any of these changes.

* A health plan meets the minimum value standard if pays at least 60% of the total cost of medical services for a standard population and offers substantial coverage of hospital and

doctor services. Most job-based plans meet the minimum value standard.

NEED HELP WITH YOUR APPLICATION?

Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a

language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.