Appendix A Health Coverage From Jobs
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1
2APPENDIX 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 (Continue)
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:
No (Stop here and go to Step 5 in the application)
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 cessation 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
Once a month
Quarterly
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 will the employee have to pay in premiums for that plan?
b. How often?
Weekly
Every 2 weeks
Twice a month
Once a month
Quarterly
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?
If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437)
Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency
at 1-800-362-1504. You may also leave a message at anytime or email us at ALLKids@adph.state.al.us.
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