Appendix A Health Coverage From Jobs Page 2
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2EMPLOYER COVERAGE TOOL
Form Approved
OMB No. 0938-1191
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. Social Security Number
-
-
EMPLOYER Information
Ask the employer for this information.
3. Employer name
4. Employer Identification Number (EIN)
-
5. Employer address (the Marketplace will send notices to this 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 be eligible in the next 3 months?
Yes (Continue)
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) (Continue)
No (STOP and return this form to employee)
Tell us about the health plan offered by this employer.
Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes. Which people?
Spouse
Dependent(s)
No
(Go to question 14)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15)
No (STOP and return form to employee)
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 didn’t 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
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and
return form to employee.
16. What change will the employer make for the new plan year?
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)
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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