Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 19
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29DOH Form 116M
ATTACHMENT C
05/2014
EMPLOYER’S HEALTH INSURANCE INFORMATION
Case Name: ________________________________
Case #: _______________________
You will need your employer or company’s Human Resources representative to complete this form.
Complete this form for each employed household member. You may copy this form. If you need more
time to finish this form, please send us the rest of the application so that we can look at your application
D34314000241929
as soon as possible. However, in some situations, we will need the information from this form to help
determine your eligibility. If you have questions regarding this form, please call 1-866-435-7414.
A. General Information
Employee Information
Employee Name:
Employee SSN#:
First
M.I.
Last
Employer Information
Employer Name:
EIN#:
Phone #:
Address:
Street
Apt.#
City
State
Zip
Who can we contact about employee health coverage at this job?
Contact Name
Phone #:
Email address:
Yes
No
1. Does your company offer health insurance? If no, skip to section D. Sign and return the form.
Yes
No
2. Is your health insurance a state employee benefit plan?
Yes
No
3. Is your health insurance offered through Avenue H?
Yes
No
4. Is the employee eligible to enroll in any insurance plan offered?
If no, please explain: _____________________________________________________________
If yes, when is/was the employee eligible to enroll? (mm/dd/yy) ____________________________
Yes
No
5. Is the employee or any family member enrolled in any insurance plan offered?
If yes, name(s) of persons enrolled: _________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Yes
No
6. Has this employee or any family member dropped/changed coverage in the last six months?
If yes, name(s): _________________________________________________________________
If yes, when did coverage end/change? (mm/dd/yy) _____________________________________
Yes
No
7. Does the employer offer a health plan that meets the *minimum value standard?
8. For the lowest-cost plan that meets the *minimum value standard offered only to 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 the wellness programs:
a.
How much would the employee have to pay in premiums for that plan?
$__________________
b.
How often?
weekly
every 2 weeks
twice a month
quarterly
yearly
Yes
No
9. Do you know what change the employer will make for the new plan year?
If yes, complete the following:
Employer won’t offer health insurance
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 not reflect the discount for wellness programs. See question 8.
a.
How much will the employee have to pay in premiums for that plan?
_____________________
b.
How often?
weekly
every 2 weeks
twice a month
quarterly
yearly
*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% of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Page 19
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