Get UT DOH 116M 2021-2024

DOH/Form 116M 05/2014 Case Employer s Health Insurance Information A l This form MUST be completed by your employer or your company s Human Resources representative. Any blanks left on this form may delay the process. l A form must be completed for each employed household member. You may copy this form* l If you have general questions about this form or the medical programs please call 1-866-435-7414. General Information Employee Information Employee name first m*i. last Employee SSN EIN Phone Address street apt. city state zip Who can we contact about employee health coverage at this job Contact Name Phone Email address oYes oNo 1. Does your company offer health insurance If no skip to section D. Sign and return the form* 2. Is your health insurance a state employee benefit plan 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 If yes name s of person s enrolled 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 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 o weekly o every 2 weeks o twice a month o quarterly o yearly 9. Do you know what change the employer will make for the new plan year If yes complete the following o Employer won t offer health insurance o 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 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 B Employer s Least Expensive Plan or Avenue H Default Plan Questions below refer to the employer s least expensive plan or the Avenue H Default Plan* oYes oNo 1. Does the employee have to enroll in order to add their dependent s 2. When will/did coverage begin mm/dd/yy 3. When does the company s next open enrollment begin mm/dd/yy 4. Complete the charts below. Do not include the cost of dental vision or other coverage if it is separate. Monthly Premium Yearly Health Plan Deductible Employee s Portion Company s Portion Individual amount Employee Family amount Employee spouse Employee child Family C 1.