Health Insurance Marketplace Coverage Options and Your Health

Health Insurance Marketplace Coverage

Options

and Your

Health Coverage

Form Approved

OMB No.

1210-0149

(expires 12-31-2026)

PART A: General

Information

Even if you are offered health coverage through your employment, you may have other coverage options through the

Health Insurance Marketplace (“Marketplace”). To assist you as you evaluate options for you and your family, this notice

provides some basic information about the Health Insurance Marketplace and health coverage offered through your

employment.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace

offers "one-stop shopping" to find and compare private health insurance options in your geographic area.

Can I Save Money on my Health Insurance Premiums in the

Marketplace?

You may qualify to save money and lower your monthly premium and other out-of-pocket costs, but only if your employer

does not offer coverage, or offers coverage that is not considered affordable for you and doesn’t meet certain minimum

value standards (discussed below). The savings that you're eligible for depends on your household income. You may also

be eligible for a tax credit that lowers your costs.

Does Employment-Based Health Coverage Affect Eligibility for

Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that is considered affordable for you and meets certain

minimum value standards, you will not be eligible for a tax credit, or advance payment of the tax credit, for your

Marketplace coverage and may wish to enroll in your employment-based health plan. However, you may be eligible for a

tax credit, and advance payments of the credit that lowers your monthly premium, or a reduction in certain cost-sharing, if

your employer does not offer coverage to you at all or does not offer coverage that is considered affordable for you or meet

minimum value standards. If your share of the premium cost of all plans offered to you through your employment is more

than 9.12%

of your annual household income, or if the coverage through your employment does not meet the "minimum

value" standard set by the Affordable Care Act, you may be eligible for a tax credit, and advance payment of the credit, if

you do not enroll in the employment-based health coverage. For family members of the employee, coverage is considered

affordable if the employee’s cost of premiums for the lowest-cost plan that would cover all family members does not

exceed 9.12% of the employee’s household income.

.12

Note:

If you purchase a health plan through the Marketplace instead of accepting health coverage offered through your

employment, then you may lose access to whatever the employer contributes to the employment-based coverage. Also,

this employer contribution -as well as your employee contribution to employment-based coverage- is generally excluded

from income for federal and state income tax purposes. Your payments for coverage through the Marketplace are made on

an after-tax basis. In addition, note that if the health coverage offered through your employment does not meet the

affordability or minimum value standards, but you accept that coverage anyway, you will not be eligible for a tax credit. You

should consider all of these factors in determining whether to purchase a health plan through the Marketplace.

Indexed annually; see https://www.irs.gov/pub/irs-drop/rp-22-34.pdf for 2023.

An employer-sponsored or other employment-based 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.

For purposes of eligibility for the premium tax credit, to meet the “minimum value standard,” the health plan must

also provide substantial coverage of both inpatient hospital services and physician services.

When Can I Enroll in Health Insurance Coverage through the

Marketplace?

You can enroll in a Marketplace health insurance plan during the annual Marketplace Open Enrollment Period. Open

Enrollment varies by state but generally starts November 1 and continues through at least December 15.

Outside the annual Open Enrollment Period, you can sign up for health insurance if you qualify for a Special Enrollment

Period. In general, you qualify for a Special Enrollment Period if you’ve had certain qualifying life events, such as getting

married, having a baby, adopting a child, or losing eligibility for other health coverage. Depending on your Special

Enrollment Period type, you may have 60 days before or 60 days following the qualifying life event to enroll in a

Marketplace plan.

There is also a Marketplace Special Enrollment Period for individuals and their families who lose eligibility for Medicaid or

Children’s Health Insurance Program (CHIP) coverage on or after March 31, 2023, through July 31, 2024. Since the onset of

the nationwide COVID-19 public health emergency, state Medicaid and CHIP agencies generally have not terminated the

enrollment of any Medicaid or CHIP beneficiary who was enrolled on or after March 18, 2020, through March 31, 2023. As

state Medicaid and CHIP agencies resume regular eligibility and enrollment practices, many individuals may no longer be

eligible for Medicaid or CHIP coverage starting as early as March 31, 2023. The U.S. Department of Health and Human

Services

is offering a temporary Marketplace Special Enrollment period to allow these individuals to enroll in

Marketplace coverage.

Marketplace-eligible individuals who live in states served by HealthCare.gov and either- submit a new application or update

an existing application on HealthCare.gov between March 31, 2023 and July 31, 2024, and attest to a termination date of

Medicaid or CHIP coverage within the same time period, are eligible for a 60-day Special Enrollment Period.

That means

that if you lose Medicaid or CHIP coverage between March 31, 2023, and July 31, 2024, you may be able to enroll in

Marketplace coverage within 60 days of when you lost Medicaid or CHIP coverage.

In addition, if you or your family

members are enrolled in Medicaid or CHIP coverage, it is important to make sure that your contact information is up to date

to make sure you get any information about changes to your eligibility. To learn more, visit HealthCare.gov or call the

Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325.

What about Alternatives to Marketplace Health Insurance

Coverage?

If you or your family are eligible for coverage in an employment-based health plan (such as an employer-sponsored health

plan), you or your family may also be eligible for a Special Enrollment Period to enroll in that health plan in certain

circumstances, including if you or your dependents were enrolled in Medicaid or CHIP coverage and lost that coverage.

Generally, you have 60 days after the loss of Medicaid or CHIP coverage to enroll in an employment-based health plan, but

if you and your family lost eligibility for Medicaid or CHIP coverage between March 31, 2023 and July 10, 2023, you can

request this special enrollment in the employment-based health plan through September 8, 2023. Confirm the deadline

with your employer or your employment-based health plan.

Alternatively, you can enroll in Medicaid or CHIP coverage at any time by filling out an application through the Marketplace

or applying directly through your state Medicaid agency. Visit https://www.healthcare.gov/medicaid-chip/getting-

medicaid-chip/ for more details.

How Can I Get More Information?

For more information about your coverage offered through your employment, please check your health plan’s summary

plan description or contact

________________________________________________________________________________________________________

______________.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit

HealthCare.gov

for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

PART B: Information About Health Coverage Offered by Your

Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to

correspond to the Marketplace application.

Employer name

Employer Identification Number (EIN)

Employer address

Employer phone number

City

State

9. ZIP

code

Who can we contact about employee health coverage at this job?

11. P

hone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

•

As your employer, we offer a health plan to:

All employees. Eligible employees are:

Some employees. Eligible employees are:

•

With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be

affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount

through the Marketplace. The Marketplace will use your household income, along with other factors, to

determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to

week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-

year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace,

HealthCare.gov

will guide you through the process. Here's the

employer information you'll enter when you visit

HealthCare.gov

to find out if you can get a tax credit to lower your monthly

premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for

employers, but will help ensure employees understand their coverage choices.

13.

Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in

the next 3 months?

(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)

(STOP and return this form to employee)

14. Does the employer offer a health plan that meets th

e minimum value standard*?

es (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 Monthly 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?

mployer won't offer health coverage

ployer 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.)

• 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)

How much would the employee have to pay in premiums for this plan? $

b. How often?

eekly

very 2 weeks

wice a month

Monthly Quarterly Yearly