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Health Insurance Marketplace
FULL-TIME AND PART-TIME (30 OR OR MORE HOURS PER WEEK)
PART B: INFORMATION ABOUT HEALTH COVERAGE OFFERED BY YOUR EMPLOYER
This section contains information about any health coverage offered by your employer If you you decide to complete an application for coverage in the Marketplace
you will be asked to provide this information information This information information is is is numbered to correspond to the Marketplace
application This dependent dependent child must be a covered dependent dependent on your HCSC health coverage prior to reaching the dependent limiting age of 26 Application and medical documentation are required We do not offer coverage If checked this coverage meets the minimum value standard and and the cost of this coverage to you is is intended to be affordable based on employee wages 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 you visit HealthCare gov to find out if you can get a a a a a tax credit to lower your monthly premiums The information below corresponds to the Marketplace
Employer Coverage Tool Completing this section is 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†?
Yes (Continue)
13a If the employee is not eligible today including as a a a a result of a a a a waiting or probationary period when is the employee eligible for coverage?
_____________________________(mm/dd/yyyy) (Continue)
No (STOP and return this form to employee)
† Regular full and part-time employees are eligible for coverage the the first day of the the month following date of hire 14 Does the employer offer a a a a health plan that meets the minimum value standard*?
Yes (Go to question 15)
No (STOP and return form to employee)
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?
Health Care Service Corporation
36-1236610
300 E Randolph Street 866-977-7378
Chicago
Illinois
60601
Employee Services
11 Phone number (if different from above)
12 Email address
As your employer we offer a a a health plan to: All employees Some employees employees Eligible employees employees are: Full- time time employees employees and part-time employees employees regularly scheduled to work 20 or or or more hours each week With respect to dependents:
We do offer coverage Eligible dependents are: spouse spouse spouse same sex spouse spouse spouse common law spouse spouse spouse registered domestic partner Illinois
civil union partner children (including natural legally adopted stepchildren domestic partner’s children children legal guardianship and children that you have in a a a a a a civil union) dependent children children of your children children are eligible if your child is enrolled as a a dependent on your your your coverage your your your grandchild must qualify as your your your tax dependent dependent disabled dependent dependent child who is is unable to earn a a a a a living is unmarried over the age of 26 and dependent upon you for primary (50 percent or or or more) support may be eligible to continue coverage as a a a a a disabled dependent under this plan beyond age 26