APPENDIX A
Health Coverage from Jobs
You
DON’T
need to answer these questions unless someone in the household is eligible for health coverage from a job.
Attach a copy of this page for each job that offers coverage.
Tell us about the
job that
offers coverage.
Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these
questions. You only need to include this p ag e when you send in your a ppl i c a t i o n, not the Employer Coverage
Tool
EMPLOYEE Information
EMPLOYER Information
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?
11.
Phone number (if different from above)
( ) –
12. Email address
Tell us about the health
plan
offered by this employer.
•
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)
NEED HELP WITH YOUR APPLICATION? Contact your County DSS (http://www.ncdhhs.gov/dss/local/) or call us at 1-800-662-7030. Para obtener una copia de
este formulario en Español, llame 1-800-662-7030. If you need help in a language other than English, call 1-800662-7030 and tell the customer service representative the
language you need. We’ll get you help at no cost to you. TTY users should call 1-800-452-2514.
14.
15.
16.
DMA-5202-A
13.
Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes
(Continue)
List the names of anyone else who is eligible for coverage from this job.
Name: Name:
Name:
No (
Stop here and go to Step 5 in the application)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage?
______________________________
Print Form
10.
11.
DMA-5202-A
EMPLOYER COVERAGE TOOL
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.
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
Tell us about the
health plan
offered by this
employer
.
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)
NEED HELP WITH YOUR APPLICATION? Contact your County DSS (http://www.ncdhhs.gov/dss/local/) or call us at 1-800-662-7030. Para obtener una
copia de este formulario en Español, llame 1-800-662-7030. If you need help in a language other than English, call 1-800662-7030 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-452-2514.
14.
15.
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)
No (
Stop and return this form to employee)
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)
