EHB Notices

//5<I-\\. New Health Ineurance Marketplace Covcrege Fo.rn App6,JUy\{tatz Optione and Your Hcalth Coverage OMB l{o. l21o.Olag (.tplr.. l.3l.2Ol7)PART A: General InformationWhen key parts ol the h€alth cer€ law lake elfecl in 2O14. lh€re will be a n6w way to buy health insurance: the Healthlnsurance Marketplace. To 6ssisl you os you evaluate oottons lor you and your lamit. lhis nolice provides 6ome bssiclntormation about the new Mark€lplac€ and omploymenl-boaed h€alIh coverage otlsr€d by your €mployer.Whrt to the Hoalth Inrurancr M.rk tpl.cc?Thg Markelplaco rs desroned to halp you lind hoallh insurarlcs thal moets your needs 9nd lils your bqdg€l. theMark€tplace ollers \"on€-6top shopping' lo tind and compar€ private h€allh insuranc€ options. You mdy also be €ligiblelor e n€w klnd ot lax crodit lhal low€rs your monthly prcmlum riohl away. Open enrollmanl lor heallh insurancocoveraoe through the Marketplsc€ begins in Oclober 2013 lor cowraOe stcrting as €6aly as January 1, 2014.Con I Savc Moicy on my Hotlth lnturaoco Prrmlum! In thc Mrrkotplaoo?You msy quality lo savo monoy Bnd lower your monthly prcmium, bul only It your €mployer do€s not olter covorage. ototlers coveraga lhat doesn't me€l certain standsrds. The savings on youf premium th6l you're elioible lor deponds onyour hous€hold income.Docr Emplolrcr Hcalth Covcragla Affcct Ellglblllty for Pr.rnlum S!v|n93 through ths Markctplaco?Yes. ll you h6vc an ollor ol hgalth covorao€ ttom your employ€r lhal mo6ls cerlaln standards, you will not be gligablelor e lex credit lhrough the Markalplace 6nd may wish to onroll in your emgloyer's heallh phn. Howav6r. you may b€6llglbls tor a tax credil that lowGr6 your fionlhly premium, or a reduollon in cedain cost-sh6rlno il your employor doosnol oll6r covorago lo you al all or does nol ofl6r coveraoo lhat meel6 cerlain slandards. lf the cost ol a glan trom youremployer lhal would cov€r you (and nol any olher memborG of your tamiv) is more lhan 9.5 o1 your householdincome fo. lhe year. or rl lha covoraoe your amoloy€r providas do6s nol m66l lhe 'minimum vslus\" standard sel by thoAllordable Care Acl, you m6y be oligiblo lor a tax credil.'Nota: It you purchaso a health plan through the Ma.k€tplace instead ot ecc€pting h€ellh coverege ollered by youlernployor. thon you tnay lose th€ €mploy€r conlrlbution (ll eny) to lhe 6mployer-olte,6d coverage- A160, this €mployercont,ibution -as woll as youa omployee conlribution to employer-olterod covorage- is otten excludod trom incoma lorFedo.al and Slate incomo tet psrpos€s. Your psyments lor covsraoa thaough tho Ma.kolplace are mado oo an aftgr-lax basas.Horv Can I Gct Mo.e Intormttlon?For more inlolanlIion aboul your covetaoo oltered by your employer. ploese check youa summsry plan dsscriDtion orcontoct Dianc Clrss€r, EHB Spccialist 94l -74t-450t 16103 or [email protected] Mark€tplaca can help you ovalual€ your cove.agq option6, includ1.t0 you, eliOibilily lor cov€rage lhrough theMatkelplace snd ils cosl. Please viiit Heslthc€.o.gov for more inlormation, including an onllne spplicetlon lof heallhinsuaance coverage and contacl inloamalion lor 6 Heallh InGUranc6 Markolplaco in youl ar6a.' 4. omploy€r-sponsored hoallh plln m€€!3 th. 'mmimum vduo rt.nctard' 't tha ptsn's !h6re ot the totat.fiowad bon€tit co3t6 cov.rodby lh6 pl€n I .o b33 rhan OO percent ot 6!ch co!t3,

PABT B: lnformation About Health Coverage Offered by Your EmployerThrs section conlsrns Inlotmalion aboul sny he€lth coverage olleted by your employer. It you decide lo complele snapDlcalron lor cove.age In lhe MarketDlace, you will be asked lo provide thas anlormation. This information is numberedto co(espood lo the Marketplace applicataon.3. BnpbyEr narn€ {. E loy.r ld€ndfit tur Nqnb.i (El ) MANATEE COI'NTY BOARD OF COUNTY COMMISSIONERS 59.fown1I I 12 MANATEF AVENI'E WEST 941-?48-{501BRADENION corrcf€ge cln wc DIANE CLASSER. EHB SPECIALISTl{ere rs some basrc anlormalion about health coveraoe ollcred by this emOloyer: .ns your employer, we olter a health plan to. D All employees. €tiqible employees sre: Pl Some employees. Elgible emptoyees are: Full lime employecs, elccled otiicials ofColcmmcntal tJnits panicipating in thc plan. retired employceri \\-ho ucrc panicipaling in thc plal on the day before thcir rctircmcnt date and who are cligible for and rcccrvrng pcriodic payments of bcnefits from the F'lorida Retrrement Systen u'loul penalty are eligiblc lbr enrollmcnt in lhc plan..Wilh resDectgtol deD6ndehls: We do oller coverage_ El€ibte ctependents sre: |. '[hc Wife or llusband ofan eligible emplo],ce. 2. Any child ofan eligiblc cmployec \rho rs undcr (hc age of26. 3. A child ofan eligible employec who is agc 26 to 30. who is (a) unmarried, (b) does not have a dcpendcnl of his/hcr own. (c) is I residenl of Florida or a full-timc or pan-tirnc studcnr, ard is (d) nol provided coveragc as a named subscribcr. insured, enrollee. or covcred p€rson undcr any oth€r group, blankct. or franchise health insurance policy or individual heallh benefils plan. or is not cntitlcd to bencfits under Title X\tlll ofthc Social Sccuriry Acr. B We do nol oller coveraOe_ E) ll checkod, lhis covetage rneets lhe mrnrmum valuo slondarcl, and the cosl ol lhrs coveraoe to yor., rs Intsnded to be allordable, b6sed on employee wages. \" Even rl your employer inlends your coveraOe to be allordable. you may still be eligible for a premtum discounl lhrough lhe Mafkelploce. The Mdrketplace will use your housahold income. along with other taclors, lo dol€rmlne whell'ier yotr m€y be eliqible lor a premium dtscounl, l{, lor example. yor./r wag€s vBry lrom week lo week (perhaps you ate an hourly employee or you work on o commission basis), il you are newly employed mid-year. or il you h:rve olher incorne loss€s. you may slill qualily lor fl premium discountll you decido lo shop lor covefage In lhe Msrketplace, flc{tlttrcare.Oov will gurd€ you throuoh the process. Here s lheemployer Inlormalion you ll enler when you visrl l lea llhcare. oc,! lo lind oul il you can qet a lar credit lo lower vourmonthly prem,ums.

Ihe anlorfnation bolow cotresponds lo the Marketplace Emoloyer Coveraoe lool- Complelino this section is oplional loremployers, bul will h€lp ensure employees understand their cove.aOe choiCes. 15 ttre €mploylc clrtlndy ellglbls to. cov.rage offGrad by thl6 amployat, or wlll lfia .mploya. bG .llglblc In thc next 3 montfi.? O Yea (Continue) 13a. lf the employee is hot eligible today, induding as a rcsult of a waitng or probationary period, when is the empbt€e eligible foi coverag€?- (mm/ddlyyyy) (Condnu€) O ll|o (STOP and return this form to emplo),ee)lf. Dqqr ttle 1cemodootrqcur cosfoi€orn a ]EXn C!.t t|r!t rEals thc mHmJrfr rat c danded? .||rplotrr) ! ves 15) E No (SIOP rnd llnm form b!5. 6Fottrl|tyhephlor|$3/)G: f!t-tchtc dtn that tncct3 $G lfln&fxrn valuc sbrxbd., ofhrtal c| t b tl|. ]rdoyaa ({bnt tidudc .mdo}t€r hr3 r,*|G!8 pfogr.mq p|o\rlde th. pignt,|n t|t!pde!€r|EllonfyninottnErorudUtsEpoarymttsf thlt tpJ shc ltch/ed ttE tmxtmun dri@unt for rny Eba@ crlsdm prograrrF, rnd ddnt b|s!d on iraln€ss programS\" rGtrIdwtctE.tdcryngfalqarcrrhyarEz nb rri5*yiin lfqlrrlunnrEcfoa. rtHnso*n.f&r a, Hory nxrdr 3'E Mont*v EIqra.E fy D ycatt b. !9f 4l]know, STOP and retutn lorm lo emDlov€e,16. What d€nge wlll the employer rnake for tt|e r|ew plan year? Employer won't ofrer health O Employcr willstart offcring coverage or d|ange tf|e prcmium for th€ lowest-cost plan o hcalth correrag€ to employe€s available only to the empaoyee tfEt meets the minimum value standard.* (Premium should ref,ect the discount for wellness prograrns. See question f5.) a. Ho, mudr would tt€ employe€ h.ve to pay in premlums for thls plan? g_ b. often? D llonttrty I erarteAy D yearty How D Weekly ElEvcry 2 ureeks f] Twte a month. An .mployst-soonsorod h€.llh Dl6n 6€6t6 th€ mtnrmum vatue st6.dard, it the plan s shste ot th6 rotat attowect bonetrt rhe olan 's no less rhan 60 oorc€nr ot such costs (Soctron 368(c) (2) (C) {rl) or the Inrehat Revenu€ C6de ot j 9A6)