connect for health coloradoCompleting this section is optional for employers, but will help ensure employeesunderstand their coverage choices.Is the employee currently eligible for coverage offered by this employer,or will the employee be eligible in the next 3 months?q Yes (Continue)If the employee is not eligible today, including as a result of a waiting or probationary period, when isthe employee eligible for coverage? (mm/dd/yyyy) (Continue)q No (STOP and return this form to employee)Does the employer offer a health plan that meets the minimum value standard*? q✔ Yes (Continue to the next question) q No (STOP and return form to employee)For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’tinclude family plans): If the employer has wellness programs, provide the premium that the employeewould pay if he/ she received the maximum discount for any tobacco cessation programs, and didn’treceive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ 43.24 b. How often? q Weekly q Every 2 weeks q Twice a month q✔ Monthly q Quarterly q Yearly If the plan year will end soon and you know that the health plans offered will change, continue to the next question. If you don’t know, STOP and return form to employee.What change will the employer make for the new plan year? q Employer won’t offer health coverage q 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. Continue to the next question.)a. How much would the employee have to pay in premiums for this plan? $ q Yearlyb. How often? q Weekly q Every 2 weeks q Twice a month q Monthly q QuarterlyDate 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 costscovered 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)855-PLANS-4-YOU (855-752-6749)TTY: 855-346-3432 ConnectforHealthCO.com2017 Employee Benefits Summary Page 51 of 52
benefit vendor contact informationINSURANCE TYPE BENEFIT GROUP CONTACT WEBSITE VENDOR NUMBER NUMBERBASIC LIFE INSURANCE 679054 (970) 498-5983 Contact County Benefits Staff (970) 498-5986DEFERRED 406342 1-800-842-2252 www.tiaa.org/larimerCOMPENSATION (457)DENTAL INSURANCE 11386 1-800-610-0201 www.deltadentalco.comEMPLOYEE COM589 1-800-272-7255 www.guidanceresources.comASSISTANCE PROGRAM 3214 1-800-950-0105 www.takecareWageWorks.comFLEXIBLESPENDING ACCOUNTSHEARING SERVICES PLAN 1-866-956-5400 www.epichearing.comLONG-TERM DISABILITY 679054 1-866-228-8742 n/aMEDICAL INSURANCE 76-411073 1-800-320-3206 www.umr.comPRESCRIPTION PLAN 1-800-424-0472 www.magellanrx.comRETIREMENT PLAN (401A) 406341 1-800-842-2252 www.tiaa.org/larimerSHORT-TERM DISABILITY 679054 1-866-228-8742 n/aSUPPLEMENTAL 12065186 Amy Griffin www.aflac.comINSURANCE POLICIES 679054 (970) 530-1208 679054VISION INSURANCE 1-800-877-7195 www.vsp.comVOLUNTARY ACCIDENTAL (970) 498-5983 Contact County Benefits StaffDEATH & DISMEMBERMENT (970) 498-5986 Contact County Benefits StaffSUPPLEMENTAL LIFE (970) 498-5983INSURANCE (970) 498-59862017 Employee Benefits Summary Page 52 of 52
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