Form 116M "Employer Health Insurance Information" - Utah

What Is Form 116M?

This is a legal form that was released by the Utah Department of Workforce Services - a government authority operating within Utah. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2014;
  • The latest edition provided by the Utah Department of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 116M by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form 116M "Employer Health Insurance Information" - Utah

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DOH/Form 116M 05/2014
Case#:_______________
Employer's Health Insurance Information
l This form MUST be completed by your employer or your company’s Human Resources
representative. Any blanks left on this form may delay the process.
l A form must be completed for each employed household member. You may copy this form.
l If you have general questions about this form or the medical programs, please call
1-866-435-7414.
A
General Information
Employee Information
Employee name _______________________________________
Employee SSN#_________________
(first, m.i., last)
Employer Information
Employer Name: ___________________________________________________________________________________________
EIN#:___________________________________________________
Phone #:________________________________________
Address:__________________________________________________________________________________________________
street
apt.#
city
state
zip
Who can we contact about employee health coverage at this job?
Contact Name:_____________________________________________________________________________________________
Phone #:_________________________________________________
Email address:__________________________________
oYes oNo
1. Does your company offer health insurance? If no, skip to section D. Sign and return the form.
oYes oNo
2. Is your health insurance a state employee benefit plan?
oYes oNo
3. Is your health insurance offered through Avenue H?
oYes oNo
4. Is the employee eligible to enroll in any insurance plan offered?
If no, please explain: ________________________________________________________________________
If yes, when is/was the employee eligible to enroll? (mm/dd/yy)_____________________________________
oYes oNo
5. Is the employee or any family member enrolled in any insurance plan offered?
If yes, name(s) of person(s) enrolled:___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
oYes oNo
6. Has this employee or any family member dropped/changed coverage in the last six months?
If yes, name(s): ____________________________________________________________________________
If yes, when did coverage end/change? (mm/dd/yy) ______________________________________________
Does the employer offer a health plan that meets the * minimum value standard?
oYes oNo
7.
8. For the lowest-cost plan that meets the * minimum value standard offered only to 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 did not receive any other
discounts based on the wellness programs:
a. How much would the employee have to pay in premiums for that plan? $__________________________
b. How often?
o weekly
o every 2 weeks
o twice a month o quarterly o yearly
oYes oNo
9. Do you know what change the employer will make for the new plan year?
If yes, complete the following:
o Employer won’t offer health insurance
o 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 not reflect the discount for wellness programs. See question 8.
a. How much will the employee have to pay in premiums for that plan?
$____________________
b. How often?
o weekly
o every 2 weeks
o twice a month o quarterly o yearly
*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% of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
DOH/Form 116M 05/2014
Case#:_______________
Employer's Health Insurance Information
l This form MUST be completed by your employer or your company’s Human Resources
representative. Any blanks left on this form may delay the process.
l A form must be completed for each employed household member. You may copy this form.
l If you have general questions about this form or the medical programs, please call
1-866-435-7414.
A
General Information
Employee Information
Employee name _______________________________________
Employee SSN#_________________
(first, m.i., last)
Employer Information
Employer Name: ___________________________________________________________________________________________
EIN#:___________________________________________________
Phone #:________________________________________
Address:__________________________________________________________________________________________________
street
apt.#
city
state
zip
Who can we contact about employee health coverage at this job?
Contact Name:_____________________________________________________________________________________________
Phone #:_________________________________________________
Email address:__________________________________
oYes oNo
1. Does your company offer health insurance? If no, skip to section D. Sign and return the form.
oYes oNo
2. Is your health insurance a state employee benefit plan?
oYes oNo
3. Is your health insurance offered through Avenue H?
oYes oNo
4. Is the employee eligible to enroll in any insurance plan offered?
If no, please explain: ________________________________________________________________________
If yes, when is/was the employee eligible to enroll? (mm/dd/yy)_____________________________________
oYes oNo
5. Is the employee or any family member enrolled in any insurance plan offered?
If yes, name(s) of person(s) enrolled:___________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
oYes oNo
6. Has this employee or any family member dropped/changed coverage in the last six months?
If yes, name(s): ____________________________________________________________________________
If yes, when did coverage end/change? (mm/dd/yy) ______________________________________________
Does the employer offer a health plan that meets the * minimum value standard?
oYes oNo
7.
8. For the lowest-cost plan that meets the * minimum value standard offered only to 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 did not receive any other
discounts based on the wellness programs:
a. How much would the employee have to pay in premiums for that plan? $__________________________
b. How often?
o weekly
o every 2 weeks
o twice a month o quarterly o yearly
oYes oNo
9. Do you know what change the employer will make for the new plan year?
If yes, complete the following:
o Employer won’t offer health insurance
o 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 not reflect the discount for wellness programs. See question 8.
a. How much will the employee have to pay in premiums for that plan?
$____________________
b. How often?
o weekly
o every 2 weeks
o twice a month o quarterly o yearly
*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% of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
B
Employer’s Least Expensive Plan or Avenue H Default Plan
Questions below refer to the employer’s least expensive plan or the Avenue H Default Plan.
oYes oNo
1. Does the employee have to enroll in order to add their dependent(s)?
2. When will/did coverage begin? (mm/dd/yy)__________________________________
3. When does the company’s next open enrollment begin? (mm/dd/yy) ____________
4. Complete the charts below. Do not include the cost of dental, vision or other
coverage if it is separate.
Monthly Premium
Yearly Health Plan Deductible
Employee’s Portion
Company’s Portion
Individual amount
$
Employee
$
$
Family amount
$
Employee + spouse
$
Employee + child
$
Family
$
C
Employee’s Health Plan Choice
Questions below refer to the plan that the employee has selected. Questions 3-7 refer to “in-network” benefits.
1. Insurance company and plan name: ____________________________________________________________
2. Policy number, if known: ______________________________________________________________________
oYes oNo
3. Is the deductible $2,500 or less per individual?
oYes oNo
4. Is the lifetime maximum benefit $1,000,000 or more?
oYes oNo
5. Does the plan pay at least 70% of an inpatient stay (after the deductible)?
6. What benefits are covered under this plan? (Check all that apply.)
o Physician visits
o Hospital inpatient services
o Pharmacy/Rx
oYes oNo
7. Does the plan cover abortion services?
If yes, under what circumstances:
o Only in the case where the life of the mother would be endangered if the fetus were carried to
term or in the case of incest or rape
o Other, please describe:______________________________________________________________________
8. Complete these charts only if they are different from the charts in Section B above. Do not include the cost of
dental, vision or other coverage if it is separate.
Yearly Health Plan Deductible
Monthly Premium
Individual amount
$
Employee’s Portion
Company’s Portion
Employee
$
$
$
Family amount
Employee + spouse
$
Employee + child
$
Family
$
oYes oNo
9. Are the employee’s children currently enrolled or do they plan to enroll in your company’s
dental plan? If yes, name(s):___________________________________________________________________
D
Signature
I certify that I am a representative of the Human Resource Department, or that I am the health insurance
contact person. The information on this form is true and correct to the best of my knowledge.
Signature: _________________________________________________________ Date: _________________________________
Name (please print): ________________________________________________________________________________________
Title: ____________________________________________________________ Phone: __________________________________
Please return completed form to:
Department of Workforce Services, PO Box 143245, SLC, UT 84114-3245
Fax: 1-801-526-9500
Toll-free Fax: 1-877-313-4717
Equal Opportunity Employer/Program: Auxiliary aids and services are available upon request to individuals with disabilities by calling
(801) 526-9240. Individuals with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
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