Fill - Free fillable Aca Notification Checklist Add Worksheet (California State University Channel Islands) PDF form

Affordable Care Act (ACA) Notification Checklist

This checklist is intended to document and ensure that departments/agencies are providing the legally required notices

to employees for compliance with the ACA. PART I documents the distribution of the legally required Health Insurance

Marketplace Coverage Options Notice to newly hired employees. PART II documents and tracks the distribution of the

legally required Summary of Benefits and Coverage Notice and the health benefit status for employees newly eligible for

health benefits. Both Parts I and II must be completed.

Upon completion, this document must be retained in the employee’s Official Personnel File.

Employee Name:

Hire Date:

Position Number:

SSN:

Tenure/Time Base:

PART I—NEW EMPLOYEES

Notice required to be provided to every new employee in your department/agency within 14 days of their hire date.

1. Health Insurance Marketplace Coverage Options and

Health Coverage Notice (One time notice to all new hires)

Date Provided

Department Representative:

PART II—EMPLOYEES NEWLY ELIGIBLE FOR HEALTH BENEFITS

Health benefit documents to be provided to employees newly eligible for health benefits by the first day the employee is

eligible to enroll in

coverage (e.g. employee is hired on August 12, the following documents must be provided to

employee no later than September 1, the earliest effective date of coverage).

1. Is employee newly eligible for health benefits?

If YES, go to question 2.

If NO, no further action required.

2. Provide the following forms:

 Summary of Benefits and Coverage Notice (One time

notice to newly eligible employees)

 Declaration of Health Coverage (Form HBD-12A)

 Health Benefits Enrollment (Form HBD-12)

Date Provided

Department Representative:

HUMAN RESOURCES OFFICE USE ONLY

Agency/Department Name:

Reviewer’s Printed Name:

Contact Number:

I certify that data stated herein is

correct, complete, and in accordance

with all laws and regulations.

Reviewer’s Name/Signature:

Date:

HEALTH INSURANCE

MARKETPLACE

COVERAGE OPTIONS

NOTICE

HEALTH BENEFITS

ELIGIBLE?

YES OR NO

HEALTH BENEFITS NOT

OFFERED

(2A, 2B, BD)

HEALTH BENEFITS

OFFERED

(1A)

HEALTH BENEFITS ACCEPTED

(3A, 3B)

HEALTH BENEFITS

DECLINED

(4A, 4B)

HEALTH BENEFITS CANCELLED

OR TEMPORARILY

SUSPENDED

(5A, 5B, 5C, 5D)

ACAS TRANSACTIONS

COMPLETED

(INITIALS)

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

New Health Insurance Coverage Options and Your Health Coverage

PART A: General Information

When key parts of the health care law took effect in 2014, there was a new way to buy health insurance in California.

To assist you as you evaluate options for you and your family, this notice provides some basic information about a new Marketplace called

Covered California, and employment-based health coverage offered by your employer.

What is Covered California?

Covered California can help you find health insurance that meets your needs and fits your budget. Covered California offers "one-stop shopping"

to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium

right away. Open enrollment for health insurance coverage through Covered California began in October 2013 for coverage that started January

1, 2014.

Can I Save Money on my Health Insurance Premiums in Covered California?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that

doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through Covered California?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through

Covered California and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly

premium or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets

certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5%

of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through Covered California instead of accepting health coverage offered by your employer, then you may

lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee

contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for

coverage through Covered California are made on an aftertax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please contact: HR Benefits Office (Insert Benefits Office contact information

here), check the campus HR benefits website (Insert link) or summary plan description.

Covered California can help you evaluate your coverage options, including your eligibility for coverage through Covered California and its cost.

Please visit www.coveredca.com

or call 888-975-1142 for more information.

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.

HRM – July 2015

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in

Covered California, you will be asked to provide this information. This information is numbered to correspond to the Covered California

application.

3. Employer name

4. Employer Identification Number (EIN)

5. Employer address

6. Employer phone number

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

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are:

Regular appointment – employee is appointed in a benefits eligible classification with a time base of at least half-time (0.5 Full Time

Equivalent (FTE)) and with a length of appointment for at least six months and one day; or

AB 211 appointment – Lecturers and Coaches (R03) in applicable year class codes who are appointed for at least six (6) weighted

teaching units (WTUs) (i.e., 0.4 time base/FTE) for at least one semester or two consecutive quarters;

If an employee does not meet CSU’s standard benefits eligibility criteria listed above, and is appointed with at least 0.75 time base/FTE

or higher regardless of length of appointment (duration) or hired to work 130 hours or more per month over the course of the appointment;

or works an average of 130 hours or more per month during any measurement period.

• With respect to dependents:

We do offer coverage. Eligible dependents are:

− Current spouse/registered domestic partner

− Disabled children of any age if enrolled prior to age 26

− Children up to age 26 for whom the subscriber has assumed a parent-child relationship and is considered the

primary care parent

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be

affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through Covered

California. Covered California will use your household income, along with other factors, to determine whether you may be eligible

for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on

a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium

discount.

If you decide to shop for coverage in Covered California they will guide you through the process. Here's the employer information you'll enter

when you visit Covered California to find out if you can get a tax credit to lower your monthly premiums.

HRM – July 2015

City

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