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
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
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
−
Natural, adopted, step, or registered domestic partner's children up to age 26
−
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.
** E
ven 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.
I
f 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
to find out if you can get a tax credit to lower your monthly
premiums.
HRM – January 2015
