NEW YORK STATE DEPARTMENT OF HEALTH
Division of Eligibility and Marketplace Integration
Your Employee may be eligible for help in paying for health insurance premiums. Please provide information about the health insurance offered
by your company. It will be used to determine if New York State can pay for the employee’s share of the premium. Pursuant to Social Services Law
Section 143, all employers of any kind doing business within the State of New York are required to furnish to the social services official and the
NYSoH, information about employees including information regarding health insurance coverage. Failure to do so may result in court action
and penalties.
Employee
Last Name: First Name:
Address:
Is this individual currently enrolled in health insurance coverage through employment with you? YES Complete Section A
NO Complete Section B
Does this individual have health insurance available to him/her now or in the future through employment with you? YES Complete Section A
NO Complete Section B
SECTION A
Name of person completing form: Phone: ( ) - Date: / /
Employer Name:
Insurance Carrier/Union Name: Carrier Phone: ( ) -
Carrier Address: Group # Policy #
Name of Covered Individuals
Family, Couple, or
Individual Coverage?
Health, Dental,
or Vision Plan?
Eligibility
Start Date
Monthly Employee
Premium
$
$
$
$
What is the standard: Deductible $ Co-Insurance $ Co-payments $
Attach a separate piece of paper if additional space is needed.
Scope of Benefits: Please check all that apply and attach a plan summary
Inpatient Hospital Outpatient Services Physician – Hospital Physician – Office Emergency Services
Home Health Services Durable Medical
Equipment
Vision Care/ Eyeglasses Inpatient Substance
Abuse Treatment
Outpatient Substance
Abuse Treatment
Diagnostic Lab/Xray Psychiatric Inpatient Psychiatric Outpatient Nursing Home Hospice
Medical Transport Dental Prescription Drug Clinic
SECTION B
If employee is NOT enrolled in an employer-sponsored health care plan, check the applicable box and attach the information requested.
Health insurance is not provided to our employees
Employee is not currently eligible to enroll, but may enroll on (date) / /
Employee is not eligible for health care coverage because:
Employee is eligible for health insurance, but has not enrolled
Attach the plan(s) summary of benefits the employee, spouse and dependents may be eligible for; and the employee cost for the benefits
If your employee is determined to be eligible to receive premium assistance in paying his/her share of the premium cost, would you accept direct
payment from the New York State of Health? YES NO If yes, Employer FEIN or Tax ID#
Return form to: Or fax to: For questions, call:
New York State of Health 1-855-900-5557 1-855-355-5777
P.O. Box 11727 (TTY: 1-800-662-1220)
Albany, New York 12111
DOH-5106 (8/14)
NYSOH – Employer Sponsored Health Insurance
Request for Information
