The Insurancenter
Dear (Contact First Name),

As part of Health Care Reform (HCR) employers are required to notify their employees of the upcoming availability of the Health Care Exchanges or Insurance Marketplaces. Exchanges or Marketplaces are due to be operational on 01-01-14 with open enrollment to begin 10-01-13.

Any employer, subject to the Fair Labor Standards Act (FLSA), is required to make this notification to all current employees no later than 10-1-13. New employees are to be notified as part of the hiring process.

You can use this helpful online tool to determine whether or not your business is subject to the FLSA and thereby, this notice: 

Below is a model notice, for your viewing information only, issued by HHS in anticipation of the 10-1-13 deadline. You should use the following link to download a clean, fillable copy of the model notice:  DOL FLSA Model Notice for Employers.

If we are alerted to any changes made within this model notice, we, as your benefit consultant, will let you know.  

Plans should be made to distribute this notice to all current employees by the due date.  This notice  contains all the required information, as of the date of this posting.   Please read it carefully prior to distributing. 

Please call or contact us if you have any questions. All of this information is readily available on The Insurancenter Facebook page for your convenience.

New Health Insurance Marketplace Coverage

Options and Your Health Coverage 

Form Approved

OMB No.1210-0149

(expires 11-30-2013) 


PART A: General Information


When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by your employer.


What is the Health Insurance Marketplace?


The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace 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 the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.


Can I Save Money on my Health Insurance Premiums in the Marketplace?


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 the Marketplace?


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 the Marketplace 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.1


Note: If you purchase a health plan through the Marketplace 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 the Marketplace are made on an after-tax basis.


How Can I Get More Information?


For more information about your coverage offered by your employer, please check your summary plan description or contact: ______________________________________________________________________________________


The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.






´┐ŻAn 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.


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 the Marketplace, you will be asked to provide this information. This information is numbered to 

correspond to the Marketplace 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:




 * With respect to dependents:


[  ]  We do offer coverage. Eligible dependents are:





[  ]  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 the Marketplace. The Marketplace 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 the Marketplace, 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.


The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employees understand their coverage choices.


13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?


[  ]  Yes (Continue)


13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage?___________________________ (mm/dd/yyyy) (Continue)


[  ]  No (STOP and return this form to employee)




14. Does the employer offer a health plan that meets the minimum value standard*?

         [  ]  Yes (Go to question 15)                       [  ]  No (STOP and return form to employee)



15. For the lowest-cost plan that meets the minimum value standard* offered only to the 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 didn't receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $_______________________


b. How often?  [  ]  Weekly      [  ]  Every 2 weeks     [  ]  Twice a month     [  ]  Monthly     [  ]  Quarterly        [  ]  Yearly



If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee.



16. What change will the employer make for the new plan year?


[  ]  Employer won't offer health coverage


[  ]  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. See question 15.)


a. How much will the employee have to pay in premiums for that plan? $______________________________


b. How often?  [  ]  Weekly      [  ]  Every 2 weeks     [  ]  Twice a month      [  ]  Monthly        [  ]  Quarterly      [  ]  Yearly


Date 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 costs covered 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