WELCOME TO OPEN ENROLLMENT

The open enrollment period for all FULL TIME EMPLOYEES to our health care plan for the coverage period of 4/1/23 through 3/31/24 begins on 4/1/23 and closes by 4/27/23. This is the opportunity to enroll if you are not currently enrolled or the opportunity to make needed changes to your information without a qualifying event. Full time employees define as employees working 30 or more hours per week. (or 130 hours a month). A full time employee will qualify for insurance after working for a consecutive 12 weeks with full time hours.

MINIMUM ESSENTIAL COVERAGE (MEC)

According to the Affordable Care Act (ACA), more commonly referred to as Obamacare, all individuals must have at least Minimum Essential Coverage (MEC) For January 1, 2019 and beyond, taxpayers are still required by law to have minimum essential coverage or qualify for a coverage exemption. However, under the TCJA, you no longer need to make a shared responsibility payment or file Form 8965 with your tax return if you don’t have minimum essential coverage for part or all of 2019. – As cited on irs.gov.

THE FOLLOWING HEALTH INSURANCE PLANS ARE CURRENTLY AVAILABLE

MEC Basic: Covers all preventive services 100% and includes telehealth and prescription discounts.

Ultra MEC: Covers all preventive services 100%, primary care visits at a $15 copay, urgent care at a $50 copay and discounts on additional services such as specialist visits, labs and x-rays. Ultra MEC also includes Virtual Health and prescription drug benefits.

Ultimate MEC: Covers all preventive services 100% and office visits, urgent care, labs and x-rays offered at various copays. Ultimate MEC includes Virtual Health and prescription drug benefits.

Minimum Value 8150: This plan has a $8,150 individual deductible and covers additional medical services such as emergency room care, hospitalization and inpatient services at referenced-based pricing, paying 120% of the Medicare allowable fee schedule. Patients will be balanced billed for any costs greater than the Medicare allowable amount. All non-preventive and copay services are subject to the $8,150 deductible. The deductible must be met before additional coverage takes effect. Minimum Value Plans are subject to affordability. Employees will not pay more than 9.61% of their pay toward employee only coverage.

ACKNOWLEDGEMENT OF RECEIPT

I, , hereby acknowledge receipt of the 2023-2024 offer of health benefits. I have been provided with the Enrollment Guide and with the information pertaining to the benefit plan offering. I have been offered a plan for myself and my qualified dependents that provides Minimum Essential Coverage (MEC).

Please choose 1:

I CHOOSE to DECLINE coverage at this time. I acknowledge that I and/or my dependent(S) may have to wait until the plan's next open enrollment period, or have a qualifying event, to request group coverage and that i may not qualify for a subidy on the PPACA Health Exchange. I also Acknowledge that i could be subject ot a penalty under the Individual Mandate.

I CHOOSE to ACCEPT coverage at this time. I authorize my employer to make salary reductions on a pretax basis for my portion of the group insurance premiums. I understand that:

• I cannot change this election during the plan year unless I have a change in status as provided in the Internal Revenue Code and Regulations.
• My Social Security benefits may be reduced by this election.
• This election replaces any previous elections and will terminate on the earlier of (1) when I am no longer being paid compensation in an amount at least equal to my total salary reduction or (2) termination of the plan.
• My employer may reduce or cancel this election if necessary to comply with provisions of the Internal Revenue Code.

Print name:

Social Security Number:

Reset Signature

PLEASE COMPLETE THE NEXT SECTION ONLY IF YOU CHOOSE TO ACCEPT COVERAGE

Name	Social Security Number
Employer	Hire Date
Date of Birth	Sex Male Female
Address	Phone Number
City/State/Zip	Email

Name	Name
Social Security Number	Social Security Number
Date of Birth	Date of Birth
Male Female Spouse Child	Male Female Spouse Child

Name	Name
Social Security Number	Social Security Number
Date of Birth	Date of Birth
Male Female Spouse Child	Male Female Spouse Child

I hereby acknowledge the offer of health insurance coverage, providing Minimum Essential Coverage (MEC) and Minimum Value plan options, for myself, and my eligible dependents. If electing coverage, I authorize my employer to make salary reductions for my portion of the insurance premiums. I understand that I may not make changes to my coverage elections until my employer’s next open enrollment period or due to a qualifying event.

Reset Signature

Date :