Free 116M Form in PDF

Instructions on Writing 116M

Filling out the DOH Form 116M can seem daunting at first glance, but with clear guidance, it becomes a straightforward process. This form is essential for capturing an employee's health insurance information accurately and comprehensively. Here is a step-by-step guide to help you or your employer's Human Resources department complete the form correctly.

1. Start by entering the Employee's Name (first, middle initial, last) in the designated field.
2. Input the eREP Case # provided to you.
3. For SSN (optional) or DOB, fill in either the employee's Social Security Number (if comfortable providing this) or their Date of Birth.
4. Write the Employer Name and the corresponding EIN # in the fields provided.
5. Answer the question regarding the company's offering of health insurance by checking Yes or No. If the answer is no, skip to section E to sign and return the form.
6. Specify when the company's enrollment period begins by entering the date in mm/dd/yy format.
7. In the Access to a Qualified Health Plan section, indicate by checking yes or no if the company offers a health plan that meets the specified criteria.
8. Describe how the plans cover abortion services, selecting the option that applies or providing details if the options do not adequately represent the available coverage.
9. In the Least Expensive Plan section, fill in the monthly premium details for various family compositions and specify the yearly deductible amounts for both individual and family plans.
10. Indicate whether this health insurance plan is a state employee benefit plan by checking yes or no.
11. If the employee is not enrolled in a health insurance plan, answer the eligibility questions in Section C. If they are enrolled, skip to Section D.
12. In Section D, provide details about the insurance plan the employee or any family member is enrolled in, including names, coverage start date, insurance company, and plan name, alongside the policy and group numbers.
13. Fill in the monthly premium cost for the employee’s chosen plan and detail how often premiums are deducted from their paycheck.
14. Complete the chart for benefits the employee is enrolled in, including medical, dental, and vision premiums, and specify the yearly health plan deductible amounts.
15. List any children who have dental coverage in the space provided.
16. In Section E, the Signature section, have the form filled out by the employer’s representative. Ensure they print their name, provide their title, phone number, and email address before signing and dating the form.
17. Finally, return the completed form to the Department of Workforce Services using the address or fax numbers provided at the bottom of the form.

By following these steps, you can fill out the DOH Form 116M efficiently, ensuring that all necessary health insurance information is communicated clearly and accurately to the Department of Health. Remember, accuracy is key when dealing with such information to avoid any potential issues or discrepancies.

What is the purpose of the DOH Form 116M?

The DOH Form 116M is designed to collect detailed information from employers about the health insurance options available to their employees. This form is filled out by the employer or the Human Resources department and covers various aspects of health insurance plans, including whether the company offers health insurance, specifics about the least expensive plan, eligibility of the employee for the health plan, and detailed information if the employee is enrolled in a company-offered health plan. Ultimately, it aids in ensuring that employees are well-informed about their health insurance options through their workplace.

How does an employer determine if their health plan meets the criteria outlined in the form?

To determine if a health plan meets the criteria outlined in the form, an employer needs to review the plan's benefits and coverage details closely. Specifically, they should confirm that the plan's deductible does not exceed $4,000 per person, it covers at least 70% of an inpatient stay after the deductible is met, and includes essential services such as physician's visits and preventative care. Additionally, the employer must verify that they cover at least 50% of the employee's premium and that the plan offers a lifetime maximum benefit of $1,000,000 or more, or does not have a maximum benefit cap. The plan's coverage on abortion services must also be identified and appropriately reported.

What should be done if an employee is not enrolled in any health insurance plan offered by the employer?

If an employee is not enrolled in any health insurance plan offered by the employer, section C of the form should be completed. This section requires the employer to indicate whether the employee is eligible to enroll in a health insurance plan and if not, why. It also inquires if the employee was eligible during the last open enrollment period and if there have been any coverage changes in the last 90 days. This information helps in understanding the employee's insurance situation and any potential barriers to their enrollment in available health plans.

What steps should be taken once the DOH Form 116M is completed?

Once the DOH Form 116M is completed, it should be returned to the Department of Workforce Services as indicated at the bottom of the form. The employer or HR representative can mail the completed form to the provided PO Box address in SLC, UT, or fax it using the provided fax numbers. It is important to ensure that the form is filled out accurately and completely to provide clear and precise information regarding the health insurance benefits available to employees. This contributes to a transparent and informed decision-making process for health coverage.

One common mistake people make on the 116M form involves skipping important sections. For instance, if the response to the question about the company offering health insurance is "No," instructions indicate to skip to section E. However, some may overlook the directive to sign and return the form, mistakenly thinking their role is complete upon reaching section E. This oversight can lead to incomplete submissions, delaying the processing of the form.

Another error occurs when individuals inaccurately complete the sections about health plan coverage, particularly concerning abortion services as described in the policy's maternity/pregnancy or exclusion sections. Given the specificity required—whether the plan does not cover abortion under any circumstances, covers elective abortion, or covers abortion only in specific situations like endangerment to the mother's life, incest, or rape—there's a risk of misinterpretation or incomplete answers. Providing inaccurate information might not only misrepresent the policy details but also lead to complications in how the form is evaluated.

Filling out the financial details related to the least expensive plan in Section B also presents challenges. Mistakes in calculating or reporting the employee's and employer's portions of the monthly premium can occur, particularly if the form filler fails to exclude costs not related to the medical insurance premium amount, such as dental and vision coverage. Accurate financial reporting is crucial, as these figures are vital for assessing the affordability and adequacy of the coverage offered to employees.

Lastly, failing to provide comprehensive information in Section D, regarding a currently enrolled health plan, is another common pitfall. Specifically, errors in detailing when coverage began, the check date for the first premium deduction, or inaccurately listing the enrolled family members and their corresponding coverage can lead to misunderstandings about the insurance's effectiveness and compliance with state health coverage requirements.

When completing the DOH Form 116M for health insurance information in the state of Utah, it's often necessary to gather and submit additional forms and documents to ensure complete and accurate processing. These documents range from personal identification to specific coverage details provided by an employer's insurance plan. Understanding these documents can help streamline the submission process and avoid delays.

• W-2 Form: This tax document shows the employee's annual wages and the amount of taxes withheld from their paycheck. It helps verify the employee's income and employment status.
• Pay Stubs: Recent pay stubs provide proof of current employment and income. This is crucial for verifying the information listed on the 116M form.
• Proof of Citizenship or Legal Status: A document such as a passport or birth certificate may be required to verify the employee's legal status and eligibility for insurance coverage.
• Insurance Cards: Copies of current insurance cards show existing coverage, which is important if the employee or their family members are already insured.
• Summary of Benefits and Coverage (SBC): This document offers a detailed breakdown of what the health plan covers and the costs involved, essential for understanding the specifics mentioned in the 116M form.
• Proof of Previous Coverage: If applicable, documents showing previous health insurance coverage help in cases where there is a need to prove continuity of coverage or explain any lapses.
• Employer's Coverage Offer Letter: Sometimes, an employer might provide a letter detailing the health insurance options available to employees. This can serve as proof of the offer mentioned in the 116M form.
• Special Enrollment Period Documentation: If enrolling due to a qualifying life event, documents supporting this event (e.g., marriage certificate, birth certificate of a newborn) are necessary.
• Notice of Marketplace Eligibility: For employees exploring options through the Health Insurance Marketplace, this notice confirms their eligibility and any subsidies for which they qualify.
• Privacy Release Form: A signed form might be required to allow the sharing of personal health information between the employer, insurance carriers, and government agencies.

Gathering these documents in advance can facilitate a smoother interaction with the DOH Form 116M and related health insurance processes. Having these documents on hand not only helps in filling out forms accurately but also ensures that all information provided to employers and insurance carriers reflects the current and complete circumstances of the employee and their family.

The Form W-4, commonly known as the Employee's Withholding Certificate, shares similarities with the DOH Form 116M in that both require information directly related to the employee's financial and insurance status. Just like the 116M form, the W-4 is filled out by the employee to instruct employers on the amount of tax to withhold from their paycheck. Both forms are crucial for accurately managing an employee's deductions and benefits, ensuring that individuals are properly registered for the appropriate tax and insurance coverages through their employer.

The Health Insurance Marketplace Application is another form that parallels the DOH Form 116M. This application is used to enroll in health insurance through the Marketplace, where one can compare and choose plans just as the 116M form outlines eligibility and coverage details for employer-offered insurance. They both collect detailed information regarding the individual's health insurance requirements, although the Marketplace Application is broader, allowing for comparisons between different plans outside of an employer's offerings.

Form I-9, Employment Eligibility Verification, while used primarily for verifying an employee's legal right to work in the United States, shares the-detail oriented nature of the 116M form. Both forms are mandatory from an employment perspective, with the I-9 ensuring an employee's work eligibility and the 116M detailing their health insurance information. However, unlike the health insurance focus of the 116M, the I-9 emphasizes documentation of identity and employment authorization.

The Summary Plan Description (SPD) document, though not a form filled out by the employee, offers information similar to what is found in the 116M form but from a different perspective. The SPD provides detailed information about the health plan offered by an employer, including eligibility, benefits, claims appeal procedures, and rights under the Employee Retirement Income Security Act (ERISA). Like the 116M form, it's a critical document for understanding employer-provided health insurance specifics, albeit functioning more as an informational guide than a form to be completed.

Lastly, the COBRA Election Notice is somewhat similar to the 116M form as it involves health insurance provisions offered by the employer, especially when an employee is facing job loss or reduction in hours that affects their health coverage. This notice gives employees information on how to continue their health insurance coverage under the employer's plan. While the 116M form collects and shares information about current health insurance options and the employee's status, the COBRA Notice offers options for maintaining coverage after experiencing a qualifying event.

When you're tasked with filling out the DOH Form 116M for Employer's Health Insurance Information, accuracy and attention to detail are paramount. Below is a guide to help ensure that you complete this form correctly and appropriately.

• Do ensure that the human resources representative or the department managing employee benefits fills out the form. Their knowledge is crucial for accuracy.
• Don't leave any sections that apply to the employed household member incomplete. If the section doesn't apply because the company doesn't offer health insurance, skip to section E as instructed.
• Do review the health insurance plan's details regarding coverage, especially the specifics about deductibles, employer's contribution, and coverage for services like inpatient stays, prescription drugs, and other listed services.
• Don't guess the answers. If unsure about the details of the health insurance plan offered, consult with the insurance provider for accurate information.
• Do be clear on how your health plan covers abortion services, as this is specifically asked in the form. Accurate information is necessary for compliance and for the employees' knowledge.
• Don't include costs for dental, vision, or other coverages in the medical insurance premium amounts unless they are bundled and cannot be separated.
• Do verify the eligibility of the employee for health insurance coverage and accurately report past enrollment opportunities or any changes in coverage within the last 90 days.
• Don't skip over the employee's health plan information if they are currently enrolled in a plan. This section is vital for understanding the benefits and costs associated with their current health plan.
• Do provide your contact information clearly in Section E for any follow-up questions and ensure the form is signed and dated.

Following these guidelines will help you fill out the DOH Form 116M correctly, providing essential health insurance information accurately and efficiently.

When discussing the intricacies of insurance provisions like those detailed in the DOH Form 116M, it's easy to encounter misunderstandings. Here, we aim to clear up some common misconceptions.

• Only large businesses need to complete the form: In reality, the DOH Form 116M is required from any employer that offers health insurance, regardless of the size of the business. This misconception often leads to smaller employers assuming they're exempt from compliance.

• It's the employee's responsibility to fill out the form: This form is actually for employers to complete on behalf of their employees. It’s a common mistake for employees to think they must fill out and submit this form themselves.

• SSN is mandatory: The form requests either an SSN or DOB, making it flexible for individuals who may not wish or be able to provide their Social Security Number. This option is sometimes overlooked, causing unnecessary concern.

• Any health plan qualifies: The form specifies criteria that qualifying health plans must meet, such as deductible limits and coverage specifics. Not every health plan offered by an employer will qualify, contrary to what some may believe.

• Abortion coverage details are optional: The form explicitly asks for information on how an employer’s health plan covers abortion services, indicating that this information is essential, not optional.

• If you don’t offer health insurance, the form is irrelevant: Employers who do not offer health insurance are still required to fill out the form, skipping to section E to sign and return it. This step confirms the absence of an offer, which is crucial information.

• The least expensive plan details aren't necessary if the employee isn't enrolled: Section B requires information about the least expensive plan regardless of enrollment status. This data is essential for evaluating the affordability of available health insurance options.

• Yearly health plan deductible information is not necessary: The form requests details about the yearly health plan deductible for both individuals and families. This information is crucial for understanding the financial implications for employees.

• The form must be returned to the Department of Health: Although it’s a Department of Health form, it specifically instructs to return the completed form to the Department of Workforce Services. This detail is crucial for ensuring the form reaches the correct department for processing.

Clarifying these misconceptions ensures that employers can accurately and effectively complete and submit the DOH Form 116M, thus maintaining compliance and supporting their employees' access to health insurance information.

Understanding the DOH Form 116M is crucial for ensuring employees receive the health insurance benefits to which they are entitled. Here are key takeaways:

• The form must be completed for each employed household member, requiring details from the employer's Human Resources representative or the department handling employee benefits.
• It starts with basic information, including the employee's name, an eREP Case number, and optional SSN or DOB, alongside the employer's name and EIN number.
• Employers are asked to specify if they offer health insurance and to give details about the enrollment period, indicating the form's role in verifying employee access to healthcare benefits.
• Section A focuses on the accessibility of a qualified health plan, probing into specifics like the network deductible, percentage of inpatient stay covered after the deductible is met, coverage extent (including physician visits, hospital care, etc.), and employer's contribution towards the employee's premium.
• It highlights the need to disclose how the health plans cover abortion services, an aspect that reflects legal and policy nuances in health insurance.
• The latter sections of the form gather insights on the least expensive health plan available, the employee's current enrollment status, details of the selected plan, and any changes in coverage, ending with a note on the dental coverage for children and a section for the employer's signature.

This form plays a vital role in the larger ecosystem of health care benefits, ensuring that employees have the necessary information about their health insurance options and aiding in the delivery of these benefits.