Market Exchange 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) ACME 5. Employer address 6. Employer phone number th 8000 E 100 St 7. City 8. State 9. ZIP code Fishers IN 0 10. Who can we contact about employee health coverage at this job? Marcia Maria, HR Business Partner 11. Phone number (if different from above) 12. Email address 000-000-00000 [email protected] Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to:  All employees. Eligible employees are: Full-time exempt and non-exempt employees working 30 hours per week. Coverage for newly eligible employees shall be effective on the first of the month following 30 continuous employment if the enrollment form is received within 31 days of the effective date of coverage. o Some employees. Eligible employees are: • With respect to dependents:  We do offer coverage. Eligible dependents are: The employee’s legal spouse, recognized under state in which employee lives, employee’s natural born child, step-child, adopted child, child in which employee is legal guardian and or who is covered under qualified medical child support order. o 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, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums. Page 27 | ACME| Plan Year 2024 Open Enrollment This Compliance Overview is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.