Free Wisconsin BadgerCare Plus Employer Verification of Health Insurance, HCF 10181 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10181 (07/08)

EVHII

WISCONSIN BADGERCARE PLUS EMPLOYER VERIFICATION OF HEALTH INSURANCE
If you have questions about completing this form, please call 1-866-710-2026. Thank you for your cooperation. Please return this completed form to: Department of Health Services, EVHI Unit, PO Box 6530, Suite 100, Madison, WI 53716, or fax to (608) 222-4523. SECTION 1 ­ BASIC INFORMATION Please provide the basic information about you, the employer. Your FEIN is a mandatory field and accuracy is extremely important. A separate form must be completed for each FEIN you have. You may make a copy of this form or you can get a copy at dhfs.wisconsin.gov/forms/DHCF/HCF10181.pdf. Employer Name Employer Address City State Zip Code Telephone Fax Number FEIN

SECTION 2 ­ DOING BUSINESS AS (if different than Section 1) If your business is operating under more than one name, provide business names and addresses for the FEIN listed in Section 1. Employer Name Employer Address City State Zip Code

Employer Name Employer Address City State Zip Code

Employer Name Employer Address City State Zip Code

Page 1 of 4

WISCONSIN BADGERCARE PLUS EMPLOYER VERIFICATION OF HEALTH INSURANCE F-10181 (07/08)

EVHII

SECTION 3 ­ CONTACT INFORMATION Please tell us who we should contact, if we have questions about the information you provided on this form. Name Address City Which method do you prefer? Preferred Time of Contact: Email Mail State Telephone Zip Code Fax Late Morning Evening Early Afternoon Late Evening Afternoon Any time Job Title Telephone Fax Number Email Address

Early Morning Late Afternoon

Morning Early Evening

SECTION 4 ­ ADDITIONAL EMPLOYER INFORMATION Provide additional information including your Wisconsin Employer Identification Number and business email (if available). Wisconsin State Employer Number Business Email Number of Employees 250 and over Under 250

SECTION 4a ­ EMPLOYER COMMENTS Indicate any comments or additional information you wish to provide in the space below. For example, if you offer health insurance coverage outside of your open enrollment period, tell us which qualifying events may give an employee a special enrollment period. If you are self-insured or offer separate dental and/or vision plans, provide that information.

Page 2 of 4

WISCONSIN BADGERCARE PLUS EMPLOYER VERIFICATION OF HEALTH INSURANCE F-10181 (07/08)

EVHII

SECTION 5A ­ HEALTH INSURANCE SUMMARY Check "yes" or "no" as it applies to your business. If you do not offer major medical health insurance coverage to any of your employees, please indicate "no" and return the form. By major medical, we mean a plan that covers doctor visits, not catastrophic coverage or Health Savings Accounts. For any question to which you answer "yes", indicate the dates the coverage is available or the dates of the open enrollment period to sign up for the coverage. Coverage Dates Begin Date End Date

Do you provide access to major medical health insurance to any of your employees? Did you have an open enrollment period? Do your employees have access to the State employees' health insurance plan?

Yes

No

Yes Yes

No No

Enrollment Period Begin Date

End Date

SECTION 5B ­ PREMIUM DETAILS) In this section, tell us to which groups you offer coverage ("employee only", "employee and spouse", and/or "employee and family"). For each group you cover, provide the total premium amount and the amount you contribute for the plan. Remember to use the plan for which you pay the highest percentage toward the premium cost. Check the box that describes how often the premiums are paid (weekly, bi-weekly, monthly, or yearly). If you offer family coverage, check the box for each family member covered under this plan. Check all the categories of coverage you provide If provided, what is the total premium for each? What is the premium amount paid by employer? How often are premiums paid? Weekly Employee Only Employee Only $ Employee Only $ Bi-weekly Monthly Employee and Spouse Family Family $ Family $

Employee and Spouse $ Employee and Spouse $ Yearly Yes No

Does a domestic partner have the same eligibility as a spouse for employee plus spouse coverage? Under family coverage, which family members are covered? Children Siblings Step-children Nieces/Nephews

Grandchildren Aunts/Uncles

Spouse Parents Domestic Partners
Page 3 of 4

WISCONSIN BADGERCARE PLUS EMPLOYER VERIFICATION OF HEALTH INSURANCE F-10181 (07/08)

EVHII

SECTION 5C ­ ELIGIBLE EMPLOYEES Please tell us which of your employees are eligible to sign up for the plans identified in Section 5. Examples: · Permanent employees working at least 20 hours/week and employed for 3 months. · All managers regardless of scheduled hours or start date. · Temporary employees working 30 hours each week and employed for 6 months. Each of these examples would be a separate group. If you have more than four groups with different criteria for eligibility for health insurance access, please copy this section or go to dhfs.wisconsin.gov/forms/DHCF/HCF10181.pdf to get a copy of this form as needed and attach it to your completed form. Employee Type Group 1 Any Permanent Temporary Number of Hours Must Work Per Week Any hours hours Job Title Length of Service Required for Enrollment Days Months Hours Once eligible, how long to enroll? Days Months Once Enrolled, when will coverage start?

Any Manager Staff

In Enrollment Month Month Following Enrollment 2 Months From Enrollment 3 Months From Enrollment Months From Enrollment

Group 2

Any Permanent Temporary

Any hours hours

Any Manager Staff

Days Months Hours

Days Months

In Enrollment Month Month Following Enrollment 2 Months From Enrollment 3 Months From Enrollment Months From Enrollment

Group 3

Any Permanent Temporary

Any hours hours

Any Manager Staff

Days Months Hours

Days Months

In Enrollment Month Month Following Enrollment 2 Months From Enrollment 3 Months From Enrollment Months From Enrollment

Group 4

Any Permanent Temporary

Any hours hours

Any Manager Staff

Days Months Hours

Days Months

In Enrollment Month Month Following Enrollment 2 Months From Enrollment 3 Months From Enrollment Months From Enrollment
Page 4 of 4

RESET FORM