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Health Insurance Marketplace Coverage Options and Your Health CoverageForm Approved OMB No. 12100149 (expires 6302023)PART A: General Information As of January 1, 2014, the Affordable Care Act (ACA)

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How to fill out notice of marketplace coverage

01

Obtain notice of marketplace coverage form from the marketplace or employer.

02

Fill out the form with your personal information such as name, address, and social security number.

03

Indicate your marketplace coverage start and end dates.

04

Sign and date the form.

05

Submit the completed form to the appropriate party by the deadline.

Who needs notice of marketplace coverage?

01

Individuals who have enrolled in marketplace coverage through the Affordable Care Act.

02

Employers who are required to provide notice of marketplace coverage to their employees.

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What is notice of marketplace coverage?

The notice of marketplace coverage is a form that employers must provide to their employees to inform them about the availability of health coverage options through the Health Insurance Marketplace.

Who is required to file notice of marketplace coverage?

Employers who are subject to the Affordable Care Act's employer mandate are required to file notice of marketplace coverage.

How to fill out notice of marketplace coverage?

Employers can fill out the notice of marketplace coverage by providing information about the health coverage options available to employees, as well as contact information for the Health Insurance Marketplace.

What is the purpose of notice of marketplace coverage?

The purpose of the notice of marketplace coverage is to inform employees about their health coverage options and to help them make informed decisions about their healthcare.

What information must be reported on notice of marketplace coverage?

The notice of marketplace coverage must include information about the employer's health coverage offerings, as well as contact information for the Health Insurance Marketplace.

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