Employee Coverage Waiver Form

Waiver of Coverage

I hereby acknowledge that I have been offered medical coverage through my employer and I am voluntarily choosing to WAIVE (DECLINE) enrollment in the employer-sponsored medical plan.

I understand that by waiving coverage at this time, I may not be eligible to enroll until the next Open Enrollment Period or unless I experience a qualifying Special Enrollment Event.

Important Notice

By opting out of employer-sponsored medical coverage, you acknowledge and understand that you will generally not be eligible for a premium tax credit for coverage purchased through the Affordable Care Act (ACA) Marketplace, if the employer coverage offered is considered affordable and meets minimum value standards.

Affordability & Minimum Value Verification

If you are unsure whether the employer-sponsored coverage offered to you meets the affordability and minimum value standards as defined by the Affordable Care Act, you are encouraged to request a review before making your decision to waive coverage. Your employer or plan administrator can assist in determining whether the coverage qualifies under these guidelines and how it may impact your eligibility for premium tax credits through the Marketplace.