956 CMR 10.04 - Employee HIRD Form

(1) General Requirements. Each Reporting Employer must provide an Employee HIRD Form for completion and signature by each Employee that declines to enroll in Employer-sponsored insurance or declines to use the Employer's Section 125 Cafeteria Plan to pay for health insurance. Each time an Employee of a Reporting Employer declines to enroll in Employer sponsored insurance or declines to use the Reporting Employer's Section 125 Plan to pay for health insurance, the Employee is required to complete, sign and return an Employee HIRD Form to the Reporting Employer.

(a) Reporting Employer. An employer is required to collect signed Employee HIRD Forms if it has either 5,500 payroll hours in any quarter or 22,000 payroll hours in a year.

(b) Required Information. The Employee HIRD Form must contain the following information:

1. Employee Name;

2. Employer Name;

3. Whether the Employee was informed about the Employer's Section 125 Cafeteria Plan;

4. Whether the Employee declined to use the Employer's Section 125 Cafeteria Plan to pay for health insurance;

5. Whether the Employee was offered Employer subsidized health insurance;

6. Whether the Employee declined to enroll in Employer subsidized health insurance;

7. If the Employee declined Employer subsidized health insurance, the dollar amount of employee's portion of the monthly premium cost of the least expensive individual health plan offered by the Employer to the Employee;

8. Whether the Employee has alternative insurance coverage;

9. The Employee's signature and the date on which the Employee signs the HIRD form.

(c) Required Acknowledgments.

1. The Employee must acknowledge that he or she has declined to enroll in Employer sponsored insurance and/or has declined to use the Employer's Section Cafeteria 125 Plan to pay for health insurance.

2. The Employee must acknowledge that if he or she declines an Employer offer of subsidized health insurance, he or she may be liable for his or her health care costs.

3. The Employee must acknowledge that he or she is aware of the individual mandate under M.G.L. c. 111M and the penalties for failure to comply with the individual mandate.

4. The Employee must acknowledge that he or she is required to maintain a copy of the signed HIRD Form and that the HIRD Form contains information that must be reported in the Employee's Massachusetts tax return.

5. The Employee must indicate that by his or her signature, he or she acknowledges the truthfulness of his or her answers.

(2) HIRD Form.

(a) Form Availability; Versions. The Connector will make available the Employee HIRD Form to Reporting Employers by posting the Form on the Connector's website, www.MahealthConnector.org . The Connector may revise the Employee HIRD Form from time to time. When an Employee is required to sign the Employee HIRD Form, the Reporting Employer must provide the Employee with the current version of the Employee HIRD form as posted on the website on the date of signature. A Reporting Employer is not required to have Employees sign an updated version of the Connector's Employee HIRD Form if the Employee signed the version in effect on the date of signature.

(b) Alternative Form. A Reporting Employer may collect the required information and acknowledgements from its Employees in any form or manner, including any electronic or other alternative media form that it deems necessary or appropriate; provided that the alternative form contains all of the required data elements listed in 956 CMR 10.04(1) and the same wording, order, and sequence and numbering of questions as they appear on the Employee HIRD Form version posted on the Connector's website.

(c) Electronic Signatures. An Employee may sign an Employee HIRD Form using an electronic signature; provided such signature complies with applicable federal and state law.

(3) The Reporting Employer must retain the signed Employee HIRD Form for a period of three years.

(a) The Reporting Employer must make available to the Connector and the Department of Revenue copies of signed Employee HIRD Forms or Alternative Forms for inspection and audit. The Reporting Employer must submit a copy of an Employee HIRD Form to the Connector or the Department of Revenue upon request.

(b) If the Employee does not comply with the Reporting Employer's request to complete and return a signed Employee HIRD Form, the Reporting Employer must document diligent efforts to obtain such Form and maintain the documentation for a period of three years.

(c) Additional Documentation. The Reporting Employer must create and retain documentation for those Employees who are not required to sign an Employee HIRD Form for a period of three years, including Employees enrolled in the Reporting Employer's sponsored health plan and Employees not eligible for the Reporting Employer's Section 125

Cafeteria Plan in accordance with 956 CMR 4.06(3)(b)4.

(4) Due Date.

(a) Annual Open Enrollment. The Reporting Employer must obtain a signed Employee HIRD Form from each Employee required to sign a Form by the earlier of 30 days after the close of the applicable open enrollment period for the Reporting Employer's health insurance, and/or its Section 125 Cafeteria Plan, or September 30^th of the reporting year. If an Employer's open enrollment period for 2007 - 2008 ended prior to July 1, 2007, and an Employee has signed an Employer form acknowledging that he or she was offered and declined Employer sponsored insurance, such Employee is not required to sign an Employee HIRD Form until the next applicable due date, in accordance with 956 CMR 10.04(4), occurring on or after July 1, 2007. If and to the extent the Employer form is effective for any period on or after July 1, 2007, the Employer must retain the signed Employer form until July 1, 2009.

(b) Change in Status Terminations. If an Employee who enrolled in an Employer sponsored health insurance plan subsequently terminates participation in the plan between applicable enrollment periods in accordance with the reporting Employer's Section 125 cafeteria Plan (and remains employed by the Reporting Employer), the Employee must sign an Employee HIRD Form within 30 days of the date participation terminated.

(c) New Hire Enrollment. The Reporting Employer must obtain the signed Employee HIRD Form from each new Employee that either declines Employer sponsored health insurance or declines to use the Employer's Section 125 Cafeteria Plan to pay for health insurance within 30 days of the close of the applicable new hire enrollment period.

(5) Signed Copy to Employee. The Reporting Employer must automatically provide a copy of each signed Employee HIRD Form to the Employee. The Reporting Employer must, upon request, provide a copy of the Employee's signed Employee HIRD Form to the Employee for use in filing the Employee's Massachusetts income tax return.

Notes

956 CMR 10.04