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Get and Sign Form 116m Fill Online, Printable, Fillable, Blank

Your company's enrollment period begin? (mm/dd/yy) Section A – Access to a Qualified Health Plan: Yes No 3. Does your company offer any health plan that meets all of the following? • The network deductible is $4,000 or less per person • The plan pays at least 70% of an inpatient stay after employee meets in-network deductible • The plan covers physician's visits, inpatient and outpatient hospital care, prescription drugs, laboratory services, preventative and wellness services,...

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