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Send medicaid form 116m via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out form 116m with our platform
- Click ‘Get Form’ to open it in the editor.
- Begin by entering the employee’s name, SSN (optional), and employer name in the designated fields.
- Answer whether your company offers health insurance. If 'No', proceed to Section E.
- Fill in the enrollment period start date and confirm if your company offers a qualified health plan by checking the appropriate boxes.
- In Section B, complete the chart detailing the least expensive plan for each coverage type, including monthly premiums and deductibles.
- If applicable, provide information about any existing health plans in Section D, including names of enrolled individuals and policy details.
- Finally, sign and date the form in Section E before submitting it as instructed.
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