(rev 9/2021)CalHR 782
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Affordable Care Act (ACA) Notification Checklist
California Department of Human Resources
State of California
This Checklist is intended to document and ensure that departments/agencies are providing the legally required notices
to employees for compliance with the ACA. Parts I and II must be completed, if applicable.
PART I documents the distribution of the Health Insurance Marketplace Coverage Options and Health Coverage Notice
to newly hired employees (e.g., new to the state, department, or agency).
PART II documents the distribution of the Summary of Benefits and Coverage Notice and the Health Benefits Plan
Enrollment form to employees newly eligible for health benefits.
Upon completion, this Checklist must be retained in the employee's Official Personnel File.
Employee Information
Employee Name Hire Date
Position Number Social Security Number Tenure/Time Base
New State Employee
If employee is appointed to a position eligible for health benefits, complete Parts I and II. If employee is not eligible for
health benefits, complete Part I only.
Current State Employee who is Newly Hired at Department/Agency OR Newly Eligible for Health Benefits
If employee is not eligible for health benefits or is continuing their health benefits eligibility in a new position, complete
Part I only. If employee has been appointed to a position that makes them newly eligible for health benefits (e.g.,
Temporary/Intermittent to Permanent/Full-time), complete Parts I or II (or Part II only, if applicable).
Part I - New Employees
The Health Insurance Marketplace Coverage Options and Health Coverage Notice is required to be provided to every
new employee in your department/agency within 14 days of their hire date.
Date Provided Department Representative
Part II - Employees Newly Eligible for Health Benefits
The following health benefit documents should be provided to employees newly eligible for health benefits by the first
day the employee is eligible to enroll in coverage (e.g., employee is hired on August 12, the following documents must
be provided to employee no later than September 1, the earliest effective date of coverage).
Summary of Benefits and Coverage Notice
Health Benefits Plan Enrollment Form (HBD-12)
Date Provided Department Representative
Human Resources Office use Only
I certify that data stated herein is correct, complete, and in accordance with all laws and regulations.
Department/Agency Name Contact Number
HR Representative Printed Name HR Representative Signature Date
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