Affordable Care Act (ACA)– Health Insurance Payment

AUTHORIZATION FOR VOLUNTARY PAYROLL DEDUCTION

I understand that my Employer will pay monthly to North Dakota Public Employees Retirement System both the

Employer and Employee premium for the group health insurance plan provided to me through my Employer under the

ACA . I hereby authorize my Employer to deduct from my salary in each pay period that I am eligible for the group

health insurance plan, the employee premium for my health insurance coverage:

1. The sum of _____$49.44 (single coverage) or ______$534.10 (family plan) will be deducted from my

paycheck each pay period, as a reimbursement for the employee portion of the monthly group health insurance

premium paid by my Employer. This deduction will continue until I terminate the coverage in writing or I am notified in

writing that I am no longer eligible for the insurance. Insurance premiums are paid a month in advance. A deduction

adjustment will be necessary to collect premiums on your first paycheck. I also understand that the Employer and

Employee contribution amounts may change annually as premiums under the State Health Insurance Plan change and

therefore, any payroll deduction will be adjusted accordingly.

2. If my salary in any given pay period in which I am obligated to reimburse my Employer for the payment by

Employer of the group health insurance plan premium, on my behalf (representing the employee cost), is not sufficient

to pay that monthly premium in full, then I further authorize my Employer to deduct the additional sum owing from any

subsequent paycheck(s) or acknowledge my Employer may bill me immediately for balance due. If I do not pay the

balance due within a 30 day grace period my insurance will be cancelled effective the 1

of the month following the

grace period. Cancellation will be for the remainder of the ACA Stability Period and I will not be COBRA eligible during

this Period.

3. If at the time that my employment is terminated for any reason, there is an outstanding balance on my

obligation to reimburse my Employer for health insurance premiums paid by Employer on my behalf, then a sum

sufficient to pay the balance due in full, or the maximum amount permitted by law may be withheld from any remaining

paycheck(s). I understand that if there is insufficient salary to pay the balance due my Employer in full at time that my

employment is terminated, and I otherwise neglect or refuse to make payment arrangements for the balance owing,

that my Employer has the option to take legal action against me in an effort to obtain the money owed and to the extent

permitted by law, the costs of the collection action.

I also understand that I can revoke this Authorization in writing, with 30 days’ notice to my Employer.

___________________________ ___________________________ _______________ ___________

Printed Employee Name Employees Signature EmplID Date

DIRECTIVE TO DISCONTINUE THE PAYROLL DEDUCTION:

I hereby terminate the above Payroll Deduction Authorization, which will terminate my group health insurance on the

first of ______________, 20___. Request must be received 30 days prior to this date.

___________________________ ___________________________ _______________ ___________

Printed Employee Name Employees Signature Empl ID # Date

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