Each Reporting Employer must provide an Employee HIRD Form for completion and signature by each Employee (an employee employed at a Massachusetts work location for a period greater than 30 days; they do not have to be Massachusetts residents) 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. The Massachusetts Division of Healthcare Finance and Policy is responsible for the form and related regulations
The Division will make available the Employee HIRD Form to Reporting Employers by posting the Form on the Division's website. The Division 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 Division's Employee HIRD Form if the Employee signed the version in effect on the date of signature.
Forms are available in English, Spanish, and Portuguese.
2010 HIRD Form in English
2010 HIRD Form in Spanish
2010 HIRD Form in Portugese