What is this?
A monthly $50 surcharge is required in addition to your medical plan premium if you have a spouse or registered domestic partner enrolled on your PEBB medical coverage, and your spouse or registered domestic partner has chosen not to enroll in employer-based group medical insurance that is comparable to Uniform Medical Plan (UMP) Classic. (Comparison must be to UMP Classic even if you are not enrolled in the plan.)
Who needs to attest (respond)?
You need to attest to this surcharge if you are enrolling your spouse or registered domestic partner on your PEBB medical coverage and you are one of the following medical plan subscribers:
- Retiree not enrolled in Medicare Part A and Part B
- COBRA not enrolled in Medicare Part A and Part B
- Leave Without Pay (LWOP)
You do not need to attest if you are not one of these subscribers, or if you are not enrolling your spouse or registered domestic partner on your PEBB medical coverage. The surcharge will not apply to your account.
What happens if I do not attest (respond)?
You will pay a monthly $50 surcharge in addition to your medical plan premium.
How do I attest or re-attest (report a change)?
Complete and submit the appropriate 2015 enrollment form as directed on the form if you are a subscriber enrolling a spouse or registered domestic partner in PEBB medical coverage. Use the 2015 Premium Surcharge Help Sheet to fill out the premium surcharge sections of the form.
Use one of the following options to report a change to your previous attestation:
When can I report a change?
You can only report a change to this surcharge in the following situations:
When adding a spouse or registered domestic partner to your PEBB medical benefits.
During the next PEBB annual open enrollment November 1-30.
Within 31 days of the day you regain eligibility for the employer contribution toward PEBB benefits.
Within 60 days of the event, if there is a change in your spouse’s or registered domestic partner’s employer-based group medical insurance.
Tool to help attest or re-attest
Use only one version of the 2015 Spousal Plan Calculator tool to attest or re-attest:
Note: If you use the interactive version of the 2015 Spousal Plan Calculator, you must click Enable Content for the calculator to work (see the example image below). Do not print or submit the interactive tool.
When do my attestations or changes take effect?
Generally, attestation changes will affect surcharges starting the first of the month after the changes were received. If attestation changes are received on the first day of the month, the change begins that day.