About the spouse or registered domestic partner coverage premium surcharge​

A monthly $50 surcharge is required in addition to your 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?

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 subscribers:
  • Employee
  • 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. This surcharge doesn’t apply to your account.

How do I respond for 2015?

My Account

Respond on My Account starting November 1, 2014 for the effective date of January 1, 2015.

OR

2015 Premium Surcharge Change Form

Complete and submit the 2015 Premium Surcharge Change Form starting November 1, 2014. Use the 2015 Premium Surcharge Help Sheet to fill out the form.

2015 Enrollment Form

A subscriber enrolling a spouse or registered domestic partner in PEBB medical coverage effective January 1, 2015 must complete and submit the appropriate 2015 enrollment form starting November 1, 2014 as directed on the form. Use the 2015 Premium Surcharge Help Sheet to fill out the form.

Tools to help respond for 2015

How do I respond for 2014?

2014 Premium Surcharge Change Form

Subscribers can change their attestation for 2014 by completing and submitting the 2014 Premium Surcharge Change Form (use this Surcharge Help Sheet to fill out the form).

2014 Enrollment Form AND Premium Surcharge Attestation Form

New or existing subscriber who is enrolling a spouse or registered domestic partner on their PEBB medical coverage in November or December 2014 must complete and submit the appropriate 2014 enrollment form AND the Premium Surcharge Attestation Form (use this Surcharge Help Sheet to fill out the form).

Due to changes in premiums for the UMP Classic, your attestation for 2014 cannot carry over to 2015. Complete and submit the 2015 Premium Surcharge Change Form to attest for 2015.

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. Attestation changes for the 2015 spouse or registered domestic partner coverage surcharge will be effective January 1, 2015.

What happens if I don’t attest?

You will pay a monthly $50 surcharge if you have a spouse or registered domestic partner enrolled on your medical coverage.