Due to COVID-19, HCA’s lobby is closed. Learn more about your customer service options.

HCA is closed Thursday, November 26 and Friday, November 27. All Apple Health (Medicaid), PEBB, and SEBB customer services phones lines will be down after 5 p.m. Wednesday, November 25 through Monday morning, November 30.

Spousal plan questionnaire 2021

 
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Use this questionnaire to determine if you need to pay a premium surcharge for your spouse or state-registered domestic partner.

If you don’t have a spouse or state-registered domestic partner on your PEBB medical plan, you don’t need to complete this questionnaire – this surcharge doesn’t apply to you.

If you have a spouse or state-registered domestic partner enrolled on your 2021 PEBB medical plan, you must:

  1. Answer YES to question 1 (the only option)
  2. YES or NO to questions 2- 6

    AND
  3. Check the corresponding boxes on your 2021 enrollment/change form or 2021 Premium Surcharge Attestation Change form and return to your payroll or benefits office (employees) or the PEBB Program (all other subscribers).