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

Spousal plan questionnaire 2020

1 2 3 4 5 6 7 8

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 2020 PEBB medical plan, you must:

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

  3. Check the corresponding boxes on your 2020 enrollment/change form or 2020 premium surcharge change form and return to your personnel, payroll or benefits office (employees) or the PEBB Program (COBRA, retirees and continuation coverage only).