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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 (SRDP).

If you don’t have a spouse or SRDP on your SEBB medical plan, you don’t need to complete this questionnaire. This surcharge does not apply to you.

If you have a spouse or SRDP enrolled on your 2021 SEBB 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 in SEBB My Account (for school employees) or on your 2021 enrollment/change form (for SEBB Continuation Coverage members).