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Spousal plan calculator

Use the SEBB Spousal Plan Calculator to determine if you need to pay the spousal surcharge.

Download the calculator now

How to use the Spousal Plan Calculator

If you answered YES to ALL of the questions on the SEBB Premium Surcharge Attestation Help Sheet (pdf) or the online spousal plan questionnaire 2021, answer the questions in the SEBB Spousal Plan Calculator (interactive tool) or (pdf) to determine if you must pay the surcharge.

Note: If you use the interactive version of the Spousal Plan Calculator, you must click Enable Content for the calculator to work. Do not print or submit the interactive tool.

Use the Summary of Benefits and Coverage from your spouse's or state-registered domestic partner's employer-sponsored medical plans to answer the Spousal Plan Calculator questions. The plans must:

  • Serve your spouse's or state-registered domestic partner's county of residence, and
  • Cost less than $109.26 (2021) for the employee's share of the monthly premium.

Complete the calculator for each medical plan that meets the criteria above, one plan at a time. Then click Calculate. If you are entering more than one plan, and at least one results in "You will have to pay the surcharge," then you will have to pay the surcharge.

Need help?

These pages will help you answer the questions in the Spousal Plan Calculator.

Where to look?

You will see Plan Type in the top right corner of the Summary of Benefits and Coverage.

Screenshot of example plan with arrow pointing to the Plan Type field on the upper right corner of the form

How to answer?

If the Plan Type says:

Answer like this:

  • HDHP
  • CDHP
  • HSA
  • HRA
  • any combination of the above (example: HDHP/HSA)

It is a high-deductible health plan.

Select YES for Question 1A.

Fill out B (see below for help).

Continue to Question 2.

  • HMO
  • PPO
  • POS

It is not a high-deductible health plan.

Select NO for Question 1A.

Skip B.

Continue to Question 2.

If yes, how much does the employer contribute each year into an individual's health savings account (HSA) or health reimbursement account (HRA)?

This information is available from your spouse's or state-registered domestic partner's employer. Ask them to ask their employer's payroll or benefits office to find the answer.

Where to look?

You will see:

  1. "What is the overall deductible?" and
  2. "Are there other deductibles for specific services?"

under "Important Questions" on the Summary of Benefits and Coverage.

Only look at the amounts for a single person (or individual) using a preferred (or in-network) provider.

Screenshot of example plan with arrows pointing to the deductible questions (rows 1 and 2) on the Important Questions/Answers table

How to answer?

If you see:

Answer like this:
Only one overall deductible (no separate deductible for prescription drugs)

Fill out A.

Skip B1 and B2.

Go to Question 3.

An overall deductible and a separate deductible for prescription drug coverage

Skip A.

Fill out B1 with the overall (or medical) deductible.

Fill out B2 with the prescription drug deductible.

Go to Question 3.

Where to look?

You will see:

  1. "Is there an out-of-pocket limit on my expenses?" and
  2. "What is not included in the out-of-pocket limit?"

under "Important Questions" on the Summary of Benefits and Coverage.

Only look at amounts for a single person (or individual) using a preferred (or in-network) provider.

Screenshot of example plan with arrows point to out-of-pocket questions (rows 3 and 4) of the Important Questions/Answer table

How to answer?

If you see:

Answer like this:
Only one out-of-pocket limit (no separate out-of-pocket limit for prescription drugs)

Fill out A.

Skip B1 and B2.

Go to Question 4.

An out-of-pocket limit and a separate out-of-pocket limit for prescription drug coverage

Skip A.

Fill out B1 with the medical out-of-pocket limit.

Fill out B2 with the prescription drug out-of-pocket limit.

Go to Question 4.

  1. Primary care visit to treat an injury or illness,
  2. Diagnostic test, and
  3. Durable medical equipment?

Where to look?

You will find all three services listed under "Common Medical Events" and "Services you May Need" on the Summary of Benefits and Coverage.

Only look at amounts for a single person (or individual) using a preferred (or in-network) provider.

Screenshot of example plan with arrows pointing to the primary care visit, diagnostic test, and durable medical equipment co-pay lines

How to answer?

If you see:

Answer like this:

The same coinsurance amount for at least two of these services

Examples:

  • One service has a copay, and the other two have the same coinsurance amount
  • All three services have the same coinsurance amount

Fill out Question 4 with the coinsurance amount you see most often.

Different coinsurance amounts, or copays and coinsurance
Examples:

  • One service has a copay, and the other two have different coinsurance amounts
  • Two services have copays, and one has coinsurance
  • All three services each have different coinsurance amounts, or copays ($) with coinsurance

Fill out Question 4 with the highest coinsurance amount you see.

Copays for all three services

Skip Question 4.

Go to Question 5.

Where to look?

You will find "Primary care visit to treat an injury or illness" listed on the Summary of Benefits and Coverage under "Common Medical Events" and "Services You May Need."

Only look at amounts for a single person (or individual) using a preferred (or in-network) provider.

Screenshot of example plan with arrow pointing to primary care visit co-pay row

How to answer?

If you see:

Answer like this:

Only a copay

Fill out Question 5 with the copay amount.

Go to Question 6.

Only a coinsurance

Skip Question 5.

Go to Question 6.

A copay and a coinsurance Skip Question 5.

Go to Question 6.

Where to look?

You will find "Emergency room services" listed on the Summary of Benefits and Coverage under "Common Medical Events" and "Services You May Need."

Only look at the amount for a single person (or individual) using a preferred (or in-network) provider.

Screenshot of example plan with arrow pointing to emergency room services co-pay row

How to answer?

If you see:

Answer like this:

Only a copay

Only a coinsurance.

Fill out Question 6 with the copay amount
Go to Question 7

Skip Question 6.

Go to Question 7.

A copay and a coinsurance

Skip Question 6.

Go to Question 7.

Where to look?

You will find "Preferred brand drugs" listed on the Summary of Benefits and Coverage under "Common Medical Events" and "Services You May Need."

Only look at the amount for a single person (or individual) using a preferred (or in-network) provider.

Screenshot of example plan with arrow pointing to preferred brand drugs co-pay row

How to answer?

If you see:

Answer like this:
A coinsurance (%)

Fill out A.

Skip B.

A copay ($)

Skip A.

Fill out B.

Complete your attestation