Fillable Printable 2015 Employee Enrollment/Change - Washingnton
Fillable Printable 2015 Employee Enrollment/Change - Washingnton
2015 Employee Enrollment/Change - Washingnton
• Type or print clearly in black ink. Inaccurate, incomplete, or illegible information may delay coverage.
• List eligible family members you wish to cover or remove from coverage. This form replaces all Employee Enrollment/
Change forms previously submitted.
2015 Employee Enrollment/Change
Additional changes you can make during the PEBB Program’s annual open enrollment
All changes become effective January 1 of the following year.
Check the box(es) next to the change requested.
Add dependent(s) Change dental plan
Remove dependent(s) Enroll after waiving medical coverage
Change medical plan Waive medical coverage due to enrollment in other employer-based group medical insurance
HCA 50-400 (10/14)
Are you making changes to an existing account?
Yes If yes, what changes? (Check all that apply in the sections below.)
No (If no, go to Section 1.)
Changes you can make anytime Give date of event/change _____________________________
Name change Address change Submit a change to a premium surcharge attestation
Remove dependent(s) from coverage due to loss of eligibility (divorce, dissolution of registered domestic partnership, death, or
other loss of eligibility for PEBB benets). Your benets ofce must receive this form no later than 60 days after the event.
If applicable, provide former dependent’s new address:
___________________________________________________________________________________________
Additional changes you can make if an event creates a special open enrollment
The PEBB Program only allows changes outside of an annual open enrollment when an event creates a special open
enrollment. The change must be allowable under Internal Revenue Code and correspond to and be consistent with a special
open enrollment event for the subscriber, the subscriber’s dependent, or both. You are required to provide proof of the event
that created the special open enrollment. Your benets ofce must receive this form and proof of the event no later than
60 days after the event. However, if adding a newborn or newly adopted child increases your premium, you must submit this
form no later than 12 months after the birth or adoption.
Check the box next to each change you are requesting and indicate the corresponding event(s) on the following page.
In most cases, the enrollment or change will be effective the rst day of the month after the event date or the date the form is
received, whichever is later.
Add dependent(s) (allowable under events 1, 2, 3, 4, 5, 6, 7, 9, 10, 11)
Enroll after waiving medical coverage (allowable under events 1, 2, 3, 4, 5, 6, 7, 9, 10, 11)
Change medical plan (allowable under events 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14)
Change dental plan (allowable under events 1, 2, 3, 4, 5, 8, 9, 10, 11, 12, 13, 14)
Remove dependent(s) (allowable under events 1, 5, 6, 9, 10)
Waive medical coverage due to enrollment in other employer-based group medical insurance
(allowable under events 1, 5, 6, 9, 10)
Give date of event _____________________________
(this section continued on next page)
Agency name Agency/subagency Insurance effective date Hire date
Subscriber’s last name First name Middle initial Social Security number
1
(continued)
Additional changes you can make if an event creates a special open enrollment
(continued from previous page)
Check the box(es) next to the corresponding event(s). The event number below must be listed next to the change(s) you are
requesting on the previous page.
1. Marriage, registering a domestic partner, as dened by Washington Administrative Code 182-12-260(2), birth,
adoption, or assuming a legal obligation for total or partial support in anticipation of adoption. Also complete a
Declaration of Tax Status form if adding a registered domestic partner and/or his or her eligible children.
2. Child becoming eligible as an extended dependent through legal custody or legal guardianship. Also complete an
Extended Dependent Certication form.
3. Child becoming eligible as a dependent with a disability. Also complete a Certication of Dependent With a Disability form.
4. Employee or dependent losing other coverage under a group health plan or through health insurance, as dened by the
Health Insurance Portability and Accountability Act (HIPAA).
5. Employee or dependent having a change in employment status that affects the employee’s or dependent’s eligibility for
their employer contribution toward employer-based group health insurance.
6. Employee or dependent having a change in enrollment under another employer-based group health insurance during its
annual open enrollment that does not align with the PEBB Program’s annual open enrollment.
7. Employee’s dependent moving from outside the United States to live within the United States or moving from inside the
United States to live outside the United States.
8. Employee or dependent having a change in residence that affects health plan availability.
9. A court order or National Medical Support Notice requiring the employee or any other individual to provide insurance
coverage for an eligible dependent of the employee.
10. Employee or a dependent becoming entitled to or losing eligibility for Medicaid or a state Children’s Health Insurance
Program (CHIP).
11. Employee or dependent becoming eligible for a state premium assistance subsidy for PEBB health coverage from
Medicaid or a state Children’s Health Insurance Program (CHIP).
12. Employee or dependent becoming entitled to or losing eligibility for Medicare, or enrolling in or cancelling enrollment in
a Medicare Part D plan.
13. Employee’s or dependent’s current health plan becoming unavailable because the employee or dependent is no longer
eligible for a health savings account (HSA).
14. Employee or dependent experiencing a disruption of care that could function as a reduction in benets for the
employee or his or her dependent for a specic condition or ongoing course of treatment (requires approval by the
PEBB Program).
Forms available at www.hca.wa.gov/pebb .
Are you or any eligible dependents already enrolled in PEBB coverage under another account?
Yes No
If yes, please contact your personnel, payroll, or benets ofce for assistance.
Subscriber’s last name First name Middle initial Social Security number
2015 Employee Enrollment/Change
2
(continued)
(continued)
2015 Employee Enrollment/Change
3
Section 1: Subscriber Information
Social Security number Last name First name Middle initial Sex
M F
Street address Apt./unit number City State ZIP Code
Mailing address (if different from above)
Apt./unit number City State ZIP Code
County of residence Date of birth (mm/dd/yyyy)
Work phone number Home phone number
Medical coverage
Cover
Waive: effective date ______________________________
If waiving, see Section 6. Note: If you waive coverage, you must be enrolled in other employer-
based group medical insurance. You cannot enroll your eligible dependents in medical.
Dental coverage
Cover
(Dental may not be waived.)
Tobacco Use Premium Surcharge
The PEBB Program requires a monthly $25 surcharge in addition to your premium if you or a family member you enroll on your
PEBB medical coverage uses a tobacco product. Tobacco use is dened as any use of tobacco products within the past two
months except for religious or ceremonial use. If you check YES or leave the check boxes blank you will pay the $25 surcharge.
See the 2015 Premium Surcharge Help Sheet for instructions on how to respond.
Does the tobacco use premium surcharge apply to you? Check one:
I previously attested to the tobacco use premium surcharge and my attestation has not changed.
YES, I have used tobacco products in the past two months.
NO, or I have used the tobacco cessation resources noted in the 2015 Premium Surcharge Help Sheet.
Section 2: Spouse or Registered Domestic Partner Information
• List an eligible spouse or registered domestic partner, as dened by Washington Administrative Code 182-12-260(2),
you wish to cover or remove from coverage.
• You may skip this section if you are not enrolling a spouse or registered domestic partner.
• Family members cannot be enrolled in two PEBB medical or dental accounts at the same time.
• If adding a spouse or registered domestic partner, you must provide proof of eligibility within PEBB’s enrollment timelines or
the spouse or registered domestic partner will not be enrolled.
• Forms and a list of documents we will accept to verify eligibility are available at www.hca.wa.gov/pebb .
Relationship to subscriber
(If adding a registered domestic partner, please attach a completed Declaration of Tax Status form.)
Spouse: date of marriage _____________________ Registered domestic partner: date registered ______________
Social Security number Last name First name Middle initial
Sex
M
F
Street address
(only if different from subscriber)
Apt./unit number
City State ZIP Code
Date of birth (mm/dd/yyyy)
Medical coverage
Cover
Remove from medical coverage Reason _________________________________________________
Dental coverage Cover
Remove from dental coverage Reason _________________________________________________
Tobacco Use Premium Surcharge
Does the tobacco use premium surcharge apply to your spouse or registered domestic partner? Check one:
I previously attested to my spouse’s or registered domestic partner’s tobacco use and the attestation has not changed.
YES, my spouse or registered domestic partner has used tobacco products in the past two months.
NO, or my spouse or registered domestic partner has used the tobacco cessation resources noted in the
2015 Premium Surcharge Help Sheet.
A
Relationship to subscriber
Check only if age 26 or older.
Disabled?
Yes No
Extended dependent validated
by court order? Yes No
Social Security number
Last name First name Middle initial Sex
M
F
Date of birth (mm/dd/yyyy)
Street address
(only if different from subscriber) Apt./unit number
City State ZIP Code
Medical coverage
Cover
Remove from medical coverage Reason _______________________________________________________
Dental coverage Cover
Remove from dental coverage Reason _______________________________________________________
Tobacco Use Premium Surcharge
Does the tobacco use premium surcharge apply to this family member? (Response required regardless of age.) Check one:
I previously attested to this family member’s tobacco use and the attestation has not changed.
YES, this family member has used tobacco products in the past two months.
NO, or this family member has used the tobacco cessation resources noted in the 2015 Premium Surcharge Help Sheet.
Subscriber’s last name First name Middle initial Social Security number
2015 Employee Enrollment/Change
4
(continued)
Section 3: Family Member Information (such as a child) Use additional forms for more members.
• You may skip this section if you are not enrolling additional family members.
• List eligible family members you wish to cover or remove from coverage.
• Family members cannot be enrolled in two PEBB medical or dental accounts at the same time.
• If adding a family member, you must provide proof of eligibility for each family member within PEBB’s enrollment timelines or
the family member will not be enrolled. If adding a child of your registered domestic partner, also attach a Declaration of Tax
Status form.
• If enrolling a dependent with a disability age 26 or older, or an extended dependent, dened by Washington Administrative
Code 182-12-260, submit the appropriate dependent certication form(s) as instructed on the form. Refer to the Employee
Enrollment Guide for eligibility information.
• Forms and a list of documents we will accept to verify eligibility are available at www.hca.wa.gov/pebb .
Section 2: Spouse or Registered Domestic Partner Information (continued from previous page)
Spouse or Registered Domestic Partner Coverage Premium Surcharge
The PEBB Program requires a monthly $50 surcharge in addition to your premium if your spouse or registered domestic partner
has chosen not to enroll in other employer-based group medical insurance that is comparable to Uniform Medical Plan Classic.
See the 2015 Premium Surcharge Help Sheet for instructions on how to respond. If you check YES below or leave this section
blank, you will pay the monthly surcharge.
Does the spouse or registered domestic partner coverage surcharge apply to you? Check one:
I previously attested to the spouse or registered domestic partner coverage premium surcharge for 2015 and the
attestation has not changed.
YES, I used the 2015 Premium Surcharge Help Sheet and completed the 2015 Spousal Plan Calculator online.
NO, I used the 2015 Premium Surcharge Help Sheet and, if needed, completed the 2015 Spousal Plan Calculator online.
Which questions, if any, on the 2015 Premium Surcharge Help Sheet did you check NO? Check all that apply.
Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Employer to determine. I used the 2015 Premium Surcharge Help Sheet and am completing and submitting a printed 2015
Spousal Plan Calculator. My employer will determine whether my spouse’s or registered domestic partner’s employer-based
group medical insurance is comparable to UMP Classic.
The 2015 Premium Surcharge Help Sheet and the 2015 Spousal Calculator are available at www.hca.wa.gov.pebb .
B
Relationship to subscriber
Check only if age 26 or older.
Disabled?
Yes No
Extended dependent validated
by court order? Yes No
Social Security number
Last name First name Middle initial Sex
M
F
Date of birth (mm/dd/yyyy)
Street address
(only if different from subscriber) Apt./unit number
City State ZIP Code
Medical coverage
Cover
Remove from medical coverage Reason _______________________________________________________
Dental coverage Cover
Remove from dental coverage Reason _______________________________________________________
Tobacco Use Premium Surcharge
Does the tobacco use premium surcharge apply to this family member? (Response required regardless of age.) Check one:
I previously attested to this family member’s tobacco use and the attestation has not changed.
YES, this family member has used tobacco products in the past two months.
NO, or this family member has used the tobacco cessation resources noted in the 2015 Premium Surcharge Help Sheet.
C
Relationship to subscriber
Check only if age 26 or older.
Disabled?
Yes No
Extended dependent validated
by court order? Yes No
Social Security number
Last name First name Middle initial Sex
M
F
Date of birth (mm/dd/yyyy)
Street address
(only if different from subscriber) Apt./unit number
City State ZIP Code
Medical coverage
Cover
Remove from medical coverage Reason _______________________________________________________
Dental coverage Cover
Remove from dental coverage Reason _______________________________________________________
Tobacco Use Premium Surcharge
Does the tobacco use premium surcharge apply to this family member? (Response required regardless of age.) Check one:
I previously attested to this family member’s tobacco use and the attestation has not changed.
YES, this family member has used tobacco products in the past two months.
NO, or this family member has used the tobacco cessation resources noted in the 2015 Premium Surcharge Help Sheet.
D
Relationship to subscriber
Check only if age 26 or older.
Disabled?
Yes No
Extended dependent validated
by court order? Yes No
Social Security number
Last name First name Middle initial Sex
M
F
Date of birth (mm/dd/yyyy)
Street address
(only if different from subscriber) Apt./unit number
City State ZIP Code
Medical coverage
Cover
Remove from medical coverage Reason _______________________________________________________
Dental coverage Cover
Remove from dental coverage Reason _______________________________________________________
Tobacco Use Premium Surcharge
Does the tobacco use premium surcharge apply to this family member? (Response required regardless of age.) Check one:
I previously attested to this family member’s tobacco use and the attestation has not changed.
YES, this family member has used tobacco products in the past two months.
NO, or this family member has used the tobacco cessation resources noted in the 2015 Premium Surcharge Help Sheet.
Subscriber’s last name First name Middle initial Social Security number
2015 Employee Enrollment/Change
5
(continued)
Subscriber’s last name First name Middle initial Social Security number
2015 Employee Enrollment/Change
6
Section 4: Medical Plan Selection Check only one.
Contact the plans for benets information; their contact information is at the end of this form.
Kaiser Foundation Health Plan of the Northwest
Kaiser Permanente Classic
Kaiser Permanente Consumer-Directed Health Plan
Uniform Medical Plan, administered by Regence BlueShield
UMP Classic
UMP Consumer-Directed Health Plan
Section 5: Dental Plan Selection Check only one.
Contact the plans for benets information; their contact information is located at the end of this form.
Preferred Provider Organization
Uniform Dental Plan, administered by Delta Dental of Washington (Group #3000)
(You may receive services from any provider.)
Managed-Care Plans
You must choose a provider from the dental plan network. Before you select a managed-care plan, be sure to call the dental
plan to verify your provider is in their network and ll in the requested information below.
DeltaCare, administered by Delta Dental of Washington (Group #3100)
Call DeltaCare at 1-800-650-1583 to verify your provider is in their network.
Dentist name or clinic code
____________________________________________________________________________________________________
(You must receive services from a DeltaCare network provider.)
Willamette Dental of Washington, Inc.
Clinic location
____________________________________________________________________________________________________
(You must receive services from a Willamette Dental Group plan provider.)
Group Health Cooperative
Group Health Classic
Group Health Value
Group Health Options Inc.
Group Health Consumer-Directed Health Plan
Please sign and date this form on the next page.
(continued)
Please sign and date this form.
Return completed form and documentation to your personnel, payroll, or benets ofce.
Section 6: Signature
Required
By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn’t, or if I do not update
this information within the timelines in PEBB rules, to the extent permitted by federal and state laws, I must repay any claims
paid by my health plan(s) or premiums paid on my behalf. My family members and I may also lose PEBB benets as of the last
day of the month we were eligible. To the extent permitted by law, PEBB or my employer may retroactively terminate coverage
for me and my dependents if I intentionally misrepresent eligibility, or do not fully pay premiums when due. In addition, I
understand that knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company is a crime, and can result in imprisonment, nes, denial of PEBB benets, and loss of my job.
If adding a registered domestic partner to my account, I declare that my domestic partner and I have registered through the
Washington Secretary of State’s Ofce or another state.
Enrollment is not complete until verication of the family member’s eligibility is successful. I understand that if I’m applying to
add a dependent to my PEBB coverage, I must provide copies of documents that verify the dependent’s eligibility within PEBB’s
enrollment timelines, or the dependent will not be enrolled.
Employees must enroll in PEBB dental, basic life, and basic long-term disability insurance. However, employees may waive PEBB
medical if they are enrolled in other employer-based group medical insurance. If I waive medical, I understand I can enroll during
the annual open enrollment period or within 60 days of a special open enrollment event as dened in PEBB rules. If I waive
medical for myself, I cannot enroll my eligible family members in medical.
I allow my employer to deduct money from my earnings to pay for insurance coverage and any applicable surcharges.
If I am enrolling in a consumer-directed health plan with a health savings account (HSA), I must meet HSA eligibility conditions.
I understand that my employer will contribute to an HSA on my behalf based on the information I have provided, and that there
are limits to these contributions and my HSA contributions (if any) under federal tax law.
I understand that if I am enrolled in PEBB retiree health coverage, I am choosing to defer that coverage for myself and any
enrolled family members effective on my eligibility date for PEBB employee health coverage. I also understand if I am enrolled in
retiree life insurance, I may keep it by completing and submitting the Employee Life and AD&D Insurance Enrollment/Change Form
and having the premiums deducted from my paycheck.
This form replaces all Employee Enrollment/Change forms previously submitted.
HCA’s Privacy Notice: We will keep your information private as allowed by law.
To see our Privacy Notice, go to www.hca.wa.gov/pebb.
Subscriber’s signature _________________________________________________ Date ______________________________
Subscriber’s last name First name Middle initial Social Security number
2015 Employee Enrollment/Change
2015 PEBB Medical Contractors
Group Health Cooperative
320 Westlake Ave. N., Suite 100, Seattle, WA 98109-5233
1-888-901-4636 or TTY 1-800-833-6388
Group Health Options Inc.
320 Westlake Ave. N, Suite 100, Seattle, WA 98109-5233
1-888-901-4636 or TTY 1-800-833-6388
Kaiser Foundation Health Plan of the Northwest
500 NE Multnomah St., Suite 100, Portland, OR 97232-2099
1-800-813-2000 or TTY 711
Uniform Medical Plan, administered by Regence BlueShield
1800 Ninth Avenue, Suite 235, Seattle, WA 98101
1-888-849-3681 or TTY 711
2015 PEBB Dental Contractors
DeltaCare, administered by
Delta Dental of Washington
9706 Fourth Avenue NE, Seattle, WA 98115-2157
1-800-650-1583
Uniform Dental Plan, administered by
Delta Dental of Washington
9706 Fourth Avenue NE, Seattle, WA 98115-2157
1-800-537-3406
Willamette Dental of Washington, Inc.
6950 NE Campus Way, Hillsboro, OR 97124-5611
1-855-4DENTAL (1-855-433-6825)
7
HCA 50-226 (2/15)
Tobacco use premium surcharge
What are “tobacco products”?
Tobacco products are dened as any product made with
or derived from tobacco that is intended for human
consumption, including any component, part, or accessory
of a tobacco product. This includes, but is not limited
to, cigars, cigarettes, chewing tobacco, snuff, and other
tobacco products.
Tobacco products do not include:
• E-cigarettes (until their tobacco-related status is
determined by the U.S. Food and Drug Administration
[FDA]).
• Tobacco cessation aids approved by the FDA, such as:
1. Over-the-counter nicotine replacement products.
• All over-the-counter tobacco cessation products
for adults ages 18 and older.
• All over-the-counter tobacco cessation products
for children under age 18 if recommended by a
doctor.
Examples of over-the-counter nicotine
replacement products include:
• Skin patches–generic (nicotine lm), private label,
or brand-name (Habitrol or Nicoderm).
• Chewing gum (also called nicotine gum)–generic
(nicotine polacrilex or Thrive), private label, or
brand-name (Nicorette).
• Lozenges–generic (nicotine polacrilex), private
label, or brand-name (Nicorette or Commit).
2. Prescription nicotine replacement products.
• Nasal spray or oral inhaler–brand name (Nicotrol)
• Products not containing nicotine, such as pills–
generic (buproprion hydrochloride) or brand name
(Chantix or Zyban)
2015 Premium Surcharge Help Sheet
• Use the information below to attest on your 2015 enrollment form or the 2015 Premium Surcharge Change Form
whether the premium surcharges apply.
• The surcharges do not apply to subscribers and any family members enrolled in PEBB dental coverage only.
• The surcharges do not apply to retirees, COBRA, or extension of coverage subscribers enrolled in Medicare Part A and
Part B.
Do not submit this help sheet with
your 2015 enrollment form or 2015
Premium Surcharge Change Form.
What is “tobacco use”?
Tobacco use is dened as any use of tobacco products
within the past two months. It does not include the
religious or ceremonial use of tobacco.
The surcharge will not apply if you and all enrolled family
members ages 18 and older who use tobacco products
are enrolled in your PEBB medical plan’s tobacco cessation
program, or if enrolled family members ages 13–17 who
use tobacco products access information and resources
at teen.smokefree.gov . Enrolled family members ages
12 and younger are automatically defaulted to NO (non-
tobacco users). You do not need to re-attest when the
family member turns age 13 unless the family member
uses, or begins using, tobacco products.
Does this mean tobacco use within the past
two months from today?
Tobacco products used within the two months before the
date you complete this form count as “tobacco use.”
What if tobacco use changes?
You must change your attestation when:
• Any enrolled family member age 13 and older starts
using tobacco products.
• All enrolled family members ages 13 and older have not
used tobacco products for two months, or have used
the tobacco cessation resources noted above.
You can change your attestation online using My Account
at www.hca.wa.gov/pebb or submit a 2015 Premium
Surcharge Change Form. Changes that add or remove a
surcharge will take effect the month after the change is
received online or by paper form. Changes received on the
rst day of the month will be made for that month.
To obtain this document in another format (such as Braille or audio), call 1-800-200-1004.
TTY users may call through the Washington Relay service by dialing 711.
(continues on next page)
Questions
YES NO
1
Are you covering your spouse or registered domestic partner in Public Employees Benets Board (PEBB)
medical coverage under your account in 2015?
2
Will your spouse or registered domestic partner be eligible for medical coverage through his or her employer
in 2015? (If your spouse or registered domestic partner will not be employed in 2015, answer NO.)
3
Will your spouse’s or registered domestic partner’s employer offer at least one medical plan that serves
your spouse’s or registered domestic partner’s county of residence in 2015?
4
Has your spouse or registered domestic partner chosen not to enroll in his or her employer’s medical
coverage in 2015?
5
Will the coverage offered by your spouse’s or registered domestic partner’s employer in 2015 NOT be
through the PEBB Program?
Answer YES if your spouse’s or registered domestic partner’s employer does not offer PEBB coverage.
Answer NO if your spouse’s or registered domestic partner’s employer does offer PEBB coverage.
6
Will your spouse’s or registered domestic partner’s share of the medical premium through his or her
employer be less than $89.31 per month in 2015?
If you answered YES to ALL of these questions,
you must do 1 and 2 below to nd out whether you
must pay the surcharge.
1. Your spouse or registered domestic partner should ask
his or her employer for a 2015 Summary of Benets and
Coverage (SBC) for all medical plans that:
• Serve the county of residence for your spouse or
registered domestic partner.
• Have a monthly premium of less than $89.31 per
month for the employee.
2. Use the 2015 Summary of Benets and Coverage (SBC)
information to answer the questions in the 2015 Spousal
Plan Calculator online tool at www.hca.wa.gov/pebb.
Or, you can download a paper version of the 2015
Spousal Plan Calculator from the website and submit it
with your 2015 enrollment form or your 2015 Premium
Surcharge Change Form.
If you don’t have access to the internet, you may
request a paper 2015 Spousal Plan Calculator from your
employer (if an employee). Retirees, COBRA, Extension
of Coverage, and Leave Without Pay subscribers may
call the PEBB Program at 1-800-200-1004 to request a
paper copy.
Spouse or registered domestic partner coverage premium surcharge
Will the spouse or registered domestic partner coverage premium surcharge apply to me?
If you don’t have a spouse or 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 registered domestic partner on your 2015
PEBB medical plan, answer YES or NO to the following questions. Check the corresponding box(es) on your 2015
enrollment form or 2015 Premium Surcharge Change Form.
If using the online 2015 Spousal Plan Calculator:
• Provide all the information requested by the form.
• Click the Compute button.
• You will be provided with the YES or NO response to
the question “Does the spouse or registered domestic
partner coverage surcharge apply to you?” Enter
this response on your 2015 enrollment form or 2015
Premium Surcharge Change Form.
If using a paper 2015 Spousal Plan Calculator:
• Provide all the information requested by the form.
• Check “Employer or PEBB Program to determine.”
• Include a copy of the 2015 Spousal Plan Calculator (not
this Help Sheet) when you submit your 2015 enrollment
form or 2015 Premium Surcharge Change Form.
• Your employer or the PEBB Program will determine
whether your spouse’s or registered domestic partner’s
employer-based group medical insurance is comparable
to UMP Classic.
If you answered NO to ANY of these questions,
you will not have to pay the surcharge if you
check NO on your 2015 enrollment form or
2015 Premium Surcharge Change Form.
