Premium Surcharge Attestation Form

Transcription

1 Premium Surcharge Attestation Form Submit this form to report whether the Public Employees Benefits Board (PEBB) Program tobacco use and spouse or domestic partner coverage premium surcharges apply to you. Important: If you do not respond by May 15, 2014, you will automatically pay surcharges starting on July 1, Save time and get instant confirmation Complete this form at through My Account. Section 1: Tobacco use premium surcharge See the attached Surcharge Help Sheet for details. A monthly $25-per-account surcharge will be required in addition to your premium if you or a family member enrolled on your PEBB medical coverage uses a tobacco product. If you and all enrolled family members who use tobacco products are enrolled in your PEBB medical plan s tobacco cessation program, the surcharge will not apply. Family member List yourself and each family member enrolled on your PEBB medical coverage. To add more family members, attach additional copies of this form. Your first name Middle initial Has this person used tobacco products in the last two months? YES NO Or he or she is enrolled in our PEBB medical plan s tobacco cessation program. If you checked YES or left the checkboxes blank for yourself or any family member(s) listed above, you will pay the monthly $25 surcharge starting July 1, (4/14) Page 1 of 8 continued

2 Section 2: Spouse or domestic partner coverage premium surcharge Complete this section only if you have a spouse or domestic partner enrolled on your PEBB medical coverage. If you have a spouse or domestic partner enrolled on your PEBB medical coverage and you check YES or leave this section blank, you will pay the monthly $50 surcharge starting July 1, A $50-per-month surcharge will be required in addition to your premium if you have a spouse or domestic partner enrolled on your PEBB medical coverage, and your spouse or domestic partner has chosen not to enroll in medical coverage through his or her employer that is comparable to Uniform Medical Plan (UMP) Classic. See the attached Surcharge Help Sheet to find out whether this surcharge applies to you. Does the spouse or domestic partner coverage surcharge apply to you? NO; I took the questionnaire on page 4 (and, if needed, completed the Spousal Plan Calculator online). EMPLOYER TO DETERMINE; I took the questionnaire on page 4, and am completing and submitting the attached Spousal Plan Calculator so my employer can determine whether my spouse s or partner s employer-based group medical insurance is comparable to UMP Classic. YES; I took the questionnaire on page 4 and completed the Spousal Plan Calculator online. Get the answer now Use the Spousal Plan Calculator at Section 3: Signature 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 provide timely, updated information, I will owe surcharges to the PEBB Program. This form replaces all Premium Surcharge Attestation Forms and electronic surcharge attestations previously submitted. HCA s Privacy Notice: We will keep your information private as allowed by law. To see our Privacy Notice, go to Name (print) Signature Date Agency name Please sign and date this form. Return it with the Spousal Plan Calculator(s) (if appropriate) to your personnel, payroll, or benefits office. Page 2 of 8

3 Surcharge Help Sheet Tobacco use premium surcharge What are tobacco products? Tobacco products are defined 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 o All over-the-counter tobacco cessation products for adults age 18 and older. o 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 film), 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) Prescription nicotine replacement products* o Nasal spray or oral inhaler brand name (Nicotrol) o Products not containing nicotine, such as pills generic (buproprion hydrochloride) or brand name (Chantix or Zyban) * To determine if a prescribed drug is covered, check with your medical plan's formulary first. What is tobacco use? Tobacco use is defined as any use of tobacco products within the past two months. It does not include the religious or ceremonial use of tobacco. If more than one enrolled family member uses tobacco products, you will not pay more than $25 per month. Does this mean use within the past two months from today or within two months before May 15? Tobacco products used within the two months before the date you complete this form count as tobacco use. Page 3 of 8

4 Spouse or domestic partner coverage premium surcharge If you have a spouse or domestic partner who is currently enrolled on your PEBB medical plan, answer YES or NO to the following questions. If you don t have a spouse or domestic partner who is currently enrolled on your PEBB medical plan, you don t need to complete this questionnaire this surcharge doesn t apply to you. Questions YES NO 1 Is your spouse or domestic partner eligible for medical coverage through his or her employer? If your spouse or domestic partner is unemployed, answer NO. 2 Does your spouse s or domestic partner s employer offer at least one medical plan that serves your spouse s or domestic partner s county of residence? 3 Has your spouse or domestic partner chosen not to enroll in his or her employer s medical coverage? 4 Is the coverage offered by your spouse s or domestic partner s employer not through the PEBB Program? YES = My spouse or domestic partner s employer does not offer PEBB coverage. NO = My spouse or domestic partner s employer does offer PEBB coverage. 5 Would your spouse s or domestic partner s share of the medical premium through his or her employer be less than $84.56 per month? If you answered YES to ALL of these questions: You may have to pay the surcharge. To find out whether you do: 1. Complete the attached Spousal Plan Calculator (on pages 5 and 6). Before you begin, your spouse or domestic partner should ask his or her employer (or employer s medical plan) for a Summary of Benefits and Coverage for all medical plans that serve your spouse s or domestic partner s county of residence and would cost an employee less than $84.56 per month. (If your spouse s or domestic partner s employer offers more than one medical plan in your spouse s or domestic partner s county of residence where the employee s cost would be less than $84.56 per month, complete the Spousal Plan Calculator for each plan.) 2. Check EMPLOYER TO DETERMINE under Section 2 of the Premium Surcharge Attestation Form. 3. Return the completed Spousal Plan Calculator with the Premium Surcharge Attestation Form to your employer. Do not include the Summary of Benefits and Coverage. Your employer will use the completed calculator to determine whether your spouse s or 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. Check NO under Section 2 of the Premium Surcharge Attestation Form. Get the answer now Use the Spousal Plan Calculator at Page 4 of 8

5 Spousal Plan Calculator It s easier online Use the Spousal Plan Calculator at If you answered YES to all the questions in the questionnaire on page 4, check EMPLOYER TO DETERMINE under Section 2 of the Premium Surcharge Attestation Form, complete this calculator, and submit it to your employer with your Premium Surcharge Attestation Form. Use the Summary of Benefits and Coverage from your spouse s or domestic partner s employer-sponsored medical plan(s) to answer the questions below. Do not return the Summary of Benefits and Coverage with this form. The plan(s) must: Serve your spouse s or domestic partner s county of residence, and Cost less than $84.56 for the employee s share of the monthly premium. Complete a Spousal Plan Calculator for each medical plan that meets the criteria above. If you have more than one plan that meets the criteria above, copy this form as needed and submit a form for each plan. For question 1A, look at the top-right corner of your spouse s or domestic partner s Summary of Benefits and Coverage next to Plan Type. See page 7 for a typical plan summary. ❶ Is this a high-deductible health plan (HDHP) or a consumer-driven health plan (CDHP)? If the Plan Type is HMO, PPO, or POS, check NO. A. YES NO B. If YES, how much does the employer contribute each year for an individual's health savings account (HSA) or health reimbursement account (HRA)? $ For questions 2 and 3, look at the Summary of Benefits and Coverage under "Important Questions." Only look at amounts for a single person (or individual) using a preferred (or in-network) provider. See page 7 for a typical plan summary. ❷ How much is/are the plan s deductible(s)? Answer either A or B. Don t answer both. A. $ Overall deductible (if you only see one deductible for the plan), OR B1. $ Medical deductible, AND B2. $ Prescription drug deductible ❸ How much is/are the plan s out-of-pocket limit(s)? Answer either A or B. Don t answer both A. $ Out-of-pocket limit (if you only see one out-of-pocket limit for the plan), OR B1. $ Medical out-of-pocket limit, AND B2. $ Prescription drug out-of-pocket limit Page 5 of 8

6 For questions 4 through 7, look at 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. See pages 7 and 8 for a typical plan summary. ❹ What is the plan s most common coinsurance among these three services: 1) Primary care visit to treat an injury or illness, 2) Diagnostic test, and 3) Durable medical equipment? If you see the same coinsurance (%) for at least two of these services, write that amount. If you see different coinsurance amounts, or copays ($) with coinsurance, write the highest coinsurance amount you see. If you only see copays for all three services, skip this question. % ❺ How much is the plan s copay for a primary care visit to treat an injury or illness? If you see only coinsurance (%), or copay ($) and coinsurance, skip this question. $ ❻ How much is the plan s copay for emergency room services? If you see only coinsurance (%), or copay ($) and coinsurance, skip this question. $ ❼ How much is the plan s coinsurance or copay for preferred brand drugs (or formulary drugs)? Answer either A or B. Don t answer both A. % Coinsurance, OR B. $ Copay Return this form with your Premium Surcharge Attestation Form to your personnel, payroll, or benefits office. Page 6 of 8

7 ABC Insurance: Example Plan Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What This Plan Covers and What It Costs Coverage for: XXXX Plan Type: ❶ A Important Questions Answers Why This Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition ❷A or ❷B1/person, $XXX/family Yes. ❷B2 for prescription drug coverage. Yes. ❸A or ❸B1/person, $XXX/family. Prescription drugs: ❸B2 Premiums, prescription drugs, balance-billed charges, and health care this plan doesn t cover. Services You May Need You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1). You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Your Cost If You Use An In-network Provider Your Cost If You Use An Out-of-network Provider Limitations and Exceptions Primary care visit to treat an injury or illness ❹ ❺ X% co-insurance none Specialist visit $X co-pay X% co-insurance none Other practitioner office visit $X co-pay X% co-insurance none Preventive care/screening/immunization No charge X% co-insurance none Diagnostic test (x-ray, blood work) ❹ X% co-insurance none Imaging (CT/PET scans, MRIs) $ X% co-insurance X% co-insurance none Generic drugs $X co-pay X% co-insurance none Preferred brand drugs ❼A or ❼B X% co-insurance none Non-preferred brand drugs $X co-pay X% co-insurance none Page 7 of 8

8 ABC Insurance: Example Plan Coverage Period: 01/01/ /31/2014 Summary of Benefits and Coverage: What This Plan Covers and What It Costs Coverage for: XXXX Plan Type: ❶ A Common Medical Event Services You May Need Your Cost If You Use An In-network Provider Your Cost If You Use An Out-of-network Provider Limitations and Exceptions More information about prescription drug coverage is available at Specialty drugs $X co-pay X% co-insurance none If you have outpatient surgery If you need immediate medical attention If you need help recovering or have other special health needs Facility fee (e.g., ambulatory surgery center) X% co-insurance X% co-insurance none Physician/surgeon fees X% co-insurance X% co-insurance none Emergency room services ❻ X% co-insurance none Emergency medical transportation X% co-insurance X% co-insurance none Urgent care X% co-insurance X% co-insurance none Home health care X% co-insurance X% co-insurance none Rehabilitation services X% co-insurance X% co-insurance none Habilitation services X% co-insurance X% co-insurance none Skilled nursing care X% co-insurance X% co-insurance none Durable medical equipment ❹ X% co-insurance none Hospice service X% co-insurance X% co-insurance none Page 8 of 8