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    v1.0.31
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyWashington HCA Spousal Calculator Policy | OpenPay…
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    CurrentWashington State Health Care AuthorityPolicy 31-2

    Use of the PEBB Spousal Plan Calculator

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    This policy governs when a PEBB subscriber enrolled in PEBB medical must use the required form and, when directed, the PEBB Spousal Plan Calculator to determine whether a premium surcharge applies for a spouse or state registered domestic partner.

    Policy Summary
    PayerWashington State Health Care Authority
    PolicyUse of the PEBB Spousal Plan Calculator
    Policy CodePolicy 31-2
    Change TypeNo material change
    Effective DateJanuary 1, 2027
    Next Review DateNot specified
    Key ActionThe subscriber must complete the required form and, if directed, the PEBB Spousal Plan Calculator to determine whether a premium surcharge applies.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    95%Premium-share threshold
    95%Actuarial-value threshold
    3WAC exception categories
    1Calculator identified for use

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    When the Spousal Surcharge Applies

    When the spouse or domestic partner surcharge applies

    A premium surcharge applies when ALL of the following conditions are met:

    ALL of the following

    • The subscriber enrolls a spouse or state registered domestic partner in PEBB medical.
    • The spouse or state registered domestic partner has chosen not to enroll in another employer-based group medical plan.
    • The spouse's or state registered domestic partner's share of the other employer-based medical premium is less than 95% of the additional cost an employee would be required to pay to enroll the spouse or state registered domestic partner in PEBB Uniform Medical Plan (UMP) Classic.< 95% of the additional PEBB UMP Classic enrollment cost
    • The other employer-based group medical plan has benefits with an actuarial value of at least 95% of the actuarial value of PEBB UMP Classic benefits.>= 95% of PEBB UMP Classic actuarial value

    Exceptions to the premium surcharge

    The subscriber will not incur a premium surcharge if ANY of the following applies:

    ANY of the following

    • The spouse's or state registered domestic partner's employer-based group medical plan would cover only urgent or emergent care because of the spouse's or state registered domestic partner's county of residence.
    • The subscriber is enrolled in both Medicare Parts A and B and in the Medicare risk pool, as described in RCW 41.05.080(3).

      No attestation is required.

    • The spouse or state registered domestic partner waived their own PEBB or School Employees Benefits Board (SEBB) medical, and the subscriber provides an attestation that the spouse or state registered domestic partner is eligible for PEBB or SEBB medical.

      Attestation is required.

    • The spouse or state registered domestic partner elected not to enroll in a TRICARE plan, and the subscriber provides an attestation that the spouse or state registered domestic partner is eligible for a TRICARE plan.

    Comparison Plan Thresholds

    Other employer-based medical premium-share threshold
    Comparison testThe spouse's or state registered domestic partner's share of the other employer-based medical premium is less than 95% of the additional cost an employee would be required to pay to enroll the partner in PEBB UMP Classic.
    Other employer-based medical actuarial-value threshold
    Minimum actuarial valueThe other employer-based group medical plan must have benefits with an actuarial value of at least 95% of the actuarial value of PEBB UMP Classic benefits.

    Required Subscriber Actions

    Documentation Required

    Complete the Required Form and Calculator

    The subscriber must complete the required form and, when directed by the PEBB Program, use the PEBB Spousal Plan Calculator to determine whether a spouse or state registered domestic partner coverage premium surcharge applies in addition to the monthly medical premium.

    • A surcharge applies when the subscriber enrolls their spouse or state registered domestic partner in PEBB medical and the spouse or partner has declined other employer-based group medical coverage where their share of the premium is less than 95% of the additional cost an employee would pay to enroll a spouse or state registered domestic partner in the PEBB Uniform Medical Plan (UMP) Classic, and the other plan's benefits have an actuarial value of at least 95% of the actuarial value of the PEBB UMP Classic benefits.
    Documentation Required

    Provide Exception Attestation

    Provide an attestation when required to document an applicable exception to the premium surcharge under WAC 182-08-185(2)(a), including exceptions involving waived PEBB or SEBB medical eligibility or declined TRICARE coverage.

    • No attestation is required, and no premium surcharge will be imposed, when the subscriber is enrolled in both Medicare Parts A and B and in the Medicare risk pool described in RCW 41.05.080(3).

    Key Terms

    Premium surcharge
    DefinitionAn additional amount imposed in addition to the subscriber's monthly medical premium when the specified conditions for spouse or state registered domestic partner coverage are met.
    PEBB Uniform Medical Plan (UMP) Classic
    DefinitionThe PEBB medical plan used as the comparison basis for the additional employee cost and actuarial value tests.
    Policy Summary
    PayerWashington State Health Care Authority
    PolicyUse of the PEBB Spousal Plan Calculator
    Policy CodePolicy 31-2
    Change TypeNo material change
    Effective DateJanuary 1, 2027
    Next Review DateNot specified
    Key ActionThe subscriber must complete the required form and, if directed, the PEBB Spousal Plan Calculator to determine whether a premium surcharge applies.
    SourceLink
    On This Page
    When the Spousal Surcharge AppliesComparison Plan ThresholdsRequired Subscriber ActionsKey Terms

    Attestation is required.

  1. No surcharge applies when the spouse or state registered domestic partner's employer-based group medical coverage would cover only urgent or emergent care because of the spouse's or partner's county of residence.
  2. An employee covering a spouse or state registered domestic partner who waived their own PEBB or School Employees Benefits Board (SEBB) medical must provide an attestation that the spouse or partner is eligible for PEBB or SEBB medical.
  3. A subscriber covering a spouse or state registered domestic partner who elected not to enroll in a TRICARE plan must provide an attestation that the spouse or partner is eligible for a TRICARE plan.
  4. When a required attestation is provided and the applicable exception is met, no premium surcharge will be imposed.