Working Spouse Surcharge Verification

Title

A short description to explain the nature of a ticket.

Working Spouse Verification Form

PLEASE READ CAREFULLY - IMPORTANT INFORMATION

THIS FORM DOES NOT ENROLL YOUR SPOUSE IN OR TERMINATE YOUR SPOUSE'S COVERAGE UNDER YOUR HEALTH PLAN.

FAILURE TO COMPLETE THIS FORM OR PROVIDE SUPPORTING DOCUMENTATION WHEN REQUIRED WILL RESULT IN A SURCHARGE BEING APPLIED TO YOUR REQUIRED PREMIUM, WHETHER OR NOT YOUR SPOUSE MEETS THE SURCHARGE CRITERIA.

The University of Delaware is committed to maintaining the affordability and sustainability of its healthcare program. To help offset the cost of covering spouses who have access to other employer-sponsored medical plans, UD applies a surcharge to employees who elect to cover a spouse meeting the criteria outlined below. To determine the applicability of the surcharge UD previously required submission of the Online Spousal Coordination Form. This form is now referred to as the Working Spouse Surcharge Verification Form, but it continues to be a requirement for spousal enrollment. To enroll your spouse in coverage, or to keep your spouse covered under your plan, the Working Spouse Surcharge Verification Form must be submitted each year during the annual open enrollment period. Please visit the Working Spouse Surcharge program website.

If you cover a spouse under your health plan, you are required to complete the Working Spouse Verification Form when the following events occur:

Enroll your spouse,
Anytime your spouse loses or gains employee coverage, and
Every year during the Annual Benefits Open Enrollment.

You, your spouse, or your spouse’s employer may be required to provide additional information.

You are responsible for understanding the requirements of the Working Spouse Surcharge program, for providing verification as noted, and for the accuracy of the information in this form.

Employees who choose to enroll a spouse in the University’s medical plan will be subject to a $200 per month surcharge ($100 per pay period for 24 pays) if:

The spouse is eligible for group medical coverage through their employer and is responsible for 50% or less of the premium for the lowest-cost employee-only plan available to them and chooses not to enroll in their employer's plan; or
The spouse is retired and has access to a health plan through their former employer or a retirement plan and is responsible for 50% or less of the premium for the lowest-cost retiree-only plan available to them and chooses not to enroll.

This surcharge is in addition to the standard medical plan premium.

You must complete this Working Spouse Surchage Verification Form each year during open enrollment or whenever there is a change to your spouse’s employment or health insurance coverage status.

Details about the spouse surcharge can be found on the Total Rewards website, under Health and Life Insurance.

Whether you have elected medical coverage for your spouse during the Open Enrollment period or as the result of a Qualifying Life Event (QLE), you will automatically be assessed the Spouse Surcharge of $200 per month. To determine if you qualify to have the surcharge waived, you MUST complete the Verification Form. If your spouse was added as a result of a QLE, the Verification Form must be provided within 30 days of the qualifying life event. If your spouse was added during the Open Enrollment period, the Verification Form MUST be completed during the Open Enrollment period. Any spouse surcharge amounts you pay before successfully completing the Verification Form cannot be refunded to you, even if the completed result confirms that you should not pay the surcharge going forward.

SECTION I: EMPLOYEE INFORMATION

Employee ID

Employee First Name

Employee M.I.

Employee's middle initial

Employee Last Name

Phone

UD email

SECTION II: SPOUSE INFORMATION

Spouse First Name

Spouse's first name

Spouse M.I.

Spouse Last Name

Spouse's surname or family name

You are completing this form due to:

My spouse is

Spouse employer medical coverage enrollment status

Does your spouse have access to employer-sponsored medical coverage for which the employer pays at least 50% of the cost?

Is your spouse enrolled in medical coverage for which a former employer pays at least 50% of the cost?

Does your spouse have access to medical coverage for which a former employer pays at least 50% of the cost?

Does your spouse provide medical coverage to his or her employees?

_

As your spouse is not employed and not enrolled in coverage through a former employer, you do not need to complete section III. Please proceed to Section IV.

_

As your spouse is employed by UD, you do not need to complete Section III. Please proceed to Section IV.

_

You do not need to complete Section III. Please proceed to Section IV.

SECTION III: SPOUSE EMPLOYER INFORMATION

I authorize the University of Delaware to contact my spouse’s employer for verification.

Spouse Employer Name

Spouse Employer Telephone Number

Spouse Health Carrier

Spouse Policy Number

Spouse Effective Date of Coverage

SECTION IV: ACKNOWLEDGMENT

I acknowledge that the information provided is true and complete to the best of my knowledge. Should I experience a Qualifying Life Event and want to make a change to my benefit elections, I understand that I am responsible for notifying Human Resources within 30 days of the event's occurrence. If I do not notify Human Resources within 30 days of the qualifying event, I must wait for the next Open Enrollment period (or another qualifying life event) to make a change to my benefits. I further understand that falsifying information regarding my spouse’s medical coverage will result in, at a minimum, the request for waiver of the spouse surcharge being denied.

Employee Signature

Your name

Your email address

Verification Code

Working Spouse Surcharge Verification

Other Fields