Form Hca 50 224 PDF Details

Navigating the complexities of health coverage can be daunting, especially when additional surcharges based on lifestyle choices or family status come into play. One critical tool in this process for subscribers of the Public Employees Benefits Board (PEBB) in Washington State is the HCA 50-224 form, also known as the Premium Surcharge Attestation Form. Designed to streamline the process of reporting applicable surcharges, this form must be submitted within specific timeframes—31 days for employees and 60 days for all other subscribers after becoming eligible for benefits. The form is divided into sections addressing different potential surcharges. Section 1 focuses on the tobacco use premium surcharge, imposing an additional monthly fee if the subscriber or any family members on the PEBB medical coverage use tobacco products. However, this surcharge can be avoided if those individuals participate in a tobacco cessation program. Section 2 addresses a surcharge related to spouse or domestic partner coverage. A significant additional monthly cost is incurred if a subscriber enrolls a spouse or domestic partner who has access to but does not utilize comparable employer-based medical coverage. Completing this form accurately ensures subscribers only pay the surcharges applicable to their situations, and by signing it, they affirm the truthfulness and completeness of the information provided, with the understanding that inaccuracies can lead to owing surcharges back to the PEBB Program. The document concludes with instructions on where to submit the completed form, emphasizing the importance of this process in managing health care costs and benefits efficiently and equitably.

QuestionAnswer
Form NameForm Hca 50 224
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names50 224 mchenry county illinois registration of domestic partnership form

Form Preview Example

See details on
Attestations Worksheet.
Step One.

Premium Surcharge Attestation Form

Submit this form no later than 31 days (for employees) or 60 days (for all other subscribers who need to attest) from the date you become eligible for benefits to report whether the tobacco use and spouse or domestic partner coverage premium surcharges apply to you.

Section 1: Tobacco use premium surcharge

A monthly $25-per-account surcharge will be required in addition to your premium if you or a family member on your PEBB medical coverage uses a tobacco product. The surcharge will not apply if you and all family members ages 18 and older who use tobacco products are enrolled in your PEBB medical plan’s tobacco cessation program, or if children ages 17 and younger who use tobacco products access

information and resources at teen.smokefree.gov.

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.

Type or print clearly in black ink. List yourself and each family

Has this person used

tobacco products in the

member you enroll on your PEBB medical coverage.

 

Select the “Yes” or “No” checkbox to attest for each family member,

 

last two months?

 

 

 

Yes

 

No

regardless of age.

 

 

 

 

 

 

 

 

 

 

 

Or he or she has used

(To list more family members, attach additional copies of this form.)

 

 

 

the tobacco cessation

 

 

 

 

 

 

 

resources noted above.

 

 

 

 

 

 

 

 

 

First name

Middle

Last name

Last four digits of

 

 

 

 

initial

Social Security no.

 

 

 

 

 

 

 

 

 

YOU:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Family

 

 

 

 

 

 

 

member:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you check “YES” or leave the checkboxes blank for yourself or any family member(s) listed above, you will pay the monthly $25 surcharge.

HCA 50-224 (9/14)

Page 1 of 2

Section 2: Spouse or domestic partner coverage premium surcharge

Complete this only if you enroll a spouse or domestic partner on your PEBB medical coverage.

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 if this surcharge applies to you on the Attestations Worksheet: Step Two.

Does the spouse or domestic partner coverage surcharge apply to you?

Yes

I used the Attestations Worksheet: Step Two, and completed the Spousal Plan Calculator online.

Find the Spousal Plan Calculator

(electronic and paper versions) at www.hca.wa.gov/pebb .

No

I used the Attestations Worksheet: Step Two (and, if needed, completed the Spousal Plan Calculator online).

Employer or PEBB Program to determine

I used the Attestations Worksheet: Step Two, and am completing and submitting a paper Spousal Plan Calculator so my employer (for employees) or the PEBB Program (for all other subscribers) can determine whether my spouse’s or domestic partner’s employer-based group medical insurance is comparable to UMP Classic.

If you enroll a spouse or domestic partner on your PEBB medical coverage and you check “YES” or leave the checkboxes above blank, you will pay the monthly $50 surcharge.

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 www.hca.wa.gov/pebb.

Name (print) ____________________________________

Last four digits of Social Security number __________

Signature _______________________________________

Date _________________________________________

Agency name ___________________________________________________________________________________

(employees only)

Please sign and date this form.

If you’re:

Return it to:

An employee

Any other subscriber

Your personnel, payroll, or benefits office, with your enrollment form.

PEBB Program

Washington State Health Care Authority

P.O. Box 42684

Olympia, WA 98504-2684

or fax to: 360-725-0771

Attach your printed Spousal Plan Calculator (if needed).

Page 2 of 2

How to Edit Form Hca 50 224 Online for Free

If you want to fill out Form Hca 50 224, you don't need to download any applications - simply try using our PDF editor. Our editor is continually evolving to provide the very best user experience attainable, and that's thanks to our resolve for continual improvement and listening closely to feedback from customers. Here is what you will need to do to begin:

Step 1: Press the "Get Form" button at the top of this page to get into our tool.

Step 2: With our advanced PDF editor, you can accomplish more than simply fill in forms. Try each of the functions and make your documents look sublime with customized textual content put in, or optimize the file's original content to excellence - all comes along with an ability to add almost any images and sign the PDF off.

Completing this form requires care for details. Make certain every blank is done properly.

1. It's important to complete the Form Hca 50 224 accurately, therefore be mindful when filling out the areas containing these fields:

Part no. 1 for filling out Form Hca 50 224

2. Soon after filling in this step, go to the next stage and enter the necessary particulars in these blanks - Family member, Family member, Family member, Family member, Family member, Family member, If you check YES or leave the, HCA, and Page of.

Guidelines on how to fill out Form Hca 50 224 stage 2

3. Completing Does the spouse or domestic, Yes, I used the Attestations Worksheet, Find the Spousal Plan Calculator, I used the Attestations Worksheet, Employer or PEBB Program to, I used the Attestations Worksheet, If you enroll a spouse or domestic, Section Signature, and By signing this form I declare is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Filling in part 3 of Form Hca 50 224

As to I used the Attestations Worksheet and I used the Attestations Worksheet, make certain you get them right here. The two of these are the most significant ones in this PDF.

4. All set to fill out this fourth section! Here you'll get all these HCAs Privacy Notice We will keep, Name print Last four digits of, Signature Date, Agency name employees only, Please sign and date this form, If youre, An employee, Any other subscriber, Return it to, Your personnel payroll or benefits, PEBB Program Washington State, and Attach your printed Spousal Plan form blanks to fill in.

PEBB Program Washington State, Your personnel payroll or benefits, and Agency name employees only of Form Hca 50 224

Step 3: Soon after rereading the fields, hit "Done" and you're all set! Get hold of your Form Hca 50 224 when you register at FormsPal for a 7-day free trial. Quickly view the pdf file in your FormsPal cabinet, together with any modifications and adjustments being all kept! FormsPal is invested in the personal privacy of our users; we make certain that all personal information entered into our tool stays confidential.

Form Hca 50 224 isn’t the one you’re looking for?

Related Documents