Between January 1, 2020 and December 31, 2020. m)—generic label, or x), private mmit). Employee optional life insurance (Medical history statement is required for a new enrollment for over the guarantee issue.) Complete the 2017 Premium Surcharge Change Form and submit to your benefits office. NOTE: Information about the cost of this plan (called the premium) will be … (d) Failure to accurately reflect an employee's premium surcharge attestation on the employee's account; (e) Enrolling an employee or their dependent in PEBB insurance coverage when they are not eligible as described in WAC 182-12-114 or 182-12-260 and it is clear there was no fraud or intentional misrepresentation by the employee involved; or Email the completed form to … me (Nicotrol) h as pills— r brand nam e s not bacco. With over 302,000 offers across 10,000 cities and easy mobile access, you’ll always find a reason to Celebrate Your Savings! • IRS now requires annual attestation of other coverage for opt out Public Employees’ Benefit Board 20. • A monthly $25-per-account surcharge will apply if the subscriber or any family member (age 13 and older) enrolled in PEBB medical uses tobacco products. Human Resources must receive your completed form no later than November 30, 2016. If you are a new or existing subscriber whose spouse or registered domestic partner is not enrolled in PEBB medical coverage in 2014, but will be enrolled effective January 1, 2015: Complete and submit the Open Enrollment 2015 enrollment/change form. CODES (1 days ago) We’re proud to offer you member-only discounts and corporate rates on everything from pizza and the zoo, to movie tickets, car rentals, and hotels! $25 is reported on your W-2. • Your employer or the PEBB Program will determine paragraph, fifth line, the phone number to contact the PEBB Program should be: 1-800-200-1004. Office Forms. Take the tobacco use premium surcharge attestation between April 1-May 15, 2014 (simply answering two questions about tobacco use). Humana and Aetna – Department of Justice. 2020 PEBB Premium Surcharge Attestation Help Sheet • Use the information below to determine whether the premium surcharges apply to you. Then attest on your 2020 PEBB enrollment form or the 2020 PEBB Premium Surcharge Attestation Change Form. • A monthly $50 surcharge will apply if a subscriber enrolls a spouse or state-registered domestic partner in PEBB Check all that apply. Question 2 Question 3 Question 4 Question 5 Question 6 Employer to determine if premium surcharge applies. Take action now! The gift card is considered taxable income. If you will be covering a spouse or registered domestic partner on your PEBB medical coverage in 2016, ... OR submitting a completed 2016 Premium Surcharge Change Form*. This document refers to Open Enrollment for 2018, which ran from November 1-30, 2017. Premium Surcharge Help Sheet and, if directed, complete the … Page 5 of 9 PEBB 107085-00301 Active (09/2018) Vision plan F Enroll VSP Basic Plan F Enroll VSP Plus — Includes the Basic Plan and PLUS additional benefits F I Decline all VSP Enrollment Optional life insurances (Complete only the sections required for enrollment.) HCA Rewards Member Perks - Employee Discounts. • Check “Employer or PEBB Program to determine.” • Include a copy of the 2016 Spousal Plan Calculator (not this Help Sheet) when you submit your 2016 enrollment form or 2016 Premium Surcharge Change Form. Office Forms. PEBB's "My Account" will accept Spousal Premium Surcharge attestations from November 1-December 31, 2015. This Sheet will help you determine whether attestation is necessary. 21 Jul 2016 … Louisville, KY 40202 … compete to enroll these seniors in their Medicare Advantage plans, and each describes the other … billion in revenue by 2020, in Other coverage for opt out Public employees ’ Benefit Board 20 Public employees ’ Benefit Board.... 4 Question 5 Question 6 Employer to determine if Premium Surcharge for 2017: 2020 pebb premium surcharge attestation help sheet easy mobile access you! Coverage ( SBC ) document will Help you choose a health plan searchable. 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