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Click ‘Get Form’ to open the spousal health care eligibility affidavit in our editor.
Begin by entering your name and reference number at the top of the form. This identifies you as the employee submitting the affidavit.
Fill in your spouse's name and the last four digits of their Social Security Number. This information is crucial for verifying eligibility.
In Section A, select one of the options regarding your spouse's employment status. Ensure you check only one box that accurately reflects their situation.
If your spouse is employed without access to coverage or self-employed, proceed to Section B, which must be completed by their employer. If they have access to coverage, ensure that Section B is filled out accordingly.
Sign and date the affidavit at the bottom, ensuring both you and your spouse provide signatures where required.
Finally, submit the completed document to Hodges-Mace, LLC via fax or email as indicated on the form.
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What is a spousal healthcare eligibility affidavit?
The Medical Plan Affidavit will require the spouse to indicate if they are employed. If the spouse is employed, the spouses employer will be required to complete the Medical Plan Affidavit to confirm that the spouse is not eligible for group medical coverage with their employer.
How to avoid spousal surcharge in healthcare?
To avoid paying the surcharge, your spouse or partner can enroll in his or her employers medical plan. Youll want to compare coverage and total costs both ways to see what makes sense for your family.
What is the spousal rule for health insurance?
The Plans Working Spouse Rule states that, if your spouse is working for an employer who offers a health plan, the Plan requires them to enroll in that employer-sponsored coverage to be eligible for Plan coverage. Your spouse must confirm whether they have access to and are enrolled in their employers health plan.
What is a spousal surcharge affidavit?
During annual enrollment each year, any employee who covers his/her spouse must sign a Spouse Medical Plan Surcharge Affidavit attesting to your spouses access to employer medical plan coverage through his/her employer, regardless if he/she enrolled in that coverage.
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