WORKING SPOUSE CERTIFICATION FOR DUAL AND FAMILY HEALTH INSURANCE ELECTIONS 

 

PLAN YEAR 2019 - 2020

 

Full-time, benefit eligible employees of Alleghany County Public Schools are offered three different health insurance plans in which they can participate. All three plans provide for single, dual (employee plus one dependent), and family (employee plus two or more dependents) coverage. Employees who opt for dual or family coverage that includes their spouse are required to certify that their spouse does not have access to health insurance coverage by another employer. If your spouse does have access through their employer but you still elect to enroll them in one of the Alleghany County Public Schools plans, you will be required to pay more toward the cost of your health insurance.  

 

The additional cost applies when your spouse:

 

1.       Is eligible for health insurance coverage through their employer; or

2.       Gains eligibility for employer coverage during the plan year.

 

The additional cost does not apply when your spouse:

 

1.       Does not work;

2.       Is a benefit-eligible employee of Alleghany County Public Schools;

3.       Is self-employed;

4.       Works but their employer does not contribute to the premium cost (employee pays 100% of the insurance premium);

5.       Works but is not eligible for health insurance coverage;

6.       Is covered by Medicare, Medicaid, state assistance programs, or the military; or

7.       Is covered under COBRA.

 

IF YOU ARE ENROLLING FOR THE FIRST TIME OR CONTINUING WITH DUAL OR FAMILY COVERAGE THAT INCLUDES YOUR SPOUSE, PLEASE COMPLETE THE CERTIFICATION BELOW.

 

Certification of Health Insurance Coverage Eligibility

 

                My spouse IS eligible to participate in a health insurance plan through their employer.

 

                My spouse IS NOT eligible to participate in a health insurance plan through another employer because they are not                 employed.            

 

                My spouse IS NOT eligible to participate in a health insurance plan through their employer because (circle applicable                 reason):

 

·         My spouse’s employer does not offer health insurance

·         My spouse is self-employed

·         My spouse’s employer offers health insurance but does not contribute to the premium cost (employee pays 100% of the premium)

·         My spouse is employed part-time and not eligible for benefits

·         Other reason                                                                                                                               

 

Alleghany County Public Schools reserves the right to require supporting documentation for the above elections.

      

I certify that, to the best of my knowledge, all of the information on this form is accurate. I understand that providing false or misleading information may result in disciplinary action as provided for in the policies and procedures of Alleghany County Public Schools.    

 

 

 

                                                                                                                                                                               

                      Employee Name                                      Signature                                           Date