Spousal/Life Partner Surcharge
Employees represented by the Philadelphia Federation of Teachers (PFT) and the School Police Assoc of Phila (SPAP) are required to pay a $75 per month surcharge if they enroll a spouse/life partner in the School District’s medical coverage and s/he is OFFERED medical coverage by their employer.
It is your responsibility as an employee to notify the Office of Employee Benefits within 30 days of a change in your spouse/life partner’s eligibility for employer coverage. Failure to truthfully attest or update this information is subject to disciplinary action, up to and including termination of employment.
We are providing you this information to help you determine if you are subject to the surcharge and how to complete the form if you are eligible to waive the surcharge. If you do nothing, the surcharge will be added to your medical insurance premium.
Unless you are changing who is currently enrolled on your medical plan, Dependent Eligibility Documents are not required.
PAGE 1
Section 1
Employee Information: Enter your employee information
Section 2
Attestation Type: PFT Spousal/Life Partner Attestation-see page 2.
Request Type: Check other and write attestation
Section 4
Covered Family Member Information: If you are not changing anyone’s enrollment, you do not need to check a box. Write in your spouse’s name. You do not need to complete demographic information for your spouse or any other family members.
Section 5
Signature and Verification: Sign and date
PAGE 2 Attestation
Complete your information and enter your spouse/life partner’s name.
Check the box that applies to your situation.
My spouse or Life Partner is:
- NOT ELIGIBLE or OFFERED for employer group health insurance.
- IS ELIGIBLE or OFFERED for employer group health insurance coverage. It does not matter is s/he is enrolled.
- IS A School District of Philadelphia employee.
Sign and Date
Which box to I check?
FIRST BOX – Surcharge is Waived
“not eligible for group health insurance coverage offered by his or her employer, I am not subject to the spousal/life partner surcharge imposed by the School District of Philadelphia.”
*** This means Your spouse is NOT able to get coverage from an employer if he/she is employed, or they may be retired or on disability.
SECOND BOX Surcharge of $75 is applied
“eligible for group health insurance coverage offered by his or her employer that (a) qualifies as minimum essential coverage, (b) is adequate, and within the meaning of the Patient Protection and Affordable Care Act. Therefore, I am subject to the spousal/life partner surcharge imposed by the School District of Philadelphia. ”
*** This means your spouse is employed and is offered medical coverage through his/her job
THIRD BOX School District of Philadelphia Surcharge is Waived
“is a School District of Philadelphia employee. Therefore, I am not subject to the spousal/life partner surcharge imposed by the School District of Philadelphia”