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PEIA Spousal Surcharge (SPSU) FAQs

West Virginia Public Employees Insurance Agency (PEIA) Spousal Surcharge (SPSU) FAQs

What is the Spousal Surcharge (SPSU)?
The Spousal Surcharge is a monthly charge you will pay, in addition to your regular medical plan coverage premium, if your working spouse has access to other employer-sponsored medical coverage but you choose to enroll him or her as a dependent on your PEIA plan.  It is a statutory requirement under West Virginia Code §5-16-13(b)(2).

How much is the spousal surcharge?
The spousal surcharge is $349.00 to $357.00 per month per policyholder - not per paycheck.  The amount varies by, “the actuarial average” of the cost of covering a spouse who has health insurance available to them through their employer.

Is the PEIA spousal surcharge legal under the Affordable Care Act?
Yes – The Affordable Care Act only establishes a limit for “Employee Only” coverage(s) and does not set a cap on the cost(s) or premiums for Family coverages. 

The cost of health insurance through my spouse’s employer is extremely expensive and we cannot afford it.  Do I still have to pay the PEIA SPSU surcharge?
Yes - If your spouse has health insurance available to them through their employer, by law the surcharge applies.

Is the cost or benefit levels of the other employer-sponsored coverage a factor in determining application of the spousal surcharge?
No

I am a retiree but my spouse works, will I be charged the Spousal Surcharge Fee if they have insurance available to them through their employer?
Yes

Does the Spousal Surcharge apply if I enroll my spouse in PEIA’s dental and vision coverage through FBMC but not in PEIA’s medical coverage?
No

My spouse has primary insurance through his employer. He is also enrolled on my PEIA insurance as secondary. Will I still be assessed the Spousal Surcharge Fee?
Yes

My spouse works part-time - is a contractor - or is a 1099 employee - but has health insurance available to them through their employer(s).  Will I have to pay the spousal surcharge?
Yes - West Virginia Code §5-16-13(b)(2) does not address issues such as work hours or the terms and conditions of the spouse’s employment.  The Code only addresses the availability of other insurance through the spouse’s employer.

My spouse is Medicare – Part A only, but works for an employer who does offer insurance.  Do I still have to pay the surcharge?
Yes - West Virginia Code §5-16-13(b)(2) does not address issues such as 3rd party insurance(s) or the terms and conditions of the spouse’s employment.  The Code only addresses the availability of other insurance through the spouse’s employer.

My spouse was just deployed by the National Guard and has TriCare insurance available to them through the military during the course of their deployment.  Does the spousal surcharge still apply?
Yes – The military is an, “employer” and there is no listed exemption for those on active duty.  West Virginia Code §5-16-13(b)(2) does not address issues such as work hours or the terms and conditions of the spouse’s employment.  The Code only addresses the availability of other insurance through the spouse’s employer.

I am actively working and my spouse has Medicare Part A but is actively employed and his current employer offers insurance. Will I have to pay the surcharge?
Yes

My spouse works remotely for a company out-of-state but their insurance lists West Virginia providers as, “out-of-network” so I keep my spouse on my PEIA plan.  Does the spousal surcharge still apply?
Yes - West Virginia Code §5-16-13(b)(2) does not address issues such as the benefit level(s) provided under the health insurance(s) available under the spouse’s employer plan.  The Code only addresses the availability of other insurance through the spouse’s employer.

If I have Medicare/Medicaid, TriCare or VA Benefits do I still have to pay the surcharge? 
No

Do I have to pay the spousal surcharge for my dependent child on my policy?
No

Is the Spousal Surcharge waived because I enroll my spouse in both his or her employer’s medical plan as primary and PEIA’s medical plan as secondary?
No

My spouse and I both have PEIA insurance. My spouse is on my plan. Why am I being charged the spousal surcharge?
 If we do not have your Plan listed with a Employee/Employee Spouse (ESPS) attribute and/or your spouse is not carrying Basic Life with PEIA through his/her participating PEIA agency, then the SPSU surcharge will be assessed.

My spouse is retired from the military but now has a job with an entity that offers health insurance, do I have to pay the spousal surcharge?
Yes - If the spouse has health insurance available to them through an employer, then the SPSU surcharge applies.

My spouse works 9 months out of the year and then goes on low earnings or unemployment for the other 3 months.  While working, they have insurance available to them - do I have to pay the spousal surcharge?
Yes - You will need to change your SPSU status each and every time your spouse gains insurance eligibility and/or loses insurance eligibility.

My spouse is off work and is applying for disability but they are still on his employer’s health insurance pending the disability application, do I have to pay the spousal surcharge?
Yes

If my spouse has access to Veterans’ Administration (VA) benefits or Tricare and I enroll him or her in the PEIA medical plan, does the Spousal Surcharge apply?
No

My spouse is paid $500.00 “in lieu of insurance” by his employer because they don’t offer employees health insurance.  Do I still have to pay the spousal surcharge?
No – “In lieu of Insurance” payments are not an offer of health insurance coverage(s) by an employer.  It is a permissible payment under provisions for small employers under the Affordable Care Act.

I am going through a divorce and am separated but I have to carry my spouse on my insurance(s) until the divorce is final.  My spouse does have access to health insurance through his employer.  Do I have to pay the spousal surcharge?
Yes - Even if you are going through a divorce you have to pay the SPSU surcharge unless you are allowed to remove the spouse from your insurance(s) by the Judge handling the divorce, or you remove the spouse when the divorce is final.  Divorces must be reported immediately to PEIA.

I forgot to send in my form and have been paying the spousal surcharge.  Can I get a refund?
No - The surcharge will also apply if you fail to complete or were late turning in the required Spouse Medical Plan Surcharge Affidavit. Spouse surcharge refunds are not retroactive and are not allowed for failure to turn in the form or turning the form in late.

My spouse has health insurance through healthcare.gov - the “Marketplace” - do I have to pay the spousal surcharge?
No - Health insurance through the market place is not, “employer sponsored” therefore the SPSU surcharge would not apply.

Will my spouse’s eligibility for any type of employer-sponsored health coverage make the spousal surcharge apply?
Yes

Can I appeal the application of the spousal surcharge?
Yes - You can appeal the application of the SPSU surcharge, however, it is based on West Virginia Law §5-16-13(b)(2) and, in order to prevail on an appeal, you would need to prove that your spouse did not have an employer sponsored health insurance plan available to them.

What if my spouse is only eligible for an employer-sponsored “mini-med” plan or other limited plan coverage?  Do I have to pay the spousal surcharge?
Yes - West Virginia Code §5-16-13(b)(2) does not address the factors of minimal coverage(s) and/or other factors.  The Code only addresses the availability of other insurance through the spouse’s employer.

How does the Spousal Surcharge work as it relates to spouses who have an open enrollment period or medical plan year that does not align with PEIA’s open enrollment period or medical plan year?
The Spousal Surcharge applies from July 1 through the date that your spouse is removed from PEIA medical plan coverage, assuming that your spouse is eligible for coverage under his or her own employer’s plan. This applies regardless of your spouse’s employer’s medical plan-year cycle. You can call your spouse’s employer to see if our change, or his or her loss of coverage, constitutes a “qualified status change” or “life event.” If so, your spouse may be able to move to his or her own employer’s coverage and be removed from PEIA’s coverage effective July 1. From PEIA’s perspective, our medical plan would consider this change in a spouse’s employer’s plan as a life event, per the language excerpted from our Summary Plan Description (SPD).

How will PEIA know if my spouse has health insurance available to them through his/her employment?
PEIA has the authority to conduct audits and reserves the right to use any and/or all resources at the State’s disposal to ensure compliance with the West Virginia Code.

My spouse is NOT offered insurance through their employer.  Does the spousal surcharge apply to me?
 No. If your spouse is not offered insurance through their employer, the surcharge does not apply to you.



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