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Health Care Spousal Surcharge Form A ×50 monthly spousal surcharges will be added to your premium if you have elected coverage for your spouse and your spouse is eligible for coverage through his/her
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Gather all necessary information, such as your 2019 premium surcharge form and any supporting documents.
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Who needs 2019 premium surcharge help?

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Individuals who are required to pay a premium surcharge for their insurance coverage in the year 2019.
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Individuals who may be eligible for exemptions or discounts on their premium surcharge and need assistance navigating the application process.
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The premium surcharge help sheet is a document that provides guidance on how to calculate and report the premium surcharges imposed on certain health insurance plans.
Employers and plan sponsors who offer health insurance plans subject to premium surcharges are required to file the premium surcharge help sheet.
To fill out the premium surcharge help sheet, you need to gather information on the health insurance plans subject to premium surcharges, calculate the surcharges based on the provided formula, and report the calculated amounts on the designated sections of the form.
The purpose of the premium surcharge help sheet is to ensure employers and plan sponsors accurately calculate and report the premium surcharges imposed on certain health insurance plans.
The premium surcharge help sheet requires employers and plan sponsors to report information such as the number of covered employees, the types of health insurance plans offered, and the calculated premium surcharges for each plan.
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