Common use of Spousal Exclusion Clause in Contracts

Spousal Exclusion. If an employee’s spouse is eligible to participate, as a current employee or retiree in group health insurance and/or prescription drug insurance sponsored by his/her employer or any public retirement plan, the spouse must enroll in such employer (or public retirement plan) sponsored group insurance coverage(s). This requirement does not apply to any working spouse who works less than 30 hours per week AND is required to pay more than 50% of the single premium to participate in his/her employer’s group health insurance coverage and/or prescription drug insurance coverage, or a retired spouse who is required to pay more than 50% of the single premium in his/her public retirement health insurance and/or prescription drug coverage. Upon the spouse’s enrollment in any such employer (or public retirement plan) sponsored group insurance coverage, that coverage will become the primary payor of benefits and the coverage sponsored by the Board will become the secondary payor of benefits. Any employee’s spouse who fails to enroll in any group insurance coverage sponsored by his/her employer or any public retirement plan, at least on a single enrollment basis at the first open enrollment opportunity with such spouse’s employer as required by this Section, shall be ineligible for benefits under such group insurance coverage sponsored by the Board. Every employee whose spouse participates in the Board of Education’s group health insurance coverage and/or prescription drug insurance coverage shall complete and submit to the Board, upon request, a written certification verifying whether his/her spouse is eligible to participate in group health insurance coverage and/or prescription drug insurance coverage sponsored by the spouse’s employer or any public retirement plan. If any employee fails to complete and submit the certification form by the required date, such employee’s spouse will be removed immediately from all health and prescription drug insurance coverages sponsored by the Board. Additional documentation may be required. A change in the employee’s spouse’s circumstances i.e., termination of spouse’s employment; or disqualification or change in spouse’s eligibility for medical benefits, the spouse will be returned to the District health insurance plan upon appropriate notification to the Treasurer’s office without a gap in coverage. If an employee submits false information or fails to timely advise the Plan of a change in the employee spouse’s eligibility for employer (or public retirement plan) sponsored group health insurance and/or prescription drug insurance, and such false information or such failure by an employee results in the Plan providing benefits to which the employee’s spouse is not entitled, the employee will be personally liable to the Plan for reimbursement of benefits and expenses, including attorneys’ fees and costs, incurred by the Plan. Any amount to be reimbursed by the employee may be deducted from the benefits to which the employee would otherwise be entitled. In addition, the employee’s spouse will be terminated immediately from group health insurance and/or prescription drug insurance coverage under the Plan. If an employee submits false information, he/she may be subject to disciplinary action by the Board, up to and including termination of employment. Any employee whose spouse has been excluded from the District’s health insurance coverage on a primary basis as a result of the operation of this section will be provided with a health insurance adjustment stipend, payable at the end of any calendar year (first payroll in January), in an amount equal to the excess paid by said spouse for single coverage for that year over $1,500. For purposes of determining this payment, the amount paid for single coverage will be the lowest cost single coverage offered by the spouse’s employer. In addition, the maximum amount of the stipend will not exceed $1,500. In order to receive payment of this stipend, the employee must provide full documentation of insurance information and paid receipts for the spouse’s premium payments.

Spousal Exclusion. If an employee’s spouse is eligible to participate, as a current employee employee, in a business or organization (e.g., partner, member), or retiree in group health insurance and/or prescription drug insurance sponsored by his/her employer employer, business, organization, or any public retirement plan, the spouse must enroll for coverage in such employer (employer, business organization, or public retirement plan) plan sponsored group insurance coverage(s)) no later than January 1st of the current school year. This requirement does not apply to any working spouse who works who: • Works less than 30 twenty (20) hours per week AND and is required to pay more than fifty percent (50% %) of the single premium to participate in his/her employer’s, business’s, organization’s, or retirement plan’s group health insurance coverage and/or prescription drug insurance coverage. • Is employed by another HESE district, provided the spouse does not receive any available payment (or a retired spouse who is required to pay more than 50% any other form of the single premium in his/her public retirement remuneration) from that HESE district for waiving health insurance and/or prescription drug coverage. Upon the spouse’s 's enrollment in any such employer (employer, business, organization, or public retirement plan) plan sponsored group insurance coverage, that coverage will become the primary payor of benefits and the coverage sponsored by the Board district will become the secondary payor of benefitsbenefits according to the primary plan’s Coordination of Benefits and participation rules. Any employee’s spouse who fails to enroll in any group insurance coverage sponsored by his/her employer employer, business, organization, or any public retirement plan, at least on a single enrollment basis at the first open enrollment opportunity with such spouse’s employer as required by this Section, shall be ineligible for benefits under such group insurance coverage sponsored by the Boarddistrict. It is the member’s responsibility to advise the district’s treasurer not later than thirty (30) days after the member has been notified of any change in eligibility that causes the member’s spouse to become eligible to participate in group health insurance sponsored by his/her employer, business, organization, or retirement plan after January 1st of the current school year. Upon becoming eligible, the employee’s spouse must enroll in any group health insurance sponsored by his/her employer, business, organization, or retirement plan unless he/she is exempted from this requirement in accordance with the exemptions stated in this Section. Every employee whose spouse participates in the Board of Educationdistrict’s group health insurance coverage and/or prescription drug insurance coverage shall complete and submit to the Boarddistrict’s treasurer, upon a provided, justified request, a written certification verifying whether his/her spouse is eligible to participate in group health insurance coverage and/or prescription drug insurance coverage sponsored by the spouse’s employer employer, business, organization, or any public retirement plan. If any employee fails to complete and submit the certification form by the required date, the district’s treasurer will notify the member, by certified mail or obtain from the member a signed receipt of personal notification, and that such employee’s spouse will be removed immediately at least thirty (30) after the treasurer has notified the member and has not received the certification from all group health and insurance and/or prescription drug insurance coverages sponsored by the Boarddistrict. Additional documentation may be required. A change in required if the employee’s spouse’s circumstances i.e., termination of spouse’s employment; or disqualification or change in spouse’s eligibility for medical benefits, the spouse will be returned to the District health insurance plan upon appropriate notification to the Treasurer’s office without a gap in coverage. If an employee submits false information or fails to timely advise the Plan of a change in the employee spouse’s eligibility for employer (or public retirement plan) sponsored group health insurance and/or prescription drug insurance, and such false information or such failure by an employee results in the Plan providing benefits to which the employee’s spouse member is not entitled, the employee will be personally liable to the Plan for reimbursement of benefits and expenses, including attorneys’ fees and costs, incurred by the Plan. Any amount to be reimbursed by the employee may be deducted from the benefits to which the employee would otherwise be entitled. In addition, the employee’s spouse will be terminated immediately from group health insurance and/or prescription drug insurance coverage under the Plan. If an employee submits false information, he/she may be subject to disciplinary action by the Board, up to and including termination of employment. Any employee whose spouse has been excluded from the District’s health insurance coverage on a primary basis as a result of the operation of this section will be provided with a health insurance adjustment stipend, payable at the end of any calendar year (first payroll in January), in an amount equal to the excess paid by said spouse for single coverage valid justification for that year over $1,500. For purposes of determining this payment, the amount paid for single coverage will be the lowest cost single coverage offered by the spouse’s employer. In addition, the maximum amount of the stipend will not exceed $1,500. In order to receive payment of this stipend, the employee must provide full documentation of insurance information and paid receipts for the spouse’s premium paymentsdocumentation.