Working Spouse Affidavit

Working Spouse Affidavit

Sumner County Employee Benefits - Finance Department Effective January 1, 2013 this form is required to be completed in full and accompany the medical enrollment form when an employee is enrolling a spouse (or seeking to continue enrollment of a

spouse) in the Sumner County Insurance Trust Medical coverage (the "County Plan"). No Spouse will be

eligible or be enrolled in the County Plan until this form is completed and returned.

*This change goes into effect January 1, 2013, and is NOT a qualifying event. Therefore, if applicable, you must remove your spouse during open enrollment OR be prepared to pay the $100.00 monthly charge for the remainder of the fiscal year. See your benefit specialist in order to make this change.

EMPLOYEE INFORMATION Employee Name: _ _ _ _ _ _ _ _ _ _ _ _ _ Employee 5S#: _ _ _ _ _ _ __

Spouse Name:

Spouse SS#:

Please circle appropriate option number: 1. My Spouse is not actively working or is self-employed. If the spouse is not actively working or self

employed, the employee will not be charged the additional surcharge.

2. My Spouse is actively working at _ _ _ _ _ _ _-', but is not offered medical insurance coverage.

If the spouse is not offered insurance coverage, the employee will not be charged the additional surcharge.

3. My Spouse works for Sumner County Board of Education in a full-time classified position which is also eligible for coverage by the County Plan. If the spouse is otherwise eligible for the county plan, the employee will not be charged the additional surcharge.

4. My spouse is working and has elected coverage through his/her employer as primary coverage and is enrolling in the County Plan as secondary coverage. If the spouse elects coverage under the County Plan, the employee will be charged the designated contribution set by Sumner County for the number of dependents enrolled plus an additional $100.00 monthly surcharge for the enrollment of the spouse.

5. My spouse is working and has declined coverage through his/her employer and is enrolling in the County Plan as primary coverage. If the spouse declines health coverage through his/her employer and elects coverage under the County Plan, the employee will be charged the designated contribution set by Sumner County for the number of dependents enrolled plus an additional $100.00 monthly surcharge for the enrollment of the spouse.

By signing below, I represent and warrant that all information provided is accurate, current and complete to the best of my knowledge. I understand that falsification of information regarding the spouse's available coverage will result in, at a minimum, DOUBLE the additional premium surcharge being assessed retro-actively back to the date of the spouse's enrollment in the County Plan and DOUBLE the additional premium surcharge to continue coverage or permanent termination of the spouse from the County Plan. In addition, willful provision of false information may result in disciplinary action against the employee, up to and including, termination. I also understand that if the status of medical coverage for my spouse changes, it is my responsibility to notify the Sumner County Benefits Department within 30 days of the change. If the Spousal Surcharge is to be discontinued due to a change, there will be no refund of the previous Spousal Surcharge deduction if the Sumner County Benefits Department is not notified within 30 days of the change. The refund will not exceed the effective date of the event.

Employee Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Date: _ _ _ _ _ __

MEMORANDUM

SUMNER COUNTY, TENNESSEE

DEPARTMENT OF FINANCE

DAVID LAWING, DIRECTOR

Certified Public Accountant

355 North Belvedere Drive, Room 302

Gallatin, TN 37066

Phone: (615) 451-6033

Fax: (615) 230-6392

TO: All Full-Time Employees

FROM: David lawing, Certified Public Accountant

DATE: March 22, 2012

RE: Health Insurance Changes

With the ever increasing costs of health care, the Sumner County Employee Insurance Trust (Ifthe Trust") is looking for the most cost effective manner to retain coverage for our employees. As you are aware, the cost of insurance provided to our employees has increased every year. This translates annually into a cost of over $16 million annually paid by the County and the Board of Education. The health care funding requirements, based on the current health insurance benefits provided, were unsustainable as demonstrated below.

26,000,000 25,000,000 24,000,000 23,000,000

21,000,000 20,000,000 19,000,000 18,000,000 17,000,000

FY2009 FV2010 1 FV20U fV2012 FY2013 FY2014 FV2015 Actual Actual Adual l,:stimatedBudgetedProjected:Projectedi

For every dollar of health insurance costs, you pay 20 cents and the County and the Board of Education pay an additional 80 cents on your behalf. The Trust has worked many hours trying to best address how to handle the ever-increasing costs. In order to help ensure the long-term viability of the health insurance trust and maintain coverage for the employees, several changes will be instituted. These changes will take place at varying times, as noted in the following.

1. Increase the emergency room co-pay from $50 to $200 per visit. This copay will be waived if admitted within 23 hours of ER visit. Effective date 5?1?2012

2. Change the Rx co-pay to the following formula. Effective date 7?1-2012

Drug Tier Generic

Current copay $5

Preferred Brand $25

Non-Preferred

$35

Brand

All mail order will remain at 2 times

Approved copay

10% with max of $30 or the actual cost of the drug whichever is less 25% with a max of $70 or the actual cost of the drug whichever is less

CareHere Clinic copay $0.00 if available

Not available

35% with a max of $120 or the actual cost of the drug whichever is less

Not available

All mail order through CareHere will

CareHere Pharmacy copay $0.00 if available

25% with a max of $70 or the actual cost of the drug whichever is less, if available 35% with a max of $120 or the actual cost of the drug whichever is less, if available

copay for prescriptions over 34 days if ordered through BlueCross. Any mailing charges, if applicable will also apply.

remain at the cost times the number of months to be filled. Any mailing charges, if applicable will also apply.

3. Elimination of Erectile Dysfunction Medications (ED) from Caremark and CareHere. Effective 5 1-2012

4. Elimination of all over the counter (OTC) drugs from Caremark and CareHere. Effective 5-1-2012

5. When an employee's spouse is eligible to be on their employer's group health plan and the spouse elects to be on the Sumner County Group Health Plan, an additional $100 a month surcharge will apply. Eligibility will not be guided by the cost in any way but Simply that the spouse is eligible to be on their employer's plan. Compliance will be by a signed affidavit annually. Effective 1-1-2013

6. Medical premiums will increase 5% effective August 1, 2012. Dental premiums will increase effective August 1,2012 as noted below.

Medical Recommended 2012-2013 (Monthly)

Type Individual

2- Person Coverage

Family

County

Employee

Total

S 444.36 S 111.10 S 555.46

S 906.68 S 226.66 S 1,133.34

$ 1.115.44 $ 278.86 $ 1,394.30

ai-weekly

$

55.55

$ 113.33

$ 139.43

Enhanced Dental Recommended 2012-2013 (Monthly)

Type Individual

2 Person Coverage

Family

County

Employee

Total

S 17.62 $

9.48 $

27.10

$

37.06 $

19.96 $

57.02

$

48.68 $

26.18 S

74.86

Bi-weekly

$

4.74

$

9.98

S

13.09

Basic Dental Recommended 2012-2013 (Monthly)

Type Individual

2 - Person Coverage

Family

County

Employee

Total

S

9.84 $

1.66 S

11.50

S 20.22 $

3.42 $

23.64

$

29.90 $

5.02 S

34.92

Bi-weekly

$

0.83

$

1.71

$

2.51

Sumner County currently provides a Flexible Spending Account (FSA), at no cost to the employee, through USAble. Amounts can be deducted from your pay check pre-tax and used to cover eligible medical expenses. A representative will be available at open enrollment to explain the details.

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