Spousal Incentive HRA - Payroll Deductions

Primary Spousal Incentive HRA Enrollee Information

First Name *

Last Name *

Phone *

Email *

Are premiums deducted when a month has a third pay period? *

Yes

Payroll Deduction Frequency *

12 (Monthly)

16 (Monthly but with third payroll deductions included)

24 (Semi-Monthly, either 15th & last day of the month or 1st and 15th)

26 (BiWeekly)

52 (Weekly)

Per Pay-Period Amount *

Supporting Health Insurance Premium Documentation *

Upload Supporting Documents Here

Example Paystub

By electing the Spousal Incentive HRA, I certify that:

I and/or my spouse and/or my eligible dependents will be enrolled in an “alternate group medical plan” (such as my spouse’s employer) at all times while I/we are enrolled in the Spousal Incentive HRA.
The alternate group medical plan does not and will not consist solely of “excepted benefits” (such as limited-scope dental or vision coverage or other limited coverage).
The alternate group medical plan is not solely an account that reimburses health care expenses up to a dollar limit, like an FSA or HRA.
The alternate group medical plan is not:
- High Deductible Health Plan (HDHP) with active contributions to a health savings account (HSA); however, as long as my spouse is not enrolled in the Spousal Incentive HRA, my spouse may contribute to an HSA and use the HSA funds. The HSA funds CANNOT be used for medical expenses for members enrolled in the Spousal Incentive HRA. All members may use the HSA funds for dental and/or vision as long as those expenses are not covered by the Spousal Incentive HRA.
- Medicare, Tricare, Medicaid or another governmental program
- Health Insurance Coverage made available through the Affordable Care Act
- Individual Policy
- Limited Benefit Health Plans
- Another Watco medical plan

Yes, I Agree

Signer's Name *

Signature *