Form Hca 50-704 Declaration Of Tax Status - Washington State Health Care Authority Page 2
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2State agency and higher-education employees
The table below shows the monthly amount that will be added to your total gross income and calculated into your withholding
tax. This will be reflected on your payroll statement, as well as your W-2.
2016 State Contribution for Medical and Dental Coverage for:
Registered
Registered Domestic Partner’s
Registered Domestic
Medical Plan
Domestic Partner
Child(ren)
Partner and Child(ren)
All medical plans
$522
$410
$932
2016 State Contribution for Dental Coverage (Without Medical Coverage) for:
Registered
Registered Domestic Partner’s
Registered Domestic Partner
Dental Plan
Domestic Partner
Child(ren)
and Child(ren)
All dental plans
$45
$45
$90
Employees of K-12 school districts, educational service districts (ESDs), and local government employer groups
Contact your payroll office for employer contribution amounts.
Retirees enrolled in Medicare Part A and Part B
The table below shows the state’s monthly contribution toward a registered domestic partner’s medical coverage, which will be
reflected in the IRS Form 1099 you receive from the Health Care Authority (HCA).
2016 State Contribution for Medical Coverage
Medical Plan
for Registered Domestic Partner
Group Health Medicare Plan
$130
Kaiser Permanente Senior Advantage
$150
Medicare Supplement Plan F Retired
$104
Medicare Supplement Plan F Disabled
$150
Uniform Medical Plan Classic
$150
All monthly amounts shown above are rounded to the nearest dollar, consistent with IRS tax reporting.
Section 2: Signature
Required
By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn’t, or if I do not
update this information within the timelines in PEBB rules, to the extent permitted by federal and state law, I must repay any
claims paid by my health plan(s) or premiums paid on my behalf. My PEBB dependent(s) may also lose PEBB benefits as of
the last day of the month of eligibility. To the extent permitted by law, PEBB may retroactively terminate coverage for my
dependent(s) if I intentionally misrepresent eligibility, or do not fully pay premiums when due. In addition, I understand that
knowingly providing false, incomplete, or misleading information to an insurance company for the purpose of defrauding the
company is a crime, and can result in imprisonment, fines, denial of PEBB benefits, and loss of my job.
I understand that:
• This declaration of responsibility may have legal implications under federal and state laws.
• A civil action may be brought against me for any losses, including reasonable attorney’s fees, if I have made a false
statement in this declaration.
• I must notify my personnel, payroll, or benefits office (if I am an employee) or the PEBB Program (if I am a retiree) if there
is a change in my domestic partnership or dependent’s tax status promptly after the change. Any change in my family
status may also directly impact the calculation of my taxable income.
HCA’s Privacy Notice: We will keep your information private as allowed by law. To see our Privacy Notice go to
Subscriber’s printed name _____________________________ Subscriber’s signature _________________________________
Subscriber’s Social Security number __________________________________ Date _________________________________
Employees: Return this completed form to your personnel, payroll, or benefits office.
Retirees: Return this completed form to:
Washington State Health Care Authority, PEBB Program, P.O. Box 42684, Olympia, WA 98504-2684
To obtain this document in another format (such as Braille or audio), call 1-800-200-1004.
TTY users may call through the Washington Relay service by dialing 711.
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