craig.nelson@mcleancountyil.gov
Any retiree and/or covered spouse enrolled in the Medical plan who uses tobacco products or chooses not to disclose will be charged $25/month more than non-tobacco users on their health insurance premiums. If both the retiree and covered spouse use tobacco products or choose not to disclose this information, they will pay $50/month more than non-tobacco users on their health insurance premiums. Tobacco users can bypass the additional charge if they testify that they will enroll in a tobacco cessation program in 2024. The information you provide will be kept confidential and will not be used for any purpose other than to determine your exemption from the surcharge.
Retiree Name
I certify that:
Do you have a spouse that is enrolled in the County medical insurance?
Spouse's Name
My spouse who is enrolled in the County medical plan:
Any retiree covering a spouse in the Medical plan with access to their own health insurance coverage through their employer will be charged a $100 per month surcharge. This surcharge does not apply to spouses without access to their own health insurance coverage or Medicare plan. This surcharge may be avoided by filling out this affidavit. Anyone with Spousal coverage who chooses not to disclose will be charged the $100 per month surcharge. The information you provide will be kept confidential and will not be used for any purpose other than to determine your exemption from the surcharge.
My spouse who is enrolled in the County medical plan is currently employed and eligible for healthcare coverage through their employer.
Sign Here
