1 Employer Information

Transcription

1 Funding Account Setup For Metallic Groups Effective 1/1/ /31/ Employer Information Check one: We are setting up new funding account(s). We are renewing and we have no account changes. If you offer an HSA or FSA, please complete Section 5. and we need to make changes. If you are a renewing employer, please contact your sales representative for a summary document and a pre-populated form from the previous year. Our employer group number is: Employer s legal name (same name that is used on the health plan) Tax ID number Street address City State ZIP Mailing address (if different than street address) Employer type Sole proprietor LLC S-Corporation Other: Number of eligible employees Plan effective date Plan end date You the employer contact or representative Phone Number Fax Number address 2 Choose the accounts you will offer your employees Discuss with your sales representative or producer the type(s) of accounts that will best fit your company needs, then indicate your choices below. As you proceed to the next sections, you will be asked for detailed information about your chosen account options. You only need to complete the checked sections. Yes, we will offer an HSA (Health Savings Account) to our employees. The HSA must be paired with the designated Metallic health plan. Yes, we will offer a Health FSA* (Flexible Spending Account) to our employees. Yes, we will offer a Dependent Care FSA* to our employees. (This choice can only be selected if you are offering a Health FSA.) * Health FSA and Dependent Care FSA additional fees apply. An Independent Licensee of the Blue Cross Blue Shield Association ( ) 1 of 5

2 3 HSA Information If the box above is checked, please complete this section. If not, continue to the next section. We will offer the following HSA Select/Plus option (choose one): Balance Silver HSA Employee only contribution Medical Deductible Employee Funded HSA $1,500 X $2,500 X Balance Bronze HSA Employee only contribution Medical Deductible Employee Funded HSA $3,850 X $5,250 X Advantages include: automatic account enrollment for your employees option to have claims streamlined which reduces the need for employees to submit receipts allows us to manage account contributions for you HSA Custodian is UMB Bank n.a. 4 Healthcare Claims Submission Most healthcare claims will streamline to your funding account based on funding account purchased. HSA Health Payment Card FSA Health Payment Card Payment method Auto-pay only Payee Provider only Eligible expenses for streamlining Health plan cost shares that are billed by the provider of services For manual claims submission, eligible expenses will be applied in the following order: HSA first, then FSA 2 of 5

3 5 Health FSA Information If the box above is checked, please complete this section. If not, continue to the next section. We will offer the following Health FSA(s): Limited Purpose Health FSA Covers qualified dental or vision expenses, or both. Rollover and grace period (pick one): Rollover will be offered up to $500 (default) Rollover will be offered up to $, but not over $500 We will offer 2½ month grace period 1 We will not offer a rollover or grace period 1 The run-out period automatically gives participants 90 days after the end of the plan year to submit receipts for expenses incurred during the plan year. 6 Contribution Schedule Contributions to Health HSA, FSA, and Dependent Care FSA accounts typically follow a company payroll schedule. Will employer make payroll contributions? Yes No Employer Contributions If yes, complete below: (fund the HSA fully within 1st 30 days of setup) Employer Contributions Payroll Type (hourly, salaried, etc.) Contribution Frequency (weekly, biweekly, etc.) First or Only Contribution Next or Final Contribution If you will fund the HSA employer contributions differently than described, please indicate frequency here: Yes No Employer Payroll Contributions on behalf of employee If yes, complete below: Employee Payroll Contributions Payroll Type (hourly, salaried, etc.) Contribution Frequency (weekly, biweekly, etc.) First Contribution Second Contribution If you will not follow a payroll schedule, describe your contribution plan and frequency here: Contribution amounts will be entered online using the employer dashboard. 3 of 5

4 7 Termination Rule When an employee leaves our organization, their account will be terminated on the last day of the month when termination occurs. 8 Plan Sponsor Approval This document is not intended as tax advice. Employers should consult with their tax advisor when establishing an HSA or FSA. Group Representative has reviewed this document carefully and warrants that it accurately reflects the accounts and services that the group has requested Premera to administer on behalf of the group(s). Further, Group Representative understands that any changes to these accounts or services requested after the plan year effective date above may result in additional charges. By signing below, Group Representative agrees that the group will abide by the terms and conditions for the funding account as stated in the Administrative Services Agreement issued by Premera. Authorized by: Group Representative Group signature X Producer Representative Producer signature X 4 of 5

5 Premera Use Only Copay Information This information will help us to substantiate expenses for your employees. Medical Plan Copay Amounts Office visit copay: $ Plan Effective : Hospital copay: $ Prescription copay: $ Dental Plan Copay Amounts Dental office copay: $ Vision Plan Copay Amounts Vision office copay: $ Glasses/contact lenses copay: $ Prescription copay: $ We will offer Pharmacy Benefit Management Retail copay: $ Mail order copay: $ Premera Contact Information Name Group ID Phone Number Fax Number address Product Codes Product Fully Insured Limited Purpose Health FSA ACLP0011 Special Purpose Health FSA ACSP0001 Dependent Care FSA Account ACDC0013 HSA Account w/o ER Contribution ACHS of 5