3302 HSA PDF

TRANSFER REQUEST PART 1. RECIPIENT PART 2. ACCEPTING HSA TRUSTEE OR CUSTODIAN Individual requesting the transfer To be completed by the. – HSA Contribution / Investment. Open PDF SU – HSA Beneficiary Designation Addendum. Open PDF – HSA Transfer Request. Open PDF. I authorize the transfer of the HSA assets in the manner described above and certify that all of the information provided by me is correct and may be relied upon .

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Emergency Room Care Services administered for conditions meeting the definition of an emergency. Physician Services Performed in an Office Setting Primary care office visits for routine care; diagnosis and treatment of an illness or injury.

Qualified medical expenses that may be paid through your HSA on a tax-free basis include most medical care and services; dental and vision care; prescription drugs; and premiums paid for COBRA, long-term care, and medical and prescription drug expenses as a retiree, including Medicare premiums. Hospice Care Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies.

Any money hda withdraw from your HSA to spend on healthcare expenses is tax free. You can see a complete list of eligible expenses at www. It is important to keep in mind that you can only use HSA funds after you have contributed them.

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Hearing Exam 1 exam per calendar year; coinsurance, deductible or copayment applies. Y ou can count on support from knowledgeable and responsive Sha staff when you have a benefits question or problem.

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The chart below provides a brief overview of the benefits offered. Inpatient Mental Health and Substance Abuse 4. Just call or send us an hssa. You can contribute money to your HSA on a pretax basis through payroll deductions.

Consumer Directed Health Plan (CDHP) & Health Savings Account (HSA)

Anesthesia and use of an operating room or related facility in a hospital or authorized institution. Deductible The amount you pay each year before the plan hss covering particular medical expenses.

You can manage your HSA at www. Primary care office visits for routine care; diagnosis and treatment haa an illness or injury. Nonemergenices are not covered. Outpatient Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification. The amount you pay each year before the plan begins covering particular medical expenses.

The Prescription Drug Program is included with this plan. The money you put into an HSA is deducted from your pay before taxes. Your unused balance accumulates year after year. The amount you must pay if you do not call Medical Management at before hospitalization and certain types of surgery, or fail to follow concurrent review procedures.

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Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home. Outpatient Lab Services for Diagnosis or Treatment. You must call Aetna at at least 14 days in advance of nonemergency treatment to request precertification or you will have no coverage. You will be responsible for out-of-network precertifications. Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies.

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Plan pays for hsaa to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits. Preventive Care Preventive physicals, well-child care including scheduled immunizations Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits.

Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. Durable Medical Equipment Purchase or Rental Splints, braces, nonsurgically implanted prostheses, specified medical jsa for use in the home.

Please call Aetna toll free at or contact the Benefits Team at for additional information. The HSA allows you to accumulate savings and carry over year after year. Dialysis, Chemo, and Radiation Services. Family deductible is cumulative.