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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Anesthesia and use of an operating hxa or related facility in a hospital or authorized institution. Plan pays for up to seven 33302 during first year for well-child care, PSA, and tests and well—woman care office visits.

Any money you withdraw from your HSA to spend on healthcare expenses is tax free. 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.

The Prescription Drug Program is included with this plan. Preventive Care Preventive physicals, well-child care including scheduled immunizations Plan pays for up to seven visits during hsx year for well-child care, PSA, and tests and well—woman care office visits.

You will be responsible for out-of-network precertifications. The amount you pay each year before the plan begins covering particular medical expenses. Primary care office visits for routine care; diagnosis and treatment of an illness or injury. Outpatient Lab Services for Diagnosis or Treatment. Hospice Care Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies.

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The money you put into an HSA is deducted from your pay before taxes.

Consumer Directed Health Plan – Office of Human Resources – Consumer Directed Health Plan

You can see a complete list of eligible expenses at www. You must call Aetna at at least 14 days in advance of nonemergency treatment to request hsz or you will have no coverage. Durable Medical Equipment Purchase or Rental Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home. Dialysis, Chemo, and Radiation Services. Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home.

Family deductible is cumulative. Inpatient Mental Health and Substance Abuse 4.

Emergency Room Care Services administered for conditions meeting the definition of an emergency. You can manage your HSA at www.

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

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.

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Deductible The amount you pay each year before the plan begins covering particular medical expenses. Hearing Exam 1 exam per calendar year; coinsurance, deductible or copayment applies. Physician Services Performed in an Office Setting Primary care office visits for routine care; diagnosis and treatment of an illness or injury.

Nonemergenices are not covered.

It is important to keep in mind that you can only use HSA funds after you have contributed them. Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies.

Hss Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification. Just call or send us an e-mail. You can contribute money to your HSA on a pretax basis through payroll deductions.

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. Your unused balance accumulates year after year. Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. Y ou can count on support from knowledgeable and responsive HR staff when you have a 3302 question or problem.

The chart below provides a brief overview of the benefits offered.