Employer Application Health & Welfare Benefit Plan Please Print Clearly in Blue or Black Ink

Transcription

1 Employer Application Health & Welfare Benefit Plan Please Print Clearly in Blue or Black Ink EMPLOYER DATA Full Legal Business Name / Plan Sponsor (herein Plan or Plan Sponsor ): Type of Business: Corporation Partnership Sole Proprietorship LLC Non-Profit Other Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: County: Phone: Fax: Nature of Business: Sic Code: # of W2 Employees: Federal Tax ID #: 500 Series Welfare Plan Number: Date Business Started: Administrative Contact Person: Phone: Executive Contact Person: Phone: Names & Address of Additional Locations / Subsidiaries / Affiliates: 1) Name: Address: 2) Name: Address: 3) Name: Address: Does your firm have Workers Comp? YES NO If YES, Name of Carrier: Does your firm have group health coverage currently in force? YES NO If YES, Name of Carrier: Policy #: Term Date: DO NOT CANCEL OTHER GROUP HEALTH COVERAGE UNTIL NOTIFIED, IN WRITING, OF ACCEPTANCE OF KEY HEALTHY PARTNERS COVERAGE. COBRA DATA Is anyone in your firm currently under COBRA, State Continuation Plan, or within their election period? YES NO If YES, please list below (Note: any COBRA applications received after underwriting approval may result in a monthly premium amount adjustment to your Key Healthy Partner Plan). Employee / Dependent Name Termination Date of Original Coverage Cobra Termination Date EMPLOYEE DATA Total Number of Employees: Full-Time Active: Part-Time: Eligible: Minimum hours (per week) required for eligibility: Total Number of Enrolling Employees: Employee waiting period from hire date: First of the month following 0 Days 30 Days 60 Days Other, Explain: Is the Waiting Period waived on the Effective Date of the plan? YES NO (Coverage will be effective on the first of the month after the waiting period. Terminations will be effective on the last day of the month after the employee or dependent is no longer eligible) Percentage of Employer Contributions: % Employee Coverage: % Dependent Coverage: Revised

2 PLAN SELECTIONS - Major Medical (Underlying Plan) Please Circle or Write In Your Choices Plan 1 Plan Type PPO HDHP If High Deductible Health Plan (HDHP) Qualified HDHP Non-Qualified HDHP See IRS definition at Plan Name Deductible: (out-of-network is 2x in-network) Coinsurance: In-Network/Out-of-Network 100% / 70% 90% / 70% 80% / 60% 70% / 50% 60% / 40% Maximum Out-of-Pocket (includes deductible) Hospital Copay $0 $100 $300 $500 Co-payment option not available for a qualified HDHP. Rx Copay Mail Order $10/$25/$50 $25/$65/$150 Rx Deductible $0 $150 $15/$35/$50 $20/$40/$80 Ded. / Coins. RX Co-payment options are not available for a qualified HDHP Primary/Specialist Copay $20/$35 $30/$45 Ded. / Coins. Primary/Specialist co-payment options are not available for a qualified HDHP. Annual Maximum $2,000,000 $5,000,000 Unlimited PPO Network PBM Catamaran (preferred) Caremark Cigna (Only for groups accessing Cigna PPO and have <50 enrolled EEs) Plan 2 Plan Type PPO HDHP If High Deductible Health Plan (HDHP) Qualified HDHP Non-Qualified HDHP See IRS definition at Plan Name Deductible: (out-of-network is 2x in-network) Qualified HDHP minimum deductible $1200 self-only and $2400 family coverage. Coinsurance: In-Network/Out-of-Network 100% / 70% 90% / 70% 80% / 60% 70% / 50% 60% / 40% Maximum Out-of-Pocket (includes deductible) Qualified HDHP maximum OOP (including deductible) $6,050 self-only//$12,100 fam Hospital Copay $0 $100 $300 $500 Co-payment option not available for a qualified HDHP. Rx Copay Mail Order $10/$25/$50 $25/$65/$150 Rx Deductible $0 $150 $15/$35/$50 $20/$40/$80 Ded. / Coins. RX Co-payment options are not available for a qualified HDHP Primary/Specialist Copay $20/$35 $30/$45 Ded. / Coins. Primary/Specialist co-payment options are not available for a qualified HDHP. Annual Maximum $2,000,000 $5,000,000 Unlimited PPO Network PBM Catamaran (preferred) Caremark Cigna (Only for groups accessing Cigna PPO and have <50 enrolled EEs) Plan 3 Plan Type PPO HDHP If High Deductible Health Plan (HDHP) Qualified HDHP Non-Qualified HDHP See IRS definition at Plan Name Deductible: (out-of-network is 2x in-network) Qualified HDHP minimum deductible $1200 self-only and $2400 family coverage. Coinsurance: In-Network/Out-of-Network 100% / 70% 90% / 70% 80% / 60% 70% / 50% 60% / 40% Maximum Out-of-Pocket (includes deductible) Qualified HDHP maximum OOP (including deductible) $6,050 self-only//$12,100 fam Hospital Copay $0 $100 $300 $500 Co-payment option not available for a qualified HDHP. Rx Copay Mail Order $10/$25/$50 $25/$65/$150 Rx Deductible $0 $150 $15/$35/$50 $20/$40/$80 Ded. / Coins. RX Co-payment options are not available for a qualified HDHP Primary/Specialist Copay $20/$35 $30/$45 Ded. / Coins. Primary/Specialist co-payment options are not available for a qualified HDHP. Annual Maximum $2,000,000 $5,000,000 Unlimited PPO Network PBM Catamaran (preferred) Caremark Cigna (Only for groups accessing Cigna PPO and have <50 enrolled EEs) Revised

3 CONSUMER DRIVEN HEALTHCARE APPLICANT AGREEMENT: Per the applicable schedule of services and fees, I hereby authorize Key Benefit Administrators, Inc. to be the third-party administrator of our: Premium Only Plan (POP) Flexible Spending Account (FSA/DCA) Health Reimbursement Arrangement (HRA) - Please see attached HRA Adoption Agreement and Bank Information High Deductible Health Plan (HDHP) Please note: FSA/HRA set up is available on a limited basis for Qualified HDHPs with a Health Savings Account (HSA). Effective Date: Patient Protection and Affordable Care Act ( PPACA ) Compliance: The Plan will at all times be in compliance with PPACA rules and regulations. PPACA requires that benefits that are offered by the Plan that are Essential Health Benefits as defined by the United States Department of Health And Human Services may not be restricted to less than a certain annual amount. If a major medical benefit of the Plan has a plan maximum below that amount, the Plan will continue to pay benefits for the Essential Health Benefit components of that benefit even though such payments would exceed the plan maximum for that benefit, but only until the Major Medical Annual Maximum of the plan is paid. Managed Care Program Except for a maternity admission, a participant or covered dependent is required to call a toll-free number upon learning of a future hospital admission, or to call within two working days after an emergency admission. This toll-free number is on the back of the plan s medical identification form. If this provision is not followed, then hospital charges and all charges related to the hospital admission may be subject to a per-admission penalty, in addition to any deductible that might apply. Maternity admissions do not require certification. However, if the newborn baby stays in the hospital longer than the mother, the newborn's continuing hospital stay must be certified at the time the decision to extend the baby s stay is made by the attending physician. Preferred Provider Network Benefits at a participating provider will be paid at in-network coinsurance level, and benefits at a non-participating provider will be paid at out-of-network coinsurance level. Benefits are paid subject to the coinsurance maximums as indicated below in the schedule of benefits. If a participant or covered dependent receives ancillary or physician services, (e.g., anesthesiologists, radiologists, emergency room physicians, pathologists, etc.) rendered by a non-participating provider at a participating facility, the services provided by the non-participating provider will be paid at the participating provider benefit level. If a condition requires treatment from a specialist and there is no such specialist available in the network, benefits will be paid at the participating provider benefit level subject to the coinsurance maximum indicated below. Utilization of a participating provider may result in a discount off of billed charges. Revised

4 Physician Services Primary Care Physician s Office Visit Copay, then paid at 100%. The copay includes labs, x-rays, injections, and medical supplies rendered in the office on the same day. Specialist s Office Visit Copay, then paid at 100%. The copay includes labs, x-rays, injections, and medical supplies rendered in the office on the same day. Office Surgery Inpatient Surgery Outpatient Surgery Assistant Surgeons Office Visit Medical Supplies Charges are limited to a maximum benefit of 25% of the surgeon s allowable amount. 100% Office copay applies if no office exam billed. Not subject to the plan year deductible. Lab and X-ray: in office 100% Not subject to the plan year deductible. Lab and X-ray: non-office. facility In-office Medical Injections In-office Allergy Injections Inpatient Physician Hospital Visits Emergency Room Physician Visits Hospital Services Emergency Room Laboratory Services 100% Not subject to the plan year deductible. Subject to coinsurance Subject to coinsurance Office copay applies if no office exam billed. Office copay applies if no office exam billed. Included in the facility copay. Non-network services are subject to the network out of pocket. Room and Board. Based on the semi-private room rate. Miscellaneous Charges Inpatient Surgery Outpatient Surgery Preferred Provider Benefit Covered Services Lab Card: Laboratory Benefit Provider (PPO Plan) 100% of covered services, not subject to the plan year deductible See Comprehensive Major Medical: Lab Card Laboratory Benefit Program for a list of covered services. Not available with some networks. Lab Card: Laboratory Benefit Provider (Qualified HDHP) % of covered services after deductible. Lab Card discounts apply Excludes patient convenience items. Emergency Room $100 copay, then paid at coinsurance level not subject to the deductible $100 copay, then paid at coinsurance level not subject to the deductible ER per visit copay waived if admitted. Non-network services are subject to the network out of pocket. ER co-payments are not available for a qualified HDHP. See Comprehensive Major Medical: Lab Card Laboratory Benefit Program for a list of covered services. Not available with some networks. Revised

5 Urgent Care Clinic $50 copay, then paid at 100%. Not subject to the plan year deductible. Routine Eye Exam 100% of eligible charges, not subject to the plan 100% of eligible charges, not subject to the Limited to $150 per person per plan year. year deductible plan year deductible Preventive/Wellness Network Non-Network Covered Services 100% Not subject to the plan year deductible. Includes, but is not limited to, labs, x-rays, pap smears, mammograms, prostate testing, immunizations, flu shots, colonoscopy, contraceptive management, and services included as part of PPACA. The following are considered Preventive Benefits under the Patient Protection & Affordable Care Act and are covered by the Plan and payable at 100% not subject to the deductible or copays when services are rendered at an in-network provider. However, non-network charges are subject to usual and customary fee limitations. This benefit is in addition to your wellness benefits that are already stated in your Plan, in some cases your wellness benefits could be more generous then the benefits listed below, in this case the better benefit will be payable. Immunizations as required by federal regulation. Screening for abdominal aortic aneurysm one time screening for abdominal aortic aneurysm by utrasonography in men age Screening and counseling to reduce alcohol misuse. Aspirin to prevent CVD. Screening for bacteriuria- screening with urine culture for pregnant women. Screening for high blood pressure adults age 18 and older. Counseling related to BRCA screening. Screening for breast cancer (mammography) for women with or without clinical breast examination (CBE). Chemoprevention of breast cancer For women at high risk for breast cancer and low risk for adverse effects of chemoprevention. Interventions to support breast feeding Interventions during pregnancy and after birth to promote breastfeeding. Screening for cervical cancer. Screening for Chlamydia infection. Screening for cholesterol abnormalities. Screening for colorectal cancer screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidosocpy or colonoscopy in adults. Chemoprevention of dental caries primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. Screening for depression starting at age 12. Screening for diabetes screening for type 2 diabetes. Counseling for healthy diet intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by a primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Supplementation with folic acid all women planning or capable of pregnancy take a daily supplemental containing 0.4 to 0.8 mg (400 to 800 ug) of folic acid. Screening for gonorrhea. Prophylactic medication for gonorrhea: newborns prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum. Screening for hearing loss screening for hearing loss in all newborn infants. Screening for hemoglobinopathies screening for sickle cell disease in newborns. Screening for hepatitis B screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit. Screening for HIV screening for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection. Screening congenital hypothyroidism screening for congenital hypothyroidism in newborns. Screening for iron deficiency anemia screening for iron deficiency anemia in asymptomatic pregnant women. Iron supplementations in children routine iron supplementation for asymptomatic children age 6 to 12 months. Screening and counseling for obesity starting at age 6. Intensive counseling can be delivered by a primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Screening for osteoporosis. Screening for PKU screening for phenlketoruria (PKU) in newborns. Screening for Rh for all pregnant women. Counseling for STIs behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. Screening for syphilis. Counseling for tobacco use for age 18 and older tobacco users, this benefit provides tobacco cessation interventions and tobacco products. Counseling for tobacco use: pregnant women provide augmented, pregnancy-tailored counseling for those who smoke. Screening for visual acuity in children screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than 5 years. Revised

6 Prescription Drugs Service Generic Drugs Copay per prescription or refill. Copay per prescription or refill. then coinsurance Limited to a 34-day supply. [Not subject to the plan year deductible [Subject to medical plan year deductible Preferred Drugs Non-Preferred Drugs Copay per prescription or refill. Copay per prescription or refill. Copay per prescription or refill. then coinsurance Copay per prescription or refill. then coinsurance Limited to a 34-day supply. [Not subject to the plan year deductible [Subject to medical plan year deductible Limited to a 34-day supply. [Not subject to the plan year deductible [Subject to medical plan year deductible Mail-in Generic Drugs Mail-in Preferred Drugs Copay per prescription or refill. Copay per prescription or refill. Not covered. Not covered. Limited to a 90-day supply. [Not subject to the plan year deductible [Subject to medical plan year deductible Limited to a 90-day supply. [Not subject to the plan year deductible [Subject to medical plan year deductible Mail-in Non-Preferred Drugs Copay per prescription or refill. Not covered. Limited to a 90-day supply. [Not subject to the plan year deductible [Subject to medical plan year deductible Biotech/Specialty Drugs Ambulance Services Type Land Air Convalescent Care Limited to 30 days per plan year. Durable Medical Equipment Limited to a plan year maximum of $10,000. Maximum is combined with prosthetics. Services that are deemed to be an Essential Health Benefit by PPACA will not be subject to the plan year maximum. Home Health Care Limited to a plan year maximum benefit of $5,000 per person. Hospice Care Maternity / Birthing Centers Revised

7 Newborn Care Physician Hospital Visit Facility Charges Organ Transplants Facility See Comprehensive Major Medical, Transplants: Physician Donor/Organ. Pregnancy If over 50 enrolled lives, this plan includes an additional transplant policy. Coverage Eligible Participants Limits Covered the same as an illness. Participant or covered spouse. Dependent children are not eligible for pregnancy benefits. Prosthetics then coinsurance Limited to a plan year maximum of $10,000. Maximum is combined with durable medical equipment. Services that are deemed to be an Essential Health Benefit by PPACA will not be subject to the plan year maximum. Second Surgical Opinion 100% of eligible charges for a second or third opinion. 100% of eligible charges for a second or third Not subject to the plan year deductible. opinion. Temporomandibular Joint Syndrome (TMJ) Facility Physician Subject to a plan year maximum of $500. Services that are deemed to be an Essential Health Benefit by PPACA will not be subject to the plan year maximum. Therapy Services - Outpatient Physical Therapy Occupational Therapy Speech Therapy Chiropractic Services Mental Health Benefit Coverage Mental health services are covered the same as illness. Substance Abuse Benefit Coverage Substance abuse services are paid the same as illness. Revised

8 FUNDING OBLIGATION The undersigned acknowledges that the Monthly Aggregate Amount (consisting of monthly claims liability plus monthly fixed costs) will be remitted to Key Benefit Administrators, Inc (KBA) each month. The undersigned acknowledges that this Monthly Aggregate Amount will include the medical claims liability, administrative expenses, fees, commissions, any compensation, and the purchase of Excess Loss Insurance for the contract period. The undersigned acknowledges and understands that if at any time funds have not been provided and there are not adequate funds available for eligible medical claim liabilities, payment for claims will not be made. IMPORTANT: Termination of the Administrative Services Agreement for any reason before the end of the annual contract term, as set forth in the Administrative Services Agreement, will immediately terminate any Excess Loss Insurance then in effect. In such an event, the employer understands that any and all Plan liabilities in excess of the Plan's Active Claims Liability Fund (as determined by KBA) will be the sole responsibility of the employer. Generally, the Plan's Active Claims Liability Fund is the amount available out of the paid Monthly Aggregate Amount for the payment of Plan liabilities after all of the above referenced fees, payments for coverage(s), compensations, commissions and any and all expenses are paid in full. The Administrative Services Agreement may be terminated immediately without further payment if funds are not remitted as required after notification by KBA. The Employee Retirement Income Security Act (ERISA) places a fiduciary responsibility on the employer, as Plan Sponsor, to ensure the Plan is adequately funded. KBA may notify all Plan Participants if your claims account is determined to be in jeopardy. (This is only a summary of general description of the funding being offered). EFFECTIVE DATE / DEPOSIT Deposit with Application: $ Requested Effective Date: Make check payable to: Key Benefit Administrators, Inc. IMPORTANT: No action will be taken on the Employer/Sponsor Application until after all required information is submitted. Final Monthly Aggregate Amount is based on actual enrollment. The Plan Options selected are subject to underwriting and the proposed Monthly Aggregate Amount is subject to change or declination. In such an event, the increased Monthly Aggregate Amount proposed under your Plan will be submitted to you as soon as practicable for your approval. The deposit amount will be returned to the applicant if the application is declined. No person other than an officer of KBA has the authority to approve a change in benefits by the plan sponsor and the undersigned agrees that any such attempt by the servicing representative is void and is not effective. Benefits are not effective until the undersigned receives written approval from KBA. Until such time, Employer agrees not to terminate present coverage. If medical information that was used during underwriting is later found to be inaccurate, the monthly aggregate amount is subject to change or coverage may be terminated or rescinded. EMPLOYER SIGNATURE APPLICANT AGREEMENT: The servicing representative has explained the details of the coverage(s) / benefits and the undersigned acknowledges reading this entire application. The undersigned states and affirms that the answers provided herein are true and complete. The undersigned acknowledges that the statements contained herein are being relied upon by KBA in determining whether to enter into an Administrative Services Agreement with the undersigned Plan Sponsor. KBA and the parties have executed a definitive Administrative Services Agreement in form provided by KBA. The undersigned, Employer and / or Plan Sponsor, understands that this is a Self-Funded health plan and the administration is provided by KBA. Part of the Aggregate Amount will be paid to an Excess Loss Provider to purchase Excess Loss Insurance. Such insurance will reimburse the Plan Sponsor for claim payments above an established maximum up to its limits of liability. Employers who choose to selffund an employee benefit plan must comply with the Employee Retirement Income Security Act of 1974 (ERISA), as amended, when applicable. Dated at (City / State): Full Legal Business Name: Signature (Must be signed by a person authorized to purchase benefits for the firm): Print Name and Title: Date (Month / Day / Year): Mail Summary Plan Description (SPDs) and Identification (ID) cards to: Employer's Business Address Agents Address Address AGENT/CONSULTANT INFORMATION Servicing Representative: SS# or EIN #: Street: City: State: Zip: Phone #: Fax #: I have explained to the Employer that final Monthly Aggregate Amount is based on actual enrollment and that the plan options selected are subject to underwriting and the proposed Monthly Aggregate Amount is subject to change or declination. I have notified the employer not to terminate present benefits until notified in writing by Key Benefit Administrators, Inc. (KBA) of acceptance of this application. I understand and have explained the waiting period in detail to the employer. Signature of Servicing Representative: Date: TPA USE ONLY Effective Date: Approved By: Date: Comments: Signing this application acts as the approval of the Plan Sponsor that KBA may process claims based on the benefits set out in the application for a period of up to 60 days from the beginning date of the benefit plan. During the 60 day period the Plan Document must be accepted by the Plan Sponsor. If not accepted within the 60 day period, claims will go on hold and not be paid until the Plan Document is accepted by the Plan Sponsor. If the benefits in the application change in the final Plan Document due to a change request by the Plan Sponsor, KBA will reprocess any impacted claims at a fee to be determined by KBA. KBA may, or may not, seek refunds of any resulting overpayments and will not be responsible for any lost discounts. Revised

9 Health Reimbursement Arrangement (HRA) Adoption Agreement HRA - Monthly Administration Services: $ 5.00 per participant $50 minimum Full Legal Business Name / Plan Sponsor (herein Plan or Plan Sponsor ): Street Address: City: State: Zip: Mailing Address (if different): City: State: Zip: County: Phone: Fax: Nature of Business: Sic Code: # of W2 Employees: Federal Tax ID #: 500 Series Welfare Number Date Business Started: Administrative Contact Person: Phone: Executive Contact Person: Phone: Note: If your Employees open a HSA Bank account, they may only participate a limited purpose FSA/ HRA. They will be unable to participate in this HRA plan. Type of Business: C Corp Partnership* S Corp* Sole Proprietorship* LLC/LLP* Non-Profit Other * Self-employed, > 2% owners, their spouse, lineal ascendants and descendants may not participate in the HRA. Names of Self - employed/2% owners, their spouse, lineal ascendants and descendants (attach a list for more) who will not be enrolled in the HRA: PLAN INFORMATION In connection herewith, the Employer makes the following statements and selections for each plan: Your HRA Plan Year must match the deductible cycle for your major medical plan which is (calendar year) The first plan year shall be: Beginning date: Ending date: Each subsequent plan year shall be: Beginning date: 1. An Eligible Employee under the HRA Plan will be an active participant in the Employer s Group Health Plan. 2. The participant effective date in the HRA is the same date as the effective date of coverage under the employer s group health plan. 3. The definition of Eligible Expenses under the HRA shall be: 5. What is the major medical coverage? Ending date: Out-of- Pocket Expenses (mark an X where applicable) Benefit Type Co-pay Deductible Co-Insurance Medical Prescription NA 4. Exclude out of network claims Yes No 7. Please indicate below how you would like your plan to pay. Coverage Benefit Type Single Family Example $5,000 $10,000 Major Medical Deductible Out of Pocket Maxmum 6. Are RX claims excluded from the major medical deductible and out of pocket maximums? Yes No HRA Reimbursement Formula HRA Coverage Employee will pay the first $ HRA pla will then pay % Up to the next $ Example: $1,000 75% $3,000 Single Family 8. The HRA plan will match the plan embedded/non-embedded deductible setup. In this example, a single Employee has $5,000 Major Medical deductible. The Employee pays the first $1,000 (HRA deductible) and then the HRA pays 75% up to $3,000. The Employee would have $2,000 total out of pocket ($1,000 HRA deductible plus 25% of $4,000). 9. This plan is intended to reimburse plan participants for qualified out-of-pocket medical expenses. Accordingly, it shall not be considered a group health plan for coordination of benefits purposes, and its benefits shall not be taken into account when determining benefits payable under any other plan. 10. This HRA does not permit rollover. 11. Qualified expenses not paid by the employer s group health plan administered by Key Benefit Administrators will automatically be submitted to your Health Reimbursement Account after the claim is processed by the group health plan claims administrator. Amounts submitted to the plan after the runout date are not eligible to be reimbursed by the plan. 12. The participant termination date in the HRA is the same date as the termination date of coverage under the employer s group health plan. 13. The runout of the plan will coordinate with the runout of the employer s group health plan. It is understood that 1) Key Benefit Administrators as the Plan Supervisor is not responsible for the tax and legal aspects of the plan; and 2) full responsibility, for the tax and legal aspects of the Plan, is assumed by the undersigned organization establishing the plan. The organization acknowledges having counseled with its legal and tax advisors with respect to the form and adoption/restatement of the plan including the selection of options. Signature (Must be signed by a person authorized to purchase benefits for the firm): Date: Revised

10 Overview of an HRA With an HRA, the employer funds an account from which the employee is reimbursed for qualified medical expenses, such as co-pays, deductibles, prescriptions, medical insurance, chiropractic care. Over-the-counter drugs that are medically necessary may also be reimbursed through an HRA. Reimbursements are not taxed to the employee and are deductible by the employer. The most common use of an HRA is in combination with a High Deductible Health Coverage (HDHP) Plan. HRAs can enhance a company s benefit package while helping to contain costs and boost employee morale. For example, you can combine your HRA with a higher-deductible health insurance plan. The employer benefits from reduced insurance cost, but the effect to the employee is lower out of pocket costs with the HRA rather than offering only the HDHP plan. Important Information You Need To Know About Your Health Reimbursement Arrangement (HRA) With Key Benefit Administrators Some Governmental Compliance Rules 1. An HRA must be funded solely with employer contributions. 2. Employers may define eligible benefits in an HRA as either expenses eligible under IRS Code 213 or employee outof-pocket expenses (e.g. deductibles, co-insurance, co-pays). 3. More than 2% Owners of an S Corp, their spouse, lineal ascendants and descendents may not participate in a Health Reimbursement Arrangement (HRA). 4. An HRA is a health plan and therefore subject to COBRA continuation requirements. 5. Health Reimbursement Arrangements are subject to Medicare reporting. Medicare reporting requires that we obtain specific information on all Employees and their Dependents on the plan. 6. The Employer must adopt a written HRA plan. It must be adopted and effective on or before the first day of the plan year to which it relates. - You will first complete the Adoption Agreement and then the HRA Plan Document will be provided by KBA. 7. An Annual 5500 filing is required only if the HRA covers over 100 people. 8. HRA reimbursements are not taxable to the employee. 9. The employer should seek advice from a tax consultant on their tax deductions for the year. 10. HRA benefits are solely available for substantiated medical expenses, lump sum pay-outs of unused funds (i.e. at separation of service) are not permissible. 11. HRAs are generally accounted for within the employer s general asset account. If an HRA is maintained within a funded trust, the plan becomes subject to ERISA compliance and reporting. 12. An HRA is subject to Nondiscrimination Rules such that the HRA cannot discriminate in favor of highly compensated employees. Administrative Information 1. If your HRA is a mid-deductible year takeover, it is important that we received the deductible/coinsurance (accumulator) information from your prior HRA Plan. 2. Please be sure to identify 2% owners, their spouse, lineal ascendants and descendents of an S Corp so that we may exclude them from the HRA plan. 3. You will receive a separate line item on your invoice for the per employee per month HRA administrative fees. 4. Your employees will receive a separate Explanation of Benefit for their HRA benefits. Revised

11 HRA Reimbursement (HRA) Bank Information - MUST BE INCLUDED WITH ALL HRA OPTIONS GROUP INFORMATION 1. Full Legal Business Name / Plan Sponsor (herein Plan or Plan Sponsor ): 2. Physical Address 3. City 4. State 5. Zip Code 6. Mail Address: (if different) 7. City 8. State 9. Zip Code 10. Primary Contact Name 11. Phone # 12. Fax # 13. Address ( ) - ( ) - Checking Account Information (**VERY IMPORTANT**: Attach MICR sheet or voided check) 1. What bank account is the underlying medical plan on? (Bank Acct #1) Employer Account KHP 2. Will KBA be administering an HRA? Yes No Note to KBA: If the group has KHP the group would have two separate bank accounts. 3. Holder of the HRA Account Client (Bank Account #2) HRA Bank Account Name: Checking Account #: Routing #:(bank #) Transit #: (top right corner/fractional #) Checking # to Start with: Bank Contact for testing purposes: Phone #: Address: City/State/Zip: 4. Second Signature Required? Yes No On claims exceeding what amount? $ 5. Checks are mailed directly to the Provider/Employee. 6. Name of the Check Signer: 7. Signature to appear on checks: *please provide clean copy of client signature 8. Checks print: Weekly Monthly 9. What day of the week would you like checks printed? Monday Tuesday Wednesday Thursday Friday 10. Check register ed to? Name: Name: Info to be displayed at the Top left of the check needs to read: Line 1: Line 2: Line 3: Line 4: Revised