2019 Open Enrollment Package

Transcription

1 Holston Conference The United Methodist Church P.O. Box 850 Alcoa, TN Holston Conference Health Benefit Plans 2019 Open Enrollment Package The Holston Conference maintains a self-insured health insurance program and other benefits for all eligible clergy, full-time Conference lay employees, and full-time lay employees of participating churches within Holston Conference. (Please refer to the current Book of Reports or Conference Journal to review eligibility guidelines.) Open enrollment begins November 1, 2018, during which current participants can change plan elections, and previously eligible/ non-participating clergy and lay may enroll for the upcoming calendar year. This packet contains everything you need for open enrollment. All completed forms must be received by the Conference by Friday, December 14, If you have any questions, please call the Benefits Office at 865/ , or fax at 865/ , or kenluton@holston.org. Included in This Packet PAGE General Information... 1 New Participant Enrollment Form... 2 Network Option Change Form... 4 Plan & Dependent Change Form... 5 Vision Coverage Enrollment Form... 6 FSA/DCA Enrollment Form (REQUIRES ENROLLMENT EACH YEAR)... 7 Health Plan Rate Sheet... 9 Plan Benefit Comparison You may also download a PDF of this complete 2019 Open Enrollment Package on-line: All Completed Forms Must Be Returned by December 14, 2018 Mail to: Holston Conference Benefits Office P.O. Box 850 Alcoa, TN or Fax to 865/ or to kenluton@holston.org

2 Holston Conference The United Methodist Church P.O. Box 850 Alcoa, TN Open Enrollment General Information DON T PANIC! All participants will receive New I.D. Cards in December Regular Healthcare Plan Update We are again pleased to be able to maintain the benefit package for 2019 with no change in deductible or out-ofpocket amounts for our regular PPO plan. The Health Savings Account (HSA) plan will have an increase in the deductible amount to $2,700 and $5,400 to remain compliant with federal regulations. We will, as in 2018, give participants the option of using both Network S and Network P for Blue Cross / Blue Shield of Tennessee providers in the State of Tennessee. A Health Insurance Rates Sheet and a Plan Benefit Comparison are included on pages 9 and 10. New Participant Enrollment If you are a new enrollee in our healthcare plan, please: Complete pages 2-3 (Holston Conference New Participant Health Insurance Enrollment Form) along with any additional forms indicated based on your elections. If you choose to participate in the Flexible Spending Account (FSA) or Flexible Dependent Care Account (FDCA), complete the included enrollment form on page 8. Network Option Changes If you use Tennessee providers, and you wish to change networks ( S to P or vice versa), please indicate your change on the enclosed Network Option Change Form (page 4). You can consult the Health Plan Rate Sheet (page 9) and to assess each network to determine which best meets your needs. Plan and Dependent Changes Please complete page 5, Plan and Dependent Change Form, if you would like to: Change from the PPO to the HSA or vice versa (Enrollment in the HSA requires establishing an account with the Holston Methodist Federal Credit Union or healthequity.com on-line.) Add or remove covered dependents Modify your coverage type (Individual, E+1, or Family) Optional Vision and Dental Coverage The optional vision coverage premiums remain unchanged from 2018; $11 for single, $18 for Employee + 1, and $27 a month for family coverage. If you wish to add, change, or drop vision coverage please, complete the vision enrollment form (page 6) Optional dental coverage is included in your PPO and HSA plans at no additional premium. Flexible Spending Accounts Flexible Medical Spending Accounts (FSA) & Flexible Dependent Care Accounts (FDCA) require re-enrollment each year. These separate benefit programs are subject to Pre-Tax funding through payroll deduction by your local church. If you wish to continue or start participation in these programs for 2019, please complete and return the enclosed enrollment form (page 8). FSA funding is subject to an annual limit of $2,700 and FDCA s limit is $5,000, You may carry over up to $500 of unused funds from 2018 to 2019, as in Participants in our regular HSA plan can still participate in an FSA, but covered expenses are limited to dental and vision related costs. In addition, you do not have to participate in our regular health plan to take advantage of the Flexible Spending Account options. If you are eligible to be covered by our regular plans, but are covered by a spousal or parent s plan etc., you are still eligible to enroll in these options. Questions? Call the Holston Conference Benefits Office 865/ or kenluton@holston.org

3 EMPLOYEE SIGNATURE DATE - - PHONE - - revised PLEASE COMPLETE NEXT PAGE FOR ALL DEPENDENTS TO BE COVERED UNDER THIS PLAN HOLSTON CONFERENCE UMC - NEW PARTICIPANT HEALTH INSURANCE ENROLLMENT FORM CHURCH / ORGANIZATION TO BE BILLED EFFECTIVE DATE CLERGY (SPECIFY) LAY EMPLOYEE QUALIFYING EVENT NEW HIRE DATE OF HIRE / / LOSS OF OTHER COVERAGE TRANSITION FROM PART-TIME TO FULL-TIME OPEN ENROLLMENT OTHER - - EMPLOYEE LAST NAME EMPLOYEE FIRST NAME MI SOCIAL SECURITY NBR. DATE OF BIRTH ADDRESS CITY STATE ZIP CODE ADDRESS HEALTH PLAN BCBST NETWORK OPTIONS FOR TENNESSEE PROVIDERS ONLY NETWORK "S" NETWORK "P" HEALTH PLAN COVERAGE OPTIONS (PLEASE SELECT ONE) INDIVIDUAL EMPLOYEE+ SPOUSE OR + ONE CHILD FAMILY HEALTH PLAN BENEFIT OPTIONS (PLEASE SELECT ONE) Regular PPO Plan HEALTH SAVINGS ACCOUNT PLAN (3) H.S.A With _: HEALTH EQUITY.COM HMFCU A/C # DO YOU WISH TO ENROLL IN THE OPTIONAL DENTAL COVERAGE AT NO ADDITIONAL PREMIUM? DO YOU WISH TO ENROLL IN THE OPTIONAL VISION COVERAGE WITH ADDITIONAL PREMIUM? YES YES NO NO S E+1 F ACKNOWLEDGEMENT I understand, and agree, that I am applying for coverage in the Holston Conference Self-Insured Health Plan administered by Blue Cross/Blue Shield of Tennessee and that my signature on this form will authorize any doctor, hospital, or other provider of treatment to furnish Blue Cross/Blue Shield of Tennessee any and all medical records pertaining to any person covered by this contract. I WILL BE COVERED BY ANOTHER HEALTH PLAN AVAILABLE TO ME AND DECLINE COVERAGE AT THIS TIME (SAVINGS ACCOUNT INFORMATION REQUIRED) 2

4 PLEASE COMPLETE THIS PAGE FOR ALL DEPENDENTS TO BE COVERED UNDER THIS PLAN DEPENDENT INFORMATION - PLEASE PROVIDE ALL INFORMATION FOR EACH PERSON TO BE COVERED / / DEPENDENT LAST NAME DEPENDENT FIRST NAME MI SOCIAL SECURITY NBR. DATE OF BIRTH / / SPOUSE LAST NAME SPOUSE FIRST NAME MI SOCIAL SECURITY NBR. DATE OF BIRTH HAS SPOUSE HAD CONTINUOUS HEALTH COVERAGE FOR THE PAST 12 MONTHS? YES NO IF NO, WHAT ARE THE DATES OF MOST RECENT COVERAGE? FROM / / TO / / / / DEPENDENT LAST NAME DEPENDENT FIRST NAME MI SOCIAL SECURITY NBR. DATE OF BIRTH NATURAL CHILD / STEP CHILD ADOPTED / LEGAL GUARDIAN OTHER (SPECIFY) HAS DEPENDENT HAD CONTINUOUS HEALTH COVERAGE FOR THE PAST 12 MONTHS? YES NO IF NO, WHAT ARE THE DATES OF MOST RECENT COVERAGE? FROM / / TO / / / / DEPENDENT LAST NAME DEPENDENT FIRST NAME MI SOCIAL SECURITY NBR. DATE OF BIRTH NATURAL CHILD / STEP CHILD ADOPTED / LEGAL GUARDIAN OTHER (SPECIFY) HAS DEPENDENT HAD CONTINUOUS HEALTH COVERAGE FOR THE PAST 12 MONTHS? YES NO IF NO, WHAT ARE THE DATES OF MOST RECENT COVERAGE? FROM / / TO / / / / DEPENDENT LAST NAME DEPENDENT FIRST NAME MI SOCIAL SECURITY NBR. DATE OF BIRTH NATURAL CHILD / STEP CHILD ADOPTED / LEGAL GUARDIAN OTHER (SPECIFY) HAS DEPENDENT HAD CONTINUOUS HEALTH COVERAGE FOR THE PAST 12 MONTHS? YES NO IF NO, WHAT ARE THE DATES OF MOST RECENT COVERAGE? FROM / / TO / / NATURAL CHILD / STEP CHILD ADOPTED / LEGAL GUARDIAN OTHER (SPECIFY) HAS DEPENDENT HAD CONTINUOUS HEALTH COVERAGE FOR THE PAST 12 MONTHS? YES NO IF NO, WHAT ARE THE DATES OF MOST RECENT COVERAGE? FROM / / TO / / USE ADDITIONAL SHEETS IF NECESSARY 3

5 Holston Conference The United Methodist Church P.O. Box 850 Alcoa, TN Network Option Change Form Blue Cross/Blue Shield of Tennessee Network P Election Form To The Holston Conference UMC Office of Pension and Health Benefits Re: Blue Cross/Blue Shield of Tennessee Network Election Form ELECTION OF COVERAGE UNDER NETWORK P I have determined that I, and any covered dependents need to use medical care providers within the State of Tennessee that accept reimbursement rates for the P Network, and not the S Network, administered by Blue Cross/Blue Shield of Tennessee. I hereby elect to have my health plan coverage offered by the Holston Conference of the United Methodist Church using the P Network. I acknowledge that by making this election I agree to a premium increase on my personal portion of the monthly premiums. I further acknowledge that this election becomes effective January 1, 2019, and can only be changed concurrently with a qualifying life event or annually during the open enrollment period. Please Print Participant Name Participant Signature & Date Participant ID Number from Your BC Card ************************************************************** ELECTION TO CHANGE COVERAGE FROM NETWORK P TO NETWORK S I have previously elected coverage under Network P and wish to change to coverage under Network S administered by Blue Cross/Blue Shield of Tennessee. I acknowledge that this election becomes effective January 1, 2019 and can only be changed concurrently with a qualifying life event or annually during the open enrollment period. Please Print Participant Name Participant Signature & Date Participant ID Number from Your BC Card 4

6 IF YOU WANT TO CHANGE YOUR NETWORK OPTIONS PLEASE COMPLETE THE "NETWORK OPTION CHANGE FORM" IN THIS PACKET Holston Conference UMC Health Insurance 2019 Plan and Dependent Change Form Complete This Form Only To Change Existing Coverage or Plan Option I WOULD LIKE TO CHANGE MY HEALTH PLAN OPTION NAME CLERGY LAY EMPLOYEE BCBST PARTICIPANT NUMBER ORGANIZATION I WOULD LIKE TO CHANGE TO THE FOLLOWING TYPE OF COVERAGE: EFFECTIVE DATE INDIVIDUAL EMPLOYEE + ONE FAMILY COVERAGE PLEASE ADD THE FOLLOWING DEPENDENTS TO MY COVERAGE: NAME DATE OF BIRTH SOCIAL SECURITY NUMBER January 1, 2019 RELATIONSHIP PLEASE REMOVE TO FOLLOWING INDIVIDUALS FROM MY COVERAGE NAME DATE OF BIRTH SOCIAL SECURITY NUMBER REASON I WOULD LIKE TO CHANGE TO THE FOLLOWING PLAN OPTION: MY CURRENT PLAN THE PPO PLAN OR H.S.A PLAN I WOULD LIKE TO CHANGE FROM THE PPO PLAN TO THE H.S.A. PLAN I WOULD LIKE TO CHANGE FROM THE H.S.A. PLAN TO THE NEW PPO PLAN (See Below for H.S.A.) NEW H.S.A. - HEALTH SAVINGS ACCOUNT INFORMATION I HAVE OPENED MY HEALTH SAVINGS ACCOUTH WITH: (REQUIRED PRIOR TO ENROLLMENT) HOLSTON METHODIST FEDERAL CREDIT UNION A/C # HEALTH EQUITY (healthequity.com) A/C # 5 SIGNATURE DATE

7 2019 VISION CARE PLAN FOR HOLSTON CONFERENCE For Active and Retired Health Plan Participants OFFERED BY BLUE CROSS / BLUE SHIELD OF TENNESSEE BENEFITS SUMMARY: ANNUAL EXAM: $20 COPAY EVERY 12 MONTHS MATERIALS: $20 COPAY FRAMES: $150 ALLOWANCE EVERY 24 MONTHS LENSES/CONTACT LENSES: $150 ALLOWANCE EVERY 12 MONTHS (limited to Eyeglass lenses or contact lenses) Cost: INDIVIDUAL COVERAGE EMPLOYEE + ONE FAMILY $11.00 per month $18.00 per month $27.00 per month If you have regular health coverage with Family or Employee + One, you can elect a lesser coverage for the vision plan; but the primary member must be covered. COMPLETE THIS SECTION IF YOU ARE NOT PRESENTLY IN THE PLAN AND WISH TO DO SO BEGINNING JANUARY 1, 2019 Please enroll me in the: Individual Plan Employee + 1 Plan Family Plan COMPLETE THIS SECTION IF YOU ARE PRESENTLY IN THE PLAN AND WISH TO CHANGE COVERAGE BEGINNING JANUARY 1, 2019 Please change my coverage FROM TO Individual Plan Employee + 1 Plan Family Plan I WISH TO DROP MY VISION COVERAGE COMPLETELY Please Print the Participant s Name Participant Signature Date Blue Cross ID # from you Card 6

8 RETURN THE COMPLETED FORM TO HOLSTON CONFERENCE BENEFITS OFFICE FSA REMINDERS Health Care Spending Account The health care spending account allows you to make pre-tax contributions to an account that may be used to pay for IRS approved health care expenses not covered under a health benefit plan for which you or your dependents for IRS tax purposes are enrolled. Examples of expenses include co-payments, deductibles, glasses and certain over-the-counter (OTC) drugs. A full listing of the eligible expenses can be found in IRS publication 502, Medical and Dental Expenses at Dependent Care Spending Account The dependent care spending account allows you to make pre-tax contributions to an account that may be used to pay for the cost of care for your children under the age of 13 or for any dependent (including your parents) who is mentally or physically incapable of selfcare and lives regularly in your household at least eight hours a day while you (or your spouse) work or attend school on a full-time basis. Eligible dependent day care includes day care centers, babysitters, or companions. You can contribute up to a maximum of $5,000 if you are a single parent or a married couple filing a joint return (combined contributions made by you and your spouse cannot exceed $5,000), or $2,500 per person if you are married and filing separately. You should review whether a dependent care FSA or the federal tax credit would be more advantageous for you. Enrolling in an FSA A new FSA enrollment election must be made each year. Participation is voluntary. You may contribute to one or both of the FSA s being offered. You do not have to be enrolled in the Company s medical/health plan to enroll in a flexible spending account. Once made, your election is irrevocable and cannot be changed during the Plan Year unless you have a qualifying status change. Expenses must be incurred within the current plan year or subsequent grace period or subject to the carryover provisions as permitted by the Plan and required by law. You will be issued a benefits debit card for ease of payment of your eligible FSA expenses. The card is valid for those continuous years that you elect to participate in the Company s FSA s up to the expiration date shown on the front of your card. Replacement fees will apply if a new card must be reissued or additional cards are requested. These fees will be deducted from your account. Effective Date of Coverage If you are a new employee, you must make your FSA election and submit this form to Human Resources within 30 days of your eligibility date. Your contributions will become effective with the first pay period following your eligibility date. If you waive coverage at the time of hire, you must wait until the next open enrollment period to elect to participate for the subsequent plan year unless you have a qualifying status change during the plan year. If you are enrolling or making an election change mid-year due to a qualifying status change, your election must be received and approved by Human Resources within 30 days of the status change date. If you are rehired in the same calendar year after a break in service that is 30 days or less, your previous FSA elections will be reinstated as of your date of hire. If the break in service is longer than 30 days or if you are rehired in a new calendar year, you will make new FSA elections which will become effective as of your rehire date. Progressive Benefit Solutions, LLC 14 Business Park Drive #8, Branford, CT FSAE/C 1005LLR REV (11/13) 7

9 FSA/DCA NEW ENROLLMENT or CHANGE FORM (Print clearly No Abbreviations) Employer Name Last Name First Name MI Social Security Number Home Address City State Zip Daytime Phone ( ) Home Phone ( ) Date of Hire Date of Birth Enrollment Status: New Hire Open Enrollment Change in Status Date of Event: You may be permitted to change your FSA election if you have a qualifying status change. To make a change, you must report the change within 30 days of the event to Human Resources. All changes are subject to Plan Administrator approval. Only expenses incurred on or after the date of your qualifying status change are eligible for reimbursement under the new election. If status change, indicate reason: Flexible Spending Account (FSA) Change in marital status Birth/adoption/placement for adoption of child Death of a dependent Change in dependent s eligibility You/your dependent becomes eligible for Medicare or Medicaid Change in residence/workplace that affects eligibility of healthcare benefits Leave without pay due to military deployment Change in your/spouses employment status that affects eligibility of health care benefits. Dependent Care Spending Account Your need for dependent care changes Your dependent care provider changes The costs of dependent care increases by more than 10% (and care is not provided by a relative) Flexible Spending Account (FSA) Dependent Care Spending Account (DCA) Qualified Transportation HSA Information Used for uninsured eligible health care expenses incurred by you or a covered dependent. Please refer to your benefit information for Plan minimum and maximum contribution amounts. Annual Election Amount $ Per Pay Period Amount Waive Coverage $ Used for eligible dependent care expenses incurred so that you and your spouse (if married) can work. Maximum contribution: $5,000 ($2,500 if married filing separately) Annual Election Amount $ Per payroll Amount Waive Coverage $ Used for eligible qualified transportation expenses for mass transit and/ or parking: Mass Transit Maximum Monthly = 260 Parking Maximum Monthly = $260 Monthly Election Amount Parking $ Mass Transit $ Are you participating in an HSA? YES NO If Yes, your FSA will be a Limited FSA for Vision & Dental Expenses only. Pay Frequency: Weekly Bi-weekly Semi-monthly Monthly Acknowledge that: I authorize my employer to reduce my pay on a pre-tax basis by the total amount of the contribution(s) noted-above. I understand that I cannot change or revoke my election(s) prior to the end of the Plan Year for which it is in effect unless I experience a Qualifying Status Change as permitted by the Plan and Section 125 of the Internal Revenue Code. Any changes to my election(s) must be filed with and approved by Human Resources within 30 days of the status change date. Any pre-tax elections I have made here will reduce my compensation for Social Security tax purposes, which could reduce my social security benefits slightly. Any amounts remaining in my flexible spending account(s) after the end of the plan year, will be subject to the Plan s specifications as required by law. I understand that my contributions can only be used for the payment of expenses incurred during the plan year for which this agreement is in effect, or the subsequent grace period or subject to the carryover provisions, as permitted by the Plan. I understand that I can change my election (s) prior to the end of the plan year for QTA (Qualified Transportation). QTA plans are governed by Section 132 of the Internal Revenue Code. Any changes must be reported to Human Resources within 30 days of the status change. All claims submitted for reimbursement are subject to substantiation requirements and I will be required to retain all itemized receipts/statements and offer them as proof of eligibility when requested by the Plan Administrator, Claims Administrator (Progressive Benefit Solutions, LLC (PBS)) or the IRS. I will not seek reimbursement of claims through my flexible spending account(s) when they are eligible for reimbursement elsewhere. I agree to use the benefits debit card for eligible expenses only. I understand the benefits debit card will be inactivated if I do not comply with the provisions of the Plan/card or upon termination of employment. I am responsible for any fees associated with the benefits debit card, not otherwise paid for by my employer. Employee Signature: Date: Progressive Benefit Solutions, LLC 14 Business Park Drive #8, Branford, CT FSAE/C 1005LLR REV (11/13) 8

10 Base Plan - BCBST Network "S" Holston Conference UMC EFFECTIVE JANUARY 1, Health Insurance Rates Optional Plan - BCBST Network "P" REGULAR PLAN MINISTERS Individual Employee + 1 Family Individual Employee + 1 Family Direct Invoice $ 844 $ 844 $ 844 $ 844 $ 844 $ 844 Minister $ 206 $ 438 $ 606 $ 227 $ 482 $ 667 Total $ 1,050 $ 1,282 $ 1,450 $ 1,071 $ 1,326 $ 1,511 VANCO Discount $ (14) $ (14) $ (14) $ (14) $ (14) $ (14) H.S.A. MINISTERS REGULAR PLAN MINISTERS H.S.A. MINISTERS Individual Employee + 1 Family Individual Employee + 1 Family Direct Invoice $ 844 $ 844 $ 844 $ 844 $ 844 $ 844 Minister $ 116 $ 139 $ 164 $ 129 $ 155 $ 179 Total $ 960 $ 983 $ 1,008 $ 973 $ 999 $ 1,023 *$600/year Conference *$1,200/year Conference *$1,200/year Conference *$600/year Conference *$1,200/year Conference *$1,200/year Conference Contribution Contribution Contribution Contribution Contribution Contribution VANCO Discount $ (14) $ (14) $ (14) $ (14) $ (14) $ (14) REGULAR PLAN LAY EMPLOYEES REGULAR PLAN LAY EMPLOYEES Individual Employee + 1 Family Individual Employee + 1 Family Employer $ 425 $ 938 $ 1,332 $ 425 $ 938 $ 1,332 Claimant $ 206 $ 438 $ 606 $ 227 $ 482 $ 667 Total $ 631 $ 1,376 $ 1,938 $ 652 $ 1,420 $ 1,999 VANCO Discount $ (7) $ (14) $ (14) $ (7) $ (14) $ (14) H.S.A. LAY EMPLOYEES H.S.A. LAY EMPLOYEES Individual Employee + 1 Family Individual Employee + 1 Family Employer $ 425 $ 938 $ 1,332 $ 425 $ 938 $ 1,332 Claimant $ 116 $ 139 $ 164 $ 129 $ 155 $ 179 Total $ 541 $ 1,077 $ 1,496 $ 554 $ 1,093 $ 1,511 *$600/year Conference *$1,200/year Conference *$1,200/year Conference *$600/year Conference *$1,200/year Conference *$1,200/year Conference Contribution Contribution Contribution Contribution Contribution Contribution VANCO Discount $ (7) $ (14) $ (14) $ (7) $ (14) $ (14) PPO PLAN EARLY RETIREES-Minister PPO PLAN EARLY RETIREES-Minister Individual Employee + 1 Family Individual Employee + 1 Family Premium $ 662 $ 1,401 $ 1,976 $ 729 $ 1,541 $ 2,172 VANCO Discount $ (7) $ (14) $ (14) $ (7) $ (14) $ (14) Only TN Providers differentiate between Network "S" and Network "P." If you use a Tennessee provider, visit to assess each network to determine which best meets your needs. 9

11 COMPARISON OF HOLSTON CONFERENCE SELF-INSURED HEALTH PLANS 2019 PPO PLAN H.S.A PLAN In Network Out of Network In Network Out of Network Preventitive Health Care Services 100% 60% After Deductible 100% 50% After Deductible Practitioner Services: Primary Care Providers $30.00 Co Pay 70% After Deductible All Other Specialist Providers $60.00 Co pay All Maternity Services $30.00 Co Pay Routine Diagnostice Services 100% 60% After Deductible 50% After Deductible Injections 100% Allergy Testing 80% After Deductible Facility Services: In Patient Hospital 80% After Deductible Out patient surgery; skilled nursing 80% After Deductible Rehab; Emergency Care 80% After Deductible Behavioral Health 80% After Deductible Other Services: Ambulance 80% After Deductible Durable Medical Equipment 80% After Deductible Prosthetics & Orthotics 80% After Deductible Home Health Services (60 Visits) 80% After Deductible Hospice 100% Therapy (60 visits) 80% After Deductible Chiropractic (30 Visits) $50 Co Pay Hearing Aids 80% After Deductible Evaluation & Infertility Testing 80% After Deductible Medical Vision Care: Exam for Injuries or disease (In Patient) 80% After Deductible 60% After Deductible Exam for Injuries or disease (Practitioner Office) $30 / $60 Co Pay Frames, Lenses, Contacts following surgery 80% After Deductible Organ Transplant Services 80% After Deductible 60% After Deductible 70% After Deductible 70% After Deductible 50% After Deductible 50% After Deductible Pharmacy Prescriotion Drug Co Payments 1 Month Supply $25/$40/$75 Pay all cost and file 2 Month Supply $50/$80/$150 claim for 3 Month Supply $50/$80/$150 reimbursement $25/$40/$75 (1) $50/$80/$140 (1) (2) $50/$80/$140 (1) (2) Pay all cost and file claim for reimbursement Annual Deductible Individual $2,000 $4,000 Family $4,000 $8,000 4th Quarter Deductible Carryover Applied $2,700 $5,400 $5,400 $10,800 Annual Out Of Pocket Individual $4,500 $9,000 $6,000 $12,000 Family $9,000 $18,000 $12,000 $24,000 H.S.A. Sponsor Contribution Single/Family $600 /$1,200 H.S.A. Contribution Limits for 2019 Single/Family inclusive of Sponsor Contribution Regular If 55 or over $3,500/$7,000 $4,500/$8,000 10