(FAMILY NAME) Qualified Small Emplyer Health Reimbursement Arrangement Effective Date:
Emplyer / Plan Administratr Emplyer Name: Address: Phne Number: ( ) - Federal Emplyer Identificatin Number: The emplyer named abve will serve as Plan Administratr. The Plan Administratr has the authrity t: Interpret the Plan fr eligibility and benefits determinatins, Determine Plan eligibility fr individuals, And Terminate r Amend the Plan. Plan Year: Waiting Perid: (Nt t exceed 90 days frm start f emplyment.) Maximum Benefit: This is the maximum amunt f benefits that will be paid ut during the curse f the Plan Year. Emplyees enrlled in the Plan will be eligible t receive reimbursements frm the Emplyer Health Care Expenses in a Plan Year r the remaining Plan Year in which they are enrlled. Emplyee Only: Family: $ (Nt t exceed Federal limits f $5,150 annually r $429.16 mnthly fr emplyees nt enrlled fr the full Plan Year.) $ (Nt t exceed Federal limits f $10,450 annually r $870.83 mnthly fr emplyees nt enrlled fr the full Plan Year.) Carry Over: $ NO CARRY OVER OF UNUSED BENEFITS BETWEEN PLAN YEARS This is the maximum amunt f unused benefits that can be carried ver frm ne Plan Year t the next Plan Year. Cash Outs are nt permissible. (May nt exceed the Annual Maximum Benefit as defined by the Cures Act. Carry ver benefits are nt required under the CURES Act.)
Health Care Expense: Health Care Expense means any amunt paid by a Participant, cvered Dependent and/r Spuse that is an expense fr individual health insurance plicy premiums reimbursable under 213(d) f the Internal Revenue Cde, excluding expenses reimbursed by any ther health plan. Individual health insurance plicies must ffer minimum essential cverage as defined by the Affrdable Care Act t be eligible fr Plan reimbursement. Health care sharing plans cannt be reimbursed under a QSEHRA Plan. Shuld the emplyee fail t maintain cverage that cnstitutes minimum essential cverage, the emplyee may be subject t penalties under the individual mandate prvisins f the ACA, and the QSEHRA reimbursements might be included in the emplyee s grss incme. HRA Accunt: The HRA accunt established fr each individual Eligible Emplyee is fully funded by the Emplyer, and any amunts remaining at the end f the plan year in excess f the Carry Over defined abve are frfeited. Any remaining funds at time f terminatin are frfeited. Eligibility and Enrllment: Eligible Emplyee: An Eligible Emplyee will autmatically becme a participant in this Plan upn cmpletin f the Waiting Perid as defined abve and submissin f an enrllment frm. Eligible emplyee is actively emplyed n the date befre the effective date, as well as any newly hired r rehired active full time emplyee. Part time emplyees, temprary emplyees, and emplyees under the age f 25 wh are included n a parent s plan are nt eligible t participate in the Plan. Enrllment: An Eligible Emplyee must cmplete an enrllment frm t participate in the Plan. Cverage will begin n mre than thirty (30) days after the cmpleted enrllment frm is received by the emplyer. Terminatin: An Eligible Emplyee s participatin in the plan shall terminate as f the earliest f: The date the emplyee ceases t be emplyed by the emplyer; The date f Plan terminatin. Cverage fllwing Terminatin f Emplyment: The terminated emplyee has a perid f thirty (30) days fllwing terminatin f emplyment fr any reasn t submit eligible expenses incurred prir t emplyment terminatin fr reimbursement by the Plan subject t the emplyee s HRA balance.
Plan Recrds: The emplyer/plan Administratr is required under the CURES Act t maintain recrds t dcument prper Plan Administratin. The Plan participant is required t furnish the emplyer/plan Administratr with the data the Administratr reasnably requests t ensure the prper administratin f the Plan, with dcumentatin f items such as prf f relatinship as needed. Expense Reimbursement The fllwing must be bserved fr eligible reimbursement f Health Care Expenses: Participant must submit a cmpleted REIMBURSEMENT REQUEST FORM n later than thirty (30) days after the clse f the Plan year OR- n later than thirty (30) days after the terminatin f emplyment. The REIMBURSEMENT REQUEST FORM must include the fllwing: Name and address f the participating emplyee; Name f the persn wh incurred the expense (emplyee, spuse, r eligible dependent); The name and address f the health care prvider r rganizatin t whm the health care expense was paid r is t be paid and the amunt f the payment; Type f eligible expense; Cpy f receipt r bill.
HEALTH SAVINGS ACCOUNT REIMBURSEMENT FORM (ATTACH RECEIPT)