We re here for you. Log in to anthem.com to view your benefits. Select Access your BenefitWallet HSA to view your HSA account. To speak to an Anthem member service representative, call the number on your Anthem ID Card. Or you can call BenefitWallet for questions about your Health Savings Account at 1 866.686.4798. If you are not enrolled in an Anthem health plan, you can continue to manage your HSA at mybenefitwallet.com. Get started using your Anthem HSA. Smart reasons to have an HSA: The money you put into your HSA, the interest you earn, and the money you withdraw to pay for health care costs are all tax free (in most states). All of the money in your HSA rolls over from year to year, and it s yours even if you change health insurance plans or change jobs. You can invest your savings in a variety of mutual funds once your balance reaches $1,000. HSA administration is provided by Xerox HR Solutions, an independent company. 2015 Xerox HR Solutions, LLC. All rights reserved. BenefitWallet is a trademark of Xerox Corporation in the United States. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Your Anthem Blue Cross and Blue Shield health plan comes with a Health Savings Account (HSA) administered by our trusted partner BenefitWallet, with The Bank of New York Mellon as the custodian. You can put tax-free money into your HSA and then use those funds to pay for your health care costs. Here are just some of them. Please see the IRS Publication 502 at irs.gov/pub502 for a complete list of approved medical and dental expenses. Coinsurance Deductibles Dental Care Doctor Visits Psychologist Visits Hearing Aids and Batteries Vision Care (including glasses, contacts, and Lasik surgery) Prescription Drugs X-Rays Here s how to get started: Activate your BenefitWallet Visa card after your account is open. Then, use the debit card to pay for your doctor visits or pick up a prescription. Access your HSA account. Log in to anthem.com and select Access your BenefitWallet HSA. Check your claims and track your account balance. You can even set your communication preferences to receive an email when a claim comes in. Add money to your HSA tax free. Automatic paycheck deductions, if offered by your company Transfer money from your personal bank account or from another HSA The maximum you are allowed to contribute to your HSA is set by the IRS and is adjusted annually. Please see IRS Publication 969 at irs.gov for the maximum amount you are allowed to add to your HSA this year. Use your HSA funds. Pay your health care bills with your BenefitWallet Visa card or set up an online payment that is sent directly to the provider. You can also choose to reimburse yourself if you paid out of pocket. Just log in to anthem.com and select Access your BenefitWallet HSA.
JOHN BRAND1 123 MAIN STREET COVINGTON GA 30016 October 26, 2015 Account Number: 95009990000005 Hello JOHN BRAND1, Welcome to your Anthem Blue Cross and Blue Shield health plan with a Health Savings Account (HSA). Your HSA is administered by BenefitWallet with The Bank of New York Mellon as the custodian. Start Saving by Opening Your HSA Today 1. Log in to anthem.com any time after your plan effective date and select Access your BenefitWallet HSA. To open your HSA prior to your health plan effective date, log in to mybenefitwallet.com and enter the HSA account number in the upper right portion of this letter. 2. Make sure your information is correct, accept terms, and choose Agree. 3. Congratulations! You ve opened your account. Now you can: Put money in tax free Check your account balance, claims and more Pay your bills or pay yourself back if you paid out of pocket Get tax information If you prefer, you can complete and return the enclosed Master Signature Card to: 1. Open your HSA account, 2. Designate an account beneficiary, or, 3. Request a checkbook Also included is additional information to help you get started using your HSA as well as the account terms and conditions. Activate Your BenefitWallet Debit Card When it Arrives After opening your account, you ll receive two personalized BenefitWallet debit cards. Follow the instructions on the sticker to activate your cards.
Questions? Call the number on your health plan ID card for questions about your plan, or call BenefitWallet about your HSA at 1 866.686.4798 or 1 855.545.4168 (for TDD callers), Monday to Friday, 8 a.m. to 11 p.m. ET, or Saturday and Sunday, 9 a.m. to 6 p.m. ET. Wishing you the best of health, The BenefitWallet Service Team 015 31K P1 BRAND 1 886C03 Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-hmo benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation (Compcare), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
John Brand1 95009990000005 123 MAIN STREET COVINGTON, GA 30016 :595000010:95009990000005< John Brand1 95009990000005 123 MAIN STREET COVINGTON, GA 30016 :595000010:95009990000005<
D015 ANY RF 06/06/08
Health Savings Account Fee and Rate Schedule Interest Rate and Monthly Fees Interest Rate... 0.150% Annual Percentage Yield (APY)... 0.150% Monthly Service Charge... $2.95* Paper statement (per statement)... $1.25 *Monthly service charge fee may be paid for you by your employer during active employment. If you leave your employer-sponsored plan, but retain your HSA, your monthly service charge is $3.25 Requests for debit card, checkbook or copies of documents First 2 debit cards issued at no cost. Replacement/Additional debit card... $5.00 First checkbook issued at no cost. Replacement/Additional checkbooks... $10.00 Copy of Check, Statement or Other Document (per item)... $5.00 Other Banking Fees when Applicable Stop Payment (per request)... $25.00 Returned Item (per instance)... $25.00 Custodian Check Issuance Fee (deducted from account balance)... $25.00 Excess Contribution Reimbursement (deducted from account balance)... $25.00 Attachments / levies / legal requests / subpoenas (per request)... $75.00 ATM Usage Fee (per usage)... $ 2.00 Statement Reconciliation / Account Research... $ 20.00 per hr / $ 10 min charge See your Health Savings Account Deposit Agreement and Disclosures for the complete terms and conditions related to your account. Note, fees disclosed will remain in effect until further notice. Interest is credited to participant accounts on the last business day of the month. For additional information regarding these fees, contact your employer, health plan or our service center. Other fees will be deducted from the balance of your Health Savings Account when incurred or as indicated. If the account balance is less than $25 at the time of the check issuance request, a fee equal to the account balance will be deducted from your account. D015 HSA Standard RFS
Rev. August 2013 FACTS WHAT DOES THE BANK OF NEW YORK MELLON DO WITH YOUR PERSONAL INFORMATION? Why? Financial companies choose how they share your personal information. Federal law gives consumers the right to limit some but not all sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what to do. What? The types of personal information we collect and share depend on the product or service you have with us. This information can include: Social Security Number Account balances Payment history Transaction history Checking account information When you are no longer our customer, we continue to share your information as described in this notice. How? All financial companies need to share customers personal information to run their everyday business. In the section below, we list the reasons financial companies can share their customers personal information; the reasons The Bank of New York Mellon chooses to share; and whether you can limit this sharing. Reasons we can share your personal information For our everyday business purposes such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, or report to credit bureaus For our marketing purposes to offer our products and services to you Does The Bank of New York Mellon share? Yes Can you limit this sharing? For joint marketing with other financial companies No No For our affiliates everyday business purposes information about your transactions and experiences For our affiliates everyday business purposes information about your creditworthiness For our affiliates to market to you No No For nonaffiliates to market to you No No Yes Yes No No No No No Questions? Call 877-472-4200
Page 2 Who we are Who is providing this notice? The Bank of New York Mellon is providing this notice to customers of Health Savings Accounts. What we do How does The Bank of New York Mellon protect my personal information? To protect your personal information from unauthorized access and use, we use security measures that comply with federal law. These measures include computer safeguards and secured files and buildings. How does The Bank of New York Mellon collect my personal information? We collect your personal information, for example, when you Open an account Make deposits or withdrawals from your account Use your credit or debit card Provide account information Give us your contact information We also collect your personal information from other parties, such as credit bureaus, affiliates, or other companies. Why can't I limit all sharing? Federal law gives you the right to limit only Sharing for affiliates everyday business purposes information about your creditworthiness Affiliates from using your information to market to you Sharing for nonaffiliates to market to you State laws and individual companies may give you additional rights to limit sharing. Definitions Affiliates Nonaffiliates Joint Marketing Companies related by common ownership or control. They can be financial and nonfinancial companies. Companies not related by common ownership or control. They can be financial and nonfinancial companies. The Bank of New York Mellon does not share information with nonaffiliates so they can market to you. A formal agreement between nonaffiliated financial companies that together market financial products or services to you. The Bank of New York Mellon doesn t jointly market. Other important information This notice applies to individual consumers who are customers or former customers. This notice replaces all previous notices of our consumer privacy policy, and may be amended at any time. We will keep you informed of changes or amendments as required by law.
*9990000005* John Brand1 95009990000005 Sample
General Instructions Purpose: Complete and return this form to open your account if you have not done so electronically, to provide a signature of record for the account, to indicate your desire to receive a checkbook for the account and to designate an account beneficiary. Checkbook: To receive a checkbook, complete the requested information on the other side of this form. If you would like to designate another person to sign checks on your account you can download the Additional Signature Authorization Form from our website or by calling the toll free number on the back of your debit card. As the account holder you remain responsible for the use of HSA funds by all authorized signors. Beneficiary Designations: To designate a beneficiary or beneficiaries for your account complete the requested information on the other side of this form. Note, one or more persons or entities may be designated as death beneficiary of your account (referred to as Primary Beneficiaries ). You may also designate one or more persons to receive your account if no Primary Beneficiary survives you (referred to as Contingent Beneficiaries ). Beneficiary designations can be made only on a form provided by or acceptable to us and will only be effective when filed with us during your lifetime. If you die before you receive all of the amounts in your account, payments from your account will be made according to your beneficiary designation(s). The following procedures will be used in processing beneficiary designations: 1. If no percentages are assigned to beneficiaries in a Beneficiary classification (Primary or Contingent), the Beneficiaries within such class will share equally. 2. If the percentage total for each Beneficiary classification (Primary and Contingent) does not equal 100%, any remaining percentages will be divided equally among the Beneficiaries within such class. 3. If in a Beneficiary classification (Primary or Contingent) a Beneficiary dies before distribution of the account is made, that deceased Beneficiary s designated share shall be divided equally among the surviving Beneficiary(ies) within the class. 4. If no Beneficiaries are named or if all the named Beneficiaries predecease the account holder, the account will be paid to spouse of the account holder if then living, or if the spouse is not then living to the estate of the account holder. A beneficiary designation remains on file and in force until a subsequent beneficiary designation form is completed by you and returned to us. Note, should we be made aware of your death we will correspond only with designated beneficiaries concerning the disposition of the account. D015 ANY RF 10/10/08