2012-09-26 CC Packet - Laserfiche WebLink

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❑ I understand the terms of a stand -alone TASC HSA Plan (sign below) Employer Signature Date TASC HSA Admin. Only - Special Instructions (7) DIRECTPAY Dire Pay Plan Selection (Check only one): [ Health Reimbursement Arrangement (HRA) ❑ Direct Reimbursement (DR) DirectP. Administration Options (Check only one): ❑ Full Administration ❑ Self Administration Number of .rticipants ERISA Plan Number Do you currently have an HRA or DR Plan? ❑ Yes ❑ No Number of full- 'me and part -time employees (needed to determine CMS Reporting Requirement): (A) Participant an. ligibility Requirements Choose one of the • Ilowing: ❑ Eligibility require ' -nts include participation in the named Health Insurance Plan. ❑ The following eligibili requirements apply (choose all that are applicable): ❑ Part -time employee orking at least hours of work per week will be included (maximum of 25 hours) ❑ Seasonal employees wo ing at least months of work within a year will be included (maximum of 7 months) ❑ Employees reaching -ars of age will be included (maximum 25 years) ❑ Current employees completing months of service with the employer will be included (maximum 36 months) ❑ New employees completing •onths of service with the employer will be included (maximum 36 months) (B) Available Benefits and Qualified Expenses Each Plan selected requires a separate DirectPay Pia • Application. Plan administration fees and funding arrangements apply to each Plan Application. Check only one Plan perApplic• 'on. Plan 1 Plan 2 Plan 3 I Plan 4 Plan 5 Plan 6 (Plan 7 0 Medical 0 Medical 0 Medical 0 Medical 0 Medical 0 Uninsured 1 0 Dental Plan Deductible Deductible & ! Deductible & Deductible, Co- Deductible, Co- Medical Only Prescription Co- Insurance pay, & Prescription pay, Co- Insurance, I Select Benefits 0 Dental Prescription I 0 Orthodontics Minimum Funding at 25% at 50% at 50% at 50% I 50% at 50% at 25% or dental -- -- - - - -._ —. 1 i premium method Funding for plans are calculated based on anticipated utilization. If you do not see your plan desi. • please call TASC Provider Services at 1.800.422.4661 to discuss plan set up. Name of Health Insurance Carrier Is your health plan a High Deductible Health Plan? ❑ Yes ❑ No If yes, please indicate the health plan deductibles: $ Individual $ Family DirectPay Deductible Amount: Individual $ Family Maximum $ ❑ by Mem. -r ❑ by Family Aggregate DirectPay /Employer Reimburses: % From $ to $ DirectPay /Employer R-' bursed $ % From $ to $ DirectPay /Employer Reim. rsed $ % From $ to $ DirectPay /Employer Reimbur- -d $ % From $ to $ DirectPay /Employer Reimburse, Maximum DirectPay /Employer reimbursement per Individual $ Maximum DirectPay /Employer reimbursement per Family $ ❑ by Member ❑ by Family Aggrega TC-3923-080111 Employer Initial 'TASC' ma, 19