ACS Mellon Health Savings Account Employer Discovery Document / Set-up Form

Transcription

1 Guidelines for completing this ACS Mellon HSA : Introduction If you are an employer, please contact your agent or broker for assistance in processing this ACS Mellon HSA Employer Discovery Document request. If you do not have an agent or broker, please contact your Blue Cross and Blue Shield of Florida (BCBSF) sales representative for assistance. If you are an agent or broker, please follow the Guidelines in the section below to determine further action. It is important that these procedures be followed in a timely manner to avoid having issues with the ACS Mellon HSA account set-up. Please complete this form as instructed and send to BCBSF for handling only when indicated in the guidelines below. Once BCBSF completes the initial set-up, ACS Mellon will contact the Funding Contact indicated on this form with next steps as appropriate. Guidelines These guidelines only apply if the employer is a) opting to have a HSA health plan this year, and b) is choosing the ACS Mellon banking arrangement. Answering these questions will enable you to determine the appropriate action to take for the timely set-up of the HSA account when the above conditions apply. 1. Is this employer new to ACS Mellon? If yes, proceed to question 4. If no, proceed to question Is this employer currently using BCBSF as a health provider? If yes, no further action is required you have indicated you already have a BCBSF ACS Mellon HSA Employer Account. If no, proceed to question You have stated this employer is currently using ACS Mellon but is not presently using BCBSF as the employer s health provider. If this is correct, please read the CRITICAL Instructions below. Special action is required if the employer presently has an ACS Mellon HSA Employer Account for its members, but BCBSF is not currently the employer s health provider. Please have the employer notify the ACS Mellon Employer Support team at (201) when this situation occurs. This is needed so that ACS Mellon may coordinate with BCBSF to perform required transition activities. Rev. April

2 4. Is this employer a Mid-Large Group (e.g. Eligible = 51+)? If yes, you will need to complete this ACS Mellon HSA Employer Discovery Document in its entirety. Please provide it to your BCBSF sales representative with your employer s enrollment package to help prevent delays in processing your request. Once BCBSF has processed your form, the employer will be notified via by ACS Mellon of account information and payroll instructions. If no, proceed to question Is this a one man Small Group (e.g. Eligible = 1)? If yes, no further action is required you have indicated the employer eligible = 1 and these one man Small Groups do not require the ACS Mellon HSA Employer Discovery Document. BCBSF will process your member, then the member will receive an ACS Mellon welcome kit when member set-up has been completed. If no, proceed to question Is this a Small Group (e.g. Eligible = 2-50) and you recently submitted the ACS Mellon information contained on this document electronically on accessblue into the Small Group Proposal Tool (SGPT) or into the Small Group Renewal Tool (SGRT)? If yes, no further action is required you have indicated you already have submitted for a BCBSF ACS Mellon HSA Employer Account via one of the accessblue systems indicated above. If no, proceed to question You have stated this employer is currently a Small Group (e.g. Eligible = 2-50) and you did not submit ACS Mellon or the Small Group electronically using the accessblue systems indicated previously. You will need to complete this ACS Mellon HSA Employer Discovery Document in its entirety. Please mail in this form with your employer s enrollment package to BCBSF to help prevent delays in processing your request. Once BCBSF has processed your form, the employer will be notified via by ACS Mellon of account information and payroll instructions. Rev. April

3 AFTER reading and answering the questions in the Guidelines located on pages 1 & 2, IF it is determined that a new ACS Mellon HSA account set-up is required, the next step will be to either: 1. Enter the information collected below electronically into the final quote into SGPT or SGRT on accessblue (if used); or 2. Return the form with your employer s enrollment package to BCBSF (if accessblue is not used). te: It is only necessary to return Pages 3-5 with your employer s enrollment package when applicable. For questions about whether this form needs to be completed or mailed based on the Guidelines provided previously, please contact your BCBSF sales representative or the BCBSF Agent Service Center. For questions regarding the payroll process or if you need assistance in filling out the remainder of the form below, please contact the HSA Employer Support Team at (201) Health Plan Name Blue Cross and Blue Shield of Florida (BCBSF) Health Plan Customer ID 052 General Employer Information - All information must be completed in its entirety to prevent delays. Employer Name Employer Address Line 1 Employer Address Line 2 Employer City Employer State Employer ZIP Code Employer Funding Contact Name Employer Funding Contact Phone Employer Funding Contact Employer Technical Contact Name Employer Technical Contact Phone Employer Technical Contact Rev. April

4 Broker Agency Name ACS Mellon Health Savings Account Broker Contact Name Broker Contact Number Broker Contact 1) High Deductible Health Plan Effective Date 2) Number of Eligible Employees 3) Expected Number of HSA Accounts 4) Who pays account set-up fees? 5) Who pays account maintenance fees? Employee Employee 6) Will the employer send contributions (employer and/or employee) to ACS Mellon on behalf of the employees? If no, please select option 7c (N/A) in question 7) below. te: Employees always have the option of making deposits to their HSA themselves via deposit slips. 7) How will ACS Mellon receive employee contributions and instructions? Please refer to the ACS Mellon Employer Guide for details on the funding/contribution options below. Employers with 50 or less employees should use option 7a, 7b, or 7c. 7a: Payroll on the Web (POW!) Method: A lump sum transfer of funds accompanied by allocation instructions entered and submitted via POW! (Payroll on the Web) application. te: This option is standard for employers with less than 75 employees and recommended for employers of any size that anticipate less than 75 member accounts. 7b: ACH Direct Deposit (via Individual ACH) Method: Employer transmits funds directly to each employee s account via the Automated Clearing House (ACH). te: The employer will need to set this up with their payroll administrator or banking institution. 7c: N/A: Employer will not transfer employee contributions to Mellon. Employees will only deposit funds via Mellon deposit slips. 7d: Excel-to-Text File with FTP Connectivity: A lump sum transfer of funds accompanied by allocation instructions in a set Excel spreadsheet format. te: This approach requires FTP connectivity and four to eight weeks set-up time. 7e: Flat File with FTP Connectivity: A lump sum transfer of funds accompanied by allocation instructions in our HSA Payroll Distribution File format. te: This approach requires FTP connectivity and four to eight weeks set-up time. Rev. April

5 8) If funding will be made via a Lump Sum Contribution (Options 7a, 7d, or 7e), what method will the employer use to transmit the lump sum payment? te: Option 7b is direct ACH into the members account. Wire Transfer ACH Check N/A te: Please select only one of the options above. If more than one option is needed, then please contact the HAS Employer Support Team at (201) for additional assistance. Rev. April