Health Reimbursement Arrangement (HRA) Implementation Packet Thank you for your interest in the Health Reimbursement Arrangement (HRA) benefit plan administration services offered by Allied Benefit Systems Inc. This packet contains all of the necessary information in order for Allied to install and begin servicing your plan. Overview of a Health Reimbursement Account With an HRA, the employer funds an account from which the employee is reimbursed for qualified medical expenses, such as copays, deductibles, prescriptions, medical insurance, chiropractic care. Reimbursements are not taxed to the employee and are deductible by the employer. The most common use of an HRA is in combination with a High Deductible Health Coverage (HDHP) Plan. HRAs can enhance a company s benefit package while helping to contain costs and boost employee morale. For example, you can combine your HRA with a higher-deductible health insurance plan. The employer benefits from reduced insurance cost, but the effect to the employee is lower out of pocket costs with the HRA rather than offering only the HDHP plan. Please review the Plan Set-Up Options Check List on the following page. Instructions are included for each page. All of the items included in this packet are used to build your plan and process the claims to your specific plan design. Please review carefully. For assistance completing any of the enclosed paperwork, contact your Sales Agent or your Account Manager at 1-888-292-0272 Please sign and complete the following documents: Health Reimbursement Account Application Worksheet Health Reimbursement Account Banking Information Page Health Reimbursement Account Signature Collection Form Banking MICR Sheet from your Financial Institution A Signature Card from your Financial Institution Submit completed HRA Implementation Packet using the following options: Submit completed documents with your National General Benefits Solutions Self-Funded Plan Paperwork or FAX: (312) - 602-6267 Email: NGBS.Implementation@alliedbenefit.com US Mail: Attn: NGBS HRA Department 200 W. Adams Suite 500 Chicago, IL 60606 Please allow 15-20 business days to build your plan as specified in this packet. Allied looks forward to providing your organization world-class service and support for years to come! Sincerely, Allied Benefit Systems, Inc Version 12.2015
Allied New HRA Plan Implementation Workbook Health Reimbursement Account Administrative Fees: $5 PEPM Total Number of Employees Enrolled Health Reimbursement Account Set-up Fee: Waived CLIENT INFORMATION Group Name: Allied Group # To be completed by Allied Address: Federal Tax ID #: Suite #: City: SIC #: Multiple Locations State: Zip: Separate Billing Address: Allied Effective Date: Main Phone: Main Fax: Primary Group Contact: Phone: Email: Group Contact: Phone: Email: Sales Rep. Contact: Phone: Email: Writing Agent Contact: Phone: Email: HRA PLAN INFORMATION 1. Do you have an existing Health Reimbursement Arrangement? Yes No 2. What is your major medical deductible coverage period? Calendar Year Plan Year **If your plan design will be reimbursing annual health insurance deductibles or coinsurance expenses, the HRA Plan Year must match the deductible cycle (e.g. deductible cycle is a calendar year 1/1 12/31 or plan year 6/1 5/31). 3. If you have an existing HRA: What is the HRA Original Effective Date: / / 4. If you do NOT have an existing Health Reimbursement Arrangement, what is the HRA Effective Date elected: / / 5. The HRA Reimbursement will be mailed to: Member (Employee) Provider Important Notes: *Eligible Expenses: The definition of Eligible Expenses under the Health Reimbursement Plan are Medical and Prescription Drugs benefits as outlined in the Assurant Self-Funded Product Summary Plan Description (SPD) * No Rollover. The Allied Administrated Health Reimbursement Plans do not permit rollover of any balance remaining in the HRA at the end of the coverage period. *Self-employed individuals (e.g., sole proprietors, partners, and more-than-2% Subchapter S corporation shareholders) may not participate in an HRA on a tax-favored basis. Please indicate below if any members of your group are not able to recieve the HRA Benefit:
Plan Design #1-100% Reimbursement Plan: HRA Benefit reimburses 100% of claims applied to the medical deductible Employee Pays Example () n/a Yes $1,000 $2,000 Yes $0 Yes $0 Employee Pays Example () $1,000 No $2,000 $0 No $0 No $0 Plan Design #3 - Co- Deductible Plan Design: pays a percentate of all claims applied to the medical deductible up to a specified maximum Percent of HRA Benefit Total HRA Benefit paid by Employee Pays Total Employee Deductible Example 1 () $1,000 No 80% $1,500 $500 $1,500 Example 2 () n/a Yes 60% $1,000 $2,000 $2,000 Donut Hole Options can only be applied in the following payment order: 1. Employee pays a portion of their deductible at 100% of specified amount 2. HRA Benefit then pays a up to a specified amount of the deductible 3. Employee is responsible for remaining deductible amountat 100%. Plan Design #4 - Total OOP (Deductible and OOP Reimbursement) Plan Design: pays a percentate of all claims applied to the medical deductible and out-of-pocket (OOP) up to a specified maximum Total Out of Pocket Eligible for HRA Benefit (OOP - ) Percent of HRA Benefit Total HRA Benefit paid by - (in dollars) Employee Portion of Max OOP (in dollars) Total Employee Responsibility (HRA Ded + EE Max OOP Portion) Example 1 () $1,000 No 4000 80% $2,500 $1,500 $2,500 Example 2 () n/a Yes 5000 60% $3,000 $2,000 $2,000 Plan Option Choosen: Plan Limit Major Medical Deductible Major Medical Out of Pocket (Deductible is included in Max OOP) Allied HRA Plan Implementation Workbook **Please complete the HRA Plan Design Worksheet below and ensure all details of your HRA Plan Design are included. HRA PLAN OPTIONS Plan Limit Major Medical Deductible Major Medical Out of Pocket Plan Limit Major Medical Deductible Major Medical Out of Pocket HRA Reimbursement Amount Plan Design #2 - Employee Plan Design: Employee pays a portion of their medical deductible at 100% of specified amount; HRA Benefit then pays remaining amount of medical deductible at 100% HRA Reimbursement Amount Plan Limit Major Medical Deductible Major Medical Out of Pocket Donut Hole Options can only be applied in the following payment order: 1. Employee pays a portion of their deductible at 100% of specified amount 2. HRA Benefit then pays a up to a specified amount of the deductible 3. Employee is responsible for remaining deductible amount at 100%. 4. Percent of HRA Benefit MUST be the same for the Deductible and OOP Reimbursement
Allied HRA Plan Banking Information Important Note: The following items MUST BE INCLUDED with ALL HRA Implementation Packets: *Completed MICR Sheet *Completed Signature Card from your Banking Institution *Starting Check Number for your HRA Account: Full Legal Business Name / Plan Sponsor: Physical Address City State Zip Mail Address: (if different) City State Zip Primary Contact Name: Phone # Fax # Email Address Checking Account Information Name of Holder of the HRA Account: HRA Bank Account Name: Checking Account #: Routing # / Transit #: (bank #) Fractional #: (top right hand corner of check) Starting check # Bank Contact for testing purposes: Phone #: Address: City/State/Zip Second Signature Required? Yes/No On claims exceeding what amount? $ Checks are mailed directly to: Provider Employee Name of the Check Signer: Signature to appear on checks: *please provide clean copy of client signature on next page. Checks print: Day of the week Checks will Print: Weekly Wednesdays Check register emailed to? All Check Register Payments will be Auto Released Name: Email: Name: Email: I hereby authorize Allied Benefit Systems, Inc., Metavante Bank or its agent(s) to initiate ACH transfer entries for the above depository. Signature: Date: Print: I hereby authorize Allied Benefit Systems, Inc., to obtain the necessary information from my Financial Institution to complete the banking set-up for a Health Reimbursement Account. Signature: Date: Print:
Date: Allied Benefit Systems, Inc. Group Name: Group Number: Signer s Name (please print): Please Mail Original to: Attn: NGBS HRA Department Allied Benefit Systems 200 W. Adams Street Suite 500 Chicago, IL 60606 Signature Collection Form You MUST use a black, fine-point felt tip pen Only one signer (sign same name 5 times) per form All five samples must be signed Stay within the box. Anything outside of the box will be truncated Do not fold this document return mail in flat Sample Signature 1 Sample Signature 2 Sample Signature 3 Sample Signature 4 Sample Signature 5
Allied New HRA Plan Implementation Agent Checklist Completed HRA Application Worksheet Completed HRA Plan Options Worksheet Completed HRA Banking Information Page MICR Sheet from the Group's Financial Institution Signature Card from the Group's Financial Institution Completed (with 5 Signatures) Signature Collection Form HRA Accumulators - for Calendar Year Plans only