3302 HSA PDF

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TRANSFER REQUEST PART 1. RECIPIENT PART 2. ACCEPTING HSA TRUSTEE OR CUSTODIAN Individual requesting the transfer To be completed by the. – HSA Contribution / Investment. Open PDF SU – HSA Beneficiary Designation Addendum. Open PDF – HSA Transfer Request. Open PDF. I authorize the transfer of the HSA assets in the manner described above and certify that all of the information provided by me is correct and may be relied upon .

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Anesthesia and use of an operating room or related facility in a hospital or authorized institution. Nonemergenices are not covered.

Please call Aetna toll free at or contact the Benefits Team at for additional information.

Consumer Directed Health Plan – Office of Human Resources – Consumer Directed Health Plan

Your unused balance accumulates year after year. The amount you hxa pay if you do not call Medical Management at before hospitalization and certain types of surgery, or fail to follow concurrent review procedures. Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits.

The chart below provides a brief overview of the benefits offered. Physician Services Performed in an Office Setting Primary care office visits for routine care; diagnosis and treatment of an illness or injury.

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You will be responsible for out-of-network precertifications.

Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home.

Y ou can count on support from knowledgeable and responsive HR staff when you have a benefits question or problem.

Durable Medical Equipment Purchase or Rental Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home. Deductible The amount you pay each year before the plan begins covering particular medical expenses. Inpatient Mental Health and Substance Abuse 4. Dialysis, Chemo, and Radiation Services. Hospice Care Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies. You can manage your HSA at www.

Primary care office bsa for routine care; diagnosis and 33302 of an illness or injury.

Family deductible is cumulative. Emergency Room Care Services administered for conditions meeting the definition of an emergency.

Consumer Directed Health Plan (CDHP) & Health Savings Account (HSA)

You can contribute money to your HSA on a pretax basis through payroll deductions. You must call Aetna at at least 14 hhsa in advance of nonemergency treatment to request precertification or you will have no coverage. Outpatient Lab Services for Diagnosis or Treatment. Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies.

Preventive Care Preventive physicals, well-child care including scheduled immunizations Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits.

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The Prescription Drug Program is included with this plan. The amount you pay each year before the plan begins covering particular medical expenses. Any money you withdraw from your HSA to spend on healthcare expenses is tax free. The HSA allows you to accumulate savings and carry over year after year. Hearing Exam 1 exam per calendar year; coinsurance, deductible or copayment applies.

The money you put into an HSA is deducted from your pay before taxes. You can see a complete list of eligible expenses at www.

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It is important to keep in mind that you can only use HSA funds after you have contributed them. Outpatient Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification. Just call or send us an e-mail. Qualified medical expenses that may be paid through your HSA on a tax-free basis include most medical care and services; dental and vision care; prescription drugs; and premiums paid for COBRA, long-term care, and medical and prescription drug expenses as a retiree, including Medicare premiums.

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