BASIC NEO

Demo HSA Open Enrollment Page

Welcome! If you will be a new 2018 participant in the Aetna High-Deductible Health Plan (HDHP), complete the information below by December 19, 2017 if you want to establish a Health Savings Account (HSA) with BASIC NEO.

If you are not already familiar with HSAs and how they work, see the information on the right to learn about the plan.

Demo HSA Open Enrollment

SSN*

Please enter without dashes
Legal first name*
Legal last name*
Date of birth*
Month
Day
Year
Address*
Street Address City State ZIP Code
Email address*
Phone number*
You may also make your own contributions to your HSA through payroll deduction. Would you like to set up payroll deductions to fund your HSA at this time?
- Yes
- No
Payroll Frequency*
HDHP Coverage Level*
The IRS considers Employee plus one HDHP as Family HDHP coverage
HSA Per Pay Deduction
Please enter a number less than or equal to 143.75.
HSA Per Pay Deduction
Please enter a number less than or equal to 287.50.
HSA Annual Deduction
($3,450 Maximum)
HSA Annual Deduction
($6,900 Maximum)
Mother's Maiden Name:*
Direct Deposit?
This Direct Deposit is not related to your payroll, but is on file with your account in the event of a reimbursement. If you request a reimbursement and do not have Direct Deposit on file, a check will be issued at a fee of $4.
Bank Name
Routing Number

Enter your 9 digit routing number.
Account Type*
Account Number
Confirmation of Eligibility

I understand that in order for me or for my Employer to contribute to a Health Savings Account (HSA) on my behalf, I must meet all of the following HSA eligibility conditions. I also understand that I must provide sufficient identifying information about my HSA to facilitate the forwarding of contributions through the Employer's payroll system to my designated HSA trustee/custodian.

1. I have single or family coverage under the Employer’s High-Deductible Major Medical Plan (the Health Plan), which I understand qualifies as a high-deductible health plan (HDHP) under Code §223(c)(2).

2. I cannot be claimed as another person's tax dependent.

3. I am not entitled to Medicare benefits.

4. If I have any health coverage other than my coverage under the Health Plan, that coverage is either (a) HDHP coverage (see Paragraph A below) or (b) permitted non-HDHP insurance or coverage (see paragraph B below).

A. Qualified HDHP Coverage is the Following:

* Self-Only Coverage: To qualify as HDHP coverage, it must have a deductible of at least $1,350 for 2018 (indexed for inflation) before any coverage is provided for eligible medical expenses (other than preventive care). In addition, the sum of the deductible and other annual out-of-pocket expenses that the insured is required to pay (such as co-pays and co-insurance, but not premiums) cannot exceed $6,750 for 2018 (indexed for inflation).

* Family Coverage: Family coverage is any coverage other than self-only coverage. Family HDHP coverage must have a deductible of at least $2,700 for 2018 (indexed for inflation) before any coverage is provided for eligible medical expenses (other than preventive care). No amounts can be paid (other than for preventive care) until the minimum required family deductible has been satisfied (i.e., there cannot be an individual deductible within the family deductible that is less than the required minimum of $2,700 for 2018, (indexed for inflation).
In addition, the sum of the deductible and other annual out-of-pocket expenses that the insured is required to pay (such as co-payments and co-insurance) cannot exceed $13,300 for 2018 (indexed ).

B. Permitted Non-HDHP Insurance or Coverage Is the Following:
* Insurance in which substantially all of the coverage relates to liabilities incurred under workers' compensation laws, tort liabilities, liabilities relating to ownership or use of property (e.g., homeowner or auto insurance), or similar liabilities as specified by the IRS; * Insurance for a specified disease or illness (e.g., cancer insurance); * Insurance that pays a fixed amount per day (or other period) of hospitalization (e.g., hospital indemnity insurance); or * Coverage for accidents, disability, dental care, vision care, or long-term care. Examples of impermissible coverage that would make me ineligible include coverage under my spouse's or domestic partner's non-HDHP health plan, general-purpose health flexible spending arrangement (health FSA), or general-purpose health reimbursement arrangement (HRA). I certify that all of the statements above are true. I agree that I will notify the Employer immediately in writing if I cease to meet any of these conditions. I also understand that the Employer may make contributions to an HSA on my behalf on the basis of my certification and that the Employer's HSA contributions and my own HSA contributions (if any) are subject to certain aggregate limits under federal tax law. I agree that my Compensation will be reduced by the amount of my required contribution for the Benefits that I have elected under the Plan and that such Salary Reductions will continue for each pay period until this Agreement is amended or terminated. I also understand that submission of this election does not initiate my coverage under any Medical or Dental Insurance policies. I must complete separate Medical and/or Dental Insurance enrollment forms to start my coverages. Salary Reductions under this Agreement reduce my Compensation for Social Security tax purposes. This means that my Social Security benefits could be decreased because of the decreased amount of compensation that is considered for Social Security purposes. I have read and agree to the terms of participation and to any applicable eligibility requirements as set forth in this Agreement. Any previous election and agreement under the Plan relating to the same Benefits, including any prior Salary Reduction Agreement, is hereby revoked. This election can be changed at any time, for any reason, effective no later than the first day of the calendar month after the change request is filed.

Please read and confirm you agree with terms.
You may make changes to your online HSA election any time up to the December 16, 2017 enrollment deadline. Make the changes you want and resubmit your election. Your prior election will be overwritten.*
- Click to confirm eligibility for the HSA
You may also enroll in a Limited Purpose Health FSA (reimburses only vision and dental expenses) or the Dependent Care FSA. If you would like to enroll in either of those plans, you will be re-directed to a new enrollment site on the next page.
Review your HSA application info above, and then click "Submit."

Welcome to BASIC - CA and Akron, OH Locations

Demo HSA Open Enrollment Page

Demo HSA Open Enrollment

You may also enroll in a Limited Purpose Health FSA (reimburses only vision and dental expenses) or the Dependent Care FSA. If you would like to enroll in either of those plans, you will be re-directed to a new enrollment site on the next page.

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