1.  I am not covered by any other medical plan (excluding an IRS-qualified HDHP), including my spouse/domestic partner’s employer coverage, Medicare, Veterans’ Affairs coverage, Tricare, or Indian Health Services coverage.

·  If I am going to be eligible for Medicare, VA coverage, Tricare or Indian Health Services anytime during 2015 I will notify my employer prior to 1/1/15.

·  If I become covered by other medical coverage, I agree to notify my employer immediately. I understand that any amount contributed to my HSA if I become ineligible is taxable to me.

2.  Neither myself nor my spouse can be enrolled in a Section 125 pre-tax plan (sometimes referred to as a Healthcare FSA for Medical Spending Account) through their employers unless it is a limited plan that reimburses only for dental and vision. My spouse also can’t be enrolled in a Health Reimbursement Arrangement (HRA) unless it is a limited plan that reimburses only for dental or vision expenses.

3.  I understand that if I am covered by my spouse’s traditional health care plan (excluding an IRS-qualified HDHP) after January 1, 2015 and I choose not to waive coverage (or my spouse is unable to drop me from coverage under their plan until their next open enrollment period) that I will be ineligible to receive funds from my employer for the purpose of establishing a HSA. I will, however, still be covered by the County’s HDHP. Pro-rated contributions can be made to your HSA account once you provide proof that you have lost other coverage and are eligible to receive them.

4.  I understand that myself and/or any family member who is covered by this HDHP and enrolled in Medicare Part A or B must enroll in Medicare Part D when initially eligible for Medicare, or upon the effective date of coverage under this plan, or he/she may pay a late enrollment penalty for life.

5.  I understand that I cannot use HSA funds on a tax-free basis to reimburse healthcare expenses for children over 18 (or 24 if in a qualifying school) that do not qualify as an IRS dependent.

6.  If I enroll a domestic partner on my medical plan, I understand I cannot use HSA funds on a tax-free basis to reimburse his/her healthcare expenses unless he/she is my legal spouse (as defined by federal law). I also understand that the contributions in excess of the maximum allowable contributions for a single filing status may be taxable under IRS guidelines, and should consult a tax advisor for guidance.

7.  I understand that I should have my Healthcare Provider(s) submit claims for covered expenses to Regence for Processing. I understand I should wait for the Explanation of Benefits from Regence before paying my provider since the amounts owed will typically be discounted from the amounts billed due to the Regence provider contracts.

8.  I understand that the single or family deductible must be met before benefits are paid by the HDHP for anyone covered by the plan.

9.  I understand that the contributions in excess of the maximum allowable contributions for a single filing status may be taxable under IRS guidelines, and should consult a tax advisor for guidance.

10.  I understand that Baker County cannot contribute an amount to the HSA that will exceed the deductible. Baker County will make contributions to the HSA according to your union contract or policy. If I terminate my employment prior to December 31st of each year, I understand I am liable for the taxes for the months that were pre-funded by my employer (unless I continue my coverage through COBRA, retiree) under the HDHP for the remainder of the year.

11.  I understand the annual contribution limits for both employee and employer contributions is $3,350 for employee only coverage and $6,650 for family coverage. I further understand that I can contribute an additional $1,000 per year if I am 55 years or older (up until Medicare eligibility).

______I have read this overview and the enrollment materials provided to me by my employer regarding rules governing contributions and reimbursements from my HSA account. If I accept contributions from my employer for the purpose of establishing a Health Savings Account and I am not eligible to receive them or if I am reimbursed for any ineligible medical expenses, I understand I am liable for any taxes and penalties that may be incurred.

I do not want to contribute an amount at this time.

I want to STOP my contribution.

I want to sign up or change my current contribution (enter the amount below).

I elect to contribute $______per pay check to my HSA account. I understand that any contributions will be deducted from my pay on a pre-tax basis. Contributions that you make to the plan can be changed at any time by filling out this form and turning it in to Admin Services.

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