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1041400-3790950Requirements Gathering Document2017 Health Savings AccountFor: Table of Contents TOC \o "1-3" \h \z \u General Information PAGEREF _Toc462907788 \h 3Client Information PAGEREF _Toc462907789 \h 3HSA Custodian PAGEREF _Toc462907790 \h 3High Deductible Health Plan (HDHP) PAGEREF _Toc462907791 \h 3Beneficiaries PAGEREF _Toc462907792 \h 3Timing of Contributions PAGEREF _Toc462907793 \h 3Timing of Distributions PAGEREF _Toc462907794 \h 4Monthly Account Statements PAGEREF _Toc462907795 \h 4Contribution Maximums PAGEREF _Toc462907796 \h 4IDV/OFAC PAGEREF _Toc462907797 \h 4Terms & Conditions PAGEREF _Toc462907798 \h 4Failure to Establish PAGEREF _Toc462907799 \h 4Optional Investment Sweeps PAGEREF _Toc462907800 \h 5Health Savings Account Plan Details PAGEREF _Toc462907801 \h 5Payroll Posting PAGEREF _Toc462907802 \h 6Tax Forms PAGEREF _Toc462907803 \h 6Contribution Imports PAGEREF _Toc462907804 \h 6Enrollment Options PAGEREF _Toc462907805 \h 7Online Enrollment PAGEREF _Toc462907806 \h 7Enrollment Census PAGEREF _Toc462907808 \h 7Establishment Application PAGEREF _Toc462907809 \h 7Participant Forms/Information PAGEREF _Toc462907811 \h 9Distribution Request Form PAGEREF _Toc462907812 \h 9Contribution Request Form PAGEREF _Toc462907813 \h 9Beneficiary Change Form PAGEREF _Toc462907814 \h 9HSA Brochure PAGEREF _Toc462907815 \h 9HSA Investment Options PAGEREF _Toc462907816 \h 9Employer Reports PAGEREF _Toc462907817 \h 9Mobile Application PAGEREF _Toc462907818 \h 10Participant Education PAGEREF _Toc462907819 \h 10Employer Portal Contacts PAGEREF _Toc462907820 \h 11Funding Process PAGEREF _Toc462907821 \h 11Funding Contacts PAGEREF _Toc462907822 \h 12Fees PAGEREF _Toc462907823 \h 12Acceptance PAGEREF _Toc462907824 \h 13General InformationClient InformationClient Name: DBA or AKA Name:Client Address:Client Tax ID:Number of Benefit Eligible:Expected Participant Count :______________________________ Entity Type (S Corp, C Corp, LLC):Industry:Tax Year End Month and Day:State Organized:Controlled Group: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list Affiliates including Tax ID#HSA CustodianHealthcare BankHigh Deductible Health Plan (HDHP)Enrollment in a HDHP (High Deductible Health Plan) is required to contribute to a Health Savings Account. A HDHP is a plan that features higher deductibles than traditional insurance plans and can be combined with HSAs to allow participants to pay for qualified out-of-pocket medical expenses on a pre-tax basis. Please see chart below to make sure your plan qualifies.BeneficiariesIt is highly recommended that each HSA participant establishes primary and contingent beneficiaries. If no beneficiaries are designated, funds are subject to probate upon death. Please Note: If you are married and you do not name your spouse as 100% primary beneficiary, they must complete the spouse consent piece of the beneficiary form.Timing of ContributionsAll contribution types, regardless of system settings, takes 2-3 business days for deductions to post to participant’s accounts.The earliest a contribution can be posted at the start of the calendar year is 2-3 business days after the holiday.Although there is some formal and informal federal guidance on situations when HSA contributions can be reversed providing there is clear documentary evidence there was an administrative or process error, there is no formal or informal guidance on the below situations and therefore funds cannot be removed from the accountholder’s HSA when these occur:Employee has change of coverage where they cease to be HSA eligible, yet the employer continues to contribute.Employee terminates employment, but employer continues to make HSA contributions.Any circumstance where there is not clear documentary evidence that demonstrates there was an administrative or processing error.Timing of DistributionsDistributions are processed daily (Checks or Direct Deposit)Checks are mailed next dayChecks - $5.00 fee per check/Direct Deposit – FREEPayment preferences can be updated via the Participant PortalDirect Deposits are posted same day and available to participants within 1-2 business days after files are loaded.Monthly Account StatementsMonthly HSA Statements are requiredStatements are provided to participants on a monthly basisPrinted statement fee is $5.00 per printed statementParticipants can opt out of paper and into electronic statements by updating their Notification Preferences in the Participant PortalContribution MaximumsHSA Contribution and HDHP Minimum Deductible and Out-Of-Pocket LimitsHDHP Minimum Deductible Amount20132014201520162017Individual$1,250$1,250$1,300$1,300$1,300Family$2,500$2,500$2,600$2,600$2,600HDHP Maximum Out-of-Pocket Amount20132014201520162017Individual$6,250$6,350$6,450$6,550$6,550Family$12,500$12,700$12,900$13,100$13,100HSA Statutory Contribution Amount20132014201520162017Individual$3,250$3,300$3,350$3,350$3,400Family$6,450$6,550$6,650$6,750$6,750Catch-Up Contributions (age 55 or older)20132014201520162017Individual$4,250$4,300$4,350$4,350$4,400Family$7,450$7,550$7,650$7,750$7,750IDV/OFACAll HSA accounts established request IDV/OFAC Verification. IDV – Identify Verification Process – A banking requirement that comes from the US Patriot Act Bill signed into law in 2001.OFAC – Office of Foreign Assets Control – Part of the US Department of the Treasury that administers and enforces economic and trade sanctions.Document to support account validation may be requested. Participants have 60 days from account establishment to submit requested documentation before the initiation of account closure.Terms & ConditionsIn addition to passing the IDV/OFAC verification process, all participants must accept the terms and conditions. Failure to Establish If either the account does not pass IDV/OFAC verification and/or the Terms and Conditions have not been accepted after 60 days from account establishment, the account will be closed and any pending contributions will be returned to the employer.Optional Investment SweepsParticipants can opt into auto investment sweeps. Minimum threshold is $2,000. If selected, funds are automatically sweep into the investment account once the available cash balance exceeds the sweep threshold amount by $100 or more. Likewise, when the available cash balance falls below the sweep threshold by $100 or more, funds will automatically sweep back to the cash account from the investment account. If auto investments are not selected, funds will remain in a cash account.Health Savings Account Plan Details Please provide information about the required spending account plans by completing the information below. Plan Name: HSA Description: Health Savings AccountPlan Year Begin:Company Contribution: FORMCHECKBOX Yes FORMCHECKBOX NoIf Yes, Amount: $If Yes, Frequency:Debit Card Expenses Allows: FORMCHECKBOX All Expenses FORMCHECKBOX 213 Expense Only*Custom Logo on Debit Card: FORMCHECKBOX Yes FORMCHECKBOX No *Single color logo card - $500 fee, Multiple colored logo card – $1,000 + (discussion during implementation)**Terminated employees will utilize the card with the company Logo upon termination.Divisions (If applicable):**Expense Tracker Feed: FORMCHECKBOX Yes FORMCHECKBOX No **Subject to carrier guidelinesMedical Carrier:Will a post-deductible HRA also be offered in conjunction with the HSA? FORMCHECKBOX Yes FORMCHECKBOX No Will a Limited Purpose FSA also be offered in conjunction with the HSA? FORMCHECKBOX Yes FORMCHECKBOX No **if implementing Post-Deductible HRA and/or LPFSA additional paperwork and fees may apply.Payroll Posting - Please choose one of the following options belowPosting of payrolls to an HSA account takes approximately 2-3 business days to be available to participants while transmitting through the banking process. There are two options to post payroll contributions. FORMCHECKBOX Option 1 - Auto Post Once Confirmed Via File – File will import immediately and will not wait until payroll date to start banking process. Funds will take approximately 2-3 business days to post from file import date. PLEASE NOTE: Files for a future calendar year cannot be posted until the year begins or contributions could be erroneously posted to a prior tax year. Example: First payroll date in January is 1/4, the contribution file should not be posted until 1/1 or later to avoid being picked up in the prior tax year. FORMCHECKBOX Option 2 – Auto Post on Payroll Date – Files imported will wait until the payroll date (determined via a schedule) to begin the banking process. Once the payroll date arrives the 2-3 day banking process will begin. This approach is not an issue during the new calendar year. Example: First payroll date in January is 1/4, the contribution file will wait until 1/4 to begin the 2-3 day banking process, no matter when the file is actually posted.These options affect all plan types administered by Benefit Strategies, LLC including HCA, DCA, HRA and Commuter Choice plan types. If option 1 is selected, all payrolls, including CDH plans, will need to be imported. CDH payroll funds are available on the day imported and are not subject to the 2-3 business day processing time.Tax FormsHealthcare Bank’s standard delivery method for 1099-SA and 5498-SA tax forms will be electronically, through the HSA Participant Portal.Forms will be maintained in the HSA Participant Portal for seven (7) years.Form 1099-SA – DistributionsForm 5498-SA – ContributionsMust include yearly total of contributions in form 8889 with tax formsContribution Imports IMPORTANT INFORMATION: Contributions are imported into the administrative system by the Employer via the Employer Portal. Access will be sent to the contact provided whom will be responsible to process the import. All HSA contributions take 2-3 business days to clear the banking process and be available to participants.For further training and instructions on processing the HSA Import for Employer and Employee Contributions. ?Please schedule a webinar to review the process after the implementation is complete and the account has been assigned to your day to day contact.Enrollment OptionsBenefit Strategies, LLC provides various flexible enrollment options for Health Savings Accounts. Please see our available options below and check the appropriate option.Important: All participants must provide a physical address to establish an HSA account. A PO Box will not be accepted per IRS regulations. *If recurring eligibility file being sent consumers ability to make profile changes will be turned off.Online Enrollment FORMCHECKBOX Online Enrollment is the most quick and efficient way to establish a Health Saving Account. The demographic census must be provided to Benefit Strategies to allow us to set up system access before the online process begins. Please also provide the dates for the online enrollment process to be open below (needs to end prior to plan administration start). The online process includes all aspects of enrollment including accepting the Terms & Conditions and beneficiary designation options.Online Enrollment Start Date:Online Enrollment End Date:Enrollment Census FORMCHECKBOX The Enrollment Census includes all information for enrollment into a Health Savings Account, including beneficiary information. PLEASE NOTE: A separate process to accept the Terms and Conditions must be completed to finalize enrollment. Options include verifying within the Participant Portal or via paper (additional fees will apply).Establishment Application FORMCHECKBOX The HSA Establishment Application includes all information for Establish a Health Savings Account, including beneficiary information. PLEASE NOTE: A HSA confirmation email from Benefits Strategies will be sent with Account Login information and participants will be required to login and accept the Terms and Conditions in order to finalize enrollment. (Fees May Apply)Ongoing EligibilityThe HSA Establishment Application can be used for ongoing eligibility. It is the Employers responsibility to enter and update ongoing enrollments once account is set up and active. Access to the online portal will be provided at that time for ease of use to update these changes throughout the plan year. Please see your assigned Account Manager if you have any questions.Participant CommunicationsEmail notifications are sent to active participants with an email address when the letters below are generated. The email notification informs the participant the associated letter is available for viewing via the Participant Portal. Health Savings Account Participant NotificationsAdvice of Deposit for HSA DistributionEnrollment Confirmation Open-Ended Plan YearHSA Account ClosureHSA Account SummaryHSA Cash Balance NotificationHSA Contribution Maximum NotificationHSA Contribution NotificationHSA Payment Issued NotificationHSA Tax DocumentHSA Recurring Contribution CreatedHSA Recurring Contribution UpdatedHSA Recurring Contribution CancelledHSA Withdrawal NotificationCustom Logo for Spending Account Self Service Home Page Indicate if a client logo will be displayed on the Participant Portal home page. FORMCHECKBOX No: Do not display the client logo on the Participant Portal home page. FORMCHECKBOX Yes: Provide a JPG, GIF, or PNG file. The logo may be in color and must be no taller than 75 pixels and no wider than 190 pixels. Participant Forms/InformationEach form will be displayed for participants to download from the Participant Portal.Sample Health Savings Account FormsDistribution Request FormUsed to file Distributions, Rollovers (to self) or Transfers (to another custodian).Contribution Request FormUsed for the manual contribution of funds into your Health Savings Account.Beneficiary Change FormUsed to add or update beneficiary information. Also used as a Spousal Consent form if spouse is not 100% primary beneficiary. HSA BrochureInformational material for participants about a Health Savings Account.HSA Investment OptionsView the investment options currently available to HSA participants.Employer ReportsPlan Management ReportsHSA Account Detail Report HSA Employer Summary Report Reports are scheduled to run on a monthly basis.Reports are posted on the Employer Portal for access by Employer Portal users. Reports will be provided in an MS Excel format when this option is available, but a PDF may be requested instead if this format is required. Mobile ApplicationBenefit Strategies Reimbursement PlanBenefit Strategies is offering the ability for iPhone or Android users to access their account information directly through their phone. Participants can access the following information through the application: Check available balancesRequest DistributionsMake a ContributionConvenient customer service contact information Participant EducationParticipant Account Demo – Introduction to Health Savings Account:Participant Account Demo – Distribution of HSA Funds: Participant Account Demo – Contribution to HSA Account:Employer Portal ContactsEnter information below for each client Human Resources contact requiring access to view employer reports via the Employer portal. A notification will be sent to each contact with information regarding use of the Employer Portal.Please list the client Human Resources contacts below who require a logon and password for access to the employer portal.Primary Human Resources ContactName: Title: Email: Phone Number: Portal Access: FORMCHECKBOX Yes FORMCHECKBOX No Secondary Human Resources ContactName: Title: Email: Phone Number: Portal Access: FORMCHECKBOX Yes FORMCHECKBOX No Human Resources (Other) Name: Title: Email: Phone Number: Portal Access: FORMCHECKBOX Yes FORMCHECKBOX No Human Resources (Other)Name: Title: Email: Phone Number:Portal Access: FORMCHECKBOX Yes FORMCHECKBOX No Number: Funding ProcessOverviewEFT funding is required for HSA Accounts. Please complete the EFT Funding agreement attached and return to Benefit Strategies, LLC immediately to avoid delay in setup. Funds for contributions are pulled from the Employer’s bank account once the contribution has settled. Posted contributions take approximately 2-3 business days to settle. Funds are pulled daily.Unclaimed ChecksClients will address the escheatment and/or other handling of unclaimed checks that have reached the 180 day expiration date. A report of unclaimed checks will be provided upon request.Funding ContactsPlease list the client funding contacts below who should receive invoicing from Benefit Strategies, LLCFunding ContactName: Title: Email: Phone Number: Funding ContactName: Title: Email: Phone Number: FeesSet-Up Fee$WaivedRenewal Fee$WaivedAdministration Fee (Active Employee)$2.95 per account per month deducted from HSA Administration Fee (Individual Termed Account)$4.00 (month) deducted from HSAInitial Set of Debit Cards (Cards come in a set of 2)$WaivedAdditional/Replacement Cards (Cards come in a set of 2)$WaivedNon-Discrimination Testing Fee (Not required if no Employer Contribution)$400 upon requestCheck Fee$5.00 (per check) deducted from HSAAccount Closure Fee$18.00 deducted from HSAPrinted Account Summary Fee$5.00 (per account summary) deducted from HSAFee Invoicing MethodEFT RequiredSpecial Notes*As long as an employee has an active HSA account containing funds, the administrative fee will apply.AcceptanceI have reviewed and approved the contents of the Health Savings Account Requirements. I certify that the contents of the Health Savings Account Requirements have been documented in a manner that accurately reflects the Health Savings Account for Client. I also understand that after the official “sign off” of the Health Savings Account Requirements and applicable best practice recommendations are received, administration will begin based on the information detailed in the Health Savings Account Requirements.Name: Title:Date:Signature:All implementation documents, once complete, should be returned directly to your implementation specialist. Email to implementation@Employer ChecklistPlease use the provided checklist to help organize your implementation requirements.?Completed Requirements Gathering Document including plan details?Payroll Option Selected?Payroll Calendar Provided (If applicable)?Enrollment Option Selected?Online Enrollment Census Provided (If applicable)?Online Enrollment Start and End Dates established (Required if Online Enrollment selected)?Enrollment Template Provided (If applicable)?Paper Enrollment Forms Provided (If applicable)?Terms & Conditions method established (Only applicable if Enrollment Template is used)?Logo provided to Benefit Strategies (If applicable)?Informational material provided to employees (If desired)?HR Contacts listed for portal access and communications?Financial Contacts listed for billing purposes?EFT Funding Agreement completed and returned to Benefit Strategies?Requirements Gathering Document Signed ................
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