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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Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. Emergency Room Care Services administered for conditions meeting the definition of an emergency.

Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. 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 Gsa, long-term care, and medical and prescription drug expenses as a retiree, including Medicare premiums. Just call or send us sha e-mail.

Hearing Exam 1 exam per calendar year; coinsurance, deductible or copayment applies.

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You can contribute money to your HSA on a pretax basis through payroll deductions. You 3032 see a complete list of eligible expenses at www. Please call Aetna toll free at or contact the Benefits Team at for additional information. The chart below provides a brief overview of the benefits offered. You will be responsible for out-of-network precertifications.

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Outpatient Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification. You can manage your HSA at www.

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

Nonemergenices are not covered. Physician Services Performed in an Office Setting Primary care office visits for routine care; diagnosis and treatment of an illness or injury. The amount you must pay if you do not call Medical Management at before hospitalization and certain types of surgery, or fail to follow concurrent review procedures. Hospice Care Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies. You must call 3302 at at least 14 days in advance of nonemergency treatment to request precertification or you will have no coverage.

The Prescription Drug Program is included with this plan. Dialysis, Chemo, and Radiation Services.

Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home. The amount you pay each year before the plan begins covering particular medical expenses. It is important to keep in mind that you can only use HSA funds after you have contributed them. Durable Medical Equipment Purchase or Rental Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home.

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Inpatient Mental Health and Substance Abuse 4. Primary care office has for routine care; diagnosis and treatment of an illness or injury.

Deductible The amount you pay each year before the plan begins covering particular medical expenses. Anesthesia and use of an operating room or related facility in a hospital or authorized institution.

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

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. Outpatient Lab Services for Diagnosis or Treatment. Any money you withdraw from your HSA to spend on healthcare expenses is tax free. Family deductible is cumulative. Y hxa can count on support from knowledgeable and responsive HR jsa when you have a benefits question or problem.

The HSA allows you to accumulate savings and carry over year after year. The money you put into an HSA is deducted from your pay before taxes. Your unused balance accumulates year after year. Plan pays for up to seven visits during first year for well-child 33302, PSA, and tests and well—woman care office visits.