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HSA Enrollent and Change Form HSA Comparison Chart
HSA Banking Institutions conventry UMB Bank Website HSA Contribution Information UMB HSA Enrollment Form Agreement UMB HSA Instruction Letter
Preferred Health Systems Health Equity Website

Please Note: Health Equity does not require enrollment through an HSA enrollment form. Health Equity will work with PHS to allow automatic enrollment. PHS simply sends HE a data file and HE then sets everyone up with an HSA account.


UMR American Chartered Website HSA Enrollment Guide UMR American Chartered HSA Application
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Health Savings Account
with Plan C

**IMPORTANT - You are not eligible for an HSA if any of the following IRS Guidelines apply to you:

  • You are enrolled in Medicare
  • You are covered by another health plan that is not a QHDHP
  • You are enrolled in the Health Care Flexible Spending Account or are covered by a spouse's Health Care Flexible Spending Account
  • You are covered by TRICARE and TRICARE for Life
  • You are covered by VA benefits and have used the VA medical services within the three-month period immediately preceding your enrollment

Through the Health Savings Account (HSA) you can set aside pre-tax money to pay for certain eligible health care expenses for yourself, your spouse or your dependent children (even if they are not covered on Plan C).

Here are a few examples of the types of expenses that are considered qualified medical expenses for HSAs:

  • Medical and dental deductibles
  • Medical and dental coinsurance
  • Medical, dental and prescription drug copayments
  • Dental and vision expenses
  • Over-the-counter medications, such as aspirin, cold medicines, antacids and cough supplements
  • Contact lens solution or cleaners
  • Long Term Care premiums

Both you and your employer contribute money to the HSA. The maximum annual contribution to an HSA for 2010 is $3,050 for single coverage and $6,150 for dependent coverage. These maximums apply to the sum of your contributions and your employer's contributions, so your maximum annual contribution for 2010 is $2,150 for single coverage and $4,800 for dependent coverage. Members between ages 55 and 65 can make additional "catch up" contributions to their HSA each year until they enroll in Medicare. The additional catch-up contribution for 2010 is $1,000.

Your HSA belongs to you and is "portable," which means that even if you leave your employer, you take your account with you and can use it to pay eligible medical expenses. Your HSA account must be connected to a Qualified High Deductible Health Plan in order to resume making personal contributions to it.

Your HSA is administered by the banking institution that corresponds with the health plan vendor you selected. To complete the enrollment process for 2010, you must set up your HSA bank account with the applicable banking institution before December 31, 2009. Your banking institution will mail you an HSA debit card and account number that you may use to set up your online account access where you may view your account activity and learn more about your account and investment options. Since the account belongs to you, you are responsible for the account fees, so be sure to review the HSA investment options and fees that apply to each banking institution.

Important: Due to IRS regulations, you cannot participate in both the HSA and the Health Care FSA during the same plan year.