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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Inpatient Mental Health and Substance Abuse 4. Outpatient Mental Health and Substance Abuse Outpatient treatment; crisis intervention; detoxification. Family deductible is cumulative.

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

You can contribute money to your HSA on a pretax basis through payroll deductions. Anesthesia and use of an operating room or related facility in a hospital or authorized institution.

Nonemergenices are not covered. 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 COBRA, long-term care, and medical and prescription drug expenses as a retiree, including Medicare premiums.

Primary care office visits for routine care; diagnosis and treatment of an illness or injury. The money you put into an HSA is deducted from your pay before taxes. 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. Physician Services Performed in an Office Setting Primary care office visits for routine care; diagnosis and treatment of an illness or injury.

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Y ou can count on support from knowledgeable and responsive HR staff when you have a benefits question or problem.

Outpatient Lab Services for Diagnosis or Treatment. Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies.

Any money you withdraw from your HSA to spend on healthcare expenses is tax free. Please call Aetna toll free at or contact the Benefits Team at for additional information. Deductible The amount you pay each year before the plan begins covering particular medical expenses. Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. Durable Medical Equipment Purchase or Rental Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home.

You can see a complete list of eligible expenses at www. The HSA allows you to accumulate sha and carry over year after year. The amount you pay each year before the plan begins covering particular medical expenses. Emergency Room Care Services administered for conditions meeting the definition of an emergency.

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Your unused balance accumulates year after year. The Prescription Drug Program is included with this plan. The chart below provides a brief overview of the benefits offered. 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.

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Hospice Care Room and board in hsw licensed facility or in your home; services of medical personnel; others services and supplies.

Dialysis, Chemo, and Radiation Services. Just call or send us an e-mail. Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits. You can manage your HSA at www.

You must call Aetna at at least 14 days in advance of nonemergency treatment to request precertification or you will have no coverage.

Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home. You will be responsible for out-of-network precertifications. Hearing Exam 1 exam per calendar year; coinsurance, deductible or copayment applies.

It 33302 important to keep in mind that you can only use HSA funds after you have contributed them.