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Health Savings Account

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Setup Fee FREE

Monthly Fee FREE

Minimum Balance Required $0.00

Debit Card FREE

Debit Card Transactions FREE

Online Banking FREE

Online Bill Payment FREE

Starter Checks FREE

Box Of 150 Traditional Checks $ 14.25

Contributions Limits Individual Policy Family Policy

2012 $3,100 $6,250

Catch Up

(over age 55)

$1,000 $1,000

Balance AER

$0.01 -$999.99 0.50%*

$ 1,000-$4,999.99 1.00%*

$ 5,000- and Over 1.25%*

*Rate subject to change

www .CountyNationalBank.com

FOR MORE INFORMli.TION PLEASE CONTACT THESE OFFICES:

Hillsdale Office: (517)439-4300 Hillsdale Office Toll Free: (888)322-1088 Hanover Office: (517)563-8332 Homer Office: (517)568-4448 Hudson Office: (517)448-8957 Jackson Cortland Office: (517)768-7200 Jackson Wisner Office: (517)783-1500 Jackson Horton Office: (517)782-2500 Jonesville Office: (517)849-9949 Litchfield Office: (517)542-2932 Somerset Center Office: (517)688-4433 Spring Arbor Office: (517)750-40 11

Healthcare Spending Driven By YOU

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COUNTY NATIONAL BANK

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www.CountyNationaiBank.com 1- 888-322-1088

Intended to cover serious illness or injury once the deductible has been met.

Used to cover small and

routine medical expenses

until the deductible is met.

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Crutches Dental treatment Diagnostic devices

Disabled dependent care expenses Drug addiction therapy

Drugs (prescription) Eyeglasses Eye surgery

Fertility enhancement Guide dog

Health institute

Health Maintenance Organization (HMO) Hearing aids and batteries

Home care Hospital services Laboratory fees

Lead-based paint removal Legal fees

Lifetime care- advance payments

Lodging (away from home for outpatient care) Long-term care

Meals (at medical facility during medical care) Medical conferences (if concerning chronic illness) Medical information plan

Medical services Medicines (prescription)

Mentally retarded, special home for Nursing home

Nursing services Operations Optometrist

Organ transplant (including donor' s expenses) Osteopath

Oxygen and oxygen equipment Prosthesis

Psychiatric care

Wig X-ray

Non-Reimbursable Medical Expenses:

Babysitting, childcare and nursing services for a healthy baby Controlled substances

Cosmetic surgery and procedures Dancing lessons

Diaper service

Electrolysis or hair removal Flexible spending account

Funeral, cremation or burial expenses Future medical care

Hair transplant Health club dues Household help

lllegal operations and treatments Insurance premiums

Maternity clothes

Medicines and drugs from other countries Nutritional supplements

Over the counter medications Personal use items

Swimming lessons Teeth whitening Veterinary fees

Weight-loss program (non-disease)

Please note Eligible Exp enses may not apply to your insurance deductible. Review your plan for details. This listing of elig ible and non elig ible

exp enses is a sample. For more inf ormation please review IR S Publication 502 "Medical and Dental Expenses ". This publication can be f ound at

the internal Revenue Service's website www.irs.gov

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COUNTY NATIONAL BANK

Wltat is an HSA?

An HSA is a tax-exempt trust or custodial account established exclusively for the purpose of paying qualified medical expenses of the account beneficiary who, for the months for which contributions are made to an HSA, is covered under a high-deductible health plan.

Wlto is eligible for a Hea/tlt Savings Account?

To be eligible for a Health Savings Account, an individual must be covered by a High Deductible Health Plan (HDHP), must not be covered by other health insurance (does not apply to specific injury insurance and accident, disability, dental care, vision care, long-term care), is not enrolled in Medicare, and cannot be claimed as a dependent on someone else's tax return.

Wlto is eligible to establish an HSA?

An eligible individ ual can establish an HSA. An eligible individual means, with respect to any month, any individual who:

is covered under a high-deductible health plan (HDHP) on the first day of such month;

is not covered by any other health plan that is not an HDHP (with certain exceptions for plans providing certain limited types of coverage);

is not enrolled in Medicare and;

may not be claimed as a dependent on another person's tax return.

Wit at kind of otlter ltea/t/1 coverage makes an individual ineligible for an HSA?

Generally, an individual is ineligible for an HSA if the individual, whi le covered under an HDHP, is also covered under a health plan (whether as an individual, spouse, or dependent) that is not an HDHP.

How does an eligible individual establislt an HSA?

Beginning January I, 2004, any eligible individual can establish an HSA with a qualified HSA trustee or custodian, in much the same way that individuals establish IRAs with qualified IRA trustees or custodians. No permission or authorization from the Internal Revenue Service (IRS) is necessary to establish an HSA. An eligible individual who is an employee may establish an HSA with or without involvement of the employer.

Wlto is a qualified HSA trustee or custodian?

Any insurance company, any bank, or any credit union can be an HSA trustee or custodian. In addition, any other person already approved by the IRS to be a trustee or custodian of lRAs is automatically approved to be an HSA trustee or custodian.

Does tlte HSA have to be opened at tlte same institution tit at provides tlte HDHP?

No. The HSA can be established through a qualified trustee or custodian who is different from the HDHP provider. Where a trustee or custodian does not sponsor the HDHP, the trustee or custodian may require proof or certification that the account beneficiary is an eligible individual, includ- ing that the individual is covered by a health plan that meets all of the requirements of an HDHP.

Wlto may contribute to an HSA?

Any eligible individual may contribute to an HSA. For an HSA established by an emp loyee, the employee, the employee' s employer or both may contribute to the HSA of the employee in a given year. For an HSA established by a self-employed (or unemployed) individual, the individual may contribute to the HSA. Family members may also make contributions to an HSA on behalf of another family member as long as that other family member is an eligible individual.

Can anyone make catch-up contributions to a Health Savings Account?

Individuals 55 and older who are covered by an HDHP can make additional catch-up contributions. They may make contributions anticipating medical expenses that wi ll not be covered under Medicare - such as a portion of prescription drug costs or Medicare Part A & B premiums. For individuals age 55 and older, additional catch-up contributions to HSA allowed in the amount of$1,000.

Contributions must stop once an individual is enrolled in Medicare.

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income while held in the HSA (i.e. inside buildup is not taxable).

Are rollover contributions to HSAs permitted?

Rollover contributions from Archer MSAs and other HSAs into an HSA are permitted. Rollover contributions need not be in cash. Rollovers are not subject to the annual contribution limits. Rollovers from an IRA , from a health reimbursement arrangement (HRA), or from a health flexible spending arrangement (FSA) to an HSA are not permitted.

When is an individual permitted to receive distributions from an HSA?

An individual is permitted to receive distributions from an HSA at any time .

Must HSA trustees or custodians determine whether HSA distributions are used?

No. HSA trustees or custodians are not required to determine whether HSA distributions are used for qualified medical expenses. Individuals who establish HSAs make that determination and should maintain records of their medical expenses sufficient to show that the distributions have been made exclusively for qualified medical expenses and are therefore excludable from gross income.

Must employers who make contributions to an employee's HSA determine whether HSA distributions are used exclusively for qualified medical expenses?

No. The same rule that applies to trustees or custodians applies to employers.

Can an HSA be offered Ullder a cafeteria plan?

Yes. Both an HSA and an HDHP may be offered as options under a cafeteria plan. Thus, an employee may elect to have amounts contributed as employer contributions to an HSA and an HDHP on a salary-reduction basis.

0 www.CountyNationaiBank.com

1-888-322-1088

Hillsdale Office: (517)439-4300

Hanover Office: (517)563-8332

Homer Office: (517)568-4448

Hudson Office: (517)448-8957

Jackson Cortland Office: (517)768-7200 Jackson Wisner Office: (517)783-1500 Jackson Horton Office: (517)782-2500

Jonesville Office: (517)849-9949

Utchfleld Office: (517)542-2932

Somerset Center Office: (517)688-4433 Spring Arbor Office: (517)750-4011

References

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