2019 HSA Contribution Change Form

This form is to be completed by the employer on behalf of the employee(s) enrolled in the Alliance Health Plan group coverage.

Employer Information

For the Month(s) of:

HSA Eligibility and Limitations

The 2019 annual maximum contribution amounts per IRS regulations are $3,500 for individual coverage and $7,000 for a family. An additional $1,000 annual contribution is allowed for those age 55 and older. These maximums include both employer and employee contributions combined.

According to the IRS, employees that fall under any of the following categories below are not eligible to contribute to a Health Savings Account (HSA):
• are enrolled in Medicare, Tricare or a Veteran’s plan
• are enrolled in additional coverage on a PPO Health Plan
• are claimed as a dependent on another person’s taxes

A dependent is eligible to enroll in an employee’s HDHP plan but HSA funds cannot be used for said dependent if employee does not claim them on their taxes.

Employer Authorization and Signature

The undersigned employer representative confirms that this applicant is a paid employee of the above named organization, working 20 or more hours per week, and that the reported salary is accurate. We understand the Health Plan coverage being requested by this applicant, upon approval, will be added to our employer’s monthly billing statement. (The employer representative cannot be the applicant.)
Authorized Employer's Signature *
clear
 +
Secured by Formsite