I understand that employees are not eligible to participate in an HSA if:
• They are enrolled in Medicare, Tricare, or a Veteran’s plan
• They are enrolled in additional coverage that is not a High Deductible Health Plan (HDHP)
• They are claimed as a dependent on another person’s taxes
I hereby authorize ALLIANCE BENEFITS to withdraw funds for the above HSA employee contribution listed.
I understand HSA employee contributions are included in the health plan insurance premium and will be billed at the same time. After the billing is collected, HSA funds will be deposited into the employee’s account by the 10th of every month. Changes (including termination of employment) to contributions must be submitted to Alliance Benefits by the 25th of the month to be included in the following month’s billing. HSA contributions cannot be refunded once collected.
All HSA employer and employee contributions must be reported on employee’s W-2, Box 12, Code W.