Health Savings Account Election

This election/change form is only for employees enrolled in the

High Deductible Medical Plan

 

Enrollment in a Health Savings Account (HSA) is governed by IRS Regulations. To be an eligible individual and qualify for the tax benefits of an HSA, you must be:

- Covered under a qualified High Deductible Health Plan as your only health coverage (except as otherwise permitted under IRS regulations)

- Not be enrolled in Medicare

- Not be claimed as a dependent on someone else’s tax return

Salem Health’s High Deductible Plan (HDP) meets IRS requirements. You may elect or change HSA contribution once per month without a qualifying life event.

• I acknowledge that I must open my HSA account before I will be eligible to make/receive contributions to my HSA.

• I acknowledge that I may only contribute to an HSA and receive the tax benefits of an HSA if I meet the eligibility requirements outlined by the Internal Revenue Code.

• I acknowledge that Salem Health cannot give me tax advice or confirm that I meet the eligibility requirements for an HSA. I may obtain information on eligibility requirements from a tax professional or the Internal Revenue Service, including IRS Publication 969.

• I acknowledge that I am not covered under Medicare, Tricare, and not covered through my spouse or domestic partner by any health plan or healthcare flexible spending account other than a qualified high-deductible plan.

• I agree to notify Human Resources if I am no longer eligible to contribute to an HSA.

• I am responsible to keep all receipts. I understand that I may be required to substantiate claims to the IRS.

My signature certifies that I am authorized to communicate the above plan information changes.