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Guide to Health Savings Accounts
by Roy Ramthun In collaboration with Patient Advocate Foundation Guide to Health Savings Accounts
by Roy Ramthun In collaboration with Patient Advocate Foundation What You Need to Know About High Deductible
Health Plans and Health Savings Accounts
Published by Patient Advocate Foundation Written by Roy Ramthun, MPH, for the benefit of the patients served and nurtured by the Patient Advocate Foundation About the Author
Roy Ramthun Roy Ramthun is a nationally-recognized expert in health policy with a special expertise in Health Savings Accounts. Mr. Ramthun led the U.S. Treasury Department's implementation of Health Savings Accounts after they were enacted into law in December, 2003. He subsequently became health policy advisor to President George W. Bush. Since leaving the White House, Mr. Ramthun formed his own health care con-sulting practice specializing in Health Savings Accounts and consumer-driven health care issues.
Mr. Ramthun has almost twenty years of health care experience, including positions in the private sector and in government. He has held positions with Humana Inc., the U.S. Senate Committee on Finance, and the Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services (CMS). Mr. Ramthun began his career in Federal service as a Presiden-tial Management Intern (PMI) under President Ronald Reagan. Mr. Ramthun holds a Bachelor of Science degree in Biochemistry from the University of Michigan, and a Master of Science degree in Public Health from the University of North Carolina in Chapel Hill.
Mr. Ramthun and his family (including two young boys) have had HSA-qualified insurance and a health savings account since 2005.
About the Publisher
Nancy Davenport-Ennis, cancer survivor, is the Founder and Chief Executive Officer of two organizations founded in 1996, National Patient Advocate Foun-dation (NPAF), a policy organization, headquartered in Washington, DC that seeks to improve access to care through regulatory and policy initiatives at the state and federal levels and Patient Advocate Foundation (PAF), a 501(c) 3 direct patient services non-profit organization, headquartered in Newport News, VA, providing professional case management services in order to resolve patient access issues. PAF served over 6 million contacts in the FY2005/2006.
Davenport-Ennis has been appointed to, and currently serves on, several national committees including an appointment by the United States Secretary of Health and Human Services as a Commissioner on the American Health Infor-mation Community (AHIC) with Health and Human Services (HHS) serving as Co-Chair of the Consumer Empowerment Working Group for AHIC, Directors Consumer Liaison Group (DCLG) with the National Cancer Institute (NCI), a voting seat on the Medicare Coverage Advisory Committee (MCAC) at Centers for Medicare and Medicaid Services, Access to Quality Cancer Care Team, a committee of C-Change, One Voice Against Cancer, Virginia Governor's Govern-ment & Regulatory Reform Task Force, Virginia Attorney General's Regulatory and Government Reform Task Force-Healthcare Working Group, Health Informa-tion Technology Council for Virginia and the Mayor's Committee on Medicaid and Physician Recruitment in Newport News, VA. She also serves on the Board of Directors for Friends of Cancer Research, the Advisory Board for the Intercul-tural Cancer Council, external Board of Review for the Siteman Cancer Center in St. Louis, MO, the PRR Advisory Board for Oncology Times, In-Touch, Coping and Managed Care and Cancer magazines. She has served as a Congressional witness before the Senate and House committees addressing access issues confronting patients. Throughout her career in patient advocacy, Davenport-Ennis' expertise has been sought by national and local media outlets for articles addressing access issues confronting patients reflecting the value of case management and/or legal interventions. Articles have appeared in The Wall Street Journal, New York Times, US News and World Report, USA Today, Washington Post, The Boston Globe; Houston Chronicle, The Daily Press, The Virginian Pilot , Inside CMS, Family Circle Magazine; Parade Magazine, Readers Digest; Prevention Maga-zine, Self Magazine, All You, Real Simple Magazine, Glamour Magazine, Nursing Spectrum, Business Week, Hematology Oncology Times, Physicians Practice Magazine, Coping Magazine, Women and Cancer, American Family Physician Monograph on Cancer, NBC Nightly News, Good Morning America, CBS affiliate stations, and the Lifetime Network Ms. Davenport-Ennis is the recipient of the 1989 Outstanding Young Woman of America Award, the Association of Community Cancer Centers Advocate of the Year Award and the U.S. Oncology Medal of Honor Award. Ms. Davenport-Ennis was also appointed to the Governor's Commission on the Uninsured in Virginia. Davenport-Ennis was also named as a Paul Harris Fellow by the National Rotary Foundation. Davenport-Ennis holds a B.A. degree in English from Campbell University. She resides in Yorktown, Virginia with her husband, John H. Ennis, Jr. and has two daughters and four grandchildren.
Guide to Health Savings Accounts: What You Need to Know About High
Deductibles Health Plans and Health Savings Accounts
has been prepared by
the Patient Advocate Foundation, (PAF) a national network for healthcare reform
and patient services located in Newport News, VA. In conjunction with Mr. Roy
Ramthun, nationally-recognized expert in health policy with a special expertise in
Health Savings Accounts (HSA). It is the intention of Patient Advocate Foundation
that this publication be an educational tool to inform consumers of the features
and benefits of Health Savings Accounts and High Deductible Health Plans. This
tool is intended to offer insight into an alternative to other insurance products of-
fered in America.
PAF would like to acknowledge and thank the many professional staff members and
leadership team representatives who provided invaluable information for this
Principle Writing and Editing:
Nancy Davenport-Ennis Health Care Consultant President and CEO HSA Consulting Services Patient Advocate Foundation Constance Goodman, RN Chief Program Officer Patient Services Administrator Patient Advocate Foundation Patient Advocate Foundation Quality Assurance Officer Supervisor Patient Services Patient Advocate Foundation Patient Advocate Foundation Senior Case Manager Patient Advocate Foundation Patient Advocate Foundation Connie Slayton RN Senior Case Manager Patient Advocate Foundation TABLE OF CONTENTS
HSA-Qualified Insurance Policies
Limits on Out-of-Pocket Expenses Is Your Policy HSA-Qualified? How to Find an HSA-Qualified Policy Health Savings Accounts
Making Contributions to Your HSA Account Establishing HSA Accounts Using Your HSA Account How Your Health Savings Account Works Beneficiaries & Estate Consequences Advantages & Disadvantages of Health Savings Accounts
Frequently Asked Questions
Glossary of Terms
How To Use This Guide
This guide is intended to help individuals and families better understand Health Savings Accounts, how they compare to traditional health insurance, and how to determine whether a Health Savings Account is right for you or your family. A worksheet is included to help you compare the financial features of the Health Savings Account to a traditional policy. In addition, a detailed comparison of a traditional PPO policy and an HSA plan prepared by the Washington Post isre-printed in Appendix 3.
The guide examines the finer details of HSA accounts and the health insurance policies that accompany them. In each section, a Patient Advocate Foundation "Buyer's Guide" provides advice, reminders, and things to consider when examining a Health Savings Account. The "Buyer's Guide" is intended to provide additional insight into the finer details of Health Savings Accounts.
Additional help is provided through answers to frequently asked questions, definitions of terms that are commonly used with Health Savings Accounts, and a description of additional resources available through the Internet. Additional help is also available through the Patient Advocate Foundation by calling 1-800-532-5274 or on the Internet at Increasingly, individuals and families are considering health insurance policies with higher deductibles than traditional policies. Sometimes, employers are asking their employees to enroll in these plans, either as an option or the only health insurance plan available to employees. Individuals and families purchasing health insurance on their own can sometimes only find affordable health insurance if they choose a policy with a high deductible.
Some, but not all, of the newer health insurance policies with high deductibles may qualify individuals and families for a new type of trust or custodial account that has certain tax advantages, called a "Health Savings Account" or "HSA." An HSA offers a way to put aside money to pay for your routine medical expenses and help you save money on taxes. HSAs are designed to fill in the gaps for "catastrophic" insurance policies that cover larger medical bills.
Most of us know that we can lower our premiums on our auto or homeowners insurance by raising our policy deductible. But few of us actually put the savings into a "rainy day" fund in case we actually have to pay our deductible when we have a claim. HSAs offer a way of putting money into that "rainy day" fund for health care. The tax benefits that come with the HSA make the opportunity that much better. This guide will provide useful information about: (1) which types of high deductible health insurance policies qualify for HSAs and which do not; (2) how to set up and use an HSA; and, (3) tips on how to help you find good resources to answer your questions.
Health Savings Accounts do not solve some or all of the problems with obtaining health insurance. However, for many individuals and families, HSAs can make health insurance more affordable while providing an alternative way of financing their medical coverage.
In 1996, federal legislation included a demonstration project which created Archer Medical Savings Accounts (MSAs). MSAs have many similarities to HSAs, including their coordination with high deductible health insurance policies and tax advantag-es. However, these accounts were limited in scope and available only to self-em-ployed individuals and employees of small businesses. In 2003, federal legislation removed the limitations on MSAs and re-named them "Health Savings Accounts." HSAs are now available to any individual or family with HSA-qualified insurance. There are no limitations on who may have an HSA based on income or employment status. However, dependent children cannot have their own HSA accounts but may be covered by the HSAs of their parents.
The term "HSA-qualified" insurance refers to health insurance policies with deduct-ibles higher than traditional policies. However, not all policies with high deductibles make individuals eligible to contribute to an HSA. In order for a high deductible policy to be an "HSA-qualified" policy, the policy must meet certain requirements relating to deductibles, out-of-pocket expenses, covered benefits, and preventive care.
In order for a high deductible health insurance policy to be "HSA-qualified," the policy must have an annual deductible that is at least $1,100 for self-only coverage or $2,200 for family coverage beginning in 2007. The policy can have an annual deductible as high as $5,500 for self-only coverage or $11,000 for family coverage in 2007. If a high deductible policy has an annual deductible below or above these amounts in 2007, it is not an NOTE: The amounts are adjusted annually for inflation and may increase from one year to the next. Policies offering "family coverage" can apply a single "umbrella deductible" to the entire family. For example, a family has a policy that has a deductible of $4,000 that applies to all medical expenses incurred by the family members. This means that one family member could incur all $4,000 of medical expenses before the deductible is satisfied. Other policies have "embedded deductibles" for individual family members. For example, a fam- ily has a policy that has an "umbrella deductible" of $5,000 but has "embed- ded deductibles" of $2,500 for each family member. This means that when any family member has incurred $2,500 of medical expenses, that family member will have satisfied their individual deductible. However, a $2,500 deductible could still apply to other family members until $5,000 in medical expenses has been incurred by all the family members combined.
NOTE: Family policies must have "embedded deductibles" for individual family members that are at least $2,200 per person or the policy is not "HSA- PAF Buyer's Guide: Make sure your policy has deductibles that meet the
requirements. The level of deductible you choose will impact your premium and savings opportunity. Higher deductibles can lower your premium significantly and increase the amount you can put into your HSA account each year. However, unless you are age 55 or older, policies with deductibles above $2,850 (self-only coverage) and $5,650 (family coverage) do not allow you to make contributions to your HSA account above these amounts Over time, you may accumulate enough funds in your HSA to lessen the impact of higher deductibles. In addition, individuals age 55 or older can make additional contributions to their HSA accounts each year, which may allow them to accept policies with higher deductibles.
Limits on Out-of-Pocket Expenses
"HSA-qualified" policies must also limit annual out-of-pocket expenses paid by the individual or family for covered benefits under the plan. After the individual or family reaches this out-of-pocket limit, the plan must pay 100% of the cost of benefits covered under the plan for the remainder of the plan year. For 2007, the out-of-pocket limit cannot be any higher than $5,500 for self-only coverage or $11,000 for family coverage. Out-of-pocket limits can be as low as $1,100 for self-only coverage or $2,200 for family coverage . If a high deductible policy has an out-of-pocket limit above or below these amounts, it is not an HSA-qualified policy.
NOTE: The amounts are adjusted annually for inflation and may increase from one year to the next. It is possible for the out-of-pocket limit to be as low as the policy deductible, in which case the plan pays 100% of covered benefits after the deductible is met. Other policies charge coinsurance (e.g., 20%) for covered benefits received after the deductible is met, up to a higher limit on total out-of- pocket expenses. Under HSA-qualified policies, the deductible, copays, and coinsurance amounts paid under the plan must count towards meeting the out-of-pocket limit on expenses.
PAF Buyer's Guide: Make sure your policy has a limit on out-of-pocket
expenses that meets the requirements. The out-of-pocket limits for HSA- qualified plans can offer two significant benefits to individuals and families when compared to traditional policies, especially for those with high medical expenses. First, some traditional policies do not have a limit on out-of-pocket expenses, leaving individuals and families exposed to unlimited and unpredictable expenses each year. Second, the deductible, copays, and coinsurance amounts paid under an HSA-qualified plan must count towards meeting the out-of-pocket limit on expenses. Under some traditional policies, the deductible and copays do not count towards meeting the out-of-pocket limit.
The level of out-of-pocket limit you choose will impact your premium. Some policies offer out-of-pocket limits as low as the deductible, meaning after you have met your deductible, the plan pays 100% of covered benefits. However, policies with higher limits may have lower premiums. Over time, you may accumulate enough funds in your HSA to lessen the impact of higher out-of-pocket limits. In addition, individuals age 55 or older can make additional contributions to their HSA accounts each year, which may allow them to accept policies with higher out-of-pocket limits.
There is a common misperception that HSA-qualified policies are "bare bones" insurance policies. This is generally not the case. Typically, the covered benefits under HSA-qualified are identical to traditional policies. The major difference is the amount of the deductible and the limit on out-of- pocket expenses.
High deductible insurance policies are subject to the same insurance laws and regulations as other policies (HMOs, PPOs, indemnity policies, etc.) This means that the same benefit mandates, premium regulations, and consumer protections prescribed by each state (and the federal government) apply to these high deductible policies. As with traditional policies, HSA- qualified policies must be approved for sale by the state insurance The only exceptions to this are policies offered by companies (typically larger companies) that self-insure their company benefits. However, these policies are regulated by a federal law known as "ERISA" which allows companies to offer policies to their workers providing the same benefits regardless of which state the employees work.
One key difference between traditional plans and HSA-qualified plans is that the deductible must apply to all covered benefits under an HSA-qualified plan, including the cost of prescription drugs. This means that an individual or family could meet their deductible solely through prescription drug expenses. If you take a lot of prescription medicines, you may pay more out of your own pocket (or use HSA funds) than the $15 or $20 copays you are used to paying, but you may also hit your deductible faster and reach higher levels of insurance coverage more quickly (e.g., 80% or 100% As with traditional policies, HSA-qualified policies may have different levels of covered benefits depending on whether they are provided by "in-network" or "out-of-network" physicians, hospitals, and other medical providers. The limits on deductibles and out-of-pocket expenses described above apply only to covered benefits from "in-network" providers.
Just like traditional policies, HSA-qualified policies may put limits on
covered benefits, such as the number of visits, limit payments to "usual,
customary, and reasonable" (UCR) amounts, use formularies or
preferred lists for prescription drugs, and require prior authorization
before services are provided. These limitations should be described in
any insurance policy contract. Be sure to read the policy contract and
determine if the coverage is what you and your family need based on
your family's history of medical care use.
PAF Buyer's Guide: As with any insurance contract, the amount of covered
benefits affects your premium. Pay close attention to the details of what is covered and under what circumstances, what is not covered (or "excluded") and under what circumstances, and the types of medical providers from which covered benefits are available. Make sure you understand what expenses count towards satisfying your policy deductible and out-of-pocket If you are chronically ill and take several prescription medications, you may satisfy your policy deductible with your drug expenses alone. Although this means that you pay the total cost of your prescriptions while your deductible is in effect, you will pay only the negotiated cost of your medicines, not the full retail price. This is one of the benefits of your HSA- qualified policy. Another benefit is that since these prescription expenses count towards meeting your deductible, you may hit your deductible and out-of-pocket limits faster than under a traditional policy, which means your policy could pay 100% of covered benefits sooner than a traditional policy.
HSA-qualified plans may provide coverage for preventive care on a first dollar coverage basis (i.e., without having to apply this expense to the policy deductible). HSA-qualified plans are not required to cover preventive care services, but most policies do offer at least some coverage for preventive care. Plans may cover 100% of preventive benefits or charge copays for the benefits. Plans may cover a limited or unlimited amount of preventive care Each qualified plan determines what services are considered "preventive care" under the plan. Federal regulations allow plans to cover services such as the following: Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual Routine prenatal and well-child care.
Child and adult immunizations.
Tobacco cessation programs.
Obesity weight-loss programs.
Screening services (see attached Appendix 1) Some, but not very many, prescription drugs can be covered as "preventive care" under your policy. Two examples of types of drugs that may be covered as "preventive care" are drugs known as: Statins that lower your cholesterol levels to prevent heart disease (e.g., Lipitor, Crestor, Mevacor, Zocor, Cholestin, Pravachol, etc.).
Angiotensin-converting Enzyme (ACE) inhibitors that can help prevent (or prevent reoccurrence of) a heart attack or stroke (e.g., Capoten, Lotensin, Vasotec, Altace, Zestril, Accupril, etc.).
NOTE: Birth control pills and devices are not considered "preventive care" for HSA-qualified plans. PAF Buyer's Guide: Look for a policy that provides coverage of preventive
care services that you will (or should) use. This will save you money in the long run and will help you maintain and improve your health. Make sure you understand the details of the preventive care services covered by your plan. Some services that are considered "preventive care" may not be covered by Some plans may charge co-pays for certain preventive services. Of course, you can use your HSA funds to pay these co-pays. Pay special attention to whether any prescription drugs are covered as "preventive care" and under what circumstances. If you are unsure, ask your insurance plan for a more detailed explanation. If you are chronically ill, it is unlikely that your medications will be considered "preventive care." Is Your Policy HSA-Qualified?
If your policy does not meet the requirements described above regarding deductibles, out-of-pocket limits, and covered benefits (including preventive care), it cannot be HSA-qualified. You must generally rely on your health insurance carrier to determine whether your policy meets the requirements and be "HSA-qualified." HSA-qualified policies generally include a statement that they meet the requirements for HSAs or are determined to be a "High Deductible Health Plan" (HDHP). Although unlikely, some older insurance policies may meet the requirements to be "HSA-qualified PAF Buyer's Guide: If you believe your current policy meets the HSA
requirements, you should ask your insurance carrier to tell you in writing whether your policy is HSA-qualified. If the carrier is unwilling or unable to do so, you should not make your own determination. It is recommended that you contact your state insurance department and/or seek legal advice from a qualified professional who can help you make a determination. If you obtain your HSA-qualified policy through your employer, you can generally rely on the company's determination.
How to Find an HSA-Qualified Policy
Companies are increasingly offering HSA-qualified policies to their workers. If your employer does not offer an HSA-qualified policy or you do not currently have an HSA-qualified policy but would like to obtain one, contact a local insurance agent or ask your current insurance company about switching to an HSA-qualified policy. You may also want to contact the state insurance department for assistance, if needed. There are also many resources available on the Internet if you search on terms like "health savings account" or "HSA." PAF Buyer's Guide: Almost every health insurance company sells HSA-
qualified policies. Ask any sales representative, agent, or broker about their experience selling HSA-qualified policies. Choose one that sells a lot of HSA-qualified policies, not just a few. Ask for references of companies or individuals to whom they have sold HSAs. If you do not currently have health insurance coverage or have a medical condition, you may be subject to medical underwriting and exclusions for pre-existing conditions when purchasing an HSA-qualified policy. HSA-qualified policies offer no greater protection against medical underwriting and/or pre-existing medical exclusions than traditional policies.
To be eligible to contribute to a Health Savings Account, not only must you have HSA-qualified insurance, but you must also not have any other first dollar coverage that could disqualify you. Other types of coverage that might disqualify you include: A traditional HMO, PPO, or indemnity policy, including cover - age under a spouse's policy A Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA), including a spouse's FSA or HRA VA benefits (if received within the past three months) General purpose HRAs and health care FSAs are not HSA-qualified plans. However, certain types of FSAs or HRAs can be compatible with an HSA. For example, if your employer offers a "limited purpose" FSA or HRA that only reimburses dental, vision, and/or preventive care expenses, you can still be eligible for an HSA. These types of plans are desirable because it offers another tax-preferred way of paying for these expenses without using your Certain types of insurance will not jeopardize your eligibility for an HSA. The following types of insurance may offer medical benefits but generally will not disqualify you if they are in place along with the HSA-qualified plan: Insurance for a specific disease or illness, as long as it pays a specific dollar amount when the policy is triggered Hospital indemnity Wellness programs offered by your employer, if they do not pay for significant medical benefits Worksite employee assistance programs (EAP), if they do not pay for significant medical benefits PAF Buyer's Guide: It is possible for you to be eligible for an HSA even
though the rest of your family is not. This is possible even if you have "family coverage" that covers the rest of your family members. However, you should be particularly careful when a family member (except dependent children) has "other coverage" because it could jeopardize your ability to have and contribute to an HSA. Although HSA-qualified policies can be used as "secondary insurance," your primary insurance may eliminate your ability to contribute to an HSA account. Be especially careful when your spouse has other insurance coverage or an FSA or HRA through his/her employer. It is not good enough to say you will never use their coverage or account to pay for your medical expenses – your spouse's plan/account must not allow your expenses to be paid (and should state this in writing). It is acceptable for your spouse's coverage/account to cover your children's medical expenses. Since dependent children cannot establish their own HSA accounts, any other coverage they may have is not It may be worthwhile considering purchasing a supplemental "hospital indemnity" policy. They can be relatively inexpensive but will help you fund your HSA account if you are hospitalized and have to pay your entire deductible all at once because you are hospitalized.
Individuals that have HSA-qualified insurance policies (and no other first dollar coverage that disqualifies them) are eligible to establish health savings accounts and make contributions each year. Contributions provide certain tax advantages as described below. Funds deposited in the account roll over automatically each year and may be invested without paying taxes on earnings. Account funds may be used tax-free to pay for qualified medical expenses. Accounts may be established with qualified institutions such as banks and credit unions. Making Contributions to Your HSA Account
Contributions to HSA accounts may be made by individuals, employers, and other individuals (including family members). Employers can make fixed dollar or "match-ing" contributions. Contributions made by employers and employees through pay-roll deduction are treated the same way as payment of health insurance premiums for tax purposes – these contributions are not counted as "income" when deter-mining income and employment taxes. This means that HSA contributions made through your job can reduce both you and your employer's income and FICA taxes.
Source of HSA Contribution
Tax Status
No income or payroll taxes (FICA) applied Employee, through payroll No income or payroll taxes Employee, but not through Deductible on employee's payroll deduction Family member or friend Deductible on recipient's income taxes Contributions can also be made outside of your employment. In this case, you pay no income taxes on your contributions. In addition, the amount you contribute to your HSA reduces your taxable income. For example, if your income is $42,000 and you make a $2,000 contribution to your HSA account, the amount of your income that is taxed is only $40,000. You are not required to itemize deductions to take the deduction for your HSA contributions. However, you do have to complete the standard Form 1040 (you cannot file the form 1040-EZ).
NOTE: HSA contributions are also deductible from state income taxes in all states except Alabama, California, New Jersey, and Wisconsin. The following states have no state income tax: Alaska, Florida, New Hampshire, Nevada, South Dakota, Tennessee, Texas, Washington, and Wyoming. Contributions may also be made by other individuals, such as family members. For example, parents may want to help their children that have recently graduated from college and are now on their own to fund their HSA accounts. In these situations, the person receiving the funds (i.e., the son or daughter) receives the tax deduction on their income taxes. These contributions may also be exempt from gift taxes for the person making the contribution (e.g., the parents). The amount that can be deposited into an HSA account each year generally equals the amount of the deductible under the individual or family's HSA-qualified policy. For example, if your policy has a $2,500 deductible, you can deposit up to $2,500 into your HSA account. However, for policies with higher deductibles, the amount you can deposit is limited to: $2,850 for individuals with self-only coverage in 2007 $5,650 for those with family coverage in 2007 NOTE: The amounts are adjusted annually for inflation and may increase from one year to the next. Individuals age 55 or older may make additional "catch-up" contributions each year. For 2007, the maximum additional contribution is $800. NOTE: For 2008, the maximum "catch-up" contribution will be $900 per person. For 2009 and future years, the maximum additional contribution is $1,000 per person. These amounts are set in federal law and are not adjusted for inflation. If your employer makes contributions to your account, the company decides how frequently to make the contributions (e.g., every payday, monthly, quarterly, etc.). If you make contributions through payroll deduction, the contributions will probably be deposited in your account with every paycheck, or at least monthly. Once the money is deposited in your account, it belongs to you. Your employer cannot tell you what to do with the funds after that point.
If the amount of contributions being made by your employer and/or by you through payroll deduction do not add up to the maximum amount you are allowed to con-tribute for the year (including catch-up contributions), you can deposit the differ-ence into your HSA account and deduct this amount on your income tax return. For example, you have a policy with a $2,500 deductible and your employer agrees to contribute $1,000 to your HSA account and you have another $1,000 deposited to your account through payroll deduction, you can make an additional deposit of $500 to your HSA account. You do not have to wait to incur medical expenses before you make this contribu-tion (e.g., $500 in example above) to your account. Contributions can be made at any time of the year and as late as the income tax filing deadline (usually April 15) in the following year. However, funds must be deposited into your HSA account before they can be used to pay for or reimburse your medical expenses. If you do not deposit the funds first, you will not receive credit for the deposits and therefore not qualify for the income tax deductions for HSA contributions.
If your HSA-qualified coverage begins in any month other than January, you may have to pro-rate your contribution for the year. For example, if your coverage under an HSA-qualified policy does not begin until July, you can only contribute 50% (6 months divided by 12 months = 50%) of your allowed contribution amount for the calendar year. Likewise, if you drop your HSA-qualified coverage at the end of June the following year, you would only be able to contribute 50% of your allowed contri-bution for that year as well. If you keep an HSA-qualified policy the second year but increase the amount of your deductible from $1,200 to $2,000, you would be able to contribute $1,600 to your account for the second calendar year, as follows: January – June: 6 / 12 = 50% of $1,200 = $600 July – December: 6 / 12 = 50% of $2,000 = $1,000 TOTAL for Year 2 = Finally, your HSA-qualified coverage must be in effect on the first day of the month to be eligible to make a contribution for that month. If your coverage begins on any day other than the first day of the month, you are not eligible to make a contribution for that month. Your eligibility to make contributions to your HSA account begins with the following month.
None of these requirements should be interpreted as meaning you have a monthly limit on the amount you can deposit in your HSA account. The requirements only13 affect your total contribution for the year, if your policy is not in effect on January 1. In the year you turn age 55, you are eligible to make the full catch-up contribution regardless of when your birthday falls during the year, if you have HSA-qualified coverage for the entire year. However, if your coverage begins on any day other than January 1, your catch-up contributions must also be pro-rated for the number of months for which you have HSA-qualified coverage, as described above.
For families with married couples, the family can open one or two HSA accounts, if both spouses are eligible. However, the total contribution to the two accounts cannot exceed the maximum allowed for the year (including pro-rated amounts). If both spouses are age 55 or older, each spouse must open an account in their own name to allow them both to make catch-up contributions. As with IRAs, joint ac-counts are not permitted.
PAF Buyer's Guide: Funds cannot be used for medical expenses until they are
deposited into the account, so it is important to make your contributions as early in
the year as you can afford to do so. If you are opening an HSA account for the first
time, you should open your HSA account and make an initial deposit as soon as
possible because only those expenses incurred on or after the date your account is
opened are eligible to be paid or reimbursed from your HSA account. After your ac-
count is opened and you have at least some funds on deposit, you can wait as late
as April 15 to make the remaining contribution to maximize your account deposits
for the previous calendar year.
Pay attention to the effective date of your coverage. If you coverage begins any day other than the first day of the month, you are not eligible to make a contribution to your HSA account until the following month. This will reduce your total allowed contribution for the year.
NOTE: If you make contributions to a family member's (non-dependent) HSA account, consult your tax advisor before making contributions. Establishing HSA Accounts
HSA accounts can be opened at any willing bank, credit union, or other qualified in-stitution. The institution is the "custodian" or "trustee" of your account. By agree-ing to offer HSA accounts, the custodian/trustee agrees to abide by banking laws, offer federal deposit insurance to protect your account, and report necessary tax information to you and the Internal Revenue Service.
The general process for establishing your HSA account is very similar to the way you open an Individual Retirement Account (IRA). You do not need permission from your employer or anyone else to establish your HSA account. The specific process varies from bank to bank. Generally, most trustees and custodians require that you complete an application form in writing, sign it, and return it by mail or fax. Some trustees and custodians have developed account opening processes that allow some aspects to be handled electronically.
Banks and credit unions are not required to open HSA accounts so don't be sur-prised that your local bank or credit union does not offer HSA accounts. Insurance companies are also approved to open your account. Many insurance companies offer HSA account services through a partnership with a major bank. This often makes it easy to get your account started. You always have the flexibility to transfer your funds to another institution of your choosing at a later date.
It is important that you open your HSA account as soon as you enroll in an HSA-qualified plan (if not before) because your HSA can only be used to pay for or re-imburse you for qualified medical expenses that you incur after your account is "established." This is an important and subtle rule -- one that can surprise you when you enroll in an HSA-qualified plan for the first time. Typically you enroll in the HSA-qualified plan first, then open the HSA account. Many trustees and custodi-ans allow you to complete the necessary account opening forms or other processes shortly before the date your HSA-qualified coverage becomes effective, so your ac-count is considered "established" on your coverage effective date. As a result, any medical expenses you incur during the first few days of coverage can be paid for or reimbursed from your account.
If your employer makes contributions to your account or allows you to make contri-butions through payroll deduction, your employer can choose a financial institution at which to deposit the funds. This makes it easier for your employer to deposit the funds into your HSA account. However, you can transfer the funds to another bank or credit union if you want your account held at a different institution.
Custodians and trustees can set administrative fees and other requirements for HSA accounts. These include things like minimum deposit requirements, minimum balance requirements, account set-up fees, account maintenance fees, etc. A re-cent survey of HSA custodians and trustees indicated the following ranges for HSA account fees: Account set-up fees – $0 - $50 (average = $14.36) Monthly maintenance fees -- $0 - $10 (average = $2.06) Transaction fees -- $0 - $5 (average = $0.27) Account closing fees -- $0 - $30 (average = $10.17) You should consider these costs when deciding where to open your HSA account(s). Most custodians and trustees pay interest on your account funds, just like they do for savings and checking accounts. The average interest rate paid is around two 15 percent. The highest rate being paid is around 5 percent. Generally, higher interest rates are offered for larger account balances. Your HSA account custodian/trustee may also offer investment options for your HSA funds. This may be an important consideration as your account balance grows over time. Your funds can be invested in the same types of investments per-mitted, including stocks, bonds, mutual funds, CDs, etc. However, each institution can decide what types of investment options it offers.
You may open and maintain more than one HSA account at different financial insti-tutions. You may deposit as much as you wish into each account as long as your total contribution to all the accounts combined does not exceed the limits for the calendar year. However, because each account custodian/trustee may charge fees, etc., it may not be wise to open too many HSA accounts.
PAF Buyer's Guide: Be sure to shop around for banks or credit unions that of-fer you good value for your HSA account funds. Some charge high fees that may offset the growth you realize through interest payments or investments. Open your HSA account before your coverage begins, or as soon as possible after it starts. Doing so will ensure that you have your account opened on the first day of your HSA-qualified insurance coverage, which for many people begins on a holiday (January 1). That will guarantee that any expenses you might incur on January 1 would be eligible for reimbursement from the account.
Using Your HSA Account
Once funds are deposited in your HSA account, you can withdraw funds to pay for qualified medical expenses directly from the account. The types of expenses that qualify for reimbursement from an HSA include more than just what your insurance covers. In fact, HSA funds can be used to cover many items and services that insurance often does not cover, including over-the-counter medications, vision care expenses (including laser eye surgery), dental care expenses (including orthodon-tia), chiropractic care, and much more (see Appendix 2).
In most instances, you cannot pay for health insurance premiums with HSA funds. However, the funds can help you pay for your health insurance premiums during periods when you are between jobs. For example, you can use your funds to pay premiums for COBRA continuation coverage from a former employer. If you are re-ceiving federal or state unemployment compensation, you can also pay your health insurance premiums with HSA funds. In either case (COBRA or unemployment), you can pay premiums for health insurance even if it is not HSA-qualified insurance. Looking towards retirement, HSA funds can be saved and used to pay for long-term care expenses and insurance, and Medicare out-of-pocket expenses (deductibles, co-pays, and coinsurance) and monthly premiums for Parts A through D. The only thing funds cannot be used to pay is premiums for Medicare Supplement (i.e., Medigap) insurance. Your HSA account funds can be used to pay for not only your qualified medical ex-penses, but also the qualified expenses incurred by your spouse and dependents. Your spouse and dependents do not need to be covered by your HSA-qualified plan.
Many banks and credit unions offer checks or debit cards that you may use to pay for expenses at the time the services are provided. These features offer easy ac-cess to your account funds, including reimbursing yourself for expenses you have already incurred. Be aware that some of these features have associated fees, es-pecially when using a debit card to withdraw "cash" from your HSA account, even if you are reimbursing yourself for a qualified medical expense.
PAF Buyer's Guide: You have great flexibility when determining how to use your
account funds. This is one of the great advantages that HSAs offer. You alone can
determine whether to use your account to pay for current medical expenses or save
the funds in your account to pay for expenses in retirement. However, be aware of
fees associated with different ways of accessing your account funds.
How Your Health Savings Account Works
HSAs and HSA-qualified insurance work very similar to traditional insurance. Some medical providers prefer to submit a claim for the services provided to the insur-ance company first and bill you after the insurance company applies their discount and your policy deductible. This ensures that your claim is for a covered service, that you get the benefit of the insurance company's negotiated fee with the provid-er, and that your expenses are counted towards satisfying your policy deductible. Your insurance company will then likely send you an "explanation of benefits" (EOB) showing the services provided, the charges submitted, and discount(s) applied. The EOB will also let you know how much you owe the medical provider. The medical provider will also likely send you a bill for the amount you owe. Again, if you have a debit card or checks to access your HSA account funds, you could use either form of payment the provider is willing to accept. You could also pay the provider in cash (or personal check or credit card) and reimburse yourself from your HSA account later.
Your account custodian/trustee and your employer do not have any responsibility to review or approve the expenses for which you use your account funds. If your tax return is audited by the IRS, you will need to prove that your medical expenses were "qualified." You will have to pay income taxes and a tax penalty (10%) on the amount that was not "qualified." Once you reach age 65 (or become disabled), you no longer have to pay the 10% penalty, just income taxes on amounts used for non-qualified expenses.
After the end of the year, you will be sent tax forms that indicate how much you contributed to your HSA account for the calendar year, how much you withdrew from the account during the year, and your ending balance on December 31. You do not need to itemize your deductions to take the deduction on your income taxes for the amount you contributed for the year. You will need to file a tax form (Form 8889) with your tax return which documents your HSA account funds and tax de-ductions.
PAF Buyer's Guide: When you go to your medical provider, you should let them
know that you have an insurance policy with a high deductible and you may end up
paying the entire amount for the services provided.
You may want to offer to pay something before you leave the provider's office, as you would do when you have to pay a co-pay under a traditional policy. Some medical providers are concerned that they will have a harder time collecting from you if you don't pay something before you leave. These concerns may make your medical providers less willing to accept your HSA-qualified insurance in the future.
If you incur medical expenses early in the year, you may not have enough funds in your account to pay or reimburse yourself for the expenses you incur. If you will not be making the maximum contribution to your account through your employer and/or by payroll deduction, you could deposit the remaining funds you are allowed to contribute into your account at any time. If you can work out a payment plan with the provider, this may give you more time to deposit funds into your account. Your employer may also be willing to loan you the money which you could pay back over time (NOTE: Employers are not required to do this.) Over time, this may not be as much of a problem if you have unused funds that roll over to the next year.
Keep track of all your EOBs and receipts. This is the only proof you have that your expenses were "qualified medical expenses." You are responsible for using your account funds appropriately. You need to keep good records to indicate that you used your HSA account funds exclusively to pay for or reimburse qualified medical expenses. These medical expenses may not be claimed as a "medical expense" if you itemize your deductions in the same year.
You can wait to reimburse yourself from your HSA account for many years into the future. There is no time limit on when you must use your HSA funds. However, if you receipts are no longer legible, you will have no proof that you incurred qualified expenses.
Beneficiaries & Estate Consequences
Upon your death, your surviving spouse automatically inherits your HSA account, unless your will specifies otherwise. The account becomes their HSA account. If your surviving spouse has HSA-qualified insurance, he/she may continue to con-tribute to the account as if it were their own. If the surviving spouse does not have a qualifying plan, he/she may not continue to contribute, but may continue to use the account as his/her own HSA for qualified medical expenses with no tax conse-quence.
If you are unmarried, the funds in the account are no longer treated as an HSA but part of your estate and will be subject to estate taxes. If the beneficiary is your es-tate, the fair market value of the account (as of the date of your death) is taxable on your final tax return. Qualified medical expenses incurred by you prior to your death may be reimbursed from the account before determining the "fair market value" of the account.
PAF Buyer's Guide: Consult your tax advisor or financial planner if you have ques-
tions about the estate tax consequences of your account.
Advantages and Disadvantages of Health savings Accounts
Security – High deductible in-
Change – You must switch to
surance and the HSA account provide high deductible insurance from tra- protection against high or unexpected ditional insurance. Sometimes this medical bills. Most policies also cover means you must change insurance preventive care services to help you carriers as well.
maintain your health and avoid illness and disease.
Affordability – HSAs make
Insecurity – Switching from
health insurance more affordable by traditional first-dollar coverage makes lowering your health insurance premi- many people uncomfortable. High ums. The savings can be substantial, deductible plans are relatively new to which can help you fund your HSA many people.
Flexibility – HSA funds can pay
Other Coverage – If you or a
for current medical expenses, includ- family member has other insurance ing expenses that insurance may not coverage that is not HSA-qualified, cover. Funds can also be saved for or has an FSA or HRA through their future needs, such as: employment, this may make you ineli-gible to contribute to an HSA.
• Health insurance or medical expenses if no longer working (unemployed or retired but not yet on Medicare) • Out-of-pocket expenses and premiums when covered by • Long-term care expenses and Control – You make all the
Control – Some people prefer
decisions about your HSA account. to have a third party (e.g., employer, You can make choices that are best insurance company) manage their for you, and physicians can be more health coverage for them. Employers effective patient advocates, with less and insurance companies are able to intrusion from insurance companies.
negotiate discounts for services and help us navigate the health care sys-tem in unique ways.
Advantages and Disadvantages of Health savings Accounts (continued)
Portability – HSA accounts are
Emergencies – When you have
completely portable. You can keep an urgent situation or emergency, it is and take your account with you even if inconvenient and sometimes imprac- tical to consider "comparison shop-ping." Thankfully, most health care is • Change jobs or become provided in non-emergency situations.
• Change your medical coverage or marital status • Move to another state Ownership – You own the
Information – Sometimes it is
funds in your account. The funds in difficult to get good information on the account remain permanently and health care prices and quality of ser- roll over from year to year, just like an vices so you can comparison shop for IRA. There are no "use it or lose it" good value in health care.
rules for HSAs.
Tax Savings – HSAs provide
Tax Filing – You must file an
triple tax savings: income tax return to take advantage of all the benefits HSAs offer. Lower (1) tax deductions when you contrib- income individuals and families may not realize all the savings of HSAs if (2) tax-free earnings through invest- they pay no income taxes.
ment(3) tax-free withdrawals for qualified medical expenses "Catch-up" contribution2 Tax Savings from Personal
2 Per person age 55 or older. Maximum is $800 per person for 2007 ($900 for 2008, and$1,000 for 2009 and later years).
3 Add contributions made by you (if not made through your job), by others, and anycatch-up contribution. Multiply total amount by applicable tax rate for your income (e.g.,15%). This is your tax savings.
HSA Contributions byothers Net increase indeductible Net increase in out-of-pocket limit HSA Worksheet Example
"Catch-up" contribution Tax Savings from Personal
HSA Contributions
(assumes 15%)

HSA Contributions by Net increase in out-of-pocket limit Frequently Asked Questions
Why should I consider a Health Saving Account for me or my family?
If you or your employer are tired of sending hundreds and hundreds of dollars each
month to your health insurance company, and would prefer to keep a big chunk of
that money for yourself to spend on health expenses or save it for the future, then
you need to look into a Health Savings Account.
Why would some one who is less healthy want a Health Savings Account?
You should also look at a health savings account if you have high medical expenses
because the catastrophic protection against very high medical expenses may be
superior to your current plan. There are two key reasons the less healthy should
choose a Health Savings Account. The first reason is to have control over their own
health care decisions and treatments, including their prescription drugs. With an
HMO, the sick must face the rationing regime in place by HMOs to contain costs,
which may include a frustrating waiting list to see a specialist or obtain a treatment,
or prescription drug formularies that may not have the most up-to-date treatments
or brand name drugs that would make them feel the best. Furthermore, in virtually
all HSA qualified plans sold, prescription drug cost count towards your deductible.
The second reason is a financial incentive. Assuming the less healthy would rather not be in an HMO or other managed care plan, then they would likely choose a fee-for-service plan. The standard fee-for-service plan has a $500 deductible, with a 20% co-pay of the next $5,000. This means the person would pay $500 for the deductible, and $1,000 for 20% of $5,000, before being covered 100%. That is $1,500 in after-tax income to be insured 100% for someone who is less healthy in a traditional, low deductible, fee-for-service health insurance plan. Plus, the premium for a traditional low deductible plan is much higher, which adds more cost. Coinsurance above deductible 0% (100% coverage) Total patient medical expenses before plan pays 100% Out-of-pocket limit Contribution to HSA Amount and tax status of out-of -pocket expenses After-tax (not deductible unless > 7.5% income) With a Health Savings Account, the same individual would pay a much smaller premium, and in most cases, the savings fund a majority of the deductible in their Health Savings Account. With a $2,500 deductible with 100% coverage thereafter, and, say $2,000 deposited tax-free in the Health Savings Account, the less healthy individual with an HSA would have to come up with $500 to be covered 100% ($2,500 deductible minus $2,000 from the Health Savings Account equals $500 to meet the deductible). The $500 can be deposited in the account to retain the tax advantage of whatever your specific tax situation is. So the choice for a less healthy individual in a traditional health plan is: (1) pay $1,500 in after-tax funds to pay to be covered 100% by their insurance ($500 deductible and 20% of the next $5,000), or in this example, with an HSA, get a tax break on the extra $500 they would need to be covered 100%. The less healthy, therefore, have a financial incentive to choose a Health Savings Account.
For an employee, spouse and child coverage, does each individual open their
own HSA account or is there one account for all? If there is one for all on the
plan, what happens to the account if the spouses divorce?
Each spouse can have their own account, and need to if you are making catch up
contributions. Either spouse can use their account for any medical expenses for
any member of the family, even if they are not covered by the HSA-qualified plan. If
the couple divorce, the divorce settlement will decide the fate of the funds.
If I get an HSA through my employer, how is it funded?
The first step is to find out what your employer is currently paying for your health
insurance. Then find out what an HSA would cost instead. Once you have that
information, you can talk to your employer and a tax adviser about ways to fund
your account. It may be cheaper for your employer to provide you with a partially
or fully funded HSA compared to what he is currently paying for employee health
care. Employer contributions to an HSA are excluded from employees' income. An
employer can also choose to match the monthly HSA contributions made by em-
ployees. When you start a new job, find out if your new employer will contribute to
your HSA each month. Employers are not obligated to contribute to your HSA, but
you may also realize premium savings which can help you fund your account.
If I use the catastrophic insurance, who pays the deductible?
You pay the deductible with cash from your HSA. It generally it takes about a year
to build up enough money in the account to pay the annual insurance deductible.
In the event you need to pay the deductible early, you can use a loan, other savings
or a credit card to make the payment first, and then repay yourself from your HSA a
few months later when enough money has accumulated in the account. As long as
you keep a record of the amount you first paid and when you paid yourself back, all
these transactions are tax-free.
If I use an out-of-network provider, will that count towards my deductible?
Can I pay for these out-of-network expenses from my Health Savings Ac-
Plans that cover out-of-network providers generally have a separate (higher) de-
ductible for medical care received from out-of-network providers. These expenses
do not count towards satisfying the deductible for medical care received from in-
network providers. However, your Health Savings Account can be used to pay for
medical care received from out-of-network providers if the care is a qualified medi-
cal expense.
Can I use my Health Savings Account for non-medical expenses?
You can spend money out of your Health Savings Account for non-medical expens-
es, but you have to pay income tax and a 10% penalty for a non-medical with-
drawal prior to age 65. At age 65, you only pay income tax on the amount of the
non-medical withdrawal.
Once I enroll in Medicare (age 65 yrs. old) can I get a Medicare Health Savings
Yes, there will be Medicare Medical Savings Accounts (similar to HSAs) available
starting in 2007. As with other private plans providing Medicare coverage, the fed-
eral government pays your plan premium and makes a contribution to your account.
More information on these Medicare plans is available in the Medicare Handbook
and on the Internet at
Is there a list of over-the-counter (OTC) drugs that are always/never/some-
times covered under an HSA?
Most OTC drugs are qualified expenses under an HSA. Unfortunately, there is no
definitive list available. Every day drugs are newly available over-the-counter.
Currently my wife and I are uninsured and generally healthy but do have some
pre-existing conditions. Will an HSA help us?
HSA-qualified plans may be more affordable but medical underwriting practices
may make it difficult for you to find an insurance carrier that will offer your coverage.
Some states have "high risk pools" that have HSA qualified plans. Check your state
insurance department to determine whether your state has a high risk pool.
If the insured's expenses exceed the pre-tax contributions early in the plan
year, will the insured have to pay the deductible with after tax dollars?
No. You can deposit the funds later in the year and reimburse your expenses af-
ter the deposits are made. The deposits will qualify for the income tax deduction
regardless of when they were made. Some employers will help their employees if
there is a large expense early in the year. Another option is to purchase a supple-
mental policy such as a hospital indemnity policy that pays a certain amount if you
are hospitalized and have to meet your deductible all at once. These policies can
be relatively inexpensive.
Additional information may be obtained from eHealth Insurance, the Council for Affordable Health Insurance, and HSA Decisions (please refer to the additional re-source section of this publication). Are HSAs considered "employer-sponsored benefit plans" that are governed
by ERISA if my employer contributes to my account?
The U.S. Department of Labor has ruled that HSAs are generally not "employer-
sponsored benefit plans" governed by ERISA, even when the employer contributes
to their HSA accounts, if:
The employee's participation in the HSA is voluntary The employer allows the employee to move his or her HSA to another custodian or trustee from where the employer deposits its contributions The employer does not place limits on employees' withdrawals from their The employer does not make investment decisions for employees or influence the employees' investment decisions How does making HSA contributions through my company save me money?
If your employer offers a Section 125 plan (also known as a "cafeteria plan") that al-
lows you to make contributions to your HSA account through payroll deduction, you
will save money by:
Avoiding paying the employee share of the federal FICA tax on the amount you contribute, which results in greater tax savings than when you contribute after-tax amounts to the HSA. The employee share of federal FICA tax is 7.65 percent.
Your tax liability and payments are reduced throughout the year when each contribution is made with each paycheck, and you do not need to wait until the end of the year to reduce your income taxes.
Your interest or investment earnings accumulate faster if you make your contributions earlier in the year rather than waiting until the year ends. Who can be considered my "spouse" or "dependent"? Can I use my HSA to
pay for expenses of a domestic partner?
Your HSA-qualified policy should specify who is considered a "spouse" or "depen-
dent" for purposes of your insurance coverage. In many cases, domestic partners
can be considered part of the "family" for policies providing family coverage. How-
ever, the rules for using your HSA funds are more rigid and specific:
Your spouse must be a person of the opposite sex to whom you are legally married as permitted under applicable state law.
"Dependents" generally must be either: A child (son, daughter, stepchild, etc.) who lives with you more than half of the year and who is 18 years or younger for the entire calendar year (or under age 24 and a student for the entire year) or is permanently and totally disabled, or A "qualifying relative" (consult an attorney or your tax advisor for If a domestic partner meets the definition of a "qualifying relative," you can use your HSA to pay for his or her qualified medical expenses tax-free. If the domestic part-ner is not a "qualifying relative," you must pay income taxes on the amount of your HSA that you use to pay for his or her medical expenses, and an additional 10% tax penalty.
Catch-Up Contribution – These are additional contributions allowed for individuals age 55 or older. These contributions are allowed in addition to the annual amounts that generally match the deductible under an HSA-qualified policy. As with all contributions, these contributions must stop once an individual becomes eligible for Medicare.
Coinsurance – The percentage (e.g., 20%) of the cost of covered benefits you must pay. Generally, coinsurance is applied after you meet your policy deductible. Contributions – Deposits to an HSA account. Contributions must be made in cash.
Copay – A fixed dollar amount (e.g., $20) you must pay directly to the medical pro-vider at the time you receive health care services.
Custodian – The bank, credit union, or other financial institution that holds your HSA account funds. In some states, the institution is considered a "trustee" of your ac-count.
Deductible – A fixed dollar amount (e.g., $1,500) you must pay each year before the plan pays for covered benefits.
Distributions – amounts paid from an HSA for qualified health care services.
Embedded Deductible – The amount any one individual family member may have to meet before the policy pays for covered benefits. This amount is generally lower than an "umbrella deductible." Also known as an "individual deductible." ERISA – A federal law (the Employee Retirement Income Security Act of 1974) that regulates the administration of employee benefit plans provided by employers. Explanation of Benefits (EOB) – A document prepared by your insurance carrier that indicates what services were provided by a medical provider, the amount the medi-cal provider charged for the services, the negotiated rate at which the benefits were payable under your insurance policy, and the amount you owe the provider for the services provided. The document also may show the amounts you have paid year-to-date towards meeting your deductible and/or out-of-pocket limit. Family coverage – For HSA purposes, any coverage that is not "self-only" coverage. "Family coverage" includes self + spouse only, self + dependent children, and self + spouse and children.
Flexible Spending Account (FSA) – A health care spending account offered through an employer to which employees make contributions through payroll deduction. The account can be used to pay for medical expenses approved by the employer. Unused funds do not roll over but revert back to the employer.
High Deductible Health Plan (HDHP) – A health plan that meets federal requirements regarding minimum deductibles, maximum out-of-pocket expenses, covered ben-efits and preventive care and makes an individual that has coverage under this type of plan eligible to contribute to a Health Savings Account. Also known as an "HSA-qualified plan." Sometimes referred to as "catastrophic health insurance plan." Health Reimbursement Arrangement (HRA) – A health care spending account fund-ed by employers that may be used for medical expenses or premiums approved by the employer. Unspent funds usually can be carried over to the next year, but can-not be taken with you if you leave the company.
Health Savings Account – An account established by an individual that has "HSA-qualified" health insurance coverage for payment of out-of-pocket expenses tax-free.
HSA-Qualified Plan – A health plan that meets federal requirements regarding mini-mum deductibles, maximum out-of-pocket expenses, covered benefits and preven-tive care and makes an individual that has coverage under this type of plan eligible to contribute to a Health Savings Account in conjunction with High Deductible Health Plans (HDHP).
In-Network – Care provided by health care professionals and facilities that have en-tered into an agreement with your insurance carrier to provide services to you and accept a negotiated fee for the services provided.
Out-of-Network -- Care provided by health care professionals and facilities that have not entered into an agreement with your insurance carrier to provide services to you and have not accepted a negotiated fee for the services provided. Medical providers may charge their full amount (no discount) for these services. Your health insurance carrier may not pay these full charges. Some insurance contracts do not include out-of-network care as a covered benefit.
Out-of-Pocket Expenses – Expenses you pay for health care services your receive. Includes deductibles, copays and co-insurance. Does not include insurance premi-ums.
Out-of-Pocket Limit (or Maximum) – A fixed dollar amount of total out-of-pocket expenses you pay, above which your health plan pays 100% of covered benefits. Qualified Medical Expense – A medical expense that is allowed to be paid tax-free from an HSA, HRA, or FSA. Section 213(d) of the federal Internal Revenue Code governs what can be a qualified medical expense. IRS Publication 502 (available at provides more information about the types of expenses considered "qualified." Trustee – The bank, credit union, or other financial institution that holds your HSA account funds. In some states, the institution is considered a "custodian" of your account.
Umbrella Deductible – The total amount of out-of-pocket expenses that a family must meet before the plan pays for covered benefits. The umbrella deductible may be met by one or any combination of family members' out-of-pocket expenses, depending on the policy design.
The following resources and websites may be helpful to you in searching for HSA-qualified plans, financial institutions offering HSA accounts, and learning more about Health Savings Accounts.
This site is the definitive site for technical information about Health Savings Accounts.
National Association of Insurance Commissioners
This site can help you quickly find your state insurance department's website for help with insurance matters.
National Association of Health Underwriters
This is the site of the professional trade association for health insurance agents. The site includes a consumer-friendly HSA Guide.
This site is a good source for people not covered by an employee health plan and who need to buy their own insurance. On this site you'll find a large selection of health plans and the ability to compare costs.
Council for Affordable Health Insurance HSA Information Center
This site has helpful information about HSAs. CAHI is a Washington, DC-based think tank.
This site is operated by America's Health Insurance Plans, the trade association for the insurance companies. This site will give you information on 1,300 health plans and tens of thousands of agents and brokers nationwide.
This site can help you find HSA account custodians and trustees.
This site is devoted to consumer-friendly education about HSAs. It includes exten-sive questions and answers and links to other helpful websites.
This site can help you find HSA insurance and account custodians and trustees. The site also has a daily newsletter and has other helpful information about HSAs.
Other Helpful Sites
The following resources and websites may be helpful to you in searching for infor-mation about the price and quality of health care products and services. There's no question that figuring out what your medical care costs and what health care pro-vider offers the best quality care won't be easy. It's definitely not as easy as pricing out a Honda Accord, fully loaded. But when it comes to your health care, spend at least the same amount of time calculating the costs as you do pricing out your new ride.
Healthwise develops consumer health information to help people make better in-formed health decisions.
Humana Inc., in partnership with advocacy group Consumer Action, has created a free website that includes a family health budget planner. On the site you will find a number of tools to help you choose the best health care plan and benefits. The planner takes you through a step-by-step questionnaire asking for information such as your current insurance status, how many times members of your family go to the doctor, how often prescription medicines are purchased and how often the family visits the dentist, eye doctor or other specialists. Once you've added the informa-tion, you get a calculation of how much you need to set aside for health expenses for the year.
35 WageWorks Inc.
Wage Works is a provider of consumer-driven tax-advantaged spending accounts for health and dependent care. The site has a contribution and savings calculator for HSAs.
HealthGrades is a health care ratings company based in Golden, Colorado that sells reports on the cost of 55 medical procedures, based on regional averages of payments made by health plans. One report costs $7.95, but if you are facing a high deductible, it's worth the price to get detailed price information. You can also get physician reports, which include the amount that individual physicians are paid by Medicare for more than 100 types of procedures and visits. HealthGrades also offers hospital ratings of 28 procedures and diagnoses at more than 5,000 non-fed-eral hospitals free. If you know you'll need to be hospitalized, for $17.95 ($2.95 for subsequent reports) you can get a more detailed hospital report that looks at the price of nearly 100 procedures. Before you buy a report, check with your employer because HealthGrades works with 125 major corporations to provide them free as a benefit.
There are several web sites that now offer consumers the opportunity to order the same diagnostic tests that they might get through traditional health care means – such as labs, hospitals and clinics. What makes these web sites unique is that consumers do not need a prescription from their doctor to have the test. Consum-ers pay up front for the tests they want and receive a receipt to submit for reim-bursement from their insurer, flexible spending account or HSA.
This web site is 10 years old and has more than 30,000 members. It provides ac-cess to information for nearly 40 chronic illnesses.
Blue Cross and Blue Shield Association "Blue Distinction"
The Association has launched "Blue Distinction," an online-based program that includes a price transparency demonstration for medical services for 17 Blue Cross and Blue Shield plans around the country.
Preventive Care Screening Services
Breast Cancer (e.g., Mammogram) Cervical Cancer (e.g., Pap Smear) Colorectal Cancer Prostate Cancer (e.g., PSA Test) Testicular Cancer Heart and Vascular Diseases Screening
Abdominal Aortic Aneurysm Carotid Artery Stenosis Coronary Heart Disease Infectious Diseases Screening
Chlamydial Infection Hepatitis B Virus Infection Human Immunodeficiency Virus (HIV) Infection Tuberculosis Infection Mental Health Conditions and Substance Abuse Screening
APPENDIX 1 (cont.)
Metabolic, Nutritional, and Endocrine Conditions Screening
Anemia, Iron Deficiency Dental and Periodontal Disease Diabetes Mellitus Obesity in Adults Musculoskeletal Disorders Screening
Obstetric and Gynecologic Conditions Screening
Bacterial Vaginosis in Pregnancy Gestational Diabetes Mellitus Home Uterine Activity Monitoring Neural Tube Defects Rh Incompatibility Ultrasonography in Pregnancy Pediatric Conditions Screening
Child Developmental Delay Lead Levels in Childhood and Pregnancy Scoliosis, Adolescent Idiopathic Vision and Hearing Disorders Screening
Hearing Impairment in Older Adults APPENDIX 2
Allowable (Tax-Free) Expenditures from
Your Health Savings Account
Examples of Allowable Expenditures from Your Health Savings Account
Alcoholism treatment
Ambulance services
Artificial limbs and teeth
Birth control pills (by prescription only)
Breast reconstruction surgery (mastectomy)
Childbirth, labor and delivery services
Chiropractic services
Christian Science Practitioner services
Contact lenses
Cosmetic surgery, but only if due to trauma or disease
Dental care
Dermatology services
Diagnostic devices
Drug addiction treatment (inpatient)
Fertility treatments
Gynecology services
Hearing aids
Home care
Hospice care
Hospital services (inpatient and outpatient)
Laboratory services
Laser eye surgery (e.g., LASIK)
Long-term care (does not include custodial care)
Maternity care
Nursing services
Medicare deductibles, copays, coinsurance, premiums
NOTE: This list is illustrative and is not meant to be an exhaustive list. There have been thousands of cases in-volving the many nuances of what constitutes "medical care" under the Internal Revenue Code, which governs Health Savings Accounts. A determination of whether an expense is qualified as "medical care" is based on all the relevant facts and circumstances. To be an expense for medical care, the expense has to be primarily for the diagnosis, cure mitigation, treatment, or prevention or alleviation of a physical or mental defect or illness. The determination often hangs on the word "primarily." Additional information is available from IRS Publication 502 (available through Consult your physician and tax advisor, if you have questions.
APPENDIX 2 (cont.)
Examples of Allowable Expenditures from Your Health Savings Account (cont.)
Nursing home careOphthalmology servicesOrgan transplants (including donor's expenses)OrthodontiaOrthopedic services, including orthopedic shoesOsteopathic servicesOver-the-counter medicinesOxygen and equipmentPediatric servicesPersonal care services for chronically ill personsPodiatry servicesPre-natal and post-natal carePrescription medicinesProstheticsPSA testsPsychiatric carePsychology servicesRadiology servicesSmoking cessation programsSplintsSurgical servicesTransportation expenses for health careVaccinesVision servicesVitamins (only if prescribed by a licensed practitioner)WheelchairsX-Rays APPENDIX 2 (cont.)
Non-Allowable (Not Tax-Free) Expenditures
from Your Health Savings Account
Examples of Non-Allowable Expenses
Advance payment for future medical expensesAthletic club membershipAutomobile insurance premiumsBaby sitting (for healthy children)Boarding school feesBottled waterCosmetics and personal hygiene productsDancing lessonsDiaper serviceDomestic helpElectrolysis or hair removalFuneral expensesHair transplantsHealth programs at resorts, health clubs, & gymsHousehold helpIllegal operations and treatmentsIllegally procured drugsMaternity clothesNutritional supplementsPremiums for life, disability, other accident insuranceScientology counselingSocial activitiesSpecial foods/beveragesSwimming lessonsTeeth whiteningTravel for general health improvement Appendix 3
The following comparison appeared in the Washington Post on October 26, 2004 The article compares how families might fare under a traditional PPO plan versus an HSA plan if they have low, medium, or high medical expenses in a given year. This article compares plans available only to federal employees for calendar year 2005 (the first year HSA plans were offered to federal employees). While this example may not be an appropriate comparison for every family, it illustrates how one could determine whether they would be better off financially under a traditional plan or an HSA.
Appendix 3 (cont.)
Patient Advocate Foundation does not endorse or recommend to any consumer or aggregate population the use of HSAs or HDHPs. Rather PAF is seeking to inform consumers of features and benefits of these products.


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