POSTAL ADDRESS HEAD OFFICE IMPORTANT - PLEASE READ CAREFULLY Please list receipts for all medical costs and ALL PRESCRIPTION CHARGES INDIVIDUALLY, below. “Consultation” or “check up” is NOT sufficient for the “Reason for Visit” section (this information is for auditand planning purposes and helps ensure that benefits are kept current). CLAIMS FORM All claims cheques are pa
Trustadmin.comPre-Tax Contributions andTax-Free Accumulation of Funds Health Savings Accounts provide both Employers and Employees an innovative way to solve the problem of rising health care costs. At Trust Administrators, we offer a comprehensive, seamless platform for administering HSAs, Flexible Spending Accounts (FSAs) and Health Reimbursement Arrangements (HRAs). HSAs Offer A Win-Win Solution Now And For The Future
Health Savings Accounts (HSAs) were created by the Medicare Prescription Drug,
Improvement and Modernization Act of 2003 adding section 223 to the Internal Revenue Code effective January 1, 2004. These individually owned accounts act like medical IRAs. HSAs allow individuals to pay for “qualified” health care expenses now using pre-tax contributions and throughout their lifetime on a “Tax-Free” basis. Employer Benefits
• Lower premiums than traditional PPOs or • Affordable premiums and more control Free contributions through a section 125 • Curb the on-going problem of shifting • Combine with an FSA using the FSA for • Account is portable, stays with owner.
• TAI administers plans from Aetna, Blue Cross & Blue Shield, California Choice, CIGNA, Guardian, Humana, Kaiser, Pacific Advantage, Principal, Nationwide, United Brokers and Consultants
• Offer TAI as the single source for all HSAs may only be established by individuals consumer-driven health care services: HSAs, with High Deductible Health Plans (HDHP) and may not be covered by another plan unless coverage is for accidents, disability, dental, solving their rising health care costs.
For 2005, an HDHP has (1) an annual deductible of at least $1,000 and a maximum of $2,650 for HSA Highlights
individual coverage and at least $2,050 for family coverage and a maximum of $5,250. These are in-network amounts. Out of network • Withdrawals or TAI reimbursement are tax- deductibles could be higher; and (2) the free if used for eligible health care expenses maximum out-of-pocket expenses are capped at $5,100 for individual coverage and $10,200 for • No “Use-it or Lose-it” forfeiture like a Flexible family coverage. Maximum out-of-pocket is Spending Account - funds roll over each year.
usually the deductible plus coinsurance for office • Works in conjunction with High Deductible Health Plans (HDHPs) from insurance companies (see Legal Requirements).
Catch-up provisions for individuals who are 55 or older is an additional $600 for 2005 ($500 in Sample List of HSA Expenses
The TAI Advantage
As an independent HSA administrator with over 20 years of medical claims experience and a national reputation, Trust Administrators offers a comprehensive range of value added services for • Competitive monthly fee for each HSA. No termination fees, no transaction fees and no • Employer administration kit with sample letter introducing HSAs to employees.
• Employee Summary with information about • Online Account management for employers and employees with detailed financial reports.
• Payment to providers or account holder.
• Account holder reimbursement through employer payroll, direct deposit or check.
• Tax Advice about “eligible” expenses. • Integrate HSA with TAI’s FSA or HRA administration for a “one” claim system. Covered Expenses Include Over-The-Counter Drugs and Medical Supplies
ANTACIDS: Alka-Seltzer, Amphojel, Anusol, Bromo Seltzer, Citrucel, Dulcolax, Ex-Lax, Fibercon, Fleets Enema, Gas-X, Maalox, Milk of Magnesia, Mylanta, Pepcid, Pepto-Bismol, Prilosec OTC, Rolaids, Tagamet, Tums, Zantac COLD-ALLERGY: Actifed, Afrin, Antihistamines, Benadryl, Chloraseptic, Chlor-Trimeton, Claritin, Cold-Eeze, Comtrex, Coricidin, Dimetapp, Drixoral, Nyquil, Robitussin, Sucrets, Sudafed, Suphedrin, Theraflu, Vics 44D DIAGNOSTIC DEVICES: Blood sugar test kits, HIV test kits, Pregnancy test kits, Thermometers MEDICAL EQUIPMENT: Beds (special needs), Breast pump, Crutches, Ionizer, Wheelchair MEDICAL SUPPLIES: Ace “Elastic” bandage, Adhesive strips (Band-aids), Adhesive tape, Butterfly bandages, Cotton balls, Insulin, Q-tips, Nicotine Patch and Gum, Saline solution, Sterile gauze pads OINTMENTS & TOPICAL TREATMENTS (supplies): Alcohol (“isopropyl”), Bacitracin, Bactine, Caladryl, Calamine, Clearasil, Corn removal medicine, Cortaid (“hydrocortison”), Freezone, Gyne-Lotrimine, Hydrogen peroxide, Lanacain PAIN RELIEVERS: Aspirin, Advil, Alleve, Anacin, Bayer, Bufferin, Cystex, Doans, Dramamine, Excedrin, Ibuprofen, Legatrin, Midol, Motrin, Naproxen, Pamprin, Tylenol 2005 Royce A. Charney, J.D. for Trust Administrators, Inc. All Rights
MEDICAL HISTORY PATIENT NAME: _____________________________________________________ DATE OF BIRTH: _______________________ Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.