Service Implementation

General Company Information
POP
FSA
HRA
HSA
COB
TRA
QID
OTH
Company Name*
Address*
Street Address
Street Address Line 2
CityState
Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Tax ID*
Please enter a valid tax id.
Company Structure*

Primary Contact*
First NameLast Name
Title / Position*
Email*
example@example.com
Name of Officer Who Will Sign Plan Documents*
First NameLast Name
Title of Officer*

125 Plan Features
Pre-Tax Premium Deductions
Major MedicalGroup Dental / VisionGroup Term LifeGroup Disability (STD/LTD)
Other Plan Features
Health Savings AccountsCash in Lieu of BenefitsVacation Buy / Sell OptionFlexible Credits
Flexible Credit Amount*

105 / HRA Financial Detail
Flat Rate per Plan Year*
Annual Benefit Amounts:
(E)mployee Only:   EE*
Employee + (S)pouse:   ES*
Employee + (C)hildren:   EC*
(F)amily:   F*

Section 105 / HRA Carryover Design
Carryover Percentage*
Percentage of unspent funds in the current year that will carry forward for use in future years. This can be any number from 0 to 100.
Carryover Cap*
The total dollar value the HRA can accumulate up to, when including all previous years carryover. The cap does not include the current year benefit. Just the accumulation of past years.
Annual Usage Cap*
The total dollar amount that a person can withdraw from their HRA in any given year. Enter NONE for no cap.

Section 105 / HRA Spend Down Design
Percentage of Accumulated HRA to be Accessible for Spend Down*
Please enter an integer between 0 and 100
Number of Months Allowed to Access Spend Down*
Spend Down is started upon loss of eligibility. So this would limit the time allowed for someone to access it after their event. This is typically 36 - 60 months, but can be any number.
Events that will allow for Spend Down Access*
Termination (Non Retirement)RetirementDeath of EmployeeDisability of EmployeeFull Time to Part TimeUSERRA Leave

Commuter Plan Options
Options Desired*
Parking ReimbursementTransit ReimbursementParking ConversionTransit Conversion
How Often Can Employees Change Election Amounts?*

Plan Year and Eligibility
Start Date / Effective Date*
MonthDayYear
Date
Renewal Date*
MonthDayYear
Typically when insurance renews or when deductible resets.
Service Time Required to Become Benefit Eligible*
How Frequently Plan will Allow Eligible Employees to Enter the Plan*
Minimum Age of an Eligible Employee
Min # of Hrs/Week of Eligible Employee
Exclude Union Employees*
YesNo
Min # of Months per Year to be Eligible as a Seasonal Employee

Deduction Cycle Information
Pay Period 1*
Date of 1st Pay Deduction*
MonthDayYear
Date
Do You Have a 2nd Pay Cycle*
YesNo

Deduction Cycle Continued
Pay Period 2*
Date of 1st Pay Deduction*
MonthDayYear
Date

Hidden Page with All the Data
DPOP
DFSA
DHRA
DHSA
DCOB
DCOM
USEY
USEN
A_SERV_AGREE
A_BAA
A_REI_APX
A_CRD_APX
A_COB_APX
A_SET_APP
A_HSA_APP
A_BNK_FRM
A_EE_SRA
A_EE_EFT
A_EE_CRD
SERVICE AGREEMENT

Payment Services Information
Want Pay*
YESNO
Bank Name*
Bank Address*
Street Address
Street Address Line 2
CityState
Zip Code
Account Number*
Routing Number*
Account Type*
CheckingSavings
Starting Check #*
Signature to Print on Mailed Checks
Clear

Understanding Debit Cards
Debit cards are an additional way for FSA and HRA participants to access their benefit dollars. They are unique and can provide convenience to the plan participants. However, they also add a layer of complexity that should be understood before implementing them in any program.
Do you wish to offer the mySourceCard MasterCard debit card to your benefit plan participants?*
YESNO
SUBSTANTIATION REQUIREMENTS
The government/IRS requires that all benefit payments (including card payments) be SUBSTANTIATED. This means the plan is required to know that each card transaction is a valid plan payment.
A valid plan payment is substantiated by providing a document that shows:
- Date of Service (must happen in current plan year)
- Service Rendered/Provided (must be an eligible service)
- Name of Claimant (must be an eligible individual)
- Amount Owed (do not have to have paid yet)
However, debit card transactions only tell us:
- Date of Payment (could be paying something from the past)
- Provider Name (not what service was received)
- Payor (not who received the service)
- Amount Paid (not amount due)
Because of this, the transactions details (or just the receipt) from the card is not good enough, and follow-up paperwork IS REQUIRED unless...
1. The transaction takes place at a certified merchant. Such merchants agree to verify that all items purchased with the card are eligible, and they agree to keep the records. The only such merchants that exist are most medium and large chain pharmacies. So, most Rx purchases are paperless.
2. The transaction amount and location matches a known co-pay in the participants health plan. The IRS has stated that if, for example, a $30 transaction takes place at a Doctor's office, it can be assumed that the date of service is the date of payment, the payor is the person receiving services, and the service provided is eligible, if it is know that such a co-pay exists on a health plan that covers that participant.
All other transactions will require paperwork follow up to be eligible. Further, we are required to temporarily block all cards who fail to follow up on such documentation, until it is resolved. Generally, if a card transaction is unresolved after 30 days, it will create a temporary block on the cards.
I understand participant card transactions that are left unsubstantiated and do not auto-clear will cause their card to be blocked after 30 days until resolved.*
Yes

Understanding Substantiation Q1
Please choose the best answer below
Most Card Transactions at Pharmacies...
Will require follow up documentationWill auto-clear if they match a known co-payWill auto-clear at any amount
Q1. CORRECT
Because most medium to large chain pharmacies are agreeing to have a point-of-sale system that assures only eligible items are purchased, most Rx transactions will auto clear at any amount. They don't even have to match a co-pay.
However, for the few pharmacies that don't have such point-of-sale systems, a copay match will clear those transactions.
Q1. INCORRECT
Because most medium to large chain pharmacies are agreeing to have a point-of-sale system that assures only eligible items are purchased, most Rx transactions will auto clear at any amount. They don't even have to match a co-pay.
However, for the few pharmacies that don't have such point-of-sale systems, a copay match will clear those transactions.

Understanding Substantiation Q2
Please choose
A participant has a benefit with plan year that runs from 1/1 to 12/31. The participant has $500 available on their benefit card.
On 6/23 of that year, they use their card at their Dentist to pay their $179 bill for a cleaning on their dependent child.
What of the following IRS required information is known from the card transaction details (or receipt). Check any/all that apply.
Date of ServiceService RenderedName of ClaimantAmount Due
Will the transaction require documentation to be submitted to Superior State?*
YesNo

Understanding Substantiation Q2
CORRECT
Unless $179 is a known co-pay match for a dental plan, that transaction will require documentation to be submitted. In general:
- We don't know the Date of Service, just date paid.
- We don't know the service rendered, even though it's at a dentist office, it could be for something like teeth whitening, which isn't eligible.
- We don't know who received the service, just the name of the cardholder who paid the bill.
INCORRECT
Unless $179 is a known co-pay match for a dental plan, that transaction will require documentation to be submitted. In general:
- We don't know the Date of Service, just date paid.
- We don't know the service rendered, even though it's at a dentist office, it could be for something like teeth whitening, which isn't eligible.
- We don't know who received the service, just the name of the cardholder who paid the bill.

Funding Debit Cards
Establishing Your Settlement Account
In order to offer cards to your employees, you must first establish a "Settlement Account". This is basically a non-interest bearing bank account that your company establishes at Armstrong Bank, who is our card issuer. All employee card transactions will draw from this single, employer owned, central account.
These are debit cards, and thus funds must be in your account, or card swipes will fail for lack of funds. Generally, the goal is to fund the account at a level that will allow for expected card activity but not have too much extra cash just sitting in the account.
To try to meet this goal, we establish 2 parameters (which can be adjusted at any time), the MINIMUM BALANCE and the REPLENISHMENT AMOUNT. They work together to keep adequate funds in your SETTLEMENT ACCOUNT, while keeping your cash tied up to a minimum.
The Minimum Balance
This is the settlement account balance threshold, such that when transactions reduce your overall balance below this amount, it will automatically initiate a Replenishment Request. Typically, your minimum balance is set at around 10% of your overall collective employee benefit balances.
The Replenishment Amount
This is the dollar amount that is requested to be put back in, or "replenished" to your settlement account any time your account drops below the minimum balance. Note, the smaller the replenishment amount, the more frequent you will get replenishment requests. The larger the replenishment amount, the further above the minimum balance threshold you get, thus extending the time between replenishment requests.
Funding Your Settlement Account
The settlement account needs funds for cards to operate. So, how do we fund that account. We offer 3 methods, however the most common and recommended form is via an EFT from one of your general operating accounts.
An EFT allows for next (business) day replenishment of the account, thus supporting lower overall cash balances, while still maintaining enough funds to cover expected transactions. There is no charge for this method.
We also accept check or wire replenishments, however the check process takes much more time (at least a week) to replenish, and both the wire and the check processing carries a transaction fee.
In closing, this is an account you own, you will be able to see all bank activity via our secure website, and should you discontinue cards, the account will be closed and balance returned to you. A SETTLEMENT APPLICATION form will need to be returned to us to open your account.
I better understand the complexities of benefit debit cards and wish to proceed with the card application process.*
Yes, continue.No, I no longer wish to offer cards.

Debit Card Information
Company Name to Appear on Cards*
Limited to 24 Characters
Debit Card Contact Name*
First NameLast Name
Debit Card Contact Email*

Health Savings Account Funding
Because HSAs are INDIVIDUALLY OWNED BANK ACCOUNTS, you as the employer have limited access. However, one feature you will have is the ability to initiate funding into any/all of the HSAs that are established under your company umbrella.
How will you fund Employees HSAs?
We are not funding themWe will mail in a check as neededWe wish to fund electronically via EFT/ACHWe will wire the funds (carries a fee)

Electronic HSA Funding
Name of Bank*
Account Type*
CheckingSavings
Account Number*
Routing Number*
Wire Instructions
Funding Your Employee’s HSAs

Funding your Employee’s Health Savings Account at HSAToday® is completely in your control. We can assist with the funding process. We offer EFT services and can debit (pull) directly from your company’s account at your instruction. Or you can push those funds via a Wire transfer or EFT to the HSA Custodian using your own Cash Management tools provided by your bank.
If your method of choice is to Wire or EFT using your own resources, then please call us at 888-665-1264 and we will supply the bank account information necessary to complete the wire transfer.
Important: There is a $15.00 Wire Fee for incoming wire transfers and your local bank may charge for outgoing wires. Consult your bank for more information.

Medical Plan Information
Plan Name / Description*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
Monthly Premium Structure*
Tiered Coverage (Common)Varies by AgeVaries by GenderVaries by Age and GenderIndividually Rated
Monthly Premium Paid to Carrier
Upload Copy of Rate Sheet
Cancelof
Do You Have Another Medical Plan?*
YESNO

Medical Plan #2 Information
Plan Name / Description*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
Monthly Premium Structure*
Tiered Coverage (Common)Varies by AgeVaries by GenderVaries by Age and GenderIndividually Rated
Monthly Premium Paid to Carrier
Upload Copy of Rate Sheet
Cancelof
Do You Have Another Medical Plan?*
YESNO

Medical Plan #3 Information
Plan Name / Description*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
Monthly Premium Structure*
Tiered Coverage (Common)Varies by AgeVaries by GenderVaries by Age and GenderIndividually Rated
Upload Copy of Rate Sheet
Cancelof
Monthly Premium Paid to Carrier

Dental Plan Information
Plan Name / Description*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
Monthly Premium Paid to Carrier*
Do You Have Another Dental Plan?*
YESNO

Dental Plan #2 Information
Plan Name / Description*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
Monthly Premium Paid to Carrier*

Vision Plan Information
Plan Name / Description*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
Monthly Premium Paid to Carrier*

HRA Plan Information
Plan Administrator / Service Provider*
Date Rates Effective*
MonthDayYear
Date
Date Rates Renew*
MonthDayYear
Date
COBRA Rate (Your Service Provider Should Provide)

FSA Plan Information
Plan Administrator / Service Provider*
Date Plan Renews*
MonthDayYear
Date

Next Steps
OK. You've completed the online application (thank you!), what's next?
Once you click submit (below), this is what to expect:
- An email will be sent to the contact listed in this application with links to the agreements we will need e-signed.
- Once the agreements have been e-signed, you will receive via email, an invoice for any setup and/or annual fees for your plan(s).
- Upon receipt of payment, we will begin the setup of your plan in our systems.
Should be Empty:

General Company Information

Plans Desired to Implement

125 Plan Features

FSA Options

105 / HRA Plan Design

105 / HRA Financial Detail

Section 105 / HRA Carryover Design

Section 105 / HRA Spend Down Design

Commuter Plan Options

Plan Year and Eligibility

Deduction Cycle Information

Deduction Cycle Continued

Hidden Page with All the Data

Payment Services Information

Understanding Debit Cards

Understanding Substantiation Q1

Understanding Substantiation Q2

Understanding Substantiation Q2

Funding Debit Cards

Debit Card Information

Health Savings Account Funding

Electronic HSA Funding

Wire Instructions

COBRA Administration

Medical Plan Information

Medical Plan #2 Information

Medical Plan #3 Information

Dental Plan Information

Dental Plan #2 Information

Vision Plan Information

HRA Plan Information

FSA Plan Information

General COBRA Information

Next Steps