Form Ms-04-1598 - Health Savings Account Bank Notification Form (Page 2 of 2) in pdf

Section II: Health Plan Information

Group ID# (If available): _______________________________

Effective Date of Medical Contract: _______________________

Number of Employees enrolling in the HSA:______________

In-Network Deductible Information:

Plan 1: Single __________________________________________ Family: ______________________________________________________

Plan 2: Single __________________________________________ Family: ______________________________________________________

Section III: Employee Enrollment Information

How will enrollment information be transmitted to Exante Bank? Select one:

My employees will enroll online at

Send PDF of all enrollment materials to the e-mail address on page 1. I will print copies and distribute to my employees.

Send me enrollment kits to distribute to my employees. (The number of kits is dependent on the number of employees

indicated above. We will send you additional kits for any new employees that join throughout the plan year.)

Batch File (Please have Exante Bank contact me to discuss format of file.)

My Oxford contact has already supplied enrollment materials to me.

Section IV: HSA Administration

A. Administration Expenses:

One-time, Set-up Fee: Oxford Health Plans will pay the one-time, set-up fee for all employees that enroll in the first three months,

starting at the health plan effective date. For all employees enrolling after the three-month mark, the set-up fee will be debited from

the Members account.

Monthly Maintenance Fee: (Fee always debited from employee’s account) Select one:

Employee will pay monthly maintenance fee.

Employer will contribute funds to employees account to pay for monthly maintenance fee.

B. Employer Contributions (Above or in lieu of monthly maintenance fee contribution):

Will employer be contributing to the employee’s HSA account? (Select one)

Yes

If yes, how will the funds be sent to Exante Bank?

Check

Wire Transfers

ACH Contribution File

(Please have Exante Bank contact me.)

Frequency of Employer Funding:

Every payroll period

One time at beginning of plan year

Quarterly

Other ___________________________

C. Payroll Deductions:

Will HSA funds be transferred into employee accounts via payroll deductions? (Select one)

Yes (Note: Group must have an existing relationship with a payroll company)

Comments and other Special Instructions:_____________________________________________________________________________

__________________________________________________________________________________________________________________

MS-04-1598

7423 R1

Form Ms-04-1598 - Health Savings Account Bank Notification Form Page 2