Fillable Enrollment Form printable pdf download

HRA VEBA Enrollment Kit

For public employees in the Northwest

basic PLaN iNFORMaTiON & ENROLLMENT FORM

Enrollment

Third-party administrator

Enrollment Kit contents:

Now that you are eligible to enroll, simply

Contact the TPA, Meritain Health, for

Basic Plan Information & Enrollment

complete the attached Enrollment Form and

information regarding your account, questions

Form

return it to your employer. IRS rules require

about claims, or to request forms. Meritain

Investment Fund Information brochure

that all employee group members defined as

Health has more than 30 years of experience

eligible must participate.

and is available to serve you from its

Investment Fund Overview (available

Minneapolis service center.

from your employer or at hraveba.org;

You will become a Participant under the

performance updated quarterly)

Plan on either: (1) the date specified by your

Please immediately notify the TPA of any

employer on your Enrollment Form; or (2) the

changes to your name, contact information, or

date upon which both a fully completed and

systematic premium reimbursement details.

introduction

signed Enrollment Form and a contribution

Congratulations! You are enrolling in the

Qualified Expenses & Premiums

have been received by the third-party

HRA VEBA Plan, a health reimbursement

administrator (TPA).

Common qualified expenses include co-pays,

arrangement for public employees in the

coinsurance, deductibles, prescriptions, etc.

Northwest.

Once the above items are received, the TPA

Eligible insurance premiums include medical,

will send you a welcome packet. Your welcome

dental, vision, tax-qualified long-term care

You can use your HRA VEBA account to

packet will provide you with:

(subject to IRS limits), Medicare Part B,

reimburse eligible out-of-pocket healthcare

• Your participant account number

Medicare Part D, and Medicare supplement

costs and premiums for you, your spouse, and

• Welcome letter confirming your employer’s

plans. Go to for a more detailed

qualified dependents. Generally, dependents

initial contribution

list.

must satisfy the IRS definition of “qualifying

• Plan Summary

child” or “qualifying relative” as of the end of

• Login directions for myHRA VEBA online

Insurance premiums paid by an employer

the calendar year in which expenses were

• Claim Form

or deducted pre-tax through a Section

incurred. See Definition of Dependent at

125 cafeteria plan, are not eligible for

investment Options

reimbursement. If you request reimbursement

of premiums deducted from a paycheck, you

You can choose either one of two participant-

The tax objectives are:

should include a letter from the employer that

directed investment options. The enclosed

confirms a pre-tax option for the deduction of

Investment Fund Information brochure contains

To enable your employer to make tax-

such premiums is not available.

detailed information. Fund fact sheets and

free contributions to the plan on your

behalf;

prospectuses are available at .

If you or your spouse have a Section 125

For your account to be credited with

Option A: Do-it-yourself

healthcare flexible spending account (FSA),

tax-free investment earnings; and

Build your own portfolio using funds from

you must exhaust the FSA benefits before

seven individual asset classes.

To enable you to obtain tax-free

submitting claims.

reimbursements for your eligible out-

Option B: Choose a pre-mix

of-pocket healthcare expenses and

Select any one of four professionally

claims

insurance premiums.

designed, pre-mixed asset allocation

Withdrawals (claims) from your account can be

portfolios.

Contributions, earnings, and withdrawals

made only for eligible out-of-pocket healthcare

(claims) are not tax reportable. You will

You can change your investment fund

expenses and premiums.

not receive a Form 1099 for earnings or

allocation up to once per calendar month.

withdrawals (claims). Unused funds in your

Simply e-mail, fax, or mail a completed Claim

account carryover from year to year.

Net investment earnings (or losses) after fund

Form or Systematic Premium Reimbursement

management and trust administrative expenses

Form to the TPA. Get these forms online at

have been deducted are credited tax-free to

, or by contacting the TPA.

your account daily.

PSE03 (Revised 8/11)

Enrollment Form

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