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r <br />-. <br />tar Char Pian 7voe (noted by <br />Set -Up Fee (due, <br />ow) ' <br />- <br />0 TASC HRA Full Administration ,. PRfCYNG , •Admin Fee ---per <br />arUcit}ant, <br />per month <br />Additional Serulcesr _. IWO:, , i Annual Renewal <br />ee <br />�. <br />- <br />(3 TASC Debit Card (included at no. charge for First Dollar Plans) - + Based an numb <br />of employees <br />Single •$4950; Pom0y-$t0,CC0 <br />ING ' No SeWp Fee <br />—!" <br />$ 0 h <br />Member (imbeddeddeductible) <br />.PRI <br />'C) TASC HRA Self -Administration INEOt • Admin Fee -per <br />roup, <br />per year (due now) <br />• Annual Renetial <br />ez <br />.. . .. _ <br />PLANINFORMATIONINFORMATI~� � ION FULL sets <br />Estimated Numier of Participants: Number of Employee; (FT+PT) to determine G41SRepordn Re qu/ emem. <br />EX'i-stlagHRA_Pn_PI <br />lanl_acet El No ❑Yes If YES, please providethefo)iawfngfnformation: <br />- ERISA 3 -Digi[ Plan 9: <br />— R of current Participants: <br />- <br />Name ofCurrent Administrator. <br />Current Run -Out: Period:.. Days <br />_ ,.Who will administer current Plari Runout? 11. tj rior no 0 TASC <br />PARTICIPANT AND ELFGIBILITY,REQUIREMEM -` I _yFlits sEIF <br />Selectooe eligibility, requirement below• -- <br />0 Eligibility requirementsinclude partidpabon in the named Health Insurance Plan fN/Afor Qualified small fmpla. er NRA Plum), or <br />:0 Eligibility requirements include (select df)that apply beoW):- ' <br />O Parttime employees wording at least _hoursof work perwee4 will be Ind uded(maxiinum 29h urs) <br />O Current employees completing_months of service with the employerwill be included (muximuqr 90 d�7s) <br />LO New employees completing_ months of service wit the employer will be Included (maximum I days <br />D Eligibllib/ requirements–OTHER: <br />PLAN DESIGN FULL sEtF <br />t Each Plan Design selected requires a separate Plan Appllwhon. Admi9istr4ticn fees erd funding arrangements apply a each p Application. <br />HRA Plan Design options (select one perAppfication)Bud etPlan Fund(ng_ The TASCead tPlaFunding Fee is calculated❑ Plani Medical Deductible Only_ At 25% asapercento the a�re.gate annual benefit <br />❑Plan 2 Medical Deductible 9 PrescriptionASSD'! under the rA6 HRA Ida. To colculareplan <br />(aRo appbes to Deductible Only ➢lout pre:alptiaas appl7 eowordJhe deductlbfel funding take 7 itail Exlosure r Funding %/12 <br />0 Plan 3: Medical Deductible & Co Insurance At 50% months. <br />O Plan 4: Medical Deductible, Cc -pay,. At 50°% Ifycu do nits a 7oaGdesfred Plan Design, <br />❑ Plan 5, Medical Deductible,_Co-Pay, Co-insurance, & Prescription At 50% please call TA ati§P0.422,4661'to discuss <br />0 Plan 6: Uninsured Medical (must be i_n_tegrated with GHP) At50% Plan setup. <br />❑ Plan 7: QSEHRA Uninsured MedicalAt 50% <br />10^ Plan 8: QSEHRA Medical InsurancePremiums At75% <br />1 0 plan 9 QSEHRA Uninsured Medical & Individual Insurance Premiums _ At 7576 <br />TAs6 HRA Pian Participant Responsibility:..Individual: S - Cl 6 <br />(amauntpartlCponN; respcnslbfzforpdor to reimhursemertsl _ ram fly Maximum: S 0'b <br />Percentae OollarAmounc Range TAS: <br />%i 5 "$ ;$ <br />Member (embedded deductible) <br />Famify Aggregate <br />HRAEmmolaver Reimbursed <br />TASC HRA/Employer Reimbursements: <br />Regulotory lunits Jar QSEHRA: <br />- <br />$ 5 <br />Single •$4950; Pom0y-$t0,CC0 <br />-�'-y-=--• <br />Max. reimbursement per Individual: <br />—!" <br />$ 0 h <br />Member (imbeddeddeductible) <br />Aa,° <br />0 b/FanilYAP-Melte <br />Paae a <br />TG]9!]03a! V <br />25E-61 <br />Employer Initial <br />i <br />