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gy "ir a' I Select one TASC HRA Plan to apply for and complete the requested information for that Plan Type (noted by corner tabs): ❑ TASC HRA Full Administration Set -Up Fee (due now) AdditionaiServiies; PRICING • Admin Fee– per participant, per month -- -- - INFO: 1 • Annual Renewal Fee El TASC Debit Card (included atno charge for First Dollar Plans) {, j • Based on number of employees PRICING ° No Set -Up Fee�� LJ TASC HRA Self -Administration • Admin Fee–per group, peryear (due now) INFO ---�.....__._�,-,__....®.m._ - • Annual Renewal Fee Pt A_N INFORMATION Estimated Number of Participants: I Number of Employees (FT+PT) to determine CMS Reporting Requirement: Existing HRA Plan in Place? : ONO CYes If YES, please provide the following information: ERISA 3 -Digit Plan #: # of Current Participants: Name of Current Administrator: – -- _ Current Run -Out Period: ; Days Who will administer current Plan Runout? ! Q Prlor Administrator ❑ TASC Select,one eligibility requirement below: 13 Eligibility requirements include participation in the named Health Insurance Plan(N/AforQualified Small Employer HRA Plans); or ❑ Eligibility requirements include (select off that apply below): O Part-time employees working at least —hours of work per week will be Included (maximum 29 hours) O Current employees completing _months of service with the employer will be included (maximum 90 days) 0 New employees Completing_ months of service with the employer will be included (maximum 90 days) h Flivihilih, ronuiromonh<_r1TVlFR• PLAN DESIGN ..®.�. ,.,._,. ............_..._ ....,..,.-..—...__....��........�, Fuu SELF. m_.. -._.,..,. Each...... Plan Design selected requires a separate Plan Application. Administration fees and funding arrangements apply to each Application. HRAPIan Design Options one perA pl/catlon) 3 Budget Plan Funding, ❑ by Member (embedded deductible) _ _ _ _— _ .._. ❑ Plan 1: Medical Deductible Only - At 25% The TASC Budget Plan Funding Fee is calculated as a percent of the aggregate annual benefit ® PIan2 Medical Deductible&Prescription At 50% under the TASC HRA Pion. To calculate plan also applies to Deductible Onfy Plant presmiptions apply toward the deductible/ -funding take Total Exposure x Funding %/12 Plan 3: Medical Deductible & Co -Insurance At 50% months. ❑ Plan4 Medical Deductible Co -pay &Prescription At S0% Regulataryllmits for QSEHRA: -. lfyou do not see your desired Plan Design, ❑ PIanS Medical_Deductible,_Co-Pay, Co -Insurance &Prescription __. At 50°% please Cali TASC at 1.800.422.4663 to discuss ❑ Plan 6: Uninsured Medical (must be Integrated with GHP) At SO% Plan setup. ❑ PIan7 QS EH RA Uri insured Medical At 50% Plan 8: QSEHRA Medical Insurance Premiums At 75% ❑ by Family Aggregate ❑ Plan 9 QSEHRA Uninsured Medical & Individual Insurance Premiums At 75% HRA tiRE1M6URSEMENTSw.....,a...._.....: Fuu 5E4F, .......::....:M......��._............®........._...,....._....m.......ea._._..,........_......�.a.,®.,....�.m,t TASC HRA Plan Participant Responsibility: Individual: $ - ❑ by Member (embedded deductible) (amount porticipant is responsiblefor prior to reimbursements) Family Maximum: $ ❑ by Family Aggregate Percentage T Amount Ranee TASC NRA/Employer Reimbursed _ _Dollar % ($ $ ... -__ J $ TASC HRA/Employer Reimbursements: Regulataryllmits for QSEHRA: _. $ -- Single Family �0—�.=--.-------_--$ -$4950; -$10,000 --1$$___--- Max. reimbursement per individual:$ - --------- I] by Member (Imbedded deductible) Max. reimbursement per Family: $ ❑ by Family Aggregate Page Employer Initial �';'cI10TASi- TC3923-010117---------