Requirements Gathering Document

2017 Health Savings Account

Table of Contents General Information Client Information Client Name: DBA or AKA Name: Client Address: Client Tax ID: Expected Participant Number of Count Benefit Eligible: :______Entity Type (S Corp, C Corp, LLC): Industry: Tax Year End Month and Day: State Organized: Controlled Yes No Group: If yes, list Affiliates including Tax ID#

HSA Custodian Healthcare Bank High Deductible Enrollment in a HDHP (High Deductible Health Plan) is required to contribute to a Health Health Plan Savings Account. A HDHP is a plan that features higher deductibles than traditional (HDHP) insurance plans and can be combined with HSAs to allow participants to pay for qualified out-of-pocket medical expenses on a pre-tax basis. Please see chart below to make sure your plan qualifies. Beneficiaries It is highly recommended that each HSA participant establishes primary and contingent beneficiaries. If no beneficiaries are designated, funds are subject to probate upon death. Please Note: If you are married and you do not name your spouse as 100% primary beneficiary, they must complete the spouse consent piece of the beneficiary form. Timing of  All contribution types, regardless of system settings, takes 2-3 business days for Contributio deductions to post to participant’s accounts. ns  The earliest a contribution can be posted at the start of the calendar year is 2-3 business days after the holiday. Although there is some formal and informal federal guidance on situations when HSA contributions can be reversed providing there is clear documentary evidence there was an administrative or process error, there is no formal or informal guidance on the below situations and therefore funds cannot be removed from the accountholder’s HSA when these occur:  Employee has change of coverage where they cease to be HSA eligible, yet the employer continues to contribute.  Employee terminates employment, but employer continues to make HSA contributions.  Any circumstance where there is not clear documentary evidence that demonstrates there was an administrative or processing error. Timing of  Distributions are processed daily (Checks or Direct Deposit) Distribution  Checks are mailed next day s  Checks - $5.00 fee per check/Direct Deposit – FREE  Payment preferences can be updated via the Participant Portal  Direct Deposits are posted same day and available to participants within 1-2 business days after files are loaded. Monthly Account  Monthly HSA Statements are required Statements  Statements are provided to participants on a monthly basis  Printed statement fee is $5.00 per printed statement  Participants can opt out of paper and into electronic statements by updating their Notification Preferences in the Participant Portal

Contribution Maximums HSA Contribution and HDHP Minimum Deductible and Out-Of-Pocket Limits HDHP Minimum Deductible Amount 2013 2014 2015 2016 2017 Individual $1,250 $1,250 $1,300 $1,300 $1,300

Family $2,500 $2,500 $2,600 $2,600 $2,600 HDHP Maximum Out-of-Pocket Amount 2013 2014 2015 2016 2017 Individual $6,250 $6,350 $6,450 $6,550 $6,550

Family $12,500 $12,700 $12,900 $13,100 $13,100 HSA Statutory Contribution Amount 2013 2014 2015 2016 2017 Individual $3,250 $3,300 $3,350 $3,350 $3,400

Family $6,450 $6,550 $6,650 $6,750 $6,750 Catch-Up Contributions (age 55 or older) 2013 2014 2015 2016 2017 Individual $4,250 $4,300 $4,350 $4,350 $4,400

Family $7,450 $7,550 $7,650 $7,750 $7,750 IDV/OFAC All HSA accounts established request IDV/OFAC Verification. IDV – Identify Verification Process – A banking requirement that comes from the US Patriot Act Bill signed into law in 2001. OFAC – Office of Foreign Assets Control – Part of the US Department of the Treasury that administers and enforces economic and trade sanctions. Document to support account validation may be requested. Participants have 60 days from account establishment to submit requested documentation before the initiation of account closure.

Terms & In addition to passing the IDV/OFAC verification process, all participants must accept the Conditions terms and conditions.

Failure to If either the account does not pass IDV/OFAC verification and/or the Terms and Establish Conditions have not been accepted after 60 days from account establishment, the account will be closed and any pending contributions will be returned to the employer.

Optional Participants can opt into auto investment sweeps. Minimum threshold is $2,000. If Investment selected, funds are automatically sweep into the investment account once the available Sweeps cash balance exceeds the sweep threshold amount by $100 or more. Likewise, when the available cash balance falls below the sweep threshold by $100 or more, funds will automatically sweep back to the cash account from the investment account. If auto investments are not selected, funds will remain in a cash account. Health Savings Account Plan Details Please provide information about the required spending account plans by completing the information below.

Plan Name: HSA Description: Health Savings Account Plan Year Begin: Company Contribution: Yes No If Yes, Amount: $ If Yes, Frequency: Debit Card Expenses Allows: All Expenses 213 Expense Only *Custom Logo on Debit Card: Yes No *Single color logo card - $500 fee, Multiple colored logo card – $1,000 + (discussion during implementation)

**Terminated employees will utilize the card with the company Logo upon termination. Divisions (If applicable): **Expense Tracker Feed: Yes No **Subject to carrier guidelines Medical Carrier: Will a post-deductible HRA also be offered in conjunction with the HSA? Yes No Will a Limited Purpose FSA also be offered in conjunction with the HSA? Yes No **if implementing Post-Deductible HRA and/or LPFSA additional paperwork and fees may apply.

Payroll Posting - Please choose one of the following options below Posting of payrolls to an HSA account takes approximately 2-3 business days to be available to participants while transmitting through the banking process. There are two options to post payroll contributions.

Option 1 - Auto Post Once Confirmed Via File – File will import immediately and will not wait until payroll date to start banking process. Funds will take approximately 2-3 business days to post from file import date. PLEASE NOTE: Files for a future calendar year cannot be posted until the year begins or contributions could be erroneously posted to a prior tax year. Example: First payroll date in January is 1/4, the contribution file should not be posted until 1/1 or later to avoid being picked up in the prior tax year.

Option 2 – Auto Post on Payroll Date – Files imported will wait until the payroll date (determined via a schedule) to begin the banking process. Once the payroll date arrives the 2-3 day banking process will begin. This approach is not an issue during the new calendar year. Example: First payroll date in January is 1/4, the contribution file will wait until 1/4 to begin the 2-3 day banking process, no matter when the file is actually posted.

These options affect all plan types administered by Benefit Strategies, LLC including HCA, DCA, HRA and Commuter Choice plan types. If option 1 is selected, all payrolls, including CDH plans, will need to be imported. CDH payroll funds are available on the day imported and are not subject to the 2-3 business day processing time.

Tax Forms Healthcare Bank’s standard delivery method for 1099-SA and 5498-SA tax forms will be electronically, through the HSA Participant Portal. Forms will be maintained in the HSA Participant Portal for seven (7) years.  Form 1099-SA – Distributions  Form 5498-SA – Contributions Must include yearly total of contributions in form 8889 with tax forms Contribution Imports

IMPORTANT INFORMATION: Contributions are imported into the administrative system by the Employer via the Employer Portal. Access will be sent to the contact provided whom will be responsible to process the import. All HSA contributions take 2-3 business days to clear the banking process and be available to participants.

For further training and instructions on processing the HSA Import for Employer and Employee Contributions. Please schedule a webinar to review the process after the implementation is complete and the account has been assigned to your day to day contact.

Enrollment Options Benefit Strategies, LLC provides various flexible enrollment options for Health Savings Accounts. Please see our available options below and check the appropriate option.

Important: All participants must provide a physical address to establish an HSA account. A PO Box will not be accepted per IRS regulations.

*If recurring eligibility file being sent consumers ability to make profile changes will be turned off. Online Enrollment Online Enrollment is the most quick and efficient way to establish a Health Saving Account. The demographic census must be provided to Benefit Strategies to allow us to set up system access before the online process begins. Please also provide the dates for the online enrollment process to be open below (needs to end prior to plan administration start). The online process includes all aspects of enrollment including accepting the Terms & Conditions and beneficiary designation options. Online Enrollment Start Date: Online Enrollment End Date: Enrollment Census The Enrollment Census includes all information for enrollment into a Health Savings Account, including beneficiary information. PLEASE NOTE: A separate process to accept the Terms and Conditions must be completed to finalize enrollment. Options include verifying within the Participant Portal or via paper (additional fees will apply). Establishment Application The HSA Establishment Application includes all information for Establish a Health Savings Account, including beneficiary information. PLEASE NOTE: A HSA confirmation email from Benefits Strategies will be sent with Account Login information and participants will be required to login and accept the Terms and Conditions in order to finalize enrollment. (Fees May Apply) The HSA Establishment Application can be used for ongoing eligibility. It is the Employers responsibility to enter and update ongoing enrollments Ongoing Eligibility once account is set up and active. Access to the online portal will be provided at that time for ease of use to update these changes throughout the plan year. Please see your assigned Account Manager if you have any questions.

Participant Communications Email notifications are sent to active participants with an email address when the letters below are generated. The email notification informs the participant the associated letter is available for viewing via the Participant Portal.

Health Savings Account Participant Notifications  Advice of Deposit for HSA Distribution  Enrollment Confirmation Open-Ended Plan Year  HSA Account Closure  HSA Account Summary  HSA Cash Balance Notification  HSA Contribution Maximum Notification  HSA Contribution Notification  HSA Payment Issued Notification  HSA Tax Document  HSA Recurring Contribution Created  HSA Recurring Contribution Updated  HSA Recurring Contribution Cancelled  HSA Withdrawal Notification Indicate if a client logo will be displayed on the Participant Portal home page.

Custom Logo for Spending Account Self Service Home Page

Participant Forms/Information Each form will be displayed for participants to download from the Participant Portal.

Sample Health Savings Account Forms Distribution Request Form Used to file Distributions, Rollovers (to self) or Transfers (to another custodian).

Contribution Request Form Used for the manual contribution of funds into your Health Savings Account. Beneficiary Change Form Used to add or update beneficiary information. Also used as a Spousal Consent form if spouse is not 100% primary beneficiary.

HSA Brochure Informational material for participants about a Health Savings Account.

HSA Investment Options View the investment options currently available to HSA participants. Employer Reports

Plan Management Reports HSA Account Detail Report HSA Employer Summary Report

 Reports are scheduled to run on a monthly basis.  Reports are posted on the Employer Portal for access by Employer Portal users.  Reports will be provided in an MS Excel format when this option is available, but a PDF may be requested instead if this format is required. Mobile Application Benefit Strategies Benefit Strategies is offering the ability for iPhone or Android users to Reimbursement Plan access their account information directly through their phone.

Participants can access the following information through the application:

 Check available balances  Request Distributions  Make a Contribution  Convenient customer service contact information

Participant Education Participant Account Demo – Introduction to Participant Account Demo – Contribution to HSA Account: Health Savings Account:

Participant Account Demo – Distribution of HSA Funds: Employer Portal Contacts Enter information below for each client Human Resources contact requiring access to view employer reports via the Employer portal. A notification will be sent to each contact with information regarding use of the Employer Portal. Please list the client Human Resources contacts below who require a logon and password for access to the employer portal.

Primary Human Resources Contact Secondary Human Resources Contact Name: Name: Title: Title: Email: Email: Phone Number: Phone Number: Portal Access: Yes No Portal Access: Yes No

Human Resources (Other) Human Resources (Other) Name: Name: Title: Title: Email: Email: Phone Number: Phone Number: Portal Access: Yes No Portal Access: Yes No Number:

Funding Process Overview EFT funding is required for HSA Accounts. Please complete the EFT Funding agreement attached and return to Benefit Strategies, LLC immediately to avoid delay in setup. Funds for contributions are pulled from the Employer’s bank account once the contribution has settled. Posted contributions take approximately 2-3 business days to settle. Funds are pulled daily.

Unclaimed Checks Clients will address the escheatment and/or other handling of unclaimed checks that have reached the 180 day expiration date. A report of unclaimed checks will be provided upon request. Funding Contacts Please list the client funding contacts below who should receive invoicing from Benefit Strategies, LLC Funding Contact Funding Contact Name: Name: Title: Title: Email: Email: Phone Number: Phone Number:

Fees Set-Up Fee $Waived Renewal Fee $Waived Administration Fee (Active Employee) $2.95 per account per month deducted from HSA Administration Fee (Individual Termed Account) $4.00 (month) deducted from HSA Initial Set of Debit Cards (Cards come in a set of 2) $Waived Additional/Replacement Cards (Cards come in a set of 2) $Waived Non-Discrimination Testing Fee (Not required if no Employer $400 upon request Contribution) Check Fee $5.00 (per check) deducted from HSA Account Closure Fee $18.00 deducted from HSA Printed Account Summary Fee $5.00 (per account summary) deducted from HSA Fee Invoicing Method EFT Required Special Notes

*As long as an employee has an active HSA account containing funds, the administrative fee will apply. Acceptance I have reviewed and approved the contents of the Health Savings Account Requirements. I certify that the contents of the Health Savings Account Requirements have been documented in a manner that accurately reflects the Health Savings Account for Client. I also understand that after the official “sign off” of the Health Savings Account Requirements and applicable best practice recommendations are received, administration will begin based on the information detailed in the Health Savings Account Requirements.

Title:

Signature:

All implementation documents, once complete, should be returned directly to your implementation specialist. Email to [email protected] Employer Checklist Please use the provided checklist to help organize your implementation requirements.

☐ Completed Requirements Gathering Document including plan details ☐ Payroll Option Selected ☐ Payroll Calendar Provided (If applicable) ☐ Enrollment Option Selected ☐ Online Enrollment Census Provided (If applicable) ☐ Online Enrollment Start and End Dates established (Required if Online Enrollment selected) ☐ Enrollment Template Provided (If applicable) ☐ Paper Enrollment Forms Provided (If applicable) ☐ Terms & Conditions method established (Only applicable if Enrollment Template is used) ☐ Logo provided to Benefit Strategies (If applicable) ☐ Informational material provided to employees (If desired) ☐ HR Contacts listed for portal access and communications ☐ Financial Contacts listed for billing purposes ☐ EFT Funding Agreement completed and returned to Benefit Strategies ☐ Requirements Gathering Document Signed