Benefits

Plan Benefits

• Available to individuals enrolled in the Value PPO
• Covers expenses incurred by you or your eligible tax dependents not paid by insurance
  • Qualified medical and prescription drug expenses
  • Dental and vision expenses once you have met your deductible
  • Complete listing in IRS publication 502 found on www.irs.gov
• For more information, view the HSA Quick Reference Guide

Contribution Summary

Under Age 55
Health Coverage	Status	You Contribute…	NU Contributes…	Total Funded
Single	Initial NU HSA Account	$700	$700	$1,400
Family*		$1,400	$1,400	$2,800
Single	Previously received NU match	$1,400	$0	$1,400
Family*		$2,800	$0	$2,800

±Age 55+
Health Coverage	Status	You Contribute…	NU Contributes…	Total Funded
Single	Initial NU HSA Account	$1,700	$700	$2,400
Family*		$2,400	$1,400	$3,800
Single	Previously received NU match	$2,400	$0	$2,400
Family*		$3,800	$0	$3,800

*Family coverage includes: you+spouse, you+child(ren) and you+spouse+child(ren).

± For individuals age 55 and older by December 31, 2013, additional “catch-up” contributions of $1,000 for 2013 are allowed and may be made via payroll deductions.

Enrollment

Newly Eligible

1. Newly eligible employees may enroll online through Self Service within 31 days of hire.
2. PayFlex will mail or email a Welcome Kit after enrollment.
3. Complete the requested information including the signature card and return it to PayFlex. You can also use PayFlex’s HealthHub to activate your account online.
4. PayFlex will mail you your debit card and checks.

Qualifying Change in Family Status

• An individual may change his HSA contributions using a Benefits Change form  within 31 days of a qualifying change in family status.

Open Enrollment

• An individual must re-enroll through Self Service to continue making contributions to the HSA the following year.
• If you do not re-enroll in the plan the following year, you may also be responsible for a monthly administrative fee assessed by PayFlex.

File a Claim

• Use your HSA debit card or the checks that you will receive from PayFlex.
• Funds must be available in your account before using your debit card or writing checks. You will be responsible for any overdraft fees.
• There is a $5 standard fee for check book reorders which includes 40 additional checks and 5 deposit slips.
• Your HSA debit card may NOT be used at an ATM to withdraw cash or to pay for non-health expenses.

Tax Implications

• The University reports each employee receiving a contribution for the calendar year as non-taxable wages on the W-2 (box 12, code W).
• There is no need to complete IRS Form 8889 or to report contributions on page 1 of IRS Form 1040.
• Form 8889 would be required for contributions to an HSA that are not deposited pre-tax through payroll (i.e. cash deposits).
• If you pass away, your HSA may be transferred to your surviving spouse tax-free, else distributions are taxable.

Separation from the University

• Your HSA is portable and you may continue to use its funds when you leave the University.
• You may not continue to make contributions to your HSA through Northwestern.
• Monthly administrative fees covered may be charged, by PayFlex, directly to your account.