TitleSummaryCategorieshf:tax:wpdmcategory
Aetna Explanation of Benefits

Sample Aetna Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra
ARPA COBRA Subsidy – IRS Guidance – Notice 2021-31

This notice clarifies some of the vague definitions in the original ARPA guidance as it relates to participants eligible for the COBRA subsidy.

, all cobra
Cigna Explanation of Benefits

Sample Cigna Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra
COBRA Count Calculator

Use this “how-to” guide & worksheet to calculate whether or not your company is considered COBRA eligible for the coming calendar …

, all cobra
Debit Card Claim Substantiation Form (FOR FSA ONLY)

Use this form to submit substantiation for a debit card claim for your FSA.

, , all claims fsa
Direct Deposit Authorization Form

Use this form to authorize direct deposit of your claim reimbursements. Consult your HR department to confirm if this option is available to you.

, , , all claims fsa hra
FSA Change of Status Form

Use this form when you want to change your Health FSA election mid-plan year

, , all fsa status
FSA Claim Reimbursement Form

Use this form to file a reimbursement claims for your FSA.

, claims fsa
FSA Debit Card – Sample Emails – Auto-Substantiated Swipe

Here are samples of the emails an FSA participant will receive when they swipe their FSA debit card for an eligible expense at a vendor who IIAS approved. These swipes do not require substantiated …

, expenses fsa
FSA Debit Card – Sample Emails – Not Auto-Substantiated Swipe

Here are samples of the emails an FSA participant will receive when they swipe their FSA debit card for an expense at a vendor who is not approved. These swipes do require substantiated …

, expenses fsa
Health Net Explanation of Benefits

Sample Health Net Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra
HRA Coinsurance Claim Form

Use this form to file a reimbursement claim from your HRA for coinsurance …

, , all claims hra
HRA Deductible Claim Form

Use this form to file a claim for reimbursable HRA expenses relating to …

, , all claims hra
IIAS Approved Pharmacy List – FSA/HSA Debit Cards

Refer to this list for pharmacies approved to substantiate FSA or HSA debit card …

, , , , all claims expenses fsa hsa
IRS Contribution Limits

IRS contribution limits for HSA, HRA, FSA, Transportation plans. Includes Highly Compensated and medical mileage limits. Shows index by …

, , , fsa hra hsa transportation-plan
Kaiser Explanation of Benefits

Sample Kaiser Permanente Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra
Leave of Absence Form

Use this form to inform SBA of an impending Leave of Absence.

, , all fsa status
Licensed Dependent Care Claim Form

Use this form to submit a claim for FSA dependent care reimbursement from a licensed provider.

, , all claims fsa
Medical Mileage Log

Use this form to track your mileage for plan reimbursement purposes.

, all logs
Non-licensed Dependent Care Claim Form

Use this form to submit a dependent care FSA claim for a non-licensed provider.

, , all claims fsa
POP Change of Status Form

Use this form when you want to increase or decrease your POP payroll deduction for insurance premiums mid-plan year due to a qualifying event.

, , all pop status
POP Election Form

Use this form to update your POP …

, all pop
Premera Explanation of Benefits

Sample Premera Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra
Premium Only Plan (POP) Election Form

Use this form to enroll in your company’s Premium Only Plan.

, all pop
QSEHRA-ICHRA-EBHRA Side-by-Side Comparison

This comparison outlines of the differences between these programs from an employer …

, all hra
Qualifying Dependent Rules

This document outlines the criteria required for a child or relative to be considered a qualified dependent of an …

, , all fsa hsa
Regence Explanation of Benefits

Sample Regence Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra
Summit Claim Form

Use this for to file a claim for reimbursement for your FSA, HRA or Transportation plan.

, , , , all claims fsa hra transportation-plan
Transit Plan Change of Status Form

Use this form to change your status mid-year if you are enrolled in a Transit Benefit Plan.

, , all status transportation-plan
Transportation Claim for Reimbursement Form

Use this form to submit a claim for reimbursement from a Transit Benefit Plan.

, , all claims transportation-plan
United Healthcare Explanation of Benefits

Sample United Healthcare Explanation of Benefits highlighted for expenses and …

, , all explanation-of-benefits-eob hra