Fiscal & Utilization Reports
Laws and Regulations
Frequently Asked Questions
Frequently Asked Questions
CONSUMER DRIVEN HEALTH PLAN (CDHP)
What is a Consumer Driven Health Plan (CDHP)?
The CDHP is a high deductible health plan that works in conjunction with a Health Savings Account or Health Reimbursement Arrangement and a wellness program. The plan has a $1,500 individual deductible (participant only tier) and a $3,000 family deductible (any tier with two or more members; family deductible includes a $2,500 individual family member deductible). To maximize benefits under the
CDHP, PEBP will continue to offer the preferred provider organization (PPO) network. The
combination of medical and pharmacy benefits are subject to the annual deductible and copayments do not apply. Generally, after meeting the combined medical and prescription drug
annual deductible amount, the plan will pay 80% coinsurance when using contracted PPO providers.
What is the annual maximum out-of-pocket for the CDHP?
The annual out-of-pocket maximum is $3,900 for an individual with no covered dependents and $7,800 for a family (all other tiers).
Once the annual maximum out-of-pocket has been met, the plan will pay 100% of covered medical and pharmacy expenses when using contracted providers.
What expenses apply to the annual maximum out-of-pocket?
Deductible and coinsurance amounts accumulate toward the annual out-of-pocket maximum.
Would the annual family maximum out-of-pocket have to be met by more than one person?
The $7,800 family maximum out-of-pocket may be met by one individual or through
a combination of claims incurred by all family members.
HEALTH SAVINGS ACCOUNT (HSA)
What is a
Health Savings Account (HSA)?
HSAs are tax-exempt accounts that are coupled with high deductible health
plans. They are employee-owned interest bearing/investment accounts that are
used to pay qualified health care expenses on a pre-tax basis. HSA funds
carryover from year-to-year and belong to the employee. HSA contributions
are reported by your employer to you and the IRS on form W-2 (box 12 using
code W). Contributions and distributions from the HSA must be reported on
annual tax returns using form 8889.
IRS requires identification on behalf of HSA account owners. In some cases,
employees will be required to provide additional identifying information.
Failure to provide identity information within a specified timeframe will
automatically convert the HSA funds to an HRA. Questions regarding
requests for identity should be directed to HealthSCOPE Benefits at 1-888-763-8232.
Are there eligibility requirements to establish an HSA?
Yes, to establish an HSA, you must be an active employee covered under a
high deductible health plan. You cannot have secondary coverage, unless that
other coverage is also a high deductible health plan or covers a specific
disease state (such as cancer insurance) or only reimburses for expenses
after you have met the deductible. If any of the following apply, you
may not establish or contribute to the HSA:
You are covered under other medical insurance coverage unless that medical insurance coverage:
(1) is also a High Deductible Health Plan as defined by the IRS; (2) covers a specific disease state (such as cancer insurance); or
(3) only reimburses for expenses after you have met the deductible
You are enrolled in Medicare, Tricare, Tribal or similar coverage
You cannot be claimed as a dependent on someone else’s tax return unless you are married filing jointly
You or your spouse has a Medical Flexible Spending Account (excludes Dependent Care or Limited Use Flexible Spending Accounts)
Your spouse has an HRA that can be used to pay for your medical expenses
You are on COBRA
You are retired
Can HSA monies be used to pay for qualifying expenses of a dependent?
You may use the HSA funds to pay for the qualified medical expenses of a
spouse or dependent child (as defined by the IRS), regardless of whether the
spouse or dependent is covered by PEBP. HSA funds may not be used for
medical expenses for a person who does not meet the IRS definition of
“dependent,” including many domestic partners, children of domestic partners
and older children who cannot be claimed on your tax return, regardless of
whether PEBP provides coverage for the child.
What happens to the HSA funds if they are not used by the end of the year, do they revert back to PEBP?
Unused HSA funds are owned by the employee and will not revert back to PEBP at any time.
What happens to the HSA when a member retires or changes to the HMO plan during Open Enrollment?
The member keeps the money. That is one of the many advantages of
the HSA. The account belongs to the employee. Many employees
choose to build HSA funds over time to use for healthcare expenses in
retirement. Others choose to use their HSA for current healthcare costs.
It's up to the employee to decide what works best for them.
Will employees receive a 1099 for tax filing?
Employees will receive Form 1099-SA with information on distributions and
Form 1099-INT with information on interest earnings. These forms are
provided to the employee in January each year.
Who can make contributions to the HSA?
Employees have the option to self-contribute to the HSA through direct
payroll deduction or by sending a check to HealthSCOPE Benefits for deposit. If
sending a check, the HSA Contribution Form must be completed and sent along
with the check to HealthSCOPE Benefits (HSB).
* Click HSA/HRA Account Status
* Login to the Member Dashboard
* Click view HSA/HRA information under Quick Links
* Click the Forms tab and select the appropriate form
Can employees make a one-time deposit to their HSA instead of having
Yes. Employees have the option of making a one-time deposit by
sending a check to HealthSCOPE Benefits for deposit into the HSA.
HEALTH REIMBURSEMENT ARRANGEMENT
What is a
Health Reimbursement Arrangement?
HRAs are PEBP-owned pass-through accounts established on behalf of eligible
CDHP primary participants. HRA funds may be used to pay for qualified
health care expenses. HRA funds carry over from year to year. Note: The Board may establish a carryover
limit in future plan years.
Who is eligible for the HRA?
The HRA is offered to certain active employees
who are not eligible for the HSA and retirees enrolled in the CDHP.
What are qualified medical expenses?
Qualified medical expenses are amounts paid for medical care as defined by
the IRS (provided reimbursements for such paid amounts are not received from
any other source, including insurance.) Qualified medical expenses include
payment of deductibles, coinsurance, dental, and vision costs incurred by
the participant, a covered spouse or any other dependent claimed on the
primary participant's annual tax return.
Participants on the CDHP may not use HRA funds to pay premiums.
How much can I contribute annually to my HSA?
The amount you or any other person can contribute to your HSA
depends on the type of CDHP coverare you have (individual or family), your
age, and the date you become eligible, and the date you cease to be an
eligible individual. The HSA contribution limits are set by the IRS and
for calendar year 2014, the maximum contribution limits are $3,300 for an
and $6,550 for a family (two or more members). Eligible individuals age 55 or older on December 31st may contribute an additional
$1,000. Note: PEBP contributions count toward these limits. Caution: As
mentioned earlier, the maximum contribution limits are subject to an
individual's eligibility based on the last month rule and testing period as
discussed below. For more information, visit
or contact HealthSCOPE Benefits at 888-763-8232.
QUALIFYING FOR AN HSA
To be an eligible individual and qualify for
an HSA, you must meet the following requirements:
You must be an active employee covered under the CDHP
You have no other coverage unless the other
coverage is also a high deductible health plan with a minimum deductible
for self-only coverage in the amount of $1,250 or Family coverage with a
minimum deductible of $2,500 (and meets the IRS definition of a high
deductible health plan).
You are not enrolled in Medicare, Tricare or
You are not claimed
as a dependent on another person's tax return
You are not covered
under a Medical FSA, HRA or your spouse has a Medical Flexible
Spending Account that may be used to pay for your health care
To be eligible
contribution to your HSA you must be covered under the CDHP and have
no other health coverage except coverage permitted by the IRS. You
cannot be enrolled in Medicare or be claimed as a dependent on
another person's tax return. You must be, or be considered, an
eligible individual on the first day of a month to make a
contribution for that month.
What is the HSA last-month rule?
If you are an eligible
individual on the first day of the last month of your tax year
(December 1), you are considered to be an eligible individual for
the entire year.
What is the HSA testing period?
If an employee is eligible to contribute to the HSA on the first day of the last month of the tax year (generally December 1), the employee may contribute up to the annual maximum if the employee is eligible to contribute to
the HSA through the end of the following year (the testing period). If the employee is not eligible
during the entirety of the testing period, any amount contributed to the HSA in excess of the prorated
annual maximum will be treated as taxable income in the following tax year and will be subject to a penalty.
The testing period begins with the last month of your tax
year and ends on the last day of the 12th month following that month
(for example, December 1, 2013 - December 31, 2014). If you fail to
remain an eligible individual during this period, other than because
of death or becoming disabled, you will have to include in income
the total contributions made that would not have been made except
for the last month rule. You include this amount in income in the
year in which you fail to be an eligible individual. This amount is
also subject to a 10% additional tax.
How do I change my HSA contribution?
Change your HSA election by using one of the following options:
Log on to the HSA section of the
HealthSCOPE Benefits website
and select "Change an Election."
Call HealthSCOPE Benefits at 888-763-8232 to request a form
to change the election.
Contact HealthSCOPE Benefits via email at
firstname.lastname@example.org request a form to change the
Do HMO participants qualify for the HSA or HRA?
HSAs and HRAs are only offered to PEBP CDHP participants.
Will the IRS allow employees to enroll in a Health Care
Flexible Spending Account (FSA) if they also have a HSA?
IRS provisions do not allow an employee to enroll in the regular health
care FSA. However, IRS provisions will allow employees with an HSA to enroll in a
Limited Purpose FSA for dental and vision care expenses only.
Can the HSA be used for medical
expenses incurred before establishing the HSA? For example, expenses
incurred for an employee while he or she is covered under the HMO
plan, then later changes to the CDHP.
The HSA can only be used for expenses
incurred on or after the date the HSA was established.
HSA DEBIT CARD
What can the debit card be used
The IRS regulates what is considered
an eligible expense. According to IRS Publication 502, medical
expenses are the cost of diagnosis, cure, mitigation, treatment,
prevention of disease, and the costs for treatments affecting any
part or function of the body. Medical expenses incurred primarily to
alleviate or prevent a physical or mental defect or illness.
They do not include expenses that are merely beneficial to general
health, such as vitamins or vacation. Examples of eligible medical
Payments for legal medical services
rendered by physicians, surgeons, dentists and other medical
Cost of medically necessary equipment
Specific information can be found at HealthSCOPE Benefits.
Information can also be found at
ARRANGEMENT FOR ELIGIBLE MEDICARE EXCHANGE ENROLLEES
Who is eligible for the Medicare
Eligible retirees covered through the
Medicare Exchange receive a Medicare Exchange HRA.
What qualifying health care expenses are eligible for reimbursement through the Medicare Exchange HRA?
Qualified medical expenses are amounts paid for medical care as defined by the IRS
(provided reimbursements for such paid amounts are not received from any other source, including insurance.) Qualified medical expenses include payment of deductibles, coinsurance, dental,
and vision costs incurred by the participant, their covered spouse and/or
dependent children. The Medicare Exchange HRA may also be used for
reimbursement of medical, dental and pharmacy premiums.
CONSUMER DRIVEN HEALTH PLAN
(CDHP) - WELLNESS BENEFIT
Will the CDHP cover wellness/preventive care?
The CDHP covers eligible wellness/preventive care services at the 100%
benefit level when using in-network providers.
Whose responsibility is it to ensure the provider bills the wellness benefit correctly?
The physician makes the determination regarding the purpose of the visit (e.g.,
was the visit for screening purposes only or was the visit a follow up for a
known medical condition?). However, it is the patient’s responsibility to inform their physician and the physician’s billing staff about the wellness benefits.
Will the CDHP cover vaccinations for overseas travel?
Generally, vaccinations required for overseas travel are covered under the
CDHP wellness benefit. However, most of the vaccines required
for overseas travel are not available through a primary care
physician. Contact your local health department for information
about the various vaccines they offer. Local health departments will
not submit billing claims to HealthSCOPE Benefits; thus, the member
has the responsibility of submitting a paper claim (accompanied by
an itemized receipt indicating the name and location of the entity
who administered the vaccines, the vaccine type, dose and cost for
each immunization and proof of your payment) for reimbursement.
Are routine laboratory tests covered under the CDHP?
Routine lab tests associated with wellness services as defined by the CDC
are covered under the wellness benefit if performed at a free-standing laboratory facility.
Lab tests not associated with wellness services are subject to deductible and coinsurance.
Please note lab tests provided in a hospital setting are not covered--except
when lab tests are performed for pre-admission testing, inpatient admission,
or emergency care. Exceptions to this provision applies for participants
residing in rural areas where there are no free-standing laboratories
within 50 miles; thus, requiring lab services to be performed in a hospital setting.
Is there a cost differential between using an outpatient hospital lab verses a free-standing lab such as Lab Corp or Quest?
Generally, hospitals charge substantially more for these
services than stand-alone laboratories. Some physicians may
refer a patient to the hospital for lab testing; however, to reduce
out-of-pocket costs, the member should request a referral to a
Updated May 1, 2014