Thank you for your interest in UnitedHealthcare’s Select HRA.

Please review the Available Product Parameters and Operational Reminders before completing the attached Select HRA Application. This information is not intended to replace or supersede the detail in the Select HRA Plan Document, but rather to ensure understanding of the available features prior to selection, and to improve case set up timelines.

Available Product Parameters
By submitting the Select HRA Application, I confirm that my HRA design falls within the Available Product Parameters listed below. Select HRA Applications that do not fit within the allowable parameters will be returned unprocessed to the UnitedHealthcare Representative.
Case Size / The Select HRA is available to UHC Small Business health plan cases – 2-99 employees.
Business Owners / The legal entity under which the organization operates will affect who is eligible for a Select HRA plan.
  • If the employer is a C-corporation, non-profit or municipality, all employees are eligible for the HRA plan.
  • The IRS prohibits self-employed (sole proprietor) individuals from participating in an HRA.
  • Partners, more than 2% S-corporation shareholders and LLC members are not eligible for the Select HRA (nor in many cases family members).

HealthPlan /
  • Health plan must be HRA-eligible with UnitedHealthcare or one of its affiliates.
  • The Select HRA will not coordinate with any secondary health coverage (e.g. Medicare).

HRA Plan Year / The Select HRA can run on a:
  1. Short Year (a plan period that is less than 12 months – cannot be less than 3 months).
  2. Policy Year (health plan period is not a calendar year)
  3. Calendar Year (if the health plan period and/or deductible period is a calendar year).
  • The initial Select HRA plan period end date must sync up with the UHC medical plan year end date or the medical deductible period end date.
  • The Select HRA term can only be modified at the beginning of the HRA plan period.
  • Consecutive short plan periods are not allowed.
  • NHP Rule – Only Calendar Year option is available.

Standard HRA or HSA / The Select HRA cannot be offered to individuals who:
  • Participate in the Standard HRA.
  • Participate in an HSA.
The Select HRA cannot be converted to or from a Standard HRA in the middle of a plan period.
Auto Claims Rollover / The following criteria apply to the auto claims rollover feature:
  • Qualifying expenses are defined in the Eligible Expenses section of the application.
  • Claims occurring between the Select HRA effective date and the completion date of the Select HRA implementation must be manually submitted by participants.
  • Only pharmacy expenses that contribute toward the health plan deductible will be processed using the auto claims feature.

Per-Person or Aggregate Accumulation /
  • Select HRA accumulation (per-person/embedded or aggregate/non-embedded) will be set up to match the Health Insurance Plan accumulation type defined on this application.
  • The per-person or aggregate selection applies to current period HRA funds and any carryover HRA funds

HRA Contribution Limits / Select HRA contributions can be defined for the following coverage types:
  1. Single Tier: Employee Only
  2. Two-Tier: Employee, Employee + 1 Dependent
  3. Three-tier: Employee, Employee +1 Dependent, and Employee + Family
  • For each selected tier, maximum HRA contribution amounts up to 50% of the corresponding health insurance plan deductible are allowed.
  • Select HRA contributions can be set as low as $50.
  • Contribution amounts can only be adjusted at Select HRA plan renewal.
  • Per-person accumulation requires the employee+1 and family contribution limits to be a multiple of the employee-only amount (e.g. Ee = 400, Ee+1 = 800, Family = 1,600).

Eligible Expenses / Select HRA funds can be used to reimburse medical expenses in the following scenarios:
  1. Deductible
  2. Deductible and Coinsurance
  3. Deductible, Coinsurance, and Copays
  • Pharmacy expenses are only covered if they accumulate toward the health plan deductible.
  • Section 213(d) expenses are not covered by the Select HRA.
  • Pacific Region & NHP Rule – Only Deductible or Deductible and Coinsurance options are available.

Covered Members / The employer indicates on the Select HRA Application whether the HRA applies to all family members covered by the health plan or employees only.
HRA Access Point / The Select HRA Access Point is the dollar amount of employee responsibility that must be met before Select HRA funds become available. This amount is specified by the employer on the application. Options include:
  • 2nd Dollar – the employee is responsible for an employer-defined amount of qualifying expense (access point); then the HRA pays for subsequent qualifying expense up to the HRA contribution limit.
Rule: The Access point amount must be at least 50% of the corresponding health insurance plan deductible.
  • 1st Dollar Shared – the HRA pays an employer-defined percentage of first dollar qualifying expense up to the HRA contribution limit. The employee is responsible for their percentage of first dollar qualifying expense. (e.g. a qualifying claim amount of $200; HRA/Employee share is 50%/50%; the HRA will reimburse $100 and the employee is responsible for $100)
Rule: Employee responsibility amounts must be at least 50% of the corresponding health insurance plan deductible.
  • 1st Dollar – the HRA pays from the first dollar of qualifying expense up to the HRA contribution limit.
  • NHP Rule – Only 2nd Dollar option is available.
  • First dollar plans are not available in all markets. Contact your UnitedHealthcare health plan representative to verify availability.

Carryover of Unused Funds /
  • Carryover of Unused funds is the amount of HRA balance at the end of the HRA plan year for each eligible employee that carries over and accumulates.
  • Carryover options are 100%,50% or 0%
  • Carryover from another HRA carrier is not available.
  • Pacific Region Rule – Carryover is required. There is no cap on year-over-year accumulation of unused fund carryover.

Debit Card / A Debit Card is not available with the Select HRA.
Mid-Year HRA Conversions / Mid-year HRA conversions are not supported. Changes can only be accommodated at Select HRA plan renewal.
Nondiscrimination Information / To ensure that the Select HRA plan benefits employees in a nondiscriminatory manner, regulations mandate that certain testing be performed. The Select HRA cannot discriminate in favor of highly compensated employees in regards to who is eligible for the plan or in the benefits being provided. All Select HRA benefits provided to highly compensated employees must be available to all other eligible employees.
Operational Reminders
By submitting the Select HRA Application, I confirm that I have read and agree to the following operational standards for Select HRA administration. I understand that this is not a comprehensive list of all operational and contractual terms, nor is it meant to replace the Select HRA Plan Document.
Claims
  • Virtually all Select HRA claims roll automatically from the UnitedHealthcarehealth plan (exception – pharmacy expenses that do not contribute to health plan deductible & adjustments to previously processed health plan claims). Manual claim submission is not necessary in these cases. Employers choosing to opt out of the auto-claims rollover feature will require their employees to submit Select HRA claims manually.
  • In-network and out-of-network claims are reimbursable.
  • Select HRA claims are processed within two business days of receipt of valid claim documentation.
  • Select HRA reimbursements go directly to members. Members are responsible for providing payment to providers.
  • Employers may choose a run-out period during which claims will continue to be processed following the conclusion of the Select HRA plan, whether the Select HRA terminates on the scheduled date or in the middle of HRA plan year. Options are 30, 60, or 90 days.

Deductible Credit
Deductible Credit is not available for new or current groups moving to policy year deductible health plans.
For employers with a new health plan on a calendar year health plan deductible, employer must notify UnitedHealthcare of YTD deductible credit for each member no later than the 15th of the month in which the Select HRA is effective. There are two ways this can be done:
  1. Procure a year-to-date deductible report from the prior carrier
  2. Have employees submit EOBs directly to Unitedhealthcare using the EOB Coversheet, available through your agent or UnitedHealthcare representative
For employers currently on a UnitedHealthcare health plan, YTD deductible credit will be posted to the Select HRA no later than the 20th of the month in which the Select HRA is effective.
HRA Prorations
Members joining mid-year: Employer specifies Select HRA contribution on the Select HRA Change Form. It is the employer’s responsibility to allocate Select HRA dollars equitably.
A Select HRA that is chosen by the employer mid-year: No proration occurs. UnitedHealthcare will administer the amount an employer specifies on the Select HRA application.
Banking
No HRA “pre-funding.” HRA claims are paid weekly from a UnitedHealthcare account, then UnitedHealthcare pulls the amount paid from the employer’s bank account on a weekly basis.
Only one bank account is allowed per employer record.
Failed ACH transactions will result in a $25 NSF charge from UnitedHealthcare, in addition to any fees the employer’s bank may charge.
Customer Service
Employers with HRA or health plan questions can call UnitedHealthcare Employer Services - 800-318-5311.
Employees with HRA or health plan questions can call UnitedHealthcare Customer Care - 877-797-7475.
Reporting
Employers receive the following Select HRA reports:
  • Weekly Check Registers: Faxed or emailed to employer contact and available online 24x7 at to notify the employer that Select HRA dollars have been paid in the previous week and that this amount will be withdrawn from the employer’s bank account.
  • Select HRA Summary Report: YTD listing of HRA utilization by employee. Available 24x7 via secured link at
Employers are responsible for performing their own 5500 Reporting.
Enrollment
Employers are responsible for supplying enrollment to UnitedHealthcare Benefit Services directly. Initially and upon renewal, this is accomplished via Enrollment spreadsheet supplied by UnitedHealthcare, completed by the employer.
Owners who are not eligible for HRA coverage must be omitted from the Enrollment spreadsheet.
Ongoing eligibility is supplied by the employer using the HRA Change Form received during the select HRA implementation process.

Operational or product questions should be directed to your agent or UnitedHealthcare representative.

SECTION IA: General Information

Health PlanCarrier
/ UnitedHealthcare NHP Oxford PHS Other: ______
Legal Company Name
/ Federal Tax ID#
Primary HRA Contact / Secondary HRA Contact
Phone Number /
Phone Number
Contact E-mail / Contact Email
Dept/Title / Dept/Title
Fax Number /
Fax Number
Broker Information:
Firm Name
Broker/Consultant Name
Phone Number
/
Federal Tax ID #
Email Address
Street Address
City / State / ZIP

SECTION IB: Additional Company Information

D/B/A Name
(if applicable)
General Phone Number / UHC Health Plan Policy Number(s) – (required)
Street Address
City / State / ZIP
Business Entity Type / Corporation
S-Corp (Individuals owning more than 2% and/or family members cannot participate in the plan)
LLC (For income tax purposes, treated as a partnership: members cannot participate in the plan)
LLP (Partners cannot participate in the plan, nor can their spouses) / Partnership (Partners cannot participate in the plan)
Non-Profit
Church
Municipality
Sole Proprietorship (Owner cannot participate in the plan)
Affiliate / Subsidiary Companies / Legal Company Name / Federal Tax ID #
UHC Representative / Name Phone Email
Number of Eligible Employees / Eligible Class of Employees / Ex: All employees enrolled in health plan
New Hire
Waiting Period / Date of Hire
First of the month following day(s) or month(s) of employment
SECTION II:
HRA Plan Period
HRA Plan Period
(if initial period will be 12 months) / Begin Date End Date
HRA Short Plan Period
(if initial period will be less than 12 months) / Begin Date End Date
Rule: The short plan period cannot be less than 3 months.

Existing HRA Information (if applicable)

Original Effective Date of your existing HRA Plan /
HRA Plan Number
If existing HRA plan is a UHC Standard HRA, provide termination date of the plan.

A Plan Number is a 3-digit 500 series number assigned to welfare and fringe benefit plans beginning with 501. Numbers should be assigned to your benefit programs sequentially and plan numbers should not be reused. Be sure to check other benefit plans and assign the three-digit number accordingly. For existing plans, this number and your original effective date can be found in the Summary Plan Description or previously filed Form 5500 return(s).

Existing HSA and FSA Information (if applicable)

Employer-Sponsored Health Savings Account? (HSA) / No
Yes
Rule: If employees participate in the HSA they are not allowed to participate in the Select HRA.
UnitedHealthcare FSA / I also have the UnitedHealthcare Flexible Spending Account
I do not offer my employees the UnitedHealthcare Flexible Spending Account

SECTION III: Checking Account Information/ACH Authorization

Reimbursements are issued from a UnitedHealthcare checking account. Reimbursements are issued to HRA participants by 1) check sent to the participant home or 2) by direct deposit to a bank account of the participant’s choice.
UnitedHealthcare will provide the client with a weekly check register indicating the total amount of reimbursements issued. Each week, UnitedHealthcare will debit from the client’s account the total issued on the check register.
Check Registers
(Check registers are emailed or faxed weekly to one or two individuals.
These contacts must be the same as in section 1A if a primary and secondary contact was listed in section 1A). / Send via Email OR Send via Fax
Contact Name / Email/Fax#
Contact Name / Email/Fax#

SECTION IV: HRA Plan Benefits(every section must be completed)

Auto-Claims Submission / Yes - Have claims roll automatically from the UnitedHealthcare health plan.
No - Do not automatically submit claims. Employees will submit claims manually.
Health Insurance Plan Design
(HRA plan reimbursement is tied to deductible of the health insurance plan) / UHC Health Insurance Effective Dates
Policy Effective Date:
Deductible Effective Date:
Rule: Adjustments to HRA employer funding and other HRA parameters are only allowed at HRA renewal. Please plan HRA parameters accordingly.
UHC Health Insurance Accumulation Type(check only one box)
Per Person / Embedded(each family member must incur single insurance deductible)
Aggregate / Non-Embedded(all family members collectively contribute toward one family insurance deductible)
Rule: Select HRA accumulation will be set up to match the Health Insurance Plan accumulation defined above.
UHCHealth Insurance Plan Deductible Amounts
$ /Single $ / EE +1 $ /Family
HRA Plan Design
(HRA plan designs must be approved by UnitedHealthcare in advance of plan implementation) / Employer’s Select HRA Contribution
(This amount will apply to the HRA Plan Year specified in Section II) / Select HRA Plan Period Contribution Amounts
$ /Single $ / EE +1 $ /Family
Rule:HRA contribution amounts up to 50% of the corresponding Health Insurance Plan Deductible Amounts listed above are allowed.
Eligible Expenses
(check only one box) / Health plan out-of-pocket - Deductible only
Health plan out-of-pocket - Deductible andCoinsurance
Health plan out-of-pocket - Deductible,Coinsurance and Copays
Whose expenses are eligible for HRA reimbursement?
(check only one box) / Employee Only
Employee + Dependents
Pharmacy expenses accumulate to the health plan deductible and out-of-pocket / Yes
No
HRA reimbursement funds available from 1st dollar of incurred eligible expense
(check only one box) / Employee is responsible for expenses up to amounts listed below, then
HRA reimburses 100% of expense up to contribution amount
Rule: Employee responsibility amounts must be at least 50% of the corresponding health insurance plan deductible listed above.
$ /Single $ / EE +1 $ /Family
HRA reimburses % of 1st dollar expense up to contribution amount
HRA reimburses 100% of 1st dollar expense up to contribution amount
First dollar plans are not available in all markets.
HRA Fund Availability / Participants will be able to access HRA funds at the start of the HRA plan year.
Deductible Credit
(New UHC clients only) / Yes (i.e.: Health plan deductible period is on calendar year health plan policy period effective date is not January 1)
No
Note: If any deductible credit is being applied from the prior carrier, employers must supply a claims report from the prior health plan carrier to UnitedHealthcare prior to the effective date of the HRA. Alternatively, employees may submit EOBs to the UnitedHealthcare prior to the HRA effective date using the EOB Coversheet (available from your UnitedHealthcare Representative).

SECTION V: HRA Account Balance Carryover / Employee Terminations

Funds Carryover -
Percentage and Maximum Amount / 100% 50% None
Select the percentage of remaining HRA funds that carry over to the next HRA plan period. If “None” is selected, employees will not be able to use current period funds after the run-out period.
Balance percentage amounts that rollover are calculated after the completion of the run-out period.
Pacific Region Rule– Carryover is required. There is no cap on year-over-year accumulation of unused fund carryover.
$ (OPTIONAL) Enter a maximum cumulative (multiple years with carryover) carryover amount.
Recommendation:HRA carryover amounts are not capped.
Incur Period –
Terminated Employees
(# of days allowed to incur claims after termination date) / 0 days End of month employee terminates
Run-out Period –Terminated Employees
(# of days allowed to submit claims after termination of employment) / 30 days 60 days 90 days
Run-out Period –
Active Employees
(# of days allowed to submit claims after the end of the HRA plan year) / 30 days 60 days 90 days

SECTION VI: Management Reporting/Enrollment