Page 101 - 2021-2022 New Hire Benefits

Purpose: The Health Savings Account (HSA) Payroll Deduction form is used to document
employee HSA contributions that will be made via payroll deduction. A general
understanding of the following terms may be helpful in completing this form.

Calendar Year Maximum Contributions: The maximum annual contribution is equal to the
pre-defined amount updated by the federal government each year to account for inflation.
Roll-over amounts from the previous years and/or MSA or another HSA, do not count toward
the maximum annual contribution.

The total amount of contributions to an HSA is based on the number of months that the
individual is covered by an HDHP as of the first day of the month. 3 months of HDHP
coverage with an annual high deductible amount of $2,000 will mean that the maximum
contribution will be 3/12ths of $2,000 or $500.

Special Note: A full year’s contribution (plus catch-up, if applicable) may be made to
your HSA when you first become eligible during that year, even if your coverage
starts December 1 .
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If you choose to contribute a full year’s contribution but are eligible only part of the
year, however, you will be subject to taxes and penalties if you don’t remain eligible
for 12 months after the year in which you first become eligible.

Your maximum includes all contributions being made to the account. If your employer is
contributing, please ensure that the total combined contributions do not exceed the maximum.
For more information please consult www.irs.gov or your tax advisor.

Calendar Year Catch-up Contributions: Catch-up contributions are HSA contributions
made in addition to any regular HSA contributions. You are eligible to make catch-up
contributions of you meet the eligibility requirements for regular contributions and have
attained age 55 by the end of your taxable year. If you are 65 and older and not enrolled in
Medicare you can contribute to your HSA and continue to contribute to make catch-up
contributions.

Health Savings Account Annual Contribution Limits

Tax HDHP Standard Contribution Catch-Up Contribution Limit Total Contribution Limit
Year Coverage Limit (age 55+) (age 55+)
Self-Only $3,600 $1,000 $4,600
2021
Family $7,200 $1,000 $8,200