Page 6 - Success Academy | 21-22 Benefits Summary
P. 6

 Health Savings Account (HSA) Plan
The HSA Plan is a High Deductible Health Plan that combines
an in-network-only medical plan with a tax-advantaged health savings bank account. On a quarterly basis, Success Academy will contribute $300 ($1,200 each year per employee) and $600 ($2,400 each year per employee with dependents) to your HSA bank account. HSA Bank manages our HSA bank accounts and may need to confirm your identity. You will receive the quarterly deposits while you are employed by Success. Employees starting mid-year will receive prorated contributions.
In addition, you can contribute up to $2,400 of your own pre-tax dollars to this account annually for Employee Only coverage and $4,800 for Employee with dependents. If you are 55 or older by the end of 2021, you can contribute an additional $1,000 to your HSA account, pre-tax. Under the HSA plan, you can pay for in-network health care expenses for you and your eligible dependents using money in your HSA bank account. What you don’t spend can be saved for future health costs.
Under the HSA Plan, preventive visits and most preventive generic prescriptions are covered at 100% — that means no copay or deductible. For all other health care expenses, you will need to pay for all costs from your HSA account until you meet your deductible ($1,500 Employee Only / $3,000 Employee + Dependents). Once the deductible is met, you will be responsible for coinsurance of 10% to a maximum of $2,000 (Employee Only) / $4,000 (Employee + Dependents). If you need to see a specialist, you do not need a referral. Non-preventive prescriptions have tiered coverage: You pay a copay of $15 - $30 - $60, depending on the type of drug, after you have satisfied the deductible. The out-of-pocket maximum is $2,000 (Employee Only) / $4,000 (Employee + Dependents). If you have a life-threatening emergency, please seek care immediately. Even though the HSA Plan has in-network coverage only, true emergencies will be covered at the in-network level. Out-of-network costs are not counted toward your deductible or out-of-pocket maximum under the HSA Plan.
Visit for a listing of network providers in the Cigna OAP Network.
• Comprehensive medical coverage.
• MoneyinyourHSAisyoursevenifyouleaveSA; it rolls over every year through retirement.
• Preventive visits are completely covered (no copay, no deductible).
• Mostpreventivegenericprescriptionsare covered (no copay, no deductible).
• Lowerout-of-pocketmaximumforyou:
Total out of pocket is $2,000, but the net cost for Employee Only is only $800 to you because Success contributes $1,200 to your HSA.
• Ifyouhaveovera$2,000HSAbankaccount balance, you can invest HSA funds into self- directed investment options.
• Afterthedeductible,therearesetprescription costs: up to $15 for generic, $30 for preferred, and $60 for nonpreferred.
• Onlycoversin-networkproviders,unless there is a true emergency, and that would be considered an in-network expense.
• Youhaveincreasedadministrativeresponsibility (save receipts, reimburse yourself from account, pay medical bills, etc.).
• FundingtoyourHSAaccountismadequarterly. If a medical expense exceeds the current funds in your account, you can reimburse yourself once funding has accrued.

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