Page 10 - QSC Benefit Summary 7-18 SO CALIFORNIA

MEDICAL INSURANCE

How the Option 1 Health Savings Account (HSA) PPO Works
The opportunity to establish and contribute to a Health Savings Account is available when you elect the HSA PPO medical
plan option. It’s like a personal, tax-free savings account for health care expenses that earns interest. Any unused money
rolls over from year to year.

QSC will make the following HSA contributions into your account: can be increased or decreased over the course of the year. The
• Employee: $46.16 Biweekly / $1,200 Annual money in your HSA is yours to save and spend on eligible health
• Family: $92.31 Biweekly / $2,400 Annual care expenses whenever you need it, whether in this plan year
• First-time Enroller/New Hire: Annual contribution, prorated or in future plan years. You can use the funds in your account
based on eligibility date to pay tax-free for qualifying out-of-pocket Medical, Dental and
Vision expenses such as deductibles, coinsurance and copays.
In addition to QSC’s contribution, you may elect to make Your account balance earns interest and the unused balance
contributions into your account up to IRS maximums: rolls-over from year to year. The money is yours to keep even if
IRS Limits 2018 2019 you leave QSC, no longer participate in a high deductible health
Employee $3,450 $3,500 plan (like the HSA PPO), or retire. You may continue to make
contributions to your HSA if you enroll in another qualified high
Family $6,900 $7,000
deductible health plan, or elect COBRA continuation coverage
Catch-up (Age 55+) $1,000 $1,000
of your HSA PPO coverage if your employment terminates.
Our HSA plan is effective July 1st through June 30th of each
year. Please note, HSA contribution limits are determined by About HSA Bank Account
the IRS on a calendar year (tax year) basis. For annual updated When you update your cart with your HSA enrollment on
IRS coverage limits available January 1st of each year, please UltiPro, the following will take place:
visit www.irs.gov. • An HSA account will be initiated on your behalf
• Money will be deposited into your HSA from two sources:
The portion of your paycheck that you contribute to your HSA QSC contributions and the amount you elect to contribute
will be taken out before you pay federal income taxes, Social
Security taxes and most state taxes (excluding state taxes in AL, Claims incurred prior to your HSA bank account establishment
CA and NJ). In addition, any contributions you make to your HSA are not eligible for reimbursement from your HSA funds.

Examples of Eligible HSA Expenses

• Providers (Doctors, Specialists, Nurses) • Providers (Optometrists,
• Prescription Drugs Ophthalmologists)
• Inpatient Hospital Services • Exams
• Laboratory & X-Ray • Glasses
Medical • Emergency Services Vision • Contact Lenses
• Acupuncture / Chiropractic • Lasik Surgery

• Providers (Dentists, Specialists,
Orthodontists) • COBRA Premiums
• Teeth Cleaning • Long-Term Care Premiums
Dental • Dental Treatment Premiums • Medicare Premiums
• Orthodontia

Examples of Ineligible HSA Expenses

Ineligible HSA expenses include expenses that are not medical or health related as well as cosmetic surgery.
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