Monthly Premium Reimbursement

Your Information

First Name:

Last Name:

Email Address:

Phone Number:

Employer:

Social Security #:

Previous Address:

City:

State:

Zip:

Current Address:

City:

State:

Zip:

Would you like to receive a monthly courtesy email reminder?

Each month you will receive an email notifying you that your recurring premium remains in effect. This email will remain in effect through policy expiration, at which time you will need to submit a new claim. We'll notify you thirty days prior to your policy expiration that it's time to renew.

Start Date:

End Date:

Amount of Monthly Premium:

Are you submitting this policy for multiple months?:

How many months are you submitting for?

Name of Covered Participant/Dependent:

Insurance Type:

Paid To:

Employer Name:

Address:

City:

State:

Zip:

Comments:

File Upload (Maximum 5 files, file size restricted to 8 MB):

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    Policy List

    Policy 1
      Add Another Policy

    Total Requested

    $0.00

    Start Date:

    End Date:

    Amount of Monthly Premium:

    Are you submitting this policy for multiple months?:

    How many months are you submitting for?

    Name of Covered Participant/Dependent:

    Insurance Type:

    Paid To:

    Employer Name:

    Address:

    City:

    State:

    Zip:

    Comments:

    File Upload (Maximum 5 files, file size restricted to 8 MB):

    Drag and drop files above or click to browse

      Reimbursement Details

      Full Name:
      Employer:
      Email Address:
      Number of Policies:
      1
      Paid To Insurance Providers:
      $0.00
      Paid To Employer:
      $0.00
      Paid to You:
      $0.00

      Check (by mail)

      New Direct Deposit

      Bank Routing #

      Bank Account #

      Account Type

      Existing Direct Deposit

      I request payment from the reimbursement account for the expenses submitted. To the best of my knowledge, my statements on this form are true and complete. I certify that all expenses for which reimbursement or payment is claimed were incurred either by me or by my eligible dependent(s). If the claim was incurred by my eligible dependents, I certify that they are enrolled in health coverage. I understand that a medical expense is considered incurred when medical care is provided to me or my eligible dependent(s), not I am formally billed, charged or have paid for the medical care. Therefore, I understand premiums for an entire year are not eligible for reimbursement until the care is given. I certify that the medical expenses in this claim are eligible for reimbursement and are “qualifying expenses” as defined by the Internal Revenue Code Section 213(d). I understand that if these medical expenses are not qualified medical expenses I may be liable for the payment of all related taxes on amounts received pursuant to this claim. I certify that the medical expenses claimed are not covered by insurance and have not been reimbursed or cannot be reimbursed under any other health plan coverage. I certify that I have not previously submitted this claim for reimbursement and that this is not a duplicate claim. I take full responsibility for the accuracy of all information I have provided. I further understand that reimbursed expenses cannot be claimed as a credit on my personal income tax return.

      As part of the Affordable Care Act, the DOL has mandated that employees be permitted to either irrevocably suspend their HRA for a fixed period of time, or permanently opt-out of the HRA by forfeiting their account balance and waiving any future contributions. Electing either option would preserve the eligibility of an individual to claim a Code § 36B premium tax credit, otherwise known as a Premium Subsidy for Healthcare Exchange coverage, should they otherwise qualify.

      Should you choose to suspend your HRA, you, your spouse and any qualifying dependents will cease to have access to the HRA and will be ineligible to incur any new expenses during the suspension. For your account to be reactivated, MidAmerica must receive a written notice requesting the account be unfrozen. Please be advised that the account becomes available at the start of the plan year following the request to unfreeze. To learn more about the Code § 36B premium tax credit, please visit: http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/The-Premium-Tax-Credit.