/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/health-savings-account-hsa/,/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/health-savings-account-hsa/resources/,

/depts/uwhealth/benefits/open-enrollment/uwhc-open-enrollment/health-savings-account-hsa/resources/2017-HSA-Enrollment-Brochure.pdf

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2017 HSA Enrollment Brochure

2017 HSA Enrollment Brochure - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWHC Open Enrollment, Health Savings Account (HSA), Resources































ENROLLMENT
State of Wisconsin
HEALTH SAVINGS ACCOUNT





Save up to 30% with a Health Savings Account (HSA)!

It’s Your Choice Open Enrollment

 Annual It’s Your Choice Open Enrollment Period: October 17 – November 11, 2016
 2017 Benefit Period: January 1 – December 31, 2017
 Note: You must re-enroll in an HSA each year, even if you plan to continue High-Deductible Health Plan
(HDHP) enrollment.
New Employee Enrollment
If you are electing to enroll in an HSA, you must enroll within 30 days of your date of hire (in an eligible position),
or first eligible appointment. Coverage will be effective on the first of the month on or following your eligibility
date.

Qualified Life Change Event
If you experience a qualified life change event, such as a marriage or divorce, birth or adoption of a child, a
change in employment status, or another qualified life change event, you may have the opportunity to enroll or
change your coverage outside of the open enrollment period. There are various rules related to qualified life
change events. Changes due to a qualifying life event must be made within 30 days from the date of the event.

Important Program Information
Expense Deadline – For the 2016 Benefit Period, you
must incur all eligible expenses by December 31,
2016.

For the 2017 Benefit Period, you must incur all eligible
expenses by December 31, 2017.

Claims Deadline – While you should always try to
submit requests for distribution during the same plan
year in which the expense was incurred, there is no
deadline to request an HSA distribution. You can only
be reimbursed for eligible expenses incurred after your
HSA was established and funded.

Re-Enrollment – You must re-enroll each year to
continue participation. Elections do not carry forward
from year to year.

Carryover – All unused HSA funds carryover year-to-
year without forfeiture.

TASC Benefits Mobile App
 The TASC Benefits mobile app lets you access your account information wherever you are – 24/7!
 To download, visit the iOS App Store or Android Marketplace and search for “eflex Benefits.”
o File claims using your mobile device’s camera –
simply take a picture of your receipt and upload.
o Keep track of any changes to your account
balance.

o View your plan end date and run-out period.
o View claims history.
o Check claim status.
o Enjoy totally secure access.
TASC Customer Care
Phone 844-786-3947 or 608-316-2408
Monday – Friday, 8:00 a.m. to 5:00 p.m.
Online https://partners.tasconline.com/ETFEmployee
Email 1customercare@tasconline.com
Mail P.O. Box 7511
Madison, WI 53707
Fax 877-231-1287


TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com 2

We look
forward to
meeting your
HSA needs!
WELCOME WELCOME




A Health Savings Account (HSA) is an individually-owned, tax-advantaged account that you can use
to pay for current or future eligible medical expenses. With an HSA, you’ll have the potential to build
more savings for health care expenses or additional retirement savings through self-directed
investment options.
What are the benefits of an HSA? How does it work?
 Pre-tax contributions reduce your taxable
income.
 Post-tax contributions are tax deductible.
 Make changes to your contribution at any time.
 Distributions for eligible medical expenses are
tax free.
 HSA funds carry over year-to-year without
forfeiture.
 Contributions to your HSA belong to you, even if
you retire or change employment.4
 Grow your savings over time by earning interest.
 After age 65, your funds can be withdrawn for
any purpose without penalty (subject to regular
income taxes).

 You can contribute to your HSA via payroll
deduction or by online transfer from your personal
bank account to your HSA. Your employer (if
eligible for employer contribution) or third parties,
such as a spouse or parent, may contribute to
your account as well.
 You can pay for eligible medical expenses with
your TASC Card or pay out-of-pocket. If you pay
out-of-pocket, you can either choose to reimburse
yourself or keep the funds in your HSA to grow
your savings.
 Manage your HSA account 24/7 via the TASC
Benefits mobile app or TASC Online account at
https://partners.tasconline.com/ETFEmployee.
Enrollment Eligibility
 State employees, except those who are eligible for the graduate assistant/short term academic staff benefits
package and are not in the Wisconsin Retirement System, are eligible to participate.
 Limited Term Employees (LTEs) who are eligible for the State of Wisconsin Group Health Insurance
Program are eligible to participate.
 Retirees1 younger than age 65 are eligible to participate.
 To enroll in an HSA, you must be enrolled in a qualified IYC HDHP. In addition:
o You cannot have any other health coverage that pays for out-of-pocket health care expenses before
you meet your plan deductible, including Medicare A and B.
o You cannot be covered by TRICARE, or have accessed your Veterans Administration (VA) benefits
in the past 90 days (to contribute to an HSA). Exceptions may apply. See HSA Participant Guide for
more details.
o You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).
o You (and your spouse) cannot have a Health Care FSA in the same year.
o Note: You must notify your human resources/benefits office of any other medical coverage
when enrolling in, and at any point while enrolled in, the HDHP and HSA.

Annual HSA Contribution Limits 2017 2016
Individual HSA Contribution Limit2 $3,400 $3,350
Family HSA Annual Contribution Limit2 $6,750 $6,750

This is the amount the Internal Revenue Service (IRS)
allows to be contributed to an individual HSA. If a married
individual’s spouse also has an HSA, the two can only
contribute up to the total contribution limit between the two
HSAs. If you are eligible, your employer may contribute
up to $750 individual/$1,500 family.

3
HSA Catch-Up Contribution Limit3 $1,000 $1,000

1: Retirees enrolled in IYC HDHP/HSA benefit option must keep HSA open and active, and pay $3.00
monthly service fee.
2: Contributions from all sources combined, such as employee, employer, and third parties (i.e. parent,
spouse, or anyone else) must not exceed these limits.
3: Health Savings Accountholders that meet these qualifications are eligible to make an HSA Catch-
Up Contribution of $1,000: age 55-65 (regardless of when in the year an accountholder turns 55), not
enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should
be pro-rated).
4: Employees that terminate employment but keep HSA open and active pay $3.00 monthly service
fee.

HEALTH SAVINGS
ACCOUNT
Annual HSA Contribution Limits
HEALTH SAVINGS
ACCOUNT

Eligible HSA Medical Expenses
Below is a partial list of eligible expenses that are reimbursable through an HSA. Eligible expenses can be
incurred by you, your spouse, or qualified dependents. For more information, see your HSA Participant Guide.
For the complete list of eligible and ineligible expenses, visit www.IRS.gov and see IRS Publications 502.
Medical Expenses Dental Expenses
 Acupuncture
 Birth control/contraceptive devices
 Birth classes/Lamaze5
 Blood pressure monitor
 Chiropractic therapy/exams/adjustments
 Co-payments
 Crutches5
 Flu shots
 Hearing aids and batteries5
 Infertility treatments
 Insulin and diabetic supplies
 Legal sterilization
 Physical exams
 Physical therapy5
 Sleep apnea services/products5
 Smoking cessation programs
 Treatment for alcohol or drug dependency
 Vaccinations
 Wrist supports/elastic straps
 X-ray fees

5: Restrictions may apply. See IRS Publication 502 for more details.

 Cleanings and exams
 Crowns and bridges
 Dental surgery
 Dental x-rays
 Dentures
 Extractions
 Diagnostic services
 Fillings
 Orthodontia
 Root canals
Vision Expenses
 Contact lenses and lens
solutions
 Eye exams
 Eye surgery
 Diagnostic services
 Laser eye
surgery/LASIK
 Prescription eyeglasses
 Seeing eye dog (buying,
training, and maintaining)
OTC Medicines and Drugs
Over-the-counter (OTC) medicines and drugs, except for
insulin, require a prescription from your physician to be
reimbursable with your TASC HSA. The prescription must be
included with each request for reimbursement.

 Cold medicines
 First Aid supplies
 Hemorrhoid treatments
 Indigestion medications
 Nicotine patches
 Pain relievers
 Pain relieving creams
 Sinus medications
Note: If you have a qualified dependent child, you can use your HSA funds to pay for their eligible medical expenses
through the end of the calendar year in which they turn 24.
Interest Rate and HSA Investment Options
 Funds in your HSA account will earn interest over time.
 Once your balance reaches $2,000, you may invest any funds above that level (in $100 increments) in a
variety of HSA investment options with varying levels of related risk and returns.
 For more information about interest rate and HSA investment options, see page 4 of the HSA Enrollment
Brochure or visit TASC Online at https://partners.tasconline.com/ETFEmployee.

How to Enroll Following Enrollment
 Annual It’s Your Choice Open Enrollment
period: October 17 – November 11, 2016
 Benefit Period: January 1 – December 31, 2017
 Deadline for New Hire Enrollment is within 30
days from hire date. Contact your human
resources/benefits office for details.
 Deadline for Qualified Life Change Event
Enrollment or Changes is within 30 days of the
date of the qualified life change event. Contact
your human resources/benefits office for details.
 See page 7 or visit www.etf.wi.gov/IYC2017 for
enrollment information, or contact your human
resources/benefits office for enrollment
instructions.
 Note: If you are continuing HDHP coverage, you
must re-enroll in HSA each year. Elections do
not carry forward from year to year.

Once you have enrolled in the HSA, you will receive:
 HSA Welcome Brochure
The HSA Welcome Brochure will provide you with
information on how to manage your HSA, set-up
your TASC Online account, your responsibilities,
and key dates. It will also provide you with
information on how to make additional
contributions, transfer funds to an investment
account, or request a distribution.
 TASC Card
Your TASC Card allows you to conveniently pay
for eligible medical expenses. Be sure to review
the Cardholder Agreement included with your
TASC Card.
o Note: If you are a current TASC participant,
you will not be issued a new TASC Card. You
will continue to use your current TASC Card.

TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com 4




A Health Savings Account (HSA) lets you save money tax-free to pay for health care expenses not
covered by insurance. If you do not use all of your HSA funds, they carry over year-to-year without
forfeiture. The money is yours, even if you leave the High-Deductible Health Plan (HDHP) or state
service.

Not only do you save on taxes, but your HSA dollars can grow over time, especially if you decide to
compound your funds. The amount you save depends on how you choose to use your HSA funds.

Building Your Nest Egg
 Funds in your HSA account will earn interest
over time.
 Once your balance reaches $2,000, you may
invest funds (in $100 increments) above that
level in a variety of HSA investment options with
varying levels of related risk and returns.

Health Savings Account Interest Rate Disclosure
HSA balances are initially invested in an FDIC insured interest-bearing account with HealthcareBank, a division
of Bell State Bank & Trust, as custodian for your HSA.

HealthcareBank uses the daily balance method to calculate interest on your HSA. This method applies a daily
periodic rate to the principal balance in your HSA each day.

The following interest rate and Annual Percentage Yield
(APY) apply and are effective as of November 1, 2015.
 Interest rates will be paid for the portion of
your daily balance within each tier.

 The interest rate and APY may change at
HealthcareBank’s discretion, at any time.

 Interest begins to accrue no later than the
business day HealthcareBank receives credit
in your HSA for the deposit of non-cash items
(for example, checks).

 Interest is compounded and credited to your
HSA monthly.

 If you close your HSA before interest is
credited, you will not receive the accrued
interest for that month.

Health Savings
Account Balance
Interest
Rate
Annual Percentage
Yield (APY)
Less than $2,000 0.05% 0.00% - 0.05%
$2,000 - $4,999.99 0.10% 0.05% - 0.08%
$5,000 - $9.999.99 0.25% 0.08% - 0.17%
$10,000 - $24,999.99 0.35% 0.17% - 0.28%
$25,000 or more 0.50% 0.28% - 0.50%

To find more information on interest rate and
HSA investment options, visit the TASC website
and click on the HSA Participant Guide.

HSA Investment Account
A unique aspect of an HSA is the ability to invest some of your savings, which may potentially increase the
value of your account for retirement. In order to invest your HSA funds, you must set up an HSA Investment
Account. See the HSA Participant Guide at https://partners.tasconline.com/ETFEMployee or your TASC Online
Tools & Resources for more details. Also see the next page for HSA Investment Option offerings.

If you do not elect to participate in the investment option, the funds will remain in your HSA earning interest at
the rate detailed above. For the most current rates and investment options, visit your TASC Online Account.
Mutual funds are not FDIC insured.


TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com 5

HSA INTEREST RATE &
INVESTMENT OPTIONS
Triple Tax Advantage
HSAs offer a triple tax advantage
by making the following tax free:
 Contributions
 Distributions
 Investment earnings



INTEREST BEARING OPTION
Fund Name Category
Annual
Percentage Rate
Annual Percentage
Yield (APY)

Rate Effective
HealthcareBank Interest Bearing Account
FDIC Insured – Bank Guaranteed Cash Equivalent 0.20%

0.20% June 1, 2012
MUTUAL FUND OPTIONS
Fund Name

Category
Mutual Fund Returns as of July 31, 2016
Symbol YTD 3 Year
Return
5 Year
Return
10 Year
Return
Expense
Ratio

James Balanced Golden Rainbow (Retail)*

Conservative Allocation GLRBX 3.00% 4.85% 6.24% 6.35% 0.97

TRowe Price Capital Appreciation Fund
(Adv)*

Moderate Allocation PACLX 7.42% 10.39% 11.81% 8.58% 1.01

Ivy Asset Strategy (A)*

World Allocation WASAX -2.28% -1.05% 1.41% 5.59% 0.99

Vanguard 500 Index (Inv)*

Large Blend VFINX 7.58% 10.99% 13.21% 7.62% 0.16

American Funds Growth Fund of America
(F1)*

Large Growth GFAFX 4.60% 10.85% 12.37% 7.50% 0.70

Vanguard Mid Cap Index (Inv)*

Mid-Cap Blend VIMSX 8.23% 10.27% 12.21% 8.40% 0.20

JPMorgan Market Expansion Index (A)*

Mid-Cap Clend OMEAX 10.57% 9.67% 12.30% 8.51% 0.97

Neuberger Berman MidCap Growth

Mid-Cap Growth NMGAX 2.97% 7.78% 9.86% 8.23% 1.12

Vanguard Small Cap Blend Index (Inv)*

Small Blend NAESX 10.29% 8.25% 11.68% 8.51% 0.20

Vanguard Small Cap Growth Index (Inv)*

Small Growth VISGX 8.00% 6.91% 10.51% 9.05% 0.20

Northern Small Cap Value*

Small Value NOSGX 10.63% 7.93% 11.26% 7.18% 1.23

Vanguard Total International Stock Index
(Inv)*

Foreign Large Blend VGTSX 4.46% 1.88% 1.70% 2.22% 0.19

American Funds Europacific Growth (F1)*

Foreign Large Growth AEGFX 2.57% 3.82% 3.62% 4.04% 0.86

Fidelity Advisor Diversified International

International FDVAX -0.72% 4.09% 4.83% 2.21% 1.22

Vanguard Emerging Market Stock Index
(Inv)*

Diversified Emerging
Markets VEIEX 12.96% 0.26% -2.65% 3.74% 0.33

Vanguard Total World Stock Index (Inv)*

World Stock VTWSX 6.20% 6.10% 6.88% - 0.25

Nuveen Real Estate Securities (A)*

Real Estate FREAX 15.59% 14.26% 12.37% 8.10% 1.30

Templeton Global Bond (A)*

World Bond TPINX -1.19% -0.15% 0.94% 6.35% 0.91

Vanguard Intermediate Term Bond Index
(Inv)*

Intermediate-Term Bond VBIIX 7.60% 5.08% 4.53% 6.20% 0.16

PIMCO Total Return (Adm)*

Intermediate-Term Bond PTRAX 4.87% 3.43% 3.41% 5.94% 0.72

Vanguard Total Bond Market Index (Inv)*

Core Bond VBMFX 6.15% 4.06% 3.42% 4.94% 0.16
Not FDIC Insured – No Bank Guarantee – May Lose Value – See TASC Online Account for Current Rates and Investment Options
*This bank acts solely as custodian with any mutual funds being offered and sold through a registered broker-dealer by prospectus only. Past performance of investments is no indication or assurance of
future performance. As with all investments, mutual funds involve risk. The investment return and principal value will fluctuate so that shares, when redeemed, may be worth more or less than their original
cost. Read the prospectus carefully before you invest. Some funds have a redemption fee under certain circumstances.
6
HSA Investment Options





Annual It’s Your Choice Open Enrollment Period: October 17 – November 11,* 2016
2017 Benefit Period: January 1 – December 31, 2017

Enroll During It’s Your Choice
 Visit www.etf.wi.gov/IYC2017 for It’s Your Choice
Open Enrollment information.
 You have three ways to enroll during the It’s Your
Choice Open Enrollment Period:
o Online
o Paper
o Telephone
 You can request a paper application from your
payroll or benefits office, or download a copy from
the TASC or ETF website.
 Your election will be effective January 1, 2017.
 Note: If you are already enrolled in a Health
Savings Account (HSA), you must re-enroll each
year to continue participation. Enrollments do not
carry forward from year to year.

* Due to November 11 being a federal holiday, mailed applications must be postmarked by
November 10, 2016.

UW System Employees
 Enrollments are done directly through the UW, not
the TASC portal/website or by telephone.
 UW System employees should refer to
www.wisconsin.edu/ohrwd/benefits or contact your
UW institution human resources department for
enrollment instructions for 2017.

State of Wisconsin & Legislature Employees
 State of Wisconsin and Legislature employees who
are paid through the STAR System should log in to
STAR at https://ess.wi.gov to make all benefits
elections during the annual It’s Your Choice period.
Contact your agency payroll and benefits staff with
any enrollment questions.
If You Are a Newly Hired Employee
 If you are electing to enroll in an HSA, you must enroll within 30 days of your date of hire (in an eligible
position), or first eligible appointment.
 Coverage will be effective on the first of the month on or following your eligibility date.
 For more information and enrollment instructions, contact your human resources/benefit office.

If You Have Experienced a Qualifying Life Change Event
 If you experience a qualified life change event, such as a marriage or divorce, birth or adoption of a child, a
change in employment status, or another qualified life change event, you may have the opportunity to enroll
or change your coverage outside of the open enrollment period.
 There are various rules related to life change events. You must enroll or make changes within 30 days from
the date of the qualifying event.
 Contact your human resources/benefit office for more information on qualifying events, to see what your
options are, how to enroll, and how to make a change.

Following Enrollment
Once you have enrolled in the HSA, TASC will send these items to you:
HSA Welcome Brochure
 The HSA Welcome Brochure will provide you with
information on how to manage your HSA.
 Follow the instructions to set-up your TASC Online
account.
 Use your online account to check your balance,
make additional contributions, transfer funds to an
investment account, or request a distribution.
TASC Card
 Your TASC Card allows you to conveniently pay for
eligible medical expenses.
 Be sure to review the Cardholder Agreement
affixed to the card.
 Note: If you are a current TASC participant, you
will not be issued a new TASC Card. You will
continue to use your current TASC Card.
7

HOW TO ENROLL

Enroll with TASC Online

1. Determine desired annual contribution amount.
a. See page 9 of this HSA Enrollment Brochure for
HSA Annual Expense Estimate Worksheet.
2. Go to the TASC Online website:
http://partners.tasconline.com/ETFemployee
a. If you are a new TASC Participant, enter a
temporary TASC username. This is your first
initial, last name, date of birth (mmddyy), and
the last four digits of your Social Security
Number (SSN).
 For example: JSmith0101771234
b. If you are a current TASC participant, enter
your current TASC username and password.
 If you do not remember your username
or password, click Forgot Username or
Password and follow the reset steps
provided.
2. Once logged in to your TASC Online Account,
click Enroll Now.
3. Enter your information.
a. You will be required to enter your SSN.
b. We recommend adding your personal email
address.
c. Click Next.
4. If applicable, add your dependent(s).
a. Enter the name(s) of your dependent(s).
b. Click Add Dependent.
c. Your dependent(s) will be displayed on the My
Dependents list.
Click Next.
5. Review your eligibility and the HSA Qualifications
to ensure you are eligible for an HSA.
a. Note: If you are enrolled in a High-Deductible
Health Plan (HDHP), you are not eligible for the
Health Care Flexible Spending Account (FSA).
See the HSA and Limited Purpose Flexible
Spending Account (LPFSA) flyers for benefit
options.
b. Click Next.





6. Review the plan rules.
a. Check the acknowledgement box indicating that
you have read the plan rules and agree to them.
b. Note: You must do this for every plan, even for
plans in which you are not enrolled.
6. Review your annual election amount.
a. Enter your desired deduction per pay period.
b. It is your responsibility to ensure your contributions
do not go beyond IRS maximum annual limits.
c. Note: Contributions from all sources combined,
such as employee, employer, and third parties (i.e.,
parent or spouse), must not exceed these limits.
7. Review your payment method.
a. Select your preferred method to receive distributions
and elect to get a TASC card.
b. If you elect direct deposit, you will need to enter
your bank information.
c. Click Next.
8. Add your beneficiaries.
a. Select your desired beneficiaries from your list of
dependents to prefill their information.
b. Click Add Beneficiary.
9. Accept the Terms and Conditions.
a. You must read and accept each agreement in order
to active your HSA.
b. Click Next.
10. Verify, submit and print.
a. Review all of your information.
b. If any changes are required, click Edit Information.
c. When you have verified that all information is
correct, print the Enrollment Confirmation page for
your records.
d. Click Next.
e. Click Submit Enrollment.
Enroll by Telephone Enroll by Paper
 Contact TASC Customer Care at 1-844-786-3947
or 608-316-2408.
 One of TASC’s friendly and knowledgeable
Customer Service Representatives will assist you.
 TASC Customer Care is open Monday through
Friday, 8:00 a.m. to 5:00 p.m.

 Request a paper application from your human
resources/benefit office, or download a copy from
the ETF or TASC website.
 Submit a completed TASC HSA Enrollment Form
to your human resources/benefit office.

Identification Verification Failure Notification
Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who
opens an HSA. This process will occur automatically upon your enrollment. If your identity cannot be verified, you will
be notified of the identity verification failure via secure email. The email notification will provide required actions to
resolve the matter. If you receive this notification, please provide the requested information within 30 days (via email
or fax). If you do not respond within 90 days, your HSA will be deactivated. To be eligible for a High-Deductible Health
Plan (HDHP), you must be enrolled in an HSA. If your HSA is deactivated, you will no longer be eligible for an HDHP.

TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com 8
Reminder: If you are a UW System employee or
a State of Wisconsin and Legislature employee
paid through the STAR system, do not enroll via
TASC Online or by phone. See the prior page for
enrollment details.




Actual Expenses
Last Year
Estimated Expenses
New Year

High-Deductible Health Plan
Expenses toward plan deductible
Prescriptions $ _______________ $ _______________
Physician visits $ _______________ $ _______________
Hospital $ _______________ $ _______________
Laboratory/testing $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Miscellaneous Health Expenses Not Covered by Insurance
Over-the-counter medication $ _______________ $ _______________
Other:___________________________ $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Dental Expenses
Dental visits $ _______________ $ _______________
Fillings $ _______________ $ _______________
Major work (root canals, crowns, dentures, etc.) $ _______________ $ _______________
Orthodontia (braces) $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Vision Expenses
Eye examination $ _______________ $ _______________
Eyeglasses $ _______________ $ _______________
Contact lenses and solution $ _______________ $ _______________
LASIK surgery $ _______________ $ _______________
Other:___________________________ $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Hearing Expenses
Hearing examination $ _______________ $ _______________
Hearing aid $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Miscellaneous Dental, Vision, and Hearing Expenses Not Covered by Insurance
Over-the-counter medication $ _______________ $ _______________
Other:___________________________ $ _______________ $ _______________
Subtotal: $ _______________ $ _______________

Additional Contribution to Maximize Annual Savings
$ _______________ $ _______________

Total Annual Amounts: $ _______________ $ _______________



TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com 9

HEALTH SAVINGS ACCOUNT
ANNUAL EXPENSE ESTIMATE WORKSHEET




TASC CARD
 Access your Health Savings Account (HSA) funds wherever you are –
just swipe to pay for eligible HSA medical expenses.
 Eliminates the need to complete paper requests for distribution.
 Automatic verification of most eligible expenses.

TASC Online Account
 Instant access to your account information and account balance 24/7.
 Easy access to your contribution and distribution histories.
 Access helpful online tools, like tax savings calculators, health care
expense tables, and more.
 Self-service feature available, such as signing up for direct deposit,
ordering additional TASC cards, reviewing your investment rates and
options, and managing your notifications.

TASC Benefits Mobile App
 Access your account information and account balance – no matter
where you are!
 Submit contribution and distribution requests by taking pictures of
your receipts with your mobile device camera.
 Download the TASC Mobile App is available for Apple and Android
phones – just search for “eflex Benefits” in the iOS App Store or
Android Marketplace.








TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com




TASC TOOLS
It’s Your Choice
Open Enrollment Period October 17 – November 11, 2016


After enrollment, don’t forget to:
 Set-up your TASC Online
Account.
 Check your email for a link
to the HSA Welcome
Brochure.
 Check your mail for your
TASC Card and Cardholder
Agreement.

Discrimination is Against the Law 45 C.F.R. § 92.8(b)(1) & (d)(1)
Total Administrative Services Corporation complies with applicable
Federal civil rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex. TASC does not
exclude people or treat them differently because of race, color,
national origin, age, disability, or sex.

TASC provides free aids and services to people with disabilities to
communicate effectively with us, such as qualified sign language
interpreters and written information in other formats.

TASC provides free language services to people whose primary
language is not English, such as qualified interpreters and
information written in other languages. If you need these services,
contact TASC’s Civil Rights Coordinator.

If you believe that TASC has failed to provide these services or
discriminated in another way on the basis of race, color, national
origin, age, disability, or sex, you can file a grievance with: Civil
Rights Coordinator, 2302 International Way, Madison, WI 53704;
Phone: 1-608-316-2408; Fax: 1-877-231-1287; Email:
CivilRightsCoordinator@tasconline.com.

You can file a grievance in person or by mail, fax, or email. If you
need help filing a grievance, TASC’s Civil Rights Coordinator is
available to help you.

You can also file a civil rights complaint with the U.S. Department of
Health and Human Services, Office for Civil Rights electronically
through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services, 200 Independence
Avenue SW., Room 509F, HHH Building, Washington, DC 20201,
1-800-868-1019, 800-537-7697 (TDD).

Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.

ATENCIÓN: si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-608-316-2408.

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus,
muaj kev pab dawb rau koj. Hu rau 1-877-533-5020 (TTY: 1-800-
947-3529).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致
電1-877-533-5020 (TTY: 1-800-833-7813).



ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos
sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-
533-5020 (TTY: 1-800-947-3529).

م قر) 877-533-5020-1 ةظوحل م: اذإ تن ك ثدحت ت ر كذا ،ةغ ل لا نإ ف تامدخ
ةدعاس م لا ة یوغ ل لا.(800-947-3529-1 :ف تاھ مص لا مك ب لاو ر فاوت ت ك ل
ناجم لا ب. لص تا م قر ب

ВНИМАНИЕ: Если вы говорите на русском языке, то вам
доступны бесплатные услуги перевода. Звоните 1-877-533-5020
(телетайп: 1-800-947-3529).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로
이용하실 수 있습니다. 1-877-533-5020 (TTY: 1-800-947-
3529).번으로 전화해 주십시오.

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ
miễn phí dành cho bạn. Gọi số 1-877-533-5020 (TTY: 1-800-947-
3529).

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht,
kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die
englisch Schprooch. Ruf selli Nummer uff: Call 1-877-533-5020
(TTY: 1-800-947-3529).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ

້ າພາສາ ລາວ, ການບ



ການຊ່ວຍເຫ

ຼື
ອດ້ານພາສາ,
ໂດຍບ

່ ເສັຽຄ່າ, ແມ່ນມ

ພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-877-533-5020 (TTY: 1-
800-947-3529).

ATTENTION : Si vous parlez français, des services d'aide
linguistique vous sont proposés gratuitement. Appelez le 1-877-
533-5020 (ATS : 1-800-947-3529).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej
pomocy językowej. Zadzwoń pod numer 1-877-533-5020 (TTY: 1-
800-947-3529).

ध्यान द
ें
: यदद आप ह िंदी बोलत ेह
ैं
तो आपके ललए म

फ्त म
ें
भाषा सहायता सेवाएं
उपलब्ध ह
ैं
। 1-877-533-5020 (TTY: 1-800-947-3529) पर कॉल कर
ें

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të
asistencës gjuhësore, pa pagesë. Telefononi në 1-877-533-5020
(TTY: 1-800-947-3529).

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit
ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag
sa 1-877-533-5020 (TTY: 1-800-947-3529).