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What is the HRA plan year? ____________ What is the insurance plan year? ______________
Is this a General Purpose Medical HRA? Yes_____ No_____
If yes, is it being (check all that apply):
_____Terminated _____Amended to a Post Deductible HRA
_____Amended to a Limited Purpose HRA _____Amended to a Suspended HRA
_____Amended to a Retirement HRA
*Any changes to the HRA must be coordinated through the HRA Plan Administrator.


In order for an employee who is enrolled in a General Purpose Medical HRA to be eligible to participate in
an HSA, the following must occur:
If the health insurance plan year is different from the HRA plan year:
The employee cannot receive HSA contributions until the HRA plan year has ended (even if their
account balance is currently at zero).
At HRA plan year-end the employee must waive participation in the General Purpose Medical HRA
for the new plan year.
If the health insurance plan year is the same as the HRA plan year:
If the employee has a zero balance at the end of the HRA plan year, they can immediately begin
to receive deposits into their HSA if they waive participation in the General Purpose Medical HRA for
the new plan year.




File: Flyer-HRA-HSA-Transition Revised 09-25-13



info@AmericanHealthValue.com
800-914-3248