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Admin America, Inc.

Alpharetta, GA 30005

770-992-5959        800-366-2961

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Consumer-Driven Health Plan(s) Implementation Kit

Home Consumer-Driven Health Plan(s) Implementation Kit

1Company
2Billing
3Broker/ Agent Contact(s)
4Plan(s)
5Eligibility
6Funding
7EDI Services
8Required Forms/Data
9Upload Files
10Client Acknowledgements & Signature
  • COMPANY INFORMATION

  • A Traditional FSA Plan Cannot Be Offered If A Group Health Plan Is Not Offered

    Company may proceed if they will be offering a LPFSA (Limited Purpose FSA), Transit and Parking Plans, and/or an HSA
  • Contact NameContact Phone#Contact Email 
  • Contact NameContact Phone#Contact Email 
Save and Continue Later
  • BILLING INFORMATION

    Billing information for admin fees
  • mm/dd/yy
  • Invoicing of Admin Fees
  • Invoicing of Admin Fees
  • Invoicing of Admin Fees
  • Invoicing of Admin Fees
  • Invoicing of Admin America
  • Contact NameContact Phone#Contact Email 
  • Contact NameContact Phone#Contact Email 
    *For minimum sized groups we will bill on an annual basis. Otherwise, we will bill monthly.
  • Click Here to Access the Admin Fees ACH Form
  • Click Here to Upload Completed ACH Form for Admin Fees
Save and Continue Later
  • BROKER / AGENT CONTACT INFORMATION

  • First and Last NameEmail AddressPhone Number 
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  • PLAN INFORMATION

  • Plan Year Begin Date (MM/DD)Plan Year End Date (MM/DD) 
    Regular 12 month plan year
  • less than 12 months
  • Short Plan Year Begin Date (MM/DD)Short Plan Year End Date (MM/DD/YY) 
    ERISA Plan Number should be a 3 digit number between 501 - 520.
    For Plan Years beginning in 2023, the Federal Max is $3,050 for a full 12 month plan year.
    For Plan Years beginning in 2022, the Federal Max is $2,500 Individual or $5,000 per family unit per calendar year.
  • Please enter a number from 1 to 74.
    Admin America will prepare your POP Documents for a $400 fee.
  • Click Here to Access the POP Online Application;

    OR send us a Sales Inquiry

    Sales Queries
    Do you have questions about Admin America's POP Document Services or any of our other Compliance and Administration Services? Send an email and we'll get in touch shortly, our dedicated sales team is ready to help.

      Your Name (required)

      Your Email (required)

      Subject

      Your Message

    Save and Continue Later
    • ELIGIBILITY INFORMATION

    • *eligibility date cannot be less than the medical insurance eligibility date.
    • employer can allow participants a certain number of days to submit claims for reimbursement which were incurred during the plan year.
    Save and Continue Later
    • FUNDING INFORMATION

    • Define each class.
    • Define each class.
      In relation to how often Admin America processes claims for reimbursement.
    • In relation to out of pocket claims for reimbursement. Not debit card transactions.
    • Allow the direct deposit of claims reimbursements into the participants personal bank account in lieu of a check.
    Save and Continue Later
    • EDI Services

      Additional fees may apply.
      If, "yes" we will need a rollover report once the run out period with the prior vendor has been finalized.
    • Provide Rollover amount defined by the previous year's plan documents. i.e.; $550 (2021 federal max)
      Admin America charges a one time $250 SetUp Fee for this service.
    • I consent to the $250 fee for Admin America to begin the integration process with the company's EDI vendor.
    • EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process.
    Save and Continue Later
    • REQUIRED FORMS & DATA

      Please upload all required bank forms and elections.
    • Click Here to Access the Bancorp Bank Debit Card Funding Authorization Form
    • Click Here to Access the AA ACH Authorization Form
    • Click Here to Access the AA ACH Authorization Form
    • Click Here to Access the Signature Authorization Form
    • Click Here to Access the FSA Enrollment Census
    • Click Here to Access the FSA Enrollment Census w ER Contributions
    • Click Here to Access the FSA Takeover Enrollment Census
    • Click Here to Access the HSA HDHP Enrollment Census
    • Click Here to Access the TRP8 Participant Election Form
    Save and Continue Later
    • Secure Uploads

    • Click Here to Upload the FSA Bank Forms and Enrollment Census
    Save and Continue Later
    • CLIENT SIGNATURE

    • Please complete the form carefully and submit accurate final balance reports. Any changes that cause Admin America Inc. to audit the account and reprocess claims will result in a $300.00 auditing fee.

      By entering your name below you are electronically signing this form.

      I understand the reprocessing fee stating above. The information I have supplied herein is accurate and should be used by Admin America Inc. as of the date in which Admin America takes over.


    • MM slash DD slash YYYY
    Save and Continue Later

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