Consumer-Driven Health Plan(s) Implementation Kit

"*" indicates required fields

1Company

2Billing

3Broker/ Agent Contact(s)

4Plan(s)

5Eligibility

6Funding

7EDI Services

8Required Forms/Data

This field is for validation purposes and should be left unchanged.

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

Legal Company Name*

DBA

Employer Tax ID Number*

Employer Entity

Employer Size*

Please enter a number from 1 to 1000000.

Employees Covered

Physical Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

Same as previous

Street Address Address Line 2 City State ZIP Code

Primary Contact*

First Last

Primary Title

Primary Email*

Enter Email Confirm Email

Primary Phone

Is There A Secondary Employer Contact?

Secondary Employer Contact*

First Last

Secondary Title

Secondary Email*

Enter Email Confirm Email

Secondary Phone

Are There Additional Employer Contacts?

Additional Employer Contacts

Contact Name

Contact Phone#

Contact Email

Contact Name

Contact Phone#

Contact Email

BILLING INFORMATION

Billing information for admin fees

Admin America Services Effective Date

mm/dd/yy

Broker Billed

Broker Address

Street Address Address Line 2 City State ZIP Code

Broker Billing Contact

First Last

Invoicing of Admin Fees

Broker Billing Email

Enter Email Confirm Email

Invoicing of Admin Fees

Employer Billing Contact Is Same As:*

Other - Complete Employer Billing Contact Information Below

Primary Employer Contact

Secondary Employer Contact

Employer Billing Contact*

First Last

Invoicing of Admin Fees

Employer Billing Email*

Enter Email Confirm Email

Invoicing of Admin Fees

Employer Billing Telephone

Invoicing of Admin America

Are There Additional Employer Billing Contacts?

Additional Employer Billing Contacts

Contact Name

Contact Phone#

Contact Email

Additional Employer Billing Contacts

Contact Name

Contact Phone#

Contact Email

Method of Payment for Admin Fees*

ACH (AA debits the Company's bank account) - <fill out the AA ACH Authorization Form.

Credit Card (Once invoice is emailed to billing contact(s), a link to our online payment system will be available)

Company sends AA Payment via ACH.

Company mails check to AA each billing cycle

Other

*For minimum sized groups we will bill on an annual basis. Otherwise, we will bill monthly.

ACH for Admin Fees Options*

I authorize the ACH debit of admin fees from same account authorized to fund claim reimbursements.

A different account will be used for the ACH debit of admin fees - fill out the AA AACH Authorization Form.

Click Here to Access the Admin Fees ACH Form

Click Here to Upload Completed ACH Form for Admin Fees

BROKER / AGENT CONTACT INFORMATION

Agent/Broker

Agent Company*

Agency Tax ID Number

Agent Physical Address*

Street Address Address Line 2 City State ZIP Code

Broker/Agent Name

First Last

Broker/Agent Email

Account Rep(s)*

First and Last Name

Email Address

Phone Number

PLAN INFORMATION

Regular Plan Year*

Plan Year Begin Date (MM/DD)

Plan Year End Date (MM/DD)

Regular 12 month plan year

Is this a Short Plan Year?*

less than 12 months

Short Plan Year

Short Plan Year Begin Date (MM/DD)

Short Plan Year End Date (MM/DD/YY)

Is this a Mid-Year Takeover of a Current Plan?

Name of Prior TPA Vendor

Prior Administrator Final Processing Date:

Accounts Offered*

HSA (Health Savings Account)

Traditional Healthcare FSA

Limited Purpose FSA

Dependent (Child) Care FSA

Qualified Parking Expenses

Transit Parking Expenses

Accounts Offered*

HSA (Health Savings Account)

Limited Purpose FSA

Dependent (Child) Care FSA

Qualified Parking Expenses

Transit Parking Expenses

ERISA Plan Number

520 (default)

Other

ERISA Plan Number should be a 3 digit number between 501 - 520.

Medical FSA Annual Election*

Max Allowed by IRS

Other

For Plan Years beginning in 2023, the Federal Max is $3,050 for a full 12 month plan year.

Medical FSA other election amount:*

Dependent Care FSA Annual Election:*

Max Allowed by IRS

Other

For Plan Years beginning in 2022, the Federal Max is $2,500 Individual or $5,000 per family unit per calendar year.

Dependent Care FSA other election amount:*

Does the employer contribute money towards the FSA?

Explain Contribution Amount and Any Stipulations in Box Provided Below:*

Optional Medical FSA Features*

Federal Rollover Max (2026 Limit: $680)

Participants have 75 days after the plan year ends to incur expenses

No Optional Features Allowed

Optional Dependent Care FSA Features

Participants have 75 days after the plan year ends to incur expenses

Other (less than 75 days)

0 Days

Upload Copay Information

Drop files here or

Max. file size: 256 MB.

We need copay information to setup parameters in the system that will disable it from requesting additional documentation to substantiate a debit card transaction or claim reimbursement

Number*

Please enter a number from 1 to 74.

Earliest Effective Date of Participant HSA Accounts

Will an HSA Qualified High Deductible Group Health Plan be Available as of the Effective Date of the HSA?*

Name of Medical Insurance Carrier:*

Does the employer contribute money towards the HSA?

If "Yes", How Much Per Employee Per Year. Please Explain:

HSA Transfers: Do Any of the Employees Have Current HSA Accounts?

Yes

If "Yes", Would You Like Assistance With Trustee to Trustee Rollovers?

Yes

Is an HRA currently offered?

Will it pay out before FSA funds?

Insurance Premiums Payroll Deducted on a Pre-Tax Basis

Group Health Insurance

Group Dental Insurance

Group Vision Insurance

Health Savings Account

Cancer/Dread Disease Insurance

Critical Illness

Hospital Indemnity

STD or LTD Disability (typically not pre-taxed)

Life Insurance (typically not pre-taxed)

Other

Please list all welfare benefits where the monthly premium is payroll deducted on a pre-tax basis.

Define "Other"

Section 125 Cafeteria Plan Start Date

provide starting month

Section 125 Cafeteria Plan End Date

provide ending month

Does Company Currently Offer an FSA Plan?

Yes

Other

Does Admin America Currently Administer Your Company's FSA Plan?

Yes

Other

Does the Company Have a Current POP (Premium Only Plan) in Place?

Yes

Other

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.

[contact-form-7 id="5"]

Tell us about any additional information that we need to know about the plan here:

ELIGIBILITY INFORMATION

Eligibility Date

*eligibility date cannot be less than the medical insurance eligibility date.

Enter Other Eligibility Date:

Entry Date

Enter Other Entry Date:

Employees to be Excluded from the Plan(s)*

Enter Employees to be Excluded from the Plan(s)*

Number of Days Participants Have to File Claims After the Plan Year Ends.*

employer can allow participants a certain number of days to submit claims for reimbursement which were incurred during the plan year.

Number of Days to File Claims*

FUNDING INFORMATION

Number of Salary Deductions Taken:*

Weekly (52)

Biweekly (24)

Biweekly (26)

Semimonthly (24)

Monthly (12)

Based on Class

Define Number of Salary Deductions Taken for Each Class of Employees:

Define each class.

1st Salary Deduction Date(s):*

Define each class.

Upload Contribution Deduction Dates Schedule

Drop files here or

Max. file size: 256 MB.

Frequency of Claim Reimbursements (FSA/TRP)*

Weekly (52) - Recommended

Bi-Weekly (24)

Bi-Weekly (26)

Semimonthly (24)

Monthly (12)

In relation to how often Admin America processes claims for reimbursement.

Check & Bank Account Admin Options*

In relation to out of pocket claims for reimbursement. Not debit card transactions.

Direct Deposit Option*

Allow the direct deposit of claims reimbursements into the participants personal bank account in lieu of a check.

Debit Card Option*

EDI Services

Additional fees may apply.

Was There A Prior Year Medical FSA Plan With A Rollover Provision?

Yes

If, "yes" we will need a rollover report once the run out period with the prior vendor has been finalized.

Rollover Amount*

Provide Rollover amount defined by the previous year's plan documents. i.e.; $680 (2026 federal max)

Final Processing Date for prior plan year

Period of time after the end of the prior plan year for participants to submit claims for reimbursement that were incurred during that plan year.

Request to map enrollment files with Company's Current EDI Vendor/Payroll?*

Yes

Other

Admin America charges a one time $250 SetUp Fee for this service.

Accept EDI Feed Pricing*

Decline EDI Option

Eligibility Files - $250

Consent to EDI Fee*

I agree to the EDI Fees

I consent to the $250 fee for Admin America to begin the integration process with the company's EDI vendor.

EDI Vendor Name

EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process.

EDI Vendor Contact Name

EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process.

EDI Vendor Contact Email

If provided, we can go ahead and send the request directly to the EDI vendor contact once the implementation phase has been completed.

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.

Applicant's Name*

Applicant's Email*

Applicant's Signature*
Your Name
Your Name
Your Name

Date*

COMPANY INFORMATION

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

BILLING INFORMATION

BROKER / AGENT CONTACT INFORMATION

PLAN INFORMATION

OR send us a Sales Inquiry

ELIGIBILITY INFORMATION

FUNDING INFORMATION

EDI Services

CLIENT SIGNATURE