Individual Coverage HRA (ICHRA) Plan Document Package $199
Additional
Plan
Document Options
$
25
Documents provided in PDF format only. Forms in MS Word format
$
25.00
$
149.00
This option entitles you to one plan document amendment in the first 24 months. Save 25% off the normal $199.00 update price.
$
0.00
Notes Section
Add any special notes regarding a dba name, delivery address
(physical and email), eligibility requirements, etc. For HRA plan
documents please give us as much detail as possible about exactly
how you would like your custom HRA to be designed. A benefit
specialist will contact you regarding specific questions, plan
design issues, or additional information needed.
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Purchaser Information
First Name:
Last Name:
Company Name:
Address:
City:
State:
Zipcode:
Phone:Ext:
Email:
FAX:
E-Mail/Ship to:
Employer Information
Employer First Name:
Employer Last Name:
Employer Company Name:
Employer Address:
Employer City:
Employer State:
Employer Zipcode:
Employer Phone:
Employer Email:
Employer FAX:
Company Information
Type of Company:
Employer Federal ID#:
State of Incorporation:
Number of Employees:
Legal Name(s) of Affiliated Company(ies)
1:
2:
3:
4:
Administrator Information
Name:
Address:
City:
State:
Zip:
Phone:
Plan Information
Effective Date is:
Plan year - The first plan year will be:
Waiting Period:
Eligibility Requirements:
How did you hear about Core Documents?
Selected Plan Option(s)
Plan Option:
Additional Plan Document Options:
Selected Benefits:
Additional Information
Protected Health Information Designee
PHI Person
Benefit Limits
Employee Only (annually) $
Employee & Eligible Dependents (annually) $
IC HRA
Benefit Availability:
Coverage available t
Choose your Benefits
Will your ICHRA coordinate with a Health FSA?
Will your ICHRA coordinate with an HSA Plan?
Premium Reimbursement by Age
Will premium reimbursement be the same for all ages?
Offering different Classes of Benefits?
Will your ICHRA offer different Benefits by Employee Class or Location?
Medicare
Medicare Premium Parts B, C, and D and supplemental coverage
Medicare out-of-pocket expenses including all allowed IRS 213(d) medical, dental, vision expenses
Employees Pretax Extra Premium
Will employees be able to pretax extra premium using a Section 125 Premium Only Plan?
Carryover of Unused Funds
Will unused funds carryover to the next Plan Year?
If carry over is allowed, describe it (max account balance, or other structure)
