Rock Hill Local School District

HRA ENROLLMENT FORM (NEW EMPLOYEES ONLY)

Necessary Documents on Left Panel

ABOUT THIS PLAN

This plan is designed to help pay for certain medical expenses. Your employer makes contributions to an account so that if you are a participant in this plan, you can be reimbursed for expenses incurred by you, and your eligible spouse and dependents.

WHAT THIS PLAN PAYS FOR

This plan will reimburse you for the following in-network expenses that you are required to pay under your group health plan:

 Medical Deductibles

Eligible expenses cannot also be reimbursed by another plan nor paid pre-tax by another health plan coverage or program.

The first $500 in deductible expenses will be paid by employee. The next $1,000 in deductible expenses will be paid by the HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The last $500 in deductible expenses will be paid by the employee. The total amount the employee may be reimbursed is $2,000.

This plan has an embedded deductible. This schedule will be applied per deductible (person) up to two deductibles. The first $500 in deductible expenses will be paid by employee. The next $1,000 in deductible expenses will be paid by the HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The last $500 in deductible expenses will be paid by the employee. The total amount the employee may be reimbursed is $4,000.

https://www.tasconline.com/