ERISAfire Wrap+ HRA Addendum Tool

1
Access Code* This field is required.Enter the access code for the broker or professional service firm you work with.
2
Your Email* This field is required.This where we'll send the addendum and any notifications, including the special link you'll need to use if you need to save your progress and come back.
yourname@company.com
3
What is the name of the ERISA plan this addendum should be added to?This is typically something like, ABC Company Welfare Benefit Plan.
4
When will this addendum be effective?If HRA benefits were provided under a different set of plan documents, the effective date of this addendum will be the first day those documents were or will be no longer the controlling documents (generally the first day of the current plan year). If HRA benefits are being offered for the first time, the effective date of this addendum will be the first day HRA benefits were or will be offered.
Date
Month
Day
Year
5
Does the plan offer more than one HRA?If HRA benefits differ in some way other than by coverage tier, then there are technically different HRAs, and separate HRA addenda will be needed. For example: if the maximum HRA reimbursement amount differs based on which medical benefit option the employee is enrolled in, then there will be a separate HRA for each medical benefit option.
YESNO
6
How should this HRA be identified?This will form part of the title of the HRA addendum, and generally it should match how the benefit is labeled on the Wrap+ Summary Table of Benefits and Coverages. Do not include "HRA" in the identifier; it is already in the addendum title. Example: If this HRA is only for enrollees in the Cigna 4000 medical benefit, and a separate HRA is for enrollees in the Aetna ABC123 medical benefit, put "Cigna 4000." This HRA addendum will then be titled, "HRA Benefit Appendix: Cigna 4000."
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Who is the HRA for?* This field is required.
Employees eligible for and enrolled in one of this company's medical plans
Employees eligible for this company's medical plan(s), whether or not they enroll in the medical plan
Employees who are eligible for but waive participation in this company's medical plan(s)
Other
8
What type of HRA is being offered?* This field is required.Note: If the HRA will reimburse 100% starting with the first dollar of out-of-pocket expenses, choose "Threshold," and put "0" when prompted for the HRA deductible/threshold later.
Threshold (the HRA itself has a deductible and is paired with a company-sponsored major medical plan)
Coinsurance (the HRA pays a percentage of out-of-pocket expenses incurred under a company-sponsored major medical plan)
Other
9
Cool. That will take a little special handling by an ERISA attorney.Describe in reasonable detail the desired HRA plan design. Who exactly is it designed for, and what exactly is it intended to do? We'll see what our ERISA wizards can do to accommodate your plan design. Simpler HRA plan designs can be accommodated for no additional charge, but more complex designs may require additional fees. You'll be advised before any fees are incurred.
Huge
Large
Normal
Small
Ok
Ok
10
HIDDEN: Prefix for out-of-pocket table
11
What amount of money must be spent before the HRA will start to reimburse?In other words, what are the thresholds, and are they embedded or aggregate? For example, if the employee is responsible for the first $1,000 in eligible expenses, and the HRA will reimburse after that point, put "1000".
Employee-Only Threshold
Employee + Spouse Threshold
Please Select
Please Select
per covered person
collectively for all covered persons
Embedded or Aggregate
Employee + Child(ren) Threshold
Please Select
Please Select
per covered person
collectively for all covered persons
Embedded or Aggregate
Family Threshold
Please Select
Please Select
per covered person
collectively for all covered persons
Embedded or Aggregate
12
What percentage of the HRA claim amount is the employee's or dependent's responsibility?In other words, what is the HRA coinsurance percentage? Use whole numbers, and do not include the percent sign. For example, if the employee is responsible for 20% coinsurance and the HRA reimburses 80%, put "20".
Employee-Only Coinsurance
Employee + Spouse Coinsurance
Employee+ Child(ren) Coinsurance
Family Coinsurance
13
HIDDEN: Suffix for out-of-pocket table
14
What is the maximum annual HRA reimbursement amount for each coverage tier?Do not include amounts not reimbursed by the HRA (i.e., amounts under the HRA threshold or that are the employee's HRA coinsurance obligation). If HRA reimbursement is not available for a particular coverage tier, put "0".
Employee-Only Reimbursement Limit
Employee + Spouse Reimbursement Limit
Please Select
Please Select
per covered person
collectively for all covered persons
Embedded or Aggregate
Employee + Child(ren) Reimbursement Limit
Please Select
Please Select
per covered person
collectively for all covered persons
Embedded or Aggregate
Family Reimbursement Limit
Please Select
Please Select
per covered person
collectively for all covered persons
Embedded or Aggregate
15
What expense types are eligible?Choose all that apply. In all cases, the expense must still be credited toward the major medical plan's out-of-pocket maximum.
Medical
Vision
Dental
Prescription Drugs
16
How must those expense types be credited under the medical plan?Choose all that apply. In all cases, the expense must still be credited toward the major medical plan's out-of-pocket maximum.
Deductible
Coinsurance
Copays
17
How long after the plan year do active employees have to submit HRA claims?This is sometimes called the claims run-out period. Express the claims submission deadline as the number of days after the end of the plan year. Example: If the claims submission deadline for a calendar year HRA is March 31, then you would enter "90" because March 31 is 90 days after December 31.
18
How long do terminated employees have to submit HRA claims?Fill in the blank. "If your employment is terminated, you must submit claims for reimbursement within __ days after _____."
Number of days
Please Select
Please Select
termination of employment
the end of the Period of Coverage
Event that days are measured from
19
Who is the HRA claims administrator?If self-administered, enter the plan sponsor company name.
Company Name
20
What is the HRA claims administrator's mailing address that employees should use for written communications?
Street Address
Suite, Floor, Other (optional)
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
Any other important contact information for HRA claims issues?
Phone number
Website
22
Ready to generate the addendum?To save your data and create your document, select "Generate addendum," and submit! To save your progress without creating a document, select "Save progress only," and submit. In both cases, a link to edit your submission data will be emailed to you.
Save progress only
Generate addendum
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