Health Savings Account (HSA) Request
  • Health Savings Account (HSA) Request

    Health Savings Account (HSA) Request

    Employees may utilize this form to enroll in or make modifications to contributions made to an HSA. Enrollments and modifications are only processed once per month. Payroll reserves the right to deny changes that will result in excess contributions as outlined by the Internal Revenue Service (IRS)
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  • While Legacy Preparatory Charter Academy (LPCA) works to prevent excess contributions to a Health Savings Account, LPCA is not responsible for penalties associated with an employees' excess contributions as outlined by the Internal Revenue Service (IRS). It is the employee's responsibility to ensure they are following all federal guidelines associated with the ownership and use of a Health Savings Account.

     

    Please view current contribution limits by visiting www.irs.gov.

      

    Contribution limits reset each year on January 1st.

     

  • Did you read and understand the information provided above?*
  • Are you currently contributing to a Health Savings Account sponsored by Legacy Preparatory Charter Academy?*

  • Tell us about your current High-Deductible Healthcare Plan

    You must be enrolled in a high-deductible plan for HSA eligibility.
  • Are you aged 55 and older?*

  • Those 55 and older are allowed by the IRS to contribute an extra $1,000 to their annual maximum amount.

  • Select which option describes your current High-Deductible Insurance Plan*

  • Annual Maximum Contributions

  • To verify you will not exceed the maximum contributions please use the following formula:

     

    New monthly contribution x remaining months in the calendar year + total contributions since Jan 1st = Maximum Contribution

     

    March 4th submission Example:
    (Based on 2024 Limits)

    $400 (new monthly) x 9 (remaining months) = $3,600 (total new contribution)

    $3,600 (New Contribution) + $1,360 (Contributions since Jan 1st) = $4,960 (Maximum Contribution)

     

     

    As of January 2024, $4,960 would be an excess contribution for an employee under age 55 with an only plan.

  • Tell us a little more about you

  • Let's Finalize

  • HSA contributions are only effective on the first day of the month. If you are submitting this form after the 3rd calendar day of the month, it will not be effective until the following month.


    Examples:

    • Submitted January 4th = Effective February 1st
    • Submitted Febrary 3rd = Effective February 1st
    • Submitted February 4th = Effectve March 1st

  • You must read verbiage provided at the start of this form.

    If you do not agree or need further information/clarification please contact benefits@legacypca.com.

  • Date*
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