BASE® QSE HRA Application

In order to properly set up your BASE® QSE HRA, you need to complete the following electronic application. Please make sure to read all of the instructions carefully. All fields indicated with an asterisk (*) are required. If at any time you need to save the application and come back to it later, you can go to the bottom and click on "Save". When clicking "Save" it would be best to copy and paste the link provided into an email to yourself or another party.

Once you have completed a section you will see a check mark next to the heading for that section. Once you have completed both sections a "Submit" button will appear to the right of the "Save" button located at the bottom of the page. You will want to click the "Submit" button, which will securely submit your application to BASE®.

Should you have any questions, please feel free to call 1-800-309-8012 to speak with a BASE® representative.

Section I

(The Benefit Coordinator is the individual at the organization who is responsible for providing plan information to participants and who will directly communicate with BASE® regarding any participant inquiries.)

NOTE: Only employees can participate in an HRA. Thus, while partnerships and sole proprietorships may sponsor an HRA plan, the following cannot participate: sole proprietors and partners. Sub-chapter S Corporations may sponsor an HRA, but special rules apply to owners/shareholders. Contact a BASE® Benefit Specialist for further details.

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Section II

Are there less than 50 full-time equivalent employees in the organization as defined by the Affordable Care Act? *
Does the employer sponsor group benefits to any of its employees? *

Maximum Reimbursement Amount for Full 12 Month Plan Year

Any plan that starts on a month other than January will be a short plan year and the maximum reimbursement amounts will be automatically prorated.
Please note the contribution maximums noted vary based on annual inflation adjustments.

 
Self-Only Coverage
Contributions cannot exceed $6,350
Family Coverage
Contributions cannot exceed $12,800
OR

Flat Amount Per Employee
Contributions cannot exceed $6,350

HRA Eligible Expenses*

The QSE HRA plan will reimburse

Employer HRA Funding*

How are benefits going to be accrued? (Please mark the one box that applies.)

Monthly Accrual – 1/12 of the HRA funds are available to the employee at the beginning of each month and the amount continues to accrue to the maximum reimbursement amount available for the plan year.
Annual Prorated – 100% of the HRA funds are available to the employee at the beginning of the plan year. Employees starting later in the plan year will have a prorated annual maximum based on the first month of eligibility.
 

Employee Eligibility Criteria

Full-time employees must work on average hours per week to be eligible.*
 

Waiting Period

An Employee who has completed consecutive calendar days of service with the Employer (the “Waiting Period”) is eligible to participate.*
 

Effective Date of Coverage

Plan coverage begins on the first day of the calendar month after the end of the Waiting Period.
 
Number of total W-2 employees in the organization *
Number of eligible W-2 employees *

The number of eligible employees that meet your eligibility criteria should be the number of employees submitted on your employee census.

 

Claim Submission Periods

The Run-Out Period is the period of time following the end of the Plan Year during which claims may be submitted for reimbursement.

Employees will have days from the end of the plan year to submit for reimbursement for expenses incurred during the previous plan year.*



Form submitted by
Name .
Phone .
Email .
Referred to BASE by (If Applicable - optional)
Name .
Phone .
Email .

Note: If you do not see a "Submit" button, you have not completed all of the required fields. Once you have completed all three sections successfully a "Submit" button will appear to the right of the "Save" button.