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Health Savings Account (HSA) Plan Design Guide

Please complete this form and return to Further, CareFirsts HSA administrator, 45 days before your effective date to ensure proper administration of your plan. Ifyou have any questions, please call Customer Service at 866-758-6119. Send your completed form via secure email to CareFirstSales@hellofurther.com or mail it to Further, c/o CareFirst, P.O.Box64193, St.Paul, MN 55164.

All fields are required. Incomplete forms will cause delays setting up your plan.

1. EMPLOYER INFORMATION

Employers name

Employers street address

City State Zip code

Employers tax ID number (required)

Type of corporation S Corporation C Corporation Partnership SoleProprietor Political Subdivision/Church LLC Non-Profit Other

Number of employees eligible for plan

Person responsible for authorization of plan design(The person listed below is responsible for signing and approving the Plan Design Guide.)

Name Title

Phone number Fax number

Email address

Main contact person(The person listed below has access to all plan information when contacting Further and will automatically be granted full access to the BlueFund Account Service Center.)

Main contact name Title

Phone number Fax number

Email address

Additional contact person(The additional contact person has access to the plan information indicated below when contacting Further. This persons online access is granted by the main contact person within the BlueFund Account Service Center.)

Additional contact name Title

Phone number Fax number

Email address

Additional contact person has access to the following information when contacting Further:

All plan data Claim billing

To grant access to additional users or to add more contacts, log into the BlueFund Account Service Center.

SUM4166-1E (6/18)

Further is an independent company that provides administrative services for CareFirst BlueCross BlueShield consumer directed health care plans and incentive cards. Further does not sell BlueCross or BlueShield products.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association.

mailto:carefirstsales%40hellofurther.com?subject=

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2. CAREFIRST INFORMATION

CareFirst account executive

Name

Phone number

Email address

CareFirst account manager

Name

Phone number

Email address

3. AGENCY/BROKERAGE INFORMATION

Name of agency/brokerage (if applicable)

Agency/brokerage address

Agency/brokerage code Agency/brokerage tax ID

Agent/brokers name (if applicable) Email address

Agent/broker code Agent/broker phone

4. TRANSFER OF ADMINISTRATION

Is Further replacing administrative services from another HSA administrator? Yes NoIf yes, members who wish to transfer dollars are required to complete the HSA Transfer Request Form (SUM4173) after the account isestablished.

5. HEALTHPLAN ADMINISTRATIVE INFORMATION

Health plan administrator Effective date

Is your plan fully insured or self insured? Fully Insured Self Insured

6. HEALTH SAVINGS ACCOUNT (HSA) PLAN OPTIONS

Plan year HSA effective date

HSA plan option (select one): SelectSaver ThriftSaver

7. ENROLLMENT DATA

Enrollment data will be sent via:

Electronic file produced by CareFirst (default) (Electronic enrollment file format requirements will be provided via email following the approval of the plan design guide.)

CareFirst BlueCross BlueShield

SUM4166-1E (6/18)

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8. CONTRIBUTION INFORMATION

Contribution methods (select one)

1. BlueFund Account Service Center (employer.carefirst.com): There are two ways to make onlinecontributions:

Schedule an ACH pull and Further will initiate an electronic transfer from your companys bank account to the designated employees HSAs. With this method, you use the BlueFund Account Service Center to identify employee accounts and contribution amounts for each pull transaction.

Create and upload a contribution file directly into Furthers system. This data is then used to generate an ACH pull transaction.

2. Secure File Transfer with ACH pull: This option allows a group to create and upload a contribution file to a secure site. An ACH pull will not be initiated unless a contribution file is received. Further will notify you to provide the information needed to set up this contribution method.

3. Direct Deposit/ACH Push: An ACH push is a customer or member initiated transaction of an electronic transfer of funds. Further will notify you to provide the information needed to set up the Direct Deposit/ACH Push program.

Account funding must be initiated by you through the standard electronic file format before each ACH transaction can occur. (Required if electronic file is selected.)

If you selected option 1 or 2 above, complete the banking information below:

I hereby authorize Further to charge our bank account through Automated Clearinghouse for HSA contributions. The following bank account information is provided to Further for initiation of this procedure.

Bank name

Bank ABA number Account type: Checking Savings(The ABA number is the nine-digit number located in the lower left corner of your check.)

Bank account number

Employer contributions

Will the employer contribute to the accounts? Yes No

9. PREMIUM ONLY PLAN (POP)

Please indicate the plan year effective date

You must have a POP in place to allow employee pre-tax contributions to the HSA. Select one of the following:

Pre-tax contributions are allowed. If checked, select one of the following:

I currently have a POP with Further. Please update my documents. I currently have a POP with another vendor. I want Further to set up a POP.

Pre-tax contributions are not allowed. Skip to Section 10 Administrative Tips.

Eligibility

Required for plan documents (generally matches that of the health plan)

Employees must work at least _____________ hours per week to be eligible

Benefits will begin on (select only one):

First of the month following date of hire Date of hire First day after completion of the waiting period 30 days 60 days 90 days Other First of the month after completion of the waiting period 30 days 60 days 90 days Other

http://employer.carefirst.com

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10. ADMINISTRATIVE TIPS

By registering through carefirst.com/myaccount, your employees have access to a powerful tool for managing their HSA, including the ability to: e

View recent claims or reimbursement requests

Make withdrawals from their account

Create and view a customized statement

Enroll in direct deposit

Manage their personal profile

Make online contributions

LOCATIONS: Multiple Further locations are available for 51+ groups only. If requesting multiple Further locations, please complete and attach the Location Addendum (SUM4172). Locations must be the same across all products administered by Further. If you wish to have different ACH accounts by location, please complete the Group ACH Authorization Agreement Form (SUM4170).

COORDINATING WITH AN FSA: For members who have an FSA and an HSA, the FSA provides reimbursement for permitted benefits, such as vision and dental care until the health plan deductible is met. Once the health plan deductible is met, all Section213(d) expenses, excluding deductible expenses, are eligible for reimbursement.

This affects only those members who are eligible to contribute to their HSA. Members who are not eligible to contribute to an HSA will have a general purpose FSA.

PLAN DOCUMENTS: Further sends a Summary Plan Description (SPD) only if part of a POP. The documents will be sent to the group contact within 60 days of receipt of the completed Plan Design Guide.

11. SIGNATURE

It is agreed that necessary information concerning current and future employees and/or their dependents who participate in this plan, and employees whose participation is to be changed or discontinued, shall be provided to Further on a timely basis.

I HAVE READ AND UNDERSTAND THE CHOICES WITHIN THIS PLAN DESIGN GUIDE. INFORMATION ON THE PLAN DESIGN GUIDE AND ANY ANCILLARY INFORMATION PROVIDED FOR THE PURPOSE OF ENROLLING IN THIS PLAN ARE, TO THE BEST OF MY KNOWLEDGE, CORRECT AND COMPLETE.

Signature Date

Printed name Title

12. FOR OFFICE USE ONLY

Further group number Sales executive

Market segment Further account manager

CareFirst account manager Further client manager

Broker partner Further enrollment specialist

Broker account manager

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224

Email Address civilrightscoordinator@carefirst.com

Telephone Number 410-528-7820 Fax Number 410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

REV. (12/17)

Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

and you may need to take action by certain deadlines. You have the right to get this information and assistance in

your language at no cost. Members should call the phone number on the back of their member identification card.

All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

answers, state the language you need and you will be connected to an interpreter.

(Amharic) -

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Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

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Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.

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(Navajo)

855-258-6518

Employers name 3: Employers street address 3: Employers City 3: Employers State 3: Employers Zip Code 3: Employers Tax ID 3: Type of Corporation: Type of Corp Other: Number of Employees Eligible 3: Name 3: Title 3: Phone number 3: Fax number 3: Email address 3: Name 4: Title 4: Phone number 4: Fax number 4: Email address 4: Name 5: Title 5: Phone number 5: Fax number 5: Email address 5: Access: HSA plan option: Name 6: Phone 6: Email 6: Name 8: Phone 7: Email 7: Name of agency-brokerage 2: Agency-brokerage address 2: Agency-brokerage email 2: Agency-brokerage tax id 2: Name of agent-broker 2: Agent-broker email 2: Agent-broker code 3: Agent-broker code 2: Transfer of Admin to Further: Health plan effective date: Insured: HSA effective date: Enrollment data via: ACH Account type: Employer contributions: Pre tax contributions: Pretax allowed options: Benefits begin: Day Waiting period: Month Waiting period: Contribution information: Confirm ACH test transaction 26: OffACH Bank name 5: ACH Bank number 5: ACH Bank account number 5: POP effective date: Eligibility hours: Eligibility day after other: Eligibility month after other 2: Date 2: Signature printed 2: Signature title 2: Further group number 2: Sales executive 2: Market segment 2: Further account manager 2: CareFirst account manager 2: Client manager 2: Broker partner 2: Enrollment specialist 2: Broker account manager 2: 1 EMPLOYER INFORMATION: 2 CAREFIRST INFORMATION: 3 AGENCYBROKERAGE INFORMATION: 4 TRANSFER OF ADMINISTRATION: 5 HEALTH PLAN ADMINISTRATIVE INFORMATION: 6 HEALTH SAVINGS ACCOUNT HSA PLAN OPTIONS: 7 ENROLLMENT DATA: 8 CONTRIBUTION INFORMATION: Yes: 9 PREMIUM ONLY PLAN POP: 10 ADMINISTRATIVE TIPS: 11 SIGNATURE: 12 FOR OFFICE USE ONLY: