Reimbursement Ford – Fill Out and Use This PDF

Ford HRA Retiree Pay Me Back Claim Form Instructions

Section 1 – One Time Annual Request for Social Security Administration (SSA) Deduct Premiums (Medicare Part B, Medicare Part C – Medicare Advantage, Medicare Part D – Prescriptions)

XComplete this section if you are requesting reimbursement for a premium that is deducted from your Social Security Check.

XIn the “Service Start Date” boxes, enter the first of the month in which you are eligible for Medicare Part B, C or D for this year. In the “Service End Date” boxes, enter the last day of the year. (If eligible for Medicare Part B, C or D on January 1, this will be January 1 to December 31.)

XEnter the annual amount of your Medicare Part B, C or D expense (the monthly amount multiplied by the number of months of coverage.)

XInclude a copy of your Social Security “Cost of Living Statement” as proof of your expense (typically mailed starting in November the year before it becomes effective) or any other Medicare statement that clearly indicates your Medicare B, C or D premiums. If the cost is not deducted from your Social Security Check, please fill out Section 2 (Health Care Premiums Not Deducted from Your Social Security Check) on the claim form in order to be reimbursed.

XYou will be reimbursed on a pro-rated monthly basis based on your annual premiums and will not exceed the current balance in your account.

Section 2 – Health Care Premiums Not Deducted from Your Social Security Check

XComplete this section if you are requesting a lump sum reimbursement for Health Care premiums that:

-were not deducted from your Social Security Check, and

-you have paid to your health plan on an after-tax basis.

XMake sure to provide documentation such as a statement from your insurance carrier, or a copy of the front and back of a cleared check that shows the premiums you have paid.

XThe Service Start and End Dates should represent the period of coverage you have paid for and are seeking reimbursement for. These dates should match the statement from your health plan indicating the coverage period you have paid for.

XKeep your original receipts and make copies to fax or mail to WageWorks.

XNote: Pre-tax deductions for premiums from your payroll or your pension plan are not eligible for reimbursement.

Ford HRA Retiree Pay Me Back Claim Form Instructions

Section 3 – Other Expenses

XIf you are requesting reimbursement for other out-of-pocket expenses that you have paid for such as co-pays, dental services, eligible over-the-counter items or other eligible expenses, please complete this section.

XAcceptable forms of documentation to show the item was an eligible expense include a receipt or an explanation of benefits from your health plan.

XDocumentation should show the date of service, amount of the expense, and a description of the expense.

XWhen completing the claim form indicate who the expense was for.

XYou may add up more than one receipt or expenses incurred for several small eligible expenses and enter that amount on the claim form. When submitting several receipts or pieces of documentation please circle the expense amounts, date of service and description on each receipt or supporting documentation. Print the earliest service start date on the claim form if requesting reimbursement for several expenses. You will also need to indicate on the claim form who the expenses were for. (Self, Spouse, Dependent)

Health Reimbursement Arrangement (HRA)

ACCOUNT HOLDER INFORMATION

Spouse/Survivor SSN* (last 4 digits) (if applicable) Email Address (complete only if new)

CERTIFICATION AND AUTHORIZATION

I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible expenses incurred by myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have already received these products and services and I have not/will not seek reimbursement of this expense from any other plan or party because I: 1) am required to pay for the premiums through withholding, 2) have paid for the premiums, 3) have already received these products and services. If I am covered under more than one health care account, reimbursement will be made according to the payment order determined by those plans and as stated on the WageWorks Web site. Use of this service indicates my acceptance of the WageWorks User Agreement at www.wageworks.com (available upon registration; enter user name and password or click on First Time User).

CLAIMS FOR OUT-OF-POCKET EXPENSES

1.One Time Annual Request for Social Security Administration (SSA) Deducted Premiums (Medicare Part B, Medicare Part C – Medicare Advantage, Medicare Part D – Prescriptions)

2. Health Plan Premiums Not Deducted from Your Social Security Check

3.Other Expenses Medical Dental Vision Prescriptions Over-the-counter

Patient’s Name