City_of_Waxahachie_HSA,_FSA_and_COBRA_Fee_Matrix.pdf
PDF 311 KB Posted
- Attached to
- HSA, FSA, & COBRA Administration Services
- Solicitation number
- RFP-2026-5-2
- Issued by
- Ellis County, Texas
About this file
This is a Fee Matrix and Service Agreement between the City of Waxahachie, Texas and Surency Life & Health Insurance Company for the administration of Health Savings Accounts (HSA), Flexible Spending Accounts (FSA), and Dependent Care Flexible Spending Accounts (DCFSA), as well as Continuation Coverage (COBRA) services. The agreement was executed on September 8, 2022, and establishes the pricing structure for administrative services supporting approximately 475 city employees. The City has delegated administrative responsibilities to Surency for managing Code 125 Cafeteria Plans that include Code 105 Health FSA, Code 129 Dependent Care FSA, Code 223 Health Savings Account Contribution Benefits, and Continuation Coverage services. The agreement includes comprehensive administrative support such as sample documents and forms, staff training, online enrollment, open enrollment meetings and packets, replacement and dependent debit cards, and electronic account statements.
The fee structure establishes a Cost Per Participant Per Month (PPPM) service charge of $3.25 for Health FSA and Dependent Care FSA administration, $1.50 for HSA administration, and $0.60 for Continuation Coverage administration, with all PPPM charges guaranteed through September 30, 2026. A flat Administration Service Charge of $50.00 applies regardless of which Component Benefits are enrolled. The agreement includes a monthly minimum service charge of $75.00 for any month in which combined PPPM charges fall below this threshold. Additional charges apply for specific services including Check Distribution ($2.50 per check), Account Closure ($25.00), Stop Payment ($25.00), Printed Account Statements ($3.00), and Annual Renewal Rate Reset ($10.00 per participant). The PPPM service charges are contingent on debit cards being issued to all participants and enrollment being received electronically; failure to meet these conditions may result in increases of $0.25 to $0.50 per month. Courier and special mailing charges are passed through to the City at cost, and custom programming is available at $175.00 per hour.
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| HSA,_FSA,_&_COBRA_Administration_Services.pdf |
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Text version
SCDH10-001 (01.03.2018) 22
Health Flexible Spending Account Schedule
Capitalized terms used in this Schedule, but not defined have the meanings given in the attached Agreement.
Group has established a Code §125 Cafeteria Plan under which a Code §105 Health FSA is offered.
Group has delegated certain administrative responsibilities with respect to the Health FSA to Surency.
The applicable monthly service charges under the Agreement and this Schedule are as follows:
Standard Service Charges Cost
Per Participant Per Month (“PPPM”) Service Charge $3.25
Additional Service Charges Cost
Run-in Claims Administration N/A
Sample Documents and Forms Included
Staff Training Included
Online Enrollment Included
Open Enrollment Meetings Included
Open Enrollment Packets (each) Included
Replacement Debit Cards Included
Dependent Cards Included
The Administration Service Charge is $50.00. The Administration Service Charge is a set fee that is the same amount regardless of how many or which Component Benefits are enrolled in by Group.
The PPPM Service Charge of $3.25 is guaranteed through September 30, 2026. The PPPM Service Charge requires debit cards be issued to all Participants and enrollment to be received in an electronic medium provided by Surency. If one or more of these conditions are not met on one or more occasions, Surency may increase the PPPM Service Charge by $0.25 and up to not more than $0.50.
Any courier or similar charges incurred will be passed through at cost to Group.
If Group terminates the services described in this Schedule, there will be a charge for a runoff period, should Group choose to request one. This charge will be negotiated at the time of termination.
SCDH10-001 (01.03.2018) 25
Dependent Care Flexible Spending Account Schedule
Group has established a Code §125 Cafeteria Plan under which a Code §129 Dependent Care Flexible Spending Account is offered. Group has delegated certain administrative responsibilities with respect to the DCFSA to Surency.
The applicable monthly services charges under the Agreement and this Schedule are as follows:
Standard Services Charges Cost
Per Participant Per Month (“PPPM”) Service Charge $3.25
Run-in Claims Administration N/A
Sample Documents and Forms Included
Staff Training Included
Online Enrollment Included
Open Enrollment Meetings Included
Open Enrollment Packets (each) Included
The Administration Service Charge is $50.00. The Administration Service Charge is a set fee that is the same amount regardless of how many or which Component Benefits are enrolled in by Group.
The PPPM Service Charge of $3.25 is guaranteed through September 30, 2026. The PPPM Service Charge requires debit cards be issued to all Participants and enrollment to be received in an electronic medium provided by Surency. If one or more of these conditions are not met on one or more occasions, Surency may increase the PPPM Service Charge by $0.25 and up to not more than $0.50.
Any courier or similar charges incurred will be passed through at cost to Group.
If Group terminates the services described in this Schedule, there will be a charge for a runoff period, should Group choose to request one. This charge will be negotiated at the time of termination.
SCDH10-001 (01.03.2018) 28
Health Savings Account Contribution Benefit Schedule
Group has established a Code §125 Cafeteria Plan under which a Code §223 Health Savings Account Contribution Benefit is offered. Group has delegated certain administrative responsibilities under the HSA Contribution Benefit to Surency.
The applicable monthly service charges under the Agreement and this Schedule are as follows:
Standard Services Charges Cost
Per Participant Per Month (“PPPM”) Service Charge $1.50
Sample Documents and Forms Included
Staff Training Included
Online Enrollment Included
Open Enrollment Meetings Included
Open Enrollment Packets (each) Included
Summary Annual Reports Included
Replacement Debit Cards Included
Dependent Cards Included
Check Distribution (per check issued) $2.50
Account Closure $25.00
Stop Payment $25.00
Printed Account Statements $3.00
Electronic Account Statements Included
The Administration Service Charge is $50.00. The Administration Service Charge is a set fee that is the same amount regardless of how many or which Component Benefits are enrolled in by Group.
The PPPM Service Charge of $1.50 is guaranteed through September 30, 2026. The PPPM Service Charge requires debit cards be issued to all Participants and enrollment to be received in an electronic medium provided by Surency. If one or more of these conditions are not met on one or more occasions, Surency may increase the PPPM Service Charge by $0.25 and up to not more than $0.50.
Any courier or similar charges incurred will be passed through at cost to Group.
SC10-001 (12.19.2019) Page 16 of 17 9.08.2022
Schedule A
Fee Schedule
A.1. Continuation Coverage Service Charges
Group shall pay Surency the Continuation Coverage service charges as listed in this Schedule.
Except as otherwise specified in this Schedule, such service charges shall remain the same for the Initial Term.
Monthly service charges per Continuation Coverage Participant per month
The monthly service charge per participant per month (“PPPM”) is based on the number of participants on the 10th day of the calendar month.
Standard Service Charges Monthly base charge
PPPM Service Charge* $0.60
Additional Service Charges
Initial Set-up Fee
(one-time charge for the Initial Term only) Waived
Renewal Fee
(for all Renewal Terms) Waived
Sample Documents and Forms Included
New Hire Notices (per new hire) Waived
Annual Renewal Rate Reset Fee (per
Participant)
$10.00
Special mailing charges incurred by Surency Passed through at cost to Group.
Custom Programming $175.00 per hour.
*PPPM Service Charge is contingent on Surency retaining the administrative fee.
The PPPM Service Charge of $0.60 is guaranteed through September 30, 2026.
SC10-001 (12.19.2019) Page 17 of 17 9.08.2022
A.2. Monthly Minimum Service Charge
Group shall pay Surency a monthly minimum service charge of $75.00 for any month in which the combined PPPM Service Charges’ total amount is less than $75.00.
Signatures
Each party is signing this Agreement on the date stated opposite that party’s signature.
City of Waxahachie
(“Group”)
Date: By:
Name:
Title:
Surency Life & Health Insurance Company
(“Surency”)
Date: September 8, 2022 By:
Name: Dean Newton
Title: President & CEO
File details come from the government source that posted it. Updated .