2024 Group MSA Enrollment Form

2024 Group MSA Enrollment Form

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Enrollee Info		Address		Eligibility Questions		Plan Selection		Ethnicity / Race (Optional)		Agreement

Thank you for your interest in the Fenyx Health Group MSA (Medical Savings Account).

Enrollment in Fenyx Health Group MSA includes both (1) establishment of the MSA bank account through one of our financial custodian partners and (2) enrollment in the medical benefits plan through Fenyx Health Insurance Company and Medicare. Your plan enrollment is not complete until both components are successfully established.

Before completing this application, please review:
- The Summary of Benefits. Our general Summary of Benefits can be found at fenyxhealth.com/documents; some groups may have a specific Summary of Benefits, which can be obtained from your benefits administrator or by calling Fenyx Health at the number below.
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

You will need to provide your social security number in this enrollment form.

Please contact Fenyx Health at 1-800-350-6626 (TTY: 711) if you have questions or need information in an accessible format or other language. Our hours are 9AM to 6PM Eastern time Monday through Friday excluding Federal holidays.
Are you the enrollee or an authorized representative? *
N/A

Enrollee
Authorized Representative
Authorized Representative's Name
N/A

First Name Last Name
Authorized Representative's Phone
N/A

### ### ####
Authorized Representative's Street Address
N/A
Authorized Representative's City
N/A
Authorized Representative's State
N/A
Authorized Representative's Zip Code
N/A
Relationship to Enrollee
N/A
Enrollee's Name
N/A

Required First Name Required Last Name
Medicare Number *
N/A

Please see your Medicare Card for your number.
Social Security Number *
N/A

Your SSN is required to verify your identity for the bank account portion of the MSA plan.
Birth Date *
N/A

Month Year
MM/dd/yyyy
Phone *
N/A

### ### ####
Email *
N/A

A unique-to-you and private email address is required for our banking and financial support programs. We may also email certain materials during the benefit year; you may opt-out at any time by calling Fenyx Health.
Group Name
N/A
Group Number
N/A
Agent NPN
N/A
Relationship To The Group *
N/A

Retiree/employee
Spouse/dependent

Will you reside in the United States for at least 183 days during each year you are enrolled in Fenyx Health Group MSA? *
N/A

Yes
No
The Centers for Medicare and Medicaid Services (CMS or "Medicare") requires that MSA enrollees reside in the United States for at least 183 days during each year they are enrolled in an MSA plan.

If you answer "No" to this question, we cannot enroll you in our plan. You may cancel this enrollment by closing your browser window/tab.

Please contact us if your residency status changes in the future.
Permanent Residence Street Address *
N/A

This cannot be a PO Box
Permanent Residence City *
N/A
Permanent Residence State *
N/A
Permanent Residence Zip Code *
N/A
Is your mailing address the same as your permanent address? *
N/A

Yes
No
Mailing Street Address
N/A
Mailing City
N/A
Mailing State
N/A
Mailing Zip Code
N/A

To enroll in Fenyx Health Group MSA, you may not have other health coverage as described below. Please answer each of the questions to help us determine if you are eligible to enroll in our plan.
Are you enrolled in a state Medicaid program? *
N/A

Yes
No
The Centers for Medicare and Medicaid Services (CMS or "Medicare") does not permit a person to enroll in an MSA plan if they are eligible for both Medicare and Medicaid.

You may continue with this enrollment request or you may cancel it by closing your browser window/tab.

If you continue, we will contact you to understand your Medicaid status and make a final determination if you are eligible to enroll in Fenyx Health Group MSA.
Are you receiving Medicare hospice benefits? *
N/A

Yes
No
The Centers for Medicare and Medicaid Services (CMS or "Medicare") does not permit a person to enroll in an MSA plan if they are receiving hospice benefits from Medicare.

You may continue with this enrollment request or you may cancel it by closing your browser window/tab.

If you continue, we will contact you to understand your hospice status and make a final determination if you are eligible to enroll in Fenyx Health Group MSA.
Will you have other health coverage in addition to Fenyx Health Group MSA? *
N/A

Yes
No

Some individuals may have other health coverage, such as other private insurance, TRICARE, Federal employee health benefits (FEHBP), Veterans Administration (VA) benefits, etc.
The Centers for Medicare and Medicaid Services (CMS or "Medicare") does not permit a person to be enrolled in an MSA plan while carrying other health benefits that may cover some or all of the annual MSA plan deductible.

Please list the names and identification numbers for this coverage so we can research and make a final determination if you are eligible to enroll in Fenyx Health Group MSA:
Name(s) of Other Coverage
N/A
ID Number(s) of Other Coverage
N/A
Group Number(s) of Other Coverage
N/A

E-sign Acceptance *
N/A

You will be provided MSA bank account disclosures and agreements upon account creation/prior to accessing your account. If you do not accept the disclosures and agreements at that time, you will be able to cancel your enrollment in the Fenyx Health Group MSA plan.

I understand I will be presented with the E-sign disclosure prior to accessing the bank account. I understand if I do not agree/accept at that time, I am able to cancel my Fenyx Health Group MSA enrollment.
Privacy Policy Acceptance *
N/A

You will be provided MSA bank account disclosures and agreements upon account creation/prior to accessing your account. If you do not accept the disclosures and agreements at that time, you will be able to cancel your enrollment in the Fenyx Health Group MSA plan.

I understand I will be presented with the privacy notice prior to accessing the bank account. I understand if I do not agree/accept at that time, I am able to cancel my Fenyx Health Group MSA enrollment.
Cardholder Agreement Acceptance *
N/A

You will be provided MSA bank account disclosures and agreements upon account creation/prior to accessing your account. If you do not accept the disclosures and agreements at that time, you will be able to cancel your enrollment in the Fenyx Health Group MSA plan.

I understand I will be presented with the cardholder agreement prior to accessing the bank account. I understand if I do not agree/accept at that time, I am able to cancel my Fenyx Health Group MSA enrollment.
Other Banking Agreements and Disclosures *
N/A

You will be provided MSA bank account disclosures and agreements upon account creation/prior to accessing your account. If you do not accept the disclosures and agreements at that time, you will be able to cancel your enrollment in the Fenyx Health Group MSA plan.

I understand I will be presented with any other disclosures and agreements prior to accessing the bank account. I understand if I do not agree/accept at that time, I am able to cancel my Fenyx Health Group MSA enrollment.
ESIGN-Version
N/A
ACHAgreemt-Version
N/A
CardholderAgreemt-Version
N/A
PrivacyPol-Version
N/A
FHPrivacyNotice-Version
N/A
StearnsPrivacyNotice-Version
N/A
TandC-Version
N/A
PatriotKYC-Version
N/A
RegCC-Version
N/A
RegDD-Version
N/A
RegE-Version
N/A
Other-Version
N/A
Please read and sign below. By completing this enrollment form, I agree to the following:
1. I must have and keep both Medicare Hospital (Part A) and Medical (Part B) to enroll/stay in Fenyx Health Group MSA. I can only be in one Medicare Advantage plan at a time, and I understand that my enrollment in this plan automatically ends my enrollment in another Medicare Advantage health plan. It is my responsibility to inform Fenyx Health of any health coverage that I have or obtain in the future.
2. Medicare MSA plans do not cover prescription drugs. I understand that if I do not have Medicare prescription drug coverage, I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future.
3. Plan enrollment is based on the calendar year. If I join during the year, my deposit and deductible amounts are prorated based on the number of months remaining in the calendar year. If I leave, voluntarily or involuntarily, the plan before 12/31 of any year, I or my estate owes a prorated portion of the current year’s deposit, based on the number of months remaining in the calendar year, to Fenyx Health to pay back Medicare. Fenyx Health may freeze and/or debit my MSA account to satisfy the amount due, however, the payback amount is due whether or not the money is available in my MSA bank account.
4. As long as I remain a plan member through 12/31 of a given year, any of the current year’s deposit remaining in the account on 12/31 belongs to me or my estate and rolls over for future use. I understand and agree that Fenyx Health may debit my MSA account without my prior approval to satisfy a disenrollment amount due and/or a late or outstanding debt owed under the financial flexibility program.
5. I understand that my enrollment into the Plan isn’t complete until my MSA bank account is established with Fenyx Health's MSA banking administrator.
6. I understand that my enrollment into the Plan includes enrollment in the financial flexibility program. I agree to pay all debts incurred under the financial flexibility program as arranged. Fenyx Health may debit my MSA account to satisfy any late or outstanding amounts due after the debt's due date.
7. I understand that I am enrolling in a plan that does not pay for any Medicare-covered expenses, including preventive services, until I meet the plan deductible amount. It is my choice to use my MSA bank account funds or out-of-pocket funds to pay for my health expenses. I may need to pay out-of-pocket before the plan pays for Medicare-covered expenses. After I meet the plan deductible, Fenyx Health Group MSA pays 100% of additional Medicare-covered expenses I incur from Medicare-participating and Medicare non-participating providers. Only Medicare-covered service/item expenses incurred from Medicare-participating and Medicare non-participating providers count toward the plan deductible. The following do not count toward the deductible: a) Non-Medicare-covered expenses regardless of provider type, b) Excess or balance billing expenses incurred from Medicare non-participating providers and c) Any expenses incurred from providers opting out of Medicare. I remain responsible for paying non-Medicare-covered expenses regardless of my plan deductible status.
8. Withdrawals made from the MSA bank account are not taxed when used for IRS-qualified medical expenses. I owe income tax and an additional penalty when using MSA funds on non-IRS qualified medical expenses. I understand I need to file IRS Forms 8853 and 1040 if using MSA funds during the year. I will seek guidance from IRS publications 969 and 502 and my tax/accounting professional.
9. I understand that Medicare coverage does not generally cover international travel, except for limited coverage near the U.S. border. I understand Fenyx Health Group MSA serves a specific service area. If I move out of that service area, I need to notify the Plan so I can disenroll and find a new plan in my new area.
10. Once I am a member of Fenyx Health Group MSA, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage from Fenyx Health to know which rules I must follow to get coverage with this Medicare Advantage plan.
11. I choose my health care services and providers. Providers can decide at every visit whether to accept or decline the Plan, however, I cannot be denied emergency care due to my insurance plan. I understand I am encouraged to confirm my providers accept the Plan prior to obtaining services. I pay any amounts owed to Fenyx Health and my providers timely and fully. Charges for Medicare-covered expenses from Medicare-participating providers are capped at 100% Medicare Fee-for-Service (FFS) rates and count toward my plan deductible; charges for Medicare-covered expenses from Medicare non-participating providers are caped at 95% Medicare FFS rates. If I receive care from a Medicare non-participating provider, they may “balance bill” me, where allowed by state law, up to a set maximum amount that may be higher than Medicare FFS rates; these excess charges are not reimbursed by the Plan and do not count toward my plan deductible. If I receive care from a provider opting out of Medicare, I enter into a private contract with the provider; charges from opt-out providers are not reimbursed by the Plan and do not count toward my plan deductible, even if they are Medicare A/B expenses that would otherwise count toward the deductible.
12. I understand that when my Fenyx Health Group MSA coverage begins (effective date), I must receive all my medical benefits from the Plan. Benefits and services contained in my Fenyx Health Group MSA “Evidence of Coverage” document are covered. Neither Medicare nor the Plan pay for benefits or services that are not covered. The annual MSA deposit will be placed into my MSA bank account early in the benefit period, however it is not guaranteed to be placed on/by my effective date; even though the funds may not yet be deposited on my effective date, I can still obtain services as a Fenyx Health Group MSA plan member.
13. I will contact Fenyx Health if I need plan information in another format and/or language.
14. By joining this Medicare Advantage plan, I acknowledge that Fenyx Health Group MSA shares my information with Medicare and other program/contract partners, who may use it to track my enrollment, to make payments and for other purposes allowed by Federal law that authorize collection of this information (see Privacy Act Statement below).
15. The information on this form is correct to the best of my knowledge. I understand that if I intentionally provide false information, I will be disenrolled from the Plan.
16. I understand that my signature, or the signature of the person legally authorized to act on my behalf, on this application means that I have read and understand the contents of this application. If signed by an authorized representative, this signature certifies a) This person is authorized under state law to complete this enrollment and b) Documentation of this authority is available upon request by Medicare.
Privacy Act Statement:

The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) Plans, improve care, and for the payment of Medicare benefits. Sections 1851 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
Typed Signature *
N/A

By typing your name, you agree the information provided is accurate to the best of your knowledge.
Hidden Date-Time Submission
N/A

Month Year Hours Minutes Select A.M. or P.M. Time
MM/dd/yyyy HH:MM
Hidden Source
N/A
Hidden Type
N/A
Hidden Status
N/A
Master Group
N/A

	Fenyx Health Group MSA 50	Fenyx Health Group MSA 100	Fenyx Health Group MSA 200
Member premium	$0	$0	$0
Deposit	$600	$1,200	$2,400
Deductible	$2,800	$4,000	$6,000
Plan-covered services out-of-pocket (deductible minus deposit)	$2,200	$2,800	$3,600

	Fenyx Health Group MSA 400
Member premium	$0
Deposit	$4,800
Deductible	$11,000
Plan-covered services out-of-pocket (deductible minus deposit)	$6,200

	Fenyx Health Group MSA 500
Member premium	$0
Deposit	$6,000
Deductible	$14,000
Plan-covered services out-of-pocket (deductible minus deposit)	$8,000

	Fenyx Health Group MSA 400	Fenyx Health Group MSA 500
Member premium	$0	$0
Deposit	$4,800	$6,000
Deductible	$11,000	$14,000
Plan-covered services out-of-pocket (deductible minus deposit)	$6,200	$8,000

2024 Group MSA Enrollment Form

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