Send the completed form to the Educational Services Center – attention payroll.
2024 Health Savings Account (HSA) Form
*Paperwork received by the 15th of the month will be effective the first pay of the following month.
- Employer contributions:
|
Year: |
Choice Blue Individual |
Choice Blue Two Person/Family |
Non-Choice Blue Individual |
Non-Choice Blue Two Person/Family |
|
2024 |
$1,300 |
$2,600 |
$1,000 |
$2,000 |
|
2025 |
$1,300 |
$2,600 |
$1,000 |
$2,000 |
|
2026 |
$1,300 |
$2,600 |
$1,000 |
$2,000 |
|
2027 |
$1,300 |
$2,600 |
$1,000 |
$2,000 |
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