Pennsylvania MTS Emergency Shield (P&C Insurance) Plan Application

I will be enrolled in an HSA-eligible health plan on my plan effective date.

I will not be enrolled in an HSA-eligible health plan on my plan effective date.

Notwithstanding anything to the contrary in this Agreement, no benefits shall be available for otherwise qualifying services and Out-of-Pocket Expenses incurred under this Agreement during the period in which a Member is an HSA-Eligible Individual that are for medical care, as defined under Internal Revenue Code section 213 (d) (“Medical Benefits”).

A Member is an “HSA-Eligible Individual” if (1) either the Member or the Employer has designated the Member as being enrolled in a high-deductible health plan that is compatible with a health savings account (“Qualifying HSA”) during the enrollment process for the Qualifying HSA plan year or before the start of any subsequent Qualifying HSA plan year, and (2) the Member has not thereafter provided an attestation to MASA, in a form satisfactory to MASA, that such Member has satisfied the statutory minimum deductible under Internal Revenue Code section 223(c) for self-only or family coverage, as applicable.

A Member may provide such an attestation to MASA at the time the Member submits a claim for Medical Benefits under this Agreement. A Member who submits such an attestation shall cease to be an HSA-Eligible Individual for purposes of this Agreement only for expenses incurred on or after the date the Member satisfies the applicable deductible, as indicated in the Member’s attestation.

MASA shall not be liable for any tax consequences to a Member or the Employer arising from a Member’s receipt of any benefits under this Agreement at any time.