2014 Consumer-Driven Health Plan with HSA

For highlights of changes to the 2014 medical plan, click here.

Plan Overview

The Consumer-Driven Health Plan (CDHP) with Health Savings Account (HSA) is designed to encourage you to focus on being a smart health care consumer and save money for future or annual medical expenses.  The plan uses the Cigna network of medical providers and combines traditional medical coverage with an optional tax-free savings account with JP Morgan Chase, called a Health Savings Account (HSA).

Allowance Max graphic4
  • NO REFERRALS - Choose the doctors you want to see – no referral required to see a specialist.
  • DEDUCTIBLE -You pay 100% of your health care expenses until you meet your annual deductible. This includes physician office visits and prescription drugs.
    > In-Network Deductible:  Employee Only - $1,600; Family - $3,200
    > Out-of-Network Deductible:  Employee Only - $3,200; Family - $6,400
  • COST SHARING - After meeting your annual deductible, you share the cost of health care expenses by paying co-insurance (a percentage of the total office visit cost).
  • PREVENTIVE CARE - Routine preventive care and qualifying preventive prescriptions are covered at 100%.
  • ALLOWANCE MAXIMUMS - Note that there are allowance maximums for preventive mammograms ($200), preventive colonoscopies ($2,250) and all MRIs ($2,300 after deductible is met). Starting 8/1/14, the allowance maximum for CT Scans ($2,000 after deductible is met).  See details.
  • OUT-OF-POCKET MAXIMUM ALLOWANCE - The most a plan member will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of that year.
    > In-Network  - Employee Only - $4000; Family - $8000
    > Out of Network  - Employee Only - $8000; Family - $16,000.

  • PRESCRIPTION - Qualifying Walmart prescriptions ($4 List) are covered at 100% after meeting your deductible.
  • MEDICARE - If you are covered under Medicare, you are eligible to participate in the Consumer-Driven Health Plan with HSA, however, you are not eligible to own an HSA Account per IRS guidelines.
  • HSA ELIGIBILITY - Per IRS rules, you must be enrolled in a Consumer-Driven Health Plan to have an HSA account; have no other health coverage; not be enrolled in Medicare; and cannot be claimed as a dependent on someone else's 2013 tax return.

How the Plan Works

hsa pig hsa coins

hsa tree

You establish a tax-free health savings account when you enroll in your benefits. The Company contributes to your account (see below) and you may also contribute any amount you wish, up to the current 2014 federal limit. (Single limit is $3,300; Family is $6,550) If you are over age 55, you may contribute an additional annual catch-up contribution of $1,000 in 2014.

It’s YourChoice how and when to use the money – you can either use it to pay for your qualified medical, dental, or vision expenses, or save it for future needs.

Whatever you don’t use in 2014 earns interest and rolls over to 2015.

With the plan, you’ll pay an annual deductible before your health plan begins to pay for eligible expenses.

A deductible is the amount of money that you’ll be required to pay before your plan starts paying benefits.

You can meet your deductible by using your HSA, your own money or both.

Only services covered by your health plan count toward your deductible. (See Summary of Benefits below for more details.)

Once you meet your deductible, you pay co-insurance, which is a percentage of your medical cost. The plan pays for the rest.

What’s more, your deductible counts toward your out-of-pocket maximum (the most you’ll pay in a given year for all covered expenses). Once you meet your out-of-pocket maximum (which includes your deductible), your plan pays covered expenses at 100%.

Health Savings Account (HSA) - Contributions

The Company's contribution to employee Health Savings Accounts in 2014 are as follows:

$500 (if you contribute $250 or more) - Employee only
$800 (if you contribute $400 or more) - Employee + Spouse
$800 (if you contribute $400 or more) - Employee + Child(ren)
$1,100 (if you contribute $550 or more) - Employee + Family
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See HSA contribution examples below.

Individual Example


Family Example

DotheMathIndividual2    Do-The-Math Family2

Any balance remaining in your HSA rolls over to the next year, and if you leave or retire from The Company, the money in your account goes with you.  It is never taxable if it is used for qualified medical expenses at any time in the future.

  • Contributions to your HSA are taken out of your paycheck before taxes – so the amount of taxes withheld are reduced.
  • You will receive an HSA Debit card which draws money directly from your HSA. Use your debit card to pay for services at the doctor’s office, at your local pharmacy, eyeglass retailer or other locations where you purchase medical-related items or services

The company pays for the basic banking fees, and the employee is responsible for any additional fees.  Please see attached fee schedule for details.

JPMorgan Chase administers your HSA account. 

Electing Your HSA

  • To receive the company's HSA contribution, you must elect the HSA account during the enrollment process.  
  • JPMorgan Chase may request additional information from you. If you don't submit the requested information by the deadline indicated, your account may not be opened.
  • You must have a physical mailing address in order to receive your HSA debit card. JPMorgan Chase will not mail your HSA debit card to a P.O. Box address.
  • If you do not receive your HSA debit card in the mail, please contact JPMorgan Chase at 866-524-2483.
  • If JPMorgan Chase has closed your account due to not receiving proper identification, and refers you to reapply online for your Health Savings Account, please go to https://preenroll.healthcare.cigna.com/healthcare/preenroll/app/bank/welcome.do and enter your information using the enrollment ID “MOHAWKHSA.”

Plan Details

*You Can Continue Paying the Lowest Incentive Rate if you Complete the Following Steps that Apply to You:
  1. Covered employee completes a biometric screening.

  2. Spouses/Domestic Partners who have access to medical coverage through their employer and elected their employer’s 2014 benefits instead of electing the Consumer-Driven Health Plan with Health Savings Account.

  3. Employee and spouse (if applicable) participates in Cigna’s Personal Health Team coaching program if contacted by Cigna.

If you do not complete the required steps above that apply to you, you will pay an additional medical contribution of $125 per month ($28.85 per week) with a maximum of $250 per month.

Click Here for Biometrics Details 

Center of Excellence Hospital

If you are admitted to a Cigna Center of Excellence Hospital (Inpatient hospital facility) and treated for one of the services listed in the COE Incentive brochure below, you will receive a $200 check after the claim is processed. Certain services require pre-certification (e.g. inpatient and outpatient surgery, mental health and substance abuse). Contact Cigna Healthcare for more Information.

Health Savings Account Dispute Process

Summary Plan Description (SPD)

pdf buttonConsumer-Driven Healthcare Plan with Health Savings Account (H.S.A.) SPD

Summaries of benefits & coverage (SBC)

Benefit Summaries

Additional Links and Information

pdf button Consumer-Driven Health Plan with HSA Plan Overview

pdf button Preventive Health Coverage Guide

pdf button HSA Welcome Brochure

pdf button HSA Beneficiary Form

pdf buttonHSA Transfer/Rollover Form 

pdf button Eligible and Ineligible Medical Expenses  (or visit the IRS site here for complete searchable list)

pdf_button Medicare and You - Guide 

pdf_button Learn about YourChoice Advocate

Additional Cigna Forms

Health Savings Account Contribution

Additional Cigna Guides & Plan Information

Contact the Benefits Service Center or CIGNA

For questions about your benefits including claims, eligibility, or to order an ID card contact

Benefits Service Center | 1-866-481-4922  OR

Cigna | 1-855-566-4295 | www.mycigna.com

1 In Ala., Calif., and N.J., contributions are prior to federal taxes but after state income taxes. Employer contribution, earned interest and investment income are all taxable as gross income for state income tax purposes. 

2. For 2014, your annual contribution is limited to $3,300 for individuals/$6,550 for families. Limits for future years will be set by the IRS. If you over age 55, you may contribute an additional annual catch-up contribution of $1,000 in 2014.


Note that this website is for educational purposes only and is not intended to replace the Mohawk Benefits Plan Documentation.
Where this information conflicts with the Plan Documentation, the Plan Documentation will prevail.