Health Savings Account (HSA) Notice to Employees Regarding Employer Contributions to HSAs - Appointment of Employer as Authorized Agent to Open an HSA

Sep 19, 2026

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Health Savings Account (HSA) notice explains eligibility for employer contributions from the City of Corpus Christi for employees covered by a High Deductible Health Plan (HDHP). Eligibility is defined under Internal Revenue Code §223, including enrollment in qualifying CDHP plans and not being claimed as a dependent or covered by non-HDHP coverage. Employees must complete and return the authorized agent form within 30 days of hire or by September 1st, certify IRC §223 eligibility, and understand receipt saving and annual IRS Form 8889 filing.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

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Eligibility for HSA Employer Contributions

HDHP and qualifying plan requirements

Disqualifying coverage and dependent rules

Spouse/children contribution eligibility

How to Receive the Employer HSA Contribution

Complete and submit the authorized agent form

Timing: within 30 days or by September 1st

Certification, recordkeeping, and Form 8889 responsibilities

Appointment of Employer as Authorized Agent to Open an HSA

Authorization to open and administer an Optum Bank HSA

Initial certifications and acknowledgements

Identity verification information to be provided

Employee and (optional) spouse second debit card request

Health Savings Account (HSA) Notice to Employees regarding Employer Contributions to HSAs This notice explains how you may be eligible to receive contributions from City of Corpus Christi if you are covered by a High Deductible Health Plan (HDHP). The City of Corpus Christi provides contributions to the Optum Health Savings Account (HSA) of each employee who is an eligible employee as defined by the Internal Revenue Code (‘‘eligible employee’’) . The complete definition of eligibility can be found in the Internal Revenue Code (IRC) § 223. Eligibility includes but is not limited to: • Participation in a qualifying high deductible plan. The City’s three eligible plans are Citicare CDHP, the Fire CDHP Plan and the CDHP Public Safety Plan. • You cannot be claimed as a dependent on another person’s tax return. • You cannot be covered under any other health plan which is not a high deductible health plan. Some examples of disqualifying coverage are Tricare, Medicare, full VA Benefits, enrollment inan FSA, or enrollment in any non-CDHP plan. • To receive the HSA Contribution made by the City for your spouse or children, they must also be eligible under IRS § 223. If you are an eligible employee, you must do the following in order to receive an employer contribution: (1) Complete the form on the next page titled “Appointment of Employer as Authorized Agent to Open and HSA” and (2) return the completed and signed form to Human Resources – Health Benefits or email the completed signed form to [EmployeeBenefits@cctexas.com](EmployeeBenefits@cctexas.com) within 30 days of your hire date or by September 1st for open enrollment. It is not possible for the City to make contributions or withhold contributions from your pay without this completed and signed form. If you don't already have an established HSA account through the City, this form must be received within 30 days of your hire date or by September 1st for open enrollment. By signing the form, you certify that you are eligible for an HSA under IRC §223 . You understand that you will be responsible for saving your medical receipts and explanations of benefits (EOB) with your tax files to substantiate that all charges to your HSA account were for eligible medical expenses, and you also understand that you are required to file IRS Tax Form 8889 Health Savings Accounts (HSAs) annually with your Federal Tax Return. ** Under the Internal Revenue Code, you must notify the City within 30 days if you (or your dependents) become ineligible to participate in an HSA under § 223** If you have any questions about this notice, you can contact Health Benefits at (361) 826-3300. The information provided is general in nature and is not intended as legal or tax advice. Since the administration of an HSA as taxpayer (your) responsibility please review IRS publications 969, Health Savings Accounts, and 502, Medical and Dental expenses. Appointment of Employer as Authorized Agent to Open an HSA By signing in below, I appoint the City of Corpus Christi (“Employer”) as my agent in order to open and administer an Optum Bank Health Savings Account (“HSA”) on my behalf, and authorize Employer to send and receive information to and from Optum Bank on my behalf in order to accomplish this purpose. Please Initial: I certify that I am eligible to contribute to an HSA under Internal Revenue Code (IRC) Section 223. If enrolling my spouse or children in coverage: I certify that my spouse and/or children are eligible under IRC §223 to receive the City contribution. See the Health Savings Account notice on the previous page and the IRC §223 for more information on eligibility and responsibilities to the IRS including saving receipts and filing tax form 8889 with your Federal tax return annually. I understand and instruct Bank unless otherwise notified to provide the Custodial and Deposit Agreement and all other HSA notices, disclosures and information related to a

FAQs

Who is eligible for City of Corpus Christi HSA contributions under the notice?

Eligibility requires coverage by a qualifying High Deductible Health Plan and meeting the Internal Revenue Code §223 definition of an eligible employee. The notice also states eligibility excludes situations such as being claimed as a dependent or having non-HDHP coverage.

What must an eligible employee do to receive an employer HSA contribution?

Complete the “Appointment of Employer as Authorized Agent to Open an HSA” form and return the completed, signed form to Human Resources–Health Benefits or email it within 30 days of hire or by September 1st for open enrollment.

What responsibilities does the employee have after signing the authorized agent form?

By signing, the employee certifies IRC §223 eligibility and understands they must save medical receipts and EOBs to substantiate eligible expenses. The notice also states IRS Form 8889 must be filed annually with the Federal tax return, and the City must be notified within 30 days if eligibility changes.

Sep 19, 2026

Upload by Gloria