Health Reimbursement Arrangements are funded with employer tax deductible dollars to reimburse employees for certain medical expenses that normally apply to the deductible of their medical plan. An employer can opt for its HRA to pay some or all of the health expenses allowed by the IRS. For example, many employers implementing high -deductible health plans are funding contributions to primarily pay for medical and pharmacy benefits that apply to the deductible. Although an HRA can have an option to carry forward unused funds from year to year, an employee cannot take their HRA funds to a new employer. A diverse selection of plan design options are available to accommodate each employer's specific needs.

HRA Documents & Forms

When filing your claim, you must attach copies of the EOB (Explanation of Benefits)/ Rx receipts. The document must include the service provider's name, the service rendered date, type of service(s) and amount employee is responsible for after applied to deductible. Canceled checks, credit card slips, or statements of balance due are NOT ACCEPTABLE.

Health Reimbursement Arrangement Claim Form
Flexible Spending Reimbursement Claim Form D
Debit Card Substantiation Claim Form
HRA Plan Design
Business Associates Agreement
HRA Enrollment Form – Debit Card
HRA Enrollment Form – Non-Debit Card
HRA COBRA Election Form
Personal Information Change Form
Direct Deposit Form

Qualified Small Employer HRA (QSEHRA) Documents & Forms

Qualified Small Employer Health Reimbursement Arrangement (QSEHRA)
Total amount of payments and reimbursements for any year cannot exceed:
2020 2021
Individual Coverage $5,250 $5,300
Family Coverage $10,600 $10,700
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A. If you did not use your take care card® and need reimbursed for a qualified expense you paid out-of-pocket, you may submit a claim to CPN for reimbursement. You will need to obtain your EOB (Explanation of Benefits), showing the dates of service, the services rendered, and amount you are responsible for. You may submit your EOB to CPN along with a completed Health Reimbursement Arrangement Claim Form provided at the top of this page. Listed at the bottom of the HRA claim form are several methods of how you may send your information to CPN.

A. Claim reimbursement payments are done by Check if the participant does not have Direct Deposit.

Remember to complete all required information and sign your HRA claim form. Unsigned claim forms will not be processed which will delay your reimbursement.

Direct Deposit

If you are not already set up for Direct Deposit, you may print, complete and return the Direct Deposit form located on this page.

  • If you change banks or switch accounts, please complete a brand new form and send to CPN as soon as possible to ensure your claim is deposited to the correct account.
A. If you cannot locate your SPD (Summary Plan Document), and CPN produced your company's SPD, you may email Dorothy Lane ( to request a copy.

IRS Notices

IRS Notice 2015-87, released December 16, 2015, discusses Health Reimbursement Arrangements (HRAs) and Healthcare Flexible Spending Accounts (FSAs) integration and individual market coverage.

Don't forget – You can submit your debit card substantiation and/or request reimbursement for out-of-pocket expenses, using your Mobile device.
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