Healthcare Cost Hardship Plan (HCHP)
To provide financial assistance to Dartmouth College employees enrolled in the Cigna Open Access Plan (OAP) or the Cigna Choice Fund (CCF) whose out of pocket expenses (not including premium contributions) exceed 7% of their household income in a calendar year. Out of pocket expenses are defined as: Copayments, Deductibles, Coinsurance. By design, this program will most benefit employees whose household is experiencing an unusual medical claim year and whose household income is in the lower ranges.
Eligibility for Reimbursement ELIGIBILITY FOR REIMBURSEMENT
- Active Dartmouth College employees with a minimum of 1 year of continued service.
- Employees must have been enrolled in a OAP or CCF plan at the time the expense was
- Dartmouth College will verify participation in Cigna plan following receipt of application.
- Reimbursement is for expenses exceeding 7% of household income .
- Household income is determined by the Adjusted Gross Income (AGI) from your most current annual tax return (Line 37 of IRS Form 1040).
- Reimbursement includes all out-of-pocket costs for services covered by the OAP and CCF plan within a single calendar year.
- Flexible Spending Account (FSA) funds must be exhausted before requesting reimbursement.
- FSA funds can be used for eligible expenses not associated with this application.
- Your elected contribution and the College contribution of $250* toward the FSA must
- *Non-exempt staff and those employees earning $60,000 or less are automatically given $250 in a Health Care Flexible Spending account. If you are part-time or your hire date is after January 1st, the amount will be prorated.
- In the case where spouses are both employees at Dartmouth College and each receives the College contribution to the FSA, the total amount of both these FSAs must be exhausted before requesting reimbursement
Maximum Annual Reimbursement
All out-of-pocket costs greater than 7% of household income are eligible for reimbursement. Out-of-pocket costs include co-payments, coinsurance and deductibles.
Application & Documentation
- Most current annual tax return, including Adjusted Gross Income (AGI) (Line 37 of IRS Form 1040)
- Supporting medical documentation (ex. medical EOB's, bills or receipts). These documents must itemize expenses.
- Proof of payment for each receipt provided.
Approval & Payment
- Reimbursement will be processed by Dartmouth College, only at designated times: June,
September, December and March (March reimbursement is for full prior calendar year).
- Deadlines to submit applications and documentation in order to receive reimbursement will be one month prior to the designated times above (ex. deadline to submit is May 1st for June 1st reimbursement).
- A completed application form, with supporting documentation, must be submitted to
the Benefits Office.
- Failure to provide all necessary information on or attached to the application form, or to respond to requests for additional information, will result in a denial of the request.
- If an employee is approved for reimbursement and incurs expenses after approval, and within the same calendar year, the employee can submit subsequent documentation with a new application cover sheet.
- The reimbursement is considered taxable income.