HSA Contributions

You and others (your employer, parents, spouse, etc) may contribute up to $4,300 (individual coverage) or $8,550 (family coverage) to your HSA for the 2025 plan year.

If eligible, your employer may add $828 (individual coverage) or $1,650 (family coverage) to your HSA. Your employer's contribution will be added in installments

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2025
ET-4307
Form Active Employee / Retiree

Medicare Eligibility Statement

You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.

HIPAA: Special Enrollment Opportunities

Program Option
  • Local Annuitant Health Program (LAHP)
  • Local Deductible Health Plan (PO14) & Supplemental Benefits
  • Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
  • Local Health Plan (PO16) & Supplemental Benefits
  • Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
  • Local High Deductible Health Plan (PO17) & Supplemental Benefits
  • Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
  • Local Traditional Health Plan (PO12) & Supplemental Benefits
  • Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
  • State Employee and Retiree Health Plan & Supplemental Benefits