Employee Forms

Employee Forms

Premium Tax-Credit Forms

  • Montana Premium Tax Credit Q/A
  • Election of Limited VEBA HRA Plan Coverage--This form allows you to elect "Limited distribution of Dental, Vision, and Long-term Care policy premium reimbursements" from your Montana VEBA HRA Account if you choose to participate in the Healthcare Exchange program. It also allows members who participate in a High Deductible Health Plan (HDHP) and a Health Savings Account (HSA) is utilized for contributions. This allows you to limit your VEBA account reimbursements to only the allowable expenses (Dental, Orthodontia, and Vision expenses). This limitation on the VEBA account will continue until such time as you are no longer on the HDHP and there are funds being contributed to the HSA account. All eligible members of the family will need to limit their reimbursement from the VEBA plan to the same dental and vision expenses until the HDHP coverage is no longer in place.

Please return all forms (except the Enrollment Form) to Montana VEBA Third-Party Administrator PO BOX 5433, Spokane, WA 99205-0433.

Please return the Enrollment Form to Health Care and Benefits Division PO Box 200130 Helena, MT 59620-0130.

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