Section 125 Flexible Spending Account EMPLOYEE ENROLLMENT INFORMATION - PDF

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Section 125 Flexible Spending Account EMPLOYEE ENROLLMENT INFORMATION What Is an FSA? Your employee benefits package allows you to participate in a Flexible Spending Account (FSA). An FSA is a pretax
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Section 125 Flexible Spending Account EMPLOYEE ENROLLMENT INFORMATION What Is an FSA? Your employee benefits package allows you to participate in a Flexible Spending Account (FSA). An FSA is a pretax benefit allowable under Internal Revenue Code (IRC) Section 125. The plan allows eligible employees to set aside a specific pretax dollar amount for unreimbursed medical, dental, vision, orthodontia, and dependent care expenses. If you have predictable out-of-pocket expenses, you may want to consider joining the FSA. You have the option to join two separate accounts under your FSA: An Unreimbursed Medical Account* can be used for eligible medical, dental, vision, and orthodontia expenses. Examples include: Office visit co-pays Deductibles Prescription eyeglasses or contact lenses Dental cleanings Note: To be reimbursed for orthodontia expenses through your FSA, a copy of an orthodontia contract (or a written statement from the orthodontist) indicating the length of treatment and schedule of payments must be submitted. A Dependent Care Account* can be used for custodial expenses for a claimed dependent. Examples include: Day care center or babysitter to allow you (and your spouse, if married) to work, actively look for work, or be a full-time student Custodial or elder care *For a partial list of common medical, dental, and health-related expenses typically considered to be qualifying expenses, please refer to the list on the back of the Flexible Spending Account (FSA) Reimbursement Claim Form for Unreimbursed Medical Expenses in this booklet or go to https://benefits.paychex.com. 1 Why Should I Participate in an FSA? An FSA provides the following benefits: Tax Savings. FSA deductions come out of your paycheck before most withholding taxes are computed. Since these deductions are a pretax benefit, it reduces your taxable income and you pay less tax. This means more take-home pay! Budgeting. Regular payroll deductions help you budget medical, dental, vision, orthodontia, and dependent care expenses. Ease and Convenience. Paychex provides you with the information and service needed for your FSA through the Paychex Online Flexible Spending Account site and the Paychex Employee Services phone line available 24 hours a day/7 days a week. How Do I Enroll in the FSA? Open Enrollment If you meet the eligibility requirements outlined in the Summary Plan Description (SPD)*, you can enroll in the FSA during the open enrollment period using our website or automated phone system. The effective date for benefit plans elected during open enrollment is January 1 of the following year. You will not be required to re-enroll in the FSA plan each year. Once enrolled, you continue to participate in the plan until you choose to cease participation. However, you may modify your election amount during open enrollment, or during the plan year, if you experience an eligible qualifying event. Please keep in mind that if you do not submit a change during open enrollment, the annual election amount currently on file will be used for the following plan year. Note: The IRS maximum annual employee contribution for Unreimbursed Medical Expenses (UME) for 2014 is $2,500. Please refer to the SPD* for your plan s maximum contribution as it may be different from this amount. Entry Date Enrollment If you are a new employee who has met the eligibility requirements outlined in the SPD, you can enroll on the website or through the phone system beginning two months before your effective date. If you enroll less than one week before the effective date, you may need to submit a paper enrollment form, which can be obtained from your employer. If you are eligible for enrollment, but do not enroll prior to your eligibility/effective deadline, you will not be eligible until January of the following year, unless a qualifying event occurs. *You can view the SPD at https://benefits.paychex.com or request a copy from your employer. 2 How Do I Know How Much to Contribute? Use the Flexible Spending Account Deduction Worksheet in the back of this booklet for assistance in calculating your eligible expenses and to determine how much money would be taken out as an FSA deduction each pay period. You can also use our online calculator available at Important: Be sure to take into consideration the maximum amount your employer allows for unreimbursed medical expenses and any amount they are contributing toward the plan. The maximum deduction allowed for medical expenses can be found in the SPD. The maximum household deduction* allowed for dependent care expenses, per federal guidelines, is $5,000. How to Enroll You can enroll one of two ways: Online 1. Access Paychex Online FSA at https://benefits.paychex.com. If you have not already registered, select Register for a New Account and follow the prompts. 2. Log on by entering your username and password and selecting your security image. 3. Select Flexible Spending Account. 4. Follow the prompts and instructions to access your account and enroll. 5. If you are successfully enrolled, you will receive a confirmation page. Please keep this page for your records. By Phone 1. Dial Listen to the options and press the option for Flexible Spending. 3. Enter your social security number. 4. You will be prompted to create a four-digit PIN. If you already have a PIN, enter it now. If you have forgotten your PIN, you will have an opportunity to recreate it. 5. Select Enroll or Make Qualifying Event Changes. 6. Select Enroll. 7. Select Dependent Care and/or Medical. 8. Enter the amount you want to contribute. You can enter annual or per-pay-period contributions. 9. Please follow all the prompts until you receive a confirmation number; otherwise, your changes will not be processed. *A household can be described as the total number of taxpayers (living as husband and wife) who are filing tax returns either jointly or separately. The amount of dependent care assistance is limited to $5,000 per tax year ($2,500 for married individuals filing separate returns). 3 What Tools Can I Use to Manage My FSA? You can access information about your FSA, including claims, payments, and balances, at any time through the Paychex Online Flexible Spending Account site at https://benefits.paychex.com. You can also call the automated Paychex Employee Services phone line at Through either option you can: Enroll in the FSA plan when initially eligible. Enroll in, or make changes to, your current annual elections during open enrollment or after a qualifying event. Review your account balance, year-to-date contributions, annual election, per-pay-period deduction amount, and reimbursement information. Retrieve claim status information. Request an SPD and additional FSA-related forms and information. Changing Your Deduction Your FSA deduction cannot be changed during the plan year unless you experience a qualifying event. Qualifying events include: Marriage* or divorce Death of your spouse* or dependent Birth or adoption of a child Termination or commencement of spouse s employment Change in employment status from part-time to full-time or full-time to part-time for you or your spouse* Unpaid leave of absence by you or your spouse Eligibility or ineligibility of Medicare/Medicaid Cost-motivated dependent care changes, such as cost increases/decreases (for example, relative becomes available to watch child) *As defined under federal law. 4 Please refer to the SPD for more information about changing your deduction. If a qualifying event has occurred, supporting documentation and enrollment modifications must be submitted to the employer within 30 days of the event. In addition, under federal regulations you cannot move money between your medical and dependent care accounts. How Do I Get Reimbursed? Eligible Expenses Medical expenses are eligible for reimbursement provided that they are to diagnose, treat, or prevent an existing medical condition and you have not been reimbursed for them through any other benefits plan. Some items may require a prescription, doctor s note, or additional certification from a medical provider to show expenses are eligible. For a partial list of common medical, dental, and health-related expenses typically considered to be qualifying expenses, please refer to the list on the back of the Flexible Spending Account (FSA) Reimbursement Claim Form for Unreimbursed Medical Expenses in this booklet or go to https://benefits.paychex.com. Submitting Claims After you have paid for a medical or dependent care expense using out-of-pocket funds, submit a request for reimbursement with documentation to substantiate the eligibility of the purchase. Claims can be submitted online, and written substantiation for each item must be faxed or mailed to Paychex. Third-party receipts must include: the name of the service provider; date(s) of service; dollar amount of the service; and a description of the service provided. A prescription, along with the prescription product name, must be included with the receipt for over-the-counter medicine and drug purchases, other than insulin. A prescription number is not considered acceptable documentation. The submission will be reviewed and, if it is approved, you will receive a check reimbursing you for your eligible expenses from your FSA. Claims are processed within two business days of receipt. You can monitor the status of your claims online. 5 Reimbursements You will have up to 90 days ( closeout period ) after the end of the plan year (December 31), or termination of your employment, to submit claims for reimbursement of incurred expenses. Eligible expenses must be incurred during the plan year (or prior to your termination date) while you are an active participant. In addition, your employer may offer a grace period following the end of the plan year, up to and including March 15, to incur expenses that may be reimbursed from your prior year s account. This only applies if you were an active participant on the last day of the plan year (December 31) and have a balance remaining in your prior year s account. If a reimbursement received by March 31, 2014, is put on hold because we need additional documentation, you have until May 15, 2014, to submit the required documentation. Note: Reimbursement requests will be processed in the order in which they are received. If your employer offers a grace period, submitting reimbursement requests for services from the previous plan year before you remit claims for eligible expenses incurred during the current year will ensure that you receive the maximum benefit. Orthodontia A copy of an orthodontia contract (or a written statement from the orthodontist) indicating the length of treatment and schedule of payments must be provided for orthodontia claims. This information is required since treatment of orthodontia is ongoing and reimbursement of medical expenses prior to services being rendered is not permitted. You will be reimbursed based on the length of treatment and schedule of payments provided on the required orthodontia contract during the plan year in which you are enrolled. You will not be reimbursed in full if the orthodontia bill is paid up front. Once Paychex receives the required contract, you must submit a claim form and itemized receipt from the service provider in order to be reimbursed. The claim form and receipt must match the amount listed on the payment schedule of the orthodontia contract. Note: You may elect to submit only one claim form each plan year for the total amount of orthodontia care as opposed to monthly amounts. Services will be allocated over the length of the contract and reimbursed as services are incurred. FSA Direct Deposit FSA direct deposit is an electronic delivery option that allows you to receive medical and dependent care claim reimbursement through direct deposit to your bank account. Contact your employer to determine if this feature is offered. 6 FSA Debit Card If an FSA debit card is offered by your employer, you may use it to access your funds and pay for FSA-eligible items and services at a point-of-sale terminal rather than submitting a claim form for reimbursement. You can also use your FSA debit card at to purchase FSA-eligible products. Depending on the items purchased, you may still be required to submit documentation to validate the expense as eligible under the Plan. Contact your employer to determine if the FSA debit card is offered. To stay up to date about vendor card acceptance and obtain the most current list of accepting merchants, refer to Claims Processing If your claim is on hold or denied, you will receive written notification explaining the reason for the hold or denial. You can access your claims status at https://benefits.paychex.com or by calling Claims submitted on the website will not be processed until all supporting documentation is submitted. Please continue to check the status of the claim on the website for confirmation that the claim has been accepted and approved. Claims can be submitted online, and written substantiation for each item must be faxed or mailed to Paychex. Third-party receipts must include: the name of the service provider; date(s) of service; dollar amount of the service; and a description of the service provided. A prescription, along with the prescription product name, must be included with the receipt for over-the-counter medicine and drug purchases, other than insulin. A prescription number is not considered acceptable documentation. Termination If your employment is terminated, you have 90 days to submit receipts for expenses incurred prior to your termination date. Additionally, you have 90 days to submit documentation for any claims that were placed on hold or required substantiation prior to your termination date. Forfeitures All claims must be submitted by March 31 of the following calendar year. If unclaimed funds remain in your account after this time, they are forfeited to the plan and cannot be reimbursed. 7 Flexible Spending Account Deduction Worksheet This is not an enrollment form. This worksheet is intended to assist you with the enrollment process by helping you calculate your applicable expenses and how much money would be in an FSA deduction each pay period. Note: Expenses incurred by or on behalf of a domestic partner and/or a domestic partner s child(ren) are not reimbursable. Medical/Dental/Vision Reimbursement Account Annual Medical Expenses, such as: Deductibles and co-pays Routine physical exams Prescriptions Chiropractic care Other Annual Dental Expenses, such as: Deductibles and co-pays Routine check-ups Orthodontia Other Annual Vision Care Expenses, such as: Exams Eyeglasses Contact lenses, solutions, cleaners Other Total Estimated Medical/Dental/Vision Expenses = $ Annual Amount # of Pay Periods* Per Pay Period (cannot exceed company max.) Dependent Care Reimbursement Account Annual Dependent Care Expenses: Payment to a dependent care facility or individual Payment to other care providers Total Estimated Dependent Care Expenses = $ Annual Amount # of Pay Periods* Per Pay Period (cannot exceed $5,000 IRS max.) Total Per-Pay-Period Reduction (Add total estimated medical/dental/vision expenses and total estimated dependent care expenses.) $ Total Per Pay Period *Weekly, 52 pay periods Biweekly, 26 pay periods Semimonthly, 24 pay periods Monthly, 12 pay periods FSA009 8/13 Paychex Use Only Client BIS ID Election Form/Compensation Reduction Agreement Flexible Spending Account SECTION 1 - EMPLOYEE INFORMATION (print) Office/Client Number Company Name Employee Telephone Number ( ) - Employee Name Social Security Number Address City State ZIP Code Address SECTION 2 - ENROLLMENT OPTIONS (select one) New Enrollment or Annual Enrollment Changes Date of Hire / / Notes: New enrollments will be effective on the first payroll of the month following the date the eligibility requirements are met. Annual enrollment changes will be effective on the first payroll following January 1. Debit Card Dependent s name (if applicable) Notes: Participants may only request a debit card if their employer has selected the service. If the debit card option is selected and the Plan does not offer the debit card service, no card will be requested. Refer to your Summary Plan Description for plan features. Participants may choose only one dependent. Change In Status Date of Event / / Note: If Change in Status has occurred, changes in enrollment and supporting documentation must be submitted to the Employer within 30 days of the event. Dependent care cost provider changes Dependent satisfies or ceases to satisfy dependent eligibility requirements Birth/Death of spouse or dependent, adoption or placement for adoption Spouse's employment commenced/terminated Status change from full-time to part-time or vice versa by employee or spouse* Eligibility or Ineligibility of Medicare/Medicaid Change from salaried to hourly or vice versa* Marriage/Divorce/Legal Separation Unpaid leave of absence by employee or spouse Return from unpaid leave of absence by employee or spouse * These changes are allowable only if eligibility is affected. SECTION 3 - ENROLLMENT ELECTION Annual Medical/Dental/Vision Election $ (UME) Cannot Exceed the Lesser of the Company Maximum or $2, Discontinue my Enrollment in Medical/Dental/Vision Care Annual Dependent Care Election $ (DCA) Maximum $5, DCA is issued for custodial care of a dependent, not for medical expenses of a dependent. Discontinue my Enrollment in Dependent Care Notes: To discontinue enrollment, a change in status reason must be selected. To calculate your per-pay-period deduction, divide your annual amount by the number of pay periods remaining in the plan year. In accordance with IRS regulations, employee contributions cannot exceed the lesser of the company s plan maximum or $2, Employers may contribute an additional amount which will be added to the Employee s contribution amount to equal the total annual election amount. SECTION 4 - AUTHORIZATION I hereby elect to participate in the Flexible Spending Account for the Plan Year / /. Any previous election and compensation reduction agreement relating to the same benefits is hereby revoked. I cannot change or revoke this election at any date prior to the next plan year unless I experience a change in status (also referred to as a qualifying event). If, during my next enrollment period, I do not complete and return a new election form during my enrollment period, I will be treated as having elected to continue my employee election as set forth in this election form for the next plan year. As a participant, I understand that all guidelines regarding enrollment are set forth in the Summary Plan Description. Reduction of Pay I understand that my pay will be reduced each pay period by the amount of my required contribution for the benefit option(s) I have elected until this agreement is amended or terminated. The reduction in my pay under this agreement will be in addition to any reductions under other agreements or benefit plans. I understand that my pay reduction will be automatically adjusted if my required contributions change while this agreement is in effect and that the plan administrator may change the amount of my pay reduction or otherwise modify this agreement if it is required to satisfy provisions of the Internal Revenue Code. Reimbursements I understand that my Employer will hold my contributions for payment of eligible expenses incurred within the Plan Year and that reimbursement will be available only for qualifying expenses. I agree to notify my Employer if I believe that any expense for which I have received reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer for any liability Employer may incur for failure to withhold income or FICA tax from any reimbursement I receive of a non-qualifying expense. I understand that I will forfeit any balances I have at
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