Flexible Spending Account

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1 Health Care Flexible Spedig Accout d 08/10

2 what is a health care flexible spedig accout? A health care flexible spedig accout is a easy, coveiet way to get more out of your paycheck. It allows you to set aside pretax dollars ad the use them to pay for certai out-of-pocket health care expeses as they occur throughout the year. You do ot have to participate i ay other health pla to be eligible to participate i a health care flexible spedig accout. How does it work? At the start of the pla year, you choose how much you wat to set aside with each paycheck subject to ay maximums set by your employer. You the withdraw moey from your accout as eeded throughout the year to reimburse yourself for the eligible health care expeses you ve paid for such as copays, coisurace (the percetage of the cost of your covered medical expeses after you meet your deductible), deductibles (the amout you pay before your pla starts to pay) ad certai visio, detal or pharmacy costs. You ca submit claims for yourself, your spouse ad other covered family members, as log as they are a qualifyig depedet uder federal tax law. Ad, with the coveiece of automatic claim submissio, there s hardly ay paperwork. You do ot have to file ay flexible spedig accout claims whe you re covered by ay CIGNA medical or pharmacy pla, or a CIGNA detal idemity or detal PPO pla. Tax advatages IRS rules allow you to cotribute to your health care flexible spedig accout with pretax dollars. That meas the moey is deposited ito your accout before deductios for icome tax, Social Security or (i most cases) state withholdig taxes. Moey set aside i your accout is worth more because it s tax-free. You pay o taxes whe you cotribute or make withdrawals. It s a easy ad smart way to save. Is a health care flexible spedig accout right for me? If you ca reliably forecast health care expeses for yourself ad your covered family members for the comig year, a health care flexible spedig accout ca be a excellet way for you to budget for ay aticipated out-of-pocket costs while cuttig your taxes. Keep i mid that your actual savigs deped o your specific situatio. Your tax advisor ca help you calculate the advatages of participatig i this program.

3 gettig started Settig up ad usig your health care flexible spedig accout is simple, but it s importat to pla your cotributios wisely. 1. Estimate costs Estimate your out-of-pocket medical expeses for the comig year for you ad your eligible depedets. Thik about how may times you usually see a health care professioal i a year. The thik about ay prescriptios you fill o a regular basis. Keep i mid what your medical, pharmacy or detal plas will cover ad how much your paymet will be uder your pla(s). Use last year s records as a guide, or ask your fiacial advisor to help you determie approximate expeses ad how much to put ito your flexible spedig accout. Remember, your employer may set a maximum allowable cotributio. 2. Set up your cotributio After you determie the amout to set aside for the year, divide the amout by the umber of paychecks you receive yearly. This is the amout your employer will take from each paycheck to deposit i your pretax, o-iterest-bearig flexible spedig accout. Remember, cotribute oly as much as you thik you ll eed (subject to pla limits set by your employer). You lose what you do t use. The IRS requires that you lose ay moey remaiig i your accout at the ed of the year. You caot withdraw the uused moey, ad you caot carry it over to the followig year. The total amout of your cotributio remais i effect for the etire year. You ca adjust your cotributio oly with a qualifyig life evet, such as the additio or loss of a depedet, or a chage i marital status. You ca, however, set aside a differet amout each year. 3. Select how you wat to submit claims to your flexible spedig accout You may use automatic claim submissio or choose to submit claims yourself. With automatic claim submissio, out-of-pocket medical expeses (such as copays, coisurace, or deductibles) will automatically be forwarded to your flexible spedig accout whe covered by ay CIGNA medical or pharmacy pla, or a CIGNA detal idemity or detal PPO pla. 4. Submit your erollmet eligible expeses Review this partial list of expeses that qualify as federal icome tax deductios uder Sectio 213(d) of the tax code. For a complete list, visit acupucture ambulace services amouts above maximum reimbursable charges artificial limbs birth cotrol pills ad devices chiropractic services coisurace amouts cotact leses ad solutios copays crutches deductibles detal ad orthodotic services hearig aids hospital charges isuli ad diabetic supplies LASIK eye surgery over-the-couter items used for treatmet of illess or ijury* physical therapy prescriptio drugs psychiatric care smokig cessatio programs vaccies visio care well-baby care wheelchairs X-rays Please ote: You may ot use the flexible spedig accout to pay for expeses for treatmets or services received solely for cosmetic purposes or to beefit your geeral well-beig. *Note: As part of the recetly eacted Health Care Reform legislatio (the Patiet Protectio ad Affordable Care Act), startig Jauary 1, 2011 you will ot be able to use a flexible spedig accout to pay for most over-the-couter drugs ad medicies uless you have a doctor s prescriptio.

4 how automatic claim submissio works Medical expeses For automatic claim submissio to apply, you must: Be covered by a CIGNA medical pla. Elect automatic claim submissio of medical expeses to your flexible spedig accout. Have o other source of reimbursemet for these expeses. Whe you use automatic claim submissio, you will be reimbursed for ay paymets made at the time of service, ad the health care professioal will be paid directly for ay additioal charges, as log as there is eough moey i your accout to cover the cost. Both you ad your doctor will receive a explaatio of beefits (EOB) for the paymets made from your accout. The EOB you receive will also idetify the remaiig balace i your accout. Pharmacy expeses For automatic claim submissio to apply, you must: Be covered by a CIGNA pharmacy pla. Elect automatic claim submissio of medical expeses to your flexible spedig accout. Have o other source of reimbursemet for these expeses. Whe you visit CIGNA participatig pharmacies, your flexible spedig accout will be used automatically to pay your out-of-pocket prescriptio costs (deductible, coisurace, copaymets). You will ot pay aythig out-of-pocket for eligible expeses uless your remaiig accout balace caot cover the cost. Detal expeses For automatic claim submissio to apply, you must: Be covered by a CIGNA detal PPO or detal idemity pla. Elect automatic claim submissio of detal expeses to your flexible spedig accout. Have o other source of reimbursemet for these expeses. Whe you use automatic claim submissio, you will be reimbursed for ay paymet you make at the time of service, ad the health care professioal will be paid directly for all other out-of-pocket expeses as log as there is eough moey i your accout to cover the cost. Both you ad your doctor will receive a EOB for the paymets made from your flexible spedig accout. The EOB you receive will also idetify the remaiig balace i your accout.

5 requestig reimbursemet You must request reimbursemet from your flexible spedig accout if: Your claims are ot processed through ay CIGNA medical or pharmacy pla or a CIGNA detal idemity or detal PPO pla. You do ot elect automatic claim submissio. 1. Complete ad sig the flexible spedig accout reimbursemet request (available o mycigna.com or by callig Customer Service). Please tape receipts to the ceter of a plai piece of paper, ad use oly oe receipt per page. Types of acceptable proofs of paymet iclude: itemized receipts ivoices explaatio of beefits statemets claim statemets Acceptable proofs of paymets must iclude the followig iformatio: health professioal or facility ame ad address date(s) of service type of service amout due/paid by you CIGNA caot accept: bak card statemets cacelled checks estimates of charges balace due statemets illegible documets Please ote: For ogoig expeses such as maiteace medicatios, the IRS requires a reimbursemet request form for each expese. 2. To avoid delay, please complete all required fields o the request form ad iclude all ecessary proofs of paymet ad other documetatio (such as prescriptios or letters of medical ecessity) as required. The followig tips ca help you complete the form: Complete all fields marked with a asterisk(*). Do ot leave the patiet area blak. If employee ad patiet iformatio is the same, either re-eter the iformatio or put same. Use a separate form for each perso who has claims. Do ot submit claims for more tha oe idividual o the same reimbursemet form. Eter the exact dates of service. A summary or rage of dates such as Jauary to Jue of 2010 or just Jue 2010 will ot be accepted. Do ot list more tha oe item o each lie. Each item must be listed o a separate lie, which may require you to submit more tha oe form. 3. Mail or fax the completed form ad all documetatio to the address o the form. Keep copies of all of your receipts ad reimbursemet claim forms. If you do ot fill i all required fields or iclude appropriate documetatio, paymet will be delayed or deied. We will sed you a letter requestig the missig iformatio. Oce we receive all ecessary iformatio, we will process your request. Submit your requests i ay amout ad throughout the pla year. If some of your eligible expeses are ogoig, such as mothly bills for maiteace medicatios, you may fid yourself filig claims regularly for the same amouts. However, the IRS requires that you submit a completed reimbursemet request form ad paid receipts for every claim. Your employer will desigate a certai year-ed cut-off date for claims. Check with your health pla maager so you do t miss this deadlie.

6 receivig reimbursemets Oce your claims have bee processed, CIGNA will issue you a reimbursemet check for your eligible expeses. If you have multiple submissios before the ed of the paymet period, you will receive oe reimbursemet check for all requests submitted. You ca save time with the coveiece of direct deposit. To eroll, log i to mycigna.com ad click o Settigs & Prefereces. Select Direct Deposit ad complete the requested iformatio. If you do ot have Iteret access, call the umber o your CIGNA ID card or CIGNA24 ( ) to request a erollmet form. You are eligible to receive the full amout of your flexible spedig accout aual cotributio for paymet of qualified health care expeses eve if payroll deductios have ot yet reached your total cotributio for the pla year. importat cosideratios We recommed that you make sure ay covered depedets meet the IRS defiitio of depedet. Depedets (other tha your spouse) must be your relative, ad you must provide more tha half of their support. Domestic parters, civil uio parters ad same-sex spouses do ot qualify. If a perso does ot meet the IRS defiitio, paymets issued from the flexible spedig accout for this oqualified idividual will be subject to tax. For more iformatio, please visit Remember, you lose what you do ot use. The IRS requires that you forfeit uused moey i your accout at the ed of your pla year. However, your employer may allow you to use moey remaiig i your accout at the ed of the pla year to pay for claims icurred durig the 2 ½ moths after your pla year eds. Please check with your employer to determie if this optio is available to you. Startig Jauary 1, 2011 you will ot be able to use a flexible spedig accout to pay for most over-the-couter drugs ad medicies uless you have a doctor s prescriptio. Go to for the most curret list of eligible items. If you eroll i the flexible spedig accout, you must remai erolled for the etire year. You ca adjust your cotributio oly with a qualifyig life evet, such as the additio or loss of a depedet, or a chage i marital status. However, you ca set aside a differet amout each year. If you or your spouse is erolled i a medical pla that qualifies for cotributios to a Health Savigs Accout, you may ot be eligible to eroll i a flexible spedig accout. If you are eligible, the qualified expeses ad pla optios available to you uder the flexible spedig accout may vary. Please check with your employer to review your pla optios, determie if you ca eroll i the flexible spedig accout, ad fid out whether you are eligible for automatic claim submissio from your medical pla to your flexible spedig accout. we re here to help mycigna.com. You have olie access to accout iformatio wheever you eed it: up-to-date balace iformatio, claim status, claim forms ad aswers to geeral questios. Health Statemets. These statemets give you a easy-to-uderstad report o your accout balace, ad claim ad paymet activity helpig you maage your accout ad make the most of your flexible spedig accout. Aswers are a phoe call away: Customer Service represetatives are available 24 hours a day, 7 days a week. Just call the toll-free umber o your CIGNA ID card or CIGNA24. CIGNA ad the Tree of Life logo are registered service marks of CIGNA Itellectual Property, Ic., licesed for use by CIGNA Corporatio ad its operatig subsidiaries. All products ad services such as CIGNA Detal PPO, ad CIGNA Detal Idemity are provided exclusively by such operatig subsidiaries ad ot by CIGNA Corporatio. Such operatig subsidiaries iclude Coecticut Geeral Life Isurace Compay (CGLIC), CIGNA Health ad Life Isurace Compay (CHLIC), ad HMO or service compay subsidiaries of CIGNA Health Corporatio ad CIGNA Detal Health, Ic. I Arizoa, HMO plas are offered by CIGNA HealthCare of Arizoa, Ic. I Califoria, HMO plas are offered by CIGNA HealthCare of Califoria, Ic. I Coecticut, HMO plas are offered by CIGNA HealthCare of Coecticut, Ic. I North Carolia, HMO plas are offered by CIGNA HealthCare of North Carolia, Ic. All other medical plas i these states are isured or admiistered by CGLIC or CHLIC. All models are used for illustrative purposed oly. Some cotet provided uder licese d 08/ CIGNA

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