Saint Mary's College. A Guide to Your Flexible Spending Account. A Balanced Approach To Saving Time And Money

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1 Sait Mary's College A Guide to Your Flexible Spedig Accout A Balaced Approach To Savig Time Ad Moey

2 Flexible Spedig Accouts Makig the most of your moey. What if you could make your earigs stretch further? A Flexible Spedig Accout (FSA) ca help you to do just that. Sait Mary's College offers you a opportuity to participate i two FSA programs: A Healthcare FSA ad a Depedet Care FSA. A FSA is a tax-effective, moey-savig optio that will help you pay for qualified healthcare expeses that are t covered by your medical pla, ad for depedet care services ecessary to eable you to work. Here s how a FSA works: Eligible medical expeses. Use pre-tax dollars to pay for eligible medical care expeses ot reimbursed by a medical pla. All IRS code 213(d) expeses are eligible, icludig your deductible, coisurace ad copays, ad expeses above usual ad customary limits, as well as out-of-pocket expeses o prescriptio drugs, detal, visio, hearig ad orthodotic care. Certai over-the-couter items may qualify, too. Depedet care costs. Pre-tax dollars ca be set aside for day care type expeses for eligible childre or adults. Expeses are eligible if they re for the care of a perso uder age 13, or a older depedet who is uable to care for themselves. They must regularly sped at least eight hours a day i your home. Maximize your savigs potetial. You will gai the most savigs from your FSA if you pla carefully. Whe you eroll i a FSA, you desigate i advace the amout of moey you wish to have deducted from your salary ad deposited ito your FSA over the legth of a year. To do this, you must estimate i advace the aual costs you wat your FSA to cover. If you uderestimate, you will deplete your FSA before the ed of the year, losig some of your tax-savigs potetial. If you overestimate ad there is moey left i your FSA at the ed of the year, you may have to forfeit some of this moey. Your employer allows you to carry over up to $500. Importat ote! While it probably is ot possible to precisely aticipate your eligible FSA costs, Meritai Health provides two calculatio worksheets to help you: FSA Worksheet ad Eligible Expeses Guide ad Depedet Care FSA Determiatio. These worksheets are located i this kit, ad iclude examples of eligible ad ieligible expeses that ca be applied towards your Healthcare ad Depedet Care FSAs. The Bottom Lie: A FSA saves you moey. Pre-tax deductios mea that your payroll taxes (federal, state ad Social Security) are decreased ad your take-home pay is icreased. Your gross earigs are adjusted to accout for the amouts withheld, ad your tax percetage is applied to a lower amout of icome. You maximize your spedable icome. Ad that s a goal we all share. These materials were created to help you uderstad the beefits available to you. This is ot a Summary Pla Descriptio ad is ot iteded to replace the beefit summary or schedule of beefits cotaied withi the Pla. If ay provisio of these materials is icosistet with the laguage of the Pla, the laguage of the Pla will gover. Meritai Health is ot a isurer or guarator of beefits uder the Pla. 1

3 Frequetly Asked Questios About FSAs If I have a questio about my FSA, whom should I call? You ca cotact your dedicated service team for help with claims questios, or for more iformatio about your beefits. The phoe umber for customer service is What is the maximum amout of moey I ca cotribute i each pla year? The IRS allows a cotributio of up to $2,550 towards the healthcare portio of your FSA. For depedet care, the IRS allows a cotributio of up to $5,000 per caledar year, or $2,500 if you are married ad filig separate tax returs. What if I wat to chage my electio mid-year? IRS regulatios do ot allow you to stop, start or chage your cotributios at ay time durig the pla year UNLESS you experiece a qualified chage i status, such as a chage i marital status, umber of depedets or employmet status. Keep i mid that the electio chage must be cosistet with the evet. How do I file a claim? Fill out a claim form ad attach your healthcare ad/or depedet care receipts. Claim forms are available iside this packet. If you eed additioal forms, cotact your beefits departmet, or access forms olie at If you have access to your FSA usig a beefits debit card, please refer to the iformatio o the ext page of this packet. How ofte ca I submit reimbursemet requests? Claims ca be submitted at ay time, ad are processed weekly o Fridays. What if I have more expeses durig the pla year tha I have cotributed at that time? The aual amout you have elected for healthcare costs is available to you at the begiig of the pla year. The amout available for reimbursemet for depedet care is limited to the balace i your accout. Here s a example: You make $1,500 i gross salary each moth ad choose to participate i a FSA. You decide to have $400 of your earigs deducted mothly to pay for eligible depedet care costs. That meas you would be taxed o oly a adjusted icome of $1,100. Your taxes would be decreased ad your take-home pay icreased by $100 a moth. That represets a savigs of early 7% of earigs. What if I still have moey i my FSA at year s ed? Your employer allows you to carry over up to $500; however, a portio of your uused fuds may be lost at the ed of the pla year. Please review the FSA Remiders page withi this kit, for the FSA claim filig deadlie. What if I termiate employmet? Reimbursemet ca oly be requested o healthcare expeses icurred before the date of your termiatio, uless you qualify ad elect cotiuatio of coverage uder COBRA. You will have 90 days followig the ed of the pla year to submit your FSA claims. 2

4 Iformatio About Your Beefits Debit Card What is a beefits debit card? Your beefits debit card is a special-purpose MasterCard that gives you a easy, automatic way to pay for qualified healthcare expeses. You ca electroically access the pre-tax dollars set aside i your FSA. How does my debit card work? It works like a MasterCard, with the value of your FSA cotributio stored o it. Whe you have a qualified, eligible expese at a busiess that accepts MasterCard debit cards, you ca simply use your beefits debit card. The amout of the qualified purchases will be deducted automatically from your accout, ad the pre-tax dollars will be electroically trasferred to the provider/merchat for paymet. Is this just like other MasterCards? No. Your beefits debit card is a special-purpose MasterCard that ca be used oly for qualified healthcare/beefits expeses. It caot be used, for istace, at gas statios or restaurats. There are o mothly bills ad o iterest. Where ca I use my beefits debit card? Your card ca be used to pay for eligible goods ad services at providers/merchats that offer these goods or services ad accept MasterCard. IRS regulatios allow beefits debit card holders to use their cards i discout stores ad supermarkets that are able to idetify FSA-eligible items at checkout. If a card holder tries to use his or her card i a discout store or supermarket that does ot offer this feature, the card may be declied. Note: I March 2010, Presidet Obama siged the Affordable Care Act, or ACA, ito law. The ACA, also kow as healthcare reform, will impact your OTC purchases. As of Jauary 1, 2011, you must ow obtai a prescriptio for ay OTC medicatios or drugs i order to receive reimbursemet from your FSA. You may use your debit card to purchase OTC items that cotai a medicie or drug as log as you preset your prescriptio to the pharmacist at the time of purchase. Please visit for further details regardig stipulatios put i place by the IRS. You may experiece some icosistecies regardig which OTC purchases will qualify at the register while stores are takig steps to comply with this ew requiremet. As a result of the ACA, the list of participatig discout stores ad supermarkets may have chaged. Be sure to visit for a curret list of participatig stores. Why do I eed to save all of my itemized bills or EOBs? You should always save itemized bills or EOBs for FSA purchases made with your beefits debit card. You may be asked to submit those documets to verify that your expeses comply with IRS guidelies. You must show the merchat or provider ame, the service received or the item purchased, the date ad the amout of the purchase. You will be otified if there is a eed to submit a receipt. What if I fail to submit receipts to verify a charge? If receipts are ot submitted as requested to verify a charge made with your beefits debit card, the card may be suspeded util receipts are received. You may be required to re-pay the amout charged. Meritai Health will otify you if your card has bee suspeded because we have ot received a receipt. Submittig a receipt or repayig the amout i questio will allow the card to become active agai. Do I eed a ew card each year? No. As log as a FSA remais part of your beefits pla ad you elect to participate each year, your card will be loaded with your ew aual electio amout at the begiig of each pla year. The debit card is valid for [five] years; however, if you skip a year, your origial card will be reactivated. Please ote: If you did ot keep your origial card, you will eed to request a ew card. If you eed a ew debit card, please call Meritai Health at or log o to Remember to always save your receipts! This is importat to cofirm that your expeses are eligible. Valid receipts display: Patiet ame. Date of service. Descriptio of service. Name ad address of provider or merchat. Amout covered by isurace if applicable. 3

5 FSA Remiders Group umber: 0198 Pla year: 1/1/ /31/2015 FSA Reimbursemet checks: Claims are processed weekly o Fridays. Healthcare FSA maximum: $2,550 Depedet Care FSA maximum: $5,000 per household or $2,500 per spouse if filig separate tax returs. Claim forms: A completed claim form must accompay every claim. Claim forms ca be obtaied from your employer or dowloaded at Ed of the year ru-out: FSA claims ca be submitted up util 3/31/16, for expeses icurred through 12/31/15. Termiated employee claim filig deadlie: You will have 90 days followig the ed of the pla year to submit healthcare FSA claims icurred while employed at Sait Mary s College. Electio chages: The IRS does ot allow chages i your aual electio uless you have a qualified chage i status. You eed to otify your employer withi 31 days of ay qualified status chage. For olie claim status iquiry, log o to Returig Users: Log i with your userame ad password or select oe of the I Forgot tabs to obtai your userame or password. Select My Flex Accout to view your FSA trasactios ad balace. New Users: Click o the lik Create A New User Accout. Eter your member ID, first ame, last ame, date of birth, zip code, group umber ad address. Check Subscriber o the ext page. Create your ow userame ad password o the subsequet page. Click Home ad log i with your ew userame ad password. Select My Flex Accout to view your FSA trasactios ad balace. Claim submissio. Mail FSA claim forms ad attachmets to: Meritai Health P.O. Box Lasig, MI Or fax to: For additioal pla iformatio: For additioal pla iformatio, refer to your Summary Pla Descriptio (SPD), cotact your employee beefits departmet, or cotact the Meritai Health FSA Departmet at:

6 The Right Balace: Look Over The Couter! Guidelies for Over-The-Couter (OTC) medicatios ad supplies for Flexible Spedig Accouts (FSAs). The Iteral Reveue Service (IRS) allows FSA reimbursemet for certai OTC items. To cofirm whether or ot a item is allowable before it s purchased, you may cotact Meritai Health toll free at or visit Importat ote: As of Jauary 1, 2011, OTC items that cotai a medicatio or drug are o loger eligible for reimbursemet through your FSA without a doctor s prescriptio. This requiremet will take place based o the date the items are purchased, ot your pla year. I other words, you must first obtai a prescriptio for ay OTC medicatios or drugs i order to obtai reimbursemet from your FSA, regardless of whe the pla year eds. OTCs that do ot cotai medicatios or drugs will ot require a prescriptio. I order for the OTC medicie ad/or drug to qualify as a prescriptio, there must be a writte or electroic order that meets the legal requiremets of a prescriptio i the state i which the medical expese is icurred. Also, that the prescriptio must be issued by a idividual who is legally authorized to issue a prescriptio i that state. How do I kow which OTCs will require a prescriptio? OTCs that will require a doctor s prescriptio iclude, but are ot limited to the followig: Acid cotrollers Allergy ad sius Atibiotic products Ati-diarrheals Ati-gas Ati-itch ad isect bite Atiparasitic treatmets Aspiri, ibuprofe, pai relief Baby rash oitmets/creams Badages that cotai atibiotic oitmet Cold sore remedies Cough, cold ad flu Digestive aids Please ote : The above list cotais examples of certai items ad should ot be cosidered a full listig. Ca I still use my beefits debit card for OTC purchases? Hemorrhoidal preps Laxatives Motio sickess Respiratory treatmets Sleep aids ad sedatives Stomach remedies Yes, you may still purchase OTC medicatios ad drugs with your debit card as log as you preset your prescriptio to the pharmacist at the time of purchase. The pharmacist will eed to ru it through their system as they would ay other prescriptio, assig a Rx umber ad otherwise meet all IRS guidelies required for debit card use. If you are uable to use your debit card at a particular pharmacy, you must pay out of pocket at the poit of sale ad the submit a maual claim requestig reimbursemet. Please visit for further details regardig IRS stipulatios. Here are some helpful tips: You ca cotiue to use your FSA fuds to purchase OTC items that do ot cotai a medicie or drug (for example: badages without atibiotic oitmets, splits, cold/hot packs, rubbig alcohol, thermometers, etc.). Isuli may cotiue to be reimbursed with or without a prescriptio. You may oly carry over up to $500 of FSA dollars, so remember to cosider these ew OTC regulatios whe estimatig the dollar amout you put i your FSA for the ext pla year. 5

7 FSA Reimbursemet Made Easy! The IRS requires proof that you received medical services before claims ca be reimbursed by your Flexible Spedig Accout (FSA). Follow these guidelies to receive prompt paymet: Submit a completed ad siged FSA claim form with these attachmets... A copy of the Explaatio of Beefits (EOB). All claims must be submitted to your isurace compay or healthcare pla before you request FSA reimbursemet. Estimates for services that have t bee received ca t be accepted. OR A receipt for copays Your office visit copay receipt must show the amout paid ad the date of service. Your prescriptio drug copay receipt must show the ame of the drug, amout paid, the date of purchase ad the ame of the patiet. Credit card receipts, cacelled checks or cash register receipts ca t be accepted for copays. OR Over-the-couter (OTC) items. Itemized cash register receipts are acceptable for OTC items/supplies that do ot cotai a medicie or drug. If the OTC item cotais a medicie or drug, you will eed to submit a cash register receipt as well as a doctor s prescriptio. A customer receipt issued by a pharmacy that idetifies the ame of the purchaser (or the ame of the perso to whom the prescriptio applies), the date ad amout of the purchase, ad a Rx umber. OR A itemized statemet from your healthcare provider if you do t have isurace coverage (for example, for detal or visio services). Special ote o orthodotic care. With your first FSA claim, submit a copy of the followig: the orthodotic cotract or siged fiacial agreemet; badig date; a siged FSA claim form; ad proof of dow paymet. For future claims, you will oly eed to submit a siged FSA claim form alog with proof of paymet. Claim submissio. Mail FSA claim forms ad attachmets to: Meritai Health P.O. Box Lasig, MI Or fax to: Prescriptios for OTCs. I order to obtai FSA reimbursemet for OTCs that cotai a medicie or drug, you must first obtai a prescriptio from your doctor. Make sure the OTC prescriptio icludes the followig: Patiet ame Name of the OTC item Date prescribed (the prescriptio will be valid for oe year from this date) Questios? Cotact customer service toll free at:

8 FSA Worksheet ad Eligible Expeses Guide Estimatig Your Healthcare Expeses. The plaig worksheet below ca help you estimate your eligible healthcare expeses that may ot be covered uder your compay s group isurace pla. Remember, all eligible healthcare expeses for you, your spouse ad your eligible depedets are reimbursable from your Healthcare FSA. Medical Expeses Estimated Pla Year Expeses Visio Expeses Estimated Pla Year Expeses Copays Cotact les supplies Deductibles Copays Lab fees Deductibles Physical exams Eye examiatios Physicia fees Prescriptio cotact leses Prescriptio drug expeses Prescriptio eyeglasses or suglasses Detal Expeses Other medical expeses Copays Deductibles Detures Examiatios Orthodotia Restorative work (crows, caps, bridges) Teeth cleaig Other Expeses Acupucture or chiropractic Hearig aids Immuizatio fees Psychiatrist, psychologist, couselig* Other eligible expeses Other detal expeses TOTAL COLUMN 1 TOTAL COLUMN 2 TOTAL COL 1 $ + TOTAL COL 2 $ = TOTAL ESTIMATED EXPENSES * Allowed for treatmet of physical or metal disorder (e.g., depressio, alcohol or drug treatmet). A diagosis is ecessary for reimbursemet. Examples of costs your Healthcare FSA may cover: Copays, deductibles, ad out-of-pocket costs Acupucture as a treatmet Certai alcoholism ad drug addictio treatmet costs Artificial teeth or detures Braille books for visually impaired Certai residetial improvemets to accommodate the disabled Eye examiatios, cotact leses (icludig cleaig ad maiteace supplies) ad eyeglasses Guide dogs for sight or hearig impaired persos Car cotrols for disabled drivers Hyposis to treat illess Lead-based pait removal Learig disability tuitio/therapy Psychological or psychiatric care Nursig home expeses Certai medical trasportatio Importat ote! Reimbursemet for certai services listed above is subject to specific requiremets. Call the IRS toll free at , or visit to obtai a copy. 7

9 Depedet Care FSA Determiatio Depedet Care Tax Credit vs. Depedet Care Flexible Spedig Accout. If you have qualifyig depedet care expeses, you may be able to choose oe or both of two ways to reduce your taxes. You may be able to obtai a tax credit (a direct reductio i the amout of taxes you otherwise would owe) or you may be able to reduce your taxable icome. This worksheet will help you decide which is better for you. If you qualify for the tax credit, you are allowed to deduct from the taxes you owe a percetage of the lesser of (1) your actual qualifyig depedet care expese or (2) $3,000 if you have oe depedet or $6,000 if you have two or more depedets. The percetage is based o your adjusted gross icome for the year. The chart to the right will help you determie your percetage. I lieu of the Depedet Care Tax Credit, each year you may elect to have a amout deducted from your paycheck before taxes ad put ito your Depedet Care FSA. This amout must be used durig the year for qualifyig depedet care expeses. I other words, you will ot have to pay taxes o the amout you cotribute to the Depedet Care FSA that is used to pay your qualifyig depedet care expeses. If, however, either you or your spouse has Eared Icome (as defied i the pla) of less tha $5,000, your icome exclusio will be limited to the amout of that Eared Icome. Use the followig worksheet to determie whether you should use the Depedet Care Tax Credit or the Depedet Care Flexible Spedig Accout. Remember to IF YOUR ADJUSTED GROSS INCOME IS: OVER compare your actual depedet care expeses to $3,000 (for oe depedet) or $6,000 (for two or more depedets). Take the lesser amout from this compariso ad multiply it by your adjusted gross icome percetage from the chart. This will be your tax credit. TO % of Dep. Care You Ca Deduct from Your Taxes: $0 $15,000 35% $15,000 $17,000 34% $17,000 $19,000 33% $19,000 $21,000 32% $21,000 $23,000 31% $23,000 $25,000 30% $25,000 $27,000 29% $27,000 $29,000 28% $29,000 $31,000 27% $31,000 $33,000 26% $33,000 $35,000 25% $35,000 $37,000 24% $37,000 $39,000 23% $39,000 $41,000 22% $41,000 $43,000 21% $43,000 20% WORKSHEET Usig the Tax Credit Usig the Depedet Care FSA Adjusted Yearly Gross Icome $. $. Subtract: Depedet Care Accout (. ) Taxable Yearly Icome $. $. Taxes Federal* ( %) $. $. State* ( %).. Social Security (geerally 7.65%) Total $. Subtract: Tax Credit (. ) Total Taxes $. * The actual tax rate will vary depedig upo your aual icome. Estimate your ow tax liability or check with your tax cosultat. Eligible Expeses: Fees paid to a childcare ceter or to a day care camp that, if providig care for more tha six childre, complies with all state ad local regulatios Fees paid to a babysitter iside or outside the home Fees paid to a relative who provides depedet care services, other tha your spouse, to your child (o the last day of the caledar year) or to a depedet you claim for federal icome tax purposes Legally madated taxes paid o behalf of the provider Ieligible Expeses: Trasportatio to ad from the place where depedet care services are provided Food, clothig ad educatio Expeses for which federal child care tax credits are take, or are claimed uder your Healthcare FSA Overight camps Tuitio See for a complete listig. 8

10 Mail completed Meritai Health form to: P.O. Box Lasig, MI REIMBURSEMENT REQUEST FORM Fax to: Customer Service: Employer Name: St. Mary s College Employee Name: SS# or ID#: Address: Telephoe #: City: State: Zip: Is this a chage of address? Y or N Select accout from which you are requestig reimbursemet, ad fill out all requested iformatio completely. For further istructios, see Guidelies for Reimbursemet o back of this form. Flexible Spedig Accout (FSA) Date of Service Name of Provider (Ex: physicia, hospital, detist, pharmacy) Type of Service (Ex. copay, Rx, ortho) Name of Patiet Amout of Expese Was this service covered by ay isurace pla? $ Y / N $ Y / N $ Y / N $ Y / N $ Y / N Total amout requested from your FSA: $ If more space is eeded, list additioal requests o a separate page. Please iclude all requests i the total. A miimum request amout (as established i your pla documet) may eed to be met before a claim ca be paid. Depedet Care Accout (DCA) Dates of Service Name of Day Care Provider From To Depedet s Name Date of Birth Amout of Expese $ $ $ Total amout requested from your DCA: $ Provider Sigature: Provider SSN# or Tax ID: Sigature ot required if siged receipt or Day Care Ceter statemet is attached. Altered receipts caot be accepted. I certify that I have actually icurred these eligible expeses. I uderstad that expese icurred meas that the service has bee provided that gave rise to the expese, regardless of whe I am billed or charged for, or pay for the service. The expeses have ot bee reimbursed or are ot reimbursable from ay other source. I uderstad that ay amouts reimbursed may ot be claimed o my or my spouse s icome tax returs. I have received ad read the prited material regardig the reimbursemet accouts ad uderstad all of the provisios. Employee Sigature: Date: 9

11 Guidelies for Reimbursemet NOTE: Icomplete or illegible submissio may result i processig delays. Be sure to iclude all ecessary iformatio, sig ad date form. Please make copies for your records, as these documets will ot be retured. If you fax your claim, keep the origial. Health Flexible Spedig Accout Attach a copy of the Explaatio of Beefits (EOB) for each submissio. All claims MUST be submitted to your isurace compay prior to request for reimbursemet. Estimates for services that have ot yet bee icurred caot be accepted. OR Submit a paid receipt for your co-paymets. Credit card receipts, caceled checks, or cash register receipts caot be accepted for copaymets. Itemized cash register receipts are acceptable for over-the-couter (OTC) items/supplies that do ot cotai a medicie or drug. If the OTC item does cotai a medicie or drug, you will eed to submit a cash register receipt as well as a doctor s prescriptio. OR If you do ot have isurace coverage, submit a itemized statemet from the provider showig the provider s ame ad address, patiet ame, date ad descriptio of service ad amout charged. Additioally, prescriptio expeses must iclude the drug ame or umber. Balace forward or paid o accout statemets caot be accepted. Orthodotic reimbursemet: For first request, submit a copy of the Service Agreemet or cotract itemizig the treatmet period, dow paymet, mothly paymet, badig date ad amout covered by isurace, if ay. For subsequet claims, submit a copy of your mothly paymet coupo ad/or itemized receipt each time you request reimbursemet. Depedet Care Reimbursemet Accout Expeses submitted must have bee icurred for the care of a qualifyig idividual for the purpose to be gaifully employed. A qualifyig idividual is (i) a depedet of yours uder age 13, (ii) a depedet of yours (or your spouse) who is icapable of carig for himself/herself. Medical ad Detal Expeses Geerally Eligible for Reimbursemet (Source: IRS Tax Publicatio 502) You Should Claim Fees for health services or supplies provided by physicias, surgeos, detists, ophthalmologist, optometrists, chiropractors, podiatrists, psychiatrists, psychologists, or Christia Sciece practitioers Acupucture Fees for hospital, ambulace, laboratory, surgical, obstetrical, diagostic, detal ad X-ray services Costs icurred, icludig room ad board, durig treatmet for alcohol or drug addictio at a hospital or treatmet ceter Special equipmet, such as wheelchairs, special hadicapped automotive cotrols, ad special phoe equipmet for the deaf Special items, such as detures, cotact leses, eyeglasses, hearig aids, crutches, artificial limbs ad guide dogs for the visio or hearig impaired Trasportatio for eeded medical therapy Nursig services Rehabilitatio expeses You Should NOT Claim Ay items which will be paid for by isurace or for which you are reimbursed by isurace or ay other health pla Bottled water Health club dues Ay illegal operatio or treatmet Programs to cotrol weight (uless the program is udertake at a physicia s directio to treat a existig illess, icludig obesity) Elective cosmetic surgery Medical isurace premiums paid outside of your compay by you or your spouse at his or her place of employmet Nursig care for a ormal, healthy baby Materity clothes Burial expeses 10

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