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1 Maricopa Couty Commuity College District A Guide to Your Flexible Spedig Accout Ope erollmet is November 17- December 5. A Balaced Approach To Savig Time Ad Moey

2 Flexible Spedig Accouts Ope erollmet is November 17- December 5. Makig the most of your moey. Maricopa Commuity Colleges will cotiue to participate i two FSA programs ow through Meritai Health: A Healthcare FSA ad a Depedet Care (Day 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. 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 will ufortuately forfeit this moey. The IRS s rule of thumb is use or lose. 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. 2

3 Frequetly Asked Questios About FSAs Ope erollmet is November 17- December 5. 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 , dial 9 ad extesio What is the maximum amout of moey I ca cotribute each 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 you ca access them olie at or you ca call Meritai Health customer service. 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; however, your employer has chose to issue checks weekly o Fridays. Claims eed to be received by Meritai Health at least five busiess days prior to this date. 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? Legislatio goverig FSAs icludes a use or lose feature, so uused fuds are lost at the ed of the pla year. Please review the FSA Remiders page withi this kit, for the FSA claim filig deadlie. How will I kow what my FSA balace is? You ca access your accout balace olie at What if I still have moey i my 2015 FSA at year s ed? Your employer has opted for the grace period extesio offered by the IRS, which allows a additioal 2 ½ moths (3/15/15) to icur expeses toward your healthcare FSA after the pla year has eded. Legislatio goverig FSAs icludes a use or lose feature, so uused fuds are 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 date of termiatio to submit your FSA claims. 3

4 Healthcare Accout. Health care plas are desiged to help pay for a wide rage of extremely importat services for you ad your depedets. However, few health care plas cover absolutely everythig. Your Health Care Accout is desiged to help you pay for those expeses that are t covered by health isurace. Who is eligible for the healthcare accout? Ay beefit eligible MCCCD employee who works a miimum of 30 hours per week ad has bee a board approved, regular employee for a miimum of oe year may participate. Additioally, based o the Affordable Care Act passed o March 30, 2010, parets ca use their FSA to pay for medical expeses for a child up to age 26, eve if the adult depedet is ot a tax depedet. Depedet Care Accout. More ad more households are fidig that they eed some kid of depedet care. Twoicome households with childre, sigle-paret families, ad households where there s a disabled or elderly depedet usually eed depedet care services. FSAs ca help with this. By settig up a Depedet Care Accout, you ca save tax dollars o what you ow pay for eligible depedet care expeses. To qualify, depedet care must be ecessary i order for you to go to work, ad if you are married, for your spouse to work. You are eligible if you are: A sigle paret; or Married ad have a workig spouse; or Your spouse is disabled ad uable to care for himself or herself; or You have a depedet for icome tax purposes who is uable to care for himself or herself. Who is eligible for the depedet care accout? Ay beefit eligible MCCCD employee who works a miimum of 30 hours per week may participate. 4

5 Heroes Earigs Assistace Relief Tax (HEART) Act. Qualified Reservist Distributios: This pla allows (i compliace with the Heroes Earigs Assistace Relief Tax (HEART) Act) the distributio of uused amouts i the employee s healthcare reimbursemet accout to qualified reservists who are called to active duty. This provisio will allow qualified reservists (defied below) who are called to military service ad who may ot be able to fully use amouts remaiig i his or her healthcare reimbursemet accout to cash out uused beefits ad ot forfeit them uder the use it or lose it rule that applies to this healthcare reimbursemet pla. A qualified reservist is a employee who is a member of a reserve compoet (the Army Natioal Guard of the US, Army Reserve, Navy Reserve, Marie Corps Reserve, Air Natioal Guard of the US, the Air Force Reserve, the Coast Guard Reserve, or the Reserve Corps of the Public Health Service) ad must be ordered or called to active duty for a period of at least 180 days or for a idefiite period. MCCCD must receive a copy of the employee s order or call to active duty before a qualified reservist distributio may be cosidered for paymet. Uder this pla, a qualified reservist distributio is the amout cotributed to the healthcare reimbursemet accout as of the date of the qualified reservist distributio request, mius healthcare reimbursemets as of that date. This distributio will be taxable to the employee. A participat who has requested a qualified reservist distributio shall forfeit the right to receive reimbursemets for medical care expeses icurred durig the pla year ad o or after the date of the distributio request. Uder this pla, a qualified reservist distributio is a distributio made betwee the date of the order or call to active duty ad the last date that reimbursemets for the healthcare reimbursemet accout could otherwise be made for the pla year icludig the grace period (e.g., March 15) that icludes the date of the order or call to active duty. No distributio may be made uless ad util the qualified reservist requests i writig to have the pla iitiate a qualified reservist distributio by writig to the healthcare reimbursemet cotract admiistrator. This provisio will apply oly to the distributios made to a employee s healthcare reimbursemet accout balace as it exists o or after Jauary 1, The healthcare reimbursemet pla admiistrator will review all requests for qualified reservist distributios o a uiform ad cosistet basis. Requests for qualified reservist distributios that are approved by the pla admiistrator shall be paid withi a reasoable time, ot to exceed 60 days after the date of the participat's request. Notwithstadig ay other provisio of the pla to the cotrary, this qualified reservist distributio from the participat's healthcare reimbursemet accout balace may be distributed without regard to whether medical care expeses have bee icurred. Remider that ay portio of the distributio that is ot reimbursed for substatiated medical care expeses will be icluded i the participat's gross icome ad wages. 5

6 Iformatio About Your Beefits Debit Card Ope erollmet is November 17- December 5. 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. If you eed a replacemet debit card, please call Meritai Health at , dial 9 ad extesio Remember to always save your receipts! This is importat to cofirm that your expeses are eligible. Valid receipts display: Merchat or provider ame. Service redered or item purchased. Date ad amout of purchase. 6

7 FSA Remiders Ope erollmet is November 17- December 5. Group umber: Pla year: 1/1/ /31/2015 FSA Reimbursemet checks: Mailed to your home weekly o Fridays (miimum reimbursemet $50.00). Claim submissio deadlie: 5 busiess days prior to check processig date. 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 or Ed of the year ru-out: Healthcare FSA: Your employer has opted for the grace period extesio offered by the IRS, which allows a additioal 2 ½ moths (3/15/16) to icur expeses toward your healthcare FSA after the pla year has eded. Depedet care FSA: You may icur depedet care claims up util the ed of the pla year (12/31/15). Healthcare ad depedet care FSA claims ca be submitted up util 4/15/16. Termiated employee claim filig deadlie: You will have 90 days followig the date of termiatio to submit claims icurred while employed at Maricopa Couty Commuity College District. Electio chages: The IRS does ot allow chages i your aual electio uless you have a qualified chage i status. You eed to otify ad submit all required documetatio to your employer withi 30 days of ay qualified status chage Claim submissio. Mail FSA claim forms ad attachmets to: Meritai Health P.O. Box Mieapolis, MN Or fax to: For olie claim status iquiry, log o to Click o the lik for First Time Users. Eter your member ID, date of birth ad group umber. Your password will the be ed to you. For additioal pla iformatio, refer to your Summary Pla Descriptio (SPD), cotact your employee beefits departmet, or cotact the Meritai Health FSA Departmet at , dial 9 ad extesio

8 The Right Balace: Look Over The Couter! Ope erollmet is November 17- December 5. 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 , dial 9 ad extesio 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, ad that the prescriptio is 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? 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 Hemorrhoidal preps Laxatives Motio sickess Respiratory treatmets Sleep aids ad sedatives Stomach remedies OTCs that will require a doctor s prescriptio iclude, but are ot limited to the followig: 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? 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. FSA balaces are use or lose, so remember to cosider these ew OTC regulatios whe estimatig the dollar amout you put i your FSA. 8

9 Direct Deposit For FSA Reimbursemets Ope erollmet is November 17- December 5. How the program works. Whe you submit a claim for reimbursemet for a eligible medical or depedet care expese, the Meritai Health claims office will process it ad, istead of sedig you a check i the mail, Meritai Health will deposit the fuds ito your checkig accout. Later, you will receive a Explaatio of Paymet (EOP), givig you the full details of the reimbursemet. A $50 miimum reimbursemet applies to all FSA claims, whether they are dispesed by check or direct deposit. How to sig up for this program. As soo as possible, complete ad retur the setup form icluded i this mailig to: Meritai Health P.O. Box Mieapolis, MN Or fax to: Alog with the setup form, you will eed to provide a copy of a voided check listig your accout ad bak routig (trasit) umbers. There is o set up fee, ad this is a oe-time set up process. You will oly eed to repeat this process if your bak accout iformatio chages. Tired of waitig to receive your FSA Explaatio of Paymet (EOP) i the mail? Now, members with direct deposit* ca view FSA EOPs olie. Whe your FSA claim is processed, you will receive a otificatio that your FSA EOP is available to view whe you log o to You have the optio to provide your address to Meritai Health if you wish to begi receivig FSA EOP otices by . If you already have your address loaded ito the Meritai Health system, you will begi receivig FSA EOP otices automatically. If you have ay questios regardig the direct deposit program, please cotact Meritai Health Customer Service at , dial 9 ad extesio Wat to receive your EOP via ? Simply provide your address to Meritai Health, ad you re o your way! Whe you elect direct deposit, simply ote your address o the direct deposit form. You ca also cotact Meritai Health ad provide your address that way. Call customer service at , dial 9 ad extesio *Members without direct deposit will cotiue to have reimbursemet checks set through the mail. Always remember to check your bak accout for verificatio of deposit. 9

10 FSA Reimbursemet Made Easy! Ope erollmet is November 17- December 5. 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. Effective Jauary 1, 2011, 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 Mieapolis, MN 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: , dial 9 ad extesio

11 FSA Worksheet ad Eligible Expeses Guide Ope erollmet is November 17- December 5. 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 Detal Expeses Prescriptio eyeglasses or suglasses 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. 11

12 Depedet Care FSA Determiatio Ope erollmet is November 17- December 5. 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. IF YOUR ADJUSTED GROSS INCOME IS: OVER Use the followig worksheet to determie whether you should use the Depedet Care Tax Credit or the Depedet Care Flexible Spedig Accout. Remember to 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. 12

13 Importat FSA Remiders! Ope erollmet is November 17- December 5. The 2015 Flexible Spedig Accout Ope Erollmet is November 17 December 5. Erollmet eds o December 5, 2014! You ca submit your 2015 Erollmet Form three ways. Choose the optio that works the best for you: 1. Mail the form to: Meritai Health N. 25th Ave Suite 410 Phoeix, AZ Att: Amy Schreiber 2. Fax the form to: Att: Amy Schreiber 3. Sca ad the form to: For the 2015 pla year, the maximum aual amout for Health Care moves up to $2,550, ad Depedet Care remais at $5,000. If you have ay questios, please call the FSA customer service departmet at: dial 9 ad extesio Beefits debit card. New members who choose the Beefits Debit Card will receive their cards by Jauary 1, Curret members save your Bey Cards to use i 2015! Your ew 2015 electio amout will be available for you to use begiig Jauary 1, Direct deposit authorizatio form. Are you receivig direct deposit for your reimbursemets? Direct deposit electios carry over oe year to the ext, oly complete a authorizatio form if you are a ew FSA member requestig direct deposit or if you are a curret member chagig your bakig iformatio. 13

14 Notes 14

15 EMPLOYEE INFORMATION FSA Erollmet Form Maricopa Couty Commuity College District LAST NAME FIRST NAME MI PLAN YEAR MCCCD EMPLOYEE ID NUMBER 0 GENDER M F BENEFIT ADMINISTRATOR SECTION 1/1/ /31/2015 GROUP # DATE OF BIRTH EFFECTIVE DATE Campus Locatio HOME ADDRESS ADDRESS DATE OF HIRE Please retur the completed form to: Meritai Health Att: Amy Schreiber N. 25 th Ave., Suite 410 Phoeix, Arizoa Fax: Att: Amy Schreiber Sca/ CITY STATE ZIP CODE PAY CYCLE (BI-WEEKLY) HOME TELEPHONE WORK TELEPHONE 9 Moth Pay 12 Moth Pay Please check all that apply: HEALTH FSA Board Approved regular positioed employees who have worked for a miimum of oe year are eligible I would like to cotribute $ aually to my Healthcare Flexible Spedig Accout for the upcomig caledar year or the remaider of the curret year. PLEASE NOTE: The maximum aual electio allowed by the IRS is $2,550 per caledar year. DCAP WAIVED I would like to cotribute $ aually to my Depedet Care (Daycare) Flexible Spedig Accout for the upcomig caledar year or the remaider of the curret year. PLEASE NOTE: The maximum aual electio allowed by the IRS is $5,000 per family or $2,500 per idividual (or spouse whe married ad filig separate tax returs) ELIGIBLE DEPENDENTS: Depedet s Name (Last, First, MI) Geder Relatioship Birth Date M F M F M F M F Spouse Child Child Child DEBIT CARD EMPLOYEE SIGNATURE REQUIRED I uderstad that the above electios will remai i effect util the last day of the caledar year idicated o this Form. I uderstad that I may chage my electios durig the caledar year oly if (1) I experiece a status chage, as defied uder the Pla ad my chage i electios is cosistet with that status chage, or (2) I exercise a Special Erollmet Right as described i the Notice of Special Erollmet Periods below. I also uderstad that if I do ot submit a ew Electio Form durig the ext aual electio period, the above electios will termiate at the ed of the caledar year for which they are effective. I uderstad that the Employer may modify my beefit electios if appropriate to isure that the Pla complies with the requiremets of the Pla ad applicable law ad that, subject to the requiremets of applicable law, the Employer has the right to amed or termiate the Pla. I uderstad that if I fail to request ad submit all required documets for Pla erollmet withi 30 days after my (ad/or my depedet s) other coverage eds, I will ot be eligible to eroll myself or my depedet(s), as applicable, durig the special erollmet period. NOTICE OF SPECIAL ENROLLMENT PERIODS If you are decliig erollmet i the Pla s health coverage optios for yourself or your depedets (icludig your spouse) because of other health isurace or group health pla coverage, you may be able to eroll yourself ad your depedets i the Pla s health coverage features if you or your depedets lose eligibility for that coverage (or if the employer stops cotributig towards your or your depedets other coverage). However, you must request erollmet withi 30 days after your or your depedets other coverage eds (or after the employer stops cotributig toward the other coverage). I additio, if you have a ew depedet as a result of marriage, birth, adoptio, or placemet for adoptio, you may be able to eroll yourself ad your depedets. However, you must request erollmet withi 30 days after the marriage, birth, adoptio, or placemet for adoptio. If you are decliig to eroll yourself or a eligible depedet for health coverage because you have (or your depedet has) existig health coverage, your employer may require that you provide a writte statemet idicatig that you are decliig coverage because of the existig health coverage. If the employer requires such a statemet ad otifies you of that requiremet, you will receive a separate form to complete ad you must complete it to preserve your right to a future special erollmet situatio followig a loss of that existig coverage. To request special erollmet or obtai more iformatio, cotact your Huma Resources represetative. Ay forfeited amouts i my Flexible Spedig Accout(s) at the ed of the grace period of the correspodig pla year will become the property of the Maricopa Commuity Colleges. (The grace period, Jauary 1st through March 15th, as defied by IRS (Notice ) permits employers to give cafeteria pla participats a additioal grace period of up to 2 ½ moths i which to use cotributios or beefits that were ot used by the ed of the pla year.) The deadlie to file prior year claims is April 15th. Ay expeses reimbursed to me from my Flexible Spedig Accout(s) do ot qualify as a deductio o my Federal ad/or State icome tax retur(s). OYO/OSO employees are ot eligible for the Health Flexible Spedig Accouts. Yes, I would like cofirmatio that my erollmet form was received. EMPLOYEE SIGNATURE DATE

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17 REIMBURSEMENT REQUEST FORM Mail completed Meritai Health form to: P.O. Box Mieapolis, MN Fax to: Customer Service: dial 9 ad Extesio Employer Name: Maricopa Couty Commuity College District 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 the back of this form. Health FSA Date of Service Name of Provider (e.g., physicia, hospital, detist, pharmacy) Type of Service (e.g., 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 Health 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 Assistace Pla (DCAP) Dates of Service Name of Day Care Provider From To Depedet s Name Date of Birth Amout of Expese $ $ $ Total amout requested from your DCAP: $ 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:

18 Guidelies for Reimbursemet NOTE: Icomplete or illegible submissio may result i processig delays. Be sure to iclude all ecessary iformatio, ad sig ad date the 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 copays. Credit card receipts, caceled checks, or cash register receipts caot be accepted for copays. 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 the 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, ophthalmologists, 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.

19 Direct Deposit Authorizatio Form To be reimbursed directly ito your bak accout, please complete this form ad mail it to the address o the right. SEND COMPLETED FORM TO: Meritai Health P.O. Box Mieapolis, MN FAX: Customer Service: Dial 9 ad extesio Type of Request New Chage Cacellatio Employee Iformatio Name: (last, first, iitial) Employer: Maricopa Couty Commuity College District Work Phoe: Social Security Number: Address: Home Phoe: City: State: Zip Code: I elect to receive my FSA EOP otice via . Address: Fiacial Iformatio Bak or Fiacial Istitutio: Name(s) o the accout: Routig/Trasit Number: Address: Accout Number: City: State: City: Checkig Accout Savigs Accout* Voided check (for checkig accout) or deposit slip (for savigs accout*) ~ This is required ~ Please place directly below Terms ad Coditios 1. You must complete, sig, ad date this authorizatio form to eroll i the direct deposit program. If you have a joit accout, the form must be siged by both parties. Oce your form is received by Meritai Health, there may be up to a 7-10 busiess day time period before the direct deposit becomes effective. Ay claims paid durig this time will be mailed to you as a check. Place check or 2. I order to take advatage of the direct deposit program, your fiacial istitutio must be a member of a Automated Clearig House (ACH). 3. You will receive a direct deposit statemet each time a electroic trasfer is made to your accout. The statemet will idicate what claims are paid, as well as year-to-date iformatio o your reimbursemet accout. It ca take up to 72 hours for a paymet to post ito your accout after Meritai Health trasmits the fuds. Please verify that the deposit has bee made ito your accout before attemptig to withdraw fuds. deposit slip here 4. It is your resposibility to otify Meritai Health of ay chages to your bak accout, such as a closure, or a chage i the accout umber. Complete this form with the ew iformatio, ad check the chage box. There may be up to a 7-10 busiess day processig period before the chage becomes effective. Durig this time, you will receive checks for ay reimbursemet claims paid. * If the savigs deposit slip does ot cotai a routig umber maitaied by your bak, you will eed to submit a bak form, or statemet o bak letterhead that verifies the accout ad routig umbers of your savigs accout. Employee / Accout Holder Certificatio 5. You may cacel direct deposit at ay time by completig this form ad checkig the cacellatio box. This will take effect as soo as the form is received ad processed by Meritai Health. 6. If a direct deposit is retured to Meritai Health, or for ay reaso caot be made to your accout, Meritai Health will ivestigate the cause ad if eeded, issue a reimbursemet check. Util the problem is corrected, you will cotiue to receive checks for ay reimbursemet claims paid. 7. Direct deposit services will remai i effect from oe pla year to the ext uless you cacel the direct deposit services. 8. Meritai Health reserves the right to automatically cacel your direct deposit services upo termiatio of employmet or termiatio of your reimbursemet accout. Questios? Please call Meritai Health at I certify that I have read ad uderstad the terms ad coditios o this form. By sigig here, I authorize my Health Reimbursemet Arragemet or Flexible Spedig Accout reimbursemets to be set to the fiacial istitutio ad accout desigated above. This authorizatio is to remai i effect util Meritai Health has bee give a reasoable amout of time to act o writte otificatio from me to termiate the deposits ad cotiue reimbursemets with mailed checks. Employee Sigature: Date: Joit Accout Holder's Sigature: Date: Note: Ay joit accout holder MUST sig this form i order to be reimbursed.

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21 MERMFSA REV0511

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