EAST DETROIT PUBLIC SCHOOLS FLEXIBLE SPENDING ACCOUNT

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1 EAST DETROIT PUBLIC SCHOOLS FLEXIBLE SPENDING ACCOUNT a Group Resources Company EAST DETROIT PUBLIC SCHOOLS FLEXIBLE SPENDING ACCOUNT 2013 PLAN YEAR Through the Cafeteria Plan provided by East Detroit Public Schools!! Plan Year January 1, 2013 December 31, 2013 Benefits include: Unreimbursed Medical $2,500 maximum $60.00 per year minimum Dependent Day Care $ 5,000 maximum $60.00 per year minimum Use pre-tax dollars to pay for items needed throughout the year. Medical FSA - Elect up to $2,500 Reimburses for deductibles, co-pays, dental, orthodontic, vision, LASIK, weight loss programs (with a note of medical necessity) smoking cessation and some over the counter items for you and your eligible dependents. Reimbursements made by check, direct deposit or debit card. Effective on January 1, 2011 the Health Care Reform Act eliminated over-the-counter medicines from the list of eligible items. Only medicines that are prescribed by a physician with a written prescription will be allowed. Eligible items allowed by the IRS without a doctor s prescription include diabetes items, diabetic lancets, diabetic supplies, diabetic test strips, glucose meters, syringes and needles, bandages, contact lens solution, denture bond. Dependent FSA- Elect up to $5,000 Reimburses for day care for children up through age 12 (includes preschool tuition) for children, latch key, day camps and elder care needed for older adults (IRS allows $5,000 per family per calendar year) Reimbursements made by check or direct deposit. Reimbursements made by check, direct deposit or debit card. Debit Cards are now being issued for a three year period of time. If you are a current Take Care Debit Card user, please note the expiration date of the card that you have. If that date is not December 31, 2012, you do not need to order a new card. You do, however, need to indicate your desire to continue to use the debit card on your 2013 FSA Enrollment Form. If the expiration date on the card that you currently have is December 31, 2012 or if you are not a current Debit Card user and would like the optional Take Care Debit Card, you must complete the enrollment form and order the debit card online through the web site when prompted. The annual cost of the card service is $15.00, which is paid by East Detroit Public Schools. If you need a 3 rd card, that card needs to be ordered online after January 1, Debit cards cannot be used for daycare reimbursements. Enrollment is only once per year. If you miss this opportunity you will need to wait until 2014 to participate, unless you have a change in family status. Check out the following web site for additional information: Don t miss out! Sign up for your FSA during open enrollment! Please submit a completed enrollment form to Administrative Services / Benefits Within (248) Fax (248) Outside (248) Web Site: click on Flex Plan links

2 EAST DETROIT PUBLIC SCHOOL DISTRICT FLEXIBLE SPENDING ACCOUNT REIMBURSEMENT ACCOUNT ELECTION FORM Plan Year January 1, 2013-December 31, 2013 Employee Name: (Please Print) Social Security Number Employee Number Date of Birth / / / / Gender: Male/Female Please Circle address: Address: Street City State Zip REIMBURSEMENT ACCOUNTS DEDUCTION EFFECTIVE DATE : Annual Amount A. Uninsured Health Care $ ($ 2,500 Max $60 Min) B. Dependent Care $ ($ 5,000 Max $60 Min) C. Dental Buy Up (Employer Funded) $ Please Circle Do you want to use the debit card service for 2013? Yes No If yes, please note the expiration date of your current debit card. If the expiration date is December 31, 2012, do you want a new card ordered for yourself? Yes No Do you need cards for a dependent? If so, please list their names below. Spouse Eligible adult child I UNDERSTAND THAT I CANNOT CHANGE MY ELECTION AND PAY REDUCTIONS UNLESS I EXPERIENCE A CHANGE IN MY FAMILY STATUS. My employer and I agree that my salary will be reduced by the amount(s) listed above for the benefit option(s) I have elected under the Flexible Spending Plan. I hereby acknowledge that I have read the Understanding of Agreements on the reverse side of this form. Further, I hereby consent to the use of my personally identifiable information, and or my dependent(s) information, which I have voluntarily provided on this form. I also hereby consent to the use of any protected health information I have furnished on my behalf, or my dependents behalf, for the sole use of providing benefits, services or any information I have requested. This agreement is subject to the terms of the East Detroit Public Schools Flexible Compensation Plan, as amended from time to time, and revokes any prior election and compensation reduction agreement relating to such plan. Employee Signature Date Employer Signature Date PLEASE SUBMIT ORIGINAL TO ADMINISTRATIVE SERVICES / BENEFITS

3 UNDERSTANDING OF AGREEMENTS I have received the printed material explaining the Plan and my options under the Plan, and, I understand that by signing this form, I am making an election which may not be changed for this Plan year other than as permitted by law and the Plan. I understand that by electing to be covered under the applicable Employer s insurance plan(s), my portion of the premium is automatically reduced from pre-tax wages under the Flexible Compensation Plan, if applicable. Further, I understand that if I do not incur expenses this Plan Year in the amount which I have elected for each benefit, the law requires that I forfeit unused amounts, resulting in a loss of take-home pay. I authorize the reduction of these amounts from my paychecks and acknowledge that these amounts are to be credited to my Flexible Compensation accounts. I authorize the Administrator to draw upon my accounts to reimburse me for eligible expenses incurred by me during the Plan Year. I understand that requests for reimbursement from the reimbursement plan(s) will only be processed if I comply with the terms and conditions of the applicable plan. I also understand that the Plan Administrator and Third Party Claims Administrator may establish rules and procedures from time to time, which also govern processing reimbursement requests. In addition, the Plan Administrator may establish rules and procedures regarding payment of remaining reimbursement contributions upon termination of employment in accordance with the applicable Flexible Benefit Plan Document(s). The Employer and Plan Administrator may take appropriate legal action to assure that reimbursements are made in accordance with the terms and conditions of the reimbursement plan(s). DEPENDENT CARE I understand that, for this Plan Year, I may be reimbursed for dependent care expenses up to the maximum of (1) Five Thousand Dollars ($5000) (Two Thousand Five Hundred Dollars ($2500) if married filing separate), (2) my spouse s earnings, if applicable, or (3) 50% of my earnings, whichever is least. I also understand that in order to receive reimbursement, I must submit receipts or other evidence that indicate who was cared for, dates of service, the actual amount paid along with the name, address and social security/tax identification number or the provider of these services. I understand that I or my spouse, if applicable, may not elect to receive the tax credit for the dependent care expenses that I have been reimbursed for under the Plan. UNINSURED HEALTH CARE EXPENSES I understand that, for this Plan Year, I may be reimbursed for expenses incurred for my medical care and the medical care of my spouse and dependents which are not covered by medical insurance or other plans up to the maximum amount deemed by the Plan. The dependent relationship must exist when the charges were incurred. If I claim reimbursement for these expenses under the Plan, the amount of the reimbursement will be tax free. Eligible medical expenses include any expenses incurred for diagnosis, cure, treatment, mitigation, or prevention of disease, or for the purpose of affecting any bodily function or structure, prescription drugs, insulin per IRS guidelines from the Patient Protection and Affordable Care Act. KEEP THIS PAGE FOR YOUR RECORDS

4 Debit Card Frequently Asked Questions East Detroit Public Schools 2013 PLAN YEAR Understanding how your FSA Debit Card works will optimize your experience with your Flexible Spending Plan. If you have questions at any time, please contact your Human Resources Representative or Employee Benefit Concepts, Inc. a Group Resources company Throughout this Q & A we will be referring to Employee Benefit Concepts (EBC). How does a (Flexible Spending) Debit Card work? Your prepaid FSA Visa Debit Card can be used to pay for qualified medical expenses anywhere Visa is accepted. It is your responsibility, however, to ensure that your FSA Visa Debit Card is used only for qualified medical expenses. What are qualified medical expenses? Qualified expenses are expenses for medical services not covered by the health care plans: deductibles, prescription and physician co-pays, vision, dental, orthodontia, chiropractic, and acupuncture services are some examples. *Effective January 1, 2011 IRS eligible over-the-counter items include adult diapers, blood glucose monitors, and diabetic test strips and drugs and medication items prescribed by a doctor with a prescription. However you should be able to purchase these items with your flex debit card, but you may need to purchase these items and submit a paper claim for reimbursement. On September 3, 2010, the IRS issued its initial guidance with respect to the new rule included in the PPACA that requires a doctor s prescription for the reimbursement of over-the-counter (OTC) drug and medicines from a FSA. The guidance confirms the following: Participants will still be able to use their FSA for purchases of ALL OTC drugs and medicines, as long as they have a doctor s prescription. The rule was effective January 1, 2011 and applies to purchases after January 1, The only acceptable forms of documentation for reimbursement for OTC drugs and medicines is a doctor s prescription, as regulated by state law along with an acceptable receipt, or a receipt indicating the Rx number in addition to date purchased, purchaser, and amount. Insulin, medical devices (crutches, blood sugar monitors, ect.) and items such as bandages, contact lens solution, denture bond, etc. will not require a prescription. What are non-qualified medical expenses? Typical examples of non-qualified FSA medical expenses: o Cosmetic treatments (dental whitening, facial treatments) or cosmetic surgeries o Over-the-counter items purchased for general health and wellness o Over-the-counter items purchased after December 31, 2010* Who verifies that purchases have been made of qualified expenses? It is the IRS guidelines along with the retailers IIAS system that determines which purchases made using the Take Care Debit Card are eligible under IRS guidelines. Therefore, as with any FSA plan, it is important to retain copies of all medical receipts. If a purchase made with your FSA Debit Card needs to be verified a letter or an will be sent directly to you requesting a copy of the pending debit card transaction receipt. You may also log in to the web site and see if a receipt will be needed. A receipt can be mailed, faxed or scanned and ed directly to EBC, along with a copy of the , letter request or the form that is available on the web site so that EBC can adjudicate the pending transaction. Do all FSA Debit Card transactions require this verification process? No. Common co-pay amounts for both prescription and medical visits will automatically be adjudicated and substantiated. Amounts that cannot be easily identified will require back-up documentation. Receipts are not required if you swipe your card at a No Receipt Retailer. A listing is available on the In July 2009, grocers and superstores with pharmacies and/or over-the-counter products must upgrade their point of sale system to be able to identify IRS qualified items from items that are not qualified. If they do not subscribe to the IRS Inventory Information Approval System (IIAS) flex debit cards will not be accepted. You will need to purchase the items with another form of payment and submit the receipts for reimbursement.

5 Because the debit cards are smart enough to approve only qualified items, participants will not be asked to submit receipts for purchases made at these certified retailers. Retailers that do not meet these requirements may not be able to accept flex benefit cards. Take care Partners retailer list is available on the web site or A regularly updated list is on the SIGIS Merchant list located on web site What happens if I use the card to purchase a non-qualified medical expense? If is it determined that your FSA debit Card was used for the purchase of a non-qualified medical expense, the amount of the non-qualified purchase will have to be repaid to EBC and you will be charged a $10.00 processing fee. What is the advantage of using an FSA Debit Card if I still have to follow up with receipts in some instances? The advantage to using an FSA Debit Card is that you are not taking money out of your pocket, or applying charges to a personal credit card to pay for your qualified medical services. No claim forms need to be filled out. Your FSA Debit Card can be used by your spouse or other eligible dependents. Example: your teen or adult child can use the Debit Card at your dentist or vision care providers office to pay for services that would otherwise have to be paid out-of-pocket. What if my provider does not accept Visa? Paper claims can always be submitted as an alternative. Using the FSA Debit Card to pay for expenses is optional. Is there a fee for using the FSA Debit Card? Yes, there is an annual fee of $15.00, which is paid for you by East Detroit Public Schools. Do I need a new FSA Debit Card each year? No. Debit Cards are now issued for a three year period. If you have a current FSA Debit Card, please note the expiration date. If your card expires on December 31, 2012, you will need to follow the instructions below to order a new card. If the expiration date is not December 31, 2012, you only need to indicate on your FSA Enrollment Form your desire to continue to use the card service. How do I request a debit card? You may request a debit card when completing the enrollment form or you can order the card online through the website. When you are logged in, you may request a debit card from the web site. Your card and spouse s card or eligible college student, if you order one, will come directly to your home in a plain white envelope in the mail within 7 to 10 business days. Will I be able to use my card immediately? Once the card has been received activation will occur at the time of your first swipe of the card but not before January 1, 2013 or your effective date, whichever is later. If I have a suspended 2012 debit card account because of a balance due or an unsubstantiated debit card swipe can I use the debit card when the new Plan Year begins on January 1, 2013? No. You will still need to submit the receipts required for the 2012 account. What happens if my card is stolen or lost? If your card has been lost or stolen, please call to report the card lost or stolen as soon as possible. A new card will be issued for you and if applicable, your dependent. Can I order an additional card? You may order additional cards on the web site. Can the debit card by used at my Daycare Center? The debit card cannot be used at the Daycare Center. If at any time you have any questions concerning the Take Care Debit Card please contact Employee Benefit Concepts, Inc. a Group Resources Company at (248) or outside 248 area (800) or via at

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