Flexible Spending Accounts (FSAs)

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1 Flexible Spending Accounts (FSAs) The County is excited to announce their partnership with a new vendor, HealthEquity, the nation s oldest and largest dedicated health savings trustee. With this partnership, we will provide hasslefree Flexible Spending Account (FSA) administration. An FSA is an employer sponsored benefits program where employees can use pre-tax dollars to pay for qualified health care or dependent care expenses. An FSA is a use or lose plan and all employees are eligible to participate in an FSA. Health Care FSAs: You can use your pre-tax contributions to your health care FSA to reimburse yourself for qualified, out-of-pocket health care expenses incurred by yourself and/or covered dependents. Qualified expenses include co-pays, deductibles, prescriptions, dental visits and procedures, orthodontics, eye exams, glasses, contacts and even Lasik surgery. HealthEquity issues FSA members a debit card for hassle-free transactions for all qualified medical expenses. Dependent Care Reimbursement: Allows you to set aside tax-free dollars from your paycheck to pay for the dependent care expenses of a qualifying tax dependent. Please visit for a variety of helpful information, including: Contribution Calculator A list of qualified health care expenses Frequently asked questions Success Stories Member Newsletters 24/7/365 toll-free phone support

2 Health Equity Flexible Spending Account (FSA) Employee Enrollment Form Return this form to Risk Management 330 Fair Lane, Building A Building Health Savings~ 2015 Plan Year Bargaining Unit: I Employer Information I~ Employer Name Account Holder Information First Name M.l. SSN Gender DMale Last Name Date of Birth (mm/dd/yyyy) DFemale Address Home Phone ( ) Physical Street Address City State ZIP Mailing Address (if different) City State ZIP Insurance Coverage ICoverage Type Coverage Effective Date D Single D Family Annual Elections Contribution Per Pay Period Number of Pay Periods Remaining in Plan Year Health Care Flexible Spending Account $ X = $ Limited Purpose Health Care Flexible Spending Account $ X = $ Dependent Care Flexible Spending Account $ X = $ Your Annual Election Amount Contribution Per Pay Period x Number of Pay Periods= Your Annual Election Amount Banking Information for Direct Deposit Name on Account: Account type: 1134 Your Name DChecking 9tl-t23-tJa Mam Street Au)'... USA DSavings _28_ lsi Paytotbe I order or Financial institution: DoOars YaurPiDmclll.laltilaliaa. II -~w.y Sim1VIIIlcy.CI digit routing number: For Cl Account number: Form must be accompanied by an actual or a copy of a voided check. (Deposit slips are not sufficient). 9 : Routing Number ' 1234 Account Number CbeckNumber (Do not include) Note: This section is not required, however payments issued via EFT are not subject to the $2 check fee. By choosing direct deposit, no confirmation will be mailed to you. To verify when your last claim was processed, please call Member Services at Please contact your bank or credit union to verify receipt of payment in your account. Direct deposit may take up to 2-3 business days to take effect. Signature D I decline to participate in the FSA plan. Print Name EE Hire Date: Benefit Start Date: ISignature IDate FSA_Employee_Enrollment_Form_

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5 FSAs: Stretching Health Care Dollars What Is a Health Savings Account? account. During open enrollment you indicate how much of your pre-tax income to put in (up to the amount allowed by your plan). Is an FSA Right for Me? or other dependent care. Whose Medical Expenses Can I Pay for Out of My FSA? Yours, Your Spouse s, and Your Dependents member claimed as a dependent on your tax return, even if they are not covered by your health plan. What Kinds of Expenses Can I Use My FSA For? Medical care expenses must be primarily to alleviate or prevent a physical or mental defect or illness. This doesn t include items they are a medical necessity). Premiums for health and other insurance aren t eligible.

6 How Does an FSA Work? During your employer s open enrollment (at the beginning of the plan year), you decide how Q: Unused funds don t roll over. There may be a run-out period when you balance for the previous year goes back to your employer. Q: plan. accumulates throughout the year and is only available as funds are deposited. balances are always reduced by any reimbursements made. Q: dependent on your tax return. Q: Yes. You can see your account reimbursements, and manage your or your

7 Hassle-Free, Dependent Care Reimbursements with HealthEquity Being a parent or caregiver is hard enough running kids back and forth to daycare, and/or care giving that just got easier dependent care expenses from your HealthEquity DCRA. Submit Once. Never submit weekly or monthly reimbursement requests recurring payments will be made to you as funds become Member Services team at Live specialists are available 24/7/365.

8 1. Log in to your member portal On the Accounts Setup for Electronic Funds Transfer screen, select Add New. 5. Select, This account will be used for reimbursements only. 6. Select Authorize. See ResourceCenter/LearnAboutFSAs/. Note that 1. Select Reimbursements/Payments under My Money. 2. On the Choose Account screen, select the appropriate DCRA account and select Enter claim record and send 3. Select Next. 4. On the Payment Type screen, select Reimburse Me. 5. Select Next. 6. On the Expense Details screen, select New and complete the Record 7. Select Next. 8. On the payment detail screen, enter the requested amount for reimbursement. You will be paid as funds become available in your account. For annual payments, enter the full Reimbursements will only be sent if there are funds available in your account. If no funds are available, your reimbursement will be sent when your employer deposits money into your account. 10. Select Reimbursement Type (check or EFT). 11. Select Next. 12. Complete and submit a Dependent Care Reimbursement Account Reimbursement Form found under Forms and Docs on your member portal. Include the date span you are Have your care provider sign and date the form. Sign and date the form yourself. Upload your completed form or fax it to HealthEquity. scan the completed form, it to the claim. - Under My Money, Reimbursement Account Detail, select DCRA from the reimbursement account dropdown. - Select Pending Claims. - Select applicable claim ID number. - Select Browse and Upload Image. send completed form to and write the applicable claim ID number on the form Copyright 2012 HealthEquity, Inc. All rights reserved. HealthEquity and the HealthEquity logo are registered trademarks or service marks of HealthEquity, Inc. Building Health Savings is a service mark of HealthEquity, Inc. HE DCRAReimb /3

9 Qualified and Non-Qualified Medical Expenses Use your health care account to pay for or get reimbursed for a variety of medical goods and services and some health insurance premiums for select accounts. See the complete list of qualified and unqualified medical expenses in IRS Publication 502 Medical and Dental Expenses. And see the complete list of qualified dependent-care expenses for a dependent-care FSA in IRS Publication 503 Child and Dependent Care Expenses. Qualified Medical Expenses Acupuncture Alcoholism (rehab, transportation for medically advised attendance at AA) Ambulance Amounts covered under another health plan Annual physical examination Artificial limbs/teeth Birth control pills/prescription contraceptives Body scans Breast reconstruction surgery following masectomy for cancer Chiropractor Contact lenses Crutches Dental treatments Eyeglasses/eye surgery Hearing aids Long-term care expenses Medicines (prescribed, not imported from other countries) Nursing home medical care Nursing services Optometrist Oxygen Stop-smoking programs Surgery, other than unnecessary cosmetic surgery Telephone equipment and repair for hearing-impaired Therapy Transplants Weight-loss program (if prescribed by a physician for a specific disease) Wheelchairs Wigs (if prescribed) Non-Qualified Medical Expenses Babysitting, child care, and nursing services for a normal, healthy baby (may qualify under a dependent-care FSA) Dancing lessons Diaper service Elective cosmetic surgery Electrolysis or hair removal Funeral expenses Future medical care Hair transplants Health club dues Insurance premiums other than those explicitly included Medicines and drugs from other countries Nonprescription drugs, medicines, and supplements (unless prescribed) Nutritional supplements, unless recommended by a medical practitioner as treatment for a specific medical condition diagnosed by a physician Teeth whitening The penalty for using HSA funds for non-qualified medical expenses is 20% if you are under age 65, plus the loss of tax-free treatment for the distribution. Keep all itemized receipts and copies of prescriptions for over-the-counter medications in case of an IRS audit. Qualified medical expenses for a limited-purpose FSA are restricted to qualified out-of-pocket costs for dental and vision care. Other expenses normally eligible under a standard FSA aren t eligible under a limited-purpose FSA. Blue Shield of California is an Independent Member of the Blue Shield Association. HealthEquity, Inc. is the custodian of your flexible spending and/or health reimbursement account and is independent from Blue Shield of California. The Bancorp Bank is the FDIC-insured and independent company that holds your HSA dollars. Neither HealthEquity nor Blue Shield of California provides medical or tax advice. Content should not in any case replace professional medical or tax advice. Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans. Copyright 2012 HealthEquity, Inc. All rights reserved. HealthEquity, the HealthEquity logo, and Building Health Savings are service marks of HealthEquity, Inc HE QME /3

10 Easy access to your account Wherever you are The new HealthEquity mobile app provides easy, on-the-go access to all of your health accounts. The free app provides comprehensive tools to help you manage transactions and maximize your health savings. Convenient, powerful tools: > > ON-THE-GO ACCESS You can access all account types wherever you go PHOTO DOCUMENTATION Simply take a photo with your device to initiate claims and payments For assistance, call: available every hour of every day > > > SEND PAYMENTS & REIMBURSEMENTS FROM HSA You can send payments to providers or reimburse yourself for out-of-pocket expenses from your HSA MANAGE DEBIT CARD TRANSACTIONS Link your debit card transactions to claims and documentation VIEW CLAIMS STATUS View the status of claims as well as link payments and documentation to claims 15 West Scenic Pointe Drive, Suite 100 Draper, UT Download the free mobile app itunes App Store Google Play 2013 HealthEquity All rights reserved.