Section 125 Flexible Spending Account. Employer information

Transcription

1 Section 125 Flexible Spending Account Employer information

2

3 Dear Valued Client: Thank you for partnering with Paychex for your company s Flexible Spending Account (FSA) plan! The enclosed materials have been designed to help you understand your FSA and minimize the time you spend administering your plan. The following information will help both your employees and your business take full advantage of the plan. Providing information before enrollment is important to maximize participation. Here are some tools you can use to educate your employees about the FSA plan. Employee Letter. Make copies of the employee letter (entitled Announcing an Important Benefit ) that explains the enrollment process and can be found on page 11 of this booklet. Be sure to complete the unreimbursed medical expense maximum and the amount the company is contributing to their FSA sections in the letter, if applicable. FSA Employee Enrollment Information Booklet. Distribute these information booklets to eligible employees during open enrollment and to newly eligible employees during the enrollment period you have designated in your adoption agreement. A copy of your signed adoption agreement was included in the Welcome Package you received shortly after starting the plan. The service period designated by your plan can be found on page 2 of the agreement. Paychex Online Flexible Spending Account. An online one-stop solution for employees FSA needs! The fastest, most efficient way for employees to enroll or to update elections is to visit the FSA website at Participants can also view account balances and submit medical, dental, vision, over-the-counter, and dependent care expense claims (Note: All claims submitted online still require substantiating receipts to verify the eligibility of the claim.) In addition, registering for the website will allow employees access to valuable resources such as lists of eligible expenses, an online Education Center, and Frequently Asked Questions (FAQs). Paychex Employee Services Phone Line. This feature provides employees easy access to information about their FSA. Participants can enroll or change enrollment information, retrieve account balances, and review their claim status by calling our automated phone line at Representatives are available to assist participants Monday through Friday from 8:00 a.m. to 8:00 p.m. ET. FSA Online Video. The video available at provides a high-level overview of how an FSA works and why it s a benefit to employees. You can provide it to employees as an instructional resource. Please review the remainder of this booklet for important information regarding your FSA plan, and call us at with any questions you may have. Representatives are available to assist you Monday through Friday from 8:00 a.m. to 8:00 p.m. ET. If your employees have questions, please refer them to the Paychex Online Flexible Spending Account website or the Paychex Employee Services phone line referenced above. Thank you for choosing Paychex. We appreciate the opportunity to assist with your FSA. Sincerely, Paychex Section 125 Services 1

4 Enrollment Now that you have decided to offer this great benefit to your employees, let s cover how they can enroll in the plan and start saving on their taxes! Initial Enrollment Employees starting an FSA need to submit their election information no later than two days before the first payroll in which the deduction is to begin. The fastest and easiest way for employees to enroll is by accessing the Paychex Online FSA site at or by calling *. In addition, the Election Form/ Compensation Reduction Agreement forms can be found in the back of this booklet. Form FSA001 allows only for the employee s election; FSA002 allows for the employee s election and the employer s contribution. Select the appropriate version for your employees use. Once the employee submits this form, you must: Verify that the form is completed and signed. Enter your Paychex client number. Return the completed form to your Paychex representative or fax completed forms to to start your plan. Once enrolled, the employee will continue to participate in the plan until they choose to cease participation or modify the election amount during open enrollment. If the employee does not submit a change, the annual election amount currently on file will be used for the following plan year. For new hire enrollment periods, return completed forms to Paychex no later than two days before the first deduction date. Open Enrollment There is an open enrollment period for all employees who have met the eligibility requirements stated in the Summary Plan Description (SPD). A copy of the SPD was included in the Welcome Package you received shortly after starting the plan. The eligibility requirements can be found on page 2 of the SPD. The effective date for new elections made during open enrollment is January 1. The open enrollment period is the 60-day period immediately preceding the plan year start date of January 1. Mid-Year Changes If an employee chooses not to enroll in the plan during the open enrollment period, they will not have another opportunity to enroll until the open enrollment period the following year, unless they experience a qualifying event in accordance with IRS regulations. Qualifying events include marriage**, divorce, death of a spouse** or dependent, birth or adoption of a child, termination or commencement of spouse s* employment, change in employment status from part-time to full-time or vice-versa for the employee or their spouse** (only in circumstances where it impacts eligibility), or leave of absence by the employee or their spouse**. Specific IRS rules govern these changes. Changes resulting from a qualifying event must be submitted within 30 days of the event. * If the enrollment date is less than six days before the entry date, the participant must enroll using a paper form. Additionally, neither the website nor the phone line will allow enrollment after the entry date, even if the request is entered before the next payroll date. **As defined under federal law. 2

5 Claims The claim process is how your employees will receive their pretax reimbursement for eligible out-of-pocket expenses funded by their payroll deductions. Eligible Expenses Paychex provides a list of common eligible expenses on the Paychex Online Flexible Spending Account site at A copy of this form (FSA011) is in the back of this booklet and can also be found in the Section 125 Flexible Spending Account Employee Enrollment Information booklet. Reimbursement Claim Forms The Flexible Spending Account (FSA) Reimbursement Claim form Unreimbursed Medical Expenses (FSA003) is used to request reimbursements for eligible out-of-pocket medical, dental, and vision expenses. Participants can access forms using the Paychex Online FSA site at A copy of the form is also included in the back of this booklet. All claims submitted online require substantiating receipts to verify the eligibility of the claim. Completed forms and receipts can be faxed or mailed to Paychex. If a claim is denied or put on hold for any reason, the participant will be notified in writing with the reason for denying or holding the claim. Participants may also visit their online account or call Paychex Employee Services for the status of their claims. The FSA Dependent Care Allowance Claim form (FSA004) can be used to submit up to a month of dependent care services at one time. Participants can access this form using the Paychex Online FSA site at A copy of this form is in the back of this booklet. Example: IRS regulations prevent reimbursement of funds before a service is incurred. If the supporting documentation for a claim includes expenses for a future period, or a current month s receipt is submitted before the entire month is over, we will reimburse a prorated weekly amount up to the current date and as the participant s balance allows. Orthodontia Coverage For orthodontia claims, participants need to submit a copy of an orthodontia contract (or a written statement from the orthodontist) indicating the length of treatment and schedule of payment, or have the orthodontist complete the Orthodontia Claim form (FSA045) available on the Paychex Online FSA site at A copy of the form is included in the back of this booklet. Participants will be reimbursed based on the length of treatment and schedule of payments, and will not be reimbursed in full if the orthodontia bill is paid up front. This is because the treatment of orthodontia is ongoing and reimbursement of medical expenses prior to treatment being rendered is not permitted by the IRS. After the contract is submitted to Paychex, the participant can submit a claim form and an itemized receipt to be reimbursed. If the Paychex Orthodontia Claim form is used, additional claim forms and itemized receipts are not required. 3

6 Claims Processing All claims for reimbursement will be processed upon receipt of the completed claim form and all supporting documentation. All claims for future service dates will be processed when the service occurs. Dependent care claims will be reimbursed to the participant up to the balance available in their account, and monthly dependent care claims with future service dates will be broken down into weekly payments. (Refer to example on page 3.) Reimbursements will be processed within two business days of receipt. Participants have up to 90 days after the end of the plan year (December 31), or termination of employment, to submit claims for reimbursement. Eligible expenses must be incurred during the plan year and prior to a participant s termination date while an active participant. In addition, you may offer a grace period following the end of the plan year (up to and including March 15) allowing participants to incur expenses that may be reimbursed from their previous year s account. This applies only if the employee is an active participant on the last day of the plan year (December 31) and they have a balance remaining in their previous year s account. Reimbursement requests will be processed in the order in which they are received and deducted from the previous year s account. Participants should submit reimbursement requests for services from the previous plan year first to ensure they receive the maximum benefit. 4

7 Additional Services Paychex is pleased to offer these additional features as added convenience to your plan. They are completely optional and may be added to your FSA at any time! Check Signing & Insertion Service With the Check Signing & Insertion Service, reimbursement checks are printed with your company s authorized signature(s), stuffed into envelopes, and mailed directly to the employee s home address. This eliminates the need to hand sign each reimbursement check. The employer or plan administrator will still receive the account balance and check register reports. FSA Direct Deposit The FSA Direct Deposit option allows FSA plan participants to receive medical and dependent care account reimbursements through electronic deposits to their bank accounts. This service is separate from the payroll direct deposit option. Funds would be electronically debited from the company s bank account and electronically transferred into the employee s designated account. There is no extra charge for FSA claims reimbursement through direct deposit. Paychex recommends checking with your bank as they may assess a service charge. FSA Debit Card If you choose this option, participants can use an FSA Debit Card to pay for FSA-eligible items and services at the point of sale instead of paying out of pocket and submitting a paper claim form for reimbursement. Each participant can request two cards one for the participant and an additional card for a spouse or dependent. Please note that depending on the items purchased, participants may be required to submit documentation to validate the expense as eligible under the plan. Funds would be electronically debited from the company s bank account and used to pay the merchant for the purchase. There is no extra charge for FSA claims reimbursement through debit card. Paychex recommends checking with your bank as they may assess a service charge. 5

8 Compliance Due to the pretax nature of the Section 125 plan, the IRS requires compliance testing to ensure that the plan is maintained as a qualified employee benefit and does not discriminate in favor of Key and Highly Compensated Employees (HCE) or owners. All participants in a Section 125 plan must be employees of the company and meet the eligibility requirements outlined in the Basic Plan Document. Self-employed individuals, partners of a partnership, and stockholders who own more than 2% of the stock in an S-Corporation are not eligible per IRS regulations. The spouses, children, parents and grandparents of these individuals are also not eligible to participate. Owner An owner is any employee who owns more than 5% of the stock, capital, or profits of the company (current or previous year), and all family members (spouse or child) of the 5% stockholder/ owner who are employed by the company. Highly Compensated Employee (HCE) A Highly Compensated Employee is: All employees who own, directly or indirectly, more than 5% of the stock, capital, or profits of the company (current or previous year). Any employee who has the authority of an administrative executive. Employees earning more than the IRS salary index amount* on an annual basis and who were among the top 20% of all employees for the previous plan year (prior year salary). All family members (spouse or child) of the HCE, including 5% stockholders/owners employed by the company. Key Employee A Key Employee is: All employees who own, directly or indirectly, more than 5% of the stock, capital, or profits of the company (current year only). Any employee who owns more than 1% of the stock capital or profits of the company and earns more than the annual IRS salary index amount*. Any employee who has the authority of an administrative executive and earns more than the annual IRS salary index amount* (current year salary). All family members (spouse, parent, grandparent, or child) of the greater than 5% stockholders/owners and greater than 1% stockholders/owners employed by the company. *The IRS salary index amount is subject to change each year. The amount specific to the current plan year will always be provided in the compliance instruction guide we mail to you semi-annually. Importance of Status Classification The Owner/HCE/Key status is used to determine if your plan is in compliance with Section 125 regulations. The compliance test calculates the amount of pretax contributions being withheld for your company s Section 125 plan. This total dollar amount is compared to the amount contributed by Owner/HCE/Key employees. If the testing is in favor of the Owner/HCE/Key employees as determined by IRS thresholds, your plan is not in compliance and the Owner/ HCE/Key employees will need to reduce their pretax participation. Paychex will assist you in performing these calculations as part of your service with us. 6

9 Plan Documents Copies of your Section 125 plan documents were included in the Welcome Package you received shortly after starting the plan. If you need additional copies for any reason, please call us at Representatives are available to assist you Monday through Friday from 8:00 a.m. to 8:00 p.m. ET. Adoption Agreement The Adoption Agreement is executed by the employer to adopt the Paychex Section 125 Plan. The Adoption Agreement designates the employer s options under the plan, which includes: employer organization and plan service provider information; plan effective dates; eligibility requirements; plan contacts; benefit plans offered by the employer to the employees; and flexible spending account minimum and maximum elections (FSA only). Basic Plan Document The Basic Plan Document that Paychex provides outlines the Section 125 plan specifics. It includes: specific description of each of the benefits under the plan, including the periods during which the benefits are provided; rules governing eligibility and participation; procedures governing participants elections under the plan (dates during which elections may be made, rules concerning revocation of elections, and plan effective dates); and the manner in which employer contributions may be made under the plan and the maximum amount of employer contributions available to any participant. Summary Plan Description The Summary Plan Description (SPD) is an IRS and U.S. Department of Labor required document that needs to be distributed to all plan participants. It must be written in a manner that will be understood by the average plan participant. It summarizes the employer-specific plan characteristics, including information concerning the plans sponsorship and administration. It must also be supplied to new participants within 90 days of their participation effective date. Note: The plan administrator and sponsor will be selected by the employer organization. Paychex, Inc. is the plan service provider. 7

10 Reports At various times throughout the year, Paychex will communicate information regarding the status of your plan through the reports explained below. Employee Deduction Report The Employee Deduction Report lists all employees enrolled in your plan (medical, dental, etc.), each employee s effective date, and the amount of their payroll deductions. Section 125 Compliance Test The Section 125 Compliance Test is sent semi-annually (spring and fall) whether your plan is in compliance or not. You may also obtain information about your compliance testing at any time throughout the year by calling or ing us at [email protected]. The report itemizes participants pretax contributions for benefits under the plan offered by Paychex during a plan year. Each employee s total is calculated by multiplying the per-pay-period contribution by the number of pay periods in which the employee will have participated by the end of the plan year. The calculations are always projected through the end of the plan year. Employee Account Balances The Employee Account Balances report summarizes all FSA participants elections, claims paid, credit available, contributions made, and the account balance. The credit available represents the difference between contributions and claims paid. The account balance represents the amount available for reimbursement. This report will be included with the reimbursement checks. FSA Check Register The FSA Check Register details the checks and/or direct deposit transactions issued for reimbursements on a specific date. The report lists the check number (or direct deposit transaction number) and the amount being reimbursed for each participant. It provides the total amount for employees being reimbursed on that date. If you provide an address, you will receive a notification of deductions for your Direct Deposit and Debit Card ACH collections for participant reimbursement. These s will provide the total of Unreimbursed Medical Expenses and Dependent Care Allowance collections for a given check date so that you are aware of the ACH amount that will debit your account. FSA Annual Election Notice The FSA Annual Election Notice letter identifies all employees not on track to meet their annual election for the current plan year. A list that includes the participant s name, annual election, year-to-date contributions, and additional contributions needed to meet the annual election is provided to you twice a year once in the spring and once in the fall. Upon receipt, it is important that you review the content and contact the Paychex Section125 department to determine the new per-pay-period amount the affected participants must contribute to allow them to meet their annual elections. Under the provisions of your plan, active participants must make the required salary contributions to meet their annual election amount (Refer to Plan Document, Article IV, Section 4.06). If participants do not contribute their full annual election, this could result in a loss to the company as the Sponsoring Employer. This rule is not applicable to dependent care expenses. 8

11 Frequently Asked Questions (FAQs) What is uniform coverage under an FSA? Uniform coverage pertains to the availability of the funds under the medical/dental expense portion of the plan. The maximum annual amount elected by a participant must be available to the participant at any time during the plan year, regardless of the amount contributed to the plan. What happens if a participant terminates employment with my company? Participants have 90 days to submit receipts for expenses incurred prior to their termination date. If the participant has an FSA Debit Card, they will be unable to use the card after the termination date. Be certain to contact us at as soon as any participant is terminated to ensure the debit card is deactivated on time. Can employees have an FSA and Health Savings Account (HSA) at the same time? Yes. Your employees can use an HSA in conjunction with an FSA; however, there are some restrictions. Your employees FSA accounts will become limited purpose and can only be used to cover dental, vision and preventative medical expenses. All other expenses should be submitted through the Health Savings Account (HSA). Will plan participants forfeit any unused funds at the end of the year? Participants have until March 31 of the following calendar year to submit claims for services incurred prior to the end of the plan year (including the grace period, if applicable). Any unused balance remaining after this time will be forfeited to the plan. Why would a participant not receive the full reimbursement for a claim submitted for dependent care services? IRS regulations prevent reimbursement of funds before a service is incurred. If the supporting documentation for a claim includes expenses for a future period, or a current month s receipt is submitted before the entire month is over, we will reimburse a prorated weekly amount up to the current date and as the participant s balance allows. For example: A participant submits a claim in November for December daycare costs of $1, December is a four-week month; therefore, the participant will be reimbursed $ each week in December (as the available balance allows). Where can participants find FSA forms? Your employees can access forms on the Paychex Online FSA site at 9

12

13 Announcing an Important Benefit Section 125 Flexible Spending Account Dear Valued Employee: We are pleased to offer you the benefit of a Flexible Spending Account (FSA). An FSA allows you to withhold money from your paycheck on a pretax basis to pay for unreimbursed medical and dependent care expenses; this ultimately means more take-home pay for you. If you have regular or predictable out-of-pocket expenses for which you are not reimbursed, consider opening an FSA to pay for: Medical/Dental Costs. Deductibles, co-payments, lab fees, unreimbursed doctor, hospital, orthodontia, and dentist fees. Dependent Care Costs. Child day care, nursery school, or custodial care for a disabled dependent. Other Related Costs. All approved, health-related expenses, such as prescriptions, prescription eyeglasses or contact lenses, dental cleanings, and ambulance costs. Note: Effective January 1, 2011, over-the-counter (OTC) medicines and drugs (other than insulin) will require a prescription from a medical practitioner in order to be eligible for reimbursement. Steps to Successful Enrollment 1. Review the Section 125 Flexible Spending Account Employee Information Booklet. This booklet explains the benefits and operation of the FSA plan. It also includes tools to assist you in planning your annual election amount. 2. Review the Paychex Online Flexible Spending Account website at FSA option. Learn about eligible expenses and view the Education Center, Help, and Frequently Asked Questions (FAQs) for more detailed plan information. 3. Determine how much you want to contribute. Use the FSA Deduction Worksheet in the Employee Information Booklet to estimate your expenses. Keep the following information in mind as you plan: You cannot exceed the maximum dependent care household limit of $5, set by the IRS. You cannot exceed the maximum unreimbursed medical expense limit of $ 4. Enroll in the plan and confirm your annual election. You can enroll online at by selecting the FSA option, or by calling Paychex Employee Services at Electronic enrollments offer you 24/7 access and immediate election confirmation.* Note: Newly eligible employees must enroll prior to the first day of the next entry date after they meet the eligibility requirements. If you do not enroll in the plan this year, the next open enrollment period for existing employees will be January 1. If you have questions about enrollment, visit FSA option, or call Paychex Employee Services at Representatives are available to assist you Monday through Friday between 8:00 a.m. and 8:00 p.m. ET. Sincerely, Paychex Section 125 Services *Paper forms can also be used for enrollment if needed. The Election Form/Compensation Reduction Agreement Form can be obtained on the website. Paper enrollment forms must be received by Paychex no later than two days before the first deduction date.

14

15 Paychex Use Only Client BIS ID Election Form/Compensation Reduction Agreement Flexible Spending Account SECTION 1 - EMPLOYEE INFORMATION (print) Office/Client Number Company Name Employee Telephone Number ( ) - Employee Name Social Security Number Address City State Zip Code Address SECTION 2 - ENROLLMENT OPTIONS (select one) New Enrollment or Annual Enrollment Changes Date of Hire / / Notes: New enrollments will be effective on the first payroll of the month following the date the eligibility requirements are met. Annual enrollment changes will be effective on the first payroll following January 1. Debit Card Dependent s name (if applicable) Notes: Participants may only request a debit card if their employer has selected the service. If the debit card option is selected and the Plan does not offer the debit card service, no card will be requested. Refer to your Summary Plan Description for plan features. Participants may choose only one dependent. Change In Status Date of Event / / Note: If Change in Status has occurred, changes in enrollment and supporting documentation must be submitted to the Employer within 30 days of the event. Dependent care cost provider changes Dependent satisfies or ceases to satisfy dependent eligibility requirements Birth/Death of spouse or dependent, adoption or placement for adoption Spouse's employment commenced/terminated Status change from full-time to part-time or vice versa by employee or spouse* Eligibility or Ineligibility of Medicare/Medicaid Change from salaried to hourly or vice versa* Marriage/Divorce/Legal Separation Unpaid leave of absence by employee or spouse Return from unpaid leave of absence by employee or spouse Termination of employment (your enrollment will be terminated) * These changes are allowable only if eligibility is affected. SECTION 3 - ENROLLMENT ELECTION Annual Medical/Dental/Vision Election $ (UME) Discontinue my Enrollment in Medical/Dental/Vision Care Annual Dependent Care Election $ (DCA) Maximum $5, DCA is issued for custodial care of a dependent, not for medical expenses of a dependent. Discontinue my Enrollment in Dependent Care Notes: To discontinue enrollment, a change in status reason must be selected. To calculate your per-pay-period deduction, divide your annual amount by the number of pay periods remaining in the plan year. SECTION 4 - AUTHORIZATION I hereby elect to participate in the Flexible Spending Account for the Plan Year / /. Any previous election and compensation reduction agreement relating to the same benefits is hereby revoked. I cannot change or revoke this election at any date prior to the next plan year unless I experience a change in status (also referred to as a qualifying event). If, during my next enrollment period, I do not complete and return a new election form during my enrollment period, I will be treated as having elected to continue my employee election as set forth in this election form for the next plan year. As a participant, I understand that all guidelines regarding enrollment are set forth in the Summary Plan Description. Reduction of Pay I understand that my pay will be reduced each pay period by the amount of my required contribution for the benefit option(s) I have elected until this agreement is amended or terminated. The reduction in my pay under this agreement will be in addition to any reductions under other agreements or benefit plans. I understand that my pay reduction will be automatically adjusted if my required contributions change while this agreement is in effect and that the plan administrator may change the amount of my pay reduction or otherwise modify this agreement if it is required to satisfy provisions of the Internal Revenue Code. Reimbursements I understand that my Employer will hold my contributions for payment of eligible expenses incurred within the Plan Year and that reimbursement will be available only for qualifying expenses. I agree to notify my Employer if I believe that any expense for which I have received reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer for any liability Employer may incur for failure to withhold income or FICA tax from any reimbursement I receive of a non-qualifying expense. I understand that I will forfeit any balances I have at the end of the year for which I have no eligible expenses to submit. FSA with an HSA If I have a Flexible Spending Account in conjunction with a Health Savings Account (HSA), I may only submit medical expenses under the Unreimbursed Medical portion of my Flexible Spending Account for dental, vision, and preventative care. My HSA may be used to pay for any remaining HSA-qualified medical expenses. Employee Signature Date / / ENROLL or REVISE ENROLLMENT at or on the FSA Information Line by dialing , Flexible Spending option. MAIL or FAX to Paychex, Section 125 Department, 1175 John Street, West Henrietta, NY Fax: FSA001 5/11

16

17 Paychex Use Only Client BIS ID Election Form/Compensation Reduction Agreement Including Employer Contribution Flexible Spending Account SECTION 1 - EMPLOYEE INFORMATION (print) Office/Client Number Company Name Employee Telephone Number ( ) Employee Name - Social Security Number Address City State Zip Code Address SECTION 2 - ENROLLMENT OPTIONS (select one) New Enrollment or Annual Enrollment Changes Date of Hire / / Notes: New enrollments will be effective on the first payroll of the month following the date the eligibility requirements are met. Annual enrollment changes will be effective on the first payroll following January 1. Debit Card Dependent s name (if applicable) Notes: Participants may only request a debit card if their employer has selected the service. If the debit card option is selected and the Plan does not offer the debit card service, no card will be requested. Refer to your Summary Plan Description for plan features. Participants may choose only one dependent. Change In Status Date of Event / / Note: If Change in Status has occurred, changes in enrollment and supporting documentation must be submitted to the Employer within 30 days of the event. Dependent care cost provider changes Dependent satisfies or ceases to satisfy dependent eligibility requirements Birth/Death of spouse or dependent, adoption or placement for adoption Spouse's employment commenced/terminated Status change from full-time to part-time or vice versa by employee or spouse* Eligibility or Ineligibility of Medicare/Medicaid Change from salaried to hourly or vice versa* Marriage/Divorce/Legal Separation Unpaid leave of absence by employee or spouse Return from unpaid leave of absence by employee or spouse Termination of employment (your enrollment will be terminated) * These changes are allowable only if eligibility is affected. SECTION 3 - ENROLLMENT ELECTION Annual Medical/Dental/Vision Election $ Annual Dependent Care Election $ (Employee Contribution - UME) Annual Medical/Dental/Vision Election $ (Employer Contribution - UME) (Employee Contribution - DCA) Maximum $5, Annual Dependent Care Election (Employer Contribution - DCA) $ DCA is issued for custodial care of a dependent, not for medical expenses of a dependent. Discontinue my Employee Enrollment in Medical/Dental/Vision Care Discontinue my Employee Enrollment in Dependent Care Discontinue my Employer Enrollment in Medical/Dental/Vision Care Discontinue my Employer Enrollment in Dependent Care Notes: To discontinue enrollment, a change in status reason must be selected. To calculate your per pay period deduction, divide your annual amount by the number of pay periods remaining in the plan year. SECTION 4 - AUTHORIZATION I hereby elect to participate in the Flexible Spending Account for the Plan Year / /. Any previous election and compensation reduction agreement relating to the same benefits is hereby revoked. I cannot change or revoke this election at any date prior to the next plan year unless I experience a change in status (also referred to as a qualifying event). If, during my next enrollment period, I do not complete and return a new election form during my enrollment period, I will be treated as having elected to continue my employee election as set forth in this election form for the next plan year. As a participant, I understand that all guidelines regarding enrollment are set forth in the Summary Plan Description. Reduction of Pay I understand that my pay will be reduced each pay period by the amount of my required contribution for the benefit option(s) I have elected until this agreement is amended or terminated. The reduction in my pay under this agreement will be in addition to any reductions under other agreements or benefit plans. I understand that my pay reduction will be automatically adjusted if my required contributions change while this agreement is in effect and that the plan administrator may change the amount of my pay reduction or otherwise modify this agreement if it is required to satisfy provisions of the Internal Revenue Code. Reimbursements I understand that my Employer will hold my contributions for payment of eligible expenses incurred within the Plan Year and that reimbursement will be available only for qualifying expenses. I agree to notify my Employer if I believe that any expense for which I have received reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer for any liability Employer may incur for failure to withhold income or FICA tax from any reimbursement I receive of a non-qualifying expense. I understand that I will forfeit any balances I have at the end of the year for which I have no eligible expenses to submit. FSA with an HSA If I have a Flexible Spending Account in conjunction with a Health Savings Account (HSA), I may only submit medical expenses under the Unreimbursed Medical portion of my Flexible Spending Account for dental, vision, and preventative care. My HSA may be used to pay for any remaining HSA-qualified medical expenses. Employee Signature Date / / Employer Signature Date / / ENROLL or REVISE ENROLLMENT at or on the FSA Information Line by dialing , Flexible Spending option. MAIL or FAX to Paychex, Section 125 Department, 1175 John Street, West Henrietta, NY Fax: FSA002 5/11

18

19 FAX: Submit or view claims ONLINE: Paychex Employee Services: , available 24/7 FOR OFFICE USE ONLY Docket # Flexible Spending Account (FSA) Reimbursement Claim Unreimbursed Medical Expenses EMPLOYEE INFORMATION (print) Employee Name Company Name Social Security Number (last 4 digits) Employee Telephone Number ( ) - Address Visit at any time to submit claims ONLINE or learn the status of your claim. All claim reimbursements will be processed within 2 business days upon receipt of the completed claim form and all supporting documentation. INSTRUCTIONS CHECKLIST: Enclose copies of all itemized bills and/or receipts from your provider or a copy of your orthodontia services contract, if applicable. Use blue or black ink only to identify FSA items on receipts. Do not use highlighter. Copies of personal checks, cancelled checks, or credit card receipts are not valid for verification of service. Verify that bills and receipts contain: date of service provider s name description of service provider s address cost of service prescription name (if expense is for a prescription)* *Over-the-counter (OTC) medicines and drugs (other than insulin) are no longer eligible for reimbursement under a medical flexible spending account unless prescribed by a medical practitioner. If you are currently funding a Health Savings Account (HSA) in addition to your FSA, your FSA is a limited purpose FSA and may only be used to pay for vision, dental, and preventative medical expenses. Sign your claim form and fax it to the number noted above. Retain a copy for your records. If you prefer, mail your claim to: Paychex, Inc., FSA Claims, PO Box 3000, Henrietta, NY Claim Name of Service Recipient Relationship to Employee SAMPLE John Doe Self Spouse Dependent 01 Self Spouse Dependent 02 Self Spouse Dependent 03 Self Spouse Dependent 04 Self Spouse Dependent Service Date(s) Service Description 07/07/07 Medical Dental Vision Pharmacy Medical Dental Vision Pharmacy Medical Dental Vision Pharmacy Medical Dental Vision Pharmacy Medical Dental Vision Pharmacy Service Amount Provider Dr. Jones $ TOTAL $ If you have more claims, please complete additional Reimbursement Claim forms. CLAIM INFORMATION I certify that the information here is true and correct; that the expenses incurred were for myself, my spouse as defined by federal law, or my eligible dependents; and that these expenses are not reimbursable under any other health plan coverage. Employee Signature Date / / $ $ $ $ FSA003 3/12

20

21 Paychex FSA Reimbursement Expenses-at-a-Glance Some items below may require a prescription, doctor s note or additional certification from a medical provider to show expenses are reimbursable under a health FSA to the extent that they are to diagnose, treat, or prevent an existing medical condition. Expenses incurred by or on behalf of a domestic partner and/or a domestic partner s child(ren) are not reimbursable. HEALTH CARE EXPENSE EXAMPLES THAT ARE ELIGIBLE: A.E.D. for home use Alcoholism treatment Ambulance services Astigmatic keratotomy Bandages Blood pressure monitors Braille books and magazines (to extent prices exceed the prices of regular books and magazines) Car equipped for disabled person (to extent price exceeds the price of regular car) Clinic charges Contact lenses/solution Co-pays and deductibles Crutches Dental retainer Dentist s fees (not cosmetic) Denture adhesives Dentures/dental implants/partials Doctor s fees (not cosmetic procedures) Eye exam/prescribed eyeglasses Eyeglass repairs for Rx glasses Diabetic supplies and test strips Diagnostic/screening services Oxygen equipment Drug addiction treatment facilities Physical exam Fertility treatments Podiatrist Guide dog/care Prescription medication Hearing aids/batteries/repairs Prescription sunglasses Hospital services Prosthesis (artificial limbs) Hot/cold packs and heating pads Rental of medical equipment Insulin Rewetting eye drops Laboratory fees Shipping costs (medical care Lasik eye surgery/radial items) keratotomy Smoking cessation prescriptions Lead-based paint removal to treat Special education for physically or lead poisoning mentally disabled family member Lodging for medical care Sperm storage fees (temporary) Medical monitoring/testing devices Sterilization Medical records fees Surgery/treatments Midwife expense (medical care) Telephone (for the deaf) Nurses expenses and board Thermometer Nursing care Transplants Obstetrical services Transportation for essential care Orthodontia (contract Vasectomies (and reversals) required) Wheelchairs Osteopath, licensed X-ray fees Ovulation monitor OVER-THE-COUNTER MEDICINE/DRUG EXAMPLES THAT ARE ELIGIBLE WITH A DOCTOR S PRESCRIPTION*: *Over-the-counter (OTC) medicines and drugs (other than insulin) are no longer eligible for reimbursement under a medical flexible spending account unless prescribed by a medical practitioner. Acne medications Allergy medications Allergy nose sprays Antacids Antifungal medications Anti-gas treatments Antihistamines Anti-itch treatments Antiseptic first aid sprays Calcium supplements Cold medications Contraceptives Cough medications/drops/syrups Decongestants Digestive aids First aid kits/supplies Gingivitis mouthwash/treatments Hemorrhoid creams/suppositories Herbal supplements Lactose intolerance pills Laxatives Medicated rubs/muscle creams Menstrual cycle medications Motion sickness medications HEALTH CARE EXPENSE EXAMPLES THAT ARE NOT ELIGIBLE: Anti-reflective lens coating Clip-on eyeglasses Cosmetic procedures/products Dental bleaching Dental floss Deodorants Diaper service Funeral expenses Illegal treatments or drugs Pain relievers/analgesics Spermicides Toothache/teething pain relievers Vitamins/minerals Wart removal treatments Weight loss/dietary supplements Yeast infection creams Insurance premiums Teeth whitening products Marital therapy Toiletries Medications imported from outside Toothbrushes U.S. Toothpaste Mouthwash Vitamins used for general health Remedial reading classes Warranties for eyeglasses Shampoo Skin moisturizers/lotions Soaps DEFINITION: An eligible dependent for Dependent Care Assistance is: Any dependent who has not attained 13 years of age and is your dependent under federal income tax rules. (If your child turns 13 during the year, you can stop your contribution at that time.) Your mentally or physically impaired spouse or a dependent incapable of caring for himself or herself (for example, an invalid parent). The dependent must spend at least eight hours per day in your home and have the same principal place of residence as you, the taxpayer, for more than one half of the taxable year. Expenses incurred for, or on behalf of, a domestic partner s child(ren) are not reimbursable. DEPENDENT CARE EXPENSES THAT ARE ELIGIBLE**: Services provided inside or outside your home, but not by your minor child or dependent Services provided by a qualified day care facility that cares for six or more individuals at the same time and complies with federal, state, and local laws Services incurred to enable you, or you and your spouse, to be employed, in search of employment, or full-time students Services for the custodial care of the dependent, not for education or meals Child care centers Family day care providers Babysitters Nursery schools Caregivers for a disabled dependent or spouse who lives with you Household services, provided that a portion of these expenses are for a qualifying dependent and are incurred to ensure maintenance of the dependent s well-being **Amount that can be reimbursed is not greater than $5,000, your earned income, or your spouse s earned income, whichever is lower. DEPENDENT CARE EXPENSES THAT ARE NOT ELIGIBLE: Dependent care provided to one of your dependents by a family member under the age of 19 who will be claimed as your dependent for tax purposes Expenses for food and clothing Education expenses, kindergarten and beyond Health care expenses for your dependents Overnight camps Transportation A more extensive listing of eligible expenses is available at Paychex Employee Services: , available 24/7 The Internal Revenue Service considers these expenses deductible and eligible for reimbursement through your FSA plan if they are to diagnose, treat, or prevent an existing condition and if you have not been reimbursed for them through any other benefit plan. FSA011 3/12

22

23 FAX: Submit or view claims ONLINE: Paychex Employee Services: , available 24/7 FOR OFFICE USE ONLY Docket # Flexible Spending Account (FSA) Reimbursement Claim Dependent Care Allowance EMPLOYEE INFORMATION (print) Employee Name Company Name Social Security Number (last 4 digits) Employee Telephone Number ( ) - Address Visit at any time to submit claims ONLINE or learn the status of your claim. All claim reimbursements will be processed within 2 business days upon receipt of the completed claim form and all supporting documentation. INSTRUCTIONS CHECKLIST: If you are completing the table below, enclose copies of all itemized bills and/or receipts from your provider. Use blue or black ink only to identify FSA items on receipts. Do not use highlighter. We will not accept copies of personal checks, cancelled checks, or credit card receipts as verification of service. Verify that bills and receipts contain: date of service provider s name dependent s name and age cost of service For your convenience, please have your Dependent Care Provider complete the Certification from Provider section below, and make sure your Dependent Care Provider signs the form. Otherwise, an itemized receipt for your dependent care expenses will be required. Sign your claim form and fax it to the number noted above. Retain a copy for your records. If you prefer, mail your claim to: Paychex, Inc., FSA Claims, PO Box 3000, Henrietta, NY Claim Name of Service Recipient Age of Service Recipient Service Date(s) Service Description Service Provider Amount SAMPLE Baby Doe 1 year 7/7/07 7/14/07 Dependent Care Ms. Smith $ Dependent Care $ 02 Dependent Care $ 03 Dependent Care $ 04 Dependent Care $ 05 Dependent Care $ TOTAL $ Note: Dependent Care Claims will be reimbursed up to the year-to-date contributions made to your account at the time of submission. If you submit for dates of service in the future or for amounts above your current contribution balance, reimbursement will automatically be issued once the date has passed and/or additional contributions have been made for this plan year. If you have more claims, please complete additional Reimbursement Claim forms. CERTIFICATION FROM PROVIDER We certify that we are providing Dependent Care Services for the employee noted above for the month of in the year of for, age. Dependent s Name Dependent s Age Dependent Care Services are custodial care for a dependent under age 13 or a dependent that is incapable of self care, and is not for school tuition. Before/after school care is a qualified expense and should be itemized to break out from cost of school tuition if applicable. Expenses incurred by or on behalf of a domestic partner s child are not reimbursable. Name of Dependent Care Provider Signature of Dependent Care Provider Date / / CLAIM INFORMATION I incurred the expenses listed above for reimbursement on behalf of my eligible dependent for reimbursable items under Section 125 of the Internal Revenue Code. Employee Signature Date / / FSA004 3/12

24

25 FAX: Paychex Employee Services: , available 24/7 Submit or view claims ONLINE: MAIL: Paychex, Inc., FSA Claims, PO Box 3000, Henrietta, NY Flexible Spending Account (FSA) Reimbursement Claim Orthodontia Services EMPLOYEE INFORMATION (print) Employee Name Company Name Social Security Number (last 4 digits) Employee Telephone Number ( ) - All claim reimbursements will be processed within 2 business days upon receipt of the completed claim form and all supporting documentation. HOW WOULD YOU LIKE TO BE REIMBURSED? Select one: DEBIT CARD I will be using my FSA Debit Card and do not want to be reimbursed monthly by check or direct deposit. Note: By selecting this option, Paychex will place your contract on file. Your card can then be used for the initial fee(s) and to make each monthly payment for the amount indicated in the contract agreement. (The debit card has a $500 limit per transaction at dental offices; any amount over the $500 can be paid out of pocket and submitted for reimbursement using the Unreimbursed Medical Expenses claim form.) OR CLAIM PAYMENTS I want to receive monthly reimbursements for my orthodontia automatically for the duration of the services based on the terms of my orthodontia contract. Notes: Your contract must be completed in full and mathematically correct for your claim to be paid out. If the terms of your contract change, promptly submit an updated contract or statement from the provider outlining the change. Per IRS guidelines, medical services are reimbursed under an FSA as services are incurred. Paychex will process your orthodontia claim on a monthly basis for the duration of the contract. If you choose to pay the full contract upfront to the provider, this will not allow your FSA plan to reimburse you the full amount upon submission. The initial fee and records fee may be reimbursed when services begin. Payment date will determine which plan year funds are reimbursed from. CLAIM AUTHORIZATION If you are not attaching a contract from the provider, please ensure that the Certification from Orthodontia Provider is completed in full and signed by the provider. If you want Paychex to process your claim by individual monthly payment, submit the Unreimbursed Medical Expenses claim form along with a copy of your orthodontia services contract. I certify that the information herein is true and correct; that the expenses incurred were for myself, spouse, or dependents; that these expenses are not reimbursable under any other health plan coverage; and that these expenses are eligible under Section 125 of the Internal Revenue Code. Employee Signature Date / / CERTIFICATION FROM ORTHODONTIA PROVIDER (to be completed by provider) Name of Orthodontia Provider We certify that we are providing orthodontia services for. Contract Information Start Date Total Dollar Amount of Contract - Initial Fee (Date Paid ) - Records Fee (if applicable) (Date Paid ) - Insurance (if applicable) - Discount (if applicable) Patient s Name = Remaining Balance = total months of service qualified monthly reimbursable amount Signature of Orthodontia Provider Date / / FSA045 5/11

26

27

28 Section 125 Department 1175 John Street West Henrietta, NY Online Flexible Spending Account Employee Website Paychex Employee Services Paychex Human Resource Services Fax / /12