Dear Flexible Spending Account (FSA) Enrollee:

Transcription

1 Dear Flexible Spending Accunt (FSA) Enrllee: Welcme t yur FSA Plan! Yu nw have 24x7 access t all yur FSA needs n the web. T access yur accunt simply lgn t Yur user name is yur first initial, last name (in all caps) and last fur digits f yur scial security number (i.e. Jhn De wuld be JDOE3333). Yur initial passwrd is: changeme. Once n the website, yu will be prmpted t change yur passwrd and asked fr a security challenge and respnse. Frm this pint, it s easy t click yur way thrugh the web-site. The web-site gives yu the ability t file claims n-line and print ff a cmpleted reimbursement frm fr submissin. Yu will als have all the necessary prgram frms available n-line fr yur use. The site als prvides yu with detailed up t-the-minute accunt infrmatin. As part f yur FSA prgram, yu will receive a MBI Debit Card. We encurage yu t take advantage f this exciting apprach in managing yur FSA. The FSA Debit Card is a special MasterCard that draws n the value f yur annual Health Care FSA and/r Dependent Care electin amunt. Each time yu incur a qualified expense nt cvered by yur regular health insurance at a business that accepts MasterCard, yu can use the Flex Debit Card. Yur qualified expenses will be deducted frm yur FSA autmatically; yur nly respnsibility will be t keep yur receipts in case they are required per IRS guidelines (see belw). The Flex Debit Card frees yu frm spending mney ut-f-pcket at the time f purchase and waiting fr reimbursement checks fr the vast majrity f expenses. The MBI MasterCard Card prvides THE MOST CONVENIENT WAY t access yur FSA cntributins. HERE S A LOOK AT REIMBURSEMENT Let s assume yu... Paying fr services ut f pcket yu wuld... With MBI yu will... Cntribute $1,000 in ne year t yur Health Care FSA Accunt (r $19.23 a week) Purchase a prescriptin (r several prescriptins) at the pharmacy, r pay a cpay at the dctr s ffice. 1. Pay what yu we. 2. Save the receipt. 3. Get a claim frm. 4. Cmplete the claim frm 5. Make a cpy f yur receipt and claim frm fr yur recrds. 6. Submit the frm and receipt fr reimbursement via fax r US mail t BenefitElect and yu will receive reimbursement 7. Wait fr reimbursement via mail/direct depsit. 1. Swipe yur MBI MasterCard 2. Save the receipts! Yu will be ntified if receipts are required (see belw). If s, use the ntificatin sent t yu as a cver sheet when returning required receipts. Receipts can als be sent in anytime alng with a Debit Card Receipt Transmittal Frm attached belw. Funds are autmatically deducted frm yur accunt! The Inventry Infrmatin Apprval System (IIAS) is nw available thrugh the MasterCard netwrk. The IIAS was designed t identify eligible healthcare purchases by cmparing the UPC r SKU number fr the items being purchased against a pre-established list f eligible medical expenses at the pint f purchase thereby eliminating the need t submit receipts at participating retail prviders (see attached listing). Receipts fr nn- IIAS prviders will still be required except fr payment f slid dllar insurance c-payments and deductibles as well as same dllar amunt expenses (i.e. prescriptin renewals). Ntificatins will be sent t yu if a receipt is required. Items will be deemed Pst Tax until the receipts are received. Thse participants, wh d nt respnd t a receipt substantiatin ntificatin within 90 days frm request, culd be subject t card suspensin. All respnses t ntificatins must be received within 6 business days after the plan year-end r the crrespnding debit card transactins may be reclassified pst tax fr IRS reprting purpses. All nn-eligible debit card claims will als be classified as pst tax fr IRS reprting purpses.

2 CLAIM FILING INSTRUCTIONS FOR HEALTH CARE EXPENSES 1. The ttal annual electin fr eligible medical expenses (less any previus reimbursements paid) may nt exceed the maximum allwed under the plan. Please review yur Summary Plan Dcument r see yur Plan Administratr fr mre infrmatin. 2. Refer t the prvisins in yur Summary Plan Dcument fr the minimum and maximum annual electin amunts. 3. Valid reimbursement claims must include a fully itemized bill including the date f service, name f claimant, type f service, etc. frm a dctr, dentist, pharmacy r ther supplier, r an explanatin f benefit statement indicating the deductible, c-insurance and amunts nt cvered by any medical/dental plan(s) (net f any amunts that have been r are t be paid by insurance r ther surces). 4. Internal Revenue Service Publicatin 502 lists the eligible tax-free expenses. An eligible expense means any item fr which yu culd have claimed a medical expense deductin n an itemized federal incme tax return fr which yu have nt therwise been reimbursed frm insurance, r sme ther surce. The expenses must be incurred by yu r yur dependents while participating in the plan and nt when they are billed t yu. CLAIM FILING INSTRUCTIONS FOR DEPENDENT CARE EXPENSES 1. The maximum amunt yu can be reimbursed during the time yu are cvered in the plan year cannt exceed the salary reductin amunts yu have elected and made under the dependent care spending accunt less any previus reimbursements paid. 2. Reimbursement payments can be made fr services prvided in r utside yur hme fr dependent child r adult dependent care in rder fr yu and yur spuse t wrk r g t schl full time. 3. Yur Maximum cntributin amunt cannt be mre than the lesser f: Yur incme r yur spuse's incme, whichever is less. If yur spuse is a full-time student r incapable f selfcare, yur spuse is cnsidered t earn $2400 per year with 1 dependent r $4800 a year with 2 r mre dependents. $5,000 per year if yur tax filing status is "married filing jintly" r "single head f husehld" r $2,500 per year if yur tax filing status is "married filing separately". 4. All expenses fr dependent care must be fr "Care". Expenses fr Kindergarten, 1st grade, and abve are nt eligible fr reimbursement accrding t the Internal Revenue Service. Cverage nly applies t: Dependents under the age f thirteen Dependent adults r children thirteen years ld r lder wh are mentally r physically incapable f self-care. 5. An itemized bill, receipt r cntract must be submitted fr reimbursement, which includes: The dependent s name The perid during which the services were rendered The name, address and taxpayer ID number f the individual r rganizatin prviding services A descriptin f the service prvided Alternatively, fr dependent care, if the abve infrmatin is dcumented n the reimbursement frm, yu may have the prvider sign the reimbursement frm in lieu f a receipt. NOTE: Cancelled checks, credit card receipts, invices r balance due statements are nt valid prf f service fr Dependent Care Expenses. Mre infrmatin n allwable claims can be fund n ur abve referenced website.

3 IMPORTANT Flexible Spending Accunt Infrmatin Yu already knw that a Flexible Spending Accunt is a smart way fr yu t put mney aside Tax Free t cver ut-f-pcket medical, dental, childcare and even dependent care csts. It s a great feeling t knw that participating in a Flexible Spending Accunt increases yur take-hme pay! Besides the savings mentined abve, Many Over-The-Cunter Drugs are eligible expenses! All yu have t d is t fllw sme simple rules (see belw). Over the Cunter Drugs The IRS has issued a new ruling fr Over the Cunter (OTC) drugs and medicatins. The IRS is nw cnsidering OTC drugs and medicatins t be reimbursable expenses. The ruling states that: 1. Reimbursements by an emplyer f amunts paid by an emplyee fr medicines and drugs purchased by the emplyee withut a physician's prescriptin are excludable frm grss incme (meaning it s an eligible FSA expense!)." In rder t be reimbursed, these items must meet the definitin f "Medical Care". "Medical Care" is defined as amunts paid fr the diagnsis, mitigatin, treatment r preventin f a disease, illness, r medical cnditin. 2. Hwever, amunts paid by an emplyee fr dietary supplements (e.g., vitamins) that are merely beneficial t the general health f the emplyee r the emplyee's spuse r dependents, are nt reimbursable r excludable frm grss incme under Cde 105(b). Yu must include cpies f yur OTC drug receipts with yur claim/transmittal frm in rder t receive reimbursement. Receipts submitted fr reimbursement f OTC drugs must indicate the actual names f the OTC drugs. This receipt displays a line item descriptin indicating which OTC drugs were purchased. THANK YOU FOR VISITING THE CONVIENANT STORE 123 LOCAL STREET ANYWHERE, USA DR: FC: 2.49 TAX:.59 TOTAL: 9.03 CASH: CHANGE:.97 SR /23/04 09:15:05 REGISTER: 6 This receipts displays unidentifiable line items that d nt indicate OTC items purchased. Items frm this receipt wuld nt be reimbursable. If yu have questins, please cntact BenefitElect at (800) (tll free) Submit yur claim frm and all supprting dcumentatin via mail r a dedicated claims fax line, which insures cnfidentiality, t ur Claims Prcessing Center at: FAX #: Claims Prcessing Center P.O. Bx Birmingham, AL 35259

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7 FOR FASTER PROCESSING, FAX this Frm and Receipts t: r Mail Frm and Receipts t: Chappelle Benefits P.O. Bx Birmingham, AL (PLEASE KEEP YOUR ORIGINALS) Questins? us at: custmerservice@chappellebenefits.cm r call us at CLAIM REIMBURSEMENT FORM (Nt fr FSA Debit Card Receipts) FSA CLAIM REIMBURSEMENT REQUEST FORM - Receipts received with this frm will be prcessed fr reimbursement. D nt use this frm fr submitting FSA Debit Card Purchase Receipts - use the frms in yur enrllment/cnfirmatin kit r dwnlad thse frm the web. Emplyee Name Emplyee ID / SSN: Daytime Phne Number Address Emplyer Name Health Care Reimbursement Claim (HCRA-nn-reimbursed medical) - Yu MUST attach a bill, receipt r Explanatin f Benefits (EOB) verifying the date f service r prduct, type f service r prduct, name f persn receiving service and amunt claimed. Date f Service Type Fr Whm (name and relatinship) Amunt 1. $ 2. $ If yu have mre items t list, please use page 2 f this claim frm. Dependent Care Reimbursement Claim (DCRA) - Yu MUST attach a bill r receipt frm yur dependent care prvider verifying the dependent s name, name, address and taxpayer ID number (SSN r TIN) f prvider, perid which services were rendered, descriptin f services and amunt. If the Dependent Care Prvider signs the apprpriate area belw, receipts are nt required. Dependent s Name, Relatinship Date f Service and Date f Birth Prvider s Name and Address Prvider s Tax ID/SSN Amunt 1. $ 2. $ PROVIDER CERTIFICATION: I hereby certify that the abve Dependent Care charges have been incurred. Dependent Care Prvider Signature If yu have mre items t list, please use page 2 f this claim frm. Date Healthcare Reimbursement Arrangement (HRA) - Yu MUST attach a bill, receipt r Explanatin f Benefits (EOB) verifying the date f service r prduct, type f service r prduct, name f persn receiving service and amunt claimed. Date f Service Type Fr Whm (name and relatinship) Amunt 1. $ 2. $ Outside Premium Reimbursement Accunt (OPRA) - Attach a bill r receipt indicating the nn-cmpany premium healthcare payment Date f Service Type Fr Whm (name and relatinship) Amunt 1. $ 2. $ I hereby certify that all items I requested t be reimbursed cmply with the Flexible Spending Accunt Plan and such items have nt and will nt be cvered by any ther plan r prgram f any emplyer r ther persn nr have these items been paid fr by a debit card r stred value card ffered with the Flexible Spending Accunt Plan. I further certify that such items will nt be deducted r taken as tax credits n my persnal federal and state incme tax returns fr any year. The cmpany des nt accept respnsibility fr direct payment t any individuals ther than the emplyee. Participant Signature X Date

8 ** IF YOU DON T HAVE ONLINE ACCESS TO YOUR ACCOUNT, PLEASE PROVIDE YOUR ABOVE AND CHECK THIS BOX [ ] - WE WILL INSTRUCTIONS. ** FOR FASTER PROCESSING, FAX this Frm and Questins? Receipts t: us at: r Mail Frm and Receipts t: custmerservice@chappellebenefits.lh1od.cm Chappelle Benefits r call us at P.O. Bx Birmingham, AL (PLEASE KEEP YOUR ORIGINALS) CLAIM REIMBURSEMENT FORM Page 2 (Nt fr FSA Debit Card Receipts) FSA CLAIM REIMBURSEMENT REQUEST FORM - Receipts received with this frm will be prcessed fr reimbursement. D nt use this frm fr submitting FSA Debit Card Purchase Receipts - use the frms in yur enrllment/cnfirmatin kit r dwnlad thse frm the web. Emplyee Name Emplyee ID / SSN: Daytime Phne Number Address Emplyer Name Health Care Reimbursement Claim (HCRA-nn-reimbursed medical) - Yu MUST attach a bill, receipt r Explanatin f Benefits (EOB) verifying the date f service r prduct, type f service r prduct, name f persn receiving service and amunt claimed. Date f Service Type Fr Whm (name and relatinship) Amunt 3. $ 4. $ 5. $ 6. $ 7. $ 8. $ 9. $ 10. $ Dependent Care Reimbursement Claim (DCRA) - Yu MUST attach a bill r receipt frm yur dependent care prvider verifying the dependent s name, name, address and taxpayer ID number (SSN r TIN) f prvider, perid which services were rendered, descriptin f services and amunt. If the Dependent Care Prvider signs the apprpriate area belw, receipts are nt required. Dependent s Name, Relatinship Date f Service and Date f Birth Prvider s Name and Address Prvider s Tax ID/SSN Amunt 3. $ 4. $ PROVIDER CERTIFICATION: I hereby certify that the abve Dependent Care charges have been incurred. Dependent Care Prvider Signature Date I hereby certify that all items I requested t be reimbursed cmply with the Flexible Spending Accunt Plan and such items have nt and will nt be cvered by any ther plan r prgram f any emplyer r ther persn nr have these items been paid fr by a debit card r stred value card ffered with the Flexible Spending Accunt Plan. I further certify that such items will nt be deducted r taken as tax credits n my persnal federal and state incme tax returns fr any year. The cmpany des nt accept respnsibility fr direct payment t any individuals ther than the emplyee. Participant Signature X Date

9 FOR FASTER PROCESSING, FAX this Frm and Receipts t: r Mail Frm and Receipts t: Chappelle Benefits P.O. Bx Birmingham, AL (PLEASE KEEP YOUR ORIGINALS) Questins? us at: custmerservice@chappellebenefits.cm r call us at mbi MasterCard DEBIT CARD RECEIPT TRANSMITTAL COVER SHEET Yur cmpliance is required t meet IRS required FSA Debit Card receipt review Use this cver sheet if yu are faxing r mailing mbi MasterCard Receipts. This is nt a claim reimbursement frm. Reimbursements will nt be prcessed if this frm is used. Emplyee Name Emplyee ID / SSN - - Daytime Phne Number Address Emplyer Name MBI MasterCard Number Attach cpies f yur receipts with this cver sheet. Acclaris will receive yur FAX and secure the cntent accrding t HIPAA Privacy requirements. Be sure that yu r thers n yur behalf secure yur data at the pint f riginatin. Original receipts will nt be returned. Nte: The custmer is respnsible fr misrepresentatin regarding requests fr reimbursement. If yu have any further questins please cntact custmer service. Date and incurred csts Transactin Date Merchant Name Fr Whm (name and relatinship) Amunt 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ Use additinal sheet(s) if necessary TOTAL AMOUNT OF ATTACHED RECEIPTS $ I certify that I am authrized t use the MasterCard issued and that by signing and using the debit card, I agree t all terms and cnditins. I understand that any transactins initiated by my use f an authrized Card are subject t the terms and cnditins f the Cardhlder Agreement received with the Card. I certify that the qualified healthcare expenditures presented with this transmittal have been received by an eligible individual and are true and accurate. I further certify that these expenses have nt, nr will be, reimbursed thrugh insurance r any ther arrangement. Participant Signature X Date