Flexible Spending Account

Transcription

1 Flexible Spending Account Enrollment Kit Enjoy more benefits and take home more money

2 More Benefits for Less Money. Sound too Good to be True? Congratulations! Your employer is offering you a Flexible Spending Account (FSA) as part of your benefits package. An FSA allows you to set aside pre-tax dollars to pay for eligible out-of-pocket healthcare and dependent care expenses. Start Saving Today with an FSA! With an FSA, you can save 30% or more on eligible healthcare, and/ or qualifying child and adult dependent care expenses. Perhaps you ve heard your friends or co-workers talking about a similar program they use to pay for things like co-pays and deductibles, dental and vision expenses, many over- the-counter medications and healthcare related products, and before-school and after-school day care expenses. Increase Your Take-Home Pay with an FSA Your increased take-home pay and savings depends on your income tax bracket. For example, if you are in the 30% tax bracket, you can save $30 for every $100 that you put into your FSA. So, if you put $1,000 into your FSA, you ll reduce your taxes while increasing your annual take-home pay by $300. Eligible Expenses Visit the IntegraFlex web site at for a comprehensive list of eligible healthcare and dependent care expenses, including many over-the-counter medicines or healthcare related products such as pain relievers and cold remedies (With a Doctor s Prescription). Other OTC Items such as Bandages and Diabetic supplies including insulin are still covered with a prescription. What Would You do with an Extra $1,050? (FSA Savings Example) *This example is intended to demonstrate possible tax savings based on a total income tax rate of 30%. Actual savings are based on individual tax situations 2

3 Important Plan Information FSA Contributions Your entire annual contribution amount is available immediately* at the beginning of the plan year to pay for eligible healthcare expenses. However, your total FSA election amount is deducted from your paycheck in equal amounts during the year. Election Changes You will be given the opportunity to make new elections during the annual enrollment period at the beginning of each plan year. Once you have made your elections and the plan year has commenced, IRS rules allow you to change your election (increase, decrease or stop your pre-tax contribution) during the plan year only if you have a qualified change in status event and the requested change is consistent with the event. The Use-It-Or-Lose-It Rule All of the money in your flexible spending account must be spent by the end of your employer s plan year, since unused funds will not be returned to you or carried over to the following year. * This applies to healthcare expenses only. Dependent care expenses are reimbursed based on the availability of funds in your account. With an FSA Save 30% or More on Eligible Out-of-Pocket Expenses Examples of eligible expenses include Healthcare expenses for you, your spouse or qualifying child or relative Office visit co-pays Prescription drugs and many over-the-counter healthcare products Chiropractic Dental including child and adult orthodontia Acupuncture Vision care including contact lenses and laser eye surgery Employment related dependent care expenses Care for your qualifying child under the age of 13 Care for your spouse or your qualifying child or relative Three Ways to Save Money Healthcare Flexible Spending Account (FSA) Use pre-tax dollars for a variety of qualifying healthcare expenses. Your participation will increase your take-home pay by reducing your taxes when you have qualified out-of pocket healthcare expenses that can be reimbursed through your Flexible Spending Account. Your annual limit for qualified healthcare expenses is determined by your employer. Dependent Care Assistance Plan Use pre-tax dollars for a variety of dependent care expenses, such as child or adult day care. By using pre-tax dollars for dependent care expenses, you will reduce your taxes while increasing your take-home pay. Current tax laws allow you to set aside up to $5,000 annually to pay for employment related child day care or adult dependent care ($2,500 if you are married and file separate returns). Your maximum allocation may not exceed the lesser of your earned income or the earned income of your spouse. At 30% off, your savings could really add up! What Expenses Qualify under a Premium Only Plan?* Medical insurance premiums Dental insurance premiums Vision insurance premiums Group Term Life insurance premiums (up to $50,000 in employee-only coverage) Disability insurance premiums - When disability insurance premiums are deducted on a pre-tax basis, income received from the disability policy becomes taxable income. Other qualified voluntary insurance (as applicable) *Your employer must elect these premiums to be eligible through the plan. What would you do with an extra $1,500? ($5,000 X 30% tax savings = $1,500) Premium Only Plan Pay your share of premiums for your employer-sponsored insurance plans with pre-tax dollars. Keep the same benefits while lowering your taxes and increasing your take-home pay with pre-tax premium contributions. We re Here for You 24 Hours a Day, 7 Days a Week! IntegraFlex s industry-leading, web-based technology provides you with the tools and resources necessary to determine how to maximize your benefits and tax savings by participating in a Flexible Benefits Plan. 3

4 How the Plans Work Flexible Spending Accounts (Healthcare and Dependent Care) Before you enroll, you ll need to decide how much you want to set aside for allowable out-of-pocket healthcare and/or dependent care expenses. Your election amount should conservatively match your estimated expenses for the plan year. Complete the Flexible Benefits Enrollment form provided by your benefits counselor or human resources representative. Each pay period, an equal portion of your annual election amount will be deducted from your gross pay and transferred to your FSA prior to calculating federal and state income* and social security taxes. Again, by participating in an FSA program, you will reduce your taxes while increasing your take-home pay. Premium Only Plan The amount you currently pay toward qualified employer sponsored benefits, such as medical, dental, and vision, will be deducted on a pre-tax basis. Since your taxable income is reduced, you will reduce your taxes while increasing your take-home pay. Go to to Determine how much to place in your healthcare account and dependent care account. An average annual savings can be as much as 30% in income tax savings. Enroll in ACH/Direct Deposit to receive your reimbursement up to five days quicker than traditional paper checks. ACH/Direct Deposit is a quicker, easier and more secure way to receive reimbursements directly to your bank account! Your employer MUST be enrolled in this feature. Check the status of a reimbursement claim within 48 to 72 hours after you ve faxed it to us, including the amount of your reimbursement and when it was issued. View your entire healthcare and dependent care FSA payment history, including all pending, approved and denied claims for the plan year. See a comprehensive list of eligible healthcare and dependent care expenses, including eligible over-the-counter medicines or healthcare related products such as pain relievers, cold remedies and bandages. To participate, complete the enrollment form or other materials provided by your HR representative or benefits counselor. *Pennsylvania does not exempt state withholding for dependent care benefits and New Jersey does not exempt state withholding for employee salary reductions. How Reimbursement Works Simply complete a FlexHRA Claim Reimbursement form and submit it along with all proper expense documentation (purchase receipts, EOBs, etc.) to IntegraFlex. Upon receipt, an IntegraFlex claims processor will review your claim and process it for payment after verifying the eligibility of all expenses and confirming receipt of all proper documentation. Healthcare and dependent care reimbursement claim forms (FlexHRA Claim Form) are available on the IntegraFlex web site at If you do not have web access, please contact an IntegraFlex participant services representative or your human resources department for a claim form. Open an FSA in 3 Easy Steps Determine how much you expect to spend on qualifying out-of-pocket healthcare and/or dependent care expenses during your upcoming plan year. When determining exactly how much you should put into your FSA Plan, be sure to plan carefully, because IRS regulations require that all unused FSA dollars are returned to your employer at the end of the plan year and cannot be carried forward. Enroll online (if available through your employer) or complete and submit a Flexible Benefits Enrollment form with your healthcare and/or dependent care elections during your employer s open enrollment period. 4

5 Healthcare Flexible Spending Account Participation Guidelines A Healthcare Flexible Spending Account (FSA) is a reimbursement account offered by your employer as part of your benefits package. Participating in the FSA plan saves you money by allowing you to use pre-tax dollars to pay for qualifying expenses not covered by insurance. Participation is voluntary, and you must satisfy any healthcare FSA eligibility requirements established by your employer in order to participate. Only eligible expenses can be reimbursed under the plan. Eligible expenses are defined by Internal Revenue Code 213(d) and your employer s plan. Expenses must be incurred by you, your spouse, or your eligible dependents during the current plan year and while you are an active participant in the plan. Medical expenses are incurred when you (or your spouse or dependents) are provided with the medical care that gives rise to the medical expenses, and not when you are formally billed, charged for, or pay for the medical care. Only out-of-pocket expenses are eligible for reimbursement. Expenses previously reimbursed by your healthcare FSA or covered by any other plan or program are not eligible for reimbursement. Generally, eligible expenses include items that are meant to diagnose, cure, mitigate, treat or prevent illness or disease. Expenses such as cosmetic surgery, insurance premiums, vitamins or items for your general well-being are not eligible for reimbursement. A comprehensive list ( FSA Quick Reference Guide-Eligible Expenses)of eligible expenses, including many over-the-counter items, is available online at: Expenses reimbursed under the healthcare FSA may not be used to claim any federal income tax deduction or credit. Minimum (if any) and maximum election amounts are determined by your employer. Your election is irrevocable during the plan year, unless you experience a qualifying change in status event. Rules regarding status changes and other qualifying events are defined by IRS regulations. Not all plans recognize all of the permissible changes. For more information regarding eligible status change events under your plan, please review your Summary Plan Description. Your contributions are subject to the use-it-or-lose-it rule. Any unused contributions are forfeited to the plan at the end of the plan year. All requests for reimbursement are subject to review and approval based on IRS guidelines. If your request is denied, you will receive an explanation from IntegraFlex including the reason for the denial and instructions for appealing your request. If you elect to participate in the plan, your employer will provide a Summary Plan Description outlining the complete rules and regulations of your plan. The expense must be eligible under the Internal Revenue Code and your employer s plan. Expenses must be incurred by you, your spouse or your eligible dependent on the date(s) indicated on claim form. All requests for reimbursement are subject to review and approval based on IRS guidelines. All such requests must satisfy all applicable guidelines as established by the IRS and any other applicable legislative or judicial bodies and the rules established by the sponsoring employer as defined within the plan s Summary Plan Description. This document provides basic information regarding participation in your employer s FSA plan. This document does not contain all of the rules Healthcare FSA Participation Process Enroll in Employer Sponsored FSA Plan Incur an Eligible Expense Pay for Expense Save your Receipt or Explantion of Benefits from Insurance Carrier Submit Claim Form and Copy of Receipt to IntegraFlex IntegraFlex reviews claim per IRS Guidelines Receive Reimbursement Your annual healthcare FSA election amount is available to you at any time during the plan year.

6 Dependent Care Flexible Spending Account Participation Guidelines A dependent care Flexible Spending Account (FSA) is a reimbursement account offered by your employer as part of your benefits package. Participating in the FSA plan saves you money by allowing you to use pre-tax dollars to pay for qualifying expenses such as day care or before and/or after school care. Participation is voluntary, and you must satisfy any dependent care FSA eligibility requirements established by your employer in order to participate. Only eligible expenses can be reimbursed under the plan. Dependent care expenses must be incurred to enable you (and your spouse, if married) to work, look for work or attend school full time for at least 5 calendar months during the tax year. Work may include actively looking for work, but does not include unpaid volunteer work. Expenses must be incurred during the plan year. Any incurred expenses must be for the care of a qualified individual. A qualified individual is a child age 12 and under or a spouse or other tax dependent who is physically or mentally incapable of self-care. The individual must also reside in the same household for more than half of the year. Per IRS regulations, a child is a qualified dependent of the custodial parent. Therefore, only the custodial parent may participate in a dependent care FSA. Expenses reimbursed under the dependent care FSA may not be used to claim any federal income tax deduction or credit. Expenses related to before and after school care or nursery school are eligible expenses, if the care is primarily custodial in nature. Your election is irrevocable during the plan year unless you experience a qualifying change in status event or the cost of care increases or decreases significantly. Rules regarding status changes and other qualifying events are defined by IRS regulations. Not all plans recognize all of the permissible changes. For more information regarding eligible status change events under your plan, please review your Summary Plan Description. Your contributions are subject to the use-it-or-lose-it rule. Any unused contributions are forfeited to the plan at the end of the plan year. Dependent care FSA reimbursements are issued as contributions (payroll deductions) are posted to your account. If you elect to participate in the plan, your employer will provide a Summary Plan Description outlining the complete rules and regulations of your plan. The expense must be eligible under the Internal Revenue Code and your employer s plan. Expenses must be incurred by you, your spouse or your eligible dependent on the date(s) indicated on claim form. All requests for reimbursement are subject to review and approval based on IRS guidelines. All such requests must satisfy all applicable guidelines as established by the IRS and any other applicable legislative or judicial bodies and the rules established by the sponsoring employer as defined within the plan s Summary Plan Description. This document provides basic information regarding participation in your employer s FSA plan. This document does not contain all of the rules Dependent Care Participation Process 1 2 Enroll in Employer Sponsored FSA Plan Incur an Eligible Expense Fees associated with kindergarten as well as tuition for school programs are not eligible for reimbursement. All requests for reimbursement are subject to review and approval based on IRS guidelines. If your request is denied, you will receive an explanation from IntegraFlex including the reason for the denial and instructions for appealing your request. The minimum election amount (if any) is determined by your employer. The pre-defined maximum election amount is $5,000 per IRS regulations ($2,500 if married and filing separately). The amount of reimbursement that you receive on a tax-free basis during the plan year cannot exceed the lesser of your earned income or your spouse s earned income Pay for Expense Save your Receipt or Statement from Day Care Provider Submit Claim Form and Copy of Receipt to IntegraFlex IntegraFlex reviews claim per IRS Guidelines Receive Reimbursement

7 Spending Your FSA Dollars On Eligible Healthcare Expenses Spending your FSA dollars on eligible healthcare expenses just got easier. The IntegraFlex FSA Benefits Card provides instant access to the money in your healthcare FSA by automatically deducting funds from the available balance in your account when you make a qualified purchase. Key Benefits of using the IntegraFlex FSA Benefits Card Easy to use. The IntegraFlex FSA Benefits Card is a stored value card that simplifies the process of paying for your qualified medical expenses. Works at most healthcare related merchants where MasterCard is accepted. You spend only the pre-tax dollars in your healthcare FSA. No waiting for reimbursement. Common Purchases and Uses for the Card Prescriptions In rare circumstances, purchases made at merchants utilizing an IIAS may fail to process appropriately. In those cases, you will be required to submit receipts or other substantiating documentation as described below. A list of merchants utilizing an IRS-approved IIAS is available online at underpublications IIAS Merchants List. Save All Receipts for Purchases Made with the Benefit Card Please remember to keep all receipts for all purchases made with the Benefit Card. Per IRS regulations, IntegraFlex may be required to request itemized receipts to verify the eligibility of purchases made with the card. All receipts or other proofs of purchase must include the dollar amount, date of service, name of provider, and a description of the purchased service or product. For over-the-counter healthcare items, the name of the product must be listed on the receipt Any receipt that does not contain the detailed information described above is not acceptable. Credit card receipts and cancelled checks are not acceptable. If the requested receipt is lost or otherwise unavailable, most providers can provide a detailed statement documenting FSA eligible purchases. Eligible over-the-counter healthcare products Office visits to a physician or dentist Vision service providers Hospital charges Using Your Benefit Card The IntegraFlex FSA Benefits Card may only be used at merchants who have a healthcare related merchant category code (such as physicians, stand-alone pharmacies, dentists, vision care offices, hospitals, and other medical care providers) or who utilize an Inventory Information Approval System (IIAS). When utilizing an IIAS, a merchant allows the Benefits Card to be used to purchase only those items identified on a list of eligible medical expenses maintained by the merchant. When purchasing eligible, healthcare related items AND ineligible, non-healthcare related items, the merchant will only accept the Benefits Card as payment for the healthcare related items. You must pay for the ineligible items with another form of payment (cash, personal credit or debit card, etc). You may not use the Benefits Card at any merchant that does not have a healthcare related merchant category code unless that merchant utilizes an Inventory Information Approval System. NOTE: Many pharmacies in retail and discount stores will not qualify as merchants with a healthcare related merchant category code. It s So Easy Using Your FSA Benefits Card The IntegraFlexFSA Benefits Card makes it easy to participate in your Employer s Healthcare FSA

8 You Will Not Be Required to Submit a Receipt When The expense matches a specific co-payment you have under your employer s medical, pharmacy, vision, or dental plans. For example, you may not be required to submit a receipt if you have a $10.00 co-pay for physician office visits, and the payment was made to a physician office in the amount of $ Recurring expenses will not result in a request for documentation as long as the expense equals the same amount, duration and provider as a previously approved expense. Recurring transactions will be processed and approved without documentation only after substantiating receipts or other documentation is provided and the initial transaction is reviewed and approved. You purchase your FSA-eligible items at a merchant utilizing an IRS-approved Inventory Information Approval System (IIAS). In limited scenarios, your claim information may be provided through an electronic file from your insurance carrier or other provider. In these scenarios, expense substantiation may not be required if the electronic claim file is accompanied by an electronic or written confirmation from the healthcare provider (e.g., your prescription benefits manager) that identifies the nature of your expense and verifies the amount. Note: You MUST still obtain and retain the third-party receipt when you incur the expense and swipe the card, even if you believe it will not be needed. All receipts should be retained for at least one year following the close of the plan year in which the expense is incurred. Three-Step Card Audit/Verification Process Should you receive written notice from IntegraFlex requesting appropriate documentation (as described above) to verify a Benefit Card purchase, you will have 30 days to respond. If you do not respond within this time frame, you will receive an additional notice. If you do not respond to either notice within the required time, your Benefit Card will be deactivated until the card purchase is verified. 1. You will receive an initial detailed notification when documentation is required to verify a purchase. 2. If we do not hear from you within 30 days from the date of the initial notice, you will receive a final notice to submit receipts within 15 days to verify your purchases and prevent your card from being deactivated. 3. If the documentation you submit is incomplete or the expense is ineligible, you will receive a notice allowing you 15 days to submit appropriate receipts or to repay the money (if your purchase is ineligible) and prevent your card from being deactivated. In an effort to deliver a Benefit Card audit notice to you as quickly as possible, we will send all notices via ; if we have your current address. If we do not have your current address, please go to the IntegraFlex Web site at and login under the employee/participants section to submit or update this information. Co-Pay Helpful Hints You may swipe your card for an amount up to five times (5x) the maximum co-payment amount to include: Single co-payment for a specific benefit If the transaction equals a multiple of a specific co-payment that is applicable to you under your employer s plan, then no additional substantiation is required; however, the transaction will fall outside of this auto adjudication (verification) category if the transaction amount exceeds five (5) times the applicable co-payment amount. Different co-payment for a specific benefit If the transaction equals a multiple of a co-payment for a particular benefit or a combination of the co-payments for a particular benefit, then no additional substantiation is required; however, this transaction will fall outside of the auto-adjudication (verification) category if the transaction amount exceeds five (5) times the maximum copayment for a particular benefit.

9 Instructions You MUST complete the Employee Information on the Salary Redirection Form to be able to participate in your Employer Sponsored FSA Benefit Plan. 2 Complete Claim Information in its entirety when submitting a claim(s). Please ensure your supporting documentation clearly indicates the requested amount. FlexHRA Claim Forms can be found on the IntegraFlex Web site at under Employee Links or the in the Employee tab under Employee forms. 3 Check the appropriate box in the Supporting Documentation section and attach Acceptable Supporting Documentation as described below. (When attaching small receipts, we suggest you photo copy them to a standard size sheet of paper prior to faxing.) A) Itemized statement or bill from your provider including - Provider name - Patient name - Description of service - Original date of service (the date of service, NOT the date of payment. The service MUST fall within the plan year for which you are enrolled and while you are a participant in the plan) - Patient portion of charge(s) B) Explanation of Benefits (EOB) from your insurance carrier C) Pharmacy statement including - Patient name - Prescribing physician - RX number - Name of the drug - Date the RX was filled - Co-payment amount *Unacceptable Documentation includes the following - Cancelled checks - Credit / cash receipts (An itemized cash register receipt is acceptable ONLY for eligible over-the-counter expenses) - Balance forward statements are NOT acceptable. 4 Sign and date Employee Certification at the bottom of the FlexHRA Claim Form. 5 Submit Claims to IntegraFlex By Fax By Claims@integra-flex.com By Mail 225 N 9 th Street. Suite 530 Boise, Idaho 83702

10 Personal Planning Worksheets Use this worksheet to estimate expenses for you, your spouse, and eligible dependents. If you participate in your employer s insurance plan(s), premiums will automatically be deducted pre-tax, unless you notify your Human Resource Department to do differently. This is not an enrollment form. Health Related Expenses Doctor office visits co-pays Deductibles Routine physical Lab fees Learning disabilities care Over-the-counter drugs (with prescription) Prescription expenses (co-pays) Prosthesis Wheelchairs Holistic healing services (medically necessary, not including holistic remedies or supplements) $ Health Plan Year Total X-Rays Dental co-pays Dental deductibles Non-cosmetic dental services Orthodontia Dental surgery Dental x-rays Contact lens & supplies Laser eye surgery Eye glasses Vision x-rays Health-Related Expenses That Require a Letter of Medical Necessity or Prescription Include OTC Medicines or Non-Prescription Vitamins Supplements from a Chiropractor, Acupuncturist, Holistic Healer Rogaine or Hair Transplant Retin-A Electrolysis Breast Pumps Health Club Memberships Massage Therapy Whirlpools Vision exams Medical miles (paid according to IRS annual limits.) Alcoholism treatment Ambulance Care for handicapped Diabetic supplies/insulin Acupuncture Drug addiction treatment Ineligible Health-Related Expenses Include Feminine Hygiene Products Dental Bleaching or Bonding Illegal Operations or Treatments Diaper Service Meals that are not for Inpatient Care Marital or Family Counseling Services by a Holistic Healer who isn t Licensed to Practice Medicine Guide animal care Eligible Hospital Charges (not covered by insurance)

11 Dependent Care Expenses Day-care centers Elder care Family child care Day camps Preschool After-school care Nanny/au pair $ Dependent Plan Year Total Premiums Paid Outside of Your Employer s Group Plan Note Not all employers offer this service. Only IRS Section 213(d) policies qualify. Please see. Accident Insurance Cancer Insurance COBRA Premiums* Dental Insurance Disability Insurance** Hospital Insurance Major Medical Insurance Medicare Ineligible Dependent Expenses Include Meals Overnight Camps Diapers Educational Expenses (including kindergarten) Incidental Fees (such as activity fees, field trips) Vision Insurance $ Plan Year Total 0*Not Available: Life Insurance and Long Term Care. **Disability Insurance becomes taxable in the event of a claim if premiums are placed pre-tax. Important You must list your dependent care provider s tax ID number on Form 2441 for your taxes each year. ($5,000 maximum for married and head of household filers or $2,500 if married filing separately. Please refer to the Summary Plan Description if your spouse is a student or disabled. Also, you and your spouse (if applicable) must be gainfully employed to participate.

12 Dependent Care Reimbursement Worksheet Use this worksheet to compare your estimated savings with the Dependent Care Tax Credit versus a Dependent Care Flexible Spending Account (FSA). You re not allowed to take the maximum amount for childcare expenses on both your flex and taxes. Amounts reimbursed through your Dependent Care FSA will reduce the amount of eligible expenses you can use to figure the tax credit on a dollar-for-dollar basis. However, you re allowed to take some deductions on flex and some on the tax credit. This tactic can be advantageous to those who max out the flex and still want the additional $1,000 that the tax credit allows. Please review the charts to see what we mean. Step 1 Estimate Your 2011 Dependent Tax Credit You may take a federal tax credit for eligible dependent care expenses up to $3,000 for one dependent, or $6,000 for two or more dependents. The amount of the credit depends on your income level. Use the following table to estimate the maximum combined tax credits you may be entitled to take on your federal tax return. For a more accurate estimate, you should contact your tax advisor and review the IRS publication 503 at Dependent Tax Credit Table If Your Federal Adjusted Gross Income is Over But Not Over Your Maximum Combined Federal Tax Credits are Estimated To Be One Dependent Two or More Dependents $0 15,000 $1.050 $2,100 15,000 17,000 1,020 2,040 17,000 19, ,980 19,000 21, ,920 21,000 23, ,860 23,000 25, ,800 25,000 27, ,740 27,000 29, ,680 29,000 31, ,620 31,000 33, ,506 33,000 35, ,500 35,000 37, ,440 37,000 39, ,380 39,000 41, ,320 41,000 43, ,260 43,000 No limit 600 1,200 Table has been obtained from IRS Publication 503, Form 2441 The table reflects 2009 tax credits. For the latest changes go to: Examples of Eligible Dependent Care Expenses Eligible dependent care expenses must be for the care of your child under the age of 13, or your spouse or other dependent(s) who are physically and/or mentally incapable of self-care. Examples of Ineligible Dependent Care Expenses Meals, Activity Fees, Late Payment Fees, Activity Fees & Supplies, Beepers, Pagers, Field Trips & Entertainment, Overnight Camps, Kindergarten, Summer School. Eligible reimbursable expenses are those dependent care expenses incurred only during the time you (and your spouse, if applicable) are working, looking for employment, or attending school full-time. IRS regulations govern the eligibility of expenses. For additional information on eligible expenses, see IRS Publication 503, available from your local IRS office.

13 Table A Federal Taxes Filing Status & Taxable Income 2010 Married-Joint Head of Household Married-Separate Single Step 2 Estimate Your 2011 Tax Savings with a Dependent Care FSA Marginal Tax Rate $ 0 $16,750 $0 - $11,950 $0 8,375 $0 8, $16,750 $68,000 $11,950 - $45,550 $8,375 - $34,000 $8,375 - $34, $68,000 - $137,300 $45,550 - $117,650 $34,000 - $68,650 $34,000 - $82, $137,300 - $209,250 $117,650 - $190,550 $68,650 - $104,625 $82,400 - $171, $209,250 - $ 373,650 $190,550 - $ 373,650 $104,625 - $186,825 $171,850 - $373, $373,650 and above $373,650 and above $186, 825 and above $373,650 and above.35 A Enter your annual adjusted gross family income $ $ 30,000 B Enter your deductions (either total itemized deductions or standard deduction)* $ $ -10,900 C Enter your personal exemtions (multiply the number of exemptions claimed by $3,400 $ $ -6,800 D Subtract line B and line C from line A to calculate your total taxable income $ $ 12,500 E Enter your marginal federal income tax rate from Table A** $ $.15 F Enter your dependent care expenses [cannot exceed the lesser of $5,000 $ $ 5,000 ($2,500 if married filing separately) or the earned income of the lower earning spouse] G Multiply line E times line F to determine your income tax savings $ $ 450 H Multiply line F times.0765 to determine your estimated $ $ 383 Social Security/Medicare tax savings*** I Total Estimated Savings with a Dependent Care FSA (Add line G and line H) $ $ 1,133 * Current standard deductions are: Married filing jointly and surving spouses= $10,900; Head of household= $8,000; married filing separately= $5,450; Single= $5,450 ** Use the next lower marginal rate if your taxable income is close to the lower end of an income range. *** Social Security savings are on the first $97,500 of income. Medicare savings = 1.45% on all amounts. Compare the Tax Credit Estimated in Step 1 with the Tax Savings Estimated in Step 2 Compare the estimated tax credit with the estimated tax savings using the Dependent Care Flexible Spending Account. The tax credits are designed to become less valuable as your income increases. Tax savings with a Dependent Day Care FSA become more valuable as your income increases. Generally, if your income tax bracket is 15% or less it would be more advantageous for you to take the tax credit rather than participating in the Dependent Care Account. However, since each person s tax situation is unique, you should talk with a tax advisor before making your final decision. Some additional points to consider: You will save state taxes in addition to federal taxes when you participate in a Dependent Care FSA. To the extent you reduce your Social Security taxes; you may also reduce your Social Security benefits. In general, families with adjusted gross income under $35,241 are eligible for the Earned Income Credit. Participating in a Dependent Care FSA will decrease your gross income and increase your credit.

14 Employee FSA/HRA Claim Form EMPLOYEE INFORMATION Employer Date Employee Name SSN Phone Number Home Address Check if New Address FLEXIBLE SPENDING ACCOUNT/HEALTH REIMBURSEMENT ARRANGEMENT CLAIM ATTACHMENTS Failure to follow these guidelines will result in reimbursement delay or possible denial. FSA REQUIREMENTS: *An Itemized Statement from the provider MUST be submitted showing: Provider s Name/Address Patient s Name Actual Date of Service when the Service was Provided Description of Service & the Amount Charged * An Explanation of Benefit (EOB) from your Medical Insurance Carrier *NOTE: The Left Two (2) Forms of Documentation ARE the ONLY Forms of Documentation that ARE Acceptable under IRS Guidelines. - Balance forward or paid on account statements CANNOT be accepted. - Credit card receipts, cancelled checks, or cash register receipts CANNOT be accepted for services. - Itemized cash register receipts are Only acceptable for over-thecounter medications. HRA REQUIREMENTS: A Copy of the Explanation of Benefits (EOB) from your Medical Insurance Carrier MUST be submitted. Recurring Expense -Estimates for services that have not yet been incurred CANNOT be accepted. NOT Paid w/ Flex Debit Card (please check method of payment) Paid w/ Flex Debit Card Service Date Name of Provider (e.g. Physician, Dentist Type of Service (e.g. Copay, Rx, Ortho, Patient Name Expense Amount Hospital, Pharmacy, Insurance Carrier, etc) Insurance Premium, etc.) Total amount requested from your FSA/Cafeteria Plan $ (Manual Amounts Only Paid for service other than with your FSA Debit Card) AND/OR HRA $ (Be Sure to Submit Your Explanation of Benefit) I certify that I have actually incurred these eligible expenses. I understand that expense incurred means the service has been provided that gave rise to the expense, regardless of when I am billed or charged for, or pay for the service. The expenses have not been reimbursed or are not reimbursable from any other source. I understand that any amounts reimbursed may not be claimed on my or my spouse s income tax returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions. Employee s Signature Date 225 N. 9 th Street, Suite 530 Boise, Idaho t f integra-flex.com

15 Employee Claims Instructions RECURRING CLAIMS INSTRUCTIONS We believe in simplicity. That s why we d like to make filing your Flexible Spending Account (FSA) claims as easy as possible with our recurring claims options. A recurring claim allows you the freedom to submit your claim only once, but continue receiving reimbursements throughout the plan year. You may set up your Dependent Care, Individual Health Premium, Parking, and Orthodontic claims on a recurring status. SETUP To get your claim set up as a recurring status, select the option that reads on the FSA/HRA Claim Form Please Check One if your claim is a recurring claim and attach a copy of your contract. Below is the information required for each type of recurring claim. INDIVIDUAL HEALTH PREMIUM: Submit a completed FSA/HRA Claim Form and a Copy of the Schedule/Declaration Page from your insurance company. Claim forms can be found on our website at under the Employee tab (across top of page) under the drop down menu under Employee forms and click on FSA/HRA Claim Form. Your Schedule/Declaration Page should show that your insurance is billed to your home address, include the valid dates of coverage, and dollar amount paid. You ll need to submit a new Schedule/Declaration Page each plan year. Individual Health Premium claims can only be paid with funds that are currently available in your FSA at the time of the claim. The balance of the claim will continue to release as you contribute more funds to your account. PARKING: Submit a completed FSA/HRA Claim Form. Because you can t typically provide documentation or a contract for parking services, your signed claim form is sufficient. By signing the claim form, you are verifying that the information is accurate should you be audited by the IRS. ORTHODONTIC: Submit a completed FSA/HRA Claim Form and a Copy of your Orthodontic Contract. The contract needs to show the charges, description of services, dates of service (can be a date range), and name of the patient. You ll need to submit a new contract each plan year. Your claim form and contract can be sent to us via , fax, or mail. Our contact information is provided below. Once we receive your claim form and contract, we ll automatically generate a payment each pay period without any more effort on your part. For fastest payment, we recommend signing up for direct-deposit should your employer offer this option. Signing up is easy. Visit under the Employee Tab (across top of page) under the drop-down menu under Employee Forms and click on the Direct Deposit Form. ALL OTHER CLAIM SUBMISSION INSTRUCTIONS Please refer to the FSA/HRA Claim Form under the Claim Attachments section that lists Both the FSA & HRA Documentation Requirements that are Acceptable under the IRS Guidelines. Please follow these guidelines in order not to delay or possibly deny your claim submissions. Please be clear with your claim submissions- -Make sure that your Itemized Statement or Explanation of Benefit (EOB) shows the Amounts Applied/Billed are the same that you list on your FSA/HRA Claim Form. Meaning your Itemized Statement or EOB should match what you list on your FSA/HRA Claim Form. Varying amounts applied/ billed ONLY slows down your claim reimbursement/submission. -You can ONLY submit claims that have been INCURRED within your Current Plan Year. Claims incurred outside of your Plan Year ARE NOT eligible for reimbursement. -Be sure to Check the appropriate boxes letting us know if your used your Flex FSA Debit Card to cover your expense or if you Paid Manually. If you Paid Manually; please be sure to list the amount you are requesting on your FSA/HRA Claim Form. 225 N. 9 th Street, Suite 530 Boise, Idaho t f integra-flex.com

16 Employee DCA Claim Form EMPLOYEE INFORMATION Employer Date Employee Name SSN Phone Number Home Address Check if New Address DEPENDENT CARE ACCOUNT CLAIM ATTACHMENTS Failure to follow these guidelines will result in reimbursement delay or possible denial. DCA REQUIREMENTS: An Itemized Statement from the provider MUST be submitted showing: Provider s Name/Address Dependent s Name Actual Date of Service when the Service was Provided The Amount Charged Daycare Provider s SSN or EIN Number Recurring Expense NOT Paid w/ Flex Debit Card DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (Please check one) Paid with Flex Debit Card Dates of Service Name of Daycare Provider From To Dependent s Name Expense Amount $ $ $ $ Daycare Provider s SSN or EIN Number Total amount requested from your DCA/Cafeteria Plan $ (Manual Amounts Only Paid for service other than with your FSA Debit Card) I certify that I have actually incurred these eligible expenses. I understand that expense incurred means the service has been provided that gave rise to the expense, regardless of when I am billed, or charged for or pay for the service. The expenses have not been reimbursed or are not reimbursable from any other source. I understand that any amounts reimbursed may not be claimed on my or my spouse s income tax returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions. Employee s Signature Date Claim Instructions-Dependent Care: Submit a completed DCA Claim Form and an IntegraFlex Dependent Care Contract. Both of these forms can be found on our website at under the Employee Tab (across top of page) under the drop-down menu under Employee Forms and click on Dependent Claim Form. You ll need to submit a new contract each plan year. Dependent Care claims can only be paid with funds that are currently available in your DCA at the time of the claim. The balance of the claim will continue to release as you contribute more funds to your account. 225 N. 9 th Street, Suite 530 Boise, Idaho t f integra-flex.com

17 Employee Enrollment Form EMPLOYEE INFORMATION Employer Name Employee Name Effective Date SSN HRA Yes No Sex M F Home Address City State ZIP Home Phone Number Work Phone Number ext. Hire Date D.O.B. REDIRECTION INFORMATION (Your is solely used for correspondence related to your benefits. It is kept confidential & not sold to any lists, etc.) By signing the salary redirection form or waiver I am signifying my understanding and acceptance of the responsibilities and requirements associated with a Section 125 Cafeteria Plan. I further understand that, though I have completed separate enrollment forms for the insurance policies to which I have applied, this form does not constitute acceptance by the companies to which I have applied. I understand and agree that an amount equal to what I have calculated will be deducted from each of my qualified pay periods from now through the end of the plan year. This amount shall continue for each pay period unless this agreement is amended or terminated. I understand the actual amount of my take home pay may increase or decrease depending upon the coverage or elections I have made. Any previous agreements under any other Flexible Benefits Plan are hereby revoked. Note: Please specify your elections in an Annual amount. Premium Deduction* $ HRA (Employer Contribution) Amount $ Medical FSA Amount $ Dependent Care FSA Amount $ *(Separate Individual Insurance Coverage) Commuter Reimbursement FSA Amount $ PLEASE READ AND INITIAL THE FOLLOWING STATEMENT I understand that on or after the first day of the plan year, I cannot change or revoke this salary redirection agreement unless I have had a qualified event under IRS rule. (May include marriage, birth, adoption, divorce or death) I understand and agree to submit only those charges eligible for reimbursement under Section 213D of the IRS code. I also agree to repay the plan for any charge submitted but not approved or eligible. Initial Names and Social Security Numbers for ANY Legal Dependents for which I may potentially apply for qualified pre-tax reimbursement (Required Information under IRS Rule) DEPENDENTS Name SSN D.O.B. Sex Relationship List Any Disabled Dependents Employee Signature Waiver- I certify that the features and benefits under a 125 Flexible Benefits Plan have been explained to me. I elect to waive all pre-tax benefits under the plan and understand that I may be prohibited from participation in this plan until the open enrollment period for the following year or in the event that I have a qualifying event as defined by the IRS. Date Employee Signature Date 225 N. 9 th Street, Suite 530 Boise, Idaho t f integra-flex.com

18 Employee Automatic Deposits Authorization Agreement I hereby authorize IntegraFlex to initiate credit entries to my account as indicated below and the depository named below, hereinafter called DEPOSITORY, to credit the same to such account. I further authorize IntegraFlex to reverse any credit entry that Integraflex makes to my account to the extent that IntegraFlex reasonably believes such entry was made in error. ACCOUNT INFORMATION Type of Account Checking Savings Depository Name Branch City State Zip Code Bank Branch Phone Number (including area code) Routing/ABA No. (see sample check below to locate number) Account Number (see sample check below to locate number) This authority is to remain in full force and effect until IntegraFlex has received written notification from me of its termination in such time and in such manner as to afford IntegraFlex and DEPOSITORY a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer-sponsored Flexible Benefits and/or Health Reimbursement plan. Employer Name Employee Last Name Employee Social Security Number Employee First Name Date Signature Date 7 78 PAY TO THE ORDER OF Date $ DOLLARS ANYTOWN BANK Anytown, MD 2000 For Date Processed Rounting Number Account Number Tape a voided check here for checking accounts, or tape a savings deposit slip here for savings accounts. Processed By (initials) 225 N. 9 th Street, Suite 530 Boise, Idaho t f integra-flex.com