Your Guide to WorkSmart Health Care and Dependent Care Flexible Spending Accounts

Transcription

1 Your Guide to WorkSmart Health Care and Dependent Care Flexible Spending Accounts 9957 Crosspoint Boulevard Indianapolis, Indiana Phone: Fax: Toll-Free: Revised Inside: All you need to know about how your Health Care and Dependent Care Flexible Spending Accounts work. All you need to know about using your Benefits MasterCard.

2 TABLE OF CONTENTS Frequently Asked Questions (FAQs)... 1 The Basics of the Benefits MasterCard... 2 The Flexible Spending Account Website... 2 HEALTH CARE FLEXIBLE SPENDING The Benefits MasterCard... 3 Health Care Flexible Spending Account... 4 Proof of Expense... 4 Whose Health Care Expenses are Eligible?... 4 Eligible Health Care Expenses... 5 Health Care Flexible Spending Account Rules... 8 DEPENDENT CARE FLEXIBLE SPENDING The Benefits MasterCard... 9 Dependent Care Flexible Spending Account Proof of Expense What Dependent Care Expenses are Eligible? Eligible Dependent Care Expenses Dependent Care Flexible Spending Account Rules FLEXIBLE SPENDING FORMS Flexible Spending Reimbursement Claim Form Flexible Spending Direct Deposit Authorization Form About this Guide: Welcome to the WorkSmart Systems Flexible Spending Account! This guide contains information about how to use the Health Care and Dependent Care Flexible Spending Accounts. Please read it carefully and completely. If you have any questions, contact the WorkSmart Flex Department at or We will be happy to assist you and answer any questions you may have about your Flexible Spending Account.

3 Flexible Spending FAQs Q. What is a Flexible Spending Account (FSA) and why would I want to participate? A. An FSA is a plan that allows you to pay for qualified, unreimbursed health care (deductible, coinsurance, copays, dental, vision, prescription and certain over-the-counter items) or dependent care expenses with pre-tax dollars. It allows you to lower your taxable income; therefore you pay less in taxes and increase your take-home pay. There is a use it or lose it rule that applies. Q. How does the FSA work? A. There are two separate accounts: Health Care and Dependent Care. You can choose to have money payroll deducted and set aside in either or both accounts throughout the year. For 2013, estimate what you anticipate your eligible expenses will be from January 1-December 31, Base your 2013 election on your estimate. Your election will be pre-tax payroll deducted in equal installments, based on your pay frequency. Q. What is the use-it-or-lose-it rule? A. Any funds that are not used by the Plan Year deadline are lost. There is also a deadline for submitting receipts. Q. What are the deadlines for the FSA Plan Year? A. Health Care Flexible Spending: You have until March 15 of the following year to incur expenses to use up the current Plan Year s funds. Receipts must be submitted to WorkSmart Systems by April 15. For expenses incurred after December 31, 2013, you will need to pay with your personal funds and submit receipts for reimbursement. Your Benefits MasterCard accesses the current year s funds, January 1-December 31. Dependent Care Flexible Spending: Expenses must be incurred by December 31 of the Plan Year. You have until April 15 of the following year to submit receipts for reimbursement. Q. What are the minimum and maximum FSA contributions for 2013? A. Health Care Flexible Spending Account: minimum of $100/year; maximum of $2,500/year Limited Flexible Spending Account: minimum of $100/year; maximum of $2,500/year Dependent Care Flexible Spending Account: minimum of $100/year; maximum of $5,000/year Q. What if I want to change or drop my deduction during the year? A. The amount you elect to contribute stays in effect until the end of the calendar year. If you experience a qualifying event, you may be allowed to change your contribution. Contact Jennifer at WorkSmart ( or ) to see if you qualify. Q. How do I know how much money I have left in my FSA? A. You can view your account online at As a first-time user, select Participant Login. On the Participant Portal page, select Create Account and complete the form as directed. The Employee ID field will be your WorkSmart Employee ID, no dashes. You will use your Benefits MasterCard number (no spaces), not the Employer ID number. Once you have completed all required fields, including user ID and password, select Submit. You will then be redirected to the login page. Once you are logged in, you will be able to check your account balance, view your claim status, etc. Q. Do I have to submit receipts for my FSA purchases? A. The FSA is a qualified part of the Section 125 plan, which is governed by the IRS. In order for WorkSmart Systems to maintain its qualified status, we must follow the IRS regulations which require WorkSmart Systems to prove the pre-tax dollars are being applied toward qualified expenses. Your submission of a receipt or explanation of benefits supports that substantiation. See the above FAQ regarding the deadlines for submitting your claims. Q. Are there certain retailers where I can use my Benefits MasterCard and not have to submit a receipt to WorkSmart for substantiation to purchase prescriptions and eligible over-the-counter products? A.. If you use the following vendors, you will not have to submit a receipt to WorkSmart: CVS, Sam s Club, Jewel, Meijer, Osco, Target, Wal-Mart, Cub Foods, Kroger, Payless, and Walgreens. If you use your Benefits MasterCard at any other retailer, you will need to submit a receipt to WorkSmart Systems to substantiate the expense. Q. What is a Limited Flexible Spending Account? A. A Limited Flexible Spending Account is an option for those who are enrolled in the High Deductible Health Plan/Health Savings Account. It allows the participant to set aside pre-tax money to use for unreimbursed dental and vision expenses. Medical and prescription expenses are not allowed in a Limited FSA. The use it or lose it rule applies to a Limited Health Care Flexible Spending Account as well. Additional FAQ s are answered on the Flexible Spending Account website. PAGE 1

4 The Basics of the Benefits MasterCard The WorkSmart Flexible Spending Accounts are paired with a Benefits MasterCard, offering convenient access to your available funds. Your Benefits MasterCard is a prepaid MasterCard that can be used at most merchants who sell health care products or services and accept MasterCard. Some important things to remember are: Debit or Credit? Even though your card is a debit card, you do not have a Personal Identification Number (PIN) with this card; therefore, all Benefits MasterCard transactions need to be processed as a credit card transaction. Use your card only for eligible expenses. Look inside this guide for a sample list of eligible expenses. If you are paying for health care expenses, use the card only in places where health care products and services are sold. Do not use your card to pay for past or future services. The IRS prohibits you from using this card to pay for services you received before your current coverage period, or for those you plan to receive in the future. Also, your card will access funds for the current Plan Year. Each time you use your card, you authorize that you are paying for eligible expenses. These expenses may be incurred by you or an eligible dependent during your current coverage period. Also, you agree that you have not and will not seek reimbursement for those expenses from any other health plan or source. Save all receipts that specifically describe the item or service you paid for with your card. For many expenses, you will be responsible for submitting receipts to document that your card was used for an eligible expense. Ineligible expenditures require account reimbursement. If you have used your card for an ineligible expense or if you fail to submit a required receipt for an eligible expense, you will be responsible for reimbursing your account for the amount of the ineligible/unsubstantiated expense. IRS regulations require that all Health Care and Dependent Care FSA disbursements be properly documented. Always save your receipts! The Flexible Spending Account Website Manage your account and get help conveniently online at From the website, you may do the following at any time: View your account balance and activity Check the status of claims and payments Download a reimbursement claim form Download a direct deposit authorization form Get answers to Frequently Asked Questions (FAQs) Here is how you get started: 1. First-time users will need their Benefits MasterCard to create an account. 2. Go to and select Participant Login. 3. On the Participant Portal page, select Create Account and complete the form as directed. The Employee ID field will be your WorkSmart Employee ID number, no dashes. Once you have completed all required fields, select Submit. You will then be redirected to the login page. 4. te your user ID and password for future reference. Have Questions? us at flex@worksmartpeo.com. If you don t have internet access, call us at , or toll-free at Your WorkSmart Benefits team is available Monday through Friday, from 8:00 A.M. until 5:00 P.M. Eastern Time, closed holidays. PAGE 2

5 The Benefits MasterCard Pay for eligible items and services at the point of sale. Funds are automatically deducted from your Health Care Flexible Spending Account. Why use the card? waiting for reimbursement Works like a credit card, providing direct access to your flex account dollars Automatically deducts from your Health Care Flexible Spending Account It s a convenient way to pay for eligible health care products and services. Save your receipts! When can you use the card? Pay for eligible health care expenses incurred by you or an eligible dependent during the current Plan Year* and while you are enrolled in the FSA. The IRS does not allow you to use your Health Care FSA funds to pay for services received before your current coverage period, or that you will receive in the future. You may use the Benefits MasterCard as of your effective date, through December 31 st of the year in which you enroll in the plan. If you elect to participate in the FSA for the subsequent year, your card will be active with access to your designation for the new plan year. Where can you use the card? Doctor and dentist offices Pharmacies Discount chain and club stores At most merchants who sell health care products or services and accept MasterCard Who can use your card? You will automatically receive one card, in your name, for your own use. You may authorize additional users and a card will be issued in the name of each person you authorize. What do you do if your card is lost or stolen? Immediately contact WorkSmart Systems at flex@worksmartpeo.com. Or call or toll-free at * Your FSA can reimburse you for expenses incurred between January 1 and March 15 based on your enrollment for the previous year, and provided you are an active employee. This must be done by a manual claim since the Benefits MasterCard can access only current year funds. PAGE 3

6 Health Care Flexible Spending Account Get reimbursed from your Health Care FSA for eligible expenses paid out-of-pocket. When to use your FSA: Some expenses are easier to pay with personal funds and then request reimbursement. For example: For a service that occurs within your enrollment period, but requires that you pay for the service in advance. You will pay for the service(s) as required by the provider and then submit a request for reimbursement from your FSA once you have received the service. If your provider does not accept MasterCard, you will need to pay with your personal funds and request reimbursement. If the expense is listed as a Maybe in the Health Care Expense list (see pages 6-8) and requires additional information for approval. How to use your FSA: Pay for your eligible expense as you usually do and save your itemized receipt. When you use your Benefits MasterCard, you will receive an from flex@worksmartpeo.com if you are required to submit documentation substantiating the charge. If you paid for the eligible expense with your personal funds, you may complete a reimbursement form. This form is included at the end of this guide, and is also available for download at: Log in to the Co-Employee Center for access to the Forms Center (Username: wsemployee; Password: ) Scan and your reimbursement form and proof of expense to flex@worksmartpeo.com; or Fax your reimbursement form and proof of expense to , or Mail your reimbursement form and photocopies of your proof of expense to: WorkSmart Flex Department 9957 Crosspoint Blvd Indianapolis, IN Claims totaling $20 or more will automatically trigger the system to issue your reimbursement. You may complete a Direct Deposit Authorization Form if you would like to receive your reimbursements via direct deposit. In order to be processed, all claims, including resubmitted claims, must be received no later than April 15 of the year immediately following the plan year. Proof of Expense You must provide proof for each expense listed on your reimbursement form, or if using your Benefits MasterCard, you must be able to provide the proof for each card transaction. Your proof of expense should be appropriate for the type of expense. Basic: Pharmacy receipt for prescriptions and other pharmacy purchase Doctor s office receipt for office visit Explanation of Benefits (EOB) from your insurance plan, for covered medical or dental expense Bill or invoice from doctor or dentist for expenses not covered by your insurance or health plan Payment contract, monthly payment coupon, or statement from your orthodontist Receipt from your optometrist or other medical service provider Basic+: Same as Basic, plus a written statement from your provider indicating (1) the diagnosis and (2) the medical necessity of the expense. Basic++: Same as Basic+, plus proof of difference in cost (1) the cost of standard, unmodified item and (2) the cost of special or modified item. The reimbursable amount is the difference between these two. Whose Health Care Expenses are Eligible? You can use your Health Care Flexible Spending Account to pay for eligible expenses incurred by you and/or a qualifying child or relative. Please see Publication 502 Medical and Dental Expenses at to determine eligibility. PAGE 4

7 Health Care Expenses Health Care Expense Eligible? Proof Required Acupuncture Basic Adoption (related medical expenses) Basic Adoption fees Alcoholism treatment Basic Allergy products (requires prescription) Basic Alternative dietary substitutes Alternative drugs and medicines (requires prescription) Maybe Basic+ Alternative healers (requires prescription) Maybe Basic+ Ambulance Basic Aspirin (requires prescription) Basic Birth control (over-the-counter) Basic Birth control pills Basic Body scans Basic Braille books and magazines (difference in cost only) Maybe Basic++ Child or newborn care instruction Childbirth classes Basic Chiropractic treatment Basic Chiropractor (office visit) Basic Christian Science practitioners Basic Co-insurance (medical, dental or vision) Basic Concierge medical services Condoms and spermicides Basic Contact lenses, cleaning solutions, etc. Basic Contraceptives (over-the-counter) Basic Co-payments (medical, dental or vision) Basic Cord blood storage (for future treatment of a birth defect) Maybe Basic+ Cord blood storage (for unidentified future use) Corneal keratotomy Basic Cosmetic surgery Counseling (for treatment of a medical condition) Basic+ Counseling (health care related) Basic+ Crutches (purchase or rental) Basic Dancing lessons (for treatment of a medical condition) Maybe Basic+ Deductibles (medical, dental or vision) Basic Dental products (excluding general health items) Maybe Basic+ Dental treatments Basic Dental veneers Maybe Basic+ Diagnostic services Basic Drug addiction treatment Basic Drugs (prescription) Basic Dyslexia treatment Basic Electrolysis Exercise equipment (for treatment of a medical condition) Maybe Basic+ Eye examinations Basic Eye related equipment/materials Basic Eyeglasses (over-the-counter) Basic Eyeglasses (prescription) Basic Face lifts Fertility monitor (over-the-counter) Basic Fertility treatment (for employee, spouse or dependent) Basic Fertility treatment (for non-dependent surrogate) Fitness programs PAGE 5

8 Health Care Expenses (Continued) Health Care Expense Eligible? Proof Required Flu shots Basic Funeral expenses Guide dog (dog, training, care) Basic Hair removal Hair transplant Health club dues Health aids and batteries Basic Herbal treatments (requires prescription) Hospital services Basic Household help Illegal operations Illegal substances Immunizations Basic Infertility treatment (for employee, spouse or dependent) Basic Insulin Basic Insulin testing materials and equipment Basic Insurance premiums Insurance premiums (employee portion or other) Laboratory fees Basic Lamaze classes Basic Laser eye surgery Basic Lasik Basic Learning disability treatments Basic Lodging (essential to receive medical care) Maybe Basic+ Long-term care services Marriage counseling Massage therapy (for treatment of a medical condition) Maybe Basic+ Mastectomy-related special bras Basic Maternity clothes Medical equipment (for treatment of medical condition) and repairs Basic Medical monitoring and testing devices Basic Medical records charges Basic Medical savings accounts Medical supplies (for treatment of a medical condition) Maybe Basic+ Medical abortion Basic Medicines (requires prescription) Basic Medicines (prescription) Basic Modified equipment Maybe Basic++ rplant insertion or removal Basic Nursing services (wages and taxes) Basic Nutritional supplements (for treatment of a medical condition) Maybe Basic+ OB/GYN fees Basic Occlusal guards to prevent teeth grinding Basic Office visits (medical, dental or vision) Basic Operations (excluding cosmetic) Basic Optometrist/ophthalmologist fees Basic Organ transplants (recipient and donor) Basic Ortho keratotomy Basic Orthodontia (adult or child) Basic Over-the-counter medication (requires prescription) Basic Ovulation monitor (over-the-counter) Basic Oxygen Basic Personal use items (toothbrush, toothpaste, etc.) PAGE 6

9 Health Care Expenses (Continued) Health Care Expense Eligible? Proof Required Physical exams Basic Physical therapy Basic Pregnancy tests (over-the-counter) Basic Premiums (health plan or insurance) Prescription drugs Basic Prosthesis Basic Psychiatric care Basic Psychoanalysis Basic Psychologist fees Basic Radial keratotomy (RK) Basic Reading glasses (over-the-counter) Basic Reconstructive surgery following mastectomy Maybe Basic+ Removal of benign mole, cyst or tumor Basic Retin-A (excluding cosmetic uses) Maybe Basic+ Rogaine Smoking cessation (programs/counseling) Smoking cessation drugs (prescription) Basic Smoking cessation gum or patches (over-the-counter) Basic Special equipment Maybe Basic++ Special foods (e.g., gluten-free or salt-free diet) Speech therapy Basic Sterilization Basic Student health fees (for medical services) Basic Sunglasses (over-the-counter) Sunglasses (prescription) Basic Supplies (for treatment of a medical condition) Maybe Basic+ Surgery (cosmetic) Surgery (excluding cosmetic) Basic Swimming lessons (for treatment of a medical condition) Maybe Basic+ Teeth bleaching or whitening Therapy (for treatment of a medical condition) Basic Toothpaste, toothbrush, floss Transgender treatments/surgery Transportation, parking and related travel expenses (essential to Maybe Basic+ receive medical care) Tubal ligation Basic UV protection clothing Vaccinations Basic Varicose veins surgery Basic Vasectomy Basic Viagra (prescription) Basic Vitamins (over-the-counter) Vitamins (prescription) Basic Weight loss counseling Maybe Basic+ Weight loss foods Weight loss program (to improve or maintain general health) Weight loss program and/or drugs (for treatment of a medical Maybe Basic+ condition) Wheelchair and repairs Basic X-ray fees Basic You can pay for eligible expenses that require Basic proof using your Benefits MasterCard. For expenses which require more than Basic proof, you will need to use an alternate payment method and then file a claim for reimbursement. PAGE 7

10 Health Care Flexible Spending Account Rules The following are rules dictated by IRS regulations: 1. By enrolling in the plan, you authorize your employer to deduct your election amount from your paycheck on a pre-tax basis. 2. Your Benefits MasterCard can be used to pay for eligible expenses incurred while you are enrolled and during the current Plan Year. Expenses are considered incurred on the date of service, not when you are billed or pay the bill. 3. Your account cannot be used to pay for expenses incurred before or after you are covered under this plan or for services you plan to receive in the future. 4. Your account can only be used to pay for medically necessary and eligible health care expenses for which you have not and will not seek reimbursement from any other health plan or source. 5. Each time you use the Benefits MasterCard, you authorize that you are paying for eligible expenses incurred by you or an eligible dependent during your current coverage period and that you have not and will not seek reimbursement for these expenses from any other health plan or source. 6. You cannot take a deduction or a tax credit on your tax return form for any health care expense paid for through this account. 7. You are responsible for maintaining documentation (e.g. detailed receipts) to verify your expenses (the nature of each expense, the amount and the date incurred). Keep these with your other important tax papers for the calendar year. You may be requested to submit these to complete the adjudication process. 8. You will have until April 15 of the calendar year immediately following the Plan Year to file claims requesting reimbursement from your account for eligible expenses incurred before March 15 (or before you stopped participating in the plan, whichever is earlier). 9. Be sure to incur eligible expenses totaling your election amount while you are covered under this plan during the Plan Year. Any balance remaining in your account after April 15 cannot be rolled over or paid out to you. Remaining funds will be forfeited. 10. If you want to participate during the next plan year, you will need to re-enroll during the open enrollment period. We are not allowed to keep you enrolled or automatically re-enroll you in flexible spending accounts. 11. You may be able to enroll, change or cancel your enrollment during the Plan Year if you have experienced a qualified change as defined by the IRS and if allowed by the plan. 12. Participation in this plan reduces your taxable income and may affect other compensation-based benefits such as life, disability and Social Security. 13. Consult a tax advisor if you have any questions regarding your personal situation. Limited Health Care Flexible Spending Account Rules In addition to the rules noted above: 1. The Limited Health Care Flexible Spending Account is restricted to eligible vision and dental expenses. 2. Medical, prescription and over-the-counter items are not eligible for reimbursement from a Limited Flexible Spending Account. PAGE 8

11 The Dependent Care Benefits MasterCard If you are enrolled in both the Health Care Flexible Spending Account and the Dependent Care Flexible Spending Account, you will use the same card for both accounts. Your funds for each flex account remain separate and they do not cross over. Why use the card? waiting for reimbursement Works like a credit card, providing direct access to your FSA dollars Automatically deducts from your Dependent Care Flexible Spending Account It s a convenient way to pay for eligible dependent care services. Save your receipts! When can you use the card? Pay for eligible dependent care expenses during the current Plan Year* and while you are enrolled in the plan. The IRS does not allow you to use your Dependent Care Flexible Spending Account funds to pay for services received before your current coverage period, or that you will receive in the future. You may use the card as of your effective date, through December 31 of the year in which you enroll in flex. If you elect flex participation for the subsequent year, your card will be active with access to your designation for the new plan year. What do you do if your card is lost or stolen? Immediately contact WorkSmart Systems at flex@worksmartpeo.com. Or call or toll-free at * Your Flexible Spending Account can reimburse you for expenses incurred between your enrollment date and December 31 of the Plan Year. PAGE 9

12 Dependent Care Flexible Spending Account Get reimbursed from your Dependent Care FSA for eligible expenses paid out-of-pocket. When to use your FSA: Some expenses are easier to pay with personal funds and then request reimbursement. For example: If your provider has a merchant code that indicates their business is anything other than a school or child care service (e.g. YMCA, individual care provider, etc.). If you need to pay the provider on a set cycle. How to use your FSA: Pay for your eligible expense as you usually do and save your itemized receipt. When you use your Benefits MasterCard, you will receive an from flex@worksmartpeo.com if you are required to submit documentation substantiating the charge. If you paid for the eligible expense with your personal funds, you may complete a reimbursement form. This form is included at the end of this guide, and is also available for download at: Log in to the Co-Employee Center for access to the Forms Center (Username: wsemployee; Password: ) For dependent care claims, you may submit an itemized receipt or simply have your dependent care provider sign your reimbursement form. Scan and your reimbursement form and proof of expense to flex@worksmartpeo.com; or Fax your reimbursement form and proof of expense to , or Mail your reimbursement form and photocopies of your proof of expense to: WorkSmart Flex Department 9957 Crosspoint Blvd Indianapolis, IN In order to be processed, all claims, including resubmitted claims, must be received no later than April 15 th of the year immediately following the Plan Year. Proof of Expense You must provide proof for each expense listed on your FSA claim form, or if using your Benefits MasterCard, you must be able to provide the proof for each card transaction. Your proof should be appropriate for the type of expense. Proof of Expense: Your provider s signature in the designated area on your claim form Formal or informal statement or bill from your provider What Dependent Care Expenses are Eligible? You can use your Dependent Care Flexible Spending Account to pay for eligible expenses to care for a qualifying child or relative. Please see Publication 503 Child and Dependent Care Expenses at to determine eligibility. PAGE 10

13 Dependent Care Expenses Child Care Expense After school programs Babysitting (in someone else s home) Babysitting (in your home) Before school programs Child care Dance lessons Educational services (other than preschool) Kindergarten Language classes Nursery school Piano lessons Preschool Private school tuition (for kindergarten and up) Sick child care Sleep-away camp Summer day camp Transportation to and from eligible care Tutoring Eligible? Elder Care Expense Adult day care Day nursing care Elder care (in your home) Elder care (outside your home) Medical care Nursing home care Senior day care Transportation to and from eligible care Eligible? PAGE 11

14 Dependent Care Flexible Spending Account Rules The following are rules dictated by IRS regulations: 1. By enrolling in the plan, you authorize your employer to deduct your election amount from your paycheck on a pre-tax basis. 2. Your Benefits MasterCard can be used to pay for eligible expenses incurred while you are enrolled and during the current Plan Year. Expenses are considered incurred on the date of service, not when you are billed or pay. 3. Your account cannot be used to pay for expenses incurred before or after you are covered under this plan or for services you plan to receive in the future. If you must pay for a service in advance, you can file a claim for reimbursement only after you begin to receive that service. 4. You will need to provide the Social Security or Tax ID number of your dependent care provider to request payments or get reimbursed from your Dependent Care FSA. You will also be required to report it to the IRS when you file your tax return form. 5. Your account can only be used to pay for work-related and eligible dependent care expenses for which you have not and will not seek reimbursement from any other plan or source. 6. You cannot take a deduction or a tax credit on your tax return form for any dependent care expense paid for through this account. 7. You are responsible for maintaining documentation (e.g. detailed receipts) to verify your expenses (the nature of each expense, the amount and the date incurred). Keep these with your other important tax papers for the calendar year. We may request these receipts to complete the adjudication process. 8. You will have until April 15 after the end of the plan year to get reimbursed from your account (by filing a claim form) for eligible expenses incurred before December 31 (or before you stopped participating in the plan, whichever is earlier). 9. Be sure to incur eligible expenses totaling your election amount while you are covered under this plan during the plan year. Any balance remaining in your account after April 15 cannot be rolled over or paid out to you and will be forfeited. 10. If you want to participate during the next plan year, you will need to re-enroll during the open enrollment period. We are not allowed to keep you enrolled or automatically re-enroll you. 11. You may be able to enroll, change or cancel your enrollment during the Plan Year if you have experienced a qualified change as defined by the IRS and if allowed by the plan. 12. Participation in this plan reduces your taxable income and may affect other compensation-based benefits such as life, disability and Social Security. 13. Consult a tax advisor if you have any questions regarding your personal situation. PAGE 12

15 Flexible Spending Account Reimbursement Form [1] Provide ALL of the information requested on this claim form. Incomplete or unclear information will result in processing delays. [2] Attach an explanation of Benefits (EOB) or itemized bill from the provider showing the provider name, description of service, date of service, total expense, amount paid and, if applicable, amount covered by insurance. [3] Attach itemized bills, with service date, from provider of qualifying expenses (e.g., co-pays, physician exams, glasses, etc.). [4] Enter dependent reimbursement requests in the box at the bottom of the form. [5] Submit pharmacy receipts showing date of service, prescription (Rx) name and number and total amount. [6] Canceled checks, credit card receipts and receipts only reflecting a balance due are not acceptable. Requestor Information SECTION 1 Employer: Employee Name: Daytime Phone Number: SSN: Address: Address: City: State: Zip: Check if this is a new address Date of Birth: / / Hire Date: / / Health Care Account Reimbursement (Enter the following information for EACH attached receipt. Do not use this area to enter dependent day care claims.) Provider Name Dates of Service Type of Service Reimbursement Amount Requested SECTION 2 Employee Certification I certify that these expenses for which reimbursement is claimed have been incurred by me and/or my eligible dependents and are not payable by any other plan and will not be deducted on my federal, state, or local income tax returns. Employee Signature (REQUIRED) Date Health Care Total: Dependent Care Account Reimbursement (Enter the following information for EACH attached receipt.) Provider Name: Provider Address: Provider Tax ID or SSN: SECTION 3 Use this space for dependent day care expenses only Provider Section Dates of Service(s): Dependent s Name(s): Total Amount Required: Provider s Signature or attach a receipt: Date: Is provider of service relating to dependent? Age: Relationship: Employee Certification I certify that these expenses for which reimbursement is claimed have been incurred by me and/or my eligible dependents and are not payable by any other plan and will not be deducted on my federal, state, or local income tax returns. Employee Signature (REQUIRED) Date Dependent Care Total: WorkSmart Systems, Inc Crosspoint Blvd. Indianapolis, IN (317) FAX (317) PAGE 15

16 Flexible Spending Account Direct Deposit Authorization Return by to: If unable to return by , please return by fax: SECTION 1 Requestor Information Employee Name: SSN: Client Company Name: Financial Institution SECTION 2 Bank Name: ACH Routing Number: Account Number: Account Type (check one): Checking Account Savings Account SECTION 3 Authorization I hereby authorize WorkSmart Systems to transfer electronic debits and credits to the bank accounts noted above. I grant WorkSmart Systems the right to correct any erroneous overpayments by debiting my account. Signature: Date: Attach Voided Check Here Attach: voided check for checking OR savings deposit slip for savings accounts. Form will not be processed without information below. WorkSmart Systems, Inc Crosspoint Blvd. Indianapolis, IN (317) Toll-Free (877) HR FAX (317) Payroll FAX (317) PAGE 16