Contents

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2 Contents About FSA 3 How FSA Works 4 Eligible Expenses 5 Setting Up Your FSA 6 Qualifying Life Status Change 9 Restrictions 10 Dependent Care Assistance Plan 11 Eligibility 13 Determining Annual Election Amount 14 Dependent Care Plan Versus Tax Credit 16 Sample Savings Calculator 17 Qualifying Life-Status Changes 18 Restrictions 19 Enrolling in the Plan 20 Reimbursement Procedures 21 Claim Procedures

3 Flexible Benefits Plan Helps You Pay for predictable, out-of-pocket expenses like unreimbursed medical expenses and dependent day care on a pre-tax basis Set aside money before taxes Rapid claims turn-around

4 How a Health Care Spending Account Works Made possible by Section 125 of the IRC Employer-sponsored plan Set aside money pre-tax for unreimbursed health care expenses

5 Deductibles, co-pays, co-insurance Prescription drugs Eye exams, contact lenses and cleaning solutions Dental and orthodontia Much, much more!! Eligible Expenses

6 Set-up Health Care Spending Account Decide how much to set aside from each check Stay within the plan maximum Include dependent expenses even if not covered by employer s plan Use the Savings Calculator on the CONEXIS website

7 Determine Annual Election Amount Divided By: Number of pay periods Monthly = 12 Semi-monthly =24 Bi-weekly = 26 Weekly = 52 = Deduction per pay period

8 Leave the Rest to CONEXIS CONEXIS handles all administration Incur expenses, file claims, obtain reimbursements up to annual election Pay no taxes on reimbursements

9 Change in marital status Change in number of dependents Spouse s employment or coverage changes Change in number of work hours Change of work site Change of residence Dependent ceases to qualify as a dependent Qualifying Life-status Changes

10 Restrictions Use your account balance or lose it Must use up account balance for services rendered during the plan year Unused balances help offset employer costs Plan carefully!

11 How a Dependent Care Assistance Plan Works Set aside money pre-tax for dependent daycare expenses Made possible by Section 125 of the IRC Employer-sponsored Plan

12 Who is Eligible? Child under the age of 13 Disabled dependent Adult dependent

13 Not your dependent under age 19 Inside your home State-approved daycare facility Eligible Daycare Providers

14 Determine Annual Election Amount Divided by: Number of pay periods Monthly = 12 Semi-monthly =24 Bi-weekly = 26 Weekly = 52 = Deduction per pay period

15 Leave the Rest to CONEXIS CONEXIS handles all administration Incur expenses, file claims, obtain reimbursements up to annual election Pay no taxes on reimbursements

16 Dependent Care Plan versus Tax Credit Dependent Care Assistance Plan or Income Tax Credit, not both If you earn more than $25,000, this plan will probably save you money Consider consulting a tax advisor

17 Sample Savings Calculator

18 Change in marital status Change in number of dependents Spouse s employment or coverage changes Change in number of work hours Change of work site Change of residence Dependent ceases to qualify as a dependent Qualifying Life-status Changes

19 Restrictions Use your account balance or lose it Must use up account balance for services rendered during the plan year Unused balances help offset employer costs Plan carefully!

20 Enrolling in the Plan Use our Savings Calculator Complete the enrollment form Plan carefully Services must have been provided or expenses must have incurred during the plan year

21 Reimbursement Procedures Obtain claim forms from your HR representative or download from website Complete forms entirely to avoid delays

22 Filing a Claim Include appropriate documentation Explanation of Benefits Itemized statement Not allowed by IRS: Cancelled checks Balance forward statements Credit card receipts

23 Receipts are not required Complete the appropriate claim form Dependent Care Claims

24 Claims Submission If you have access to a scanner, you may submit claims through the website: You may fax claims via CONEXIS s toll-free fax number: Mail claims to: CONEXIS Cafeteria Plan Services P.O.Box Dallas, TX

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