PayFlex Health Care Flexible Spending Account (FSA)
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1 PayFlex Health Care Flexible Spending Account (FSA) Want to help reduce your taxable income and increase your take home pay? Think about enrolling in a health care Flexible Spending Account (FSA). You can set aside money from your paycheck (on a pretax basis) to use for eligible health care expenses. What makes the health care FSA so great? Contribute pretax dollars from your paycheck, up to the Internal Revenue Service (IRS) limit. Your full contribution is available at the start of the plan year. If you and your spouse both have a health care FSA, you can each contribute up to the IRS limit. You can use this account to pay for eligible health care expenses for you, your spouse and your tax dependents. These expenses may include: o Copays, coinsurance and deductibles o Dental expenses (orthodontia, crowns, bridges, etc.) o Vision expenses (LASIK eye surgery, glasses, contacts, etc.) o Prescription drugs and over-the-counter (OTC) items* Paying the PayFlex way is easy! Once funds are available in your account, you can: Use the PayFlex Card, your account debit card (if offered): It s a convenient way to pay for eligible expenses. The card knows when the expense is eligible. There is also no claim filing! Pay yourself back: Pay for eligible expenses with cash, check or your personal credit card. Submit a claim to PayFlex to pay yourself back. You can even have your claim payment deposited directly into your checking or savings account. Pay your provider: Use PayFlex s online feature (if offered) to pay your provider directly from your FSA. Important Note: Save your itemized statements and receipts for your expenses, as well as your Explanations of Benefits (EOBs) from your insurance carrier. Things to keep in mind View the current IRS contribution limits on the PayFlex member website. Review your expenses from last year and this year. Then, think about what you expect to spend next year. FSAs have a use-it-or-lose-it rule. This means you ll lose any unused funds at the end of the run out period. o The run out period gives you extra time to submit claims to pay yourself back. View your claim filing deadline on the PayFlex member website. You can t change your contribution unless you have a change in status, such as: o Legal marital status o Number of tax dependents (birth, adoption or death) o Employment status that affects eligibility o Dependent coverage (i.e., reached age limit, gain or loss of student status, marriage) Questions? Visit your PayFlex member website and click Contact Us. We re here to help Monday Friday, 7 a.m. 7 p.m. CT and Saturday, 9 a.m. 2 p.m. CT. *You need to get a written prescription from your doctor in order to use your FSA dollars for over the counter drugs and medicines. This material is for informational purposes only. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about PayFlex, go to (10.14)
2 PayFlex Flexible Spending Account (FSA) Paying for eligible dental expenses When using your Flexible Spending Account (FSA) funds to pay for eligible dental expenses, it s important to know your payment options. Take a look at the following chart and information, along with the Frequently Asked Questions (FAQs). Payment Options Benefits of this option Things to consider Option 1: (Preferred method) Once you receive an Explanation of Benefits (EOB) from your insurance provider showing the amount you owe, pay for your dental service using the PayFlex Card, your account debit card. Expense is automatically deducted from your health care FSA Ensures you only pay for what you owe Helps keep your card active Eliminates claim filing You may be required to provide the Explanation of Benefits (EOB) to PayFlex at a later date to confirm your expense was eligible. Be sure to keep your EOBs. To confirm an expense is eligible, IRS regulations require proof of the date of service, description of service or product and the amount you owe. This information is provided on an EOB. Option 2: (Next best method) Once you have received dental treatment, pay for the bill with cash, check or personal credit card. Then submit a claim to PayFlex for reimbursement. Quick reimbursement Helps keep your card active If the itemized statement from your dentist indicates insurance has been filed, is pending or is estimated, you must wait to submit your claim until after you receive your EOB from your insurance provider. Note: Make sure to send a copy of your EOB or itemized statement with your claim. Option 3: (Choose this option only if your dentist requires you to pay before insurance pays.) Once you have received dental treatment, pay the bill with the PayFlex Card, your account debit card, at your dentist office. Expense is automatically deducted from your health care FSA Eliminates claim filing If your dentist charges you for an estimated amount OR an amount that is greater than the amount you owe (after insurance pays its portion), your FSA will be placed into overpayment* status and action will be required. To resolve your overpayment* status, submit payment to PayFlex or submit a claim for a previously unreimbursed eligible expense to repay your FSA. By taking action, your card will remain active. If you or your dentist receives reimbursement from any other coverage, such as insurance, ask your dental provider to credit any amount over what you owe, back to the PayFlex Card, your account debit card. If that is not possible, you re responsible for reimbursing the plan for the amount overpaid. Note: The eligible amount is the amount you owe after your insurance pays its portion of the bill. If your dentist requires either partial or full payment on the date of your service and indicates on your statement that insurance has been filed, it s pending or is estimated, it s best to pay with a form of payment other than your PayFlex Card when this happens. You can also wait until you receive an Explanation of Benefits (EOB) from your insurance provider showing the amount you owe and then pay for your dental bill with your PayFlex Card, your account debit card A (4/14)
3 Key things to remember 1. You can t use your card to pay for cosmetic dental procedures, such as dental veneers, bonding and teeth whitening. 2. You should only swipe your card for the amount you are responsible to pay. For Example: Let s say you visit the dentist to repair a cracked filling. You receive a bill for $300. Your dentist estimates that your out-of-pocket expense is $72. Since you only have the estimate, you should wait to receive the Explanation of Benefits (EOB) from your insurance company. Once you have the EOB, then you ll know how much you have to pay. For this example, let s say insurance paid 80% of the cost, and you re responsible for $60. To pay the $60, you can give your dentist the number on the PayFlex Card, your account debit card. Or you can pay out of pocket and submit a claim to pay yourself back. 3. There may be times that you re asked to confirm you used your PayFlex Card for an eligible dental expense. If we need you to do this, we ll send a Request for Documentation letter to you and post an alert online. For Example: Let s say you use your card to pay for a dental service. The amount comes out of your FSA. Based on the merchant description (example below) it isn t clear what you paid for with your PayFlex Card. Date Merchant Amount Account 7/18/2014 ABC Family Dentist $45.70 (2014) Health Care FSA We ll send you a Request for Documentation letter. This letter is requesting documentation for the payment. You will need to send in the EOB or detailed statement to confirm the transaction was for an eligible expense. The EOB or receipt must also confirm the date of purchase or service. You can respond to the request online, from your PayFlex member website. Click Learn More next to the alert for claims requiring substantiation. Then select your card payment and upload your EOB. You can also submit a claim via the PayFlex Mobile App. Or fax or mail your documentation with a copy of the letter. Note: The IRS requires that all health care cards are used for eligible expenses. So it s important that you keep all your EOBs and detailed receipts and statements. Frequently Asked Questions (FAQs) 1. I used my PayFlex Card to pay for a dental expense and my dentist overcharged me. Who s responsible for fixing this issue? If you were overcharged by your dentist, you re responsible for getting reimbursement for the amount you were overcharged. In order to keep your PayFlex debit card active, you must do one of the following: Mail a check to PayFlex for the amount you were overcharged to repay your account. Submit a claim for another eligible expense to cover the overcharged amount. Have your dentist credit the amount back to your PayFlex debit card. 2. I received a bill from my dentist for an estimated amount and I used my PayFlex debit card to pay the bill. Why did I receive an Explanation of Benefits notice from PayFlex that states my account is in overpayment*? A (4/14)
4 In this situation, your account is in overpayment* status because the amount you owe is unknown. Once your insurance provider has paid their portion, the amount you owe will be confirmed. To keep your card ACTIVE and avoid overpayment*, it s best not to use the PayFlex Card until insurance has processed the claim and provided you with an Explanation of Benefits showing the amount you owe. 3. I used my PayFlex debit card at the dentist and it was approved. Why am I receiving a Request for Documentation letter for my dental expenses? According to IRS guidelines, PayFlex is required to verify that all purchases made with the PayFlex Card, your account debit card are eligible expenses. Usually, you ll receive a letter if the merchant description from the card swipe doesn t clarify the date of service, description of service, or the amount you owe. In order to keep your card ACTIVE, you must provide an Explanation of Benefits from your insurance provider or an itemized statement from your dentist. The documentation must include: date of purchase or service amount of purchase or service description of item or service name of merchant or service provider name of patient 4. What s the difference between an Explanation of Payment (EOP) from PayFlex and an Explanation of Benefits (EOB) from my dental insurance provider? An Explanation of Payment from PayFlex is a document telling you what claims have been approved for reimbursement, denied, or whether your account is in overpayment* status. An Explanation of Benefits from a dental insurance provider is a statement that details what services have been paid by the insurance plan and what is owed to the dentist by the insured individual. *Overpayment status occurs when you have been reimbursed for an expense that has been denied. When your account is placed in overpayment status, the PayFlex Card will be temporarily suspended until PayFlex receives/processes the required documentation or payment. Want to know more? Visit your PayFlex member website, and click Contact Us. This material is for informational purposes only. The information describes the Flexible Spending Account ( FSA ) in general terms. FSA plans are governed by the rules of Section 125 of the Internal Revenue Code and will be administered in accordance with those rules. Estimate fund amounts carefully. Unused funds will be forfeited either after the last day of the plan year or at the end of the grace period if your plan offers one. Eligible expenses may vary from employer to employer. In case of a conflict between your plan documents and the information in this material, the plan documents will govern. Please refer to your employer s Summary Plan Description ( SPD ) for more information about your covered benefits. Information is believed to be accurate as of the production date; however, it is subject to change. To learn more about PayFlex, visit A (4/14)
5 Dependent Care Flexible Spending Account (FSA) Help reduce your taxes and increase your take home pay! A dependent care FSA lets you set aside money from your paycheck on a pretax basis. You can then use the FSA to pay for eligible out-of-pocket dependent care expenses for: Your dependent who is under the age of 13 Your spouse or dependent who is incapable of self-care Some common eligible expenses include: Child and adult day care Summer day camps Preschool Before and after school care Getting started First, estimate the amount of dependent care expenses you expect to have during the year. Second, determine how much you want to contribute. The yearly maximum contribution limit set by the Internal Revenue Service (IRS) is $5,000 per family. How to use your funds Once funds are available in your account, PayFlex makes it easy to pay for your expenses! Use the PayFlex Card, your account debit card (if offered). o It s a convenient way to pay for eligible expenses. o The card knows when the expense is eligible. o No claim filing! Pay yourself back: Pay for eligible expenses with cash, check or your personal credit card. Submit a claim to PayFlex to pay yourself back. You can even have your claim payment deposited directly into your checking or savings account. Pay your provider: Use PayFlex s online feature (if offered) to pay your provider directly from your FSA. Note: Save your itemized statements and receipts for your expenses, as well as your Explanations of Benefits (EOBs) from your insurance carrier. Important Notes: To use your dependent care funds, you must be working. If you re married, your spouse must either be working, looking for work, a fulltime student or incapable of self-care. Funds become available as they are deducted from your paycheck, and deposited into your account. You can pay yourself back from your account for services already received. Questions? Visit your PayFlex member website, and click Contact Us. We re available Monday Friday from 7 a.m. 7 p.m. CT and Saturday from 9 a.m. 2 p.m. CT to help you. This material is for informational purposes only. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about PayFlex, go to A (7/14)
6 Health Care and Dependent Care Flexible Spending Accounts Enrollment Form I. Personal Information (Please print clearly and provide complete and accurate information.) Your Employer: Employer Use Only Re-enrollment New Change Effective Date 1st Deduction Date Payroll Mode W B S M Q Division Code Member # Your Name (This may be your SSN or employer assigned number) (Last) (First) (MI) Address City State Zip - Check if this address is new within last year. Date of Birth / / Hire Date / / II. Election Information (Please check the appropriate box to indicate if you wish to enroll, or do not wish to enroll, and sign below.) Yes, I wish to participate in the flexible spending account plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s) indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. Employer-sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis. I have been offered the opportunity to enroll in the flexible spending account plan and do not wish to enroll at this time. However, my employer-sponsored benefit coverage contributions are automatically reduced from my compensation on a pre-tax basis. BENEFIT CHOICES Healthcare Flexible Spending Account The minimum and/or maximum contribution amounts are determined by your employer. Dependent Day Care Flexible Spending Account The minimum contribution amount is determined by your employer; however the maximum contribution amount of $5,000 is set by the IRS. If married, and your spouse is disabled, a full-time student or earns less than you, lower limits may apply. Please refer to the IRS guidelines for further information. PER PAY PERIOD AMOUNT NUMBER OF PAY PERIODS PLAN YEAR AMOUNT $. X = $. $. X = $. I understand that: This election can only be changed or revoked during the Plan Year if I have a change in status as defined in the Plan or if I am no longer eligible to participate. The new election must be consistent with my change in status, must be applied for within 30 days of the change, and is subject to final approval by my employer. This election will be automatically changed or cancelled, if necessary, to comply with provisions of the Internal Revenue Code or if required employersponsored benefit contributions increase or decrease. The maximum exclusion under a Dependent Care Reimbursement Account for married individuals filing a joint return is $5,000 per calendar year. Married individuals filing separately will get a lower exclusion ($2,500 per calendar year). IRS Form 2441 must be filed with my personal income tax return. Any amounts remaining in my reimbursement accounts at the end of the Plan Year will be forfeited. Salary contributed into one reimbursement account cannot be transferred and used for expenses in any other account. A new Enrollment Form must be completed each Plan Year. If I do not complete and return an Enrollment Form during Open Enrollment, I forfeit the opportunity to participate in the Benefit Choices outlined above. Social Security and Medicare taxes are not being withheld on the amount of my salary reduction under this election. The amount of salary reductions may not be claimed on my or my spouse s income tax returns. If my employment terminates, only medical expenses incurred through my period of coverage as defined in the Plan can be considered for reimbursement. I understand all claims submitted for reimbursement are subject to substantiation requirements and I am required to, and agree to, provide documentation as requested. If using the PayFlex Debit Card, I agree to use the card for eligible expenses only and retain all itemized receipts/statements. I agree to read and adhere to the cardholder statement I receive with the card and I understand the card is subject to inactivation if I do not comply with the provisions or upon termination of employment. Any expenses I pay for with the PayFlex Debit Card or for which I claim reimbursement will not have been nor will I seek to have reimbursed elsewhere. III. Pre-Authorization for Direct Deposit (If you are already enrolled in direct deposit or do not wish to, ignore this section.) I authorize PayFlex Systems USA, Inc. to initiate a credit and/or debit entry to my account for my PayFlex reimbursements. This agreement is to remain in full effect until written notification is supplied by me to PayFlex terminating this agreement. A VOIDED CHECK MUST ACCOMPANY DIRECT DEPOSIT APPLICATION Employee Signature Date Rev.1/2012
7 Parking/Transportation Reimbursement Account Enrollment Form I. Personal Information (Please print clearly and provide complete and accurate information.) *EMPLOYER MUST FILL-IN* Re-enrollment New Change Effective Date 1st Deduction Date Payroll Mode W B S M Q Division Code Your Employer Employer ID # (EMPLOYER MUST FILL-IN) Member # Your Name (This may be your SSN or employer assigned number) (Last) (First) (MI) Address City State Zip - Check if this address is new within last year. Date of Birth / / Hire Date / / II. Election Information (Please check the appropriate box to indicate if you wish to enroll, or do not wish to enroll, and sign below.) Yes, I wish to participate in the parking/transportation reimbursement account plan and authorize payroll reduction from my salary on a pre-tax basis in the amount(s) indicated below, and continuing until this election is amended or terminated or until the Plan Year ends. I have been offered the opportunity to enroll in the parking/transportation reimbursement account plan and do not wish to enroll at this time. BENEFIT CHOICES Parking Reimbursement Account (cannot exceed 2012 statutory limit - $240 per month) Transportation Reimbursement Account (cannot exceed 2012 statutory limit -$125 per month) AMOUNT PER PAY DAY $. $. FOR EXAMPLE: Let s say you elect $240/month for parking and $125 for transportation. With 24 pay periods, the amount deducted per pay day would be $ for parking and $62.50 for transportation. With 26 pay periods, the amount deducted per pay day would be $ for parking and $57.69 for transportation. Although your benefits under the transportation plan are not subject to federal income tax (up to the statutory limits), they may be subject to state income tax in certain states. You should consult your tax advisor with any questions you have about your specific tax situation. I understand that: This election can only be changed or revoked for future periods of coverage provided that the change is made before the earlier of: a) the period to which it relates; and b) the receipt of Eligible Transportation Expense benefits to which it relates. Such election shall be effective the first pay period after my Employer processes the change. This election will be automatically changed or cancelled, if necessary, to comply with provisions of the Internal Revenue Code or if required benefit contributions increase or decrease. Salary contributed into one reimbursement account cannot be transferred and used for expenses in any other account. A new Enrollment Form must be completed prior to the start of the Plan Year. If I do not complete and return a new Enrollment Form during open enrollment, this election will cancel. Social Security (FICA) tax is not being withheld on the amount of my salary reduction under this election. The amount of salary reductions may not be claimed on my or my spouse s income tax returns. I understand all claims submitted for reimbursement are subject to substantiation requirements and I am required to, and agree to, provide documentation as requested. If I cease to participate in the plan, amounts remaining in my account after eligible reimbursements will be forfeited. If using the PayFlex Card, I agree to use the card for eligible expenses only. Any expenses I pay for with the card will not have been nor will I seek to have reimbursed elsewhere. I agree to read and adhere to the cardholder statement I receive with the card and I understand the card is subject to inactivation if I do not comply with the provisions or upon termination of employment. III. Pre-Authorization for Direct Deposit (If you are already enrolled in direct deposit or do not wish to, ignore this section.) I authorize PayFlex Systems USA, Inc. to initiate a credit and/or debit entry to my account for my PayFlex reimbursements. This agreement is to remain in full effect until written notification is supplied by me to PayFlex terminating this agreement. A VOIDED CHECK MUST ACCOMPANY DIRECT DEPOSIT APPLICATION Employee Signature Date Rev. 2/2012
8 Attention All Employees Great News!! Benefits are now available to you! CONSIDER THE POSSIBILITIES If an accident or a serious illness temporarily keeps you from earning your income, how will you pay your bills during recovery? Will you use some of your savings? Will you try to borrow money? Will you sell some of your assets? Protect your Paycheck. AFLAC offers these insurance policies: Accident/Disability Hospital Confinement Indemnity Cancer/Specified Disease Hospital Intensive Care Specified Health events Dental Ca License # OD75299 Jerald Reed: mrsirreed@gmail.com Without it, no insurance is complete
9 LPS HR FORM (141) Optional to Complete Commuter Check Sign-up Form Commuter Checks are vouchers that employees obtain through pre-tax deductions and then use to purchase high value tickets for public transit. Commuter Checks enable you to take advantage of a tax code provision that allows you to deduct up to $130 per month in pre-salary in 2015 for public transit fees. Commuter Checks can also be used for BART parking fees. Depending on your tax bracket, you may have a substantial tax savings by using Commuter Checks. You can use them to purchase passes or tickets for any transit service in the Bay Area. is a helpful website. LPS employees must purchase Commuter Checks monthly through the Commuter Check website, LPS will provide employees with a login and password. You can choose to receive a check or personalized commuter check Mastercard that you will then use to purchase your transit pass. Orders must be placed by the 10 th of the month to receive benefits for the next month. For example in order to receive Commuter Check benefits for December, one must place their order by November 10 th. LPS strongly recommends signing up for a Clipper card, Employees can load pre-tax funds directly onto their Clipper card. Name: (Please Print) By signing below, you acknowledge that: The Commuter Check will only be used for your own ticket purchases. LPS is authorized to deduct from my paycheck monthly the amount of Commuter Checks. I have ordered through the website. You have read and understood all of the terms above. Employee Signature Date
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