AT A GLANCE. Flexible Spending Accounts. brought to you by: Summary - Combined Health FSA and DC FSA - Run-Out Period (rev

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1 AT A GLANCE Flexible Spending Accounts brought to you by: Summary - Combined Health FSA and DC FSA - Run-Out Period (rev )

2 Health FSAs and Dependent Care FSAs This document is a summary of the options available to you under your employer s plan. If you elect to participate in a Health FSA and/or a Dependent Care FSA, you will receive an informational booklet describing these options in more detail. If you have any questions regarding the information contained in this summary, please contact the HRemote FLEX Line at (800) What Is A Health FSA? A general Health Care Flexible Spending Account ( Health FSA ) is an employer-sponsored savings account for health care expenses. A Health FSA allows you to set aside pre-tax dollars out of your paycheck to pay for eligible health care expenses. You are not taxed on the money put into the Health FSA, and you can use the account to pay for qualified out-of-pocket health care costs like your deductible and copays, but not your premium. Each year you will estimate the health care expenses you expect to incur and the amount you would like to contribute to your Health FSA (up to an annual maximum contribution set by your employer and limit permitted by law). ). Any unused funds will be forfeited at the end of the run-out period. FSAs were created to enable employees to use pre-tax dollars for health care expenses that were not otherwise covered by employer-sponsored health coverage. These accounts gained more popularity in the 2000s, and have underwent a few changes with the Affordable Care Act (ACA), including the addition of an annual contribution limit. Health FSAs can save you money on taxes while helping you regularly put aside money for health care expenses. If carefully planned, using a Health FSA for health care costs can be an asset to your family s budget. What Is A Dependent Care FSA? A Dependent Care FSA (also referred to as a DCAP), is an employer-sponsored program that helps you with the cost of dependent care expenses. Once a Dependent Care FSA is established for you, you may be reimbursed on a pre-tax basis for eligible expenses associated with child care (child must be under 13 years of age) or for the care of an incapacitated spouse or dependent. Each year you will estimate the dependent care expenses you expect to incur and the amount you would like to contribute to your Dependent Care FSA (up to the annual maximum contribution set by your employer and limit permitted by law). Any unused funds will be forfeited at the end of the run-out period which is determined by your employer.

3 General Information Benny cards may only be used for eligible expenses that Is a Health FSA or Dependent Care FSA right for me? Health FSAs and Dependent Care FSAs can save you money because you do not have to pay taxes on the amount deferred. Health FSAs and Dependent Care FSAs can help pay for certain out of pocket expenses. Whose expenses may be reimbursed? Money in your Health FSA or Dependent Care FSA can be utilized by you and any of your eligible dependents (as defined by your employer s plan documents). Can I change my deduction? Generally contributions cannot be changed midyear unless a permitted IRS change in status event occurs (e.g., marriage, divorce, birth, significant change in spouse s employment, etc.). What kind of receipt do I need to submit? The IRS requires certain information to be located on the receipt. To expedite claims processing you should ensure that your receipt has the following information: provider name, provider tax ID, date of actual service, service description or code, and the amount of the out of pocket expense. Where can I find a claim form? Claim forms are available on HRemote page of the Kapnick website. Go to and download the PDF from the Kapnick HRemote FLEX tab or go to: : are not covered by your insurance. As a general rule, every claim paid with the Benny card MUST be reviewed and substantiated. The IRS allows automatic substantiation for certain Benny card transactions. Kapnick will notify you if a receipt is needed for one of the following transactions: transactions over $50; or transactions that are outside of the basic co-pays. If your card is lost, a $10 fee will be charged to your Health FSA or Dependent Care FSA. New cards are automatically reissued once every five years. NOTE: Your employer may not have your Dependent Care FSA connected to your Benny card. If your Dependent Care FSA is not connected to your Benny card you will need to submit claims and required substantiation as indicated below. When Are My Contributions Available for Use? All monies you elect to contribute to your Health FSA are available on the first day of the plan year. Monies you elect to contribute to your Dependent Care FSA are distributed based on the available balance in your account at the time of a claims submission. Benny Card Program Using your Health FSA or Dependent Care FSA Your employer participates in the Benny card program. The Benny card program is very similar to a debit or credit card. You may either submit claims or swipe your Benny card. If you swipe your Benny card, money will be deducted from your Health FSA or Dependent Care FSA as appropriate. How Do I Submit a Claim or Required Substantiation? You may submit a claim or provide required substantiation by utilizing one of the following methods: Mail a claim form and receipt via USPS to: Kapnick Insurance Group Attn: HRemote FLEX Department 333 S. Industrial P.O. Box 1801 Adrian, MI Fax a claim form and receipt to (517) ; a claim form and receipt to flex@kapnick.com; Upload a photo of the receipt to the online portal; OR Upload a photo using the Kapnick HRemote FLEX 1mobile app.

4 Online Portal The online portal provides you with the convenience of logging into your account within the comforts of your own home. Attention First-time Users: login and set up information will be sent to your home address after you have elected your contributions for the plan year. For portal login instructions and claim submission go to kapnick-flex-account/. Kapnick HRemote FLEX 1Mobile App Submitting claims and providing required substantiation is as easy as reaching for your smartphone or tablet. The Kapnick HRemote FLEX 1Mobile app is available as an Apple or Android app and can be downloaded to your smartphone or tablet through Apple or Google play. The Kapnick HRemote FLEX 1Mobile app is free and allows you to view your account at any time. You can view account balances and details, submit account claims, check the status of a claim, and capture and upload pictures of your receipts anytime, anywhere on any iphone, Android or tablet device. You can also sign up to receive account alerts via text message. Select Action Required Select Claim Take Picture of Receipt & Submit Run-Out Period The following defined term is important; it may provide you with an additional opportunity or additional time to use your Health FSA or Dependent Care FSA: Run-Out Period: Your run-out period is a set period of time, after the last date of the plan year, during which you may continue to use your Benny card or submit a claim for reimbursement of expenses incurred for qualified benefits during the plan year. Note: New services CANNOT be incurred during your run-out period; this is only a period of time to submit claims for payment or reimbursement that occurred during the plan year. The run-out period dates are determined by your employer.

5 HEALTH FSA: ELIGIBLE AND INELIGIBLE EXPENSES ELIGIBLE EXPENSE (examples): Acupuncture Ambulance Artificial Limb Bandages Contact lenses Crutches Dental treatment (excluding whitening) Eye glasses Eye surgery guide dog services Hospital services Lab fees Medications Physical exams Stop smoking programs Therapy Transplant Weight loss programs (if used to treat a specific disease) Wheel chair X-rays INELIGIBLE EXPENSES (examples): Cosmetic surgery and procedures Electrolysis Insurance premiums and interest Marriage or career counseling Personal trainers Sunscreen (less than 30 SPF) Swimming lessons Some over-the-counter medication (e.g., acid controllers, cough/cold/flu, foot care) not prescribed by a physician (except insulin) Some expenses can be covered if there is a letter of medical necessity provided with the claim that is signed by your physician. For a full list of covered expenses go to and click on the Kapnick HRemote FLEX tab. DEPENDENT CARE FSA: ELIGIBLE AND INELIGIBLE EXPENSES ELIGIBLE EXPENSE (dependent children under age 13): Before and after school programs Summer day camps Day care (licensed provider with tax ID) Preschool/nursery school Sick child care ELIGIBLE EXPENSE (incapacitated adults and dependents): Adult day care Elder care (licensed provider with tax ID) Senior day care INELIGIBLE EXPENSES (dependent children under age 13): Dance lessons Educational services (other than preschool) Kindergarten charges Language lessons Private school tuition Sleep away camp Sports fees Tutoring INELIGIBLE EXPENSES (incapacitated adults and dependents): Transportation Nursing home care* Medical care* Day nursing care* *This expense may be covered under a Health FSA. The information contained in this Summary is presented for informational purposes only. In case of a discrepancy between this Summary, the Informational Guide referred to in this Summary and the actual plan document; the actual plan document controls. Reviewed by the Compliance Department of Kapnick Insurance Group ( )

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