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1 FLEXIBLE Spedig Accouts Icrease Your Spedig Power Flexible Spedig Accouts (FSAs) allow you to pay for out-of-pocket health care ad depedet day care expeses with tax-free moey. You deposit a set amout out of your paycheck ito these accouts before ay taxes are calculated. Throughout the year, you are reimbursed from the accouts for eligible health care ad depedet day care expeses. This is a great way to icrease your spedig power ad decrease your taxes! Lear More Olie Example: Usig the FSA for her health care expeses, Laura icreased her spedig power by over $400 per year. Here s how she did it: Without FSA With FSA Aual pay $36,000 $36,000 Cotributio to FSAs N/A $2,000 Taxable icome (W-2 earigs) $36,000 $34,000 Federal ad state icome taxes $5,200 $4,912 FICA (Social Security + Medicare) $2,754 $2,601 Total taxes $7,954 $7,513 After tax expeses $2,000 N/A Net spedable icome $26,046 $26,487 Tax savigs with FSAs N/A $437 Icrease i spedable icome: N/A $437 Example: Adrew uses the FSA for both depedet care ad health care expeses. He has a three-year-old i preschool ad his day care expeses are $5,000. Adrew wears cotact leses ad eeds to have two detal crows doe. He estimates his out-of-pocket medical expeses at $2,000 for the year. Adrew gives himself a istat 6.2% raise by usig the FSA. Here s how: Without FSAs With FSAs Aual pay $65,000 $65,000 Cotributio to FSAs N/A $7,000 Taxable icome (W-2 earigs) $65,000 $58,000 Federal ad state icome taxes $16,250 $14,500 (25% bracket) FICA (Social Security + Medicare) $4,973 $4,437 Total taxes $21,223 $18,937 After tax expeses $7,000 N/A Net spedable icome $36,777 $39,063 Tax savigs with FSAs N/A $2,286 Icrease i spedable icome: N/A $2,286 The iformatio i this brochure is summary i ature ad is iteded for educatioal purposes oly. For specific iformatio about your FSA Pla, please refer to the Summary Pla Descriptio ad/or Pla Documet. I the evet that this brochure is ot i accordace with the official Pla documets, the official Pla documets shall prevail. Revisio Date 09/17

2 A Few FSA Groud Rules Flexible Spedig Accouts are allowed by the IRS as log as certai rules are followed. Some of the rules apply to both types of accouts ad are give here. There are two separate accouts: The Health Care ad Depedet Care FSAs are two separate accouts. You caot use moey deposited i the Health Care FSA to pay depedet day care expeses, or vice versa. You have to substatiate your claims. The IRS requires detailed documetatio to prove that your claim is legitimate. If you provide this documetatio, your claim will be reimbursed promptly. Without it, your claim will be deied. Receipts must cotai the followig iformatio: 1. Date of service 2. The Service Provider s ame 3. Descriptio of service 4. For whom the service was provided 5. Charges/out-of-pocket cost You will oly be reimbursed for eligible expeses icurred durig pla participatio. Each accout has specific rules for what is cosidered eligible. Those rules are give uder the discussio for each type of accout later i this brochure. Pla carefully so you use all the moey i your accout each pla year, or you may lose it. Some (but ot all) employers allow for a portio of each pla year s Health Care FSA fuds to be carried over ito the ext pla year (some limitatios apply). See your Summary Pla Descriptio to determie if the carryover optio is available i your pla. If it is, it will oly apply to your Health Care FSA fuds, ot your Depedet Care FSA fuds. If you termiate employmet, this is cosidered the ed of your pla year. You may be able to make arragemets to cotiue your coverage through COBRA. About Your Pla Pla details vary from compay to compay. See your summary pla descriptio for details o the followig features: Cotributio limits: The maximum amout you ca cotribute to the accouts is determied by your employer. The pla year: Pla years vary from compay to compay ad may ot be a caledar year. It s importat that you kow the pla year dates so you ca estimate expeses properly. The grace period: Some (but ot all) plas also offer a short period of time after the ed of the pla year i which you ca cotiue to use up your prior year s accout balace. You must be participatig at the ed of the pla year to take advatage of the grace period. This grace period is typically a couple of moths. The Carryover: Some plas do ot allow for a grace period, but istead allow a portio of your Health Care FSA fuds to be rolled over ito the ext pla year. Certai restrictios may apply. The claim deadlie: Each pla has a period of time called the ru-out period, durig which you ca submit claims for expeses icurred i the prior pla year. Claims received after the ed of the ru-out period will be deied. 2

3 The Health Care FSA The Health Care FSA allows you to use tax-free dollars for eligible health care expeses that are ot covered by isurace for you, your legal spouse ad your eligible depedets. You determie the amout of moey you would like to deposit ad it is deducted before ay taxes are take from your paycheck. You ca the use that moey to pay for eligible health care expeses. Your etire aual electio amout is available o the first day of the pla year. If you submit a claim for more tha your curret balace, you will be reimbursed up to your aual electio amout. This allows you more flexibility i how you icur ad claim expeses. Your pla year is the period of time you are participatig i the pla. It begis wheever you eter the pla. You caot be reimbursed for expeses icurred before you etered the pla. Note: Some (but ot all) plas allow you to carry over a amout of up to $500 of your Health Care FSA moey ito the ext pla year. See your Summary Pla Descriptio to fid out if the carryover provisio is part of your pla. Some limitatios apply. Eligible Depedets The IRS specifically defies who is cosidered to be a eligible depedet for the Health Care FSA. You may oly submit expeses for yourself ad your eligible depedets. A depedet is eligible whether or ot he/she is covered o your health pla, as log as he/she is: your spouse; or your child who is age 26 or youger. You may also use the FSA for eligible health care expeses for ay other perso who resides i your home for at least six moths of the year ad for whom you claim a depedecy deductio o your federal icome taxes. HELPFUL HINT Your depedet does ot have to be covered o your health isurace for you to ru their out-of-pocket expeses through the Health Care FSA. As log the perso is a eligible depedet, their eligible expeses qualify for reimbursemet. Here s a example of how a Health Care FSA claim might work. LIZ Jauary 1, aual electio amout....$1,500 Jauary paycheck cotributios...$125 Jauary 31, submits claim for doctor visit....$500 Reimbursemet amout....$500 Remaiig available balace $1,000 3

4 Partial List of Commo Eligible ad Ieligible Expeses The list of expeses for which you ca claim reimbursemet from the Health Care FSA is extesive. This sectio provides just a few of the most commoly claimed expeses so that you ca get a idea of how you might use the accout. If you are cosiderig budgetig for a expesive procedure like LASIK, major detal work or orthodotia, have a evaluatio ad receive your cost estimates before you set the moey aside i your FSA. Please keep i mid that the list of eligible expeses is determied by the Iteral Reveue Service (IRS) Code Sectio 213, ad is ot at your employer s or TRI-AD s discretio. The IRS also requires you to provide documetatio provig that your claim is eligible. This is discussed more i the sectio titled Usig Your FSA. This list is a geeral guidelie ad is ot iteded to be a guaratee of reimbursemet or eligibility. Please review your employer-sposored Summary Pla Descriptio ad erollmet materials for specific iformatio, or cosult your persoal tax advisor. HELPFUL HINT Access to a extesive list of eligible items is available o TRI-AD s FSA Participat Toolkit, or by loggig ito your FSA accout at 4 Lear More Olie Your estimated Some Commo Eligible Expeses expeses Acupucture, acupressure, ad other therapies for specific medical coditios $ Chiropractic visits $ Cotraceptives $ Detal care $ Eye care: exams, LASIK ad other visio correctio procedures, prescriptio glasses, prescriptio suglasses, cotact leses ad cotact solutios $ Fertility treatmets $ Hearig aids $ Isurace copays $ Medical supplies $ Orthodotia based o cotract paymet arragemets $ Physical therapy for a specific medical coditio $ *Prescriptio drugs (No-cosmetic) $ Idividual psychology ad psychiatry fees i coectio with a specific medical coditio $ **Recostructive surgery related to a medical coditio $ Smokig cessatio programs $ Treatmet for alcoholism ad drug addictio $ Aual Total $ Items that may be eligible uder specific coditios ** Family couselig is eligible if it is related to a medical coditio (for example, couselig associated with a cacer diagosis or drug addictio treatmet). Geeral marital ad family couselig is ot eligible. ** Reti-A for a specific medical coditio such as ace treatmet ** Weight loss programs if prescribed by a doctor ** Over-the-Couter items The IRS requires a prescriptio for over-the-couter (OTC) drugs ad medicies to be cosidered eligible expeses i your FSA. Herbs, vitamis ad mieral supplemets are oly eligible with a letter of medical ecessity. Commo ieligible expeses iclude Premiums for other health plas, icludig COBRA Cosmetic procedures (teeth whiteig/veeers, liposuctio, Botox, etc.) Fitess programs used for geeral welless Herbs, mierals, vitamis ad other supplemets used for geeral welless Warraty programs * Drugs over $50 require drug ame o receipt. ** Additioal documetatio is required (i.e., a letter of medical ecessity or, i the case of OTC drugs or medicies, a formal writte prescriptio).

5 Depedet Care FSA The Depedet Care FSA lets you use tax-free dollars to pay for child ad elder day care costs icurred so that you ad your spouse may work or atted school full-time. This accout is ot to cover your depedets health care expeses; use the Health Care FSA for that. The IRS allows a family maximum cotributio of $5,000 per caledar year to the Depedet Care FSA. If your spouse also participates i a Depedet Care FSA, your combied cotributios caot be higher tha the family maximum. If you are married ad file separate tax returs, the maximum amout you ca cotribute is $2,500. Special rules apply for determiig the eared icome of a spouse who is disabled, a full-time studet or uemployed. Please cotact TRI-AD or your tax advisor for more iformatio. Ulike the Health Care FSA, the amout available for reimbursemet from your Depedet Care FSA is the amout you have cotributed to date. If a claim Eligible Expeses exceeds the amout curretly i your accout, you will receive partial paymets based o your accout balace util the expese is fully paid or your cotributios for the pla year cease. Eligible Depedets The depedet must live i your home for at least eight hours a day to qualify for Depedet Care FSA expeses. The depedet must also meet at least oe of the followig requiremets: Depedet care i or outside your home $ Preschool tuitio, if part of the total depedet care $ Before ad after school care $ Summer day camps (icludig activity-based camps where the activity ad day care fees are itegrated). Overight camps, summer school programs, food ad equipmet costs are ot eligible for reimbursemet. For example, if your child goes to soccer camp, the day camp costs would be eligible but equipmet fees would ot. $ Aual Total $ Uder age 13 who you claim as a depedet o your icome tax retur or if you are legally separated or divorced, for whom you are the custodial paret. A child, spouse or other depedet who has bee deemed physically or metally icapable of self-care, ad for whom you claim a depedecy deductio o your federal icome taxes. Your estimated expeses IRS Guidelies Depedet care expeses paid to oe of your depedets are ot reimbursable. For example, moey you pay to your 17-year-old to watch your 12-year-old caot be claimed. Day care ceters that care for more tha six childre must be licesed. Expeses ca oly be reimbursed after they have bee icurred. If you prepay your day care, you may ot submit it for reimbursemet util after the service has bee redered. For example, if you pay for the etire moth of July o July 1, you may ot submit your reimbursemet request util July 31. Depedet Care FSA or Federal Icome Tax Credit: Which is Right for You? The IRS allows a tax credit for depedet care. You caot claim the same expeses for both the Depedet Care FSA ad Federal Icome Tax Credit, so you eed to decide which is better for you. I geeral, higher wage-earers ad those with oe eligible depedet beefit more from the Depedet Care FSA, ad lower wage-earers ad those with more tha oe child may beefit more from the tax credit. Your situatio is uique, so we suggest you cosult with your tax advisor before makig your choice. Lear More Olie 5

6 Erollig i the FSA Plas Oce you have estimated your expeses, you are ready to eroll. You ca eroll at the followig times: Durig your compay s aual ope erollmet Withi 31 days of the date you first become eligible to participate Withi 31 days of the date a qualified status chage (e.g., birth, divorce) occurs, or as permitted by your compay s pla. Chagig Your Electio Oce you eroll, your electio will remai i effect for the etire pla year. Your compay s pla may allow you to chage your electios if you have a status chage such as marriage, birth or divorce. Electio chages made because of a qualifyig evet must be cosistet with the status chage. For example, if you have a baby, you may icrease your Health Care FSA electio, but you may ot decrease it. Your aual electio will be divided by the umber of pay periods i the pla year. For example, if you have 24 pay periods per year ad you elect $2,400, your per-pay-period deductio would be $100. Employers have differet methods for acceptig erollmets. Please follow your employer s istructios for successfully erollig i the pla. Frequetly Asked Questios Ca I participate if I m ot erolled i my compay s health pla? Yes. You ca still participate i oe or both FSA plas. Why should I participate if I have health care coverage? You could sigificatly icrease your spedable icome! The amout you elect to cotribute is deposited ito the FSA before taxes are deducted from your paycheck, so you pay your eligible expeses with tax-free dollars. This ca mea a sigificat discout o those expeses. What happes if I termiate my participatio or employmet, or my positio is reduced to part-time durig the year? Health Care FSA Oce your employmet is termiated, or if you have a qualified status chage that permits you to termiate your pla participatio, or if you o loger meet eligibility requiremets, your pla year is over. The oly expeses that you may submit are those you icurred from your etry date through your date of termiatio, if eligible. If you elect COBRA, you ca cotiue to submit expeses util your accout balace is zero. Depedet Care FSA Check your Summary Pla Descriptio for iformatio regardig whe expeses may be icurred. Some employers plas allow you to be reimbursed for expeses you icur after your termiatio/ reductio i hours date util the ed of the pla year. Other employers plas (ot all) require you to icur all expeses o or before termiatio. The Depedet Care FSA caot be cotiued through COBRA. Cotiue submittig the eligible expeses you have before the last day of your compay s ru-out period as described i the Summary Pla Descriptio. Sometimes, the ru-out will be measured from your termiatio date rather tha the ed of the pla year. You will be reimbursed all the moey you have cotributed to your accout if your claims meet or exceed your cotributios. What happes if I have moey left i my accout at the ed of the pla year? Due to curret IRS regulatios, ay moey left i your FSAs at the ed of the pla year may be forfeited. You caot be paid out your balace i cash. Some plas allow for a amout of up to $500 of your Health Care FSA fuds to be carried over ito the ext pla year. Some limitatios may apply; see your Summary Pla Descriptio. Note: your employer may have adopted the grace period for your pla. If so, ad you are participatig i the pla the last day of the pla year, you have util the ed of the grace period to sped your remaiig balace. Please check your Pla Highlights olie to see if the grace period applies. Durig what timeframe are expeses eligible for reimbursemet? A expese is icurred o the date you receive the service or treatmet, ot the date you are billed or whe you paid for the service.* Oly eligible expeses that you icur durig the pla year (ad ay applicable grace period) will be reimbursed. You will have a ru-out period after the ed of the pla year durig which you ca submit claims for expeses icurred durig the pla year. This ru-out period varies from compay to compay, so please check your Pla Highlights olie for iformatio. * There are special rules for orthodotia reimbursemet. See TRI-AD s website for details. How do I get reimbursed? Log ito your FSA accout at ad click o Eter a New Claim. Sca ad upload your documetatio. Claims may also be submitted through the mobile app oce you have registered. How will I kow how much moey I have i my accout(s)? You ca check your accout balace 24 hours a day, seve days a week o TRI-AD s website, through the mobile app, or by callig You will also receive iformatio with each reimbursemet check, or a otificatio via for direct deposits. 6

7 Usig Your FSA Maagig Your Accout Olie Whe you log ito your accout at, you will fid may tools ad features to help you make the most of your FSAs. Claims area Access the Claims area to submit a claim olie, check the status of ay claims you have filed, view a history of your claims or provide documetatio to substatiate your claim(s). The TRI-AD Beefits debit card If your pla has the debit card, you ca check the status of a card trasactio, provide documetatio to substatiate a card trasactio, access the cardholder agreemet ad more. You ca also report a lost/stole card, request a replacemet or order cards for your depedets over age 16. Direct Deposit Setup Eter your bak accout iformatio to have your reimbursemet automatically deposited each time a claim is approved. This is the fastest, easiest ad safest way to receive your reimbursemets without havig to worry about mail delays or misplaced checks. Resources The Resources area of the site is the place to go to lear more about FSAs, icludig plaig tools ad Frequetly Asked Questios. Eligible Expese List Before you icur a expese or submit a claim, access a comprehesive, up-to-date list of eligible expeses to make sure the item, service or treatmet is cosidered a eligible expese by the Iteral Reveue Service. (Cotiued o page 8) You do t wat to sed it. We do t wat to ask for it. But the IRS requires it. TRI-AD requests documetatio to substatiate your claim or debit card trasactio because the Iteral Reveue Service (IRS) requires that all claims be substatiated. Eve if your icurred expese is at a medical or detal provider s office, we request documetatio because we do t kow what treatmet or procedure you had there. Remember, ot all services provided by medical, detal ad other healthcare providers are eligible for reimbursemet through your FSA. For example, you could have had your teeth whiteed at the detist (a cosmetic procedure that is ot FSA eligible). Check 5 The IRS requires 5 pieces of iformatio to substatiate every claim. Whether you re filig a claim for reimbursemet, or providig documetatio to back up your debit card trasactio, the followig iformatio must be provided: The date the service was icurred (ot the date you paid the bill) The service provider s ame For whom the service was provided The charges or out-of-pocket expese amout A clear descriptio of service If you do ot provide all of the required iformatio, your claim will be delayed, deied or your debit card may be deactivated. Give Us Your Address Log i at ad update your Persoal Profile, icludig your otificatio prefereces, so we ca let you kow your claim is beig processed. Lear More Olie 7

8 (Cotiued from page 7) Maagig your Accout O the Go Access your accouts from your mobile device (Adroid phoe, iphoe ad ipad) with our mobile app. Dowload it for free from the Apple Store TM or Google Play TM. With the features available i the app, you ca: Check your balace View claim status Maage your providers View iformatio o your electios, paymets ad cotributios Submit a claim Take a picture of your receipt ad attach it to your claim. Lear More Olie Filig a Claim is as Easy as Log ito your accout ad eter your claim:. Log ito your FSA accout at. Create a ew claim ad provide your claim iformatio ad ay required documetatio, or use the mobile app to submit your claim. 2. Provide the supportig documetatio. IRS rules say that your documetatio must show: The date the service was icurred (ot the date you paid the bill) The service provider s ame To whom the service was provided The charges or out-of-pocket expese amout A clear ad detailed descriptio of service or item Acceptable documetatio: Examples of acceptable documetatio are: isurace compay Explaatio of Beefit forms (EOBs), receipts showig the above iformatio, ad bag tags for prescriptios. Uacceptable documetatio: Bak card statemets, isurace compay claim forms, caceled checks, estimates of expeses ad balace forward statemets are ot valid documetatio. 3. Upload your documetatio: After you provide your basic claim iformatio, you ca upload your documetatio at that time right to TRI-AD s site, ad attach it to your claim as part of filig the claim. Mobile app users may take a photo of their receipts to submit right through the phoe. Cotact Iformatio TRI-AD Participat Services represetatives are available Moday through Friday from 5:00 a.m. to 6:00 p.m. Pacific Time. Phoe: (888) FSA Fax: (866) or (760) Web: flexmail@tri-ad.com The iformatio cotaied herei is cosidered to be geeral i ature. I the evet that aythig o this brochure differs from the iformatio cotaied i your compay s pla provisios as set forth i the Summary Pla Descriptio ad/or Pla documet, those documets shall prevail. 8