How much should I contribute?

Transcription

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2 1 An FSA, or Flexible Spending Account, is a benefit you can choose during Open Enrollment. By contributing pre-tax dollars to an FSA, you can save an average of 30 percent on health care and dependent care costs. The money you contribute is not subject to payroll taxes, which can result in substantial tax savings! Choose one or both QUICK NOTES An FSA is like a savings account for health care and dependent care expenses. It saves you more than 40 percent because you contribute pre-tax dollars! Health Care FSA Choose this FSA to pay for medical, prescription, dental and vision expenses you or your family incur. Eligible expenses: Eyeglasses Co-pays Prescriptions LASIK Dental work Orthodontia And MUCH more! Dependent Care FSA Use this FSA to cover expenses for a dependent child or parent. Eligible expenses: Adult or child care Pre-school Day camp Before/after school care Elder care And MUCH more! VIEW ALL Health Care EXPENSES: VIEW ALL DEPENDENT CARE EXPENSES: 2

3 2 Calculate how much you need with our online calculator. This handy tool will suggest how many pre-tax dollars you may want to contribute. You can get started by estimating your expenses below. Health Care FSA: Type of expense Examples Estimated annual cost Deductibles Medical, dental, vision $ Co-payments/ The amount not covered $ co-insurance Dependent Care FSA: by your health plans Prescriptions Antibiotics, blood pressure. $ medication, etc Vision Glasses, contacts, solution, exams, etc. $ Dental Cleanings, orthodontics, crowns, etc. $ Health care mileage Trips to and from doctor, dentist, etc. $ Total expenses $ Type of expense Examples Estimated annual cost Child care expenses Day care, before/after school care, $ day camp, preschool In-home care In your home or someone else s $ Elder care services Adult day care center $ Total expenses $ ONLINE CALCULATOR: 3

4 It s easy. You can enroll in an FSA during your company s Open Enrollment period. Once you ve enrolled, you ll receive confirmation of your election amount. And you can start saving! Step 1: Use one of the tools below. Step 2: Enroll in an FSA during Open Enrollment. TOOLKIT 3 ONLINE CALCULATOR: VIEW ALL HEALTH CARE EXPENSES: VIEW ALL DEPENDENT CARE EXPENSES: FOR MORE INFORMATION: VIEW MORE DETAILS: Details Section 4

5 Understanding the rules If I don t use the money in my FSA, do I lose it? It s true. The IRS mandates that if you don t use up your FSA account balance by the end of the plan year, you lose the money. So make sure to access your account online to see your balance, claim filing deadline, claim submission deadline and claim information. When can I change my contributions? Certain life changes allow you to enroll in an FSA or make changes to your current FSA contribution. When you get married or have a child, you are able to start contributing to an FSA or alter your contribution amount in order to accommodate the health care and dependent care expenses of your growing family. What happens to my FSA if I terminate employment? Participation in the FSA ends if you terminate employment. You may submit a claim for reimbursement of eligible expenses after your participation ends. The expenses must have been incurred prior to the plan termination date and they must be submitted within the run-out period. 5 What is the run-out period? The run-out is a specified period of time after the end of the plan year in which you may continue to submit claims incurred during your period of coverage. This is not a period when you are able to continue to incur new expenses, but rather it allows you time to gather and submit expenses before forfeitures are applied. How do changes in Health Care Reform affect me? One of the biggest changes that will affect your Health Care FSA is eligibility for over-thecounter (OTC) expenses. As of 1/1/2011, OTC medicines are only reimbursed by an FSA if they are prescribed by a doctor. This change only applies to medicine. Supplies, such as contact lens solution and bandages, are not affected by the change. In addition, Insulin remains eligible without a prescription. Effective 1/1/2013, individual employee contributions to a Health Care FSA will be limited to $2,500 per year. 5

6 Getting reimbursed How do I submit a claim? Once you re enrolled, all you have to do is incur an eligible expense, log onto your account and file your claim online. You can even upload your receipt or Explanation of Benefits online. If you don t have access to the online forms, you can request one from Ceridian and mail or fax in your receipts with the completed form. Once your claim is approved, you will be reimbursed according to your employer s scheduled reimbursement dates. How do I make sure my claim isn t denied? In order to process your reimbursement, the IRS requires that you provide a copy of your receipt or an Explanation of Benefits from your insurance company. Whichever document you send, it should include the following pieces of information: 5 Date of service Amount due (i.e., patient responsibility amount) Provider name Type of service or service description (e.g., Cleaning or Crown are valid descriptions; Dental is not) When will I get reimbursed? With a Health Care FSA, you will be reimbursed even if your eligible expenses exceed your amount of contributions to date. With a Dependent Care FSA, you will be reimbursed once your contributions cover your expenses. Will a Health Care FSA reimburse me for these eligible expenses if incurred by my dependents? You may claim expenses for all persons who are covered under your employer-sponsored medical plan. Expenses incurred by a non-covered dependent may not be reimbursable from your FSA. Consult your Summary Plan Document for more details. 6

7 Flexible Spending Account Enrollment Form Employee Information Account ID Please provide your SSN if you are completing this form as part of your first Ceridian FSA election. Otherwise, you may provide your Account ID. Your Account ID is the 10 digit number found on most FSA correspondence from Ceridian. Please include the leading zeros. Example: Social Security Number Last Name First Name M.I. Mailing Address Number Street Apt. Daytime Phone ( ) City State Zip Code FSA Election Plan Year: 1/1/2014 to 12/31/2014 FSA Plan Benefit Amount Health Care FSA I elect to participate. My annual contribution is $ I elect not to participate. Minimum Plan Year Contribution Amount: $ Maximum Plan Year Contribution Amount: $ Dependent Care FSA I elect to participate. My annual contribution is $ I elect not to participate. Minimum Plan Year Contribution Amount: $ Maximum Plan Year Contribution Amount: $ * * If you are married and file jointly, your combined contributions may not exceed $ If you are married and file separately, your individual contributions may not exceed $ Authorization I understand that by signing and submitting this form, I authorize the adjustment of my annual taxable salary based on my elections above, with the tax protected funds being transferred into my Flexible Spending Account. My election cannot be changed during the plan year, unless I experience an eligible change in status. I further understand that this form must be signed and dated prior to my plan effective date to be eligible to participate in this plan year. Any unused amounts remaining in my account at the end of the plan year will be forfeited. However, I will have a specified period of time (indicated in the FSA enrollment materials) after the end of the plan year or date of my termination to submit receipts for reimbursement for services received during the plan year or coverage period. I also certify that I, and my spouse, dependent(s) and/or adult children if applicable, will only use the Flexible Spending Account Card that I will receive in connection with employer s Health Care Flexible Spending Account Plan and in Section 213 of the Internal Revenue Code. I further certify that I will not seek reimbursement from any other plan for any medical expense paid with the Flexible Spending Account Card, nor will I claim any federal income tax deduction or credit with respect to such expense. Employee Signature X Date TO BE COMPLETED BY EMPLOYER Company Name R & L Carriers, Inc. (C1) Client ID L06194 Plan Year From 1/1/2014 to 12/31/2014 Division Class Effective Date Medical Plan ID Dental Plan ID Vision Plan ID Pharmacy Plan ID Pay ID RBA1922

8 Benefits Card Additional Card Request Employee Information (All Fields Required. If more than 2 cards are needed, please complete additional form(s) as needed.) Employee Last Name First Name Middle Initial Social Security Number - - Employer Name Client Code Daytime Phone Number ( ) First Additional Card User Information Last Name First Name Middle Initial Social Security Number - - Relationship to Employee (check one box) Spouse Dependent or Adult Child 18 years of age or older Date of Birth / / I agree to use the Benefits Card only for eligible medical care expenses under the Reimbursement Plan of the Employee listed above and as defined in Section 213(d) of the Internal Revenue Code. I further certify that I will not seek reimbursement from any other plan for any medical expense paid with the Benefits Card, nor will I claim any federal income tax deduction or credit with respect to such medical expense. First Additional User Signature X Date Second Additional Card User Information Last Name First Name Middle Initial Social Security Number - - Relationship to Employee (check one box) Spouse Dependent or Adult Child 18 years of age or older Date of Birth / / I agree to use the Benefits Card only for eligible medical care expenses under the Reimbursement Plan of the Employee listed above and as defined in Section 213(d) of the Internal Revenue Code. I further certify that I will not seek reimbursement from any other plan for any medical expense paid with the Benefits Card, nor will I claim any federal income tax deduction or credit with respect to such medical expense. Second Additional User Signature X Date Employee Authorization I agree to ensure that each Additional User identified above will use the Benefits Card only in connection with my employer s Reimbursement Plan (the Plan ) for eligible medical care expenses, as defined in the Plan and in Section 213(d) of the Internal Revenue Code. I certify that each Additional User qualifies as either my spouse (as defined by Federal laws), dependent or adult child (as defined by the Plan) that is18 years of age or older. I further certify that neither I, nor any Additional User, shall seek reimbursement from any other plan for any medical expense paid with the Benefits Card, nor claim any federal income tax deduction or credit with respect to such medical expense. Employee Signature X Date Please return completed form to Ceridian via fax at You may also mail to: Ceridian, P.O. Box , St. Petersburg, FL If for any reason an additional card cannot be issued a Ceridian Representative will contact you. RBA1911 LH Ceridian Corporation. All rights reserved. BenCard Req 01/10

9 Direct Deposit Authorization Reimbursement Account Please attach a voided check or Savings Account Direct Deposit Form here. Instructions This form should be completed upon initial enrollment of the benefit and need not be resubmitted each new plan period. You should remit this form if you have new or updated banking information to provide. Please print all information legibly. Attach a voided check if you designate a checking account. Do not submit a deposit slip. If you designate a savings account attach a completed Savings Account Direct Deposit Form from your financial institution. Please sign and date the form. Omission of signature will delay processing. Mail completed form to the address indicated at the bottom of the page. Notify Ceridian immediately of any account changes or account closings. Direct Deposit authorization requires that all account and bank routing numbers be verified for accuracy before any funds are transferred. Eligible claims submitted during the 10-day verification period will be reimbursed with a check. After the verification period, reimbursements will be posted to your bank account two to four days after the scheduled reimbursement date. You will receive a Reimbursement Statement through the mail. Always verify your statement to make sure it is not a negotiable check. Participant Information First Name Last Name Social Security Number - - Daytime Telephone ( ) Employer Name Client Code Bank Information Check only one: Set up Direct Deposit for: Checking (please attach void check above) Savings (please attach a Savings Account Direct Deposit Form from your financial institution Change Account Information Cancel Direct Deposit Full Bank Name Telephone ( ) Bank Routing Number (9-digit number on lower left of check) Bank Account Number (to 17-digits) Important The designated account must be in your name. Processing of your Direct Deposit information will be delayed if you do not include both the bank account number and the bank routing number. Contact your bank if you are unsure of your bank account information. Authorization I hereby authorize Ceridian to initiate credit entries for depositing my reimbursements into my account designated above and, if necessary, make corrections for any entries made to my account in error. This authority is to remain in full force and effect until Ceridian has received written notification from me of its termination in such time and in such manner as to afford Ceridian a reasonable opportunity to act on it. Signature Date Please return completed form to Ceridian via fax at You may also mail to: Ceridian, P.O. Box , St. Petersburg, FL RBA1910