Diocese of Owensboro. FSA Open Enrollment Packet. Effective 01/01/2018 thru 12/31/2018

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Laurel Marsh
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1 Diocese of Owensboro FSA Open Enrollment Packet Effective 01/01/2018 thru 12/31/2018 Open Enrollment Period 11/16/ /30/2017

2 FSA - Flexible Spending Account Eligibility: * All Full-Time employees working at least 20 hours per week are eligible to participate in the FSA. * Contributions can begin the 1st of the month following 90 days after date of hire. * Members contributing to the FSA do NOT need to be enrolled in the Diocesan medical plan. Election Changes: * Federal regulations state that once you have made an election for a designated contribution amount, you CANNOT make changes during a plan year except for specific changes in status. The Diocesan Human Resources can provide a list of these changes. Contribution Maximum: * Employee maximum contribution limit is $2,000. This is all that can be contributed. * Members CAN contribute to their own FSA even if spouse has one. Carryover Rules: * Members are allowed to carryover a maximum of $500 to the next plan year. (January - December) * This plan has a "use-it or lose-it" function.

3 Open Enrollment for Flexible Spending Accounts November 16 November 30, 2017 It s Open Enrollment time for Flexible Spending Accounts (FSA). Open enrollment begins November 16 th thru November 30 th. The Diocese is offering full-time employees working 20 hours or more per week the choice to enroll in a FSA plan. Coverage begins January 1, 2018 and ends December 31, Employees don t have to be enrolled in the Anthem health plan to participate with the FSA. All eligible employees must complete the Diocese of Owensboro s Flexible Spending Account Enrollment Form to participate. All forms must be given to the person at your location who handles benefits by Thursday November 30, The maximum annual amount you may contribute to the Diocese s FSA plan is $2,000 from 01/01/ /31/2018. Please read carefully Anthem s Health Flexible Spending Account Frequently Asked Questions Document. Should you have any questions please contact the Diocese s Human Resource Department at

4 Please Print Employee Name Last, First, Middle Initial Diocese of Owensboro Flexible Spending Account Enrollment Form Plan Year - January 1, 2018 to December 31, 2018 Number of Pay Periods per Year: Home Address City/State/Zip Code Social Security Number Health Care Contributions I elect to participate in the Flexible Spending Account plan for the upcoming plan period. I understand that I can contribute to my Health Care Account each plan year. I want the following amounts to be taken from my salary: Medical Expense Flexible Spending Account (Medical FSA) Maximum Annual Election Allowed: $2,000 $ * Per Pay Period $ *Annual Total (= PPP x ) *Please note: the amount per pay period and the annual total must equal the same amount and cannot exceed the maximum.* Health Care Automatic Reimbursement I certify that expenses reimbursed through my FSA will be incurred by me (and/or my spouse and/or my eligible dependents) and will not be reimbursed by another plan. I (or we) will not use the expenses reimbursed through the FSA program as deductions or credits when filing my (our) individual income tax return. Approval I understand that my contributions to each account can only be used to reimburse eligible expenses under each account and that I forfeit any funds remaining in my account at the end of the plan period. I further understand that I cannot change my contributions unless I have a qualified family status change and that my salary reduction contributions will continue for the remainder of the plan period unless a qualified change is made. My Social Security benefits may be reduced since Social Security taxes are not paid on my contributions. I authorize payroll reductions as contributions to my health and/or dependent care accounts as indicated above. Employee Signature: Date: Revised 11/16

Flexible Spending Account (FSA)

Flexible Spending Account (FSA) Confirmation Form 3880 (11/2016) Page 1 of 7 The following form collects the critical information WageWorks needs to prepare and properly service your program for the upcoming