Flexible Spending Account Benefit Programs

Transcription

1 Flexible Spending Account Benefit Programs The Flexible Spending Accounts (FSAs) offered under the Bosch Choice Welfare Benefit Plan help you save money by letting you set aside money on a Pre-Tax basis to pay for eligible expenses. There are two types of accounts: Healthcare FSA. This FSA reimburses you for eligible outof-pocket medical, dental and vision expenses. There are two types of Healthcare FSAs available to you Traditional and Limited Purpose. If you have a Health Savings Account through the CDHP Medical Plan (see the Healthcare Benefit Programs section), you are only allowed to participate in a Limited Purpose Healthcare FSA. Dependent Day Care FSA. This FSA helps reimburse you for out-of-pocket expenses related to the care of your dependents while you are working. For More Information Administrative details and procedures can be found in the Administrative Information section. If you have questions about the information in this SPD, you can contact the Bosch Benefits Center at ( internationally). Bosch Choice April

2 In This Section See Page Benefits-at-a-Glance Participating in FSAs How Your Accounts Work Changing Contributions During the Year How Much You Can Deposit How Much Can Be Reimbursed Pre-Tax Contributions Issues to Consider When Coverage Ends Healthcare FSA Whose Expenses Can Be Reimbursed Eligible Healthcare Expenses Non-eligible Healthcare Expenses Making Contributions during a FMLA Leave of Absence COBRA Continuation Coverage for Healthcare FSAs Dependent Day Care FSA Whose Expenses Can Be Reimbursed Eligible Dependent Day Care Expenses Non-eligible Dependent Day Care Expenses Making Contributions during a Leave of Absence Federal Dependent Tax Credit Paying Yourself Back Submitting Expenses Claim Decisions and Appeals Right of the Plan to Obtain Information April 2015 Bosch Choice

3 Benefits-at-a-Glance Flexible Spending Accounts (FSAs) help you pay for eligible expenses with money that is free from most income taxes. You put aside a portion of your pay on a Pre-Tax basis to cover eligible out-of-pocket healthcare or dependent day care expenses. That portion of your pay is not subject to federal, Social Security, and, in most cases, state or local income taxes. Then, when you or your dependents incur an eligible expense, the FSA reimburses you for the expenses that you ve paid. The table below provides a comparison of the key features of the Healthcare FSAs and Dependent Day Care FSA. FSA Comparison Who s Eligible Who Contributes HSA Eligible Bosch associates enrolled in the Bosch CDHP 80 or CDHP 90 Benefit Options Bosch, with associate contributions optional Traditional Healthcare FSA Any Bosch associate who does not have an HSA Associate only Limited Purpose Healthcare FSA Any Bosch associate enrolled in the Bosch CDHP 80 or the CDHP 90 Benefit Options, and who also has an HSA Dependent Day Care FSA All eligible Bosch associates Bosch Choice April

4 Annual Contribution Limits Eligible Expenses Funding Rules HSA For the 2015 calendar year, up to $3,350 individual, $6,650 family on a Pre-Tax basis Reduced dollar for dollar by Bosch s contribution to the HSA each calendar year. If you are age 55 or older, you may contribute an additional $1,000 per calendar year See Eligible Expenses in the Healthcare Benefit Programs section of this SPD. See IRS Publications 502 and 969 for details Funds earn interest at a rate established by BenefitWallet; funds remaining at Plan Year end may be rolled over for use in future years Traditional Healthcare FSA Limited Purpose Healthcare FSA Associates may contribute between $120 and $2,550 to a Healthcare FSA each Plan Year on a tax-free basis. Medical expenses Prescription drug expenses Dental expenses Vision expenses See IRS Publications 502 and 969 for details Dental expenses Vision expenses See IRS Publications 502 and 969 for details Dependent Day Care FSA Associates may contribute between $120 and $5,000 to a Dependent Day Care FSA each Plan Year on a tax-free basis. Pre-kindergarten education Care outside your home Dependent day care or day camp Transportation to get the dependent to and from a care facility (eligible only if transportation is provided by the caregiver) Age restrictions apply See IRS Publications 503 for details Funds do not earn interest; funds remaining at Plan Year end are forfeited 90 April 2015 Bosch Choice

5 Participating in FSAs This section explains who is eligible to participate in FSAs, making changes during the year, how the accounts work, how much you can deposit and be reimbursed, Pre-Tax contribution issues to consider, when coverage ends and how to continue coverage through COBRA. How Your Accounts Work The Flexible Spending Accounts help you save money by offering you the ability to set aside money on a Pre-Tax basis. There are three types of flexible spending accounts: Traditional Healthcare FSA, Limited Purpose Healthcare FSA, and Dependent Day Care FSA. You may elect to participate in either a Healthcare FSA (whether Traditional or Limited Purpose) or the Dependent Day Care FSA or both. Your participation in a Health Savings Account (HSA) will determine which type of Healthcare FSA you can enroll in. Because of the many tax advantages an HSA provides, if you have an HSA, the government only allows you to participate in a Limited Purpose Healthcare FSA at the same time as the HSA. If you don t have an HSA (or are ineligible for Pre-Tax contributions to an HSA) but are enrolled in a CDHP, you may still participate in a Traditional Healthcare FSA by calling the Bosch Benefits Center. Payroll deductions will be taken out of your regular pay to reach your annual goal amount and deposited into an account set up specifically for you. If you elect to contribute to both a Healthcare and Dependent Day Care FSA, two separate accounts will be maintained. When you incur eligible expenses, you simply submit a claim for reimbursement as outlined under Paying Yourself Back on page 104. Contributions to the FSAs are deposited on a Pre-Tax basis. This means that you will not pay federal (and in most cases state) income tax or Social Security taxes on the money contributed to the FSAs. However, there are some important tax regulations you need to consider when deciding how much to contribute. See IRS Rules under Pre-Tax Contributions Issues to Consider on page 94 for more information. The Bosch Choice Welfare Benefit Plan Year runs from April 1 to March 31 of the following year. Your Flexible Spending Account contribution elections do not carry over from year-to-year. Unspent balances are forfeited. To continue contributing, you must re-enroll every Plan Year during the Annual Enrollment period. Bosch Choice April

6 Please review your paycheck after you enroll to make sure that the appropriate deductions are being processed. If you have any questions, contact the Bosch Benefits Center at ( internationally). When Contributions Begin Your FSA contributions will begin as soon as administratively possible following your election. The amount you elect to put in your accounts is contributed over the Plan Year in equal installments, through payroll deductions, on a Pre-Tax basis. Note: If you are enrolling at any time other than Annual Enrollment, the amount you elect to contribute will be deducted in equal installments, based on the number of deduction periods remaining in the Plan Year (i.e., if you are enrolling in November, the amount you elect will be deducted in equal installments through March 31). Be sure to review your paycheck after you enroll to make sure that the appropriate deductions are being processed. If you have any questions, contact the Bosch Benefits Center at ( internationally). Changing Contributions During the Year You may experience certain events during the Plan Year that would allow you to change your contributions to the FSAs; these are referred to as change in status events. To receive the coverage you want, you must change your contributions within 60 days of the event. If you do not change your contributions within 60 days of the event, your next opportunity to make a change will be during the Annual Enrollment period. You can enroll or change the level of contributions to the FSAs during the year only if a change in status event occurs. The following are change in status events for the FSAs: You or your eligible dependents become eligible or ineligible for FSA coverage because of a change in: legal marital status (such as marriage, divorce, legal separation or annulment), number of dependents (such as birth, death, adoption, placement for adoption* or court ordered guardianship), an eligible dependent s status (for example, your dependent is no longer eligible for coverage due to age or student status), or employment status (for example, ending or starting employment, changing from part-time to full-time or vice versa, or a change in residence or worksite if it affects eligibility for benefits). For the Healthcare FSA only, you or your eligible dependents become eligible for or lose COBRA coverage or extended coverage under USERRA, Medicare or Medicaid. For the Dependent Day Care FSA only, you experience a significant increase or decrease in your eligible dependent day care expenses for a dependent day care provider who is not your relative, or your dependent day care provider changes. * Placement for adoption means that, in anticipation of a child s adoption, the person with whom the child is being placed has the legal obligation for at least 50% of the child s support. 92 April 2015 Bosch Choice

7 If you experience a change in status event as listed above, you have 60 days from the date of the event to access the Bosch Benefits Center website or call the Bosch Benefits Center and change your benefit elections. For contact information, see the Contact Information section of this SPD. The benefit change you request must be consistent with the qualifying life event. For example, if you have a baby, you can enroll or increase contributions to the Dependent Day Care FSA; however, you cannot drop or decrease contributions to that account. For all change in status events, your new elections will become effective on the date of the event if you provide timely notice of the event. If you do not provide timely notice of the change in status event and complete a new election within the 60-day timeframe, your contributions will remain as is and any money deposited into the accounts will not be refunded. How Much You Can Deposit The following chart provides current contribution amounts for the Plan Year (April 1 March 31). FSA Minimum Plan Year Contribution Maximum Plan Year Contribution Traditional Healthcare $120 $2,550 Limited Purpose Healthcare $120 $2,550 Dependent Day Care $120 $5,000 The following calendar year limits also apply to the Dependent Day Care FSA: if you are married or in a domestic partnership and file a joint tax return, you and your spouse/domestic partner may contribute only a combined total of $5,000, if you are married or in a domestic partnership and file separately, you and your spouse/domestic partner may contribute only $2,550 each, if you are married or in a domestic partnership and your spouse/domestic partner earns less than $5,000, you cannot be reimbursed for more than your spouse/domestic partner s/domestic partner s earned income (unless your spouse/domestic partner is disabled or a full-time student), and if you are married or in a domestic partnership and your spouse/domestic partner is disabled or a full-time student, he or she will be treated as earning $250 each month ($500 if you are caring for two or more dependents, including your spouse/domestic partner). Bosch Choice April

8 Note Refunds from the FSAs due to incorrect enrollments are not allowed per IRS rules. How Much Can Be Reimbursed How much you can receive depends on the Flexible Spending Account from which you request reimbursement: You can receive reimbursement from your Healthcare FSA (Traditional or Limited Purpose) up to the total amount elected for the year regardless of how much is in your account when you make your request. You can receive reimbursement from your Dependent Day Care FSA only up to the balance that is in your account at the time you submit your request. As more money is deposited into your account, you will receive the balance of the amount requested. For more information about submitting expenses, see Paying Yourself Back on page 104. Pre-Tax Contributions Issues to Consider This section provides important information that may affect how much you elect to contribute to the Flexible Spending Accounts. IRS Rules By allowing you to contribute to the FSAs on a Pre-Tax basis (meaning that you pay no federal income or Social Security taxes, and in most cases no state taxes on your contributions), the Internal Revenue Service (IRS) has established the following rules: Rule 1 Use It or Lose It. If your eligible expenses are less than what you have put into the account at the end of the Plan Year, any unused money cannot be returned to you or carried over into the next Plan Year. Rule 2 No Transfers. The Healthcare and Dependent Day Care FSAs must be maintained separately money cannot be transferred from one account to the other. You cannot use your Healthcare FSA for reimbursement of dependent day care expenses, or vice versa. In addition, any amount remaining in either of your accounts when your participation in the Plan ends will also be forfeited. If you have dependent day care expenses, you also need to consider whether it would save you more money to use the Dependent Day Care FSA, the child care tax credit (that can be claimed on your federal taxes) or both. It may be helpful to discuss these options with your financial or tax advisor, and to review IRS Publication 503 (available at Additional information is located under Dependent Day Care FSA beginning on page 101. Please Note: Certain nondiscrimination rules apply the FSAs. If, at any time, the Company determines that the FSAs may not satisfy any of these nondiscrimination rules, the Company may take whatever action it deems appropriate to comply with these rules. The action may include, without limitation, changing your elections, with or without your consent, but the Company will notify you of any changes to your FSA elections. 94 April 2015 Bosch Choice

9 Plan Carefully Contribute only as much as you think you will need for the Plan Year any money in your account(s) not used for eligible expenses at the end of the Plan Year will be forfeited. Note: Claims can be submitted up until June 30 for eligible expenses incurred by March 31 (the last day of the Plan Year). Effect on Other Benefits Making Pre-Tax contributions to the FSAs may slightly reduce your future Social Security benefits. For most people, the reduction will be very small. Unemployment or Workers Compensation benefits may also be slightly reduced if you become eligible for them. When Coverage Ends Except for rights outlined under COBRA Continuation Coverage for Healthcare FSAs, your ability to contribute to the Healthcare and Dependent Day Care FSAs will end if: your employment ends for any reason, including retirement, you are no longer eligible for the FSAs, you fail to pay required contributions, or the Plan is terminated, canceled or amended. Although you may file a claim up until June 30 for any qualified expenses incurred during the Plan Year while you were still covered by the FSA, expenses incurred after your coverage ends generally will not be reimbursed. Note: For the Dependent Care FSA, you can incur expenses after your termination of employment up until March 31 (the end of the Plan Year) and submit them for reimbursement; however, keep in mind that expenses for reimbursement must be submitted on or before the June 30 deadline. When coverage ends, you may continue contributing on an After-Tax basis to the Traditional or Limited Purpose Healthcare FSA for the duration of the Plan Year in which a qualifying event occurs. See COBRA Continuation Coverage for Healthcare FSAs on page 100 and COBRA Continuation Coverage in Healthcare Benefit Programs for more information about continuing your coverage under COBRA. Note You may be able to continue contributing to the Healthcare FSA on an After-Tax basis; see COBRA Continuation Coverage for Healthcare FSAs on page 100 for more information. Bosch Choice April

10 Healthcare FSA Eligible Dependents This definition of dependent is different from that used for the Dependent Day Care FSA. Although the Benefit Programs may pay for many of your healthcare expenses, not all your bills will be covered. You can pay for those expenses that are not covered by the Healthcare Benefit Programs through your Healthcare FSA. There are two Healthcare FSAs available under this Plan: Traditional Healthcare FSA. This FSA can be used to pay for expenses such as medical, dental and vision plan deductibles, prescription drug coinsurance, prescription eyeglasses and contacts, and prescribed over-the-counter drugs. Limited Purpose Healthcare FSA. This FSA is available to associates who participate in a Health Savings Account (HSA) and can be used only to pay eligible dental and vision care expenses. (See Medical Benefit Program in the Healthcare Benefit Programs section for more information about HSAs.) Regardless of the option you elect, you can contribute from $120 to $2,550 to the Healthcare FSA each Plan Year. Whose Expenses Can Be Reimbursed Your Healthcare FSA can be used to reimburse: your own healthcare expenses, and healthcare expenses incurred by your spouse/domestic partner and other eligible dependents, even if they are not covered by a Medical Benefit Program. Refer to Who Is Eligible in Participating in the Plan for who is an eligible dependent. Eligible Healthcare Expenses Eligible healthcare expenses are unreimbursed expenses for medical care for you and your eligible dependents that are not covered by a healthcare plan and that would qualify as deductions on your federal tax return. These expenses must not have been reimbursed through insurance or any other source. Generally, eligible healthcare expenses are incurred for the diagnosis, cure, treatment or prevention of disease. 96 April 2015 Bosch Choice

11 Traditional Healthcare FSA Eligible healthcare expenses for the Traditional Healthcare FSA include: health insurance deductibles, coinsurance and/or copays for services and supplies; for example: doctor s office visits, eye exams, prescription drugs; charges above the Reasonable and Customary amount covered by a healthcare plan (i.e., charges you are required to pay to your healthcare provider), and expenses not covered by a healthcare plan, such as: medically necessary aids prescribed by a physician, including hearing aids, false teeth, orthopedic shoes, crutches, braces and elastic hosiery, surgery to correct or improve vision, prescription sunglasses, routine foot care, smoking cessation programs, smoking cessation drugs that are prescribed by a physician and are not available over-the-counter, weight loss programs, treatments and prescriptions that are prescribed by your physician to treat a medical illness (for example, heart disease), life improvement tools for the visual or hearing impaired, including guide dogs, Braille books and magazines and telephone equipment, special schools that teach Braille to a visually impaired person, lip-reading to a hearing impaired person and remedial language training to correct a condition caused by a birth defect, childbirth classes for the mother-to-be only, over-the-counter medications or drugs, but only if prescribed by a physician, or infertility treatments. Limited Purpose Healthcare FSA Eligible healthcare expenses for the Limited Purpose Healthcare FSA include coinsurance and/or copays for dental and vision care services. For a complete list of eligible healthcare expenses, you can review PayFlex s website at healthhub.com. You also can review IRS Publication 502 or 969 at the IRS website at or on the CDHP Resource Center. Bosch Choice April

12 Non-eligible Healthcare Expenses You cannot use your Healthcare FSA (Traditional or Limited Purpose) to reimburse expenses for: over-the-counter medications or drugs unless prescribed by a physician, insurance premiums (contributions to participate in the Bosch Choice Welfare Benefit Plan or any other insurance premiums), amounts covered by any medical, dental or vision plan (including Medicare or any other state or federal program), weight loss programs and treatments that are not prescribed by your physician to treat a medical illness (for example, heart disease), supplies not related to an illness, disease or defect, charges for a nurse to care for a healthy baby, cosmetic surgery, dental bleaching or any other teeth whitening, illegal surgical procedures or drugs, expenses incurred before your date of participation in the Healthcare FSA or after the date your participation ends, medical care for which you take an itemized tax deduction on your federal tax return, expenses incurred for a dependent who is not an eligible dependent, dependent day care expenses (these should be considered for reimbursement through your Dependent Day Care FSA), expenses for long-term care, treatment or care that is merely beneficial to one s general health, such as an expense for recreation, or health clubs and nutrition, even if prescribed by a physician, expenses that are incurred after the end of the Plan Year (March 31). If you are uncertain if a healthcare expense qualifies for reimbursement under the Traditional or Limited Purpose Healthcare FSAs, contact the claims administrator for assistance (see Submitting Expenses on page 104 for information) or review PayFlex s website at healthhub.com. Any reimbursement paid for an ineligible healthcare expense under the Healthcare FSA will be subject to applicable income and other taxes. 98 April 2015 Bosch Choice

13 Making Contributions during a FMLA Leave of Absence Paid Leave If you are taking a paid FMLA leave of absence, you will continue making contributions to the Healthcare FSA on a Pre-Tax basis pursuant to your enrollment form. Your participation in the Healthcare FSA will continue as if you had never left your employment and you may be reimbursed for eligible healthcare expenses incurred during the period of your leave. Unpaid Leave If you take an unpaid leave of absence, you have the following choices: End your participation in the Healthcare FSA and stop making contributions to it during the period of your leave. Taking unpaid leave qualifies as a change in status event that would permit you to stop your contributions to the Healthcare FSA. If you elect to end your coverage under the Healthcare FSA, healthcare expenses incurred during the period of your leave would not be eligible for reimbursement even if you resume participation in the Healthcare FSA when you return from your leave. If you have not incurred claims that exceed your current contributions, then you may elect to remain out of the Healthcare FSA or you may elect to resume your participation in the Healthcare FSA for the remainder of the Plan Year. If you return from the leave during the same calendar year and you have received reimbursements of claims in excess of your current contributions, you will resume your participation in the Healthcare FSA for the remainder of the Plan Year. When you resume participation in the Healthcare FSA, you may either: resume participation at the level in effect before your leave started and increase your Pre-Tax payroll deductions for the remaining portion of the calendar year to make up the unpaid contributions (which allows you to be reimbursed up to the full amount you had elected for the calendar year); or resume participation by keeping your payroll deductions at the same level as was in effect before your leave began (your annual coverage level will be prorated, and the total amount you will be entitled to be reimbursed from your Healthcare FSA will be reduced by the amount of the contributions you did not make during the period of your leave). You may not, however, reduce your benefit elections for the Healthcare FSA below the amount already reimbursed to you from the Healthcare FSA. Continue your participation in the Healthcare FSA but discontinue contributions during the period of your leave. If you elect to continue your participation in the Healthcare FSA during the period of your leave, upon your return from leave during the same calendar year, your Pre-Tax payroll deductions will be automatically increased to make up the unpaid contributions you did not make during your leave. Healthcare expenses incurred during your leave are eligible for reimbursement. Bosch Choice April

14 Important Note To elect COBRA continuation coverage for your Healthcare FSA, you must have an unused balance in your account at the time of termination or when your participation in the Healthcare FSA would otherwise end. Returning From Leave during a Subsequent Calendar Year Upon your return to employment with the Company during a subsequent calendar year, you will be able to make a new election under the Healthcare FSA for that calendar year. You will not, however, be able to make Pre-Tax contributions in one Plan Year for coverage that would be effective during a subsequent calendar year. Before taking a leave of absence, you should discuss your choices with the Company to determine what choice is best for you. COBRA Continuation Coverage for Healthcare FSAs The COBRA continuation coverage that you may elect for the Healthcare FSA is different from the COBRA continuation coverage that you may elect for the Healthcare Benefit Programs. You may elect COBRA continuation coverage for your Healthcare FSA only if you have an unused balance in your account at the time of termination or when your participation in the Healthcare FSA would otherwise end (i.e., you must have not already received reimbursements of claims in excess of your current contributions at the time of the qualifying event). COBRA continuation coverage for the Healthcare FSA is only available until the end of the Plan Year in which the qualifying event occurs. If you are eligible for COBRA continuation coverage for the Healthcare FSA, you would have to pay for the coverage on an After-Tax basis (plus a two percent administrative fee, if applicable). Reimbursement cannot occur until the money is paid and processed into your account. 100 April 2015 Bosch Choice

15 Dependent Day Care FSA Many families require dependent day care services for their children or sometimes for a disabled parent. This type of care can be expensive which is why the Company offers the Dependent Day Care FSA. You can set aside tax-free dollars to help pay for those expenses. In order to use this account, you must follow the guidelines listed below: you must be at work during the time your eligible dependents (as listed under Whose Expenses Can Be Reimbursed ) are receiving care, if you are married or in a domestic partnership, your spouse/domestic partner must also be working, attending school full-time or be physically or mentally disabled, and if you are married or in a domestic partnership, and your spouse/domestic partner earns less than $5,000, you cannot be reimbursed for more than your spouse s/domestic partner s earned income, unless your spouse/domestic partner is disabled or a full-time student. For more information about contribution limits, see How Much You Can Deposit on page 93. Whose Expenses Can Be Reimbursed You can use the Dependent Day Care FSA to pay for care provided to your eligible dependents, including: your children under age 13 whom you include as exemptions for tax purposes, and dependents of any age who are unable to care for themselves because of a mental or physical disability and who have the same residence as you for more than one-half of the calendar year. Periodic verification through medical records will be required. Eligible Dependent Day Care Expenses Eligible expenses are those that would qualify for a child care tax credit on your federal tax return. These services may be provided inside or outside your home by babysitters, companions or eligible day care centers. Services, however, may not be provided by someone you claim as a dependent on your tax return or by your child under the age of 19. If care is provided for a disabled dependent (over the age of 13), the care must be provided at your home or the dependent must regularly spend at least eight hours each day in your home. Eligible Dependents This definition of dependent is different from that used for the Healthcare FSA, as well as for other Benefit Programs. Bosch Choice April

16 The following types of dependent day care expenses are eligible for reimbursement through this account: summer day camp, pre-school, day care center, before- or after-school care, care provided inside or outside your home by anyone other than your spouse/domestic partner or your dependents, a nurse or caregiver for an elderly relative, and services of a housekeeper whose duties include, in part, providing for a qualified dependent. For a complete list of eligible dependent day care expenses, you can review PayFlex s website at healthhub.com, review Publication 503 on the IRS website at or ask for Publication 503 from your local IRS office. Day Care Inside Your Home If services are performed in your home, you may be required to treat the caregiver as an employee and withhold income and Social Security taxes. See IRS Publication 926 for more information about household employees. Day Care Outside Your Home If the facility you select provides care for more than six non-resident individuals, it must comply with all state and local regulations in order to have the expenses reimbursed. Record Keeping In order to pay dependent care expenses with Pre-Tax dollars, you need to keep a record of the name, address and Social Security number (or federal employer identification number) of each person or organization that is paid to provide care. You will need to include this information on IRS Form 2441 that is filed with your tax return (or Schedule 2 if you file Form 1040A). Non-eligible Dependent Day Care Expenses You cannot use your Dependent Day Care FSA to reimburse expenses for: care provided by your spouse/domestic partner, your dependents for income tax purposes or your children under age 19, expenses for which you claim a dependent care tax credit on your federal income tax return, expenses incurred for a dependent during any period that you could not claim that individual as a dependent on your income tax return, expenses incurred before your date of participation in the Dependent Day Care FSA or after the date your participation ends, kindergarten tuition, 102 April 2015 Bosch Choice

17 overnight camp (prorating for daytime hours is not allowed), agency referral charges or finder s fees for placement of a nanny, caregiver s transportation to or from the dependent care location, healthcare expenses (these should be considered for reimbursement through your Healthcare FSA), cost for clothing, entertainment or food, and housekeeping expenses not related to dependent care. If you are uncertain if an expense qualifies for reimbursement under the Dependent Day Care FSA, contact the claims administrator for assistance (see Submitting Expenses on page 104 for information) or review PayFlex s website at healthhub.com. Any reimbursement paid for ineligible dependent day care expenses under the Dependent Day Care FSA will be subject to applicable income and other taxes. Making Contributions during a Leave of Absence If you take a paid or unpaid leave of absence (whether or not FMLA qualified) that lasts for no more than two calendar weeks, you will remain a participant in the Dependent Day Care FSA during this time. Any eligible dependent day care expenses incurred during your leave are eligible for reimbursement from your Dependent Day Care FSA. If your leave is unpaid, your Pre-Tax payroll deductions will be adjusted, when you return from leave during the same Plan Year, to make up any amounts missed during your leave. If you take a paid or unpaid leave of absence (whether or not FMLA qualified) that lasts two or more calendar weeks, your participation in the Dependent Day Care FSA will end, and you will need to re-elect participation upon your return from leave by contacting the Bosch Benefits Center. Federal Dependent Tax Credit You are not eligible to receive both federal dependent care tax credits and reimbursement under the Dependent Day Care FSA for the same expense. Before enrolling in the Dependent Day Care FSA, you should determine whether reimbursement of eligible dependent day care expenses under the Dependent Day Care FSA is better for you than the federal dependent care tax credits that may be available for the same expense. You can find the tax credit amount in IRS Publication 503, available on the IRS website at Keep in mind, unless your spouse/domestic partner is disabled or a full-time student, you cannot take a child care tax credit or use the Dependent Day Care FSA if your spouse/domestic partner does not work. You ll have to decide which option is best for your situation. A tax advisor can help you determine the best approach. Bosch Choice April

18 Paying Yourself Back Keep in Mind If you have money remaining in your Healthcare FSA as the end of the Plan Year approaches, you may wish to buy an extra pair of glasses, prescription sunglasses or contact lenses to use the money. When you have eligible expenses, you will generally need to pay for them out of pocket and submit a claim for reimbursement. You may submit claims to your Traditional or Limited Purpose Healthcare FSA up to your total annual contribution at any time during the year. For the Dependent Day Care FSA, you may only be reimbursed up to the amount you have contributed at the time you submit your claim. Submitting Expenses To be reimbursed for expenses, simply complete and submit a claim form, available online at the Bosch Benefits Center, along with the following information: a copy of the bill, the date of service, details about the expenses, including: For Healthcare FSA. An Explanation of Benefits (EOB) statement (to receive this statement, you must first file a claim with your healthcare plan), For Dependent Day Care FSA. Dependent information (name and age) and the provider s name, address, tax ID number or Social Security number, and a receipt of payment. Send your claims to: PayFlex Systems USA, Inc. P.O. Box 3039 Omaha, NE Or use Express Claims at healthhub.com to file online. For your records, be sure to make copies of all the information you submit. Claims will be processed timely, provided you have included all necessary information and documentation. Deadline for Submitting Expenses You have until June 30 each year to submit any expenses incurred during the previous Plan Year. The Plan Year is April 1 through March 31. If you still have a balance in your account after June 30, that money will be forfeited. 104 April 2015 Bosch Choice

19 Claim Decisions and Appeals Healthcare FSAs If your claim for a benefit is denied in whole or in part, you will be notified by the Claims Administrator within 30 days of the date your claim was received. It will include: the specific reasons for denial, references to the Plan provisions on which the denial is based, a description of any additional material or information that is needed to complete or support your claim and why it is needed, and procedures for how you can appeal your claim. In some cases, it may take up to 15 extra days to review your claim application; however, any extension will not go beyond 45 days from the date your claim was first received. If additional time is necessary, you will be notified by the end of the initial 30-day period of: the reasons for the delay, and an estimate of when your claim will be resolved. If additional information is needed to process your claim, you will be given at least 45 days to furnish that information. You also have the right to receive, on written request and without charge, copies of information relevant to your claim. Appealing a Claim You have 180 days from the date you receive the written denial of your claim to appeal. An appeal is a review by the Claims Administrator. Your appeal will not be reviewed by the same person (or their subordinate) who denied the claim in the first place. In addition, if a medical issue is involved, an independent medical opinion will be obtained. The Claims Administrator has 60 days from the date it receives your appeal to respond. Although the decisions of the Claims Administrator are final and binding, if you are not satisfied with the results of the appeal, you may have the right to file a lawsuit under the Employee Retirement Income Security Act (ERISA). However, you must file such a suit no more than 180 days after you are notified of the result of the appeal and you may not file such a suit unless you have first complied with the claims and appeals procedures in a timely manner. See Your Right to Benefits in the Administrative Information section for more information about lawsuits under ERISA. Address for Claim Appeals An appeal, or any information regarding an appeal, must be sent in writing to: PayFlex P.O. Box 3039 Omaha, NE Bosch Choice April

20 Dependent Day Care FSAs If a claim for a benefit is denied in whole or in part, you or your beneficiary will be notified by the Claims Administrator within 90 days of the date the claim was received. In some cases, it may take up to 90 extra days to review the claim application; however, any extension will not go beyond 180 days from the date the claim was first received. If additional information is needed to process the claim, you or your beneficiary will be given at least 45 days to furnish that information. Appealing a Claim You or your beneficiaries have 60 days from the date you or your beneficiary receive the written statement to appeal. An appeal is a review by the Claims Administrator. The Claims Administrator has 60 days from the date it receives the appeal to respond. The decisions of the Claims Administrator are final and binding. Address for Claim Appeals An appeal, or any information regarding an appeal, must be sent in writing to: PayFlex 700 Blackstone Centre Omaha, NE Right of the Plan to Obtain Information The Plan may provide or obtain any information needed for proper administration of the Flexible Spending Accounts. You may also need to provide additional information, if requested, in order to receive reimbursements. Overpayment The Plan may recover payments (from persons or plans) that exceed Plan provisions for expenses paid on behalf of you or your dependents. If an overpayment is made, the Plan will request that the money be returned. If the excess is not returned voluntarily, the Plan reserves the right to bring a legal action for the excess, or to offset other benefits, to the extent permitted by law. 106 April 2015 Bosch Choice