Enroll in a Flexible Spending Plan and... Give Yourself a Raise! Look Inside to Find Out How... to pay your eligible medical and dependent daycare expenses with the swipe of a Flex Convenience debit card! No out-of-pocket expenses No waiting for reimbursement Virtually no claim forms Same great tax savings Finally, Flex is EASY & CONVENIENT!
Flexible Benefits with Flex Convenience What is a Flexible Spending Account? A Flexible Spending Account is an employer-sponsored benefit that allows you to pay for certain medical expenses (not covered by your medical plan) for you, your spouse and eligible tax dependents with pre-tax dollars. You may also use pre-tax dollars in a Flexible Spending Account to pay for dependent daycare expenses that allow you and your spouse to work. Because this benefit uses pre-tax dollars, a Flexible Spending Account is a great way for you to save money on your healthcare and dependent daycare costs while increasing your take home pay! You will save on Federal, State and FICA taxes on dollars you contribute. This means, depending on your tax bracket, you could save up to 45%* on every plan dollar you spend. You can calculate your estimated savings by visiting Calculate your Savings on our Flex website: Introducing the Flex Convenience Debit Card With the MGIS Flex Convenience card, accessing your Flex dollars is easier than ever. The card offers a convenient way to pay your portion of eligible out-ofpocket expenses at the point-of-service, which eliminates the burden of paying up front for the service and waiting for reimbursement. INCREASE YOUR TAKE HOME PAY WITH AN FSA Without a Flex Plan WITH a Flex Plan Your Annual Income $40,000 $40,000 Contribution to $0 $2,000 Flex Account (before taxes) Taxes Paid $14,000 $13,300 (estimated at 35%) After-Tax Income $26,000 $26,700 Increase in Take Home Pay with Flex $700 Get the card and enjoy the savings! How it Works Using the card is easy as 1-2-3. You simply: 1. Give the provider the card at the time of service to pay for your portion of the eligible expense. 2. Have the provider swipe the card for the amount of your portion of the eligible expense. The amount will automatically be debited from your Flex Account. 3. Obtain and save receipts from providers for expenses paid with the card. The card may be used at eligible service provider locations that accept Visa or MasterCard. The card can only be swiped for the amount in your account. If you try to swipe the card for more than is available in your account, the transaction will be denied. You can check your account balance 24 hours a day, 7 days a week by visiting our Flex website. Remember, you must keep receipts for expenses paid with the card (such as itemized bills for healthcare visits, glasses, prescription drugs and daycare services). Receipts are required by the IRS to substantiate the eligibility of your expense. Visit our website to learn more about Flex * Actual savings will vary depending on a participant s tax bracket.
Flexible Benefits with Flex Convenience About the Plans Here is a brief overview of the different types of Flexible Spending Plans that may be offered by your employer. Visit our Flex website for further details. Healthcare Flexible Spending Account (FSA) A Healthcare FSA is a medical reimbursement plan that allows you to pay for eligible medical-related expenses (under IRS 213) with pre-tax dollars. Eligible expenses may include copayments, deductibles, prescription drugs, certain over-the-counter medications, eyeglasses/contacts and much more! Please visit the Forms section of our website for a complete listing of allowable expenses. Dependent Care Assistance Plan (DCA) By enrolling in a DCA, you can use pre-tax dollars to pay for daycare expenses for your child or qualifying dependent. Only expenses that allow you and, if married, your spouse to work are eligible for reimbursement under the plan. Depending on your tax bracket, participating in the DCA plan will typically save you more money than taking the dependent care tax credit on your tax return. Health Reimbursement Arrangement (HRA) An HRA is 100% funded by your employer for the purpose of reimbursing medical, dental, pharmacy or vision charges not reimbursed by the standard healthcare plan. Your employer will designate the allowable expenses under the plan as well as the contribution amount per employee. Transportation Fringe Benefit Plan A Transportation Fringe Benefit Plan allows you to pay for qualified, employment-related parking, transit passes and vanpooling expenses with pre-tax dollars. WHAT YOU SHOULD KNOW BEFORE YOU ENROLL IRS Guidelines require substantiation of every card purchase; therefore, you must keep your receipts and submit a copy of your receipts to MGIS, if requested. Services must be incurred during the current Plan Year. If you are billed after the close of the Plan Year for a service incurred during the Plan Year, you may still be reimbursed for that service. Use it or lose it. Any funds not used by the end of the current Plan Year will be forfeited to the Plan. Depending on your Plan, there is a specified grace period after the end of the Plan Year to submit reimbursement requests for services incurred during that Plan Year. If your service provider does not accept Visa or MasterCard you will be required to pay for the service and submit a manual Reimbursement Request Form (available on the Flex website). How to Enroll To enroll in the Plan, all you have to do is complete an Election Form and give it to your employer. Indicate on the form for each account in which you are enrolling the amount you want deducted from each paycheck and the total annual amount you are contributing. Complete the Direct Deposit Application to have reimbursements (for expenses not paid with the card) automatically deposited into your personal bank account. Visit Our website serves as a useful tool. By visiting the website you have access to detailed information about Flexible Spending Plans and how they work. You may also visit the website to download forms and view your account status/balance. Medical Group Insurance Services, Inc. Toll-free: 1.866.WeRFlex (937.3539) Fax: 801.990.2401 Email: flexinfo@mgis.com Internet:
Medical Group Insurance Services, Inc. 1849 W. North Temple Salt Lake City, UT 84116-3067 F-0647 10/04 e-mail: flexinfo@mgis.com Toll-free: 1.866.WeRFlex (937.3539) Fax: 801.990.2401 Internet:
Flexible Benefits A Product of the MGIS Group Benefits Division Direct Deposit Facts Fast Your money should be deposited in your account within 48 business hours after your claim is processed. (Checks can take up to 10 days). Secure The Automated Clearing House (ACH) system is a secure, private network. Convenient No trips to the bank to deposit a check No check-cashing fees. You will not have to worry about lost or stolen checks. Even if you are sick or on vacation, you can be sure that your reimbursement will be deposited into your account, safe and ready to use. ACH transactions are returned at a lower rate than checks. There were nearly 14 billion ACH payments made in 2005 4.4 billion of those were direct deposits. 97% of those who use Direct Deposit are satisfied. You sign up for Direct Deposit only once. Questions you may have... How do I set up my account for direct deposit? Complete and sign the Direct Deposit application and attach a voided check. We will accept a clear photocopy of a voided check. Please fax or mail the completed form back to us at: MGIS Attn: Flex Dept. 1849 West North Temple Salt Lake City, UT 84116-3067 Fax: (801) 990-2401 Do I have to use a certain financial institution to participate in Direct Deposit? Any institution in the United States that is a member of the ACH network can be used. What should I do if I change financial institutions? If your account is changing or has been closed, please let us know as soon as possible. You must complete a new Direct Deposit application with new account information. Why do you ask for a voided check when I sign up for Direct Deposit? We need the financial institution identification number (also known as the routing and transit number) as well as the account number that appears on checks. The voided check ensures the information is correct. Does using Direct Deposit cost me any money? No. In fact, your financial institution may offer free checking for using Direct Deposit. Visit our website to learn more about Flex F-05-DirDeposit_071106 For more information, contact Medical Group Insurance Services, Inc. 800.969.6447 866.WeRFlex (937.3539) flexinfo@mgis.com
Flexible Benefits The Flex Website Visit our website...to access helpful Flex resources and learn more about Flex! Check your account balance 24 hours a day Find answers to frequently asked questions Learn what expenses are eligible for reimbursement under the Plan Download the forms you need How to Set Up Your Account and Check your Account Balance: 1. Go to 2. Click on the Employee Account Access link located in the center of the page. 3. The first time you login, you will need to set up an account by clicking on the Create Account link. To create an account, you will need your Employee ID (Social Security number) and your Flex Convenience card number. 4. After setting up your account, you can simply login with the User ID and Password you selected. 5. When you login, you can view your account balance, account activity and the status of your claims. If you have any questions or do not have access to the Internet, please contact MGIS at 1.800.969.6447 F-F23_081705 Medical Group Insurance Services, Inc. 1.866.WeRFlex (937.3539)
FLEXIBLE BENEFITS PLAN ELECTION FORM To enroll, complete the following information, sign the form and return it to your Human Resources Representative. PLAN INFORMATION EMPLOYER NAME: PLAN YEAR: PLEASE PRINT OR TYPE EMPLOYEE INFORMATION NAME LAST FIRST MI HOME ADDRESS DATE OF HIRE (Required) MMDDYY SOCIAL SECURITY NUMBER NUMBER AND STREET CITY STATE ZIP CODE DATE OF BIRTH E-MAIL ADDRESS PHONE NUMBER GENDER LOCATION/DEPARTMENT M F MMDDYY PARTICIPANT S EFFECTIVE PLAN DATE ELECTION INFORMATION (Only if different than beginning of Plan Year shown above) DATE OF FIRST PAYROLL DEDUCTION I understand that the rules of the Internal Revenue Code allow me to use part of my salary on a pre-tax basis to purchase one or more of the following qualified benefits. I hereby elect to participate in my employer s Flexible Benefits Plan as indicated below. MMDDYY OPTION I PREMIUM CONVERSION ACCOUNT (PCA OR POP) The group insurance premiums you pay through payroll deductions. AUTOMATIC No election required. Unless you notify your employer to the contrary, your share of the insurance premiums will automatically be paid with pre-tax dollars. PLEASE CHECK YOUR ELECTION(S) AND FILL IN AMOUNT IF APPLICABLE BENEFIT ELECTION OPTIONS ELECTION DEDUCTION OPTION II HEALTHCARE FLEXIBLE SPENDING ACCOUNT (FSA) You can elect up to the maximum amount as designated by your employer s Plan. YES NO $ PER PAY PERIOD NO. OF PAYCHECKS (i.e., 12, 26, etc.) $ ANNUAL OPTION III DEPENDENT CARE ASSISTANCE PLAN (DCA) Maximum of $5,000 per Plan Year if single parent or if married and filing a joint Tax Return. Maximum of $2,500 if married and filing separately. YES NO $ PER PAY PERIOD NO. OF PAYCHECKS (i.e., 12, 26, etc.) $ ANNUAL PARTICIPANT ELECTION AUTHORIZATION I have reviewed and understand the terms and conditions on the back of this page and in my company s Summary Plan Description. I understand that I can not change or revoke this election at any time during the Plan Year unless I have a Qualifying Life Event change (including marriage, divorce, death, birth or adoption of a child, change or termination of spouse s employment, change in dependent care provider or such other events as the Plan Sponsor determines will permit a change or revocation of an election). I further acknowledge that I am responsible for keeping all receipts verifying all eligible expenses claimed under the Flex Convenience card and must submit such receipts to MGIS for claims substantiation upon request. CHOOSE ONE: YES, the benefits of this Plan have been explained to me and I elect to participate as indicated above. I have read the disclosure on the back of this form and hereby agree to the terms of the disclosure by signing this form. NO, I do not want to participate in an FSA or DCA at this time, but I understand that I will automatically be enrolled in a PCA/POP. I further understand that I will not have another opportunity to enroll in an FSA or DCA until the next Open Enrollment period unless I have a Qualifying Life Event change. OPTIONAL: I would like to request an additional card for my spouse or tax dependent: ADDITIONAL CARDHOLDER NAME DATE OF BIRTH SOC. SEC # PARTICIPANT S SIGNATURE X DATE HR s SIGNATURE X DATE SERVICED BY MGIS Medical Group Insurance Services, Inc. 1849 W North Temple Salt Lake City, Utah 84116 1.866.WeRFlex (937-3539) Fax 801.990.2401 e-mail: flexinfo@mgis.com F-F08_BASE_011105
TERMS AND CONDITIONS Qualifying Medical Care and Dependent Care Expenses: I understand that reimbursement will be available only for qualifying medical care expenses as listed under 213 and qualifying dependent care expenses as listed under 129 and 21 of the Internal Revenue Code for me and my eligible dependents. These expenses must be incurred while I am enrolled in the Plan. I agree to notify the Plan Sponsor or MGIS if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to repay the Plan on demand by way of check or payroll deduction for any expense paid for with the Flex Convenience card that is not allowed under 213, 129 or 21 of the Internal Revenue Code. I attest that I understand claimed medical expenses can not be reimbursed under the Healthcare FSA Plan if the expense has been or will be paid in the future by any other plan and acknowledge that the medical expenses have not been reimbursed or are not reimbursable under any other insurance plan coverage. I further acknowledge that I am responsible for keeping all receipts verifying all eligible expenses claimed under the Plan and must submit such receipts to MGIS for claims substantiation, upon request. Participation Rules: I understand that reimbursement account eligibility, enrollment and benefits information is available from my Plan Sponsor. I authorize payroll deductions for the benefit elections indicated on this Election Form. I understand that I cannot change or revoke this compensation reduction agreement at any time during the Plan Year except for the occurrence of a Qualifying Life Event. In the case of a Qualifying Life Event, I must complete a Change Form no later than 30 days after the date the Qualifying Life Event occurs if I want to enroll in a reimbursement account or change my reimbursement account elections or amounts. Any amounts remaining in the account(s) represented by this Election Form at the end of the Plan Year, past the claims filing limit, will be forfeited to the Plan under the guidelines of the Internal Revenue Code. THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE PLAN SPONSOR S CAFETERIA PLAN, MEDICAL REIMBURSEMENT PLAN, AND/OR DEPENDENT CARE ASSISTANCE PLAN AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION REDUCTION AGREEMENT RELATING TO SUCH PLAN(S). AUTHORIZATION I authorize the use and disclosure of my protected health information as described below. My protected health information is individually identifiable health information, including demographic information, collected from me or created or received by a healthcare provider, a health plan, my employer, or a healthcare clearinghouse and that relates to: (i) my past, present, or future physical or mental health or condition; (ii) the provision of healthcare to me; or (iii) the past, present, or future payment for the provision of healthcare to me. Medical Group Insurance Services, Inc. (MGIS) is authorized to use or disclose my protected health information for the purpose of administering my 125 account. I further authorize MGIS to release my protected health information to my spouse and/or my tax dependent(s). I understand that I may decline disclosure of my protected health information (to my spouse and/or tax dependent/s) by submitting a written notification to MGIS. All protected health information pertaining to the reimbursement of a 125 claim may be used and disclosed by MGIS. I understand that if my protected health information is to be received by individuals or organizations that are not healthcare providers, healthcare clearinghouses or health plans covered by federal privacy regulations, my protected health information described above may be re-disclosed and no longer protected by federal privacy regulations. I understand that I may revoke this authorization at any time by sending a written notification to MGIS, and this revocation will be effective for future uses and disclosures of protected health information. However, I further understand that this revocation will not be effective: (i) for information that MGIS already has used or disclosed, relying on this authorization or (ii) if the authorization was obtained as a condition for coverage by MGIS and, by law, MGIS has a right to contest the coverage. I understand that this authorization expires upon termination of my employer s plan. Medical Group Insurance Services, Inc. 1849 W north Temple Salt Lake City, Utah 84116 1.866.WeRFlex (937-3539) Fax 801.990.2401 e-mail: flexinfo@mgis.com F-F08_BASE_011105
DIRECT DEPOSIT APPLICATION Instructions 1. Print clearly and use black ink 2. Complete the required information 3. Attach an entire VOIDED CHECK (do not use a deposit slip) 4. Sign and date application 5. Send to Medical Group Insurance Services, Inc. (MGIS) NAME OF EMPLOYER EMPLOYEE NAME SOCIAL SECURITY NUMBER EMAIL ADDRESS I would like my reimbursements deposited to the bank account indicated below. BANK NAME ACCOUNT NUMBER BRANCH CHECKING SAVINGS I hereby authorize Medical Group Insurance Services, Inc. (hereafter MGIS), to deposit any amounts owed me by initiating credit entries to my account at the financial institution (hereinafter BANK) indicated above. Further, I authorize BANK to accept and to credit any credit entries indicated by MGIS to my account. In the event that MGIS deposits funds erroneously into my account, I authorize MGIS to debit my account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until MGIS and BANK have received written notice from me of its termination in such time and in such manner as to afford MGIS and BANK a reasonable opportunity to act on it. EMPLOYEE SIGNATURE X DATE If you have ANY QUESTIONS concerning this form, please contact MGIS. Your service representative will be happy to assist you. Qualified assistance is available by calling toll-free 800.969.6447 Monday Friday, 7:30 am 5:00 pm MST. TAPE VOIDED CHECK HERE (DO NOT STAPLE) MAIL TO MEDICAL GROUP INSURANCE SERVICES, INC. AT THE ADDRESS LISTED BELOW: Medical Group Insurance Services, Inc. 1849 W North Temple Salt Lake City, Utah 84116 1.866.WeRFlex (937-3539) Fax 801.990.2401 e-mail: flexinfo@mgis.com F-F09_101504