Dayton Public Schools HRA Plan Design Effective Date: January 1, 2016 Coverage Period: January 1 December 31 HEALTH CARE REIMBURSEMENT ARRANGEMENT (HRA) Your Personal Tax Free Health Reimbursement Arrangement If you have coverage under your employer s group health insurance plan but are ineligible to contribute to a Health Savings Account (HSA), you will receive a benefit known as a Health Reimbursement Arrangement (HRA). HRA Benefits* This plan year, your employer will fund your HRA with: *$750 per Employee-Only contract *$1,500 per Family contract The funds may be used for eligible expenses for the employee, their spouse and their dependent children. From this unique account you can be reimbursed for eligible out of pocket medical, vision and dental expenses...tax free! Getting Started This brochure includes answers to many commonly asked HRA questions as well as includes a page listing examples of eligible and non-eligible expenses. A claim form and claim instructions can also be found in this brochure. *Maximum HRA Benefit is prorated for those who are newly eligible following the initial open enrollment period. If you have already received employer funding into your HSA, you will not receive additional funding. FlexBank Administrators 1250 W. Dorothy Lane, Suite 107 Dayton, Ohio 45409 Phone: 937.299.5515 Fax: 937.299.7992 Free Phone: 888.677.8373 Free Fax: 888.677.9373 www.flexbank.net Please refer to the HRA Summary Plan Description (SPD) for complete plan design details. You have the option of waiving your HRA benefit each Plan Year. See your Benefits Administrator if you would like to decline coverage.
HRA FAQs How do I request reimbursement? We want to make it easy for you to obtain reimbursement. In order to process your request, we must receive a signed claim form as well as itemized receipts. How long will it take to make a withdrawal? Reimbursement requests are processed on a daily basis. You may be reimbursed by check or direct deposit. Direct deposit takes approximately two business days to appear in your bank account. When can I submit requests to withdraw money from my HRA? You may request reimbursement at any time. However, many people accumulate a number of receipts and submit them all at once. Do I have to submit all requests for reimbursement before the end of the plan year in order to be reimbursed? No. You will have up to 90 days after the plan year to make requests for reimbursement. I was billed $100 in March for my surgery last October. Can I be reimbursed with this year s money? Unfortunately, no. Reimbursements are made based upon your date of service, not when you paid the bill. I have dental insurance but my dentist makes me pay a portion of my bill at the time of service. Can I get reimbursed for what I have paid? Not immediately. Where you are responsible for a percentage of the expense, before we can reimburse you, you must first submit these types of expenses to your insurance company. Your insurance company will then send you a summary of your medical claims indicating what amount, if any, insurance has paid. This is known as an Explanation of Benefits (EOB). We need a copy of this EOB in order to reimburse you. What happens if I terminate employment? You may continue to submit requests for reimbursement for allowable expenses incurred through the termination of your participation in your group health plan. You have 90 days after the end of the plan year to submit the eligible expenses to FlexBank. Who is eligible for HRA reimbursement? You may request reimbursement for eligible expenses for your spouse and eligible dependents. Children are eligible for reimbursement from the HRA through age 26 even if they are not considered your dependent. Generally, HRAs are subject to COBRA continuation. Please see your benefits administrator for more information.
HRA Sample Eligible Expenses Eligible Expenses Acupuncture Alcoholism / Drug treatment Ambulance charges Arthritis gloves Artificial limbs Artificial teeth Bandages / Band-Aids Blood pressure monitors Blood sugar test kits/strips Body scans (MRIs) Breast Pumps and supplies Carpal tunnel wrist support Chiropractic fees Contact lenses & solutions Contraceptives Co-pays Co-insurance Costs for physical or mental illness confinement CPAP devices Crutches Deductible expenses Dental implants Dental treatment Dentures Diabetic supplies Eyeglasses & eye exam First aid kits Flu shots Hearing aids & batteries Incontinence supplies Insulin supplies Laboratory fees Laser eye surgery Liquid adhesive for small cuts Mastectomy related bras Medical alert bracelet Medical records charges Midwife Mileage Occlusal guards Orthodontic fees Orthopedic shoe insert Ovulation monitor Oxygen Physical therapy Prescriptions Pregnancy test kits Prosthesis Psychiatric care Reading glasses Rehydration solution (Pedialyte) Rubbing alcohol Saline solution Seeing eye dog Shipping & handling for eligible medical expenses Smoking cessation programs Special communication equipment for the deaf Speech therapy Sterilization fees Sunscreen Taxes on medical services & products Telephone for hearing impaired Thermometer Transportation expenses primarily for medical care Walkers Wheelchair X-rays Dual Purpose Expenses Requires a doctor's note or Rx w/ a diagnosis stated Air purifier Compression hose Medical alert bracelet Dietary supplements Health club dues Humidifier Hypnosis Petroleum jelly Massage therapy Vitamins Weight loss programs Over the Counter Medicines (OTC) Requires a valid prescription Acne treatment Antacids Antibiotic ointments Anti-itch creams Allergy medicines Cold medicines Diaper rash cream Eye drops Laxatives Lice treatment Motion sickness Pain relievers Smoking cessation products Wart remover treatments Ineligible Expenses Cosmetic procedures Dental floss Deodorant Electrolysis Eyeglasses/contacts warranty Face creams & moisturizers Hearing aid warranty Hand lotion Imported drugs Late fees Marital counseling Maternity clothes Mattresses Missed appointment fee Mouthwash Non-prescription sunglasses Prepayments Sunglass clips Teeth whitening Toiletries & cosmetics Toothbrushes & toothpaste Vitamins for general health FlexBank reimburses DAILY! Within 24 business hours of receiving your claim form and itemized receipts, FlexBank will issue a check, or directly deposit your reimbursement into your personal bank account. Review your account 24-7 You may view your account balance 24-7 at www.flexbank.net. Call FlexBank! If you have questions and want to talk with someone in person vs. researching online, please call FlexBank s office Monday Friday from 8:00 am to 5:00 pm at 888.677.8373. This is a partial listing of eligible expenses. For more information email Claims@FlexBank.net or call FlexBank at 888.677.8373.
A) You have been contacted by FlexBank asking that you provide documentation to verify that the debit card expenses are eligible. HRA Debit Card Claim Form Use this claim form if: OR B) You did not use your debit card and would like to be reimbursed for you expenses incurred out of pocket. EMPLOYEE NAME LAST 4 DIGITS OF EMPLOYEE SOCIAL SECURITY # EMPLOYER NAME PLEASE CHECK IF NEW ADDRESS DAYTIME PHONE # YOUR EMAIL HOME ADDRESS CITY STATE ZIP DO YOU OR YOUR ELIGIBLE DEPENDENTS HAVE INSURANCE COVERAGE FOR ANY OF THE FOLLOWING: HEALTH? YES NO DENTAL? YES NO VISION? YES NO To the best of my knowledge and belief, my statements in this Claim Form are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year and for eligible plan participants. I certify that these expenses have not been previously reimbursed under this plan, an HSA, or any other benefit plan and will not be claimed as an income tax deduction, nor will I seek reimbursement from any other source. The following person has authorization to speak with FlexBank on my behalf regarding the information contained in this claim. Name Employee's Signature Date I DID use with my Medical Debit Card. I DID NOT use my Medical Debit Card. Please itemize expenses below and attach receipts that includes the following information: Provider or Merchant Name Patient Name Service(s) Received or Item(s) Purchased Date of Service Amount of Expense Rx receipts must include: patient name, medication name or number, date of service, amount of expense. If your medical or dental expense was submitted to insurance, a summary or an Explanation of Benefits (EOB) from your insurance company showing what they paid and what you owe is required. Visit www.mybenny.com for your account balance and to view all of your Benny Card activity, as well as monitor FlexBank s requests for documentation required in order to approve your previous transactions. Your member ID is your full social security number without dashes. Date of Service HEALTH CARE EXPENSES Name of Patient Description of Service Provided Amount via Mail: FlexBank Administrators, 1250 W. Dorothy Lane, Suite 107, Dayton OH 45409 via Fax: 937.299.7992 or 888.677.9373 via Email: Claims@FlexBank.net via Mobile: http://www.flexbank.net/m/ Questions? Call us 888.677.8373 or visit our website www.flexbank.net. TOTAL
HRA Enrollment Form Section I. Employee Information Employer Name: Plan Year: Division #: Employee Name: Social Security Number: Street: City: State: Zip: Birth Date: Hire Date: Effective Date of Participation: Male Female Section II. Health Reimbursement Arrangement (HRA) Type 1. I do not and will not Type 2. My spouse contributes to Single contribute to a Health a Health Savings Account. Savings Account in my I do not contribute to an Family name. HSA. I decline HRA coverage for this Plan Year. I elect: General-purpose HRA for medical, vision and dental expenses. I elect General Purpose HRA (medical, vision, dental) for: Employee only Employee & children Note name of spouse: Participant should not submit receipts for spouse. Type 3. I own and/or my spouse owns a Health Savings Account. I elect: Limited HRA for vision, dental, postdeductible medical expenses. Section III. Authorization Date Employee Signature
Employer Name: HRA Employee Eligibility Form ** This form must be completed in its entirety to comply with Federal Regulations.** Division: Employee Name: Male Female Date of Birth: Social Security #: Street: City: State: Zip: Date of Hire: HRA Eligibility Date: Termination/Benefit End Date: HRA Benefit Amount: Benefit Information Type of Coverage: Employee Only Employee + Children Family Employee + Spouse Dependents Covered by HRA First Name Last Name Social Security # Date of Birth Relationship to Employee Medicare Eligibility Is the employee or any dependent enrolled in Medicare? Yes No Medicare Participant Name: 1. Medicare Health Insurance Claim Number (HICN): 1. 2. 2. Effective date of eligibility/entitlement: Reason for Medicare coverage: 1. 2. 1. 2. Part A Part B Part A & B Part D Age End Stage Renal Disease (ESRD) Disability Disability & ESRD Employee Signature Date Revised October 2011 www.flexbank.net Phone: 937.299.5515 ~ Free Phone: 888.677.8373 ~ Fax: 937.299.7992 1250 W. Dorothy Lane, Suite 107, Dayton OH 45409