FLEX ENROLLMENT INFORMATION Help Center: 303-369-7886, 800-651-4855 24HourFlex Fax: 303-369-0003, 800-837-4817 Email: info@24hourflex.com www.24hourflex.com 24HourFlex.com 2851 S. Parker Road, #230 Aurora, CO 80014 Form: 2010 3 FEK 24HourFlex.com is a division of RPS Plan Administrators, Inc.
JOIN THE CAFETERIA PLAN PARTICIPATION IN A FLEXIBLE SPENDING ACCOUNT Flexible Spending Account (FSA) offers to you an easy way to reduce your taxes. When you participate in an FSA, you are only taxed on the income left over after you have paid certain out-of-pocket healthcare and daycare expenses. An FSA provides to you valuable benefits and tax savings since many of your normal expenses can be paid with pre-tax money. An FSA is a voluntary plan which allows you to set aside some of your compensation on a tax-free basis into Healthcare and/ or Dependent Care Spending Accounts. As you incur expenses during the plan year, you are reimbursed from these accounts. Through an FSA you can pay with pre-tax dollars the same expenses you have been paying with after-tax dollars. Enrolling in a Healthcare FSA Can Save You Money Annual Tax Savings FSA NO FSA If your taxable income is $30,000.00 $30,000.00 Pre-tax contribution ($2,000.00) $0.00 Taxable income after FSA contribution $28,000.00 $30,000.00 Federal income & Social Security taxes ($5,964.50) ($6,417.50) After-tax dollars spent on eligible expenses $0.00 ($2,000.00) Available after-tax income $22,035.50 $21,582.50 Savings with an FSA $453.00 None This example is intended to demonstrate typical tax savings. Your actual savings will depend on your salary., how much you contribute into the FSA, your tax bracket, how you file your taxes (single, married, etc.), your health, etc. Generally, participants save 15% 30% on eligible items purchased using their FSA dollars. THE TAX SAVINGS ARE SIGNIFICANT Money which you place into the FSA escapes Federal and State income tax and Social Security Tax. By adding these three tax brackets together, you will find that your tax savings are equal to 15% to 30% of the amount contributed to the FSA. JOINING THE PLAN IS SIMPLE First, you must be eligible for the plan. Next, decide which Spending Account(s) you want to participate in-the Medical FSA and/or the Dependent Care FSA. Estimate your annual expenses in each account, and complete your employer s Benefits Enrollment Form. For example, assume you have a child in daycare at a cost of $400 per month, or $4,800 per year. Complete your Benefits Enrollment/Change Form with an annual daycare election of $4,800 ($184.62 per pay period). Beginning with your first paycheck following your enrollment effective date, $184.62 will be deducted from your check on a pre-tax basis. As you incur daycare expenses, complete a Claim Form (available from 24HourFlex.com), attach receipts, and 24HourFlex.com will reimburse you for your day care expense with your tax-free dollars. In this example, $4,800 has escaped federal and state taxation, and you have saved an estimated $1,000 in taxes. BE SURE YOU UNDERSTAND THE CAFETERIA RULES 1. If consistent with your Summary Plan Description, you may change your annual election only if you have a change in family status. This includes: Birth, death, or adoption of a child Change in the employee s legal marital status, including marriage, divorce, death of spouse, legal separation, or annulment Termination or commencement of employment by the employee, spouse, or dependent Change in work schedule, including a reduction or increase in hours worked by the employee, spouse, or dependent or any other change in employment status that affects eligibility for benefits Change in the eligibility status of a dependent Change in residence or worksite of employee, spouse, or dependent accompanied by a gain or loss of insurance coverage as a result of the move Change in daycare providers resulting in a significant change in daycare cost 2. Any qualified expenses which you incur prior to your date of termination from the plan can be submitted to the plan for reimbursement, providing these claims are submitted by the end of your plan s grace period. (Please see the 24HourFlex. com website for a more detailed explanation). 3. Generally, all expenses that you submit for reimbursement must be for services rendered to you within the FSA plan year, and during the period of time that you were a participant in the plan. 4. Please make sure you can use all the money you set aside. Generally you have 90 days after the end of the plan year to submit expenses for services rendered to you during the plan year. After that, any money left in your account will be forfeited by you. Under IRS rules the forfeited money cannot be returned to you. (Some employers have a shorter or a longer grace period. eg 30, 60 or 120 days) WHAT DAYCARE EXPENSES ARE ELIGIBLE? You may be reimbursed for daycare expenses incurred for a dependent under the age of 13, or a dependent child or adult who is physically or mentally incapable of caring for themselves. These expenses must be incurred during the period of time that you are a participant in the Dependent Care plan and so you (and your spouse, if you are married) can be gainfully employed. If the expenses are incurred for services provided by a dependent care facility which provides care for more than six individuals not residing at the facility, the center must be licensed. The expenses cannot be paid or payable to a child of yours who is under the age of 19. For more information, go to 24HourFlex.com or review your company s Summary Plan Description. 1
COMMON ELIGIBLE MEDICAL EXPENSES INCLUDE: Insurance co-pays and deductibles Medical: medical doctor fees, office visit charges, annual physical exams, x-rays, Orthopedic shoes Physical therapy Vision: vision exams, cost of frames and lenses, including prescription sunglasses, contact lens and lens solutions, cost of maintaining contact lenses, LASIK eye surgery Hearing exams and hearing aids Medicines and drugs: Prescription and Over-The-Counter (OTC) drugs. (See important note below) Dental: exams, x-rays, fillings, false teeth, retainers, caps, crowns, orthodontia, braces Chiropractors Acupuncturists Psychiatric and psychological care Non-elective cosmetic surgery Alcohol and drug rehabilitation programs Stop-smoking programs, if prescribed for a specific illness Weight-loss programs, if prescribed for a specific illness Medical supplies prescribed by a medical professional for a specific ailment. Includes braces, crutches, walkers, wheelchairs Ambulance or special transportation COMMON ELIGIBLE OVER-THE-COUNTER MEDICAL EXPENSES INCLUDE: NOTE: Over-The-Counter (OTC) purchases through 2010 are eligible for reimbursement. Due to the recent Healthcare Reform, effective January 1, 2011, OTC medicines will not be eligible for reimbursement, unless prescribed by a medical professional. This restriction does not apply to medical and vision care supplies such as contact lens solutions, bandages, diabetic supplies and test kits. Antiseptics: antiseptic wash or ointment for cuts or scrapes, Benzocaine swabs, Boric Acid powder, First aid wipes, Hydrogen Peroxide, Iodine tincture, Rubbing Alcohol, Sublimed Sulfur powder Asthma Medications: Bronchodilator/Expectorant tablets, Bronchial asthma inhalers Cold, Flu, And Allergy: Allergy medications, Cold relief syrup, Cold relief tablets, Cough drops, Cough syrup, Flu relief tablets or liquid, Medicated chest rub, Nasal decongestant inhaler, Nasal decongestant spray or drops, Nasal strips to improve congestion, Sinus & Allergy homeopathic nasal spray, Sinus medications, Throat lozenges, Vapor patch cough suppressant Diabetic: Diabetic lancets, Diabetic supplies, Diabetic test strips, Glucose meters Ear/Eye/Nose Care: Airplane ear protection, Saline nose drops, Eye drops, Ear drops for swimmers, Ear water-drying aids, Homeopathic earache tablets, Contact lens solutions Health Aids: Antifungal treatments, Adhesive or elastic bandages, Cold or hot compresses, Denture adhesives, Diuretics and water pills, Hemorrhoid relief, Incontinence supplies, Lice control, Medicated bandages, Motion sickness tablets, Respiratory stimulant ammonia, Sleeping pills and aids Pain Relief: Arthritis pain reliever, Bunion and blister treatments, Itch relief, Orajel, Pain relievers, aspirin and non-aspirin, Throat pain medications Personal Test Kits: Cholesterol tests, Colorectal cancer screening tests, Home drug tests, Ovulation indicators, Pregnancy tests, Blood Pressure meter, Thermometers Pregnancy: Birth-control pills, Condoms, Spermicidal gels Skin Care: Acne medications, Anti-itch lotions, Bunion and blister treatments, Cold sore and fever blister medications, Corn and callus removal medications, Diaper rash ointment, Eczema cream, Sunscreen lotions, Sun-burn medications, Medicated bath products, Wart removal medications Stomach Care: Acid reducers, Antacid gum, Antacid liquid, Antacid tablets, Anti-diarrhea medications, Gas prevent food enzyme dietary supplement, Gas relief drops for infants and children, Ipecac syrup, Laxatives, Pinworm treatment, Prilosec, Upset stomach medication COMMON IN-ELIGIBLE EXPENSES: Vitamins and dietary supplements Kindergarten tuition expenses Elective cosmetic surgery Health club dues Aromatherapy Baby oil, baby wipes Cosmetics, toiletries, tooth brushes, dental floss, deodorants, facial care, fade creams, shampoo and conditioners, skin care products Spider vein treatments Cotton swabs Feminine care Hair re-growth Low carb foods Oral care Petroleum jelly Teeth whitening systems Breast pumps Social activities such as dancing or swimming lessons Drunk driving classes Nursing care for a healthy baby Expenses to improve one s general health Long term care After 2010, OTC medicines or drugs will be ineligible, unless prescribed (per the recent Healthcare Reform). 2
THE 24HOURFLEX BENEFITS CARD ADDED CONVENIENCE THE 24HOURFLEX BENEFITS CARD ADDS CONVENIENCE TO YOUR The Card allows flex participants to pay for eligible products and services at approved CAFETERIA FLEXIBLE SPENDING ACCOUNT. Without the 24HourFlex Benefits Card: you must first pay for your out-of-pocket expense with your own funds and then apply for a reimbursement of those expenses by completing a Flex Claim Form. With the 24HourFlex Benefits Card: you can present your 24HourFlex Card at the point of purchase and charge those expenses to your flexible spending account rather than paying for the expense first and then getting reimbursed. WHAT GOOD IS THE 24HOURFLEX CARD? The 24HourFlex Card pays your eligible medical expenses instantly from your available FSA funds. The 24HourFlex Card allows you to pay your co-payments and deductibles using the Card. They will auto-approve meaning no further receipts will be required. You can use the 24HourFlex Card to pay for online mail-order prescriptions. NO RECEIPTS REQUIRED When you use your card to purchase FSA-eligible items at a merchant with an IRS compliant inventory approval system, no receipts will be required to be submitted. Thousands of merchants have installed this inventory approval system and more merchants are being added all the time. Please check our website www.24hourflex.com for the latest list. 1-800 CONTACTS Albertsons SuperValu CVS Cubs SuperValu Dominick s King Soopers/City Market Kroger Longs Lucky SuperValu OSCO SuperValu vendors and service providers, such as pharmacies and doctor offices. Pavilions Safeway Sam s Club Shoppers SuperValu Target Walgreens Wal-Mart VisionDirect.com Vons The 24HourFlex Card provides secure, 24-hour access to your flex account through our website, www.24hourflex.com DO I STILL NEED TO KEEP AND SUBMIT MY RECEIPTS? Yes, you will need to submit copies of your receipts to 24HourFlex unless the charge equals the exact amount of one of your healthcare providers co-payment amounts, is a pre-approved repetitive expense, or the merchant has an IRS-compliant inventory approval system in place. 24HourFlex will notify you in writing when a receipt is required to be submitted. It is a good idea to retain all your receipts! WHAT ARE SOME EXAMPLES OF ELIGIBLE FSA LOCATIONS AND PROVIDERS? Examples of qualified FSA locations and providers include: Hospitals, Physician Offices, Dental Offices, Vision Service Locations, Pharmacies, Durable Medical Supply Locations, and Home Healthcare Services. DO I CHOOSE DEBIT OR CREDIT AT THE CREDIT CARD TERMINAL WHEN I USE MY CARD? Choose credit, there is no PIN number associated with the card. WHAT IF THE DOCTOR S OFFICE, OR SOME OTHER PROVIDER, DOESN T TAKE CREDIT CARDS? In this instance, you will pay the provider with cash or a check and then submit a Claim Form to 24HourFlex for reimbursement. Blank Claim Forms are available online at www.24hourflex.com WHAT SHOULD I DO IF I ACCIDENTALLY USE THE CARD FOR AN INELIGIBLE EXPENSE? If you use your card for an ineligible expense you will receive a notice from 24HourFlex, requiring you to reimburse your flex account for the ineligible amount. This money will be placed back into your flex account and will be available to use for future eligible expenses. HOW DO I KNOW HOW MUCH MONEY IS IN MY FSA ACCOUNT? Complete balance and transaction information is available to you online at www.24hourflex.com; choose FSA Login. CAN I ORDER ADDITIONAL CARDS FOR MY FAMILY? Yes. You can request additional debit cards online at www.24hourflex.com. There is no charge for additional cards. WHAT DO I DO IF MY 24HOURFLEX BENEFITS CARD IS LOST OR STOLEN? Lost or stolen cards must be reported. You must call the bank at 1-866-679-7649. You will need to verify your mailing address. 3
WHAT IS AN ACCEPTABLE RECEIPT? NOT AN ELIGIBLE RECEIPT HOW DO I SUBMIT MY RECEIPTS TO 24HOURFLEX? Once a month, 24HourFlex will mail to you a report showing any debit card charges that require receipts. Simply follow the instructions on the report. Do not use a blank 24HourFlex claim form to submit receipt requests. WHERE CAN I VIEW MY CARD ACTIVITY? All of your personal debit card transaction information is available to you online at www.24hourflex.com. Acceptable Receipts must include each of the following: Date of the service What service was performed Vendor providing the service Amount to be reimbursed WHY ARE RECEIPTS REQUIRED? The IRS has issued specific instructions that Cafeteria plans must follow when offering a debit card. Per these federal government regulations, receipts are required for any Cafeteria debit card purchase unless the amount of the purchase matches a medical, dental, hospital, or prescription drug co-pay; or unless the transaction is a repetitive transaction that has been pre-approved. However, some merchants have installed an IRS-compliant inventory approval system in which case no receipts are required. Please see a more detailed explanation on page 3 of this booklet. WHO DETERMINES THE CO-PAY AMOUNTS THAT WILL AUTOMATICALLY ADJUDICATE (APPROVE)? Each client of 24HourFlex has a specific medical and dental insurance plan. The specific co-pay amounts for each client are coded into the 24HourFlex system so that Cafeteria claims matching those co-pay amounts will automatically approve. WEB ACCESS INSTRUCTIONS 24HOURFLEX.COM Once you have received in the mail your 24HourFlex Convenience card, take the following steps to access your 24HourFlex Flex account online. STEP 1: Log on to www.24hourflex.com STEP 2: Click on FSA Login STEP 3: Click on New User (Be sure to have your pop-up blocker turned off) STEP 4: Input your SSN, date of birth, email address, and security information to create a username and password To have your password reset, contact Cafeteria Help Center at 800-651-4855 DOESN T 24HOURFLEX ALREADY KNOW WHAT I PURCHASED ON THE 24HOURFLEX CARD? No. 24HourFlex knows only the date, amount, and place of the transaction. A description of the purchased item is not captured by the card vendor or 24HourFlex, and is not given to 24HourFlex. SO IF I HAVE TO PROVIDE COPIES OF RECEIPTS, WHAT BENEFIT IS THE 24HOURFLEX CARD? The primary value of the card is that you have immediate access to the funds in your Cafeteria plan; you do not have to wait for a reimbursement. And, many of the expenses you charge on the 24HourFlex card will automatically approve. WILL RECEIPTS BE REQUIRED EVEN FOR CHARGES AT HOSPITALS OR DOCTORS OFFICES? If the amount does not equal a stated co-pay, or the amount is not a repetitive transaction that has been pre-approved by 24HourFlex, you must submit a receipt. There are many expenses at hospitals or doctors offices that are not eligible medical expenses, i.e., flowers, vitamins, etc.. ADDITIONAL WEB FEATURES Check account balance Review completed or pending payments Order additional debit cards for dependents Add or change direct deposit information 4
WEB ACCESS FEATURES LEARNING CENTER VISIT THE 24HOURFLEX LEARNING CENTER AT 24HOURFLEX.COM Select a video to learn details about your Flexible Spending Account Plan. 24HourFlex Cafeteria Overview, Part 1 & Part 2 24HourFlex Dependant Care Overview How to Submit a Claim Online 24HourFlex Online Account Overview Why Do You Ask for Receipts? 24HourFlex Debit Card Explained HEALTHCARE PLANNING WORKSHEET MEDICAL EXPENSES NOT COVERED BY INSURANCE Deductible $ Co-pays Coinsurance Routine physician visits Prescription Drugs Insulin/Syringes Annual physicals Chiropractic Treatments OTC medicines* Acupuncture Medical Equipment (crutches, oxygen, etc) Fertility Enhancement Massage Therapy for specific medical treatment Osteopath Podiatrist Smoking cessation programs Therapy treatments Weight loss programs, prescribed as treatment for specific disease Other: Subtotal Medical $ Annual Estimate * After 2010, OTC medicines or drugs will be ineligible, unless prescribed (per the recent Healthcare Reform). DENTAL EXPENSES NOT COVERED BY INSURANCE Annual Estimate Checkups/cleanings $ Annual Deductible X-rays Fillings Root Canals Crowns Bridges Dentures Extractions Oral Surgery Orthodontia Other: Subtotal Dental $ VISION AND HEARING EXPENSES NOT COVERED BY INSURANCE Annual Estimate Exams $ Eyeglasses Reading Glasses Prescription Sunglasses Contact lenses Contact Lens solution Corrective Eye Surgery (LASIK, PRK, cataract) Hearing Exams Hearing Aids Batteries for Hearing Aids Other: Subtotal Vision and Hearing $ Total Unreimbursed Healthcare Expenses $ 5
13582 Claim Form 1) Please use this document as the fax cover sheet and do not use any other fax cover sheet. 2) Copies of receipts are required to verify your reimbursement requests and must be faxed together with this claim form as a single fax. 3) Please PRINT when filling out this form, keep your original receipts and a copy of this claim form for your records. 4) Attached receipts must include the date of service, the type of service/product provided and the amount (credit card receipts are not valid). SSNumber - - Please sign and date in the space provided at the bottom of the form For optimum accuracy, avoid contact withboxedgesasinthisexample: 1 2 3 4 5 6 7 8 9 0 Participant Last Name First Name M I Day Phone Employer E-mail Address MedFSA Medical Spending Account; Day care - Dependent Care Spending Account; HRA Health Reimbursement Account; OIP - Outside Insurance Premium Account, QPK - Qualified Parking Expense; QTR - Qualified Transit Expense Describe Service or if Day Care Date of Service Claim Type (see above legend) include signature of Provider Choose only one (Who service was for) Amount to be Reimbursed 1 2 3 4 5 I certify the above expenses were incurred during the Plan Year of coverage by me or my eligible dependents and have not been previously reimbursed by this Plan or any other source, nor are the expenses reimbursable by any other source. To the best of my knowledge, I affirm the above claims are eligible and proper expenses arising under the Plan. I understand that I will be liable for all applicable taxes and penalties for claims which are not eligible and proper expenses under the Plan. I understand that I cannot claim as deductions on my personal income tax Form 1040 expenses for which I have been reimbursed. By including my e-mail address above, I consent to 24hourflex communicating with me via e-mail about all matters pertaining to this claimform. Participant Signature Scan and email to claims@24hourflex.com Fax to 303-369-0003 or 1-800-837-4817 or Mail to Date 24HourFlex ATT: Claims 2851 S. Parker Road, Suite 230 Aurora, CO 80014 To insure legibility (eliminating processing delays) you may go to www.24hourflex.com, fill out this form on-line and then print it, sign it and send it in as your claim form.
Help Center: 303-369-7886, 800-651-4855 24HourFlex Fax: 303-369-0003, 800-837-4817 Email: info@24hourflex.com www.24hourflex.com 24HourFlex.com 2851 S. Parker Road, #230 Aurora, CO 80014 Form: 2010 3 FEK 24HourFlex.com is a division of RPS Plan Administrators, Inc.