EMployEE Education FSa Flexible Spending accountsmilford.massteacher.org/files/HR FSA Infomation.pdf · A FSA is an account that an employee sets up with HR Concepts (similar to a

Flex Plans • HSA’s • Commuter Plans • HRA’s • Dental Plans • COBRAPhone: 603-647-1147 • Fax: 1-866-978-7868 • email: [email protected]

www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101

EMployEE Education FSa

Rev. 02/12FSA-STD-EDU-1A

Flexible Spending accounts - Healthcare Flexible Spending Account (FSA)

- Dependent Care Account (DCA)

Healthcare Reimbursement accounts

What are they? A FSA is an account that an employee sets up

with HR Concepts (similar to a savings account). It enables them to deduct money out of their payroll on a pretax basis and directly deposit these funds into an account with HR Concepts. These funds can later be withdrawn from this account on a tax free basis to pay for eligible medical, dental, vision, over the counter, and prescription expenses for themselves, their spouse, and eligible children. They are a great way to save taxes and reduce your out of pocket expenses!

How do they Work? Before the effective date of your FSA plan year

(Decided by your employer), you will calculate how much money you think you and your dependents will spend during the plan year on your out of pocket expenses for medical, dental, vision, over the counter, and prescription expenses. You then take this annual number and divide it by the amount of payrolls during the plan year and this amount will be deducted from your payroll each period and deposited into your FSA. For example, if you wanted to put $520 in the account, and you are paid on a weekly basis, then $520 divided by 52 payrolls would equal $10 per paycheck. This money comes out before you pay Federal Tax, FICA Tax, and State Tax. When you add up your tax savings with your money in this account, you effective ly have increased your take home pay.

You will have the opportunity to change your elec-tion each plan year and also if you have a qualifying event; which includes marriage, divorce, death, or birth in your immediate family. If you have a qualifying event, you can increase or decrease your annual elec tion within a 30 day period following the event.

Examples of tax Savings no FSa FSa

Annual Income $30,000 $30,000

FSA Contributions $ 0 $ 1,000

Taxable Pay $30,000 $29,000

Minus Taxes (Bases on 30%) $ 9,000 $ 8,700

Take Home Pay $21,000 $20,300

Minus(Medical/dental/Vision/Costs) $ 1,000 $ 0

Total Take Home Pay $20,000 $20,300

What you Saved $ 0 $ 300

How do i Get My Money out? There are two ways you can get your money out of

the account. 1 You can submit a claim online, mail it, fax it, or

drop the claim off to us along with the receipt showing the expense.

2 You can use the VISA you received from us after you enrolled. To use the VISA, simply present it at the doctor’s office or phar-macy. Only use this card for eligible expenses and keep your receipts, you may be contacted to verify the expense.

You can use your entire annual election on the first day the plan starts, however, you will forfeit any unused funds if not used by the end of the plan year. You do have 90 days after the end of a plan year to submit your expenses that were incurred during the plan year.




Rev. 02/12FSA-STD-EDU-1B

Flexible Spending accounts (continued)- Healthcare Flexible Spending Account (FSA)

- Dependent Care Account (DCA)

dependent care Reimbursement accounts

What are they? A DCA is an account that an employee sets up with HR

Concepts (similar to a savings account). It enables them to deduct money out of their payroll on a pretax basis and direct ly deposit these funds into an account with HR Concepts. These funds can later be withdrawn from this account on a tax free basis to pay for eligible Dependent Care Expenses (Preschool, Day Care, Baby Sitting, After School Programs, and Adult Day Care). They are a great way to save taxes and reduce your out of pocket expenses!

How do they Work? Before the effective date of your DCA plan year (Decided by

your employer), you will calculate how much money you think you will spend for eligible dependent care expenses for the plan. You then take this annual number and divide it by the amount of payrolls during the plan year and this amount will be deducted from your payroll each period and deposited into your DCA. For example, if you wanted to put $4,999.80 in the account, and you are paid on a weekly basis, then $4,999.80 divided by 52 payrolls would equal $96.15 per paycheck. This money comes out before you pay Federal Tax, FICA Tax, and State Tax. When you add up your tax savings with your money in this account, you effectively have increased your take home pay.

You will have the opportunity to change your election each plan year and also if you have a qualifying event; which includes marriage, divorce, death, or birth in your immediate family. If you have a qualifying event, you can increase or decrease your annual election within a 30 day period follow ing the event.

How Much can i put into My account? The maximum reimbursement limit is $5,000 per year or

$2,500 if married and filing separately. If a spouse is not work-ing, but is a student, then the monthly maximum will be $200 for one child, and $400 for 2 or more children. All of these limits apply to the date the eligible expense is incurred, not the date billed or paid.

How do i Get My Money out? There are two ways you can get your money

out of the account. 1 You can submit a claim online, mail it, fax it, or

drop the claim off to us along with the receipt(s) showing the expense.

2 You can use the VISA you received from us after you enrolled. To use the VISA, simply present it at the daycare facility you use if they accept credit card payments. You can use your card for only the amount you have left in your account. Only use your VISA for eligible expenses and keep your receipts, you may be contacted to verify the expense.

Funds are deposited into your DCA on a per payroll basis. You will have the opportunity to withdraw your funds throughout the plan year, but only for what is in the account. You do have 90 days after the end of a plan year to submit your expenses that were incurred during the plan year, but after this point, any unused funds will be for-feited back to your employer to offset claims and administration expenses.

What are the Guidelines? You must follow the guidelines set below in order for your dependent care expense reimbursement to be eligible. These guidelines are as follows:

1. Dependent care expenses cover your dependent children 12 or younger, or a spouse/tax dependent who is mental ly or physically incapable of caring for him or herself.

2. The dependent care expense incurred must allow a single parent or both married parents to be gainfully employed or attend school full -time during the time the child is being taken care of.

3. Your dependent must live in your home for at least 8 hours a day.

4. Any day care center or program must meet the state and local requirements in order to be eligible.

5. A babysitter can watch the dependent inside or outside the home, as long as the sitter is at least 19 years old, and is not your spouse or someone you claim on your tax return as a dependent.




Rev. 02/12FSA-STD-WRKSHT-2A

Healthcare Flexible Spending Account (FSA) Worksheet/Election Calculator

Examples of Eligible Expenses Medical: deductibles, co pays, co-insurance, diagnostic tests, durable medical equipment, lab work, chiropractic care, acupuncture, and massage therapy.

Dental: exams, x-rays, cleanings, fillings, sealants, root canals, dentures, crowns and orthodontia.

Vision: exams, contacts, glasses, laser eye surgery, prescription sunglasses, and contact lens solution.

Prescriptions: all prescriptions are covered. This includes over the counter medications with a RX.

Over the Counter: first aid supplies, hearing aids, orthopedic inserts, thermometers, and sunscreen.

* Treatments for cosmetic reasons are not covered.* Some services/purchases need to have a note of medical necessity or prescription to be eligible.* You can access an updated list of eligible expenses at: http://hcet.ebia.com/hrcllc. Please contact HRC for access code first. Please note this list of eligible expenses is subject to change according to the IRS.

Examples of Ineligible: cosmetic surgery, teeth whitening, toothpaste, family counseling, shampoo, laser hair removal and deodorant.

Examples of Expenses requiring documentation: vitamins, pain relief, digestive aids, allergy medication, acid controllers, cold & flu medications and eye drops.

(These items must be used to treat the condition and cannot be for preventative purposes. A doctor’s prescription or note of medical necessity is required.)

How do you determine your Expenses? you can use this worksheet to estimate how much you will need to put into your FSa. please be conservative and don’t forget that this account covers you, your spouse, and eligible children.

Health care Expenses you your Spouse your children Deductibles: Medical $_______ $_______ $_______ dental $_______ $_______ $_______ Vision $_______ $_______ $_______ Co-pays: Medical $_______ $_______ $_______ dental $_______ $_______ $_______Dental Care $_______ $_______ $_______Prescriptions $_______ $_______ $_______Vision Care: Eye Exams $_______ $_______ $_______ Glasses $_______ $_______ $_______ contacts $_______ $_______ $_______Chiropractic $_______ $_______ $_______Other $_______ $_______ $_______total Estimated Expenses (a.) $_______ (B.) $_______ (c.) $_______ (total annual Election) (d.) $_________ (add total of lines a, B and c above)

number of pay periods divide line d. above By in plan year (E.)__________ line E. (this is your deduction per payroll) $________




Rev. 02/12FSA-STD-WRKSHT-2B

Dependent Care Account (DCA) Worksheet/Election Calculator

things to Remember understand that your election is based on the eligible expenses allowed by the iRS. these expenses must meet the following requirements:

1. daycare expenses must be incurred during the plan year for the care of a dependent age 12 or younger.

2. daycare expenses may be incurred for a spouse or other tax dependent that is mentally or physically incapable of caring for him or herself.

3. the expense needs to be incurred during the time that you and your spouse (if applicable) are gainfully employed and at work.

4. the daycare provider must be either a babysitter that cares for the dependent in or outside of your home or a daycare center that meets state and local requirements, such as, a pre-school, summer day camp, and after school programs. any form of day care provider you use needs to provide you with a tax id or social security num ber.

5. Expense cannot exceed your taxable compensation, or your spouse’s actual earned income.

you can use this worksheet to estimate how much you will need to put into your dca. please remember to be conservative, but don’t forget that all the money you put into this account goes in on a pre-tax basis and comes out tax-free!

How do you determine your Expenses? Weekly dependent care Expenses

Preschool (A.)$ _________

Daycare (B.) $ _________

Baby Sitting (C.) $ _________

After School Programs (D.)$ _________

Adult Daycare (E.) $ _________

total Estimated Weekly daycare Expenses (F.) $ _________ (add lines a - E)

total Estimated annual dependent care Expenses this plan year (G.) $ _________ (Multiply Line F. above by the total number of weeks this plan year. Please remember that this amount cannot exceed $5,000 Or $2,500 if married and filing separately. If it does, please adjust the amount accordingly)

number of pay periods divide line G. above By in plan year (H.)__________ line H. (this is your deduction per payroll) $________

QuEStionS?... Please don’t hesitate to contact HR Concepts!

HR Concepts, LLC“Your Third Party Administrator of Choice”


www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101FSA-STD-IRS-3 Rev. 02/12

The IRS Receipt Submission Policy

We want to thank you for choosing to participate in your company’s benefit plan administered by HR Concepts. In order for you to maximize your experience using your account, it is important for you to understand the IRS rules surrounding the use of a debit card with a Flexible Spending Account. This regulation allows you to use the VISA we provided to you, but requires you to submit your receipts for certain type of expenses. Keeping your receipts has always been a part of the law, however, now you may need to submit them to verify what was purchased with your card. There are some exceptions that enable you to NOT have to submit your receipts. These exceptions are:

1) If you use your card to pay for co pays, associated with your company’s group health plan, for services or prescriptions, you will not have to send to us your receipts if the co pay matches the co pays set forth in your company sponsored health plan. You can charge up to 5 times the single co pay without having to verify your expense.

2) If you have a re occurring expense and your charge will always be the same dollar amount, all you will need to do is submit your receipt with your claim form and let us know this will be a re occurring expense and we will authorize the use of your card for this exact amount without the need to submit receipts for a period of time. From time to time we may contact you to re verify the expense.

3) If you shop at a merchant that has an Inventory Information Approval System (IIAS), your card will only work for eligible items. Every item these merchants sell is coded according to the IRS 213D list of eligible expenses. Since your card will only work for eligible items, you will not be required to submit your receipt. To see the latest list of participating merchants please refer to our website, www.hrconcepts.biz.

If you use your VISA and it does not fall into one of the above categories, you will be receiving a receipt notification by email or mail (if we do not have your email address). Please call us and provide us with your current valid email address. If you are notified to submit your receipts, mail or fax your receipts along with the letter we sent you requesting the receipts. The IRS has made this a mandatory process, so please help us by sending in your receipts when requested. Failure to submit the receipts may result in your card being turned off and the expense will need to be paid back into your account.

Thank you again for using HR Concepts as your administrator of choice. It is our pleasure in being able to provide you with exceptional customer service and the latest technology. If you have any additional questions, please don’t hesitate to contact us!

Sincerely,

HR Concepts, LLC



www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101Rev. 09/12FSA-STD-CLAIM-4A

Universal Receipt Submission/Claim Form

Part I Employee Information ( Please check if this is a new address)

Employee Name: SSN: - - Mailing Address:

City: State: Zip: Email Address for all correspondence:

Telephone: Employer Name: Plan Year :

Part II. Instructions for submitting form (Please Read Carefully)1. Fill out entire form and make sure to indicate below in the appropriate section if you are submitting a claim for reimbursement or if

you are sending us your receipts for verification of an expense you were already reimbursed for because you used the VISA we sent to you.

2. If you are submitting for reimbursement of an FSA claim, check whether the claim is for the current plan year or previous plan year.3. Reimbursement is only for expenses that will not be reimbursed from any other source. These expenses must have been incurred

within the plan year. Some plan designs allow claims to be incurred 75 days after the end of the plan year, please verify before submitting. You have up to 90 days after the end of a plan year to submit expenses that are eligible for reimbursement.

4. All 3rd party documentation supporting your request for reimbursement must be attached. This supporting documentation must show date of service (Not the payment date), amount of expense that you are responsible for, who it was for, and a brief description of expense.

5. Dependent Care Reimbursement requests must have a signature from the provider as well as the tax ID# of the provider filled in below.

6. Dependent Care Reimbursements may be submitted in advance of future service dates. You will receive a reimbursement check from your account according to your payroll cycle. The amount you receive will be equal to your payroll deduction or account balance, whichever is greater. If the amount of the reimbursement check is going to exceed your actual expense for the said time frame, you are required to notify HR Concepts so that we may adjust the claim.

Part III. Purpose of this form (Please check Only one box and fill in the appropriate section below)

Healthcare FSA Claim Submission (Complete Section IV.) Dependent Care FSA Claim Submission (Complete Section V. below) Healthcare Reimbursements Arrangement (HRA) Claim Submission (Complete Section VI. Below) Receipt Submission for Verification of VISA Use for an FSA or HRA Claim (Complete Section VII.)

Part IV. Healthcare FSA Claim Information

*Please Check Appropriate Plan Year Current Plan Year Previous Plan YearName of Covered Person

(Spouse, Dependent)Date of Service(Not Payment Date)

Type of Service(Medical, Dental, Vision) Description of Services

Amount of Claim

Total of Healthcare FSA Claim: $ ____________



www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101Rev. 09/12FSA-STD-CLAIM-4B

Part V. Dependent Care FSA Claim Information

*Please Check Appropriate Plan Year Current Plan Year Previous Plan Year

Name of Provider Date of Service(Not Payment Date)

Type of Service(Daycare, Preschool, Day Camp, etc)

Provider Signature & Tax ID#(Have provider sign here or attach receipt)

Amount of Claim

Total of Dependent Care FSA Claim: $ ____________

Part VI. Healthcare Reimbursement Arrangement (HRA) Claim Information

If you have used all of your HRA funds from your employer and your claim is not completely covered by these funds, please check the box below if you want HR Concepts to apply your remaining unpaid balance of this claim towards any funds available in your Healthcare FSA.

Submit any unpaid HRA claims toward my Healthcare FSA.Name of Covered Person(Self, Spouse, Dependent)

Date of Service(Not Payment Date)

Type of Service(Medical, Dental, Vision) Description of Services

Amount of Claim

Total of Healthcare Reimbursement Arrangement (HRA) Claim: $ ____________

Part VII. Receipt Submission for Verification of VISA Use for an FSA or HRA Claim

Name of Covered Person Date of Service Type of Service Description of ServicesAmount of

Claim

Total of VISA Charges: $ ____________

Part VIII. Signature

The above statements and submitted information for reimbursement are true. I am only submitting for reimbursement for eligible expenses that I incurred for myself or legal dependents. I certify that I have not been nor will I be reimbursed for these submitted reimbursements from any other source. I further certify that I will not claim these expenses as a tax deduction.

Employee Signature: Date: / /



www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101FSA-STD-DD-5 Rev. 09/12

Authorization Agreement For Direct Deposits

Employer Name _____________________________________________________________________________

Employee Name _____________________________________________ Social Security#_____-_____- ______

Email Address (Required): _____________________________________

I hereby authorize HR Concepts, LLC, hereinafter called HRC, to initiate credit entries to my Checking Savings account (select one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account. I further authorize HRC, to initiate debits from the aforementioned account indicated below, and to debit the same from such account if an error is made in processing. Processing errors can include a payment that was made via my HR Concepts VISA that was deemed ineligible, or if a forced post puts my flexible spending account with HR Concepts in the negative.

Depository Name: ________________________ City: ________________________________ State: ________

Routing #: _______________________________ Account #: ___________________________

Confirm Routing #: ________________________ Confirm Account #: ____________________

This authorization is to remain in full force and effect until HR Concepts has received written notification from me of its termination in such time and in such manner as to afford HR Concepts and DEPOSITORY a reasonable opportunity to act on it.

DATE: / / SIGNATURE______________________________________________________

Please return completed form to HR Concepts along with a voided check or savings deposit slip to address below.

NOTE: ALL WRITTEN CREDIT/DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. HR CONCEPTS WILL NOT BE RESPONSIBLE FOR INCORRECT BANKING INFORMATION IF VOIDED DOCUMENTS ARE NOT INCLUDED WITH THIS FORM.



www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101FSA-STD-ENROLL-6 Rev. 09/12

Flexible Spending Accounts Enrollment Form

I authorize my employer to make the following pre-tax reductions from my paycheck according to the elections I have chosen below. These elections cannot be changed until the beginning of the next plan year or if I have a qualifying event; which includes within my immediate dependents, marriage, divorce, death or birth. I will only submit claims for reimbursement or through my VISA that are eligible. If I am reimbursed for a claim that wasn’t eligible, I will be responsible for paying the ineligible amount back into the plan through sending payment or having it deducted from my paycheck.

(PLEASE CHECK THE ACCOUNTS YOU WANT TO ENROLL IN AND FILL IN THE AMOUNTS BELOW)

HEALTHCARE FLExIBLE SPENDINg ACCOUNT ❑ Regular FSA ❑ Limited Purpose FSA (For HSA Participants) Annual Election for Medical, Dental, and Vision for my family: $ __________ Check the number of pay periods this plan Year: ❑ 52 ❑ 26 ❑ 24 Other: __________The Amount per Pay Period Reduced from my check for this Account $ __________ (Divide the Annual Election by the Number of Pay Periods Above)

(I understand that my election is based on the eligible expenses allowed by the IRS. Any expense that I have includedthat is not eligible for reimbursement, will not be paid; any question on eligibility will be determined by my employer.)

❑ DEPENDENT CARE ACCOUNTS Annual Election for Dependent Care Expenses: $ __________ Check the number of pay periods this plan Year: ❑ 52 ❑ 26 ❑ 24 Other: __________The Amount per Pay Period Reduced from my check for this Account $ __________ (Divide the Annual Election by the Number of Pay Periods Above)

I understand that my election is based on the eligible expenses allowed by the IRS. These expenses must meet the following requirements:1. Dependent Care expenses must be incurred during the plan year for the care of a dependent age 12 or younger.2. Dependent Care expenses may be incurred for a spouse or other tax dependent that is mentally or physically incapable of caring for them self.3. The expense needs to be incurred during the time that you and your spouse (if applicable) are gainfully employed.4. The Dependent Care provider must be either a babysitter that cares for the dependent in or outside of your home or a day care center that

meets state and local requirements, such as, a pre-school, summer day camp, and after school programs. Any form of dependent care provider you use needs to provide you with a tax ID or social security number.

5. Expense cannot exceed your taxable compensation, or your spouse’s actual earned income.

I understand that I cannot change my election during the plan year unless I have a qualifying event and claims must be incurred within the plan year that I’m seeking reimbursement from. If I do not utilize all of the monies set aside into this account, then I will forfeit this amount. My social security benefit may be reduced by this election. I will have up to 90 days beyond the end of the plan year to submit claims that I incurred during the plan year.

Employee Signature: ___________________________________________ Date: ____/____/_____ Accepted By Employer: ___________________________________

Please be sure to return this from to your Employer for approval

First Name: __________________________ Last Name: _________________________________ SSN: ______/______/_______

Street Address: _______________________ City: ____________________ St: ____ Zip: __________ Phone#: _______________

Additional dependent Visa cards: Recipients must be 18 or older

Name:__________________________ DOB: _____/______/______ SSN: _____-_____-______ Relationship: ________________

Name:__________________________ DOB: _____/______/______ SSN: _____-_____-______ Relationship: ________________

Email Address for All Correspondence: ____________________________________ 1st Payroll Deduction Date: ____/____/_____

Company Name: ______________________________________________________ EE Effective Date on plan: ____/____/______



www.HRConcepts.biz • 111 Charles Street • Manchester, NH 03101FSA-SetUp-7 Rev. 09/12

How to set up an account online:Please go to our Online Account Setup page http://hrconcepts.biz/setup for instructions on retrieving your username, creating an account password, and entering new user security questions to complete your online account profile. If you already have an account you can login directly from https://employee.hrconcepts.biz.

Trouble accessing your account?1. The Password Length must be a minimum of 6 characters and is case sensitive.

2. When resetting your password your answers to security questions are case sensitive.

3. Password History: Your password must not be one of your last 12 passwords used.

4. Account Inactivity: After 120 days of inactivity you must follow the password reset process in order to access your account again..

HR Concepts’ Mobile BenefitsCheck your balances, transactions, and claim details on your Android or iOS device. View all claims requiring receipts and submit new receipts by taking a picture with your mobile device.

Apple Store iOS Mobile Application Android Market Mobile Application* Claims Requiring Receipts – View all your

claims requiring receipts right from the main Accounts screen (only displayed when you have claims requiring receipts).

* Add Receipts – Add receipts from the Claims Requiring Receipts screen or by selecting a claim from the Account Details screen. Take a picture of a receipt.

* Check available balances 24/7

* View Receipts – View receipts submitted from your benefits portal or from the mobile app.

* Reset Login Information – If your password has changed, you may tap this link on the login screen, allowing you to re-enter your username and password.

Text Message AlertsSMS text message alerts are available for all mobile devices on AT&T, Nextel, Sprint, Verizon, and T-Mobile networks! You can opt in/out via the Consumer Portal and configure which alerts you prefer.

Web Browser Minimum Requirements:• Internet Explorer needs to be version 6.0 or newer

• Firefox needs to be version 1.2 or newer

• Opera needs to be version 9.1 or newer

• Safari needs to be version 1.3.2 or newer

• Adobe Reader 7.0 or newer (required for reports, statements, and forms)

HR Concepts Email CommunicationsPlease add the following domains to your “safe senders” white list to ensure you receive all email communications from HR Concepts.

Icpbounce.com - Email from this domain will include general reminders, updates, and notifications regarding enhancements, service issues, or plan offerings directly from HR Concepts.

Secure.psmtp.com - Email from this domain is for encrypted messages containing sensitive information.

Evolution1.com - Email coming from this domain is directly related to your online account.

Documents

EMployEE Education FSa Flexible Spending accountsmilford.massteacher.org/files/HR FSA Infomation.pdf · A FSA is an account that an employee sets up with HR Concepts (similar to a