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Sample Flexible Spending Account Forms Letters and Reports
Page
54
Data Gathering Form – Used to gather data about the client and their plans during the
implementation stage.
59 Sample FSA Brochure – Given to eligible employees prior to or during open enrollment. This
form may be customized to meet the needs of each client.
73 Section 213 Eligible Expense List – Given to eligible employees prior to of during open
enrollment. It is also part of our welcome package that we send out to all newly enrolled
participants at the beginning of each plan year. This form can be customized to meet the needs of
each plan.
82 Sample employee debit card brochure
85 Sample Employer debit card brochure
88 Sample Enrollment Form
89 Sample Welcome Letter – Sent in the Welcome package to all enrolled participants at the
beginning of each plan year. All Welcome Packages are customized to meet the needs of each
client.
92 Active Employee Report – This report is sent out as part of the monthly billing and reporting cycle.
It is also available on our web site and is updated daily.
94 Employee Account Balance Report – This report is sent out as part of the monthly billing and
reporting cycle. It is also available on our web site and is updated daily.
98 Sample Explanation of Benefits and Payment Check – This EOB is sent out after for each
processed claim. Participants who elect ACH will still receive this EOB.
100 Sample Close To The Year End Warning Letter – This letter is sent out typically in the 10th
month of the plan year and will alert each participant of their account balance.
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Sample Flexible Spending Account Forms Letters and Reports
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Data Gathering Form – Used to gather data about the client and their plans during the
implementation stage.
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HR SIMPLIFIED FSA
DATA GATHERING FORM
Name of Organization: __________________________________________________________
(Enter name exactly as it appears on tax returns and is to appear in the documents .)
Federal Employer ID No: _______________________ Date Incorporated/Organized:_________
Mailing Address: _______________________________________________________________
City: ___________________________________
State: ___________
Zip: ___________
Street Address: _______________________________________________ Zip: ___________
Organization Type:
Corporation.
Sub-chapter "S" Corporation
Professional Corporation
Professional Association
Partnership
Sole Proprietorship
Government Agency
LLC Limited Liability Company
Other ______________________________________________
NOTE: Only employees can participate in a cafeteria plan. Thus, while partnerships, sole proprietorships and Subchapter “S” corporations may sponsor cafeteria plans, the following cannot participate: sole proprietors, partners,
and greater than 2% shareholders in Sub-chapter “S” corporations.
The Employer/Organization entity is operating pursuant to the laws of the State of
.
Principal Business Activity Code: ___ ___ ___ ___ ___ ___
Nature Of Business: ____________________________________________________________
PLAN ELECTIONS
Plan No.:
501
Plan Begin Date:
______
Plan Name: Section 125 Cafeteria Plan
____/____/____
Plan Effective Date: ____/____/____
Plan End Date:
____/____/____
First Year Effective Date: ____/____/____
ELIGIBILITY REQUIREMENTS
1. The following class of employees is eligible to participate:
All
Salaried Employees Only
Hourly Employees Only
Other ____________________________________________________________________
Tax penalties may be imposed if the Plan contains eligibility requirements that have the effect of favoring highly
compensated employees. Consult your tax advisor before limiting participation in the Plan.
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PAGE 2
DATA GATHERING FORM
2. The following employees are excluded from participation:
No exclusions.
Part-time employees normally expected to work less than _______ hours a week.
Employees under the age of _______.
Union employees (unless the bargaining agreement provides for coverage).
Non-resident aliens.
Other: _______________________________________________________________
Section 125 does not specifically provide for election exclusions. Consult your tax advisor before excluding
any classification(s) of employees.
3. The service period employees must complete before being eligible to participate is as
follows:
For the initial plan year, any one employed on the Plan Effective Date and for
subsequent Plan Years
As of date of hire.
Number of days after date of hire: _________
Number of months after date of hire: ____________
For all plan years
As of date of hire.
Number of days after date of hire: _________
Number of months after date of hire: ____________
Employees must be in service or on the job as one of the eligibility requirements.
4. Once the employees are eligible, they can begin participating in the plan:
Date employee becomes eligible.
First day of pay period following the date employee becomes eligible.
First day of month following the date employee becomes eligible.
First day of quarter following the date employee becomes eligible.
First day of Plan Year following the date employee becomes eligible.
5. Termination of FSA coverage:
Event date
End of month
BENEFITS
Check the benefits to be offered under this Plan:
Core Health Benefits
Non-Core Supplemental Health Benefits
Group Term Life Benefits
Short Term Disability Benefits
Long Term Disability Benefits
PRO PLUS FSAS
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Cash Benefits
Medical and Dental Expense FSA
Dependent Care FSA
Vacation Purchase Program
Individually Owned Health Insurance
SECTION 125 CAFETERIA PLAN
JUNE 1999
PAGE 3
DATA GATHERING FORM
CONTRIBUTIONS
Overall Maximum for all Benefits: $_______________
Cannot be beyond reach of all employees. Rule of thumb: Do not exceed estimated annual salary of lowest paid
eligible employee on the payroll which will be prorated for any Plan Year less than 12 months.
Medical/Dental: FSA: Minimum: $_______________
Maximum: $ _________________
Dependent Assistance: Minimum: $_______________
Maximum: $ _________________
Dependent Care contributions cannot exceed $5,000 or, if Participant is married and filing separately, $2,500.
REIMBURSEMENTS
Claims Closing Date: ____/____/____ (Last day to submit claims after the plan year ends for
active employees)
Claims Grace Period: _________ (For terminated employees - number of days to submit
claims after employee terminates or no longer participates in the plan)
Use Up Clause for Dependent Care
Yes
No (Are claims incurred for Dependent Care
after termination but before plan year end allowable?)
Minimum Check Amount: $25.00
Reimbursement checks for claims will be issued:
Every payday
______ times a month.
______ days after claim is received.
Reimbursements must be paid at least once a month.
BENEFIT COORDINATOR
The Benefit Coordinator is the individual at the Employer to whom Employees should direct communications and
inquiries.
Name: _______________________________________________________________________
Title: ________________________________________________________________________
Company Name: _______________________________________________________________
Address: _____________________________________________________________________
City ___________________________________
State:_________Zip: _________________
Telephone ___________________________ Alternate Phone: _________________________
e-mail ______________________________ Website: ________________________________
BANK ACCOUNT
Name of Bank: ________________________________________________________________
Bank Address:_________________________________________________________________
Bank City: ____________________ Bank State: _______ Bank Zip Code: _______________
Name on Account: _____________________________________________________________
Account Number: ______________________________________________________________
Bank Routing No. (MICR) (Ex: 123456789): ____________________________________________
Bank Routing No. (Bank Info) (Ex: 111-42/348): ________________________________________
PRO PLUS FSAS
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SECTION 125 CAFETERIA PLAN
JUNE 1999
PAGE 4
DATA GATHERING FORM
Person Signing Check: __________________________________________________________
DEDUCTION AND PAYMENT LIMITATIONS
Are all the employees paid on the same schedule?
Yes
No
The employees are paid as following: (Enter as many frequencies as are needed.)
Weekly
First pay date after effective date:_________________________________
Biweekly
First pay date after effective date: ____________________
Semi-Monthly
First pay date after effective date: ____________________
Second pay date after effective date: __________________
Monthly First pay date after effective date:_________________________________
Other _______________________________________________________________
The deductions are taken:
Each time the employee is paid, or
__________________________________________________________________________
PRO PLUS FSAS
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SECTION 125 CAFETERIA PLAN
JUNE 1999
Sample FSA Brochure – Given to eligible employees prior to or during open enrollment. This form
may be customized to meet the needs of each client.
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Using Your
Flexible
Benefit
Plan
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FLEXIBLE SPENDING ACCOUNTS
Imagine being reimbursed for out of pocket healthcare and dependent care expenses
with tax-free dollars! By taking advantage of current tax law, Flexible Spending Accounts
allow you to stop imagining and begin saving.
Flexible Spending Accounts (FSA) allow you to pay eligible healthcare and dependent care
expenses with pre-tax dollars. You will not pay federal or social security taxes and in most
cases, state or local taxes on funds deducted for your plan. By using pre-tax dollars you
are able to stretch your hard earned money by 28% to 43% on every dollar you choose to
contribute to your FSA plan depending on your tax bracket. Tax savings result in increased
after tax income.
HOW DOES IT WORK? SIMPLE.
The amount you elect is deducted from your paycheck and stored in your individual FSA
account until you need it. As often as you like you can request reimbursement by filling out a
claim form provided to you and submitting it along with your receipt to HR Simplified. A check
will promptly be sent to you for expenses you have incurred.
WILL IT WORK FOR ME?
Almost everyone has a number of necessary predictable expenses that are not covered by their
insurance programs. You can pay for your out of pocket healthcare expenses for yourself, your
spouse or your dependents incurred during the plan year. If you have medical expenses such
as prescription co-pays, prescription eyeglasses, chiropractic services, or childcare expenses
an FSA account will work for you.
There are two types of reimbursement accounts in which you can have money deducted from
your payroll check before taxes:
Health Care Expenses reimbursement for a wide variety of things such as medical copays and out of pocket expenses, dental, orthodontia, eyeglasses, many over the
counter drugs, etc.
Dependent Care Expense reimbursement for day care expenses for your qualified
dependent/child.
This brochure will help you understand Flexible Spending Accounts. It covers how Flexible
Spending Accounts work and describes the two accounts in detail, explains the rules governing
the accounts, the reimbursement process, and how you can elect to participate in the Flexible
Spending Accounts. Prior to electing to participate in an FSA, it is important that you read and
understand this brochure.
This brochure is not intended to replace your employer’s Summary Plan Description.
After you read this material, if you have any questions, please feel free to contact the flexible
spending department at HR Simplified at 866/812/4812..
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WHAT TO THINK ABOUT BEFORE ENROLLING
There is typically a minimum reimbursement check amount of $25.00 with the exception of endof-year claims processing.
Any money you do not use from an FSA for expenses incurred during a plan year will be
forfeited.
This is governed under the IRS “use-it-or-lose-it” rule. To avoid forfeiting any money, you
should estimate your expenses very carefully. Most groups allow for a 60 or 90 day grace
period to submit all your claims for expenses incurred during the prior plan year. Please check
you plan document for the length of time your plan allows. IRS regulations do not allow money
to be transferred between reimbursement accounts. You cannot transfer unused funds from
Healthcare to Dependent care accounts or the other way around.
You may elect to have your claims paid by check or have funds directly deposited into your
account if your group has that option. The Direct Deposit Authorization form will be included in
your Flex Spending kit.
Once you have enrolled in an FSA, you may NOT make any changes to your election unless
you have a change in family status such as:
Marriage
Divorce
Birth or adoption
Gain/involuntary loss of spouse’s medical or dental coverage
Change in your spouse’s employment status
Death of a dependent (child or spouse)
Unpaid FMLA or Non-FMLA leave
Change in Dependent Care providers
Should one of the above occur during the plan year, you might be able to change or revoke
your current election. The change in election must be consistent with the change in status that
has occurred. You must contact your Benefits department for the necessary forms within 30
days of the change in status.
HEALTHCARE REIMBURSEMENT ACCOUNTS
Most people have a number of necessary, predictable expenses that are not covered
by their insurance plans. The Healthcare Reimbursement Account will allow you to pay
for these expenses with pre-tax dollars. With this account, you can pay for your out of
pocket healthcare expenses for you and your eligible dependents that are incurred
during your plan year and while you are an active participant. In general, eligible
expenses are “health care” expenses, which have not been reimbursed and are not
reimbursable from another source (i.e. insurance). The definition of “heath care”
expenses includes amounts paid “for the diagnosis, cure, mitigation, treatment, or
prevention of disease, or for the purpose of affecting any structure or function of the
body.” Note that prevention in this regard means that the disease or medical condition
already exists or is imminently probable. In addition, the care or treatment must be
directly related to the particular condition. This does not include expenses for care or
treatment, which are merely beneficial to general health or cosmetic in nature.
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Transportation expenses, which are primarily for and essential to medical care are also
considered eligible expenses.
EXAMPLES OF ELIGIBLE EXPENSES
The following table lists some of the eligible expenses as defined by IRS Code 213:
Acupuncture
Adoption-medical expense
Alcoholism Treatment
Ambulance
Artificial Limbs and Teeth
Birth Control Pills
Chiropractors
Christian Science Practitioners
Coinsurance/deductibles-related services
Contact Lenses/Solutions
Crutches
Dental Treatment
Diagnostic Services
Drug Addiction Treatment
Eye Exams/Glasses
Flu Shots
Hearing Aids/Batteries
Immunizations/Vaccines
Insulin
Laboratory Fees
Learning Disability Tuition Fees
Laser Eye Surgery
Medicines
Nursing Services
Operations/Surgery
Optometrists
Osteopath
Physical Therapy
Prescribed Massage Therapy
Psychiatric Care
Psychoanalysis
Psychologist
Smoking Cessation
Sterilization
Wheelchair
X-Rays
EXAMPLES OF OVER THE COUNTER DRUGS
Allergy Prevention & Treatment
Benadryl, Sudafed, Actifed, Chlora, Trimaton,
and Nassalcrom
Antacids and Acid Reducers
Gas-X, Maalox, Mylanta, Tums, AXID, AR,
Pepcid AC, Prilosec OTC, Tagamet HB, and
Zantac 75, AXID AR, Pepcid AC
Antidiarraheal and Laxitives
Ex-Lax, Pepto-Bismol, Immodium A.D. and
Kaopectate
Cough Suppressants
Robitussin, Vicks 44, Chloraseptic
Internal Analgesic/antipyretic
Advil, Aleve, Children’s Motrin, Nuprin,
Excedrin, Tylenol, Bayer
Smoking Cessation
Commit, Nicoderm CQ, Nicorette, Nicotrol
For a more complete list of allowable over the counter drugs please refer to the Section 213 list
of eligible expenses.
EXAMPLES OF EXPENSES THAT ARE NOT ELIGIBLE
Bottled Water
Breast Augmentation
Cosmetic Surgery
Custodial Care in an Institution
Diaper Services
Electrolysis
Funeral Expenses
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Hair Transplants/Removal
Insurance Premiums
Marriage/Family Counseling
Non-therapeutic Massage Therapy
Vitamins for general health
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Some other expenses that you incur during the year may not be eligible for reimbursement
under current IRS regulations such as:
Healthcare expense not yet rendered. Healthcare services do not have to be paid, but
must have been rendered during the plan year and while an active employee to be
eligible for reimbursement.
Insurance premiums are not eligible for reimbursement through your FSA account. This
includes contact lens insurance.
Expenses paid by an insurance company are not eligible for reimbursement-only the
portion you have to pay out of your pocket for your healthcare and dental expenses for
reimbursement.
Certain expenses require a letter of medical necessity from your doctor in order for you to be
reimbursed from your FSA. The letter must state specifically what illness or disease is being
treated or prevented and the length of time you will be required to use this treatment. Two
examples are:
Massage Therapy
Weight loss programs. Qualified expenses include behavioral counseling, nutritional
counseling, pharmacology and surgery rendered by a licensed professional. Meals and
nutritional supplements, health club dues and over-the-counter products are NOT
reimbursable.
REIMBURSEMENTS PRIOR TO FULL DEDUCTIONS
You may submit medical claims for reimbursement that exceed your current account balance
but not in excess of your annual elections. The funds that you are reimbursed will be recovered
as deductions continue to be deposited into your account throughout the plan year.
To obtain reimbursement from your FSA, you must complete a claim form and attach itemized
receipts from the service provider or EOB’s (Explanation of Benefits) from your insurance
company. Itemized receipts must include:
Name of employee or dependent receiving care
Dates of service (must be within the plan year)
Name of Service Provider
Charges incurred
 Amount paid by insurance company
Canceled checks, bankcard receipts, credit card receipts and credit card statements are
NOT acceptable forms of documentation. You are responsible for paying your healthcare
provider directly.
Each employer sets his or her own maximum and minimum contribution limit.
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HEALTHCARE REIMBURSEMENT…
Which is Better for You? After tax or before tax? Let's look at an example using $150.00
monthly of reimbursable expenses both ways -with and without a Flexible Spending Account.
Tax Savings Example $30,000 Income
NO FSA
FSA
GROSS MONTHLY INCOME
PRE-TAX HEALTHCARE
EXPENSES
$2,500
0
$2,500
$150
TAXABLE INCOME
FEDERAL TAX (15%)
STATE TAX (5%)
FICA TAX (7.65%)
$2,500
$375
$125
$191
$2,350
$352
$117
$179
AFTER-TAX HEALTHCARE
EXPENSES
$150
$0
MONTHLY SPENDABLE INCOME $1,359
Tax Savings
$23.00
$ 8.00
$12.00
$1,485
FSA SAVINGS TOTAL:
$43 PER MONTH
$516 PER YEAR
Tax Savings Example $60,000 Income
NO FSA
FSA
GROSS MONTHLY INCOME
PRE-TAX HEALTHCARE
EXPENSES
$5,000
$0
$5,000
$150
TAXABLE INCOME
FEDERAL TAX (28%)
STATE TAX (5%)
FICA TAX (7.65%)
$5,000
$1,400
$250
$383
$4,850
$1,358
$242
$371
AFTER-TAX HEALTHCARE
EXPENSES
$150
$0
MONTHLY SPENDABLE INCOME
$2,817
$2,879
FSA SAVINGS TOTAL
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Tax Savings
$42.00
$ 8.00
$12.00
$62 PER MONTH
$744 PER YEAR
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THE BETTER YOU PLAN! THE MORE YOU SAVE!
In the example for $60,000 income, the employee has no tax savings to show for the $4,320 in
after-tax Healthcare expenses. In fact, not until expenses exceed 7.5% of Adjusted Gross
Income would any taxes be saved. By comparison, if the employee had placed $4,320 in a
Flexible Spending Account, he or she would have realized a tax saving of $1,764, which
translates into a $1,764 increase in spendable earnings.
Note: This example makes general assumptions as to the tax liability in this situation. Your actual taxes
depend on your personal situation.
How to Set Up Your Healthcare Reimbursement
Account
STEP ONE
Carefully estimate your eligible healthcare expenses for the upcoming year. You should
use the special Expense Estimation Worksheet on page 11 to help you to determine your
annual healthcare expenses.
STEP TWO
Determine your contributions. Contact your employer to obtain an enrollment form, which
instructs your company to set aside a certain amount of money for your expenses. This amount
will be contributed on a pre-tax basis from each of your paychecks to your Healthcare Spending
Account. Remember the amount you select will be set aside before any federal, social security,
or, in most cases, state taxes are calculated.
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DEPENDENT CARE REIMBURSEMENT
ACCOUNT
INTRODUCTION
The Dependent Care FSA allows you to pay for day care expenses for your qualified
dependent/child with pre-tax dollars.
ELIGIBILITY REQUIREMENTS
Eligible dependents are defined as:
Under age 13
Physically or mentally unable to care for themselves
such as:
Disabled spouse
Disabled child
Elderly parents that live with you
For dependent care expenses to be eligible for reimbursement, you must be working during the
time your eligible dependents are receiving care. If you are married, your spouse must be either
Working at the time the day care services are rendered
A full-time student for at least 5 months during the year
Mentally or physically disabled and unable to provide care for him or herself
In the event of divorce, non-custodial parent cannot make a claim unless they have
custody 6 or more months per year
CONTRIBUTION LIMITS
The annual maximum contribution may not exceed the lesser of the following:
$5,000 ($2,500 if married filing separately)
Your wages for the year or your spouse’s if less If a spouse is disabled or a student
the maximum is $200 for one child $400 for two or more
The maximum is reduced by a spouse’s contribution to a Dependent Care FSA
The annual minimum contribution for a plan is set by each employer.
REIMBURSEMENT IS NOT IN ADVANCE OF DEDUCTIONS
You will only be reimbursed for up to your account balance at the time you submit your claim. If
your claim is for more than your account balance, the unreimbursed portion of your claim will be
tracked by us. You will be automatically reimbursed as additional deductions are taken and
deposited into your account, until your entire claim is paid out.
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HOW TO RECEIVE REIMBURSEMENT
To obtain reimbursement from your dependent care account, you must complete a claim form
and attach itemized receipts that include:
Name of Dependent Receiving Care
Dates of Service
Name of Service Provider
Social Security or Tax ID Number
Canceled checks, bankcard receipts, credit card receipts and credit card statements are
NOT acceptable forms of documentation. You are responsible for paying your provider
directly.
Eligible dependent care expenses are those expenses you must pay for the care of an eligible
dependent so that you and your spouse can work. The care may be provided either in your
home or at a licensed center outside of your home. If the care is provided in your home, then
the service cannot be provided by a child of yours under age 19, by your spouse or by your
dependents. If the care is provided outside of your home, the facility must be in compliance with
all applicable state and local regulations.
If dependent care is provided outside your home, your dependent must return to your
home for at least eight hours each day.
EXAMPLES OF ELIGIBLE EXPENSES
The following table lists some of the eligible expenses as defined by IRS Code 213:
Au Pair
Baby Sitters
Nursery School
Day Camps
Private Pre School
Licensed Day Care Centers
Nannies
Sick Child Centers
Before and After Care
Day Care for an Elderly Dependent
EXAMPLES OF INELIGIBLE EXPENSES
Only those dependent care expenses that enable you and your spouse to work are eligible.
Educational costs and weekend or evening-out babysitting do not qualify. Overnight camp
expenses are also ineligible.
You cannot be reimbursed for any dependent care expenses if your spouse does not work,
unless your spouse is a full-time student or is disabled.
Kindergarten expenses are ineligible as an expense if it is primarily educational,
regardless if it is half or full day, private or public state mandated or voluntary.
Transportation, books, clothing, food, entertainment and registration fees are
ineligible if these expenses are billed separately.
For a complete list of eligible expenses see IRS Publication 503 “Dependent Care Expenses.”
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EXAMPLES OF INELIGIBLE EXPENSES
Days you or your spouse do not work (although you may still have to pay the provider):
Leave of Absence
Vacation
Baby Sitting for Social Events
Care provided by children under 19 (or by anyone you claim as a dependent)
First Grade and above
Food Expenses (if separated from dependent care expense)
Overnight Camps
Registration Fees
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DEPENDENT CARE REIMBURSEMENT…
Which is Better for You? After tax or before tax? Let's look at an example using $360
monthly of reimbursable expenses both ways -with and without a Flexible Spending Account.
Tax Savings Example $30,000 Income
NO FSA
FSA
GROSS MONTHLY INCOME
PRE-TAX DEPENDENT CARE
$2,500
$0
$2,500
$416
TAXABLE INCOME
FEDERAL TAX (15%)
STATE TAX (5%)
FICA TAX (7.65%)
$2,500
$375
$125
$191
$2,084
$312
$104
$159
AFTER-TAX DEP. CARE
$416
$0
MONTHLY SPENDABLE INCOME $1,393
Tax Savings
$63.00
$21.00
$32.00
$1,509
FSA SAVINGS TOTAL:
$116 PER MONTH
$1,392 PER YEAR
Tax Savings Example $60,000 Income
NO FSA
FSA
GROSS MONTHLY INCOME
PRE-TAX DEPENDENT CARE
$5,000
$0
$5,000
$416
TAXABLE INCOME
FEDERAL TAX (28%)
STATE TAX (5%)
FICA TAX (7.65%)
$5,000
$1,400
$250
$383
$4,584
$1,283
$229
$350
AFTER-TAX DEP. CARE
AFTER-TAX HEALTHCARE
EXPENSES
$0
$416
$0
$0
MONTHLY SPENDABLE INCOME
$2,551
$2,722
FSA SAVINGS TOTAL
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Tax Savings
$117.00
$21.00
$33.00
$171 PER MONTH
$2,052 PER YEAR
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HOW TO SET UP YOUR DEPENDENT CARE
REIMBURSEMENT ACCOUNT
STEP ONE
Carefully estimate your eligible dependent care expenses for the upcoming year. Then use the
special Expense Estimation Worksheet on the following page to help you determine your total
expenses for the year. The Dependent Care Account is a superior method in most situations
with the exception of low-income employees. One big advantage with the Dependent Care
Spending Account is that you realize the savings immediately rather than waiting until
you file your tax return.
STEP TWO
Contact your employer to obtain an enrollment form, which instructs your company to set aside
a certain amount of money for your expenses. This amount will be contributed on a pre-tax
basis from each of your paychecks to your Dependent Care Spending Account. Remember the
amount you select will be set aside before any federal, social security, or, in most cases, state
taxes are calculated.
Expense Estimation Worksheet
This worksheet will help you determine your annual expenses for each reimbursement
account. Remember to be conservative with your estimates because unused
funds must be forfeited. Good planning and careful estimating is the best way to take
full advantage of your FSA.
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ESTIMATING YOUR QUALIFYING HEALTHCARE EXPENSES
Healthcare deductibles
Healthcare co-payments and coinsurance
Prescription drugs
Vision exams, glasses, contacts
Dental/Orthodontia
Routine exams, physicals and immunizations
Counseling/Psychotherapy
Expenses for disabled dependents
Over the Counter Drugs
Other allowable expenses
TOTAL ESTIMATED HEALTHCARE EXPENSES
FOR THE PLAN YEAR (Consult your plan)
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
$__________________________
$__________________________
$__________________________
$__________________________
ESTIMATING YOUR DEPENDENT CARE EXPENSES
Child daycare expenses
Preschool expenses
Summer day camp expenses
Adult daycare expenses
Other eligible expenses
$_______________________
$_______________________
$_______________________
$_______________________
$_______________________
TOTAL ESTIMATED DEPENDENT CARE EXPENSES
$_____________________
FOR THE PLAN YEAR (Max. $5,000/ Min. $120)
($2,500 maximum if married and filing separate tax returns)
TOTAL ESTIMATED EXPENSES FOR PLAN YEAR $______________________
DIVIDED BY THE NUMBER OF PAY PERIODS
÷______________________
FSA DEDUCTION PER PAY PERIOD =
$______________________
HR Simplified, Inc
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Section 213 Eligible Expense List – Given to eligible employees prior to of during open enrollment.
It is also part of our welcome package that we send out to all newly enrolled participants at the
beginning of each plan year. This form can be customized to meet the needs of each plan.
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Eligible Expense List for Your Flexible Spending Plan
What Expenses Can Be Reimbursed Under a Health FSA?
The following Table describes whether certain types of medical expenses qualify as reimbursable medical care under your Flexible
Spending Plan.
Caution Regarding Use of the Table:
Confirming that an expense is for medical care under the Table does not mean that the expense is reimbursable. A health FSA can only
reimburse expenses incurred for medical care under Code § 213 if other requirements in the Code including those for claims substantiation
are also met. In addition, provisions specific to your employers’ Summary Plan Description will also determine if an expense is
reimbursable.
The statements under the second column are intended to briefly highlight the general principles. Final determination will occur at
the time reimbursement is requested.
Expense
Is the Medical Care Expense Reimbursable?
Acupuncture
Administrative costs
Adoption—medical expenses incurred before
adoption is finalized.
Air conditioner
Yes, if it is to treat a medical condition.
Generally no. These are not medical care.
Yes, for medical expenses incurred before an adoption is finalized, if the child was a legal dependent when services
were provided.
Maybe. It must be primarily used by the sick person to treat a medical condition. If it is attached to the home (e.g.
central air conditioning), only the amount spent that is more than the value added to the property can be reimbursed.
Also, if others benefit from the air conditioning, only the sick person’s pro rata amount is reimbursable.
Yes. But only if recommended by a physician to treat a specific medical condition such as a severe allergy.
Yes. Amount paid for inpatient treatment, including meals and lodging, at a therapeutic center for alcohol addiction.
Transportation expenses associated with attending meetings of an Alcoholics Anonymous group in the community
would also be medical care if attending on a physician’s advice that membership is necessary to treat alcoholism.
Generally no, if the product is one that would be owned even without allergies, such as a pillow or a vacuum. However,
an air purifier or water filter necessary to treat a specific medical condition may be allowable.
Air purifier
Alcoholism treatment
Allergy treatment products and household
improvements to treat allergies (e.g., filters,
pillows, special vacuums, etc.)
Alternative healers, dietary substitutes and
drugs and medicines
Ambulance
Artificial limb
Artificial teeth
Automobile modifications
Baby-sitting and childcare
Battery-powered toothbrush
Birth control pills
Birthing classes
Blood pressure monitoring devices
Blood sugar test kit
Body Scan
Braille books and magazines
Breast pumps
Breast reconstruction surgery
Capital expenditures
Cayenne Pepper
Chelation therapy
Childbirth classes
Chinese herbal doctor & herbal treatments
Chiropractors
Maybe. Non-traditional healing treatments provided by professionals maybe eligible under certain circumstances, but
the IRS looks at them very closely. The expenses must be legal. However, the expenses are not reimbursable if the
remedy is a “food or substitute for food” that the person would normally consume to meet nutritional requirements. It
now appears that drugs and medicines recommended by alternate healers can qualify as medical care.
Yes.
Yes
Yes
Yes, if for physically handicapped persons.
No. Baby-sitting, childcare, and nursing services for a normal, healthy baby are not reimbursable.
Maybe, but only if prescribed by a physician to treat a specific dental ailment.
Yes. Health FSAs are permitted to reimburse medicines and drugs that meet the definition of medical care under Code
213(d), including medicines purchased over the counter as well as prescription drugs.
See Lamaze.
Yes.
Yes. Items such as blood sugar test kits and test strips are diagnostic items and would be reimbursable.
Yes
Yes. Only amount paid by visually-impaired person, above the cost of regular printed material
Generally no. Ordinarily not reimbursable if for convenience, scheduling, or other personal reasons. But if there is an
underlying medical reason (for example the participant’s physician recommends a breast pump because the participant
has a breast abscess). May need to provide physician letter of medical necessity.
Yes. Amounts paid for breast reconstruction surgery following a mastectomy for cancer are reimbursable.
Maybe. A capital expense may be reimbursed if its purpose is to provide medical care for the participant, spouse, or
dependent. A capital expense for portable medical items is reimbursable if it is bought only for use of the sick person.
Expenses for improvements or special equipment added to a home may also be reimbursed if the main purpose of the
item is medical care. How much is reimbursable depends on the extent to which the expense permanently improves the
property and whether others (besides the sick person) benefit.
Yes, if used to primarily treat a specific medical condition.
Yes, if used to treat a medical condition such as lead poising.
See Lamaze.
Maybe. Non-traditional healing treatments provided by professionals maybe eligible under certain circumstances, but
the IRS looks at them very closely. The expenses must be legal. However, the expenses are not reimbursable if the
remedy is a “food or substitute for food” that the person would normally consume to meet nutritional requirements.
Yes.
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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Christian Science practitioners
Circumcision
COBRA premiums
Co-insurance amounts and deductibles
Contact lenses and related materials and
equipment
Contraceptives
Controlled substances
Cosmetics
Cosmetic procedures (including cosmetic
surgery)
Counseling
Crutches
Dancing lessons
Deductibles
Dental treatment
Dependent care expenses
Diagnostic services
Diapers or diaper service
Disabled Dependent Care Expenses
DNA, collection and storage
Drug addiction treatment
Drug overdose, treatment of
Drugs
Dyslexia
Ear Plugs
Egg donor fees
Eggs and embryos, storage fees
Electrolysis or hair removal
Elevator
Exercise equipment or programs
Eye examinations, eyeglasses and related
equipment and material
Fertility enhancement
Fitness programs
Flu shots
Fluoridation device
Foods
Funeral expenses
Maybe. Payment for prayers of authorized practitioners may be reimbursable in certain circumstances. Non-traditional
healing treatments provided by practitioners may be eligible under certain circumstances, but the IRS looks at them very
closely. The treatments must be legal.
Yes.
No.
Yes, if underlying expense would be reimbursed if entirely paid by the individual.
Yes. Amounts paid for lenses needed for medical reasons, as well as material and equipment needed for using lenses,
such as saline solution and enzyme cleaner. Contact lens insurance would not be reimbursable.
Yes. Health FSAs are permitted to reimburse medicines and drugs that meet the definition of medical care under Code
213(d), including medicines purchased over the counter as well as prescription drugs.
No, if the substance violates federal law. This is true even if a state law allows use of the controlled substance with a
physician’s prescription and the participant gets that prescription.
No. Cosmetics such as face creams, deodorants, hand lotions, or any similar preparation used for ordinary cosmetic
purposes are not reimbursable.
No, except for amounts paid for surgery necessary to improve a deformity arising from congenital abnormality, personal
injury from an accident or trauma, or a disfiguring disease. “Cosmetic surgery” means any procedure that is directed at
improving the patient’s appearance and does not meaningfully promote the proper function of the body or prevent or
treat illness or disease. May need to provide physician letter of medical necessity.
Maybe. If it is marriage counseling, no. If it is for a medical reason, then yes. See Psychiatric care and Psychologist.
Yes. Amount paid to rent or buy. Substantiation should include amount paid plus evidence of hospital or doctor office
care.
No, if prescribed by a physician for improvement of general health. Maybe, if prescribed by a physician for a specific
medical condition (e.g., as part of rehabilitation program after surgery).
See Co-insurance.
Yes. Amount paid for treatment including fees for X-rays, fillings, braces, extractions, dentures, orthodontia, etc. The
reimbursable amount is limited if the treatment includes pre-payment for services that haven’t been provided.
No.
Yes
No, not unless amounts are paid to relieve the effects of a particular disease.” Consequently, adult diapers used to
relieve incontinence should be reimbursable, as contrasted with diapers for newborn babies whose need for them simply
evidences normal health. Although there may be personal element in the adult diaper expense, it would not have been
incurred “but for” the medical condition
Yes, if the expenses are for medical care of the disabled dependent. Note that some disabled dependent care expenses
that qualify as medical expenses may also qualify as work-related expenses for purposes of taking a credit for dependent
care (Code 21) or for reimbursement under a dependent care assistance program (DCAP). These expenses can be
applied towards the dependent care credit, the DCAP or a medical deduction, but the same expenses cannot be applied
for more than one claim.
Generally no. However, temporary storage may be reimbursable under some circumstances, such as where the DNA is
collected as part of the diagnosis, treatment or prevention of an existing or imminent medical condition. “Temporary” is
not defined, however, one consideration might be whether it is within the same plan year.
Yes. Amounts paid for an inpatient’s treatment at a therapeutic center for drug addiction are reimbursable.
Yes, so long as the treatment qualifies as medical care.
Yes, if legally procured and generally accepted as medicines and drugs. Health FSAs are permitted to reimburse
medicines and drugs that meet the definition of medical care under Code 213(d), including medicines and drugs
purchased over the counter as well as prescription drugs.
See Language training.
Yes, to the extent prescribed by a physician for a specific medical condition (e.g., ear tubes).
Yes. Amounts paid for the egg donor fee, an agency fee, an egg donor’s medical and psychological testing, insurance
for post-procedure donor medical and psychological assistance and the legal fees for preparation of the egg donor
contract.
Maybe, with respect to fees for temporary storage for immediate conception. Storage fees for undefined future
conception probably aren’t considered medical care. “Temporary” is not defined; however, one consideration might be
whether it is within the same plan year.
Generally no. See Cosmetic procedures.
Installing an elevator on the advice of a physician so that a participant or dependent of the participant with heart disease
will not have to climb stairs may be reimbursable to the extent of the amount in excess of value enhancement to the
property.
Generally no, unless recommended by a physician to treat a specific medical condition.
Yes. Amount paid for eyeglasses and lenses prescribed by a physician for medical reasons, and eye examinations.
Materials and equipment needed for using the eyeglasses, such eye cleaner, should be reimbursable as well. Also see
Contact lenses and related equipment and materials, and Sunglasses.
Yes, to the extent procedures are intended to overcome an inability to have children. Examples are IVF (in vitro
fertilization), including temporary storage of eggs or sperm, surgery, (including an operation to reverse prior surgery
preventing someone from having children), shots, treatments, and GIFT (gamete intrafallopian transfer). Expenses paid
to or for an in vitro surrogate may not be medical care unless the surrogate is a tax dependent.
See Exercise equipment or programs.
Yes. Immunizations to prevent disease should qualify, even though no medical condition has been diagnosed.
Yes. For fluoridation services, amount should be limited to cost allocable to current plan year.
See Special foods.
No. These are not for medical care.
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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Gambling problem, treatment for
Genetic testing
Glucose monitoring equipment
Guide dog or other animal aide
Hair removal and transplants
Health club dues
Health institute fees
Hearing aids
Herbs
Holistic or natural healers, dietary
substitutes and drugs and medicines.
Home care
Hormone replacement therapy (HRT)
Hospital services
Household help
Illegal operations and treatments
Immunizations
Inclinator
Infertility treatments
Insulin
Insurance premiums
Laboratory fees
Lactation consultant
Lamaze classes
Language training
Laser or Lasik eye surgery
Lead-based paint removal
Learning disability
Lifetime care-advance payments
Lodging at a hospital or similar institution
Lodging not at a hospital or similar
institution
Lodging of a companion
Lodging while attending a medical
conference
Long-term care services
Marijuana or other controlled substances
Massage therapy
Mastectomy-related special bras
Maternity clothes
Mattress
Meals at a hospital or similar institution
Meals not at a hospital or similar institution
Maybe. See Alcoholism treatment.
A gray area. To the extent it is done to determine possible defects (e.g., if mother is over age 35), it is probably
reimbursable. But not reimbursable if it is done just to determine the sex of the fetus
Yes. Items such as blood glucose meters and glucose test strips are diagnostic items and would be reimbursable.
Yes, if the expense is for buying, training and caring for animals used by a vision-impaired or hearing-impaired person.
See Cosmetic procedures.
Generally no. However, fees paid for specific services at a health club (e.g. physical therapy) may be reimbursable if
recommended by a medical practitioner and substantiated by his or her statement that treatment is necessary to alleviate
a physical or mental defect or illness.
Yes, if paid o the health institute for treatment recommended by a physician who makes a written statement that it is
necessary to alleviate a physical or mental defect or illness.
Yes. Amount paid for hearing aid and batteries for its operation.
See Vitamins
Maybe. Non-traditional healing treatments provided by professionals maybe eligible under certain circumstances, but
the IRS looks at them very closely. The expenses must be legal. However, the expenses are not reimbursable if the
remedy is a “food or substitute for food” that the person would normally consume to meet nutritional requirements. It
now appears that drugs and medicines recommended by alternate healers can qualify as medical care.
See Nursing Services.
Yes, if legally procured and generally accepted as medicines or drugs. Health FSAs are permitted to reimburse
medicines and drugs that meet the definition of medical care, including medicines purchased over the counter as well as
prescription drugs.
Yes. Expenses of inpatient care (plus meals and lodging) at a hospital or similar institution are reimbursable if the main
reason for being there is to get medical care.
No, except for certain expenses that may qualify as nursing services. See Nursing services.
No, even if they are rendered or prescribed by a licensed medical practitioner.
Yes. Even in the absence of a specific diagnosis immunizations to prevent disease should qualify.
Yes, if it otherwise qualifies as medical care and is detachable from the property and purchased only for the use of a
sick person. See Capital expenses.
See Fertility enhancement.
Yes. Equipment needed to inject the insulin, such as syringes or insulin pumps would also qualify as medical expense.
No.
Yes. Amounts paid for lab fees that are a part of medical care
Maybe. If a woman is having lactation problems and cannot breastfeed her child, then the expense of a lactation
consultant may be allowable.
Some of it. Expenses may be reimbursable to the extent that instruction relates to birth and not child rearing. The fee
will have to be apportioned to exclude instruction in topics such as newborn care. Also, amounts for the coach or
significant other are not eligible.
Yes, if for a child with dyslexia or a disabled child.
Yes. See Radial keratotomy. Radial keratotomy is reimbursable. Amounts paid for radial keratotomy or other laser
eye surgery are reimbursable if the procedures are done primarily to promote the correct function of the eye.
Yes, for the cost of removing lead-based paints from surfaces in the home to prevent a child who has or has had lead
poisoning from eating the paint. These surfaces must be in poor repair and within the child’s reach. The cost of
repainting is not a medical expense.
Yes. Amount paid to special school or specially-trained teacher, which is prescribed by physician, for a child who has
severe learning disabilities caused by mental or physical impairments.
No. This is part of a fee paid monthly or as a lump sum under an agreement with a retirement home.
Sometimes. If the main reason is to receive medical care.
Yes, up to $50 per night if these conditions are met: (1)the lodging is primarily for and essential to medical care; (2)the
medical care is provided by a physician in a licensed hospital or medical care facility related to (or equivalent to) a
licensed hospital; (3)the lodging isn’t lavish or extravagant; (4)there is no significant element of personal pleasure,
recreation or vacation in the travel.
Yes, if accompanying a patient for medical reasons and all of the conditions described above are also met. For example,
if a parent is traveling with a sick child, up to $100 per night ($50 for each person) can be reimbursed.
No.
Generally not reimbursable under a health FSA.
See Controlled substances.
Generally no, unless recommended by physician to treat a specific injury or trauma. A letter from a medical practitioner
evidencing that the individual has a health condition and that the message therapy is being used to treat the condition
may be necessary.
Generally no, unless physician prescribes for mental health treatment. The administrator should get a physician’s
certification of medical need. See Reconstructive surgery following a mastectomy.
No.
Unlikely, unless use is almost exclusively to treat medical condition. The IRS will likely use a three-part test evaluating
the (1) severity of condition; (2) uniqueness of mattress to treatment of condition (e.g., is it a special mattress or
hospital bed or just a more expensive “extra-firm” mattress); and (3) lack of functionality as a general purpose
furnishing.
Yes, if the main reason for being there is to receive medical care.
Probably not. The IRS has taken the position that expenses for meals and lodging while traveling to receive medical
treatment aren’t medical care.
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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Meals of a companion
Meals while attending a medical conference
Medic alert bracelet or necklace
Medical conference admission and
transportation to transportation to/from
Medical information plan changes
Medical monitoring and testing devices
Medical records charges
Medical services
Medicines
Mentally retarded, special home for
Naturopathic healers, dietary substitutes and
drugs and medicines.
Nonprescription drugs and medicines
Norplant insertion or removal
Nursing home expenses
Nursing services
Nutritionist’s professional expenses
Nutritional supplements
Obstetrical expenses
Occlusal guards to prevent teeth grinding
Operations
Optometrist
Organ donors
Orthodontia
Osteopath
Over-the-counter medicine (e.g., aspirin
Calcium supplements, etc.)
Ovulation monitor
Oxygen
Patterning exercises
Personal use items
Physical exams
Physical therapy
Pregnancy test—over-the-counter
Prenatal Vitamins
Pre-payment for services
Prescription drugs
Prescription drug discount programs
Propecia
Prothesis
Psychiatric care
Psychoanalysis
Psychologist
No, even if accompanying a patient for medical reasons.
No.
Yes, if recommended by a medical practitioner in connection with treating a medical condition.
Yes. Amounts paid by an individual for expenses of admission and transportation to a medical conference relating to
the chronic disease of the individual’s dependent are reimbursable, if primarily essential to the medical care of the
dependent. Transportation expenses include transportation to the city where conference is held, plus local
transportation to the conference. The cost of meals and lodging while attending the conference is not allowed.
Yes, to cover the current year’s storage costs. Amounts paid to a plan that keeps medical information so that it can be
retrieved from a computer data bank for medical care are reimbursable.
Yes. Examples of such devices are blood pressure monitors, syringes, glucose kit, etc.
Yes. An expample is the fee associated with transferring medical records to a new medical practitioner.
Yes. Amounts paid for legal medical services prescribed by physicians.
Yes, if legally procured and generally accepted as medicines and drugs. Health FSAs are permitted to reimburse
medicines and drugs that meet the definition of medical care under Code 213(d), including medicines and drugs
purchased over the counter as well as prescription drugs.
Maybe.The cost of keeping a mentally retarded person in a special home (not the home of a relative) on the
recommendation of a psychiatrist to help the person adjust from life in a mental hospital to community living may be
reimbursable.
Maybe. Non-traditional healing treatments provided by professionals maybe eligible under certain circumstances, but
the IRS looks at them very closely. The expenses must be legal. However, the expenses are not reimbursable if the
remedy is a “food or substitute for food” that the person would normally consume to meet nutritional requirements. It
now appears that drugs and medicines recommended by alternate healers can qualify as medical care.
See Over the Counter Lists.
Yes.
Sometimes. Expenses for medical care in a nursing home or home for the aged for the participant, the participant’s
spouse or dependent, including meals and lodging, are reimbursable if the main reason for being there is to get medical
care. If the main reason for being in the home is not to get medical care (e.g. for personal or family reasons), then the
cost that is for medical care or nursing services may be reimbursable (but the cost of meals or lodging is not). Any
expenses that are for qualified long-term care services cannot be reimbursed on a tax-free basis through a health FSA.
Yes, including nurses’ board where paid by the participant. Amounts spent in wages and other nursing services.
Services need not be performed by a nurse, so long as the services are of a kind generally performed by a nurse. Does
not include nursing services for a healthy baby.
Maybe, if the treatment relates to a specifically diagnosable medical condition. Probably not reimbursable if the
expense is for general health.
The cost of nutritional supplements, vitamins, herbal supplements and natural medicines are not reimbursable if they
are merely beneficial for general health. They may be reimbursable if recommended by a medical practitioner for a
specific medical condition.
Yes.
Yes.
Yes. Amount paid for legal operations, but not for cosmetic surgery operations. See Cosmetic procedures.
See Eye exams and eyeglasses.
See Transplants.
Generally yes, unless care is for cosmetic purposes.
Yes.
See Over the Counter Lists.
Yes.
Yes. Amount paid for oxygen and equipment for breathing problems caused by a medical condition.
Yes. Amounts paid to an individual for giving patterning exercises to a mentally retarded child are reimbursable.
Generally no, unless it is used primarily to prevent or alleviate a physical or mental defect or illness. See Cosmetics,
Toiletries, and Capital expenditures.
Generally yes, but not employment-related physicals.
Generally yes, so long as required for a specific medical condition.
Yes.
See Vitamins.
No
Yes. See Drugs.
Generally no. This is a program where an individual pays a fee to get a card that provides a 20% discount off all drugs.
A filled prescription may itself be reimbursable.
Generally no, if purchased for cosmetic purposes (e.g. to treat male pattern baldness) even if recommended by a
medical practitioner. But may be reimbursable if for a specific medical condition that is not for cosmetic purposes or, if
it is, that ameliorates a deformity arising from one specified events in the safe harbor from the cosmetic procedures
exception from medical care.
See Artificial limb.
Yes. Amount includes cost of supporting mentally ill dependent at a special center that provides medical care.
Yes, except amount paid as part of training to be psychoanalyst.
Yes. Expenses for medical care.
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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Radial keratotomy
Reading glasses
Recliner chair
Reconstructive surgery following
mastectomy
Retin-A
Rogaine
Rubdowns
Safety glasses
Schools and education, special
Screening tests
Seeing-eye dog
Shipping and handling fees
Sick-child facility
Sleep deprivation testing and treatment
Smoking cessation program
Special foods (e.g., gluten-free or salt- free
diet)
Sperm, storage fees
Stem cell, harvesting and/or storage of
Sterilization procedures
Student health fee
Sunglasses
Sunglasses Clips
Supplies to treat medical condition (e.g.,
bandages, gauze, batteries for hearing aids.
Surgery
Surrogate expenses
Swimming lessons
Tanning salons and equipment
Taxes on medical services and products
Teeth whitening
Telephone for hearing-impaired persons
Television for hearing-impaired persons
Therapy
Transplants
Transportation to and from a medical
conference
Yes. Amounts paid for radial keratotomy or other laser eye surgery are reimbursable if the procedures are done
primarily to promote the correct function of the eye. Corneal ring segments (removable plastic half-rings that
correct vision) would appear to be reimbursable under this category.
Yes, if they correct a defect.
Generally no, unless use is almost exclusively to treat medical condition. The IRS will likely use a three-part test
(similar to that applicable to mattresses and beds) evaluating the (1)severity of the condition; (2)uniqueness of item to
treatment of condition; and (3)lack of functionality as general purpose chair.
A gray area. The IRS has informally indicated that this would be considered cosmetic surgery.” However, with the
passage of the Women’s Health and Cancer Rights Act, it is likely that reconstructive surgery would be viewed as
surgery “necessary to ameliorate a personal injury.
Generally no, if purchased for cosmetic purposes even if recommended by a physician. But may be reimbursable if
prescribed by a physician for a specific medical condition (such as acne).
Generally no. See Retin-A.
Generally, no, unless a physician determines that these are necessary to treat a specific illness.
Likely no, unless prescribed. See Eye examinations and Eyeglasses.
Payments made to a special school for a mentally impaired or physically disabled person are reimbursable if the main
reason for using the school is its resources for relieving the disability. Includes such items as teaching Braille to a
vision- impaired child, teaching lip reading to a hearing-impaired child, or giving remedial language training to correct
a condition caused by a birth defect. Meals, lodging and ordinary education supplied by the special school is only
medical care if the child is at the school primarily for relieving the disability. If the child is at the school to benefit from
the courses and disciplinary methods, the expenses won’t qualify.
Yes, if the tests are used for medical diagnosis. (e.g. cholesterol screenings)
See Guide dog.
Yes, so long as the fees are paid to obtain an item for medical care and are not unreasonable.
Probably not, unless primary purpose is for medical care.
Probably yes, if under the care of a physician.
Generally yes. Amounts paid for a stop-smoking program are reimbursable, as are amounts for prescribed drugs. Over
the counter drugs and medicines used to stop smoking would also be reimbursable.
Yes, if prescribed by a physician to treat a specific illness or ailment, to the extent the cost of amounts paid exceeds cost
of commonly available versions of the same product.
Maybe, with respect to fees for temporary storage for immediate conception. Storage fees for undefined future
conception probably aren’t considered medical care. “Temporary” is not defined; however, one consideration might be
whether it is within the same plan year.
Perhaps, if there is a specific and imminent medical condition that the stem cells are intended to treat. For example, the
cost of harvesting and storing stem cells because a newborn has a birth defect and the stem cells would be needed in the
near future might be allowable. But collection and storage indefinitely, just in case an item might be needed is not
medical care.
Yes. Amount paid for a legal operation, including vasectomy.
No. If the fee is simply the cost of belonging to the program, such fees aren’t reimbursable.
Yes, if they are prescription sunglasses. Amount paid for eyeglasses and lenses needed for medical reasons, and eye
examinations. Possibly for non-prescription sunglasses if recommended by physician to alleviate an eye condition.
No, if they are not corrective.
Yes. If supply is not a drug or biological, is incurred to treat a specific medical condition, and is not a personal comfort
item.
See Operations.
Generally, no, even if they are for medical care of the surrogate or her unborn child. What is key is the relationship
between the expenses and the procedure, which needs to be performed upon the participant or the participant’s spouse
or dependent-typically neither the surrogate nor her unborn child will qualify.
No, if recommended by a physician for improvement of health. Maybe, if prescribed by a physician for a specific
medical condition.
Generally no, if prescribed by a physician for general health. Possibly, if incurred to treat a specifically diagnosable
condition (e.g., skin disorder), so long as there is no personal element (e.g., use by other family members).
Generally yes, to the extent that a tax is imposed on reimbursable medical care or products. This includes local, sales,
service and other taxes.
Generally no, at least not if done for cosmetic purposes. But if tooth discoloration (rising to the level of deformity) was
caused by disease, birth defect or injury, expenses for teeth whitening might be reimbursable. See Cosmetic surgery.
Yes, for amounts paid for purchase and repair of special telephone equipment for hearing-impaired person. There is no
published position on whether the cost of a wireless telephone for a deaf person is reimbursable. See Capital expenses.
Yes. The cost of equipment that displays the audio part persons, such as the cost of an adapter that attaches to a regular
set or the cost of a specially equipped television to the extent it exceeds the cost of a regular model is reimbursable. See
Capital expenses.
Yes, if provided for medical care (and not just for the general improvement of mental health, relief of stress or personal
enjoyment). See also Patterning exercises, Psychoanalysis, Psychologist and Schools and education, special.
Yes. Amounts paid for surgical, hospital, laboratory, and transportation expenses for organ donor.
Yes. Amounts paid by an individual for expenses of admission and transportation to a medical conference relating to
the chronic disease of the individual’s dependent are reimbursable, if primarily essential to the medical care of the
dependent. Transportation expenses include transportation to the city where conference is held, plus local
transportation to the conference. The cost of meals and lodging while attending the conference is not allowed.
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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Transportation and related travel expenses
for person receiving medical care
Transportation of someone other than the
person receiving medical care
Treadmill
Tuition for special needs program (e.g.,
reading program for dyslexia)
Tuition including separate breakdown for
medical expenses
Umbilical cord, freezing and storing or
Unusual and customary, charges in excess of
Vaccines
Varicose veins
Vasectomy
Viagra
Vision correction procedures
Vision discount programs
Vitamins
Weight-loss program and/or drugs
prescribed to induce weight loss.
Wheelchair
Wigs
X-ray fees
YMCA day camp
Yes, if the expenses are primarily for and essential to medical care. These include car expenses, bus, taxi, train, plane,
ferry fares and ambulance services. Instead of actual car expenses, 12 cents a mile is reimbursable for use of car to
obtain medical care. Parking fees and tolls can also be reimbursed.
Yes, in some cases. Transportation expenses of the following persons may be reimbursed: (1) a parent who must go
with a child who needs medical care; (2) a nurse or other person who can give injections, medications or other treatment
required by a patient who is traveling to get medical care and is unable to travel alone; and (3) visits to see a mentally ill
dependent, if recommended as part of a treatment.
Generally no, unless recommended by a medical practitioner to treat a medical condition. For example, if the individual
can establish that the reason for the treadmill is to treat a medical condition (such as obesity), and the expense would
not have been incurred “but for” that medical condition, it might be reimbursable.
Probably not, unless primary purpose is for medical care. See Learning disability and Schools and education,
special.
Yes. Charges for medical expenses that are separately broken down in a bill for tuition or a college or private school are
reimbursable, if they are for specific medical services (and not for medical care generally).
Perhaps, if there is a specific medical condition that the umbilical cord in intended to treat. Collection and storage
indefinitely, just in case it is needed is not medical care. “Temporary” is not defined, however, one consideration might
be whether it is within the same plan year. The cost of storing blood because a newborn has a birth defect and the cord
blood would be needed in the near future might be allowable for reimbursement.
Yes. Medical expenses in excess of an insurance plan’s usual, customary, and reasonable charges are reimbursable if
the underlying expense would be reimbursable.
Yes. See Immunizations.
No, if the procedure is directed at improving the patient’s appearance and does not meaningfully promote the proper
function of the body or prevent or treat illness or disease. May be reimbursable if the procedure promotes the proper
function of the body or prevents or treats an illness or disease. See Cosmetic procedures.
Yes. See Sterilization.
Yes, to the extent prescribed by a physician to treat a medical condition.
Yes, medical procedures that correct vision, including laser procedures such as LASIK and radial keratotomy are
reimbursable.
Generally no. May be allowed to extent actual medical treatment is received (e.g., medical exam).
Maybe, if recommended by a medical practitioner to treat a specific medical condition but not if they are merely
beneficial for general health.
Yes, if the weight-loss program is recommended by a physician to treat an existing disease (such as obesity, heart
disease or diabetes), and is not simply to improve general health, then the expenses are reimbursable. However, the
costs of food associated with a weight loss program, (such as special weight watchers-type dinners) would not be, since
they just meet normal nutritional needs.
Yes. Amount paid for purchase as well as cost of operation and upkeep of a wheelchair if needed for the relief of
sickness or disability.
Maybe. The full cost of a wig purchased if prescribed by a physician for the mental health of a patient who has lost all
of his or her hair from disease or treatment (e.g., chemotherapy or radiation).
Yes. Amounts paid for X-rays received for medical reasons.
Generally no. However, if it is a special program that is therapeutic and treats a specific disability, then the expense
might be reimbursable.
Over the Counter Medications
The lists below are not intended to be exhaustive. Other drugs not listed may fall into one of the categories described below.
Over the counter drugs and medicines cannot be “stockpiled” for use in a future plan year. Stockpiling is defined as purchasing amounts larger than can be consumed in
the current plan year. A “reasonable amount” criteria will be applied.
1. Over the Counter Drugs Used Primarily for Medical Care
Typically reimbursable with proper receipt. No recommendation from a health care provider is needed.
Type of Drug
Allergy Prevention & Treatment
Antacids and Acid Reducers
Anticandial
Anthistamines
Antidiarraheal and Laxatives
Ant-fungal
Anti-itch Lotions and Creams(e.g.,for athletes
foot,jock itch,bug bites,poison ivy)
Cold Sore/Fever Blister
Cough Suppressants
Decongestant/Nasal Decongestant and Cold
Remedies
Diaper Rash Ointments
Eye Drops for Allergy/Cold Relief
Hemorrhoid Treatments
Examples
Benadryl, Sudafed, Actifed, Chlora Trimaton, and Nasalcrom
Gas-X, Maalox, Mylanta, Turns, AXID AR, Pepcid AC, Prilosec OTC, Tagament HB, and Zantac 75
Femstat 3, Gyne-Lotrimin, Mycelrx-7, Monistat 3,7, and Vagistat-1
Actidil Syrup and Capsules, Actifed, Allerest, Benadryl, Claritin, Chlor-Trimeton, Contac, Dimetane, Drixoral,
Nyquil, Sudafed,Tavist-1, and Triaminic
Ex-Lax, Pepto-Bismol, Immodium A.D. and Kaopectate
Lamisil AT, Lotramin AF, and Micatin
Bactine, Caldecort, Cortaid, Hydrocortisone, Lanacort, Calamine Lotion, Benadryl Cream, Caladryl, Cortaid,
Lamisil AT, Lotramin AF, and Micatin
Abreva Cream
Robitussin, Vicks 44, Chloraseptic
Advil Cold and Sinus, Afrin, Afrinol, Aleve Cold and Synus, Children’s Advil Cold, Duration, Dristan Long Lasting,
Neo-Synephrine-12 Hour, Orrivin, Sudafed, Tavist-D, Tylenol Cold and Flu, Thera-flu, Alka Seltzer Cold and Flu,
Nyquil, Actidil Syrup and Capsules, Actifed, Allerest, Benedryl, Claritin, Chlor-Trimeton, Contac, Dimetane.
Balmax and Desitin
Ocu Hist
Preparation H, Hemorid, and Tronolane
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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www.hrsimplified.com
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Internal Analgesic/antipyretic
Menstrual Cycle Medications
Migraine
Motion Sickness Medication
Nicotine Gum or Patches and Smoking
Cessation Aids
Pediculicide(head lice)
Poison Ivy Protection
Smoking Cessation
Toothache and teething pain relievers
Advil, Aleve, Children’s Motrin, Nuprin, Excedrin, Tylenol, Bayer
Midol, Pamprin, and Premysyn PMS
Advil Migraine Liqui-gels, Excedrin Migraine, Motrin Migraine Pain
Dramamine and Marizine
Nicorette, Nicotrol, and Nicodin
Nix
Ivory Block
Commit, Nicoderm CQ, Nicorette, Nicotrol
Orajel
2. Dual Purpose Over the Counter Drugs
Reimbursable with Health Care Provider’s Note Listing Diagnosis of a Medical Condition and Recommendation of OTC Drug
Anti-baldness/hair loss/hair replacement such as Rogaine, but only if to replace hair loss due to a medical condition and not for balding due to age.
Medicated shampoo to treat a specific medical condition like psoriasis and only the amount in excess of the cost of normal shampoo. Many plan sponsors may exclude
completely to avoid having to determine whether the cost of a medicated shampoo exceeds the cost of regular shampoo.
Dental fluoride treatments, special mouthwashes, or treatments for gingivitis.
Fiber supplements such as Benefiber and Metamucil.
Glucosamine/chondrotin for arthritis or other medical condition (not reimbursable if taken for overall joint health).
Herbal supplements used to treat a specific disease such as St. John’s Wort for depression.
Nose strips for proper breathing or other medical conditions
Retin-A and other acne medicines (not reimbursable if used for cosmetic purposes such as wrinkle reduction).
Snoring cessation aids and medications such as Breathe Right Spray, Snorezz.
Weight loss/dietary supplements must be for a specific medical condition such as obesity.
3. Over the Counter Drugs Primarily Not Reimbursable
OTC Drugs or other products that are not for medical care.
Deodorants
Face creams, moisturizers, eye creams, and wrinkle reducers
Hair removal treatments and waxes
Mouth washes, antiseptics and oral anesthetics
Teeth Whitening kits and powders
Toothpaste
Vitamins taken to improve overall-health
What Expenses Can Be Reimbursed Under a Dependent Care Assistance program (DCAP)?
The following Table describes whether certain types of dependent care assistance expenses qualify as employment-related expenses under
Code § 21 and therefore would be eligible for the Dependent Care Credit.
Caution Regarding Use of the Table:
Confirming that an expense is employment-related expense under the Table does not mean that the expense is reimbursable. A DCAP can
only reimburse expenses incurred for dependent care assistance under Code § 21 if other requirements in the Code (including those for
claims substantiation) are also met. In addition, provisions specific to your employers’ Summary Plan Description will also determine if
an expense is reimbursable.
The statements under the second column are intended to briefly highlight the general principles. Final determination will occur at
the time reimbursement is requested.
Expense
After-school care or extended day programs
(supervised activities for children after the
regular school program).
Is the Expense Eligible to Be “Employment-Related”
Yes. These programs are generally custodial in nature. Although children are supervised by qualified adults, the
primary purpose of these programs is to care for children while parents are at work.
Assisted Living.
See Custodial or elder care expenses
Au pair expenses.
Yes, but not airfare and other fixed costs.
Baby-sitter inside or outside participant’s
household.
Yes, unless the baby-sitter is a child of the employee (or spouse) under age 19, or is otherwise claimed as a
dependent by the employee or spouse on the IRS Form 1040.
Chauffeur.
No.
Child of participant, amounts paid to.
No, unless child is age 19 or older and cannot be claimed as a dependent of the participant or participant s spouse
Code § 129(c).
Cook
Generally, no. See Household services
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
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Or visit us online
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7 of 8
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Custodial or elder care expense.
Only if (a) such expenses are not attributable to medical services, and (b) the qualifying individual regularly
spends at least eight hours each day in the taxpayer’s household.
Dependent care center expenses.
Yes
Disabled spouse or tax dependent lives outside
household.
No. They must regularly spend at least eight hours per day in the employee’s household
Educational expenses—first grade and above.
No. Educational expenses for a child in first or higher grades are not considered expenses for care.
Educational expenses—kindergarten.
No. Such expenses are primarily educational in nature, regardless of half- or full-day, private or public school,
state-mandated or voluntary.
Educational expenses—pre- kindergarten
nursery school.
Yes if the primary purpose of the expense is to care for the child so that the parent can work. Most nursery
schools, even Montessori, are custodial in nature.
Elder care.
See Custodial or elder care expenses
FICA and FUTA taxes of day care provider.
Yes.
Food expenses.
No, if charged separately from dependent care expense. May be eligible if inseparably part of dependent care
charge.
Gardener.
No.
Household services e.g., housekeeper, maid, cook.
General1y no, except where attributable in part to child care.
Housekeeper.
Generally, no, except where attributable in part to child care. See Household services.
Incidental expenses—e.g., extra charges for
diaper changing, special activities, etc.
No, if charged separately from dependent care expense. May be eligible if part of dependent care charge.
Kindergarten.
See Educational expenses—kindergarten.
Long-term Care Expenses.
See Custodial or elder care expenses. Note that long-term care insurance cannot be offered under a cafeteria plan.
Looking for work—dependent care expenses
incurred to enable employee to look for work.
Yes.
Maid.
Generally, no. See Household services
Nanny expenses.
Yes, to the extent expense is attributable to dependent care expenses and expenses of household services
attributable in part to care of qualifying individual. See Registration fees
Nursery school.
See Educational expenses—pre-kindergarten expenses/nursery school.
Nursing home expenses.
See Custodial or elder care expenses.
Overnight camp expenses.
No. Amounts paid for services outside the employee’s household at a camp where the qualifying individual stays
overnight are not employment-related expenses.
Registration fees for care.
Probably not. Most registration fees do not go toward the care of a qualifying individual. For example, a
registration fee to a nanny service would not be for the care of a child.
However, if the fees are allocable to actual care—and not described as a materials or other fees—IRS officials
have informally indicated that fees might be reimbursable.
Relative of participant, expenses paid to—e.g.,
parent or grandparent of participant.
Yes, unless relative is a tax dependent of the participant or child under age 19.
Self-employment (expenses incurred in
connection with).
Yes.
Sick employee (that is, care for a dependent while
the sick employee stays home).
No. However, IRS officials have informally indicated that the limitation applicable to a “sick” employee was
intended to apply to long-term illness.
Summer day-camp.
Yes, to the extent attributable to care of dependent regardless of whether the program includes instruction for
sports or other extracurricular activities. The primary purpose of the expense for summer day-camp should be
custodial in nature and not educational. The IRS closely scrutinizes child care expenses for summer camps and
similar recreational activities.
Transportation expenses.
No, if charged separately from dependent care expense. May be eligible if part of dependent care charge. The IRS
closely scrutinizes child care expenses involving foreign travel.
Unemployment—expenses incurred to enable
employee to look for work.
See Looking for work—expenses incurred to enable employee to look for work.
Volunteer work—expenses incurred to enable
employee to volunteer.
No, if the volunteer work is unpaid or for nominal pay.
Questions? Please call HR Simplified at 866-812-4812, M-Th 7:00am to 7:00pm CT and Fridays 7:00am to 5:00pm CT
Or visit us online
www.hrsimplified.com
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Sample employee debit card brochure
82 of 101
W
hat is it about employee
health-care programs
that seems so complicated at first
glance? Maybe it’s all those initials
you need to understand even before
you start. Like HMOs, PPOs, and yes,
EXPERIENCE THE BENEFIT
FSAs. It’s enough to make even the
most dedicated employee throw up
their hands in frustration.
It’s time we dispelled all that.
Because when it comes to FSAs,
For more information,
contact your HR Department
the advantages can really work
to your benefit.
www.mbibenefits.com
83 of
101
Still unsure about FSAs?
Let’s spell out the benefits for you.
A
n FSA can be used for uncovered health-care costs such as doctor copays, LASIK surgery, orthodontics, certain over-the-counter medicines, dependent care and transportation expenses.
Let’s start with the definition
taxed, your health-care purchase power is
account. So it’s as convenient as using an
of FSA. Quite simply, it
substantially increased. Let’s say you’re in a 30%
ordinary credit card. What’s more, the MBI
is in dollars
stands for Flexible Spending
tax bracket. You can now use 30% more of your
Benefits Card virtually
and sense.
Account, and it can be an
own money to buy health-care services and
eliminates the endless paper-
Safety in
A remarkable
indispensable part of your
products. Why should Uncle Sam benefit from
work and reimbursement wait
numbers.
$20 billion is
overall benefits program.
your hard-earned income?
time which used to make FSAs
With over
Stretch your
so complex and cumbersome.
one million
money further.
For optimal convenience, your
cardholders
Use your FSA
benefits card offers 24/7 online
and counting,
FSA popularity
put into FSA
accounts
annually by
employees just
like you.
Here’s how it works.
The MBI Difference.
An FSA is an account your
Of course, not all FSAs are
employer sets up so you can
created equal. Yours, for instance,
pay for a variety of health-
is accessed via the best thing to
care needs like insurance
happen to FSAs since FSAs – the
copays, deductibles, even
MBI Benefits CardTM. Created by
some dental and vision-care costs. But here’s
the best part. Your FSA is funded entirely by
MBI, the industry leader in debit
card technology, your benefits
dollars to
access so you can check your
purchase
account balance plus other vital
clearly the
Tylenol®and other
information with a single click.
smart choice.
eligible OTC
products that you
use everyday.
MBI is
To learn more about the benefits
of FSAs and the MBI Benefits Card, simply ask
your pre-tax income. So you save money on
card lets you pay for eligible
health-care costs. That’s like found money to
health-care expenses virtually
you’ll discover that FSAs and the MBI Benefits
spend on all those everyday items you and
everywhere MasterCard3 and/or Visa3 are accepted.
Card spell real savings from A to Z.
your employer. Once you know the facts,
your family need!
The MBI Benefits Card makes using your FSA
Another way to look at an FSA is this. Because
dollars as simple as ABC. For starters, the card
the money you put into your account isn’t
deducts each payment directly from your FSA
84 of 101
The MasterCard3 Brand Mark is a registered trademark of MasterCard International Incorporated. Visa3 is a registered trademark of Visa USA.
The smart choice is MBI.
Sample Employer debit card brochure
85 of 101
A letter from the CEO ...
As a former senior executive for one of America’s largest health
plans, I remember when managed care was considered the radical
alternative to traditional health insurance. Today, it is the primary
vehicle for providing health coverage to millions of America’s
employees and their families.
Now we are witnessing another revolution, called consumer-driven
health care, where more of the decision making is shifting from
the employer to the employee. And, like managed care, the need
to reduce health care costs – without compromising on quality –
is the driving force for its emergence.
MBI.
Quite simply we’re the smartest choice.
The federal government recognized this with its approval of vehicles
like Flexible Spending Accounts and Health Savings Accounts. Savvy
employers from America’s largest corporations are making these
tools available to their employees as a way to save on health care.
We at MBI are proud to play a role in helping employers and
employees get the most out of these flexible spending accounts.
MBI is a technology company whose software is helping administrators,
employers, employees and health plans make access to these benefit
accounts convenient, secure and in the not-too-distant future,
totally paperless.
MBI is the acknowledged leader in electronic benefit payment
software, thanks in part to our ability to deliver solutions that have
always been out in front of the changing health-care marketplace.
While our MBI Benefits Card is the debit card of choice for employees
at over 12,000 companies, it is the technology behind our card that
makes the millions of transactions our cardholders make in pharmacies,
at physicians’ and dentists’ offices, a positive, effortless experience.
Robert L. Natt
Chief Executive Officer
(p) 888.852.6334
(f ) 781.895.4934
www.mbibenefits.com
86 of 101
A
s an employer, you’re always looking for ways to enhance the benefits programs you offer employees.
Which explains why FSAs (Flexible Spending Accounts), utilizing debit cards, have become so popular.
But before you go with just any benefits card, we suggest you consider which card is the most
effective, and backed by the company with the most experience.
The smart choice is MBI.
An FSA can be used for uncovered health-care costs such as doctor visit copays, LASIK surgery, orthodontics, certain over-the-counter medicines, dependent care & transportation expenses.
“
We always
promote the MBI
As the market leader in benefits card
set aside in an FSA can be used to cover
By offering the MBI Benefits Card to your
MBI’s innovative electronic payment
technology, only MBI gives you the
out-of-pocket health-care costs like doctor
employees, more and more of them will find
system can handle all your account needs.
advantages of FSAs coupled with the
visit copays, LASIK surgery, orthodontics
out just how easy and attractive FSAs are.
The MBI Benefits Card will allow you to
features of the industry’s most advanced
and certain over-the-counter medicines.
consolidate your benefit programs and
Benefits Card when
benefits card. With the MBI Benefits
explaining our
CardTM, your employees can pay for
Your employees simply
eligible expenses everywhere MasterCard%
present their MBI
and/or Visa% are accepted, without the
Benefits Card to their
tedious paperwork and reimbursement
doctor or other health-
complexities of lesser solutions. The
care provider and
bottom line? Only MBI makes flexible
MBI’s proprietary sub-
benefits programs run so smoothly and
stantiation technology
cost-effectively. Which is why we lead the
does everything else.
market with 12,000 employer partners
By swiping their card,
and over one million cardholders to date.
employees can avoid
Staples’ goal to
taking money out of
make both
Here’s how it all works. Instead of paying
their pockets or filling
customers’
uncovered health-care costs with money
out cumbersome claim
and associates’
they’ve already paid taxes on, employees
forms and waiting for
lives easier.
designate pre-tax wages for their FSA to
reimbursement.
use for these expenses. The result: It’s like
Employees can even
getting a 30 percent discount* on out-of-
keep track of their
pocket health-care costs instead of using
account balances day
after-tax dollars for these purchases. Money
or night on MBI’s cardholder website.
flexible benefits
program. It would
be difficult to take
away the card
once employees
start using it.
Our employees
love it.
”
Louisa St. George
Benefits Specialist
Ann Taylor
“
Staples is
Not only does MBI help you increase
provide access to Flexible Spending Accounts,
employee satisfaction, it can deliver
Health Savings Accounts, Dependent Care,
big savings to your bottom line.
or Transit Accounts, all on one card.
enhance the array
of benefits we
offer our
associates. The
MBI Benefits
”
Carla Leonardo
Analyst,
Benefit Strategy & Design
Staples
* Based on an employee tax bracket of 30%
The MasterCard% Brand Mark is a registered trademark of MasterCard International Incorporated. Visa% is a registered trademark of Visa USA.
Each pre-tax dollar that your employees
In the nearly 10 years since MBI invented
designate into an FSA translates to a
the concept, the card has established an
7.65% savings in your FICA contributions.
industry presence second to none, with
Therefore, the more your employees
200 Third Party Administrator (TPA)
contribute to their FSA and use the card,
partners and over 12,000 employer groups.
MBI are simply
wonderful.
Employees love
a simple swipe
and the eligible
expenses are
processed.
Benefits Card is a great way to increase
Now, with over 70 percent of the market,
your FSA enrollment because employees
MBI’s experience makes our Benefits Card
will use it, like it, and spread the word
the logical choice. The same is true when
among their coworkers. In fact, many of
it comes to HRAs, HSAs, dependent care
our Fortune 500 clients have experienced
plans and transportation/parking accounts.
growth in FSA enrollment upwards
It’s time your company experienced the
of 75% and contribution increases
benefits of MBI.
of 50% after instituting the card.
For more information, contact your administrator
or call MBI at 888.852.6334
87 of 101
”
Diana L. Johnson
Director of Benefits
Affiliated Computer
Services, Inc.
the more you save. Offering the MBI
Card embodies
provided by
the ease of use …
always looking
for ways to
“
The services
Sample Enrollment Form
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Flexible Benefit Plan Enrollment/Change Form
Plan Information
Enrollment (Check one below)
Open Enrollment
New Hire
Qualifying Event (Please explain below)
__________________________________________
Enrolling for Plan Year:
June 1, 2004 to May 31, 2005
Qualifying Event Change ONLY
Increase payroll deduction amnt/List new amnt below.
Decrease payroll deduction amnt/List new amnt below.
Inactivate account/Date of last p/r deduct ________
YTD contributions as of last paycheck $_________
Employee Information (PLEASE PRINT CLEARLY)
Name:
Social Security Number:
Mailing Address (Reimbursement checks mailed to this address; PLEASE PRINT CLEARLY):
City:
State:
Zip Code:
Gender:
Male
Female
Marital Status:
Married
Area Code /Daytime Phone #: Important: Number of times you get paid per year:
(
)
A) Every week (52)
Single
D) 2 times/month (26)
Select the Options You Want: (Select one or more)
Participation
Health Care Reimbursement Account
Includes all eligible health care expenses. Subject to annual
maximum of $_______. Does not require participation in employer’s
health insurance plan.
Dependent Care Reimbursement Account
Includes all eligible dependent care expenses. Subject to annual IRS
maximum of $5,000 per Head of Household or married couple filing
jointly.
Payroll
Deduction
Amount
Plan
Year
Amount
$______
$______
$______
$______
Yes
No
Yes
No
Waiver of Pre-Tax Benefits Under The Flexible Benefits Plan
I elect to waive all pre-tax benefits under the Flexible Benefits Plan, but understand that I may elect similar
coverage(s) on an after-tax basis. Except for a Change in Status, I understand that I cannnot elect pre-tax benefits
until the next Anniversary Date and any after-tax coverages shall be outside the Plan.
Your (Employee) Signature
X
Date:
Designation of Beneficiary: In the event of my death, my designated beneficiary may have certain obligations
and responsibilities to file claims and seek payment of benefits under the terms of the plan. I therefore designate
as my beneficiary under the plan:
Name
Relationship
Address
Date:
Your (Employee) Signature
X
To Be Completed By Employer Only: (Please COMPLETE this section for correct processing of form.)
New Hire/Qualifying Event ONLY
Employee Location # (If applicable) __________
Date account is effective: ________________________
Date of first payroll deduction: ____________________
Comments:
Total # of pay dates remaining in plan year: __________
Employer Signature
X
Date:
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Sample Welcome Letter – Sent in the Welcome package to all enrolled participants at the beginning
of each plan year. All Welcome Packages are customized to meet the needs of each client.
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John Doe
10400 Yellow Circle Drive
Minnetonka, MN 55343
Dear John,
HR Simplified is pleased to be selected as the Flexible Spending Account Administrator for Musicland Group,
Inc. for the 04/01/2005 thru 3/31/2006 Plan Year. To assist you in submitting claims this Flex Spending Kit
includes the following:
Direct Deposit Authorization Form
Flex Claim Form
List of Eligible Expenses
Release of Information Authorization Form – You must complete and return this form if you want
information provided to anyone other than the plan participant. For instance, if you want your spouse
to be provided with any of your FSA information you must complete this form.
Claim submission tips are listed on the back of your claim form, please take a few minutes to review them.
Following these guidelines will ensure that your claims will be processed on a timely basis and not returned to you
for further completion. A new claim form will be enclosed with each reimbursement check or notice of direct
deposit you receive. Please note that the minimum check reimbursement amount issued is $25.00 and that claims
will be paid on a weekly basis. All claims received in our office by Wednesday will be processed for payment on
the following Monday.
If you prefer to have your claim reimbursements deposited directly into a bank account, please fill out the Direct
Deposit Authorization form and return it to HR Simplified. Since it takes 7-10 days to process this form, any claims
submitted during this period will be reimbursed to you via check.
Below is a summary of the accounts you have elected under your Employer's Section 125 Plan for the Plan Year
beginning 04/01/2005 and ending 3/31/2006. If you do not agree with these elections, please contact us as soon as
possible.
Benefit Description
Employee
Deduction
Amount
Employee
Deduction
Frequency
Annual
Election
FSA Medical
25.00
BI-WEEKLY
650.00
FSA Dependent Care
100.00
BI-WEEKLY
2600.00
For current information on your Flexible Spending Account, visit our website at www.mypretax.com. To access
your personal data, enter your User Name: First Name, Last Name and the last four digits of your social security
number (ex: John Doe 1234) and your Password: PDK47SL43, then click Submit Login.
We will be sending you a $5 VISA gift card as a way to thank you for your participation in the FSA for the 20052006 plan year. It is being sent under separate cover and should arrive within 4 to 6 weeks.
Feel free to contact us with any questions you may have. Our phone number is (763)746-7400 or (866)812-4812.
Our fax number is (763)746-7439 or (877)591-4249.
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Active Employee Report – This report is sent out as part of the monthly billing and reporting cycle.
It is also available on our web site and is updated daily.
92 of 101
Active Employee Report
Page: 1
12/01/2003 - 12/01/2003
HR SIMPLIFIED INC
435 FORD RD SUITE 320
MINNEAPOLIS, MN 55426
SSN
Employment
Status
Employee Name
Termination
Date
Division
123-45-6789
Doe, John
Active
N/A
DEPT 200
111-11-1111
Hall, Rebecca
Active
N/A
DEPT 100
999-99-9999
Hanson, Doug
Active
N/A
DEPT 200
321-65-4987
Hernandez, Julio
Active
N/A
DEPT 300
654-65-4654
Jameson, Nadia
Active
N/A
DEPT 300
321-45-6789
Jones, Jim
Active
N/A
DEPT 200
222-22-2222
Smith, Jim
Active
N/A
DEPT 100
Total Count
7
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Printed: 12/11/2003 15:33:37
Employee Account Balance Report – This report is sent out as part of the monthly billing and
reporting cycle. It is also available on our web site and is updated daily.
94 of 101
Employee Account Balances
HR SIMPLIFIED INC
As of: 12/11/2003
Page: 1
From: 01/01/2003 To: 12/31/2003
SS#
Annual
Election
Employee Name
YTD
Claims
Employee
Deposits
Employer
Deposits
Claims
Paid
Available
Credit
Account
Balance
Benefit: Dependent Care
123-45-6789
999-99-9999
321-45-6789
John Doe
Doug Hanson
Jim Jones
Count: 3
Dependent Care
5000.00
4996.32
1800.00
400.00
75.00
250.00
4583.48
4580.28
1650.00
0.00
0.00
0.00
400.00
75.00
150.00
4183.48
4505.28
1500.00
4183.48
4505.28
1500.00
11796.32
725.00
10813.76
0.00
625.00
10188.76
10188.76
1200.00
1200.00
1080.00
480.00
1200.00
0.00
550.00
80.00
0.00
65.00
1100.00
1100.00
990.00
440.00
1100.00
0.00
0.00
0.00
0.00
0.00
0.00
550.00
80.00
0.00
65.00
1200.00
650.00
1000.00
480.00
1135.00
1100.00
550.00
910.00
440.00
1035.00
5160.00
695.00
4730.00
0.00
695.00
4465.00
4035.00
16956.32
1420.00
15543.76
0.00
1320.00
14653.76
14223.76
Benefit: Medical Reimbursment Account
123-45-6789
111-11-1111
321-65-4987
654-65-4654
222-22-2222
John Doe
Rebecca Hall
Julio Hernandez
Nadia Jameson
Jim Smith
Medical Reimbursment Account Count: 5
Employer Totals:
95 of 101
Printed: 12/11/2003 03:34:43 PM
Employee Account Balances
HR SIMPLIFIED INC
As of: 12/11/2003
Page: 1
From: 01/01/2003 To: 12/31/2003
SS#
Annual
Election
Employee Name
YTD
Claims
Employee
Deposits
Employer
Deposits
Claims
Paid
Available
Credit
Account
Balance
Division: DEPT 100
Benefit: Medical Reimbursment Account
111-11-1111
222-22-2222
Rebecca Hall
Jim Smith
1200.00
1200.00
550.00
65.00
1100.00
1100.00
0.00
0.00
550.00
65.00
650.00
1135.00
550.00
1035.00
2400.00
615.00
2200.00
0.00
615.00
1785.00
1585.00
2400.00
615.00
2200.00
0.00
615.00
1785.00
1585.00
5000.00
4996.32
1800.00
400.00
75.00
250.00
4583.48
4580.28
1650.00
0.00
0.00
0.00
400.00
75.00
150.00
4183.48
4505.28
1500.00
4183.48
4505.28
1500.00
11796.32
725.00
10813.76
0.00
625.00
10188.76
10188.76
John Doe
1200.00
0.00
1100.00
0.00
0.00
1200.00
1100.00
Medical Reimbursment Account Count: 1
1200.00
0.00
1100.00
0.00
0.00
1200.00
1100.00
12996.32
725.00
11913.76
0.00
625.00
11388.76
11288.76
1080.00
480.00
80.00
0.00
990.00
440.00
0.00
0.00
80.00
0.00
1000.00
480.00
910.00
440.00
1560.00
80.00
1430.00
0.00
80.00
1480.00
1350.00
1560.00
80.00
1430.00
0.00
80.00
1480.00
1350.00
Medical Reimbursment Account Count: 2
DEPT 100 Division Account Balances:
Division: DEPT 200
Benefit: Dependent Care
123-45-6789
999-99-9999
321-45-6789
John Doe
Doug Hanson
Jim Jones
Count: 3
Dependent Care
Benefit: Medical Reimbursment Account
123-45-6789
DEPT 200 Division Account Balances:
Division: DEPT 300
321-65-4987
654-65-4654
Julio Hernandez
Nadia Jameson
Count: 2
DEPT 300 Division Account Balances:
96 of 101
Printed: 12/11/2003 03:36:04 PM
Employee Account Balances
HR SIMPLIFIED INC
As of: 12/11/2003
Page: 2
From: 01/01/2003 To: 12/31/2003
SS#
Employee Name
Employer Totals:
Annual
Election
YTD
Claims
16956.32
1420.00
Employee
Deposits
15543.76
Employer
Deposits
0.00
Claims
Paid
Available
Credit
Account
Balance
1320.00
14653.76
14223.76
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Printed: 12/11/2003 03:36:04 PM
Sample Explanation of Benefits and Payment Check – This EOB is sent out after for each
processed claim. Participants who elect ACH will still receive this EOB.
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HR SIMPLIFIED INC
PAY TO THE
ORDER OF
000009
Testing EXCEL BANK
EDINA, MN 55410
CBA FOR: HR SIMPLIFIED INC
435 FORD ROAD, SUITE 320
MINNEAPOLIS, MN 55426
75-1489/910
08/16/2004
DATE
JOHN DOE
$********75.00
AMOUNT
Seventy Five Dollars and 00/100 Cents
JOHN DOE
435 FORD ROAD
MINNEAPOLIS, MN 55426
VOID AFTER 180 DAYS
C000009C A091014898A 20ˆ4370‡C
000009
EXPLANATION OF FLEXIBLE SPENDING BENEFITS
HR SIMPLIFIED INC
Claim
Number
434033
John Doe
Date of
Service
Benefit
Description
07/15/2004
MED REIM
Crystal Clinic
Claim
Amount
Employee Totals:
YEAR-TO-DATE STATUS
Benefit Description
Annual
Election
Claims
Submitted
Claims
Paid
Medical Reimbursment Account
1200.00
125.00
125.00
Prior
Payments
Check
Amount
75.00
0.00
75.00
75.00
0.00
75.00
Contributed
To Date
750.00
Account
Balance
Available
Credit
625.00
1075.00
99visit
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If you have any questions, please call 866-812-4812 or
our web site at www.mypretax.com
Sample Close To The Year End Warning Letter – This letter is sent out typically in the 10th month
of the plan year and will alert each participant of their account balance.
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August 16, 2004
John Doe
435 Ford Road
Minneapolis, MN 55426
HR SIMPLIFIED INC
Plan Year: 01/01/2004 - 12/31/2004
It is a good idea to review the status of your Flexible Benefit Accounts as the plan year end
approaches. As you know, any funds left in your account at the end of the plan year will be
forfeited. You will have 90 days after the plan year ends to submit claims for expenses incurred
during the plan year. If you terminated during the plan year, expenses must have been incurred
while you were an active participant.
Following is the status of your flexible spending account(s) as of the date of this letter:
Current Annual Election
MEDICAL
REIMBURSMENT
ACCOUNT
1200.00
Total Claims Submitted
Total Claims Paid
125.00
125.00
Total Deduction Withheld
Less Paid Claims
Employee Balance
750.00
125.00
625.00
Current Annual Election
Less Total Claims Submitted
Remaining Credit for Year
1200.00
125.00
1075.00
If you have any questions, do not hesitate to contact us at (866) 812-4812 or (952) 544-2902.
HR Simplified, Inc.
Flexible Spending Department
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