Enrollment Kit
Enjoy more benefits and take home more money
2
Increase Your Take-Home Pay with an FSA
Your increased take-home pay and savings depends on your in-come tax bracket. For example, if you are in the 30% tax bracket, you can save $30 for every $100 that you put into your FSA. So, if you put $1,000 into your FSA, you’ll reduce your taxes while increasing your annual take-home pay by $300.Eligible Expenses
Visit the IntegraFlex web site at www.integra-flex.com for a com-prehensive list of eligible healthcare and dependent care expenses, including many over-the-counter medicines or healthcare related products such as pain relievers and cold remedies (With a Doctor’s Prescription). Other OTC Items such as Bandages and Diabetic supplies including insulin are still covered with a prescription.
Congratulations! Your employer is offering you a
Flexible Spending Account (FSA) as part of your
benefits package. An FSA allows you to set aside
pre-tax dollars to pay for eligible out-of-pocket
healthcare and dependent care expenses.
Start Saving Today with an FSA!
With an FSA, you can save 30% or more on eligible healthcare, and/ or qualifying child and adult dependent care expenses. Perhaps you’ve heard your friends or co-workers talking about a similar program they use to pay for things like co-pays and deductibles, dental and vision expenses, many over- the-counter medications and healthcare related products, and before-school and after-school day care expenses.
More Benefits for Less Money.
Sound too Good to be True?
What Would You do
with an Extra $1,050?
(FSA Savings Example)
3
Important Plan Information
FSA ContributionsYour entire annual contribution amount is available immediately* at the beginning of the plan year to pay for eligible healthcare ex- penses. However, your total FSA election amount is deducted from your paycheck in equal amounts during the year.
Election Changes
You will be given the opportunity to make new elections during the annual enrollment period at the beginning of each plan year. Once you have made your elections and the plan year has com-menced, IRS rules allow you to change your election (increase, decrease or stop your pre-tax contribution) during the plan year only if you have a qualified change in status event and the re-quested change is consistent with the event.
The Use-It-Or-Lose-It Rule
All of the money in your flexible spending account must be spent by the end of your employer’s plan year, since unused funds will not be returned to you or carried over to the following year.
* This applies to healthcare expenses only. Dependent care expenses are reimbursed based on the availability of funds in your account.
Three Ways to Save Money
Healthcare Flexible Spending Account (FSA) Use pre-tax dollars for a variety of qualifying healthcare expenses. Your participation will increase your take-home pay by reducing your taxes when you have qualified out-of pocket healthcare expenses that can be reimbursed through your Flexible Spending Account. Your annual limit for qualified healthcare expenses is determined by your employer.Dependent Care Assistance Plan
Use pre-tax dollars for a variety of dependent care ex-penses, such as child or adult day care. By using pre-tax dollars for dependent care expenses, you will reduce your taxes while increasing your take-home pay.
Current tax laws allow you to set aside up to $5,000 annually to pay for employment related child day care or adult dependent care ($2,500 if you are married and file separate returns). Your maximum allocation may not exceed the lesser of your earned income or the earned income of your spouse. At 30% off, your savings could really add up!
Premium Only Plan
Pay your share of premiums for your employer-spon-sored insurance plans with pre-tax dollars. Keep the same benefits while lowering your taxes and increasing your take-home pay with pre-tax premium contributions.
What Expenses Qualify under a Premium Only Plan?* • Medical insurance premiums
• Dental insurance premiums • Vision insurance premiums
• Group Term Life insurance premiums
(up to $50,000 in employee-only coverage)
• Disability insurance premiums - When disability insur-ance premiums are deducted on a pre-tax basis, income received from the disability policy becomes taxable income.
• Other qualified voluntary insurance (as applicable)
*Your employer must elect these premiums to be eligible through the plan.
IntegraFlex’s industry-leading, web-based technology provides you with the tools and resources necessary to determine how to maximize your benefits and tax savings by participating in a Flexible Benefits Plan.
We’re Here for You — 24 Hours a
Day, 7 Days a Week!
Examples of eligible expenses include • Healthcare expenses for you, your spouse or qualifying child or relative
• Office visit co-pays
• Prescription drugs and many over-the-counter healthcare products
• Chiropractic
• Dental — including child and adult orthodontia • Acupuncture
• Vision care — including contact lenses and laser eye surgery
Employment related dependent care expenses • Care for your qualifying child under the age of 13 • Care for your spouse or your qualifying child or relative
With an FSA Save 30% or More on
Eligible Out-of-Pocket Expenses
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How the Plans Work
Flexible Spending Accounts (Healthcare and Dependent Care) Before you enroll, you’ll need to decide how much you want to set aside for allowable out-of-pocket healthcare and/or dependent care expenses. Your election amount should conservatively match your estimated expenses for the plan year.
Complete the Flexible Benefits Enrollment form provided by your benefits counselor or human resources representative.
Each pay period, an equal portion of your annual election amount will be deducted from your gross pay and transferred to your FSA prior to calculating federal and state income* and social security taxes. Again, by participating in an FSA program, you will reduce your taxes while increasing your take-home pay.
Premium Only Plan
The amount you currently pay toward qualified employer sponsored benefits, such as medical, dental, and vision, will be deducted on a pre-tax basis.
Since your taxable income is reduced, you will reduce your taxes while increasing your take-home pay.
To participate, complete the enrollment form or other materials provided by your HR representative or benefits counselor. *Pennsylvania does not exempt state withholding for dependent care benefits and New Jersey does not exempt state withholding for employee salary reductions.
How Reimbursement Works
Simply complete a FlexHRA Claim Reimbursement form and submit it along with all proper expense documentation (purchase receipts, EOBs, etc.) to IntegraFlex. Upon receipt, an IntegraFlex claims processor will review your claim and process it for payment after verifying the eligibility of all expenses and confirming receipt of all proper documentation.Healthcare and dependent care reimbursement claim forms (FlexHRA Claim Form) are available on the IntegraFlex web site at www.integra-flex.com. If you do not have web access, please contact an IntegraFlex participant services representative or your human resources department for a claim form.
Go to www.integra-flex.com to
• Determine how much to place in your healthcare account anddependent care account. An average annual savings can be as much as 30% in income tax savings.
• Enroll in ACH/Direct Deposit to receive your reimbursement up to five days quicker than traditional paper checks. ACH/Direct Deposit is a quicker, easier and more secure way to receive reimbursements–directly to your bank account! Your employer MUST be enrolled in this feature.
• Check the status of a reimbursement claim within 48 to 72 hours after you’ve faxed it to us, including the amount of your reimbursement and when it was issued.
• View your entire healthcare and dependent care FSA payment
history, including all pending, approved and denied claims for the plan year.
• See a comprehensive list of eligible healthcare and dependent care expenses, including eligible over-the-counter medicines or healthcare related products such as pain relievers, cold remedies and bandages.
Determine how much you expect to
spend on qualifying out-of-pocket
healthcare and/or dependent care expenses
during your upcoming plan year.
When determining exactly how much
you should put into your FSA Plan, be
sure to plan carefully, because IRS
regula-tions require that all unused FSA dollars are
returned to your employer at the end of the
plan year and cannot be carried forward.
Enroll online (if available through
your employer) or complete and
sub-mit a Flexible Benefits Enrollment form with
your healthcare and/or dependent care
elec-tions during your employer’s open
enroll-ment period.
Healthcare Flexible Spending
Account Participation Guidelines
• All requests for reimbursement are subject to review and
ap-proval based on IRS guidelines. If your request is denied, you will receive an explanation from IntegraFlex including the reason for the denial and instructions for appealing your request.
• If you elect to participate in the plan, your employer will provide
a Summary Plan Description outlining the complete rules and regulations of your plan.
The expense must be eligible under the Internal Revenue Code and your employer’s plan. Expenses must be incurred by you, your spouse or your eligible dependent on the date(s) indicated on claim form. All requests for reimbursement are subject to review and approval based on IRS guidelines. All such requests must satisfy all applicable guidelines as established by the IRS and any other applicable legislative or judicial bodies and the rules established by the sponsoring employer as defined within the plan’s Summary Plan Description.
This document provides basic information regarding participation in your employer’s FSA plan. This document does not contain all of the rules
A Healthcare Flexible Spending Account (FSA) is a
reimbursement account offered by your employer as
part of your benefits package. Participating in the FSA
plan saves you money by allowing you to use pre-tax
dollars to pay for qualifying expenses not covered by
insurance. Participation is voluntary, and you must
satisfy any healthcare FSA eligibility requirements
established by your employer in order to participate.
•Only eligible expenses can be reimbursed under the plan. Eligible expenses are defined by Internal Revenue Code §213(d) and your employer’s plan.
•Expenses must be incurred by you, your spouse, or your eligible dependents during the current plan year and while you are an ac-tive participant in the plan. Medical expenses are incurred when you (or your spouse or dependents) are provided with the medical care that gives rise to the medical expenses, and not when you are formally billed, charged for, or pay for the medical care. •Only “out-of-pocket” expenses are eligible for reimbursement.
Ex-penses previously reimbursed by your healthcare FSA or covered by any other plan or program are not eligible for reimbursement. •Generally, eligible expenses include items that are meant to
diag-nose, cure, mitigate, treat or prevent illness or disease. •Expenses such as cosmetic surgery, insurance premiums,
vitamins or items for your general well-being are not eligible for reimbursement.
•A comprehensive list ( FSA Quick Reference Guide-Eligible Expenses)of eligible expenses, including many over-the-counter items, is available online at: www.integra-flex.com.
•Expenses reimbursed under the healthcare FSA may not be used to claim any federal income tax deduction or credit.
• Minimum (if any) and maximum election amounts are determined
by your employer.
• Your election is irrevocable during the plan year, unless you
expe-rience a qualifying change in status event. Rules regarding status changes and other qualifying events are defined by IRS regula-tions. Not all plans recognize all of the permissible changes. For more information regarding eligible status change events under your plan, please review your Summary Plan Description. • Your contributions are subject to the “use-it-or-lose-it” rule. Any
unused contributions are forfeited to the plan at the end of the plan year.
• Your annual healthcare FSA election amount is available to you at
any time during the plan year.
Healthcare FSA
Participation Process
1
5
2
6
3
7
4
Enroll in Employer Sponsored
FSA Plan
Incur an Eligible Expense
Pay for Expense
Save your Receipt or Explantion
of Benefits from Insurance Carrier
Submit Claim Form and Copy of
Receipt to IntegraFlex
IntegraFlex reviews claim per
IRS Guidelines
Dependent Care Flexible Spending
Account Participation Guidelines
A dependent care Flexible Spending Account (FSA)
is a reimbursement account offered by your
em-ployer as part of your benefits package.
Participat-ing in the FSA plan saves you money by allowParticipat-ing
you to use pre-tax dollars to pay for qualifying
expenses such as day care or before and/or after
school care. Participation is voluntary, and you
must satisfy any dependent care FSA eligibility
requirements established by your employer in
order to participate.
• Only eligible expenses can be reimbursed under the plan.
De-pendent care expenses must be incurred to enable you (and your spouse, if married) to work, look for work or attend school full time for at least 5 calendar months during the tax year. Work may include actively looking for work, but does not include unpaid volunteer work. Expenses must be incurred during the plan year. • Any incurred expenses must be for the care of a qualified
individ-ual. A qualified individual is a child age 12 and under or a spouse or other tax dependent who is physically or mentally incapable of self-care. The individual must also reside in the same household for more than half of the year.
• Per IRS regulations, a child is a qualified dependent of the
“cus-todial parent.” Therefore, only the cus“cus-todial parent may partici-pate in a dependent care FSA.
• Expenses reimbursed under the dependent care FSA may not be
used to claim any federal income tax deduction or credit.
• Expenses related to before and after school care or nursery school
are eligible expenses, if the care is primarily custodial in nature. • Fees associated with kindergarten as well as tuition for school
programs are not eligible for reimbursement.
• All requests for reimbursement are subject to review and
ap-proval based on IRS guidelines. If your request is denied, you will receive an explanation from IntegraFlex including the reason for the denial and instructions for appealing your request.
• The minimum election amount (if any) is determined by your
employer. The pre-defined maximum election amount is $5,000 per IRS regulations ($2,500 if married and filing separately). The amount of reimbursement that you receive on a tax-free basis during the plan year cannot exceed the lesser of your earned income or your spouse’s earned income.
• Your election is irrevocable during the plan year unless you
experience a qualifying change in status event or the cost of care increases or decreases significantly. Rules regarding status changes and other qualifying events are defined by IRS
regula-tions. Not all plans recognize all of the permissible changes. For more information regarding eligible status change events under your plan, please review your Summary Plan Description. • Your contributions are subject to the “use-it-or-lose-it” rule. Any
unused contributions are forfeited to the plan at the end of the plan year.
• Dependent care FSA reimbursements are issued as contributions (payroll deductions) are posted to your account.
• If you elect to participate in the plan, your employer will provide a Summary Plan Description outlining the complete rules and regulations of your plan.
The expense must be eligible under the Internal Revenue Code and your employer’s plan. Expenses must be incurred by you, your spouse or your eligible dependent on the date(s) indicated on claim form. All requests for reimbursement are subject to review and approval based on IRS guidelines. All such requests must satisfy all applicable guidelines as established by the IRS and any other applicable legislative or judicial bodies and the rules established by the sponsoring employer as defined within the plan’s Summary Plan Description.
This document provides basic information regarding participation in your employer’s FSA plan. This document does not contain all of the rules
Dependent Care
Participation Process
1
5
2
6
3
7
4
Enroll in Employer Sponsored
FSA Plan
Incur an Eligible Expense
Pay for Expense
Save your Receipt or Statement
from Day Care Provider
Submit Claim Form and Copy of
Receipt to IntegraFlex
IntegraFlex reviews claim per
IRS Guidelines
Spending Your FSA Dollars
On Eligible Healthcare Expenses
Spending your FSA dollars on eligible healthcare
expenses just got easier. The IntegraFlex FSA
Ben-efits Card provides instant access to the money in
your healthcare FSA by automatically deducting
funds from the available balance in your account
when you make a qualified purchase.
Key Benefits of using the IntegraFlex FSA Benefits Card • Easy to use. The IntegraFlex FSA Benefits Card is a stored
value card that simplifies the process of paying for your qualified medical expenses.
• Works at most healthcare related merchants where MasterCard
is accepted.
• You spend only the pre-tax dollars in your healthcare FSA.
• No waiting for reimbursement.
Common Purchases and Uses for the Card • Prescriptions
• Eligible over-the-counter healthcare products • Office visits to a physician or dentist
• Vision service providers • Hospital charges Using Your Benefit Card
The IntegraFlex FSA Benefits Card may only be used at merchants who have a healthcare related merchant category code (such as physicians, stand-alone pharmacies, dentists, vision care offices, hospitals, and other medical care providers) or who utilize an Inven-tory Information Approval System (IIAS).
• When utilizing an IIAS, a merchant allows the Benefits Card to be used to purchase only those items identified on a list of eligible medical expenses maintained by the merchant. • When purchasing eligible, healthcare related items AND
ineligible, non-healthcare related items, the merchant will only accept the Benefits Card as payment for the healthcare related items. You must pay for the ineligible items with another form of payment (cash, personal credit or debit card, etc).
• You may not use the Benefits Card at any merchant that does not have a healthcare related merchant category code un-less that merchant utilizes an Inventory Information Approval System. NOTE: Many pharmacies in retail and discount stores will not qualify as merchants with a healthcare related merchant category code.
• In rare circumstances, purchases made at merchants utiliz-ing an IIAS may fail to process appropriately. In those cases, you will be required to submit receipts or other substantiating documentation as described below. A list of merchants utilizing an IRS-approved IIAS is available online at www.sig-is.com underPublications—IIAS Merchants List.
Save All Receipts for Purchases Made with the Benefit Card Please remember to keep all receipts for all purchases made with the Benefit Card. Per IRS regulations, IntegraFlex may be required to request itemized receipts to verify the eligibility of purchases made with the card.
• All receipts or other proofs of purchase must include the dollar amount, date of service, name of provider, and a description of the purchased service or product. For over-the-counter healthcare items, the name of the product must be listed on the receipt
• Any receipt that does not contain the detailed information described above is not acceptable. Credit card receipts and cancelled checks are not acceptable.
• If the requested receipt is lost or otherwise unavailable, most providers can provide a detailed statement documenting FSA eligible purchases.
It’s So Easy Using
Your FSA Benefits Card
You Will Not Be Required to Submit a Receipt When • The expense matches a specific co-payment you have under
your employer’s medical, pharmacy, vision, or dental plans. For example, you may not be required to submit a receipt if you have a $10.00 co-pay for physician office visits, and the pay-ment was made to a physician office in the amount of $10.00. • Recurring expenses will not result in a request for documenta-tion as long as the expense equals the same amount, duradocumenta-tion and provider as a previously approved expense. Recurring transactions will be processed and approved without documen-tation only after substantiating receipts or other documendocumen-tation is provided and the initial transaction is reviewed and approved. • You purchase your FSA-eligible items at a merchant utilizing an
IRS-approved Inventory Information Approval System (IIAS). • In limited scenarios, your claim information may be provided
through an electronic file from your insurance carrier or other provider. In these scenarios, expense substantiation may not be required if the electronic claim file is accompanied by an elec-tronic or written confirmation from the healthcare provider (e.g., your prescription benefits manager) that identifies the nature of your expense and verifies the amount.
Note: You MUST still obtain and retain the third-party receipt when you incur the expense and swipe the card, even if you believe it will not be needed. All receipts should be retained for at least one year following the close of the plan year in which the ex-pense is incurred.
Co-Pay Helpful Hints
You may swipe your card for an amount up to five times (5x) the maximum co-payment amount to include:
• Single co-payment for a specific benefit If the transaction equals a multiple of a specific co-payment that is applicable to you under your employer’s plan, then no additional sub- stantiation is required; however, the transaction will fall outside of this auto adjudication (verification) category if the transaction amount exceeds five (5) times the applicable co-payment amount.
• Different co-payment for a specific benefit If the transaction equals a multiple of a co-payment for a particular benefit or a combination of the co-payments for a particular benefit, then no additional substantiation is required; however, this transaction will fall outside of the auto-adjudication (verification) category if the transaction amount exceeds five (5) times the maximum co- payment for a particular benefit.
Three-Step Card Audit/Verification Process
Should you receive written notice from IntegraFlex requesting ap-propriate documentation (as described above) to verify a Benefit Card purchase, you will have 30 days to respond. If you do not respond within this time frame, you will receive an additional notice. If you do not respond to either notice within the required time, your Benefit Card will be deactivated until the card purchase is verified.
1. You will receive an initial detailed notification when documenta-tion is required to verify a purchase.
2. If we do not hear from you within 30 days from the date of the initial notice, you will receive a final notice to submit receipts within 15 days to verify your purchases and prevent your card from being deactivated.
Instructions
You MUST complete the Employee Information on the Salary
Redirection Form to be able to participate in your Employer Sponsored FSA Benefit Plan.
Complete Claim Information in its entirety when submitting a claim(s). Please ensure your supporting documentation clearly indicates the requested amount. FlexHRA Claim Forms can be found on the IntegraFlex Web site at www.integra-flex.com under Employee Links or the in the Employee tab under Employee forms.
Check the appropriate box in the Supporting Documentation section and attach Acceptable Supporting Documentation as described below. (When attaching small receipts, we suggest you photo copy them to a standard size sheet of paper prior to faxing.)
A) Itemized statement or bill from your provider including
- Provider name - Patient name
- Description of service - Original date of service (the date of service, NOT the date of payment. The service MUST fall within the plan year for which you are enrolled and while you are a participant in the plan)
- Patient portion of charge(s)
B) Explanation of Benefits (EOB) from your insurance carrier C) Pharmacy statement including
- Patient name - Prescribing physician - RX number
- Name of the drug - Date the RX was filled - Co-payment amount
*Unacceptable Documentation includes the following
- Cancelled checks
- Credit / cash receipts (An itemized cash register receipt is acceptable ONLY for eligible over-the-counter expenses)
- Balance forward statements are NOT acceptable. Sign and date Employee Certification at the bottom of the FlexHRA Claim Form.
Submit Claims to IntegraFlex
By Fax 208.287.0311
By Email [email protected] By Mail 225 N 9th Street. Suite 530
Boise, Idaho 83702
5
2
3
Personal
Planning Worksheets
Health-Related Expenses That Require a
Letter of Medical Necessity or Prescription Include
• OTC Medicines or Non-Prescription Vitamins
• Supplements from a Chiropractor, Acupuncturist, Holistic Healer • Rogaine or Hair Transplant
• Retin-A • Electrolysis • Breast Pumps
• Health Club Memberships • Massage Therapy • Whirlpools
Ineligible Health-Related Expenses Include
• Feminine Hygiene Products • Dental Bleaching or Bonding • Illegal Operations or Treatments • Diaper Service
• Meals that are not for Inpatient Care • Marital or Family Counseling
• Services by a Holistic Healer who isn’t Licensed to Practice Medicine
Health Related Expenses
Doctor office visits co-pays Deductibles
Routine physical X-Rays
Dental co-pays Dental deductibles
Non-cosmetic dental services Orthodontia
Dental surgery Dental x-rays
Contact lens & supplies Laser eye surgery Eye glasses Vision x-rays Vision exams
Medical miles (paid according to IRS annual limits.)
Alcoholism treatment Ambulance
Care for handicapped Diabetic supplies/insulin Acupuncture
Drug addiction treatment Guide animal care
Eligible Hospital Charges (not covered by insurance)
Lab fees
Learning disabilities care
Over-the-counter drugs (with prescription)
Prescription expenses (co-pays)
Prosthesis Wheelchairs
Holistic healing services (medically necessary, not including holistic remedies or supplements)
$ Health Plan Year Total
Premiums Paid Outside of
Your Employer’s Group Plan
Note Not all employers offer this service. Only IRS Section 213(d)
policies qualify. Please see.
Accident Insurance Cancer Insurance COBRA Premiums* Dental Insurance Disability Insurance** Hospital Insurance Major Medical Insurance Medicare
Vision Insurance
$ Plan Year Total
*Not Available: Life Insurance and Long Term Care. **Disability Insurance becomes taxable in the event of a claim if premiums are placed pre-tax.
Dependent Care Expenses
Day-care centers Elder care Family child care Day camps Preschool
After-school care Nanny/au pair
$ Dependent Plan Year Total
Ineligible Dependent Expenses
Include
• Meals
• Overnight Camps • Diapers
• Educational Expenses (including kindergarten)
• Incidental Fees (such as activity fees, field trips)
Important
Dependent Care
Reimbursement Worksheet
$0 15,000 $1.050 $2,100 15,000 17,000 1,020 2,040 17,000 19,000 990 1,980 19,000 21,000 960 1,920 21,000 23,000 930 1,860 23,000 25,000 900 1,800 25,000 27,000 870 1,740 27,000 29,000 840 1,680 29,000 31,000 810 1,620 31,000 33,000 780 1,506 33,000 35,000 750 1,500 35,000 37,000 720 1,440 37,000 39,000 690 1,380 39,000 41,000 660 1,320 41,000 43,000 630 1,260 43,000 No limit 600 1,200Over But Not Over One Dependent Two or MoreDependents If Your Federal
Adjusted Gross Income is Your Maximum CombinedFederal Tax Credits are Estimated To Be
Dependent
Tax Credit Table
Use this worksheet to compare your estimated
sav-ings with the Dependent Care Tax Credit versus a
Dependent Care Flexible Spending Account (FSA).
You’re not allowed to take the maximum amount
for childcare expenses on both your flex and taxes.
Amounts reimbursed through your Dependent Care
FSA will reduce the amount of eligible expenses you
can use to figure the tax credit on a dollar-for-dollar
basis. However, you’re allowed to take some
deduc-tions on flex and some on the tax credit.
This tactic can be advantageous to those who max
out the flex and still want the additional $1,000 that
the tax credit allows. Please review the charts to see
what we mean.
Step 1 Estimate Your 2011 Dependent Tax Credit
You may take a federal tax credit for eligible dependent care ex-penses up to $3,000 for one dependent, or $6,000 for two or more dependents. The amount of the credit depends on your income level. Use the following table to estimate the maximum combined tax cred-its you may be entitled to take on your federal tax return. For a more accurate estimate, you should contact your tax advisor and review the IRS publication 503 at www.irs.gov.
Examples of Eligible
Dependent Care Expenses
Eligible dependent care expenses must be for the care of your child under the age of 13, or your spouse or other dependent(s) who are physically and/or mentally incapable of self-care. Eligible reimbursable expenses are those dependent care expenses incurred only during the time you (and your spouse, if applicable) are working, looking for employment, or attending school full-time.
IRS regulations govern the eligibility of expenses. For additional information on eligible expenses, see IRS Publication 503, avail-able from your local IRS office.
Examples of Ineligible
Dependent Care Expenses
Meals, Activity Fees, Late Payment Fees, Activity Fees & Sup-plies, Beepers, Pagers, Field Trips & Entertainment, Overnight Camps, Kindergarten, Summer School.
Step 2 Estimate Your 2011 Tax Savings
with a Dependent Care FSA
A Enter your annual adjusted gross family income $ $ 30,000
B Enter your deductions (either total itemized deductions or standard deduction)* $ $ -10,900
C Enter your personal exemtions (multiply the number of exemptions claimed by $3,400 $ $ -6,800
D Subtract line B and line C from line A to calculate your total taxable income $ $ 12,500
E Enter your marginal federal income tax rate from Table A** $ $ .15
F Enter your dependent care expenses [cannot exceed the lesser of $5,000 $ $ 5,000 ($2,500 if married filing separately) or the earned income of the lower earning spouse]
G Multiply line E times line F to determine your income tax savings $ $ 450
H Multiply line F times .0765 to determine your estimated $ $ 383
Social Security/Medicare tax savings***
I Total Estimated Savings with a Dependent Care FSA (Add line G and line H) $ $ 1,133
* Current standard deductions are: Married filing jointly and surving spouses= $10,900; Head of household= $8,000; married filing separately= $5,450; Single= $5,450 ** Use the next lower marginal rate if your taxable income is close to the lower end of an income range.
*** Social Security savings are on the first $97,500 of income. Medicare savings = 1.45% on all amounts.
$ 0 – $16,750 $0 - $11,950 $0 – 8,375 $0 – 8,375 .10 $16,750 – $68,000 $11,950 - $45,550 $8,375 - $34,000 $8,375 - $34,000 .15 $68,000 - $137,300 $45,550 - $117,650 $34,000 - $68,650 $34,000 - $82,400 .25 $137,300 - $209,250 $117,650 - $190,550 $68,650 - $104,625 $82,400 - $171,850 .28 $209,250 - $ 373,650 $190,550 - $ 373,650 $104,625 - $186,825 $171,850 - $373,650 .33 $373,650 and above $373,650 and above $186, 825 and above $373,650 and above .35
Married-Joint Head of Household Married-Separate Single MarginalTax Rate
Table A Federal Taxes
Filing Status & Taxable Income 2010
Compare the Tax Credit Estimated in Step 1
with the Tax Savings Estimated in Step 2
Compare the estimated tax credit with the estimated tax savings using the Dependent Care Flexible Spending Account. The tax credits are designed to become less valuable as your income increases. Tax savings with a Dependent Day Care FSA become more valuable as your income increases. Generally, if your income tax bracket is 15% or less it would be more advantageous for you to take the tax credit rather than participating in the Dependent Care Account. However, since each person’s tax situation is unique, you should talk with a tax advisor before making your final decision. Some additional points to consider:
Recurring Expense NOT Paid w/ Flex Debit Card Paid w/ Flex Debit Card
(please check method of payment)
FSA REQUIREMENTS:
*An “Itemized Statement” from the provider MUST be submitted showing:
• Provider’s Name/Address • Patient’s Name
• “Actual” Date of Service when the Service was Provided • Description of Service & the Amount Charged
* An Explanation of Benefit (EOB) from your Medical Insurance Carrier
*NOTE: The Left Two (2) Forms of Documentation ARE the ONLY Forms of
Documentation that ARE Acceptable under IRS Guidelines.
- Balance forward or paid on account statements CANNOT be accepted.
- Credit card receipts, cancelled checks, or cash register receipts
CANNOT be accepted for services.
- Itemized cash register receipts are Only acceptable for over-the-counter medications.
225 N. 9
thStreet, Suite 530 | Boise, Idaho 83702 | t. 208.287.0310 | f. 208.287.0311 | integra-flex.com
Employee
EMPLOYEE INFORMATION
Employer Date
Employee Name SSN
Phone Number Email
Home Address Check if New
Address
FLEXIBLE SPENDING ACCOUNT/HEALTH REIMBURSEMENT ARRANGEMENT
CLAIM ATTACHMENTS – Failure to follow these guidelines will result in reimbursement delay or possible denial.
HRA REQUIREMENTS:
A Copy of the Explanation of Benefits (EOB) from your Medical Insurance Carrier MUST be submitted.
-Estimates for services that have not yet been incurred CANNOT be accepted.
FSA/HRA
Claim Form
Total amount requested from your FSA/Cafeteria Plan $ (Manual Amounts Only–Paid for service other than with your FSA Debit Card) AND/OR
HRA $ (Be Sure to Submit Your Explanation of Benefit)
Service Date Name of Provider (e.g. Physician, Dentist Type of Service (e.g. Copay, Rx, Ortho, Patient Name Expense Amount
Hospital, Pharmacy, Insurance Carrier, etc) Insurance Premium, etc.)
I certify that I have actually incurred these eligible expenses. I understand that expense incurred means the service has been provided that gave rise to the expense, regardless of when I am billed or charged for, or pay for the service. The expenses have not been reimbursed or are not reimbursable from any other source. I understand that any amounts reimbursed may not be claimed on my or my spouse’s income tax returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions.
225 N. 9
thStreet, Suite 530 | Boise, Idaho 83702 | t. 208.287.0310 | f. 208.287.0311 | integra-flex.com
Employee
Claims
Instructions
RECURRING CLAIMS INSTRUCTIONS
We believe in simplicity. That’s why we’d like to make filing your Flexible Spending Account (FSA) claims as easy as possible with our recurring claims options. A recurring claim allows you the freedom to submit your claim only once, but continue receiving reimbursements throughout the plan year. You may set up your Dependent Care, Individual Health Premium, Parking, and Orthodontic claims on a recurring status.
SETUP
To get your claim set up as a recurring status, select the option that reads on the FSA/HRA Claim Form “Please Check One” if your claim is a recurring claim and attach a copy of your contract.” Below is the information required for each type of recurring claim.
INDIVIDUAL HEALTH PREMIUM: Submit a completed FSA/HRA Claim Form and a Copy of the Schedule/Declaration Page from your insurance company.
Claim forms can be found on our website at www.integra-flex.com under the Employee tab (across top of page) under the drop down menu under Employee
forms and click on FSA/HRA Claim Form. Your Schedule/Declaration Page should show that your insurance is billed to your home address, include the valid dates of coverage, and dollar amount paid. You’ll need to submit a new Schedule/Declaration Page each plan year. Individual Health Premium claims can
only be paid with funds that are currently available in your FSA at the time of the claim. The balance of the claim will continue to release as you contribute more funds to your account.
PARKING: Submit a completed FSA/HRA Claim Form. Because you can’t typically provide documentation or a contract for parking services, your signed
claim form is sufficient. By signing the claim form, you are verifying that the information is accurate should you be audited by the IRS.
ORTHODONTIC: Submit a completed FSA/HRA Claim Form and a Copy of your Orthodontic Contract. The contract needs to show the charges, description
of services, dates of service (can be a date range), and name of the patient. You’ll need to submit a new contract each plan year.
Your claim form and contract can be sent to us via email, fax, or mail. Our contact information is provided below. Once we receive your claim form and contract, we’ll automatically generate a payment each pay period without any more effort on your part. For fastest payment, we recommend signing up for direct-deposit should your employer offer this option. Signing up is easy. Visit www.integra-flex.com under the Employee Tab (across top of page) under the drop-down menu
under Employee Forms and click on the Direct Deposit Form.
ALL OTHER CLAIM SUBMISSION INSTRUCTIONS
Please refer to the FSA/HRA Claim Form under the Claim Attachments section that lists Both the FSA & HRA Documentation Requirements that
are “Acceptable” under the IRS Guidelines. Please follow these guidelines in order not to delay or possibly deny your claim submissions.
Please be clear with your claim
submissions--Make sure that your “Itemized” Statement or Explanation of Benefit (EOB) shows the Amounts Applied/Billed are the same that you list on your FSA/HRA Claim Form. Meaning your “Itemized” Statement or EOB should match what you list on your FSA/HRA Claim Form. Varying amounts applied/ billed ONLY slows down your claim reimbursement/submission.
-You can ONLY submit claims that have been INCURRED within your Current Plan Year. Claims incurred outside of your Plan Year ARE NOT
eligible for reimbursement.
-Be sure to “Check” the appropriate boxes letting us know if your used your Flex FSA Debit Card to cover your expense or if you Paid Manually.
DCA REQUIREMENTS:
An “Itemized Statement” from the provider MUST be submitted showing:
• Provider’s Name/Address • Dependent’s Name
• “Actual” Date of Service when the Service was Provided • The Amount Charged
• Daycare Provider’s SSN or EIN Number
Total amount requested from your DCA/Cafeteria Plan $ (Manual Amounts Only–Paid for service other than with your FSA Debit Card)
225 N. 9
thStreet, Suite 530 | Boise, Idaho 83702 | t. 208.287.0310 | f. 208.287.0311 | integra-flex.com
Employee
EMPLOYEE INFORMATION
Employer Date
Employee Name SSN
Phone Number Email
Home Address Check if New
Address
DEPENDENT CARE ACCOUNT
CLAIM ATTACHMENTS – Failure to follow these guidelines will result in reimbursement delay or possible denial.
DCA
Claim Form
Recurring Expense
NOT Paid w/ Flex Debit Card
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (Please check one) Paid with Flex Debit Card
Dates of Service
Name of Daycare Provider From To Dependent’s Name Expense Amount
$ $ $ $
Daycare Provider’s SSN or EIN Number
I certify that I have actually incurred these eligible expenses. I understand that expense incurred means the service has been provided that gave rise to the expense, regard-less of when I am billed, or charged for or pay for the service. The expenses have not been reimbursed or are not reimbursable from any other source. I understand that any amounts reimbursed may not be claimed on my or my spouse’s income tax returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions.
Employee’s Signature Date
Claim Instructions-Dependent Care: Submit a completed DCA Claim Form and an IntegraFlex Dependent Care Contract. Both of these forms can be found on our website at
Employee
225 N. 9
thStreet, Suite 530 | Boise, Idaho 83702 | t. 208.287.0310 | f. 208.287.0311 | integra-flex.com
EMPLOYEE INFORMATIONEmployer Name Effective Date
HRA Yes No
Employee Name SSN
Sex M F
Home Address City State ZIP
Home Phone Number Work Phone Number ext.
Hire Date D.O.B. Email
(Your email is solely used for correspondence related to your benefits. It is kept confidential & not sold to any lists, etc.)
REDIRECTION INFORMATION
By signing the salary redirection form or waiver I am signifying my understanding and acceptance of the responsibilities and requirements associated with a Section 125 Cafeteria Plan. I further understand that, though I have completed separate enrollment forms for the insurance policies to which I have applied, this form does not constitute acceptance by the companies to which I have applied. I understand and agree that an amount equal to what I have calculated will be deducted from each of my qualified pay periods from now through the end of the plan year. This amount shall continue for each pay period unless this agreement is amended or ter-minated. I understand the actual amount of my take home pay may increase or decrease depending upon the coverage or elections I have made. Any previous agreements under any other Flexible Benefits Plan are hereby revoked.
Note: Please specify your elections in an Annual amount.
Premium Deduction* $ HRA (Employer Contribution) Amount $ Medical FSA Amount $ Dependent Care FSA Amount $ Commuter Reimbursement FSA Amount $
*(Separate Individual Insurance Coverage)
PLEASE READ AND INITIAL THE FOLLOWING STATEMENT
I understand that on or after the first day of the plan year, I cannot change or revoke this salary redirection agreement unless I have had a qualified event under IRS rule. (May include marriage, birth, adoption, divorce or death) I understand and agree to submit only those charges eligible for reimbursement under Section 213D of the IRS code. I also agree to repay the plan for any charge submitted but not approved or eligible.
Names and Social Security Numbers for ANY Legal Dependents for which I may potentially apply for qualified pre-tax reimbursement (Required Information under IRS Rule)
DEPENDENTS
Name SSN D.O.B. Sex Relationship
List Any Disabled Dependents
Employee Signature Date
Waiver- I certify that the features and benefits under a 125 Flexible Benefits Plan have been explained to me. I elect to waive all pre-tax benefits under the plan and understand
that I may be prohibited from participation in this plan until the open enrollment period for the following year or in the event that I have a qualifying event as defined by the IRS.
Employee Signature Date
Enrollment
Form
Employee
225 N. 9
thStreet, Suite 530 | Boise, Idaho 83702 | t. 208.287.0310 | f. 208.287.0311 | integra-flex.com
1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0
7 78
Rounting Number Account Number
PAY TO THE ORDER OF ANYTOWN BANK Anytown, MD 2000 For Date $ DOLLARS
Tape a voided check here for checking accounts, or
tape a savings deposit slip here for savings accounts.
I hereby authorize IntegraFlex to initiate credit entries to my account as indicated below and the depository named below, hereinafter called DEPOSITORY, to credit the same to such account. I further authorize IntegraFlex to reverse any credit entry that Integraflex makes to my account to the extent that IntegraFlex reasonably believes such entry was made in error.
ACCOUNT INFORMATION
Type of Account Checking Savings Depository Name
Branch
City State Zip Code
Bank Branch Phone Number (including area code) Routing/ABA No. (see sample check below to locate number)
Account Number (see sample check below to locate number)
This authority is to remain in full force and effect until IntegraFlex has received written notification from me of its termination in such time and in such manner as to afford IntegraFlex and DEPOSITORY a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer-sponsored Flexible Benefits and/or Health Reimbursement plan.
Employer Name
Employee Last Name Employee Social Security Number
Employee First Name Date
Signature Date
Date Processed
Processed By (initials)
