Flexible Spending Accounts

(1)

Exchange | HR Outsourcing | COBRA | FSA | DCA | POP | HRA | HSA | PRA | DRA | Commuter | Wellness | Payroll

Phone: 603-647-1147 • Fax: 1-866-978-7868 • email: [email protected] • www.HRCTS.com • 111 Charles Street • Manchester, NH 03101

Rev. 10/13 FSA-STD-EDU-1A Rev. 10/13

Flexible Spending Accounts

- Healthcare Flexible Spending Account (FSA)

- Dependent Care Account (DCA)

Healthcare Reimbursement Accounts

What Are They?

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 These funds can later be withdrawn from this account on a tax free basis to pay for eligible medical, dental, vision, over the counter, and prescription expenses for themselves, their spouse,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

How Do They Work?

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

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

Examples of Tax Savings

No FSA

FSA

Annual Income

$30,000

FSA Contributions

$ 0

$ 1,000

Taxable Pay

$30,000

$29,000

Minus Taxes (Bases on

30%)

$ 9,000

$ 8,700

Take Home Pay

$21,000

$20,300

Minus

(Medical/dental/Vision/Costs)

$ 1,000

$ 0

Total Take Home Pay

$20,000

$20,300

What You Saved

$ 0

$ 300

How Do I Get My Money Out?

There are two ways you can get your money out of the account.

1 You can submit a claim online, mail it, fax it, or drop the claim off to us along with the receipt showing the expense.

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

You can use your entire annual election on the first day the plan starts. Please refer to your plan documents regarding how funds are handled at the end of the plan year. You do have 90 days after the end of a plan year to submit your expenses that were incurred during the plan year.

FSA-STD-EDU-2B

Dependent Care Account (DCA)

Worksheet/Election Calculator

Things To Remember

Understand that your election is based on the eligible expenses allowed by the IRS. These

expenses must meet the following requirements:

1. Daycare expenses must be incurred during the plan year for the care of a dependent

age 12 or younger.

2. Daycare expenses may be incurred for a spouse or other tax dependent that is mentally

or physically incapable of caring for him or herself.

3. The expense needs to be incurred during the time that you and your spouse (if

applicable) are gainfully employed and at work.

4. The daycare provider must be either a babysitter that cares for the dependent in or

outside of your home or a daycare center that meets state and local requirements, such

as, a pre-school, summer day camp, and after school programs. Any form of day care

provider you use needs to provide you with a tax ID or social security num ber.

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

income.

You can use this worksheet to estimate how much you will need to put into your DCA.

Please remember to be conservative, but don’t forget that all the money you put into this

account goes in on a pre-tax basis and comes out tax-free!

How Do You Determine Your Expenses?

Weekly Dependent Care Expenses

Preschool

(A.)$ _________

Daycare

(B.) $ _________

Baby Sitting

(C.) $ _________

After School Programs

(D.)$ _________

Adult Daycare

(E.) $ _________

Total Estimated Weekly Daycare Expenses

(F.) $ _________ (Add Lines A - E)

Total Estimated Annual Dependent Care Expenses This Plan Year

(G.) $ _________

(Multiply Line F. above by the total number of weeks this plan year. Please remember

that this amount cannot exceed $5,000 Or $2,500 if married and filing separately. If it does, please adjust the amount accordingly)

Number of Pay Periods

Divide Line G. Above By

In Plan Year (H.)__________

Line H. (This is your deduction per payroll) $________

(2)

EMPLOYEE EDUCATION

_FSA

EMPLOYEE EDUCATION

_FSA

Rev. 10/13 Rev. 10/13

FSA-STD-EDU-1B

Healthcare Flexible Spending Account (FSA)

Worksheet/Election Calculator

Examples of Eligible Expenses

Medical: deductibles, co pays, co-insurance, diagnostic tests, durable medical equipment, lab work,

chiropractic care and acupuncture.

Dental: exams, x-rays, cleanings, fillings, sealants, root canals, dentures, crowns and orthodontia. Vision: exams, contacts, glasses, lasik eye surgery, prescription sunglasses and contact lens solution. Prescriptions: all prescriptions are covered. This includes over the counter medications with a RX. Over the Counter: first aid supplies, hearing aids, orthopedic inserts, thermometers, and sunscreen. * Treatments for cosmetic reasons are not covered.

* Some services/purchases need to have a note of medical necessity or prescription to be eligible.

* You can access an updated list of eligible expenses at: http://hcet.ebia.com/hrcllc. Please contact HRCTS for access code first. Please note this list of eligible expenses is subject to change according to the IRS.

Examples of Ineligible: cosmetic surgery, teeth whitening, toothpaste, family counseling, shampoo, laser hair

removal and deodorant.

Examples of Expenses requiring documentation: vitamins, pain relief, digestive aids, allergy medication, acid

controllers, cold & flu medications, eye drops and massage therapy.

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

How Do You Determine Your Expenses?

You can use this worksheet to estimate how much you will need to put into your FSA. Please be conservative and don’t forget that this account covers you, your spouse, and eligible children.

Health Care Expenses

You

Your Spouse

Your Children

Deductibles: Medical $_______ $_______ $_______ Dental $_______ $_______ $_______ Vision $_______ $_______ $_______ Co-pays: Medical $_______ $_______ $_______ Dental $_______ $_______ $_______ Dental Care $_______ $_______ $_______ Prescriptions $_______ $_______ $_______ Vision Care: Eye Exams $_______ $_______ $_______ Glasses $_______ $_______ $_______ Contacts $_______ $_______ $_______ Chiropractic $_______ $_______ $_______ Other $_______ $_______ $_______

Total Estimated Expenses

(A.) $_______ (B.) $_______ (C.) $_______

(Total Annual Election)

(D.) $_________ (Add total of lines A, B and C above)

Number of Pay Periods

Divide Line D. Above By

In Plan Year (E.)__________

Line E. (This is your deduction per payroll) $________

FSA-STD-EDU-2A

Flexible Spending Accounts

- Healthcare Flexible Spending Account (FSA)

- Dependent Care Account (DCA)

Dependent Care Reimbursement Accounts

What Are They?

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

How Do They Work?

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

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

How Much Can I Put Into My Account?

The maximum reimbursement limit is $5,000 per year or $2,500 if married and filing separately. If a spouse is not work ing, but is a student, then the monthly maximum will be $200 for one child, and $400 for 2 or more children. All of these limits apply to the date the eligible expense is incurred, not the date billed or paid.

How Do I Get My Money Out?

1 You can submit a claim online, mail it, fax it, or drop the claim off to us along with the receipt(s) showing the expense.

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

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

What Are the Guidelines?

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

1. Dependent care expenses cover your dependent children 12 or younger, or a spouse/tax dependent who is mental ly or physically incapable of caring for him or herself. 2. The dependent care expense incurred must allow a single

parent or both married parents to be gainfully employed or attend school full time during the time the child is being taken care of.

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

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

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Rev. 10/13 Rev. 10/13

FSA-STD-EDU-1B

Healthcare Flexible Spending Account (FSA)

Worksheet/Election Calculator

Examples of Eligible Expenses

Medical: deductibles, co pays, co-insurance, diagnostic tests, durable medical equipment, lab work,

chiropractic care and acupuncture.

Dental: exams, x-rays, cleanings, fillings, sealants, root canals, dentures, crowns and orthodontia. Vision: exams, contacts, glasses, lasik eye surgery, prescription sunglasses and contact lens solution. Prescriptions: all prescriptions are covered. This includes over the counter medications with a RX. Over the Counter: first aid supplies, hearing aids, orthopedic inserts, thermometers, and sunscreen. * Treatments for cosmetic reasons are not covered.

* Some services/purchases need to have a note of medical necessity or prescription to be eligible.

* You can access an updated list of eligible expenses at: http://hcet.ebia.com/hrcllc. Please contact HRCTS for access code first. Please note this list of eligible expenses is subject to change according to the IRS.

Examples of Ineligible: cosmetic surgery, teeth whitening, toothpaste, family counseling, shampoo, laser hair

removal and deodorant.

Examples of Expenses requiring documentation: vitamins, pain relief, digestive aids, allergy medication, acid

controllers, cold & flu medications, eye drops and massage therapy.

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

How Do You Determine Your Expenses?

You can use this worksheet to estimate how much you will need to put into your FSA. Please be conservative and don’t forget that this account covers you, your spouse, and eligible children.

Health Care Expenses

You

Your Spouse

Your Children

Deductibles: Medical $_______ $_______ $_______ Dental $_______ $_______ $_______ Vision $_______ $_______ $_______ Co-pays: Medical $_______ $_______ $_______ Dental $_______ $_______ $_______ Dental Care $_______ $_______ $_______ Prescriptions $_______ $_______ $_______ Vision Care: Eye Exams $_______ $_______ $_______ Glasses $_______ $_______ $_______ Contacts $_______ $_______ $_______ Chiropractic $_______ $_______ $_______ Other $_______ $_______ $_______

Total Estimated Expenses

(A.) $_______ (B.) $_______ (C.) $_______

(Total Annual Election)

(D.) $_________ (Add total of lines A, B and C above)

Number of Pay Periods

Divide Line D. Above By

In Plan Year (E.)__________

Line E. (This is your deduction per payroll) $________

FSA-STD-EDU-2A

Flexible Spending Accounts

- Healthcare Flexible Spending Account (FSA)

- Dependent Care Account (DCA)

Dependent Care Reimbursement Accounts

What Are They?

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

How Do They Work?

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

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

How Much Can I Put Into My Account?

The maximum reimbursement limit is $5,000 per year or $2,500 if married and filing separately. If a spouse is not work ing, but is a student, then the monthly maximum will be $200 for one child, and $400 for 2 or more children. All of these limits apply to the date the eligible expense is incurred, not the date billed or paid.

How Do I Get My Money Out?

1 You can submit a claim online, mail it, fax it, or drop the claim off to us along with the receipt(s) showing the expense.

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

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

What Are the Guidelines?

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

1. Dependent care expenses cover your dependent children 12 or younger, or a spouse/tax dependent who is mental ly or physically incapable of caring for him or herself. 2. The dependent care expense incurred must allow a single

parent or both married parents to be gainfully employed or attend school full time during the time the child is being taken care of.

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

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

(4)

EMPLOYEE EDUCATION

_FSA

EMPLOYEE EDUCATION

_FSA

Rev. 10/13 FSA-STD-EDU-1A Rev. 10/13

Flexible Spending Accounts

- Healthcare Flexible Spending Account (FSA)

- Dependent Care Account (DCA)

Healthcare Reimbursement Accounts

What Are They?

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

How Do They Work?

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

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

Examples of Tax Savings

No FSA

FSA

Annual Income

$30,000

FSA Contributions

$ 0

$ 1,000

Taxable Pay

$30,000

$29,000

Minus Taxes (Bases on

30%)

$ 9,000

$ 8,700

Take Home Pay

$21,000

$20,300

Minus

(Medical/dental/Vision/Costs)

$ 1,000

$ 0

Total Take Home Pay

$20,000

$20,300

What You Saved

$ 0

$ 300

How Do I Get My Money Out?

1 You can submit a claim online, mail it, fax it, or drop the claim off to us along with the receipt showing the expense.

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

You can use your entire annual election on the first day the plan starts. Please refer to your plan documents regarding how funds are handled at the end of the plan year. You do have 90 days after the end of a plan year to submit your expenses that were incurred during the plan year.

FSA-STD-EDU-2B

Dependent Care Account (DCA)

Worksheet/Election Calculator

Things To Remember

Understand that your election is based on the eligible expenses allowed by the IRS. These

expenses must meet the following requirements:

1. Daycare expenses must be incurred during the plan year for the care of a dependent

age 12 or younger.

2. Daycare expenses may be incurred for a spouse or other tax dependent that is mentally

or physically incapable of caring for him or herself.

3. The expense needs to be incurred during the time that you and your spouse (if

applicable) are gainfully employed and at work.

4. The daycare provider must be either a babysitter that cares for the dependent in or

outside of your home or a daycare center that meets state and local requirements, such

as, a pre-school, summer day camp, and after school programs. Any form of day care

provider you use needs to provide you with a tax ID or social security num ber.

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

income.

You can use this worksheet to estimate how much you will need to put into your DCA.

Please remember to be conservative, but don’t forget that all the money you put into this

account goes in on a pre-tax basis and comes out tax-free!

How Do You Determine Your Expenses?

Weekly Dependent Care Expenses

Preschool

(A.)$ _________

Daycare

(B.) $ _________

Baby Sitting

(C.) $ _________

After School Programs

(D.)$ _________

Adult Daycare

(E.) $ _________

Total Estimated Weekly Daycare Expenses

(F.) $ _________ (Add Lines A - E)

Total Estimated Annual Dependent Care Expenses This Plan Year

(G.) $ _________

(Multiply Line F. above by the total number of weeks this plan year. Please remember

that this amount cannot exceed $5,000 Or $2,500 if married and filing separately. If it does, please adjust the amount accordingly)

Number of Pay Periods

Divide Line G. Above By

In Plan Year (H.)__________

Line H. (This is your deduction per payroll) $________

(5)

Exchange I HR Outsourcing | COBRA | FSA | DCA | POP | HRA | HSA | PRA | DRA | Commuter | Wellness | Payroll

FSA-STD-EDU-5 Rev. 10/13

FSA-STD-IRS-3 Rev. 10/13

a Flexible Spending Account. This regulation allows you to use the VISA we provided to

you, but requires you to submit your receipts for certain type of expenses. Keeping your

receipts has always been a part of the law, however, now you may need to submit them to

verify what was purchased with your card. There are some exceptions that enable you to

NOT have to submit your receipts. These exceptions are:

1) If you use your card to pay for co pays, associated with your company’s group health

plan, for services or prescriptions, you will not have to send to us your receipts if the

co pay matches the co pays set forth in your company sponsored health plan. You can

charge up to 5 times the single co pay without having to verify your expense.

2) If you have a re occurring expense and your charge will always be the same dollar

amount, all you will need to do is submit your receipt with your claim form and let us

know this will be a re occurring expense and we will authorize the use of your card for

this exact amount without the need to submit receipts for a period of time. From time to

time we may contact you to re verify the expense.

3) If you shop at a merchant that has an Inventory Information Approval System (IIAS),

your card will only work for eligible items. Every item these merchants sell is coded

according to the IRS 213D list of eligible expenses. Since your card will only work for

eligible items, you will not be required to submit your receipt. To see the latest list of

participating merchants please refer to our website, www.hrcts.com.

If you use your VISA and it does not fall into one of the above categories, you will be

receiving a receipt notification by email or mail (if we do not have your email address).

Please call us and provide us with your current valid email address. If you are notified

to submit your receipts please: upload via participant portal, mobile app, or mail/fax your

receipts along with the receipt request letter sent to you to HRCTS. The IRS has made this a

mandatory process, so please help us by sending in your receipts when requested. Receipts

must include date of service, dollar amount, and description of service provided. Remember

you can always view if any receipts are needed by logging on to your online account.

Thank you again for using HRC Total Solutions as your administrator of choice. It is our

pleasure in being able to provide you with exceptional customer service and the latest

technology. If you have any additional questions, please don’t hesitate to contact us!

Sincerely,

(6)

Phone: 603-647-1147 • Fax: 1-866-978-7868 • email: [email protected] • www.HRCTS.com • 111 Charles Street • Manchester, NH 03101 Rev. 10/13

UNIVERSAL CLAIM FORM

FSA-STD-CLAIM-4A

Phone: 603-647-1147 • Fax: 1-866-978-7868 • email: [email protected] • www.HRCTS.com • 111 Charles Street • Manchester, NH 03101 Rev. 10/13

Universal Claim Form

FSA-STD-CLAIM-4A

Employee Information

For timely and accurate processing, please complete entire form Last 4 Digits of SSN (Required) Phone Number

First Name Last Name Email Address Employer Name

Lim. Purpose FSA Dependent Care FSA HRA HRA, then FSA Receipts-Debit Card

Enter only one Claim Code per detail section

Date of Service Provider Person Receiving Service (Required for HRA)

Claim Code Description of Service Claim Amount

________________________________________________________________________________________

Tax ID (Dependent Care FSA only) Daycare Provider Signature (Dependent Care FSA only)

________________________________________________________________________________________

Claim Total: $

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

_______________________________________________________________________________________

Employee Signature Date

Health Care FSA Claims

Codes:

(7)

Phone: 603-647-1147 • Fax: 1-866-978-7868 • email: [email protected] • www.HRCTS.com • 111 Charles Street • Manchester, NH 03101 Rev. 10/13 FSA-STD-CLAIM-4B

2. Review the Claim Codes.

Enter Claim Code that corresponds with your plan into the box.

[ F ] Health Care FSA Claims [ L ] Limited Purpose FSA [ D ] Dependent Care FSA [ H ] HRA

[ HF ] HRA first, then FSA [ R ] Receipts

3. Complete the Claims Section. 4. Sign and date the claim form.

Important Notes for Claim Submission 1. Claims will be processed the same day if

received by 10:00

2. Please allow 3 business days from the day you submit your claim form before viewing the status on your Participant Portal.

3. Remember to send appropriate claim documentation in with your form to

substantiate the expenses you are submitting for reimbursements. Claim documentation must include the provider name, the dates(s) of service, a description of the expenses incurred and the expense amount. Cancelled checks and non-itemized credit card receipts are not valid forms of documentation.

4. Retain original copies of the claim form and expense documentation for your files; Claim Forms, receipts and claims information will not be returned.

5. Refer to your company or Summary Plan Description for the length of your run out period, which determines the number of days you have after the plan year ends to submit claims.

6. When submitting claims for your HRA Expenses: please claim the full eligible deductible amount shown on your Explanation of Benefits or receipt. We will automatically make any calculations necessary in accordance with your plan design. You must submit an Explanation of Benefits (EOB) and not a bill from your provider for HRA expenses.

Mobile Apps & SMS Text Alerts

Save time and hassles while you make the most of your HSA, HRA, and FSA accounts by checking your balances,

submitting a claim, and taking a picture of your receipt on your Android or iOS device. No more losing receipts! Find our mobile app on the Google Play store or on iTunes.

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

Customer Service Call Center Hours: Monday – Friday 8:30am-7:30pm ET

Live Chat: http://hrcts.com

Phone: (603) 647-1147 option 1 Fax: (866) 978-7868

Email: [email protected]

Rev. 10/13 FSA-STD-CLAIM-4A

For timely and accurate processing, please complete entire form Last 4 Digits of SSN (Required) Phone Number

First Name Last Name

Email Address Employer Name

Lim. Purpose FSA Dependent Care FSA HRA HRA, then FSA Receipts-Debit Card

Enter only one Claim Code per detail section

________________________________________________________________________________________

Tax ID (Dependent Care FSA only) Daycare Provider Signature (Dependent Care FSA only) Claim Total: $

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

_______________________________________________________________________________________

Employee Signature Date

Health Care FSA

Claims Codes:

2

3

(8)

FSA-STD-DD-5 Rev. 10/13

Authorization Agreement For Direct Deposits

Employer Name _____________________________________________________________________________ Employee Name _____________________________________________ Social Security#_____-_____- ______ Email Address (Required): _____________________________________

I hereby authorize HRC Total Solutions, LLC, hereinafter called HRCTS, to initiate credit entries to my



Checking



Savings account (select one) indicated below at the depository financial institution named below,

hereinafter called DEPOSITORY, and to credit the same to such account. I further authorize HRCTS, to initiate debits from the aforementioned account indicated below, and to debit the same from such account if an error is made in processing. Processing errors can include a payment that was made via my HRC Total Solutions VISA that was deemed ineligible, or if a forced post puts my flexible spending account with HRC Total Solutions in the negative. Depository Name: ________________________ City: ________________________________ State: ________ Routing #: _______________________________ Account #: ___________________________

Confirm Routing #: ________________________ Confirm Account #: ____________________

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

DATE: / / SIGNATURE______________________________________________________

Please return completed form to HRC Total Solutions along with a voided check or savings deposit slip to address below.

(9)

FSA-STD-ENROLL-6 Rev. 10/13

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

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

HEALTHCARE FLExIBLE SPENDINg ACCOUNT

❑

_{Regular FSA}

❑

_{Limited Purpose FSA (}

For HSA Participants

)

Annual Election for Medical, Dental, and Vision for my family: $ __________

Check the number of pay periods this plan Year: ❑ 52 ❑ 26 ❑ 24 Other: __________ The Amount per Pay Period Reduced from my check for this Account $ __________

(Divide the Annual Election by the Number of Pay Periods Above)

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

❑

_{DEPENDENT CARE ACCOUNTS}

Annual Election for Dependent Care Expenses: $ __________

Check the number of pay periods this plan Year: ❑ 52 ❑ 26 ❑ 24 Other: __________ The Amount per Pay Period Reduced from my check for this Account $ __________

(Divide the Annual Election by the Number of Pay Periods Above)

I understand that my election is based on the eligible expenses allowed by the IRS. These expenses must meet the following requirements: 1. Dependent Care expenses must be incurred during the plan year for the care of a dependent age 12 or younger.

2. Dependent Care expenses may be incurred for a spouse or other tax dependent that is mentally or physically incapable of caring for them self. 3. The expense needs to be incurred during the time that you and your spouse (if applicable) are gainfully employed.

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

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

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

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

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

Additional dependent Visa cards: Recipients must be 18 or older

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FSA-STD-SETUP-7 Rev. 10/13

How to set up an account online:

Please go to our Online Account Setup page http://hrcts.com/setup for instructions on retrieving your

username, creating an account password, and entering new user security questions to complete your online account profile. **Please note your online account will be available to you within 30 days of your plan effective date. If you already have an account you can login directly from https://employee.hrcts.com.

Trouble accessing your account?

1. The Password Length must be a minimum of 6 characters and is case sensitive. 2. When resetting your password your answers to security questions are case sensitive. 3. Password History: Your password must not be one of your last 12 passwords used.

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

HRC Total Solutions’ Mobile Benefits

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

Apple Store iOS Mobile Application Google Play Android Mobile Application

* Claims Requiring Receipts – View all your claims requiring receipts right from the main Accounts screen (only displayed when you have claims requiring receipts).

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

* Check available balances 24/7

* View Receipts – View receipts submitted from your benefits portal or from the mobile app. * Reset Login Information – If your password has

changed, you may tap this link on the login screen, allowing you to re-enter your username and password.

Text Message Alerts

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

Web Browser Minimum Requirements:

• Internet Explorer needs to be version 6.0 or newer • Firefox needs to be version 1.2 or newer

• Opera needs to be version 9.1 or newer • Safari needs to be version 1.3.2 or newer

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

HRC Total Solutions Email Communications

Please add the following domains to your “safe senders” white list to ensure you receive all email communications from HRC Total Solutions.

Icpbounce.com - Email from this domain will include general reminders, updates, and notifications regarding

enhancements, service issues, or plan offerings directly from HRC Total Solutions.

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

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