YOU RE GOING TO NEED A BIGGER BANK. BASIC FLEX

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BASIC

_FLEX

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Without a Flexible Spending Plan

Gross Taxable Wage $500.00

Federal, FICA & State Tax -133.25 Insurance premium co-pay -40.00

Take Home Pay $326.75

Average Weekly out-of-pocket expenses

Medical Expenses -50.00

Child/Dependent Care -70.00

Amount left to spend $206.75

With a Flexible Spending Plan

Gross Taxable Wage $500.00

Average Weekly out-of-pocket expenses

Insurance premium co-pay -40.00

Medical/Dental/Vision -50.00

Child/Dependent Care -70.00

Taxable Wage $340.00

Federal, FICA & State Tax -90.61

Amount left to spend $249.39

Do you pay medical expenses? How about insurance premiums? Child care? If you answered yes to any of these questions then keep reading because we are going to put more money in your pocket. The IRS established Section 125 to help alleviate some of the burden of medi-cal, dental, vision and dependent care bills. With BASIC Flex, you elect to have a certain dollar amount transferred from your paycheck into a special account to pay for expenses as they occur. This money is taken from your gross pay prior to taxes. You save by not having to pay federal and most state and local taxes, as well as Social Security and Medicare taxes, on the amount you set aside.

Take a look at the example below of a typical household to see just how much money you could save.

PAYCHECK.

GET MORE OUT OF YOUR

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PAYCHECK.

If you’re one of the many people who spend money on child care while at work, a Dependent Care Reimbursement Account is a logical choice. Using BASIC Flex is like getting child care on sale. The money is deducted before taxes so you don’t pay federal, state and Social Security and Medicare taxes on that amount. The savings range from 25% to 40% depending upon your tax bracket.

Determine your amount to put into your Dependent Care Account and start saving. A single parent or a married couple ﬁ ling jointly can elect up to $5000 per family, while a married person ﬁ ling separately can elect up to $2,500 (It’s $2,500 for that person but still $5,000 for the family). Unlike the Medical Reimbursement Account, this is a pay-as-you-go account. Re-imbursements are not made until funds are available. Remem-ber, left-over money is forfeited, so elect only what you know you’ll spend.

Here is an illustration of a current participant’s savings using BASIC Flex.

REQUIREMENTS

• You and your spouse must be employed or actively seeking employment or at-tending school full time. • Child care provider must

claim payments as income. • Child must be under 13

years old and considered a dependent for income tax purposes. If your child turns 13 during the plan year, ex-penses are no longer eligible for reimbursement.

• A spouse or dependent who is incapable of self-care and regularly spends at least eight hours per day in your home (i.e. an invalid parent). • Provider may not be a

minor child or dependent for income tax purposes (i.e. an older child).

• If the services are provided by a day care facility, that facility must comply with state day care regulations. • Services must be for the

physical care of the child, not for education, meals, regis-tration, etc.

• Overnight camps are not eligible for reimbursement • This is a pay-as-you-go

ac-count. Your employer will not advance any money.

• Expenses paid for Kindergar-ten are not eligible.

DEPENDENT CARE REIMBURSEMENT

Election Amount Savings

Total $5000 $1778

•assuming 28% Federal tax, 7.65% Social Security and Medicare tax

This family saved close to $2,000! That’s enough for a family vacation, college savings or the extra cushion many families need each month.

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With BASIC Flex you can save 25%-40% on your out-of-pocket medical expenses. Simply calculate your estimated medical expenses for the year and have that amount set aside in a Medical Reimbursement Account. The money is taken before taxes, so you don’t pay federal, state and Social Security and Medicare taxes on that amount. It’s like paying wholesale instead of retail.

We have provided an example of how a current participant calculated the amount they elected for BASIC Flex. Be sure to base YOUR estimate on known expenses because left over money is forfeited. Only 1 in 500 participants ever lose any money.

IRS regulations govern the eligibility of claims which include those that are not fully covered by a health care plan and are prescribed by a physician or other licensed professional, primarily for preventing, treating or mitigating a physical defect or illness. The IRS does not allow reimbursement for the following: cosmetic surgery, insurance premiums, teeth bleaching / whitening, health club fees, nutritional supplements/vita-mins, marriage counseling, eyeglass sun clips and prepayment of services. For more details, refer to IRS Publication No. 502.

MEDICAL REIMBURSEMENT

When you incur an eligible out-of-pocket expense, you fax, e-mail or mail your documentation to BASIC and receive a tax free reimbursement. Reimbursement requests are processed daily, ﬁ ve days a week.

Charges Savings Deductible $500 $180 Co-pays $450 $162 Prescriptions $480 $171 Contacts $220 $78 Dental $100 $36 Over-the-counter items $75 $27 Total $1795 $654

•assuming 28% Federal tax, 7.65% Social Security and Medicare tax _{If you have questions at}

any-time regarding BASIC Flex simply call 800.444.1922 x 1 and speak to a BASIC Flex Account Representative.

The full amount of your election is available

for reimbursement upon the ﬁ rst day of

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SPECIAL NEEDS _____ Stop smoking

programs

_____ Weight loss program2

_____ Massage therapy2

_____ Massage therapy _____ Transportation $.18

mile to and from doctor/hospital OVER-THE-COUNTER DRUGS _____ Allergy medicine _____ Antacids _____ Anti-diarrhea medicine _____ Bactine _____ Band-aids

_____ Bug bite medication (not bug spray) _____ Calamine lotion _____ Carpal tunnel wrist

supports _____ Cold medicines _____ Cold/hot packs

for injuries _____ Cough drops

_____ Diaper rash ointments _____ First aid cream _____ Hemorrhoid

medication

_____ Home pregnancy tests _____ Incontinence supplies _____ Laxatives

_____ Liquid adhesive for small cuts

_____ Menstrual cycle products for pain and cramp relief

_____ Motion sickness pills _____ Nasal sinus sprays _____ Nasal strips _____ Nicotine gum or

patches for stop-smoking purposes _____ Pain reliever _____ Pedialyte for sick

child’s dehydration _____ Pills for persons who

are lactose intolerant _____ Products for muscle pain or joint pain i.e., Bengay

_____ Reading glasses _____ Rubbing alcohol _____ Sinus medications _____ Sleeping aids used to

treat occasional insomnia

_____ Special ointment or cream for sunburn _____ Spermicidal foam _____ Visine and other such

eye drops _____ Wart remover treatments TOTAL ESTIMATED EXPENSES $ ___________________ MEDICAL _____ Acupuncture _____ Chiropractor _____ Podiatrist _____ Deductible _____ Co-pays _____ Doctor fees _____ Ofﬁ ce visit _____ Prescriptions _____ Hospital bills _____ Laboratory fees _____ Medic alert bracelet _____ Dermatologist _____ Immunizations _____ Obstetrical expenses _____ Routine physicals _____ X-rays

_____ Well baby checkups DENTAL _____ Orthodontic1 _____ Dentures/bridge/ crowns _____ Fluoride treatments & seals

_____ Cleanings and ﬁ llings _____ Root canals _____ Extractions HEARING _____ Hearing exam _____ Hearing aids _____ Special batteries VISION _____ Glasses _____ Eye exam _____ Contact lenses _____ Contact lens solution _____ Prescription sunglasses _____ LASIK surgery DIABETIC SUPPLIES _____ Insulin _____ Glucometer _____ Syringes/Needles _____ Test Strips BIRTH CONTROL DEVICES _____ Condoms _____ Prescriptions _____ Sterilization THERAPY _____ Physical therapy _____ Learning disability _____ Psychologist fees for

medical care _____ Psychiatric care MENTAL/PHYSICAL IMPAIRMENTS _____ Wheelchair _____ Crutches _____ Walker

EXPENSES.

SAVE MONEY ON THESE

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•

According to the IRS, any money left in your account becomes the property of your employer and cannot be returned to you. Most people use their remaining money by good planning . . . such as getting a physical or dental checkup, new glasses or purchase over-the-counter prod-ucts. Rarely is there ever more than 5% left in the account. Your tax savings will more than outweigh this amount. • Services must be rendered during the plan year for which

you enroll, unless your plan includes the new IRS 2 ½ month Grace Period. If you are a new employee entering the plan during a plan year, services must be rendered after your eligibility or election date. Please contact your beneﬁ ts coordinator for details regarding your speciﬁ c plan.

• To receive reimbursements AFTER your plan year has ended, refer to the Summary Plan Description booklet to ﬁ nd out how long you have to submit remaining claims. • If an expense is covered by your health insurance plan,

FIRST submit your bills to the insurance company, THEN submit the insurance company’s explanation of beneﬁ ts (EOB) or ﬁ nal billing from the provider along with your reimbursement request.

• For expenses not covered by your health plan, you must submit the BILL you received when the service was pro-vided. This bill must show the date of service, name of the provider, type of service, and charge for the service. • Premiums paid for Health Insurance cannot be reimbursed

through the Medical Reimbursement Account.

• Your pre-tax contributions through your BASIC Flex plan could reduce your future social security beneﬁ ts; however studies show it is usually less than 1%.

• Flex Beneﬁ ts end upon termination of employment and/or participation.

YOU MAY CHANGE YOUR ANNUAL ELECTION IF YOU HAVE A QUALIFIED CHANGE IN STATUS, SUCH AS:

Marriage

Birth

Death

Divorce

Adoption

While this booklet provides general information about a plan, a Summary Plan Description Booklet containing further details is available. If you have speciﬁ c questions regarding your particular situation, you may want to consult an attorney or accountant.

If you have questions throughout the year, refer to your Summary Plan Description booklet, visit www.basiconline.com, ask your Beneﬁ ts Coordinator, or contact a BASIC Flex Account Representative at 800.444.1922 x 1.

THE FACTS.

ACQUAINT YOURSELF WITH

Visit www.basiconline.com to access:

• a list of FAQs • a list of eligible

expenses

• claim/veriﬁ cation forms • calculator to estimate

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THE FACTS.

PREMIUM CONTRIBUTIONS

G I elect to participate (check all that apply)

GHealth Insurance G Group Life Insurance G Disability Insurance G Dental Insurance The amount of salary reduction needed to pay premiums under the insured

portions of the Plan will be determined by my employer. G I elect NOT to participate

DEPENDENT CARE ACCOUNT

G I elect to participate (not to exceed $5000 or $2500 if married ﬁ ling separately) $ ________________ Annually

G I elect NOT to participate

MEDICAL REIMBURSEMENT ACCOUNT

G I elect to participate (not to exceed employer limit of $_______________) $ ________________ Annually

G I elect NOT to participate DIRECT DEPOSIT

G I elect to participate (please do not ﬁ ll out if you are already participating, unless you are changing accounts) G checking account OR G savings account

Financial Institution (name of bank): ________________________________________

Routing Number (always 9 digits): ______________________ Account Number: _________________________ If you would prefer, you can attach a voided check

I request that my periodic paychecks for the plan year be reduced on a pro rata pre-tax basis by the sum of my medical reimbursement, dependent care and premium contributions to the plan, with such amount to be allocated among the benefi ts I selected above. I understand this election form cannot be revoked or changed during the plan year unless there is a qualifi ed change in status as defi ned in the Summary Plan Description (SPD). I certify that I will only claim reimbursement for eligible expenses for myself and/or qualifi ed dependents as defi ned in the SPD. I further certify that these expenses will not be reimbursed under any other benefi t plan. I understand any unused dollars remaining in my account(s) at the end of the plan year will be forfeited. I have examined this agreement and to the best of my knowledge, it is true, correct and complete.

Employee Signature _____________________________________________________ Date ___________________

CHECK EXAMPLE

  

routing number account number check number

BASIC

_FLEX

PLEASE PRINT AND WRITE CLEARLY. INFORMATION BELOW IS USED TO ENSURE ACCURATE ENROLLMENT.

Employer Name: _________________________________________________________________________________ Participant/Employee Name: ______________________________________ Social Security #: ______-_____-______ Address: ______________________________________________________ Date of Birth: _____/______/_______ City, State, Zip: _________________________________________________ Phone Number: ___________________ E-mail Address: ______________________________________ (Notiﬁ cation of direct deposit payment is sent via e-mail) Pay Period: G Weekly G Semi-Monthly (twice a month) G Bi-Weekly (every other week) G Monthly

YOU RE GOING TO NEED A BIGGER BANK. BASIC FLEX

BASIC

FLEX

Without a Flexible Spending Plan

With a Flexible Spending Plan

PAYCHECK.

GET MORE OUT OF YOUR

PAYCHECK.

DEPENDENT CARE REIMBURSEMENT

MEDICAL REIMBURSEMENT

EXPENSES.

SAVE MONEY ON THESE

•

Marriage

Birth

Death

Divorce

Adoption

THE FACTS.

ACQUAINT YOURSELF WITH

THE FACTS.

  

BASIC

FLEX

ARE FREE.

THE BEST THINGS IN LIFE

V

Very few people say “No” to something for nothing. Yet,

V

Very few people say “No” to something for nothing. Yet,

V

amazingly there are still people who don’t have a Flexible

V

amazingly there are still people who don’t have a Flexible

V

Spending Account. Numbers don’t lie. Take a look at the

examples we have provided inside to see how you can

take that special vacation this year or buy that new TV

you’ve been eyeing with your tax savings. BASIC Flex is

truly the last great tax break. Don’t wait another year to

start saving.

BASIC

FLEX

_FLEX

_FLEX

_{Spending Account. Numbers don’t lie. Take a look at the}

_FLEX