Testfle spending forms.pdf

FLEXIBLE BENEFIT PROGRAM – SECTION 125
Non-reimbursed medical, dental, vision costs
Child or elderly dependent care costs
Enrollment in the flex benefit program is voluntary!

There are new rules and regulations, please read the attached material before
signing up for this program.

Please contact the Personnel/Payroll office for additional information.
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PLEASE SIGN AND RETURN THIS FORM BY JUNE 30, 2006
IMPORTANT INFORMATION

Plan Year: July 1, 2006 to June 30, 2007
Enrollment Process:
You must complete an enrollment form to participate in the Spending Accounts
each year during the enrollment period. If an enrollment form is not completed
during open enrollment, your enrollment will be canceled and you will not be able
to join until the next anniversary date of the plan.

Eligibility Requirements:
You will be eligible to join the plan on the first day of the month following 31 days
of employment if you are a contracted full-time, or contracted part-time
employee. Substitute employees and employees that are paid on an hourly basis
are not eligible.
Deductions:
Payroll deductions are taken on a 10-month basis from September through June.
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In order for you to get the most benefit from your plan, we want to remind you of a
few things concerning your reimbursement claim forms.
The claim forms are separated into two expense areas:
HEALTH CARE- For reimbursement of medical expenses
DEPENDENT CARE- For reimbursement of child care/dependent
care expenses.
To be reimbursed, you must fill in an amount on the claim form next to these
items and attach a receipt or bill from the provider (canceled checks are not
considered receipts; the receipt must come from a third party). Then, submit the
claim form and bill or receipts to the Benefits Office. If you do not complete a
claim form and turn in an appropriate receipt or bill, you will not be reimbursed.
Remember to sign your claim form.

The minimum reimbursement check is $5.00 except at the end of the plan year.

DO NOT HESITATE TO CALL!!
We are ready to help you get the greatest benefits possible from your plan. Please call the Benefits Office at 766-1100 X 309 if you have any questions. HEALTH CARE REIMBURSEMENT ACCOUNT
The Health Care Reimbursement Account allows you to pay for your uninsured medical expenses with pre-tax dollars. With this account, you can pay for your out of pocket medical expenses for yourself, your spouse and all of your dependents for medical services that are incurred during your plan year. The maximum you may place in this account for the plan year is $3,000. EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES
FEES/CO-PAYS/DEDUCTIBLES:
Acupuncture
Prescription Eye glasses/Contacts lenses Physician Smoking-cessation programs and prescribed drugs designed to alleviate nicotine withdrawal. Mileage, Parking & Tolls (You may be reimbursed $.12 a mile plus parking and tolls when medical reasons make it necessary to travel) Artifical limbs & breasts (only if reconstructive) Routine Physicals Birth control pills, patches (e.g. Norplant) Therapeutic care for drug and alcohol addiction
Tuition fees for medical care, if the college furnishes a breakdown of medical charges
Orthodontic expenses (not solely for cosmetic reasons)
NOTE: Orthodontic treatment is reimbursed according to your payment plan with the
orthodontist. FOR EXAMPLE: If your payment plan is set up to pay $200.00 a month
for the orthodontic treatment, you can be reimbursed $200.00 a month for the payments
that become due during the plan year.
This list is compiled from IRS publication 502. If you are unsure that your expected
medical expense will be eligible under tax code regulations, please call Flexible Benefit
Administrators at 766-1100 X 309 before making your election for the plan year or refer
to IRS Publication 502: “Medical & Dental Expenses”. This publication can be ordered
by calling the IRS at (800) 829-3676. There is also a copy in each school office.
OVER THE COUNTER DRUGS, PRODUCTS OR FORMULAS are eligible for
reimbursement.

EXPENSES THAT NEED DOCUMENTATION FROM YOUR PHYSICAN TO BE
ELIGIBLE THROUGH THE HEALTH CARE ACCOUNT
EXPENSES FOR IMPROVEMENT OF GENERAL HEALTH are not eligible for
reimbursement even if a doctor prescribes the program. However, if the program
is prescribed for a specific medical condition (e.g. Obesity, Emphysema), then
the expense would be eligible. We must have a letter from your doctor on file for
each plan year stating specifically what illness or disease is being treated or
prevented and the length of time you will be required to use this treatment in
order to reimburse for any of these types of expenses.

NOTE: For Weight Loss Program, only the cost of the program is an eligible
expense. Any cost for food or food supplements is not an eligible expense.
COSMETIC expense and treatments are not eligible. This applies to any
procedure that is directed at improving the patient’s appearance and does not
meaningfully promote the proper function of the body or prevent or treat an
illness or disease. If any cosmetic treatment is necessary to correct a deformity
or abnormality, a personal injury or a disfiguring disease, then the expense would
be eligible. We must have a letter from your doctor stating the specific medical
condition being treated in order to reimburse for this type of expense.



EXPENSES NOT ELIGIBLE FOR REIMBURSEMENT THROUGH THE
HEALTH CARE ACCOUNT
*** ESTIMATES for medical expenses that have not been rendered cannot be
reimbursed. Medical services do not have to be paid for, however, the services must have
been rendered during the plan year, to be eligible for reimbursement.
*** PREMIUM EXPENSES for any insurance policies are not eligible for
reimbursement through the Health Care Account. This includes contact lens insurance.
*** EXPENSES PAID BY AN INSURANCE COMPANY are not eligible for
reimbursement through the Health Care Account. Only the portion you have to pay out of
your pocket for your medical expenses is eligible for reimbursement.
OBTAINING A REIMBURSEMENT FROM YOUR HEALTH CARE ACCOUNT
To obtain a reimbursement from your Health Care Account, you must complete a
Claim Form. This form is available from your employer (See sample Claim Form
in back of handbook). You must attach a receipt or bill from the service
provider which includes all the pertinent information regarding the expense:
Amount covered by insurance (if applicable )
NOTE: In order to be eligible for reimbursement through the Health Care Account, the
medical expense must be incurred during the plan year. IRS defines “incurred” as when
the medical care is provided (or date of service), not when you are formally billed,
charged for, or pay for the care. FOR EXAMPLE: If you go to the doctor on June 25th
and your plan year begins on July 1st, this expense is not eligible in the new plan year.
Even if you pay for this expense after July 1st, the “date of service” was before the plan
year began and therefore is not eligible.
THE HEALTH CARE ACCOUNT IS A PRE-FUNDED ACCOUNT

This means that you can submit a claim for medical expenses in excess of your account
balance. You will be reimbursed your total eligible expense up to your annual election.
The funds that you are pre- funded will be recovered as deductions continue to be
deposited into your account throughout the plan year.
FLEX NOTE:
The maximum you can place in your Health Care Account is $3,000.00
OBTAINING A REIMBURSEMENT FROM YOUR DEPENDENT CARE
ACCOUNT
To obtain a reimbursement from your Dependent Care Account you must complete a
Claim Form. This claim form is available from your employer. You must attach a receipt
from the service provider which includes all of the following:
Name of dependent receiving care
Date(s) care was provided (must match Claim Form)
Name of service provider
Social Security or Tax I.D. number of the provider
Amount of the charge

NOTE: Dependent care expenses can only be reimbursed after the care is
provided. This means that advance payments of dependent care expenses
cannot be made. FOR EXAMPLE If you pay for a summer day camp for your child
in May but the camp is the first week in July, we cannot reimburse you for this
expense until July when the service is provided.
THE DEPENDENT CARE ACCOUNT IS NOT A PREFUNDED ACCOUNT

This means that you will only be reimbursed up to your account balance at the time you submit
your claim. If your claim is for more than your account balance, the unreimbursed portion of your
claim will be tracked by the Flexible Benefit Administrators. You will be automatically
reimbursed as additional deductions are taken and deposited into your account, until your entire
claim is paid out.

FLEX NOTE:
The maximum you can place in your Dependent Care Account is $5,000.00


CLAIM FILING DATES

Claims are processed once each month. If a claim is received in the office of Flexible
Benefit Administrators by the 15th of the month, your reimbursement check will be sent
to you on the 20th of the month. (Please remember that the claim must be received in
the office on the cut off date.) If the claim is received after the cut off date, it will be
held and processed the next processing cycle.
COMMON ERRORS TO AVOID WHEN FILING CLAIMS

• Canceled checks, cash register receipts or credit card receipts are sent in place of receipts • “Previous balance” statements or “payment on account” receipts submitted in place of actual date of service itemized bills or receipts
Your claim form may be returned to you or delayed in processing for improper or
insufficient documentation. If you have questions about your claims, you may
contact the Benefit Administrator at 766-1100 X309, from 8:00 a.m. to 3:00 p.m.,
Monday through Friday.
REIMBURSING THE PROVIDER OF SERVICE

All reimbursements will be sent to you directly. We cannot send payments to your
doctor or day care providers. After receiving payment from your account, you are
responsible for paying your providers.
MINIMUM CHECK AMOUNT

The check must be over $5.00 to be disbursed, except at the end of the plan
year. If you submit a claim under the minimum check amount the request will be
saved in the computer and a check will be cut when another claim is received
making the total over $5.00.
ELIGIBILE DEPENDENTS
If you claim a person as a dependent on your federal income taxes, then their
expenses would qualify for reimbursement under your Flexible Benefit Plan.
Therefore, your spouse would qualify if you file a joint return and your children,
step children or parents would qualify as long as you claim them as dependents
on your federal income taxes.
_________________________________________ SSN#_______/_____/_________
HEALTH CARE EXPENSES
I hereby file claim for the medical expenses below. I certify that each expense was incurred on the date
and for the person and reason noted and has not been reimbursed ( and is not reimbursable) under any
other health plan coverage. Attached are receipts or bills as evidence of my expenses incurred during
the plan year.
DEPENDENT CARE EXPENSES
I hereby file claim for the child or dependent care expenses noted below. I certify that each expense
was incurred on the dates and for the persons noted and has not been reimbursed ( and is not
reimbursable) under any other plan. Attached are receipts or bills as evidence of my expenses
incurred during the plan year. Please note that receips must come from the day care provider and
have the dates of service, a description of the expense, the amount charged and the provider's SS# or
Tax ID#.
I authorize the service provider to release any information requested by the Plan Administrator in
connection with this request for reimbursement.

Source: http://nhgs.tec.va.us/employment/flexspendingforms.pdf