Colby-Sawyer College Flexible Spending Accounts (FSA) Benefit

Colby-Sawyer College
Flexible Spending Accounts (FSA)
Benefit Summary
2
Flexible Spending Accounts (FSA)
Congratulations!
Your employer through CGI Employee Benefits Group is offering you a Flexible Spending Account (FSA) as
part of your benefits package.
Start Saving Today with an FSA:
FSAs provide you with an important tax advantage that can help you pay health care and dependent care
expenses on a pre-tax basis. By anticipating your family’s health care and dependent care costs for the next
year, you can actually lower your taxable income and increase your spendable income. As an employee, you
agree to set aside a portion of your pre-tax salary in an account, and that money is deducted from your
paycheck over the course of the year. The amount you contribute to the FSA is not subject to Social Security
(FICA), federal, state, or local income taxes — effectively adjusting your annual taxable salary.
The example below illustrates how a flexible spending account can save you money.
Bob and Jane’s combined gross income is $30,000. They have two children and file their income taxes jointly.
Since Bob and Jane expect to spend $2,000 in adult orthodontia and $3,300 for daycare next plan year, they
decide to direct a total of $5,300 into their FSAs.
Without FSAs
Gross income:
With FSAs
$30,000
$30,000
0
-5,300
30,000
24,700
-2,550*
-1,755*
State
-900**
-741**
FICA
-2,295
-1,890
After-tax earnings:
24,255
20,314
-5,300
0
$18,955
$20,314
FSA contributions:
Gross income:
Estimated taxes:
Federal
Eligible out-of-pocket
Medical and dependent care expenses:
Remaining spendable income:
Spendable income increase:
$1,359
*Assumes standard deductions and four exemptions. ** Varies, assume 3%. The example above is for illustrative purposes only. Every
situation varies and we recommend that you consult a tax advisor for all tax advice.
3
Flexible Spending Accounts (FSA)
Medical Reimbursement Account
The Medical Reimbursement Account lets you pay for certain IRS-approved medical care expenses not
covered by your insurance plan with pre-tax dollars. For example, cash that you now spend on deductibles,
copayments, or other out-of-pocket medical expenses can instead be placed in the Medical Reimbursement
Account pre-tax, to pay for these expenses. The annual maximum amount you may contribute to the Medical
Reimbursement Account is $3,000.
Dependent Care FSA:
The Dependent Care FSA lets you use pre-tax dollars towards qualified dependent care such as caring for
children under the age 13 or caring for elders. The annual maximum amount you may contribute to the
Dependent Care FSA is $5,000 (or $2,500 if married and filing separately) per calendar year. Examples
include:
The cost of child or adult dependent care
The cost for an individual to provide care either in or out of your house
Nursery schools and preschools (excluding kindergarten)
To ensure that your situation and the type of care being provided meets IRS requirements refer to IRS Form
2441, which is available at your local post office, public library, or online at www.irsforms.gov. You may also
contact a CGI representative for assistance in determining your status.
FSA Contributions:
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. Your entire annual contribution amount is available immediately*
at the beginning of the plan year to pay for eligible healthcare expenses. However, your total FSA
election amount is deducted from your paycheck in equal amounts during the year.
*This applies to healthcare expenses only. Dependent care expenses are reimbursed based on the availability of funds in your
account.
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
commenced, IRS rules allow you to change your election (increase, decrease or stop your pretax contribution) during the plan year only if you have a qualified change in status event and the
requested change is consistent with the event.
The Use-It-Or-Lose-It Rule
A ll of th e m o n e y i n yo u r f le xi b le sp e n di n g acco u nt m ust b e sp e nt b y t h e e nd
o f yo ur em p l o ye r ’s p l a n ye a r , s i nc e u n u s e d f u n d s wi l l n o t b e r e t u r n e d t o yo u
o r c a r r i e d o ve r t o t h e f o l l o w i n g ye a r .
4
Flexible Spending Accounts (FSA)
Questions?
Q. How do I file for reimbursements?
A: The amounts you have elected will be deposited into your reimbursement account(s) each pay period. You
may submit manual claims or use your benefit card. Use CGI’s Submittal of Receipts Form to submit claims
for purchases made using the benefit card. Use CGI’s Claim for Reimbursement Form to submit receipts
when requesting reimbursement of personal funds used; CGI will send a reimbursement check upon receipt of
this form.
Instructions for filing claims for reimbursement using manual claims:
1) Complete the Claim for Reimbursement Form, remembering to indicate the company you work for,
provide your social security number and requested information, and sign the bottom of the form.
2) Before sending the claim to the address below, be sure to attach any bills, receipts, or Explanation of
Benefits (EOB) to verify expenses listed. Claims can also be faxed to us at (603) 232-9363. If you fax
your claims, please be sure the receipts are legible. Send claims to:
CGI Employee Benefits Group
Claims Processing Department
171 Londonderry Turnpike
Hooksett, NH 03106
3) Upon receipt of your form and corresponding receipts, the Plan Administrator with then verify that all
submitted claims are eligible. If there is any question of eligibility, a CGI representative will contact you.
4) Every effort is made to process your claim weekly. Most claims are processed weekly. (You do not
have to submit claims every week; you may do so as frequently or as infrequently as you wish until your
funds are depleted.)
Instructions for filing claims using your benefit card:
1) Use your benefit card at eligible vendors, including most pharmacies, doctor’s offices, and hospitals.
Swipe the card at the point of sales as if you were using a personal credit card. Your benefit card
balance is automatically adjusted to reflect the purchase. There is no need to enter a pin; the card is
verified by signature. Make sure to KEEP YOUR RECEIPTS!
2) Complete the Submittal of Receipts Form and attach the receipts that correspond with your benefit
card purchase. The IRS requires that all receipts be accessible to the Plan Administrator, so please
remember to ALWAYS keep your receipts. You will be notified via email for the expenses that require
receipts for substantiation. If the requested receipts are not received in a timely manner, your card may
be subject to deactivation.
3) Upon receipt of this form, the Plan Administrator will verify that all benefit card transactions are eligible.
If not, you will be notified and your card may be subject to deactivation.
5
Flexible Spending Accounts (FSA)
Questions?
Q. How do I know my account balance?
A: You should track the use of your account at home; however you can check your account balance online at
www.cgibenefitsgroup.com. Click on the “FSA Balance” tab on the right hand side.
For your first time logging in, please contact your CGI representative to obtain a temporary Login ID and
Password. You will be required to change your User ID and Password after you log in for the first time. If you
have any problem accessing your account online or if you do not have access to the internet, please contact a
CGI representative.
Q. What if my needs change after I enroll?
A: Since the elections you choose are binding until the next enrollment period, it is very important that you plan
your expenses carefully. Once you authorize payroll deductions to your reimbursement account(s), you may
not cancel or change those elections or add coverage until the next enrollment period. The only exception is if
you have a major change in family status. The change must be on account of and consistent with one of the
following events:
• Marriage
• Divorce
• Death of a spouse or child
• Birth or adoption of a child
• Termination of a spouse’s employment
When one of these changes occurs, complete the Change in Family Status Form. If you are not sure that
your circumstances meet any of the requirements, please contact a CGI representative.
Q. How long do I have to submit claims after the end of the Plan Year?
A: You are given 90 days after the last day of your plan year to submit claims for prior year expenses.
Remember, the date of service must occur during the plan year. Example: You plan year ends on December
31st. You incurred an expense for a service that occurred during the plan year (i.e., before Dec. 31st). You may
submit for that expense any time before March 31st of the next year to receive reimbursement.
6
Eligible Medical Expenses
The products and services listed below are examples of medical expenses eligible for payment under a
Medical Reimbursement Account, to the extent that such services are not covered by your medical and dental
insurance plan. Unfortunately, we cannot provide definitive list of “qualified medical expenses.” A determination
of whether an expense is for “medical care” is based on all the relevant facts and circumstances. To be an
expense for medical care, the expense has to be primarily for the prevention or alleviation of a physical or
mental defect or illness.
• Acne treatment
• Acupuncture
• Administrative costs
• Adoption - pre-adoption medical
expenses
• Alcoholism treatment
• Allergy medications
• Ambulance
• Annual Physical Exam
• Antacid
• Antihistamine
• Artificial limbs & teeth
• Aspirin
• Automobile modifications – if for
physically handicapped person
• Bandages
• Birth control pills
• Blood pressure monitoring devices
• Blood sugar test kit & test strips
• Body scan
• Braille books/magazines
• Breast reconstruction surgery following
mastectomy
• Car modifications – if for physically
handicapped person
• Carpal tunnel wrist supports
• Certain home improvements to
accommodate a disability
• Contraceptives
• Condoms
• Chiropractor
• Chondroitin
• Circumcision
• Co-insurance amounts and deductibles
• Contact lenses – also materials &
equipment
• Crutches
• Decongestants
• Dental treatment
• Dentures and denture adhesives
• Diabetic supplies
• Diagnostic items/services
• Disabled dependent care expenses
• Drug addiction treatment
• Drug overdose, treatment of
• Prescription drugs
• Over-the-counter drugs
• Ear plugs – for medical purposes
• Fertility enhancement
• Fluoridation device or services
• Full body electronic scans
• Glucose monitoring equipment
• Guide dog/other animal aid
• Health institute fees – only if prescribed
by a physician
• Hearing aids
• Hemorrhoid treatments
• Hormone replacement therapy (HRT)
• Hospital services
• Hot/cold packs
• Inclinator
• Insect bite creams and ointments
• Insulin
• Laboratory fees
• Language training
• Laser eye surgery/Lasik
• Lead-based paint removal
• Learning disability, instructional fees
• Legal fees to authorize treatment for
mental illness
• Lodging at a hospital or similar
institution
• Massage therapy – only if
recommended by a physician to treat a
specific trauma or injury
• Meals at a hospital
• Medic Alert bracelet or necklace
• Medical services
• Menstrual pain relievers
• Motion sickness pills
• Nasal strips or sprays – only to treat
sinus problems; not to prevent snoring
• Nicotine gum or patches
• Norplant insertion or removal
• Nursing home medical expenses
• Nursing services provided by a nurse or
attendant
• Nutritional supplements – only if they
are recommended by a medical
practitioner as treatment for a specific
medical condition diagnosed by a
physician
• Obstetrical expenses
• Occlusal guard to prevent teeth
grinding
• Operations
• Optometrist
• Organ donors/transplants
• Orthodontia
• Osteopath fees
• Ovulation monitor
• Oxygen
• Pain relievers
• Physical exams
• Physical therapy
• Pregnancy test kits
• Prescription glasses/sun/reading
• Preventive care screenings
• Prostheses
• Psychiatric care
• Psychoanalysis
• Psychologist
• Qualified long-term care treatment
• Radial keratotomy
• Screening tests
• Sinus medications
• Sleep deprivation treatment
• Smoking cessation programs
• Special education
• Special food required for diet by
physician
• Special home costs for mentally
retarded
• Special medical equipment installed in a
home
• Special TV/telephone equipment for
hearing impaired
• Spermicidal foam
• Sterilization procedures
• Prescription sunglasses
• Sunburn cream/ointments
• Surgery
• Taxes on medical services and products
• Therapy
• Toothache/teething pain relievers
• Transplants
• Transportation expenses for person to
receive medical care
• Trips related to medical service
• Tuition for special needs program
• Vaccines/Immunizations
• Vasectomy
• Veterinary fees – for the care of seeingor hearing-impaired animals
• Weight loss program/drugs – if
prescribed by a physician
• Wheelchair
• Wig
• X-ray fees
7
Ineligible Medical Expenses
The items listed below are examples of products and services that are NOT eligible for reimbursement under
your Medical Reimbursement Account, according to the IRS. Typically, expenses for items that promote
general health are not eligible expenses. Please note that this list is not all-inclusive, and is subject to change.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Babysitting and Child Care
Controlled Substances
Cosmetics
Cosmetic Surgery
Dancing Lessons
Diapers or Diaper Service
Electrolysis or Hair Removal
Funeral Expenses
Future Medical Care
Hair Transplant
Health Club Dues
Health Coverage Tax Credit
Household Help
Illegal Operations and Treatments
Insurance or COBRA Premiums
Late Fees for Medical Bills or Missed Appointment Fees
Lodging or Meals at a Medical Conference
Maternity Clothes
Meals not at a Hospital or Similar Institution or Meals for a Companion
Medical Newsletters
Medicines and Drugs from Other Countries
Nutritional Supplements or Food – (unless they are recommended by a medical practitioner as
treatment for a specific medical condition diagnosed by a physician)
Personal Use Items
Surrogate Expenses
Swimming Lessons
Tanning Salons and Equipment
Teeth Whitening
Veterinary Fees – except for the care of seeing- or hearing-impaired animals
Weight-Loss Program (if for appearance, general health, or sense of well-being)
8
Flexible Spending Account Forms
Election Form and Contribution Agreement:
Complete this form to enroll in the Medical Reimbursement Account and/or the Dependent Care Account.
Flex Claim Form:
Complete this form when requesting reimbursement for medical expenses eligible under the plan. Remember
to include the appropriate receipts when you submit the form.
Benefit Card Submittal of Receipts Form:
Complete this form and submit with necessary receipts to validate benefit card purchases.
Change in Family Status Form:
Submit this form to change your family status when requiring a mid-year change in election.
Planning Worksheet:
You may use this worksheet to help you determine the amount of money you wish to allocate to your Medical
Reimbursement Account.
Summary of Claims Submitted Worksheet:
You may use this worksheet to track claims submitted
For assistance in completing any of the above forms, please contact your CGI representative.
Contact Information:
Your CGI Representative is: Jen Perron
E-Mail: jperron@cgibenefitsgroup.com
Phone: (603) 232-9356
Fax: (603) 232-9363
Check account balance online at: www.cgibenefitsgroup.com
Toll Free: (888) 383-0088
Send claim forms to: CGI Employee Benefits Group, Claims Dept.
171 Londonderry Turnpike
Hooksett, NH 03106
9
NOTES______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Notes
10
© CGI Employee Benefits Group, 2008