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EMPLOYEE OPEN ENROLLMENT RESOURCE
GUIDE
PRAIRIE STATE COLLEGE
A08116
HOW ALLIED CAN HELPFSAs require proper administration, and the IRS penalties for noncompliance exist. Allied handles all aspects of administration to not only meet your compliance obligations but to also keep employees happy.
EMPLOYEE BENEFITSEmployees pay less in taxes and have more take-home pay.
EMPLOYER BENEFITSEmployers can also save on taxes. Payroll taxes are reduced by 7.65 percent of the total employee contributions to the FSA.
HOW IT WORKSAs covered expenses are incurred, the employee conveniently uses an Allied Flex Card to automatically deduct funds from their Flex account. No more using cash for co-pays or submitting claim forms and waiting for reimbursement. Plus, easy-to-use tools at AlliedBenefit.com allow employees to track their Allied Flex account expenses, balances, and claims from anywhere, anytime.
Allied FSA Debit Card
Allied Flex adds to your competitive benefits package and shows you value your employees’ medical and financial health. Both your organization and your employees enjoy the benefits of paying less in taxes.
WHAT IS AN FSA?An FSA is a special account where an employee sets aside pre-tax money, via payroll deduction, to pay for certain out-of-pocket costs. There are two types of FSAs:
• Healthcare FSA – Covers out-of-pocket healthcare expenses, such as copayments, deductibles, some drugs,and more.
• Dependent Care FSA – Covers costs associated with caring for children, a disabled spouse, elderly parents orother dependents while working or attending school full-time.
Flex Plan Highlights
• $2,650 individual IRS maximum• $500 Rollover Provision- your employer has adopted the IRS rule allowing you to carry
over up to $500 of unused flex funds remaining at year-end to be used for qualified medicalexpenses incurred in the subsequent year. All unused funds over $500 will be forfeited.
Dependent Care Flexible Spending Account • $5,000 household IRS maximum
Claim Submission Deadline – Health FSA and Dependent Care FSA
• All 2019 flex claims must be submitted by March 31, 2020.• All claims submitted after this 3 month extension will be denied or applied to the new flex plan
year if incurred dates apply.• Use it or Lose it Rule: IRS regulations require that any money left in the account after this
deadline will revert back to the plan.
- contribution limits, provisions and claim submission deadlines
Health Flexible Spending Account
Allied Flex Debit Cards - Health FSA Only
• Flex debit cards are automatically issued to all participants at no cost.• Flex debit cards are good for 3 years - please review the expiration date.• Debit cards for dependents may also be requested at no additional cost.
Direct Deposit Reimbursement
• Easy and instantaneous payments utilizing the bank account of yourchoice.
Employee Web Account Access
4. Click “Submit Request” to complete your request. After submitting your request you willreceive an email from [email protected]. Please follow the directions from
this email to complete the process.
3. Enter all required information on the Request Account page.
Information inputted must match what was included on your enrollment form exactly. Please pay attention to SSN, DOB, and case sensitive prompts!
Your group number can be found on the title page of this document.
*You must have a private emailaccount to utilize this tool.
1. Visit www.alliedbenefit.comto login.
2. Click Register.
Allied Benefit Systems, Inc. P 800.288.2078200 West Adams, Suite 500 F
Chicago, IL 60606 E [email protected]
Group Number Employer Location (if applicable)
Employee UID or SSN Flex Plan Year
Address City State Zip
Dental/Vision
Provider's Signature (or attach receipt)
I certify that the expenses for which I am requesting reimbursement for meet the following conditions:-
---
- I have not and will not itemize and deduct, nor claim credit for these expenses on my income tax returns.- I understand that reimbursement will be made in accordance of the provisions of the Plan.
Employee Signature Date
312-416-2870
$
$
Date of Service
SECTION A - EMPLOYER/EMPLOYEE INFORMATION
SECTION B - REIMBURSEMENT REQUEST
Please attach all receipts that apply to required reimbursements. For dependent care, please attach receipts and signature of the Dependent Care Provider.
HEALTH FSA EXPENSES
Employer Name
Daytime Phone
Employee Name
Employee Email Address
$
$
Date of Service
DEPENDENT CARE ASSISTANCE EXPENSES
$
$
Amount of ExpensesOtherRxMedical
$
$
$Total Reimbursement Requested:
$
Name of Dependent Expenses Were Incurred For Dependent(s) Age Amount of Expenses
$
Total Reimbursement Requested: $
Provider's Tax ID Number or SSN
The above expenses were incurred for services or supplies for me and/or my eligible dependents listed above which either reside with me in a parent child relationship or are legally dependent on me for their support.
I understand that any amounts not used for qualified expenses by the end of the Plan Year or Grace Period will be forfeited to my Employer.
The above services and supplies were furnished to me or my dependents on or after my effective date with the Plan.I have not been reimbursed for the above expenses, nor have any of my dependents been reimbursed for these expenses.
SECTION C - EMPLOYEE CERTIFICATION
Allied Benefit Systems, Inc. P 800.288.2078
200 West Adams, Suite 500 F
Chicago, IL 60606 E [email protected]
Group Number Employer Location (if applicable)
Bank Account Type
Bank Account Number:
DIRECT DEPOSIT ENROLLMENT FORM
Employee Name Employee SSN
Bank Name
Bank Routing Number:
Checking Savings
• You must activate your account on www.alliedbenefit.com in order to receive an email notification each time a claim is
processed.
•Since you will no longer receive paper claim checks in the mail with account balance information, this information will be
available via our secure website www.alliedbenefit.com.
•When Allied processes a claim, the funds will be deposited 4-6 days following the processed date shown on the website.
•If your bank name, bank routing number, and/or your bank account number has changed, please inform Allied of this change
immediately.
•In the event that your banking information has changed and a claim is processed, a manual check will be processed for
reimbursement and you will be asked to submit updated information.
PLEASE NOTE WE MUST RECEIVE A VOIDED CHECK IN ORDER TO SET UP YOUR ACCOUNT
312.906.8879
SECTION A - EMPLOYER/EMPLOYEE INFORMATION
SECTION B - BANK INFORMATION
Employer Name
