FSA with Flex Card Enrollment Kit€¦ · Contact Lens Solution Laser Vision Correction. Medical Supplies. Bandages Digital Thermometers First Aid Kits Over-the-Counter Medications

Flexible Bene�t Service Corporation©Flexible Benefit Service Corporation.

FSA with Flex CardEnrollment Kit

Contact Us:www.myflexaccount.com

p: 888-345-7990 // f: [email protected] [email protected]

What’s inside:

Getting to Know: FSA with Flex Card

Eligible Expenses

Flex Card Overview

FSA Carry Over Overview

Participant Web Site & Mobile App Overview

Election Form

Flexible Bene�t Service Corporation

©Flexible Benefit Service Corporation.

A Flexible Spending Account (FSA) is an employer-sponsored benefit that allows you to pay for certain eligible expenses using money that is not taxed. FSAs are a great way to save money while keeping you and your family healthy and protected.

FSA with Flex Card

Save up to 30% on everyday health care expenses!

There are two types of FSAs. A Health Care FSA lets you pay for eligible medical, dental and vision care expenses that are not covered by your insurance plan.

A Dependent Care FSA allows you to use tax-free dollars for qualified child or elder care expenses.

Why You Need It

A smart way to plan for expected

health care and dependent care expenses

Save up to 30% on a variety of eligible expenses

Increase your take home pay by reducing your taxable income

Easy and convenient access to FSA funds and account information

You could save up

to $600 each year with an FSA!



Without FSAYour gross annual pay $35,000

Estimated tax rate (30%) -$10,500

Your net annual pay $24,500

Your annual healthcare expenses -$2,000

Your final take-home pay $22,500

With FSAYour gross annual pay $35,000

Your annual FSA Election -$2,000

Your adjusted gross pay $33,000

Estimated tax rate (30%) -$9,900

Your final take-home pay $23,100

FSA with Flex Card

How it WorksYou decide how much to contribute to the FSA. The amount you elect is divided up over your pay periods for the year and deducted from your paycheck before any payroll taxes are applied. You can use your FSA to pay for eligible expenses for you and all of your dependents, even if they are not covered under your primary health plan.

How You Use ItFlex makes it easy to access your FSA with the convenience of the Flex Card. The card allows you to pay for eligible expenses directly from your FSA, avoiding out-of-pocket expenses, cumbersome paperwork and reimbursement delays.

How You Manage ItGet account information anytime with our easy-to-use web site and mobile app. See your account balance in real time, file a claim for reimbursement and check on claim status. You can receive real time information and important updates via email or text message, and with our proactive texting feature, simply text “BAL” to receive a real time account balance.

How You PlanYou should look at your expected out-of-pocket expenses for the upcoming year to properly plan ahead. Be conservative with your election, because IRS rules state that you must forfeit any unused funds at the end of the plan year. For the most part, FSA elections are final and cannot be changed during the plan year.

In this example, you’d take home $600 more with an FSA!

Learn more myflexaccount.com

How Much Can You Save?The example below illustrates how much you can save by participating in the FSA



FSAs can save you up to 30% on everyday expenses

Health Care FSA

Common FSA Eligible Expenses

Health Plan Related Expenses

Prescription Drugs Co-payments Doctor Visits Hospital Charges

Dental Care

Dental Exams and Cleanings Fillings, Root Canals and Crowns Dentures and Bridges Orthodontia

Vision Care

Eyeglasses Contact Lenses Contact Lens Solution Laser Vision Correction

Medical Supplies

Bandages Digital Thermometers First Aid Kits Over-the-Counter Medications (prescription required)

Dependent Care FSA

Day Care Centers Preschool Charges Before- and After-School Care Summer Day Camp In- and Out-of-Home Care for Children or the Elderly



The Flex Card is a simple way to pay for qualified expenses without having to pay anything out-of-pocket. Best of all, one debit card can provide access to all Flex Accounts – FSA, HSA, HRA and Commuter.*

How it Works

Your Flex Card gives you easy access to the funds in your Flex Account by swiping the card at the point of sale. The card can be used at any qualified service provider that accepts MasterCard, and funds are automatically transferred from the benefit account directly to qualified providers. There are no out-of-pocket costs to you and no need to file a claim for reimbursement.

In the event that you have multiple benefit accounts, you only need one Flex Card. Our technology understands which purchases should be applied to any one of your accounts. It’s one smart card!

Easy as 1 – 2 – 3

1. Check your account balanceYou can view your transaction history, current balance, claim status and more by logging in to myflexaccount.com or via our convenient mobile app

2. Swipe your Flex CardSwipe the card at the point-of-sale for eligible products and services

3. Keep all your receiptsIn some instances, Flex will notify you that we need additional documentation to confirm that your purchase was eligible. It’s very important that you save your documentation and submit the information right away when necessary.

Your Convenient Way to Pay

The Flex Card

The Flex Card eliminates the

hassles of claims submission and

waiting for a reimbursement

check.

*Check with your employer for the Flex account available to you.

Visit myf lexaccount.com for more information about using your Flex card.

Learn more at myflexaccount.com

1. What is substantiation?Before we get into the details of what substantiation means with your debit card, let’s simplify the meaning of

the word. The actual definition of substantiate is to validate, verify, prove, confirm or authenticate.

Your Flex Card and Flex Accounts are regulated by the IRS, and their rules require that all of your debit card

transactions must be substantiated. This means, purchases made with the debit card must be proven to be

eligible under the plan.

Some of your transactions—such as known co-pays and IIAS transactions—will automatically

substantiate with no additional information required. All other transactions will require

documentation in order to substantiate the claim as an eligible expense.

2. I used my Flex Card at my doctor or dentist’s office, why do I need to substantiate?Even though a doctor or dental office is an eligible location, not all services provided are eligible under the

plan. IRS regulations require that Flex verify the eligibility of all expenses charged to

the debit card.

3. What information is required for substantiation?In order to substantiate your transaction, you must provide Flex with a third party statement

which includes the following information:

● The name of the person for whom the service was provided

● The date that service was provided

● The total amount of the expense

● The name of the provider

● The type of service provided

Substantiating Your Flex Card Claims

ABC Medical

555 AnystreetChicago, IL 60010

773-945-4569

STORE: REGISTER:001CASHIER: 764bASSOCIATE: 0012E

SUBTOTAL 259.00SALES TAX 21.45TOTAL 281.44

AMOUNT TENDERED

VISA 281.44

ACCT:*******1245

EXP:*****

APPROVAL:9999

CARDHOLDER: JANE SMITH

TOTAL PAYMENT 281.44

TRANSACTION: 1/8/2005 2:40 PM

CARDHOLDER SIGNATURE:

_______________________________

CUSTOMER RECEIPT

ORIGINAL TRANSACTION INFO STORE: 0032 REGISTER: 001 DATE: 12/31/2014 NUMBER: 5194

259.00

-----------------------------

-----------------------------

----------------------------------------------------------

-----------------------------

----------------------------------------------------------

Chicago Medical GroupPO BOX 202Chicago, IL 60012


10/18/14STATEMENT DATE

CARD NUMBER

CHECK CARD USING FOR PAYMENT

SIGNATURE

EXPIRATION DATE

$65.00PAY THIS AMOUNT

SHOW AMOUNT PAID HERE

123584PATIENT ACCT#

FOR BILLING INQUIRIES: 773-302-9874

10/10/14 XXXX4 $200.00

$140.00 $60.00

$15.00 $5.00

$65.00$65.00

OFFICE VISIT, 25 MIN

10/10/14 XXXX5 $20.00BLOOD DRAW

John Doe324 Main St.Chicago, IL 60011

DATE OFSERVICE

CODE DESCRIPTION OF SERVICE CHARGES INSURANCE PAYMENTS

BALANCE

CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS 90-120 DAYS AMOUNTDUE:

Make Checks Payable to ABC Dental325 Greenway DriveSuite #652Chicago, IL 60164

Statement #: 22587941Date: December 21, 2014Customer ID: 254789

Reminder: Please include the statement number on your check.Terms: Balance due in 30 DAYS.

Customer Name: Jon G. Castro

Statement #: 22587941

Date: 12/21/14

Amount Due: $125.00

STATEMENT

Date Type Invoice # Description Amount Payment

Total

Balance

Phone: (773) 436-0001Fax: (773) 436-0002Email: [email protected]

Anthony Doe100 Ohio ave.Chicago, IL 60601

Explanation of Benefits (EOB) THIS IS NOT A BILL12-12-14

Customer Service: 1-800-854-8894

Claim InformationMember Name: Anthony DoeGroup No: 987654321Identification No: CDE32165498Claim No: 202000000235XPatient Name: Anthony Doe

Total Billed $45.00Total Benefits Approved $16.20Amount you may owe provider $1.80

Service Description Service Date AmountBilled

NotCovered

Covered

The following shows how this claim was adjusted

Summary

Service Information

Coverage Information

Bill To: Dr. Dale Jones ABC Dental 325 Greenway Drive Suite #652 Chicago, IL 60164

12/10/14 54556874133 Balance Forward 125.00 125.00

$125.00

IMAGING RADIOLOGISTICS LLCMEDICAL EMERG X-RAY

PARTICIPATING PROVIDER OPTION (PPO REDUCTION)

Your 10% Coinsurance Amount..............

Total covered benefits approved for this claim: $16.20 to IMAGING RADIOLOGISTICS LLC 12-12-14

Totals

11/09/14 45.00 27.00 (1)

-$27.00

1.80

18.00

45.00 27.00 18.00

Totals

Deductions

Total Deductions

Total Benefits Approved

Amount You May Owe Provider

45.00 27.00 18.00

-$1.80

$16.20

$1.80

RSM HealthCareABC Medical


773-945-4569



AMOUNT TENDERED

VISA 281.44

ACCT:*******1245

EXP:*****

APPROVAL:9999





_______________________________

CUSTOMER RECEIPT


259.00

-----------------------------

-----------------------------

----------------------------------------------------------

-----------------------------

----------------------------------------------------------




CARD NUMBER


SIGNATURE

EXPIRATION DATE



123584PATIENT ACCT#


10/10/14 XXXX4 $200.00

$140.00 $60.00

$15.00 $5.00

$65.00$65.00




DATE OFSERVICE


BALANCE







Date: 12/21/14

Amount Due: $125.00

STATEMENT


Total

Balance








NotCovered

Covered


Summary

Service Information



12/10/14 54556874133 Balance Forward 125.00 125.00

$125.00





Totals

11/09/14 45.00 27.00 (1)

-$27.00

1.80

18.00

45.00 27.00 18.00

Totals

Deductions

Total Deductions



45.00 27.00 18.00

-$1.80

$16.20

$1.80

RSM HealthCare

Both of these are Acceptable Documentation, because they include the provider’s name, the patient’s name, the date of service, a description of the service being billed and the amount charged.

ABC Medical


773-945-4569



AMOUNT TENDERED

VISA 281.44

ACCT:*******1245

EXP:*****

APPROVAL:9999





_______________________________

CUSTOMER RECEIPT


259.00

-----------------------------

-----------------------------

----------------------------------------------------------

-----------------------------

----------------------------------------------------------




CARD NUMBER


SIGNATURE

EXPIRATION DATE



123584PATIENT ACCT#


10/10/14 XXXX4 $200.00

$140.00 $60.00

$15.00 $5.00

$65.00$65.00




DATE OFSERVICE


BALANCE







Date: 12/21/14

Amount Due: $125.00

STATEMENT


Total

Balance








NotCovered

Covered


Summary

Service Information



12/10/14 54556874133 Balance Forward 125.00 125.00

$125.00





Totals

11/09/14 45.00 27.00 (1)

-$27.00

1.80

18.00

45.00 27.00 18.00

Totals

Deductions

Total Deductions



45.00 27.00 18.00

-$1.80

$16.20

$1.80

RSM HealthCareABC Medical


773-945-4569



AMOUNT TENDERED

VISA 281.44

ACCT:*******1245

EXP:*****

APPROVAL:9999





_______________________________

CUSTOMER RECEIPT


259.00

-----------------------------

-----------------------------

----------------------------------------------------------

-----------------------------

----------------------------------------------------------




CARD NUMBER


SIGNATURE

EXPIRATION DATE



123584PATIENT ACCT#


10/10/14 XXXX4 $200.00

$140.00 $60.00

$15.00 $5.00

$65.00$65.00




DATE OFSERVICE


BALANCE







Date: 12/21/14

Amount Due: $125.00

STATEMENT


Total

Balance








NotCovered

Covered


Summary

Service Information



12/10/14 54556874133 Balance Forward 125.00 125.00

$125.00





Totals

11/09/14 45.00 27.00 (1)

-$27.00

1.80

18.00

45.00 27.00 18.00

Totals

Deductions

Total Deductions



45.00 27.00 18.00

-$1.80

$16.20

$1.80

RSM HealthCare

Unacceptable Documentation

Does not includedescription of item

or service being billed.

Does not include thedate of service, onlythe payment date.

Unacceptable Documentation

Does not includeoriginal date of

service.

Does not includedescription ofitem or service

being billed.

The following examples illustrate acceptable and unacceptable statements and information for debit card substantiation:


Generally, an Explanation of Benefits (EOB) from your insurance company or an itemized statement from the

provider should include all of the necessary information. Please note that provider statements containing a

“balance forward” amount and credit card or cash register receipts are not sufficient for the purposes

of substantiation.

4. How do I substantiate my Flex Card transactions?Your debit card transactions can be substantiated online through your participant account

at www.myflexaccount.com.

Alternately, if you receive an letter or email requesting additional information on the transaction, you can

attach your documentation and return the information to Flex via fax or email.

5. Will I be notified when substantiation is required?

Yes, if a transaction cannot be automatically substantiated, then you will receive an email from Flex requesting

additional information. If we do not have an email address on file for you, then we will mail a letter to your

home. If the information is not received after the initial notification, then you will receive additional reminders

that substantiation is required.


Substantiating Your Flex Card Claims

6. What happens if I don’t substantiate a transaction?If substantiation is not received in accordance with your plan—normally within 30 days of the transaction—

your debit card will be suspended and you will not be able to use your debit card for new purchases until the

outstanding transaction is substantiated. If your debit card is placed in suspended status, you will receive a

communication from Flex to let you know.

7. What happens if I have an ineligible transaction?

Ineligible transactions can be repaid directly to Flex. Once Flex receives your repayment amount, your FSA

will be resolved and the amount will be refunded into your account.

Please send repayments to:

Flexible Benefit Service Corporation

8700 W. Bryn Mawr Avenue, Suite 1010S

Chicago, IL. 60631



How it Works

Carryover up to $500 of unused FSA funds into the following plan year

You can spend your carried over funds at any time during the next plan year, and even carry it over to the following year, if needed

The carry over amount does not impact your following year maximum election—you can still contribute up to the maximum allowed by your employer

How it Helps

Eliminates much of the worry about “use it or lose it”

No more rushing to spend FSA funds on unnecessary items at the end of your plan year

FSAs now have more flexibility and less risk

FSA Carryover

In October 2013, the US Department of Treasury made arguably the most significant change to Flexible Spending Accounts (FSAs) since their inception in the 1970s. This change modified the “use it or lose it” rule that has governed FSAs for decades, giving you the ability to carryover unused FSA funds into the following plan year.

FSAs just got a whole lot better with carryover!


The myflexaccount.com participant web site offers you a helping hand with your FSA, HRA, HSA, or Commuter Plan before and after logging in.

Resources Available Before You Log in

Get general account questions answered with these useful resources:

Educational videos Eligible expense lists

Plan calculators FAQs and more

myf lexaccount.com For Participants

Manage Your Benefits Online

Get started on your way to Save & Spend Healthy

Visit myflexaccount.com today


Resources Available After You Log in

Get the details for yourself and any dependents:

View your benefit information, including account balance, transaction history and claim status

Submit new claims online and add receipts to pending claims

Edit personal demographic information

Update reimbursement method

Track medical, dental, vision and prescription expenses

Get important announcements from your employer

Set communication preferences

Register your mobile phone for SMS text alerts

Enroll online (if applicable)

Manage your Flex Card (if applicable)

Pay your provider directly or reimburse yourself for services you’ve paid for out-of-pocket

from myflexaccount.com.

myf lexaccount.com | For Participants

Pay Providers or Pay Yourself

Download the free My Flex Account Mobile App today!


The secure My Flex Account Mobile App helps you make smart money moves by providing convenient access to your FSA, HRA or HSA.

Easily:

My Flex Account Mobile App

Save and Spend Healthy On-the-Go

Check account balance

Get transaction details and claim status

Submit new claims and add receipts to pending claims

Update reimbursement method

Manage your Flex Card (if applicable)

Submit New Claims in a Snap

Simply take a photo of your receipt or Explanation of Benefits

from your phone or tablet.

Personal Information (*Required)

Enter Annual Election

Acknowledgement and Signature

FSA Election Form

© Flexible Benefit Service Corporation

myflexaccount.comf: 844-859-7306 // [email protected] 8700 W. Bryn Mawr Avenue, Suite 1010S, Chicago, IL 60631

*Company Name: *Effective Date of Election:

*Employee Name:

*Address:

Phone Number:

Date of Hire: *SSN:

*City:

Fax Number:

*State:

*Email Address:

*Date of Birth:

*Gender:

*Zip Code:

Date:

Fax- # of Pages:

FSA Elections

Health Care FSA**

Dependent Care FSA

Pay Period Frequency(W, B, S or M*)

First Payroll Date Affected

Annual Election Amount

$

$

*Pay Period Frequency: W = Weekly; B = Biweekly; S = Semi-monthly; M = Monthly

Remember, when your needs change, FlexFSA does too! You can change your premium elections any time you have a qualifying event that would change the status and/or premium amount of your employee insurance (i.e. marriage, divorce, birth or death of a child, death of a spouse, adoption or change of employment by spouse).

I acknowledge that I am authorizing the company to deduct equal amounts from my paychecks to collect the designated pre-tax column above. I recognize that these selections constitute a deliberate binding decision on my part that may not be changed until the enrollment period for the next plan year or if I experience a change in status

I elect NOT to participate in any portion of the FlexFSA plan. (i.e FSA, Dependent Care, Limited Purpose).OR

Employee Signature: Date:

Employee Signature: Date:

Download the free My F lex Account mobile app today!

Save and Spend Healthy On-the-Go

Documents

FSA with Flex Card Enrollment Kit€¦ · Contact Lens Solution Laser Vision Correction. Medical Supplies. Bandages Digital Thermometers First Aid Kits Over-the-Counter Medications