NCAP 2018 Benefit Information Packet

NCAP 2018 Benefit Information Packet

1

Northwest Community Action Partnership

2018 Summary Benefit Plan Description - .75 FTE or Above

Northwest Community Action Partnership is offering Options for our Benefit program. Get

started by carefully reading the information contained in this guide and share it with your family.

If you are a new hire, these forms and applications are due within seven days of hire and the

benefits will be effective the first day of the month following 60 days from the date of hire.

Employees are encouraged to fill out the required enrollment forms on the first day of

employment.

Northwest Community Action Partnership has an annual open enrollment period for benefit

selection every year and staff has an opportunity to review the Benefit Choices available and

make changes for the upcoming plan year of January 1st to December 31st.

Remember, you’ll need to complete the necessary forms and applications and submit them to

Katy Hughbanks, Payroll Clerk. If you have questions, please feel free to contact Katy at 308-

432-3393 or [email protected].

Benefit Dollars Benefit Options

Full-Time Employees are given Benefit

Dollars to pay for the “Benefit Options”

that Northwest Community Action

Partnership provides.

75-100% FTE $450 per month

Benefit Options provided by Northwest

Community Action Partnership that an

employee can use their Benefit Dollars for

are:

Group Health Insurance

Group Dental Insurance

Group Vision Insurance

Group Retirement Fund

Voluntary Group Term Life Insurance

Voluntary Short Term Disability

During Enrollment If you don’t make an election…

Review your benefit coverage and make

adjustments, if necessary.

Complete the necessary Benefit Enrollment

Forms

If enrolling in an option for the first time,

complete the necessary applications and

return them with your enrollment forms.

If you do not complete the necessary Benefit

Enrollment Forms and applications by the due

date you will not be enrolled in any benefits and

will not receive benefit dollars. This will continue

until the next open enrollment period, unless you

have a qualifying event. A qualifying event is:

Getting married/ Divorced

Losing coverage/ other special enrollment

Having a baby or adopting a child

Death of a spouse or child

mailto:[email protected]


2

GROUP HEALTH INSURANCE Our health plan options are provided through Blue Cross Blue

Shield (BCBS) of Nebraska, and offer both in-network and out-of-

network coverage. BCBS of Nebraska offers a national network of

providers which include 94 percent of Nebraska doctors. To locate a

network provider, visit Blue Cross Blue Shield of Nebraska online at

www.nebraskablue.com or call 800-642-3022.

For 2018, Northwest Community Action Partnership will offer three choices for group health

insurance. More information about each of the plans is listed on the next page and located on the

website under Employee Documents.

Coverage for Children Under Age 26 To comply with the Affordable Care Act, commonly

known as “Health Care Reform,” dependent children will remain eligible for medical coverage

until age 26, even if coverage is available through another health plan.

NCAP meets the requirement of the Affordable Care Act by providing a health insurance plan

that meets the minimum essential benefits requirement also we meet the affordability

requirement by providing benefit dollars and a health insurance subsidy, if applicable, to help

cover premium costs.


3

Comparison of Health Insurance Options

Best Network NetworkBlue #39 NetworkBlue #54 Option #42

Copays (PCP/SPC) ** $30/$50 Deductible and

Coinsurance $30/$50

Deductible $2,500/$5,000 $2,500/$5,000 $3,000/$6,000

Coins (Member Pays) 30% 20% 30%

Out-of-Pocket (Single/

Family)

$5500/$11000 $3575/$7150 $6,000/$12,000

Pharmacy $10; $30; $50; $100 Deductible and

Coinsurance $15; $45; $80;

$150

Telehealth Services (by a

designated provider)

Deductible and

Coinsurance $10 Copay $10 Copay

Out Of Network

Deductible (Single/Family) $5000/$10000 $5000/$10000 $6,000/$12,000

Coinsurance (Member Pays) 50% 40% 50%

Out-Of-Pocket

(Single/Family

$11000/$22000 $9000/$18000 $12,000/$24,000

**PCP/SPC: Primary Care Physician/Specialist

Please note: See the Summary of Benefits Coverage or Summary Plan Description for details on both

Plan options available to you. A copy can be found in Dropbox under Fiscal Forms All Agency in the HR

Folder under Benefits. If you need a copy in paper form, it is available upon request.

2018 Premium Rates

**Total Premium Costs listed above are before benefit dollars are applied.

Coverage Choices #39 #54 #42

Employee $792.72 $630.02 $704.71

Employee/Child(ren) $1277.00 $1102.54 $1233.22

Employee/Spouse and Family health insurance coverage is not offered. Due to this change, employee’s spouses

may be eligible for insurance coverage through the Marketplace and be able to receive subsidies based on

their income.


4

Group Dental Insurance Our dental plan options are provided through Dental By Design Insurance Company

This Dental program from Companion Life

provides total access to any dentist giving your

employee the freedom to choose a provider and

needed services with no network restrictions.

Benefit payment allowances vary, depending on the

area in which the services are rendered.

Services Network Coverage

Program Deductible

Per individual

Family Limit

Waived for Type I

service?

$100 Lifetime

No Limit

No

Type I

Preventive Services 100%

Oral exams, cleanings (2

per 12 months)

Bitewing X-Rays (1 per

12 months)

Space Maintainers

Pain Treatment

Sealants

Full mouth X-Rays

Type II

Basic Services

Benefit Waiting Period

80%

Fillings, anesthesia

Simple & surgical

extractions

Endodontics, oral

surgery

Periodontics

None

Type III

Major Services


50%

Crown inlays, onlays

Dentures, bridges,

implants

12 months

Contract Year Maximum $1500

Type IV Orthodontia

Child(ren) Only

Lifetime Maximum

Deductible


50%

Child(ren) Only

$1000

None

12 Months

Takeover Benefit Preferred*

Class Description Monthly Rate

Employee $38.82

Family $120.33

Employee + Spouse $73.80

Employee +

Child(ren)

$73.80


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Group Vision Insurance

*Standard Contact Lens GGFitting: spherical clear contact lenses in conventional wear planned replacement (example include, but not limited to,

disposable, frequent replacement, etc.)

**Premium Contact Lens Fitting: all lens designs, materials and specialty fittings other than Standard (ex. toric, multifocal, etc.)

+Eyeglass lenses are pain in lieu of the contact lenses benefit. Once in a 12-month period defined by last date of service.

++The contact lens benefit is paid in lieu of eyeglass lenses. Once in a 12-month period defined by the last date of service.

Disclaimer: This is a summary of benefits only. Please refer to the policy for comprehensive benefit details

Payment is based upon allowable charges in the area in which the service is rendered.

Employee has choice of either Option Vision by Design Vision Essentials Option

(Exam Only)

Vision Select Option

(Exam and Eyewear)

Vision Care Services

Exam with Dilation (as necessary):

Contact Lens fit and Follow-up:

(Contact Lens fit and two follow-up visits

are available once a comprehensive eye

exam has been completed)

Standard*

Premium**

In Network

$10 copay

N/A

N/A

In Network

$10 Copay

$0 Copay

$0 Copay, $10 off retail,

then apply $55 allowance

Out-of-Network

$35 allowance

$40 allowance

$40 allowance

Frames: Any available frame at provider

location

In Network Only

35% of retail price when complete

pair of eyeglasses purchased;

otherwise 20% discount

In Network

$130 frame allowance

20% off balance over balance

Out-of-Network

$72 allowance

Standard Plastic Lenses:

Single

Bifocal

Trifocal

Member Pays:

$50

$70

$105

In Network

$10 Copay

$10 Copay

$10 Copay

Out-of-Network

$25

$40

$55

Lens Options:

UV Coating

Tint (Solid and Gradient)

Standard Scratch Resistant Coating

Standard Polycarbonate

Standard Anti-Reflective Coating

Standard Progressive (add-on to Bifocal)

Other Add-ons and Services

Member Pays:

$15

$15

$15

$40

$45

$65

20% off retail

In Network

Member Pays:

$15

$15

$15

$40

$45

$65

20% off retail

Out-of-Network

Discount available

only at Network

providers and

retailers

Contact Lenses: (Material only)

Medically Necessary

Conventional:

15% off retail price

N/A

Conventional and Disposable:

In Network

$0 Copay

$120 allowance

15% off balance over

allowance (conventional only)

Pain in full

Out-of-Network

$96 allowance

$200 allowance

Frequency:

Examination

Frames

Eyeglass Lenses

Contact Lenses (in lieu of eyeglass lenses)

12 months

24 months

12 months+

12 months ++

12 months

24 months

12 months+

12 months++

Monthly Rates:

Employee Only

Employee plus one

Employee plus two

Family

$1.27

$2.33

$2.73

$3.59

$9.34

$17.64

$20.88

$27.79


6

Retirement Benefit Dollar Option

Northwest Community Action Partnership’s is offering benefit dollars that you may elect to

allocate to a 403(b) or a ROTH IRA. This opportunity to save for retirement may have tax-

advantages based on the plan selected. A retirement account provides additional income for

retirement. Employees choosing to enroll in this benefit option must set up a 403(b) or a ROTH

IRA retirement account. The accounts will be held with American Funds.

You may be able to rollover distributions you have received from other plans. To do so, contact

Buck Mintken at Security First Investments in Rushville to see if other accounts are eligible for

rollover and to fill out the paperwork to complete the process.

You have the ability to direct the investments of your account at any time while you are enrolled.

Buck Mintken, with LPL Financial LLC, is available to assist you in making these investment

decisions and changes.

Generally, your account may only be distributed upon retirement, terminations of employment,

death or disability, and after attaining the age 59 ½.

Upon the end of your employment at NCAP, you may elect to have your vested benefit

distributed to you, or rolled over to an IRA or another plan, as soon as administratively feasible.

Distribution forms are provided when an individual has an end date with the agency.

Employees are 100% vested and eligible to participate

the first day of the month following 60 days of

employment. You will be able to direct the

investment for your account. Gains as well as losses

can occur. NCAP will not provide investment advice

or guarantee the performance of any investment you

choose. Buck Mintken, who is affiliated with LPL

Financial LLC, is NCAP’s financial representative

advisor and can assist you in your financial planning

decisions. You can contact him at 308-327-2907.


7

Cafeteria Plan - Now, Your Paycheck Can Buy More!

Sometimes referred to as a cafeteria plan, flex plan or a Section 125 plan, a Flexible

Spending Account (FSA) lets you set aside a certain amount of your paycheck into an

account—before paying income taxes.

During the year, participants have access to this account for reimbursement of expenses that

insurance does not cover.

For example:

Deductibles, co-pays and other eligible expenses not covered by insurance.

Prescription drugs and medical supplies.

Over-the-counter drugs that are medically necessary like allergy medications, aspirin or

antacids.

(Rx) Prescription required.

Dietary supplements and vitamins with doctor's letter of medical necessity.

Dental services, orthodontics and dentures.

Eyeglasses, contacts, solutions and eye surgery.

Weight-loss programs with a doctor's letter of medical necessity.

Weight-loss over-the-counter drugs.

(Rx) Prescription required

Chiropractic services.

Vitamins with doctor's letter of medical necessity.

Psychiatric care and psychologist's fees.

Smoking-cessation programs.

Smoking cessation over-the-counter drugs.

(Rx) Prescription required

Adult and child daycare services.

Adoption expenses.

When you use tax-free dollars to pay for these expenses, you realize an increase in your

spending power, and substantial tax savings.

$500 of any remaining FSA funds will automatically be rolled into the next year’s plan.

What is a Flexible Spending Account Plan?

A benefit provided by your employer that lets you set aside a certain amount of your

paycheck into an account before paying income taxes. Then, during the year you can be

directly reimbursed from your account for qualified healthcare and dependent care expenses.

Why should I participate in the Healthcare Reimbursement Account when I already have

health insurance?

This account is used to pay for expenses that are not covered by insurance. For example,

your insurance may not cover annual physicals, co-payments, eye exams, eye surgery,

glasses, orthodontics, prescription drugs or dental care, just to name a few.


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Changes during the Year You will have the opportunity to review your benefits

yearly for the next plan year. Generally, you cannot

change your benefit elections during the plan year,

except in the case of a qualified change in status,

such as marriage or birth of a child, or in some cases

due to a special enrollment right. Generally, qualified changes in status should be reported to

Northwest Community Action Partnership within 30 days of the event.

Benefit Enrollment Forms can be accessed on our website under Employee Documents.

If you have questions regarding any of NCAP’s benefits please contact:

Katy Hughbanks

308-432-3393

[email protected]

If you have questions regarding Health, Dental, Vision, Disability, or Life Insurance benefits

please contact:

Jeremy Chizek or Tracy Pritchard

Ellerbrock-Norris

1-308-698-0114

[email protected] or [email protected]

If you have questions regarding only group Health Insurance please contact:

Blue Cross Blue Shield

1-888-592-8961

www.nebraskablue.com

If you have questions regarding only Retirement please contact:

Buck Mintken at Security First Investments in Rushville

American Funds

308-327-2907

If you have questions regarding only the Cafeteria plan or a Flexible Spending Account (FSA):

Dee Allen Sawyer

First Concord Benefit Group

402-328-2172

[email protected]

http://www.ezflexplan.com/fcbg/

www.myflexonline.com



http://www.nebraskablue.com/


http://www.ezflexplan.com/fcbg/

http://www.myflexonline.com/

Blue Cross and Blue Shield of Nebraska is an Independent Licensee of the Blue Cross and Blue Shield Association. 31-072 (09-01-16) Page 1 of 4

PO Box 3248 • Omaha, Nebraska 68180-0001

BlueFreedom/SelectBlue Employee Enrollment Form

New Group New Hire Change

Section A. Applicant Information

Social Security Number Name (Last) (First) (MI) (Title) Date of Birth (MM/DD/YYY) Male Female

Are you a member of a federally-recognized American Indian or Alaska Native tribe? Yes No

Home Phone Number Work Phone Number Cell Phone Number Marital Status: Single

Married Divorced Address (Street, PO Box) (City) (State) (Zip+4 Code) (County) Height:

Weight: Group Name (Employer or Organization) Date Employed with Group Hours Worked per Week

Are you, your spouse or your dependent(s) current or former Blue Cross and Blue Shield insureds or applicants? If Yes, please give name(s) & ID number(s). Yes No

Are you or your spouse terminating other Blue Cross and Blue Shield coverage? If Yes, please give reason and date and complete Section F. Loss of Coverage Yes No

The group health/dental program has been offered to me and after seriously considering its benefits, I have decided: not to enroll myself in the health plan. not to enroll myself in the dental plan. not to enroll myself and my dependents in the health plan. not to enroll myself and my dependents in the dental plan. not to enroll my dependents in the health plan. not to enroll my dependents in the dental plan.

Coverage in the health/dental plan is declined because: I am enrolled and/or My dependents are enrolled, under my spouse's health coverage. My spouse is employed by (name of firm) I am enrolled and/or My dependents are enrolled, under my spouse's dental coverage. I am enrolled and/or My dependents are enrolled, under a COBRA continuation coverage or state continuation coverage. I have and/or My dependents have, individual coverage through Medicare Medicaid SCHIP another insurance company Other reason(s)

Signature of Applicant: Date:

Section C. Health And Dental Election(s) For Newly Eligible Employees

I Hereby Apply For:

One Person Family Employee and Spouse Employee and Child(ren)

If Dual Option Group Please indicate deductible $

If High Deductible Health Plan, Select One:

Health Savings Account (HSA)

One Person Family Employee and Spouse Employee and Child(ren)

(If Applicable To Your Plan)

MEDICARE SUPPLEMENT (Not available to active employees or their spouses age 65 and older unless the group has fewer than 20 full and/or part-time employees.)

(Please complete Form 37-044, if applicable) No Account Set-Up Required

NETWORK OPTION (not all options may be available to you under your Plan) NEtwork BLUE Premier Select BlueChoice Other - Network Name:

Within the past six months, have you or any dependents used tobacco products four or more times a week? Yes No

DENTAL HEALTH

Section B. Declination of Coverage Complete only if you elect not to participate in the group insurance offered.

Please print and complete all sections of this enrollment form with black ballpoint pen. Be sure to complete all questions in full. Incomplete enrollment forms cause unnecessary delays. If you need more space for any answers, you can use a separate piece of paper. Please include your name and social security number. Complete Section B, if applicable.

For Internal Use Group No. Group Dept.

Name (Last) (First) (MI) (Title) Social Security Number

Page 2 of 4 31-072 (09-01-16)

Section D. Personal Data

List below spouse and other dependent(s) to be covered including eligible dependent children under age 26. List in order of age - oldest first.

Full Name (Last, First, MI) Social Security Number

Date of Birth (MMDDYYYY)

M

F

Relation to Employee

Section E. Coverage Change Election(s) For Current Members I Hereby Apply For The Following Changes In Coverage: Health Only Dental Only Both

Change To: One Person Coverage Employee and Spouse Coverage Employee and Child(ren) Coverage Family Coverage

Change Reason: Marriage Divorce Spouse Deceased Other: Date:

Add New Dependent(s): Date Dependent(s) joined your household: (Complete Section D.)

Date Dependent(s) joined your household: (Complete Section D.)

Date Dependent(s) joined your household: (Complete Section D.)

Change Network Options (if applicable) NEtwork BLUE Premier Select BlueChoice Other - Network Name:

Other Health Changes:

Within the past six months, have you or any dependents used tobacco products four or more times a week? Yes No

Section F. Loss of Coverage - Special Enrollment Are You or Dependent terminating (or losing) other health coverage?

If Yes, please complete the following:

1) Give us the reason for loss of other health coverage:

Yes No

Employment terminated Death, divorce, or legal separation I/we voluntarily chose to drop other insurance

Spouse employment terminated

2) Coverage termination date:

I/we have reached the end of COBRA coverage Other:

3) Please provide the notice of termination, or loss of eligibility documentation from the other insurance company.

Section G. Medicare Secondary Payor Information Are you, your spouse, or dependent(s) enrolled in Medicare? Yes No If the answer is “Yes,” please fill in requested information below: If Medicare: Name of Beneficiary Medicare HIC #: Part A effective date: Part B effective date: Reason for entitlement (check all applicable boxes): Age Disability End stage renal disease

Page 3 of 4 31-072 (09-01-16)


Section H. Health History Answer each question YES or NO. For conditions answered "Yes," give details below. This information is necessary for rating purposes. Your enrollment for health coverage will not be declined based on answers to these questions, or any health status-related factors. You should not disclose genetic information (including family history). If you are a new hire or changing your coverage, you are not required to complete this section. To request a copy of our Privacy Policy, contact us in Omaha 402-390-1820 or toll free 800-642-8980.

1. In the past 5 years, have you or any of your dependents been tested, diagnosed or treated (including prescription medication usage) or been

advised to seek treatment for:

1. Alcohol or drug abuse............................................................................................................................................. Yes No

2. Arthritis, Bone, Joint, Spine, Muscle or Connective Tissue Disorder..................................................................... Yes No

3. Autoimmune disease, including Crohn's disease, Lupus or Multiple Sclerosis...................................................... Yes No

4. Cancers, tumors or polyps...................................................................................................................................... Yes No

5. Circulatory, blood or heart disorders including high blood pressure....................................................................... Yes No

6. Cirrhosis, hepatitis or any other disease of the liver............................................................................................... Yes No

7. Cystic Fibrosis or Rheumatic Fever........................................................................................................................ Yes No

8. Digestive disorders including any conditions of the colon, esophagus, gallbladder, intestines, pancreas or stomach.... Yes No

9. Diabetes, hyperthyroidism, hypothyroidism or any endocrine disorder or disease................................................ Yes No

10. Manifested genetic or developmental disorders including use of growth hormones.............................................. Yes No

11. HIV / AIDS or any other immune system disorder.................................................................................................. Yes No

12. Infertility or any other reproduction system disorder............................................................................................... Yes No

13. Lung disease or disorder........................................................................................................................................ Yes No

14. Neurological disorders including Alzheimer's, Cerebral Palsy, Epilepsy, migraines, Parkinson's or seizures........ Yes No

15. Organ transplant..................................................................................................................................................... Yes No

16. Paralysis including paraplegia and quadriplegia.................................................................................................... Yes No

17. Vascular disorders including stroke, CVA or TIA.................................................................................................... Yes No

2. In the past 5 years, have you or any of your dependents been hospitalized, had surgery or plan to have surgery for any illness, injury or condition or is anyone currently pregnant?......................................................................................... Yes No

3. In the past year, have you or any of your dependents incurred medical or pharmacy expenses in excess of $5,000?...... Yes No

For any "Yes" answers identified above, please provide complete details below. Attach a separate piece of paper if necessary. Question Number

Person

Condition

Treatment Performed or Recommended

Degree of Recovery

Page 4 of 4 31-072 (09-01-16)


Section I. Acknowledgement and Authorizations I represent that my answers and statements in this enrollment form are true and complete to the best of my knowledge and belief. I understand that any intentional misrepresentation in this enrollment form may cause the coverage to be void. I further understand that Blue Cross and Blue Shield of Nebraska reserves the right to accept or decline this enrollment form and that no right whatever is created by it. I authorize Blue Cross and Blue Shield of Nebraska to obtain and/or release medical information to the extent necessary for processing claims. I authorize my employer to deduct from my earnings any required premiums.

By providing your telephone numbers you agree that we, along with our affiliates and/or vendors, may call or text any phone numbers you give us, including a wireless number, using an automatic telephone dialing system and/or prerecorded message. Without limit, these calls may be about treatment options, other health-related benefits and services, enrollment, payment, or billing.

Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents other coverage). However, you must request enrollment within 31 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption or placement for adoption. If you are declining coverage for yourself or your dependents because of coverage under Medicaid or a State Child Health Insurance Program (SCHIP), you may be able to enroll yourself or your dependents in this plan if that coverage terminates due to a loss of eligibility. You must request enrollment in the plan no later than 60 days after the termination of coverage.

Additionally, if you decline coverage and you or your dependents become eligible for premium assistance for this group health plan under Medicaid or SCHIP, you or your dependents may be able to enroll in the plan at that time. You must request enrollment no later than 60 days after the date you are determined to be eligible for the premium assistance.

To request special enrollment or obtain more information contact our Member Services Department at 402-390-1820 or toll free 888-592-8961.

Signature of Applicant:

Date:

Form #125DC2 01/18

First Concord Benefits Group

Employer: NW Community Action Part.

Plan Year: 1/1/2018 to 12/31/2018 . No.Payrolls: 26

YES I want the convenience of using the take care debit card to pay for qualified expenses.

E-MAIL (required-if YES): .

NO At this time, I do NOT want to use the take care debit card.

Flexible Spending Account (FSA)

Allows you to use pre-tax dollars to pay for expenses which are not covered, or are not eligible for payment through any group health care plan(s), under which you or your spouse are covered.

_______ YES, I elect to participate: $______________Per Pay $_______________Annual Amount

Dependent Care Spending Account The Dependent Care Spending Account allows you to use pre-tax dollars to pay for eligible Dependent Care Expenses which allow you or your spouse (if applicable) to work, look for work, or attend school on a full-time basis.


Group Premium Payment Plan The Premium Payment Plan allows you to pay for your portion and your dependent(s) portion of employer-provided benefits on a pre-tax basis. I understand that my share of these insurance benefits will be paid with pre-tax dollars.


_______ NO, I WAIVE my right to participate and understand that I will lose all tax savings I may have received as a participant.

My employer and I agree that my taxable income will be reduced each pay period by the amount set forth in this agreement. I understand that I may only change my election in the event of certain changes in my status. Prior to the first day of each plan year, I will be offered the opportunity to change my benefit election for the upcoming plan year. Any qualified expenses that are submitted by me will be reimbursed to me on a tax-free basis. Any contributions that are not used during the plan year or after termination of employment or benefits will be forfeited and will not be paid to me in cash or used in a later plan year.

Employee Signature: ______________________________________ Date: _______________

www.firstconcord.com

Phone: 402-423-4454

Fax: 402-423-4549

www.ezflexplan.com/fcbg

I.R.C. Section 125 Enrollment Form

$2,650 maximum election

$5,000 maximum election

LastName____________________FirstName____________ Date of Birth _______SocSecNo.______________

Home Address ____________________________________City_________________State_____Zip_________

DEBIT CARD REQUEST/ CONTINUATION I understand that the take care debit card is available to pay only qualified expenses. I also understand that if a payment is

made that is not for qualified expenses, I will repay my employer. For any expenses not repaid by me, I authorize my

employer to deduct the amount from my paycheck (if permitted by law). www.myflexonline.com

http://www.firstconcord.com/

http://www.ezflexplan.com/fcbg

http://www.myflexonline.com/

Form #125DC2 01/18

Flexible Spending Account (FSA)

Only individuals eligible for employer-provided major medical coverage can be offered the health FSA

(Unreimbursed Medical).

This account allows you to pay for out-of-pocket medical, dental, hearing and vision expenses with pre-tax dollars.

Examples of these expenses may be, but are not limited to insurance deductibles, medical exams, hearing, dental

expenses, vision expenses, orthodontia and Prescription Drugs. All health care expenses must be for the diagnosis,

cure, mitigation, treatment or prevention of disease or for the purpose of affecting any structure or function of the body

to be a qualified health care expense under the plan.

Dependent Day Care Spending Account

This account allows you to pay for day care expenses on a pre-tax basis throughout the plan year.

Only those dependent care expenses which allow you (and your spouse if you are married)to be gainfully employed are

eligible. This excludes care which is primarily for medical or educational purposes.

Eligible Dependents - Dependent children under age 13, or any other dependent who is incapable of caring for

himself or herself, whose principal residence is your home and you can claim as a dependent on your federal tax return.

Eligible Expense - Reimbursement is limited to the income of the lower earning spouse and also $5,000/year;

$2,500 if married, filing a separate return. Married employees in separate plans can only be reimbursed in total $5,000.

The reimbursement amount may not exceed the employee’s salary; or for married employees, the lesser of the spouse’s

salaries (subject to certain exceptions). If your spouse is a full time student or incapable of caring for himself or herself,

the maximum is $200 per month for one child or $400 per month for two or more children.

Eligible Providers - A licensed day care center which cares for six or more persons

A unlicensed provider caring for less than six persons

An in-home provider, as long as that provider is not your child under age 19 or someone you or your spouse can claim

as a dependent for tax purposes.

For more information, see IRS publication 503, available from your local IRS office.

Group Insurance Premiums This account allows you to pre-tax your group-sponsored insurance plans. Group term life up to a maximum of $50,000

may be deducted pretax. Please note that most health insurance plans provide life insurance as well. This needs to be

noted in your calculations. (i.e. medical life insurance $10,000 therefore $40,000 term life may be deducted).

Dependent life insurance is not eligible for pretax deductions.

All claims will be paid from actual bills, or copies of actual bills. For Unreimbursed Healthcare Spending Account claims you may

also submit a copy of your EOB form from your insurance carrier. These must contain the name of the provider of service, date(s)

that the services were provided and the amount charged. They must be attached to a completed First Concord Benefits Group

“Claim for Reimbursement” form.