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Flexible Benefit Plan
Enrollment Guide
Ozarks Technical Community College
01/01/16 – 12/31/16
Instructions for Using This Guide:
1. Review the information and decide how this plan benefits you. 2. Estimate your out-of-pocket health care expenses using the worksheet. 3. Enroll or waive participation by completing the election process. through the online www.hrbenefitsdirect.com/Med-Pay or complete the Direct Deposit portion of the enclosed Plan Participation Form.
5. Return the completed Form to your employer or complete the online enrollment process as
instructed by Human Resources. Forms returned after deadline may not be accepted.
6. Call for assistance: Please contact Med-Pay's FSA Customer Service if you have questions
regarding your FSA benefits or the enrollment process. The information included in the Guide is for explanation only and is not intended as tax advice.
In all matters where tax or legal advice is needed the services of professional counsel should be sought.
FLEXIBLE SPENDING ACCOUNT ADMINISTRATION CONTACT INFORMATION
Phone Number for Customer Service: (417) 841-4134 or (800) 777-9087
Fax Number: (417) 841-4117
Email Addresses: Claims Processing (For submitting claims and documentation for Benny Card transactions):
[email protected] [email protected] Eligibility (For reporting address, name and election changes):
[email protected]
Mailing Address: Med-Pay,Inc
Physical Address: Med-Pay, Inc.
1650 E Battlefield Ste 300 Springfield, MO 65808 Springfield, MO 65804 Attn: FSA/HRA Department Attn: FSA/HRA Department Med-Pay, Inc.
Hours of Operation
Monday – Friday; 8:30am –4:30pm Central Standard Time The Tax Saving Benefit
of an FSA Plan
Flexible Spending Accounts (FSAs) are reimbursement accounts that allow you to pay for certain eligible expenses with tax-free dollars. Through pre-tax salary reduction and reimbursement, you convert taxable income into non-taxable benefits. The result is reduced tax withholdings and more take-home pay. FSA participation
results in tax savings of approximately 30% for all dollars run through the plan.
Your employer offers two types of FSA Plans:
1. Unreimbursed Medical FSA (FSA) can be used to pay for eligible unreimbursed health care expenses (not
covered or paid by any insurance) incurred by you, your spouse and your dependents. Common expenses that qualify for reimbursement are: doctor visits, deductibles, co-payments, prescriptions,
mental health care, dental services (including orthodontics), chiropractor services, eye exams, glasses and
contacts. A general listing of reimbursable and non- reimbursable expenses is included in this Guide. For further
details refer to the list in the Document Library on www.hrbenefitsdirect.com/Med-Pay.
Per IRS regulations the plan maximum elections are as follows: FSA $2,550.
Note: If you make contributions into a Health Savings Account, you cannot participate in this FSA plan.

2. Dependent Care FSA (DCAP) can be used to pay for eligible dependent care expenses (daycare, childcare)
so you and your spouse can work, look for work or attend school full-time. Covered expenses must be for a qualified child who is a d ependent children age 12 and under or is a person of any age whom you claim as a dependent on your taxes and who is mentally or physically incapable of caring for himself or herself and spends at least 8 hours a day in your household. Eligible expenses include childcare (nursery, preschool or private sitter), before and after-school care and day camps. Ineligible expenses include kindergarten tuition, overnight camps, and expenses paid to a tax- dependent. Please note: A dependent care credit is available on your annual tax return. With a DCAP, you will receive your
tax savings throughout the year rather than once a year when you file your taxes. You can only claim under the
dependent care credit any expenses exceeding the amount you contributed pre-tax to your DCAP.
Per IRS regulations the plan maximum elections are as follows: DCAP $5,000 per family per tax year.

Important Notes and Reminders about Your FSA Plan:
Current Plan Participants:
• Any remaining funds in your 2015 Plan year account can be used for expenses incurred by 12/31/15. All claims incurred for the plan year must be filed by 3/31/16. • If you do not use all of the funds you contributed into the account, the remaining balance will be forfeited. Any unused balance cannot be refunded or rolled over. • If you terminate employment, only claims incurred prior to your termination date are eligible. All claims must be filed within 90 days of termination. If you qualify for and elect COBRA, claims may be incurred during the remainder of the plan year. New Plan Participants:
• Any remaining funds in your 2016 Plan year account can be used for expenses incurred by 12/31/16. All claims incurred for the plan year must be filed by 3/31/17. • If you do not use all of the funds you contributed into the account, the remaining balance will be forfeited. Any unused balance cannot be refunded or rolled over. • If you terminate employment, only claims incurred prior to your termination date are eligible. All claims must be filed within 90 days of termination. If you qualify for and elect COBRA, claims may be incurred during the remainder of the plan year. • Your FSA annual election cannot change during the plan year except in the event of a recognized Status Change or Qualifying Event. • Per IRS regulations the plan maximum elections are as follows: FSA $2,550 and DCAP $5,000 per family per tax year. HOW TO RECEIVE REIMBURSEMENT:
File a claim or use your Benny Card
• Each employee with an Unreimbursed Medical FSA account (not the DCAP account) will receive a debit card ("Benny" card) they may use for such items/services as follows: medical office visit copays, prescription copays, medical plan deductible/coinsurance, dental expenses, vision expenses and over-the-counter items that are NOT considered a drug or medicine (bandages, contact lens solution, support braces, ice/heat packs, etc.). Debit card is loaded with the full annual election amount for use beginning on the first day of the plan year. Card purchases must be made for the amount equal to or less than the amount available in the account. The transaction will otherwise reject. If the merchant is unable to successfully process the payment, pay for the purchase with another form of payment and file the receipt to Med-Pay for processing. To replace a lost or stolen card and order a new one, contact Med-Pay immediately. A $10 fee will be deducted from your flex account. Debit card transactions (along with other account information and non-debit card claims submitted) are posted real time and accessible 24/7 on the employee portal (https://hrbenefitsdirect.com/med-pay). • Under IRS Revenue Ruling 2003-43, every debit card transaction must be substantiated (fully validated by an independent third party, proving that the card has been used for eligible medical expenses). Substantiation can be through auto-adjudication or documentation submitted by the employee. If the transaction is not properly substantiated, the card must be suspended until amounts are recouped from the employee. If documentation is required, it will be noted on the employee portal and a monthly statement will be emailed/mailed to the employee. o The Ruling allows for Auto-adjudication (auto-substantiation) for the following transactions:  Purchases at any pharmacy meeting the IIAS requirements (The pharmacy has registered that they have inventoried their items to determine eligibility under flex plans.) You may search for eligible pharmacies at Some pharmacies include Walgreens, Wal-Mart, George's, Convenient Care, Mercy, Grove, Family, Sam's Club and CVS.  All purchases which exactly match insurance plan co-pay amounts (up to a multiple of five); and  A recurring transaction for which the receipt for the first purchase was provided to Med-Pay. At the beginning of the month, the employee will receive a statement indicating transactions for which itemized receipts must be provided to Med-Pay for substantiation. A second notice is provided the next month for any outstanding receipts. A final notice is sent the third month stating the debit card has been suspended if the documentation is still not provided. It will remain suspended until the documentation is provided. • If the employee does not use a debit card for their purchase or if the employee is filing a claim for a Dependent Care Assistance Plan, the employee must file a manual claim for reimbursement. • Manual claim or substantiation: Claims/substantiations may be filed by U.S. mail, scan/email, scan/upload to employee portal, faxed or hand-delivered to Med-Pay. (See front page for contact information.) Proper itemized receipts will contain ALL of the following information: patient name, provider, date of service, details of services and the charges incurred. A new claim must be filed with the claim form (available on the employee portal). The substantiation request letter or a claim form must be used as a cover sheet with the remission. • Employees may choose to have banking information on file with Med-Pay in order to receive any reimbursements as a direct deposit into a checking or savings account. A notification of deposit will be mailed to the employee when a reimbursement is direct deposited. Without this information, all reimbursements will be made as a check. The notification or check will also contain year-to-date plan information. The direct deposit option can be added at any time. The employee may make this change on the employee portal https://hrbenefitsdirect.com/med-pay. • All claims must be filed before the deadline (see front page) in order to be considered timely filed for consideration Med-Pay's Customer Service department is available to answer any questions about the FSA plan. Contact: (417) 841-4134 or (800) 777-9087.
About The Benny Card
• The Benny Card is a limited merchant category Visa® Card which provides instant access to FSA funds, reducing out-of-pocket expenditures for which you must file a claim and await reimbursement. • By using the Benny Card, there is less paperwork to submit. It is designed to work at merchants with a health-care merchant category code, such as a doctor's office, hospital, dentist or optometrist. Charges are automatically approved at many of these locations, so you will only need to submit requested receipts instead of submitting all receipts to Med-Pay. o Card transactions which match your employer-sponsored plan copays will automatically substantiate. Therefore, you will not need to submit receipts. o The Benny Card will also work at retail merchants which have an Inventory Information Approval System (IIAS) in place. The IIAS will provide automatic substantiation at the point of sale for FSA-eligible items. This means you can only purchase eligible items with your card at these locations, and you will not need to submit receipts. o A recurring transaction for which the receipt for the first purchase in a plan year was provided to Med-Pay will also automatically substantiate. • Receipts will need to be submitted for debit card purchases that do not meet the above auto-substantiation criteria. You will receive a statement at the beginning of the month if there are transactions for which receipts are required for substantiation. The receipt must contain the following information: Patient Name, Provider, Date of Service, Details of the Service and the Patient Responsibility. An Explanation of Benefits from the insurance plan or superbill from the provider works best. • Your card(s) will be mailed to the address on file with Med-Pay's FSA department. Keep your card even if you have used all available funds from your account. The card will not expire for 3 years. Your new election in
subsequent years will be loaded to this card. If you lose your card and need to order another one, a $10 fee
will be deducted from your flex account. Please contact Med-Pay to order new cards.
Note: According to IRS requirements, save your receipts. Even if you are not required to provide receipts for
substantiation of the charges, you should keep your receipts in case of a tax audit. Contact Med-Pay for more information about the Benny Card.
What's Reimbursable?
This non-exhaustive list of expenses reimbursable by your Medical Flexible Spending Account is based on Internal Revenue Code 213(d). Please note that there have been important changes in the way over-the-counter drugs and www.hrbenefitsdirect.com/Med-Pay for further information, or please feel free to contact us if you have any questions about eligible expenses. Reimbursable Expenses:
Diagnostic devices Practical nurse fees Artificial limbs Drug & alcohol addiction treatment Prescribed medicine (if not cosmetic; Artificial teeth Drug & medical supplies hair-loss medications are not reimbursable) Automobile modifications (hand controls, Eyeglasses, incl. exam fee Psychiatrist's care Routine physicals Handicapped persons' schools Smoking cessation (prescribed drugs and non-drug program) Blood pressure monitor Special communications equipment for Braille books & magazines Lactation expenses Care for mental handicap Chiropractors Laser eye surgery Special education for the blind Copays, deductibles, & coinsurance Learning disability - special school fees Transportation expenses for medical Contact lenses & supplies Contraception Obstetrical expenses (after services have Costs for physical/mental illness Operations (medically necessary) Tuition at special school for the Deductible, all family members Orthodontia (special rules apply) Dentist fees (if not cosmetic: e.g., teeth Orthotics/Orthopedic shoe inserts whitening is a non-reimbursable expense) Physical therapy Reimbursable with a Letter of Medical Necessity:
OTC Dru gs and Medicines are Reimbursable with a
Prescrip
These items may be reimbursable if accompanied by a note Over-the-counter (OTC) drugs and medicines require a from a doctor recommending the item to treat a specific prescripti on for FSA reimbursement. The prescription must medical condition. This form is available on en by a physician on an official prescription pad and must include the name of the patient, the specific OTC drug or medicine and the number of refills or duration of • Cord blood storage treatment. You may submit a copy of the prescription and a • Home improvements for medical conditions receipt for purchase of the product with your reimbursement • Nutritionist claim form. The prescription is good for the full plan year. • Orthopedic shoes (not mass-produced) • Vitamins & nutritional supplements (only if Some OTC medications are listed below: recommended by a doctor for a specific medical • Acid control medication (Prevacid, Prilosec, Zantac, etc.) • Weight loss to treat existing disease • Acne treatment gy medication (Zyrtec, Claritin, etc.) acids (Tums, etc.) Not Reimbursable through your FSA plan:
Anti-i tch medication medication Cough drops Cosmetic surgery (unless restorative) Nicoti ne patches or gum Finance Charges Pain relievers (Advil, Tylenol, etc.) Sleep aid medication Imported drugs (Canada, Mexico) Stomach remedies (Pepto-Bismol, etc.) • Marriage counseling Missed appointment fees • Personal hygiene products • Teeth whitening • Toothbrushes • Vision Club Memberships Estimating Your Expenses
Use this worksheet to help estimate what out-of-pocket expenses you can pay with tax-free dollars through a Flexible Spending Account (FSA). 1. Medical/Dental/Vision FSA:
What is your estimate of medical/dental/vision costs to be incurred during the plan year and not reimbursed by insurance or another benefit plan? Be sure to include expenses for you, your spouse and all dependents, even if they are not enrolled under your employer's insurance coverage. Confirm the eligibility of an expense on our website (www.hrbenefitsdirect.com/Med-Pay) or call us to discuss. Medical:
Insurance Deductibles $ _
Copays and Coinsurance (amount not paid by insurance) $ _
Routine Exams (Physicals, Ob-Gyn, etc.) $ _
Prescription Drugs (Including birth control) $ _
Over-the-Counter Medications (only with a prescription) $ _
Over-the-Counter Non-Drug Medical Items $ _
Dental:
Insurance Deductibles, if applicable $ _
Copays and Coinsurance (amount not paid by insurance) $ _
Exams, Cleaning, X-rays, etc. (NOT teeth whitening) $ _
Fillings, Caps, Crowns, Bridges, etc.
Orthodontia (Braces) Note: Special rules apply Vision Care:
Exams, Contacts, Glasses, LASIK Surgery) Hearing Care (Exams, Hearing Aids & Batteries, etc.) Other unreimbursed medical expenses:
Total Medical/Dental/Vision Expenses = $ /Year 2. Dependent Care FSA:
If your spouse works or if you are a single parent, how much do you pay for employment-related dependent day care or childcare services for children age 12 and under? Remember to take into account vacation and other time off work during the year. Only fees for actual care may be reimbursed. Kindergarten tuition, overnight camps and expenses paid to a tax-dependent are ineligible. Total Dependent Care Expense = $ _/Year
Remember:
• Over-the-counter medicines and drugs require a prescription for reimbursement. Over-the-counter non-drug medical items and insulin are reimbursable without a prescription. • Reimbursement is based on the date of service, not the date of payment. In order for you to be reimbursed from your
FSA funds, the date the expense is incurred (NOT PAID) must be within the current plan year and while you are an active participant in the plan. • Prepayments, such as deposits for surgery, dental work or dependent care summer programs, are not eligible for reimbursement until the service has actually been rendered. • You have 91 days after the end of your plan year or 90 days after termination to file reimbursement claims for eligible
• Your Dependent Care and Medical/Dental/Vision FSAs are two separate plans, and funds cannot be transferred between • Please call us or visit our website, www.hrbenefitsdirect.com/Med-Pay, for any questions about eligible expenses. Flexible Benefit Plan and Flexible Spending Accounts
1. My portion, if any, of insurance premiums for eligible employer-sponsored insurance plans elected for myself and my dependents wil be
automatically pre-taxed unless I sign a Pre-Tax Waiver form provided by my employer. My employer may adjust pre-tax premiums if rates change during the year, but I may not be able to change my election during the Plan Year. 2. I cannot change or revoke my elections prior to the start of the next plan year, unless I have a Change in Status or other Qualifying Event
described in the Plan. The Summary Plan Description ("SPD") includes a full explanation. 3. Signing this form does not initiate my coverage under any insurance policy.
4. My Plan Year benefit elections may be slightly rounded, if necessary, to allow per-pay-period salary reductions.
5. Unused amounts remaining in Flexible Spending Accounts for the Plan Year and applicable run out period(s) wil be forfeited.
6. I can only submit claims for expenses incurred during the Plan Year while I am an active participant in the Plan. Such reimbursement requests
must be submit ed with appropriate documentation (claim form and proper receipts as defined in this guide) no later than 91 days after the end of the Plan Year or 90 days after termination of plan participation, whichever comes first. 7. All claims filed after March 31st for a charge that was incurred in the prior year, wil be ineligible.
8. My benefit account(s) and claim data may be maintained on a computer system providing automated access.
9. Participation in this Plan may mean paying less Social Security tax, which could reduce my future Social Security benefits.
10. Enrollment in the Medical Flexible Spending Account listed covers me and my eligible dependents, if any. I understand that FSA enrollment may
impact my eligibility, or eligibility of my spouse or dependent(s), for a Health Savings Account (HSA). I also understand that I cannot change or reduce my Medical FSA during the plan year in order to enroll in an HSA. 11. This document provides general information about a Flexible Benefit Plan. For more specific information, I will review my Plan's SPD.
12. Due to IRS non-discrimination rules for flex plans, in some circumstances the pre-tax elections of Highly Compensated Employees or Key
Employees must be adjusted mid-year to meet IRS compliance testing guidelines. If you are deemed to be a Highly Compensated Employee or Key Employee, your election may be reduced or discontinued in such a circumstance. If so, the benefits administrator wil provide notice and further details.
Flex Card (If offered by your plan)
After completing the Benny Card - Initial Signup on the Plan Participation Form, as an FSA participant you wil receive a Benny Card™ Visa Card and agree to use it according to these Acknowledgments and the Cardholder Agreement that wil be provided with the card. 1. I understand that the Flex Card is restricted to certain merchant categories and approved IIAS vendors and is not accepted at all Visa Card
authorized locations. 2. I understand that I may not obtain a cash advance with the card at any merchant, bank or ATM.
3. I understand that the card is to be used exclusively for Qualified Expenses as defined by the plan(s) in which I participate. If the card is used for an
expense that is not a Qualified Expense, I understand that I am indebted to my employer and must repay the full amount of the non-qualified expense. Repayment for non-qualified expenses may be in the form of an of setting claim or a personal check. 4. I acknowledge that IRS rules require me to save all invoices and receipts related to any expense paid with the card. I agree that, upon request, I
wil submit these documents for review by the Plan Service Provider. I understand that failure to submit a proper receipt in a timely manner wil cause the expense to be treated as a non-qualified expense and may cause my card to be suspended. 5. I understand that a proper receipt wil contain the following information: Patient Name, Provider Name, Date of Service, Details of Service and
Amount of Patient Responsibility. 6. I understand that I wil be assessed a $10.00 replacement card fee if I lose or misplace my card(s). I also understand that if I request more than
two cards, I wil be assessed a $10.00 fee for each additional card.
Direct Deposit Reimbursement Authorization Agreement
1. I hereby authorize Med-Pay, Inc. (hereinafter "Plan Service Provider") to initiate credit entries (electronic and otherwise) and, if necessary, debit
entries and adjustments for any erroneous credit entries to my Personal Bank Account in the financial institution named (hereinafter "Financial 2. This authority is to remain in force until the Plan Service Provider has received writ en notification from me of its termination in such time and
manner as to af ord Plan Service Provider and Financial Institution a reasonable opportunity to act on it. I can discontinue this arrangement at any time and receive reimbursements monthly by check. 3. I acknowledge that my Flexible Spending Account (FSA) information will be available to me 24 hrs/day by internet (www.hrbenefitsdirect.com/Med-Pay),
and that I will not receive written verification each time a reimbursement payment is made. Please complete, sign and return the Plan Participation Form in order for your election to
become effective. There is no automatic re-enrollment in your FSA plans.
Staying Informed
With 24/7 access to the secure online portal, www.hrbenefitsdirect.com/Med-Pay, you can:
 Make changes to your contact information  Add or change your direct deposit information  View account balances  Fill out and print a claim form  Che ck the s ta tus of your cla im s  Vie w im a ge s of cla ims you ha ve s ubm itte d through the porta l.  View Benny Log into your Med-Pay FSA account online portal:
First Time Users: Go to www.hrbenefitsdirect.com/Med-Pay and scroll down on the page until you see the blue Sign In box. Follow the instructions for "First Time Users" for your initial login. You will be prompted to choose a new user name and password for future use. Forgot user name and/or password: If you have logged in before but have forgotten your username and/or password, click the "Forgot Password?" link and follow the steps to have your login information reset, or you may call our FSA department at (417) 841-4134 or (800) 777-9087. Med-Pay, Inc. will mail direct deposit confirmations or checks with account balances to help you keep track of your account. Access to more
Flex-Eligible Items
Flexible Benefit Plan Participation Form
Please Print Clearly! Employer: OZARKS TECHNICAL COMMUNITY COLLEGE Division/Location: Plan Year: 01/01/2016 through 12/31/2016
Employee Name: Social Security # _ Birth Date: _
First Name Last Name
Mailing Address: _
Street City State Zip
Paycheck Frequency: _Weekly _ Bi-Weekly _ Semi-Monthly _ Monthly _ Other
Email Address: Home Phone: Cell Phone:
(If email is listed, this is how we will communicate with you)
Reason for Eligibility: _Timely Enrollment After Waiting Period _ Special Enrollment Open Enrollment
Flexible Spending Accounts:
Plan Year Benefit Elections: Effective Date _
Request to PARTICIPATE:
A. Unreimbursed Medical/Dental/Vision FSA (FSA) $ /Plan Year
Employer: Please Complete
The cost paid by you or your dependents for eligible expenses (Maximum $2,550/ Year)) FSA (MEDICAL) Per Pay Period Deduction amount: which is not reimbursed by insurance or any other party. B. Dependent Care FSA (DC AP) $ /Plan Year
FSA (DCAP) Per Pay Period Employment-related custodial care for qualifying dependents IRS Family Maximum $5,000/ Year) Deduction amount: (children age 12 and under or disabled dependent adults). First Paycheck Deduction Date: Request to WAIVE FSA/DCAP Participation:
The Flexible Benefit Plan has been explained, and I elect to waive participation in Flexible Spending Accounts. I Please Initial to Indicate Approval: understand that without a Change in Status or other Qualifying Event described in the Plan, my next opportunity to enroll will be at the start of the next plan year; if not changed, this waiver will continue in effect indefinitely. Flex Benny Card - ONLY for Initial Signup
Employer: Is employee a
I want a Benny Card. IMPORTANT: If you already have a Benny Card DO NOT complete this section. You will participant in your group automatically receive new cards in the mail just prior to your current card expiring. If you and/or your dependent have lost health plan? Yes No
your card(s), please call Med-Pay's FSA department. Direct Deposit Set-up
Type of Account:
IMPORTANT: Only include a voided check if this is a new election or your account
information has changed. You may add or change Direct Deposit information any time during the plan year by Please Check One:
logging into your account online www.hrbenefitsdirect.com/Med-Pay. I am signing up for Direct Deposit for the first time. I would like to change my Please tape a Voided Check here. account information. I would like to keep my (Do not use a deposit slip.) account information as is. Please remove the direct deposit A voided check supplies the account numbers and routing information required by the bank to establish
option and send checks for my your Direct Deposit arrangement. Deposit slips sometimes do not include all needed information.
reimbursements. By signing below, I certify that I have read the Flexible Spending Accounts Acknowledgments (enclosed) and, if applicable, the Benny Card Acknowledgments and/or the Direct Deposit Reimbursement Authorization Agreement. I agree to the terms of participation listed in this Guide. I authorize my employer to adjust my compensation by the amount of my Benefit Elections shown above. Signature: _ Date: _
Med-Pay, Inc., 1650 E Battlefield Ste. 300 · Springfield, MO 65804 ·Phone: (417) 841-4134 · (800) 777-9087 · Fax (417) 841-4117 · Email: [email protected]– Website: www.hrbenefitsdirect.com/Med-Pay

Source: https://hr.otc.edu/media/uploads/2016/04/Flexible-Spending.pdf