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Flexible Spending Account (FSA)
• Significant savings• 24/7 web access• Fast, efficient, convenient• The benefit that benefits everyone A Flexible Spending Account (FSA) Estimate Your Expenses: is an employee benefit plan established under IRC You can maximize your FSA account by planning Section 125 that allows you to pay for everyday health ahead carefully and using this helpful tool. You care, dependent care expenses and certain individual may also use the FSA calculator on our website, premium expenses with pre-tax dollars.
LifetimeBenefitSolutions.com. Some common items to consider are also listed in the chart: An FSA saves you money by reducing your taxable income. The FSA amount you elect will be subtracted Health Care Account
from your gross income. Federal, state and FICA taxes are then calculated on the lower amount. When you (or your spouse or dependents) incur an eligible expense, you'll receive reimbursement from the funds you've set Dental Expenses not covered by insurance aside from your paycheck.
Health Care Component: Vision Expenses (Exams, Glasses, Lenses) This account helps you save money on everyday out- Hearing Expenses (Exams, Hearing Aids) of-pocket medical expenses such as medical copays, Prescription Drugs coinsurance, prescription drugs, orthodontics, vision expenses, hearing aids, dental services, eligible Eligible Over-the-Counter Items over-the-counter (OTC) items and more. Qualifying Diabetic Supplies dependents for FSA purposes include children through Therapy (Physical Therapy, Speech, Chiro) the end of the year in which they turn 26.
Limited Purpose FSA: A limited-purpose FSA is much like a general-purpose Total Estimated Health Care Expenses health FSA. The main difference is that the limited-purpose account is set up to reimburse only eligible Dependent Care Account
FSA dental and vision expenses. These plans allow you Payment to Dependent Care Facility to contribute to an HSA as well.
Payment to Dependent Care Individual Dependent Care Component ($5000 maximum): Payment to Adult Care Provider This account helps you save money on daycare Total Estimated Dependent Care Expenses expenses for dependent children and adults so you can work. Qualifying dependents include children Total Health Care PLUS Dependent Care under age 13, whom you claim as a dependent on your federal income tax return (special rules apply for Know the Details: divorced parents), a disabled spouse and any other Be sure to budget for each account expense dependent on your tax return who resides with you and separately. Elections to and reimbursements from is physically or mentally disabled.
these accounts cannot be blended. Also, a use-it-or-lose-it provision may apply, so plan ahead carefully.
Plan Ahead for your FSA! You must re-enroll in this Plan each year. You cannot Planning ahead is important when signing up for your change your election during a Plan year unless you company's FSA Plan and understanding the benefits incur a qualifying life event, such as marriage/divorce, offered is critical. Read your Summary Plan Description (SPD) carefully to understand the specific terms of your Plan. The Plan Document governs your rights and benefits under each Plan and is available through your employer.
Claims Processing and Claims deadlines apply. Be sure to carefully read your Summary Plan Description (SPD) to understand the terms and deadlines associated with your Plan. Customer Service: Most of your questions can be answered by visiting the website. If you prefer to speak with a customer service representative, call 800-327-7130 Monday-Thursday from 8am EST to 5pm EST and Friday from 9am EST to 5pm EST. You can also email our Customer Service department at [email protected].
Go Direct or Go GreenReceive your reimbursement quicker, and avoid the $30 check minimum and a trip to the bank by completing a Direct Deposit form online. Provide or update your email address online and help Submit your claims online to receive the fastest us go green. You'll receive only plan related information reimbursement for an eligible out-of-pocket expense. such as account statements, claim related information Supporting receipts and documentation can be and Request for Information (RFI) letters (for Card scanned and attached to your online claim, or you can email, fax or mail the required paperwork. Another option is to download a paper Reimbursement Request form. Complete the form by itemizing your expenses Our mobile app enables you to easily and securely and following the instructions found directly on the access your health care spending accounts. You can form. Reimbursement Request forms and required view account balances and detail, submit claims, and documentation can either be mailed or faxed for capture and upload pictures of your receipts anytime, anywhere on iPhone, Android or tablet devices. Web AccessView your account online 24/7 via LifetimeBenefitSolutions.com.
While online, you can:• Submit claims for reimbursement• View claims history• Sign up for Direct Deposit• Check your available balance• Access forms such as Direct Deposit, Certification of Medical Necessity, Release of Information and various Reimbursement Request forms • Enter your email address to receive important Plan related materials• Use our online services, such as our online calculator to estimate your out-of-pocket expenses and our online eligible expense listing To access your account online, visit LifetimeBenefitSolutions.com and click on the Participants link. Select Reimbursement Accounts: FSA/HRA/HSA/QTB then click on the green login button. For detailed instructions on how to view your account online, click on the link for Login Directions to Your Reimbursement Account located under the green login button. Your initial username will be your social security number (or whatever identifier your employer provides). Your password will be the first letter of your first name (lower case) followed by your five digit zip code.
Qualifying Health Care ExpensesAcupuncture Drug overdose, treatment of Occlusal guards to prevent Eye examinations, eye Taxes on medical services Alcoholism treatment glasses, equipment and Telephone for hearing Artificial limbs Fluoridation services impaired persons Artificial teeth Guide dog; other service Television for hearing Asthma treatments impaired persons Hospital services Oxygen Physical exams Braille books and magazines Breast reconstruction surgery Preventive care screenings Transportation expenses following mastectomy Laser eye surgery; Lasik for person to receive Chelation therapy Lodging at a hospital or Psychiatric care similar institution Radial keratotomy Tuition evidencing separate Co-insurance amounts Mastectomy-related breakdown for medical Medical alert bracelet or Sleep deprivation treatment Smoking cessation programs Vision correction procedures Dental treatment Medical information Stop smoking program Drug addiction treatment Medical records charges Supplies to treat medical Obstetrical expenses Potentially Qualifying Health Care ExpensesA Certification of Medical Necessity Form must be completed by your physician.
AA meetings, transportation Dyslexia treatment Nutritionist's expenses Fitness programs Lactation consultant Occupational therapy Alternative healers Gambling problem, Personal trainer fees Automobile modifications Language training Lead-based paint removal Home improvements (such Lodging of a companion Ultrasound, prenatal Books, health related as exit ramps, widening Long-term care services Varicose veins, treatment of Car modifications doorways, elevator, etc.) Veterinary fees (service Childbirth classes Hormone replacement Mineral supplements Weight loss programs Ineligible Health Care ExpensesAppearance improvements Electrolysis or hair removal Late fees (e.g., for late Funeral expenses payment of bills for Tanning salons and Controlled substances in Hair removal and transplants medical services) violation of federal law Maternity clothes Cosmetic procedures Illegal operations and Missed appointment fees Qualifying Over-The-Counter (OTC) ItemsArthritis gloves Eye drops (Example: Visine) Orthopedic shoe inserts Bandages (Examples: Contact lenses, materials Pregnancy test kits Band- Aid, Curad, Ace) Blood pressure monitoring Glucose monitoring Dentures, denture adhesives Blood sugar test kits and Diabetic supplies (including Medical monitoring and Carpal tunnel wrist supports Ear wax removal products This is not a comprehensive list and is subject to change at any time and without notice.
Potentially Qualifying OTC Expenses Drug and Medicine items require a prescription completed by your physician and are not eligible for payment with the HealthSpending Card. Other items in this category require a Certification of Medical Necessity form completed by your physician.
Compression hose Probiotics Rehydration Cough suppressants Holistic or natural healers, solution (Example: and drugs and medicines Pediacare, Robitussin, Allergy treatment products; Incontinence supplies Sinus medications (Example: household improvements Decongestants (Examples: Insect bite creams and to treat allergies Dimetapp, Sudafed) ointments (Examples: Antacids (Examples: Maalox, Benadryl, Cortaid) Prilosec OTC, Zantac) Diaper rash ointments and Lactose intolerance tablets Sunburn creams and Antibiotic ointments (Exam- creams (Example: Desitin) (Example: Lactaid) ples: Bacitracin, Neosporin) Diarrhea medicine Laxatives (Example: Ex-Lax) Antihistamines (Examples: (Examples: Imodium, Medicines and drugs Benadryl, Claritin) Menstrual pain relievers Throat lozenges (Examples: Anti-itch creams (Examples: Dietary supplements Motion sickness pills Cepacol, Chloraseptic) Benadryl, Cortaid, Ivarest) Eczema treatments (Examples: Bonine, Toothache and teething pain Expectorants (Examples: relievers (Example: Orajel) Comtrex, Robitussin) Nasal strips or sprays Fiber supplements Nutritional supplements Pain relievers (Examples: Wart remover treatments Advil, Aspirin, Tylenol) Claritin, an allergy drug Hemorrhoid treatments Yeast infection medications Cold medicine (Examples: Example: Preparation H) Prenatal vitamins The IRS has not yet released a Comtrex, Sudafed) detailed and brand specific list of drugs and medicine.
Ineligible OTC ExpensesDental floss Feminine hygiene products Diapers or diaper service Shaving cream or lotion Perfume, Cologne Skin moisturizers, hand lotion Eligibility rules for OTC items may change. Drug and Medicine items require a physician's prescription, and may not be purchased with a Health Spending Card. The ability to pay for eligible items with the Health Spending Card may vary by merchant and is dependent on the merchant's IIAS system.
This is not a comprehensive list and is subject to change at any time and without notice. Items listed in each category may be reclassified into another category depending on future IRS guidance. Eligible Dependent Care Expenses• Care in your home, some- • Education expenses for • Day camp (not overnight) one else's home, or in a a child not yet in expenses if the camp daycare center for child care kindergarten, such as qualifies as a daycare and/or eldercare. Licensing nursery school expenses.
requirements may apply.
• Expenses paid to a relative • FICA and FUTA payroll • Registration fees for a are eligible, however, the taxes of the daycare relative cannot be under • Before and after school care age 19 or a tax dependent.
for children under age 13.
Note: This is not a comprehensive list.

Source: http://tstboces.org/wp-content/uploads/2015/06/Flexible-Spending-Account-Enrollment-Kit.pdf