Flexible Spending Account Plan Enrollment Form

Employee Information






State:
Zip:





Flexible Benefit Plan Pre-Tax Elections
1. Health Care Spending Account (HCSA). Eligible health expenses include medical, dental, vision, and hearing expenses incurred by me or my dependents during the Plan Year for "the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body." See IRS Publications 969 and 502 for more information.
  To determine what your effective date will be, click HERE to check the benefit waiting periods.
         
     
$ X =
  Maximum Election allowed: $250 minimum/$2,700 maximum

2. Dependent Care Assistance Program (DCAP). Active state employees who are GIC health care benefits eligible and have eligible dependent care expenses, for a dependent child under the age of 13 and/or a disabled adult dependent, that are necessary for the employee (and spouse, if married) to be able to work may enroll in the DCAP program. Employees must work at least 18.75 hours in a 37.5 hour workweek or 20 hours per 40 hour workweek. To maintain eligibility, you must continually meet the hourly minimums. Employees hired during the Plan Year are eligible for DCAP on the first day of employment. Enrollment forms must be submitted to your Payroll Coordinator within 10 calendar days from your date of hire. Maximum $5,000 at beginning of plan year, $192.30 per biweekly pay period ($2,500 if married filing separately).
 
         
     
$ X =
  Maximum Election allowed: $5,000 ($2,500 if married filing separately)
Please note that the DCAP program has maximum elections based on Calendar year and household. There is a maximum of $192.30 per bi-weekly pay period.
Acknowledgement and Agreement

 


Flexible Spending Account Plan Terms and Conditions

I UNDERSTAND THAT:

  • By participating in the Flexible Benefit Plan, my employer will deduct from my pay check: $2.00 per month from the first monthly paycheck, and my pre-tax election amount from every paycheck, equally divided by the number of pay periods in the plan year.
  • I understand that the IRS defines eligible expenses and I am responsible for ensuring that my expenses are reimbursable.
  • I am responsible for knowing and abiding by the Plan rules, as outlined in the Plan Handbook, available at www.benstrat.com/gic-fsa.
  • I cannot change my election during the Plan Year unless I have a qualifying change in status as described in the Plan Handbook.
  • I am responsible for deciding how much to elect under the Plan(s) and for meeting all Plan deadlines. Expenses paid under the HCSA or DCAP cannot be reimbursed from any other source.
  • Expenses must be incurred during the Plan Year or the Grace Period. The Grace Period is a 2 ½ month period following the end of the Plan Year during which I may continue to incur expenses for the prior plan year. (July 1, 2020 - September 15, 2020).
  • The IRS imposes a strict "use-it-or-lose-it" rule, which means money left in a pre-tax account at the plan year end is forfeited.
  • I am responsible for ensuring that my claims are properly submitted to and received by Benefit Strategies on or before all applicable deadlines. All FY2020 claims must be received by Benefit Strategies by the claim Filing Deadline, which is October 15, 2020.
  • Qualifying expenses are those incurred by me or by my qualified legal dependents.
  • I can only use my Health Care Spending Account (Benefit Strategies) debit card for qualifying health care expenses as defined by IRS guidelines. The IRS requires me to keep documentation of all my card transaction expenses and submit documentation to the administrator, upon request. If I do not provide the requested documentation, IRS regulations require that the card be deactivated. Misuse of the card, including not submitting requested documentation, may result in permanent card revocation and required repayment of ineligible expenses.
  • If I have not enrolled to be reimbursed by Direct Deposit, I will be mailed reimbursement checks to my address on file. I understand that there is a minimum of $25.00 per mailed check, unless the plan year has ended.

Important Information Regarding Enrollment and Changes

ADMINISTRATIVE FEE

Participants pay a $2.00 monthly administrative fee, regardless of whether they enroll in one or both accounts.

ELIGIBILITY AND ANNUAL MAXIMUM AND MINIMUM FOR HCSA AND DCAP

HCSA: Active state employees who are GIC benefits eligible may participate in the HCSA program. Enrollment in one of the GIC’s benefit plans is not required. Employees must work at least 18.75 hours in a 37.5 hour workweek or 20 hours per 40 hour workweek. To maintain eligibility, you must continually meet the hourly minimums.  You may claim health care expenses under the HCSA plan for you, your spouse, and/or your eligible tax dependents for claims incurred after your plan participation effective date. Employees hired during the plan year are eligible on the first day of the month following 60 calendar days from the first date of employment or two calendar months, whichever comes first. You must submit your online enrollment within 10 calendar days from your date of hire. Minimum $250; Maximum $2,700.

DCAP: Active state employees who are GIC health care benefits eligible and have eligible dependent care expenses, for a dependent child under the age of 13 and/or a disabled adult dependent, that are necessary for the employee (and spouse, if married) to be able to work may enroll in the DCAP program. Employees must work at least 18.75 hours in a 37.5 hour workweek or 20 hours per 40 hour workweek. To maintain eligibility, you must continually meet the hourly minimums. Employees hired during the Plan Year are eligible for DCAP on the first day of employment. Enrollment forms must be submitted to your Payroll Coordinator within 10 days from your date of hire. Maximum $5,000 at beginning of plan year, $192.30 per biweekly pay period ($2,500 if married filing separately).

CHANGE IN STATUS

Elections may be changed if you experience a qualifying "change in status" and changes must be consistent with your qualifying event. The following life events may provide a change in status, per Internal Revenue Service rules. Changes in:

  • Legal marital status
  • Number of dependents
  • Employment status that changes your program eligibility
  • Work schedule that changes your program eligibility
  • Dependent satisfies or ceases to satisfy eligibility requirements
  • Certain judgments, decrees, or orders pertaining to child or spouse

To terminate your elections under a valid status change, enter a zero dollar amount in the HCSA/DCAP section(s) of the enrollment form. Payroll Coordinators must obtain the appropriate supporting documentation of your status change (e.g. a copy of a marriage or birth certificate). See the Participant Handbook for additional information, including Leaves of Absence and Leaving State Service. Change requests must be submitted online within 60 days of the qualifying event.

ELECTRONIC SIGNATURE AND COORDINATOR NOTIFICATIONS

Your E-signature is binding; your agency benefits coordinator will receive your enrollment information through Benefit Strategies' secure employer portal.

ELIGIBLE EXPENSES UNDER A DEPENDENT CARE ASSISTANCE PLAN (DCAP)

To qualify for DCAP reimbursement, your expenses must be work related (as defined by the IRS)*. Work related expenses enable you or your spouse to work or to look for work and are expenses for the protection and well-being of the dependent. Dependents must be under the age of 13 or, if older, not capable of self-care. Examples of eligible expenses might be:

  • Child Care centers, caring for six or more children and meet the IRS’ definition of a qualified day care center
  • Caregivers for a disabled spouse or dependent who lives with the participant and is not capable of self-care
  • Babysitters for work-related expenses
  • Before school or after school care
  • Day Camp (not overnight camps)
  • Household expenses, if a portion of such expenses are to ensure a qualifying dependent’s well-being and protection

EXAMPLES OF INELIGIBLE EXPENSES UNDER A DCAP

  • Expenses for services not yet provided, even if you must pay in advance
  • Babysitting for social events, or services that are not "work-related" as defined by the IRS
  • Education or tuition expenses (kindergarten or higher)
  • Overnight camp
  • Expenses incurred while you are not working or looking for work

Note: If you are divorced, only expenses incurred by the custodial parent may be considered

* See IRS Publication 503 for guidance on what expenses qualify or consult a tax professional. The IRS has rules regarding expenses paid to relatives and IRS Publication 503 provides some guidance on whether or not those expenses would qualify for DCAP reimbursement. You are responsible for ensuring your anticipated expenses are eligible for reimbursement prior to enrolling in this plan.

ELIGIBLE EXPENSES UNDER A HEALTH CARE SPENDING ACCOUNT (HCSA)

Eligible expenses are those that are medically necessary (as defined by the IRS)**, prescribed by a licensed practitioner, and are not reimbursed from another source. Examples of eligible expenses might be:

  • Copays
  • Deductibles
  • Coinsurance
  • Prescription vision expenses not covered by insurance
  • Dental care not covered by insurance

EXAMPLES OF INELIGIBLE EXPENSES UNDER A HCSA

  • Expenses for services not yet provided, even if you must pay in advance
  • Expenses paid under any other source (such as another insurance plan)
  • Cosmetic treatments, medications, or surgery (such as teeth whitening, face lifts, hair transplants, etc.)
  • Expenses for general health and well-being (such as fitness programs, exercise equipment, health club memberships, etc.)
  • Insurance premiums
  • Expenses that are not properly substantiated

** IMPORTANT: See IRS Publications 969 and 502 for guidance on what expenses qualify or consult a tax professional. Eligible expenses are discussed in the Participant Handbook available on the GIC’s website, www.mass.gov/gic/fsa. Additional information is also located at www.benstrat.com/gic-fsa. You are responsible for ensuring that your expenses are eligible.


THIS IS NOT TAX OR LEGAL ADVICE.
IF YOU HAVE QUESTIONS, CONSULT THE IRS OR A TAX PROFESSIONAL.