Sign Up and Save with FSAFEDS www.FSAFEDS.com

TEL: 877-FSAFEDS (372-3337)

TTY: 866-353-8058 Monday through Friday from 9 a.m. until 9 p.m., Eastern Time

Keep More of Your Money

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Open Season is November 14 through December 12, 2016

Deadline to Enroll

How to Get Started

With FSAFEDS, you can enroll in a Flexible Spending Account (FSA) and use pre-tax money to pay for eligible expenses for you, your spouse, and your eligible dependents. An FSA gives you a tax break – allowing you to keep more of your hard-earned money – and it’s simple to use.

How you use an FSA depends on the FSA you select. Just choose the FSAs that are best for you and your family:

During Open Season, you’ll need to register for an account on the FSAFEDS website. It’s a quick online process. Select New to this Site? to begin. After you’ve registered, log in to your online account, click Enrollment, and follow the step-by-step instructions to make your FSA elections.

To help with this process, you may also call an FSAFEDS Benefits Counselor toll-free at 877-FSAFEDS (372-3337) Monday through Friday from 9 a.m. until 9 p.m., Eastern Time. You must register your account before the end of Open Season.

Open Season begins on November 14, 2016. You have until Open Season closes at midnight Eastern Time on December 12, 2016 to enroll.

This booklet explains your options and how FSAs work. You can also find a wealth of information online at www.FSAFEDS.com. Browse the website to learn even more.

Since enrollment in an FSA is completely voluntary, you must choose to enroll or re-enroll each year – your participation will not automatically carry over from year to year.

Flexible Spending Account Covered Products or Services

Health Care FSA (HCFSA) Eligible medical, dental, and vision expenses

Limited Expense Health Care FSA (LEX HCFSA)(Select this FSA or the Health Care FSA, but not both.) Eligible dental and vision expenses

Dependent Care FSA (DCFSA) Eligible child or adult daycare services

Now’s the Time to Enroll

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What’s New through FSAFEDS During Open Season, USPS employees can enroll in FSAs through FSAFEDS. The FSA program will no longer be administered by UnitedHealthcare in 2017. The plan differences between UnitedHealthcare and FSAFEDS are highlighted below.

New Features and Plan Changes• Who can participate: Eligible employees (career and non-career) can participate in FSAFEDS

if they meet FEHB requirements.* Plus, USPS new hires can enroll in FSAFEDS during Open Season. There is no longer a one-year waiting period.

• Carryover: This is an exciting new feature because with Carryover, your “use or lose” risk is significantly reduced if you have in a Health Care FSA (HCFSA) or Limited Expense Health Care FSA (LEX HCFSA) through FSAFEDS. If you enroll in an HCFSA or LEX HCFSA for the 2017 benefit period, you can carry over up to $500 to your 2018 account if you re-enroll during Open Season next year.

Due to IRS rules, HCFSAs and LEX HCFSAs cannot have both Carryover and a grace period, so the Postal Service FSAs will no longer have a grace period under the FSAFEDS Program. Any balance above $500 in your 2017 HCFSA or LEX HCFSA account must be used by December 31, 2017, or it will be forfeited. If you still have money remaining in your 2016 FSA that’s administered by United Healthcare, you must use those funds by March 15, 2017. Dependent Care FSAs still have a 2 ½ month grace period in which employees must use FSA funds or they are forfeited. Carryover limitations do not apply to this FSA because of IRS regulations.

Visit the Explore Your Options webpage on www.FSAFEDS.com to find out which FSAs are best suited for you and your family.

* FEHB eligibility requirements: If you are eligible for the Federal Employees Health Benefits (FEHB) Program and are an active employee of the Executive Branch or of another agency that participates in FSAFEDS, you are eligible to participate in a Health Care FSA (HCFSA) with FSAFEDS. You need only be eligible to participate in FEHB – you do not need to be currently enrolled.

However, a Limited Expense Health Care FSA (LEX HCFSA) is different. You must be enrolled in a FEHB with a Health Savings Account (HSA), or have a spouse who is enrolled in a non-FEHB HSA-qualified HDHP and has an HSA, to enroll in a LEX HCFSA.

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• Reimbursement options: If you plan to enroll in a Health Care FSA, you have the option of using Paperless Reimbursement, which automatically reimburses your eligible health care, retail pharmacy, dental, and vision expenses under participating FEHB and FEDVIP plans. There is little or no paperwork involved, and in many cases, you will receive your reimbursement before your bill is due.

Or if you prefer, rather than reimbursing your claims automatically, your Health Care FSA or Limited Expense FSA expenses are saved to your online FSAFEDS account so you can decide if, how, and when you receive reimbursement. This option is called Pick and Process. Just identify your participating FEHB or FEDVIP plan during enrollment.

Please note: These two options are not available for a Dependent Care FSA. If you have this account, just submit your claims using the method that works best for you.

• Claims: While the FSAFEDS Program does not offer a debit card, there are several convenient claim submission options – including online, mobile app, fax and mail. Check out the FSAFEDS app – it’s the easiest way to manage your FSA. All 2017 FSA claims must be submitted by April 30, 2018.

Learn More!Visit the FSAFEDS website and review the Frequently Asked Questions. Or during Open Season, contact an FSAFEDS Benefits Counselor toll-free at 877-FSAFEDS (372-3337), TTY: 866-353-8058, Monday through Friday from 9 a.m. until 9 p.m., Eastern Time. Benefits Counselors will be happy to answer any questions you may have.

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Flexible Spending Accounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

FSAFEDS Eligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Health Care FSA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Limited Expense Health Care FSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Dependent Care FSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

How FSAs Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

FSAFEDS App . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Reimbursement and Payment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Receipt Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Orthodontia Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Claims Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

FSAs and Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Qualifying Life Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Leave Without Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Separation or Retirement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Military Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Additional Online Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Table of Contents

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A Flexible Spending Account (FSA) lets you to set aside part of your paycheck before taxes are taken out, and then you can use that tax-free money to pay for eligible expenses for you, your spouse, and eligible dependents.

With an FSA, you reduce your taxes by saving an average of 30% on the amount you contribute. You save on eligible health care and dependent care expenses that you may be paying for now out of pocket. The type of FSA you have determines which expenses are eligible.

Flexible Spending Accounts

Savings Example Without an FSA, you would still pay for these expenses, but you would do so using money remaining in your paycheck after federal (and often state and local) taxes are deducted.

Annual Tax Savings Example*Civil Service Retirement

System (CSRS)Federal Employees

Retirement System (FERS)

FSA NO FSA FSA NO FSA

If your taxable income is: $50,000 $50,000 $50,000 $50,000

Pre-tax FSA contribution: ($2,000) $0 ($2,000) $0

Taxable income: $48,000 $50,000 $48,000 $50,000

Federal income and Social Security taxes: ($8,886) ($9,395) ($11,842) ($12,495)

After-tax dollars spent on eligible expenses: $0 ($2,000) $0 ($2,000)

Available after tax income: $39,134 $38,605 $36,158 $35,505

Savings with an FSA: $529* or 26% $653* or 33%

*This example illustrates tax savings based on 25% federal and 7.65% FICA taxes, which results in savings on eligible expenses paid through an FSA. State and local taxes are not included. Actual savings will vary based on your individual tax situation, and on whether you are covered under Civil Service Retirement System (CSRS) or Federal Employees Retirement System (FERS). You may wish to consult a tax professional for more information on the tax implications of an FSA.

Find out how much you will save by using the FSA Savings Calculators on the FSAFEDS website.

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Plans Offered by FSAFEDS The types of products or services that are FSA-eligible depend on what type of FSA you have. Explore the following pages in this booklet to learn which programs are best suited for you and your family.

Type of FSA The Savings Power of this FSA

Health Care FSA (HCFSA)

• Pays for eligible medical, dental, and vision care expenses for you and your dependents – those not covered by your health care plan or elsewhere.

• It’s a smart, simple way to save money while keeping you and your family healthy and protected.

• Plus – you can carry over up to $500 remaining in your account from one plan year to the next, so the “use or lose” risk is significantly reduced.

Limited Expense Health Care FSA (LEX HCFSA)

• Helps you save on eligible out-of-pocket dental and vision expenses if you’re enrolled in an HSA-qualified, high deductible health plan and have a Health Savings Account (HSA).

• Plus – you can carry over up to $500 remaining in your account from one plan year to the next, so the “use or lose” risk is significantly reduced.

Dependent Care FSA (DCFSA)

• Pays for eligible dependent care services, such as preschool, summer day camp, before or after school programs, and child or adult daycare.

• It’s a smart, simple way to save money while taking care of your loved ones so you can continue to work, look for work, or go to school full-time.

• Dependent Care FSA does not cover dependent medical expenses.

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FSA Contributions

FSAFEDS Benefit Period

Once you decide which FSAs work best for you and your family, decide how much to contribute. With the savings calculators available at www.FSAFEDS.com, it’s easy to estimate your contributions and add up your savings.

The FSAFEDS benefit period (plan year) is January 1 through December 31 for an HCFSA or LEX HCFSA. After the benefit period ends for HCFSA and LEX HCFSA accounts, you can carry over up to $500 remaining in your account to the following year if you re-enroll in FSAFEDS.

For a DCFSA, the benefit period is January 1 through March 15 of the following year. It’s longer because a DCFSA has a grace period, but no Carryover.

Minimum and Maximums: The minimum contribution amount is $100. The maximum amount you can contribute to an HCFSA or LEX HCFSA is $2,600. And by law, the maximum amount that can be contributed to a DCFSA is $5,000 per household ($2,500 if married filing separately).

Availability of FSA Funds: After you enroll, the money for your FSA is deducted automatically from your paycheck before taxes are taken out.

• All HCFSA or LEX HCFSA funds are available on January 1 – the first day of the benefit period (plan year).

• DCFSA funds are only available when withdrawn from your paycheck and deposited into your account. Unlike the health care account, the money that you have set aside to pay dependent care expenses is only available for use as the funds are deducted from your paycheck.

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When to Enroll

Health Care FSA

The timing of your enrollment depends on your situation: • Current employees sign up for an FSA during Open Season.• New employees may enroll up to 60 days from their enter-on-duty date, but before October 1,

or wait for Open Season.• Enroll within 30 days following Open Season if unable to enroll during Open Season for reasons

outside of your control. Learn about Belated Enrollment on the FSAFEDS website.• Employees experiencing a qualifying life event, like marriage or the birth of a baby, have 60 days

from the date of the event to enroll in the FSAFEDS Program. This must be done before October 1 or you can wait for Open Season.

Why Enroll in a Health Care FSA?

• Use pre-tax funds and save an average of 30 percent on eligible health care expenses• Access the full amount of your account on day one of the FSAFEDS plan year• Carry over up to $500 from one plan year to the next when you re-enroll in a

Health Care FSA

FSAFEDS EligibilityAll USPS employees (career and non-career) can participate in FSAFEDS as long as they meet the FEHB eligibility requirements. You do not need to be enrolled in FEHB, just eligible to participate.

For a LEX HCFSA, you also must be enrolled in an FEHB with a Health Savings Account (HSA), or have a spouse who is enrolled in a non-FEHB HSA-qualified HDHP and has an HSA to enroll.

A Health Care FSA (HCFSA) is a pre-tax benefit account that may be used to pay for eligible medical, dental, and vision care expenses that may not be covered by your health care plan or elsewhere.

It’s a smart, simple way to save money while keeping you and your family healthy and protected. Plus, if you re-enroll in the FSAFEDS Program during Open Season, you can carry over up to $500 remaining in your account from one plan year to the next.

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How You Save With a Health Care FSA, you use pre-tax dollars to pay for qualified out-of-pocket health care expenses. The money you contribute to a Health Care FSA is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

And since you can carry over up to $500 remaining in your account from one plan year to the next, there’s no reason not to take advantage of the tax savings this year – and every year.

Examples of Health Care FSA Eligible Expenses• Medical expenses: co-pays, co-insurance, and deductibles• Dental expenses: exams, cleanings, X-rays, and braces• Vision expenses: exams, contact lenses and supplies, eyeglasses, and laser eye surgery• Professional services: physical therapy, chiropractic and acupuncture• Prescription drugs, insulin, and prescribed over-the-counter medicine• Over-the-counter health care items: bandages, pregnancy test kits, blood pressure monitors, etc.

Examples of Ineligible Health Care FSA Expenses• Cosmetic surgery and procedures, including teeth whitening• Herbs, vitamins, and supplements used for general health• OTC medicines without a prescription (except insulin)• Insurance premiums• Family or marriage counseling• Personal use items such as toothpaste, shaving cream, and makeup• Prescription drugs imported from another country

See more eligible and ineligible expenses under Support Center at www.FSAFEDS.com.

Over-the-Counter MedicinesAll over-the-counter (OTC) medicines or drugs (excluding insulin) require a doctor’s prescription to be eligible expenses. See the OTC Quick Reference Guide for more information at www.FSAFEDS.com. It’s located in Resources under Support Center.

OTC products that are not medicines or drugs (such as sunscreen, bandages or contact lens solution), and are purchased to alleviate or treat a medical condition are eligible items for reimbursement through an HCFSA without a prescription. Vitamins and other dietary supplements that are merely beneficial to the general health of an individual remain ineligible for reimbursement. Please refer to HCFSA Eligible Expenses under Support Center at www.FSAFEDS.com for details about specific OTC items.

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Limited Expense Health Care FSA

Why Enroll in a Limited Expense Health Care FSA?

Examples of Limited Expense Health Care FSA Eligible Expenses

• Maximize your tax savings with both an HSA and a Limited Expense Health Care FSA• Use pre-tax funds and save an average of 30 percent on eligible out-of-pocket dental

and vision expenses you have now, while using your HSA to save for future health care expenses

• Access the full amount of your account on day one of the FSAFEDS plan year• Carry over up to $500 from one plan year to the next when you re-enroll in a

Limited Expense Health Care FSA

If you’re enrolled in an HSA-qualified high-deductible health plan and have a Health Savings Account (HSA), you can increase your savings with a Limited Expense Health Care FSA (LEX HCFSA). This pre-tax benefit account helps you save on eligible out-of-pocket dental and vision care expenses

while taking advantage of the long-term savings power of an HSA. Plus, if you re-enroll in FSAFEDS during Open Season, you can carry over up to $500 remaining in your

account from one plan year to the next.

How You Save With a Limited Expense Health Care FSA, you use pre-tax dollars to pay qualified out-of-pocket dental and vision care expenses. The money you contribute to this account is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

• Vision exams• LASIK surgery• Contact lenses

• Eyeglasses• Dental cleaning• X-rays

• Fillings• Crowns• Orthodontia

Examples of Ineligible Limited Expense Health Care FSA Expenses• Insurance premiums• Medical expenses, including

deductibles, co-insurance, and co-pays

• Cosmetic procedures

• Expenses for services incurred after the coverage period ends

• Expenses reimbursed by an insurance provider or other health plan

• Personal use items, such as toothpaste, razors, and shampoo

• Dental whitening procedures and kits

Find a full list of eligible and ineligible expenses under Support Center at www.FSAFEDS.com.

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Dependent Care FSA

Why Enroll in a Dependent Care FSA?

Examples of Dependent Care FSA Eligible Expenses

• Use pre-tax funds and save an average of 30 percent on dependent care services• Reduce your overall tax burden – funds are withdrawn from your paycheck for deposit

into your account before taxes are deducted• Take advantage of several convenient, no-hassle payment and reimbursement options

A Dependent Care FSA (DCFSA) is a pre-tax benefit account used to pay for eligible dependent care services, such as preschool, summer day camp, before or after school programs, and child or adult

daycare. It’s a smart, simple way to save money while taking care of your loved ones so that you can continue to work, look for work, or go to school full-time.

How You Save With a Dependent Care FSA, you use pre-tax dollars to pay for qualified out-of-pocket dependent care expenses. The money you contribute to a Dependent Care FSA is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

• Care for your child who is under age 13 - Before and after school care - Babysitting and nanny expenses - Daycare, nursery school, and preschool - Summer day camp

• Care for your spouse or a relative who is physically or mentally incapable of self-care and lives in your home

Examples of Ineligible Dependent Care FSA Expenses• Money paid to your spouse, your child under

age 19, a parent of your child who is not your spouse, or a person that you or your spouse is entitled to claim as a personal tax exemption as a dependent

• Expenses related to care for a disabled spouse or tax dependent living outside your home

• Educational expenses (such as summer school and tutoring programs)

• Tuition for kindergarten and above• Food expenses (unless inseparable from care)• Incidental expenses (such as extra charges for

supplies, special events, or activities unless inseparable from care)

• Overnight camp• Health care related expenses (such as

prescriptions, copays, or OTC medicine) for your dependents

Check out more eligible and ineligible expenses under Support Center at www.FSAFEDS.com.

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Important: A Dependent Care FSA is not an account for your dependent’s health care expenses. If you have a Health Care FSA, you may use those funds to cover eligible health care expenses incurred by your spouse and dependents.

How FSAs WorkStep 1: Determine Your Annual ElectionIf you are eligible to participate in the FSAFEDS Program, decide how much to contribute to your FSA account based on how much you plan to spend in the upcoming year on eligible out-of-pocket expenses.• For Health Care FSA and Limited Expense Health Care FSA, you can contribute up to a

maximum of $2,600* to your account each year. Keep in mind, you may carry over up to $500 remaining in your account from one plan year to the next.

• For Dependent Care FSA, you can contribute to up to a maximum of: - $2,500 per year if you are married and file a separate tax return* - $5,000 per year if you are married and file a joint tax return or if you file as single or

head of household**• Your maximum contribution may not exceed these earned income limitations: - If you are single, the earned income limitation is your salary, excluding contributions

to your Dependent Care FSA - If you are married, the earned income limitation is the lesser of your salary, excluding

contributions to your Dependent Care FSA, or your spouse’s salary

* IRS annual contribution limit for 2017.** If you and your spouse are both eligible to contribute to a Dependent Care FSA through your respective employers, you and your spouse may not each claim $5,000. Please note you may not “double-dip” expenses (e.g., expenses reimbursed under your Dependent Care FSA may not be reimbursed under your spouse’s Dependent Care FSA and vice versa).

Please note: As an annual account, the money you contribute to your Dependent Care FSA must be used within the plan year and 2 ½ month grace period. So it’s important to estimate how much you spend on eligible dependent care expenses each year before you decide how much to contribute to your Dependent Care FSA. You will lose the funds remaining in your account after the benefit period ends.

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Step 2: Enroll to Start SavingAfter deciding how much to contribute to your account, enroll in the FSAs best suited for you and your family. After you’re enrolled, your funds are withdrawn automatically from each paycheck for deposit into your account before taxes are deducted. • For a Health Care FSA and Limited Expense Health Care FSA, the total annual election amount is

available on day one of your plan year.• For a Dependent Care FSA, as soon as your account is funded, you can use your balance to pay

for many eligible dependent care expenses. You may only use the funds that are available in your account, not the entire election amount.

How You Sign UpYou enroll in or renew your enrollment in your FSAs through FSAFEDS during Open Season each year. If you experience a qualifying life event (QLE), you can also enroll or make changes to your current FSA enrollment.

Step 3: Pay for Eligible ExpensesUse your FSA funds to pay for eligible expenses, and decide which reimbursement or payment option to use.

How to Use Your FSA FundsWith a variety of convenient reimbursement and payment options, your FSA makes it easy for you to get reimbursed for hundreds of eligible expenses and services. Learn more about your reimbursement and payment options in this booklet as well as on the FSAFEDS website.

How to Use Your AccountSimply log in to your FSAFEDS online account at any time to manage all aspects of your FSA:• Check account balances• Submit claims and view claims status• Look up eligible expenses• Select your reimbursement methods (by check or direct deposit)• Choose to receive account alerts by email or text

Or you can log in to your account any time with the FSAFEDs app. Just download this handy app to your mobile device and log in with the same username and password as your online account.

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You’ll love the convenience of the FSAFEDS app! It’s free, and the quickest way to manage your FSA – even on the go.

With the app, you can:• Check your balance• Submit claims by snapping photos of receipts• Sign up and receive account alerts by text or email• View and edit your account profile• Have your dependent care provider sign directly in the app to create an electronic receipt• Maintain a list of providers so you don’t have to retype contact information

Just download this free app to your mobile device, then log in using the same username and password as your online account. (Your account must be registered before you can use the FSAFEDS app.)

Submit Claims Anytime, AnywhereReady to use the app to submit a claim? Here’s what to do:• Log in and select Submit Receipt or Claim• Select whether to submit a claim or pay a provider• Follow the prompts to enter claim details• Use the app to take a photo of your receipt or upload

a photo from your mobile device• Tap Submit Claim to authorize the claim and finish

the submission

It’s that easy and you’ll send in your claim in a matter of moments.

App Store is a service mark of Apple Inc.

Google Play is a trademark of Google, Inc.

FSAFEDS App

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With a variety of convenient options, using your FSA dolars couldn’t be any easier. When enrolling, decide which option works best for you.

Reimbursement Options• Paperless Reimbursement: Enroll in paperless reimbursement, and when claims are filed with a

participating FEHB or FEDVIP plan, you will be automatically reimbursed for eligible out-of-pocket HCFSA expenses based on the claim information FSAFEDS receives from your plan. There is little or no paperwork involved, and in many cases, you will receive your reimbursement before your bill is due. Keep in mind this feature is only available if you enroll in an HCFSA. For more information about paperless reimbursement enrollment and more, see page 19.

• Pick and Process: This option gives you control over which medical, pharmacy, dental, and vision claims are paid using FSA dollars. If you choose this option, you will see an online summary of available claims to process in your online account. Simply select when you want any of them processed. To participate in this option, you must identify your FEHB and/or FEDVIP plan during enrollment.

Claims SubmissionSubmit your claim in one of three ways:

Online• Log in to your account. If this is your first time logging into your FSAFEDS account, you’ll need to

register first before logging in.• Once you have logged into your account, click Submit Receipt or Claim and select your

Reimbursement Option.• Follow the step-by-step instructions.• Upload digital copies of your itemized receipts (and other documentation, if needed).

FSAFEDS App• Log in to the FSAFEDS app using the same username and password as your online account.• Select whether to submit a claim or pay a provider.• Follow the prompts to enter claims details.• Take photos of your itemized receipts (and other documentation, if needed) or upload from

your mobile device.• Tap Submit Claim to authorize the claim and finish the submission.

Reimbursement and Payment Options

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Fax or Mail• Download the form you need from the File A Claim dropdown menu.• Fill in all the information requested on the form and sign it.• Fax or mail the form, along with copies of your itemized receipts

(and other documentation, if needed) to:

Fax866-643-2245 (toll-free) or 650-577-5340

MailFSAFEDS Program – ClaimsP.O. Box 14127Lexington, KY 40512-4127

Most payments are received in five to seven business days after you file a claim. For additional information, check out the Submitting Claims Quick Reference Guide. It’s located in Resources under Support Center at www.FSAFEDS.com.

Payment OptionsFSAFEDS also offers these convenient payment features:

Pay Me Back – Direct Deposit Set up direct deposit, and once a claim has been processed and approved, your reimbursement will be deposited directly into your bank account. This is the quickest and most secure way to receive your reimbursements. Plus, there’s no waiting around for a check in the mail.

To set up direct deposit:

1. Log in to your online account.2. Click Profile in the upper right-hand corner.3. Select Reimbursement Method buttons on the left menu.4. Enter your bank name, bank account number, bank routing number, and type of account.5. Click Save Changes to finalize the process. Please keep in mind it takes 7-10 business days

to establish direct deposit.

Pay Me Back – CheckHave a check mailed to you after a claim has been processed and approved.

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Pay My ProviderArrange for us to send payments directly to your health care or dependent care provider.

To pay a provider:

1. Log in to your online account.2. Select Submit Receipt or Claim.3. Choose Pay My Provider.4. Select the account that should pay your provider.5. Set up one-time or recurring monthly payment.6. Enter the required payment details and select Submit Claim.7. Upload digital copies of your invoices or receipts.

Paperless Reimbursement EnrollmentIf you enroll during Open Season, you will be prompted to sign up for paperless reimbursement. You can enroll or cancel your participation in paperless reimbursement throughout the benefit period, until September 30 – which is the last day to make changes before the next Open Season.

After Open Season, paperless reimbursement is effective the next business day after you enroll. Please be sure to manually submit claims covered under your FEHB plan and/or FEDVIP plan that are processed before paperless reimbursement is effective.

More Information about Paperless Reimbursement:• It does not change your relationship or obligations to your health care provider.• It doesn’t speed up the time it takes your provider to submit a claim to your FEHB

and/or FEDVIP plan. • It does not decrease the time it takes for your plan to process your claim. You are expected to

make payments for your out-of-pocket expenses as requested by your provider.• If you participate in paperless reimbursement, your FEHB plan or FEDVIP plan automatically

forwards your claims to FSAFEDS each week. It may take up to 10 to 12 business days from the time your FEHB plan submits your claim until your funds are deposited into your account via electronic funds transfer (EFT) – otherwise known as direct deposit.

• The payment schedule for retail and mail-order pharmacy vendors is generally longer than what you may experience for medical, dental and vision claims. That means, your pharmacy claims will most likely take longer for reimbursement.

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Receipt RequirementsFSAs are regulated by the Internal Revenue Service (IRS). IRS regulations state when filing a claim, your expenses listed must be incurred by you, your spouse, or eligible dependent during the coverage period and the dates noted on the claim. You must also file your claim with the appropriate supporting documentation. That means, save each and every receipt – you’ll most likely need it.

Health Care FSA and Limited Expense Health Care FSAYou must have a receipt or an explanation of benefits from your insurance carrier for each health care claim you submit against your account. For quick processing, make sure all receipts include these five pieces of information: Patient’s Name – the name of the person who received the service or for whom the item was purchased. For retail store purchases, this information may be excluded.Provider’s Name – the provider that delivered the service or the merchant where the item was purchased.Date of Service – the date when services were provided or the item was purchased.Type of Service – a detailed description of the service provided or item purchased. A pharmacy prescription receipt is sufficient for prescriptions.Cost – the amount paid for the service or product and/or the portion that is not reimbursed through your insurance carrier.

Please note: For some expenses, a Letter of Medical Necessity Form from a doctor may be required. You’ll find it in Other Forms under File A Claim at www.FSAFEDS.com.

Dependent Care FSAThere are three ways to submit a Dependent Care FSA claim:

1. Use the FSAFEDS app to have the dependent care provider certify the service by providing a signature on your mobile device.

2. Have the dependent care provider certify the service by signing the completed claim form.3. Submit a claim with an itemized statement from the dependent care provider.

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For quick processing, make sure receipts include the following five pieces of information:• Dependent’s Name – the name of the person who received the service.• Provider’s Name – the provider that delivered the service.• Date of Service – the date when services were provided.• Type of Service – a detailed description of the service provided.• Cost – the amount paid for the service. Dos and Don’ts of Receipts• DO use your insurance carrier’s Explanation of Benefits (EOB) statement for health care receipts,

especially if your insurance paid a portion of the expense.• DO make sure your receipt is legible; check that it isn’t too dark or light and that information is not

cut off.• DO include stamped provider information on handwritten receipts.• DON’T send credit card receipts, cancelled checks, or balance forward statements as they

typically do not include all five key pieces of information.• DON’T use highlighters on your receipts.

For an easy way to manage your receipts, take a photo of each receipt and store them in your FSAFEDS app.

Orthodontia ExpensesYou incur the expense for orthodontia work before submitting a claim for reimbursement, so it’s important to save your receipts. You’ll be able to submit a claim for expenses you pay during the current benefit period (plan year), even if the actual braces were put on before the current benefit period. Initial payments for orthodontia expenses can be reimbursed with a paid receipt.

However, you cannot be reimbursed for any work completed prior to your effective date in the plan. For details on eligible orthodontia expenses, view the Orthodontia Quick Reference Guide available in Resources under Support Center on the FSAFEDS website.

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Claims AppealsYou have the right to appeal any FSAFEDS denial that involves your Health Care FSA, Limited Expense Health Care FSA, or Dependent Care FSA. Common reasons for appealing a claim include:• A claim or request for reimbursement was not paid in full.• A product or service that you believe is an eligible expense was denied.• A request to change an election due to a qualifying life event was not approved.

Step 1: Informal AppealIf you disagree with FSAFEDS’ decision or need additional information about your claim denial, please contact an FSAFEDS Benefits Counselor within 30 calendar days from the date of the decision to request a more detailed explanation. You may contact an FSAFEDS Benefits Counselor toll-free at 877-FSAFEDS (372-3337), TTY: 866-353-8058, Monday through Friday from 9 a.m. until 9 p.m., Eastern Time.

Step 2: First-Level Written AppealIf you are not satisfied with the outcome of the informal appeal, you may request a formal appeal by following these steps:• Submit your appeal request in writing to FSAFEDS for reconsideration. You must send FSAFEDS

your written request within 60 calendar days of the initial decision. Be sure to sign your submission in order for it to be considered.

• Please include the following along with your written appeal request: - An explanation of why you disagree with the denial. Please base your appeal on specific

provisions outlined in the FSAFEDS Frequently Asked Questions (FAQs), IRS regulations that govern all pre-tax benefit programs, or other details at www.FSAFEDS.com.

- Copies of documents that support your claim, such as a physician’s Letter of Medical

Necessity, Explanation of Benefit (EOB) from your FEHB or other insurance plan, and/or detailed bills from your provider. If you choose, you may also submit information such as operative reports, medical records, or other medical details that support your claim.

• Fax or mail your appeal request and any necessary documentation to:

- Toll-free fax: 866-852-2599

- Mail: FSAFEDS Program – Appeals, P.O. Box 14800, Lexington, KY 40512-4800

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FSAFEDS has 30 calendar days from the date your request is received to do one of the following:

• Approve your appeal and process your claim.• Provide written communication that FSAFEDS has upheld the denial.

FSAFEDS will send you a notification of the outcome of your appeal. You will receive an email if you have an email address noted in your online account; if not, you will receive a letter in the mail.

Step 3: Second-Level Written AppealIf you do not agree with the FSAFEDS’ decision to uphold the denial, you have an additional 30 calendar days from the date of the denial to file another appeal for reconsideration. Please submit the appeal for reconsideration in writing and sign it prior to sending it to FSAFEDS.

Upon receipt of the second appeal, the FSAFEDS Appeals Committee will meet to review and ensure that your appeal has been handled properly. This procedure includes a claims processing review and consideration of any new documentation that you may submit. FSAFEDS will make a decision on your second-level appeal within 30 calendar days from the date that your request is received.

If the FSAFEDS Appeals Committee reverses the denial, your claim will be paid.

• If the FSAFEDS Appeals Committee upholds the original denial, you will be sent an email telling you why your claim does not meet IRS or Plan guidelines for reimbursement. The email will also let you know that you have the right to file a final appeal with FSAFEDS within 30 calendar days from the date of the denial, and it will be forwarded to an Independent Third Party for review. If FSAFEDS does not have your email address on file, a letter will be sent to the mailing address listed in your online account.

Step 4: Final Appeal for Independent Third Party ReviewIf you do not agree with FSAFEDS’ decision to uphold the denial of your second-level appeal, you will have an additional 30 calendar days from the date of the denial to file another appeal for reconsideration. The appeal must be sent for reconsideration in writing and you must sign it prior to sending it to FSAFEDS.

An independent third party reviews all documentation submitted for final appeal. The arbitrator has 30 calendar days from the date of your final appeal request to review your appeal and respond to you by email. If FSAFEDS does not have your email address on file, a letter will be sent to the mailing address listed in your online account. The final decision is binding and cannot be appealed further by you, the Postal Service, OPM, or WageWorks, Inc.

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FSAs and TaxesHealth Care FSA and Limited Expense Health Care FSAIf you use a Health Care FSA (HCFSA) or Limited Expense Health Care FSA (LEX HCFSA) to pay for eligible health care expenses, you cannot deduct those same expenses on your federal income tax return. However, your entire allotment (FSA contribution) is deducted from your pay before taxes are taken out, so it’s considered pre-tax.

If you itemize your medical expenses on your tax return, you can only deduct the amount of your total medical expenses that exceed 10 percent of your adjusted gross income (AGI). By contrast, when you use an HCFSA to pay for medical and health care expenses, you receive a tax deduction without having to meet the 10 percent AGI minimum. The money you allot to an FSA is also exempt from FICA (Social Security and Medicare) taxes, a deduction that is not available on your federal income tax return. If your eligible medical expenses exceed the 10 percent threshold by a significant amount, you might want to consult with a tax professional to determine which option is best for you.

Dependent Care FSAYou are not permitted to claim the same expenses on both your federal income taxes and Dependent Care FSA (DCFSA), although in certain situations you may be able to take advantage of both the DCFSA and the Child and Dependent Care Tax Credit.

If you have two or more qualifying individuals as dependents, the IRS allows you to apply up to $6,000 of dependent care expenses to your taxes. The maximum allowable under a DCFSA is $5,000, so you may apply the $1,000 incremental difference between the DCFSA maximum and the Child and Dependent Care Tax Credit if you have two or more dependents and your expenses exceed $5,000. The chart below helps to illustrate:

Please note: For the Child and Dependent Care Tax Credit, which is different than your DCFSA, you may use up to $3,000 of the expenses paid in a year for one qualifying individual, or $6,000 for two or more qualifying individuals. These dollar limits must be reduced by the amount of any dependent care benefits that you exclude from your income.

To determine which option is best for you, please seek guidance from your tax advisor.

Maximum Allowed Deduction DCFSA Federal Tax Credit

One Dependent $5,000 $3,000

Two or More Dependents $5,000 $6,000

Qualifying Life EventsA qualifying life event (QLE) allows you to enroll or change your FSA election (contribution). These events are defined by the IRS and include:• Change in your legal marital status (i.e., marriage, legal separation, divorce, or death of

your spouse)• Change in employment status (for you, your spouse, or dependent) that affects eligibility for

health insurance benefits• Change in your number of tax dependents• Birth or date you adopt a child, or placement for adoption• Death of your spouse or dependent• Change in your dependent’s eligibility (for example, your child reaches age 13 and is no longer

eligible under a DCFSA)• Change in your child care/elder care provider or cost or coverage, such as a significant cost

increase charged by your current daycare provider, or a change in your daycare provider. This applies to a DCFSA only. It does NOT apply to a HCFSA or LEX HCFSA.

Please note: A dependent is anyone you claim on your federal income tax return or someone claimed on a joint return you file with another.

How to Request a Qualifying Life EventIf you or your dependents experience a QLE, you may enroll or change your current election(s) in the FSAFEDS program. To report a QLE and change your election, submit a Qualifying Life Events Form that’s available in Other Forms under File A Claim at www.FSAFEDS.com.

Keep in mind that your requested change must be consistent with the event that prompted the election change.

Example: If you adopt a baby, you may want to increase your HCFSA and DCFSA elections to accommodate the added medical expenses and daycare costs you may incur for your new child. Or, you may wish to decrease your DCFSA if your spouse decides to stay home with your child and you no longer have eligible daycare costs.

If your requested change is due to the birth or adoption of a child, the change will be retroactive to the child’s date of birth, date of adoption, or placement for adoption, consistent with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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Additionally, you cannot reduce your HCFSA, LEX HCFSA or DCFSA election(s) below the amount already reimbursed or currently in your account balance.

After September 30 of any benefit period, only those QLEs resulting in a decrease in the annual election will be considered. QLEs resulting in an increase in the annual election or a first time enrollment will not be accepted due to the limited number of pay periods remaining in the calendar year. Learn more at www.FSAFEDS.com.

Leave Without PayDuring a period of Leave Without Pay (LWOP) or other non-pay status during the benefit period (plan year), your agency will not withhold your allotment (FSA contribution) during that time.

If you go into a period of LWOP and have not pre-paid your allotment, your FSAFEDS account will be frozen. You will not be eligible for reimbursement of any health care expenses incurred during the LWOP period until you return to pay status and your allotments are successfully restarted.

However, if you have a Dependent Care FSA, dependent care expenses you incur during your leave that meet IRS guidelines may be eligible for reimbursement.

Example 1: If you incur the expenses in order to allow you and your spouse to work, or for your spouse to attend school full-time, you may be reimbursed up to your account balance. When you return to pay status, FSAFEDS will recalculate your allotments based on the number of pay dates remaining in the benefit period.

During your period of LWOP, you can continue coverage that reflects your current election so that allowable expenses you incur during that time will be eligible for reimbursement. This can occur in one of two ways:

• Prepay your election by accelerating your allotments prior to your period of LWOP. Allowable health care expenses incurred during your leave will be eligible for reimbursement. If you have a DCFSA, dependent care expenses you incur during your leave will not be eligible for reimbursement unless they meet IRS guidelines for eligible expenses. To meet these criteria, you must incur the expenses as a result of you and your spouse, if married, needing to work, looking for work, or attending school full-time during the leave. Eligible expenses may be reimbursed up to your account balance.

• Freeze your account. You will not be eligible for reimbursement of any health care expenses incurred during that period until you return to pay status and your allotments are successfully restarted. You have until midnight Eastern Time on April 30 following the end of the benefit period to submit claims for eligible health care expenses incurred prior to your period of LWOP. If you return to pay status during the same benefit period your LWOP began, FSAFEDS will recalculate your allotments based on the number of pay periods remaining in the benefit period. You will forfeit any funds remaining in your account and will not be eligible for Carryover if your account is not fully funded or if it remains frozen during the rest of the benefit period.

Please note: that the only instance in which entering an LWOP status is considered a QLE is if an individual is activated to military service.

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Example 2: Let’s say you elected $1,300 for the benefit period to be deducted over 26 pay periods, resulting in a deduction of $50 per pay period. Then, you go on LWOP after eight pay periods ($400 already deducted). That leaves $900 of the $1,300 to be deducted from your pay for the rest of the year. You then return to pay status with nine pay dates remaining in the year. FSAFEDS would recalculate your allotments by spreading the remaining $900 over the remaining nine pay dates. Your “new” deduction would be $100 per pay period so that your account is funded in full by the last day of the year.

If your period of LWOP is related to a QLE, you have the additional option of canceling your election for the remainder of the year and reducing your coverage to the amount deposited at the start of your leave. Expenses you incur during your leave will not be eligible for reimbursement under any of your FSAs.

Example 3: Mike goes on LWOP effective October 1. He returns to his position the following January 15. Mike can file claims for Health Care FSA expenses incurred up to his October 1 leave date, but any expenses incurred from October through his January return date are ineligible for reimbursement, unless he prepaid his allotments.

Separation or Retirement The balances in your Health Care FSA (HCFSA), Limited Expense Health Care FSA (LEX HCFSA) and Dependent Care FSA (DCFSA) are treated differently if you separate or retire before the end of the calendar year.

Your HCFSA or LEX HCFSA will terminate as of the date of your separation or retirement. There are no extensions. Any eligible health care expenses incurred prior to the date of separation will still be reimbursed but those incurred after the separation date are not reimbursable, even if you accelerated your allotments. If you used your entire elected amount before FSAFEDS has deducted it from your pay, you will not be responsible for the remaining allotments.

Your DCFSA remaining balance can continue to be used to pay for eligible dependent care expenses until your account balance is depleted or the end of the calendar year, whichever comes first.

Please note: In order to take advantage of the 2 ½ month grace period for your DCFSA, you must be actively employed and making allotments through December 31 of the benefit period (plan year).

Example: Richard is enrolled in both an HCFSA and DCFSA for the benefit period but retires midway during the benefit year on July 1. He may only submit claims for health care expenses which are incurred prior to his July 1 separation date, but he can continue to incur dependent care expenses through December 31 of that benefit year or until his balance is depleted. He would not be eligible for the grace period under his DCFSA.

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Military DutyThe HEART Act (Public Law No. 110-245) contains tax benefits and incentives for individuals in military service. The HEART Act allows qualified reservists to receive a taxable distribution of their unused Health Care FSA (HCFSA) or Limited Expense Health Care FSA (LEX HCFSA). This taxable distribution is known as a qualified reservist distribution (QRD). FSAFEDS adopted the HEART Act, effective January 1, 2009.

FSAFEDS participants are eligible to request a QRD if they are enrolled in an HCFSA or LEX HCFSA and are:• A member of the Army National Guard, Air National Guard, Army Reserve, Navy Reserve,

Marine Corps Reserve, Air Force Reserve, Coast Guard Reserve or Reserve Corps of the Public Health Service, and

• Called to active duty for a period of 180 days or more, or for an indefinite period of time

Such eligible participants are referred to as qualified reservists.

You may want to request a QRD if you have a balance in your HCFSA or LEX HCFSA and think you might not be able to incur sufficient eligible expenses to deplete your account before your active duty commences.

Rather than forfeit those funds, you can have your balance refunded to you. The drawback is that the distribution will be taxable wages, and you give up your ability to submit eligible expenses for the remainder of the benefit period.

How to Request a Qualified Reservist DistributionIf you meet the requirements to request a QRD, you can submit a request form during the period beginning with the date of the order or call to active duty and ending on the last day of the benefit period during which the order or call to active duty occurs.

To request a QRD, download the HEART Act QRD Form in Other Forms under File A Claim at www.FSAFEDS.com. Complete and sign the form, then mail your completed form to the address noted on the form, along with a copy of your call to duty papers to FSAFEDS.

QRD requests will be processed as soon as possible, usually within two weeks of receipt. However, in some circumstances, it may take up to 60 days to process your request.

When your QRD is processed, it means that FSAFEDS has confirmed your refund amount and sent your refund to your payroll processor for action. It may take several pay periods from the time your payroll processor receives the refund to the time it shows up on your paycheck.

Refund DeterminationTo determine your refund, FSAFEDS calculates the current amount in your HCFSA or LEX HCFSA and subtract the amount of claims reimbursed. Once this balance is confirmed, you are notified of the exact dollar amount in your account.

Example: Let’s say you submitted all eligible claims for reimbursement on June 15. Your HCFSA annual election is $2,600, your total claims paid to date is $900 and your total allotment amount is $1,300. Within a short period of time, FSAFEDS approves your QRD request and sends you an approval letter via email. The total amount of your QRD is $400, which is calculated by starting with your total allotment ($1,300) minus the reimbursement amount ($900).

Receiving Your RefundYou will receive your QRD refund on your paycheck as taxable wages. After FSAFEDS processes your QRD request, FSAFEDS sends the refund to your payroll provider so they can include it in your salary. The refund amount will be subject to the same employment taxes and deductions as your other taxable salary.

After Requesting a QRDFSAFEDS will close your HCFSA or LEX HCFSA after yourQRD is processed. No further deductions will be takenfrom your pay for the remainder of the benefit period. For more information, check out the HEART Act FAQs at www.FSAFEDS.com.

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Additional Online ResourcesAt www.FSAFEDS.com under Support Center, you’ll find an online resource page. It’s filled with additional materials you may need to help you make the most of your FSA. See a listing of these available resources here for your convenience.

Forms and WorksheetsCapital Expense Worksheet (PDF) - Helps to determine if your expense is eligible

Dependent Care Tax Credit Worksheet (PDF) - Assists Dependent Care FSA participants in determining the best option between the federal tax credit and a Dependent Care FSA

Mileage Worksheet (PDF) - Helps to track mileage to and from a medical provider

Quick Reference GuidesAppeals Process (PDF) - Learn how the appeals process works regarding denied claims

Submitting Claims (PDF) - Know how to successfully complete an FSAFEDS claim form

Health Care Reform (PDF) - Check out how the health care reform legislation affected health care

Leave Without Pay (LWOP) (PDF) - Understand eligibility regarding a LWOP event

Orthodontia (PDF) - Know how to claim reimbursement for orthodontia expenses

Over-the-Counter (OTC) (PDF) - Learn which OTC expenses are eligible for reimbursement

Paperless Reimbursement (PDF) - Find out about the paperless reimbursement process, participating plans and how to enroll

Qualifying Life Events (QLEs) (PDF) - Understand which life events qualify as QLEs under an FSA, how they may affect your FSA election and how to let us know if you experience a QLE

Important Deadlines - View important dates and time frames for FSAFEDS

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Supplement InformationThe 2015 Federal Flexible Benefit Plan (FEDFLEX) (PDF) - The official plan document that governs FSAFEDS. This is a legal document that conforms to the IRS regulation that states a plan document must be available to participants. This is not a quick reference guide.

IRS Publication 502 (PDF) - Note: While insurance premiums are included in Publication 502, they are NOT reimbursable expenses for FSA purposes.

IRC Section 105 (PDF) - Information regarding Section 105 of the Internal Revenue Code and the treatment of medical expenses.

IRC Section 125 (PDF) - Information regarding Section 125 of the Internal Revenue Code covering cafeteria plans.

The information presented in this booklet is not all-inclusive, nor a guarantee of eligibility or payment. Eligibility will be determined by the applicable provisions of the plan, based on Internal Revenue Service regulations for FSA programs.

The term “savings” herein refers only to tax savings and actual savings are dependent on individual tax rates. No part of this document constitutes tax, financial, or legal advice. Please consult your advisor regarding your personal situation and whether this is the right program for you.

© 2014-2016 WageWorks, Inc. All rights reserved. WageWorks, Inc. is a third party administrator for FSAFEDS sponsored by the U.S. Office of Personnel Management.

FSAFEDS is Available to HelpIf you have questions or need additional information, please contact FSAFEDS. FSAFEDS Benefits Counselors are available Monday through Friday from 9 a.m. until 9 p.m., Eastern Time.

TEL: 877-FSAFEDS (372-3337)

TTY: 866-353-8058

www.FSAFEDS.com

FSAFEDS Program – Claims P.O. Box 14127 Lexington, KY 40512-4127

4184-FEDS (11/2016)