Kent State University Flexible Spending Accounts Summary ... · Flexible Spending Account (DCFSA)...

Kent State University Division of Human Resources Flexible Spending Accounts – Summary Plan Description Revised 04/2016

Plan Year

January 1 – December 31

Division of Human Resources

University Benefits, Heer Hall

P.O. Box 5190

Kent, OH 44242

Kent State University Flexible Spending Accounts Summary Plan Description

of 18 Kent State University Division of Human Resources Flexible Spending Accounts – Summary Plan Description Revised 04/2016

Table of Contents

IMPORTANT CONTACT INFORMATION ................................................................................................................................ 3

FSA SUMMARY PLAN DESCRIPTION OVERVIEW ................................................................................................................... 4

INTRODUCTION ............................................................................................................................................................................ 4

ABOUT THIS BOOKLET ................................................................................................................................................................... 4

FOR MORE INFORMATION ............................................................................................................................................................. 4

HEALTH CARE FLEXIBLE SPENDING ACCOUNT ..................................................................................................................................... 5

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT ............................................................................................................................... 5

YOUR CONTRIBUTIONS .................................................................................................................................................................. 5

ELIGIBLE EXPENSES ....................................................................................................................................................................... 6

TAX ADVANTAGE .......................................................................................................................................................................... 6

SOME IMPORTANT RULES .............................................................................................................................................................. 7

A FINAL WORD ............................................................................................................................................................................ 8

FREQUENTLY ASKED QUESTIONS ......................................................................................................................................... 9

HOW THE PLAN WORKS ............................................................................................................................................................ 9

1. Am I eligible to participate in a Flexible Spending Account (FSA)?............................................................................. 9

2. When can I enroll in an FSA? ...................................................................................................................................... 9

3. When can I use my Health Care FSA? ......................................................................................................................... 9

4. When can I use my Dependent Care FSA? ................................................................................................................ 10

5. What is an eligible medical expense? ....................................................................................................................... 10

6. Are there expenses the Health Care FSA does not cover? ........................................................................................ 11

7. What is an eligible dependent care expense? .......................................................................................................... 11

8. Are there expenses the Dependent Care FSA does not cover? ................................................................................. 11

9. Will I be required to submit reimbursement forms or provide receipts for eligible expenses or services that I paid

for with my FSA Visa Debit Card? ...................................................................................................................................... 12

10. Can I change my FSA elections anytime? ............................................................................................................. 12

11. What if I am a new hire? ...................................................................................................................................... 12

12. What do I do when a qualifying event/status change occurs? ............................................................................ 12

13. What are some examples of a qualifying event or status change? ..................................................................... 13

14. When are Reimbursement checks or deposits issued? ........................................................................................ 13

15. Can I transfer any of my election amounts between my Health Care FSA and Dependent Care FSA? ................ 13

16. What if I am on an unpaid leave of absence? ...................................................................................................... 13

17. Can I terminate my participation? ....................................................................................................................... 13

HEALTH CARE FSA ORTHODONTIC REIMBURSEMENT GUIDELINES ................................................................................................... 15

18. How are the payments made from my Health Care FSA for Orthodontic treatments? ....................................... 15

IRS “USE IT OR LOSE IT” RULE .................................................................................................................................................. 16

19. What happens if I don’t use my entire election amount within the timeframe? ................................................. 16

APPEALING A DENIED CLAIM .................................................................................................................................................... 17

20. What if my request for reimbursement is denied? .............................................................................................. 17

GENERAL INFORMATION ABOUT THE PLAN ....................................................................................................................... 18


Benefits Services

[email protected]

Important Contact Information

Medical Mutual Flexsave 1-800-525-9252 2060 E. 9th Street www.mytakecareplan.com Dept. MZ04-2W-8317 (educational website) Cleveland, Ohio 44115 www.myflexonline.com

(participant website) Lost or Stolen Cards 1-866-679-7649

Impact (EAP) 1-800-227-6007 23240 Chagrin Blvd., #500 www.myimpactsolution.com Beachwood, OH 44122 Login: kent

Medical Mutual of Ohio 1-800-586-4509 P. O. Box 6018 www.medmutual.com Cleveland, OH 44101-1018

Anthem Blue Cross/Blue Shield 1-866-811-9727 P. O. Box 37180 www.anthem.com Louisville, KY 40233-7180

Caremark, Inc. 1-888-202-1654 Attn: Claims Dept. www.caremark.com P. O. Box 686005 San Antonio, TX 78268-6005

Delta Dental – PPO 1-800-524-0149 P. O. Box 9085 www.deltadentaloh.com Farmington Hills, MI 48333-9085

EyeMed 1-866-723-0514 Attn: OON Claims www.eyemedvisioncare.com P. O. Box 8504 Mason, OH 45040-7111

http://www.mytakecareplan.com/

http://www.myflexonline.com/

http://www.myimpactsolution.com/

http://www.medmutual.com/

http://www.anthem.com/

http://www.caremark.com/

http://www.deltadentaloh.com/

http://www.eyemedvisioncare.com/


FSA Summary Plan Description Overview

Introduction

Most employees pay some health care expenses out of their pockets each year that are not covered by the

University medical, dental or vision plans or their spouse's health care coverage. Many employees also have

dependent and elder care expenses that allow them to work. These expenses are normally paid after income

taxes have been withheld from your paycheck. This means you have already paid income taxes on the money

you use to pay those expenses. The Health Care Flexible Spending Account (HCFSA) and Dependent Care

Flexible Spending Account (DCFSA) offer you a way to pay those expenses, but save the taxes.

As you will see in this information, the tax savings can really add up. Because tax savings can be substantial, the Internal Revenue Service requires the University to follow some rules about participating in the FSA Plans, and the rules may seem a little intimidating. However, most of the rules are simply intended to make you plan carefully ahead of time. As with any tax or legal issues, you should always consider consulting your personal lawyer or tax consultant before making a decision to participate in an FSA account. The university does not provide legal or tax advice to employees for personal matters.

The FSA Program is intended to qualify as a “cafeteria plan” under the Internal Revenue Code and will be interpreted in a manner consistent with the requirements of Sections 125 of the Internal Revenue Code and the regulations thereunder. In addition, it is intended that benefits paid or expenses reimbursed to participants under the FSAs will be excludible from their gross incomes under the Internal Revenue Code.

About this Booklet The information contained in this SPD is intended to be used as a summary of and a general guide to the FSA Program. This SPD does not include all FSA Program details. The university has the sole authority to interpret the terms and conditions of, and address questions that arise under, the administration of the FSA Program. If any provision of this SPD conflicts with the terms of the FSA Program, the terms of the FSA Program shall prevail over this SPD.

Be sure to carefully read all of this information.

For More Information If you would like additional information about the FSA:

Contact Medical Mutual FlexSave at 1-800-525-9252 or access the Medical Mutual FSA participantwebsite at www.myflexonline.com. This site also allows enrolled participants to verify account balances,payment history, and claim details.

Contact University Benefits at 330-672-3107 or [email protected] for information regarding yourappointment classification, benefits eligibility, forms, and other general information.

Access the Human Resources Forms Library website at www.kent.edu/HR. Click on Benefits and FlexibleSpending Accounts. This website contains a copy of the FSA SPD, enrollment forms, reimbursement forms,FSA worksheets and a list of eligible and ineligible health care expenses. On this website there is also accessto the Medical Mutual FSA education website www.mytakecareplan.com.


mailto:[email protected]

http://www.kent.edu/HR



Health Care Flexible Spending Account

You make tax-free deposits through payroll deduction. The taxes you would have paid on that money stay inyour paycheck.

When you have an eligible expense (for example, a bill for an eye exam and contact lenses in excess of whatis covered by your vision plan), you are able to access the funds in your account in two different ways.

1. Use the FlexSave debit card to pay for the services2. Pay for the expenses out of pocket and then submit a claim form to FlexSave to receive

reimbursement

Dependent Care Flexible Spending Account You make tax-free deposits through payroll deduction. The taxes you would have paid on that money stay in

your paycheck.

When you have an eligible bill (for example, a bill for childcare or elder care expenses), you are able toaccess the funds in your account in two different ways.

1. Use your FlexSave debit card to pay for the services.2. Pay for the expenses out of pocket and then submit a claim form to FlexSave to receive

reimbursement.

Your Contributions You may enroll in either or both of the Accounts and you decide how much to contribute to each Account. Deposits to the Flexible Spending Accounts will be deducted in equal payments each month in which you receive your base pay. You can deposit any amount from a minimum of $120 and up to a maximum of $5,000 per year ($10 and $416 a month if you are paid over 12 months) in the HCFSA.

Important Note: The maximum contribution to the HCFSA is $2,500.

Most employees can deposit between a minimum of $120 and up to a maximum of $5,000 per year ($10 and

$416 a month if you are paid over 12 months) in the DCFSA. However, your maximum contribution will be less if

either of the following IRS restrictions applies to you:

If you are married and file separate income tax returns, you may deposit only up to $2,500 per year ($208 amonth) in the DCFSA.

Your annual DCFSA deposit cannot be greater than your annual income or that of your spouse, whichever is

lower. If your spouse is a full-time student, and you have one qualifying dependent, your spouse's annual

income is assumed to be $200 times the number of months he or she is in school. If you have more than one

qualifying dependent, your spouse's annual income is assumed to be $400 times the number of months he or

she is in school.


Eligible Expenses Health Care Flexible Spending Account

Many of the health care expenses that your medical, dental and vision plans do not pay can be reimbursed

through the HCFSA. Some eligible expenses under the HCFSA include:

Deductibles and co-insurance amounts under your medical and dental plans;

Orthodontia expenses;

Eyeglass and contact lenses expenses in excess of the vision plan coverage; and

Keep in mind, only expenses that have not been paid by your medical, dental or vision plan, or any other medical,

dental or vision plan, are eligible under the HCFSA.

Dependent Care Flexible Spending Account

The DCFSA reimburses you for the care of your eligible dependents that allow you, and your spouse, if you are

married, to work or attend school full-time. An eligible dependent is a child under age 13. Older dependents,

such as a spouse, parent, or older child, are also eligible if they are physically or mentally incapable of caring for

themselves, reside in your home at least eight hours per day, and are claimed as your dependents for income tax

purposes.

Examples of eligible expenses under the DCFSA include:

Day Care;

After-School Care; and

Home Health Worker

Services may be provided in or out of your home (but not in a nursing home) by someone who is not your

dependent for income tax purposes. Day care centers caring for six or more children must be licensed. In order

to receive tax-free Flexible Spending, the federal government requires you to provide the Tax Identification

Number (TIN) of your dependent care provider. The TIN for an individual is his or her Social Security Number.

Tax Advantage Like the pre-tax medical contributions, your contributions to the HCFSA and DCFSA are deducted from your

paycheck before any federal or state income taxes or Medicare contributions are withheld. That means the

money is tax-free when you put it into the Accounts, and it remains tax-free when you are reimbursed. The tax

savings offered by the HCFSA and DCFSA can be significant, even if you have a small number of eligible

expenses. Let's look at an example:

Assume you decide to go ahead with the dental work your dentist has recommended for your son and the

portion of the expenses that you will have to pay during any given year for a total $1,000. By depositing that

money in the HCFSA, you could save $250, assuming combined federal and state income taxes and

Medicare contributions of 25%. If you were in a 35% combined income tax bracket, your total savings would

increase to $350.

Now, let's look at an example where the tax savings can be even greater:


Assume you are married, and you and your spouse both work full-time. Your day care expenses for your

child total $2,500 a year. If you are in a 25% combined tax bracket, you can pay the $2,500 through the

DCFSA and save about $625 a year in taxes. That stays in your pocket. If you were in a 35% combined tax

bracket, your savings would increase to about $875.

DCFSA vs. Federal Childcare Tax Credit

The federal government offers a tax credit on the same types of dependent care expenses that are reimbursed through the DCFSA. You cannot claim the same expenses under the Federal Childcare Tax Credit that you have already received Flexible Spending for under the DCFSA. In fact, any Flexible Spending you receive from the DCFSA reduces, dollar for dollar, the amount of tax credit that is available to you. For most employees, that means you will have to choose either the DCFSA or the tax credit. You may wish to discuss which method works best for you with your own personal tax advisor. In general, most employees with total household adjusted gross incomes greater than $28,000 will benefit more from using the DCFSA. Employees with total household adjusted gross incomes of less than $20,000 will benefit more from the tax credit. If your total household income is between $20,000 and $28,000 you should consult a tax advisor.

Some Important Rules In exchange for the tax savings offered by the Flexible Spending Accounts, the Internal Revenue Service

imposes some important rules:

The amount you elect to deposit in each of the Flexible Spending Accounts stays in effect for the entire planyear. No changes can be made except under limited circumstances. HCFSA deposits and DCFSA deposits can be increased, decreased or stopped, but only if you have an eligible change in family or work status. Changes in family and work status may include events like a marriage, divorce, birth or adoption of a child, loss of a dependent or a change in your spouse's employment status. This must be communicated within 31 days of the event or no changes can be made.

You will have until March 15th of the following year after your contributions were made to accumulate yourexpenses. For example, if you contributed to a HCFSA this year, you can submit eligible health care expensesincurred through March 15 of the following year. This gives you a better opportunity to use the fundsaccumulated in your account for payment of expenses and cuts down on your chances of forfeiting anyunused funds.

The Dependent Care Flexible Spending Account (DCFSA), also administered by Medical Mutual, will allowyou to contribute up to $5,000 each year on a tax-free basis to pay for daycare expenses.

This DCFSA cannot be used for childcare providers who do not report their earnings for income tax purposes. For any remaining balance, all expenses must be incurred between January 2016 and March 15, 2017. You cannot use your FlexSave debit card for expenses incurred during this period; you must pay out-of-pocket and submit a claim form to FlexSave for reimbursement. All claims must be submitted by June 29, 2017.

Please remember, if you do not use the funds in your Health Care or Dependent Care Flexible SpendingAccounts by the dates specified, they will be forfeited as required by IRS regulations.

Like most tax-qualified plans, Flexible Spending Accounts are subject to certain nondiscrimination tests thatmay require you to reduce your deposit. If you are affected, you will be notified.


These rules show how important it is for you to plan carefully. Only deposit enough money in the Accounts to cover

expenses you are sure you will have during your enrollment year. The worksheets included in this information will

help you calculate your likely expenses for the year.

But, keep in mind, even if you forfeit a small amount of money, the tax savings may more than make up for your loss.

A Final Word The Health Care Flexible Spending Account and the Dependent Care Flexible Spending Account are excellent

ways to set aside money for your vision, dental and medical expenses or dependent care expenses and savetaxes at the same time.

However, if you do not use the money in your account(s) during the Plan year, IRS regulations require that youforfeit any money left unused in your account.

Be sure and ask any questions you have about the Flexible Spending Accounts at your employee meeting. Youcan also call University Benefits with questions at 330-672-3107.


Frequently Asked Questions1

HOW THE PLAN WORKS

1. Am I eligible to participate in a Flexible Spending Account (FSA)?Full-Time benefit-eligible faculty and staff are able to participate in the FSA. If you are unsure whether you areeligible to participate in the FSA, you should contact University Benefits in the Human Resources Departmentat 330-672-3107 or [email protected].

Important Note: You do not need to enroll or participate in the university’s medical or dental plans in order to participate in an FSA.

2. When can I enroll in an FSA?You may enroll during the following times:

During annual open enrollment;

Within 31 days of employment in an eligible appointment; or

Within 31 days of a qualifying event/status change, as described in “Question #12” below.

Important Note: Re-Enrollment in an FSA is NOT automatic. You must re-enroll each plan year if you would like to

participate in an FSA.

3. When can I use my Health Care FSA?

An eligible health care expense must be incurred before you can be reimbursed from your Health Care FSA.

You “incur” expenses when the care is provided, rather than when you are billed or pay for the care with the

exception of orthodontia expenses.

When you have an eligible expense (s) (for example, a doctor’s office visit or prescription co-pay), you are

able to access the funds in your account in two different ways.

1. Use the FlexSave debit card to pay for the services at the point of service,

2. Pay for the expenses out of pocket and then submit a claim form to FlexSave to receive reimbursement,

Your contributions will accumulate in your Health Care FSA during the plan year. Your annual

election amount is available on day one of the plan year.

Eligible expenses for which you are requesting reimbursement must be incurred during the plan year

or the grace period (January 1 of the current plan year – March 15 of the following year), subject to

your eligibility to participate in the FSA.

1 This FAQ is provided for informational purposes and should not be considered legal or tax advice. If you are planning to

participate in an FSA plan, you may wish to consult a personal tax specialist.



There is a minimum disbursement limit of $5.

The money reimbursed from your Health Care FSA is paid directly to you. A paper check will be sent

to your home address on file with the university or a direct deposit will be made to the bank account

on file with FlexSave. It is your responsibility to pay the service provider for incurred expense.

Requests for reimbursement from your Health Care FSA must be submitted no later than June 30 following

the end of the plan year. Any unused amounts remaining in your Health Care FSA after this deadline must be

forfeited. See “IRS Use It or Lose It Rule” section of this SPD.

4. When can I use my Dependent Care FSA?Funds are available upon deposit after payroll deduction. An eligible dependent care expense must be

incurred before you can be reimbursed from your Dependent Care FSA. You “incur” expenses when the care

is provided, rather than when you are billed or pay for the care.

If you incur an eligible dependent care expense, you are able to access your account in two different ways:

1. Use the FlexSave debit card to pay for the services

2. Pay for the expenses out-of-pocket and then submit a claim form with proof of payment to MedicalMutual FlexSave to receive reimbursement

Important Note: You can be reimbursed only up to the then current balance in your Dependent Care FSA when you file the request for reimbursement.

Eligible dependent care expense for which you are requesting reimbursement must be incurred during theplan year or the grace period (January 1, 2016 – March 15, 2017), subject to your eligibility to participatein the FSA.

There is a minimum disbursement limit of $5.

The money reimbursed from your Dependent Care FSA is paid directly to you. A paper check will be sentto your home address on file with the university, or a direct deposit will be made to the bank account onfile with FlexSave. It is your responsibility to pay the service provider for the incurred expense.

Requests for reimbursement from your Dependent Care FSA must be submitted no later than June 29,2017 following the end of the plan year. Any unused amounts remaining in your Dependent Care FSAafter this deadline must be forfeited. See the “IRS Use It or Lose It Rule” section of this SPD.

5. What is an eligible medical expense?The following list, while not intended to be complete, illustrates expenses that may be reimbursed under the

Health Care FSA. Restrictions may apply. For detailed explanations of these expenses, or for additional

information regarding eligible health care expenses, you should review the list online at

www.mytakecareplan.com .



Deductibles–expenses for which you may be required to pay under a medical, dental, vision or

prescription drug plan, prior to the plan paying its portion of remaining eligible expenses.

Copayments/Coinsurance–your payments or share of the cost for medical, dental, vision, or prescription

drug expenses.

Services with age or frequency restrictions–your costs for health plan services that have plan limitations.

Certain services not covered by your health plan (provided they meet the definition of an eligible expense,

as stated above).

Breast pumps and supplies that assist lactation are also eligible expenses.

6. Are there expenses the Health Care FSA does not cover?

Yes. For detailed explanations, or for additional information regarding ineligible expenses, you should review

the information online at http://www.mytakecareplan.com

7. What is an eligible dependent care expense?

The following list, while not intended to be complete, illustrates expenses that may be reimbursed under the

Dependent Care FSA. Restrictions may apply. For detailed explanations of these expenses, or for additional

information regarding eligible health care expenses, you should review the list online at

http://www.mytakecareplan.com.

1) Day Care;

2) After-School Care; and

3) Home Health Worker

8. Are there expenses the Dependent Care FSA does not cover?IRS Publication 503 also outlines examples of expenses that are not eligible for reimbursement from your DependentCare FSA. According to the IRS, the following expenses are not eligible for reimbursement from your Dependent CareFSA:

Expenses incurred for child care for a domestic partner’s dependent child(ren) unless the individual is your taxdependent.

Non-employment related care, such as baby-sitting fees during nonworking hours.

Payments for care provided by a child’s parent or step-parent (e.g., your former spouse who is the child’s non-custodial parent).

Convalescent or nursing home expenses for a parent of a disabled spouse.

Overnight camp expenses.

Educational expenses for a child in kindergarten, first grade or above. Certain kindergarten expenses may be eligibleif you can demonstrate that all or a portion of the expenses are primarily for the care of a child (and not educational in




nature). Kindergarten expenses that are strictly educational in nature (and billed as tuition) are not eligible for reimbursement.

Child care expenses that enable you or your spouse to do volunteer work.

Health care expenses for your dependents.

9. Will I be required to submit reimbursement forms or provide receipts for eligible expenses or services that I paid for with my FSA Visa Debit Card?

In most instances, you will not need to provide receipts/documentation for expenses or services paid for with your FSA Visa debit card.

Medical Mutual uses a substantiation (validation) process to “match” charges from EOB’s to debit card

swipes. However, listed below are some examples of instances where you may be required to submit

receipts/documentation or complete a reimbursement form:

a) The first time you use your FSA Visa debit card for a recurring expense (e.g. out of pocket

expenses for physical therapy, orthodontia or chiropractor visits, etc.)

b) Your FSA debit card is used to pay for vision claims or dental claims

You may contact Medical Mutual FlexSave at 1-800-525-9252 if you have additional questions concerning

your Health Care or Dependent Care Flexible Spending Account

10. Can I change my FSA elections anytime?No. The amount you elect to deposit in each of the Flexible Spending Accounts stays in effect for the entireplan year. No changes can be made except under limited circumstances. Flexible Spending Account depositscan be increased, decreased or stopped, but only if you have an eligible qualifying event/ status change. Seequestion #12 for more information.

11. What if I am a new hire?You must enroll within 31 days of your date of hire (or the date you become employed in an eligible appointment) in order to participate in an FSA. In this case, the election you make will be in effect for the remainder of the current plan year.

If you do not enroll within the 31-day period, you may not have the opportunity to participate in an FSA untilthe next plan year.

12. What do I do when a qualifying event/status change occurs?If a qualifying event/status change occurs, you must complete an FSA Election Form, available online at http://www.kent.edu/hr/forms/ to make changes to your FSA election(s). Documentation is required for qualifying event/ status changes.

The completed form must be submitted to the Office of Human Resources Benefit Services department within 31 days of the change in status. Qualifying event/status changes must be approved.

http://www.kent.edu/hr/forms/


Changes to your coverage and contributions will be effective as of the date of the qualifying event/status change.

Important Note: If you do not complete and submit an FSA Election Form within 31 days of the date of the qualifying event/status change, you will not be allowed to make a change until the next annual open enrollment period or upon the occurrence of a future qualifying event/status change.

13. What are some examples of a qualifying event or status change?Qualifying events/status change events include:

Change in your legal marital status (marriage, death of a spouse, divorce, annulment);

Change in the number of your dependents (birth, death, adoption or placement for adoption);

Change in your employment status or the employment status of your spouse or your dependents(termination or commencement of employment, strike or lockout, commencement of or return from anunpaid leave of absence);

Change in your employment status or the employment status of your spouse or dependent that results inthe individual becoming eligible, or ceasing to be eligible, under any cafeteria plan or other employeebenefit plan of your employer or the employer of your spouse or dependent;

Event that causes your dependent to satisfy or cease to satisfy the requirements for coverage due toattainment of age or any similar circumstances; or

Significant change in cost of coverage (Dependent Care FSA only)

14. When are Reimbursement checks or deposits issued?Checks and direct deposits are processed daily and reimbursement requests may be as low as $5.00.

15. Can I transfer any of my election amounts between my Health Care FSA and Dependent Care FSA?No. You cannot transfer funds between your accounts. Furthermore, any amount remaining in your Flexible Spending Accounts at the end of the reimbursement period will be forfeited. See the “IRS Use It or Lose It Rule” section of this SPD.

Carefully calculate the amount that you contribute to your Health Care or Dependent Care Flexible Spending

Accounts. The Flexible Spending Accounts Worksheet, available online at http://www.kent.edu/hr/forms

can help you estimate your out-of-pocket eligible expenses.

16. What if I am on an unpaid leave of absence?In the event you are on an unpaid leave of absence, you must contact the Benefits Office to make arrangements to continue payments in order to maintain your benefit while you are on leave.

17. Can I terminate my participation?In general, your participation in an FSA will terminate on the earliest of the following:

December 31 of the applicable plan year (i.e., the last day of the plan year for which the benefit was

http://www.kent.edu/hr/forms


elected). In this case, you must re-enroll in an FSA during the annual open enrollment period to participate in an FSA during the following plan year

Because of a qualifying event/status change, the date you revoke your election to participate in an FSA.You must contact University Benefits at (330) 672-3107 or [email protected] within 31 days of thequalifying event/status change occurrence;

The date you transfer to an ineligible appointment or no longer meet the eligibility requirements; or

The date the university terminates the FSA Program.

The date your employment with the university terminates, including due to your retirement; you mustsubmit reimbursement requests for expenses that were incurred during your employment toward thebalance in your FSA within 30 days of your separation date.



HEALTH CARE FSA ORTHODONTIC REIMBURSEMENT GUIDELINES Orthodontic treatment is typically rendered over an extended period of time. Orthodontists typically bill for services in one of two ways: (1) upfront deposit plus monthly payments over the course of treatment or (2) upfront payment in full. In both cases, visits to the orthodontist for treatment may occur several times a month, or once every few months for adjustments.

The university allows reimbursement for pre-paid orthodontia expenses, up to your Health Care FSA election amount, regardless of the date of service. The payment must have been made during the applicable FSA plan year. Only the portion of your orthodontic payment(s) that are not paid by your dental insurance or any other plan is considered an eligible expense.

Important Note: Orthodontia differs from other dental procedures that require the actual service to be performed

and paid for within the FSA plan year.

18. How are the payments made from my Health Care FSA for Orthodontic treatments? Initial orthodontia services, such as moldings, diagnostic records fees, consultation fees, etc., are

reimbursable when performed if the expenses are separate from the contracted treatment. Theseexpenses are typically not included in the total treatment cost for orthodontia and would require a fullycompleted claim form with an itemized bill. If these services are performed during the FSA plan year inwhich you are requesting reimbursement, they will be considered eligible expenses.

It is a common practice for providers to require an upfront deposit before the start of orthodontiatreatment. This expense is eligible for reimbursement with a fully completed claim form, an itemized billindicating the upfront deposit and proof of payment.

A monthly liability for orthodontic treatment is reimbursable from:- An orthodontist coupon booklet indicating monthly payments.- A paid receipt.- A monthly statement.

Finance charges are not eligible for reimbursement.

If payment is made in full for the orthodontic treatment, and proof of payment is included with thecompleted claim form, the full payment amount will be reimbursed up to your Health Care FSA electionamount.


IRS “USE IT OR LOSE IT” RULE

19. What happens if I don’t use my entire election amount within the timeframe?You should carefully calculate the amount you contribute to a Dependent Care FSA and/or a Health CareFSA for a particular plan year. The Flexible Spending Accounts Worksheet, available online athttp://www.kent.edu/hr/forms/benefits/upload/health-care-dependent-care-flexible-spending-account-bulletin.pdf, can help you estimate your out-of-pocket expenses.

This is very important because there are no exceptions to these rules:

The IRS requires that any amount remaining in your FSA(s) at the end of the reimbursement period(January 1, 2016 through March 15, 2017) be forfeited. This is known as the IRS “use it or lose it” rule.

You cannot transfer money from one FSA to another. In other words, you cannot use your DependentCare FSA to reimburse health care expenses and you cannot use your Health Care FSA to reimbursedependent care expenses.

Important Dates and Deadlines For FSA Plan Year 2016, subject to your eligibility to participate in the FSA

Program Plan Year January 1, 2016– December 31, 2016 Your pre-tax payroll contributions will

be made during the plan year, which is a 12-month period.

Incurred Claims Window (including grace period)

January 1, 2016 – March 15, 2017 You may use the funds in your FSA(s) for incurred eligible expenses during the plan year and the grace period January 1 of the current plan year through March 15 of the following year. The plan year plus the grace period is a 14.5-month period.

Reimbursement Period January 1, 2016 – June 29, 2017 You may request reimbursement for eligible expenses incurred during the reimbursement period.

Reimbursement Filing Deadline

June 29, 2017 All requests for reimbursement must be received by FlexSave no later than June 30 of the following plan year, or you will forfeit the unclaimed balance in your FSA(s).

Resignation/ Separation /Retirement

During the Plan Year Requests for reimbursement must be submitted within 30 days of separation

http://www.kent.edu/hr/forms/benefits/upload/health-care-dependent-care-flexible-spending-account-bulletin.pdf




APPEALING A DENIED CLAIM

20. What if my request for reimbursement is denied? If a claim under your Health Care FSA or Dependent Care FSA is denied in whole or in part, you will receive a written

notice. The notice will be provided within 30 days and will include the following:

-A description of any additional material or information necessary for you to perfect the claim and/or reason for theclaim denial.

Forward any additional information and documentation as requested to Medical Mutual FlexSave.

If your claim continues to be denied and you wish to file an appeal, you may request a review of the denial claim by

completing a benefits appeal form within 60 days after you receive the notice described above. A decision will bemade on the appeal within 31 days after the request for review is received, unless additional time is necessary inwhich case a decision will be made no later than 60 days after the request for review is received.

Please forward your appeal to the Plan Administrator

Kent State University

Loretta B. Shields, PHR, Executive Director, Benefits & Wellness

Heer Hall

P. O. Box 5190

Kent, OH 44242-0001

(330) 672-8314

[email protected]

Please contact University Benefits at 330-672-3107 or [email protected] if you have questions or to receive an appeal form.

All determinations by the University’s FSA administrator are final and binding. You must exhaust the claims andappeal procedures of the FSA before you may file suit in court. If you exhaust those procedures and decide to file suitin court, that suit must be brought within 180 days following the date that the decision to deny your appeal was made.



General Information About the Plan

The university unilaterally reserves the right to amend or modify the FSA Program at any time and for any reason or no reason, except to the extent provided in a collective bargaining agreement.

The university unilaterally reserves the right to discontinue or terminate the FSA Program, or specific benefits provided by the FSA Program, at any time and for any reason or no reason, except to the extent provided in a collective bargaining agreement. Any such discontinuation or termination will be done without prejudice to claims incurred prior to the termination date.

Employer Information

Kent State University

Loretta Shields, Executive Director, Benefits and Wellness HR Services – Heer Hall

P. O. Box 5190

Kent, OH 44242-0001

(330) 672-8314

[email protected]

Request for Reimbursement

Mail – FlexSave, MZ: 04-2W-8317

2060 East Ninth Street

Cleveland, OH 44115-1355

Phone – 1-800-525-9252

Fax – 440-878-4890

Online – https://www.myflexonline.com

Filing an AppealKent State UniversitySheba N. Marshall, PHR, Assistant Manager, University Benefits HR Services – Heer Hall P. O. Box 5190 Kent, OH 44242-0001 (330) 672-8348 [email protected]

https://www.myflexonline.com/

Kent State University Flexible Spending Accounts Summary ... · Flexible Spending Account (DCFSA)...

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