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1044575-3792220Flexible Spending Account Administration Guide and Requirements Gathering DocumentFor: (Client Name)Table of Contents TOC \o "1-3" \h \z \u Client Information PAGEREF _Toc462736513 \h 4Non-Discrimination Testing PAGEREF _Toc462736514 \h 6Funding Process PAGEREF _Toc462736515 \h 8Overview PAGEREF _Toc462736516 \h 8Claims Funding and Maintenance Deposit PAGEREF _Toc462736517 \h 8Check Information PAGEREF _Toc462736518 \h 8Unclaimed Checks PAGEREF _Toc462736519 \h 8Funding Reports PAGEREF _Toc462736520 \h 9Funding Samples PAGEREF _Toc462736521 \h 9Methods for posting payroll deductions PAGEREF _Toc462736522 \h 10Enrollment And Eligibility PAGEREF _Toc462736524 \h 13Open Enrollment Census PAGEREF _Toc462736525 \h 13Online Enrollment Census (Demographics Only) PAGEREF _Toc462736527 \h 13Paper Enrollment Form PAGEREF _Toc462736528 \h 13Ongoing Eligibility Method PAGEREF _Toc462736529 \h 14Plan Document PAGEREF _Toc462736530 \h 15FSA Plan Design PAGEREF _Toc462736531 \h 16Eligibility requirements (hours per week): PAGEREF _Toc462736533 \h 16Waiting Period for new employees: PAGEREF _Toc462736534 \h 16Debit Card Requirements PAGEREF _Toc462736537 \h 20Initial Debit Card Distribution PAGEREF _Toc462736538 \h 20Employer Reports PAGEREF _Toc462736539 \h 22Employer Portal Users and Access Levels PAGEREF _Toc462736540 \h 23Participant Forms PAGEREF _Toc462736541 \h 24Claim Reimbursement Form PAGEREF _Toc462736542 \h 24Direct Deposit Authorization Form PAGEREF _Toc462736543 \h 24Health Care Eligible and Ineligible FSA Expenses PAGEREF _Toc462736544 \h 24Physician Statement PAGEREF _Toc462736545 \h 24Participant Communications PAGEREF _Toc462736546 \h 25Fees PAGEREF _Toc462736547 \h 25Acceptance PAGEREF _Toc462736548 \h 26Client InformationClient Name: DBA or AKA Name:Client Address:Client Tax ID:Number of Benefit Eligible:Expected Participant Count ___________________Entity Type (S Corp, C Corp, LLC):Industry:Tax Year End Month and Day:State Organized:Controlled Group: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, list Affiliates including Tax ID#Main Client ContactName:Title:Email Address:Telephone: Secondary Client ContactName:Title:Email Address:Telephone:Broker ContactName:Title:Agency:Email Address:Telephone:Broker will be copied on all implementation, renewal and escalated emails. Check this box if broker should not be copied on these emails: FORMCHECKBOX What unique employee identifier will you be using: FORMCHECKBOX SSN FORMCHECKBOX Employee ID (must be 9 digits) FORMCHECKBOX SSN FORMCHECKBOX Employee ID (must be 9 digits) Medical Carrier:Divisions: FORMCHECKBOX Yes FORMCHECKBOX NOList of Divisions: Timing of Claim PaymentsMailed or faxed claims are scanned and queued for processing within 1-3 business days of receipt. Uploaded claims are immediately available for processing. Once available for processing, claims are typically approved or denied within 2-4 business days. Notifications for denied claims and for claims where more information is required are sent each day for claims processed the prior day. Check and direct deposit files are created three times per week for claims approved as of prior business day.Checks are mailed next dayDirect deposits are posted same day and available to participants within 1-2 business days after files are loaded.Eligible ExpensesIRS Code 213 eligible and ineligible expense list will be used to determine eligible expenses. RequirementsClaims may be filed through the participant’s online portal, the Benefit Strategies mobile app, or by submitting a paper claim form via secure email, fax or mail. Claims must include only expenses eligible for reimbursement as defined by federal regulations and not previously submitted with a claim. Documentation supporting the claim must be included with each claim filed, such as invoices, Explanation of Benefits (EOB) or Medicare Summary, a copy of both sides of cancelled checks (for dependent care only), or receipts that include the following information:Patient or dependent nameDate of serviceDescription of serviceExpenses incurredNote: Claims for dependent care expenses paid in advance of the Service Date will be denied until the service date has passed – Mid-Year FSA ChangesMid-year FSA election changes can only be made per IRS qualified events. Changes to elections must correlate with the change in the event. For example, a divorce would constitute a decrease in election, a marriage or birth would constitute an increase in election, as of the effective date of the event.Non-Discrimination Testing Non-discrimination testing is available upon request and subject to a fee. Upon request, client is sent information and forms to complete, including providing census information on all employees. If testing results in election amounts needing to be cutback, the client must provide the cutback amount for each impacted participant to Benefit Strategies so adjustments can be made in our system. Note: Clients are responsible for providing written notification to affected employees of any election amount and/or deduction changes. Do you want to have your plan(s) tested for the new plan year? Yes – please see the materials located HERE for next steps when ready for testing. NoAdministering Run Out From Current TPAIf an FSA is already in place and you are changing administration to Benefit Strategies with the start of the new plan year, the outgoing administrator should handle the outgoing plan year run-out and Grace Period option. If the outgoing plan year has the $500 rollover option, rollover balances will need to be provided to Benefit Strategies once the run-out period has ended. Takeover From Current TPATakeover TemplateA takeover implementation means Benefit Strategies will take over the administration of your current plan year during the current plan year. Because we will have taken over the administration mid-year, we will then handle the run-out at plan year end, as well as the Grace Period and Rollover options, as applicable. Takeovers can be done at any point in the plan year, up to 31 days prior to the plan year end date. Example: If plan year ends December 31, takeover must happen December 1 or earlier.A fee applies for the takeover implementation.Typically, the outgoing administrator will want a claim filing/debit card black out period so all in-house claims can be settled and final balances provided to Benefit Strategies.The attached Takeover Enrollment census should be used to provide Benefit Strategies, LLC with FSA enrollment information for all current participants if we are taking over the plan mid year. Benefit Strategies will request updated year to date payroll, and claims paid information after the chosen black out period has ended to ensure all information on account is up to date.Are you requesting a mid-year takeover implementation? FORMCHECKBOX No FORMCHECKBOX Yes – complete questions to the rightBenefit Strategies must be provided with the following information in a mutually agreed upon format in order to do a takeover:Enrollment CensusCurrent Balances Year To Date Payroll DeductionsClaim History (if this can’t be provided, we are unable to prevent a claim previously paid by the prior TPA from being submitted to Benefit Strategies and paid out again.) If you are requesting a mid-year takeover implementation, what is the current plan year end date? Will the takeover plan year and the new plan year requirements be the same? FORMCHECKBOX Yes FORMCHECKBOX No, new plan year differences are: Funding Process OverviewBenefit Strategies pays claims three times per week. Claims are paid in advance and clients are invoiced weekly for claims paid the prior week. Claims Funding and Maintenance DepositPlease complete the Claims Funding Agreement and EFT Form (if applicable) and return with this document.Checks and direct deposit payments are drawn against a Benefit Strategies, LLC bank account.Check and direct deposit files are created three times per week for claims approved as of the prior business day and sent to fulfillment.A Claims Funding Request report (invoice for claims paid) is emailed to clients weekly for the prior week’s claims reimbursements. Funding amounts are due within 2 business days after receipt of the funding request. Payment is made to Benefit Strategies, LLC either by check (Manual Invoice), ACH payment, or EFT debit. A Maintenance Deposit is required to mitigate the risk of Benefit Strategies paying claims in advance. The Maintenance Deposit is determined by taking total annual elections divided by 26. The Maintenance Deposit remains with Benefit Strategies until the point that the client terminates FSA services. At the time the amount of the Maintenance Deposit will be returned. The Maintenance Deposit amount is revisited only when a new plan is added or a current plan is dropped, or there is a significant change in enrollment. Check InformationA brief explanation is included with each claim payment check.Participants may contact Customer Service to request a claim payment check be voided and reissued if the check is lost and has not yet been cashed.All claim payment checks indicate “Void after 180 Days”. In our experience, banks will still cash checks after the 180 daysUnclaimed ChecksClients will address the escheatment and/or other handling of unclaimed checks that have reached the 180 day expiration date. No updates to Lightouse1 will be made with regard to unclaimed checks that have expired. A report of unclaimed checks will be provided upon request.Funding ReportsA claims funding invoice and claims funding report will be emailed weekly to the financial contact(s) you indicate below. The invoice provides notification of the amount required for funding claims paid the prior week (debit card transactions and claim reimbursement requests) as well as any adjustments, and debit card fees (if applicable). The report provides the details to support the invoice.Client Financial ContactsFinancial ContactName: Title: Email: Phone Number: Financial ContactName: Title: Email: Phone Number: Financial ContactName: Title: Email: Phone Number: Financial ContactName: Title: Email: Phone Number: Division SubtotalsFunding invoices and/or reports will contain divisional subtotals if applicable.Funding SamplesClaims Funding Invoice and Detail SampleClaims Funding Invoice and Detail with Divisions SampleMethods for posting payroll deductionsMethods for posting payroll deductions. Choose one of the following options: Best Practice for posting payroll deductions is via File Import: Benefit Strategies will import the payroll file to post the deductions. You will be responsible for sending a payroll file each pay period of actual deductions. Payroll files will be expected two days prior to deduction date.? This method reduces processing time and minimizes the need for confirmation of changes. Alternative Method:?Anticipated Deductions/Compare Method Benefit Strategies will post anticipated payroll deductions (based on annual election amount divided by pay periods) each pay period. You will be responsible for sending a payroll file each pay period of actual deductions. We will run a comparison and correct any posted deductions needed. In comparison to the recommended best practice, this method often has longer processing times and may increase the need for confirmation of changes.*For both payroll file methods, it is recommended to send a full eligibility file. Please see Enrollment & Eligibility section for more information.Benefit Strategies payroll file spec will be completed and sent:From Client: From Vendor: Frequency(s): File contact Name: File contact Phone: File contact Email: Testing needs to be completed with Benefit Strategies prior to the Go Live date. Vendors sending files often require a long lead time. Please send the payroll file spec to your vendor immediately and confirm their ability to comply with the testing timeline. For additional details on Payroll file testing or specifications, please contact dataservices@ for assistance.Payroll system rounding FORMCHECKBOX Standard (anytime deduction is 3 decimals places .005 or higher will round up, less than .005 will round down. Ex. $25.274 will round down to $25.27 and $25.275 will round up to $25.28) FORMCHECKBOX Up (Anytime deduction is 3 decimal places, will round up. Ex. $25.271 will round to $25.28) FORMCHECKBOX Down (Anytime deduction is 3 decimal places, will round down. Ex. $25.279 will round to $25.27)Are deduction adjustments made with the first pay period or last? FORMCHECKBOX First pay period FORMCHECKBOX Last pay periodSubmission of Payroll CalendarTo ensure employee payroll contributions are in alignment with anticipated scheduled payroll deductions, please include a copy of your new payroll calendar.Please provide a payroll calendar or use the following template located HERE, Will you be providing multiple payrolls? If so, please see additional tabs in the payroll calendar.LOA - Leave of AbsencePlease see attachment for detail explanations of the following 3 options that are available.Choose one of the following options, if applicable: Prepay Pay as you go Pay upon returnFSA Continuation Coverage InformationIs your company subject to FMLA? FORMCHECKBOX Yes FORMCHECKBOX NoIs your company subject to COBRA? FORMCHECKBOX Yes FORMCHECKBOX NoAre you aware that FSAs are COBRA eligible plans and the rules for determining how much of the FSA can be COBRA'd? FORMCHECKBOX Yes FORMCHECKBOX NoIs COBRA administration handled in-house, by Benefit Strategies, or other?If other administrator: Name:Address:Telephone Number:Enrollment And EligibilityOpen Enrollment CensusOnline Enrollment Census (Demographics Only)Paper Enrollment FormThe attached Open Enrollment census should be used to provide Benefit Strategies, LLC with FSA enrollment information after your Open Enrollment period has ended.? The attached Online Open Enrollment Census should be used if offering online open enrollment with Benefit Strategies.? Once the census is complete and returned follow up directions will be provided for you to send to participants to enroll directly online.? This option requires a 6 week window prior to your effective date.Open Enrollment Start Date:Open Enrollment End Date:?The attached Paper Enrollment from should be used to provide Benefit Strategies, LLC with FSA enrollment information after your Open Enrollment period has ended. Please note: Enrollment information is due to Benefit Strategies, LLC by the below time frame in order to ensure debit cards are mailed prior to the plan start date:January effective dates: No later than December 1st. All other months: At least 20 days prior to the plan start date.Enrollments received after this date may still have cards mailed prior to the start date but we are not able to guarantee it.Ongoing Eligibility MethodHow will we be receiving on-going eligibility:From Client: From Vendor: Frequency(s): File contact Name: File contact Phone: File contact Email: FTP Address: IMPORTANT: Testing needs to be completed with Benefit Strategies prior to the Go Live date. Vendors sending files often require a long lead time. Please send the eligibility file spec to your vendor immediately, and confirm their ability to comply with the testing timeline. For additional details on eligibility file testing or specifications, please contact dataservices@ for assistance. *If recurring eligibility file is being sent consumers ability to make profile changes will be turned off.?Client direct entry in administrator portal:Plan DocumentPlan DocumentsBenefit Strategies will provide a Section 125 Plan Document and a Summary Plan Description. Choose one of the options. FORMCHECKBOX Benefit Strategies provide new plan document (chose this if you have never offered an FSA before)Plan Name: FORMCHECKBOX Use standard naming convention (Client Name Section 125 Plan Document) FORMCHECKBOX Other Name:Plan Number: FORMCHECKBOX Use standard plan number, 501 FORMCHECKBOX Other: Number FORMCHECKBOX Benefit Strategies provide re-stated plan document (chose this if you currently offer an FSA Plan)Effective date of current plan document:Name of current plan document:Current Plan Number in plan: FORMCHECKBOX Benefit Strategies is not responsible for plan document or Summary Plan DescriptionInformation needed for plan document creationWill FSA eligible employees also be offered a Health Savings Account (HSA)? FORMCHECKBOX Yes FORMCHECKBOX NoWill FSA eligible employees also be offered a Health Reimbursement Account (HRA)? FORMCHECKBOX Yes FORMCHECKBOX No Do employees have pre-tax deductions? FORMCHECKBOX No FORMCHECKBOX Yes (complete below) FORMCHECKBOX Medical FORMCHECKBOX Dental FORMCHECKBOX Vision FORMCHECKBOX HSA contributions FORMCHECKBOX LTD FORMCHECKBOX STD FORMCHECKBOX Other: How is the pre-tax deduction election made: FORMCHECKBOX Automatic election – employee must opt out to un-elect FORMCHECKBOX Upon hire and election carries over year to year FORMCHECKBOX Upon hire and employee re-elects annuallyAre employees offered cash back in lieu of benefits FORMCHECKBOX No FORMCHECKBOX Yes – Describe:Will the employer allow an employee to drop employer health coverage when the employee experiences a reduction of hours (mid-year) and still maintains eligibility in the group health plan FORMCHECKBOX Yes FORMCHECKBOX NoMay an employee who experiences a mid-year qualifying event be permitted to drop group health plan coverage in order to obtain coverage through the Marketplace FORMCHECKBOX Yes FORMCHECKBOX NoWhen does coverage under the plan terminated for Dependents? FORMCHECKBOX The final day of the month of the Dependent’s 26 birthday FORMCHECKBOX The end of the calendar year of the Dependent’s 26 birthdayThere are several plan design options for Health FSAs and Dependent Care FSAs. Clients can choose between two standard Health FSA plan designs and two standard Dependent Care FSA plan designs. In addition, clients with 500 ore more benefit eligible employees can instead choose a custom plan design. FSA Plan DesignFSA Plan Types to Implement FORMCHECKBOX Healthcare Reimbursement Account (Health FSA) FORMCHECKBOX Dependent Care Reimbursement Account (Dependent Care FSA)Effective Date:End Date:Are you running a Short Plan Year (SPY)? If yes, maximum election amount should be pro-rated. FORMCHECKBOX No FORMCHECKBOX Yes – SPY State Date:SPY End Date:Are you aware that employees offered FSA must also be offered group health plan coverage? FORMCHECKBOX Yes FORMCHECKBOX NoEligibility requirements (hours per week):Waiting Period for new employees:When does coverage end after employee termination?:Are you aware a self-employed individual, partner or person who owns more than 2% of the outstanding stock of the company is not eligible for FSA enrollment? FORMCHECKBOX Yes FORMCHECKBOX NExplanation of Plan Design Option Components:Dependent Care Spend Down:As Dependent Care FSAs are not COBRA eligible, the Dependent Care Spend Down provides a way to avoid terminated participants from forfeiting any balance in their account as of the date of termination. The Spend Down permits the terminated participant to continue to incur expenses through the end of the plan year (and Grace Period if applicable) and submit for reimbursement against the balance in their account as of the date of termination. Grace Period (Heath FSA and Dependent Care FSA option) Allows participants to continue to incur expenses during the 2 ? month period following the plan year end date. Does not change run-out date for claims submission. HEART Act (Health FSA option): Allows members of the US Military Reserves who are called to Active Duty during the FSA Plan Year to be protected from some or all of forfeiture through a Qualified Reservist Distribution (QRD). QRD calculation methods:Method A: Amount contributed to Health FSA as of Active Duty date minus any reimbursements already received. Method B: Health FSA annual election amount minus reimbursements already received. Method C: Other (amount can’t exceed the annual election minus reimbursements). Rollover (Health FSA Option) Allows participant balances up to $500 to rollover to the next plan year. If the participant does not elect in the new plan year, an account will open automatically to receive the rollover funds. Maximum Rollover cannot exceed $500. Minimum balance to rollover may be established to avoid paying admin fees on participants with a very small dollar balance who do not elect in the next plan year. The Health FSA cannot have both the Grace Period and the Rollover.Run-out Period:Number of day after plan year end date in which participants can submit for reimbursement for expenses incurred during the Plan Year (and Grace Period if applicable.) A run-out period can also be established for participants who terminate mid-plan year. Health FSA Plan Design OptionsWill there be an employer contribution to the Health FSA: FORMCHECKBOX No FORMCHECKBOX Yes,$(match can not exceed $500)Choose One Health FSA Plan Design. Clients with less than 50 benefit eligible employees should select one of the standard plan design options listed below (HCA Rollover or HCA Grace Period). Clients with 500+ benefit eligible employees may choose a standard plan design option or create a custom plan design. FORMCHECKBOX Standard Plan: HCA Rollover FORMCHECKBOX Standard Plan: HCA Grace Period FORMCHECKBOX CustomHCA RolloverHCA Grace PeriodHCA CustomRollover $100 Minimum $500 Maximum No FORMCHECKBOX No FORMCHECKBOX Yes*Minimum:MaximumGrace PeriodNoYes FORMCHECKBOX Yes* FORMCHECKBOX No Maximum Annual Election$2,600* $2,600** FORMCHECKBOX $2,550 FORMCHECKBOX Other:$Minimum Annual Election$100$100 FORMCHECKBOX No Minimum FORMCHECKBOX Other:HEART ActYesQRD Method AYesQRD Method A FORMCHECKBOX No FORMCHECKBOX YesQRD Method:Run-Out Period after Plan Year Ends90-days 90-days FORMCHECKBOX 90-days FORMCHECKBOX Other:daysRun-Out Period for Participants Terminated From Plan 90-days from termination date 90-days from termination date FORMCHECKBOX 90-days from termination date FORMCHECKBOX Other:days from: FORMCHECKBOX Termination date FORMCHECKBOX Plan Year end date*Cannot have both the Grace Period and the Roll Over** If the federal maximum changes, at the next plan renewal the maximum will be changed to match the new federal maximum Dependent Care FSA Plan Design OptionsChoose One Dependent Care FSA Plan Design. Clients with less than 50 benefit eligible employees should select one of the standard plan design options listed below (DCA No Grace Period or DCA Grace Period). Clients with 500+ benefit eligible employees may choose a standard plan design option or create a custom plan design. FORMCHECKBOX Standard Plan: DCA No Grace Period FORMCHECKBOX Standard Plan: DCA Grace Period FORMCHECKBOX DCA CustomDCA No Grace PeriodStandard Plan Grace PeriodDCA CustomGrace PeriodNoYes FORMCHECKBOX Yes FORMCHECKBOX No Maximum Annual Election$5,000* $5,000* FORMCHECKBOX $5,000 FORMCHECKBOX Other:$Minimum Annual Election$100$100 FORMCHECKBOX No Minimum FORMCHECKBOX Other:Dependent CareSpend Down**YesYes FORMCHECKBOX Yes FORMCHECKBOX No Run-Out Period after Plan Year Ends90-days 90-days FORMCHECKBOX 90-days FORMCHECKBOX Other:daysRun-Out Period for Participants Terminated From Plan 90-days from plan year end date90-days from plan year end date FORMCHECKBOX 90-days from termination date FORMCHECKBOX Other:days from: FORMCHECKBOX Termination date FORMCHECKBOX Plan Year end date*For standard plans, if the federal maximum changes, at the next plan renewal the maximum will be changed to match the new federal maximum. **If yes this option allows a terminated employee to continue to be reimbursed for eligible dependent care expenses through the end of the plan year.Debit Card Requirements Do you want FSA debit cards for participants? FORMCHECKBOX Yes FORMCHECKBOX NoShould cards be turned on for both Health FSA and Dependent Care FSA? FORMCHECKBOX Yes FORMCHECKBOX NoWill Employer or Employee for the initial set of 2 cards? FORMCHECKBOX Employer FORMCHECKBOX EmployeeIf Employer paid, will cards be automatic or optional? FORMCHECKBOX Automatic FORMCHECKBOX OptionalWill Employer or Employee pay fro additional/replacement sets of 2 cards FORMCHECKBOX Employer FORMCHECKBOX EmployeeInitial Debit Card DistributionThe attached example illustrates the Benefit Strategies Flex Express Card. An example is also provided of the card carrier that is included with the cards as well as the envelope in which the set of cards are sent. Debit Cards come in sets of 2 identical cards, both in the name of the participant. An eligible dependent can sign the back of one of the cards for their use. Additional/replacement cards can be ordered. If you select the Grace Period Option for your plan design, cards are left on during the Grace Period and will pull from the prior Plan Year first. When funds are exhausted it will then pull from the current Plan Year.If you elect cards for the Health FSA, cards will be set to work with merchants transmitting a Merchant Category Code (MCC) associated with healthcare (i.e. doctor office, hospital, pharmacy, dental office, vision center, pharmacy.) If you elect cards for a Limited Purpose FSA, cards will be set to work with merchants transmitting a MCC associated with dental and vision care.If you elect cards for a Dependent Care FSA, cards will be set to work with merchants transmitting a MCC associated with childcare facilities, adult day care facilities, etc. Enrollment information is due to Benefit Strategies, LLC by the below time frame in order to ensure debit cards are mailed prior to the plan start date:January effective dates: No later than December 3rd. All other months: At least 20 days prior to the plan start date.Enrollments received after this date may still have cards mailed prior to the start date but we are not able to guarantee it.If you have more than one account type associated to a card (Health FSA and Dependent Care FSA for example), the system determines which account to debit based on the MCC. Participants are required to maintain receipts with their tax records for IRS purposes. Auto-substantiation of debit card transactions reduces the need for participants to send in receipts to substantiate a debit card transaction. Auto-substantiation takes place through the following:IIAS – When a card is used at healthcare merchants (doctors, dentists, pharmacies, etc.) that predominantly sell medical services/products and utilize the Inventory Information Approval System (IIAS), only eligible items will process under the card transaction. For this reason, no documentation is required to be submitted to substantiate the card transaction. Debit cards are sent to the participants’ home addresses. Send initial cards: FORMCHECKBOX Automatically upon enrollment FORMCHECKBOX If employee requests cards at enrollment*Custom Logo on Debit Card: FORMCHECKBOX Yes FORMCHECKBOX No (please allow 4 to 6 weeks)Debits cards are not available for participants on Health FSA COBRA coverage. Copay Matching Optional Copay Matching – The IRS permits copay matching, up to five times the amount of a copay. This means when a card transaction matches an employer copay amount, or up to five times that amount, no documentation is required to be submitted to substantiate the card transaction. FORMCHECKBOX Implement copay matching (complete and return the attached Copay Matching Template.) FORMCHECKBOX Do not implement copay matchingDebit Card Date of ServiceDebit cards should be only used for services and expenses within the current plan year. Paying a medical bill for a service date that was incurred in a previous plan year is considered a non-qualified expense. Debit card claims will be denied for repayment if the date of service is not within the plan year of the account from which funds were drawn.Debit Card Date of Service during Grace Period (if applicable)Debits card transactions made during the Grace Period for services and expenses incurred during the Grace Period will pull first from the prior plan year; when prior plan year funds are exhausted, the card will pull from the current plan year funds. Debit card transactions made during the Grace Period for services and expenses incurred in the prior plan year will be denied and repayment requested if there are insufficient funds available from the prior plan year to cover the full amount of the debit card transaction.Debit Card Substantiation NotificationsTwo notifications are sent via email (if email is not provided a letter will be mailed to address on file) to request that participants provide substantiation for debit card claims that are not auto substantiated. Notifications are sent at 7 days and 37 days from the date of the debit card transaction. Transaction Dispute ProcessIf a participant believes their account has been charged in error, the participant should call the phone number on the back of their debit card as soon as possible. If appropriate, an Activity Dispute form will be provided to the participant. This form must be completed and submitted as soon as a disputed transaction is identified. Note: Activity Dispute forms must be received within 90 calendar days from original transaction(s) settlement date. Employer Reports Account Balance Report SampleEnrollment Report SamplePayroll Deduction Report SampleReports are scheduled to run on a monthly basis.Reports are posted on the Employer Portal for access by Employer Portal users with reporting permission. Reports will be provided in an MS Excel format when this option is available, but a PDF may be requested instead if this format is required. Employer Portal Users and Access LevelsEnter information below for each Employer Portal user and the level of access required. An email will be sent to each contact with information regarding use of the Employer Portal and log in credentials.Employer Portal UserName: Title: Email: Phone Number: Access LevelEmployer Portal UserName: Title: Email: Phone Number: Access Level:Employer Portal UserName: Title: Email: Phone Number: Access LevelEmployer Portal UserName: Title: Email: Phone Number: Access Level:Participant FormsSpending Account Self Service Forms – all forms are located on under the FSA tab as well as within the employer and employee portals.Claim Reimbursement Form Used to file Health and Dependent Care Account Claims if faxed or mailed instead of being entered directly in the Consumer Portal or through the mobile app.Direct Deposit Authorization Form Used if direct deposit account information is faxed or mailed instead of being entered directly in the Consumer Portal. Health Care Eligible and Ineligible FSA Expenses List of Health Care Expenses based on a list of eligible and ineligible expenses as provided for under IRS Publication 502.Physician StatementTo be used for “dual use” services: Any service not typically considered eligible but recommended by a physician on a case by case basis to cure, alleviate or mitigate a medical condition or to treat an existing disease. Example: massage therapy to treat migraines.Note: This is not to be used for over-the-counter (OTC) medications and drugs. A prescription is required for those items to be eligible. Participant EducationParticipant Account Demo – Introduction to Flexible Spending Account: Participant Account Demonstration:Participant Online Enrollment Demonstration:Participant Communications FSA participants include employees, COBRA participants, or terminated employees still within their run out and/or grace period and require the ability to file claims against their spending account balances. Email notifications are sent to active participants with an email address when the letters below are generated. The email notification informs the participant the associated letter is available for viewing via the Consumer Portal. Spending Account Self Service NotificationsNotice TypeEmail SampleClaim Denial Emailed NotificationClaim Denial with Repayment RequiredAdvice of Deposit for Claim ReimbursementFeesSet Up Fee: $Invoiced To: Renewal Fee: $Invoiced To: Plan Takeover Fee: $Invoiced To:Monthly Admin Fee and Minimum Monthly Invoiced Amount : $Invoiced To:Initial Card Fees $Replacement/Additional Card Fees: $ Invoiced To: Invoiced To:Non-Discrimination Testing Per Plan Per Test (done upon request) :$Invoiced To:AcceptanceWe have reviewed and approved the contents of the Flexible Spending Account Administration Guide and Requirements Gathering Document (dated). We certify that the content included is in a manner that accurately reflects the Flexible Spending Account Requirements for (client name). By signing this document we understand Benefit Strategies, LLC will begin administering Flexible Spending Accounts based on the information detailed in this document. Any changes made to the plan design after implementation is complete will be deemed a plan change. Plan changes made off of renewal may be subject to a plan re-build fee. AuthorizationAuthorized SignatureTitlePrinted NameDateThank you for partnering with Benefit Strategies; we look forward to working with you and your employees! Please sign this form and return it via email to implementation@ Benefit Strategies, LLC ................
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