Www.wasatchbenefit.com
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Cafeteria Plan FSA
A Cafeteria Plan FSA can reimburse you or help you pay for eligible Cafeteria Plan expenses not covered by your health plan. The portion of your paycheck you put into your FSA is taken out before you pay federal income taxes, Social Security taxes and most state taxes. It's a great way to save money. Explore the topics below to learn more:
Eligible Expenses
Here are just some expenses you can pay with your Cafeteria Plan FSA:
• Health plan co-pays and more
• Dental work and orthodontia
• Doctor's fees
• Eye exams and eyeglasses
• Contact lenses and saline solution
• Hearing aids
• Chiropractic treatment
• Laboratory fees
• Prescriptions
• Mental health counseling
All expenses must be qualified medical, vision, pharmacy or dental benefit expenses, as defined in Section 213(d) of the Internal Revenue Code.
Effective January 1, 2011 over-the-counter medicines will not be FSA-eligible without a doctor's prescription as a result of Cafeteria Plan Reform.
Dependent Day Care FSA
You can contribute up to $5,000 into your Dependent Day Care FSA each year. If you are married, both you and your spouse must work, and you and your spouse must each earn at least $5,000 per year, unless your spouse is a full-time student. If you are married and you and your spouse file separate tax returns, the maximum contribution is $2,500 per person. The minimum contribution is $260.
Tax Savings
Generally, contributions you make to your FSA are not subject to federal income taxes or social security taxes. In most instances, there are no state taxes taken out either. The amount you may save depends upon:
• The amount you put into your FSA
• The tax percentage you would normally pay on that money (tax bracket)
Let's say you want $2,000 taken out of your paycheck this year to put into your FSA. The money you direct to your FSA is taken out of your check before taxes are taken out. That reduces your taxable income by $2,000.
Let's say you normally pay 30 percent in federal, social security and state taxes on your income. In this example, you would enjoy a tax savings of 30 percent of the $2,000. In other words, you could get a $600 tax savings on the $2,000 you directed to your FSA.
This example should not be taken as tax advice. See a tax advisor to seek the best advice for your situation. To see how much you may save, check out our FSA Savings Calculator on .
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Getting Reimbursed is easy. We offer two options. You may complete a Request for Payment Form and remit to Wasatch Employee Benefits along with your receipts for the expenses to: P.O. Box 510566, SLC, UT 84151, or fax to 801.521.8780. There is no need to fill out a paper claim form, you may swipe your myResource Card at your point of service and the funds are withdrawn from your account. Wasatch Employee Benefits reimburse eligible Cafeteria Plan expenses up to the full amount of your annual FSA contribution, minus any amount already reimbursed.
Request for Reimbursement Form
|COMPANY | |Dept | |
|NAME: | |SS#: | |
Please read the Reimbursement Account Rules and Claim Filing Instructions before completing this claim.
* Information below must be completed
|MEDICAL EXPENSE CLAIMS |
|Date of Service| | | | |Description of |Claim Amount |
| |Patient Name |Patient’s SS# |Relationship |Name of Provider |Service | |
| | | | | | |$ |
| | | | | | |$ |
| | | | | | |$ |
| | | | | | |$ |
| | | | | | |$ |
| | | | | | |$ |
| | | | | | |$ |
| | | | | | |$ |
|$ |
|DEPENDENT CARE CLAIMS |
|Date of Service |Dependent Name | |Dependent Care |Dependent Care |Provider |Claim |
|From To | |Age |Provider Name |Provider Address |Tax Id#/SS# |Amount |
| | | | | | | |$ |
| | | | | | | |$ |
| | | | | | | |$ |
| | | | | | | |$ |
|$ |
EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were not reimbursed by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense reimbursed through this account as deductions or credits when filing my (our) individual income tax return.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider, files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Employee Signature: Date: ________ /________ /________
Ready to decide the amount you want in your FSA? It's good to plan ahead.
• Consider the medical, vision or pharmacy costs not covered by a health plan. Need dental work? How about contact lenses? Buy cold medicine, aspirin and sunscreen throughout the year? Your FSA may help pay for these items and more.
• Also look at family changes that might have an impact on your expenses.
Just remember this: FSA dollars are "use-it-or-lose-it" funds. Account balances cannot be carried over from year to year. If you have any unused funds at the end of the plan year, or at the end of any applicable grace period, those funds will be forfeited. That's an IRS requirement. So estimate what you want to direct to your FSA carefully. For help deciding how much to contribute, check out the FSA Savings Calculator on our website, .
Cafeteria Plan Election Form
EMPLOYER NAME: ___________________________________________________________
EMPLOYEE INFORMATION
|First Name |Last Name |Soc. Sec. # |Email Address(optional) |
|Address |City & State |Zip Code |Phone Number |
Listed below are the benefits that may be available under the plan. Please indicate which benefits you wish to select by completing the total per deduction-period cost and the amount paid by the pre-tax reduction. The selections will remain in effect until a subsequent election form is filed, in accordance with the plan.
| |Annual Election |Per-Pay-Period |
|Annual Elections | |Deduction |
| | | |
|Medical Reimbursement Account – FSA | | |
|Dependent Care Reimbursement Account | | |
AUTHORIZATION: By signing this form I acknowledge that I am authorizing the company to deduct equal amounts from my paychecks to collect the designated pr-tax amount indicated above. I recognize that these selections constitute a deliberate binding decision on my part that shall not be changed until the enrollment period for the next plan year or if I experience a change in status.
Signature___________________________________ Date______________________
To Decline Participation: The benefits of the plan have been thoroughly explained to me, but I choose not to participate.
Signature____________________________________ Date______________________
Wasatch Employee Benefit Service, Inc., 102 West 500 South, Suite 205, SLC, UT 84101
801.521.8777 – Fax 801.521.8780 – wats 800.748.4423
Website-
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