Employee
Open Enrollment
Resource Guide
P
rairie State College
A08116
Allied FSA Debit Card
WHAT IS AN FSA?
An FSA is a special account where an employee sets aside pre-tax money, via payroll deduction, to
pay for certain out-of-pocket costs. There are two types of FSAs:
Healthcare FSA – Covers out-of-pocket healthcare expenses, such as copayments, deductibles,
some drugs, and more.
Dependent Care FSA – Covers costs as sociated with caring for children, a disabled spouse, elderly
parents or other dependents while working or attending school full-time.
HOW IT WORKS
As covered expenses are incurred, the employee conveniently
uses an Allied Flex Card to automatically deduct funds from
their Flex account. No more using cash for co-pays or
submitting claim forms and waiting for reimbursement. Plus,
easy-to-use tools at AlliedBenefit.com allow employees to
track their Allied Flex account expenses, balances, and claims
from anywhere, anytime.
HOW ALLIED CAN HELP
FSAs require proper administration, and the IRS penalties for
noncompliance exist. Allied handles all aspects of
administration to not only meet your compliance obligations
but to also keep employees happy.
Flex Plan Highlights
$2,750 individual IRS maximum ($50 increase from 2019)
$500 Rollover Provision your employer has adopted the IRS rule allowing you
to carry over up to $500 of unused flex funds remaining at year end to be used for
qualified medical expenses incurred the following year. Unused funds over $500
will be forfeited.
Dependent Care Flexible Spending Account
$5,000 household IRS maximum
Claim Submission Deadline – Health FSA and Dependent Care FSA
All 2020 flex claims must be submitted by March 31, 2021.
All claims submitted after this three (3) month extension will be denied or applied to the new
flex plan
year if incurred dates apply.
Use it or Lose it RuleIRS regulations require that any money left in the account after this
deadline will revert back to the
plan.
contribution limits, provisions, and claim submission deadlines
Health Flexible Spending Account
Allied Flex Debit CardsHealth FSA Only
Flex debit cards are automatically issued to all participants at no cost.
Flex debit cards are good for 3 years. Please review the expiration date.
Debit cards for dependents may also be requested at no additional cost.
Direct Deposit Reimbursement
Easy and instant payments to the bank account you designate.
Requesting an Alliedbenefit.com Account
3. Enter all required information on the Website Account Request page.
Information entered must exactly match what was included on your
enrollment. Please pay attention to SSN, DOB, and case sensitive prompts.
4. Click "Submit" to complete your request. You will then receive an email
from notifications@alliedbenefit.com. Please follow the directions from this
email to complete the process.
*You must have a private email account to utilize this tool.
1. Visit Allied's homepage
at www.Alliedbenefit.com
to login.
2. Click "Register".
Allied Benefit Systems, Inc. P 800.288.2078
200 West Adams, Suite 500 F
Chicago, IL 60606 E flexclaims@alliedbenefit.com
Group Number Employer Location
(if applicable)
Employee UID or SSN
Flex Plan Year
Address Cit
y
State Zip
Dental/Vision
Provider's Signature (or attach receipt)
-
-
-
-
- I have not and will not itemize and deduct nor claim credit for these expenses on my income tax returns.
- I understand that reimbursement will be made in accordance with the provisions of the Plan.
Employee Signature Date
312-416-2870
$
$
Date of Service
SECTION A - EMPLOYER/EMPLOYEE INFORMATION
SECTION B - REIMBURSEMENT REQUEST
Please attach all receipts that apply to required reimbursements. For dependent care, please attach receipts and signature of the
Dependent Care Provider.
HEALTH FSA EXPENSES
Employer Name
Daytime Phone
Employee Name
Employee Email Address
$
$
Date of Service
DEPENDENT CARE ASSISTANCE EXPENSES
$
$
Amount of ExpensesOtherRxMedical
$
$
$
Total Reimbursement Requested:
$
Name of Dependent Expenses Were
Incurred For Dependent(s) Age Amount of Expenses
$
Total Reimbursement Requested:
$
Provider's Tax ID Number or SSN
The above expenses were incurred for services or supplies for me and/or my eligible dependents listed above who reside with
me in a parent/child relationship or are legally dependent on me for their support.
The above services and supplies were furnished to me or my dependents on or after my effective date with the Plan.
I have not been reimbursed for the above expenses, nor have any of my dependents been reimbursed for these expenses.
I understand that any amounts not used for qualified expenses by the end of the Plan Year or Grace Period will be forfeited to my
Employer.
SECTION C - EMPLOYEE CERTIFICATION
I certify that the expenses for which I am requesting reimbursement meet the following conditions:
click to sign
signature
click to edit
Allied Benefit Systems, Inc.
P 800.288.2078
200 West Adams, Suite 500
F
Chicago, IL 60606
E eligibility@alliedbenefit.com
Group Number
Employer Location (if applicable)
Bank Account Type
Bank Account Number:
Employee Name
Employee SSN
Bank Name
Bank Routing Number:
Checking
Savings
• You must activate your account on www.alliedbenefit.com to receive an email notification for each processed claim.
•Since you will no longer receive paper claim checks in the mail with account balance information, this information will be
available via our secure website www.alliedbenefit.com.
•When Allied processes a claim, the funds will be deposited 4-6 days following the processed date shown on the website.
•If your bank name, bank routing number, and/or your bank account number has changed, please inform Allied of this change
immediately.
•In the event that your banking information has changed and a claim is processed, a manual check will be processed for
reimbursement and you will be asked to submit updated information.
PLEASE NOTE WE MUST RECEIVE A VOIDED CHECK IN ORDER TO SET UP YOUR ACCOUNT
312.906.8879
Employer Name
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