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FSAGUIDE (Lake Superior State University)

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BROWSE LAKE SUPERIOR STATE UNIVERSITY FORMS

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Medical and Dependent Care Expenses
FSAGUIDE
basiconline.com
TAX SAVINGS FOR
Page 1
WHAT IS A
Flexible Spending Accounts (FSA) are
part of Section 125, established by the
IRS. Section 125 allows employees to
set aside money for future medical and
child care costs on a pre-tax basis.
A Medical FSA can be used to cover:
• Insurance deductibles
• Co-payments and coinsurance
• Prescriptions
• Dental or vision expenses
FLEXIBLE SPENDING
SAVINGS
You save between 15%-40% by not having to pay federal, most state and local taxes,
as well as Social Security and Medicare taxes for every dollar elected for an FSA.
The savings really add up.
Without an FSA With an FSA
Gross taxable wage $500.00 Gross taxable wage $500.00
Federal, FICA & State Tax -113.25
Group Insurance premium
contribution
-40.00
Group Insurance premium
contribution
-40.00
Average weekly out-of-pocket
medical expenses
-50.00
Take home pay $346.75 Taxable wage $410.00
Average weekly out-of-pocket
medical expenses
-50.00 Federal, FICA & State Tax -92.86
Amount left to spend $296.75 Amount left to spend $317.14
FSA Tax Savings per week $20.39
• Assuming 15% Federal tax, 7.65% FICA Tax (Social Security and Medicare)
Below is an example of a how a current participant
calculated the amount they elected for medical FSA.
Be sure to base YOUR estimate on known expenses.
The full amount of your medical election is available
for reimbursement upon the fi rst day of your plan year.
When you incur an eligible out-of-pocket expense,
submit your itemized documentation to BASIC and
receive a tax free reimbursement.
IRS regulations govern the eligibility of claims which include those that are not fully covered by
a health care plan and are prescribed by a physician or other licensed professional, primarily
for preventing, treating or mitigating a physical defect or illness. The IRS does not allow
reimbursement for the following: cosmetic surgery, insurance premiums, teeth bleaching /
whitening, nutritional supplements/vitamins, marriage counseling, debt counseling, eyeglass
sun clips and prepayment of services. For more details, refer to IRS Publication No. 502.
MEDICAL FSA
Charges Savings
Deductible $500 $113
Co-pays $450 $101
Prescriptions $480 $108
Contacts/Vision
services
$220 $49
Dental $100 $22
Over-the-counter
items+
$75 $16
Total $1825 $409
• Assuming 15% Federal tax, 7.65% FICA Tax (Social Security and Medicare)
+ Over-the-counter items require a letter of medical necessity
Page 2
ACCOUNT?
LIMITED PURPOSE FLEX
DESIGNED FOR INDIVIDUALS WITH A
HEALTH SAVINGS ACCOUNT (HSA)
IRS regulations do not allow you to contribute
to an HSA and participate in a standard
Medical FSA, however, you may enroll in a
Limited Purpose FSA. If you or your spouse
change to an HDHP option (with HSA) during
your Flex plan year and you are enrolled in a
standard Medical FSA, you are not allowed to
make or receive HSA contributions or change
your FSA Plan type.
The difference between Medical FSA and a
Limited Purpose FSA is eligible expenses. A
Limited Purpose FSA plan is only for dental and
vision expenses.
A Limited Purpose FSA works just like a regular
FSA, except for the limited type of eligible
expenses. You designate a certain amount of
money to be taken out of each paycheck to be
deposited into your LPFSA account.
You cannot use funds from both your LPFSA
and your HSA to cover the same eligible
expense, even if the expense is considered
eligible under both plans.
An HSA Account does not affect your
eligibility for a dependent care account.
Page 3
MEDICAL, DENTAL
& VISION
Co-pays
Co-insurance
Deductibles
MEDICAL*
Acupuncture
Chiropractor
Podiatrist
Doctor fees
Offi ce visit
Prescriptions
Hospital bills
Laboratory fees
Medic alert bracelet
Dermatologist
Immunizations
Obstetrical
expenses
Routine physicals
X-rays
Well baby
checkups
DIABETIC SUPPLIES*
Insulin
Glucometer
Syringes/Needles
Test Strips
HEARING*
Hearing exam
Hearing aids
Special batteries
THERAPY*
Physical therapy
Learning disability
Psychologist fees for
medical care
Psychiatric care
VISION*
Glasses
Eye exam
Contact lenses
Contact solution
Prescription
sunglasses
LASIK surgery
Visine and eye drops
Reading glasses
Eyeglass repair kits
Orthokeratology
Seeing eye dog (buying,
training, and maintaining)
DENTAL*
Orthodontic
Dentures/bridge/crowns
Fluoride treatments & seals
Cleanings and fi llings
Root canals
Extractions
Dental x-rays
Occlusal guards
Reconstruction/implants
BIRTH CONTROL
DEVICES*
Condoms
Prescriptions
Sterilization
PHYSICAL
IMPAIRMENTS*
Wheelchair
Crutches
Walker
Custom made orthopedic
shoes and inserts
SPECIAL NEEDS*
Transportation to and from
doctor/hospital (call for
current mileage rates and
guidelines)
OVER-THE-COUNTER
ITEMS*
Sunscreen
Band-aids
Carpal tunnel wrist supports
Cold/hot packs for injuries
Home pregnancy tests
Incontinence
supplies
Liquid adhesive for small
cuts
Nasal strips
* PLEASE NOTE:
This list is a broad overview
of eligible expenses; not
all services provided by
a provider or practitioner
are eligible under the IRS
regulations.
Please call BASIC
regarding your specifi c
item or treatment, prior
to election, to confi rm
eligibility.
IRS regulations govern the eligibility of items and claims. As a Flex Administrator,
BASIC helps ensure that you and your employer stay within these regulations.
QUALIFIED EXPENSES
Visit www.basiconline.com/Medical-FSA-Election-Worksheet.pdf for
a qualifi ed expense worksheet to help you estimate your
out of pocket costs.
Page 4
EXPENSES THAT REQUIRE A LETTER
OF MEDICAL NECESSITY
The IRS allows reimbursement of the
following, with a copy of the physi-
cian’s statement of medical necessity,
that includes the specifi c product/ser-
vice and a diagnosis. Treatment cannot
be for general health or well being. A
copy needs to be submitted with every
reimbursement request and a new letter
needs to be reinstated every 12 months.
Health club fees/gym memberships
Nutritional supplements/vitamins
Massage therapy
Acne medication
Weight loss programs (i.e. Weight
Watchers and Jenny Craig) - Program
fees are eligible but food portions are
not.
Stop smoking programs/items
OVER-THE-COUNTER MEDICINE
Acid controllers
Antibiotic products
Anti-diarrheas/gas
Anti-itch/insect bite
Antiparasitic
treatments
Baby rash creams
Cold sore remedies
Cough, cold & fl u
Digestive aids
Feminine anti-fungal/anti-itch
Hemorrhoidal preps
Laxatives
Pain relief
Sleep aids & sedatives
Stomach remedies
CALCULATE SAVINGS
Visit www.basiconline.com/fsasavingscalculator
to use our calculator to estimate the size of your
tax saving, annually or per pay check, when you
choose to participate in BASIC Flex!
EXAMPLES OF
INELIGIBLE EXPENSES
The IRS does not allow
reimbursement for the
following:
Cosmetic surgery
Insurance premiums
Marriage/debt counseling
Eyeglass sun clips
Eyeglass or contact warranty
Prepayment of services
Special (dietary) foods
Personal care items
Sanitary products
Diapers
Deodorant
Chapstick
Face cream or moisturizers
Eye serums or wrinkle creams
Teeth bleaching/whitening
Toothbrushes/toothpaste
Floss/fl ossing devices
Mouthwash
Protein shakes/meal replacement
DEPENDENT ELIGIBILITY
• You and your spouse must be employed or
actively seeking employment or attending
school full time.
• Child must be a dependent under 13 years of
age and be in your custodial care more than
50% of the calendar year. Once your child
turns 13 during the plan year, expenses are no
longer eligible for reimbursement.
• A spouse or dependent who is incapable of
self-care and regularly spends at least eight
hours per day in your home (i.e. an invalid
parent).
SERVICE REQUIREMENTS
• Provider may not be a minor child or
dependent for income tax purposes
(i.e. an older child).
• Service provider must claim payments as
income and comply with state regulations.
• Services must be for the physical care of the
child, not for education, meals, etc.
• Overnight camps are not
eligible for reimbursement.
• Expenses paid for Pre-K are eligible but
kindergarten and higher is not.
If you qualify for the Child Care Credit, the same IRS rules apply. If you have 2 or more children and spend more than $5,000 for child care, you may have additional tax credits available to you. For more details,
refer to IRS Publication No. 503
Page 5
Without an FSA With an FSA
Gross taxable wage $500.00 Gross taxable wage $500.00
Federal, FICA & State Tax -113.25
Dependent care election
($5,000 divided by 52 weeks)
-96.15
Take home pay $386.75 Taxable wage
$403.85
Average weekly out-of-pocket
medical expenses
-96.15 Federal, FICA & State Tax
-91.47
Amount left to spend $290.60 Amount left to spend $312.36
FSA Tax Savings per week $21.78
Annual Savings $1132.56
DEPENDENT CARE FSA
• Assuming 15% Federal tax, 7.65% FICA Tax (Social Security and Medicare)
A single parent or a married couple fi ling jointly can elect up to $5,000 per family, while a
married person fi ling separately can elect up to $2,500 per person, but equal $5,000 for the
family. Just as with Medical FSA, you save between 15%-40% by not having to pay federal,
most state and local taxes, as well as Social Security and Medicare taxes for every dollar
elected for Dependent Care FSA.
Unlike a Medical FSA, Dependent Care FSA is a pay-as-you-go account. Funds are not
advanced by your employer.
FSA BENEFIT DEBIT CARD
ELIMINATE PAYING OUT-OF-POCKET
AND WAIT FOR REIMBURSEMENT.
FSA Benefi t Debit Cards can be used at
qualifi ed locations including hospitals,
physician, dental offi ces, pharmacies and
merchants with specifi c certifi cation.
The IRS regulates the rules regarding
eligible expenses; therefore, there will be
some transactions that need to be
substantiated for eligibility. At BASIC,
we have an 87% auto substantiate rate for
debit card purchases. There are, however,
some instances when participants will be
required to submit itemized documentation
for their FSA Benefi t Debit Card
purchases.
In all cases, itemized documentation
for transactions should be kept.
Debit Cards will be suspended if
documentation is not provided.
Debit Card availability is determined by
your employer. Please check with your
benefi ts department to fi nd out if a debit
card is available.
Page 6
ADDITIONAL
DETAILS
PLAN RULES ARE COMPANY SPECIFIC
While this booklet provides general information about a plan,
a Summary Plan Description (SPD) containing further details is
available. If you have specifi c questions regarding your particular
situation, you may want to consult your company Benefi ts
Coordinator, an attorney or accountant.
Refer to the Summary Plan Description (SPD) to fi nd out how
long you have to submit remaining claims after your plan year or
coverage has ended.
CHANGES TO YOUR CONTRIBUTIONS
You may change your annual election if you have a qualifi ed
change in status (marriage, birth, adoption, death or divorce).
The change in status must correlate with the event and be made
within 30 days of the event. For example, if the event is a birth,
you may increase your election, not decrease it.
END OF YEAR BALANCE
According to the IRS, money left in your account may become the
property of your employer and cannot be returned to you. Please
see the Summary Plan Description (SPD) for further details. Most
people use all their funds by good planning . . . such as getting
a physical, dental checkup or new glasses. Rarely is there ever
more than 5% left in the account, and the tax savings more than
outweigh this amount.
ELIGIBILITY
Flex Benefi ts end upon termination of employment and/or
participation.
Services must be rendered during your current period of
coverage. For new employees entering the plan during the plan
year, services must be rendered after your eligibility or election
date, whichever is later.
If you have questions at anytime
call 800-372-3539 and speak to
a BASIC Flex Account Manager.
I elect to participate (check all that apply)
Health Insurance
Group Life Insurance
Disability Insurance
Dental Insurance
HSA Contributions
Vision Insurance

Other(s)__________________________
The amount of salary reduction needed to pay premiums under the insured portions
of the Plan will be determined by my employer.
I elect NOT to participate
I elect to participate $____________ annually (may not exceed employer limit of $____________)
Annual election will be divided by the number of pay periods in the plan year or the remaining number of pays
for mid-year enrollments
This Medical Reimbursement Account is a Limited Purpose Account for HSA eligibility (see page 2)
I elect NOT to participate
I elect to participate $____________ annually (may not exceed $5000 or $2500 if married fi ling separately)
Annual election will be divided by the number of pay periods in the plan year or the remaining number of pays
for mid-year enrollments
I elect NOT to participate
I elect NOT to participate
Use account information on fi le
Use account information below
No Direct Deposit
Checking account OR
Savings account
Financial Institution: ________________________________________
Routing Number: _______________________________________ Account Number: __________________________
TEAR ALONG THIS LINE
I request that my periodic paychecks for the plan year be reduced on a pro rata pre-tax basis by the sum of my medical reimbursement, dependent care and premium contributions to the plan,
with such amount to be allocated among the benefi ts I selected above. I understand this election form cannot be revoked or changed during the plan year unless there is a qualifi ed change in
status as defi ned in the Summary Plan Description (SPD). I certify that I will only claim reimbursement for eligible expenses for myself and/or qualifi ed dependents as defi ned in the SPD. I further
certify that these expenses will not be reimbursed under any other benefi t plan. I understand any unused dollars remaining in my account(s) at the end of the plan year may be forfeited. I have
examined this agreement and to the best of my knowledge, it is true, correct and complete.
Employee Signature _____________________________________________________ Date ___________________
BASIC
FLEX
Employer Name: _______________________________________________________________________________
Participant Name: ______________________________________ Social Security #: __________________________
Address: _____________________________________________________________________________________
City: _________________________________________________ State: ___________ Zip: ____________________
Phone Number: ________________________________________ Birthdate: ________________________________
E-mail Address: ______________________________________ (Notifi cation of direct deposit payments are only sent via e-mail)
Pay Period:
Weekly
Semi-Monthly (twice a month)
Bi-Weekly (every other week)
Monthly
PLEASE PRINT CLEARLY TO ENSURE ACCURATE ENROLLMENT AND FUTURE COMMUNICATION.
PREMIUM CONTRIBUTIONS
MEDICAL REIMBURSEMENT ACCOUNT
DEPENDENT CARE ACCOUNT
DIRECT DEPOSIT (NOT ALL EMPLOYERS ALLOW DIRECT DEPOSIT AS A REIMBURSEMENT OPTION)
FSA Enrollment Form
EMPLOYER USE
Please complete for
mid-year enrollments
Date of fi rst deduction:
_________________
Eligibility date:
_________________
Lake Superior State University
01/03/2020
2,700.00
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Completed 22 August 2020

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