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SAVE MONEY WHILE KEEPING YOU AND YOUR FAMILY (HRC Total Solutions)

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Phone: 603-647-1147 • (F): 1-866-978-7868 • customerservice@hrcts.com • www.HRCTS.com • 111 Charles St • Manchester, NH 03101
Healthcare Flexible Spending Account (FSA)
SAVE MONEY WHILE KEEPING YOU AND YOUR FAMILY HEALTHY
FSA
Why enroll in a Healthcare
Flexible Spending Account?
• Save an average of 30% on a wide variety
of eligible healthcare expenses by paying
for them on a pre-tax basis
• No waiting—access the full amount of
your annual election on the first day of
your plan year
• Save time—choose from several
convenient, hassle-free
payment and
reimbursement options.
How Does the FSA Work?
You chose to enroll in the FSA through your
employer, which is administered by HRCTS.
Complete the election form indicating how
much you would like to withhold from your
payroll on a pre-tax basis. HRCTS sends you
a VISA debit card preloaded with your full
election amount to pay for qualified
medical, dental, and vision expenses during
the FSA Plan Year. You save money by
putting the funds away pre-tax, and you
have the entire election available to you on
day one to help cover out-of-pocket
healthcare expenses for you, your spouse,
and eligible tax dependents.
Examples of Eligible Expenses
• Medical – deductibles, co-pays, co-insurance, diagnostic tests, lab work, chiropractic care
• Dental – orthodontia, x-rays, fillings, sealants, crowns, root canals, and dentures
• Vision - contacts, glasses, Lasik eye surgery, prescription sunglasses and contact lens solution
• Prescriptions - all prescriptions are covered
• Over-the-Counter – medications, first aid supplies, hearing aids, orthopedic inserts,
thermometers, menstrual products and sunscreen
* Treatments for cosmetic reasons are not covered.
* Some services/purchases need to have a letter of medical necessity to be eligible.
* You can access an updated list of eligible expenses at: http://expenses.hrcts.com
* Please note this list of eligible expenses is subject to change according to the IRS Regulations.
How Do I know How Much to Elect?
You may elect up to the employer’s designated maximum, not to exceed the IRS maximum.
However, we have provided you with an expense worksheet to help you calculate how much you
should put away pre-tax per year. You then take the total amount you wish to elect for the year,
and divide it by the number of payrolls your company has in a year, and this determines your
payroll deduction.
This money comes out before you pay Federal Tax, FICA Tax, and State Tax.
When you add up your tax savings with your money in this account, you
have effectively increased your take home pay.
Phone: 603-647-1147 • (F): 1-866-978-7868 • customerservice@hrcts.com • www.HRCTS.com • 111 Charles St • Manchester, NH 03101
Health Care Expenses
You
Your
Spouse
Other
Dependent(s)
Deductibles
Medical
Dental
Vision
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
Co Pays
Medical
Dental
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
Dental Care
$ _______
$ _______
$ _______
Prescriptions
$ _______
$ _______
$ _______
Vision Care
Eye Exams
Glasses
Contacts
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
$ _______
Chiropractic and/or Acupuncture
$ _______
$ _______
$ _______
Other Eligible Expenses
$ _______
$ _______
$ _______
Total Estimated Expenses
$ _______
$ _______
$ _______
Total Annual Election
Add above lines together. $ __________
Total Annual Election ÷ Total # Pay Periods = Payroll Deduction
$ _______________ ÷ ________________ = $ _____________
FSA
How Do I Access My Funds?
There are two ways for you to access the funds in your Flexible Spending Account!
• VISA Debit Card – HRCTS will provide you with a smart debit card, which
you can use to pay for eligible expenses such as prescriptions, co-pays,
over the counter items, and so much more. When you are at a provider or a merchant
with an IIAS (Inventory Information Approval System), you simply swipe your card and it will
deduct the eligible expenses from your account. Always keep a receipt of payment to verify the
expense.
• Submit a manual claim – You can also submit a claim online, via fax, mail, or mobile app, as long
as you attach an itemized receipt showing the eligible expense. Receipts are required in order to
process claims, and must have service date/purchase date, description of service/item
purchased, name of provider/merchant, and the expense amount.
CALCULATE HOW TO SAVE BELOW!
You can use this worksheet to estimate how much you will need to put into your FSA. Please be
conservative and don’t forget that this account covers you, your spouse, and eligible dependents.
Save an average of 30% on a wide variety of eligible healthcare expenses
by paying for them on a pre-tax basis!
Please refer to your plan documents regarding how funds are handled at the end of the plan year. You
have 90 days after the plan year ends to submit for expenses which were incurred in the plan year.
Phone: 603-647-1147 (F): 1-866-978-7868 customerservice@hrcts.com www.HRCTS.com 111 Charles St Manchester, NH 03101
Dependent Care Flexible Spending Account (DCA)
IT’S YOUR MONEY SO WHY NOT KEEP MORE OF IT?
Guidelines
*You must follow the guidelines set below in order for your dependent care expense to be eligible for
reimbursement.
1. Dependent care expenses cover qualified dependent children 12 or younger, or a
spouse/tax dependent who is mentally or physically incapable of caring for themselves.
2. Dependent care expenses incurred must allow a single parent or both married parents to be
gainfully employed or attend school full time during the time the child is being taken care of.
3. Your dependent must live in your home for at least 8 hours each day.
4. Any day care center or program must meet the state and local requirements in order to be
eligible.
5. A babysitter can watch the dependent inside or outside the home, as long as the sitter is at
least 19 years of age, and is not your spouse or someone you claim on your tax return as a
dependent.
How Does a Dependent Care Account Work?
A DCA is a pre-tax saving account which the IRS allows you to put funds into. You can then use these
funds for qualified dependent care expenses, such as preschool, summer day camp, before or after
school programs, and child or adult daycare. You may choose to enroll in the DCA through your
employer, which is administered by HRCTS. Complete the election form indicating how much you
would like to withhold from your payroll on a pre-tax basis. It is a smart, simple way to save money
while taking care of your loved ones so you can continue to work.
All figures in this table are estimates, and based on an annual salary of $60,000 and maximum contributions to the benefit
account. Your salary, tax rate, dependent care expenses, and tax savings may be different.
SAVE money, while
caring for the ones you
LOVE!
DC
A
Phone: 603-647-1147 (F): 1-866-978-7868 customerservice@hrcts.com www.HRCTS.com 111 Charles St Manchester, NH 03101
Dependent Care Flexible Spending Account (DCA)
Weekly Dependent Care Expenses
Preschool
$ _________
Daycare
$ _________
Babysitting
$ _________
After School Program
$ _________
Before School Program
$ _________
Custodial/Adult Care
$ _________
Disabled spouse/Dependent Care
$ _________
Total Estimated Weekly Expense
$ _________
Total Weekly Election x 52 = Annual Election
$ __________________ x 52 = $ _____________
Annual Election ÷ # Pay Periods = Payroll Deduction
$ ___________ ÷ ______ = $ _____________
How Do I Access My Funds?
There are two ways for you to access the funds in your Dependent Care Account!
VISA Debit Card – HRCTS will provide you with a smart debit card which
you can present at the day care facility you use if they accept credit
cards as a form of payment. Always keep a receipt of payment to verify
the expense. You can only use your card for the amount you have in your account.
Submit a manual claim – You can also submit a claim online, via fax, mail, or mobile app. You
can submit your claim three ways.
o Submit a completed claim form with your provider’s signature. (no receipt required)
o Submit one claim form with your provider’s signature or receipt at the beginning of the year
for the whole year if you have the same expense all year.
o Submit a completed claim form with an itemized receipt including: service start and end
date, description of service, provider, expense amount, tax ID #, and the dependent receiving
the service.
CALCULATE HOW TO SAVE BELOW!
You can use this worksheet to estimate how much you want to elect into your DCA.
The amount you put into an DCA is called an "election," and your election cannot be more than the
maximum amount set by the IRS. Currently, the maximum amount is $5,000 each plan year. There
is also a $5,000 maximum per family per calendar year. However, if you’re married and file separate
tax returns, the maximum is $2,500.
Average Cost for an Infant in a
Center
As a % of a Married Couple’s Median Income
DCA
Phone: 603-647-1147 • (F): 1-866-978-7868 • customerservice@hrcts.com • www.HRCTS.com • 111 Charles St • Manchester, NH 03101
FLEXIBLE SPENDING ACCOUNT (FSA) CLAIM AND RECEIPT
SUBMISSION
To complete a Flexible Spending Account reimbursement request (a claim), you have the following
options:
There are two reimbursement options.
1. Pay out-of-pocket and submit for reimbursement using the claim form and provide a receipt.
The claim can be submitted via mail, fax, email, mobile app, or online via the participant portal.
2. Pay with your FSA debit card and submit an itemized receipt or Explanation of Benefits (EOB)
as substantiation.
Completing a Universal Claim Form:
➢ Submit a claim form with an itemized receipt or EOB to substantiate the purchase.
➢ The claim form must be completed entirely, dated, signed and must have the following five
pieces of information to be accepted for processing.
1. Claim Code F – corresponding to the FSA
2. Service Date or Purchase Date (if payment is for an eligible item, and not a service)
3. Description of Service (prescriptions, copay, office visit, glasses, etc.)
4. Provider (the name of the merchant or provider who performed the service)
5. Claim Amount (the total amount for the service)
Note: Please sign the bottom of the claim form authorizing HRCTS to process the claim.
Substantiating a Purchase:
If you have made a purchase using your FSA debit card, you may be required to substantiate your
purchase. The purpose of this is to ensure the purchase was FSA-eligible and to keep you in
compliance with all IRS regulations.
If you receive communication from HRCTS requesting a receipt for a purchase please ensure your
receipt follows the necessary guidelines and has all the information required to process. HRCTS
will request the receipt from you one time.
FSA
Phone: 603-647-1147 • (F): 1-866-978-7868 • customerservice@hrcts.com • www.HRCTS.com • 111 Charles St • Manchester, NH 03101
Example of Acceptable Substantiation:
Required Information
1. Provider Name
2. Date of Service
3. Description of Service
4. Claim Amount
Please Note: HRCTS has a receipt form which can be used to collect the required
information, if you cannot obtain an itemized receipt
When will HRCTS ask me for a receipt?
Depending on the location in which your FSA debit card was used, HRCTS may require a receipt.
Generally this is done because the location where you made the purchase provides both eligible
and non-eligible services under the IRS Guidelines.
The most common receipt requests will be for dental and vision expenses.
What will happen to my claim if my receipt does not have all the required information?
Upon receiving your claim, HRCTS will review to ensure all required information is on both the
claim form and the receipt.
If information is missing, HRCTS will reach out to you requesting more Information, which allows
you to collect the missing data and submit to HRCTS to finish processing your claim.
If we still do not receive all the required information, then we will deny the claim.
Is my Credit Card Slip showing I paid for services acceptable?
No, your credit card slip will not be acceptable as a receipt.
The reason for this is a credit card receipt only shows the date in which you PAID for the service,
and the amount you paid. It does not show the date of service or description of service.
A payment for a service may be made before or after the date of service, and HRCTS must ensure
all expenses are incurred within the plan year to be eligible for reimbursement.
Contact Customer Service: Monday – Friday 8: 30am-7:30pm EST
(603) 647-1147 Option 1 (866) 978-7868 customerservice@hrcts.com LiveChat
FSA
Phone: 603-647-1147 (F): 1-866-978-7868 customerservice@hrcts.com www.HRCTS.com 111 Charles St Manchester, NH 03101
DEPENDENT CARE ACCOUNT (DCA) CLAIM AND RECEIPT
SUBMISSION
To complete a Dependent Care Account reimbursement request (a claim), you have the following
options:
There are two reimbursement options.
1. Pay with your DCA debit card and submit an itemized receipt for substantiation.
2. Pay out of pocket and submit for reimbursement using the claim form with the provider’s
signature. The claim can be submitted via mail, fax, email, mobile app, or online via the
participant portal.
Completing a Universal Claim Form:
Submit a claim form using code “D” for DCA claim.
When the claim form is signed by your provider, it serves as substantiation.
The claim form must be completed entirely, and must have the following information to be
accepted for processing:
1. Service Date (start date & end date)
2. Description of Service (ex: daycare, summer camp, after school care, adult daycare)
3. Provider (the name of the merchant or provider who performed the service)
4. Claim Amount (the total amount for the service)
5. Tax ID # (or Social Security Number, if the provider does not have a Tax ID)
6. Signature of Provider
Note: Please sign the bottom of the claim form authorizing HRCTS to process the claim.
SUBMIT ONE CLAIM FORM FOR THE ENTIRE YEAR!
YES! You can submit one claim form for the entire elected amount at the start of the
plan year.
Complete the claim form with the start and end date of the service. Then in the claim
amount box, submit for the full elected amount.
Once received, HRCTS will review to ensure the form is complete with all required
information. Once approved, you will then receive payment directly to you via check
or direct deposit in the exact amount withheld from payroll.
DCA
Phone: 603-647-1147 (F): 1-866-978-7868 customerservice@hrcts.com www.HRCTS.com 111 Charles St Manchester, NH 03101
Submitting an Itemized Receipt:
If you are submitting a claim form with an itemized receipt (Option 2), please ensure the receipt
has the required information below.
Example of Acceptable Substantiation:
Required Information
1. Date of Service
2. Description of
Service
3. Provider’s Name
4. Claim Amount
5. Tax ID #
6. Person receiving the
service
Note: No additional documentation is required if all 5 items are included on the
receipt/documentation from the provider.
Example of an Unacceptable Substantiation:
Required Information
1. Date of Service MISSING
2. Description of Service
MISSING
3. Providers Name
4. Claim Amount
5. Tax ID # MISSING
6. Person receiving the
service MISSING
Contact Customer Service: Monday – Friday 8: 30am-7:30pm EST
(603) 647-1147 Option 1 (866) 978-7868 customerservice@hrcts.com LiveChat
DCA
Phone: 603-647-1147 (F): 1-866-978-7868 customerservice@hrcts.com www.HRCTS.com 111 Charles St Manchester,
NH 03101
SET UP YOUR ONLINE ACCOUNT
Go to our Online Account Setup page
http://hrcts.com/setup for instructions on
retrieving your username, creating an account
password, and entering new user security
questions to complete your online account
profile.
Note: Your online account will be available to
you within 30 days of your plan effective date.
If you already have an account you can login directly from https://employee.hrcts.com
TROUBLE ACCESSING YOUR ACCOUNT?
1. Your password must be a minimum of six characters, and is case sensitive.
2. When resetting your password, the answers to your security questions are case sensitive.
3. Password History: Your password must not be one of your last 12 passwords used.
4. Account Inactivity: After 180 days of inactivity, you must follow the password reset
process in order to access your account again.
HRCTS MOBILE APP:
Download the HRC Total Solutions App and check your balance and final filing date, submit claims,
and upload receipts on any Android or iOS device.
View all claims requiring receipts, and submit new receipts by taking a picture with your mobile
device.
SMS TEXT ALERTS
SMS text message alerts are available for all mobile devices on AT&T, Sprint,
Verizon, US Cellular and T-Mobile networks! You can opt in/out via the
Consumer Portal and configure which alerts you prefer to receive by
selecting “Update Notification Settings” under the Statements &
Notifications tab. Some alert options include:
AUTOMATIC PHONE SYSTEM
You can access your available balance, final filing date, final service date, eligible amount, and
your most recent transactions all from a toll-free automated phone service!
This service is available 24/7 to all participants enrolled in an FSA, DCA, HRA, or HSA plan. Just
select option 6 when calling HRCTS, or you can reach this service directly by calling (877) 415-
8093.
You will need to have a phone number on file in your online account, along with your ZIP code,
in order to use this service.
Claim Confirmation
Receipts Needed for Debit Card
Transaction
Claim Denial
Receipt Reminder
HSA Account Summary
Expense Notification
HRCTS
Phone: 603-647-1147 • (F): 1-866-978-7868 • customerservice@hrcts.com • www.HRCTS.com • 111 Charles St • Manchester, NH 03101
Flexible Spending Account (FSA) Enrollment Form
I. Account Holder Profile Information
First Name:
Last Name:
SSN:
Date of Birth:
Email Address:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip:
Home Phone:
Cell Phone:
Gender: ☐ Male ☐ Female
Marital Status: ☐ Married ☐ Single
Employer:
II. Election
I authorize my employer to make the following pre-tax deductions from my paycheck according to the elections I have chosen below.
These elections cannot be changed until the beginning of the next plan year or if I have a qualifying event such as marriage, divorce,
death, or birth. I will only submit claims for reimbursement or through my VISA that are eligible. If I am reimbursed for a claim that
wasn’t eligible, I will be responsible for paying the ineligible amount back into the plan through sending payment or having it deducted
from my paycheck.
Effective Date:
1
st
Payroll Deduction Date:
Number of Payrolls this plan year: ☐52 ☐26 ☐24 ☐12 ☐Other #____
Healthcare Standard FSA
Employee Annual Election: $ ___________
Per Pay Period Election: $ ___________
Healthcare Limited FSA
(Only If enrolled in a HSA)
Employee Annual Election: $ ___________
Per Pay Period Election: $ ___________
Dependent Care Account
Employee Annual Election: $ ___________
Per Pay Period Election: $ ___________
III. Direct Deposit Setup
Bank Name: ☐ Checking ☐ Savings
Account Number:
Routing Number:
Address:
City:
State:
Zip:
IV. Debit Card
A Debit Card will automatically be issued in the account holders name and shipped to the address above. Once the enrollment is
processed it should arrive within 10-14 days.
Note: To issue separate debit cards to any dependents 18 years of age or older, please complete the following section.
Name:
DOB:
SSN:
Relationship:
Name:
DOB:
SSN:
Relationship:
V. Authorization
Signature __________________________ Date ______________
Employer Authorization:________________________
**Please be sure to return this form to your employer for approval. **
Did you know you could use your FSA to save money
on everyday health essentials like baby health items,
health trackers, pain relief products and more?
Use your FSA funds or risk forfeiting your money.
Don’t know
how to spend
your FSA money?
Learning Center
Get daily money-
saving info
Use your FSA card
or any major credit card
Need an Rx?
We’ll work with you to
make getting one easier
Are your health
needs eligible?
Easily check with our
expansive Eligibility List
24/7 support,
FREE shipping on
orders over $50
The largest selection
of guaranteed
FSA-eligible products
Want 10 bucks to spend on your health?
Visit FSAstore.com/FlyerHRCTS and
use code FCHRCTS10 at checkout.
$
10
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SAVE MONEY WHILE KEEPING YOU AND YOUR FAMILY (HRC Total Solutions)

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Completed 18 April 2021

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