Flex Convenience® - Instant Benefits

Transcription

Flex Convenience
®
It’s about saving you TIME and MONEY
Advantage of Enrolling
You could save up to 45%* on every plan dollar you spend!
By enrolling in a Flex Benefit plan you will use pre-tax dollars for eligible medical
and dependent care expenses not covered by insurance—resulting in more take
home pay. You will save Federal, State and FICA taxes on dollars you contribute.
This means, depending on your tax bracket, you could save up to 45%* on every
plan dollar you spend.
You can calculate your estimated savings by visiting “Calculate your Savings!” at:
www.We-R-Flex.com
Use the
Flex Convenience Card
The Flex Convenience card makes it easy!
With the MGIS Flex Convenience card, utilizing a Flex Benefit plan is easier than ever.
When you use the card:
● No out-of-pocket expenses
● No waiting for reimbursement
● Same great tax savings
The MGIS Flex Convenience card works just like a debit card to pay for your eligible
expenses. For more information and a complete listing of eligible expenses visit the
Flex website:
www.We-R-Flex.com
In this Packet
You will find the information you need to make a decision
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For More Information
Information sheets detailing the plans your employer is offering
Information about how the card works
An Election Form
A Direct Deposit Form
A manual Reimbursement Request Form (to be submitted for eligible expenses
incurred but not reimbursable by the debit card)
Contact Medical Group Insurance Services, Inc. (MGIS)
Internet:
Phone:
E-mail:
www.We-R-Flex.com
1.866.WE-R-FLEX (937.3539)
[email protected]
* Actual savings will vary depending on your individual tax bracket.
FORM 01-4/22/03
HEALTH CARE FLEXIBLE SPENDING ACCOUNT
(For out-of-pocket health care expenses for you, your spouse & dependents)
IRC SECTION 125
Information Sheet
1. WHAT IS A HEALTH CARE FLEXIBLE
SPENDING ACCOUNT?
A Health Care Flexible Spending Account (FSA) is an
account to which you contribute part of your pay before
Social Security, Medicare and Federal Income (withholding)
Tax, to pay for qualified medical, dental and certain vision
expenses for yourself, your spouse, and/or your dependents.
2. WHAT ARE QUALIFIED EXPENSES?
Qualified expenses include medical, dental and vision
expenses for services incurred during the Plan Year for the
diagnosis, treatment or prevention of disease, and for
treatments affecting any part or function of the body. The
expense must be necessary to alleviate a physical defect or
for prevention of illness. Services performed solely for
cosmetic reasons generally are not eligible. Expenses that are
merely beneficial to one’s general health (i.e., various overthe-counter drugs) are NOT eligible. Expenses paid by
insurance are NOT eligible. Qualified vision expenses
include prescription glasses and contacts. (See reverse side
for partial listing of eligible expenses.)
3. WHY SHOULD I PARTICIPATE IN A HEALTH CARE
FLEXIBLE SPENDING ACCOUNT?
Normally, you would receive an income tax deduction for
qualifying medical, dental and vision expenses that exceed
7.5% of your adjusted gross family income. (Few taxpayers
ever meet that qualification or receive a tax deduction.)
With the Health Care Flexible Spending Account, every
dollar contributed to your account escapes both FICA and
Federal Withholding taxes. For example, if you and your
family incur $1,000 in qualified medical, dental and vision
out-of-pocket expenses, you will save about $276 in taxes by
using the Health Care Flexible Spending Account (Federal
Income Tax 20% + Medicare and Social Security 7.65%).
4. HOW DO I PARTICIPATE?
A) Determine regular medical, dental and vision expenses
you and your dependent(s) will incur during the Plan
Year. The worksheet on the back of this sheet can help
you calculate your expenses.
B) Enter the amount you want to set aside before taxes on
the Election Form. Each pay period, your employer will
deduct this amount from your paycheck and deposit the
funds directly into your Health Care Flexible Spending
Account.
5. HOW DO I USE THE MGIS FLEX CONVENIENCE® CARD?
First, give the provider (doctor, hospital, pharmacist, etc.)
your medical insurance card. When they ask you to pay
your portion of the copayment or deductible, give them the
MGIS Flex Convenience® card.
You can also use your card to pay for your portion of the
eligible expenses by calling in or writing your card number
on a ‘balance due’ statement from the provider. Remember,
you can only do this if the service was performed (or
expense incurred) during the current Plan Year and after
insurance has paid its portion (if applicable).
Keep all receipts (such as medical, dental, prescription drug,
and bills for glasses and contacts). This information is
required by the IRS to substantiate the eligibility of the
expense. MGIS may ask for documentation to verify your
request for reimbursement. If you do not have the receipts,
you will be required to reimburse the Plan.
The card will not work if you go over your available
balance. As with a normal debit card, only the funds
remaining in your account are available for reimbursement.
You can check your balance in your FSA 24 hours a day by
logging onto the Flex website and registering. Simply log on
to: www.We-R-Flex.com and follow the instructions.
6. IF THE PROVIDER DOESN’T ACCEPT THE DEBIT CARD,
WHAT INFORMATION IS NECESSARY TO SUBMIT A
REQUEST FOR REIMBURSEMENT?
• The date of service(s) (service must be performed during
the current Plan Year)
• The type of service(s) performed
• The cost of the service(s) performed
• Completion of a Reimbursement Request Form
7. CAN I REVOKE MY ANNUAL ELECTION AMOUNT?
Generally, no. However, if you have a qualified change in
status (marriage, divorce, birth, adoption, unpaid leave of
absence, change in employment status of you or your spouse
from full-time to part-time or vice-versa) you can revoke
your annual elected amount and make a new election for the
remainder of the Plan Year (provided your change is
consistent with the event). Your election change request
must be submitted to MGIS within 30 days of the
qualifying event.
Medical Group Insurance Services, Inc. • P.O. Box 16110 • Salt Lake City, Utah 84116 • 1.866.WeRFlex (937-3539) • Fax 801.990.2401 • e-mail: [email protected]
FORM 02-4/22/03
www.We-R-Flex.com
8. WHAT IS THE “USE IT OR LOSE IT” PROVISION?
You may submit a request for reimbursement for expenses
incurred through the last day of the Plan Year. Generally,
you will have a 30- to 90-day grace period after the end of
the Plan Year to submit the Reimbursement Request Form
for expenses incurred in the prior Plan Year. IRS regulations
stipulate that any unused or unclaimed balances remaining
in your account, after the grace period, are forfeited to your
employer.
9. WHAT IF I TERMINATE OR RETIRE AND HAVE MONEY
IN MY ACCOUNT?
Reimbursement is dependent upon the specifications in
your employer’s Plan Document. Expenses must be
incurred prior to your termination date, unless COBRA is
available and elected.
10. WHEN DO I ELECT TO PARTICIPATE?
Each year, during the Open Enrollment period and prior to
the Plan renewal date, you must complete a new Election
Form for the upcoming Plan Year.
11. HOW WOULD I ACCESS MY ACCOUNT INFORMATION?
You may access your account balance and/or transaction
history 24 hours a day by logging onto the MGIS Flex
website (www.We-R-Flex.com) and following the
instructions.
12. ARE THERE ANY NEGATIVES?
You must use all the funds for eligible expenses during the
Plan Year. Unused funds are forfeited to your employer.
Your Social Security benefits may be reduced slightly due to
lower taxable income.
13. WHAT EXPENSES ARE NOT ELIGIBLE?
• Insurance premiums (sponsored by your employer)
• Expenses reimbursed by other sources or insurance
• Expenses not incurred during the Plan Year
• Non-qualifying expenses per IRS Code Section 213*
14. WHAT HAPPENS IF MY REQUEST FOR REIMBURSEMENT
IS GREATER THAN THE AMOUNT OF MONEY IN MY
ACCOUNT?
IRS regulations require your employer to make available, for
your use, your annual elected amount, from the first day of
the Plan Year (i.e., you can be reimbursed $200 even
though you have only contributed $100 of your annual
election amount year to date). For information on what
happens if you terminate during the Plan Year, see Item 9.
QUALIFYING HEALTH CARE EXPENSES UNDER
IRS CODE SECTION 213 (PARTIAL LIST ONLY*)
• Insurance deductibles and copayments
• Lasik Surgery
• Prescriptions, prescribed vitamins which are not available
over the counter and birth control pills
• Chiropractor, osteopath, acupuncture, etc.
• Dental treatments (X-rays, fillings, crowns, etc.)
• Orthodontia, dental surgery, exams, cleanings
• Eyeglasses, contacts, vision exams and optometrist visits
• Hearing aids, aids and assistance for the handicapped
• Doctor and hospitalization expenses and services
• Lab fees, physical exams, X-rays and vaccinations
• Nursing services
• Psychiatrist, psychologist and psychotherapy visits
• Surgery, sterilization, gynecology, obstetrics, anesthesia
• Visit our website for a complete listing of eligible expenses:
www.We-R-Flex.com
HEALTH CARE
FLEXIBLE SPENDING ACCOUNT WORKSHEET
Visit www.We-R-Flex.com to use an automated calculator.
Estimate expenses for yourself, spouse and dependents for the
upcoming Section 125 Plan Year.
Estimated
Annual Amount
MEDICAL
Deductibles
Copayments
Doctor visits
Prescriptions
Other (misc.)
__________
__________
__________
__________
__________
DENTAL
Copayments
Crowns, bridges
Other (misc.)
__________
__________
__________
VISION
Exams
Lenses, frames
Contact lenses
__________
__________
__________
Total Health Care Expenses
__________
Your Tax Bracket (22.65% to 46.25%) X_________
(Income tax plus 7.65% FICA)
Your Estimated Annual Savings __________
* Refer to IRS Code Section 213 or consult your tax advisor for further information. (Does not include insurance premiums; only Section 213 expenses are allowable.)
FORM 02-4/22/03
www.We-R-Flex.com
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
(For your dependent care expenses that allow you to work)
IRC SECTION 129
Information Sheet
1. WHAT IS IT?
A Dependent Care Flexible Spending Account under the
Internal Revenue Code (IRC) Section 129 is an employer
plan that provides employees “Dependent Care Assistance.”
The Plan allows you to avoid both FICA and Federal
Income Tax on qualifying child and dependent care
expenses. A qualifying individual is:
• Your dependent who is under age 13 at the time care is
provided and for whom you would claim as a dependent
on your tax return,
• Your spouse who is physically or mentally incapable of
caring for himself or herself, or
• Your dependent (age 13 and over) who is physically or
mentally incapable of caring for himself or herself and
for whom you are entitled to a dependency exemption.
This could include parents who are dependents. See
instructions on IRS form 2441 for other rules and
exceptions.
2. WHAT ARE THE MAXIMUM BENEFIT LIMITS?
The IRS currently allows a maximum of $5,000 per year per
family or $2,500 if you are married filing a separate return.
3. WHAT EXPENSES ARE ELIGIBLE FOR REIMBURSEMENT?
• Dependent expenses that allow you to work (if married,
both you and your spouse must work, be looking for
work, or be a full-time student)
• Expenses for a qualifying dependent’s care (inside or
outside your home) incurred during the Plan Year
• Nursery school
• Taxes on wages you pay a person for qualifying child
and/or dependent care expenses
Expenses NOT eligible for reimbursement include:
• The cost of education for kindergarten or higher (before
and after school care is eligible)
• The cost of overnight camp
• Transportation costs
• Expenses incurred while you are not working due to
illness or injury
• Any amounts you pay to: (1) a dependent for whom you
are entitled to a dependency exemption, and (2) your
child who is under age 19 at the end of the Plan Year
This is a partial list. For a more detailed list of eligible
expenses, visit our website: www.We-R-Flex.com.
4. WHY SHOULD I PARTICIPATE?
In most cases, you will realize greater tax savings by
participating in this Plan than by claiming the tax credit on
your 1040. (See reverse page for comparison worksheet.)
5. HOW DOES THE PLAN WORK?
Each pay period, your employer will deduct the amount you
elected to have withheld from your paycheck. No FICA or
Income Taxes will be deducted from this elected amount.
These contributions will be held in a disbursement account
in your name until withdrawn for your qualifying expenses.
6. HOW DO I CALCULATE MY DEPENDENT CARE FLEXIBLE
SPENDING ACCOUNT EXPENSES?
• Estimate total expenses for the Plan Year
• Divide by the number of pay dates (12, 24, 26, etc.)
• Enter the amount on the Election Form
Important: When calculating your dependent care expenses
take into account times when you will not be at work (i.e.,
holidays, sick days and vacation time off) as well as times
when your child will be in school and the care will not be
required.
7. HOW DO I GET REIMBURSED?
As you incur expenses, you can pay the provider with the
MGIS Flex Convenience® debit card or submit copies of your
receipts with a signed and dated Reimbursement Request
Form to MGIS at the address listed below. Your
reimbursement amount will be deducted from your
account. You cannot be reimbursed for more than what you
have contributed year to date.
8. WHAT INFORMATION IS NECESSARY TO RECEIVE A
MANUAL REIMBURSEMENT?
IRS regulations require you to provide:
• The date(s) care was provided or incurred
• The cost of the care
• Your provider’s name and Tax ID number or Social
Security number (if a babysitter)
• A signed receipt or invoice from your provider (canceled
checks are not valid receipts)
• A completed Reimbursement Request Form
FORM 03-4/22/03
www.We-R-Flex.com
11. WHAT IF I QUIT OR TERMINATE AND HAVE MONEY IN
MY ACCOUNT?
Reimbursement is dependent upon the specifications in
your employer’s Plan Document. Your expenses must be
incurred prior to your termination date, unless COBRA is
available and elected.
9. CAN I REVOKE MY ANNUAL DEPENDENT CARE
ELECTION AMOUNT?
The IRS allows election changes for: marriage, divorce,
birth or adoption of a child, change in your or your spouse’s
employment status, unpaid leave of absence, and changes in
day care rates which are beyond the control of the
participant. Otherwise, your election amount remains the
same throughout the Plan Year.
Note: You must still file IRS Form 2441 with your tax return
to report the Tax ID#(s) of your dependent care
provider(s) to the IRS.
10. WHAT HAPPENS IF I INCUR FEWER EXPENSES THAN MY
ELECTED AMOUNT?
Unused or unclaimed balances are forfeited to your
employer (“use it or lose it”). Be conservative when
determining your annual election amount.
WORKSHEET FOR COMPARING DEPENDENT CARE TAX SAVINGS
Section 129 Tax Savings Versus 1040 Tax Credit
USING EMPLOYER’S SECTION 129 PLAN
Your Annual Eligible Expenses ($5,000 maximum)
$______________ /YEAR
Your Tax Bracket (generally 23-35%)
(7.65% FICA + 15% to 27% Federal Income Tax)
X _____________ %
Your Section 129 Savings
$____________/YEAR
TAXES (2003 RATES)
FICA (Social Security)
7.65% to $87,000 then 1.45% on income over $87,000
Federal Income Tax (based on taxable income after deductions):
SINGLE
$0–$6,000 ....................................................10%
$6,001–$28,400 ...........................................15%
$28,401–$68,800 .........................................27%
$68,801–$143,500 .......................................30%
$143,501–$311,950 .....................................35%
$311,951 OR HIGHER..............................38.6%
MARRIED (FILING JOINT TAX RETURN)
$0–$12,000........................................................... 10%
$12,001–$47,450.................................................. 15%
$47,451–$114,650................................................ 27%
$114,651–$174,700.............................................. 30%
$174,701–$311,950.............................................. 35%
$311,951 OR HIGHER ...................................... 38.6%
TAKING INCOME TAX CREDIT (FORM 2441 CREDIT ON YOUR 1040)
Your Annual Eligible Expenses
($3,000 maximum for 1 child; $6,000 maximum for 2 or more children)
$______________ /YEAR
Your Dependent Care Tax Credit Percentage
(See chart below to determine your percentage)
X _____________ %
Your Tax Credit Savings
$______________ /YEAR
ADJUSTED GROSS INCOME CREDIT %
$0–$14,999..............................................35%
$15,000–$16,999.....................................34%
$17,000–$18,999.....................................33%
$19,000–$20,999.....................................32%
$21,000–$22,999.....................................31%
$23,000–$24,999.....................................30%
$25,000–$26,999.....................................29%
$27,000–$28,999.....................................28%
ADJUSTED GROSS INCOME
CREDIT %
$29,000-$30,999 .................................................... 27%
$31,000–$32,999.................................................... 26%
$33,000–$34,999.................................................... 25%
$35,000–$36,999.................................................... 24%
$37,000–$38,999.................................................... 23%
$39,000–$40,999.................................................... 22%
$41,000–$42,999.................................................... 21%
$43,000 OR HIGHER ............................................. 20%
THIS CHART IS PROVIDED FOR INFORMATION PURPOSES ONLY. MGIS DOES NOT GUARANTEE ITS ACCURACY NOR DOES
MGIS PROVIDE ANY LEGAL OR ACCOUNTING ADVICE. PLEASE CONSULT YOUR ATTORNEY OR TAX ADVISOR.
FORM 03-4/22/03
www.We-R-Flex.com
PREMIUM CONVERSION ACCOUNT
(For your payroll deducted premiums)
IRC SECTION 125
Information Sheet
6. CAN I REVOKE MY PREMIUM CONVERSION AMOUNT?
1. WHAT IS IT?
Premium Conversion, under Internal Revenue Code (IRC)
Section 125, allows you to avoid FICA and Federal Income
(withholding) Tax on your monthly deduction for qualified
group insurance premiums.
This can only happen if you have a qualified change in
family status during the Plan Year. If your group insurance
premiums change, your deduction will be adjusted
automatically.
7. HOW DO I PARTICIPATE?
2. HOW DOES IT WORK?
You may be required to complete an Election Form,
furnished by your employer, authorizing your employer to
make a pre-tax payroll deduction. Your Payroll Department
will automatically adjust your monthly deduction for
qualifying insurance premiums from an “after-tax” to a
“pre-tax” basis.
3. WHAT INSURANCE PREMIUMS QUALIFY?
• Premiums for group term life insurance policies with a
face value of $50,000 or less. (Section 79)
• Premiums for group medical, dental, vision, accident
and/or disability insurance. (Section 106)
• Qualified premiums you pay for yourself, spouse and/or
dependents.
(Please note that any policy that builds cash value or allows
for a refund of premium is not a qualified plan. Any
disability or salary insurance premium paid pre-tax has a
taxable benefit.)
Your withholding taxes will decrease and your net takehome pay (spendable income) will increase.
Because Social Security tax will not be deducted from the
amount used to pay for qualifying insurance premiums, your
Social Security benefits may be slightly reduced.
Unless you notify your employer to the contrary, your share
of out-of-pocket premiums will be automatically deducted
from your pay on a pre-tax basis.
EXAMPLE
Jack earns $30,000 annually and his employer deducts $200
per month ($2,400 per year) from his paycheck to pay the
premiums for covering his wife and child under the company’s
group insurance plan.
WITHOUT PREMIUM CONVERSION
Gross (taxable) Pay
Taxes (estimated at 25%)
Insurance Deduction
NET TAKE HOME PAY
$30,000
(-7,500)
(-2,400)
$20,100
WITH PREMIUM CONVERSION
Gross (taxable) Pay
Pre-tax Insurance Deduction
Taxable Pay
NET TAKE HOME PAY
$30,000
(-2,400)
$27,600
(-6,900)
$20,700
Jack has INCREASED his take home pay by $600 per year
($50 per month) by participating in his employer’s IRC
Section 125 Premium Conversion Plan.*
*Actual savings may vary based on individual circumstances.
FORM 04-11/8/02
www.We-R-Flex.com
PREMIUM REIMBURSEMENT ACCOUNT
(For your INDIVIDUALLY OWNED qualified health insurance premiums)
IRC SECTION 125
Information Sheet
7. HOW AND WHEN DO I GET REIMBURSED?
1. WHAT IS IT?
A Premium Reimbursement Account, under Internal
Revenue Code (IRC) Section 125, allows you to use “taxfree” dollars to pay for individually owned, qualified
insurance policies for yourself which are not sponsored by
an employer. Not all policies are qualified.
8. WHAT TYPES OF POLICIES ARE NOT ELIGIBLE?
• Life insurance
2. WHAT INSURANCE PLANS ARE ALLOWED?
• Only policies owned by the participant (not spouse or
children)
• Hospital, Surgical and Medical
• Group insurance sponsored by another employer
• Long Term care
• COBRA premiums for your dependents
•
• Sight Loss and Dismemberment
Policies owned by your dependents
Please note: The IRS has determined that any policy that
builds cash value or allows for a refund of premium if the
benefit is not utilized is not a qualified plan.
• Wage Continuation and Disability Income
•
Submit a copy of your policy (at the beginning of the Plan
Year only) and a Reimbursement Request Form with a copy
of the insurance premium notice.
Accidental Death Benefit
You can avoid taxes on your premiums (Social Security
tax at 7.65% and Federal Income Tax of generally 15%
to 27%).
Because you do not pay Social Security taxes on your
premiums, your Social Security benefits may be slightly
reduced. Disability Insurance benefits would be converted
from tax-free benefits to taxable income.
5. CAN I REVOKE MY PREMIUM REIMBURSEMENT AMOUNT?
You can revoke your existing election and make a new
election for the remainder of the Plan Year if one of the
following occurs:
• Change in family status
• Your independent premium increases or decreases
during the Plan Year
• Your independent coverage significantly changes or is
canceled
EXAMPLE
You earn $30,000 annually and pay $200 per month ($2,400 per
year) out of pocket for your individual health insurance policy.
WITHOUT PREMIUM REIMBURSEMENT
Gross (taxable) Pay
Insurance Deduction
NET TAKE HOME PAY
$30,000
(-7,500)
(-2,400)
$20,100
WITH PREMIUM REIMBURSEMENT
Gross (taxable) Pay
Pre-tax Insurance Deduction
Taxable Pay
NET TAKE HOME PAY
$30,000
(-2,400)
$27,600
(-6,900)
$20,700
By participating in your employer’s IRC Section 125 Premium
Reimbursement Plan you would INCREASE your net take
home pay by $600 per year ($50 per month).*
*Actual savings may vary based on individual circumstances.
6. HOW AND WHEN DO I PARTICIPATE?
Each year during the Open Enrollment period you should
determine your annual election amount and enter that
amount on the Election Form.
FORM 05-11/8/02
www.We-R-Flex.com
HOW THE CARD WORKS
Welcome to the Flexible Spending Plan!
The debit card offers a convenient way to pay your portion of
eligible expenses for medical, dental, pharmacy, glasses, contacts, etc.
Here’s how easy it is to use the card:
1.
Give the provider (doctor, hospital, pharmacist, etc.) your medical insurance card first. When asked to pay your portion of the
copayment or deductible, give them the MGIS Flex Convenience® card. You can also use your card to pay for your portion of an
eligible bill (after insurance has paid their portion, if applicable) by calling in or writing your card number on a ‘balance due’ statement
from the provider. Remember, you can only pay for a service performed (or expense incurred) during the current Plan Year.
2.
Keep all receipts for expenses purchased with the card (such as bills for medical and dental visits, prescription drugs, and glasses
and contacts), as the IRS requires this information. MGIS may ask for documentation to verify the eligibility of your claim. If you do not
have the receipts, you will be required to reimburse the Plan.
3.
You can check the balance in your FSA or DCA account 24 hours a day by logging onto the “Account Access” link at
www.We-R-Flex.com and following the instructions.
Other points to remember:
•
You can only use the card to pay for un-reimbursed medical, dental or dependent care expenses. The system is programmed to
detect the type of provider and will decline the transaction if used inappropriately (i.e., the card will not be accepted at a gas station).
•
You can’t use the card for ineligible items, such as gum or candy, at a pharmacy. If you use the card at an eligible provider, but
purchase an ineligible item, MGIS will request reimbursement. Remember, YOU are responsible to only use the card for eligible
expenses per IRS Guidelines.
•
The card can only be ‘swiped’ for the amount available in your Flex Account.
Health Care Accounts: The amount available is the amount allotted for the year, minus any deductions you’ve already made. If
you try to use the card for more than that amount, the entire transaction will be denied. However, you can instruct the provider
to swipe the card for the balance in your account and pay the rest in cash or by check.
Dependent Care Accounts: You can only withdraw the amount you have contributed through payroll deductions, year to date.
To obtain more details log onto www.We-R-Flex.com or call 1.866.WeRFlex (937.3539).
Reasons why your card may not work:
•
You are trying to use the card for more than is available in your account. Check your account balance prior to using the card. Ask the
provider to swipe only up to that amount.
•
The provider is not using a correct System Merchant Code for the card. If the transaction fails more than twice, call MGIS at
1.866.WeRFlex (937.3539).
•
You are using a card that has been deactivated. If you notify MGIS that a card has been lost or stolen, the card will be deactivated.
Make sure you do NOT attempt to use the old card once you have reported it lost or stolen, as it will not work.
•
If the provider does not accept MasterCard® you will have to pay the amount due and submit a request for reimbursement to MGIS.
You can download a Reimbursement Request Form at www.We-R-Flex.com. Complete the form, attach the provider receipt with
your name on it and submit it to Medical Group Insurance Services, Inc. at 1849 W. North Temple, SLC, Utah 84116, or fax it to
801.990.2401. (Keep a copy for your records.)
FORM 07-4/22/03
www.We-R-Flex.com
FLEXIBLE BENEFITS PLAN—ELECTION FORM
PLAN INFORMATION
EMPLOYER NAME:
PLAN YEAR:
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
EMPLOYEE NAME
EMPLOYEE DATE OF HIRE (Required)
____________________________________________________
___________________________________________________________________
LAST
FIRST
MI
MM/DD/YY
EMPLOYEE HOME ADDRESS
_______________________________________________________________________________________________________________________________________________
NUMBER AND STREET
CITY
STATE
ZIP CODE
SOCIAL SECURITY #
DATE OF BIRTH
EMPLOYEE E-MAIL ADDRESS
GENDER
________________________________________
______________________________________________
__________________________________
M F
LOCATION/DEPARTMENT__________________________________________________
PARTICIPANT’S EFFECTIVE PLAN DATE__________________________________
(Only if different than beginning of Plan Year shown above)
ELECTION INFORMATION
I understand that the rules of the Internal Revenue Code allow me to use part of my salary on a pre-tax basis to purchase one or more of the following qualified benefits.
I hereby elect to participate in my employer’s Flexible Benefits Plan as indicated below.
OPTION I
PREMIUM CONVERSION ACCOUNT (PCA OR POP)
AUTOMATIC
The Group insurance premiums you pay through payroll deductions.
No election required. Unless you notify your employer
to the contrary, your share of the insurance premiums
will automatically be paid with pre-tax dollars.
PLEASE CHECK YOUR ELECTION(S) AND FILL IN AMOUNT IF APPLICABLE
BENEFIT ELECTION OPTIONS
ELECTION
OPTION II
HEALTHCARE FLEXIBLE SPENDING ACCOUNT (FSA)
You can elect up to the maximum amount
as designated by your employer’s Plan.
OPTION III
DEPENDENT CARE ASSISTANCE PLAN (DCA)
Maximum of $5,000 per Plan Year if single parent or if married and filing a
joint Tax Return. Maximum of $2,500 if married and filing separately.
DEDUCTION
YES

NO

$ ___________
YES

NO

$ ___________
NO. OF PAYCHECKS
(i.e., 12, 26, etc.)
PER PAY PERIOD
$__________
ANNUAL
NO. OF PAYCHECKS
(i.e., 12, 26, etc.)
PER PAY PERIOD
$__________
ANNUAL
I have reviewed and understand the terms and conditions on the back of this page and in my company’s Summary Plan Description. I understand that I can not change or revoke
this election at any time during the Plan Year unless I have a Qualifying Life Event change (including marriage, divorce, death, birth or adoption of a child, change or termination of
spouse’s employment, change in dependent care provider or such other events as the Plan Sponsor determines will permit a change or revocation of an election). I further
acknowledge that I am responsible for keeping all receipts verifying all eligible expenses claimed under the Flex Convenience® card and must submit such receipts to
MGIS for claims substantiation upon request.

YES, the benefits of this Plan have been explained to me and I elect to participate as indicated above.

I have read the disclosure on the back of this form and hereby agree to the terms of the disclosure by signing this form.
PARTICIPANT’S SIGNATURE
X
DATE
SERVICED BY MGIS
F-F08_BASE_100303
www.We-R-Flex.com
TERMS AND CONDITIONS
Qualifying Medical Care and Dependent Care Expenses: I understand that reimbursement will be available only for “qualifying medical care
expenses” as listed under § 213 and “qualifying dependent care expenses” as listed under § 129 and § 21 of the Internal Revenue Code for me
and my eligible dependents. These expenses must be incurred while I am enrolled in the Plan. I agree to notify the Plan Sponsor or MGIS if I
have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to repay the Plan on
demand by way of check or payroll deduction for any expense paid for with the Flex Convenience® card that is not allowed under § 213,
§ 129 or § 21 of the Internal Revenue Code. I attest that I understand claimed medical expenses can not be reimbursed under the Healthcare
FSA Plan if the expense has been or will be paid in the future by any other plan and acknowledge that the medical expenses have not been
reimbursed or are not reimbursable under any other insurance plan coverage. I further acknowledge that I am responsible for keeping all
receipts verifying all eligible expenses claimed under the Plan and must submit such receipts to MGIS for claims substantiation, upon request.
Participation Rules: I understand that reimbursement account eligibility, enrollment and benefits information is available from my Plan
Sponsor. I authorize payroll deductions for the benefit elections indicated on this Election Form. I understand that I cannot change or revoke this
compensation reduction agreement at any time during the Plan Year except for the occurrence of a Qualifying Life Event. In the case of a
Qualifying Life Event, I must complete a Change Form no later than 30 days after the date the Qualifying Life Event occurs if I want to enroll in a
reimbursement account or change my reimbursement account elections or amounts. Any amounts remaining in the account(s) represented by
this Election Form at the end of the Plan Year, past the claims filing limit, will be forfeited to the Plan under the guidelines of the Internal
Revenue Code.
THIS AGREEMENT IS SUBJECT TO THE TERMS OF THE PLAN SPONSOR’S CAFETERIA PLAN, MEDICAL REIMBURSEMENT PLAN,
AND/OR DEPENDENT CARE ASSISTANCE PLAN AS AMENDED FROM TIME TO TIME IN EFFECT, SHALL BE GOVERNED BY AND
CONSTRUED IN ACCORDANCE WITH APPLICABLE LAWS, SHALL TAKE EFFECT AS A SEALED INSTRUMENT UNDER APPLICABLE
LAWS, AND REVOKES ANY PRIOR ELECTION AND COMPENSATION REDUCTION AGREEMENT RELATING TO SUCH PLAN(S).
AUTHORIZATION
I authorize the use and disclosure of my protected health information as described below.
My protected health information is individually identifiable health information, including demographic information, collected from me or created or
received by a healthcare provider, a health plan, my employer, or a healthcare clearinghouse and that relates to: (i) my past, present, or future
physical or mental health or condition; (ii) the provision of healthcare to me; or (iii) the past, present, or future payment for the provision of
healthcare to me.
Medical Group Insurance Services, Inc. (MGIS) is authorized to use or disclose my protected health information for the purpose of administering
my § 125 account. I further authorize MGIS to release my protected health information to my spouse and/or my tax dependent(s). I
understand that I may decline disclosure of my protected health information (to my spouse and/or tax dependent/s) by submitting a
written notification to MGIS.
All protected health information pertaining to the reimbursement of a § 125 claim may be used and disclosed by MGIS.
I understand that if my protected health information is to be received by individuals or organizations that are not healthcare providers, healthcare
clearinghouses or health plans covered by federal privacy regulations, my protected health information described above may be re-disclosed
and no longer protected by federal privacy regulations.
I understand that I may revoke this authorization at any time by sending a written notification to MGIS, and this revocation will be effective for
future uses and disclosures of protected health information. However, I further understand that this revocation will not be effective: (i) for
information that MGIS already has used or disclosed, relying on this authorization or (ii) if the authorization was obtained as a condition for
coverage by MGIS and, by law, MGIS has a right to contest the coverage.
I understand that this authorization expires upon termination of my employer’s plan.
F-F08_BASE_100303
www.We-R-Flex.com
DIRECT DEPOSIT APPLICATION
INSTRUCTIONS
1.
2.
3.
4.
5.
Print clearly and use black ink
Complete the required information
Attach an entire VOIDED CHECK
(do not use a deposit slip)
Sign and date application
Send to Medical Group Insurance Services, Inc. (MGIS)
NAME OF EMPLOYER ___________________________________________________________________________________
EMPLOYEE NAME ___________________________________ SOCIAL SECURITY NUMBER ________________________
I would like my CAFETERIA PLAN REIMBURSEMENTS deposited to the bank account indicated below.
BANK NAME ________________________________________ BRANCH _________________________________________
ACCOUNT NUMBER__________________________________
I hereby authorize Medical Group Insurance Services, Inc. (hereafter MGIS), to deposit any amounts owed me by initiating credit entries to
my account at the financial institution (hereinafter BANK) indicated above. Further, I authorize BANK to accept and to credit any credit
entries indicated by MGIS to my account. In the event that MGIS deposits funds erroneously into my account, I authorize MGIS to debit my
account for an amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until
MGIS and BANK have received written notice from me of its termination in such time and in such manner as to afford MGIS and BANK a
reasonable opportunity to act on it.
EMPLOYEE SIGNATURE
X ________________________________________________
DATE __________________
If you have ANY QUESTIONS concerning this form, please contact MGIS. Your service representative will be happy to assist you.
Qualified assistance is available by calling toll-free (866) WE-R-FLEX (937-3539) Monday–Friday, 7:30 am–5:00 pm MST.
STAPLE
VOIDED CHECK
HERE
MAIL TO MEDICAL GROUP INSURANCE SERVICES, INC. AT THE ADDRESS LISTED BELOW:
FORM 09-11/8/02
www.We-R-Flex.com
PLEASE MAKE COPIES OF THIS FORM FOR FUTURE CLAIMS
MEDICAL
REIMBURSEMENT REQUEST FORM
(For Healthcare Flexible Spending Account (FSA) Qualifying Medical Expenses)
NOTE:
This form MUST be completed to receive reimbursement for out-of-pocket medical expenses for your Flexible Spending Account(s).
These services MUST have been incurred during the current Plan Year. An itemized copy of the provider’s itemized bill or your
insurance company’s “Explanation of Benefits” verifying the date and the cost of service MUST be attached to this form. Your
claim will not be processed until these items are received by MGIS. Credit card receipts or cancelled checks cannot be accepted.
RETURN COMPLETED FORM AND ALL DOCUMENTATION TO:
MEDICAL GROUP INSURANCE SERVICES, INC.
PO BOX 16110
SALT LAKE CITY, UT 84116-0110
FAX: 801.990.2401
PLEASE COMPLETE ENTIRE FORM. PRINT OR TYPE (USE ADDITIONAL SHEETS IF NECESSARY)
EMPLOYER NAME:
PLAN YEAR:
EMPLOYEE NAME: _______________________________________________________ SOCIAL SECURITY NUMBER: _______-______-_______
LAST
FIRST
MI
EMPLOYEE HOME ADDRESS: ________________________________________________
_________________________
NUMBER AND STREET
_____
CITY
_______________
STATE
ZIP
CHECK HERE IF THIS IS A CHANGE IN ADDRESS
EMPLOYEE DAY PHONE: (
)
EMPLOYEE E-MAIL:
INDICATE WHICH COVERAGES YOU HAVE:
(CHECK ALL THAT APPLY)
MEDICAL
DENTAL
VISION
IS A SPOUSE AND/OR DEPENDENT INCLUDED:
UNDER THIS COVERAGE?: (CHECK ONE)
YES
NO
UNREIMBURSED MEDICAL EXPENSES
(QUALIFYING MEDICAL EXPENSE FOR YOU OR ANY TAX DEPENDENT)
See IRC Section 213 for qualifying Healthcare expenses or consult your tax advisor for more information.
DATED
EXPENSE
INCURRED
(MM/DD/YY)
SERVICE PROVIDER
(clinic, pharmacy,
doctor, store, etc.)
DESCRIPTION OF EXPENSE
RELATION TO
PARTICIPANT
AMOUNT PAID
(TOTAL
EXPENSE)
AMOUNT PAID
BY INSURANCE
(IF ANY)
AMOUNT
PAID BY
YOU
TOTAL UNREIMBURSED MEDICAL CLAIMS $
To the best of my knowledge and belief, my statements on this Request for Reimbursement are complete and true. I understand that I am solely responsible for the validity of claims
submitted to my Flexible Spending Account and/or Health Care Reimbursement Account. I am claiming reimbursement only for eligible expenses incurred by myself, spouse and/or
covered dependents (for FSA reimbursement, these expensed must have been incurred during the Plan Year shown above) and certify that these expenses have not been
reimbursed under this Plan or by any other source and that they will not be reimbursed by any other source or insurance. I hereby authorize my Flexible Spending Account to be
reduced by the amount(s) shown above.
X _____________________________________________
DATE ____________________________
If you have questions or need assistance, call the number listed below or visit our website.
FORM 10FSA-071703
www.We-R-Flex.com
PLEASE MAKE COPIES OF THIS FORM FOR FUTURE CLAIMS
DEPENDENT DAYCARE
REIMBURSEMENT REQUEST FORM
(For Qualifying Dependent Care Assistance Plan (DCA) Babysitting Expenses/Elder Daycare Expenses)
NOTE:
This form MUST be completed to receive reimbursement for out-of-pocket Dependent Daycare expenses for your Dependent Daycare
Account(s). These services MUST have been incurred during the current Plan Year. An itemized copy of the provider’s itemized
bill/receipt verifying the name of the care provider, the provider’s Tax ID or Social Security Number and signature, and the
date(s) of service MUST be attached to the back of this form. Your claim will not be processed until these items are received by
MGIS. Credit card receipts cannot be accepted.
RETURN COMPLETED FORM AND ALL DOCUMENTATION TO:
MEDICAL GROUP INSURANCE SERVICES, INC.
PO BOX 16110
1849 W. NORTH TEMPLE
SALT LAKE CITY, UT 84116-0110
FAX: 801.990.2401
PLEASE COMPLETE ENTIRE FORM. PRINT OR TYPE (USE ADDITIONAL SHEETS IF NECESSARY)
EMPLOYER NAME:
PLAN YEAR:
EMPLOYEE NAME: _______________________________________________________ SOCIAL SECURITY NUMBER: _______-______-_______
LAST
FIRST
MI
EMPLOYEE HOME ADDRESS: ________________________________________________
_________________________
NUMBER AND STREET
CITY
_____
_______________
STATE
ZIP
CHECK HERE IF THIS IS A CHANGE IN ADDRESS
EMPLOYEE DAY PHONE: (
)
EMPLOYEE E-MAIL:
UNREIMBURSED DAYCARE EXPENSES
(QUALIFYING BABYSITTING EXPENSES/ELDER DAYCARE EXPENSES)
See IRC Section 129 for qualifying Dependent Care expenses or consult your tax advisor for more information.
COVERED PERIOD
START DATE
END DATE
PERSON WHO
RECEIVED CARE
DATE OF BIRTH
AGE AT TIME
OF SERVICE
CARE PROVIDER NAME
TOTAL UNREIMBURSED DCA CLAIMS
AMOUNT
$
CARE PROVIDER INFORMATION
THIS SECTION MUST BE COMPLETED FOR REIMBURSEMENT
BABYSITTER INFORMATION
DAYCARE CENTER INFORMATION
NAME: _________________________________________________________ DAYCARE CENTER NAME: ________________________________________
ADDRESS: ______________________________________________________ ADDRESS: ______________________________________________________
_______________________________________________________________ ________________________________________________________________
SOCIAL SECURITY #: _____________________________________________ TAX ID#_________________________________________________________
_______________________________________________________________ ________________________________________________________________
DAYCARE PROVIDER’S SIGNATURE (REQUIRED)
To the best of my knowledge and belief, my statements on this Request for Reimbursement are complete and true. I understand that I am solely responsible for the validity of claims
submitted to my Dependent Care Assistance Plan Account. I am claiming reimbursement only for eligible expenses incurred by myself for my spouse and/or covered dependents (for
DCA reimbursement, these expensed must have been incurred during the Plan Year shown above) and certify that these expenses have not been reimbursed under this Plan or by
any other source and that they will not be reimbursed by any other source or insurance. I hereby authorize my Dependent Care Account to be reduced by the amount(s) shown above.
X _____________________________________________
DATE ____________________________
If you have questions or need assistance, call the number listed below or visit our website.
FORM 10dcA-082003
www.We-R-Flex.com