FSA Debit Card Guide

IMPORTANT: Please Read

There are many misconceptions about debit cards and FSAs. Before you read any further, it’s important to understand that using the FSA debit card does NOT eliminate the need to file paperwork with Flexible Benefit Service Corporation (FLEX).

To learn more about the requirements for your debit card claims, go directly to Section 3, page 4.

The FlexMoney Card® is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. Section 1: Understanding Your FSA Debit Card

1. What is the FlexMoney Card?

Your FlexMoney Card® is a Visa® debit card that gives you easy access to the funds in your Health Care Flexible Spending Account (FSA), and a convenient way to pay for eligible health care expenses. Using the debit card eliminates the need for you to pay out-of-pocket and wait for reimbursement.

2. When will I receive my debit card?

Once the debit card is ordered, it will be delivered to your mailing address on file within 7 to 10 business days.

3. Can I have multiple debit cards?

You will automatically receive one debit card when you enroll in the Health Care FSA. If you need additional debit cards for your spouse or dependents, you can order extras online through www.flexiblebenefit.com. You can receive up to four total debit cards per family, and there is no charge for the additional debit cards.

4. How do I activate my debit card?

Once you receive your debit card in the mail, you’ll need to activate it by calling 800-963-2071. The number and instructions for activation will be on the front of the debit card.

5. What if my debit card is lost or stolen?

If your debit card is lost or stolen, please contact our Customer Service Team at 866-472-5351 immediately. A replacement debit card will be sent within 14 days. You can also logon to flexiblebenefit.com to report your debit card as lost or stolen.

The FlexMoney Card® is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. PG.1

Learn more at f lexiblebenef it.com 866-472-5351 6. Is there a daily transaction limit?

There is a daily debit card transaction limit of $7,500 or 10 transactions, whichever comes first.

7. Can I manage my account online?

Yes, you can create an online account at www.flexiblebenefit.com that will allow you to check your balance and account details, view debit card transactions, access forms and educational materials, and more.

8. Who do I contact with questions?

For any questions regarding your debit card or your account information, please contact our Customer Service Team at 866-472-5351 or [email protected].

Section 2: Using Your FSA Debit Card

1. How does the debit card work?

Present the debit card as payment for eligible goods and services. Qualified purchases will be paid directly from your Health Care FSA. The FlexMoney Card works like any other debit card, except for a few important differences:

● It is limited to specific merchants and eligible expenses, which are determined by the benefit you selected.

● Your debit card transactions can be done as debit with the PIN provided, or as credit with no PIN required.

● The debit card cannot be used at an ATM or for cash back when making a purchase.

2. Where can I use my debit card?

You can use your debit card at qualified locations including hospitals, physician and dental offices, pharmacies and merchants with IIAS certification.

The FlexMoney Card® is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. PG.2

Learn more at f lexiblebenef it.com 866-472-5351 3. What is IIAS?

IIAS is an Inventory Information Approval System as specified by the IRS. This system allows retailers to automatically substantiate eligible Health Care FSA purchases through their inventory control system (UPS or SKU number.)

For example, if you purchase contact lens solution, which is an eligible expense, the UPC code will recognize that item as eligible and will allow the charge on your debit card.

4. What if I buy multiple items and not all are eligible?

If a retailer has the IIAS system, only the eligible items will be processed on your debit card. You will need to purchase any other, non-eligible items with another form of payment.

5. How can I find an IIAS merchant?

Retailers such as Walgreens®, CVS®, Walmart® and many more have implemented the IIAS system. For a complete list of vendors, you can check online at www.sig-is.org.

6. What expenses are eligible?

Depending on your employer’s benefit plan, it can include anything from hospital stays and doctor or dentist visits to prescription drugs and eye glasses. For a detailed listing of eligible expenses, visit the Resources section of www.flexiblebenefit.com.

7. What if there is not enough money in the account to cover the entire purchase?

The transaction will be denied, and you will need use another form of payment. You can file a request for reimbursement with Flex, and we will review your account and reimburse you with any remaining funds. Alternatively, you can ask the merchant to charge the debit card for the remaining balance and use another form of payment for the additional cost.

8. What if a doctor or merchant does not accept the debit card?

You will need to use another form of payment and submit a request for reimbursement.

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Learn more at f lexiblebenef it.com 866-472-5351 Section 3: Substantiating Your FSA Debit Card Claims

1. What is substantiation?

Before we get into the details of what substantiation means with your debit card, let’s simplify the meaning of the word. The actual definition of substantiate is to validate, verify, prove, confirm or authenticate.

Your FlexMoney Card and Health Care FSA are regulated by the IRS, and their rules require that all of your debit card transactions must be substantiated. This means, purchases made with the debit card must be proven to be eligible under the plan.

Some of your transactions—such as known co-pays and IIAS transactions—will automatically substantiate with no additional information required. All other transactions will require documentation in order to substantiate the claim as an eligible expense.

2. I used my debit card at my doctor or dentist’s office, why do I need to substantiate?

Even though a doctor or dental office is an eligible location, not all services provided are eligible under the plan. IRS regulations require that Flex verify the eligibility of all expenses charged to the debit card.

3. What information is required for substantiation?

In order to substantiate your transaction, you must provide Flex with a third party statement which includes the following information: ● The name of the person for whom the service was provided ● The date that service was provided ● The total amount of the expense ● The name of the provider ● The type of service provided

The FlexMoney Card® is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. PG.4

Learn more at f lexiblebenef it.com 866-472-5351 The following examples illustrate acceptable and unacceptable statements and information for debit card substantiation:

Both of these are Acceptable Documentation, because they include the provider’s name, the patient’s name, the date of service, a description of the service being billed and the amount charged.

CHECK CARD USING FOR PAYMENT CHECK CARD USING FOR PAYMENT Make Checks Payable to Make Checks Payable to Phone: (773) 436-0001 Phone: (773) 436-0001 ABC Dental Fax: (773) 436-0002 ABC DentalRSM Fax: (773) 436-0002 RSM Chicago Medical Group CARD NUMBER EXPIRATION DATE Chicago Medical Group CARD NUMBER Email: EXPIRATION [email protected] DATE Email: [email protected] ABC Medical ABC Medical HealthCare PO BOX 202 PO BOX325 202 Greenway Drive 325 Greenway Drive HealthCare STATEMENT DATE PAY THIS AMOUNT PATIENT ACCT# STATEMENT DATE PAY THIS AMOUNT PATIENT ACCT# Chicago, IL 60012 Chicago, IL 60012 Explanation of Benefits (EOB) THIS IS NOT A BILL Explanation of Benefits (EOB) THIS IS NOT A BILL 555 Anystreet 555 Anystreet Suite #652 Suite #652 10/18/14 $65.00 123584 10/18/14 $65.00 123584 12-12-14 12-12-14 Chicago, IL 60010 Chicago, IL 60010 Chicago, IL 60164 Chicago, IL 60164 773-945-4569 SIGNATURE 773-945-4569 SIGNATURE SHOW AMOUNT SHOW AMOUNT FOR BILLING INQUIRIES: 773-302-9874 PAID HERE PAID HERE ------FOR BILLING INQUIRIES: 773-302-9874 STORE: REGISTER:001 STORE: REGISTER:001 STATEMENT STATEMENT CASHIER: 764b CASHIER: 764b Anthony Doe Customer Service: 1-800-854-8894 Anthony Doe Customer Service: 1-800-854-8894 ASSOCIATE: 0012E ASSOCIATE: 0012E Statement #: 22587941 Bill To: Dr. Dale Jones Statement #: 22587941 Bill To: Dr. Dale Jones ------Date: December 21, 2014 ABC Dental Date:100 Ohio ave. December 21, 2014 ABC Dental 100 Ohio ave. John Doe Chicago Medical Group John Doe Chicago Medical Group Customer ID: 254789 325 Greenway Drive CustomerChicago, ID: IL 60601 254789 325 Greenway Drive Chicago, IL 60601 CUSTOMER RECEIPT 324 Main St. CUSTOMERPO BOX RECEIPT 202 324 Main St. PO BOX 202 Suite #652 Suite #652 Chicago, IL 60011 Chicago, IL 60012 Chicago, IL 60011 Chicago, IL 60012 Chicago, IL 60164 Chicago, Claim IL 60164 Information Claim Information ORIGINAL TRANSACTION INFO ORIGINAL TRANSACTION INFO Member Name: Anthony Doe Member Name: Anthony Doe

Group No: 987654321 Group No: 987654321 STORE: 0032 STORE: 0032 REGISTER: 001 REGISTER: 001 Identification No: CDE32165498 Identification No: CDE32165498 Date Type Invoice # Description Amount Payment Balance Date Type Invoice # Description AmountClaim No: Payment 202000000235XBalance Claim No: 202000000235X DATE: 12/31/2014 DATE OF CODE DESCRIPTION OF SERVICE CHARGES DATE: INSURANCE12/31/2014 BALANCE DATE OF CODE DESCRIPTION OF SERVICE CHARGES INSURANCE BALANCE NUMBER: 5194 NUMBER: 5194 Patient Name: Anthony Doe Patient Name: Anthony Doe SERVICE PAYMENTS SERVICE PAYMENTS Summary Summary 12/10/14 54556874133 Balance Forward 125.00 125.00 12/10/14Total Billed 54556874133 $45.00Balance Forward 125.00 125.00 Total Billed $45.00 259.00 259.00 Total Benefits Approved $16.20 Total Benefits Approved $16.20 10/10/14 XXXX4 OFFICE VISIT, 25 MIN $200.00 10/10/14 XXXX4 OFFICE VISIT, 25 MIN $200.00 Amount you may owe provider $1.80 Amount you may owe provider $1.80 ------$140.00 $60.00 $140.00 $60.00 SUBTOTAL 259.00 SUBTOTAL 259.00 SALES TAX 21.45 SALES TAX 21.45 The following shows how this claim was adjusted The following shows how this claim was adjusted TOTAL 281.44 TOTAL 281.44 10/10/14 XXXX5 BLOOD DRAW $20.00 ------10/10/14 XXXX5 BLOOD DRAW $20.00------AMOUNT TENDERED AMOUNT TENDERED Service Information Service Information VISA 281.44 VISA 281.44 $15.00 $5.00 $15.00 $5.00 Amount Not ACCT:*******1245 ACCT:*******1245 Service Description Service Date Amount Not Covered Service Description Service Date Covered Covered EXP:***** EXP:***** Billed Covered Billed APPROVAL:9999 APPROVAL:9999 IMAGING RADIOLOGISTICS LLC IMAGING RADIOLOGISTICS LLC CARDHOLDER: JANE SMITH CARDHOLDER: JANE SMITH TOTAL PAYMENT 281.44 TOTAL PAYMENT 281.44 MEDICAL EMERG X-RAY 11/09/14 45.00 27.00 (1) 18.00 MEDICAL EMERG X-RAY 11/09/14 45.00 27.00 (1) 18.00

------TRANSACTION: 1/8/2005 2:40 PM TRANSACTION: 1/8/2005 2:40 PM Totals 45.00 27.00 18.00 Totals 45.00 27.00 18.00 CARDHOLDER SIGNATURE: CARDHOLDER SIGNATURE:

Coverage Information Coverage Information ______$125.00 Total $125.00 Total Totals 45.00 27.00 18.00 Totals 45.00 27.00 18.00 Reminder: Please include the statement number on your check. Reminder: Please include the statement number on your check. PARTICIPATING PROVIDER OPTION (PPO REDUCTION) -$27.00 PARTICIPATING PROVIDER OPTION (PPO REDUCTION) -$27.00 Terms: Balance due in 30 DAYS. Terms: Balance due in 30 DAYS. Deductions Deductions Your 10% Coinsurance Amount...... 1.80 Your 10% Coinsurance Amount...... 1.80 Customer Name: Jon G. Castro CustomerTotal Name: Deductions Jon G. Castro -$1.80 Total Deductions -$1.80

Total Benefits Approved $16.20 Statement #: 22587941 StatementTotal #:Benefits 22587941 Approved $16.20

Amount You May Owe Provider $1.80 Date: 12/21/14 Date: Amount You 12/21/14 May Owe Provider $1.80 30-60 DAYS 60-90 DAYS 90-120 DAYS 90-120 DAYS CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS 90-120 DAYS CURRENT AMOUNT Total covered benefits approved for this claim: $16.20 to IMAGING RADIOLOGISTICS LLC 12-12-14 Total covered benefits approved for this claim: $16.20 to IMAGING RADIOLOGISTICS LLC 12-12-14 AMOUNT Amount Due: $125.00 $65.00 Amount Due: $125.00 $65.00 DUE: $65.00 DUE: $65.00

CHECK CARD USING FOR PAYMENT CHECK CARD USING FOR PAYMENT Make Checks Payable to Phone: (773) 436-0001 Make Checks Payable to Phone: (773) 436-0001 ABC Dental Fax: (773) 436-0002 RSM ABC Dental Fax: (773) 436-0002 RSM Chicago Medical Group CARD NUMBER EXPIRATION DATE Chicago Medical Group CARDEmail: NUMBER [email protected] EXPIRATION DATE Email: [email protected] ABC Medical PO BOX 202 ABC Medical 325PO Greenway BOX 202 Drive HealthCare HealthCare STATEMENT DATE PAY THIS AMOUNT PATIENT ACCT# 325 Greenway Drive Chicago, IL 60012 STATEMENT DATE PAY THIS AMOUNT PATIENT ACCT# Explanation of Benefits (EOB) THIS IS NOT A BILL 555 Anystreet SuiteChicago, #652 IL 60012 Explanation of Benefits (EOB) THIS IS NOT A BILL 10/18/14 $65.00555 Anystreet123584 Suite #652 12-12-14 Chicago, IL 60010 Chicago, IL 60164 10/18/14 $65.00 123584 12-12-14 773-945-4569 SIGNATURE Chicago, IL 60010 SHOW AMOUNT Chicago, IL 60164 773-945-4569PAID HERE SIGNATURE FOR BILLING INQUIRIES: 773-302-9874 SHOW AMOUNT ------PAID HERE STATEMENT STORE: REGISTER:001 ------FOR BILLING INQUIRIES: 773-302-9874 CASHIER: 764b Anthony Doe Customer Service: 1-800-854-8894 ASSOCIATE: 0012E STORE: REGISTER:001 Statement #: 22587941 Bill To: Dr. Dale Jones STATEMENT ------Date: December 21, 2014 ABC Dental 100 Ohio ave. John Doe CASHIER:Chicago 764b Medical Group Anthony Doe Customer Service: 1-800-854-8894 ASSOCIATE: 0012E Customer ID: 254789 325 Greenway Drive Chicago, IL 60601 Statement #: 22587941 Bill To: Dr. Dale Jones CUSTOMER RECEIPT 324 Main St. PO BOX 202 100 Ohio ave. ------Suite #652 Date: December 21, 2014 ABC Dental Chicago, IL 60011 Chicago, IL 60012 John Doe Chicago Medical Group Chicago, IL 60164 Customer ID: 254789 Claim Information 325 Greenway Drive Chicago, IL 60601 ORIGINAL TRANSACTION INFO CUSTOMER RECEIPT Member Name: Anthony Doe Unacceptable 324 Main St. PO BOX 202 Unacceptable Group No: 987654321 Suite #652 STORE: 0032 Chicago, IL 60011 Chicago, IL 60012 REGISTER: 001 Identification No: CDE32165498 Date Type Invoice # Description Amount Payment Balance Chicago, IL 60164 Claim Information DATE: 12/31/2014 Documentation ORIGINAL TRANSACTION INFO Documentation Claim No: 202000000235X DATE OF CODE DESCRIPTION OF SERVICE CHARGES INSURANCE BALANCE Patient Name: Anthony Doe Member Name: Anthony Doe NUMBER: 5194 SERVICE PAYMENTS Summary Group No: 987654321 STORE: 0032 REGISTER: 001 12/10/14 54556874133 Balance Forward 125.00 125.00 Total Billed $45.00 Identification No: CDE32165498 Does not include Total BenefitsDoes Approved not include $16.20Date Type Invoice # Description Amount Payment Balance Claim No: 202000000235X 259.00 10/10/14 XXXX4 OFFICE VISIT, 25 MIN $200.00 DATE: 12/31/2014 DATE OF CODE DESCRIPTION OF SERVICE CHARGES INSURANCE BALANCE NUMBER: 5194 Amount you may owe provider $1.80 Patient Name: Anthony Doe ------Summary ------description of item SERVICE PAYMENTS original date of $140.00 $60.00 SUBTOTAL 259.00 or service being service. 12/10/14 54556874133 Balance Forward 125.00 125.00 Total Billed $45.00 SALES TAX 21.45 The following shows how this claim was adjusted TOTAL 281.44 259.00 Total Benefits Approved $16.20 ------10/10/14 XXXX5 BLOOD DRAW $20.00 10/10/14 XXXX4 OFFICE VISIT, 25 MIN $200.00 ------billed. Amount you may owe provider $1.80 ------Service Information AMOUNT TENDERED ------Does not include VISA 281.44 $15.00 $5.00 $140.00 $60.00 ACCT:*******1245 SUBTOTAL 259.00 Service Description Service Date Amount Not Covered EXP:***** Does not include the SALES TAX 21.45 description of Billed Covered APPROVAL:9999 The following shows how this claim was adjusted TOTAL 281.44 IMAGING RADIOLOGISTICS LLC CARDHOLDER: JANE SMITH date of service, only ------10/10/14 XXXX5 BLOOD DRAW $20.00 item or service TOTAL PAYMENT 281.44 ------MEDICAL EMERG X-RAY 11/09/14 45.00 27.00 (1) 18.00

------the payment date. AMOUNT TENDERED being billed. Service Information TRANSACTION: 1/8/2005 2:40 PM VISA 281.44 45.00 27.00 18.00 $15.00 Totals$5.00 Amount Not CARDHOLDER SIGNATURE: ACCT:*******1245 Service Description Service Date Covered EXP:***** Billed Covered APPROVAL:9999 Coverage Information IMAGING RADIOLOGISTICS LLC ______CARDHOLDER: JANE SMITH Total $125.00 TOTAL PAYMENT 281.44 MEDICAL EMERG X-RAY 11/09/14 45.00 27.00 (1) 18.00 Totals 45.00 27.00 18.00 ------Reminder: Please include the statement number on your check. PARTICIPATING PROVIDER OPTION (PPO REDUCTION) -$27.00 TRANSACTION: 1/8/2005 2:40 PM Terms: Balance due in 30 DAYS. Deductions Totals 45.00 27.00 18.00 1.80 CARDHOLDER SIGNATURE: Your 10% Coinsurance Amount...... Customer Name: Jon G. Castro Total Deductions -$1.80

Statement #: 22587941 Total Benefits Approved $16.20 Coverage Information ______$125.00 Date: 12/21/14 Amount You May Owe Provider $1.80 Total Totals 45.00 27.00 18.00 CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS 90-120 DAYS AMOUNT Total covered benefits approved for this claim: $16.20Reminder: to IMAGING RADIOLOGISTICS Please include LLC 12-12-14 the statement number on your check. $65.00 Amount Due: $125.00 PARTICIPATING PROVIDER OPTION (PPO REDUCTION) -$27.00 $65.00 DUE: Terms: Balance due in 30 DAYS. Deductions Your 10% Coinsurance Amount...... 1.80 CustomerPG.5 Name: Jon G. Castro Total Deductions -$1.80 Statement #: 22587941 Total Benefits Approved $16.20

Date: 12/21/14 Amount You May Owe Provider $1.80

Learn more at f lexiblebenef it.comCURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS 90-120 DAYS AMOUNT 866-472-5351 Total covered benefits approved for this claim: $16.20 to IMAGING RADIOLOGISTICS LLC 12-12-14 $65.00 Amount Due: $125.00 $65.00 DUE: Generally, an Explanation of Benefits (EOB) from your insurance company or an itemized statement from the provider should include all of the necessary information. Please note that provider statements containing a “balance forward” amount and credit card or cash register receipts are not sufficient for the purposes of substantiation.

4. How do I substantiate my debit card transactions?

Your debit card transactions can be substantiated online through your participant account at www.flexiblebenefit.com. When you logon and view your claims information, all of the transactions that require substantiation will be listed in a category called “Needs Receipts.”

You can scan and upload the appropriate documentation and attach it to the claim, or you can print a customized coversheet that contains all of the claim details and use it to fax, mail or email the information to Flex.

5. Will I be notified when substantiation is required?

Yes, if a transaction cannot be automatically substantiated, then you will receive an email from Flex requesting additional information. If we do not have an email address on file for you, then we will mail a letter to your home. If the information is not received after the initial notification, then you will receive additional reminders that substantiation is required.

6. What happens if I don’t substantiate a transaction?

If substantiation is not received in accordance with your plan—normally within 30 days of the transaction—your debit card will be suspended and you will not be able to use your debit card for new purchases until the outstanding transaction is substantiated. If your debit card is placed in suspended status, you will receive a communication from Flex to let you know.

7. What happens if my debit card is suspended?

Your debit card can be reactivated if you send the information necessary to substantiate the outstanding charge. Please note that it take 2-3 business days for reactivation once the documentation is received and the transaction has been substantiated.

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Learn more at f lexiblebenef it.com 866-472-5351 8. My debit card has been suspended. Can I still access my FSA?

Yes, if you ever have to pay out of pocket for any reason, you can file a claim with Flex and we will reimburse you. You will still need to provide the appropriate documentation so that our Claims Team can verify that the expense was eligible.

9. What if my transaction was not eligible or I am unable to provide appropriate documentation?

If your transaction was ineligible or if you cannot provide the requested documentation, you may instead pay back the plan for the unsubstantiated amount or use other unreimbursed expenses to offset the charge.

10. I’ve had debit cards in the past with other FSA providers and never had to substantiate a transaction before. Why do I have to do this with Flex?

The IRS updates their regulations regarding substantiation periodically and Flex follows the most current regulations, which include the need to verify transactions which do not follow the guidelines for auto-substantiation.

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Learn more at f lexiblebenef it.com 866-472-5351