2012 Employer Renewal Packet
TASC CARD
TASC, 2302 International Lane, Madison, WI 53704 • 800-422-4661 • www.tasconline.com Table of Contents
Employer Materials Make the Most of your FSA Program...... 3 Renewal Checklist...... 4 Employer Enrollment Guide...... 6 TASC Claim ConneX is ready to work for you...... 9 Non-Discrimination Testing Instructions...... 10 Non-Discrimination Testing Worksheet...... 14 TASC’s “Confidentially Speaking” Reporting Program...... 16
Employee Materials Advantages of a Flexible Spending Account...... 18 How to Enroll Online...... 20 Stay Connected Wherever You Go: MyTASC Mobile App, Text, Email...... 21 Eligible and Ineligible Expenses...... 22 Prescription Order Form...... 26 Direct Deposit Election Form...... 28 The TASC Card: MyBenefits. MyCash. MyWay...... 29 Additional TASC Card Request for Spouse or Dependent...... 30 Othodontia Worksheet & Instructions...... 31
TASC, 2302 International Lane, Madison, WI 53704 • 800-422-4661 • www.tasconline.com Make the Most of your FSA Program
Don’t Lose Value by Overlooking Employee Education
By offering a FlexSystem FSA, you provide a valuable benefit to your employees. But it is also important to let them know why they would Increased participation leads to want to participate. Increased participation not only helps your employees greater tax savings for both save money, it also benefits your bottom line! employees and employers! A Win-Win Opportunity • Your employees save nearly 30% on their eligible healthcare and/or
dependent care expenses by using pre-tax dollars. • Employers save on payroll taxes for each and every dollar of Employer Savings Example employee participation. • Employers owe no payroll taxes on employee FSA contributions. Average participation in an FSA: 20-30% • With increased participation rates, employer tax savings can offset 25 Employees the cost of FSA administration. Average election of Healthcare FSA Dollars: $1,500 = $37,500 in pre-tax dollars You will see increased employee satisfaction and retention by offering this attractive employee benefit and promoting the 10 Employees Average election of Dependent Care FSA Dollars:$5,000 features and substantial value. = $50,000 in pre-tax dollars Provide Education on the Plan Benefits Total = $87,500 Education helps your employees understand the “true cost” of Multiplied by Employer’s FICA contribution of 7.65% healthcare and realize the valuable tax savings through = $6,693.75 in Annual Employer Savings*! participation in FlexSystem FSA: The Plan Pays for Itself! • Group meetings *This amount increases if you include the savings in healthcare • Introductory letters premiums! • Online tax savings calculator (TASC Web site) • Educational materials (flyers, posters, etc.)
Promote the Attractive Plan Features • The TASC Card provides a convenient way for your employees to pay for eligible out-of- pocket expenses directly from their available FlexSystem balance(s). • With the MyCash feature, reimbursements are automatically made to the TASC Card, and those funds can be spent any way, anywhere, at any retailer that accepts Visa. • TASC Mobile offers a freemobile app and text messaging that allows FlexSystem Participants to access their account from anywhere at any time!
TASC • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623 • www.tasconline.com
FX-4251-101511 Renewal Checklist Review & Renew
New Features Added This Year
TASC is dedicated to making life easier for you and your employees with new and improved enhancements to FlexSystem. Some of the most exciting new additions are noted below.
• Option to enter a Run Out End Date for terminated Participants that is different from active participant’s Run Out End Date.
• MyTASC Mobile App – Easily access your FlexSystem account balances using your mobile device. Free downloads from Apple App Store and Android Market for your smartphone or tablet.
• MyCash – The new TASC Card holds a separate account just for reimbursements. Instead of waiting several days to receive a reimbursement check in the mail, the reimbursement will be directly deposited in the cardholder’s MyCash account. TASC Card holders enrolled in direct deposit will still receive reimbursement via direct deposit; all other participants will receive reimburse- ment directly on their TASC Card. MyCash funds can be used just like cash at any retailer that accepts Visa. Funds can be transferred to a personal checking or savings account, or withdrawn at an ATM.
• MyService Center – Find all the information you need to evaluate the quality of our service. View the status of your service requests, view reports and activity.
Notification Features Available on MyTASC
Participant communications may be sent via e-mail or text message. Sign up online at www.tasconline.com. A valid e-mail address is required for participants to access their account information via the web and to receive e-mail notifications about their claim payment and account status. Employees without an e-mail address may set one up for free with an e-mail hosting service such as Gmail, Hotmail, Yahoo, etc. The perfect time to collect and enter their e-mail address in MyTASC is at enrollment time.
Notifications are sent for any of the following: • Current balance information before the end of the Plan Year, includes Grace Period and Run Out Period • Upon receipt of a Request for Reimbursement (RFR) • When a Request for Reimbursement has been paid • When a Request for Reimbursement has been denied • Request for Reimbursement Forms
Interested in Offering the TASC Card?
If you don’t currently offer the FlexSystem TASC Card to your FSA Participants but would like to, simply complete and return the FlexSystem TASC Card Application, available at the FlexSystem Renewal Resource site. After you are signed up, the TASC Card forms and materials may be distributed to your eligible employees. Please contact TASC Added Advantage at 888-595-2261, ext. 17730 or [email protected] for questions.
Renewal Basics m Update all Plan information in MyTASC for the new Plan Year. All information must be completed before your Participants can enroll. Refer to the details in Step 1 of the Employer Enrollment Guide. m Determine how you will collect your eligible employees enrollment information:
Paperless (online) - The easiest and most efficient method for enrollment. Employees simply enroll online at www.tasconline. com. Refer to the “How to Enroll Online” flyer included in the renewal download. Paper enrollment - For those employees who cannot enroll online, customized paper enrollment forms are available in your MyTASC account under the Enrollment Management screen. Employees return these forms to you for entry into MyTASC. Details are in Step 2 of the Employer Enrollment Guide.
If you collect enrollment information via another source, you may wish to utilize the MyTASC “Upload Microsoft Excel Enroll Spreadsheet” option to add the data into MyTASC. Refer to Step 4d in the Employer Enrollment Guide for details. m Communicate and Provide Education to your eligible employees. Set a deadline date that your open enrollment period will end. Be sure to leave yourself enough time to finalize the enrollments at least two (2) weeks prior to the start date of your new Plan Year. If your Plan renews on January 1, enrollments must be finalized no later than December 7 to ensure new Participants receive TASC Cards by Janaury 1. Communicate the open enrollment deadline date to your eligible employees and provide them with educational materials and enrollment information accessible at the FlexSystem Renewal Resource (see link at top of previous page). Print all materials and distribute paper copies to eligible employees. Notify employees that a valid e-mail address is required to access the on-line enrollment and their account via the web. Employees without a valid e-mail address may set one up for free with an e-mail hosting service such as Gmail, Hotmail, Yahoo, etc. Only benefit related e-mails are sent to this address; no SPAM or other notifications are sent. m Begin the Enrollment Process: Participants enroll online or complete the customized Enrollment Form. m For Paper Enrollments only, update the Participant’s elections in MyTASC. Refer to Step 4 of the Employer Enrollment Guide. m Finalize your Enrollments: Review Participant contribution amounts and submit online. m Distribute the Summary Plan Description (SPD) to all Participants. m Review the Non-Discrimination Testing Memo. Please note that testing is completed at the end of the Plan Year. If you would like TASC to complete your non-discrimination testing, be sure to submit your Plan information for the current Plan Year no later than 45 days before the last day of your Plan year. m Form 5500: Employers that have 100 or more Participants in the Medical (Out-of-Pocket) Flexible Spending Account only, in any given Plan Year, must file a Form 5500 after the close of their Plan. Compliance is the employer’s responsibility and failure to file the annual return can result in penalties. Form 5500 must be filed by the last day of the seventh month after the PlanY ear ends. If needed, a one-time extension may be requested by filing IRS Form 5558 by the date of the original filing deadline.
If you would like TASC to complete your Form 5500 filing, go to www.tasconline.com/5500// and complete the 5500 Data Request Form and submit it to TASC. Upon receipt of your completed Data Request Form, TASC will prepare the Form 5500 and Summary Annual Report (SAR). It is the Employer’s responsibility to sign and submit the Form 5500 electronically. Once TASC has prepared the forms, an e-mail will be sent to you with instructions on how to electronically sign and submit your Form 5500.
No further communication will be sent out regarding Form 5500. If TASC does not receive your completed Data Request Form, it is assumed that you do not wish to utilize this service.
TASC • 2302 International Lane • Madison, WI 53704-3140 • 1-800-422-4661 • Fax: 608-245-3623 • www.tasconline.com
The information in this communication is confidential and may be used by the authorized recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-3438-103111
Employer Enrollment Guide Step-by-Step instructions to complete your enrollment!
Step 1: Renew or Set Up Your Plan Enter all of your Plan information under Plan Management and verify that it is accurate and complete. This is critical to ensure your new Plan is set up correctly. If you choose to add the TASC Card, complete the TASC Card Application and submit it to TASC.
a. Login at www.tasconline.com using your username and password. These can be obtained through the web site or by contacting our Customer Care Center at 1-800-422-4661.
b. Click on the Plan Management link Renewing clients select “Renew.” New Clients select the Details link.
c. Enter Payroll Verification Report dates Enter the dates TASC should expect to receive the Participant payroll contributions for each payroll cycle. This is very important to ensure the payment of Participant Requests for Reimbursement will not be interrupted.
d. Enter the Plan’s account information Eligibility requirements Plan maximums TASC Card Copay Amounts (if card is elected) Number of days for Run Out Period and Grace Period Number of days for a terminated participant’s Run Out Period, if applicable to your plan
Step 2: Select Enrollment Option Eligible employees can enroll online or via paper enrollment forms.
a. Enrollments must be submitted (finalized) at least 2 weeks prior to your new Plan Year start date. Plans with a January 1 effective date need to have enrollments submitted by December 7. This is to ensure new Participants receive TASC Cards by January 1.
b. Select the Enrollment Management link.
c. To obtain a list of Participant usernames (Participant TASC ID), select “Download Microsoft Excel Enroll Spreadsheet”.
d. For paper enrollments, select “Download Customized Enrollment Forms.”
Step 3: Communicate and Educate a. Set a deadline date for your enrollment period to end and communicate the deadline to all eligible employees. Remember to leave yourself enough time to finalize the enrollments two weeks prior to the start of your new Plan Year. b. Distribute the educational materials to all eligible employees from the renewal download at: www.tasconline.com/flexsystemclientrenewal.html.
© Total Administrative Services Corporation FX-3597-103111 c. Provide FSA eligible employees not currently enrolled in FlexSystem with the Client ID# for the Plan. New enrollees need the Client ID# to access the enrollment site. Prospective employees with questions concerning the Plan, can enter the Client ID# when calling TASC and be quickly routed to an appropriate FlexSystem Customer Care Specialist.
Step 4: Enroll Employees
All enrollments are entered online at www.tasconline.com. You may begin to complete the enrollment process at any time, even if you do not have all of your employee’s enrollment information. Prior to starting enrollment, select the Plan Management link and verify the plan shows a “Set Up” status.
For all enrollments review and update each employee’s e-mail address and phone number in MyTASC. An e-mail address is required for a participant to access their account via the web and to receive claim payment and account status notifications. No SPAM or other e-mails are sent to this address. By entering the home phone number, participants calling from their home phone are swiftly identified and routed directly to a FlexSystem Customer Care Specialist. Participants appreciate how quickly this routes them through the phone prompts. Phone numbers are used for phone recognition only.
a. Online Enrollment – Eligible employees complete their own enrollment online. Distribute the “How to Enroll Online” flyer to all eligible employees. (Distribute all additional enrollment materials at this time.) A valid e-mail address is required for the employee to access on-line enrollment and account information via the web. Employees without an e-mail address may set one up for free with an e-mail hosting service such as Gmail, Hotmail, Yahoo, etc. Once employees have completed their enrollment, login to your account and review each enrollment for accuracy. Select the Enrollment Management link, select the Plan and view all employees that have completed their enrollment. A red asterisk next to an employee’s name indicates that they have completed their enrollment.
b. Paper Enrollment – Enter Existing Participants (re-enrollment) Select Enrollment Management and the new Plan Year from the drop down. Locate the employee, select “Profile,” enter their e-mail address and phone number, and verify the street address. A valid e-mail address is required for employees to access their account via the web. Go back to the employee list, select “Elections” and enter the annual election for each benefit. Review the information and select “Save” to complete. Repeat the above for all employees.
c. Paper Enrollment – Entering New Participants From the Enrollment Management screen, select the new Plan Year from the drop down and select “Enroll Participant”, then “New Participant.” Enter the employee’s name, e-mail address, phone number, street address and select “Next.” A valid e-mail address is required for employees to access their account via the web. Select their elected benefits, enter the annual election amounts and select “Next.” Review all information and select “Save” to complete.
d. Enrollment via an Excel Spreadsheet From the Enrollment Management screen, select the new Plan Year from the drop down. Select the Download Enrollment Input File link. Click “Download” in the first pop-up window and “Open” in the next. Enter or modify your employee’s information following the column titles. You may be able to copy and paste from your database; however do not change the existing format of the FlexSystem spreadsheet. Ensure each participant has an e-mail address listed on the spreadsheet. E-mail addresses are required for participants to access their account via the web and to receive e-mail notifications about their claim payment status. Enter an e-mail address for all participants missing this information. (Participants will only receive e-mails concerning their claim and account status.)
© Total Administrative Services Corporation FX-3597-103111 Be sure to enter in the Client ID and Plan ID for all Participants. Once all employees have been entered on the spreadsheet, save the file to your local drive. Return to your Enrollment Management tools and select “Upload Microsoft Excel Enroll Spreadsheet.” Click on the “Browse” button, find and highlight your saved file and select “Open.” (After selecting “Open,” you will need to refresh the page by going to Client Manager and then back to Enrollment Management to continue.) Choose the Plan Year in Setup, select the Approved but not Submitted tab and you will see all of your Participants. Note: If employees are listed in the Unapproved Enrollment tab, then the upload failed. Look for an e-mail from tasconline.com that will tell you what is wrong and why the upload failed. Select “Submit” and the Plan will open to the new Plan Year’s Payroll Verification Report.
Step 5: Finalize Enrollments Once you have all enrollment information entered and confirmed for accuracy, submit your enrollments.
a. For Online or Paper Enrollments, select the Unapproved Enrollment tab and verify your employee’s elections. b. Select the Approve All button or select employees individually and select “OK.” c. After all enrollments have been approved, select the Approved But Not Submitted tab, select “Submit.” This step must be completed for enrollments to be finalized.
Step 6: Review Contributions & Funding View the online Payroll Verification Report (PVR) to verify Participants’ deduction amounts and review your current funding selection. This must be completed after the Start Date of your Plan and before your first Payroll Verification Date.
a. Select “Client Manager” and then Payroll Verification Report.
b. Select the new Plan Year and review all Participants’ deduction amounts. The amounts in MyTASC must match each employee’s payroll deduction amount.
c. To view the deduction amount for each benefit, select the By Benefit link.
d. Edit deductions that are incorrect. Select the Account link. Select the Contribution Tab. Click on the Change link and edit the contribution amount(s).
e. Submit payment by selecting the “Submit” button. Be sure to do this in advance of the Expected Date of Receipt listed on the Payroll Verification Report (PVR) Date. This will ensure funds are available for Participants’ Requests for Reimbursement. Note: this portion of Step 6 is not necessary if the Auto ACH feature has been enabled on your Plan.
Step 7: Nondiscrimination Testing To ensure your Plan complies with all of the rules and regulations of the Internal Revenue Services, please review the Nondiscrimination Testing Memo and take action, if necessary.
Step 8: Summary Plan Description (SPD) Your Participants are now enrolled and your FlexSystem Plan is in place and operating. You must now download the Summary Plan Description and deliver it to all FlexSystem Participants. The Summary Plan Description will be available online following your Plan start date. Access your Summary Plan Description by: a. From the Client Manager screen, select the Plan Management link. b. Select “View SPD.” c. Review your Summary Plan Description to ensure all information is accurate. d. Distribute the Summary Plan Description to all Participants in the Plan.
© Total Administrative Services Corporation FX-3597-103111 TASC Claim ConneX is ready to work for you!
Claim ConneX is a service option provided by TASC to alleviate the time and labor costs associated with claims processing through our FlexSystem and DirectPay programs.
Similar to the concept of the TASC Card, Claim ConneX is designed to streamline and simplify the reimbursement process and to reduce workload for all concerned. This electronic auto submittal and auto adjudication of claims will come at no additional cost to the Client or Participant. Our goal with this technology, as always, is to increase customer satisfaction! How it Works When an Employer chooses to use the Claim ConneX service, they Employer Features submit the completed Claim ConneX Client Authorization & Enrollment Form to TASC. We then begin working with the designated Carriers to • Faster, efficient service! establish the workflow*. • No cost to utilize • Reduces manually filed claims Once Claim ConneX is established for a FlexSystem and/or DirectPay Plan, TASC begins to receive claims automatically from the insurance • Maximizes employee benefit program carrier on behalf of the Participant. • Saves time with Carrier file feeds • Saves time with mass claims processing Add Value to Your Benefits Program! • Works for businesses of all sizes Employers who enroll in this technology receive faster administrative service and increase the value of their employee benefits program. Participant Features Service will be faster and more efficient. Plan Participants no • No need to submit a Request for longer need to submit a request for reimbursement and provide Reimbursement (RFR) claim substantiation. With Claim ConneX, the entire process is • No need to submit substantiation automated and turnaround time is greatly reduced! (keep receipts for personal records) • Eliminates risk of fax transmission error Employee confusion will be alleviated. Greater coordination • Quicker reimbursement turnaround from TASC and integration between health insurance carriers and the reimbursement Plan will mean fewer questions about “when and For enrollment information, please visit: how” to submit claims, or whether a claim is in process. www.tasconline.com/claimconnex/ Paperwork will be reduced! This is just one more example of how TASC is going green. And with less paperwork, quality will increase and privacy of personal health information will be further protected.
*Please note, in some cases TASC may need to obtain a carrier-specific authorization form. In addition, while most carriers will perform electronic claim feeds for benefit accounts (i.e. FSA, HRA, HSA, etc.), TC-4327-083010 certain carriers may not be equipped to do so; Claim ConneX is not available for those carriers at present. In either case, TASC will contact you.
TASC offers a complete suite of quality services, including the following: 2302 International Lane, Madison, WI 53704-3140 COBRA I ERISA I FSA I FMLA I HRA I HSA 800-595-2261 • Fax 608-241-4584 [email protected] • www.tasconline.com
TASC 2302 International Lane Madison, WI 53704-3140 800-422-4661 Fax: 608-245-3623 www.tasconline.com
To: FlexSystem Clients
Subject: Non-Discrimination Testing Instructions
Non-Discrimination Testing Guidance has been provided under the 2007 proposed cafeteria plan regulations as to when non-discrimination testing must be completed for a Flexible Spending Account (FSA). This guidance indicates that testing must be completed at the end of the plan year. Due to these regulations, TASC requests the non-discrimination testing worksheet be completed and submitted 45 days prior to the end of your plan year.
It is important for each employer to monitor their plan at all times during the plan year for possible discrimination issues and to make any corrections before the plan ends.
Testing Process The non-discrimination data worksheet that you need to complete is included with this kit. Complete the data worksheet using data from your current Plan Year (not your renewing Plan Year). Submit your completed data worksheet to TASC approximately 45 days prior to the end of your plan year to allow enough time for completion of the testing and to make any required adjustments for discriminatory plans. If preferred, an employer may request TASC to perform additional testing at the beginning of the plan year, or at any other time during the plan year, in conjunction with or in place of the end of the year testing. Simply place a request to Premium Services. Keep in mind the regulations require testing to be completed and in compliance as of the end of the plan year. If your plan has a significant change after the data worksheet has been submitted, additional testing may need to be completed to ensure the plan is still in compliance as of the last day of the plan year. Fax or mail your completed data worksheet to TASC: Fax: 608-245-3623 Mail: 2302 International lane Madison, WI 53704-3140 You will be notified of the results of your plan’s testing approximately 30 days after receipt of the completed data worksheet.
Instructions The elections of highly compensated employees are limited to 33 percent of what the non-highly compensated group contributes. Consider all employer and employee contributions made through your Cafeteria Plan for insurance, medical out-of-pocket FSA, dependent care FSA, non-employer sponsored insurance premiums, health savings account (HSA), etc. when making this determination.
Enter your Client Name, Client ID# and the plan year starting and ending dates at the top of the form.
The information in this communication is confidential and may be used by the authorized Recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-4258-042811
Definition of a Highly Compensated Employee o All officers of the corporation and/or o Owners of more than 5% of all classes of stock, and/or o Employees who earned in excess of the defined limit in the preceding year, limits are $110,000 for 2010 and 2011, and if elected by the Employer are in the top 20% in income (refer to the 20% Top Paid Group Rules below), and/or o Employees who are a spouse or a dependent (under Code 152) of employees meeting any of the above definitions.
Definition of Compensation For purposes of determining whether an employee is an HCE “compensation” means the employee's compensation from the employer for the year. This includes salary deferral and salary reduction amounts from the following sources: Section 125 cafeteria plan; Qualified transportation fringe benefit plan under 132(f)(4); 401(k) plan; Simplified employee pension plan (SARSEP); SIMPLE plan under Code 408(p); Tax sheltered annuity under Section 403(b); Code 457 plan.
In the case of a self-employed individual, compensation means that person’s earned income for the year.
20% Top Paid Group HCE Determination Employers having difficulty passing non-discrimination testing may find it advantageous to use the 20% Top Paid Group Rules in determining who is a highly compensated employee (HCE). First determine who your HCEs are under the definition provided above. Then complete the process below for the 20% Top Paid Group Rules to see if this reduces the number of HCEs. If so, using this method may help the Plan pass non-discrimination testing. This HCE determination method may be used for any year and once elected must be applied consistently with respect to all plan years beginning in the same calendar year for all plan non-discrimination testing (retirement and non-retirement plans).
Determining the HCEs in the 20% Top Paid Group is a two-step procedure.
First, determine the number of employees that corresponds to 20% of the employer’s employees. In determining this number, the employees below may be excluded even if the plan allows their participation. Take the total number of employees, remove the exclusions below and multiply the remainder by 20%. The result is the “20% number”. Employees who have not completed six months of service by the end of the year. For this purpose, an employee’s service in the immediately preceding year is added to service in the current year in determining if the exclusion applies to a particular employee in the current year. Employees who normally work less than 17.5 hours per week.
The information in this communication is confidential and may be used by the authorized Recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-4258-042811
Employees who normally work not more than six months during any year. The determination is made on the basis of the facts and circumstances of the particular employer as shown by the employer’s customary experience in the years preceding the determination year. An employee who works on one day during a month is deemed to have worked during that month. Employees who have not attained age 21 by the end of the year. Nonresident aliens with no U.S. source income. Employees included in a unit of employees covered by a collective bargaining agreement, if at least 90% are covered by the collective bargaining agreement and the plan tested covers only non-union employees.
Secondly, identify the employees who received the most compensation during the prior year. The only exclusions that may be applied for this step are: Employees who have not performed any services in the testing year. Employees covered by a bargaining unit (as noted above).
For example, even if an employee who normally works for less than 17.5 hours is excluded in determining the number of HCEs, that employee may be a member of the top paid group.
Make a list of the employees in descending order of compensation (highest paid to lowest paid). Stop after reaching the number determined in step 1 (20% of employees). These employees are the top paid group. Only those employees in the top paid group whose compensation exceeds the compensation limit are the HCEs to use in the non-discrimination testing.
If the result of the 20% Top Paid Group reduces the number of HCEs, it may be more advantageous for an employer to use this method for non-discrimination testing. Keep in mind the consistency requirement in respect to all plan non-discrimination testing as noted above.
Example of 20% Top Paid Group Determination
Employer X has 200 active employees during the determination year, 80 of them work less than 17.5 hours per week. Employer X excludes all employees who normally work less than 17.5 hours per week in determining the number of employees in the top paid group. The employer top paid group for the determination year consists of 20 percent of 120 or 24 employees.
All 200 of the employer’s active employees must then be ranked in order by compensation received during the prior year. The 24 employees the employer paid the greatest amount of compensation, above the compensation limit for the prior year, are considered to be the employees in the top paid group and are the HCEs for non- discrimination testing.
Step 1 – Highly Compensated Employees Identify who your highly compensated individuals are (that participate in any pre-tax account offered through your Cafeteria Plan) for this Client ID, (if none, write “none”). Attach additional sheets if necessary. Enter the annual amount the company contributes to each highly compensated employee’s group health insurance premiums offered under your Cafeteria Plan. (If zero, enter 0.00.) Enter the annual amount the highly compensated individuals pay for insurance premiums offered under your Cafeteria Plan. (If zero, enter 0.00.)
The information in this communication is confidential and may be used by the authorized Recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-4258-042811
Enter the annual amount the highly compensated individuals contribute to a Health Savings Account (HSA) under the Cafeteria Plan. Enter the annual amount the company contributes to a highly compensated individuals Health Savings Account (HSA) under the Cafeteria Plan. Enter the combined amount of HCE subtotals for Step 2.
Step 2 – Non-Highly Compensated Employees Enter the annual amount the company contributes to all other employee’s (the non-highly compensated employees) group health insurance premiums offered under your Cafeteria Plan. Enter “none” if the company does not provide any insurance benefits. Enter the annual amount of the employee’s portion of group health insurance premiums offered under the Cafeteria Plan (all non-highly compensated employees added together). Do not include daycare, medical reimbursement, transportation, or Non-Employer Sponsored Insurance Premium elections. Enter the annual amount the non-highly compensated individuals contribute to a Health Savings Account (HSA) under the Cafeteria Plan. Enter the annual amount the company contributes to a Health Savings Account (HSA) under the Cafeteria Plan for non-highly compensated employees. (If zero, enter 0.00.) Enter the combined amount of NHCE subtotals for Step 3.
Step 3 – Other Pre-Tax Contributions Offered Through your Cafeteria Plan If applicable, please indicate any other pre-tax employer and employee contributions to benefits that TASC may not be aware of (e.g., separate dental, term life, other insurance, etc.) for your non-highly compensated employees. Do not include 401(k), other retirement, long-term disability or FlexSystem contributions. Please enter any other pre-tax employer and employee contributions to benefits that TASC may not be aware of (e.g., separate dental, term life, other insurance, etc.) for your highly compensated employees. Do not include 401(k), other retirement, long-term disability or FlexSystem contributions. Enter the combined Employer and Employee NHCE Subtotal amount and the combined Employer and Employee HCE Subtotal amount.
Step 4 – Carrier and Coverage Data With TASC’s continuing efforts to be a voice for employers and employees in healthcare reform, TASC is requesting information on your current insurance coverage. Please enter this information to help us continue with these efforts. Your information will not be shared with any outside sources.
The information in this communication is confidential and may be used by the authorized Recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-4258-042811 Non-Discrimination Testing Worksheet
As part of our service to you, TASC reviews your Plan for discrimination of Non-Highly Compensated Employees (NHCEs) according to IRS Regulations. You will be notified of your results and what options you have in the event the Plan fails the testing. If you would like TASC to complete your Flexible Spending Account non-discrimination testing, please provide all of the information requested below and submit to TASC.
Client Name ______Client ID # ______
Plan Year start and end dates: From ______/ ______/ ______To ______/ ______/ ______
Step 1: Highly Compensated Employees (HCEs)
Highly Compensated Group Sponsored Premiums HSA Contributions Provided Employee Name Under the Cafeteria Plan Under the Cafeteria Plan Annual Annual Annual Employee Annual Employee Employer Pre-Tax Employer Pre-Tax Contributions Contributions Contributions Contributions ______$______$______$______$______$______$______$______$______$______$______$______$______$______$______$______$______
Combined HCE Subtotal: $______
Step 2: Non-Highly Compensated Employees (NHCEs)
Group Sponsored Premiums HSA Contributions Provided Under the Cafeteria Plan Under the Cafeteria Plan
Annual Annual Annual Annual Employer Employee Pre-Tax Employer Employee Pre-Tax Contributions Contributions Contributions Contributions
$______$______$______$______Combined NHCE Subtotal: $______
TASC • 2302 International Lane • Madison, WI 53704-3140 • 1-800-422-4661 • Fax: 608-245-3623 • www.tasconline.com The information in this communication is confidential and may be used by the authorized recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-3055-101111 Step 3: Other Pre-Tax Contributions Through Your Cafeteria Plan
Non-Highly Compensated Highly Compensated Benefit Type Contributions Contributions Annual NHCE Annual HCE Annual NHCE Employee Annual HCE Employee Employer Pre-Tax Employer Pre-Tax Contributions Contributions Contributions Contributions ______$______$______$______$______$______$______$______$______
NHCE Subtotal: $______HCE Subtotal: $______
Step 4: Carrier and Coverage Data
Health Plan Coverage Types Offered Number of Deductible Carrier Name (Family, Single+1, Employee Only, etc) Employees on Amount the Plan ______$______$______$______$______
TASC • 2302 International Lane • Madison, WI 53704-3140 • 1-800-422-4661 • Fax: 608-245-3623 • www.tasconline.com The information in this communication is confidential and may be used by the authorized recipient only for its intended purpose only. Any other use or disclosure is prohibited. FX-3055-101111
TASC’s ‘Confidentially Speaking’ Reporting Program
What is ‘Confidentially Speaking’?
The Confidentially Speaking program guarantees that TASC employees, customers, and vendors can safely and anonymously communicate with management regarding sensitive information. We respect and value your opinions, and hope you will feel comfortable using this program to communicate serious problems or concerns.
Confidentially Speaking is administered by Global Compliance, an independent organization that is contractually forbidden to disclose your personal information to TASC (unless you give them permission).
Why did TASC Implement This Program?
A renewed interest in corporate governance, spurred by the Sarbanes-Oxley Act,1 has motivated many organizations to implement an anonymous reporting hotline. Because TASC’s Confidentially Speaking system helps employees, customers, and vendors voice their opinions and concerns, we’re able to gain valuable feedback that otherwise might not be forthcoming. Finally, besides helping our efforts to mitigate risk, this information helps us maintain an ethical environment within TASC.
As part of our organization’s core values and best practices, we expect TASC to conduct business in a legal and ethical manner. We do not condone any illegal or unethical behavior. All members of our TASC team are asked to let us know immediately if they become aware of unacceptable activity occurring within the organization. TASC management in turn takes steps to appropriately address the issue.
Examples of unacceptable activities and unethical behavior may fall under the following categories: Accounting, Auditing, and Financial Concerns Conflict of Interest Falsification of Information Release of Proprietary Information Fraud, Deceit, and Embezzlement Securities Violations 2 Theft, Safety Concerns, Company Policy Violations
Rev 8/4/2011 Pg 1 of 2 TC-4569-080411 How Does it Work?
If you have knowledge about the occurrence of unethical activity, promptly report the situation to a Confidentially Speaking representative: via website: www.tascconfidentiallyspeaking.com via phone: 877-874-8416. As a provider of this information you may remain 100% anonymous, no matter the method of reporting.
Reporting via website: The user-friendly website makes reporting easy. It walks you through each step of the reporting process, which includes answering a few questions required as part of the feedback collection process. You may also upload supporting documents to the website.
If you wish to receive follow-up information, you may do so in two ways. You may create a custom website password to allow you to check the case status and communicate anonymously. Or, you may provide an e-mail address to receive follow-up information anonymously.
Reporting via phone: If you would rather call, a highly trained representative will thoroughly interview you about the issue. It is advantageous to be as upfront as possible with the interviewer.
Once the report/call is complete, you will receive a unique code related to your report which will allow you to check the case status and/or to follow-up on the matter.
After reporting: The issue will be investigated and escalated as necessary and appropriate. As mentioned above, besides helping our efforts to mitigate risk, this information helps us maintain an ethical environment within TASC. Comments and feedback provided via Confidentially Speaking are taken seriously and may directly affect the success and culture of our organization.
We encourage you to use the Confidentially Speaking program! We guarantee your anonymity.
Thanks for all the work you put in to make TASC a great company!
TASC Management
IMPORTANT NOTES
1 In response to the major corporate and accounting scandals including Enron, Tyco Int’l, and WorldCom, a United Stated federal law commonly known as the Sarbanes-Oxley Act (SOX) was passed in 2002. The SOX Act makes it illegal for an organization to retaliate against an employee who reports accounting or audit irregularities or any other illegal or unethical behavior. The Confidentially Speaking program uses best practices associated with anonymous hotlines to address such behavior.
2 To ensure the success of this program, it is vital that you respect our intent to establish an anonymous feedback system. Employees are asked not to abuse this program, which is not intended to replace Human Resources involvement, and is not to be used to lodge complaints or communicate unwarranted, troublesome messages about other employees.
Rev 8/4/2011 Pg 2 of 2 TC-4569-080411 Advantages of a Flexible Spending Account
Increase Your Take-Home Pay by 33 million Americans Reducing Your Taxable Income!
A Flexible Spending Account (FSA) allows you to save money every year save up to 30% on your eligible healthcare and/or dependent care expenses every year by using pre- by participating in a FSA tax dollars. 2009 Nielson Consumer Research
Consider how much you spend for healthcare and/or dependent care for you and your qualified dependents Pre-Tax Savings Example in one year, including: Without FSA With FSA • prescription drugs/medications Gross Monthly Pay: $3,500 $3,500
• medical/dental office visit co-pays Pre-Tax Contributions • eye exams and prescription glasses/lenses Medical/Dental Premiums $0 -$300 Medical Expenses $0 -$100 • vaccinations Dependent Care Expenses $0 -$400 TOTAL: $0 -$800 • daycare tuition Why not reduce these expenses by using pre- Taxable Monthly Income $3,500 $2,700 tax dollars instead of after-tax dollars? With rising Taxes (federal, state, FICA): -$968 -$747 healthcare costs, every penny counts! Out-of-pocket Expenses: -$800 $0 Monthly Take-home Pay: $1,732 $1,953 By using pre-tax dollars, you are taxed on a lower gross salary, thereby saving money that would Net Increase in Take-Home Pay = $221/mo! otherwise be spent on federal, state and FICA taxes, For illustration purposes only. Actual dollar amounts may vary. and so you increase your take home pay!
How it Works
The FSA is offered through your employer and adminstered by TASC FlexSystem. When you choose to enroll in a Healthcare FSA and/or Dependent Care FSA, you decide the dollar amount you want to contribute to each account based on your estimated expenses for the upcoming year. The funds will be deducted pre-tax in equal amounts from each paycheck throughout the plan year. For every dollar you put into these accounts, the more money you save by paying less in taxes.
As you incur eligible expenses, you simply submit a request for reimbursement to TASC to receive reimbursement from your FSA, up to the amount of your annual contribution. For additional convenience, your employer has provided you with a TASC Card to purchase eligible medical and dependent care expenses with your FSA funds at the point of purchase, which eliminates the need for reimbursement.
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4245-072010 How to Determine Your FSA Important Considerations Contributions FSA Funds do not Rollover:
a Understand the IRS contribution limits It is important to be conservative in making elections for your Plan during the Plan year (available because any unused funds left in your FSA at the close at the online enrollment site). of the Plan Year are not refundable to you. You are urged to take precautionary steps, such as tracking account balances on the FlexSystem website and/or a Review the eligible and ineligible expense using the Interactive Voice Response System, to avoid lists for Healthcare FSA and Dependent having funds remaining in your account at year-end. Care FSA. Note the changes to OTC drugs as of January 1, 2011. Using the Grace Period, or purchasing eligible over-the- counter items are ways to utilize leftover FSA funds. a Determine which eligible expenses you expect to incur during the Plan year and Changing Elections During the Plan Year: how much you will spend. You may change your FSA elections during the Plan year only if you experience a change of status such as: a The total amount you project to be spent on eligible healthcare and/or dependent care • a marriage or divorce • birth or adoption of a child, or expenses during the Plan year is the • a change in employment status amount you should contribute to your FSA. Refer to the Change of Election Form (available from your employer) for a complete list of circumstances acceptable for changing elections mid-year.
SaveSave up up to to 30% 30% onon healthcare expenses! expenses!
For More Information • Easy online enrollment Learn more about Flexible Spending Accounts • Convenient payroll deductions and obtain additional resources online at: • Immediate access to funds www.tasconline.com • TASC Card option • Multiple methods to request a 2302 International Lane reimbursement Madison, WI 53704-3140 • Direct Deposit 800-422-4661 Telephone 608-245-3623 Fax • 24/7 Account access (web and phone) • Toll-free customer service How to Enroll Online
Determine Your FSA Elections FSA Healthcare To enroll in FlexSystem, you must first choose which Flexible Spending Account(s) you wish to FSA Dependent Care participate in for the Plan year. Then you must determine your elections to be contributed pre-tax into each type of FSA from every payroll over the course of the Plan year. Your elections are specific to each FSA and may only be used for expenses incurred for that account type, meaning that dollars set aside for dependent care may be used for dependent care expenses only and not for medical expenses, etc. Easy Online Enrollment Online enrollment into the FlexSystem is available 24-hours a day from the convenience and privacy of your own home. Once you are enrolled, you may access your FlexSystem account balances online at any time.
New Enrollees (new to the Plan): You must obtain the Client ID from your employer. Then go to www.tasconline.com/tasconline/ flexsystem/enroll to establish your personal Username and Password. (Please note, a valid e-mail address is required to authenticate your account. If you do not have an e-mail address, you may set one up for free with an e-mail hosting service such as Gmail, Hotmail, Yahoo, etc.) Follow the system prompts to enroll.
Renewing Enrollees: If you have forgotten your Password, simply select the “Forgot my password” link. An e-mail with your password will be sent to your e-mail address. You may also use your 12-digit TASC ID located on your Request For Reimbursement Form in place of your Username to log in.
Steps to Re-Enroll Online: 1. Go to www.tasconline.com. 2. Login using your username and password. 3. Click the green Continue button on the Participant Manager screen. 4. Select the appropriate Plan from the drop down menu. Select the benefits you wish to enroll in by clicking on “Elect” next to the benefit name. 5. Enter the total yearly election amount (repeat for each benefit desired). 6. Enter your direct deposit information and click Submit.
For enrollment assistance, call a FlexSystem Customer Care Representative at 1-800-422-4661.
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4247-101111 STAY CONNECTED WHEREVER YOU GO: MyTASC Mobile App, Text, E-mail
The MyTASC Mobile App is a fast and accessible account managment tool for FlexSystem Flex- ible Spending Accounts! With MyTASC Mobile App, you are now able to securely access your FlexSystem account balances from anywhere at any time using your mobile device.
MyTASC Mobile App Features: • Check FlexSystem account balances from anywhere at any time • Free download from Apple App Store and Android Market for your smartphone or tablet • Easy login with your current MyTASC username and password • Secure account access through Secure Socket Layer (SSL) encryption over the Internet
For more information on TASC Mobile or to download the free MyTASC Mobile App, please visit www.tasconline.com/ mobile.
Text Messaging and E-mail Notification TASC Mobile also offers text messaging (SMS) and e-mail notification. You may use these mobile services daily to obtain account balances, request reimbursements, and receive account status alerts.
To sign up to receive e-mail and text notifications for your Flex Account, log in to your MyTASC account, click Profile, enter or update your mobile phone number and e-mail address, and select Save. Follow the instructions provided to complete the verification process and set your desired notifications in your Profile.
Text Notifications FSA Account Text Messaging Instructions Account Balance Check Text TASC BAL to number 41411 Request for Reimbursement (RFR) Submission Text TASC RFR
TASC, 2302 International Lane, Madison, WI 53704 • 800-422-4661 • www.tasconline.com FX-4277-100611 Eligible Expenses
Due to Health Care Reform, effective 1/1/2011, over-the- counter (OTC) medicines and drugs, except for insulin, will FSA Healthcare require a prescription from your physician to be reimbursed from your Health FSA. The prescription will need to be included with each over-the-counter medicine or drug claim request submitted. Health-related supplies purchased over-the-counter continue to be eligible without additional documentation. Below is a sample list of permissible expenses reimbursable through a Full Scope Health Flexible Spending Account (FSA) that are incurred by you, your spouse, or qualified dependents. Please note a Limited Purpose Healthcare FSA only allows dental and vision expenses. Medical Expenses • Pregnancy test • Prescription drugs and medications • Acupuncture • Psychotherapy, psychiatric and psychological service • Artificial limbs • Reading glasses • Bandages • Sales tax on eligible expenses • Birth control, contraceptive devices • Services connected with donating an organ • Birthing classes/Lamaze – only the mother’s portion • Sleep apnea services/products (as prescribed) (not the coach/spouse) and the class must be only for • Smoking cessation programs birthing instruction, not child rearing • Treatment for alcoholism or drug dependency • Blood pressure monitor • Vaccinations • Blood sugar test kits/test strips • Wrist supports, elastic wraps • Chiropractic therapy/exams/adjustments • X-ray fees • Contact lens and contact lens solutions • Co-payments • Crutches (purchased or rented) OTC Medicines and Drugs • Deductible and co-insurance • Diabetic supplies Purchases after 12/31/10 will require a prescription or a • Eye exams Prescription Order Form for reimbursement. • Eyeglasses, contacts, or safety glasses, prescription only • Bengay, Flexall, pain relieving creams or gels (warranties are not reimbursable) • Calamine lotion • Flu shots • Canker/cold sore relievers • Hearing aids and hearing aid batteries (warranties are • Cold medicines not reimbursable) • Corn removal • Heating pad • Diaper rash ointment • Incontinence supplies • GasX, baby gas drops • Infertility treatments • Hemorrhoid creams and treatments • Insulin • Hydrogen Peroxide or rubbing alcohol • Lactation expenses (breast pumps, etc.) • Indigestion or anti-acid relievers • Laser eye surgery; LASIK • Laxatives • Legal sterilization • Nicotine patch • Medical supplies to treat an injury or illness • Pain relievers (Tylenol, Advil, Aspirin, etc) • Mileage to and from doctor appointments • Sinus medicines • Nasal strips • Suppositories • Optometrist’s or ophthalmologist’s fees • Teething gel • Orthopedic inserts • Wart removal medication • Physicals • Physical therapy (as medical treatment) • Physician’s fee and hospital services
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4248-050411 Eligible Expenses
Dental Expenses FSA Healthcare • Braces and orthodontic services • Cleanings • Crowns • Deductibles, co-insurance • Dental implants • Dentures, adhesives • Fillings
For the Disabled • Automobile equipment and installation costs for a disabled person in excess of the cost of an ordinary automobile; device for lifting a mobility impaired person into an automobile • Braille books and magazines in excess of cost of regular editions • Note-taker, cost of, for a hearing impaired child in school • Seeing eye dog (buying, training and maintaining) • Special devices, such as a tape recorder or typewriter for a visually impaired person • Visual alert system in the home or other items such as a special phone required for a hearing impaired person • Wheelchair or autoette (cost of operating/maintaining)
Healthcare Expenses Requiring Additional Documentation Following are some expenses eligible only when incurred to treat a diagnosed medical condition. This type of expense requires a Prescription Order Form from your physician to be submitted along with your request for reimbursement that contains the medical necessity of the expense, the diagnosed condition, the onset of the condition and the physician’s signature.
• Ear plugs • Massage treatments • Nursing services for care of a special medical ailment • Orthopedic shoes (excess cost of ordinary shoes) • Oxygen equipment and oxygen • Speech therapy • Support hose • Varicose vein treatment • Veneers • Wigs (for mental health condition of individual who loses hair because of a disease)
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4248-050411 Ineligible Expenses
The following healthcare expenses are not eligible for reimbursement: FSA Healthcare
Ineligible Expenses for FSA Healthcare • Athletic mouth guards • Maternity clothes • Auto insurance providing medical coverage • Mattress • Chapstick/lip balm • Medicare premiums • Contributions to state disability funds • Medicated shampoos, conditioners, and soaps • Cosmetic surgery, cosmetic dentistry or other • Mobile telephone used for personal calls as well as cosmetic procedures calls to physician • Cosmetic supplies (make up, facial soaps/creams and • Nursemaids or practical nurses who render general moisturizers, etc) care for healthy infants • Deodorant • OTC drugs/medications without a prescription • Dental floss (effective January 1, 2011) • Diaper service • Pajamas/slippers purchased to wear in hospital • Diet: special diets and/or cost of special foods • Personal use items (toothbrush, vacuum, pillow, shampoo, taken as substitute for regular diet mattress, etc) • Dietary and fiber supplements • Physical treatment unrelated to specific health • Divorce: expenses of divorce when doctor or problems (massage for general well-being, stress, psychiatrist recommends divorce depression, or chiropractic wellness program) • Distilled water purchased to avoid drinking • Premiums for coverage through other medical plans fluoridated city water or for use in medical (i.e., spouse’s employer-sponsored plan or individual plan) equipment • Private hospital rooms • Domestic help: payments to domestic help, • Safety glasses (non-prescription) companion, babysitter, chauffeur, etc. who • Special foods purchased to replace nutrition or for primarily render services of a non-medical nature general health needs, such as diet foods. • Electrolysis/hair removal • Sun Glasses (non prescription) and Sun Clips • Exercise equipment and fees • Teeth whitening • Eye drops for general comfort • Toiletries • Eyeglass cases • Toothbrush (includes prescribed electric ones) • Hand sanitizer • Toothpaste • Health club or athletic club membership fees • Vacuum cleaner purchased by an individual with • Herbal supplements dust allergy • Illegal treatment or medication • Vitamins and/or supplements • Insurance premiums, all types • Warranties • Lanyards • Weight loss drugs/programs for general well being • Lotions or skin moisturizers • Marriage counseling
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4248-030811 Eligible Expenses
The following dependent care expenses are permissible for reimbursement through a Section 125 FSA Dependent Care Flexible Spending Account. Please refer to your FSA Summary Plan Description (SPD).
Eligible Expenses for FSA Dependent Care Eligible dependent care expenses must be employment related.
• Day Camp -- primary purpose must be custodial care and not educational in nature
• Dependent care expenses that are necessary for you (and your spouse) to work, actively look for work, or attend school full-time.
• Dependent care for a child under age 13
• FICA/FUTA taxes of day care provider
• Late pick up fees
• Nanny expenses attributed to dependent care
• Nursery school (Pre-School)
• Registration fees -- when allocated to dependent care services that have been provided
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4248-030811
Prescription Order Form
Make sure to sign and date the order form. For assistance call 1‐800‐422‐4661. Have your order form and 12 digit TASC ID number ready. Please print.
1. This form replaces the Letter of Medical Necessity. Use this form to be reimbursed for products and services that require physician authorization such as Over‐the‐Counter (OTC) medicines or drugs and other non‐OTC medicine products and services. 2. Complete Section I (including your signature and the date) and Section II (Patient Name, Treatment Prescribed and Reason for Treatment) prior to visiting your Medical Practitioner. 3. Bring this form with you to your next medical appointment and request that the attending Medical Practitioner complete Section II (Instructions/Restrictions) and Section III. 4. Instruct them to follow the specific pharmacy/prescription laws in their respective state when completing the Instructions/Restrictions portion (Section II). 5. You may use the same form for each individual in your household for whom you purchase healthcare expenses, as long as the same Medical Practitioner is completing the form 6. TASC Card purchases of OTC medicines or drugs require a prescription from your medical practitioner. Do not use this Prescription Order Form when using your TASC Card to purchase OTC medicines or drugs. The Prescription Order Form may be used in place of a prescription for all other methods of Requests for Reimbursement (online, faxed, or mailed). 7. FlexSystem and DirectPay Participants must submit a copy of this completed form to TASC with each Request for Reimbursement (if submitting online, include a copy with your receipts and Veriflex (FlexSystem only) Cover sheet). Prescription Order Forms received without a Request for Reimbursement or Veriflex (FlexSystem only) Cover Sheet will not be processed. AgriPlanNOW and BizPlanNOW Participants should retain the completed Form for their own records.
SECTION 1
Employer (Company) Name: ______Participant (Employee) TASC 12‐Digit ID #: ______
Participant’s Last Name: ______First Name: ______M.I.: ______
Signature: ______Date: _____ / _____ / _____
The statements on this document are complete and true, to the best of my knowledge and belief. I understand that the IRS regulates my employee benefit account and that the guidelines are implemented as a means of ensuring compliance. I further understand that it is my responsibility to comply with these guidelines and to avoid submitting duplicate or ineligible requests.
SECTION II Patient’s Name Prescribed Reason for Treatment Instruction/Restrictions (if applicable) Treatment Products/Services
SECTION III I hereby certify that the treatment plan(s) listed above is medically necessary to treat the ailment or medical condition listed above. This treatment plan is neither for cosmetic reasons nor for general health and well‐being.
______Medical Practitioner’s Name (PLEASE PRINT) State of Prescriptive Authority
______/ _____ / _____ Medical Practitioner’s Signature Date
Effective 1/1/2011, purchases of Over‐the‐Counter (OTC) medicines and drugs (other than insulin) will only be reimbursable if accompanied by a prescription or Prescription Order Form from your medical practitioner. Please note when using your TASC Card to purchase OTC medicines or drugs, a prescription is required. The Prescription Order Form or a prescription may be used when submitting Requests for Reimbursement via online, fax or mail.
OTC medicines or drugs that will require a prescription or Prescription Order Form AFTER Dec. 31, 2010 include the following: Acid Controllers Anti‐Itch & Insect Bite Digestive Aids Pain Relievers Allergy & Sinus Antiparasitic Treatments Feminine Anti‐Fungal Respiratory Treatments Antibiotic Products Cough/Cold/Flu Hemorrhoidal Medication Sleep Aids/Sedative Anti‐Gas Diaper Rash Ointment Laxatives Stomach Remedies
OTC products that will remain eligible and need no physician authorization include the following: Bandages/First Aid Contact Lens Solution Heating Pads Orthopedic Aids Blood Pressure Kits Denture Products Hot/Cold/Steam Packs Pregnancy/Fertility Kits Canes & Walkers Diabetes Testing Supplies Incontinence Products Splints/Supports/Braces Condoms Durable Medical Equip. Insulin Thermometers Contact Lenses Hearing Aid Batteries Nebulizers Wheelchair & Accessories
Other products and services that require a Prescription Order Form or other physician authorization to show the expense is to treat a medical condition include the following: Air Purifier Massage Therapy Orthopedic Shoes (excess Support Hose Automobile Modifications Nutritionist’s Professional cost only) Varicose Vein Treatment Ear Plugs Fees Special Foods (excess cost Whirlpool/Spa Exercise Equipment only) Wigs
DEFINITIONS For the purposes of this form... 1) “Medical Practitioner” generally includes the following health professionals: physician (MD/DO), physician assistant, nurse practitioner, dentist, optometrist and podiatrist. 2) “Prescription Order” is any order for drugs or medical supplies signed by a licensed medical practitioner granted prescriptive authority by the laws of the state. It contains the name, strength and quantity of the medicine/product prescribed, directions for use and number of refills (if applicable).
RESTRICTIONS The Medical Practitioner’s signature may NOT be preprinted in the states of Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, South Carolina, Tennessee, Virginia and Washington. Montana, Pennsylvania and South Dakota – the use of this form is prohibited; a prescription is required.
TASC • 2302 International Lane • Madison, WI 53704-3140 • 1-800-422-4661 • www.tasconline.com
© Total Administrative Services Corporation The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose. Any other use or disclosure is prohibited. TC-4471-033111
Direct Deposit Election Form
Note for re-enrolling Participants: If you already have an established Direct Deposit account with FlexSystem, do not submit a new Direct Deposit Form. If you do not have a direct deposit account set up with FlexSystem and wish to avoid a check processing fee for each reimbursement, log onto www.tasconline.com and use the Direct Deposit Setup link to enter your applicable information. It’s that easy! If you do not have web access, complete this form and return it to FlexSystem, along with a voided check or savings account deposit slip to the addresses listed below.
I hereby authorize Total Administrative Services Corporation, hereinafter called TASC, to initiate credit entries for ______(name) to my checking/savings account indicated below and the financial institution named below, hereinafter called FINANCIAL INSTITUTION, to credit the same to such account. I acknowledge that the origination of ACH transactions to my checking/savings account must comply with the provisions of U.S. law.
______Financial Institution Name Branch
______Address City/State Zip
______Client Name Client ID #
______Participant ID # Participant E-mail Address
______Participant Home Phone Number Participant Mobile Phone Number
______Checking/Saving Account Routing Number – 9 digits Checking/Saving Account Number – 6-13 digits
This account is a: (check one) Checking Savings
This authority is to remain in full force and effect until TASC has received written notification from me of its termination in such time and manner as to afford TASC or my FINANCIAL INSTITUTION a reasonable opportunity to act on it.
Notes: . Single entry reversals do not require authorization by the Receiver. . Due to our effort to ensure accuracy in establishing your direct deposit account, your initial transactions will occur by check. Please allow 7-10 days for processing. Thank you for your patience. . You must notify us immediately of any changes in your financial institution. . This authorization may be revoked only by notifying TASC in the manner indicated above. . Note: There may be a check-processing fee applied to a check reimbursement. . A Service Fee of $30.00 will be charged to the Participant for the reissue of lost, stolen, or expired paper-copy checks. This Service Fee is avoided with the election and submittal of this Direct Deposit Election Form.
You must attach a copy of a voided check to this form to activate this service to your checking account. We cannot accept checking account deposit slips.
To activate this service do one of the following: 1. Access www.tasconline.com and use the Direct Deposit Setup link to enter your applicable information. 2. Fax this completed form and voided check (if a checking account) or deposit slip (if a savings account) to: 608-245-3623. 3. Mail this completed form and voided check (if a checking account) or deposit slip (if a savings account) to: FlexSystem, 2302 International Lane, Madison, WI 53704.
The information contained in this communication is confidential and to be used by TASC employees and representatives for its intended purpose only. Total Administrative Services Corporation TC-3142-062911 The TASC Card: MyBenefits. MyCash. MyWay.
Congratulations! Your employer has elected the TASC Card feature for your Plan. Please read this Simplify your healthcare and information to become familiar with your TASC Card. dependent care FSA! Fast and Convenient MyBenefits—The TASC Card is used to conveniently access the available funds in your Flexible Spending Account(s) for eligible purchases.
Rather than paying out-of-pocket and waiting to be reimbursed, the claim card allows you to pay for MyWay—With two accounts on one card, the eligible expenses at the point of purchase/service TASC Card is more versatile than ever! MyCash for your eligible medical, dependent care, and/or funds can be used to pay for eligible expenses if no transportation expenses. The amount of the expense funds are available in your benefits account. Retail is automatically deducted from your FSA balance and and healthcare items can be purchased in one paid directly to the authorized healthcare or dependent transaction. And MyCash funds be transferred to a care provider. No need to submit your claim by paper, personal savings or checking account, or withdrawn fax, or the web. at an ATM (with a PIN). What is an Eligible Expense? How to Request a TASC Card MyBenefits funds may only be used for eligible Once you are enrolled in FlexSystem and your expenses under your healthcare FSA and/or employer has finalized your company’s enrollment, dependent care FSA (whether using the TASC Card or a TASC Card in your name will be mailed to your submitting a reimbursement request). A list of eligible address. You may also request one additional TASC and ineligible expenses as defined by the IRS is Card for your dependent at no charge. Replacement included in your FSA enrollment kit. cards are available for a minimal fee. Where Can the TASC Card be Used? 24/7 Account Access The TASC Card looks like a typical debit card, but You can view your FSA balance and TASC Card is used as a credit card for eligible medical, and transactions online by logging into your MyTASC dependent daycare expenses, based on the funds account at www.tasconline.com. available for those benefits as defined by your Plan.
MyCash—If a business does not accept the TASC Merchant Types Card, submit a request online (at www.tasconline. Medical Clinics and Hospitals com/MyTASC), or mail or fax your paper request to Dental Offices the address on your Request for Reimbursement Hearing and Vision Care Centers Form. Your reimbursement will be deposited in your Pharmacies (including mail order) card’s cash account (unless you elect direct deposit). Over-the-Counter Sales Your MyCash funds can be used just like cash at any Day Care Centers retailer that accepts Visa.
www.tasconline.com • 2302 International Lane • Madison, WI 53704-3140 • 800-422-4661 • Fax: 608-245-3623
FX-4249-100411 Additional TASC Card Request for Spouse or Dependent
Give your dependent the flexibility of their own TASC Card. The additional TASC Card offers your spouse or dependent the same convenience and advantages you enjoy! To request a TASC Card for your spouse or dependent, just complete sections 1, 2, and 3 below, sign and date the application and fax to 608-245-3623 for processing. How is the TASC Card issued? The TASC Card and a standard Cardholder Agreement will be mailed directly to your mailing address within 7–15 business days. Can I have more than one additional TASC Card? Each participant receives one additional card for their spouse or dependent free of charge. A $10.00 fee will apply for each subsequent TASC Card generated. This fee will be deducted from your FlexSystem account upon the creation of the card(s). Each application may be used to request one additional card; subsequent requests will require additional applications.
Section 1: Participant Information ______Employee Name (Last, First, MI) Employee TASC 12-digit ID # ______Employer Name Employer TASC 12-digit ID # (Optional)
Section 2: Spouse or Dependent Information ______Spouse or Dependent Name (Last, First, MI)
Participant Authorization for an Additional Card I understand that the above named individual will have access to my flexible spending account(s). I accept all responsibility for all TASC Card transactions incurred by the above named individual and for submitting the supporting documentation, as requested, for those TASC Card transactions. I acknowledge and agree that upon any inappropriate or fraudulent use of the TASC Card, or termination of employment, I will immediately return all TASC Cards issued for use against the account to my Employer.
Section 3: Agreement m I hereby request an Additional TASC Card for the above named spouse or dependent. I understand and agree to the above authorization terms. ______Participant Signature Date
TASC • 2302 International Lane • Madison, WI 53704-3140 • 1-800-422-4661 • Fax: 608-245-3623 • www.tasconline.com
The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose. Any other use or disclosure is prohibited. FX-3586-041811
Orthodontia Worksheet & Instructions
The treatment of orthodontic expenses under a Medical Flexible Spending Account (FSA) is different than other medical expenses because services generally span more than one Plan Year. Under IRS regulations the service must be reimbursed from the same FSA Plan Year in which the services were provided and the service must have been incurred. Nevertheless, IRS officials have informally commented that a pre-payment of orthodontia expenses is permissible in certain instances. Below are the various options for reimbursement of orthodontic services, instructions on how to submit a reimbursement request for orthodontic expenses and instructions on completing the Orthodontia Worksheet.
If a service agreement or contract has been drawn between the orthodontic provider and participant agreeing on services provided and payments due over the course of the treatment, the participant is reimbursed on a monthly basis according to the agreement. Reimbursements for these payments may span over one or more FSA Plan Years, as per the agreement. For example, if the agreement indicates a one-time payment of $500 upon placement of the braces and a monthly fee of $50 thereafter for 2 years, the amounts eligible for reimbursement are those incurred within each Plan Year (up to your current remaining balance). Pre-payments of monthly fees are not reimbursable as the service must be provided and payment must have a due date within your Plan Year coverage period. (Payments due in one Plan Year cannot be reimbursed from the next Plan Year.)
If full payment is required by the orthodontic provider before services can begin, the total cost for the treatment is eligible for reimbursement when the work is started and the payment is made. A one-time reimbursement for the total cost of the treatment up to your current available balance may be made from your current Plan Year Medical FSA. For example, if a full payment of $3,000 is required at time of placement and your current Medical FSA balance is $2500, you are eligible to be reimbursed for $2500.
If the orthodontic provider does not offer the options above, complete the Orthodontia Worksheet to determine the monthly amount that may be eligible for reimbursement from your Medical FSA.
Loan payments and interest on a loan are not eligible expenses. Thus, the TASC Card cannot be used to make payments to a loan company. Complete the Orthodontia Worksheet if no other receipt or contract is available from the orthodontic provider.
Submitting orthodontia expenses for reimbursement:
1. A Request for Reimbursement Form must be completed each time you want to be reimbursed. 2. With each Request for Reimbursement, include a copy of the orthodontic contract, coupon (if provided a payment book) or itemized receipt. All documentation must clearly indicate the month and year of the service provided (or payment due date), the monthly payment amount, the name of the provider and a description of the service (orthodontia, braces, placement or banding fee). 3. In the absence of a contract or service agreement: a. Complete the Orthodontia Worksheet b. Have it signed by your orthodontist; c. Submit with each Request for Reimbursement. 4. Initial payments, banding or placement fees are eligible for reimbursement upon placement. An itemized receipt must accompany the Request for Reimbursement Form that indicates the service is a banding or placement fee instead of a monthly fee. 5. A Request for Reimbursement of payment in full for orthodontic treatment at the start of the orthodontic services requires an itemized receipt from the orthodontic provider to accompany the Request for Reimbursement.
Total Administrative Services Corporation P.O. Box 8837 Madison, WI 53707-8837 800-422-4661 Fax 1-800-296-3529 www.tasconline.com
FX-4579-083011
Orthodontia Worksheet & Instructions
In the absence of a contract or service agreement the orthodontic provider must apportion the total cost of the treatment, less the initial payment due and any payments expected from your insurance company or provider discounts to the remaining number of months required for treatment. This will determine the monthly payment amount eligible for reimbursement from the Medical FSA. Include a copy of this completed form with each Request for Reimbursement Form submitted to TASC.
1. Enter the total cost for the duration of the treatment in the Total Cost section in below. 2. Enter in any insurance payments and provider discounts. 3. Enter the estimated portion of the total cost that is apportioned to the services provided in the first visit (when the braces are applied) in the Initial Payment Due section. (Generally one-third or less of the total cost.) 4. Subtract the insurance payments, provider discounts and initial payment due from the total cost and enter this amount in the Total Remaining Balance section. 5. Enter the number of months the treatment is expected to continue after placement of the braces. 6. Divide the Total Remaining Balance by the number of months and enter this amount in the Monthly Payment section. This is the amount eligible for reimbursement from the FSA on a monthly basis.
______Participant Name Participant 12-Digit ID#
______Employer Employer 12-Digit ID# (optional)
______Patient Name Date Treatment Begins (Mo/Day/Yr)
Total Cost for Orthodontia Services: $ ______Subtractions Insurance Payments: $______
Provider Discount: $______
Initial Payment Due (upon placement of braces): $______
Total Remaining Balance: $ = Number of Months Monthly Payment & ______Eligible Monthly Signature of Orthodontic Service Provider Date Reimbursable Amount ______Printed Name of Orthodontic Service Provider
Total Administrative Services Corporation P.O. Box 8837 Madison, WI 53707-8837 800-422-4661 Fax 1-800-296-3529 www.tasconline.com
FX-4579-083011