Tax-Favored Accounts - myBenefits

Tax-Favored Accounts - myBenefits

2016

Tax-Favored Accounts

State of Florida People First

Reference Guide

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State of Florida • People First

What’s New

• HSA contribution for family coverage (including any state contribution) is

$6,750

Table of Contents

3 Eligibility Requirements

Appeal Process

4 Health Investor HSA

6 Flexible Spending Accounts

8 Medical Reimbursement

Account

11 myMRA Card

13 Limited Purpose Medical

Reimbursement Account

14 Dependent Care

Reimbursement Account

16 FSA Worksheets

17 Changing Your Coverage

18 COBRA Questions and Answers

19 How Participation May Affect

Other Benefits

20 Deferred Compensation

Worksheet

21 Online Claim Submission

Instructions

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Eligibility Requirements

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Who is Eligible to

Participate in the

Flexible Spending

Account (FSA)

Program?

All full-time and part-time employees filling established positions are entitled to participate in the FSA program. Employees who do not fill established positions (e.g.,

OPS employees) are eligible for the DCRA account only.

How Does Leave

Affect my FSA?

If you go on unpaid leave, your Dependent

Care Reimbursement Account cannot be continued once your leave begins. You may, however, be able to continue your

Medical Reimbursement Account (MRA). If you elect to continue your MRA, you may arrange to pre-pay the balance of your annual election before you leave the payroll or make payments directly after you leave the payroll.

While on leave, if you continue your MRA, you may still incur and be reimbursed for eligible expenses, though your myMRA card is not active. Simply submit a Claim

Form online or by fax or mail.

To change or to continue your MRA coverage, contact the People First Service

Center within 60 days of the event by visiting the People First website at https://

peoplefirst.myflorida.com, or by calling 1-866-663-4735; TTY 1-866-221-

0268.

Specific guidelines about leave policies can be obtained from your Agency

Personnel Office or the People First Service

Center. In addition, the Family and Medical

Leave Act (FMLA) may affect your rights to continue coverage while on leave.

How Does Termination

Affect my FSA?

If you terminate employment, your

Dependent Care Reimbursement

Account cannot be continued following termination. You may be able to change or continue your Medical Reimbursement

Account (MRA) however.

To change or to continue your MRA coverage, contact the People First Service

Center within 60 days of the event by visiting the People First website at https://peoplefirst.myflorida.com, or by calling 1-866-663-4735; TTY 1-866-221-

0268.

Specific guidelines about termination can be obtained from your Agency Personnel

Office or the People First Service Center.

Terminations

If you participate in a Medical

Reimbursement Account and terminate your State employment, you must complete a Medical Reimbursement

Account Termination of Employment

Form. Forms are available by accessing the People First website or by contacting the People First Service Center. If you terminate participation in the plan, claims for medical expenses incurred after the last payroll deduction, will not be eligible for reimbursement.

However, should contributions to your account stop for any reason, payment of claims will be suspended, regardless of your account balance. For participants who have terminated, claim payments will be suspended until the People First Service Center receives a signed Medical

Reimbursement Account Termination of Employment Form with selection and payment. Participants going on leave must contact their Personnel

Office for existing options.

NOTE: One option on the form is to have your balance deducted from your annual or sick leave on a pre-tax basis. This option will allow you to be reimbursed for expenses incurred through the end of the plan year.

Appeal Process

If you have a request for a mid-plan year election change, FSA reimbursement claim or other similar request denied, in full or in part, you have the right to appeal the decision by sending a written request within 90 days of the denial for review to the People First Service Center.

Your appeal must state:

• the date of the services for which your request was denied

• a copy of the denied request

• the denial letter you received

• why you think your request should not have been denied and

• any additional documents, information or comments you think may have a bearing on your appeal.

NOTE: Appeals are approved only if the extenuating circumstances and supporting documentation are within the

State’s and the IRS’ regulations governing the plan.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

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Health Investor HSA

What is a Health Savings Account?

Providing economical health care in the face of rising costs is a major issue facing the nation. To deal with this issue and help you plan for future health expenses, you will have the choice of enrolling in the Health Investor HMO or PPO, coupled with a Health

Savings Account (HSA). These options enable individuals who are willing to take greater responsibility for their medical care the opportunity to reduce their insurance premiums and save money for future health expenses.

A Health Savings Account (HSA) is a tax-free account that can be used to pay health care expenses. Unlike money in a Medical Reimbursement Account, the funds do not have to be spent in the plan year they are deposited. Money in the account, including interest or investment earnings, accumulates tax-free, so the funds can be used to pay qualified medical expenses in the future

1

. An important advantage of an HSA is that it is owned by the employee. If you leave your job, you can take the account with you and continue to use it for qualified medical expenses.

How Can I Change my HSA

Contribution Amount?

To change your benefits, you can visit the People First Service Center website at https://peoplefirst.myflorida.com or contact the People First Service Center by phone at 1-866-663-4735; TTY 1-866-

221-0268. Specialists are available Monday through Friday, 8:00 a.m. – 6:00 p.m. ET.

How do I Get Funds

Out of my HSA?

After enrolling in the HSA and completing an HSA application, your contributions will be sent to the custodian, Tallahassee State

Who is Eligible to

Contribute to an HSA?

• Employees must be covered by the

State’s Health Investor PPO or Health

Investor HMO. These are the eligible high deductible health plan options.

• Employees cannot be covered by any other health plan that is not a qualified high deductible health plan, including

Medicare. However, they may be covered for specific injuries, accidents, disability, dental care, vision care and long-term care.

• Participants cannot be claimed as a dependent on another person’s tax return.

How Much May I Contribute to my HSA?

If you enroll in an HSA and elect to make contributions, your contributions are deducted on a pre-tax basis. An individual with single coverage may contribute up to

$3,350 (including any State contribution) a year to an HSA. Those covering more than one family member may contribute up to

$6,750 (including any State contribution) a year. These limits, established by the federal government and subject to change, are tied to the rate of inflation. An individual age 55

2 and older may make

“catch-up” contributions of up to $1,000 above the limits shown above in 2016.

You may also make after-tax contributions, which apply toward the maximum annual limit(s). You will receive additional information when you enroll.

Will the State Make a

Contribution to my Health

Investor HSA?

Yes! If you enroll in a high deductible HMO or PPO and elect an HSA, the State will make a contribution of up to $500 (annual) for an individual with single coverage or $1,000 (annual) for an individual with family coverage. Of course, you must be an active, full-time or part-time employee to qualify for the State’s contribution.

Bank, a division of Synovus® Bank. The

HSA custodian will establish an individual account for you and mail you up to two

VISA® debit cards to your home address at no charge. You may order additional cards or a small supply of checks by contacting the HSA Customer Service

Line at

1-877-367-4HSA. You may use the debit card or checks to get funds out of your HSA. Remember, as long as you are taking funds out for qualified medical expenses incurred on or after the date the

HSA was established, there are no taxable consequences to you. However, if you withdraw funds for ineligible expenses, you may have to pay taxes and penalties on those funds, unless you reimburse your

HSA for the ineligible amount.

NOTE: You do not have to make a contribution to your HSA (although this option is available) to receive the State’s contribution. You must simply enroll in a high-deductible health plan and elect to have an HSA. The State’s contribution is made each pay period over the course of a calendar year, in equal amounts.

Even if you are not sure that you want to contribute to an HSA beginning in

January, you may wish to enroll to ensure you receive the State’s contribution.

Will I Be Charged Any

Banking or Custodian Fees?

Yes, the custodian will charge you $2 per month for your HSA. This fee includes the VISA® debit card, all transaction fees associated with the card, monthly statements and other banking services.

There is a $.50 charge to process each check you write to get funds from your

HSA. The custodian will deduct these fees automatically from your HSA. Other fees may apply, including fees for insufficient funds. Refer to the Tallahassee State Bank

Schedule of Fees and Charges for more information.

1 Please consult your tax advisor or IRS Publication 502 with questions regarding these expenses, qualified health plans, and tax information.

a division of Synovus Bank

2 The “catch-up” contribution rule applies to employees who are or become age 55 prior to 12/31 of the election year.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Health Investor HSA

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When Can I Enroll?

Mid-year enrollees are now allowed to make the full annual contribution as long as they become eligible before December 1 of any year and if they continue to be an eligible individual for 12 months beginning with the last month in the year in which the individual became an eligible individual. Previously HSA-eligible participants were allowed to make contributions on a pro-rated, monthly basis.

If an individual does not remain HSA-eligible during the following tax year, the portion of HSA contributions attributable to months that the individual was not actually HSA-eligible will be included in their gross income, subject to a 10 percent penalty (unless the individual dies or becomes disabled).

Can I Transfer Funds from my IRA to my HSA?

A one-time irrevocable trustee-to-trustee transfer of IRA funds to an HSA will be allowed as long as the transferred amount does not exceed the annual HSA contribution limits 1 . Any transfer from an IRA to an HSA will reduce the maximum amount that may be contributed to an HSA during a calendar year.

Are my HSA Funds Invested?

Your funds will be held in an interest-bearing checking account at

Tallahassee State Bank. The current HSA rates

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, which are subject to change at any time are .100% APY for balances up to $999; .150%

APY for balances of $1,000 - $4,999; .200% APY for balances of

$5,000 - $24,999; and .250% APY on balances of $25,000 or more.

To check the current rate on this account, call the HSA Customer

Service Line at 1-877-367-4HSA.

Are There any Special Tax Forms or Tax

Reporting that I Must Complete When

Filing my Income Taxes?

The bank will send your tax filing information, after the end of the taxable year, for your use in reporting contributions to your HSA and to report any withdrawals or distributions from your HSA. It is important that you save receipts, invoices and any explanations of benefits received from your health insurance carrier as documentation, in case you are ever asked to show proof of qualified medical expenses to the IRS.

What if I Exceed the Annual Contribution

Limits Established by the IRS?

The People First Service Center will monitor your HSA contributions made through payroll deduction and send an alert to your payroll administrator and advise that you are exceeding your contribution limits. The custodian may send a courtesy notice reminding you to check your account balance and ensure that you are not exceeding the allowable annual contribution limits. You may decrease or stop your contributions accordingly, but the best way to ensure that you do not exceed the annual contribution limit is to elect a per-pay-period contribution that ensures you will not exceed the annual limit. Of course, you can add the “catch-up” contribution amount to these annual limits if you are age 55 or older. The catch-up contribution for 2016 is $1,000.

May I Have an HSA and Medical

Reimbursement Account?

Yes, individuals may enroll in a Limited Purpose Medical

Reimbursement Account to pay certain eligible expenses. The

Limited Purpose Medical Reimbursement Account may be used to pay expenses not covered by your Health Investor HSA or a high deductible health plan, including dental, vision and preventive care expenses. Dependent Care Spending Account eligibility is not affected by your HSA participation. Additional information will be available with your enrollment information.

Information is also available by contacting the People First

Service Center at 1-866-663-4735 or visiting the website at https://peoplefirst.myflorida.com.

Remember, Limited Purpose Medical

Reimbursement Accounts are available to HSA participants. Dependent Care Spending Account eligibility is not affected by your HSA participation.

1

Please consult a tax advisor. Certain restrictions apply.

2

The rate is effective as of July 1, 2015.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

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Flexible Spending Accounts

What is a Flexible Spending Account?

The State provides you with IRS tax-favored Flexible Spending Accounts (FSAs) to stretch your medical expense and dependent care dollars.

Flexible Spending Accounts feature:

• IRS-approved reimbursement of eligible expenses tax free

• per-pay-period deposits from your pre-tax salary

• savings on income and Social Security taxes and

• security of paying anticipated expenses with your FSA.

Is an FSA Right for Me?

If you spend money on recurring eligible expenses during your plan year, you may save money by paying for them with an FSA. A portion of your salary is deposited into your

FSA each pay period.

• You decide the amount you want deposited.

• You are reimbursed for eligible expenses before income and Social Security taxes are deducted.

• You save income and Social Security taxes each time you receive wages.

What Types of FSAs are Available?

The State offers you a Medical Reimbursement Account as well as a Dependent Care

Reimbursement Account. If you incur both types of expenses during a plan year, you can establish both types of FSAs.

Receiving Reimbursement

Your reimbursement will be processed within five business days from the time

People First receives your properly completed and signed Claim Form. To avoid delays, follow the instructions for submitting your requests located in the

FSA materials you will receive following enrollment.

Direct Deposit (when available)

Enroll in Direct Deposit to expedite the time of your reimbursement.

• FSA reimbursement funds are automatically deposited into your checking or savings account.

• There is no fee for this service.

• You don’t have to wait for postal service delivery of your reimbursement

(however, you will receive notification that the claim has been processed).

Medical Reimbursement Accounts

Medical expenses not covered by your insurance plan may be eligible for reimbursement using your Medical

Reimbursement Account, including:

• co-payments

• eyeglasses

• orthodontia and

• Over-the-Counter items.

Dependent Care Reimbursement

Accounts

Dependent care expenses, whether for a child or an elder, include any expense that allows you to work, such as:

• day care services

• in-home care

• nursery and preschool and

• summer day camps.

Where Can I Get Information about FSAs?

If you have specific questions about FSAs:

• Visit myBenefits.myFlorida.com

• Call

1-866-663-4735;

TTY 1-866-221-0268.

Please note that due to our Privacy

Policy, we will not discuss your account information with others without your verbal or written authorization.

Annual Gross Income

FSA Deposit for Eligible Expenses

Taxable Gross Income

Federal, Social Security Taxes

Annual Net Income

Cost of Eligible Expenses

Spendable Income

(With FSA) (Without FSA)

$31,000.00

- 2,550.00

$28,450.00

- 5,885.25

$31,000.00

- 0.00

- 6,401.50

$31,000.00

$22,564.75

- 0.00

$24,598.50

- 2,550.00

$22,564.75

$22,048.50

* Based upon a 20.65% tax rate (15% federal and 5.65% Social Security) calculated on a calendar year.

Manage your account: https://peoplefirst.myflorida.com

Refer to the

Medical Reimbursement Account and

Dependent Care Reimbursement Account sections of this

Reference Guide for specifics on each type of FSA.

Learn more: myBenefits.myFlorida.com

Flexible Spending Accounts

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FSA Guidelines:

1. The IRS does not allow you to pay your medical or other insurance premiums through either type of FSA.

2. You cannot transfer money between FSAs or pay a dependent care expense from your

Medical Reimbursement Account or vice versa.

3. The deadline to file claims is April 15 for reimbursement of eligible FSA expenses incurred during the previous plan year.

4. An IRS Revenue Notice permits a “grace period” of two months and 15 days following the end of your 2016 Plan Year (December 31, 2016) for a Medical Expense FSA. This grace period ends on March 15, 2017. Funds will be automatically deducted from any remaining dollars in your 2016 Medical Expense FSA balance.

You should not confuse the grace period with the plan’s “run-out” period. The run- out period extends until April 15, 2017. This is a period for filing claims incurred anytime during the 2016 Plan Year, as well as claims incurred during the grace period mentioned above.

5. You may not receive insurance benefits or any other compensation for expenses which are reimbursed through your FSAs.

6. You cannot deduct reimbursed expenses for income tax purposes.

7. You may not be reimbursed for a service which you have not yet received.

8. Be conservative when estimating your medical and/or dependent care expenses for the plan year. IRS regulations state that any unused funds which remain in your

FSA after a plan year ends, and all reimbursable requests have been submitted and processed, cannot be returned to you nor carried forward to the next plan year.

What Documentation of Expenses do I Need to Keep?

The IRS requires FSA customers to maintain complete documentation, including keeping copies of statements, invoices or bills for reimbursed expenses, for a minimum of one year.

How do I Get the

Forms I Need?

To obtain forms you will need after enrolling in either a Medical

Reimbursement or Dependent Care

Reimbursement Account, such as a Claim

Form, and Letter of Medical Need visit myBenefits.myFlorida.com, or call

1-866-663-4735; TTY 1-866-221-0268.

Will Contributions Affect my Income Taxes?

Salary reductions made under a cafeteria plan, including contributions to one or both FSAs, will lower your taxable income and taxes. These reductions are one of the money-saving aspects of starting an FSA.

Depending on the state, additional state income tax savings or credits may also be available. Your salary reductions will reduce earned income for purposes of the federal Earned Income Tax Credit (EITC).

To help you choose between the available taxable and tax-free benefits, or a combination of both, consult your tax advisor and/or the IRS for additional information.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

8

Medical Reimbursement Account

What is a Medical Reimbursement Account?

A Medical Reimbursement Account is an IRS tax-favored account you can use to pay for your eligible medical expenses not covered by your insurance or any other plan. These funds are set aside from your salary before taxes are deducted, allowing you to pay your eligible expenses tax-free. A partial list of these eligible expenses can be found on the next page.

Acupuncture

Drugs

Eyeglasses treatments

Wheelchairs

Whose Expenses are Eligible?

Your Medical Reimbursement Account may be used to reimburse eligible expenses incurred by:

• yourself

• your spouse

• your qualifying child or

• your qualifying relative.

Annual Contribution Limits

For Medical Reimbursement

Accounts:

Minimum Annual Deposit: $60

Maximum Annual Deposit: $2,550

An individual is a qualifying child, if they:

• are a U.S. citizen, national or a resident of the U.S., Mexico or Canada

• have a specified family-type relationship to you

• live in your household for more than half of the taxable year

• are 26 years old or younger at the end of the taxable year and

• have not provided more than one-half of their own support during the taxable year.

An individual is a qualifying relative if they are a U.S. citizen, national or a resident of the

U.S., Mexico or Canada and:

• have a specified family-type relationship to you, are not someone else’s qualifying child and receive more than one-half of their support from you during the taxable year or

• if no specified family-type relationship to you exists, are a member of and live in your household (without violating local law) for the entire taxable year and receive more than one-half of their support from you during the taxable year.

NOTE: There is no age requirement for a qualifying child if they are physically and/ or mentally incapable of self-care. An eligible child of divorced parents is treated as a dependent of both, so either

Can Travel Expenses be Reimbursed?

Travel expenses primarily for, and essential to, receiving medical care, including health care provider and pharmacy visits, may be reimbursable through your Medical

Reimbursement Account. With proper substantiation, eligible expenses can include:

• actual round-trip mileage

• parking fees

• tolls and

• transportation to another city.

Are Prescriptions Eligible for Reimbursement?

Yes, most filled prescriptions are eligible for Medical Reimbursement Account reimbursement, as long as you properly substantiate the expense. Proper submission of the reimbursement request is needed to ensure that the drug is eligible for reimbursement. The IRS requires the complete name of all medicines and drugs be obtained and documented on pharmacy invoices (including prescription number, date(s) of service and total dollar amount). This information must be included when submitting your request to People First for reimbursement.

reimbursement.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Medical Reimbursement Account

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Over-the-Counter Expenses

Your Over-the-Counter (OTC) items, medicines and drugs may be reimbursable through your Medical Reimbursement

Account. Save valuable tax dollars on certain categories of OTC items, medicines and drugs, such as: allergy treatments, antacids, cold remedies, first-aid supplies and pain relievers.

You may be reimbursed for OTCs through your Medical Reimbursement Account if:

• you have a prescription from a physician (for any OTC item classified as a drug or medicine)

• the item, medicine or drug was used for a specific medical condition for you, your spouse and/or your dependent(s)

• the submitted receipt clearly states the purchase date and name of the item, medicine or drug

• the reimbursement request is for an expense allowed by your employer’s

Medical Reimbursement Account plan and IRS regulations and

• you submit your reimbursement request in a timely and complete manner already described in your benefits enrollment information.

NOTE: OTC items, medicines and drugs, including bulk purchases, must be used in the same plan year in which you claim reimbursement for their cost. It is your responsibility to remain informed of updates to this listing, which can be found at www.irs.gov/pub/irs-pdf/p502.pdf.

As soon as an OTC item, medicine or drug becomes eligible under any of the categories above, it will be reimbursable retroactively to the start of the then current plan year. Certain items on the

IRS eligibility list may not be approved as part of your medical plan, check your plan documents before making any purchase or claim.

Newly eligible OTC items, medicines and drugs are not considered a valid change in status event that would allow you to change your annual Medical

Reimbursement Account election or salary reduction amount. Be sure to maintain sufficient documentation to submit receipts for reimbursement. You may resubmit a copy of your receipt from your records if a rejected OTC expense becomes eligible for reimbursement later in the same plan year.

Is Orthodontic Treatment

Reimbursable?

Orthodontic treatment designed to treat a specific medical condition is reimbursable through your Medical Reimbursement

Account if the proper documentation is provided:

• a written statement, bill or invoice from the treating dentist/orthodontist showing the type and date the service was incurred, the name of the eligible individual receiving the service, the cost for the service and

• a copy of the patient’s contract with the dentist/orthodontist for the orthodontia treatment (only required if a participant requests reimbursement for the total program cost spread over a period of time).

Reimbursement of the full or initial payment amount may only occur during the plan year in which the braces are first installed. For reimbursement options available under your employer’s plan, including care that extends beyond one or more plan years, refer to the information provided following your enrollment, or call People First Service Center at

1-866-663-4735; TTY 1-866-221-0268.

When are my Funds

Available?

Once you sign up for a Medical

Reimbursement Account and decide how much to contribute, the maximum annual amount of reimbursement for eligible health care expenses will be available throughout your period of coverage.

Since you don’t have to wait for the cash to accumulate in your account, you can use it to pay for your eligible health care expenses at the start of your deductions.

Should I Claim my Expenses on IRS Form 1040?

With a Medical Reimbursement Account, the money you set aside for health care expenses is deducted from your salary before taxes. It is always tax free, regardless of the amount. By enrolling in a Medical

Reimbursement Account, you guarantee your savings.

Itemizing your health care expenses on your IRS Form 1040 may give you a different tax advantage, depending on their percentage of your adjusted gross income. You should consult a tax professional to determine which avenue is right for you.

Are Some Expenses

Ineligible?

Expenses not eligible for reimbursement through your Medical Reimbursement

Account include:

• insurance premiums

• vision warranties and service contracts and

• cosmetic surgery not deemed medically necessary to alleviate, mitigate or prevent a medical condition.

Important HSA Eligibility Information

You cannot be enrolled in a Medical Reimbursement Account (MRA) and a Health Savings Account (HSA) at the same time. If you currently have an MRA and you plan to enroll in an HSA for the next plan year, you must use all MRA funds before December 31. This means your claims must be submitted and reimbursed by December 31; otherwise, you will be ineligible for the HSA until April 1 of the following year.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

10

Medical Reimbursement Account

When do I Request Reimbursement?

You may use your Medical Reimbursement Account to reimburse eligible expenses after you have sought (and exhausted) all means of reimbursement provided by your employer and any other appropriate resource. Also keep in mind that some eligible expenses are reimbursable on the date available, not the date ordered.

How do I Request Reimbursement?

Requesting reimbursement from your Medical Reimbursement Account is easy. Simply follow the instructions available on Page 21 or online at myBenefits.myFlorida.com

to complete a Claim Form electronically, or fax or mail a correctly completed copy along with the following:

• an invoice or bill from your health care provider listing the date you received the service, the cost of the service, the specific type of service and the person for whom the service was provided or

• an Explanation of Benefits (EOB)* from your health insurance provider that shows the specific type of service you received, the date and cost of the service and any uninsured portion of the cost and

• a written statement from your health care provider indicating the service was medically necessary if those services could be deemed cosmetic in nature, accompanied by the invoice or bill for the service.

Please note that cancelled checks or credit card receipts (or copies) listing the cost of eligible expenses are not valid documentation for Medical

Reimbursement Account reimbursement.

Fax Toll-Free:

1-888-800-5217

Mail to:

People First Service Center

Flexible Spending Account

PO Box 14766

Lexington, KY 40512-4766

* EOBs are not required if your coverage is through an HMO.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

myMRA Card

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The

myMRA Card is a convenient option that allows electronic reimbursement of eligible expenses under your employer’s plan and IRS guidelines. Because it is a payment card, when you use the

myMRA Card to pay for eligible expenses, funds are electronically deducted from your account.

myMRA Card Advantages

You can use the myMRA Card for your eligible, non-medicinal Over-the-Counter

(OTC)* expenses at drugstores. Other advantages include:

• instant reimbursements for healthcare expenses

• instant approval of all prescription expenses, as well as some medical, vision and dental (others require documentation)

• no out-of-pocket expense and

• easy access to your account funds.

NOTE: You cannot use the myMRA Card for cosmetic dental expenses or eye glass warranties.

Using the myMRA Card

For eligible expenses, simply swipe the

myMRA Card like you would with any other credit card. Whether at your healthcare provider or drugstore, the amount of your eligible expenses will be automatically deducted from your

Flexible Spending Account. With the 2011

IRS ruling, you may not use your

myMRA

Card for OTC drugs at the pharmacy counter with a prescription. For OTC drugs requiring a prescription, you can submit documentation for reimbursement. Please see Page 10 for instructions. You still will be able to use your

myMRA Card for non-drug OTC items and devices, such as bandages and contact lens solution, as long as you shop at merchants that have an industry standard (IIAS) inventory system that can verify the eligibility of items at checkout. An updated list of IIAS merchants is maintained at www.sigis. com. For all other qualified expenses, such as medical and dental co-payments, the

myMRA Card will be used normally.

Two cards will be sent to you in the mail; one for you and one for your spouse or eligible dependent. You should keep your cards to use each plan year until their expiration date.

Remember, you must go to https://peoplefirst.myflorida.com to activate your card, see your account information and check for any outstanding

Card transactions. Employees must provide a valid email address fi for the “Go Green” option, before activating the

myMRA Card.

When do I Send in

Documentation for a

myMRA Card Expense?

You must send in documentation for certain

myMRA Card transactions, such as those that are not a known office visit or prescription co-payment (as outlined in your health plan’s Schedule of Benefits).

When requested, you must send in documentation for these transactions.

Documentation for a card expense is a statement or bill showing:

• name of the patient

• name of the service provider

• date of service

• type of service (including prescription name) and

• total amount of service.

NOTE: This documentation must be sent with a

Claim Form. Your claim cannot be processed without all of these materials.

Like all other FSA documentation, you must keep your

myMRA Card expense documentation for a minimum of one year, and submit it when requested. See

Page 21 for more information about obtaining a Claim Form.

If you fail to send in the requested documentation for an myMRA Card expense, you will be subject to:

• withholding of payment for an eligible paper claim to offset any outstanding

myMRA Card transaction

• suspension of your

myMRA Card privileges

• payback through payroll deduction

NOTE: Card transaction disputes must be filed within 60 days of the transaction date.

What Happens if I Have

Money Left in my Account at the End of the Plan Year?

These funds will be used first until exhausted — through March 15, 2017, which is the grace period allowed by the IRS. Then, subsequent claims will be debited from your new plan year account balance. For more information on the grace period, see Page 7.

What Agreement am I

Making When I use the myMRA Card?

For more information about the

myMRA

Card, see the Cardholder Agreement that accompanies it.

Important Numbers:

Lost or Stolen Card

24 hours a day

1-888-462-1909

Dispute Line

Mon - Fri, 7 a.m. - 10 p.m. ET

1-866-663-4735

* OTC drugs and medicines require a prescription to qualify for FSA reimbursement. Any OTC item requiring a prescription may not be purchased with the

myMRA Card.

Manage your account: https://peoplefirst.myflorida.com

The

myMRA Card Visa

®

Card is issued by UMB.

Learn more: myBenefits.myFlorida.com

12

myMRA Card

Using Your Card Examples

Your Transaction is

Auto-adjudicated:

01/15/16 Swipe card at pharmacy for $25 prescription

02/01/16 View online account information

$25 charge shows in black (no documentation needed)

Your Transaction

Requires Documentation:

03/02/16 Swipe card at doctor’s office for $45.11 co-insurance

You must send in documentation for certain

myMRA

Card transactions, such as those that are not a known office visit or prescription co-payment (as outlined in your health plan’s Schedule of Benefits).

Receive Card

Documentation

Needed e-mail in April

Receive Card

Scheduled for

Suspension e-mail in May

After Second e-mail the Card is Suspended

07/04/16

Go to the MRA website to view online account information

$45.11 charge is highlighted in color (documentation needed to substantiate amount) under Outstanding

Payment Card Transactions needed Documentation

– CURRENT PLAN YEAR

Go to the MRA website to view online account information

$45.11 charge is highlighted in color (documentation needed to substantiate amount)

Card suspended due to documentation not being received for the $45.11 charge

Swipe card at doctor’s office for $52.00, charge denied because card is suspended

07/18/16 Send in documentation (Explanation of Benefits from health carrier or itemized bill or receipt) detailing $45.11 doctor’s charge, account cleared and card reactivated.

What Happens if I Do Not

Submit Documentation?

If you fail to send in the requested documentation for an myMRA Card expense, you will be subject to:

• withholding of payment for an eligible paper claim to offset any outstanding myMRA Card transaction

• suspension of your

myMRA Card privileges

• payback through payroll deduction

What Should I Do if my Card is Suspended?

If your Card is suspended you must send in documentation to substantiate the transaction.

Documentation for a card expense is a statement or bill showing:

• name of the patient

• name of the service provider

• date of service

• type of service (including prescription name) and

• total amount of service.

NOTE: This documentation must be sent with a

Claim Form. Your claim cannot be processed without all of these materials. Like all other FSA documentation, you must keep your myMRA

Card expense documentation for a minimum of one year, and submit it when requested.

Once your properly completed documentation is received

and processed, your Card will be reactivated in 24 - 48 business hours. You will also receive an e-mail notifying you that your

Card has been reinstated.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Limited Purpose Medical Reimbursement Account

13

For Health Investor HSA Participants Only

What is a Limited Medical Reimbursement Account?

A Limited Purpose Medical Reimbursement Account is designed specifically for employees who wish to take advantage of a Health

Savings Account (HSA), while continuing to enjoy the tax savings expected from an FSA. Much like a Medical Reimbursement Account, funds are set aside from your salary before taxes are deducted, allowing you to pay your eligible expenses tax free.

However, the funds in a Limited Purpose Medical Reimbursement Account can only be used for dental, vision and preventive care expenses not covered by your high deductible health plan. Your HSA is designed to be used for all other medical-related expenses. A partial list of eligible Limited Purpose Medical Reimbursement Account expenses can be found on this page.

Aside from these minor differences, a Limited Purpose Medical Reimbursement Account follows the same procedures for reimbursement as a Medical Reimbursement Account.

Annual Contribution Limits

For Limited Purpose Medical

Reimbursement Accounts:

Minimum Annual Deposit: $60

Maximum Annual Deposit: $2,550

Limited Purpose

MRA Eligibility

Your Limited Purpose Medical

Reimbursement Account may be used to reimburse eligible expenses incurred by yourself, your spouse, your qualifying child or your qualifying relative.

Please see the Flexible Spending

Account FAQs at https://peoplefirst.myflorida.com.

NOTE: There is no age requirement for a qualifying child if they are physically and/or mentally incapable of self-care.

An eligible child of divorced parents is treated as a dependent of both, so either or both parents can establish a Limited

Purpose Medical Reimbursement Account.

Only the custodial parent of divorced or legally-separated parents can be reimbursed using the Dependent Care

Reimbursement Account.

Whose expenses are eligible?

Your Limited Purpose Medical

Reimbursement Account may be used to reimburse eligible expenses incurred by:

• yourself

• your spouse

• your qualifying child or

• your qualifying relative.

An individual is a qualifying child if they:

• are a U.S. citizen, national or a resident of the U.S., Mexico or Canada

• have a specified family-type relationship to you

• live in your household for more than half of the taxable year

• are 18 years old or younger (23 years, if a full-time student) at the end of the taxable year and

• have not provided more than one-half of their own support during the taxable year (and receive more than one-half of their support from you during the taxable year if a full-time student age

19 through 23 at the end of the taxable year).

When are my Funds

Available?

Once you sign up for a Limited Purpose

Medical Reimbursement Account and decide how much to contribute, the maximum annual amount of reimbursement for eligible expenses will be available throughout your period of coverage.

Since you don’t have to wait for the cash to accumulate in your account, you can use it to pay for your eligible expenses at the start of your plan year, which is

January 1.

Partial List of Medically

Necessary Eligible Expenses

1

screening reimbursement.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

14

Dependent Care Reimbursement Account

What is a Dependent Care Reimbursement Account?

A Dependent Care Reimbursement Account is an IRS tax-favored account you can use to pay for your eligible dependent care expenses to ensure your dependents (child or elder) are taken care of while you and your spouse (if married) are working. These funds are set aside from your salary before taxes are deducted, allowing you to pay your eligible expenses tax free. A partial list of these eligible expenses can be found on this page.

Annual Contribution Limits

For Dependent Care

Reimbursement Accounts:

Minimum Annual Deposit*: $60

Maximum Annual Deposit*: The maximum contribution depends on your tax filing status as the list on this page indicates.

* Including administrative fee

DCRA Eligibility

You may use your Dependent Care

Reimbursement Account to receive reimbursement of eligible dependent care expenses for children under age 13; however, a qualified dependent may be any person you take care of who lives in your home and depends on you for support. To see if your dependents qualify read IRS Publication 503, Dependent Care

Expenses, at www.irs.gov.

Please seethe Flexible Spending

Account FAQs at https://peoplefirst.myflorida.com.

What is my Maximum

Annual Deposit?

• If you are married and filing separately, your maximum annual deposit is

$2,500.

• If you are single and head of household, your maximum annual deposit is

$5,000.

• If you are married and filing jointly, your maximum annual deposit is $5,000.

• If either you or your spouse earn less than $5,000 a year, your maximum annual deposit is equal to the lower of the two incomes.

• If your spouse is a full-time student or incapable of self-care, your maximum annual deposit is $3,000 a year for one dependent and $5,000 a year for two or more dependents.

When are my Funds

Available?

Once you sign up for a Dependent Care

Reimbursement Account and decide how much to contribute, the funds available to you depend on the actual funds in your account. Unlike a Medical Reimbursement

Account, the entire maximum annual amount is not available during the plan year, but rather after your payroll deductions are received.

Should I Claim Tax Credits or Exclusions?

Since money set aside in your Dependent

Care Reimbursement Account is always tax free, you guarantee savings by paying for your eligible expenses through your IRS tax-favored account. Depending on the amount of income taxes you are required to pay, participation in a Dependent Care

Reimbursement Account may produce a greater tax benefit than claiming tax credits or exclusions alone.

Remember, you cannot use the dependent care tax credit if you are married and filing separately. Further, any dependent care expenses reimbursed through your Dependent Care

Reimbursement Account cannot be filed for the dependent care tax credit, and vice versa.

Partial List of Eligible

Dependent Care Expenses*

After school care

Baby-sitting fees

Day care services

Elder care services

In-home care/au pair services

Nursery and preschool

Summer day camps

NOTE: Budget conservatively. No reimbursement or refund of Dependent Care FSA funds is available for services that do not occur within your plan year.

* IRS-qualified expenses are subject to federal regulatory change at any time during a tax year.

Certain other substantiation requirements and restrictions may apply, and will be supplied to you following enrollment.

To help you choose between the available taxable and tax-free benefits, or a combination of both, consult your tax advisor and/or the IRS for additional information.

Are Some Expenses

Ineligible?

Expenses not eligible for reimbursement through your Dependent Care

Reimbursement Account include:

• books and supplies

• child support payments or child care if you are a non-custodial parent

• healthcare or educational tuition costs and

• services provided by your dependent, your spouse’s dependent or your child who is under age 19.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Dependent Care Reimbursement Account

15

Will I Need to Keep any

Additional Documentation?

To claim the income exclusion for dependent care expenses on IRS Form

2441 (Child and Dependent Care

Expenses), you must be able to identify

A properly completed request will help speed along the process of your reimbursement, allowing you to receive your check or

Direct Deposit promptly.

How do I Request Reimbursement?

your dependent care provider. If your dependent care is provided by an individual, you will need their Social

Security number for identification, unless he or she is a resident or non-resident alien who does not have a Social Security number. If your dependent care is provided by an establishment, you will need its Taxpayer Identification number.

If you are unable to obtain a dependent care provider’s information, you must compose a written statement that explains the circumstances and states that you made a serious and earnest effort to get the information. This statement must accompany your IRS Form 2441.

When do I Request

Reimbursement?

You can request reimbursement from your

Dependent Care Reimbursement Account as often as you like. However, your approved expense will not be reimbursed until the last date of service for which you are requesting reimbursement has passed.

Also, remember that for timely processing of your reimbursement, your payroll contributions must be current.

Requesting reimbursement from your

Dependent Care Reimbursement Account is easy. Simply follow the instructions available on Page 21 or online at

MyBenefits.myFlorida.com to complete a

Claim Form electronically, or fax or mail a correctly completed copy with the following:

• Social Security number

• the name, age and grade of the dependent receiving the service

• the cost of the service

• the name and address of the provider and

• the beginning and ending dates of the service.

Be certain you obtain and submit the above information when requesting reimbursement from your Dependent

Care Reimbursement Account. This information is required with each request for reimbursement. Cancelled checks or credit card receipts (or copies) listing the cost of eligible expenses are not valid documentation for Dependent Care

Reimbursement Account reimbursement.

Fax Toll-Free:

1-888-800-5217

Mail to:

People First Service Center

Flexible Spending Account

PO Box 14766

Lexington, KY 40512-4766

NOTE: If you elect to participate in the

Dependent Care Reimbursement Account, or if you file for the Dependent Care Tax

Credit, you must attach IRS Form 2441, reflecting the information above, to your

1040 income tax return. Failure to do this may result in the IRS denying your pre-tax exclusion.

Be certain you obtain and submit all needed information when requesting reimbursement from your Dependent Care

Reimbursement Account. This information is required with each request for reimbursement.

A properly completed request will help speed along the process of your reimbursement, allowing you to receive your check or Direct Deposit promptly.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

16

FSA Worksheets

Go to http://www.myBenefits.myFlorida.com/calculator/index.htm to estimate your expenses online or use the worksheets below to determine how much to deposit in your FSA. You calculate the amount you expect to pay during the plan year for eligible, uninsured out-of-pocket medical and/or dependent care expenses. This calculated amount cannot exceed established IRS and plan limits. (Refer to the individual FSA descriptions in this Reference Guide for limits.)

Be conservative in your estimates, since any money remaining in your accounts cannot be returned to you or carried forward to the next plan year.

Account Worksheet

Worksheet

UNINSURED MEDICAL EXPENSES

$

÷ ÷

This is your pay period contribution.

* If you are a new employee enrolling after the plan year begins, divide by the

This is your pay period contribution.

* If you are a new employee enrolling after the plan year begins, divide by the

You can go to http://myBenefits.myFlorida.com/health/forms_and_resources/cost_estimators to estimate your FSA expenses.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Changing Your Coverage

17

Am I Permitted to Make Mid-plan Year

Election Changes?

Under some circumstances, your employer’s plan(s) and the IRS may permit you to make a mid-plan year election change to your

FSA election, or vary a salary reduction amount, depending on the qualifying event and requested change.

How do I make a change?

You can change your Flexible Spending Account (FSA) election(s), or vary the salary reduction amounts you have selected during the plan year, only under limited circumstances as provided by your employer’s plan(s) and established IRS guidelines. See the Making Changes page at the

myBenefits.myFlorida.com

website to learn about allowable mid-plan year changes. Election changes must be consistent with the event. Your employer will in its sole discretion, review on a uniform and consistent basis, the facts and circumstances of each properly completed and timely submitted mid-plan year election change form.

To Make a Change: You have 60 days, including the date of the event, to make an allowable change. For birth, adoption, marriage and work events, you may make your elections online at https:// peoplefirst.myflorida.com. For all other events, you must call the

People First Service Center. Documentation supporting your event may be required. Upon the approval and completion of processing your election change request, your existing FSA(s) elections will be stopped or modified (as appropriate). Generally, mid-plan year, pre-tax election changes can only be made prospectively, no earlier than the first payroll after your election change request has been received by your employer, unless otherwise provided by law. If your FSA election change request is denied, you will have

180 days, from the date you receive the denial, to file an appeal.

What is my Period of Coverage?

Your period of coverage for incurring expenses is your full plan year, unless you make a permitted mid-plan year election change. For a Medical Reimbursement Account, a mid-plan year election change will result in split periods of coverage, creating more than one period of coverage within a plan year with expenses reimbursed from the appropriate period of coverage.

Money from a previous period of coverage can be combined with amounts after a permitted mid-plan year election change.

However, expenses incurred before the permitted election change can only be reimbursed from the amount of the balance present in the Medical Reimbursement Account prior to the change. Mid-plan year election changes are approved only if the extenuating circumstances and supporting documentation are within your employer's Medical Reimbursement Account plan and the IRS regulations governing the plan.

For example: You elect to contribute $1,000 at the beginning of the plan year and experience a qualifying event on June 1. If you then elect to contribute an additional $1,000 to your Medical

Reimbursement Account, your account is now funded with

$2,000, which may be used toward any expenses after June 1.

However, any expenses incurred before June 1, may only be reimbursed using the original $1,000 you elected to contribute prior to experiencing the qualifying event change.

Split periods of coverage do not apply to Dependent Care

Reimbursement Accounts.

What are the IRS Special Consistency Rules

Governing Changes in Status?

Dependent Care Expenses – You may change or terminate your Dependent Care Reimbursement Account election when a Change in Status (CIS) event affects (i) eligibility for coverage under an employer’s plan, or (ii) eligibility of dependent care expenses for the tax exclusion available under IRC (Internal

Revenue Code) § 129.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

18

COBRA Questions and Answers

What is Continuation Coverage?

Federal law requires that most group health plans, including Medical Flexible Spending

Accounts (Medical Reimbursement Accounts), give employees and their families the opportunity to continue their health care coverage when there is a “qualifying event” that would result in a loss of coverage under an employer’s plan. “Qualified beneficiaries” can include the employee covered under the group health plan, a covered employee’s spouse and dependent children of the covered employee.

Each qualified beneficiary who elects continuation coverage will have the same rights under the plan as other participants or beneficiaries covered under the plan, including special enrollment rights.

How Long will Continuation

Coverage Last?

If you fund your Medical Reimbursement

Account entirely, you may continue your

Medical Reimbursement Account (on a post-tax basis) only for the remainder of the plan year in which your qualifying event occurs, if you have not already received, as reimbursement, the maximum benefit available under the Medical Reimbursement Account for the year. For example, if you elected a

Medical Reimbursement Account benefit of

$1,000 for the plan year and have received only

$200 in reimbursement, you may continue your Medical Reimbursement Account for the remainder of the plan year or until such time that you receive the maximum Medical

Reimbursement Account benefit of $1,000. The participant must elect to continue coverage no later than 60 calendar days from (a) the employment termination date; or (b) the date the participant is notified by the Department of his or her eligibility to continue participation.

You should take into account that a failure to continue your group health coverage will affect your future rights under federal law. Finally, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 60 days after your group health coverage ends because of the qualifying event listed above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you.

How Much Does Continuation

Coverage Cost?

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. For Medical Reimbursement

Accounts, the cost for continuation of coverage is a monthly amount calculated and based on the amount you were paying via pre-tax salary reductions before the qualifying event.

When and How Must

Payments for Continuation

Coverage be Made?

First Payment for Continuation Coverage

If you elect continuation coverage, you do not have to send any payment for continuation coverage with the COBRA Election Form.

However, you must make your first payment for continuation coverage within 45 days after the date of your election. (This is the date the Election Notice is post-marked, if mailed.)

If you do not make your first payment for continuation coverage within that 45 days, you will lose all continuation coverage rights under the Plan.

How can you Elect

Continuation Coverage?

Each qualified beneficiary has an independent right to elect continuation coverage. For example, both the employee and the employee’s spouse, or only one of them, may elect continuation coverage. Parents may elect to continue coverage on behalf of their dependent children only. A qualified beneficiary must elect coverage by the date specified on the COBRA Election Form. Failure to do so will result in loss of the right to elect continuation coverage under the Plan.

A qualified beneficiary may change a prior rejection of continuation coverage any time until that date.

Your first payment must cover the cost of continuation coverage from the time your coverage under the Plan would have otherwise terminated up to the time you make the first payment. You are responsible for making

Manage your account: https://peoplefirst.myflorida.com

Keep Your Address Updated

In order to protect your family’s rights, you should keep your employer and

People First informed of any changes in the addresses of family members.

You should also keep a copy, for your records, of any notices you send to your employer.

sure that the amount of your first payment is enough to cover this entire period. You may contact the People First Service Center to confirm the correct amount of your first payment.

Periodic Payments for

Continuation Coverage

After you make your first payment for continuation coverage, you will be required to pay for continuation coverage for each subsequent month of coverage. Under the

Plan, these periodic payments for continuation coverage are due on the first day of each month. If you make a periodic payment on or before its due date, your coverage under the

Plan will continue for that coverage period without any break.

Instructions for sending your first payment for continuation coverage will be shown on your

COBRA Election Notice/Form.

Grace Periods for Periodic Payments

Although periodic payments are due on the dates shown above, you will be given a grace period of 60 days to make each periodic payment. Your continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. If you pay a periodic payment later than its due date but during its grace period, your coverage under the Plan will be suspended as of the due date and then retroactively reinstated (going back to the due date) when the periodic payment is made. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that payment, you will lose all rights to continuation coverage under the Plan.

Learn more: myBenefits.myFlorida.com

How Participation May Affect Other Benefits

19

For More Information

This COBRA Q&A section does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available from your employer.

For more information about your COBRA rights, the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee

Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa.

When you participate in the Pretax

Premium component and/or the

Reimbursement Account component of the Flexible Spending Accounts Program, you save both federal income and social security taxes. However, participation may affect the benefits you receive from other tax-deferred or employee benefit plans:

Social Security

Over the long run, paying less Social

Security taxes could slightly reduce your

Social Security retirement or disability benefits. However, the taxes you save over the years should more than offset the slight reduction you might see at retirement.

Florida Retirement

System (FRS)

Your benefits from the FRS are not affected in any way by your participation in the

Flexible Spending Accounts Program.

FRS benefits are calculated on your gross salary before pre-tax premiums or reimbursement account contributions are deducted.

Life Insurance and

Pay Raise Calculations

Your pay raises and the value of your

State Group Life Insurance will continue to be based on your base annual earnings, before pre-tax premiums or reimbursement account contributions deducted. FSA participation will have no impact.

State University

System Optional

Retirement Program

If you participate in the State University

System Optional Retirement Program

(ORP), the amount contributed by the

State to your ORP account will not be affected by your participation in either part of the Flexible Spending Accounts

Program. However, the maximum that you may contribute to the ORP will be based on your adjusted gross income, after pre-tax premium and/or reimbursement account contributions. Please contact the Division of Retirement for further information.

State Deferred

Compensation Plan

The State Deferred Compensation Plan allows you to tax-defer 25 percent or a maximum $10,000 per year of your income (after FSA deductions are taken), whichever is less. If you contribute the maximum or near maximum allowed under the State Deferred Compensation

Plan, you should be aware that the

Flexible Spending Accounts Program may affect your maximum allowed deferral.

The examples and worksheets on Page

20 will help you determine if you might be affected. Contact the State of Florida

Deferred Compensation Office or your deferred compensation provider if you have any questions.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

20

Deferred Compensation Worksheet

The following example shows how a deferred compensation contribution could be affected by participation in pre-tax premiums and/ or reimbursement accounts.

Example:

Annual Salary

Annual Pre-tax Health and Insurance Premium

Reimbursement Account Contribution

Annual Pre-tax Supplemental Insurance Premium

Adjusted Gross Income

$ 31,000

$ 1,394

$ - 0

$ - 0

$ 29,606

Maximum Deferred Compensation Contribution x .25

$ 7,401.50

(or $14,000, whichever is less)

In this example, the participant could contribute a maximum of $7,401.50 ($29,606 X 25%) to his

Deferred Compensation Plan. If he were contributing his maximum of 25 percent before participating in the pre-tax premium plan, his deferral amount would have been $7,750 ($31,000 X 25%). He would need to contact his deferred compensation provider to make an adjustment. If your current annual deferred compensation contribution is more than the amount shown on your maximum deferral line, you will need to contact your deferred compensation provider to make an adjustment in your deferral.

Your Deferred Compensation Worksheet:

Annual Salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

Annual Pre-tax Health and Life Insurance Premium . . . .

$

Annual Reimbursement Account Contribution . . . . . . . .

$

Annual Pretax Supplemental Insurance Premium . . . . . .

$

Adjusted Gross Income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

Maximum Deferred Compensation Contribution . . . . . . x .25

Maximum Deferral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$

(or $14,000, whichever is less)

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

Online Claims Submission Instructions

21

Instructions

Follow these simple instructions to submit your completed, scanned claim form and supporting documentation online through https://PeopleFirst.MyFlorida.com. Instructions are also available online at MyBenefits.myFlorida.com, or contact the People First

FSA/HSA Team for assistance by calling 1-866-663-4735 and selecting option 1, then press 2 to enter your security information, then select option 2 for benefits followed by option 4 for FSA/HSA.

Before You Scan

• Acceptable document formats are .pdf, .jpg, .bmp, .gif or .pdf.

• Individual file sizes cannot exceed 3 megabytes (3MB).

• Scans must be in black and white, not color.

• Be sure to have your completed claim form and supporting documentation scanned before beginning the process.

Refer to your scanner’s instruction manual for information on saving your documents in the proper format and within the acceptable file size limit.

Submitting A Claim

1. To use the PeopleFirst FSA Online Claims Submission

How to Print/Save the Online Fillable Claim Form

Depending on the version of Adobe you have on your computer, you may not be able to save directly from the form. Instead you will need to “print” the form to your computer. Follow the below steps on how to save.

· Select File/Print

· Select the PDF “printer”

· Print

· Choose the destination you would like the form to be saved

· You can now access the form from the location where it was “printed/saved” and use to upload to the site.

process, you must first log in to your account at https://PeopleFirst.MyFlorida.com.

2. Once you have logged in, click on the “Health & Insurance” link.

From there click on the “Your Benefits” link.

Troubleshooting

If you receive an error message or the confirmation page does

3. In the “Helpful Links” section, click “FSA Information”. From there you may select the “Claims” tab at the top of the screen and then choose “Online Claims Submission” from the drop down not load:

1. Possible Causes

• The file size of your scanned document(s) may exceed

3 megabytes.

menu.

4. From here, simply follow the online instructions:

• Choose the account type for which you are submitting a claim, (DCRA or MRA)

• The file may not be the appropriate document format.

2. Solutions

• Double-check the file size and make adjustments, if necessary, by rescanning the document(s) and saving to a

1. If submitting an MRA claim, then you will be asked to choose from the following:

2. I used my myMRA card to pay for these expenses.

3. Please reimburse me for these out of pocket expenses.

smaller file size.

• Make sure the scanned document(s) are saved in a .pdf, .jpg,

.bmp or .gif format.

4. Please apply documentation as substitution toward card transactions requiring documentation.

• Enter the dollar amount of the claim in the appropriate box.

• Click “Next.”

5. Follow the instructions on the next page:

• Attach your completed and signed claim form.

press 2 to enter your security information, then select option 2 for benefits followed by option 4 for FSA/HSA.

• Attach your supporting documentation (receipts, invoices, etc).

• Click “Submit.”

Contact the People First FSA/HSA Team for assistance by calling 1-866-663-4735 and selecting option 1, then

6. Be sure to write down the confirmation number for future reference.

Manage your account: https://peoplefirst.myflorida.com

Learn more: myBenefits.myFlorida.com

People First Service Center

Flexible Spending Accounts

P.O. Box 14766 • Lexington, Kentucky 40512

1-866-663-4735; TTY 1-866-221-0268 https://peoplefirst.myflorida.com

Information contained herein does not constitute an insurance certificate or policy. Certificates will be provided to participants following the start of the plan year, if applicable.

PF/CONV /0715

© People First 2015

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