How to Complete this Form



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How to Complete this Form


1.Place your cursor in the highlighted blank in each field.

2.You can use the tab or arrow keys to move from one data field to another.

3.For those questions that utilize check boxes, double click on the box that applies and choose “checked”.

4.Once completed, save the document and send to your Relationship Manager.


Complete This Form and Return It to Your Relationship Manager


The following form collects the critical information WageWorks needs to prepare and properly service your program for the upcoming plan year. If there are no changes to your plan from the last plan year complete the first page only. Once received by your Relationship Manager and entered into the database, the information will populate the relevant data fields and displays on our employer and participant websites.
FSA Plan Confirmation Form


FSA Program Information


Program Sponsor/Employer Name/ER ID

     

Services Requested



 Health Care FSA

 Dependent Care FSA

 HSA-compatible Health Care FSA


Estimated # of Eligible Employees      

Estimated # of Participants      

ENR File expected Date      

Date Completed (required)      

Completed By (required)      

ER Contact Signature (required):      _________________________________________________

Authorization: My signature above certifies that I am authorized to communicate the below plan information changes.

No Plan Changes- Complete this section only


Plan

Health Care FSA

Dependent Care FSA

There are no changes to the plan this year.

All plan features and set up will remain the same as last year.

 No changes

 No changes

Plan Code - Please provide a code for each plan.

Important! This code will need to be updated on the PSF file for the new plan year.



     

     

Open Enrollment Begin Date

What is the first day eligible participant can enroll during open enrollment?

Important! The Open Enrollment dates drive the re-elect email reminders for existing participants.

     

     

Open Enrollment End Date

What is the last day eligible participant can enroll during open enrollment?

     

     



If there are any changes to your plan or the enrollment processes complete this form in its entirety.

I. FSA Plan Set-Up

A. Plan Basics


Plan

Health Care FSA

Dependent Care FSA

Plan Name - Please provide a name for each plan.

     

     

Number of Eligible Employees

     

     

Plan Start Date

     

     

Plan End Date

     

     

Qualified Changes

Does this plan allow eligible participants to enroll, change or cancel their election (following a qualified change) in the middle of the plan year?

 Yes

 No


 Yes

 No


Eligible Dependents

What individuals and dependents are eligible to receive benefits under this plan?


 Spouse (Legally Married Spouse per IRS definition)

 Relative (Qualifying Relative per IRS definition)

 Other: _______________________________________

Select ONE:

As the employer, you determine whether you want to extend dependent coverage to adult children through age 26. A change to this definition may require an amendment to your plan document.

 Child (Qualifying Child per IRS definition)

OR

 Child (Qualifying Child as required for medical plans under the Affordable Care Act; age 26 or less as of the calendar year in which the expense was incurred)




B. Plan Features





Payment Features

What payment features are available under this plan?


 WageWorks Health Care Card

 Pay My Provider

 Pay Me Back

 Automatic Health Plan Claims Reimbursement



Eligible Expenses

What expenses are payable as benefits under this plan?


 Standard FSA (according to current IRS regulations)

 Custom Expense List (If custom expenses are needed, please clearly define requirements to your Account Manager to ensure support can be provided. Note: custom expenses cannot be supported on the WageWorks Health Care Card.)



Qualified Changes

What life events do you allow for participants to add, remove, or change coverage?


 Standard list (according to IRS regs)

 Custom List (If custom qualified changes are needed, please clearly define requirements to your Account Manager to ensure support can be provided.)

 Plan does not allow mid-year changes in enrollments following qualified life events




C. HSA-compatible FSA Option


WageWorks offers a unique type of Health Care FSA plan that allows an employee who is covered under an HSA to also participate in a Health Care FSA. This plan is referred to as an HSA-compatible FSA.

Once an employee has met the deductible for their High Deductible Health Plan (HDHP), the account may be used for items and services typically covered by a standard FSA.

Here is how this plan works:


  • This HSA-compatible FSA cannot be used for medical or pharmacy expenses until the participant’s deductible for their HDHP is met.

  • If the employee is designating their FSA as HSA-compatible, they must select this benefit prior to the plan year start date. There is no option to change from a standard FSA to an HSA-compatible FSA once the plan year begins.

  • Per IRS regulations, an employee may not self certify that they have met the deductible of their HDHP plan. proof that an employee has met their HDHP deductible must be verified either by the employer or by the employee submitting proof to WageWorks that the plan’s HDHP deductible has been met (depending on plan setup choice selected below).

  • If the employers High Deductible Health plan has a higher deductible than the minimum required statutory amount, the HSA compatible FSA can begin reimbursing medical or pharmacy expenses when the statutory amount is met.

Please indicate below how the HSA-compatible FSA will be set up and maintained during the plan year,(or choose “HSA-compatible FSA Option Not Available” if this does not apply to your program:

 Employee Management of Initial Enrollment Selection of HSA-compatible Option and Post-HDHP Deductible Substantiation

(Selection on Employee Site prior to plan year start and/or by ER via enrollment file.  Proof that the HDHP deductible has been met is provided to WageWorks by the employee submitting the HDHP Form along with substantiation documentation of the HDHP deductible to WageWorks and/or by the Employer via PSF.)

 Employer Managed Initial Enrollment Selection & Employee Managed Post-HDHP Deductible Reset

(Selection on Employee Site is not available.  The employee submits the HDHP Form and proof of deductible met to WageWorks and/or by the Employer.)

This option also allows both the Employer and the Employee to provide documentation to enable the account to be used for standard FSA eligible items after the HDHP deductible has been met.

 Employer Managed Initial Enrollment Selection & Employer Managed Post-HDHP Deductible Reset

(Selection on Employee Site is not available.  Post-deductible reset made by the Employer.)

This option is recommended only if the Employer will be handling the initial selection of the HSA-compatible FSA option as well as providing the documentation that the employee has met the HDHP deductible, thus enabling the reimbursement of standard eligible items after the HDHP deductible has been met.


 Post-HDHP Deductible FSA Not Available

 HSA-Compatible FSA Not Available




D. Plan Setup


Plan

Health Care FSA

Dependent Care FSA

Mid-Year Claims Deadline

How long does a participant have to file claims if coverage ends before the Plan End Date?

Note: This rule is different than the end of plan year rule below as this rule applies in scenarios where participants’ coverage ends mid-year for reasons such as termination or through a qualified life event.

A “Claim it by” deadline date will be displayed to the participant online and on their statement of activity.

    Days after Coverage End Date

    Days + end-of-month after Coverage End Date

    Months after Coverage End Date

    Months + end-of-month after Coverage End Date

    Days after Plan End Date

    Days + end-of-month after Plan End Date

    Months after Plan End Date

    Months + end-of-month after Plan End Date

 Same as previous year



    Days after Coverage End Date

    Days + end-of-month after Coverage End Date

    Months after Coverage End Date

    Months + end-of-month after Coverage End Date

    Days after Plan End Date

    Days + end-of-month after Plan End Date

    Months after Plan End Date

    Months + end-of-month after Plan End Date   

 Same as previous year      



Carryover Option

Allow employees to carry over up to $500 of their unused WageWorks Health Care FSA account balance remaining at the end of a plan year.

If Carryover is set to Yes Grace Period cannot be allowed.

If electing Carryover ensure an amendment is completed and plan documents updated.

 Yes

Maximum Carryover Amount $   

 No

Participant Options:



 Allow election for limited coverage in next plan year (Recommend)

 Allow election to forfeit (Recommended only if ER does not offer HSA-compatible / limited coverage)

 Allow election to forfeit OR for limited coverage in next plan year (Not Recommended)

 None


Grace Period

How much additional time do active participants have after the Plan End Date to incur eligible expenses?

Each participant will have a “Spend It by” date displayed on their online statement of activity, based on their coverage end date and any applicable grace period.

A participant must be re-enrolled in the new plan year for the card to be available during the Grace Period.

If Carryover is set to Yes (above) Grace Period cannot be allowed.

 2 ½ months

 2 months

 1 month

 No grace period

Grace period supported on the debit card if debit card offered:

 Yes  No



Note: Card transactions made during the grace period will be paid from the previous plan year balance, until those funds are exhausted, before making payments from the current plan year account. 

 2 ½ months

 2 months

 1 month

 No grace period



End-of-Plan Claims Deadline

How long does a participant have to file claims if covered through the Plan Year End Date?

This should be the total run-out from the end of the plan year (not from the end of the grace period if a grace period applies).

    Days after Plan End Date

    Days + end-of-month after Plan End Date

    Months after Plan End Date

    Months + end-of-month after Plan End Date

 Same as previous year



    Days after Plan End Date

    Days + end-of-month after Plan End Date

    Months after Plan End Date

    Months + end-of-month after Plan End Date

 Same as previous year



Leave of Absence

Would you want WW to use system logic that would automatically create a period of non-coverage that prevents claims from being paid during that period but keep one continuous coverage period?

 Yes  No  Same as previous year

If yes is selected a participant will be covered under one continuous coverage period connected to a single account that has a period of non-coverage

Claims incurred during the period of non-coverage are denied (based on service date).


Claims Appeal Process

Select the appropriate appeals process (with or without the second level of review from the plan sponsor) for this plan consistent with your formal plan document. Some non-grandfathered plans may be required to offer Employee Benefits Security Administration (EBSA) external review which should be determined by the plan sponsor.


 WageWorks reviews initial appeals and the employer is the second level of review with final authority. (Standard)

 WageWorks reviews initial appeals and the employer is the second level of review with final authority (except option to be further appealed to EBSA for external review).

 WageWorks reviews all appeals and has final authority.

 WageWorks reviews all appeals and has final authority (except option to be further appealed to EBSA for external review).





E. Account Funding


Plan

Health Care FSA

Dependent Care FSA

Annual Election Amount

What is the minimum and maximum annual election amount per participant?

Do not include additional benefits that may be contributed by Program Sponsor over the election amount.

$      ($1) Minimum

$      Maximum

 Same as previous year

The statutory contribution limit is $2,500 on Health Care Flexible Spending Accounts ("health FSAs") for plan years that begin on or after January 1, 2013.


$      ($1) Minimum

$      ($5,000) Maximum

 Same as previous year

The statutory limit for pre-tax Dependent Care benefits is $5,000 per calendar year.


Additional Funding Amount

Are there additional funds that may be contributed by Program Sponsor over the election amount?

$     

This amount Controls funding above Election Amount. Any additional funds contributed by the Program Sponsor are not included in the $2500 statutory contribution limit. Health FSAs can include employer contributions of $500 or up to a dollar for dollar match of each participant's election.

$     

This amount Controls funding above Election Amount.


F. Plan Offer Details


Offer Plan

Health Care FSA

Dependent Care FSA

Enrollment Source

What method will your eligible participants use for enrollment?

 WageWorks Site

 Third Party Site

 Company Site or Application

 Same as previous year



 WageWorks Site

 Third Party Site

 Company Site or Application

 Same as previous year



Enrollment Method

How will WageWorks be notified that eligible participants are enrolled in this plan?

 Online Enrollment using WageWorks Site

 Enrollment File

 Same as previous year


 Online Enrollment using WageWorks Site

 Enrollment File

 Same as previous year


Enrollment Message

For Participants that do not enroll on the WW site this message is displayed on the Participants Site to eligible participants who inquire about enrollment during open enrollment or the new hire enrollment periods.

     

     

Email Enrollment Confirmations

Would you like a confirmation email to be sent to participants following the receipt of their enrollment record in our database (via any method)? (Note: If 0 is sent for ENR’s, 0’s will display on the confirm)

 Yes  No


 Yes  No


Changes to New Hire Eligibility

Have you made any changes to your New Hire eligibility rules? Such as new hire waiting period, days in the enrollment window, date coverage ends.

 Yes  No

If yes detail plan changes here:      



 Yes  No

If yes detail plan changes here:      



Updates to how Qualified Changes are handled

Have you made any changes to your Mid-Year change rules? Such as are they allowed, where can changes be made, and the change window.

 Yes  No

 Mid-Year changes are not allowed

If yes detail plan changes here:      


 Yes  No

 Mid-Year changes are not allowed

If yes detail plan changes here:      


Election Change Message

For Participants that cannot make changes on the WW site this message is displayed on the Participants Site to enrolled participants who inquire about making changes.

     

     


Open Enrollment File Date

What date can WageWorks expect your open enrollment file, if applicable?

     

Or

 Enroll on WageWorks website



     

Or

 Enroll on WageWorks website



Additional Plan Information

Provide additional plan details that are required for plan setup or any changes that WageWorks should be aware of for the new plan year.

     


     




For distribution to contracted clients of WageWorks, Inc.
All other reproduction or distribution is strictly prohibited and is in violation of our contractual arrangement.
FSA Open Enrollment Confirmation Form – June 2014

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