GREATER GREEN BAY YMCA - THE EMPLOYEE INFORMATION PACKET FOR HEALTH AND DAYCARE FLEXIBLE SPENDING PLANS
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GREATER GREEN BAY YMCA
PRESENTS
THE EMPLOYEE INFORMATION PACKET FOR
HEALTH AND DAYCARE
FLEXIBLE SPENDING PLANS
P.O. Box 5546
De Pere, WI 54115-5546
Phone: (920) 339-0351
Fax #’s: (920) 339-0038 or (920) 339-5736
www.benefitadvantage.comTABLE OF CONTENTS Benefits offered ……………………………………………………………………………………… Pg. 3 How the plan works ………………………………………………………………………………….. Pg. 4 Enrollment, Incurring Expenses, Requesting Reimbursement ………………………………………. Pg. 4 Claim submission and Inquiry ………………………………..…………………………………….…Pg. 5 What types of expenses are eligible for reimbursement? ……………………………………………..Pg. 6 What types of expenses are not eligible for reimbursement? …………………………………………Pg. 7 Frequently asked questions …………………………………………………………………………..Pg.8-9 Plan Information Sheet ………………………….……………………………………………………Pg.10 CONFIDENTIALITY STATEMENT By enrolling in the Flexible Spending Account (FSA) and submitting FSA claims, you specifically authorize the Plan, Benefit Advantage Inc., and their respective agents, employees, sub-contractors, and assigns to use your personal information in their possession to administer the Plan (including the evaluation of eligibility for reimbursement under the Plan) to detect or prevent fraud or misrepresentation and to further disclose such information as is reasonably required for such purposes. You further authorize any provider, insurer, or other entity to release any health or treatment information for the purposes of administering the Plan (including determining eligibility for Plan benefits) or detecting or preventing fraud or misrepresentation and waive and release any claims related to the use, disclosure or release of such information so long as the information is used in furtherance of Plan administration or processing or evaluating a claim for benefits under the plan. This authorization does not and is not intended to in any way limit any right the Plan or Benefit Advantage Inc., or their respective agents, employees, subcontractor, and assigns may have under applicable state or federal law or regulation regarding the use of such information.
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
The IRS states that an eligible dependent for the purpose of a Dependent Care reimbursement Plan is a child under
13 years old and living with you. An eligible dependent, regardless of age, may also include your mentally or
physically impaired spouse/dependent/child that is living with you regardless of age and incapable of caring for him
or herself.
To be eligible to participate in this account all of the following must apply:
1. The expenses must be necessary to allow you and your spouse to work, seek employment, or attend
school full time.
2. These providers must declare the funds you pay them as income on their tax returns.
A. Eligible providers include:
Child care centers
Family day care providers
Babysitters
Nursery schools *this does not include tuition for kindergarten
Caregivers for disabled dependent or spouse who lives with you
The IRS states the annual maximum amount a family may withhold in a dependent care plan is the lesser of
$5,000 per family, or you or your spouse's income. A single parent is eligible for this program with the above
limitations.
If you and your working spouse have dependent care accounts with your employers, the maximum combined
contribution is $5,000. Married individuals filing separate tax returns can each claim a maximum of $2,500
through a flexible spending account.
If you are married and your spouse is a full-time student or unable to care for himself, or herself, you may claim
$2,400 if you have one (1) dependent, or $4,800 if you have more than one dependent.
HEALTH CARE FLEXIBLE SPENDING ACCOUNT
The Health Flexible Spending Account (FSA) gives you the benefit of allocating money pre-tax to reimburse you
for out-of-pocket medical expenses for you and your dependents during a Plan year. Dependents include your
spouse, children residing with you, or a parent for whom you claim on your taxes as a dependent. You do not need
to participate in your Company's group insurance plan in order to participate in the Health Care Flexible Spending
Account.
Page 6 identifies some of the common medical and health-related expenses that the Internal Revenue Service
considers to be eligible for reimbursement through a Health FSA. These expenses are only eligible for
reimbursement provided that you have not been reimbursed for them by another source. Expenses incurred for
cosmetic purposes are not eligible for reimbursement.
Eligible expenses include, but are not limited to, your medical and dental deductibles, co-pays, vision and hearing
care, expenses in excess of "usual, reasonable and customary" charges and other health care costs not covered
under your or your spouse's insurance plan.HOW IT ALL WORKS
Enrollment
Prior to the beginning of each plan year, you may elect the amount that you want to contribute to the plan.
Throughout the plan year equal payroll deductions will be taken from your pay before Federal, State, and
Social Security taxes are assessed. The deduction will then be deposited into your Flexible Spending
Account(s).
You must indicate the annual amount you would like to contribute, sign, and date your election form by
the deadline set by your employer. Please review the Plan Information included for specific Plan dates.
Dependent Care Flexible Spending-
Your election may not exceed $5000.00 per family, per year.
Health Care Flexible Spending-
Your election limit is set by your employer. Please refer to the enclosed Plan Information.
Once the Plan year begins, your election is irrevocable and cannot be changed unless there is a qualifying
event. Please refer to your SPD for further information.
Incurring Expenses
As you incur qualified Medical expenses, you will complete and send to Benefit Advantage a
reimbursement request form itemizing your expenses with supporting documentation. The expenses must
be for services incurred during the current plan year. You will have a run off period after the close of the
plan year to submit your requests for expenses incurred during the previous plan year. Please refer to your
Summary Plan Description (SPD) for limits on your plan.
If your employment terminates during the plan year, you may only submit claims incurred up to your
termination date. After you terminate, you will have a submission period to submit claims, please refer to
your SPD for details.
Documenting your expenses
All documentation included with your claim form must have the following listed:
Date of Service, Description of Service, Patient Name, Provider Name and Patient Responsibility. Credit
Card receipts, copies of Cancelled Checks, and Statements from your provider that list codes for a
description are not considered valid documentation. Cash register receipts for Over the Counter items
must also list a description of the item purchased.
Reimbursements
All qualified claim requests will be processed and issued to you within 5 business days. A Direct Deposit
payment will be issued directly to the participant and it is the responsibility of the participant to forward
these funds on to their provider if necessary. Benefit Advantage will not send any funds to the provider.
Dependent Care Daycare expenses are reimbursed up to the cash
Pays Up To balance in your account.
Cash Balance Unpaid claims are reimbursed as additional funds
are credited to your account via payroll deductions.
Health Care You may be reimbursed your entire annual health
Pays Up To care election at any time during the plan year after you have incurred
Annual Election the expense.CLAIM SUBMISSION AND INQUIRY
You can review your account online at www.benefitadvantage.com
Online Account Status
To obtain your flexible spending account balance or claim status information:
Select Customer Login
Employee ID = Participants Social Security Number (without spaces or dashes)
Enter Pin code= Last four digits of Social Security Number
*This can be changed per the request of the participant to another four digit number*
You will be prompted to add your e-mail address.
After first log in, User ID will be your e-mail address, and password will remain the same.
Reimbursement Claim Forms
To access the claim form on our website:
Select Forms
Select Flexible Spending Account
Select the appropriate form, Medical Claim form, Dependent Care Claim form, or
Recurring Orthodontia claim form
Print the selected claim form, complete, then mail or fax to Benefit Advantage.
CLAIMS SUBMISSION
Mailing Address: Benefit Advantage
P.O. Box 5546
De Pere, WI 54115-5546
Fax Numbers: (920) 339-0038 or (920) 339-5736
Phone Number: (920) 339-0351ELIGIBLE EXPENSES The following list identifies some of the common medical and health-related expenses the Internal Revenue Service considers to eligible for reimbursement through a Health FSA, provided you have not been reimbursed for them through any other benefit coverage. Expenses incurred for cosmetic purposes are not eligible. The recently enacted Patient Protection and Affordable Care Act of 2010 changes the rules for the purchase of over-the- counter (OTC) products using Flexible Spending Account (FSA) effective January 1, 2011. **Over-the-Counter medicines will not be eligible for reimbursement without a prescription after 1/1/2011. Acupuncture Itemized Hospital bills Alcoholism treatment Laboratory fees Ambulance hire Childbirth Classes Artificial limbs Lasik vision surgery Artificial teeth Lodging for medical care($50 per person per night) Aspirin** Mileage for medical care Bandages Nurse’s fees Birth control pills Obstetrical expenses Braces Operations Braille books and magazines Orthodontic treatment Car controls for the disabled Orthopedic shoes Care for the mentally disabled Over the Counter Medicines** Chiropractors Oxygen Co-pay Physician’s fees Contact lenses and supplies Prescription drugs Crutches Psychiatric care Dental fees Routine physical Dermatologist Smoking cessation program/related drugs Diagnostic fees Sterilization fees Drug addiction therapy Surgical fees Eyeglasses, including exam fee Telephone for the hearing impaired Fees for practical nurse Television display for hearing impaired First Aid Kits Psychotherapy Guide dog and its upkeep Tuition at special schools for disabled Health insurance deductibles Wheelchair Hearing devices and batteries Wigs - for medical reasons Hypnosis for treatment of an illness X-rays Insulin and diabetic supplies Note: This is not an all-inclusive list. If you have questions regarding an expense, please call Benefit Advantage at (800) 686-6829 and speak with a representative.
INELIGIBLE EXPENSES
The IRS does not allow the following expenses to be reimbursed under the Health FSA. Expenses to promote general
health are not eligible expenses.
The recently enacted Patient Protection and Affordable Care Act of 2010 changes the rules for the purchase of over-the-
counter (OTC) products using Flexible Spending Account (FSA) effective January 1, 2011.
**Over-the-Counter medicines will not be eligible for reimbursement without a prescription after 1/1/2011.
Breast Feeding Classes Massage Therapy*
Breast Pumps Maternity Clothes
Bonding * Over-the-Counter Medicines**
Canceled Appointment Fees Personal Trainer
Cosmetic Surgery/Procedures Prescription Drug Discount
Dancing Lessons Program Premiums
Diaper Service Special Foods
Discounts/Write-offs Student Health Fee
Electrolysis Swimming Lessons
Exercise Equipment* Teeth Whitening/Bleaching
Hair Loss Medications* Toiletries, Toothpaste, Etc.
Hair Transplant Veneers
Illegal Operation or Treatment Vision or Health Discount Program Premiums
Insurance Premium Interest Charge Vitamins/Supplements
Insurance Premiums Weight Loss Programs &/or Drugs
Marriage Counseling
* Eligible only with Doctor’s certification identifying the medical condition, prescribed
treatment, and duration of treatment. Amount reimbursed may be the difference of a common
item and the special item.
Note: This is not an all-inclusive list. If you have questions regarding an expense, please
call Benefit Advantage at (800) 686-6829 and speak with a representative.FREQUENTLY ASKED QUESTIONS
Q1 What are the advantages to this new Flexible Q6 How do I get reimbursed for Health Care expenses?
Benefit Plan, and how will it affect me? A6 To request reimbursement from Benefit Advantage you must
A1 A Flexible Benefit Plan is another benefit Plan that allows complete a claim form, and include a copy of the itemized
you to have certain expenses deducted from your paycheck statement for the services that were provided. Please note that
before taxes, thus reducing the amount of taxes you pay, we cannot accept credit card bills/receipts or canceled checks as
giving you more spendable income for the year. You have proof of service.
two choices. They are:
1. Health Care Reimbursement Account (i.e.: If you know your Orthodontic expenses will remain at the same
medical, dental and vision expenses.) dollar amount for the calendar year, you are encouraged to use a
2. Dependent Care Reimbursement Account Recurring Ortho Care Reimbursement Request Form. This
(i.e.: daycare, babysitter*) allows you to submit the reimbursement form only once to
*Babysitter must report income Benefit Advantage along with your Ortho Contract, and we will
release a claim on your behalf every month. You must notify
us if the provider or amount of your claim changes. This
Q2 Do I have to participate in all choices? form is also available in your Human Resource Department.
A2 No. Those who do not have children, a spouse The Recurring Claim Form does not carry over into the
or parents requiring daycare will not be interested in the next plan year. At re-enrollment time, you must fill out a new
Dependent Care Account. Recurring Form and submit it to Benefit Advantage.
Q3 Is this an automatic election or do I need to sign a form? Q7 I've been deducting medical and dental expenses on my
A3 Every employee must complete a form(s) to enroll. Return income taxes. Can this continue if I enroll in the
your completed form(s) to the Human Resource Department Flexible Benefit Plan?
before the last day of open enrollment. A7 Currently you can deduct on your income tax return only the
portion of your expenses that exceeds 7-1/2% of your household
Q4 Can I change my amount or get into the plan after the income. The Flexible Benefit Plan gives you immediate first
beginning of the plan year? dollar savings on Federal, State (except in PA and NJ) and
A4 You may change your election during the plan year only if FICA taxes. You may not claim expenses reimbursed from
you have a change in family status, such as marriage, your flexible spending plan on your tax return.
divorce, death, birth, or adoption. Otherwise, you will have
to wait until the next enrollment period. The change you Q8 If I allocate $100 into my Health Care Expense Account,
make must be consistent with the qualifying event. If you and I incur only $80 of charges for the calendar year, what
have any of the above qualifying events, you must contact happens to the $20?
your Human Resource Department within 30 days of the A8 The IRS states that if you do not have expenses that equal the
event. money you have set aside on a pre-tax basis, you lose the
amount remaining in your account at the end of the year. This
Q5 Who determines what is an eligible expense that I can is why we ask you to be cautious with your election. Your
claim reimbursement for? employer cannot return forfeited amounts directly to you.
A5 The IRS formulates the guidelines for the Health FSA
Accounts and determines what is eligible. A list of some
eligible expenses is included within this publication.FREQUENTLY ASKED QUESTIONS,
CONTINUED
Q9 What forms do I need to send to Benefit Advantage for Q13 How does participation in the Flexible Benefit Plan affect
reimbursement for dependent care expenses? information on my W-2 form?
A9 You need to complete a Day Care Reimbursement Request Form A13 Your taxable income on the W-2 form will be reduced by
with receipts showing amount of payment, date of service contributions to any portion of the Flexible Benefit Plan. Funds
provided, Tax I.D. or Social Security number of your dependent contributed to the Dependent Care Account will be shown in a
care provider. If your dependent care provider does not issue separate location on the W-2 form as a non-taxable item.
receipts, a signature line is provided on the reimbursement form
for their signature and Tax I.D. or Social Security number. Q14 If I terminate employment, what happens to the money I
have allocated to the Plan?
If you know your monthly dependent care expense will remain at A14 You will have a grace period following termination to submit
the same dollar amount for the calendar year, you are encouraged claims for reimbursement of expenses that were incurred on
to use the Recurring Daycare Reimbursement Request Form. This your termination date or prior. Any unused amount after the
form allows you to submit the reimbursement form only once to run off period will be forfeited if you terminate with a positive
Benefit Advantage, and we will see that you are reimbursed balance. You may be eligible to elect to continue your
accordingly. You must notify us if the provider or amount of participation in the Health FSA with COBRA.
your claim changes. Additional forms are available in your
Human Resource Department. The Recurring Claim Form does Q15 Once I file an eligible medical, dental, or dependent care
not carry over into the next plan year. At re-enrollment time, expense, how long do I have to wait until Benefit Advantage
you must fill out a new Recurring Form and submit it to Benefit reimburses me.
Advantage. Recurring claims are released at the end of the first A15 Benefit Advantage sends out reimbursements on a daily basis
full week of each month. and guarantees a 5 business-day turnaround on claims. You can
review your claim status at www.benefitadvantage.com.
Q10 My mother-in-law baby-sits for my two children. She doesn't
claim this income on her income taxes. Can I participate in Q16 Will I receive a report showing me how much money I have
the dependent care account? used from the Plan?
A10 No. You may participate in the Dependent Care Reimbursement A16 You may view your account status at anytime at
Account only if the daycare provider claims the amount you pay www.benefitadvantage.com . On our website you can review
them on their income taxes. your claim history, payment history and current balance.
Benefit Advantage also sends a statement the last quarter of the
Q11 I over-calculated my dependent care expenses. Can I get the Plan Year to employees who still have money in their accounts.
leftover money in my account at the end of the year? This statement is a reminder to use your money so you do not
A11 No. Money left in your dependent care account must be forfeited forfeit any left over funds.
according to IRS regulations. (See question 8)
Q17 Who do I contact with questions or concerns on the Flexible
Q12 I am currently using the Child Care Credit on my income tax Benefit Plan?
return. Can I use the Flexible Benefit Plan also? Which gives A17 Call Benefit Advantage at (920) 339-0351 or (800) 686-6829.
me greater savings?
A12 It is possible to use both; however, expenses in the Dependent
Care Account reduce expenses allowed by the Child Care Credit
dollar for dollar.
The Child Care Credit on your income tax return allows expenses
up to $3,000 for one child and $6,000 for two or more children.
This is a credit of taxes owed when your tax return is filed. The
Dependent Care Account allows immediate elimination of
Federal, State (except PA and NJ) and FICA taxes on expenses up
to $5,000 regardless of the number of children.
Please contact the individual who prepares your income tax return
for assistance in determining which program provides the greatest
savings for you.GREATER GREEN BAY YMCA
Plan Information
Flexible Spending Accounts
Would you like to reduce your out-of-pocket medical, dental, vision and daycare expenses by saving tax dollars?
If you, or your family, incur qualified expenses during a plan year, you can enjoy tax savings simply by changing
the way you pay for health care and daycare expenses.
Participation in a Flexible Spending Account is completely optional. Whether or not you choose to participate,
you must complete an election form and return it to JANE HALVERSON by ____________________.
Listed below are some highlights of the Flexible Spending Accounts, which are important to remember.
Health FSA claims are paid from the general assets of the plan sponsor. There is no separate fund
or account that secures the promised benefit.
The Plan Year is 1/1/2011 – 12/31/2011
Annual Health Care Account maximum is $4420.00.
Annual Health Care Account minimum is $26.00.
Annual Limited Healthcare Reimbursement Account maximum is $4420.00.
Annual Limited Healthcare Reimbursement Account minimum is $26.00.
Annual Dependent Care Account maximum is $5000.00.
Annual Dependent Care Account minimum is $0.00.
After the plan year-ends, you have 90 Days to submit expenses incurred during that plan year.
If your employment terminates during the plan year, you will have 90 Days to submit claims
incurred up to your termination date.
Be conservative, the IRS states that any unused funds will be forfeited.
Your election will remain in effect for the entire plan year, unless you have a
qualifying status change and the change is consistent with the qualifying event.
Direct deposit carries over from year to year. ONLY new participants need to fill out a direct
deposit form or existing participants making a change to the account which deposits are made.
You may review your account details on our website at www.benefitadvantage.com
Benefit Advantage, Inc.
P.O. Box 5546
De Pere, WI 54115-5546
Phone: (920) 339-0351
www.benefitadvantage.com3431 Commodity Lane
GREATER GREEN BAY YMCA
Green Bay, WI 54304 EMPLOYEE ENROLLMENT FORM
Ph: (920) 339-0351
Fax:(920) 339-0038
PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION
NAME:________________, ____________ SSN#:____-_____-______ DOB: __________
(LAST, FIRST, M) (00/00/0000)
ADDRESS:_______________________________________E-MAIL:________________________
CITY:________________ STATE:___ ZIP:______ WORK PHONE:_(____)____________
FIRST PAYROLL DATE:___-___-___COVERAGE EFF. DATE ___-____-____ FREQUENCY:________
(BI-WEEKLY, SEMI-MONTHLY, ETC.)
Salary Redirection for Insurance Premiums
I understand that any eligible premiums I am obligated to pay for insurance coverage for my dependents and myself will be
deducted from my pay on a BEFORE-TAX basis unless I otherwise direct. This is in addition to the Flexible Spending
Account Elections below:
Please note that you may not elect again until the start of the new plan year unless you have a qualifying event. Please see
your Human Resources director for a list of qualifying events.
Healthcare Reimbursement Account
Yes, I would like to participate in the Healthcare Reimbursement Account.
Pay period Deduction $________ X #_____ of pay periods = $_________ Annual Election.
(PLEASE DO NOT ROUND)
No, I choose not to participate.
Day Care/ Dependent Care Spending Accounts
Yes, I would like to participate in the Day Care/ Dependent Care Spending
Per Pay period Deduction $_______ X #_____of pay periods = $__________ Annual Election.
(PLEASE DO NOT ROUND)
No, I choose not to participate.
Limited Healthcare Reimbursement Account—for HSA Participants Only
Yes, I would like to participate in the Healthcare Reimbursement Account.
Pay period Deduction $________ X #_____ of pay periods = $_________ Annual Election.
(PLEASE DO NOT ROUND)
No, I choose not to participate.
* You will only be reimbursed from the Dependent Care Expense FSA to the extent that you have funded the account to date.
I understand that the choices I have indicated above must remain in effect for the entire plan year unless I have a change in family status. A change in family
status includes the birth or adoption of a child, marriage, divorce, death, spouse losing or gaining a job, or a change in employment status from part-time to full-
time or full-time to part-time.
I understand that the IRS requires any funds remaining in a flexible spending account at the end of the Plan Year must be forfeited by me to be returned to my
employer. I understand there is a 60 - 90 day grace period after the Plan Year end in which to submit expenses as long as the expenses were incurred within the
Plan Year. (Consult your employer to see which grace period applies.)
The effective date of the Plan Year and the end of the Plan Year should be verified with your Employer, (the Plan Administrator).
I hereby give my employer permission to reduce my salary by the above elected amounts.
Signature: ______ Date: _______________________________PO Box 5546
De Pere, WI 54115-5546
Phone (920) 339-0351
Fax (920) 339-0038 GREATER GREEN BAY YMCA
FSA Authorization Agreement for Direct Deposit
Print Your Name: ___________________________________________________________________
Print Your SS#: ____________________________________________________________________
Effective Date: _____________________________________________________________________
The information listed below is necessary to completely process the direct deposit funds into a specific
bank account. (Please print all of the following information.)
New Change Cancel
Checking (Must attach voided check) Savings (Please verify information with bank)
This information is for Benefit Advantage’s use only and will not be disclosed to an outside party.
Transit ABA Routing #: __________________________________________________________
Account Number #: __________________________________________________________
Name of Bank: __________________________________________________________
I authorize my Section 125 Health Care FSA, Dependent Care FSA, Transit & Parking FSA, and
Section 105 HRA reimbursements to be sent to the financial institution listed above and to be
deposited in the designated account. I understand I may direct deposit to only one bank account.
In the event funds are deposited erroneously into my account, I authorize Benefit Advantage to debit
my account not to exceed the original amount of the credit.
I also understand that all direct deposits are made though the Automated Clearing House (ACH), and
that funds availability is subject to the limitations of the ACH as well as my financial institution.
Benefit Advantage will not be held liable for any bank fees, overdrafts, etc… associated with these
reimbursements.
Employee Signature: _____________________________ Date: ___________________
Once Benefit Advantage receives this authorization, there is a 10-day waiting period before direct deposit
takes effect. Claims received within this period will be paid via check.
Return this form to address or fax number at the top of the page.
*To view account status online: www.benefitadvantage.com# Pages
Mail: PO Box 5546 ______
De Pere, WI 54115-5546
Fax: (920) 339-0038
Phone: (800)686-6829 GREATER GREEN BAY YMCA
FLEXIBLE SPENDING REQUEST CLAIM FORM
Last First MI
NAME: SS#
Street City State ZIP
ADDRESS: PHONE: ( )
Please check if this is a new address
MUST FILL OUT MEDICAL EXPENSE CLAIMS
Date of Service
Patient Name Relationship MM/DD/YY Name of Provider Claim Amount Description of Service
SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE SAMPLE
John Doe Spouse 01/01/03 Prevea Clinic $10.00 Office Visit
Total:
YOU MUST ATTACH DOCUMENTATION THAT INCLUDES THE FOLLOWING INFORMATION FOR YOUR CLAIM TO BE PAID.
Date(s) Service Performed,
Type of Expense* (i.e. eye exam),
Amount of expense incurred,
Name of Patient, & Service Provider.
*Codes are not appropriate form of a description of your expense.
EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were not reimbursed
by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense
reimbursed through this account as deductions or credits when filing my (our) individual income tax return.
The Internal Revenue Service regulates this Flexible Spending Account. Our documentation guidelines are intended as a means to qualify your expenses for approval
and reimbursement. It is the responsibility of each participant to comply with these guidelines and to avoid submitting duplicate or ineligible claims. Failure to
comply with the above requirements will delay the payment of your claim. There is a $20 stop payment fee for all checks that need to be reissued due to no fault
of Benefit Advantage. Direct Deposit is available at no charge and is highly recommended.
Employee Signature: ____________________________________ Date: ____________
If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for balance details.
***Original receipts will not be returned, please keep a copy for your own records. ***
11/17/2010HOW TO FILE YOUR REQUEST
Definition of Medical Care:
Must be “for diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting
any structure or function of the body”. Special rules may apply.
STEP I
Complete ALL personal information on the reimbursement request form. All items you are requesting
reimbursement for should be itemized. Failure to complete your claim form could result in a delay or
denial of your claim.
STEP II
Attach proper documentation to the claim form.
All documentation included with your claim form must have the following listed: Date of Service,
Description of Service, Patient Name, Provider Name and Patient Responsibility. Credit Card receipts,
copies of Cancelled Checks, and Statements from your provider that list codes for a description are not
considered valid documentation. Cash register receipts for Over the Counter items must also list a
description of the item purchased.
If you have more claims than the spaces provided please attach additional claim forms.
STEP III
SIGN the request form.
Our goal is to process payments within 24 hours of receipt with proper documentation. We guarantee a
5 working day turnaround maximum.
This outline is intended for quick reference. If you have any additional questions, please call the
Flexible Spending Account Department at (920) 339-0351 or (800) 686-6829, available 8-4:30pm,
Monday through Thursday and 8-4 pm on Friday Central Standard Time.
***Original receipts will not be returned, please keep a copy for your own records. ***
11/17/2010Benefit Advantage Phone: (920) 339-0351
P.O. Box 5546 Fax: (920) 339- 0038
De Pere, WI 54115-5546 Fax: (920) 339-5736
RECURRING ORTHO CARE
REIMBURSEMENT REQUEST FORM
EMPLOYER NAME: GREATER GREEN BAY YMCA
EMPLOYEE NAME:
ADDRESS:
SOCIAL SECURITY #:
DAYTIME PHONE #:
ORTHO CONTRACT MUST BE ATTACHED
*This claim form is valid for one plan year
I have attached a signed statement from the above stated Provider verifying the amount and frequency of
charges. I agree that if the amount changes or if for any reason the expenses are not incurred as scheduled, I will
notify Benefit Advantage immediately in writing.
Name of Provider:
For (Name of Patient)
The charge for the care is $ per month, beginning on / / & ending on / / .
Start Date of treatment ___________ Term of Treatment_____________________
I understand that reimbursements will be made only to the extent that my Flexible Spending Account annual
election allows. Any unused funds remaining in the account at the end of the plan year will be forfeited.
This claim form is only valid for the current plan year and will be posted to your Flexible Spending Account at the
end of the first full week of every month.
* If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for balance details.
EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement requested from my accounts were incurred by me (and/or my spouse and/or eligible
dependents), were not reimbursed by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement
under my Reimbursement Plans. I (or we) will not use the expense reimbursed through this account as deductions or credits when
filing my (our) individual income tax return.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Signature Date ______________________________
Plan Participant
11/17/2010# Pages
Mail: PO Box 5546
De Pere, WI 54115-5546 ______
Fax: (920) 339-0038
Phone: (800)686-6829
GREATER GREEN BAY YMCA
DAYCARE REQUEST CLAIM FORM
Last First
NAME: MI SS#:
Street City
ADDRESS: State ZIP PHONE : ( )
Please check if this is a new address
DAYCARE EXPENSE CLAIMS
DATE OF SERVICE DEPENDENT DEPENDENT CLAIM PROVIDER *PROVIDER
FROM TO NAME BIRTH DATE AMOUNT TAX ID#/SS# NAME
$
$
$
$
$
$
Total: $
*Please make sure you sign the bottom of this form.
PROVIDER VERIFICATION
* Signature of Provider mandatory if no Federal Tax ID is given above or documentation attached.
I verify that the above charges are accurate as described.
_____________________________________ _____________________ ____________________
Provider Signature Federal Tax ID Number Date
Please Note: The daycare provider must declare this as income on their tax return.
If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for
balance details.
Daycare expenses are reimbursed up to the cash balance in your account. Unpaid claims are reimbursed as more funds are
received from your employer and credited to your account.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Employee Signature: Date: ____________________HOW TO FILE YOUR REQUEST
Definition of Dependent Care:
Must be for care of an eligible dependent by IRS regulations enabling you or your spouse to work, seek
employment, or attend school full-time.
Definition of Eligible Dependents:
The IRS states that an eligible dependent is less than 13 years old and living with you. An eligible dependent
may also include your mentally or physically impaired spouse/dependent/child who is living with you and
incapable of caring for him or her self.
*The provider of the care MUST declare the funds you pay them as income on their tax returns.
CHECKLIST Fill out only if you are manually submitting claims throughout the
year
Documentation must be attached
Sign the bottom of the claim formBenefit Advantage Phone: (920) 339-0351
P.O. Box 5546 Fax: (920) 339- 0038
De Pere, WI 54115-5546 Fax: (920) 339-5736
RECURRING DAYCARE
REIMBURSEMENT REQUEST FORM
Please Print:
EMPLOYER NAME: GREATER GREEN BAY YMCA
EMPLOYEE NAME:
ADDRESS:
SOCIAL SECURITY #:
DAYTIME PHONE #:
I verify that I make regular ongoing payments to:
Name of Day Care Provider:
Provider Tax ID Number:
For (Name of Dependent):
Dependent Birth Date:
This claim form is only valid for the current plan year.
The charge for the care is $ per month, beginning on / / & ending on / / .
PROVIDER VERIFICATION
* Signature of Provider mandatory if no Federal Tax ID is given above or documentation attached.
I verify that the above charges are accurate as described.
_____________________________________ _____________________ ____________________
Provider Signature Federal Tax ID Number Date
Please Note: The daycare provider must declare this as income on their tax return.
I agree that if the amount changes or if for any reason, such as illness or vacation, the expenses are not incurred as scheduled, I will
notify Benefit Advantage immediately in writing.
If your reimbursement is sent to you via direct deposit, please review your account at www.benefitadvantage.com for balance details.
A Recurring Claim allows Benefit Advantage to enter a claim on your behalf automatically at the beginning of each month. This is
not a recurring payment. A claim will be posted to your Dependent Care Account at the end of the first full week of every month.
Reimbursements to you will occur as funds are received by Benefit Advantage from your employer. Deposit dates may vary month to
month. Benefit Advantage will not be held responsible for any late charges or overdraft fees related to the payment of your daycare
provider.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Employee Signature: Date: ____________________
Plan ParticipantHOW TO FILE YOUR REQUEST
Definition of Dependent Care:
Must be “for care of an eligible dependent by IRS regulations enabling you or your spouse to work or to seek
employment”
Definition of Eligible Dependents:
The IRS states an eligible dependent is less than 13 years old and living with you. An eligible dependent may
also include your mentally or physically impaired spouse/dependent/child who is living with you and
incapable of caring for him or her self.
*The provider of the care MUST declare the funds you pay them as income
CHECKLIST Make sure you complete the entire form:
Enter amount paid to daycare provider per month
Enter Begin Date of the recurring costs
Enter End Date of plan year or date no longer have daycare costs
Enter Dependents Name
Enter Dependents Date of Birth
Have Provider Sign Claim Form and enter Tax Id # or SS#
Sign the bottom of the claim formYou can also read
