WELLS FARGO INSURANCE SERVICES CITY OF PETALUMA - FLEX BENEFITS
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WELLS FARGO
INSURANCE SERVICES
FLEX BENEFITS
CITY OF PETALUMAWELLS FARGO INSURANCE SERVICES
FLEX BENEFITS
SIGN UP NOW FOR A PAY INCREASE!
Let Wells Fargo Insurance Services help you save money on your medical and childcare expenses by
enrolling in a Healthcare Flexible Spending Account (FSA) and/or a Dependant Care Assistance Program
(DCAP).
What is a Health FSA?
A benefit provided by your employer that lets you set aside a predetermined amount (contribution) of
your paycheck into an account before paying Federal, State and FICA taxes. Then, during the plan
year, you can be directly reimbursed from your account for qualified healthcare expenses.
WITHOUT Health FSA Plan WITH Health FSA Plan
Average Monthly Salary $2,000 Average Monthly Salary $2,000
Less Estimated Federal Less Out-of-Pocket
Withholding (15%) - 300 Health Care Expenses -150
Less Estimated FICA (7.65%) - 153 Taxable Income $1,850
Less Estimated Federal
Net Take Home Pay: $1,547 Withholding (15%) - 277.50
Less Out-of-Pocket Less Estimated FICA (7.65%) - 141.53
Health Care Expenses -150
Net Take Home Pay/
EXPENDABLE INCOME: $1,397 EXPENDABLE INCOME: $1,430.97
What is DCAP?
A benefit provided by your employer that lets you set aside a predetermined amount (contribution) of
your paycheck into an account before paying Federal, State and FICA taxes. Then, during the plan
year, you can be directly reimbursed from your account for qualified dependant care expenses.
Qualified expenses include; nursery care provided inside your home, dependant care expenses incurred
for the care of a qualified dependant that regularly spends 8 hours per day in outside care.
WITHOUT DCAP WITH DCAP
Average Monthly 2 Income Salary $5,000 Average Monthly 2 income Salary $5,000
Less Estimated Federal Less Out-of-Pocket
Withholding (15%) - 750 Dep. Care Expenses -400
Less Estimated FICA (7.65%) - 383 Taxable Income $4,600
Less Estimated Federal
Net Take Home Pay: $3,867 Withholding (15%) - 690
Less Out-of-Pocket Less Estimated FICA (7.65%) - 352
Dep. Care Expenses -400
Net Take Home Pay/
EXPENDABLE INCOME: $3,467 EXPENDABLE INCOME: $3,550Wells Fargo Insurance Services Health Flexible Spending Account
(FSA)
F.A.Q.s
Why Should I participate in a Health FSA when I already have Health Insurance?
This account is used to pay for expenses that are not covered by insurance. For example, your insurance may not
cover annual physicals, co-payments, eye exams, eye surgery, prescription glasses, orthodontics, prescription
drugs, or dental care, just to name a few. See “Eligible Health Care Expenses”
What expenses are NOT considered eligible for reimbursement?
The following list of expenses would not be considered eligible health care expenses:
-Cosmetic Surgery -Medicines or Drugs used for Cosmetic purposes
(unless Medically Necessary) (unless Medically Necessary)
-Dancing and/or Swimming lessons -Swimming Pools, Hot Tubs
-Drugs, even if prescribed to aid Hair Growth -Exercise Equipment
-Expenses not incurred in a valid Plan Year -Teeth Whitening
-Expenses reimbursed under any Health Plan -Vacation
-Health Club Dues -Vitamins and food supplements- even if
-Health Insurance Premiums prescribed by a physician
-Marriage Counseling
Can I change or cancel my contribution amount during the Plan Year?
Only if you have a valid Change-in-Status, such as: marriage, birth, adoption, or a change in your or your
spouse’s employment status. Please see your administrator for more information on the Change-of-Status rules.
How do I get reimbursed for my expenses?
Once you have completed the enrollment form, you will receive all necessary forms and instructions on how to file
your claim. Simply complete the claim form, attach a copy of the healthcare bill or explanation of benefits, and
mail or fax your claim to Wells Fargo Insurance Services Flex Benefits Department. Within 5-10 business days,
you will receive your reimbursement via a check mailed to your home address or direct deposit (if initiated).
Do I have to wait for my contributions to be deposited into my account in order to make a claim for
reimbursement?
Once the initial contribution is made, the FULL amount you set aside each Plan Year (annual election
amount) for your health FSA is available to you at any time throughout that Plan Year as long as you are an active
Plan Participant.
What Happens to my contributions if I do not incur enough qualified expenses, or neglect to file a claim in
the time specified in my SPD?
Should you not incur enough expenses, or neglect to file a claim, you will forfeit any amount contributed to your
Health FSA. Also, any Health FSA reimbursements that are unclaimed (for example, checks that have not been
cashed) by the close of the Plan Year will be forfeited to the Plan. For this reason, please estimate your health
expenses accordingly.
What if I terminate employment for any reason?
Your coverage will terminate on the date of your termination. However, if your account has a positive
balance (meaning you have contributed more funds than you have been reimbursed for), you may continue
participation in the Plan on an after-tax basis through COBRA. You will be notified by your administrator
within the legal timeframes of your rights to elect COBRA.
Are there any negatives?
Yes. Since you do not pay Social Security taxes on your contributions, your future benefits may be slightly
reduced. Most tax advisors would tell you that the benefit of saving taxes now would be far greater than the
potential loss of Social Security Benefits when you retire. Please see your tax consultant for more information.Eligible Health Care Expenses
Acupuncture (excludes remedies and treatments prescribed by Midwife
acupuncturist) Nursing Care
Alcohol and Drug Rehabilitation Optometrist
Ambulance Orthodontia Expenses (as treatment is provided) *
Artificial Limbs and Teeth Orthopedic devices
Birth Control Pills Over the Counter Medications**
Chiropractor Oxygen
Christian Scientist Practitioners Pediatrician
Co-payments Physical Therapy (provided by a Licensed Therapist with
Crutches proof of Medical Necessity)
Deductibles Physician (M.D. or D.O.) Fees
Dental Fees, Oral Surgery Podiatrist
Dentures Prescription Drugs
Diagnostic Fees Psychiatrist
Eye Exam, Prescription Eye Glasses, Contact Lenses, Contact Lens Psychologist
Solution, Enzyme Cleaners Rental or Purchase of Medical Equipment (including
Eye Surgery (LASIK, Cataracts, etc.) special Equipment for handicapped Persons)
Gynecologist Surgery (other than cosmetic, unless deemed medically
Hearing Devices and Batteries necessary)
Hospital Bills Transportation Expenses relative to Illness
Insulin Obstetrics
Laboratory Fees
Lip Reading Lessons
Medical Examinations
Eligible Over-the-Counter Expenses
Antiseptics Diabetes Pain Relief Stomach Care
Antiseptic wash or ointment for Diabetic lancets Arthritis pain reliever Acid reducers
cuts or scrapes Diabetic supplies Bunion and blister treatments Antacid gum
Benzocaine swabs Diabetic test strips Itch relief Antacid liquid
Boric Acid powder Glucose meters Orajel Antacid tablets
First aid wipes Ear/Eye Care Pain relievers, aspirin and Anti-diarrhea medications
Hydrogen Peroxide Airplane ear protection non-aspirin Gas prevent food enzyme
Iodine tincture Ear drops for swimmers Throat pain medications dietary supplement
Rubbing Alcohol Ear water-drying aid Personal Test Kits Gas relief drops for infants
Sublimed Sulfur powder Ear wax removal drops Cholesterol tests and children
Asthma Medications Homeopathic earache Colorectal cancer screening Ipecac syrup
Bronchodilator/Expectorant tablets tests Laxatives
tablets Contact lens solutions Home drug tests Pinworm treatment
Bronchial asthma inhalers Health Aids Ovulation indicators Prilosec
Cold, Flu, and Allergy Antifungal treatments Pregnancy tests Upset stomach medications
Medications Denture adhesives Skin Care
Allergy medications Diuretics and water pills Acne medications
Cold relief syrup Hemorrhoid relief Anti-itch lotion
Cold relief tablets Incontinence supplies Bunion and blister treatments
Cough drops Lice control Cold sore and fever blister
Cough syrup Medicated bandages medications
Flu relief tablets or liquid Motion sickness tablets Corn and callus removal
Medicated chest rub Respiratory stimulant medications
Nasal decongestant inhaler ammonia Diaper rash ointment
Nasal decongestant spray or Sleeping aids Eczema cream
drops Medicated bath products
Nasal strips to improve Wart removal medications
congestion
Sinus & allergy homeopathic
nasal spray
Sinus medications
Vapor patch cough
suppressant
*We cannot accept a claim for the entire contracted amount. We will accept claims for the initial down payment usually associated with the
appliances. Monthly payments will also be accepted as the charge for the medical services rendered for that month.
**Only those medications used to treat a medical condition, illness, or disease. Items used for the general health of an individual are not
eligible under this Plan.
Over the counter medications must also be purchased in a quantity consistent with the illness that is being treated- “Bulk” purchases of
OTC items will not be covered!
***Plan restrictionsEstimate Your Expenses
Certain health care expenses for you and your dependants may not be totally covered by your group
insurance. Use this list to determine the annual out-of-pocket expenses you and your family are likely to
incur in the coming plan year.
POSSIBLE EXPENSES
Health Expenses Amount
Deductible $________________
Co-Insurance $________________
Doctor Visits/Copays $________________
Prescription/Over-the-Counter Medication $________________
Prescribed Medical Supplies $________________
Physical Therapy $________________
Psychiatrist / Therapist $________________
Lab, X-Ray, and Diagnostic Fees $________________
Chiropractor $________________
Acupuncture $________________
Hearing Exam / Supplies $________________
Misc. $________________
Dental Expenses $________________
Deductible $________________
Co-Insurance $________________
Cleanings (Twice a year) $________________
X-Rays $________________
Fillings and Crowns $________________
Orthodontics (can be for any age- regardless of Ins.) $________________
Oral Surgery $________________
Dentures $________________
Misc. $________________
Vision Expenses $________________
Eye Exam $________________
Prescription Glasses $________________
Prescription Sunglasses $________________
Contact Lenses $________________
Contact Lens Cleaning Supplies $________________
LASIK Surgery $________________
Misc. $________________
TOTAL ANNUAL EXPENSES $________________
-You may wish to consult your checkbook, receipts, and insurance explanation of benefits for the prior
year for assistance in estimating these expenses.Wells Fargo Insurance Services Dependent Care Assistance Program
(DCAP)
F.A.Q.s
Why should I participate in the DCAP when I can take the dependent care credit on my annual tax
return?
If your family income is over $30,000, you will most likely benefit from this plan rather than taking
advantage of the current income tax credit. For your personal tax savings, please check with your tax
consultant.
Can I change or cancel my contribution amount during the Plan Year?
Only if you have a valid Change-in-Status, such as: marriage, birth, adoption, or a change in your or your
spouse’s employment status. DCAP also allows for provider change or significant cost change to be used as a
qualifying event. Please see your administrator for more information on the Change-of-Status rules.
What DCAP restrictions are there?
• “Dependent” refers to a dependent under the age of 13, or a mentally or physically disabled dependent of any age.
• Dependent Care expenses must be incurred to allow an employee and spouse, if married, to work or attend school (full time
for spouse).
• $5,000.00 maximum contributions per calendar year unless you are married and are filing separate returns, in which case the
maximum contribution is $2,500 per calendar year.
• Dependent care facility, if required, must be State Licensed.
• Services for care cannot be provided by a dependent.
• Pre-taxing dependent care precludes you from taking the after-tax child care credit on your annual income tax.
What expenses are NOT considered eligible for reimbursement?
The following list of expenses would not be considered eligible dependent care expenses:
-Kindergarten Fees -Incidental expenses (diapers, activities, etc.)
-Elementary School Expenses -Housekeeper, Maid, Cook
(for First Grade or above) -Mass Transit or Parking
-Expenses not incurred in a valid Plan Year -Entertainment Expenses
-Food -Transportation
-Overnight Camp Fees -Day Camps with a specific scholastic/training agenda
-Day Care Expenses for a child 13 years of age or older, unless Physically or Mentally incapable of self care
How do I get reimbursed for my expenses?
Once you have completed the enrollment form, you will receive all necessary forms and instructions on how to file
your claim. Simply complete the claim form, attach a copy of the healthcare bill or explanation of benefits, and
mail or fax your claim to Wells Fargo Insurance Services Flex Benefits Department. Within 5-10 business days,
you will receive your reimbursement via a check mailed to your home address or direct deposit (if initiated).
Do I have to wait for my contributions to be deposited into my account in order to make a claim for
reimbursement?
No, BUT you will only be paid out funds that you have previously contributed. Any claimed amounts over your
current balance will be paid out automatically upon receipt of future contributions.
What happens to my contributions if I do not incur enough qualified expenses, or neglect to file a claim in
the time specified in my SPD?
Should you not incur enough expenses, or neglect to file a claim, you will forfeit any amount contributed to your
DCAP account. Also, any DCAP reimbursements that are unclaimed (for example, checks that have not been
cashed) by the close of the Plan Year will be forfeited to the Plan. For this reason, please estimate your Dependent
expenses accordingly.
What if I terminate employment for any reason?
You will have a limited amount of time to incur and submit for qualified expenses.
Please see your SPD for information on claim filing time limits
Are there any negatives?
Yes. Since you do not pay Social Security taxes on your contributions, your future benefits may be slightly
reduced. Most tax advisors would tell you that the benefit of saving taxes now would be far greater than the
potential loss of Social Security Benefits when you retire. Please see your tax consultant for more information.WELLS FARGO INSURANCE SERVICES
FLEX BENEFITS DEPARTMENT
CUSTOMER CARE LINE
(888) 336-7471
CLAIM FAX LINE
(800) 231-3213You can also read
