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FREQUENTLY ASKED QUESTIONS

Premera Blue Cross provides choice, convenience and control to help you better understand Personal Funding
Accounts. Personal Funding accounts include Health Savings Accounts (HSA) and Flexible Spending Accounts
(Special Purpose FSA, Healthcare FSA, and Dependent Day Care FSA). The Frequently Asked Questions (FAQs)
below will help you understand the Personal Funding Account options available. These FAQs are not a substitute for
your employer’s summary plan description and other communications regarding your benefits. In case of a conflict
between these FAQs and the materials provided by your employer, your employer’s materials will be controlling.

HEALTH SAVINGS ACCOUNT
Account Basics
What is a Health Savings Account (HSA)?
A Health Savings Account (commonly called an HSA) is an alternative to traditional health insurance; it is a savings
product that offers a different way for consumers to pay for their healthcare. HSAs enable you to pay for current
health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.
You must be covered by a qualified High Deductible Health Plan (HDHP) to be able to make contributions to an
HSA. An HDHP generally has a lower premium cost than traditional health insurance. The money that you save on
premiums can then be put into the Health Savings Account. You own and control the money in your HSA.
Decisions on how to spend the money are made by you without relying on a third party or a health insurer. You also
decide what types of investments to make with the money in the account in order to make it grow.
What are the benefits of establishing an HSA?
1. Tax Savings - An HSA provides you with triple tax savings:
a. Tax deductions when you contribute to your account and/or tax free income when your employer
contributes to your account;
b. Tax free earnings, if any, through investments; and,
c. Tax free withdrawals for qualified medical expenses.
2. Affordability–A qualified High Deductible Health Plan–accompanied by an HSA–carries a higher
deductible than traditional insurance, but lower monthly premiums. Savings from lower premiums can be
put toward funding the HSA.
3. Flexibility–You can use the funds in your account to pay for current medical expenses or save the money
for future needs. Money saved can be invested and your account may grow through investment earnings,
which are tax-free. You also have control over how much money to contribute to the account, subject to
IRS limitations, and which medical expenses to pay from the account.
4. Ownership and Portability–HSAs are owned by you, not your employer. Additionally, accounts are
completely portable meaning you can keep your HSA even if you change jobs, change your medical
coverage or become unemployed.
How does an HSA work?
1. Funding. You and your employer may contribute, subject to IRS limitations, to your HSA. You can change
your contributions during the year. (Please refer to your Employee Benefits Handbook or call the Benefits
Call Center at 844-231-3476 for a copy of your employer’s contribution schedule if applicable.) The
contributions are paid to an account owned by you, which you can continue to access after your
employment ends.
2. Accessing Funds. When you have eligible healthcare expenses, pay for them with your Healthcare
Payment Card, or pay out of pocket and request reimbursement online. Remember to always keep your
receipts. You may need them to avoid taxation of your distribution, in case of an IRS audit.

021170 (01-2015)

An Independent Licensee of the Blue Cross Blue Shield Association

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If you pay for an eligible expense out-of-pocket. if you are under the age of 65. Qualified medical expenses under an HSA include: deductibles under the High Deductible Health Plan. What types of medical expenses are not eligible under an HSA? Examples of expenses that are not HSA eligible include gym memberships. Contributions and Investment Options How much can I contribute to my HSA each year? For 2015. we recommend you establish your account as soon as you are eligible to do so. vision care costs. you will also be subject to a 20% tax penalty.” which you can download from irs.350 and the maximum contribution for employees with family coverage under an HDHP is $6. Unspent HSA funds rollover into the next year.000 per person. 4.650. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 2 .3. the maximum contribution that can be made for employees with single coverage under an HDHP is $3. In addition. If you decide the HSA is right for you. we will promptly process your request and reimburse you either by check–or by direct deposit if you sign up for that feature. Eligible Expenses What types of medical expenses are eligible under an HSA? There are IRS rules for accessing funds in an HSA. cosmetic procedures and surgeries. For a complete list of approved healthcare expenditures. check with your employer. or order by calling 1-800-TAX FORM. You cannot reimburse qualified medical expenses incurred before your account is established. Log on to your online account and visit the Account Claim Center. Participants’ age 55 or older (and not yet enrolled in Medicare) can make additional "catch-up" contributions of up to $1. or order by calling 1-800-TAX FORM. prescription medications and some over-the-counter medications. medical copayments or coinsurance. nutritional supplements. Can I make changes to the amount I contribute to my HSA during the plan year? You can change the amount you contribute to your HSA from month-to-month at any time during the year. Can I use my HSA to pay for medical expenses incurred before I set up my account? No. please refer to IRS Publication 969. Account Management. dental care costs. 5. the funds used for that expense will be taxed as gross income. “Health Savings Accounts and Other Tax-Favored Health Plans.” which you can download from irs. view transactions and more. you will need to submit a request for reimbursement. long-term care costs. If your payment was out-of-pocket and you choose to use your HSA funds. Both individuals and Alaska Air Group can contribute to HSAs. What happens if I use the account for a non-eligible expense? If you use the account for a non-eligible expense. If you are married and your spouse is covered under an HDHP. HSA funds can also be used to pay for COBRA or certain retiree medical insurance premiums. Please note that you will receive your money sooner if you use direct deposit. Please note: These amounts are indexed annually for inflation. Please refer to IRS Publication 969.gov. see your claims history. Reimbursement Processing. If you are changing the amount contributed via payroll on a pre-tax basis. which can provide extra financial help to many early retirees. this limit must be coordinated between the two spouses. Distributions from HSAs are tax-free if the distributions are used to pay qualified medical expenses. “Health Savings Accounts and Other Tax-Favored Health Plans.gov. Requesting Reimbursement. Log on to your online account regularly to check your account balance.

Failure to maintain eligibility for HSA contributions for a period of 13 consecutive months beginning with the month of the IRA transfer for any reason other than death or disability would result in income tax and a 10-percent additional tax on the transferred amount. and both spouses have established an HSA in their name. you may later make an additional transfer if you switch to family coverage. This option allows you to make or change contributions on a recurring basis or one-time basis. The maximum amount of the additional transfer is equal to the difference between the amount transferred while you had self-only coverage and the maximum deductible limit for family coverage for the year. In other words. What catch-up contribution options are available to me if I am over 55? Individuals 55 and older who are covered by an HDHP can make additional catch-up contributions each year until they enroll in Medicare or are otherwise ineligible to contribute to an HSA. before income taxes and FICA taxes). This information is reported on Form 5498 and Form 1099SA respectively. If you and your spouse are both 55 and older.. Does an HSA have a mandatory distribution requirement? No. there are no mandatory distribution requirements for an HSA. when combined with other HSA contributions for the year. What investment options will I have with my HSA? You may have up to three basic choices if you decide to contribute to an HSA: 1) an interest bearing account. If only one spouse has an HSA.. you cannot also take a deduction for these contributions on your personal income taxes. both forms must be sent to you as the account holder and to the IRS. If you have self-only coverage and you transfer amounts from your IRA to an HSA." i.e. If you turned 55 this year. the amount of the rollover cannot exceed the applicable annual HSA contribution limit (which would vary depending on whether the person has individual or family HDHP coverage) when combined with any other HSA contributions you made for that year. Note: Contributions via the Contribution Center are made post-tax and can be deducted on your income tax return subject to IRS limitations. 2) a Money Market Account. only that spouse can make the "catch-up" contribution. is subject to the annual HSA maximum contribution. or 3) a Mutual funds account.e. If you did not have HDHP coverage for the full year. Unlike 401(k)s and IRAs. you can make the full catch-up contribution regardless of when your 55th birthday falls during the year. Can I make contributions through my employer on a "pre-tax" basis? If your employer offers a "salary reduction" plan (also known as a "Section 125 plan" or "cafeteria plan"). 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 3 . The additional "catch-up" contribution to HSA is limited to $1. and had HDHP coverage for the full year. This amount. you may prorate your "catch-up" contribution for the number of full months you were "eligible. If you do so. Can I transfer funds from my IRA to my HSA? How much can I transfer? The IRS allows a one-time transfer of IRA funds to an HSA. then both spouses can make "catch-up" contributions. or you may use the special full-year contribution rule described above if you wish.You can also make non-payroll contributions changes using the Contribution Center in your online account. and both spouses are HSA eligible individuals. had HDHP coverage. you (the employee) can make contributions to your HSA on a pre-tax basis (i. What information is reported to the IRS? The HSA custodian or trustee is required to report the total contributions made to your HSA each year as well as the total amount of funds taken from the account each year.000 per year.

You must have a qualified HDHP if you want to open and contribute to an HSA. The funds in your account roll over automatically each year and remain in your HSA indefinitely until used. • Customer Service representatives are available to assist you at 877-AAG-3525 How will I be able to use my HSA funds? You will receive a Healthcare Payment Card to access your HSA. However.Health Insurance Coverage Can I use an HSA if I have health insurance? Yes. How long do I have to use my HSA for qualified expenses? You can use your HSA to pay for qualified expenses incurred any time after you opened your HSA. you can also use your account to pay for your share of retiree medical insurance premiums. When you enroll in Medicare. What happens to the money in my HSA after I turn age 65? You can continue to use your account tax-free for out-of-pocket health expenses. deductibles. Your online account is secure and updated in real time. What happens to the money in my HSA if I no longer have HDHP coverage? Once funds are deposited into the HSA. You should always save your itemized receipts and other paperwork to verify qualified expenses for when you withdraw funds. the account can be used to pay for qualified medical expenses tax-free. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 4 . How can I find out my account balance and review transactions? Account Balance and Claims Status information is available three ways: • Log on to your online account at any time for balance information. These types of plans also have annual limits on how much you have to pay out-of-pocket in the form of deductible. you can continue to use it for future medical expenses. but since you own the HSA. called HSA savers. Once you discontinue coverage under an HDHP and/or get coverage under another health plan that disqualifies you from an HSA. What happens if I leave the company or retire during the plan year? HSAs are completely portable. What is a High Deductible Health Plan (HDHP)? A deductible is the amount of dollars that you must pay for covered healthcare expenses before your health plan will provide coverage. co-pays. If your employer paid the administrative costs. You can also pay for eligible expenses with any other form of payment and request reimbursement from your account. which means you retain ownership of the funds after you leave the company. you can set up and contribute to an HSA only while covered under a qualified High Deductible Health Plan. There is no time limit between when you incur the qualified expenses and when you withdraw the corresponding amount from your HSA. You cannot use your account to purchase a Medicare supplemental insurance or "Medigap" policy. you can no longer make contributions to your HSA. A high deductible health plan (HDHP) is an insurance plan that has a higher than average deductible. whether it is now or at some point in the future. even if you no longer have HDHP coverage. you may become responsible for cost incurred after you terminate your employment. See Healthcare Payment Card FAQs for more information about your payment card. pay for current expenses out of pocket so that they can invest their HSA money and grow the account for future use. copayments and coinsurance fees. Some people. If you have retiree health benefits through your former employer. you can use your account to pay Medicare premiums. There is no time limit on using the funds. and coinsurance under any part of Medicare.

If the purchase was using a Healthcare Payment Card. unlike the HSA. medical equipment. decide how much to contribute to your account. you will need to submit a request for reimbursement by clicking “Add New Claim. Remember to always keep your receipts. Your employer may limit what expenses your Healthcare FSA reimburses. can also be reimbursed through an FSA. coinsurance or copayment amounts for your health plan. hearing aids and chiropractic care. Depending on your tax bracket. A Dependent Day Care FSA (also known as a Dependent Day Care Assistance Program (DCAP)) covers employment-related expenses for child care. Funding. you can be reimbursed for eligible expenses that you are already incurring! How does an FSA work? 1. pay with your Healthcare Payment Card. Log on to your online account and visit the Claim Center found in the Personal Funding Account area. please see Dependent Day Care FAQs.” Fill out the requested information and follow directions to complete the online claims submission process. you do not own any particular assets. If you are not married at the time of your death. Typical expenses under this account include charges for day care. or pay out-of-pocket and request reimbursement online. please refer to your Employee Benefits Handbook or call your Benefits Call Center at 844-231-3476 for more information. Requesting Reimbursement/Substantiating Purchases. 2. A Healthcare FSA can cover medical. Plus. eye glasses or contact lenses. Accessing Funds. Common qualified expenses that a Healthcare FSA will usually cover include the deductible. • Dependent Day Care FSA: If you have children and have to pay for child care. such as cold and allergy medicines. There are two types of flexible spending accounts: a Healthcare FSA and a Dependent Day Care FSA. you are likely to have out-of-pocket medical expenses each year. the employee. pain relievers and antacids. your spouse becomes the owner of the HSA when you die unless a different beneficiary is specified. If your payment was out-of-pocket. For more information. Qualified expenses must be for services that allow you to be able to go to work. nursery school and elder care (though not if it is for medical care) for your qualifying dependents. • Healthcare FSA: Even with the best health plan. The contributions are tracked as a bookkeeping account. dental or vision expenses that you would otherwise pay for out-of-pocket.Can I borrow against my HSA? No. This amount is deducted from your paycheck on a pre-tax basis. Every dollar you set aside in your account reduces how much you pay in income taxes. You can also submit a claim by printing out a fax cover sheet and faxing the cover sheet with your itemized receipts to the number shown on the form. HEALTHCARE FLEXIBLE SPENDING ACCOUNT Account Basics What is a Flexible Spending Account or FSA? Flexible Spending Accounts are valuable employee benefits that you allow to use pre-tax dollars to pay for eligible expenses. Many over the counter drugs. 3. What happens to my HSA when I pass away? If you are legally married at the time of your death. you may save up to 30% or more in taxes. a dependent day care account can help stretch your hard-earned dollars. the HSA becomes part of your taxable estate. When you have an eligible healthcare expense. you may skip the request for reimbursement and simply print out the pre-filled form and fax the cover sheet with your itemized receipts to the number 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 5 . dental work and orthodontia. You cannot borrow against or pledge funds in your HSA. What are the benefits of a Healthcare FSA? Your biggest advantage is the tax savings. but. You.

please refer to IRS Publication 969. “Health Savings Accounts and Other Tax-Favored Health Plans.gov. this is not allowed. or • Amounts covered by your health plan or reimbursable through other insurance.4. Claims Processing. the Healthcare FSA can be used for eligible medical expenses. • Long term care insurance. • Hair transplants.gov. dental care costs. For a complete list of eligible expenses. What types of expenses are not eligible for reimbursement with a Healthcare FSA? Services that are typically not eligible or reimbursable include: • Skin or teeth bleaching/whitening. the request will be denied. please refer to your Employee Benefits Handbook or call your Benefits Call Center at 844-231-3476 for more information. • Cosmetic surgery or treatments of any kind. • Electrolysis. Qualified medical expenses are defined as: deductibles.” which you can download from irs. Eligible Expenses What types of expenses are eligible for reimbursement from a Healthcare FSA? The IRS provides the rules for accessing funds from an FSA. prescription medications and some over-the-counter medications. What happens if I use the Healthcare FSA for a non-eligible expense? If you file a manual request for reimbursement of a non-eligible expense. Please remember that credit card receipts. We will promptly process your request and reimburse you either by check or direct deposit if you sign up for that feature. What happens if I don’t claim all the money in my account? The IRS regulates Flexible Spending Accounts under Internal Revenue Code Section 125. shown on the form. or order by calling 1-800-TAX FORM. • Health club dues. Your employer may limit what expenses your Healthcare FSA reimburses. • Long term care services. you will be required to reimburse your account for that transaction. please refer to IRS Publication 969.” which you can download from irs. you may be required to pay income taxes. or order by calling 1-800-TAX FORM. Log in to your online account regularly to check your account balance. vision care costs. In general and subject to limitations discussed below. According to the IRS 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 6 . Please note that you will receive your money sooner if you use direct deposit. “Health Savings Accounts and Other Tax-Favored Health Plans.550 for the 2015 plan year. • Insurance Premiums. 5. If you fail to reimburse the account. copayments or coinsurance. non-itemized cash register receipts and cancelled checks are not acceptable forms of documentation. Account Management. Can I transfer money from my Dependent Day Care FSA to my Healthcare FSA (or vice versa)? No. To find a general list of non-eligible expenses. Contributions and Tax Information How much can I contribute to Healthcare FSA? The IRS-defined maximum contribution amount is $2. If you used the Healthcare Payment Card and the expense is deemed ineligible after the expense is already paid. • Contract fees for maintenance/replacement of contact lenses or eyeglasses.

You can also pay for eligible expenses with any other form of payment and request reimbursement from your account. All eligible out-of-pocket expenses incurred by you and your qualified dependents can be reimbursed by your Healthcare FSA. If you do not elect COBRA. spouse or dependent to include termination. and can be used to offset administrative costs of the plan. Valid changes in status for the Healthcare FSA include: • Legal marital status change– marriage.guidelines. return from an unpaid leave of absence • Dependent eligibility–situations where a dependent satisfies or ceases to satisfy the rules for eligible dependents due to the attainment of age. switching from part-time to full time or vice versa. Can I make changes to my Healthcare FSA? Once an election for the Healthcare FSA has been made. Health Insurance Coverage What if I am not covered under my company’s health insurance plan? If you are an Alaska Air Group employee. you are eligible to be reimbursed for qualified expenses incurred while you were employed and the account was active. How can I find my account balance and review transactions? Account Balance and Claims Status information is available 24 hours a day. • Call 877-AAG-3525 for balance information. Who are qualified dependents? Dependents must be either your spouse or someone who qualifies as your dependent under Section 105(b) of the Internal Revenue Code. adoption. divorce. your employer. What information is reported to the IRS? We do not supply information to the IRS related to an individual Healthcare FSA. the “use it or lose it” clause applies to any unused funds with the exception of a $500 carryover to the next plan year. you cannot change the amount unless you terminate employment with your company or there is an appropriate change in status and your requested change is consistent with your change in status. death of a dependent • Employment–change in employment status of employee. student status. may be required to file an IRS form 5500 which includes aggregate participation information but does not include individual FSA information. Requests for reimbursements should be submitted prior to the end of your employer’s runoff period. The unused funds are retained by the plan. The plan sponsor. Using Your Account How will I be able to access my Healthcare FSA funds? You will receive a Healthcare Payment Card to access your FSA. you must participate in the medical plan to enroll in a Healthcare FSA. Can I enroll in a Healthcare FSA to reimburse my spouse’s deductible and copayment expenses? Yes. Your online account is secure and updated in real time. death of spouse. legal separation or annulment • Change in number of dependents– birth. even if such dependents are not enrolled in your employer’s health plan. See Healthcare Payment Card FAQs for more information about your payment card. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 7 . The remaining funds are not transferable from one plan year to another and they are not available for other benefits. or similar circumstances as provided in the plan • Change in residence What happens if my employment terminates? Deductions for your Healthcare FSA will end when your employment ends unless your employer is obligated to offer you COBRA continuation and you elect this option. seven days a week: • Log on to your online account at any time for balance information.

Requesting Reimbursement/Substantiating Purchases. 3. non-itemized cash register receipts and cancelled checks are not acceptable forms of documentation. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 8 . 4.gov. please refer to IRS Publication 969. What types of expenses are not eligible for reimbursement with a Dependent Day Care FSA? Services that are typically not eligible or reimbursable include: • Child support payments. Follow the directions to complete the submission online or print out the fax cover sheet and fax the cover sheet with your itemized receipts to the number shown on the form. pay out-of-pocket and request reimbursement online. Please note that you will receive your money sooner if you use direct deposit. • Kindergarten or school tuition. Click “Add New Claim” to submit a request for reimbursement. nursery and pre-schools. typically decide how much to contribute to your account. or order by calling 1-800TAX FORM.gov. When you have an eligible expense. you can be reimbursed for qualified dependent day care expenses that you are already incurring! How does a Dependent Day Care FSA work? 1. you may save up to 30% or more in taxes. Depending on your tax bracket. Expenses include before school or after school care. For a complete list of eligible expenses. Remember to always keep your receipts. 5. nursery school and elder care (though not if it is for medical care) for your legal tax dependents. Typical expenses under this account include charges for day care. Log on to your online account and visit the Claim Center found in the Personal Funding Account area. If you have children and have to pay for child care. Account Management. The contributions are tracked as a bookkeeping account. Accessing Funds. you do not own any particular assets.” which you can download from irs. Please remember that credit card receipts. “Health Savings Accounts and Other Tax-Favored Health Plans. but. • Fees for services that have yet to occur (e. Log in to your online account regularly to check your account balance. “Health Savings Accounts and Other Tax-Favored Health Plans. a Dependent Day Care FSA can help stretch your hard-earned dollars..g. and custodial care for dependent adults. please refer to IRS Publication 969. Every dollar you set aside in your account reduces how much you pay in income taxes. Funding. You. For a general list of approved dependent day care expenditures.DEPENDENT DAY CARE FLEXIBLE SPENDING ACCOUNT Account Basics What is a Dependent Day Care FSA? A Dependent Day Care FSA (also known as a Dependent Day Care Assistance Program (DCAP)) is a valuable employee benefit that allows you to have pre-tax dollars withheld from your paycheck to pay for un-reimbursed dependent day care expenses. day care. 2. or order by calling 1-800-TAX FORM. summer day camp deposits). This amount is deducted from your paycheck on a pre-tax basis. unlike the HSA. the employee. Qualified expenses must be for services that allow you to be able to go to work. What are the benefits of a Dependent Day Care FSA? Your biggest advantage is the tax savings. We will promptly process your request and reimburse you either by check or direct deposit if you sign up for that feature.” which you can download from irs. Claims Processing. Plus. Eligible Expenses What types of expenses are eligible for reimbursement with a Dependent Day Care FSA? The IRS provides for rules for accessing funds in a Dependent Day Care FSA and mandates that these funds be used for dependent day care expenses that are incurred to allow you to work. A Dependent Day Care FSA covers employment-related expenses for child care.

To find a general list of non-eligible expenses please refer to IRS Publication 969..000. What information is reported to the IRS? The amount reimbursed to your from the Dependent Day Care Assistance Program will be reported to the IRS on your Form W2 at the end of the year by your employer.e. How does participating in the Dependent Day Care FSA differ from using other tax credits relating to dependents? Reimbursements under the dependent day care account must be for employment-related expenses. The IRS determines what expenses may be reimbursed. the Dependent Day Care Credit may be more advantageous than participating in the Dependent Day Care FSA and care should be used in determining which method to select. Can I transfer money from my Dependent Day Care FSA to my Healthcare FSA (or vice versa)? No. according to IRS regulations. IRS Publication 503 Child and Dependent Day Care Expenses contain detailed information for determining whether a taxpayer may claim the Dependent Day Care Credit. Also. What happens if I use the account for a non-eligible expense? The request will be denied. if applicable. the limit cannot exceed the annual income of the employee (or spouse. For some employees. funds that are not claimed during the plan year are forfeited. Who are qualified dependents? Dependents must be either your spouse or someone you can claim as an exemption for federal income tax purposes. or to allow your spouse to be a full-time student. or Overnight camp.500 per spouse per year if the spouses file separate federal tax returns.gov. to be gainfully employed or to look for work. The limit is reduced to $2.” which you can download from irs. you may not contribute more than $5. if less) for the year. This is called the "use it or lose it" clause. Contributions and Tax Information How much can I contribute to my Dependent Day Care FSA? For a Dependent Day Care FSA. your employer. Your qualifying child under Internal Revenue Code Section 152 who is under age 13 and for whom you are the custodial parent. The Dependent Tax Credit is an alternative to using a Dependent Day Care FSA and is a credit against tax liability. this is not allowed. registration and/or activity fees. The unused funds are retained by the plan sponsor. or order by calling 1-800-TAX FORM. Health Insurance Coverage What if I am not covered under my company’s health insurance plan? You and your family can still participate in Dependent Day Care Flexible Spending Account. According to the IRS guidelines. To be covered through your Dependent Day Care FSA. the individual must meet one of the following criteria: 1. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 9 . the combined limit for the couple is $5. “Health Savings Accounts and Other Tax-Favored Health Plans.• • Meals or transportation. and may be used to offset administrative costs of the plan. The limit applies on a combined basis for married couples (i. What happens if I don’t claim all the money in my account? The IRS regulates Flexible Spending Accounts under Internal Revenue Code Section 125. Employment-related means an expense for dependent day care that allows you and your spouse. Funds are not transferable from one plan year to another and they are not available for other benefits.000).

Your online account is secure and updated in real time. You are eligible to be reimbursed for qualified expenses that were incurred before your termination date.. It is provided to give you quick access to the funds in your account and should only be used at eligible locations for qualified plan expenses. due to change in providers) If my child turns 13 during the plan year. It provides a convenient way to access your HSA or Healthcare FSA and pay for qualified medical expenses quickly. adoption. seven days a week: • Log on to your online account at any time for balance information. your deductions will end when your employment ends. Can I make changes to my account? Once an election for the Dependent Day Care FSA has been made. easily and with almost no paperwork. return from an unpaid leave of absence • Dependent eligibility– situations where a dependent satisfies or ceases to satisfy the rules for eligible dependents due to the attainment of age. Having a child attain age 13 is a qualifying event and a reason to terminate your contributions to the Dependent Day Care FSA. death of a dependent • Employment– change in employment status of employee. death of spouse.2.g. Your spouse who is physically or mentally incapable or caring for him or herself.birth. divorce. unless they are physically or mentally incapable of caring for themselves. Valid changes in status for the Dependent Day Care FSA include: • Legal marital status change–marriage. You are no longer eligible to be reimbursed for care for a child once the child turns 13. legal separation or annulment • Change in number of dependents . When paying for eligible expenses. Is this a regular credit card? No. Using Your Account How will I be able to access my Dependent Day Care FSA funds? You can pay for eligible expenses with any form of payment and request reimbursement from your account. student status. the Healthcare Payment Card is a stored-value. no personal identification number (PIN) is needed. How can I find my account balance and review transactions? Account Balance and Claims Status information is available 24 hours a day. may I still use my Dependent Day Care FSA through the end of the plan year? No. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 10 . HEALTHCARE PAYMENT CARD Why did I receive this card? The Healthcare Payment Card is offered as an enhancement to your benefits package. simply swipe the card anywhere your card type (example: Visa) is accepted. Your dependent as defined under Internal Revenue Code Section 152 who is physically or mentally incapable of caring for him or herself. or similar circumstances as provided in the plan • Changes in cost of coverage (e. switching from part-time to full time or vice versa. What happens if my employment terminates? For a Dependent Day Care FSA. spouse or dependent to include termination. 3. you cannot change the amount unless you terminate employment with your company or there is an appropriate change in status. How do I activate my card? Your card will be automatically activated the first time you use it. restricted-use card to access funds from your HSA or Healthcare FSA (as applicable). or.

department stores and wholesale clubs that comply with an IRS-required Inventory Information Approval System (IIAS). The card is programmed to work only at merchant locations that are designated as healthcare merchants based on their Merchant Category Code (MCC). What are the benefits of the card? The main benefit of the Healthcare Payment Card is convenience. • For a list of Retailers Accepting Healthcare Payment Cards. Rather than paying out-of-pocket for qualified expenses. Examples of transactions that should not require receipts include: 1. To use this card without a PIN. Examples of qualified merchants include pharmacies. reducing the need to submit receipts or worry about rejected claims. these expenses may include deductibles. it will be up to you to remember to send the receipts and file the claim. Copayments that match your employer’s group health insurance plan. 4. An itemized receipt should include the date of service. It allows you immediate access to your Healthcare Flexible Spending Account (FSA) or Health Savings Account (HSA) funds. select “credit” at the payment terminal. Your card includes a preset PIN which is the last four digits of your card number. see premera. There are many products and services that meet the approved healthcare expenditures requirements as defined by the IRS. name and address of the provider. filing a claim and then waiting for reimbursement. grocery stores. • Doctor and dentist offices. attach your receipts and fax to the claims department.). and they will swipe your card like any other credit card to pay for your purchase. Where can I use my Healthcare Payment Card? Your Healthcare Payment Card can be used nationwide at a qualified service provider that accepts your card type (Visa or MasterCard. to use this card. Please ask for an itemized receipt in case it is required for substantiation. copays.com/merchants • Pharmacies are also required to comply with IIAS in order to accept Healthcare Payment Card. If you use another form of payment. How does the card work? Provide your card to a qualified merchant or provider. IIAS compliant stores automatically check to ensure items purchased with a Healthcare Payment Card are qualified healthcare account expenses. either online or manually by paper. using the card will allow you to access your funds directly and pay the provider. 3. and the cost and description of the service provided. etc. coinsurance. it also automatically sends a reminder about receipts. 2. Purchases made at certain supermarkets. Your Healthcare Payment Card will only be accepted at supermarkets. vision centers and hospitals will continue to accept Healthcare Payment Cards with no requirement to comply with IIAS. grocery stores. prescription drugs. vision care and dental care. To select a different PIN. When our claims system recognizes a card swipe. or PIN. Funds for eligible expenses will be transferred directly to the provider or merchant from your healthcare account. Depending on your account. Another benefit is that when you swipe the card. vision centers and hospitals. doctor and dentist offices. call 888-999-0121. a claim is created for you eliminating the need to fill out a claim form. you will not have to wait to be reimbursed. While you may still need to fax receipts for substantiation purposes. Recurring expenses of the same dollar amount and same location that have been previously substantiated. Some merchants may require a personal identification number. You can use that reminder as the claim fax cover sheet. department stores and wholesale clubs that automatically provide substantiation through an inventory control system. Copayments that match your employer’s group pharmacy benefit. An additional benefit is that some payment card purchases can be auto-substantiated without your receipts. over-the-counter drugs. Do I still need to keep my receipts? Yes! Third party documentation is required any time you use your payment card or request reimbursement except 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 11 .What can I purchase with my card? The IRS requires that health account funds be used only for healthcare expenditures.

If it’s not a simple copayment. If you fail to reimburse the account. Can the Healthcare Payment Card identify how much will be paid by my health plan for the product or service? No. Always save your receipts! What happens if I use the card for an ineligible expense? For most types of accounts. and • Amount charged. If swiped as “debit”. you may be required to pay income taxes and an additional penalty tax. so hold on to these receipts as well. such as Flexible Spending Accounts (FSAs). You can also check online to see if your claim requires receipts by logging on to your account and selecting your personal funding account. pay for the charge another way and contact Customer Service afterwards to determine the reason for the denial. That is why. you can ask the merchant to swipe the card for the available amount and then use another form of payment to pay the difference. What happens if I’m at a legitimate provider and my Healthcare Payment Card doesn’t work? You should first check if the provider swiped your card as a "credit" transaction or “debit” transaction. If your balance is less than the cost of the service or expense. always hold on to your receipt* in case further documentation is requested. If you fail to submit required receipts within 45 days. you will be required to submit documentation to verify that the card was used to pay for an eligible expense. credit card receipts and cancelled checks alone do not provide proper substantiation. How will I know if I need to submit a receipt for substantiation? If a receipt is needed.for the instances listed above. doctors’ offices and hospitals. If you see a notice. if you use the card for an ineligible expense. The Healthcare Payment Card utilizes the merchant code of the provider to determine if the location typically sells or dispenses legitimate healthcare expenses. Valid locations include pharmacies. your payment card will be deactivated. in some instances. confirm you entered the PIN correctly. If you used a Health Savings Account (HSA) to pay for an ineligible expense. *Please note that non-itemized cash register tapes. you will be required to reimburse your account for that transaction. the IRS may require you to present receipts to verify your tax return. you will be notified by email or letter. then the provider is either not a qualified merchant or they have not properly set up their merchant code. Will the card know which expenses are eligible and which are not? While the card can identify a healthcare location based on the Merchant Category Code. you need to submit receipts. • Name and address of service provider or merchant. You can go online to request reimbursement for any eligible expenses in which the card was not used. If the card still does not work. it cannot identify the items or services purchased. What are some reasons my card may be denied? The IRS has set up rules regarding when payment cards can be used. The receipt must contain the following information: • Date of service. you should wait for the claim to go through your insurance company and you receive your Explanation of Benefits (EOB) showing your financial 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 12 . Therefore. What if I don’t submit my receipts? You must provide the receipts within the time requested or the transaction will be deemed ineligible. the amount of the ineligible expense(s) may be withheld from your pay or added to your W-2. If the card is not approved. and you will be required to refund the amount of the transaction. • Description of the service or expense provided. you still need to submit your expense through your regular claims procedure used by your health plan to determine what your share of the cost will be. we do not need receipts for HSA transactions. However. Under current regulations. Your card may also be denied if the amount requested from your card is more than your available balance.

You should only charge the amount that your insurance company doesn’t cover. address. What if my provider doesn’t have a charge card terminal? You can still use funds from your account. some doctors sell nutritional supplements and vitamins which are not eligible. 021170 (01-2015) An Independent Licensee of the Blue Cross Blue Shield Association 13 . some services such as teeth whitening are not.responsibility. the IRS requires that we receive documentation to identify the service performed is an eligible expense. I used my payment card at the dentist’s office. If the current plan year has expired. the IRS requires that we receive documentation to identify the service performed is an eligible expense. I used my payment card at the doctor’s office. Keep this in mind if you incur services or expenses towards the end of a plan year and are waiting for the EOB from your insurance company. you may not use your card at dependent day care locations. you will have to pay with another form of payment and then submit a request for reimbursement. some procedures are not. Therefore. then enter a reimbursement request online and submit your itemized receipts. Therefore. Receipts must contain the following information: • Date of service • Name. a qualified merchant. Can I use my Healthcare Payment Card to pay for services incurred in the previous plan year? No. you should file claims manually. non-itemized cash register tapes. but you still requested receipts–why? While most procedures performed in a dentist’s office are eligible expenses. therefore it would pull money from the current plan year instead of the previous plan year. However. you may pay for qualified dependent day care expenses out of pocket. How do I pay for dependent day care expenses? Unfortunately. A card transaction is processed with an assumed date of service equal to the date of the card swipe. but you still requested receipts–why? While most procedures performed in a doctor’s office are eligible expenses. credit card receipts and cancelled checks alone do not provide proper substantiation. If you enrolled in a Dependent Day Care FSA. Itemized receipts must be provided to substantiate dependent day care expenses in compliance with IRS guidelines. and taxpayer identification number of provider • Description of the service provided • Amount charged • Name and age of the dependent Please note. a qualified merchant. Copays can usually be paid with the Healthcare Payment Card at the point-of-service. For instance.