UNDERSTAND

A Medical Flexible Spending Account (FSA) is an IRS-approved, tax-exempt account that saves you valuable tax dollars on eligible medical expenses. Each pay period, an amount of money that you have specified is deducted from your gross pay before federal income, Social Security, and Medicare taxes are calculated. Our plan is administered by Application Software, Inc. (ASI).

How a Flexible Spending Account Works

When you enroll, you estimate your family's annual health expenses and choose the amount of money you want to set aside pre-tax for the plan year. For 2010, this amount must be between $240 and $3,600. The amount you choose is deducted evenly from your paychecks throughout the year based on your length of appointment (e.g. 9, 10, 11 or 12 months).

As you incur eligible medical expenses, you may request withdrawals from your account to reimburse yourself for out-of-pocket expenses incurred by submiting a claim form with your bills to ASI. Reimbursement will be issued in the form of a check or direct deposit reimbursement, whichever you elected.

Any FSA funds that you do not use during the plan year are forfeited.

Eligibility

Any employee who is eligible for Public Employees’ Benefits Board (PEBB)-sponsored benefit programs can create an FSA. Expenses can be reimbursed for your:

• spouse,
• tax-qualified domestic partner (QDP), and
• Internal Revenue Code (IRC)-eligible dependents.

These individuals do not need to be covered under your PEBB medical plan for their expenses to be reimbursed from your FSA.

Enrollment Requirements

Current plan participants MUST re-enroll in the plan each year in order to continue participation. Open Enrollment is held during the month of November each year prior to January 1 of the following year, the date when the FSA goes into effect.

New hires who wish to enroll in an FSA must do so within 31 days from date of hire. Participation becomes effective the first day of the month following receipt of the properly completed enrollment form.

Current University employees experiencing a qualifying life event may enroll in an FSA within 60 days from date of the qualifying event. Participation becomes effective the first day of the month following receipt of the properly completed enrollment form. See qualifying life events.

Enrollment Considerations

Consider the following before enrolling in an FSA:

• Be conservative with your estimates: Any money you do not spend during the plan year will be forfeited.
• Anticipated expenses: Determine whether some of your anticipated expenses are FSA eligible. View the List of Eligible and Ineligible Expenses on the plan administrator's website.
• Changing deductions: You cannot change the amount of money deducted from your pay during the plan year unless you have a qualifying life event that allows a medical plan change like marriage, birth or adoption, divorce, death, or change in residence.
• Filing claims: All claims must be submitted to the plan administrator at ASI who determines whether they qualify for reimbursement.
• Planned surgery: Before undergoing a planned surgical procedure for which you will want reimbursement, be sure you understand any documentation and approval requirements that will be necessary. See the FSA Enrollment Guide or contact the plan administrator at 1-800-659-3035.
• "Run-out period": You have a 90-day grace period at the end of a plan year to claim reimbursement for eligible medical expenses. For example, you have until March 31, 2010, to submit claims for 2009 medical expenses.
• Grace Period: The IRS permits a "grace period" of two months and 15 days following the end of your plan year for a Medical Expense FSA. During the grace period, you may incur expenses and submit claims for these expenses. Funds will be automatically deducted from any remaining dollars in your Medical FSA. The grace period is not the same "run-out period." The run-out period extends until March 31 each year. This is a period for filing claims incurred anytime during the plan year, as well as claims incurred during the grace period.
• You cannot receive insurance benefits or any other compensation for expenses reimbursed through your FSA.
• Income Tax Deductions: Expenses reimbursed from an FSA cannot be deducted on your federal tax return because the money from the FSA is tax exempt.
• No Advance Reimbursement: You may only be reimbursed for services you have received.

ACT

Online Enrollment

1. Review the eligibility and enrollment requirements (above) to ensure that you can enroll in FSA.
2. Use the FSA worksheet to estimate your eligible, uninsured out-of-pocket medical expenses for the plan year.
3. To enroll in a 2010 FSA: Enroll online before midnight on November 30, 2009. Go to http://pebb.asiflex.com/enrollment/enrollment.htm.
4. To enroll in a 2009 FSA—either as a new hire or current employee experiencing a qualifying life event—see the special instructions at http://pebb.asiflex.com/enrollment/enrollment.htm.

Paper Enrollment

1. Review the eligibility and enrollment requirements (above) to ensure that you can enroll in FSA.
2. Use the FSA worksheet to estimate your eligible, uninsured out-of-pocket medical expenses for the plan year.
3. Go to ASI's website: http://pebb.asiflex.com/enrollment/enrollment.htm.
4. Download and complete the 2010 Enrollment Form before midnight on November 30, 2009.
   Note: If you are enrolling in a 2009 FSA—either as a new hire or current employee experience a qualifying life event—see the special instructions at http://pebb.asiflex.com/enrollment/enrollment.htm.
5. Be sure to indicate the University of Washington on the form,
6. Before the end of the enrollment eligibility period, either fax the form to ASI at 1-866-381-9682 or mail the form to:

US Mail Address	UPS, Fedex etc. Address
ASI PO Box 6044 Columbia, MO 65205-6044	ASI 201 W. Broadway, Suite 4C Columbia, MO 65203

DO NOT send the enrollment form to UW Benefits & WorkLife.

Request your FSA funds

After enrollment in the FSA, you don't have to wait for cash to accumulate to use your account. The maximum annual amount you plan to contribute is available throughout your period of coverage. To access your FSA funds, you need to file a reimbursement claim.

Filing a Reimbursement Claim

To request reimbursement from your FSA, take the following steps:

1. Download and complete a FSA Claim Form including the following items with your claim:
   • A receipt, invoice, or bill from your healthcare provider listing the date you received the service, the cost of the service, the type of service, and the person for whom the service was provide, and
   • An Explanation of Benefits (EOB) from your health insurance provider that showing the type of service you received, the date and cost of the service, any uninsured portion of the cost.
   • A written statement of medical necessity from your healthcare provide for services that could be deemed cosmetic.
2. Submit the form to ASI at the following addresses:

US Mail Address	UPS, Fedex etc. Address
ASI PO Box 6044 Columbia, MO 65205-6044	ASI 201 W. Broadway, Suite 4C Columbia, MO 65203

DO NOT send the claim form to the UW Benefits & Work/Life Office.

Claims must be filed by March 31 for expenses incurred during the previous calendar year. Any dollars from the previous year not claimed by March 31 are forfeited as required under the tax code.

Debit Card Option

The FSA Debit Card allows you to make purchases at known health care providers and have the funds deducted directly from your FSA balance with no money out of pocket. The card is swiped like a regular credit card. You will still be required to submit a claim form for the transaction. See "Filing a Reimbursement Claim" section above.

When you sign up for the FSA program, you can print the debit card application directly from ASI's website. Your card will arrive within 7-10 business days of submitting it to ASI. See detailed information about this option.

Receiving your FSA Funds

If you have submitted a claim by completing the paper form, you may choose to have the funds returned to you by check or through direct reimbursement option, whichever you elected.

You should receive your reimbursement within 10 days from the time you mail your properly completed reimbursement request. To avoid delays, be sure to include all the necessary information on the reimbursement form and mail or fax it directly to the FSA administrator.

Direct Reimbursement Option

You have the option to have your FSA reimbursement checks deposited directly into your checking or savings account. You will still receive notification that the claim has been processed. To apply, complete the Direct Deposit form or call ASI Customer Service at 1-800-659-3035.

Continuation of Benefits

Upon leave of absence, lay-off, or termination of employment, you may be eligible to continue your FSA through the end of the leave or calendar year by special arrangement with ASI. For more information, call ASI at 1-800-659-3035.

Note: The Dependent Care Assistance Program (DCAP) may not be continued after layoff or termination of employment.

EXPLORE

Contact Information

Customer Service Center Phone: 1-800-659-3035
Claim Submission Fax: 1-866-381-9682
Customer Service Email: asi@asiflex.com*
ASI Website: http://pebb.asiflex.com/

*Emailed claims will not be accepted.

Eligible Expenses

List of Eligible and Ineligible Expenses

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• HR Contacts

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