Medical Expense Reimbursement (FSA) Plan
The County offers you a great way to save money by paying for certain medical care
expenses with pre-tax dollars. The FSA plan is convenient and easy to use.
Annual Limits Increased
The IRS announced that the annual maximum contribution for flexible spending accounts
(FSA) increased from $2,500 to $2,550. If an employee’s MOU, Compensation
Plan, Salary Ordinance, or Employment Contract allows for contributions up to the
Internal Revenue Code (IRC) annual maximum, the employee may elect to contribute
up to $2,550 for plan year 2015-16.
Roll Over Implemented
In 2014 the IRS issued a new ruling that allows employers to roll over up to $500
of participant funds remaining in their FSA Account at the end of each plan year.
Plan participants must enroll in the next plan year to be eligible for the roll over.
For a complete list of eligible groups,
Existing participants: If in an eligible group, up to
$500 of funds remaining at the end of the 2014-15 FSA plan year will automatically
roll over to the 2015-16 FSA plan year upon a confirmed enrollment. Any unused amounts
in excess of $500 for 2014-15 will be forfeited.
New Participants: This roll over provision will automatically
be applied to eligible plan participants who make an FSA election beginning in the
2015-16 plan year.
How the Plan Works
To view a short video that provides an overview of the plan features that are available,
With an FSA, employees elect to set aside a portion of their biweekly salary before
taxes are calculated and taken out. The money that is set aside is placed into the
employee’s account, from which reimbursement for qualifying medical care expenses
that the participant, their spouse or eligible dependent(s) incur.
Employees are eligible to participate in an FSA if they are covered under a Memorandum
of Understanding, Compensation Plan, Employment Contract, or Contract with an entity
that expressly provides eligibility for an FSA.
Per IRS regulations, an employee’s election is irrevocable. Employees may
not revoke or change their election for the remainder of the Plan Year unless a
Section 125 qualifying mid-year Change-in-Status Event is experienced.
Employees may enroll in an FSA:
- During the annual Open Enrollment period each year
- Within sixty (60) days of a Section 125 Qualifying Change-in-Status Event. The requested
FSA election change must be consistent with the event. This may include but is not
limited to the following midyear Change-in-Status Events:
- Commencement of County employment (New Hire)
- Hired into a position that makes you newly eligible to participate in the plan or
changes your benefits (e.g. employer match)
- Divorce or legal separation
- Death of spouse or dependent
- Birth or adoption of a child or placement for adoption/guardianship
- Termination of spouse's employment
- Commencement of spouse's employment
The requested FSA election change must be consistent with the event. For more information
regarding midyear Change-in-Status Events, refer to the
Cafeteria Plan/Section 125 webpage.
FSA plan elections are only valid for the current plan year. Plan participants must
elect to enroll each year in order to continue participation.
ThereThere is an annual maximum contribution of $2,550 pursuant to IRS regulations.
The minimum and maximum contribution amounts correspond with the employees bargaining
unit allowable contributions, which may not coincide with the IRS maximum. Please
refer to the appropriate Memorandum of Understanding, Exempt Compensation Plan,
Salary Ordinance, or Contract for specific minimum and maximum contribution limits.
Use It or Lose It and Roll Over Provisions
Be as accurate as possible when estimating the total annual FSA contribution amount.
If you are in an eligible group/unit, you will be allowed to roll over up to $500
of unused funds at the end of the plan year. Do not contribute more money into the
FSA than will be used or rolled-over, as it is subject to forfeit. Forfeited funds will be applied
toward the cost of administering the plan.
When requesting reimbursement for over-the-counter medicines (OTC) or a general
health expense, the claim must include the following documentation:
- A legal prescription for the OTC medicines. Prescription must include date issued,
patient name, provider’s address and license number, medication name, duration
of prescription including recommended dosage or number of refills
- An FSA Verification of Medical Necessity Form, also referred to as a Letter of Medical
Necessity (LMN) completed by a provider establishing that a specific product and/or
service is medically necessary to cure, mitigate, treat, or prevent a disease and
will be primarily used to alleviate or prevent a physical or mental defect or illness.
To view a list of eligible expenses, refer to the
FSA Eligible Medical Expense List.
All claims for reimbursement are subject to review and require both a claim reimbursement
form and copies of supporting documentation.
Employees have the option to file claims either electronically or manually.
- Electronic: Submit claim and upload supporting documentation (e.g. receipts) online
via the FSA/DCAP Participant Portal. If claiming mileage online, participant must
upload a print out of an online map source (e.g. mapquest) that includes the starting
and ending destination points and total miles traveled.
- Manual: Submit paper reimbursement claim form and copies of supporting documentation.
If claiming mileage, the mileage expense worksheet section of the Medical Expense
Reimbursement (FSA) Plan Claim form must be completed.
Claimed expenses must clearly indicate for whom the expense(s) is incurred, be itemized
per individual and should not be listed as a combined expense. Supporting documentation
from the provider, vendor, or merchant (independent third parties*) should clearly
demonstrate the information listed on the claim form in order for EBSD to substantiate
claimed expenses. For additional information on submitting claims, please refer
to the FSA Summary Plan Description.
Claims for reimbursement shall contain the following:
- Date of service(s) or sale(s)
- For services/treatment (e.g. office visit), list the date employee or eligible dependent
incurred service/treatment from a provider. Do not list the date paid for the service
- For sales, list the date product was purchased from a merchant or vendor
- Amount claimed for reimbursement of service/treatment or sale incurred
- Indicate the amount paid or billed for the services received or product purchased
- Provider or merchant name
- Expense Category (e.g. medical expense, dental, vision, etc.)
- Type of Expense (e.g. office visit, orthodontic, prescription eyeglasses, over-the-counter
- Name of person who the expense (e.g. treatment/service/sale) was incurred
In addition to the above, supporting documentation from the provider, vendor, or
merchant (e.g. receipt, statement, or bill) must include the following:
- Description of service or product rendered
- Payment received for expense
- Amount paid to other party (e.g. insurance) for expense
- For manual claims in which mileage has been claimed, a print out of an online map
source (e.g. mapquest) that includes the starting and ending destination points
and total miles traveled
*Note: Canceled checks to providers, vendors, or merchants are not sufficient as
stand-alone documentation, as they do not satisfy the independent third party documentation
The methods to obtain reimbursement for eligible medical care expenses from an FSA
account are as follows:
- Benefit Card: Employees have the ability to access FSA account funds directly at
the point of service using the Benefit Card. This will commonly be referred to as
a "Benny" card. The card allows employees to obtain real time reimbursement
for expenses that are able be auto substantiated without having to file a claim
form or supporting documentation. Select expenses are able to be reimbursed at point
of sale or service, but may require additional documentation in order to be approved.
- Mileage claims for eligible medical expenses that were reimbursed via the Benefit
Card must be submitted using the Medical Expense Reimbursement (FSA) Plan claim
form to obtain reimbursement.
Note: If you participate in both the County's Medical Expense Reimbursement (FSA)
Plan and the Dependent Care Assistance Plan (DCAP), account funds will be accessible
on the same Benefit Card. For more information, see Frequently Asked Questions.
- Direct Deposit and Checks: In accordance with the County’s Direct Deposit Policies,
FSA reimbursements will be issued via Direct Deposit. FSA claim reimbursement will
be deposited in the employee’s balance account on file with EMACS. Employees
can view their designated balance account via EMACS – Self Service or the FSA/DCAP
Participant Portal. In the case of unforeseen circumstances that impact the account
(e.g. identity theft), employees will be able to request that funds be issued via
check for the duration of one pay period.
Claims for eligible expenses incurred within the plan year must be submitted for
reimbursement no later than ninety (90) days after the end of the plan year.
NOTE: This webpage contains only a summary and partial listing of FSA Plan benefits,
terms, conditions, exclusions and limitations. For a full and complete listing,
please refer to the appropriate plan document. If any differences appear between
this summary and the plan document, the information in the plan document shall govern.
FSA Enrollment Form
FSA Reimbursement Claim Form
FSA Verification of Medical Necessity Form
FSA Plan Document
FSA Notice of Privacy Practice
DCAP Participant Portal Login
FSA Eligible Medical Expense List
Medicines and Products
Frequently Asked Questions (FAQs)
Employee Benefits and Services Division
157 West Fifth Street, First Floor
San Bernardino, CA 92415-0440
Interoffice Mail Code: 0440
Phone: (909) 387-5787
Fax: (909) 387-5566