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Employee Benefits
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.

What's New

The Employee Benefits and Services Division (EBSD) is pleased to announce the following features:

  • FSA/DCAP Participant Portal
  • Benefit Card
  • Direct Deposit

These new features will become available 7/26/2014. They will allow employees to quickly and easily file claims, upload receipts, and access account information!

To view a short video that provides an overview of the new features, click here.

How the Plan Works

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.

Eligibility

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.

Enrollment

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)
    • Marriage
    • 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.

Contribution Limits

There is an annual maximum contribution of $2,500 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
Be as accurate as possible when estimating the total annual FSA contribution amount. Do not contribute more money into the FSA than will be used, as it is subject to forfeit. Forfeited funds will be applied toward the cost of administering the plan.

Eligible Expenses

When requesting reimbursement for over-the-counter medicines (OTC) or a general health expense, the claim must include the following documentation:

OTC Medicines:

  • 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

General Health:

  • 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.

Claims Reimbursement

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 medicines etc.)
  • 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 requirements.

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.

Run-out 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.

Forms

FSA Enrollment Form
FSA Reimbursement Claim Form
FSA Verification of Medical Necessity Form

Additional Information

Exempt FSA Plan Document
General FSA Plan Document
FSA Notice of Privacy Practice (NOPP)

Resources

FSA DCAP Participant Portal Login
FSA Eligible Medical Expense List
Over-the-Counter Medicines and Products
Frequently Asked Questions (FAQs)
FSA Summary Plan Description (coming soon)

Contact Information

Employee Benefits and Services Division
157 West Fifth Street, First Floor
San Bernardino, CA 92415-0440
Interoffice Mail Code: 0440
e-mail: hrfsadcap@hr.sbcounty.gov
Phone: (909) 387-5787
Fax: (909) 387-5566

 

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