FLEXIBLE BENEFIT PLAN
Flexible Spending Accounts (FSAs) allow you to set aside
pre-tax payroll deductions to pay for out-of-pocket health
care expenses such as your deductibles, copays and
coinsurance, as well as dependent care expenses.
NOTE: The information in this section does not apply to Fort Lewis College.
This Plan is offered on a voluntary basis and participation may require an administration fee.
When you choose to participate in the Flexible Benefit Plan, your monthly taxable income is reduced.
Dollars elected in the health care spending account are available to you at any time during the Plan Year.
You can claim reimbursement for eligible expenses, incurred while you are active in the plan, up to your
maximum elected amount.
Health Care Spending Account
The maximum amount of reimbursement for health care expenses is $2,550 per Employee, per calendar
year. If you wish to continue to participate in this benefit you must re-enroll in the plan each year.
Through the Health Care Spending Account, eligible out-of-pocket expenses incurred by you, your spouse
and Dependents during the Plan Year include the following items: deductibles, copayments, (non-cosmetic)
dental work, orthodontics, prescriptions, eye care, glasses, LASIK and PRK procedures, contact lenses and
more. Prescribed medications include medications that are also available over the counter as long as
participants have prescriptions from their physicians. Generally, if a medical expense is considered eligible
as a medical deduction on your federal tax return it may be eligible for pre-tax payments within your
Flexible Benefit Plan. Health-related insurance premiums cannot be paid through a Health Care Spending
Account. For a complete list of qualified medical expenses, see www.24hourflex.com.
Expenses for your Eligible Dependents may be reimbursed through this account even if they are not enrolled
in the CHEIBA Trust medical, dental or vision plans. Expenses paid by another insurance plan are not eligible
for reimbursement through the Health Care Spending Account.
HEART Act (Heroes Earnings Assistance and Relief Tax Act of 2008)
If you are a member of a reserve unit and are ordered or called to active duty, then you may be able to
request a Qualified Reservist Distribution (QRD) from your Health Flexible Spending Account (FSA). A QRD is
a taxable cash distribution of amounts from your Health FSA that is not dependent on whether you have
incurred medical expenses. You can only request this distribution if you are ordered or called to active duty
for a period in excess of 180 days or for an indefinite period. You may only request this distribution during
the period beginning on the date of the order or call and ending on the last date that reimbursements could
otherwise be made under the Plan for the Plan Year which includes the date of the order or call.
COBRA Option for the Health Care Spending Account
In the event of a COBRA qualifying event you may be eligible to continue participation in your Health Care
Spending Account through the end of your current Plan Year. This option only applies if you have a positive
balance in your account at the time of your termination or other eligible event. If you elect COBRA you must
continue to make contributions and can submit claims for reimbursement for expenses incurred while you
are on COBRA.
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FLEXIBLE BENEFIT PLAN
Dependent Care Spending Account
You can pay up to $5,000 per family, per calendar year, for child or dependent care necessary to your
employment with pre-tax dollars. When using the Dependent Care Spending Account your expenses must
be incurred during the Plan Year. You are limited to $5,000 per year or to the income of the lesser earning
spouse (whichever is less). If your spouse is disabled or is a full-time student five months or more each year,
then the spouse’s income is considered to be $250 per month if you have one child or dependent or $500
per month if you have two or more children or dependents.
The number of children or dependents does not impact the $5,000 limit. If you are married and filing
separate tax returns, you are limited to $2,500 per spouse, per calendar year. If you wish to continue to
participate in this benefit you must re-enroll in the plan each year.
Eligible expenses must be for children under the age of 13 or for older dependents with a physical or mental
disability requiring supervision so you can work and the individual has gross income less than the exemption
amount. All care expenses must be necessary to employment. Ineligible expenses include payments for
referral services, parenting seminars, tuition expenses including kindergarten, child support payments, and
payments to a spouse or other dependent for the care of the child or dependent. Overnight camp is not an
Under current IRS regulations you must report the care provider’s name, address and Tax ID or Social
Security number on your federal tax return. This requirement is the same for both the pre-tax spending
account and the federal tax credit. You cannot pay your spouse or other dependents to care for your
children or dependents.
The child or Dependent must live in your home on average eight hours per day. Eligible expenses include in-
home care, a child care home, child care center, summer camp, before and after-school programs and adult
If you have a cost change for day care during the Plan Year you may be eligible to change your election. See your
Human Resources/Benefits Office for details.
You can also use a combination of the tax credit and the pre-tax program. However, when a combination is used
you are limited to the tax credit limits for the total dollars allowed.
Expenses paid through a dependent care spending account cannot be claimed as a tax credit on your income tax
return or submitted to any other source for reimbursement.
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FLEXIBLE BENEFIT PLAN
You must enroll for the Health Care Spending Account and the Dependent Care Spending Account on an
annual basis. You may change elections during the Plan Year only when a qualifying status change occurs as
described earlier in this summary and in accordance with IRS rules governing tax qualified flexible benefit
plans. Changes in a daycare provider would allow for a change in the election of the participant. They
would be allowed to stop, increase or decrease their election for this reason. Changes must be requested
within 31 days of the status change and must be approved by the Human Resources/Benefits Office.
"Use it or Lose it" - Health Care and Dependent Care Spending Accounts
You must incur eligible expenses during the Plan Year while you are an active Participant in the plan. All
claims must be received no later than April 15th of the year following the Plan Year. Dollars not claimed by
April 15th will be forfeited unless your employer offers the Roll-Over Option.
For those employers who offer a Roll-Over Option, employees participating in the Health Care Spending
Account may carryover up to $500 in unused funds into the next Plan Year. These funds will
automatically carryover to the next Plan Year if you are still in the plan as of the last day of the current
Plan Year. Please contact your Human Resources/Benefits Office for details on the rollover option.
BASIC PLAN RULES
Health Care and Dependent Care Spending Accounts
All eligible expenses must be incurred after your effective date and during the Plan Year. The incurred date
is considered the date you or your Eligible Dependent received the care, services, medicines, or purchased
Your contributions are elected specifically to one or two accounts. The funds are maintained separately and
cannot be combined for reimbursement purposes. For example, you cannot be reimbursed from your
Health Care Spending Account for dependent care expenses.
During the enrollment process, you must carefully consider your health and child/dependent care needs and
estimate predictable expenses you will incur during the Plan Year. Important - any contributions to these
accounts that are not used for eligible expenses incurred during the Plan Year will be forfeited unless your
employer offers the Roll-Over Option. Plan carefully and set aside dollars only for those expenses you know
you will incur.
You may not change your contribution during the Plan Year except in the case of a qualifying status change
(as described earlier in this summary). Requested election changes must be submitted in writing to the
Human Resources/ Benefits Office within 31 days of the qualifying status change and all approved election
changes must be on account of or corresponding with a change in status that affects eligibility for coverage
under an employer’s plan.
The Defined Contribution Pension Plan retirement benefits are based on the dollars contributed to the plan
over your total years of employment.
These contributions may be based on your taxable wages which are reduced by your participation in the
Flexible Benefit Plan. However, you may be able to increase your voluntary retirement plan contributions to
compensate for this reduction in contributions and reduction in future retirement benefits.
Public Employee Retirement Association (PERA) contributions are not paid on any dollars re-directed
through participation in the Flexible Benefit Plan. PERA retirement benefits are based on your highest
average salary. If you are within your final three years of employment under PERA, you may want to elect
after-tax payments for insurance premiums and decline participation in the spending accounts. Please
contact your Human Resources/Benefits Office for additional information.
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FLEXIBLE BENEFIT PLAN
24HourFlex is your Flexible Benefit Plan Administrator (except for Fort Lewis College). Check with your
Human Resources/Benefits Office regarding administration fees for participation in the Flexible Benefit Plan
For those Employers who offer the debit card, Employees participating in a Health Care Spending Account
may request a Benny Card which will be credited with their plan year elected amount. This card can be used
at most qualified health merchants; for example, pharmacies, doctor’s offices, dental offices, vision centers,
etc. When purchasing services or items with your Benny Card, you may be required to submit receipts to
show these purchases are qualified expenses. This is an IRS requirement.
Spending account reimbursement checks will be written to you personally and mailed to your home
address. You may also set up direct deposit by logging into your individual 24HourFlex account and entering
your banking information.
Health Care Spending Account Required Documentation
You must submit a copy of your provider statement or Explanation of Benefits (EOB) from the insurance
carrier along with your signed claim form when submitting for reimbursement. The following is a list of
The itemized statement or EOB must include the date of service, service provided, family member for
whom the service was provided, amount paid and documentation that the expense was not paid by an
Eligible expenses cannot be paid by an insurance company or other company spending plan
Expenses must be incurred during the Plan Year, while you are an active Participant in the plan
Prescription tags or statement from pharmacy. Cash receipts are not acceptable.
Itemized receipt from store showing over-the-counter qualified expense. Receipt must show name of
item purchased, date, who from and amount.
To be reimbursed for mileage expenses, including driving Dependents to and from medical appointments,
submit your vehicle odometer readings, with the starting and ending mileage and the points of travel
(where you traveled to and from). Include the name of the family member requiring treatment, the reason
and the date of the visit. Sign and date the claim form, then submit it with the proper documentation for
Expenses reimbursed in the Flexible Benefit Plan cannot be claimed as a deduction on your tax return.
Reminder: The definition of qualified medication expenses for purposes of Flexible Spending
Accounts is limited to prescribed medications and insulin. Prescribed medications include
medications that are also available over the counter as long as participants have prescriptions from
Dependent Care Spending Account Required Documentation
Your signed claim form must be accompanied by an itemized statement from the provider. The statement
must include the following information:
name of the Dependent
type of service rendered
name of the provider
date(s) of service
Social Security number or Tax ID number of the provider
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FLEXIBLE BENEFIT PLAN
For your convenience, claims can be submitted electronically at participant.24hourflex.com.
Telephone: ................................................................................................................................... 1-800-651-4855
Email: .................................................................................................................................. firstname.lastname@example.org
Participant Website: .................................................................................................. participant.24hourflex.com
Address:............................................................................................................. 7100 E. Belleview Ave, Suite 300
Greenwood Village, CO, 80111
Website: ............................................................................................................................. www.24hourflex.com
NOTE: This is only an overview of your Flexible Benefit Plan. Ask your Human Resources/Benefits Office
for further details and explanations. If discrepancies are found, depend upon the plan document itself
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