Flexible Spending Accounts - Allegiance Flex Advantage

What is a Flexible Spending Account?

A Flexible Spending Account (FSA) is a tax-free account that allows you to use pre-tax dollars to pay for your out-of-pocket prescriptions, medical, dental, vision or childcare expenses. As a benefits eligible employee, you can enroll in both a Health Care Spending Account and a Dependent Care Spending Account.

There are two great advantages to enrolling:

1. You can pay for your eligible expenses with pre-tax dollars
2. You will lower the taxes taken out of your pay

---

What are the deadlines that I need to be aware of?

Important Note — Use It Or Lose It

The services or expenses that you are claiming for either the Healthcare FSA or Dependent Care FSA must occur during the plan year, April 1, 2012 - March 31, 2013, AND be submitted to Allegiance before the deadline, June 30, 2013. Any unclaimed dollars remaining in your account will be forfeited!

For this reason, it is important to remember that when you enroll, you enroll for the entire plan year, so please plan accordingly. You can use a tax savings calculator to help you decide what amount to elect.

Back to the top

---

What expenses can I claim?

Health CareSpending Account

A health care FSA allows you to use pre-tax money to pay for essential health care services that are not covered, or are partially covered by your medical and dental insurance plans. It also reimburses many other expenses and services that are not covered by insurance, such as over-the-counter medications, massage therapy, chiropractic work and many more.

• Detailed list of qualified health care expenses

Limit: The plan year maximum contribution limit for the health care FSA is $2,500. If your spouse also has a healthcare FSA, your individual contribution limit is still $2,500.

---

Dependent Care Spending Account

A dependent care FSA creates a tax break for childcare or elder care expenses that make it possible for you to work or attend school full-time.

• Detailed list of qualified dependent care expenses
• An Employee’s Guide to Dependent Care Assistance Programs

Limit: The maximum contribution limit for the dependent care FSA is limited by the IRS. They allow no more than $5,000 per household ($2,500 if you are married and file a separate tax return) be set aside in a calendar year.

Back to the top

---

When can I sign up and when is it effective?

You may enroll:

• Within 31 days of your initial date of hire. The account goes into effect the first day of the month following your enrollment.
• During Open Enrollment. The account becomes effective the first day of April. You must actively re-enroll in the FSA program each year to take advantage of the tax savings.
• Within 31 days of, and consistent with, a qualifying event. The account goes into effect the first of the month following the qualifying event.

How do I enroll?

We make it very easy for you to save by offering payroll deductions. If you are enrolling as a new employee or during open enrollment, please complete this form

If you would like to make a mid-year change, consistent with a qualifying event, please complete this form.

Back to the top

---

How do I get reimbursed from my account?

You can submit your claims online!

Allegiance processes claims daily and will process and pay your claims within 2-3 business days following receipt. Making sure that your claim forms are complete will speed up your refund. Reimbursement checks are mailed to your home or can be sent via direct deposit to your savings or checking account. Authorizing payments into your bank account by direct deposit will speed up your reimbursement payment.

• All of Allegiance’s Flexible Spending Account Forms

Debit Card Option

You have the option to elect a debit card as a part of your flex plan to pay for your medical and/or dependent care expenses. Documentation for the expense may be required, and should be saved for all debit card transactions.

• Additional Debit Card Information

Healthcare FSA

You can start submitting requests as soon as services are provided, but eligible expenses can only be incurred on, or after, the first day of your plan year. You may submit reimbursement requests as frequently, or infrequently, as you prefer. For the Health Care FSA, the full annual contribution amount is available on the date your enrollment begins.

Complete a Healthcare FSA claim form and include documentation from an independent third party that includes:

1. Date(s) of service (please note this is different from payment or billing date)
2. Provider information
3. Description of the service
4. Amount Charged
5. The name of the person for whom the service was provided

Dependent Care FSA

You are allowed to be reimbursed only up to what you have had deducted from your paycheck at that point for the Dependent Care FSA. Requests in excess of this amount will be reimbursed as additional deductions are taken from your paycheck.

Complete a Dependent Care FSA claim form and either:

A. Attach a receipt from the provider that includes:

1. The date of dependent care services
2. Provider information
3. Description of the service
4. Amount charged
5. The name of the person(s) for whom the service was provided

OR

B. Complete the claim form and have the dependent care provider sign the affidavit section on this form. No additional documentation or receipts are required if the provider signs this section.

Back to the top

---

Who do I contact if I have questions?

Your Flexible Spending Accounts are administered by Allegiance, please contact Allegiance directly to:

• Check on the status of a submitted claim
• Change your address
• Check on your balance

Hours:	8:00 a.m. to 5:00 p.m.
Phone:	877-424-3570
Claims Fax:	877-424-3539
Email:	flex-inquire@askallegiance.com
Website:	www.allegianceflexadvantage.com
Address:	2806 S. Garfield St. P.O. Box 4346 Missoula, MT 59806
Check your account:	Log in to your online account (your current flex balance can be found in the “Reimbursement Accounts” section)

For more details on your FSA plan, please see the Summary Plan Description Book. (25 pgs)

Back to the top