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WageWorks HealthCare Choice Flexible Spending Account With Debit Card
Maximum Annual Election: $5,000
Minimum Annual Election: $300
Waiting Period: None
Health Care Flexible Spending Account Tax-Free Worksheet Illustration
The Health Care Choice Card
Use your card to pay for eligible products
and services. Funds are deducted automatically from your Health Care Choice FSA.
Why
Use the Card
• No claims to file; no need to get
reimbursed
• Simply swipe your card and select "credit"—no PIN required
• Deducts automatically from your Health Care Choice FSA
• Most convenient way to pay for most eligible health care products and services
When
to Use the Card
• Pay for eligible health care products and
services received by you or an eligible dependent during your coverage period.
• Pay for products and services on the day you receive them. Regulations
prohibit use of the card to pay for eligible expenses received in the past or to
be received in the future.
• Your card expires on the expiration date printed on the card or the date you
discontinue coverage, whichever comes first.
Where
to Use the Card
• Doctor and dentist offices, pharmacies,
discount chain and club stores—if their products and services are covered under
your plan.
• At most merchants who sell health care products or services and accept either
Visa or MasterCard debit cards.
How
to Use the Card
• Separate your eligible items from your
non-eligible items at the counter when you shop at pharmacies, drugstores,
supermarkets or club stores.
• Use your Health Care Choice Card to pay for your eligible items, and another
form of payment for the non-eligible items.
• Give your card to the merchant or service provider, or swipe it yourself.
• Select "credit" (No PIN required), and then sign for the transactions.
• Save your receipt or other documentation that describes the items you have
paid for. It may be requested by WageWorks or the IRS to verify you used your
account to pay for eligible products or services.
Additional Information About Using Your Health Care Choice Card
1. You must activate your card before you use it. Simply call (866) 363-4128 and enter the information requested.
2. Use your card for eligible health care expenses only. See chart for a complete list of eligible expenses. This card can only be used in places where health care products and services are likely to be sold.
3. Do not use your card to pay for past or future services. Tax regulations prohibit you from using this card to pay for services you received before your current coverage period or those you plan to receive in the future.
4. Each time you use your card, you authorize that you are paying for eligible expenses incurred by you or an eligible dependent during your current coverage period and that you have not and will not seek reimbursement for these expenses from any other health plan or source.
5. Save all receipts that describe exactly what you paid for with your card. We may ask you to submit these to show you used your card for eligible health care expenses.
6. Debit or credit? Choose credit. Even though this is not a credit card, choose the credit option. Your card has no PIN.
7. Review your monthly statements. They contain important information about your account, including if you are required to verify any purchases you made with the card.
8. Your plan may require you to reimburse your account in the amount of any card purchase if you cannot show the card was used for eligible health care products and services.
How to order additional cards
1. Log on to www.wageworks.com
2. Enter your user name and password (or click on "First-Time User? Register Now" to complete the simple online registration process)
3. Click on the "Health Care" tab
4. Select "Request Additional Card"
5. Provide first name, last name and Social Security Number of the person who will use the card
• The first additional card is provided free
of charge
• There is a charge for the second card
• No more than three cards are available per account (one for you, the employee,
and two for use by your eligible dependents)
If
You Lose Your Card or if it is Stolen
Contact WageWorks immediately at our
toll-free number: (877) 924-3967.
Health Care Pay My Provider
Pay your providers directly from your
Health Care Choice FSA.
Why
Use Pay My Provider
• No claims to file; no need to get
reimbursed
• Works like a bill pay service
• Deducts automatically from your Health Care Choice FSA
• Most convenient way to pay for most recurring eligible health care services
When
to Use Pay My Provider
• Regularly scheduled payments for eligible
services such as orthodontic or chiropractic care
• When your doctor or dentist bills you for the amount not covered by your
health plan
• To pay an invoice for an eligible service you already received and that
expense requires only basic proof of service
• When you need to make a payment of $20 or more
How to Use Pay My Provider
1. Log on to www.wageworks.com
2. Click on the "Health Care" tab
3. Click "Request Pay My Provider"
4. Confirm or enter your email address
5. Enter your provider information
6. Enter patient information
7. Enter your payment amount
8. WageWorks will make the requested payment from your account and mail it directly to your provider
9. WageWorks will send you an email each time a requested payment is made
Health Care Pay Me Back
Get reimbursed from your Health Care Choice
FSA for eligible products and services you pay for out of pocket.
When
to Use Pay Me Back
Some products and services are easier to
pay for first, and then get reimbursed. For example:
• When your provider requires you to pay
before you receive the product or service. Pay for the service as required, and
then file your claim after you have received the service.
• The expense is listed as a "Maybe" in the What’s Covered list, meaning it
requires additional information to get approved.
• You receive a bill from your provider after your health plan pays and your
portion is less than $20, the minimum Pay My Provider payment amount.
How
to Use Pay Me Back
• Pay for your eligible products and
services as you usually do and save your detailed receipt.
• Complete a Health Care Pay Me Back form. You can download a form after you log
in to www.wageworks.com
• Fax your form and appropriate proof of expense to the number indicated on the
form.
• Or, mail your form and photocopies of your proof of expense to the address
indicated on the form.
• Check your claims status online anytime by logging on to
www.wageworks.com.
• All claims (including resubmissions) must be received no later than your Claim
It by date (displayed on your monthly statement) to be eligible for
reimbursement.
Who’s
Covered by Your Health Care Choice FSA?
You can use your Health Care Choice FSA to
pay for health care expenses incurred by the following people (per the new IRS
rules effective 01/01/05) even if they are not covered by your employer’s health
plan:
• Yourself
• Your spouse
• Your qualifying child*
• Your qualifying relative*
*Special rules allow a dependent to be eligible for this plan even when that dependent does not qualify to be claimed as your tax dependent on your tax return form. For more information, go to www.wageworks.com/forms/hcdependents.pdf and contact your personal tax advisor.
what's covered by your health care choice fsa?
|
Product/Service |
Category |
Covered? |
|
Acne treatments (over-the-counter) |
Medical |
Yes |
|
Acupuncture |
Medical |
Yes |
|
Adoption (medical expenses related to) |
Medical |
Yes |
|
Adoption Fees |
N/A |
No |
|
Alcoholism Treatment |
Medical |
Yes |
|
Allergy and sinus medicine and products (over-the-counter) |
Medical |
Yes |
|
Allergy Medication (prescription) |
Pharmacy |
Yes |
|
Allergy Treatments |
Medical |
Yes |
|
Alternative Dietary Supplements (for treatment of a medical condition) |
Medical |
Maybe |
|
Alternative Drugs and Medicines (for treatment of a medical condition) |
Medical |
Maybe |
|
Alternative Healers (for treatment of a medical condition) |
Medical |
Maybe |
|
Ambulance and Emergency Health Services |
Medical |
Yes |
|
Anesthesia (for non-cosmetic purposes) |
Medical |
Yes |
|
Antacid (over-the-counter) |
Medical |
Yes |
|
Antibiotic Ointment (over-the-counter) |
Medical |
Yes |
|
Aspirin or Other Pain Reliever (over-the-counter) |
Medical |
Yes |
|
Asthma Medicines or Treatments (over-the-counter) |
Medical |
Yes |
|
Bandages and Related Items (over-the-counter) |
Medical |
Yes |
|
Birth Control (over-the-counter) |
Medical |
Yes |
|
Birth Control (prescription or other) |
Medical |
Yes |
|
Blood Pressure Monitor |
Medical |
Yes |
|
Body Scans |
Medical |
Yes |
|
Braille Books and magazines (difference in cost only) |
Vision |
Maybe |
|
Breast Pump (to compensate for a medical condition) |
Medical |
Maybe |
|
Breastfeeding Classes |
N/A |
No |
|
Cancer (fixed indemnity, $XX per day) Insurance Premiums |
N/A |
No |
|
Canker and Cold Sore Treatments (over-the-counter) |
Medical |
Yes |
|
Chest Rubs (over-the-counter) |
Medical |
Yes |
|
Child or Newborn Care Instruction |
N/A |
No |
|
Childbirth Classes |
Medical |
Yes |
|
Chiropractic Care |
Medical |
Yes |
|
Chiropractic Office Visit or Treatment |
Medical |
Yes |
|
Christian Science Practitioners |
Medical |
Yes |
|
COBRA Premiums |
N/A |
No |
|
Co-Insurance (dental) |
Dental |
Yes |
|
Co-Insurance (medical) |
Medical |
Yes |
|
Co-Insurance (prescription) |
Pharmacy |
Yes |
|
Co-Insurance (vision) |
Vision |
Yes |
|
Cold and Flu Medicine (over-the-counter) |
Medical |
Yes |
|
Cold Cream (over-the-counter) |
N/A |
No |
|
Compression or Anti-Embolism Socks, Stockings, or Hose |
Medical |
Yes |
|
Condoms and Spermicides |
Medical |
Yes |
|
Contact Lenses, Cleaning Solutions, Etc. |
Vision |
Yes |
|
Contraceptives (prescription or over-the-counter) |
Medical |
Yes |
|
Co-Payment (dental) |
Dental |
Yes |
|
Co-Payment (medical) |
Medical |
Yes |
|
Co-Payment (other) |
Medical |
Yes |
|
Co-Payment (vision) |
Vision |
Yes |
|
Cord Blood Storage (for unidentified future use) |
N/A |
No |
|
Corneal Keratotomy |
Vision |
Yes |
|
Cosmetic Surgery |
N/A |
No |
|
Cough Drops and Sore Throat Lozenges (over-the-counter) |
Medical |
Yes |
|
Cough Syrup (over-the-counter) |
Medical |
Yes |
|
Counseling (for treatment of a medical condition) |
Medical |
Yes |
|
CPR Classes (adult or child) |
N/A |
No |
|
Crutches, Canes, or Like Equipment (purchase or rental) |
Medical |
Yes |
|
Dancing Lessons (for treatment of a medical condition) |
Medical |
Maybe |
|
Deductible for Dental Plan |
Dental |
Yes |
|
Deductible for Medical Plan |
Medical |
Yes |
|
Deductible for Prescription Plan |
Pharmacy |
Yes |
|
Deductible for Vision Plan |
Vision |
Yes |
|
Dental |
Dental |
Yes |
|
Dental Care (for non-cosmetic purposes) |
Dental |
Yes |
|
Dental Co-Payment |
Dental |
Yes |
|
Dental Insurance or Plan Premiums |
N/A |
No |
|
Dental Products (for treatment of a dental condition, not general health) |
Dental |
Maybe |
|
Dental Reconstruction |
Dental |
Yes |
|
Dental Veneers |
Dental |
Maybe |
|
Dentures, Bridges, Etc. |
Dental |
Yes |
|
Diabetic Monitor |
Medical |
Yes |
|
Diagnostic Services |
Medical |
Yes |
|
Dietary Supplements (for treatment of a medical condition) |
Medical |
Maybe |
|
Drug Addiction Treatments |
Medical |
Yes |
|
Drugs (experimental or imported) |
N/A |
No |
|
Drugs (prescription) |
Pharmacy |
Yes |
|
Dylexia Treatment |
Medical |
Yes |
|
Ear Drops and Wax Removal (over-the-counter) |
N/A |
No |
|
Educational Classes or Tuition |
N/A |
No |
|
Electrolysis |
N/A |
No |
|
Emergency Kits (over-the-counter) |
N/A |
No |
|
Exercise Equipment (for treatment of a medical condition) |
Medical |
Maybe |
|
Eye Examinations |
Vision |
Yes |
|
Eye-Related Equipment/Materials |
Vision |
Yes |
|
Eye Surgery or Treatment to Correct Vision |
Vision |
Yes |
|
Eyeglasses (over-the-counter) |
Vision |
Yes |
|
Eyeglasses (prescription) |
Vision |
Yes |
|
Face Lifts |
N/A |
No |
|
Fertility Monitor (over-the-counter) |
Medical |
Yes |
|
Fertility Treatment (for employee, spouse, dependent) |
Medical |
Yes |
|
Fertility Treatment (for non-dependent surrogate) |
N/A |
No |
|
First Aid Kits (over-the-counter) |
N/A |
No |
|
Fitness Programs |
N/A |
No |
|
Flu Shots |
Medical |
Yes |
|
Funeral Expenses |
N/A |
No |
|
Gastrointestinal Medication (over-the-counter) |
Medical |
Yes |
|
Guide Dog (dog, training, care) |
Vision |
Yes |
|
Hair Regrowth Products |
N/A |
No |
|
Hair Removal |
N/A |
No |
|
Hair Transplant |
N/A |
No |
|
Hair Treatments |
N/A |
No |
|
Hand Lotion (over-the-counter) |
N/A |
No |
|
Health Club Dues |
N/A |
No |
|
Health Insurance or Plan Premiums |
N/A |
No |
|
Health Savings Account (HAS) contributions |
N/A |
No |
|
Hearing Aids and Batteries |
Medical |
Yes |
|
Herbal or Homeopathic Medicines (over-the-counter) |
N/A |
No |
|
Hospital (fixed indemnity, $XX per day) Insurance Premiums |
N/A |
No |
|
Hospital Fees |
Medical |
Yes |
|
Hospital Services |
Medical |
Yes |
|
Household Help |
N/A |
No |
|
Illegal Operations or Substances |
N/A |
No |
|
Immunizations |
Medical |
Yes |
|
Infertility Treatment (for employee, spouse or dependent) |
Medical |
Yes |
|
Insulin, Testing Materials and Supplies |
Medical |
Yes |
|
Insurance or Health Plan Premiums |
N/A |
No |
|
Lab (medical) |
Medical |
Yes |
|
Laboratory Fees |
Medical |
Yes |
|
Lactose Intolerance (over-the-counter) |
Medical |
Yes |
|
Lamaze Classes |
Medical |
Yes |
|
Laser Eye Surgery |
Vision |
Yes |
|
Lasik |
Vision |
Yes |
|
Late Payment Fees Charged by Health Care Provider |
N/A |
No |
|
Laxatives (over-the-counter) |
Medical |
Yes |
|
Learning Disability Treatments |
Medical |
Yes |
|
Lice Treatment (over-the-counter) |
Medical |
Yes |
|
Listening Therapy |
Medical |
Yes |
|
Lodging (essential to receive medical care) |
Medical |
Maybe |
|
Long-Term Care Premiums (up to IRS tax-free limit, $490 in 2004) |
N/A |
No |
|
Long-Term Care Services |
Medical |
No |
|
Long-Term Disability Insurance Premiums |
N/A |
No |
|
Magnetic Therapy (over-the-counter) |
N/A |
No |
|
Marriage Counseling |
N/A |
No |
|
Massage Therapy (for treatment of a medical condition) |
Medical |
Maybe |
|
Mastectomy-Related Special Bras |
Medical |
Yes |
|
Maternity Clothes |
N/A |
No |
|
Medical Abortion |
Medical |
Yes |
|
Medical Co-Insurance |
Medical |
Yes |
|
Medical Co-Payment |
Medical |
Yes |
|
Medical Equipment (for treatment of medical condition) and Repairs |
Medical |
Yes |
|
Medical Insurance or Plan Premiums |
N/A |
No |
|
Medical Literature, Books, Pamphlets or Audio |
N/A |
No |
|
Medical Monitoring and Testing Devices |
Medical |
Yes |
|
Medical Records Charges |
Medical |
Yes |
|
Medical Savings Account (MSA) Contributions |
N/A |
No |
|
Medical Supplies (for treatment of a medical condition) |
Medical |
Maybe |
|
Medicare Premiums, Medicare Supplement, and Medicare Alternative Insurance or Plan Premiums |
N/A |
No |
|
Medicines (over-the-counter) |
Medical |
Yes |
|
Medicines (prescription) |
Pharmacy |
Yes |
|
Mileage ($.15 per documented mile for travel to/from eligible health care) |
Medical |
Yes |
|
Modified Equipment (difference in cost only) |
Medical |
Maybe |
|
Monitors and Test Kits (over-the-counter) |
Medical |
Yes |
|
Motion and Nausea |
Medical |
Yes |
|
Nasal Sprays |
Medical |
Yes |
|
Nasal Strips (over-the-counter) |
N/A |
No |
|
No-Show Fees Charged by Health Care Provider |
N/A |
No |
|
Non-Prescription Drugs and Medicines (for non-cosmetic purposes) |
Medical |
Yes |
|
Norplant Insertion or Removal |
Medical |
Yes |
|
Nursing Services (wages and taxes) |
Medical |
Yes |
|
Nutrition Supplements (for treatment of a medical condition) |
Medical |
Maybe |
|
OB/GYN Fees |
Medical |
Yes |
|
Occlusal Guards to Prevent Teeth Grinding |
Dental |
Yes |
|
Occupational Therapy (related to a medical condition or disability) |
Medical |
Yes |
|
Office Visits (medical) |
Medical |
Yes |
|
Office Visits (chiropractic) |
Medical |
Yes |
|
Office Visits (dental) |
Dental |
Yes |
|
Office Visits (psych/therapy) |
Medical |
Yes |
|
Office Visits (vision) |
Vision |
Yes |
|
Operations (for non-cosmetic purposes) |
Medical |
Yes |
|
Optometrist/ Ophthalmologist Fees |
Vision |
Yes |
|
Oral Care (over-the-counter) |
N/A |
No |
|
Organ Transplants (recipient and donor) |
Medical |
Yes |
|
Ortho Keratotomy |
Vision |
Yes |
|
Orthodontia |
Dental |
Yes |
|
Orthodontia (braces and retainers) |
Dental |
Yes |
|
Over-the-Counter (eligible medical) |
Medical |
Yes |
|
Over-the-Counter Acne Treatments |
Medical |
Yes |
|
Over-the-Counter Allergy and Sinus Medicine |
Medical |
Yes |
|
Over-the-Counter Antacid |
Medical |
Yes |
|
Over-the-Counter Antibiotic Ointment |
Medical |
Yes |
|
Over-the-Counter Aspirin or Other Pain Reliever |
Medical |
Yes |
|
Over-the-Counter Asthma Medicines or Treatments |
Medical |
Yes |
|
Over-the-Counter Bandages and Related Items |
Medical |
Yes |
|
Over-the-Counter Canker and Cold Sore Treatments |
Medical |
Yes |
|
Over-the-Counter Chest Rubs |
Medical |
Yes |
|
Over-the-Counter Cold and Flu Medicine |
Medical |
Yes |
|
Over-the-Counter Cold and Flu Prevention |
Medical |
Yes |
|
Over-the-Counter Cold Cream |
N/A |
No |
|
Over-the-Counter Cough Drops and Sore Throat Lozenges |
Medical |
Yes |
|
Over-the-Counter Cough Syrup |
Medical |
Yes |
|
Over-the-Counter Health Care Products (eligible) |
Medical |
Yes |
|
Over-the-Counter Health Care Products (non-eligible) |
N/A |
No |
|
Over-the-Counter Medication |
Medical |
Yes |
|
Over-the-Counter Products for Dental Ailments |
Dental |
Yes |
|
Over-the-Counter Products for General Dental Care |
N/A |
No |
|
Over-the-Counter Vision Products |
Vision |
Yes |
|
Ovulation Monitor (over-the-counter) |
Medical |
Yes |
|
Oxygen |
Medical |
Yes |
|
Pain Reliever (over-the-counter) |
Medical |
Yes |
|
Personal Use Items (toothbrush, toothpaste, etc.) |
N/A |
No |
|
Physical Exams |
Medical |
Yes |
|
Physical Therapy |
Medical |
Yes |
|
Pregnancy Tests (over-the-counter) |
Medical |
Yes |
|
Prescription Co-Insurance |
Pharmacy |
Yes |
|
Prescription Co-Payment |
Pharmacy |
Yes |
|
Prescription Drugs (for non-cosmetic purposes) |
Pharmacy |
Yes |
|
Prescription Drugs for cosmetic purposes |
N/A |
No |
|
Prescription Drugs for Hair Regrowth |
N/A |
No |
|
Prescription Insurance or Plan Premiums |
N/A |
No |
|
Propecia (for treatment of a medical condition) |
Medical |
Maybe |
|
Prosthesis |
Medical |
Yes |
|
Psych/Therapy |
Medical |
Yes |
|
Psychiatric Care |
Medical |
Yes |
|
Psychoanalysis |
Medical |
Yes |
|
Psychologist Fees |
Medical |
Yes |
|
Radial keratotomy (RK) |
Vision |
Yes |
|
Reading Glasses (over-the-counter) |
Vision |
Yes |
|
Reconstructive Surgery (following accident or medical procedure or condition) |
Medical |
Maybe |
|
Removal of Benign Mole, Cyst or Tumor |
Medical |
Yes |
|
Retin-A (for non-cosmetic purposes) |
Medical |
Maybe |
|
Rogaine or Other Hair Regrowth Medications (even is prescribed) |
N/A |
No |
|
Rx (prescription) |
Pharmacy |
Yes |
|
Smoking Cessation (programs/counseling) |
Medical |
Yes |
|
Smoking Cessation Drugs (prescription) |
Medical |
Yes |
|
Smoking Cessation Gum or Patches (over-the-counter) |
Medical |
Yes |
|
Special Equipment |
Medical |
Maybe |
|
Special Foods (gluten-free, salt-free or other for treatment of medical condition) |
Medical |
Maybe |
|
Special School (for mental and physical disabilities) |
Medical |
Maybe |
|
Speech Therapy |
Medical |
Yes |
|
Sterilization |
Medical |
Yes |
|
Student Health Fees (for dental services) |
Dental |
Yes |
|
Student Health Fees (for medical services) |
Medical |
Yes |
|
Student Health Fees (for prescriptions) |
Pharmacy |
Yes |
|
Student Health Fees (for vision services) |
Vision |
Yes |
|
Sunglasses (over-the-counter) |
N/A |
No |
|
Sunglasses (prescription) |
Vision |
Yes |
|
Sunscreen (over-the-counter) |
N/A |
No |
|
Supplies (for treatment of a medical condition) |
Medical |
Maybe |
|
Surgery (for non-cosmetic purposes) |
Medical |
Yes |
|
Swimming Lessons (for treatment of a medical condition) |
Medical |
Maybe |
|
Teeth Bleaching or Whitening |
N/A |
No |
|
Teeth Grinding Prevention Devices |
Dental |
Yes |
|
Therapy (for treatment of a medical condition) |
Medical |
Yes |
|
Toothpaste, toothbrush, floss, etc. |
N/A |
No |
|
Transgender Treatments/Surgery |
N/A |
No |
|
Transportation, Parking and Relative Travel Expenses (essential to receive medical care) |
Medical |
Maybe |
|
Tubal Ligation |
Medical |
Yes |
|
Tuition or Educational Classes |
N/A |
No |
|
UV Protection Clothing |
N/A |
No |
|
Vaccinations |
Medical |
Yes |
|
Varicose Vein Removal Surgery |
Medical |
Yes |
|
Vasectomy |
Medical |
Yes |
|
Viagra and Similar Prescription Medications |
Pharmacy |
Yes |
|
Vision |
Vision |
Yes |
|
Vision Co-Insurance |
Vision |
Yes |
|
Vision Co-Payment |
Vision |
Yes |
|
Vision Insurance or Plan Premiums |
N/A |
No |
|
Vitamins (over-the-counter, for general health purposes) |
N/A |
No |
|
Vitamins (prescription) |
Pharmacy |
Yes |
|
Weight Loss Counseling |
Medical |
Maybe |
|
Weight Loss Foods |
N/A |
No |
|
Weight Loss Program (to improve or maintain general health) |
N/A |
No |
|
Weight Loss Program (for treatment of a medical condition) |
Medical |
Maybe |
|
Wheelchair and Repairs |
Medical |
Yes |
|
X-Ray (medical) |
Medical |
Yes |
|
X-Ray Fees (dental) |
Dental |
Yes |
|
X-Ray Fees (medical) |
Medical |
Yes |
*The HSA-Compatible FSA (when available and if applicable) does not cover any Medical or Pharmacy expenses. Log on to www.wageworks.com to learn more about the HSA-Compatible FSA Option.
Health Care Expenses
You can pay for eligible expenses that
require Basic proof using your Health Care Choice Card, Pay My Provider or Pay
Me Back. For expenses requiring more than Basic proof, you will need to use an
alternate payment method and then file a Pay Me Back claim - along with the
required additional information - to get reimbursed.
Proof of Expense
BASIC: Any product or service with "Yes"
under "Covered?"
You must provide proof for each expense listed on
your Pay Me Back claim form. Your proof should be appropriate for the type of
expense:
• Pharmacy receipt for prescriptions and
other pharmacy purchases
• Doctor’s receipt for office visit
• Explanation of Benefits (EOB) from your insurance or health plan, for covered
medical and dental expenses
• Bill or invoice from doctor or dentist for expenses not covered by your
insurance or health plan
• Payment contract, monthly payment coupon or statement from your orthodontist
• Receipt from your optometrist or other medical service provider
BASIC +: Any product or service with
"Maybe" under "Covered?" (that is not a special or modified item).
Same as Basic, plus a written statement from your
provider indicating (1) the diagnosis and (2) the medical necessity of the
product or service.
BASIC ++: Any product or service with
"Maybe" under "Covered?" that is a special or modified item.
Same as Basic+, plus proof of difference in cost:
(1) the cost of standard, unmodified item and (2) the cost of special or
modified item. The reimbursable amount is the difference between these two.
Health Care Choice FSA Rules
The following rules are dictated by IRS
regulations:
1. By enrolling in the plan, you authorize your employer to deduct your election amount from your paycheck on a pre-tax basis.
2. Your account can be used to pay for eligible expenses incurred while you are enrolled during the plan year. Expenses are considered incurred on the day of service, not when you are billed or pay.
3. Your account cannot be used to pay for expenses incurred before or after you are covered under this plan or for services you plan to receive in the future.
4. Your account can only be used to pay for medically necessary and eligible health care expenses for which you have not and will not seek reimbursement from any other health plan or source.
5. Each time you use the card, you authorize that you are paying for eligible expenses incurred by you or an eligible dependent during your current coverage period and that you have not and will not seek reimbursement for these expenses from any other health plan or source.
6. You cannot take a deduction or a tax credit on your tax return form for any health care expense paid for through this account.
7. You are responsible for maintaining documentation (e.g. detailed receipts) to verify your expenses (the nature of each expense, the amount and the date incurred). Keep these with your other important tax papers for the calendar year. You may be requested to submit these per your monthly statement.
8. You will have until your Claim It by date to get reimbursed from your account (by filing a Pay Me Back claim form) for eligible expenses incurred before your Spend It by date. Both dates are displayed online and on your monthly account statement and subject to change should you stop participating in this plan before the end of the plan year.
9. Be sure to incur eligible expenses totaling your election amount before your Spend It by date. Any balance remaining in your account after your Claim It by date cannot be rolled over or paid out to you and will be forfeited.
10. If you want to participate during the next plan year, you will need to re-enroll during the open enrollment period. We are not allowed to keep you enrolled or automatically re-enroll you.
11. You may be able to enroll, change or cancel your enrollment during the plan year if you have experienced a qualified change as defined and if allowed by your employer’s plan.
12. Participation in this plan reduces your taxable income and may affect other compensation-based benefits such as life, disability and Social Security.
13. Consult a tax advisor if you have any questions regarding your personal situation.
WageWorks Dependent Care Choice Flexible Spending Account
WageWorks Dependent Care Choice FSA allows you to use pre-taxed dollars toward your child and/or adult day care expenses.
Maximum Annual Election: $5,000
Minimum Annual Election: None
Waiting Period: None
Dependent Care Flexible Spending Account Worksheet
Dependent Care Pay My Provider
Pay your providers directly from your
Dependent Care Choice FSA.
Why
Use Pay My Provider
• No claims to file; no need to get
reimbursed
• Works like a bill pay service
• Deducts automatically from your Dependent Care Choice FSA
• Most convenient way to pay for eligible dependent care services on a monthly
basis
When
to Use Pay My Provider
• You have predictable dependent care
expenses each month
• Your dependent care provider does not require payment in advance (before the
first of the month) and will accept monthly payments
How to Use Pay My Provider
1. Log on to www.wageworks.com
2. Click on the "Dependent Care" tab
3. Click "Request Pay My Provider"
4. Confirm or enter your email address
5. Enter your provider information
6. Enter dependent information
7. Enter your payment amount
8. WageWorks will make the requested payment from your account and mail it directly to your provider
9. WageWorks will send you an email each time a requested payment is made
Dependent Care Pay Me Back
Get reimbursed from your Dependent Care
Choice FSA for eligible expenses you pay for out of pocket.
When
to Use Pay Me Back
Some expenses are easier to pay for first,
and then get reimbursed. For example:
• When your provider requires you to pay in
advance (before the first of the month during which services will be provided).
Pay for the services as required, and then file your claim after you have
received the service.
• Your provider wants to get paid other than monthly
• Your expenses vary month to month
How
to Use Pay Me Back
• Pay your dependent care provider as you
usually do and save your detailed receipt (or have your dependent care provider
sign your claim form).
• Complete a Dependent Care Pay Me Back form, which can be downloaded from the
Print Forms page at www.wageworks.com.
• Fax your form and proof of expense to the toll-free number indicated on the
form.
• Or, mail your form and photocopies of your proof of expense to the address
indicated on the form.
• Check your claims status online anytime by logging on to
www.wageworks.com.
• All claims (including resubmissions) must be received no later than your Claim
It by date (displayed on your monthly statement) to be eligible for
reimbursement.
Who’s
Covered by Your Dependent Care Choice FSA?
You can use your Dependent Care Choice FSA
to pay for work-related care for your eligible dependents:
• Your qualifying child—under the age of 13
• Your spouse, or qualifying child or relative—who is physically or mentally
incapable of self care*
*Special rules allow a dependent to be eligible for this plan even when that dependent does not qualify to be claimed as your tax dependent on your tax return form. For more information, go to http://www.wageworks.com/forms/dcdependents.pdf and contact your personal tax advisor.
What’s Covered by Your Dependent Care Choice Account?
All of the following must be true about the
dependent care:
• The care is provided while you work or to enable you to work. If you are married, the care is provided while your spouse also works or to enable your spouse to work or go to school full-time (at least five months a year) or while your spouse is incapable of self-care.
• The care may be provided by a relative or a non-relative, but is not provided by your child under the age of 19 (tax dependent or not) or another tax dependent.
• Your care provider conforms to state and local laws (including being licensed, if required) and is able to provide you with his/her Social Security or Tax ID number. You will need this to request a payment or file a claim.
Proof
of Expense
You must provide proof for each dependent
care service listed on your Pay Me Back claim form. Your proof should be
appropriate for the type of expense:
• Your provider’s signature in the designated
area on your claim form
• Photocopy of your cancelled check (front and back)
• Formal or informal statement or bill from your provider
|
Dependent Care Services |
Covered? |
|
Adult Day Care Center |
Yes |
|
After School Program |
Yes |
|
Au Pair |
Yes |
|
Babysitting (not work-related, for other purpose) |
No |
|
Babysitting (work-related, in your home or someone else’s) |
Yes |
|
Babysitting by your relative who is not a tax dependent (work-related) |
Yes |
|
Babysitting by your tax dependent (work-related or for other purposes) |
No |
|
Before- or After-School Program |
Yes |
|
Child Care |
Yes |
|
Custodial Elder Care (not work-related, for other purpose) |
No |
|
Custodial Elder Care (work-related) |
Yes |
|
Dance Lessons |
No |
|
Day Nursing Care |
No |
|
Dependent or Elder Care (while you work, to enable you to work or look for work) |
Yes |
|
Educational Services (for preschool) |
Yes |
|
Educational, Learning or Study Skills Services |
No |
|
Elder Care (in your home or someone else’s) |
Yes |
|
Extended Care (supervised program before or after regular school hours) |
Yes |
|
Household Services (housekeeper, maid, cook, etc.) |
No |
|
Housekeeper who cares for child (only portion of payment attribute to work-related child care) |
Yes |
|
Kindergarten tuition |
No |
|
Language Classes |
No |
|
Medical Care |
No |
|
Nanny |
Yes |
|
Nursery School |
Yes |
|
Nursing Home Care |
No |
|
Payroll Taxes Related to Eligible Care |
Yes |
|
Piano Lessons |
No |
|
Preschool |
Yes |
|
Private School Tuition (for kindergarten and up) |
No |
|
School Tuition |
No |
|
Senior Day Care |
Yes |
|
Sick Child Care |
Yes |
|
Sleep-Away Camp |
No |
|
Summer Day Camp |
Yes |
|
Transportation To and From Eligible Care |
No |
|
Tutoring |
No |
Dependent Care Choice FSA Rules
The following rules are dictated by IRS
regulations:
1. By enrolling in the plan, you authorize your employer to deduct your election amount from your paycheck on a pre-tax basis.
2. Your account can be used to pay for eligible services incurred while you are enrolled during the plan year. Expenses are considered incurred on the day of service, not when you are billed or pay.
3. Your account cannot be used to pay for expenses incurred before or after you are covered under this plan or for services you plan to receive in the future. If you must pay for a service in advance, you can file a claim for reimbursement only after you begin to receive that service.
4. You will need to provide the Social Security or Tax ID number of your dependent care provider to request payments or get reimbursed from your Dependent Care Choice FSA. You will also be required to report it to the IRS when you file your tax return form.
5. Your account can only be used to pay for work-related and eligible dependent care expenses for which you have not and will not seek reimbursement from any other plan or source.
6. You cannot take a deduction or a tax credit on your tax return form for any dependent care expense paid for through this account.
7. You are responsible for maintaining documentation (e.g. detailed receipts) to verify your expenses (the nature of each expense, the amount and the date incurred). Keep these with your other important tax papers for the calendar year.
8. You will have until your Claim It by date to get reimbursed from your account (by filing a Pay Me Back claim form) for eligible expenses incurred before your Spend It by date. Both dates are displayed online and on your monthly account statement and subject to change should you stop participating in this plan before the end of the plan year.
9. Be sure to incur eligible expenses totaling your election amount before your Spend It by date. Any balance remaining in your account after your Claim It by date cannot be rolled over or paid out to you and will be forfeited.
10. If you want to participate during the next plan year, you will need to re-enroll during the open enrollment period. We are not allowed to keep you enrolled or automatically re-enroll you.
11. You may be able to enroll, change or cancel your enrollment during the plan year if you have experienced a qualified change as defined and if allowed by your employer’s plan.
12. Participation in this plan reduces your taxable income and may affect other compensation-based benefits such as life, disability and Social Security.
13. Consult a tax advisor if you have any questions regarding your personal situation.
WageWorks Flexible Spending Account - General Information
How to Activate your Card
How much should I set aside per year?
What are my tax savings?
Please remember as required by law, any money in your Health Care or Dependent Care Account not used by the end of the plan year will be forfeited Therefore, it is in your best interest to be conservative when estimating your contribution. But keep in mind that your tax savings may more than make up for any extra dollars you leave in your account at the end of the year. If you are in doubt about an expense, please contact WageWorks for assistance.
Also, in line with Internal Revenue Service guidelines, you can change your election if you have a qualifying status change during the plan year. This includes change in legal marital status, change in number of tax dependents, termination or commencement of employment, dependent satisfies or ceases to satisfy dependent eligibility requirements, or a judgment, decree or order. However, the adjustment in your election must be relevant to the change in status and the requested election change has to be in line and consistent with the event. All requests must be submitted to WageWorks Corporation for approval.
The
WageWorks Web Site
Manage your account and get help
conveniently online.
You
can do all this online anytime
• View your account activity and balance
• Check status of claims and payments
• Download claim forms
• Update your contact information
• Request Pay My Provider payments
• Order an additional card
• Get help
If
you have not yet registered
Complete the simple online registration
process:
1. Go to www.wageworks.com and click on "First-Time User? Register Now".
2. Enter the information requested so we can identify you.
3. Confirm or update the contact information in your Profile.
4. Review the User Agreement and confirm your acceptance.
If
you have already registered
Go to
www.wageworks.com and enter your user name and password.
If
you don’t have Internet access
Call us at (877) 924-3967. Our automated
voice response system can assist you around the clock. Customer service
representatives are available during normal business hours.