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

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.

*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.

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.

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WageWorks Dependent Care Choice FSA allows you to use pre-taxed dollars toward your child and/or adult day care expenses.

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 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.

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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.
 

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