Flexible Spending Accounts (FSAs), administered by [FSA Carrier], allow you to set aside pre-tax dollars to pay for eligible health and dependent care expenses. As an eligible employee, you may choose to enroll in one or both Flexible Spending Accounts. Each year, you must elect the annual amount you want to contribute to each account. Your contributions will be deducted pre-tax from your paycheck which can help reduce your taxable income.
Health Care FSA – IRS Annual Maximum $x: Your Health Care FSA will reimburse you for eligible expenses that you, your spouse[/domestic partner], and your children incur during the plan year. The entire annual amount you elect can be used at any time during the plan year even though your contributions are deducted each paycheck. When you incur an eligible expense, you can use your [FSA Carrier] debit card or pay out-of-pocket and submit a reimbursement request with documentation.
Eligible expenses include copays, coinsurance, deductibles, orthodontia, glasses/contact lenses, and much more. For a complete list, refer to IRS Publication 502: Medical and Dental Expenses, available at www.irs.gov/publications.
[Note: if you are enrolled in the HDHP with HSA, you are not eligible to participate in the Health Care FSA.]
Limited Purpose FSA – IRS Annual Maximum $x: HDHP with HSA participants are eligible to participate in the Limited Purpose Health Care FSA to set aside pre-tax dollars for eligible dental and vision expenses only.
Dependent Care FSA – IRS Annual Maximum $x: Your Dependent Care (or daycare) FSA lets you use “before-tax” dollars to pay daycare expenses for children age 12 and under, or for elder dependents unable to care for themselves. The care must be necessary for you and your spouse to remain employed. Care may be provided through live-in care, babysitters, or licensed daycare centers. Unlike the Health Care FSA, you can be reimbursed only up to the amount available in your account after your payroll contributions.