Page 11 - 2022 Benefit Guide Fives Inc

Flexible Spending Reimbursement Accounts

Flexible Spending Accounts (FSAs) are designed to save you money on your taxes. Each pay period, funds are deducted from your
pay on a pretax basis and are deposited to your Account. You then use your funds to pay for eligible health/dental/vision care or
dependent care (daycare) expenses.
Plan Carefully: Elections can only be modified mid-year if a qualifying event occurs.
In addition, unused funds may be forfeited if you do not have enough eligible claims.

For more information
Account Type Eligible Expenses Annual Contribution Limits

Most medical, dental and vision care expenses that are not
Health Care FSA covered by your health plan (such as copayments,
coinsurance, deductibles, eyeglasses and certain over the Maximum contribution is $2,750 per year
counter medications)
Minimum contribution is $100 per year.
Enroll if you are in a PPO Medical Plan.

Only dental and vision care eligible expenses that are not Maximum is for any Health Care or
Limited Purpose FSA covered by your plan (such as copayments, deductibles, Limited Purpose combined for your
orthodontia, eyeglasses, laser-vision) family
Enroll if you are in a CDHP.

Dependent care expenses (such as day care, after school Maximum contribution is $5,000 per year
Dependent Care FSA programs or elder care programs) so you and your spouse ($2,500 if married and filing separate tax
can work or attend school full-time returns)
Minimum contribution is $100 per year.

Access your 2022 account through Fidelity (log on to netbenefits.com)

Your FSA elections are effective from January 1 through December 31. Claims for reimbursement Note that FSA elections DO
must be submitted by March 31 of the following year. Please plan your contributions carefully. NOT automatically continue
from year to year; you must
2022 Plan Grace Period - An extension of unused Health Care or Limited Purpose 2022 balances actively enroll each year.
will be available. Any remaining 2022 balance can be used for eligible expenses incurred January
1 - March 15, 2023. The remaining 2022 funds will be forfeited, if claims are not submitted by
March 31, 2023. A debit card is available to
pay for your eligible
Save on Your Taxes with an FSA expenses. Simply swipe
The chart below is an example of how much you can save when you use the FSAs to pay for your your card for copays,
predictable health care.
deductible, etc. and the
Flexible Spending Account Example of Savings provider will be paid directly
Example of Savings With FSA Without FSA from your account. Per IRS
requirements, keep all
Your taxable income $50,000 $50,000
documentation of expenses
Pretax contribution to FSA $2,000 $0
as it may be required to be
Federal and Social Security taxes* $11,701 $12,355
submitted to verify the
After-tax dollars spent on eligible expenses $0 $2,000
eligible charge.
Spendable income after expenses $36,299 $35,645
Tax savings with the FSA $654 N/A

*This is an example only, and may not reflect your actual experience. It assumes a 25% federal income tax rate marginal
rate and a 7.7% FICA marginal rate. State and local taxes vary, and are not included in this example. However, you will also
save on any state and local taxes as well.

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