Page 25 - Volcom Benefit Summary 2019 Hawaii

FLEXIBLE

SPENDING

ACCOUNTS

You can set aside money in Flexible Spending Accounts
(FSA) before taxes are deducted to pay for certain health and
dependent care expenses, lowering your taxable income and Important
increasing your take home pay. Only expenses for services
incurred during the plan year are eligible for reimbursement FSA Rules
from your accounts. A new enrollment is required each year,
even if you do not plan to change the amount(s) set aside. Plan Year: January 1 - December 31
Please remember that you must save your receipts, just in
case Discovery Benefits needs a copy for verification. Also, all
receipts should be itemized to reflect what product or service HEALTH CARE FSA
was purchased. Credit card receipts are not sufficient per IRS Up to $500 of any unspent funds remaining in your
guidelines. Health Care Spending Account at the end of the
plan year will carry-over to the next plan year, and
unspent funds above $500 will be forfeited.
HEALTH CARE FSA
This plan is used to pay for expenses not covered under your
health plans, such as deductibles, coinsurance, copays, and IMPORTANT NOTE FOR HSA
expenses that exceed plan limits. Employees may defer up to MEDICAL PARTICIPANTS
$2,750 pre-tax per year. Eligible expenses include: If you enroll in the HSA medical plan and contribute
to your HSA account, you may only participate in the
Health Care FSA to cover out-of-pocket Dental and
Vision expenses through the Limited Purpose Plan.
Coinsurance, Medical and Dental Eye Exams,
Copays and Prescriptions and Eyeglasses
Deductibles Orthodontia and Lasik Eye DEPENDENT CARE FSA
Surgery Unused funds will not be returned to you or carried
over to the following year. You must file claims by
DEPENDENT CARE FSA the end of the plan year.

This plan is used to pay for eligible expenses you incur for child
care, or for the care of a disabled dependent, while you work.
Employees may defer up to $5,000 pre-tax per year. Eligible
expenses include:
EDUCATIONAL
VIDEO

Licensed nursery schools, Adult daycare facilities Flexible Spending Accounts
qualified childcare centers, http://video.burnhambenefits.com/fsa
after school programs,
summer camps (under age
13), preschool

25