Page 7 - OrangeTheory Benefits Guide 07-2019_FINAL - NonCA

Flexible Spending Account Benefits

Flexible Spending Accounts (FSAs) are special tax-advantaged
accounts used to pay for eligible out-of-pocket health care and
dependent care expenses. If elected, your account(s) will be
Important FSA Rules
funded with tax-free dollars using convenient payroll deductions.
Only expenses for services incurred during the plan year are
eligible for reimbursement from your accounts. If you are using Health Care FSA
your debit card, you must save your receipts, just in case Because FSAs can give you a significant tax
Discovery Benefits (FSA Administrator) needs a copy for advantage, they must be administered according to
verification. Also, all receipts should be itemized to reflect what specific IRS rules:
product or service was purchased. Credit card receipts are not
sufficient per IRS guidelines. With the Health Care FSA, up to $500 of any
unspent funds remaining in your account at the end
Health Care FSA of the plan year will carry-over to the next plan
year. Any unspent funds above $500 will be
This plan is used to pay for expenses not covered under your
health plans, such as deductibles, coinsurance, copays and forfeited.
expenses that exceed plan limits. Employees may defer up to
$2,700 pre-tax per year. Eligible expenses include: Important Note for HSA Medical Participants:
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
Coinsurance, Medical and Dental Eye Exams, Plan.
Copays and Prescriptions and Eyeglasses and
Deductibles Orthodontia Lasik Eye Dependent Care FSA
Surgery
Unused funds will NOT be returned to you or
Go to www.fsastore.com to shop for FSA-eligible products, and carried over to the following year. You must file
for a list of eligible expenses. Ineligible HSA expenses include claims by June 30, 2020.
expenses that are not medical or health-related as well as
cosmetic surgery. To find out which specific expenses are eligible,
view the searchable eligibility list at www.DiscoveryBenefits.com/
eligibleexpenses.

Dependent Care FSA
This plan is used to pay for eligible expenses you incur for child Video – Learn About
care, or for the care of a disabled dependent, while you work. Flexible Spending Accounts
Employees may defer up to $5,000 pre-tax per year. Eligible
expenses include: http://video.burnhambenefits.com/fsa

Licensed nursery schools, Adult daycare facilities
qualified childcare centers, after
school programs, summer
camps (under age 13),
preschool

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