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AMERICOMP BENEFITS, INC.
FLEXIBLE SPENDING ACCOUNTS NOTEBOOK
FOR THE EMPLOYEES OF
ATLANTA PUBLIC SCHOOLS
Dependent Day Care Accounts
Medical Reimbursement Accounts
Your company has established a flexible spending account (the
Plan ) to allow you to make your own decisions about your benefit
needs. The Plan provides you with a way to set aside amounts from
your payroll deposits so you can pay for certain health care
expenses on a tax-free basis. This booklet explains, in general
terms, how your cafeteria plan works.
HOW THE REIMBURSEMENT PROGRAM WORKS
Here is an overview of how the Dependent Day Care and Medical
Reimbursement accounts work.
The amount of money you elect to set aside for the plan year will be
deposited over the course of the plan year on a per-pay period basis.
Refer to your enrollment form for the maximum eligible amount to
be set aside for your medical reimbursement account.
As you incur expenses, you will pay for the expenses with your own
money or use your Flexible Spending Debit Card. After you have
incurred the expenses, you can claim reimbursement from your
account(s) for any expenses you paid for with your own money. As
long as you are making contributions to the Plan, the full annual
amount of coverage you have elected (reduced by any prior
reimbursements received during the Plan year) will be available for
reimbursement at any time during the Plan year for the medical
For the dependent daycare account, only the amount currently
deposited in your account will be available (reduced by any prior
reimbursements received during the Plan year).
All claims must be submitted for reimbursement within ninety- (90)
days of the close of the Plan year in order to be considered for
payment. If submitted after that date, claims will be denied and any
funds in the account will be forfeited to your employer.
ELECTING THE RIGHT AMOUNT TO DEPOSIT INTO
YOUR PERSONAL ACCOUNT
Be cautious when estimating your expenses for the forthcoming
plan year because overestimating will result in forfeitures. Every
year, during your group s open enrollment, you will be given the
opportunity to elect how much money you want to deposit into your
account(s) for the upcoming plan year. Although you should take
advantage of the maximum tax savings offered by the Plan,
overestimating will result in forfeiture. You may wish to consult
your individual tax advisor.
ELIGIBLE DEPENDENT DAYCARE EXPENSES
Daycare expenses are covered for children under age thirteen (13).
These expenses must be incurred to allow the custodial parent(s) to
remain actively employed.
The following is a brief listing of common fees that are and are not
eligible under a flexible dependent daycare program:
Late Pick Up Fees
Routine Daycare Fees
Before & After School Care
Day Camp Fees
As a general rule, all outdoor activities that a daycare center
charges extra for, are not considered eligible expenses.
The receipts for the daycare center or baby sitter should have their
address, social security number/tax identification number, dates
services rendered and fees charged.
Your spouse is not considered an eligible daycare provider. You
can only have people whom you cannot claim an exemption on
your taxes for, perform daycare services.
Sometimes an employee is paying a mother or mother-in-law to take
care of the child(ren). If you have advised the caregiver that you
will not report the funds to the IRS so the caregiver will not be
taxed on the fees, then you cannot be reimbursed for these expenses
under a dependent daycare account plan.
Also, remember both custodial parents must be working in order for
either spouse to enroll in a dependent daycare program.
Daycare expenses incurred while your at home spouse volunteers
or does charity work are not covered. The only times an employee
with an at home spouse can enroll for dependent daycare benefits
Your at home spouse is self-employed on a full-time basis;
Your at home spouse is mentally or physically unable to take
care of the child(ren); or
Your at home spouse is going to school full-time; or
Your at home spouse is job hunting on a full-time basis.
ELIGIBLE MEDICAL EXPENSES
An eligible medical expense under a flexible spending account plan
must satisfy this definition: Amounts paid for the diagnosis, cure,
mitigation or prevention of disease, or for treatment affecting any
structure or foundation of the body, and for transportation
primarily for essential medical care. This also includes insulin
and all prescription drugs. A brief listing of covered and non-
covered expenses follows on the next page:
Invitro-fertilization & fertility treatments
Smoking-cessation programs & associated
medications (prescription & over the counter)
Weight Loss Programs for specific medical
condition (letter from physician would be
physician for specific medical condition such
as Obesity, Hypertension, Diabetes, etc.
(letter from physician would be required)
Here are Examples of Expenses that are NOT Eligible
Cosmetic Surgery or Services Marriage Counseling
OVER-THE-COUNTER DRUGS AND MEDICINES
Over-the-counter drugs and medicines may now be reimbursable under your Health Care Spending
Account. The expenses that may be reimbursed depend on whether the drug or medicine treats a specific medical condition
or is used mostly for a person s general good health. Drugs and medicines
which are primarily used for a person s general good health (e.g., mouthwash) may only be reimbursed
if it is used to treat a specific medical condition and proper documentation from the doctor or dentist is
submitted. Most over-the-counter drugs or medicines are eligible; cosmetic, toiletry, or sundry items are
Pain relievers (aspirin, Tylenol, Advil, Midol, Motrin, Ibuprofen, Bayer, Aleve, Doan s, Excedrin, Anacin, etc.) Cold/sinus medicines (Actifed, Sudafed, Dimetapp, Drixoral, Robitussin, Triaminic, Comtrex, Theraflu etc.) Antacids (Axid AR, Pepcid, Prilosec, Tagamet, Zantac, Tums, Rolaids, Alka-Seltzer, Maalox, Mylanta, Pepto-Bismol, Gaviscon, Gas-X etc.) Allergy medicine ( Alavert, Benadryl, Chlor-trimeton, Claritin, Tavist, etc.) Cough syrup Laxatives Hemorrhoid medicine Sore muscle medicines (Ben Gay) Nicotine patches and gum Athletes foot medicine Medical ointments (Neosporin, Bacitracin etc.)
Expenses Requiring Additional Documentation
Medicated Shampoo Mouthwash Dietary Supplements Vitamin Supplements Nutritional Supplements
Vitamins for general good health Facial creams Deodorants Toothpaste Bug repellant Sunscreens
A store receipt showing the place of purchase is required and must include
the date of purchase, name of the item and the amount charged. For expenses requiring additional
documentation, a letter of medical necessity from your physician or dentist will be required.
SMARTFLEX DEBIT CARD
We are offering the SmartFlex Debit Card to be used for the dependent day care and
medical spending accounts. The SmartFlex Card can be used at any participating
merchant that accepts VISA. Examples of participating merchants are Physicians
Offices, Hospitals, Dental Offices, Vision Service Locations, Pharmacies, Durable
Medical Supply Locations, Home Healthcare Services, any facility where you purchase
over the counter drugs, and any dependent day care provider that accepts VISA.
To use the SmartFlex Debit Card simply present your card at time of payment to make
qualified purchases for medical care goods and services directly from your flex
account. You may use your SmartFlex Card for eligible medical, dental and vision
expenses up to the maximum amount you have selected for the plan year. You may use
your card for eligible dependent day care expenses up to the amount available in your
account at that time. If the amount swiped exceeds your available projected annual
benefit, the transaction will be declined. The card is swiped as a credit card and no pin
number needed. As a member of the Flex Plan, each time you incur an Eligible
Expense, these choices are available. You have a choice of using the SmartFlex Card
which will automatically take the funds out of your flex account, or you can pay for the
eligible expenses and then file a claim to be reimbursed. You can check the balance in
your account at any time by going to. Your member ID is your SSN
and your password is the last four digits of your SSN.
If you use the SmartFlex Card and it is swiped for a single doctor office copay or single
prescription copay within the medical plan for your employer the amount will
automatically adjudicate in our system. If the amount swiped is for coinsurance,
deductible, multiple prescriptions or doctor office copays, or over the counter
medicines you are responsible for faxing or mailing us the itemized statement from the
provider showing the date(s) and services incurred, name of the provider and the
amount of the expense. You may be asked to provide the Explanation of Benefits from
your insurance carrier. Do not swipe the card for prior year expenses. If this happens
you will be asked to reimburse the funds back to us. We ask that you provide the
required documentation within 15 days. If you do not provide it within 30 days of the
date of service your SmartFlex Card will be disabled and you will have to submit all
claims by fax or mail and wait for reimbursement. If you use the card for dependent
day care expenses you are still required by the Internal Revenue Service to provide us
with a receipt from the day care provider showing dates of service, amount charged
and the name and tax ID or SSN of the provider.
You will be provided one card for yourself when you enroll in the flexible spending
benefits plan. If additional cards are needed for a spouse or dependent there is a one
time $5.00 fee per card that comes out of your flexible spending account. Please
complete the Dependent Card Request Form and return to us.
CHANGES IN CONTRIBUTIONS
You may change the amount of money you are depositing into your
accounts during your company s annual open enrollment with
those requested changes to be effective on the Plan s renewal date.
In addition, you may make a revision if you experience a change
in status event as defined by the IRS regulations. Some examples
of change in status events are:
Adoption of child(ren) or birth of child(ren);
Death of your spouse and/or child(ren);
Termination or commencement of your spouse s job;
For dependent daycare, if your non-family member daycare
provider increases or decreases their fees; and
Also, for dependent daycare, your child turning age 13.
Remember, you must make your written request for a change based
on a change in status within sixty- (60) days of the event date (date
of marriage, date of divorce decree, date of birth, etc.) in order for
the request to be handled. If submitted after this timeframe, the
requested revision will not be able to be made. Also, note the
requested change must be consistent with the change in status
TERMINATION OF CONTRIBUTIONS
Your ability to make contributions to the Plan ends if you retire,
become disabled, die, are laid off or terminate employment for any
other reason. If you take a leave of absence, you have the option of
stopping the deduction while on leave and either double/triple up
before taking the leave or when you return (if deductions will be
taken during the same plan year). If you terminate employment
with your company, you will be able to continue your medical
reimbursement account under the Consolidated Omnibus Budget
Reconciliation Act of 1986 (COBRA), if your company is subject to
this federal mandate.
Whether or not you continue the medical reimbursement account
under COBRA is entirely up to you. Remember, the full annual
benefit for the medical reimbursement account has to be made
available to you as of the first day of the plan year. If you terminate
and have not used your money and you incur an expense after your
date of termination off of the Plan, you will be able to continue this
benefit under COBRA.
Remember, when continuing under
COBRA, you are paying with after tax money and you are paying
2% more than the actual premium due to administrative service fees
imposed by the COBRA administrator.
This will not apply to your dependent daycare account. You can
only claim the funds that were deducted from your pay and
deposited into your account, prior to termination. However, the
claims can be incurred after your date of termination but must be
incurred during the plan year and the expenses must be incurred
because you become actively employed or are actively looking for
FILING A CLAIM
To file a claim for reimbursement of eligible expenses,
submit a completed claim form to AmeriComp Benefits for each
participant you are requesting reimbursement on at the address
below along with a receipt for each expense, including the
Name of the claimant (person receiving services);
Nature of services or supplies incurred or purchased;
Name and address of the provider of service. If it is a daycare
provider, we will also need their tax identification number;
Amount of charges (itemized);
Date each service incurred;
When submitting medical reimbursement claims for all services
besides your prescription copays and office visit copays, we will
need a copy of your insurance carrier s Explanation of
Benefits (E.O.B.) before we can process these items.
Your claims should either be mailed or faxed to our office. If you
mail them, do not fax them and vice versa.
AmeriComp Benefits, Inc.
Post Office Box 4319
Columbus, Georgia 31914
Fax Number: (706) 327-1160
(706) 327-6511 or (800) 868-0196
IF YOUR CLAIM(S) IS/ARE DENIED
If disagreements arise, we hope they will be resolved quickly and
informally. However, if that is not possible, procedures have been
developed so that you can appeal the decision.
If a claim if denied, either totally or partially, you will receive a
written notice as to that effect along with the reason(s) for the
denial. If you disagree with a claim denial, you may make a written
request to the Plan Administrator for a review of the claim. The
request must be made within sixty- (60) days of the denial date.
Within sixty- (60) days after a written request for a review is
received, you will receive a written notice of the final decision or of
the reason(s) for the delay in reaching a final decision if special
circumstances require an extension of time. In any event, a final
decision will be reached, and you will be notified within one
hundred twenty- (120) days after your written request for review is
Your company is obligated by federal law to ensure that the Plan
does not discriminate in favor of highly compensated or key
employees. Specific discrimination tests must be applied to the
Plan. If the Plan fails to satisfy the tests, highly compensated
employees may be required to have their participation in the Plan
Your company will notify any highly compensated
employees who may be affected by these tests.
If the Plan Changes or Ends/Terminates
Your company reserves the right to amend, suspend or terminate
the Plan, in whole or in part, at any time for whatever reason it
finds appropriate, including but not limited to financial losses or a
merger with or acquisition of or by another corporation. This
means the Plan may be discontinued in its entirety, modified to
provide different levels of benefits, modified to provide a different
distribution of cost sharing between your company, its employees
and retirees, or amended in any other way. If such a termination or
any material amendment occurs, you will be promptly notified.
The Plan and all of its records are maintained and a copy is on file
at your company s main office.
Effect of Employment
Eligibility to participate in this Plan has no effect on your
employment status with your company.
participation in the Plan does not constitute a commitment from
your company to continue your employment.
Your Rights Under ERISA
As a participant in the Plan, you are entitled to certain rights and
protections under the Employer Retirement Income Security Act of
1974 (ERISA). ERISA provides that all Plan participants shall be
1. Examine, without charge, at the Plan Administrator s office and
at other specified locations, such as worksites, all Plan
documents, including insurance contracts and copies of all
documents filed by the Plan with the U.S. Department of Labor,
such as detailed annual reports and Plan descriptions;
2. Obtain copies of all Plan documents and other Plan information
upon written request to the Plan Administrator.
administrator may make a reasonable charge for the copies.
3. Receive a summary of the Plan s annual financial report. The
Plan Administrator is required by law to furnish each participant
with a copy of this summary annual report.
In addition to creating rights for Plan participants, ERISA imposes
duties upon the people who are responsible for the operation of the
Plan. The people who operate your Plan, called fiduciaries of
the Plan, have a duty to do so prudently and in the interest of you
and other plan participants and beneficiaries. No one, including
your employer, or any other person, may fire you or otherwise
discriminate against you in any way to prevent you from obtaining
a benefit or exercising your rights under ERISA.
If your claim for benefits is denied in whole or in part, you must
receive a written explanation of the reason(s) for the denial. You
have the right to have the Plan review and reconsider your claim.
Under ERISA, there are steps you can take to enforce the above
rights. For instance, if you request materials from the Plan and do
not receive them within thirty- (30) days, you may file suit in a
In such a case, the court may require the Plan Administrator to
provide the materials and pay you up to one hundred dollars
($100.00) a day until you receive the materials, unless the materials
were not sent because of reasons beyond the control of the Plan
Administrator. If you have a claim for benefits that is denied or
ignored, in whole or in part, you may file suit in a state or federal
If it should happen that the Plan fiduciaries misuse the Plan s
money, or if you are discriminated against for asserting your rights,
you may seek assistance from the U.S. Department of Labor, or you
may file suit in a federal court. The court will decide who should
pay court costs and legal fees. If you are successful, the court may
order the person you have sued to pay these costs and fees. If you
lose, the court may order you to pay these costs and fees, for
example, if it finds your claim is frivolous.
If you have any questions about your Plan, you should contact the
Plan Administrator. If you have any questions about this statement
or about rights under ERISA, you should contact the nearest Area
Office of the U.S. Labor-Management Services Administration,
Department of Labor.
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