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This worksheet will help you estimate the expenses for you, your spouse, and eligible dependents.
Transfer the plan year total for each section to the enrollment form in order to participate.
A. Group Medical Premiums
**Employer will deduct these premiums automatically pre-tax
_____ Dental insurance _____ Disability insurance*
_____ Group term-life insurance** _____ Group health insurance
_____ HMO insurance _____ Intensive care insurance
*Disability insurance benefits are taxable when premiums are placed pre-tax.
**Term-life limit: Up to $50,000 pre-tax on employee only; spouse/dependent life not available.
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B. HEALTH FSA
PLAN YEAR TOTAL
The items purchased must be used to alleviate
Health Insurance Related Expenses
General Medical Related Expenses
or treat personal injuries or sickness and not for
____ IRS $.12/ per mile, tolls and parking
INELIGIBLE Medical Related Expenses
Supplements from chiropractor, acupuncturist,
____ Drug addiction treatment (inpatient)
INELIGIBLE for general health
Uncertain about whether or not an expense is
deductible – email the FLEXPERT?
Just go to
our website www.eflexgroup.com and click on
C. Dependent FSA:
PLAN YEAR TOTAL $_________________________________
($5,000 Maximum for Married and Head of Household Filers or $2,500 if Married Filing Separately. For Individuals with a spouse who is a student or disabled, refer to the Summary Plan Description.)
D. Individual Health Premium Account:
PLAN YEAR TOTAL $_________________________________
(NOTE: The Premiums for these policies must be personally billed to the employee at home to qualify.)
____ Major Medical Insurance ____ Medicare Insurance
* Disability Insurance becomes taxable in the event of a claim if premiums are placed pre-tax.
THIS IS NOT AN ENROLLMENT FORM
THE MOST FREQUENTLY ASKED QUESTIONS
ABOUT SECTION 125
How do I get reimbursed for my expenses?
In general, first
, submit the claim form by fax or mail. The fax form, back to us, is on our website ready to print. You can
email the form filled out to us from the website, but you need to fax or scan the claim information along with the form. Note: faxing is best
be sure the information attached to the claim form lists the expenses incurred within the
plan year, dates the service took place, and the name of the provider
clearly. The claim form has the directions on the
sign the claim form! For Dependent Care
, you would include the name, address, and taxpayer identification
number (TIN) of the care provider and a receipt for daycare services incurred.
If I set aside money pre -tax for my dependents, and myself why would I lose the money if I don’t
spend those dollars?
-This is an IRS guideline, not eflexgroup.com’s or
your employer’s. Second-
The eflexgroup pre
-tax plan acts like an insurance policy in order to qualify for tax-free status. For example, if you
own a medical insurance policy and do not make a claim, the insurance company will not refund any unused premiums. Third-
eflexgroup.com will send you a statement disclosing the balance in your accounts approximately 2 months prior to
the end of the plan year. eflexgroup.com allows you 90 days from the end of the plan year to submit claims incurred during
the plan year. If you have a balance, it is important that you use this balance up before the end of your plan year. Remember
that the dates of service must be incurred within the plan year.
Is eflexgroup.com, going to replace my group insurance benefits?
No way. In fact, your employer is enhancing your benefits by adding these new choices.
4. How do I get service?
efg has a website for your use that will help answer most of your questions. You can ask “Flexpert” common questions. You can email us, download a fax form, or look up your accounts over the Internet at www.eflexgroup.com. You can also call us at: 608.243.8277
What if I have a claim early in the plan year?
The Plan will pay the entire claim up to your annual maximum election in the Health FSA only.
Your elected payroll
deductions will continue throughout the remainder of the plan year. The availability of funds does not apply
FSA and Individual Premium Account. They will be reimbursed as they are deposited with eflexgroup.com. Please note that
if you leave your employ “owing money”, your employer will ask you to repay the difference before you leave.
Can I change my eflexgroup.com flex plan during the plan year?
Yes, if you have an “IRS qualifying event” such as a birth, death in the family, marriage, divorce, child ceasing to be your
dependent, adoption, employment or termination of employment of spouse from full time to part time or vice versa. Any
changes must take place within 30 days of the event. NOTE: Conception is not a qualified event.
If my funds run low in the Dependent FSA reimbursement account can I use funds in my Health
FSA to pay for dependent care expenses?
No. Each account acts in accordance with a specific IRS regulation and funds cannot be transferred between accounts.
What is the history of Section 125 pre -tax plans and why are we hearing about this now?
Section 125 first appeared in the tax code in 1978, but employers did not take advantage of it until 1986. Prior to the Tax
Reform Act of 1986 you were allowed a 100% tax deduction for medical expenses on your tax returns. Since 1986
individuals must exceed 7.5%
of their adjusted gross income in order to get a tax break for medical expenses. With
eflexgroup.com flex all qualified medical deductions and dependent care expenses can be reimbursed with tax-free dollars.
For dependent care is it more beneficial to take the deduction on my Federal tax return or to put
the expenses through the eflexgroup.com flex plan?
Generally, most people experience greater tax savings utilizing the eflexgroup.com flex plan, although it depends on your
eflexgroup.com mentioned that this plan could lower my social security benefits when I retire. Is
It is our experience that eflexgroup.com flex will have a minimal effect on social security.
CURRICULUM VITAE University of Ioannina Ioannina 45 110 GREECE Nationality Qualifications Profession Education University of Ioannina, Department of Physics, PhD in Medical Biophysics, Department of Medical Biophysics, Medical School, University of Manchester, U.K. Present appointment : Prof. in Medical Physics, Medical School, University of Ioannina, Creece.
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