applies). Same as previous year Same as previous year Leave of Absence Yes No Same as previous year If yes is selected a participant will be covered under one continuous Would you want WW to use system logic coverage period connected to a single account that has a period of that would automatically create a period of non-coverage that prevents claims from being paid during that period but Claims incurred during the period of non-coverage are denied (based on keep one continuous coverage period? service date). Claims Appeal Process WageWorks reviews initial appeals and the employer is the second level of review with final authority. (Standard) Select the appropriate appeals process WageWorks reviews initial appeals and the employer is the second level of (with or without the second level of review with final authority (except option to be further appealed to review from the plan sponsor) for this EBSA for external review). plan consistent with your formal plan document. Some non-grandfathered WageWorks reviews all appeals and has final authority. plans may be required to offer Employee Benefits Security Administration (EBSA) WageWorks reviews all appeals and has final authority (except option to external review which should be be further appealed to EBSA for external review). determined by the plan sponsor. E. Account Funding Plan Health Care FSA Dependent Care FSA Annual Election Amount $ ($1) Minimum $ ($1) Minimum $ Maximum $ ($5,000) Maximum What is the minimum and maximum annual election amount per Same as previous year Same as previous year participant? The statutory contribution limit is $2,500 The statutory limit for pre-tax Do not include additional benefits that on Health Care Flexible Spending Dependent Care benefits is $5,000 may be contributed by Program Accounts ("health FSAs") for plan years per calendar year. Sponsor over the election amount. that begin on or after January 1, 2013. Additional Funding Amount $ $ Are there additional funds that may be This amount Controls funding above This amount Controls funding Election Amount. Any additional funds above Election Amount. contributed by Program Sponsor over contributed by the Program Sponsor are the election amount? not included in the $2500 statutory contribution limit. Health FSAs can include employer contributions of $500 or up to a dollar for dollar match of each participant's election.
applies). Same as previous year Same as previous year Leave of Absence Would you want WW to use system logic that would automatically create a period of non-coverage that prevents claims from being paid during that period but keep one continuous coverage period? Yes No Same as previous year If yes is selected a participant will be covered under one continuous coverage period connected to a single account that has a period of Claims incurred during the period of non-coverage are denied (based on service date). Claims Appeal Process Select the appropriate appeals process (with or without the second level of review from the plan sponsor) for this plan consistent with your formal plan document. Some non-grandfathered plans may be required to offer Employee Benefits Security Administration (EBSA) external review which should be determined by the plan sponsor. WageWorks reviews initial appeals and the employer is the second level of review with final authority. (Standard) WageWorks reviews initial appeals and the employer is the second level of review with final authority (except option to be further appealed to EBSA for external review). WageWorks reviews all appeals and has final authority. WageWorks reviews all appeals and has final authority (except option to be further appealed to EBSA for external review). E. Account Funding Plan Health Care FSA Dependent Care FSA Annual Election Amount What is the minimum and maximum annual election amount per participant? Do not include additional benefits that may be contributed by Program Sponsor over the election amount. $ ($1) Minimum $ Maximum Same as previous year The statutory contribution limit is $2,500 on Health Care Flexible Spending Accounts ("health FSAs") for plan years that begin on or after January 1, 2013. $ ($1) Minimum $ ($5,000) Maximum Same as previous year The statutory limit for pre-tax Dependent Care benefits is $5,000 per calendar year. Additional Funding Amount Are there additional funds that may be contributed by Program Sponsor over the election amount? $ This amount Controls funding above Election Amount. Any additional funds contributed by the Program Sponsor are not included in the $2500 statutory contribution limit. Health FSAs can include employer contributions of $500 or up to a dollar for dollar match of each participant's election. $ This amount Controls funding above Election Amount.
FSA-Open-Enrollment-Confirmation-Form-2015.docx