PLAN HEALTHCARE FSA DEPENDENT CARE FSA Annual Election Amount $ ($1) Minimum $ ($1) Minimum $ Maximum $ Maximum What is the minimum and maximum annual election amount per participant? Same as previous year Same as previous year Do not include additional benefits that may be The statutory contribution limit is The statutory limit for pre-tax contributed by Program Sponsor over the election $2,600 on Healthcare Flexible Dependent Care benefits is $5,000 amount. Spending per calendar year. Accounts (“health FSAs”) for plan years that begin on or after January 1, 2017. Additional Funding Amount $ $ Are there additional funds that may be contributed by This amount controls funding above This amount controls funding above Program Sponsor over the election amount? Election Amount. Any additional Election Amount. funds contributed by the Program Sponsor are not included in the $2,600 statutory contribution limit. Health FSAs can include Employer contributions of $500 or up to a dollar for dollar match of each election. participant’s PLAN OFFER DETAILS OFFER PLAN HEALTHCARE FSA DEPENDENT CARE FSA Enrollment Source WageWorks Site WageWorks Site Third Party Site Third Party Site What method will your eligible participants use for enrollment? Company Site or Application Company Site or Application Same as previous year Same as previous year Enrollment Method Online Enrollment using Online Enrollment using WageWorks Site WageWorks Site How will WageWorks be notified that eligible participants are enrolled in this plan? Enrollment File Enrollment File Same as previous year Same as previous year Enrollment Message For participants that do not enroll on the WageWorks Site, this message is displayed on the Participant Site to eligible participants who inquire about enrollment during open enrollment or the new hire enrollment periods. Email Enrollment Confirmations Would you like a confirmation email sent to participants following the receipt of their enrollment record in our database (via any method)? (Note: If 0 is sent for ENR, 0 will display on the confirmation.) Changes to New Hire Eligibility Have you made any changes to your New Hire eligibility If Yes, detail plan changes here: If Yes, detail plan changes here: rules? Such as changes to the new hire waiting period, days in the enrollment window, or date coverage ends. Updates to how Qualified Changes are handled Have you made any changes to your Mid-Year If Yes, detail plan changes here: If Yes, detail plan changes here: change rules? Such as updates to changes allowed, where changes can be made, or the change window.
PLAN HEALTHCARE 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 $2,600 on Healthcare Flexible Spending Accounts (“health FSAs”) for plan years that begin on or after January 1, 2017. $ ($1) Minimum $ 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 $2,600 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. PLAN OFFER DETAILS OFFER PLAN HEALTHCARE FSA DEPENDENT CARE FSA Enrollment Source What method will your eligible participants use for enrollment? WageWorks Site Third Party Site Company Site or Application Same as previous year WageWorks Site Third Party Site Company Site or Application Same as previous year Enrollment Method How will WageWorks be notified that eligible participants are enrolled in this plan? Online Enrollment using WageWorks Site Enrollment File Same as previous year Online Enrollment using WageWorks Site Enrollment File Same as previous year Enrollment Message For participants that do not enroll on the WageWorks Site, this message is displayed on the Participant Site to eligible participants who inquire about enrollment during open enrollment or the new hire enrollment periods. Email Enrollment Confirmations Would you like a confirmation email sent to participants following the receipt of their enrollment record in our database (via any method)? (Note: If 0 is sent for ENR, 0 will display on the confirmation.) Changes to New Hire Eligibility Have you made any changes to your New Hire eligibility rules? Such as changes to the new hire waiting period, days in the enrollment window, or date coverage ends. If Yes, detail plan changes here: If Yes, detail plan changes here: Updates to how Qualified Changes are handled Have you made any changes to your Mid-Year change rules? Such as updates to changes allowed, where changes can be made, or the change window. If Yes, detail plan changes here: If Yes, detail plan changes here:
3880-fsa-er-oe-conf-frm-08-2017.docx