General FSA Guidelines

• When submitting an FSA reimbursement request by paper, the form must be signed to be approved.
• Reimbursements are generally paid on Fridays for electronic claims submitted by Tuesday of each week.
• Reimbursements are generally paid on Fridays for paper claims processed by Friday of the previous week.
• When you receive your check, you will also receive an explanation of what has been paid and the amount of your current account balance.
• You must submit claims for the plan year by April 30 of the following year.
• You must thoroughly complete claim forms, including the patient name, exact service dates, the provider name, and the amount claimed.
• Expenses paid by your FSA cannot be claimed as income tax deductions.
• The plan is governed by Internal Revenue Service (IRS) guidelines.

Medical / Dental Instructions:

• Insurance premiums cannot be claimed according to federal FSA provisions.
• Some over-the-counter (OTC) purchases are eligible for reimbursement. Click here to learn more. (Adobe Acrobat Document).
• Attach a copy of your Explanation of Benefits from Deseret Mutual or another third-party payer. If you don’t include these items, your claim will be returned.
• If the expenses are for services not covered by your medical/dental coverage, attach copies of your itemized bills.
• Balance-due statements are not accepted.
• Canceled checks are only accepted for orthodontic services when accompanied by payment coupons. You may also submit receipts from the orthodontist showing the payment date, name of patient, and the amount paid.
• You can only be reimbursed for services rendered during the plan year while you are a member. The plan year includes a grace period (January 1 – March 15 of the following year) as long as you are still an active participant on December 31.

Dependent Care Instructions:

FSA covers charges for:

• Baby sitters or companions
• Day-care centers that meet state and local regulations if they provide care for more than six nonresident people
• Day-care centers with less than six nonresident people
• Preschool
• Persons providing care who are not:
  • Claimed as a dependent on your (or your spouse's) tax return.
  • Your children/stepchildren younger than 19 at the end of the plan year.
  • Your spouse.
• Expenses for household services which at least partly include the care of a qualifying individual.

Charges are covered only if:

• The dependent being cared for is claimed as a dependent on your tax return and is:
  • Younger than 13.
  • Physically or mentally incapable of self-care and regularly spends at least eight hours a day in your household (this does not mean daily but frequently, on a regular basis).
  • You may also claim expenses if you are a divorced or a legally separated taxpayer with custody of a disabled or younger-than-13 child, even if you have released the right to a dependency exemption.

Contribution Limits:

• Single or Married Filing Separately = $2,500.00 per year
• Married Filing Jointly = $5,000.00 per year

Contributions cannot exceed your earned income or your spouse's earned income, whichever is less.

Charges submitted must enable both you and your spouse to work, unless your spouse is a full-time student or disabled. If your spouse is a full-time student, or is physically or mentally incapable of self-care, the spouse is deemed to have earned an income of $200 if dependent care expenses apply to one dependent, or $400 if dependent care expenses apply to two or more dependents for each month of disability or school attendance.

Remember:

• If you elect to participate in FSA for dependent care, you may not claim a dependent care credit on your tax return for the portion claimed in FSA.
• You cannot use any FSA funds allocated for dependent care expenses for any other purpose, including medical expenses.
• If you do not use the money in your account for services rendered during the plan year while you are a participant, you will lose any amounts not spent at the end of the plan year (which includes the new grace period). If you end employment during the plan year, no further contributions will be allowed. Also, you will not be reimbursed for expenses incurred after your termination date.
• You will forfeit any balances in your FSA at the end of the month in which you end employment or go part time, unless you enroll in COBRA and choose to continue after-tax contributions to your account.
• Attach an invoice or a copy of the canceled check for payment to a day-care center or to an individual who provides the care.
• If an individual provides the care, please include his/her Social Security number.
• If the provider takes care of more than six children (not including his/her own), he/she must be licensed by the state.
• The individual who provides the care cannot be your spouse or your child younger than 19.
• Expenses claimed cannot exceed your earned income or your spouse's earned income, whichever is less.
• Dependent care is care provided for dependents who you claim on your tax return and who are younger than 13 or who are physically or mentally incapable of self-care and regularly spend at least eight hours a day in your household (this does not mean daily but frequently, on a regular basis

Submitting Your Claim:

• Send paper claim forms and any necessary attachments to: Deseret Mutual Benefit Administrators – FSA, P.O. Box 45530, Salt Lake City, Utah 84145
• You may also fax your paper claims to 801-578-5903

If You Have Any Questions:

Write to the address above, call Deseret Mutual at the appropriate telephone number, or visit our Web site:

Salt Lake City Area: 1-801-578-5600
Toll Free: 1-800-777-3622
Web Site: www.dmba.com