FSA1 2012-2024 free printable template

• Are your Employees claiming a maximum dollar amount for their out-of-pocket expenses? Is your Employee claiming more than their out-of-pocket expenses are claimed for the month? • Does the Employee have medical coverage through your Plan? • Is the Employee on their employer health plan? • Is your Employee on a plan other than an HMO? † Is your Employee claiming their own expenses on their claim? • Are any of your Employees on a plan with no deductible? (such as AARP) • Are there any special medical expenses that apply to this claim? • Does your Exchanges have any restrictions or caveats to this claim? • Does your Exchanges have income limiting exclusions related to FSA claims?‡ • Is there an employer deduction limit for each employee? Note that while the “process claim only from current year funds” box applies to this claim, if your FSA funds are exhausted, or you decide to settle your claim with a full payment, you are encouraged to use your current year's FSA balance that is included with your current year's paycheck or have a new FSA balance available before making a settlement payment. If this is the case, then please note that if you are unable to pay all the claim within 60 (thirty) days of the month in which the claim was incurred, UHF may be required to reject your claim or to request additional documentation from UHF. This could delay your ability to receive federal employer contributions or even lead to a delay in the processing of FSA payments when eligible. If your employer is offering a low contribution employer health plan, and you are eligible to participate without paying a tax penalty, you should consult your employer As to whether your employer can contribute to an FSA.