SECURITY FLEX 125 PROGRAM
Medical Expense Reimbursement
Flexible Spending Account
(Maximum Annual: $2,500.00)
Dependent Care Reimbursement
Flexible Spending Account
(Maximum Annual: $5,000.00)
John D. Webb
600 S. Santa Fe, Suite C
Salina, Kansas 67401
(888)756-6670
[email protected]
SM
Security Flex 125 Program® Enrollment Booklet
Save on Your Out-of-Pocket Medical and
Dependent Care Expenses
Save Money on FFICA
ICA and Income Tax
Handy Flex Card for Easy Payments
Instant Access to 100% of Medical Account Value
Health Care Reform – Changes affecting
Security Flex 125 plan
Over-the-counter medicines require a doctor’s prescription.
Effective January 1, 2011 no over-the-counter medicines, other than insulin, are eligible for
reimbursement without a prescription. Examples of items that will require a prescription are: pain
medication, cold medication and allergy medication.
Over-the-counter items that are not medicine are still eligible for reimbursement without a prescription.
Examples of items that are still eligible without a prescription are: Bandages, ace wraps, crutches and
contact lens solution.
Over-the-counter items that require a prescription are not able to be purchased with the flex debit card.
These items will require a manual claim to be submitted.
Limitation on Salary Reductions Beginning January 1, 2013
Health care reform imposes a $2,500 limit on annual salary reduction contributions to medical
reimbursement FSAs effective for taxable years beginning January 1, 2013. The $2,500 limit is a
calendar-year limit that applies to all plans. The limit is a flat dollar amount and applies on a perparticipant basis. The $2,500 amount is indexed for inflation for taxable years after December 31, 2013.
Table of Contents
Can You Use More Spendable Income? .................................................................................................................... 2-3
Qualifying expenses.................................................................................................................................................... 4-5
Submitting Claims .................................................................................................................................................... 6-10
Security Benefit’s Flex Convenience Card .............................................................................................................11-13
Security Flex 125 Reimbursement Claim Form.........................................................................................................14
Security Flex 125 Employee Benefit New Year Enrollment Form ........................................................................... 16
Employee Benefit Worksheet....................................................................................................................................... 18
Advantages To You:
1. Save money on taxes by contributing to your account with pre-tax dollars.
2. Security Benefit funds 100% of your medical expense account
from day one, so you don’t have to wait for the benefits of participating.
3. Avoid the hassle of paperwork by using the handy Flex Card to
pay for eligible medical expenses like prescriptions or co-pays.
ENROLLMENT BOOKLET
Participants in the Security Flex 125 Flexible Benefits plan can experience the following tax savings by
funding their medical and dependent care expenses with pre-tax dollars: 1
1
Federal Income Tax (Filing jointly, taxable income not over $61,300)
+ Social Security
+ Estimate of State Tax Savings 2
Total Savings
15.00%
7.65%
5.00%
27.65%
1
FICA withholding may vary by state and employer. State income tax savings vary by state and are not applicable in states without income tax and in
PA and NJ.
2
Based on estimated rates.
Please see page 11 for important information regarding the
Security Benefit Flex 125 convenience card.
SECURITY FLEX 125 PROGRAM®
CAN YOU USE MORE SPENDABLE INCOME?
Why Pay Taxes That You Don’t Have to Pay
The Security Flex 125 Program offered through your employer allows you to pay less in taxes and take home
more of your hard earned income. Here’s how it works.
Section 125 of the Internal Revenue Code allows employers to set up Flexible Spending Accounts for medical
and child care expenses as part of their cafeteria plans. As an employee, you can set aside part of your income
on a pre-tax basis for medical and/or child care expenses that you will incur over the course of the year.
Then, after you pay for child care or eligible medical expenses, you simply submit the bill or receipt with the
proper form and you will be reimbursed for your expenses from the Flexible Spending Account.
Here’s how the Security Flex 125 Program can help increase your spendable income:
Employee Savings With Medical Care Services
Without
125 Plan
With
125 Plan
Gross Pay
Medical and Dental Plan Premiums
Non-reimbursed Medical Expenses
Total Taxable Income (for Federal Purposes)
$36,000.00
0.00
0.00
$36,000.00
$36,000.00
700.00
600.00
$34,700.00
Deductions From Pay*
Federal Withholding
State Withholding
FICA and Medicare Tax
Medical and Dental Plan Premiums
Total Income Deductions
$ 5,400.00
1,008.00
2,754.00
700.00
$ 9,862.00
$ 5,205.00
1,008.00
2,654.55
0.00
$ 8,867.55
Take Home Pay
Total Taxable Income
Non-reimbursed Medical Expenses
Income Deductions
$36,000.00
600.00
9,862.00
$34,700.00
0.00
8,831.15
After-Tax Take Home Compensation
$25,538.00
$25,832.45
*Federal, State and FICA tax vary from state to state.
ENROLLMENT BOOKLET
By using the Flexible Spending Account for medical expenses, you could have an increase in your
spendable income of almost $25 per month. That’s an annual increase of almost $300.
SECURITY FLEX 125 PROGRAM®
2
Employee Savings With Dependent Care Services
Without
125 Plan
With
125 Plan
Gross Pay
Non-reimbursed Dependent Care Expenses
Total Taxable Income (for Federal Purposes)
$36,000.00
0.00
$36,000.00
$36,000.00
4,800.00
$31,200.00
Tax Deductions From Pay*
Federal Withholding
State Withholding
FICA and Medicare Tax
Medical and Dental Plan Premiums
$ 5,400.00
1,008.00
2,754.00
0.00
$ 4,680.00
1,008.00
2,386.80
0.00
Total Income Deductions
$ 9,162.00
$ 8,074.80
Take Home Pay
Total Taxable Income
Non-reimbursed Medical Expenses
Income Deductions
$36,000.00
4,800.00
9,162.00
$31,200.00
0.00
7,940.40
After-Tax Take Home Compensation
$22,038.00
$23,125.20
*Federal, State and FICA tax vary from state to state.
By using the Flexible Spending Account for child care expenses, you could have an increase of over
$90 per month in your spendable income. That’s an annual increase of almost $1,100.
While most medical and child care expenses are eligible for reimbursement, some restrictions do
apply. Read the Security Flex 125 booklet carefully before enrolling in the plan.
ENROLLMENT BOOKLET
You must be enrolled by your employer’s deadline to participate in the program, so contact
your employee benefits personnel today to learn more about how you can benefit from the
Security Flex 125 Program!
3
SECURITY FLEX 125 PROGRAM®
What Qualifies
Medical Expenses*
The medical reimbursement account will set aside part of your income on a pre-tax basis for
medical expenses that you will incur during the coverage period. The coverage period is the
effective date of the plan or the date the employee enrolls in the plan through the plan year or
grace period end date. Expenses are incurred when the service is provided and not when the
employee is formally billed, charged for, or pays for the medical care.
Medical expenses include payments you make for the diagnosis, treatment or prevention of
disease or for the treatment affecting any part or function of the body. Samples of these expenses
would include charges and co-pays for medical appointments, Lasik eye surgery and prescription
medications. Cosmetic procedures are not eligible for reimbursement.
Any expenses reimbursed through your account cannot be claimed for income tax purposes.
The following is a partial listing of medical expenses which are allowed and disallowed through
your FSA. Please refer to IRC Section 213(d) for a complete listing of allowed expenses. You are
also able to find additional details on eligible expenses on our website under the Forms section.
ALLOWED
MEDICAL EXPENSES
• Acupuncture
• Ambulance
• Chiropractor fees
• Coinsurance (co-pays and
deductibles for health,
dental and vision)
• Corrective eye surgery
• Crutches (purchase or rental)
• Hearing aids and hearing
aid batteries
• Hospital services
• Immunizations
• Insulin and equipment
needed to inject the insulin
• Laboratory fees
• Medicines (prescriptions)
• Organ donation/transplantation
• Orthodontic fees
• Over the counter medicines
(with prescription)
• Prescription eyeglasses,
sunglasses, Contact Lenses
and solutions associated
with their care
•
•
•
•
DISALLOWED
MEDICAL EXPENSES
• Chapped lip treatments
• Cosmetic surgery (expenses
exceptions if medically
necessary)
• Dancing lessons, swimming
lessons, etc., even if
recommended for the general
improvement of your health
• Electrolysis or hair removal
• Face creams, moisturizers,
suntan lotions
• Funeral Expenses
• Hair transplant
(i.e. Rogaine, Propecia)
• Insurance premiums – for
individual and/or spouses
health, dental, and/or policies
covering loss of earnings, loss
of a limb or eyesight
• Maternity clothes
• Medicated shampoos and soaps
(unless prescribed by
a doctor)
• Teeth Bleaching
• Toiletries
• Toothbrushes, toothpaste
• Vitamins and supplements
for maintaining general
good health
ALLOWED
OVER-THE-COUNTER
MEDICATIONS
Reimbursable:
• Bandaids, bandages, gauze
pads, first aid kits
• Cold/hot packs for
injuries, crutches
• Contact lens solution, cleaners
Carpal tunnel wrist supports
Condoms, spermicidal foam
Insulin
Nasal strips for snoring
•
•
•
•
Orthopedic shoe inserts
Pregnancy test kits
Reading glasses
Thermometers (ear or mouth)
*It is possible that changes in the IRS rules can affect the Allowed and/or Disallowed Expenses categories.
SECURITY FLEX 125 PROGRAM®
ENROLLMENT BOOKLET
•
•
•
•
Physical, Dental and Eye exams
Reading glasses
Surgery/operations
Weight-loss program and/or
drugs to induce weight loss
when prescribed for a
specific diagnosis
• Well-child care
• Wheelchair
• X-ray fees
4
Dependent/Day Care Expenses*
The dependent care account will set aside part of your
income on a pre-tax basis for child/dependent care
expenses that you incur during the coverage period.
The coverage period is the effective date of the plan
or the date the employee enrolls in the plan through
the plan year or grace period end date. Expenses are
incurred when the service is provided and not when the
employee is formally billed, charged for, or pays for the
dependent care.
Expenses include payments made for the care of a child
under 13 and/or a dependent regardless of age who
requires care due to an inability to care for him or herself, to enable you (and,
if married, your spouse) to remain gainfully employed. For dependents to be
eligible, they must spend at least eight hours a day in your home. You must
declare them as dependents (or have the ability to declare them as dependents
except for their level of gross income) on your Federal tax return.
Reimbursement for amounts cannot be claimed if paid to your spouse or tax
dependent. Any expenses reimbursed through your account cannot be claimed
for income tax purposes. Reimbursements can only be received up to the
amount deposited for your payroll deductions.
The following is a partial listing of dependent care expenses which are allowed
and disallowed through your FSA. You are also able to find additional details on
eligible expenses on our website under the Forms section.
Please remember day care expenses must be incurred to be eligible for reimbursement.
ALLOWED DEPENDENT/
DAY CARE EXPENSES
• Licensed day care facility
• Preschool program
• In-home child and dependent
• Day camp expenses
• Elder care
• Any other qualified dependent
• Services solely for the purpose
• Day care for children past
care expenses as defined by
the IRS
care services
ENROLLMENT BOOKLET
DISALLOWED
DEPENDENT/
DAY CARE EXPENSES
5
• Overnight camp
of household cleaning
their 13th birthday
*It is possible that changes in the IRS rules can affect the Allowed and/or Disallowed Expenses categories.
SECURITY FLEX 125 PROGRAM®
Submitting Claims
You may send in claims throughout the year. Only claims for
services incurred during the coverage period are eligible for
reimbursement. The coverage period is the effective date of
the plan or the date the employee enrolls in the plan through
the plan year or grace period end date. Expenses are incurred
when the service is provided and not when the employee is
formally billed, charged for, or pays for the services.
Expenses must be incurred before reimbursement can be
made. For example, if you prepay your day care provider
at the first of the month or if you are required to pay for
dental expenses prior to the services being provided,
you cannot submit a claim for those expenses until the
services have been received. IRS regulations specifically
mandate, “A flexible spending account cannot make advance
reimbursement of future or projected expenses.”
It is important that you plan your deposits carefully. Please
remember that unused amounts may not be carried forward
in the next plan year. In accordance with Internal Revenue
Service guidelines, money remaining in the plan at the end of
the plan year will be forfeited if a claim for reimbursement is
not submitted by the end of the run-out period. The run-out
period is the 90 day period following the end of the plan year
or grace period, if applicable.
ENROLLMENT BOOKLET
A claim form must be completed and signed when submitted a flexible spending claim. You must
attach legible copies of itemized receipts, statements, or an explanation of benefits from your
insurance provider. An itemized receipt must include
• The provider name and address
• Date of service
• For whom the service was provided
• Charges for the service
• Service(s) that were provided
SECURITY FLEX 125 PROGRAM®
6
Submitting Claims
(continued)
Common reasons claims may be denied or delayed
• Statements showing balance due or received on account
• Claim forms received without a signature
• Services not incurred during the coverage period
The claim form provides a space for you to itemize your claim.
This is useful when you have multiple items with varying
amounts. The worksheet allows you to review your claims and
ensure that they contain all the required information.
Medical reimbursement claims are processed within three to
five business days after they are received in good order. You
should receive reimbursement of your claims within seven to ten
business days.
Dependent care reimbursement can only be paid up to the
amount of deposits received in your account. If a claim is
received for more than your deposits the claim will be placed
on-hold waiting on additional deposits to be received. You will
need the provider’s name and address, social security number
or tax identification number for your records. Dependent care
claims are processed within one to three business days after they
are received in good order. You should receive reimbursement of
your claims within five to seven business days.
Please note: All claims received will be retained at Security Benefit and will not be
returned once received.
John River pays his day care
provider on March 1 for March
day care. He immediately sends
in his claim for reimbursement.
Why doesn’t he receive his
reimbursement until the end
of the month?
Answer
The IRS has indicated that
expenses are not reimbursable
until the expense has been
incurred. Day care expenses
claimed are for the time you and
your spouse go to work. Therefore,
expenses will not be incurred
until the end of March. Your
claim will be held until the
end of the month before
being processed.
You should check with your
employer to determine when the
dependent care deposits will be
sent to Security Benefit. According
to IRS regulations, dependent care
reimbursements cannot be made
until Security Benefit has received
the employer’s deposit. Therefore,
your claim could be received,
processed and pended until the
employer’s deposit is received.
Once that deposit and your claim
have been received, a payment
will be mailed to you or an
automatic deposit will be
directed to your bank.
ENROLLMENT BOOKLET
7
Example
SECURITY FLEX 125 PROGRAM®
Reasons Why Claims May Not Be Reimbursed
All claims received will be processed. However, only those claims that are
eligible for reimbursement according to IRS regulations will be reimbursed.
Claims received that are not eligible for reimbursement will be kept in your
Security Benefit file. You will receive a letter indicating the reason that the claim
is ineligible for payment. If you have some claims that are reimbursable and
some that are not, you will receive a statement. The statement of benefits will list
the reasons why ineligible claims could not be paid.
Many scenarios exist that may prevent or delay processing of a claim. The most
frequent reasons are listed below. The boldfaced portion will appear on your
statement as listed below. Please refer to this list to troubleshoot your claim.
Reasons
Covered by insurance – Explanation of
Benefit shows the insurance provider paid the
expense.
Date of Service in the future –
Reimbursement for future expenses are not
eligible for reimbursement.
Duplicate receipt – The expense has been
received for reimbursement previously.
Expense incurred outside of plan dates
– The expenses submitted were not within
your plan year. Only expenses incurred within
the plan year, prior to your last date of
employment, are eligible for reimbursement.
Expense incurred prior to employment
or after termination of employment –
Expenses incurred prior to your employment
or after termination date are not eligible for
reimbursement.
Ineligible Expense – Expense not eligible
according to IRS requirements.
Insufficient funds – You have received
reimbursement for your maximum election for
the current plan year; therefore, no further
reimbursement is available.
Insurance premium ineligible – Insurance
premiums are not a qualifying expenses.
Itemized receipt required – Please submit
an itemized statement for the claim. Itemized
statements should include: provider name
and address, date of service, patient name,
unreimbursed charges for the services,
services provided or an EOB from your
insurance company.
Maximum contribution paid out – You have
received reimbursement for your maximum
election for the current plan year; therefore, no
further reimbursement is available.
SECURITY FLEX 125 PROGRAM®
ENROLLMENT BOOKLET
Cosmetic expense ineligible – Per IRS
regulations cosmetic procedures do not
qualify. This includes cosmetic surgery or other
procedures that are for improving the patient’s
appearance and don’t meaningfully promote
the proper function of the body or prevent or
treat illness /disease.
8
Reasons (continued)
No Claim Form Received – Please submit a
signed claim form with your itemized receipt.
Receipt unreadable – The documentation that
was received was not a readable copy.
Offset ineligible transaction – The
reimbursement request was used to offset an
overpayment on the account.
Received on account ineligible –
Documentation received shows balance due
or amount paid. Itemized statements should
include: provider name and address, date of
service, patient name, unreimbursed charges
for the services, services provided or an EOB
from your insurance company.
Over-the-counter needs prescription – As
of January 1, 2011 IRS requires all over-thecounter medications to have a prescription.
Plan year deadline expired – Claims incurred
during your plan year must be submitted no
later than 90 days after the plan year ends. We
received your claim after this time as a result
no payment is available.
Signature required – All forms must be signed
by the participant.
You will have 180 days following receipt of this notification in which to appeal
the decision.
Appeals should be directed to:
Benefit Claims Administration
ERISA Appeals Administrator
PO Box 750600
Topeka KS 66675-0600
You may submit written comments, documents, records and other information
relating to the claim. If you request, you will be provided reasonable access to and
copies of all documents, records and other information relevant to the claim free
of charge.
Upon receipt of additional information related to the claim, we will review the
claim and provide a written response to the appeal within 60 days. (This period
may be extended an additional 60 days under certain circumstances.)
ENROLLMENT BOOKLET
You also have the right to bring a civil action under section 502 of ERISA
following denial of a claim.
9
SECURITY FLEX 125 PROGRAM®
Service Options
Web Access
The 24-hour website for your Section 125
Flexible Spending Account is www.securityflex.com
You will need to create an account for first-time login. To
create your account you will need your Flex Convenience
Card number or your Employer Identification Number.
The employer identification number can be found on
your welcome letter.
Fax Access
For 24-hour toll-free fax access for flex reimbursement,
call: 1-866-477-6526.
Phone Access
For personalized telephone support,
call 1-800-888-2461 toll free,
Monday-Friday from 8:00 am to 5:00 pm Central Time.
Paperless Communication
You can receive paperless communication regarding your
flexible spending account by providing your email address.
Please login to the website and update your email address
or email [email protected] and request your
email address be added to your account.
Providing your email address will allow you to receive
quarterly balance summaries, year-end reminders, email
communications on your claims once they are processed.
ENROLLMENT BOOKLET
If your email address is not on file you will not receive
quarterly balance statements. You will receive one
reminder at year end via mail.
SECURITY FLEX 125 PROGRAM®
10
Important Information Regarding the
Flex Convenience Card® (Mbi Benefits Card ®)
Purchases made with the Flex Convenience® card (Mbi Benefits
Card®) may still require proof of charges and claims. Below are
some guidelines your must follow when making purchases with
your card.
• If you have a recurring expense that is an odd dollar amount or
over $100.00. Please call: 1.800.888.2461 and we will enable
your card to accept the recurring expense. (e.g. orthodontia,
prescriptions, etc.)
• IRS regulations require that you keep copies of receipts and
invoices on all purchases made with your card or any other
submitted claims within your Flex Spending Account.
• The Flex Convenience card may not be accepted in all locations.
Please check with your pharmacy or drug store before placing
your order.
• Security Benefit may also request a copy of your receipt and
invoices for charges paid through your Flex Convenience card.
Your receipt and/or invoices must show:
• As of July 2009, the IRS requires all Drug Stores and Pharmacies
to have their UPC Codes on the standardized System. This means
some of the smaller stores may no longer accept the Flex Cards if
they have not updated their system.
o Name of provider
o Date of purchase
o The item or services purchased
o Your cost
o Name of person for whom the purchase was
made (i.e. child’s doctor appointment,
spouse’s prescriptions, etc.)
ENROLLMENT BOOKLET
If you receive a letter or notification requesting more
information/documentation and do not respond, your Flex
Card will be turned off. You will typically have 10 days to
respond after the date of the notice.
11
SECURITY FLEX 125 PROGRAM®
• If you accidentally use the card for ineligible expenses you will
be required to send a check or money order to refund the charge
back to the plan. If the refund is not received we will request
your employer withhold the amount from your pay on an
after-tax basis.
If you need further assistance with a claim/card reimbursement
please contact us at 1.800.888.2461.
Security Benefit’s
Flex Convenience Card (Mbi Benefits Card®) FAQ
Exactly what is the “convenience” of the card?
The card allows you to pay for eligible expenses at the point of
service. The convenience is:
• Immediate access to FSA account – you avoid paying with
cash or check
• Immediate payment of the expense – you avoid waiting for a
reimbursement check
• Claim form for documentation provided to you by mail or
e-mail
The ease of use at the point of sale and the reduced burden of
having to pay money out-of-pocket, completing a claim form and
waiting for a reimbursement has proven to be extremely convenient
for plan participants.
How does the Mbi Benefits Card® work?
The Mbi Benefits Card® is accepted only at certain merchants. This
includes physician offices, hospitals, dental offices, pharmacies
(including mail order), hearing/vision care provides, etc. As you
incur health care expenses, you present your card for payment. The
card system will validate that your coverage is active and that you
have available funds to cover the transaction. You must retain
documentation of the expense, as you may be required to
substantiate transactions in some cases by providing copies of the
documentation. We recommend that you keep all documentation in
a separate envelope for the entire plan year in the event the
information is requested. For example, itemized receipts listing the
merchant name, name of the item/product, date and amount will be
requested for all over-the-counter purchases. Use the card only for
qualifying expenses, otherwise, you’ll have to write a check back to
the plan or the card will be deactivated. The card works great for
prescription drug or office visit co-pays. If you purchase a
prescription drug along with non-qualifying items, be sure to ask
the merchant to ring up the prescription separately so that you can
use the card. You can use the card for other health expenses,
including medical, dental, vision and hearing. The card is valid for
a three-year period and will contain information regarding your
current plan year election. Each year when you re-enroll, the card
will reflect that plan year election amount(s).
Is this process paperless?
No. Although there is no requirement for you to complete
conventional claim forms, additional documentation will be required
in order to meet IRS guidelines. Therefore, you must keep copies of
all receipts and itemized statements (not the credit card receipt) for
each purchase for the entire plan year. You’ll receive a letter, or
email, requesting the documentation and you will be required to
submit this information to substantiate the expense according to
IRS regulations. You will need to return the signed letter, or email,
along with the documentation. DO NOT SEND IN THE REQUESTED
INFORMATION ON A REGULAR CLAIM FORM. In some cases, you will
not need to send in documentation. This occurs when your expense
matches a copay that is preset to match copays that may apply to
your employer’s health insurance.
What type of additional documentation is required?
The documentation is the same information required for traditional
paper claim forms. You must keep copies of all transaction receipts
for each card purchase so that these can be provided to the
administrator upon request. This includes itemized cash register
receipts that list the merchant name, name of the item/product,
date and amount (for items such as hearing aid batteries, contact
lens solutions or over-the-counter medicines/drugs), insurance plan
Explanation of Benefit (EOB) statements, and itemized statements
(for vision or other health care expenses). (It does not include the
credit card receipt.) For prescription drugs purchased at a
pharmacy, this would include the pharmacy receipt (or you can
request a printout from your pharmacy). Whenever possible,
however, you should purchase prescriptions through any available
mail-order service as this not only reduces your costs, it can also
help reduce or even eliminate the documentation requirements! We
recommend you keep all documentation in a separate envelope at
home or work for the entire plan year. REMEMBER, THIS
DOCUMENTATION NEEDS TO BE RETURNED ALONG WITH THE SIGNED
LETTER, OR EMAIL.
ENROLLMENT BOOKLET
What is the Mbi Benefits Card®?
The Mbi Benefits Card® is a debit card that can simplify the process
of paying for eligible expenses. It is an alternative to the traditional
method of filing claims. You can use the card at qualifying
merchant locations wherever MasterCard is accepted – from
physician and dental offices to pharmacies and vision service
locations.
SECURITY FLEX 125 PROGRAM®
12
Security Benefit’s
Flex Convenience Card (Mbi Benefits Card ®) FAQ
What happens if I forget to reply to the letter requesting
additional documentation?
In the event the request for additional information is ignored, a
second letter is generated giving you additional time to respond. If
there is no reply to the second request, collection procedures will
begin. The card will be deactivated and you will be required to make
reimbursement to the plan by personal check.
What happens if I accidentally use the card for ineligible or
non-qualifying expenses?
Be sure to have merchants ring up your qualifying expenses
separately from your other personal items so you can use the card. In
the event the card is misused, you will be required to write a
personal check back to the plan. If you do not reimburse the plan,
the card will be deactivated and collection procedures will begin. In
addition, your employer will be contacted.
Are there any limitations on the usage of the card?
Aside from the specific merchant codes and the plan year election
amount, there are no limitations. There are no transaction fees, and
you have unlimited use of the card. Remember, though, that you
must use the card for qualifying items only!
Will I receive a cardholder agreement?
Yes, you will receive a Fund Transfer Disclosure Statement
(cardholder agreement) that you should carefully read and must
abide by. You must also read the back of your convenience card, and
sign it. By using the card, you agree to the provisions of the
cardholder agreement. That is, you agree to use the card only for
qualifying expenses, and to provide documentation upon request.
ENROLLMENT BOOKLET
Must I use the card for all expenses I incur?
No. During the plan year, you can file traditional paper claims or use
the Mbi Benefits Card®. Remember, the card is valid for a three-year
period, so if you choose not to use it at all, we recommend you keep
the card in a safe and secure place in the event you wish to use it in
future years.
13
Will I receive a statement or an accounting of my Mbi Benefits
Card® transactions?
All transactions, whether they are paper claims or card transactions,
will be reflected on your periodic statements provided by Security
Benefit. You can also access our web site at www.securitybenefit.com
SECURITY FLEX 125 PROGRAM®
How do I report a lost or stolen card?
Lost or stolen cards must be reported as soon as possible. During our
normal hours of operation, contact us at 1-800-888-2461. Before or
after business hours and weekends, lost or stolen cards may be
reported at www.theflexcard.com. There is a $10.00 fee for card
replacement for any reason.
Can I order a card for my dependents?
Yes. You can order an extra convenience card for your spouse or
college student by completing the application provided. Please be
certain that your dependent fully understands how to appropriately
use the card for qualifying expenses only, and that they retain copies
of documentation of each transaction. There is a one-time cost of
$5.00 for one additional card.
What happens if I have a $1,000 limit on my Mbi Benefits Card®,
but I have a $1,500 transaction?
Transactions exceeding your card limit or available balance will be
rejected. For this reason, as you use the convenience card throughout
the year, you should check your available balance at www.
securitybenefit.com. This way you will know how much is available
and you can request that the merchant charge only up to the
available balance on the card. You may pay for the transaction and
file a claim. Your reimbursement would only be for the amount of
money you elected, minus the card fee and any other expenses
incurred previously. You would not be able to get more
reimbursements during the plan year either using the card or by
claim forms as you would exceed your election amount.
If I terminate employment, can I continue to use the
Mbi Benefits Card®?
No. The card is inactivated at that time. If you have qualifying
expenses to submit after your termination of employment, you can
use the traditional method of filing a claim form with appropriate
documentation. Claim forms are available on the web site.
(Remember, though, that your qualifying expenses must be incurred
during your period of coverage.)
®
Security Flex 125 Program ®
Medical/Dependent Care
Reimbursement Program Claim Form
Questions? Call our National Service Center at 1-800-888-2461.
Instructions
Use this form to request medical expense or dependent care reimbursement. Please type or print.
1. Complete all sections of the form and attach legible copies of itemized statements or an Explanation of Benefits
from your insurance provider.
2. You must sign Section 2 of this form. If the form is not signed, your claim will not be processed.
3. Claims may be submitted by fax, email or postal mail. Please retain a copy for your records.
4. Claims must be submitted in good order prior to the run-out date in your plan.
5. Do not use this claim form for Flex Convenience Card transactions or a claim that was submitted online.
1. Provide Personal Information
Employer Name ______________________________________________________________________________________________________
Social Security Number_______________________________________ Daytime Phone
Name of Employee_______________________________________________
First
Mailing Address_________________________________________________
Street Address
______________________________________
______ ____________________________________________
MI
Last
_____________________ ______ ________________________
City
State ZIP Code
❑ Check if address change
Email Address______________________________________________________________
By providing an email address you consent to receive electronic communications regarding your Flexible Spending
Account via email.
You are able to update your email address at www.securityflex.com or by contacting Security Benefit by phone, email, or
postal mail.
2. Provide Signature
I agree:
– That this claim represents qualifying medical or dependent care expenses not covered/reimbursed by insurance.
– My signature below confirms my understanding and agreement with this requirement.
– I further understand that any claim that does not meet these requirements may result in this payment being
considered a taxable payment by the IRS.
– I understand that the direct deposit arrangement will continue until Security Benefit receives written notification
from me stating otherwise.
– This is to certify that I have incurred expenses that qualify for reimbursement under my employer’s Security Benefit
Medical/Dependent Care Reimbursement Program. None of these expenses have previously been submitted.
– I certify that these expenses will not be paid or reimbursed by any insurance company or from any other source or I may
be subject to IRS fines and/or penalties of perjury. I hereby request reimbursement for these expenses to the extent
allowable. I understand that at the end of the plan year all unpaid claims (even if less than $25.00) will be reimbursed in
full and that any remaining fund balances at the end of the plan year will be forfeited to my employer.
– By providing an email address, I consent to receive all communications regarding this plan via email.
x____________________________________________________________________________________________________
Signature of Employee
________________
Date (mm/dd/yyyy)
Please Continue Â
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32-94589-00 2012/02/12 (1/2)
3. Provide Summary of Itemized Bills
❑ Dependent Care Expenses (DCA)
Provider Name
Dependent Name
Age
See IRC Section 129 for qualifying DCA expenses.
Date of Service Requested Amount
Total DCA Request
❑ Unreimbursed Medical Expenses (FMR/FSA)
Provider Name
Patient Name
Description of Date of Service Requested Amount
Service
See IRC Section 213 for qualifying FMR/FSA expenses.
Total FMR/FSA Request
4. Reimbursement Method
❍ Request reimbursement by direct deposit
❍ Request reimbursement by check
Please provide your bank information below if you wish to have payments from Security Benefit made by direct deposit
to your bank account. If any information is missing your request may be delayed. You may also attach a void check to
ensure necessary information is provided. Receipt by said bank of such credit entries shall be deemed receipt by you.
Bank Account Type (please check one):
Bank Name
❍ Checking
❍ Savings
__________________________________________________________________________________________________________
Name on Bank Account
______________________________________________________________________________________________
Bank Routing Number ________________________________________________________________________________________________
Bank Account Number (Do not include the check number)
____________________________________________________________
11234567891 12233582492 0001
DO NOT INCLUDE CHECK NUMBER
0001
Routing Number
Account Number
Date
$
Dollars
11234567891 12233582492 0001
For additional information on eligible expenses you may also review the Qualified Expense Chart available on
our website under the Forms section.
Mail to: Security Benefit • PO Box 750600 • Topeka, KS 66675-0600 or
Fax to: 1-866-477-6526
Visit us online at www.securityflex.com • E-mail: [email protected]
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EMPLOYEE BENEFIT WORKSHEET
Planning to save is easy! This simple worksheet helps you estimate your expenses for the plan year.
Estimated Dependent Care Expenses:
Dependent care required for you and your spouse to continue working.
Total Estimated Dependent Care Expenses for this plan year: $_____________
Estimated Out of Pocket Medical Expenses (for you, your spouse and any tax dependents):
Medical
Insurance Premiums of any kind are not covered
Medical Co-pays:
$ _______________/plan year
Coinsurance
$ _______________/plan year
Prescription Drugs
$ _______________/plan year
Over-the-counter Medication (see eligible expenses) $ _______________/plan year
Dental
Coinsurance
$ _______________/plan year
Orthodontia
$ _______________/plan year
Non-covered (major services)
$ _______________/plan year
Hearing
Coinsurance/Exams
$ _______________/plan year
Hearing Aid
$ _______________/plan year
Vision
Coinsurance/Exams
$ _______________/plan year
Glasses
$ _______________/plan year
Contact Lenses
$ _______________/plan year
Corrective Eye Surgery
$ _______________/plan year
Miscellaneous
$ _______________/plan year
_________________________________
$ _______________/plan year
_________________________________
$ _______________/plan year
_________________________________
$ _______________/plan year
Total Estimated Medical Expenses for this plan year: $_____________
SECURITY FLEX 125 PROGRAM®
ENROLLMENT BOOKLET
Other
18
Rules For IRC SEC. 125 Flexible Benefit Plans
The Security Flex 125 Program qualifies under Section 125 of the Internal Revenue Code, which allows employers to set up Flexible
Spending Accounts (FSA) for dependent care and/or medical expenses as part of their cafeteria plans. These expenses can be paid
with “before-tax” dollars. Below are the rules that the plan must adhere to:
Plan Year Rules
Examples of Eligible Medical Expenses
• During the plan year, you are only allowed to make changes
in the benefits selected if there is a family status change. (For
example marriage, divorce, birth, death, etc.)
Medical expenses not paid by your health insurance including
(but not limited to):
• All dollars set aside in an FSA plan must be used during the
plan year. Any dollars not spent by the end of the plan year
must be forfeited.
• Prescriptions
• Only charges for services provided or expenses incurred during
the coverage period year are eligible for reimbursement.
• Amounts paid under the plan are not eligible as tax deductions
on your Federal Income Tax Return.
Maximum Contributions
• The maximum allocation to your Medical Reimbursement
account may not exceed the annual plan maximum determined
by your employer.
• The maximum dependent care expense allowed is $5,000 per
calendar year per household ($2,500 in the case of a separate
return filed by a married person).
Eligible Expenses
• Expenses for you, your spouse and any taxable dependents
are eligible.
• The Dependent Care FSA allows expenses for: (a) your
dependent under age 13 for whom you may claim an exemption
deduction, or (b) your dependent who is physically or mentally
not able to care for himself or herself and who relies on you
for the majority of his or her support, or (c) your spouse who is
physically or mentally not able to care for himself or herself.
®
22-09100-15 2012/02/12
• Co-pays and deductibles for health, dental and vision
• Orthodontia
• Prescription eyewear including: eyeglasses, sunglasses, contacts
and solutions associated with their care.
Under the IRC Sec. 125 Flexible Benefit plan, you designate
the amount of dollars that you plan to use at the beginning
of the plan year. These dollars are applied to the appropriate
account (Medical or Dependent Care) each month. You
may submit claims for payment (subject to a minimum
reimbursement of $25). You may submit with each claim as
many bills or receipts as you have accumulated. Qualifying
medical expenses will be reimbursed up to your annual
election upon receipt of proper documentation, regardless
of your account balance. Dependent Care expenses are
reimbursed as funds are available in the account. Your
reimbursement may not exceed your account balance.
Tired of rising healthcare
costs? Put the power of
healthcare savings into your
own hands.
Flexible Spending Accounts, or FSAs, are a great
way for you to take advantage of a pre-tax benefit
account offered through your employer. These
accounts are a simple way for you to save on outof-pocket healthcare costs not covered by your
insurance plan. With healthcare costs continuing to
rise, why wouldn’t you participate in an FSA?
By taking advantage of your FSA, you can:
• Reduce your taxes
• Increase your take-home pay
• Pay for rising healthcare expenses with
pre-tax dollars
For more information, contact your plan
administrator or human resources department.
Still unsure about FSAs?
Take a look inside.
MasterCard® is a registered trademark of
MasterCard International Incorporated.
This card is issued by M&I Bank FSB pursuant to license by
MasterCard International Incorporated.
An FSA can be
used for healthcare
costs, such as
doctor co-pays,
LASIK surgery,
eyeglasses,
contact lenses,
orthodontics,
eligible over-thecounter products*,
prescriptions and
much more.
FSA
popularity
is in dollars
and sense.
A remarkable
$20 billion
is put into
FSA accounts
annually by
employees
just like you.
Let’s start with the definition of
an FSA. Quite simply, it stands for
Flexible Spending Account and it
can be an indispensable part of your
overall benefits program.
Here’s how it works. An FSA is an
account your employer sets up
so you can pay for a variety of
healthcare needs, like insurance
co-pays, deductibles, specific
over-the-counter healthcare
products and even some dental and
vision-care costs. But here’s the best
part: your FSA is funded entirely
by your pre-tax income. So you
can save money and offset rising
healthcare costs. And the more
dependents you have, the greater
your savings!
* Effective January 1, 2011, over-the-counter
medicines and drugs that are not prescribed
by a physician will not qualify as a medical
expense under IRS Code Section 213(d).
Here’s another way to look at an FSA: by setting aside
healthcare funds pre-tax, you can increase your savings
and ultimately your spending power. Below is an
example of the tax savings you could enjoy by taking
advantage of an FSA.
Annual Salary Before Taxes
FSA Contribution
Taxable Income
Less Taxes
- Federal Income Tax*
(estimate 15%)
- FICA 7.65%
Less Healthcare Expenses
Take-Home Pay
Tax Savings
With
an FSA
Without
an FSA
$30,000
- 1,500
$28,500
$30,000
0
$30,000
- 6,455
0
22,045
$340
- 6,795
- 1,500
21,705
$0
* If your federal income tax rate is higher than 15 percent or if you pay
state or local income taxes, you can save even more!
Savings and convenience
Although your FSA will be deducted through your
payroll, you’ll have access to your entire FSA contribution
on the first day of your plan. That means you can cover
all your healthcare costs without waiting to accumulate
funds throughout the year.
You can also plan for large healthcare expenditures,
like surgery, because you choose how much to put
into your FSA account. In addition, some employers
may offer a plan extension that allows you to continue
to spend unused FSA funds for an additional period of
time after the plan year ends.
Instant access and
no paperwork.
Of course, not all FSAs are created equal. Yours, for
instance, is accessed via the Benefits Card MasterCard®, provided by your employer. The Benefits Card
lets you pay for eligible healthcare expenses virtually
everywhere Debit MasterCard® cards are accepted.
Stretch your money further. Use your FSA dollars to
purchase eligible over-the-counter products that you
use every day – it’s simple!
The Benefits Card makes using your FSA
dollars simple and easy. The card deducts
each payment directly from your FSA
account. So it’s as convenient as using
an ordinary credit card. What’s more, the
Benefits Card virtually eliminates the
endless paperwork and reimbursement
wait time that used to make FSAs so
complex and cumbersome. All you
have to do is save receipts for all your
FSA purchases in the event they are
requested by your plan administrator.
In many cases you won’t have to send
in a receipt, because with the Benefits
Card, your purchases will be autosubstantiated at thousands of retailer
locations nationwide.* Because they have
an Inventory Information Approval System
(IIAS) in place, these retailers will know
instantly which items you purchase are
eligible FSA purchases. With one swipe of
your benefits card, approved purchases
will be authorized and debited from your
FSA account. You will be asked to remit
another form of payment for the noneligible items. For optimal convenience,
your Benefits Card offers 24/7/365 online
access, so you can check your account
balance and other vital information with a
single click.
To learn more about the benefits of
FSAs and the Benefits Card, simply ask
your employer. Once you know the
facts, you’ll discover that FSAs and the
Benefits Card spell real savings.
* For a complete list of retailers, contact your
benefits administrator.
Your Benefits
Card
provides
instant access
to your FSA
dollars at the
physician’s
office,
emergency
room,
dentist,
pharmacy
and other
eligible
locations.
The Benefits
Card is fast,
convenient,
secure and
simple to use.
So sign up
today and
look for your
Benefits Card
in the mail.