Flexible Benefit Plan

Enrollment Guide

Instructions for Using This Guide:

1 Review the information and decide how this plan benefits you.
2 Estimate your benefit using the worksheet.
3 Enroll or waive participation by completing the Plan
Participation Form, or enroll online at www.ProBenefits.com
(if offered by your employer).
4 Update or add your Direct Deposit information online at
www.ProBenefits.com or complete the Direct Deposit portion
of the Plan Participation Form.
5 Return the completed Form to your employer or complete
online enrollment by the announced deadline.

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This Guide contains general, explanatory information about a Flexible Benefit Plan. Flex Plans are governed by IRS regulations, which may be amended from time to time.
Information in this Guide is correct as of the date of printing, but please consult your company benefits administrator, a ProBenefits representative, or ProBenefits.com for the most
current information. If you enroll in the Plan, your Summary Plan Description ("SPD") will contain a full explanation of the Plan and your rights under the Plan.
 The Benefit
Flexible Spending Accounts (FSAs)
Flexible Spending Accounts (FSAs) are reimbursement accounts that allow you to pay
for certain eligible expenses with tax-free dollars. Through pre-tax salary reduction and
reimbursement, you convert taxable income into non-taxable benefits. The result is reduced
tax withholdings and more take-home pay. FSA participation results in tax savings of
approximately 30% for all dollars run through the plan.

There are two types of FSAs:

1. Medical/Dental/Vision FSA can be used to pay for
eligible unreimbursed medical expenses (not covered or
paid by any insurance) incurred by you, your spouse, and
your dependents. A general listing of reimbursable and non-
reimbursable expenses is included in this Guide. For more
information visit www.ProBenefits.com.
2. Dependent Care FSA can be used to pay for eligible de-
pendent care expenses (daycare, childcare) so you and your
spouse can work, look for work, or attend school full-time.
Covered expenses must be for:
Dependent children age 12 and under; or
A person of any age whom you claim as a dependent on your taxes and who is mentally or
physically incapable of caring for himself or herself.
Eligible expenses include childcare (nursery, preschool or private sitter), before and after-school
care, and day camps.
Ineligible expenses include kindergarten tuition, overnight camps, and expenses paid to a tax-
dependent.

Important Notes About FSAs:

There are varying FSA plan designs that treat unused
funds at the end of the plan year differently. For more
information about how your plan treats unused funds,
please refer to your Summary Plan Description (SPD).
Your FSA annual election cannot change during the
plan year except in the event of a recognized Status
Change or Qualifying Event.
Per IRS regulations, dependent care elections cannot
exceed $5,000 per family per tax year.
Please visit www.ProBenefits.com for more detailed
information on the IRS rules governing FSA plans.

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 Whats Reimbursable?
This non-exhaustive list of expenses reimbursable by your Medical Flexible Spending Account is based on Internal
Revenue Code 213(d). Please note that there have been important changes in the way over-the-counter drugs and
medicines are reimbursed. See www.ProBenefits.com for further information, or please feel free to contact us if
you have any questions about eligible expenses.
Reimbursable Expenses
Acupuncture Diagnostic fees Physician fees
Ambulance Diagnostic devices Practical nurse fees
Artificial limbs Drug & alcohol addiction treatment Prescribed medicine (if not cosmetic;
Artificial teeth Drug & medical supplies hair-loss medications are not
Automobile modifications (hand controls, Eyeglasses, incl. exam fee reimbursable)
lifts, etc.) Guide dog Psychiatrist's care
Bandages Handicapped persons' schools Psychologist's fees
Birth control Hearing devices & batteries Routine physicals
Blood pressure monitor Insulin Smoking cessation (prescribed drugs and
Braille books & magazines Laboratory fees non-drug programs)
Care for mental handicap Lactation expenses Special communications equipment for
Chiropractors Laser eye surgery the deaf
Copays, deductibles, & coinsurance Learning disability - special school fees Special education for the blind
Contact lenses & supplies Obstetrical expenses (after services have Surgical fees
Contraception been performed) Transportation expenses for medical
Costs for physical/mental illness Operations (medically necessary) service
Crutches Orthodontia (special rules apply; see Tubal ligation
Deductible, all family members www.ProBenefits.com) Tuition at special school for the
Dentist fees (if not cosmetic: e.g., teeth Orthotics/Orthopedic shoe inserts handicapped
whitening is a non-reimbursable Osteopath fees (licensed) Vasectomy
expense) Oxygen Wheelchair
Dentures Physical therapy X-rays

OTC Drugs and Medicines: Reimbursable with a Prescription Reimbursable with a Letter of Medical Necessity
Over-the-counter drugs and medicines now require a prescription These items may be reimbursable if accompanied by a note
for FSA reimbursement. The prescription must be written by a from a doctor recommending the item to treat a specific
physician on an official prescription pad and must include the medical condition. Other special rules may apply - see
name of the patient, the specific OTC drug or medicine, and the www.ProBenefits.com for more information.
number of refills or duration of treatment. You may submit a copy Cord blood storage
of the prescription and a receipt for purchase of the product with Home improvements for medical conditions
your reimbursement claim form. Nutritionist
Acid control medication (Prevacid, Prilosec, Zantac, etc.) Orthopedic shoes (not mass-produced)
Acne treatment Vitamins & nutritional supplements (only if recommended
Allergy medication (Zyrtec, Claritin, etc.) by a doctor for a specific medical condition)
Antacids (Tums, etc.) Weight loss to treat existing disease
Anti-itch medication John Smith 37 Wigs
6/3/15
Cold medication
Cough drops
Nicotine patches or gum
Zyrtec daily L E Not Reimbursable
Pain relievers (Advil, Tylenol, etc.)
Sleep aid medication
M
for 3 months P Cosmetic surgery (unless restorative) Finance charges

A
Food Imported drugs (Canada, Mexico) Insurance
Stomach remedies
(Pepto-Bismol, etc.)
E X premiums for individual policies Long-term care expenses
Marriage counseling Missed appointment fees Personal
hygiene products Spa fees Teeth whitening Toothbrushes
An example prescription for an Jane Doe, Toothpaste Warranties (including extended eyeglasses or
Over-the-Counter medicine:
MD corrective lens warranties, such as Eyewear Protection Plans)

2634 Reynolda Road Winston-Salem, NC 27106-3817 (336) 761-1850 (888) 722-8382 Fax (877) 761-1850 [email protected] www.ProBenefits.com
 5555 5555 5555 5555
5150
VALID
THRU

J Q PARTICIPANT
09/17

About the Flex Card

Please note: Your plan may not offer the Flex Card or your plan details may differ slightly from those below.
Contact your employer or ProBenefits for more information.

The Flex Card is a MasterCard limited merchant

category card. It is designed to work at merchants
with a health-care merchant category code, such as
a doctors office or hospital; at these locations,
card transactions which match your employer-
sponsored group health plan copays will be
automatically approved. You will need to submit
documentation to ProBenefits for other amounts.
The Flex Card will also work at retail merchants
which have an Inventory Information Approval
System (IIAS) in place. The IIAS will provide
automatic adjudication at the point of sale for
FSA-eligible items; this means you can only
purchase eligible items with your card at these
locations, and you will not need to submit
paperwork for these charges. However, per IRS
requirements, you should always keep your Top Five Benefits
receipts on file.
of the Flex Card
For a complete listing of eligible Merchant
Category Codes and a listing of IIAS Retail
Merchants where the Flex Card is accepted, please 1. Cashless FSA Transactions: The Flex
visit our website at www.ProBenefits.com. Card provides instant access to FSA funds,
reducing out-of-pocket expenditures.
2. Less Paperwork to Submit: Charges are
Important Notes About the Card: automatically approved at many locations
Save your receipts! You may not always need to where the card is accepted, so in many
submit them to ProBenefits, but the IRS requires cases you will only need to save your
that you keep them on file in case of an audit. receipts instead of submitting them to
For expenses not paid with your card, you can ProBenefits.
still submit a regular reimbursement claim form. 3. Online Account Access: See personal
The card is just one way to access your FSA. account information including your
Your card(s) will be mailed to the address on file available balance and transaction history.
with ProBenefits. 4. Free Cards: There is no fee for cards
Keep your card! Your card will not expire for 3 for you and your spouse or dependent.
years, so if you use up your FSA funds during this 5. Flexibility: You can still file reimburse-
plan year, save your card for use next year.
ment claims if you forget your card or
Your card is for medical expenses only - it cannot choose not to use it.
be used for dependent care (daycare) expenses.

2634 Reynolda Road Winston-Salem, NC 27106-3817 (336) 761-1850 (888) 722-8382 Fax (877) 761-1850 [email protected] www.ProBenefits.com
 Estimating Your Expenses
Use this worksheet to help estimate what out-of-pocket expenses you can
pay with tax-free dollars through a Flexible Spending Account (FSA).
1. Medical/Dental/Vision FSA
What is your estimate of medical/dental/vision costs to be incurred during the plan year and not reimbursed
by insurance or another benefit plan? Be sure to include expenses for you, your spouse, and all dependents,
even if they are not enrolled under your employer's insurance coverage. Confirm the eligibility of an expense
on our website (www.ProBenefits.com) or call us to discuss!
Medical
Insurance Deductibles $________
Copays and Coinsurance (amount not paid by insurance) $________
Routine Exams (Physicals, Ob-Gyn, etc.) $________
Prescription Drugs (Including birth control) $________
Over-the-Counter Medications (only with a prescription) $________
Over-the-Counter Non-Drug Medical Items $________
Dental
Insurance Deductibles, if applicable $________
Copays and Coinsurance (amount not paid by insurance) $________
Exams, Cleaning, X-rays, etc. (NOT teeth whitening) $________
Fillings, Caps, Crowns, Bridges, etc. $________
Orthodontia (Braces) Note: Special rules apply $________
Vision Care (Exams, Contacts, Glasses, LASIK Surgery) $________
Hearing Care (Exams, Hearing Aids & Batteries, etc.) $________
Other unreimbursed medical expenses $________

Total Medical/Dental/Vision Expenses $________/Year

2. Dependent Care FSA
If your spouse works or if you are a single parent, how much do you pay for employment-related dependent
day care or childcare services for children age 12 and under? Only fees for actual care may be reimbursed.
Kindergarten tuition, overnight camps, and expenses paid to a tax-dependent are ineligible.
Total Dependent Care Expense $_________/Year

Remember:
Due to changes in the laws governing FSA plans, over-the-counter medicines and
drugs now require a prescription for reimbursement. Over-the-counter non-drug
medical items and insulin are still reimbursable without a prescription.
Reimbursement is based on the date of service, not the date of payment. In order
for you to be reimbursed from your FSA funds, the date the expense is incurred
must be within the current plan year and while you are an active participant in the plan.
Prepayments, such as deposits for prenatal care/delivery, surgery, dental work, or dependent care summer
programs, are not eligible for reimbursement until the service has actually been rendered.
You have 90 days after the end of your plan year or 90 days after your last day of plan participation to file
reimbursement claims for eligible expenses.
Your Dependent Care and Medical/Dental/Vision FSAs are two separate plans, and funds cannot be trans-
ferred between them.
Please call us or visit our website, www.ProBenefits.com, for any questions about eligible expenses.

2634 Reynolda Road Winston-Salem, NC 27106-3817 (336) 761-1850 (888) 722-8382 Fax (877) 761-1850 [email protected] www.ProBenefits.com
 Staying Informed
At www.ProBenefits.com:
Use an interactive FSA Savings Calculator to
see how much you save with the Flexible
Spending Account
Make changes to your contact information
Add or change your direct deposit information
View account balances
Submit a claim online, or print a claim form for
faxing or mailing
Check the status and view images of claims you
have submitted

Logging in to your ProBenefits.com account: After enrollment for your plan is complete, you can
Go to www.ProBenefits.com and click the My access your Flexible Spending Account information at
Account button in the upper right corner. If you have any time on our secure website. When logged in to your
never logged in before, follow the instructions for account, you will be able to view account balances,
First Time Users for your initial login, and then claim information, pending Flex Card transactions, and
choose a new user name and password for future use. even images of claims you have submitted.
If you have logged in before but have forgotten your ProBenefits will also email claim and payment
username and/or password, click the Forgot confirmations to help you keep track of your account -
Username or Password link and follow the steps to provide your email address on your Plan Participation
have your login information reset. Form, or add or change your email address and other
contact information online at www.ProBenefits.com.

Contact Us
Scan this code with
Email: [email protected] your mobile device for
quick access to our
Phone: (336) 761-1850 FSA Savings Calculator
and other useful
(888) 722-8382 enrollment information
on our website.
Mailing Address:
2634 Reynolda Road
Winston-Salem, NC 27106-3817
Website:
www.ProBenefits.com

The information included in this Guide is for explanation only and is not intended as tax advice.
In all matters where tax or legal advice is needed, the services of professional counsel should be sought.
Flexible Benefit Plan Participation Form Please print clearly!

Employer:
Employee Name: First Name Last Name
Social Sec#:
Mailing Address: Street City St. Zip

Birth Date: Hire Date: Email: ProBenefits will email Claims & Payment Verifications

Flexible Spending Accounts Plan Year Benefit Elections Employer: Please complete
o Request to PARTICIPATE Med FSA Amount/Pay Pd.

A. Medical / Dental / Vision Care $ / Plan Year

The cost paid by you or your dependents for medical, vision [Employer-set minimums Dep FSA Amount/Pay Pd.
or dental care which is not reimbursed by insurance. and maximums apply]

B. Dependent Care $ / Plan Year

Employment-related custodial care for qualifying dependents First Payroll Date Impacted
[IRS Family Maximum $5000/yr]
(children age 12 and under; or dependent, disabled adults).

o Request to WAIVE Initial to Indicate Approval

The Flexible Benefit Plan has been explained and I elect to waive participation in Flexible Spending Accounts. I
understand that without a Change in Status or other Qualifying Event described in the Plan, my next opportunity
to enroll will be at the start of the next plan year; if not changed, this waiver will continue in effect indefinitely.

Flex Card - ONLY for Initial Signup (If offered by your plan) Employer: Is employee a
o I want a Flex Card. IMPORTANT: If you already have a ProBenefits Flex Card, DO NOT complete this participant in your group
section. You will automatically receive a new card in the mail when your current card expires. If you and/or health plan? oYes oNo
your dependent have lost your card(s) or you skipped a year of FSA participation, please contact ProBenefits.

Home Phone #:__________________________________ Mothers Maiden Name:_______________________________________

For security purposes only

Additional Card for Spouse or Dependent:________________________________________ Relationship:________________________

21 characters maximum including spaces (i.e., Spouse or Child)

Weekly Direct
Deposit Signup IMPORTANT: If you are re-enrolling for a new plan year and you already receive
(If offered by your plan) Direct Deposit reimbursements, DO NOT complete this section unless your
bank information has changed. You may also add or change Direct Deposit information
Type of Account: any time during the plan year by logging into your account online at www.ProBenefits.com.
o Checking
o Savings
Please check one:
Please tape a Voided Check (not deposit slip) here.
o I am signing up for
Direct Deposit for A voided check supplies the account numbers and routing information
the first time. required by the bank to establish your Direct Deposit arrangement.
o I would like to (Deposit slips sometimes do not include all needed information.)
change my account
information.

By signing below I certify that I have read the Flexible Spending Accounts Acknowledgments and, if applicable, the Flex Card Acknowledgments
and/or the Direct Deposit Reimbursement Authorization Agreement on the reverse of this page. I agree to the terms of participation listed in this
Guide. I authorize my employer to adjust my compensation by the amount of my Benefit Elections shown above.

Signature ___________________________________ Date: ____________

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 Acknowledgments
Flexible Benefit Plan and Flexible Spending Accounts
1. My portion, if any, of insurance premiums for eligible employer-sponsored insurance plans elected for myself and my dependents will
be automatically pre-taxed unless I sign a Pre-Tax Waiver form provided by my employer. My employer may adjust pre-tax premiums
if rates change during the year, but I may not be able to change my election during the Plan Year.
2. I cannot change or revoke my elections prior to the start of the next plan year, unless I have a Change in Status or other Qualifying
Event described in the Plan. The Summary Plan Description (SPD) includes a full explanation.
3. Signing this form does not initiate my coverage under any insurance policy.
4. My Plan Year benefit elections may be slightly rounded, if necessary, to allow per-pay-period salary reductions.
5. I understand that the Annualization Rule (Uniform Coverage Rule) applies to the Medical/Dental/Vision FSA and entitles me to
reimbursement up to the full annual election at any time during the plan year once eligible expenses are incurred. I understand the
Annualization Rule does not apply to the Dependent Care FSA, and that Dependent Care reimbursements cannot exceed contributions
for the plan year to date. This means that eligible childcare expenses can only be reimbursed as contributions are deducted from my
pay, and even though an expense may be eligible and approved, reimbursement will not be made until sufficient funds are contributed.
6. Depending on my plan design, unused amounts remaining in Flexible Spending Accounts for the Plan Year and applicable runout
period(s) may be forfeited.
7. I can only submit claims for expenses incurred during the Plan Year while I am an active participant in the Plan. Such reimbursement
requests must be submitted with appropriate documentation (claim form and provider receipts) no later than 90 days after the end of the
Plan Year or 90 days after termination of plan participation, whichever comes first.
8. My benefit account(s) and claim data may be maintained on a computer system providing automated access.
9. Due to privacy concerns, ProBenefits will discuss claim information only with me as the participant.
10. Participation in this Plan may mean paying less Social Security tax, which could reduce my future Social Security benefits.
11. Enrollment in the Medical Flexible Spending Account listed covers me and my eligible dependents, if any. I understand that FSA
enrollment may impact my eligibility, or eligibility of my spouse or dependent(s), for a Health Savings Account (HSA). I also
understand that I cannot change or reduce my Medical FSA during the plan year in order to enroll in an HSA. Note: To enroll in an
Employee-Only or Employee-Plus-Children Medical FSA or a Limited FSA (covering only dental/vision expenses), see your
benefits administrator for a special form.
12. This document provides general information about a Flexible Benefit Plan. For more specific information, I will review my Plan's SPD.
13. Due to IRS non-discrimination rules for flex plans, in some circumstances the pre-tax elections of Highly Compensated Employees or
Key Employees must be adjusted mid-year to meet IRS compliance testing guidelines. If you are deemed to be a Highly Compensated
Employee or Key Employee, your election may be reduced or discontinued in such a circumstance. If so, the benefits administrator will
provide notice and further details.
Flex Card (If offered by your plan)
After completing the Flex Card - Initial Signup on the Plan Participation Form, as an FSA participant you will receive a mySourceCard
MasterCard and agree to use it according to these Acknowledgments and the Cardholder Agreement that will be provided with the card.
1. I understand that the Flex Card is restricted to certain merchant categories and approved IIAS vendors and is not accepted at all
MasterCard authorized locations.
2. I understand that I may not obtain a cash advance with the card at any merchant, bank or ATM.
3. I understand that the card is to be used exclusively for Qualified Expenses as defined by the plan(s) in which I participate. If the card is
used for an expense that is not a Qualified Expense, I understand that I am indebted to my employer and must repay the full amount of the
non-qualified expense. Repayment for non-qualified expenses may be in the form of an offsetting claim, a personal check, electronic draft
from my personal checking or savings account, a post-tax deduction from my paycheck, or other options established by my employer.
4. I acknowledge that IRS rules require me to save all invoices and receipts related to any expense paid with the card. I agree that, upon
request, I will submit these documents for review by the Plan Service Provider. I understand that failure to submit the receipt(s) in a
timely manner will cause the expense to be treated as a non-qualified expense and may cause my card to be suspended.
5. I understand that I may be assessed a $10.00 replacement card fee if I lose or misplace my card(s). I also understand that if I request
more than two cards (one for myself and one for my spouse or a dependent), I may be assessed a $10.00 fee for each additional card.
Direct Deposit Reimbursement Authorization Agreement (If offered by your plan)
1. I hereby authorize ProBenefits, Inc. (hereinafter Plan Service Provider) to initiate credit entries (electronic and otherwise) and, if
necessary, debit entries and adjustments for any erroneous credit entries to my Personal Bank Account in the financial institution named
(hereinafter Financial Institution).
2. This authority is to remain in force until the Plan Service Provider has received written notification from me of its termination in such
time and manner as to afford Plan Service Provider and Financial Institution a reasonable opportunity to act on it. I can discontinue this
arrangement at any time and receive reimbursements monthly by check, if offered by my plan.
3. I acknowledge that my Flexible Spending Account (FSA) information will be available to me 24 hrs/day by internet (www.ProBenefits.com),
and that I will not receive written verification each time a reimbursement payment is made.

Please complete and sign the Plan Participation Form on the reverse of this page.

2634 Reynolda Road Winston-Salem, NC 27106-3817 (336) 761-1850 (888) 722-8382 Fax (877) 761-1850 [email protected] www.ProBenefits.com