Debit Card Merchant List 90% Merchant List Direct Deposit and Opt Out Form Orthodontia Reimbursement Overview and Instructions Flexible Spending Account Enrollment/Election Form Healthcare Claim Form Dependent Care Claim Form Potential Expenses FSA FAQs for Employees FSA FAQs for Employers Letter of Medical Necessity Check Claims Plan Comparison Tool Cost Calculator Healthcare Terms Stretch your healthcare dollars with our EmpowerSM FSA Plan. A medical flexible spending account (FSA) allows you to set aside money for healthcare expenses and to use it tax-free. Use your FSA to pay for expenses such as copays, deductibles, many over-the-counter medications, first aid supplies, contact lenses and eyeglasses for you and your family items you would be paying for anyway! The benefit of the FSA is that you can pay for these items with pre-tax dollars. If you contribute to a health savings account (HSA), the IRS requires any accompanying FSA to be for "limited use." Save on taxes by reducing your taxable income Pay for common expenses with tax-free dollars Easy and convenient

Eligible expenses are determined by the employer based on IRS guidelines. For a listing of eligible medical expenses please see United States Code 26 Section 213(d) or IRS Publication 502 or check with your employer. Note: While insurance premiums are included in Publication 502, they are NOT reimbursable expenses for FSA purposes. Separate FSAs can be set up for dependent care expenses also. Please check with your employer to learn if this is an option for you.

How an FSA works Contribute from your paycheck. Your pre-determined contributions are deducted from your pay before taxes are calculated. Your employer decides the minimum and maximum contribution amounts for medical FSAs. (The IRS limits the contribution amounts for dependent care FSAs.) Money goes into your FSA. Your contributions are deposited into your FSA. Get reimbursed tax-free. When you have an eligible expense, you are reimbursed from your FSA. For medical FSAs, you can be reimbursed up to your full annual election from the first day of the plan year even though the full amount has not been deducted from your pay. Dependent care FSAs must have an available balance to cover reimbursement claims. How to get money from your FSA There are three ways to get your money from your FSA after you've paid an eligible medical expense. Automatic Claims Submission (paperless) Any medical, dental or pharmacy claim from a HealthPartners plan offered by your employer will automatically be forwarded to your HealthPartners FSA for processing. You do not need to fill out or submit any paper forms for these types of expenses (not offered on limited-use FSA plans where only dental and vision expenses are eligible). Claim Form For expenses not automatically forwarded (such as over-the-counter purchases), you can file a claim by mail or by fax. Healthcare Claim form, Dependent Care Claim form. Debit Card Some employers offer a debit card that automatically takes money from the FSA to pay for eligible medical expenses. Check with your employer to learn if this option is available to you. How to start Determine how much you want to set aside in your FSA. Review your medical claims from last year to estimate the dollar amount to elect for the coming year. View a checklist of potential FSA expenses. Direct deposit You can sign up to have your FSA reimbursements directly deposited into your bank account. There are no checks to lose and no trips to the bank to make a deposit. Direct deposit of your reimbursement makes using an FSA even easier. Fill out a Direct Deposit and Opt Out form today. Log on to your secure member page to check your claims. Use it or lose it. The IRS requires that FSA money be used during the period of coverage. A new rule allows employers to give employees a grace period after the year-end to use up any remaining funds. See your summary of benefits for details. Note: if you have a dependent covered under your health plan that does not qualify as a dependent under the federal tax code, you must opt-out of the automatic claims submission feature. You may also want to opt-out of the automatic claims submission feature if you have coverage under a spouse's healthcare plan and you want your spouse's plan to pay claims first. To opt-out of the automatic claims submission feature, complete the Direct Deposit and Opt Out form. To learn if a dependent you have covered under your plan does not qualify under the federal tax code, call Member Services at 952-883-7000 or 866-443-9352.