Benefits Enrollment & Reference Guide - Harford County Public ...

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Benefits Enrollment & Reference Guide - Harford County Public ...

Flexible Spending Account (FSA) Highlights

Type of

FSA

Maximum Annual

Contribution

Examples of

Eligible Expenses*

Health Care $5,000

Dependent Care $5,000

(NOTE: Deduction amounts

must be in whole dollar

increments)

(NOTE: Deduction amounts

must be in whole dollar

increments)

• orthodontia**

• copayments

• deductibles

• acupuncture

• chiropractic care

• hearing aids and batteries

• licensed day care facility, child or adult

• pre-school or nursery school

(not kindergarten)

• before and after-school programs

• eyeglasses

• smoking cessation expenses

• LASIK eye surgery

• Prescription drug copayments

• certain OTC supplies

• care in someone else’s home

• housekeeper who performs dependent

care duties

• day care provided by a non-dependent

relative over the age of 19

* The Internal Revenue Service (IRS) determines which expenses are eligible and which are ineligible. For a detailed list of examples, please refer to www.hfsbenefits.com.

** For orthodontia reimbursement, send a copy of your orthodontia agreement (orthodontic contract) along with your completed claim form when treatment

begins. The orthodontic agreement must state:

1. The beginning date of service

2. The approximate length of service

3. Total cost of service

4. Record fee

5. Initial fee (down payment)

6. Subsequent monthly fees

7. Total insurance coverage (if applicable)

** The fee for orthodontic records is eligible for reimbursement on the date the x-rays, photos, and casts are taken. Proper documentation is a statement of

services rendered from orthodontist. The initial fee (down payment) is eligible for reimbursement on the date of the first treatment. Again proper documentation

is a statement of services rendered from orthodontist.

Subsequent monthly fees are eligible for reimbursement as monthly orthodontic adjustments occur. Proper documentation is a statement of services rendered, a

receipt from orthodontist showing date of payment (“orthodontic” clearly noted on receipt), or a copy of payment stub from orthodontic payment booklet.

Special payment schedules, which do not coincide with dates of service (such as full payment at banding) will be paid in equal installments over the period of

service. Orthodontics is an ongoing treatment and the IRS prohibits pre-payment of these services. FSA Frequently Asked Questions.

Harford County Public Schools – Benefits Enrollment & Reference Guide 55

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