Reimbursement Account Information and Procedures

The company Application Software, Inc. (ASI) is the State's contracted Third Party Administrator (TPA) and recordkeeper for the FlexElect Program Medical Reimbursement Account (MRA) and Dependent Care Reimbursement Account (DCRA). Employees must complete Attachment H - FlexElect Reimbursement Claim Form (CalHR ) in order to receive reimbursement from their account. The company ASI will process all reimbursement account claims. Once completed, the original white copy of the form must be submitted to ASI along with appropriate country email list documentation (e.g., receipt, doctor's statement, itemized bill) to substantiate their medical or dependent care expenses in order to be reimbursed. The carbon pink copy should be retained by the employee. Employees enrolled in a DCRA may have their daycare provider sign the statement on the front of the CalHR , certifying that the services were provided, in lieu of attaching a receipt. The daycare provider's tax I.D. or social security number must also be included on the reimbursement claim form. In December, all participants who elected to enroll or reenroll into a MRA and/or a DCRA for the next plan year will receive a supply of Reimbursement Claim Forms. After completion of the claim form, it should be mailed or faxed along with supportive documentation to. Questions regarding reimbursement claims should be directed to ASI at the following toll free number --- or InfoLine ( hours - days a week) Period of Coverage for Reimbursement IRS Codes stipulate that eligible expenses, for purposes of the reimbursement accounts, must be for services/supplies received/purchased between the effective date of participation through December of the same plan year. The effective date of participation is the effective date of enrollment (i.e., January for those enrolling during the open enrollment period). If a participant is enrolled in the Medical Reimbursement Account and cancels his/her coverage before December , he/she may only submit claims for expenses incurred during the months for which they have contributed. Employees may get confused about when they can start claiming expenses because even though January is the start of the new plan year, reimbursement account deductions begin with the December pay period paycheck and continue through the following November pay period paycheck. This is because the December wages are dated January (of the following year) and are considered earnings for the next tax year. Submission of Reimbursement Claim Forms Employees who are enrolled in both a MRA and DCRA may request reimbursement from both accounts on one form by completing the appropriate sections. However, they will receive two reimbursement checks, one for each type of account. If employees are submitting reimbursement claims for two separate plan years, they must use two separate claim forms to ensure that reimbursement is made from the correct plan year account.