CAFETERIA PLAN:
FLEXIBLE SPENDING ACCOUNTS
Within your Section 125 / Cafeteria Plan, there are three primary types of Flexible Spending
Accounts.
FSA – Medical Spending Account
FSA – Medical Spending accounts are for medical expenses you pay completely out of your
own pocket.
FSA - Medical Spending accounts are “pre-funded” which means that your entire election is
available for reimbursement on the first day of the plan year, even before your first deduction.
Examples of Eligible Expenses:
● Co-Pays
● Prescription Costs
● Health Insurance Deductible
● Dental Services
● Orthodontics
●
●
●
●
●
Mileage
Chiropractic Visits
Contacts / Solution
Eye Exams and Glasses
Lasik Surgery
When submitting claims, make sure your receipts or documentation show the date of
service, description of service, the amount of the expense, who the service was for, and who
provided the items or services.
Dependent Care
Dependent Care accounts allow up to $5,000 per family for day care expenses while you or
your spouse are at work.
Dependent Care accounts are not pre-funded. You can only be reimbursed with funds that
are actually in the account.
In order to qualify, your dependents must be:
A child under the age of 13
A child/spouse/dependent who is physically incapable of self-care and spends at least
8 hours a day in your household.
A dependent child that will be claimed on your current year taxes.
Please check with your tax professional for information on the available tax credit.
Qualified expenses for reimbursement include adult and child day care centers, and before/
after school care. Please note that day care services may not be reimbursed if it is provided
by immediate family members.
Individual Supplemental Medical Insurance Premium Account
Refers to any eligible insurance premiums that you are paying out of your own pocket. This
includes non-employer-provided dental and vision insurance and some
supplemental insurance. Individual Major Medical Insurance is NOT eligible.
You will be reimbursed automatically each time a contribution is received if we have a claim.
CHICAGO • GREAT BEND • LAWRENCE • MANHATTAN • OVERLAND PARK • WICHITA
ESTIMATED CAFETERIA SAVINGS EXAMPLE
Weekly gross pay
Cafeteria Plan expenses (Before taxes)
WITHOUT PLAN
$500.00
WITH PLAN
$500.00
($25.00)
$475.00
$500.00
Salary subject to taxes
Taxes:
Federal Tax (15%)*
State Tax (3%)
FICA Tax (7.65%)
($75.00)
($15.00)
($38.25)
($128.25)
$371.25
($25.00)
$346.25
Total Taxes
After Tax Pay
Cafeteria Plan Expenses (After Tax)
Take Home Pay
($71.25)
($14.25)
($36.34)
($121.84)
$353.16
$0.00
$353.16
$
$
Net Increased Income per week
Net Increased Income per Year
6.91
359.32
ESTIMATE YOUR SAVINGS
WITHOUT PLAN
1 Weekly gross pay
2 Cafeteria Plan expenses (Before taxes)
3 Salary subject to taxes (1-2)
Taxes:
Federal Tax (15%)*
State Tax (3%)
FICA Tax (7.65%)
4 Total Taxes (Sum of Taxes)
5 After Tax Pay (3-4)
6 Cafeteria Plan Expenses (After Tax)
7 Take Home Pay (5-6)
8 Net Increased Income per week (7 Column 1-2)
Net Increased Income per Year (8*52 Weeks)
*Tax Rate is Subject to your Income Tax Bracket
WITH PLAN
KEATING & ASSOCIATES, INC
FLEX ELECTION FORM AND
SALARY REDUCTION AGREEMENT
1011 Poyntz Ave, Manhattan, KS 66502
(785) 537-0366 • (866) 537-0366 • FAX (877) 537-0747
For the
______ plan year
Employer
Employee name
E-mail
Address
Street Address
City
State
Employee Social Security No. _______________________________ Birth date
Effective date of enrollment
/
/_______
Zip+4
Phone no.
First payroll reduction date
/
/_______
No. of pay periods
I authorize my employer to make the following salary reductions:
Before-Tax Group Insurance Premiums- I elect to pay the following premiums through a before-tax reduction of my salary:
Per Pay
Period
Annual*
1.
Medical
$
$
4.
Health Savings Account
2.
Dental
$
$
5.
Other (specify below)
Vision
$
$
3.
Per Pay
Period
Annual*
Medical Care Reimbursement Account──including deductibles, co-insurance and other expenses not paid
by insurance as described in Part A on the back of this form.
$
$
$
$
$
$
Dependent Care Reimbursement Account──for reduction limits and eligibility information of dependent
care expenses see Part B on page two.
$
$
Other ________________________________
$
$
$
$
*Individual Premiums for major medical coverage are not eligible.*
Total pre-tax expense
I understand that:
● I cannot change this election during the plan year unless I have a change in status.
● If I terminate employment, I have 90 days to turn in claims for dates of service that occurred prior to my termination.
● Any amounts remaining in my reimbursement accounts at the end of the year will be forfeited.
● My Social Security benefits may be reduced by this election.
● My employer may reduce or cancel this election as necessary to comply with provisions of the Internal Revenue Code.
Employee Signature ________________________________________________________________________________ Date
WAIVER OF PRE-TAX BENEFITS UNDER THE FLEXIBLE BENEFITS PLAN
I elect to waive all pre-tax benefits under the Flexible Benefits Plan, but I understand that I may elect similar coverage(s) on an after-tax basis. I understand
that I cannot elect pre-tax benefits until the next anniversary date, and any after-tax coverage shall be outside the plan.
Employee Signature ________________________________________________________________________________ Date
FORM REV 12‐12‐14 PART A MEDICAL CARE EXPENSES (I.R.C. §213)
The following are examples of medical or medically-related expenses which may be claimed as qualified health care expenses under the plan. All health
care expenses must be for the diagnosis, cure, mitigation, treatment or prevention of disease or for the purpose of affecting any structure or function of
the body to be a qualified health care expense under the comp-flex plan.
● Hospital, laboratory, surgery and x-ray expenses.
● Fees from medical doctors, chiropractors, osteopaths, nurses, psychologists, dentists, Christian Science practitioners and other licensed healing arts
practitioners for diagnosis, treatment, routine exams and other non-diagnostic services.
● Co-insurance and deductibles.
● Artificial limbs and teeth.
● Braces, crutches, orthopedic shoes and wheelchairs. Vision and hearing exams, eyeglasses, contacts and hearing aids (including
batteries). ● Prescribed drugs including insulin
● Care and treatment of alcoholism and alcohol and drug addiction.
● Transportation for medical treatment of specific problems including ambulance.
● Miscellaneous medical services and supplies.
—
PART B DEPENDENT CARE EXPENSES (I.R.C. §129)
Only those dependent care expenses which allow you (and your spouse if you are married) to be gainfully employed are eligible. This excludes care
which is primarily for medical or educational purposes.
Eligible dependents:
● Dependent children under age 13, or any other dependent who is incapable of caring for himself or herself and whose principal residence is your home.
Eligible expenses:
● Reimbursement is limited to the income of the lower earning spouse and also $5,000 per year; $2,500 if married, filing separate return. Married
employees in separate plans can only be reimbursed in total for $5,000. The reimbursement amount may not exceed the employee’s salary; or for
married employees, the lesser of the spouse’s salaries (subject to certain exceptions). If your spouse is a full time student or incapable of caring for
himself or herself, the maximum is $200 per month for one child or $400 per month for two or more children.
Eligible providers:
● A licensed day care center which cares for six or more persons.
● An unlicensed provider caring for less than six persons.
● An in-home provider, as long as that provider is not your child under age 19 or someone you or your spouse claim as a dependent for tax purposes.
—
PART C─INDIVIDUAL PREMIUM EXPENSES
Eligible expenses:
● Premiums paid for dental, vision or disability* insurance, Medicare Part B and other disease specific premiums.
*If disability insurance premiums are paid pre-tax, any benefits received are taxable to the employee.
● College/private school student health fees.
Ineligible expenses:
● Major medical health premiums
● Whole life policies.
● Your spouse’s group insurance premiums (insurance sponsored by spouse’s employer).
● Lifetime care (nursing home) policy premiums.
PART D CHANGE IN STATUS
The amounts reduced from your salary for group insurance premiums, medical care, dependent care and/or individual insurance premium reimbursement
accounts may not be changed unless you have a change in status for the following reasons, the change is consistent with the change in status and such
change is permitted by your employer.
—
● Marriage, divorce, legal separation or annulment of marriage of the employee.
● Birth or adoption of a child (or placement of a child for adoption) of the employee.
● Gain or loss of a dependent.
● Change in employment status of employee, spouse or dependent─includes an increase or
decrease in hours worked, switching from full-time to parttime employment or vice-versa, a strike or lockout occurring at the place of employment, or commencement of or return from a leave of absence.
● Change in the place of residence or worksite of employee, spouse or dependent─if a participant moves out of the service area of an HMO or PPO, he
or she may change the annual election amount of the pre-tax group insurance premium, NOT the medical care reimbursement account. Dependent
care annual elections may be changed at this time also if the new provider’s rates are different than the previous provider’s rates.
● Significant cost or coverage changes in employee’s or spouse’s group health insurance plan─if this occurs, only items 1-7 on page one of this form
may be changed.
● Significant increase or decrease for dependent care expenses. For more information, see IRS publication 503, “Child and Dependent Care Credit,”
available from your local IRS office.
FORM REV 12‐12‐14 Keating & Associates, Inc.
Claim Form
1011 Poyntz Ave, Manhattan, KS 66502
Name:
Last four digits of Social Security #:
Address Change:
Employer:
E-Mail:
FSA – Medical Claim Information (Please complete)
Date of Service
Person for whom
Expense was incurred
Provider - attach copy of receipt**
Amount
1.
/
/
$
2.
/
/
$
3.
/
/
$
4.
/
/
$
5.
/
/
$
Medical Care Total
$
Dependent Care Claim Information
To/From Service dates
Daycare Provider attach receipt/statement
Amount
1.
/
/
-
/
/
$
2.
/
/
-
/
/
$
3.
/
/
-
/
/
$
Dependent Care Total $
*Under penalties of perjury, I swear that the amounts indicated above are reimbursable to me,
incurred by me during the plan year, paid by me during the plan year, and satisfy the requirements of
the employee cafeteria benefit plan of
.
(Your Company Name)
Date:
Employee Signature:
SEND COMPLETED FORM
AND RECEIPTS TO:
Keating & Associates, Inc.
Cafeteria Department
1011 Poyntz Ave.
Manhattan, KS 66502
537-0366
CONTACT INFO:
claims@keatinginc.com
Fax: 785-537-0747 Local
Fax: 877-537-0747 Toll Free
**The qualified receipt must include: the date of service, the description of service, whom it
was for, who provided the services, and the amount of the expense.**
What is a qualified receipt?
A qualified receipt must be included with any claims submitted to Keating &
Associates. A qualified receipt includes the:
•
•
•
•
•
Date of service, (not date of payment or billing date)
Description of the item or service claimed
Whom the item or service was for
Who provided the items or services
The amount of the expense
Examples of items that can NOT be used as a qualified receipt are:
• Credit Card Receipts
• Register Receipts (Unless for Over-the-Counter Items that qualify or have a
doctor’s prescription)
• Statements of Accounts
• Voided Checks
• Remittance Slips or Statements
Examples of items that CAN be used as a qualified receipt are:
•
•
•
•
Explanation of Benefits from your insurance provider
Prescription Leaflets
Printout from Pharmacy
Statement or receipt from provider with the above listed requirements (must
list service, not balance forward)
Mileage Rates for 2015
•
0.23 cents per mile for travel expenses related to medical care with a date
of service between 01/01/2015-12/31/2015.
1011 Poyntz Ave. • Manhattan, KS 66502 • Phone (785) 537-0366
(785) 537-0747 Local Fax • (877) 537-0747 Toll Free Fax
Website Access
Every participant in the cafeteria plan has their own personal cafeteria website.
You can access your website from anywhere 24 hours a day! On your website you
can:




Check your available balance.
Enter claims and print claim forms.
See pending & completed payments.
Make address changes or personal information changes.
To register for you employee website, please follow the steps below. Once you
have registered for the first time, you simply have to log in as a registered user
and you are on your way.




Go to www.keatinginc.com
Select “Cafeteria Plan Participants” under “Current Clients” on the top.
Click on the phrase “My Employee Account”.
Register as a new user using your SSN, DOB & valid Email address.
OR
 Sign in to your account.
1011 Poyntz Ave.  Manhattan, KS 66502  Phone (785) 537-0366
(785) 537-0747 Local Fax  (877) 537-0747 Toll Free Fax
Direct Deposit – Credit Authorization Form
I (we) hereby authorize Keating & Associates, Inc., hereinafter called COMPANY, to initiate credit entries for Cafeteria Plan
Reimbursements to my (our) account indicated below and the financial institution named below, hereinafter called
FINANCIAL INSTITUTION, to credit the same to such account. I (we) acknowledge that the origination of ACH transactions
to my (our) account must comply with the provisions of U.S. law.
___________________________________
Financial Institution Name
____________________________________
Branch
______________________________________________________________________________________
Address
City/State
Zip
___________________
Routing Number
___________________
Account Number
Type of Acct:  Checking  Savings
This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us)
of its termination in such time and manner as to afford COMPANY and FINANCIAL INSTITUTION a reasonable opportunity
to act on it.
___________________________________
Print Your Name
____________________________________
Print Your Employer’s Name
___________________________________
Social Security Number
___________________________________
Signature
____________________________________
Date
PLEASE ATTACH COPY OF VOIDED CHECK TO THIS FORM
**** Once a direct deposit is set up with Keating & Associates, Inc., no paper
confirmation of deposit will be sent to an employee. The employee will be responsible for
verifying their deposit through their employee website. ****
KEATING & ASSOCIATES, INC
1011 Poyntz Ave, Manhattan, KS 66502
(785) 537-0366 • (866) 537-0366 • FAX (877) 537-0747
NONDISCRIMINATION
TESTING FOR SECTION 125
Flexible benefit plans may not discriminate in favor of highly-compensated or key employees. The nondiscrimination
requirements cover eligibility to participate as well as availability and utilization of benefits. The requirements clearly indicate
that the plan cannot be primarily for the benefit of highly-compensated or key employees.
If benefits are available only to highly-paid employees, or are used disproportionately by this group, the plan will not comply
with the nondiscrimination requirements. Although discrimination does not automatically result in disqualification of the plan,
if a plan does not satisfy the requirements, highly-compensated participants lose the tax advantages of pretax salary
reductions.
Complete the Employee Wage Information attached to this form as follows:
Column 1—Employee name
All eligible employees' names must be listed, even those not participating in the Section 125 plan.
Column 2—Employee social security number
Column 3—Employee level
Indicate employee level using the following key:
 HC - Highly-compensated (see definition below)
 K - Key employee (see definition below)
 HCK - Highly-compensated and key employee
 E - Employee
 U — Employee whose annual salary is less than $25,000.00
Highly-compensated (defined in IRS § 125):
- An officer of the employer, or
- 5 percent owner of the employer, or
- Anyone who received compensation for the preceding year in excess of $115,000 (indexed annually)
Key employee (defined in IRS § 416(1) (1)):
- An officer making more than $165,000 (based on 2013 indexing), or
- An owner of more than 5 percent of the employer, or
- An owner of more than 1 percent of the employer who earned more than $165,000
Column 4—Five percent owner
Indicate whether the employee is a 5 percent or greater owner by checking Yes or No.
Column 5— Estimated employee gross salary for the coming plan year
Indicate the employees' estimated gross earnings for the coming plan year. Include bonuses and commissions.
Column 6—Employee pre-tax Section 125 deductions for the plan year
Indicate the estimated total premium (i.e. group health, dental, vision, accident, hospital indemnity, and flex
spending election) amounts that employees will have withheld from their paychecks pre-tax in the coming
plan year.
FORM REV 02.24.2014
FORM REV 10.14.2013
How to Use the MyFlexMobile Application – iPhone or Android
iPhone Application: Go to the iTunes store and search for “MyFlexMobile” and download
Android Applciation: Go to the Play Store and search for “MyFlexMobile” and download

Login to the App o Click on the MyFlexMobile App icon to access the login page
o Enter or set-up your username and password (same username and
password as MyFlexOnline.com)

To submit a claim or debit card receipt
o Select “Submit New Receipt”
o To upload a claim, click on “Flex Claim” or to submit a receipt for debit card use select
“Flex Card Receipt”
o At the Instructions page, select “Next” to proceed
o Enter the date of service
o Enter total amount
o Enter a photo – you can upload from your phone or “take a photo”
o “Retake” or “Use” the photo
o Read the Attestation Statement and “Submit”
o Select “Done” to submit another claim or “Log Out” to exit

View your account benefits and balance(s) by selecting “Account”

View your account history by selecting “All”
MyFlexMobile
You’ll love the convenience of the MyFlex Mobile app. This handy free mobile app is
the quick and easy way to manage all of your flex benefits. Download MyFlexMobile to
your smartphone, log in to your account, and check your balances, submit claims, snap
photos of receipts, get alerts by text or email—all on the go!
SM
WHY YOU NEED IT
• Snap a photo of receipts and submit them instantly
for payment to avoid the headache of verifying
card transactions
• File claims, view transactions, and check account
balances on the go
• Receive account alerts by email and text messages
for the ultimate mobile convenience
HOW IT WORKS
MyFlexMobile makes managing your benefits quick,
easy, and completely mobile. It automates and streamlines
everything—there are no forms to fill out, nothing to mail
in. This handy mobile app works with:
• Healthcare Flexible Spending Account
• Dependent Care Flexible Spending Account
• Health Savings Account
• HSA-Compatible Flexible Spending Accounts
• Health Reimbursement Arrangement
• Commuter benefits
MyFlexMobile
HOW YOU USE IT
It’s easy to use MyFlex Mobile. Simply download this free
app to your iPhone or Android smartphone, log in to your
take care account, and use MyFlexMobile to:
SM
• File a claim
• Snap a photo of receipts and submit them instantly
for payment
• View transactions and account and card balances
• Sign up for text messages or email alerts about
your account(s)
HOW YOU GET IT
Download MyFlexMobile from the iTunes Store or
Google Play—it’s free.
© 2014 take care® plans. All rights reserved. The term “savings” herein refers only to tax savings and actual savings are dependent on individual tax
rates. No part of this document constitutes tax, financial, or legal advice. Please consult your advisor regarding your personal situation and whether
this is the right program for you.
3757 (11/2014)