P.O. Box 1392 Addison, TX 75001-1392
(888) 483-1392 • Fax (888) 211-1392 • www.ntalifebsg.com
Section 125 Flexible Benefit Program
Cafeteria Plan Administration
Common Remitter Billing
Benefits Consultation and Plan Design
Health Savings Account Administration
Quick Access to Flexible Spending Accounts
Online Billing and Enrollment
On Site Enrollment Assistance
Everything is FSA Eligible!
Access the FSAStore through our website
www.ntalifebsg.com under the FSA Shopping tab!
90-213 (10.13) Bryan
YOUR CAFETERIA PLAN PROGRAM
(An Overview for Employees…..Doing the Math)
Your Cafeteria Plan Program allows you to take advantage of paying for selected items on a pre-tax basis such as
Group Health, Health Expenses (Medical Flexible Spending Accounts (FSAs)), Dependent Care Expenses (DCAs),
and Supplemental Health (Cancer and Heart products). The cost of the items you select is then deducted from
your paycheck prior to paying your taxes. By using pre-tax dollars to pay for these programs, you save on federal,
state (if applicable), as well as FICA, Medicare and other payroll taxes. Alternatively, you would be paying for these
programs with your after-tax dollars. By using pre-tax dollars, your take-home income increases as approximated
below:
Annual Income
Pre-Tax Expenses (For example, group medical
premiums, medical and dependent care flexible
accounts to be reimbursed, and supplementary
health premiums).
Taxable Income
Estimated Taxes @ 25% Rate
FICA and Medicare @ 7.65% Rate
After-Tax Expenses
(For example, group medical premiums,
medical & dependent flexible accounts to
be reimbursed, and supplementary health
premiums).
Net Take-Home Pay
Take-Home Pay Annual Increase
Group Health Premiums
The expenses which can be paid pre-tax from this
component include your payroll-deducted premiums
for health, dental, or vision insurance.
Without a Cafeteria
Plan
With a Cafeteria Plan
$40,000
$0
$40,000
$4,000
$40,000
($10,000)
($3,060)
($4,000)
$36,000
($9,000)
($2,754)
$0
$22,940
$0
$24,246
$1,306
All figures are annual
(or over $100 per month)
Supplementary Health Premiums
The expenses which can be paid pre-tax from this
component include your payroll-deducted premiums
for the Cancer and Heart NTA Life programs.
FLEXIBLE SPENDING ACCOUNT
ELIGIBLE EXPENSES
Healthcare FSA Eligible Expenses:
Dental
Dental X-rays
Dentures and Bridges
Exams and teeth cleaning
Extractions and fillings
Gum treatment
Oral surgery
Orthodontia and braces
Vision
Eyeglasses and contact lenses
Laser eye surgeries
Prescription sunglasses
Radial keratotomy/LASIK
Hearing
Hearing devices and batteries
Hearing examinations
Lab Exams/Tests
Blood tests and metabolism tests
Body scans
Cardiographs
Laboratory fees
X-rays
Medical Equipment/Supplies
Crutches and wheel chairs
Hospital beds
Medic alert bracelet or necklace
Nebulizers
Prosthesis
Syringes
Wigs*
Medical Procedures/Services
Acupuncture
Ambulance
Hospital services
Infertility treatment
Physical exams
Service animals
Vaccinations and immunizations
Dependent Care FSA
Eligible Expenses:
Household services (including a maid or
cook) provided they are directly related
to the care of the “qualified dependent”
Medication
Insulin
Prescription drugs
Weight loss drugs*
Actual physical care of the “qualified
dependent”
Obstetrics
OB/GYN exams
OB/GYN prepaid maternity fees
(Reimbursable after date of birth)
Pre and postnatal treatments
A dependent care center, if they provide
care for 7 or more individuals (day care
only), and comply with all applicable
laws and regulations
Nursing home for an invalid parent, for
day care only
If the employee is married, dependent
childcare is generally reimbursed as long
as the spouse is either employed, a fulltime student, or is incapable of caring
for himself or herself or the dependent.
Practitioners
Allergist
Chiropractor
Dermatologist
Homeopath or naturopath*
Osteopath
Physician
Psychiatrist or psychologist
Important Note:
Therapy
Alcohol and drug addiction
Counseling
(not marital, financial or career)
Massage*
Occupational
Physical
Speech
Weight loss programs*
As of January 1, 2011 OTC medications
and drugs without a doctor’s prescription
are not reimbursable through the
healthcare FSA. The prescription
requirement only applies to OTC items
that contain a medicine or drug (i.e.,
cold medicines, aspirins, acid controllers,
allergy and sinus drugs, etc.).
Healthcare FSA Ineligible Expenses:
Contact lens or eyeglass insurance or
discount programs
Cosmetic surgery/procedures
Diaper service
Personal trainer
Insurance premiums and interest
Long-term care premiums
Marriage counseling
Please note: Expenses marked with an asterisk (*) are “potentially eligible expenses” that require
a Letter of Medical Necessity from your healthcare provider to qualify for reimbursement.
This is not a complete listing. For more information, please visit
www.irs.gov.
Maternity clothes
Teeth bleaching or whitening
Vitamins or nutritional supplements*
IMPORTANT INFORMATION ABOUT YOUR
PREPAID BENEFITS CARD
Ten Important Things Our Team Thought You Should Know
RECEIPTS & SUBSTANTIATION (SAVE
YOUR RECEIPTS)
REQUESTS FOR RECEIPTS OR
OTHER DOCUMENTATION
1. The IRS has established specific guidelines that
require all FSA transactions-even those made using
a healthcare debit card (i.e. your Benny card)-to be
substantiated. Substantiation simply means that
a purchase must be verified as an eligible medical
expense. The good news is that a majority of eligible
expenses made by a healthcare debit card will be autosubstantiated at the point of sale through verification
by the third-party merchant.
6. If substantiation is required we will mail you a
receipt or other documentation request. The first two
(2) receipt requests are sent by email, if we have an email
address on file. If not, a hard copy letter is sent through
the mail. The final request letter is sent 120 days after
the transaction date and at that time the card could be
temporarily suspended until the proper documentation
is received and adjudicated.
2. Auto-substantiation may also occur through
recurring claims that exactly match the provider
and dollar amount for a previously approved and
substantiated transaction and through co-pay matching
for charges that exactly match the dollar amount or a
multiple of such co-pay amount.
3. If your transactions do not qualify for autosubstantiation through one of the methods listed
above, then they must be manually substantiated with
receipts or other documentation submitted for review
to us. SAVE YOUR RECEIPTS!
4. MOST DENTAL/VISION PROVIDER
VISITS WILL REQUIRE RECEIPTS. This is because
the dollar amount of the transaction is not an even
dollar amount or equal to a multiple of your co-pay,
is not recurring, and cannot be auto-substantiated.
Therefore, the only way to substantiate your
transaction is manually. SAVE YOUR RECEIPTS!
5. Recurring claims must be set up as a recurring
claim each new calendar year.
ACCOUNT INFORMATION
7. To check your balance and transaction history
please register your account at www.mybenny.com.
8. Please inform us of an address or e-mail change to
ensure correspondence is being delivered properly. Also if
you are set up on ACH (direct deposit) for your claims,
please notify us of any banking changes. Direct deposit
forms are located on our website www.ntalifebsg.com.
CARDS
9. New Benny cards are automatically re-issued
by Evolution Benefits two (2) weeks prior to the
expiration date.
10. There is a $5.00 replacement fee to replace a
lost Benny card. The cards are issued in increments
of 2 in the employee’s name only, but your spouse or
child may use the cards. The re-issue usually takes 7-10
business days from the request date.