Not for municipalities

FSA Worksheet doc format of FSA_worksheet.doc
– use this worksheet to help calculate your election amount.

2014 HCSA Participants Re-Enroll online during the Fall October 14 - December 5, 2014 open enrollment for 2015 benefits. 

2015 HCSA Enrollment form for new participants doc format of 2015FSA_enrollform.doc
- Enroll in HCSA benefits for 2015 during the October 14 - December 5, 2014 Open Enrollment and as a 2015 new hire.

Flexible Spending Account Status Change form doc format of 2015FSA_enroll_changeform.doc
– use this form to increase or decrease your contribution to, or terminate your election in Flexible Spending Account within 30 days of a qualifying event during the plan year. You must submit this form with supporting documentation within 30 days of the qualifying event: change in legal marital status; change in number of dependents; change in employment status; change in work schedule that affects your eligibility for the program; change in dependent’s FSA eligibility, or a judgment decree pertaining to your spouse or child.

HCSA Claim Form doc format of GIC_FSA_claimform2015.doc
- use this form to submit HCSA and DCAP claims for reimbursement.

2015 HSCA Notice and Election Form doc format of COBRA_HCSA_Notice_App.doc
- HCSA Enrollees may elect to contribute to the HCSA account under COBRA by making direct payments on an after-tax basis.

HCSA COBRA Acknowledgement Form doc format of COBRA_HCSA_Ackn_COBRA_Notice.doc
- State employees enrolled in HCSA who are leaving state service use this form to acknowledge that they have been advised of their right to HCSA COBRA benefits.

Open Enrollment Re-enrollment Instructions doc format of openenrollment_online_reenrollment_instructions.doc
2014 participants re-enroll for 2015 benefits; use these instructions to re-enroll online.


HCSA Questions?

Contact ASIFlex; 1-800-659-3035

  2015 Calendar Year Flexible Spending Account Handbook doc format of 2015_FSAparticipant_handbook.doc

This information provided by the Group Insurance Commission .