Not for municipalities

FSA Worksheet docx format of HCSAexpenseworksheet.docx
– use this worksheet to help calculate your election amount.

Re-enroll Online – If you are a half-year 2016 FSA participant, re-enroll online during the Open Enrollment Period.

  * Open Enrollment Re-enrollment Instructions – (Available during Open Enrollment) If you are a half-year 2016 FSA participant, re-enroll for fiscal year 2017 benefits online during the Open Enrollment period. 

   * Re-enrollment Screen Shots – (Available during Open Enrollment) These screen shots show you what you’ll see as you re-enroll in FSA benefits online.

2016 Enrollment Form doc format of 2016_GIC_FSA_Half-Year_Enrollment_Form.doc
–  Also use this form if you are hired on December 5, 2015, or later, use this form to enroll in partial year benefits. Return the completed form to your Payroll Coordinator.

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.

Flexible Spending Account Appeal Form docx format of FSA_Appeal_Form.docx
- If you disagree with a denied claim or adverse decision regarding your HCSA or DCAP benefit (e.g. claim for reimbursement denial, eligibility for pre-tax benefits or election change), and you feel this denial was made in error you may file a formal appeal by using this form.

HCSA Questions?

Contact ASIFlex; 1-800-659-3035

  2016 Flexible Spending Account Handbook doc format of 2016FSA_Participant_Handbook.doc


This information provided by the Group Insurance Commission .