Not for municipalities

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

Open Enrollment Re-enrollment Instructions doc format of 2016FSA_Online_Enrollmentinstructions.doc
– If you are a 2015 FSA participant, re-enroll for half-year 2016 benefits online during the Open Enrollment period. 

Fall 2015 Open Enrollment Form doc format of 2016_GIC_FSA_Half-Year_Enrollment_Form.doc
– during the October 13–December 4 open enrollment, enroll for half year benefits.  If you are not a current participant, use this form to enroll for coverage effective January 1 – June 30, 2016.  Return the completed form to your Payroll Coordinator no later than Friday, December 4, 2015.

2016 Half-Year Enrollment Form doc format of 2016_GIC_FSA_Half-Year_Enrollment_Form.doc
– use this form to enroll in FSA benefits if you are hired on December 5, 2015 or later.

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 .