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. 

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.

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.

2014 HCSA Enrollment form doc format of 2014FSAenrollmentform.doc
- Enroll in HCSA benefits as a 2014 new hire.

Not for municipalities

2014 HCSA Claim Form doc format of FSAclaim_form.doc
- use this form to submit HCSA and DCAP claims for reimbursement.

2014 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 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 Questions?

Open Enrollment for 2015 Participants - Contact ASIFlex; 1-800-659-3035

2014 Participants - Benefit Strategies 1-877-FLEXGIC (1-877-353-9442); flexgic@benstrat.com

2014 Calendar Year Flexible Spending Account Handbook doc format of 2014FSAHandbook.doc


This information provided by the Group Insurance Commission .