Not for municipalities
FSA Worksheet doc format of FSA_worksheet.doc
– use this worksheet to help calculate your election amount.

2015 HCSA Enrollment form for new participants doc format of 2015FSA_enrollform.doc
- Enroll in HCSA benefits for 2015 as a 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 (not yet available) 2015 participants will re-enroll for 2016; these instructions will explain the online re-enrollment steps.


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 .