Not for municipalities

HCSA Enrollment form for 2014 doc format of 2014FSAenrollmentform.doc
- Enroll in HCSA benefits as a new hire or during this 2014 year with a qualifying event.

2014 HCSA Participants Re-Enroll online during the Fall 2014 open enrollment for 2015 benefits.

Abbreviated Re-Enrollment Instructions (Not currently available)

Comprehensive Re-Enrollment Instructions (Not currently available)

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

HCSA COBRA 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 FSAstatuschangeform.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?

Benefit Strategies 1-877-FLEXGIC (1-877-353-9442);

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


This information provided by the Group Insurance Commission .