To request reimbursement for eligible health care expenses under HCFSA, you must complete an HCFSA Claims Form and provide proper documentation. Filing a claim is easy. Here's how:
List each expense and claimant separately on the Claims Form;
Attach an Explanation of Benefits (EOB) statement from the health insurance carrier for medical expenses and from the Welfare Fund for dental, vision, and/or hearing expenses showing the unreimbursed balance;
- Attach copies of receipts or billing statements from the provider. The receipts and billing statements must include:
Note: Medical care must be for expenses to diagnose, cure, mitigate, treat or prevent disease, or to affect any structure or function of the body.
While eligible health care expenses of any amount up to your Plan Year goal amount are reimbursable, you must accumulate claims totaling at least $50 before submitting a Claims Form, unless your account balance is less than $50.00.
All completed Claims Forms must be submitted directly to the FSA Program Administrative Office and received by the last day of the month in order to be processed for that month. You will only be reimbursed for health-related expenses that are provided during the applicable Plan Year or Grace Period.
Note: No reimbursement can be made prior to the service actually being provided. Claims should be submitted in a timely manner.
A Grace Period is provided, from January 1 through March 15 following the close of the plan year, during which you may submit claims for eligible health care expenses incurred during the Grace Period using the remaining balance in your previous year's account, if any.
A Claims Run-Out Period is provided, from January 1st through May 31st following the close of the Plan Year's Grace Period, to submit claims for services performed during the previous Plan Year or Grace Period.
Download the FSA Program Forms
HCFSA Claims Denial
If, for any reason, it is necessary for the FSA Administrative Office to deny a claim, you will receive a denial letter stating the reason for denial.
You may appeal the denial by filing a written appeal with the Appeals Panel within 60 days after your receipt of the denial notice. The Appeals Panel will review your claim and make a determination within 60 days after receipt of your written notice for appeal, unless an extention of time is required. You will receive notice of the extention period within 60 days after the receipt of your written notice of appeal. The extention period may last for up to 60 days.
Reimbursement for approved claims processed during one month will be automatically deposited into the account you indicate on your Enrollment/Change Form or Direct Deposit Form by the close of the following month. Or you may choose to have reimbursement checks sent to your home address. Claims will be reimbursed up to the total amount of your election, less the maximum administrative fee of $4.00 per month ($48.00 per Plan Year) and any claims previously reimbursed, regardless of the current balance in your account.
Note: Payments will be made directly to you, not to the service provider.
HCFSA Account Statements
Every calendar quarter, you will receive a statement indicating all monthly contributions to your account, processed claims, a maximum account administrative fee of $4.00 per month, and your available balance. If you are receiving reimbursement through direct deposit, you will still receive a monthly claims payment statement.
After the Claims Run-Out Period, you will receive an annual statement that reflects the total amount contributed to and reimbursed from your account for the Plan Year.
In addition, the amount you contributed to HCFSA will be reflected on your Form W-2, which you receive from your employer. For federal tax purposes your gross income will reflect the adjusted amount.
Note: You must add back the amount listed as IRC 125 on your Form W-2 to your state/city gross wages.
Learn more about your W-2 from the Office of Payroll Administration
See the Flexible Spending FAQ