BASIC Consumer Driven Accounts (CDA)

FSA – Medical and Dependent Care

• FSA Enrollment Booklet – A guide to what is an FSA, the tax benefits, a list of common medical eligible expenses, an outline of Dependent Care regulations, and a short description of BASIC FSA features.
• FSA Enrollment Form – Single page enrollment form for participants.
• FSA Open Enrollment PowerPoint (Please be sure to update slides to align to your specific FSA Plan).
• FSA Open Enrollment Recording – Record presentation on how BASIC’s FSA works for you to share with your employees. Please be sure to add any specifics related to your FSA Plan.
• FSA Savings Calculator – Estimate the tax savings, annually or per paycheck, by participating in BASIC FSA.
• FSA Medical Eligible Expenses – A partial list of reimbursable medical expenses for FSA participants.
• Participant Request a Reimbursement Flyer – Learn the multiple ways participants can request reimbursement with the new CDA system.
  Without an active email on file, participants can’t access the CDA system to use the fastest, easiest way to request reimbursement. In those cases, this FSA reimbursement form can be used to submit their reimbursement request. It can be mailed or faxed. Please keep in mind that reimbursement time is increased when using this method over the CDA system or benefits app.
• Dependent Care FSA Eligible Expenses – List of common eligible and ineligible dependent care expenses.
• Dependent Care Contract
• Orthodontia Contract
• 5500 Request Form – Use this form to request BASIC to handle your 5500 for your Health FSA plan when required.

HRA

• HRA Enrollment Form – Single page enrollment form for participants.
• Participant Request a Reimbursement Flyer – Flyer outlining the multiple ways participants can request reimbursement from an HRA Account.
  Without an active email on file, participants can’t access the CDA system to use the fastest, easiest way to request reimbursement. In those cases, this HRA reimbursement form can be used to submit their reimbursement request. It can be mailed or faxed.
• Recurring Individual Premium Reimbursement Request Form – This form should be used to request a recurring reimbursement for individual premiums (Retiree HRA, ICHRA, or QSEHRA).
• 5500 Request Form – Use this form to request BASIC to handle your 5500 for your HRA plan when required.

Commuter – Parking and Transit

• Parking and Transit Guide – This guide is designed to explain IRS regulations and current year maximums.
• Parking and Transit Enrollment Form – Single page enrollment form for participants.
• Participant Request a Reimbursement Flyer – Learn the multiple ways participants can request reimbursement with the new CDA system.
  Without an active email on file, participants can’t access the CDA system to use the fastest, easiest way to request reimbursement. In those cases, this Parking and Transit Reimbursement Form can be used to submit their reimbursement request. It can be mailed or faxed. Please keep in mind that reimbursement time is increased when using this method over the CDA system or benefits app.

HSA

• BASIC HSA Guide – A guide to what is an HSA, eligibility requirements, additional IRS regulations, and current IRS minimums and maximums.
• BASIC HSA Enrollment Form – This document is for employees looking to open a Health Savings Account (HSA).
• HSA Account Transfer Form – This form should be used when a participant wants to initiate a transfer of funds FROM another account TO their BASIC HSA.
• HSA Contribution Request Form – Participants should use this form to make a normal, mistaken distribution, rollover or transfer contribution to their BASIC HSA.
• Disbursement Request for HSA – Step-by-step flyer on how participants can request a disbursement from their BASIC HSA.
• HSA Beneficiary Change Spousal Consent Form – Participants may use this form to designate or change their beneficiary. If married in common law or in a community property or marital property state, you must designate your spouse as your Primary Beneficiary. If they wish to designate someone other than their spouse, their spouse must agree by signing in the Spousal Consent section. Spouse’s signature must be notarized.
• Investment Tool Kit Instructions – How to manage HSA investments on the Consumer Driven Accounts system.
• HSA Investment List – Current lineup of HSA investments.

ICHRA

• Abbreviated ICHRA Model Notice – This notice is required to be distributed annually to eligible employees 90 days before benefit effective date.
• ICHRA Model Notice
• ICHRA Model Attestations
• ICHRA Substantiation – Employer Responsibilities – Explains the employer responsibilities with regard to the annual substantiation of any participant’s individual health insurance coverage and ongoing substantiation of the participant’s individual health insurance coverage on a monthly basis.
• ICHRA Affordability Determination and Non Discrimination Rules