Flexible Spending Account Plans  

The City of Mesa Flexible Spending Plan offers you the opportunity to set aside pre-tax dollars from your paycheck to pay for either health care or dependent care (child or elder care) expenses that would normally be paid out of pocket.  Enrolling in the flexible spending account program reduces your taxable income. 

When enrolling in the Flexible Spending Account(s), especially for the first time, estimate eligible expenses carefully. FSA is a use it or lose it program. Any money left in the account after the 90-day deadline will be forfeited to the Employee Benefit Trust Fund.

FSA participants may not seek reimbursement for health care or dependent care (child/elder care) expenses for Committed Partner or Committed Partner children/elders under FSA accounts.

Health Flexible Spending Account

The Health Flex plan allows you to set aside up to $2,500 to pay for eligible out-of-pocket health care expenses that are not covered by your insurance.  This amount may change in future years.

Examples of these reimbursable expenses include:

  • Deductibles
  • Coinsurance
  • Copayments
  • Certain items not covered by insurance

Dependent Care Flexible Spending Account

The Dependent Care Flex Plan allows participants to set aside up to $5,000 per household to pay for eligible child or elder care services that are needed so that the participant and spouse (if applicable) can work. Once a qualifying child care expense is incurred, the receipts may be submitted to the Employee Benefits Administration Office for reimbursement from this dependent care FSA.  All claims will be reviewed for eligibility and accuracy.  Reimbursements made from this account will be equal to the amount of the claim, but not more than the current balance in the dependent care FSA.  This account is for day care expenses ONLY. Dependent medical/dental/vision expenses are not reimbursable through the dependent care flex account.

Examples of dependent care arrangements which qualify include:

  • A Dependent (Day) Care Center, provided it complies with applicable state and local laws if care is provided by a facility for more than six individuals
  • An educational institution for pre-school children
  • For school-age children (Kindergarten through age 12), only expenses for before and after school care are eligible. Tuition fees do not apply
  • An "individual" who provides care inside or outside your home (who is not your spouse, child under age 19 or anyone you claim as a dependent for federal income tax purposes).

How to Enroll

  • New employees may enroll in the FSA program upon hire 
  • New hires not electing FSA must wait until Open Enrollment to enroll for the following calendar year
  • All other employees may enroll during the annual Open Enrollment period for the following calendar year
  • A change in status (as defined by the IRS) may qualify a member to elect FSA mid-year *


*Examples of a change in status
may include: 

  • Change in legal marital status, including marriage, divorce, legal separation 
  • Change in number of dependents, including birth, adoption, placement for adoption, or death 
  • Change in employment status or work schedule for either you, your spouse, or your dependent child
  • Change in dependent status due to attainment of the maximum age as defined by the Plan  

Please note: Mid-year FSA enrollments/changes must be made within 31 days of the qualifying event and must be consistent with the change. More information regarding Change in Status requirements may be found in the Plan Document.

**Due to Federal requirements, participants MUST re-enroll every year for FSA if they wish to continue participation for the following calendar year **


Reimbursement for Expenses

FSA expenses (Health and Dependent) for which a participant receives reimbursement are not eligible as a deduction for income tax purposes. Claims may be submitted for reimbursement up to 90 days after the end of a calendar year in which you are enrolled. 

How to submit FSA Claims

Health Care claims:
After you are enrolled in the Health FSA, you may submit claims for reimbursement of eligible expenses incurred during the calendar year for which you are enrolled. Claims must be submitted to the Employee Benefits Administration Office on a Health Care FSA Reimbursement Claim Form, and must include the expense type, date, and itemized amount. All expenses must be submitted with proper documentation:

Health and Dental claims - must include an Explanation of Benefits (EOB)

Prescriptions - itemized receipt(s) or statements from the pharmacy or Prescription Benefit Manager
 
Orthodontia Expenses - must be submitted with the orthodontia contract from the orthodontist along with proof that you have paid the expense for which you are requesting reimbursement (if the orthodontia contract itself does not already provide that proof). The orthodontia contract must indicate initial fee charged, estimated insurance payment, initial start date, duration of treatment and proof of partial or full down payment.


  • Full Payment for Orthodontic Treatment: If payment is made in full for the orthodontic treatment, and proof of payment is included with the completed reimbursement form and the contract, the full payment amount will be considered for reimbursement subject to your annual health care FSA election amount minus any healthcare FSA reimbursement amounts already processed in that year.

  • Initial, Monthly, Quarterly or Periodic Payment for Orthodontic Treatment: For each initial or periodic request for orthodontic FSA reimbursement, you must submit a contract with the initial claim and a completed and signed claim form with an itemized bill/statement from the orthodontist for each periodic reimbursement request. The itemized bill/statement must show the periodic charge consistent with the original orthodontic contract submitted with the initial claim.

Dependent care claims:
Have your child's day care provider certify and complete Section D of the Dependent Care FSA Reimbursement Claim Form, or you can have them provide you with an itemized statement that shows the name and address of the day care center; dependent(s) name; itemized expense amounts; dates of service for which payment has been made; and tax identification number (or SSN).  Non-itemized receipts, credit card receipts and balance due bills are NOT ACCEPTABLE proof of expenses.  Late fees are not eligible for reimbursement.
 
Unacceptable Proof of Expenses
Non-itemized receipts, credit card receipts and balance due bills are NOT ACCEPTABLE proof of expenses. Non-covered health care expenses will also need additional information such as a Letter of Medical Necessity (LMN) or an itemized prescription to be considered.  Note that submitting a LMN for your claim does NOT guarantee reimbursement - IRS guidelines may provide further limitations. 
 
Future Dates of Service - Cannot be submitted for reimbursement. IRS guidelines require services to be incurred before you can be reimbursed - it's not the date you paid the out-of-pocket expense but the incurred date that matters (except orthodontia, see above).
 
Submit completed Health Care or Dependent Care FSA Reimbursement Claim Form(s) along with appropriate documentation via mail, hand delivered, interoffice, fax, or email:
 
Location:                    Employee Benefits Administration Office
                                    Mesa City Plaza
                                    20 E. Main St, Suite 600
                                    Mesa, AZ 85201

Mailing Address:       P O Box 1466, Mesa AZ 85211-1466

Phone Number:         (480) 644-2299

Fax Number:              (480) 644-4548

Email:                          Benefits.Info@mesaaz.gov


FSA Forms
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FSA Enrollment

Health Care FSA Claim Dependent Care FSA Claim


Account Balance

Your account balance will be included on your Explanation of FSA Benefits whenever you receive a reimbursement check. You may also login at CHIP to view your FSA account, or contact the Employee Benefits office at (480) 644-2299.

If you have a question on how a claim was paid, please send an email to Benefits.Info@mesaaz.gov.

For more information about this program, please refer to FSA portion of the Plan Document, or  contact the Employee Benefits Office at (480) 644-2299, Opt 5.

  

 

Employee Benefits
20 E Main Street, Suite 600
Mesa, AZ 85201
Open Mon -Thurs 7am-6pm
(480) 644-2299 - Phone
(480) 644-4548 - Fax

Option 2: Medical/Dental Verify

Other Questions

Password Resets

Option 3: Claim Status

Option 4: Retiree Questions

Option 5: Flex Spending


E-mail (password resets cannot be done via email)

Forms

Federally Mandated Notices