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Flexible Spending Account Enrollment Form - State of Oregon - oregon

Flexible Spending Account Enrollment Form - State of Oregon - oregon 2025

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The document is an enrollment form for the PEBB Dependent Care Flexible Spending Account (FSA) for the 2008 plan year, intended for newly hired employees or during Open Enrollment. It outlines the process for enrolling, contribution limits based on filing status, and necessary employee information. The form includes sections for employee details, contribution amounts, dependent information, and requires a signature to confirm eligibility and understanding of the program's terms.

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How do I enroll in FSA?

Participants must actively enroll each Open Season if they wish to have a flexible spending account in the next year. To enroll, visit the FSAFEDS website or call 1-877-FSAFEDS (372-3337). TTY 1-800-952-0450.

How do I file for FSA?

Use Form 8889 to: Report health savings account (HSA) contributions (including those made on your behalf and employer contributions), Figure your HSA deduction, Report distributions from HSAs, and. Figure amounts you must include in income and additional tax you may owe if you fail to be an eligible individual.

Can you enroll in FSA without enrolling in medical?

FSA eligibility Generally, employees dont need to be enrolled in a health insurance plan to open an FSA. If you have a health savings account (HSA), you likely wont be eligible for a general healthcare FSA, because theyre used to pay for the same types of medical expenses.

How do I apply for FSA eligibility?

FSA Eligibility An employee must be eligible for group medical plan (not enrolled, only eligible) in order to be eligible for Medical FSA. Generally, pre-tax benefits may only be afforded to the employee, their spouses and dependents.

Can an employee enroll in an FSA at any time?

Eligible employees can enroll in FSAFEDS each year during the Federal Benefits Open Season (the November/December timeframe). Open Season enrollments are effective January 1 of the following year.

Can you enroll in FSA outside of open enrollment?

You can only take advantage of a special enrollment period if you have a qualifying event or experience a complex issue and if your plan allows for the change. If eligible, youll typically have 30 to 60 days from the date of the special circumstance or qualifying life event to make changes to your FSA.

Is FSA enrollment automatic?

Note: FSA enrollment is NOT automatic each year you must enroll in your FSA every year. See the Frequently Asked Questions. Review additional health FSA information and tips.

What form do you get for FSA?

Form W-2 - Flexible Spending Account (FSA) A flexible spending account (FSA) allows employees to be reimbursed for medical or dependent care benefits from an account they set up with pretax dollars.

Flexible Spending Account Enrollment Form - State of Oregon - oregon 2025

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