FSA Election Form - moore 2025

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Normally, you can only elect contributions into your FSA during a yearly open enrollment period, but there are exceptions. A qualifying event affects your eligibility for coverage under your specific FSA plan. When a qualifying event occurs, many employers allow you to make a mid-year change in elections.
You decide how much you want to put into the FSA(s) youre enrolling in, up to the maximum allowed. Your employer divides the annual election total by the number of pay periods youll have in the plan year. This increment comes out each pay period.
If a qualifying event occurs and you want to make a change in your election, you should notify your FSA administrator within 30 days of the event. You can find the contact information for your benefits administrator on the back of your FSA card or by contacting your human resources department.
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.
FSAs are funded through payroll deductions. The full amount of our FSA is available immediately at the employees plan start date. The employer then deducts the contribution amount that the employee elects from the employees paycheck.
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In order to enroll in an FSA, the account must be offered through an employer. Your employer or benefits administrator will guide you through enrollment. As part of this enrollment, youll need to elect the amount of funds you want to set aside for the plan year.
You can only change the amount you contribute to your dependent care FSA when you experience a permitted election change event. Examples of a permitted election change event include a change to your marital status, the number or eligibility of your dependents, or a change to you or your spouses employment status.

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