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FlexSystem & HSA Plan Documents

In order to provide pre-tax benefits under Code 125, a written Plan Document must be in place and officially adopted by the employer. Complete the steps below and follow the instructions to retrieve and adopt your Plan Document as soon as possible.  

   1. Download the Plan Document instructions and complete the process as indicated.

  • Premium Only Plans (POP): Download the Plan Document (FX-4798) (no other benefits components apply).
  • Full FSA Plans (includes Self-Administration Plans): Download the Plan Document (FX-4798) and all applicable benefits components (or select the Standard Plan Documents link below).
  • Health Savings Account (HSA): Download the Plan Document and any other benefits component included in your Plan.
  • Full FSA, POPs, Self-Administration, and HSAs: Complete the Adoption Agreement in Article XI of the Plan Document.

   2. Retain the Adoption Agreement and all Plan Documents for your records (do not send to TASC).

   3. A Standard Plan Document PDF link is available below to download the standard forms as one document.
       If your Plan includes additional benefits, select and download the additional forms from the list below.

PLAN DOCUMENTS & FORMS

Instructions: (FX-4828)
Download the instructions for adopting your Cafeteria Plan Document.

Standard Plan Document w/Instructions: (combined)
This link contains all of the following documents in one pdf: Instructions, Cafeteria Plan Document, Health FSA, Dependent Care FSA, Non-Employer Sponsored Premium, Heart Act, and Grace Period (Dependent Care FSA and Non-Employer Sponsored Premium). Select any additional documents applicable to your Plan from the list below.

Plan Document: (FX-4798)
Cafeteria Plan Document for your Premium Only Plan (POP), Flexible Spending Account (FSA), or Health Savings Account (HSA).

Medical or Medical-Related Expense Reimbursement Benefit Plan (Healthcare FSA): (FX-4793)
Allows reimbursement of qualified medical, dental, or vision expenses.

Non-Excepted Health FSA Benefits Plan (NEFSA): (FX-4965)
Allows reimbursement of qualified medical, dental, or vision expenses for an employer that has a non-excepted health FSA (e.g., does not offer group health plan coverage). This Plan is subject to additional compliance requirements. Refer to the Instructions link above for additional details on the description of a NEFSA and the additional compliance requirements. NOTE: To offer this benefit, you must also offer Group Health Insurance to your employees.

Health FSA Grace Period: (FX-4796)
Adds a two and one-half month extension in which Participants may incur eligible expenses.

Heart Act: (FX-4797)
Military cash out for Participants called to active duty. This is a standard component of the TASC documents. If you choose not to include this option, a customized Summary Plan Description (SPD) will be required. Additional fees may apply.

Limited Health FSA:  (FX-4822)
Select this document if your Plan includes a Health FSA and a Health Savings Account (HSA). It amends the Health FSA to be compatible with the Health Savings Account (HSA).

SIMPLE Health FSA (Uniform Percentage Contributions): (FX-4829)
Select this document if you have elected a SIMPLE Health FSA that uses the uniform percentage method to determine the employer contribution amount.

SIMPLE Health FSA (Matching Contributions): (FX-4830)
Select this document if you have elected a SIMPLE Health FSA that uses the matching method to determine the employer contribution amount.

Dependent Care Benefits Plan: (FX-4794)
Allows reimbursement of Dependent Day Care expenses for qualified dependents.

Dependent Care Grace Period: (FX-4795)
Adds a two and one-half month extension in which Participants may incur eligible expenses.

Dependent Care Spend Down: (FX-4824)
Allows terminated Dependent Care Participants to incur and submit qualified expenses through the end of the Plan Year.

Non-Employer Sponsored Premium Account Plan (NESP): (FX-4792)
Allows reimbursement of qualified individual health Plan premiums that are not employer sponsored. NOTE: To offer this benefit, you must also offer Group Health Insurance to your employees.

NESP Grace Period: (FX-4816)
Adds a two and one-half month extension in which Participants may incur eligible expenses.

Carryover Opt-Out Amendment-HFSA: (FX-4950)
To remove the Carryover option from your health FSA Plan, select this document.

FSA - SECTION 125 - FLEXIBLE SPENDING ACCOUNTS | HRA - SECTION 105 - HEALTH REIMBURSEMENT ARRANGEMENTS | HSA - HEALTH SAVINGS ACCOUNTS | COBRA ADMINISTRATION | FMLA ADMINISTRATION | ERISA ADMINISTRATION | PAYROLL ADMINISTRATION