Self-funded, annual account that covers eligible health or care-related expenses; health care FSA, limited purpose FSA, dependent care FSA
Self-funded account to cover deductible and eligible expenses
Employer-funded account to cover health-related expenses
Self-funded account to cover parking and/or transit expenses for your work commute
Flexible Spending Accounts are pre-tax funds that you can set aside for either health care purchases (HCFSA), vision and dental services and goods (LPFSA) or dependent care services (DCFSA).
These accounts typically require a document or receipt that show what services or goods you purchased, and MyChoice Accounts will verify the amount, date of service, eligibility of the expense in order to provide your refund.
You may also submit the information in these forms directly online through your Benefitsolver login or through the MyChoice Mobile App instead of completing the form below. Finally, the easiest way to pay for eligible expenses in the future would be to use the purple MyChoice Accounts debit card you received upon enrollment. Replacement cards are free.
Health care or limited purpose flexible spending account claim form (HCFSA or LPFSA): If you have paid for eligible services or items out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.
Dependent care flexible spending account claim form (DCFSA, DCAP): If you have paid for eligible services or items out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.
Letter of Medical Necessity Form: Some items on the eligible expenses list require a doctor’s sign-off to verify that the medication or treatment that you are purchasing is medically necessary and thus, eligible to purchase with your FSA. Review the eligible expenses list to validate your expense. If it is listed as “LMN,” you will need your doctor to complete this form as part of your documentation.
LPFSA MyChoice Accounts HDHP Deductible Met Form: For Limited Purpose (dental + vision) FSAs, use this form to attest that you have met your health plan deductible and that your limited purpose FSA should be transitioned to a health care FSA for the remainder of the plan year.
Health Savings Accounts (HSAs) are tax-free accounts that participants fund throughout the year. These accounts never “expire,” and continue to roll over year after year. Additionally, if you change employers, the account is portable, so you do not lose access to your funds.
Receipts/documentation are not required in order to access your HSA. At MyChoice Accounts, we recommend keeping personal records of your receipts and documents for your HSA-eligible expenses.
To access your funds, we recommend using your purple MyChoice Accounts debit card you received upon enrollment. Additional or replacement cards are available upon request. If you’ve already purchased HSA eligible items and would like to be reimbursed from your HSA, use your online login or MyChoice Mobile App to request a funds transfer. You can receive either a check or have the funds directly deposited to your bank account.
UMB Beneficiary Designation Form: All HSAs participants should designate an account beneficiary. Complete this form and follow the instructions for submission to ensure your HSA beneficiary is set up.
UMB Trustee-to-Trustee Transfer of Assets Form: Complete and submit this form according to the instructions if you would like to transfer an HSA from another provider TO your MyChoice Accounts HSA.
UMB HSA Account Closure Form: Complete and submit this form according to the instructions if you would like to close your MyChoice Accounts HSA.
UMB HSA Contribution Form: Complete and submit this form according to the instructions if you would like to make a post-tax (non-payroll deduction) contribution to your HSA.
NOTE: UMB forms require your MyChoice Accounts HSA account number. To retrieve that:
Health Reimbursement Account (HRAs) are employer-funded accounts that can cover a wide range of eligible expenses. Each employer determines what categories their HRA will cover (such as medical services and items, prescriptions-only, dental and vision, or health plan premiums). If you have questions about your eligible expense list, please ask your benefits team or log on to your online benefits platform.
If you need to file a reimbursement claim, the fastest and easiest way to do that is through your online benefits portal or through the MyChoice Mobile App. You may also fill and submit the appropriate form below according to the form instructions.
HRA Claim Form: If you have paid for eligible HRA expenses out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.
Retiree HRA: premium-only reimbursement form
Retiree HRA: medical + premium reimbursement form
Commuter benefits are self-funded accounts that help offset the costs of commuting to and from your workplace. Transit accounts cover trains, subways, commercial carpool/vanpool, ferries and more. Parking accounts help participants pay for parking at or near their place of work.
The IRS dictates how these funds can be used and whether expenses can be reimbursed. For transit accounts, participants must use their MyChoice Accounts debit card to purchase fare or pay for the transit expense. The IRS does not allow transit reimbursement. For parking accounts, participants may find it easiest to use their MyChoice Accounts debit card or file a reimbursement claim either online, by using the MyChoice Mobile App, or by filling and filing the following form below.
MyChoice Accounts Parking Claim Form: If you have paid for eligible commuter parking expenses out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.
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