Ohio Department of Health
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Effective Jan. 1, 2021, ConnectYourCare, a part of Optum Financial, is managing the State of Ohio Flexible Spending Accounts and Commuter Benefits programs. The Health Care Spending Account (HCSA) is a tax-favored account that provides the opportunity for eligible employees to defer on a pre-tax basis a minimum of $240 or up to a maximum of $2,500 into an account to pay for eligible expenses not paid by their health, vision, or dental insurance plans. There is no administrative fee for participants. A payment card, a prepaid debit card, is issued to all participating employees; the ConnectYourCare payment card facilitates payment of eligible current plan year healthcare expenses. Information regarding eligible expenses may be found in the FSA 2021 Reference Guide.

Limited Purpose Spending Account 
The Limited Purpose Spending Account (LPSA) is used to pay for eligible dental and vision expenses not paid for by your insurance or other plan. See the Limited Purpose SA tab below for full details. 

For more detailed information about the HCSA, LPSA, or the payment card, visit: connectyourcare.com/StateofOhio, the portal of the State of Ohio’s program vendor, ConnectYourCare. Although the payment card is used from plan year to plan year, it is loaded with the newly elected annual amount on Jan. 1 and can only be used during the plan year.

About Health Care Spending Accounts

Enrollment

Enrollment Opportunities

To enroll in a Health Care Spending Account (HCSA), an employee must: 

1. Be a permanent part-time or permanent full-time employee with sufficient pay to cover the election amount; and 
2. Enroll within 31 days of the hire date, if there is no probationary period served; or 
3. Enroll within 31 days of completing probation; if there is a probationary period served. 

Benefits are based on the current calendar year.

It is not necessary to be enrolled in the State of Ohio’s health benefits to participate in the Health Care Spending Account. If both a husband and wife are state employees, both may participate in the Health Care Spending Account as separate individuals.

If an employee does not enroll at hire or the end of probation as noted above, other enrollment opportunities are as follows.

1. During the annual open enrollment period. 
2. Following a change in status: IRS regulations govern Section 125 Cafeteria Plans. A change in status can be made to the employee’s Flexible Spending Account election as a result of a life event. To make a change in status, you must complete the Change in Status form. The time frame for notification is within 31 days of the qualifying event. 
3. Change in Status and new hire enrollment must be made from Jan. 1 through Sept. 30.

Consistency Rule: Proposed change in status must be consistent with the type of change experienced. For example, add a dependent and increase election amount, or drop a dependent and decrease the election amount.

Enrollment Forms

2021 Health Care Spending Account Enrollment Form

Special Exemption Enrollment Form (For use between April 12-June 1, 2021

Special Exemption Enrollment Form

Health Care & Dependent Care Change Form

Health Care Spending Account Worksheet

Limited Purpose Spending Account Worksheet

Limited Purpose Spending Account

If you are enrolled in a qualified high-deductible health plan (HDHP) and have a Health Savings Account (HSA), you can maximize your savings with Limited Purpose Spending Account (LPSA). This pre-tax account helps you save on eligible out-of-pocket dental and vision expenses. If you quit or are terminated from your job and still have money left in your account, the money remains in your account and you may elect COBRA.

Eligibility:

  • You must meet the qualifications for an HCSA (permanent employee who has completed an initial probationary period if applicable) and have sufficient pay to cover the election amount
  • You must be enrolled in qualifying high-deductible health plan (HDHP) with an annual deductible of at least $2,700 for family coverage and $1,350 for single coverage
  • You qualify for and elect to contribute to a Health Care Savings Account (HSA)
  • And your spouse is not enrolled in the standard Health Care Spending Account with her/his employer

Enrollment must occur within 31 days of eligibility or during the open enrollment period. If you complete your initial probationary period between Oct. 1 and Dec. 31, you are eligible to enroll during Open Enrollment for the next plan year.

The Limited Purpose SA is used to pay for eligible dental and vision expenses not paid for by your insurance or other plan. These expenses can be incurred by you, your spouse, a qualifying child or relative. Your full annual contribution amount is available at the beginning of the plan year, so you don’t have to wait for the money to accumulate.  

Annual Limited Purpose SA Limits:
Minimum Annual Deposit: $240
Maximum Annual Deposit: $2,500

Remember that the limit is per employee, so if have a spouse with a Limited Purpose FSA, they can contribute up to $2500 in their account as well, even if you both work for the State of Ohio.

Carryover:
You may carryover a minimum of $50 and a Maximum of $500 from one plan year to the next. This means that if you have between $50 and $500 remaining in your Limited Purpose SA on Dec. 31, 2020, you can transfer that amount to the 2021 plan year. Keep in mind that you must use current year funds before using carryover funds.

Minimum Carryover: $50
Maximum Carryover: $500

Limited Purpose Spending Account Fund Availability:
Once you sign up for a Limited Purpose Spending Account and decide how much to contribute, the maximum amount of your annual contribution will be available for reimbursement of eligible dental and vision expenses throughout your period of coverage.

Since you don’t have to wait for the funds to accumulate in your account, you can use it to pay for eligible dental and vision expenses once your account becomes effective.

For employees on a biweekly pay schedule, deductions will be taken from the first 24 pay periods of the calendar year.

Eligible Expenses for a Limited Purpose Spending Account:

  • Dental care, both preventive and restorative
  • Orthodontia, child and adult
  • Vision care, eyeglasses, contacts lenses and solutions
  • Eye surgery, including laser vision correction

See connectyourcare.com/StateofOhio for more information.

Ineligible Expenses for a Limited Purpose Spending Account: 

  • Medical products and services
  • Prescription drugs
  • Mental health services

Health Care Spending Account vs. Ohio Med HDHP Enrollment:
Employees and/or spouses enrolled the Ohio Med HDHP (high deductible health plan) with the health savings account (HSA) are not eligible to enroll in a traditional Health Care Spending Account.

Conversely, if you or your spouse enroll in a Health Care Spending Account for calendar year 2021, neither you nor your spouse is eligible to enroll in the Ohio Med HDHP with an HSA in the spring of 2021.

This also applies if you will have a carryover balance in your Health Care Spending Account as of Dec. 31, 2020.

Registration/Online Enrollment

Online enrollment is only available during Open Enrollment in October. Before you can enroll online, you must register. 

Go to connectyourcare.com/StateofOhio to register for access to your flexible spending accounts. 

  • Click the Log in/Sign up button
  • Enter the your personal username and password (not your OH|ID Workforce User ID)

Your account is automatically set up to send a reimbursement check via U.S. mail.

Add your banking information if you want reimbursements directly deposited. 

You will need to create a username and password.

Claims

 

HCSA Claim Form

Claim Submission

Claims may be submitted to ConnecYourCare by logging on to connectyourcare.com/StateofOhio, where you can enter claim details and attach receipts directly. Also, using your mobile phone, you can take a picture of your receipt and submit the receipt via the ConnectYourCare mobile app. 

Health Care Spending Account Claim Form

Claims Tips

Claims can be filed by using:

  • ConnectYourCare card for instant payment
  • Pay Me Back Form – Fax or mail the HCSA Pay Me Back Claim Form to ConnectYourCare
  • Pay My Provider – Request payment to be made directly to the provider via your HCSA at connectyourcare.com/StateofOhio
  • myCYC mobile app to upload the receipts

To avoid any delays in claims processing, your documentation must include all IRS required information:

  1. Patient name
  2. Provider name
  3. Date of service
  4. Service description
  5. Amount charged or your cost (e.g. your deductible or co-pay amount or the portion not covered by your insurance

Claim Rejection Reasons

Top reasons that claims are rejected by ConnectYourCare include: 

  • Ineligible expense
  • Missing information
  • Service date outside plan year
  • Unclear information
  • Duplicate claim
  • No description or code for type of service
  • Submitted without the date of service
  • Submitted without supportive documentation of expenses
  • Submitted unsigned

Appeals

To Appeal a Denied Claim

If you feel your claim was denied in error, you have the right to file an appeal by writing a letter that explains why you believe the claim should be approved:

1.The appeal must be submitted in writing and mailed to:

FSA Claims Appeal Department
307 International Circle, Suite 200
Hunt Valley, MD 21030

2.The appeal must be received within 180 days of the date you receive notice that your claim was denied.

3. Submit additional information related to your claim along with your appeal, such as: written comments, documents, records, a letter from your health care provider indicating medical necessity of the denied product or service, any other information you feel will support your claim.

4. It is possible to request copies of all documents and information related to your denied claim. These will be provided at no charge.

5. You will be notified of the decision regarding your appeal in writing by ConnectYourCare within 31 days of receipt of your written appeal.

IRS Rules

Carryover/Forfeiture
If you have money remaining in your Health Care Spending Account on Dec. 31, a minimum of $50 up to a maximum of $500 will transfer to the next plan year. Any amount less than $50 or more than $500 is subject to the IRS forfeiture rule.

Visit connectyourcare.com/StateofOhio for further information about the carryover. 

Federal regulations require that any unspent balance at the end of the calendar year, or at the end of the month of your employment termination, will be forfeited, unless your employer participates in the carryover. To avoid possible forfeiture at the end of the year, use the Health Care Spending Account Worksheet to calculate the appropriate amount.

Payroll Deductions

In order to meet the annual election amount, the program takes deductions from the first 24 pay-periods of the year if paid bi-weekly. Mid-year enrollment and Change in Status adjustments will be calculated over the remaining pay-periods of the year. 

For employees paid monthly, the annual election amount will be divided by 12 and deducted from your monthly paycheck. 

ConnectYourCare (CYC) Payment Card

Your ConnectYourCare payment card works just like a debit card with current year election amount loaded onto your card. There is no annual fee. All that is needed is to swipe your card at a participating provider to purchase eligible items from your health care spending account. The card does not use a PIN so there is no need to remember yet another four-digit code. It’s versatile. The card enables health care spending account participants to access their account benefits more quickly to pay eligible expenses, and can be used at most retail pharmacies.

Keep your receipts! You may need to provide receipt documentation on occasion for some purchases that are made. 

The IRS requires card suspension, when substantiating documentation is not provided when required. A grace period is provided to allow payment card users reasonable time to submit the required documentation.

If you do not submit documentation to ConnectYourCare within 90 days, your ConnectYourCare card may be suspended, as required by IRS guidelines. Submit a completed Health Care Spending Account (HCSA) Claim Form to avoid deactivation of your card.

Warning: The debit card cannot be used to pay for any prior year claims.

After Jan. 1, any prior year claims must be submitted online or by paper, since the new program year's funds have been loaded onto your card. Failing to follow this process will cause the debit card to be suspended and may result in loss of the prior year funds.

Note: A payment card is not available for dependent care spending accounts.

Direct Deposit

Enrolling into direct deposit is the fastest way to receive your reimbursement. Flexible Spending Account reimbursement funds are automatically deposited into your checking or savings account within 72 hours of your claim approval. There is no fee for this service. You do not have to wait for postal service delivery of your reimbursement. However, you will receive notification via mail that the claim has been processed.

To apply, call ConnectYourCare Customer Service at 844-881-7147 for assistance or update your account by logging in at: connectyourcare.com/StateofOhio. Please note that processing your direct deposit enrollment may take four to six weeks.

IIAS Merchants

Over-the-Counter and prescription purchases with the card are only accepted at IIAS certified merchants. For all other qualified expenses, such as medical and dental co-payments, the ConnectYourCare card may be used normally for current program year. To find out if a pharmacy or drugstore near you accepts the card, go to the Special Interest Group for Inventory Information Approval System (IIAS) Standards website at sigis.com for the most up-to-date list of merchants with the IRS-approved inventory system. 

ConnecYourCare is available at 844-881-7147 to answer questions or provide assistance in determining whether the selected provider is IIAS certified. Customer service representatives are available 24/7.

Change in Status

In order to make a change in an existing account, you must submit a Change in Status (CIS) Form along with supporting documentation to ConnectYourCare. Upon approval, the change will become effective the first of the month following the approval date. If your FSA change request is denied, you have 60 days from the date you received the denial, to file an appeal. The State of Ohio only allows changes to be made between Jan. 1 and Sept. 30.

The requested change can only be made if the completed form and appropriate supportive documentation is received by ConnectYourCare within 31 days from the date of the IRS qualifying event. 

Below are examples of qualifying change in status events and acceptable forms of documentation:

Qualifying Event Documentations
Marriage Official or temporary copy of marriage certificate
Divorce Copy of divorce decree that includes a judge's
signature and date the divorce was finalized
Legal separation Copy of the legal separation decree including
the effective date
Death of Employee, Spouse
or Dependent
Copy of death certificate
Adoption or Placement for
Adoption of a Child
Copy of adoption papers or other court-issued
forms that include the judge's signature
Birth of a Child Birth certificate, crib card or hospital bill
Starting and/or Return from 
Unpaid Leave of Absence for
Employee (i.e., Family Medical
Leave Act)
Letter from the employer or personnel office
stating the date the unpaid leave of absence began
or the date of return to payroll

 
Gain or loss of spouse's or
dependent's eligibility for
health insurance coverage due
to a change in employment
Letter from spouse's or Dependent's employer
stating the date of the employment change and
the nature of the change in health insurance
coverage
Gain or loss of a dependent's
eligibility status by attaining a
specified age or due to a
change in student or marital
status
Copy of birth certificate, documentation from
dependent's college, such as a tuition bill or
diploma, or a marriage certificate

*Coverage effective date is the date of the birth or the adoption.

COBRA Continuation 

If you are COBRA eligible and retire or terminate employment with the State of Ohio, you will receive a packet with additional information regarding your COBRA coverage option. The packet will provide instructions for next steps and contact information. If you have unspent contributions in your HCSA or LPSA, you may continue your HCSA or LPSA (on a post-tax basis) only for the remainder of the plan year in which your qualifying event occurs. However, if you have already used or been reimbursed more than you have contributed, you cannot continue the HCSA or LPSA under COBRA.

Termination of Employment/COBRA

If you terminate employment or retire, you can continue certain Health Care Spending Account (HCSA) benefits through COBRA by calling ConnectYourCare Customer Service at 855-687-2021 Monday - Friday, 8 a.m. to 8 p.m., or via fax at 443-681-4606.

If you have unspent contributions in your HCSA, you may be eligible to continue your HCSA (on a post-tax basis) for the remainder of the plan year in which your qualifying event occurs. However, if you have already used or been reimbursed for more than you have contributed, you are not eligible to continue HCSA under COBRA. 

COBRA Eligibility Examples

Contributions greater than claim reimbursements/card use:
If you elected a Health Care Spending Account benefit of $1,000 for the plan year, contributed $300 pre-tax dollars and received $100 in card use/claims reimbursements, you are eligible for COBRA coverage to continue your HCSA for the remainder of the plan year or until you receive the maximum HCSA of $1,000.

Contributions less than claim reimbursements /card use:
If you elected a Health Care Spending Account benefit of $1,000 for the plan year, contributed $300 pre-tax dollars and received $600 in card use/claims reimbursements, you are not eligible for COBRA coverage to continue your HCSA for the remainder of the plan year. 

If you are not eligible or do not choose to enroll in COBRA, your benefits will terminate at the end of the month in which the event occurred. You have 90 additional days to file claims incurred while your account was active. Any unclaimed funds will be forfeited according to IRS regulations. Please refer to your COBRA packet. 

Retirement

If you are scheduled to retire within the upcoming calendar year, you are eligible to enroll during Open Enrollment to take advantage of FSA benefits while you are employed with the State of Ohio.

Upon retirement, you can continue your Health Care Spending Account (HCSA) benefits on a post-tax basis through COBRA for the remainder of the plan year if you have unspent contributions in your HCSA. However, if you have already received reimbursement for more than you have contributed, you are not eligible for COBRA.

If you are not eligible or choose not to participate in COBRA, your benefits will terminate at the end of the month in which you retire. You will have 90 days from the termination date to file claims for your account. Any unclaimed funds will be forfeited according to IRS regulations.

Third-Party Administrator Contact Information

ConnectYourCare, a part of Optum Financial, is the State’s Flexible Spending Accounts program administrator. 

ConnectYourCare customer service representatives are available 24/7 at ohio@connectyourcare.com or 844-881-7147.

Dependent Care Spending Account


The Dependent Care Spending Account (DCSA) is a tax-favored account that provides the opportunity for eligible employees to defer on a pre-tax basis a minimum of $240 or up to a maximum of $5,000 (dependent on tax status) into an account to pay for eligible child care, dependent care, and elder care expenses. For more detailed information about the DCSA, visit: connectyourcare.com/StateofOhio, the portal for the State of Ohio’s program vendor, ConnectYourCare.

About Dependent Care Spending Accounts

Enrollment

Enrollment Opportunities

To enroll in a Dependent Care Spending Account, an employee must: 

  • Be a permanent part-time or permanent full-time employee with sufficient pay to cover the election amount; and 
  • Have a qualifying dependent(s) with dependent care or eldercare expenses, i.e. daycare.

Both a husband and wife, regardless if they are state employees, may participate in the DCSA as separate individuals, but cannot exceed the $5,000 IRS maximum per family.

If an employee does not enroll at hire, other enrollment opportunities are as follows:

1. During the annual open enrollment period;
2. Following a change in status: IRS regulations govern Section 125 Cafeteria Plans. A change in status can be made to the employee’s Flexible Spending Account election as a result of a life event. To make a change in status, you must complete the 
Change in Status formThe time frame for notification is within thirty (31) days of the qualifying event; or
3. Change in Status and new hire enrollment must be made from Jan. 1 through Sept. 30.

Consistency Rule: Proposed change in status must be consistent with the type of change experienced. For example: add a dependent and increase election amount, or drop a dependent and decrease the election amount.

Enrollment Form

Health Care & Dependent Care Change Form

Dependent Care Spending Account Worksheet

Registration/Online Enrollment

Online enrollment is only available during Open Enrollment in October. Before you can enroll online, you must register. 

Go to connectyourcare.com/StateofOhio to register for access to your FSA accounts. 

  • Click on Employee Registration.
  • Click Next
  • Enter the last four digits of your State of Ohio User ID and your date of birth (mm/dd). Be sure to use the forward slash in the date of birth.
  • Follow the prompts.
  • Enter your email address to receive notifications such as when a claim is received or processed.
  • Add your banking information if you want reimbursements directly deposited. Your account is automatically set up to send a reimbursement check via US mail.

You will need to create a user name and password.

Claims

DCSA Claim Form

Claim Submission

Claims may be submitted to ConnectYourCare by logging on to connectyourcare.com/StateofOhio, where you can enter claim detail and attach receipts directly.  

Send documentation to:

Claims Department
PO Box 622317
Orlando, FL 328620-2317

Dependent Care Spending Account (DCSA) Claim Form 

Claims Tips

Claims can be filed by using:

  • Pay Me Back Form – Fax or mail the DCSA Pay Me Back Claim Form to ConnectYourCare
  • Pay My Provider – Request payment to be made directly to the provider via your DCSA at connectyourcare.com/StateofOhio
  • myCYC mobile app – Upload the receipts or have the dependent care provider sign

To avoid any delays in claims processing, your documentation must include all IRS required information:

  1. Provider name
  2. Date of service
  3. Service description
  4. Amount incurred for service
  5. Dependent name

Claim Rejection Reasons

Top reasons that claims are rejected by ConnectYourCare include: 

  • Ineligible expense
  • Missing information
  • Service date outside plan year
  • Unclear information
  • Duplicate claim
  • No description or code for type of service
  • Submitted without the date of service
  • Submitted without supportive documentation of expenses
  • Submitted unsigned

Special Age Limit Relief for DCSA

The age limit relief replaces age 13 for age 14 for a very limited number of plan participants.

Only applicable for claims incurred during a plan year where the election period ended on or before Jan. 31, 2020, (“Original Plan Year”) or in the immediately following plan year, only regarding the funds remaining in the account at the end of the Original Plan Year, not any new elections for a plan year with an election period ending on or after Feb. 1, 2020.

Appeals

To Appeal a Denied Claim
If you believe your claim was denied in error, you have the right to file an appeal by writing a letter that explains why you believe the claim should be approved:

1. The appeal must be submitted in writing and mailed to:

FSA Claims Appeal Department
307 International Circle, Suite 200
Hunt Valley, MD 21030

2. The appeal must be received within 180 days of the date you receive notice that your claim was denied.

3. Submit additional information related to your claim along with your appeal, such as: written comments, documents, records, a letter from your health care provider indicating medical necessity of the denied product or service, any other information you feel will support your claim.

4. It is possible to request copies of all documents and information related to your denied claim. These will be provided at no charge.

5. You will be notified of the decision regarding your appeal in writing by ConnectYourCare within 31 days of receipt of your written appeal. 

IRS Forfeiture Rule

Federal regulations require that any unspent balance at the end of the calendar year, or at the end of the month of your employment termination, will be forfeited. To avoid possible forfeiture at the end of the year, please use the Dependent Care Spending Account Worksheet to calculate the appropriate amounts.

Payroll Deductions

In order to meet the annual election amount, the program takes deductions from the first 24 pay-periods of the year if paid bi-weekly. Mid- year enrollment and Change in Status adjustments will be calculated over the remaining pay-periods of the year. 

For employees paid monthly, the annual election amount will be divided by 12 and deducted from your monthly paycheck. 

Direct Deposit

Enrolling into direct deposit is the fastest way to receive your reimbursement. Flexible Spending Account reimbursement funds are automatically deposited into your checking or savings account within 72 hours of your claim approval. There is no fee for this service. You do not have to wait for postal service delivery of your reimbursement. However, you will receive notification via mail that the claim has been processed.

To apply, call ConnectYourCare Customer Service at 844-881-7147 for assistance or update your account by logging in at: connectyourcare.com/StateofOhio. Processing your direct deposit enrollment may take four to six weeks.

Change in Status

In order to make a change in an existing account, you must submit a Change in Status (CIS) Form along with supporting documentation to WageWorks. Upon approval, the change will become effective the first of the month following the approval date. If your FSA change request is denied, you have 60 days from the date you receive the denial, to file an appeal. The State of Ohio only allows changes to be made between Jan. 1 and Sept. 30.

The requested change can only be made if the completed form and appropriate supportive documentation is received by WageWorks within 31 days from the date of the qualifying event. 

Below are examples of qualifying CIS events and acceptable forms of documentation:



*Coverage effective date is the date of the birth or the adoption.

Termination of Employment/COBRA

If you terminate, your Dependent Care Spending Account (DCSA) will terminate the end of the month in which the event occurs. You have 90 additional days to file claims incurred while your account was active by submitting a DCSA Pay Me Back Claim Form Any unclaimed funds will be forfeited according to IRS regulations.

COBRA is not offered for DCSA.

Third-Party Administrator Contact Information

For employees considering enrollment in the 2021 plan year:

ConnectYourCare, a part of Optum Financial, is the State’s Flexible Spending Accounts program administrator. 

ConnectYourCare customer service representatives are available 24/7 at ohio@connectyourcare.com or 844-881-7147.

General Contact

Ohio Department of Administrative Services
30 E. Broad St., 27th Floor
Columbus, Ohio 43215
Local: 614-466-8857 
Toll Free: 800-409-1205, option 2

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