Purpose: This action is used to establish contributions into a Medical and/or Dependent Care Reimbursement Account.
Note: Employees may enroll in one or both plans.
Filling out the application:
Employees must be eligible to enroll in the State's medical plan to qualify for FSA Enrollment. If you are not eligible, the following error message will be displayed when attempting to access the FSA Enrollment application, "You are not eligible for medical insurance, please contact the Office of Group Insurance".
This portion of your application is prepopulated with some information from your personnel record.
This portion allows you to choose the type of FSA plan and the amount you wish to contribute. You may choose to contribute to a Medical FSA and/or a Dependent Care FSA.
This portion is informational ONLY. Please read the information provided for details pertaining to the Debit Card that is automatically issued as part of enrolling in an FSA plan.
Please read the Additional Information at the bottom of the form. Once you have read through the statement of understanding, you must return to the Signature portion of the form and select 'Yes' or 'No'.
Now that you have completed your application, scroll to the top and choose an option:
You cannot submit this application unless you selected 'Yes' for the employee signature to agree to the terms of the plan.
You can follow the status of your application by going to Views > My Self-Service. In My Self-Service, you should only have
one FSA Enrollment Application. If there are extra FSA applications, please delete them. Any FSA Enrollment Applications that were created and not submitted during open enrollment will be automatically deleted when the open enrollment period ends.
During open enrollment, if you need to make a change to your current FSA due to a qualifying event, you'll need to contact the Office of Group Insurance (OGI). If you select the FSA Enrollment Application option from the Self-Service menu, you will receive two options: