Due to COVID-19, HCA’s lobby is closed. Learn more about your customer service options.

Medical FSA (Flexible Spending Arrangement) and DCAP (Dependent Care Assistance Program)

Information and requirements related to administering the PEBB Medical Flexible Spending Arrangement (FSA) and Dependent Care Assistance Program (DCAP) programs.

Only employees of state agencies and higher education institutions are eligible to participate in the PEBB Medical Flexible Spending Arrangement (FSA) and the Dependent Care Assistance Program (DCAP).

View the DCAP election changes due to COVID-19 (April 17, 2020).

Note: The information contained on this page does not pertain to employer groups participating in PEBB benefits.

Medical FSA

  • Medical FSA reimburses qualified medical expenses.

  • The employee determines the annual contribution amount for their Medical FSA. The annual minimum is $240 and the annual maximum for 2019 was $2,650.  The annual maximum for 2020 is $2,700.

  • The full amount selected is available on the first day of the month the employee is enrolled.

    • If the employee enrolled during annual open enrollment: January 1 of the next year.

    • If the employee enrolled mid-year: Enrollment begins the first of the month following the date the form is received by the employees' personnel, payroll or benefits office. If that day is the first day of the month, enrollment begins that day.

  • Employees who choose a CDHP (Consumer-Directed Health Plan) with an HSA (Health Savings Account) are not eligible to enroll in an Medical FSA in the same plan year.

For more information, visit the PEBB Medical FSA webpage.

DCAP

  • DCAP reimburses qualified dependent care expenses (e.g., babysitting, daycare, prekindergarten, and registration fees).

  • Qualified dependents include:

    • Dependents under the age of 13 who qualify as an IRS dependent.

    • A spouse or any other IRS-recognized dependent who is physically or mentally incapable of self-care.

    • Elder care expenses for a qualifying relative who is physically or mentally unable to care for himself or herself.

  • The maximum annual amount is $5,000. If the employee and spouse file separate tax returns, the maximum annual amount is $2,500 each.

For more information, visit the PEBB DCAP webpage.

The Medical FSA and DCAP plan is administered by Navia Benefit Solutions. Forms are available on the Navia Benefit Solutions' website  at www.pebb.naviabenefits.com under Forms.

For enrollment processes that involve completing a form, follow these basic guidelines:

Annual open enrollment

Employee must
submit the ...​
​Submit the form to ... ​By when ... ​Enrollment begins ...
Medical ​FSA and DCAP OE Enrollment form.

All employees:  Submit forms directly to Navia Benefit Solutions (address is available on the form). Employees may also enroll online through the Navia Benefit Solutions' website.

All employers:

  • If the employee submits the form to the benefits office, verify the form was received timely.
  • Verify the form is completed in full* including:
    • Employee information is correct, including SSN and agency/institution name.
    • The "Open Enrollment" checkbox is selected.
    • The form is signed by the employee.

When the review is complete:

  • Date stamp the form with the date your office received the form. If mailed, save the envelope or make a note of the postmark date.
  • Fax or mail the forms to Navia Benefit Solutions (send weekly to Navia Benefit Solutions during open enrollment).
  • Include a cover sheet with the employee's enrollment form and indicate that the form was received timely by your agency. Include contact information.

If the form was received after open enrollment ended, advise the employee they will not be enrolled and of their right to appeal through the regular appeals process.

​​No later than the end of
annual open enrollment.
​January 1 of the next year.
  • ​Agency will be notified by Navia Benefit Solutions, through the established process, of enrollment and the deduction per pay check amount.
  • Processes were established with the payroll systems during the implementation.
  • Depending on the established process, agencies may be required to enter the payroll deduction amount for each employee into their payroll system​.

*An incomplete form may result in missed deductions or the employee experiencing problems with accessing their Medical FSA and/or DCAP benefits timely for the plan year.

Newly eligible employees

Employee  must
submit the ...
​Submit the form to ... ​By when ... ​Enrollment begins ...
Medical FSA and DCAP Mid-year Enrollment form.

All employees: Submit forms to their personnel, payroll or benefits office

Employers:

  • When the employee submits the form, verify the form was received timely
  • Verify the form was completed in full* including:
    • The employee information is correct, including SSN and agency/institution name.
    • The "New Hire" checkbox is selected.
    • The form is signed by the employee.

When the review is complete:

  • Date stamp the form with the date your office received the form. If mailed, save the envelope or make a note of the postmark date.
  • Sign and date the form in the employer signature box.
  • Fax or mail the form to Navia Benefit Solutions per instructions on the form.
  • Include a cover sheet with your contact information and indicate that the form was received timely.

If the form is not received timely, advise employee the form is untimely. Provide the employee with their right to appeal following the regular appeals process.

​No later than 31 days after the employee's date of eligibility (generally the date of hire).

​First of the month following the date the form is received by the agency's personnel, payroll or benefits office. If that day is the first of the month, enrollment begins that day.

  • Agency will be notified by Navia Benefit Solutions, through the established process, of enrollment and the deduction per paycheck amount.
  • Processes were established with the payroll systems during the implementation.
  • Depending on the established process, agencies may be required to enter the payroll deduction amount for each employee into their payroll system​.

*An incomplete form may result in missed deductions or the employee experiencing problems with accessing their Medical FSA and/or DCAP benefits for the plan year.

Special open enrollment

​Employee must
submit the ...
​Submit the form to ... ​By when ... ​Enrollment/Changes effective ...

Medical FSA and DCAP Change of Status form, and Proof of the event.​

All employees: Submit forms and proof of the event to their personnel, payroll or benefits office

Employers:

  • When the employee submits the form, verify the form was received timely.
  • Verify the form was completed in full* including:
    • The employee information is correct, including SSN and agency/institution name.
    • The correct checkbox is selected describing the event.
    • The form is signed by the employee.
    • The event allows enrollment or a change to the Medical FSA/DCAP election (request proof of the event, if not already submitted by the employee). Note: An agency transfer is not a qualifying event to enroll in or change an Medical FSA or DCAP election.

When the review is complete:

  • Date stamp the form with the date your office received the form. If mailed, save the envelope or make a note of the postmark date.
  • Sign and date the form to indicate the information is correct and proof of the event was provided. Note: Navia Benefit Solutions will not process a Change of Status form that does not include a personnel, payroll, or office review.
  • Fax, email or mail the form to Navia Benefit Solutions per instructions on the form.
  • Include a cover sheet with your contact information, an indication the form was received timely and the event has been verified.

If the form is not received timely or the event does not allow enrollment in or a change to the Medical FSA/DCAP election, advise employee they will not be enrolled or the change will not be made and of their right to appeal through the regular appeals process.

​No later than 60 days after the date
of the event that triggered the special open enrollment.

​The first day of the month following the later of the event date or the date the form is received. If that day is the first of the month, the enrollment/change
begins on that day.

If the SOE is due to birth, adoption or assumption of legal obligation in anticipation of adoption, the enrollment/ change will begin the first of the month in which the event occurs.

  • Agency will be notified by Navia Benefit Solutions, through the established method, of enrollment and the deduction per paycheck amount.
  • Processes were established with the payroll systems during implementation.
  • Depending on the established process, agencies may be required to enter the payroll deduction amount for each employee into their payroll system.

*An incomplete form may result in missed payroll deductions or the employee experiencing problems with accessing their Medical FSA and/or DCAP benefits for the plan year. A form without the employer signature and contact information cannot be processed.

Transfer employees

Applies to employees who transfer between state agencies and higher education institutions only.

​If the new position is benefits eligible, the employee must submit the ... Submit the form to ...​ ​By when ... ​Enrollment ...

Medical FSA and DCAP Agency Transfer form​.

All employees: Submit forms to their personnel, payroll or benefits office

Employers:

  • When the employee submits the form, verify the form was received timely and there is no more than 30 days' lapse in employment.
  • The form is completed in full* including:
    • Employee information is correct, including SSN and agency/institutions name.
    • The form is signed by the employee.

When the review is complete:

  • Date stamp the form with the date your office received the form. If mailed, save the envelope or make a note of the postmark date.
  • Sign and date the form in the employer signature box.
  • Fax or mail the form to Navia Benefit Solutions per instructions on the form.
  • Include a cover sheet with your contact information and an indication that the form was received timely.

Note: An agency transfer is not a qualifying event for the employee to change his or her Medical FSA and/or DCAP election(s).

No later than 30 days after the date of the transfer, but before the end of the plan year ​Enrollment continues.
  • Agency will be notified by Navia Benefit Solutions, through the established process, of enrollment and the deduction per pay check amount.
  • Processes were established with the payroll systems during the implementation.
  • Depending on the established process, agencies may be required to enter the payroll deduction amount for each employee into their payroll system​.

*An incomplete form may result in missed deductions or the employee experiencing problems with accessing their Medical FSA and/or DCAP benefits for the plan year.

Terminated employees

If an employee is terminated,
the employer must submit the ...
Submit the form or notification to ...​ ​By when ... ​Enrollment ends ...
Termination form or
send an email notification.
  • Fax or mail the form to Navia Benefit Solutions per instructions on the form.
  • Contact the designated account manager.
As soon as possible. ​The last day of the month the employee
terminates.
  • The employee may only submit claims to Navia Benefit Solutions that were incurred through the last day of the month of termination

  • If the employee will receive a final paycheck after the end of the month of the termination, Medical FSA and/or DCAP contributions should not be taken from the final paycheck. This will help avoid future adjustments. 

LWOP employees

If an employee is on approved
LWOP and loses eligibility for
benefits, the employer must
submit the...
Submit the form or notification to ...​ ​By when ... ​Report the...
Medical FSA and DCAP Change in Status form or send an email notification.
  • Fax or mail the form to Navia Benefit Solutions per instructions on the form.
  • Contact the designated account manager:
As soon as known. ​Start date of leave when the employee's leave begins
AND end date of the leave when the employee returns.

Guidance resources

Common questions and issues

Contact

Naiva Benefit Solutions designated account manager

Chelsea Allen
Email:
 ESTeam4@naviabenefits.com