The Health Care Authority contracts with Navia Benefit Solutions to manage the Limited Purpose Flexible Spending Arrangement (FSA), process claims, and provide customer service for Public Employees Benefits Board (PEBB) employees. Who is eligible? The Limited Purpose FSA is available to PEBB benefits-eligible employees who work at state agencies, higher-education institutions, and community and technical colleges as described in Washington Administrative Code (WAC) 182-12-114. How can a Limited Purpose Flexible Spending Arrangement (FSA) help me? A Limited Purpose FSA allows you to set aside pre-tax money from your paycheck to pay for out-of- pocket vision and dental costs. It is intended for subscribers who are enrolled in a consumer-directed health plan (CDHP) with a health savings account (HSA). Here are some ways you can benefit from a Limited Purpose FSA: • Setting aside a portion of your pay with a Limited Purpose FSA reduces your annual taxable income. • Your Limited Purpose FSA helps you pay for out-of-pocket vision and dental expenses. (See “What expenses are eligible?”) • Your Limited Purpose FSA is compatible with your HSA, so you can spend funds from both accounts in the same plan year. This benefit allows you to save your HSA funds for medical expenses. • You can set aside as little as $120 or as much as $3,050 for the calendar year. The full amount you elect to set aside for your Limited Purpose FSA is available on your first day of coverage for expenses. • You can use your Limited Purpose FSA for you, your spouse or state-registered domestic partner, or other qualified dependent’s vision and dental expenses, even if they are not enrolled on your PEBB health plans. How does the Limited Purpose FSA work? • You estimate your dental and vision expenses for the plan year, then enroll in a Limited Purpose FSA for that amount. The more accurate you are in estimating your expenses, the better this benefit will work for you. • You cannot change your election amount after the plan year starts unless a qualifying event, like a birth or marriage, creates a special open enrollment, or you cease to be eligible for the employer contribution toward PEBB benefits. • The amount deducted from your pay is your annual election amount divided by the number of paychecks you will receive in the plan year. • Your election will be deducted from your paycheck pre-tax throughout the plan year, so you don’t pay FICA (7.65%) or federal income tax (10-37%) on your elected dollars. • You cannot cancel participation in the Limited Purpose FSA once the plan year starts unless you end employment or retire. • Unused Limited Purpose FSA balances up to $640 will carry over to the next plan year. To receive carryover, you must a) enroll in an FSA for the next plan year to carry over any amount up to $640, or b) have at least $120 remaining in your account to carry over any balance between $120 and $640. Any funds above $640, or below $120 if you do not re-elect, will be forfeited to the plan administrator, the Health Care Authority. See the “Carryover and claim submission deadline” section for details. • You must enroll in a Limited Purpose FSA again for each year you want to participate. Enrollment does not automatically continue from plan year to plan year. When can I enroll and how do I do it? There are three occasions when you are eligible to enroll in a Limited Purpose FSA. 1. You are newly eligible. Enroll no later than 31 days after the date you become eligible for PEBB benefits. To enroll, fill out the PEBB Midyear Enrollment Form and return it to your payroll or benefits office. You can find the form online at pebb.naviabenefits.com, or request it from your employer. 3