34 Tex. Admin. Code § 85.9 - Payment of Claims from Reimbursement Accounts
(a) Claim for reimbursement.
(1) Claims for reimbursement of expenses
incurred during an eligible employee's period of coverage in the plan year may
be submitted at any time during the plan year, but not later than December 31
following the close of the plan year.
(2) Claims shall be paid to the extent of
available flexible benefit dollars allocable to the applicable type of expenses
and shall only be paid out of flexible benefit dollars for the plan year, in
which the expense was incurred. The TPA shall compare the participant's
available balance and the amount of the expense to make certain that claims are
paid according to the provisions of the Code and these rules.
(3) Expenses incurred prior to becoming a
participant or after the last day of a plan year, shall not be covered by this
plan. A terminated participant may continue to file claims for eligible
expenses incurred during the employee's period of coverage within the plan
year, if applicable, to exhaust reimbursement account balances no later than
December 31 following the close of the plan year.
(4) Claims shall be submitted in a manner
prescribed by the Employees Retirement System of Texas or its designee,
accompanied by such bills, receipts or other proof of incurring the expense as
the plan administrator or its designee may require.
(5) A claim form must be submitted each time
reimbursement or payment is requested, unless using the debit card.
(6) The dependent care and health care
reimbursement accounts are separate accounts, and funds from one account may
not be used to reimburse expenses of the other account.
(b) Debit Card transactions.
(1) Debit card payments for eligible expenses
incurred during a participant's period of coverage in the plan year may occur
at any time during the plan year.
(2) Transactions shall be processed to the
extent of available flexible benefit dollars allocable to the applicable type
of expenses and shall only be paid out of flexible benefit dollars for the plan
year in which the expense was incurred. The TPA shall compare the participant's
available balance and the amount of the expense to make certain that claims are
paid according to the provisions of the Code and these rules.
(3) Expenses incurred prior to becoming a
participant shall not be covered by this plan. Expenses incurred by a
participant may be covered only in the plan year in which the expense is
actually incurred. Upon a participant's termination, the debit card will be
automatically deactivated. Paper claims may be filed for eligible expenses
incurred during the participant's period of coverage within the plan year in
which he was a participant. All claims for reimbursement from account balances
must be filed no later than December 31 immediately following the close of the
plan year.
(4) Participants may be
required to submit bills, receipts or other proof of incurring the expense as
the plan administrator or its designee may require.
(5) Reimbursements or payments made using the
debit card may require additional supporting documentation as may be requested
by the plan administrator or its designee, and the participant must maintain
his own records to substantiate the eligibility of all expenses for individual
income tax purposes, if necessary.
(c) Reimbursement of claims to participants.
(1) Payment of eligible expenses shall be
made directly to the participant by the plan administrator or its designee
unless payment for dependent or health care expenses is made directly to the
applicable provider through use of a debit card, other similar technology, or
other means approved by the plan administrator.
(2) The plan administrator may establish or
waive the minimum payment as deemed necessary.
(3) Reimbursements to participants or
dependent care providers shall be made at least once each month.
(4) Dependent care reimbursement shall at no
time exceed the greater of the balance of the participant's account for the
plan year at the time of the reimbursement, or an amount equal to the monthly
salary reduction amount.
(5) Health
care reimbursement shall at no time exceed the eligible employee's election and
employer contributions, if applicable, for the eligible period of coverage in
the plan year.
(d)
Participant's responsibility.
(1) An employee
or former employee will be held liable for any overpayments of benefits as a
participant in the reimbursement accounts. The method of repayment shall be
determined by the plan administrator or its designee, and until full
restitution is made by the participant, no further claims payment from any
TexFlex accounts will be made to the participant by the plan administrator or
its designee.
(2) A health care
reimbursement account participant who has insufficient funds during the plan
year is liable for the monthly health care election amount and must pay for it
with after-tax dollars, unless as described in §
85.3(b)(3)(D) of
this title (relating to Eligibility and Participation). Should the participant
fail to contribute to the account with after-tax dollars, upon the
participant's return to active duty, payroll deduction will be required to
recover the election amounts due.
Notes
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