HCSA/DCA Change Form - GIC

Commonwealth of Massachusetts

Complete and submit this form for the following events. Employee or GIC Coordinator may complete/submit for all events, except 6) below (Coordinator Only)

Currently enrolled employees who have a qualifying life event and wish to adjust their elections or election amounts (add, drop, change) may do so by completing the form.
Employees not currently enrolled, but have had a qualifying life event which makes them eligible to enroll may do so by completing the form. NOTE: If you are enrolling for the first time due to a qualifying life event, you MUST also complete and submit the enrollment form found at massfsatasc.com
You are starting or ending a Leave of Absence (LOA)
You are submitting a reclassification request, where you are transferring from one agency to another agency
You are requesting a payroll refund, due to a payroll deduction error
Termination of employment (Coordinator Only)

To be completed and submitted by GIC Coordinator (on behalf of employee)

1. First Name(Required)

2. Employee Middle Name(Required)

Enter middle name. If they don't have one, enter N/A.

3. Last Name(Required)

4. Employee ID Number(Required)

*** PLEASE USE THE SAME EMPLOYEE ID NUMBER EVERYTIME YOU ENTER NEW INFORMATION IN THIS FORM FOR THE SAME EMPLOYEE*****

5. Employee Email(Required)

*** PLEASE USE THE SAME EMPLOYEE EMAIL EVERYTIME YOU ENTER NEW INFORMATION IN THIS FORM FOR THE SAME EMPLOYEE ***

6. Phone Number(Required)

Enter your 10-digit phone number with area code.

Phone Type

7. Employee Street Address(Required)

8. Employee Address 2(Required)

If you do not have a value for this field, then enter NA.

9. Employee City(Required)

10. Employee State(Required)

11. Employee Postal Code(Required)

Must be a minimum of 5 digits (e.g. 02110)

This field is hidden when viewing the form

Country/Region

12. Employee's Current Agency Type(Required)

See GIC Agency Listing. When you select your agency type, a new drop down menu will appear to select your agency name. Take your time and scroll through list to find your agency name. If your agency name is not listed, scroll to bottom and select ‘not listed.’

12. A. Agency Name - HRCMS - Commonwealth of MA(Required)

12. A. Agency Name - Other - Commonwealth of MA(Required)

12. A. Agency Name - UMass Commonwealth of MA(Required)

12. B. Since you selected 'Not Listed' in 12 A., enter the name of the agency here(Required)

13. Employee 12-Digit TASC Participant ID

Your 12-Digit TASC Participant ID can be found on the back of your TASC Card.

14. GIC Coordinator Name(Required)

Election Change

Currently enrolled employees who have had a qualifying event and wish to adjust their account may do so by completing this information, and submitting this form within 60 days of the event date of the status change listed below. Changing the FSA does not allow a refund of already contributed funds, which can include deductions taken before the request is processed and approved. NOTE: approved changes to elections will be effective the first of the month after the request is approved.

Supporting documentation MUST be provided to substantiate any change in status. Submit the supporting documentation along with this form. Acceptable documentation is listed below next to each change of status event type.

If a qualifying event has occurred and the employee wishes to enroll in an FSA for the first time, please indicate the qualifying event and new election amount below, and then complete the New Hire & Mid-Year Enrollment form. Both forms must be submitted together. Please note: For Dependent Care Assistance Program (DCAP), there is a limit of $192.30 per bi-weekly pay period. Please calculate the elections accordingly.

15. Qualifying Event Resulting in Change of Coverage

NOTE: If you select #3, you must also complete and submit the New Hire & Mid-Year Enrollment form if making a new election due to a qualifying event. IN THE EVENT OF TERMINATION: If an employee is being terminated, select option 1 and complete the remaining fields.

15 A. Date of qualifying event for reducing election amount(Required)

15. B. New Reduced Annual Election Amount - HCSA(Required)

Please enter an amount between $250 and $3200 or enter N/A if not applicable.

15. C. New Reduced Annual Election Amount - DCAP(Required)

Please enter an amount between $250 and $5000 or enter N/A if not applicable.

15 A. Date of qualifying event for increasing election amount(Required)

15. B. New Increased Annual Election Amount - HCSA(Required)

Please enter an amount between $250 and $3200 or enter N/A if not applicable.

15. C. New Increased Annual Election Amount - DCAP(Required)

Please enter an amount between $250 and $5000 or enter N/A if not applicable.

15 A. Date of qualifying event(Required)

15. B. New Annual Election Amount - HCSA(Required)

Please enter an amount between $250 and $3200 or enter N/A if not applicable.

15. C. New Annual Election Amount - DCAP(Required)

Please enter an amount between $250 and $5000 or enter N/A if not applicable.

16. Qualifying event(Required)

Before making your selection, open this DOCUMENT to see what supporting documentation is required when submitting this change request.

NOTE: If change is due to a Leave of Absence (LOA), you must report the start – and end – for LOA. If you do not know the end date when you are notifying the beginning of a LOA, complete and submit this form again at the end of your LOA indicating the ending date.

16. A. LOA Start Date(Required)

16. A. LOA End Date(Required)

16. B. Is employee enrolled in a HCSA Account?(Required)

Yes

16 – HCSA: Select type of Leave of Absence (LOA)(Required)

Paid Deductions will continue to be taken from the employee’s pay each pay period and the HCSA coverage will continue uninterrupted.

- Expenses can be incurred before, during, and after the Leave of Absence (LOA). (If an employee changes to an unpaid status, GIC Coordinators are responsible for notifying TASC of any changes during the LOA on behalf of the employee).

Unpaid (Prepay, Direct Pay, Pay upon Return or No Coverage with Adjusted Election) - Prepay and Direct Pay Options are only available if requested in advance of the start of LOA.

Direct Pay: Employees have the option to be directly billed for premiums and administration fees while on LOA. - Direct Pay deductions will be post-tax, as they are not occurring through payroll. TASC will invoice the employee once a month, at the beginning of the month, with the amount due. - The employee must pay the premium no later than the first pay date of the month on which the employee would have received a paycheck had they been active.

- Payments must be made in a timely manner for the HCSA debit card and account to remain active. There is no grace period for a missed direct payment. If payment is not paid by the due date, then coverage is discontinued until the employee’s return to active status.

Paid

Unpaid

16 – HCSA: Select type of Unpaid LOA(Required)

16 – HCSA: Enter the last payroll date with deduction for HCSA

16. C. Is employee enrolled in DCAP account?(Required)

Yes

16 – DCAP: Select type of Leave of Absence (LOA)(Required)

Paid Deductions will continue to be taken from the employee’s pay each pay period and the DCAP coverage will continue uninterrupted.

- Expenses can be incurred before, during, and after the Leave of Absence (LOA). (If an employee changes to an unpaid status, GIC Coordinators are responsible for notifying TASC of any changes during the LOA on behalf of the employee).

Unpaid (Prepay, Direct Pay, Pay upon Return or No Coverage with Adjusted Election) - Prepay and Direct Pay Options are only available if requested in advance of the start of LOA.

Direct Pay: Employees have the option to be directly billed for premiums and administration fees while on LOA.

- Direct Pay deductions will be post-tax, as they are not occurring through payroll. TASC will invoice the employee once a month, at the beginning of the month, with the amount due. - The employee must pay the premium no later than the first pay date of the month on which the employee would have received a paycheck had they been active.

- Payments must be made in a timely manner for the DCAP debit card and account to remain active. There is no grace period for a missed direct payment. If payment is not paid by the due date, then coverage is discontinued until the employee’s return to active status.

Paid

Unpaid

16 – DCAP: Select type of Unpaid LOA(Required)

16 – DCAP: Enter the last payroll date with deduction for DCAP

17. Attach supporting documentation for qualifying event

ALL Qualifying Events selected in Question 16 require supporting documentation, except for a Leave of Absence. Open this DOCUMENT to see what supporting documentation is required for each qualifying event. Acceptable file extensions include jpeg, pdf, or word document.

Accepted file types: jpeg, jpg, pdf, docx, Max. file size: 50 MB.

18. Is reclassification required?

Yes

18. A. New Agency Type - Commonwealth of MA(Required)

18. B. New Agency Name - HRCMS - Commonwealth of MA(Required)

18. B. New Agency Name – Other - Commonwealth of MA(Required)

18. B. New Agency Name – UMass - Commonwealth of MA(Required)

18. C. Date of Change(Required)

18. D. Reason for Reclassification(Required)

18. E. Attach Reclassification Documentation

Acceptable file extensions include jpeg, pdf, or word document.

Accepted file types: jpeg, jpg, pdf, docx, Max. file size: 50 MB.

19. Is a payroll refund being requested?

Yes

19. A. Payroll Date of Error

19. B. Deduction Codes? (select all that apply)

HCSA

DCAP

19. C. HCSA Error Amount

19. D. DCAP Error Amount

19. E. Plan year payroll error occurred:

19. F. Reason for Refund Request

19. G. Attach Payroll Refund Documentation

Acceptable file extensions include jpeg, pdf, or word document.

Accepted file types: jpg, pdf, docx, Max. file size: 50 MB.

20. Is the employee terminating employment with The Commonwealth of MA?(Required)

Yes

20. A. Date state employment ended(Required)

20. B. Enter Last Payroll Date with deduction for Dependent Care Assistance Program or enter NA if employee was not enrolled: If enter date, enter as MM/ DD/ YYYY.(Required)

20. C. Enter Last Payroll Date with deduction for Health Care Savings Account or enter NA if employee was not enrolled. If enter date, enter as MM/ DD/ YYYY.(Required)

24. Enter full name of person completing this form(Required)

WHEN YOU CLICK SUBMIT IT IS CONSIDERED 'SUBMITTED' IF YOU RECEIVE A MESSAGE ON THE SCREEN THAT SAYS 'Thank you for submitting the change form on massfsatasc.com.'"