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Shipping: 10000 Shelbyville Road, Suite 110, Louisville, KY 40223
Mailing: P.O. Box 43653, Louisville, KY 40253-0653
(502) 244-1161 FAX (502) 244-1162
www.bmsllc.net
Annual Renewal Form
Section 125 Plan and Flexible Spending Accounts
Company Name: .City of Jeffersonville
Renewal Plan Year: 4/112007- 12/31/2007 (Short Plan Year)
As an authorized representative of the above company, the undersigned elects to renew the
administration of our Section 125 Plan and Flexible Spending Accounts with Benefit
Marketing Solutions LLC effective the-first day of the renewal Plan Year noted above. The
administrative fees associated with our Phan for the duration of the Plan Year areas follows:
Fee Schedule-Please Check Option Selected
(Note: You will be invoiced for all fees.)
X Annual Renewal Fee: $150.00
.Option 1-FSA No Debit Card
Per Participant Fee: $4.50 per participant per month*
Option 2 -FSA Debit Card EMPLOYER Paid
Per Participant Fee: $6.00 per participant per month's
WITH FLEX DEBIT CARD*"`
Fee includes two cards (employee plus one extra.) Additional
cards are $7.00 each card (paid by participant.) jEMPLOYEE
MUST HAVE A VALID E-MAIL ACCOUNT TO BE ISSUED
DEBIT CARD.)
Option 3 -FSA Debit Card EMPLOYES Paid
Per Participant Fee: $4.50 per participant per month*
WITH FLEX DEBIT CARD** PLUS
$18.00 EMPLOYEE Paid Annual Fee
(Can be pre-taxed from Health FSA Acct.) -Fee includes two
cards (employee plus one extra.) Additional cards are $7.00
each card. jEMPLOYEE MUST HAVE A VALID E-MAIL
ACCOUNT TO BE ISSUED DEBIT CARD.]
'*Only one monthly fee if participant is enrolled in both the Health FSA and the Dependent
Daycare Account. Minimum fee for all groups will be at least $30.00 a month. Additional fees
may be charged for re-enrollment meetings -please contact your BMS representative if fees
are applicable. However, standard enrollment materials are always provided and.
teleconferences are recommended.
BMS LLC ~
**Minimum Debit Card Enrollment Requirement: 20 participants (if less than 20 participants,
annual or quarterly pre-funding of contributions required.) ACH Direct Deposit of funding is
required with Debit Card (please complete page 4 with Account information.) Pre-funding may
also be necessary based on daily use of the Debit Card by Employees. Also, Debit Card
Agreement Form MUST be executed prior to implementation (new debit card groups only.)
BMS LLC Responsibilities
• Plan Update Services -plan review and document preparation annually. This service
includes client and participant notification of rules and. regulation changes. It also
includes necessary discrimination testing, HIPAA compliance and assistance with
complying with IRS guidelines associated with Section 125 Plans.
• Participant Enrollment Assistance -includes preparation of educational materials,
enrollment forms, worksheets, claims forms, etc. Enrollment meetings are available if
approved based on fee schedule noted above.
• Participant Account Management.- includes entering participant per pay contributions,
claims review and adjudication, claim reimbursement, account balance tracking,
entering of all terminations, additions and status change requests and quality customer
service through the dedicated Employee FSA website link at www.bmsllc.net, toll-free
interactive voice response (IVR) line (877) BMS-FLEX or by contacting the BMS LLC
office and your assigned Customer Service Representative.
• Claims Services -claims are processed daily with all properly prepared and
documented claims that are .received. being finalized and reimbursed on Tuesday and
Friday of each week. Participants can receive .their reimbursements via. a check or
direct deposited through ACH. debit Card services are available to participants as
well if selected. by the Employer. A Debit Card Agreement must be executed prior to
', debit card implementation. Ask BMS LLC about more details as it relates to claims
substantiation for debit card transactions.
• Reporting -employers have access to a variety of reports including Eligibility Report,
Disbursement. Liability Report, Check Register Report, Year-To-Date Summary
Reports, etc. via online through the dedicated Employer Only website link at
www.bmsllc.net. Other special reports can be provided to the Employer; however,
there may be additional fees for other reports (other than the most common, standard
reports noted above) that are available upon request. Note: Participants can obtain
reports online at their dedicated Employee FSA website link at www.bmsllc.net.
• Accounting -BMS LLC processes. all ..paycheck contributions received from the
employer each month and performs account reconciliation of .all deposits. Employers
can submit contributions to BMS,.I_LC_va check or BM,S LLC can draft an assigned
account via ACH Direct. Deposit at the beginning of each month for all. contributions. for
that month or other methods as agreed to by both BMS LLC .and the employer (NOTE:
ACH Direct Deposit is the required funding method with Debit -Card installation.)
Funding Accounts are audited on at least a quarterly basis. by the BMS LLC Account
Department.
• Invoicing -annual or monthly invoices for the above services will be sent based on the
information noted above. in fee schedule... Invoices are .mailed the 15t" of the month
and are due within 30 days of the date of the invoice. Payments received after 30
BMS LLC 2
days from the date of the invoice may result in BMS LLC holding the processing of
claims for your participants, and .may be subject to termination of the contract for
delinquent payment.
Employer Responsibilities
• General Compliance -the employer is ultimately responsible for all .Plan activities
including general compliance, HIPAA, IRS Code and all other applicable laws and
regulations. The employer should review all documents provided by BMS LLC in order
to understand fully the Plan design. If the Debit Card is implemented, the employer
agrees to assist BMS LLC with obtaining re-payment of ineligible debit card use via
.payroll deduction or garnishment, if other methods fail in obtaining proper re-payment
from the participant.
:• Enrollment -the employer shall provide completed enrollment information to BMS LLC
by 1.) Completion of manual election forms, 2.) Through the BMS LLC employer-only
website link at www.bmsllc.net, 3.) By employee electronic enrollment at the FSA
website link at www.bmsllc.net (if applicable) or 4.) By providing a census of
enrollment (in a specific format provided by BMS LLC.)
• Eligibility Changes -the employer shall notify BMS LLC of changes in employee
eligibility (i.e. additions, terminations, change in Family Status, etc.) within at least 5
business days of the change. BMS LLC must be notified. in a timely manner in order to
properly administer the account(s) in accordance with IRS regulations. BMS LLC .has
the, authority to charge additional fees for an employer's failure to notify BMS LLC of a
', change in a timely manner. This fee could be at least $25.00 per transaction. This fee
may also be assessed for late enrollees not received in adequate time. for the proper
renewal of the Plan. Employers can use a-mail, fax or mail to communicate the
changes to BMS LLC or, utilize the employer-only website link at www.bmslic.net.
• Account Deposits and Contributions -the employer shall remit the deposits of the total
contributions for their participants on a per pay or monthly cycle via check, ACH
transaction executed by BMS LLC, or other methods as agreed to in advance by both
BMS LLC and the Employer. (NOTE: If the Employer elects to implement the Flex
Debit Card, ACH transactions of all deposits is required allowing the Employer's
account to always be "funded" to' cover received debit _card transactions. The Debit
Card Agreement must be .executed by those Employers implementing the Flex Debit
Card.) The employer is required to submit a report itemizing their .deductions. for
participants along with their deposit. BMS LLC may require a minimum' pre-funding of
contributions in .order to allow for', a_ start-up balance to adjudicate claims received at
the start of the Plan Year.. Also, employers must be aware that at any time during the
Plan Year, the employer could be required per IRS guidelines to provide additional
deposits to cover participant claims (when in excess of deposits on hand) as needed
and requested by BMS LLC. Full accounting of such activity will be provided to the
employer. BMS LLC has the authority and obligation to stop adjudication of participant
claims as they wait to receive required funding. If adequate funding is still not received
after several requests, BMS LLC has.. the authority to terminate. our services
immediately.
BMS LLC 3
Please confirm your Health FSA Annual Election Maximum for the New Plan Year:
Current Annual Maximum: 1 500 New Annual Maximum:$
(if no change, please indicate)
NOTE: If you elected to implement the 2 % month grace period last Plan Year,
it is assumed that you wish to continue for the new Plan Year. This section
will only be applicable if you wish to implement this service beginning with
this renewal Plan Year.
Under IRS Notice 2005-42, Section 125 Plans may allow participants to access unused
amounts after the end of a Plan Year to pay or be reimbursed for expenses for qualified
benefit under the Health FSA and Dependent Daycare Account incurred during a "grace
period" of up to 2 '/ months after the close of a Plan. Year.. Any unused amounts are not
forfeited at the end of Plan Year, but at the end of the grace period.
For example, if your Plan Year ends 12/31/07, participants have until 3/15/07 to incur
expenses during this 2 '/2 month grace period. They will then have an additional 15 days to
submit .claims (3/31/07.) Expenses will be reimbursed first from any available funds
remaining from the prior Plan Year and then from the current .Plan Year's. amounts. Claims
will be paid in the order in which they are provided.
Implementation of the 2'/z month grace period is at the discretion of the employer.
YES, we would like to implement the 2 % month grace period for the Health FSA and
Dependent Daycare Account for our participating employees.
NO, we elect NOT to implement the 2 % month grace period for the Health FSA and
Dependent Daycare Account for our participating employees.
BMS LLC 4
Employer Bank Name
Routing #: Bank Acct. #:
agree to accept BMS LLC as the Third Party Administrator for our Section 125 Plan and
Flexible Spending Account for the term of the Plan Year noted above and agree to the fee
schedule outlined in this Annual Renewal Form.. Once.. BMS LLC receives confirmation of
your renewal of their services, a representative of BMS LLC will contact you regarding
finalization of the enrollment process.
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