Choose which Section 125 FSA or Cafeteria Plan Components You Want


Online Order Form for Section 125 Plan Documents with HSA Module:

First, choose the Plan or combination of Plans that meet your needs from the following 4 options:

Section 125 Premium Only Plan (POP) with HSA Module - $179 one-time setup fee
	Section 125 Premium Only Plans with the HSA Modules allow Employers to pretax insurance premium including primary health insurance such as PPO, HMO and HSA Plans. This document package also allows the pretax treatment of ancillary benefits such as dental, vision, accident, cancer, hospital indemnity, and term life insurance up to $50,000. The HSA module allows employers to also pretax the HSA savings component that goes to the bank. HSA contributions can be changed if the employee wants to increase or decrease the amount going to the health savings account.
Section 125 POP with HSA Module and Health FSA - $328 one-time setup fee
	The Premium Only Plan (POP) and Health FSA for medical expense reimbursements combination includes the new HSA module. This combination allows employees to pretax primary and ancillary insurance premium and the HSA savings component, plus the Health Flexible Spending Account that allows employees to use pre-tax dollars to pay medical bills not covered by their insurance. The Health FSA has special language to limit Health FSA reimbursements to only dental, vision and preventative care for employees also participating in an HSA Plan.
Section 125 POP w/ HSA Module & Dependent Care FSA - $328 one time setup fee
	The Section 125 Premium Only Plan (POP) and Dependent Care Assistance Plan FSA combination allows employees to pretax insurance premium, HSA savings, and establish a Flexible Spending Account to reimburse dependent care expenses incurred as a result of employment.
Full Cafeteria Plan - POP with HSA Module, Health FSA and Dependent Care FSA $429 one-time setup fee
	The full Section 125 Cafeteria Plan includes all three, Premium Only Plan (POP) with HSA Module, Health FSA, and the Dependent Care Assistance FSA Plans outlined above. This option allows you to save $98 by combining all 3 Plans together in one document.

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HSA Section 125 POP

Dependent Care FSA

HSA Fax Order Form

IMPORTANT: Many small employers take insurance premium and medical expense reimbursement deductions without the knowledge that a formal Plan Document and Summary Plan Description are required by the Internal Revenue Code. Many CPAs, bookkeepers, and accountants are unaware of this requirement. The penalty for non-compliance may include disallowance of all deductions, payment of all delinquent taxes plus interest and penalties.