Flexible Spending Account (FSA) Enrollment Application

Purpose: This action is used to establish contributions into a Medical and/or Dependent Care Reimbursement Account.

  • Medical Reimbursement Account = Reimburses out-of-pocket medical costs not covered by your insurance plan.
  • Dependent Care Account = Reimburses the cost of dependent care when you or your spouse work or attend school

 Note: Employees may enroll in one or both plans.


Filling out the application:

Employees must be eligible to enroll in the State's medical plan to qualify for FSA Enrollment. If you are not eligible, the following error message will be displayed when attempting to access the FSA Enrollment application, "You are not eligible for medical insurance, please contact the Office of Group Insurance". 

  • All FSA deductions are automatically ended after the last pay period in June.
  • A new FSA application must be completed each year during the annual Open Enrollment period.
  • When the open enrollment period ends, all FSA applications with a 'Draft' status will be automatically deleted.


Section 1: Application Information (Employee Information)

This portion of your application is prepopulated with some information from your personnel record.

  • Phone number is a required field.
  • Email Address is a required field.


Section 2: Elections

This portion allows you to choose the type of FSA plan and the amount you wish to contribute. You may choose to contribute to a Medical FSA and/or a Dependent Care FSA.

  • Select 'Yes' or 'No' for both Health Care FSA and Day Care (Dependent Care) FSA.
  • If you selected 'Yes' for one or both, enter the FSA contribution amount you want taken for each pay period in dollars and cents (e.g. - $19.65).
    • Note: If the amount you enter is less than the minimum or more than the maximum limit amount, you will receive an error message.
  • If you are making a change to your current FSA plan, you will see the amount(s) you elected in the Pay Period Election box(es).
    • Note:
      • Changes cannot be made to your current FSA account unless there is a qualifying, 'change in status', event.
      • The date you submit your FSA change determines the pay date the deduction is taken, which may be up to 2 pay periods.



Section 3: Debit Card

This portion is informational ONLY. Please read the information provided for details pertaining to the Debit Card that is automatically issued as part of enrolling in an FSA plan.


Section 4: Signature and Additional Information

Please read the Additional Information at the bottom of the form. Once you have read through the statement of understanding, you must return to the Signature portion of the form and select 'Yes' or 'No'.

  • By selecting 'Yes', you are agreeing to everything in the Additional Information and Signature sections and will have an electronic signature and date attached to the form.
  • If you select 'No' because you do not agree to the Additional Information and/or Signature section, please return to the top of the form and click the 'Cancel' button. You will return to the IPOPS Self-Service main menu.
    • Note: FSA Enrollment Applications require a 'Yes' to process.





Completed Application 

Now that you have completed your application, scroll to the top and choose an option: Submit, Save, Cancel, Print, or Help.

You cannot submit this application unless you selected 'Yes' for the employee signature to agree to the terms of the plan.


  • Submit - will route your FSA Enrollment Application to the Office of Group Insurance (OGI) and the following message will be displayed: "Online Enrollment application has been submitted for processing. Based on your application, coverage will begin on [Date]. A premium adjustment will be processed if needed. To view your submitted application, go to Views > My Self-Service. For additional information, contact the Office of Group Insurance".
    • Note:OGI will review your application and either submit or decline it. If OGI declines your application, they must add a comment, which is available for you to view by opening your application and clicking the 'Comments' button.
  • Save - will save your document in a draft status and the following message is displayed: "Online enrollment application has been saved as a Draft. To complete this application, go to Views > My Self-Service. For additional information, contact the Office of Group Insurance".
  • Cancel - you will receive the following message: "You have chosen to exit without saving your changes. If you wish to do this, press OK". By choosing 'OK', you will be taken back to the Self-Service Views. If you choose 'Cancel', the FSA application remains open.
  • Print - sends your print request to a designated printer.
  • Help - will open the Payroll Guide.
  • Delete - once a document has been saved or submitted there will be a 'Delete' button displayed in the top navigation frame.


Following the Status of your FSA Enrollment Application

You can follow the status of your application by going to Views > My Self-Service. In My Self-Service, you should only have one FSA Enrollment Application. If there are extra FSA applications, please delete them. Any FSA Enrollment Applications that were created and not submitted during open enrollment will be automatically deleted when the open enrollment period ends.


Making a Change During Open Enrollment

During open enrollment, if you need to make a change to your current FSA due to a qualifying event, you'll need to contact the Office of Group Insurance (OGI). If you select the FSA Enrollment Application option from the Self-Service menu, you will receive two options:


  • Select 'Next' ONLY if you want to create a new FSA deduction for the new fiscal year.
  • Select 'Cancel' and contact the Office of Group Insurance (OGI) to make changes to your current FSA.