Cicero School District 99

BEFORE YOU BEGIN

Have the following ready:

• Social Security Numbers and birthdates for dependents
• Beneficiary details for life insruance (name, DOB, SSN)

STEP 1: LOGIN INSTRUCTIONS

1. Go to Plansource
2. Use the following format to log in:
   • Username: First initial of your first name up to first six letters of last name last four of digits of your Social Security Number
     • Example: Jane Anderson with SSN ending in 1234 → janders1234
   • Password: Your birthdate in YYYYMMDD format
     • Example: August 14, 1962→ 19620814
3. You will be prompted to change your password upon first login. Be sure to save your new password for future accesss. Passwords reset to your birthdate each Open Enrollment cycle. 

If you have trouble logging in or accessing Plansource please submit a HR HELPDESK TICKET for assistance.

STEP 2: ADD DEPENDENTS

• On the “Review My Family” page, click “Add Family Member”
• Enter required information for each dependent (spouse, child, etc.)
• Click “Save” to return to your Family Summary

STEP 3: ELECT BENEFITS

1. Navigate to the Benefits Dashboard
2. Click “Shop Plans” next to each benefit category (medical, dental, etc.)
3. Select a plan and click “Edit Family Covered” to assign dependents
4. Click “Update Cart” to confirm your selection
5. Repeat for each benefit category

STEP 4: COMPLETE CHECKOUT

• Click “Review & Checkout” once all selections are made
• Review your elections and dependents carefully
• Print or email your confirmation for your records
• Changes can be made within your enrollment window by clicking “Continue Enrollment”

MULTILINGUAL SUPPORT & SPANISH RESOURCES

Spanish-speaking employees can download step-by-step instructions here. Spanish video tutorials are also available.

INSTRUCCIONES PARA LA INSCRIPCION ABIERTA 

VIDEO LIBRARY – ESPANOL

A qualified life event allows you to make changes to your benefit elections outside of the regular Open Enrollment period. All changes must be submitted within 30 days of the event.

WHAT QUALIFIES AS A LIFE EVENT?

You may make benefit changes if you experience:

• Birth or Adoption of a child
• Marriage
• Divorce
• Loss of other coverage (e.g., spouse’s employer coverage ends)

Changes must be submitted within 30 days of the event date.

HOW TO SUBMIT A LIFE EVENT IN PLANSOURCE

1. Go To PlanSource
2. Log in using your username and password
3. Click “Make a Change to My Benefits”
4. Select the applicable life event and enter the exact event date
   • Use birthdate for newborns
   • Use wedding date for marriage
   • Use court-finalized date for divorce
   • Use last day of other coverage for loss of coverage
5. Click Continue
6. Confirm your personal information
7. Add or update dependents as needed
8. Begin enrollment by selecting or updating:
   • Medical
   • Dental
   • Supplemental Life
   • Flexible Spending (FSA/DCA)
9. Make your elections or select “Decline” as needed
10. Enter/update beneficiary information if prompted
11. Click “Review and Checkout” → then click “Checkout” to complete your changes
12. Upload required supporting documents (see below)

REQUIRED DOCUMENTATION

Upload documents directly in PlanSource. If you’re unable to do so, contact the Benefits Specialist for assistance. Life events may take up to two weeks to be reviewed and approved after all required documentation is submitted. 

Your Form 1095-C (proof of health insurance coverage) is available through your PlanSource account.

HOW TO VIEW AND DOWNLOAD YOUR TAX DOCUMENTS

1. Go to PlanSource and log in with your credentials
2. In the left-hand menu, click on “Documents.”
3. Click the “Tax Documents” tab to access your forms
4. Click On “Prior Calendar Years”
5. Scroll and select the year (e.g., 2024)
6. Click “View Form”
7. Once the form is open, click the download icon or right-click to save
8. Open the saved file and print or store for your records

GO PAPERLESS

• While viewing your documents, check the box labeled “Go Paperless”
• Click Submit to receive all future tax documents digitally — secure, fast, and eco-friendly

Tip: If you can’t find the downloaded form, check your Downloads folder or the download arrow at the top-right of your browser. 

Cicero School District 99 is committed to protecting the privacy and confidentiality of your Protected Health Information (PHI) as required under the Health Insurance Portability and Accountability Act (HIPPA).

YOUR RIGHTS REGARDING PHI

As an employee, you have important rights related to how your health information is handled:

• You may request to view or receive a copy of your PHI maintained by the District’s health plan
• You may request corrections if you believe your records are inaccurate or incomplete
• You can request that PHI be sent to an alternative address or method to protect your privacy
• You can request limits on how your PHI is used or shared
• You will be notified in the event of any unauthorized access to your PHI
• You may request a record of certain disclosures made of your PHI, exlcuding routine ones (e.g., claims processing)

USE AND DISCLOSURE OF PHI

Your PHI may be used or disclosed for:

• Treatment (e.g., coordinating care)
• Payment (e.g., processing insurance claims)
• Health Care Operations (e.g., quality assessments, audits)
• Legal Requirements (e.g., responding to court orders)
• Public Health And Safety (e.g., disease reporting, workplace injury claims)
• Plan Administration (e.g., appeals, claims audits)

PHI will not be used for marketing, employment screening, or sold without your written authorization.

HOW TO GET HELP OR ASK QUESTIONS

If you have questions or concerns about your privacy rights or wish to file a complaint, contact:

Tina Cruz

Benefits Specialist

Cicero School District 99

5110 W. 24^th Street, Cicero, IL 60804

(708) 863-4856

TCruz@cicd99.edu

Cicero School District 99 uses the Tyler Infinite Visions Employee Self-Service Portal to give you access to important employment, payroll, and benefit information — anytime, anywhere.

HOW TO LOG IN (CURRENT EMPLOYEES)

1. Go to iVisions
2. Enter your district email address as the username
3. Use your network password to log in
4. On your first login only, verify your identity by entering
   • Last 4 digits of your Social Security Number
   • Date of Birth (MM/DD/YYYY)
   • Home Zip Code

DESCARGAR INSTRUCCIONES EN ESPANOL

WHAT YOU CAN DO IN THE PORTAL

The Infinite Visions Portal allows you to:

• View paychecks, tax documents (W-2, 1095-C), and YTD summaries
• Manage direct deposits and W-4 tax withholding settings
• View employment contracts, certifications, and compensation statements
• Track vacation, sick, and personal day balances
• Submit expense reimbursement requests
• Access and update personal and emergency contact info

PORTAL ACCESS FOR FORMER EMPLOYEES (RESIDENT ACCESS)

Former employees can still access their payroll history, tax documents, and personal info through the Resident Access portal.

RESIDENT ACCESS REGISTRATION LINK

Note: Use your personal email address to register

1. Visit the link above
2. Select “Retiree Access” or “Sign Up for a New Account”
3. Enter your:
   • Last 4 of SSN
   • Date of Birth
   • ZIP Code
4. Follow prompts to complete account setup
5. Once registered, you can:
   • View recent pay stubs
   • Download tax forms (W-2, 1095-C)
   • Access address/contact info

Important: You must complete the termination process through HR to activate Resident Access.

PLANS AVAILABLE

Cicero District 99 offers medical coverage through Blue Cross Blue Shield of Illinois (BCBSIL). Employees can choose from three comprehensive plans based on their needs:

Note: BA1 refers to teacher salary classification. Rates are based on payroll group (10- or 12- month). Bi-weekly deductions over 12 months for most full time employees. 21 checks for Bus Drivers. 

HEALTH REIMBURSEMENT ACCOUNT (HRA)

Employees enrolled in either HMOI or BAHMO plans are eligible to receive a District-funded HRA reimbursement to help offset for the $250 in-patient hospital copay. Submit an Explanation of Benefits (EOB) and a claim form to HR for reimbursement.

• Available only to employees on an HMO plan
• Reimburses up to $250 per hospital admission
• Submit claims anytime during the year

How To Submit an HRA Claim:

1. Complete the HRA Claim Form
2. Include:
   • Date of service
   • Provider name and address
   • Description of service
   • Amount charged
   • Explanation of Benefits (EOB) from BCBSIL
3. Submit your completed claim to Tina Cruz

Claims may be submitted throughout the plan year

PRESCRIPTION DRUG COVERAGE

All medical plans include prescription benefits. Copays differ based on the type of medication and order method.

Retail Pharmacy (30-day supply):

• Generic: $10 copay
• Preferred Brand: $40 copay
• Non-Preferred Brand: $60 copay

Mail Order/ 90-day Retail Supply:

• Generic: $20 copay
• Preferred Brand: $80 copay
• Non-Preferred Brand: $120 copay

Employees and dependents enrolled in any District 99 health insurance plan receive prescription drug coverage administered by Prime Therapeutics.

Key Resources:

• Drug List For Cicero SD99:
  • Select “Basic Drug List for Employer-offered Plans: Large Group (51 or more)
  • CLICK HERE TO VIEW THE DRUG LIST
• Claim Forms and Mail Order Access:
  • Use the FORM FINDER and select the appropriate option.

OUT-OF-POCKET (OOP) COSTS:

All plans include fully covered preventive care.

EXTENDING COVERAGE FOR DISABLED DEPENDENTS (AGE 26 )

District 99 offers continued health insurance coverage for disabled dependents beyond age 26, as long as they meet medical and support criteria.

Eligibility Requirements:

• Disability occurred before age 26
• Dependent is financially supported by the employee
• Cannot engage in gainful employment

How to Apply:

1. Download and complete the DISABLED DEPENDENT CERTIFICATION FORM
2. Physician must complete medical certification
3. Submit completed form to Blue Cross and Blue Shield of Illinois
   • Mail: P.O. Box 805107, Chicago, IL 60680-4112
   • Fax: 312-729-2490

Allow up to 30 business days for processing.

IMPORTANT MEDICARE PART D NOTICE

Employees and retirees who are eligible for Medicare should be aware of their rights under Medicare Part D.

✅ YOUR CURRENT COVERAGE IS CREDITABLE

Cicero District 99’s prescription plan meets or exceeds Medicare standards. This means:

• You can delay enrolling in Medicare Part D without penalty
• If you enroll in Medicare later, you won’t pay a late fee as long as you maintain District coverage

Medicare Open Enrollment: October 15 – December 7

Special Enrollment Period: Available within 2 months of losing empolyer coverage

⚠️ IF YOU DROP COVERAGE

You must enroll in Medicare Part D within 63 days to avoaid a permanent late enrollment penalty.

QUESTIONS?

Lauren Novack

Benefits Contact, Cicero School District #99

5110 W. 24^th Street, Cicero, IL 60804

(708) 863-4856

PLANS & RATES (PER PAYCHECK)

Cicero District 99 offers two dental coverage options to meet your needs through BCBS of Illinois — BlueCare Dental PPO (DPPO) and BlueCare Dental HMO (DHMO). Each plan provides a different approach to care and cost, allowing you to choose based on flexibility, network size, and out-of-pocket expenses.

Free Dental HMO: Available at no cost if enrolled in HMOI or BAHMO health insurance plans. You must opt in through PLANSOURCE to receive the benefit.

PLAN COMPARISON

PPO Coverage Book: Nationwide network, out-of-network coverage, annual deductible, and orthodontia coverage for children.

HMO Coverage Book: In-network only, no deductible, copay-based schedule, and full orthodontia for children & adults (after copay).

BLUECARE DENAL PPO (DPPO)

A flexible plan that allows you to visit any licensed dentist, with the greatest savings when you choose in-network providers:

• Annual Benefit Maximum: $1,000 per person
• Deductible
  • In-Network: $50 Individual | $150 Family
  • Out-of-Network: $75 Individual | $225 Family
• Preventive Services
  • 100% covered in-network
  • 80% covered out-of-network
• Basic Services (fillings, extractions, sedation): 80% coverage
• Major Services (crowns, root canals, prosthodontics): 50% coverage
• Orthodontics
  • 50% for children up to age 19
  • Lifetime Maximum: $1,000

BLUECARE DENAL HMO (DHMO – PLAN 830)

A managed care plan with no deductibles or annual maximums. Requires selecting a primary care dentist from the DHMO network.

• Annual Maximum: None
• Deductible: None
• Preventive Services: $0 copay (fully covered)
• Common copays
  • Fillings: $25-$50
  • Root Canal: $250-500
  • Crowns: $410-485
• Orthodontics (Member, Spouse, or Dependent): $4,600
• Emergency Care: $20 for pain relief, up to $50 reimbursement out-of-area
• Dependent Coverage: Up to age 26 (or 30 for eligible military dependents)

HOW TO SUBMIT A DENTAL CLAIM (PPO ONLY)

1. Complete the Dental Claim Form (provided by BCBSIL or your provider)
2. Include:
   • Patient name and ID number
   • Itemized bill with service codes
   • Dentist’s name, address, and tax ID
3. Mail claims to: Blue Cross and Blue Shield of Illinois
   • P.O. Box 23059
   • Belleville, IL 62223-0059

Note: DHMO members do not need to file claims — your dentist will handle it directly with the plan

COVERAGE FOR DISABLED DEPENDENTS

Eligible disabled dependents may continue dental coverage beyond age 26 if:

• The disability began before age 26
• The dependent is primarily supported by the subscriber

DOWNLOAD THE DISABLED DEPENDENT CERTIFICATION FORM

Submit the complted forms to BCBSIL at the address listed above.

RATES (PER PAYCHECK)

Vision coverage is offered through VSP.

Free Vision Coverage: Available at no cost if enrolled in HMOI or BAHMO medical plans.

WHAT’S COVERED

• Annual eye exams ($10 copay)
• Eyeglass lenses (standard lenses at $0 copay)
• Frames: Up to $270 allowance at select providers
• Contact lenses: Up to $250 allowance in lieu of glasses
• Discounts on laser vision correction

VSP VISION CARE – PRIMARY VISION PLAN

Cicero District 99 provides comprehensive vision benefits through VSP Vision Care. Here’s what’s included:

ESSENTIAL MEDICAL EYE CARE (INCLUDED WITH VSP)

VSP members get access to urgent and medical eye care beyond routine exams:

• $0 retinal screening for diabetic members
• $20 copay for:
  • Pink eye
  • Sudden vision changes
  • Monitoring dry eye, galucoma, and diabetic eye disease

ONLINE ACCESS & SHOPPING WITH VSP

• Shop for glasses/contacts at Eyeconic.com
• Free shipping, returns, and Virtual Try-On tool
• 20% off glasses/sunglasses as a VSP member

EXTRA MEMBER PERKS

• $20 frame allowance for featured brands
• Eyewear Protection Program: 1 year replacement warranty for broken frames

DO I NEED A VSP CARD?

No card is needed. Just provide your name and birthdate.

Want a reference card? Log into vsp.com to download one.

EYEMED VISION CARE (ALTERNATIVE OPTION FOR HMO HEALTH MEMBERS)

• 1 exam per year
• 40% off additional glasses
• 20% off non-covered items
• 15% of LASIK
• Accepted at LensCrafters, Target Optical, Pearle Vision, etc.

HEARING WELLNESS – TRUHEARING DISCOUNT PROGRAM

All VSP members get access to TruHearing, which offers:

• Up to 60% off hearing aids
• 1-year of follow-up visits, cleanings, and adjustments
• 80 free batteries (non-rechargable models)
• National network of 7,000 providers

DISTRICT-PAID BASIC COVERAGE

Cicero District 99 provides all eligible full-time employees with basic group term life and accidental death & dismemberment (AD&D) coverage at no cost to you through Dearborn Life Insurance Company (affiliate with BCBSIL). Coverage varies by employee category and is automatic — no enrollment required.

Certified Staff, Classified Staff, and All Other Full Time Employees Working At Least 30 Hours Per Week:

• Coverage Amount: $30,000 Life and AD&D
• Premium: 100% paid by the District
• Waiver of Premium: Coverage continues without cost if disabled for 6 months prior to age 60, until recovery or age 65
• Termination: Coverage ends at retirement
• Accelerated Death Benefit: Receive up to 75% coverage if diagnosed with terminal illness (max $150,000, min $7,500)
• Coversion Option: Convert to individual Whole Life policy upon separation or loss of eligibility 
• Additional Services
  • Beneficiary Resource Services: Legal, financial, and grief counseling
  • Travel Assistance: Emergency medical, legal, or communication help while traveling

Certified Administrators:

• Coverage Amount: $50,000
• All other benefits are the same as above, including waiver of premium, accelerated death benefit, and conversion privilege.

CONVERSION TO WHOLE LIFE INSURANCE

If you lose eligibilty or separate employement, you can convert your group policy to an individual Whole Life policy. 

• No medical exam required
• Must apply within 31 days of losing group coverage
• Minimum coverage: $2,000; up to the amount held under the group policy

Download Conversion Application Form and mail completed application and first premium to:

Dearborn Life Insurance Company

Attn: Department 6006

1020 31^st Street, Downers Grove, IL 60515

Phone: (800) 367-6401

GROUP TERM LIFE VS. WHOLE LIFE INSURANCE

VOLUNTARY SUPPLEMENTAL LIFE INSURANCE

You can purchase additional life insurance coverage for yourself, your spouse, and your children through Blue Cross Blue Shield / Deaborn National.

Employee Coverage Options:

• Choose from: $25,000 to $250,000 (in $25,000 increments)
• New Hire Guarantee Issue: Up to $150,000 without medical underwriting (EOI required above this amount)

Spouse Coverage:

• Up to 50% of your elected amount (maximum $125,000)
• New Hire Guarantee Issue: $20,000
• Must be elected with employee coverage

Child(ren) Coverage

• Coverage up to 10% of your amount, up to $10,000 total for children 6months-age 19 (23 if full-time student)
• Flat monthly cost: $0.13 per $1,000 of coverage
• Birth–14 days: $0
• 15 days–6 months: $500

MONTHLY PREMIUMS PER CHECK (EMPLOYEE EXAMPLES)

Premiums are based on age and coverage amount, and are deducted from payroll twice per month. Rates shown are for employees. Spouse and dependent rates vary. Evidence of Insurability (EOI) is required for late enrollments or increases beyond the guarantee issue amount.

EVIDENCE OF INSURABILITY (EOI)

Required if:

• Enrolling after initial eligibility period
• Electing coverage above Guarantee Issue
• Annual increases > $10,000

DOWNLOAD EOI FORM

PORTABILITY (VOLUNTARY LIFE)

• Available at termination
• Coverage continues at age-based premium
• Portability Application must be submitted within 31 days

VOLUNTARY GROUP LIFE INSURANCE – NCPERS (PRUDENTIAL)

Cicero School District 99 IMRF employees are eligible to enroll in NCPERS Voluntary Group Decreasing Term Life Insurance, underwritten by Prudential and offered through the National Conference on Public Employee Retirement Systems (NCPERS).

• Premium: Only $16/month – guaranteed to never increase, regardless of age
• Coverage Type: Group Decreasing Term Life (higher benefits at younger ages, gradually decreasing with age)
• Maximum Benefit: Up to $325,000 (includes accidential death coverage)

Dependent Coverage (Included):

• Spouse/Domestic Partner: Up to $20,000
• Children (under age 26): $4,000 per child
• No additional cost – included in your $16 premium

NEW: Student Loan Protection Benefit:

If you become totally disabled and meet the plan criteria, you may qualify for reimbursement of up to $50,000 or 10% of your coverage toward your outstanding student loans — and no extra cost

Enrollment Details:

• Open Enrollment Period: May 1 – May 31 annually
• Effective Date: First of the month following your payroll deduction
• Eligibility: No medical exams or health questions required during Open Enrollment

ENROLLMENT FORM

Coverage Continuation After Employment

• Eligible for continuation into retirement if receiving a monthly pension from IMRF
• Coverage and rate remain the same after retirement

Manage Your Coverage

• Update Your Contact Info Here
• If you’re enrolled in NCPERS, submit this separate Change Of Address Form
  • Fax to (904) 212-3636
  • Or Email to: NCPERS@memberbenefits.com

Designate or Update Beneficiaries:

It is critical to keep your beneficiary information current.

1. Complete the NCPERS Beneficiary Form
2. Submit to:
   • Mail: Member Benefits, 10739 Deerwood Park Blvd, Suite 200-B, Jacksonville, FL 32256
   • Fax: (904) 212-3636

Questions? Call Member Benefits at 1-800-525-8056

At Cicero District 99, your health and well-being go beyond insurance coverage. Take advantage of these free wellness tools and support programs offered through Blue Cross Blue Shield of Illinois (BCBSIL).

WELL ONTARGET® WELLNESS PORTAL

A personalized wellness experience with: 

• Health assessments
• Fitness & nutrition tracking tools
• Digital self-management courses (e.g., stress, sleep, weight)
• Blue Points℠ rewards program (earn points for healthy habits)

BLUE365® DISCOUNT PROGRAM

Exclusive discounts for BCBSIL members on:

• Gym memberships 
• Vision exams and eyewear
• Hearing aids
• Weight loss and nutrition services

Register via BAM to get weekly deals and updates

FITNESS PROGRAM – EXCLUSIVE MEMBER ACCESS

Stay active with access to over 12,000 fitness centers nationwide, live virtual classes, and exclusive health discounts.

• Family-Friendly Bundles Available
• Studio classes with 30% off every 10^th class
• Automatic montly payments via card or bank
• Mobile app for class tracking, check-ins, and goal setting

Enroll Here

📞 Prefer help? Call 888-762-BLUE (2583), Monday–Friday, 7 AM–7 PM CT

Cicero School District 99 employees have access to AFLAC supplemental insurance, designed to provide cash benefits directly to you and your family when facing unexpected illnesses, accidents, or other financial challenges not fully covered by major medical insurance.

AVAILABLE PLANS

AFLAC provides cash benefits paid directly to employees. Coverage helps prevent financial hardship during unexpected medical events. Plans are guaranteed renewable and portable at the same group rates without annual increases. 

Cicero School District 99 offers different retiree insurance pathways depending on employee classification (IMRF or TRS) and retirement age.

IMRF RETIREE INSURANCE OPTIONS

✅ If Retiring Between Ages 62 and 65

Custodial Employees

• Option 1: Stay on District Health Insurance
  • Individual coverage fully paid by District until age 65 or Medicare eligbility
  • Employee pays any additional union-negotiated portion
• Option 2: Enroll in IMRF-Endorsed Plans (medical, dental, drug, long-term care)
• Option 3: Obtain private insurance independently
• Option 4: COBRA Continuation (18 months, full premium 2% fee)

PSRP Employees

• Option 1: Remain on District Insurance at active employee rate until age 65
  • Coverage is individual only
  • Dependents can elect COBRA
• Options 2-4: Same as above

IMRF Premiums 

• Blue Advantage HMO: $765.55
• HMO Illinois: $814.47
• PPO: $1,093.15

✅ If Under Age 62 or Over 65 at Retirement

All IMRF Employees

• May remain on District insurance at full premium cost
• Single coverage only; no dependents
• Additional options
  • IMRF-Endorsed Plans
  • Private insurance
  • COBRA (18 months)

TRS (CERTIFIED) RETIREE INSURANCE OPTIONS

✅ Under Age 65 at Retirement

1. District Reimbursement Option
   • $375/month reimbursement toward personal insurance
   • Increases to $400/month if not Medicare-eligible within 5 years
   • Ends at age 65 or upon Medicare eligibility 
   • Must submit proof of premium costs monthly
2. District Insurance Continuation Option
   • Continue on single coverage only
   • Pay full premium cost (same as IMRF retirees)
   • Not eligible for reimbursement if choosing this route
3. TRS Insurance Option (TRIP)
   • Must enroll directly through TRS
   • Includes medical and prescription options
4. COBRA (not recommended)
   • 18-month continuation of current plan
   • Pay full premium 2% fee
   • Administered by PlanSource
   • Watch for enrollment info mailed ~45 days before coverage ends

✅ Age 65 and Over at Retirement

1. Personal Insurance Option
   • Obtain private Medicare Supplement or Advantage Plan
2. TRIP (TRS Insurance Plan)
   • Enroll via TRS directly
3. COBRA
   • Technically available but not recommended due to cost and Medicare interaction

Cicero District 99 offers two pre-tax Flexible Spending Accounts (FSA) to help you save money and manage out-of-pocket medical and dependent care expenses.Save up to 30% annually through payroll deductions. 

HEALTHCARE FSA

Use pre-tax dollars to cover eligible medical, dental, vision, and pharmacy expenses for you and your dependents.

• Maximum Contribution: $2,500 per plan year
• Eligible Expenses: Medical copays, prescriptions, dental services, glasses, contacts, and over-the-counter medications
• More Covered Expenses: Deductibles, coinsurance, orthodontics, eye exams, and prescribed medications 
• Use-it-or-Lose-it: Unused funds at year-end are forfeited
• Plan Year: Expenses must be incurred between July 1 – June 30 and submitted by June 30
• Immediate Fund Access: Full election amount is available to you on day one

DEPENDENT CARE FSA

Helps pay for eligible child or elder care expenses so you can work.

• Maximum contribution: $5,000 per household per plan year. $2,500 if married filing separately
• Eigible Dependents: Children under 13. Disabled spouse or adult dependents incapable of self-care
• Eligible Expenses: Daycare, nursery school, preschool, summer day camps, before/after school programs, elder care
• Not covered: Overnight camps, K-12 school, care by spouse or child under 19
• Access: Funds are available as contributed per paycheck

Important: You are responsible for making sure your total household contribution does not exceed the IRS limit of $5,000

HOW TO SUBMIT A CLAIM

Submit via PlanSource Portal (Fastest)

Or Submit by Fax/Mail:

Fax: (877) 767-8804

Mail: PO Box 160940, Altamonte Springs, FL 32714

Required Documentation:

• FSA Claim Form: Patient name, date of service, provider name, service description, and amount
• Prescription Claims: Prescription info and pharmacy receipt
• DCA Claim Form: Date of service, provider name, service type, amount, and provider Tax ID/SSN

ACCOUNT ACCESS & MOBILE APP

Manage your FSA/DCA online or on-the-go:

• Register or log here
• App: Download the My Benefits Accounts App (iOS or Android)
• Check balances, submit claims, track reimbursements, and set up direct deposit 

PLANSOURCE FSA BENEFITS DEBIT CARD (MASTERCARD)

• Automatically issued when you enroll in FSA or Dependent Care
• Valid for three years
• Use it at most providers and pharmacies that accept MasterCard
• Tip: Always save receipts in case documentation is required
• Accepted at doctor’s offices, dental/vision clinics, pharmacies
• Retailers: CVS, Walgreens, Target, Walmart (IIAS-certified)

REQUIRED DOCUMENTATION

You may be required to submit itemized receipts to confirm eligible use. Keep all receipts for IRS substantiation.

• Includes: Provider name, service/item description, date, and cost
• Not acceptable: Credit card receipts without itemized detail

FEES

• $4.68/month administrative fee
• $1.50 per issued debit card (includes any dependent cards)
• Card is valid for 3 years
• Ineligible purchaes may lead to card deactivation if not resolved

Cicero District 99 offers an annual insurance stipend for eligible employees who decline, waive, or reduce district-provided health insurance coverage for yourself and/or your family. Staff may receive additional compensation, depending on their level of health plan participation. Your decision is submitted through PlanSource when you complete the Insurance Stipend application during your enrollment process.

AVAILABLE STIPEND OPTIONS & ELIGIBILITY

Note: You may still enroll in other district insurance options (like dental, vision, or life insurance) and remain eligible for the stipend — eligibility is based only on your medical insurance election. The stipend amount is prorated based on your hire date and paid according to district payroll guidelines. All stipend amounts are prorated based on the effective date of enrollment or coverage changes.

HOW TO ELECT THE STIPEND VIA PLANSOURCE

You must re-elect the stipend annually during Open Enrollment or within 30 days of hire or a qualifying life event.

1. Go to PlanSource
2. Login using your username and birthdate-based password
3. Click “Get Started” and review your personal and dependent info
4. Click “ Add Family Member” if you’re eligible for family coverage
5. Make your health insurance election (select plan or decline coverage)
6. Click “Update Cart” and continue
7. On the next screen, select your stipend amount based on your eligibility 
8. Check the boxes for any dependents that qualify you for family-level stipend
9. Upload documentation (only required the first time)
10. Click “Review & Checkout” to finalize your election
11. Email yourself a copy of your elections
12. Complete the “To Do List” in PlanSource to upload necessary documents 

REQUIRED DOCUMENTATION

If you’re electing a stipend based on family eligbility, you’ll need to provide verification documents.

For Children (under 26):

• Birth certificate
• Court documentation

For Spouse or Civil Union Partner:

• Marriage or Civil Union Certificate 
• Proof of joint residency (joint bank statement, cell phone bill, mortgage statement, real estate deed, joint tax return)

NOTIFICATION OF STIPEND STATUS

After completing your elections:

• PlanSource will notify you when your documents have been reviewed
• You can check your benefits dashboard to confirm:
  • Approved: Your stipend appears as elected
  • Denied: Stipend will not appear under your elected benefits

Check PlanSource regularly to verify approval and ensure your elections are complete.