LP-HCFSA Conversion Form

LPFSA Conversion Form

Eligible employees can utilize this form to update a Limited Purpose Flexible Spending Account (LPFSA) enrollment to an Health Flexible Spending Account (Health FSA) once their deductible has been met.
Employee Details

Please confirm personal details associated with your Benepass account.
First Name
Last Name
Work Email Address
Employer Name
Proof of Deductible
IRS guidelines allow an employee to "convert" their Limited Purpose Flexible Spending Account (LPFSA) to an Health Flexible Spending Account (Health FSA) only under certain conditions. Employees must meet their health insurance deductible, and provide proof, to convert their account type.

Converting your LPFSA to a HCFSA is beneficial for eligible employees as it expands the categories of eligible spending to include IRS-approved medical expenses (as opposed to only qualified vision and dental under an LPFSA).
Please upload proof that your deductible has been met

This can be a formal note from your health carrier, or a screengrab showing your deductible and YTD spending.
Cancelof
(Optional) Notes about your uploaded image:
Please provide clarity if the uploaded image is unclear.
Next Steps
Submission of this form will create a ticket for the Benepass support team, who will initiate the enrollment update.

Within 2 weeks of submission, you will receive notice that your enrollment has been updated, and you will see your benefit name on your account change. Once updated, your remaining FSA balance will then be available for any approved HCFSA purchases.

No other action is required - you will utilize the same card as before!
Email
example@example.com
jotformname
Should be Empty:

LPFSA Conversion Form

Employee Details

Proof of Deductible

Next Steps