Health Reimbursement Arrangement (HRA) for City of Lewiston

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1 Non Union Employees Health Reimbursement Arrangement (HRA) for City of Lewiston HRA means Health Reimbursement Arrangement. The HRA allows your employer to reimburse participating employees for all IRS Code Section 213(d) eligible expenses without it being treated as taxable income to you. Please refer to the attached eligible expense list. How much will the HRA Plan Reimburse & Who is Eligible? Eligibility*: Employees and IRS-defined dependents enrolled in the MMEHT Anthem PPO 500 Group Health Plan Maximum Benefit: PPO 500: $1200 Single / $2400 Family PPO 1500: $1700 Single / $3400 Family Plan Year Period: January 1, 2019 through December 31, 2019 Runout Period**: Claims incurred during the Plan Year Period continue to be processed for 90 days after the Plan Year end date Covered Expenses: All medical, vision & dental expenses eligible under IRS Code Section 213(d) How do I get a reimbursement from the HRA plan? You may access your account from our website at Complete an HRA Claim Form (copy attached) which has been tailored to your specific plan. Attach your itemized receipt(s) and , fax or mail the claim form with the receipts to Group Dynamic, Inc. (Instructions & phone numbers are on the bottom of the HRA Claim Form); Group Dynamic, Inc. (GDI) will process your reimbursements on a weekly basis as long as we receive your request by noon on Tuesday. Itemized Receipts A Word of Caution! The IRS requires that you have an itemized receipt of services received. Credit card slips are not sufficient. An itemized receipt contains the following: Provider s Name Cost of Service Date of Service Patient Name Description of Service GDI Website: You may view HRA claims paid and your account balance at Go to and select Participants from the Log In menu; Are you a New User? Click on Create your new username and password. GDI Customer Service: If you have questions regarding your HRA benefit, please feel free to contact GDI at or Mention your employer name and ask to be directed to the Reimbursement Team. * Company shareholders, domestic partners or participants with secondary medical coverage may be required by the IRS to waive HRA coverage. Likewise, any eligible employee may opt out of HRA Coverage. See your employer for more information. ** If your coverage ends mid-year (due to termination of employment or change in eligibility status) the Runout Period begins the day after coverage ends. 10/31/18

2 Non Union Employees HRA CLAIM FORM City of Lewiston HRA Claim Year: January 1, 2019 through December 31, 2019 Health Plan Renewal Date: January 1 EMPLOYEE INFORMATION Employee Name: Maximum Reimbursement: Eligible Expenses: Eligible Participants: Claim Reimbursement Submit: PLAN PARAMETERS Last 4 Digits of SSN: HRA-S-GX-00 Employees and IRS-defined dependents enrolled in the MMEHT Anthem PPO 500 Group Health Plan All medical, vision and dental expenses eligible under IRS Code Section 213(d) Employees and IRS-defined dependents enrolled in Anthem Group Health Plan. HRA Claim Form with Group Health Plan Explanation of Benefits (EOB) OR the itemized receipt or statement from the service provider. QUALIFIED EXPENSES Provider Name Service(s)/Item(s) Purchased Services for (Name/Relationship) Service Dates Expense TOTAL: Submit Claims To: Group Dynamic, Inc. Address: 411 US Route One, Falmouth, ME claims@gdynamic.com Fax: I request reimbursement for my qualified medical expenses. I certify that I incurred these expenses as a participant in the HRA plan established by the employer named above and that these expenses must qualify for reimbursement under the terms of my employer's plan expenses and the Internal Revenue Code and cannot be claimed as credits or deductions on my personal income tax. I understand that reimbursements from this plan are paid from my employer's HRA Plan and I acknowledge that I am responsible for paying each provider for the medical services received. I have retained copies of the documentation enclosed with this request. I understand that materials submitted will not be returned to me. SIGNATURE: DATE: GDI Use Only: NE Reimbursement requests received before 12 Noon (ET) on Tuesday will be processed that week. Requests received after 12 Noon (ET) on Tuesday will be processed the following week. Phone: Website: 10/31/18

3 Accessing Your HRA On Line The GDI Participant Portal gives you easy, secure whenever you need it. access to your HRA Get Started at the GDI Home Page Go to and click on Login at the top right side of the screen, then select Participants. Enter your Username and Password, or click on New User to create your Username and Password. Other Great Portal Features View account activity, balances, claims and reimbursements history Use the tabs at the top of the page for more functions and account management Download the GDI Mobile App from the messagee center on the homepage Set up text message alerts to receive notices on your mobile device Questions Visit our website or call (800) U.S. Route One, Falmouth, ME (800)

4 HRA Eligible Expenses IRS Code Section 213(d) The list below includes generally eligible IRS Code Section 213(d) expenses. Items marked with a * require a copy of a current prescription (written on a prescription pad). The prescription must be submitted each time a request for reimbursement is submitted for these items. Remember: 1. All services must be provided by a licensed practitioner. 2. Stockpiling of supplies is prohibited by the IRS. 3. Services must be rendered or items purchased during the plan year. Acupuncture Alcoholism treatment program fees Allergy medicine* Ambulance service Antacids* Anti-Diarrhea medicine* Artificial limbs Bandages Braille books and magazines (above the cost of regular print) Car Modifications for equipment installed for the use of a person with a disability Childbirth classes (mother's costs only) Chiropractic care Christian Science practitioner fees Co-insurance charges Co-payments Cold medicine* Cold/Hot packs for injuries Contact lenses (including cleanser and saline solution) Cough drops* Crutches Deductible expenses Dental expenses (non-cosmetic services only) Dentures Diabetic supplies Dietary Supplements* Drug addiction treatment at a therapeutic center Eye drops* Eye exams Eyeglasses First aid kit Gauze pads Guide dog or other animal used by a person with a physical disability Hearing aids/batteries Herbs* Hospital fees Immunizations Incontinence supplies Insulin Lasik Surgery Laboratory fees Laxatives* Learning disability (fees paid to a special school or a specially trained tutor for a child with severe learning disabilities caused by mental or physical impairments, provided that the child's physician recommends that the child attend the school or be tutored) Massage therapy (only if prescribed by a physician for a specific diagnosis and provided by a licensed massage therapist) Medical services provided by physicians, surgeons, and specialists (noncosmetic services only) Mileage related specifically to transportation to/from an eligible medical appointment Motion-sickness medications* Nasal Spray* Nicotine gum or patches* Ointments for muscle or joint pain or for first aid purposes* Operations Optical care provided by Optometrists, Ophthalmologists or Opticians Organ transplants Orthodontics Orthotic Inserts Osteopathic treatment Oxygen Pain relief medications* Physical exams (unless employment related) Physical therapy Prescription drugs (non-cosmetic uses only) Prosthesis Psychiatric care Psychoanalysis Psychological treatment Pre-natal vitamins* Pregnancy test kits Reading glasses Rubbing Alcohol* Sales tax payable for eligible services or items Sinus medicines* Smoking cessation programs Special foods (prescribed by a physician at costs in excess of the costs of commonly available products) Special schools for a mentally impaired or physically disabled person if the primary reason for using the school is its resources for relieving the disability (e.g. a school that teaches Braille to a visually impaired child or teaches American Sign Language to a hearing impaired child) Suppositories* Thermometers Vaccines Vision Correction Surgery Vitamins* Wheelchair costs X-rays 2018

5 Anthem" 3ftr?'::,BiT:Maine 04,06.6e, I An indap nden( tic 6e of tff Blue CrGs ard g,ue Shietd Registared mrks of the Blre Cross afil Blua Shield AssociatDn crecd009 slng t-:lf.+ z013o7j 1Bo0 Jsoo f,'.e.lf 2013A tiild& Env [14,026] 5 cf5 EXPLANATION OF BENEFITS THIS IS NOT A BILL W NOW HAVE A DEDICATED CUSTOMER SERVICE UNI' ESPECIALLY FOR YOU. {SEE SACK OF PAGE 1) A PAYMENT SUMMARY AND AN EXPTANATION OF COOES ARE AT THE ENO OF THIS STATEMENT ff,ltll,tl,,tl'ilil,ltilt,ltltlltttltttlh,ttt,l,illilt1trrlf,rrl ***x***x*x*x*xxxx*aut0xx3-di6it 0q0 lqbeb l, AT 0.3aq PAGE: DATE: 10F 06/2L1r3 l Si necesita ayuda en espanol para entender este documento, puede soltcttarla sin costo adicional, llamando al nimero de servicio al cliente que aparece al dorso de su tarjeta de identifrcacion o en el folleto de inscripci6n. PATIENT: PROVIDER/ SERVICE t{ortiiing LAB ANALYSIS IIORTHII{G LAB AIIALYSIS TIORTHING LAB ANALYSIS CLAIMS PAYABLE TO YOUR PROVIDERS. HMO MAINE & HMO CHOICE CLAIM: P PLAH CODE: HMOSL STATUS TREAT- AIIOUTIT AITOUHT AI.IOU}IT PATIENT CODE DATE(S) }.IEI{TS C}IARCED COVERED PAID BALAHCE I'ESSACE REDUCTIOII CODE A}IOUNT A O6/I4/L3 I E 2.39.gg A APSl A14I A 06/L4/I3 I 22.AO 14, A84L 2.98 APST A141 A O5/L4/L3 I A841 APSI A14I 3.77 claiil ToTALS DEDUCTIBLE IIET- Iil TIETHONK O. OO IIIDIVIDUAI- FIHILY DEDUCTIBI-E }IET - OUT OF HETI{ORX rildrvlouat FAI{IIY CO$ISURANCE IIET- INDIVIDUAL- FAIIILY- COIIISURAHCE I{ET- IHDIVIDUAL. FA}IILY. YOU I'IAY BE BILLED FOR AI.IOU}ITS DISPTAYED III TIIE PATIENT BALAHCE CO[UI{H. PLEASE REFER TO IIESSAGE CODES BELOI{ FOR APPROPRIATE DEFII{ITIOIIS. STATUS CODES: A - APPROVED AJ - ADJUSTIIEIIT IP - ITI PROCESS R - REJECTED V - VOID MESSAGE CODES: APS1 THIS CLAII{ HAS BEEN PAID AT THE PREFENRED NEFERRED LEVEL OF BEHEFITS AE4I AI{OUNT PAID HAS BEETI REDUCED BECAUSE OF COII{SURANCE. COITISURANCE IS THE PERCENTAGE OF EXPENSES THAT ARE THE RESPONSTBILITY OF THE PATIEIIT. A}IOUNT COVERED LIilITED TO iihat YOUR HEALTH PLAII'S ALLOTAHCE IS FOR THIS PROCEDURE. A14I PAYI{E}IT HAS BEEN I{ADE DIRECTTY TO THE PROVIDER OF SERVICE ON YOUR BETIALF COMMENTS: ATITHEIT BLUE CROSS AND BLUE SHIEI.D PROVIDES AD'TINISTRATIVE CLAII,IS PAYI'E}IT SERVICES ONIY A}ID DOES }IOT ASSUI{E AIIY FI}IANCIAL NISK OR OBLICATIOII I{ITH RESPECT TO CLAITIS (EXCEPT STOP LOSS OR RISK SHARINC OBLIGATIONS, IF ANY) rt{ t{etflor( out 0F ilethon( =4