Balancing Life. Welfare Benefits Plan Summary. inspiring possibilities

Transcription

1 Balancing Life Welfare Benefits Plan Summary inspiring possibilities

2 What s Inside Welfare Benefits Plan...2 FSAs At-A-Glance...3 The Basics...4 Eligibility Enrollment Contributions When Participation Begins Making Changes How Flexible Spending Accounts Work...8 Health Care FSA Benefits...10 Eligible Health Care Expenses Eligible Health Care Expenses of Dependents Incapacitated Dependents Ineligible Health Care Expenses Dependent Care FSA Benefits...14 Eligible Dependent Care Expenses Ineligible Dependent Care Expenses Making an FSA Claim...16 Filing a Claim Claims and Appeal Procedures Other Plan Information...19 When Participation Ends Coverage During A Leave of Absence Coverage During a Military Leave of Absence Continuation of Participation Qualifying Events for Associated and Covered Dependents Your Benefits Applying for Continuation of Participation Impact On Your Other Benefits Plan Administration This is a summary of the flexible benefits available under the Advocate Health Care Network Welfare Benefits Plan (the Plan ). While every effort has been made to accurately describe the Plan, this booklet as a summary does not cover all the details of the Plan or how the rules will apply to every person, in every situation. The complete rules that govern the Plan are contained in the official Plan document. In the event of a discrepancy between the information contained in this summary and the official Plan document, the Plan document will always govern. Advocate intends to continue the Plan, but, reserves the right to amend, modify or terminate the Plan, in whole or in part, at any time for any reason. In the event of a change, the Plan document will always govern. If the Plan is terminated, your coverage will end; however, you will be entitled to Plan benefits for any covered services incurred before the date the Plan was terminated. This booklet is not a contract of employment and nothing in the Plan gives any associate the right to be retained in the service of Advocate Health Care Network ( Advocate ) or any of its affiliated companies. 1

3 Welfare Benefits Plan The Advocate Health Care Network Welfare Benefits Plan (the Plan ) is designed to provide eligible associates of Advocate Health Care Network ( Advocate ) and its affiliated companies that participate in the Plan ( Advocate Companies ) two types of pre-tax benefits: The opportunity to have contributions for the cost of medical, dental, disability and vision coverage deducted from their pay on a pretax basis, and The opportunity to set aside dollars in a Health Care and/or Dependent Care Flexible Spending Account ( FSA ) through pre-tax payroll contributions, then use this money to reimburse eligible health care and dependent care expenses on a tax-free basis. Pre-tax contributions whether used to pay the cost of medical, dental, disability or vision coverage or directed into a FSA are deducted from your pay before income and Social Security taxes are calculated. This reduces your taxable income and, in turn, the taxes you pay. In effect, the pre-tax contributions reduce your out-of-pocket cost for medical, dental, disability and vision coverage and the cost of eligible health care and dependent care expenses for which you are reimbursed through a FSA. You can participate in one or both of the FSAs offered through the Plan. Health Care FSA You can use this account to reimburse yourself the cost of eligible health care expenses (for you and your covered dependents) that are not paid by insurance or another benefit plan. Dependent Care FSA You can use this account to reimburse yourself the cost of eligible dependent care expenses for the care of your dependent child(ren) and/or incapacitated adult dependents while you (and, if you are married, your spouse) are at work. Note: Eligible health care expenses for your covered dependents are reimbursable only through the Health Care FSA, not through the Dependent Care FSA. Important! How you can use your Health Care FSA depends on the type of medical coverage in which you are enrolled. If you are enrolled in the: PPO/DRP or EPO/DRP and you: suspend your Deductible Reimbursement Account (DRA) during annual enrollment you can use your Health Care FSA to pay eligible medical, dental, vision and prescription drug expenses throughout the year (or pay these expenses out of your own pocket). do not suspend your DRA eligible medical expenses that apply against your annual deductible must be paid from your DRA first. You can use your Health Care FSA to pay eligible medical expenses only after you exhaust your DRA balance. However, you can use your Health Care FSA to pay eligible dental, vision and prescription drug expenses right from the start. HMO if you have a Copay/Coinsurance Reimbursement Account (CCRA) you must use your Health Care FSA to pay eligible medical expenses first. You can use your CCRA to pay medical copayments and coinsurance only after you exhaust your Health Care FSA balance. However, you can use your Health Care FSA to pay eligible dental, vision and prescription drug expenses throughout the year. 2

4 FSAs At-A-Glance This section highlights selected key features and selected covered services of the FSA portion of the Plan. For more detailed information, see Health Care FSA Benefits (pages 10 13) and Dependent Care FSA Benefits (pages 14 15). Feature How the Health Care FSA Works How the Dependent Care FSA Works When Participation Begins Annual Contribution Limits Eligible Expenses 3 Cost of Participation If eligible (and you have made an election), you may enroll in a Health Care FSA: after 30 days of employment with Advocate or one of its affiliated companies, during any subsequent annual enrollment, or within 30 days of a qualified work, family or eligible life status change (see Work, Family or Eligible Life Status Change, page 6). In general, your contributions will begin with the next available payroll (although contributions you elect to make during annual enrollment will not begin until the first pay period of the next year). Minimum: $200 Maximum: $2,600 Deductibles 3, copayments and/or coinsurance 4 amounts you pay under any medical or dental coverage Out-of-pocket expenses you pay for eligible services that aren t covered by any other medical or dental coverage Expenses for hearing care and vision care services, and Expenses for prescription drugs. You pay the full cost of your participation in a Health Care FSA through payroll deduction contributions that you elect to make to this account each year, subject to annual contribution limits (see below) If eligible (and you have made an election), you may enroll in a Dependent Care FSA: after 30 days of employment with Advocate or one of its affiliated companies during any subsequent annual enrollment, or within 30 days of a qualified work, family or eligible life status change (see Work, Family or Eligible Life Status Change, page 6). In general, your contributions will begin with the next available payroll (though contributions you elect to make during annual enrollment will not begin until the first pay period of the next year). Minimum: $200 Maximum 1 : $5,000 per family ($2,500 if married and you and your spouse file separate tax returns) Dependent care expenses for dependents who: are under age 13 and living with you for more than half the year, or are physically or mentally disabled (including an elderly parent or disabled child or spouse in your care) and living with you for more than half the year. You pay the full cost of your participation in a Dependent Care FSA through payroll deduction contributions that you elect to make to this account each year, subject to annual contribution limits (see below). 1 If you are a highly compensated employee, your maximum contribution amount may be further limited by the Plan Administrator in order to satisfy nondiscrimination tests that are required by the tax rules. 2 Eligible health care expenses to be applied against your Health Care FSA contributions for a given year (Year 1) may be incurred at any time during a 14-½ month period January 1 of Year 1 through March 15 of the following year (Year 2) provided that you are a participant in the Health Care FSA on the last day of the plan year. When you file a claim for reimbursement of eligible health care expenses that were incurred during the additional two-and-a-half month grace period (January 1 through March 15 of Year 2), these expenses will be applied against any remaining balance in your Health Care FSA from your Year 1 contributions. If these expenses are greater than this remaining balance, the excess will be applied automatically against your Year 2 Health Care FSA contributions. Note: This grace period extension for incurring eligible expenses does NOT apply to dependent care services for which you may file a claim against your Dependent Care FSA. 3 If you have a DRA: If you have suspended your DRA, the entire deductible amount that you pay during the year is an eligible expense. If you have NOT suspended your DRA, only the remaining deductible that you pay after the DRA is exhausted is an eligible expense. 4 If you have a CCRA: Copayments and coinsurance are not paid from the CCRA until your Health Care FSA is exhausted. 3

5 The Basics Eligibility To be eligible to participate in the Plan, you must be employed by an Advocate Company and have completed 30 days of employment with Advocate or one of its affiliated companies as a: Full-time associate who works at least 40 hours per work week (or who works 36 hours per week and is classified as an E9 or N9 associate), Part-time A associate who works at least 32 (but less than 40) hours per work week, or Part-time B associate who works at least 20 (but less than 32) hours per work week Satisfying these requirements means that you are a benefits-eligible associate or in a benefits-eligible position or status as referred to throughout this summary. Enrollment To enroll initially or to change your existing coverage after a transfer to benefits-eligible status, you must log on to advocatebenefits.com. You will receive a system-generated Benefits Enrollment Guide, which will specify your designated enrollment period. Advocate reserves the right to periodically audit the eligibility process and request documentation from Plan participants to verify eligibility for the Plan or the payment of benefits under the Plan. Associates found to be involved in acts of dishonesty are subject to disciplinary action, up to and including termination of employment. Contributions Medical, Dental, Disability and Vision Coverage While Advocate subsidizes a significant portion of the cost of your medical, dental, disability and vision care coverage, you may also be required to share in the cost of this coverage. Your share of this cost for the coverage you elect is automatically deducted from your pay each pay period on a pre-tax basis which means that these contributions are not subject to federal, state and Social Security taxes. In effect, pre-tax contributions reduce your taxable income and, in turn, the taxes you pay. The resulting tax savings reduce your out-of-pocket cost for coverage. If you enroll a domestic partner or civil union partner under your coverage, your contributions for the cost of coverage for you and your other eligible dependents are taken on a pre-tax basis, but in accordance with federal tax laws your contributions for the coverage of your domestic partner or civil union partner are taken from your pay on an after-tax basis, and you will have an additional amount added to your taxable income that is equal to the amount Advocate pays for your domestic partner s or civil union partner s medical, dental and/or vision coverage. For additional information, please review the Partner Information Guide. Important! You should review your enrollment materials carefully to ensure you are aware of your designated enrollment period. If you do not enroll during your designated enrollment period, you will not be able to enroll for coverage until the next annual enrollment period unless you have a qualified work, family or eligible life status change (see Work, Family or Eligible Life Status Change, page 6). 4

6 Flexible Spending Accounts If you elect to participate in a FSA, you make contributions to your FSA. Your contributions are deducted from your pay each pay period on a pre-tax basis which means that these contributions are not subject to federal, state and Social Security taxes. In effect, pre-tax FSA contributions reduce your taxable income and, in turn, the taxes you pay. The resulting tax savings reduces the out-of-pocket cost for eligible health care and dependent care expenses for which you are reimbursed through a FSA. If you enroll in a FSA during annual enrollment, the amount you elect to contribute to a FSA for the year will be prorated into 26 equal installments (which corresponds to the number of bi-weekly pay periods in a year). This prorated amount will be deducted from your pay each pay period throughout the year. If you are a new hire or are transferred to benefits-eligible status mid-year, the amount you elect to contribute to a FSA will be prorated into equal installments based on the remaining number of pay periods in the year and this prorated amount will be deducted from your pay each pay period for the balance of the year. Eligible health care expenses to be applied against your Health Care FSA contributions for a given year (Year 1) may be incurred at any time during a 14-½ month period January 1 of the current year (Year 1) through March 15 of the following year (Year 2) provided you are a participant in the Health Care FSA on the last day of Year 1. When you file a claim for reimbursement of eligible health care expenses incurred during the additional two-and-a-half month grace period (January 1 through March 15 of Year 2), these expenses will be applied against any remaining balance in your Health Care FSA from your Year 1 contributions. If these expenses are greater than this remaining balance, the excess will be applied automatically against your Year 2 Health Care FSA contributions. Note: This grace period extension for incurring eligible expenses does not apply to dependent care expenses under your Dependent Care FSA. How do I enroll in a FSA? Once you are hired in or transferred to a benefits-eligible position, you will receive a Benefits Enrollment Guide. To enroll initially or to change your existing coverage after a transfer to benefits-eligible status, you must log on to Advocate Benefits at advocatebenefits.com. You can use any computer that has Internet access, whether at home or work, including a kiosk at your Advocate work location. When Participation Begins Your participation in the Plan can begin on the day after you complete 30 days of employment with Advocate or one of its affiliated companies and are in a benefits-eligible position with an Advocate Company as long as you enroll during your designated enrollment period. If you subsequently want to enroll in the Plan and do so within 60 days of your hire date or, if later, the date you transfer into benefits-eligible status, the coverage you elected will begin retroactive to your original eligibility date. Eligible expenses have been incurred for services on or after the effective date of coverage. Your contributions to the FSAs will take effect as soon as possible, starting with a pay period following the date you complete your enrollment. If you do not enroll within 60 days of your hire or the date you transfer into benefits-eligible status, you will not be able to enroll in the Plan until the next annual enrollment period or until you have a qualified work, family or eligible life status change (see Work, Family or Eligible Life Status Change, page 6). 5

7 Once your participation begins, it will continue for the balance of the current calendar year as long as you remain eligible and continue to make your elected contributions. You must renew your participation in a FSA each calendar year by re-enrolling during annual enrollment. Making Changes You may change your Plan elections during any annual enrollment period. Changes made during an annual enrollment period take effect on the next January 1. You also may change your elections under the Plan following a qualified work, family or eligible life status change (see Work, Family or Eligible Life Status Change below). Work, Family or Eligible Life Status Change To change your elections (other than a disability plan election) under the Plan following a qualified work, family or eligible life status change, you must request that change within 30 days of the event, and your change in Plan elections must be consistent with the status change. To request an election change due to a qualified work, family or eligible life status change, contact Advocate Benefits Service Center online at advocatebenefits.com. The change in your coverage election will generally take effect as of the date the status change event occurred if you notify Advocate Benefits Service Center of the status change within 30 days of the status change event. If you do not notify Advocate Benefits Service Center within 30 days of the event, but do so within 90 days of the event, the effective date of your coverage change will be as of the date you contact Advocate Benefits Service Center (and you will not be refunded any contributions paid from the date of the event through the date you contact Advocate Benefits Service Center). However, if you have a newborn, you adopt a child or a child is placed with you for adoption and you notify Advocate Benefits Service Center within 90 days of the date of the event, a requested change in coverage will be made retroactive to the date of the birth, adoption or placement for adoption. If you do not notify Advocate Benefits Service Center of the change within 90 days of the event, you will have to wait until the next annual enrollment period to change your coverage elections (and you will not be refunded any contributions paid from the date of the event through the first day of the following plan year unless you have another status change). You will need to provide copies of supporting documents for certain types of qualified work, family or eligible life status changes (e.g., if you get married, you will need to provide a marriage certificate). You will be notified if documentation supporting the type of change you request is required. If you do not provide the documentation within 45 days of the date you request a status change, your elections will go back to what they were before you requested the change and you will not be able to make any change to your elections under the Plan until the next open enrollment period unless you have another life status change. You have a qualified work, family or eligible life status change if: You marry or you meet the criteria to add a domestic partner or civil union partner (see definition in Partner Information Guide) You have a newborn, you adopt a child (under age 26) or a child (under age 26) is placed with you for adoption You have a court order requiring coverage of a child (under age 26) under an Advocate health plan 6

8 You divorce or legally separate from your spouse, have your marriage annulled or end a domestic partnership or civil union partnership Your child becomes eligible or is no longer eligible for coverage You or your dependents lose coverage under another employer s plan 1 Your, your spouse s (or domestic partner s or civil union partner s) or child s employment status changes and loses eligibility for his or her group coverage You, your spouse (or domestic partner or civil union partner) or child starts or changes employment status and becomes eligible for coverage under the Plan Your spouse (or domestic partner or civil union partner) or a child dies You or a dependent loses coverage under Medicaid or CHIP, or becomes eligible for a state premium assistance subsidy from Medicaid or CHIP 2 You, your spouse (or domestic partner or civil union partner) or a dependent becomes entitled to or loses eligibility for Medicare or Medicaid You and your spouse s (or domestic partner s or civil union partner s) benefit coverage or cost of coverage under the Plan changes significantly 3 You or your spouse (or domestic partner or civil union partner) go on an unpaid leave of absence, or You, your spouse (or domestic partner or civil union partner) or your child change place of residence that results in a gain or loss of eligibility for coverage. Important! If you falsify your qualified work, family or eligible life status change, you will be subject to disciplinary measures up to and including termination of employment. In addition, the Internal Revenue Service may impose penalties for anyone purposely providing false information regarding pre-tax benefits. You will be responsible for any pretax benefits of a non-covered person who was falsely added as a dependent. Additional information about qualified work, family or eligible life status changes is available on advocatebenefits.com > Benefits Information > Status Change. Rehire Policy If you terminate employment with an Advocate Company or reduce your hours of work to nonbenefits-eligible status and then at least 30 days later become benefit-eligible or return to work with an Advocate Company, you will be treated as a new hire for purposes of participation in the Plan. There will be a 30-day waiting period before benefits can become effective. (See the Eligibility Section on page 4). If you are rehired or become benefits-eligible in less than 30 days after your termination of employment or loss of benefits-eligible status, you will be re-enrolled under the Plan with your same benefit elections that were in place immediately before your termination of employment or loss of benefitseligible status. If you are rehired by an Advocate Company within 12 months of your termination of employment with and while receiving severance benefits from an Advocate Company, your participation in the Plan will be reinstated with the same benefit elections as those in effect immediately prior to your termination of employment. 1 This status change event does not apply with respect to your Health Care FSA. 2 You may request coverage under the medical, dental, and vision plans due to this status change within 60 days after the event. 3 This status change event does not apply with respect to your Health Care FSA. 7

9 How Flexible Spending Accounts Work If you elect to participate in the Plan, you can have money deducted from your pay throughout the year on a pre-tax basis and put into either a Health Care FSA or Dependent Care FSA, or you can elect to put money into both types of FSAs. You can then use this money to reimburse yourself for eligible expenses you incur during the year after your effective date. You choose how much you want to put into each type of FSA (subject to any minimum or maximum amount for the FSA). If you are enrolling in a FSA during annual enrollment, the amount you choose to contribute to your FSA during the next calendar year will be prorated into 26 equal installments and deducted from your pay each bi-weekly pay period throughout the year. If you are a new hire or transfer into a benefits-eligible status mid-year, the amount you elect to contribute to a FSA for the balance of the year will be prorated into equal installments based on the remaining number of pay periods in the year and will be deducted from your pay each bi-weekly pay period for the remainder of the year. FSA contributions are deducted on a pre-tax basis, reducing your pay before income and Social Security taxes are calculated. Then, as you incur eligible health care and/or dependent care expenses, you submit a claim and are reimbursed for these expenses with your pretax contributions. Because your contributions are tax-free going into your FSA(s) and are tax-free when they are paid out to you you pay less in taxes each year. These tax savings in effect reduce your out-of-pocket cost for these expenses. Bottom line, getting reimbursed for your eligible health care and dependent care expenses with tax-free dollars is like getting these services at a discount. Important! In exchange for the tax break you get by participating in a FSA, the IRS requires that you forfeit any money left in a FSA at the end of the year. Since you can only change your contributions during an annual enrollment period unless you have a qualified work, family or eligible life status change, it is important for you to plan carefully to determine exactly how much money you will need to contribute to a FSA for the next year to avoid forfeitures. You must renew your participation in a FSA each year during annual enrollment. Your election to participate in the plan one year will not automatically rollover to the following year. You have until March 31 of the year following the year of your election to file a claim for reimbursement under the FSAs. For example, if you elect to contribute to a FSA for 2017, you will have until March 31, 2018 to file a claim for reimbursement from your 2017 contributions. If you have questions, you can contact the FSA Claims Administrator (See the Making A FSA Claim section beginning on page 16). Using a Benny Card Debit Card to Pay Eligible Health Care Expenses When you enroll in (and contribute to) a Health Care FSA, you will receive a Benny Card debit card 1. This card works just like a bank debit card, enabling you to pay for eligible health care expenses with funds automatically debited from your Health Care FSA balance. This means no Health Care FSA reimbursement claims to file! Important! You should save receipts for eligible health care expenses that you pay with the Benny Card as you may have to substantiate your claims. 1 This card is good until the expiration date, five years from the date issued, but is inactive when you do not enroll for a specific plan year. 8

10 If you elect to participate in a Health Care FSA, you will receive a packet of information containing your Benny Card and instructions for use. Caution: Do not use the Benny Card to pay expenses that can by reimbursed by your Advocate DRA (EPO and PPO participants). How FSAs Can Save You Money: An Example Let s assume that you are married, have two children under the age of five and you and your spouse both work. Let s also assume that your combined household income is $70,000 and that you and your spouse file taxes jointly. If you elect to participate in the Plan and contribute a total of $4,500 to your FSA accounts for the coming year $1,000 to your Health Care FSA and $3,500 to your Dependent Care FSA here s how much your participation in the FSAs can save you in taxes for the year. Note: Federal Income taxes are based on 25% marginal tax rate, Social Security taxes equal 7.65% of annual salary and Illinois state income taxes equal 3%. Standard head of household deduction and three personal exemptions at 2011 IRS rates. This is an example for illustrative purposes only. Your actual taxes and potential tax savings will depend on your actual household income, tax bracket and pre-tax contributions to the FSA(s). In this example, you could save approximately $1,600 in taxes as a result of your $4,500 in pre-tax contributions. These tax savings offset a portion of your combined $4,500 in eligible health care and dependent care expenses, in effect reducing your out-of-pocket cost to approximately $2,900 ($4,500 minus $1,600). That s the pre-tax advantage the FSAs offer. Combined Household Income Contributions to: If you do NOT participate in FSAs If you DO participate in FSAs $70,000 $70,000 $0 $0 $1,000 $3,500 Taxable Income $70,000 $65,500 Estimated Income and Social Security Tax $24,955 $23, After-tax Income $45,045 $42, After-tax Expenses for: $1,000 $3,500 Reimbursement from: $40,545 Spendable Income (after reimbursement) +$0 +$0 $1,000 $3,500 $37, $1,000 +$3,500 $40,545 $42, Potential Tax Savings $0 $1,

11 Health Care FSA Benefits Eligible Health Care Expenses Your Health Care FSA can reimburse you for most eligible expenses that are not paid by the Plan s medical and dental benefits or any other group health coverage. Eligible expenses include costs for medical, dental, vision and hearing services and prescription drugs that you, your spouse or other eligible dependents pay during your period of participation in the FSA. Eligible expenses include but are not limited to the cost of medical, dental, vision and hearing services that are not paid by group health plans including: Deductibles 1 Copayments 2 Coinsurance 2 Charges above the maximum allowance (or usual and customary amount) Private hospital room differential Eligible expenses also include the cost of the following health care services (to the extent the cost of these services is not covered by your medical or dental coverage): Lab Exams/Tests Blood tests Cardiographs Diagnostic Laboratory fees Metabolism tests Spinal fluid tests Urine/stool analyses X-rays Prescription Medications, Insulin & Diabetic Supplies Prescription drugs including contraceptive products Insulin and diabetic supplies Obstetric Services Lamaze class for mother s instruction related to birth Mid-wife expenses OB/GYN exams OB/GYN prepaid maternity fees reimbursable after date of birth Post-natal/pre-natal treatment Pre-natal vitamins Dental Services Crowns and bridges Dental x-rays Dentures and denture adhesives Exams/teeth cleaning Extractions Fillings Gum treatment Oral surgery Orthodontia/braces expenses reimbursed over period of time appliances are worn 1 If you have a DRA: If you have a suspended DRA, the entire deductible amount that you pay during the year is an eligible expense. If you have NOT suspended your DRA, only the remaining deductible that you pay after the DRA is exhausted is an eligible expense. 2 If you have CCRA: Copayments and coinsurance are not paid from the CCRA until your Health Care FSA is exhausted. 10

12 Other Medical Treatments/Procedures Acupuncture Alcoholism inpatient treatment Cosmetic surgery if medically necessary Drug addiction Hearing exams Hospital services Infertility In-vitro fertilization Norplant insertion or removal Patterning exercises Physical examinations not employment related Physical therapy Pregnancy tests Rolfing Smoking cessation programs Speech therapy Sterilization Transplants includes organ donor Vaccinations/immunizations Vasectomy Well baby care Other Medical Equipment, Supplies and Services Abdominal/back supports Ambulance services Arches/orthopedic shoes Bandages Breast pumps and lactation supplies Carpal tunnel wrist supports Cold packs Contact lenses, materials and equipment Contraceptives Counseling for a medical condition, but not marriage or family counseling Crutches First aid kits Gauze pads Guide dog for visually/hearing impaired person Health club dues if incurred for medical care needs (letter of medical necessity required) Hot packs Hospital bed Medic alert bracelet or necklace Ovulation monitor Oxygen equipment Prescribed medical and exercise equipment Prosthesis Reading glasses Splints/casts Support hose if medically necessary Syringes Thermometers Transportation expenses essential to medical care Treatment of learning disability special school/teacher Tuition fee at special school for disabled child Wheelchair Over-the-Counter Drugs and Equipment Requiring Annual Letter of Medical Necessity* Acne treatments Allergy medicines Antacids Antihistamines Aspirin Antiseptics such as bactine Calamine lotion Calcium supplements Cold medicines Contraceptive products Cough suppressants Decongestants Depression treatments such as St. John s Wort Diaper rash ointments and creams Diarrhea medicine Dietary supplements or herbal medicines Ear plugs Exercise equipment Eye care products such as visine Fiber supplements First aid creams Fitness programs Glucosamine/chondroitin * Note: Reimbursements for the cost of over-the-counter medicines or drugs (other than insulin) will be allowed only if they are prescribed by a health care provider. Expenses for insulin as well as over-the-counter medical devices and supplies are reimbursable even without a prescription. 11

13 Hemorrhoid treatments suppositories and creams Homeopathic drugs Hormone therapy medications Incontinence supplies Insect bite creams and ointments Lactose intolerance pills Laxatives Liquid adhesive for small cuts Massage therapy Menopause treatments Menstrual cycle products for pain and cramp relief Motion sickness pills Mouthwash Muscle or joint pain products such as Ben Gay, Tiger Balm Nicotine gum or patches for smoking-cessation purposes Pain relievers Pediatric dehydration products such as pedialyte Prenatal vitamins Retin-A Rogaine Rubbing alcohol if used primarily for skin care Shampoos and soaps that are medicated Sinus medications Sunburn creams and ointments Sleeping aids Special foods cost difference of common product Sunscreens Throat lozenges Toothache and teething pain relievers Treatment program at a health club Varicose vein treatment Vitamins Wart remover treatments Weight-loss drugs to treat obesity Weight loss programs and/or drugs Wigs if prescribed for the mental health of a patient who has lost all hair from disease or treatment Vision Services Artificial eyes Contact lenses Contact lens solution Eye examinations Eyeglasses Laser eye surgeries Ophthalmologist Optometrist Sunglasses if corrective Radial keratotomy or lasik eye surgery Note: You can be reimbursed for covered health care expenses through the Health Care FSA, or you can take a tax deduction but you cannot do both. Usually, the tax deduction is available only to people with extremely high medical expenses not covered by a health plan. If you have high medical or dental expenses, you may want to consult a tax adviser to determine which approach will work best for you. * Note: Reimbursements for the cost of over-the-counter medicines or drugs (other than insulin) will be allowed only if they are prescribed by a health care provider to treat an existing medical condition. Expenses for insulin as well as over-the-counter medical devices and supplies are reimbursable even without a prescription. 12

14 Eligible Health Care Expenses of Dependents In addition to your own eligible expenses, the eligible expenses incurred by your dependents can be reimbursed through your Health Care FSA. For purposes of your Health Care FSA, your dependents include: Your lawful spouse, and Your children up to age 26. Your children include: Natural children Stepchildren Adopted children (including children placed with you for adoption) Foster children, and Any children for whom you have legal guardianship Incapacitated Dependents A dependent child will remain eligible to have his or her eligible expenses reimbursed through your Health Care FSA beyond the date coverage would otherwise be lost if the child is: Unmarried. Mentally or physically incapacitated, and Dependent upon you for support and maintenance. Diapers or diaper service for newborns Face creams Face and body moisturizers Feminine hygiene products Hair colors Hand lotions Insurance premiums or warranty fees Lip balm Lipstick Makeup Nail polish Nasal strips or sprays Perfumes Permanent waves Safety glasses if they are not corrective Shaving cream/lotion Sunglass clips if they are not corrective Suntan lotions primarily cosmetic, but contain a sunscreen component Toiletries Toothbrushes Toothpaste Vitamins for general well-being Expenses that you incur before your participation in the Plan begins or after it ends also are not eligible for reimbursement from your Health Care FSA. Advocate will request proof of the dependent s incapacity after he or she reaches the Plan s age limit. Proof of incapacitation must be provided within 45 days of the dependent s loss of eligibility. In addition, Advocate may have the dependent examined by a physician to verify the incapacity. Ineligible Health Care Expenses Expenses that are not eligible for reimbursement through your Health Care FSA include but are not limited to the cost of any therapy or treatment not for medical care, as well as the cost of: Babysitting and child care Canceled appointment fees Colognes Cosmetics Deodorants 13 Note: For a more detailed list of eligible and ineligible health care expenses, refer to Publication 502 of the Internal Revenue Service, available from the IRS at or online at irs.gov. Please note that even though some of the expenses listed in Publication 502 such as contributions for qualified long-term care insurance may be claimed as a deduction on your federal income tax return, they are not eligible expenses for reimbursement through your Health Care FSA. Also note that expenses qualify for the Health Care FSA based on when the service is provided, regardless of when billed or paid. If you have any questions about the expenses that qualify for reimbursement through your Health Care FSA, you should contact the FSA Claims Administrator.

15 Dependent Care FSA Benefits You can use a Dependent Care FSA to reimburse yourself for eligible dependent day care expenses if they enable you and, if you re married, your spouse to work. The maximum annual contribution you can make to your Dependent Care FSA is $5,000 a year, subject to the following limits. If you are married and file a joint tax return you and your spouse together are limited to a total combined contribution of $5,000 a year. That means if your spouse contributes $2,000 to a Dependent Care FSA with his or her employer, you cannot contribute more than $3,000 into your Advocate Dependent Care FSA. If one of you earns less than $5,000 in a year, your combined contributions cannot be greater than that annual income amount. If you and your spouse file separate tax returns you each may contribute up to a maximum of $2,500 a year into a Dependent Care FSA. If your spouse does not work you cannot use a Dependent Care FSA unless your spouse is a full-time student or disabled. In this case, it is assumed that your spouse earns $250 a month if you have one dependent ($500 a month if you have two or more dependents) and this income figure will be used to determine the maximum amount you can contribute to a Dependent Care FSA for the year Note: If you contribute to the Dependent Care FSA, you must complete IRS Form This form provides space for you to list all dependent care providers for whose services you have paid during the year and includes space to write in each provider s tax ID number. Eligible Dependent Care Expenses You can only claim dependent care expenses for dependents who: Are under age 13 and living with you for more than half of the year, or Are physically or mentally disabled (including an elderly parent or disabled child or spouse in your care) and living with you for more than half of the year. Expenses that can be reimbursed from your Dependent Care FSA include but are not limited to the cost of: Care at licensed nursery schools, day camps (not overnight camps) and centers for dependent children or adults After school programs at kindergarten and beyond Wages for individuals who provide care inside or outside your home Household services related to the care of dependents who live with you, and Federal and state employment taxes you pay for an individual employed to provide dependent care. Note: When you file your federal income tax return, you will be required to supply the name, address and Social Security or tax identification number of the individual or organization providing day care. If you are unable to supply this information, you should not use a Dependent Care FSA to reimburse yourself for these day care services. In addition, Advocate may have the physically or mentally disabled dependent examined by a physician to verify the incapacity. In addition, Advocate is required to regularly perform tests to ensure that Plan contributions comply with IRS rules. Advocate may limit the amount highly compensated associates may contribute to a Dependent Care FSA to ensure the Plan will pass the test. 14

16 Ineligible Dependent Care Expenses Expenses that are not eligible for reimbursement through a Dependent Care FSA include but are not limited to the cost of: Care provided by your spouse or family member who is claimed as a dependent on your income tax return or who is under age 19 Diaper changing fees Discounts Educational services including boarding school for a child in kindergarten or higher grade level Entertainment Fees for lessons Field trips Food, clothing or transportation Household services housekeeper, maid or cook (unless incidental to child care) Late payment fees Maternity leave if you or your spouse are on maternity leave and you place your other child(ren) in day care, those expenses will not be eligible Overnight camp Services received before the effective date of your participation in the Dependent Care FSA or after your termination Transportation for day care Note: For a more detailed list of eligible and ineligible dependent care expenses, refer to Publication 503 of the Internal Revenue Service, available from the IRS at or online at irs.gov. If you have any questions about the expenses that qualify for reimbursement through your Dependent Care FSA, you should contact the FSA Claims Administrator. What if the eligible dependent care expenses I submit for reimbursement are greater than my current Dependent Care FSA balance? If at any time during the year the eligible expenses you submit for reimbursement exceed the amount in your Dependent Care FSA when you file the claim, you will be reimbursed as contributions are made to your account. That means if you submit a reimbursement claim for eligible dependent care expenses that is greater than the amount currently available in your Dependent Care FSA, you initially will be reimbursed only up to the amount available in your account; the remaining balance of the claim will be reimbursed to you as additional contributions are added to your Dependent Care FSA through payroll deductions. In addition, expenses that are claimed as a deduction or credit on your federal income tax return are not eligible for reimbursement through a Dependent Care FSA. 15

17 Making a FSA Claim Filing a Claim To receive a reimbursement from your FSA, you need to fill out a FSA claim form and send it to the FSA Claims Administrator. Note: You do not need to file a claim for any eligible health care expenses that you pay using your Benny Card. However, you should save receipts for these expenses in case you need to submit an expense substantiation form. Either log in to your Tri-Star account and efile your claim or submit your completed FSA claim form along with the required evidence of an eligible expense, as described below: For eligible health care expenses, please submit (to the extent applicable): an Explanation of Benefits (EOB) form from the medical or dental plan the receipt for any out-of-pocket costs you pay for prescription drugs an itemized bill showing the name of the provider and patient, a description of the service or supply provided, the date it was received and the total cost copayment receipts for any copayment amounts you may have paid under your medical, dental or vision coverage Note: Orthodontic expenses generally involve an orthodontic treatment plan, which you will need to submit to the FSA Claims Administrator, along with your claim documenting the expected duration, cost of service and insurance coverage, and proof of payment. For any applicable subsequent claims, indicate on the claim form the amount and month you are claiming for reimbursement as well as proof of payment. For eligible dependent care expenses a bill or receipt indicating that it was for dependent or child care and the period of care. Canceled checks are not acceptable documentation. If a bill or receipt is not available, have the service provider sign the appropriate space and fill in his or her tax ID number on the front of the claim form. You can authorize reimbursements to be made by automatic direct deposit to your checking account by reporting this online through your Tri-Star account. If you do not authorize automatic direct deposit, reimbursements will be made by a check that is mailed to your home. Claims and Appeal Procedures Advocate has delegated its claims administration authority for initial benefit determinations and appeals related to the Plan to the FSA Claims Administrator. However, Advocate retains authority for final benefit determinations. Once I file a claim, when can I expect to receive reimbursement from my account? Reimbursements generally will be made within approximately two weeks after a claim is received by the FSA Claims Administrator. The exception would be if you file a dependent care claim with no money available in your Dependent Care FSA. In this case, you will not receive reimbursement until your next contribution (made through automatic payroll deduction) is credited to your account. 16

18 Benefit Determinations If your claim for reimbursement from your FSA is denied, you will receive a written notice from the FSA Claims Administrator within 30 days after the claim was received, as long as all required information was provided with the claim. Sometimes, additional time is necessary to process a claim because of circumstances beyond the control of the Claims Administrator. If an extension is necessary, the FSA Claims Administrator will notify you in writing within the initial 30-day period of the reasons for the extension and the date by which it expects to make a decision. The extension will be no longer than 15 days, unless additional information is requested. If the extension is necessary because you failed to provide all required information, the notice of the extension will describe the additional information needed. You will have 45 days to provide the additional information. If all the additional information is received within 45 days, the FSA Claims Administrator will notify you of its claim decision within 15 days after the information is received. If you do not provide the needed information within the 45-day period, the FSA Claims Administrator will deny the claim. Any notification of denial will: Include the specific reason(s) for the denial, Refer to the specific Plan provisions on which the denial is based. Describe any additional material or information necessary to perfect the claim and explain why such information is necessary. Describe the applicable appeal procedures, and Disclose any internal rule, guideline, protocol or similar criterion used in denying the claim (or state that information will be provided free of charge upon request). How and where do I file claims for reimbursement from the FSAs? In general, claims for reimbursement from the Plan must be filed with the FSA Claims Administrator in writing using a FSA claim form. However, you do not need to file a claim for any eligible health care expenses that you pay for using your Benny Card. You cannot carry over funds in your FSAs from one year to the next (except for the 2-½ month grace period for Health Care FSAs). Amounts not used will be forfeited under the IRS rules governing FSAs. You will, however, be given until March 31 of the year following your contributions to submit a request for reimbursement for any expenses incurred during a year. Note: Don t forget eligible health care expenses incurred during the first two-and-one-half months of a year may be applied against any remaining balance in your Health Care FSA from your prior year contributions. If these expenses are greater than this remaining balance, the excess will be applied automatically against your current year Health Care FSA contributions. Reimbursements will be made only to you, the associate. If it is determined that a reimbursement was made in error, you must repay the reimbursement to the Plan. If this reimbursement is not repaid, Advocate is required by law to rescind the reimbursement and adjust your taxable income for the year. Questions About Benefit Determinations If you have questions or concerns about a benefit determination, you may informally contact the FSA Claims Administrator before requesting a formal appeal. If the FSA Claims Administrator cannot resolve your question to your satisfaction over the phone, you may submit your question in writing. Remember, however, that if you are not satisfied with a benefit determination, you may appeal it immediately without first informally contacting the FSA Claims Administrator (see Appeals on page 18). 17

19 What happens if I have not used all of the money in my FSA(s) by the end of the year? All funds in your Dependent Care FSA must be used for eligible expenses incurred during the year for which the contributions were made. All funds in your Health Care FSA must be used for eligible expenses incurred during the year for which the contributions were made or in the first two and one-half months of the following year. You cannot carry over unused funds from one year to the next (other than during the 2-1/2 month grace period for Health Care FSAs). Any unused account balance remaining after you have submitted your reimbursement requests for the applicable plan year will be forfeited, as required by Internal Revenue Code rules. Appeals How to File an Appeal If you disagree with a benefit determination, you may contact the FSA Claims Administrator in writing to formally request an appeal. You have 180 days from receipt of the notice of denial to file an appeal. All appeals must be in writing. You may submit comments, documents and other information in support of your appeal. The review of appeal will take into account any information you submit, even if it was not submitted or considered as part of the initial determination. Upon request and free of charge, you will be provided reasonable access to and copies of all documents, records and information relevant to your claim. Your request for appeal must include: The patient s or dependent s name, The date of the service, The provider s name, The reason you believe the claim should be paid, and Any documentation or other written information to support your request for claim payment. All appeals will be processed as described below. First Level Appeals The FSA Claims Administrator is responsible for reviewing first level appeals. The review of the first level appeal will be considered without regard to the initial benefit determination. Someone other than the individual involved in the initial benefit determination or a subordinate of that individual will be appointed to decide the first level appeal. A notification of denial of your first level appeal will include the same information as listed above for denials of claims. The health care professional consulted for the first level appeal will not be the professional (if any) consulted during the prior determination or a subordinate of that professional. The FSA Claims Administrator also will identify medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the benefits determination being appealed, even if the advice was not relied upon in making the benefit determination. Second Level Appeals If you wish to further appeal the FSA Claims Administrator s denial of your first level appeal, you can submit a second level appeal. All second level appeals should be submitted in writing to the Plan Administrator within 180 days after you receive the notice of determination on your first level appeal. Like first level appeals, the review of a second level appeal will not consider prior determinations and will be conducted by a panel of reviewers who were not involved in the prior determinations. Also, if the first level appeal was denied based on a medical judgment, the Plan Administrator will consult a health professional other than the professional consulted for the first level appeal. The Plan Administrator will provide you written notification of the determination not later than 30 days after receipt of your request for a second level appeal. Denial notifications of second level appeals will include the information listed for the initial claim and first level appeal denials. 18