>>> Welcome Packet <<< State of Indiana Retiree Information Packet. Retirement Medical Benefits Account Plan

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1 Retirement Medical Benefits Account Plan >>> Welcome Packet <<< State of Indiana Retiree Information Packet State of Indiana Retirement Medical Benefits Account Plan Frequently Asked Questions Claim Form Registration Form Direct Deposit Authorization Approved Substantiation for HRA Claims Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC

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3 Welcome to the State of Indiana Retirement Medical Benefits Account Plan Welcome to the State of Indiana (State) Retirement Medical Benefits Account Plan (Plan). The State has established this Plan as a benefit to employees who retire and are eligible for and have received a normal, unreduced or disability retirement benefit (as determined by statutes and codes governing a State public employee retirement fund). As a Qualified Retiree of the State, you are eligible to receive benefits from this Plan. Subject to conditions and limitations described in the Plan, you will be reimbursed from your Reimbursement Account for Qualifying Expenses incurred by you and/or your Covered Dependents. Key Benefit Administrators (KBA) has the privilege of administering this special Plan for Qualified Retirees of the State. To assist you with information relating to how the Plan works, KBA is providing this Retiree Information Packet. This Packet includes a list of the most Frequently Asked Questions, a Claim Form (please make copies for your ongoing use), a Retiree Registration form, and the option to utilize Direct Deposit for the reimbursements for your account claims submitted to us. Also, even if you decide to pay in advance for your premiums with your insurance company, the State will only have KBA reimburse you for the current month, as it occurs. Therefore, each month ahead of the current month claimed will need to have a new claim form submitted to KBA. It is very important that you complete the Retiree Registration form and return it to KBA as soon as possible so that we have your most current up-to-date information on record. This information will need to be maintained over the coming years, so it is your responsibility to assure KBA has the most recent information in your file at all times. NOTE: In the event of a bank deposit rejection because the retiree fails to advise KBA of a change in the banking account utilized for direct deposits, a fee of $30.00 may be assessed. Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC

4 RETIREMENT MEDICAL BENEFITS ACCOUNT PLAN * FREQUENTLY ASKED QUESTIONS This packet is only a brief overview of benefits that may be eligible under your Plan. Please refer to the State s website for additional information: What is a Retirement Medical Benefits Account Plan? It is a State-funded Health Reimbursement Arrangement that reimburses Qualified Retirees for certain health insurance premiums up to a maximum limit. What expenses are eligible for reimbursement under the Plan? Qualifying Expenses include: premiums under an insurance policy for group or individual coverage of the Qualified Retiree and/or his or her Covered Dependents including medical, dental, vision, tax-qualified long-term care (subject to the limitations in Code Section 213(d)(10)) and Medicare supplement policies premiums, the State s Medicare complementary policy and coverage of the Qualified Retiree and/or his or her Covered Dependents under Medicare Part B and Medicare Part D premiums. Important Exceptions The following expenses will not be treated as Qualified Expenses under the Plan: 1. Expenses paid, reimbursed or reimbursable by any insurance, accident, health or worker s compensation plan, 2. Expenses paid, reimbursed or reimbursable under a Code Section 125 Flexible Benefits Plan, such as doctor/rx co-pays, or deductibles. 3. Expenses incurred while the individual is neither a Qualified Retiree nor a Covered Dependent, or 4. The individual is not legally obligated to pay. Who is considered to be a Covered Dependent? The term Covered Dependent means an individual to whom the Qualified Retiree is legally married (excluding a common-law spouse) or who qualifies as a dependent child of the Qualified Retiree at the time the expense is incurred, the spouse and dependent children of a deceased Qualified Retiree. Can I pay ahead on my premiums and be reimbursed? The State only allows reimbursements to occur on the month currently presented, or prior months. No future dates can be reimbursed until the month occurs, and a signed claim should be presented each month. How and when may I receive reimbursement for Qualified Expenses? To receive reimbursement for Qualified Expenses, you must send a copy of the proper documentation of your Qualified Expense along with a signed claim form (a copy of the claim form is included in this packet please make copies) to Key Benefit Administrators (KBA) to the address, fax number, or listed below. Proper documentation includes a bill or receipt showing the type of insurance, the name of the provider, the name of the Qualified Retiree and/or the spouse or Covered Dependent, the month(s) covered, the amount of the premium and proof of payment. FlexPro TM Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC Fax #: Flexpro@keybenefit.com Reimbursements will be issued on a weekly basis. Checks/Vouchers will be mailed or ed directly to the Qualified Retiree s home. (It is important that you notify KBA immediately if your address or changes.) May a Covered Dependent continue to receive reimbursements after a Qualified Retiree s death? Yes, if a Covered Dependent incurs Qualifying Expenses after the death of a Qualified Retiree, those expenses will continue to be eligible for reimbursement until the balance in the Reimbursement Account is zero or the individual ceases to qualify as a Covered Dependent by remarriage or no longer meeting the definition of dependent. We do ask that a Death Certificate be sent to establish the account in the dependent s name. What happens when my account balance is reduced to zero? Once you have used all available funds previously contributed to your account by the State during your employment, and the additional bonus contribution (if applicable) upon your retirement, and your Plan account balance reaches zero, you will no longer be eligible to continue participation in the Plan. Who may I call if I have questions? You may call KBA at or Customer Care Representatives are available to assist you from 8:00 a.m. to 5:00 p.m. Monday through Friday.

5 State of Indiana Retirement Medical Benefits Account Plan Claim Form THIS FORM MUST ACCOMPANY EACH GROUP OF RECEIPTS SUBMITTED 980 Retiree Name: Retiree SSN: - - address: Home Address: Number & Street City State Zip Code Daytime Phone Number: Number of pages: Please check if new address, or phone number To the best of my knowledge and belief, my statement in this Request for Reimbursement is complete and true. I am claiming reimbursement only for Qualified Premium Expenses incurred by me, my spouse, or my Covered Dependent(s) during the applicable plan year. I certify that these expenses have not been reimbursed by any other source, are not pre-taxed under a Section 125 Flexible Benefits Plan, nor will any reimbursement be sought from any other source. I authorize my Retirement Medical Benefits Account Plan be reduced by the amount requested. Employee Signature: Date: Signature Required Insurance Premium Expenses: Insurance Premium receipts or statements must be from an independent third-party and must include the Name of the Retiree, Spouse or Covered Dependent, Name of the Provider, Type of Insurance, the month(s) covered and the Amount of the Insurance Premium. Proof of payment is also required. If necessary, please add additional pages. Name of Retiree or Covered Dependent Month(s) Covered Name of Provider (i.e., Anthem) Type of Insurance Amount of Premium Total: The following reimbursement request rules apply: Insurance expenses must be incurred within the appropriate retiree eligibility period. Photocopies are acceptable. Please retain a copy of all claims for your own records. Cancelled checks are only acceptable as proof of payment not as receipts. This form must be signed and submitted with the applicable information. NOTE: In the event of a bank deposit rejection because the retiree fails to advise KBA of a change in the banking account utilized for direct deposits, a fee of $30.00 may be assessed. Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC * *** Fax: * Flexpro@Keybenefit.com

6 State of Indiana Retirement Medical Benefits Account Plan Retiree Registration Form Please complete the following information and return this form to KBA at the address listed below. Please Print Legibly Retiree Name: SSN: - - Home Address: Number & Street City State Zip Code * address (optional): Daytime Phone Number: DOB: Spouse Name: SSN: DOB: Dependent Name: SSN: DOB: Dependent Name: SSN: DOB: Dependent Name: SSN: DOB: Dependent Name: SSN: DOB: A covered dependent means an individual to whom the Retired Participant is legally married (excluding a common law spouse) or who qualifies as a dependent of the Retired Participant under Code Section 152 (determined without regard to subsections (b)(1), (b)(2) and (d)(1)(b) at the time the Qualifying Expense is incurred. *We are Going Green and need your address your deposit voucher will be sent to your address that you supply secured and efficient! IMPORTANT! Please notify KBA immediately if you change your address! Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC * *** Fax: * Flexpro@Keybenefit.com

7 STATE OF INDIANA HRA SB DIRECT DEPOSIT AUTHORIZATION FORM Employee Retiree Name Retiree SSN Employer: State of Indiana - Effective Retirement Date: I hereby authorize and request the Key Family of Companies to initiate credit entries to the account indicated below: Checking Account Savings Account Account Number Bank ACH Transit Routing Number (use the TRN from your Checking Account, not the number on the Savings Deposit Slip) Depository (Bank Name) Branch City State This authorization will remain in effect until written notice is received by the Key Family of Companies that terminates this authorization. NOTE: In the event of a bank deposit rejection because the retiree fails to advise KBA of a change in the banking account utilized for direct deposits, a fee of $30.00 may be assessed. Signature Date CHECKING ACCOUNT A VOIDED CHECK MUST BE ATTACHED SAVINGS ACCOUNT A WITHDRAWAL SLIP MUST BE ATTACHED Please attach a voided check (or withdrawal slip for savings account). If this is not available you must obtain the correct ACH transit routing number and bank account number from your bank where you want your reimbursement deposited. Key Benefit Administrators P.O. Box 1179 Ft. Mill, SC

8 PO Box 1179, Ft. Mill, SC APPROVED SUBSTANTIATION FOR STATE OF INDIANA HRA CLAIMS: When submitting a claim for your insurance premium reimbursement, KBA will need the following THREE pieces of documentation supplied each month: IMPORTANT NOTE: THE STATE OF INDIANA'S MEDICAL PLANS ARE ELIGIBLE UNDER THE SB501 HRA WITH PASSAGE OF HB1019. This account is not eligible for out-of-pocket medical costs only PREMIUMS: NOTE: This benefit is not taxable by the IRS, therefore, premiums can only be reimbursed if they are not paid by the retiree as "pre-taxed" - most employers will pre-tax premiums, so if you're still working with another employer, those premiums may not be eligible. SEND EACH MONTH Plus: This One DESCRIPTION OF SUBSTANTIATION: Claim Form, Signed by Retiree If on Medicare A, B, C or D Benefits: The annual letter from Social Security outlining the payments being taken from your monthly stipend. For RX Supplement D, only the premium is eligible, not co-pays on the prescriptions. If amount increases, send new letter for our records to correlate with yours. HOW OFTEN TO SEND: Each Month A Claim is Filed We will need the SSA annual letter the first time Medicare benefits are claimed. Thereafter, only if the amount taken from the monthly stipend changes, to substantiate the amount indicated for reimbursement. If 65 or older & have a Supplemental Policy: BE SURE TO SEND Eligible Proof of Payment: Or This One Or This One Or This One AND: A copy of the summary page indicating the cost and type of coverage. If still working at another employer: Have employer provide a written statement indicating the group insurance plan is fullyinsured and premiums are not paid with pre-tax dollars. If pre-taxed, you may not be reimbursed. If retired before eligible for Medicare benefits, and have a fully-insured medical insurance policy: A copy of the policy summary page indicating the cost and type of coverage. Cancelled Check (a copy of the written check will not be sufficient), Bank Statement, Credit Card Statement, Receipt for Cash Rendered for Payment, Statement from Insurance Carrier showing proof of payment, etc. Each month a claim is filed, attach a copy of the policy statement which indicates the monthly, quarterly or annual amount paid, & other eligible proof of payment, as shown below. Each month send a copy of paycheck stub for the month claimed for reimbursement. Each month a claim is filed, attach a copy of the policy statement which indicates the monthly, quarterly or annual amount paid, & other eligible proof of payment, as shown below. NOTE: Claims must be made on a monthly basis to assure retiree or eligible dependent(s) are not deceased. The payments must be incurred before they are eligible to be reimbursed and cannot be paid out beyond the current month.