NATIONWIDE HEALTH SAVINGS ACCOUNT (HSA PROGRAM)

Transcription

1 NATIONWIDE HEALTH SAVINGS ACCOUNT (HSA PROGRAM) Program Document & Summary Program Description July 2017 (Any changes to the SPD since this date are included in the applicable Benefits Bulletins.)

2 TABLE OF CONTENTS Introduction... 4 About Health Savings Accounts... 4 Summary of Benefits... 4 Who is Eligible and How to Enroll... 5 Eligibility... 5 Enrollment... 6 New Associates... 6 Annual Enrollment... 6 Mid-Year Election/Changes... 6 HSA Contributions... 7 Maximum IRS Total Contribution Amount... 7 Maximum Program Associate Contributions... 8 Additional Contributions... 9 Rollover Features... 9 Associate Catch-Up Contributions... 9 Employer Contributions... 9 Matching Contributions... 9 Wellness Program Incentives Investment of HSA Contributions Reimbursable Expenses...10 How to Receive Benefits Under the Program Qualified Medical Expenses Non-Qualified Medical Expenses Additional HSA information...12 Excess Contributions Designation of Beneficiary Reporting Contributions & Distributions on Your Tax Return Retiree Healthcare Credit Termination of Employment, Death Or Divorce...13 Termination of Employment Death of Associate Divorce of Associate Claim Review and Appeals...14 Timing of Notification of Initial Benefit Determination Claim Denial Appeal of Adverse Benefit Decision Administration...15 Appointment of the Program Administrator Administrative Powers and Duties Allocation or Delegation of Duties and Responsibilities Compensation Program Modification and Amendment of Program...16 Right to Amend the Program

3 Right to Terminate the Program Miscellaneous Provisions...17 Conditions Precedent to Actions Against Program Administrator or the Company Determination Final and Conclusive Service of Legal Process No Guarantee of Employment Definitions

4 INTRODUCTION This document amends, restates, and combines into one document both the Nationwide Health Savings Account Program document and the associated summary program description, and is effective as of July 1, This Program document replaces and supersedes any Program document and summary program description that has been published previously. Many words used in this Program document have special meaning. These words appear in capital letters and are defined for you either in the Definitions section of this document or in the subsection where the capitalized term first appears. The Nationwide Health Savings Account Program ( HSA or the Program ) is a savings or investment account that allows Eligible Associates to pay for current and future qualified medical expenses on a taxfree basis. ABOUT HEALTH SAVINGS ACCOUNTS You gain choice and control over your health care decisions and expenditures when you establish your HSA to complement any of Nationwide s sponsored medical coverage options (including Kaiser coverage). An HSA is an account funded by you and Nationwide. The HSA can help you to cover, on a tax free basis, medical plan expenses that you are required to pay out-of-pocket, such as deductibles or co-pays. It may even be used to pay for, among other things, certain qualified medical and dental expenses not covered under the medical plan design. Amounts may be distributed from the HSA to pay non-medical expenses, but are subject to income tax and may be subject to IRS penalty unless you are over 65 at the time of the distribution (see the section on Reimbursable Expenses/Non-Qualified Medical Expenses). HSA balances are never forfeited and automatically carry forward from year to year for future medical expenses. If your employment terminates, for any reason (including a long-term disability or retirement), the funds in your HSA will continue to be owned and controlled by you. Earnings on HSA balances are generally not taxed, which means these accounts can grow on a tax free basis. Thus, HSAs offer three kinds of potential federal tax savings: tax-free contributions, tax-free growth on the amounts contributed, and tax-free distributions. SUMMARY OF BENEFITS If you enroll in a Nationwide sponsored medical option, you have the opportunity to set aside pre-tax money in the Nationwide HSA through payroll deductions. Nationwide also matches a portion of your payroll contributions dollar for dollar up to an annual maximum of $450 for single coverage and $900 for family coverage. Money in your account can be used tax free, to pay medical expenses until you meet your deductibles, as well as to pay for co-pays and other qualified medical, dental and vision expenses. If you are contributing to the HSA, incentive reward dollars ($260) for completion of the My Health program are also deposited into the HSA. 4

5 WHO IS ELIGIBLE AND HOW TO ENROLL Eligibility Federal tax law requires that you be covered under a qualified high-deductible health plan (HDHP) in order to be eligible for an HSA and that you not have other non-hdhp health coverage (with certain exceptions). In order to be eligible to make payroll deductions and eligible to receive an employer contribution to your HSA, you must be an Active Associate covered under a Nationwide sponsored medical coverage option, which is intended to qualify as a HDHP. You must also certify that you (1) cannot be claimed as another person s tax dependent; (2) are not entitled (generally, both eligible and enrolled) to Medicare benefits; and (3) do not have any health coverage other than HDHP coverage except for certain types of permitted insurance. Examples of other health coverage that disqualify you from contributing to an HSA include: Coverage under another employer-sponsored group health plan including a general purpose Flexible Spending Account ( FSA ) or Health Reimbursement Account ( HRA ) Medicare Part A, Part B, or Part D coverage Tricare coverage Medicaid coverage You are permitted to have insurance that provides benefits only for certain items. Examples of other health coverage that do not disqualify you from contributing to an HSA include: Insurance in which substantially all of the coverage relates to liabilities incurred under workers compensation laws, tort liabilities, or liabilities related to ownership or use of property Coverage for a specific disease or illness LEARN MORE The IRS periodically updates the eligibility rules for HSAs. For more information about HSAs, including who is eligible, other health coverage that might disqualify an individual from being eligible, contribution limits, and other rules, see IRS Publication 969 (Health Savings Accounts and Other Tax-Favored Health Plans). Hospital indemnity coverage that pays a fixed amount per day (or other period) Limited purpose FSA or HRA You can also have coverage (whether provided through insurance or otherwise) for the following items: Accidents (ex. Nationwide Supplemental Accident Plan) Disability Dental care Vision care Long-Term care 5

6 Enrollment New Associates If you elect a Nationwide sponsored medical option, you may enroll in the HSA when you are hired. When you enroll, you elect an annual amount that the Program Administrator then converts into a payroll period contribution amount by dividing the annual amount elected by the number of payroll periods remaining in the calendar year. EXAMPLE If you elect an annual contribution amount of $500 and there are 10 payroll periods remaining in the calendar year, the $500 would be divided equally and $50 would be deducted from each bi-weekly pay period for the remainder of the calendar year. The Associate Service Center ( ASC ) should receive your enrollment within 60 days of your date of hire. Coverage is effective on the first of the month following one month of active employment. If you elect to participate in a Nationwide sponsored medical option and don t actively waive participation in the HSA, you will be automatically enrolled in the HSA for the remainder of the plan year. Your annual contribution amount will be $450 for single coverage and $900 for family coverage. Annual Enrollment Each year in the fourth quarter, there is an annual enrollment period for Nationwide benefits. If you enroll in a Nationwide sponsored medical option, you may also enroll in the HSA at this time. Elections made during the annual enrollment period are effective January 1 st of the immediately following calendar year. If you currently participate in Nationwide sponsored medical coverage and don t actively waive participation in the HSA during annual enrollment, you will be automatically enrolled in the HSA. Your annual contribution amount will be the higher of (1) the amount you currently contribute, or (2) $450 for single coverage and $900 for family coverage. Mid-Year Election/Changes If you elected a Nationwide sponsored medical option, but waived participation in the HSA, you may enroll anytime during the year. You may also change the amount of your annual election at any time during the year. In these cases, enrollment or changes in the HSA election will be effective the next bi-weekly pay period or as soon as administratively feasible after you submit your enrollment. 6

7 HSA CONTRIBUTIONS All funds placed into your HSA are owned and controlled by you, subject to any reasonable administrative restrictions imposed by the HSA Trustee. Maximum IRS Total Contribution Amount The maximum annual IRS total contribution limit is an indexed amount established annually by the IRS. The maximum annual contribution generally is available only if you are eligible for all 12 months during the year. If you are eligible for only part of the year, your limit is prorated on a monthly basis. However, if you are an Eligible Associate in December, in a given year, you will be deemed to have been an Eligible Associate for the entire calendar year. In order to take full advantage of this rule, you must maintain your HSA eligibility for the next 13 months. The IRS maximum contribution depends in part on whether you are enrolled in family coverage. For purposes of the IRS limit, family HDHP coverage is any coverage other than self-only coverage. The IRS has a special rule for married individuals, which provides that if both you and your spouse are HSA-eligible and one of you has family HDHP coverage, the HSA contribution limit is a joint limit based on family coverage, which is to be divided equally between you and your spouse unless you and your spouse agree on a different division. If one spouse is not HSA-eligible, this special rule does not apply. If both you and your spouse are 55 or older, your contribution limit is increased by the additional catch-up contribution for each of you. Each spouse must make the additional contribution to his or her own HSA. The amount you or any other person can contribute to your HSA depends on the type of HDHP coverage you have, your age, the date you become an Eligible Associate, and the date you cease to be an Eligible Associate. The maximum limits set forth by federal regulations may be found on the IRS website at Nationwide Associates Married to Nationwide Associates: If both spouses are Nationwide associates and both are enrolled as an associate in a Nationwide sponsored medical option: Each associate is eligible for the applicable maximum matching contribution deposit into his/her individual HSA. CAUTION! The IRS maximum contribution limit for family coverage still applies to both spouses/associates combined. It is the associates responsibility to ensure they do not exceed the maximum total contribution limit. Nationwide processes the contribution elections, but does not monitor the limits. 7

8 Maximum Program Associate Contributions Each year, the Company sets an annual contribution limit for Eligible Associates, and publishes these limits in the Annual Enrollment Benefits Bulletin. The associate s annual contribution limit is equal to the Maximum Total Contribution established by IRS guidelines (discussed above) less the Company s available matching contributions and My Health wellness program incentives. The Company assumes full participation in the My Health program (when establishing the annual contribution limit). You elect the annual amount you wish to contribute up to the maximum associate contribution limit and the Program Administrator converts this amount into a payroll period contribution amount. The Company deducts your contribution from each bi-weekly paycheck. You can change your HSA contribution amount any time during the year, and the change will be effective as soon as administratively feasible after you submit your change on the HR Web. Additional information regarding the maximum limits set forth by federal regulations may be found on the IRS website at EXAMPLE 1 For all of 2016, Chris Smith is enrolled in associate-only Nationwide sponsored HDHP coverage. The 2016 IRS contribution limit for non-family coverage is $3,350. The maximum program contribution limit is calculated as follows: 2016 IRS Maximum Total Contribution: $3,350 Less Nationwide Matching Contributions: $450 My Health participation credit: $260 Equals the Program Contribution Limit: $2,640 (plus $1,000 catch-up if 55+) EXAMPLE 2 For all of 2016, Alex Jones is enrolled in Nationwide sponsored family HDHP coverage. The 2016 IRS contribution limit for family coverage is $6,750. The maximum program contribution limit is calculated as follows: 2016 IRS Maximum Total Contribution: $6,750 Less Nationwide Matching contribution: $900 My Health participation credit: $260 Equals the Program Contribution Limit: $5,590 (plus $1,000 catch-up if 55+) 8

9 Additional Contributions You can make additional HSA contributions so long as the total contributions made by you, plus any contributions made on your behalf by the Company or others do not exceed the maximum annual IRS contribution limit that applies to you. Any additional HSA contributions you wish to make must be made directly to your HSA with guaranteed funds (e.g., certified check, cashier s check, or money order). Please contact the Claims Administrator for information on making additional contributions. Because additional contributions are not made through payroll deductions, they will not immediately reduce your taxable income. You may, however, use the contributions to reduce taxable income by completing the necessary forms when filing your tax return. Rollover Features You may rollover amounts in other HSAs into the Program. In addition, you are permitted to make a direct, one-time transfer (rollover) from an Individual Retirement Account ( IRA ) (subject to certain limitations). You should review the IRS annual maximum limits and consult your tax advisor with specific questions regarding your IRA to HSA rollover. Contact the Claims Administrator for information on transferring funds. Associate Catch-Up Contributions An additional annual catch-up amount (also determined on a monthly basis) can be contributed for Eligible Associates who are enrolled in a Nationwide sponsored medical option and will have reached age 55 prior to the end of the calendar year. The Company does not match catch-up contributions. Employer Contributions Matching Contributions When you contribute to the Program through payroll deductions, the Company will provide you with a 100% matching contribution up to an annual maximum of $450 for associate coverage and $900 for family coverage. If you are enrolled in and have a payroll deduction to the HSA in the first pay period of the calendar year, up to 50% of the Company s annual matching contribution is deposited into your account on the first pay period of the calendar year based on your annual election. The remaining matching contribution is deposited, each bi-weekly pay period, based on your contributions for that pay period, up to the maximum matching contribution limit. If your first contribution to the HSA is after the first pay period of the calendar year, you will receive the Company matching contribution, based upon your contributions each pay period, up to the maximum matching contribution limit. The Company s matching contributions are 100% vested. The matching contribution is not considered taxable income and, therefore, is not subject to income tax withholding. NOTE: Tax treatment may vary for certain state and local taxes. 9

10 Wellness Program Incentives Associates who complete the My Health Program requirements and who are actively contributing to the HSA, will receive a $260 incentive reward deposit in January. The My Health Program incentive reward is based on wellness program completion for the prior Program year. Investment of HSA Contributions The Program Administrator offers investment options for your HSA account balance. You may change your investment election for future contributions or transfer funds between the investment options at any time. The Program provides four investment options for your HSA contributions: FDIC-Insured HSA Deposit Account Fidelity International Index Investor Class Fidelity Total Market Index Investor Class Dreyfus Bond Market Index Fd Basic The Program Administrator will invest your initial contributions in the FDIC-Insured HSA Deposit Account unless you make an alternate investment election. Please remember that claim reimbursements may only be paid from your available balance in the FDIC-Insured Deposit Account. The Company does not endorse or recommend any of the available investment options. You should consult with a tax advisor or financial consultant to determine what, if any, investment options are appropriate for you. REIMBURSABLE EXPENSES How to Receive Benefits Under the Program There are multiple ways you can submit a request for distribution for reimbursement through the Claims Administrator (currently WageWorks): (1) WageWorks Health Care Card: You can use your Health Care Card at health care providers (doctors, dentists, vision providers, etc.) to pay for qualified medical expenses and at merchants with an IRS-approved inventory system. (2) WageWorks Website and Mobile App: Through the website or the Mobile App, you can request that you, or the provider, be paid directly. You should submit to the Claims Administrator for reimbursement only those qualified medical expenses incurred after the date your HSA is established. Please contact the Claims Administrator in the event of a mistaken distribution from your HSA. 10

11 You may submit a request for distribution up to the amount in your FDIC-Insured HSA Deposit Account on the date of the request. If you invested any portion of your HSA, as described above, you may need to transfer funds to the FDIC-Insured Account prior to requesting a distribution. If the amount requested exceeds the value of your account as of the processing date, the Program Administrator will not pay the amount in excess of the FDIC-Insured account balance, and you will have to resubmit the remainder of the expense for reimbursement. Qualified Medical Expenses Qualified medical expenses only include the medical expenses (as defined in Internal Revenue Code Section 213(d)) incurred by you, your Spouse and Dependents. Qualified medical expenses also include contributions or premiums for COBRA, qualified long-term care insurance, health coverage while receiving unemployment, and Medicare premiums/contributions (once you reach Social Security retirement age). Generally, over-the-counter drug expenses are not eligible for reimbursement from an HSA unless prescribed by a physician. A complete description and a definitive list of what constitutes eligible medical expenses is available in IRS Publications 969 and 502 which are available from the IRS website at Non-Qualified Medical Expenses HSA funds may also be used to pay for non-qualified health expenses but will generally be subject to income tax and a 20% additional tax unless an exception applies (i.e., your death, your disability, or your attainment of age 65). You should review the IRS guidelines previously referenced, and consult your tax advisor with specific questions regarding the tax implications of your non-qualified medical expenses. IMPORTANT! Be sure to keep your receipts and medical records. If these records verify that you paid qualified health expenses using your HSA, the HSA distributions will not result in additional taxable income when filing your tax return. However, if you cannot demonstrate that you used your HSA to pay qualified health expenses, you may need to report the distribution as taxable income on your tax return. The Program Administrator and Claims Administrator will not verify that distributions from your HSA are for qualified health expenses. Consult your tax advisor to determine how your HSA affects your unique tax situation. The IRS may request receipts during a tax audit. The Company, Program Administrator and the Claims Administrator are not responsible or liable for the misuse by participants of HSA funds, or for the use by participants of HSA funds for non-qualified health expenses. For detailed information regarding qualified medical expenses, please refer to: 11

12 ADDITIONAL HSA INFORMATION Excess Contributions When determining your annual contribution limit, you are responsible for determining whether you were an Eligible Associate for each month. For each month you were not an Eligible Associate, you must reduce your annual contribution limit appropriately. This may result in the amount withheld on a payroll basis being in excess of your annual HSA contribution limit. If this occurs, you must contact the Claims Administrator to request a return of any excess contributions. You must make all corrections before the date of your federal tax return for the effective year. Amounts that exceed the contribution maximum are not tax-deductible and will be subject to an excise tax unless withdrawn as an excess contribution prior to your federal tax return due date the following year. Because eligibility to contribute to the HSA is also based on coverage you have through any other source, you are responsible for determining your annual contribution limit. Please consult with your tax advisor to determine your annual contribution limit. Designation of Beneficiary You should choose a beneficiary when you set up your HSA. If your spouse is the designated beneficiary of your HSA, it will be treated as your spouse s HSA after your death. If your spouse is not the designated beneficiary, your account stops being an HSA, and the fair market value of the HSA becomes taxable to the beneficiary in the year in which you die. If you fail to name a beneficiary or your beneficiary predeceases you, your remaining account balance will be distributed to your estate. If your estate is the beneficiary, the value is included on your final income tax return. You can make or change your beneficiary designations through the Claims Administrator. Reporting Contributions & Distributions on Your Tax Return You are required to report all contributions to your HSA on Form 8889 and file it with your Form 1040 or Form 1040 NR. You should include all contributions made for the applicable tax year. Contributions made by Nationwide and qualified HSA distributions are also shown on the form. You should receive Form 5498-SA from the Claims Administrator showing the total amount contributed to your HSA during the year. Nationwide s contributions also will be shown in box 12 of Form-W-2, with code W. The Claims Administrator will report any distributions to you and the IRS on Form 1099-SA. Your contribution and distribution forms will be made available to you through the Claims Administrator. 12

13 Retiree Healthcare Credit The Retiree Healthcare Credit is an additional way to pay for qualified medical expenses after you retire and become entitled to Medicare. Please refer to the Nationwide Retiree Health Care Company Credit Summary Program Description and the Health Reimbursement Account Summary Plan Description for further details and additional information regarding eligibility and requirements for these plans. TERMINATION OF EMPLOYMENT, DEATH OR DIVORCE Termination of Employment If your employment terminates, for any reason (including a long-term disability or retirement), the funds in your HSA will continue to be owned and controlled by you. You may submit claims for reimbursement for qualified medical expenses, including expenses that are incurred after your termination of employment, subject to the availability of funds in your HSA. However, you will no longer be eligible for matching contributions and you will be responsible for paying the Claims Administrator s administrative fees. These fees are automatically deducted from the account. You have several options: Continue to maintain the account, receive distributions from the account and if you are enrolled in a HDHP and meet all other IRS requirements, you may contribute to the HSA. If you have access to another HSA or open another HSA, you may be able to roll over your account balance to this HSA. Continue to receive distributions from the account until the balance is depleted and then close the account. The Company does not pay the HSA s administrative fees for terminated associates. Your HSA is not subject to continuation coverage under COBRA. Death of Associate In the event of your death, your account balance will be transferred to your designated beneficiary. See the section above on Designation of Beneficiary for more information about the tax implications of naming a Spouse as your beneficiary. Divorce of Associate A domestic relations order, or agreement of separation can divide your HSA account or can cause transfer of all or part of the HSA. In this case, the account continues as an HSA. 13

14 IMPORTANT! Be sure to notify WageWorks and Bank of New York Melon if your name changes or if you have a change of address. You may be asked to provide documentation regarding these important changes. Due to the Patriot Act, financial institutions are required to have accurate and current information regarding your name and address. If BONY Melon does not have current information, or if you do not provide it upon request, they will be forced to liquidate and close your HSA. CLAIM REVIEW AND APPEALS Timing of Notification of Initial Benefit Determination A Claim for Benefits must be filed with the Claims Administrator. The Claims Administrator will notify the Claimant of any Adverse Benefit Determination within a reasonable period of time, but not later than 30 days after receipt of the claim. The 30-day period may be extended one time by the Claims Administrator for up to 15 days, provided that the Claims Administrator both determines that such an extension is necessary due to matters beyond its control, including a failure of the Claimant to submit the information necessary to decide the claim, and notifies the Claimant, before the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the Claims Administrator expects to render a decision. If the 30-day period is extended due to a failure of the Claimant to submit the information necessary to decide the claim, the notice of extension will specifically describe the required information, and the Claimant will be afforded at least 45 days from receipt of the notice within which to provide the specified information. Claim Denial The Claims Administrator shall provide a Claimant with written or electronic notification of any Adverse Benefit Determination. The notification will set forth, in a manner calculated to be understood by the Claimant, the following: The specific reason or reasons for the Adverse Benefit Determination Reference to the specific provisions of this document and/or IRS regulations on which the Adverse Benefit Determination is based A description of any additional material or information necessary for the Claimant to perfect the claim and an explanation of why such material or information is necessary; and A description of the Claims Administrator's review procedures and the time limits applicable to such procedures. 14

15 Appeal of Adverse Benefit Decision A Claimant will have a reasonable opportunity for a full and fair review of a claim and Adverse Benefit Determination. The Claims Administrator makes the final decision on a Claim Denial. The Program Administrator makes the final decision on all appeals. The following is important information about the appeal process: A Claimant has 180 days following receipt of a notification of an Adverse Benefit Determination within which to appeal the determination. A Claimant will have the opportunity to submit written comments, documents, records, and other information relating to the Claim for Benefits. A Claimant will be provided, upon request and free of charge, reasonable access to, and copies of, all relevant documents to a Claimant's Claim for Benefits. The review of the Adverse Benefit Determination will take into account all written comments, documents, records, and other information submitted by the Claimant relating to the claim to the Claims Administrator (or Program Administrator), without regard to whether such information was submitted or considered in the initial benefit determination. The review will not afford deference to the initial Adverse Benefit Determination. The Program Administrator will notify the Claimant of its benefit determination on review not later than 60 days after receipt by the Program Administrator of the Claimant's request for review of an Adverse Benefit Determination. ADMINISTRATION Appointment of the Program Administrator The members of the Program Administrative Committee are appointed by the Nationwide Benefits Committee. The administration of the Program, as provided herein, including the payment of all benefits, shall be the responsibility of the Program Administrator. Administrative Powers and Duties The Program Administrator shall have the power to take all actions required to carry out the provisions of the Program and shall further have the following powers and duties, which shall be exercised in a manner consistent with the provisions of the Program: To exercise discretion and authority to construe and interpret the provisions of the Program, to determine eligibility to participate in the Program, and make and enforce rules and regulations under the Program to the extent deemed advisable To decide all questions as to the rights of associates under the Program and such other questions as may arise under the Program 15

16 To file or cause to be filed all such annual reports, returns, schedules, descriptions, financial statements and other statements as may be required by any federal or state statute, agency, or authority To obtain from the Company and associates such information as shall be necessary to the proper administration of the Program To determine the amount, manner, and time of payment of benefits hereunder To notify the associates and other covered individuals, in writing, of any amendment or termination of the Program, or of a change in any benefits available under the Program To prescribe such actions as may be required for associates to make elections under this Program; and To do such other acts as it deems reasonably required to administer the Program in accordance with its provisions, or as may be provided for or required by law. Allocation or Delegation of Duties and Responsibilities The Program Administrator may designate any person or persons to carry out its respective responsibilities. Any person or group of persons may serve in more than one capacity with respect to the Program. Compensation Any associate, agent, representative or other person performing services to or for the Program shall be entitled to reasonable compensation for services rendered, unless such person is the Company or already receives full-time pay from the Company, and shall also be entitled to receive reimbursement for expenses properly and actually incurred. PROGRAM MODIFICATION AND AMENDMENT OF PROGRAM Right to Amend the Program The Program may be amended at any time upon the approval of the Benefits Committee of Nationwide Mutual Insurance Company by an action documented in writing. The amendment will be effective on the day of approval or at such earlier or later date as the Benefits Committee may determine. Right to Terminate the Program The Board of Directors of Nationwide Mutual Insurance Company may terminate this Program effective as of any day of any month for any reason. The Board of Directors of the other Companies may terminate such Company s participation in the Program as of any day of any month for any reason. The Program Administrator shall, after receiving notice from the Company, notify all affected associates under the 16

17 Program that such Program, or the participation of any Company, is being terminated and that coverage under the Program shall be terminated effective as of the selected date. If the Company shall be dissolved, be deemed bankrupt or insolvent, or be merged with another company, the Program shall be considered as terminated hereunder effective as of such dissolution, bankruptcy, insolvency, or merger, unless the successor of the Company, if any, shall simultaneously adopt this Program and become the sponsor thereof. Upon such involuntary termination, the Program Administrator shall notify all associates under the terminated Program that the Program has been terminated and that their coverage has been terminated as of the termination date described above. In the event of termination of this Program, the Program Administrator shall immediately notify all affected associates of such termination and their coverage thereunder, and that all affected associates must submit and file all unreported and unpaid claims for benefits under the Program, if any, within 90 days from such notice, or their claims will be void. After this time, an associate may choose to maintain the account, receive distributions from the account and if enrolled in a HDHP and meet all other IRS requirements, may continue to contribute to the account, but will be responsible for paying the Claims Administrator s administrative fees. MISCELLANEOUS PROVISIONS Conditions Precedent to Actions Against Program Administrator or the Company No action shall be brought against the Program Administrator or the Company by an associate unless, as a condition precedent thereto, the associate for whom benefits are claimed shall have fully complied with all the terms and provisions of this Program, or until the appeal with respect to such benefits has been denied in writing by the Program Administrator. Determination Final and Conclusive As a condition precedent to participation, each associate agrees that whenever the Program Administrator or the Company makes reasonable determinations in the administration of the Program, such determinations shall be final and conclusive with respect to each such affected associate. Service of Legal Process The Agent for Service of Legal Process is: Nationwide Mutual Insurance Company Associate Vice President - Litigation-Discovery Unit Attn: Service of Process Team Three Nationwide Plaza ( ) Columbus, OH Telephone:

18 No Guarantee of Employment The Program does not guarantee employment to any associate of the Company. Benefits provided under the Program depend on continued employment and eligibility. The philosophies, policies, procedures, and benefits described herein are not conditions of employment, nor do they imply, create or constitute an employment contract between the Company and any associates. The Company has an "employment at will" relationship with its associates. This means that either the Company or each associate has the right to terminate employment at any time, with or without reason. DEFINITIONS Active Associate Active Associate means: (a) An individual who is performing services for a Company in an employment relationship and who is regularly scheduled to work at least: (i) hours per week, (ii) hours per biweekly Pay Period, or (iii) hours per semimonthly Pay Period, and (b) Paid a stipulated salary. Company or Companies Company" or Companies means Nationwide Mutual Insurance Company, Nationwide Mutual Fire Insurance Company, and/or Farmland Mutual Insurance Company, and any subsidiaries or affiliates thereof whose Board of Directors has duly adopted the Program for its associates. Claimant Claimant means a Program participant or the individual who is submitting a claim on behalf of a Program participant after the Program participant s date of death. Claims Administrator The party retained by the Company to provide administrative services in connection with payment of claims from time to time. With respect to an initial Claim for Benefits the party to whom the Program Administrator may delegate the responsibility, via written agreement or as otherwise delegated in writing, for the responsibilities of determining initial Claims for Benefits; and With respect to an appeal of an Adverse Benefit Determination, the Program Administrator. Dependent An Active Associate s dependent, as defined in Internal Revenue Code Section 105(b). Generally, an individual is a Dependent under Internal Revenue Code Section 105(b) if they are dependent as defined in Internal Revenue Code Section 152, determined without regard to subsections (b)(1), (b)(2), or (d)(1)(b). 18

19 Eligible Associate An Active Associate who, with respect to any calendar month, is: (a) Covered under a Nationwide sponsored high deductible health plan as of the 1 st day of the month; (b) Not covered by any other health plan that is not a high deductible health plan (including Medicare Parts A, B or D) and that provides coverage for any benefit which is covered under the high deductible health care plan; and (c) Not claimed on someone else s tax return for the same tax year. Pay Period The bi-weekly period for which an associate is paid. Program Program means the Nationwide Health Savings Account Program as set forth in this document or as it may be hereafter amended. Program Administrator "Program Administrator" means the Program Administrative Committee, as established and appointed by the Benefits Committee of Nationwide Mutual Insurance Company. Program Year "Program Year" means each annual period beginning on January 1 and ending December 31. Spouse Spouse means an individual who is lawfully married to an Active Associate under any state law. For purposes of this definition, the term state means any state of the United States, the District of Columbia, any territory or possession of the United States and any foreign jurisdiction having the legal authority to sanction marriages. 19

20 Analysts from the Associate Service Center can answer your questions about enrollment. Call the Associate Service Center at or CPO-0812AO.1 (06/17) 20