Ecolab Post Retirement Benefits Plan Health Reimbursement Arrangement. Summary Plan Description. January 1, 2018

Transcription

1 Ecolab Post Retirement Benefits Plan Health Reimbursement Arrangement Summary Plan Description January 1, 2018 This document is the Summary Plan Description ( SPD ) for this benefit. This SPD is required by federal law called the Employee Retirement Income Security Act of 1974 ( ERISA ). This SPD reflects the terms of the benefit in effect as of January 1, Ecolab has the right to amend or terminate all or part of the Plan at any time v SPD-Ecolab

2 TABLE OF CONTENTS Introduction... 1 Eligible Retirees... 1 Dependents... 2 Effective Date of Participation... 4 Surviving Spouses, Domestic Partners and Dependents... 4 Termination of Coverage... 4 Coverage and Benefits Information... 5 Carryover of HRA Allocations... 7 Reimbursement of Eligible Expenses... 7 Benefits Limitations and Overpayments... 7 Benefit Claims and Appeals... 8 Participation Claims and Appeals... 8 Benefits if I Die... 9 Coordination of Benefits... 9 Notices... 9 Subrogation and Reimbursement ERISA Plan Information Statement of ERISA Rights i

3 Introduction Ecolab Inc. ( Ecolab ) has established the Health Reimbursement Arrangement ( HRA ) component of the Ecolab Post Retirement Benefits Plan ( Plan ) for the benefit of certain post-65 Medicare-eligible retirees of Ecolab and participating affiliated employers who meet the Plan s eligibility criteria. (Ecolab and participating affiliates are collectively referred to herein as the Employer ). The purpose of the HRA component of the Plan is to reimburse eligible retirees for certain health insurance premiums and other medical expenses they incur in limited circumstances, which are not reimbursed from other sources. 1 The HRA component is intended to meet the requirements of a self-insured medical reimbursement plan for purposes of Sections 105 and 106 of the Internal Revenue Code, as amended ( Code ), as well as a health reimbursement arrangement as defined in IRS Notice , so that reimbursements for eligible expenses are excludable from your taxable income. The Plan, including the HRA component, is also intended to be exempt from the Affordable Care Act as a separate retiree-only plan pursuant to ERISA Section 732(a) and IRC Section 9831(a)(2). The material provisions of the HRA component of the Plan are summarized in the following pages, but this summary plan description ( SPD ) is qualified in its entirety by reference to the full text of the formal Plan document, a copy of which is available for inspection at Ecolab s offices or upon request to the Plan Administrator. In the event of any conflict between the terms of this SPD and the terms of the Plan document, the terms of the Plan document will control. Eligible Retirees You are eligible to participate in the HRA component of the Plan if you meet all of the following conditions: you are at least 65 and have enrolled in Medicare Part B, or you are not yet Medicare-eligible but your Medicare-Eligible Dependent (defined below) has enrolled in Medicare Part B and you are enrolled in the Ecolab Post Retirement Benefits Plan; and you meet the conditions of one of the Grandfathered Groups described below. 1. Medicare Part B Enrollment. You must enroll in Medicare Part B to be eligible for the HRA component of the Plan. Also, if your Spouse, Domestic Partner or Dependent is Medicare-eligible, then they must enroll in Medicare Part B for you to obtain an additional HRA allocation on account of such person s Medicare eligibility. If you do not enroll in Medicare Part B within your initial enrollment period for Medicare Part B, you will permanently lose eligibility for the HRA component of the Plan; similarly, if your Spouse, Domestic Partner or Dependent fails to enroll in Medicare Part B during his or her initial enrollment period for Medicare Part B, no HRA allocation will ever be made under the Plan on account of such person s Medicare eligibility and such person will also never be entitled to benefits as a surviving Spouse, Domestic Partner or Dependent. If you are at least age 65 and Medicare-eligible but not enrolled in Medicare Part B as of December 31, 2017, then you will have a one-time opportunity to enroll in Medicare Part B during its annual open enrollment period (January 1 through March 31, 2018) and receive an HRA allocation. You must enroll with OneExchange within 90 days of your effective date of Medicare Part B coverage (July 1, 2018) to be eligible for the HRA allocation. If you are at least age 65 and eligible for Medicare Part B as of December 31, 2017, and do not enroll in Medicare Part B by March 31, 2018, no HRA allocation will ever be available under the Plan for you. In that case, your Spouse, Domestic Partner or Dependent will also never be entitled to benefits as a surviving Spouse, Domestic Partner or Dependent. 2 1 The OneExchange Enrollment packet mailed to your home includes a Funding and Reimbursement insert that lists your HRA benefit amount, based on your eligibility and enrollment criteria. Contact the Plan Administrator if you have questions. 2 A similar rule applies for your Spouse, Domestic Partner, or Dependent who is at least age 65 and Medicare-eligible but not enrolled in Medicare Part B as of December 31, Refer to the Dependents section of this SPD. 1

4 2. Grandfathered Groups. Grandfathered Group One. You are in this group if you: (1) retired from Ecolab on or before June 30, 1993 and you were participating in the Ecolab Post Retirement Benefits Plan on that date; or (2) were actively employed by Ecolab or another Participating Employer on June 30, 1993 and met one of the following requirements as of that date: (a) you were at least age 65; (b) you were at least age 55 with 10 or more years of Eligibility Service; or (c) the sum of your age and years of Eligibility Service was at least 70 years. Grandfathered Group Two. You are in this group if, as of February 28, 2002, you were: (1) an Ecolab Eligible Employee who was at least 50 years old and had 5 or more years of Eligibility Service; or (2) a Participant in the Post Retirement Benefits Plan but were not a member of Grandfathered Group One. Medically Grandfathered Group. You are in this group only if you were an Ecolab employee or dependent eligible for medically grandfathered status. This is a frozen group. Nalco Grandfathered Group. You are in this group if you: (1) had a vested benefit under the Nalco Company Retirement Income Plan as of December 31, 2002 (whether PRAP or VRIP ), and (2) completed at least 10 years of Eligibility Service after attaining age 45. You must also enroll or have enrolled in the Plan during your initial enrollment period following your retirement date (or, for legacy Nalco retirees, during the open enrollment period for 2017 Plan coverage), and your participation in the Plan has not terminated (other than due to rehire by Ecolab). Ineligible (Excluded) Individuals. You are not eligible if, at the time that you retire, you are: (1) classified by the Participating Employer as a temporary employee, a leased employee, or independent contractor; (2) covered by a collective bargaining agreement or contract that does not provide for your participation; (3) covered by a contract or agreement that does not provide for your participation; (4) a non-resident alien whose compensation from the Participating Employer does not constitute income from U.S. sources and are not classified by the Participating Employer as a Foreign Service Employee or Globalist; or (5) not a U.S. citizen and are employed by a Participating Employer outside of the U.S. Employees of certain divisions of Ecolab or a Participating Employer acquired through purchase may not be Eligible Retirees or may have special rules relating to how years of service before and after the acquisition are credited. Call the Ecolab Benefits Center at for additional information on eligibility under the Plan. Reclassification as Eligible. If you are reclassified as Eligible by a court, an administrative body or the Employer on a retroactive basis, you will be eligible for coverage only during periods that follow the reclassification. No Plan coverage will be retroactive. Dependents In general, your Medicare-Eligible Dependents are not eligible to participate in the HRA component of the Plan, but you are eligible for an allocation to your HRA and are entitled to be reimbursed from your HRA for any Eligible Expenses you incur on behalf of your Medicare-Eligible Dependents. The only exception is that your surviving Medicare-eligible Spouse, Medicare-eligible Domestic Partner and Medicare-eligible Dependent Children will be eligible to participate in the HRA component of the Plan after your death if all other eligibility criteria are met. No other dependents are eligible to become Participants in the Plan, and you cannot be reimbursed from your HRA for expenses you incur as a result of any other dependents. Medicare-Eligible Dependents are: (1) your Medicare-eligible Spouse or Medicare-eligible Domestic Partner who is at least age 65; and (2) your Medicare-eligible Dependent Child(ren) who is at least age 65. Proof of Dependent Status. You may periodically be required to provide proof of Medicare-Eligible Dependent status, such as a birth certificate, marriage certificate or domestic partner affidavit. Spouse. Spouse means a person you became married to under the law of any jurisdiction, as long as such marriage has not been legally terminated. Your Spouse is no longer a Medicare-Eligible Dependent on the date your participation ends for any reason, except in the event of your death. 2

5 Domestic Partner. Domestic Partner means a person, other than your Spouse, who meets either (1) or (2) below: 1. You and your partner are at least 18 years old and, under the laws of any government jurisdiction, the parties to a (1) civil union, (2) registered domestic partnership, or (3) similar, legally-recognized arrangement, that has not been dissolved or revoked; or 2. You and your partner have filed with the Company an affidavit, in a form prescribed by the Plan Administrator, attesting that (1) you have an ongoing and committed Spouse-like relationship; (2) you intend to continue your relationship indefinitely; (3) each of you is 18 years of age or older and competent to enter into a contract; (4) neither of you is the Spouse or Domestic Partner of anyone else; (5) you are not related by blood closer than permitted by marriage law in your state of residence; (6) you have shared a principal residence for at least the previous six months and intend to do so indefinitely; (7) you are jointly responsible for the direction and financial management of your household and take joint responsibility for each other s financial obligations; and neither you nor such person has revoked this affidavit. To the extent you maintain an HRA that may be used to reimburse eligible expenses of your Medicare-eligible Domestic Partner or your surviving Medicare-eligible Domestic Partner has coverage under the HRA, income will be imputed as required by the tax code. Dependent Child. Dependent Child means a child who: 1. has one of the following relationships to you or to your Spouse or Domestic Partner: biological child; legally adopted child; step child; child placed for legal adoption; foster child; or legal ward (child for whom you or your Spouse or Domestic Partner are legal guardian); and 2. is a disabled Dependent, defined as your child for whom you provide proof of disability when requested, and who is not self-supporting due to physical, mental or intellectual disability. If your Spouse, Domestic Partner or Dependent is Medicare-eligible, then they must enroll in Medicare Part B in order for you to obtain an HRA allocation under the Plan on account of such person s Medicare eligibility. If your Spouse, Domestic Partner or Dependent fails to enroll in Medicare Part B during his or her initial enrollment period for Medicare Part B, you will never receive any additional HRA allocation on account of such person s Medicare eligibility and such person will also never be entitled to benefits as a surviving Spouse, Domestic Partner or Dependent. If your Spouse, Domestic Partner or Dependent is at least age 65 and Medicare-eligible but not enrolled in Medicare Part B as of December 31, 2017, then your Spouse, Domestic Partner or Dependent will have a one-time opportunity to enroll in Medicare Part B during its annual open enrollment period (January 1 through March 31, 2018) for you to be eligible to receive HRA allocations on account of their Medicare eligibility. You must provide the necessary information about the newly-covered individual to OneExchange within 90 days of the effective date of their Medicare coverage (July 1, 2018) to be eligible for an HRA allocation on account of such newly-enrolled person. If your Medicare-eligible Spouse, Domestic Partner or Dependent is at least age 65 and eligible for Medicare Part B as of December 31, 2017, and does not enroll in Medicare Part B by March 31, 2018, no HRA allocation will ever be available to you on account of such person s Medicare eligibility, and such person will also never be entitled to benefits as a surviving Spouse, Domestic Partner or Dependent. Your dependent will no longer be a Medicare-Eligible Dependent on the earlier of: (1) the date the individual no longer meets the definition of a Medicare-Eligible Dependent for any reason; or (2) the date your participation terminates, other than in the event of your death. You must notify OneExchange within 30 days of the following events: 3

6 Your spouse or domestic partner no longer meets the definition of a Spouse or Domestic Partner for any reason, including divorce or separation; Your child no longer meets the definition of Dependent Child for any reason; Your Spouse, Domestic Partner or Dependent Child loses Medicare-eligibility; or Your Spouse, Domestic Partner, or Child passes away. Effective Date of Participation An Eligible Retiree becomes a participant in the HRA component of the Plan on the later of January 1, 2018, or the date that he or she has satisfied all of the following requirements: He or she has become eligible for and enrolled in Medicare Part B, or has a Medicare-Eligible Dependent; He or she or a Medicare-Eligible Dependent has reached age 65 and is covered by an individual health insurance policy obtained through OneExchange; and He or she has completed any enrollment forms or procedures required by the Plan Administrator. Surviving Spouses, Domestic Partners and Dependents Surviving Spouses, Domestic Partners and Dependents will be eligible to participate in the HRA component of the Plan only as follows: If an employee dies before he or she terminates employment, and otherwise would have qualified as an Eligible Retiree at retirement, his or her surviving Medicare-Eligible Dependents will be eligible to participate in the HRA component of the Plan. If an employee who was an Eligible Retiree dies while enrolled in the Plan, his or her surviving Spouse, Domestic Partner and/or Dependent who were enrolled in the Pre-65 component of the Plan or for whom the Eligible Retiree was receiving an additional HRA allocation under the Post-65 Component of the Plan at the time of the Eligible Retiree s death will be eligible to participate in the HRA component of the Plan when such individual meets the other eligibility criteria to be eligible for the HRA component (becoming a Medicare- Eligible Dependent). In such cases, surviving Spouses, Domestic Partners or Dependents will be eligible to participate in the HRA component of the Plan only during periods when he or she is a Medicare-Eligible Dependent, and subject to the Termination of Coverage provisions of the Plan document and this SPD. The HRA will be credited with an amount based on the surviving Spouse, Domestic Partner or Dependent s effective date of participation. Such individual s effective date of participation in the HRA component of the Plan will be the date that the individual is covered by an individual health insurance policy obtained through OneExchange. A surviving Spouse, Domestic Partner, or Dependent who is a Medicare-Eligible Dependent at the time of, or within six (6) months of, the Eligible Retiree s death, will also receive credit for the remaining allocation (or a portion of the remaining allocation, in the case of multiple surviving Medicare-Eligible Dependents) in the Eligible Retiree s HRA (including carry-over amounts). In all other cases, the Eligible Retiree s remaining HRA allocations will be not be credited to any other person, and will not be transferable or inheritable. Termination of Coverage Your benefits under the Plan will end on: (1) the date you lose eligibility (e.g., due to committing fraud against the Plan or failing to meet the requirements of an Eligible Retiree); (2) the day prior to the date you are rehired by the Employer as an active employee; (3) the date you cease to be eligible for the benefit under the Plan as it may be amended; (4) the date that you cease to be eligible for Medicare; (5) the date of your death; (6) the date the benefit or Plan is terminated; (7) if you fail to make any required premium contributions, the last date for which you paid premium contributions; or (8) the date you voluntarily terminate coverage. Any termination of coverage is permanent (you cannot reenroll in the Plan), except in the case in which an Eligible Retiree was re-employed as an active employee of Ecolab and retires again. In general, your Spouse, Domestic Partner and/or Dependent do not have benefits under this HRA component of the Plan. 4

7 The benefit you receive under the Plan on account of your Spouse s, Domestic Partner s, or Dependent s Medicare eligibility, and any benefits for a surviving Spouse, Domestic Partner or Dependent, will end on: (1) the date such individual loses eligibility (e.g., due to committing fraud against the Plan or failing to meet the requirements of a Medicare-Eligible Spouse, Domestic Partner, or Dependent or Eligible Surviving Spouse, Domestic Partner or Dependent); (2) the day prior to the date you or your Spouse, Domestic Partner or Dependent are hired by the Employer as an active employee; (3) the date you or your Spouse, Domestic Partner or Dependent ceases to be eligible for the benefit under the Plan as it may be amended (except as described in the Surviving Spouse, Domestic Partners and Dependents paragraph above); (4) the date that you or your Spouse, Domestic Partner or Dependent, as the case may be, cease to be eligible for Medicare; (5) the date of your Spouse s, Domestic Partner s or Dependent s death; (6) the date the benefit or Plan is terminated; (7) if you or your Spouse, Domestic Partner or Dependent fails to make any required premium contributions, the last date for which premium contributions were paid; or (8) the date you or your Spouse, Domestic Partner or Dependent voluntarily terminates coverage. Any termination of coverage is permanent (no one can reenroll in the Plan), except in the case in which an Eligible Retiree was re-employed as an active employee of Ecolab and retires again. Coverage and Benefits Information HRAs and Benefits Credits. Only one HRA will be established for you, even if you have Medicare-Eligible Dependents. Except in the case of an eligible surviving Spouse, Domestic Partner or Dependent, Medicare-Eligible Dependents will not be eligible to have their own HRA. An HRA Benefit Credit will be credited to your HRA by the Employer in the amount specified in the Funding and Reimbursement insert in your OneExchange Enrollment Packet. Your Benefit Credit will be allocated to your HRA annually, on January 1. If you become eligible for the HRA benefit and establish an HRA mid-year, or if you gain a Medicare-Eligible Dependent mid-year, you will receive a prorated HRA Benefit Credit on account of that individual. The prorated amount will be the annual Benefit Credit determined for you (including amounts attributable to Medicare-eligibility of a Medicare-Eligible Dependent), multiplied by the number of months during the calendar year in which you, or the Medicare-Eligible Dependent, is eligible to have expenses reimbursed from the HRA component of the Plan, and divided by 12. Any prorated Benefit Credits will be allocated to your HRA as soon as reasonably practicable after the effective date of the change. If one or more of your Medicare-Eligible Dependents for which you are receiving an HRA Benefit Credit no longer meets the definition of a Medicare-Eligible Dependent, or passes away, you must notify OneExchange within 30 days. Your HRA credit for that calendar year will not be reduced; however, in future calendar years, your HRA benefit will be reduced to reflect the remaining number of your Medicare-Eligible Dependents. Expense Reimbursements. Your Benefit Credit will be reduced from time to time by the amount of any Eligible Expenses for which you are reimbursed under the Plan. At any time, you may receive reimbursement for Eligible Expenses up to the amount in your HRA (or, for Eligible Expenses that are catastrophic prescription drug expenses, even if those amounts exceed your HRA balance). An HRA is merely a bookkeeping account on the Employer s records; it is not funded and does not bear interest or accrue earnings of any kind. All benefits under the Plan are paid entirely from the Employer s general assets. You cannot make any contributions to your HRA. Eligible Expenses. An Eligible Medical Expense for purposes of this Plan is one of the expenses listed below that is incurred by you or your Medicare-Eligible Dependent while you are a Participant in the Plan: Premiums for medical and prescription drug insurance purchased through OneExchange. An Eligible Medical Expense is an expense incurred by you or any Medicare-Eligible Dependent for medical care, as that term is defined in Code Section 213(d) (generally, expenses related to the diagnosis, care, 5

8 mitigation, treatment or prevention of disease), but excluding dental and vision plans. Some common examples of items that are Eligible Medical Expenses include 3 : Medications (in reasonable quantities) prescribed by a doctor (without regard to whether the medication is available without a prescription) or insulin; Dermatology; Physical therapy; Chiropractor treatments; Hearing aids; and Wheelchairs. Some examples of common items that are not Eligible Medical Expenses include: Long-term care services; Cosmetic surgery or similar procedures (unless the surgery is necessary to correct a deformity arising from a congenital abnormality, accident or disfiguring disease); Funeral and burial expenses; Household and domestic help; Massage therapy; Custodial care; Health club or fitness program dues (unless specific requirements are satisfied); and Cosmetics, toiletries, toothpaste, etc. Catastrophic Prescription Drug Costs. Prescription medications (in reasonable quantities) are Eligible Expenses, regardless of your HRA balance, if medication costs for the Plan Year for you or your Medicare- Eligible Dependent exceed certain catastrophic amounts. You will be eligible for reimbursement of covered qualifying prescription drug expenses for the applicable Plan Year, if you, or your Medicare-Eligible Dependent (as applicable), incurs covered qualifying prescription drug expenses that exceed the true out of pocket (TrOOP) limit set by CMS for the applicable Plan Year ($5,000 in 2018). Qualifying prescription drug expenses are expenses for medications prescribed by a doctor (without regard to whether the medication is available without a prescription) and insulin. If you or your Medicare-Eligible Dependent becomes eligible for reimbursement of qualifying prescription drug expenses during a Plan Year, all claims for prescription drug Eligible Expenses that exceed the TrOOP limit for that person will be reimbursed for the remainder of the applicable Plan Year with no dollar limit. Your HRA balance will not be reduced by the amount of the catastrophic prescription drug claims; instead, your HRA balance will be automatically be increased to cover the cost of claims submitted and approved as Eligible Expenses for catastrophic prescription drug coverage. Expenses for medical care, as that term is defined in Code Section 213(d), to the extent the Plan is required to pay primary to Medicare during the first 30 months of end stage renal disease. The following are examples of expenses that may not be reimbursed from your HRA: Expenses incurred for qualified long-term care services; Expenses incurred for dental or vision insurance premiums, or dental or vision services even if such amounts might qualify as Code Section 213(d) medical expenses; Expenses that exceed your HRA balance, unless the expenses are reimbursable catastrophic prescription drug costs; and Expenses that have been reimbursed by another plan or for which you plan to seek reimbursement under another health plan. 3 For more information about what items may or may not be Eligible Medical Expenses, refer to IRS Publication 502 under the headings What Medical Expenses are Includible and What Expenses Are Not Includible. (Be careful in relying on this Publication, however, as it is specifically designed to address what medical expenses are deductible on Form 1040, Schedule A, not what is reimbursable under a health reimbursement arrangement.) 6

9 Only Eligible Expenses incurred by you including expenses for your Medicare-Eligible Dependents (or by your Medicare-Eligible Dependent in the case of a surviving Medicare-Eligible Dependent) while a Participant in the Plan may be reimbursed from your HRA. Eligible Expenses for medical care or prescription drugs are incurred when the medical care or prescription drugs are provided, not when you (or your Medicare-Eligible Dependent in the case of a surviving Medicare-Eligible Dependent) are billed, charged or pay for the expense. Health insurance premiums are incurred for the coverage period to which they apply. No other expenses are eligible for reimbursement under this Plan, even if they are for medical care, as that term is defined in Code Section 213(d). You may not obtain reimbursement of any Eligible Expenses incurred after the date your eligibility for the HRA ends. You have until the March 31 following the end of the year in which your eligibility ends, however, to request reimbursement of Eligible Expenses you incurred before your eligibility ended. If you need more information regarding whether an expense is an Eligible Medical Expense under the Plan, contact OneExchange at (866) Carryover of HRA Allocations If you do not use all of the amounts credited to your HRA during a Plan Year, those amounts will be carried over to subsequent Plan Years. Reimbursement of Eligible Expenses When you select coverage through OneExchange, most of the participating insurers allow you to choose to have premiums that are Eligible Expenses automatically reimbursed from your HRA, until the HRA funds are depleted. You can also submit a claim for premiums that are Eligible Expenses directly to OneExchange and be reimbursed from your HRA funds. To be reimbursed for Eligible Expenses, including premiums, medical care or catastrophic covered qualifying prescription drug expenses, you must complete a reimbursement form and mail or fax it to OneExchange at the contact information listed in the ERISA Plan Information section of this SPD. For catastrophic covered qualifying prescription drug expenses, you will also need to submit proof of the date you met the catastrophic coverage threshold, which will include a copy of your explanation of benefits or EOB. You can obtain a reimbursement form from OneExchange. Your claim is deemed filed when it is received by OneExchange. If your claim for reimbursement is approved, you will be provided reimbursement as soon as reasonably possible following the determination. You can choose to be reimbursed by direct deposit or check. Claims are paid in the order in which they are received by OneExchange. Any HRA payments that are unclaimed (e.g., uncashed benefit checks or unclaimed electronic transfers) will automatically be cancelled ninety (90) days after the check was mailed or the payment was otherwise attempted, and the amount will be restored and available for reimbursement from your HRA; however, HRA payments that are unclaimed for more than ninety (90) days following your termination of coverage in the HRA benefit will automatically be forfeited. Benefits Limitations and Overpayments Benefits do not vest under this Plan. Benefit payments are limited to the amount due under the Plan and late benefit payments will not include interest or penalties. If a benefit overpayment is made, you are required to promptly repay it. If you do not, the overpayment may be offset from future benefit payments, or, if that is not feasible, by withholding funds from any amounts due to you from the Employer. If all other attempts to recoup the overpayment/erroneous payment are unsuccessful, the Plan Administrator may treat the overpayment as a bad debt, which may have tax implications for you. 7

10 Benefit Claims and Appeals Initial Review. If your claim for reimbursement is wholly or partially denied, you will be notified in writing within 30 days after OneExchange receives your claim. If OneExchange determines that an extension of this time period is necessary due to matters beyond the control of the Plan, OneExchange will notify you within the initial 30-day period that an extension of up to an additional 15 days will be required. If the extension is necessary because you failed to provide sufficient information to allow the claim to be decided, you will be notified and you will have at least 45 days to provide the additional information. The notice of denial will contain: the reason(s) for the denial and the Plan provisions on which the denial is based; a description of any additional information necessary for you to perfect your claim, why the information is necessary, and your time limit for submitting the information; a description of the Plan s appeal procedures and the time limits applicable to such procedures; and a description of your right to request all documentation relevant to your claim. Appeal Review. If your request for reimbursement under the Plan is denied in whole or in part and you do not agree with the decision of OneExchange, you may file a written appeal. You should file your appeal with the Plan Administrator at the address provided in the ERISA Plan Information section of this SPD no later than 180 days after receipt of the denial notice. You should submit all information identified in the notice of denial, as necessary, to perfect your claim and any additional information that you believe would support your claim. You will be notified in writing of the decision on appeal no later than 60 days after the Plan Administrator receives your request for appeal. The notice will contain the same type of information provided in the first notice of denial provided by OneExchange. The Plan Administrator is the named fiduciary for benefit claims and appeals and has complete discretionary power and authority to make benefit determinations. A benefit is not payable unless the Plan Administrator says that it is. You are required to complete the claims and appeal procedure before you can bring a claim in federal court. After you have completed the claims and appeal procedure, you have a limited time to bring a claim in court. See the Limitation of Legal Action section below for more information. Participation Claims and Appeals If you believe that you have been improperly denied eligibility to participate in the Plan, enroll dependents or correct HRA allocations, you may file a Participation Claim with the Plan Administrator at the address provided in the ERISA Plan Information section of this SPD. Only you or your authorized representative (or a parent or guardian on behalf of a minor child) can pursue a claim for benefits under the Plan. Any authorized representative must be designated as an authorized representative in writing in a form acceptable to the Plan Administrator. A Participation Claim is a claim that relates to anything other than a claim for the payment of benefits that is made by a Claimant in accordance with the Plan s procedures for filing a Participation Claim. Participation Claim includes claims of eligibility to participate in the Plan and to correct Benefit Credits. Claim Submission. A Participation Claim must be submitted to the Plan Administrator in writing and include the reason why you believe that the Participation Claim is valid. Completion and submission of enrollment, coverage change or other forms required by the Plan Administrator satisfies these requirements. A Participation Claim must be made in the manner required by the Plan Administrator and within the period applicable to the type of claim at issue: A request to enroll in Plan coverage must be made within the retiree enrollment period required by the Plan. A request to correct the amount of a Benefit Credit must be made within 60 days of the date of the improper credit. 8

11 Initial Review. The Plan Administrator will provide its initial review determination to you within 90 days of receiving the Participation Claim. This period can be extended by up to 90 days in special circumstances, if notice is given to you. If a Participation Claim is denied in whole or part, the Plan will provide you with: the reason(s) for the denial and the Plan provisions on which the denial is based; a description of any additional information necessary for you to perfect your claim, why the information is necessary, and your time limit for submitting the information; a description of the Plan s appeal procedures and the time limits applicable to such procedures; and a description of your right to request all documentation relevant to your claim. Appeal Review. You must appeal an initial Participation Claim denial within 30 days of your receipt of the denial. The appeal must be in writing and include the reason why you believe that the Participation Claim is valid. You may submit written comments, documents, records, and other information to the Plan Administrator and the information will be considered on review regardless of whether it was submitted or considered in the initial review. The Plan will provide you with reasonable access to documents, records, and other information which are, in the judgment of the Plan Administrator, relevant to the Participation Claim. The Plan Administrator will provide its appeal review determination to you within 60 days of receiving the appeal of the denial of the Participation Claim. This period can be extended by up to 60 days in special circumstances, provided notice is given to you. If the Participation Claim is denied on appeal review, the Plan will provide written notice to you that includes the reason(s) for the continued denial. You are required to complete the claims and appeal procedure before you can bring a claim in federal court. After you have completed the claims and appeal procedure, you have a limited time to bring a claim in court. See the Limitation of Legal Action section below for more information. Benefits if I Die Your HRA is immediately forfeited upon death, but your estate or representatives may submit claims for Eligible Expenses incurred by the Eligible Retiree and his or her Medicare-Eligible Dependents before his or her death. Claims must be submitted within 180 days of his or her death. Please refer to the Surviving Spouse, Domestic Partners and Dependents section. Coordination of Benefits Only medical care expenses that have not been or will not be reimbursed by any other source may be Eligible Expenses (to the extent all other conditions for Eligible Expenses have been satisfied). You must first submit any claims for medical expenses to the other plan or plans before submitting the expenses to this Plan for reimbursement. Notices Conditions of Participation. Participation in the Plan by an Eligible Retiree is voluntary. As a condition of participation, each Eligible Retiree and Medicare-Eligible Dependent agrees to: 1. be bound by all of the terms and conditions of the Plan and, for an individual health insurance policy, the Insurance Policy; 2. make the contributions required; and 3. furnish such information and execute such instruments and forms as the Plan Administrator or OneExchange may request. Committing Fraud or Intentional Misrepresentation Against the Plan If you commit fraud or intentional misrepresentation of a material fact against the Plan (which may include enrolling someone in coverage, or submitting a claim for someone, who you know or should know does not qualify as your Medicare-Eligible Dependent, continuing enrollment of someone in coverage who you know or should know has lost 9

12 eligibility or filing a false claim) the Plan (or your Participating Employer) may take action, which may include the following: 1. Termination of Plan Coverage. Your coverage may be terminated. Coverage for the person you enrolled may be terminated. If you have committed fraud or made an intentional misrepresentation of a material fact, coverage may be terminated retroactively. 2. Repayment of Plan Benefits. You may be responsible for all benefits paid for a person who was not eligible for coverage or as a result of a false claim. 3. Notification of Law Enforcement. Law enforcement may be notified that you have committed intentional misrepresentation or fraud against the Plan. Limitation of Legal Action. No action with respect to eligibility to participate or for any benefit under this Plan may be brought more than six (6) months following the final decision in the final appeal review brought pursuant to the claim and appeal procedure set forth above, or for eligibility claims, the participation claims and appeals procedure described in this SPD. In no event can any action with respect to eligibility to participate or with respect to any benefit under this Plan be brought more than three (3) years after the date the event giving rise to the claim occurred. Choice of Venue. All litigation in any way related to the Plan (including but not limited to any and all claims brought under ERISA, such as claims for benefits and claims for breach of fiduciary duty) must be filed in the United States District Court for the District of Minnesota. No Guarantee of Tax Consequences. Although Ecolab intends to provide certain Plan benefits on a tax-free basis, Ecolab does not guarantee that the benefits are tax-free or the tax consequences to you. You are responsible to pay any local, state or federal taxes that you owe as a result of your Plan participation or receipt of Plan benefits. Availability of the Plan s HIPAA Notice of Privacy Practices. You can obtain a copy of the Plan s HIPAA Notice of Privacy Practices, which describes your privacy rights under the Health Insurance Portability and Accountability Act of 1996, from the Plan Administrator or from the Insurer for an insured benefit. The separate HIPAA Plan amendment is part of the Plan document. Qualified Medical Child Support Orders. The Plan Administrator will determine whether an order requiring the Plan to provide group health coverage to a child is a Qualified Medical Child Support Order ( QMCSO ). You can obtain a copy of the QMCSO procedures on request and free of charge from the Plan Administrator. If you are not enrolled, you will be required to enroll in order to enroll your child pursuant to a QMCSO. You must pay the premium required for coverage. In addition, the Plan will allow reimbursement of Eligible Expenses for a child of yours (as defined by applicable state law) in accordance with a QMCSO to the extent the QMCSO does not require coverage not otherwise offered under this Plan. The Plan Administrator will make a determination as to whether the order is a QMCSO in accordance with the Plan s QMCSO procedures. The Plan Administrator will notify both you and the affected child once a determination has been made. You may request a copy of the Plan s QMCSO procedures, free of charge, by contacting the Plan Administrator at the address listed in the ERISA Plan Information section of this SPD. COBRA Continuation Coverage. Under a federal law called COBRA, a Medicare-Eligible Dependent under the Plan, such as the spouse, former spouse or dependent child of a Participant, who has an individual HRA under the Plan and who loses coverage due 10

13 to the Employer s bankruptcy, or a dependent child who has an individual HRA under the Plan and loses coverage due to no longer being a Medicare-Eligible Dependent, may elect to continue coverage under the Plan for a limited time after the date they would otherwise lose coverage. These are called qualifying events. Ecolab applies these COBRA rules to domestic partners as well. Note that the Medicare-Eligible Dependents are required to notify the Plan Administrator in writing of a dependent child losing dependent status within 60 days of the event or they will lose the right to continue coverage under the Plan. If a Medicare-Eligible Dependent elects to continue coverage, he or she is entitled to the level of coverage under the Plan in effect immediately preceding the qualifying event. He or she may also be entitled to an increase in his or her HRA equal to the amounts credited to the HRAs of similarly situated Participants (subject to any restrictions applicable to similarly situated Participants) so long as he or she continues to pay the applicable premium. In order to continue coverage, the qualified beneficiary must pay a monthly premium equal to 102% of the cost of the coverage, as determined by the Plan Administrator. The Plan Administrator will notify qualified beneficiaries of the applicable premium at the time of a qualifying event. Coverage may continue for up to 36 months following the qualifying event, but will end earlier upon the occurrence of any of the following events: The date the qualified beneficiary s HRA is exhausted; The date the qualified beneficiary notifies the Plan Administrator that he or she wishes to discontinue coverage; Any required monthly premium is not paid when due or during the applicable grace period; The date, after the date of the qualified beneficiary s election to continue coverage, that he or she becomes covered under another group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of the qualified beneficiary; or The Employer ceases to provide any group health plan. If you lose coverage due to a COBRA qualifying event (such as bankruptcy of the employer), COBRA continuation coverage may be elected to temporarily continue coverage as provided in this section. You must notify Ecolab Human Resources in writing within 60 days of a qualifying event (other than bankruptcy of the employer) that results in a loss of coverage. If you do not notify Ecolab within 60 days, COBRA continuation coverage rights will be lost. Any covered Eligible Retiree or Eligible Dependent who loses Plan coverage as a result of a qualifying event will be eligible to elect to temporarily continue Plan coverage under a federal law called COBRA as described below. For Eligible Retirees, the only qualifying event is bankruptcy of the employer. For dependent children who are covered under the Plan, the qualifying events are: (1) loss of Eligible Dependent status under the Plan; or (2) the bankruptcy of the retiree s employer. For a surviving Medicare-Eligible Spouse/Domestic Partner, the only qualifying event is Employer bankruptcy. Maximum COBRA Coverage Period. The continuation coverage period for a covered dependent is up to 36 months from the date of the qualifying event if coverage under the Plan would otherwise terminate due to a qualifying event. If your qualifying event was bankruptcy of the Employer and your Employer (or any employer in a controlled group of which the Employer was part) maintains a group health plan, your coverage can generally be continued under that group health plan until you die, and coverage for your dependents can generally be continued for up to 36 months from the date of your death. The maximum COBRA coverage periods described above will not be extended even though coverage under the Plan is continued unintentionally, resulting in a delay in termination of coverage, or the Employer reduces or subsidizes, in whole or in part, the premium an individual is required to pay for COBRA coverage. The continuation coverage periods described above are maximum periods that will be reduced as described below. 11

14 You Must Provide Notice to the Plan Administrator of Certain Events. There are four instances in which you are required to notify the Plan Administrator or COBRA Administrator of an event. They are below. If you fail to provide the required notice within the period noted below, the right to elect to continue coverage will be lost. The notice must be in writing, must contain the information described below, and must be mailed by first class mail, postage prepaid. You or your covered dependent must notify the COBRA Administrator of your child s ceasing to qualify as a dependent under the Plan within 60 days of the date of the qualifying event. If the COBRA Administrator is not given the required notice within 60 days, any right to continue coverage will be lost. The notice must contain the following information: The name and address of the retiree; The name and address of each dependent covered by the Plan; A description of the qualifying event; The date of the qualifying event; and A reference to the HRA component of the Plan under which the affected individuals are covered. Type of COBRA Coverage Available. An individual electing COBRA continuation coverage may elect to continue the Plan coverage in effect immediately before the qualifying event. If, however, the coverage provided to similarly situated retirees is eliminated and the Employer continues to maintain other medical coverage, the individual will have the right to elect that coverage. While the individual can only elect to continue health care coverage he or she had at the time of the qualifying event, as long as he or she continues the coverage, he or she will have the same coverage options that he or she would have had if the qualifying event had not occurred. Who May Elect COBRA Coverage. If you are eligible for COBRA coverage, you can make the election for yourself and for any one or more of your dependents who are eligible for COBRA coverage. If you do not make the election, your Spouse or Domestic Partner can make the election for himself or herself and any covered Dependent Child. Finally, if none of you, your Spouse, or your Domestic Partner make the election for a covered Dependent Child, the dependent may make the election for himself or herself. Impact of COBRA on other Federal Law Rights. In considering whether to elect continuation coverage, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse s employer) within 30 days after your group health coverage ends because of a qualifying event. You will also have the same special enrollment right at the end of the continuation coverage period if you get continuation coverage for the maximum time available to you. COBRA Election Period. After a qualifying event or receiving notice of a qualifying event (if notice is required), the COBRA Administrator will send a notice regarding COBRA election rights to individuals eligible for COBRA. The individuals will have 60 days from the date of such notice (or from the date coverage would otherwise terminate because of the qualifying event, if the coverage would stop after the notice is sent) in which to file a written election to continue your coverage. If the individual does not file the required election form within this 60-day period, he or she will lose the right to continue coverage under the Plan. The election form must be submitted to the address specified in the election form. COBRA Premium. You (or your dependent) must pay the full premium, plus a 2% administration fee, for any coverage you continue. (The charge will be higher for coverage extended on account of disability.) The premium will be the same premium that would be paid for a person in your situation with respect to whom no qualifying event had occurred (but will include any portion the Employer normally pays). The first premium payment, covering the period between the date coverage would otherwise stop and the date of the payment, must be made within 45 days after the date you file the election to continue coverage. Subsequent premiums are due monthly on the day of the month coverage would have stopped if COBRA continuation had not been elected, and coverage will end if your or your dependent fails to pay the premium for any month within 30 days after the due date. 12

15 No COBRA Coverage Pending Election or Payment. You will not have COBRA coverage until you have elected the coverage and made the required premium payment. Once you make the election and pay the premium, coverage will be reinstated retroactively to the date you lost your coverage. Termination of Coverage. The continuation coverage will terminate when the first of the following events occurs. 1. The 36-month maximum continuation period ends. 2. You fail, or your dependent fails to pay the initial premium within 45 days after your election, in which case you will be treated as not having elected to continue your coverage. 3. You fail, or your dependent fails to pay any other premium within 30 days after it is due, in which case your coverage will end as of the end of the last period for which you made a timely premium payment. 4. After electing continuation coverage, you become, or your dependent becomes covered by any other group health plan that does not limit or exclude coverage because of a preexisting condition. Coverage already in place at the time of the continuation coverage election will not cause termination of continuation coverage. 5. The Employer ceases to provide group health benefits to any of its retirees. 6. The continuation coverage is terminated for cause (e.g., you commit fraud against the Plan). If You Have Questions. Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the Plan Administrator (see contact information below) or the COBRA Administrator. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) Keep the Plan and COBRA Administrator Informed of Address Changes. To protect your family s COBRA continuation rights, you should keep the Plan and COBRA Administrator informed of any changes in the addresses of family members. Keep Copies of Any Notices You Send to the Plan or COBRA Administrator. You should also keep a copy, for your records, of any notices you send to the Plan and COBRA Administrator. Subrogation and Reimbursement Insured vs. Self-insured. Subrogation and reimbursement under an individual health insurance policy will be as provided in the Insurance Policy. This section applies to the self-insured HRA. Subrogation and Reimbursement Rights. Subrogation is the substitution of one person or entity in the place of another with reference to a lawful claim, demand or right. Immediately upon paying or providing any benefit, the Plan shall be subrogated to and shall succeed to all rights of recovery, under any legal theory of any type for the reasonable value of any services and benefits the Plan provided to participants, from any or all of the following listed below. In addition to any subrogation rights and in consideration of the coverage provided by this Summary Plan Description, the Plan shall also have an independent right to be reimbursed by participants for the reasonable value of any services and benefits the Plan provides to participants, from any or all of the following listed below: 1. Third parties, including any person alleged to have caused a participant to suffer injuries or damages. 2. Any person or entity who is or may be obligated to provide benefits or payments to a participant, including benefits or payments for underinsured or uninsured motorist protection, no-fault or traditional auto insurance, medical payment coverage (auto, homeowners or otherwise), workers compensation coverage, other insurance carriers or third-party administrators. 3. Any person or entity who is liable for payment to a participant on any equitable or legal liability theory. These third parties and persons or entities are collectively referred to as Third-Parties. 13