NationalONE VEBA Overview. (includes comparison to NationalONE plan)

Transcription

1 NationalONE VEBA Overview (includes comparison to NationalONE plan) July 2014 June 2015

2 The VEBA Trust The VEBA Plan is short for Voluntary Employee s Beneficiary Association Plan. This plan allows for you to manage your rising health care costs. You are given a high deductible health insurance plan with the financial assistance of a VEBA trust account. Your employer contributes money to the VEBA trust account to help with your health care expenses. As you use services, you can use the funds in your VEBA trust account to pay for these expenses. VEBA is a tax free trust in which your employer will be depositing contributions on your behalf to the VEBA Trustee, TrustPoint Deposits will be invested into a money market mutual fund to avoid risk, but allow for interest to be earned Enrollment in the VEBA is automatic; if you elect the high deductible medical plan, you are enrolled. Page 2

3 Contributions Teachers Effective July 1, 2014 contributions to the $2000/$4000 VEBA trust account will be 80% of deductible For employees with Single coverage the contribution is $1,600 annually ($500 deposited in VEBA account July 2014 with deposits of $100 each month thereafter through June 2015) For employees with Family coverage the contribution is $3,200 annually ($1000 deposited in VEBA account July 2014 with deposits of $200 each month thereafter through June 2015) Food Service Effective July 1, 2014, contributions to the $1150 VEBA plan will be $ annually for single coverage and $1, annually for family coverage. The contributions will be deposited in equal monthly installments. *Contribution amounts for all employees will be prorated and administered as applicable due to coverage changes, hire and termination dates. Page 3

4 How does the reimbursement process work? 1. You seek medical care and the provider submits the claim to HealthPartners. 2. HealthPartners applies discount, verifies deductible and sends you and the provider an Explanation of Benefits (EOB). 5. CHS processes claim, sends money to you and you pay your provider. 3. If deductible is not met, the provider sends you a bill. 4a. Complete a VEBA claim form, attach a copy of the EOB, send to CHS for processing. 4b. Use your Benny Card to pay bill, eliminates Step 5. Page 4

5 The VEBA Trust The plan year for the VEBA runs from July 1 through June 30, with a period of 90 days afterwards to submit expenses for that prior period called the run-out period. Money that remains in your account at the end of the plan year will be rolled into the next plan year after the run-out period has expired. Eligible expenses are the same as your Health Flexible Spending plan. Reimbursements are made by completing a claim form, attaching the proper documentation. Typically this is an Explanation of Benefit (EOB) and submitting to Corporate Health Systems (CHS). You can elect to receive your reimbursement funds either by check, directly deposited into your checking/saving account or may you elect a Benny Card. A Benny card allows you to pay for your eligible expenses using a debit card. The card deducts each payment directly from your VEBA account. There is a $18/plan year administrative fee. Page 5

6 The VEBA Trust The monthly administration fee is $3.09/month and will be deducted quarterly from the VEBA trust account. You can check your account information via the CHS website ( which contains your election, deposits, interest earned, claims, payments, summary plan descriptions, reimbursement schedule, claim forms and an extensive listing of eligible expenses. In the event you leave the District VEBA health plan with money in your account, your will be able to continue to submit claims for medical expenses until the balance is exhausted. In the event of the death of the participant with money in your account, your tax dependents will be able to continue to submit claims for medical expenses until the balance is exhausted. Page 6

7 Next Steps If you want to enroll in the high deductible medical plan with the VEBA trust, you need to access the District s on-line enrollment system and select NationalONE VEBA Plan. (Note the specific name of the plan will depend on your bargaining unit) CHS will send you a welcome mailing which includes a confirmation of your election, a claim form, envelope, reimbursement schedule, pin number for accessing the website How To Contact Corporate Health Systems Website: Claim Processor: Renee Heggelman rheggelman@corphealthsys.com Phone: ext 125 Fax: Page 7

8 Assumption that the average office visit costs $110 Remember: Routine Preventative Physicals are covered 100% under all plans Plan has a prescription copay of $8 generic preferred, $16 brand preferred and $32 non preferred; an office visit copay of $25 and a $200 per person deductible (maximum of $400 per family). The Teacher VEBA plan has a deductible of $2,000 per person and a maximum of $4,000 per family. Page 8

9 Mary is a single, healthy female who takes advantage of preventive care visits. In a typical year, she usually sees the doctor twice. She has a preferred brand prescription for Singulair that costs $120 (retail) and is filled twice per year Plan 2000/4000 VEBA* ($1600 VEBA Trust) *Annual premiums $871 $394 Office visits $50 $220 Rx drugs $32 $240 Total estimated maximum costs $953 $854 Reimbursable expenses in VEBA n/a $460 Cost after VEBA reimbursement $953 $394 VEBA Balance n/a $1140 *Based on 12 months of VEBA participation Page 9

10 Scenario 2: Teachers High Healthcare User-Family Cindy s family includes two children under the age of 6 and her husband. During the year there are a total of 15 visits to the doctor and 2 prescriptions per month between all the family members. The prescriptions filled included 12 preferred generic and 12 preferred brand ($1,500 total retail cost) Plan 2000/4000* VEBA Plan ($3200 VEBA Trust) *Annual premiums $4,675 $2,337 Office visits $375 $1,650 Rx drugs $288 $1,500 Total estimated maximum costs $5,338 $5,487 Reimbursable expenses in VEBA n/a $3,150 Cost after Employer VEBA reimbursement $5,338 $2,337 VEBA Balance n/a $50 *Based on 12 months of VEBA participation Page 10

11 HEALTH REIMBURSEMENT ARRANGEMENT(HRA) with VOLUNTARY EMPLOYEE BENEFICIARY ASSOCIATION (VEBA)

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13 Plan Outline Administrator: Corporate Health Systems, Inc. Local Phone: (952) Toll Free Phone: (888) Website: Plan Year: July 01 June 30 Employee Eligibility: Waiting Period for Enrollment: (Time employee must wait before being eligible to enroll) Initial Enrollment Period: (Time frame after the waiting period during which employee must enroll) Coverage Termination Date upon loss of eligibility: Employees who are eligible for and enrolled in one of the following high deductible health plans: VEBA $ % VEBA $ % You will be automatically enrolled if you are an eligible employee 30 days Employer contributions cease the day a participant loses eligibility. Expenses can be submitted against the participant s account balance until the participant s account balance reaches zero Percent of Unused Balance that rolls over into the next plan year: 100% Annual Employer HRA Contribution: Employer HRA Contribution Funding: HRA Run-Out Period: (This is the number of days after the end of a plan year you have to file a claim that was incurred within the plan year) To be determined by the District Last day of each month 90 days

14 Commonly Asked Questions What is HRA? HEALTH REIMBURSEMENT ARRANGEMENT ~Allows reimbursement of your un-reimbursed health, dental and optical expenses and is funded by your employer. You may also seek reimbursement for premiums for Medicare Part A and Part B, Medicare Supplement Plans and COBRA continuation. How do I enroll? You can enroll during your company s annual open enrollment period which is typically during the 1-2 months prior to your employer s Plan Anniversary Date (you will be notified with exact dates). The ONLY other opportunity you may have to make or change an election is if you experience a Family Status Change. How are the HRA rules determined? The IRS determines the rules and regulations for the HRA. All HRA s must meet IRS Revenue Rulings and IRS Notice and be in accordance with Sections 105 and 106 of the Internal Revenue Code of 1986 and with Revenue Ruling (June 26, 2002). Where are the funds held? The funds are held in a VEBA 501(c) (a) trust account managed by Trust Point and invested in an interest earning money market account. Are my HRA expenses coordinated with my Flexible Spending Health Care account? Yes. If you participate in the Flexible Spending Health Care account, expenses must first be submitted and processed under the Flexible Spending Health Care account and those monies exhausted prior to reimbursement under the HRA account. When are HRA funds available to me for reimbursement? Once your Flexible Spending Health Care account is exhausted (if applicable), you can be reimbursed for money which your employer has already contributed to your HRA account. If your employer has not yet contributed an amount equal to your claim, Corporate Health Systems will reimburse you up to the amount contributed, pending the remaining amount until further contributions have been made. The remainder of the claim, up to the deposited amount, will be paid out automatically until the entire claimed amount has been reimbursed. How do I get information regarding my HRA Account? Go to to view your account s claim history, account balance and payment history. Claim forms can also be printed from the website. Your user ID and PIN number will be mailed to your home. Your account information can only be accessed with these codes. You can also contact your Corporate Health Systems Benefit Administrator. To view additional frequently asked questions please go to and open the LINKS tab on the home page. What happens to money I do not use by the end of the plan year? If you do not have claims that equal or exceed the amount of the annual contribution, your remaining funds will be moved to the next plan year and will be available to you for reimbursement after the plan run-out period has been exhausted. This summary is only an outline of general information. It is not a contract for coverage. Please refer to your summary plan description or certificate for detailed information

15 Commonly Asked Questions Continued Is there an alternative way to be reimbursed? Yes, the debit card is an alternative to traditional reimbursement methods. While it does not completely eliminate reimbursement claim forms, it can significantly reduce them. When used for expenses such as office visit and prescription co pays, which make up 55% of all claims, a claim form will not be required. You may be asked to provide documentation of the expense, if the expense cannot be auto-adjudicated. Simply swipe your card at an eligible location such as pharmacies, physician or dental offices and the funds are directly withdrawn from your HRA Account and auto-adjudicated eliminating all out of pocket expenses and reimbursement waiting periods. Corporate Health Systems may request documentation for claims paid using the debit card that cannot be autoadjudicated. Corporate Health Systems will request that you submit documentation to support your purchase via . You then submit your receipt and a copy of the to Corporate Health Systems and your claim will be processed without your completing a traditional reimbursement claim form. If you do not submit the required documentation, your debit card will be deactivated and the expense paid using the debit card will be deducted from your paycheck. It is important that you retain documentation for ALL claims, regardless of the reimbursement method. Where can I use my Debit Card? The IRS now requires that the Debit Card can only be used at health care providers who have a health care-related merchant category code (such as physicians, dentists, vision care offices, hospitals, and other medical care providers) or at grocery stores, discount stores and pharmacies who utilize an Inventory Information Approval System (IIAS). You may not use the Debit Card at any merchant, including pharmacies, that does not have a health care related merchant category code unless that merchant or pharmacy utilizes an IIAS. When utilizing an IIAS, the Debit Card may be used to purchase only those items identified on a list of eligible medical expenses maintained by the merchant. When purchasing eligible health care-related items AND ineligible non-health care-related items, the merchant will only accept the Debit Card as payment for the health care-related items. You must pay for the ineligible items with another form of payment (cash, personal credit or debit card, etc). In rare circumstances, purchases made at merchants utilizing an IIAS may fail to process appropriately. In those cases, you will be required to submit substantiating documentation as described below. You must maintain proper documentation for purchases made with your Debit Card. A list of merchants utilizing an IIAS is available in the LINKS tab on the home page online at Please note that some merchants, including Walgreens, have implemented a custom IIAS solution and do not appear on this list. Please remember to keep documentation for all purchases made with the Debit Card. Per IRS regulations, we may be required to request itemized receipts to verify the eligibility of purchases made with the card. Valid documentation of a purchase must include the dollar amount, date of service, name of provider, and a description of the purchased service or product. For over-the-counter health care items, the name of the product must be listed on the receipt. Any receipt that does not contain the detailed information described above is not acceptable. Credit card receipts are not acceptable. If the requested receipt is lost or otherwise unavailable, most providers can provide a detailed statement documenting HRA eligible purchases. Important point to remember: You cannot use your Debit Card at stores that do not participate in IIAS, even if you have used your Debit Card at these stores before. (Your transaction will be declined.) This summary is only an outline of general information. It is not a contract for coverage. Please refer to your summary plan description or certificate for detailed information.

16 Commonly Asked Questions continued: How do I submit a claim? To be reimbursable, the Participant must have incurred an eligible expense after his/her entry date into the plan. An expense is incurred when the Participant is provided with the care giving rise to the expense, not when the service is billed or paid. Reimbursement shall not be made for future projected expenses. Complete a Request for Reimbursement claim form and submit an ITEMIZED BILLINGS for each line you have filled out. Receipts must include the following information: Nature of the expense the specific service that was provided (not payment on accounts) Date of service when the service happened (not when the service was paid for) Person receiving service (can be an eligible dependent) Amount of the service Name of the provider clinic name and/or doctor s name and address If any of these requirements are not met, the line missing the documentation cannot be paid until the corrected portion is received. All other lines with correct documentation will be paid. The IRS regulates the requirements for documentation. All claims must be incurred during the plan year. Claims incurred outside of the plan year, before your enrollment date or after your participation terminates, will not be reimbursed. Claim forms and documentation must be mailed, faxed or ed to: Corporate Health Systems, Inc. PO Box: Eden Prairie, MN Fax: (952) rheggelman@corphealthsys.com Now you have the ability to enter your claims via the CHS Website. Simply Go to 1. On the Home Page, you may simply select the I want to File a Claim button 2. Enter your claim information, and upload the receipt, on the form that appears and click Add Claim. The claim is then added to the Claims Basket. 3. When all claims are entered in the Claims Basket, click Submit to send the claims for processing. 4. The Claim Confirmation page displays. You may print the Claim Confirmation Form as a record of your submission. If you did not upload a receipt, print another Claim Confirmation Form to submit to CHS, attaching the required receipts. OR if a receipt is required, you will see the Upload Receipt link. Click on it and the Receipts Needed screen displays. 5. For each claim that requires a receipt, click Upload Receipt on the far right and follow instructions. (Your receipt must be in pdf, jpg, or gif format.) 6. The Receipt Uploaded confirmation appears: Your receipt has been uploaded. You may upload additional receipts if needed until the claim is approved. 7. After uploading, you may also click View Confirmation and print the form for your records. When must a claim be incurred in order to be eligible? All claims must be incurred during the plan year. Claims incurred outside of the plan year, before your enrollment date or after your participation terminates, will not be reimbursed. This summary is only an outline of general information. It is not a contract for coverage. Please refer to your summary plan description or certificate for detailed information.

17 Eligible HRA Expenses The HRA covers a variety of health care services that may not be included in certain medical and dental insurance plans. All medical, dental and optical expenses that qualify as medical deductions under IRS rules will qualify for reimbursement under this plan. Below is a short list of example expenses; both allowable and not allowable. HRA EXPENSES ALLOWED: Dental and Orthodontic Care: Artificial teeth or dentures Braces, orthodontic devices Therapy and Treatments: X-ray treatments Speech therapy Alcoholism treatment Drug therapy treatment Legal sterilization Acupuncture Physical therapy treatment Vaccinations Hair transplant (if medically necessary) Electrolysis (if medically necessary) The cost of a weight loss program (only to treat obesity as prescribed by a physician) Fees and Services: Physicians fees Hospital services fees Services of chiropractors Christian Science practitioner Services connected with donating an organ Hearing Expenses: Hearing aids and batteries Eye Care: Eyeglasses Contact lenses Contact Solution Lasik surgery Medical Equipment: Wheelchair or autoette (cost of operating/maintaining) Excess cost of orthopedic shoes over cost of ordinary shoes Crutches (purchased or rented) Excess cost of special mattress prescribed to alleviate arthritis Prescribed oxygen equipment and oxygen used to relieve breathing problems Support hose (if medically necessary) Artificial limbs Insurance Premiums: Health and dental Insurance (including individual and nonemployer sponsored coverage and including continuation premiums Long Term Care Insurance Co-Payments: Health insurance out-of-pocket Dental insurance out-of-pocket Prescription medication copayments Assistance for individuals with disabilities: Cost of guide for the visually impaired Special devices, such as tape recorder and typewriter, for the visually impaired Costs of equipping automobile Cost of Braille books and of regular editions Seeing Eye Dog Psychiatric Care: Services of psychotherapists, psychiatrists and psychologists Physical Exams Prescription & Over-the-counter medications: Prescription co-payments Over-the-counter medications used to treat a medical condition (with doctor s prescription) HRA EXPENSES NOT ALLOWED: Illegal medication Mechanical exercise device not prescribed Vacuum cleaner purchased by an individual with dust allergy Expenses of divorce when doctor or psychiatrist recommends divorce Sunglass clips Life Insurance premiums Contributions to State disability funds Maternity clothes Insurance against loss of income, life, limb or eyesight Distilled water purchased to avoid drinking fluoridated city water supply Mobile telephone used for personal calls as well as calls to physician Treatments unrelated to a specific problem (for example, massage for general well-being) Marriage counseling Nursemaids or practical nurses in charge of healthy infants Cosmetic procedures Over-the-counter supplements/vitamins or other substances related to general good health. THE IRS WILL CHANGE THIS LIST FROM TIME TO TIME. FOR A COMPLETE AND CURRENT LISTING OF HEALTH EXPENSES SEE IRS PUBLICATION 502.

18 Eligible Over-the-Counter Medications What documentation is required when I submit an Over-the-Counter medication expense? The nature of the expense the name of the medication must be on the receipt OR a copy of the packaging (i.e. box) must be attached to the claim form Date of Service Amount of service Name of the provider Prescription from your physician, if required Why are certain items not reimbursable? All reimbursable items must meet the definition of Medical Care in particular, the medication must cure, mitigate, treat or prevent or affect the structure or function of the body. Certain items (as listed toward the bottom of this page) do not meet this definition of Medical Care. What if I wish to be reimbursed for items not on these lists? Contact Corporate Health Systems for additional information regarding reimbursable Over-the-Counter medications. OVER-THE-COUNTER EXPENSES ALLOWED: (The items below do not represent a complete list) Band-Aids, bandages, gauze Birth control Catheters Cold pack Condoms Contact lens supplies & solutions Denture adhesives Diagnostic tests & monitors Elastic bandages & wraps First aid kits Hot pak Incontinence supplies Insulin & diabetic supplies Ostomy supplies Pedialyte for dehydration Reading glasses Rubbing alcohol Wheelchairs, walkers & canes OVER-THE-COUNTER EXPENSES ALLOWED ONLY WITH A DOCTOR S PRESCRIPTION: (The items below do not represent a complete list) Acne Treatments Allergy & sinus medicine Antacids Antibiotic products Anti diarrhea medicine Anti-gas Anti-itch & insect bite Anti-parasitic treatments Aspirin Baby rash ointments & creams Bactine Bee Sting kits Bug bite ointments Calamine lotion Carmex/Blistex/Medicated lip balms Cold medicine Cough drops, lozenges Diaper rash ointments Digestive aids Feminine anti-fungal / anti-itch First aid cream Hemorrhodial preps Lactaid for lactose intolerance Laxatives Menstrual cycle products for pain Motion Sickness pills Muscle pain creams Nasal strips medicated/vapor only Nicotine gum and patches Pain reliever Respiratory treatments Sinus sprays Sleeping aids & sedatives Sunburn ointment Suppositories Visine eye Wart remover THE IRS WILL CHANGE THIS LIST FROM TIME TO TIME. FOR A COMPLETE AND CURRENT LISTING OF HEALTH EXPENSES SEE IRS PUBLICATION 502.

19 Eligible Over-the-Counter Medications Continued OVER-THE-COUNTER EXPENSES ALLOWED ONLY WITH A DOCTORS NOTE: These items would not normally be eligible for reimbursement under your HRA plan, but, could be if used to treat a specific medical condition. The IRS requires a letter from your attending physician stating your medical condition and also stating that the following item is being prescribed for treatment of that condition. (The items below do not represent a complete list) Acne Treatments Feminine hygiene products St. John s Wart for depression Weight loss medications Fiber supplements for constipation Glucosamine/Chondroitin for arthritis Hormone therapy for menopause Lactaid for lactose intolerance Orthopedic shoes Sunscreen for cancer Prenatal vitamins OVER-THE-COUNTER EXPENSES NOT ALLOWED: (The items below do not represent a complete list) Chapstick Face creams and moisturizers Vitamins* Cosmetics Food, food replacements Toiletries Dietary supplements Medicated shampoos and soaps Toothbrush/toothpaste * Vitamins would not normally be eligible for reimbursement under your HRA plan, but, could be if used to treat a specific medical condition. The IRS requires a letter from your attending physician stating your medical condition and also stating that the vitamin is being prescribed for treatment of that condition. THE IRS WILL CHANGE THIS LIST FROM TIME TO TIME. FOR A COMPLETE AND CURRENT LISTING OF HEALTH EXPENSES SEE IRS PUBLICATION 502.

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21 ISD # Reimbursement Schedule Reimbursement Request Deadline Date **Reimbursements Distributed By 07/15/ /22/ /31/ /07/ /15/ /22/ /29/ /05/ /15/ /22/ /30/ /07/ /15/ /22/ /31/ /07/ /14/ /21/ /26/ /03/ /15/ /22/ /30/ /06/ /15/ /22/ /30/ /06/ /13/ /20/ /27/ /06/ /13/ /20/ /31/ /07/ /15/ /22/ /30/ /07/ /15/ /22/ /29/ /05/ /15/ /22/ /30/ /07/ /31/2015* 08/07/2015* 08/31/2015* 09/04/2015* 09/30/2015* 10/07/2015* Claims must be received by the end of the day on the Reimbursement Request Deadline Date in order to be paid on the Reimbursements Distributed By Date. For employees electing to have Direct Deposit, your reimbursement is deposited on the Reimbursements Distributed By Date. If you choose to have a standard check mailed to you, the check is mailed on the Reimbursements Distributed By Date. * If your employer renews their flex contract with CHS for the next plan year, that year s reimbursement schedule will be used for reimbursement distribution dates: if not, the dates listed above will be used. If you have unused HRA money from the previous plan year, that money will not be available for claims in the new plan year until the run out period of the previous plan year is complete. **If the Reimbursements Distributed by date conflicts with a holiday, your reimbursement will be mailed the next working day.

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23 Corporate Health Systems, Inc. Reimbursement Account Authorization Form AUTOMATIC DIRECT DEPOSIT EMPLOYEE NAME: (Last) (First) (MI) TELEPHONE NUMBER: ( ) SOCIAL SECURITY NUMBER: EMPLOYER: DIVISION OR LOCATION: FINANCIAL INSTITUTION: BRANCH: CITY: STATE: ZIP: CHECKING (Attach a Voided Check) SAVINGS For Savings Only: indicate 9-digit Routing/Transit Number For Savings Only: indicate Accounting Number I hereby authorize Corporate Health Systems, Inc. to deposit reimbursements from my Reimbursement Account directly into my checking or savings account indicated above. I also authorize the financial institution named above to accept my deposits and to credit the amount to my account. This authority will remain in effect until Corporate Health Systems, Inc. has received written cancellation notice from me in such time and such manner as to afford my employer a reasonable opportunity to act upon it. Date: Signature: Please note: The first time a reimbursement is made on an Automatic Direct Deposit basis, your financial institution will process the reimbursement as a trial run. The funds will not actually be deposited to your account. Instead you will be issued a reimbursement check that you will have to cash and deposit yourself. After the trial run all subsequent reimbursements will be deposited directly into your account. Remember to attach a voided check if you want deposits made to your checking account. AUTOMATIC DIRECT DEPOSIT Another Convenient Feature of Your Reimbursement Account You have the option to have your Reimbursements automatically deposited into your checking or savings account. This added service is designed to save you time handling your reimbursements from the plan. Instead of receiving a check for your Reimbursement, which you need to take to your bank or credit union to deposit, you will receive a notification stating the amount that has been deposited directly into your checking or savings account. You will continue to receive the flexible spending account summary highlighting the activity of your Reimbursement account(s) from Corporate Health Systems, Inc. To sign up for Automatic Direct Deposit: Fill out the form completely, including: your name, Social Security number, telephone number, name and location of your financial institution and the name of your employer, including your division or location. Mark the appropriate box to indicate whether your Reimbursements will be deposited to your checking or savings account. If Savings, please indicate the 9 digit Federal Routing/Transit Number of your account. Attach a voided check to the form if you want Reimbursements deposited in your checking account. Sign the form and mail it along with the voided check to: Corporate Health Systems, Inc. P.O. Box Eden Prairie, MN If you participated in this option with Corporate Health Systems, Inc. last plan year and your banking information has not changed, you do not need to complete this form again as your banking information is still on file.

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25 REQUEST FOR REIMBURSEMENT Instructions: FAILURE TO COMPLETE ALL SECTIONS OF THE FORM MAY DELAY THE PROCESSING OF YOUR CLAIM. Please print or type the requested information. For all types of claims, complete Part I of the form. Complete Part II for any medical/dental/optical/over the counter type of expenses. Complete Part III for any dependent daycare expense. You MUST document each expense by either attaching itemized receipts or have the provider complete the provider certification section (daycare only). Attach copies (do not send originals) of the receipts for each expense showing who the service is for, the provider or store name, the incurred date (not paid date), the amount, and the nature of the expense. If you are submitting more than one expense, number the receipt copy to correspond to the line number on which the expense is listed. Sign and date the form. Please make a copy of this form for your records and send the original with attached receipts to: Corporate Health Systems, Inc. Attn: Reimbursement Claims P.O. Box Eden Prairie, MN or Fax to (952) ~ Phone (952) PART I EMPLOYEE INFORMATION EMPLOYEE NAME EMPLOYER NAME LAST 4 DIGITS OF SOCIAL SECURITY NUMBER ADDRESS CITY / STATE / ZIP CHECK IF NEW ADDRESS PART II MEDICAL / DENTAL / OPTICAL / OVER THE COUNTER EXPENSES LINE 1 PERSON RECEIVING SERVICE PROVIDER S NAME (Doctor, Dentist, Etc.) OVER THE COUNTER PRODUCTS (Store Name) SERVICE DATE (MO/DAY/YR) REQUESTED AMOUNT NATURE OF EXPENSE OR NAME OF PRODUCT OFFICE USE TOTAL AMOUNT REQUESTED: PART III DEPENDENT DAYCARE EXPENSES LINE DEPENDENT S NAME WHO IS RECEIVING THE SERVICE SERVICE DATE RANGE REQUESTED AMOUNT AGE OF DEPENDENT PROVIDER S CERTIFICATION SIGNATURE AND EXPENSE AMOUNT DAYCARE PROVIDER S NAME (MO/DAY/YR - MO/DAY/YR) 1 /$ 2 /$ 3 /$ 4 /$ 5 /$ OFFICE USE TOTAL AMOUNT REQUESTED: I certify the above information is correct and the expenses claimed were incurred by me or my eligible dependents after my effective date of coverage in my employer s reimbursement benefit plan but prior to the end of my employer s plan year. I certify these expenses are not eligible for reimbursement under any other plan, and comply with the requirements of this plan. I have not and will not claim these expenses on my personal income tax return. I certify, to the extent required by federal law, that I will file the designated form with the IRS by April 15 of the year after the expenses were incurred. EMPLOYEE SIGNATURE FSA FORM /2007 DATE

26 A REMINDER ABOUT REIMBURSABLE HEALTH CARE EXPENSES See your Summary Plan Description for additional information. 1. You can use a Medical Reimbursement Account to get reimbursed for any eligible expenses not paid in full by another plan, or for any eligible expenses not covered by your health plan. An eligible expense must meet the following requirements: Must be directed or prescribed by a physician, except for eligible over-the-counter products. Must be directly related to a physical or mental condition. Expenses must be incurred on or after the effective date of the plan and while you are a participating employee. Expenses must be incurred for you, your spouse, or other person who qualifies as an eligible dependent for federal income tax purposes. 2. Examples of eligible expenses include: Deductibles (the part of covered expenses you pay before your health plan pays any benefits). Coinsurance amounts (the percent of covered expenses you must pay, if any, after the deductible requirement has been met). Dental expenses, such as, exams or other accepted services. Vision care expenses, such as, eye examinations and eyeglasses. Hearing care expenses, including hearing examinations and hearing aids. Routine physical examinations Prescription medications Over the counter medicines and products 3. You must furnish proof the expenses were incurred by attaching an itemized statement from the provider. If a statement is attached, please write the corresponding line number which the expense is listed (taken from column (1) on the front of the form). 4. HRA/VEBA Eligible Expenses (if applicable): Eligible expenses are subject to your employer s HRA/VEBA Plan Document. See the HRA/VEBA plan document for a list of eligible expenses as they may differ from those listed above. A REMINDER ABOUT REIMBURSABLE DAY CARE EXPENSES 1. In order for your day care expenses to qualify for reimbursement from the Day Care Expense Account, the following requirements must be met: If you are married, your spouse must be working for pay, attending school or seeking employment while you are at work. The children receiving day care must be under the age of 13 at the time the day care services are provided, or the person receiving care must be physically or mentally incapable of self care. The provider cannot be listed as a dependent on your federal income tax form, and, if the provider is your own child, must be at least 19 years of age. Expenses must be incurred on or after the effective date of the plan and after the date you become a plan participant. Under federal law, when you file your income tax return with the IRS you must also report the name, address, and taxpayer identification number of all providers of dependent day care services whose fees were reimbursed to you under this plan during the year. Failure to do so constitutes tax fraud unless the provider of these services is a 501(c) (3) tax-exempt organization. If you have questions on how this might affect your tax filing, refer them to your tax advisor. 2. If the amount of day care expense reimbursement you receive for a calendar year exceeds your earnings if you are single, or the earnings of the lower paid spouse if you are married, the difference must be reported as taxable income for the year. There are special rules if your spouse is a full time student or is physically or mentally incapable of self care. Again, see your tax or legal advisor. 3. You must furnish proof that the expenses were incurred either by having the provider complete the Certification of Provider Section of the form or by attaching an itemized statement from the provider. If a statement is attached, please write on that statement the line number (taken from column (1) from the front of the form) corresponding to that item of expense. 4. If there is not enough money in your Day Care Expense account to cover in full the eligible expenses listed on this form, you will be reimbursed up to the amount of your account balance. Additional reimbursements due you will be temporarily suspended. Suspended amounts will automatically be processed each time reimbursements are paid.

27 CONSUMER PORTAL QUICKSTART GUIDE Welcome to your Corporate Health Systems Benefit Accounts Consumer Portal. This one-stop portal gives you 24/7 access to view information and manage your Flexible Spending Account(s)(FSA)/Health Reimbursement Account(HRA/VEBA). It enables you to: Our one-stop portal provides you with: Anytime, anyplace access to your FSA/HRA/VEBA, including online viewing of your election and 24/7/365 availability, download FSA/HRA/VEBA information, forms and notifications File a claim online Upload receipts and track expenses View up-to-the-minute account balances View your account activity, claims history and payment (reimbursement) history Report a lost/stolen Card and request a new one Update your personal profile information Change your login ID and/or password Download plan information, forms and notifications We know from Web usage statistics that you ll most likely use the portal to: File a claim online View account balances View account activity, including deposits, balance and payments View plan information, forms and notifications The portal is designed to be easy to use and convenient. You have your choice of three ways to navigate this site: 1. Work from sections within the Home Page, 2. Hover over the six tabs at top of Home Page to see drop-down menus, or 3. Follow links at the bottom of each page.

28 HOW DO I LOG ON TO HOME PAGE? 1. Go to 2. Enter your login ID and password (both provided by CHS). 3. Click Login. The Home Page is easy to navigate: The top section shows messages from your employer and links to employee information. To assist in getting you to the most common tasks, the I Want To section contains the most frequently used options within the consumer portal. On the far right, Available Balance links to the Account Summary page, where you can see and manage your accounts. The Message Center section displays alerts and relevant links that enable you to keep current on your accounts. The Quick View section graphically displays some of your key account information. You can also hover over the tabs at top or use links at the bottom of the page. 2

29 HOW DO I FILE A CLAIM AND UPLOAD A RECEIPT? 1. On the Home Page, you may simply select the I want to File a Claim button OR on the Home Page, under the Accounts tab, click File Claim link. 2. Enter your claim information, and upload the receipt, on the form that appears and click Add Claim. The claim is then added to the Claims Basket. 3. For submitting more than one claim, click Add Another Claim, select the Account Type and complete the form and click Add Claim. 4. When all claims are entered in the Claims Basket, click Submit to send the claims for processing. 5. The Claim Confirmation page displays. You may print the Claim Confirmation Form as a record of your submission. If you did not upload a receipt, print another Claim Confirmation Form to submit to the administrator, attaching the required receipts. OR if a receipt is required, you will see the Upload Receipt link. Click on it and the Receipts Needed screen displays. 6. For each claim that requires a receipt, click Upload Receipt on the far right and follow instructions. (Your receipt must be in pdf, jpg, or gif format.) 7. The Receipt Uploaded confirmation appears: Your receipt has been uploaded. You may upload additional receipts if needed until the claim is approved. 8. After uploading, you may also click View Confirmation and print the form for your records. NOTE: If you see a Receipts Needed link in the Message Center section of your Home Page, click on it. A listing of any Claims Requiring Receipts will appear. 3

30 HOW DO I VIEW CURRENT ACCOUNT BALANCES AND ACTIVITY? 1. For current Account Balance only, on the Home Page, see the Available Balance section. 2. For all Account Activity, on the Home Page, click on the Available Balance link to bring you to the Account Summary page. Then you may select the underlined dollar amounts for more detail. For example, click on the amount under Eligible Amount to view enrollment detail. HOW DO I VIEW MY CLAIMS HISTORY? 1. On the Home Page, click on Available Balance and then select the Claim amount in the Submitted Claims column for the applicable account you would like to view claims history for. HOW DO I VIEW MY PAYMENT (REIMBURSEMENT) HISTORY? 1. On the Home Page, under the Accounts tab, click Payment History on the drop-down menu. 2. You will see reimbursement payments made to date, including debit card transactions. 3. Click View Detail on the far right to see claim details. HOW DO I REPORT A DEBIT CARD MISSING AND/OR REQUEST A NEW CARD? 1. On the Home Page, under the Profile tab, click Debit Cards on the drop-down menu. 2. Under the Actions column on the Debit Cards form, click Report Lost/Stolen or Order Replacement and follow instructions. HOW DO I UPDATE MY PERSONAL PROFILE? 1. On the Home Page, under the Profile tab, click your choice on the drop-down menu: Profile Summary or Bank Accounts. 2. Click any link on the Profile screen: Update Profile or Add/Update Dependent or Update Bank Account. Some profile changes will require you to answer an additional security question. 3. Complete your changes in the form. 4. Click Submit. 4