APPENDIX E HEALTH CARE AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS. Your UPHSFlex Medical Benefits Program

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1 APPENDIX E HEALTH CARE AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS Your UPHSFlex Medical Benefits Program You may elect to contribute to a Health Care Flexible Spending Account and/or a Dependent Care Flexible Spending Account to reimburse yourself for eligible out of pocket expenses, as described in this Appendix E. These benefits are administered by ADP and UPHS. DB1/

2 DB1/ Health and Dependent Care Flexible Spending Account

3 TABLE OF CONTENTS HEALTH AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) PLANS... 1 SPENDING ACCOUNTS OVERVIEW... 1 HEALTH CARE SPENDING ACCOUNT... 2 Eligible Expenses... 2 Ineligible Expenses... 3 Health Care Spending Account 2½ Month Extension... 4 DEPENDENT CARE SPENDING ACCOUNT... 4 Qualifications for Dependent Care Spending Account... 5 Eligible Expenses... 5 Ineligible Expenses... 6 Maximum Tax-Free Reimbursement... 6 Federal Dependent Care Tax Credit... 7 Federal Earned Income Credit... 7 HOW TO FILE FOR REIMBURSEMENT FROM THE SPENDING ACCOUNTS... 8 DB1/ i-

4 Health and Dependent Care Flexible Spending Account (FSA) Plans This section of the handbook provides information regarding flexible spending account benefits under the UPHS Health and Welfare Plan. For other important information relating to the FSA Plans, please refer to the following sections of the "General Information" section of this handbook. Participation Continuation of Coverage under COBRA Plan Administrator Additional Information Third Party Recovery Recoupment No Assignment of Benefits Qualified Medical Child Support Order Statement of ERISA Rights Spending Accounts Overview Spending Accounts provide valuable benefits designed to give you a tax-effective way to reimburse yourself on a tax-free basis for certain health care and dependent care expenses. The Health Care Spending Account is designed to help you pay certain health care expenses that you and your dependents may incur. The Dependent Care Spending Account is intended to qualify as a dependent care assistance benefit and help you pay qualified dependent care expenses. Before the Plan Year (July 1 June 30) begins, or when you first meet the Plan's eligibility requirements, you may elect to have a portion of your pay contributed to either or both Spending Accounts on a pre-tax basis. You estimate the amounts that you will require in each account for the year and divide the result by the number of pay periods remaining in the year. This equal amount will be deducted from your gross pay each pay period before taxes. Remember, it is important that you estimate your expenses carefully for the next year because IRS regulations state that any money set aside in these accounts not used for expenses incurred during the same year must be forfeited (except as provided in "Health Care Spending Account - 2½ Month Extension" below). THE DOLLARS CANNOT BE RETURNED TO YOU. This is the "use it or lose it" rule required by the IRS. Please note that you will not be entitled to receive interest or any other earnings on contributions allocated to your Spending Account(s). Forfeited amounts are used to offset the cost of administering the Spending Accounts. The general features of a Spending Account are as follows: Dollars you place in a Spending Account are taken out of your pay before they are taxed; The money in a Spending Account can only be used to reimburse eligible expenses incurred in the same Plan Year (except as provided in "Health Care Spending Account - 2½ Month Extension" below); DB1/

5 You will not be entitled to receive interest or any other earnings on contributions made to a Spending Account; Money in one Spending Account cannot be used to pay for items covered by the other Spending Account; nor can money in one Spending Account be transferred to the other Spending Account; Claims are paid as soon as is reasonably practicable; Coverage normally ceases upon your termination of employment (unless you cease coverage before that date in accordance with the Plan's rules on election changes). However, if you are receiving pay continuation, coverage will cease as of the last day of the pay continuation period or the last day of the plan year, whichever occurs first; You have until December 31 to submit claims for health care expenses incurred while you were an active participant during that Plan Year (July 1st June 30th), even if you terminate employment during the Plan Year. However, if you were an active participant (or a COBRA participant) in the Health Care Spending Account on June 30th of any Plan Year, you will have additional time to incur health care expenses. See "Health Care Spending Account - 2½ Month Extension" below; and If your participation in the Health Care Spending Account terminates and you elect COBRA, you will make your contributions on an after-tax basis. Note that COBRA continuation coverage will not continue beyond the Plan Year in which coverage is lost. Health Care Spending Account The Health Care Spending Account may be used to pay any health care expense that would qualify for a medical deduction under IRS rules, with the exception of premiums paid for other health plan coverage (including Medicare or plans maintained by the employer of your spouse or dependent) and certain longterm care expenses. Generally, the expenses covered must be "medically necessary" or prescribed by a licensed physician to qualify. Of course, health care expenses reimbursed through your Health Care Spending Account cannot be claimed as an additional deduction for income tax purposes. Expenses must be incurred on behalf of you, your spouse, your child, stepchild or legally adopted child (or a child placed with you for adoption) until the end of the calendar year in which the child attains age 26 and any dependent with respect to whom you are entitled to claim a deduction on your federal income tax return (or would be entitled to claim a deduction but for the dependent's gross income). You may contribute from $60 to $2,550 to a Health Care Spending Account. Eligible Expenses Sample health care expenses include, but are not limited to: Deductibles and co-payments; Medical, dental, prescription drug and vision expenses not covered by any insurance or a benefit plan; Over the counter medications will only be reimbursable if you have a prescription from your doctor. Ambulance fees; Chiropractic services; DB1/

6 Radial Keratotomy and Lasik surgery; Remedial reading classes for a child suffering from dyslexia; Hearing aids; Infertility services; Nicotine gum and certain nicotine patches not requiring a prescription; Wheelchairs; Seeing-eye dog and its maintenance; Special school costs for physically or mentally disabled children; Smoking cessation programs (but see below for exclusion for nicotine gum and patches); Weight loss programs (where there has been a diagnosis of a particular medical condition); Breast pumps and supplies that assist lactation; Prosthetics; and Durable medical equipment. Ineligible Expenses In general, any expenses that cannot be claimed as medical expenses for income tax purposes are not reimbursable. Ineligible expenses include, but are not limited to: Premiums for health insurance; Certain long-term care expenses; Cosmetic surgery (except in limited circumstances); Electrolysis; Health club dues not related to a specific medical condition; Non-prescription medicines and drugs; Dental bonding and bleaching; Services for which any insurance reimburses you; and Services rendered before you become a participant in the Plan and after your participation has ended. Refer to IRS Publication 502, "Medical and Dental Expenses," (available on the IRS' website at for more information regarding eligible and ineligible medical expenses. DB1/

7 Note: Publication 502 should be used for general reference purposes only. Notwithstanding what the publication says, premiums for health insurance and certain long-term care expenses are NOT eligible for reimbursement. Also, as noted above, expenses for non-prescription medicines and drugs are eligible for reimbursement, although such expenses are not deductible for income tax purposes. Health Care Spending Account 2½ Month Extension In order to maximize the value of your Health Care Spending Account, you have a 2½ month extension at the end of the Plan Year (July 1st June 30th) to incur additional health care expenses, which will help you use any funds remaining in your Health Care Spending Account for the prior year. This extension applies to you only if you were an active participant (or a COBRA participant) on June 30th, even if you terminate employment or otherwise cease to be an active participant during the 2½ month extension. This means you will have until September 15th to incur eligible expenses for reimbursement from contributions made to your Health Care Spending Account for the Plan Year ending on the prior June 30th. For example, if you have a Health Care Spending Account for the July 1, 2016 June 30, 2017 Plan Year, and you are an active participant (or a COBRA participant) in the Health Care Spending Account on June 30, 2017, eligible expenses that you incur during the period July 1, 2016 September 15, 2017, can be submitted against your Health Care Spending Account balance as of June 30, Expenses incurred during the extension must be submitted no later than December 31 immediately following the end of the extension period. Your Health Care Spending Account will be adjusted so that any eligible expenses will first be applied against any remaining account balance from the prior Plan Year before eligible expenses are applied against the current Plan Year's account balance. (This reconciliation sometimes requires crediting your prior year's account balance and debiting your prior year's account balance.) If your prior Plan Year's account balance is exhausted, eligible expenses incurred during the 2½ month extension will be applied against the current Plan Year's balance, if any. Dependent Care Spending Account The Dependent Care Spending Account is designed to help you pay for eligible expenses directly related to the "well-being and protection" of a "qualifying individual" (defined below). To be eligible, the services must make it possible for you and your spouse to work or to attend school on a full-time basis. Any type of dependent care that you could legally claim if you were filing for credit on your income taxes is eligible for funding under the Dependent Care Spending Account. You may contribute from $260 to $5,000 to a Dependent Care Spending Account. You should note that your contributions in any calendar year will be limited to $5,000 as well, unless your annual gross compensation exceeds $115,000, in which case the most you may contribute to a Dependent Care Spending Count is limited to $1,700 annually. All claims for Dependent Care Spending Accounts must be incurred during the plan year (July 1- June 30) and must be submitted no later than September 30 th immediately following the plan year end. The 2 ½ month extension does not apply to the Dependent Care Spending Account. For the purposes of this plan, a qualifying individual includes: Your child, grandchild, brother or sister who is under age 13, who resides in your household for more than one-half of the year and who does not provide more than one-half of his or her own support for the year (if you are divorced or separated, certain qualifications and special custody/support rules may apply); A disabled spouse who resides in your household for more than one-half of the year; and DB1/

8 A disabled relative or household member who is principally dependent on you for support and who resides in your household for more than one-half of the year. Note: A disabled dependent must spend at least eight hours a day in your home. A disabled dependent who is confined to an institution for care would not qualify. To be eligible to use this account, you must be actively working during the time your eligible dependent(s) is (are) receiving care; provided, however, that care provided during certain "short" or "temporary" absences for illness or vacation may be eligible if you are required to pay for such care on a weekly or longer basis. Also, if you work part-time, you do not have to allocate expenses between time worked and time not worked if you are required to pay for care on a weekly or longer basis. Qualifications for Dependent Care Spending Account You qualify to use this account if: You are a single parent; You have a working spouse; Your spouse is a full-time student for at least five (5) months during the year you are working; or Your spouse is disabled and unable to provide for his or her own care. Eligible Expenses Eligible dependent care expenses include: Services provided to care for eligible dependents while you are at work, as long as the provider submits a tax ID or social security number. If you are married, your spouse must also be employed (or seeking employment), enrolled as a full-time student, or disabled for your expenses to qualify. Expenses incurred while you are not working (e.g., sick day, vacation, etc.) do not qualify for reimbursement. However, expenses incurred during certain short or temporary absences for illness or vacation may be eligible for reimbursement if you are required to pay for dependent care on a weekly or longer basis. Also, if you work part-time, you do not have to allocate expenses between time worked and time not worked if you are required to pay for care on a weekly or longer basis; Household services, if attributable to the care of your dependent; The services of a day care center (if the center provides care for more than six individuals, other than residents, it must comply with all applicable state and local laws); The services at a day camp, including a camp that specializes in a particular activity (such as a soccer or computer camp); Care for a disabled dependent provided outside your home as long as the dependent is a child under age 13 or is in your home for at least eight hours a day; Certain education expenses for example, the cost of nursery school, including lunches if your child is not yet in the first grade; DB1/

9 Expenses for care provided in your home, as long as the care is not provided by someone you or your spouse claims as a dependent on your federal income tax return, or your child who is under age 19 (even if you no longer claim that child as a dependent); and Agency fees, application fees or deposits, if you are required to pay these expenses in order to obtain the related care. To make sure your situation and the type of care being provided meets IRS requirements; refer to IRS Form 2441 and IRS Publication 503, "Child and Dependent Care Expenses." In addition, you should know that if you use a dependent care provider inside your home you may be considered the employer of that individual and may be responsible for withholding and paying employment taxes. For more information, refer to IRS Publication 926, "Employment Taxes for Household Employees." These forms and publications are available on the IRS' website ( and also should be available at your local post office or public library. Ineligible Expenses In general, any expenses that cannot be claimed as dependent care expenses for income tax purposes are not reimbursable. Ineligible expenses include, but are not limited to the following: Overnight camp; Activity fees; Non-employment related care, such as babysitting fees during non-working hours; School transportation; Schooling in the first grade and beyond; and Pre-first grade schooling that can be separated from the cost of care. Maximum Tax-Free Reimbursement Generally, amounts reimbursed from your Dependent Care Spending Account are tax-free to you. However, federal law provides that the amount excluded from your gross income cannot exceed the lesser of: $5,000 ($2,500 if you are married and filing separate federal income tax returns); Your annual income; or Your spouse's annual income. If your spouse is (1) a full-time student for at least five months during the year or (2) physically and/or mentally handicapped, there is a special rule to determine his or her annual income. To calculate the income, determine your spouse's actual taxable income (if any) earned each month that he or she is a full-time student or disabled. Then, for each month, compare this amount to either $250 (if you claim expenses for one dependent) or $500 (if you claim expenses for two or more dependents). The amount you use to determine your spouse's annual income is the greater of the actual earned income or these assumed monthly income amounts of either $250 or $500. By making an election under the Plan to contribute to a Dependent Care Spending Account, you are representing to the Company that your contributions to the Account are not expected to exceed these limits. DB1/

10 If you are married and filing separate federal income tax returns, the $2,500 limit described above will not apply if you are (1) legally separated or (2) your spouse did not reside with you for the last six months of the calendar year, you maintained a household that was your dependent's primary residence for more than six months during the year and you paid more than half of the expenses of that household. The $5,000 maximum limit is a household limit if you are married filing a joint federal income tax return. Therefore, if both you and your spouse participate in a dependent care assistance plan (through UPHS or through another employer), your combined maximum tax-free benefit is $5,000 in a calendar year. To qualify for tax-free treatment, you are required to list on your federal income tax return the names and taxpayer identification numbers of any person who provided you with dependent care services during the calendar year for which you have claimed a tax-free reimbursement. The identification number of a care provider who is an individual and not a care center is that individual's social security number. Your care provider should be made aware of this reporting requirement. By making an election to contribute to a Dependent Care Flexible Spending Account, you are representing to the UPHS that your contributions to the account are not expected to exceed the applicable tax-free reimbursement limit. Some Special Timing Considerations Your contributions to the Dependent Care Flexible Spending Account are subject to some special timing considerations. The Spending Account is administered on a plan year that begins each July 1 and ends each June 30. However, the federal income tax reimbursement limits for the Dependent Care Flexible Spending Account (as described above) are based on a calendar year. You should plan carefully when you calculate your annual contribution. For example, if you first contribute to the plan during the first half of the calendar year (January 1 through June 30), and your contributions are more than $2,500 for such period, you should make certain that your contributions for the second half of the calendar year (July 1 through December 31) are less than $5,000 so that your contributions for the calendar year do not exceed $5,000. Federal Dependent Care Tax Credit Dependent care expenses for which you are reimbursed from your Dependent Care Spending Account will not qualify for the federal tax credit available with respect to dependent care expenses. Under the Internal Revenue Code, you are entitled to a dollar for dollar credit against your income tax liability in an amount equal to a specified percentage of your qualifying dependent care expenses. For purposes of the credit, there are limitations on the dollar amount of qualifying dependent care expenses that can be taken into account. These limitations are reduced dollar for dollar by dependent care expenses reimbursed under the Account. In addition, these expenses cannot be taken into account to the extent they exceed the lesser of your or your spouse's earned income. Therefore, you must determine whether it is more advantageous for you not to establish a Dependent Care Spending Account in order to avail yourself of the federal tax credit. In making this determination, it is important to consider that the amount of compensation you elect to reduce under the Plan is not subject to federal income tax, and is not subject to Social Security withholding tax (FICA) (7.65% up to $118,500 in 2016). If you are not certain as to what extent, if any, it is to your advantage to participate in the Plan, you should consult your personal tax advisor. Federal Earned Income Credit Another tax credit available under current tax law is the earned income credit. This credit also reduces dollar for dollar the federal tax you have to pay, but is calculated somewhat differently from the dependent care credit described above. The credit is available to individuals with a child who is under age 19 (under DB1/

11 age 24 if a student) or who is totally and permanently disabled. An additional credit is available to individuals with a child who is under one year old. The credit does not depend on the amount you pay in child care expenses. The earned income credit has no effect on the amount you can contribute under the Dependent Care Spending Account for dependent care expenses, and the earned income credit cannot be claimed for any individual for whom you claim the child care credit described above. Moreover, the use of the Dependent Care Spending Account may result in a reduction in your taxable income, thus qualifying you for the earned income credit where you would not otherwise have qualified. How to File for Reimbursement from the Spending Accounts When you want to be reimbursed for expenses, you must first pay the expense and then submit the appropriate claim forms and supporting documentation to the Plan Administrator. Claims for reimbursement may be submitted at any time up to 90 days following the end of the Plan Year. The Plan Administrator has contracted with the third party administrator listed in Appendix A to provide administrative services under the Spending Accounts. Forms must be accompanied by copies of bills, invoices, receipts, or other statements showing the amount of such expenses and the date on which incurred, together with any additional documentation that the Company may request. Claims are processed daily for eligible and complete claims. The average turnaround time from receipt of a complete claim and claim payment is five days. Remember, an incomplete claim form increases the amount of time required to send you your reimbursement check. Claims Procedure For purposes of this "Claims Procedure" section, the Plan Administrator (or any third party to whom the Plan Administrator has delegated the authority to review and evaluate claims) shall be referred to as the "Claims Administrator" at the initial claim level and the "Appeals Administrator" at the appeal level. A request for benefits is a "claim" subject to these procedures only if it is filed by you or your authorized representative in accordance with the Plan's claim filing guidelines. In general, claims must be filed in writing with the following provider: ADP P.O. Box Louisville, KY Appeals should be filed as follows: UPHS Appeals Committee c/o ADP P.O. Box Louisville, KY Any claim that does not relate to a specific benefit under the Plan (for example, a general eligibility claim or a dispute involving a mid-year election change) must be filed with the Plan Administrator at the following address: Plan Administrator 3001 Market Street Suite 320 Philadelphia, PA A request for prior approval of a benefit or service where prior approval is not required under the Plan is not a "claim" under these rules. Similarly, a casual inquiry about benefits or the circumstances under which benefits might be paid under the Plan is not a "claim" under these rules, unless it is determined that your inquiry is an attempt to file a claim. If a claim is received, but there is not enough information to DB1/

12 allow the Claims Administrator to process the claim, you will be given an opportunity to provide the missing information. If you want to bring a claim for benefits under the Plan, you may designate an authorized representative to act on your behalf so long as you provide written notice of such designation to the Claims Administrator and/or the Appeals Administrator identifying such authorized representative. Claims Not Involving a Specific Benefit In the case of a claim not involving specific benefit (for example, a general eligibility claim or a dispute involving a mid-year election change), the Plan Administrator will respond to you within 30 days after receipt of the request. If the Plan Administrator denies your claim (in whole or in part), the Plan Administrator will provide you with written notice of the denial. The decision of the Plan Administrator cannot be appealed. Claims Involving Benefits Time Periods for Responding to Initial Claims If you bring a claim for benefits under the Health Care Spending Account, the Claims Administrator will respond to your claim within 30 days after receipt of the claim. If the Claims Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Claims Administrator will notify you within the initial 30-day period that the Claims Administrator needs up to an additional 15 days to review your claim. If such an extension is necessary because you failed to provide the information necessary to evaluate your claim, the notice of extension will describe the information that you need to provide to the Claims Administrator. You will have no less than 45 days from the date you receive the notice to provide the requested information. If you bring a claim for benefits under the Dependent Care Spending Account, the Claims Administrator will respond to you within 90 days after receipt of the claim. If the Claims Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Claims Administrator will notify you within the initial 90-day period that the Claims Administrator needs up to an additional 90 days to review your claim. Notice and Information Contained in Notice Denying Initial Claim If the Claims Administrator denies your claim (in whole or in part), the Claims Administrator will provide you with written notice of the denial (although initial notice of a denied urgent care claim may be provided to you orally). This notice will include the following: Reason for the Denial - the specific reason or reasons for the denial; Reference to Plan Provisions - reference to specific provisions on which the denial is based; Description of Additional Material - a description of any additional material or information necessary for you to perfect your claim and explanation why such information is necessary; Description of Any Internal Rules - with regard to a claim for benefits under the Health Care Spending Account, a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to you free of charge at your request; and Description of Claims Appeals Procedures - a description of the Plan's appeals procedures and the time limits applicable for such procedures (such description will include a statement that you are eligible to bring a civil action in Federal court under Section 502 of ERISA to appeal any DB1/

13 adverse decision on appeal and a description of any expedited review process for urgent care claims). Appealing a Denied Claim for Benefits If your initial claim for benefits under the Health Care Spending Account is denied by the Claims Administrator, you may appeal the denial by filing a written request (or an oral request in the case of an urgent care claim) with the Appeals Administrator within 180 days after you receive the notice denying your initial claim for benefits. If you decide to appeal a denied claim for benefits, you will be able to submit written comments, documents, records, and other information relating to your claim for benefits (regardless of whether such information was considered in your initial claim for benefits) to the Appeals Administrator for review and consideration. You will also be entitled to receive, upon request and free of charge, access to and copies of, all documents, records and other information that is relevant to your appeal. If your initial claim for benefits under the Dependent Care Spending Account is denied by the Claims Administrator, you may appeal the denial by filing a written request with the Claims Administrator within 60 days after you receive the notice denying your initial claim for benefits. If you decide to appeal a denied claim for benefits, you will be able to submit written comments, documents, records, and other information relating to your claim for benefits (regardless of whether such information was considered in your initial claim for benefits) to the Appeals Administrator for review and consideration. You will also be entitled to receive, upon request and free of charge, access to and copies of, all documents, records and other information that is relevant to your appeal. Time Periods for Responding to Appealed Claims If you appeal a denied claim for benefits under the Health Care Spending Account, the Appeals Administrator will respond to your claim within 60 days after receipt of the appeal. If you appeal a denied claim for benefits under the Dependent Care Spending Account, the Appeals Administrator will respond to you within 60 days after receipt of the claim. If the Appeals Administrator determines that an extension is necessary due to matters beyond the control of the Plan, the Appeals Administrator will notify you within the initial 60-day period that the Appeals Administrator needs up to an additional 60 days to review your claim. Notice and Information Contained in Notice Denying Appeal If the Appeals Administrator denies your claim (in whole or in part), the Appeals Administrator will provide you with written notice of the denial (although initial notice of a denied urgent care claim may be provided to you orally or via facsimile or other similarly expeditious means of communication). This notice will include the following: Reason for the Denial the specific reason or reasons for the denial; Reference to Plan Provisions reference to specific provisions on which the denial is based; Statement of Entitlement to Documents a statement that you are entitled to receive, upon request and free of charge, access to and copies of, all documents, records and other information that is relevant to your claim and/or appeal for benefits; Description of Any Internal Rules with regard to a claim for benefits under the Health Care Spending Account, a copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the appeal determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to you free of charge at your request; and DB1/

14 Statement of Right to Bring Action a statement that you are entitled to bring a civil action in Federal court under Section 502 of ERISA to pursue your claim for benefits. The decision of the Appeals Administrator shall be final and conclusive on all persons claiming benefits under the Plan, subject to applicable law. If you challenge the decision of the Appeals Administrator, a review by a court of law will be limited to the facts, evidence and issues presented during the claims procedure set forth above. The appeal process described herein must be exhausted before you can pursue the claim in Federal court. Facts and evidence that become known to you after having exhausted the appeals procedure may be submitted for reconsideration of the appeal in accordance with the time limits established above. Issues not raised during the appeal will be deemed waived. DB1/