HEALTH REIMBURSEMENT ARRANGEMENT (HRA) BENEFIT GUIDE 2015

Transcription

1 HEALTH REIMBURSEMENT ARRANGEMENT (HRA) BENEFIT GUIDE 2015 Corporate Health Systems, Inc. [Benefit Communication Solutions] Technology Drive, Suite B Eden Prairie, MN Phone (952) Fax (952)

2 NOTICE This is a benefit summary only and may not outline all of your benefits. When you enroll, you will receive a summary plan description or certificate of coverage. This booklet does not replace, supplement or change any of the individual benefit product summary plan descriptions or certificates of coverage and should not be used in determining actual benefits available. Remember this is a summary only and the legal plan documents determine actual benefits. Please be aware that if there are differences between the statements in this booklet and actual legal plan documents or laws, the legal course will prevail. Contact the insurance carrier for more information and answers to specific questions, or see your Human Resource Office for a copy of the plan document before making a decision. This booklet provides an overview of the following insurance benefits: Health Reimbursement Arrangement (HRA) Corporate Health Systems is the Benefit Administrator for the above insurance benefits. concerning these benefits please contact Corporate Health Systems at the number listed below. For questions Renee Heggelman (952) ext. 125 [email protected] You may also contact your employer s benefits representative. Erin Francis (651) To verify coverage or for questions concerning how a specific claim will be paid, please consult the applicable insurance carrier or plan document of the coverage in question. Neither Corporate Health Systems nor your employer can quote benefits for reasons involving accuracy and confidentiality. When in doubt, contact Corporate Health Systems and you will be directed to the appropriate resource.

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

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5 Plan Outline Administrator: Corporate Health Systems, Inc. Local Phone: (952) Toll Free Phone: (888) Website: Plan Year: January 01 December 31 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: Please refer to your District employment contract First of the month following or coincident with date of hire 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: Difference between the District contribution to the high deductible health insurance premium and the cost of the actual premium Employer HRA Contribution Funding: 50% of the total District contribution will be made on January 15, % of the total District contribution will be made on July 15, % of the total District contribution will be made on October 15, 2015

6 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. 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

7 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 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.

8 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) [email protected] You now have the ability to enter your claims via the CHS Website. Simply log into your account, click on File A Claim, complete all applicable fields, and click on the submit button. Once you have submitted your claim, you can either upload your receipt and or simply fax your receipt for review. Step by step instructions will be included with your confirmation mailing if you choose to enroll in the medical health plan with the HRA component. 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 or before your enrollment date will not be reimbursed. Claims incurred after your participation terminates can be reimbursed, if you file the request for reimbursement during the plan year and if you have funds remaining in your HRA account. 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.

9 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.

10 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.

11 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.

12 Below is the updated 2015 VEBA table. VEBA BARGAINING GROUP FAMILY SINGLE Bus Drivers/Assist Bus Mechanics CAS DOSS KC Supervisors Maintenance Nutrition Services Office Prof PACE Paraprofessional Principal Teacher (.8 FTE) Teacher (.9 FTE) Teacher (1.0 FTE) Tier 1 Independent Tier 2 Independent Tier 3 Independent Tier 4 Independent

13 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement This is only a summary. This plan reimburses medical expenses not covered elsewhere. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling (651) Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? $0 See the chart starting on page 2 for your costs for services this plan covers. No. No. This plan has no out-ofpocket limit Yes, up to the individual s account balance No. No. Yes. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. There s no limit on how much you could pay during a coverage period for your share of the cost of covered services. Not applicable because there s no out-of-pocket limit on your expenses. This plan will pay for covered services only up to this limit during each coverage period, even if your own need is greater. You re responsible for all expenses above this limit. The chart starting on page 2 describes specific coverage limits. This plan treats providers the same in determining payment for the same services. You can see the specialist you choose without permission from this plan. Some of the services this plan does not cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 1 of 8

14 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) Your cost sharing does not depend on whether a provider is in a network. Common Medical Event Services You May Need Your Cost Limitations & Exceptions If you visit a health care provider s office or clinic Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/screening/immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees If you have a test If you need drugs to treat your illness or condition No Charge Coverage is limited to individual s account balance If you have outpatient surgery Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 2 of 8

15 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement Common Medical Event Services You May Need Your Cost Limitations & Exceptions If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses Dental check-up No Charge Coverage is limited to individual s account balance Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 3 of 8

16 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Amounts that exceed the individual s account balance Cosmetic surgery Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Dental care (Adult) Hearing aids Infertility treatment Long-term care Non-emergency care when traveling outside the U.S. Private-duty nursing Routine eye care (Adult) Routine foot care Weight loss programs Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 4 of 8

17 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement Health Reimbursement Arrangement Employer Contributions VEBA VEBA BARGAINING GROUP FAMILY SINGLE BARGAINING GROUP FAMILY SINGLE Bus Drivers/Assist Paraprofessional Bus Mechanics Principal CAS Teacher (.8 FTE) DOSS Teacher (.9 FTE) Kids Club Supervisors Teacher (1.0 FTE) Maintenance** Tier 1 Independent Nutrition Services Tier 2 Independent Office Prof Tier 3 Independent PACE Tier 4 Independent Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 5 of 8

18 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at [6]. You may also contact government agencies including your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact the plan at (651) Language Access Services: [7] [Spanish (Español): Para obtener asistencia en Español, llame al (651) [7] [Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa (651) [7] [Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 (651) [7] [Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' (651) To see examples of how this plan might cover costs for a sample medical situation, see the next page. Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 6 of 8

19 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays up to individual s account balance Patient pays remainder Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays under this plan: Deductibles $0 Co-pays $0 Co-insurance $0 Limits or exclusions * Total * * Amount in excess of individual s account balance Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays up to individual s account balance Patient pays remainder Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays under this plan: Deductibles $0 Co-pays $0 Co-insurance $0 Limits or exclusions * Total * * Amount in excess of individual s account balance Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. 7 of 8

20 South Washington County School District #833 Coverage Period: January 01, 2015 December 31, 2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Employee (including former employee) and family Plan Type: Expense Reimbursement Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs may include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Questions: Call (651) or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call EBSA (3272) to request a copy. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to other accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. 8 of 8

21 Frequently Asked Questions on the Benny Prepaid Benefits Card General Questions on the Benny Prepaid Benefits Card 1. What is the Benny Prepaid Benefits Card? The Benny Prepaid Benefits Card is a special-purpose Visa Card that gives participants an easy, automatic way to pay for eligible health care/benefit expenses. The Card lets you electronically access the pre-tax amounts set aside in your benefit accounts such as Flexible Spending Accounts (FSAs) and Health Reimbursement Accounts (HRAs). 2. How does the Prepaid Benefits Card work? It works like a Visa Card, with the value of your account(s) contribution stored on it. When you or your dependents have eligible expenses at a business that accepts Visa debit cards, you simply use your Card. The amount of the eligible purchases will be deducted automatically from your account and the pretax dollars will be electronically transferred to the provider/merchant for immediate payment. 3. How does the Prepaid Benefits Card change how the participant is reimbursed for expenses? Before the Prepaid Benefits Card became available, you had to pay for your eligible expenses at the time of purchase, submit claim forms along with all receipts, and then wait for the reimbursement to be processed. Checks were issued and mailed to you, who then cashed the checks. In essence, you paid twice through payroll deduction and then at the point of sale then had to wait for reimbursement. However, with the Prepaid Benefits Card, you simply swipe your Cards and the funds are automatically deducted from your respective benefit account(s) for payment. The Card eliminates most out-of-pocket cash outlays and paperwork, as well as the need to wait for reimbursement checks. 4. Is the Prepaid Benefits Card just like other Visa Cards? No. The Prepaid Benefits Card is a special-purpose Visa Card that can be used only for eligible health care/benefits expenses. It cannot be used, for instance, at gas stations or restaurants. There are no monthly bills and no interest EVOLUTION1, INC. ALL RIGHTS RESERVED. Benny Prepaid Benefits Card FAQ BCP

22 5. How many Prepaid Benefits Cards will I receive? You will receive two Cards. If you would like additional Cards for other family members, you should contact your Corporate Health Systems Benefit Administrator. There is a $5.00 fee for each additional card. 6. Will I receive a new Prepaid Benefits Card each year? No, you will not receive a new Card each year. If you will again have a benefit associated with the Card for the following plan year and you used the Card in the current benefit year you will simply keep using the same Card the following year. The Card will be loaded with the new annual election amount at the start of each plan year or incrementally with each pay period, based on the type of account(s). 7. What if the Prepaid Benefits Card is lost or stolen? You can visit On the Home Page, under the Profile tab, click Debit Cards on the drop-down menu. Under the Actions column on the Debit Cards form, click Report Lost/Stolen or Order Replacement and follow the step by step instructions In addition to the above step, you should call your Corporate Health Systems Benefit Administrator to report a Card lost or stolen as soon as they realize it is missing, so the Administrator can turn off their current Card(s) and issue replacement Card(s). There is a $5.00 fee for each replacement card. Getting Started and Activating Your Card 1. How do I activate my Card? You should call the toll-free number on the activation sticker on the front of the Card or visit the web site on the back of the Card. You can use both Cards once the first Card is activated you do not need to activate both. You should wait one business day after activation to use your Cards. Each Card user should sign the Card with his or her own name. 2. What dollar amount is on the Prepaid Benefits Card when it is activated? For Health Care FSAs, the dollar value on the Card will be the annual amount that you elected to contribute to your respective employee benefit account(s) during their annual benefits enrollment. It s from that total dollar amount that eligible expenses will be deducted as you/your dependents use the Cards or submit manual claims. Some other types of accounts, like HRAs, are funded incrementally at each pay period, so it is especially important to be aware of account balances in order to avoid Card declines at the point of service EVOLUTION1, INC. ALL RIGHTS RESERVED. Benny Prepaid Benefits Card FAQ BCP

23 Using the Card 1. Where can I use the Prepaid Benefits Card? IRS regulations allow you/your dependents to use your Prepaid Benefits Cards in participating pharmacies, mail-order pharmacies, discount stores, department stores, and supermarkets that can identify FSA/HRAeligible items at checkout and accept Visa prepaid cards. Eligible expenses are deducted from the account balance at the point of sale. Transactions are fully substantiated, and in most cases, no paper follow-up is needed. You can find out which merchants are participating by visiting the web site on the back of the Card or consulting with your assigned Corporate Health Systems Benefit Administrator. Some plan designs may also allow you/your dependents to use the Cards in pharmacies that have certified that 90% of the merchandise they sell is FSA/HRA-eligible. However, since these pharmacies cannot identify the eligible items at the point of sale, another form of auto substantiation or paper follow-up will be required. You can also use the Card to pay a hospital, doctor, dentist, or vision provider that accepts Visa. In this case, EB uses its auto-substantiation technology to electronically verify the transaction s eligibility according to IRS rules. If the transaction cannot be auto substantiated, paper follow-up will be required. 2. Are there places the Prepaid Benefits Card won t be accepted? Yes. The Card will not be accepted at locations that do not offer the eligible goods and services, such as hardware stores, restaurants, bookstores, gas stations and home improvement stores. Cards will not be accepted at pharmacies, mail-order pharmacies, discount stores, department stores, and supermarkets that cannot identify FSA/HRA-eligible items at checkout. The Card transaction may be declined. You can find out which merchants are participating by visiting the web site on the back of the Card or consulting with your assigned Corporate Health Systems Benefit Administrator. 3. If asked, should I select Debit or Credit? Your Prepaid Benefits Card is actually a prepaid card. But, since there is no prepaid selection available, you should select Credit. You do not need PIN and cannot get cash with the Prepaid Benefits Card. 4. How does the Card work in participating pharmacies, discount stores, department stores, and supermarkets? a. Bring prescriptions, vision products, eligible OTCs and other purchases to the register at checkout to let the clerk ring them up. (Please note: The list of eligible OTC items changed per the Patient Protection and Affordable Care Act of Contact your Plan Administrator for more information.) b. Present the Card and swipe it for payment. c. If the Card swipe transaction is approved (e.g., there are sufficient funds in the account and at least some of the products are FSA/HRA-eligible), the amount of the FSA/HRA-eligible purchases is deducted from the account balance and no receipt follow up is required. The clerk will then ask for another form of payment for the non-fsa/hra-eligible items. d. If the Card swipe transaction is declined, the clerk will ask for another form of payment for the total amount of the purchase. e. The receipt will identify the FSA/HRA-eligible items and may also show a subtotal of the FSA/HRAeligible purchases. f. In most cases, the participant will not receive requests for receipts for FSA/HRA-eligible purchases made in participating pharmacies, discount stores, department stores, or supermarkets EVOLUTION1, INC. ALL RIGHTS RESERVED. Benny Prepaid Benefits Card FAQ BCP

24 5. Why do I need to save all of their itemized receipts? You and your other eligible users should always save itemized receipts for FSA and HRA purchases made with the Prepaid Benefits Card. You may be asked to submit receipts to verify that the expenses comply with IRS guidelines. Each receipt must show: the merchant or provider name, the service received or the item purchased the date and the amount of the purchase. The IRS requires that every card transaction must be substantiated. This can occur through automated processing as outlined by the IRS (e.g. copay matching, etc.). If the automated processing is unable to substantiate a transaction, the IRS requires that itemized receipts must be submitted in order to validate expense eligibility. 6. How long do I need to save their itemized receipts? You should save itemized receipts for FSA and HRA until the end of the benefit year and/or grace period (if applicable). 7. What if I lose their receipts or accidentally swipe the Card for something that s not eligible? Usually the service provider can recreate an account history and provide a replacement receipt. In the event that a receipt cannot be located, recreated, or if the expense is ineligible for reimbursement, you can send a check or money order to Corporate Health Systems for the amount so it can be credited back to your FSA/HRA account. 8. Can I use the Prepaid Benefits Card for prescriptions ordered prior to activating the Card? No. The Card must be activated prior to the order and/or purchase date of prescriptions. In some cases, you need to wait 1 business day after activating the Card to purchase prescriptions at the pharmacy. For example, if the Card is activated on Tuesday, a prescription can be ordered and picked up on Wednesday. 9. Can I use the Prepaid Benefits Card if I receive a statement with a Patient Due Balance for a medical service? Yes. As long as you have money in your account for the balance due, the services were incurred during the current plan year, and the provider accepts Visa debit cards, you can simply write the Card number on the statement and send it back to the provider. 10. If I am asked for the CVV when paying the balance due or when placing an order by phone or online. What is this and where is it found? CVV stands for Card Verification Value. It is a 3-digit number that can be found on the back of the card to the right of the signature panel. 11. How do I know how much is in my account? You can visit for current Account Balance only, on the Home Page, see the Available Balance section. Or, you can call your Corporate Health Systems Benefit Administrator at the phone number on the back of the Card to obtain your current balance. You/your dependents should always know the account balance before making a purchase with the Card EVOLUTION1, INC. ALL RIGHTS RESERVED. Benny Prepaid Benefits Card FAQ BCP

25 12. What if I have an expense that is more than the amount left in my account? By checking your account balance often either online or by calling your Corporate Health Systems Benefit Administrator at the phone number shown on the back of the Card you will have a good idea of how much is available. When incurring an expense that is greater than the amount remaining in the account, you may be able to split the cost at the register. (Check with the merchant.) For example, you can ask the clerk to use the Prepaid Benefits Card for the exact amount left in the account, and then pay the remaining balance separately. Alternatively, you can pay by another means and submit the eligible transaction manually via a claim form with the appropriate documentation to your Corporate Health Systems Benefit Administrator. 13. What are some reasons that the Prepaid Benefits Card might not work at point of sale? The most common reasons why a Card may be declined at the point of sale are: a. The Card has not been activated. b. The Card has been used before the 24-hour period after activation is over. c. You have insufficient funds in your employee benefit account to cover the expense. d. Non-eligible expenses have been included at the point-of-sale. (Retry the transaction with the eligible expense only.) e. The merchant is encountering problems (e.g. coding or swipe box issues). f. The pharmacy, discount store, department store, or supermarket cannot identify FSA/HRA-eligible items at checkout according to IRS rules. 14. Am I responsible for charges on lost or stolen Prepaid Benefits Cards? If the Plan Administrator and the issuing bank are notified within 2 business days, you will not be responsible for any charges. If the notification is after 2 days, you may be responsible for the first $50 or more. Replacement Cards may be purchased. 15. Whom I call if they have questions about the Prepaid Benefits Card? Call your Corporate Health Systems Benefit Administrator at the phone number shown on the back of the Card. 16. Can a I use the Prepaid Benefits Card to access last year s money left in the account this year? The IRS allows for a grace period in the current year to use up funds carried over from the prior year. Check with your Corporate Health Systems Benefit Administrator to find out how the grace period is handled for your specific program. 17. How will I know to submit receipts to verify a charge? You will receive an from your Corporate Health Systems Benefit Administrator if there is a need to submit a receipt. All receipts should be saved per the IRS regulations. 18. What if I fail to submit receipts to verify a charge? If receipts are not submitted as requested to verify a charge made with Prepaid Benefits Card, then the Card may be suspended until receipts are received. You will be required to repay the amount charged. The Plan Administrator will advise you that the Card has been suspended, if a receipt is not received. Submitting a receipt or repaying the amount in question will allow the Card to become active again. If documentation is not received for the expense and you do not submit repayment to your Corporate Health Systems Benefit Administrator, then the amount will be withheld from your paycheck as an aftertax deduction to make your account whole again EVOLUTION1, INC. ALL RIGHTS RESERVED. Benny Prepaid Benefits Card FAQ BCP

26 Review of Cardholder Follow-Up Process for IRS Compliance Save Receipts With tax advantaged plans (e.g FSA, HRA etc.), the IRS requires participants to save original store (or provider of service) itemized receipts for every expense transaction. In the event of an IRS audit, these documents will be needed to prove expense eligibility. What is an itemized receipt? An itemized receipt must include: merchant or provider name, services received or item purchased, date of service, and amount of the expense. Cancelled checks, handwritten receipts, card transaction receipts or previous balance receipts cannot be used to verify an expense. We suggest that employees keep their itemized receipts in one place (perhaps using the Save the Receipt envelopes provided), so they re readily available when they receive a request. Auto-Substantiation The IRS does not require receipts to be submitted for prepaid card transactions that can be substantiated electronically. Our card program s technology uses all of the IRS-approved methods (e.g. Inventory Information Approval Systems [IIAS], co-payment matching, PBM data matching, etc.) to auto substantiate transactions and reduce paperwork for cardholders. Follow-up Letter Request For transactions that cannot be verified automatically, you will receive an notification asking you to furnish an itemized receipt or other proof that the Card was used for an eligible expense. Some of the more common instances in which you will receive a letter include: When benefit plan data is not available and the card has been used to pay a co-insurance bill from a provider. When you or your dependents are not covered by your employer plan. Overpayment process If we cannot verify that a card transaction was for an FSA/HRA-eligible expense, you will be asked to pay the money back into the benefit account or it will be deducted from your pay check. Cardholder Follow-Up Schedule 1 Days We will send receipt request letters for any transaction that cannot be auto substantiated, and notify you that the Card will be suspended if receipts are not submitted within the specified time frame. 15 Days We will verify transaction eligibility based on additional information received (submitted receipts, additional electronic data, etc.). We will validate appropriate card transactions and recover dollars paid out for ineligible card transactions. 30 Days We will suspend cards for those cardholders who have not submitted receipts within the allotted time, or, who have not paid back expenses determined to be ineligible. 30 Days We will reinstate cards for those cardholders who have submitted additional proof of eligibility, or who have returned dollars paid out for ineligible expenses. We will continue to suspend cards and recover ineligible expenses from those who have not submitted valid proof or returned funds. If you have any questions or feedback about your Prepaid Benefits Card, or your overall program, please contact us at (888) ext 125 or Your questions and feedback are important to us EVOLUTION1, INC. ALL RIGHTS RESERVED. Employer Letter_Receipt Requests BCP

27 Things you should know about payment AT YOUR OFFICE VISIT Did you know that if you have a health plan with co-insurance (not a co-pay plan), it is NOT necessary to pay your provider at the time of your visit? It s true! Here are a few key things you should know: 1. Health care providers (including dentists and eye doctors) are contractually obligated to bill your insurance carrier FIRST. Now, they would like you to pay while you re in their office, but you are not obliged to. You do not need to pay anything until you have received your Explanation of Benefits (EOB) from your health or dental plan and the bill from the provider that shows the balance owed AFTER your insurance has paid its portion of the claim. However, if you feel obligated to pay your estimated portion at the time of service, make sure you hold on to your itemized receipt as it may be required to verify the Card transaction. 2. The only charge you SHOULD pay at your office visit is a co-payment if you have a plan that requires it. IMPORTANT NOTE: Your Benny Prepaid Benefits Card is NOT your insurance card that shows you are eligible for benefits; it is simply a payment method for your out-of pocket expenses. Once you receive your bill in the mail from an eligible provider, you can use your Card to pay the patient balance due amount. 3. Here are the steps to follow when you get a provider bill to make a payment using your Card: Write your Card number on the portion of the bill that allows for credit card payment. (If your bill does not have that option, you can call the provider s billing office and they can take your number over the phone.) Sign in the appropriate area. Provide the expiration date. You may also need to include a CVV. The CVV is the three-digit number on the back of your card near the signature panel. Return the completed form to your provider. As required by the IRS for these types of accounts! EC

28 Why did I get a receipt request when I used my Card? Now that you ve been using your Prepaid Benefits Card, you may have received an asking for a receipt to verify the eligibility of a purchase. We do all we can to automatically verify your Card transactions, as required by the IRS. However, if we re unable to, you will receive an requesting itemized receipts for card transactions. We want to help you understand and/or reduce these s, so here are a few things you should know. How to AVOID receiving an 1. If you have a deductible plan with co-insurance, don t use your Card to pay the provider at the point of care. It is not necessary to pay the provider until you have received an Explanation of Benefits (EOB) and/or the bill with the patient balance-due after it had been submitted to your insurance. You can then write your Card number on the invoice and return for payment. However, if a doctor or dentist insists that you pay at the point of service, use another form of payment and then submit a manual claim. 2. Only use your Card for dependents covered under your health plan. 3. Only use your Card at pharmacies that can separate eligible items from non-eligible items. To find out which merchants are participating, visit the web site or call the number on the back of the Card. You WON T receive an 1. If you have a benefit plan with co-payments. 2. When prepaid card transactions are verified electronically. If you are asked to provide a receipt, it must include: merchant or provider name, service received or item purchased, date of service, and amount of the expense. Cancelled checks, handwritten receipts, your Card transaction receipts or previous balance receipts cannot be used to verify an expense. If you don t have the receipt, you can contact the provider who can usually supply the receipt from their files. Paying with your Benny Prepaid Benefits Card makes it easy and keeps cash in your wallet! EC

29 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 Reimbursement Accounts. It enables you to: 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 The portal is designed to be easy to use and convenient. You have your choice of two ways to navigate this site: 1. Work from sections within the Home Page, 2. Hover over or click on the six tabs at the top All Rights Reserved Evolution1, Inc. a WEX Company

30 HOW DO I LOG ON TO HOME PAGE? 1. Go to 2. Enter your login ID (ssn without the dashes) and password (changeme). 3. Click Login. The Home Page is easy to navigate: Easily access the Available Balance and I Want To sections from the left-hand navigation area. The I Want To section contains the most frequently used features for the Consumer Portal. In the left-hand column 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 the top of the page All Rights Reserved Evolution1, Inc. a WEX Company

31 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 Claims 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 All Rights Reserved Evolution1, Inc. a WEX Company

32 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 AND STATUS? 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. 2. For an alternative perspective, you may also view claims history and status for all claim types including dependent care on the Dashboard. 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. You will see reimbursement payments made to date, including debit card transactions. 2. 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, Banking or Login Information. 2. Click any link on the Profile screen: Update Profile or Add/Update Dependent or Add Beneficiary. Some profile changes will require you to answer an additional security question. 3. Complete your changes in the form. 4. Click Submit All Rights Reserved Evolution1, Inc. a WEX Company

33 HOW DO I GET MY REIMBURSEMENT FASTER? The fastest way to get your money is to sign up online for direct deposit to your personal checking account. Before you begin, make sure that your employer is offering direct deposit setup online. 1. On the Home Page, under the Accounts tab, click Change Payment Method on the drop-down menu. 2. Select Direct Deposit and click Change Payment Method. The Add Bank Account: Direct Deposit Setup page displays. 3. Enter your bank account information, and click Submit. 4. The Payment Method Changed confirmation displays. HOW DO I CHANGE MY LOGIN AND/OR PASSWORD? 1. On the Home Page, click on the Profile tab, and select Login Information on the left-hand side of the screen. 2. Follow instructions on the screen. (For a new account, the first time you log in, you will be prompted to change the password that was assigned by your plan administrator. Follow the instructions.) 3. Click Save. HOW DO I VIEW OR ACCESS DOCUMENTS & FORMS? 1. On the Home Page, use the Tools & Support tab. 2. Click any form or document of your choice. NOTIFICATIONS? 1. On the Home Page, under the Statements & Notifications tab, click the Statements & Notifications tab. 2. Click any link of your choice. Receipt Reminders, Account Statements, Advice of Deposits, Denial Letters, or Denial Letters with Repayments are a few options. PLAN INFORMATION? 1. On the Home Page, under the Accounts tab, click Account Summary on the drop-down menu. 2. Click the applicable account in the first column on the left and the Plan Rules open in another browser OR on the Home Page, under the Accounts tab, click Plan Descriptions on the drop-down menu for basic information. Then click each applicable plan to see the Plan Detail screen. MORE HELPFUL INFORMATION On the Home Page, under the Tools & Support tab, you may find links that connect you to helpful information supplied by your account administrator. These may be links to websites or to other valuable resources that enable you to manage your healthcare more effectively All Rights Reserved Evolution1, Inc. a WEX Company

34 South Washington County School District # Reimbursement Schedule Reimbursement Request **Reimbursements Deadline Date Distributed By 01/15/ /22/ /30/ /06/ /13/ /20/ /27/ /06/ /13/ /20/ /30/ /06/ /15/ /22/ /30/ /07/ /15/ /22/ /29/ /05/ /15/ /22/ /30/ /07/ /15/ /22/ /30/ /06/ /14/ /21/ /28/ /04/ /15/ /22/ /30/ /07/ /15/ /22/ /30/ /06/ /13/ /20/ /30/ /07/ /15/ /22/ /30/ /06/ /29/ /05/ /29/ /07/ /31/ /07/2016 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 the Reimbursements Distributed by date conflicts with a holiday, your reimbursement will be mailed the next working day.