Visa Inc. Health and Dependent Care Flexible Spending Accounts Summary of Benefits July 1, 2013
Health and Dependent Care Flexible Spending Accounts i Table of Contents INTRODUCTION... 1 CONTRIBUTING TO A FLEXIBLE SPENDING ACCOUNT... 1 Overview of How the FSAs Work... 1 Forfeitures... 3 Re-Enrollment Required During Open Enrollment... 3 HEALTH CARE FSA... 4 Meaning of Eligible Medical Care Expenses... 4 Whose Eligible Medical Care Expenses May Be Reimbursed?... 7 Maximum Election Amount for Health Care FSA... 8 Health Care Tax Deduction... 8 Termination of Health Care FSA Participation Mid-Year... 8 COBRA Continuation for Health Care FSA... 9 DEPENDENT CARE FSA... 10 Meaning of Eligible Dependent Care Expenses... 10 Qualifying Individuals... 12 Election Amount for Dependent Care FSA... 12 Dependent Care FSA vs. Dependent Care Tax Credit... 13 IRS Form 2441 Required... 14 Termination of Dependent Care FSA Participation Mid-Year... 14 Continuation Coverage... 14 HOW TO REACH THE CLAIMS ADMINISTRATOR... 14
Health and Dependent Care Flexible Spending Accounts ii REQUESTING REIMBURSEMENTS... 14 Requesting Reimbursements... 14 Amount of Health FSA Reimbursement... 15 Amount of Dependent Care FSA Reimbursement... 15 Important Information about the Healthcare FSA Debit Card... 15 CLAIMS PROCEDURES... 17 Time Frame for Initial Claim Determination... 17 If You Receive an Adverse Benefit Determination... 17 Procedures for Appealing an Adverse Benefit Determination... 18
Health and Dependent Care Flexible Spending Accounts 1 INTRODUCTION This document summarizes the Health and Dependent Care Flexible Spending Accounts ( Health and Dependent Care FSAs ), effective July 1, 2013. The FSAs are offered under the Visa Welfare Benefits and Cafeteria Plan. Please refer to the summary plan description for the Visa Welfare Benefits and Cafeteria Plan for information regarding FSA eligibility, how to enroll, when coverage begins and ends, how to pay for coverage, making changes mid-year, your rights under ERISA, general administrative information, and definitions of terms that are capitalized, but not defined, in this document. CONTRIBUTING TO A FLEXIBLE SPENDING ACCOUNT Overview of How the FSAs Work Here is how the Health and Dependent Care FSAs work: The FSAs allow you to pay for certain Eligible Medical Care and Dependent Care Expenses (defined below) with pre-tax contributions. You must make an election to participate in the FSAs. There are limits to the amounts that you can contribute, which are discussed below. Your contributions to the FSAs are deducted from your pay before federal and, in most cases, state income and FICA taxes are applied. That means they will not be included in your gross taxable income, so there is less income to tax (compared to paying with after-tax dollars) and you reduce your current taxes. Although your contributions are not subject to FICA taxes, which may reduce your Social Security benefit slightly at retirement, this reduction rarely outweighs the financial advantages of using your FSAs. When you incur an Eligible Health or Dependent Care Expense, you pay the expense, then submit the appropriate claim form along with a receipt for the expense to TRI-AD. TRI-AD is the claims administrator for the FSAs. See the Requesting Reimbursements section below for more information on how to claim reimbursements.
Health and Dependent Care Flexible Spending Accounts 2 You will then be reimbursed with tax-free dollars for Eligible Health and Dependent Care Expenses that you incur during the Plan Year. You must estimate your expenses carefully because of the use or lose rule described below. An Example Here is an example of how the FSAs can help save you money money you would otherwise pay in taxes. This example assumes you are married and have two children, your combined annual income is $50,000 and you contribute $2,000 to a Health or Dependent Care FSA in 2013. With Health or Dependent Care FSA Without Health or Dependent Care FSA Combined annual income $50,000 $50,000 Pre-tax contributions (2,000) 0 Standard deduction (11,900) (11,900) Exemptions (4 x $3,800) (15,200) (15,200) Taxable income $20,900 $22,900 Income tax (assume 15%) (3,135) (3,435) Employee FICA taxes (7.65%) (3,672) (3,825) Total tax liability $6,807 $7,260 After tax health expense 0 (2,000) Take home pay $41,193 $40,740 Tax savings* $453 * Estimates assume you are filing a joint tax return, take the standard deduction and claim four exemptions. State taxes have not been included but could represent additional savings if you would have otherwise paid state tax on the money you contribute to your FSAs. The actual amount you save in taxes will depend on your personal situation. 2012 Standard Deductions and Exemptions have been used in this example.
Health and Dependent Care Flexible Spending Accounts 3 Forfeitures The amount in your Health and/or Dependent Care FSA may be forfeited for one of the following reasons. Forfeitures will be applied towards the costs of administering the FSAs. Use or Lose Rule If you do not claim reimbursement of your entire Health and/or Dependent Care FSA account balance for any Plan Year, you will forfeit any amounts remaining in your accounts. This is an IRS rule known as the use or lose rule. You have until March 31 of the following calendar year to submit claims for eligible Health or Dependent Care Expenses you incur in the previous Plan Year. Any balance remaining after that time is forfeited and cannot be rolled over or cashed out. For example, if you have claims for the 2013 Plan Year, you must submit those claims to TRI-AD by March 31, 2014. If you do not, your claim will not be processed and you will forfeit the balance of your FSA. Also, if you elect $2,500 for the Health FSA for 2013, but you incur only $1,500 of Eligible Medical Care Expenses in 2013, you will forfeit $1,000. Missing Participant/Uncashed Checks If TRI-AD is unable to locate you in order to send your reimbursement, or if you fail to cash your reimbursement checks, such reimbursements will be forfeited as of December 31 following the Plan Year in which the expense for which the reimbursement was requested was incurred. Re-Enrollment Required During Open Enrollment Your election under the Health and Dependent Care FSAs for a Plan Year will not automatically renew for the next following Plan Year, and will end on December 31. If you would like to re-enroll in the Health and Dependent Care FSAs for the next following Plan Year, you must re-enroll during Open Enrollment by using www.visabenefitsonline.com.
Health and Dependent Care Flexible Spending Accounts 4 HEALTH CARE FSA Meaning of Eligible Medical Care Expenses Eligible Medical Care Expenses that may be reimbursed from your Health FSA are any IRS-approved health care expenses that are incurred for medical care (as defined under Internal Revenue Code Section 213(d)) and that are not covered by your medical, dental or vision plan. Eligible Medical Care Expenses generally include amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease, and for treatments affecting any part or function of the body. The expenses must be primarily to alleviate or prevent a physical or mental defect or illness. Note: You cannot claim reimbursement for expenses that are paid through your medical plan or any other medical coverage or expenses for which you take a deduction on your annual tax return. Examples of Eligible Medical Care Expenses Eligible Medical Care Expenses include out-of-pocket health care expenses, such as deductibles, co-payments, eyeglasses, prescription drugs, chiropractors and hearing aids. In addition, the following is a list of some IRS-approved health care expenses for which you can seek reimbursement through the Health Care FSA. Please note that in certain cases the full amount of Eligible Medical Care Expenses may not be reimbursed because of IRS rules. Please contact the Plan Administrator if you have any questions regarding specific reimbursements. Acupuncture Ambulance Body scans Contact lenses and cleaning supplies Cost of Braille books and magazines that exceed the cost of a regular edition Eye-related equipment/materials (Eyeglasses and contact lenses) First aid kits (over-the-counter)
Health and Dependent Care Flexible Spending Accounts 5 Hearing aids and batteries Hydrotherapy Infertility treatment for self, spouse or dependent; In vitro fertilization Laser vision correction (laser or LASIK eye surgery) Learning disability treatments Necessary cosmetic surgery (e.g., reconstruction due to a birth defect) Nursing services, wages and taxes Organ transplant, recipient or donor s or possible organ donor s expenses Orthodontia expenses Orthopedic shoes (the excess cost of special form over normal) Ovulation monitor (over-the-counter) Pregnancy tests (over-the-counter) Prescribed medicines and drugs Psychiatric treatment and psychoanalysis, including the cost of supporting a mentally ill dependent at a specially equipped center Sacroiliac belt and truss Seeing eye dog and its maintenance (purchase, training, care) Services of a Christian Science practitioner Special equipment installed in your home or car for medical reasons Special school costs for physically and mentally handicapped children, including special tutoring fees Sterilization, vasectomy
Health and Dependent Care Flexible Spending Accounts 6 Telephone-teletype cost and television adapter for closed caption service for a deaf person Wheelchair and repairs For a complete list of eligible medical care expenses, please refer to IRS Publication 502, Medical and Dental Expenses, which is available from the IRS by calling 1-800-829-3676. You can also download copies of the publication at http://www.irs.gov. Examples of Expenses That Are Not Eligible Medical Care Expenses Here are some expenses that are not reimbursable through the Health Care FSA: Adoption fees Athletic or health club expenses/dues to maintain or improve physical fitness Premiums and contributions for health coverage of any kind Babysitting expenses incurred while you go to the doctor Boarding school fees paid for a child while the parent is recuperating from illness Bottled water COBRA premiums Dance lessons (even if advised by physician) Diaper service Domestic help (even if needed because of a Spouse/Domestic Partner s illness) Elective cosmetic surgery Funeral expenses Food or beverage substitutes (except cost of special foods over what would have ordinarily been spent on food if necessary because of an allergy) Hair removal products
Health and Dependent Care Flexible Spending Accounts 7 Hair transplants for cosmetic purposes Homeopathic medicines (over-the-counter) Household help Insurance premiums Late payment fees charged by health care providers Long-term care premiums of any kind Marriage counseling or legal fees for divorce Maternity clothes Over the counter drugs without a prescription Scientology fees Sunglasses, non-prescription Tattooing Teeth whitening/bleaching Transportation costs of a disabled person to and from work Travel for reasons of health (even if prescribed by physician) Tuition and travel expenses to send a child to a particular school for a beneficial change in environment Vitamins, general wellness (over-the-counter) Weight reduction programs and foods for general health Whose Eligible Medical Care Expenses May Be Reimbursed? Your Health FSA can be used to reimburse Eligible Medical Care Expenses incurred by: You;
Health and Dependent Care Flexible Spending Accounts 8 Your Spouse; Your child, up to and including the year in which the child turns age 26, without regard to whether the child is a student, married, or living at home; or Your qualifying child or qualifying relatives. These terms are explained in the Tax Consequences section of the SPD for the Visa Welfare Benefits and Cafeteria Plan. Note: Unless your Domestic Partner and/or his children are also your qualifying relative or qualifying child (as applicable), you will not be able to claim reimbursement from your Health FSA for any of their medical care expenses. Maximum Election Amount for Health Care FSA You can contribute a minimum of $50, and a maximum of $2,500 per Plan Year to the Health Care FSA. Health Care Tax Deduction If you use money from your Health Care FSA for an Eligible Medical Care Expense, you cannot claim that expense as a deduction on your income tax return. In determining whether a tax deduction or reimbursement through your Health Care FSA is better for you, keep in mind that under IRS rules only medical expenses that exceed 7.5% of your adjusted gross income can be deducted from your income taxes. Many people do not have expenses high enough to qualify for this deduction. Termination of Health Care FSA Participation Mid-Year If you terminate participation in the Health FSA mid-year (for example, you terminate employment mid-year), you may submit claims for Eligible Health Care Expenses as long as those services are provided no later than your last day of employment (unless you elect COBRA continuation coverage, which is available in limited circumstances described below). You must submit claims for these expenses by March 31 following the last day of the Plan Year, otherwise the balance will be forfeited.
Health and Dependent Care Flexible Spending Accounts 9 COBRA Continuation for Health Care FSA Under a federal law commonly known as COBRA, you, your Spouse and any persons whose Eligible Health Care Expenses may be reimbursed from your Health FSA may elect to temporarily continue participation in the Health Care FSA in certain instances where coverage otherwise would be reduced or terminated. Generally, your participation in the Health Care FSA ends as of your termination date. However, if you have not already spent more than you contributed to the account before termination, you may elect COBRA continuation coverage through the end of the Plan Year. This means that you may submit claims for reimbursement of Eligible Medical Care Expenses incurred during the remainder of that Plan Year. At the time you cease participation in the Health Care FSA, the Plan Administrator will provide you with the required COBRA continuation coverage explanation and election forms. You have sixty days after the date your participation in the Health Care FSA would otherwise cease to elect COBRA. If you elect COBRA continuation coverage: Your contributions to your account will be after-tax, and will be equal to 102% of the amount you previously paid each month. You have 45 days after your COBRA election to pay the monthly after-tax contributions required to bring your coverage up to date. You must submit claims for reimbursement by March 31 following the last day of the Plan Year. Any balance remaining in your account after March 31 following the last day of the applicable Plan Year will be forfeited. In no event will you be able to participate in the Health Care FSA for Plan Years following the Plan Year in which you cease participation in the Health Care FSA, even if your COBRA continuation period is still in effect for your other health care coverage(s).
Health and Dependent Care Flexible Spending Accounts 10 DEPENDENT CARE FSA Meaning of Eligible Dependent Care Expenses Eligible Dependent Care Expenses include amounts paid for the care of Qualifying Individuals (defined below), or for related household services that include the care of a Qualifying Individual, that allow you (and your Spouse, if you are married) to work or look for work. Whether your expenses allow you and your Spouse to work or look for work depends on the facts, for example: Your Spouse is treated as working during any month he or she is a full-time student or is physically or mentally not able to care for him or herself. The cost of a baby sitter while you and your Spouse go out to eat after work is not normally a work-related expense. Expenses are not considered work-related merely because you incurred them while you were working. They must enable you to be gainfully employed. In addition, amounts paid for dependent care do not qualify for reimbursement if they are paid to: (a) your own child who is under the age of 19 at the end of the year; (b) a person for whom you could claim an income tax exemption as a dependent under the Internal Revenue Code; (c) your Spouse; or (d) the parent (who is not your Spouse) of your qualifying child who is under age 13. Examples of Eligible Dependent Care Expenses Here is a list of some IRS-approved dependent care expenses for which you can seek reimbursement through the Dependent Care FSA: A nanny; A day care center (includes before/after school. If it provides care for more than six individuals it must meet state and local regulations) Elder/dependent care facility
Health and Dependent Care Flexible Spending Accounts 11 Housekeeper, maid or cook, as long as he or she is at least responsible for the well-being and protection of a Qualifying Individual (including meal and lodging expenses) Babysitters or companions, including your children age 19 or over and relatives whom you cannot claim as exemptions on your federal tax return Nursery school or preschool Day camp. Note that if the expenses are incurred for services outside your household, they must be incurred for the care of a Qualifying Individual under age 13, or a Qualifying Individual who regularly spends at least 8 hours per day in your household. For a complete list of eligible dependent care expenses, please refer to IRS Publication 503, Child and Dependent Care Expenses, which is available from the IRS by calling 1-800-829-3676. Or, you can download a copy of the publication at http://www.irs.gov. Examples of Expenses That Are Not Eligible Dependent Care Expenses Here are some examples of dependent care expenses that are not payable through the Dependent Care FSA: Nursing home charges Overnight camp School fees for children in kindergarten and up Expenses you deduct or for which you take a tax credit on your federal income tax return Food or clothing expenses for your dependent (except for small amounts paid for these items which cannot be separated from the cost of caring for the person) Transportation expenses Amounts you pay for dependent care while you are off work because of illness.
Health and Dependent Care Flexible Spending Accounts 12 Qualifying Individuals Generally, a Qualifying Individual is your: Qualifying child who is younger than age 13 or who is physically or mentally incapable of self-care and who has the same principal place of residence as you for more than half of the year. Qualifying child is defined in the Whose Eligible Medical Care Expenses May Be Reimbursed section above. Spouse who is physically or mentally incapable of self-care and who has the same principal place of residence as you for more than half of the year; or Qualifying relative who is physically or mentally incapable of self-care and who has the same principal place of residence as you for more than half of the year. Qualifying relative is defined in the Whose Eligible Medical Care Expenses May Be Reimbursed section above. Election Amount for Dependent Care FSA The minimum amount that you can elect to contribute to your Dependent Care FSA for the Plan Year is $50. The maximum amount that you can elect to contribute to your Dependent Care FSA for the Plan Year is the lesser of: $5,000, if you are: married and file a joint federal income tax return (if you are married and reside with your Spouse, but you file separate returns, the maximum amount is $2,500); single; the head of household for federal income tax purposes; or married but filing a separate return, if your Spouse: (i) maintains a separate household for the last six months of the calendar year; (ii) your household is the principal place of residence of a Qualifying
Health and Dependent Care Flexible Spending Accounts 13 Individual; and (iii) you furnish more than one-half the cost of maintaining such household; or The earned income of you or your Spouse. Your Spouse will be deemed to have earned income of $250 ($500 if you have two or more Qualifying Individuals) for each month in which your Spouse is: (i) physically or mentally incapable of caring for himself, or (ii) a full-time student. This means that if you are married, generally you will not be able to participate unless your Spouse is employed. Dependent Care FSA vs. Child Care Tax Credit Under current federal tax law, you can be reimbursed for Eligible Dependent Care Expenses with pre-tax dollars through the Dependent Care FSA, or you can claim a Child Care Tax Credit for dependent care expenses when you file your federal income tax return. For 2013, the federal Child Care Tax Credit applies to up to $3,000 in eligible expenses for one qualifying dependent, or up to $6,000 in eligible expenses for two or more qualifying dependents. You may be able to use both approaches, but you cannot take a deduction for the same expenses twice. In addition, the amount of expenses that will qualify for a tax credit will be reduced, dollar for dollar, by any amount you receive from a Dependent Care FSA. In addition to the Child Care Tax Credit, you should also consider whether other tax credits may be adversely affected by your participation in the Dependent Care FSA. Please refer to IRS Publication 503 for more detailed information on the Child Care Tax Credit. In addition, for specific advice about your situation, you should consult a tax advisor.
Health and Dependent Care Flexible Spending Accounts 14 IRS Form 2441 Required If you participate in the Dependent Care FSA, you must file IRS Form 2441 with your federal income tax return to report the amount of dependent care assistance provided to you. Termination of Dependent Care FSA Participation Mid-Year If you cease participation in the Dependent Care FSA mid-year (for example, because you terminate employment mid-year), you may continue to spend-down your Dependent Care FSA and submit claims for reimbursement of Eligible Dependent Expenses incurred prior to the end of the Plan Year of termination. For example, if you terminate employment in August 2013, and you have $1,000 remaining in your Dependent Care FSA, you may claim reimbursement of $1,000 of Eligible Dependent Care Expenses that you incur up to December 31, 2013. You must submit claims for these expenses by March 31 following the last day of the Plan Year, otherwise the balance will be forfeited. Continuation Coverage The Dependent Care FSA cannot be continued under COBRA. If you take a leave of absence, you must elect whether to continue or revoke your Dependent Care FSA. You will not be able to claim reimbursement for any dependent care expenses incurred while you are on a leave of absence, whether paid or unpaid. HOW TO REACH THE CLAIMS ADMINISTRATOR You can reach TRI-AD, the third party administrator for the Health and Dependent Care FSAs, by calling 1-888-844-1372 or by visiting www.visabenefitsonline.com. REQUESTING REIMBURSEMENTS Requesting Reimbursements Generally, any eligible expense incurred during the Plan Year may be paid from your FSA for that Plan Year. Expenses are incurred when the service is received, not the date you are billed or charged for it or pay for it. However, you cannot use your account to pay for services you receive before or after the Plan Year, during
Health and Dependent Care Flexible Spending Accounts 15 another Plan Year, for services you will receive in the future (even if you had to pay for them in advance) or before you enroll in the Plan. To receive Health Care and Dependent Care FSA reimbursements, you must submit a claim form to TRI-AD. A claim form is included in your Welcome Kit, and forms are also available on http://benefitsource.visa.com/ under the Forms section. You can submit your claim at anytime by either faxing or mailing your claim form and receipt to TRI-AD. Claims will be paid as soon as administratively practicable after you submit a claim. If you did not receive a Welcome Kit or you need a claim form, call TRI-AD at 1-888-844-1372 or go to TRI-AD s Web site at www.visabenefitsonline.com. Amount of Health Care FSA Reimbursement You will be reimbursed for Eligible Medical Care Expenses, up to the amount of your request, provided that your total reimbursements during a Plan Year do not exceed the total amount of your Health Care FSA salary reduction election for that Plan Year, as reduced for previous reimbursements. Any money remaining in your Heath Care FSA after you submit your request will be applied to future requests throughout the Plan Year. After each Plan Year ends you will receive a statement that identifies the amount remaining in your account, if any. Amount of Dependent Care FSA Reimbursement You will be reimbursed for Eligible Dependent Care Expenses, up to the amount that has already been credited through contributions to your Dependent Care FSA at that time, minus reimbursements already made during the Plan Year. Remaining claim amounts will be reimbursed as you make additional contributions to your Dependent Care FSA during the Plan Year. Important Information about the Health Care FSA Debit Card For Health Care Expense Only. FSA accounts are closely governed by IRS regulations to ensure that the funds are only used for Eligible Medical Care Expenses. Therefore, the FSA Visa debit card has restrictions that are slightly different than all other Visa card products. It cannot be used at all merchant locations that accept Visa debit. When using your FSA Visa debit card to pay for
Health and Dependent Care Flexible Spending Accounts 16 Eligible Medical Care Expenses, be careful not to include items that do not qualify for reimbursement. Accidentally purchasing a non qualified item, such as a pack of gum, with your FSA Visa debit card will require you to repay the ineligible amount or submit a paper claim to offset the amount of the purchase. Sign your Receipt. The FSA Visa debit card is a signature based card with no PIN capability. This means that a signature receipt is required each time you make a purchase using this card. PIN based debit transactions at the point of sale or ATM cash access is not allowed. Always Select, Credit. When using your FSA Visa debit card at a point of sale terminal, please make sure that you always select the Credit option. Selecting Credit at the terminal will ensure a signature receipt and the transaction will be processed without requiring a PIN. If prompted to use a PIN, select, No or Cancel. Save Your Receipts. The use of FSA Visa debit card is subject to the rules published by the IRS. It is therefore important to save all of your receipts as proof of Eligible Medical Care Expenses for at least 12 months following the end of the Plan Year. If TRI-AD cannot identify an item you purchased with your card as an Eligible Medical Care Expense, they may ask you to provide proof of this purchase. For this reason, when requested, please send in your receipts as quickly as possible, following the instructions in the request. TRI-AD needs a receipt that identifies the item or services purchased and the date of purchase. A receipt that does not include these details will not be considered as sufficient proof of eligible purchase. Please note the failure to submit itemized receipts when requested may lead to suspension of your FSA Visa debit card. If your receipts are misplaced or if your provider did not provide an acceptable receipt, you may need to submit paper claims until the expenses can be resolved. If you fax your receipts to TRI-AD, please make sure that you allow a couple of days for processing.
Health and Dependent Care Flexible Spending Accounts 17 CLAIMS PROCEDURES Time Frame for Initial Claim Determination The claim administrator will notify you of an adverse benefit determination within 30 days after receipt of a claim. An adverse benefit determination is any denial, reduction or termination of a benefit, or a failure to provide or make a payment, in whole or in part, for a benefit. A 15-day extension may be allowed to make a determination, provided that the claim administrator determines that the extension is necessary due to matters beyond its control. If such an extension is necessary, the claim administrator must notify you before the end of the first 30-day period of the reason(s) requiring the extension and the date it expects to provide a decision on your claim. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension must also specifically describe the required information. You then have 45 days to provide the information needed to process your claim. If an extension is necessary due to your failure to submit necessary information, the plan s time frame for making a benefit determination is stopped from the date the plan administrator sends you an extension notification until the date you respond to the request for additional information. If You Receive an Adverse Benefit Determination The claim administrator will provide you with a notification of any adverse benefit determination, which will set forth: The specific reason(s) for the adverse benefit determination References to the specific plan provisions on which the benefit determination is based A description of any additional material or information needed to process the claim and an explanation of why that material or information is necessary
Health and Dependent Care Flexible Spending Accounts 18 A description of the plan s appeal procedures and the time limits applicable to those procedures, including a statement of your right to bring a civil action under ERISA after an appeal of an adverse benefit determination Any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse benefit determination or a statement that a copy of this information will be provided free of charge to you upon request If the adverse benefit determination was based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your medical circumstances or a statement that such explanation will be provided free of charge upon request. Procedures for Appealing an Adverse Benefit Determination If you receive an adverse benefit determination, you may ask for a review. You, or your authorized representative, have 180 days following the receipt of a notification of an adverse benefit determination within which to appeal the determination. You have the right to: Submit written comments, documents, records and other information relating to the claim for benefits Request, free of charge, reasonable access to and copies of all documents, records and other information relevant to your claim for benefits A review that takes into account all comments, documents, records and other information submitted by you related to the claim, regardless of whether the information was submitted or considered in the initial benefit determination A review that does not defer to the initial adverse benefit determination and that is conducted neither by the individual who made the adverse determination, nor that person s subordinate A review in which the named fiduciary consults with a health care professional who has appropriate training and experience in the field of medicine involved in
Health and Dependent Care Flexible Spending Accounts 19 the medical judgment, and who was neither consulted in connection with the initial adverse benefit determination, nor the subordinate of any such individual. This applies only if the appeal involves an adverse benefit determination based in whole or in part on a medical judgment (including whether a particular treatment, drug or other item is experimental) The identification of medical or vocational experts whose advice was obtained in connection with the adverse benefit determination, regardless of whether the advice was relied upon in making the decision. Ordinarily, a decision regarding your appeal will be reached within 60 days after receipt of your request for review of your claim. The claim administrator s notice of an adverse benefit determination on appeal will contain all of the following information: The specific reason(s) for the adverse benefit determination References to the specific plan provisions on which the benefit determination is based A statement that you are entitled to receive, upon request and free of charge, reasonable access to and copies of, all documents, records and other information relevant to your claim A statement describing any voluntary appeal procedures offered by the plan and your right to obtain the information about such procedures and a statement of your right to bring an action under ERISA Any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse benefit determination; or a statement that a copy of this information will be provided free of charge to you upon request If the adverse benefit determination was based on a medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the adverse determination, applying the terms of the plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.