Flexible Spending 125 Cafeteria Plan

FLEXIBLE SPENDING 125 CAFETERIA PLAN

The initial waiting period for the Flexible Spending Plan is first of the month after 90 days of full- time employment or at Open Enrollment for the upcoming plan year. The plan is based on calendar year.

Flexible Spending Plans(s) are offered to allow an employee the opportunity to put some of his/her salary aside before taxes to pay for many common out-of-pocket expenses. Essentially, the Flexible Spending Plan(s) allows an employee to reduce their gross income, effectively reducing the amount they pay in Federal, Social Security, and some State taxes. The employer also realizes savings on FICA withholding tax for each participating employee.

A Healthcare Flexible Spending Plan allows you to save for medical, dental or vision expenses with tax-free dollars for the payment of:

 Reimbursable expenses, those qualifying expenses that are not reimbursed by your medical, dental, or vision coverage. Certain over-the-counter (OTC) products are eligible for reimbursement. Some OTC products may require a supporting physician prescription or Letter of Medical Necessity (LOMN). The $2550 limit will remain in place for the 2017 Plan Year unless the IRS increases the allowable limit.

 Dependent/child care, as designed under Section 129 of the Internal Revenue Code, up to $5,000.00 annually ($2,500 if your married and file separately) for the care of the children up to the age of 13 or for the care of a mentally or physically disabled family member.

Only expenses incurred on or after your effective date through the end of the “benefit period,” are eligible for reimbursement. With Dependent Care reimbursement can be made up to the amount currently available in your account.

2016 Health Care FSA Plan participants who are active employees as of December 31, 2016 may utilize the “FSA Carryover Provision” introduced last year.  If you have $500 or less in unused funds in your 2016 Health Care FSA at the end of the plan year (12/31/16), those funds will automatically roll into your Health Care FSA for 2017.  The FSA Carryover Provision replaces the prior 90-day grace period (until March 31st) allowing claims to be submitted for the prior plan year.

Employees must enroll and elect an amount for each new plan year. If we do not receive a new election form each year, the employee will be dropped from the plan at the end of the prior plan year.

Please be aware these Flexible Spending Plans are “use it or lose it” plans. Use-it-or-lose-it refers to an IRS requirement that if you do not use the money you elected in your FSA account, that money will be subject to forfeiture. Balances remaining in the healthcare reimbursable account in “excess” of $500 will be forfeited if not utilized in the 2016 Plan Year. Deadline to submit claims for current plan year is the last day of the plan year.

Employees are encouraged to be cautious when estimating their future out-of-pocket expenses for the coming plan year. If this is your first time participating in a Flex Plan, please be conservative when electing the dollar amount.

Example: If an employee elected $2,000 for the 2016 Flex Healthcare Plan but only uses $1000 during the course of the plan year, $500 will roll over to the 2017 Plan and they will forfeit $500.

(More information on the back of this page) Suggestions for submitting reimbursement requests: 1. Please do not submit claims until after services are rendered and you have appropriate “Explanation of Benefits” (EOB) or super-bill showing your true out-of- pocket expense. 2. If you are a participant in a reimbursement plan through your insurance carrier or employer, please file for reimbursement with that program first. You may file a flex reimbursement request if you have remaining out-of-pocket expenses after your first reimbursement. 3. Please keep a copy of all paperwork submitted to Sunwest. 4. Reimbursable expenses (medical, dental and vision claims) must all be processed by your insurance carrier first. It doesn’t matter if it is in-network or out-of-network. Chiropractic care must be submitted and processed by your insurance carrier first before Flex reimbursement will be considered. We need the EOB from your insurance carrier. 5. Reimbursement for Orthodontics will be based on the contract between employee and orthodontist. (We will need a copy of the signed contract between you and the orthodontist.) 6. Reimbursement for prescription drugs requires a copy of the pharmacy receipt not just a store receipt. Store receipts do not show the name of the person receiving the prescription.

Over-the-counter (OTC) products that are not considered to be medicines or drugs are reimbursable without a doctor’s prescription. (Items listed below are an example not a comprehensive listing.) Band Aids Elastic Bandages & Wraps Birth Control First Aid Supplies Braces & Supports Insulin & Diabetic Supplies Catheters Ostomy Products Contact Lens Supplies & Solutions Reading Glasses Denture Adhesives Wheelchairs, Walkers, Canes Diagnostic Tests & Monitors

Over-the-counter (OTC) products that will always require a doctor’s prescription. (Items listed below are an example not a comprehensive listing.) Acid Controllers Feminine Anti-Fungal/Anti-Itch Allergy & Sinus Hemorrhoid Preparations/Suppositories/Cream Antibiotic Products Laxatives Anti-Diarrheal Motion Sickness Anti-Itch & Insect Bite Pain Relief Baby Rash Ointments/Creams Respiratory Treatments Cold Sore Remedies Sleep Aids & Sedatives Cough, Cold, & Flu Remedies Stomach Remedies Digestive Aids

Dual Purpose Over-the-counter (OTC) products that have a medical purpose and a personal/cosmetic or general health purpose. Before items can be considered for reimbursement, either a doctor’s prescription and/or a Letter of Medical Necessity (LOMN) will be required. (Items listed below are an example not a comprehensive listing.) Dental Fluoride Treatments Nose Strips for Proper Breathing1 Dietary Supplements Orthopedic Inserts Fiber Supplements Sleeping Aids Herbal Supplements Snoring Cessation Aids & Medication

Ineligible Over-the-counter (OTC) products that will not be reimbursed even with a prescription or Letter of Medical Necessity from a physician. (Items listed below are an example not a comprehensive listing.) Cosmetics Mouthwash, Antiseptics & Oral Anesthetics Deodorants Multi-Vitamins Face Creams & Cleansers Q-Tips/Cotton Balls Feminine Hygiene Products Teeth Whitening Kits & Products Hair Removal Treatments & Waxes Toiletries(Soaps, Shampoo, Toothpaste, Toothbrush) Lotions & Moisturizers Wrinkle Reducers