BENEFICIO DE LAS OPERACIONES 1%

When deciding how much to contribute to the account, keep in mind that IRS regulations require any amounts left over at the end of the plan year

to be forfeited. And, you cannot change your contribution amount during the plan year unless you have a qualifying event (see page 1-13) If You Are Enrolled on the Health Reimbursement Medical Plan:

Order of Reimbursement Between

Accounts for Medical Expenses

If you are enrolled in the Health Reimbursement Medical Plan and have funds available in your

in your HRA will be used first to pay your out of pocket medical and prescription expenses covered by the plan. Once the funds in your HRA have been “spent” you may use your Health Care Flexible Spending Account for those out of pocket medical expenses.

If You Are Enrolled on the Health Savings Medical Plan:

Limited Purpose Health Care Flexible

Spending Account

Expenses reimbursed by a limited purpose Health Care Flexible Spending Account (Health FSA) are restricted until you reach your plan’s deductible. Here’s how it works:

Before you meet your medical plan deductible,

your Health FSA funds are available only for certain expenses, including:

● Dental care and orthodontia, such as fillings, X-rays, braces, caps and mouth guards

● Vision care, including eyeglasses, contact lenses, solutions and supplies, and LASIK eye surgery

● Health care not covered under a medical plan

● Prescriptions and over-the-counter items are reimbursable only for dental, vision and preventive care.

After you meet your medical plan deductible:

● You will get reimbursed for all Health FSA qualified health care expenses, except your deductible.

If you elected the Health Savings medical option but are, or become, ineligible to receive contributions to a health care savings account (HSA), your account will not be subject to the restrictions of a Limited Purpose Health Care

What Is Covered?

Qualifying medical care expenses are defined by the IRS as amounts “paid for the diagnosis, cure, medication, treatment, or prevention of disease, or for transportation primarily for and essential to medical care.” All expenses must be qualified medical, vision, pharmacy or dental benefit expenses as defined in Section 213(d) of the Internal Revenue Code.

Some examples of items that qualify for reimbursement are:

● Any deductibles and coinsurance you may have to pay under your elected Medical, Dental, or Vision option.

● Dental expenses not paid by dental insurance. ● Cost of eyewear and lenses if you waive the

Vision Service Plan

● Any health charges in excess of Medical, Dental and Vision Plan limits, for example:

● Additional cost to you if a second surgical opinion or hospital pre-admission

certification is not obtained when required or HMO guidelines are not followed; ● Dental expenses in excess of plan payments

(such as orthodontia costs in excess of $2,000); and

● Vision expenses in excess of VSP payments. ● Any IRS-eligible health care charges not

covered by the Medical, Dental and Vision plans, and not specifically excluded by this plan (see page 14-3).

● Other health care services that would qualify as medical deductions under IRS rules include: ● Legally obtained, generally accepted over

the counter medicine and drugs used for personal medical care to mitigate pain and/ or treat disease or illness or for the purpose of affecting any structure or function of the body. Examples include: antacid, allergy medicine, pain reliever, cold medicine from pharmacy, and over-the-counter Claritin®

● You will only be able to receive

reimbursement under the health flexible spending account for your over the counter (OTC) drugs and medicines with a doctor’s prescription. You will need

to remit your receipt for the OTC drugs and medicine along with your doctor’s prescription to receive reimbursement or use your debit card at the pharmacy counter.

● Weight loss programs prescribed by a physician for treatment of a specific disease or ailment, such as obesity or hypertension; the cost of diet food items in not eligible; ● Special medical equipment, such as oxygen

equipment;

● Nursing services for care of a specific medical ailment;

● Cost of a nurse’s room and board if paid by the employee where a nurse’s services qualify;

● Services of psychotherapists, psychiatrists, and psychologists;

● Acupuncture;

● Reversal of sterilization; ● Physical therapy;

● Expenses for services connected with donating an organ;

● Cost of a guide for a blind person; ● Cost of a note-taker for a deaf child in

school;

● Prescription drugs or insulin;

● Cost of Braille books and magazines in excess of the cost of regular editions; ● Household visual alert system for deaf

person;

● Excess costs of specifically equipping an automobile for a disabled person over the cost of an ordinary automobile; device for lifting disabled person into automobile;

● Wigs (where necessary due to mental health of individual who loses hair because of disease);

● Hearing aids and care; and

● Cost of fluoridation of home water supply advised by a dentist.

The expenses may be incurred for services provided to you, your spouse, any person who would qualify as your dependent under federal income tax rules (even if they are not covered under the Medical, Dental, or Vision option you select), and your adult child up to age 26.

You can obtain a complete list of eligible expenses on HealthEquity’s web site, www.healthequity. com./providence.

Some IRS eligible expenses are excluded from this Plan.

Exclusions

Expenses which do not qualify for reimbursement through the Health Care Flexible Spending Account include:

● Medical expenses that are eligible for

reimbursement from available balances in your health reimbursement account.

● If you are enrolled on the Health Savings Medical Plan and open an health savings account (HSA), you will not be able to use the Health Care Flexible Spending account for the amounts applied to your plan deductible. (if you have your HSA through HealthEquity this exclusion will be administered for you.) ● Charges for services obtained before the

effective date of your contributions to the account for the plan year

● Charges for services obtained after the

discontinuance of contributions to the account for the plan year

● Health care insurance premiums

renders services of a nonmedical nature ● Nursemaids or practical nurses who render

general care for healthy infants

● Cosmetic surgery, unless medically necessary and allowed under IRS regulations

● Tattoos and ear piercing ● Religious cult deprogramming

● Fees for exercise, athletic or health club memberships

● Physical treatments unrelated to a specific health problem (for example, massage for general well-being);

● Payments for Church of Scientology auditing and processing

● Marriage counseling provided by clergy member ● Weight reduction programs for general well-

being and appearance ● Any illegal treatment

● Psychoanalysis undertaken to satisfy a student’s curriculum requirement

● Cost of items for general health or appearance, such as vitamins, dietary supplements,

toiletries, cosmetics, and sundry items (for example, soap, tooth brushes)

● Cost of illegal drugs

● Cost of nonprescription drugs, except as defined on page 14-2

● Abortion or sterilization

● Drugs which act as, or which under the Ethical and Religious Directives for Catholic Health Care Services Part 4 (fifth edition) are considered to act as, abortifacients

● Maternity clothes ● Diaper service

● Vacuum cleaner purchased by individual with dust allergy

● Mechanical exercise device not specifically prescribed by doctor

● Insurance against loss of income; loss of life, limb, or sight

● Contributions to state disability funds ● Long Term Care premiums and expenses ● Over the counter drugs and medicines without

a physician’s prescription