benefits Dependent Care Flexible Spending Account Plan Document and Summary Plan Description January 2016

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Plan Document and Summary Plan Description

Dependent Care Flexible Spending Account

A Component of the Mayo Flexible Spending Account Plan

January 2016

benefits

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Dependent Care Flexible Spending Account

(A Component of the Mayo Flexible Spending Account Plan)

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT HOW TO USE THIS DOCUMENT

HOW TO USE THIS DOCUMENT

The Table of Contents on page 5 provides an overview of the detailed information in the Plan. You will also find a Glossary of terms used in the Plan document beginning on page 27.

To quickly search for a specific word or phrase, simply press your “Ctrl” and “F” keys simultaneously to open the search function.

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HEALTH CARE FLEXIBLE SPENDING ACCOUNT INTRODUCTION

INTRODUCTION

Mayo Clinic sponsors the Dependent Care Flexible Spending Account (“Plan”), which is a component of the Mayo Flexible Spending Account Plan, to reimburse eligible employees of Mayo Clinic and other participating employers for dependent care expenses on a pre-tax basis. Effective January 1, 2016, this document sets forth the benefits under the Plan and replaces all previous Plan statements and descriptions. There are separate summaries for the Health Care Flexible Spending Account and Pre-Tax Health Savings Account Plan which are the other components of the Mayo Flexible Spending Account Plan.

Because this document is intended to give employees an easily understood explanation of the Plan, it also serves as the summary plan description. Privacy rules required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are part of this Plan and are stated in a separate document that is available from the Plan Administrator.

Many of the provisions in the Plan are interrelated. Therefore, please review this entire document so that you understand fully what your benefits and responsibilities are under this Plan. The right of Mayo Clinic to amend or terminate this Plan is explained in the administrative section of this document.

The pre-tax payments under this Plan are permitted under Section 125 of the Internal Revenue Code, subject to certain rules and limitations, including the requirement of a written plan document. This

document includes the written Pre-Tax Premium Payment Rules for this Plan (“Pre-Tax Premium Rules”). The Plan will be administered in accordance with these rules and limitations and with any subsequent amendment to or clarification of the rules and limitations. The Pre-Tax Premium Rules are not subject to ERISA. The plan year for the Premium Payment Rules is the calendar year.

You should also consider the fact that an adult dependent child who may be eligible for coverage under the Mayo Medical Plan is not an eligible family member under this Plan unless that adult child is your tax dependent for Federal income tax purposes. If you have any questions about whether your child is a tax dependent, please consult your tax advisor.

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HEALTH CARE FLEXIBLE SPENDING ACCOUNT CONTACT INFORMATION

CONTACT INFORMATION

Mayo Clinic Health Solutions is the Claim Administrator for the Dependent Care Flexible Spending Account and processes claims and answers claim questions for the Plan.

Mayo Clinic Health Solutions customer service representatives are available to answer any questions or concerns regarding Plan. Phone lines are open from 7 a.m. to 7 p.m. (Central Time) Monday through Friday (excluding holidays).

For enrollment or eligibility questions, please contact Mayo Clinic’s Employee Service Center. The Employee Service Center is your contact for this Plan. Phone lines are open from 7 a.m. to 6 p.m. (Central Time) Monday through Friday (excluding holidays).

QUESTIONS ABOUT PLAN

Mayo Clinic Health Solutions 4001 41 Street NW Rochester, MN 55901-8901

507-266-5580 (local) 1-800-635-6671 (toll free) TDD at 1-800-407-2442 (toll free) www.mayoclinichealthsolutions.com

QUESTIONS ABOUT ENROLLMENT/ELIGIBILITY

Mayo Clinic Employee Service Center 200 First Street SW

Rochester, MN 55905 507-266-0440 (local) 1-888-266-0440 (toll free)

Waycross, GA staff to contact local Human Resources office

The Employee Service Center and Mayo Clinic Health Solutions Customer Service have access to translation services to meet the needs of many non-English speaking persons.

El presente Resumen del Plan de Descripción, que también sirve como documento del plan, está redactado en inglés y ofrece detalles sobre sus derechos y beneficios bajo el Plan Médico de Mayo. Si tiene alguna dificultad para entender cualquier parte de este documento, por favor comuníquese con el Centro para Servicios al Empleado o con el Servicio de Atención al Cliente de Mayo Clinic Health Solutions, a los números que constan abajo.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT TABLE OF CONTENTS

ELIGIBILITY AND PARTICIPATION

Who is eligible for coverage?

If you are classified by a participating employer for payroll and personnel purposes as an employee who is regularly scheduled to work at least half-time [forty (40) hours or more per pay period] for the

employer, you are considered an eligible employee and eligible to enroll on the first day of employment and during the annual open enrollment. If you have eligible dependents and qualifying dependent care expenses (See the “Definition of Dependents” and “Eligible Expenses” sections of the Plan for more information on these requirements). Regularly scheduled means your schedule on file with your employer is .5 FTE or more. A .4 FTE working extra hours does not qualify as regularly scheduled to work .5 FTE.

An employer’s classification is conclusive and binding for purposes of determining benefit eligibility under the Plan. No reclassification of an employee’s or non-employee’s status for any reason by a third party, whether by a court, governmental agency, or otherwise, and without regard to whether or not the employer agrees to the reclassification, shall make the employee retroactively or prospectively eligible for benefits. Any uncertainty regarding an employee’s classification will be resolved by excluding that person from eligibility.

Waiting Period. There is no waiting period. An eligible employee is eligible for coverage on the first day of employment or change to eligible status with the employer.

FMLA Covered Persons. Family Medical Leave Act leaves of absence will be administered according to applicable law and policies established by the employer. Copies of FMLA policies are available from the employer.

Military Leave Covered Persons. Military leaves of absence will be administered according to applicable law and policies established by the employer. Copies of military leave policies are available from the employer.

Leave of Absence. Employees who would normally be working as a regular employee for the employer for at least the required number of hours per pay period to qualify as an eligible employee, but who are on an employer approved leave of absence, including approved personal, disability, parental, and/or military leave, remain eligible employees for the duration of the approved leave. Any contributions, however, that are made during unpaid or third-party paid leaves have to be made with after-tax dollars.

When You Can You enroll?

The following paragraphs describe enrollment.

Initial Enrollment

Eligible employees. An eligible employee has 31 days from the date he/she first satisfies the definition of eligible employee to enroll for coverage in the Plan. This is called the initial

enrollment period. Enrollment materials are available from the designated person of the employer. Enrollment materials must be completed and returned to the Plan Administrator or its designee within the 31 day period. If enrollment does not occur within this initial period, the eligible employee may enroll in the Plan only if a “special enrollment” situation occurs or during the annual open enrollment.

Open Enrollment

Prior to the start of a coverage year, the Plan has an open enrollment period. If you wish to

participate, you must enroll each year. At that time, you may elect to enroll, increase, decrease your contributions, or drop coverage. The terms of the open enrollment period, including duration

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of the election period, shall be determined by the Plan Administrator and communicated prior to the start of the open enrollment period. Once your elections are effective, you may not change them until the next annual enrollment period unless you experience a “special enrollment.” The open enrollment effective date of coverage is January 1.

Can I change or cancel my enrollment during the year?

Because you contribute to the Plan on a pre-tax basis, federal law limits your ability to change benefit elections during the year. This means that once you make your enrollment, you cannot change or cancel it

unless you experience an event that qualifies under the Change in Status Events listing. Your change must

be both on account of and consistent with the change in status event. Change in status events and consistency requirements that apply to the Plan are described in the chart below. You may be asked to provide proof of your change in status event and the date the event occurred. Failure to do so may result in denial of your change request.

You must contact the Employee Service Center within 31 days of the event to request a change. Change in Status Event Permitted Election Changes Marriage Enroll or increase coverage because of

new dependent(s) with eligible expenses.

Cancel coverage if your spouse does not work outside the home.

Cancel or decrease coverage if your spouse has dependent care benefits that will reduce your expenses.

Divorce, Annulment, or Legal Separation Enroll or increase coverage if as a result

of divorce you have new or additional expenses for eligible dependent(s).

Decrease or cancel coverage if your dependent(s) with eligible expenses will reside with spouse and your dependent care needs are reduced or eliminated.

Death of spouse Enroll or increase coverage if as a result of the death you have new or additional expenses for eligible dependent(s).

Decrease or cancel coverage if your spouse had eligible dependent care expenses.

Decrease in Number of Dependents

(divorce, death of spouse, adoption, death, etc.)

Enroll or increase coverage.

Decrease or cancel coverage if the death of a dependent affects your need for dependent care.

Dependent Loses Eligibility Decrease or cancel coverage only

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Change in Status Event Permitted Election Changes Dependent Gains Eligibility Enroll or increase coverage only relating

to dependent gaining eligibility.

Change in Status Event Permitted Election Changes Employment Status Changes of Spouse —

You or dependents gain or lose eligibility under the dependent care component of another flexible benefit plan

Enroll or increase coverage because of loss of other coverage (e.g., if you participated in spouse’s plan and spouse loses coverage).

Cancel or decrease coverage if as a result of spouse’s employment status change you no longer have eligible expenses (e.g., spouse is terminated).

Your Employment Status Changes —

You gain or lose eligibility under your employer’s Plan

Enroll in coverage if you have gained eligibility for the Plan and you have eligible dependent care expenses. If you have lost eligibility in an employment related change such as termination or moving from a benefit eligible to benefit ineligible job

classification, your coverage and pre-tax election will be canceled. You can continue to submit any expenses you incurred before your coverage was canceled until March 31 of the following year.

Residence Change Enroll, increase, or decrease coverage, as applicable, if your dependent care coverage costs or needs change as a result of the residence change.

Certain Changes under Spouse’s Employer’s Plan. If they are due to and correspond with a permitted change made under your spouse’s employer’s plan (for example, if your spouse’s employer adds a new dependent care option mid-year and your spouse elects coverage under the new option) or during the annual enrollment period of your spouse’s employer’s plan, if it (and the plan year) is different from Mayo’s annual enrollment and Plan year.

Enroll or increase coverage if you are dropping coverage under spouse’s plan.

Cancel or decrease coverage if you and/or any dependent(s) will be covered by spouse’s plan.

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Change in Status Event Permitted Election Changes Change to Cost or Coverage Needs Increase or Decrease if your dependent

care costs (as long as the day care provider is not your relative) or coverage needs change. For example, if your day care center increases its rates, you can increase your contributions prospectively as long as you have not already elected to contribute the annual maximum.

Similarly, if your work hours change and you need fewer (or more) hours of day care, you can make a corresponding change to your election.

How do I cancel coverage or reduce my coverage level?

Some changes to your Dependent Care Flexible Spending Account will happen automatically. For example, if you terminate or are no longer eligible for coverage under the Plan, your coverage will automatically be terminated. If you return to work to a benefit eligible position within 30 days of your termination, your benefits are automatically reinstated at the previous election level. If you are rehired or otherwise become benefit eligible after 30 days, you are treated as a new hire.

What is my deadline to change my election?

If you experience one of the change in status events listed above and want to enroll in the plan, or change or cancel your enrollment in the Plan, contact your Human Resources office within 31 days of the occurrence of the event.

What if I have questions about enrolling or changing my election after a change in status?

Mayo Clinic administers the Plan according to the rules and retains the discretion to determine whether you can make the desired cancellation or reduction of coverage. If you have further questions, contact your Human Resources office.

When does my coverage become effective?

The date on which coverage becomes effective depends on when enrollment occurs.

a. Enrollment within Initial Enrollment Period. The effective date of coverage for eligible

employees who enroll during the initial enrollment period is the first day of employment or change to eligible status with the employer.

Open Enrollment Period. If an eligible employee does not enroll within the initial enrollment period, he or she must wait until the next open enrollment period unless a “special

enrollment” situation occurs. The effective date of coverage would be the first day of the coverage year for which the open enrollment period was held. Additional information is available on page 7.

b. Change in Status. When enrollment occurs as the result of a change in status described

above, your new elections will be effective the first payroll period following the date your completed election change is approved.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT WHEN DOES COVERAGE END

WHEN DOES COVERAGE END

Employee Coverage Ends

Coverage ends at midnight on the earliest of the following dates:

• The day in which you terminate employment with the employer.

• The day in which your employment position or status changes such that you are no longer an

eligible employee.

• The date the employer terminates the Plan or its participation in the Plan.

• The date of your death.

• If the Plan is amended so that you lose coverage, the effective date of the amendment.

• The last day of the Plan year for which you have a benefit election in effect.

• The last day of the pay period following the date you request your benefit election be terminated

as a result of, and consistent with, a change in status event or leave of absence rule.

Effect of Termination of Coverage

On the date your participation ends, no further reductions in pay will be contributed to your accounts. All

claims must be submitted for reimbursement by March 31 following the year in which your participation

terminated. In the event of your death, the person entitled to receive payment under applicable law can submit claims for expenses incurred prior to your death to the extent those claims would have been eligible for reimbursement to you.

Effect of Return to Employment

The following special rules apply when you return to work for the employer:

Thirty (30) Days or Less

If you return to work within 30 days of the date you terminated employment, your prior elections will be reinstated automatically for the remainder of the Plan year.

After 30 Days

If you return to work more than 30 days from the date you terminated employment, you will be treated as a newly hired employee, and the initial enrollment rules will apply. Refer to the “Initial Enrollment” section for more information.

Additional Termination of Coverage Rules

Your participation under the Plan will terminate immediately upon termination of the Plan or will terminate at midnight upon the occurrence of the earliest of:

• The date you provide fraudulent information to obtain Plan benefits or coverage including

falsifying information on your application for coverage and/or submitting fraudulent, altered, or duplicate billings for personal gain. If any claims are mistakenly paid for expenses incurred due to such fraudulent information, the employee will be required to reimburse the Plan.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

This section details how the Plan works and outlines the eligible expenses under the Plan.

Annual Contributions

The Plan allows you contribute up to $5,000 pre-tax dollars annually to a Dependent Care Flexible Spending Account to pay for eligible out-of-pocket dependent care expenses incurred in order for you and, if you are married, your spouse to work or look for work. You may be reimbursed under the

Dependent Care Flexible Spending Account for qualifying expenses for “day care.” In administering the Account the employer may, in its sole discretion, consult various Internal Revenue Service publications, rulings, notices, and other authorities to determine if an expense is eligible.

The minimum employee contribution is $5 per payroll, or $120 annually. The maximum family contribution is the lesser of $5,000 annually, your earned income, or your spouse’s earned income. Special rules apply if your spouse is a student or incapable of self-care; please contact the Employee Service Center if this applies to you. If you and your spouse file federal income tax returns separately, the maximum contribution election is $2,500.

To be eligible for reimbursement, the expense must be incurred during the Plan year and must not be

reimbursed by any other dependent care reimbursement accounts. Expenses are incurred when services are provided, not when you are billed for or pay for the services.

Note that you may not claim a dependent care tax credit on your federal income tax return for expenses

for which you were reimbursed from your Dependent Care Flexible Spending Account.

Tax Benefits

You will save money when you use pre-tax dollars to reimburse your eligible dependent care expenses. In most cases, you will not pay Federal Income Tax (approx. 10-35 percent), State Income Tax

(approx. 3 percent), or Social Security (FICA) Tax (approx. 7.65 percent) on the amount you contribute to or are reimbursed from the Plan.

Because your contributions are deducted before your social security taxes are calculated, your social security benefit may be affected. In addition, for expenses reimbursed under Dependent Care Flexible Spending Plan, you may not claim a dependent care tax credit on your federal income taxes. For some employees, it may be preferable to use the dependent care expense tax credit rather than to participate in the Plan. The tax savings when you participate in the Plan will vary from taxpayer to taxpayer based on personal circumstances, exemptions, deductions, and filing status. You may want to discuss these issues with your tax advisor.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

Employee Contributions

You must carefully plan the amount you wish to contribute because the Plan is governed by federal regulations and restrictions.

Important points to remember:

• No Tax Credit. You cannot take a tax credit on your federal income tax return for expenses

reimbursed from your Dependent Care Flexible Spending Account.

• No Change to Election. During the year you cannot change your contribution election except

under certain conditions, see Change in Status Events for details.

• Use It or Lose It. If your contributions during the year exceed the eligible expenses you incur

during that year, you will forfeit the excess money in your account at the end of the year.

• Filing Deadline. Even if you incur eligible expenses for the year, if you do not file a claim for

reimbursement of those expenses before the filing deadline, you will forfeit the amount remaining in your account. The filing deadline for the year is March 31 of the following year.

Definition of Dependent

The definition of dependent for this Plan is different than for Mayo’s Medical Plan or for the Health Care Flexible Spending Account. Generally, your dependent for purposes of reimbursement from your

Dependent Care Flexible Spending Account (and as used throughout this Plan) is an individual who meets the following criteria:

• Your child or sibling (or the descendent of a sibling) who is under age 13, who has the same

principal place of abode as you for more than one-half of the Plan year, and who has not provided more than one-half of his or her own support for the Plan year

• A relative (or any other individual who has the same principal place of abode as you for the Plan

year and who is a member of your household) who depends on you for at least half his/her support and who is physically or mentally incapable of caring for himself or herself

• Your spouse, if he or she is physically or mentally incapable of caring for himself or herself., who

has the same principal place of abode as you for more than one-half of the Plan year

Information Regarding Your Account

Detailed information about your account contributions and payments are available by accessing the Self Service Tools on your Human Resources website. Account information may also be obtained by calling Human Resources.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT ELIGIBLE EXPENSES

ELIGIBLE EXPENSES

Important Note: In administering the Plan, the Plan Administrator and HRAS may, in its sole discretion, consult various Internal Revenue Service publications, rulings, notices, and other authorities to determine if an expense is eligible. The Plan Administrator reserves the right to deny payment for any service it considers ineligible.

Dependent care expenses for which you submit a claim must be “employment related.” This means the expenses must be necessary to allow you (and your spouse, if married) to work or to look for work. The following is a list of eligible dependent care expenses:

• After school or extended day programs

• Dependent care center expenses

• Dependent care expenses incurred in connection with self-employment: that

allows one or more custodial parent(s) to be gainfully employed

• Dependent care provider inside or outside the participant’s houshold (unless the

care is being given by a child of the employee under age 19 or otherwise claimed as a dependent by the employee)

• Employment of an au pair. Up front fees may be reimbursed proportionately

over the duration of the au pair agreement.

• Expenses paid to relative of participant for dependent care (unless the care is

being given by a child of the employee under age 19 or otherwise claimed as a dependent by the employee)

• FICA and FUTA taxes of daycare provider

• Nanny expenses

• Preschool and nursery school expenses

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT INELIGIBLE EXPENSES

INELIGIBLE EXPENSES

Important Note: In administering the Plan, the Plan Administrator and Mayo Clinic Health Solutions may, in its sole discretion, consult various Internal Revenue Service publications, rulings, notices, and other authorities to determine if an expense is eligible. The Plan Administrator reserves the right to deny payment for any service it considers ineligible.

The following is a list of ineligible dependent care expenses:

• Activity fees

• Chauffeur

• Disabled spouse or tax dependent living outside the home

• Educational expenses (kindergarten and above)

• Expenses incurred in another plan year

• Expenses paid to relative of participant for dependent care if care is provided by

a child of the employee under age 19 or otherwise claimed as a dependent by the employee

• Food expenses

• Household services (i.e., cook, gardener, housekeeper, maid, etc.)

• Overnight camp expenses

• Pre-payment of dependent care expenses

• Transportantion expenses

• Vacation day fees for which the participant for dependent care did not receive

care on the day(s) charged

These examples are not intended to be comprehensive. If you have questions about whether an expense is reimbursable, call Mayo Clinic Health Solutions at the number listed in the Contact Information.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIM PAYMENT AND APPEAL PROCEDURES

CLAIM PAYMENT AND APPEAL PROCEDURES

Important Notes:

Unless specifically noted, oral inquiries about coverage and benefits are not considered claims or appeals. All time periods described in this section are in calendar days, not business days.

If you do not file a claim or follow the claim procedures, you are giving up important legal rights.

The addresses for Claim Administrators and Committees responsible for deciding claims in the Plan are

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CLAIM PROCEDURE

This Section explains how to submit claims for reimbursement from your Dependent Care Flexible Spending Account.

Filing an Initial Claim

Important Note: Dependent care expenses for which you submit a claim must be “employment related.” This means the expenses must be necessary to allow you (and your spouse, if married) to work or to look for work.

Time for Filing a Claim

Your claim must be received by the Claim Administrator no later than March 31 following the year in which the expense was incurred. You will forfeit or lose any funds remaining in your Dependent Care Flexible Spending Account after all your claims received by the Claim Administrator through March 31 are processed.

Filing a Claim

Your claims may be submitted by using the online portal or Dependent Care Flexible Spending Account claim form. Forms are available by contacting Mayo Clinic Health Solutions or on the Mayo intranet. You must complete a Dependent Care Flexible Spending Account claim form. The claim form must include the six-digit Mayo Employee ID number in order to be processed, or it will be returned to you. If necessary, attach to the claim form a receipt or itemized statement from your provider. The receipt or statement should include the following information:

• Amount of the charges

• Date(s) of service

• Name and address of provider

• Names and ages or dependent for whom care was provided

• Provider Social Security Number or Tax ID Number

Claim Decision

The Claim Administrator will typically decide your claim within 30 days. If your claim is denied in whole or in part, you will receive a written notification.

You may be notified that an extension of up to 15 days is needed to decide your claim. If the extension is required because you need to provide additional information in order for your claim to be decided, you will be given at least 45 days to provide that information.

Claim Payment

Your reimbursement of pre-tax Dependent Care Flexible Spending Account monies will be provided to you by means of check or direct deposit.

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APPEAL PROCEDURE

Time for Filing First Level Appeal

You must file an appeal within 180 days after the date you received notice your claim is denied.

Filing of First Level Appeal

Your written appeal must be submitted to the Claim Administrator and must include the following information:

• Name of plan

• Your name and address

• Information regarding the denial for claim benefits,

• A statement that you are appealing the denial of benefits

• The reason(s) you disagree with the denial of your claims

• Any information, documents, or arguments you want considered in the first

appeal

Appeal Decision

The Claim Administrator will generally decide your appeal within 30 days after its receipt. If your appeal is denied, you will be notified in writing.

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GENERAL RULES FOR CLAIM PROCEDURES

Authority

Mayo Clinic is the Plan Administrator and has delegated the authority to decide benefit claims and appeals the Claims Administrator described in these claim procedures. The Claims Administrator has the discretion, authority, and responsibility to make final decisions on all factual and legal questions under the Plan, to interpret and construe the Plan and any ambiguous or unclear terms, and to determine whether a participant is eligible for benefits, and the amount of the benefits. The Claim Administrator may rely on any applicable statute of limitations as a basis to deny a claim. The Claims Administrators’ decisions are conclusive and binding on all parties.

Time Limits for Commencing Legal Action

If you file your initial claim within the required time and the Claim Administrator denies your claim and appeal, you may sue over your claim (unless you have executed a release on your claim). You must, however, commence that suit within three years from the time your initial claim was submitted.

Exhaustion of Administrative Remedies

Before commencing legal action to recover benefits or to enforce or clarify rights, you must exhaust the claim and review procedures for this Plan.

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CLAIM ADMINISTRATION FOR CLAIMS AND

APPEALS

The Claims Administrator for claims and appeals of denied claims is the following:

Plan Claim Administrator

Dependent Care Flexible Spending Account

Mayo Clinic Health Solutions PO Box 211698

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT GENERAL PROVISIONS

GENERAL PROVISIONS

Applicable Law

The Plan is intended to be construed, and all rights and duties hereunder are to be governed, in accordance with the laws of the State of Minnesota, except to the extent federal law applies.

Conformity with Governing Law

If any provision of the Plan is contrary to any law to which it is subject, such provision is hereby amended to conform thereto.

Construction of Terms

Words of sex will include persons and entities of any sex. The plural will include the singular, and the singular will include the plural.

Assignment Prohibited

You may not pledge or assign your benefits under the Plan to anyone else.

No Guarantee of Employment

Participation in the Plan will not be construed as giving you any right to continue in the employ of the employer. You will remain subject to discharge by the employer to the same extent had the Plan not been adopted.

Non-Discrimination Policy

The Plan will not discriminate against you or your eligible dependents based on race, color, religion, national origin, disability, sex, or age.

Plan Provisions Binding

The provisions of the Plan will be binding upon you and your eligible dependents and their respective heirs and legal representatives, upon the employer, its successors and assigns, and upon the Plan Administrator, Claim Administrator, and any other provider of services to the Plan.

Section Titles

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT PLAN ADMINISTRATION

PLAN ADMINISTRATION

Powers and Duties of the Plan Administrator

The Plan Administrator will have the powers and duties of the general administration of the Plan including the following:

• The discretion to determine all factual and legal questions relating to the eligibility of individuals

to participate, or for you to remain a participant in the Plan and to receive benefits under the Plan.

• To require any person to furnish such reasonable information as the Plan Administrator may

request for the proper administration of the Plan as a condition of eligibility to participate under the Plan and to receive any benefits under the Plan.

• To delegate to other persons authority to carry out any duty or power which under the terms of the

Plan or applicable law would otherwise be a responsibility of the Plan Administrator.

• To maintain or to delegate to others the duty of maintaining all necessary records for the

administration of the Plan.

• To interpret the provisions of the Plan and to make and publish such rules and procedures for

regulation of the Plan and to prescribe such forms as the Plan Administrator will deem necessary.

Records

The Plan Sponsor, the Plan Administrator, the Claim Administrator, and others to whom the Plan Sponsor has delegated duties and responsibilities under the Plan shall keep accurate and detailed records of any matters pertaining to administration of the Plan in compliance with applicable law.

Assignment of Benefits

Your right to receive benefits under the Plan is personal to you and may not be assigned or be subject to anticipation, garnishment, attachment, execution, or levy of any kind, or be liable for the debts or obligations of you.

Amendment and Termination of Plan

Mayo Clinic reserves the right to amend or terminate the Plan or any benefit option described in any document for the Mayo Flexible Spending Account Plan including this document at any time, for any reason, and in any respect. Mayo Clinic’s right to amend or terminate the Plan or benefit options includes, but is not limited to, changes in the eligibility requirements, employee and employer

contributions, benefits provided, and termination of all or a portion of any coverage(s) provided under the Plan. If the Plan or any benefit option is amended or terminated, you will be subject to all the changes effective as a result of such amendment or termination and your rights will be reduced, terminated, altered, or increased accordingly as of the effective date of the amendment or termination. You do not have ongoing rights to any plan or program benefit.

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT NON-ERISA STATUS OF PLAN

NON-ERISA STATUS OF PLAN

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT PLAN ADMINISTRATIVE INFORMATION

PLAN

ADMINISTRATIVE INFORMATION

Plan Sponsor, Plan Administrator Mayo Clinic 200 First Street SW Rochester, MN 55905 (507) 266-0440

Plan Sponsor EIN 41-6011702

Agent for Service of Legal Process Mayo Clinic

c/o William A. Brown, Assistant Treasurer 200 First Street SW

Rochester, MN 55905 (507) 266-0440

Plan Fiscal Year January 1 - December 31

Collectively Bargained Groups The Plan is maintained in part pursuant to one or more collective bargaining agreements. A copy of any such agreements may be obtained by you upon written request to the Plan Administrator and is available for examination.

Type of Plan The Dependent Care Flexible Spending Account is not governed by ERISA.

The Health Care Flexible Spending Account is an employee welfare program that is governed by ERISA.

The Pre-Tax Health Savings Account Plan is not governed by ERISA.

Type of Administration Contract Administration

Source of Contributions This Plan is funded with employee contributions and all benefits are paid from the general assets of Mayo Clinic.

Claim Administrators

Please Note: The claim administrators

perform claim processing services pursuant to a written contract; they do not insure benefits

under Mayo Flexible Spending Account Plan.

Mayo Clinic Health Solutions PO Box 211698

Eagan, MN 55121 1-800-635-6671 (toll free) 507-266-5580 (local)

Components of Mayo Flexible Spending Account Plan

Dependent Care Flexible Spending Account Health Care Flexible Spending Account HIPAA Privacy Rules

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Employers Participating in Mayo Flexible Spending Account Plan

Flexible Spending Account Plan Options Available

Charterhouse Dependent Care Flexible Spending Account

Health Care Flexible Spending Account Mayo Pre-Tax Health Savings Account

Franklin Heating Station Dependent Care Flexible Spending Account

Gold Cross Ambulance Service Dependent Care Flexible Spending Account

Mayo Clinic Dependent Care Flexible Spending Account

Mayo Clinic Arizona Dependent Care Flexible Spending Account

Mayo Clinic Florida Dependent Care Flexible Spending Account

Mayo Clinic Health Solutions Dependent Care Flexible Spending Account

Mayo Clinic Health System-Austin and Albert Lea Dependent Care Flexible Spending Account

Mayo Clinic Health System-Cannon Falls Dependent Care Flexible Spending Account

Health Care Flexible Spending Account Mayo Pre-Tax Health Savings Account Mayo Clinic Health System-Decorah Clinic

Physicians

Dependent Care Flexible Spending Account Health Care Flexible Spending Account Mayo Pre-Tax Health Savings Account

Mayo Clinic Health System-Eau Claire Clinic Dependent Care Flexible Spending Account

Mayo Clinic Health System-Eau Claire Hospital Dependent Care Flexible Spending Account

Mayo Clinic Health System-Fairmont Dependent Care Flexible Spending Account

Health Care Flexible Spending Account Mayo Pre-Tax Health Savings Account Mayo Clinic Health System-Franciscan Healthcare,

Inc.

Dependent Care Flexible Spending Account Health Care Flexible Spending Account Mayo Pre-Tax Health Savings Account Mayo Clinic Health System-Lake City Medical

Center

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Mayo Clinic Health System-Mankato Dependent Care Flexible Spending Account

Mayo Clinic Health Systems-New Prague Dependent Care Flexible Spending Account

Mayo Clinic Health System-Owatonna Dependent Care Flexible Spending Account

Mayo Clinic Health System-Red Cedar, Inc. Dependent Care Flexible Spending Account

Mayo Clinic Health System-Red Wing Dependent Care Flexible Spending Account

Mayo Clinic Health System-Waycross Dependent Care Flexible Spending Account

Mayo Clinic Hospital-Rochester Dependent Care Flexible Spending Account

Mayo Clinic Jacksonville Dependent Care Flexible Spending Account

Mayo Collaborative Services Dependent Care Flexible Spending Account

Health Care Flexible Spending Account Mayo Pre-Tax Health Savings Account Mayo Foundation for Medical Education and

Research

Mayo Medical Laboratories New England Dependent Care Flexible Spending Account

Rochester Airport Company Dependent Care Flexible Spending Account

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT GLOSSARY

GLOSSARY

Claim Administrator

The Claim Administrator’s responsibilities typically consist of initially determining the validity of claims and administering benefit payments under the Plan.

Coverage Year

The time period, not to exceed twelve (12) months, from the effective date of the Plan to the anniversary date. All subsequent coverage years shall begin on the anniversary date and consist of a period of not more than twelve (12) months. The Plan’s coverage year is January 1 through December 31.

Dependent

Generally, your dependent for purposes of reimbursement from your Dependent Care Flexible Spending Account (and as used throughout this Plan) is an individual who meets the following criteria:

• Your child or sibling (or the descendent of a sibling) who is under age 13, who has the same principal place of abode

as you for more than one-half of the Plan year, and who has not provided more than one-half of his or her own support for the Plan year or

• A member of your family (or any other individual whose principal residence is your home and who is a member of

your household) and who depends on you for at least half their support and who are physically or mentally incapable of caring for themselves or

• Your spouse, if he or she is physically or mentally incapable of caring for himself or herself and who has the same

principal place of abode as you for more than one-half of the Plan year.

Employee

A person classified by the employer for payroll and personnel purposes as a regular employee, except it shall not include a self-employed individual as described in Section 401(c) of the Internal Revenue Code of 1986. All employees who are treated as self-employed by a single employer under Subsections (b), (c), or (m), or Section 414 of the Internal Revenue Code of 1986 are treated as employed by a single employer for purposes of the Plan. Employee does not include any person classified by the employer as any of the following:

• Any individual who is a temporary employee.

• Any individual who is a supplemental or non-benefit eligible employee.

• Any individual included within a unit of employees covered by a collective bargaining unit unless such agreement

expressly provides for coverage of the employee under the Plan.

• Any individual who is a nonresident alien and receives no earned income from the employer from sources within the

United States.

• Any individual who is a leased employee as defined in Section 414 (n) (2) of the Internal Revenue Code of 1986.

• Any individual who performs services for the employer through, and is paid by, a third-party (including but not limited

to an employee leasing or staffing agency) even if such individual is subsequently determined to be a common law employee of the employer.

• Any individual who performs services for the employer pursuant to a contract or agreement (whether verbal or written)

which provides that such individual is an independent contractor or consultant, even if such individual is subsequently determined to be a common law employee of the employer.

An employer’s classification is conclusive and binding for purposes of determining benefit eligibility under the Plan. No reclassification of a worker’s status for any reason by a third party, whether by a court, governmental agency, or otherwise, and without regard to whether or not the employer agrees to the reclassification, shall make the worker retroactively or prospectively eligible for benefits. Any uncertainty regarding a worker’s classification will be resolved by excluding that person from eligibility.

Employer

Mayo Clinic and any subsidiary or affiliated entities recognized by Mayo Clinic as eligible to participate and that agree to participate in

the Plan. In this document, employer shall mean the participating employers listed in the Plan Administrative Information section.

ERISA

Employee Retirement Income Security Act of 1974, as amended from time to time.

Expenses Incurred

An expense is incurred when the dependent care service is provided.

FMLA

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DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT GLOSSARY

Open Enrollment Period

The period of time occurring toward the end of the coverage year during which eligible employees may elect to begin coverage for themselves under the Plan effective the first day of the upcoming coverage year.

Plan

The Dependent Care Flexible Spending Account, a component of the Mayo Flexible Spending Account Plan for the provision of pre-tax benefits, as amended from time to time.

Plan Administrator

The Plan Administrator is Mayo Clinic. The Plan Administrator retains ultimate authority for the Plan including final appeal determinations.

Plan Participant

An eligible employee whose enrollment form has been accepted, whose coverage is in force, and whose coverage has not terminated.

Plan Sponsor

Mayo Clinic is the Plan Sponsor.

Regularly Scheduled

The schedule on file with your employer is your regular schedule. If it is .5 FTE or more you qualify to enroll in certain benefit plans with your employer. A schedule of .4 FTE working additional hours does not qualify as regularly scheduled.

Spouse

An individual who is legally married to an eligible employee under the law of the domestic state or foreign jurisdiction having legal authority to sanction the marriage.

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