January 2012 FSA SPD 1
ENABLING STRENGTHS | INSPIRED PEOPLE | My Life. Even Better.
Flexible Spending Account
(FSA)
Summary Plan Description
Effective January 1, 2012
St. Mary’s Health System
Evansville, IN
January 2012 FSA SPD 2
St. Mary’s Health System | Flexible Spending Account (FSA) | Evansville, IN
Who is eligible Full and Part-time employees regularly authorized to work at least 40 hours per pay period Eligibility Date Thirty (30) days of continuous employment
Benefit Amount Healthcare Reimbursement Account
Minimum Annual Election $260 Maximum Annual Election $2,500
Dependent Daycare Reimbursement Account Minimum Annual Election $260
Maximum Annual Election $5,000 Your Cost for
Coverage
The associate pays the entire contribution on a pre-tax basis.
Plan Administrator ADP
Plan Outline
January 2012 FSA SPD 1
For Questions About Eligibility Your Local Human Resources Department
For Questions About the Plans ADP Participant Services
To speak with a representative, call 800.654.6695
To File a Claim ADP Benefit Services
2575 Westside Parkway, Suite 500 Alpharetta, GA 30004-3852
To Appeal a Claim ADP FSA Claims Appeal
P.O. Box 1801
Alpharetta, GA 30023-1801
For COBRA Information Ceridian Benefit Services
800.877.7994
www.ceridian-benefits.com
January 2012 FSA SPD 1
Plan Outline ... 2
Your Contact Information ... 1
Introduction ... 3
Glossary ... 4
Section 1: Eligibility and Participation ... 7
Eligibility ... 7
Enrollment ... 7
Change Events ... 8
Participant Contributions ... 8
Family and Medical Leave Act ... 8
When Coverage Begins ... 9
When Coverage Ends ... 9
COBRA Continuation Coverage for Health Care FSA ... 10
USERRA Continuation Coverage for Health Care FSA ... 12
Qualified Medical Child Support Order... 13
Right to Amend or Discontinue the Plans ... 14
Section 2: Flexible Spending Account (FSA) Benefits ... 15
Health Care FSA ... 15
Dependent Care FSA ... 18
Section 3: Other Plan Provisions ... 20
Use It or Lose It Rule ... 20
Effect of FSA Participation on Tax Credits and Social Security Benefits ... 20
Qualified Reservist Distribution... 20
Section 4: Claims Procedures ... 22
Filing a Claim ... 22
Timing of Claims Review ... 23
If Your Claim is Denied ... 24
Appealing a Denied Claim ... 24
Overpayment of Claims ... 25
Misrepresentations ... 25
Section 5: Your ERISA Rights... 26
Receiving Information About the Plan and Benefits ... 26
Continuing Your Group Health Coverage ... 26
Prudent Actions by Plan Fiduciaries ... 26
Enforcing Your Rights ... 27
Assistance with Your Questions ... 27
Section 6: Group Health Plan Privacy Practice Notice ... 28
Our Responsibilities ... 28
How We May Use and Disclose Your Health Information ... 28
Other Uses of Health Information ... 32
January 2012 FSA SPD 2
Your Rights Regarding Your Health Information ... 32
Who This Notice Applies To ... 34
Changes to This Notice ... 34
Complaints ... 34
January 2012 FSA SPD 3
Ascension Health and your Participating Employer offer two flexible spending accounts (FSAs) — The Health Care FSA and the Dependent Care FSA — that let you set aside pre-tax dollars from your paycheck to help pay for many common health care or dependent day care expenses. Participation is voluntary and you can choose to enroll in either account, both or neither.
If you elect to participate in an FSA, a non-interest bearing bookkeeping account is set up to keep a record of pre-tax contributions allocated to the account and any reimbursements made from the account for eligible expenses.
This Information Is a Summary
The information in this summary plan description (SPD) is intended to serve as a summary of the Ascension Health Medical Expense Flexible Spending Plan, or “Health Care FSA” and the Ascension Health Dependent Care Flexible Spending Plan, or “Dependent Care FSA” (Plans), effective January 1, 2012. You should refer to the official Plan documents for
details.
If there are any discrepancies between the information in this SPD and the official Plan documents, the terms of the Plan documents will prevail.
This SPD does not constitute a contract of employment or a guarantee of benefits or future employment. In addition, your eligibility for and participation in the Plans as described in this SPD should not be construed as an employment contract.
Certain words in this SPD are capitalized. These words are defined in the “Glossary” section. You may find it helpful to consult the “Glossary” section as you read this SPD.
Introduction
“You” or “your” refers to the Eligible Associate, any Eligible Dependents, any Qualified Beneficiary or other
continuation participant covered under the Plans. “Days” refers to calendar days.
The following pages of this SPD explain provisions that generally apply to Eligible Associates of all Participating Employers that offer flexible spending account benefits.
The “Plan Outline” section of this SPD contains specific requirements and provisions that apply to Eligible Associates of your Participating Employer.
January 2012 FSA SPD 4
The following terms may help you in reading and understanding this SPD.
ADP —The claims administrator for the Plans.
Associate — Any individual who is classified by a Participating Employer as an employee.
Change Event — A change in status or change in family status event that is described in the Internal Revenue Code Section 125 cafeteria plan adopted by the Participating Employer of the Eligible Associate.
Change of Benefits Date — The effective date of a mid-year election change due to a Change Event. The Change of Benefits Date for a Change Event related to birth, adoption or placement for adoption is the date of the birth, adoption or placement for adoption. The Change of Benefits Date for all other Change Events is as soon as administratively possible after the requested change is filed.
Child — The Eligible Associate’s natural child, legally adopted child, child placed with Eligible Associate for adoption, foster child, orstepchild. Child shall also include any child for whom the Eligible Associate has been granted court-appointed full legal custody or guardianship.
COBRA — The continuation of health coverage that must be offered in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985.
Eligible Associate — An Associate who is in the class of Associates eligible to participate in the Plan, as specified in the Addendum/Joinder Agreement of each Plan applicable to the Participating Employer and the “Plan Outline” section of this SPD. Eligible Associate does not include a leased employee or independent contractor, regardless of any retroactive reclassification as a common law employee.
Eligible Dependent — An Eligible Associate’s Spouse or Child who is either less than age 26, or a
Child who is age 26 or older if: − Unmarried,
− Permanently and totally disabled prior to the attainment of age limits under the Plans,
− Receiving over half his or her support from the Eligible Associate or Eligible Associate’s Spouse, and
− Eligible to be claimed as a dependent on the Eligible Associate’s or Eligible Associate’s Spouse’s federal income tax return.
A Child is permanently and totally disabled if he or she is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
January 2012 FSA SPD 5 Eligible Dependent Day Care Expenses —Expenses that have not been reimbursed by any other source and are considered eligible under IRS Publication 503, “Child and Dependent Care Expenses.”
Eligible Health Care Expenses —Expenses that have not been reimbursed by any other source and are considered eligible under Code Section 213(d) and IRS Publication 502, “Medical and Dental Expenses.” Eligible Health Care Expenses do not include health or long-term care insurance premiums, expenses relating to long-term care services, expenses (such as abortions or sterilizations) that would violate the ethical or religious principles of Catholic health facilities. Also, the cost of over-the-counter drugs is not an Eligible Health Care Expense unless you first obtain a prescription from your physician.
Entry Date — The date as specified in the “Plan Outline” section of this SPD on which you become a Participant in the Plans after completing the required enrollment process and satisfying any waiting period applicable to you.
ERISA — The Employee Retirement Income Security Act of 1974, as amended.
Health Ministry —A legal entity related to Ascension Health.
Participant — Any Eligible Associate, Eligible Dependent, Qualified Beneficiary, other
continuation participant or other individual who is covered in accordance with the Plans and the “Eligibility and Participation” and “Plan Outline” sections of this SPD.
Participant Contribution — Any amount the Plan Administrator may require you to contribute for coverage under the Plans (see the “Plan Outline” section of this SPD).
Participating Employer — The Plan Sponsor or any Health Ministry that adopts the Plans.
Plans— The Ascension Health Medical Expense Flexible Spending Plan (the “Health Care FSA”) and the Ascension Health Dependent Care Flexible Spending Plan (the “Dependent Care FSA”), as amended from time to time.
Plan Administrator — Ascension Health, or such other person or committee that Ascension Health may appoint to administer the Plans.
Plan Outline — A brief description of some of the key features of the Plans as offered by your Participating Employer.
Plan Sponsor — Ascension Health.
Plan Year — The calendar year.
Qualified Beneficiary — Any person afforded rights of continued benefits under COBRA as a result of a qualifying event as defined in COBRA.Qualified Beneficiary includes only the following:
Eligible Associate
Eligible Associate’s Spouse
Eligible Dependent Child
January 2012 FSA SPD 6 Qualifying Individual — A person age 12 and under for whom you can claim on your federal income tax return, or your Spouse or other dependent who is physically or mentally incapable or caring for himself or herself and for more than one half of the year has the same principal residence as you do.
Spouse — An individual legally married to an Eligible Associate (even if legally separated), including an individual who is the common-law spouse, in states that recognize common-law marriage, of an Eligible Associate, if such individual and the Eligible Associate are of opposite sex.
January 2012 FSA SPD 7
When you first become eligible to enroll in the Plans, your local Human Resources Department will provide an enrollment package that explains how to enroll, the deadline, and your share of the cost of coverage. You must notify your local Human Resources
Department of any change (marriage, birth of a Child, change of address, etc.) within 30 days of the event. If you don’t enroll when first eligible, you may enroll later at the next Open Enrollment date (or earlier if your situation changes).
Eligibility
All Associates in your Participating Employer’s class of Eligible Associates may participate in the Plans. Please see the “Plan Outline” section of this SPD for your Participating
Employer’s eligibility requirements.
Enrollment
This section describes the enrollment process for flexible spending account benefits.
Initial Enrollment Period
When you first become an Eligible Associate, your local Human Resources Department will send you an enrollment package. It will explain all of the steps you need to take to enroll as well as the deadline date for enrolling.
If you enroll by the deadline, you will become enrolled on the Entry Date specified by your Participating Employer. (Please see the “Plan Outline” section of this SPD.) If you fail to enroll during the initial enrollment period, you may enroll during the next Open Enrollment Period or after a Change Event.
Open Enrollment Period
You may choose or change your participation in the Plans during your Participating Employer’s annual Open Enrollment Period. The choices you make during the Open Enrollment Period will become effective on the first day of the next Plan Year. Once payroll deductions have started, you may not make any changes in your choices until the next Plan Year or until you have a Change Event.
Section 1: Eligibility and Participation
Enroll on Time
If you fail to enroll by the deadline date stated in your enrollment package, you will not have coverage under the Plans until the next
enrollment opportunity.
Update Your Address Be sure to file your current address and any changes of address with your local Human Resources Department. Any communication addressed to you at your latest post office address on file will be binding upon you for all purposes of the Plans.
January 2012 FSA SPD 8
Change Events
Because your benefit elections are part of a Section 125 plan, tax laws prevent you from changing your benefit elections during the Plan Year, except in the case of a life event change, or “Change Event.”
You may change your benefit elections during the year only if:
You have a qualifying change in status,
You report the change within 31 days of the event,
The change affects your eligibility under one of the employer-provided benefit plans, and
The election you make is consistent with your change in status. Examples of qualifying changes in status are:
You get married or divorced
A change in dependent Children through birth, adoption, custody, court order, or death
Your Spouse becomes employed or unemployed
Your Child no longer meets the eligibility requirements
You become disabled
Your Spouse becomes disabled or dies
You change from full-time to part-time, or part-time to full-time employment
You, your Spouse, or your dependent has a change in residence
To change your benefit elections, you must request the change in writing within 31 days after the Change Event and identify the event that resulted in the change you are requesting. The requested change must be consistent with the Change Event.
Election changes will be effective on your Change of Benefits Date. If you file the request later than 31 days after the Change Event, no changes will be made to your elections or Participant Contributions, but you may make the necessary change during the next Open Enrollment Period for the following Plan Year.
Participant Contributions
Contributions are required to participate in the Plans. Your enrollment materials will include details about any required Participant Contributions, based upon the type and level of coverage in which you are enrolled.
Family and Medical Leave Act
If you take a leave of absence under the Family and Medical Leave Act of 1993, you have the option of continuing or discontinuing your coverage in the Health Care FSA. Consult with your local Human Resources Department to discuss your options under the Health Care FSA before taking the leave.
January 2012 FSA SPD 9
When Coverage Begins
Coverage begins on the Entry Date indicated in the “Plan Outline” section of this SPD, provided you have completed any required enrollment materials and have made any required contributions.
When Coverage Ends
Eligible Associates
Your coverage ends at 11:59 p.m. on the date in which you no longer meet the definition of Eligible Associate. You may continue Health Care FSA coverage, at your cost, for a limited time. (Please see the “COBRA Continuation Coverage for the Health Care FSA” section of this SPD.)Different rules may apply in the event of salary continuation or severance
payments.
Eligible Dependents
Your dependents’ coverage ends at 11:59 p.m. on the date in which they no longer meet the definition for Eligible Dependent.
Termination for Cause
Your coverage can also be terminated for Cause. If your coverage is terminated retroactively, you may be required to repay benefits you received after the date your coverage is
terminated.
Coverage Can Be Terminated for “Cause” Your coverage can be terminated for:
Your failure to complete, sign and/or provide to the Plan Administrator any information, document or form that Ascension Health determines is
reasonably necessary for the administration of the Plans or Plan Sponsor functions
Willful engagement in misconduct that is materially injurious to the Plans Dishonesty in connection with the provision of benefits under the Plans Fraudulent or unethical conduct or an intentional misrepresentation of a
material fact related to or affecting the provision of benefits under the Plans Being indicted or charged with any crime constituting a felony
Failure to pay any amounts due to the Plans or a Participating Employer Coverage can be terminated retroactively for:
Failure to timely pay Participant Contributions
Fraudulent or unethical conduct or an intentional misrepresentation of a material fact related to the provision of benefits under the Plans
January 2012 FSA SPD 10 Reinstatement
If, during the same Plan Year, you terminate employment and return to employment within 30 days, your prior elections will be reinstated automatically. However, if you return after 30 days or longer, you will be treated as a new hire (see “Initial Enrollment Period”) unless your Participating Employer has a different rule for reinstatement.
COBRA Continuation Coverage for Health Care FSA
Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), Qualified Beneficiaries have the option of continuing participation in the Health Care FSA until the end of the plan year at group rates if the Eligible Associate would otherwise lose coverage because of any of the following events:
You no longer are employed by your Participating Employer (whether voluntarily or involuntarily, except if terminated for gross misconduct).
Your work hours are reduced below the minimum level necessary to be eligible for the Health Care FSA.
You move to a position with your Participating Employer in which you are not eligible to participate in the Health Care FSA.
While termination of employment normally triggers a right to only 18 months of
continuation coverage, if your employment terminates less than 18 months after you become entitled to Medicare, the continuation coverage for your Eligible Dependents who are
Qualified Beneficiaries can continue for 36 months after the date on which you become entitled to Medicare.
Each Qualified Beneficiary will have an independent right to elect continuation coverage. Covered Eligible Dependents who are Qualified Beneficiaries can continue to be covered under the Medical Expense Flexible Spending Plan for up to 36 months if they would otherwise lose coverage due to any of the following events:
The Eligible Associate dies
The Eligible Associate and his or her Spouse divorce or become legally separated
An Eligible Dependent Child no longer satisfies the Medical Expense Flexible Spending Plan’s definition of Eligible Dependent (for example, the Child reaches the Eligible Dependent age limit)
Extended Coverage for Disabled Individuals
Qualified Beneficiaries may be able to extend coverage for themselves and other family members who are Qualified Beneficiaries for up to an additional 11 months if they:
Are disabled on the date of eligibility for continuation coverage, or
Become disabled within the first 60 days of the continuation coverage period.
Qualified Beneficiaries are subject to the same rights and rules as those who participate in the Health Care FSA.
January 2012 FSA SPD 11
To qualify, the Social Security Administration must officially determine that the person became disabled prior to the 61st day of the continuation coverage period. Also, that person
must notify the Participating Employer in writing of this disability determination before the first 18 months of continuation coverage ends and within 60 days after receiving notification from Social Security that the disability determination has been made. (Please see the “Your Contact Information” section of this SPD).
If the disability ends during the 11 months of extended coverage, that person must notify the Participating Employer within 30 days. Continuation coverage will end on the last day of the month in which the disability ends.
Cost
Individuals who choose continuation coverage must pay for such coverage. They will be charged up to 102% of the full cost of coverage depending on the coverage option they choose. Disabled Qualified Beneficiaries and their family members who choose to continue coverage beyond their initial 18-month continuation period will be charged up to 150% of the full cost of coverage during the 11-month disability extension. Contributions must be paid from the date coverage otherwise would have ended.
Second Qualifying Event
If a Qualified Beneficiary other than an Eligible Associate elects continuation coverage and experiences a second qualifying event within the initial 18-month period, he or she may be able to extend coverage further, but only up to a total of 36 months. The second qualifying event must occur while the Qualified Beneficiary has continuation coverage.
For example, the family of an Eligible Associate who is laid off becomes eligible for 18 months of continuation coverage. They elect the coverage and then, 7 months later, the Eligible Associate dies. The surviving covered Eligible Dependents are entitled to 36 months of continuation coverage from the date of the Eligible Associate’s termination of employment (the initial qualifying event).
You must send a written notice of the second qualifying event to the Participating Employer at the address shown in the “Your Contact Information” section of this SPD.
Notification
You must notify the Participating Employer within 60 days after a divorce or legal separation occurs or within 60 days after a covered Eligible Dependent Child loses eligible status. This notice must be sent to the Participating Employer at the address shown in the “Your
Contact Information” section of this SPD. Failure to provide this notice within the required timeframe will result in a loss of COBRA continuation coverage rights.
Once the Participating Employer receives the notice, the Participating Employer will send a continuation of coverage notice to the individuals in question along with a continuation of coverage election form, which allows the individuals to indicate whether they want such coverage.
January 2012 FSA SPD 12
Individuals must elect continuation coverage within 60 days after the later of:
The date active coverage ceases under the Plan, or
The date of the notice informing such individuals of their COBRA continuation rights.
Termination
Continuation coverage will end before the maximum coverage period if one of these events occurs:
You fail to make contributions on time
You become entitled to Medicare after you have elected COBRA continuation coverage
The Participating Employer stops providing group health care coverage for Associates
You become covered under another group health program after you have elected COBRA continuation coverage
You cease to be disabled during the 11-month disability extension period
The Plan Administrator terminates your coverage for Cause
If you have questions concerning your continuation coverage rights, you should contact the COBRA service provider (see the “Your Contact Information” section of this SPD). In order to protect your family’s COBRA rights, you should keep your Participating Employer and the Plan Administrator informed of any changes in the addresses of your family
members. You should also keep a copy, for your records, of any notices sent to the Plan Administrator or your Participating Employer.
USERRA Continuation Coverage for Health Care FSA
If you are called to serve in the United States uniformed services, your benefits under the Health Care FSA may be protected by the Uniformed Services Employment and
Reemployment Rights Act of 1994 (USERRA). You may qualify to choose to continue coverage under the Health Care FSA for up to 24 months from the date your leave of absence begins.
USERRA was signed into law in order to ensure that, under certain conditions, those who serve their country can retain their civilian employment and benefits. The continuation coverage mandated under USERRA is separate coverage from that provided under COBRA, although they may run concurrently, which means that they begin at the same time. However, COBRA coverage can continue for up to 18 months, while USERRA coverage can continue for up to 24 months. In addition, COBRA coverage may be terminated for additional reasons that do not apply to USERRA coverage. Eligibility for TRICARE (formerly CHAMPUS) or active duty military coverage will not terminate coverage under USERRA continuation coverage.
If your period of uniformed service is less than 30 days, you are not required to pay more for USERRA coverage than the amount you pay for coverage under the Medical Expense
Flexible Spending Plan as an active Eligible Associate. For longer periods, your cost for USERRA coverage will be the same as for COBRA continuation coverage — 102% of the full cost of coverage.
January 2012 FSA SPD 13
If you were ever on a leave of absence due to military service or are thinking about leaving employment to serve in the military, please contact your local Human Resources
Department to learn more about your rights under USERRA.
Qualified Medical Child Support Order
The Medical Expense Flexible Spending Plan will provide benefits in accordance with the applicable requirements of any Qualified Medical Child Support Order (as defined in Section 609(a) of ERISA) as soon as administratively feasible after the Plan Administrator
determines that the medical child support order is a Qualified Medical Child Support Order, as described below.
Definitions
For purposes of this section, the following terms will have the meanings given them below:
“Alternate recipient” means any Child of a Participant who is recognized under a medical child support order as having a right to participate in the Medical Expense Flexible Spending Plan.
“Medical child support order” means a judgment, decree or order issued by a court of competent jurisdiction, including approval of a settlement agreement, which is either made pursuant to a State domestic relations law and provides for child support and/or health benefit coverage for a Child of a Participant, or which enforces a law relating to medical child support described in section 1908 of the Social Security Act, as added by section 13822 of the Omnibus Budget Reconciliation Act of 1993 (Medicaid), with respect to the Medical Expense Flexible Spending Plan.
“Qualified Medical Child Support Order (QMCSO)” means a medical child support order which creates, recognizes or assigns to an alternate recipient the right to receive medical benefits for which a Participant is eligible under the Medical Expense Flexible Spending Plan. In order to be qualified, the order must:
− Clearly specify the name and address of the Participant and each alternate recipient covered by the order and reasonably describe the type of coverage to be provided or the manner in which such coverage can be determined
− Specify the period to which the order applies and the plans which are subject to the order
− Not require that the Medical Expense Flexible Spending Plan provide any type or form of benefit or any option not otherwise provided under the Medical Expense Flexible Spending Plan, except to the extent necessary to meet the requirements of a law relating to medical child support described in section 1908 of the Social Security Act (Medicaid)
Procedures
The Plan Administrator will use the following procedures to verify whether any judgment, decree or order is a QMCSO and to administer the provision of benefits under any such order, subject to such changes as are consistent with applicable law and regulations:
January 2012 FSA SPD 14 Upon receiving a medical child support order, the Plan Administrator will promptly
notify the Participant and the alternate recipient of the receipt of the order and the Medical Expense Flexible Spending Plan's procedures for determining whether the order is a QMCSO. Within a reasonable period thereafter, the Plan Administrator will
determine whether the order satisfies the requirements for a QMCSO and notify the parties of its decision.
The alternate recipient will be permitted to designate a representative for the receipt of copies of notices that are sent to the alternate recipient.
Status of Alternate Recipients
For all purposes under ERISA, an alternate recipient will be treated as a beneficiary under the Medical Expense Flexible Spending Plan.
Right to Amend or Discontinue the Plans
Ascension Health and your Participating Employer are committed to maintaining the Plans. However, Ascension Health (the Plan Sponsor) reserves the right to amend or terminate the Plans in whole or in part, at any time, and for any reason, without advance notice. Amendment or termination of the Plans shall be effective if it is approved in writing by a duly authorized officer of Ascension Health, or if it is adopted pursuant to Ascension Health’s procedures allocating or delegating authority to act on behalf of Ascension Health, as such procedures exist from time to time.
Any Participating Employer will be permitted to discontinue or revoke its participation in the Plans. Coverage under these Plans will automatically terminate with respect to all Participants of a Participating Employer as of the date the Participating Employer ceases to participate in the Plans.
January 2012 FSA SPD 15
Participation in FSA benefits is optional. If you wish to participate, you may contribute to either the Health Care FSA, Dependent Care FSA or both. The two accounts are separate but work in similar ways. Each year, you specify how much of your pay you want deposited into each account. This amount is deducted from your paycheck on a pre-tax basis in equal amounts each pay period, and is then deposited into your account.
Be careful and conservative when estimating how much to put into your FSAs. You will forfeit any amounts not used for eligible expenses incurred during the Plan Year.
Fortunately, many health care and dependent day care expenses are predictable from year to year. Even expenses that are not routine may be known well in advance, like nonemergency surgery and childbirth.
Since you do not pay federal income tax on the money in
your FSAs, every time you use your account to pay for an eligible expense, it’s like getting a discount equal to your income tax bracket. You don’t pay FICA (Social Security) taxes, or, in most cases, state taxes, on this money either, increasing your tax savings even more.
Health Care FSA
How the Health Care FSA Works
The Health Care FSA helps you save money on health care expenses that aren’t covered by a medical, prescription drug, dental or vision plan. If you wish to participate in the Health Care FSA, estimate your health care expenses for the upcoming Plan Year; then decide how much to deposit into your account. When estimating expenses, consider that the Health Care FSA covers Eligible Health Care Expenses incurred by both you and your Eligible
Dependents. Also, you and your Eligible Dependents do not have to be enrolled in any of the Ascension Health health care plans to participate in the Health Care FSA.
Your deposits into your Health Care FSA are made in equal amounts from each paycheck with convenient pre-tax payroll deductions. When you have an Eligible Health Care
Expense, you either use your electronic payment card at the time the expense is incurred, or submit a claim to reimburse yourself with pre-tax dollars from your account.
Section 2: Flexible Spending Account (FSA) Benefits
The Health Care FSA and Dependent Care FSA are completely separate
accounts. You may not use deposits to your Health Care FSA to fund dependent day care expenses or vice versa.
For an Eligible Health Care Expense to be reimbursed, you must have incurred the expense between January 1 of the current Plan Year and December 31 of the same year.
Electronic Payment Card
The electronic payment card allows you to pay for Eligible Health Care Expenses at the time you incur the expense. Here’s how it works:
You elect to use the card — You must agree to abide by the terms and conditions of the cardholder agreement, including any fees applicable to use the card, limits to the card usage, and the Health Care FSA’s right to withhold and offset for ineligible claims.
Use the card at any eligible merchant — At the time you incur Eligible Health Care Expenses, use the card as you would any other credit or debit card.
Retain your receipts — Keep all your receipts for one year following the close of the Plan Year in which the expense is incurred. You may need to submit the receipt to the Plan Administrator to substantiate a claim. Make sure your receipts include the nature of the expense, date the expense was incurred and the amount of the expense.
Health Care FSA Deposit Limits
The maximum deposit you can make to the Health Care FSA per Plan Year varies by Participating Employer (see the “Plan Outline” section of this SPD for your Participating Employer’s maximum deposit amount); the minimum deposit amount is $260.
The full amount that you have elected as your annual deposit is available at any time during the Plan Year (reduced by any prior reimbursements) to pay for eligible expenses, regardless of how much you have contributed to the Health Care FSA up to that point.
Covered Health Care Expenses
To be eligible for reimbursement under the Health Care
FSA, expenses must be incurred for the diagnosis, cure, relief, treatment or prevention of sickness or injury. The following are examples of Eligible Health Care Expenses under the Health Care FSA:
Amounts not paid by your (or your Spouse’s) medical, prescription drug, dental or vision coverage, including:
− Deductibles
− Copayments for your share of expenses paid as a percentage
− Amounts above the limits for medical, prescription drug, dental and vision plans
Non-covered dental, vision (exams, frames, lenses and contact lenses) and hearing care (exams and aids)
Non-covered physician fees
Hospital services, including anesthesiology
Diagnostic services, including laboratory and x-ray fees
Prescription medications, including insulin
Nursing services for care of a specific medical condition
The amount you elected for your annual deposit is available to you at any time during the Plan Year to cover Eligible Health Care Expenses.
January 2012 FSA SPD 17 Hospice care
Chiropractor and osteopath services
Psychotherapist, psychiatrist and psychologist services
Treatment for alcoholism or drug dependency
Physical therapy
Acupuncture
Organ donation expenses
Cost of guide or seeing-eye dog for the blind
Orthodontia expenses not paid by a dental plan
Wheelchair and costs for equipping an auto for a disabled person
Crutches and artificial teeth or limbs
Oxygen and oxygen equipment
Certain smoking cessation programs and prescription drugs designed to alleviate nicotine withdrawal
Weight reduction programs undertaken at a physician’s direction to treat an existing disease
Over-the-counter medications and drugs for which you have a prescription from your physician
Any other out-of-pocket medical, prescription drug, dental or vision expenses allowed as deductions by the IRS on your federal tax return (except insurance premiums)
Exclusions – The Health Care FSA does not cover:
Premiums for health, auto, disability, accident, life or long-term care insurance
Health spa and club memberships, dance lessons or weight reduction programs for general health maintenance
Cosmetic surgery and other similar procedures (unless related to a congenital defect, accidental injury or disfiguring disease)
Nonprescription drugs (including vitamins), cosmetics and dietary supplements that are for the purpose of improving or maintaining general health
Nonmedical expenses, such as electronic air filters and hot tubs, unless prescribed by a physician
Physical treatments (e.g. massage) that aren’t related to a specific health condition
Transportation expenses to and from work, even if disabled
Illegal operations and treatments
Custodial care in an institution
Long-term care services
Marriage and family counseling or divorce costs
Expenses incurred before you begin contributing to the Health Care FSA
Any other expenses specifically excluded in the “Plan Outline” section of this SPD or enrollment materials
For a complete list of eligible and ineligible expenses, see Code Section 213(d) and IRS Publication 502, “Medical and Dental Expenses.” You may request these publications from the IRS, or view them online by going to www.irs.gov/formspubs/index.html.
Dependent Care FSA
How the Dependent Care FSA Works
If you wish to participate in the Dependent Care FSA, estimate your dependent day care expenses for the upcoming Plan Year; then decide how much to deposit into your account.
When estimating expenses, consider that the Dependent Care FSA covers only those expenses necessary:
For you to work,
For your Spouse to work, attend school full time, or look for work,
For you to work part time and attend school full time, or
Because your Spouse is incapacitated.
Your deposits into your Dependent Care FSA are made in equal amounts from each
paycheck with convenient pre-tax payroll deductions. When you have an Eligible Dependent Day Care Expense, submit a claim to reimburse yourself with pre-tax dollars from your account.
Dependent Care FSA Deposit Limits
The maximum deposit you can make to the Dependent Care FSA per Plan Year is based on your tax filing status as follows:
Single or married and filing jointly — $5,000
Married filing separately — $2,500
In addition, if you are married, your annual deposit amount cannot exceed the earned income of the lower-paid
Spouse. If your Spouse is a student or incapacitated, your Spouse is considered to “earn” $250 per month if you have one Child or $500 if you have two or more Children. If your Spouse is employed elsewhere and contributes to a similar account, your family cannot contribute more than the maximum amount allowed by this Dependent Care FSA, dependent upon your tax filing status as listed above.
The minimum deposit you can make to the Dependent Care FSA is $260.
The amount available to you for reimbursement of Eligible Dependent Day Care Expenses is the amount of your account balance at the time your request is processed.
You have from January 1 of the current enrollment year to December 31 of the same year to incur Eligible
Dependent Day Care Expenses.
You may only be reimbursed up to the balance in your account at the time your claim is processed to cover your Eligible Dependent Day Care Expenses.
Covered Dependent Care Expenses
The following are examples of Eligible Dependent Day Care Expenses and are only covered if the individual receiving care is considered to be a Qualifying Individual under the Dependent Care FSA:
Dependent day care provided in your home by a babysitter, housekeeper or relative who is not a dependent
Dependent day care provided outside your home, including qualified day care centers, day camp, preschool and before- and after-school programs
Elder care for dependents who live with you.
Generally, eligible child care costs include only those for the actual care of your Child or disabled Spouse — not costs for education, supplies or meals, unless those costs cannot be separated from the cost of care.
Exclusions – The Dependent Care FSA does not cover
expenses for:
Care provided by your Child under age 19 or any other dependent you claim on your tax return
Care obtained for reasons other than work, such as social and volunteer activities
Care that could be provided by your employed Spouse while not at work
Care provided by your Spouse or the parent of the Qualifying Individual
Overnight camp
Food, clothing, education (kindergarten and above), entertainment and transportation to and from the day care location
Agency referral charges and finder’s fees
Care paid for by another organization or provided at no cost to you
Nursing home and other dependent day care services for dependents not living with you at least eight hours a day
Dependents not considered to be Qualifying Individuals under the Dependent Care FSA
Charges incurred before you begin contributing to the Dependent Care FSA
Any other services specifically excluded in the “Plan Outline” section of this SPD or enrollment materials
The Dependent Care FSA also does not cover expenses claimed as a federal income tax credit.
For a complete list of eligible and ineligible expenses, see IRS Publication 503, “Child and Dependent Care Expenses.” You may request this publication from the IRS, or view it online by going to www.irs.gov/formspubs/index.html.
“Qualifying Individual” means an Eligible Dependent:
You can claim on your federal income tax return who is age 12 or under, and for whom you are the custodial parent for more than one half of the year; or
Who is your Spouse or other dependent who is physically or mentally incapable of caring for himself or herself, lives with you for at least half the year and is
considered to be your tax dependent.
Use It or Lose It Rule
The FSAs can be a very valuable benefit for you. In
exchange for the tax savings offered, the IRS imposes what is known as the “Use It or Lose It” rule. This rule states that all of your annual deposit must be spent on eligible expenses you incur during the Plan Year, or any leftover money must be forfeited. Forfeited money is used by the Plan Administrator to offset administrative expenses and future costs of the Plans.
Please note: Because the Health Care FSA and Dependent Care FSA are separate accounts, you may not use money from your Health Care FSA to pay for dependent day care expenses or vice versa.
Effect of FSA Participation on Tax Credits and Social Security Benefits
Participating in an FSA may affect other tax credits and benefits. Consult your tax advisor to see how these provisions might affect your personal tax situation.
Claim for Household and Dependent Care Credit
You may not claim any other tax benefit for the tax-free amounts received by you under the Dependent Care Flexible Spending Plan. However, if you have any unreimbursed dependent care expenses remaining after depleting your Dependent Care FSA account, those amounts may be eligible for the dependent care credit on your federal income tax return.
Social Security Benefits and Other Tax-Related Benefits
When you contribute to an FSA, it reduces the amount of your taxable compensation. Accordingly, there could be a decrease in your Social Security benefits and/or other benefits (e.g. pension, disability and life insurance) that are based on taxable compensation. However, in most cases, any possible reduction in these benefits is far outweighed by the tax savings you receive by using an FSA.
Qualified Reservist Distribution
Ascension Health has adopted the qualified reservist distribution provisions of the HEART Act (Heroes Earnings Assistance and Relief Tax Act of 2008) into its Health Care FSA. Under this provision, Participants in the Medical Expense Flexible Spending Plan who are called to active duty in the U.S. military for at least 180 days can receive a distribution,
Section 3: Other Plan Provisions
Go online to
www.flexdirect.adp.com to check the balance in your FSA account at any time. If you don’t spend your annual deposit on eligible expenses during the Plan Year, any money left over in your account will be forfeited. Once the Plan Year has ended, you have until March 31 of the following year to submit a claim for
January 2012 FSA SPD 21
without penalties, of the unused balance from their Health Care FSA ― amounts that may otherwise be forfeited.
To qualify for this distribution, you must be a “reservist” as defined in 37 U.S.C. Section 101, which means you must be a member of one of the following:
Army National Guard of US Army Reserve
Navy Reserve
Marine Corps Reserve Air National Guard of US Air Force Reserve
Coast Guard Reserve
Reserve Corps of the Public Health Service
Your request for distribution must be made after the order for active duty is issued, but before the last day of the Plan Year.
The amount of your distribution is restricted to the amount actually contributed to the Health Care FSA at the time of the request, minus any reimbursements actually received. This distribution is taxable, and will be reported as income on your W-2 for the year in which you receive the distribution.
To apply for a Qualified Reservist Distribution, you must complete the Qualified Reservist Distribution Form available from your local Human Resource Department. The approved reimbursement amount will be processed through the Plan Administrator.
To be reimbursed for Eligible Health Care and Dependent Day Care Expenses, you will need to submit a Request for Reimbursement Form along with a written statement substantiating your claim. Claim forms are available from ADP or your local Human Resources Department.
Please note: If you pay for your Eligible Health Care Expenses with your electronic payment card, you will not need to file a claim. However, remember to save your receipts for one year in case ADP requests copies to verify your claim.
Filing a Claim
When you incur an Eligible Health Care or Dependent Day Care Expense, you must pay for the expense at the time of purchase or billing, if applicable, and then file a claim for
reimbursement. Request for Reimbursement Forms are available from ADP or your local Human Resources Department. You do not need to file a claim for Eligible Health Care Expenses that are paid with your electronic payment card.
Expenses are incurred on the date the service is rendered, not billed (except for durable medical equipment, such as a wheelchair). In addition, expenses must be incurred in the same Plan Year you make deposits to your FSA. You have until March 31 of the following year to submit claims for expenses incurred during the prior Plan Year. For example, for 2012, you have from January 1, 2012 to March 31, 2013 to submit your claims for
reimbursement for your 2012 Eligible Health Care and Dependent Day Care Expenses.
Process for Submitting Claims
Send the completed Request for Reimbursement Form to ADP at the address on the form, along with appropriate documentation as follows:
Health Care Account Dependent Care Account
Documentation Needed Itemized statement from the provider with name of person receiving the
services or materials, date(s) of service, nature of
expense and amount of expense, or
Explanation of Benefits (EOB) from the Plan, or
If the expense is for an over-the-counter drug or medicine (other than insulin), a receipt from the pharmacy with the
prescription number
Itemized bill including names of dependent and provider (must also give provider’s Social Security or tax ID Number) date(s) of service, nature of services and amount of expense
Amount Reimbursed Up to the total deposit elected
for the Plan Year Up to the current account balance You may be required to submit additional substantiation to the extent deemed necessary by ADP to support your claim.
After your information is received, ADP will process your claim. If the claim is determined to be an eligible expense, you will receive reimbursement as soon as possible. If the expense is determined to be ineligible, you will receive notification as such.
Timing of Claims Review
After you file a claim, ADP will notify you of its benefit determination within 30 days after receipt of claim. This period may be extended one more time for up to 15 days if the
extension is necessary due to matters beyond the control of the Plans. You will be provided written notice of the need for additional time prior to the end of the 30-day period.
If the reason for the additional time is that you need to provide additional information, you will have 45 days from the notice of this extension to obtain that information. The time period during which ADP must make a decision will be suspended until the earlier of the date you provide the information and/or the end of the 45-day period.
If Your Claim is Denied
If your claim is denied, a notice of adverse benefit determination will be provided in writing or electronically and will include:
The specific reason or reasons for the denial,
Reference to the specific Plan provisions on which the denial is based,
A description of any additional information necessary for you to perfect your claim, why the information is necessary and your time limit for submitting the information,
A description of the Plan’s review procedures and the time limits applicable to such procedures, and
Your right to request all documentation relevant to your claim.
Appealing a Denied Claim
If you disagree with the claim denial, you or an authorized representative may file a written appeal within 180 days after the receipt of the original notice of denial. You should submit all information identified in the notice of denial as necessary to perfect your claim and any additional information you believe would support your claim.
If the claim is again denied, you will be notified in
writing no later than 30 days after receipt of the appeal by ADP. When you receive your denial of appeal notice from ADP, the notice will contain the same items as listed under the “If Your Claim is Denied” section.
You may file a written appeal with the Plan Administrator within 60 days after receiving the first level appeal denial notice from ADP if you still disagree with the decision. You should submit all information identified in the notice of denial as necessary to perfect your claim and any additional information you believe would support your claim.
If the Plan Administrator denies your second level appeal, you will receive notice within 30 days after the Plan Administrator receives your claim. The notice will contain the same items as listed under the “If Your Claim is Denied” section.
If you need assistance understanding your benefit determination or have
questions about your rights to appeal a denied claim, contact ADP.
To appeal a claim, you will need to send notification of your desire to appeal within 180 days from receipt of your claim denial. Be sure to include the following:
Participant’s name ID and claim numbers Also, indicate whether the person requesting the appeal is the Eligible Associate, Eligible Dependent or authorized representative.
Other Important Appeals Information
Each level of appeal will be independent from the previous level (i.e., the same person(s) or subordinates of the same person(s) involved in a prior level of appeal would not be involved in the appeal).
On each level of appeal, the claims reviewer will review relevant information you submit, even if it is new information.
The Plan Administrator is required to give the Participant notice of any internal rules, guidelines, protocols or similar criteria used as a basis for the adverse determination.
You cannot file suit in federal court until you have exhausted these appeals procedures, however, you have the right to file suit under ERISA Section 502 following an adverse appeal decision.
Participants have the right to request and obtain documents, records and other information as it pertains to their claim and the Plans.
Additional Recourse
If you have exhausted the appeals process and ADP continues to deny your claim or you do not receive a timely decision, you have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the decision on review. You and the Plan
Administrator may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office. You may also contact the Employee Benefits Security Administration at 866.444.3272.
Overpayment of Claims
If any benefit is mistakenly paid or overpaid by thePlans, either in whole or in part, the Plan Administrator reserves the right to offset amounts to be paid in the future as benefits under the Plans with respect to you or any members of your family, or to recover such mistakenly paid amounts or overpayments from and among any person to, or for, or with respect to whom such amounts were paid. Any Associate who performs services that are or may be compensated in part by benefits payable pursuant to the Plans hereby consents to venue and jurisdiction of any court in which the Plan Administrator files suit in accordance with this section.
Misrepresentations
Anyone who, with intent to defraud or knowing that he/she is facilitating a fraud, submits an application or files a claim containing a false, incomplete or misleading statement is guilty of fraud. The Plan Administrator reserves the right to take appropriate action in any instance where fraud is an issue.
January 2012 FSA SPD 26
As a Participant in the Medical Expense Flexible Spending Plan, you are entitled to certain rights and protections under ERISA.
Receiving Information About the Plan and Benefits
You have the right to:
Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing the Medical Expense Flexible Spending Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Medical Expense Flexible Spending Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Medical Expense Flexible Spending Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) and updated SPD. The Plan Administrator may make a reasonable charge for the copies.
Receive a summary of the Medical Expense Flexible Spending Plan’s annual financial reports. The Plan Administrator is required by law to furnish each Participant with a copy of this summary annual report.
Continuing Your Group Health Coverage
You have the right to continue health care coverage for yourself, Spouse or dependents if there is a loss of coverage under the Medical Expense Flexible Spending Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this SPD and the documents governing the Medical Expense Flexible Spending Plan for the rules that explain your COBRA continuation rights.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Participants in the Plan, ERISA imposes duties upon the people who are responsible for the operation of the Plan. The people who operate the Medical Expense Flexible Spending Plan, called “fiduciaries” of the Medical Expense Flexible Spending Plan, have a duty to do so prudently and in the interest of you and other Participants in the Plan and beneficiaries. No one, including your Participating Employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
January 2012 FSA SPD 27
Enforcing Your Rights
If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the documents that govern the Medical Expense Flexible Spending Plan or the latest annual report from the Medical Expense Flexible Spending Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may
require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator.
If you have a claim for benefits that is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan Administrator’s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court. If it should happen that the fiduciaries of the Medical Expense Flexible Spending Plan misuse the Medical Expense Flexible Spending Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about the Medical Expense Flexible Spending Plan, you should contact ADP. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
January 2012 FSA SPD 28
This Notice describes privacy practices relating to the Medical Expense Flexible Spending Plan and does not apply to the Dependent Care Flexible Spending Plan. Please review this section carefully as it describes how health information about you may be used and disclosed and how you can get access to this information.
Our Responsibilities
Ascension Health takes the privacy of your health information seriously. The Medical Expense Flexible Spending Plan is required by law to maintain that privacy and to provide you with this Notice of Privacy Practices. This Notice is provided to tell you about our duties and practices with respect to your information. The Medical Expense Flexible Spending Plan is required to abide by the terms of this Notice currently in effect.
How We May Use and Disclose Your Health Information
The following categories describe different ways we use and disclose health information. For each category we explain what we mean and give some examples. Not every use or
disclosure in a category will be listed. However, all of the ways the Medical Expense Flexible Spending Plan is permitted to use and disclose information will fall within one of the
categories.
To the Plan Sponsor. The Medical Expense Flexible Spending Plan may disclose your
information to the Plan Sponsor in certain situations, and may permit any health
insurance company or HMO with whom you have benefits to disclose your information to the Plan Sponsor. The Plan document that governs the Medical Expense Flexible Spending Plan must restrict how the Plan Sponsor uses and discloses your information, however.
In addition, the Medical Expense Flexible Spending Plan may disclose your "summary health information" to the Plan Sponsor to obtain premium bids from health plans for the Medical Expense Flexible Spending Plan’s coverage or to amend the Medical
Expense Flexible Spending Plan. "Summary health information" means your information that identifies you and summarizes your claims history, expenses or types, but the
information will not identify you any more specifically than your ZIP code.
Also, the Medical Expense Flexible Spending Plan may disclose to the Plan Sponsor whether or not you are participating in the Medical Expense Flexible Spending Plan or are enrolled or disenrolled. The Medical Expense Flexible Spending Plan may disclose your information to the Plan Sponsor to carry out plan administration functions.
January 2012 FSA SPD 29
The Medical Expense Flexible Spending Plan may not disclose your information to the Plan Sponsor for the purpose of employment-related actions or decisions or in
connection with any other employee benefit plan of the Plan Sponsor.
For Payment. We may use and disclose your health information for the purpose of:
− Obtaining premiums or to determine or fulfill the responsibility for coverage and provision of benefits under the Medical Expense Flexible Spending Plan
− Coordination of benefits or the determination of cost sharing amounts − Adjudication or subrogation of health benefit claims
− Processing claims − Billing
− Claims management − Collection activities
− Obtaining payment under a contract for reinsurance (including stop-loss insurance and excess of loss insurance)
− Review of health care services with respect to medical necessity − Coverage under a health plan
− Appropriateness of care, or justification of charges for the treatment and services provided to you
− Utilization review activities, including precertification and preauthorization of services, and concurrent and retrospective review of services
− Disclosure to consumer reporting agencies of any of the following protected health information:
• Name and address
• Date of birth
• Social Security Number
• Payment history
• Account number
• Name and address of any relevant health care provider and/or health plan We may also provide your information to another entity for its payment activities and disclose your information to another entity for certain health care operations of that entity.
Some examples of the uses and disclosures for payment include the following. (Please note that, as is the case with the other examples in this Notice, these examples are merely a few of the many types of uses and disclosures that might be made.) The Medical
Expense Flexible Spending Plan will disclose your health information to the Medical Expense Flexible Spending Plan’s third-party administrator (TPA) so the TPA can process claims you make under the Medical Expense Flexible Spending Plan. The Medical Expense Flexible Spending Plan also may disclose such information to other health plans in order to determine which plans (this Plan or the other plans) should pay such claims. Health information, such as your medical history, also could be disclosed to your health care providers in order to determine whether a particular course of treatment is experimental, investigational or medically necessary.
January 2012 FSA SPD 30 For Treatment. Unlike health care providers, the Medical Expense Flexible Spending Plan
does not actually provide treatment. Instead, the Medical Expense Flexible Spending Plan is a mechanism to provide payment for or reimbursement of the costs of health care. Although the Medical Expense Flexible Spending Plan does not actually provide treatment, it may disclose health information to physicians or other health care providers in order to enable them to treat you.
For example, disease management services may be provided through the Medical Expense Flexible Spending Plan, in which case health information may be disclosed in order to enable your health care providers to deliver such services. Or, the Medical Expense Flexible Spending Plan may disclose to your primary care physician the name of a specialist who is treating you so that they may coordinate your care.
For Health Care Operations. We may use and disclose your health information for health
care operations including:
− Conducting quality assessment and improvement activities, including outcomes evaluation and development of clinical guidelines
− Population-based activities relating to improving health or reducing health care costs − Reviewing the competence or qualifications of health care professionals
− Evaluating practitioner and provider performance, and the performance of the Medical Expense Flexible Spending Plan
− Accreditation, certification, licensing, or credentialing activities
− Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care
(including stop-loss insurance and excess of loss insurance)
− Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and compliance programs
− Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies
− Business management and general administrative activities of the Medical Expense Flexible Spending Plan, including:
• Management activities relating to implementation of and compliance with the requirements of the HIPAA regulations
• Customer service
• Resolution of internal grievances
• Consistent with the applicable requirements of the HIPAA regulations, creation of de-identified health information or a limited data set
Examples of the foregoing include the following: The Medical Expense Flexible Spending Plan may engage in activities in which the quality of care provided under the Medical Expense Flexible Spending Plan is evaluated and, in doing so, may use health information or disclose such information to an organization performing the evaluation.
