Healthcare FSA Summary Plan

HEALTHCARE FLEXIBLE SPENDING ACCOUNT (FSA) SUMMARY PLAN

Participant Information

Plan Identification

Plan Name:    Plan Number:

Plan Sponsor / Employer:

Plan Year (From / To): to    Effective Date:

Summary of Benefits and Administrative Rules

Purpose: The Healthcare Flexible Spending Account (FSA) permits eligible participants to pay for qualifying medical, dental and vision expenses using pre-tax salary reduction contributions. This Summary Plan describes eligibility, elections, claims procedures, reimbursement rules and participant responsibilities under the Plan.

Eligibility and Participation

Eligibility: Employees classified as eligible under employer policy may participate. To enroll, an eligible employee must complete required election forms within the annual enrollment period or within the time permitted following a qualified change in status.

Enrollment Date: Elections become effective on the first day of the plan period or as otherwise specified by employer policy. If different, special enrollment rules apply as set by the Plan Administrator.

Contributions and Elections

Participant Election (Annual): The annual salary reduction election selected by the participant for the Plan Year is $ and will be contributed by pre-tax payroll deductions according to the employer's payroll schedule.

Contribution Limit: Maximum allowed by the Plan for the Plan Year is $ . Employer contributions, if any, are described separately in employer communications.

Eligible Expenses and Substantiation

Eligible Expenses: Reimbursements are available only for expenses that meet the Plan's criteria for eligible medical, dental and vision expenses incurred during the participant's period of coverage. The Plan Administrator has final authority to determine eligibility of any expense.

Substantiation: All claims must be substantiated with itemized receipts, Explanation of Benefits, date of service, provider name, and expense description. The Plan may require additional documentation and may deny reimbursement if adequate substantiation is not provided.

Claims Filing and Reimbursement

Claims Deadline: Claims for expenses incurred during a Plan Year must be submitted no later than unless a different run-out period is specified by the Plan Administrator.

Reimbursement Method: Select applicable method(s) provided by this Plan:

Grace Period / Carryover / Forfeiture

Plan Feature Options (check applicable):

Forfeiture: Any amounts remaining beyond applicable grace period or carryover limitations will be forfeited to the Plan in accordance with Plan terms.

Election Changes and Qualifying Events

Election Changes: Participant election changes during a Plan Year are permitted only if the participant experiences a permitted change in status under Plan rules and timely notifies the Plan Administrator. Permitted changes include, but are not limited to, changes in marital status, number of dependents, or employment status as defined by the Plan.

Claims Review and Appeals

Initial Determination: The Plan Administrator will provide a written explanation for any denial of a claim, stating the reason for denial and the information necessary for the participant to perfect the claim.

Appeal Rights: A participant may appeal an adverse determination. To initiate an appeal, submit a written appeal within days of receipt of the denial. The appeal will be reviewed by an appropriate fiduciary who was not involved in the initial determination. The participant may submit written comments, documents and other information for consideration.

Plan Administration, Amendment and Termination

Plan Administrator: The Plan Administrator is the named employer or its designated administrator. Administrative address:

Amendment and Termination: The Plan Sponsor reserves the right to amend, modify or terminate the Plan at any time, subject to applicable law. No amendment or termination will deprive participants of accrued rights to reimbursement for eligible expenses incurred prior to the effective date of such action, except as permitted by law and Plan provisions.

Participant Responsibilities and Certifications

By enrolling in the Plan and/or signing this Summary, the participant certifies that all information provided is true and authorizes payroll salary reduction as elected. The participant further certifies that claims submitted are for eligible expenses incurred during the applicable coverage period and that any funds received will not be claimed as a deduction or credit on any tax return. The Plan reserves the right to recover any erroneous or ineligible reimbursements.

Privacy and Release of Information

The participant authorizes the release of medical and billing information, to the extent necessary for claims adjudication, to the Plan Administrator, third-party administrator and designated fiduciaries. Such information will be used only for Plan administration and subject to applicable confidentiality protections.

Recovery of Erroneous Payments

If a participant receives reimbursement in error, the Plan may offset future reimbursements, recover the amount by payroll deduction, or seek direct repayment. The participant agrees to cooperate in recovery efforts.

Signature and Acknowledgement

I acknowledge that I have received and reviewed this Healthcare FSA Summary Plan and understand the rules governing eligibility, elections, claims and reimbursements. I understand my responsibilities and the potential consequences for submitting ineligible claims or failing to provide required documentation.

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