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© Hitesman & Wold, P.A. 2019 <br />Cafeteria Plan <br />Summary Description (3-11) <br />ii <br /> <br /> <br />TABLE OF CONTENTS <br />INTRODUCTION ................................................................................................................................. 1 <br />PART I. GENERAL INFORMATION ABOUT THE PLAN ............................................................................. 2 <br />1.1 What is the purpose of the Cafeteria Plan? ................................................................... 2 <br />1.2 When did the Cafeteria Plan take effect? ...................................................................... 2 <br />1.3 What Optional Benefits are offered through the Cafeteria Plan? ..................................... 2 <br />1.4 Who can participate in the Cafeteria Plan? .................................................................... 3 <br />1.5 When do I become a Participant and how long does participation last? .......................... 3 <br />1.6 How do I enroll and make benefit elections? ................................................................. 4 <br />1.7 What is the maximum election I can make under the Cafeteria Plan? ............................. 5 <br />1.8 Can I change my election during the Plan Year? ........................................................... 5 <br />1.9 Who holds the funds I have set aside under the Cafeteria Plan? .................................. 13 <br />1.10 What if I terminate my employment during the Plan Year? .......................................... 13 <br />1.11 Will I have any administrative costs under the Cafeteria Plan? ..................................... 13 <br />1.12 How long will the Cafeteria Plan remain in effect? ....................................................... 13 <br />1.13 Are my benefits taxable? ........................................................................................... 13 <br />1.14 What is the impact on my Social Security benefits? ..................................................... 14 <br />1.15 What contributions are made to the Cafeteria Plan? .................................................... 14 <br />1.16 What if coverage is provided to someone other than your spouse and tax dependents? 15 <br />1.17 How are claims determined? ...................................................................................... 16 <br />1.18 How are insurance refunds handled? .......................................................................... 18 <br />1.19 Who has authority to interpret the Plan? .................................................................... 18 <br />PART II. GROUP MEDICAL BENEFITS ................................................................................................. 19 <br />2.1 What benefits are provided? ...................................................................................... 19 <br />2.2 How do I become a Participant in this portion of the Cafeteria Plan? ............................ 19 <br />2.3 How is my cost of group medical coverage paid? ........................................................ 19 <br />2.4 What if I am no longer eligible? ................................................................................. 20 <br />2.5 Can coverage be continued? ...................................................................................... 20 <br />2.6 What if I am subject to a medical child support order? ................................................ 20 <br />PART III. GROUP DENTAL BENEFITS ................................................................................................. 21 <br />3.1 What benefits are provided? ...................................................................................... 21 <br />3.2 How do I become a Participant?................................................................................. 21 <br />3.3 How is my cost of group dental coverage paid? .......................................................... 21 <br />3.4 What if I am no longer eligible? ................................................................................. 22 <br />3.5 Can coverage be continued? ...................................................................................... 22 <br />3.6 What if I am subject to a medical child support order? ................................................ 22 <br />PART IV. DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT .............................................................. 23 <br />4.1 What benefits are provided? ...................................................................................... 23 <br />4.2 How do I become a Participant in the Dependent Care FSA? ........................................ 23 <br />4.3 What is my account? ................................................................................................. 23 <br />4.4 What are the maximum benefits I may receive?.......................................................... 23 <br />4.5 Who is a “Qualifying Individual” for whom I can submit claims for reimbursement? ...... 24 <br />4.6 What if two people claim a child as a Qualifying Individual? ......................................... 26 <br />4.7 What is an "Eligible Expense"? ................................................................................... 27 <br />4.8 How do I receive reimbursements under the Dependent Care FSA? ............................. 28 <br />4.9 What limits apply to reimbursements under the Dependent Care FSA? ......................... 30