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© Hitesman & Wold, P.A. 2019 Cafeteria Plan Summary Description (3-11) iii 4.10 Will I be taxed on the Dependent Care FSA benefits I receive? .................................... 30 4.11 If I participate in the Dependent Care FSA, will I still be able to claim the household and dependent care tax credit on my federal income tax return? ........................................ 30 4.12 What is the dependent care tax credit? ...................................................................... 30 4.13 When would it be better for me to use the tax credit? ................................................. 31 4.14 What if I am no longer eligible? ................................................................................. 31 4.15 What if I receive benefits in error? ............................................................................. 31 4.16 What if the dependent care expenses I incur during the Plan Year are less than the annual benefit I have elected? .............................................................................................. 31 4.17 What reporting will I receive? .................................................................................... 31 4.18 Is the Dependent Care FSA Plan governed by ERISA? ................................................. 32 4.19 Is the Dependent Care FSA Plan subject to COBRA? .................................................... 32 4.20 Is the Dependent Care FSA Plan subject to HIPAA? ..................................................... 32 PART V. HEALTH FLEXIBLE SPENDING ACCOUNT ............................................................................... 33 5.1 What benefits are provided? ...................................................................................... 33 5.2 How do I become a Participant?................................................................................. 33 5.3 What is my account? ................................................................................................. 33 5.4 What are the maximum reimbursements I may receive?.............................................. 33 5.5 What is an "Eligible Expense"? ................................................................................... 33 5.6 How do I receive my reimbursements under the Health FSA? ...................................... 35 5.7 What limits apply to reimbursements under the Health FSA? ....................................... 39 5.8 What is the Grace Period? ......................................................................................... 39 5.9 What if I am no longer eligible? ................................................................................. 40 5.10 Can coverage be continued? ...................................................................................... 40 5.11 Can I carryover my account to the next Plan Year? ..................................................... 40 5.12 What if I receive benefits in error? ............................................................................. 40 5.13 What if I am subject to a child support order? ............................................................ 40 PART VI. HSA CONTRIBUTION FEATURE ............................................................................................ 41 6.1 What benefits are provided? ...................................................................................... 41 6.2 Am I eligible and how do I become a Participant? ....................................................... 41 6.3 What is Permitted Insurance and Permitted Coverage? ................................................ 41 6.4 What is my HSA? ...................................................................................................... 42 6.5 What are the limits on the amount of contributions? ................................................... 42 The maximum contributions you may make through this HSA Contribution Feature shall be determined in accordance with the following rules: ..................................................... 42 6.6 What happens if my contributions exceed the contribution limit? ................................. 43 6.7 What are the tax consequences of the HSA Contribution Feature? ............................... 43 6.8 What are the rules regarding distributions from my HSA? ............................................ 43 6.9 When does my participation end? .............................................................................. 43 6.10 Can the contributions made to my HSA be forfeited? ................................................... 43 6.11 What are the reporting requirements? ........................................................................ 44 PART VII. LIMITED SCOPE HEALTH FLEXIBLE SPENDING ACCOUNT .................................................... 45 7.1 What benefits are provided? ...................................................................................... 45 7.2 How do I become a Participant?................................................................................. 45 7.3 What is my limited scope medical expense account? ................................................... 45 7.4 What are the maximum reimbursements I may receive?.............................................. 45 7.5 What is an "Eligible Expense"? ................................................................................... 46 7.6 How do I receive my reimbursements under the Limited Scope Health FSA? ................. 48 7.7 What limits apply to reimbursements under the Limited Scope Health FSA? .................. 51 7.8 What is the Grace Period? ......................................................................................... 52