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© Hitesman & Wold, P.A. 2019 Cafeteria Plan Summary Description (3-11) 37 card provider that verifies, at the time of purchase, that the goods being purchased constitute medical care. (6) You swipe the card at the health care provider like you do any other credit or debit card. When you incur an Eligible Expense at a doctor’s office or pharmacy, such as a co-payment or prescription drug expense, you swipe the card at the provider’s office much like you would a typical credit or debit card. The provider is paid for the expense up to the maximum reimbursement amount available under your account (or as otherwise limited by the program) at the time you swipe the card. Every time you swipe the card, you certify to the Plan that the expense for which payment is being made is an Eligible Expense and that you have not been reimbursed by any other source nor will you seek reimbursement from another source. (7) You must obtain and retain a receipt/third party statement each time you swipe the card. You must obtain a third party statement from the health care provider (e.g. receipt, invoice, etc.) each time you swipe the card that includes the following information: (i) The nature of the expense (e.g. what type of service or treatment was provided). If the expense is for an over the counter drug, the written statement must indicate the name of the drug; (ii) The date the expense was incurred; and (iii) The amount of the expense. Although it is not required to be submitted for all purchases, you must retain this receipt for one year following the close of the Plan Year in which the expense was incurred. Even though payment may be made under the card arrangement, a written third party statement may be required to be submitted (except as otherwise provided in the Cardholder Agreement). You will receive a letter from the Claims Administrator if a third party statement is needed. If requested, you must provide the third party statement to the Claims Administrator within 30 days (or such longer period provided in the letter from the Claims Administrator) of the request. (8) There are situations where the third party statement will not be required to be provided to the Claims Administrator. There may be situations in which you will not be required to provide the written statement to the Claims Administrator, including: (i) Co-Pay Match. No written statement is required if the electronic payment card is used at medical care providers (i.e., merchants or service- providers that have health care related merchant category codes such as physicians, pharmacies, dentists, vision care offices, and hospitals) and the payment matches a specific co-payment you have under one of the Employer’s group health plans for the particular service that was provided or a multiple of that co-payment of not more than five (5) times the dollar amount of the co-payment. For example, if you have a $10 co-pay for physician office visits, and the payment was made to a physician office in the amount of $10, $20, $30, $40, or $50, you will not be required to provide the third party statement to the Claims Administrator.