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© Hitesman & Wold, P.A. 2019 Cafeteria Plan Summary Description (3-11) 48 7.6 How do I receive my reimbursements under the Limited Scope Health FSA? (a) Periodic Reimbursements. When you incur an expense that is eligible for reimbursement, you submit a claim to the Claims Administrator on a claim form that will be supplied to you. The claim form may be submitted via email, facsimile, mail, or the Claims Administrator’s website. The claim form will typically set forth: (1) the amount, date and nature of the expense, (2) the name of the person or entity to which the expense was paid, (3) your statement that the expense has not been reimbursed, and you will not seek reimbursement for the expense, from any other source, and (4) such other information as the Plan Administrator may require, including copies of bills or receipts from the provider(s) to support your claim. If there are enough dollars credited to your Limited Scope Health FSA, you will be reimbursed for your Eligible Expenses according to the schedule established by the Plan Administrator. Claims Deadline. You may submit claims for reimbursement of Eligible Expenses incurred during the Plan Year for ninety (90) days following the end of that Plan Year. This period following the end of the Plan Year during which claims for reimbursement may be filed is referred to as the “claims run-out period.” Grace Period. You may submit claims for reimbursement of Eligible Expenses incurred after the Plan Year for up to sixty (60) days following the end of that Plan Year. This period following the end of the Plan Year during which claims for reimbursement may incurred is referred to as the “grace period.” (b) Electronic Payment Card Claims. The electronic payment card allows you to pay for Eligible Expenses at the time that you incur the expense. The electronic payment car d works as follows: (1) You must make an election to use the card. In order to be eligible for the electronic payment card, you must agree to abide by the terms and conditions of the electronic payment card program as set forth herein and in the electronic payment cardholder agreement (the “Cardholder Agreement”), including agreeing to any fees applicable to participate in the program, limitations as to card usage, the Plan’s right to withhold and offset ineligible claims, etc. You must agree to abide by the terms of the program each Plan Year. A Cardholder Agreement will be provided to you. The card will be turned off effective the first day of each Plan Year if you do not affirmatively agree to abide by the terms of the program for the new Plan Year. The Cardholder Agreement is part of the terms and conditions of your Plan and this Summary Plan Description. (2) The balance of the card is limited. The balance of the card is limited to the balance of your account. (3) The card will be turned off when coverage terminates. The card will be turned off when your coverage under the Limited Scope Health FSA terminates.