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CAFETERIA PLAN ADOPTION AGREEMENT FOR City of Orono © 2020 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan Adoption Agreement 1-888-816-4234, www.medsurety.com 4 ARTICLE XV: DISABILITY BENEFITS Not offered as a part of the Cafeteria Plan. 15.3(c) Type of Benefits: Long term disability coverage Short term disability coverage 15.6 Tax Consequence: Insurance Premiums paid pre-tax Insurance Premiums paid after-tax ARTICLE XVI: INDIVIDUAL PREMIUM FEATURE Not offered as a part of the Cafeteria Plan. 16.3(a) Claims Run-Out period: N/A – no reimbursements provided. Thirty (30) days. Sixty (60) days. Ninety (90) days. Other: 16.3(b) Dependent means: As provided in the Basic Plan Document. Other: 16.3(g) Insurance Contract means: As provided in the Basic Plan Document (i.e., just specialty coverages). Other: 16.6 Benefit administered by: Claims Administrator. Plan Administrator. 16.6 Form of Benefit: Reimbursements. Direct payments. Both reimbursements and direct payments. 16.7 Reimbursement Upon Termination of Participation: N/A – no reimbursements provided. Expenses incurred while a Participant may be reimbursed if submitted within Claims Run-Out Period identified in Section 16.3(a). Expenses incurred while a Participant may be reimbursed within 30 days following termination of participation. Expenses incurred during Plan Year (whether while a Participant or after participation ceases) may be reimbursed if submitted within Claims Run-Out Period identified in Section 16.3(a). Other: ARTICLE XVII: INDIVIDUAL MEDICAL PREMIUM FEATURE Not offered as a part of the Cafeteria Plan. 17.3(a) Claims Run-Out period: N/A – no reimbursements provided. Thirty (30) days. Sixty (60) days. Ninety (90) days. Other: 17.3(b) Dependent means: As provided in the Basic Plan Document. Other: 17.6 Benefit administered by: Claims Administrator. Plan Administrator. 17.6 Form of Benefit: Reimbursements. Direct payments. Both reimbursements and direct payments. 17.7 Reimbursement Upon Termination of Participation: N/A – no reimbursements provided. Expenses incurred while a Participant may be reimbursed if submitted within Claims Run-Out Period identified in Section 17.3(a). Expenses incurred while a Participant may be reimbursed within 30 days following termination of participation. Expenses incurred during Plan Year (whether while a Participant or after participation ceases) may be reimbursed if submitted within Claims Run-Out Period identified in Section 17.3(a). Other: ARTICLE XVIII: HSA CONTRIBUTION FEATURE Not offered as a part of the Cafeteria Plan. 18.3(b) HSA Trustee/Custodian: As provided in the Basic Plan Document. A trustee/custodian selected by Participant. 18.3(d) High Deductible Health Plan means: As provided in the Basic Plan Document (i.e., any HDHP). A group high deductible health plan sponsored by the Employer. A high deductible health plan the cost of which is at least partially reimbursed under the Employer’s individual coverage health reimbursement arrangement Other: 18.4 Certification of HSA eligibility is: Required. Not required. 18.7 Limits on Contributions: As provided in the Basic Plan Document. Other: