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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 5 ARTICLE XIX: LIMITED SCOPE HEALTH FLEXIBLE SPENDING ACCOUNT Not offered as a part of the Cafeteria Plan. 19.3(b) Claims Run-Out period: Thirty (30) days. Sixty (60) days. Ninety (90) days. Other: 19.3(c) Dependent means: As provided in the Basic Plan Document. Other: 19.3(f) Limited Scope Medical Expense means: As provided in the Basic Plan Document. Only expenses for dental and vision. Other: 19.8 The maximum reimbursement a Participant may receive for a Plan Year is: An amount equal to the maximum salary reduction contribution allowed under Code § 125(i). Other: $2,850 is the maximum election a Participant may make for a Plan Year. $500 is the minimum election a Participant may make for a Plan Year. For a short Plan Year, the maximum reimbursement is: Not applicable. Pro-rated. Unchanged. For Participants joining the Plan mid-Plan Year, the maximum is: Pro-rated. Unchanged. 19.9 Reimbursement Upon Termination of Participation: Expenses incurred while a Participant may be reimbursed if submitted within the Claims Run-Out Period identified in Section 19.12(b). Expenses incurred while a Participant may be reimbursed within 30 days following termination of participation. Other: 19.12(a) Grace Period: Does not apply to Limited Scope ME Account. Applies to the Limited Scope ME Account. 19.12(a)(1) Grace Period expires: N/A Two and one-half months after end of Plan Year. Other: 60 days from the last day of the Plan Year. 19.12(b)(1) Account carryover: Does not apply to Limited Scope ME Account. Applies to the Limited Scope ME Account. Maximum Account Carryover is: $_ _______ 19.12(b)(4) Carryover available to: N/A As provided in the Basic Plan Document. Only Participants who elect a benefit for the following Plan Year. 19.12(b)(5) Forfeiture of carryover: N/A As provided in the Basic Plan Document. Other: 19.17(d) Other Limited limitations are as follows: None. Other: ARTICLE XX: CASH PAYMENT Not offered as a part of the Cafeteria Plan. 20.2(a) Cash out of the “unspent” portion of the Employer Contribution: Not available. Available for Employees selecting Employee only Medical - $915 (Can be used as above, cost of Medical is $734.84 leaving $180.16 in credits) and for Employees Selecting Employee Plus - $1,638.25 – (Emp Children cost is $1,305.12 leaving $333.13 in credits; 20.2(b) Cash in lieu of coverage: Not available Available for Employees waiving Medical - $180.16 - Can be used for Dental, FSA, LPFSA, Dep Care, or taken as cash 20.3 Payment: Annual amount of Cash Payment is prorated and paid in equal monthly installments. Annual amount of Cash Payment is prorated and pain in equal installments each payroll. Other: Will be paid out Post Tax to Employee ARTICLE XXI: GROUP VOLUNTARY INSURANCE BENEFITS Not offered as a part of the Cafeteria Plan. 21.3(a) Group Voluntary Insurance includes the following types of insurance policies: