10-10-2022 Council Packet - Laserfiche WebLink

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© 2019 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan 1-888-816-4234, www.medsurety.com Basic Plan Document 20 (1) The electronic payment card will be cancelled when the Participant ceases to participate in the Health Flexible Spending Account and the Limited Scope Health Flexible Spending Account (as applicable). (2) The balance of the electronic payment card shall be limited to th e amount in the applicable Participant’s reimbursement-type account(s). (3) A Participant must certify in writing prior to issuance of the electronic payment card that: (i) the electronic payment card will be used only for eligible expenses that have not been reimbursed under any other plan covering similar benefits; (ii) the Participant will not seek reimbursement for any expense paid with the electronic payment card under any other plan covering benefits; and (iii) the Participant will obtain and retain a third party statement from the health care provider containing the information necessary to substantiate that the expense paid by the card was an eligible expense. The electronic payment card shall include a statement providing that each use of the card shall constitute a reaffirmation of the certification. (4) For eligible expenses, the electronic payment card may be used only at merchants who are health care providers (e.g., doctor’s office, hospital, pharmacy, etc.) or other merchants identified in applicable IRS guidance. (5) Each time the electronic payment card is used, a Participant shall obtain and retain a third party statement from the health care provider containing the information necessary to substantiate that the expense paid by the card was an eligible expense. (6) Claims shall be substantiated in one of the following manners: (i) The Participant shall provide, upon request by the Claims Administrator (or its designee), the third party statement with respect to the claim; (ii) For eligible expenses, the payment was made to a merchant who is a health care provider and it matches a specific copayment the Participant has under a group medical or group dental plan sponsored by the Employer or a multiple of that copayment of not more than five (5) times the dollar amount of the copayment; (iii) For eligible expenses, the payment was made to a merchant who is a health care provider and is for an expense with the same amount, duration, and health care provider as a previously approved expense under this Plan; (iv) For eligible expenses, the payment was made to a merchant who is a health care provider and the electronic claim file with respect to the expense is accompanied by an electronic or written confirmation from the health care provider that identifies the amount of the e xpense and verifies that the expense is an eligible expense; or