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© 2019 Hitesman & Wold, P.A. MEDSURETY, LLC Cafeteria Plan 1-888-816-4234, www.medsurety.com Basic Plan Document 48 ARTICLE XIV. LIMITED SCOPE HEALTH FLEXIBLE SPENDING ACCOUNT 14.1 Separate Written Plan. For purposes of Section 105 of the Code, this Article shall constitute a separate written plan providing for the reimbursement of Limited Scope Medical Expenses. This is a separate and distinct “plan” from the Health Flexible Spending Account described under Article XI. To the extent necessary, other provisions of the Plan are incorporated by reference. 14.2 Purpose. The purpose of this Article is to provide Participants with the opportunity to be reimbursed for certain eligible Limited Scope Medical Expenses. This Article is intended to qualify as a medical reimbursement plan under Section 105 of the Code so that pay ments received under this portion of the Plan are excludable from the gross income of the Participant under Section 105(b) of the Code. This Article is also intended to be “permitted coverage” for purposes of determining eligibility for health savings account contributions under Section 223 of the Code. 14.3 Definitions. (a) Account means the record keeping account established by the Plan Administrator for each Plan Year for each Participant from whom an Election to create such an account is received. (b) Claims Run-Out Period means the period of time specified in the Adoption Agreement that begins on the first day following the close of the Plan Year or, if applicable, the Grace Period. (c) Dependent means, unless otherwise specified in the Adoption Agreement, a Tax Dependent. (d) Grace Period means the period described in Section 19.12(a). (e) Highly Compensated Individual means an individual who is highly compensated as defined in Section 105(h)(5) of the Code. (f) Limited Scope Medical Expense means, unless otherwise limited in the Adoption Agreement, an expense: (1) for dental or vision care within the meaning of “medical care” as defined in Section 213(d) of the Code, incurred during the applicable Plan Year by a Participant or by the Participant’s Spouse or Dependent before they have incurred expenses in excess of the Minimum Annual Deductible; and (2) for medical care as defined in Sections 213(d) and 106(f) of the Code, incurred during the applicable Plan Year by a Participant or the Participant’s Spouse or Dependent after they h ave incurred expenses in excess of the Minimum Annual Deductible. Notwithstanding the foregoing, Limited Scope Medical Expenses shall not include: (1) expenses incurred prior to satisfaction of the Minimum Annual Deductible for dental and vision care of t he type covered under the Participant’s “qualifying high deductible plan” under Section 223(c)(2) of the Code, and (2) premiums for any health (e.g., medical, dental, vision, etc.) or long - term care insurance or coverage. For purposes of determining wheth er the Minimum Annual Deductible has been satisfied, only expenses for medical care (as defined in Section 213(d)) that are also covered by the Participant’s high deductible health plan (e.g., count toward such plan’s deductible) shall be taken into account. (g) Minimum Annual Deductible means the applicable minimum annual deductible for a high deductible health plan under Section 223(c)(2)(A)(i) of the Code. For Participants who have either a Spouse or Dependents during the Plan Year, the Minimum Annual Deductible shall be the minimum deductible for family coverage. For Participants who