Eligible Expenses for Reimbursement The Health ......Plan Provisions As with most plans, certain provisions and limitations are asso-ciated with HRAs, like: HRA must be funded in full

Plan ProvisionsAs with most plans, certain provisions and limitations are asso-ciated with HRAs, like:

■ HRA must be funded in full by the employer.■ HRA will pay only for substantiated out-of-pocket medical

expenses.■ HRA does not allow for cash-out. ■ Plan must also be available for COBRA continuation on the

same basis as other medical plans offered to employees.

Limitations■ Premiums for any medical coverage cannot be paid out of the

HRA account.■ Flexible Spending Accounts must be utilized before the HRA

account. ■ HealthPlan Services will not provide COBRA administration.

Eligible Expenses for Reimbursement(Not all-inclusive)• Acupuncture• Alcohol and drug rehabilitation (inpatient treatment only)• Ambulance• Anesthetist• Artificial limbs and teeth• Birth control pills• Blood pressure monitoring device• Chiropodist• Chiropractor• Christian Science Practitioners• Contact lenses, solution and cleaner• Co-payments and deductibles for medical visits• Dental care and dentures• Diabetic supplies• Eye exams and eyeglasses• Guide dog (purchase, training and care of animals

used by visual or hearing impaired)• Gynecology/Obstetrics• Hearing aids and batteries• Home health care• Hospital and skilled nursing facility expenses• Immunizations• Insulin• Invitro fertilization (surrogate must be tax dependent

in order to be reimbursable)• Laboratory fees• Laser eye surgery• Medical ID bracelet• Midwife • Obstetrics• Optometrist• Orthodontia expenses as treated is provided• Orthopedic shoes• Osteopath• Outpatient clinic• Pediatric care• Physical therapy provided by a licensed therapist• Podiatrist• Prescription drugs (only those requiring a prescription

by a doctor for its use)

• Psychiatrist• Psychologist• Rental or purchase of medical equipment, including special

equipment for use by handicapped persons• Stop smoking programs and prescription drugs for smoking

cessation• Supportive or corrective devices• Transportation expenses relative to medical care (including

mileage at the current rate allowed by the Tax Code)• Weight loss programs (requires doctor diagnosis of obesity)• X-rays

Ineligible Expenses for Reimbursement(Not all-inclusive)• Bleaching/teeth whitening• Capital expenditures• Cosmetic procedures• Dancing or swimming lessons• Exercise equipment• Expenses not incurred during the coverage period• Expenses reimbursed under any health plan or source• Hair loss items• Health club dues• Herbs/vitamins/supplements that do not require a prescrip-

tion for use• Hot tubs• Insurance premiums• Marriage counseling• Massage for non-medical reasons• Mattresses• Non-prescription drugs to aid in smoking cessation• Personal use items• Vacation• Vacuum cleaners

HealthPlan Services – Your one-stop source for HRA administration!

For more than three decades, HealthPlan Services has provided superior service, versatility and support to more than 100,000 businesses and 1.5 million members nationwide. As one of the country’s leadingthird party administrators, our ability to combine cutting-edge technology with industry know-how helps companieslike yours take advantage of all HRA offers.

For more information on HRA plans, please contact HealthPlan Services today at 800-545-6441

Introducing…

The Health Reimbursement Arrangement

throughHealthPlan Services

The Affordable Answer to Today’s Rising Healthcare Costs

15218 10/03

It’s a fact…Healthcare costs are on the rise!Employers everywhere are scrambling to find competitive coverage alternatives that satisfyemployee needs while keeping costs to a minimum. HealthPlanServices understands these chal-lenges and introduces an affordableanswer – the Health ReimbursementArrangement (HRA).

Take a closer look -HRAs are federally approvedprograms that offer a simple, cost-effective approach to the complex world of health insurance.By raising deductibles and co-pay-ments on major medical insurance

plans; premiums can be lowered. The money saved by theincreases are used to fund an HRA which is set up toreimburse employee out-of-pocket medical expenses, as noted in IRC section 213(d)*.

Beneficial to everyone, HRAs provide employers taxdeductions for reimbursed out-of-pocket expenses paid to employees; as well as the ability to custom-design plans, giving more control over health coverage.Employees can have more control over their health careand their reimbursements are tax free as well.

The HPS HRA Plan design optionsfeature:

Bridge Plan■ The Bridge plan HRA plan design can be combined

with higher deductible or limited coverage insuranceproducts. The Bridge HRA plan design may be designat-ed to be used only for deductible, co-pays, or a limitedlist of expenses

Comprehensive■ Covers all necessary medical expenses as noted in IRC

Section 213(d)*. Could exclude items like LASIK sur-gery or orthodontia

Limited■ Covers only one of two medical expenses

(i.e. vision or dental).

■ Other benefit offerings.

■ Blankets holes in limited coverage insurance products.

■ Limits employer’s liability.

Insurance Only■ Employers can deliver specific contributions for

insurance coverage. (i.e. Long Term Care insurance premiums)

* Eligible Expenses According to IRS Tax Code

Ready – willing – and able! HealthPlan Services’ team of dedicated professionals is on-call – ready to help make the most of your HRA opportunity by:

■ Developing a custom-fit plan document for your organization;

■ Providing plan document updates;

■ Handling all recordkeeping for HRA;

■ Reimbursing your employee claims;

■ Offering assistance in maintaining compliance with IRS policies;

■ Doing whatever it takes to help you succeed.

The Health Reimbursement Agreement (HRA) benefits both your and your employees. Take a minute to review the chart below and see for yourself:

Employers:

■ Can offer more cover-age options – increasedmedical deductibles andco-payments make plansaffordable.

■ Can provide employ-ee’s greater control overhealth care decisions.

■ Can develop custom-designed packages foremployees.

■ Can enjoy significanttax advantages.

Employees:

■ Can make importantdecisions about theirhealth care.

■ Can have more controlover what "type" of carethey want covered.

■ Can receive tax-freereimbursements.

■ Can roll over unusedfunds every year ifemployer makes thisoption available.

Features of an HRA with HPS

Employer funded contributions can be carried over from year to year according to the PlanDesign

IRS approved program.

No cash out allowed.

Experienced provider of Section 125 plan and record keeping serviceavailable.

HealthPlan Services’ HRA is not associated with major medical carriers

HRA works with higher deductible medical plans.

Benefits of an HRA with HPS

Employer does not lose money they have contributed. This feature benefits the Employee so they will not lose reimbursement funding as well.Employers receive income tax deduction for amounts contributed to the HRA when employees obtain reimburse-ments for qualified claims.

Unused funds revert to the Employer if the Employee doesnot elect COBRA at time of termination or retirement.

Seamless transition for employees choosing HRAs and FSAs. Employer administration time and expenses arereduced when HPS handles the record keeping.

Employers do not need to change HRA providers whenchanging medical plans. If the HRA accompanies a majormedical plan administered by HPS the start up fee is 50%less.

Deductibles and/or co-payments can be increased to reducemajor medical premiums.

Filing a claim is as easy as 1-2-3!1. First, employees should complete and submit an HRA

Expense Reimbursement form along with third-party documentation to HealthPlan Services.

2. Once the claim is received, the HPS team will reviewand process the request for reimbursement. (Employeeswill only be reimbursed up to the maximum amount current-ly available in their HRA account.)

3. Reimbursement checks or invoice are sent twice amonth to the HR director of the company for delivery to employees – it’s that easy.

❚ Sending in unacceptable documentation with a reim-bursement form will slow down the process. Should youhave any questions on what documents are acceptable,please call HPS at 800-762-7896.

❚ For their records, employees should keep a copy of allclaims submitted. There will be a $50 fee for pullingprocessed claims.

Denied claimsParticipants have 45 days in which to complete a claimthat was not filled out correctly. If additional information isneeded, employees will receive notification by letter.Should you have any questions, please call HealthPlanServices.

The employer is the plan administrator and it is your finaldecision as whether or not to pay for denied claims.Claims denied in whole or in part may be appealed in writing to the plan administrator within 180 days of thedenial, and the claim must be reviewed within 60 days. All appealed claims are referred to the plan administratorfor final decision.

The Health Reimbursement Arrangement through HealthPlan Services The Affordable Answer to Today’s Rising Healthcare Costs

HEALTHPLAN SERVICES Health Reimbursement Arrangement Account

HealthPlan Services, Inc. P.O. Box 31215 Tampa, FL 33630-3215 (800) 762-7896

Please print all information.

ENROLLMENT FORM

EMPLOYEE INFORMATION Name Social Security Number - - Address Date of Birth / / City State Zip Telephone Number ( ) - Employer Name: Email Address _______________________ II. Spouse/ Dependent Information Marital Status:

Married Single

Last Name First Name Soc. Sec. # Date of Birth Relationship

III. EMPLOYER CONTRIBUTION . Annual

Pledge Number

Of Pays Pledge Per

Pay Period $ ÷ $

$ ÷ $ WAIVE COVERAGE_________ TOTAL: $ ÷ $ INITIAL

IV. EMPLOYEE AUTHORIZATION – I understand the maximum amount that can be contribute to my Health Reimbursement Arrangement Account, is $__________ per plan year. My employer has elected a maximum contribution of $__________

Employee Signature (DO NOT SIGN BEFORE READING ABOVE) Date

For Office Use Only: Effective Date: Total Contribution Per Pay Period: $

Health Reimbursement Arrangement

© Copyright 2005 SunGard Inc. 08/01/05

1

ADOPTION AGREEMENT FOR

HEALTH REIMBURSEMENT ARRANGEMENT

The undersigned Employer adopts Health Reimbursement Arrangement and elects the following provisions: EMPLOYER INFORMATION 1. EMPLOYER’S NAME, ADDRESS AND TELEPHONE NUMBER

Name:

Address: Street

City State Zip

Telephone: 2. EMPLOYER’S TAXPAYER IDENTIFICATION NUMBER: 3. TYPE OF ENTITY

a. [ ] Corporation (including Tax-exempt or Non-profit Corporation) b. [ ] Professional Service Corporation c. [ ] S Corporation d. [ ] Limited Liability Company that is taxed as:

1. [ ] a partnership or sole proprietorship 2. [ ] a Corporation 3. [ ] an S Corporation

e. [ ] Sole Proprietorship or Non-profit Corporation f. [ ] Partnership (including Limited Liability) g. [ ] Governmental Entity h. [ ] Other:

NOTE: S Corporation shareholders, partners, sole proprietors, and members of a Limited Liability Company generally cannot participate in the Heath Reimbursement Arrangement.

PLAN INFORMATION 4. PLAN NAME:

5. EFFECTIVE DATE

a. [ ] This is a new Health Reimbursement Arrangement effective as of __________________ (hereinafter called the “Effective Date”).

b. [ ] This is an amendment and restatement of a previously established Health Reimbursement Arrangement of the Employer which was originally effective __________________ (hereinafter called the “Effective Date”). The effective date of this amendment and restatement is _____________________.

6. NUMBER assigned by the Employer

a. [ ] 501 b. [ ] 502 c. [ ] 503 d. [ ] Other:



2

7. PLAN ADMINISTRATOR’S NAME, ADDRESS AND TELEPHONE NUMBER: (If none is named, the Employer will become the Administrator.) a. [ ] Employer (Use Employer address and telephone number). b. [ ] Use name, address and telephone number below:

Name:

Address:

Street City State Zip

Telephone:

8. CLAIMS ADMINISTRATOR’S NAME, ADDRESS AND TELEPHONE NUMBER: (If none is named, the Employer will serve as the Claims Administrator.) a. [ ] Employer (Use Employer address and telephone number). b. [ ] Use name, address and telephone number below:

Name:

Address:

Street

City State Zip Telephone:

ELIGIBILITY REQUIREMENTS 9. ELIGIBLE EMPLOYEES

a. [ ] N/A. No exclusions. b. [ ] The following are excluded (select all that apply):

1. [ ] Union Employees 2. [ ] Non-resident aliens 3. [ ] Employees who are not eligible for the Employer’s group medical plan 4. [ ] Salaried Employees 5. [ ] Hourly Employees 6. [ ] Leased Employees 7. [ ] Part-Time Employees scheduled to work at least _________ hours per week. 8. [ ] Other:

10. THE FOLLOWING AFFILIATED EMPLOYERS will adopt this Health Reimbursement Arrangement as Participating

Employers (if there is more than one, or if Affiliated Employers adopt this after the date the Adoption Agreement is executed, attach a list to this Adoption Agreement of such Affiliated Employers including their names, addresses and taxpayer identification numbers): a. [ ] N/A b. [ ] Name of Affiliated Employer (s):

11. CONDITIONS OF ELIGIBILITY

Any Eligible Employee will be eligible to participate in the Health Reimbursement Arrangement upon satisfaction of the following: a. [ ] Date of Hire (No service required) b. [ ] Same conditions as Employer's group medical plan c. [ ] ________ years after date of hire d. [ ] ________months after date of hire e. [ ] ________days after date of hire f. [ ] Other: _____________________________________________________________________________



3

12. EFFECTIVE DATE OF PARTICIPATION An Eligible Employee who has satisfied the eligibility requirements will become a Participant on a. [ ] the day on which such requirements are satisfied. b. [ ] the first day of the month coinciding with or next following the date on which such requirements are

satisfied. c. [ ] the first day of the calendar quarter coinciding with or next following the date on which such requirements

are satisfied. d. [ ] the first day of the pay period coinciding with or next following the date on which such requirements are met. e. [ ] the first day of the Coverage Period coinciding with or next following the date on which such requirements

are satisfied. f. [ ] same date as Employer’s group medical plan. g. [ ] Other:

BENEFITS 13. MAXIMUM BENEFIT PER COVERAGE PERIOD:

a. [ ] $_________ b. [ ] Other:_________

14. COVERAGE PERIOD is:

a. [ ] monthly b. [ ] quarterly c. [ ] yearly d. [ ] Other:

15. THIS ARRANGEMENT SHALL REIMBURSE: (select all that apply)

a. [ ] co-payments under the Employer’s group medical plan b. [ ] deductibles under the Employer’s group medical plan c. [ ] all medical expenses within the meaning of Code Section 213, including non-prescription drugs d [ ] medical insurance premiums e [ ] dental, vision and preventative care only or expenses in excess of the deductible (HSA also provided) with

the following further limitations:_____________________________________________________________ f [ ] the following types of medical expenses ONLY: g. [ ] Other:

16 IF THE EMPLOYER MAINTAINS A HEALTH FLEXIBLE SPENDING ACCOUNT, WHICH PLAN SHALL PAY

EXPENSES FIRST? a. [ ] N/A. The Employer does not maintain a Health Flexible Spending Account and/or Cafeteria Plan.

b. [ ] This Plan (Heath Reimbursement Arrangement). c. [ ] The Health Flexible Spending Account under the Employer’s Cafeteria Plan.

17. IS THE EMPLOYER SUBJECT TO THE FAMILY AND MEDICAL LEAVE ACT? If b. is selected, FMLA will not apply

a. [ ] Yes.

b. [ ] No. 18. IS THE PLAN SUBJECT TO COBRA? If b. is selected, COBRA will not apply

a. [ ] Yes.

b. [ ] No. 19. CARRY FORWARD: Amounts not used during a Coverage Period shall:

a. [ ] Be carried forward to the next Coverage Period, in an amount up to $_____________. However, the maximum accumulation limit for a Coverage Period is $____________

b. [ ] Shall be forfeited.



4

20. RETIREES OR OTHER TERMINATED EMPLOYEES SHALL:

a. [ ] Shall continue to be eligible for reimbursement of any remaining balances.

b. [ ] May not participate and any unused amounts are forfeited. 21. A CLAIM may be submitted up to ______________ days after

a. [ ] the end of the Coverage Period

b. [ ] the end of each calendar year c. [ ] Other:___________________________________________________________________________

22. DEBIT/CREDIT CARDS shall be provided by the Employer for Medical Expenses:

a. [ ] Yes

b. [ ] No

23. HEALTH SAVINGS ACCOUNT provided by the Employer:

a. [ ] Yes

b. [ ] No



5

This Adoption Agreement may be used only in conjunction with The Health Reimbursement Arrangement Basic Plan Document. This Adoption Agreement and the Health Reimbursement Arrangement document shall together be known as Health Reimbursement Arrangement. EMPLOYER By: PARTICIPATING EMPLOYER (if applicable) By: PARTICIPATING EMPLOYER (add additional signature lines as necessary): By:

This agreement specifies the services to be pro-vided by HealthPlan Services, Inc. “HPS” to “Employer” ____________________________regarding the administration of the Employer’sHealth Reimbursement Account for the planyear beginning.

AdministratorThe Employer shall be the Plan Administratorand HPS shall be engaged as a subcontractor inthe performance of administrative services forthe plan.

Services to be provided by HPS1. Plan Update Service. This service includes a

plan review and amendment documents if needed.

2. Employee Enrollment Assistance. This service includes educational materials such as brochures and enrollment forms. Enrollment packets including claim forms and instructions for filing.

3. Employee Eligibility Changes. We will make changes in employee eligibility as provided to us by the Employer. Our staff will process all changes properly reported tous prior to five working days of your payroll date.

4. Employer Account Management. The Employer maintains this account with sufficient funds to cover disbursements. HPS will provide claim adjudication and monthly year to date reports based on this account.

5. Participant Assistance. Employees have 24-hour access to their accounts via the Internet and daytime access to our 800-line call center. Employee statements are included on claim reimbursements and are provided 60 days prior to plan-year end.

6. Annual Plan Compliance. Services include compliance with discrimination testing requirements. A “signature-ready” IRS Form 5500 is provided.

7. Optional Services. Services available for an additional charge include:

■ Monthly employee statements■ Reports delivered “Second Day Air”■ Reports delivered “Overnight”

Review these options and elect any optionalservices at the bottom of this agreement.

Responsibilities of the Employer1. Plan Documents. Secure legal review of

the Health Reimbursement AccountDocument and amendments and SummaryPlan Description from Employer’s legalcounsel.

2. Enrollment. Complete new plan year enrollment procedures completely and on a timely basis as described in the attached Enrollment Kit.

3. Eligibility Changes. Notify HPS of changes in employee eligibility at least 5 business days prior to the first payroll date affected. HPS must be notified by email ([email protected]) or fax (813-289-7937) on the enclosed form. Please mail the original form to:

HealthPlan Services Section 125PO Box 31215Tampa, FL 33630-3215

4. Discriminatory Plans. Initiate any action required in the event the plan(s) become discriminatory.

Fees for Services1. Start up Fee. This is a one-time fee for plan

implementation. The fee is $500 for planadministration only. The fee is $250 if amedical product is administered atHealthPlan Services. The fee is $______________.

2. Monthly Service Fee. This fee includes services provided by HPS (excludingOptional Services). The number of partici-pants in the Plan determines the monthlyfee. A minimum $50 monthly fee will becharged. The monthly fees are as follows:

■ 1-50 participating employees$5 per participant / per month

■ 51-150 participating employees$4 per participant/ per month

■ 151+ participating employees $3 per participant / per month

The fee is $_________________ per monthper participant.

HEALTH REIMBURSEMENT ARRANGEMENTAdministrative Services Agreement

15138HRA 9/04

3. Renewal Fee. The renewal fee is $150 for group implementation.

4. Fees for Optional Services. If you choose any optional services, additional fees will beadded as follows:■ Check Signing Fee. There will be a

one-time fee of $60 if HPS is given the authority to sign and distribute employeereimbursement checks.

Fees added to Annual Compliance Fee:■ Reports delivered “Second Day Air”-

Fee is $25 per report delivered.■ Reports delivered “Overnight” – Fee is

$50 per report delivered.

Fees added to Participant Fee: ■ Monthly employee statements – Fee is

90¢ per employee.■ Invoicing and Collection. Fees will be

invoiced monthly.

Reports and DataAll reports and data remain the property of theEmployer. HPS will provide the Employer alldata, upon request, in the electronic or printedformat used by HPS in its administrative proce-dure.

Optional Services(Additional fees will be applied – see fee sectionfor amount.)Please check any additional services that youwould like provided:

❑ Monthly employee statements❑ Reports delivered “Second Day Air”❑ Reports delivered “Overnight”

Reimbursement Method

Please check one:

❑ Signature Required (reimbursement checks will be mailed to employer for signature and disbursement to employee)

❑ Signature Authorization - $60 one time fee (reimbursement checks are signed and disbursed to employees by HPS)

❑ Fax Disbursement Reports - Employer to generate reimbursement checks

ACCEPTED BY

Printed Name

Signature

Date