PEBP FLEXIBLE SPENDING ACCOUNT (FSA) HEALTH CARE …

1 1 PEBP FLEXIBLE SPENDING ACCOUNT (FSA) HEALTH CARE (MEDICAL) FSA DEPENDENT CARE FSA LIMITED PURPOSE/SCOPE FSA PLAN YEAR 2019 (EFFECTIVE JULY 1, 2018 JUNE 30, 2019) Public Employees Benefits Program Administered By: Box 3627 Little Rock, AR 72203 1-888-7 NEVADA (1-888-763-8232) 901 S. Stewart Street, Suite 1001 Carson City, Nevada 89701 (775) 684-7000 (800) 326-5496 Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 2 Contents Amendment Log ..6 Welcome PEBP Participant ..7 Accessing Other Information ..8 The Basics of FLEXIBLE SPENDING Accounts ..8 FLEXIBLE SPENDING Accounts .. 8 HEALTH Care (Medical) FSA .. 8 HEALTH Care FSA When You Do Not Have an HSA.

2 8 Limited Purpose/Scope FSA When You Do Have an HSA .. 9 Dependent Care FSA .. 9 Who Qualifies for Reimbursement of Expenses for these Plans? .. 9 FSA & Participants on Family Medical Leave Act (FMLA) Leave .. 10 FSA Tax 10 Before Tax or Pre-Tax .. 10 Tax Savings .. 10 FSA Eligibility and Enrollment .. 12 Eligibility Criteria .. 12 Enrollment .. 12 HEALTH Care, Limited Purpose and Dependent Care FSA .. 13 Mid-Year Qualifying Life Status Events Table .. 13 Claims Processing .. 16 Claim Forms .. 16 Reimbursement .. 17 Establishing & Using Your Medical FSA or Limited Purpose/Scope 18 Estimate you and your Family s Annual Out-of-Pocket HEALTH Care Expenses .. 18 Enroll in the Medical HEALTH Care FSA or Limited Purpose/Scope FSA .. 18 Incur Medical Care Expenses .. 18 File Claims .. 18 Using the FSA Debit Card to pay for your Medical expenses .. 18 Is there a Cost for the Card? .. 18 How do I Request a Card? .. 18 Can I Request a Replacement Card if I Lose One?

3 19 Where Can the Cards be used? .. 19 Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 3 When Do I Have to Turn in Paperwork? .. 19 What Happens if I Do Not Submit Requested Documentation? .. 20 Maximum Plan Election .. 20 Does this Plan provide a Carryover Provision? .. 20 HEALTH Care/Limited Purpose FSA .. 21 Qualifying Expenses .. 21 Non-Qualifying Expenses .. 21 Changes Due to the Patient Protection and Affordable Care Act (PPACA) .. 22 Dependent Care FSA .. 23 Qualifying Expenses .. 23 Non-Qualifying Expenses .. 23 Establishing & Using the Dependent Care FSA .. 23 Estimate your Total Dependent Care Expenses for the Plan Year .. 23 Enroll in the Dependent Care FSA.

4 23 Receive Dependent Care Services .. 24 File Claims .. 24 Receive Reimbursements .. 24 Termination of Participation .. 27 Continuation of Coverage under COBRA .. 27 HEALTH Reimbursement Only .. 27 FSA Rights and Responsibilities .. 28 Participant Responsibilities .. 28 Employer Responsibilities .. 28 Delegation of Responsibilities .. 28 Claims Administrator Responsibilities .. 29 FSA Frequently Asked Questions (FAQs) .. 30 If I redirect (pre-tax) part of my pay, will I make less money? .. 30 Why should I participate in the medical reimbursement ACCOUNT if I already have medical insurance? .. 30 How much does it cost me? .. 30 What is the catch? .. 30 What if I do not use all of the money in my FLEXIBLE SPENDING ACCOUNT ? .. 30 Are there any negatives that I should know about? .. 30 Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 4 Will the Medical HEALTH Care FSA carryover affect my enrollment in the PEBP HEALTH Savings ACCOUNT ?

5 31 What if I am already in the FSA? .. 31 If I enroll in the PEBP HEALTH Savings ACCOUNT (HSA), can I still enroll in the regular Medical HEALTH Care FSA? .. 31 Are there any restrictions if my spouse also contributes through his/her employer s FSA plan? .. 31 When can I make changes? .. 31 What are my rights on claims appeals? .. 34 General Notices and Provisions .. 35 General Provisions .. 35 Effective Date of the Plan .. 35 Type of Administration .. 35 Plan Administrator .. 35 Plan Sponsor and Plan Administration .. 35 Plan Fiduciary .. 35 Plan Changes .. 36 Plan Compliance .. 36 Plan is not an Employment Contract .. 36 Plan Right to Recovery .. 36 Plan Termination .. 37 Benefits Not 37 Clerical Error .. 37 Conformity with Statute(s) .. 37 Death .. 37 Incapacitation .. 38 Incontestability .. 38 Legal Actions .. 38 Limits on Liability .. 38 Lost Distributees .. 38 Misrepresentation .. 38 Pronouns .. 39 Section 125 .. 39 Tax Benefits .. 39 Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 5 Privacy Notice Definitions.

6 39 Rights That You Have .. 42 For Further Information .. 43 Effective Date .. 43 PEBP Security 44 Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 6 Amendment Log Any amendments, changes or updates to this document will be listed here. The amendment log will include what sections are amended and where the changes can be found. Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 7 Welcome PEBP Participant Welcome to the State of Nevada Public Employees Benefits Program (PEBP).

7 PEBP provides a variety of benefits such as medical, dental, life insurance, long-term disability, FLEXIBLE SPENDING accounts, and other voluntary insurance benefits for eligible State and local government employees, retirees, and their eligible dependents. As a PEBP participant, you may access whichever benefit plan (the Consumer Driven HEALTH Plan, the Premier Exclusive Provider Organization (EPO) Plan, or HEALTH Maintenance Organization (HMO) Plan) is offered in your geographical area that best meets your needs, subject to specific eligibility and Plan requirements. You are also encouraged to research Plan provider access and quality of care in your service area. All PEBP participants choosing the Consumer Driven HEALTH Plan should examine this document, the PEBP Self-Funded PPO Dental Plan Master Plan Document (MPD), the HEALTH and Welfare Wrap Plan Document, the Section 125 Document, and the PEBP Enrollment and Eligibility MPD. These documents are available at Master Plan Documents are a comprehensive description of the benefits available to you.

8 Relevant statutes and regulations are noted throughout this document for reference. In addition, helpful material is available from PEBP or any PEBP vendor listed in the Participant Contact Guide. PEBP encourages you to stay informed of the most up to date information regarding your HEALTH care benefits. It is your responsibility to know and follow the requirements as described in PEBP s Master Plan Documents. Sincerely, Public Employees Benefits Program Public Employees Benefits Program FLEXIBLE SPENDING ACCOUNT Summary Plan Description Plan Year 2019 8 Accessing Other Information You will also want to access the following documents for information related to dental, life, enrollment and eligibility, COBRA, third-party liability and subrogation, HIPAA and Privacy and Security and mandatory notices.

9 These documents are available at State of Nevada PEBP HEALTH and Welfare Wrap Plan Consumer Driven HEALTH Plan (CDHP) Master Plan Document CDHP Summary of Benefits and Coverage for Individual and Family PEBP PPO Dental Plan and Summary of Benefits for Life and Long-Term Disability Insurance Master Plan Document Premier Plan Master Plan Document Premier Plan Summary of Benefits and Coverage for Individual and Family HEALTH Plan of Nevada Evidence of Coverage (EOC) and Summary of Benefits and Coverage PEBP Enrollment and Eligibility Master Plan Document FLEXIBLE SPENDING Accounts (FSA) Summary Plan Description Section 125 HEALTH and Welfare Benefits Plan Document Medicare Retiree HEALTH Reimbursement Arrangement Summary Plan Description The Basics of FLEXIBLE SPENDING Accounts FLEXIBLE SPENDING Accounts FLEXIBLE SPENDING Accounts (FSAs) are a way to pay Out-of-Pocket (un-reimbursed) HEALTH care expenses (medical FSA) and dependent care expenses (Dependent Care FSA) on a before-tax basis.

10 This Plan is administered in accordance with regulations of Section 125 of the Internal Revenue Code. For information regarding Section 125, please see the Section 125 HEALTH and Welfare Benefits Plan Document available at HEALTH Care (Medical) FSA A HEALTH care FSA, sometimes referred to as a medical FSA or general purpose FSA, is a savings option for active employees covered under the PEBP Consumer Driven HEALTH Plan (CDHP) with an HRA, Premier Plan and HMO who do not qualify for a HEALTH Savings ACCOUNT (HSA). HEALTH Care FSA When You Do Not Have an HSA You may include all medical, dental and vision expenses not covered or not reimbursed by insurance which are incurred by the taxpayer or their eligible dependents during the Plan Year for medical care as defined in Section 213(d) of the Internal Revenue Code. Please refer to IRS Publication 502 under the section titled What Medical Expenses Are Includible for further details on qualifying expenses.