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.

2 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 .. 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.

3 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? .. 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?

4 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 .. 23 Receive Dependent care Services .. 24 File Claims .. 24 Receive Reimbursements .. 24 Termination of Participation.

5 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?

6 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 ? .. 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?

7 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.

8 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 .. 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.

9 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). 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.

10 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.