What does the Beniversal FSA provide?

• Tax-free money for medical and dependentcare expenses

• Convenient access to account funds throughthe Beniversal® Prepaid MasterCard®

• On-the-go account access with theBRiMobile app

• Streamlined online account support throughBRiWeb

• Friendly and knowledgable participantservices representatives to assist with yourquestions

Visit www.Benefi tResource.com

www.BenefitResource.com

Flexible Spending Accounts Flexible Spending Accounts (FSAs)(FSAs)

What is a Flexible Spending Account?

A Flexible Spending Account (FSA) is an IRS-approved account that allows you to pay for eligible medical and dependent care expenses on a tax-free basis.

How does the tax savings work? When you enroll in your employer sponsored Flexible Spending Account, your contributions are not subject to Federal, FICA and most state taxes. This means you bring home more money in your paycheck!

Who can participate? In order to participate in the plan, you need to meet the eligibility requirements set by your employer. If you or your spouse is reporting contributions to an HSA, generally you will not be eligible to participate in a Medical FSA. Please contact your employer or refer to your plan documentation for more details and eligibility requirements.

How do elections work? Prior to the start of a plan year or when you become eligible, you will make an annual election for medical and/or dependent care expenses separately (as applicable). Elections do not carry over from year to year. Check with your employer about the maximum (and any applicable minimum) amounts you can set aside in a Medical FSA and Dependent Care FSA. Generally, once you have enrolled in the plan, you cannot change your elections during that plan year unless you have a certain qualifying event (e.g. marriage, death, change in employment status, etc.) that may allow a change in your plan year election amounts. More information is also available in your plan documentation.

When can I access FSA funds? Services must be provided during the plan year designated in your plan documentation and you cannot access FSA funds until the service is provided. The IRS allows one exception for orthodontia expenses. Refer to your plan documentation regarding any unused funds at the end of the plan year.

Calculate your personalized tax savings at www.Benefi tResource.com.

The fi gures above are for illustration purposes only. Actual savings and tax rates may vary.

Tax Savings ExampleAnnual Income $50,000Anticipated Medical Expenses $2,500

Without Plan With PlanFederal Income Tax Paid $12,500 $11,875State Income Tax Paid $3,000 $2,850FICA $3,825 $3,634Total Taxes Paid $19,325 $18,359

Disposable Income $30,675 $31,640

Annual Tax Savings $966

AcupunctureAlcoholism treatmentAllergy treatments (if prescribed)AmbulanceArthritis glovesArtifi cial limbsArtifi cial teethAsthma devices and medicines

(if prescribed) BandagesBody scansBraille books and magazinesBreast pumpsBreast reconstruction surgery

following mastectomyCancer screeningsCarpal tunnel wrist supportsChiropractorsCircumcisionCo-insurance amountsCo-paymentsCouseling, when used to treat

diagnosed medical conditionCPAP (continuous positive airway

pressure) devicesCrutchesDental sealants

Dental services and proceduresDentures and denture adhesivesDiabetic suppliesDiagnostic items/servicesDrug addiction treatmentDrug overdose, treatment ofDurable medical equipmentEye examinations, eyeglasses,

equipment, and materialsFirst aid kitsFlu shotsFluoridation servicesGauze padsGuide dogHearing aidsHospital servicesImmunizationsInsulinLaboratory feesLactation consultantLaser eye surgery, LasikLiquid adhesive for small cutsLodging at a hospital or similar

institutionMastectomy-related special brasMedical alert bracelet or necklaceMedical information plan charges

Medical monitoring and testing devices (e.g. blood-sugar test kits and test strips)

Medical practitioner’s fee for online or telephone consultation

Medical records chargesMidwifeNorplant insertion or removalObstetrical expensesOcclusal guards to prevent teeth

grindingOperations / SurgeriesOptometristOrgan donorsOrthodontiaOrthopedic shoe insertsOsteopath feesOvulation monitorOxygenPhysical examsPhysical therapyPregnancy test kitsPrescription drugs and medicines,

for the purpose of medical care (not general health or cosmetic purposes)

Preventive care screenings

ProsthesisPsychiatric careRadial keratotomyReading glassesRehydration solutionRubbing alcoholScreening testsSleep-deprivation treatmentSpeech therapyStop-smoking programsTelephone equipment or television for

hearing-impaired personsThermometersTransplantsTransportation expenses for person

to receive medical care, may include car mileage or alternative transportation costs

VaccinesVision correction proceduresWalkersWheelchairX-ray fees

Eligible Over-the-Counter Medical Supplies

Adult incontinence products (e.g. Depends)Birth control products (e.g. prophylactics) (if allowed by your plan)Contact lens solutionDenture adhesivesFirst aid supplies (e.g. band-aids)Health monitors (e.g. blood pressure, cholesterol, HIV,

thermometers)Hearing aid batteriesHeat wraps (e.g. ThermaCare)Heating pads, hot water bottlesInsulin & diabetic suppliesMedicine dropper/spoon Motion sickness devicesSupports/braces (e.g. ankle, knee, wrist, therapeutic glove)

Eligible Over-the-Counter Drugs & Medicines (require a prescription)

Once your account is open, you will have access to a detailed eligible expense look up table. Simply log in to your account at www.Benefi tResource.com and select

Eligible Health Care Expense Table under the FSA/HRA tab.

What are eligible medical expenses?

This list is intended to be used as a quick reference of potentially eligible medical expenses and does not guarantee that an expense will be eligible. Please see your plan documents to verify what expenses are reimbursable under your plan. This list is not intended to be an all encompassing list and may be updated from time to time. Eligible expenses for Flexible Spending Accounts (FSAs) are governed by Section 213(d) of the Internal Revenue Code. In addition to the list below, there are over 150 additional items or expense types that are considered potentially eligible. These may require prescriptions or a letter of medical necessity when submitting a reimbursement request.

Acne medicationsAllergy and sinus medications

(e.g. Benadryl, Claritin, Sudafed)Anti-fungal medications

(e.g. Lotramin AF)Anti-itch medications (e.g. Caladryl) Cold sore medicationsCough, cold & fl u remediesDecongestantsDiaper rash ointmentsEar wax removal dropsFirst aid creamsGastrointestinal aids (e.g. antacids,

anti-diarrhea medicines, non-fi ber laxatives, nausea medications)

Lactose intolerance pillsMotion sickness pillsNasal sprays for congestion

(e.g. Afrin)Pain relievers (e.g. aspirin, Excedrin,

Tylenol, Advil, Motrin)Sleeping aidsSmoking cessation medications

(e.g. nicotine gum or patches)SuppositoriesToothache relievers (e.g. Orajel)Wart remover medicationsYeast infection creams (e.g. Monistat)

Tax Savings Estimate: Estimate your total annual estimated tax savings.

Dependent Care FSA Estimate: Estimate your eligible out-of-pocket dependent care expenses.

Medical FSA Estimate: Estimate your eligible out-of-pocket medical expenses. Out-of-pocket expenses includeservices for you, your spouse and eligible dependents.

FSA Expense & Tax Savings Estimate Worksheet

General Expenses$ ___________ Offi ce visits / doctor’s fees

(actual cost if deductible applies or total co-payments)

$ ___________ Immunizations / Vaccines$ ___________ Laboratory fees / X-rays$ ___________ Over-the-counter drugs and medicines

(prescription required)

$ ___________ Over-the-counter medical supplies $ ___________ Prescription Drugs$ ___________ SUBTOTAL

Hospitalization & Specialist Expenses$ ___________ Emergency Room $ ___________ Hospital Bills

$ ___________ Specialists or alternative medicine (Acupuncture, chiropractor, physical therapy, specialists fees, etc.)

$ ___________ Surgery$ ___________ OTHER MEDICAL EXPENSES NOT SPECIFIED$ ___________ SUBTOTAL

Dental$ ___________ Cleanings / Dental Exams$ ___________ Fillings / Dental procedures$ ___________ Orthodontia$ ___________ X-rays$ ___________ SUBTOTAL

Vision$ ___________ Corrective eye surgery & eye wear$ ___________ Eye exams$ ___________ Prescription glasses / contact lenses$ ___________ SUBTOTAL

Hearing$ ___________ Hearing Aids$ ___________ Hearing Exams$ ___________ SUBTOTAL

$ ___________ TOTAL MEDICAL FSA ESTIMATE

Dependent Care Expenses$ _____________ Adult Day Care$ _____________ Child Day Care / In-home Dependent Care$ _____________ Nursery School

$ _____________ TOTAL DEPENDENT CARE FSA ESTIMATE

Amounts . A. ENTER TOTAL MEDICAL FSA ESTIMATE (See Plan Highlights for the maximum limits that may apply.) $ __________________B. ENTER TOTAL DEPENDENT CARE FSA ESTIMATE (See Plan Highlights for the maximum limits that may apply.) $ __________________C. TOTAL EXPENSES (Line A + Line B) $ __________________

D. TAX RATE (Enter percentage of your gross salary that you pay in Federal, State and Local Taxes. (If uncertain, use 30%.)) ________________ %

E. FICA (includes Social Security and Medicare) ________________ %F. TOTAL TAX RATE (Line D + Line E) ________________ %

G. ESTIMATED ANNUAL TAX SAVINGS (Line C x Line F) $ __________________

What do I need to know about FSAs?

Medical FSAA Medical FSA can be used to pay for eligible medical expenses provided to you, your spouse or eligible dependents.

• Upon enrolling in a Medical FSA, you have accessto your full plan year election amount.

• The tax-free amount you can set aside in aMedical FSA per plan year can be found in yourPlan Highlights. Your Plan Highlights also containother specifi c information about your employersponsored plan.

• Expenses must be primarily to prevent, treat,diagnose or mitigate a physical or mental defector illness. The eligibility of an expense is governedby the IRS. Common eligible expenses include:• Co-payments, co-insurance and deductible

expenses• Dental care (e.g. exams, fi llings, crowns)• Vision care, eyeglasses, contact lenses• Chiropractic care• Prescription drugs and certain over-the-counter

medical items

• Expenses cannot be for personal care, cosmeticor general health purposes.

• Some expenses are only eligible if certifi ed by alicensed medical provider as medically necessary.

• Expenses cannot be reimbursed from any othersource (e.g. insurance).

• Refer to your Plan Highlights for details regardinghow unused Medical FSA funds are treated.

• While you can use the Medical FSA for medicalexpenses for a spouse or dependent, you cannotuse Medical FSA funds for dependent careexpenses (e.g. child care) and vice-versa.

Dependent Care FSA A Dependent Care FSA can be used to reimburse dependent care expenses (e.g. child care) for a qualifi ed person. These expenses enable you to be gainfully employed and, if married, enable your spouse to be gainfully employed, look for work or attend school full-time.

• The qualifi ed person must spend at least 8 hoursper day in your home and is one of the following:• Dependent child under the age of 13 and for

whom you can claim a tax exemption.• Spouse or dependent who is physically or

mentally incapable of self-care, lives with youfor more than half of the year, and for whom youcan claim a tax exemption.

• The tax-free amount you can set aside percalendar year in a Dependent Care FSA can befound in your Plan Highlights.

• Common eligible expenses, include:• Before/after school care• Child Care / in-home dependent care• Day care facility• Nursery school• Adult care

• Services provided for education, overnight campsor services provided by the child’s parent orother dependent for income tax purposes are noteligible expenses.

• The amount available for reimbursement ofdependent care expenses is limited to the cashbalance in your Dependent Care FSA.

• Refer to your Plan Highlights for details regardinghow unused Dependent Care FSA funds aretreated.

• You cannot claim a federal tax credit for anyexpenses reimbursed through a Dependent CareFSA. Consult a tax professional to determine ifit would be more to your advantage to elect aDependent Care FSA or to use the federal taxcredit.

Use the FSA Expense & Tax Savings Estimate Worksheet included in the booklet to help you estimate how much you should elect.

For more information on these or other account information, please visit us at www.Benefi tResource.com.

1. Click Participants under Secure Login.2. Once on the Participant Login page, please enter:

Company Code: Provided by your employerLogin ID: Default Login ID selected and provided by your employer. You may change it upon initial login.Initial Password: 5 digit home zip code (You will be prompted to change the password upon initial login.)

3. BRiWeb will open to a Dashboard which provides a quick snapshot of your account(s) and profi le. Tomanage your FSA, select the FSA/HRA tab.

To view a quick video demo of BRiWeb, visit BRI Resources at www.Benefi tResource.com.

Download the BRiMobile appBRiMobile is your on-the-go account access to view balances and recent transactions, submit claims and send receipts. BRiMobile app is available for iPhone, iPad and Android devices. Learn more at www.Benefi tResource.com/tools or download the app from the Apple App Store or Google Play.

Contact Participant ServicesParticipant Services is available to assist with your questions by phone, chat and email. Representatives are available in English and Spanish.

Phone: (800) 473-9595, Monday - Friday, 8am - 8pm (Eastern Time)

Email: ParticipantServices@Benefi tResource.com

Live Chat: Available through the participant login at www.Benefi tResource.com, Monday - Friday, 8am - 5pm (Eastern Time).

How do I access my FSA?

Log in to BRiWebBRiWeb is your secure participant login for managing your accounts with Benefi t Resource. BRiWeb allows you to view balance and transaction information, submit claims, download plan documents and much more.

To log in, go to www.Benefi tResource.com:

How do I access my FSA? (Continued)

Use the Beniversal Card (if offered)The Beniversal Prepaid MasterCard can be used at qualifi ed merchants providing medical products and services, such as: doctors, dentists, medical labs, hospitals, medical supply stores, vision centers and certain drugstores and retail merchants. (A list of drugstores and retail merchants is available at www.Benefi tResource.com).

When using your card, always save your itemized receipts. With an FSA, the IRS requires Benefi t Resource to verify that 100% of transactions are for eligible expenses. Since some qualifi ed merchants also offer services/items that are not eligible, Benefi t Resource may contact you requesting additional documentation on a transaction.

Requested receipts and documentation for card transactions can be submitted online at www.Benefi tResource.com, through the BRiMobile app or by fax/mail. Instructions will be provided in the request.

Submit a ClaimWhen not using the Beniversal Card or for Dependent Care expenses, you can submit a claim with your itemized receipt or supporting documentation. Claims can be submitted:

• Online at www.Benefi tResource.comOnce logged in to your account, go to the FSA/HRA tab and select Submit Online Claim. Follow the on screen instructions.

• Through the BRiMobile appDownload the BRiMobile app from the Apple App Store or Google Play.

• By faxing/mailing a claim formClaim forms can be downloaded and printed from www.Benefi tResource.com.

Reimbursements are paid weekly. To receive your reimbursements by direct deposit, please log into www.Benefi tResource.com and set up your direct deposit account information.

The Beniversal Card is issued by The Bancorp Bank pursuant to license by MasterCard International Incorporated. The Bancorp Bank; Member FDIC. MasterCard is a registered trademark of MasterCard International Incorporated. ©2015 Benefi t Resource, Inc. All rights reserved.

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Frequently Asked Questions

&Plan Highlights

(1) What is a Flexible Spending Account (FSA)?A Flexible Spending Account (FSA) is part of the benefit plan offered to you by your employer and allows you to use tax-free dollars to pay for certain medical and/or dependent care expenses. There are two types of FSAs: a Medical FSA (for eligible medical services provided to you, your spouse or your eligible dependent) and a Dependent Care FSA (for eligible dependent care expenses).

(2) Who is eligible to elect an FSA?Eligibility requirements for a Medical FSAand a Dependent Care FSA are indicated in your Plan Highlights.

(3) Is there a maximum or minimum annual amount that I can elect for an FSA?Any applicable maximum/minimum amounts for your annual FSA elections are indicated in your Plan Highlights.

(4) Can I elect a Medical FSA and a Dependent Care FSA?Yes. Participation in each FSA is completely voluntary - you can enroll in one, both or neither. To participate, you must make your election(s) prior to the beginning of each new plan year.

(5) What is the advantage of enrolling in an FSA?Enrolling in an FSA allows you to make tax-free salary contributions to pay for eligible medical and dependent care expenses that are not covered or reimbursed by any other source. FSAs increase your take-home pay by reducing taxable income, making these out-of-pocket expenses more affordable!

(6) What employee taxes are eliminated by contributing to a Medical or Dependent Care FSA?You will not pay federal income tax, Social Security tax and most state taxes (varies by state) on contributions to a Medical and/or Dependent Care FSA.

(7) Since I will not pay Social Security taxes on money contributed to an FSA, will my Social Security benefits be lower when I retire or if I become disabled?Tax-free contributions may slightly reduce your Social Security benefits. However, the value of your tax savings with an FSA should more than offset the slight reduction in Social Security benefits in future years.

(8) What dollar amount is available in my FSA?

• The amount available for a Medical FSA = the total amount you elected for the current plan year minus any prior payments and reimbursments.

• The amount available for a Dependent Care FSA = the total payroll deductions posted to your Account for the current plan year minus any prior payments and reimbursements.

(9) How can I determine my account balance?There are several ways you can determine your account balance:

• Your account balance will be displayed on the Explanation of Benefits (EOB) issued with each reimbursement check/Direct Deposit advice.

• Account information can be accessed 24/7:

• at www.BenefitResource.com and using the secure account inquiry system

• via the BRiMobile app or mobile device users

• You may call Benefit Resource Participant ServicesT: (800) 473-9595(8am - 8 pm Eastern Time, Monday - Friday).

(10) Who is responsible for determining if an expense is eligible?Eligibility of expenses is dictated by the IRS and those guidelines are used by Benefit Resource. The services of an attorney are utilized if an additional opinion is needed or research is required to clarify the eligibility of an expense.

Flexible Spending Account FAQs: General

(11) Are expenses eligible if services are provided prior to my effective date in the plan?No. Services must be provided on or after your effective date.

(12) Can money in a Medical FSA be used for a Dependent Care FSA?No. Money directed to one type of account can be used onJy for expenses relating to that account. This is trueeven if all the money in one account is not used and the other account runs short.

(13) If I elect too much for my FSA during the plan year and cannot use it, what happens to the extra funds?Refer to your Plan Highlights regarding unused FSA funds. Any forfeited funds are returned to your employer,but the IRS has imposed strict regulations on the use of these funds (they cannot be refunded to theemployees who forfeited them). Employees should be conservative when estimating the amount to elect for anFSA.

(14) Can I change my FSA election during the plan year?Generally, your election cannot be changed during a plan year unless you experience a Qualified StatusChange (QSC) as defined by the Internal Revenue Service. A change in election must be on account of aQSC event, so the election change must be made within the time frame required by your Employer after theQSC.

For example, you may be permitted to prospectively change an election during a plan year when one of the following changes in status occurs that affects eligibility for coverage: • Change in your legal marital status (e.g. marriage, legal separation, divorce, annulment, death ofa spouse) .• Change in number of tax dependents (e.g. birth, adoption, placement for adoption, death).• Change in your dependent's eligibility for coverage due to the dependent's age, student status, marital

status or similar circumstance (e.g. your child reaches age 13 so is no longer eligible for coverage undera Dependent Care FSA) .

• Change in employment status of employee, spouse, or dependent that affects eligibility for the FSA .• Change in residence or worksite of employee, spouse or dependent that affects eligibility for the FSA .• Change in dependent care costs or coverage (e.g. change in your day care provider).

If you, your spouse or an eligible dependent experiences a QSC event, you may change your FSA election(s) as long as the requested change is consistent with the event. For example: . If you have a new baby, you may increase your Medical FSA and/or Dependent Care FSA election(s) to

accommodate the added medical and/or day care expenses for this new child . . If you have a new baby and your spouse terminates employment to stay home with the child, you may decrease your

Dependent Care FSA election since you no longer have eligible day care expenses for that child . • If you currently have eligible day care expenses for your pre-schooler, you may decrease your Dependent

Care FSA election when the child starts school during the plan year since you would no longer have eligibleday care expenses for that child.

(15) Will my FSA election automatically continue after my current plan year ends?No. You must enroll again before the beginning of each new plan year. This gives you a chance to change your election each plan year as your circumstances change.

(16) What happens if my employment terminates before the end of the plan year?

• Your Medical FSA will terminate as of the date your employment terminates. Eligible medical services provided prior to your date of termination will still be eligible for reimbursement, but services provided after the date of termination will not be eligible unless you are eligible for and elect to continue coverage under COBRA. See additional information in your SPD or Plan Document.

• Your Dependent Care FSA balance will continue to be available for reimbursement of eligible services provided at any time within your plan year.

(17) If I terminate employment, can I receive a refund for the cash balance remaining in my FSA?No. IRS regulations do not allow this.

The Employer maintains a Plan Document; if anything in this document conflicts with the Plan Document. then the Plan Document controls.

FAQs FSA GENERAL: Continued

Beniversal Card FAQs

(1) What is a Beniversal® Card?The Beniversal® Prepaid MasterCard® allows you to use funds from your Medical Flexible Spending Account (FSA) and/or HealthReimbursement Account (HRA) to pay for eligible medical expenses at qualified merchants that accept Debit MasterCard.

(2) When can I start using my Beniversal Card?Before using your card, you must:• Activate and sign the card (follow the instructions received with your card).• Wait to use the card on or after your effective date in the plan.

(3) What dollar amount is available on my Beniversal Card after I activate it?• The amount available for a Medical FSA = the total amount you elected for the current plan year minus any prior payments and reimbursements. Check your plan

documents to determine if prior year funds are available on the card.• The amount available for an HRA = the total funds posted to your current plan year account minus any prior payments and reimbursements.

(4) Where can I use my Beniversal Card?Your card will only work at Qualified Merchants who accept Debit MasterCard. Qualified Merchants include medical providers such as:

• Chiropractors• Doctors• Dentists

• Hospitals• Medical labs• Medical supply stores

• Orthodontists• Podiatrists• Vision Centers

• IIAS merchants• 90% merchants

(5) What is an IIAS merchant?• An IIAS merchant has an Inventory Information Approval System (IIAS) that automatically identifies eligible medical expenses.• Here’s how it works:

– Have the sales clerk total your entire purchase.– Use your Beniversal Card first, which will automatically pay for the eligible medical items.– Use another form of payment for the remaining amount.

• A list of IIAS merchants is available at the Benefit Resource website at www.BenefitResource.com.• You usually will not need to submit a receipt to verify the eligibility of a purchase made at an IIAS merchant, but save your receipt just in case.

(6) What is a 90% merchant?• A 90% merchant has registered with a national organization, certifying that 90% or more of its revenue is from the sale of eligible medical items.• If a merchant has more than one location, each location must be registered.• A list of 90% merchants is available at www.BenefitResource.com.• You usually will need to submit documentation to verify the eligibility of a purchase at a 90% merchant, so save your receipt.

(7) What can I purchase with my Beniversal Card?• Use your card to pay for medical expenses that are eligible under your plan. Check the plan information from your employer for additional details.• Do not use your card for ineligible expenses, such as teeth whitening, health club memberships or cosmetic procedures.• Expenses must be for you, your spouse or your eligible dependent(s), unless otherwise restricted under your employer’s plan.• General information about eligible expenses is available at www.BenefitResource.com.

(8) Can I use my card to purchase over-the-counter (OTC) items?If you have a General Medical FSA, eligible OTC medical items can be purchased with your Beniversal Card (see examples in the OTC Chart atwww.BenefitResource.com). For an HRA, check your Plan Highlights to see if any OTC expenses are eligible.

(9) What if I order my prescription through an online or mail order program?When payment information is requested for a prescription service, you can simply provide your Beniversal Card number and related account details.

(10) If asked, should I select “Debit” or “Credit”?Select CREDIT to sign for the purchase or DEBIT to enter a PIN. Information on how to request a PIN is included when you receive your card. There is no ATM orcash access associated with this card.

(11) What should I do with my receipts?Save them! In fact, save all documentation related to medical expenses paid with your Beniversal Card. The documentation must include provider name, type ofservice, date of service and cost of service. (For prescriptions drugs, documentation must include the drug name). • IRS regulations require all FSA/HRA transactions to be verified for eligibility.• The technology built into your card provides a way to verify many card transactions automatically.• When a card transaction cannot be verified automatically, the IRS requires that you submit followup documentation. Benefit Resource will contact you when this is

necessary. This often happens if you use the card for the following:- Dental and vision expenses.- Expenses that are not co-payments under your employer-sponsored health insurance plan. - Expenses at a 90% merchant.

(12) What if I lose these documents?• See if your provider or insurance company can provide copies for you. An Explanation of Benefits (EOB) generally provides all the required information.• If you cannot provide the required document(s) or if an expense is ineligible you may repay the expense or provide a substitute claim to offset it.

The Employer maintains a Plan Document; if anything in this document conflicts with the Plan Document, then the Plan Document controls.

The Beniversal Prepaid MasterCard is issued by The Bancorp Bank pursuant to license by MasterCard International Incorporated. The Bancorp Bank; Member FDIC. MasterCard is a registered trademark of MasterCard International Incorporated.

Rev. 05/2016

• If you take no action:- Your FSA and/or HRA may be suspended.- Your eligibility to participate in the plan may be suspended.- The amount of the expense may be deducted from your wages on an after-tax basis.

• Card purchases not verified as an eligible expense will be reported as taxable income, per IRS regulations.

(13) Can I use the Beniversal Card to pay for a service before it is provided?No. IRS regulations require that a service be provided before using FSA or HRA funds. (The IRS allows an exception to this rule for orthodontia expenses. Use ofFSA/HRA funds for orthodontia may be based either on date of service or payment due date.)

(14) Can I use the Beniversal Card to pay a bill that has a “Balance Due” for an eligible service?Yes, as long as the payment is completed in the same plan year that the service was provided. However, if followup documentation is requested for the expense,itemized detail will need to be provided as explained above.

(15) Can I use my card to pay for services that were provided prior to participating in the plan?No, IRS regulations do not allow this. The date of service determines whether the expense is eligible, not the date of payment. A service is only eligible if it isprovided in your current plan year and after you begin participating in the plan.

(16) What if a provider requires me to pay in full at the point-of-sale, even if part of the expense will be paid from another source?Do not use your Beniversal Card if any part of the expense will be reimbursed from another source (such as your health insurance carrier). Pay the required amountwith some other means and then submit a claim to Benefit Resource for reimbursement of the eligible amount not reimbursed elsewhere.

(17) What are some reasons my Beniversal Card might not work at the point-of-sale?• Your card has not been activated.• Your balance is less than the full expense.• You attempted to purchase items that are not eligible under your plan.• You attempted to use your card at a non-qualified merchant.• The merchant is not registered in an eligible network.• The merchant is having technical problems.• The home address you gave the merchant did not match the address on file with your Beniversal Card.

(18) What should I do if I cannot use my Beniversal Card at the point-of-sale?Use another form of payment for the eligible item(s) and then submit a completed claim with supporting documentation to Benefit Resource. You can do this in oneof the following ways:(a) The BRiMobile app allows mobile device users to submit claims on-the-go.(b) Log in to the Benefit Resource website, under the FSA/HRA Plans tab, select Submit an Online Claim (if allowed by your plan). Complete your claim form,

then either upload it to Benefit Resource or print it so you can fax or mail it to Benefit Resource.(c) Complete a paper claim form (available from the Benefit Resource website or your employer) and fax or mail it to Benefit Resource.

(19) How do I know how much is in my account?Checking your account balance before using the card will help ensure you have sufficient funds to cover the entire amount of your eligible purchase.• Account information is available 24/7 when you log in to www.BenefitResource.com or via the BRiMobile app for mobile device users.• You can call the toll-free number on the back of your card, Monday - Friday, 8am - 8pm (Eastern Time).

(20) What if an expense is more than the amount remaining in my account?• If the merchant can do a split transaction, tell the clerk you wish to use the Beniversal Card for the exact amount left in your account and then pay for the

remaining amount with another form of payment.• If the merchant cannot do a split transaction, use another form of payment and submit a claim to Benefit Resource for reimbursement from the funds remaining in

your account.

(21) Do I need a new Beniversal Card each plan year?No. As long as you continue to participate in an FSA or HRA, you can continue using your card through the expiration date on the card.• Your new Medical FSA election will be loaded on your card at the beginning of each new plan year. (Medical FSA funds from the prior plan year will no longer be

available on the card after that plan year ends.)• HRA funds will be available on your card per your HRA Plan Highlights.

(22) What happens if I terminate employment or stop participating in the plan?Your card will be automatically cancelled when you stop working for the employer or stop participating in the plan. Claims for eligible expenses may be submittedfor reimbursement per your Plan Highlights.

(23) Where do I go for answers to my questions?• Information is available 24/7 at www.BenefitResource.com.• The Benefit Resource Participant Services Department is available online via Live Chat (Monday - Friday, 8am - 5pm (Eastern Time) with participant login access)

or by calling (800) 473-9595, Monday - Friday, 8am - 8pm (Eastern Time).

(24) What if I lose my card or need another one?To minimize unauthorized use of your card, be sure to report a lost card immediately by calling Benefit Resource at (800) 473-9595. You can request replacementcards at the same number. (There is a fee associated with card replacement. Fee details are available in your Cardholder Agreement. A third party may opt to pay thisfee on your behalf. Check with your plan administrator.)

BENIVERSAL CARD FAQs: Continued

*Please review your Summary Plan Description for details of IRS regulations. Eff.01/2018 The Employer maintains a Plan Document; if anything in this document conflicts with the Plan Document, then the Plan Document controls.

A. General Plan Information

1. Employer name: Enloe Medical Center.

2. Plan name: Enloe Medical Center Flexible Benefit Plan.

3. Plan type: The Plan is a welfare plan designed to provide benefits permitted under Section 125 of the Internal Revenue Code (IRC). The Planname and Plan number should be used in any formal correspondence relating to the Plan.

4. Eligibility requirements: Must be an employee of Enloe Medical Center who works at least 24 hours a week.• If you or your spouse is reporting contributions to a Health Savings Account (HSA), you are not eligible for a Medical FSA.

5. The effective date on which you can begin participating in the Plan: On the first of the month once the eligibility requirements have been met.

6. Kinds of group insurance for which you can pay your share of premiums through the Plan: Medical, Dental and Vision Insurances.The Health Benefits that are offered under the Premium Payment Component are the Medical, Dental and Vision Plans. An Eligible Employeecan elect:

7. To participate in the Premium Payment Component by electing to pay for his share of the premiums for Health Benefits Plan on a pre-taxSalary Reduction basis (Premium Payment Benefits);

8. To pay for his share of the premiums with after-tax deductions outside of this Plan; or9. To Opt-Out of participation in Health Plan Benefits and receive a monthly credit of $50 in lieu of group health coverage and $7 in lieu o group

dental coverage, subject to withholding for income and payroll taxes.NOTE: Employees who are covered on the Enloe medical plan as dependents of another Employee are not eligible to receive the Opt-Outcredit.

B. The Plan Year begins on January 1 and ends on December 31.

C. Plan effective date: January 1, 1990.

D. Plan number: 501.

E.

F.

Employer ID number: 94-1603784.

Name, address, phone number of the Plan Administrator:

12. Agent for service of process: Enloe Medical Center.B. Flexible Spending Accounts (FSAs)

1. Types of FSAs

Medical FSA(a) Maximum amount you can set aside per Plan Year for reimbursement of eligible medical expenses as defined by IRC Section 213(d)

except for insurance premiums: $2,650.(b) For active participants:

• Eligible services must be provided:ο after your effective date in the Plan andο during the Plan Year.

(c) If you become ineligible (including termination of employment) during the Plan Year:• Eligible services must be provided:

ο after your effective date in the Plan,ο during the Plan Year andο prior to the date on which you become ineligible.

• The Beniversal Card may no longer be used to access Medical FSA funds. You may submit a claim for reimbursement of eligibleexpenses.

Dependent Care FSA (a) Maximum amount you can set aside per calendar year for reimbursement of eligible dependent care services, as defined by IRC Section

21(b), is limited to the smallest of the following amounts:• $5,000 if single or if married and filing jointly; $2,500 if married and filing separately.• The earned income of the participant.• The earned income of the participant’s spouse.

(b) For active participants:• Eligible services must be provided:

ο after your effective date in the Plan andο during the Plan Year.

FLEXIBLE BENEFIT PLAN with Beniversal® MasterCard®

PLAN HIGHLIGHTS*

Enloe Medical Center 1531 Esplanade Chico, CA 95926 (530) 332-7300

*Please review your Summary Plan Description for details of IRS regulations. Eff.01/2018 The Employer maintains a Plan Document; if anything in this document conflicts with the Plan Document, then the Plan Document controls.

(c) If you become ineligible (including termination of employment) during the Plan Year:• Eligible services must be provided:

ο after your effective date in the Plan andο during the Plan Year in which you become ineligible.

2. Claims for FSAs

Claim submission time frames(a) Claims must be received by Benefit Resource, Inc. before the end of the 60 day run-out after the Plan Year ends.(b) Claims denied during the run-out may be resubmitted, but must be received by Benefit Resource within 21 days after the run-out ends.(c) Eligible participants are allowed to rollover up to $500 of unused Medical FSA funds to the next Plan Year after the end of the time frame

in (b) is completed for the current Plan Year. The minimum amount that can rollover must be greater than $10.(d) Any funds remaining in your Medical or Dependent Care FSA after this will be forfeited.

Claim reimbursements (a) Complete your claim following all instructions.(b) Claims received with proper documentation will be processed within 5 business days.(c) Claim reimbursements are processed daily.(d) There is a minimum reimbursement amount of $15 (except during the run-out after the end of the Plan Year).(e) A claim should never be submitted for an expense that has been paid for with a Beniversal Card or reimbursed from any other source.

3. Beniversal Card for Medical FSA

(a) The Beniversal Card allows you to access Medical FSA funds to pay for eligible medical services at qualified merchants.(b) The card may only be used to pay for eligible medical services after they have been provided. The IRS allows one exception: eligibility of

orthodontia expenses can be based on either date of payment, date of service or payment due date on coupons/statements.(c) Payment of a current Plan Year medical service with the card must be completed before the Plan Year ends.(d) Once a new Plan Year begins, only Medical FSA funds associated with the new Plan Year will be available on the card.(e) You are advised to save all documentation related to medical expenses paid with your card, as IRS regulations require all transactions to

be verified for eligibility.(f) If a card transaction cannot be automatically verified, you will be contacted to submit documentation for that transaction.(g) Medical expenses paid with the card should never be submitted for claim reimbursement.

PLAN HIGHLIGHTS* : Continued

1. Determine your election amount(s) for Medical FSAand Dependent Care FSA separately.Utilize the FSA Expense & Tax Savings Estimate Worksheet in thisbooklet or visit www.Benefi tResource.com to access the onlinecalculators.

TIPS: Be a little conservative in your estimates. Check your Plan Highlights to see what happensto funds that you do not use by the end of the plan year. Also, be sure to check with youremployer or review your Plan Highlights for any minimum or maximum limits that may apply,along with any restrictions on eligible expenses.

2. Enroll in the FSAYour employer will provide you detailed instructions regarding how andwhen enrollment will need to be completed.

If online enrollment is offered by your employer, go towww.Benefi tResource.com, click on Participants under Secure Login.To log in, enter:

Company Code: Provided by your employerLogin ID: Default Login ID selected and provided by your employer.

You may change it upon initial login.Initial Password: 5 digit home zip code

(You will be prompted to change the password upon initial login.)

Once logged in, go to the FSA/HRA tab and select the enrollment link. Follow the on screen prompts to complete your enrollment.

3. Begin using your account.If you have enrolled in a Medical FSA for the fi rst time and the BeniversalCard is offered, it will arrive in a plain white envelope from Benefi tResource. Once you receive your card, you will need to activate itby calling the number on the activation sticker. If you already have aBeniversal Card, you can continue to use the card through the expirationdate. If you are not using a card or have dependent care expenses, youcan begin submitting claims for reimbursement.

Please check with your employer or refer to your Plan Highlightsregarding any restrictions that may exist regarding eligible expenses andtime frames for using funds and reimbursing eligible expenses.

Getting Started

Rev. 08/2015FSA 200-17

245 Kenneth Drive ◊ Rochester NY 14623-4277Toll-free: (866) 996-5200 ◊ Fax: (585) 424-7273 ◊ www.Benefi tResoure.com

Questions? Visit us online at: www.Benefi tResource.com

Contact us: (800) 473-9595, Monday - Friday, 8am - 8pm (Eastern Time), by email at ParticipantServices@Benefi tResource.com or with Live Chat via participant login at

www.Benefi tResource.com, Monday - Friday, 8am - 5pm (Eastern Time)

What do participants think of their

Beniversal FSA?

“Everyone is very helpful and responsive. I’ve used the Live Chat a few times- I love it!!!!”

“The BRI staff have always been very helpful, courteous, and knowledgeable; and your website is very user-friendly. Keep it up!”

“I’m always pleased when I don’t need to contact an organization for help or to sort out problems because it means the business is doing a lot of things right to avoid trouble in the fi rst place.”

“I recommend daily that my co-workers get this card!”