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«Summary Plan Description SAS Institute Inc. Premium Conversion and Flexible Spending Account Plan Full-Time and Part-Time Employees of SAS and ...»

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Under the Health Care FSA, an “Eligible Medical Expense” is an expense that has been incurred by

you, your spouse, or your eligible dependent that satisfies the following conditions:

–  –  –

 The expense has not been reimbursed by any other source and you will not seek reimbursement for the expense from any other source.

The Internal Revenue Code generally defines “medical care” as any amounts incurred to diagnose, treat or prevent a specific medical condition or for purposes of affecting any function or structure of the body.

The cost of over-the-counter drugs or medicines other than insulin may not be reimbursed from your Health Care FSA unless you (or your dependent) have a prescription for such drug or medicine.

The following is a sample list of medical expenses which the IRS has typically considered deductible for income tax purposes under Section 213(d) of the Internal Revenue Code and which can be reimbursed through your Health Care FSA. Please note that the list below is subject to change based on modifications to the Internal Revenue Code. You may contact the Claims Administrator for questions regarding services not listed or refer to IRS Publication 502 for eligible expenses.

• Acupuncture

• Alcoholism Treatment

• Ambulance Service

• Anesthetist

• Artificial Limbs

• Automobile modifications if it is for physically handicapped persons

• Birth Control Pills/Contraceptive Devices

• Breast Pumps

• Capital Expenses (special equipment installed in home or for improvements if main reason is for medical care)

• Charges above Plan Maximum Dollar Limits

• Charges above usual, customary & reasonable charges (as determined by the Participant’s Health Plan)

• Chiropractors

• Christian Science Practitioner for medical care

• Contact Lenses (prescription lenses not covered by insurance; not cosmetic lenses)

• Co-payments and deductibles (not covered by insurance plans)

• Cost for Physical or Mental Illness

• Confinements

• Crutches

• Dental Fees (not covered by insurance; excluding cosmetic services)

• Dermatologists

• Eyeglasses (lenses, frames, exams not covered by insurance)

• Hearing Devices (batteries and repairs)

• Hospital Fees (not covered by insurance; excluding services for cosmetic procedures)

• Immunizations

• Insulin

• Laboratory Fees

• Medical Monitoring & Testing Devices such as blood pressure monitors (for diagnosis of high blood pressure) and glucose kits and syringes (for diagnosis for diabetes)

• Mileage (Requires that the member keep a log showing the date they drove to an appointment or pharmacy to pick up prescription and number of miles driven. The log must match dates on physician and pharmacy receipts.)

• Nursing Home (medical portion only)

• Nursing Services

• Obstetrical Expenses

• Orthodontia (adult orthodontia requires a letter of dental purpose; excludes cosmetic only orthodontia)

• Osteopaths (licensed)

• Over-the-counter medications prescribed by a medical provider

• Oxygen

• Physician Fees (excluding cosmetic services)

• Pregnancy Test (over-the-counter)

• Prosthetics and Orthotics

• Psychiatric Care

• Radial Keratotomy and Lasik surgery (and any other vision correction surgery)

• Routine Physicals and Other Non-Diagnostic Service or Treatment

• Smoking Cessation Programs

• Special Diets for necessary medical treatment (requires annual letter of medical purpose each year)

• Sterilization

• Surgical Fees (including experimental and reconstructive procedures when medically necessary)

• Telephone (specially equipped for person who is deaf; requires letter of medical purpose)

• Therapeutic Care for Drug and Alcohol Addiction

• Therapy (physical or occupational when medically necessary)

• Transplants (including donor’s costs)

• Transportation essential to medically necessary care

• Vasectomy

• Weight Loss Programs when prescribed by a physician for a weight related medical condition (Documentation is required each new year and must include diagnosis, type of exercise and how the patient is to do the required exercise.)

• Wheelchair

• Wound Care Supplies when required after major surgery or when medically necessary

• X-ray Fees

INELIGIBLE MEDICAL EXPENSES

The following is a sample list of health care expenses which may not be reimbursed through the Health Care FSA, even if they otherwise qualify as “medical care” expenses. Please note that the list below is subject to change based on modifications to the Internal Revenue Code. You may contact the Claims Administrator for questions.

• Accident and other health care/dental insurance premiums

• Adoption Expenses

• Athletic Club Membership (unless incurred primarily for medical care)

• Babysitting Fees

• Carbon Monoxide Detectors

• Cosmetic Surgery (any procedure or product intended to improve a patient’s physical appearance but not to meaningfully promote the body’s proper functioning or to prevent or treat illness or disease)





• Dental Bonding and Bleaching

• Dust Elimination System

• Electrolysis

• Expenses for which the Participant received benefits from any other health care, dental, vision, hearing or prescription plan

• Food (unless taken to alleviate specific ailment)

• Guardianship of Mental Patient

• Hair Transplants

• Heating System (installed to ease allergy)

• Illegal Drugs, Surgery and Treatments

• Living Expenses

• Maternity Clothes

• Nurse Caring for Healthy Child

• Nutritional Supplements

• Over-the-counter medications (unless prescribed)

• Power Steering in Automobiles

• Prepayment of services

• Retirement or Rest Home (no proof of medical services rendered)

• Social Activities (even if recommended by doctor to improve general health)

• Special Diet (when prescribed as substitute for regular diet to provide ordinary nourishment)

• Swimming Pool (installed for general health)

• Vacation Expenditures (even if recommended by a doctor)

• Vitamins (non-prescription)

HEALTH CARE FLEXIBLE SPENDING ACCOUNT CLAIMS FILING

You may be reimbursed for Eligible Medical Expenses incurred during the Plan Year. So long as your coverage remains effective, the full annual coverage amount you have elected, reduced by the amount of previous reimbursements for Eligible Medical Expenses incurred during the Plan Year, will be available for reimbursement. The benefit to you is that you do not have to wait until the amount you have actually contributed to your Health Care FSA is sufficient to cover an out-ofpocket medical expense before you actually incur the expense. Your subsequent contributions will be used to repay the Employer for the reimbursement.

Under the Health Care FSA, you have two reimbursement options. You can complete and submit a written claim for reimbursement after incurring the expense (see “Traditional Paper Claims” below for more information), or you can use a debit card (see “Electronic Payment Card” below for more information) to pay the expense. You can use either method.

Traditional Paper Claims: After you incur an Eligible Medical Expense, you may file a claim with the Claims Administrator by completing and submitting a reimbursement form. You may obtain a form from the SAS Benefits Department or online from the SAS Benefits website or the Claims Administrator’s website. You must include with your reimbursement form a written statement from an independent third party (e.g., an itemized statement, receipt, explanation of benefits (EOB), etc.)

associated with each expense that indicates the following:

 The nature of the expense (e.g. what type of service or treatment was provided). If the expense is for an over-the-counter drug, you must submit the prescription, a copy of the prescription, or other documentation that a prescription has been issued, such as a receipt identifying the patient, the date and amount of the purchase, and an Rx number.

 For expenses covered partially by health insurance, a copy of your EOB showing the amount your insurance did not pay.

 The date(s) the service or expense was incurred.

 The name and address of the provider or entity to which the expense was or is to be paid.

–  –  –

The Claims Administrator will process the claim once it receives the reimbursement form from you.

If the expense is determined to be an Eligible Medical Expense, you will be reimbursed as soon as practicable after your claim is processed (but only up to the annual amount you have elected to contribute to your Health Care FSA). If the expense is determined to not be an “Eligible Medical Expense,” you will receive notification of this determination.

Electronic Payment Card: The debit card allows you to pay for Eligible Medical Expenses at the

time that you incur the expense. The debit card works as follows:

 You must make an election to use the card. In order to use the debit card, you must agree to abide by the terms and conditions of the debit card program as described in the cardholder agreement. Among other things, the cardholder agreement may impose limitations as to card usage, and it may give your employer the right to withhold amounts from your wages or to reduce future reimbursements to offset amounts paid or reimbursed for ineligible claims. In addition, debit card fees may apply. The cardholder agreement will be provided to you, and you may be required to sign a new cardholder agreement each year.

 You must certify proper use of the card. You must certify that the card will be used only for Eligible Medical Expenses, that you will not use the card for expenses that have already been reimbursed and that you will not seek reimbursement for expenses paid for with the card.

 Use of the card is limited to health care providers (including pharmacies) and certain other qualifying vendors. Use of the card for Health Care FSA Plan expenses is limited to merchants that are health care providers (doctors, pharmacies, etc.), and certain other vendors that qualify under federal tax rules.

 Swipe the card at the health care provider like you do any other credit or debit card.

When you incur an Eligible Medical Expense at a doctor’s office or pharmacy or other eligible vendor, you can use the Health Care FSA Plan debit card much like you would any other debit card or a typical credit card. The provider or vendor is paid for the expense up to the maximum reimbursement amount available under the Health Care FSA Plan (or as otherwise limited under the cardholder agreement) at the time that you use the card. Every time you use the card, you certify to the Plan that the expense for which payment under the Health Care FSA Plan is being made is an Eligible Medical Expense, that the expense has not already been reimbursed and that you will not seek reimbursement for the expense.

 Substantiation of over-the-counter drug purchases. The cardholder agreement may impose special rules for purchases of over-the-counter medicines or drugs, or prohibit such purchase altogether.

 Obtain and retain a receipt/third party statement each time you swipe the card. Each time you use the debit card, you must obtain a statement from the health care provider or

vendor (e.g., receipt, invoice, etc.) that includes the following information:

• The nature of the expense (e.g. what type of service or treatment was provided). If the expense is for an over the counter drug, you must submit the prescription, a copy of the prescription, or other documentation that a prescription has been issued, such as a receipt identifying the patient, the date and amount of the purchase, and an Rx number.

• The date(s) the service or expense was incurred.

• The name of the provider or entity to which the expense was or is to be paid.

–  –  –

• The patient’s name.



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