«Summary Plan Description SAS Institute Inc. Premium Conversion and Flexible Spending Account Plan Full-Time and Part-Time Employees of SAS and ...»
The change in cost rules apply to the Dependent Care FSA only if the dependent care provider is not your relative.
If the Plan Administrator determines that your coverage under a SAS Health Care Plan has been significantly curtailed, you may change your election to drop such coverage. You may also elect coverage under another benefit option which provides similar coverage, provided the new election is consistent with the reason the change is permitted.
If the Plan adds a benefit option during the Plan Year, you may change your elections to enroll in the new option.
CERTAIN JUDGEMENTS, ORDERS OR DECREESIf a judgment, decree or order resulting from a divorce, separation, annulment or custody change requires your dependent child (including a foster child who is your tax dependent) to be covered under a SAS Health Care Plan or the Health Care FSA, you may change your election to add such coverage for the dependent child. If the judgment, decree or order requires that another individual (such as your former spouse) provide accident or health coverage for the dependent child, and such coverage is actually provided, you may change your election to drop such coverage for the dependent child under this Plan.
MEDICARE OR MEDICAID ELIGBILITYIf you, your spouse, or your dependent becomes entitled to Medicare or Medicaid (other than coverage consisting solely of benefits under Section 1928 of the Social Security Act that provides for the distribution of pediatric vaccines), you may change your elections under this Plan to cancel coverage for the person affected. Similarly, if you, your spouse, or your dependent who has been entitled to Medicare or Medicaid loses eligibility for such coverage, you may change your elections under this Plan to begin or increase coverage under the Plan for the person affected.
PARTICIPATION DURING A LEAVE OF ABSENCEThe term “Leave of Absence” shall mean any absence authorized by the Employer under its standard personnel practices or under the Family and Medical Leave Act of 1993 (FMLA), as applied in a uniform and nondiscriminatory manner to all persons similarly situated. Eligible Leaves of Absence include short-term and long-term disability, paternity leave, adoption leave, workers’ compensation leave of absence, personal leave of absence, military leave and FMLA leave.
If you are on a paid Leave of Absence you will continue to participate in the Plan for the duration of the Leave of Absence.
If you are on an approved unpaid Leave of Absence, other than a Personal Leave of Absence, you may continue to participate in the Plan for the duration of the Leave of Absence unless the unpaid Leave of Absence qualifies as an event that permits a mid-year election change, in which case you may change your election as described in the section entitled “Mid-Year Benefit Election Changes.” There are special rules that apply if you take an approved unpaid Leave of Absence pursuant to the Family and Medical Leave Act (“FMLA”) or the Uniformed Services Employment Reemployment Rights Act (“USERRA”).
If you take unpaid FMLA leave or unpaid USERRA leave, you may elect to either continue your participation or discontinue your participation in the Health Care FSA for the duration of the Leave of Absence. In other words, you do not have to satisfy the rules governing mid-year election changes in order to revoke your election to participate.
If you continue to participate in the FSA during an unpaid Leave of Absence, your coverage will terminate if you fail to make a required payment for coverage. In addition, if you take unpaid USERRA leave, your coverage will terminate if you are required to apply for or return to a position or employment and fail to do so. Upon termination of USERRA coverage, you may be entitled to continue coverage under the Health Care FSA Plan pursuant to COBRA; any period of COBRA coverage will be reduced by the period of USERRA coverage you already received during your military Leave of Absence.
You must notify the SAS Benefits Department if you desire to make a change to your FSA election on account of a Leave of Absence.
If you revoke your participation in the Health Care FSA during an approved unpaid FMLA Leave or unpaid USERRA Leave and upon return from the Leave of Absence you elect to resume your participation in the Health Care FSA, you may (1) resume coverage at the original level and make up the salary contributions that were not paid during the Leave of Absence, or (2) resume coverage at a level that is prorated to reflect the non-payment of premiums during your Leave of Absence and resume your salary contributions at the level originally elected.
If the Leave of Absence is unpaid, you can pay the required salary contributions with pre-tax dollars before the Leave of Absence begins, pay the required salary contributions while you are on the Leave of Absence with after-tax dollars, or upon return to work, pay outstanding contributions with pre-tax dollars. Since the IRS does not allow reimbursements for dependent care expenses while you are not working, you cannot claim reimbursement under the Dependent Care FSA for expenses incurred during your Leave of Absence.
The FMLA requires employers to provide up to a total of 12 weeks of unpaid, job-protected leave during a 12-month period to eligible employees for certain family and medical reasons. Your rights under the FMLA are described in greater detail in the other SAS policies and procedures. This provision is intended to comply with the law and any pertinent regulations, and its interpretation is governed by them. For more information, contact the SAS Benefits Department.
APPEALING DENIED CLAIMSIf a claim is denied, in whole or in part, you will receive a written explanation of the denial that includes the specific reason or reasons for the denial, specific reference to the Plan provision on which the denial is based, a description of additional information necessary to perfect the claim, a description of the Plan’s claims review procedures and the time limits applicable to such procedures, including a statement of your right to bring a civil action under ERISA following an adverse determination on review, a statement of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the claim determination or a statement that a copy of such rule, guideline, protocol or other criterion will be provided free of charge to you upon request, and, if the claim determination was based on medical necessity or experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or a statement that such explanation will be provided free of charge upon request.
You may request that your claim be reviewed. If you want to appeal the denial of your claim, you must write to Flores & Associates within 180 days of the date of the denial at P.O. Box 31397 Charlotte, NC 28231-1397.
In connection with an appeal, you have the right to review pertinent documents, records, and other information relevant to your claim and to submit written comments, documents, records, and other information relevant to the appeal of your claim for benefits. Copies of all relevant information relevant to your claim, will be provided free of charge by Flores & Associates, upon request.
Your claim will be given a full and fair review. The Claims Administrator will reconsider your claim, taking into account all comments, documents and other information that you have submitted in support of your claim and will notify you of its determination within 60 days after receipt of the request for review. The decision on review will not give deference to the initial adverse claim determination and will be conducted by an individual who is not the same individual who made the initial adverse claim determination or a subordinate of such individual. If the claim determination is based in whole or in part on a medical judgment, including a determination with regard to whether a particular treatment, drug or other item is experimental, investigational, or not Medically Necessary or appropriate, the Claims Administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. This professional will be an individual who is neither an individual who was consulted in connection with the initial claim determination nor a subordinate of such an individual.
The Claims Administrator has the exclusive discretionary authority to construe and to interpret the Plan, to decide all questions of eligibility for benefits and to determine the amount of such benefits, and its decisions on such matters are final and conclusive. Any interpretation or determination made pursuant to such discretionary authority shall be upheld on judicial review, unless it is shown that the interpretation or determination was an abuse of discretion (i.e., arbitrary and capricious). Benefits under the Plan will be paid only if the Claims Administrator decides in its discretion that the claimant is entitled to them.
PROTECTIONS UNDER ERISAAs a Participant in this Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974, as amended (ERISA).
ERISA provides that all Plan Participants shall be entitled to:
RECEIVE INFORMATION ABOUT THE PLAN AND ITS BENEFITSExamine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites, all documents governing the Plan, including contracts and a copy of the latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including contracts, and copies of the latest annual report (Form 5500 series) and updated SPD. The Plan Administrator may make a reasonable charge for the copies.
Receive a summary of the Plan’s annual financial report. The Plan Administrator is required by law to furnish each Participant with a copy of this summary annual report.