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COMMONWEALTH OF KENTUCKYKENTUCKY EMPLOYEES’ HEALTH PLAN (KEHP)HEALTH FLEXIBLE SPENDING ACCOUNT (FSA)SUMMARY PLAN DESCRIPTION (SPD)Plan Year: January 1, 2016 through December 31, 2016Effective Date: January 1, 1991Amended and Restated: January 1, 2016Employer’s Federal Tax Identification Number: 61-0600439

TABLE OF CONTENTSPLAN INFORMATION . 3INTRODUCTION . 3GENERAL INFORMATION ABOUT THE PLAN . 4ELIGIBILITY . 8ELIGIBILITY REQUIREMENTS . 8ELIGIBILITY EXCEPTIONS . 8MEDICARE ELIGIBLE EMPLOYEES . 8ELIGIBLE DEPENDENTS . 8COVERAGE INFORMATION . 10ELECTIONS . 10PERMITTED ELECTION CHANGES . 10LEAVES OF ABSENCE . 11UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT . 12EMPLOYEE EFFECTIVE DATE OF COVERAGE . 13TERMINATION OF COVERAGE . 13MODIFICATIONS TO THE PLAN . 14REIMBURSEMENT . 15CONTRIBUTIONS . 15ELIGIBLE EXPENSES . 15CLAIM REIMBURSEMENT . 16OVERPAYMENT OR REIMBURSEMENT ERRORS . 16MAXIMUM AMOUNT OF REIMBURSEMENT . 17DENIED CLAIMS . 17UNUSED FSA FUNDS . 17PLAN ACCOUNTING . 18APPENDIX 1 – CLAIMS INSTRUCTIONS . 19CLAIMS SUBMISSION . 19CLAIMS PROCESS . 21APPENDIX 2 - OTHER NOTICES . 23NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT . 23HIGHLY COMPENSATED EMPLOYEES . 23NO EMPLOYMENT RIGHTS CONFERRED . 23MEDICARE AND MEDICARE SECONDARY PAYER . 23WOMENS HEALTH CARE AND CANCER RIGHTS ACT (WHCRA) . 24MENTAL HEALTH PARITY. 24THE GENETIC INFORMATION NONDISCRIMINATION ACT (GINA). 24SOCIAL SECURITY BENEFITS . 25APPENDIX 3 -HIPAA - PRIVACY OF PROTECTED HEALTH INFORMATION. 26HIPAA NOTICE OF PRIVACY PRACTICES . 27APPENDIX 4 - ELIGIBLE EXPENSES . 29ALLOWABLE EXPENSES . 29DISALLOWED EXPENSES . 30APPENDIX 5 - COBRA. 31CONTINUATION COVERAGE FOR EMPLOYEE. 31CONTINUATION COVERAGE FOR SPOUSE OF EMPLOYEE . 31CONTINUATION COVERAGE FOR DEPENDENT OF EMPLOYEE . 32NOTIFICATION AND PREMIUMS . 32TERMINATION OF RIGHTS . 33ADDITIONAL INFORMATION . 33QUALIFIED BENEFICIARIES . 33AFFECT OF COBRA ON YOUR HEALTH FSA . 34APPENDIX 6 - DEFINITIONS. 35SUMMARY . 36

PLAN INFORMATIONINTRODUCTIONThe Plan Sponsor has established and continues to maintain this Health Flexible SpendingAccount (the “FSA” or the “Plan”) for the benefit of its Employees and their eligible dependentsas provided in this document. The FSA provides reimbursement for the cost of eligible medical,dental, or other similar expenses without taxation to you individually.The purpose of this SPD is to briefly describe the expenses that qualify for reimbursement, aswell as provide an outline of other important information concerning the Plan, such as the rulesyou must satisfy before you can elect the FSA and the laws that protect your rights. This SPDdescribes the basic features of the FSA, how the FSA operates, and how you can get themaximum advantage from the FSA.This SPD describes the current provisions of the Plan which are designed to comply withapplicable legal requirements. The Plan is subject to federal laws, such as the Internal RevenueCode and other federal and state laws which may affect your rights. The provisions of the Planare subject to revision due to a change in laws or due to pronouncements by the Internal RevenueService (IRS) or other federal agencies. The Plan Sponsor may also amend or terminate thisPlan. If the provisions of the Plan that are described in this SPD change, the Plan Administratorwill notify you.There is also a Plan Document that governs the FSA which you may review if you desire. In theevent there is a conflict between this SPD and the Plan Document, the Plan Document willcontrol.One of the most important features of our Plan is that the benefits being offered are generallyones that you are already paying for, but normally with money that has first been subject toincome and Social Security taxes. Under our Plan, these same expenses will be paid for with aportion of your pay before income or Social Security taxes are withheld. This means that youwill pay less tax and have more money to spend and save.KEHP has contracted with WageWorks, Inc. (“WageWorks”) to provide certain administrativeservices with respect to the FSA, such as claims processing and medical expense payment andreimbursement.Read this SPD carefully so that you understand the provisions of the Plan and the benefits youwill receive. You should be fully informed before you enroll in the Plan and remain informed asa plan member. If you have any questions, you should contact KEHP at 888-581-8834 or theSpending Account Administrator, WageWorks, at 877-430-5519.Participation in the Plan does not give any Participant the right to be retained in the employ ofhis or her Employer or any other right not specified in the Plan. If you have any questionsregarding your rights and responsibilities under the Plan, you may also contact the PlanAdministrator.3

GENERAL INFORMATION ABOUT THE PLANThis section contains general information that you may need to know about the Plan.1.Plan Name. Kentucky Employees’ Health Plan (KEHP) Health Flexible SpendingAccount (FSA).2 (a). The provisions of the Plan became effective on January 1, 1991, which is called theEffective Date of the Plan.2 (b). The provisions of the amended Plan became effective on January 1, 2016.3.The Plan’s start date begins on January 1, 2016, and ends when you are no longer eligibleto participate in the Plan. Your Plan's records are maintained on a twelve-month periodof time. This is known as the Plan Year. The Plan Year begins on January 1 and ends onDecember 31.4.Employer/Plan Sponsor Information.identification number are:The Employer’s name, address and taxCommonwealth of Kentucky501 High Street, Second FloorFrankfort, KY 40601Toll Free: 888-581-8834Local: 502-564-6534Tax ID#: 61-06004396.The Plan shall be governed under the laws of the Commonwealth of Kentucky.7.Plan Administrator Information. The name, address and business telephone number ofthe Plan’s Administrator is:Commonwealth of KentuckyDepartment of Employee Insurance501 High Street, Second FloorFrankfort, KY 40601Toll Free: 888-581-8834Local: 502-564-6534The Plan Administrator keeps the records for the Plan and is responsible for the Plan. ThePlan Administrator will also answer any questions you may have about the Plan. Youmay contact the Plan Administrator for any further information about the Plan.4

8.Name and Address of the Plan Manager or “Spending Account Administrator” whereclaims should be submitted:WageWorks, Inc.P.O. Box 14053Lexington, KY 40512Phone: 1-877-430-5519The Spending Account Administrator manages your Health FSA including the receiptand payment of claims and the appeal of any claim denials.9.Service of Legal Process:The Plan Administrator is the Plan’s agent for service of legal process.10.Type of Administration:The type of Administration is Employer Administration.11.Eligibility Requirements.This FSA is available to those Employees as defined in KRS 18A.225 whose Employerparticipates in the KEHP Flexible Spending Account (FSA)/HRA program. The termEmployee means a person, including an elected public official, who is regularlyemployed by any department, board, agency, or branch of state government, and who is acontributing member to any one (1) of the retirement systems administered by the state.See KRS 18A.225 and KRS 18A.227. Part-time Employees expected to work less than30 hours per week are not eligible to participate in the FSA.Terminated Employees shall cease to be a Participant. They shall have 90 days after theend of the calendar year of the claim service date to submit expenses for reimbursementfor expenses incurred up to their termination date.12.Plan Entry Date. The Entry Date for eligible Employees shall be the same as theEmployer's group Medical Plan. You will be eligible to join the Plan on the first day ofthe second month after you become an eligible Employee in accordance with yourEmployer’s eligibility rules.13.Benefits. The Plan shall reimburse eligible Employees for the cost of eligible medicalexpenses (as defined under Internal Revenue Code Sections 105 and 213 (without regardto the limitations contained in Code Sec. 213(a)), and any accompanying regulations orother applicable Treasury guidance or information and as further described below),subject to your FSA contribution amount. (None of your FSA funds may be paid in cashor other form of distribution, other than through reimbursement of actual expensesincurred.)5

Types of Eligible Medical Expenses. The following types of medical expenses qualify forreimbursement under the Plan: Medical

01.01.2016 · COMMONWEALTH OF KENTUCKY . KENTUCKY EMPLOYEES’ HEALTH PLAN (KEHP) HEALTH FLEXIBLE SPENDING ACCOUNT (FSA) SUMMARY PLAN DESCRIPTION (SPD) Plan Year: January 1, 2016 through December 31, 2016 . Effective Date: January 1, 1991 Amended and Restated: January 1, 2016 Employer’s Federal Tax Identification Number: 61-0600439