Page 9 - MCU Benefits Enrollments Guide

Health Reimbursement Arrangement

Employee-only coverage: After the Employee satisfies the first $1,000 of incurred in-
network deductible expenses, the Plan will reimburse the next $3,000 of the
deductible. Once the deductible has been satisfied, the Plan will also reimburse the Employee’s
portion of major medical expenses that are applied to coinsurance up to the out of pocket max
of $6,000. Maximum potential reimbursement is $5,000 ($3,000 for deductible expenses and
$2,000 for coinsurance expenses). Note that this Plan will NOT reimburse incurred copays that
also apply to the out of pocket maximum limit.

Employee + 1 or more coverage: See the Employee-only description above. This reimbursement
schedule applies to both deductible and coinsurance tiers. Maximum potential reimbursement
is $10,000.

The reimbursements are available for In-Network services ONLY, excluding copay services. For
detailed information on this benefit, please consult your HRA summary plan description.

HRA FAQs
What is an Eligible Medical Expense?
Eligible Medical Expenses are expenses incurred by you or your Eligible Dependents that are
described in the Plan Information Summary and that satisfy the following conditions: a) the
expenses are medical care expenses that otherwise qualify for a deduction under IRS Code § 213;
b) the expenses have not been or will not be reimbursed by any other source; and c) the expenses
must have been incurred during the Coverage Period set forth in the Plan Information Summary.
The Plan is designed as a simple deductible and coinsurance reimbursement plan. Only expenses
defined as Eligible Medical Expenses (in the Plan Information Summary) are eligible for
reimbursement. The following expenses are not eligible for reimbursement under the Plan: 1)
qualified long-term care services; and 2) health insurance premiums (including COBRA premiums).
For purposes of this Plan, an expense is "incurred" when the Participant or beneficiary is furnished
the medical care or services giving rise to the claimed expense. You may not be reimbursed for any
expenses arising before the Plan became effective, before you became a Participant in the Plan, or
for any expenses incurred after your participation in the Plan terminates except to the extent
provided below.

How do I receive benefits (reimbursements) under the Plan?
You will receive reimbursement forms to submit to ProBenefits. You must complete the
reimbursement form and submit it with the necessary documentation described in the Plan
Information Summary for review. You will not be reimbursed for Eligible Medical Expenses if the
reimbursement exceeds the annual reimbursement amount (the Cap) set in the Plan Information
Summary. Reimbursement forms can be found on the ProBenefits website.

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