Page 9 - MCU Benefits Guide

Health Reimbursement Account

Employee-only coverage: After the Employee satisfies the first $1,000 of incurred in-network
deductible expenses, the Plan will reimburse the next $4,000 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 $6,000 ($4,000 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 $12,000.

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.

How long do I have to file a claim?
Claims for reimbursement must be submitted within 90 days from the date of the Explanation of Benefits.

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