Document Woodburn_doc_6b2df9c42b

CIS Trust Healthcare Flexible Spending Account (FSA) Program Summary Plan Description Effective January 1, 2026 The Healthcare Flexible Spending Account Program forms part of a Cafeteria Plan as defined in Section 125 of the Internal Revenue Code. The program is designed to permit an eligible employee to contribute on a pre-tax salary reduction basis to an account for reimbursement of qualified healthcare expenses. ---PAGE BREAK--- i Table of Contents Healthcare Flexible Spending Account Program TAX SAVINGS EXAMPLE FREQUENTLY ASKED QUESTIONS REGARDING FLEXIBLE SPENDING ACCOUNT PROGRAMS Q. WHAT IS A FLEXIBLE SPENDING ACCOUNT PROGRAM (FSA)? Q. WHAT ARE THE FSA PROGRAMS UNDER THE PLAN? Q. WHO CAN PARTICIPATE IN AN FSA PROGRAM? Q. IF I MAKE PRE-TAX CONTRIBUTIONS TO AN FSA PROGRAM, WON’T I MAKE LESS MONEY? Q. WHY SHOULD I PARTICIPATE IN THE HEALTHCARE FSA PROGRAM IF I ALREADY HAVE MEDICAL OR DENTAL INSURANCE? Q. HOW MUCH WILL BE DEDUCTED FROM MY PAYCHECK FOR THE BENEFITS I SELECT? Q. WHEN CAN I MAKE A CHANGE IN MY ELECTION? Q. WHEN DOES PARTICIPATION BEGIN? Q. WHAT IF I’M ALREADY PARTICIPATING IN AN FSA PROGRAM? Q. WHAT IS THE “OPEN ENROLLMENT PERIOD” AND THE “PLAN Q. WHAT IF I DON’T USE ALL OF THE MONEY I ELECT IN AN FSA PROGRAM? Q. WHAT IF I WILL BE TRANSITIONING FROM A TRADITIONAL MEDICAL PLAN TO A HIGH DEDUCTIBLE HEALTH PLAN (HDHP) WITH A HEALTH SAVINGS ACCOUNT (HSA) AND HAVE UNUSED DOLLARS IN MY HEALTHCARE FSA AT THE END OF THE YEAR? Q. ARE THERE ANY NEGATIVES THAT I SHOULD KNOW ABOUT? Q. WHEN WILL MY PARTICIPATION IN AN FSA PROGRAM TERMINATE? Q. WHAT IF I AM CALLED TO ACTIVE DUTY? Q. WHAT IF I AM REHIRED AFTER TERMINATING EMPLOYMENT? Q. WHAT IF I GO ON FMLA LEAVE? Q. HOW CAN I GET ANSWERS TO OTHER QUESTIONS? Q. HOW QUICKLY WILL MY CLAIMS UNDER AN FSA PROGRAM BE PAID? Q. IS DIRECT DEPOSIT AVAILABLE? Q. WHAT HAPPENS IF MY CLAIM FOR REIMBURSEMENT IS DENIED? HEALTHCARE FSA PROGRAM SUMMARY STEPS TO PARTICIPATE IN THE HEALTHCARE FSA PROGRAM IMPORTANT HEALTHCARE FSA PROGRAM INFORMATION Reimbursement Eligibility Rules Non-Qualifying Healthcare Expenses 11 ---PAGE BREAK--- ii FLEXIBLE SPENDING ACCOUNT CLAIMS 12 INTERNET ACCESS 14 GENERAL PLAN INFORMATION 15 ---PAGE BREAK--- 1 TAX SAVINGS EXAMPLE By electing to contribute a portion of your salary to the FSA Program, you essentially use this money to pay for expenses on a TAX-FREE basis that would otherwise be paid out of your take- home pay. This example shows how the FSA Program could save this employee $840 in taxes! Without FSA With FSA Savings with FSA Gross Income (Married – Joint Income) $80,000 $80,000 Standard Deduction $27,700 $27,700 FSA Contributions (Available to Reimburse Healthcare Expenses) $3,050 Federal Taxable Income $52,300 $49,250 Federal Tax * $6,276 $5,910 $366 State Income Tax * $4,550 $4,309 $241 Social Security (FICA) Tax $4,001 $3,768 $233 Paycheck After Taxes $62,963 $62,123 Expenses Not Run Through the FSA $3,050 $0 Employee’s Spendable Income $62,123 $62,963 $840 This employee could increase their spendable income by $840 by using the FSA!! *Estimate based on the 2022 IRS and Oregon tax rates for a hypothetical married employee filing jointly and is only offered as an example. If you have questions about your tax situation, contact a tax professional, as this example does not constitute tax advice. ---PAGE BREAK--- 2 FREQUENTLY ASKED QUESTIONS REGARDING FLEXIBLE SPENDING ACCOUNT PROGRAMS Q. WHAT IS A FLEXIBLE SPENDING ACCOUNT PROGRAM (FSA)? The Flexible Spending Account Program (the “FSA Program”) forms part of the CIS Employee Benefits Trust Plan (the “Plan”). An FSA Program allows you to voluntarily set aside money to pay for medical, dental and other qualified healthcare expenses. Without the FSA Program, you would have to pay for these expenses with after-tax dollars – that is, with money that you have already paid taxes on. The money that you elect to contribute under the FSA Program is automatically deducted from your gross wages before federal, state and Social Security taxes are withheld. The contributions are not considered taxable income, and therefore do not appear on your W-2 Form as taxable income. Since your taxable income is reduced, so are your taxes. Q. WHAT ARE THE FSA PROGRAMS UNDER THE PLAN? The Plan makes available one FSA Program. The Healthcare Flexible Spending Account Program (the “Healthcare FSA Program”) has been established to reimburse you for certain qualified medical, dental and vision care expenses incurred by you or your family members that are not covered by an employer’s medical and dental insurance plans (or any other group health plan). Q. WHO CAN PARTICIPATE IN AN FSA PROGRAM? An employee is eligible to participate in an FSA Program if the employee: • Is regularly scheduled to work the number of hours required by the employer; and • Has satisfied the employer’s waiting period. The following classes of employees and other individuals cannot participate in an FSA Program: • Contract workers and independent contractors; • Temporary employees and casual employees (employees hired short-term to meet specific needs of the employer, as determined in the employer’s sole discretion); and • Individuals paid by a temporary or other employment or staffing agency. Q. IF I MAKE PRE-TAX CONTRIBUTIONS TO AN FSA PROGRAM, WON’T I MAKE LESS MONEY? No. Your spendable income will increase by the amount of your tax savings. ---PAGE BREAK--- 3 Q. WHY SHOULD I PARTICIPATE IN THE HEALTHCARE FSA PROGRAM IF I ALREADY HAVE MEDICAL OR DENTAL INSURANCE? The Healthcare FSA Program can save you taxes on each dollar you spend for qualified healthcare expenses that are not reimbursed by insurance. For example, the Healthcare FSA Program covers expenses for the portion of the cost of office visits, eye exams, glasses, prescription drugs, medications used to treat medical conditions, and hospital care that is not covered by medical insurance (e.g. co- payments, co-insurance, etc.). Q. HOW MUCH WILL BE DEDUCTED FROM MY PAYCHECK FOR THE BENEFITS I SELECT? Your salary reduction amount for a pay period is the amount equal to the total annual contribution for the benefits you elected, divided by the number of remaining pay periods in the plan year following your participation effective date. Q. WHEN CAN I MAKE A CHANGE IN MY ELECTION? In general, once you have enrolled in (or have chosen not to enroll in) an FSA Program for a plan year, the enrollment election must remain in effect for the rest of the plan year. In other words, you generally will not be able to modify or revoke your FSA Program election until the next open enrollment. An exception to this general rule applies upon the event of a “qualified status event change.” Under this exception, you may change your election if you, your spouse, or a dependent experience an event (listed below) which results in a gain or loss of eligibility for coverage under an FSA Program, or a similar plan maintained by your spouse’s or dependent’s employer, and your desired election change corresponds with that gain or loss of coverage. If these events occur, a change may be made to your election. 1. Your legal marital status changes through marriage, divorce, death, legal separation or annulment. 2. The number of your dependents changes by reason of birth, adoption (or placement for adoption), legal guardianship or death. 3. You, your spouse or any of your dependents have a change in employment status that affects eligibility under an employee benefit plan of your employer, or a plan maintained by the employer of your spouse or dependent. If you terminate employment or take a leave of absence, you must wait at least 31 days after termination or leave of absence to qualify. 4. One of your dependents satisfies or ceases to satisfy the requirements for coverage under an employee benefit plan of your employer, or a plan maintained by the employer of your spouse or a dependent, due to attainment of age or any similar circumstances. 5. You changed your election under another employer-sponsored plan, as long as the change made under the other plan was permitted by IRS regulations or was made for a plan year ---PAGE BREAK--- 4 that is different from the plan year of the FSA Program the year beginning January 1 and ending December 31). 6. You are served with a judgment, decree or court order, including a Qualified Medical Child Support Order (“QMCSO”), regarding coverage for a dependent. If the order requires you to pay for medical expenses not paid by insurance for a dependent child, then you may add or increase coverage under the Healthcare FSA Program. If the order requires that another person pay for medical expenses not paid by insurance for the dependent child, then you may drop or reduce coverage under the Healthcare FSA Program. 7. If you, your spouse, or a dependent become covered under Medicare or Medicaid, you may drop or reduce coverage under the Healthcare FSA Program. 8. If you, your spouse, or a dependent lose eligibility for coverage under Medicare or Medicaid, or under another group health plan, you may add or increase coverage under the Healthcare FSA Program. The election change request must be filed within 60 days of the date of the qualifying event and becomes effective on the 1st of the month following the event and approval of the request. If you have questions regarding a change in elections, please call CIS Benefits at 1-[PHONE REDACTED]. Q. WHEN DOES PARTICIPATION BEGIN? If you are an existing employee, you must enroll online during Open Enrollment (unless a “qualified status event change” occurs, as described above). Your participation in the FSA is January 1 through December 31 of the new plan year. If you are a new employee or are newly eligible, you must enroll online through CIS-Connect (the benefits portal) within 60 days of your date of hire or the date you gained eligibility. If you fail to enroll within the required timelines, you will not be able to participate in an FSA Program until the next open enrollment period (unless a “qualified status event change” occurs, as described above). Enrollment during the plan year is effective the 1st of the month following enrollment. Q. WHAT IF I’M ALREADY PARTICIPATING IN AN FSA PROGRAM? Participation in the Healthcare FSA Program terminates at the end of each plan year. You MUST re-enroll each plan year to continue your participation. Q. WHAT IS THE “OPEN ENROLLMENT PERIOD” AND THE “PLAN YEAR”? The open enrollment period is the period prior to the beginning of the plan year during which you have an opportunity to elect to participate in an FSA Program by enrolling online through the benefits portal: www.cisbenefits.org. You will be notified of the timing and duration of the open enrollment period. The plan year is the 12 months beginning January 1 and ending on December 31. ---PAGE BREAK--- 5 Q. WHAT IF I DON’T USE ALL OF THE MONEY I ELECT IN AN FSA PROGRAM? In exchange for the tax advantages associated with the Healthcare FSA Program, the IRS generally requires that any money left over in your account at the end of the plan year be forfeited. Except as provided below, unspent amounts cannot be carried forward to pay for expenses incurred in the following plan year. If you do not use all the money in your Healthcare FSA account for a plan year, the balance is not entirely forfeited. Instead, the unspent balance of the account will be carried over to the following plan year. Pursuant to IRS and CIS rules, the amount to be carried over is limited to the lesser of the remaining balance of your Healthcare FSA account, or (ii) $660 for the 2026 plan year. The $660 maximum will be adjusted from time to time by the IRS to reflect cost-of-living increases. If you do not elect to enroll in the Healthcare FSA program for the following plan year, your unspent Healthcare FSA account will be carried over (up to the $660 limit for the 2026 plan year). However, the carryover must be spent during that year. Any remaining balance as of the end of the following plan year is not eligible for a second carryover, but instead will be forfeited. By reason of the “use-it-or-lose-it” rule, and the restrictions on mid-year election changes discussed above, it is very important that you carefully estimate your eligible expenses before deciding how much to contribute for expenses incurred during the year. ASI can help you estimate your allowable expenses for the plan year. Q. WHAT IF I WILL BE TRANSITIONING FROM A TRADITIONAL MEDICAL PLAN TO A HIGH DEDUCTIBLE HEALTH PLAN (HDHP) WITH A HEALTH SAVINGS ACCOUNT (HSA) AND HAVE UNUSED DOLLARS IN MY HEALTHCARE FSA AT THE END OF THE YEAR? If you have unused dollars in your Healthcare FSA at the end of the year, the unused dollars (up to $660 for the 2026 plan year) may be moved to a “limited purpose” Healthcare FSA upon request. Carrying over the unused dollars to the general Healthcare FSA would make you ineligible for a HSA. By moving to a “limited purpose” plan, you can be HSA eligible and still use the carryover money for qualifying dental, vision, and preventive care services for you and eligible family members. “Preventive care” includes, but is not limited to, periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals, routine prenatal and well-childcare, child and adult immunizations, tobacco cessation programs, obesity weight-loss programs, and screening services. Q. ARE THERE ANY NEGATIVES THAT I SHOULD KNOW ABOUT? Yes, because you are not paying Social Security tax on the portion of your income that you contribute to the Plan, your Social Security benefits may be reduced. However, if you invest your tax savings, in many cases you would have more money available at retirement than the benefit you would have received from the amount not paid into Social Security. ---PAGE BREAK--- 6 Expenses reimbursed by the Healthcare FSA Program may not be deducted on your individual income tax return. Likewise, expenses deducted on your income tax return may not be filed for reimbursement through the Healthcare FSA Program. Q. WHEN WILL MY PARTICIPATION IN AN FSA PROGRAM TERMINATE? You will cease to be a participant in an FSA Program upon the earliest of the following dates: • The expiration of the plan year for which you have elected to participate in the FSA Program (unless you elect to continue participating during the open enrollment period for the next plan year, or are eligible for a Healthcare FSA account carryover for that next plan year); • The date on which you cease to be eligible to participate in the FSA Program because of retirement, termination of employment, layoff, reduction in hours, or any other reason; or • The termination of the FSA Program. If you are an active employee and experience a circumstance that permits a change of election under the terms of the FSA Program and you wish to stop all future contributions to the FSA Program, your future contributions will stop but you will continue to be a participant in the plan. Your annual election will be changed to the amount you contributed to date for the current plan year. You will have the ability to continue to file claims for the remainder of the current plan year. If you have not spent all of the contributed funds by the end of the current plan year, any such remaining funds in the Healthcare FSA Program will carry over to the next plan year (up to the $660 maximum). If you terminate employment during a plan year, you will cease to be eligible to participate in an FSA Program. Employees participating in the Healthcare FSA Program may elect COBRA coverage continuation on an after-tax basis, as described in the Healthcare FSA Program Summary section of this booklet. Q. WHAT IF I AM CALLED TO ACTIVE DUTY? If you are in the military reserves and are called to active duty for a period that will last at least 180 days (or for an indefinite period), then you may request a distribution of the unspent balance of your account under the Healthcare FSA Program. The request must be made to CIS Trust the Plan Administrator. The request must be made in sufficient time to allow the distribution to be made by the end of the plan year that includes the date of the call to active duty. In no event will the distribution be permitted to be made prior to the date of your call to active duty. Q. WHAT IF I AM REHIRED AFTER TERMINATING EMPLOYMENT? If you terminate employment with the employer, but you return to work within 30 days during the same plan year, your participation will be reinstated as it was. You will have the option of reinstating your coverage at the same annual level you had prior to your termination or reinstating ---PAGE BREAK--- 7 your coverage at the same per pay period amount with a reduced annual amount. Should you choose the same annual amount, your per pay period contributions will be adjusted so that your total contributions for the year will equal your annual coverage amount. Should you return to work after 30 days during the same plan year, you may make a new election for the remainder of the plan year. Q. WHAT IF I GO ON FMLA LEAVE? If you go on FMLA leave, you can continue to participate in the Healthcare FSA Program. Please refer to the FMLA paragraph in the Healthcare FSA Program Summary. If your Healthcare FSA Program coverage ceases while you are on FMLA leave for any reason (including for non-payment of premiums), then you may re-enter the Healthcare FSA Program upon return from FMLA on the same basis as you were participating prior to the leave. You will be entitled to elect whether to be reinstated in the Healthcare FSA Program at the same coverage level as in effect before the FMLA leave (with increased contributions for the remaining period of coverage) or at a coverage level that is reduced pro-rata for the period of FMLA leave during which you did not pay premiums. If you elect a coverage level that is reduced pro-rata for the period of FMLA leave, the amount withheld from your compensation on a payroll-by-payroll basis for the purpose of paying under the Healthcare FSA Program will be equal to the amount withheld prior to the period of FMLA leave. Q. HOW CAN I GET ANSWERS TO OTHER QUESTIONS? Check ASI’s website www.asiflex.com. You can email ASI at [EMAIL REDACTED] or call ASI toll free at 1-[PHONE REDACTED]. A representative is available from 5 a.m. to 5 p.m. Pacific Time, Monday through Friday, and from 7 a.m. to 11 a.m. Pacific Time on Saturday. Q. HOW QUICKLY WILL MY CLAIMS UNDER AN FSA PROGRAM BE PAID? ASI will process your claim no later than the first banking day following their receipt of the claim. Valid healthcare claims will be paid on the day processed up to your annual election less prior payments. If there is a problem with your claim, ASI will notify you on the day the claim is processed either by U.S. Mail or by email. Q. IS DIRECT DEPOSIT AVAILABLE? Yes. You may have your claims payments sent directly to your checking, money market or savings account. ASI will send a notice of each payment to you. ASI can send this notice via email, if you prefer. Email and direct deposit provide you with the fastest, safest payment method, as well as the fastest notification method. Q. WHAT HAPPENS IF MY CLAIM FOR REIMBURSEMENT IS DENIED? If your claim is denied, in whole or in part, ASI will notify you in writing within 30 days of the date of receipt of your claim. This time period may be extended for an additional 15 days for matters beyond the control of ASI, including in cases where a claim is incomplete. ASI will provide written notice of any extension, including the reasons for the extension and the date by which a decision by ASI is expected to be made. When a claim is incomplete, the extension notice ---PAGE BREAK--- 8 will also specifically describe the information required. You will have 45 days from receipt of the notice in which to provide the specified information. Decision on your claim will be suspended until the specified information is provided. Notice of a denied claim will include: • The specific reasons for the denial; • The specific plan provisions on which the denial is based; • A description of any additional material or information necessary for you to validate the claim, and an explanation of why such material or information is necessary; and • Appropriate information on the steps to be taken if you wish to appeal the claim denial. If your claim is denied, in whole or part, you (or your authorized representative) may request that the claim denial be reviewed. The request must be made in writing to CIS, the Plan Administrator. Your appeal must be made in writing within 60 days of your receipt of the notice that the claim was denied. If you do not appeal on time, you will lose the right to appeal the denial and the right to file suit in court. Your written appeal should state the reasons that you feel your claim should not have been denied. It should include any additional facts or documentation that you feel supports your claim. You may review (upon request and at no charge) documents and other information relevant to your appeal. Your appeal will be reviewed and decided by CIS in a reasonable time (no later than 60 days) after CIS receives your request for review. If the decision on review affirms the initial denial of your claim, you will be furnished with a notice of adverse benefit determination on review setting forth: • The specific reasons for the decision on review; and • The specific plan provisions on which the decision is based. ---PAGE BREAK--- 9 HEALTHCARE FSA PROGRAM SUMMARY The Healthcare FSA Program is intended to qualify under the IRS rules so that amounts reimbursed to you are eligible for exclusion from your taxable income. You can elect to participate in the Healthcare FSA Program by enrolling online on CIS-Connect. STEPS TO PARTICIPATE IN THE HEALTHCARE FSA PROGRAM 1. Estimate your family’s annual out-of-pocket healthcare expenses. You may include expenses for anyone included on your federal tax return (spouse, children, etc.). Include predictable expenses only. 2. Enroll. If enrolling during Open Enrollment, you’ll enter the amount - divided by the number of paychecks you’ll receive during the plan year - online in the Healthcare FSA section on CIS-Connect. If enrolling mid-year as a New Hire or if newly eligible, enter the amount divided by the number of paychecks you’ll receive for the remainder of the plan year online on CIS-Connect within the required timeline. 3. File claims. After you have received healthcare services and know the amount of your responsibility for the bill (for example, by an Explanation of Benefits (“EOB”) statement), you may submit a claim for reimbursement of those expenses to ASI. 4. Receive reimbursements. ASI will review your claim, and if approved will reimburse you within one business day of receipt of your claim. IMPORTANT HEALTHCARE FSA PROGRAM INFORMATION Annual Maximum: $3,300* Annual Minimum: There is no minimum. *The annual maximum will be adjusted from time to time to reflect cost-of-living increases. Reimbursement Eligibility Rules Qualifying healthcare expenses incurred by you or your dependents are eligible for reimbursement from the Healthcare FSA Program if they meet all of the following requirements: • The expenses were incurred during the plan year you were enrolled in the Healthcare FSA Program; • The expenses were paid for qualified healthcare expenses, as identified by IRS rules; • The expenses have not been and will not be paid by your employer’s medical or dental program, or by another employer’s group health benefit plan or any other insurance policy or program; and • The expenses have not and will not be deducted on your tax return. ---PAGE BREAK--- 10 Qualifying Healthcare Expenses include only those expenses that are defined under the IRS rules as medical or other healthcare expenses (such as dental and vision care expenses) and are not reimbursed by any other insurance or another plan. Qualifying healthcare expenses include amounts incurred for the diagnosis, cure, mitigation, treatment, or prevention of disease, and for treatments affecting any part or function of the body. The expenses must be primarily to alleviate or prevent a physical or mental defect or illness. All insurance premiums, long-term care expenses, and cosmetic expenses are excluded. Refer to IRS Publication 502 for further details on qualifying healthcare expenses. You may link to this publication from ASI’s website. The purpose of Publication 502 is to assist people with their income tax filing. It does not specifically address Healthcare FSA Programs. However, most of the items listed as deductible in Publication 502 can be claimed under the Healthcare FSA Program. Expenses reimbursed by the Healthcare FSA Program may not be deducted on your income tax return. Similarly, expenses deducted on your income tax return may not be filed for reimbursement through the Healthcare FSA Program. You can only claim reimbursement for a plan year for expenses incurred or for services performed during the plan year (rather than for expenses merely paid in the plan year, which is the rule for income tax deduction purposes as stated in Publication 502). Please contact ASI at [EMAIL REDACTED], or by phone at (800) 659-3035, if you have any questions regarding particular expenses. Below is a partial listing of qualified healthcare expenses. Remember, expenses can only be claimed based on the date incurred, regardless of the date you are billed or pay for the expense. • Deductibles • Co-pays • Doctor’s fees • Dental expenses • Vision care expenses • Prescription glasses • Contact lenses and solutions • Corrective eye surgery • Prescribed drugs and medicines (legal) used to treat a medical condition • Insulin • Orthodontia (braces) • Routine physicals • Medical equipment • Hearing aids (including batteries) • Transportation expenses related to illness • Chiropractor’s fees • Over-the-counter drugs • Menstrual care products ---PAGE BREAK--- 11 Non-Qualifying Healthcare Expenses This is a partial list of healthcare-related items that are not permitted to be reimbursed under the Healthcare FSA Program. There may be other items that do not qualify that are not listed here. • Cosmetic procedures (e.g. face-lifts, skin peeling, teeth whitening, veneers, hair replacement or removal of spider veins) • Sunglasses (non-prescription) • Toiletries (other than menstrual-care products) • Medicines, drugs, herbs, or vitamins for general health and not used to treat a specific medical condition • Health club dues (not prescribed for a particular condition) • Any type of insurance premium • Warranties • Long-term care expenses • Prescription drugs imported from another country Coverage Continuation (“COBRA”). To the extent required by COBRA, a participant who terminates employment may elect to continue the coverage elected under the Healthcare FSA Program even though participation in the program would otherwise expire. Continuation coverage will not extend beyond the end of the current plan year and may terminate earlier if a premium is not paid within 30 days of its due date. Payments for expenses incurred during any period of continuation will not be made until the contributions for that period are received by the Plan Administrator. An administrative charge of 2% is assessed for each premium paid for continuation coverage. Participants on leave under the Family Medical Leave Act (“FMLA”) are entitled to maintain coverage for the Healthcare FSA Program. You must pay for coverage during your leave by making payments directly to your employer each month. You may also have such amounts withheld from any ongoing compensation being paid to you (such as accrued sick leave or vacation). ---PAGE BREAK--- 12 FLEXIBLE SPENDING ACCOUNT CLAIMS ASI, (800) 659-3035 [EMAIL REDACTED] PO Box 6044 Columbia, MO 65205-6044 Claims processed daily – within 1 day World Wide Web www.asiflex.com for claim forms and personal account information Allowable expenses must be incurred during the portion of the plan year that you are a participant. Claims must be filed by March 31 following the end of the plan year. After March 31, your account will be closed and any balance remaining will be forfeited (or a limited amount will be carried over in the case of unspent Healthcare FSA funds) in accordance with federal regulations. You must submit a completed claim form along with copies of invoices or statements from the provider or other independent third party to serve as proof that you have incurred an allowable expense in order to receive payment. Statements are required to include: • The provider’s name; • The date(s) of service; • A description of the service(s); and • The expense amount. For healthcare expenses, a copy of an Explanation of Benefits (“EOB”) statement from your insurance company will be adequate proof. Copies of personal checks and paid receipts, without the above information, are not acceptable. Documentation or copies will not be returned. For over-the-counter items, the receipt or documentation from the store must include the name of the drug printed on the receipt. You must indicate the existing or imminent medical condition (items such as vitamins and nutritional supplements may require a physician’s statement) for which the item will be used on the receipt, on the claim form, or on a separate enclosed statement each time these items are claimed. Purchases for general good health will not be accepted. You can submit a claim online or download claim forms on the ASI website at www.asiflex.com. You may request paper copies by phone at (800) 659-3035. Orthodontic expenses that are paid in advance of the treatment can be reimbursed. To request a reimbursement of the advance payment, you must include a copy of the treatment contract or invoice along with proof of payment or a receipt of payment. Payment from the Healthcare FSA Program for expenses incurred during the plan year will be made up to the approved amount of your claim or your remaining annual election, whichever is less. Your Healthcare FSA Program funds are available on the first day of the plan year. However, your contributions will continue for the remainder of the plan year. ---PAGE BREAK--- 13 Direct deposit into the bank account of your choice is available for your claim payments. By using direct deposit, you will not need to wait for a check to arrive to deposit yourself. A notice that a payment was made will be sent to you. This direct deposit notice is available by U.S. Mail or by email. If you prefer, a check can be mailed to you instead of directly deposited. Email notice. If you choose direct deposit, ASI can send the notices of claim payments directly to your email account. ---PAGE BREAK--- 14 INTERNET ACCESS You can access information regarding your account under the Healthcare FSA Program on the Internet 24 hours a day, 7 days a week by logging into your account, as described below. Information is continually updated. You can find out if a claim has been processed, a payment has been made, or your current balance using Internet access. Information for the current plan year is viewable (the previous plan year until March 31 following the end of that plan year is available as well). You can also file claims online or by using the mobile app. And, you can purchase FSA eligible items through the FSA Store from your account. To access your account: • Go to http://www.asiflex.com • Click on “Online Access/Account Detail” and then choose “Participant/Account Detail” o For new users: click on the “Create an account” button and follow the directions to set up your account. Be sure to remember your Username, Password and Security Image as you will need these the next time you log in. o For previous users: type in your Username and Password and click on the “Sign in” button. Then click on your Security Image. • Under View Available Accounts, choose the account you wish to view. • Select the plan year you wish to view. • All transactions for the plan year are shown. Information is continually updated. • Be sure to click “Log out” when you finish. This closes out your account for security purposes. ---PAGE BREAK--- 15 GENERAL PLAN INFORMATION Name of the Plan CIS Employee Benefits Trust Plan, which includes the component Healthcare Flexible Spending Account Program Plan Sponsor CIS Trust (CIS) 15875 Boones Ferry Road Lake Oswego, OR 97035-3401 (503) 763-3800 Plan Administrator CIS Trust (CIS) 15875 Boones Ferry Road Lake Oswego, OR 97035-3401 (503) 763-3800 Claims Administrator ASI PO Box 6044 Columbia, MO 65205-6044 (800) 659-3035 [EMAIL REDACTED] The plan year is the twelve-month period beginning January 1 and ending December 31. Healthcare FSA Program Administration The FSA Program is not underwritten by an insurance company, and benefits are not guaranteed by a contract of insurance. The maximum contributions that may be made under an FSA Program for a participant is the total of the maximums that may be elected or otherwise designated as contributions for benefits as described in the Healthcare FSA Program Summary section. ASI has been hired to perform certain administrative functions for the FSA Program. ASI processes all claims for the Healthcare FSA Program. If you have any questions concerning claims, please contact ASI by mail at: P.O. Box 6044, Columbia, MO 65205; by phone at 800- 659-3035; by email at [EMAIL REDACTED]; or on-line at www.asiflex.com. Other Information In preparing this summary of the Healthcare FSA Program (the “Program”), we have done our best to explain their various features in straightforward, non-technical language. Of course, this information is based on a legal plan document that governs the FSA Program. It is not our intention in summarizing the material features of the Program to change the meaning expressed by the formal plan document. If we have inadvertently indicated anything that disagrees or is inconsistent with the legal plan document, the formal plan document is the one we must follow in the administration of the Program and in determining your rights under the Program. A copy of that plan document is available for your review by contacting CIS. You may be charged reasonable photocopying charges if a hard copy is requested. ---PAGE BREAK--- 16 ASI and CIS will perform their duties as the Claims Administrator and the Plan Administrator, respectively, and in their sole discretion will determine an appropriate course of action in light of the reason and purpose for which the Program is established and maintained. In particular, ASI and the Plan Administrator will have full, discretionary authority to interpret all plan documents, and make all interpretive and factual determinations as to whether any individual is entitled to receive any benefit under the terms of the Program. Any interpretation of the terms of any plan document, and any determination of fact adopted by ASI or the Plan Administrator, will be final and legally binding on all parties. Any interpretation will be subject to review only if it is arbitrary, capricious, or otherwise an abuse of discretion. Any review of a final decision or action of ASI or the Plan Administrator will be based only on such evidence presented to or considered by ASI or the Plan Administrator at the time of the decision that is the subject of review. Accepting any benefits or making any claim for benefits under the Program constitutes agreement with and consent to any decisions that ASI or the Plan Administrator make in their sole discretion, and further constitutes agreement to the limited standard and scope of review described by this section. To the extent permitted by law, ASI, the Plan Administrator, and any other party assuming a fiduciary or decision making role will not incur any liability for any act or for failure to act except for their own willful misconduct or willful breach of the Program. The standard will be one of ordinary care. Benefits Offered: • Healthcare Flexible Spending Account (FSA) Program