9a. Appendix A FedFlex Plan Document Dec 2024.pdf

The Federal Flexible Benefits

Plan “FedFlex”

Revised as of

December 2024

Document Revised as of: October 2024

Recent Document Revision History

• December2024: Amended definition of “Employee” for purposes of Health Care Flexible Spending Arrangements (HCFSAs) and Dependent Care Flexible Spending Arrangements (DCFSAs) to include certain uniformed service members in the Coast Guard, Public Health Service Commissioned Corps, National Oceanic and Atmospheric Administration Commissioned Corps, and Active Guard Reserve member under Title 32 orders. Amended definition of “Employee” for purposes of HCFSAs and DCFSAs to exclude employees of the United States Postal Service. Amended to add OPM authority to conduct a Special Enrollment Period in 2025 for certain uniformed service members to enroll in Flexible Spending Arrangements and to clarify requirements related to withdrawal from the Plan.

• October 2023: Amended to include uniformed service members of the regular component of the Army, Marine Corps, Navy, Air Force or Space Force, and Active Guard Reserve members under Title 10 orders in the definition of “Employee” for purposes of Dependent Care Flexible Spending Arrangements (DCFSAs); added provisions related to required administrative fees and withdrawal of Plan adoption.

• December 2021: Amended to permit flexibilities allowed due to the COVID-19 pandemic and to increase carryover amount for Health Care Flexible Spending Arrangements (HCFSAs) and Limited Expense HCFSAs (LEX HCFSAs) and to index future increases per IRS guidance.

• October 2017: Amended to include employees of the State Justice Institute in the definition of “Employee” for purposes of Medical Plan, HCFSAs and DCFSAs.

• September 2016: Amended to include employees of the United State Postal Service in the definition of “Employee” for Plan purposes and to align election limitations of FSAs so that new elections are not allowed after September 30 of the Plan Year.

• September 2014: Amended to permit carryover of unused allotments in HCFSAs and LEX HCFSAs.

• November 2013: Amended to include a health benefits plan offered by an appropriate Small Business Health Options Program (SHOP) in the definition of “Medical Plan.”

• December 2010: Amended to add references to age 26 dependents to the definitions of Temporary Continuation of Coverage, Eligible Health Care

Expenses under HCFSAs and LEX HCFSAs, and Qualifying Life Events.

• December 2008: Amended to allow Qualified Reservists ordered to active duty to request a distribution from their HCFSA or LEX HCFSA to avoid forfeiture.

• December 2006: Amended to allow a one-time qualified Health Savings Account (HSA) distribution pursuant to 26 U.S.C. Section 106(e).

• January 2006: Amended to permit pre-tax premiums for Dental and Vision Plans; to offer LEX HCFSAs; to allow eligible employees to make pre-tax allotments to HSAs; and to permit a grace period for HCFSAs and DCFSAs.

• January 2004: Amended to offer HCFSAs and DCFSAs.

Table of Contents

Contents Document Revised as of: October 2024

Table of Contents

Article 1. Introduction

1.1 Purpose of Plan

1.2 Cafeteria Plan Status

1.3 Flexible Spending Arrangement Plan Status

Article 2. Definitions

2.1 “Adopting Employer”

2.2 “Benefit Period”

2.3 “Code”

2.4 “Covered Employee”

2.5 Reserved

2.6 “Dental Supplemental Benefit Plan” or “Dental Plan” means a dental benefits plan participating in the Federal Employees Dental and Vision Insurance Program “FEDVIP” established under 5 U.S.C. Chapter 89A

2.7 “Dependent”

2.8 “Dependent Care Flexible Spending Arrangement” or “DCFSA” or “Day Care FSA”

2.9 “Effective Date”

2.10 “Eligible Dependent Care Expenses”

2.11 “Eligible Health Care Expenses”

2.12 “Employee”

2.13 “Employer”

2.14 “FEHB Program”

2.15 “Flexible Spending Arrangements” or “FSA”

2.16 “Form”

2.17 “FSA Initial Effective Date”

2.18 “FSA Initial Plan Year”

2.19 “Grace Period”

2.20 “Health Care Flexible Spending Arrangement” or “HCFSA”

2.21 “Health Savings Account” or “HSA”

2.22 “High Deductible Health Plan” or “HDHP”

2.23 “Initial Effective Date”

2.24 “Initial Effective Date for Dental Plan and Vision Plan”

2.25 “Initial Plan Year”

2.26 “Initial Plan Year for Dental Plan and Vision Plan”

2.27 “Limited Purpose Health Care Flexible Spending Arrangement”

2.28 “Limited Expense HCFSA” or “LEX HCFSA”

2.29 “Limited Enrollment HCFSA” or “LEN HCFSA” [RESERVED]

2.31 “Medical Plan”

2.32 “Open Season”

2.33 “OPM”

2.34 “Plan”

2.35 “Plan Agent”

2.36 “Plan Administrator”

2.37 “Plan Year”

2.38 “Qualifying Dependent”

2.39 “Qualified Reservist”

2.40 “Qualified Reservist Distribution” or “QRD”

2.41 “Reemployed Annuitant”

2.42 “Summary of Benefits”

2.43 “Temporary Continuation of Coverage” or “TCC”

2.44 “U.S.C.”

2.45 “Vision Supplemental Benefit Plan” or “Vision Plan”

Article 3. Coverage

3.1 Commencement of Coverage under the Plan

3.2 Termination of Coverage under the Plan

3.3 Reinstatement of Former Covered Employee

Article 4. Optional Benefits Coverages

4.1 Coverage Options

4.1.1 Account Option

4.2 Options for Medical Plan, Dental Plan and Vision Plan

4.3 Health Care Flexible Spending Arrangement Options

4.3.1 Health Care Flexible Spending Arrangement

4.3.2 Limited Purpose Health Care Flexible Spending Arrangement

4.3.2.1 Limited Expense Health Care Flexible Spending Arrangement or LEX HCFSA

4.3.2.2 Limited Enrollment Health Care Flexible Spending Arrangement. [Reserved]

4.3.2.3 Limited Expense Limited Enrollment Health Care Flexible Spending Arrangement. [Reserved]

4.4 Dependent Care Flexible Spending Arrangement

4.5 Health Savings Account “HSA.”

4.6 Allotments

4.7 Cash Election Procedure for Employees Covered under a Medical Plan

4.8 Failure to Obtain and Return Cash Election Form for Employees Covered under a Medical Plan.

4.9 Election Procedures under a Dental Plan and/or a Vision Plan

4.10 Election Procedures under a Flexible Spending Arrangement

4.11 Failure to Return Flexible Spending Arrangement Election Form

4.12 Reserved

4.13 Reserved

4.14 Reserved

4.15 Reserved

4.16 Irrevocability of Election by Covered Employee during the Plan Year

4.17 Reserved

4.18 Adjustment of Allotments

4.19 Automatic Termination of Election

4.20 Failure to Pay Premiums

4.21 Leave Without Pay

4.22 Qualified Reservist Distributions Under the HCFSA

Article 5. Payment of Claims for Flexible Spending Arrangements

5.1 Claims Reimbursement for Eligible Health Care Expenses

5.2 Claims Reimbursement for Eligible Dependent Care Expenses

5.3 Payment of Claims

5.4 Reserved

5.5 Expenses

5.6 Minimum Reimbursement Amount

5.7 Repayment of Unsubstantiated Reimbursements

5.8 Claims Appeal Process

5.9 Coordination of Benefits under HCFSA

5.10 Post-Mortem Payments

5.11 Inability to Locate Payee

5.12 Non-Alienation of Benefits

5.13 Electronic Fund Transfers

Article 6. Administration of Plan

6.1 Plan Administration

6.2 Eligibility Decisions

6.3 Accounting

6.4 Audit and Review of Plan Agent

6.5 Examination of Records

6.6 Reliance on Tables, etc

6.7 Nondiscriminatory Exercise of Authority

6.8 Reserved

Article 7. Amendment or Termination of Plan

Article 8. Miscellaneous Provisions

8.1 Information to be Furnished

8.2 Limitation of Rights

8.3 Governing Law

8.4 Adoption Agreements

8.4.1 Required Fees

8.4.2 Withdrawal From the Plan

8.5 Transition Relief

8.6 Severability

8.7 Flexibilities due to COVID-19:

8.8 Special Enrollment Period for Certain Covered Employees

The Federal Flexible Benefits Plan

Article 1. Introduction.

1.1 Purpose of Plan. The purpose of this Plan is to provide Employees a choice between cash and pre-tax coverage under a Medical Plan, Vision Plan, Dental Plan, Health Care Flexible Spending Arrangement (HCFSA) and/or Dependent Care Flexible Spending Arrangement (DCFSA).

1.2 Cafeteria Plan Status. This Plan is intended to qualify as a “cafeteria plan” under Section 125 of the Internal Revenue Code of 1986, as amended, and applicable regulations, and is to be interpreted in a manner consistent with the requirements of Section 125.

1.3 Flexible Spending Arrangement Plan Status. The HCFSAs are offered pursuant to a self-insured medical expense reimbursement plan under Code Section 105. The DCFSAs are offered under Code Section 129. FSAs are intended to allow Employees to pay medical and dependent care expenses using pre-tax dollars and are intended not to discriminate as to eligibility or benefits in favor of the prohibited group under Code Sections 105, 125, and 129.

Article 2. Definitions.

Whenever used, these terms have the following meanings unless a different meaning is clearly required by the context:

2.1 “Adopting Employer” means the Executive Branch of the Federal Government.

Adopting Employer also means an Employer that signs an adoption agreement, accepted by OPM, to participate in this Plan with respect to a coverage option described at Section 4.1. An Employer remains an Adopting Employer until the Plan terminates, the Adopting Employer withdraws from the Plan, or OPM terminates the Adopting Employer’s participation in the Plan or coverage option.

2.2 “Benefit Period” means the period of time during which a Covered Employee may incur Eligible Health Care Expenses or Eligible Dependent Care Expenses and may be paid or reimbursed for such expenses. For the DCFSA, this period is the Plan Year and the Grace Period. For an HCFSA, this period is the Plan Year.

2.3 “Code” means the Internal Revenue Code of 1986, as amended from time to time.

2.4 “Covered Employee” means an individual who is an Employee under Section 2.12, is employed by an Adopting Employer, and satisfies coverage requirements under Article 3.

2.5 Reserved

2.6 “Dental Supplemental Benefit Plan” or “Dental Plan” means a dental benefits plan participating in the Federal Employees Dental and Vision Insurance Program “FEDVIP” established under 5 U.S.C. Chapter 89A.

2.7 “Dependent” for purposes of HCFSA and DCFSA, and no other purpose, means any individual who is a tax dependent of the Covered Employee as defined in Code Section 152(a) and with respect to whom the Covered Employee is entitled to an exemption under Code Section 151(c). For the purpose of an HCFSA, an individual’s status as a dependent is determined without regard to Code Section 152(b)(1), (b)(2), and (d)(1)(B). A child described in Code Section 152(e) shall be treated as a dependent of both parents (except that for purposes of a DCFSA, if the parents are divorced or separated, the individual is the dependent of the custodial parent).

2.8 “Dependent Care Flexible Spending Arrangement” or “DCFSA” or “Day Care FSA” means an account established by the Employer for designated allotments made by the Employee for reimbursement of Eligible Dependent Care Expenses.

2.9 “Effective Date” for an Employer means the date that an Employer becomes an Adopting Employer.

2.10 “Eligible Dependent Care Expenses” is defined in Section 4.4.c.

2.11 “Eligible Health Care Expenses” is defined in Section 4.3.1.c. A Covered Employee who holds an HSA or whose spouse holds an HSA may only incur eligible health care expenses under the LEX HCFSA. These expenses are described in Section 4.3.2.1 as LEX HCFSA Eligible Health Care Expenses.

2.12 “Employee” means:

a. For purposes of the Medical Plan, and no other purpose;

1. an employee of the United States Postal Service, an employee of the State Justice Institute, or an employee as defined in 5 U.S.C. Section 8901(1) except that Employee does not include: employees of the Judicial Branch; employees of the District of Columbia government; or employees not eligible to participate in the FEHB Program in accordance with applicable statutes and regulations; or

2. a Reemployed Annuitant.

b. For purposes of the Dental Plan and the Vision Plan and for no other purpose;

1. an employee of the United States Postal Service, an employee of the District of Columbia Courts, or an employee as defined in 5 U.S.C. Section 8901(1) except that Employee does not include employees not eligible to participate in the FEHB Program in accordance with applicable statutes or regulations; or

2. a Reemployed Annuitant.

c. For purposes of the Health Care Flexible Spending Arrangement and no other purpose;

1. an employee of the State Justice Institute or an employee as defined in 5 U.S.C.

Section 8901(1); except that Employee does not include: employees of the Judicial Branch; employees of the District of Columbia government; or employees not eligible to participate in the FEHB Program in accordance with applicable statutes and regulations; or

2. a Reemployed Annuitant; or

3. when in pay status in accordance with 37 U.S.C. Section 204, an employee who is a uniformed service member of

(A) the regular component of the Army, Marine Corps, Navy, Air Force, Space Force, Coast Guard, or Public Health Service Commissioned Corps; or

(B) the National Oceanic and Atmospheric Administration Commissioned Corps when performing active duty pursuant to 33 U.S.C. Section 3002(b)(1); or

(C) the Coast Guard Reserve component described in 14 U.S.C. Section 3701 when performing active duty for a period that exceeds 180 days, in accordance with 10 U.S.C.

Sections 12311 and 12301(d); or

(D) the Reserve component of the Army, Marine Corps, Navy, or Air Force performing active Guard and Reserve duty, as defined at 10 U.S.C. Section 101(d)(6), pursuant to 10 U.S.C. Section 12301(d) or 32 U.S.C. Section 502(f)(1)(B).

d. For purposes of the Dependent Care Flexible Spending Arrangement and no other purpose;

1. an employee of the State Justice Institute or an employee as defined in 5 U.S.C.

Section 8901(1); except that Employee does not include: employees of the Judicial Branch; employees of the District of Columbia government; or intermittent employees with no fixed work schedule whose tour of duty is expected to be 180 days or less; or

2. a Reemployed Annuitant; or

3. when in pay status in accordance with 37 U.S.C. Section 204, an employee who is a uniformed service member of

(A) the regular component of the Army, Marine Corps, Navy, Air Force, Space Force, Coast Guard, or Public Health Service Commissioned Corps; or

(B) the National Oceanic and Atmospheric Administration Commissioned Corps when performing active duty pursuant to 33 U.S.C. Section 3002(b)(1); or

(C) the Coast Guard Reserve component described in 14 U.S.C. Section 3701 when performing active duty for a period that exceeds 180 days, in accordance with 10 U.S.C.

Sections 12311 and 12301(d); or

(D) the Reserve component of the Army, Marine Corps, Navy, or Air Force performing active Guard and Reserve duty, as defined at 10 U.S.C. Section 101(d)(6), pursuant to 10 U.S.C. Section 12301(d) or 32 U.S.C. Section 502(f)(1)(B).

2.13 “Employer” means an employer of an Employee. In the case of an Employee whose payroll office is not an Executive Branch payroll office, the Employer is the entity that issues pay on behalf of the Employee.

2.14 “FEHB Program” means Federal Employees Health Benefits Program described in 5 U.S.C. Section 8901, et seq.

2.15 “Flexible Spending Arrangements” or “FSA” means Health Care Flexible Spending Arrangement and Dependent Care Flexible Spending Arrangement.

2.16 “Form” means a paper form, electronic enrollment or other written notice approved by OPM.

2.17 “FSA Initial Effective Date” means July 1, 2003.

2.18 “FSA Initial Plan Year” for an Employer means the period beginning on the FSA Initial Effective Date and ending on December 31 of that same year.

2.19 “Grace Period” means the two-month and 15-day period immediately following the end of a Plan Year during which a Covered Employee may incur Eligible Dependent Care Expenses and may be paid or reimbursed for such expenses.

2.20 “Health Care Flexible Spending Arrangement” or “HCFSA” means an account established by the Employer for designated allotments made by the Employee for reimbursement of Eligible Health Care Expenses. A Covered Employee who holds an HSA or whose spouse holds an HSA may only enroll in a HCFSA for limited expenses, known as a LEX HCFSA.

2.21 “Health Savings Account” or “HSA” means an account as defined in Code Section 223.

2.22 “High Deductible Health Plan” or “HDHP” means a health benefits plan as defined in Code Section 223.

2.23 “Initial Effective Date” for the Executive Branch of the Federal Government means October 1, 2000.

2.24 “Initial Effective Date for Dental Plan and Vision Plan” for the Executive Branch of the Federal Government means December 31, 2006.

2.25 “Initial Plan Year” for an Employer means the period beginning on the Effective Date and ending on December 31 of that same year.

2.26 “Initial Plan Year for Dental Plan and Vision Plan” for an Employer means the period beginning on the Initial Effective Date for Dental Plan and Vision Plan and ending on December 31 of the subsequent Plan Year.

2.27 “Limited Purpose Health Care Flexible Spending Arrangement” means an account as defined in Section 4.3.2.

2.28 “Limited Expense HCFSA” or “LEX HCFSA” means an account as defined in Section 4.3.2.1

2.29 “Limited Enrollment HCFSA” or “LEN HCFSA” [RESERVED].

2.30 “Limited Expense Limited Enrollment HCFSA” or “LEXLEN HCFSA” [RESERVED].

2.31 “Medical Plan” means an OPM-contracted FEHB health benefits plan or a health benefits plan offered by an appropriate SHOP as determined by the Director pursuant to section 1312(d)(3)(D) of the Affordable Care Act [42 USC 18032(d)(3)(D)].

2.32 “Open Season” refers to the annual period as set forth in 5 CFR § 890.301(f)(1) and (2).

2.33 “OPM” means the United States Office of Personnel Management.

2.34 “Plan” means The Federal Flexible Benefits Plan as set forth, together with any and all amendments, supplements and regulations published under Title 5 of the Code of Federal Regulations. If there is a conflict between The Federal Flexible Benefits Plan and the regulations, the regulations will govern. The Plan may also be known as “FedFlex.”

2.35 “Plan Agent” means a third-party administrator under contract to OPM to provide designated administrative services with regard to the Plan.

2.36 “Plan Administrator” means OPM.

2.37 “Plan Year” means the 12-month period ending on each December 31 after the Initial Plan Year.

2.38 “Qualifying Dependent” for purposes of DCFSA, and no other purpose, means:

a. a Dependent of the Covered Employee who is under the age of thirteen (13); or

b. a Dependent or spouse of the Covered Employee who is mentally or physically incapable of caring for himself or herself.

In the case of divorced parents, the child is treated as a qualifying dependent of the custodial parent as provided under Code Section 21(e)(5).

2.39 “Qualified Reservist” means a Covered Employee (but not the spouse or Dependent of a Covered Employee) who is a member of: the Army National Guard;

the Air National Guard; the Army Reserve; the Navy Reserve; the Marine Corps Reserve; the Air Force Reserve; the Coast Guard Reserve; or the Reserve Corps of the Public Health Service.

2.40 “Qualified Reservist Distribution” or “QRD” means the taxable distribution of the balance of a Qualified Reservist’s HCFSA as set forth in Section 4.22.

2.41 “Reemployed Annuitant” means an individual who is retired from the Federal Government, is reemployed as an employee as defined in 5 U.S.C. Section 8901(1), and who continues to receive an annuity.

2.42 “Summary of Benefits” means a written document available during each FEHB Open Season that describes the flexible spending arrangement benefits under the Plan.

2.43 “Temporary Continuation of Coverage” or “TCC” means coverage that may be available to a Covered Employee who leaves Federal service, or to a dependent who loses coverage because they no longer qualify as an eligible family member, or to a child who turns age 26 and loses coverage under the Medical Plan.

2.44 “U.S.C.” means the United States Code, as amended from time to time.

2.45 “Vision Supplemental Benefit Plan” or “Vision Plan” means a vision benefits plan participating in the Federal Employees Dental and Vision Insurance Program (FEDVIP) established under 5 U.S.C. Chapter 89B.

Article 3. Coverage.

3.1 Commencement of Coverage under the Plan.

a. An Employee will become a Covered Employee on the latest of:

1. The Effective Date for their Adopting Employer; or

2. The first day they become an Employee.

b. If an Employee is eligible to participate in a cafeteria benefit plan offered by another Executive Branch Employer, then that Employee is not covered under this Plan with respect to the same or similar type of benefit offered by the other Executive Branch Employer (with the exception of dental and/or vision benefits). In addition, no Employee may be covered under more than one premium conversion plan for premiums paid to: (a) the Medical Plan; or (b) the Dental Plan; or (c) the Vision Plan, respectively.

3.2 Termination of Coverage under the Plan. A Covered Employee will cease to be a Covered Employee as of the earliest date on which any of the following occurs:

a. the Plan terminates;

b. termination of employment;

c. the date the Covered Employee’s election or deemed election to receive benefits under the Plan terminates; or

d. the Covered Employee’s ’Employer ceases to be an Adopting Employer.

3.3 Reinstatement of Former Covered Employee. A former Covered Employee will become a Covered Employee again if and when the employee meets the coverage requirements of Section 3.1. A reinstated Covered Employee’s election will be subject to the provisions of Section 4.16.

Article 4. Optional Benefits Coverages.

4.1 Coverage Options. Each Covered Employee may choose under this Plan to receive their pay for any Plan Year in cash or to have a portion of it applied on a pre-tax basis as Employer provided coverage toward (a) the Medical Plan; (b) the Dental Plan; (c) the Vision Plan; (d) an HCFSA; and/or (e) a DCFSA.

4.1.1 Account Option. Each Covered Employee may choose under this Plan to receive their pay in cash or to have a portion of it applied on a pre-tax basis as an Employer provided contribution toward an HSA pursuant to Section 4.5.

4.2 Options for Medical Plan, Dental Plan and Vision Plan.

a. Coverage and benefits to be provided by the Medical Plan. Medical Plan coverage and benefits will be provided not by this Plan but by the Medical Plan. The types and amounts of benefits available under the Medical Plan, the requirements for participating in the Medical Plan and the other terms and conditions of coverage and benefits under the Medical Plan are as set forth in 5 U.S.C. Section 8901, et seq.

and 42 U.S.C. Section 18032, applicable regulations, and applicable official statements of benefits, all of which are incorporated by reference into this Plan.

b. Coverage and benefits to be provided by the Dental Plan. Dental Plan coverage and benefits will be provided not by this Plan but by the Dental Plan. The types and amounts of benefits available under the Dental Plan, the requirements for participating in the Dental Plan and the other terms and conditions of coverage and benefits under the Dental Plan are as set forth in 5 U.S.C. Chapter 89A, and applicable regulations as well as the Dental Plan contracts and benefit brochures, all of which are incorporated by reference into this Plan.

c. Coverage and benefits to be provided by the Vision Plan. Vision Plan coverage and benefits will be provided not by this Plan but by the Vision Plan. The types and amounts of benefits available under the Vision Plan, the requirements for participating in the Vision Plan and the other terms and conditions of coverage and benefits under the Vision Plan are as set forth in 5 U.S.C. Chapter 89B, and applicable regulations as well as the Vision Plan contracts and benefit brochures, all of which are incorporated by reference into this Plan.

d. Cash. A Covered Employee may elect to receive cash in lieu of the optional pre-tax premiums for Medical Plan, Dental Plan, and/or Vision Plan coverage described in Section 4.2.a, 4.2.b, and 4.2.c, respectively, in accordance with the election procedures described in Sections 4.7, 4.8, and 4.9. For purposes of the Medical Plan only, a Covered Employee may use cash to participate in a Medical Plan on an after-tax basis. The Employer will continue to pay its share of the cost of premiums under the Medical Plan.

e. Pre-tax Medical Plan coverage. If a Covered Employee does not elect the cash option under this section, the Covered Employee’s pay will be reduced through an allotment as described in Section 4.6, and an amount equal to the reduction will be contributed by the Employer to a Medical Plan designated by the Covered Employee to cover the Covered Employee’s share of the cost of the premium.

f. Pre-tax Dental Plan coverage. If a Covered Employee elects to enroll in the Dental Plan, the Covered Employee’s pay will be reduced through an allotment as described in Section 4.6, and an amount equal to the reduction will be contributed by the Employer to a Dental Plan designated by the Covered Employee to cover the Covered Employee’s Dental Plan premium.

g. Pre-tax Vision Plan coverage. If a Covered Employee elects to enroll in the Vision Plan, the Covered Employee’s pay will be reduced through an allotment as described in Section 4.6, and an amount equal to the reduction will be contributed by the Employer to a Vision Plan designated by the Covered Employee to cover the Covered Employee’s Vision Plan premium.

4.3 Health Care Flexible Spending Arrangement Options.

a. FedFlex offers Covered Employees a traditional general purpose Health Care Flexible Spending Arrangement (HCFSA) as described in Section 4.3.1, or a Limited Purpose Health Care Flexible Spending Arrangement (LEX HCFSA), as described in Sections

4.3.2.

4.3.1 Health Care Flexible Spending Arrangement.

a. Cash. A Covered Employee will receive cash in lieu of the optional pre-tax coverage described below, in accordance with the procedures described in Sections 4.10 and 4.11.

b. Health Care Flexible Spending Arrangement allotment. A Covered Employee may make an allotment as described in Section 4.6 and an amount equal to the allotment will be contributed by the Employer to an HCFSA to pay for Eligible Health Care Expenses incurred during the HCFSA Benefit Period. A Covered Employee who makes an allotment to an HCFSA and the spouse of the Covered Employee are not eligible to contribute to an HSA.

c. Eligible Health Care Expenses. Eligible medical, dental, and vision expenses are expenses incurred during the Benefit Period and while the Employee is a Covered Employee, by the Covered Employee, or the Covered Employee’s spouse, Dependent or child defined at 26 U.S.C. § 152(f)(1) who has not attained the age of 27 as of the end of the Covered Employee’s taxable year, that:

1. meet the criteria of a medical, dental, or vision expense under Code Section 213(d), and with respect to reimbursement of expenses incurred for medicine or drugs, which are treated as reimbursements for medical expenses under Code Sections 105 and 106(f);

2. will not be taken as a deduction from income on the Employee’s federal income tax return in any tax year;

3. are not covered, paid, reimbursed, or reimbursable from any other source;

4. do not exceed the amount that the Employee has elected to have allotted for HCFSA reimbursement for the Plan Year, plus any amounts carried over from the prior Plan Year, less previous reimbursement of Eligible Health Care Expenses made during the Benefit Period;

5. do not include any expense incurred for qualified long-term care services as defined in Code Section 7702B(c);

6. do not include premiums for other health insurance, dental supplemental benefits, and/or vision supplemental benefits;

7. are not limited to the amount in the Covered Employee’s HCFSA at the time a claim is reimbursed, but are limited to the Covered Employee’s entire allotment to the HCFSA for the Plan Year plus any amounts carried over from the prior Plan Year (properly reduced for prior reimbursements during the Benefit Period).

d. Claims incurred. Eligible Health Care Expenses are reimbursable when incurred.

Expenses are treated as incurred when the care that gives rise to the expense is provided, and not when the Employee is billed or pays for the medical care;

however, in case of orthodontia and over-the-counter medicines and products, expenses are incurred when paid.

e. Unused allotments. Except as set forth in Section 4.22 and paragraph (f) of this Section, any amounts allotted for the Plan Year will be forfeited if a claim for reimbursement of Eligible Health Care Expenses is not postmarked or electronically transmitted by April 30 following the end of the Plan Year.

f. Carryover of unused funds. Up to five hundred and fifty dollars ($550.00), or such greater amount as IRS guidance may permit, of unused allotments for the Plan Year may be carried over to the subsequent Plan Year. The amount unused for the Plan Year is the amount unused after Eligible Health Care Expenses have been reimbursed at the end of the Plan’s run-out period for the Plan Year. Funds carried over will remain available to reimburse Eligible Health Care Expenses (defined with respect to the Plan Year in which they are incurred) in the subsequent Plan Year if the Covered Employee makes an allotment to an HCFSA or a LEX HCFSA for that Plan Year as described in Section 4.6.

4.3.2 Limited Purpose Health Care Flexible Spending Arrangement.

A Limited Purpose Health Care Flexible Spending Arrangement means a Limited Expense Health Care Flexible Spending Arrangement (LEX HCFSA) as described in

4.3.2.1 ; a Limited Enrollment Health Care Flexible Spending Arrangement (LEN HCFSA) as described in 4.3.2.2; or a Limited Expense Limited Enrollment Health Care Flexible Spending Arrangement (LEXLEN HCFSA) as described in 4.3.2.3.

4.3.2.1 Limited Expense Health Care Flexible Spending Arrangement or LEX HCFSA.

For purposes of this Section 4.3.2.1 only, “Covered Employee” refers to a Covered Employee who is eligible to contribute to an HSA account or whose spouse is eligible to contribute to an HSA account.

a. Cash. A Covered Employee will receive cash in lieu of the optional pre-tax coverage described below, in accordance with the procedures described in Sections 4.10 and 4.11.

b. LEX HCFSA allotment. A Covered Employee may make an allotment as described in Section 4.6 and an amount equal to the allotment will be contributed by the Employer to an LEX HCFSA to pay for Limited Expense Coverage Eligible Health Care Expenses incurred during the LEX HCFSA Benefit Period.

c. LEX HCFSA Eligible Health Care Expenses. Eligible dental and vision expenses are expenses incurred during the Benefit Period and while the Employee is a Covered Employee, by the Covered Employee, or the Covered Employee’s spouse, Dependent or child defined at 26 U.S.C. § 152(f)(1) who has not attained the age of 27 as of the end of the Covered Employee’s taxable year that:

1. meet the criteria of a dental or vision expense under Code Section 213(d), and with respect to reimbursement of expenses incurred for medicine or drugs, which are treated as reimbursements for medical expenses under Code Sections 105 and 106(f);

2. will not be taken as a deduction from income on the Employee’s federal income tax return in any tax year;

3. are not covered, paid, reimbursed, or reimbursable from any other source;

4. do not exceed the amount that the Employee has elected to have allotted for LEX HCFSA reimbursement for the Plan Year, plus any amounts carried over from the prior Plan Year (less previous reimbursement of LEX HCFSA Eligible Health Care Expenses made during the Benefit Period);

5. do not include any expense incurred for qualified long-term care services as defined in Code Section 7702B(c);

6. do not include premiums for other dental supplemental benefits, and/or vision supplemental benefits;

7. are not limited to the amount in the Covered Employee’s LEX HCFSA at the time a claim is reimbursed, but are limited to the Covered Employee’s entire allotment to the LEX HCFSA for the Plan Year plus any amounts carried over from the prior Plan Year (properly reduced for prior reimbursements during the Benefit Period).

d. Claims incurred. LEX HCFSA Eligible Health Care Expenses are reimbursable when incurred. Expenses are treated as incurred when the care that gives rise to the expense is provided, and not when the Employee is billed or pays for the medical care; however, in case of orthodontia and over-the-counter medicines and products, expenses are incurred when paid.

e. Unused allotments. Except as set forth in Section 4.22 and paragraph (f) of this Section, any amounts allotted for the Plan Year will be forfeited if a claim for reimbursement of LEX HCFSA Eligible Health Care Expenses is not postmarked or electronically transmitted by April 30 following the end of the Plan Year.

f. Carryover of unused funds. Up to five hundred and fifty dollars ($550.00), or such greater amount as IRS guidance may permit, of unused allotments for the Plan Year may be carried over to the subsequent Plan Year. The amount unused for the Plan Year is the amount unused after Eligible Health Care Expenses have been reimbursed at the end of the Plan’s run-out period for the Plan Year. Funds carried over will remain available to reimburse Eligible Health Care Expenses (defined with respect to the Plan Year in which they are incurred) in the subsequent Plan Year if the Covered Employee makes an allotment to a LEX HCFSA or an HCFSA for that Plan

Year as described in Section 4.6.

4.3.2.2 Limited Enrollment Health Care Flexible Spending Arrangement. [Reserved]

4.3.2.3 Limited Expense Limited Enrollment Health Care Flexible Spending Arrangement. [Reserved]

4.4 Dependent Care Flexible Spending Arrangement.

a. Cash. A Covered Employee will receive cash in lieu of the optional pre-tax coverage described below, in accordance with the procedures described in Sections 4.10 and 4.11.

b. Dependent Care Flexible Spending Arrangement allotment. A Covered Employee may make an allotment as described in Section 4.6 and an amount equal to the allotment will be contributed by the Employer to a DCFSA to pay for Eligible Dependent Care Expenses incurred during the DCFSA Benefit Period.

c. Eligible Dependent Care Expenses means employment-related expenses under Code Section 21(b)(2) incurred for the care of a Qualifying Dependent and household services necessary to enable the Covered Employee and spouse, if any, to be gainfully employed, look for employment, or attend school full-time. Eligible Dependent Care Expenses must be incurred while the Employee is a Covered Employee or after separation from service during the Benefit Period, and:

1. are limited to amounts paid for services rendered in the Covered Employee’s home or amounts paid for services rendered outside of the Covered Employee’s home only if they are for the care of a Qualifying Dependent: (i) defined in Section 2.38.a, or (ii) defined in Section 2.38.b and who regularly spends at least 8 hours each day in the Covered Employee’s household. Services rendered in a dependent care center as defined in Code Section 21(b)(2)(D) must satisfy the requirements of Code Section 21(b)(2)(C);

2. are limited to the amount the Covered Employee has allotted for reimbursement of Eligible Dependent Care Expenses for the Plan Year less any prior reimbursement of Eligible Dependent Care Expenses during the Benefit Period;

3. are limited to the amount in the Covered Employee’s DCFSA at the time a claim is reimbursed; and

4. are not covered, paid, reimbursed, or reimbursable from any other source.

d. Claims incurred. Eligible Dependent Care Expenses are reimbursable when incurred.

Expenses are treated as incurred when the services that give rise to the dependent care expense are provided, and not when they are billed for or paid for; in the case of au pair fees, or fees for a child care placement agency, up-front fees paid to an organization to secure an au pair or child care provider are reimbursable proportionately over the duration of the agreement to employ the au pair or child care provider.

e. Unused allotments. Any amounts allotted for the Plan Year will be forfeited if a claim for reimbursement of Eligible Dependent Care Expenses is not postmarked by April 30 following the end of the Plan Year.

4.5 Health Savings Account “HSA.”

a. A Covered Employee who is an eligible individual pursuant to Code Section 223 and IRS guidance shall establish an HSA with an HSA Trustee or Custodian to account for allotments, contributions or other payments used to fund the HSA.

b. Each Covered Employee’s HSA will be credited with the sum of:

1. amounts allotted as pre-tax HSA allotments as provided in paragraph (c) of this Section by the Covered Employee, if any;

2. premium pass-through amounts, as defined in paragraph (d) of this Section, if any;

and

3. other contributions permitted under Code Section 223 and other IRS guidance.

The Covered Employee’s total contribution to an HSA for the Plan Year and eligibility for monthly contributions during a plan year are limited in accordance with Code and IRS guidance.

c. Allotment Election

1. Cash. A Covered Employee will receive cash in lieu of the optional pre-tax HSA unless the allotment is in accordance with Section 4.5.c.2.

2. HSA Allotment.

(A) A Covered Employee who is an HSA holder may make an allotment pursuant to Section 4.6 and an amount equal to the allotment will be contributed by the Employer to the Covered Employee’s HSA.

(B) A Covered Employee who is an HSA holder may revoke the allotment election made pursuant to Section 4.6 using the HSA revocation procedure described in Section 4.5.e.

(C) A Covered Employee who is no longer an eligible individual pursuant to Code Section 223 may not contribute allotments to an HSA account, and must revoke the allotment election made as described above.

(D) If a Covered Employee who is an HSA holder is on leave without pay (LWOP), or has insufficient pay, the Employer will not contribute the Covered Employee’s allotments during the period of LWOP or insufficient pay. The Covered Employee’s allotments that would otherwise be made during the period of LWOP or insufficient pay may be prepaid using the allotment election procedure as described in Section 4.5.c. as permitted by the Employer and its payroll provider or the Covered Employee may pay directly on an after-tax basis, as long as the annual limit is not exceeded.

d. Premium Pass-Through. For purposes of this section, premium pass-through amounts are amounts that a Medical Plan that is an HDHP contributes to an HSA.

e. HSA Election Procedure, Modifications and Revocations. An election to make, change, or revoke an HSA allotment must be made in a form acceptable to the Employer at a time the Employer or its payroll provider is able to affect a pre-tax allotment.

HSA allotments are not subject to a mandatory 12-month period of coverage. A Covered Employee who elects to make HSA allotments may modify the allotment at any time as long as the change is prospective and in accordance with the administrative procedures established by the Covered Employee’s payroll provider.

Section 4.18 does not apply.

The HSA allotment election continues into a subsequent Plan Year unless or until the Covered Employee modifies or revokes that allotment election.

f. No Forfeiture. Any balance that may remain in a Covered Employee’s HSA at the end of a Plan Year is automatically carried forward in the account. No HSA account balance is subject to forfeiture.

g. These rules apply to HSAs notwithstanding Section 4.16 or any other provisions in this plan.

4.6 Allotments. Reduction of pay for coverage options elected under Section 4.1 and Section 4.1.1 will occur via an allotment to the agency under 5 U.S.C. 5525, or its functional equivalent, and any applicable regulations. The allotment for any pay date may not exceed the amount of the Covered Employee’s pay available for allotment for that pay period. Allotments are deemed to be made voluntarily.

a. Medical Plan. For a Covered Employee who elects pre-tax Medical Plan coverage under Sections 4.2 and 4.7, pay will be reduced by the amount equal to the Covered Employee’s share of their Medical Plan premium. A Covered Employee must elect an HDHP to be eligible to contribute to an HSA.

b. Dental Plan. For a Covered Employee who elects Dental Plan coverage under Sections 4.2 and 4.9, pay will be reduced by the amount equal to the Covered Employee’s Dental Plan premium.

c. Vision Plan. For a Covered Employee who elects Vision Plan coverage under Sections

4.2 and 4.9, pay will be reduced by the amount equal to the Covered Employee’s Vision Plan premium.

d. HCFSA. For a Covered Employee who elects pre-tax contributions to an HCFSA under

Sections 4.3.1 or 4.3.2 and 4.10, pay will be reduced by the amount elected for the year, apportioned substantially equally among the remaining pay periods for such year. A Covered Employee may elect an HCFSA allotment for a Plan Year of an amount within the limits stated in the Summary of Benefits.

e. DCFSA. For a Covered Employee who elects pre-tax contributions to a DCFSA under Sections 4.4 and 4.10, pay will be reduced by the amount elected for the year, apportioned substantially equally among the remaining pay periods for such year. A Covered Employee may elect a DCFSA allotment for a Plan Year of an amount within the limits stated in the Summary of Benefits.

f. HSA. For a Covered Employee who elects pre-tax contributions to an HSA under Section 4.5.c.2, pay will be reduced by the amount elected per pay period.

4.7 Cash Election Procedure for Employees Covered under a Medical Plan.

a. Initial Plan Year election procedure. A Covered Employee who is enrolled in a Medical Plan may elect to receive cash in lieu of coverage as described in Section 4.2 and may obtain an election Form from the Employer. The Covered Employee must obtain, complete and return this election Form to the agency human resources office on or before the day designated by the Employer, but in no event later than the day before the first day of the first pay period that begins on or after the Effective Date. The election shall be effective as of the first day of the first pay period that begins on or after the Effective Date.

b. New Covered Employee election procedure. As soon as practicable after an individual becomes a Covered Employee under Section 3.1 or 3.3, the Employer shall have available the election Form described in Section 4.7.a. If the Covered Employee enrolls in a Medical Plan and wishes to elect the cash option described in Section 4.2.d for the balance of the Plan Year, the Covered Employee must obtain, complete and return this election Form to the agency human resources office together with the Medical Plan enrollment Form during the period permitted for new enrollment in the FEHB Program. The election will be effective prospectively as of the first day of the first pay period for which Medical Plan coverage becomes effective.

c. Reemployed Annuitant election procedure. If the new Covered Employee is a Reemployed Annuitant who is already enrolled in a Medical Plan as an annuitant, and that Covered Employee wishes to elect the cash option described in Section 4.2.d, the Covered Employee must obtain, complete and return this election Form to the agency human resources office within 60 days of becoming a Covered Employee under 3.1. The election will be effective as of the first day of the first pay period following the Employer’s receipt of the Form.

d. Open Season election procedure. At the time prescribed for the annual Open Season for the FEHB Program, a Covered Employee who enrolls or remains enrolled in a Medical Plan may elect to receive cash in lieu of coverage as described in Section 4.2.

The Employer shall have available the written election Form described in Section

4.7.a. The Covered Employee must obtain, complete and return this election Form to the agency human resources office on or before the last day of the Open Season.

The election shall be effective on the same day as all FEHB Open Season changes. If, for any reason, OPM conducts a special Open Season, the above procedure shall apply, except that the election shall be effective as of the date that OPM shall prescribe.

e. Change in status election procedure. A Covered Employee may not revoke an election during a Plan Year except in the case of a change in status described in Section 4.16.

4.8 Failure to Obtain and Return Cash Election Form for Employees Covered under a Medical Plan.

a. Initial Plan Year. A Covered Employee’s failure to return a completed election Form to the Employer on or before the Effective Date for the Initial Plan Year shall constitute an election of pre-tax premium coverage under Section 4.2.e.

b. New Covered Employees and Reemployed Annuitants. A Covered Employee’s failure to obtain and return a completed election Form to the Employer on or before the date described in Section 4.7 for the Plan Year in which they became a Covered Employee, shall constitute an election of pre-tax premium coverage under Section 4.2.e.

c. Subsequent Plan Years. A Covered Employee’s failure to obtain and return a completed election Form to the Employer on or before the date described in Section 4.7.d, for any subsequent Plan Year shall constitute a re-election of the same option as was in effect for the Covered Employee just prior to the end of the preceding Plan Year. If the Covered Employee’s prior Plan Year election was pre-tax premium coverage, failure to return a completed election Form to the Employer on or before the date described in Section 4.7.d shall also constitute election of an allotment under Section 4.6.

4.9 Election Procedures under a Dental Plan and/or a Vision Plan.

a. A Covered Employee’s election to enroll in a Dental Plan and/or a Vision Plan constitutes an election of pre-tax premium coverage under Section 4.2.f and/or 4.2.g.

b. Initial Plan Year for Dental Plan and Vision Plan election procedure. Prior to the Initial Effective Date for Dental Plan and Vision Plan, a Covered Employee may elect to allot on a pre-tax basis, an amount equal to the premium required to purchase coverage under a Dental Plan and/or Vision Plan. The Covered Employee must obtain an election Form for this purpose from OPM or its Plan Agent. The Covered Employee must complete and return this election Form to OPM or its Plan Agent on or before the day designated, but in no event later than the Initial Effective Date for Dental Plan and Vision Plan except that a Covered Employee who is not actively at work at any time during the official enrollment period for the Initial Plan Year for

Dental Plan and Vision Plan may enroll on the first date they could have made an election as determined by the OPM or its Plan Agent The election will be effective prospectively as of the first day of the pay period that begins following acceptance of the election Form by OPM or its Plan Agent, but no earlier than the Initial Effective Date for Dental Plan and Vision Plan. Elections made during the Initial Plan Year for Dental Plan and Vision Plan remain in effect until the end of the following Plan Year.

c. New Covered Employee election procedure. As soon as practicable after an individual becomes a Covered Employee under Section 3.1 or 3.3, OPM or its Plan Agent shall make available the election Form described in Section 4.9.b. If the Covered Employee wishes to elect coverage under the Dental Plan and/or Vision Plan for the balance of the Plan Year, the Covered Employee must complete the Form and return it to OPM or its Plan Agent on or before the day designated by the Employer under Section 4.9.b for pre-tax coverage under a Dental Plan and/or Vision Plan. The election will be effective prospectively as of the first day of the pay period that begins following acceptance of the election Form by OPM or its Plan Agent.

d. Reemployed Annuitant election procedure. Reemployed Annuitants with a break in service of at least 30 days will be treated as new Covered Employees for purposes of Dental Plan and/or Vision Plan elections. For Reemployed Annuitants with a break in service of less than 30 days, Dental Plan and/or Vision Plan elections previously in effect will be automatically reinstated as provided in Section 4.16.f.

e. Open Season election procedure. At the time prescribed for the annual Open Season, a Covered Employee may enroll, remain enrolled, or change their enrollment in a Dental Plan and/or a Vision Plan. OPM or its Plan Agent shall make available the election Form described in Section 4.9(b). The Covered Employee must complete and submit the Form to OPM or its Plan Agent on or before the last day of the Open Season. The election shall be effective on January 1 of the next Plan Year. If, for any reason, OPM conducts a special Open Season, the above procedure shall apply, except that the election shall be effective as of the date that OPM shall prescribe.

f. Subsequent Plan Years. A Covered Employee’s failure to obtain and return a completed election Form to OPM or its Plan Agent on or before the date described in Section 4.9.e, for any subsequent Plan Year shall constitute a re-election of the same option as was in effect for the Covered Employee just prior to the end of the preceding Plan Year.

g. Absentee/belated enrollment. If a Covered Employee is unable to elect coverage under the Dental Plan and/or Vision Plan during an annual Open Season for the FEHB Program for reasons outside of their control, the Covered Employee may make a belated enrollment within 30 days of the first date they could have made an election as determined by OPM or its Plan Agent.

h. Change in status election procedure. A Covered Employee may not revoke an election during a Plan Year except in the case of a change in status described in Section 4.16.

4.10 Election Procedures under a Flexible Spending Arrangement.

a. New Covered Employee election procedure. As soon as practicable after an individual becomes a Covered Employee under Section 3.1 or 3.3, the Employee may elect to allot an amount in lieu of pay on a pre-tax basis to an FSA, in an amount not to exceed the limits described in Section 4.6.d for the HCFSA and Section 4.6.e for the DCFSA.