FSA_-_Exhibit_5_-_Updated_v2.docx

Contents

SOM MEDICAL PART 2: Attachments O-Q DRAFT DATE: 10/29/2013

FLEXIBLE SPENDING ACCOUNT ADMINISTRATION

SOM Medical RFP Part 2 – Page Attachment S-1

Solicitation No. F10B2600045 1 Exhibit 5-1 Exhibit 5-1: Offeror Information Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: Please complete each cell with the requested information. Items in the response column with the words "Choose an Item" contain a drop-down list of options. Please select a response from those options as applicable.

Response

Click here to enter text. Click here Click here Click here

Click here to enter text. Click here Click here Click here

Click here to enter text. Click here Click here Click here

Click here to enter text. Click here Click here Click here

Complete Claims

Claims Requiring Follow up

Health Care FSAs

Dependent Daycare FSAs

Percentage

Please complete the following tables with the requested reference information.

If available, please provide at least one (1) government client reference.

V. CONTACT INFORMATION

Primary contact of person authorized to execute this proposal

Exhibit 5-2: Explanations and Deviations Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: All deviations from the specifications of the Request for Proposal (RFP) must be clearly defined using this worksheet. Explanations must be numbered to correspond to the question number and section number to which it pertains. If additional space is required, submit a separate attachment labeled “Exhibit 5-2b: Explanations and Deviations” using the same table format. Most importantly, keep all explanations brief. In the absence of any identified deviations, your organization shall be bound to the terms of the RFP.

Please indicate if “Exhibit 5-2b: Explanations and Deviations” is provided: Choose Yes or No.

Exhibit 5-3: Plan Design Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: Any deviations between the State's proposed plan design and the proposed plan design of the Offeror must be noted in the space provided below. If there are no deviations in the Offeror's proposed plan design, please enter the phrase "No Deviations" in the space provided.

Notwithstanding the Plan Year in which a reimbursement for eligible employment-related dependent daycare expenses is made, the total reimbursements to an Employee in any calendar year shall not exceed the lesser of:

(i) the Participant's earned income, as defined in Section 129(e)(2) of the Code;

(ii) the actual or deemed earned income of the Participant's spouse, or

(iii) the maximum amount permitted under Code Section 129(a)(2)(A) ($5,000 or $2,500 if married filing separately).

(i) the dependent(s) for whom services were performed,

(ii) the nature of the services performed and the cost,

(iii) the relationship, if any, of the person performing the services to the covered Employee, and

(iv) if the services were performed in a day care center, a statement that the day care center complies with all applicable laws and regulations of the state of residence.

Enrollment and Coverage Effective Dates Eligible persons must elect or waive benefits during an annual open enrollment period. New employees must elect or waive coverage within 60 days of hire. Participation is on a prospective basis only beginning with the first day of the month following date of hire or qualifying event. No retroactive adjustments are permitted.

Enrollment elections may not be changed until the next open enrollment period, unless provided by State regulation or applicable federal law, for example, HIPAA, §1.125-4 Internal Revenue code section §1.125, or Treasury Regulation.

Exhibit 5-4: Compliance Checklist Representations made by the Offeror in this proposal become contractual obligations that must be met during the contract term.

Instructions: Please complete each item with the requested information. Items in the response column with the words "Choose” contain a drop down list of options. Please select a response from those options as applicable. NOTE: All "No" responses must be addressed in "Exhibit 5-2: Explanations and Deviations.”

Yes or No

General Services and Performance

1.) Send a minimum of three (3) collection letters via mail or email 2.) Maintain and document dates of each collection attempt 3.) If a Member fails to deliver necessary documentation within 60 calendar days, Contractor shall suspend the Member’s debit card and require paper submission for future expenses.

4.) Contractor shall request refunds (pursue overpayments) or offset future manual claims with the Member’s outstanding overpayment.

5.) If the Contractor fails to demonstrate appropriate and efficient recovery efforts, the Contractor shall reimburse the State for the improper payment.