Flexible Spending Account 2005

Warren Wilson College

Flexible Spending Account Plan

Summary Plan Description

Effective as Amended and Restated January 1, 2005

TABLE OF CONTENTS

Introduction....................................................................................................................................... 1

Flexible Spending Account................................................................................................................. 1 ...........

Eligibility............................................................................................................................................ 2

Annual Open Enrollment Period............................................................................................. 2

Change in Status Events......................................................................................................... 2

Consistency Rule................................................................................................................... 3

Other Events that May Allow Election Changes...................................................................... 3

How the Spending Accounts Work.................................................................................................... 4

Tax Advantages................................................................................................................................. 5

Social Security/Other Benefits May Be Affected..................................................................... 5

Medical Spending Account................................................................................................................ 5

Eligible Medical Expenses...................................................................................................... 5

Medical Expenses Not Eligible for Reimbursement................................................................. 7

Submitting a Claim................................................................................................................. 7

Unused Balances................................................................................................................... 8

Dependent Care Spending Account................................................................................................... 8

Eligible Dependent Care Expenses......................................................................................... 9

Tax Credit Versus Dependent Care Spending Account........................................................... 9

Submitting a Claim............................................................................................................... 10

Unused Balances................................................................................................................. 10

Changes to Employee’s Status......................................................................................................... 10

Medical Spending Account.................................................................................................. 10

Dependent Care Spending Account..................................................................................... 12

More Important Facts About the Reimbursement Accounts.............................................................. 12

Appealing a Denied Claim................................................................................................................ 15

Statement of ERISA Rights.............................................................................................................. 16

Appendix A – COBRA CONTINUATION OF COVERAGE........................................................ 19

Appendix B – LIMITATIONS ON DISCLOSURE OF PROTECTED HEALTH

INFORMATION TO THE EMPLOYER................................................................ 22

Warren Wilson College has implemented a Section 125 Cafeteria Plan and a Flexible Spending Account Plan to enable you to purchase certain benefits on a pre-tax basis. The Flexible Spending Account Plan consists of two reimbursement accounts that are further described below.

If there is any difference between information described in this Summary Plan Description and the Plan’s formal documentation, the formal documentation will control. The formal documentation is subject to rules, regulations, and interpretations under Section 125 of the Internal Revenue Code and other provisions of the Internal Revenue Code.

FLEXIBLE SPENDING ACCOUNTS

As benefit options under the Warren Wilson College Section 125 Cafeteria Plan, the Warren Wilson College Flexible Spending Account Plan enables you to use pre-tax dollars to pay for many medical and dependent care expenses. There are two separate reimbursement accounts available to you:

• Medical Spending Account for qualifying medical, dental and vision expenses incurred by you and your eligible dependents; and

• Dependent Care Spending Account for the costs of day care for your children or other eligible dependents.

Special rules apply to the types of expenses eligible for reimbursement under each account. This booklet provides guidelines for using these accounts and lists some of the eligible expenses. If you have questions about flexible spending accounts, contact Warren Wilson College.

Each Employee who normally performs services for the Employer of at least 30 hours per week may elect to participate in the Plan as of the beginning of the next following Coverage Period. Any Employee whose employment begins after the beginning of a Coverage Period may begin participation on the first day of the month after completing 0 months of service with the Employer.

An annual enrollment period will be scheduled by the Company prior to the beginning of each plan year. At that time you will receive enrollment materials describing the Flexible Spending Accounts and the other options available to you under the Plan.

If you decide to participate in one or both of the Flexible Spending Accounts, you must elect the total amount of your annual compensation you wish to deposit into each account during the next plan year. The amount you elect to deposit into the appropriate Flexible Spending Account will be deducted prorata from your pay beginning the first payday of the plan year. After an election is made, it may not be modified until the next annual enrollment period unless there is a Change in Status or other IRS authorized event that allows an election change.

Rules of the Internal Revenue Code require that generally, you may not change the amount you are depositing to your Flexible Spending Account Plan until the next annual enrollment period. However, you will be allowed to make a change if the change is a Change in Status Event and the Consistency Rule is satisfied. Valid Change in Status Events include the following:

* Change in Employee’s Legal Marital Status (marriage, divorce, annulment, legal separation or death of spouse).

* Change in Number of Dependents (events that change an employee’s number of dependents, such as birth, adoption, placement for adoption or death).

* Change in Employment Status of Employee, Spouse or Dependent (any of the following that change the employment status of the employee, the employee’s spouse, or the employee’s dependent: termination or commencement of employment, strike or lockout, beginning or returning from an unpaid leave of absence, change in worksite, or a change from an eligible to an ineligible employment status or classification).

* Dependent Satisfies (or Ceases to Satisfy) Dependent Eligibility Requirements (events that cause an employee’s dependent to satisfy or cease to satisfy eligibility requirements for coverage, such as due to age, student status, or similar circumstances).

* Change in Residence (a change in the place of residence of the employee, spouse, or dependent).

Other Change in Status Events may be allowed if they are acceptable under interpretations of the Internal Revenue Code. If you have questions, please ask your Employer’s benefits representative.

If you experience a Change in Status Event and desire to make a change, you must make the change no later than 30 days following the Event.

A change must be “on account of and correspond with” a Change in Status Event. To meet this requirement, the change that you wish to make must be on account of and correspond with a Change in Status Event that affects eligibility for coverage under an employer’s plan. This rule is satisfied as to the Dependent Care Spending Account if the Change in Status Event affects expenses under that Account, such as when the child becomes 13 years old and is no longer a qualifying individual. The determination of whether a requested change is “on account of and consistent with” a Change in Status Event will be made by the Plan Administrator (in its sole discretion) in accordance with interpretations of the Internal Revenue Service. If you have questions, please ask your Employer’s benefits representative.

* Cost Changes. This event applies to Dependent Care Spending Accounts, but not to Medical Spending Accounts. If the caregiver is a relative, no change is permitted.

* Significant Coverage Change/Curtailment. This event applies to Dependent Care Accounts, but not to Medical Spending Accounts. It may apply, for example, when there is a change in provider, or eligibility for state-funded school resulting in decreased need for child care expenses.

* Change in Coverage of Spouse or Dependent Under Other Employer’s Plan. This event applies to Dependent Care Accounts, but not to Medical Spending Accounts. If there is a change in your, your spouse’s, or your dependent’s coverage under another employer’s plan, you may be allowed to change your election under the Plan provided that the change is on account of and consistent with the change in coverage that is made under the other employer’s plan and is also consistent with the rules under Section 125 of the Internal Revenue Code.

• Judgment, Decree, or Order. If a judgment, decree, or order (collectively called “order”) resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order under the Employee Retirement Income Security Act) requires an employee to cover a child under the Medical Spending Account, the employee may increase deposits to cover the child. Likewise, if the order requires another individual to provide coverage for the child and coverage is, in fact, provided, then the employee may reduce deposits.

• Medicare and Medicaid. If an employee, spouse, or dependent becomes entitled to Medicare or Medicaid (other than coverage only for pediatric vaccines), the employee may make a change to reduce deposits to the Medical Spending Account to take into account Medicare or Medicaid. Likewise, if the employee, spouse, or dependent loses eligibility for coverage under Medicare or Medicaid, the employee may increase deposits to the Medical Spending Account to take into account loss of that coverage.

Additionally, the Plan’s Administrator may modify your election(s) downward during the plan year if necessary to prevent the Plan from becoming discriminatory within the meaning of the federal income tax law.

You can use your Flexible Spending Accounts to pay for a variety of expenses related to medical care and dependent day care. You may participate in one account or both accounts, or you may decide not to participate at all.

• During the annual enrollment period you indicate the total amount you wish to deposit in each account during the coming year.

• The annual amount you elect will be divided evenly over the appropriate number of pay periods. Each pay period, an equal portion of the total amount will be deducted from your compensation and credited to the appropriate account(s).

• When you incur eligible expenses, you submit a reimbursement account claim form together with the original itemized bill or receipt or the explanation of benefits (EOB) form from your insurance carrier.

• In accordance with the Uniform Reimbursement Requirement for Flexible Spending Accounts under the provisions of the Internal Revenue Code, you may obtain reimbursement up to the amount you have elected to deposit into your Medical Spending Account.

• Reimbursements for dependent day care expenses are allowed up to the amount actually in your Dependent Care Spending Account at the time you submit your request. If your claim exceeds the amount currently available in your Dependent Care Spending Account, you receive additional reimbursements as more money is deposited into your account through payroll deductions.

The cash compensation (wages) you receive from Warren Wilson College is taxable. However, when you allocate a portion of your compensation on a pre-tax basis to be used for payment of your benefits, your taxable income is reduced by the amount you have allocated to benefits. This allocation results in a reduction of federal and, in most cases, state income taxes.

You do not have to pay taxes on the money you receive as reimbursement of eligible medical or dependent care expenses from your Flexible Spending Account Plan.

Since you do not pay Social Security taxes on any compensation you deposit to your Medical Spending Account or your Dependent Care Spending Account, your future Social Security benefit could be slightly reduced. Although this reduction usually is quite small, it could occur if your compensation falls below the annual Social Security taxable wage base as revised each year. The resulting decrease in your taxable compensation could impact other benefits which may be available through your employer.

You can deposit between $0.00 and $8,000.00 of your compensation into your Medical Spending Account each year. You can use the money in your account to reimburse yourself for any eligible medical expense for yourself or your dependents which has not been paid by any other benefit plan. For purposes of the Medical Spending Account, eligible dependents include your spouse, your dependent children, and any other person who is your dependent for federal tax purposes (i.e., any person for whom you claim an exemption on your tax return).

Eligible medical expenses include most expenses that qualify as medical expenses under the Internal Revenue Code. A partial listing of eligible expenses includes the following; items marked with an asterisk (*) may require additional documentation or reimbursement may be limited to the difference between a normal item and a special need item:

Hearing Expenses including testing and hearing aids plus batteries and repairs

Braille or other special books/items or cost of specially equipping home or car for access by disabled person*

Medically necessary cosmetic services (e.g., following accident or mastectomy, etc.)

Alternative/Holistic Services: medically necessary treatment by licensed or certified practitioners including acupuncture and massage therapy

If you use the Medical Spending Account to pay for a particular medical expense, you cannot claim the same expense as a deduction on your income tax return.

If you receive a reimbursement from your Medical Spending Account and reimbursement for the same expense through your medical or dental coverage or another health care plan, you must refund the reimbursement you received from your Medical Spending Account to the Plan.

Not all medical expenses are eligible for reimbursement from your Medical Spending Account. Here are some examples of expenses which are not eligible for reimbursement:

* Cosmetic Expenditures (e.g., teeth whitening, dermabrasion, chemical peels or spider vein treatment)

* General Wellness expenses (e.g., health club dues, special foods and supplements, vitamins, exercise programs and equipment, or weight loss programs)

* Insurance Premiums (e.g., replacement insurance for contact lenses or other health plan policies)

* Other: Shipping & Handling Charges, Missed Appointment, Late Payment or Interest Charges

You can submit a claim for an eligible medical expense at any time during the Plan Year. Obtain a Request For Medical Reimbursement form from the claims administrator or your benefits representative and attach a copy of the original itemized bill or receipt for an expense not covered under your medical, dental, or vision coverage, or the explanation of benefits from the insurance carrier. Reimbursements will be made at least monthly.

The money you deposit in your account for the Plan Year will be used to reimburse you for eligible expenses incurred in that year only. You incur an expense when the service is provided, and not when the bill is sent or payment is made. For example, if the Plan Year is the calendar year, and you had a physical exam in 2000 and paid for it in 2001, you cannot submit a claim for the cost to your 2001 Medical Spending Account.

You can continue to submit claims for eligible medical expenses incurred during the Plan Year until February 28 following the end of the Plan Year.

If you have any money left in your account at the end of the year, and you have not submitted claims for that money by the February 28 deadline, you will forfeit your unused balance.

All forfeitures from Plan participants will be used by the employer to offset any losses it has incurred for benefit payments under the Medical Spending Account Plan and/or to reduce costs of administering the Plan. After this, forfeitures may be used in any manner authorized by relevant law.

You can deposit between $0.00 and $5,000.00 of your compensation into your Dependent Care Spending Account each year. (If you are married, and your spouse files a separate tax return, you can deposit only up to $2,500.) You can use the money in your account to reimburse yourself for dependent care costs which you incur so that you and your spouse (if any) can work. If you are married but your spouse does not work, he or she may be considered working during any month that he or she is a full-time student or is incapable of caring for himself or herself.

There are additional limits on the amount you can deposit to this account. The amount of your deposit cannot be greater than your income or your spouse’s, whichever is lower. For example, if you earn $15,000 a year and your spouse earns $4,500, the maximum you can deposit for dependent care expenses is $4,500.

Under this special rule, if your spouse is a full-time student or is incapable of caring for himself or herself, he or she is assumed to have a monthly income of $250 if you have one eligible dependent, or $500 if you have two or more eligible dependents.

You can use your Dependent Care Spending Account to pay for dependent care expenses for qualifying individuals. A qualifying individual is:

• a child under age 13 whom you are entitled to claim as a dependent on your federal tax return; and/or

• a spouse or other dependent (e.g., your parent or your spouse’s parent) who is physically or mentally incapable of self care, who has the same principal place of abode as the Participant for more than half of the taxable year, and who spends at least eight hours a day in your home. [Note that unless a technical correction is made to the Internal Revenue Code, effective as of January 1, 2005, such dependent must also have gross income that is less than the exemption amount ($3,200 in 2005).]

• care at dependent care centers that meet all applicable state and local requirements and provide care for more than six individuals;

• services from individuals (other than you or your spouse’s dependent or child less than age 19) who provide care inside or outside your home;

• services of a housekeeper, maid, cook or similar employee, for that portion of the time which is related to the care of a qualified individual.

The caregiver may be a relative if he or she is at least 19 years old and is not someone you can claim as a dependent on your federal tax return. Expenses or fees related to education cannot be reimbursed. Other expenses not listed above that are authorized by the Internal Revenue Code may be reimbursed.

The federal government allows you to take a tax credit on your federal income tax return for qualified dependent care expenses. The difference between the Dependent Care Spending Account and the tax credit is that the Dependent Care Spending Account provides a reduction of your taxable income, while the tax credit offers a direct reduction of the amount of tax you pay.

Your individual financial circumstances will determine which method is best for you. You might wish to consult with a tax consultant or financial advisor before making a decision.

You can submit a claim for an eligible dependent care expense at any time during the Plan Year. Obtain a No Wait Dependent Care Reimbursement form from the claims administrator or your benefits representative and attach the original itemized bill or receipt from the provider of services, showing the provider’s Social Security number (or tax identification number), the dates of service and the amount. Reimbursement for eligible expenses will be processed within 24 hours after receipt of the claim.

The money you deposit in your account for the Plan Year will be used to reimburse you for eligible expenses incurred in that year only. An expense is incurred when the care is provided, and not when the bill is sent or payment is made.

You can continue to submit claims for eligible dependent care expenses incurred during the Plan Year until February 28 following the end of the Plan Year.

If you have any money left in your account at the end of the year, and you have not submitted claims for that money by the February 28 deadline, you will forfeit your unused balance.

All forfeitures from Plan participants will be used by the employer to reduce costs of administering the Plan or may be used in any manner authorized by relevant law.

If your employment status changes, participation in each of the reimbursement accounts may affected. The effects of certain changes are described below.

Medical Spending Account

Your participation in the Medical Spending Account would be affected as follows, based on the type of employment change involved.

• Leave of absence under the FMLA. Your deposits may continue for as long as you are on paid leave or, if the leave is unpaid, you may elect to continue under the Account and make deposits in a manner approved by your employer. You should discuss payment methods with your employer if you are on unpaid leave. If you wish, you can elect to cease making deposits while you are on FMLA leave. If you cease making deposits, you will not be considered a participant in the plan, and you will not receive reimbursement for expenses incurred during the time you were not a participant. When you return from FMLA leave, you can be reinstated in your account. If any generally applicable changes were made to the plan while you were out, those changes will also apply to you.

Upon return from an FMLA leave during which coverage terminated, the Employer may require reinstatement into a health benefit that is a medical reimbursement spending account, provided that Employees on a non-FMLA leave are also required to be reinstated into the spending account. Upon reinstatement, whether or not required, the Employee may not retroactively elect spending account coverage for claims incurred during the period when the coverage was terminated. The Employee may resume coverage at the level in effect prior to the beginning of the leave, thus increasing premium payments upon return from the leave or, alternatively, the Employee may elect to resume coverage at a reduced level, continuing premium payments in the same amount as in effect before the leave. For example, if an Employee has elected $1,200 of annual coverage under a medical reimbursement account ($100 pre-tax funding monthly) and is on an FMLA leave during April, May, and June, during which coverage ceases, Employee on return from the leave in July may resume coverage at $1,200 by paying $150 per month from July through December. Alternatively, the Employee may resume coverage at the reduced level of $900 annually by paying $100 per month from July through December.

• Non-FMLA Leave of Absence. If your employer’s policies provide for a paid leave of absence that is not covered by the FMLA, your deposits continue as long as your salary continues. If your leave of absence is unpaid, you may have a permissible Change in Status Event that would allow you to discontinue your deposits and cease participation. Please refer to the section on “Change in Status Events.” If you want to continue deposits even though you have had a Change in Status, those deposits would be made with after tax income. Upon return from a non-FMLA leave during which coverage terminated, the Employer may require reinstatement into a health benefit that is a medical reimbursement spending account. Upon reinstatement, whether or not required, the Employee may not retroactively elect spending account coverage for claims incurred during the period when the coverage was terminated. The Employee may resume coverage at the level in effect prior to the beginning of the leave, thus increasing premium payments upon return from the leave or, alternatively, the Employee may elect to resume coverage at a reduced level, continuing premium payments in the same amount as in effect before the leave.

• Death. In the event of your death, your deposits stop. However, your surviving dependents may submit for reimbursement, eligible expenses incurred prior to your death. Claims for eligible expenses incurred prior to your death must be submitted by February 28 following the close of the Plan Year.

• Change to ineligible employment status. Your deposits stop. However, you can continue to request reimbursement of eligible expenses incurred through the date of the employment status change. Claims must be submitted by February 28 following the close of the Plan Year.

• Termination of employment. Your deposits stop with the last paycheck you receive after termination. However, you may continue to request reimbursement of eligible expenses incurred through your termination date. Claims must be submitted by February 28 following the close of the Plan Year.

If the events described above cause a loss of coverage under the Medical Spending Account, you may have experienced a “qualifying event” under COBRA. COBRA is generally applicable to employers who employ 20 or more employees. If COBRA applies and you lose coverage due to a qualifying event, then those who were covered under the Medical Spending Account before the qualifying event may be able to continue participation in the Medical Spending Account by timely electing and paying for COBRA coverage. In addition to the premium deposits, which will generally be made on an after-tax basis for COBRA coverage, a 2% administrative fee may be charged. See Exhibit A at the end of this Summary Plan Description for more information about COBRA. COBRA is not available if you have a negative account balance as of the qualifying event.

A change in employment status would affect your participation in the Dependent Care Spending Account generally the same way as listed above for the Medical Spending Account with the following two exceptions:

(1) COBRA: Dependent Care Spending Accounts are not considered health plans; therefore, federal COBRA regulations do not apply. Coverage or service dates may not be extended beyond your date of termination or date of death.

(2) Leave of Absence: If you take any leave of absence, you can cease your deposits only if the leave of absence also qualifies as a Change in Status Event. A leave of absence qualifies as a Change in Status Event only if it is unpaid. Please remember that an eligible dependent care expense is one that allows you and your spouse to work. If you or your spouse are not working, dependent care expenses incurred during that time may not be expenses that are properly reimbursable. For this reason, you may want to consider timely ceasing deposits if you take an unpaid leave of absence. If you choose to continue deposits, those deposits would be made on an after-tax basis.

The Plan is provided through and administered by your Company. Claims are administered by Flores & Associates, LLC, 200 S. Tryon St., Suite 1100, Charlotte, NC 28202 (the “Claims Administrator.”)

The Warren Wilson College Section 125 Cafeteria Plan and Flexible Spending Account Plan. The Flexible Spending Account Plan contains two component accounts: Medical Spending Accounts and Dependent Care Spending Accounts.

Warren Wilson College’s Plans are fully described in the Plans’ legal documents. There is another booklet available to you that describes the Section 125 Cafeteria Plan. This booklet describes the major provisions of the Flexible Spending Account Plan in easy to understand terms. It is shorter and far less technical than the Plans’ legal documents. If there is any conflict or inconsistency between this booklet and the Plans’ legal documents, or if this booklet does not cover or only partially covers any provision in the legal documents, the Plans’ legal documents govern. If you have any questions about the Plans or if you would like to examine the Plans’ legal documents, contact Warren Wilson College. It is intended that the Plans will be administered in accordance with all relevant statutory and governmental authority. To the extent that any Plan provision is contrary to any statutory and governmental authority, such authority will govern operation of the Plans.

The Plan Administrator has the discretionary authority to administer the Plan in all of its details, including determining eligibility for benefits and construing all terms of the plan. The Plan Administrator has the discretion to determine all questions of fact and/or law that may arise in connection with the administration of the Plan. The Plan Administrator may assign its duties to others. The function of claims administration, in accordance with the terms of the Plan documentation, has been assigned to the Claims Administrator.

The agent for service of legal process for the Warren Wilson College Flexible Spending Account Plan is:

The Plan year begins on January 1 and ends on December 31. However, the first Plan Year is a short year that begins on the Effective Date and ends on December 31

The Medical Spending Account is a type of welfare plan under ERISA that reimburses eligible medical expenses that are not reimbursed from other sources. The Dependent Care Spending Account is authorized by Section 129 of the Internal Revenue Code and reimburses eligible dependent care expenses. The Section 125 Cafeteria Plan is authorized by Section 125 of the Internal Revenue Code and allows payment for certain benefits on a pre-tax basis.

Employees contribute to the plan through pre-tax dollars that are elected by the employee and authorized by the Section 125 Cafeteria Plan. Employees select the amount of their contributions, up to authorized limits. A minimum contribution may be required.

Benefit Payments

Benefits are paid from the employer’s general assets. There is no independent source of funds or any insurance contract that guarantees the payment of benefits. For administrative convenience, the Claims Administrator processes all claims for reimbursements on behalf of the employer.

If required by any Qualified Medical Child Support Order (“QMCSO”) defined in ERISA Section 609(a), the Plan will extend benefit to a Participant’s non-custodial child. Participants and beneficiaries can obtain from the Plan Administrator, without charge, a copy of procedures used for determining whether an order satisfies the requirements of ERISA.

Warren Wilson College intends to continue the Plan indefinitely. However, it reserves the right to change or to terminate the Plan, or to eliminate any benefit under the Plan, at any time without the consent of any participant or dependent. Warren Wilson College or any authorized officer or representative of Warren Wilson College can make changes to or terminate the Plan. You will be notified if any changes are made.

The following information is provided regarding claims and review procedures for benefit plans that are covered by the Employee Retirement Income Security Act (“ERISA”). It is based upon regulations issued by the U.S. Department of Labor. Only the Medical Spending Account under this Plan is a benefit that is covered by ERISA.

Claims Decisions. If a claim is denied, you will be provided written notice setting forth the specific reason or reasons for the denial, specific reference to pertinent plan provisions on which the denial is based, and a description of any additional material or information necessary to perfect the claim (including an explanation of why such material or information is necessary), and appropriate information as to the steps to be taken if you wish to submit a denied claim for review. While claims will usually be processed sooner than 90 days, the law provides that a 90-day period to process a claim is reasonable. The law also provides that if there are special circumstances, the 90-day period can be extended to 180 days. If an extension of time from 90 days is needed for processing, written notice of the extension will be furnished before the end of the initial 90-day period. The extension notice will indicate the special circumstances requiring an extension of time and the date by which a decision on the claim is expected to be given. If notice of the denial of a claim is not furnished in accordance with the 90- and 180-day time periods provided in this paragraph, you should consider the claim to be deemed denied, and you should proceed with the appeal process described below.

Appeal Process. If a claim is denied in whole or in part, you or your authorized representative have the right to request the Plan Administrator to review the claim. This request must be submitted in writing. You may appeal the denial by using the following procedure:

• Within 60 days of receipt of a notice of denial on the claim, or within 60 days after a claim is deemed denied, you (or your authorized representative) must send a written request for a review of the claim. Your request should be sent to the Claims Administrator, which will forward your request for review to the Plan Administrator. You may review pertinent documents and submit issues and comments in writing. These actions must be taken at your own expense.

• Within 60 days (or no later than 120 days if additional time is needed due to special circumstances) after the request for review is received, the Plan Administrator will make a decision. If special circumstances require additional time, you will be given written notice, before expiration of the initial 60-day period, that additional time is needed. The decision on review will be in writing and will include specific reasons for the decision, as well as specific references to the pertinent plan provisions on which the decision is based.

The Plan Administrator has the final discretionary authority to make benefit decisions, and its decision will be final and binding.

STATEMENT OF ERISA RIGHTS

If you are a Participant in the Medical Spending Account Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all Plan Participants shall be entitled to:

Examine, without charge, at your Plan Administrator’s office and at other specified locations such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, if any, and a copy of any latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.