Rock Hill Local School District

HRA CLAIM FORM

HRA ENROLLMENT FORM (NEW EMPLOYEES ONLY)

Necessary Documents on Left Panel

ABOUT THIS PLAN

This plan is designed to help pay for certain medical expenses. Your employer makes contributions to an account so that if you are a participant in this plan, you can be reimbursed for expenses incurred by you, and your eligible spouse and dependents.

WHAT THIS PLAN PAYS FOR

This plan will reimburse you for the following in-network expenses that you are required to pay under your group health plan:

 Medical Deductibles

Eligible expenses cannot also be reimbursed by another plan nor paid pre-tax by another health plan coverage or program.

The first $500 in deductible expenses will be paid by employee. The next $1,000 in deductible expenses will be paid by the HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The last $500 in deductible expenses will be paid by the employee. The total amount the employee may be reimbursed is $2,000.

This plan has an embedded deductible. This schedule will be applied per deductible (person) up to two deductibles. The first $500 in deductible expenses will be paid by employee. The next $1,000 in deductible expenses will be paid by the HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The next $500 in deductible expenses will be paid by the employee. The next $500 in deductible expenses will be paid by HRA (Employer). The last $500 in deductible expenses will be paid by the employee. The total amount the employee may be reimbursed is $4,000.

It is also easy to submit a claim form for reimbursement. Along with the claim form you will need to include the Explanation of Benefit (EOB). Your documentation must include the date of the expense, a description of the item or service, the name of the store or provider and the amount you must pay.

Save your receipts and other documentation. In many cases no further action is required, but occasionally we may need to ask you for additional documentation as proof that your expense was eligible.

Claims can be filed online at www.chard-snyder.com, emailed to askpenny@chard-snyder.com, through our mobile app, or faxed to 888.245.8452. Chard Snyder will issue payments directly to you by Direct Deposit for expenses that are reimbursable.

The runout period to submit a claim for active employees is 90 days after the end of the calendar year. The runout period to submit a claim for terminated employees is 90 days after the date of termination.

If you have questions about this plan, contact Chard Snyder online at www.chard-snyder.com, email askpenny@chard-snyder.com, or call 800.982.7715.

This is only a brief summary of this plan. Please see the Summary Plan Description (SPD) for more important information concerning this plan, such as the rules you must satisfy before you become eligible, the time period you have to submit a claim and other plan requirements. Your SPD is available through your human resources department.

Plan Summary

Federal regulations may change plan features without notice at any time. The information contained in this Page 2 of 2

publication is not, nor is it intended to be, legal or tax advice. © 2015 Chard Snyder & Associates, LLC. All rights reserved.