Flexible Spending Account (FSA) - Lourdes Health Network

Lourdes Health NetworkPasco, WAFlexible Spending Account(FSA)Summary Plan DescriptionEffective January 1, 2012January 2012 FSA SPD 1ENABLING STRENGTHS | INSPIRED PEOPLE | My Life. Even Better.

Plan OutlineLourdes Health Network | Flexible Spending Account (FSA) | Pasco, WAWho is eligibleEligibility DateBenefit AmountAll active full-time and part-time non-exempt employees assigned to work at least 48 hoursper pay period; All active full-time exempt, management, and professional hourly employeesassigned to work at least 40 hours bi-weekly per pay period.First day of the month following date of hireHealthcare Reimbursement AccountMinimum Annual Election $260Maximum Annual Election $2,500Dependent Daycare Reimbursement AccountMinimum Annual Election $260Maximum Annual Election $5,000Effective date: January 1, 2013Your Cost forCoveragePlan AdministratorThe associate pays the entire contribution on a pre-tax basis.ADPJanuary 2012 FSA SPD 2

Your Contact InformationFor Questions About EligibilityFor Questions About the PlansTo File a ClaimYour Local Human Resources DepartmentADP Participant ServicesTo speak with a representative, call 800.654.6695ADP Benefit Services2575 Westside Parkway, Suite 500Alpharetta, GA 30004-3852To Appeal a ClaimADP FSA Claims AppealP.O. Box 1801Alpharetta, GA 30023-1801For COBRA InformationCeridian Benefit Services800.877.7994www.ceridian-benefits.comJanuary 2012 FSA SPD 1

Your Rights Regarding Your Health Information ................................................................................. 32Who This Notice Applies To .................................................................................................................... 34Changes to This Notice .............................................................................................................................. 34Complaints ................................................................................................................................................... 34Section 7: Plan Information ........................................................................................................................... 35January 2012 FSA SPD 2

IntroductionAscension Health and your Participating Employer offer two flexible spending accounts(FSAs) — The Health Care FSA and the Dependent Care FSA — that let you set aside pretaxdollars from your paycheck to help pay for many common health care or dependent daycare expenses. Participation is voluntary and you can choose to enroll in either account, bothor neither.If you elect to participate in an FSA, a non-interest bearing bookkeeping account is set up tokeep a record of pre-tax contributions allocated to the account and any reimbursementsmade from the account for eligible expenses.This Information Is a SummaryThe information in this summary plan description (SPD) is intended to serve as a summaryof the Ascension Health Medical Expense Flexible Spending Plan, or “Health Care FSA”and the Ascension Health Dependent Care Flexible Spending Plan, or “Dependent CareFSA” (Plans), effective January 1, 2012. You should refer to the official Plan documents fordetails.“You” or “your” refers to theEligible Associate, any EligibleDependents, any QualifiedBeneficiary or othercontinuation participantcovered under the Plans.“Days” refers to calendar days.should not be construed as an employment contract.If there are any discrepancies between the informationin this SPD and the official Plan documents, the termsof the Plan documents will prevail.This SPD does not constitute a contract ofemployment or a guarantee of benefits or futureemployment. In addition, your eligibility for andparticipation in the Plans as described in this SPDCertain words in this SPD are capitalized. These words are defined in the “Glossary”section. You may find it helpful to consult the “Glossary” section as you read this SPD.The following pages of this SPD explain provisions that generally apply to EligibleAssociates of all Participating Employers that offer flexible spending accountbenefits.The “Plan Outline” section of this SPD contains specific requirements andprovisions that apply to Eligible Associates of your Participating Employer.January 2012 FSA SPD 3

GlossaryThe following terms may help you in reading and understanding this SPD.ADP —The claims administrator for the Plans.Associate — Any individual who is classified by a Participating Employer as an employee.Change Event — A change in status or change in family status event that is described in theInternal Revenue Code Section 125 cafeteria plan adopted by the Participating Employer of theEligible Associate.Change of Benefits Date — The effective date of a mid-year election change due to a ChangeEvent. The Change of Benefits Date for a Change Event related to birth, adoption or placement foradoption is the date of the birth, adoption or placement for adoption. The Change of Benefits Datefor all other Change Events is as soon as administratively possible after the requested change is filed.Child — The Eligible Associate’s natural child, legally adopted child, child placed with EligibleAssociate for adoption, foster child, or stepchild. Child shall also include any child for whom theEligible Associate has been granted court-appointed full legal custody or guardianship.COBRA — The continuation of health coverage that must be offered in accordance with theConsolidated Omnibus Budget Reconciliation Act of 1985.Eligible Associate — An Associate who is in the class of Associates eligible to participate in thePlan, as specified in the Addendum/Joinder Agreement of each Plan applicable to the ParticipatingEmployer and the “Plan Outline” section of this SPD. Eligible Associate does not include a leasedemployee or independent contractor, regardless of any retroactive reclassification as a common lawemployee.Eligible Dependent — An Eligible Associate’s Spouse or Child who is either less than age 26, or aChild who is age 26 or older if:− Unmarried,− Permanently and totally disabled prior to the attainment of age limits under the Plans,− Receiving over half his or her support from the Eligible Associate or Eligible Associate’s Spouse,and− Eligible to be claimed as a dependent on the Eligible Associate’s or Eligible Associate’s Spouse’sfederal income tax return.A Child is permanently and totally disabled if he or she is unable to engage in any substantial gainfulactivity by reason of any medically determinable physical or mental impairment that can be expectedto result in death or that has lasted or can be expected to last for a continuous period of not lessthan 12 months.January 2012 FSA SPD 4

Qualifying Individual — A person age 12 and under for whom you can claim on your federalincome tax return, or your Spouse or other dependent who is physically or mentally incapable orcaring for himself or herself and for more than one half of the year has the same principal residenceas you do.Spouse — An individual legally married to an Eligible Associate (even if legally separated), includingan individual who is the common-law spouse, in states that recognize common-law marriage, of anEligible Associate, if such individual and the Eligible Associate are of opposite sex.January 2012 FSA SPD 6

Section 1: Eligibility and ParticipationWhen you first become eligible to enroll in the Plans, your local Human ResourcesDepartment will provide an enrollment package that explains how to enroll, the deadline,and your share of the cost of coverage. You must notify your local Human ResourcesDepartment of any change (marriage, birth of a Child, change of address, etc.) within 30 daysof the event. If you don’t enroll when first eligible, you may enroll later at the next OpenEnrollment date (or earlier if your situation changes).EligibilityAll Associates in your Participating Employer’s class of Eligible Associates may participate inthe Plans. Please see the “Plan Outline” section of this SPD for your ParticipatingEmployer’s eligibility requirements.EnrollmentThis section describes the enrollment process for flexible spending account benefits.Initial Enrollment PeriodWhen you first become an Eligible Associate, your local Human Resources Department willsend you an enrollment package. It will explain all of the steps you need to take to enroll aswell as the deadline date for enrolling.If you enroll by the deadline, you will become enrolled onthe Entry Date specified by your Participating Employer.(Please see the “Plan Outline” section of this SPD.)If you fail to enroll during the initial enrollment period,you may enroll during the next Open Enrollment Periodor after a Change Event.Enroll on TimeIf you fail to enroll by thedeadline date stated in yourenrollment package, you willnot have coverage under thePlans until the nextenrollment opportunity.Open Enrollment PeriodYou may choose or change your participation in thePlans during your Participating Employer’s annualOpen Enrollment Period. The choices you makeduring the Open Enrollment Period will becomeeffective on the first day of the next Plan Year.Once payroll deductions have started, you may notmake any changes in your choices until the next PlanYear or until you have a Change Event.Update Your AddressBe sure to file your currentaddress and any changes ofaddress with your local HumanResources Department. Anycommunication addressed to youat your latest post office addresson file will be binding upon youfor all purposes of the Plans.January 2012 FSA SPD 7

When Coverage BeginsCoverage begins on the Entry Date indicated in the “Plan Outline” section of this SPD,provided you have completed any required enrollment materials and have made any requiredcontributions.When Coverage EndsEligible AssociatesYour coverage ends at 11:59 p.m. on the date in which you no longer meet the definition ofEligible Associate. You may continue Health Care FSA coverage, at your cost, for a limitedtime. (Please see the “COBRA Continuation Coverage for the Health Care FSA” section ofthis SPD.) Different rules may apply in the event of salary continuation or severancepayments.Eligible DependentsYour dependents’ coverage ends at 11:59 p.m. on the date in which they no longer meet thedefinition for Eligible Dependent.Termination for CauseYour coverage can also be terminated for Cause. If your coverage is terminated retroactively,you may be required to repay benefits you received after the date your coverage isterminated.Coverage Can Be Terminated for “Cause”Your coverage can be terminated for:• Your failure to complete, sign and/or provide to the Plan Administrator anyinformation, document or form that Ascension Health determines isreasonably necessary for the administration of the Plans or Plan Sponsorfunctions• Willful engagement in misconduct that is materially injurious to the Plans• Dishonesty in connection with the provision of benefits under the Plans• Fraudulent or unethical conduct or an intentional misrepresentation of amaterial fact related to or affecting the provision of benefits under the Plans• Being indicted or charged with any crime constituting a felony• Failure to pay any amounts due to the Plans or a Participating EmployerCoverage can be terminated retroactively for:• Failure to timely pay Participant Contributions• Fraudulent or unethical conduct or an intentional misrepresentation of amaterial fact related to the provision of benefits under the PlansJanuary 2012 FSA SPD 9

ReinstatementIf, during the same Plan Year, you terminate employment and return to employment within30 days, your prior elections will be reinstated automatically. However, if you return after 30days or longer, you will be treated as a new hire (see “Initial Enrollment Period”) unless yourParticipating Employer has a different rule for reinstatement.COBRA Continuation Coverage for Health Care FSAUnder the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), QualifiedBeneficiaries have the option of continuing participation in the Health Care FSA until theend of the plan year at group rates if the Eligible Associate would otherwise lose coveragebecause of any of the following events:• You no longer are employed by your Participating Employer (whether voluntarily orinvoluntarily, except if terminated for gross misconduct).• Your work hours are reduced below the minimum level necessary to be eligible for theHealth Care FSA.• You move to a position with your Participating Employer in which you are not eligible toparticipate in the Health Care FSA.While termination of employment normally triggers a right to only 18 months ofcontinuation coverage, if your employment terminates less than 18 months after you becomeentitled to Medicare, the continuation coverage for your Eligible Dependents who areQualified Beneficiaries can continue for 36 months after the date on which you becomeentitled to Medicare.Each Qualified Beneficiary will have an independent right to elect continuation coverage.Covered Eligible Dependents who are Qualified Beneficiaries can continue to be coveredunder the Medical Expense Flexible Spending Plan for up to 36 months if they wouldotherwise lose coverage due to any of the following events:• The Eligible Associate dies• The Eligible Associate and his or her Spouse divorce orbecome legally separated• An Eligible Dependent Child no longer satisfies theMedical Expense Flexible Spending Plan’s definition ofEligible Dependent (for example, the Child reaches theEligible Dependent age limit)Qualified Beneficiaries aresubject to the same rightsand rules as those whoparticipate in the HealthCare FSA.Extended Coverage for Disabled IndividualsQualified Beneficiaries may be able to extend coverage for themselves and other familymembers who are Qualified Beneficiaries for up to an additional 11 months if they:• Are disabled on the date of eligibility for continuation coverage, or• Become disabled within the first 60 days of the continuation coverage period.January 2012 FSA SPD 10

To qualify, the Social Security Administration must officially determine that the personbecame disabled prior to the 61 st day of the continuation coverage period. Also, that personmust notify the Participating Employer in writing of this disability determination before thefirst 18 months of continuation coverage ends and within 60 days after receiving notificationfrom Social Security that the disability determination has been made. (Please see the “YourContact Information” section of this SPD).If the disability ends during the 11 months of extended coverage, that person must notifythe Participating Employer within 30 days. Continuation coverage will end on the last day ofthe month in which the disability ends.CostIndividuals who choose continuation coverage must pay for such coverage. They will becharged up to 102% of the full cost of coverage depending on the coverage option theychoose. Disabled Qualified Beneficiaries and their family members who choose to continuecoverage beyond their initial 18-month continuation period will be charged up to 150% ofthe full cost of coverage during the 11-month disability extension. Contributions must bepaid from the date coverage otherwise would have ended.Second Qualifying EventIf a Qualified Beneficiary other than an Eligible Associate elects continuation coverage andexperiences a second qualifying event within the initial 18-month period, he or she may beable to extend coverage further, but only up to a total of 36 months. The second qualifyingevent must occur while the Qualified Beneficiary has continuation coverage.For example, the family of an Eligible Associate who is laid off becomes eligible for18 months of continuation coverage. They elect the coverage and then, 7 monthslater, the Eligible Associate dies. The surviving covered Eligible Dependents areentitled to 36 months of continuation coverage from the date of the EligibleAssociate’s termination of employment (the initial qualifying event).You must send a written notice of the second qualifying event to the Participating Employerat the address shown in the “Your Contact Information” section of this SPD.NotificationYou must notify the Participating Employer within 60 days after a divorce or legal separationoccurs or within 60 days after a covered Eligible Dependent Child loses eligible status. Thisnotice must be sent to the Participating Employer at the address shown in the “YourContact Information” section of this SPD. Failure to provide this notice within the requiredtimeframe will result in a loss of COBRA continuation coverage rights.Once the Participating Employer receives the notice, the Participating Employer will send acontinuation of coverage notice to the individuals in question along with a continuation ofcoverage election form, which allows the individuals to indicate whether they want suchcoverage.January 2012 FSA SPD 11

Individuals must elect continuation coverage within 60 days after the later of:• The date active coverage ceases under the Plan, or• The date of the notice informing such individuals of their COBRA continuation rights.TerminationContinuation coverage will end before the maximum coverage period if one of these eventsoccurs:• You fail to make contributions on time• You become entitled to Medicare after you have elected COBRA continuation coverage• The Participating Employer stops providing group health care coverage for Associates• You become covered under another group health program after you have electedCOBRA continuation coverage• You cease to be disabled during the 11-month disability extension period• The Plan Administrator terminates your coverage for CauseIf you have questions concerning your continuation coverage rights, you should contact theCOBRA service provider (see the “Your Contact Information” section of this SPD). Inorder to protect your family’s COBRA rights, you should keep your Participating Employerand the Plan Administrator informed of any changes in the addresses of your familymembers. You should also keep a copy, for your records, of any notices sent to the PlanAdministrator or your Participating Employer.USERRA Continuation Coverage for Health Care FSAIf you are called to serve in the United States uniformed services, your benefits under theHealth Care FSA may be protected by the Uniformed Services Employment andReemployment Rights Act of 1994 (USERRA). You may qualify to choose to continuecoverage under the Health Care FSA for up to 24 months from the date your leave ofabsence begins.USERRA was signed into law in order to ensure that, under certain conditions, those who servetheir country can retain their civilian employment and benefits. The continuation coveragemandated under USERRA is separate coverage from that provided under COBRA, althoughthey may run concurrently, which means that they begin at the same time. However, COBRAcoverage can continue for up to 18 months, while USERRA coverage can continue for up to 24months. In addition, COBRA coverage may be terminated for additional reasons that do notapply to USERRA coverage. Eligibility for TRICARE (formerly CHAMPUS) or active dutymilitary coverage will not terminate coverage under USERRA continuation coverage.If your period of uniformed service is less than 30 days, you are not required to pay more forUSERRA coverage than the amount you pay for coverage under the Medical ExpenseFlexible Spending Plan as an active Eligible Associate. For longer periods, your cost forUSERRA coverage will be the same as for COBRA continuation coverage — 102% of thefull cost of coverage.January 2012 FSA SPD 12

If you were ever on a leave of absence due to military service or are thinking about leavingemployment to serve in the military, please contact your local Human ResourcesDepartment to learn more about your rights under USERRA.Qualified Medical Child Support OrderThe Medical Expense Flexible Spending Plan will provide benefits in accordance with theapplicable requirements of any Qualified Medical Child Support Order (as defined in Section609(a) of ERISA) as soon as administratively feasible after the Plan Administratordetermines that the medical child support order is a Qualified Medical Child Support Order,as described below.DefinitionsFor purposes of this section, the following terms will have the meanings given them below:• “Alternate recipient” means any Child of a Participant who is recognized under a medicalchild support order as having a right to participate in the Medical Expense FlexibleSpending Plan.• “Medical child support order” means a judgment, decree or order issued by a court ofcompetent jurisdiction, including approval of a settlement agreement, which is eithermade pursuant to a State domestic relations law and provides for child support and/orhealth benefit coverage for a Child of a Participant, or which enforces a law relating tomedical child support described in section 1908 of the Social Security Act, as added bysection 13822 of the Omnibus Budget Reconciliation Act of 1993 (Medicaid), withrespect to the Medical Expense Flexible Spending Plan.• “Qualified Medical Child Support Order (QMCSO)” means a medical child supportorder which creates, recognizes or assigns to an alternate recipient the right to receivemedical benefits for which a Participant is eligible under the Medical Expense FlexibleSpending Plan. In order to be qualified, the order must:− Clearly specify the name and address of the Participant and each alternate recipientcovered by the order and reasonably describe the type of coverage to be provided orthe manner in which such coverage can be determined− Specify the period to which the order applies and the plans which are subject to theorder− Not require that the Medical Expense Flexible Spending Plan provide any type orform of benefit or any option not otherwise provided under the Medical ExpenseFlexible Spending Plan, except to the extent necessary to meet the requirements of alaw relating to medical child support described in section 1908 of the Social SecurityAct (Medicaid)ProceduresThe Plan Administrator will use the following procedures to verify whether any judgment,decree or order is a QMCSO and to administer the provision of benefits under any suchorder, subject to such changes as are consistent with applicable law and regulations:January 2012 FSA SPD 13

• Upon receiving a medical child support order, the Plan Administrator will promptlynotify the Participant and the alternate recipient of the receipt of the order and theMedical Expense Flexible Spending Plan's procedures for determining whether the orderis a QMCSO. Within a reasonable period thereafter, the Plan Administrator willdetermine whether the order satisfies the requirements for a QMCSO and notify theparties of its decision.• The alternate recipient will be permitted to designate a representative for the receipt ofcopies of notices that are sent to the alternate recipient.Status of Alternate RecipientsFor all purposes under ERISA, an alternate recipient will be treated as a beneficiary underthe Medical Expense Flexible Spending Plan.Right to Amend or Discontinue the PlansAscension Health and your Participating Employer are committed to maintaining the Plans.However, Ascension Health (the Plan Sponsor) reserves the right to amend or terminate thePlans in whole or in part, at any time, and for any reason, without advance notice. Amendmentor termination of the Plans shall be effective if it is approved in writing by a duly authorizedofficer of Ascension Health, or if it is adopted pursuant to Ascension Health’s proceduresallocating or delegating authority to act on behalf of Ascension Health, as such proceduresexist from time to time.Any Participating Employer will be permitted to discontinue or revoke its participation in thePlans. Coverage under these Plans will automatically terminate with respect to all Participantsof a Participating Employer as of the date the Participating Employer ceases to participate inthe Plans.January 2012 FSA SPD 14

Section 2: Flexible Spending Account (FSA) BenefitsParticipation in FSA benefits is optional. If you wish to participate, you may contribute toeither the Health Care FSA, Dependent Care FSA or both. The two accounts are separatebut work in similar ways. Each year, you specify how much of your pay you want depositedinto each account. This amount is deducted from your paycheck on a pre-tax basis in equalamounts each pay period, and is then deposited into your account.Be careful and conservative when estimating how much toput into your FSAs. You will forfeit any amounts not usedfor eligible expenses incurred during the Plan Year.Fortunately, many health care and dependent day careexpenses are predictable from year to year. Even expensesthat are not routine may be known well in advance, likenonemergency surgery and childbirth.The Health Care FSA andDependent Care FSA arecompletely separateaccounts. You may not usedeposits to your Health CareFSA to fund dependent daycare expenses or vice versa.Since you do not pay federal income tax on the money inyour FSAs, every time you use your account to pay for an eligible expense, it’s like getting adiscount equal to your income tax bracket. You don’t pay FICA (Social Security) taxes, or, inmost cases, state taxes, on this money either, increasing your tax savings even more.Health Care FSAHow the Health Care FSA WorksThe Health Care FSA helps you save money on health careexpenses that aren’t covered by a medical, prescriptiondrug, dental or vision plan. If you wish to participate in theHealth Care FSA, estimate your health care expenses forthe upcoming Plan Year; then decide how much to depositinto your account. When estimating expenses, considerthat the Health Care FSA covers Eligible Health CareExpenses incurred by both you and your EligibleFor an Eligible Health CareExpense to be reimbursed,you must have incurred theexpense between January 1of the current Plan Year andDecember 31 of the sameyear.Dependents. Also, you and your Eligible Dependents do not have to be enrolled in any ofthe Ascension Health health care plans to participate in the Health Care FSA.Your deposits into your Health Care FSA are made in equal amounts from each paycheckwith convenient pre-tax payroll deductions. When you have an Eligible Health CareExpense, you either use your electronic payment card at the time the expense is incurred, orsubmit a claim to reimburse yourself with pre-tax dollars from your account.January 2012 FSA SPD 15

Electronic Payment CardThe electronic payment card allows you to pay for Eligible Health Care Expenses at the timeyou incur the expense. Here’s how it works:• You elect to use the card — You must agree to abide by the terms and conditions of thecardholder agreement, including any fees applicable to use the card, limits to the cardusage, and the Health Care FSA’s right to withhold and offset for ineligible claims.• Use the card at any eligible merchant — At the time you incur Eligible Health Care Expenses,use the card as you would any other credit or debit card.• Retain your receipts — Keep all your receipts for one year following the close of the PlanYear in which the expense is incurred. You may need to submit the receipt to the PlanAdministrator to substantiate a claim. Make sure your receipts include the nature of theexpense, date the expense was incurred and the amount of the expense.Health Care FSA Deposit LimitsThe maximum deposit you can make to the Health Care FSA per Plan Year varies byParticipating Employer (see the “Plan Outline” section of this SPD for your ParticipatingEmployer’s maximum deposit amount); the minimum deposit amount is $260.The full amount that you have elected as your annualdeposit is available at any time during the Plan Year(reduced by any prior reimbursements) to pay for eligibleexpenses, regardless of how much you have contributed tothe Health Care FSA up to that point.The amount you elected foryour annual deposit isavailable to you at any timeduring the Plan Year tocover Eligible Health CareExpenses.Covered Health Care ExpensesTo be eligible for reimbursement under the Health CareFSA, expenses must be incurred for the diagnosis, cure, relief, treatment or prevention ofsickness or injury. The following are examples of Eligible Health Care Expenses under theHealth Care FSA:• Amounts not paid by your (or your Spouse’s) medical, prescription drug, dental or visioncoverage, including:− Deductibles− Copayments for your share of expenses paid as a percentage− Amounts above the limits for medical, prescription drug, dental and vision plans• Non-covered dental, vision (exams, frames, lenses and contact lenses) and hearing care(exams and aids)• Non-covered physician fees• Hospital services, including anesthesiology• Diagnostic services, including laboratory and x-ray fees• Prescription medications, including insulin• Nursing services for care of a specific medical condition

• Hospice care• Chiropractor and osteopath services• Psychotherapist, psychiatrist and psychologist services• Treatment for alcoholism or drug dependency• Physical therapy• Acupuncture• Organ donation expenses• Cost of guide or seeing-eye dog for the blind• Orthodontia expenses not paid by a dental plan• Wheelchair and costs for equipping an auto for a disabled person• Crutches and artificial teeth or limbs• Oxygen and oxygen equipment• Certain smoking cessation programs and prescription drugs designed to alleviate nicotinewithdrawal• Weight reduction programs undertaken at a physician’s direction to treat an existingdisease• Over-the-counter medications and drugs for which you have a prescription from yourphysician• Any other out-of-pocket medical, prescription drug, dental or vision expenses allowed asdeductions by the IRS on your federal tax return (except insurance premiums)Exclusions – The Health Care FSA does not cover:• Premiums for health, auto, disability, accident, life or long-term care insurance• Health spa and club memberships, dance lessons or weight reduction programs forgeneral health maintenance• Cosmetic surgery and other similar procedures (unless related to a congenital defect,accidental injury or disfiguring disease)• Nonprescription drugs (including vitamins), cosmetics and dietary supplements that arefor the purpose of improving or maintaining general health• Nonmedical expenses, such as electronic air filters and hot tubs, unless prescribed by aphysician• Physical treatments (e.g. massage) that aren’t related to a specific health condition• Transportation expenses to and from work, even if disabled• Illegal operations and treatments• Custodial care in an institution• Long-term care services• Marriage and family counseling or divorce costs• Expenses incurred before you begin contributing to the Health Care FSA• Any other expenses specifically excluded in the “Plan Outline” section of this SPD orenrollment materialsFor a complete list of eligible and ineligible expenses, see Code Section 213(d) and IRSPublication 502, “Medical and Dental Expenses.” You may request these publications fromthe IRS, or view them online by going to www.irs.gov/formspubs/index.html.January 2012 FSA SPD 17

Dependent Care FSAHow the Dependent Care FSA WorksIf you wish to participate in the Dependent Care FSA,estimate your dependent day care expenses for theupcoming Plan Year; then decide how much to depositinto your account.When estimating expenses, consider that the DependentCare FSA covers only those expenses necessary:You have from January 1 ofthe current enrollment yearto December 31 of the sameyear to incur EligibleDependent Day CareExpenses.• For you to work,• For your Spouse to work, attend school full time, or look for work,• For you to work part time and attend school full time, or• Because your Spouse is incapacitated.Your deposits into your Dependent Care FSA are made in equal amounts from eachpaycheck with convenient pre-tax payroll deductions. When you have an Eligible DependentDay Care Expense, submit a claim to reimburse yourself with pre-tax dollars from youraccount.Dependent Care FSA Deposit LimitsThe maximum deposit you can make to the Dependent Care FSA per Plan Year is based onyour tax filing status as follows:• Single or married and filing jointly — $5,000• Married filing separately — $2,500You may only be reimbursedup to the balance in youraccount at the time yourclaim is processed to coveryour Eligible Dependent DayCare Expenses.In addition, if you are married, your annual deposit amountcannot exceed the earned income of the lower-paidSpouse. If your Spouse is a student or incapacitated, yourSpouse is considered to “earn” $250 per month if you haveone Child or $500 if you have two or more Children.If your Spouse is employed elsewhere and contributes to asimilar account, your family cannot contribute more thanthe maximum amount allowed by this Dependent Care FSA, dependent upon your tax filingstatus as listed above.The minimum deposit you can make to the Dependent Care FSA is $260.The amount available to you for reimbursement of Eligible Dependent Day Care Expensesis the amount of your account balance at the time your request is processed.

Covered Dependent Care ExpensesThe following are examples of Eligible Dependent DayCare Expenses and are only covered if the individualreceiving care is considered to be a Qualifying Individualunder the Dependent Care FSA:• Dependent day care provided in your home by ababysitter, housekeeper or relative who is not adependent• Dependent day care provided outside your home,including qualified day care centers, day camp,preschool and before- and after-school programs• Elder care for dependents who live with you.Generally, eligible child care costs include only those forthe actual care of your Child or disabled Spouse — notcosts for education, supplies or meals, unless those costscannot be separated from the cost of care.Exclusions – The Dependent Care FSA does not coverexpenses for:“Qualifying Individual”means an EligibleDependent:• You can claim on yourfederal income taxreturn who is age 12 orunder, and for whom youare the custodial parentfor more than one halfof the year; or• Who is your Spouse orother dependent who isphysically or mentallyincapable of caring forhimself or herself, liveswith you for at least halfthe year and isconsidered to be yourtax dependent.• Care provided by your Child under age 19 or any other dependent you claim on your taxreturn• Care obtained for reasons other than work, such as social and volunteer activities• Care that could be provided by your employed Spouse while not at work• Care provided by your Spouse or the parent of the Qualifying Individual• Overnight camp• Food, clothing, education (kindergarten and above), entertainment and transportation toand from the day care location• Agency referral charges and finder’s fees• Care paid for by another organization or provided at no cost to you• Nursing home and other dependent day care services for dependents not living with youat least eight hours a day• Dependents not considered to be Qualifying Individuals under the Dependent Care FSA• Charges incurred before you begin contributing to the Dependent Care FSA• Any other services specifically excluded in the “Plan Outline” section of this SPD orenrollment materialsThe Dependent Care FSA also does not cover expenses claimed as a federal income taxcredit.For a complete list of eligible and ineligible expenses, see IRS Publication 503, “Child andDependent Care Expenses.” You may request this publication from the IRS, or view itonline by going to www.irs.gov/formspubs/index.html.

Section 3: Other Plan ProvisionsUse It or Lose It RuleThe FSAs can be a very valuable benefit for you. Inexchange for the tax savings offered, the IRS imposes whatis known as the “Use It or Lose It” rule. This rule statesthat all of your annual deposit must be spent on eligibleexpenses you incur during the Plan Year, or any leftovermoney must be forfeited. Forfeited money is used by thePlan Administrator to offset administrative expenses andfuture costs of the Plans.Please note: Because the Health Care FSA and DependentCare FSA are separate accounts, you may not use moneyfrom your Health Care FSA to pay for dependent day careexpenses or vice versa.Go online towww.flexdirect.adp.com tocheck the balance in yourFSA account at any time. Ifyou don’t spend your annualdeposit on eligible expensesduring the Plan Year, anymoney left over in youraccount will be forfeited.Once the Plan Year hasended, you have until March31 of the following year tosubmit a claim forexpenses.Effect of FSA Participation on Tax Creditsand Social Security BenefitsParticipating in an FSA may affect other tax credits and benefits. Consult your tax advisor tosee how these provisions might affect your personal tax situation.Claim for Household and Dependent Care CreditYou may not claim any other tax benefit for the tax-free amounts received by you under theDependent Care Flexible Spending Plan. However, if you have any unreimbursed dependentcare expenses remaining after depleting your Dependent Care FSA account, those amountsmay be eligible for the dependent care credit on your federal income tax return.Social Security Benefits and Other Tax-Related BenefitsWhen you contribute to an FSA, it reduces the amount of your taxable compensation.Accordingly, there could be a decrease in your Social Security benefits and/or other benefits(e.g. pension, disability and life insurance) that are based on taxable compensation. However,in most cases, any possible reduction in these benefits is far outweighed by the tax savingsyou receive by using an FSA.Qualified Reservist DistributionAscension Health has adopted the qualified reservist distribution provisions of the HEARTAct (Heroes Earnings Assistance and Relief Tax Act of 2008) into its Health Care FSA.Under this provision, Participants in the Medical Expense Flexible Spending Plan who arecalled to active duty in the U.S. military for at least 180 days can receive a distribution,

without penalties, of the unused balance from their Health Care FSA ― amounts that mayotherwise be forfeited.To qualify for this distribution, you must be a “reservist” as defined in 37 U.S.C. Section101, which means you must be a member of one of the following:• Army National Guard of US• Army Reserve• Navy Reserve• Marine Corps Reserve• Air National Guard of US• Air Force Reserve• Coast Guard Reserve• Reserve Corps of the Public Health ServiceYour request for distribution must be made after the order for active duty is issued, butbefore the last day of the Plan Year.The amount of your distribution is restricted to the amount actually contributed to theHealth Care FSA at the time of the request, minus any reimbursements actually received.This distribution is taxable, and will be reported as income on your W-2 for the year inwhich you receive the distribution.To apply for a Qualified Reservist Distribution, you must complete the Qualified ReservistDistribution Form available from your local Human Resource Department. The approvedreimbursement amount will be processed through the Plan Administrator.January 2012 FSA SPD 21

Section 4: Claims ProceduresTo be reimbursed for Eligible Health Care and Dependent Day Care Expenses, you willneed to submit a Request for Reimbursement Form along with a written statementsubstantiating your claim. Claim forms are available from ADP or your local HumanResources Department.Please note: If you pay for your Eligible Health Care Expenses with your electronic paymentcard, you will not need to file a claim. However, remember to save your receipts for one yearin case ADP requests copies to verify your claim.Filing a ClaimWhen you incur an Eligible Health Care or Dependent Day Care Expense, you must pay forthe expense at the time of purchase or billing, if applicable, and then file a claim forreimbursement. Request for Reimbursement Forms are available from ADP or your localHuman Resources Department. You do not need to file a claim for Eligible Health CareExpenses that are paid with your electronic payment card.Expenses are incurred on the date the service is rendered, not billed (except for durablemedical equipment, such as a wheelchair). In addition, expenses must be incurred in thesame Plan Year you make deposits to your FSA. You have until March 31 of the followingyear to submit claims for expenses incurred during the prior Plan Year. For example, for2012, you have from January 1, 2012 to March 31, 2013 to submit your claims forreimbursement for your 2012 Eligible Health Care and Dependent Day Care Expenses.Process for Submitting ClaimsSend the completed Request for Reimbursement Form to ADP at the address on the form,along with appropriate documentation as follows:

Health Care AccountDocumentation Needed • Itemized statement fromthe provider with name ofperson receiving theservices or materials, date(s)of service, nature ofexpense and amount ofexpense, orAmount Reimbursed• Explanation of Benefits(EOB) from the Plan, or• If the expense is for anover-the-counter drug ormedicine (other thaninsulin), a receipt from thepharmacy with theprescription numberUp to the total deposit electedfor the Plan YearDependent Care AccountItemized bill including namesof dependent and provider(must also give provider’sSocial Security or tax IDNumber) date(s) of service,nature of services and amountof expenseUp to the current accountbalanceYou may be required to submit additional substantiation to the extent deemed necessary byADP to support your claim.After your information is received, ADP will process your claim. If the claim is determinedto be an eligible expense, you will receive reimbursement as soon as possible. If the expenseis determined to be ineligible, you will receive notification as such.Timing of Claims ReviewAfter you file a claim, ADP will notify you of its benefit determination within 30 days afterreceipt of claim. This period may be extended one more time for up to 15 days if theextension is necessary due to matters beyond the control of the Plans. You will be providedwritten notice of the need for additional time prior to the end of the 30-day period.If the reason for the additional time is that you need to provide additional information, youwill have 45 days from the notice of this extension to obtain that information. The timeperiod during which ADP must make a decision will be suspended until the earlier of thedate you provide the information and/or the end of the 45-day period.

If Your Claim is DeniedIf your claim is denied, a notice of adverse benefit determination will be provided in writingor electronically and will include:• The specific reason or reasons for the denial,• Reference to the specific Plan provisions on whichthe denial is based,• A description of any additional informationnecessary for you to perfect your claim, why theinformation is necessary and your time limit forsubmitting the information,• A description of the Plan’s review procedures andthe time limits applicable to such procedures, and• Your right to request all documentation relevant toyour claim.Appealing a Denied ClaimIf you disagree with the claim denial, you or anauthorized representative may file a written appealwithin 180 days after the receipt of the original noticeof denial. You should submit all information identifiedin the notice of denial as necessary to perfect yourclaim and any additional information you believe wouldsupport your claim.If you need assistanceunderstanding your benefitdetermination or havequestions about your rights toappeal a denied claim, contactADP.To appeal a claim, you willneed to send notification ofyour desire to appeal within180 days from receipt of yourclaim denial. Be sure to includethe following:• Participant’s name• ID and claim numbersAlso, indicate whether theperson requesting the appeal isthe Eligible Associate, EligibleDependent or authorizedrepresentative.If the claim is again denied, you will be notified inwriting no later than 30 days after receipt of the appeal by ADP. When you receive yourdenial of appeal notice from ADP, the notice will contain the same items as listed under the“If Your Claim is Denied” section.You may file a written appeal with the Plan Administrator within 60 days after receiving thefirst level appeal denial notice from ADP if you still disagree with the decision. You shouldsubmit all information identified in the notice of denial as necessary to perfect your claimand any additional information you believe would support your claim.If the Plan Administrator denies your second level appeal, you will receive notice within 30days after the Plan Administrator receives your claim. The notice will contain the same itemsas listed under the “If Your Claim is Denied” section.

Other Important Appeals Information• Each level of appeal will be independent from the previous level (i.e., the same person(s)or subordinates of the same person(s) involved in a prior level of appeal would not beinvolved in the appeal).• On each level of appeal, the claims reviewer will review relevant information you submit,even if it is new information.• The Plan Administrator is required to give the Participant notice of any internal rules,guidelines, protocols or similar criteria used as a basis for the adverse determination.• You cannot file suit in federal court until you have exhausted these appeals procedures,however, you have the right to file suit under ERISA Section 502 following an adverseappeal decision.• Participants have the right to request and obtain documents, records and otherinformation as it pertains to their claim and the Plans.Additional RecourseIf you have exhausted the appeals process and ADP continues to deny your claim or you donot receive a timely decision, you have the right to bring a civil action under Section 502(a)of ERISA if you are not satisfied with the decision on review. You and the PlanAdministrator may have other voluntary alternative dispute resolution options, such asmediation. One way to find out what may be available is to contact your local U.S.Department of Labor office. You may also contact the Employee Benefits SecurityAdministration at 866.444.3272.Overpayment of ClaimsIf any benefit is mistakenly paid or overpaid by the Plans, either in whole or in part, the PlanAdministrator reserves the right to offset amounts to be paid in the future as benefits underthe Plans with respect to you or any members of your family, or to recover such mistakenlypaid amounts or overpayments from and among any person to, or for, or with respect towhom such amounts were paid. Any Associate who performs services that are or may becompensated in part by benefits payable pursuant to the Plans hereby consents to venue andjurisdiction of any court in which the Plan Administrator files suit in accordance with thissection.MisrepresentationsAnyone who, with intent to defraud or knowing that he/she is facilitating a fraud, submitsan application or files a claim containing a false, incomplete or misleading statement is guiltyof fraud. The Plan Administrator reserves the right to take appropriate action in any instancewhere fraud is an issue.

Section 5: Your ERISA RightsAs a Participant in the Medical Expense Flexible Spending Plan, you are entitled to certainrights and protections under ERISA.Receiving Information About the Plan and BenefitsYou have the right to:• Examine, without charge, at the Plan Administrator’s office and at other specifiedlocations, such as worksites and union halls, all documents governing the MedicalExpense Flexible Spending Plan, including insurance contracts and collective bargainingagreements, and a copy of the latest annual report (Form 5500 Series) filed by theMedical Expense Flexible Spending Plan with the U.S. Department of Labor andavailable at the Public Disclosure Room of the Employee Benefits SecurityAdministration.• Obtain, upon written request to the Plan Administrator, copies of documents governingthe operation of the Medical Expense Flexible Spending Plan, including insurancecontracts and collective bargaining agreements, and a copy of the latest annual report(Form 5500 Series) and updated SPD. The Plan Administrator may make a reasonablecharge for the copies.• Receive a summary of the Medical Expense Flexible Spending Plan’s annual financialreports. The Plan Administrator is required by law to furnish each Participant with acopy of this summary annual report.Continuing Your Group Health CoverageYou have the right to continue health care coverage for yourself, Spouse or dependents ifthere is a loss of coverage under the Medical Expense Flexible Spending Plan as a result of aqualifying event. You or your dependents may have to pay for such coverage. Review thisSPD and the documents governing the Medical Expense Flexible Spending Plan for therules that explain your COBRA continuation rights.Prudent Actions by Plan FiduciariesIn addition to creating rights for Participants in the Plan, ERISA imposes duties upon thepeople who are responsible for the operation of the Plan. The people who operate theMedical Expense Flexible Spending Plan, called “fiduciaries” of the Medical ExpenseFlexible Spending Plan, have a duty to do so prudently and in the interest of you and otherParticipants in the Plan and beneficiaries. No one, including your Participating Employer,your union, or any other person, may fire you or otherwise discriminate against you in anyway to prevent you from obtaining a welfare benefit or exercising your rights under ERISA.January 2012 FSA SPD 26

Enforcing Your RightsIf your claim for a welfare benefit is denied or ignored, in whole or in part, you have a rightto know why this was done, to obtain copies of documents relating to the decision withoutcharge, and to appeal any denial, all within certain time schedules.Under ERISA, there are steps you can take to enforce the above rights. For instance, if yourequest a copy of the documents that govern the Medical Expense Flexible Spending Plan orthe latest annual report from the Medical Expense Flexible Spending Plan and do not receivethem within 30 days, you may file suit in a federal court. In such a case, the court mayrequire the Plan Administrator to provide the materials and pay you up to $110 a day untilyou receive the materials, unless the materials were not sent because of reasons beyond thecontrol of the Plan Administrator.If you have a claim for benefits that is denied or ignored, in whole or in part, you may filesuit in a state or federal court. In addition, if you disagree with the Plan Administrator’sdecision or lack thereof concerning the qualified status of a medical child support order, youmay file suit in federal court. If it should happen that the fiduciaries of the Medical ExpenseFlexible Spending Plan misuse the Medical Expense Flexible Spending Plan’s money, or ifyou are discriminated against for asserting your rights, you may seek assistance from the U.S.Department of Labor, or you may file suit in federal court. The court will decide who shouldpay court costs and legal fees. If you are successful, the court may order the person you havesued to pay these costs and fees. If you lose, the court may order you to pay these costs andfees, for example, if it finds your claim is frivolous.Assistance with Your QuestionsIf you have any questions about the Medical Expense Flexible Spending Plan, you shouldcontact ADP. If you have any questions about this statement or about your rights underERISA, or if you need assistance in obtaining documents from the Plan Administrator, youshould contact the nearest office of the Employee Benefits Security Administration, U.S.Department of Labor, listed in your telephone directory or the Division of TechnicalAssistance and Inquiries, Employee Benefits Security Administration, U.S. Department ofLabor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtaincertain publications about your rights and responsibilities under ERISA by calling thepublications hotline of the Employee Benefits Security Administration.January 2012 FSA SPD 27

Section 6: Group Health Plan Privacy Practice NoticeThis Notice describes privacy practices relating to the Medical Expense Flexible SpendingPlan and does not apply to the Dependent Care Flexible Spending Plan. Please review thissection carefully as it describes how health information about you may be used and disclosedand how you can get access to this information.Our ResponsibilitiesAscension Health takes the privacy of your health information seriously. The MedicalExpense Flexible Spending Plan is required by law to maintain that privacy and to provideyou with this Notice of Privacy Practices. This Notice is provided to tell you about ourduties and practices with respect to your information. The Medical Expense FlexibleSpending Plan is required to abide by the terms of this Notice currently in effect.How We May Use and Disclose Your Health InformationThe following categories describe different ways we use and disclose health information. Foreach category we explain what we mean and give some examples. Not every use ordisclosure in a category will be listed. However, all of the ways the Medical Expense FlexibleSpending Plan is permitted to use and disclose information will fall within one of thecategories.• To the Plan Sponsor. The Medical Expense Flexible Spending Plan may disclose yourinformation to the Plan Sponsor in certain situations, and may permit any healthinsurance company or HMO with whom you have benefits to disclose your informationto the Plan Sponsor. The Plan document that governs the Medical Expense FlexibleSpending Plan must restrict how the Plan Sponsor uses and discloses your information,however.In addition, the Medical Expense Flexible Spending Plan may disclose your "summaryhealth information" to the Plan Sponsor to obtain premium bids from health plans forthe Medical Expense Flexible Spending Plan’s coverage or to amend the MedicalExpense Flexible Spending Plan. "Summary health information" means your informationthat identifies you and summarizes your claims history, expenses or types, but theinformation will not identify you any more specifically than your ZIP code.Also, the Medical Expense Flexible Spending Plan may disclose to the Plan Sponsorwhether or not you are participating in the Medical Expense Flexible Spending Plan orare enrolled or disenrolled. The Medical Expense Flexible Spending Plan may discloseyour information to the Plan Sponsor to carry out plan administration functions.January 2012 FSA SPD 28

The Medical Expense Flexible Spending Plan may not disclose your information to thePlan Sponsor for the purpose of employment-related actions or decisions or inconnection with any other employee benefit plan of the Plan Sponsor.• For Payment. We may use and disclose your health information for the purpose of:− Obtaining premiums or to determine or fulfill the responsibility for coverage andprovision of benefits under the Medical Expense Flexible Spending Plan− Coordination of benefits or the determination of cost sharing amounts− Adjudication or subrogation of health benefit claims− Processing claims− Billing− Claims management− Collection activities− Obtaining payment under a contract for reinsurance (including stop-loss insuranceand excess of loss insurance)− Review of health care services with respect to medical necessity− Coverage under a health plan− Appropriateness of care, or justification of charges for the treatment and servicesprovided to you− Utilization review activities, including precertification and preauthorization ofservices, and concurrent and retrospective review of services− Disclosure to consumer reporting agencies of any of the following protected healthinformation:• Name and address• Date of birth• Social Security Number• Payment history• Account number• Name and address of any relevant health care provider and/or health planWe may also provide your information to another entity for its payment activities anddisclose your information to another entity for certain health care operations of thatentity.Some examples of the uses and disclosures for payment include the following. (Pleasenote that, as is the case with the other examples in this Notice, these examples are merelya few of the many types of uses and disclosures that might be made.) The MedicalExpense Flexible Spending Plan will disclose your health information to the MedicalExpense Flexible Spending Plan’s third-party administrator (TPA) so the TPA canprocess claims you make under the Medical Expense Flexible Spending Plan. TheMedical Expense Flexible Spending Plan also may disclose such information to otherhealth plans in order to determine which plans (this Plan or the other plans) should paysuch claims. Health information, such as your medical history, also could be disclosed toyour health care providers in order to determine whether a particular course of treatmentis experimental, investigational or medically necessary.January 2012 FSA SPD 29

• For Treatment. Unlike health care providers, the Medical Expense Flexible Spending Plandoes not actually provide treatment. Instead, the Medical Expense Flexible SpendingPlan is a mechanism to provide payment for or reimbursement of the costs of healthcare. Although the Medical Expense Flexible Spending Plan does not actually providetreatment, it may disclose health information to physicians or other health care providersin order to enable them to treat you.For example, disease management services may be provided through the MedicalExpense Flexible Spending Plan, in which case health information may be disclosed inorder to enable your health care providers to deliver such services. Or, the MedicalExpense Flexible Spending Plan may disclose to your primary care physician the name ofa specialist who is treating you so that they may coordinate your care.• For Health Care Operations. We may use and disclose your health information for healthcare operations including:− Conducting quality assessment and improvement activities, including outcomesevaluation and development of clinical guidelines− Population-based activities relating to improving health or reducing health care costs− Reviewing the competence or qualifications of health care professionals− Evaluating practitioner and provider performance, and the performance of theMedical Expense Flexible Spending Plan− Accreditation, certification, licensing, or credentialing activities− Underwriting, premium rating, and other activities relating to the creation, renewal orreplacement of a contract of health insurance or health benefits, and ceding, securing,or placing a contract for reinsurance of risk relating to claims for health care(including stop-loss insurance and excess of loss insurance)− Conducting or arranging for medical review, legal services, and auditing functions,including fraud and abuse detection and compliance programs− Business planning and development, such as conducting cost-management andplanning-related analyses related to managing and operating the entity, includingformulary development and administration, development or improvement ofmethods of payment or coverage policies− Business management and general administrative activities of the Medical ExpenseFlexible Spending Plan, including:• Management activities relating to implementation of and compliance with therequirements of the HIPAA regulations• Customer service• Resolution of internal grievances• Consistent with the applicable requirements of the HIPAA regulations, creation ofde-identified health information or a limited data setExamples of the foregoing include the following: The Medical Expense FlexibleSpending Plan may engage in activities in which the quality of care provided under theMedical Expense Flexible Spending Plan is evaluated and, in doing so, may use healthinformation or disclose such information to an organization performing the evaluation.January 2012 FSA SPD 30

The Medical Expense Flexible Spending Plan may submit health information to aninsurance company that provides “stop-loss” coverage to Ascension Health. The MedicalExpense Flexible Spending Plan may provide health information to auditors who reviewoperations of the Medical Expense Flexible Spending Plan in order to ensure that claimsare being paid properly and that no fraud or abuse is occurring in connection with theMedical Expense Flexible Spending Plan.• Incidental Uses and Disclosures. We may occasionally inadvertently use or disclose your healthinformation when such use or disclosure is incident to another use or disclosure that ispermitted or required by law.• Disclosures to You. Upon a request by you, we may use or disclose your health information inaccordance with your request.• Limited Data Sets. We may use or disclose certain parts of your health information, calleda "limited data set," for purposes of research, public health reasons or for our health careoperations. We would disclose a limited data set only to third parties who have providedus with satisfactory assurances that they will use or disclose your health information onlyfor limited purposes.• Disclosures to the Secretary of Health and Human Services. We might be required by law todisclose your health information to the Secretary of the Department of Health andHuman Services, or his/her designee, in the case of a compliance review to determinewhether the Medical Expense Flexible Spending Plan is complying with privacy laws.• De-ldentified Information. We may use your health information, or disclose it to a third partywhom we have hired, to create information that does not identify you in any way. Oncewe have de-identified your information, it can be used or disclosed in any way accordingto law.• As Required By Law. We will disclose your health information when required to do so byfederal, state or local law.• Marketing. The Medical Expense Flexible Spending Plan may use or disclose yourinformation to make communications to you about its products or services or benefits,as well as to describe its network or details of the Medical Expense Flexible SpendingPlan. If health-related products or services add value to the Medical Expense FlexibleSpending Plan’s benefits, but are not part of it, and are available only to an enrollee ofthe Medical Expense Flexible Spending Plan, we may use or disclose your information todescribe such products or services. In addition, we may use or disclose your informationfor marketing if communications are made face-to-face or if they are in the form of apromotional gift of little value.• Health Oversight Activities. We may disclose your health information to a health oversightagency for activities authorized by law. These oversight activities might include audits,investigations, inspections, and licensure. These activities are necessary for thegovernment to monitor the health care system, government programs, and compliancewith civil rights laws.• Judicial Purposes. We may disclose your health information in response to a court oradministrative order. We may also disclose your health information in response to asubpoena, discovery request or other lawful process by someone else involved in thedispute, but only if efforts have been made to tell you about the request or to obtain anJanuary 2012 FSA SPD 31

order protecting the information requested.• Military and Veterans. If you are a member of the armed forces, we may release yourhealth information as required by military command authorities. We may also releasehealth information about foreign military personnel to the appropriate foreign militaryauthority.• National Security and Intelligence Activities. We may release your health information toauthorized federal officials for intelligence, counterintelligence, and other nationalsecurity activities authorized by law.• Protective Services for the President and Others. We may disclose your health information toauthorized federal officials so they may provide protection to the President, otherauthorized persons or foreign heads of state or to conduct special investigations.• Treatment Alternatives and Health-Related Benefits. We may use and disclose your healthinformation to tell you about or recommend possible health-related benefits or servicesthat may be of interest to you.• Individuals Involved In Payment for Your Care. We may release health information about youto your responsible party, friend or family member who is involved with payment foryour care.• Third Parties. The Medical Expense Flexible Spending Plan may disclose your informationto a third party that performs services on behalf of the Medical Expense FlexibleSpending Plan, such as its third party administrator, but only if the third party signs acontract agreeing to protect your information.• Disclosures of Records Containing Drug or Alcohol Abuse Information. Because of federal law, wewill not release your health information if it contains information about drug or alcoholuse without your written permission except in very limited situations.Other Uses of Health InformationOther uses and disclosures of health information not covered by this Notice or the laws thatapply to us will be made only with your written authorization. If you provide usauthorization to use or disclose your health information, you may revoke that authorization,in writing, at any time. If you revoke your authorization, we will no longer use or disclosehealth information about you for the reasons covered by your written authorization. Youunderstand that the Medical Expense Flexible Spending Plan is unable to take back anydisclosures we have already made under the authorization.Your Rights Regarding Your Health InformationYou have the following rights regarding health information we maintain about you:• Right to Request Restrictions. You have the right to request a restriction or limitation on thehealth information we use or disclose about you for payment or health care operations.You also have the right to request a limit on the health information we disclose aboutyou to someone who is involved in your care or the payment for your care. TheMedical Expense Flexible Spending Plan is not required to agree to your request.January 2012 FSA SPD 32

If we do agree, we will comply with your request unless the information is needed toprovide you emergency treatment.To request restrictions, you must make your request in writing to the Vice President,Compensation & Benefits. In your request, you must tell us (1) what information youwant to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whomyou want the limits to apply.• Right to Request Confidential Communications. You have the right to request that wecommunicate with you or your responsible party about health matters in an alternativeway or at a certain location.To request confidential communications, you must make your request in writing to theVice President, Compensation & Benefits. You must include the reason for the request,and we will accommodate your request if the disclosure of information could endangeryou. Your request must specify how or where you wish to be contacted.• Right to Inspect and Copy. You have the right to inspect and copy information regardingenrollment, payment, claims adjudication and case or medical management recordsystems maintained by us.To inspect and copy this information, you may submit your request in writing to the VicePresident, Compensation & Benefits. If you request a copy of the information, we maycharge a fee for the costs of copying, mailing or other supplies associated with yourrequest.• Right to Amend. You have the right to ask us to amend your health and/or billinginformation for as long as the information is kept by the Medical Expense FlexibleSpending Plan. To request an amendment, your request must be made in writing andsubmitted to the Vice President, Compensation & Benefits. In addition, you mustprovide a reason that supports your request.We may deny your request for an amendment if it is not in writing or does not include areason to support the request. In addition, we may deny your request if you ask us toamend information that:− Was not created by us, unless the person or entity that created the information is nolonger available to make the amendment− Is not part of the health information kept by or for the Medical Expense FlexibleSpending Plan− Is not part of the information that you would be permitted to inspect and copy− Is accurate and complete• Right to an Accounting of Disclosures. You have the right to request a list of certaindisclosures that we have made of your health information. To request this list ofdisclosures, you must submit your request in writing to the Vice President,January 2012 FSA SPD 33

Compensation & Benefits. Your request must state a time period that may not be longerthan six years and may not include dates before April 14, 2003. Your request shouldindicate in what form you want the list (for example, on paper or electronically). The firstlist you request within a twelve-month period will be free. For additional lists, we maycharge you for the costs of providing the list. We will notify you of the cost involved andyou may choose to withdraw or modify your request at that time before any costs areincurred.• Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. Youmay ask us to give you a copy of this Notice at any time. Even if you have agreed toreceive this Notice electronically, you are still entitled to a paper copy of this Notice.Who This Notice Applies ToThis Notice describes the Medical Expense Flexible Spending Plan’s practices and those ofall employees, staff, other personnel of the Medical Expense Flexible Spending Plan, and theadministrators contracted by the Medical Expense Flexible Spending Plan to performadministrative services.Changes to This NoticeWe reserve the right to change this Notice. We reserve the right to make the revised Noticeeffective for health information we already have about you as well as any information wereceive in the future. The Notice will contain on the first page, in the top right-hand comer,the effective date. In addition, if we revise the Notice and you are still a Participant of theMedical Expense Flexible Spending Plan, then you may receive a copy of the Noticecurrently in effect upon request.ComplaintsIf you believe your privacy rights have been violated, youmay file a complaint with the Medical Expense FlexibleSpending Plan or with the Secretary of the Department ofHealth and Human Services. To file a complaint with theMedical Expense Flexible Spending Plan, contact the VicePresident, Compensation & Benefits. All complaints mustbe submitted in writing. You will not be penalized for filinga complaint.Vice President,Compensation & BenefitsAscension Health11775 Borman DriveSt. Louis, MO 63146314.733.8000If you have any questions about this Notice, please contact the Vice President,Compensation and Benefits.January 2012 FSA SPD 34

Section 7: Plan InformationOfficial Plan Names• Ascension Health Medical ExpenseFlexible Spending Plan• Ascension Health Dependent CareFlexible Spending PlanPlan DescriptionHealth and dependent care pre-tax spendingaccountsPlan Number 515Employer Identification Number 31-1662309Plan Sponsor and AdministratorAscension Health4600 Edmundson RoadSt. Louis, MO 63134314.733.8000Type of AdministrationThese Plans are jointly administered byAscension Health and ADPPlan YearAgent for Service of LegalProcessPlan records are administered on a calendaryearbasis beginning January 1 and endingDecember 31 of each yearAscension Health4600 Edmundson RoadSt. Louis, MO 63134314.733.8000Type of FundingYou and your Participating Employer paythe cost of this benefit.January 2012 FSA SPD 35