SUPPLEMENTAL HEALTH REIMBURSMENT ACCOUNT PLAN (HRA) effective July 1, 2021

ELIGIBILITY

Initial and Continuing Eligibility
An Employee is eligible for participation in the HRA on the first day of the month when an HRA is established for him. An HRA is established for an Employee when his Dollar Bank Account has more than a twelve (12) month reserve for health care premiums. Any Employer Contributions in excess of a twelve (12) month reserve in an Employee’s Dollar Bank Account will be permanently transferred to an HRA Account for the Employee. You will continue to participate in the HRA as long as funds remain in your HRA Account. There is NO LIMIT on the amount of Employer Contributions that can be held in the Participant’s HRA Account.

Example: The current health premium is $1,287 per month. Your Dollar Bank balance must be more than $15,444 for the establishment of an HRA account. On 01/31/2024, Member A has a Dollar Bank balance of $16,444. He will have $1,000 transferred to an HRA account on 02/01/2024. On 01/31/2024, Member B has a Dollar Bank balance of $5,744. He will not have an HRA account until his Dollar Bank balance is more than $15,444.

HRA BENEFITS
A Participant may receive reimbursement for Covered Expenses up to an aggregate allowance of $15,000 in a Plan Year. For services covered under the Health, Dental and Vision Plan documents, Covered Expenses for the purposes of this Plan include only the following:

ALL PARTICIPANTS
(1) Medical, dental and vision Deductibles, Co-pays and/or Co-insurance;
(2) Prescription Drug costs not covered by another Insurance Carrier Policy;

(3) DENTAL expenses not covered by another Insurance Carrier policy:
            ◦ Dental X‐Rays
            ◦ Dentures, Bridges and Crowns
            ◦ Exams and Teeth Cleaning (once every 6 months)
            ◦ Extractions, Root Canals and Fillings
            ◦ Oral Surgery
            ◦ Orthodontia for dependent children (once per lifetime)
            ◦ Periodontal Services

(4) Vision expenses not covered by another Insurance Carrier policy:
            ◦ Eye Exam (every per calendar year)
            ◦ Eyeglasses-Frames and Lens (every per calendar year)     
            ◦ Laser Eye Surgeries
            ◦ Prescription Safety Eyewear (every per calendar year)
            ◦ Contact Lens (12 month supply per calendar year)

(5)  Hearing Aid expenses not covered by another Insurance Carrier policy:

• Hearing Aid(s) (every three years)
• Hearing Aid(s) Repairs

This benefit does not cover any of the following:

• Office Visits with an Audiologist
• Diagnostic or Routine Hearing Exams
• Replacement Batteries
• Hearing Aids Provided for Cosmetic Purposes

FOR RETIREES AND SEPAPARATED EMPLOYEES ONLY:
(6) Medicare supplement premiums;
(7) COBRA premiums; and,
(8) Individual or family fully insured health insurance premiums.

The following Covered Expenses will not be reimbursed:
Expenses incurred more than one (1) calendar year from date of service;
Expenses covered by any other plan of benefits; or,
Expenses incurred before the HRA Plan or your HRA Account was established.

We have retained the services of BPAS to administer the HRA.
BPAS contact information:

Customer Service– 866-401-5272
Website: U.BPAS.COM
Mobile APP: BPASClaims
Claims Fax#: 866-254-2942

Claims Mailing Address:
820 Gessner Rd, Ste 1250
Houston, TX 77024

Please review the HRA Guide on how to file claims for reimbursement, check your HRA balance, view claim history and contact information.