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<br />© 2012 Hitesman & Wold, P.A. City of Elk River <br />Flexible Benefits Plan <br />41 <br />ARTICLE XVII. <br />LIMITED SCOPE MEDICAL EXPENSE REIMBURSEMENT PLAN <br />17.1 Purpose. The purpose of this Article is to provide Participants with the opportunity to be <br />reimbursed for certain eligible Limited Scope Medical Expenses as an Optional Benefit under the <br />Plan. This Article is intended to qualify as a medical reimbursement plan under Section 105 of <br />the Code so that payments received under this portion of the Plan are excludable from the gross <br />income of the Participant under Section 105(b) of the Code. This Article is also intended to be <br />“permitted coverage” for purposes of determining eligibility for health savings account <br />contributions under Section 223 of the Code. <br />17.2 Separate Written Plan. For purposes of Section 105 of the Code, this Article shall constitute a <br />separate written plan providing for the reimbursement of Limited Scope Medical Expenses. This <br />is a separate and distinct “plan” from the Medical Expense Reimbursement Plan described under <br />Article XV. To the extent necessary, other provisions of the Plan are incorporated by reference. <br />17.3 Definitions. <br />(a) Claims Run-Out Period means the period beginning on the first day following the close <br />of the Grace Period and ending on thirty (30) days from the close of the Grace Period. <br />(b) Dependent means an individual who is a Tax Dependent. <br />(c) Highly Compensated Individual means an individual who is highly compensated as <br />defined in Section 105(h)(5) of the Code. <br />(d) Limited Scope Medical Expense Account (“Limited Scope ME Account”) means <br />the record keeping account established by the Plan Administrator for each Plan Year for <br />each Participant from whom an Election to create such an account is received. <br />(e) Limited Scope Medical Expense means an expense incurred during the applicable <br />Plan Year by a Participant or by the Spouse or Dependent of a Participant for dental and <br />vision within the meaning of “medical care” as defined in Section 213(d) of the Code. <br />However, a Participant may not be reimbursed for dental and vision care of the type <br />covered under the “qualifying high deductible plan” under Section 223(c)(2) of the Code, <br />and a Participant may not be reimbursed for the cost of other dental or vision coverage <br />such as premiums paid under plans maintained by an employer of the Participant's <br />Spouse or individual policies maintained by the Participant or his or her Spouse or <br />Dependent. “Limited Scope Medical Expense” shall include drugs and medicine only to <br />the extent allowed by Section 106(f) of the Code. <br />17.4 Limited Scope Medical Expense Account. The Limited Scope ME Account will be credited <br />with the amount elected by the Participant and the Employer Contribution, if any, at the <br />beginning of the Plan Year. A Participant’s Limited Scope ME Account will be decreased from <br />time to time in the amount of payments made to the Participant for eligible Limited Scope <br />Medical Expenses incurred during the Plan Year and Grace Period, if applicable. <br />17.5 Claims Determination. Claim submission, determination, and appeals shall be handled in <br />accordance with Article VI. <br />17.6 Incurred Expenses. To be reimbursable, an eligible Limited Scope Medical Expense must have <br />been incurred after participation in this portion of the Plan began and during the Plan Year for <br />which reimbursement is claimed or the Grace Period related to such Plan Year, if applicable. An <br />expense is “incurred” when the Participant is provided with the care which gives rise to the <br />eligible Limited Scope Medical Expense, not when the service is billed or paid. Reimbursement <br />shall not be made for future projected expenses. Notwithstanding the foregoing, pursuant to and <br />Page 134 of 254