STATE EMPLOYEES’ PREMIUM ONLY PLAN Health Reimbursement Arrangement

State of Alabama State Employees’ Insurance Board Effective January 1, 2014

STATE EMPLOYEES’ INSURANCE BOARD 201 South Union Street, Suite 200 Post Office Box 304900 Montgomery, Alabama 36130-4900 Phone:

334.263.8341

Toll Free: 1.866.836.9737 Website: www.alseib.org

INTRODUCTION The State Employees’ Premium Only Plan is a health reimbursement arrangement plan established by the State Employees’ Insurance Board pursuant to Act 2013-245. The State Employees’ Insurance Board (“SEIB”) hereby adopts this State Employees’ Premium Only Plan (“SEPOP”) for the purpose of allowing full-time, active employees of the State of Alabama to obtain reimbursement of eligible health care expenses incurred by such employees. The SEIB intends the SEPOP to qualify as a “health reimbursement arrangement” as that term is defined under IRS Notice 2002-45 and 2013-54 and a medical reimbursement plan under Sections 105 and 106 of the Internal Revenue Code of 1986, as amended, and the Plan will be interpreted at all times in a manner consistent with such intent. Benefits under SEPOP will be paid only if the SEIB decides in its discretion that a participant is entitled to them. The SEIB shall have the power to make all reasonable rules and regulations required in the administration of the SEPOP and for the conduct of its affairs, to make all determinations that the SEPOP requires for its administration, and to construe and interpret the SEPOP whenever necessary to carry out its intent and purpose and to facilitate its administration. All such rules, regulations, determinations, constructions and interpretations made by the SEIB shall be binding upon all Participants and all other interested parties. The SEIB reserves the right to modify its benefits, level of benefit coverage and eligibility/participation requirements at any time, without notification to Participants. When such a change is made, it will apply as of the modification’s effective date to any and all charges incurred by Participants on that day and after, unless otherwise specified by the SEIB. Any change may cause your benefits to be different than those described in this booklet. The SEIB can terminate the SEPOP at any time for any reason. Your Plan benefits will end if this happens.

ARTICLE I ADOPTION AGREEMENT 1.1 Name of Plan: The State Employees’ Premium Only Plan (“SEPOP”). 1.2 Plan Sponsor: State of Alabama 1.3 Plan Administrator: State Employees’ Insurance Board 201 South Union Street, Suite 200 Montgomery, AL 36104 1.4 Effective Date: January 1, 2014 1.5 Eligible Participant: Active, full-time employee of the State of Alabama eligible for coverage under the State Employees’ Health Insurance Plan (“SEHIP”) who opts out of the SEHIP and is enrolled in a Qualified Group Health Care Plan. 1.6 Account: One SEPOP Account will be established for each Participant. 1.7 Timing of Credit: Benefit Dollars will be credited to SEPOP Accounts on the first day of each calendar month. 1.8 Carryover of Accounts: Benefit Dollars remaining in a SEPOP Account at the end of a Plan Year shall be carried over to the following Plan Year to reimburse Participants for premiums paid to qualified health plans incurred during subsequent Plan Years.

ARTICLE II DEFINITION OF TERMS 2.1 Definitions: Whenever used in this Plan, the following terms shall have the meanings set forth below. “Benefit Dollars” means the amount credited to a Participant’s SEPOP Account for the provision of benefits under the Plan. “Claims Administrator” means Blue Cross Blue Shield of Alabama. “SEIB” means the State Employees’ Insurance Board. 3

“Health Care Expense” means premiums for qualified group health care insurance coverage (other than SEHIP) eligible for reimbursement. Eligible group health care premiums shall not include premiums reimbursed or reimbursable under any private, employer-provided, or public health care reimbursement or insurance arrangement or any amount claimed as a deduction on the federal income tax return of the Participant or the Participant’s Spouse. Health care premiums are incurred when the Participant pays the premium. “HIPAA” means the Health Insurance Portability and Accountability Act of 1996, as amended from time to time. “Participant” a person who participates in this Plan as specified under Section 3.1. “Plan” means this plan, the State Employees’ Premium Only Plan (“SEPOP”) named in Section 1.1 and set forth herein, as may be amended from time to time. “Plan Year” means the twelve (12)-month period commencing on each January 1. “PHI” means protected health information as described in 45 C.F.R. § 164.103, and generally includes individually identifiable health information held by or on behalf of the Plan. “Premium(s)” means the periodic charges which are required to be paid by you or your spouse to an insurance carrier in order to maintain your coverage under the plans. “SEHIP” means the State Employees’ Health Insurance Plan. “SEPOP” means the State Employees Premium Only Plan. “SEPOP Account” means the hypothetical account established for a Participant to hold his or her Benefit Dollars. “Spouse” means the opposite sex Spouse of a Participant, as determined by the SEIB. “Qualified Group Health Care Plan” means an employer group health plan providing minimum value or otherwise providing minimum essential coverage as defined under the Affordable Care Act under which a Participant is covered. The Marketplace, Medicare, Medicaid and Tricare are not qualified group health care plans under the SEPOP. “Qualified Group Health Care Plan Premium” means a premium paid by a Participant or a Participant’s spouse to maintain your coverage under a Qualified Group Health Care Plan.

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ARTICLE III PARTICIPATION 3.1 Agreement to Participate: You may participate in the SEPOP if you: a. are an eligible Participant; b. complete an enrollment form or any other required enrollment procedures; and c. are approved by the SEIB to participate in the SEPOP. 3.2 Enrollment An eligible Participant may enroll in the SEPOP at any time after opting out of the SEHIP and enrolling in a Qualified Group Health Care Plan, subject to SEPOP rules and procedures, by submitting a completed enrollment form directly to the SEIB. Participants may terminate participation in the SEPOP at any time, subject to SEPOP rules and procedures, and reenroll in the SEHIP, subject to SEHIP rules and procedures. 3.3 Cessation of Participation: Other than voluntary termination of participation, participation in the SEPOP will also end: a. on the date that a Participant is no longer an active full-time employee; or b. on the date a Participant is no longer covered by a Qualified Group Health Plan; or c. on the date of a Participant’s death; or d. on the effective date of any amendment to the SEPOP that renders a Participant ineligible to participate; or e. on the date that the SEIB stops offering the SEPOP. Note: a Participant in the SEPOP who retires from state service and at the time of retirement has a balance remaining in his or her SEPOP Account may continue to participate in the SEPOP until the remaining balance is exhausted. However, at retirement all credits to a retiree’s SEPOP Account will cease. If a Participant in the SEPOP dies and at the time of death has a balance remaining in his or her SEPOP Account, the surviving spouse may continue to participate in the SEPOP until the remaining balance is exhausted. However, upon death of the Participant all credits to the deceased Participant’s SEPOP Account will cease. Reimbursement from the Participant’s SEPOP Account after termination of participation shall be governed by Section 5.2

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ARTICLE IV FUNDING 4.1 Funding: The SEPOP is funded solely by the State of Alabama. In no event may any benefits under the Plan be funded with Participant contributions. The SEPOP Account balance does not accrue interest at any time.

ARTICLE V BENEFITS 5.1 Provision of Benefits: Once you become a Participant, a SEPOP Account will be established for you. The SEPOP Account is a notional bookkeeping account that keeps a record of Benefit Dollars allocated to your account and reimbursements made to you under the SEPOP. You have no property rights to your SEPOP Account. $150 Benefit Dollars will be credited each month to a Participant’s SEPOP Account. The amounts described above may be changed at any time by the SEIB. SEPOP account balances can only be used to reimburse eligible group health care premiums incurred after the establishment of the SEPOP account. No other expenses are eligible for reimbursement. The SEPOP will reimburse Participants for eligible health care premiums, up to the balance in the Participant’s SEPOP Account. A Participant shall be entitled to reimbursement under this Plan only for eligible group health care premiums incurred after he or she becomes a Participant in the Plan and before his or her participation has ceased. In no event shall any benefits under this Plan be provided in the form of cash or any other taxable or nontaxable benefit other than reimbursement for group health care premiums. Each Plan Year, a specified amount of Benefit Dollars will be allocated to a Participant’s SEPOP Account. The amount of Benefit Dollars allocated to a Participant’s SEPOP Account is determined at the sole discretion of the SEIB. Nevertheless, the annual amount of Benefit Dollars allocated to each Participant’s SEPOP Account will be determined in a uniform and non-discriminatory manner in comparison to other similarly situated employees. The SEPOP does not contain a Maximum Account Balance. Benefit Dollars remaining in the SEPOP at the end of the Plan Year will roll over to the next Plan Year if a Participant remains enrolled in the SEPOP. 5.2 Amount of Reimbursement: At all times during the Plan Year, a Participant shall be entitled to benefits under this Plan for payment of eligible group health care premiums in an amount that does not exceed the 6

balance of his or her SEPOP Account. Each reimbursement hereunder shall be a charge to such SEPOP Account available to pay eligible group health care premiums under the Plan. Benefit Dollars (not real dollars) are used to pay 100% of the cost of eligible group health care premiums, up to the allocation in a Participant’s SEPOP Account. If a Participant doesn’t spend all Benefit Dollars in a Plan Year, any unused SEPOP Account balance rolls over into the next Plan Year. SEPOP Benefit Dollars are subject to two restrictions: 1) they may only be used for eligible group health care premiums as defined in this Summary, and 2) Benefit Dollars will be forfeited if a Participant terminates employment for any reason and the Benefit Dollars in the SEPOP Account will revert back to the Plan, subject to COBRA rights explained below. Benefit Dollars are lost when participation in the SEPOP ceases. 5.3 Claims Submission When you pay for eligible group health care premiums you are responsible for requesting reimbursement from the Plan by completing and submitting a reimbursement form to Claims Administrator, Blue Cross Blue Shield of Alabama (BCBSAL). The reimbursement form can be found on the BCBSAL internet website at www.bcbsal.com. Appropriate documentation must be included with your claim for reimbursement. Appropriate documentation includes, at a minimum, a copy of your group insurance premium bill. You may submit claims for eligible group health care premiums along with appropriate documentation to the BCBSAL in one of the following three ways: 1. Online - You may scan, upload, fax, or mail in your group insurance premium bill after completing the online reimbursement form on the BCBSAL’s internet website. 2. Fax - You will need to print, complete, and sign a reimbursement form available on the BCBSAL’s website and then fax the form along with your supporting documentation to BCBSAL. 3. Mail - You will need to print, complete, and sign a reimbursement form available on the BCBSAL’s website and then mail the form along with your supporting documentation to the BCBSAL. 5.4 Reimbursements Your claim is deemed filed when it is received by the BCBSAL. If your claim for reimbursement is approved, you will be provided reimbursement as soon as reasonably possible following the determination. Claims are paid in the order in which they are received by BCBSAL. The maximum reimbursement amount that you can receive is equal to your SEPOP Account balance at the time the request for reimbursement is processed. Claims submitted and approved over the amount currently available in a Participant’s SEPOP Account can be reimbursed by future SEPOP Account Allocations. Claims will be considered back to the original start date for a Participant and paid as SEPOP Account Benefit Dollars become available.

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Payments for reimbursements of approved group health care premiums are made daily. Reimbursements will be paid via check. 5.5 Overpayments If the Plan pays benefits for expenses incurred, and it later determines that all or some of the payment received was made in error, you will be required to refund the overpayment or erroneous reimbursement to the Plan. If you do not refund the overpayment, the Plan reserves the right to offset future reimbursements equal to the overpayment or, if that is not feasible, to withhold such funds from any amounts due to you from the Plan. If all other attempts to recoup the overpayment/erroneous payment are unsuccessful, the SEIB may treat the overpayment as a bad debt, which may have tax implications for you. In addition, if the SEIB determines that you have submitted a fraudulent claim, the SEIB may terminate your coverage in the SEPOP. 5.6 Payments for Group Insurance You will pay your group health care premiums directly to the employer who sponsors the qualified group health care plan you choose or the insurance company or claims administrator for the plan, as directed by the qualified group health care plan. You will then request and receive reimbursement from your SEPOP Account by a check mailed to you or via direct deposit.

5.7 Rights to Appeal: Claims that are partially or wholly denied may be appealed to the SEIB as provided in Section 6.3. 5.8 Carryover of Accounts: To the extent a Participant has a balance in his or her SEPOP Account at the end of a Plan Year, the balance shall be carried over to following Plan Years to the extent elected by the SEIB. 5.9 Death: In the event the Participant dies without a spouse, his or her SEPOP Account shall be forfeited; provided, however, that his or her estate or representatives may submit claims for eligible group health care premiums incurred by the Participant prior to the Participant’s death, as long as such claims are submitted no later than one-hundred five (105) days after the end of the plan year. 5.10 Continuation Under COBRA: If you lose coverage as a result of a "qualifying event" under COBRA, you may have the right to continue coverage under your SEPOP Account. Persons who are entitled to buy COBRA coverage are called "qualified beneficiaries." You may not make a COBRA election to continue coverage under the SEPOP unless you also continue coverage under your eligible group health care plan.

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ARTICLE VI ADMINISTRATION 6.1 Plan Administrator: The Plan Administrator is the SEIB. The Plan Administrator is responsible for the performance of all reporting and disclosure obligations required to be performed by the plan administrator under the IRS Code. The Plan Administrator shall be the designated agent for service of legal process with respect to the Plan. 6.2 Duties of the Plan Administrator: The Plan Administrator shall have the sole discretion and authority to control and manage the operation and administration of the Plan. The Plan Administrator shall have complete discretion to interpret the provisions of the Plan, make findings of fact, correct errors, supply omissions, and determine the benefits payable under this Plan. All decisions and interpretations of the Plan Administrator made in good faith pursuant to the Plan shall be final, conclusive and binding on all persons, subject only to the appeal procedure, and may not be overturned unless found by a court to be arbitrary and capricious. 6.3 Claims Appeal Procedure: Within sixty (60) days of receipt by a claimant of a notice under Section 5.3 denying a claim in whole or in part, the claimant or his or her duly authorized representative may request in writing a full and fair review of the claim by the Plan Administrator. In connection with such review, the claimant or his or her duly authorized representative may, upon request, have reasonable access to, and copies of, all documents, records and other information relevant to the claim for benefits, and may submit issues and comments in writing. The Plan Administrator shall make a decision promptly, but not later than sixty (60) days after the Plan Administrator’s receipt of a request for review. The decision on review shall be in writing, in a manner calculated to be understood by the claimant, and shall include: a. Specific reasons for the decision; b. Specific references to the pertinent plan provisions on which the decision is based; c. A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits; d. A copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the initial determination or a statement that such a rule, guideline, protocol, or other criterion was relied upon in making the appeal determination and that a copy of such rule will be provided to the claimant free of charge upon request. The decision of the Plan Administrator shall be final and conclusive on all persons claiming benefits under the Plan, subject to applicable law. 9

6.4 Nondiscriminatory Operation: All rules, decisions, interpretations and designations by the Plan Administrator under the Plan shall be made in a nondiscriminatory manner, and persons similarly situated shall be treated alike. ARTICLE VII HIPAA 7.1 HIPAA Business Associate Agreements This Article permits the Plan to disclose PHI to the Plan Sponsor and the Claims Administrator to the extent that such PHI is necessary for the Plan Sponsor and the Claims Administrator to carry out its administrative functions related to the Plan. In that regard, the SEIB has entered into HIPAA Business Associate Agreements with the Plan Sponsor and the Claims Administrator to ensure that the SEPOP is in compliance with requirements set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and accompanying regulations, as amended from time to time and the Health Information Technology for Economic and Clinical Health Act (HITECH), and any regulations promulgated thereunder. ARTICLE VIII GENERAL PROVISIONS 8.1 Amendment and Termination: Although the SEIB intends to maintain the Plan for an indefinite period, the SEIB reserves the right to amend, modify, or terminate this Plan at any time, including but not limited to the right to modify eligibility for participation, benefits paid by the Plan, the amount of Benefit Dollars to be credited and the right to reduce or eliminate existing SEPOP Accounts. Notwithstanding anything to the contrary contained in this Section or elsewhere in the Plan, the Plan Administrator shall have the authority to approve all technical, administrative, regulatory and compliance amendments to the Plan, and any other amendments that the Plan Administrator shall deem necessary or appropriate. 8.2 Status of Benefits: Neither the State of Alabama nor the Plan Administrator makes any commitment or guarantee that any amounts paid to or for the benefit of a Participant under this Plan will be excludable from the Participant’s gross income for federal, state, or local income tax purposes. It shall be the obligation of each Participant to determine whether each payment under this Plan is excludable from the Participant’s gross income for federal, state, and local income tax purposes and to notify the Plan Administrator if the Participant has any reason to believe that such payment is not so excludable. Any Participant, by accepting a benefit under this Plan, agrees to be liable for any tax that may be imposed with respect to those benefits, plus any interest as may be imposed.

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8.3 Applicable Law: The Plan shall be construed and enforced according to the laws of the state of State of Alabama, to the extent not preempted by any Federal law. 8.4 Capitalized Terms: Capitalized terms shall have the meaning set forth in Article II. 8.5 Severability: If any provision of this Plan shall be held invalid or unenforceable, such invalidity or unenforceability shall not affect any other provision, and this Plan shall be construed and enforced as if such provision had not been included.

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10/2013

State Employees Premium Only Plan Enrollment Form Return completed form to: State Employees’ Insurance Board, PO Box 304900, Montgomery AL 36130-4900 Telephone: 334.263.8312 Toll Free: 1.866.833.3378 Fax: 334.517.9908 EMPLOYEE INFORMATION (PLEASE PRINT) Name:

SEHIP Contract or SSN #

Date of Birth ______/______/_______

Address: City, State and Zip: Telephone Numbers (work number is required) Work: ( ) Email Address:

Ext:

Home: (

)

Name of health plan for which you will be seeking reimbursement of premiums: Employer Name: Group Number: Contact number: ( ) What is the State Employees’ Premium Only Plan (SEPOP)? The SEPOP is a premium only Health Reimbursement Arrangement (HRA) funded solely by the State of Alabama from which active employees are reimbursed for other employer group health insurance premiums. Who is eligible? Any active full-time employee of the State of Alabama eligible for coverage under the State Employees’ Health Insurance Plan (SEHIP) who has opted out of the SEHIP is eligible to enroll in the SEPOP. What’s the benefit to enrolling in the SEPOP? When you enroll in the SEPOP an account will be established for you into which the State will credit $150 each month. You can then use these tax free Benefit Dollars to pay premiums for other employer group health insurance (e.g. coverage offered through your spouse’s employer). That’s a free benefit of up to $1,800 per year. Can SEPOP Benefit Dollars be used for any health care premium? No. SEPOP Benefit Dollars can only be applied toward premiums of other employer group health plans meeting the minimum value and essential health benefits criteria as defined under the Affordable Care Act (employers should provide their employees with this information). Will Benefit Dollars in your SEPOP account roll over each year? Yes. If you don’t spend all your Benefit Dollars in a Plan Year, any unused SEPOP Account balance rolls over into the next Plan Year. In this manner your SEPOP Account may “grow” almost like a savings account. How do you enroll? You can enroll in the SEPOP at any time during the year by completing this form and returning it to the SEIB. Remember you must first opt out of the SEHIP before you can enroll in the SEPOP. How do you dis-enroll? You can dis-enroll in the SEPOP and re-enroll in the SEHIP at any time during the year. When you dis-enroll in the SEPOP or terminate your employment, any Benefit Dollars in your SEPOP Account will revert back to the Plan. Important – Read Carefully Before Signing The SEPOP is intended to qualify as a “health reimbursement arrangement” as that term is defined under IRS Notice 2002-45 and 2013-54 and a medical reimbursement plan under Sections 105 and 106 of the Internal Revenue Code of 1986, as amended, and the Plan will be interpreted at all times in a manner consistent with such intent. I understand that I will only seek reimbursement for premiums for health insurance coverage that qualify for such reimbursement under IRS regulations. I hereby certify that I have completely read and fully understand the terms and conditions of the SEPOP and all information furnished is true and complete. Employee Signature: _______________________________________________________

Date: _________________________________________

Request for Reimbursement Preferred Health FSA/HRA Attach a copy of the itemized bill and an Explanation of Benefits (EOB) (if applicable) along with proof of payment. All documentation must include the patient name, description of service provided, date provided, and the charge. Be sure to sign and date this form before sending it with all attachments to the address shown.

An Independent Licensee of the Blue Cross and Blue Shield Association

I certify that the attached expenses are eligible for reimbursement from my designated Health FSA/HRA and that they qualify as deductions as outlined by the U. S. Internal Revenue Code or by my employer. I request reimbursement up to the limit allowed in my account. I further certify that these expenses have not been reimbursed and are not reimbursable under any other benefit plan. A dependent must be considered an eligible dependent under the applicable provisions of section 105 and 106 of the U.S. Internal Revenue Code. Signature of Employee

Date

/

Blue Cross and Blue Shield of Alabama Preferred Blue Accounts P.O. Box 11586 Birmingham, Alabama 35202-1586 1-800-213-7930 Toll Free Fax 1-877-889-3610 Visit our web site www.bcbsal.com for detailed account information

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Important: This form is not used to reimburse you for your Blue Cross and Blue Shield of Alabama health benefits. It may only be used to request a payment from a tax-deferred, employee-funded spending account established by your employer under Section 125 of the U.S. Internal Revenue Code or from your HRA established by your employer. Payments from such an account may only be made for qualified expenses on behalf of qualified dependents when such expenses have not been reimbursed and are not reimbursable by any other benefit plan.

SECTION 1:

EMPLOYEE INFORMATION

FIRST NAME

MI

DATE OF BIRTH

LAST NAME

NOTE: Your Preferred Blue Account number is your Blue Cross and Blue Shield of Alabama contract number. If you do not have your account number, please contact Customer Service at 1-800-213-7930. HOME PHONE (Please include area code)

PREFERRED BLUE ACCOUNT NUMBER

/

–

/

WORK PHONE (Please include area code)

COMPANY NAME

SECTION 2:

HEALTH FSA/HRA REIMBURSEMENT INFORMATION

In order to be properly reimbursed, complete this section for each eligible expense and attach all necessary itemized receipts. (Please do not highlight items on your receipts.) TYPE SERVICE MEDICAL VISION DENTAL ORTHODONTICS RX/OTC PREMIUM* OTHER

PATIENT’S FIRST NAME

TYPE SERVICE

PATIENT’S FIRST NAME

RELATIONSHIP

COVERED BY INSURANCE

DEPENDENT

/

/ COPAY

SELF

DEDUCTIBLE

/ COINSURANCE

OTHER

YES

•

NO

LAST NAME

SPOUSE

COVERED BY INSURANCE

DEPENDENT

YES

AMOUNT

NO

DATE OF SERVICE

/

/ COPAY

DEDUCTIBLE

/ COINSURANCE

OTHER

SELF

/

DOCUMENTATION ATTACHED

YES

•

NO

LAST NAME

SPOUSE

COVERED BY INSURANCE

DEPENDENT

YES

AMOUNT

NO

DATE OF SERVICE

/

/ COPAY

DEDUCTIBLE

/ COINSURANCE

OTHER

SELF

/

DOCUMENTATION ATTACHED

PATIENT’S FIRST NAME

YES

•

NO

LAST NAME

SPOUSE

COVERED BY INSURANCE

DEPENDENT

YES

AMOUNT

NO

DATE OF SERVICE

/

/ COPAY

DEDUCTIBLE

/ COINSURANCE

*The premium reimbursement is available to select HRA plans only.

CL-472 (Rev. 12-2013)

AMOUNT

NO

/

DOCUMENTATION ATTACHED

PATIENT’S FIRST NAME

MEDICAL VISION RELATIONSHIP DENTAL ORTHODONTICS DATE OF BIRTH RX/OTC OTHER TYPE CHARGE

YES

DATE OF SERVICE

TYPE CHARGE

MEDICAL VISION RELATIONSHIP DENTAL ORTHODONTICS DATE OF BIRTH RX/OTC OTHER TYPE CHARGE TYPE SERVICE

SPOUSE

DATE OF BIRTH

MEDICAL VISION RELATIONSHIP DENTAL ORTHODONTICS DATE OF BIRTH RX/OTC OTHER TYPE CHARGE TYPE SERVICE

SELF

LAST NAME

OTHER

DOCUMENTATION ATTACHED

/ YES

•

NO

TOTAL

•

Helpful Tips for Successfully Filing a Request for Reimbursement. 1. Complete your Request for Reimbursement Form neatly. If your form can not be read properly, it cannot be processed accurately. • Do not highlight receipt items. Circle them instead. (High-lighter when faxed or scanned can appear as black or gray) • Only submit expenses for an eligible dependent. An eligible dependent must meet the provisions of sections 105 and 106 of the U. S. Internal Revenue Code. 2.

Provide appropriate supporting documentation. IRS rules state that you must provide appropriate documentation.

• Documentation for an eligible healthcare expense must show: The date of service (the date you incurred the expense) The name of the service provider To whom the service was provided (patient’s name) The out of pocket expense (amount you paid for the service) A clear and detailed service/procedure description • Documentation for an eligible premium payment must show: The name and address of the company to whom the premium payment was made The policy number of your insurance A list of those covered under the policy The date of the premium payment The time period the premium payment covered What is acceptable documentation? Examples of proper documentation are: • An Explanation of Benefits (EOB) from your insurance carrier showing the above information. If the EOB indicates the procedure is not covered by your health insurance plan, you may be required to submit an itemized statement from the provider. • For premium payments, a premium notice with proof of payment or check stub showing the premium deduction. • For prescription drugs, a pharmacy statement including the name of the pharmacy, patient’s name, date the RX was filed, patient’s cost, RX number and name of the drug. • Over-the-counter (OTC) medications and other “dual purpose” items will not be reimbursed without a written doctor’s prescription. You must also include an itemized receipt indicating the item purchased.

Unacceptable documentation for healthcare expenses: Bank card statements, credit card receipts, canceled checks, estimates of expenses, account balance statements and balance forward statements are not valid documentation.

3.

Sign your form. An unsigned form will stop your reimbursement!

4.

Submit your form. Completed forms can be submitted on our website at www.bcbsal.com, with the Alabama Blue mobile app on your smart phone, by mail, or by fax to our toll-free number.

CL-472 (Rev. 12-2013)

STATE EMPLOYEES’ INSURANCE BOARD 201 South Union Street, Suite 200 Post Office Box 304900 Montgomery, Alabama 36130-4900 Phone:

334.263.8341

Toll Free: 1.866.836.9737 Website: www.alseib.org