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❑ Medicare Supplemental Insurance Premiums <br />❑ Prescription Drug Insurance Premiums <br />❑ COBRA Insurance Premiums <br />❑ Dental Insurance Premiums <br />❑ Dental Out -of- Pocket Expenses* <br />❑ Vision Insurance Premiums <br />❑ Vision Out -of- Pocket Expenses* <br />❑ Qualified Long -Term Care Insurance Premiums <br />❑ Non - Prescription medications allowed under IRS guidance* <br />❑ Other qualifying medical expenses (describe)* <br />*See Section V.A, for a discussion ofnondiscrimination rules which may apply to non - collectively bargained, self - insured Plans. <br />XI. Benefits After the Death of the Participant <br />In the event of a Participant's death, the following shall apply: <br />A. Surviving Spouse and /or Surviving Dependents <br />The surviving spouse and /or surviving eligible dependents (as defined in Section XII.D) of the deceased Participant are <br />immediately eligible to maintain the account and utilize it to fund eligible medical benefits specified in Section X above. <br />Upon notification of a Participant's death, the Participant's account balance will be transferred into Dreyfus Cash <br />Management fund* (or another fund selected by the Employer). The account balance may be reallocated by the <br />surviving spouse or dependents. <br />*An investment in the Dreyfus Cash Management money market fund is not insured orguaranteed by the Federal Deposit Insurance <br />Corporation or any othergovernment agency. Although the fund seeks to preserve the value ofyour investment m $1.00 per share, it is <br />possible to lose money by investing in the fund Investors should consider the investment objectives, risks, charges, and expenses ofthe fund <br />carefully before investing. You may visit us at www.icmarc.org or call 800- 669 -7400 to obtain aprospectus that contains this and other <br />information about the fund. Read the prospectus carefully before investing. <br />If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance <br />may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the <br />account will revert to the Plan to be applied as specified in Section VIII. <br />B. No Surviving Spouse or Surviving Dependents <br />If there are no living spouse or dependents at the time of death of the Participant, the account will revert to the Plan to <br />be applied as specified in Section VIII. <br />XII. The Plan will operate according to the following provisions: <br />A. Employer Responsibilities <br />1. The Employer will submit all VantageCare Retirement Health Savings Plan contribution data via electronic submission. <br />2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal <br />information updates via electronic submission. 'This includes but is not limited to termination notification and <br />benefit eligibility notification. <br />B. Participant account administration and asset -based fees will be paid through the redemption of Participant account <br />shares, unless agreed upon otherwise in the Administrative Services Agreement. <br />