25E - AGMT - EMPL BENEFITS - Laserfiche WebLink

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EX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Plan A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Section B.) Definition of retirement: ❑ Sameas Section Vll.B. ❑ Other ❑ At separation from service with the following restrictions ® NO restrictions ❑ Other B. Termination prior to general benefit eligibility: In case whcrc rhe gencml bencfir eligibility a% onrlined in Section IKA includes a retirement component, a Participant who separates from service of the Employer prior to retirement will be eligible to receive benefits: m Immediately upon separation from service ❑ Other C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social SecurityAdministration ® u defined by the Employer's primary retircmcnt plan ❑ other _ will become immediately eligible to receive medical benefit payments from his/her VantageCare Retirement Health Savings Plan account. D. Upon the death of the Participant, benefits shall become payable as outlined in Section XI. X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: ® All Medical Expenses eligible under IRC Section 213' other than (i) direct long-term care expenses, and (ii) expenses for mcdicincq or drugs which are not prescribed drugs (other than insulin). ❑ 'Ihe following Nledical Expenses eligible under IRC Section 213` other than (I) direct long -terra care expenses, and (ii) expenses for medicines or drugs which arc not prescribed drugs (other than insulin). Select only the expenses you wish to cover under the V;mtageCam Retirement Health Savings Plan: ❑ Medical Insurance: Premiums ❑ Medical Oto -of -Pocket Expenses, ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums al 25E-102