HRA CARRYOVER. Waiver HRAs: Unused amounts up to and including $2,100 remaining in your Waiver HRA at the end of the Plan Year may be carried over to the next Plan Year provided you are eligible to elect an HRA. CDHP Integrated HRAs: Unused amounts up to and including $7,500 remaining in your CDHP Integrated HRA at the end of the Plan Year may be carried over to the next Plan Year. You must elect the same type of HRA in a subsequent Plan Year for the funds to carry over.

; Waiver General Purpose HRA at least annually at open enrollment.

to be covered under another group health plan that provides minimum value, you agree to notify KEHP within 30 days of the date that the other group health plan coverage ceased. In this event, coverage under the Waiver General Purpose HRA will be terminated and you may elect a KEHP health insurance plan option or the Waiver Limited Purpose HRA. Unused funds remaining in the Waiver General Purpose HRA upon termination are forfeited. You are permitted to permanently opt out of and waive future reimbursements

.arketplace or governmental plans such as TRICARE, Veteran's Benefits, Medicare, or Medicaid. A group health plan that provides “minimum value” means the plan pays at least 60% of the total allowed cost of covered benefits/services and participants or members in the plan are required to pay no more than 40% of the total allowed cost of covered benefits/services. If you elect a Waiver General Purpose HRA and cease to be covered under another group health plan that provides minimum value, you agree to notify KEHP within 30 days of the date that the other group health plan coverage ceased. In this event, coverage under the Waiver General Purpose HRA will be terminated and you may elect a KEHP health insurance plan option

... group mean plan" does not include individual policies purchased through the mental plans such as TRICARE, Veteran's Benefits, Medicare, or Medicaid. A group vides "minimum value" means the plan has at least one cost of

WAIVER GENERAL PURPOSE HRA RULES. If you elect a Waiver General Purpose HRA, you declare that you and your spouse and dependents, if applicable, are enrolled in another group health plan that provides minimum value. A "group health plan" refers to coverage provided by an employer, an employer organization, or a union. A "group health plan" does not include individual policies purchased through the

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DEDUCTION FROM EARNINGS. When you enroll in insurance coverage (health, dental, vision, or life) or an FSA, you authorize your employer to deduct from your earnings the amount required to cover your employee contribution to the FSA and insurance coverage you elected, including any arrears you may owe. Deductions for FSA and the employee contributions to health, dental, and vision insurance are made on a pre-tax basis unless you sign a Post-Tax Request Form. Deductions for life insurance premiums are made on a post-tax basis.

DEPENDENT ELIGIBILITY. You certify that each enrolled dependent meets the dependent eligibility requirements as set forth in the SPDs, MBBs, and CoCs. DEI will require supporting documentation to verify the eligibility of any dependent enrolled or requesting to be enrolled in benefits. Spouses and step-children may be subject to periodic re-verification upon notice to you. Your failure to properly document dependent eligibility will result in the termination of the unverified dependent from your insurance plan(s).

employment by either spouse/planholder. NOTE: Effective 1/1/2025, there will not be new cross-reference plans offered for newly eligible enrollees. Planholders with existing eligibility for cross-reference plans may have such eligibility extended past 1/1/2025.

CROSS-REFERENCE. The cross-reference payment option for health insurance may be available to spouses who are both eligible to participate in KEHP and have at least one dependent. If your spouse and you are eligible and elect the cross-reference payment option for health insurance, you are planholders with family coverage. Upon a loss of eligibility by either spouse, the remaining planholder will default to a parent-plus coverage level. The cross-reference payment option ceases upon loss of eligibility or employment by either spouse/planholder. NOTE: Effective 1/1/2025, there will not be new cross-reference plans offered for newly eligible enrollees. Planholders with existing eligibility for cross-reference plans ma

THIRD PARTY ADMINISTRATORS. DEL uses third parties, including Anthem, CVS/Caremark, HealthEquity, Castlight, SmartShopper, and Metropolitan Life Insurance Company (MetLife) to provide certain administrative functions. DEI may communicate with you directly or through these third parties about your insurance coverage, your benefits, or health-related products or services provided by or included in the Commonwealth's group health, dental, vision, or life insurance plans.

WAIVING HEALTH INSURANCE COVERAGE. If you elect to waive KEHP health insurance coverage, with a without a Waiver Health Reimbursement Arrangement (HRA), you are doing so voluntarily. If your employer participates in the Waiver HRA program, there are two options available: the Waiver General Purpose HRA and the Waiver Limited Purpose HRA. You understand that you will be eligible for the Waiver General Purpose HRA only if you have other group health plan coverage. You further understand that your spouse and eligible dependents, if applicable, cannot be covered under the Waiver General Purpose HRA unless your spouse and dependents also have other group health plan coverage.

HEALTHEQUITY HEALTHCARE CARD. HealthEquity will administer FSAs and HRAs for the 2025 Plan Year and will issue a HealthEquity Healthcare Card to you for the payment of eligible Healthcare FSA and HRAA expenses. Your HealthEquity Healthcare Card will be suspended if requested claim verification is not sent to HealthEquity within ninety (90) days after the card swipe. You agree to follow all rules and guidelines established by the Plan concerning the HealthEquity Healthcare Card. The Plan reserves the right to deny access to the card, require repayment, deduct/withhold from your paycheck, and offset your Healthcare FSA or HRA if you fail to verify a claim.

PLAN INFORMATION. You have read and understood the 2025 Benefits Selection Guide (BSG). Plan rules and limitations are contained in the KEHP Summary Plan Descriptions (SPD) or Medical Benefit Booklets (MBB) and the Summary of Benefits and Coverage (SBC). Life, dental, and vision insurance rules and limitations are outlined in Certificates of Coverage (CoC). All benefits for your eligible dependents and you will be provided in accordance with the rules and limitations in the SPDs, MBBs, BSG, SBCs, and CoCs. You will abide by all terms and conditions governing participation, membership, and receipt of services from the plan(s) in which you have enrolled and as set forth in the SPD, MBB, and CoC. In the event of a conflict between the terms of coverage stated in the SPDs, the MBBs, the BSG, the SBCs, and the CoCs, the terms of coverage stated in the SPDs or MBBs and CoCs will govern.

seconda montn atter a new employee or newly eligible employee is eligible to enroll for non-commonwealth paid employees and up to the first day of hire for commonwealth paid employees. Employees are enrolling in life insurance must be actively at work, full time, on the day the employee's insurance is scheduled to begin.

reimburse you for eligible expenses that are incurred during the subsequent Plan Year. You may use the Healthcare FSA carry over amounts whether or not you elect a Healthcare FSA for the subsequent Plan Year. Amounts over $640 remaining in your Healthcare FSA at the end of the Plan Year are forfeited. All funds remaining in a Healthcare FSA account where there have been no new contribution elections for two consecutive Plan Years will be forfeited.

EFFECTIVE DATE OF ELECTIONS. If you are electing a health plan, dental plan, vision plan, or a Flexible Spending Account (FSA) during open enrollment, the coverage will be effective January 1 of the following Plan Year. If you are a new employee or a newly eligible employee, the coverage will be effective on an FSA outside of open enrollment, the FSA and your insurance coverage will be effective the first day of the second month after a new employee or newly eligible employee is eligible to enroll for non-common wealth paid employees and up to the first day of hire for common wealth paid employees. Employees enrolling in life insurance must be actively at work, full time, on the day the employee's insurance is scheduled to begin.

EFFECTIVE DATE OF ELECTIONS. If you are electing a health plan, dental plan, vision plan, or a Flexible Spending Account (FSA) during open enrollment, the coverage will be effective January 1 of the following Plan Year. If you are a new employee or a newly eligible employee electing insurance coverage or an FSA outside of open enrollment, the FSA and your insurance coverage will be effective the first day of the

HEALTHCARE FSA ELECTION AND CARRYOVER. You may elect to contribute up to $3,200 into a Healthcare FSA for Plan Year 2025 to pay for eligible health care expenses not paid for by your health insurance plan. Unused amounts of at least $50 and up to a maximum of $640 remaining in your Healthcare FSA at the end of the Plan Year will carry over to the next Plan Year and may be used to

CHILD AND ADULT DAYCARE FSA ELECTION AND CARRYOVER. If you choose a Child and Adult Daycare FSA, you are eligible to seek reimbursement, as authorized by 26 U.S.C. Sections 21 and 129, for dependent care expenses. You may elect to contribute up to $2,500 (or $5,000 in the case of an Employee who is married and filing jointly) into a Child and Adult Daycare FSA for Plan Year 2025. The Child and Adult Daycare FSA may only reimburse eligible dependent care expenses that are incurred during the applicable coverage period. Funds in your Child and Adult Daycare FSA may only be used to reimburse eligible child and adult daycare expenses and may not be refunded upon termination of the FSA for any reason. Funds contributed into a Child and Adult Daycare FSA will not carryover to the next plan year.

An Employee and Retiree (where applicable) may affix a signature to a paper copy of the KEHP Health Insurance Enrollment Application, the Group Life Insurance Application, the Group Dental or Vision Applications, or an electronic version of the applications. By typing your name on an electronic application or by logging in and using your unique KHRIS User ID and enrolling through the Employee Self-Service portal, you are agreeing to conduct enrollment in life, health, dental, and vision insurance coverage by electronic means, thereby creating a legal and binding contract, as well as consenting to receiving any and all records or disclosures in electronic form at the election of DEI or your employer as described in Section 4A below. By affixing your signature in either manner, you understand and agree that:

I. PRIORITY OF PAYMENTS. Any moneys submitted to DEI that you intend to be used to fund your FSA or pay for insurance premium contributions may first be used to pay other priority debts that may be due and owing, such as taxes and child support.