Section 14-52-51 - Reimbursement claim form; filing requirements(a) To receive benefits under the plan, a participant shall submit a written claim for reimbursement to the third-party administrator, except that a written claim shall not be required for a participant who has opted to use a debit card for the payment of medical expenses, as provided under section 14-52-51.1. The claim shall be filed and received by the third-party administrator in accordance with the Code and other applicable state laws: (1) At any time during the plan year; provided the participant maintains eligibility;(2) Within ninety days after the end of the plan year; provided the eligible medical or employment-related dependent care expense was incurred during the plan year;(3) Within ninety days following the date a participant separates from service; provided the eligible medical or employment-related dependent care expense was incurred during the plan year and prior to separation from service;(4) Within ninety days after the employee ceases to be a participant; provided the eligible medical or employment-related dependent care expense was incurred during the plan year and prior to cessation of participation; and(5) Extension of unused amounts. Pursuant to Notice 2020-29 and Notice 2020-33, considering this plan offers a medical expense reimbursement spending account and/or a dependent care expense account reimbursement spending account, and the plan has a grace period that ends within 2020 or the plan year ends within 2020, the plan may permit expenses to be paid or reimbursed through December 31, 2020.(b) The claim shall be on a form prescribed by the director and shall include the following: (1) The name, address, and last four digits of the social security number of the participant;(2) The type of benefit claimed;(3) The amount of reimbursement being requested; and(4) Any other information reasonably required by the director or third-party administrator.(c) For a claim involving an event addressed in paragraphs (a)(2) through (a)(4), the participant shall provide complete information within the ninety day run-out period to enable the third-party administrator to render a determination. A claim that was submitted on a timely basis but that requires additional information or correction of the claim and that is not received by the third-party administrator by the end of the ninety day run-out period will not be allowed.(d) The minimum amount of a claim for reimbursement shall be $25 or any other amount approved by the director; provided that at the end of the plan year, the minimum amount may be less than $25 or the other amount approved by the director.(e) The maximum amount of a claim for reimbursement of eligible medical expenses shall be the amount specified in the participant's compensation reduction agreement plus the amount of any limited rollover from a prior year; provided that whenever a participant receives a reimbursement, the maximum amount shall be reduced by the amount of the reimbursement. The maximum amount of a claim for employment-related dependent care expenses shall be the amount of contributions remaining in a participant's spending account.(f) A participant shall provide whatever proof the director or third-party administrator may reasonably require to verify the claim.[Eff. 9/13/99; am AUG 05 2004] (Auth: HRS § 78-30) (Imp: HRS § 78-30)[Am and comp 12/2/2021] (Auth: HRS § 78-30) (Imp: HRS § 78-30)