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MissionSquare Retirement Health Savings Program Return Book <br />D. Upon the death of the Participant, benefits shall become payable as outlined in <br />Section XI. <br />X. Permissible Medical Benefit Payments <br />Select one option. <br />Benefits eligible for reimbursement under the plan are as allowed under IRC Section 213 other than <br />direct long-term care expenses. <br />9 Option 1: All Medical Benefits* <br />❑ Option 2: Insurance Premiums Only <br />❑ Option 3: Select Expenses* you wish to cover under the Employer's welfare benefits plan: <br />❑ Medical Insurance Premiums <br />❑ Medical Out -of -Pocket Expenses <br />❑ Medicare Part B Insurance Premiums <br />❑ Medicare Part D Insurance Premiums <br />❑ 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 />12 <br />* Non -collectively bargained plans that reimburse medical expenses other than insurance premiums should consult their benefits <br />counsel regarding welfare plan nondiscrimination rules if the employer elects to make contributions based on a percentage of <br />earnings. <br />