Establishes the plan in writing, as ERISA §402 requires, and records the Employer's elections. Modeled on the limited-scope dental and vision HRA described in IRS Notice 2002-45 and 26 CFR §54.9831-1(c)(3). Employees receive the Summary Plan Description separately.

{{COMPANY_LEGAL_NAME}} Dental and Vision Health Reimbursement Arrangement

Plan Document and Adoption Agreement

{{COMPANY_LEGAL_NAME}}, organized under the laws of {{COMPANY_STATE}} (the "Employer"), adopts this Dental and Vision Health Reimbursement Arrangement (the "Plan"), effective on the date it selected during onboarding.

1. What the Plan is

1.1 The Plan reimburses employees, and their covered dependents, for dental and vision expenses that are medical care under Internal Revenue Code §213(d). It is a health reimbursement arrangement under IRS Notice 2002-45 and a self-insured medical reimbursement plan under Code §105(b) and §106, so that reimbursements are excluded from the employee's income.

1.2 The Employer funds the Plan entirely. No salary reduction, cafeteria plan election, or employee contribution is permitted.

1.3 The Plan provides only limited-scope dental and vision benefits under 26 CFR §54.9831-1(c)(3)(iii), and any employee may decline coverage. It is therefore an excepted benefit, not subject to the Affordable Care Act market reforms, including the prohibition on annual dollar limits.

1.4 The Plan is a limited-purpose HRA and does not affect a participant's eligibility to contribute to a health savings account under Code §223.

2. Elections

Plan name	The {{COMPANY_LEGAL_NAME}} Dental and Vision Health Reimbursement Arrangement
Plan number	501, or the next available number if 501 is in use
Plan year	Calendar year. The first plan year runs from the effective date to December 31.
Annual benefit	{{ANNUAL_MAXIMUM}} per covered person per plan year, not prorated, no carryover
Eligible employees	Every employee of the Employer, from the date of hire (Section 3)
Dependents	Covered or not as the Employer elected during onboarding
Funding	Employer general assets, drawn from the bank account the Employer links in Denta
Plan administrator and named fiduciary	The Employer
Third-party administrator	Denta, Inc.

3. Who is covered

3.1 Every employee. Every common-law employee of the Employer is eligible from their date of hire. There is no minimum hours requirement and no waiting period. The Employer enrolls employees through Denta, and may not exclude an employee in a way that favors highly compensated individuals under Code §105(h).

3.2 Who cannot participate. Self-employed individuals, including sole proprietors, partners, and more-than-2% shareholders of an S corporation, and anyone who is not a common-law employee, such as an independent contractor. The Code does not permit tax-free reimbursement for them.

3.3 Dependents. Where elected, the employee's spouse or domestic partner and the employee's children under age 27. Each covered person has their own annual benefit.

3.4 Declining coverage. An employee may decline coverage for themselves or a dependent at any time by telling the Employer, and may rejoin at the start of a later plan year.

3.5 Coverage ends on the last day of the month in which employment ends or the Plan terminates. Expenses incurred before then remain reimbursable if claimed within 12 months of the date of service.

4. What the Plan pays

4.1 Eligible dental and vision expenses incurred by a covered person during a plan year, up to the annual benefit, to the extent they are medical care under Code §213(d):

• dental: services furnished by a licensed dentist for the diagnosis, treatment, or prevention of disease of the mouth, including CDT codes D0100 through D8999;
• vision: eye examinations, prescription eyeglasses and contact lenses, and other services furnished by a licensed optometrist or ophthalmologist for the treatment of the eye.

4.2 The Plan does not pay for cosmetic procedures under Code §213(d)(9), including whitening (D9972 through D9975) and veneers or contouring done for appearance and non-prescription eyewear; any amount above the annual benefit; expenses incurred outside the coverage period; expenses paid by other coverage; expenses deducted under Code §213; or premiums for any health coverage.

4.3 The Plan pays what the provider charges, up to the annual benefit, at any licensed dentist, optometrist, or ophthalmologist. Where Denta has a contracted rate with a provider, that rate is the charge and the covered person is not balance billed.

5. Claims and appeals

5.1 Every reimbursement is substantiated by an itemized claim or receipt showing the patient, provider, date, service, and amount. The Plan may pay the provider directly or reimburse the covered person.

5.2 Denta applies the Plan's terms to each claim and decides it within 30 days, extendable once by 15 days on notice. A denial states the reason, the provision relied on, any information needed, and how to appeal.

5.3 A claimant may appeal to the Employer within 180 days. The Employer reviews the claim fresh, through someone who did not make the original decision, and answers within 60 days with reasons and notice of the right to sue under ERISA §502(a). This appeal must be exhausted before a civil action.

6. Funding and administration

6.1 Benefits are paid from the Employer's general assets, drawn from the bank account the Employer links in Denta, as claims are approved. No trust is created. The Employer alone funds every approved claim, including claims paid after the plan year ends. Denta does not insure or guarantee any benefit.

6.2 The Employer is plan sponsor, plan administrator, and named fiduciary under ERISA §402(a), with discretionary authority to interpret the Plan and decide appeals. It is also the agent for service of legal process.

6.3 Denta, Inc. performs ministerial functions under an Administrative Services Agreement: eligibility records, claim intake, applying the Plan's terms, payment, and reporting. It is not a fiduciary under ERISA §3(21).

6.4 The Plan is intended to satisfy Code §105(h), and the Employer may limit a highly compensated individual's benefit as needed to do so.

7. COBRA and HIPAA

7.1 If the Employer had 20 or more employees on more than half its typical business days last calendar year, a covered person who loses coverage through a qualifying event may continue it under COBRA for 18 months (36 months for events other than termination or reduced hours) at up to 102% of the applicable premium set by the Employer. Otherwise this Section does not apply.

7.2 The Plan discloses protected health information to the Employer only for plan administration under 45 CFR §164.504(f)(2). The Employer will not use it for employment decisions or other benefit plans, will restrict access to the employees who administer the Plan, will report any contrary use, and will return or destroy it when no longer needed. Adopting this Plan is the Employer's certification to those conditions.

8. Amendment, termination, general

8.1 The Employer may amend or terminate the Plan at any time by written action. Termination does not affect claims for expenses incurred before it.

8.2 Benefits are not assignable, except that the Plan may pay a provider directly. The Plan may recover overpayments, including by offset, and may end the coverage of anyone who knowingly submits a false claim.

8.3 Nothing in the Plan is a contract of employment. ERISA governs, state law applies only where not preempted, and an unenforceable provision does not affect the rest.

9. Adoption

By signing, the undersigned adopts this Plan on behalf of the Employer with the elections in Section 2 and certifies that they are authorized to do so.