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OPTIONAL SERVICES Description of Standard Service Fee Applied POP - Premium Only Plan is the building block of the Section 125 Plan. It $150.00 allows for certain employee paid group insurance premiums to be paid with one time pre-tax dollars. ICHRA - PREMIUM ONLY PLAN WITH INDIVIDUAL COVERAGE MEDICAL PREMIUM FEATURE AND HSA FEATURE $300.00 This Premium Only Plan allows employees participating in an ICHRA to pay one time their portion of their individual medical premium with pre-tax dollars through payroll deduction 125 PREMIUM ONLY PLAN + HSA + INDIVIDUAL PREMIUMS $450.00 Allows for pre-tax contributions for group plans, HSA Contributions, Individual one time Premium Feature and cash-in-lieu of coverage/cashable flex credits. SECTION 125 CAFETERIA PLAN A cafeteria plan is a separate written plan maintained by an employer for employees that meets the specific requirements of and regulations of section 125 of the Internal Revenue Code. It provides participants an opportunity to receive certain benefits on a pretax $750.00 basis. This plan covers all benefits an employer offers and allows for pre-tax one time contributions for group plans, HSA Contributions, Individual Premium Feature and cash-in-lieu of coverage/cashable flex credits, FSA, LPFSA, DCAP, Transportation and H CAFETERIA PLAN AND PREMIUM ONLY PLAN UPDATES Updating of the pre-tax benefits documents with federal language changes or $150.00 employer benefit changes. NONDISCRIMINATION TESTING Under Section 105(h) of the tax code the two tests a plan is required to meet are: 1. Eligibility test: The plan cannot discriminate in favor of highly compensated individuals as to eligibility to participate. Highly compensated $400.00 individuals consist of the five highest paid officers, more than 10 percent per run shareholders and the highest paid 25 percent of all employees. 2. The benefits test: The benefits provided under the plan must not discriminate in favor of highly compensated individuals. The benefits test has two components: testing for discrimination on the face of the plan and testing for discrimination in operation. FORM 5500 PREPARATION AND ELECTRONIC FILING (ERISA PLANS ONLY) $650 per Health and Welfare return (5500 form) and up to two schedules from the following list of schedules as applicable A or C schedules. Additional costs: $650.00 required per run $750.00 per return per year for corrected or amended returns (same criteria as above) $125.00 to complete a SAR (Summary Annual Report) *Note this service DOES NOT included distribution of the SAR to employees* MedSurety LLC agrees to complete the client MEDSURETY, LLC 23 Administration Agreement (Non-ERISA) Exhibit Business Associate Agreement