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2. Dental Plan Covera�e. Roseville Dental Plan. Description. Payment of the employee cost for coverage under the City of This dental plan is described in the Dental Plan Summary Plan 3. Life Insurance Covera�e. Payment of the employee cost of up to $50,000 of coverage under the City of Roseville Life Insurance Plan. This life insurance plan is described in the Life Insurance Plan Summary Plan Description. 4. Medical Reimbursement. If you elect medical reimbursement coverage, you can use your Pay Conversion Contributions to be reimbursed for medical expenses incurred during the Period of Coverage for a Plan Year that are related to the diagnosis, treatment, or prevention of disease or for sickness and injury. Premiums for insurance coverage and similar expenses e.(�., payments for HMO coverage) are not reimbursable. If you elect to receive medical reimbursement coverage, within the Plan's limits you will elect your level of coverage for the Plan Year. The maximum level of coverage is Five Thousand Dollars ($5,000) per Plan Year. IRS Publication 502, which you may obtain from the Internal Revenue Service, describes only tax-deductible medical expenses, which are many of the expenses eligible for reimbursement. All of the expenses described in §213(d) of the Internal Revenue Code, with the exception of long-term care, are eligible for reimbursement under this Plan. There are some key differences between Publication 502 and §213(d). Three key differences between Publication 502 and this Plan are: (1) Expenses under this Plan are reimbursable upon the date incurred and not the date paid, and goes by the Plan Year and not the tax year. (2) Health insurance premiums are NOT reimbursable through the medical reimbursement portion of this Plan. (3) Over-the-counter medicine and drugs (excluding toiletries, cosmetics and dietary supplements taken for general health) are reimbursable under this Plan. The following list gives examples of the types of inedical expenses covered. However, an expense is ineligible for reimbursement to the extent that it is covered by any insurance policy or will be reimbursed from any other source. In addition, expenses for cosmetic procedures that are not medically necessary are not eligible for reimbursement. Surgical services Hospital services Laboratory services Medicine and drugs Ambulance services Pre-natal care Orthodontia Vision care Contact lenses Seeing eye dogs Tape recorders for blind persons 8 X-Ray treatments Nursing services Dental services Insulin Chiropractic and osteopathic services Chemical dependency services Psychiatric care Prescription eyeglasses Hearing aids Wheelchairs Crutches