HomeMy WebLinkAbout2011/12/06 Item 07CITY COUNCIL
AGENDA STATEMENT
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CHULAVISTA
DECEMBER 6, 2011, Item
ITEM TITLE: RESOLUTION ADOPTING THE CITY OF CHULA VISTA
CAFETERIA BENEFITS PLAN FOR 2012
SUBMITTED BY: DIItECTOR OF HUMAN RESOURCES & INFORMATION
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REVIEWED BY: CITY MANAGER
ASSISTANT CITY ANAGER S~
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SUMMARY
The Internal Revenue Code requires that the Section 125 Cafeteria Benefits Plan offered
by the City to its employees be in a written document and that the document be formally
adopted by the City Council on or before the first day of the plan year. Adoption by
resolution of the attached plan document fulfills the City's obligation for the 2012 plan
year.
ENVIRONMENTAL REVIEW
Not applicable.
RECOMMENDATION
That Council adopt the plan by resolution.
BOARDS/COMMISSION RECOMMENDATION
Not applicable.
DISCUSSION
In June 1998, the City established its first Section 125 Cafeteria Benefits Plan. In
compliance with Internal Revenue Code §125(d) the City Council annually adopts a
written plan document prior to the first day of the plan year. The first day of the City's
plan year is January 1, 2012.
This Plan Document lays out how the City offers eligible employees the choice between
cash and certain nontaxable benefits (such as health insurance), thereby allowing
employees to pay for the benefits they choose on a pre-tax basis.
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DECEMBER 6, 2011, Item tJ
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The specific health plans offered and their structure are not part of this Cafeteria Plan
Document. They are included in what is known as the Summary Plan Document that was
given to eligible employees as part of their open enrollment materials to assist them in
making their benefit choices. The plans offered and their structure are determined after
our broker, Barney and Barney, extensively markets and negotiates with providers to
provide coverage comparable to the prior year while keeping the increase in costs to the
City and its benefited employees to a minimum. All employee groups are advised of the
offers and the plan structures that will provide the least increase in premium costs.
Under current cafeteria plan regulations having an approved written plan is critical.
Without a written plan or if the written plan does not comply with applicable
requirements regarding content and timing of adoption, then the plan is not a cafeteria
plan and employees' elections will be taxable. The City has timed its open enrollment
period for 2012 to comply with these regulations and to meet provider cutoff deadlines
for enrollment to ensure employees are covered without interruption.
The City's Plan includes the following required information:
• Description of available benefits
• Participation rules
• Election procedures
• Manner of contributions
• Maximum amount of contributions
• The plan year
• The plans provisions for complying with flexible spending arrangements
(FBAs)
The attached Plan incorporates all of the operating rules prescribed in Code § 125 and the
regulations thereunder.
DECISION MAKER CONFLICT
Staff has reviewed the decision contemplated by this action and has determined that it is
not site specific and consequently the 500 foot rule found in California Code of
Regulations section 18704.2(a)(1) is not applicable to this decision.
CURRENT YEAR FISCAL IMPACT
The flex allotment and cafeteria plan change from year to year and have been accounted
for in the current year fiscal budget.
ONGOING FISCAL IMPACT
None with this action.
ATTACHMENTS
Attachment A -2012 City of Chula Vista Cafeteria Benefits Plan
Prepared by: Edith Quicho, Benefits Manager
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CAFETERIA BENEFITS PLAN
FOR
THE CITY OF CHULA VISTA
Amended and Restated as of January 1, 2012
Established June 1998
Human Resources and
Information Technology Services Departments
City of Chula Vista
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SECTION 125 CAFETERIA BENEFIT PLAN
ADOPTION AGREEMENT
The undersigned Employer hereby adopts the Section 125 Cafeteria Benefit Plan for
those Employees who shall qualify as Participants hereunder. The Employer herby
selects the following Plan Specifications:
A. EMPLOYER INFORMATION
Name of Employer:
Address:
City of Chula Vista
276 Fourth Ave.
Chula Vista, CA 91910
Employer Tax ID:
Nature of Business:
Name of Plan:
95-6000690
Municipal Government
City of Chula Vista Cafeteria Benefits
Plan
B. EFFECTIVE DATE
Original Effective Date of Plan:
Effective Date of Amendment:
June 1998
January 1, 2012
C. ELIGIBILITY REQUIREMENTS FOR PARTICIPATION
Eligibility requirements for each component plan under this Section 125
document will be applicable and, if different, will be listed in Item F.
Employee Status: Directly employed by the City of Chula
Vista in a full- or part-time benefited
status.
Length of Service: First day of employment in a benefited
status.
D. PLAN YEAR The current plan year will begin on
January 1, 2011 and end on December
31.2011.
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E. EMPLOYER CONTRIBUTIONS
Non-Elective Contributions:
Non-Elective Contributions
Safe
Elective Contributions (Salary
Reduction):
The maximum amount available to each
Participant for the purchase of certain
elected benefits (Group Medical
Insurance, Group Dental Insurance,
Group Vision, Dental/Medical/Vision and
Dependent/Child Care Reimbursement
and Cash Payment Option) with non-
elective contributions will be:
Confidential $11,936
CVEA $11,436
Executive $14,836
MM,MMCF,MMUC $12,436
PROF,PRCF,PRUC $12,436
Senior Managers $13,436
WCE $12,436
Mayor/Council $14,836
For Employees represented by POA/IAFF
-The employer pays the full cost of the
Kaiser Permanente Plan for employees
and their dependents or the annual
premium less $600 for non-Kaiser plans.
For dental coverage the City will pay an
amount equal to the pre-paid dental
premium for the coverage level elected.
Each Participant may authorize the
Employer to reduce his or her
compensation by the amount needed for
the purchase of benefits elected, less the
amount ofnon-elective contributions. An
election for salary reduction will be made
on the Benefit Election Form.
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F. AVAILABLE BENEFITS
Each of the following components should be considered a plan that comprises
this Plan.
Group Medical Insurance
Mandatory for all employees
except those who are covered
by their City Employee Spouse
or who are represented by MM,
MMUC,MMCF,PROF,
PRCF,PRUC and can provide
evidence of other qualified
coverage.
The terms, conditions, and limitations for
the Group Medical Insurance will be as
set forth in the insurance policy or policies
described below: (See Section V of the
Plan Document).
2. Dentallnsurance
3. Vision Insurance
4. DentallMedicallVision
Reimbursement Account
The terms, conditions and limitations for
the Dental Insurance will be as set forth in
the insurance policy or policies described
below: (See Section V of the Plan
Document).
The terms, conditions and limitations for
the Dental Insurance will be as set forth in
the insurance policy or policies described
below: (See Section V of the Plan
Document).
The terms conditions and Limitations for
the Dental/Medical/Vision
Reimbursement Account will be as set
forth in Section VI of the Plan Document
and described below:
Minimum Coverage: $0 per Plan Year
Maximum Contribution: $5,000 from all
sources per Plan Year.
Recordkeeper: Wage Works
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5. DegendenUChild Care The terms conditions and Limitations for the
Reimbursement Account DependenU Child Care Reimbursement
Account will be as set forth in Section VII of the
Plan Document and described below:
Minimum coverage: $0 per Plan Year
Maximum Coverage-$5,000 per plan year from all
sources ($2,500 per plan year from all sources for a
married employee filing separate tax returns).
Recordkeeper: Wage Works
6. Cash Payment Option Any Flex Plan allotment remaining after electing
mandatory medical coverage may be allotted to
this taxable option.
The following benefits AFLAC Cancer Insurance
are only available AFLAC Basic Dental Coverage
through Elective AFLAC Accident Insurance
Contributions (Salary AFLAC Hospital Indemnity
Reduction): Insurance
AFLAC Specified Health Event Insurance
The terms condition and limitations for the
AFLAC programs will be as set forth in Section
VIII of the Plan Document.
Administered by: AFLAC
The Plan shall be construed, enforced, administered, and the validity
determined in accordance with the applicable provisions of the Employee
Retirement Income Security Act of 1974 (as amended) if applicable, the
Internal Revenue Code of 1986 (as amended), and the laws of the State of
California. Should any provision be determined to be void, invalid, or
unenforceable by any court of competent jurisdiction, the Plan will continue to
operate, and for purposes of the jurisdiction of the court only, will be deemed
not to include the provision determined to be void.
This Plan is hereby adopted the 6`h day of December, 2011.
ey:
Title:
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THIS DOCUMENT IS NOT COMPLETE WITHOUT PAGES 7 THROUGH 22
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SECTION 125 CAFETERIA BENEFITS PLAN
SECTION 1
PURPOSE
The Employer is establishing this Cafeteria Benefits Plan in order to make a broader
range of benefits available to its Employees and their Dependents. The Plan allows
Employees to choose among different types of benefits and select the combination
best suited to their individual goals, desires, and needs. These choices include an
option to receive certain benefits in lieu of taxable compensation.
In establishing this Plan, the Employer desires to attract, reward, and retain highly
qualified, competent employees, and believes this Plan will help achieve that goal.
It is the intent of the Employer to establish this Plan in conformity with Section 125 of
the Internal Revenue Code of 1986, as amended, and in compliance with applicable
rules and regulations issued by the Internal Revenue Service. This Plan will grant to
eligible Employees an opportunity to purchase qualified benefits, which when
purchased alone by the Employer, would not be taxable.
SECTION II
DEFINITIONS
The following words and phrases appear in this Plan and will. have the meaning
indicated below unless a different meaning is plainly required by the context:
"Administrator" means the Human Resources Department of the City of Chula
Vista, or other such person or entity that it appoints as its designee.
"Annual Enrollment Period" means the period designated by the Administrator
which precedes the commencement of each Plan Year during .which Eligible
Employees can elector modify the amount contributed for Benefits.
"Applicable Law" means the Internal Revenue Code of 1986, and the same as may
be amended from time to time, plus all regulations promulgated with respect thereto.
Reference to any section or subsection of the Code includes reference to any
comparable or succeeding provision of any legislation which amends, supplements
or replaces such section or subsection.
"Benefit Election Form" See Enrollment Form.
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"Benefit Package Option" means a qualified benefit under Code Section 125 (f)
that is offered under the Cafeteria (Flexible) Benefits Plan, or an option for coverage
under an underlying health plan (such as an HMO or PPO option under a health
plan).
"Benefits" or "Qualified Benefits" means the following benefits available under
the Flex Plan:
(a) Group Medical Insurance
(b) Dependent/Child Care Reimbursement Account
(c) Dental/MedicalNision Reimbursement Account
(d) Cash Compensation (Post-Tax)
(e) Health Premiums for Non-Tax Qualified Dependents (Post-
Tax)
(f) Vision Insurance
(g) Dental Insurance
(h) Certain AFLAC Plans available via salary reduction only.
In order for a benefit to be qualified, a participant must also meet federal and/or state
tax requirements, including Code Section 152, etc.
"Child" means for these purposes will include (1) a natural child, (2) a stepchild, (3)
a legally adopted child, (4) a child placed with the employee for legal adoption, (5) a
foster child and (6) a child placed under the legal guardianship of the employee. In
addition and in order to comply with OBRA 1993: a child will include a child for
whom the employee or covered dependent spouse or Life Partner is required to
provide coverage due to a Medical Child Support Order. A Qualified Medical Child
Support Order (QMCSO) will also include a judgment, decree or order issued by a
court of competent jurisdiction or through an administrative process established
under state law and having the force and effect of law.
"Code" means the Internal Revenue Code of 1986, as amended.
"Dental/MedicalNision Reimbursement Account" Shall have the meaning
assigned to it by Section 6.01 of the Plan attached hereto as Exhibit A.
"Dependent" means an individual including:
(a) Participant's legal spouse;
(b) Life Partner (see definition bf Life Partner)
(c) Child of the employee, spouse or Life Partner who is under 26 years of
age (group medical insurance only);
(d) Unmarried child of the employee, spouse or Life Partner who is dependent
upon the employee for support and if they are under 25 years of age (all
other plans except group medical);
And
(e) Unmarried child of any age who is incapable of self-support due to mental
or physical handicap and such handicap began before attainment of
limiting age
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Note: A child who is eligible for an employer-sponsored medical benefits plan
where he/she works shall not be eligible for benefits under the City of Chula Vista's
medical plan, even if the child does not elect to be covered under his/her employer's
medical benefits plan.
"Dependent/Child Care Reimbursement Account" shall have the same meaning
assigned to it by Section 6.02 of the Plan Attached hereto as Exhibit A.
"Effective Date" of this Flex Plan was June 1998.
"Eligible Employee" means any active, full- or part-time employee of the City of
Chula Vista employed in a benefited status.
"Employee" means an individual that the Employer classifies as active, full-time or
part-time, who is on the Employer's W-2 payroll, include elected and appointed
officials but does not include the following: (a) any leased employee or an individual
classified as a contract worker, independent contractor, temporary employee or
casual employee for the period during which such individual is so classified, whether
or not any such individuals are on the Employer's W-2 payroll or determined by the
IRS or others or be common-law employees of the Employer; (b) any individual who
performs services for the Employer but who is paid by a temporary or other
employment or staffing agency for the period during which such individual is paid by
such agency, whether or not such individual are determined by the IRS or others to
be common-law employees of the Employer.
"Employer" means the City of Chula Vista.
"Enrollment Form" means the form or forms whether paper or electronic provided
by the Employer or the Administrator for the purpose of allowing an Eligible
Employee to participate in this Cafeteria Benefits Plan by employer contributions and
by electing Salary Reductions to pay for Benefits. It includes an agreement pursuant
to which an Eligible Employee or Participant authorizes the employer to make Salary
Reductions.
"Enrollment Period" means the period designated by the Administrator which
allows new employees to select Benefits for the current Plan Year and shall be the
first 30 days following each new Eligible employee's hire date.
"Entry Date" shall mean the date that an Eligible Employee shall become a
Participant:
(a) on the first day of the Flex Plan Year if the Eligible Employee's elects are
made during the annual Enrollment Period, or
(b) on the first day of the pay period coinciding with the receipt of the
Enrollment Form by the Participant's Employer, provided the new hire
makes such request within 30 days after the date of employment, or
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(c) on the first day coinciding with the date of satisfying the plan's eligibility
requirements.
"FMLA" means the Family and Medical Leave Act of 1993, as amended.
"Flex Plan Year" means the twelve-month period commencing on January 1 and
ending on December 31St.
"Health Plan" means the group medical, dental and vision plans maintained by the
City for its employees, as amended from time to time and are automatically
incorporated by reference under this Flex Plan. A Participant may request a copy of
the plan(s) from the Human Resources Benefits Division.
"HIPAA" Means the Health Insurance Portability and Accountability Act of 1996 as
amended.
"Life Partner" means: both you and your partner are eighteen (18) years of age or
older and are capable of consenting to the domestic partnership; neither of you can
be married to another or be a member of another domestic partnership; you cannot
be related by blood in a way that would prevent you from being married to each
other in this state; you must share the same principal place of abode, with the intent
to continue doing so indefinitely (this means that both partners share the same
residence, however, it is not necessary that the legal right to possess the common
residence be in both names); You are jointly financially responsible for "basic living
expenses; defined as basic food, water, shelter, and any other basic living
expenses. Life partners do not need to contribute equally to the cost of these
expenses as long as they agree that both are responsible for the cost; neither of you
have had a different domestic partner in the last six (6) months unless a previous
domestic partnership terminated by death.
"Non-elective Contribution(s)" means any amount which the Employer, pursuant
to Labor Agreements contributes on behalf of each Participant to provide benefits for
such Participant and his or her Dependents, if applicable, under one or more of the
Benefit Plan Option(s) offered under the Plan. The amount shall be calculated for
each plan year in a uniform and nondiscriminatory manner and in the case of POA
and IAFF employees will be based upon the Participant's elected coverage
dependent status, and for all others may be based on the commencement or
termination date of the Participant's employment during the Plan Year, and such
other factors as the Employer shall prescribe. To the extent set forth in the
Summary Plan Description or enrollment material, the Employer may make non-
elective contribution available to Participants and allow Participants to allocate the
Non-elective Contributions among the various Benefit Plan Options offered under
the Plan in a manner set forth in the Summary Plan Description or enrollment
material. In no event will any Non-elective Contribution be disbursed to a Participant
in the form of additional, taxable Compensation except as otherwise provided in the
Summary Plan Description or enrollment material.
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"Participant" means all Eligible Employees.
"Period of Coverage" means that portion of the Flex Plan Year for which one is a
Participant. In no event shall the period of coverage commence prior to, nor
terminate after, the commencement and ending dates of the Flex Plan Year.
"Qualified Benefits" means any benefit excluded from the Employee's taxable
income under Chapter 1 of the Code other than Sections 106 (b), 117,124, 127 or
132 and any other benefit permitted by the Income Tax Regulations (i.e. any
premiums for Life Partners who are not otherwise tax qualified dependents). Long
term care is not a "Qualified Benefit"
SECTION III
ELGIBILITY, ENROLLMENT, AND PARTICIPATION
3.01 ELIGIBILITY: Each Employee of the Employer who has met the eligibility
requirements of Item C of the Adoption Agreement will be eligible to participate
in the Plan on the entry date specified or the effective date of the Plan, which
ever is later. The Employer must notify the Employee of his eligibility to
participate in the Plan so that the Employee shall complete the necessary
enrollment forms on or before the entry date.
3.02 ENROLLMENT: An eligible Employee may enroll (or re-enroll) in the Plan by
submitting to the Employer, during an enrollment period, an Election Form
which specifies his or her benefit elections for the Plan Year and which meets
such standards for completeness and accuracy as the Employer may establish.
A Participant's Election Form shall be completed prior to the beginning of the
Plan Year, and shall not be effective prior to the date such form is submitted to
the Employer. Any Election. Form submitted by a Participant in accordance with
this Section shall remain in effect until the earlier of the following dates: the
date the Participant terminates participation in the Plan; or, the effective date of
a subsequently filed Election Form.
A Participant's right to elect certain benefit coverage shall be limited hereunder
to the extent such rights are limited in the Policy. Furthermore, a Participant
will not be entitled to revoke an election after a period of coverage has
commenced and to make a new election with respect to the remainder of the
period of coverage unless both the revocation and the new election are on
account of and consistent with a change in status, or other allowable events, as
determined by Section 125 of the Internal Revenue Code and the regulations
thereunder. Notwithstanding anything to the contrary herein, to the extent
required by the Health. Insurance Portability and Accountability Act of 1996, the
Plan shall permit special enrollment period for employees who have previously
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declined coverage under the Plan; a new dependent may also justify a special
enrollment period.
3.03 DEFAULT ENROLLMENT:
(a) Employees of the CVEA, WCE, MAYOR, COUNCIL, CITY ATTORNEY,
CITY CLERK, EXECUTIVE, SENIOR MANAGER, MID-MANAGER, MID-
MANAGER CONFIDENTIAL, MID-MANAGER UNCLASSIFIED,
PROFESSIONAL, PROFESSIONAL CONFIDENTIAL, PROFESSIONAL
UNCLASSIFIED, AND CONFIDENTIAL employee groups who fail to
make their elections during Open Enrollment will have their current
medical and life insurance automatically continued in to the next Plan year
as if the Employee elected to keep them. All other coverage, including
dental, vision and reimbursement accounts will stop. Any Flex Allotment
funds remaining after the health coverage election will be placed in the
taxable cash option.
In the case of a newly eligible employee, failure to turn in the completed
enrollment forms within 30 days from eligibility date will result in automatic
enrollment in the least costly medical coverage for employee only with
any remaining funds placed in the taxable Cash Payment Option.
(b) POA and IAFF employees who fail to make their benefit elections
either within 30 days of their eligibility date or during open enrollment will
only be enrolled in the Kaiser Employee Only plan.
3.04 TERMINATION OF PARTICIPATION: A Participant's coverage will stop on
the last day of the month in which eligibility ends for any of the following
reasons:
a. The date the Participant terminates employment by death,
disability, retirement or other separation from service; or
b. The date the Participant ceases to work for the Employer as an
eligible Employee;
c. The date of termination of the Plan;
d. The first date a Participant fails to pay required contributions
while on a leave of absence, or
e. The date an employee is on a leave of absence without benefits.
Dependent coverage will end the earlier of the last day the employee's
coverage ends or on the last day of the month in which he or she is no longer
an eligible dependent.
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3.05 SEPARATION FROM SERVICE: The Employer shall, on a reasonable and
consistent basis, permit an Employee who separates from the employment
service of the Employer during a Plan Year to revoke his existing elections
and terminate the receipt of benefits for the remaining portion of the Plan
Year.
3.06 QUALIFYING LEAVE UNDER FAMILY LEAVE ACT: Notwithstanding any
provision to the contrary in this Plan, if a Participant goes on a qualifying paid
or unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), to
the extent required by the FMLA, the Employer will continue to maintain the
Participant's existing coverage under the Plan with respect to the benefits
under Section V and Section VI of the Plan on the same terms and conditions
as though they were still an active Employee. If the Employee fails to return
to work after such leave for any reason other than the serious illness of the
employee or the family member for whom the leave was granted or through
no fault of the employee, they will be required to pay all Cafeteria Benefits
Plan monies paid to them, or on their behalf during the absence.
3.07 COVERAGE. WHILE ON A LEAVE OF ABSENCE WITH BENEFITS:
Employees who are authorized to take a leave with benefits (e.g. Military
Leave as approved by the City Council) will continue to be covered under the
Plan until the expiration of their leave.
3.08 COVERAGE WHILE ON A LEAVE OF ABSENCE WITHOUT BENEFITS:
Employees on an unpaid leave of absence for any reason other than those
under Section 3.06 and 3.07 are no longer eligible for participation in the
Plan. If an employee returns from an unpaid leave of absence without
benefits, the date the coverage is reinstated will depend on the employee's
date of return. If the employee returns to work on or before the 15th of the
month, coverage will be reinstated retroactive to the first of the month. If an
employee returns after the 15th of the month, coverage will be reinstated the
first of the following month.
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SECTION IV
CONTRIBUTIONS
4.01 EMPLOYER CONTRIBUTIONS: The Employer may pay the costs of the
benefits elected under the Plan with funds from the sources indicated in Item
E of the Adoption Agreement. The Employer Contribution may be made up of
Non-Elective Contributions and/or Elective Contributions authorized by each
Participant.
4.02 IRREVOCABILITY OF ELECTIONS: A Participant may file a written election
form with the Administrator before the end of the current plan year revising
the rate of his contributions. or discontinuing such contributions effective as of
the first day of the following Plan Year. The Participant's Elective
Contributions will automatically terminate the date his employment
terminates. Except as provided in this Section 4.02 and Section 4.03, a
Participant's election under the Plan is irrevocable for the duration of the plan
year to which it relates. The exceptions to the irrevocability requirement
which would permit amid-year election change in benefits and the salary
reduction amount elected are set out in the Treasury regulations promulgated
under Code Section 125, which include the following:
(a) Chanoe in Status. A Participant may change or revoke his election under the
Plan upon the occurrence of a valid change in status, but only if such change
or termination is made on account of, and is consistent with, the change in
status in accordance with the Treasury regulations promulgated under
Section 125. The Employer, in its sole discretion as Administrator, shall
determine whether a requested change is on account of and consistent with a
change in status, as follows:
(1) Change in Employee's legal marital status, including marriage, divorce,
death of spouse, legal separation, and annulment;
(2) Change in number of Dependents, including birth, adoption, placement
for adoption, and death;
(3) Change in employment status, including any employment status
change affecting benefit eligibility of the Employee, spouse or
Dependent, such as termination or commencement of employment,
change in hours, strike or lockout, a commencement or return from an
unpaid leave of absence and change in work site. If the eligibility for
either the Cafeteria Plan or any underlying benefit plans of the
Employer of the Employee, spouse or Dependent relies on the
employment status of that individual, and there is a change in that
individual's employment status resulting in gaining or losing eligibility
under the Plan, this constitutes a valid change in status. This category
only applies if the benefit eligibility is lost or gained as a result of the
event. If an Employee terminates and is rehired within 30 days, the
Employee is required to step back into his previous election. If the
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Employee terminates and his rehired after 30 days, the- Employee may
either step back into the previous election or make a new election;
(4) Dependent satisfies, or ceases to satisfy, Dependent eligibility
requirements due to attainment of age, gain or loss of student status,
marriage or any similar circumstances; and
(5) Resident change of Employee, spouse or Dependent, affecting the
Employee's eligibility for coverage.
(b) Special HIPAA Enrollment Riohts. If a Participant, spouse, or Dependent
enrolls in the health insurance plan pursuant to special enrollment rights
under HIPAA, the Participant may make a corresponding change in election
under this Plan. Special enrollment rights under the health insurance plan
will be determined by the terms of the health insurance plan.
(c) Certain Judoments. Decrees or Orders. If a judgment, decree or order
resulting from a divorce, legal separation, annulment or change in legal
custody (including a qualified medical child support order [OMCSO]) requires
accident or health coverage for a Participant's child or for a foster child who is
a dependent of the Participant, the Participant may have amid-year election
change to add or drop coverage consistent with the Order.
(d) Entitlement to Medicare or Medicaid. If a Participant, Participant's spouse or
Participant's Dependent who is enrolled in an accident or health plan of the
Employer becomes entitled to Medicare or Medicaid (other than coverage
consisting solely of benefits under Section 1928 of the Social Security Act
providing for pediatric vaccines), the Participant may cancel or reduce health
coverage under the Employer's Plan. Loss of Medicare or Medicaid
entitlement would allow the Participant to add health coverage under the
Employer's Plan.
(e) Family Medical Leave Act. If an Employee is taking leave under the rules of
the Family Medical Leave Act, the Employee may revoke previous elections
and re-elect benefits upon return to work.
(f) COBRA Qualifvino Event. If an Employee has a COBRA qualifying event (a
reduction in hours of the Employee, or a Dependent ceases eligibility), the
Employee may increase his pre-tax contributions for coverage under the
Employee's Plan if a COBRA event occurs with respect to the Employee, the
Employee's spouse or Dependent. The COBRA rule does not apply to
COBRA coverage under another Employer's Plan.
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4.03 OTHER EXEPTIONS TO THE IRREVOCABILITY OF ELECTIONS.
Other exceptions to the irrevocability of election requirement permit mid-year
election changes an apply to all qualified benefits except for
Dental/MedicalNision Reimbursement Plan, as follows:
(a) Change in Cost. If the cost of a benefit package option under the Plan
significantly increases during the plan year, Participants may (i) make a
corresponding increase in their salary reduction amount, (ii) revoke their
elections and make a prospective election under another benefit option
offering similar coverage, or (iii) revoke election completely if no similar
coverage is available, including in spouse or dependent's plan. If the cost
significantly decreases, employees may elect coverage even if they had not
previously participated and may drop their previous election for a similar
coverage option in order to elect the benefit package option that has
decreased in cost during the year. If the increased or decreased cost of a
benefit package option under the Plan is insignificant, the participant's salary
reduction amount shall be automatically adjusted.
(b) Significant curtailment of coverage.
(i.) With no loss of coverage. If the coverage under a benefit
package option is significantly curtailed or ceases during the
Plan Year, affected Participants may revoke their elections for
the curtailed coverage and make a new prospective election for
coverage under another benefit package option providing similar
coverage.
(ii.) With loss of coverage. It there is a significant curtailment of
coverage with loss of coverage, affected Participants may
revoke election for curtailed coverage and make a new
prospective election for coverage under another benefit
package option providing similar coverage, or drop coverage if
no similar benefit package option is available.
(c) Addition or Sionificant Improvement of Benefit Package Option. If during the
Plan Year a new benefit package option is added or significantly improved,
eligible employees, whether currently participating or not, may revoke their
existing election and elect the newly added or newly improved option.
(d) Change in Coverage of a Spouse or Dependent Under Another Emplover's
Plan. If there is a change in coverage of a spouse, former spouse, or
Dependent under another employer's plan, a Participant may make a
prospective election change that is on account of and corresponds with a
change made under the plan of the spouse or Dependent. This rule applies if
(1) mandatory changes in coverage are initiated by either the insurer of
spouse/dependent's plan or by the spouse/dependent's employer, or (2)
11/4/2011 226 PM
Page 16 of 24
~-18
option changes are initiated by the spouse/dependent's employer or by the
spouse/dependent through open enrollment.
(e) Loss of coverage under other group health coverage. If during the Plan Year
coverage is lost under any group health coverage sponsored by a
governmental or educational institution, a Participant may prospectively
change his or her election to add group health coverage for the affected
Participant or his or her spouse or dependent.
4.04 CASH BENEFIT: Available amounts not used for the purchase of benefits
under this Plan may be considered a cash benefit under the Plan payable to
the Participant as taxable income to the extent indicated in Item E of the
Adoption Agreement.
4.05 PAYMENT FROM EMPLOYER'S GENERAL ASSETS: Payment of benefits
under this Plan shall be made by the Employer from Elective Contributions
which shall be held as part of its general assets.
4.06 EMPLOYER MAY HOLD ELECTIVE CONTRIBUTIONS: Pending payment of
benefits in acEOrdance with the terms of this Plan, Elective Contributions may
be retained by the Employer in a separate account, or if elected by the
Employer and as permitted or required by regulations of the Internal Revenue
Service, Department of Labor or other governmental agency, such amounts
of Elective Contributions my be held in a trust pending payment.
4.07 MAXIMUM EMPLOYER CONTRIBUTIONS: With respect to each Participant,
the maximum amount made available to pay benefits for any Plan Year shall
not exceed the Employer's Contribution specified in the Adoption Agreement
and as provided in this Plan.
SECTION V
GROUP MEDICAL INSURANCE BENEFIT PLAN
5.01 PURPOSE: These benefits provide the group medical insurance benefits to
Participants.
5.02 ELIGIBILITY: Eligibility will be required in Items F(1), F(2), and F(3) of the
Adoption Agreement.
5.03 DESCRIPTION OF BENEFITS: The benefits available under this Plan will be
as defined in items F(1), F(2), and F(3) of the Adoption Agreement.
5.04 TERMS. CONDITONS AND LIMITATIONS: The terms, conditions and
limitations of the benefits offered shall be as specifically described in the
Policy identified in the Adoption Agreement.
11/4/2011 2:26 PM
Page 17 of 24
7-19
5.05 COBRA: To the extent required by Section 49808 of the Code and Sections
601 through 607 of ERISA, Participants and Dependents shall be entitled to
continued participation in this Group Medical Insurance Benefit Plan by
contributing monthly (subject to taxation) 102% of the amount of the premium
for the desired benefits during the period that such individual is entitled to
elect continuation coverage, provided, however, in the event the continuation
period is extended to 29 months due to disability, the premium to be paid for
the continuation coverage for the 11 month extension period shall be 150% of
the applicable premium.
5.06 SECTION 105 AND 106 PLAN: It is the intention of the Employer that these
benefits shall be eligible for exclusion from the gross income of the
Participants covered by this benefit plan, as provided in Code Sections 105
and 106, and all provisions of this benefit plan shall be construed in a manner
consistent with that intention. It is also the intention of the Employer to
comply with the provision of the Consolidated Omnibus Budget Reconciliation
Act of 1985 as outlined in the policies identified in the Adoption Agreement.
However, eligibility for tax qualified benefits will be subject to all state and
federal regulations. In order to receive tax free benefits, a participant must
meet all other state and federal eligibility guidelines.
5.07 CONTRIBTUIONS: Contributions for these benefits will be provided by the
Employer on behalf of a Participant as provided for in Item E of the Adoption
Agreement.
5.08 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT:
Notwithstanding anything to the contrary herein, the Group Medical Insurance
Benefit Plan shall comply with the applicable provision of the Uniformed
Services Employment and Reemployment Rights Act of 1994.
SECTION VI
DENTAUMEDICAWISION REIMBURSEMENT PLAN
6.01 The Plan Document for this option is included in the attached Exhibit A and is
incorporated by reference.
11/4/2011 2:26 PM
Page 18 of 24
7-20
SECTION VII
DEPENDENT/CHILD CARE REIMBURSEMENT PLAN
7.01 The Plan Document for this option is included in the attached Exhibit A and is
incorporated by reference.
SECTION VIII
AFLAC CANCER, BASIC DENTAL COVERAGE, ACCIDENT INSURANCE,
HOSPITAL INDEMNITY INSURANCE, SPECIFIED HEALTH EVENT
INSURANCE
8.01 The Plan Document for these options is included in the attached Exhibit B
and is incorporated by reference.
SECTION IX
AMENDMENT AND TERMINATION
9.01 AMENDMENT: The Employer shall have the right at any time, and from time
to time, to amend, in whole or in part, any or all of the provisions of this Plan,
provided that no such amendment shall change the terms and conditions of
payment of any benefits to which Participants and covered dependents
otherwise have become entitled to under the provisions of the Plan, unless
such amendment is made to comply with federal or local laws or regulations.
The Employer also shall have the right to make any amendment retroactively,
which is necessary to bring the Plan into conformity with the Code. In
addition, the Employer may amend any provision or any supplements to the
Plan and may merge or combine supplements or add additional supplement
to the Plan, or separate existing supplements into an additional number of
supplements.
9.02 TERMINATION: The Employer shall have the right at any time to terminate
this Plan, provided that such termination shall not eliminate any obligations
of the Employer which therefore have arise under the Plan.
11/4/2011 2:26 PM
Page 19 of 24
7-21
SECTION X
ADMINISTRATION
10.01 NAMED FIDUCIARIES: The Administrator shall be the fiduciary of the Plan.
10.02 APPOINTMENT OF RECORDKEEPER: The Employer may appoint a
Reimbursement Recordkeeper which shall have the power and
responsibility of performing Recordkeeping and other ministerial duties
arising under the Dental/Medical/Vision Reimbursement Plan and the
Dependent/Child Care Reimbursement Plan provisions of this Plan. The
Reimbursement Recordkeeper shall serve at the pleasure of, and may be
removed by, the Employer without cause. The Recordkeeper shall receive
reasonable compensation for its services as shall be agreed upon from time
to time between the Administrator and the Recordkeeper.
10.03 POWERS AND RESPONSIBILITIES OF ADMINISTRATOR:
a. General. The Administrator shall be vested with all powers and
authority necessary in order to amend and administer the Plan, and
is authorized to make such rules and regulations as it may deem
necessary to carry out the provisions of the Plan. The
Administrator shall determine any questions arising in the
administration (including all questions of eligibility and
determination of amount, time and manner of payments of
benefits), construction, interpretation and application of the Plan,
and the decision of the Administrator shall be final and binding on
all persons.
b. Recordkeeping. The Administrator shall keep full and complete
records of the administration of the Plan. The Administrator shall
prepare such reports and such information concerning the Plan and
the administration thereof by the Administrator as may be required
under the Code or ERISA and the regulation promulgated
thereunder.
c. Inspection of Records. The Administrator shall, during normal
business hours, make available to each Participant for examination
by the Participant at the principal office of the Administrator a copy
of the Plan and such records of the Administrator as may pertain to
such Participant. No Participant shall have the right to inquires as
to or inspect the accounts or records with respect to other
Participants.
11/4/2011 2:26 PM
Page 20 of 24
7-22
10.04 COMPENSATION AND EXPENSES OF ADMINISTRATOR: The
Administrator shall serve without compensation for services as such. All
expenses of the Administrator shall be paid by the Employer. Such
expenses shall include any expense incident to the functioning of the Plan,
including, but not limited to, attorneys' fees, accounting and clerical charges,
actuary fees and other costs of administering the Plan.
10.05 LIABILITY OF ADMINISTRATOR: Except as prohibited by law, the
Administrator shall not be liable personally for any loss or damage or
depreciation which may result in connection with the exercise of duties or of
discretion hereunder or upon any other act or omission hereunder except
when due to willful misconduct. In the event the Administrator is not
covered by fiduciary liability insurance or similar insurance arrangements,
the Employer shall indemnify and hold harmless the Administrator from any
and all claims, losses, damages, expenses, (including reasonable counsel
fees approved by the Administrator) and liability (including any reasonable
amounts paid in settlement with the Employer's approval) arising from any
act or omission of the Administrator, except when the same is determined to
be due to the willful misconduct of the Administrator by a court of competent
jurisdiction..
10.06 DELEGATION OF RESPONSIBILITY: The Administrator shall have the
authority to delegate, from time to time, all or any part of its responsibilities
under the Plan to such person or persons as it may deem advisable and in
the same manner to revoke any such delegation of responsibility which shall
have the same force and effect for all purposes hereunder as if such action
had been taken by the Administrator. The Administrator shall not be liable
for any acts or omissions of any such delegate. The delegate shall report
periodically to the Administrator concerning the discharge of the delegated
responsibilities.
10.07 RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION: The
Administrator may release or obtain any information necessary for the
application, implementation and determination of this Plan or other Plans
without consent or notice to any person. This information may be released
to or obtained from any insurance company, organization, or person subject
to applicable law. Any individual claiming benefits under this Plan shall
furnish to the Administrator such information as may be necessary to
implement this provision.
11/4/2011 2:26 PM
Page 21 of 24
7-23
10.08 CLAIM FOR BENEFITS: To obtain payment of any benefits under the Plan
a Participant must comply with the rules and procedures of the particular
benefit program elected pursuant to this Plan under which the Participant
claims a benefit.
10.09 PROTECTED HEALTH INFORMATION: The provisions of this Section
shall be effective on April 14, 2004 or at such other date required by 45 CFR
Section 164.534. The Plan may disclose PHI to employees of the Employer
with employee benefits responsibility or to employees with oversight
responsibility for third party administrator claims administration. Access to
and use by such individual must be restricted to plan administration
functions that the plan sponsor performs for the Plan. The applicable claims
procedures under the Plan shall be used to resolve any issues of non-
compliance by such individuals. The Plan may disclose PHI to such
individual only if the Employer certifies that the Plan documents have been
amended to incorporate the following specific provisions, and the Employer
agrees to comply with. them. The Employer will:
• Not use or further disclose PHI other than as permitted
by the plan documents or as required by law;
• Ensure that any agents or subcontractors to whom it
provides PHI received from the Plan agree to the same
restrictions and conditions that apply to the Employer;
• Not use or disclose PHI for employment-related actions
or in connection with any other employee benefit plan;
• Report to the Plan any use of disclosure of the
information that is inconsistent wit the permitted uses or
disclosures;
• Make available to Plan participants, consider their
amendments, and upon their request, provide them with
an accounting of PHI disclosures;
• Make its internal practices and records relating to the use
and disclosure of PHI received from the Plan available to
the Department of Health and Human Services upon
request; and
• Will, if feasible, return or destroy all PHI received from
the Plan that the Employer still maintains in any form and
retain no copies of such information when no longer
needed for the purposes for which the disclosure was
made, except that, if such return or destruction is not
feasible, limit further uses no disclosure to those
purposes that make the return or discretion o the
information infeasible.
11/4/2011 2:26 PM
Page 22 of 24
7-24
For purposes of this Section, "PHI" is "Protected Health Information" as
defined in 45 CFR Section 164.501, which is individually identifiable health
information that is maintained or transmitted any a covered entity, as defined
in 45 CFR Section 16.4104.
SECTION XI
MISCELLANEOUS PROVISIONS
11.01 FORMS AND PROOFS: Each Participant or Participant's Beneficiary eligible
to receive any benefit hereunder shall complete such forms and furnish such
proofs, receipts, and release as shall be required by the Administrator.
11.02 NON-ASSIGNABILITY: No benefit under the Plan shall be liability for any
debt, liability, contract, engagement or tort of any Participant or his
Beneficiary, nor be subject to charge, anticipation, sale, assignment, transfer,
encumbrance, pledge, attachment, garnishment, execution or other voluntary
or involuntary. alienation or other legal or equitable process, nor transferability
by operation of law.
11.03 CONSTRUCTION:
(a) Words used herein in the masculine or feminine gender shall be construed
as the feminine or masculine gender, respectively where appropriate.
(b) Words used herein in the singular or plural shall be construed as the plural
or singular, respectively, where appropriate.
11.04 NONDISCRIMINATION: In accordance with Code Section 125(b)(1), (2),
and (3), this Plan is intended not to discriminate in favor of Highly
Compensated Participants (as defined in Code Section 125(e)(1) as to
contributions and benefits nor to provide more that 25% of all qualified
benefits to Key Employees. If, in the judgment of the Administrator, more
than 25% of the total non-taxable benefits are provided to Key Employees, or
the Plan discriminates in any other manner (or is at a risk of possible
discrimination), then notwithstanding any other provision contained herein to
the contrary, and in accordance with the applicable provision of the Code, the
Administrator shall, after written notification to affected Participants, reduce or
adjust such contributions and benefits under the Plan as shall be necessary
to insure that, in the judgment of the Administrator, the Plan shall not be
discriminatory.
11.05 ERISA The Plan shall be construed, enforced, and administered and the
validity determined in accordance with the applicable provision of the
Employee Retirement Income Security Act of 1974 (as amended), the Internal
Revenue Code of 1986 (as amended), and the laws of the State indicated in
the Adoption Agreement. Notwithstanding anything to the contrary herein, the
11/4/2011 2:26 PM
Page 23 of 24
7-25
provisions of ERISA will not apply to this Plan if the Plan is exempt from
coverage under ERISA. Should any provisions be determined to be void,
invalid, or unenforceable by any court of competent jurisdiction, the Plan will
continue to operate, and for purposes of the jurisdiction of the court only will
be deemed not to include the provision determined to be void.
11/4/2011 2:26 PM
Page 24 of 24
7-26
~tt~f
r„~y EXHIBIT A
,w ..-
~,,,_,..
arv of
CHIJLA VISTA
DENTAL/MEDICAL/VISION
AND
DEPENDENT/CHILD CARE
REIMBURSEMENT ACCOUNTS
PLAN DOCUMENT
Amended as of January 1, 2012
Established June 1998
Human Resources and
Information Technology Services Departments
City of Chula Vista
7-27
Intentionally Left Blank
7-28
Table of Contents
.........................................._.......1
........................................
PREAMBLE ....................................._.
ARTICLEI-DEFINITIONS
1.01 Affiliated Employer ...............~::........................................... ................................._
.....2
1.02 After-Tax Contributions .....................................................
......
......................
..........2
.
1.03 .........
Anniversary Date ....................................................... ..
....................
....2
1.04 BenefitPtan Ophoa(s .................. ...................
1.05 Board of Directors ............................................................... .................................2
..............
.
1.06
......
Change in Status ...........................................................
2
.
..................
.....................
1.07
..............................................
Code .......................................
2
.............
...........
..
1.08 ...............................
Compensation ...................................... .
....................
...........2
.......
1.09 Dependent .......................................................................... ................
....2
1.10 ...............
Dependent Care Spending Accoun ................... .......
.......................
3
............
1.11 .............
Earned Income ...................................................... ..................
......3
........
1.12 Effective Date ...................................................................... ....................
3
1.13 ..
EligibleEmployment Related Expenses ........................ ...................................
.-.--.....3
1.14 Eligible Medical Expenses ................................................ '...•..-..-.'..-.'
.....
.................. 3
1.15
..
Employee ..........................................................................
.................
..................... 4
1.16 I;mployer ............................................................................
.......
.......
...............
1.17 ERISA ................................................................................. 4
....................
1.18 Fie.+dble Spending Account(s) ........................................... ...................................4
...
1.19 Health Care Spending Account ........................................ ................................
4
1.20 Highly Compensated Individual ..................................... ................................
....
..............4
.
1.21 Key Employee ................................................................... ......
.
..............
4
1.22 Non-elective Contributions .................. ....
.................. 5
1.23
..
Participant ......................................................................
..................
..........................5
.
1.24
................................................................
Plan ................... ..
.....
.
...
........... 5
.
1.25
.....
Ylan Administrator .....................................................
.
.......................
................. 5
1.26
..
Ylan Year .........................................................................
...................
.
5
1.27
.............
..................
Pretax Contnbution(s .....................
..
..................................
_.......'...5
1.28 QualiRed Benefit .............................................................. ' ...'.•
.................
...5
1.08B Qualifying Individual ................ ....
...'.•..5
...
1.30 Qualifyiog Services .......................................................... ..........................
5
1.31 Salary Reduction Agreement ......................................... ..............................
....... ............6
......
..
1.32 Spouse ...............................................................................
..
SPD .
................
.....................................6
1.33 .............................
Summary Plan Description or ..................6
1.34 ..... ...............
Student .....:................................. .................. ...................
ARTICLE II -- ELIGIBILITY AND PARTICIPATION
2.01 Eligibility to Participnte ........................................................................................
2.02 Termination of Participation ...............................................................................7
2.03 Eligibility to Participate in Flexible Spending Accounts ..................................7
................................ 7
2.04 Qualifying Leave Under Family Leave Act ....................... 7
2.05 Non-FMLA Leave .......................................................................
-~-
7-29
ARTICLE III -ELECTIONS ......................................................................................................8
3.01 Election of Contributions ......................................................... ............................8
8
3.02 Initial Election Period .............................................................. ............................
8
3.03 Annual Election Period ............................................................ ............................
.....9
3.04 Change of Elections ................................................................. ........................
9
3.05 Impact of Termination of Employment on Election ............ .............................
ARTICLE IV - YREMIIJD'I PAYMENTS AND CREDTTS AND DEBITS TO
.....10
..
ACCOUNTS ....................._....._............:.:............................................ .
...................
g .................................................
4.01 Source of Benefit Fundin ... 10
...........................
1D
4.02 Reduction of Certain Elections to Prevent Discrimination . ...........................
.........................................................
ARTICLE V - BENEFTI'S ....................
............................11
11
..................... ...............
5.01 Qualified Benefits ............................... .....:......................
...........11
5.02 Cash Benefit ............................................................................ ..............
...
.....
ARTICLE VI -REIMBURSEMENTS ..........................................._....-..
............................12
01 Health Care Spending Account Reimbursement ................
6
............................12
.
02 Dependent Care Spending Account Reimbursement ..........
6 ............................12
.
..................
6.03 Receiving Reimbursement ...................................
............................ l 3
13
6.04 Substantiation of Expenses ................................................... .............................
13
05 Rlpnyment of Excess Reimbursements ...............................
6 .............................
.
06 Reimbursement Following Cessation of Participation .......
6 .............................13
.
07 Coordination of Benefits Under the Health Care Spending Account............ ]4
6
.
.....................
6.08 Disbursement Reports .................... .................. .............................14
14
6.09 Timing of Reimbursements .................................................. .............................
...............14
.
...................
6.10 Statements ........................................................... ............
.
.........14
6.11 Post-Mortem Puyments ......................................................... .
...................
14
6.12 Non-Alienation of Beoelits ................................................... ..........
....................
. l4
6.13 Mental or Physical Incompetency ....................................... .............................
..14
6.14 Inability to Locate Payee ..................................................... ........
................... .
15
6.15 Tax Effects of Reimbursements .......................................... ......
...................... .
I ~
6.16 Forfeiture of Unclaimed Reimbursement Account Benefits ..........................
........
ARTICLE VII -PLAN ADMINISTRATION ....................................
..............................16
7.01 Allocation of Authority .....................................:.................. ..............................16
16
02 Provision for Third Party Adminstrators ...........:..............
7 ..............................
.
.................
7.03 FiducinryLiability ....................... ...................... ...............................17
17
7.04 Compensation of Plan Administrator ............................... ...............................
....... l7
.
.....
7.05 Bonding ..........................:................................................
.
....
enses
E
...
....................
...............................17
..
.........................
xp
7.06 Payment of Administrative ....17
7.07 Fundin Polic ..........................................
g Y ........................... ...........................
ARTICLE VIII-FUNDING AGENT ...................:._................................. ...............................18
.......
ARTICLE IX -- CLAIMS PROCEDURES._ .....................................
................................19
ARTICLE X -AMENDMENT OR TERMINATION OF PLAN .......... ................................20
.....................20
cy ..............................................................
10.01 Permanen ..........
...........
d
A
' ...........
................................20
...................................
men
s Right to
10.02 Employer 20
10.03 Employer's Rfgbt to Terminate ....:................................... ................................
20
i
on ..................
10.04 Determination of Effecrive Date of Amendment or Terminat
ARTICLE XI -- GENERAL PRO VISIONS .............................................. ................................21
11.01 Not an Employment Contract .......................................... .................................2[
..21
11.02 Applicable Laws ................................................................ ...............................
. ,; _
7-30
11.03 ................
Requirement for Proper Forms ................. ....................................... z t
21
..........
11.04
................................
Multiple Functions ......................
.......................
21
..........................
11.05 TaeEffcets ................................................................... .............
....21
.
11.06 Gender and Number ...................................................
..
..........................
......
.....................21
.
11.07 ....
Headings .................................................................. .
.................
..2]
11.08 ..........
Incorporation by Re ereoce ............................. .
.....................................
21
11.09 Severabili .................................
ty ................................ ....................
.....2:
.......
...
11.10 .....................................
Effect of Mistalte .................. . .
........................
ARTICLE XII -CONTINUATION COVERAGE UNDER COBRA •...•-..••••-•••••••••••••••••••.23
............................ Z 4
ARTICLEXIII-ffiPAAPRIVACYANDSECURITY .............................. 'a
13.01
.................................
Scope and Purpose ..............................
..................... .-- 24
.......
13.02 Effective Date ........................................................................ ,
.......................
_4
.
13.03 Use and Disclosure ofPHI ................................................... .
............................
....24
13.04 ...................
Conditions Imposed on Employer ................... ..........................
25
13.05 Designated Employees Who May Receive Pffi ................. .....................
......... 25
13.06 Restrictions on Employee with Access to PHI ................... ..........................
.........25
13.07
..............................
Policies and Procedures ........................
......................
... 25
13.08 ............
Organized Health Care Arrangement ................... ............................
26
13.09
.
....................................................
Privacy Ofticia ............... ..
.
,,,,,.,.26
..........
.
13.10
.............................
Noncompliance .......................................
.
...........
...............26
13.11
12
13 Definitions ............................................................................
.
Interpretation and Limited Applicability ........................ ................
...............................27
.
13.13
............
Services Performed for the Employer ...................
...............................27
iii -
7-31
PIt?vAMBLE
Effective prior to 1991 (and as Amended and Restated on January 1, 2009), CITY OF CHULA
VISTA established a Cafeteria Plan (the "Plan") for its Employees for purposes of providing eligible
Employees with the opportunity to choose from among [he Benefit Plan Options available under the Plan.
The Plan is intended to qualify as a cafeteria plan under the provisions of Code § 125.
The Health Care Spending Accoun[ ("HCSA"),_ is intended to qualify as a Code § 105 self=insured
medical expense reimbursement plan, and that the 6eneFts provided under the Health Care Spending
Account be eligible for exclusion from the Participant's income for federal income tax purposes under
Code § I OS(h)_ The Dependent Care Spending Account ("DCSA"), is intended to qualify as a Code § 129
dependent Gaze assistance plan and that the benefits provided under the Dependent Care Spending
Account be eligible for exclusion from the Participant's income for federal income tax purposes under
Code § 129. Although printed within this document, the HCSA and DCSA Plans are separate written
plans for purposes of administration and nondiscrimination requirements imposed by Sections 105 and
129 of the Code.
atsa~au
7-32
CITY OF CHiJLA VISTA
CAFETERIA PLAN
ARTICLE I
DEFINITIONS
1.01 "Affiliated Employer" means any entity tvho is considered with the Employer to be a single
employer in accordance with Code Section 414(b), (c), or (m).
1.02 "After-tax Contribution(s)" means amounts wititlteld from an Employee's Compensation
pursuant to a Salary Reduction Agreement afrer all applicable state and federal taxes have been
deducted. Such amounts are withheld for purposes of purchasing one or more of the Benefit Plan
Options available under the Plan.
1.03 "Anniversary Date" means the first day of any Plan Year.
1,04 "Benefit Plan Option(s)" means those Qualified Benefits available to a Participant under this
Plan as set forth in the Summary Plan Description, as amended and/or restated from time to time.
1.05 "Board of Directors" means ttte Board of Directors or outer governing body of the Employer
(the "Board"). The Board of Directors, upon adoption of this Plan, appoinu the Plan
Administrator to act on the Employer's behalf in all matters regarding the Plan.
1.06 "Change in Status" means any of the events described in dte Summary Plan Description, as well
as any other events included under subsequent changes to Code Section 125 or regulations issued
under Code Section 125, that the Plan Administrator (in its sole discretion) decides to recognize
on a uniform and consistent basis as a reason to change the election mid-year. Note: See the
Summary Plan Description for requirements that must be met to permit certain mid-year election
changes on account of a Change in Status.
1.07 "Code" means the Internal Revenue Code of 1986, as amended.
1.08 "Compensation" means the cash wages or salary paid to an Employee by ills Employer.
1.09 "Dependent" means any individual wlto is a tax dependent of the Participant as defined
generally in Code Section 152; however, for health plan purposes, a Dependent is defined as set
forth in Code Section 105(b) and for Dependent Care FSA (if offered under the Plan) purposes, a
Dependent also means an individual described in Code Section 21(e)(5) (i.e., dependent of the
parent tvitlt custody for the greatest portion of the year).
1.10 "Dependent Care Spending Account" shall have the moaning assigned to it by Section 6.02 of
the Plan.
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1.11 "Earned Income" means all income derived from wages, salaries, tips, self-employment, and
other Compensation (such as disability or wage continuation benefits), but only if such amounts
are includible in gross income for the taxable year.z asuchtas amounts receiveduunder as pension
excluded from earned income under Code § 32(c)( ),
or annuity, or pursuant to workers' compensation.
1.12 "Effective Dnte" of this P{an means the original effective date of the Cafeteria plan, or the
amended and restated effective date, set forth in the SPD.
1.13 "Eligible Employment Related Expenses" means those Ce at n5e tohexv ensles for 1 ousehold and
Employment-Related Expenses under Cade § 21(b)(2) ( g P
dependent raze services necessary for gainful employment) if paid for 6y tite Employee to
provide Qualifying Services other than amounts paid to:
(a) an individual with respect to whom a Dependent deduction is allowable under Code §
15l (a) to the Participant or his Spouse;
(b) the Participant's Spouse; or
(c) a child of the Participant who is under 19 years of age at the end of the taxable year in
wlitch the expenses were incurred.
l.ld "Eligible Medical Expenses" means those expenses that are eligible for reimbursement under
the Health Care Spending Account as set forth in the SPD, incurred by the Employee, or the
Employee's Spouse or Dependents, after the date of the Employee's participation in the Health
Care Spending Account and during the Ptan Year to the extent that the expense satisfies the
conditions set forth in the Summary Plan Description and are for medical care as defined by Code
§ 213(d). For purposes of iltis Plan, the following expenses are not considered Eligible Medical
Expenses even if they otherwise constitute medical raze under Code § 213(d):
i) Expenses for qualified long term care services (as defined in Code § 7702B); and
iq Expenses for ttealtlt insurance premiums.
For purposes of this Plan, an expense is °incurred" when the Participant or beneficiary is
furnished the medical raze or services giving rise to the claimed expense, regardless of when the
expense is paid.
1.15 "Employee" means an individual who the Employer classifies as a common-law employee end
who is on dte Employer's W-2 payroll, but does not include any of the following: (a} any leased
employee (including, but not limited to, those individuals defined in Code § 4l4(n)); (b) an
individual classified by the Employer as a contract worker or independent contractor, (c) an
individual classified by the Employer as a temporary employee or casual employee, vvltether or
not any such persons are on the Employer's W-2 payroll; and (d) any individual who performs
services for the Employer but who is paid by a temporary or other employment agency such as
"Kelly," "Manpower," etc.; or any employee covered under a collective bargaining agreement,
except as otherwise provided for in the collective bargaining agreement.
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1.16 "Employer" means CITY OP CFiTJLA V7STA and any Affiliated Employer who adopts the
Plan pursuant to authorization provided by the Employer. Norividtstanding dte previous sentence
when the Plan provides that the Employer has a certain power (e.g., the appointment of a third
party administrator, entering into a contract with a third party insurer, or amendment or
termination of the plan) the term "Employer" shall mean only CITY OF CHULA VISTA.
Affiliated Employers wlto adopt the Plan shall be bound by the Plan as adopted and subsequently
amended unless they clearly withdraw from participation herein. Affiliated Employers wlto have
adopted dte Plan are set forth in the Summary Plan Description.
1.17 "FRIBA" shall mean ills Employee Retirement Income Security Act of 1974, as amended.
1.18 "Flexible Spending Account{s)" shall be the funding mechanism by which amounts are
witltlteld from an Employee's Compensation and retained for future Healtt Care Spending
Account Payments (tlte "HCSA") (as defined in Section 1.18 herein) and Dependent Care
Spending Account Payments (ills "DCSA")(as defined in Section 1.10 herein} to ills extent
adopted by the Employer as set forth in the Summary Plan Description. No money shall actually
be allocated to any individual Participant Account(s); any suc(t Account(s) shall be of a
memorandum nature, maintained by the Administrator for accounting purposes, and shall not be
representative of any identifiable trust assets. No interest will be credited to or paid on amounts
credited to.the Participant Account(s).
1.19 "Health Care Spending Account" shall have the meaning assigned to it by Section 6.O1 of the
Plan
1.20 "Highly Compensated Individual" means an individual defined under Code § 105(It), l25(e)
or 414(q), as amended, as a "Itigltly compensated individual" or a "highly compensated
employee."
1.21 "Key Employee" means an individual vvlto is a "key employee" as defined in Code § l25(b}(2),
as amended.
1.22 "Non-elective Contribution(s)" means any amount which the Employer, in its sole discretion,
may contribute on behalf of each Participant to provide benefits for such Participant and his or
lter Dependenu, if applicable, under one or more of ills Benefit Plan Option(s) offered under ills
Plan. The amount of employer contribution that is applied cowards ills cost of the Benefit Plan
Option(s) for each Participant and/or level of coverage shall be subject to the sole discretion of
the Employer and may be adjusted upward or downward at any time in ills contributing
Employer's sole discretion. The amount shall be calculated for each Plan Year in a uniform and
nondiscriminatory manner and may be based upon the Participant's dependent status,
commencement or termination date of ills Participant's employment during the Plan Year, and
such other factors as ills Employer shall prescribe. To the extent set forth in the Summary Plan
Description or enrollment material, ills Employer may make Non-elective Contributions available
to Participanu and allow Participants to allocate the Non-elective Contributions among the
various Benefit Plan Options offered under the Plan in a manner set forth in the Summary Plan
Description or enrollment material. In no event will any Non-elective Contribution be disbursed
to a Participant in the form of additional, taxable Compensation except as otherwise provided in
the Summary Plan Description or enrollment material.
21 SipJll
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1.23 "Participant" means an Employee wlto becomes a Participant pursuant to Article II.
1.24 "Plan" means this Cafeteria Plan as set for herein.
115 "Plan Administrator" means the person(s) or Committee identified in the Summary Plan
Description that is appointed by the. Employer with authority, discretion and responsibility to
manage and direct the operation and administration of the Plan. If no such person is named, the
Plan Administrator shall be the Employer..
1.26 "Plan Year" shall be the period of coverage set forth in the Summary Plan Description.
1.27 "Pretax Contribution(s)" means any amount witltlreldl able state and federal lases have been
pursuant to a Salary Reduction Agreement before any app
deducted. The amounts are ~vidtlteld for purposes of purchasing one or more of the Benefit Plan
Options available under the plan. This amount shall not esceed the premiums or contributions
attributable to the most costly Benefit Plan Option afforded hereunder, and for purposes of Code
§ 125, shall be treated as an Employer contribution (this amount may, however, be treated as an
Employee contribution for purposes of state insurance laws).
1.28 "Qualified Benefit" means any benefit excluded from the Employee's taxable income under
Chapter 1 of the Code other than Sections 106{b), I ]7, 124, 127, or I32 and any other benefit
permitted by the Income Tas Regulations (i.e., any group-term life insurance coverage that is
includable in gross income by virtue of exceeding the dollar limitation on nontaxable coverage
under Code § 79). Notvvithstanding the previous sentence, long-term care insurance is not a
"Qualified Benefit."
1.29 "Qualifying Individual" means an .individual defined as a "Qualifying Individual" in the
Summary Plan Description.
1.30 "Qonlifying Services" means services relating to the care of a Qualifying Individual that enable
the Participant or his Spouse to remain gainfully employed which are performed:
(a) in the Participant's home; or
(b) outside the Participant's home for (1) the care of a Dependent of the Participant who is
under age 13, or (2) the care of any other Qualifying Individual who resides at least eight
(8) hours per day in [he Participant's household. If the expanses are incurred for services
provided by a dependent care center (i.e., a facility that provides care for more titan 6
individuals not residing at the facility), the center must comply with all applicable state and
local laws and regulations.
1.31 "Salary Reduction Agreement" means fire actual or deemed agreement pursuant to which an
eligible Employee or Participant elects to contribute his share of dte cost of chosen Benefit Plan
Options with Pretax or After-tae Contributions and/or Benefit Credits (if offered under the Plan)
in accordance with Article tI[ herein. If Ste Employer utilizes an interactive voice response ([VR)
system or ~veb-based program for enro{Iment, the Salary Reduction Agreement may be
maintained on an electronic database in accordance with all applicable federal and/or state laws.
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1.32 "Spouse" means an individual who is legally married to a Participant (and who is treated as a
spouse unde[ the Code), but for purposes of the Dependent Care Spending Account Plan
provisions, shall not include an individual wlto, although married to the Participant, files a
separate federal income tax return, maintains a separate, principal residence from the Participant
during the last six months of the taxable year, and does not furnish more than one-half of the cost
of maintaining the principal place of abode of the Qualifying Individual.
1.33 "Summary Ptan Description" or SPD" means the Cafeteria Plan SPD and all appendices
incorporated into and made a part of 8re SPD that is adopted by the Employer and associated to
this plan Document, and as amended from time to time. The SPD and appendices are
incorporated hereto by reference.
1.34 "Student" means an individual who, during~each of five (5) C~emo;m ryefi~ coon of whicrh g the
Plan Year, is a full time student at any collene or university, p
conduct of formal instruction, and which routinely maintains a regular faculty and curriculum and
normally has an enrolled student body in attendance at the Iccation where its educational
activities are regularly presented.
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ARTICLE II
ELIGIBILITY AND PARTICIPATION
2.01 Eligibility to Participate. Each Employee who satisfies the eligibility requirements se[ forth in
[he SPD shall 6e eligible to participate in this Plan as of the Eligibility Date se[ forth in the SPD.
Eligibitity to participate in this Plan means only that [he Eligible Employee is entitled to
contribute Iris share of the cost of applicable Benefit Plan Options for which be is eligible with
Pretax Contributions. The provisions of this Article ere not intended to override any eligibility
requirement(s) or waiting period(s) specified in the applicable Benefit Plan Option(s) and [Ire
terms of eligibility and participation for the Benefit Plan Option(s) offered under the Plan shall be
subject to the requirements specified in the governing documents of the Benefit Plan Options.
2.02 Terminarion of Participation. Participation shall terminate on the eazliest of the dates set foNt
in the SPD.
2.03 Eligibility to Pnrticipate in Flexible Spending Accounts. Each employee who satisfies the
eligibility requirements set forth in the SPD shat! be eligible to participate in the Flexible
SpemdingAccounts, if adopted by the Employer, on the applicable Eligibility Date set forth in the
SPD.
Z.04 Qualifying Leave Under Family Leave Act. Nohvithstanding any provision to the contrary in
dtis Plan, if a Participant goes on a qualifying leave under the Family and Medical Leave Act of
1993 (the "FMLA"), then to the extent required by the FMLA, the Participant will be entitled to
continue the Participant's Benefits Package Options that provide health coverage (including
Health Caze Spending Account benefits to the extent offered under the Plan) on the same terms
and conditions as if the Participant were still an active Employee. The regoV;a de6y the
continuing coverage, procedures for PMLA leave and payment option(s) p
Employer (as described above) will be set forth in the SPD and will be administered in
accordance with the regulations issued under Code § ]25 and in accordance tivitlt the FMLA.
2.05 Non-F'YII~A Leave. If a Participant goes on an unpaid leave of absence that does not affect
eligibility under this Plan or the Benefit Plan Options chosen by the Participant, then the
Participant will continue to participate and the contributions due for the Participant will be paid
by one or more of the payment options described in the SPD and implemented by the Employer
on a uniform and consistent 6asi5 in accordance with the Employer's internal policy and
procedure. If a Participant goes on an unpaid leave that affects eligibility, under this Plan or the
Benefit Plan Options chosen by the Participant, the election change rules in Section 3.04 wilt
apply. If such policy requires coverage to continue during the leave but permits a Participant to
discontinue contributions while on leave, the Participant will, upon returning from leave, be
required to repay the contributions not paid 6y the Participant during the leave.
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ARTICLE III
ELECTIONS
3.01 Election of Contributions. A Participant may elect any combination of Pretax Contributions or
After-tax Contributions (to the extent set forth in the enrollment material) to fund any Benefit
Plan Option available under the Plan, provided that only Qualified Benefits may be funded with
Pretax Contributions. The Employer. may, but is not required, to allocate Non-elective
Contributions to one or more Benefit Plan Options offered under the Plan and to the extent set
forth in the SPD or enrollment material, may allow the Participants to allocate his allotted share
ofNon-elective Contributions among the various Benefit Plan Options in a manner set forth in
the SPD or enrollment material.
3.02 Initial Election Period.
(a} Currently Eligible Employees. An Employee who is eligible to become a Participant in
[Iris Plan as of the Effective Date must complete, sign and file a Salary Reduction
Agreement with the Ptan Administrator (or its designated third party administrator as set
forth on the Salary Reduction Agreement) during the election period (as specified by the
plan Administrator} immediately preceding the Effective Date of the Plan in order to
become a Participant on dte Effective Date. The elections made by the Participant on this
initial Salary Reduction Agreement shall 6e effective, subject to Sections 3.04 and 3.05, for
the Plan Year beginning on the Effective Dnte.
(b) Netv Employees and Employees Who Have Not Yet Satisfied The Plan's Waiting
Period. An Employee ~vlto becomes eligible to become a Participant in this Plan after the
Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan
Administrator (or its designated third party administrator as set forth on the Salary
Reduction Agreement) during the initial Election Period set forth in tl~e SPD or the
enrollment material. Participation will commence under this Plan as set. forth in the SPD.
Coverage under the component Benefit Plart Options tivill be effective in accordance with
the governing provisions of such Benefit Plan Options (but in no event prior to the
election).
(c) Failure to Elect. An eligible Employee who fails to complete, sign and file a Salary
Reduction Agreement in accordance with paragraph (a) or (b) above during an initial
election period may become a Participant on a later date in accordance with Section 3.03 or
3.oa.
3.03 Annual Election Period. Each Employee who is a Participant in this Plan or vvlto is eligible to
become a Participant in this Plan shall be notified, prior to each Anniversary Date of this Plan, of
Iris right to become a Participant in this Plan, to continue participation in this Plan, or to modify
or to cease participation in this Plan, and shall be given a reasonable period of time in which to
exercise such right: such period of time shall be known as the "Annual Election Period." The
date on wlriclt the Annual Election Period commences and ends will be set forth in the SPD or the
enrollment material. An Election is made during the Annual Election Period in the manner set
forth in the SPD. The consequences of failing to make an election during the Annual Election
Period will be set forth in the SPD.
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3.04 Change of Elections.
A Participant shall not make any changes to the Pretax Contribution amount or, where applicable,
to the Participant's elected allocation of Non-elective Contributions except for under the
circumstances set forth in the SPD and for changes made during the Annual Election Period,
changes caused by termination of employment or cessation of eligibility, and changes pursuant to
the Family and Medical Leave Act.
Except as provided in the SPD for HIPAA special enrollment rights arising from the birth,
adoption, or placement for adoption of a child, all election changes shall be effective on a
prospective basis only (i.e., election changes will become effective no earlier than the first day of
the first pay period coinciding with or immediately following the date that the election change
was filed) but, as determined by the Plan Administrator, election changes may become effective
later to the extent the coverage in the applicable component plan commences later. Tite
circumstances under which a Participant may change Itis election under this Plan is set forth in the
SPD.
3.05 Impact of Terminarion of Employment on Election or Cessation pf Eligibility. Termination
of employment or cessation of eligibility shall automatically revoke any Salary Reduction
Agreement. Except as provided below, if revocation occurs under this Section 3.05, no new
election, with respect to Pretax Contributions may be made by such Participant during the
remainder of the Plan Year except as set forth in the SPD.
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ARTICLE IV
PREMIUM PAYMENTS AND CREDTTS AND DEBITS TO ACCOUNTS
4.01 Source of Benefit Funding. The cost of coverage under the component Benefit Plan Options
shall be funded by Participant's Pretax and/or After-tax Contributions and/or any Non-etective
Contributions provided by [he Employer. The required contributions for each Benefit Plan
Options offered under the plan shall ha made known to employees in enrollment materials.
Pretax or After-tax Contributions (as elected by the Employee on the Salary Reduction
Agreement and permitted by the Employer) shall equal the contributions required from the
Participant less an available Non-elective Contributions allocated thereto by the Employer, or
where applicable, the Participant for coverage of the Participant or the Participants Spouse or
Dependents under the Benefit Plan Options elected by the Participant under this Plan. Amounts
withheld from a Participant's Compensation as Pretax Contributions or After-tax Contributions
shall be applied to fund benefits as soon as administratively feasible. The maximum amount of
Pretax Contributions, plus any Non-elective Contribution made available by the Employer, shall
not exceed the aggregate cost of the Benefit Plan Options elected.
A.02 Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator
determines, before or during any Plan Year, that the Plan may fail to satisfy for such Plan Year
any requirement imposed by the Code or any limitation on Pretax Contributions allocable to Key
Employees or to Highly Compensated [ndividtials, the Plan Administrator shall take such
action(s) as Ite deems appropriate, under rules uniformly applicable to similarly situated
Participants, to assure compliance with such requirement or limitation. Such action may include,
without limitation, a modification or revocation of a Highly Compensated Individuals or Key
Employee's election without the consent of such Employee.
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ARTICLTJ V
BENEFITS
5.01 Qualified Beaefiis. The maximum benefit a Participant may elect under this Plan shall not
exceed the sum of the aggregate premium and/or contribution for all Benefit Plan Option(s) set
forth in the SPA
5.02 Cash Benefit. To the extent that a Participant does not elect to have the maximum amount of his
Compensation contributed as a Pretax Contribution or Afrer-tax Contribution hereunder, such
amount not elected shall 6e paid to the Participant in tJte form of normal Compensation payments;
provided however, that any applicable Non•elective Contributions may not be received in the
form of cash compensation, except as otherwise provided for in the SPD or the enrollment
material.
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ARTICLE VI
REILVIBiJRSCMENTS
6.01 Health Care Spendiug Account Reimbursement. Eaclt Participant's Health Care Spending
Account will be credited with amounts withheld from the Participant's Compensation and any
Non-elective Contributions allocated thereto by the Employer or where applicable, dte
Participant. The Account will be debited for health care reimbursements disbursed to the
Participant in accordance with this Article VI. The entire amount elected by the Participant on
the salary Reduction Agreement as an annual amount for the Plan Year for health care
reimbursement less any health care reimbursements already disbursed to the participant for
Expenses incurred during the plan year shall 6e available to the Participant at anyrovided that the
Plan Year ~vithovt regard to the balance in the Health Care Spending Account (p
periodic contributions have been made). T)tus, the maximum amount of Health Care
Reimbursement at any particular time during the Plan Year will not be related to the amount that
a participant ltas had credited to Iris Health Care Spending Account. In no event will the amount
of Health Care Reimbursements in any Plan Year exceed the annual amount specified for the Plan
Year in the Salary Reduction Agreement for Health Care Reimbursement. Any amount credited
to the Health Care Spending Account shall be forfeited by the Participant and restored to the
Employer if it Itas not been applied to provide Health Care Reimbursement within the run out
period seR forth in the SPD. Amounts so forfeited shall 6e used in a manner that is permitted
within the applicable Department of Labor or Internal Revenue. Service regulations. Ttte
maximum annual reimbursement under the Health Care Spending Account shall be set forth in
the SPD. The Employer may establish a minimum annual reimbursement amount as set forth in
dte SPD.
The Employer Itas the discretion to establish a grace period following the end of the Plan Yeaz
during which amounts unused as of dte end of the Plan Year may be used to reimburse Eligible
Medical Expenses incurred during the grace period. In no event can the grace period exceed hva
(2) months and fifteen (15) days following the end of the Plan Yeaz. The Employer may
establish aRun-out Period following the end of the grace period. If adopted, all amounts
allocated to the HCSA that are not used to reimburse Eligible Medical Expenses incurred during
the Plan Year and/or the grace period shat{ be forfeited.
6.02 Dependent Care Spending Account Reimbursement. Each Participant's Dependent Care
Spending Account will be credited with amounu withheld from the Participant's Compensation
and any Non-elective Contributions allocated thereto by the Employer or where applicable, fire
Participant. The Account will be debited for Dependent Care Reimbursements disbursed to the
Participant in accordance with this Article VI. In the event that the amount in the Account is less
than Utat amount of reimbursable claims at any time during the Plan Year, the excess part of the
claim will be carried over into following months within the same Plan year, to be paid out as the
Dependent Care Spending Account balance becomes adequate. In no event will the amount of
Dependent Care Reimbursements exceed the amount credited to the Dependent Care Spending
Account. Any amount allocated to the Dependent Care Spending Account shall be forfeited by
the Participant and restored to the Employer if it has not been applied to provide Dependent Care
Reimbursement for the Plan Year within the run out period set forth in the SPD. Amounts so
forfeited shall be used in a manner that is not prohibited by applicable federal or state law. The
maximum annual reimbursement under the Dependent Care Spending Account shall 6e set forth
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7-43
in dte SPD. The Employer may establish a minimum annual reimbursement amount as set forth
in the SPD.
The Employer Itas the discretion to establish a o ace period following the end of the Plan Year
during which amounts unused as of the end of dte Plan Yeaz may be used to reimburse Eligible
Employment Related Expenses incutred during the grace period. In no event can the grace period
exceed nvo (2) months and Ffteea (15J days following the end of the Plan Year. The Employer
may establish aRun-out Period following_tlte end of the Plan Year. All amounts allocated to the
DCSA that are not used to reimburse Eligible Employment Related Expenses incursed during the
Plan year and/or the Grace Period shall be Forfeited.
6.03 Receiving Reimbursement. Payment shall be made to the Participant in easlt as reimbursement
for Eligible Medical Expenses incursed by the Participant or his Dependents or Eligible
Employment Related Expenses incursed by the Participant while Ile is a Participant during [Ile
plan Year for which dte Participants election is effective provided that the substantiation
requirements of Section 6.D4 herein are satisfied. If applicable, however, the employer may offer
to have the participant choose to make payment for eligible medical expense or eligible
employment related expenses with an electronic payment card arrangement The terms of dte
electronic payment card arrangement will be set forth in the SPD.
6.04 Substantiation of Expenses. Each Participant must submit an expense for reimbursement in
accordance with the terms of the SPD and provide the required substantiation set forth in the SPD
or as otherwise requested by the Plan Administrator (or its designee).
6.05 Repayment of 1;xcess Reimbursements. If, as of the end of the any Plan Year, it is determined
that a Participant has received payments under this Ptan that exceed the amount of Eligible
Medical Expenses or Eligible Employment Related Expenses that have been substantiated by
such Participant during the Plan Year as required by Section 6.04 herein, the Plan Administrator
shall give the Participant prompt written notice of any such excess amount, and the Participant
shall repay the amount of such excess to the Employer within sixty (60) days of receipt of such
notification.
6.06 Reimbursement Following Cessation of Pnrticipation. Participants in [he Health Care
Spending Account may submit claims for reimbursement for Eligible Medical Expenses incurred
during the Plan Year and before the date of participation in the Pian ceases so long as the claim is
submitted prior to the end of the run out period set forth in the SPD. Unless a COBRA election is
made as set forth in the SPD, Participants shall not be entitled to receive reimbursement for
Eligible Medical Expenses incurred after employment ceases under this Section. Participants in
the Dependent Caze Spending Account may submit claims for reimbursement for Eligible
Employment Related Expenses incurred during the Plan Year and before the date of participation
in the Dependent Care Spending Account ceases so long as the claim is submitted prior to the end
of the run out period set forth in the SPD. Any unused reimbursement benefits aFthe expiration
of the Plan Year (as set forth in the SPD) For the Health Care or Dependent Care Spending
Accounts shall 6e treated in accordance with Section 6.01.
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7-44
6.07 Coordination of Benefits Under the Health Care Spending Account. The Health Care
Spending Account is intended to pay benefits solely for otherwise unreimbursed medical
expenses. Accordingly, it shall not be considered a group health plan for coordination of benefits
purposes, and its benefits shall not be taken into account when determining benefits payable
under any other plan.
6.08 DD~be~ Sall benefitsstltat alre tolbe pazdmfrom the Employer'segeneratloassets pnrsuanrttoo Ile
provisions of the Plan.
6.09 Timing of Reimbursements. Reimbursements shall be made as soon as administratively
feasible after the Plan Administrator or its designee has received the required forms.
6.10 Statements. The Plan Administrator or its designated third party administrator may periodically
famish each Participant with a statement, showing the amounts paid or expenses incurred by the
Employer in providing reimbursements under dte Health Care Spending Account andlor
Dependent Care Spending Account
6.21 Post-Mortem Payments. Any benefit payable under the Health Care Spending Account or
Dependent Care Spending Account after the death of a Participant shall be paid to his surviving
Spouse, otherwise, to his estate. If there is doubt as to the right of any beneficiary to receive any
amount, the Plan Administrator may retain such amount until the rights thereto are determined,
without liability for any interest thereon.
6.12 Non-Alienation of Benefits. Except as expressly provided by the Administrator, no benefit
under tfte Plan shall be subject in any manner to anticipation, alienation, safe, transfer,
assignment, pledge, encumbrance or charge, and any attempt to do so shall 6e void. No benefit
under the Plan shall in any manner be iiable for or subject to the debts, contracts, liabilities,
engagements or torts of any person.
6.13 Mental or Physical Incompetency. Every person receiving or claiming benefits under the Plan
shall be presumed to be mentally and physically competent and of age until the Plan
Administrator receives a written notice, in a form and manner acceptable to it, that such person is
mentally or physically incompetent or a minor, and drat a guardian, conservator or other person
legally vested with the care of Iris estate Itas been appointed.
6.14 Inability Eo Locate Payee. If the Plan Administrator is unable to make payment to any
Participant or other person to whom a payment is due under the Plan because he cannot ascertain
the identity or whereabouts of such Participants or other person after reasonable efforts have been
toasucl~ Parfi t pant for other peson strall be forfeited afterla reasona6letime afte~the date any
such payment first became due.
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6.15 Tax Effects of Reimbursements. Neither [he Employer, nor the Plan Administrator makes any
warranty or other representation as to whether any reimbursements made under the Plan will be
treated as excludable from gross income for local, state, or federal income tax purposes. If for
any reason it is determined that any amount paid for the benefit of a Participant or Beneficiary are
includable in an Employee's gross income for local, federal, or state income tax purposes, then
under no circumstances shall the recipient have any recourse against the Plan Administrator or the
Employer with respect to any increased taxes or other losses or damages suffered by the
Employees as a result thereof. The Plan is designed and intended to be operated as aself-insured
medical reimbursement plan under Code § 105 or aself-dependent care assistance plan under
Code § 129.
6.16 Forfeiture of Unclaimed Reimbursement Account Benefits. Any Health Care or Dependent
Care Spending Account reimbursement benefit payments that are unclaimed (e.g. uncashed
benefit checks) by the close of the Plan Year following the Plan Year in which the Eligible
Medical Expense or Eligible Employment Related Expense was incurred shall be forfeited.
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ARTICLE VII
PLAN ADMII~ISTRATION
7.01 Allocation of Author're . e IteoB saa Pl DAdministr toplthablkeeps the reco ds for[he Phan and
officer of the Employ ) pp
shall control and manage the operation and administration of ttte Plan. The Ptan Administrator
shall have the exclusive right to interpretthe Plan and to decide all matters arising thereunder,
including the right to make determinations of fact, and construe and interpret possible
ambiguities, inconsistencies, or omissions in the Plan and the SPD issued in connection ~vitlt the
plan. All determinations of the Plan Administratoc with respect to any matter hereunder shall be
conclusive and binding on all persons. Without limiting the generality of the Foregoing, the Plan
Administrator shall have the following powers and duties:
(a) To require any person to furnish such reasonable information as he may request for the
purpose of the proper administration of the Plan as a condition to receiving any benefits
under the Plan;
(b) To make and enforce such rules and regulations and prescribe the use of such forms az he
shall deem necessary for the efficient administration of the Plan;
(c) To decide on questions concerning the Plan and the eligibility of any Employee to
participate in the Plan and to make or revoke elections under [he Plan, in accordance with
the provisions of the Plan;
(d) To determine the amount of benefits which shall be payable to atry person in accordance
with dte provisions of the Plan; to inform the Employer, insurer as appropriate, of the
amount of such benefits; and to provide a full and fair review to any Participant whose
claim for benefits Itas been denied in whole or in part;
(e) To designate outer persons to carry out any duty or power which may or may not otherwise
be a fiduciary responsibility of the Plan Administrator, under the terms of the Plan. Suctt
entity will be referred to as a third party administrator and shall be idendited in the SPD;
(!) To keep records of all acts and determinations, and to keep all such records, books of
account, data and outer documents as may be necessary for the proper administration of the
Plan; and
(g) To do all things necessary to operate and administer the Plan in accordance with its
provisions.
7.02 Provision for Third Party Administrators. The Plan Administrator, subject to approval of the
Employer, may employ the services of such persons, as it may deem necessary or desirable in
connection with the operation of the Plan and may rely upon all tables, valuations, certificates,
reports and opinions furnished thereby. Such entity will be identified in the SPD as a third party
administrator. Unless otherwise provided in the service agreement, obligations under this Plan
sftall remain the obligation of the Employer.
i6
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7.03 F 61fry f rr atny accts or orlfailure to act exceptfor the'rlown wilful misconduct~orlw'dlful breach
ofthis Plan.
7.04 Compensation of Plan Administrator. Unless otherwise determined by the Employer and
permitted by law, any Plan Administrator who is also an employee of the Employer shall serve
without compensation for services rendered in such capacity, but the Employer shall pay all
reasonable expenses incurred in the performance of their duties.
7.05 Bonding. Unless otherwise determined by the Employer, or unless required by any federal or
state law, the Plan Administrator shall not be required to give any bond or other security in any
jurisdiction in connection with the administration ofthis Plan.
7.Ob Payment of Administrative )/xpenses. The Employer currently pays all reasonable expenses
incurred in administering the Plan.
7.07 Funding Policy. The Employer shall have the right to enter into a contract with one or more
insurance companies for the purposes of providing any Benefit Plan Options offered under the
Plan and to replace any of such insurance companies or contracts. Any dividends, retroactive rate
adjustmettis or other refunds of any type that may become payable under any such insurance
contract shall not be assets of the Plan but shall be the property of, and shall be retained 6y the
Employer. The Employer will not be liable for any loss or obligation relating to any insurance
coverage except as is expressly provided by this plan. Such limitation shall include, but riot be
limited to, losses or obligations, which pertain to the following:
(a) Once insurance is applied for or obtained, the Employer will not he liable far any loss
which may result from the failure to pay premiums to the extent premium notices are not
received by the Employer;
(b) To the extent premium notices are received by the Employer, the Employer's liability for
the payment of such premiums will be limited to such premiums and will not include
liability for any outer loss which result from such Failure;
(c) The Employer will not be liable for the payment of any insurance premium or any loss that
may result from the failure to pay an insurance premium if the benefits available under this
plan are not enough to provide for such premium cost at the time it is due. ]n such
circumstances, the Employee will be responsible for and see to the payment of such
premiums. The Employer will undertake to notify a Participant if available benefits under
this plan are not enough to provide for an insurance premium but wit! not 6e liable for any
failure to make such notification;
(d) Wlten employment ends, the Employer will have no liability to take any step to maintain
any policy in force except as may be specifically required otherwise in this plan, and the
Employer will not be liable for or responsible to see to the payment of any premium after
employment ends.
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ARTICLE VIII
FUNDING AGENT
Tlie Plan shall be funded with amounts withheld from Compensation pursuant to Salary Reduction
Agreements, and/or Non-elective Contributions provided by the Employer, if any. The Employer will
apply all such amounts, without regard to their'source, to pay for the welfare benefits provided herein as
soon as administratively fe¢sible and shall complywith alt applicable regulations.
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ARTICLE IX
CLAIMS PROCEDURES
The Plan has established procedures for reviewing claims denied under this Ptan and those claims review
procedures are set forth in the SPD. The Plan's claim review procedures set forth in the SPD shall only
apply to issues germane to the pretax benefits available under this Plan (i.e., such as a determination of: a
plan document) and to~lre extent offered underothelPlan'tclaims fortbenefits under the Flewble Spend'mg
Accounts.
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ARTICLE X
AMENDMENT OR TERH'IIl~'ATTON OF PLAN
iD.01 Permanency. While the Employer fully expects that this Plan will continue indefinitely, due to
unforeseen, future business contingencies, permanency of the Plan will 6e subject to the
Employer's right to amend or terminate the Plan, as provided in Sections 10.02 and 10.03, below.
Nothing in this Plan is intended to be or_shall be construed to entitle any Participant, retired or
otherwise, to vested or non-terminable benefits.
10.02 Employer's Rigltt to Amend. The Employer reserves the right to amend at any time any or all
of the provisions of the Plan. All amendments shall be made in writing and shall be approved by
the Employer in accordance with its normal procedures for transacting business (e.g. by approval
by the Board of Directors through a meeting or unanimous consent of all Board members). Such
amendments may apply rehoactively or prospectively as set forth in the amendment. Each
Benefit Plan Option shall 6e amended in accordance with the terms specified therein, or, if no
Employer sltalldbe deemed approved and adopt dtby any,Affiliated Employer.dment made by
10.03 EmployeF's Right to Terminate. The Employer reserves the right to discontinue or terminate
die Plan without prejudice at any time and for any reason without prior notice. Such decision to
[enninate the Plan shall be made in writing and shall be approved by [he Employer in accordance
with its normal procedures for transacting business. Affiliated Employers may withdraw from
participation in the Plan, but may not terminate the Plan.
10.04 Deierminatioa of Effective Date of Amendment or Termination. Any such amendment,
discontinuance or termination shall be effective as of such date as die Employer shall determine.
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is~Pm i
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ARTICLIJ XI
GENERAL PROVISIONS
11.01 Not an Employment Contract. Neither this Plan nor any action taken with respect to it shall
confer upon any person the right to continue employment with any Employer.
11.02 Applicable Laws. The provisions of the Plan shall be construed, administered and enforced
according to applicable federal law and the laws of the State of Controlling Law, as set forth in
the Plan Information Appendix of the SPD, to the extent not preempted.
11.03 Requirement for Proper Forms. All communications in connection with the Plan made by a
Participant shall become effective only when duly executed on any forms as may be required and
furnished by> and filed with, the Plan Administrator.
11.04 Multiple Functions. Any person or group of persons may serve in more than one fiduciary
capacity with respect [o the Plan.
11.05 Tax Effects. Neither the Employer, nor the Plan Administrator makes any warranty or other
representation as to whether any Pretax Contrfossr ncome for local state, or federal ncome t x
hereunder will be treated as excludable from g
purposes. If for any reason it is determined chat any amount paid for the benefit of a Participant
or Beneficiary are includable in an Employee's gross income for local, federal, or state income
tax purposes, then under no circumstances shalt the recipient have any recourse against Ute Plan
Administrator or the Employer with respect to any increased taxes or other losses or damages
suffered by the Employees as a result thereof. The Plan is designed and intended to operate as a
"cafeteria plan" under Code § 125.
11.06 Gender and Nnmber. Masculine pronouns include the feminine as well as the neuter genders,
and Ute singulnr shall include Ute plural, unless indicated otherwise by the context..
11.07 Headings. The Article and Section headings contained herein are for convenience of reference
only, and shalt not be construed as defining or limiting the matter contained thereunder.
11.08 Incorporation by Reference. The acmal terms and conditions of the separate component
Benefit Plan Options offered under Utis Plan are contained in separate, written documents
governing each respective benefit, and shall govern in the event of a conflict between the
individual plan document, and Utis Plan as to substantive content. To that end, each such separate
document, as amended or subsequently replaced, is hereby incorporated by reference as if fully
recited herein. In addition, the SPD for this Plan contains many of the actual terms and
conditions of this Plan. To that end, [he SPD as amended from time to time, is incorporated
herein.
11.09 Severability. Should a court of competent jurisdiction subsequently invalidate any part of Utis
Plan, the remainder thereof shall be given effect to the maximum extent possible.
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11.10 T.ffect of Mistake. In the event of a mistake as to the eligibility or participation of an Employee,
or the allocations made to the account of any Participant, or the amount of distributions made or
to be made to a Participant ar other person, the Plan Administrator shall, to the extent it deems
possible, cause to be allocated or cause to be withheld or accelerated, or otltenvise make
adjustment of, such amounts as will in its judgment accord to such Participant or other person the
credits to the account or distributions to which Ile is properly entitled under the Plan. Such action
by the Plan Administrator may include withholding of any amounts due the Plan or the Employer
from Compensation paid by the Employer_
77 .
Zl Siptltl
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ARTICLI'; X1I
CONTINUATION COVLRAGZ; UNDUR COBRA
The SPD includes COBRA continuation of coverage provisions that shall be applicable to the Health Care
Spending Account, if offered under the Plan, to the extent the plan sponsor is subject to COBRA (as it
amended ERISA, the Code and the Public Health Service Act).
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ARTICLE XIII
HIPAA PRIVACY AND SECIRtITY
13.01 Scope and Purpose. The Health Caze Spending Account (the "Plan" will use protected health
information ("PHI") to the extent of and in accordance with the uses and disclosures pemtitted by
the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). Specifically, the
Plan will use and disclose PH[ for purposes related to health care treatment, payment for health
care and health care operations asset forth below.
13.02 Effective Date. Tltis Article XIII is effective on April 14, 20D3 or such later effective date of the
Privacy Rules with respect to the client.
13.03 Use and Disclosure of PHI.
a) General. The Plan will use PHI to the extent of and in accordance with the usaesn?ent
disclosures permitted by HIPAA, including but not limited to health care treatment, p y
for health care, health care operations and as required by la~v. The Privacy Notice will list the
specific uses and disclosure of PHI that will be made by the Plan.
6) Disclosure to the Employer. The Plan vvitl disclose PHI to the Employer, or where
applicable, an AfEliate only upon receipt of written certification from the Employer that:
i. The Plan document has been amended to incorporate the provisions in this Article XIII;
and
ii. The Employer agrees to implement the provisions in Section 13.04 herein.
13.04 Conditions Imposed on Employer. Nottvitlistanding any provision of the Plan to the contrary,
the Employer agrees:
n) Not to use or disclose PHI other than as permitted or required by this Article XIII or as
required by law;
b) To ensure that any agents, including a subcontractor, to whom the Employer provides PHI
received from the Plan agree to the same restrictions and conditions that apply to the
Employer with respect to PHi received or created on behalf of the Plan;
c) Not use or disclose an individual's PHI for employment related purposes (including hiring,
firing, promotion, assignment or scheduling) unless authorized by the Individual;
d) Not to use or disclose an Individual's PHi in connection with any other non-health benefit
program or employee benefit plan of the Employer unless authorized 6y the Individual;
e) To report to the Plan any use or disclosure of PHI that is inconsistent with this Article XIII, if
it becomes aware of an inconsistent use or disclosure;
A To provide Individuals with access to PHI in accordance with 45 C.F.R. § 164.524;
~a -
?IS7pd11
7-55
g) To make available PHI for amendment and incorporate any amendmenu to PHI in
accordance with 45 C.F.R § 164.526;
h) To make available the information required to provide an accounting of disclosure in
accordance with 45 C.F.R. § 154.528;
i) To make internal practices, books' and records relating to the use and disclosure of PHI
received from the Plan available to the Secretary of Health and Human Services for purposes
of determining the Plods compliance with HIPAA;
j) If feasible, to return or destroy all PHI received from the Plan that the Employer maintains in
any form, and retain no copies of such PHI when no longer needed for the purpose for which
disclosure was made. If return or destruction is not feasible, limit further uses and disclosures
to those purposes that make the return or destruction infeasible; and
lc) To ensure adequate separation between [Ite Plan and Employer as required by 45 C.F.R. §
164.604(t)(2)(iii) and described in this Article XIII.
13.05 Designated Employees Wlro May Receive Pffi. In accordance with the Privacy Rules, only
certain Employees who perform Plan administrative functions may be given access to PHI.
Those Employees who have access [o PHI from the Plan are listed in dre Privacy No[ice, either by
name or individual position.
13.06 Restrictions on Employee with Access to PHI. The employees who have access to PHI listed
in dre Privacy Notice may only use and disclose PHI for Plan Administration functions that the
Employer performs for the Plan, as set forth in the Privacy Notice, including but not limited to,
quality assurance, claims processing auditing, and monitoring.
13.01 Policies and Procedures. The Employer will implement Policies and Procedures setting forth
operating rules to implement the provisions hereof.
13.08 Organized Health Care Arrangement. The Plan Administratot intends the Plan to form part of
an Organized Health Care Arrangement along with any other Benefit under a covered health plan
(under 46 C.F.R § 160.103) provided by the Employer.
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13.09 Privacy Official. The Plan shall designate a Privacy Official, wlto will be responsible for the
Plan's compliance +vith HIPAA. The Privacy Official may contract with or otherwise utilize the
services of attorneys, accountants, brokers, consultant, or other third party experts as the Privacy
Official deems necessary or advisable. In addition, and nohvithstanding any provision of this
Plan to the contrary, the Privacy Official shall have the authority [o and be responsible for.
a) Accepting and verifying the accuracy and completeness of any certification provided by the
Employer under this Article XIII;
b) Transmitting the certification to any third parties as may be necessary to permit them to
disclose PHI to Employer;
c) Es[ablislting and implementing policies and procedures with respect to PHI that are designed
to ensure compliance by the Plan wiUt Ute requirements of HIPAA;
d) Establishing and overseeing proper training of Uie Plan, or Employer personnel +vlto will have
access to Protected Health Information;
e) Any other duty or responsibility that the Privacy Official, in Iris or her sole capacity, deems
necessary or appropriate to comply with Ure provisions of HIPAA and the purposes of Utis
Article XQI.
13.10 Noncompliance. Tile Employer shall provide a mechanism for resolving issues of
noncompliance, including disciplinary sanctions for personnel whe do not comply with the
provisions of this Article XIII.
13.11 Definitions. As used in this Article XIII, each of the following capitalized terms shall have the
respective meaning given below:
"Individual" means the person who is the subject of the health information created, received or
maintained 6y the Plan or Employer
"Organized Health Care Arrangement" means the relationship of separate legal entities as
defined in 45 C.F.R. § 160.103.
"Privacy Notice" means the notice of the Plan's privacy practices distributed to Plan participants
in accordance with 45 C.F.R. § 164.62Q, as amended from time to time.
"Privacy Rules" means the privacy provisions of HIPAA and Ute regulation in 45 C.F.R. Parts
160 and 164.
"Protected Health Information or PHI" means individually identifiable health information as
defined in 45 C.F.R. § 160.103.
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13.12 Interpretation and Limited Applicability. This Article XIII serves the sole purpose of
complying with the requiremenu of HIPAA and shall be interpreted and construed in a manner to
effectuate this purpose. Neither this Article XIII nor the duties, powers, responsibilities, and
obligations listed herein sltalf be taken into account in determining the amount or nature of the
Benefiu provided to any person covered under this Plan, nor shall they insure to the benefit of
any third parties. To the extent [hat any of the provisions of this Article XIII are no longer
required by HIPAA, they shall be deemed deleted and shall have no further force or effect.
13.13 Services Performed for the >;mployer. Nonvithstandingavy other provision of this Plan to the
contrary, all services performed by a business associate for the Plan in accordance with the
applicable service agreement sltalf be deemed to be performed on behalf of the Plan and subject
to the administrative simplification provisions of HIPAA contained in 45 C.F.R. parts 160
through 164, except services that relate to eligibility and enrollment in dte Plan. [f a business
associate of the Plan performs any services that relate to eligibility and enrollment to the Plan,
these services shall be deemed to be performed on behalf of the Employer in its capacity as Plan
Sponsor and not on behalf of the Plan
13.14 HCSATythe IEmployep$villE~nsurettheatfollowi nPAwithSerespectegtolatelectronictPt
a) That administrative, physical and technical safeguards that reasonably and appropriately
protect the confidentiality, integrity, and availability of the electronic PHI that it creates,
receives, maintains or transmits on behalf of the plan are implemented in accordance
with the applicable rules and regulations under HIPAA.
b) Tltat reasonable and appropriate security measures are implemented to support adequate
separation as required by Section ] 3.03(k) herein.
c) Tltat any agents, including a subcontractor, to wham the Employer provides PHI
received from the Plan agree to the same restrictions and conditions that apply to the
Employer under this Section 13.13.
d) That any security incidenu of which it becomes aware that are inconsistent with this
Section 13.14 are reported to the Plan
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The Plan shall also designate a Security Official, who will be responsible for the Plan's
compliance with the security provisions of H1PAA. The Security Official may contract with or
otherwise utilize the services of attorneys, accountants, brokers, consultants, or outer third party
experts as the Security Official deems necessary or advisable. In addition, and nonvitltstanding
any provision of this Plan ro the contrary, the Security Official shall have the authority to and be
responsible for:
(a) Accepting and verifying [he accuracy and completeness of any certification
provided by the Emp{oyer under this Article V[I;
(b) Transmitting the certification to any third parties as may be necessary to permit
them to disclose electronic PHI to Employer,
(c) Establishing and implementing pclicies and procedures with respect to electronic
PHI that are designed [o ensure compliance by the Plan with the security
requirements of HIPAA;
(d) Establishing and overseeing proper training of the Plan, or Employer personnel
wlto will have access to electronic PHI;
(e) Any other duty or responsibility that the Security Official, in his or her sole
capacity, deems necessary or appropriate to comply with the security provisions
" of H[PAA and the purposes of this Article VIII.
IN ~rylTN1;SS WFIi'/REOF, the Employer has executed this Cafeteria Plan as of the date set
Forth below.
CITY OF CH[JLA VISTA
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\i!~ EXHIBIT B
~.
......~~
crn of
CHULA VISTA
VOLUNTARY PLAN
AFLAC
PLAN DOCUMENT
Amended as of January 1, 2012
Human Resources and
Information Technology Services Departments
City of Chula Vista
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Intentionally Left Blank
7-61
Af#ac.
Dear EDITH QUICHO:
Thank you for choosing Aflac's Flex One® flexible benefits plan. We appreciate your business
Enclosed is a packet containing the documents necessary to establish a cafeteria plan with the assistance of Flex One. Please
carefully review the Flexible Benefts Plan Document and Summary Plan Description (SPD), and verify that all of the information
about benefts offered, eligibility, plan administration, and funding is correct.
Please notice that the sample Flexible Benefts Plan Document refers to the Summary Plan Description with regard to many of
the plan's provisions. This approach eases administration and reduces the risk of inconsistency between the Flexible Benefits
Plan Document provisions and the Summary Plan Description provisions. For example, if you have changes in the plan, most of
the plan changes will only require formal adoption by the governing body of the employer and distribution of a Summary of
Material Modifcations (discussed in more detail below). You should also note that these documents are only sample documents
typical of a plan intended to qualify as a Section 125 Cafeteria Plan with the terms and conditions thereof, and that they may
need to be modified to conform to your individual circumstances.
Aflac has developed these documents with legal counsel, and it is Aflac's intent and belief that the documents inform satisfy the
requirements of IRS Code Section 125. However, Aflac is not in the business of offering legal counsel or tax advice, and thus,
Aflac cannot and does not make any representations about the legal or tax effect of these documents upon any particular
employer. Therefore, it is each employer's responsibility to determine, with the assistance of the employer's own legal counsel,
the suitability of these particular documents, and the legal and tax effect of these plan documents upon the employer and its
employees.
Since AFlac has no control ovef your subsequent modification and/or administration of the plan and since the Internal Revenue
Service will not render an opinion as to a plan's qualified status under IRS Code Section 125, Aflac makes no representation
(express or implied) as to your plan's qualification under IRS Code Section 125 and related provisions as adopted and
subsequently amended by you.
You, as sponsoring employer, bear sole responsibility for amending your plan (as necessary) to comply with existing tax law
and future changes, for meeting all reporting and disclosure requirements imposed by applicable law, and for the daily
administration of your plan. As such, we recommend you review the following important information:
Important Compliance Issues
Nondiscrimination Testing. This test is at the very core of the legal requirements imposed by Section 125 of the Internal
Revenue Code. Failure to satisfy these requirements will cause adverse tax consequences to highly compensated and/or key
employees and could possibly disqualify the plan. For details regarding your nondiscrimination testing requirements, please
refer to the Flex One Account Establishment Information Checklist.
Qualified Premiums. Certain insurance premiums that cover the employee (or in the case of accident or health coverage other
than life insurance, the employee and tax dependents/family) may be included in the Flexible Benefts Plan Documents if adopted
as part of your benefits plan. These include the following:
• Group Term Life Insurance covering the employee (eligible under IRS Code Section 79) that is equal to or less than
$50,000 (Life insurance coverage on dependents is not eligible for pre-tax treatment.)
• Accidental-Death and Dismemberment (AD&D) coverage
• Medical, dental, hospital indemnity, cancer insurance, vision, hearing, and other qualifed accident and health premiums
Effects on taxes. When including health, medical, and disability income policies within the Flexible Benefits Plan, paying for
coverage on a pre-tax basis may cause insurance benefit payments under medical coverage to be subject to federal and state
taxes if benefit payments from all medical policies/plans are in excess of actual medical expenses. Paying for disability income
policies with pre-tax premiums will cause the benefits payable thereunder to be taxable.
Continuation of Coverage. Health benefits offered through a cafeteria plan may be subject to the continuation coverage
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"). See the SPD for more details.
Continuation of Coverage During FMLA Leave. Health benefits (including health FSA benefits) and nonhealth benefits offered
through a cafeteria plan are subject to the continuation and reinstatement provisions of the Family and Medical Leave Act of
1993 ("FMLA"). See Question 13 of the SPD for more details on coverage offered under the Plan during FMLA leave.
COVLET
7-62
HIPAA Privacy and Security Requirements. During the course of providing participants with health coverage under a health
FSA (if applicable), the plan will have access to information about covered individuals that is deemed to be protected health
information (PHI) by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA Privacy and Security Rules
apply to health plans, including health FSAs. The employer is solely responsible for ensuring that the employer and the plan
comply with HIPAA's rules. If you are a Health FSA plan sponsor, Aflac is enclosing a privacy packet (Important Privacy
Information) with an overview of the HIPAA Privacy Rules. Aflac is also including general HIPAA language in the sample
documentation (Section 10.16 of the Flexible Benefits Plan Document and, for full plans only, Appendix II to the SPD). The
privacy information provided in this cafeteria plan packet is not provided with the intent of fully satisfying your HIPAA obligations.
HIPAA's Privacy Rules are complicated, and their effects may vary for each plan. Please consult with your legal counsel
regarding your required actions and plan language for your company and plan to achieve HIPAA compliance.
Plan Administration and Maintenance
Plan Document Maintenance. Each plan sponsor is responsible for reviewing the Flexible Benefits Plan Documents to
ensure that they are consistent with the desired plan design and any legal requirements that may apply in your state. For your
added convenience and your future reference, the most current version of the sample cafeteria plan packet will be available on
the Aflac Web site (aflac.com) and through the Flex One IVR (1-677-353-9487). As we make changes to the sample cafeteria
plan documents to correspond with changes in applicable laws, you can access the updates quickly and easily.
Summary Plan Description. All plan sponsors are required to give each eligible employee a copy of the SPD within 120 days of
the effective date of the initial plan year and within 90 days of the effective date of coverage for all subsequent plan years. If an
employer makes a change in the plan, the employer must provide employees with a summary of the changes [a Summary of
Material Modifications (SMM)] within 60 days of the adoption of the change. Note: While the plan and related documents are
copyrighted, Aflac gives you limited permission to copy the documents as necessary for distribution to your employees for use
solely in the operation of your own cafeteria plan.
Payroll Instructions. Payroll instructions will be thoroughly reviewed with you or your payroll representative by your Aflac
agent.
Emolovee Eliaibilitv and Elections
New Employees. For details regarding employee eligibility, please refer to Section 2.01 of the Flexible Benefits Plan Document
Employees of Affiliated Companies. If the requirements of IRS Code Section 414(b), (c), (m ), or (o) are satisfied, the
employees of an afriliated company may be able to participate in this plan. Please consult with your tax advisor concerning the
potential impact of IRS Code Section 414(b), (c), (m), and (o).
Benefit Election Changes. Employees generally cannot change their election to participate in the pre-tax contribution payment
option or vary [he pre-tax contributions they have selected. For details regarding important exceptions to this general rule, please
refer to Section 3.04 of the Plan Document and Question 9 of the SPD.
Due to the complexity of cafeteria plans, we recommend that you consult with your accountant, attorney or other tax advisor
concerning the plan provisions, administration, and operation before executing the Plan Documents. Remember that your
cafeteria plan will not be effective until your plan is adopted. NOTE: The Flexible Benefits Plan Documents must be signed
PRIOR TO THE EFFECTIVE DATE. If your Flexible Benefits Plan Document is executed after the effective date, the IRS may
attempt to challenge the qualified status of your plan. We recommend that you retain any evidence that you have showing that
your plan was adopted and that enrollments were completed prior to the effective date. If no pre-tax deductions have been made
thus far, you may consider changing the start date of your cafeteria plan.
Aflac will use its best efforts to provide employers with information from time to time about developments concerning Section 125
Cafeteria Plans. However, for reasons stated above, it is the employer's responsibility to maintain the qualified status of the
Section 125 Cafeteria Plan in form and in operation.
We value the trust you have placed in us. If you need our help or if you have any questions, please call us toll-free at
1-800-32-FLEX1 (1-800-323-5391). Our customer service representatives are here to assist you Monday through Friday from 8
a.m. to 7 p.m. Eastern time
Sincerely,
Aflac Benefit Services Department
Enc.
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FLEX ONE®ACCOUNT ESTABLISHMENT INFORMATION AND CHECKLIST
Important steps for establishing vour Flex One account
For all Flex One Cafeteria Plans:
^ Employer's Acknowledgment: After executing and adopting your Plan Document, please sign and date the
Employer's Acknowledgment in order to officially adopt and execute your plan. Place-the signed and dated Employer's
Acknowledgment in your files with a copy of your Plan Document Packet.
^ Summary Plan Description: A copy must be provided to each eligible employee as soomas possible. Regulations
require distribution within 120 days of the effective date of the initial plan year and within 90 days of the effective date
of coverage for all subsequent plan years.
P For all Flex One plans with FSAs when Flex One is the claims processor:
To ensure that your account is established in a timely manner, the following documents must be returned to Flex One at least 70
working days prior to the effective date of your plan. You may return these documents by toll-free fax to (877) FLEX-SRA
(877-353-9772) or by mail to Aflac Beneft Services/Flex One, 1932 Wynnton Road, Columbus, GA 31999-9950.
^ Salary Redirection Agreements (SRAs): Completed SRAs for all Flexible Spending Account (FSA) participants must
be returned to Flex One.
^ Reimbursement Services Agreement (RSA): The RSA must be signed in the second signature block and returned
to Flex One. It will be signed by Flex One and returned to you for your records.
Important information for administering vour Flex One account
^ Plan Identification Number (PIN): The Department of Labor regulations require that welfare benefit plan sponsors assign
a three-digit PIN number to their welfare plans (including cafeteria plans) for identification purposes. Numbering for welfare
plans should begin at 501 and proceed consecutively. If you have other plans (e.g., health coverage) assign the next open
number. This number must be indicated on the Summary Plan Description.
^ Affiliated Companies: Only those companies described in Section 414(b), (c) or (m) of the Internal Revenue Code can
participate in a cefeteria plan. In addition, if there are affiliated companies, nondiscrimination testing may be affected by
affiliated companies. Consult your tax advisor.
^ 5500 and Summary Annual Report: There is no Form 5500 filing requirement for the cafeteria plan itself. ~ IRS Notice
2002-24 suspended this requirement. Please note that Notice 2002-24 does not affect annual reporting requirements under
ERISA. Thus, welfare benefit plans subject to ERISA, which may include Health Flexible Spending Accounts (FBAs), must
continue to file Form 5500 and any applicable schedules (unless an applicable exception applies) even if the benefts are
funded through the cafeteria plan. You should contact your tax or legal advisor to find out if your Plan is subject to ERISA
and whether fling a Form 5500 (including any applicable schedules) for your Plan is required.
^ Nondiscrimination Testing: Tax nondiscrimination tests, including the Eligibility, Contributions and Benefits, and
Concentration of Benefts tests, must be performed. In the rase of Flexible Spending Accounts (FBAs), nondiscrimination
tests must be performed for each FSA. Upon request, Aflac Benefit Services will assist you at no extra charge with the
Cafeteria Plan Key Employee 25% Concentration Test, Dependent Care 55% Average Benefit Test, and Dependent Care
5% Shareholder Test.
^ Health FBAs: You, as Plan Sponsor, are responsible for ensuring that the Health FSA maximum, is in line with your risk
tolerance/ Remember IRS Notice 2005-42 allows an additional 2 '/z month period (i.e., grace period) in which to incur
additional medical expenses. If you have selected the grace period teature, the Aflac sample plan incorporates this
extension for Health FSAS.
^ Eligibility: Any eligibility waiting period for pre-tax benefits should generally be unifonnly applies. You, as Plan Sponsor,
are responsible for ensuring that the eligibility period listed in your plan documents does not violate Internal Revenue
Service or Department of Labor regulations.
^ Privacy: You, as Plan Sponsor, are responsible for ensuring that your plan does not violate the privacy requirements set
forth in the Gramm-Leach-Bliley Act of 1999 (GLB) and, if applicable, the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). GLB regulates the privacy of financial information and applies to all Flex One plans (see the attached
"Privacy Practices"). HIPAA protects privacy by regulating the disclosure of protected health information (PHI), so Plan
Sponsors of only Health FBAs must comply with HIPAA privacy requirements (Health FSA Plan Sponsors only, see the
attached "Important Privacy Information").
* If you have any questions regarding this checklist, please contact Flex One toll-free at (877) FLEX-IVR (877353-9487),
and one of our Customer Service Representatives can assist you Monday through Friday from 8:00 A.M. to 7:00 P.M. EST.
Emolover Acknowledgment: Your signature verifies that an Aflac sales representative has reviewed the above information with
you.
Signature Printed Name Date
CKLIST
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PRIVACY PRACTICES
Protecting the privacy and confidentiality of employer and participant information through our Flex One® cafeteria plan services is
very important to American Family Life Assurance Company of Columbus (Aflac) and American Family Life Assurance Company of
New York (Aflac New York). Throughout this notice when we use the name "Aflac," we will be referring to both organizations.
Accordingly, we strive to comply with each of the following practices in everything we do:
• We do not sell, rent, lease or otherwise disclose personal information about employers or employees of an employer
for purposes unrelated to our products and services. The personal information of our customers is of paramount
importance to us. Therefore, we provide this information only to our employees, agents and third parties as required to allow
them to help us develop and provide our insurance and employee beneft products and services.
• We work to ensure information integrity and security. We use technology tools and design our business practices to help
ensure that the personal information of the employer and employees of the employer are properly gathered, stored and
processed. We also work to maintain the security of, and internal and external access to, the personal information of our
customers through the use of technology and our business practices.
• We expect our agents and employees to respect the personal information of our customers. Aflac has business policies
and practices in place to help ensure that its employees and agents carry out these practices and otherwise protect the personal
information. Both employees and agents are subject tc censure, dismissal or termination for violation of these policies.
These Privacy Practices apply to our U.S. customers. Due to legal and cultural differences, our practices may vary outside the
United States.
Aflac and our agents provide this notice to let you know about the current privacy practices of Aflac, and our agents. You do not
need to do anything in response to this notice. This notice is merely to inform you about how we safeguard your
information.
Collection of Information
As part of AFlac's normal operating procedures, Aflac (and our agents ailing on our behalf) need to obtain information from both the
employer and the participant to service the flexible spending accounts. Aflac and our agents may collect nonpublic personal
information (which includes both nonpublic personal financial information and nonpublic personal health information) about Aflac
customers, including but not limited to:
• Information from the employer or the participant (including names, addresses, Social Security numbers, financial and marital
status, and health and dependent child-care information);
• Information about the employer or the participants' transactions with Aflac or our agents (including claims, payment information
and banking information);
• Information from the employer or the participants' health care providers (including drug receipts and medical information),
employers (including beneft elections and employment information) and family members.
Disclosure of Information
Aflac may disclose the nonpublic personal fnancial information we collect, as described above, as well as information about your
transactions with us (such as your election amounts, premiums and payment history) to our agents or other third parties who perform
services for us or functions on our behalf, including the marketing of Aflac services. Afac may also disclose the nonpublic personal
financial information we collect to other third parties as authorized by you, or as required or permitted by law.
Our agents will make disclosures of the employer or the participants' nonpublic personal financial information only while acting on
Aflac's behalf and, furthermore, will make such disclosures only as Aflac itself is permitted to make.
Neither Aflac nor our agents will use or share with other parties any nonpublic personal health information about our customers for
any purpose other than the servicing of the employer's fle>able spending account plan by Aflac or on our behalf, or to which the
customer consents.
Neither Aflac nor our agents will further disclose any nonpublic personal information about a former customer of Aflac other than as
may be required or permitted by law.
Confidentialiri and Securiri
Aflac and our agents will safeguard, according to strict standards of security and confidentiality, any information we collect, receive or
maintain about Aflac's customers. Aflac maintains administrative, technical and physical safeguards to ensure the security and
confidentiality of the employer and employees, and the employer information and records; to protect against anticipated threats or
hazards to such records; and to protect against unauthorized access to or use of such information or records.
Internally, Aflac limits access to our customers' information to only those employees who need access to the information to perform
their job functions. Employees who misuse information are subject to disciplinary actions. Externally, we do not disclose customer
information to any third parties unless we have previously informed the customer of the disclosure, have been authorized to do so by
the customer, or are required or permitted to make the disclosure by law or our regulators.
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TABLE OF CONTENTS
FLEXIBLE BENEFITS PLAN
PREAMBLE
ARTICLE I -DEFINITIONS
1.01 "Affiliated Employer"
1.02 "After-tax Contribution(s) "
1.03 "Anniversary Date"
1.04 "Benefit Plan(s) or Policy(ies) "
1.05 "Board of Directors"
1.06 "Change in Status"
1.07 "Code"
1.08 "Compensation"
1.09 "Dependent"
1.10 "Dependent Care Expense Reimbursement"
1.11 "Earned Income"
1.12 "Effective Date"
1.13 "Eligible Employment-Related Expenses"
1.14 "Eligible Medical Expenses"
1.15 "Employee"
1.16 "Employer"
1.17 "FRIBA"
1.18 "Medicare Care Expense Reimbursements"
1.19 "Highly Compensated Individual"
1.20 "Key Employee"
1.21 "Nonelective Contdbution(s)"
1.22 "Participant"
1.23 "Plan"
1.24 "Plan Administrator'
1.25 "Plan Year" "
1.26 "Pre-tax Contribution(s)"
1.27 "Qualified BenefY'
1.28 "Qualifying Employment-Related Expenses"
1.29 "Qualifying Individual"
1.30 "Qualifying Services"
1.31 "Reimbursement Account(s)"or"Account(s)"
1.32 "Salary Redirection Agreement' or "SRA"
1.33 "Spouse"
1.34 "Student"
1.35 "Summary Plan Description' or "BPD"
1.36 "Trustee"
ARTICLE II -ELIGIBILITY AND PARTICIPATION
2.01 Eligibility to Participate
2.02 Termination of Participation
2.03 Eligibility to Participate in Reimbursement Accounts
2.04 Qualifying Leave Under FMLA
2.05 Non-FMLA Leave
ARTICLE III -BENEFIT ELECTIONS
3.01 Election of Contributions
3.02 Initial Election Period
3.03 Annual Election Period
3.04 Change of Elections
3.05 Impact of Termination of Employment on Election or Cessation of Eligibility
ARTICLE IV -BENEFIT FUNDING AND CREDITS AND DEBITS TO ACCOUNTS
4.01 Source of Benefit Funding
4.02 Reduction of Certain Elections to Prevent Discrimination
4.03 Medical Care Expense Reimbursement
4.04 Dependent Care Expense Reimbursement
ARTICLE V -BENEFITS
5.01 Qualifed Benefits
5.02 Cash Beneft
5.03 Repayment of Excess Reimbursements
5.04 Termination of Reimbursement Accounts
5.05 Coordination of Benefits Under the URM
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ARTICLE VI -PLAN ADMINISTRATION 8
6.01 Allocation of Authority 8
6.02 Payment of Administrative Expenses 9
6.03 Reporting and Disclosure Obligations 9
6.04 Indemnification 9
6.05 Substantiation of Expenses 9
6.06 Reimbursement 9
6.07 Annual Statements 9
ARTICLE VII -FUNDING AGENT
ARTICLE VIII -CLAIMS PROCEDURES
ARTICLE IX - AMENDMENT OR TERMINATION OF PLAN 10
9.01 Permanency 10
9.02 Employer's Right to Amend 10
9.03 Employer's Right to Terminate 10
9.04 Determination of Effective Date of Amendment or Termination 10
ARTICLE X -GENERAL PROVISIONS 10
10.01 Not an Employment Contract 10
10.02 Applicable Laws 10
10.03 Post-Mortem Payments 10
10.04 Nonalienation of Benefits 10
10.05 Mental or Physical Incompetency 10
10.06 Inability to Locate Payee 10
10.07 Requirement for Proper Forms 10
10.08 Source of Payments 10
10.09 Multiple Functions 11
10.10 Tax Effects - 11
10.11 Gender and Number 11
10.12 Headings 11
10.13 Incorporation by Reference 11
10.14 Severability 11
10.15 Effect of Mistake 11
10.16 Provisions Relating to Insurers 11
10.17 Forfeiture of Unclaimed Reimbursement Account Benefits 11
10.18 HIPAA Privacy 11
ARTICLE XI -CONTINUATION COVERAGE UNDER COBRA 11
EMPLOYER'S ACKNOWLEDGEMENT 12
ATTACHMENT I -SUMMARY PLAN DESCRIPTION (SPD)
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PREAMBLE
The Employer hereby establishes a Flexible Benefits Plan ("Plan") for its Employees for purposes of providing eligible
Employees with the opportunity to choose from among the fringe benefits available under the Plan. The Plan is
intended to qualify as a cafeteria plan under the provisions of Code Section 125. T_he Dependent Care Expense
Reimbursement Plan ("DDC") is intended to qualify as a Code Section 129 dependent care assistance plan, and the
Medical Care Expense Reimbursement Plan ("URM") is intended to qualify as a Code Section 105 medical expense
reimbursement plan. Although printed within this document, the DDC and URM Plans are separate written plans for
purposes of administration and all reporting and nondiscrimination requirements imposed by Sections 105 and 129 of
the Code and all applicable provisions of ERISA. The DDC and the URM are available only if designated as a Benefit
Plan or Poliey in the Summary Plan Description (SPD).
FLEXIBLE BENEFITS PLAN
ARTICLE I -DEFINITIONS
1.01 "Affiliated Employer" means any entity who is considered with the Employer to be a single employer in accordance
with Code Section 414(b), (c), or (m) of the Code.
1.02 "After-tax Contribution(s)" means amounts withheld from an Employee's Compensation pursuant to a Salary
Redirection Agreement (SRA) after all applicable state and federal taxes have been deducted. Such amounts are
withheld for purposes of purchasing one ormore of the Benefit Plans or Policies available under the Plan.
1.03 "Anniversary Date" means the frst day of any Plan Year.
1.04 "Benefit Plan(s) or Policy(ies)" means those Qualifed Benefits available to a Participant under this Plan as set forth in
the SPD, as amended and/or restated from time to time.
1.05 "Board of Directors" means the Board of Directors or other governing body of the Employer (the "Board"). The Board,
upon adoption of this Blan, appoints the Plan Administrator to act on the Employer's behalf in all matters regarding the
Plan.
1.06 "Change in Status" means any of the events described in the SPD, as well as any other events included under
subsequent changes to Code Section 125 or regulations issued under Code Section 125, that the Plan Administrator (in
its sole discretion) decides to recognize on a uniform and consistent basis as a reason to change the election mid-year.
Note: See the SPD for requirements that must be met to permit certain mid-year election changes on account of a
Change in Status.
1.07 "Code" means the Internal Revenue Code of 1986, as amended.
1.08 "Compensation" means the cash wages or salary paid to an Employee by the Employer.
1.09 "Dependent' means any individual who is a tax dependent of the Participant as defined generally in Code Section
152(a) except as otherwise set forth in Code Section 21 (for Dependent Care FSA purposes, if offered under the Plan),
Code Section 105 (for health plan purposes, if offered under the Plan), and Code Section 223 (for Health Savings
Account purposes, if offered under the Plan). Also, for DDC purposes, a Dependent shall also be defined as in Code
section 21(e)(5) (i.e., dependent of the custodial parent as defined in Code Section 152(e)).
1.10 "Dependent Care Reimbursement" shall have the meaning assigned to it by Section 5.01 of the Plan.
1.11 "Earned Income" means all income derived from wages, salaries, tips, self-employment, and other Compensation
(such as disability or wage continuation benefits), but only if such amounts are includable in gross income for the
taxable year. Earned income does not include any other amounts excluded from earned income under Code § 32(c)(2),
such as amounts received under a pension or annuity, or pursuant to workers' compensation.
1.12 "Effective Date" of this Plan is the effective date set forth in the SPD.
1.13 "Eligible Employment-Related Expenses" means those Qualifying Employment-Related Expenses (as defined below)
paid or incurred incident to maintaining employment after the date of the Employee's participation in the DDC and
during the Plan Year (plus any applicable grace period extension as described in the SPD), other than amounts paid to:
(a) an individual with respect to whom a Dependent deduction is allowable under Code Sec. 151(c) to the
Participant or his Spouse;
(b) the Participant's Spouse; or
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(c) a child of the Participant who is under 19 years of age at the end of the taxable year in which the expenses
were incurred.
1.14 "Eligible Medical Expenses" means those expenses incurred by the Employee,, or the Employee's Spouse or
Dependents, after the date of the Employee's participation in the URM and during the Plan Year (plus any applicable
grace period extension as described in the SPD) to the extent that the expense satisfies the conditions set forth in the
Summary Plan Description and are for "medical care" as defined by Code Section 213(d). For purposes of this Plan,
the following expenses are not considered "Eligible Medical Expenses" even if they otherwise constitute "medical care"
under Code Section 213(d): i) expenses for qualified long term care services (as defined in Code § 77028(c)); and ii)
expenses incurred for health insurance premiums. For purposes of this Plan, an expense is "incurred" when the
Participant or benefciary is furnished the medical care or services giving rise to the claimed expense, regardless of
when the expense is paid.
1.15 "Employee" means any individual who is considered to be in a legal employer-employee relationship with the Employer
for federal tax-withholding purposes. Such term includes "former employees" for the limited purpose of allowing
continued eligibility for benefits hereunder for the remainder of the Plan Year it which an employee ceases to be
employed by the Employer. The term "Employee" shall not include any leased employee (as that term is defined in
Code Section 414(n)) or any self- employed individual who receives from the Employer "net earnings from self-
employment" within the meaning of Code Section 401(c)(2) unless such individual is also an Employee.
1.16 "Employer" means the Employer and the Affiliated Employers named in the SPD provided, however, that when the
Plan provides that the Employer has a certain power (e.g., the appointment of a Plan Administrator, entering into a
contract with a third party insurer, or amendment or termination of the plan) the term "Employer" shall mean only that
entity named on the first line of the Plan Information Summary of the SPD, and not any Affiliated Employer. Affiliated
Employers who sign the Plan Information Summary and/or otherwise adopt the Plan shall be bound by the Plan as
adopted and subsequently amended unless they clearly withdraw from participation herein.
1.17 "FRIBA" shall mean the Employee Retirement Income Security Act of 1974, as amended.
1.18 "Health Care Reimbu7sement" shall have the meaning assigned to it by Section 5.01 of the Plan.
1.19 "Highly Compensated Individual" means an individual defined under Code Section 105(h), 125(e), or 414(q), as
amended, as a "highly compensated individual" or a "highly compensated employee."
1.20 "Key Employee" means an individual who is a "key employee" as defined in Code Section 125(b)(2), as amended.
1.21 "Nonelective Contribution(s)" means any amount that the Employer, in its sole discretion, may contribute on behalf of
each Participant to provide benefts for such Participant and his or her Spouse and Dependents, if applicable, under one
or more of the Benefit Plan(s) or Policy(ies) offered under the Plan. The amount of employer contribution that is applied
towards the cost of the Benefil Plan(s) or Policy(ies) for each Participant and/or level of coverage shall be subject to the
sole discretion of the Employer. The amount of Nonelective Contribution for each Participant may be adjusted upward
or downward in the contributing Employer's sale discretion. The amount shall be calculated for each Plan Year in a
uniform and nondiscriminatory manner and may be based upon the Participant's dependent status, commencement or
termination date of the Participant's employment during the Plan Year, and such other factors as the Employer shall
prescribe. To the extent set forth in the SPD or enrollment material, the Employer may make Nonelective Contributions
available to Participants and allow Participants to allocate the Nonelective Contributions among the various Benefit
Plans or Policies offered under the Plan in a manner set forth in the SPD of additional, taxable Compensation except as
otherwise provided in the SPD or enrollment material.
1.22 "Participant" means an Employee who becomes a Participant pursuant to Article II.
1.23 "Plan" means the Flexible Benefits Plan, the SPD (defined in Section 1.35 herein) and (if applicable) the related Trust
created by this document.
1.24 "Plan Administrator" means the person(s) or Committee identified in the SPD that is appointed by the Employer with
authority, discretion, and responsibility to manage and direct the operation and administration of the Plan. If no such
person is named, the Plan Administrator shall be the Employer.
1.25 "Plan Year" shall be the period of coverage set forth in the SPD (as extended by any applicable grace period as set
forth in the BPD).
1.26 "Pre-tax Contribution(s)" means amounts withheld from an Employee's Compensation pursuant to a Salary
Redirection Agreement before any applicable state and federal taxes have been deducted. The amounts are withheld
for purposes of purchasing one or more of the Benefit Plans or Policies available under the Plan. This amount shall not
exceed the premiums or contributions attributable to the most costly Benefit Plan or Policy afforded hereunder, and for
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purposes of Code Section 125, shall be treated as an Employer contribution (this amount may, however, be treated as
an Employee contribution for purposes of state insurance laws).
1.27 "Qualified Benefit" means any benefit excluded from the Employee's taxable income under Chapter 1 of the Code
other than Sections 106(b), 117, 124, 127, or 132 and any other beneft permitted by the Income Tax Regulations
(i.e., any life insurance coverage that is includable in gross income by virtue of exceeding the dollar limitation on
nontaxable coverage under Code Sec. 79). Notwithstanding the previous sentence, long-term care insurance is not a
"Qualifed Benefit."
1.28 "Qualifying Employment-Related Expenses" means those expenses that would be considered to be
employment-related expenses under Section 21(b)(2) of the Code (relating to expenses for household and dependent
care services necessary for gainful employment) if paid for by the Employee to provide Qualifying Services.
1.29 "Qualifying Individual" means an individual defined as a "Qualifying Individual" in the Summary Plan Description.
1.30 "Qualifying Services' means services relating to the care of a Qualifying Individual that enable the Participant or his
Spouse to remain gainfully employed which are performed:
(a) in the Participant's home; or
(b) outside the Participant's home for (1) the care of a Dependent of the Participant who is under age 13, or (2) the
care of any other Qualifying Individual who resides at least eight (8) hours per day in the Participant's
household. If the expenses are incurred for services provided by a dependent care center (i.e., a facility that
provides care for more than six (6) individuals not residing at the facility), the center must comply with all
applicable state and local laws and regulations.
1.31 "Reimbursement Account(s)" or "Account(s)" shall be the funding mechanism by which amounts are withheld from
an Employee's Compensation and retained for future Health Care Reimbursement (as defined in Section 1.18 herein)
and Dependent Care Reimbursement (as defined in Section 1.10 herein) to the extent adopted by the Employer as set
forth in the SPD. No money shall actually be allocated to any individual Participant Account(s); any such Account(s)
shall be of a memorandum nature, maintained by the Administrator for accounting purposes, and shall not be
representative of any identifiable trust assets. No interest will be credited to or paid on amounts credited to the
Participant Account(s).
1.32 "Salary Redirection Agreement" or "SRA" means the actual or deemed agreement pursuant to which an eligible
Employee or Participant elects to contribute his share of the cost of chosen Benefit Plans or Policies with Pre-tax or
After-tax Contributions and/or Benefit Credits (if offered under the Plan) in accordance with Article III herein. If the
Employer utilizes an interactive voice response (IVR) system or web-based program for enrollment, the SRA may be
maintained on an electronic database in accordance with all applicable federal and/or state laws.
1.33 "Spouse' means an individual who is legally married to a Participant (and who is treated as a spouse under the Code),
but for purposes of the Dependent Care Reimbursement Plan provisions, shall not include an individual who, although
married to the Participant, files a separate federal income tax return, maintains a separate, principal residence from the
Participant during the last six months of the taxable year, and does not furnish more than one-half of the cost of
maintaining the principal place of abode of the Qualifying Individual.
1.34 "Student" means an individual who, during each of five (5) or more calendar months during the Plan Year, is a full time
student at any college or university, the primary function of which is the conduct of formal instruction, and which
routinely maintains a regular faculty and curriculum and normally has an enrolled student body in attendance at the
location where its educational activities are regularly presented.
1.35 "Summary Plan Description' or "SPD" means the document attached as Attachment I to the Plan document that
describes the term of Plan not set forth herein. The SPD and all applicable appendices are incorporated hereto by
reference.
1.36 "Trustee' (if applicable) means the person(s) or institution (and their successors) named on the signature page
attached hereto, who have assented to being so named by their signature to this Agreement, otherwise empowered to
hold and disburse the funds that are created hereunder.
ARTICLE II -ELIGIBILITY AND PARTICIPATION
2.01 Eligibility to Participate. Each Employee who satisfies the eligibility requirements set forth in the SPD shall be eligible
to participate in this Plan as of any applicable entry date set forth in the SPD. The provisions of this Article are not
intended to override any eligibility requirement(s) or waiting period(s) specified in the applicable Beneft Plans or Policies
and the terms of eligibility and participation for the Benefit Plan(s) or Policy(ies) offered under the Plan shall be subject
to the requirements specified in the governing documents of the Benefit Plans or Policies.
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2.02 Termination of Participation. Participation shall terminate on the earliest of the dates set forth in the SPD
2.03 Eligibility to Participate in Reimbursement Accounts. Each Employee who satisfes the eligibility requirements set
forth in the SPD shall be eligible to participate in the Reimbursement Accounts, if adopted by the Employer, on the date
set forth in the SPD. Participation in the Reimbursement Accounts shall be effective on the date set forth in the SPD.
2.04 Qualifying Leave Under FMLA. Notwithstanding any provision to the contrary in this Plan, if a Participant goes on a
qualifying leave under the Family and Medical Leave Act of 1993 (the "FMLA"), then to the extent required by the FMLA,
the Participant will be entitled to continue the Participant's Benefit Plans or Policies that provide health coverage
(including URM benefits to the extent offered under the Plan) on the same terms and conditions as if the Participant
were still an active Employee. The requirements for continuing coverage, procedures for FMLA leave, and payment
option(s) provided by the Employer (as described above) will be set forth in the SPD and will be administered in
accordance with the regulations issued under Code Section 125 and in accordance with the FMLA.
2.05 Non-FMLA Leave. If a Participant goes on an unpaid leave of absence that does not affect eligibility under this Plan or
the Benefit Plans or Policies chosen by the Participant, then the Participant will continue to participate and the
contributions due for the Participant will be paid by one or more of the payment options described in the SPD. If a
Participant goes on an unpaid leave that affects eligibility under this Plan or the Benefit Plans or Policies chosen by the
Participant, the election change rules in Section 3.04 will apply. If such policy requires coverage to continue during the
leave but permits a Participant to discontinue contributions while on leave, the Participant will, upon returning from
leave, be required to repay the contributions not paid by the Participant during the leave.
ARTICLE III -BENEFIT ELECTIONS
3.01 Election of Contributions. A Participant may elect any combination of Pre-tax Contributions or After-tax Contributions
(as set forth in the SPD) to fund any Benefit Plan or Policy available under the Plan, provided that only Qualified
Benefits may be funded with Pre-tax Contributions. The Employer may, but is not required, to allocate Non-elective
Contributions to one or more Benefit Plans or Policies offered under the Plan and to the extent set forth in the SPD or
enrollment material, roay allow the Participants to allocate his allotted share of Nonelective Contributions among the
various Benefit Plans or Policies in a manner set forth in the SPD or enrollment material.
3.02 Initial Election Period.
(a) Currently Eligible Employees. An Employee who is eligible to become a Participant in this Plan as of the
Effective Date must complete, sign and file an SRA with the Plan Administrator during the election period (as
specified by the Plan Administrator) immediately preceding the Effective Date of the Plan in order to become a
Participant on the Effective Date. The elections made by the Participant on this initial SRA shall be effective.
subject to Section 3.04, for the Plan Year beginning on the Effective Date.
(b) New Employees and Employees Who Have Not Yet Satisfied The Plan's Waiting Period. An Employee
who becomes eligible to become a Participant in this Plan after the Effective Date must complete, sign and file
a SRA with the Plan Administrator (or its designated third party administrator as set forth on the SRA) during
the Initial Election Period set forth in the SPD or the enrollment material. Participation will commence under
this Plan as set forth in the SPD. Coverage under the component Benefit Plans or Policies will be effective in
accordance with the governing provisions of such Benefit Plans or Policies.
(c) Failure to Elect. An eligible Employee who fails to complete, sign and file a SRA in accordance with
paragraph (a) or (b) above during an initial election period may become a Participant on a later date in
accordance with Section 3.03 or 3.04.
3.03 Annual Election Period. Each Employee who is a Participant in this Plan or who is eligible to become a Participant in
this Plan shall be notifed, prior to each Anniversary Date of this Plan, of his right to become a Participant in this Plan, to
continue participation in this Plan, or to modify or to cease participation in this Plan, and shall be given a reasonable
period of time in which to exercise such right: such period of time shall be known as the Annual Election Period. The
date that the Annual Election Period commences and ends will be set forth in the SPD or the enrollment material. An
election is made during the Annual Election Period in the manner set forth in the SPD. The consequences of failing to
make an election during the Annual Election Period will be set forth in the SPD.
3.04 Change of Elections. A Participant shall not make any changes to the Pre-tax Contribution amount or, where
applicable, to the Participant's elected allocation of Nonelective Contributions except for election changes permitted
under this Section 3.04, and for changes made during the Annual Election Period (Section 3.03), changes caused by
termination of employment (Section 3.05) and changes pursuant to the Family and Medical Leave Act (Section 2.04).
Except as provided in the SPD for HIPAA special enrollment rights arising from the birth, adoption, or placement for
adoption of a child, all election changes shall be effective on a prospective basis only (i.e., election changes will become
effective no earlier than the first day of the first pay period coinciding with or immediately following the date that the
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election change was filed) but, as determined by the Plan Administrator, election changes may become effective later to
the extent the coverage in the applicable component plan commences later.. The circumstances under which a
Participant may change his election under this Plan are set forth in the SPD.
3.05 Impact of Termination of Employment on Election orCessation of Eligibility. Termination of employment or
cessation of eligibility shall automatically revoke any SRA. Except as provided below, if revocation occurs under this
Section 3.05, no new election with respect to Pre-Tax Contributions may be made by such Participant during the
remainder of the Plan Year. Rules governing elections for former participants rehired during the same Plan Year shall
be set forth in the SPD.
ARTICLE IV -BENEFIT FUNDING AND CREDITS AND DEBITS TO ACCOUNTS
4.01 Source of Benefit Funding. The cost of coverage under the component Beneft Plans or Policies shall be funded by
the Participant's Pre-tax and/or After-tax Contributions and/or any Nonelective Contributions provided by the Employer.
The required contributions for each of the Benefit Plans or Policies offered under the Plan shall be made known to
employees in enrollment materials. Pre-tax or After-tax Contributions (as elected by the Employee on the SRA) shall
equal the contributions required from the Participant less any available Nonelective Contributions allocated thereto by
the Employer, or where applicable, the Participant for coverage of the Participant or the Participant's Spouse or
Dependents under the Benefit Plans or Policies elected by the Participant under this Plan. Amounts withheld from a
Participant's Compensation as Pre-tax Contributions or Aker-tax Contributions shall be applied to fund benefits as soon
as administratively feasible. The maximum amount of Pre-tax Contributions plus any Nonelective Contributions made
available by the Employer for Benefit Plan(s) or Policy(ies) offered under this Plan shall not exceed the aggregate cost
of the Benefit Plan(s) or Policy(ies) elected by the Employee.
4.02 Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator determines, before or during
any Plan Year, that the Plan may fail to satisfy for such Plan Year any requirement imposed by the Code or any
limitation on Pre-tax Contributions allocable to Key Employees or to Highly Compensated Individuals, the Plan
Administrator shall take such action(s) as he deems appropriate, under rules uniformly applicable to similarly situated
Participants, to assure compliance with such requirement or limitation. Such action may include, without limitation, a
modification or revocation of a Highly Compensated Individual's or Key Employee's election without the consent of such
Employee.
4.03 Health Care Reimbursement. To the extent offered under the Plan, each Participant's URM will be credited for Health
Care Reimbursement with amounts withheld from the Participant's Compensation and any Nonelective Contributions
allocated thereto by the Employer or where applicable, the Participant. The Account will be debited for Health Care
Reimbursements disbursed to the Participant in accordance with Article V of this document. The entire amount elected
by the Participant on the SRA as an annual amount for the Plan Year for Health Care Reimbursement less any Health
Care Reimbursements already disbursed to the participant for Expenses incurred during the Plan Year (plus any grace
period as set forth in the SPD) shall be available to the Participant at any time during the Plan Year without regard to the
balance in the Health Care Account (provided that the periodic contributions have been made). Thus, the maximum
amount of Health Care Reimbursement at any particular time during the Plan Year will not relate to the amount that a
Participant has had credited to his URM. In no event will the amount of Health Care Reimbursements in any Plan Year
(plus any grace period as set forth in the SPD) exceed the annual amount specified for the Plan Year in the SRA for
Health Care Reimbursement. Any amount credited to the Health CareAccount shall be forfeited by the Participant and
restored to the Employer-if it has not been applied to provide Health Care Reimbursement within the Run-Off period set
forth in the SPD. Amounts so forfeited shall be used in a manner that is permitted within the applicable Department of
Labor ("DOL") or Internal Revenue Service ("IRS") regulations. The maximum annual reimbursement under the URM
shall be set forth in the SPD. The Employer may establish a minimum annual reimbursement amount as set forth in the
SPD.
4.04 Dependent Care Reimbursement. To the extent offered under the Plan, each Participant's DDC will be credited for
Dependent Care Reimbursement with amounts withheld from the Participant's Compensation, and any Nonelective
Contributions allocated thereto by the Employer or where applicable, the Participant. The Dependent Care Account will
be debited for Dependent Care Reimbursements disbursed io the Participant in accordance with Article V of this
document. In the event that the amount in the Account is less than the amount of reimbursable claims at any time
during the Plan Year, the excess part of the claim will be carried over into following months within the same Plan Year,
to be paid out as the Dependent Care Account balance becomes adequate. In no event will the amount of Dependent
Care Reimbursements exceed the amount credited to the Dependent Care Account for any Plan Year. Any amount
allocated to the Dependent Care Account shall be forfeited by the Participant and restored to the Employer if it has not
been applied to provide Dependent Care Reimbursement for the Plan Year within the Run-Off period set forth in the
SPD. Amounts so forfeited shall be used in a manner that is not prohibited by applicable federal or state law. The
maximum annual reimbursement amount shall be set forth in the SPD. The Employer may establish a minimum annual
reimbursement amount as set forth in the SPD.
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ARTICLE V -BENEFITS
5.01 Qualified Benefits. The maximum benefit a Participant may elect under this Plan shall not exceed the sum of i) the
aggregate premium for all Benefit Plan(s) or Policy(ies) set forth in the SPD (other than Health and DDC); ii) the
maximum annual Health Care Reimbursement under the URM as set forth in the SPD (if offered under the Plan); and iii)
the maximum annual Dependent Care Reimbursement under the DDC as set forth in the SPD (if offered under the
Plan).
(a) Special Rules for Health Care Reimbursement. To the extent offered under the Plan, payment shall be
made to the Participant in cash as reimbursement for Eligible Medical Expenses incurred by the Participant or
his Spouse or Dependents while he is a Participant during the Plan Year (plus any grace period extension as
specified in the SPD) for which the Participant's election is effective provided that the substantiation
requirements of Section 6.05 herein are satisfied.
(b) Special Rules for Dependent Care Reimbursement. To the extent offered under the Plan, payment shall be
made to the Participant in cash as reimbursement for Eligible Employment Related Expenses incurred by him
while a Participant, during the Plan Year (plus any applicable grace period extension as described in the SPD)
for which the Participant's election is effective, provided that the substantiation requirements of Section 6.05
have been satisfied.
5.02 Cash Benefit. To the extent that a Participant does not elect to have the maximum amount of his Compensation
contributed as a Pre-tax Contribution or After-tax Contribution hereunder, such amount not elected shall be paid to the
Participant in the form of normal Compensation payments; provided, however, that any applicable Nonelective
Contributions may not be received in the form of cash compensation, except as otherwise provided for in the SPD or the
enrollment material.
5.03 Repayment of Excess Reimbursements. If, as of the end of any Plan Year, it is determined that a Participant has
received payments under this Plan that exceed the amount of Eligible Medical Expenses and/or Eligible Employment
Related Expenses that have been substantiated by such Participant during the Plan Year as required by Section 6.05
herein, the Plan Administrator shall give the Participant prompt written notice of any such excess amount, and the
Participant shall repay the amount of such excess to the Employer within sixty (60) days of receipt of such notification.
5.04 Termination of Reimbursement Accounts. Coverage under the URM and/or DDC shall cease as of the day in which
a Participant is no longer employed by the Employer or when a premium payment for the respective plan(s) has been
missed for any reason. Provided, however, that Participants may submit claims for reimbursement for Eligible
Employment-Related Expenses arising during the Plan Year at any time until the end of the Run-Off period set forth in
the SPD. Participants in the URM may submit claims for reimbursement for Eligible Medical Expenses arising during
the Plan Year and before the date of separation from service at any time until the end of the Run-Off period set forth in
the SPD. Unless a COBRA election is made as set forth in the SPD, Participants shall not be entitled to receive
reimbursement for Eligible Medical Expenses incurred after employment ceases under this Section. Any unused
reimbursement benefits at the expiration of the Plan Year (as set forth in the SPD) shall be treated in accordance with
Sections 4.03 or 4.04. A special grace period may be applicable with regard to URM and/or DDC participation after the
close of the Plan Year (see SPD).
5.05 Coordination of Benefits Under the URM. The URM is intended to pay benefits solely for otherwise unreimbursed
medical expenses. Accordingly, it shall not be considered a group health plan for coordination of benefits purposes, and
its benefits shall not be taken into account when determining benefits payable under any other plan.
ARTICLE VI -PLAN ADMINISTRATION
6.07 Allocation of Authority. The Board of Directors or applicable governing body (or an authorized officer of the
Employer) appoints a Plan Administrator that keeps the records for the Plan and shall control and manage the operation
and administration of the Plan. The Plan Administrator shall have the exclusive right to interpret the Plan and to decide
all matters arising thereunder, including the right to make determinations of fact, and construe and interpret possible
ambiguities, inconsistencies, or omissions in the Plan and the SPD issued in connection with the Plan. In the case of an
insured Benefit Plan or Policy, the insurer shall be the named fiduciary with respect to benefit claim determinations
thereunder, and with respect to benefit claims shall have all of the powers of the Plan Administrator described herein.
All determinations of the Plan Administrator with respect to any matter hereunder shall be conclusive and binding on all
persons. Without limiting the generality of the foregoing, the Plan Administrator shall have the following powers and
duties:
(a) To require any person to furnish such reasonable information as he may request for the purpose of the proper
administration of the Plan as a condition to receiving any benefits under the Plan;
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(b) To make and enforce such rules and regulations and prescribe the use of such forms as he shall deem
necessary for the efficient administration of the Plan;
(c) To decide on questions concerning the Plan and the eligibility of any Employee to participate in the Plan and to
make or revoke elections under the Plan, in accordance with the provisions of the Plan;
(d) To determine the amount of benefts which shall be payable to any person in accordance with the provisions of
the Plan; to inform the Employer or insurer as appropriate, of the amount of such benefts; and to provide a full
and fair review to any Participant whose claim for benefits has been denied in whole or in part;
(e) To designate other persons to carry out any duty or power which may or may not otherwise be a fiduciary
responsibility of the Plan Administrator, under the terms of the Plan. Such entity will be referred to as a third
party administrator and shall be identifed in the SPD;
(f) To keep records of all acts and determinations, and to keep all such records, books of account, and data and
other documents as may be necessary for the proper administration of the Plan; and
(g) To do all things necessary to operate and administer the Plan in accordance with its provisions.
6.02 Payment of Administrative Expenses. Except as otherwise provided in the SPD, the Employer currently pays all
reasonable expenses incurred in administering the Plan.
6.03 Reporting and Disclosure Obligations. Unless specified otherwise, it shall be the Employer and Plan Administrator's
sole responsibility to comply with all filing, reporting, and disclosure requirements, imposed by the DOL and/or IRS,
specifically including, but not limited to creating, fling and distributing Summary Annual Reports, Form SSOOs, and
SPDs. Furthermore, the Employer and Plan Administrator shall be required to amend the Plan as is necessary to
ensure compliance with applicable tax and other laws and regulations.
6.04 Indemnification. The Plan Administrator shall be indemnified by the Employer against claims, and the expenses of
defending against such claims, resulting from any action or conduct relating to the administration of the Plan except
claims arising from gross negligence, willful neglect, or willful misconduct.
6.05 Substantiation of Expenses. Each Participant must submit a written Claim Form to the Plan Administrator identifed
in the SPD or its designated plan service provider [o receive reimbursements from the URM and/or DDC, on a form
provided by the Plan Administrator accompanied by a written statement/bill from an independent third party stating that
the expense has been incurred, and the amount thereof. The forms shall contain such evidence, as the Plan
Administrator shall deem necessary as to substantiate the nature, the amount, and timeliness of any expenses that may
be reimbursed.
6.06 Reimbursement. Reimbursements shall be made as soon as administratively feasible after the required forms have
been received by the Plan Administrator identified in the SPD or its designated plan service provider. Reimbursements
of less than $15 may be carried forward and aggregated with future reimbursements until the reimbursable amount is
greater than $15. However, claims for reimbursements outstanding at the end of the Plan Year (plus any grace period
as set forth in the SPD) shall be reimbursed without regard to the $15 threshold limit. Year-end expense
reimbursements must be submitted to the Plan Administrator within 90 days of the close of the Plan Year for which the
SRA is effective, and during which such expense was incurred, in order to be eligible for reimbursement.
6.07 Annual Statements. The Plan Administrator shall furnish each Participant with an annual statement, showing the
amounts paid or expenses incurred by the Employer in providing Medical and/or Dependent Care Expense
Reimbursement during the previous calendar year and the respective Reimbursement Account balance(s) on or before
January 31 following the close of the applicable Plan Year.
ARTICLE VII -FUNDING AGENT
The Plan shall be funded with amounts withheld from Compensation pursuant to SRAs, and/or Nonelective Contributions
provided by the Employer, if any. The Employer will apply all such amounts, without regard to their source, to pay for the welfare
benefits provided herein as soon as administratively feasible and shall comply with all applicable regulations promulgated by the
DOL taking into consideration any enforcement procedures adopted by the DOL. If a Trust is designated Funding Agent in the
SPD, an appropriate Trust Agreement shall be attached at the end of this Plan.
ARTICLE VIII -CLAIMS PROCEDURES
The Plan has established procedures for reviewing claims denied under this Plan and those claims review procedures are set
forth in the SPD. The Plan's claim review procedures set forth in the SPD shall only apply to issues germane to the pre-tax
benefts available under this Plan (i.e., such as a determination of: a Change in Status; change in cost or coverage; or eligibility
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and participation matters under this Cafeteria Plan document), and to the extent offered under the Plan, claims for benefits under
the Reimbursement Accounts.
ARTICLE IX -AMENDMENT OR TERMINATION OF PLAN
9.01 Permanency. While the Employer fully expects that this Plan will continue indefinitely, due to unforeseen, future
business contingencies, permanency of the Plan will be subject to the Employer's right to amend or terminate the Plan,
as provided in Sections 9.02 and 9.03 below. Nothing in this Plan is intended to be or shall be construed to entitle any
Participant, retired or otherwise, to vested or non-terminable benefits.
9.02 Employer's Right to Amend. The Employer reserves the right to amend at any time any or all of the provisions of the
Plan. All amendments shall be made in writing and shall be approved by the Employer in accordance with its normal
procedures for transacting business (e.g. by approval by the Board of Directors through a meeting or unanimous
consent of all Board members). Such amendments may apply retroactively or prospectively as set forth in the
amendment. Each Benefit Plan or Policy shall be amended in accordance with the terms specified therein, or, if n0
amendment procedure is prescribed, in accordance with this section. Any amendment made by the Employer shall be
deemed to be approved and adopted by any Affiliated Employer.
9.03 Employer's Right to Terminate. The Employer reserves the right to discontinue or terminate the Plan without
prejudice at any time and for any reason without prior notice. Such decision to terminate the Plan shall be made in
writing and shall be approved by the Employer in accordance with its normal procedures for transacting business.
Affiliated Employers may withdraw from participation in the Plan, but may not terminate the Plan.
9.04 Determination of Effective Date of Amendment or Termination. Any such amendment, discontinuance, or
termination shall be effective as of such date as the Employer shall determine. No amendment, discontinuance or
termination shall allow the return to any Employer of any Reimbursement Account balance for its use for any purpose
other than for the exclusive benefit of the Participants and their beneficiaries except as provided in Section 4.03 and
4.04 herein.
ARTICLE X -GENERAL PROVISIONS
10.01 Not an Employment Contract. Neither this Plan nor any action taken with respect to it shall confer upon any person
the right to continue employment with any Employer.
10.02 Applicable Laws. The provisions of the Plan shall be construed, administered and enforced according to applicable
federal law and the laws of the state of the principal place of business of the Employer to the extent not preempted.
10.03 Post-Mortem Payments. Any beneft payable under the Plan after the death of a Participant shall be paid to his
surviving spouse (if any), otherwise, to his estate. If there is doubt as to the right of any beneficiary to receive any
amount, the Plan Administrator may retain such amount until the rights thereto are determined, without liability for any
interest thereon.
10.04 Nonalienation of Benefits. Except as expressly provided by the Plan Administrator, no benefit under the Plan shall be
subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, or charge, and any
attempt to do so shall be void. No benefit under the Plan shall in any manner be liable for or subject to the debts,
contracts, liabilities, engagements, or torts of any person.
10.05 Mental or Physical Incompetency. Every person receiving or claiming benefits under the Plan shall be presumed to
be mentally and physically competent and of age until the Plan Administrator receives a written notice, in a form and
manner acceptable to it, that such person is mentally or physically incompetent or a minor, and that a guardian,
conservator or other person legally vested with the care of his estate has been appointed.
10.06 Inability to Locate Payee. If the Plan Administrator is unable to make payment to any Participant or other person to
whom a payment is due under the Plan because it cannot ascertain the identity or whereabouts of such Participants or
other person after reasonable efforts have been made to identify or locate such person, such payment and all
subsequent payments otherwise due to such Participant or other person shall be forfeited one year after the date any
such payment first became due.
10.07 Requirement for Proper Forms. All communications in connection with the Plan made by a Participant shall become
effective only when duly executed on any forms as may be required and furnished by, and fled with, the Plan
Administrator. -
10.08 Source of Payments. The Employer, the Trust fund (if selected as Funding Agent), and any insurance company
contracts purchased or held by the Employer or funded pursuant to this Plan shall be the sole sources of benefits
under the Plan. No Employee or beneficiary shall have any right to, or interest in, any assets of the Employer upon
10 PLANDOC
7-75
termination of employment or otherwise, except as provided from time to time under the Plan, and then only to the
extent of the benefts payable under the Plan to such Employee or beneficiary.
10.09 Multiple Functions. Any person or group of persons may serve in more than one fidu_ ciary capacity with respect to the
Plan.
10.10 Tax Effects. Neither the Employer, its agents, the Plan Administrator, nor the Trustee makes any warranty or other
representation as to whether any Pre-tax Premiums made to or on behalf of any Participant hereunder will be treated as
excludable from gross income for local, state, or federal income tax purposes. If for any reason it is determined that any
amount paid for the benefit of a Participant or Beneficiary is includable in an Employee's gross income for local, federal,
or state income tax purposes, then under no circumstances shall the recipient have any recourse against the Plan
Administrator or the Employer with respect to any increased taxes or other losses or damages suffered by the
Employees as a result thereof. The Plan is designed and is intended to be operated as a "cafeteria plan" under Section
125 of the Code.
10.11 Gender and Number. Masculine pronouns include the feminine as well as the neuter genders, and the singular shall
include the plural, unless indicated otherwise by the context.
10.12 Headings. The Article and Section headings contained herein are for convenience of reference only, and shall not be
construed as defining or limiting the matter contained thereunder.
10.13 Incorporation by Reference. Except for the Medical and Dependent Care Expense Reimbursement Plan(s), the actual
terms and conditions of the separate component Benefit Plans or Policies offered under this Plan are contained in
separate, written documents governing each respective benefit, and shall govern in the event of a conflict between the
individual plan document, and this Plan as to substantive content. To that end, each such separate document, as
amended or subsequently replaced, is hereby incorporated by reference as if fully recited herein. The provisions of the
Medical and Dependent Care Expense Reimbursement Plan(s) are reproduced herein, but shall constitute separate
plans for purposes of all applicable Code and ERISA provisions.
10.14 Severability. Should any part of this Plan subsequently be invalidated by a court of competent jurisdiction, the
remainder thereof shall be given effect to the maximum extent possible.
10.15 Effect of Mistake. In the event of a mistake as to the eligibility or participation of an Employee, the allocations made to
the account of any Participant, or the amount of distributions made or to be made to a Participant or other person, the
Plan Administrator shall, to the extent it deems possible, cause to be allocated or cause to be withheld or accelerated, or
otherwise make adjustment of, such amounts as will in its judgment accord to such Participant or other person the
credits to the account or distributions to which he is properly entitled under the Plan. Such action by the Administrator
may include withholding of any amounts due the Plan or the Employer from Compensation paid by the Employer.
10.16 Provisions Relating to Insurers. No insurer shall be required or permitted to issue an insurance policy or contract that
is inconsistent with the purposes of this Plan, nor be bound to take any action not in accordance with the terms of any
policy or contract with this Plan. The insurer shall not be deemed to be a party to this Plan, nor shall it be bound to
interpret the construction or validity of the Plan. The insurer shall be protected from its good faith reliance on the written
representations and instructions of the Trustee and the Plan Administrator, and shall not be responsible for the initial or
continued qualified status of the Plan.
10.17 Forfeiture of Unclaimed Reimbursement Account Benefits. Any Reimbursement Account beneft payments that are
unclaimed (e.g., uncashed benefit checks) by the close of the Plan Year following the Plan Year in which the Health or
Dependent Care Expense was incurred shall be forfeited.
10.18 HIPAA Privacy. To the extent a URM is offered under the Plan, the rights and obligations of an individual covered
under the URM, the Employer and Plan, with respect to permitted uses and disclosures of a covered individual's
protected health information, set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be
summarized in the SPD.
ARTICLE XI -CONTINUATION COVERAGE UNDER COBRA
The SPD includes provisions that shall be applicable to the URM to the extent the URM is a "group health plan" as def ned
by Code §§ 49806 and 5000(b)(1) and the regulations promulgated thereunder and to the extent it is offered under
the Plan. The intent of those provisions (as incorporated in this Article) is to extend continuation rights required by
COBRA.
11 PLANDOC
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IN WITNESS WHEREOF, the Employer has executed this Plan as of the date set forth below.
EMPLOYER'S ACKNOWLEDGMENT
As evidenced by the formal execution of this document, the undersigned Employer adopted and established this Plan on the
Effective Date as the Flexible Benefits Plan of the undersigned Employer. In doing so, the undersigned Employer acknowledges
that the Summary Plan Description ("SPD") and this Plan document are important legal instruments with significant legal and tax
implications.
The Employer also acknowledges that it has read this SPD and the Plan document in their entirety, has consulted independent
legal and tax counsel other than representatives of American Family Life Assurance Company of Columbus (Aflac), to the extent
considered necessary, and accepts full responsibility for participation of Employees hereunder and the operation of the Plan.
The Employer acknowledges that, as sponsor and Plan Administrator, it shall have sole responsibility to comply with all filing,
reporting, and disclosure requirements imposed by the DOL, IRS, or any other government agency, specifcally including, but not
limited to, creating and filing Form 5500s and preparing and distributing SPDs and performing required nondiscrimination
testing. Furthermore, the Employer further acknowledges that it shall bear sole responsibility for amending the Plan as
necessary to ensure compliance with applicable tax, labor, and other laws and regulations. The Employer acknowledges receipt
of the checklist of Plan Sponsor Responsibilities included provided with the applicable plan document request form and has
agreed to the obligations set forth therein.
It is also understood and agreed that American Family Life Assurance Company of Columbus (Aflac), and its subsidiaries,
agents, and representatives, are not providing legal or tax advice to the undersigned Employer in connection with this Plan and
that no representations are made by it with respect to the operation of the Flexible Benefits Plan pursuant to the documents
provided by American Family Life Assurance Company of Columbus (Aflac) to the Employer.
This Plan shall be construed and enforced according to the Internal Revenue Code of 1986, as amended from time to time, the
applicable regulations thereto, and the laws of the state of the principal place of business of the Employer.
IN WITNESS WHEREOF, the Employer has caused this Plan and Summary Plan Description to be executed on the day of
to ratify the adoption of the Plan adopted and effective as of the Effective Date.
WITNESS:
Corporate Officer
ATTACHMENT I -SUMMARY PLAN DESCRIPTION
Employer:
By: _
Title:
Date:
12
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PLANDOC
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
PLAN INFORMATION SUMMARY
The Employer named below establishes a Flexible Benefits Plan (the "Plan") as set forth in this Summary Plan Description
("SPD") as of the Effective Date set forth below. The purpose of the Plan is to provide eligible Employees a choice between
cash and the specifed welfare benefts described in this Plan Information Summary (see "Benefts Provided Under the Plan").
Pre-tax Contribution elections under the Plan are intended to qualify for the exclusion from income provided in Section 125 of the
Internal Revenue Code of 1986.
FLEXIBLE BENEFITS PLAN
EMPLOYER INFORMATION
1) Name and Address of Employer: CITY OF CHULA VISTA
Plan Administrator: EDITH QUICHO
276 FOURTH AVENUE
CHULA VISTA, CA 91910
The Plan Administrator has the exclusive right to interpret the Plan and to decide all matters arising under [he Plan, including the
right to make determinations of fact and to construe and interpret possible ambiguities, inconsistencies, or omissions in the Plan
and this SPD.
2) Employer's Telephone Number: (619) 585-5620
3) Employer's Federal Tax
Identification Number: 95-6000690
4) Plan Number Assigned to Cafeteria
Plan (e.g., 501 if this is the first ERIS A
Plan Number assigned):
5) 125 Start Date: 01101110
6) Effective Date of this Plan: 01101110
7) Last Day of the Plan Year: 12131110
Subsequent Plan Years: 0 1 /01-1 2131
8) Name and Address of SAME
FSA Claim Administrator:
9) Name and Address of registered IRENE MOSLEY
agent for service of legal process:
10) Affiliated Employers that will participate in the Plan
11) Employer's Type of Business: OTHER
ELIGIBILITY
All Employees employed by the Employer shall be eligible to participate under the Plan xe ceot the following:
An eligible Employee may become a Participant in the Plan:
[ X ] Immediately, upon the first day of employment (but not prior to the Effective Date of the Plan).
[ ] On the day following commencement of employment.
[ ] On the first day of the month following days of employment.
[ ] Other: OTHER
provided the Employee completes a Salary Redirection Agreement ("SRA"). However, eligibility for coverage under any
given Benefit Plan or Policy shall be determined by the terms of that Benefi[ Plan of Policy, and reductions of the
Employee's Compensation to pay Pre-tax or After-tax Contribution(s) shall commence when the Employee becomes
covered under the applicable Benefit Plan or Policy.
An eligible Employee may become a Participant in the Dependent Care and/or Medical Expense Reimbursement Plan(s) (if
elected below):
[ ] On the same day such Employee is eligible for the Pre-Tax Contribution benefits under the Plan.
[ ] On the day following commencement of employment.
[ ] On the first day of the month following days of employment.
[ ] Other: OTHER, provided the Employee completes an SRA selecting such benefits.
SPD
7-78
BENEFITS PROVIDED UNDER THE PLAN
The following Benefit Plans and Policies subject to the terms and conditions of the Plan are available for election by eligible
Employees. The maximum a Participant can contribute via the SRA is the maximum aggregate cost of the Benefit Plans or
Policies elected minus any Nonelective Contribution made by the Employer. It is intended that such Pre-tax Contribution
amounts shall, for tax purposes, constitute an Employer contribution, but may constitute Employee contributions for state
insurance law purposes. Copies of the Benefit Plans or Policies (or a list of eligible Policy numbers) shall be attached as an
appendix to this Plan.
[ ] Medical Coverage
[ ] Vision Care Coverage
[ ] Disability Income -Short Term (A&S)
[ X ] Cancer Insurance
[ X ] Dental Coverage
[ ] Group Term Life Insurance
[ ] Disability Income- Long Term (LTD)
[ ] Intensive Care Insurance
[ X ] Accident Insurance
[ X ] Hospital Indemnity Insurance (HIP)
[ X ] Specified Health Event
[ ] Personal Sickness Indemnity (PSI)
[ ] Medical Care Expense Reimbursement described in Appendix I to this SPD, not to exceed $ per Plan Year pursuant to the
CITY OF CHULA VISTA~Nledical Care Expense Reimbursement Plan.
Name and Address of Medical Care Expense Reimbursement Plan
COBRA Administrator (if applicable):
[ ] Dependent Care Expense Reimbursement described in Appendix I to this SPD, not to exceed $5,000 per Plan Year or
$2,500 for married filing separate returns pursuant to the CITY OF CHULA VISTA Dependent Care Expense
Reimbursement Plan.
[ ] Health Savings Account (as defined in Code Section 223) established with the following
Custodian/Trustee:
[ ] Opt-out Option: See Employer enrollment material.
THE FUNDING AGENT
The Employer selects the following Funding Agent for the Plan (check one):
^ The Employer, which will comply with the requirements of Article VII of the Plan.
^ The Flexible Benefits Trust created concurrently with the execution of the Plan, which shall receive contributions under
the Plan in accordance with Article VII of the Plan.
ADMINISTRATIVE EXPENSES
Administrative Expenses incurred in operating the Plan shalt be paid by (check one):
^ The Employer, except as otherwise noted in the Plan.
^ The Participants, except as otherwise noted in the Plan.
2 SPD
7-79
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
Introduction
Your employer (the "Employer") is pleased to sponsor an employee beneft program known'as a "Flexible Benefts Plan" (the
"Plan") for you and your fellow employees. Under federal tax laws, it is also known as a "cafeteria plan". It is so called because
it lets you choose from several different insurance and fringe benefit programs according to your individual needs. The Employer
provides you with the opportunity to use pre-tax dollars to pay for them by entering into a salary redirection arrangement instead
of receiving a corresponding amount of your regular pay. This arrangement helps you because the benefits you elect are
nontaxable; you save Social Security and income taxes on the amount of your salary redirection. Alternatively, your Employer
may allow you to pay for any of the available benefits with after-tax contributions on a salary deduction basis.
This Summary Plan Description ("SPD") describes the basic features of the Plan, how ii operates, and how you can get the
maximum advantage from it. Information relating to the Plan that is specific to your Employer is described in the Plan
Information Summary attached to the front of this SPD. You will be referred to the Plan Information Summary throughout the
SPD. The Plan is also established pursuant to a plan document into which this SPD has been incorporated. If there is a conflict
between the official plan document and the SPD, the plan document will govern.
In some rases, the Employer may adopt a Medical Care andlor Dependent Care Reimbursement Plan. If so, they will be listed in
the Plan Information Summary as "Benefits Provided under the Plan," and the SPD for each Reimbursement Plan adopted by the
Employer will be set forth in Appendix I to this SPD. To the extent that the Employer adopts a Medical Care Reimbursement
Plan as indicated in the Plan Information Summary, a summary of your rights and obligations under HIPAA's privacy rules is
attached to this SPD as Appendix II.
You may also be able to make pre-tax contributions to a Health Savings Account (as defined in Code Section 223) through this
Plan if Health Savings Accounts are identified as an included benefit under "Benefits Provided under the Plan" in the Plan
Information Summary. If Health Savings Accounts are identified as a benefit plan option offered under the Plan, your rights and
obligations in regard to such contributions will be set forth in the Health Savings Account Contribution Appendix attached hereto.
Questions & Answers about the Flexible Benefits Plan
Q-1. What is the purpose of the Plan?
The purpose of the Plan is to allow eligible employees to pay for certain benefts offered under the Plan (called "Benefit
Plans or Policies") with pre-tax dollars called "Pre-tax Contributions". Pre-tax Contributions are described in more detail
in O-8 of this SPD.
O-2. What benefits can I purchase on a pre-tax basis through the Plan?
You will be able to choose to participate in the Plan's various pre-tax options by filling out any required enrollment
form(s) for the component Beneft Plans or Policies offered under the Plan. The complete list of Benefit Plans or
Policies offered under the Plan is located in the Plan Information Summary under "Benefits Offered Under the Plan:'
NOTE: You may only contribute with Pre-tax Contributions towards the cost of Benefit Plans or Policies that cover you,
your legal Spouse, and/or your tax Dependents defined under Internal Revenue Code Section 152. Each Benefit Plan or
Policy may define eligible Dependents more narrowly for purposes of coverage under the particular Benefit Plan or
Policy.
O.3. Who can participate in the Plan?
Each employee of the Employer (or an Affiliated Employer identified in the Plan Information Summary) who satisfies the
eligibility requirements described in the Plan Information Summary and who is eligible to participate in any of the Benefit
Plans or Policies offered under the Plan will be eligible to participate in this Plan as of the date described in the Plan
Information Summary (see O-5 of this SPD for instructions on how to become a Participant). Those employees who
actually participate in the Plan are called "Participants." The terms of eligibility of this Plan do not override the terms of
eligibility of each of the Benefit Plans or Policies offered under the Plan. For the details regarding eligibility provisions,
beneft amounts, and premium schedules for each of the Benefit Plans or Policies, please refer to the plan summary for
each of the Benefit Plans or Policies listed in [he Plan Information Summary.
Only coverage for an Employee and the Employee's Dependents may be paid for under this Plan. A dependent is
defined generally as an individual who would be considered the Employee's spouse under the federal income tax code
or the Employee's tax dependents as defined in Code Section 152; however, for purposes of health benefits and
Dependent Care Reimbursement ("DDC") benefits offered under the Plan, a dependent is defined as (i) for health plan
purposes, as set forth in Code Section 105(b) and (ii) for DDC purposes, as any person who meets the requirements to
be a "qualifying individual" as defined in the DDC component SPD.
O-4. When does my participation in the Plan end?
You continue to participate in the Plan until (i) you elect not to participate in accordance with O-9 of this SPD; (ii) you no
longer satisfy the eligibility requirements described in the Plan Information Summary; (iii) you terminate employment
with the Employer; or (iv) the Plan is terminated or amended to exclude you or the class of employees of which you are
a member. If your employment with the Employer is terminated during the Plan Year or you otherwise cease to be
eligible, your active participation in the Plan will automatically cease, and you will not be able to make any more
SPD
7-S~
Pre-tax Contributions under the Plan. If you are rehired within the same Plan Year or you become eligible again, you
may make new elections, provided that you are rehired or become eligible again more than 30 days aker you terminated
employment or lost eligibility. If you are rehired or again become eligible within 30 days or less, your prior elections will
be reinstated and remain in effect for the remainder of the Plan Year unless you again lose eligibility.
Q-5.
Q-6.
Q-7.
How do I become a Participant?
You become a Participant by signing an individual Salary Redirection Agreement ("SRA") on which you elect one or
more of the Beneft Plans or Policies available under the Plan, as well as agree to a salary redirection to pay for those
benefits so elected. You will be provided an SRA when you first become eligible to participate in this Plan. You must
complete the form and turn it into the Personnel Office during the applicable enrollment period described in O-6 below.
What are the enrollment periods for entering the Plan?
If you are eligible on the effective date of the Plan, you must enroll during the enrollment period immediately preceding
the effective date of the Plan. Otherwise, you must enroll during eitherthe "Initial Enrollment Period" or the "Annual
Enrollment Period". You will be notifed of the dates that each enrollment period. begins and ends in the enrollment
material provided to you prior to each enrollment period. If you make an election during the Initial Enrollment Period,
your participation in this Plan will begin on thelater of your eligibility date described in the Plan Information Summary,
the first pay period coinciding with or next following the date that your election is received by the Plan Administrator (or
its designated claims administrator) or the date coverage under a Benefit Plan or policy that you elect begins. The
effective date of coverage under the applicable Benefit Plan(s) or Policy(ies) is governed by the terms of each Beneft
Plan or Policy, as set forth in the governing documents for each Benefit Plan or Policy. The election that you make
during the Initial Enrollment Period is effective for the remainder of the Plan Year and generally cannot be revoked
during the Plan Year unless you have a Change in Status event as described in Q-9 below. If you do not make an
election during the Initial Enrollment Period, you will be deemed to have elected not to participate in this Plan for the
remainder of the Plan Year. You may, however, be covered by certain Benefit Plans or Policies automatically (and be
required to contribute with pre-tax dollars) even if you fail to make an election. These automatic Benefit Plans or
Policies are called "Default Benefits" and will be identified in the enrollment material that you receive.
The election that you make during the Annual Enrollment Period is effective the first day of the next Plan Year and is
irrevocable for the entire Plan Year unless you have a Change in Status event described in O-9 below. A Participant
who fails to complete,"sign, and fle an SRA during the Annual Enrollment Period as required shall be deemed to have
elected to continue participation in the Plan with the same benefit elections as during the prior Plan Year (adjusted to
reFlect any increase/decrease in applicable premiums), and except for a Change in Status, will not be permitted to
modify his election until the next Annual Enrollment Period. Notwithstanding the foregoing, annual elections for
participation in the Medical Care and Dependent Care Expense Reimbursement Plans, if offered under the Plan, must
be made by submitting an SRA prior to the beginning of each Plan Year -- no deemed elections shall occur with respect
to such benefits.
The Plan Year is generally a 12-month period (except during the initial or last Plan Year of the Plan). The beginning and
ending dates of the Plan Year are described in the Plan Information Summary.
What tax advantages are available through the PIan7
Suppose your monthly gross pay is $2,500 per month and your cost for coverage is $140 per month. Also, suppose
your total withholdings (income tax and Social Security) are 22.65%. After paying for coverage from your after-tax pay,
your take home pay is $1,794. However, under the pre-tax premium plan, you will be considered to have received
$2,360 gross pay rather than $2,500 for tax purposes with $140 contributed for medical coverage. This means your
take home pay will be $1,825 with the pre-tax premium plan rather than $1,794 without it. Thus, you save $31 per
month ($372 per year) by participating in the pre-tax premium plan. The Table below illustrates this savings.
With Cafeteria Plan Without Cafeteria Plan
Q-8.
Gross Monthly Pay $2,500 $2,500
Pre-Tax Coverage Under Plan 140 --
Taxablelncome 2 360 2.500
Estimated Federal Tax (15%) 354 375
FICA Tax 181 191
After-tax Coverage
Take Home Pay
Monthly Savings: $31.00
140
1,825 1,794
How are my contributions under the Benefit Plans or Policies made?
When you become a Participant, your share of the contributions for the elected Beneft Plan or Policy(ies) will be paid
with Pre-tax Contributions elected on the SRA. Pre-tax Contributions are amounts withheld from your gross income
before any applicable federal and state taxes have been deducted (some state tax laws do not recognize Pre-tax
Contributions). In addition, all or a portion of the cost of the Benefit Plans or Policies may, in the Employer's discretion,
be paid with contributions made by the Employer on behalf of each Participant (these are called "Nonelective
Contributions"). The amount of Nonelective Contribution that is applied towards the cost of the Benefit Plan(s) or
SPD
1-8~
Policy(ies) for each Participant and/or level of coverage is subject to the sole discretion of the Employer, and it may be
adjusted upward or downward in the Employer's sole discretion. The Nonelective Contribution amount will be calculated
for each Plan Year in a uniform and nondiscriminatory manner and may be based upon your Dependent status,
commencement or termination date of your employment during the Plan Year, and such other factors that the Employer
deems relevant. In no event will any Nonelective Contribution be disbursed to you in the form of additional, taxable
Compensation except as otherwise provided in the enrollment material. To the extent set forth in the enrollment
material, the Employer may make available a certain amount of Nonelective Contributions and then allow you to
allocate the Nonelective Contributions among the various Benefit Plan(s) or Policy(ies) that you choose (subject to
restrictions described in the enrollment material).
Q-9. Can I ever change my election during the Plan Year?
Generally, you cannot change your election to participate in the Plan or vary the Pre-tax Contribution amounts although
your election will terminate if you are no longer working for the Employer or no longer eligible under the terms of the
Plan. Otherwise, you may change your elections for Pre-Tax Contributions only during the Annual Enrollment Period,
and then, only for the coming Plan Year. There are several important exceptions to this general rule: You may change
or revoke your previous election during the Plan Year if you fle a written request for change with the Plan Administrator
(or its designated claims administrator) within 30 days of any of the following events:
1. Change in Status. If one or more of the following "Changes in Status" occur, you may revoke your old election and
make a new election, provided that both the revocation and new election are on account of and correspond with the
Change in Status (as described below). Those occurrences that qualify as a Change in Status include the events
described below, as well as any other events that the Plan Administrator determines are permitted under
subsequent IRS regulations:
a change in your legal marital status (such as marriage, legal separation, annulment, or divorce or death of
your Spouse);
a change in the number of your tax Dependents (such as the birth of a child, adoption or placement for
adoption of a Dependent, or death of a Dependent);
any of the folowing events that change the employment status of you, your Spouse, or your Dependent that
affect benefit eligibility under a cafeteria plan (including this Plan and the Plan of another employer) or other
employee benefit plan of yours, your Spouse, or your Dependents. Such events include any of the following
changes in employment status: termination or commencement of employment, a strike or lockout, a
commencement of or return from an unpaid leave of absence, a change in worksite, switching from salaried to
hourly-paid, union to non-union, or part-time to full-time; incurring a reduction or increase in hours of
employment; or any other similar change which makes the individual become (or cease to be) eligible for a
particular employee benefit (NOTE: The specific rules governing election changes when you take a leave of
absence are described in 0-13 of this SPD);
an event that causes your Dependent to satisfy or cease to satisfy an eligibility requirement for a particular
benefit (such as attaining a specified age, getting married, or ceasing to be a student);
a change in your, your Spouse's or your Dependent's place of residence
If a Change in Status occurs and you want to make a corresponding election change, you must inform the Plan
Administrator and complete a new election within 30 days from the date of the event. The election change must be
on account of and correspond with the Change in Status event as determined by the Plan Administrator with the
exception of special enrollment resulting from birth, placement for adoption or adoption, all election changes are
prospective.
As a general rule, a desired election change will be found to be consistent with a Change in Status event if the event
affects eligibility for coverage. A Change in Status affects eligibility for coverage if it results in an increase or
decrease in the number of Dependents who may benefit under the plan. In addition, you must also satisfy the
following specific requirements in order to alter your election based on that Change in Status:
- Loss of Dependent Eligibility. For accident and health benefts (e.g., health, dental and vision coverage, and
Medical Care Reimbursement Plan), a special rule governs which types of election changes are consistent with
the Change in Status. For a Change in Status involving your divorce, annulment or legal separation from your
Spouse, the death of your Spouse or your Dependent, or your Dependent ceasing to satisfy the eligibility
requirements for coverage, your election to cancel accident or health benefits for any individual other than your
Spouse involved in the divorce, annulment, or legal separation, your deceased Spouse or Dependent, or your
Dependent that ceased to satisfy the eligibility requirements, would fail to correspond with that Change in
Status. Hence, you may only cancel accident or health coverage for the affected Spouse or Dependent.
Example: Employee Mike is married to Sharon, and they have one child. The employer offers a calendar year
cafeteria plan that allows employees to elect no health coverage, employee-only coverage,
employee-plus-one-Dependent coverage, or family coverage. Before the plan year, Mike elects family
coverage for himself, his wife Sharon, and their child. Mike and Sharon subsequently divorce during the plan
year; Sharon loses eligibility for coverage under the plan, while the child is still eligible for coverage under the
plan. Mike now wishes to cancel his previous election and elect no health coverage. The divorce between Mike
SPD
~-82
and Sharon constitutes a Change in Status. An election to cancel coverage for Sharon is consistent with this
Change in Status. However, an election to cancel coverage for Mike and/or the child is not consistent with this
Change in Status. In contrast, an election to change to employee-plus-one-Dependent coverage would be
consistent with this Change in Status. However, there are instances in which you may be able to increase your
Pre-tax Contributions to pay for COBRA coverage of a Dependent child or yourself.
• Gain of Coverage Eligibildy Under Another Employer's Plan. For a Change in Status in which you, your Spouse,
or your Dependent gain eligibility for coverage under another employer's cafeteria plan (or Benefit Plan or
Policy) as a result of a change in your marital status or a change in your, your Spouse's, or your Dependent's
employment status, your election to cease or decrease coverage for that individual under the Plan would
correspond with that Change in Status only if coverage for that individual becomes effective or is increased
under the other employer's plan.
• Dependent Care Reimbursement Plan eenefRs (if offered under the Plan. See the list of Beneft Plans or
Policies offered under the Plan in the Plan Information Summary). With respect to the Dependent Care
Reimbursement Plan beneft (it offered by the Plan), you may change or terminate your election only if (1) such
change or termination is made on account of and corresponds with a Change in Status that affects eligibility for
coverage under the Plan; or (2) your election change is on account of and corresponds with a Change in Status
that affects the eligibility of Dependent care assistance expenses for the available tax exclusion.
Example: Employee Mike is married to Sharon, and they have a 12 year-old daughter. The employer's plan
offers a Dependent care expense reimbursement program as part of its cafeteria plan. Mike elects to reduce his
salary by $2,000 during a plan year to fund Dependent care coverage for his daughter. In the middle of the
plan year when the daughter turns 13 years old, however, she is no longer eligible to participate in the
Dependent care program. This event constitutes a Change in Status. Mike's election to cancel coverage under
the Dependent care program would be consistent with this Change in Status.
• Group Term Life Insurance, Disabilty Income, or Dismemberment Benefits (if offered under the Plan. See the
list of Beneft Plans or Policies offered under the Plan in the Plan Information Summary). For group term life
insurance, disability income, and accidental death and dismemberment benefits, if you experience any Change
in Status (as described above), you may elect either to increase or decrease coverage.
Example: Employee Mike is married to Sharon, and they have one child. The employer's plan offers a
cafeteria plan which funds group-term life insurance coverage (and other benefits) through salary reduction.
Before the plan year Mike elects $10,000 of group-term life insurance. Mike and Sharon subsequently divorce
during the plan year. The divorce constitutes a Change in Status. An election by Mike either to increase or to
decrease his group-term life insurance coverage would each be consistent with this Change in Status.
2. Special Enrollment Rights. If you, your Spouse, and/or a Dependent are entitled to special enrollment rights under a
Benefit Plan or Policy that is a group health plan, you may change your election to correspond with the special
enrollment right. Thus, for example, if you declined enrollment in medical coverage for yourself or your eligible
Dependents because of outside medical coverage and eligibility for such coverage is subsequently lost due to certain
reasons (i.e., due to legal separation, divorce, death, termination of employment, reduction in hours, or exhaustion of
COBRA period), you may be able to elect medical coverage under the Beneft Plan or Policy for yourself and your
eligible Dependents who lost such coverage. Furthermore, if you have a new Dependent as a result of marriage, birth,
adoption, or placement for adoption, you may also be able to enroll yourself, your Spouse, and your newly acquired
Dependents, provided that you request enrollment within the Election Change Period. An election change that
corresponds with a special enrollment must be prospective, unless the special enrollment is attributable to the birth,
adoption, or placement for adoption of a child, which may be retroactive up to 30 days. Please refer to the group health
plan description for an explanation of special enrollment rights.
Effective April 1, 2009, if you or your eligible Dependent (1) lose coverage under a Medicaid Plan under Title XIX of the
Social Security Act; (2) lose coverage under a State Children's Health Insurance Program (SCRIP) under Title XXI of the
Social Security Act; or (3) become eligible for group health plan premium assistance under Medicaid or SCRIP and you
are entitled to special enrollment rights under a Benefit Plan or Policy that is a group health plan, you may change your
election to correspond with the special enrollment right. Thus, for example, if you declined enrollment in medical
coverage for yourself or your eligible Dependent(s) because of medical coverage under Medicaid or SCRIP and eligibility
for such coverage is subsequently lost, you may be eligible to elect medical coverage under a Beneft Plan or Policy for
yourself and your Dependent(s). You must request an election change to enroll in group plan coverage within 60 days
from the date (1) the coverage terminates under the Medicaid or SCRIP plan or (2) the Employee or dependent child is
determined eligible for state premium assistance. Please refer to the group health plan summary description for an
explanation of special enrollment rights.
3. Certain Judgments, Decrees and Orders. If a judgment, decree or order from a divorce, separation, annulment, or
custody change requires your Dependent child (including a foster child who is your tax Dependent) to be covered under
this Plan, you may change your election to provide coverage for the Dependent child identified in the order. If the order
requires that another individual (such as your former Spouse) cover the Dependent child, and such coverage is actually
provided, you may change your election to revoke coverage for the Dependent child.
4. Entitlement to Medicare or Medicaid. If you, your Spouse, or a Dependent becomes entitled to Medicare or Medicaid,
you may cancel that person's accident or health coverage. Similarly, if you, your Spouse, or a Dependent who has been
entitled to Medicare or Medicaid loses eligibility for such, you may, subject to the terms of the underlying plan, elect to
begin or increase that person's accident or health coverage.
SPD
7-83
5. Change in Cost. If you are notified that the cost of your Benefit Plan or Policy coverage under the Plan significantly
increases or decreases during the Plan Year, you may make certain election changes. If the cost signifcantly
increases, you may choose either to make an increase in your contributions, revoke your election and receive coverage
under another Benefit Plan or Policy that provides similar coverage, or drop coverage altogether if no similar coverage
exists. If the cost significantly decreases, you may revoke your election and elect to receive coverage provided under
the option that decreased in cost. For insignificant increases or decreases in the cost of Benefit Plans or Policies,
however, your Pre-tax Contributions will automatically be adjusted to reflect the minor change in cost. The Plan
Administrator will have final authority to determine whether the requirements of this section are met. (Please note that
none of the above "Change in Cast" exceptions are applicable to a Medical Care Reimbursement Plan, to the extent
offered under the Plan.)
Example: Employee Mike is covered under an indemnity option of his employer's accident and health insurance
coverage. If the cost of this option significantly increases during a period of coverage, the Employee may make a
corresponding increase in his payments or may instead revoke his election and elect coverage under an HMO option.
6. Change in Coverage. If you are notified that your Benefit Plan or Policy coverage under the Plan is significantly
curtailed, you may revoke your election and elect coverage under another Benefit Plan or Policy that provides similar
coverage. If the signifcant curtailment amounts to a complete loss of coverage, you may also drop coverage if no other
similar coverage is available. Further, if the Plan adds or signifcantly improves a benefit option during the Plan Year,
you may revoke your election and elect to receive on a prospective basis coverage provided by the newly added or
significantly improved option, so long as the newly added or significantly improved option provides similar coverage.
Also, you may make an election change that is on account of and corresponds with a change made under another
employer plan (including a plan of the Employer or another employer), so long as: (a) the other employer plan permits
its participants to make an election change permitted under the IRS regulations; or (b) the Plan Year for this Plan is
different from the Plan Year of the other employer plan. Finally, you may change your election to add coverage under
this Plan for yourself, your Spouse, or your Dependent if such individual(s) loses coverage under any group health
coverage sponsored by a governmental or educational institution. The Plan Administrator will have final discretion to
determine whether the requirements of this section are met. (Please note that none of the above "Change in Coverage"
exceptions are applicable to the Medical Care Reimbursement Plan, to the extent offered under the Plan.)
Additionally, your election(s), may be modifed downward during the Plan Year if you are a Key Employee or Highly
Compensated Individual (as defined by the Internal Revenue Code), if necessary to prevent the Plan from becoming
discriminatory within tfie meaning of the federal income tax law.
Q-10. How long will the Plan remain in effect?
Although the Employer expects to maintain the Plan indefinitely, it has the right to modify or terminate the program at
any time for any reason. It is also possible that future changes in state or federal tax laws may require that the Plan be
amended accordingly.
Q-11. What happens if my claim for benefits under this Plan is denied?
This SPD describes the basic features of the Plan. If your claim is for a benefit under one of the component Benefit
Plans or Policies, you will generally proceed under the claims procedures applicable under the component Benefit Plan
or Policy (see the plan summary for each of the Benefit Plans or Policies that you elect). However, if you are denied a
benefit under this Plan, the claims procedure under this Plan will apply. You will be notified if your claim under the Plan
is denied. The notice of denial will be furnished to you within 30 days after receiving your claim. However, if additional
time is needed to process your claim you will be notified before the initial 30-day period has expired. The notice will
explain why an extension is necessary and the date a decision is expected to be rendered. In no event will an extension
go beyond 15 days after the end of the initial 30-day period. The notice of the denial will include the specifc reasons for
the denial and the relevant plan provisions on which the denial was based.
If your claim is denied in whole or in part, you may appeal by requesting a review of the denied claim, as set forth in the
notice of denial, within 180 days after you receive notice of the denial. If there are two levels of appeal (as indicated in
the notice of denial), you will have a reasonable amount of time in which to request a second review and such time
period will be identified in the notice of denial. As part of the appeal process (whether there is one or two appeals), you
or your authorized representative may examine documents, records, and other information relevant to your claim and
submit issues, documents and comments in writing. Within 60 days after the request for review is received, you will be
notified in writing of the decision on review.
The notice of denial will indicate whether there are one or two levels of appeals and will contain the same type of
information provided to you in the first notice of denial. If there are two levels of Plan appeals, the decisions on appeal
will be made within 30 days after the request for each review is received. The Plan Administrator is the claims fiduciary
for making the final decision under the plan.
In the event of your death, your benefciary has the same rights and is subject to the same time limits and other
restrictions that would otherwise apply to you under the claims procedures explained above.
Q-12. What effect will Plan participation have on Social Security and other benefits?
Plan participation will reduce the amount of your taxable compensation. Accordingly, there could be a decrease in your
Social Security benefts and/or other benefits (e.g., pension, disability and life insurance) that are based on taxable
compensation.
SPD
7-84
Q-13. What happens if I take a leave of absence?
(a) If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), to the extent
required by the FMLA, the Employer will continue to maintain your Benefit Plans or Policies providing health
coverage on the same terms and conditions as though you were still active (e.g., the Employer will continue to pay
its share of the contribution to the extent you opt to continue coverage).
(b) Your Employer may elect to continue all coverage for Participants while they are on paid leave (provided
Participants on non-FMIA paid leave are required to continue coverage). If so, you will pay your share of the
contributions by the method normally used during any paid leave (for example, with Pre-tax Contributions if that is
what was used before the FMLA leave began).
(c) In the event of unpaid FMLA leave (or paid leave where coverage is not required to be continued), if you opt to
continue your group health coverage, you may pay your share of the contribution with after-tax dollars while on
leave, or you may be given the option to pre-pay all or a portion of your share of the contribution for the expected
duration of the leave with Pre-tax Contributions from your pre-leave compensation by making a special election to
that effect before the date such compensation would normally be made available to you provided, however, that
pre-payments of Pre-tax Contributions may not be utilized to fund coverage during the next Plan Year, or by other
arrangements agreed upon between you and the Plan Administrator (for example, the Plan Administrator may fund
coverage during the leave and withhold amounts from your compensation upon your return from leave). The
payment options provided by the Employer will be established in accordance with Code Section 125, FMLA and the
Employer's internal policies and procedures regarding leaves of absence. Alternatively, the Employer may require
all Participants to continue coverage during the leave. If so, you may elect to discontinue your share of the required
contributions until you return from leave. Upon return from leave, you will be required to repay the contribution not
paid during the leave in a manner agreed upon with the Administrator.
(d) If your coverage ceases while on FMLA leave (e.g., for non-payment of required contributions), you will be
permitted to re-enter the Plan upon return from such leave on the same basis as you were participating in the Plan
prior to the leave, or as otherwise required by the FMLA. Your coverage under the Benefit Plans or Policies
providing health coverage may be automatically reinstated provided that coverage for Employees on non-FMLA
leave is automatically reinstated upon return trom leave.
(e) The Employer may, on a uniform and consistent basis, continue your group health coverage for the duration of the
leave following your failure to pay the required contribution. Upon return from leave, you will be required to repay
the contribution in a manner agreed upon by you and Employer.
(f) If you are commencing or returning from unpaid FMLA leave, your election under this Plan for Benefit Plans or
Policies providing non-health benefits shall be treated in the same manner that elections for non-health Beneft
Plans or Policies are treated with respect to Participants commencing and returning from unpaid non-FMLA leave.
(g) If you go on an unpaid non-FMLA leave of absence (e.g., personal leave, sick leave, etc.) that does not affect
eligibility in this Plan or a Benefit Plan or Policy offered under this plan, then you will continue to participate and the
contribution due will be paid by pre-payment before going on leave, by after-tax contributions while on leave, or with
catch-up contributions after the leave ends, as may be determined by the Administrator. If you go on an unpaid
leave that affects eligibility under this Plan or a Benefit Plan or Policy, the election change rules in O-9 of this SPD
will apply. The Plan Administrator will have discretion to determine whether taking an unpaid non-FMLA leave of
absence affects eligibility.
Q-t 4. Is there any other information that I should know about the Plan?
Participation in the Plan does not give any Participant the right to be retained in the employ of his or her Employer or
any other right not specifed in the Plan. The Plan Administrator's name, address and telephone number appear in the
Plan Information Summary attached to the front of this SPD. The Plan Administrator has the exclusive right to interpret
the Plan and to decide all matters arising under the Plan, including the right to make determinations of fact, and
construe and interpret possible ambiguities, inconsistencies, or omissions in the Plan and this SPD. Other important
information such as the Plan Number and Plan Sponsor's name and address has also been provided in the Plan
Information Summary.
SPD
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RESOLUTION NO. 2012-
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CHULA VISTA ADOPTING THE CITY OF CHULA VISTA
CAFETERIA BENEFITS PLAN FOR 2012
WHEREAS, the Internal Revenue Code requires that the Section 125 Cafeteria Benefits Plan
offered by the City to its employees be in a written document and that the document be formally
adopted by the City Council on or before the first day of the plan year; and
WHEREAS, in June 1998, the City established its first Section 125 Cafeteria Benefits Plan;
and
WHEREAS, in compliance with Internal Revenue Code §125(d) the City Council annually
adopts a written plan document prior to the first day of the plan year; and
WHEREAS, the first day of the City's plan year is January 1, 2012; and
WHEREAS, this Plan Document lays out how the City offers eligible employees the choice
between cash and certain nontaxable benefits (such as health insurance), thereby allowing employees
to pay for the benefits they choose on a pre-tax basis; and
WHEREAS, the specific health plans offered and their structure are not part of this Cafeteria
Plan Document; and
WHEREAS, they are included in what is known as the Summary Plan Document that was
given to eligible employees as part of their open enrollment materials to assist them in making their
benefit choices; and
WHEREAS, the plans offered and their structure are determined after our broker, Barney
and Bamey, extensively markets and negotiates with providers to provide coverage comparable to
the prior year while keeping the increase in costs to the City and its benefited employees to a
minimum; and
WHEREAS, all employee groups are advised of the offers and the plan structures that will
provide the least increase in premium costs; and
WHEREAS, under current cafeteria plan regulations having an approved written plan is
critical; and
WHEREAS, without a written plan or if the written plan does not comply with applicable
requirements regarding content and timing of adoption, then the plan is not a cafeteria plan and
employees' elections will be taxable; and
WHEREAS, the City has timed its open enrollment period for 2012 to comply with these
regulations and to meet provider cutoff deadlines for enrollment to ensure employees are covered
without interruption; and
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Resolution No. 2012-_
Page 2
WHEREAS, The City's Plan includes the following required information: description of
available benefits, participation rules, election procedures, manner of contributions, maximum
amount of contributions, the plan year, and the plans provisions for complying with flexible spending
arrangements (FBAs).
NOW, THEREFORE, BE IT RESOLVED that the City Council of the City of Chula
Vista does hereby adopt the City of Chula Vista Cafeteria Benefits Plan for 2012.
Presented by
Kelley Bacon
Director of Human Resources
Information Technology Services
and
Approved as to form by
~
Glen R. Googins
City Attorney
7-87