HomeMy WebLinkAbout2012/12/11 Item 16CITY COUNCIL
AGENDA STATEMENT
a ,~
~~ CITY OF
-r- CHUTAVISiA
- ~ DECEMBER 11, 2012, Item
ITEM TITLE:
SUBMITTED BY:
REVIEWED BY:
RESOLUTION ADOPTING THE CITY OF CHULA VISTA
CAFETERIA BENEFITS PLAN FOR 2013
DIRECTOR OF HUMAN RESOURCES & INFORMATION
TECHNOLOGY SE
CITY MANAGER - -
ASSISTANT CITY~GIANAGER ~~
4/STHS VOTE: YES ~ NO ~X
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 Eby 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 2013 plan
year.
ENVIRONMENTAL REVIEW
Staff has reviewed the proposed activity for compliance with the California
Environmental Quality Act (CEQA) and has determined that this proposed activity is not
a "Project" as defined under section 15378 of the State CEQA Guidelines because if will
not result in a physical change to the environment; therefore, pursuant to Section
15060(c)(3) of the State CEQA Guidelines the action proposed is not subject to CEQA.
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, 2013.
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DECEMBER 11, 2012, Item
Page 2 of 3
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.
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 Summazy 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 2013 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. Staff is not independently aware, nor
has staff been informed by any City Councilmember, of any other fact that may, constitute a
basis for a decision maker conflict of interest in this matter.
CURRENT YEAR FISCAL IMPACT
The flex allotment and cafeteria plan change from year to year have been accounted for
in the current fiscal year budget. In fiscal year 2012, the City expended $10.7 million on
these benefits for all funds.
Prepared by: Edath Quichq Benefrts Manager
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DECEMBER 11; 2012, Item
Page 3 of 3
" ONGOING. FISCAL IMPACT
Flex allotment and medical benefits are negotiated with the City's bargaining groups.
Unrepresented employees and elected officials also receive flex allotments. With the
exception of Public Safety, the City shares the cost of health insurance premiums on a
50/50 basis. For Public Safety the City assumes the full cost of the medical premium
increases. The increases in flex benefits reflected on the table below illustrate the increase
in health insurance premiums on an annual basis. The impact to future budgets and the
five-year financial forecast will depend on the outcome of future negotiations with the
City's bargaining groups and changes in health insurance premiums.
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Barxainin8 Unit
2005
2006
2007
2008
2009
2010
2011
2012 2005-2012
% Chavge
Covfidemial $ 8646 $ 9066 $ 9,R6 b 9726 $ 10176 $ .10882 $ 11 48 $ .11936 38.7%
Chda Vista Em to ees Association $ $146 $ 8,566 $ 9 26 $ 9,226 $ 9,676 $ 10382 $ 10,848 $ 11,436 40.4%
Bxecntive $ 11346 $ 11,966 $ 12626 $ 12,626 $ 13,076 $ 13982 $ 1424R $ 14,836 2R.5 %
Mid Manor ecs andPmfessionaLc $. . 9,146 S 9566 $ 10226 $ 10226 $ . 10,676 $ 11382 $ 11,848 $ 72,436 360%
Senior Mavaee~ $ 70146 $ IOS66 $ 17 26 $ 11226 $ 11676 $ 12,382 $ 12,848. $ 13936 32,4%
Western Couned of En "nee[s $ 9,146 $ 11966 $ L2626 $ 12,626 $ 10,676 $ 11383 $ 11,848 $ 12936 360%
Mawr&Cowcd $ 11546 $ 11966 $ 12626 $ 12,626 $ 73D'16 $ 13.7ffi $ 14248 3 14,836 285%
Publie Safety Police/Fue ~ $ 9240 $ 9572 $ 10,832 $ 70,752 $. . 11,652 $ 12y56 $ 13,888 $ 15,112 63.5%
~ Poblic Safety employxs do no[ arrive FLEX Albtmrn[s, but have neyq[iued fu0 payment of mmrans premiums. Amounts sM1mvn M1aw been calwLUed bored on [M1e evere~ ofan
Employee+Family ms[for Kaiser and AnnaM1Ulth premiums and denial premiums paidmfull by the City.
"'ATTACHMENTS
Attachment A -2013 City of Chula Vista Cafeteria Benefits Plan
Prepared by: Edith Qutcho, Benefits Manager
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~~cr,
~~
CHULA VISfA
CAFETERIA BENEFITS PLAN
' FOR
` THE CITY OF CHULA VISTA
, Amended and Restated as of January 1, 2013
Established June 1998
II Human Resources and
Information Technology Services Departments
City of Chula Vista
'16-4
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 hereby
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, 2013
C. ELIGIBILITY REQUIREMENTS FUR PARTIGIPA I wN
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. Part-time benefited employees
must be authorized to work at least half-
- time or 40 hours biweekly.
Length of Service:
First day of employment in a benefited
status.
D. PLAN YEAR The current plan year will begin on
January 1, 2013 and end on December
31, 2013.
2
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E. EMPLOYER CONTRIBUTIONS
Non-Elective Contributions
Non-Elective Contributions
Safe
Elective Contributions (Salary
Reduction):
Flexible Allotment.
The maximum amount available to each
Participant for the purchase of certain ~ ,
elected benefits (Group Medical
Insurance, Group Dental Insurance,
Group Vision, Dental/Medicat/Vision and
DependenUChild Care Reimbursement
and Cash Payment Option) with non-
elective contributions will be:
Confidential ---$12,386
CVEA $11,886
Executive $15,162
MM,MMCF,MMUC $12,762
PROF,PRCF,PRUC $12,762
Senior Managers $13,762
_
WCE $12,762
Mayor/Council. $15,162
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 HMO
plans: For employees enrolled in a non-
Kaiser PPO plan, the City will pay an
amount equal to the City's share for the
non-Kaiser HMO premium..
For dental coverage the City will pay an
' amount equal to the pre-paid dehtal
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 of non-elective contributions. Ah
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.
1. 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. Dental/Medical/Vision
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 Vision 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: $2,500 from all
sources per Plan Year.
Recordkeeper: WageWorks
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5. Dependent/Child Care The terms conditions and Limitations for the
Reimbursement Account Dependent/ 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: WageWorks
6. Cash Payment Option Any Flex Plan allotment remaining after electing
mandatory medical coverage may be allotted to
this taxable option.
7. 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
AFLAC Critical Illness 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
8. Employee Assistance This free and confidential service is available to
Program benefited employees and their household
members.
The terms condition and limitations for the EAP
program will be set forth in Section IX of the
Plan Document.
Administered by: Aetna Resources for Living
(dba Horizon Health .EAP -Behavioral Services)
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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
~lifornia. Should any provision be determined to be void, invalid, or,
~~,~taforceable by any court of competent jurisdiction, the Plan will continue to
,~a~~te, and fior purposes of the jurisdiction of-the court only, will be deemed
Sot to include the provision determined to be void.
Ths'Plan is hereby adopted the 11th day of December, 2012.
. ~ By:
Title: City Mayor
THIS DOCUMENT IS NOT COMPLETE WITHOUT PAGES 7 THROUGH 23
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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 11
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 elect or 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)
(b)
(c)
(d)
(e)
(fl
(g)
(h)
Group Medical Insurance
Dependent/Child Care Reimbursement Account
Dental/Medical/Vision Reimbursement Account
Cash Compensation (Post-Tax)
Health Premiums for Non-Tax Qualified Dependents (Post-
Tax)
Vision Insurance
Dental Insurance
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/Medical/Vision 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 of Life Partner)
(c) Child of the employee, spouse or Life Partnerwho is under 26 years of
age;
And
(d) 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
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
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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 elections 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 Employer, provided the new hire makes such
request within 30 days after the date of employment, or
(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.
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"`Flex Plan Year" means the twelve-month period commencing on January. 1 and
ending on December 315x:
"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 (T8) 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-
e 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.
"Participant" means all Eligible Employees
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"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 hot 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: Ah eligible Employee may enroll (or re-enroll) in the Plan by
submitting to the Employer, during an enrollment period, an Election ,Form
t 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
PlarnYear, 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 extenYsuch .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
declined coverage under the Plan; a new dependent may also justify a special
enrollment period.
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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 AND MEDICAL 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 expiratidn 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 Pian 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
e 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) Change 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
14
16-17
.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; and
(5) Resident change of Employee, spouse or Dependent, affecting the
Employee's eligibility for coverage.
(b) Special HIPAA Enrollment Rights. If a Participant or a Participant's
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 termsof the health insurance plan.
(c) Certain Judgments, Decrees or Orders. If a judgment, decree or order
resulting from a divorce, legal separation, annulment or change in legal
custody. (including aqualified 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 or a 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 and Medical Leave Act. If an Employee is taking leave under the '
,rules of the Family and Medical Leave Act, the Employee may revoke
previous elections and re-elect benefits upon return. to work.
4.03 OTHER EXCEPTIONS TO THE IRREVOCABILITY. OF ELECTIONS.
Other exceptions to the irrevocability of election requirement permit mid-year
• election changes and apply to all qualified benefits except -for
Dental/Medical/Vision 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 behefit 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
15 ..
16- 18
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 urider another benefit
package option providing similar coverage, or drop coverage if
no similar benefit package option is available.
(c) Addition or Significant 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 Employer'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 df
spouse/dependent's plan or by the spouse/dependent's employer, or (Z}
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 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.
46
16-19
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 accordance 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 shalF be as specifically described in the
Policy identified in the Adoption Agreement.
5,05 COBRA: To the extent required by Section 49806 of the Code and Sections
601 through 607 of ERISA, Participants and Dependents shalt 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
17
16-20
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
DENTAL/MEDICALNISION REIMBURSEMENT PLAN
6.01 The Plan Document for this option is included in the attached Exhibit A and is
.incorporated by reference.
18
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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, CRITICAL ILLNESS INSURANCE
8.01 The Plan Document for these options is included in the attached Exhibit B
and is incorporated by reference.
SECTION IX
EMPLOYEE ASSISTANCE PROGRAM
9.01 The Plan Document for this benefit is included in the attached Exhibit C and is
incorporated by reference.
SECTION X
AMENDMENT AND TERMINATION
10.01 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.
19
16-22
10.02 TERMINATION: The Employer shall have the right at any time to terminate
this Plan, provided that such termination shall not eliminate any obligatiohs
of the Employer which therefore have arise under the Plan.
SECTION XI
ADMINISTRATION
11.01 NAMED FIDUCIARIES: The Administrator shall be the fiduciary of the Plan.
11.02 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
DepehdenUChild 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.
11.03 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
behefits), 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.
20
16-23
11.04 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.
11.05 LIABILITY OF ADMINISTRATOR: Except. as prohibited by law, the
' Administrator shall not be liable personally for any loss or damage or
depreciatiori 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 Admihistrator from any and
all claims, losses, damages, expenses, (including reasenable 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.
11.06 DELEGATION OF RESPONSIBILITY: The Administrator shall have the
.authority to delegate, from time to dime, 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
periodicaAy to the Administrator concerning the discharge of the delegated
responsibilities.
11.07 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 Pfan shall furnish
to the Administrator such information as may be necessary to implement this
provision.
1.1.08 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.
21
16-24
11.09 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.
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.
22
16-25
SECTION XII
MISCELLANEOUS PROVISIONS
12.01 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.
12.02 NON-ASSIGNABILITY: No benefit under the Plan shall be liable 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. _
12.03 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.
12.04 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.
12.05 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
provisions of ERISA will not apply to this Plan if the Plan is exempt from
coverage under ERISA. Should any provisions tie 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.
23
16-26
EXHIBIT A
motif l~
r~~
cm of
CHUW VISfA
DENTAL/MEDICAL/VISION
AND
DEPENDENT/CHILD CARE
REIMBURSEMENT ACCOUNTS
PLAN DOCUMENT
Amended and Restated as of January:1, 2013
Established June 1998
Human Resources and
Information Technology Services Departments
City of Chula Vista
16-27
Table of Contents
P REAIVIB L E ................................................................................................................................... 4
ARTICLE I -DEFINITIONS.......: ....................................................................................:..........5
1.01 Affiliated Employer ........................................................................ .....................5
1.02 After-Tax Contributions ................................................................ ..................... 5
1.03 Anniversary Date ............................................................................ .....................5
1.04 Benefit Plan Option(s) .................................................................... ..................... 5
1.05 Board of Directors .......................................................................... ..................... 5
1.06 Change in Status ............................................................................. .....................5
1.07 Cade ................................................................................................. ..................... 5
1.08 Compensation .................................................................................. .....................5
1.09 Dependent ........................................................................................ .....................5
1.10 Dependent Care Spending Account .............................................. ..................... 5
1.11 '--
Earned Income ...:......................................:....:................................ -
..................... ~
1.12 Effective Date ...................................:.............................................. .....................6
1.13 Eligible Employment Related Espenses ........................................ ..................... 6
1.14 Eligible Medical Expenses ..........................:................................... ..................... 6
1.15 Employee .......................................................................................... .....................6
1.16 Employer .......................................................................................... .....................6
1.17 Flexible Spending Account(s) ......................................................... .....................7
1.18 Health Care Spending Account ..................................................... ..................... 7
1.19 Highly Compensated Individual .................................................... .......:............. 7
1.20 Key Employee .................................................................................. .....................7
1.21 Non-elective Contribution(s) .......................................................... ....:................7
1.22 Participant ....................................................................................... .....................7
1.23 Plan ................................................................................................... .....................7
1.24 Plan Administrator ......................................................................... .....................8
1.25 Plan Year ......................................................................................... ............:........8
1.26 Pretax Contribution(s) .............................................:..................... ............::....... 8
.1.27 Qualified Benefit ............................................................................. .....................8
1.28 Qualifying Individual ...................................................................... .....................8
1.29 Qualifying Services ....................:...:..............................................: .......:.............. 8
1.30 Salary Reduction Agreemeot ........................................................ ......................8
1.31 Spouse ............................................................................................. ...................... 8
1.32 Summary Plan Description or SPD .............................................. ......................9
1.33 Student ...................................::....................................................... ......................9
ARTICLE II --ELIGIBILITY AND PARTICIPATION .................................... ....................10
2.01 Eligibility to Participate ................................................................ .................... 10
2.02 Termination of Participation ........................................................ .................... 10
2.03 Eligibility to Participate in Flexible Spendin Acco _ ~,_;,_.. 10
2.04 Qualifying Leave Under Family eave Act ................................. .................... 10
2.05 Non-FIVILA Leave .........................................:................................ .................... 10
ARTICLE III -- ELECTIONS ................................................................................ ....................11
3.01 Election of Contributions .............................................................. .................... l l
3.02 Initial Election Period .................................................................... .................... 11
3.03 Annual Election Period ................................................................. .................... 11
3.04 Change of Elections ....................................................................... ....................12
3.05 Impact of Termination of Employment on Election .........:......... ....................12
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16-28
ARTICLE IV -- PREbHIM PAYbIENTS AND CREDITS AND DEBITS TO
ACCOUNTS ....................................................................................................................13
4.01 Source of Benefit Funding ................................................................................. 13
4.02 Reduction of Certain Elections to Prevent Discrimination ............................ 13
ARTICLE V -- BENEFITS
14
5.01 Qualified BeneSts ............................................................................................... 14
5.02 Cash Benefit ........................................................................................................ 14
ARTICLE VI -- REIMBURSEMENTS ..................................................................................... 15
6.01 Health Care Spending Account Reimbursement ............................................ IS
6.02 Dependent Care Spending Account Reimbursement ..................................... IS
6.03 Receiving Reimbursement ................................................................................ 16
6.04 Substantiation of Expenses ............................................................................... 16
6.05 Repayment of Escess Reimbursements ........................................................... 16
6.06 Reimbursement Following Cessation of Participation ................................... 16
6.07 Coordination of Benefits Under the Health Care Spending Accouut ........... 16
6.08 Disbursement Reports ..............................................................:........................ 17
6.09 Timing of Reimbursements ............................................................................... 17
6.10 Statements ........................................................................................................... 17
6.11 Post-Mortem Payments ..................................................:.................................. 17
6.12. Non-Alienation of Benefits ................................................................................ 17
6.13 Mental or Physical Incompetency .................................................................... 17
6.14 Inability to Locate Payee ................................................................................... 17
6.15 Tax Effects of Reimbursements ........................................................................ 17
6.16 Forfeiture of Unclaimed Reimbursement Account Benefits :.............:........... 18
ARTICLE VII -- PLAN ADMINISTRATION ........................................°--------°----------.----.----- 7 9
7.01 Allocation of Authority .......................................................... ............................ l9
7.02 Provision for Third Party Adminstrators ............................ ............................ 19
7.03 Fiduciary Liability ................................................................. ............................ 19
7.04 Compensation of Plan Administrator .................................. ............................20
7.05 Bonding ......................................................................:............ .....................::.....20
7.06 Payment of Administrative Expenses ................................... ............:............... 20
7.07 -Funding Policy ........................................................................ ............................20
ARTICLE VHI -- FUNDING AGENT ..........................................................................:........... 21
ARTICLE LY -- CLAIMS PROCEDURES ...............................................................................22
ARTICLE X-- AMENDb1ENT OR TERbHNATION OF PLAN ..........................................23
10.01 Permanency ..............:......................................................................................... 23
10.02 Employer's Right to Amend .............................................................................. 23
10.03 Employer's Right to Terminate ........................................................................ 23
10.04 Determination of Effective Date of Amendment or Termiaation .................. 23
ARTICLE XI -- GENERAL PROVISIONS .............................................................................. 24
11.01 Not an Employment Contract ......................:.................................................... 24
11.02 Applicable Laws ................................................................................................. 24
11.03 Requirement for Proper Forms ........................................................................ 24
11.04 Multiple Functions ............................................................................................. 24
11.05 Tas Effects .......................................................................................................... 24
11.06 Gender and Number .......................................................................................... 24
11.07 Headings ............................................................................................................. 24
11.08 Incorporation by Reference .............................................................................. 24
11.09 Severability ......................................................................................................... 24
-ii_
16-29
11.10 Effect of Mistake ................................................................................................ 24
ARTICLE XH -- CONTINUATION COVERAGE ..................................................................26
ARTICLE XHI- HH'AA PRNACY AND SECURITY .........................................................27
13.01 Scope and Purpose ..................................................................... .................:......27
13.02 Effective Date ............................................................................. ........................27
13.03 Use and Disclosure of PHI ......................................................... ........................27
13.04 Conditions Imposed on Employer ............................................ ........................27
13.05 Designated Employees Who May Receive PHI ....................... ...........:............ 28
13.06 Restrictions on Employee with Access to PHI ......................... ........................ 28
13.07 Policies and Procedures ............................................................. ........................28
13.08 Organized Health Care Arrangement ....................................: :.......................28
13.09 Privacy Official .......................................................................... ........................28
13.10 Noncompliance ........................................................................... ........................29
13.11 Definitions ................................................................................... ........................29
13.12 Interpretation and Limited Applicability ................................ ........................29
13.13 Services Performed for the Employer ...................................:. ........................29
13.14 Security of Electronic PHI ........................................................ ........................ 30
Ill -
16-30
PREAMBLE
Effective prior to 1991 (and as Amended and Restated on January 1, 2013), the 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 the 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 Account ("HCSA"), is intended to qualify as a Code § 105 self-insured
medical expense reimbursement plan, and that the benefits provided under the HCSA be eligible for
exclusion from the Participant's income for federal income tax purposes under Code § 105(b). The
Dependent Care Spending Account (``DCSA"), is intended to qualify as a Code § 129 dependent care
assistance plan and that the benefits provided under the DCSA 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 I29 of the Code.
-4-
16-31
CITY OF CHULA VISTA
CAFETERIA 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).
1.02 "After-taz Contribution(s)" means amounts withheld from an Employee's Compensation
pursuant to a Salary Reduction Agreement or Election Form after all applicable state and federal
taxes have been deducted. Such amounts aze 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 Yeaz. `
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 the Board of Directors or other governing body of the Employer
(the `'Board"). The Board of .Directors, upon adoption of this Plan, appoints the Plan
Administrator to act on the Employer's behalf in all matters regazding the Plan.
1.06 "Change in Status" means any of the events described in the 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-yeaz. 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 "Cade" 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; however, for health plan purposes (including any applicable
Beneft Plan Option(s) and the Health Care .Spending Account), a Dependent is defined as set
forth in Code Section 105(b); and for Dependent Care Spending Account purposes (if offered
under the Plan), a Dependent also means an individual described in Code Section 21(e)(5) (e.g.,
Dependent of the parent with custody for the greatest portion of the yeaz).
1.10 "Dependent Care Spending Account" shall have the meaning assigned to it by Section 6.02 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 includible in gross income for the taxable yeaz. Earned Income does not include any amounts
.~_
16-32
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 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 expenses that would be considered to _
be Employment-Related Expenses under Code § 21(b)(2) (relating to expenses for household and
dependent care services necessary for gainful employment) if paid for by the Employee to
provide Qualifying Services other than amounts paid to:
', (a) an individual with respect to whom a Dependent deduction is allowable under Code §
15.1(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
whichYhe expenses were incurred.
'1.14 "Eligible Medical Expenses".means those expenses that are eligible for reimbursement under ; ' ,
the HCSA 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 HCSA and during the Pl'ah Yeaz "
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 this Plan, the following
expenses aze not considered Eligible Medical Expenses even if they otherwise constitute medical
care under Code § 213(d):
i) Expenses for qualified long term care services (as defined in Code § 7702B); and
ii) Expenses for health insurance premiums; and
iii) Effective January 1, 2011, expenses for a medicine or drug unless'such medicine or drug is
a prescribed drug (determined without regard to whether such drug is available without a
prescription) or is insulin.
For purposes of this Plan, an expense is "incurred" when the Participant or beneficiary is
furnished the medical Gaze 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 and
who is on the Employer's W-2 payroll, but does not include ahy of the following: (a) any leased
employee (including, but not limited to, those individuals defined in Code § 414(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, whether or
not any such persons aze on the Employer's W-2 payroll; and (d) any individual who perfoims
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.
1.16 "Employer" means City of Chula Vista ,and any Affiliated Employer who adopts the Plan
pursuant to authorization provided by the Employer. Notwithstanding the previous sentence
6-
16-33
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 who adopt the Plan shall be bound by the Plan as adopted and subsequently amended
unless they clearly withdraw from participation herein. Affiliated Employers who have adopted
the Plan are set forth in the Summary Plan Description.
1.17 "Fle%ible Spending Account(s)" shall be the funding mechanism by which amounts are
withheld from an Employee's Compensation and retained for future Health Care Spending
Account Payments (the "HCSA',') (as defined ih Section 1.18 herein). and Dependent Care
Spending Account Payments (the "DCSA")(as defined in Section 1.10 herein) to the 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 such Account(s) shall be of a
memorandum nature, maintainedby 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). ""'
1.18 "Health Care Spending Account" shall have the meaning assigned to it by Section 6.01 of the
Plana
1.19 "Highly Compensated Individual" means an individual defined under Code § 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 § 125(b)(2),
as amended.
1.21 "Nbu-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
her Dependents, if applicable, under one or more of the Benefit Plan Option(s) offered under the
Plan. The amount of Employer contribution that is applied towazds the cost of the Benefit Plan
Option(s) for each Participant and/or level of coverage shall be subject to the sole discretidn of
the Employer and may be adjusted upwazd or downward at any time in the 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 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 enrollmentmaterial, the Employer may make Non-elective Contributions 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.
1.22 "Participant" means an Employee who becomes a Participant pursuant to Article II.
1.23 "Plan" means this Cafeteria~Plan as set forth herein.
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t6-34
1.24 "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:
1.25 "Plan Year" shall be the period of coverage set forth in the Summary Plan Description
1.26 "Pretax Contribution(s)" means any amount withheld from the Employee's Compensation
pursuant to a Salary Reduction Agreement or Election Form before any applicable state and
federal taxes have been deducted. The amounts are withheld for purposes of purchasing one or
more of the Benefit Plan Options available under the plan. This amount shall not exceed. the
premiums orcontributions 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).
1.27 "Qualified Benefit" means any benefit excluded from the Employee's taxable income under
Chapter 1 of the Code other than Sections 106(6), 117, 124, 127, or 132 and any other benefit
permitted by the Income Tax Regulations (e.g., any group-term life insurance coverage that is
includable in gross income by virtue of exceeding the dollaz limitation on nontaxable coverage
under Code § 79). Notwithstanding the previous sentence, long term care insurance is not a
"Qualified Benefit "
1.28 "Qualifying Individual" means an individual defined as a "Qualifying Individual" in the
Summary Plan Description.
1.29 "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 wfio is,
under age 13, or (2) the caze 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 6
individuals not residing at the facility) the center must comply with all applicable state and
local laws and regulations. `
.1.30 "Salary Reduction Agreement" 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 Plan
Options with Pretax or After-tax Contributions (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 Salary Reduction Agreement or Election Form may be
maintained on an electronic database in accordance with all applicable federal and/or state laws.
1.31 "Spouse" means an individual who is legally marred to a Participant (and who is treated as a,
Spouse under the Code), ,but for purposes of the Dependent Care Spending Account 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
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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
. 1.32 "Summary Plan Description" or "SPD" means the Cafeteria Plan SPD and all appendices
incorporated into and made a part of the 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. .
1.33 "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.
9
. 16=36
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 the Eligibility Date set forth in the SPD.
Eligibility to participates in this Plan means only that the Eligible Employee is entitled to
contribute his share of the cost of applicable Benefit Plan Options for which he is eligible with
Pretax Contributions. The provisions of this Article are not intended to override any eligibility
requirement(s) or waiting period(s) specified in the applicable Benefit Plan Option(s) and the
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 Termination of Participafion. Participation shall tenriinate on the earliest of the dates set forth
in the SPD.
2.03 Eligibility,to Participate in Flexible Spending Accounts. Each Employee who satisfies the
eligibility requirements set forth in the SPD shall be eligible to participate in the Flexible,
Spending Accounts, if adopted by the Employer, on the applicable Eligibility Date set forth in the
SPD.
2.04 Qualifying Leave Under Family Leave Act. 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 Benefits Package Options that provide health coverage (including
HCSA'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 leaue 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 § 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 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 basis 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 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.
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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 emolhnent material, may allow the Participants to allocate his allotted share
of Non-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-£o become a Participant in
this Plan as of the Effective Date must complete, sign and file a Salary Reduction
Agreement or Election Form with the Plan Administrator (or its designated Third Party
Administrator as set forth on the Salary Reduction Agreement or Election Form) 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 Salary Reduction Agreement or Election
Form shall be effective, subject to Sections 3.04 and 3.05, for the Plan Yeaz 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 Salary Reduction Agreement or Election
Form with the Plan Administrator (or its designated Third Party Administrator as set'forth
on the Salary Reduction Agreement or Election Form) during the initial Election Period set
forth in the SPD or the emollment material. Participation will commence under this Plan as
set forth.in the SPD. Coverage under the component Benefit Plan Options will 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 or Election Form in accordance with pazagraph (a) or (b) above
during an initial election period may became a Participant on a later date ih 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 notified, 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 on which 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
ll-
16-38
` forth in the SPD. The consequences of failing to make an election during the Arinual Election
Period will be set forth in the SPD.
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 (e.g., election changes will become effective no eazlier 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. 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 or Cessation of Eligibility. Termination
' of employment or cessation of eligibility shall automatically revoke any Salary Reduction
Agreement or Election Form. 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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` 1b-39
ARTICLE IV
PREMIUM PAYMENTS AND CREDITS 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-elective
Contributions provided by the Employer. The required contributions for each Benefit Plan
Option offered under the plan shall be made known to Employees in enrollment materials. Pretax
or After-tax Contributions (as elected by the Employee on the Salary Reduction Ageement or
Election Form 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.
4.02 Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator
determines, before or during any Plan Yeaz, 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 Individuals, the Plan Administrator shall take such
action(s) as he deems appropriate, under rules uniformly applicable to similazly 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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16-40
ARTICLE V
BENEFITS
5.01 Qualified Benefits. 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 SPD.
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 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 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
REIMBURSEMENTS
6.01 Health Care Spending Account Reimbursement. Each Participant's HCSA will be credited
with amounts withheld from the Participant's Compensation and any Non-elective Contributions
allocated thereto by the Employer or where applicable, the Participant. The Account will be
debited for health caze reimbursements disbursed to the Participant in accordance with this.
Article VI. The entire amount elected by the Participant on the Salary Reduction Agreement or
~_ Election Form as an annual amount for the Plan Yeaz for health care reimbursement less any
health care reimbursements already disbursed to the participant for Expenses incurred during the
Plan Year shall be available to the Participant at any time during the Plan Year without regard to
the balance in the HCSA (provided that the periodic contributions have been made). Thus, the
maximum amount of health care reimbursement at any particular time during thePlah Yeaz will
not be related to the amount that a Participant has had credited to his HCSA. 1n no event will the
amount of health care reimbursements in any Plan Year exceed the arihual amount specified for
the Plan Year in the Salary Reduction Agreement or Election Form for health caze
reimbursement.- Ariy amount credited to the HCSA shall be forfeited by the Participant and
restored to the Employer if it has not been applied to provide health caze reimbursement within
the run out period set forth iri the SPD. Amounts so forfeited shall be used in a manner that is
'permitted within the applicable Department of Labor or Internal Revenue Service regulations.
The maximum annual reimbursement under the HCSA shall beset forth in the SPD. The
Employer.may establish a minimum annual reimbursement amount as set forth in the SPD,
.The Employer has established a Grace Period following the. end of the Plan Year during which
amounts unused as of the 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 two (2)
months and fifteen (15) days followingYhe end of the Plan Yeaz. The Employer has established a
Run-out Period following the end of the Grace Period. 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 shall be forfeited.
6.02 Dependent Care Spending Account Reimbursement. Each Participant's DCSA will• be
credited with amounts withheld from the Participant's Compensation and any Non-elective
Contributions allocated thereto by the Employer or where applicable, the 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 that
amount of reimbursable claims at any time during the Plan Yeaz, the excess part of the claim will
. be carried over into following months within the same Plan year, to be paid out as the DCSA
- balance becomes adequate. In no event will. the amount of dependent care reimbursements
exceed the amount credited to the DCSA. Any amount allocated to the DCSA shall be forfeited
by the Participant and restored to the Employer if it has not been applied to provide dependent
care reimbursement far the Plan Year within. the Run-Out (Claim-It-By) 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 DCSA shall be set forth in the SPD.
The Employer may establish a minimum annual reimbursement amount as set forth in the SPD.
-15_
16-42
The Employer has established a Grace Period following the end of the Plan Yeaz during which
amounts unused as of the end of the Plan Year may be used to reimburse Eligible Employment
Related Expenses incurred during the Grace Period. In no event can the Grace Period exceed two
(2).months and fifteen (15) days following the end of the Plan Year. The Employer may establish
a Run-Out Period following the end of the Plan Year. All amounts allocated to the DCSA that
are not used to reimburse Eligible Employment Related Expenses incurred during the Plan year
and/or the Grace Period shall be forfeited.
6.03 Receiving Reimbursement. Payment shall be made to the Participant in cash as reimbursement
for Eligible Medical Expenses incurred by the Participant or his Dependents or Eligible
Employment-Related .Expenses incurred by the Participant while he is a Participant during the
-Plan' Year for which the Participant's election is effective, provided that the substantiation
-requirements of Section-6:04 herein aze satisfied. if applicable, however, the Employer. may offer
to have the Participant choose to make payment for Eligible Medical Expenses with an electronic
payment card arrangement. The terms of the 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
of as otherwise requested by the Plan Administrator (or its designee).
6.05 Repayment of Excess Reimbursements. If, as of the end of the any Plan Year, it is determined
that a Participant has received payments under this Plan 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 Participation. Participants in the HCSA may submit
claims fot reimbursement for Eligible Medical Expenses incurred during the Plan Year and
before the date of participation in the Plan ceases.so long as the claim is submitted prior to the
end of the run out period set forth in the SPD. Unless a continuation coverage 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
DCSA may submit claims for reimbursement for Eligible Employment-Related Expenses
` incurred during the Plan Year and before the date of participation in the DCSA ceases so long as
the claim is submitted prior to the end of the run out period set forth in the SPD. If provided
under the DCSA, however, and as set forth in the SPD, Participants may submit claims for
reimbursement for Eligible Employment-Related Expenses incurred during the Plan Year at any
time until the last day of the run out. period after the end of the Plan Year for which the election
had been in effect, and to receive reimbursement hereunder. Any unused reimbursement benefits
' at the expiration of the Plan Year (as set forth in the SPD) for the HCSA or DCSA shall be treated
in accordance with Section 6.01.
' 6.07 Coordination of Benefits Under the Health Care Spending Account. The HCSA is intended ~
to pay benefits solely for otherwise unreimbursed medical expenses, Accordingly, it shall not be
16
= ~ 16-43
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 Disbursement Reports. The Plan Administrator, shall issue directions to the Employer
concerning all benefits that are to be paid from the Employer's general assets pursuant to the
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 furnish each Participant with a statement, showing the amounts paid or expenses
incurred by the Employer in providing reimbursements under the HCSA and/or DCSA.
6.11 Post-Morfem Payments. Any benefit payable under the HCSA or DCSA 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 aze determined, without liability for any interest thereon.
6.12 Non-Alienation. of BeneSts. Except as expressly provided by the 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.
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 that a guazdian, conservator or other person
. legally vested with the care of his estate has beeri appointed.
6.14 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 he 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 after a reasonable time after the date any
such payment first became due.
6.15 Tas Effects of Reimbursements. Neither the 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 caze assistance plan under
Code § 129.
_t~-
16-44
6.16 Forfeiture of Unclaimed Reimbursement Account Benefits. Any HCSA or DCSA
reimbursement benefit payments that are unclaimed (e.g., un-cashed 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.
18-
16-45
ARTICLE VII
PLAN ADMINISTRATION
7:01 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. All determinations of the Plan Administrator with respect to any matter hereunder shall be
conclusive and binding on al1'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 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 benefits which shall be payable to any person in accordance
' with the 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 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 identified in the SPD;
(f), To keep records of all acts and determinations, and to keep all such records, books of
account, 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.
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
shall remain the obligation of the Employer.
'7.03 Fiduciary Liability. To the extent permitted by law, the Plan Administrator shall not incur any
liability for any acts or for failure to act except for their own willful misconduct or willful breach
of this Plan.
19-
16-46
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 of this Plan.
7.06 Payment of Administrative Expenses. 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
.adjustments 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 by 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 not be
Limited to, losses or obligations, which pertain to the fallowing:
(a) Once insurance is applied for or obtained, the Employer will not be liable for any loss
which may result from the failure to pay premiums to the extent premium notices aze not
received by,the Employer;
' (b) To the extent premium notices are aeceived 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 other 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. In 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
e this plan are not enough to provide for an insurance premium but will not be,liable for any
failure to make such noti$cation;
(d) When 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.
-20-
16-47
ARTICLE VIII ,
FUNDING AGF~NT
• The :Plan shall be funded with amounts withheld from Compensation pursuant to Salary Reduction
Agreements or Election Forms, and/oc Non-elective Contributions provided by the Employer, if any. The
" Employer will apply all such amounts,' without regazd to their source, to pay for the welfaze benefits
provided herein as soon as administratively feasible and shall comply with all applicable regulations.
- zt
16-48
' ARTICLE IX
• 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 pretax benefits available under this Plan (e.g., such as a determination of: a
Change in Status; change in costs or coverage; or eligibility and participation matters under this Cafeteria
plan document) and to the extent offered under the Plan, claims for benefits under the Flexible Spending
Accounts.'
ARTICLE X
AIVIENDD/ENT OR TERbIINATION OF PLAN
10.01 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 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 bene5ts.
10.02 ,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 Boazd 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 Option shall be amended in accordance with the terms"specified therein, or, if no
amendment procedure is prescribed, in accordance with this section. Any amendment made by
the Employer shall be deemed approved and adopted by any Affiliated Employer.
10.03 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 isaccordance
with its normal procedures for transacting business. Affiliated Employers may withdraw from
participation in the Plan, but may not terminate the Plan.
10.04 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.
_23_
16-50
ARTICLE 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.OA Multiple Functions. Any person or group of persons may serve in more than one fiduciary
capacity with respect to the Plan.
11A5 Tas Effects. Neither the Employer, nor the Plan Administrator makes any warranty or other
representation as to whether any Pretax Contributions 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 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 operate as a
"cafeteria plan" under Code § 125.
11.06 Gender and Number. Masculine pronouns include the feminine as well as the neuter genders,
and the singular shall include the plwal, unless indicated otherwise by the context.
11.07 Headings. The Article and Section headings contained herein aze for convenience of reference
only, and shall not be construed as defining or limiting the matter contained thereunder.
11.08 Incorporation by Reference. The actual terms and conditions of the separate component
.Benefit Plan Options offered under this Plan are contained in separate, written documents
governing each respective benefit, and shall govern is 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. In addition, the SPD for this Plan contains many of the actual terms and
conditions of this Plan. To that end, the SPD as amended from time to time, is incorporated
herein.
11.09 Severability. Should a court of competent jurisdiction subsequently invalidate any part of this
Plan, the remainder thereof shall be given effect to the maximum extent possible.
11.10 Effect 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
24 -
16-51
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 Plan Administrator may include withholding of any amounts due the Plan or the Emp]oyer .
from Compensation paid by the Employer.
25 -
16-52
ARTICLE XII
CONTINUATION COVERAGE
The SPD includes continuation of coverage provisions that shall be applicable to the HCSA, 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).
?6 -
16-53
ARTICLE XHI
HIPAA PRIVACY AND SECURITY
13.01 Scope and Purpose. The HCSA (the "Plan" will use protected health information("PHI") to the
extent of and in accordance with the uses and disclosures permitted by the Health Insurance
Portability and Accountability Act of 1996 ('`HIPAA"). Specifically, the Plan will use and
disclose PHI for purposes related to health care treatment, payment for health care and Health care
operations as set forth below.
13.02 Effective Date. This Article XIII is effective on April 14, 2003 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 uses and
disclosures permitted by HIPAA, including but not limited to health caze treatment, payment
for health care, health care operations and as required by law. The Privacy Notice will list the
specific uses and disclosure of PHI that will be made by the Plan.
b) Disclosure to the Employer. The Plan will disclose PHI to the Employer, or where
applicable, an Affiliate 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. Notwithstanding any provision of the Plan to the contrary,
the Employer agrees:
a) 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 oc employee benefit plan of the Employet unless authorized by 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;
f) To provide Individuals with access to PHI in accordance with 45 C.F.R. § 164.524;
_27_
16-54
g) To make available PHI for amendment and incorporate any amendments to PHI in
accordance with 4~ C.F.R.§ 164.26;
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 determiningthe Plan's compliance with H1PAA;
j) If feasible, to return or destroy al] 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
k) To ensure adequate separation between the Plan and Employer as required by 45 C.F.R. §
164.504(f)(2)(iii) and described in this Article XIII.
13.05 Designated Employees ~Vho May Receive PHL 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 to PHI from the Plan are listed in the Privacy Notice, either by
name or individual position.
13.06 Restrictions on Employee with Access to PHI. The Employees who have access to PHI listed
in the 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.
13.07 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 Administrator intends the Plan to form part of
an Organized Health Care Arrangement along with any other Benefit under a covered health plan
(under 45 C.F.R. § 160.103) provided by the Employer.
13.09 Privacy Official. The Plan shall designate a Privacy Official, who will be responsible for the
Plan's compliance with 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 notwithstanding any provision of this
Plan to the contrary, the Privacy Official shall have the authority to 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;
zs -
16-55
c) Establishing and implementing policies and procedures with respect to PHI that are designed
to ensure compliance by the Plan with the requirements of HIPAA;
d) Establishing and overseeing proper training of the Plan, or Employer personnel who will have
access to Protected Health Information;
e) Any other duty or responsibility that the Privacy Official, in his or her sole capacity, deems
necessary or appropriate to comply with the provisions of HIPAA and the purposes of this
Article XIIL
13.10 Noncompliance. The Employer shall provide a mechanism for resolving issues of
noncompliance, including disciplinary sanctions for personnel who 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 by 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. § 164.520, as amended from time to time.
"Privacy Rules" means the privacy provisions of HIPAA and the 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.
13.12 Interpretation and Limited Applicability. This Article XIII serves the sole purpose of
complying with the requirements 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 shall be taken into account in determining the amount or nature of the
Benefits provided to any person covered under this Plan, nor shall they insure to the benefit of
any third parties. To the extent that 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 Employer. Notwithstanding any other provision of this Plan to the
contrary, al] services performed by a business associate for the Plan- in accordance with the
applicable service agreement shall be deemed to be performed on behalf of the Plan and subject
to the adminisfrative simplification provisions of HIPAA contained in 45 C.F.R. parts 160
through 164, except services that relate to eligibility and enrollment in the Plan. If 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.
-29-
16-56
13.14. Security of Electronic PHI. Effective the date that HIPAA's security regulations apply to the
HCSA, the Employer will ensure the following with respect to electronic PHI:
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) That reasonable and appropriate security measures aze implemented to support adequate
separation as required by Section 13.03(k) herein.
c) 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 under this Section 13.13.
d) That any security incidents of which it becomes aware that are inconsistent with this
Section 13.14 are reported to the Plan.
The Plan shall also designate a Security Official, who will be responsible for the Plan's
compliance with the security provisions of HIPAA. The Security Official may contract with or
otherwise utilize the services of attorneys, accountants, brokers, consultants, or other third party
experts as the Security Official deems necessary or advisable. hi addition, and notwithstanding
any provision of this Plan to the contrary, the Security Official shall have the authority to and be
responsible for:
(a) Accepting and verifying the accuracy and completeness of any certification
provided by the Employer under this Article VII;
(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 policies and procedures with respect to electronic
PHI that aze designed to ensure compliance by the Plan with the security
requirements of HIPAA;
(d) Establishing and overseeing proper training of the Plan, or Employer personnel
who 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 HIPAA and the purposes of this Article VIII.
so -
16-57
IN WITNESS WHEREOF, the Employer has executed this Cafeteria Plan as of the.date set
.forth below:
. CITY OF CHULA VISTA
$y_ KELLEY BACON
Title: DIRECTOR OF HUMAN RESOURCES &
i R CES
31-
16-58
EXHIBIT B
~~~~/
r~~
cm of
CHULA VISTA
VOLUNTARY PLAN
AFLAC
PLAN DOCUMENT
Amended and Restated as of January 1, 2013
Human Resources and
Information Technology Services Departments
City of Chula Vista
16-59
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 specified welfare benefits described in this Plan Information Summary (see "Benefits Provided Under the Plan").
Pre-tax Contribution elections under the Plan areintended to qualify for the exclusion from income provided in Section 125 of the
Internal Revenue Code of 198fi.
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 thePlan and to decide all matters arising under the Flan, 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 ERISA
' Plan Numberassigned):
5) 125 Start Date: ~ 01/01/10
6) Effective Date of this Plan:. ~ 12/15111 -
7) Last Day of the Plan Year: 12/31/11
Subsequent Plan Years: 01 /01-1 2131
8) NameandAddresspf SAME - '
-
FSACIaimAdministrator:
9) Name andAddressof registered IRENE MOSLEY -
agent for serviceoflegal process: -
" 10) Affiliated Employers that wilt participate inthe Plan
11) Employer's.Type of Business: _, OTHER -
ELIGIBILITY '
All Employees employed by the Employer shall be eligible to participate under the Plan except the following: -
An, eligible Employee may become aParticipant 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.-0THER -
~~ 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 Beneft Plan of Policy, and reductions of the
Employee's Compensation'to pay Pre-tax or After-tax Contribution(s) shall commence wheh the Employee becomes
covered under the applicable Benefit Plan or Policy. ~, ~ -
An. eligible Employee may become a Participant in the Dependent Careahdlor 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.
[ j On the day following commencement of employment.
[ ~ ] On the first day of the month following days of employment.
( ] Other: OTHER provided thefmployee completes an SRA selecting such benefits.
1 - SPD
16-60
BENEFITS PROVIDED UNDER THE PLAN
,. _ The following Beneft Plans and Policies subject to the terms and conditioris 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 Beneft 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 (A8S)
[.X ], Cancerlnsurance
_ [.X ] Dental Coverage -
] 'Group Term Life Insurance ~ ~ -
[ ] Disability Income -Long Term (LTD) _ ,
[ X ] intensive Care Insurance - -
' [ X ] Accident Insurance ~ _-- -
' - [ X. ]' Hospital Indemnity Insurance (HIP)
- ~ (X ] Specified Health Event,
- ~ ~ [ X ] Personal Sickhess 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 Medical CareExpense Reimbursement Plan. -
Nameand 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 ,
Custotlian/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 FlexibleBenefits 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 shall 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
~6-61
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
Introduction
Your employer (the "Employer") is pleased to sponsor an employee benefit program known as a "Flexible Benefits 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 arrangemerifinstead
of receiving a corresponding amount of your regular pay. This arrangement helps you because the benefts you elect are
nontaxable; you save Social Security and income taxes on theamount of ypursalary redirection. Alternatively,~your Employer
may allow you to pay for any of the available benefts with after-tax contributions on a salary deduction basis.
This Summary Plan Description ("SPD") describes the basic features of the Plan, how it 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 cases, the Employer may adopt a Medical Care and/or Dependent Care Reimbursement Plan. If so, they will be listed in
the Plan Information Summary as "Benefts 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 defned in Code Section 223) throughthis
Plan if Health Savings Accounts are identified as an included beneft 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
O-1. What is the purpose of the Plan?
The purpose of the Plan is to allow eligible employees to pay for certain benefits offered under the Plan (called "Benefit
' ' Plans or Policies") with pre-tax dollars called "Pre-tax Contributions". Pre-tax Contributions are described inmore detail
• in O-8 of this SPD. -
- Q-2. What benefits can I purchase on a pre-fax basis through the PIan7
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 defned under Internal Revenue Code Section 152. Each Benefit Plan or
_ Polidy may define eligible Dependents more narrowly for purposes of coverage under the particular Benefit Plan or
Policy.
Q-3, Who can participate in the Plan? '
Each employee of the Employer (or an Affiliated Employer identified in the Plan Information Summary) who satisfes 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,
benefit amounts, and premium schedules for each of the Benefit Plans or Policies, please refer to the plan summary fo'r
each of the Benefit Plans or Policies listed in the 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 defned in Code Section 152; however, for purposes of health benefts 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-0. 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 youare
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
3 SPo
16-62
Pre-taxContributions under the Plan. If you are rehired within the same Plan Year or you become-eligible agairi,.you
may make new elections, provided that you are rehired or become eligible again mote than 30 days after 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. 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 Benefit Plans or Policies available under the Plan, as well as agree to asalary redirection to pay for those
benefits soelecfed. You will be provided an SRA when you frst become eligible to participate in this Plan. Youmust
complete the form and turn it in to the Personnel Office during the applicable enrollment period described in Q-6 below.
Q-6. 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 either the "Initial Enrollment Period" or the "Annual
- ~ Enrollment•Period". You will be notifed of the dates that each enrollment period begins and ends in 4he enrollment
materaa(provided to you prior to each enrollment period. If youmake an election during the InitiahEnrollment Period,
yourparticipation inlhis Plan will begin on the later of your eligibility date described in the Plan Information Summary,.
' the f rst 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 setforth. 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 antl generally cannot be revoked
during the Plan Year unless you have a Change in Status event as described in-0-9 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 Beneft[ Plans or Policies automatically (and be
- required to contribute with pre-tax dollars) even if you fail to make an election. These automatic Beneft Plans or
Policies are called "Default Benefts" and will be identified in the enrollment material that you receive.
The election that you make during the Annual Enrollment Period is effective the frst day of the next Plan Year and is
irrevocable for the entire Plan Year unless you have a Change in Statusevent described in O-9 below. A Participant
who fails to complete, sign, and file 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 Plah 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. -
Q-7. What tax advantages are available through the Plan? -
. 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 willbe $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 CafeteriaPlan Without Cafeteria Plan
. Gross Monthly Pay $2,500 ~, - $2,500 .
Pre-Tax Coverage Under Plan 140 -
Taxable Income 260 2.500
Estimated Federal Tax (15%) 354 375 - ~~
FICA Tax 161 191
' After-tax Coverage 140 - ~ -
'Take Home Pay 1,825 1,794 - '
Monthly Savings: $31.00
Q-6. How are my contributions under the BenefitPlans or Policies made?
When you .become a Participant, your share of the contributions for the elected Benefit 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 adtlition, 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
.. _ 4 ~ sl=o
16-63
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 Yearin'a uniform and nondiscriminatory manner and may be based .upon your Dependent status,
commencementor 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 othervvise 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 Beneft Plan(s) or Poligy(ies) that you choose (subject.tc
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-taz 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 Anriual Enrollment Period,
and then, only for the coming Plan Year. There are several important exceptions to this general rule: You may change
on revoke your previous election during the Plan Year if you,file 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 following events that change the employment status of you, your Spouse, or your Dependent that.
- affect benefiheligibility 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 warit 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 benefits (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 Changein 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 elecf 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 ho health coverage. The divorce between. Mike
- ~ 5 ~ ~ SPD
16-64
and Sharon constitutes a Change in Status: Ah 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-taxContributions to pay For COBRA coverage of a Dependent child or yourself.
• .Gain of Coverage Eligibility 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 Beneft 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 Benefits (t 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 benefit (if 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 [o 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 Benefit Plans or Policies offered under the Plan in the Plan Information Summary). For group term life
insurance, disability income, and accidental death and dismemberment benefts, if you experience any Change
in Status (as described above), you may elect either to increaseor 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 ofgroup-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
Beneft 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 pf
COBRA period), you maybe able to elect medicab coverage under the Beneft Plan or Policyfor 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, yout 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 tp 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 Stale Children's Health Insurance Program (SCRIP) under Title XXI of the
Social SecurityAct; or (3) become eligible for group health plan premium assistance under Medicaid or SCRIP and you
are entitled to special enrollment rights under a Beneft 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 Benefit 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 pr health coverage.
SPD
16-65
5. Change in Cost. If you are notified that the cost of your i3enefii Plari or Policy coverage under the Plan significantly
increases or decreases during the Plan Year, you may make certain election changes. If the cost, significantly
increases,ybu may choose either to make an increase in your contributions, revoke your election and receive coverage
under another Beneft Plan or Policy that provides similar coverage, or drop coverage altogether if no similar coverage
' exists. If the cost signifcantly 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 Beneft 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 Cost" exceptions are applicable to a Medical Care Reimbursement Plan, to the extent
• offered underthe~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 signifcantly increases during a period of coverage, the Employee may make a
corresponding increase inhis payments or may instead revoke hiselection 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 signifcantly
curtailed, you may revoke your election and elect coverage under another Benefit Plan or Policy that provides similar
coverage. If the significant 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 significantly improves a beneft option during the Plari 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,gr 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 modified 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 themeaning 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, ithas 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 beneft under one of the component Beneft
Plans or Policies, you will generally proceed under the claims procedures applicable under thecomponent Benefit Plan
or Policy (see the plan summary for each of the Benefit Plans or Policies [hat 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 notifed 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 specific reasons for
the denial and the relevant plan provisions on which the denial was based.
If yourclaim is denied in whole orin 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 [he request for review~is received, you will be
notifed in writing of the decision on-review.
Themotice of denial will indicate whether there are. one or two levels of appeals and will contain the same type df
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 fduciary
for making the final decision under the plan.
In 'the event of your death, your beneficiary 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 benefits and/or other benefits (e.g., pension, disability and life insurance) that are based on taxable
compensation. _
~ ~ SPD-~
~6-66
Q-13. What happens if I take a leave of absence? '
(a) If you go on a qualifying unpaid leaveunder 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 tho same terms and conditions as though you were still active (e.g., the Employer will continue to pay
its share of the contribution fo 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-FMLA paidleave 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 he 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 Gode 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 Employeeson non-FMLA
leave is automatically reinstated upon return from 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 Benefit
Plans or Policies are treated with respect to Participants commencing and returning from unpaid non-FMLA leave.
(g) If you gb 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 BenefitPlan or Policy offered under this plan, then you will continue fo 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
leavethat affects eligibility under this Plan or aBenefit Plan or Policy, the election changerules 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-14. Is there any other information that I should know about the Plah?
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 specified 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
16-67
~~sr~
~„-
CHULA VISfA
EXHIBIT C _
EMPLOYEE ASSISTANCE
' PROGRAM
AETNA RESOURCES FOR
LIVING
(dba Horizon Health EAP -
Behavioral Services)
PLAN DOCUMENT
Amended and Restated as of January 1, 2013.
Human Resources and
Information Technology Services Departments
City. of Chula Vista
16-68
HORIZON HEALTH EAP-BEHAVIORAL SERVICES
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
TABLE OF.CONTENTS
°: ~ I. DEFINITTONS ..........:.........................................:.....................:........:.............................................. ............2
IL HOW TO OBTAIN BENEFITS ...............:...........:.............................:.........................:..............:.... ............3
. , .. III. EMERGENCY SERVICES .......................:...................................................................................... ............4
... IV. ~CRISISINTERVENTION ............................................................................................................... ..:.........4
. :. ~ V. PERIODIC-FEES ...................................................:...................................................................:...... ...:........4 -
VI. _ _:
OTHER CHARGES ..............................:........................:.............:....................................................
...........:5 .
VII. PREPAYMENT OF FEES :.....................................................::....................................................... ............5
VIII. CHOICE OF EAP PROVIDERS ......................:...........................................................................:. .............5
IX. FACILITIES .........................:.....:..................................................................................................... .............5 .
' X. LIABILITYOF HORIZON HEALTH EAP-BEHAVIORAL SERVICES /MEMBERS ..:..... .............5
A. LIABILITY OF HORIZON HEALTH EAP-BEHAVIORAL SERVICES ................................................... .............5 -
B. LIABQ,ITY OF MEMBERS .............................................................................................................. .............5
' - C. MEMBER LIABILITY TO NON-EAP PROVIDERS ..:......................................................................... .............6
' ~XL.' PROVIDER COMPENSATION .:................................................................................................... .............6
' XII. SECOND OPINION POLICY .................................................................:...................................... ........:..::6
XIII. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE .................:.............._ .............7
' - XIV. '
~ ~TERbHNATION OF BENEFITS ...........................................................................................:....... .............7
' A. CANCELLATION OF THE GROUP CONTRACT FOR NONPAYMENT OF PREMIUMS ............................ .............7
' ~
. B. REINSTATEMENT OF THE CONTRACT AFTER CANCELLAT[ON .............................:........................ ...:..........8
~
~ C. MEMBER TERMINATION FOR NON-ELIGIBILITY ....................:..................................................... ..............8
D. TERMINATION FOR GOOD CAUSE ..........................:.............................:....................................... ..............8 '
', XY. CONTINUITY OF CARE ..........:..................:.............:.........................:........................................ ..............9
A. NEW MEMBERS .....................................................................:..................................................... ..............9
. ~ .. 1) Eligibiliry ......................_.............._......._..::........._..............._....................._........._......... .._..........9 . _~
` . _' ?) Access.....:.__........_..........__ ..........:...............................................:..................................... ._...........9
... B. TERMINATED EAP PROVIDERS ................................................................................................... .....:......10 .
- _ - ~ Evidence of Coverage
16-69
XVI. CONTINUATION OF GROUP COVERAGE .........................................................................................10
A. COBRA CONTEVUATION OF COVERAGE ....................................................................:................:...........10
., B. CAL-COBRA CONTINUATION OF COVERAGE .........................................................................................11
.. ~ I) Eligibility for Cal-COBRA Continuation Coverage ..................................................................._...11
' ~) NotificatiodafQualifyingEvents.._.........._ ...................................._.............................:........_......11
3) Cal-COBRA Enrollment and Premiuminformation ..............::._............................._.....................72
4) Termination of Cal-COBRA Continuation Coverage .............._.._................_....._._.....................12
XVII. COMPLAINT AND GRIEVANCE PROCEDURE
13
XViII. MISCF.LLANEOUS ....................................................................................................................................15
A. CONFIDENTIALITYPOLICY ............................................................................................:....... ..................15
B. MEIvffiERCONSENT ............................................................................................................... ..................15
' ~, C. HORIZON HEALTH EAP-BEHAVIORAL SERVICES' POLICIES .........................:........:.............. ..................16
' D. HORIZON HEALTH EAP-BEHAVIORAL SERVICES' PUBLIC POLICY COMMITTEE ................... ..................16
E. TERM AND RENEWAL PROVISIONS ........................................................................................ ..................16
- - F. IMPORTANT INFORMATION ABOUT ORGAN AND TISSUE DONATIONS .............................. _.. ...................16
EXHIBIT A - SCHEDULE OF BENEFTTS, LIMITATIONS, AND EXCLUSIONS ..................:.............:........17
. A. BENEFITS ..................................................................................................:.............................................17-
: B. LIMITATIONS .....................................................................................ERROR! BOOKMARK NOT DEFINED.
C. ExciusloNS .................................:.........................................................................................................18
EXHIBIT B -COMPARISON OF BENEFITS
ii EvidenceafCoverage
16-70
HEALTH AND HUMAN RESOURCE CENTER
(dba HORIZON HEALTH EAP-BEHAVIORAL SERVICES)
7676 Hazard Center Drive, Suite 1100
'San Diego, CA 92108
1-800-342-8111
EMPLOYEE ASSISTANCE PROGRAM
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
The Employee Assistance Program (EAP) is being offered by your employer to provide you with
confidential assistance from licensed mental health professionals. These professionals can help.
with problems affecting your life at work as well as at home. Such problems include marital
issues, family relationships, depression and anxiety, alcohol and drug issues, and/or problems
within the workplace.
The EAP counselors will conduct a thorough assessment of your problem and together with you
will decide on an action plan that will either resolve the issue within the EAP sessions or will
refer you to appropriate providers and/or community resources that have been reviewed by the
EAP. Your involvement with the EAP counselor will be at no cost to you.
This Combined Evidence of Coverage and Disclosure Form constitutes only a summary of
the health plan. The EAP Services Agreement must be consulted to determine the exact
terms and conditions of coverage. A copy of the agreement will be furnished on request
' and is available from your employer.
This Combined Evidence of Coverage and Disclosure Form discloses the terms and conditions of
coverage. It also provides you with important information on how to obtain Benefits and the
` circumstances under which Benefits will be provided to you. PLEASE READ IT
CAREFULLY. Individuals with special health care needs should read carefully those sections
that apply to them.
-Keep this publication in a safe place where you can easily refer to it when you are in need of
Benefits. '
t
Contact Horizon Health EAP-Behavioral Services at 1-800-342-8111 to receive additional
information about Benefits.
Enclosed as Exhibit B is Horizon Health EAP-Behavioral Services' matrix of covered services.
1 Evidence of Coverage
~6-~~
I. DEFINITIONS
The following terms have the following meanings for purposes of this Combined Evidence of
Coverage and Disclosure Forma
A. "Act" means the Knox-Keene Health Care Service Plan Act of 1975_,_ as amended
(Califomia Health and Safety Code, Sections 1340 et-seq.).
B. "Benefits" means the services to which Members are entitled under an EAP Services
Agreement, and which are described in Exhibit A to this Combined Evidence of
Coverage and Disclosure Form:
~. _ C: "EAP Provider" means the licensed assessment and short-term counseling mental health
professionals employed by, or under contract with, Horizon Health EAP-Behavioral
Services to provide Benefits to Members.
D. "EAP Services Agreement" means the Employee Assistance Program (EAP) Services
Agreement between Horizon Health EAP-Behavioral Services and a Group, which
- establishes the terms and conditions governing the provision of Benefits to Members by
Horizon Health EAP-Behavioral Services.
E. ``Exclusion" means any provision of an EAP Services Agreement whereby coverage for
Benefits is entirely eliminated, and which is set forth in Exhibit A to this Combined
Evidence of Coverage and,Disclosure Form.
F. "Group„ means the company that has entered into an EAP Services Agreement with
Hotizori Health EAP-Behavioral Services for Horizon Health EAP-Behavioral Services
to provide Benefits to Members.
G. "Plan" means Health and Human Resource Center, Inc:, doing business as Horizon
Health EAP-Behavioral Services.
H. "Limitation" means any provision of an EAP Services Agreement, other than an
Exclusion, which restricts Benefits, and which is set forth in Exhibit A to this Combined
Evidence of Coverage and Disclosure Form.
I. "Enrollee" means any eligible employee of Group who (1) resides in Califomia and (2)
may be covered' under the Act.
J. "Member" means an Enrollee covered by the Group, as defined above, the Enrollee's
children under the age of 26, persons covered under, the Enrollee's health benefit plan,
and persons residing with the Enrollee, including domestic partners.
' K. "Periodic Fees" means the monthly amounts due and payable to Horizon Health EAP-
Behavioral Services by a Group for providing Benefits to Members.
' ~ ~
• _ 2 Evidence of Coverage
16-72
- L. "Einereency Services" means medically necessary transport using the 911 system or '
medical screening, examination and evaluation by a physician to determine if an
emergency medical condition or psychiatric emergency medical condition exists.
M. •"Crisis Intervention" means assessment and problem solving in situations which you feel
require immediate attention. Crisis intervention is available 24 hours per day, 7 days a
week by telephone, and face to face by appointment. To access, call 1-800-342-8111.
_ N. "Emer¢ency Medical Condition" means a medical condition manifesting itself by acute '
symptoms of sufficient severity' (including severe pain) such that the absence of
.immediate medical attention could reasonably be expected by the Member to result in
any of the following:.
-Placing the Member's health in serious jeopardy;
• Serious impairment to bodily functions;
` Serious dysfunction of any bodily organ or part; or
Active labor, meaning labor at a time that either of the following would occur
1) There is inadequate time to effect safe transfer to another hospital prior to
delivery; or
2) A transfer poses a threat to the health and safety of the Member or unborn child.
II. HOW TO OBTAIN BENEFITS
_ Unless otherwise provided herein, you axe entitled to Benefits from an EAP Provide"r. You
must obtain Benefits by calling 1-800-342-8111. Upon contact, Horizon Health EAP-
Behavioral Services will determine your eligibility for Benefits and arrange for Benefits.
All Benefits must be provided by Horizon Health EAP-Behavioral Services or by an EAP
Provider referred to by Horizon Health EAP-Behavioral Services. Local and, toll-free
telephone numbers are available to access Benefits. Appointments with EAP Providers are
readily available. and, depending on your desire for a particular time and location, most
appointments are offered within forty-eight (48) hours of contact. .,
Horizon Health EAP-Behavioral Services does not directly provide specialty services beyond
assessment, brief counseling and/or referral. Horizon Health EAP-Behavioral Services' role
in the referral process is to function as an advocate for you to obtain necessary and
appropriate levels of care; usually under your group health plan. Your EAP Provider will
assist you in securing potential referral resources.
.During or after business hours, any Member may access a licensed mental health professional .
for a telephone assessment. The telephone assessor may provide crisis intervention over the
telephone, arrange asame-day appointment with an EAP Provider in your area, or, assist you
' . in obtaining more intensive, acute care services.
3 Evidence of Coverage
16-73
III. EMERGENCY SERVICES
Emergency services are medically necessary ambulance and ambulance transport services
provided through the 911 emergency response system and medical screening, examination,
and evaluation by a physician, or other personnel, to the extent provided by law, to determine
if an Emergency Medical Condition.or psychiatric emergency medical condition exists; and,
if it does, the care, treatment, and/or surgery by a physician necessary'to relieve or eliminate
the Emergency Medical Condition or psychiatric emergency medical condition within the
capabilities of the facility.
What To Do When You Require Emergency Services
If you believe that you need Emergency Services, you should call 911 or go to the nearest
emergency medical facility for treatment. The Plan does not cover emergency medical
services. -- -
It is appropriate for you to use the 911 emergency response system, or alternative emergency
system in your area, for assistance in an emergency situation described above when
ambulance transport services are required and you reasonably believe that your condition is
immediate and serious and requires emergency ambulance transport services to transport you
to an appropriate facility
IV. CRISIS INTERVENTION
If you need crisis intervention or problem solving, call Horizon Health EAP-Behavioral
Services at 1-800-342-8111. Horizon Health EAP-Behavioral Services provides crisis
intervention both during andafter business hours at this number. A member who is currently
outside the Plan service area and requires this'service can call 1-800-342-8111. Members
can obtain care if they are temporarily outside of the Plan service area. Members can also be
scheduled for an appointment on an urgent basis following assessment by a licensed clinician
over the telephone
V. PERIODIC FEES
Horizon Health EAP-Behavioral Services bills the Group for Periodic Fees and the Group
remits such fees to Horizon Health EAP-Behavioral Services each month during the term of
the EAP, Services Agreement for Members entitled to receive Benefits during such month.
Horizon Health EAP-Behavioral Services may change the Periodic Fees and/or Benefits
under the EAP Services Agreement, effective thirty (30) days after receipt by the Group of
written notice from Horizon Health EAP-Behavioral Services setting forth any such change,
but in no event during the then-existing thirty-six (36) month term of the EAP Services
Agreement. There are no co-payments, deductibles, or charges to you for Benefits.
Evidence of Coverage
16-74
VI. OTHER CHARGES '.
+ The Plan will bil[ the Group for additional- services or benefits provided under the
Agreement. The' Group will remit payment to the Plan within thirty (30) days of receipt of
invoice.
VII. PREPAYMENT OF FEES
The Member does not pay co-payments, deductib]es, or fees for the Plan. All fees are paid
by the Group. "
VIII. CHOICE OF EAP PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW '
FROM 'WHOM OR WHAT GROUP OF PROVIDERS BENEFITS MAY BE
• OBTAINED: You will be referred to an EAP Provider in accordance with your clinical, '
appointment time, and' location needs. You should call Horizon Health EAP-Behavioral.
Services at 1-800-342-8111 to determine the names and locations of EAP Providers.
EAP contracted"providers include licensed psychologists, licensed clinical social workers,
• and licensed marriage and family therapists. Psychiatrists are not provided through the EAP.
Members, are given names of contracted providers in their area with knowledge in the
problem area that is .indicated. You may also request a list of providers, and this will be
- ~ provided forthe geographic area, customized by specialty, if you prefer.
IX. FACILITIES
- - The location of Providers is obtained by calling Horizon Health EAP-Behavioral Services at
1-800-342-811 L If you prefer, a customized list of providers will be provided upon request.
' This is arranged by zip code in the area specialty that you request.
X. LL~BILITY OF HORIZON HEALTH EAP-BEHAVIORAL SERVICES /MEMBERS "
A. Liability of Horizon Health EAP-Behavioral Services
In the event Horizon Health EAP,Behavioral Services fails to pay EAP Providers for
Benefitsprovided to you, you shall not be liable to EAP Providers for any sums owed by
Horizon Health EAP-Behavioral Services.
B. Liability of Members
It is not contemplated that Members would make payment to Plan providers for benefits.
If this has occurred, the Member may contact the Plan at 1-800-342-8111 to be
-reimbursed. There is no restriction on assignment of sums payable to the Member by the
' health plan. '
_" 5 Evidence of Coverage
16-75
C. Member Liability to Non-EAP Providers
You may be liable to non-EAP Providers for the cost of services rendered when such
services are not authorized or referred by Horizon Health EAP-Behavioral Services.
XL PROVIDER COMPENSATION
Horizon Health EAP-Behavioral Services compensates EAP Providers through an agreement
by which they are paid a fixed amount of money based on hours worked, number of
Members seen; or number of sessions provided. Providers are compensated within thirty
(30) days after claim is received.
Horizon Health EAP-Behavioral Services does not distribute financial bonuses or use any
other incentive program to compensate its EAP Providers other than the methods of
compensation defined above. _
Members may request further information about Horizon Health EAP-Behavioral Services'
EAP Provider reimbursement policies and procedures by contacting Horizon Health EAP-
Behavioral Services' Manager, Provider Relations, at 1-800-342-8111 or the Member's EAP
Provider.
XII. SECOND OPINION POLICY
You may request-a second opinion regarding both treatment recommended by the treating
EAP Provider and treatment desired by you. Horizon Health EAP-Behavioral Services will
.authorize second opinions where the second opinion is consistent with professionally
recognized standards of practice. The second opinion request will not result in a change in
what is and is not, a Benefit as described in the EAP Services Agreement and this Combined
Evidence of Coverage and Disclosure Form. Horizon Health EAP-Behavioral Services may
deny coverage for second opinion requests for services not listed as Benefits in the EAP
Services Agreement and this Combined Evidence of Coverage and Disclosure Form.- If
Horizon.. Health EAP-Behavioral Services denies such a request, you will bear the financial
responsibility for any self-directed second opinion. There will be no cost to you if the second
opinion is received from an EAP Provider under contract with the Plan. If you request a
second opinion from a provider not under contract with Horizon Health EAP-Behavioral
Services, you must provide an explanation as to why an EAP Provider cannot render such an
opinion. The Horizon Health EAP-Behavioral Services Medical Director shall review the
request to determine whether there is an EAP Provider qualified to render a second opinion..
Requests for second opinions may be made by contacting the Director, Clinical Quality
Improvement at (1-800-342-8111) or in writing to 7676 Hazard Center Drive, Suite 1100,
San Diego, CA 92108. All requests for second opinions shall be processed and approved of
denied by Horizon Health EAP-Behavioral Services within five (5) business days of receipt.
Request's related to urgent care'or crisis intervention shall be processed and approved or
denied within forty-eight (48) hours of receipt.
Evidence of Coverage
16-76
XIII. ELIGIBILITY/ENROLLMENT/EFFECTIVE DATE OF COVERAGE
,All Enrollees identified by the Group prior to the effective date of the EAP Services
` Agreement and all persons covered under the identified Enrollee's health benefit plan or
residing with the identified Enrollee shall be entitled to Benefits as of such effective date.
The Group shall be responsible for notifying Horizon Health EAP-Behavioral Services of "
" any Enrollee who becomes newly eligible after the effective date of the EAP Services
Agreement. Horizon Health EAP-Behavioral Services shall rely upon the determination by
the Group as to which Enrollees are eligible for Benefits under the EAP Services Agreement.
Any disputes or inquiries regarding eligibility, including rights regarding renewal,
reinstatement and the like, shall be referred by Horizon Health EAP-Behavioral Services to
the Group, which shall then advise Horizon Health EAP-Behavioral Services of its
determination with respect to the.matter.
XIV. TERMINATION OF BENEFITS
Usually, your enrollment in the Plan terminates when the"Group or Enrollee is no longer.
eligible for coverage under the employer's EAP Plan. In most instances, the Group
determines the date in which coverage will terminate. Coverage can be terminated, however,
because of other circumstances as well, which are described below.
A. Cancellation of the Group Contract for Nonpayment of Premiums
Continuing coverage under this EAP Plan is subject to the terms and conditions of the
Group's EAP- Services Agreement with the Plan. If the EAP Services Agreement is
cancelled because the Group failed to pay the required premiums when due, then
coverage for you and all your dependents will end 15 days after the Group mails you the
Notice Confirming Termination of Coverage.
The Plan will mail your Group a notice at least 30 days before any cancellation of
coverage. This Prospective Notice of -Cancellation will provide information to your
Group regarding the consequences of your Group's-failure to pay the premiums due
within 15 days of the date the notice was mailed.
If payment is not received from your Group within 15 days of the date the Prospective
Notice of Cancellation is mailed, 'the Plan will mail the Group a Notice Confirming
Termination of Coverage, which the Group will then forward to you. This notice will
provide you with the following infoanation:
1) That the Group Contract has been cancelled for non-payment of premiums;
2) The specific date and time when your Group coverage ends, which will be rio sooner
than 15 days after the Notice Confirming Termination of Coverage is mailed to you.
7 Evidence of Coverage
16-77
B. Reinstatement of the Contract after Cancellation
If the Group Agreement is cancelled for the Group's nonpayment of premiums, then the
Plan will permit reinstatement of the Group Agreement if the Group pays the amounts
owed within 15 days of the date of the Notice Confirming Termination is mailed to the
Group.
C. Member Termination for Non-Eligibility
In addition to terminating. the EAP Services Agreement, the Plan may terminate a
Member's coverage for any of the following reasons:
The Member no longer meets the eligibility requirements established by the Group
and/or Plan;
The Member lives or works outside the Plan Service Area and does not work inside
the Plan Service Area (except for a child who is covered as a dependent).
Ending Coverage -Special Circumstances for Enrolled Family Members.
Enrolled Family Members terminate on the same date of termination as the Group. If
there is a divorce, the Spouse loses eligibility at the end of the month in which a final
judgment or decree of dissolution of marriage is entered. ~ Dependent children lose their
eligibility when they reach the Limiting Age of 26 and do not qualify for extended
coverage as a disabled dependent.
D. Termination for Good Cause
The Plan has the right to terminate your coverage under this EAP Plan in the following
situation:
-Fraud or Misrepresentation. Your coverage may be terminated if you knowingly
provide false information (or misrepresent a meaningful fact) oh your enrollment
form or fraudulently or .deceptively use services or facilities of the Plan, its
Participating Providers (or knowingly allow another person to do the same).
Termination is effective. immediately on the date the Plan mails the Notice of
- Termination, unless the Plan has specified a later date in that notice.
If coverage is terminated for the' above reason, you forfeit all rights to enroll in the
COBRA Plan.
Under no circumstances will a Member be terminated due to health status or the need for
' EAP Services. Any Member who believes his or her enrollment has been terminated due
to the Member's health status or requirements for EAP Services may request a review of
' the termination by the California Department of Managed Health Care. For more
information, contact our Customer Service Department.
g Evidence ojCoverage
~6-~8
-NOTE: If the EAP,Services Agreement is terminated by the Plan, reinstatement with the
- Plan is subject to al] terrns and conditions of the EAP Services Agreement between the Plan
and the employer.
XV. CONTINUITY OF. CARE
A. New Members
1) -Eligibility '
Any newly covered Member with an acute, serious, chronic, or other mental health
condition who has been receiving, services from. a licensed mental health provider
who is not on the Horizon Health EAP-Behavioral Services panel is eligible for
continuation of care. This does not include the services of psychiatrists, as the EAP ,
benefit does not include psychiatric care. If you are newly covered under the EAP,
you will be offered the option of continued care with your non-plan provider through
the EAP. The Manager of Provider Relations or the Director of Clinical Services will
review all requests for continued care with anon-plan provider. Consideration will -
be given to the potential clinical effect that a change of provider would have on your
treatment for the condition. Notification of the referral acceptance is by telephone
and a referral confirmation to the provider. If the provider declines to provide
services, you will be notified in writing.
2) Access
You may access the services bf the provider by calling Horizon Health EAP-
Behavioral Services and indicating to the Intake person that you have. an ongoing.
client-patient relationship with the Provider. You then should ask the Provider to call
and provide information to Provider Relations to be added to the panel for you. The
non-plan provider must agree to continue until one of the following occurs:
- a. The episode of care is completed. -
b. Your benefit is exhausted, in which case you will be transitioned to other ongoing
care.
c. A reasonable transition period is determined on a case-by-case basis, during
which time you would continue to see the non-plan provider. The decision as to
how long-this time will be takes into consideration the severity of your condition
and, the amount of time reasonably necessary to effect a safe transfer. This will be
determined on a case-by-case basis with input from you and. the therapist as to
,. when it is safe to transition.you to another provider, or into the full service health
" -plan. The Medical Director will be consulted on these decisions.
The following conditions must be met to receive continuing care services from a
licensed mental health provider who is not on the Horizon Health EAP-Behavioral
Services panel:
a. Horizon Health EAP-Behavioral Services must authorize the continuing care.
. 9 Evidence of Coverage
16-79
b. The requested treatment must be a covered benefit.
c. The non-plan provider must agree in writing to the same contractual terms as a
plan provider; which includes payment rates.
d. The Member must be new to Horizon Health EAP-Behavioral Seiices.
B. Terminated EAP Providers
Should Horizon Health EAP-Behavioral Services terminate an EAP Provider for
reasons other than a disciplinary cause, fraud, or other criminal activity,. you may be
able to continue receiving Benefits from the terminated provider following the
termination, if the provider agrees in writing to continue to provide Benefits under the
_ terms and conditions of his/her agreement with Horizon Health EAP-Behavioral
Services. To inquire about continued care, you should contact the Member Services
Department.
XVI. CONTINUATION OF GROUP COVERAGE
A. COBRA Continuation of Coverage
If the Group is subject to the Consolidated Omnibus Budget Reconciliation Act
(COBRA) of 1985, as amended, you may be entitled to continuation of Group coverage
under that act (COBRA Coverage). You may qualify for COBRA Coverage if you lose
Group coverage due to the occurrence of certain qualifying events. Such events include,
but are not limited to:
. ° • Termination or separation from employment for reasons other than gross misconduct.
• Reduction of work hours.
• Death of the Participant.
• `Termination of eligibility of a spouse due to divorce or legal separation.
• Termination of eligibility of a dependent child.
• Covered dependent if Member becomes eligible for Medicare
COBRA Coverage extends up to thirty-six (36) months, depending upon your qualifying
event. COBRA Coverage may be terminated on the occurrence of certain events, .
including you becoming eligible for coverage under Medicare. In addition, COBRA
Coverage is not available to certain Members, including those Members who have certain
other coverage at the time of the qualifying event. You may obtain complete information
on COBRA qualifying events, COBRA Coverage termination circumstances, and
ineligibility for COBRA Coverage from the Group.
The Group is responsible for providing you with notice of your right to receive COBRA
Coverage. You must provide Horizon Health EAP-Behavioral Services, br the Group,
with a written request for COBRA Coverage within sixty (60) days of eligibility for such
coverage or receipt of notice of the qualifying event. Qualified Members must make
payment of Periodic Fees to the Group or COBRA administrator within forty-five (45)
10 Evidence of Coverage
~6-8~
days of such written request. Members, whose continuation of coverage under COBRA
will expire may be eligible for continuation of coverage under Cal-COBRA:
' -B. Cal-COBRA Continuation of Coverage
1) Eligibility for Cal-COBRA Continuation Coverage
If a Group is subject to the California Continuing Benefits Replacement Act (Cal-
. COBRA)„ Members may be entitled to continuation of Group coverage under that act
(Cal-COBRA Coverage). A Group is subject to Cal-COBRA continuation coverage
• if it: a) employs 2 - 19 employees on at least 50% of its working days during the
preceding calendar year; or if the employer was not in business during any part of the
previous year and employed 2 - 19 eligible employees on at least 50% of its working
days during 4he previous calendar quarter; b) is not subject to the federal
:Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA). If
Rhe employer is subject to Cal-COBRA, you and your dependants may qualify-for
Cal-COBRA if you would lose coverage due to one of the following Qualifying
Events: -
• Termination of employment or reduction in work hours fot reasons other than
gross misconduct. •
Death of Enrollee.
Termination of eligibility of a spouse due to divorce or legal separation.
Termination of eligibility of a dependent child.
Covered dependant if Member is entitled to Medicare. '
,.
Member whose COBRA coverage will expire.
Cal-COBRA Coverage extends for up to thirty-six (36) months from the Qualifying
Event unless earlier terminated by the occurrence of certain events.
-The Group is responsible for providing Members with notice of their right to receive •
' Cal-COBRA, Coverage. The Member must provide the Group or COBRA
administrator with a written request for Cal-COBRA Coverage within sixty (60) days
of eligibility for such coverage or receipt of notice of the Qualifying Event. Eligible
Members must make payment of Periodic Fees to Horizon Health EAP-Behavioral '
Services within forty-five (45) days o£such written request.
2) Notification of Qualifying Events
It is the responsibility of the Member to notify Horizon Health EAP-Behavioral
Services of the occurrence of any of the Qualifying Events noted below within sixty
(60) days. The Qualifying Events that the Member is responsible for notifying
include: •
' •. Subscriber's death.
11 Evidence of Coverage
` 16-81
• Spouse ceases to be eligible due to divorce or legal separation.
• Loss of dependent status by a Dependent enrolled in the group benefit plan.
• With respect to a covered Dependent only, the Subscriber's entitlement to
Medicare.
The Group must notify Horizon Health EAP-Behavioral Services within thirty (30)
days of a termination of employment or reduction in work hours, which would result
in ending coverage under the Member's group benefit plan. Failure to notify Horizon
Health EAP-Behavioral Services within sixty (b0) days of the occurrence of a
Qualifying Event will disqualify the Member from receiving continuation coverage.
Notifications of a Qualifying Event are generally made to the Group or the Group's
COBRA Administrator. If the Member has questions, he/she may contact the Group,
or Horizon Health EAP-Behavioral Services at 1-800-342-811 I ..
3) Cal-COBRA Enrollment and Premium Information
Within fourteen (14) days of receiving notification of a Qualifying Event, Horizon
Health EAP-Behavioral Services will send enrollment and premium information,
including aCal-COBRA Election Form. The Member must return the completed
Cal-COBRA Election Form within the required time period. The Cal-COBRA
Election Form must be received within sixty (60) days of the latest of these
occurrences:
• The date coverage under the Plan was terminated or will terminate due to a
Qualifying Event; or
• The date the Member was sent the Cal-COBRA enrollment and premium
information.
Horizon Health EAP-Behavioral Services must receive the first Cal-COBRA
premium payment within forty-five 45 days of the date the Member's Cal-COBRA
Election Form was received. Failure to send the correct premium amount with forty-
five (45) days will disqualify [he Member from continuatio^ coverage under Cal-
COBRA. The first premium payment equals the amount of all premiums due from
the first month following the Qualifying Event through the current month. After the
initial payment, Cal-COBRA premiums are due on the first day of each month. The
Cal-COBRA premium is generally 110% of the premium charged to the Group for
employees. The Member's enrollment in Cal-COBRA will not occur until Horizon
Health EAP-Behavioral Services receives both the Cal-COBRA Election Form and
the first Cal COBRA premium payment.
4) Termination of Cal-COBRA Continuation Coverage
Usually, a Member's Cal-COBRA continuation coverage will last up to thirty-six (36)
months. The continuation coverage shall end automatically if the individual becomes
eligible for Medicare or becomes covered under any group health plan not maintained
t? Evidence of Coverage
16-82
by the employer or any other health plan, regardless of whether that coverage is less
valuable. The Member's Cal-COBRA continuation coverage may terminate early if
the Member moves out of Horizon Health EAP-Behavioral Services' service area,,
does not pay the .required premium within fifreen (15) days of it being due, or
commits fraud or deception in using Horizon Health EAP-Behavioral Services'
services, or obtains other group coverage.
If the group benefit plan is terminated prior to the date that the Member's Cal-
COBRA continuation coverage would expire, the Member's coverage with Horizon
Health EAP-Behavioral Services will expire. The Member has the opportunity to
continue coverage under the any group benefit plan purchased by the Group. If the
Group purchases a new plan, that plan will send the Member premium information
and enrollment forms. The Member may continue coverage for the remainder of the
Cal-COBRA continuation period. It is important for the Member to keep Horizon
Health EAP-Behavioral Services and the group updated if there are any changes of
address.- The Cal-COBRA continuation coverage will terminate if the Member fails
to enroll and pay premiums to the new group benefit plan within thirty (30) days after
receiving notification of the termination of the Horizon Health EAP-Behavioral
Services group benefit plan.
If the group changes its EAP benefit to another plan, the Members coverage with
Horizon Health EAP-Behavioral Services will expire, and you will be given the
opportunity to continue coverage with the new plan. The new plan is required to
provide coverage for the balance of the Cal-COBRA continuation coverage period.
XVII. COMPLAINT AND GRIEVANCE PROCEDURE
A grievance is a written or oral expression of dissatisfaction regarding Horizon Health EAP-
Behavioral Services and/or an EAP Provider, including quality of care concerns, and includes
a complaint, dispute, request for reconsideration, or appeal made by you or your
representative. A complaint is the same as a grievance.
You are entitled to present complaints and grievances within one year of the occurrence.
Horizon Health EAP-Behavioral Services is obliged to seek to resolve such complaints and
grievances in a timely fashion. Horizon Health EAP-Behavioral Services has established a
procedure for processing and resolving your complaints and grievances.
Should you desire to register a complaint or grievance with Horizon Health EAP-Behavioral
Services concerning Benefits, you can either call Horizon Health EAP-Behavioral Services at
the toll-free telephone number 1-800-342-8111, or access the website at
www.horizoncarelink.com to either download the complaint form or to fill it out online. To
request a copy of the Horizon Health EAP-Behavioral Services Complaint Form, write
directly to Horizon Health EAP-Behavioral Services at 7676 Hazard Center Drive, Suite
1100, San Diego, CA 92108. The telephone call or letter should be addressed to the Director,
Clinical Quality Improvement. Horizon Health EAP-Behavioral Services will acknowledge
each complaint and grievance within five (5) days of receipt. The Director, Clinical Quality
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Improvement will receive and investigate all Member complaints and grievances. The
Director, Clinical Quality Improvement will respohd to you stating the disposition and the
rationale within thirty (30) days of receipt of the grievance. If the grievance is not resolved
to your satisfaction, a second level of review may be requested within ten (10) days of
notification of such disposition. Any such request will be reviewed by the Medical Director
and responded to within seventy-two (72) hours of receipt.
Linguistic and cultural needs will be addressed by translation of grievance forms and
procedures into languages other than English. Using TTY lines and varying the means by
which an Enrollee may submit a grievance, including verbally to Horizon Health EAP-
Behavioral Services' staff (bi-lingual capability), on website (Spanish and English), verbally
by provider (multi-language capability), or interpreter. This allows Enrollees to submit
grievances in a linguistically appropriate manner. When you are seen with the aid of an
interpreter, the interpreter or counselor reading this statement will explain the information
that is normally provided in a written format. - _
If you have a complaint or grievance about the services you have received, or will receive in
the future, you may notify your counselor (or interpreter), who will supply them with a
grievance form and a description of the process. If you wish to submit the grievance through
your counselor or interpreter, you may do so.
,Visually impaired clients may phone the Director of Quality Improvement directly at 1-800-
342-8111. The Director of Quality Improvement will describe the grievance procedure, and
take the grievance information. In this case, the appropriate letters would be sent, and the
client contacted by telephone so that the letter can be read. Hearing impaired clients may file
a grievance using the telephone number 858-712-1080 to contact Horizon Health EAP-
Behavioral Services.
If the complaint or grievance involves a delay, modification; or denial of service related to a
clinically emergent or urgent situation, the review will be expedited and a response provided
in writing to you within three. (3) days from receipt of the complaint or grievance. There is
no requirement that you participate in Horizon Health EAP-Behavioral Ser'vices' grievance
process before requesting a review by the California Department of Managed Care
(Department) in the case of an urgent or emergent grievance. The criteria for determining
emergent situations are whether you are assessed to be at imminent risk to seriously harm
yourself or another person, or are so impaired in judgment as to destroy property or be unable
to care for your own basic needs. The criteria for determining urgent situations are whether
you are assessed to be significantly distressed, and are in any medical danger due to the level
of the problem, or are experiencing a reduced level of functioning due to more than a
moderate impairment resulting in an inability to function in key family/work roles.
You, or the agent acting on your behalf, may also request voluntary mediation with Horizon
Health EAP-Behavioral Services prior to exercising the right to submit a grievance to the
Department. The use of mediation services will not preclude your right to submit a grievance
to the Department upon completion of the mediation. In order to initiate mediation, you, or
the agent acting on your behalf, and Horizon Health EAP-Behavioral Services will
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voluntarily agree to mediation. Expenses for the mediation will be borne equally by the
parties. The Department will have no administrative or enforcement responsibilities in
connection with the voluntary mediation process. Mediations will take place in San Diego,
California unless otherwise determined by the parties.
Pursuant to Section 1365(b) of the Act, any Member who alleges his enrollment has been
canceled or not renewed because of his health status or requirement for services may request
review by the Department.
The California Department of Managed Health Care is responsible for regulating health care
service plans. If you have a grievance against your health plan, you should first telephone
your plan at (1-800-342-8111) and use the plan's grievance process (or locate their grievance
form on Horizon Health EAP-Behavioral Services' website at Kww.horizoncarelink.com)
before contacting the Department. Utilizing this grievance procedure does not prohibit any
potential legal rights or remedies that may be available to you. If you need help with a
grievance involving an emergency, a grievance that has not been satisfactorily resolved by
your plan, or a grievance that has remained unresolved for more than thirty (30) days, you
may call the Department for assistance. You may also be eligible for an Independent
Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an
impartial review of medical decisions made by a health plan related to the medical necessity
of a proposed service or treatment, coverage decisions for treatments that are experimental or
investigational in nature and payment disputes for emergency or urgent medical services.
The Department also has atoll-free telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The Department's intemet web site
http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions
online. The Plan's grievance process and the Department's complaint review process are in
addition to any other dispute resolution procedures that may be available to you, and your
failure to use these processes does not preclude your use of any other remedy provided by
law.
XVIII. MISCELLANEOUS
A. Confidentiality Policy
A STATEMENT DESCRIBING HORIZON HEALTH EAP-BEHAVIORAL
SERVICES' POLICIES AND' PROCEDURES FOR PRESERVING THE
CONFIDENTIALITY.OF MEDICAL RECORDS IS AVAILABLE AND WILL BE
FURNISHED TO A MEMBER UPON REQUEST.
B. Member Consent
Under the EAP Services Agreement, the Group makes Benefits which are consistent with
professionally recognized standards of practice, available to Members. The EAP
Services Agreement is subject to amendment, modification or termination, in accordance
with the provisions thereof, or by mutual agreement between Horizon Health EAP-
Behavioral Services and the Group, without the consent or concurrence of Members. By
accepting Benefits hereunder, all Members legally capable of contracting, and the legal
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representatives of all Members incapable of contracting, agree to all terms, conditions
and provisions of the EAP Services Agreement.
C. Horizon Health EAP-Behavioral Services' Policies
Horizon Health EAP-Behavioral Services may adopt reasonable policies, procedures,
rules and interpretations to promote orderly and efficient administration of the EAP
Services Agreement.
D. Horizon Health EAP-Behavioral Services' Public Policy Committee
Horizon Health EAP-Behavioral Services has established a Public Policy Committee that
includes, among others, Members of Groups that have contracted with Horizon Health
EAP-Behavioral Services for Benefits. This committee meets quarterly and the Horizon
Health EAP-Behavioral Services Board of Directors reviews the reports and
recommendations of the committee. Any Member desiring more..information about this
committee should contact Horizon Health EAP-Behavioral Services at I-800-342-8111.
E. Term and Renewal Provisions
The initial term of the EAP Services Agreement is thirty-six (36) months. Thereafter the
agreement is automatically renewed for successive twelve (12) month periods, subject to
the termination provisions contained therein.
F. Important Information about Organ and Tissue Donations
Organ and tissue transplants have helped thousands of people with a variety of problems.
The need for donated organs, corneas, skin, bone and tissue continues to grow beyond the
supply. Organ and tissue donation provides you with an opportunity to help others.
Almost anyone can become a donor. There is no age limit. If you have questions or
concerns you may wish to discuss them with your doctor, your family; or your clergy.
Resources for Information:
• For information and donor card call 1-800-355-SHARE.
• Request donor information from the Department of Motor Vehicles.
• On the Internet, contact All About Transplantation and Donation (www.transweb.org).
• Department of Health and Human Services, contact http://www.organdonor.gov.
Share your decision with family.
If you decide to become a donor:
• Sign the donor card in the presence of family members.
• Have your family sign as witnesses and pledge to carry out your wishes.
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EXHIBIT A -SCHEDULE OF BENEFITS, LIMITATIONS, AND EXCLUSIONS
Employee Assistance Program
A. Benefits.
1) Individual, couple, or family assessment and brief counseling for personal, marital,
family, relationship, work-related, and alcohol or substance abuse problems. Brief
counseling is provided when, in the judgment of the EAP provider, the issues meet
community standards of practice for brief counseling within eight (8) private
counseling sessions per separate incident. A"session" is defined as either an in-
person or telephone consultation with the Member, of approximately one hour in
duration. Sessions are used to identify or work on resolving the issues or conditions
` that the Member is experiencing. Anew incident for the same Member would
involve different issues or conditions. Benefits will be consistent with professionally
recognized standards of practice. A separate incident involves a single underlying
issue or condition, regardless of the number of same or different events involving the
issue or condition. The Plan shall make the clinical determination as to what
constitutes a separate incident.
2) Referrals are offered to Members whose problem cannot be resolved within the scope
of the eight (8) sessions per separate incident. The EAP Provider works with the
Member to identify resources of an appropriate type and level of care beyond the
benefit.
3) Referrals to other resources are offered to Members if the type of care is outside of
the scope of practice of this benefit.
4) 24-hour crisis hotline, 7 days/week.
5) Referrals for legal consultation.
6) Referrals for financial counseling.
7) Identity theft consultation. '
8) Childcare/Eldercare database on Horizon Health website.
B. Limitations
1) The Benefits provided to Members by Horizon Health EAP-Behavioral Services are
limited in nature as described in sections 1-8 above.
2) Horizon Health EAP-Behavioral Services will make a good faith effort to provide or
arrange for the provision of Benefits to Members, in the event of certain
circumstances; such as major disaster, epidemic, riot or civil insurrection.
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C. Exclusions.
1) Inpatient treatment of any kind, or outpatient treatment for any medically treated
illness.
2) Psychiatrist services.
3) Prescription drugs.
4) Counseling services beyond the number of sessions covered by the benefit.
5) Services by counselors who are not Participating Providers.
6) Court ordered treatment or therapy, or any treatment or therapy ordered as a condition
oP parole, probation, custody, or visitation evaluations, or paid for by Workers'
Compensation.
7) Formal psychological evaluations which normally involve psychological testing and
result in a written report.
8) Fitness for duty evaluations which are used to evaluate whether an employee is safely
able to perform his or her duties. This typically includes psychological testing and a
written report
9) Investment advice (nor does Horizon Health EAP-Behavioral Services loan money or
pay bills).
10) Legal representation in court, preparation of legal documents, or advice in the areas
of taxes, patents, or immigration.
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EXHIBIT B
HEALTH AND HUMAN RESOURCE CENTER
(dba HORIZON HEALTH EAP-BEHAVIORAL SERVICES)
EMPLOYEE ASSISTANCE PROGRAM
EXHIBIT B -COMPARISON OF BENEFITS
The Employee Assistance Program (EAP) is being offered by your employer to provide you with
confidential assistance from licensed mental health professionals. These professionals can help
with problems affecting your life at work as well as at home. Such problems include marital issues,
family relationships, depression and anxiety, alcohol and drug issues, and/or problems within the
workplace.
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS
AND IS A SUMMARY ONLY. THE COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE
FORM AND THE EAP SERVICES AGREEMENT SHOULD BE CONSULTED FOR A DETAILED
DESCRIPTION OF BENEFITS, LIMITATIONS AND EXCLUSIONS.
A. Deductible Not applicable
B. Lifetime Maximum Not applicable
C. Professional Services The EAP provides:
Psychosocial Assessment
Treatment Referrals and Resources for Psychosocial Problems
24-hour Crisis Telephone Access
Eight (8) Counseling Sessions Per Incident
Legal Referrals
Financial Counseling Referrals..
Identity Theft Consultation
D. Outpatient Services Please see Item C: Professional Services
E. Hospitalization Services None -
F. Emergency Health Coverage Please see Item C: Professional Services
G. Ambulance Services None
H. Prescription Drug Coverage None
I. Durable Medical Services None
J. Mental Health Services Please see Item C: Professional Services
K Chemical Dependency Services Please see Item C: Professional Services
L. Home Health Services None
M. Other None
Members pay no co-payment. Coverage is limited to: a) eligible employees; b) the eligible
employee's children under the age of 26; c) persons covered under the eligible employee's health
benefit plan; d) persons residing with the eligible employee, including domestic partners.
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RESOLUTION NO. 2013-
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CHULA VISTA ADOPTING THE CITY OE CHULA VISTA
CAFETERIA BENEFITS PLAN FOR 2013
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 § l25(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, 2013; 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 20 L3 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 2013.
Presented by
Kelley Bacon
Director of Human Resources and
Information Technology Services
Approved as to form by
„~ /1t-
Glen Googins.
City Attorney
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