HomeMy WebLinkAbout2013/12/10 Item 10 -- ���-� CITY COUNCIL
, ' -° � � AGENDA STATEMENT
_`��� �,� �vr�
_ _ �� CffY OF
CHULA VISfA
DECEMBER 10, 2013, Item1�
ITEA4 TITLE: RESOLUTION ADOPTII�TG THE CITY OF CHLJLA VISTA
CAFETERIA BEI�TEFITS PLAN FO 2014
SUBNIITTED BY: DEPUTY CITY I� \' GER �
RE�'IEWED Bl': CIT7' A4ANAGER / �/ ' - �
ASSISTA�\iT CITY i 4Ah?AGER(�
�� y
�hTHS VOTE: YES � NO ❑X
SUi��VIARY
The Intemal Revenue Code requires that the Section 12� Cafeteria Benefits Plan offered
by the City to its employees be in a ���ritten document and that the document be formally
adopted by the City Council on or before the first day of the plan yeaz. Adoption by
resolution of the attached plan document fulfills the Cih�'s oblieation for the 2014 plan
t�eaz.
ENVIRONMENTAL REVIE�V
Staff has re��ie�tied the proposed activity for compliance with the California
Environmental Quality Act (CEQA) and has detemuned that this proposed activiri� is not
a "ProjecY' as defined under section 1>378 of the State CEQA Guidelines because if�vill
not result in a phvsical chanee to the environment; therefore; pursuant to Section
1�060(c)(3) of the State CEQA Guidelines the action proposed is not subject to CEQA.
RECOMMENDATION
That Council adopt the plan bv resolution.
BOARDS/COi1'il�ZISSION RECOMMENDATION
\ot applicable.
DISCUSSION
In June 1998. the Cin� established its first Section 12� Cafeteria Benefits Plan. In
compliance ���ith Intemal Re��enue Code y 12�(d) the Citv Council annually adopts a
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DECEMBER 10. 2013. Item ��
Page 2 of 3
��ritten plan document prior to the first day of the plan yeaz. The first day of the City's
plan year is January l, 2014.
This Plan Document lays out how the City offers eligible employees the choice between
cash and certain nontaxable benefits (such as health insurance), thereby allo���ine
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 aze 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
mal:ing their benefit choices. The plans offered and their structure are determined after
our broker, Barney and Barney; e�tensively 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 2014 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
(FSAs)
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
Reeulations section 18704.2(a)(1) is not applicable to this decision. Staff is not
independenth�a���aze; 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.
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--- --- DECEMBER 10: 20li, Item /�
PaQe 3 of 3
LINK TO STRATEGIC GOALS
The City's Strateeic Plan has five major goals: Operational E�cellence; Economic
Vitaliri�. Healthv Communiri�. Suon2 and Secure I�Teiehborhoods and a Connected
Communit}�. Adopting the Ciri� s Cafeteria Benefit Plan document supports the
Operational Excellence goal as it helps attract and retain quality emplo}�ees. A Cafeteria
Benefit Plan is an ad��antaee for both the Cin and its employees because it allo�rs health
premiums to be deducted on a pre-tax basis. For the emplo��ee, it reduces the amount of
federal and state taxes the emplo}°ee has to pa}�. For the Citv, it reduces its pa}�roll ta�
liabilitv.
CURRENT YEAR FISCAL IDIPACT
The flex allotment and cafeteria plan yeaz to }�eaz chanee for all funds �i�as accounted for
in the fiscal year 2013/14 budget. The actual rate increases are in line ���ith the projected
increases used as part of the development of the budeet. The City spent �11.0 million in
fiscal ��eaz 2012/13 on these benefits for all funds.
ONGOING FISCAL IAZPACT
Flex allotments aze neeotiated ��th the Citv's bareaining eroups. Unrepresented
emplo}�ees and elected officials also receive flex allotments. \Vith the ezception of
Public Safety bazgaining groups; the City shares the cost of health insurance premiums on
a �0/�0 basis. For Public Safen� bazgaining groups, the Cih� assumes the full cost of the
medical premium increases. The increases reflected on the tables belo�v illustrate the
increase in the health insurance premiums on an annual basis. The impact to future
budeets and the five-��eaz financial forecast ���ill depend on the outcome of neeotiations
��ith the Citv`s bargaining groups and the changes and in health insurance premiums.
. �
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Attachments
2014 Cih�of Chula Vista Cafeteria Benefiu Plan
Exhibit A—Dental/�ledical/Vision & DependendChild Care Reimbursement Accounts
Ea:hibii B—Voluntarv Plan(Aflac)
E�hibit C—Employee Assistance Program
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RESOLUTION NO. 20]3
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF .
CHULA VISTA ADOPTTI��G THE CITY OF CHULA VISTA
CAFETERIA BENEFITS PLAN FOR 2014
WHEREAS, the Internal Revenue Code requires that the Section 12� 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 12� Cafeteria Benefits
Plan; and
���HEREAS, in compliance ���ith Internal Revenue Code y 125(d) the City Council
annually adopts a written plan document prior to tbe first day of the plan year, and
WHEREAS, the first day of the City's plan year is January 1, 2014; and
WHEREAS, this Plan Document lays out how the City offers eligible employees the
choice bet�veen cash and certain nontaxable benefits (such as health insurance), thereby allo�ving
employees to pay for the benefits they choose on a pre-taY 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 tifiat is I:nown as the Summary Plan Document that
was given to eligible employees as part of their open enrollment materials to assist them in
mal:ing their benefit choices; and
WHEREAS, the plans offered and their structure are determined afrer our broker, Bamey
and Barne}�, 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 aze advised of the offers and the plan structures that �i�ill
provide the least increase in premium costs; and
WHEREAS, under current cafeteria plan regulations having an approved N�ritten plan is
critical; and
WHEREAS, without a �i�ritten plan or if the ���ritten 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 ta�able; and
J:�Anomev\FIA'AL RESOS AIQD ORDIi�'ANCES�2013\I2 10 13\R6S0-HR-Cafetcria Benefits 2014.doc
1 I/?5/?013 9:40 AM
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Resolution I�`o. 2013-
Paee 2
�VHEREAS; the City has timed its open enrollment period for 2014 to comply �rith these
rewlations and to meet provider cutoff deadlines for enrollment to ensure employees aze covered
�;�ithout interruption; and
WHEREAS; The Cin�'s Plan inciudes the follo��ine required information: description of
available benefits, panicipation rules, election procedures; manner of contributions, ma�imum
amount of contributions; the plan ��ear, and the plans pro��isions for compl��ing with flexible
spendine arraneements (FSAs).
Np«r THEREFORE. BE IT RESOLVED that the Cin Counci] of the Citti� of Chula
Vista does hereby adopt the Cit}� of Chula Vista Cafeteria Benefits Plan for 2014.
Presented by Approved as to form b��
���.�, ,�/��� ��1',,,,9',, �'
I�elley con Glen R. Googins
Deputy.Cit�� Manaeer City Attome}�
. J:Waomev�Fi?�AL RESOS A\D ORDIhA\CES�Oli\12 IO 13UtE50-HR-Cafeteria Benefits 3014.doc
I t/ZS/?013 9:40 A,\1
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CHULA VISTA
CAFETERIA BENEFITS PLAN
FOR
THE CITY OF CHULA VISTA
Amended and Restated as of January 1, 2014
Established June 1998
Human Resources Department
City of Chula Vista
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SECTION 125 CAFETERIA BENEFIT PLAN
ADOPTION AGREEMENT
The undersigned Employer hereby adopts the Section 125 Cafeterra 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: City of Chula Vista
Address: 276 Fourth Ave.
Chula Vista, CA 91910
Employer Tax ID: 95-6000690 -_
Nature of Business: Municipal Government
Name of Plan: City of Chula Vista Cafeteria Benefits
Plan
B. EFFECTIVE DATE
Original Effective Date of Plan: June 1998
Effective Date of Amendment: January 1, 2014
C. ELIGIBILITY REQUIREMENTS FOR PARTICIPATION
, Eligibility requirements for each component plan under this Section 125
document will be applicable and, if different, will be listed in Item F.-
Employee Status: Directly employed by the City of Chula
Vista in a full- or part-time benefited
status. Part-time benefited employees
must be authorized to work at least haif-
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, 2014 and end on December
31, 2014.
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E. EMPLOYER CONTRIBUTIONS
Non-Elective Contributions: Flexible Allotment
The maximum amount available to each
Participant for the purchase of certain
elected benefits (Group Medical
Insurance, Group Dentalinsurance,
Group Vision, Dental/MedicalNision and
DependenUChild Care Reimbursement
and Cash Payment Option) with non-
elective contributions will be:
Confidential ==$13,074
CVEA $12,574
Executive $15,850
MM,MMCF,MMUC $13,450
PROF,PRCF,PRUC $13,450
Senior Managers $14,450
WCE $13,450
Mayor/Council $15,850
Non-Elective Contributions For Employees represented by POA/IAFF
Safe —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
pians. 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 dental
premium for the coverage level elected.
Elective Contributions (Salary Each Participant may authorize the
Reduction►: Employer to reduce his or her
compensation by the amount needed for
the purchase of benefits elected, less the
amount of non-elective contributions. An
election for salary reduction will be made
on the Benefit Election Form or via
Employee Online enrollment.
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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 The terms, conditions, and limitations for
Mandatory for all employees the Group Medical Insurance will be as
except those who are covered set forth in the insurance policy or policies
by their City Employee Spouse described below: (See Section V of the
or who are in ciassifications (all Plan Document).
groups except CVEA, POA and
IAFF), who can provide
evidence of other qualified
, coverage.
2. Dental Insurance 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).
3. Vision Insurance 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).
4. Dental/MedicalNision The terms conditions and limitations for
_ Reimbursement Account the Dental/MedicalNision
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: 52,500 from all
sources per Plan Year.
Recordkeeper: WageWorks
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5. DependenUChild Care The terms conditions and Limitations for the
Reimbursement Account DependenU Child Care Reimbursement
Account will be as set forth in Section VII of the
Plan Document and described below:
Minimum coverage: $0 per Plan Year
Maximum Coverage-$5,000 per plan year from all
sources ($2,500 per plan year from all sources for a
married employee filing separate tax returns).
Recordkeeper: 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 Intensive Care Insurance
Contributions (Salary AFLAC Accident Insurance
Reduction): AFLAC Hospital Indemnity Insurance
AFLAC Specified Health Event Insurance
The terms condition and limitations for the
AFLAC programs will be as set forth in Section
VIII of the Plan Document.
Administered by: AFLAC
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
California. Should any provision be determined to be void, invalid, or
unenforceable by any court of competent jurisdiction, the Plan will continue to
operate, and for purposes of the jurisdiction of the court only, will be deemed
not to include the provision determined to be void.
This Plan is hereby adopted the 10�' day of December, 2013.
By:
Title: Citv Mavor
TNIS 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 II
DEFINITIONS
The following words and phrases appear in this. Plan and will have the meaning
indicated below unless a different meaning is plainly required by the context:
"Administrator" means the Human Resources Department of the City of Chula
Vista, or other such person or entity that it appoints as its designee.
"Annual Enrollment Period" means the period designated by the Administrator
which precedes the commencement of each Plan Year during which Eligible
Employees can 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 (fl
that is offered under the Cafeteria (Flexible) Benefits Plan, or an option for coverage
under an underlying health plan (such as an HMO or PPO option under a health
plan).
"Benefits" or "Qualified Benefits" means the following benefits available under
the Flex Plan:
(a) Group Medicallnsurance
(b) Dependent/Child Care Reimbursement Account
(c) Dental/MedicalNision Reimbursement Account
(d) Cash Compensation (Post-Tax)
(e) Health Premiums for Non-Tax Qualified Dependents (Post-
Tax)
(fl Vision Insurance
(g) Dentallnsurance --
(h) Certain AFLAC Plans available via salary reduction only
In order for a benefit to be qualified, a participant must also meet federal and/or state
tax requirements, including Code Section 152, etc.
"Child" means for these purposes will include (1) a natural child, (2) a stepchild, (3)
a legally adopted child, (4) a child placed with the employee for legal adoption, (5) a
foster child and (6) a child placed under the legal guardianship of the employee. In
addition and in order to comply with OBRA 1993: a child will include a child for
whom the employee or covered dependent spouse or Life Partner is required to
provide coverage due to a Medical Child Support Order. A Qualified Medical Child
Support Order (QMCSO) will also include a judgment, decree or order issued by a
court of competent jurisdiction or through an administrative process established
under state law and having the force and effect of law. -
"Code" means the Internal Revenue Code of 1986, as amended.
"Dental/Medical/Vision Reimbursement AccounY' Shall have the meaning
assigned to it by Section 6.01 of the Plan attached hereto as Exhibit A.
"DependenY' means an individual including:
(a) ParticipanYs legal spouse;
(b) Life Partner (see definition of Life Partner)
(c) Child of the employee, spouse or Life Partner who 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 AccounY' 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
o�cials 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. !t 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 315t.
"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 the employee and their partner are eighteen (18) years
of age or older and are capable of consenting to the domestic partnership; neither
can be married to another or be a member of another domestic-partnership; cannot
be related by blood in a way that would prevent them from being married to each
other in this state; they 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); They 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 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 ParticipanYs elected coverage
dependent status, and for all others may be based on the commencement or
termination date of the ParticipanYs employment during the Plan Year, and such
other factors as the Employer shall prescribe. To the extent set forth in the
Summary Plan Description or enrollment material, the Employer may make non-
� elective contribution available to Participants and allow Participants to allocate the
Non-elective Contributions among the various Benefit Plan Options offered under
the Plan in a manner set forth in the Summary Plan Description or enrollment
material. In no event will any Non-elective Contribution be disbursed to a PaRicipant
in the form of additional, taxable Compensation except as otherwise provided in the
Summary Plan Description or enrollment material.
"ParticipanY' 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 not a "Qualified BenefiY'
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
enroliment forms on or before the entry date.
3.02 ENROLLMENT: An eligible Employee may enroll (or re-enroll) in the Plan by
submitting to the Employer, during an enrollment period, an Election Form
which specifies his or her benefit elections for the Plan Year and which meets
such standards for completeness and accuracy as the Employer may establish.
A ParticipanYs Election Form shall be completed prior to the beginning of the
Plan Year, and shall not be effective prior to the date such form is submitted to
the Employer. Any Election Form submitted by a Participant in accordance with
this Section shall remain in effect until the earlier of the following dates: the
date the Participant terminates participation in the Plan; or, the effective date of
a subsequently filed Election Form.
A ParticipanYs right to elect certain benefit coverage shall be limited hereunder
to the extent such rights are limited in the Policy. Furthermore, a Participant
will not be entitled to revoke an election after a period of coverage has
commenced and to make a new election with respect to the remainder of the
period of coverage unless both the revocation and the new election are on
account of and consistent with a change in status, or other allowable events, as
determined by Section 125 of the Internal Revenue Code and the regulations
thereunder. Notwithstanding anything to the contrary herein, to the extent
required by the Health Insurance Portability and Accountability Act of 1996, the
Plan shall permit special enrollment period for employees who have previously
declined coverage under the Plan; a new dependent may also justify a special
enroliment 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 wili stop. Any Flex Ailotment
funds remaining after the heaith 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 wiil 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 ParticipanYs 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.
12
10-17
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 ParticipanYs existing coverage under the Pian with
respect to the benefits under Section V and Section VI of the Plan on the
same terms and conditions as though they were still an active Employee. If
the Employee fails to return to work after such leave for any reason other than
the serious illness of the employee or the family member for whom the leave
was granted or through no fault of the employee, they will be required to pay
all Cafeteria Benefits Plan monies paid to them, or on their behalf during the
absence.
3.07 COVERAGE WHILE ON A LEAVE OF ABSENCE WITH BENEFITS:
Employees who are authorized to take a leave with benefits (e.g. Military
Leave as approved by the City Council) will continue to be covered under the
Plan until the expiration of their leave.
3.08 COVERAGE WHILE ON A LEAVE OF ABSENCE WITHOUT BENEFITS:
Employees on an unpaid leave of absence for any reason other than those
under Section 3.06 and 3.07 are no longer eligible for participation in the
Plan. If an employee returns from an unpaid leave of absence without
benefits, the date the coverage is reinstated will depend on the employee's
date of return. If the employee returns to work on or before the 15"' 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 reinsYated the
first of the following month.
13
10-18
SECTION IV
CONTRIBUTIONS
4.01 EMPLOYER CONTRIBUTIONS: The Employer may pay the costs of the
benefits elected under the Plan with funds from the sources indicated in Item
E of the Adoption Agreement. The Employer Contribution may be made up of
Non-Elective Contributions and/or Elective Contributions authorized by each
Participant.
4.02 IRREVOCABILITY OF ELECTIONS: A Participant may file a written election
form with the Administrator before the end of the current plan year revising
the rate of his contributions or discontinuing such contributions effective as of
the first day of the following Plan Year. The ParticipanYs Elective
Contributions will automatically terminate the date - his employment
terminates. Except as provided in this Section 4.02 and Section 4.03, a
FaRicipanYs 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 a mid-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) Chancie 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
10-19
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 efigibility
requirements; and
(5) Resident change of Employee, spouse or Dependent, affecting the
Employee's eligibility for coverage.
(b) Speciai HIPAA Enroliment Riqhts. If a Participant or a ParticipanYs
Dependent enrolls in the health insurance plan pursuant to special enrollment
rights under HIPAA, the Participant may make a corresponding change in
election under this Plan. Special enrollment rights under the health insurance
plan will be determined by the terms of the health insurance plan.
(c) Certain Judqments Decrees or Orders. If a judgment, decree or order
resulting from a divorce, legal separation, annulment cr change in legal
custody (including a qualified medical child support order [QMCSO]) requires
accident or health coverage for a ParticipanYs child or for a foster child who is
a dependent of the Participant, the Participant may have a mid-year election
change to add or drop coverage consistent with the Order.
(d) Entitlement to Medicare or Medicaid. If a Participant or a ParticipanYs
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) Familv 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/MedicalNision Reimbursement Plan, as follows:
(a) Chanqe in Cost. If the cost of a benefit package option under the Plan
significantly increases during the plan year, Participants may (i) make a
corresponding increase in their salary reduction amount, (ii) revoke their
elections and make a prospective election under another benefit option
offering similar coverage, or (iii) revoke election completely if no similar
coverage is available, including in spouse or dependenYs 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
10-20
decreased in cost during the year. If the increased or decreased cost of a
benefit package option under the Plan is insignificant, the participanYs salary
reduction amount shall be automatically adjusted.
(b) Siqnificant curtailment of coveraqe.
(i.) With no loss of coverage. If the coverage under a benefit
package option is significantly curtailed or ceases during the
Plan Year, affected Participants may revoke their elections for
the curtailed coverage and make a new prospective election for
coverage under another benefit package option providing similar
coverage.
(ii.) With loss of coverage. It there is a significant curtailment of
coverage with loss of coverage, affected Participants may
revoke election for curtailed coverage and make a new
prospective election for coverage under another benefit
package option providing similar coverage, or drop coverage if
no similar benefit package option is available.
(c) Addition or Siqnificant Improvement of Benefit Packaqe Oqtion. 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) Chanqe in Coveraqe of a Spouse or Dependent Under Another Emplover's
Plan. If there is a change in coverage of a spouse, former spouse, or
Dependent under another employer's plan, a Participant may make a
prospective election change that is on account of and corresponds with a
change made under the plan of the spouse or Dependent. This rule applies if
(1) mandatory changes in coverage are initiated by either the insurer of
spouse/dependenYs plan or by the spouse/dependenYs employer, or (2)
option changes are initiated by the spouse/dependenYs employer or by the
spouse/dependent through open enrollment.
(e) Loss of coveraqe under other qroup health coveraqe. If during the Plan Year
coverage is lost under any group heaith 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.
16
10-21
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 Empioyer'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 avail�ble under this Plan will be
as defined in items F(1), F(2)', and F(3) of the Adoption Agreement.
5.04 TERMS. CONDITONS AND LIMITATIONS: The terms, conditions and
limitations of the benefits offered shall be as specifically described in the
Policy identified in the Adoption Agreement.
5.05 COBRA: To the extent required by Section 49806 of the Code and Sections
601 through 607 of ERISA, Participants and Dependents shall be entitled to
continued participation in this Group Medical Insurance Benefit Plan by
contributing monthly (subject to taxation) 102% of the amount of the premium
for the desired benefits during the period that such individual is entitled to
elect continuation coverage, provided, however, in the event the continuation
period is extended to 29 months due to disability, the premium to be paid for
the continuation coverage for the 11 month extension period shall be 150% of
the applicable premium.
5.06 SECTION 105 AND 106 PLAN: It is the intention of the Employer that these
benefits shall be eligible for exclusion from the gross income of the
Participants covered by this benefit plan, as provided in Code Sections 105
17
10-22
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 ali 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/MEDICAWISION REIMBURSEMENT PLAN
6.01 The Plan Document for this option is included in the attached Exhibit A and is
incorporated by reference.
18
10-23
SECTION VII
DEPENDENT/CHILD CARE REIMBURSEMENT PLAN
7.01 The Plan Document for this option is included in the attached Exhibit A and is
incorporated by reference.
SECTION VIII
AFLAC CANCER, BASIC DENTAL COVERAGE, ACCIDENT INSURANCE,
HOSPITAL INDEMNITY INSURANCE, SPECIFIED HEALTH EVENT
INSURANCE
8.01 The Plan Document for these options is included in the attached Exhibit B
and is incorporated by reference.
SECTION IX
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 federai 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
10-24
10.02 TERMINATION: The Employer shall have the right at any time to terminate
this Plan, provided that such termination shall not eliminate any obligations
of the Employer which therefore have arise under the Plan.
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
DependenUChild 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 arid
determination of amount, time and manner of payments of
benefits), construction, interpretation and application of the Plan,
and the decision of the Administrator shall be final and binding on
all persons.
b. Recordkeeping. The Administrator shall keep full and complete
records of the administration of the Plan. The Administrator shall
prepare such reports and such information concerning the Plan and
the administration thereof by the Administrator as may be required
under the Code or ERISA and .the regulation promulgated
thereunder.
c. Inspection of Records. The Administrator shall, during normal
business hours, make available to each Participant for examination
by the Participant at the principal office of the Administrator a copy
of the Plan and such records of the Administrator as may pertain to
such Participant. No Participant shall have the right to inquires as
to or inspect the accounts or records with respect to other
Participants.
20
10-25
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
depreciation which may result in connection with the exercise of duties or of
discretion hereunder or upon any other act or omission hereunder except
when due to willful misconduct. In the event the Administrator is not covered
by fiduciary liability insurance or similar insurance arrangements, the
Employer shall indemnify and hold harmless the Administrator from any and
all claims, losses, damages, expenses, (including reascnable 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 wiilful 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 time, all or any part of its responsibilities
under the Plan to such person or persons as it may deem advisable and in
the same manner to revoke any such delegation of responsibility which shall
have the same force and effect for all purposes hereunder as if such action
had been taken by the Administrator. The Administrator shall not be liable for
any acts or omissions of any such delegate. .The delegate shall report
periodically to the Administrator concerning the discharge of the delegated
responsibilities.
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 Pian or other Plans
without consent or notice to any person. This information may be released to
or obtained from any insurance company, organization, or person subject to
applicable law. Any individual claiming benefits under this Plan shall furnish
to the Administrator such information as may be necessary to implement this
provision.
11.08 CLAIM FOR BENEFITS: To obtain payment of any benefits under the Plan a
PaRicipant 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
10-26
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;
. RepoR 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
10-27
SECTION XII
MISCELLANEOUS PROVISIONS
12.01 FORMS AND PROOFS: Each Participant or ParticipanYs Beneficiary eligibie
to receive any benefit hereunder shall complete such forms and furnish such
proofs, receipts, and release as shali 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 femimine 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, fhe
provisions of ERISA will not apply to this Plan if the Plan is exempt from
coverage under ERISA. Should any provisions be determined to be void,
invalid, or unenforceable by any court of competent jurisdiction, the Plan will
continue to operate, and for purposes of the jurisdiction of the court or�ly will
be deemed not to include the provision determined to be void.
23
10-28
EXHIBIT A
��S//
��
crrr oF
CHULA VI57A
DENTAL/MEDICAL/VISION
AND
DEPENDENT/CHILD CARE
REIMBURSEMENT ACCOUNTS
PLAN DOCUMENT
Amended and Restated as of January 1, 2014
Human Resources Department
City of Chula Vista
10-29
CITY OF CHULA VISTA
FLE�IBLE BEA'EFITS PLAN
SIP_1iMARY PLA�1' DESCRIPTION
TABLE OF COA'TENTS
CAFETERIA PLAN COD�IPOA�ENT SUDIM.ARY..................................................................................2
Q-1. What is the purpose of the Cafeteria Plan?.............................................................................2
Q-2. Who can participate in the Cafeteria Plan?.............................................................................2
Q-3. How do]become a participant?.............................................................................................2
Q�. When does my participation in the Cafeteria Plan end?.........................................................3
Q-5. What are tax advantages and disadvantages of participating in.the Cafeteria Plan?..............3
Q-6. What are the election periods for entering the Cafeteria Plan? ..............................................4
Q-7. Under what circumstances can I change my election during the Plan Yeaz?.........................5
Q-8. How is my Beuefit Plan Option coverage paid for under this Cafeteria Plan?.......................�
Q-9. What happens to my participation under the Cafeteria Plan if I take a leave of absence?.....6
Q-10. How loog will the Cafeteria Plan remain in effect?................................................................7
Q-11. What happens if my request for a benefit under this Cafeteria Plan is denied? .....................7
HE.ALTH CARE SPENDIIVG ACCOUIQT COMPONENT SUMMARY.............................................8
Q-1. Who can participate in the Health Caze Spending Account?..................................................8
Q-2. How do I become a Participant?.............................................................................................8
Q-3. What is my Health Care Spending Account?.........................................................................9
Q-4. When does my coverage under the Health Care Spending Account end?..............................9
Q-5. Can I ever change my Health Care Spending Account election?.................._.......................9
Q-6. WUat happens to my Health Care Spending Account if I take an approved leave of
absence?.....................................................:......................................:...................................10
Q-7. What is the maximum annual Health Care Spending Account amount that I may elect -
under the Health Care Spending Account, and how much will it cost?...............................10
Q-8. How are Health Care Spending Account benefits paid for under this Plan?........................10
Q-9. What amounts will be available for Health Care Spending Account Reimbursement at
any particular time during the Plan Year?............................................................................10
Q-10. How do I receive reimbursement under t6e Health Care Spending Account?.....................I1
Q-11. What is an"Elieible Medical Expense?.........................................-----........_....................11
Q-12. When must the expenses be incurred in order to receive reimbursement?...........................12
Q-13. What if the "Eligible Medical Expenses" I incur during the Plan Year are less than the
annual amount I have elected for the Health Care Spending Account Reimbursement?.....13
Q-14. What happens if a Claim for Benefits under the Health Care Spendine Account is
denied?..................................................................................................................................13
Q-15. V✓hat happens to unclaimed Health Caze Spending Accouot Reimbursements? .................14
Q-16. What is continuation covera�e?............................................................................................]4
Q-17. Will my health information be kept confidential?................................................................16
Q-18. How long will the Health Care Spending Account remain in effect? ..................................16
DEPENDENT CARE SPENDIA'G ACCOUNT COMPONENT SUD4MARY...................................18
i
10-30
Q-1. R'ho can participate in the Dependent Caze Spendine Account?.........................................18
Q-?. How do I become a Participant?...........................................................................................18
Q-3. R'hat is my•'Dependent Care Spending Account?'.............................................................18
Q�. R'6en does my coveraee under the Dependent Care Spendine Account end?.....................18
Q-�. Can I ever chanee my Dependent Care Spendino Accouot election?..................................19
Q-6. What happeos to my Dependent Care Speudine Account if I take an unpaid leave of
absence?................................................................................................................................19
Q-i. �What is the maximum annual Dependent Caze Spendine Account Reimbursement that I
may elect under the Dependent Care Spendin�Account?....................................................19
Q-8. How do 1 pay for Dependent Caze Spendioe Account Reimbursemenu?............................20
Q-9. \�'hat is an "Eli�ible Employment-Related Expease" for which I can claim a
reimbursement?....................................................................................................................20
Q-10. Hou�do I receive reimbursement under the Dependent Care Spendina Account?...............21
Q-11. VJhen must the expenses be incurred in order to receive reimbursement?...........................22
Q-12. Nhat if the "Eli�ble Employmeot-Related Expenses" I incur durine the Plan Yeaz aze
less than the annual amount of coveraee I have elected for Dependent Care Spending
Account Reimbursement?.....................................................................................................23
Q-li. R'ill I be taxed on the Depeodent Cue Spending Account benefits I receive?....................23
Q-14. If 1 participate in the Dependent Caze Spending Account, will I still be able to claim the
household and dependent care credit on my federal income tax retum?..............................23
Q-15. ��'hat is the household and dependent care credit?...............................................................23
Q-16. VJhat happens to unclaimed Dependent Caze Spendina Account Reimbursements?...........24
Q-17. R'hat happens if my claim for reimbursement under the Dependent Care Spendine
Accountis denied?............................................................................................................�...24
Q-18 How loug will t6e Dependent Cue Spendine Account remain in effect?............................24
PL.�\L\'FOR�L4TION SUAIDLaR1'....................................................................................................15
?.. Employer/Plan Sponsor Information.......................:............................................................2�
B. Cafeteria Plan Component Information......:......................................:..................................26
C. Health Caze Spendin2 Account Component Information.....................................................2S
D. Dependent Care Spending Account Compouent Information..............................................30
APPENDIt I—CL.�,IA1S REVIER' PROCEDURE..............................................................................31
APPENDIX II—T.a.Y:1D V.4NTAGES EXADIPLE..............................................................................33
APPENDLY III—ELECTIOA' Cfi�\GE CHART................................................................................34
ii
10-31
CITY OF CHULA VISTA
FLEYIBLE BEA'EFITS PLAN
SUDIDIARY PLAN DESCRIPTION ("SPD")
Ciry of Chula Vista (the "Employer") is pleased to sponsor an employee benefit progam I;nou�n as a
"Fleaible Benefits Plan' (the "Plan") for you and your fellow employees. It is so-called because it leu
you choose from several different employee benefit plans (which we refer to as "Benefit Plan Options")
according to yow individual needs, and allows you to use pretax dollars to pay for them by entering into a
salary reduction arraneement with the Employer. This Plau helps you because the benefits you elect aze
nonta�cable (e.e., you save social securiry and income taxes on the amount of your salary reduction).
Altematively, to the eatent described in your enrollment materials, you may choose to pay for any of the
available benefits with After-tax Contributions as deductions from your salary.
This Plan has three compouents:
i. A Cafeteria Plan Component. The Cafeteria Plan Component allows you to pay your share of
certain underlying welfare benefit plans (called "Benefit Plan Options") with Pretax
Contribucions.
ii. The Health Care Spending Account ("HCSA"). The HCSA allows you to elect to use a
specified amount of Pretax Contributions to be used for reimbursement of Eligible Medical
Expenses. The HCSA is iutended to qualify as a Code Section 105 self-insured medical
reimbursement Plan.
iii. The Dependent Caze Spending Accoun[ ("DCSA"). The DCSA allows you to elect to use a
specified amount of Pretax Contributions to be used for reimbursement of Eli2ible
Employment-Related Expenses. The DCSA is intended to qualify as a Code Section 129
dependent care assistance plan.
Each of tbe three components is summarized in this document. Information relating to the Plan that is
specific to your Employer is described in the Plan Information Summary. For example, you can find the
identity of the Thud Party Administrator, the Employer, and the Plan Administraror in the Plan
Information Summary as well as the Plan Number and any applicable contact information. Each
summary and the attached Appendices coustitute the Summary Plan Description for the Cafeteria Plan.
The SPD (collectively, the Summary Plan Description or °SPD") describes the basic features of the Plaq
how it operates, and how you can get the maximum advantage from it. The Plan is also established
pursuant to a plan document into which this SPD has becn incorporated. However, if there is a conflict
between the official plan document and the SPD, the plan document will govem. Certain terms in this
Summary are capitalized. Capitalized terms reflect important tcrms that are specifically defined in this
Summary or in the Plan Document into which this Summary is incorporated. You should pay special
attention to these terms as they play an important role in defining your rights and responsibilities under
this Plan.
Panicipation in the Plan does not give any Participant the right to be retained in the employment oF his or
her Employer or any other right not specified in the Plan. If you have any questions regazding your nghts
and responsibilities under the Plan, you may also contact the Plan Administrator(who is identified in the
Plan Information Summary).
I
10-32
CITY OF CHLTI.A VISTA
FLESIBLE BENEFITS PL.�\'
SU�1n1�R]'PLA.\ DESCRIPTI01
Cafeteria Plan Component Summary
Q-1. R'ha[ is the purpose of[he Ca(eteria Plan?
The purpose of the Cafeteria Plan is to allow elioible Employees to pay for certain benefit plans called
"Benefit Plan Options" with pretax dollars called "Pretax Cona-ibutioas." The BeneSt Plan Options to
w�hich you may contribute a�ith Pretax Contributions under this Cafeteria Plan aze described in the Plan
Information Summary. Pretax Convibutions are described in more detail below.
Q-?. R'ho cao participate in the Ca(eteria Plan°
Each Employee of the Employer(or an Affiliated Employer listed in the Plau Information Summaz}�) who
� (i) sausfies the Cafeteria Plan Elieibiliry Requirements and (ii) is also elieible to participate in any of the
Benefit Plan Options, w211 be eligible to participate in tLis Cafeteria Plan. If you meet these requuemenu,
��ou may become a Panicipant on the Cafeteria Plau ElieibiGty Date. I'he Cafeteria Plan Elieibility
Requiremenrs and Elieibility Date aze described in the Plan Information Summary. Those Employees
who actually participate in the Cafeceria Plan aze called"Participants.'°
The terms of eGgibiliry of this Cafeteria Plan do not override the terms of eligibility of each of the Benefit
Plan Oprions. In other words, if you aze elieible to participate in this Cafeteria Plan, it does not
necessanly mean you aze elieible to participate in the Benefit Plan Qpdons. For the de[ails reoazdine
elieibilip� provisions; benefit amounts, and premium schedules for each of the Benefit Plan Options,
please refer to the plan summary of each of the Benefit Plan Options. If you do not have a summary for
each of the Benefit Plan Options, }•ou should contact the Plan Administrator for information on how to
obtain a copy.
You may only pay for the co��eraee of yourself and your ta�c dependenu; however, for health plan
purposes and the Health Care Spendine Account), a Dependeot is ao}•cluld of yours who as of the end of
the tanable yeaz has not attained aee nventy-seveu (27)), even if he/she is married or is not a tax
dependent.
Q-3. How do I become a Participant?
If qou have otherw�ise satisfied the Cafeteria Plan Eligibility Requiremenu, you become a Participant by
si�ine an individual Salary Reduction Agreement (sometimes referred to as an "Elecdon Form') on
µ'hich you a�ee to pay for t6e Benefit Plan Options that you choose with Pretax Contributions. You w�ll
be provided with a Salary Reduction Agreement or Electiou Form on or before }�our Cafeceria Plan
Eligibility Date. You must complete the form and submit it to the Plan Administrator or its desi�nated
Tlurd Party Administraror (as indicated o0 or u�ith the Salary Reduction Agreement), during one of the
election periods described in C�-6 below. 1'ou may also euroll durine the yeaz if you previously eleceed
not to participate and you experience a chan�e described below that allows you to become a Participant
during the year. If.that occurs, you must complete an Election Change Form durine the Election Chanoe
Period described in �-7 below. In no event can you become a Participaut in this Cafetena Plan prior to
the date you complete and properlq submit the Salary Reduction A�eement to the appropriace persoo(s).
�
10-33
In some cases, the Employer may require you to pay your share of the Benefit Plan Option coveraee that
you elect with Pretax Contributions. If that is the case, your election to participate in the BeneSt Plan
Options(s)will constitute an election under this Cafeteria Plan.
Enrollment may also be accomplished via telephone, voice response technolow, electronic
communication, web or online enrollmen[ systems, or any other method prescribed by the Plan
Administrator.
Q-4. R`hen does m�� participation in the Cafeteria Plan end?
Your coverage under the Cafeteria Plan ends on the earliest of the followinL to occur:
a. The date t6at you make an election not ro participate in accordance with this Cafeteria Plan
Component Summary; •
b. The date you no lon�er satisfy the Eligibility Requirements of this Cafetena Plan or all of the
Benefit Plan Options;
c. The date that you[erminate employmeut with the Employer; or
d. The date that the Cafeteria Plan is either terminated or amended to exclude you or the class of
Employees of which you aze a member.
If your employment with the Employer is terminated during the Plan Yeaz or you otherwise cease to be
eligible, your active participation in the Cafeteria Plan will outomoricollv cease, and you will not be able
to make any more Pretax Contributions under the Cafeteria Plan except as otherwise provided pursuant to
Employer policy or individual arrangement (e.g., a severance arrangement where the former Employee is
permitted to continue paying for a Benefit Plan Option out of severance pay on a preta�c basis). If you are
rehired within the same Plan Year and are eligible for the Cafeteria Plan (or you become eligible again),
you may make new elections, if you are rehired or become eligible again more than 30 days afrer you
temunated employment or lost eligibility (subject to any limitations imposed by the Benefit Plan
Option(s)). lf you are rehired or again become eligible within 30 days or less of your temvnation date,
your Cafeteria Plan elections that were in effect when you temunated employment or stopped being
eligible will be reinstated and remain in effect for the remainder of the Plan Yeaz(unless you are allowed
to change your election in accordance with the terms of the Plan).
Q-5. R'hat are taz advantages and disadvantages oS participating in the Cafeteria Plan?
You save both federal i�come tax and FICA (Social Security) ta�ces by participating in the Cafeteria Plan.
There is an example in Appendix Il that illustrates the tax savings you might e�:perience as a result of
participating in the Cafeteria Plan.
Participation in the Cafeteria Plan will reduce the amount of your taxable compensation. Accordinely,
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.
3
10-34
Q-6. ��'hat are the election periods for entering the Cafeteria Plan?
The Cafeteria Plan basically has three election periods: (i) the "Initial Election Period," (ii) the "Annual
Elecdon Period,' and (iii) the "Election Chanee Period." which is the period fo1loH�ing the date you have
a Chaoee in Starus Event. The follou�ino is a summary of the Initial Election Period and the Annual
Election Period. �
O-6a. [f�hat is the Initial Election Period?
If you w�ant to participate in the Cafeteria Plan when you aze first. hired, you must enroll
durin�the"Initial Electiou Period" described in the enrollment materials you u�ll recei�e. if
you make an election durine the Initial Election Period, your participation in this Cafeteria
Plan uzll begin on the later of your EligibiGty Date or the first pay period coinciding �Rt6 or
next followine the date that your election is received by the Plan Administrator (or its
desi�ated Ilurd Pam�Administntor). The effective date of coveraee under the Benefit Plan
Options will be effecrive on the date established in the eoveming documents of the Benefit
Plan Options. TLe elecrion t6at you make duriue the Initial Election Period is effective for
the remainder of the Plan Yeaz and eeoerall}� cannot be chanoed durine the Plan Year unless
you have a Chanse in Status Event described in Q=i below. �
If}�ou do not make an election during the Initial Election Period, you w�ll be deemed to ha've .
elected no[ to participate in this Cafeteria Plan for the remainder of the Plan Yeaz. Failure to
make an election under this Cafeteria Plan generally resulu in no coveraoe under the Benefit
Plan Oprions; however, the Employer may provide coveraee under certain Benefit Plan
Options automatically. These automatic benefiu aze called "Default Benefiu." Any Default
BeneSt provided by your Employer will be identified in the enrollment materials. In
addition, vour shaze of the contributions for such Default Benefits mav be automaticallv
withdrawv from your pay on a pretax basis. You will be notified in the enrollment materials
whether there will be a correspondin2 Pretax Contribution for suc6 default benefits.
O-6b. l6hat is the Annual E(ection Period?
The Cafeteria Plan also has an "Annual Election Period" during which you may enroll if you
did not enroll during the Initial Election Period or change }•our elections for the next Plan
Year. The Annual Election Period will be idendfied in the enrollment materials disvibuted to
you prior to the rinnual Election Period. The election that you make during the Annual
Election Period is effective the first dav of the oext Plan Year and cannot be chansed durina
the entire Plan Year unless you have a Chauge iu Status Event described in�)-_-i_below. �
If you fail to complete, si�, and file a Salary Reductioo A�eement durine the ,annual
Election Period;you ma}�be deemed to have elected to continue participation in the Cafeteria
Plan with [he same Benefit Plan Option elections [hat you had on the last day of the Plan
Year in which che :�nnual Election period occurred (adjusted [o reflect an}� increue/decreue
in applicable premium/convibutions). This is called an '`Everereen Election:' Altematively;
the Plan Adminisuaror ma}�deem you to have elected not to participate in the Cafeteria Plan
for che next Plan Year if vou fail to make an election durine the Annual Election Period. The
consequences of failing to make an electioa durine the :�nnual Election Period aze described
in the Plan Informazion Summarv.
�
10-35
I
The Plan �'ear is generally a 12-month period (the initial or last Plan Yeaz of the Plan could be an
exception). The beginning and ending dates of the Plan Year are described in the Plan Information
Summarv.
Q-7. Under what circumstances can I change my election during the Plan Year?
Generally, you cannot chaoge your election under this Cafeteria Plan during the Plan Year. There are,
however, a few exceptions. �
First, your election will automatically terminate if you terminate employment or lose eligibiliry under this
Cafeteria Plan or uoder all of the Benefit Plan Options that you have chosen.
Second, you may voluntarily change your election during the Plan Year if you satisfy the following
conditions (prescnbed by federal law):
a. You eaperience a "Change of Status EvenY' that affects your eligibility under this Cafeteria Plan
and/or Benefit Plan Option; or
b. You experience a significant Cost or Covera�e Change; and
c. You complete and submit a wntten Election Change Form within the Election Chanee Period
described in the Plan Information Summarv. y
Change in Status E��ents and Cost or Coverage Changes recognized by this Cafeteria Plan, and the rules
surrounding election changes in the event you experience a Change in Status Event or Cost or Coverage
Change aze described in Aooendix III -Election Chanee Chart.
Third, an election under this Cafetena Plan may be modified downward during the Plan Yeaz if you are a
Key Employee or Highly Compensated Individual (as defined by the Intemal Revenue Code), if
necessary to prevent the Cafetena Plan &om becoming discriminatory within the meaning of the
applicable federal iocome ta�c law.
If coverage under a Benefit Plau Option ends, the corresponding Preta�c Contnbutions for that coverage
will automatically end. No election is needed to stop the contributions.
Q-8. How is my Benetit Plan Option coverage paid for under this Cafeteria Plan?
You may be given a choice to pay for any Benefit Plan Option coverage that you elect with Pretax or
After-ta�c Contributions. The enrollment materials you receive will indicate whether you have an option
to choose to pay with Pretax or Afrer-ta�c Contributions.
When you elect to paRicipate both in a Benefit Plan Option and this Cafeteria Plan, an amount equal to
your share of the annual cost of t6ose Benefit Plan Options that you choose divided by the applicable
number of pay periods you have during that Plan Year is deducted from each paycheck afrer your election
date. If you have choseu to use PretaY Conh-ibutions (or it is a Plan requirement), the deduction is made
before any applicable federal and/or state ta�ces are withheld.
An Employer may choose to pay for a shaze of the cost of the Benefit Plan Options you choose with Non-
elective Employer Contributions. The amount of Non-elective Employer Contributions that is applied by
the Employer towards the cost of the Benefit Plan Option(s) for each Participant and/or level of coveraee
5
10-36
is subject to the sole discretion of the Employer and it may be adjusted upwazd or dowvwazd in the
Employer's sole discretion. The A'on-elective Employer Conuibution amount will be calculated for each
Plan Yeaz in a uniform and nondiscriminatory manner and may be based upon your dependent status.
commencement or termination date of your emplo}rtnent during the Plao Year, and such other factors that
the Employer deems rele��ant. ln no event ��ill any A'on-elective Employer Contribution be disbursed to
}•ou in the form of additional taxable compensation except as otherwise pro��ided in the enrollment
material or the Plan Infoanation Summarv.
Q-9. R`hat happens to my participation under the Cafeteria Plan if I take a leave of absence?
The followine is a eeneral summarv of the rules reearding panicipation in the Cafeteria Plan (and tl�e
Benefit Plan Opdons) during a leave of absence. The specific election chanees that you can make under
this Cafeteria Plan followzne a leave of absence aze described in the Election Chanee Chan and the rules
reeardine coveraee under the Benefit Plan Options durine a lea��e of absence w•ill be described in the
Benefit Plan Option summaries. If there is a conflict between the Election Chanse Chart/Benefit Plan
Opdon Summaries and this Q-9, t6e Election Chanee Chart or Benefit Plan Option summary; whichever
is applicable, wzll conuol.
a. If you eo on a qualifying unpaid leave uoder the Family and\ledical Leave�ct of 1993 (F\q.A).
the Employer will continue to maintain your Benefit Plan Opdons that procide health co��eraae on
the same terms and conditions az though you w�ere still active to the extent required by FYII A
(e.g., the Employer will continue to pay iu shaze of the contribution to the extent you opt to
continue co��erage).
b. Your Employer may elect to continue all health coverage for Panicipanu w hile they aze on paid
leave (provided Participao[s on nou-FMLA paid leave are required to continue coveraee).. If so,
you will pay your share of the contributions by the method normalh� used durine aoy paid lea��e
(for example,with PretaC Contributions if that is what was used before the FMLA leave beean).
c. In the event of unpaid FD4LA lea�-e (or paid leave where coveraQe is not required to be
continued); if you opt to continue your goup health coveraee, you may pay your share of the
contribution in one of the follo�t�ing ways:
i. With Afrertax Contributions while you aze on leave.
ii. You may pre-pay all or a portion of your share of the contribution for the expected duration
of t6e leave with Pretax Cootributions from your pre-leave compensation by makins a
special election to that effect before the date such compensation would normally be made
available to you. Hou�ever, pre-payments of Pretaac Contributions may not be utilized to
fund coverage during the next Plan Year.
iii. By other arraneemenu a2reed upon betu-een you and the Plan Administrator (for example,
the Plan Adminisvator may fund coveraee durine the leave and u ithhold amounu from
your compensarion upon your retum &om leave).
The pay�nent options provided by the Emplo}�er uill be established in accordance with Code
Section 12�, FMLA and the Employer's intemal policies and procedures regardine leaves of
absence and ��ill be applied uniformly to all Patticipants. Altemativel}�; the Emplo}�er may
require all Participants to continue coveraee durin2 the leave. If so, }�ou may elec[ to discontinue
6
10-37
I
your share of the required contributions until you retum from leave. Upon retum from leave, you
will be required to repay the contribution not paid during the lea��e in a manner a�eed upon u�th
the Plan Administrator. The Election Change Chart will let you l;now whether you are able to
drop your coverage or whether you are required to continue coverage during the leave.
d. ]f your coverage ceases while on FMLA lea��e (e.g., for non-payment of required contributions),
you will be pernvtted to re-enter the Cafeteria Plan and the Benefit Plan Option upon retum from
such lea��e on the same basis as you were participating in the plaus prior [o the leave, or as
otherwise required by the F?dI.A. Your coverage under the Benefit Plan Options providin�
health covera2e may be automatically reinstated provided that coverage for Employees on non-
FMLA leave is automatically reiastated upon retum from leave.
e. The Employer may, on a uniform and consistent basis, continue your group health coverage for
[he duration of the leave following your failure to pay the required contribution. Upon retum
fmm leave, you will be required to repay the contribution in a manner agreed upon by you and
the Employer. - -
f. If you are commencing or retuming from unpaid FMLA leave, your electiou under this Cafeteria
Plan for Benefit Plan Options providing non-health benefits shall be treated in the same manner
that electio�s for non-health Benefit Plan Options are treated with respect to Paaicipanu
commencing and retuming&om unpaid non-FMLA leave.
g. If you go on an unpaid non-FMLA leave of absence (e.g., personal leave, sick leave, etc.) that
does not affect eligibiliry in this Cafeteria Plan or a Benefit Plan Option offered under this
Cafeteria Plau, then you will continue to participate and the contribution due will be paid by pre-
paymeot before going on leave, by Afrer-tax Contributions while on leave, or with catch-up
contributions afrer the leave ends, as may be detemuned by the Plan Adminis[ratoc If you go on
an unpaid leave that affects eli=ibility under this Cafeteria Plan or a Benefit Plan Option, the
election change rules described berein will apply. The Plan Administrator will have discretion to
detemune w6ether takine an unpaid non-FMLA leave of absence affects eligibility.
Q-10. How long w�ill the Cafeteria Plan remain in effect?
Although the Employer expects to maintain the Plan indefinitely, it has the right to modify or terminate
the Plan or any of its component programs at any time for any reason. Plan amendments and terminations
will be conducted iu accordance�vith the terms of the Plan document.
Q-11. R'hat happens if roy request for a beneSt under this Cafeteria Plan is denied?
You will have the right to a full and fair review process. You should refer to Anpendix I for a detailed
summary of the Claims Procedures under this Cafeteria Plan.
�
10-38
cirl�oF cfr�za«sTa
FLElTBLE BE\'EFITS PL,�\
SiJ�L�LaRl'PL.�\' DESCRIPTION
Health Care Spendine�ccount Component Summary
Q-1. ��'ho can participate in the Health Care Spending Account?
Each Employee who satisfies the HCS.4 Elieibility Requiremenu is elieible to participate oo the HCSA
Eli�ibiliry Date. The HCSA Eligibilin� Requiremenu and Eligibility Date aze described in the Plan
Information Summarv.
Q-2. Ho�r do I become a Participant°
If you 6ave otheru�ise satisfied the HCSA Eligbili[y Requiremena, you�become a Participant in the
HCSA by electine Health Caze Sa��ngs Account benefiu durin� the Initial or?.nnual Election Periods as
described in the Cafeteria Plan Component S>>mman�), yo�panicipation in the HCS.4 will be effectice
on the date that you make an election or on your HCSA Eligibility Date; whiche��er is later. See the Plan
Information Summary for your Employer's Plan specifics. If you have made an election to participate
and you w�ant to panicipate during the next Plan Yeaz, you must mal:e an election during the Annual
Elecdon Period, even if you do not chanee your curreut election. Everffeen Elecrions do not apply to
HCSA elecaons. �
You may also become a Participant if you experience a Chanee in Status Event or Cost or Coveraee
Chan�e that permits you to enroll mid-year(See�-7 of the Cafeteria Plan Component Summary for more
details reearding mid-veaz election chanees and the effective date of those chaoees).
Once you become a Participant, your "Elieible Dependenu" also become'covered. For purposes of the
HCSA, Eligible Dependenu are the follow�in2:
(i) Your leeal Spouse (as determined by state law to the extent consistent �ith the federal
Defense of Marriage Act) and
(ii) An}�other individuals �6o w ould qualify as a tax Dependent, includine any child of yours �tiho
as of the end of tbe taxable year has not attained a�e twenty-se��en(27).
If the Plan Aduunistrator receives a qualified medical child support order (QD4CS0) relatine to the
HCSA, the HCSA w'ill provide the health benefit coverage specified in the order to the person or persons
("altemate recipients")nazned in[he order to the extent the QD1C50 does not require covera�e the HCSA
does not otherwise provide. "Altemace recipienu" include any child of the Pazticipan[ u�ho the Plan is
required to co��er pursuau[ to a Q�4CS0. A "medical child suppon order" is a legal jud�ent, decree or
order relatine to medical child support. A medical child suppon order is a QvICSO to the extent it
satisfies certain conditioas requued by law. Before providine any co��era�e to an altemate recipient; the
Plan Administretor must determine whether the medical ctuld suppon order is a QAICSO. If the Plan
Administrator receives a medical child suppon order relatine to your HCSA, it will notifi�you in w�ritino,
and afrer receivine the order. it will inform vou of iu determination of w�hether or not the order is
s
10-39
qualified. Upon request to the Plan Administrator, you may obtain, without char�e, a copy of the Plan's
procedures eoveming qualified medical child support orders.
Q-3. R'hat is my Health Care Spending Account? -
If you elect to participate in the HCSA, the Employer will establish a`Health Care Spending AccounP' to
keep a record of the reimbursements you are entitled to, as well as the coutributions you elected to
withhold for such benefiu during the Plan Yeaz. No actual account is established; it is merely a
bookkeeping account. Benefits under the HCSA are paid as needed from the Employer's general assets
except as otherwise set forth in the Plan Information Summary.
Q-4. When does m}'coverage under the Health Care Spending Account end?
Your coverage under the HCSA ends on the earlier of the following to occur. See the Plan Information
Summap� for your Employer's Plan specifics.
a. Thc date you elect not to participate in accordance with the Cafeteria Plan Component Summary;
b. The last day of the Plan Year unless you make an election during the Annual Election Period;
c. The date you no looger satisfy the HCSA Eligibility Requirements;
d. The date you tersninate employment; or
e. The date the Plan is ternunated or you or the class of eligible Employees of which you are a
member are specifically excluded from the Plan. You may be entitled to elect Continuation
Coverage (as described in Q-16 below) under the HCSA once your coverage ends because you
terminate employment or experience a reduction in hours of employmen[.
Coveraee for your Eligible Dependents ends on earliest of the following to occur:
a. The date your coverage euds;
b. The date that your Dependents cease to be eligible Dependents (e.g., you and your Spouse
divorce); or
c. The date the Plan is temtinated or amended to exclude the individual or the class of Depeudents
of which the individual is a member from coverage under the HCSA.
Pou and/or your covered Dependents may be entitled to continue coverage if coverage is lost for certain
reasons. The Continuatiou of Coverage provisions are described in more detail below.
Q-5. Can I ever change my Health Care Spending Acwunt election?
You_can change your election under the HCSA in the following situations:
a. For ony reason during the Annuol Election Period. You can change your election dunng the
Annual Election Period for any reason. The election change will be effective the first day of the
Plan Year following the end of the Annual Election Period.
b. Fo!lowing o Change in Smtus Event. You may change your HCSA election during the Plan Yeaz
only if you experience an applicable Change in Status Event. See (�-7 of the Cafetena Plan
Compooent Summary for more information on election changes. NOTE: lou may not make
HCSA election changes as a result of anp Cost or Coverage Changes.
9
10-40
Q-6. R'hat happens to my Health Care Spending Account if I take an approved leace of absence?
Refer to the Cafeteria Plan Component Summary and the Election Change Chan to deternune what, if
any; specific chanees you can make durin� a leave of absence. If your HCSA coverage ceases durine an
FD4LA leave,you may,upon returnine from FMLA leave, elect to be reinstated in the HCSA at either�
a. T6e same coverage le��el in effect before the FMLA leave (with increased contributions for the
remainino period of coverage); or
b. At the same coveraee le��el that is reduced pro-rata for the period of F\QLA leave during wluch
you did not make any contributions.
Under either scenario;expenses incurred durine the period that your HCSA coveraee w�az not in effect aze
not elieible for reimbursement under this HCS.A.
Q-7. �Vhat is the maximum annual Health Care Spending Account amount that I ma��elect
under the Health Care Spending Account, and how much will it cast?
l'ou may elect any annual reimbursemeot amount subject to the marimum annual HCSA amouot and the
minimum reimbursement amouot described in the Plan Information Summary. You will be_required to
pay the annual contribution equal to the coverage level you have chosen reduced by any Non-elective
Employer Contributions allocated to your HCSA.
Any c6ange in your HCSA election also will chanee the maximum available reimbursement for the
period of coverage after the election. Such maximum available reimbursements w•ill be deteanined on a
prospective basis only by a method detemuned by tbe Plan Adminiscrator that is in accordance wlth
applicable law. The Plan Administrator (or its designated Third Party Administrator) uill notify you of
the applicable method when you make your election chanee.
Q-8. Ho�v are Health Care Spending Account benefts paid for under this Plan?
�1'hen you complete the Salary Reducdon Ageement or Election Forzn,you specify the amount of HCSA
reimbursemeot you wish to pay for with Pretax Conuibutioas and/or Non-elective Employer
Co�tributions; to the extent available. Your enrollment materials will indicaze if Non�lecti��e Employer
Contributions aze available for HCS.4 coveraee. Thereafrer, each paycheck will be reduced by an amount
equal to pro-rata shaze of the annual contribution; reduced by any Non-elective Employer Contributions
allocated[o vour HCSA.
Q-9. R'hat amounts�•ill be aeailable far Health Care Spending account Reimbursement at an��
particular time during the Plan Year?
So lone as coveraee is effective, the full, annual amount of Health Care Spending Account reimbursement
}�ou have elected, reduced 6y the amount of previous HCSA reimbursemen[s received durine the Plan
Yeaz, ��ill be a��ailable at any time durine the Plan Yeaz, w•ithout re�azd to how much you ha��e
conuibuted.
l0
10-41
Q-10. How da I recei��e reimbursement under the Health Care Spending Account?
If you elect to participate in the HCSA, you will have to take certain steps to be reimbursed for your
Eligible Medical Expenses. �b'hen you incur an Eligible Medical Ezpense,you file a claim with the Plan's
Third Party Administrator by completing and submitting a Request for Reimbursement Form. You may
obtain a Request for Reimbursement Form from the Plan Administrator or the Third Party Administrator.
You must include with your Request for Reimbursement Form a written statement from an independent
third party(e.g. a receipt, EOB, etc)associated with each expense that indicates the following:
a. The nature of the expense (e.g. what type of service or treatment was provided). If the expense
is for an over the counter drug, the written statement must indicate the name of the drue;
b. The date the expense was incurred; and
c. The amount of the expense.
The Third Paity Administrator will process the claim once it receives the Request for Reimbursemeut
Form from you. Reimbursement for expenses that aze determined to be Eligible Medical Expenses will
be made as soon as possible after receiving the claim and processing it. If the expense is determined to
not be an "Eligible Medical Expense" you will receive notification o£ this determination. You must
submit all claims for reimbursement for Eligible Medical Expenses dudng the Plan Year in which they
were incurred or during the Run Out Period. The Run Out Period is described in the Plan Information
Summary.
Q-11. �Yhat is an "Eligible Medical Eapense?"
An "Eligible Medical Expense" means an expense that has been incurred by you and/or your eligible
Dependents that satisfies the followwg conditions:
a. The expense is for"medical caze"as defined by Code Section 213(d); and
b. The expense has not been reimbursed by any other sources, and you will not seek reimbursement
for the expense from any other source. �
The Code generally defines "medical care" as any amounts incurred to diagnose, treat, or prevent a
specific medical condition or for purposes of affecting any function or structure of the body. Not e��ery
health-related expense you or your eli2ible Dependents incur constitutes an expense for "medical care.'
For example, an expense is not for "medical care;' as that term is defined by the Code, if it is merely for
the beneficial health of you and/or your eligible Dependents(e.g.,vitamins or nutritional supplements that
are �ot taken to veat a speci5c medical condition) or for cosmetic purposes, unless necessary to correct a
deformiry arising from illness, injury, or birth defect. You may, in the discretion of the Th'ud Party
Administrator/Plan Administrator, be required to provide additional documentation from a health caze
provider showing that you have a medical condition and/or the particular item is necessary to treat a
medical condition. Expenses for cosmetic purposes are also not reimbursable unless they aze necessary to
correct an abnormality caused by illness, injury, or birth defect.
In addition, certain expenses that mieht otherwise constitute "medical care° as defined by the Code are
not reimbursable under any Health Care Spendin�Account(per Treasury regulations):
a. Health insurance premiums;
�t
10-42
b. Expenses incurred for qualified lone-term care sen ices;
c. Effective ]anuary I, 2011; expenses for a medicine or drue unless such medicine or drue is a
prescribed drug (determined without reeard to whether such dru2 is available w•ithout a
prescription)or is iasulin; and
d. Any other expenses that aze specifically excluded by the Emplo}�er.
For a list of Eli�ible Dledical Expenses, eo to wu�v.waeew�ods.com and euter your user uame and
password.
If you have opted for the HSA-Compatible or Limited Purpose Health Care Spendine Account, then only
those elieible dental and vision expeases may be paid under the Plan while your limited coverage is
effective.
Q-12. �yhen must the expenses be incurred in order to receive reimbursement?
Elioible Medical Expeases must be incurred during the Plan Yeaz and wtiile you aze a Participant in the
Plan. "Incurred" meaas that the service or creatment sivine rise to the expense has been provided. If you
pay for an expense before you are provided the sercice or treatment, the expense may not be reimbursed
until you have been provided the sen�ice or treatment. Ezcept as provided below, you may not be
reimbursed for any expenses azisina before the HCS.4 becomes effective, before your Salary Reduction
Affeement or Election Form becomes effective, or for anv expenses incurred afrer the close of the Plan
Yeaz, or, afrer a separatioo from sen�ice or loss of eliQibility (except for expenses incurred durine an
applicable continuation period). ' y
Your Employer has estabGshed a `Grace Period" for the HCSA offered under the Fle�cible Benefits Plan
that follows the end of the Plan Yeaz during wluch amounu you have allocated to the HCSA that is
unused at the end of the Plan Yeaz mav be used to reimburse Eligible �ledical Expenses incurred during
the Grace Period.
The Grace Period will begin on the first day of the Plan Year follow�in� the effective date and u�ill end
two (2) months and fifreen (1�) da}•s later. For example, if the Plan Yeu ends December 31, 20li, the
Grace Period beeins]anuary 1, 201�and ends D4arch 1�, 2014.
�
In order to take advaotaee of the Grace Period,you must be
• A Participant in the HCSA on the last day of the Plan Year to which the Grace Period relates, or
� A Qualified Beneficiary w6o is receivins continuation coveraee under the HCSA on the last day
of the Plan Y'eaz to which the Grace Period relates.
TLe followine additional rules will apply to the Grace Period:
• Eli¢ible `4edical Expenses incurred durina a Grace Period and approved for reimbursemeot will
be paid first from available amounu that w�ere remainine at che eod of che Plan Yeu to which the
Grace Period relates and then from any amounts that aze a��ailable to reimburse expenses incurred
durin¢the current Plan Year.
12
10-43
For example, assume that �200 remains in the HCSA sub-account at the end of the 2013 Plan
Year and further assume that you have elected to allocate $2,400 to the HCSA for the 2014 Plan
Year. lf you submit for reimbursement an Eligible Medica] Expense of$500 that was incurred on
the March 15, 2014, �200 of your claim will be paid out of the unused amounts remaining in the
HCSA from the 2013 Plan Yeaz and the remaining $300 will be paid out of amounts allocated to
your HCSA for 2014.
. Expenses incurred during a Grace Period must be submitted before the end of[he Run-Out Period
described in this SPD. This is the same Run-Out Period for expenses incurred during the Plan
Year to which [he Grace Period relates. Any unused amounts from the end of a Plan Yeaz to
which the Grace Period relates that aze not used to reimburse Eligible Medical Expenses incurred
either during the Plan Year to which the Grace Period relates or during the Grace Period will be
forfeited if not submitted for reimbursement before the end of the Run-Out Period.
� You may not use HCSA amounts to reimburse Eligible Employment Related Expenses and
DCSA amounts may not be used to reimburse Eligible Medical Expenses.
Q-13. �Vha[if the"Eligible Medical Eapenses"I incur during the Plan Year are less than the
annual amount I hace elected for the Health Care Spending Account Reimbursement?
You will not be entided ro receive any direct or indirect payment of any amount that represents the
difference between the acmal Eligible Medical Expenses you have incurred and the anoual coverage level
you have elected. Any amount allocated to a HCSA shall be forfeited by the Par[icipant and restored to
the Employer if it has not been applied to provide reimbursement for Eligible Medical Expenses incurred
during the Plan Yeaz that are submitted for reimbursement within the Ruu-Out Period described in the
Plan Information Summary. Amouots so forfeited shall be used to offset administrative expenses and
future wsts, ancUor applied in a manner that is consistent with applicable rules and regulations (per the
, Plan Administrator's sole discretion).
The Plau Administrator will deterrtune what this amount is on a uniform basis, consiste�t with applicable
law and IRS interpretations. Notwithstandine any other provision of this Plan, an indi��idual who has
selected a Qualified Reservist Disuibution shall be considered to have made such election as an
altemative to continuation coverage or USERRA coverage continuation for the HCSA (except as may
otherwise be required by applicable law).
Q-14. R'hat happens if a Claim for Benefits under the Health Care Spending Account is denied?
You will have the right to a full and fair review process. You should refer to Aonendix I for a detailed
summary of the Claims Procedures under this Plan.
13
10-44
Q-li. R'hat happens to unclaimed Health Care Spending Account Reimbursements?
Any HCSA reimbursement benefit pa}�ments that are unclaimed (e.g., uncashed benefit checks) by the
close of the Plan Year following the Plan Year in w�hich the Elieible D4edical Expense was incurred shall
be forfeited.
Q-16. R'hat is Confinuation Cocerage7
Federal law requues most private and eovemmental employers sponsoring ffoup health plans to offer
employees and their families the opportuniry for a temporary exrension of health caze coverase (called
"Continuation Covera2e") at ffoup rates i❑ cenain instances u�here coveraee under the plans would
ot6erw•ise end. Ihese rules apply to this HCSA, unless the Emplo}•er spoasorine the HCSA is not subject
to these rules (e.e., the employer is a "small�mplo��ei' or the HCSA is a church plan). The Plan
Administrator can tell you whet6er the Emplo}•er is subject to federal continuation rules (thus subject [o
the follou�ing rules). These rtiles aze intended to summarize the continuarion righu set fonh under fedeml
law. lf federal law chanees, only the riehu provided under applicable federal law w•ill apply. To the
extent that any ereater rights aze set forth herein; tl�ey shall not apply.
i3'hen Coveraee Mm Be Continued
Only "QuaGfied BeneSciaries" are elieible to elect Continuation Coveraee if they lose coverage as a
result of a "Qualifi�ine Event." A "Qualified Beneficiarv' is the Participant, co�•ered Spouse and�or
covered Dependent child at the time of the Qualifyine Event.
A Qualified Beneficiary has the ri�ht ro continue covera2e if he or she loses coveraee as a result of
certain QuaGfying Eveots. The table below describes the qualifi�ing events that may entitle a Qualified
Beneficiary to continuation coverage:
Covered Co��ered Covered
- - Em lovee ` S use De endent
1. Covered Employee's termination of ✓ ✓ ✓
employment or reduction in Lours
of em lo��meut
2. Divorce or Leeal Se aration � ✓
3. Child ceasine to be an eliaible I ✓
De endent �
4. Death of the covered Em lo��ee ✓ ✓
There are special rules pertaining to Health Caze Spending Accounu that determine when continuation
coverage is extended. Continuation Coverage is only extended when}•ear-todate deposiu exceed yeaz-to-
date claims paid.
TvDe ofContinuation CoveraQe
If you choose Continuation Co��eraee, ��ou ma�� continue the level of co�era�e }�ou had in effect
immediately precedine the Qualifi�ina Eveot. However, if Plan benefiu are modified for similazl}�
situated active Employees, theo the�� will be modified for you and other Qualified Beneficiaries as �ell.
14
10-45
ABer electiug Continuation Co��erage, you will be eligible to make a change in your benefit election u�ith
respect to the HCSA upon the occurrence of any event that pemvts a similarly simated active Employee
to make a benefit election change during a Plan Year.
If you do not choose Continuation Coverage, your coverage under the HCSA will end with the date you
would otherwise lose coveraee.
A'otice Requirements
You or your covered Dependeuts (including your Spouse) must notify the continuation coverase
Administrator identified in the Plan Information Summary in writing of a divorce, legal separation, or a
child losing Dependent starus under the Plan within 60 days of the later of the date of the event or the date
on which coverage is lost because of the event. Your written notice must identify the Qualifying Event,
the date of the Qualifying Event, and the Qualified Beneficiaries impacted by the qualifying event. When
the continuation coverage Administrator is notified that one of these evenu has occurred, the Plan
Administrator w�ill in tum notify you that you have the right to choose Continuation Coverage by sending
you the appropriate election forms. Notice to an Employee's Spouse is ueated as notice to any covered
Dependenu who reside with the Spouse. You may be required to provide additional supporting
documentation.
An Employee or covered Dependent is responsible for notifying tl�e continuation co��erage Administrator
if he or she becomes covered under another group health plan.
Election Procedures and Deadlines
Each Qualified Beneficiary is entided to make a separate election for continuation covera�e under the
Plan if they are not otherwise covered as a result of another Qualified Beneficiary's election. In order to
elect Continuation Coverage, you must complete the Election Form(s) within 60 days from the date you
would lose coverage for one of the reasons described above or the date you are sent notice of your right to
elect Continuation Coverage, whichever is later and send it to the continuation coverage Administrator
identified in the Plan Information Summary. Failure ro return the election form within the 60-day period
will be considered a waiver of your Continuation Coverage rights.
Cost
You will have to pay. the entire cost of your Continuation Coverage. The cost of your Continuation
Coverage will not exceed 102% of the applicable premium for the period o£Continuation Coverage. The
first contribution aRer electing Continuation Coverage wil] be due 45 days afrer you make your election.
Subsequent contributions are due the first day of each month; however, you have a 30-day grace period
followine the due date in which to make your conuibution. Failure to make contributions witlun this time
period will result in automatic termination of your Continuation Coverage.
\4'hen Continuation Covera�e Ends
The maximum period for whicb coverage may be continued is the end of the Plan Year in which the
Qualifying Event occurs. However, in certain situations, the maximum duration of coverage mav be 18
or 36 months from the Qualifying Event (depending on the type of qualifying event and the le��el of Non-
�s
10-46
elecave Contributions procided by the Employer). You will be notified of che applicable maximum
duration of Continuation Co��eraee when you have a Qualif��ing Evenc. Re�azdless of d�e maximum
period Continuation Coveraee ma} end eazlier for any of the follow in�reasons:
a. If the contribution for your Continuation Co��eraae is not paid on time or it is significantly
insufficient (Note: if your payment is insufficient by the lesser of 10% of the required premium,
_ or 550,you��ill be eiven 30 days to cure the shortFall);
b. If you become covered under another group health plan and aze not acrually subject to a pre-
e�stine condition exclusion limitation;
c. If you become entitled to D4edicaze; or
d. lf the Employer no longer provides �oup health coveraee to any of iu Employees.
Q-17. �Vill mc health informafion be kept confidential7
Under the Health Insurance Ponabiliry and Accountability Act of 1996 ("HTP:A.A"), eroup bealth planc
such as the HCSA and the Thud Pam Administrators aze required to take steps to ensure that cenain
°protected health information' is kept confidentiaL You may receive a separate notice that outlines the
Employer's health privacy policies.
Q-18. How long�cill the Health Care Spendiug Account remain in effect?
Althoueh the Emplo��er expects to maintain the Plan indefinitely, it has the rieht to modify or terminate
the Plan or any of iu Component Pro�ams at any time and for any reason.
tb
10-47
Newborns' and Alothers' Health Protection Act of 1996
Group health plans and health insurance issuers generally may not,under federal law, restrict benefits for
any hospital length of stay in connection with cluldbirth for the mother or newbom child to less than 48
hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal
law generally does not prohibit the mother's or newbom's attending provider, afrer consulting with the
mother, &om dischareing the mother or her newbom earlier than 48 hours (or 96 hours, as applicable). In
any case; plans and issuers may not, under federal law, require that a provider obtain authorization from
the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
»
10-48
CITY OF CALZA V'ISTA
FLE.lIBLE BE\EFITS PL.�\'
SIT�I�iARP PL�\DESCRIPTION
Dependent Care Spending�lccount Component Summan
Q-1. R'ho can participate in the Dependent Care Spending Account?
Each Employee H�ho satisfies the DCSA Elieibilin- Requiremenu is eli�ible to participate in the DCSA
on the DCSA Eliaibiliry Date. The DCSA Elioibiliry Requuements and Eli�ibiliry Date aze descnbed in
the Plan Information Summary.
Q-?. How do I become a Participant? _
If you have otherw�se satisfied the DCSA Elieibilirv Requiremenu, you become a Panicipant in the
DCSA by electine Dependent Caze Reimbursement benefits durine the Initial or Annual Election Periods
descnbed in � of the Cafetena Plan Component Summary. Your participation in the DCSA will be
effective on the date that vou make the election or vour DCSA Elieibilin�date, whichever is later: See the
Plau Information Summary for your Employer's Plan specifics. If you have made an election to
participate and you want to participate durine the next Plan Yeaz, you may be required to make an
election during the Annual Election Period, even if you do not change your current elecrion.
Altematively, if your Employer's Plan allows "E��erereen Elections."you may be deemed to have elected
to continue your Benefit Plan Option elections in affect as of the end of the Plan Year in which the
Annual Election Period took place.
You may also become a Participant if you experience a Chanee in Status E��ent or Cost or Coveraae
Chanee that permits you to enroll mid-year(See�--i of the Cafeteria Plan Component Summary for more
details regazdin�mid-yeaz election chanees and the effecti��e date of those chanees).
Q-3. R'hat is m}'"Dependent Care Spending Accou�t?"
If you elect to participate in the DCSA, the Employer w�ill establish a "Dependent Caze Spending
Account" to keep a record of the reimbursemenu you aze entided to; as well as the contributions }�ou
elected to withhold for such benefits durine the Plan Yeaz. No actual account is established: it is merelv a
bookkeepina account �
Q—t. When does my coverape under the Dependent Care Spending Account endT
Y"our coveraee under the DCS:� ends on the eazlier of the followine to occur. See che Plan Information
Summar}�for your Employer's Plau specifics.
a. The date}�ou elect no[to par[icipate in accordance wich the Cafeteria Plan Component Summan-:
b. The last dav of the Plan Yeaz unless vou make an elecrion durins the Annual Eleccion Period:
c. I'he date you no lonaer satisfy the DCSA Elisibilitv Requuemenu;
d. The date you teruunate employment; or
1S
10-49
e. The date the Plan is ternunated or you or the class of eligible Emplo��ees of which you aze a
member are specifically excluded from the Plan.
Q-5. Can I ever change m}'Dependent Care Spending Account elecrion?
You can change your election under the DCSA in the following situations:
a. For any reason during the Ann:�al Election Period. You can change your election durin� the
Annual Election Period for any reason. The election change uzll be effective the first day of the
Plan Year following the end of the Annual Election Period.
b. Following o Change in Status Event or Cost or Coverage Change. You may chanee youc DCS.A
election durin� the Plan Year only if you experience an applicable Change in Status Event or
there is a sienificant Cost or Coverage change. See �-7 of the Cafeteria Plan Component
Summary for more information on election changes.
Q-6. What happens to my Dependent Care Spending Account if I take an unpaid leave of
absence?
Refer to the Ca£eteria Plan Component Summary and the Election Chanee Chart to detemvne what,if any
specific changes you can make during a leave of absence.
Q-7. What is the maaimum annual Dependent Care Spending Account Reimbursement that I
may elect under the Dependent Care Spending Account?
The annual amount cannot exceed the maximum DCSA reimbursement amount specified in Intemal
Revenue Code Section 129. The IRS Code Section 129 maximum amount is currently �5,000 per
calendaz year if you:
a. Are married and file ajoint retum;
b. Are mamed, but your Spouse maintains a separate residence for the last 6 months of the calendar
year, you file a separate tax retum, and you furnish more than one-half the cost of maintaining
those Dependents for whom you are eligible to receive ta�c-free reimbursements under the DCSA;
or
c. Are single.
If you aze married and reside together, but file a separate federal income tax retum, the maximum
Dependent Care Spending Account Reimbursement that you may elect is $2,500. In addition, the amount
of reimbursement that you receive on a tax-free basis during the Plan Year cannot exceed the lesser of the
eamed income (as defined in Code Section 32) or your Spouse eamed income.
Your Spouse will be deemed to have eamed income of$250 if you have one Qualifying Individual and
$500 if you have two or more Qualifying Individuals (described below), for each montli in �vhich your
Spouse is:
a. Physically or mentally incapable of caring for himself or herself, or
b. A full-time student(as defined by Code Section 21).
19
10-50
Q-8. Ho�v do I par for Dependent Care Spending Accouut Reimbursements'
�'�'hen you complete the Salary Reduction Ageement or Election Form, you specify the amount of DCS.4
Reimbursement you wish to pa}• for with Pretax Contributions and/or Non-elective Emplo}•er
Conuibutions, to the extent available. Your enrollment material K1II indicate if \'on�lective
Contributions aze available for DCSA co��eraee. Thereafrer, each papcheck will be reduced by an amount
equal to a pro-rata share of the annual contribution, reduced by any Non-elective Employer Conuibutioas
allocated to your DCSA.
Q-9. R'hat is an "Elipible Employment-Related Eapense' for�vhich I can claim a
reimbursementT
You may be reimbursed for work-related dependent care expenses ("Elieible Employment-Related
Expenses"). Generally, an expense must meet all of the follo�we conditions for it to be an Elieible
Employment Related Erpense: - �
a. T'he expense is incurred for services rendered afrer the date of your electioo ro receive DCSA
reimbursement benefits and during the calendar yeaz to which it applies.
b. Each individual £or�vhom you incur the expense is a"Qualifyine Individual." A Qualifying
Individual is: `
(i) An individual aee 12 or under who is a "qualifi�ing cluld" of the Employee as defined
in Code Section 1�2(a)(1). Generally speakine, a "qualifying child" is a child (includine a
brother, sister, step sibling) of the Employee or a descendant of such cbild (e.e. a niece,
nephew, erandchild) who s6ares the same principal place of abode uith you for more than
half the yeaz and does not provide over half of his/her support.
(ii) A Spouse or other tax Dependent(as defined in Code Section 152)w6o is physicall}�or
mentally incapable of canng for himself or herself and who has'the same principal place of
abode as you for more thau half of the yeaz. `
Nore: There is a special rule for children of divorced pazenu. If you are divorced, the child
is a qualifi�ing indi��idual of the"custodial"parent(as defined in Code Section 1�2);
c. The espense is incurred for the care of a Qualifying Individual(as described above);or for related
household sen�ices, and is incurred to enable you (and your Spouse; if applicable)to be sainfully
employed. Expenses for ovemisht stays or ovemieht camps aze no[ elieible. Tuidon expenses
for kindereanen(or above)do not qualify.
d. If the expense is incurred for services ouuide your household and such expenses aze incuired for
the care of a Qualifying Individual who is aQe li or older, such Dependenc must reeulazly spend
at least S hours per day in your home.
e. If the expense is incurred for sen�ices pro�-ided by a dependeot caze center (i.e., a facility that
provides caze for more than 6 individuals not residin=at the facility), the center complies �ith all
applicable state and local laws and reeulations.
?o
10-51
�
f. The expense is not paid or payable [o a "child" (as defined in Code Section 152(�(I)) of yours
who is under age 19 the entire year in whic6 the expense is incuned or an individual for whom
you or your Spouse is entitled to a personal tax exemption as a Dependent.
g. You must supply the taxpayer identification number for each dependent care service pro��ider to
the IRS with your annual ta�c retum by completing IlZS Form 2441.
You are encouraged to consult your personal tas advisor or IRS Publication 17 "Your Federal Income
Tax"for further guidance as to wbat is or is not an Eligible Employment-Related Expense if you have any
doubts. In order to exclude from income the amounts you receive as reimbursement for dependent care
expenses, you are �enerally required to provide the name, address, and taxpayer identification number of
the dependent care service provider on your federal income tax return.
Q-10. How do I receive rcimbursement under the Dependent Care Spending Account?
Under this DCSA, you have two reimbursement options. You can complete and submit a written Claim
Form for reimbursement ("Pay Me Back Claim'). Alternatively, you can request pa}�nent directly to
your provider("Pay My Provider"). The following is a summary of how both opuons work.
When you incur an Eligible Employment-Related Expense, you file a claim with the Plan's Third Party
Administrator by completing and submittiog a Pay Me Back Claim Form. You may obtain a Pay Me
Back Claim Form at www.wageworks.com. Simply enter your user name and password, or select First
Time User to complete the online registration process to access your account online. You must include
with your Pay Me Back Claim Form a written statement from an independent third party (e.g., a receipt,
etc.) associated with each expense that indicates the following:
a. The date(s)the eapense was incurred;
b. 7he nature of the expense(e.g.,what type of service was provided); and
c. The amount of the expense.
The Third Party Administrator will process the claim once it receives the Pay Me Back Claim Form from
you. Reimbursement for expenses that are deternuned to be Eligible Employment-Related Expenses will
be made as soon as possible after receiving the claim and processing it. If the expense is determined to
not be an "Eligible Employment-Related Expense," you will receive notification of this determination.
You must submit aIl clauns for reimbursement for Eligible Employment-Related Expenses during the
Plan Yeaz in which they were incurred or during the Claim-It-By or Run-Out Period. The Run-Out
Period is described in the Plan Information Summary.
If your claim was for an amount that was more than your current DCSA balance, the excess part of the
claim will be carried over into following months,to be paid out as your balance becomes adequate.
You must incur the expense in order to receive payment. "Incurred"means the service has been pro��ided
without regard to whether you have paid for tbe service. Payments for advance services are not
reimbursable because they have not yet been incurred. For example, Employee A pays the monthly day
care fee on January 1 and then submits a copy o£the receipt on January 3. The expense for the entire
month is not reunbursable until the services for that month have been performed. In addition, you must
certify w�ith each claim that you have not been reimbursed for the expense(s) from any other source and
you wil] not seek reimbursement from any other source.
��
10-52
�
Q-11. ��'hen must the espenses be incurred in order to receive reimbursement? �
Eli�ble Employment-Related Expenses must be incurred during the Plan 1'ear. 1`ou may not be
reimbursed for auy expeuse arisins before the DCSA become effective; before your Salarv Reduction
Ageement or Election Form becomes effecti�e, or for any expenses incurred after the close of the Plan
Yeaz and unless noted otherwise in [he Plan Information Summary, afrer your pamcipation the DCSA
ends.
Your Employer has established a "Grace Period" for the DCSA offered under the Flesible Benefits Plan
that follows the end of the Plan Yeaz durine u�hich amounts you have allocated to the DCSA that is
unused at the end o£the Plan Yeaz may be used to reimburse Eli�ible Employmen[ Related Expenses
incurred durine the Grace Period.
The Grace Period will begin on the first day of the Plan 1'eaz followine the effecri<<e date and Hill end
tuo (2) months and fifreeo Q�) da}�s later. For example, if the Plan Peai ends December 31, ZOli; the
Grace Period begins January 1, 2014 and ends�4arch 1�, 2014. _
In order to tal:e advantaee of the Grace Period you must be a Panicipant in the DCS.� on the last day of
the Plan Yeaz to which the Grace Period relates.
The followine additional rules will apply to the Grace Period:
• Eligible Employment Related Espenses incurred during a Grace Period and approved for
reunbursement will be paid fsst from available amounts that were remainine at the end of the
Plan Yeaz to which tbe Grace Penod relates and then from any amounts that aze available to
reimburse expenses incurred duriug the current Plan 1'eaz.
For example, assume that SZ00 remains in the DCSA sub-acwunt at the end of the 20li Plan
Year and further assume that you ha��e elected to allocate 52,400 to the DCSA for the 201� Plan
Year. If you submit for reimbursement an Eligible Emplo}�nent Related Expense of 5�00 that
was incurred on the D4azch 15, 2014, 5200 of your clairn will be paid out of the unused amounts
remainine in the DCSA from the 2013 Plan 1'ear and the remainine 5300 will be paid out of
amounts allocated to your DCSA for 2014. �
• Expenses incurred durine a Grace Period must be submitted before the end of the Run-Out Period
described io this SPD. This is the same Run-Out Period for expenses incurred durine the Plan
Year to w•hich the Grace Period relates. Anv unused amounts from the end of a Plan Yeaz to
which the .Grace Period relates that aze not used to reimburse Eligible Employment Related
Expenses inwrred either during the Plan Year to wbich t6e Grace Period relates or durino the
Grace Period «�ill be forfeited if not submitted for reunbursement before the end of the Run-0ut
Period.
• You may not use DCSA amounu to reimburse Elieible biedical Expenses and HCSA amounu
ma}�not be used to reimburse Eli�ible Emplo}�ent Related Espenses. .
»
10-53
Q-12. 1i'hat if the"Eligible Emplo��ment-Related Expenses"I incur during the Plan 1'ear are less
than the annual amount of coverage I have elected for Dependent Care Spending Account
Reimburseroent?
You will not be entitled to receive any direct or ind'uect payment of any amount that represents the
difference between the actual Eligible Employment-Related Expenses you have incurred, on the one
hand, and the annual DCSA reimbursement you have elected and paid for, on the other. Any amount
credited to a DCSA shall be forfeited by the Participant and restored to the Employer if it has not been
applied to provide the elected reimbursement for any Plan Year by the end of the Claim-I[-By or Run-Out
Period following the end of the Plan Yeaz for which the election was effective. Amounts so forfeited
shall be used to offset reasonable administrative expenses and future costs and/or otherwise permitted
under applicable law.
Q-13. w'ill I be taxed on the Dependent Care Spending Account benefits I recei��e?
You will not normally be taaed on your DCSA reimbursements so long as��our family a�ereeate DCSA
reimbursement (under this DCSA and/or aoother employer's DCSA) does not exceed the maximum
annual reimbursement limits descnbed above. However, to qualify for tax-free treatment, you will be
required to list the names and taxpayer identification numbers on your annual ta�c retum of auy persons
who provided you with dependent care services during the calendar year for which you have claimed a
tax-free reimbursement.
Q-14. If I participate in the Dependent Care Spending Account,will 1 still be able to claim the
household and dependent care credit on my federal income tax return?
You may not claim any other tax benefit for the tax-free amounts received by you under this DCSA,
although the balance of your Eligible Employment-Related Expenses may be eligible for the dependent
care credit.
Q-15. What is the household and dependent care credit?
The household and dependent care credit is an allowance for a percentaee of your annual, Eligible
Employment-Related Expenses as a credit against your federal income tax liabiliry under the U.S. Tax
Code. In determinin�what the tax credit would be, you may take into account 53,000 of such expenses
for one Qualifying Individual, or $6,000 for two or more Qualifying Individuals. Depending on your
adjusted gross income (AGI), the percentage could be as much as 35% of your Eligible Employmeut-
Related Expenses (to a ma�cimum credit amount of $1,050 for one Qualifying Individual or $2;100 for
two or more Qualifying Individuals), to a minimum of 20% of such expenses. The maximum 35% rate
must be reduced by 1°/a (but not below 20%) for each $2,000 portion (or any fraction of$2,000) of your
adjusted gross incomes over$I5,000 for tarable years beginning after 2002 and before 2013.
Illustration: Assume you have one Qualifying lndividual for whom you have incurred Eligible
Employment-Related Expenses of�3,600, and that yocr adjusted gross income is $21,000. Since only
one Qualif}�ing Individual is involved, the credit will be calculated by applying the appropriate percentage ,
m the first S3;000 of the expenses. The percentage is, in tum, arrived at by subtractine one percentaee
point from 35% for each 52,000 0£your adjusted gross income over ^�15,000. The calculation is: 35% --
[521,000 — 15,000)/52,000 x 1% = 32%. Thus, your tax credit would be �3,000 x 32% _ �960. If you
23
10-54
had incurred che same expenses for tu�o or more Qualifying Indi��iduals, your credit would ha��e been
53,600 x 32%= 51,1�2, because the entire expense would have been taken into account, not just the fust
53.000.
Q-16. ��'hat happens to unclaimed Dependent Care Spending�lccount Reimbursements'
Any DCSA reimbursements that are unclaimed (e.e.; uncashed benefit checl-s) by the close of the Plan
1'ear follow�ng the Plan Year in Hhich the Eli�ible Emploti�nent-Related Expease was incurred shall be
forfeited.
Q-17. R'ha[ happens if my claim for reimbursement under the Dependent Care Speoding Account
is denied?
You u�ll have the right to a full and fair review process. You should refer to .qooendix I for a detailed
summarv of the Claims Procedures under tivs Plan.
Q-1S How�long w�ID the Dependent Care Speuding Account remain in effect?
Alchoueh the Employer expecu to maintain the Plan indefinitely, it has the right to modify or temunate
the progam at any time for auy reason.
��
10-55
PLAN INFORMATION SUMMARY
TO THE CITY OF CHULA VISTA PLAN
SUMD4ARY PLA1V DESCRIPTION
This Appendix provides information specific to the City of Chula Vista Cafeteda Plan.
A. Employer/Plan Sponsor Inforroation
]. Nazne, address and phone number of Plan City of Chula Vista
Sponsor: 276 Fourth Avenue
Chula Vista.CA 91910
619-585-5620
2. Name, address and phone number of Plan
Administrator. City of Chula Vista
276 Fourth Avenue
The Plnn Admmimator shal/have the uclusive righ(fo inrerprel!he Chula V ista, CA 91910
Plan and m decide all matten arising under the Plon, including 1he
nght to make determinations of faa, and construe and interpre� 619-585-5620
possi6le amb�gurties. mcons�stencier, or om�ssrons in !he Plan and
the SPD�ssued in connecfion with the Plan.
3. Federal Tax Identification 95-6000690
4. Controlling Law: California
5. Plan Number: 501
6. Initial Effective Date: Prior to 1991
Ths is the dare that the Plan wos first eslablished
7. Amended and Restated Date: January 1, 2013
8. Initial Plan Year: January 1 through December 31
9. All subsequent Plan Years (If different from 8) --
10. Affiliated Employers partici ating in the Plan: NA
1 I. Third Party Administrator: WageWorks,lnc.
1]00 Park Place
4`"Floor
San Mateo, CA 94403
��
10-56
B. Cafeteria Plan Component Information
(a) Cafeteria Plan Eligibilih� Requiremeots and EGgibilih• Date. Each Emplo}�ee who is
a reaular full-fime or part-time Employee �r�orl:ing a minunum of 20 hours per week and
u�ho is elieible for coverage or panicipation under any of the Benefit Plan Options
("Cafeteria Plau Eligibilin� Requirements) w�ill be eligible to panicipate in this Plan on
the date of h've("Cafereria Plan Elisibiliq�Date`).
The Employee's commencement of panicipation in the Plan is conditioned on the Emplo}'ee
properl}• completing and submittine a Salary Reducdon A�eement or Elecdon Form as
summarized in this SPD. Elieibility for coveraee under any given Benefit Plan Option shall be
determined aot by ttus Plan but by the terms of that Benefit Plan Option.
(b) Cafeteria Plan .�.nnual Election Rules. \Vith respect to Benefit Plan Option elections, including
the HCSA and DCSA elections; failure to make an election during the ,annual Election Period
will result in the folloH�ine deemed election(s):
� Dental, V'ision, HCSa and DCSA - The Employee u�Il be deemed to have elected not
to panicipate durine the subsequent plan year. Co��erase under the Bene&t Plan Options
offered under the Plan will end the last day of the Plan Yeaz in w�hich the,lnnual Election
Period occurred.
� Diedical - The Employee u�ill be deemed to have elected to continue his BeneSt Plan
Option elections in effect as of the end of the plan 1'ear in which the Annual Election
Period took place; unless Employee notifies the company in writins of a qualifying status
chanee or at any time before the end of the Plan Year for the following Plan Yeaz.
This is called an"Ever�een Election".
(c) Change of Election Period. If you experience a Chanse in Status E��ent or Cost or Coverase
Change as described in the Cafeteria Plan Component�Summary and in the Election Chan¢e
Chart, you may make the pemutted election chanees described in the Election Chanae Chart
either bv makine a mid-vear elecdon chanee online at u��w.waeeworl:s.com or bv subminins an
Election Chan�e Form u�ithio 30 days after the date of the event. If you aze participatine in an
insured arran�ement that pro��ides a looeer Elecuon Chanee Period, the Election Chaooe Period
described in the insurance policy will apply. �
(d) Benefits Plan Options: The Employer elecu to offer ro eligible Employees the followioe
Benefit Plan Option(s) subjec[ to the terms and condicions of che Plan and the terms and
conditions of the Benefit Plan Options. These Benefit Plan Option(s) are specifically
incorpoiated herein by reference.
The maximum Preta�c Conuibutions a Panicipant can convibute via the Salary Reduction
A�reement is the ae�egate cost of the applicable Benefi[ Pian Options selected reduced by any
\'on-elective Contributions made bv the Employer. It is intended that such Preta.x Contribution
?6
10-57
amounts will, for tax purposes, constitute an Employer contribution,but may constitute Employee
conuibutions for state insurance law purposes.
1. Premium Eapense Plan (Medical,Dental,Vision)
2. Health Care Spending Account
3. Dependent Care Spending Account
�7
10-58
C. Health Care Spendine Account Component Information
(a) HCSA Elie bilih� Requirements and Elie bility Date. Each Employee who is a rewlaz full-
time or part-time Employee w�orkine a minimum of 20 hours per week (HCSA Eligibility
Requiremenu) is elieible to participate in the HCSA on the date of hire ("HCSA Eligibility
Date").
(b) Annual Health Care Spendina Account Amount. The maximum annual HCSA reimbursement
may not exceed the lesser of the HCSA reimbursement amount elected for that year or Si,000.
Effecuve Januan� 1, 2013, the maximum annual HCSA reimbursement may not exceed the lesser
of the HCSA reimbursemen[ aznount elected for that}�eaz of 52,500. (This amount is indexed to
reflect any anticipated cost of livins adjustment as assi�ed by the IRS). The minimum
reimbursement amount that may be elected under the HCSA is 50._
(c) Coverage Effectice Date for QualiSed Changes
Co��eraee following a qualified life cbanee will beein on any day of the month follou�ina �-our
request for uew enrollment or change in eorollment.y
(d) Co��erage End Date for Qualified Changes
If coveraee is re��oked folloµ-ine a qualified life chanoe, coverage will end on an�� dav of the
month following the request to revoke coveraee.
(e) Coverage End Date Under the Health Care Spending Account
Coveraee will end iaunediateh•upon cessation of paaicipation under the HCSA.
(� Run-Out Period (Claim-It-By Date). The Claim-It-By Date/Run-Out Period is the deadline
date in which expenses incurred durine a coverage period must be submitted to be elieible for
reimbursement. Claims must be received bv this date to be elieible for reimbursement &om the
Plan. . �
a. The �lid-Year Run-Out Period for temunated Employees ends 3 months afrer their
termination date.
b. The End-of-Plan Run-Out Period for an Emplo��ee who is co��ered through the end of
the Plan 1'eaz ends 3 months afrer the end of the Plan 1'ear.
(g) Grace Period. The Grace Period is the two months and fifreen day period afrer the end of che
Plan 1'ear for ��hich Eli�ible �4edical Expenses can continue to be incurred should a balance
remain in the account as of the last day of the Plan Year. Each Plan Year the Grace Period will
beein January I and end D4azch 1�. All expenses incurred durine the Grace Period w�ith the intent
to use up any monies from the previous Plan 1'eaz, must be submitted w�ithin the Endof-Plan
Run-Out Period.
�g
10-59
I
(h) Conrinuation Coverage Administrator. The Continuation Coverage administrator for the
HCSA is Ciry o£Chula Vista is WageWorks.
(i) Dlethod of Funding. HCSA benefits are paid from the Employer's general asseu.
29
� 0—s�
D. Dependeut Care Spending Account Compooent lnformation
(a) DCSA. Eligibility Requirements and Elisibilitp Date. Each Employee w•ho is
a reeular full-time or part-time Employee workine a minimum of 20 hours per w�eek
(DCSA Eli�ibility Requiremenu) is elieible to participate in the DCS.� on date of hire
("DCSA Eligibility Date").
(b) Annual Dependent Care Spending Account Amount. The maximum annual DCSA
reimbursement each calendar yeaz may not exceed the lesser of the DCSA reimbursement amount
elected for that year or 5�,000 (or 52,500 for married filline separate renuns). The minimum
reimbursement amount t6at may be elected under the DCSA is 50.
(c) Co�•erage End Date Under the Dependent Care Spending Accaunt.
Covera2e will end immediately upon cessation of participation under the DCSA.
(d) Run-Out Period (Claim-It-B}� Date). I'he Claim-It-By Date/Run-Out Period is the deadline
date in wtuch e�penses incurred during a co��eraee period must be submitted to be elieible for
reimbursement. Claims must be recei��ed by this date to be eGgible for reunbursement from the
Plan.
a. The A1id-]'ear Run-Out Period for terarinated Employees ends 3 months after their
termination date.
b. The End-of-Plan Run-Out Period for Emplo}•ees who are covered through the end
of the Plan Yeaz ends 3 months after the end of the Plan Year.
(e) �lethod of Funding. DCS.�benefits are paid from the Employer's general asseu.
�o
10-61
APPENDIX I—CLAIMS REVIEW PROCEDURE
The Plan has established the following claims review procedure in the event you are denied a benefit
under this Ptan. The procedure se[ forth below does not apply to benefit claims filed under the Benefit
Plan Options other than the Health Care Spending Account and Dependent Care Spending Account.
Step 1: Arotice of deniol is received from Third Partv Adminish-ator. If your claim is denied, you will
receive wntten notice from the Third Party Administrator that your claim is denied as soon as reasonably
possible, but no larer than 30 days afrer receipt of the claim. For reasons beyond the conhol of the Third
Party Administrator, the Third Party Administrator may take up to an additional 15 days to review your
claim. You will be provided wzitten notice of the need for additional time prior to the end of the 30-day
period. If the reason for the additional time is that you need to provide additional information, you will
have 45 days from the notice of the extension to obtain that information. The time period during �i�hich
the Third Party Administrator must make a decision will be suspended unfil the earlier of the date that you
provide the information or the end of the 45-day period.
Step 2: Revlew your notice carefully. Once you have received your notice from the Third Party
Administrator,review it carefully. The notice will contain:
a. The reason(s) for the denial and the Plan provisions on which the denial is based;
b. A description o£ any additional information necessary for you to perfect your claim, why the
information is necessary, and your time limit for submitting the information;
c. A description of the Plan's appeal procedures and the time limits applicable to such procedures;
and
d. A right to request all documentation relevant to your claim.
Step 3: Ifyou disogree x�ith the decision,frle an appeal. If you do not agree with the decision of the
Third Party Adminisuator, you may file a written appeal. Your appeal must be received within 180 days
of the date you received notice that your claim was denied. You should submit all information identified
in the notice of denial as necessary to perfect your claim and any additional information that you believe
would support your daun to: \4'ageWorl-s Claims Appeal Board, P.O. Box 991, Mequon,WI 53092-0991
or fax to 877-220-3248. The Appeal Review Process is documented at
w�v.wageworks.com/hcdcappeals.pdf.
Step 4: Second notice of denial is received fi�om 77�ird Pm•ty Adnsii7ish�ator. If the claim is again denied,
you H�ill be notified in w�ritin� by the Third Party Administrator as soon as possible but no later than 30
days after receipt of the appeal.
Step 5: Review your iaotice corejully. You should tal:e the same action that you take in Step 2 described
above. The notice will contain the same type of information that is provided in the first notice of denial
provided by the Third Party Administrator.
Step 6: If vou still disagree with the Third Par7y Adminisb-ator's decision,file a second level appeal with
the Plon Administrator. If you still do not agree with the Third Party Administrator's decision and you
wish to appeal, you must file a written appeal with the Plan Administrator within the time period set fonh
in the first level appeal denial notice from the Third Party Administrator. You should eather any
31
� �-62
additional information that is identified in the notice as necessarv to perfect your claim and any other
information that}�ou belie��e will support your claun.
If the Plan Administrator denies your second level appeal,�-ou will recei��e notice�vithin 30 davs after the
Plan Administrator receives your claim. The notice ��ill contain the same q�pe of information that w�as
referenced in Step 1 above.
Important Information
Other important information reearding}�our appeals:
a. Health Caze Spending Account Only: Each level of appeal ��ill be independent from the
previous le��el (i.e., the same person(s) or subordinates of the same person(s) involved in
a prior le<<el of appeal will not be involved in the appeal);
b. On each level of appeal, the Third Pam� Administrator uill review relevant information
that you submit even if it is new information; and - = •
c. You cannot file suit in federal coun until you have exhausted these appeals procedures.
3?
' 10-63
APPENDI%II—TAX ADVANTAGES EXAb1PLE
As indicated in the SPD, participating in the Plan can actually increase your take home pay. Consider the
following ezample:
1'ou aze married and have one child. The Employer pays for 80% of your medical insurance premiums,
but only 40% for your family. You pay 52,400 in premiums ($400 for your share of the Employeeonly
premium plus �2;000 for family coverage under the Employer's major medical insurance plan). You earn
�50,000 and your Spouse(a student)eams no income. You file ajoint ta�c retum.
If cou participa[e in If you do no[participate
[he Cafe[eria Plan in the Cafe[eria Plan
1. Gross Income S50,000 SSQ000
2. Salan�Reductions for Premiums $2,400(pretax) " SO
3. Adjusted Gross Income $47,600 $50,000
4. Standard Deduction ($9,700) • ($9,700)
5. Exemptions (59,300) (59,300)
6. Tazable Income $28,600 531,000
7. FederalIncome Tas (53,590) ($3,904)
(Line 6 s applicable tax schedule) -
8. FICA Tax(7.65%s Line 3 Amount (53,641) (53,825)
9. After-tax Contributions (SO) (52400)
10. Pa�•After'I'ases and Contributions $40,365 539,821
ll. Take Aome Pay Difference $544
33
10-64
:1PPE\DIh III—ELECTIO\' CfL�\GE CI�ART
The followine is a summary of the election changes that aze permitted under this Plan. However, please
note that election chanoes that are permitted under this Plan may not be permitted under the Benefit Plan
Option (e.e., the insurance carrier ma}• not allow a change). If a chanoe is not permitted under a Benefit
Plan Option, no election chanee is permitted under the Plan. Likewise, a Benefit Plan Option may allow
an elecrion change that is not permitted by this Plan. In that case; �-our pretax reduction may not be
chaneed even though a co�•eraoe chanee is permitted.
Fust, ��e descnbe the eeneral rules re�ardine election chanees that are established b}�the IItS. Then, you
should look to the chart to determine under a�hat cucumstances you are permitted to make an election
under this Plan and the scope of the chanees you may make.
1. Chanae in Status. Election chanees may be allowed if a Participant or a Panicipant's Spouse or
Dependent expeneoces one of the Change in Status Events set fonh in the chart. The election chanee
must be on account of and corsespond wzth the Chanee in Starus E��ent as determined b}• [he Plan
Administrator (or its desi�ated Third Pam Administrator). \'�'ith the exception of enrollment
resulting from binh, placement for adoption or adoption, all election chanees are prospective
(generall}' the first of the month followine the date you make a new election with the Third Pam
Administrator but it may be earlier dependine on the Employer's intemal policies or procedures). As
a eeneral rule, a desired election chanae will be found to be consistent with a Chanee in Stams Event
if the event the Chanee in Stanu affecu eliQibility for coveraee. A Chanee in Status affects elisibility
for coveraee if it resulu 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 requuemeots in order to alter
vour election based on that Chanee in Status:
• Loss of Dependent Eli;ibilin•. For accident and health benefits (e.e., health, dental and vision
coveraee), a special rule govems which types of election.chan2es are consistent w ith the Chanee
in Stams. For a Chanee in Status involvins a divorce, annulmeut or legal separation, tLe death of
a Spouse or Dependent, or a Dependent ceasing to satisfy the eliability requirements for
coveraee; an election to cancel accident or health benefits for any indiaidual other than the
Spouse invoh•ed in the .divorce, annulment, or leeal separation, the deceased Spouse or
Dependent, or the Dependent that ceased to satisfy the eli�ibility requirements, would fail to
correspond with that Chanoe in Status. Hence, you may only cancel accident or health coverage
for the affected Spouse or Dependent However; there aze instances in which you may be able to
increase your Pretax Contributions to pay for continuation coveraee of a Dependent. Contact the
Third Parrv Administrator for more information.
Example: Employee Mike is married to Sharon, and thev hwe one child. The Employer
offers a calendar year cafeteria plan that allows emplovees m elect no health covera�e,
employee-only covera,;e. employee-plus-one-dependent coverage, or family coverage. Before
the plan year, MiF.e eleca familv covera,;e jor himself, his wife Sharon, and rheir child. �IiFe
and Sharon subsequently divorce during the plan year; Sharon loses eli�ibiliry for coverage
under the plan, while the child is stil!eli,�ible for coverage under the plan. Mike now wishes
to cancel his previous election and elect na health coverage. The divorce benveen Mikz and
Sharon constitutes a Change in Status. An election to cancel covera�e for Sharon is
33
10-65
consistertt ivith this Cha�ige in Status. However, ar2 electior� to cancel coverage for Mike
and/or the child is not consistent with this Cha�rge in Status. In contrast, an election to
change to emplovee p[us-one-dependent coi�erage wozdd be consistent with this Chan,;e in
Status.
• Gain of Coverage EligibiliN Under Another Emplover's Plmz. For a Change in Status in which a
Par[icipant or his or ber Spouse or Dependent gain eligibiliry for coverage under another
employer's cafeteria plan or benefit plan as a result of a change in marital status or a change in
the Participanfs, the Participant's Spouse's, or the ParticipanYs Dependent's employment status,
an election to cease or decrease coverage for that individual under the Plan would correspoud
with that Change in Status only if coverage for that individual becomes effective or is increased
under the other employer's plan.
+ Dependent Care Sper7ding Accoemt Benefits. With respect to the Dependent Care Spending
Account benefit, an election change is permitted only if(1) such change or termination is made
on account of and corresponds with a Change in Status that affecrseliglbility for coverage under
the Plan; or(2) the election change is on account of and corresponds with a Change in Status that
affects the eligibility of Dependent Care Spending Account expenses for the available tax
exclusion.
Example: Emploi�ee Mike is married to Sharon, and thev have a 12 year-o[d daughter. The
Employer's p[on offers a dependent care spendi�7g account rei»7bursenaent progrorn as part
of its cafeteria plan. Nlike elects to reduce his salan� by $2,000 during a plan year to fund
dependent care coverage for his daughter. In the middle of the plan vear x�hen t/ie daugJzter
turns 13 years old, however, she is no longer eligible to participate in the dependent care
program. This event constitutes a Change in Status. Mike's election to cancel coverage
zmder the dependent care program would be consistent with this Change in Status.
+ Group Term Life Insurance, Disabilit}+Income, or Dismemberment Benefits (if offered iuider the
Plon. See the lisr of Benefit Plan Options ofjered under dze Plan). For group ter[n life insurance,
disability income and accidental death and dismemberment benefits only if a Participant
experiences any Change in Status (as described above), an election to either increase or decrease
coverage is permitted.
Example. Employee Mike is ma�ried to Sharor7 and thev I:ave one child. The Employer's
plan offers a cafeteria plmt which funds group-term life insurance coverage (and other
benefits) througlz salary reduction. Before the plan vear Mike elects $IQ000 oJgroup-term
life insm-ance. A1ike asd Sharon subsequenth� divorce d:rrirag the plan vear. The divorce
constitutes a Change in Status. An election bv Mtke either to increase or to decrease his
gro¢�p-te�m life insurmace coverage would each be coiasis�ent with this Giange in Status.
2. Special Enrollment Rights. If a Participant, ParticipanCs Spouse and/or Dependent are entitled to
special enrollment riehts under a Benefit Plan Option that is a group health ptan, an election change
to correspond with the special enrollment right is pernutted. Thus, for example, if an otherwise
eligible Employee declined enrollment in medical coverage for the Employee or the Employee's
eligible Dependents because of outside medical coverage and eligibiliry for such coverage is
subsequently lost due to certain reasons (e.g., due to legal separation, divorce, death, termination of
;s
10-66
employment, reduction in hours, or e�chaustioo of a covera�e continuation period), the Employee may
be able to elect medical coveraee under the Plan for the Employee and his or her eligible Dependents
who lost such covera�e. Furthermore, if an otheruise elieible Emplo}ee eains a new Dependent as a
result of marriaee. birth adopuoq or placement for adoption the Emplo}�ee may also be able to
enroll the Employee, t6e Employee's Spouse, and [he Employee's newly acquued Dependent,
provided that a request for enrollment is made within the Chanse of Elecuon Period. An election
chanoe that corresponds u�ith a special enrollment must be prospective, unless the special enrollment
is attributable to the birth, adoption; or placement for adoption of a child,which may be retroactive up
to 30 days. Please refer to the aroup health plan summary description for an ezplanation of special
enrollment ri1�ts.
Effective April 1, 2009, if an otheru�ise eli2ible Employee (1) loses coverage under a Medicaid Plan
under I itle XI?C of the Social Securiq� Acr, (2) loses coveraoe under State Children's Health
Insurance Pro�am (SCHIP) under Tide YXI of the Social Securiry Act; or (3) becomes eligible for
ffoup health plan premium assistance under \4edicaid or SCHIP, the Employee is entitled to special
enrollment riahts under a Benefit Plan Option that is a �oup health plan, and an election chanoe ro
correspond w�ith the special enroliment rieht is permined. Thus, for example, if an otherw�ise eli�ible
Employee declined enrollment in medical co��eraee for the Employee or the Employee's eGgible
Dependenu because of inedical coveraee uuder D4edicaid or SCHIP and elieibility for such covera2e
is subsequendy lost, the Employee may be able to elect medical coverage under a Benefit Option for
the Employee and his or her elieible Dependenu who lost such coverage. Furthermore; if an
otherw•ise eligible Employee and/or Dependent eains elieibilin for �oup health plan premium
assistance from SCHIP or D4edicaid, the Employee may also be able to enroll the Emplovee, and the
Employee's Dependent, pro��ded that a request for enrollment is made u�ithin the 60 days from [he.
date of the loss of ot6er coveraae or eligibility for premium assistance. Please refer to the eroup
health plan summary description for an explanation of special enrollment riehts.
3. Certain Judgments,Decrees and Orders. If ajudgnent, decree or order from a di��orce,separation,
annulment or custody chanee requires a Dependent_child (includine a foster child who is your taac
Dependent) to be covered under this Plan, an election change to provide coverage for the Dependent
child identiSed in the order is permissible. If the order requires that another individual (such as your
former Spouse) cover the Dependent child, and such coveraee is actually provided, qou may chanee
your election to revoke coveraQe for the Dependeut child.
4. Entitlement to �tedicare or liedicaid. If a Participant or the Participanrs Dependents become
entitled to D4edicaze or Medicaid, an election to cancel that person's accident or healch coveraee is
permitted. Similazly, if a Panicipant or Patticipant's Dependena who have been entitled to \4edicaze
or �ledicaid loses eligibility for such, you may elect to beein or increase that person`s accident or
health coveraee.
�. Cha�ge in Cost If the cost of a Benefit Plan Option si�ificandy increases; a Pazdcipant may
choose either to make an increase in contributions, re��oke the election and receive coveraee under
another Beoefit Plan Option that provides similar coveraee, or drop coverage altoeether if no similar'
coverage exists. If the cost of a Benefit Plan Opcion si�ificantly decreases;a Participant w�ho elected
to pazticipate in another Benefit Plan Opcion ma}� revoke the election and elect to receive coverase
provided under the Benefit Plan Option that decreased in cost. In additioa othen«se eGgible
36
� 0-6�
Employees who elected not to participa[e in the Plan may elect to participate in the Benefit Plan
Option that decreased in cost. For insignificant increases or decreases in the cost of Benefit Plan
Options, however, Pretax Contributions �vill automatically be adjusted to reflect the minor chanee in
cost. The Plan Administrator�rill have final authority to determine �vhether the requuements of this
sectiou are met. (Please note that none of the above "Change in Cost" exceptions are applicable to a
Health Care Spendine Accoun[.)
Example: Employee Mike is covered under an indenvaity option of his enaployer's occidenl ond
health insurance coverage. If the cost of this optiwa srg�iificmitly increares d:ming a period of
coverage, the Employee may make a correspondrng increase in his payments or mav instead revoke
his election and eleet coverage under an HMO option.
6. Change in Coverage. If covera�e under a Benefit Plan Option is significantly curtailed, a Participant
may elect to revoke his or her election and elect coverage under another Benefit Plan Option that
provides similar coverage. I£the significant curtailment amounts to a complete loss of coverage, a
Participant may also drop coverage if no other similar coverage is available. Further, if the Plan adds
or si¢nificantly improves a benefit option during the Plan Year, a Participant may revoke his or her
election and elect ro receive, on a prospecti��e basis, coverage provided by the newly added or
significantly improved option, so long as the newly added or sia ificantly improved option pro��ides
similar coverage. Also, a Participant may make an election change that is on account of and
corresponds with a change made under auother employer plan (including a plan of the Employer or
another employer), so long as: (a) t6e other employer plan permits iu participants to make an
election change perntitted under the applicable Treasury regulations; or(b)the Plan Year for this Plan
is different from the Plan Year of the other employer plan. Finally, a Participant may change his or
her election to add coverage under this Plan for the Participant, the Participant's Spouse or
Dependents if such individual(s) ]oses 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 Health Care Spending Accouut.)
The following is a chart reflecting the election changes that may be made under tbe Plan with respect to
each Benefit Plan Option. In addition, election changes that are pernutted undcr this Plan are subject to
any limitations imposed by the Benefit Plan Options. lf an clection change is pemutted by this Plan but
not by the Benefit Plan Option,no election change under this Plan is permitted.
37
� �-68
Change in Stnms Even[ I Major Afedinl I Deotal and�ition Health Care Dependent Care Employtt Group
Speoding Accouot Spending Attount Life ADSD and
(fSCSA) (DCSA) Disabilin�Co��enpe
I.Change in Status� : .:=,:a_, -''.: .. :.:. ...: ....:. ...:::.. . . . . . . _ - - -_��:fi, .-,:_:� - --_
A:Change in Employee's Leg'al D'farital Status <-:-- - , - ° : . -
1. �Gain Spouse Employa ma)'rnroll Same as previous Emplo7re mzy Employx may ea:oli Employee may
(marriage) or increau elario¢for cohunn(I:o[e: enroll or inc:rase or increaze[o enroll,iacmu,
newly eligible Spouse HIPA4 spxial elation for aew•ly accommoda[e neaiy dxlcsse,or ceau
and D<penden[ enrolLnrnt ngh6 elig�ble Spocse or eligible Deprndenu or co�erzee cvrn wtm
children(Ko[e:lindtt li�ely do no[apph�). Dependrna,or dxrtaze or ctau eGgbiliry is uot
IItS`tag-along" likdy decrmse coverage if ncw impact�.
in[elpretaaon,new aod' elxrion if Spouse i5 no[
precziscing Employee or employcd or makes a
Deprndrncs may be Dependrna become DCSA covera¢e
eorolled);tovemee an elig3le clection unda
opcion Ie.g..HMO co Dependrn��da Spwise's plan.
PPO)change may be uew Spmsse's health
made;Employce may plan(Note:HIPP.P.
¢coke or darmse speual eurollmrnt
Employa's or righ[s likeh�do no[
Dc'rendrn['S rnve2g< appW)
onlv a�hrn such
co��erege becoma .
eExove or is
inc.�eased undcr tht
Spwsse's plan.Also,
see HIPAA special
enrolLnrnt rule below.
?.Lose Spouse Empbyee may re�nAc Same as pmious Employr may Employee may rnroll Employm may
(dicorce,legal dcetion o[t�y for column(�ote: dxrease el«uon or incrmse m enroll,iocccau,
separaHon. Spolue;coverage HIPA.4 spxial ior former Spouu accommod:te nrniy dxr.zse,or ceax
annulmen4 dea[h of opcion(e.g.,FQvfO�o enrollmrn[righrs who losa eGp,�bl<Dependen¢ coverz¢e evm whrn
Spouse)(See loss of PPO)changc may be liAdy do not eGgibiliry(\ote: (e.¢.,due ro dcnh of eliebiliry is no[
' Dependen[eGgibilin� mad<;Employcemay appty). HIPA4spciial spous<)ordeccreseoz impaded
beloe�for discussion elxt covcrnge for sdf enrolUnrne righu cease co��emee ii
of Dependent or Dependena w�ho liAdy do noc eligibiliry is lose (<.g.,
elisibiGh'Io55 lose eli06iliry under apply).Employee because Depmdent
followine di�'orce� Spouse's plan if mch may enroll or ¢ow asida with ex-
separa[ion,e[c) indi.idualloses inc¢asedeaion Spousej.
elieibiliry as a result where covea¢e
of�he divorce,leeai losi undrr Spous<'s
' separarion,annulmen4 health plzn.
ordratL. (I�oie:
linda IRS'Yag-
along"inttryretauoq
any Dependrnts may
be rnrolled so lone zs
a�teatt one Depeadrnt
hu lost coveaee
uadec the$pouse's
plan)
�$
� �-69
Chanee in Sta[us Event Major Medical Dental and Visiun Hcalth Care Dependent Care Emploree Group
Spending Account Spending Account Lifq ADBD and
(HCSA) (DCSA) Disabilin�Cocerage
_ _ _ . _ _ _ _ _ � ._ ., . ,..1. ' _
B:Chang�eint6eNumber�ofEmployee'sDependeuts�F :i`�`�,:' '-'" :,.'t`�;'�;. - r .
1.Gain Dependen[ Employee may enroll Same as prev�ous Same as previous Employee may enmll Employee may
(birth�adoption� or increase coveage column(Note: column(Note. or iucrease to enroll,increasq
for newly-eligible H�P..4 special HIPAP,spenal accommodatc newly decreaze,or cease
Dependent(and any enrollmrn[rights enrolLnen[rights ehgible Dependrnts coveage even whrn
o[her Deprndrnu who liAel}'do m[ ' Gkely do no[ (and any oth<r elig�b�liry is not
aere noi previously apply). apply). Dependents who wem impacted
covered under IRS nol previously
"tag-along"mle); - covered under IFtS
coveage op[ion(e g., "tag-along"rule).
HMO co PPO)change
may be made;
Employee may revoAe �
ordecrease
Employee's or
Dependen['s coverage
if Employee buomes
eLgible under
Spouse's plan. Also,
I see HIPAA special
enrollment rule below.
2.LoSe Dependent Employee may drop Same as previous Employee may Employee may Employee may
(death) coveage onl,v for[he column. decrease or cease decrease election for enroll,inaease,
- Dependent who loses elecnon for� Dependent who loses decreaze,oc cease
ehgib�liry;covecaee Dependent who eligibiGty. cov<age even when
option(e.g.,FAfO to loses eligi6ility. eligibiGry is not
PPO)change may be �mpac[ed.
made.
. _ - ..;i -- �:..-r, . � .,.� . , .. .. , _ . . . ,
C.Change_iu Emplo}meut Stattis of Employee;Spouse,or Depeodenf That Affect's'Eligibility.�- .' = .
1.Cammencement of Emplo��ment by Employee, Spouse, or Depeudent•(or Other Change in Employmen[ S[atus) That Triggers
Eli�ibiliq.
a.Commencemen[ ProvideA elig�bih[y Same az previous Same as prev�ous Sarne as prev�ous Employee may
of Employment b)' �azs gained for this column. column. columri enroll,mcmase,
Empla]ee or coverage,Employee decrease,or cease
Other Chanee in may add coverage for cov<rage n•en whcn
Empioymen[ Employee,Spouseor eligibiGryisnoe
S[atus(e.g.,PT to Dependena and impacced
F'T,hourlp to coveage option(e.g.,
salaried,etc.) HMO�o PPO)change
Triepering maybemade.
Elipibilip'Under
Cam onent Plan
39
� �—�0
C6ange in Stams E��eot �fajor Dfedical Dental and��sion Healt6 Care Depeodent Care Emplq�ee Gmup
Spending Account Spending Account Lifq ADSD snd
(HCSA) (DCSA) Disabi7in'Covense
b.Commencemen[ Employee may m�ok< Sam<as pre��ious Employa may Employee ma7 maF:e Employee may
of Employment by or durrase elxtion as <olumn. appartnde datease or incrmse eixcion m enroq incrcsse,
. Spouseor roEmployee's, orcroseHCSA rtflatneu�eliabilin d«rczseorceau
Dependent or S,wnse's,or decuon if gxiat (e.g.,if Spouce cocenge n�rn a�hm
Other Depe�drne's co��eaee cligibilin for p¢viousl��did no[ - Spouse's or
Emplocment ii Employeq Spouse hmlth covcragc worF:).EmpkyG msy Dependrnt s
Eveot Triggering or Dependrnc is added unda Spouse's or rtvoAe decdoa zs m elig�biliq•a no�
EG�ibilin�linder ro Spoacds or DependrnPs plan. Dependrne's coeem¢• impac�d
Their Employer's DepeadnPs � if Dependrn[is zdd�
Plao coverage;coverag< ro Spouse's plaa.
option(e g.,FII.fO m
PPO)change may be �
madc.
2.Termination of Emplo}'ment b�� Emplocee. Spouse,or Dependeot(or O[her Change in EmploymenP$[atus)That Causes Loss of
Elipibilin�
a Termination of Employee may rcvoAe Same az pm�iocs Same as pmious Employx may revoke Employee may
Emplo)'ee's or decrcase elecuon wlumn. column. or dxrase elxdon w enroll,increase,
Emplopmen[or for Empbyee,Spouse mflen loss oi darease or ceax
O[her Change in or Deprndena who � � � <ligibilirv. wv�n¢c n�rn uten
Employmen[ lose eligbiliry under eGgibiliry¢noe
S[a[us(e.e., fie plaa Iu addivoq affaced.
unpaid lea��e,FT oeherpre�iously
to PT,strike� eli¢ible Dependentt '
salaried[o hourh�, mav ako be enrollcd
etc)Resulting in a und<r'vg-along"
Loss of Eligibilin� ruie. Coveage op�ion �
(I-A90 ro PPO) �
chzne<mav be made.
i. Terminaaoo Prior elecoons ae Same as previous Same az plevious Same as prtvious Sam<az pfevious
and Rehire �+�n3nation azc cohimn. colwnn. colwm. cohunn.
��'ithin 30 Dacs reinsia�ed unless
. � ano[herevrnt6u
«cuaed[hat allows a �
change(as an -
altc.naove,Employa
may prohibit
partitipation until ooa
lan year).
ii.Termina[ion Employa may make Sarne as pm��iouc Same as prt�ious Same as pce�iou Same as prz�ious
andRehire newelecdons. column. columu. column. cohum.
After 30 Dacs
b.Terminatlon af Employec may enmll Sarne as previovs Employtt may Employee may enroll Employee may
$pouse's or or increase daiion column(l�o�a enroll or increase or incmase it Spouse cnroll,incrtau,
Dependent's for Employcq Spouse HIPAA sperial HCSA decdou if or Deprndrn�loses deaease or cmu
" Emplopmen[(or ar Deptt�drn6 W't�o enmllment riehs Spouse or eligibility for DC5.4 evrn ufirn digibifiry
ot6er c6ange in lose eligibility unda likely do not Deprndrnt losa Employx may is not a5oce�.
emplo}'ment statvs Spoisse's or apply). elieibiliry for 6ealt6 decrcase or ccaze
resulting in a bss of Depa�drnc's coverz¢e(l�oce: DCSA dmuon u
elipibilin�under Employds Plan.In HIPA4 spaial Spouse's loss o:
[6eir Emplopers addi�ion,o`ha enrolLnrnt righa cmploymentrtndc.s
plao) prn+iwsly eligible likely do not Depwdrnu iadieiSle.
Deprndrnu may also apply).
be enrolled under
'ta¢-alon °rule.
'0
� �—��
Change in Status E�'ent Dtajor bledical Den[al and Vision Health Care Dependen[Care Emplq'ee Group
Speriding Account Speoding Account Life,ADSD and
(HCSA) �pCSp) Disabilin'Corerege
Coverage option(e.g.,
FA90 to PPO)chauge
may be made;See
HIPAA special
enrolLnen[rule below.
__ - <�".5 .. �'!i,.?�,[Y.`�:�-�:r�.::",-f. 4..�c',c.'=:,.:,;�� �. . . .4;..ia. _ _ -�;� .
D - Event Causing Employee's Dependent to Safisfv or Cease to Satisfy�Eligibility Requ�remen[s - '`�'`c:;�":�;,-�`�-�_
:`, - - • . -�-. � . - . .- . � .:':`s,•.;:,+:
. - —.� �:.:,.- . .... -- - . ._: ,.. . . - - - . _.. , -...
�-_(Also see dsscusstoo of ga�n/loss of elig�b�Lry mder Dependent or Spouse's Employer's plan) �;°',-;`r �i�'•`; .
"-. .. . . ,:,.;..� �;....,.c . n..._. «._ _�,. .,- �._.. u. r � . - `'.r.'
1.Eren[b)'R'hich Employee may enroll Same as prev�ous Employee may e Employee may Employec may
Dependen[Sa[isfies or increase eluuon column. mcrease election or increase elecnon or enroll,increase,
Eligibility for affec[ed enrol(only�f enroll m[ake inro decreaz<or cease
Requirements Undef Dependrnt[n Dependent gains accoun[expenses of even when elig�b�Ley
Employer's Plan addition,Employee digibiliry under affecred Dependen[. is not affected.
(attaining a specified may apparen�ly add HCSA.
age,becoming single, prev�ously eligible
becoming a studeny (but mt enrolled)
etc.) Dependents under '
"tag-along"mle;
coveage optmn(e g.,
HMO to PPO)change
mav bc made.
?.E�'en[b}'�l'hich Employee may $ame as prev�ous Employee may Employee may Employee may
Dependent Ceases to darease or mvoke column. . durease election ro decrease or drop enroll,increase,
Sa65fi'Eligibili[y� election only for taAe into account election to take inro decrwse or cease
. Requiremen[sUnder aHectedDependent. ineGgibiliryof accoun[expensesof co�erageevenwhrn
Emploqer's Plan Covenge op[ion(ag., expensu of affected Dependrnt. eGgibiGry is mt
(attaining a specified HM1fO to PPO)change aSecmd affected.
age,getting married, may be made. Dependent,but
ceasing to be a studen4 only if eligibiliry is
etc.) bst.
E.Chan e in Place of Residence of Em lo �ee;S �o_ � � endent' ' � � ` �� � � � `� �
::: -._ , „ �. ., .. _ . _._. .. _ _
g . . �i p ) p use;orDep� ., ;;',:,,''�,, ,.. . , .. .., ,. �,.'r'�- .::•.`,..' :..
. -_ -
,..,
..
„ ,;., . . . . � , ..� _ � ,*r•: ::;;.:
1.D4ove Tripeers Employee may enroll Same as prev�ous No change ullowed, N/A Dependen[care Employet may
Elisibilit}• or increaze election column. even�f underlying eLgibil�ty�s not mcrea5e or decrease
for newly ehg�ble health coveage generally affecwd by even�f Spouse's or
Empbyee,Spouse,or change occurs. place of residentt(bu� DependenPs
Dep<ndrnc. ellso, � see chanee m ehg�biliry is noc
other prcviously , coveaee below). affected.
' eligibl<Dependen6
may be re-ertmlled -
under"tag-along"
rule;coverage opuan
(e.g.,HMO ro PPO)
chan e ma be made
�I
� �-�2
Change io Sta[us E�'ent Diajor Dfedical Den[al and�lsioo Health Care Depeodmt Care Emplo�'ee Group
Spendiug A¢ount Speodioe Attrouot Life AD6D and
(HCSA) �pC$p) Disab�L'n Coven�e
2.DIo�'e Causes Loss o Employtt may rcvoke Sarve as prc��ous t:o change allowcd, \L4.Ikpendrnt care Emplovee mav
Elisibili[}'(e.g., ��a�on or makc new column cvrn if underlying eheibilin is not cnroll,inc`easc,
EmplO�'ee or dxdoo if�he thange hml[6 cov<aYe ¢eneally affa[cd by dxre.se or c¢se
Dependent moces ���dbce affttu chanee occurs. plzce of msideoce(but even atm eligbilicy
outside kL�fO sen'ice �°Employtt's, see chan¢e in is no�affxced.
Spoase's or covezge below).
area)
Dey�rrndenPs
eG�biliry for
co�xmgc optioa
_ . _:. -. . - _ . . :_ . „- �. _, . .. ..
_ ' ' � • ' ' ' _ _ "' '"'__ -
. .. - _ :
-IL, 'Cos[Chan�es With?.utomahc IncreaselDecrease in Elecave Coutribu4ons pacmaiag�ptwa-�noa��m chaaga a�d�t:.�zr3 ia
�-. . -..._. .e ...: •�.*.:.>...-:� � _ --- - ¢ --:-..�.r+. � ,.-�„• - — — -
.cr_ �_.;'.r � a �'•.:.� -'".-.��t;= �-":v..-�-. ' — : "�.'. - ' ' -
_ . Faploymcoa�3u6o�atrs)..,.�"•_ - - . :Cn"<'-�c'j - '..s. :5?'" `_ - _-��� '
P1an may $ame as pre��ous '�o chan¢e Application is unclmr. $ame az Mzjor
aumma[ically increase columrt. pertniaed. Presumably,plan may Medical column.
or dxmase(on a auromatically incrmse
reasoaable and or dareau(on a
coasisieni bssis) reasonable az�d
afix[ed Employtes' coasis[ea[basis) .
dati�e contribudons affeaW Employca'
u¢derthe plan,so elecnretonvibutians
lone u the[erms of underche plan,w
eh<plan requ'vc lone az che ernns of
Employces to make the plan require
such comsponding Employx5 to make
chanees. such cortapondin¢
changa.
: . - . . ... .. . . .- ._, .: . . . , . , _ . . _
— _ ,--� :.. :, .. �.-_.:-,_t..-. ' -.: - ._I _ ' '
,t . .. , .
III. Significant Cost Changes:::��>=':`:�..,.,,._ _::. ��.::,. __.. . . ::.-�_�-:•., . . ,:,. ;;_: �:„..."� --
Sis.ifican�Cost Same as previous I�o chanee Same az Major Same u Afajor
Incrcese:Affected column. permiaed. Medical m�umn for Medical column.
Employee may si�5cant cosc
increase dxtion inc:ease,ezee�t no
cocrespondingly OR chanee em be made
� re��oke elenion and � ufien i6e cosc change
elecc coverege under is imposed by a
another bene5t plan Dependent care
opvou pmviding � pro�ider utio is a
similar coreage. If rlarire o,`[he
no opuon pro��dine Employa.
similar coverag<is
ava�lable,Employtt
' mav m•oAe<larioa
Si�i�cant Cost
Deaease:Employees
mac ela[coverege
(evrn if had not
paztiripated bcfole)
wich dxreattd cost,
2nd Iaay dcop ekction
for similar co�<mee
{�
10-73
Chanpe in Sta[us E�'ent Major Medical Den[al and�'isiun Heal[h Care Dependent Care Employee Group
Spending Accaunt Spendins Account Life ADdD nnd
(HCSA) (DCSA) Disabilin�Coveraee
op[mn.
Though undear,i[
appears that[ag-along
concep�c may apply.
. . ...... . , _ ..,..r.. .� .. . . __ . . ''S )'T�...,.'.;£ , ' _ _ '
_IV�.Sign�caotCoveiage_Curtailment i�norwi�houcLossofco�erae -S'� -=�- -
Without Loss of Same as previous No change Election�change may $ame u Dfajor
Coveagr.Affected column pertm¢ed. apparently be made bled�cal column.
partic�pant may whenever Ihere is a
revoke election for change m prov�der or
cunaileA coveage and a change in hours of
make new prospative Dependent care
election for coverage
under another benefit
plan option which
provides similar
coveage.
W`ith Loss of
Covenge:Affected
. pamcipant may
re�oAe election for
curtailed coverege and
maAe new prospecdve
election for covecage
under anoiher benefit
plan option which
provides similar
coverege OR drop
coverege�fno similaz
benefit plan option�s _
ava�labie
V::Addition or S�gmficant Impro'vemeot of Benefit Plau Option - - °'' ' -- _
Elig�ble employees Same u previous No change Ehgible employees Sarne as prcvious
(whe[her currendy column. pertmned. (whether cuerently column.
participaung or not) participating or not)
may revoAe their may revoAe their
existing elecnon and existing elunon and
elece the newly added elect the newly added
(or newly�mproved) (or newly improved)
option. opnon.
7'hough undear,i[
appears that tag-along
mnrepts may apph�
a3
10-74
Chaoge io Stams E�'ent Dtajor Dfedital ( Dental and�isioo Healt6 Care Dependeot Care Empiorre Group
SpendingAttaunt Speoding.�aount LifeADSDand
(HCSA) (DCSA) Disabilin'Covm�e
�7.'Chanee in Co��era�e�Gnder Other Emplo}�er's Cafetena Plan�oi QuaGSed BeneHrs Plau,�'���;.;':�;;:,.�<„��_,;�; ;_,-.:;
�:(In ard�foc elecnon cLan¢es to be pamitted nnder[his excepaon,the elecuon change must be oa a`cco�mt of a�d corsespond uith che cha�gc m coverage
;:.
.. undrr die oLhv`Employer_s cafrtena plan or_quali5ed ben<5u plan.In�addinon,e�`her(1)cLe pta�of the othc Employer musc pennic elections speri5rd
'�"enda[he limble r_eulttiobs_and an decfion mtist a<tual] ���a�,�d«��n `i�;o� � ��� ' ' ���..�
. app. .:' _ . _ . . Y: . P (-)?fle Emj1o}_ee,s_caf'atria plan mus[pmuit decdons faca
e.<�odofcovcraeediffemntfr�that�undatheo[hQEmploYerplan(`elcctioalotk'nile).'�=:-.:'::`Y- .",:".' ss-' �.
�"�-A. Other Emplo}�er's�Pla'n lucreases Co��erage�,:�„ � c. "�-: � ' - ' ..
Emplo��ee may Same a5 pre�ious \o change �Eoployee may Same aS pm�ious
decrease or m�oke column. pmniard. decrezse or m�oke colwm.
elec[ion for elation tor
&nployx,Spousq or Employee,Spouse,or
Deprndrnct if Depeudmu if '
Employc.$pouse,or Empto}'ee,Spouse,or
Depmdrnrs have Depeodma have
elaud or�ecaved elueed or Iecaved
car.esponding cocrapondiog
incrcued cov<mge iocreazed covemg<
under other under other
emolover's lan. em lover's lan
,., ,. .,- _ _ - ' -_. - . .... ' .; � :. -._:� : . '
,. . .. .- . .. ._' _' _
��� B.�_Other Employers Plan Decreases oi'Ceases'Coverage'_.�"���`:.� - '`��== -=��� _
Emplo7ee may rnroll Same as prc.�ious No change. Employee may Same u pmious
or incsase elxnon cohuun. pe+miaed. incrmse eix[ion for colueun.
for Employee,Spouse. ' Employa,Spouse,or _
or Dependrnts if Depa�den6 if
Employce,Spouse,or EmployG,Spouse,or
Deprndmts have Deprndwa have
elx[ed or cecrived elecred or recrired
ca.rspondine . cocraponCine
dxreased coveaee deccesccd co��eea¢e
u�er o[her u.lder o[her
employer s plan. Employei s plan.
.,�C. �Open Enrollment linder Plan of Other Emploper;: __ - - _ „
Co:responding Cortaponding \ochange Corsespoudin¢ ComsponLing
chzn¢a can be made changa can be pamined. chan¢a czn be made chan¢a ezn be made
uvda Employer's made undQ under Employer's under Employer's
plan. Employer'S plan. plaa plaa
4-1
10-75
Change in Sta[us E�'en[ Dtajor 1lfedical Dental and\'ision HcaIM Care Dependent Care Empioyee Croup
Spending Accuunt Spending Account Lifa AD&D and
(HCSA) (DCSA) Disabilih'Co��erave
. : ... . .., _ _ ,_. .
VII.FMLALeaVe't:..,�.;a: � �_ � � �,'� � ; .,,. �. _ i_: _ _- ,
, (Fmployees can fund tkus coverege 6y(1)pre payuig their contr�bu�on obhganons�on'a pre tax basYS�(so long as the leave does no[streddle nvo plan�%
�;'yeairs);;(2)'msking;con2ibution`s''on�a,month-by-mont}i liasis(pee,taz�if�[hey_aze receiving salazy connnuznou'paymmts); or,(3)cetchiog up;on[hev�"'
^ - �•.tW
'�"f.. .. :. . .., r. �' .:. ' .. , ' t,. :PT` ri. ' � y, � _
.
..conmbutioas u on retumu� �from[t�e leave)' ' -
.� �:..�. :. ....:�> ..'.�t,i.;49�::�:.;:'_ ' ' _ _
�,.:, , .. �Yl.r..�t,a ,:..i_"� ,. ,. , _ .
.
.�.< ,' .
. ...'. ... . '_
,'��A:�, Employee's;Commencement of FMLA Leave';� ' � ",�_, ,� � ��� i?�, + ' " �� � "!;°�'' •
� .,, ...,_:,r•.��... .. . .... .. .. .... . . ;�
_
.,, .
, :� ,. _ . , ....
.- ,..;. ,. •: �. , . � � . � „ '"_ ' . ':: ,. .-'�-'. .
' Employee can make Same u previous Same us prev�ous Employee map revoke Same as previous
same elecnons as column. column. dection and make column.
employee on nom another eluhon as
FbfLA leave. In prov�ded under
addmon,an employer FMLA.
must allow an
Emplo}�ee on unpaid
FMLA leave either m
revoke covernge or[o
continue coverage but
allow Employee[o
diuontinue pa}�nen[
of fus or her share of
the contribution
during Ne leave(fie .
Employer may �
recoverthe
Employee's share of
con[nbu�onswhen �
the Employee re[ums
to worA) FhiLA also
a0ows an Employer to
reqmre[hat
Emplovees on paid
FMLA leave ron[inue
coveageif
Emplovees on non-
FMLA paid leave are
required to con[irme
coveaee.
._..__:�:.'.._....�: .: ._.re. -.r .._ '. __:_.-.-_ _ _ _ - _-; ._ _
.:� '
'-�i,B.�" Emplo}'ee's Retum from FNII.A Lea�e - -�' :� :
.,.,. . . . . <_ . .. __ -_. .... . .. . . ... . ... .... . _ .� . .....— • - - -.., . . .. . ..... . . . .
Employee may make Same az previous Same as previous Employee may make Same a5 previous
a new elec[ion if column. column. Note chat, a oew decvon if column.
coveaee[ermma[ed upon reNm,an covem¢e[eiminared
while on FTILA leave. Employee whose while on FMLA leave.
In addi[ion,an coverage has In addition,an
Employer ma7 requrze lapsed has[he ngh[ Employer may require
an Employee[o be [o resume coverage an Employee[o be
remstared in h�s or her at nor wverage reinstated in his or her
45
� �-�6
Change in Status E�'ent I �lajor Dfedir+l Dentai and\$ion I Hea1tL Care Dependent Carc Employee Group
Spending A<rount Spending Attount Life.aD&D and
(FICSa) �p�p� Disabilip Co�'enee
elxaon apon rrnw level(aod mzF:e up elecuoo upon rcn��-+
from leave if unpaid precuums) from Icave if
Employces wLo remm or a[a level Emplove4 a{�o reNm
from a non-FTiLA reduced pinmte for Gom a non-FTi1A
paid leave are [he missed leace are requited m
requiced[o be contributiou be reinsta[ed in thc'v
reinstaced in their elx[ions.
CIM[lORS.
, . .� . .. - ,. `-- •. -. ,:. .r a:,�,..,. .-__ - _- - - . - . .. _
_ r-_.c.; r_.-. - - -�_ w-�.-;�.>:`.,.'- - �. _ v.
_ . _ . .. ...._ �y..;..� ... �
-�...: .. -_.. :- . �.. « ;.�t. �a,s.<
_I%. HIPA.4 Special Eniollment R�gti[s(See rela[ed eicepdon for add�t�on of new Dependents)y_.
-..z. - . � .:�- .__..,__.-_._....- • --•' ' --- - -
�. �. .:�.,. �, . - _ �, - -- : ��- .� .:.:�...,r. :.:er > ;= _ -
'��A:°SpecialEnrollmentforLossofOt6erAealt6`CoJerage� _ _ -r_- _;';';��`= t"' . _
_ ;.: i _ .
Employs may elect \o change \o chaa¢e \o ckia.igt pertni¢ed. ��'Ro chzn�e
covage for penniaed,unless permined,unless =_ . p�nictai.
Empio7m,Spouu,or plan is subjat to HCSA is subjxt[o
Dependrnc..�hohaz HIPA.4 HIPA.4.
lostothercoveraee
(COBR4 coveraee
exhausted or
tcrtninared,no longer
eG¢ible for non-
COBRA coveaee or
Employer
conmbudons for non-
COBA4 covem¢e
ttcmina[ai,ctc.)
Thoueh undear,it
appra�schattag-along
concepa mav a h�.
-`"� B.��.Special Enrollment for Acguisition of New'Dependent b}•.Birth,-ilfarriage,Adoption,or Placement for Adoption. -
'_'.- . ' - - ... , - � - -- - � '� �-- - � .� - � .. .
,., � ,
��- '"(If nrn'bom or new3y adopted child is enro➢ed unda kiIPP.A's spaial nila,ch�ild's co�'tmge may be retrozciive[o date of birth,adopaaq ':,-;'. � � .
� ;.'or pkcemrnt for adop[ion;Ec�ployee mzy change ialary ieduc�ion deotio¢to pa}for extrx cas[of child's cov�nge`u.�oactive[o da;e ofbirth,zdopfion,(�
..: ..
- �� or"�laccmrntforad tioaFormavia¢e;fo4emceis'tffativo � udelv. � -- - - �
._',�• ' .r.._..-..:- • _ � - . "
"''"' -...,�. : .::.....:. .Employee_mayelett=-�,:Nuchzn'e�•�' : '. \o�change:;':a�::r;•Nochau6e ".�.,'.,�.': __ �Nochzngd.-
� g ` o .
; . _ ... _ . .. . ' . . - . '
, -.• ' .:. , cov c for -_ ^�'- amitttd��mlas,� ttmitttd,n¢less � ermi¢W.' � ��_" �pecmined. -
.: . ; .' . .. R?6 P P P - _
'�� ' `'-` �� ' ' Employee-Spoau,- planissub)eclro HCSAissub�ect �-! �{ '� _
.+-rY-C-•:�%;7�^•••• - • - _ _ - ,_ _; - ..s.: . s
' arDcpcndrnt --_ HffAA.�.,, n W HIPAA- -Y '`r.:: -
�- _ . �.,e.P'�� 3: - z ,.. ,, ,
T-� E�mplepiov�des ,� y A - _ � ' Y 4 '
�� ` }� thatelxvonof--w � v�" -�' _� � # —
th' :.F . __" _ � •4i�=`' 'tiY�IT'f - ar{�s f '-{. t � ✓.yt�kJ .i�i' "
s- -__.,3:y:t:..7-� cn��ezge mav alzo w.�.t tc +s - .,..c -- .-.. i.:, _ - _
'r- x, .f eitend toprn�ovsh.. �s..r.s _ _ -,F - - �r v, 'ri+{y' _
�, ' ' _' . , , '
���.�= ... ' . . . ,..
-:.r_: - eLmble(butnoicet'°'� hf ..��, _ �_+• � " -
cvolle� _ - .� .�; -
- - �a:." ' ' '
Depmden6. '" "
�. . . . -., .. . .. . .... = _ . :--- _ ._ :...e. _ , __ r . :
'�'C., Special Enrollment for'Loss of Jiedicaid under.TiUe-YLY�oLthe-Social�Securin•, Act State Children's Health `.
_ .. _ . . .�. . .. .
� .LL�,Insurance unde�Tide JiA'I of t6e Social Securit}�Ac4pr elie bilih�ior group health plan premium_assistance. -
i .
_:.. ..... �. _ .. -- _ _ -�, : _ ,. - - ' � .
�. '; (If newbom or uewjv adopi-d ctuld �s enrolled unda.H�AA s special rula ctuld s cov�ege�may,be_rcnoa�u;e to c'aze of birth,adopnoq or.'
L:.:a-.�. .� :t�"..- .- " " . �,a.., a.......� ---.�_- '
platemenc fae adoption.Emplova may change�salazy ieducdo'n dttno¢w pav For fxtra<ost of<hild's cov�age retroacme to date of birth,_zLopuoq ,.
::.<�.. . .-.. _.. .. .... . _.__,.: r . -
. . . . : .. . :� "' ,. ...
r�- `: or lacemmt for xdo aon.) . ._.•.,�°• , ,.• - - . .
.'s> -
46
� �—��
Chanee in Srams Erent Dfajor Dfedical Dental and Vision Health Care Dependent Care Emplq�ee Group
Spending Account Spendine Account Life,AD&D and
(HCSA) (DCSA) Disabilin Cocerage
Employce may dect No change No change No chance perm�tted. No change
covemgc for perm�tted,unless permined,unless permrted.
Employee,or plan is sub�ect ro plan is sub)ect to
Deprndent.Unclear, H�AA. H�AA
but appears election of
coveage may also
extrnd io pre��ously
eligible @ut not ye�
enroiled)Dependents.
... ,,,y: ..".-.:;,:- :-','-_�. ,..: , - .. s; ' ' ...i.:.;:�' ' ' _
',._.ti:_� -... . _ �._.....:^..y,;;=:1=�;v n��?5"g,"'>':. �_v:5�.c:," '" - 2.yi�.:[.c'_s'�^fi:��� ' ' _
�l..<fY. ! i��ln[�:��•G' 'I Y 'S;
X:COBRAEveuts _ .�v.�-��h �_ — , `���� '*'�^..i' - %y,� - -
Employee may Sarne az previous No change No chan¢e pertmRed. No change
mcrease pre-tax columu. pertnitted. pertmtted.
convibuuonsundcr
Employer's plan far "
coveage if COBRA
event(or sim�lar state
lau�continuation
coverzge evrne)
ocwrs with respect m
[he Employee,
Spouse,or
Dependents.v�th
respui to u�hich�he
COHRA quaGfymg
event otcurted(such
u a loss of elig�biliry
for regular coveage
due to lass of
Deprndent staNS or a
reduction in hours,
eic.)and if apphcable,
the mdmdual still
qualifies as a tax
Dependentof
Em loyee.
'�„�:'.�>,;3.:,.,..,. .>. .: ��.: ' - - . _' - .
.._,_ �. •y '•;.y,i v :'>.,
..... . ...... ., _ . - .x: �r`
.. . :.....�.;.,. � :�.:.... .q... ,. _ .
- .:e.;. j:rt�: ' s x:" - - - ' _
`�XI:Jud men �Decree-o�OrdeE„ -- - - . - -
g � ''�:':-' -
,..
_.,,.. .
r.._,�,•-�,
.. :-...� "_. _ . v . -.. ._..v.it:.::.Aa:Y:.. �"'� _ _ _ __ _ _ _ ' "
i:i%A"rS��OrderThat�R'e uire's'Covera efor�the��Child�Under�Eru lo��ee'sPlan,�;'•`��;�"'.°::-,--,:-��. � . �-'S:�-��_:.`.::::-;i:�":°- ,-_
:. .. ...:... .:. . ....9....,_... - s........... .. .., .:`
P ) -
Employee may change Same as pre�ious Same as prev�ous No change permitted. No change
elcetion to provide column column. p��jaW.
coverag<for�hc child.
7Lough unclear,i[
appears Ihattag-along
conce ts may a ly.
�';
,f"B.�;��O�de�That Requires Spouse;�Fo�me�Spouse,or OtherYu'di��dual��to Pi»vide�Coi�erage�for the Child;�_���',�`„-���-..��.
�.-..,.. ' ,_ . .. -.,. .. . , o:••b.::.v'.:%Ti: _
,.. .,�..... -. ..r.:. . . .... .....L. :..n•s[._ .... r.'„Y, .
Employee may change Same as prev�ous Same as previous R No change permmed�. �No change ,
election eo cancd column column. pttmined.
co�•eage for che chi]d
4J
10-78
Chause in Status E�'eot ]tajor Dfedical Dental and�isioo Health Care Depeoden[Care Employce Group
Spendio�Attouot Spendin�Attonnt Li(eADBDand
(ACSA) �pCSp� Disabilin Co�enge
_"...''_"...-;::1�.._.:: - _' •'. �. - - -_- _
�a7I:�fed�caie or 1ied�caid " - - ;�-- ' .� - - l - -- -- -
` '
_� -. -- , . , -. _. .. -. "-.. :. - �' - r ._� >%- d..i-: , ' Y._ -�_ ,. -, " ,' � - . ' ��
',--A:� �Emploj'ee, Spouse,or D'epeudent Enrolled in_Emplo��er`s Accideut or Health_Plau Becomes Entitled to�4edicare �
' -o�DfediCaid.(Other ihan covcrnge ioldy for'pediamc vucmes) ._�_- 3 -".-i ' " � . .- :
Employee may elea linlikely tf:at Emplo��ee may I:o ctun¢e permiced. \o ctwige
ro<ancel or reduce Employee can dea apparendy darease pmniaed.
covemge for ro drop drntal or or¢voAe deaion
Employee,Spouse,or �ision covemge; or inerease elec[ioa - -
Dependrn4 az pmsumably, if HC5.4 is dropped
appGable. Employee must due eo
cetaincovemge. �fedicaNMedimid
and prior Emplo)•a
coveaee nas more
com rehrnsive.
_-�B.:Emplo}�ee,_Spouse,-or-Dependent:Loses;EGgibility..for_�iedicare�or \iedicaid. (och�r ctan oo.��age solei;� for pe�+���o �
�, .xccmal�: - - - - --
�Employee may elect Unlikely tha[ Employee may 'No change pertnitmd No chaoge
w commence or Employee ean elect apparendy increue pr.mitted.
incRZCe covemge for ro add dental or or daream or
Empiayee,Spouce,or vision cov<nge, moAe davon
Depeodrn4 az presumably, u�here Employer
appGcable. Employce canuoL plan el«ced due ro
7tou¢h unclear,it loss ofdigibiliry
appea[stha[ta¢-along for
� concepts ma��apply. MedicarelAlydimid
is more
comprehensive
than
T7edicarelMedipid
43
� �-�9
EXHIBIT B
��Slj
s�
cm oF
CHUTA VI57A
VOLUNTARY PLAN .
AFLAC
PLAN DOCUMENT
Amended and Restated as of]anuary 1, 2014
Human Resources Department
City of Chula Vista
10-SO
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
. PLAN INFORMATION SUMMARY
The Employer named below esiablishes a Flebble Benefits Plan (ihe 'Plan') as sei forh in this Summary Plan Description
("SPD") 2s of ihe Efrective Date set forth below. The purpose of ihe Plan is to provide eligible Employees a choice between
cash and ihe specified welfare benefits described in this Plan Information Summary (see 'Benefits Provided Under ihe Plan').
Pretax Contribution elections under the Plan are intended to qualify for the exclusion from income provided in Section 125 of the
Intemal Revenue Code of 1986.
FLEXIBLE BENEFITS PLAN .
EMPLOYER INFORMATION
1) Name and Address of Employer: XITY OF CHULA VISTA
Plan Administrator: EDITH QUICHO
276 FOURTH AVENUE
CHULA VISTA, CA 91910
The Plan Adminisirator has ihe exGusive right to interpret the Plan and to decide all matters arising under the Plan, inGuding 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) Empioyers Federal Tax '
Ideniification Number. 95-6000690 -
4) Plan Number Assigned to Cafeteria
Plan (e.g., 501 if this is the first ERISA
Plan Number assigned):
5) 125 Start Date: 01101/10
6) Effective Date of this Plan: 12115/11
7) Lasi Day of the Plan Year: 12131/11
Subsequeni Plan Years: 01101-12131
8) Name and Address of SAME
� FSA Claim Administrator:
9) Name and Address of registered IRENE MOSLEY
agent for service of legal process: �
10) A�liated Employers that will participa;e in the Plan :
. 71) Employer's Type of Business: OTHER
ELIGIBILITY
All Employees employed by the Employer shall be eligible to participate under ihe Plan exceot the following:
An eligible Employee may become a Participant in the Plan:
[ X ] Immediately, upon the first day of employment(but noi prior to ihe Effective Date of the Pian). �
[ ] On the day following commencement of employment.
[ ] On the first day of the month following days of employment.
[ j Other. OTHER_
provided the Employee compfetes a Salary Rediredion Agreement ("SRA'). However, eligibility for coverage under any
given Benefit Plan or Policy shall be determined by the terms of that Benefii Plan of Policy, and reductions of the
Employee's Compensation to pay Pre-tax or After-tax Coniribution(s) shall commence when the Employee becomes
covered under the applicable Benefit Plan or Policy. - �
An eligible Employee may become a Partiapant in ihe Dependent Care and/or Medical Expense Reimbursement Plan(s) (if
elected below):
[ ] On the same day such Employee is eligible for the Pre-Tax Contribution benefits under the Plan.
[ ] On the day following commencement of employment.
[ ] On ihe first day of the month following days of employment.
[ ] Other: OTHER, provided the Employe=completes an SRA selecting such benefits.
� sao
10-81
BENEFITS PROVIDED UNDER THE PLAN
The following Beneft Plans and Policies subject to the terms and conditions of the Plan are available for election by eligible
Employees. The maximum a Participant can contribute via the SRA is the maximum aggregate cost of the Beneft Plans or
Policies elected minus any Nonelective Contribution made by [he Employer. It is intended that such Pre-tax Contribution
amounts shall, for tax purposes, constitute an Employer contribution, but may constitute Employee contributions for state
insurance law purposes. Copies of the Benefit Plans or Policies (or a list of eligible Policy numbers) shall be attached as an
appendix to this Plan.
[ ) Medical Coverage
[ ] Vision Care Coverage
[ ] Disability Income-Short Term (A8S)
[ X ] Cancer Insurance
[ X ] Dental Coverage
[ ] Group Term Life Insurance
[ ] Disability Income- Long Term (LTD)
[ X j In[ensive Care Insurance
[ X ] Accideni Insurance - -
[ X ] Hospital Indemnity Insurance(HIP)
[ X ] Specified Health Event
[ X ] Personal Sickness Indemnity(PSI) .
[ ] Medical Care Expense Reimbursement described in Appendix I to this SPD, not to exceed $ per Plan Year pursuant to the
XITY OF CHULA VISTA Medical Care Ezpense Reimbursement Plan. �
Name and Address of Medical Care Expense Reimbursement Plan
COBRA Administrator(if applicable):
[ ] Dependent Care Expense Reimbursement described in Appendix I to this SPD, not to exceed $5,000 per Plan Year or
$2,500 for married filing separate retums pursuant to the XITY OF CHULA VISTA Dependent Care Expense
Reimbursement Plan. . .
[ ] Health Savings Account (as defined in Code Section 223) established with the following
Custodian/Trustee:
[ ] Opt-out Option: See Employer enroliment material.
THE FUNDING AGENT
The Employer selects the following Funding Agent for the Plan (check one):
❑ The Employer,which will comply with the requirements of Article VII of the Plan.
❑ The Flexible Benefits Trust created concurrently with the execution of the Plan, which shall receive contributions under
the Plan in accordance with Article VII of the Plan. .
ADMINISTRATIVE EXPENSES
Administrative Expenses incurred in operating the Plan shall be paid by(check one):
❑ The Employer, except as otherwise noted in the Plan.
❑ The Participants, except as othenvise noted in the Plan.
2 SPD
� �-$2
FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION
Introduc[ion
Your empioyer (the 'Employer) is pleased to sponsor an employee benefit program known as a "Flexible Benefits Plan' (ihe
'Plan')for you and your fellow employees. Under federal tax laws, it is also knovm as a "cafeteria plan'. It is so called because
it lets you choose from severel 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 eniering into a salary redirection arrangement instead
of receiving a corresponding amount of your reguiar pay. This arrangement helps you because the benefits you elect are
nontaxable; you save Social Security and income taxes on the amount of your salary redirection. Aiiematively, your Employer
may allow you to pay for any of ihe available benefits with after-tax coniributions on a salary deduction basis.
This Summary Plan Description ("SPD°) describes the basic features of the Plan, how it operates, and how you can aet the
mabmum advantage from it. Information relatin9 to ihe Plan that is specific to your Employer is described in the Plan
Informa;ion 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,ihe plan document will govem.
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 Infortnation Summary as"Benefiis Provided under[he 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 ihat 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 defin�d in Code Section 223)through ihis
Plan if Health Savings Accounts are identified as an included benefit under 'Benefits Provided under ihe Plan" in [he Plan
Information Summary. If Heaith Savings Accounts are identified as a benefii plan option offered under the Plan, your rights and
obiigations in regard to such contributions will be set forth in the Health Savings Account Contribution Appendix attached hereto.
Questions &Answers about the Flexible Benefits Plan
Q-1. What is the purpose of the Plan? �
The purpose of ihe Plan is to allow eligible employees to pay for certain benefits offered under ihe Plan (called 'Benefit
Plans or Policies')with pre�tax dollars called"Pre-tax Contributions°. Pretax Contribu[ions are described in more delail
in Q-8 of this SPD.
Q-2. What benefts can I purchase on a pre-tax basis through [he Plan?
You will be able to choose to participate in the Plan's various pre-tax options by filling oui any required enrollment
form(s) for the component Benefit 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 Pretaz Contributions towards ihe cost of Benefit Plans or Policies that cover you,
. your legal Spouse, and/or your tax Dependents defined under Intemal Revenue Code Section �52. Each Benefit Plan or
Policy may define eligible Dependents mo�e narrowly for purposes df coverage under the particular Benefit Plan or
Policy. • '
Q-3. Who can participate in the Plan?
Each employee of the Employer(or an A�liated Employer identified in ihe Plan Information Summary)who satisfies the
eligibiiity reqwrements described in the Plan Information Summary and who is eligible to participate in any of the Beneft
Plans or Policies offered under the Plan will be eligible to participate in this Plan as of ihe date descnbed in the Plan
Information Summary (see Q-5 ot this SPD for instructions on how to become a Participani). Those employees who
actually participate in the Plan are called "Partiapants.' 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 amounis, and premium schedules for each of the Benefii Plans or Policies, please refer to [he plan summary for
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 inwme tax code
or the Employee's tax dependents as defined in Code-Section 752; however, for purposes of health benefi.s 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 rzquirements to
be a"qualifying individual°as defined in ihe DDC component SPD. �
Q-4. When does my participation in the Plan end?
You continue to participate in the Plan until (i)you elect not to participate in accordance with Q-9 of this SPD; (ii)you no
Ionger satisfy the eligibility requirements described in the Plan Information Summary; (iii) you terminate employment
with the Employer, or(iv)the Plan is tertninated or amended to exclude you or the class of employees of which you are
a member. If your employment with the Employer is tertninated during ihe Plan Year or you othenvise cease to be
eligible, your adive participation in the Plan will automatically cease, and you will no; be zble to make any more
3 SPD
10-83
Pr�tax Contributions under the Plan. If you are rehired within the same Plan Year or you become eligible again, you
may make new elections, provided that you are rehired or become eligible again more ihan 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.
�•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 a salary redirection to pay for those
benefts so elected. You will be provided an SRA when you first become eligible lo participate in this Plan. You must
complete the form and turn it in to the Personnel Office during the applicable enrollment period described in Q-6 beiow.
Q-6. What are the enrollment periods for entering the Plan?
If you are eligible on ihe effective date of the Plan, you must enroll during the enrollment period immediately preceding
the effeclive date of the Plan. Otherwise, you must enroll during either the "Initial Enrollment Period" or the "Annual
Enrollment Period". You will be notified of the dates that each enrollment period begins and ends in the enrollment
material provided to you prior to each enrollment period. If you make an election during the Initial Enrollment Period,
' your participation in this Plan will begin on the later of your eligibility date described in the Plan Information Summary,
the frst pay period coinciding with or neM following ihe date[hat 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 Beneft Plan(s) or Policy(ies) is governed by the terms of each Beneft
Plan or Policy, as set forth in the goveming documents for each Benefit Plan�or Policy. The election that you make
during the Initial Enrollment Period is effective for the remainder of the Plan Year and generelly cannot be revoked
during the Plan Year unless you have a Change in Status even[ as described in-Q-9 below. If you do not make an
election during the Initial Enrollment Period, you will be deemed to have elected not to participate in this Plan for the '
remainder of the Plan Year. You may, however, be covered by certain Benefit Plans or Policies automatically (and be
required to contribute with pre-tax dollars) even if you fail to make an election. These automatic Beneft Plans or
Policies are called "Default Benefits°and will be identifed in the enrollment material that you receive.
The election that you make during the Annual Enrollment Period is effective the frst day of the nexl Plan Year and is
irrevocable for the entire Plan Year unless you have a Change in Status event described in Q-9 below. A Participant
who fails to complete, sign, and file an SR,4 during the Annual Enrollment Period as required shall be deemed to have
elected to continue participation in the Plan with the same beneft elections as during the prior Plan Year (adjusted to
reflect any increase/decrease in applicable premiums), and except for a Change in Status, will not be permitted to
modify his election un[il 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 benefts.
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 monihly gross pay is 32,500 per month and your cost for coverage is $140 per month. Also, suppose
your total withholdings (income taz 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 rether than $2,500 for tax purposes with $�40 contributed for medical coverage. This means your
take home pay will be $1,825 with the pre-tax premium plan rather than $1,794 without it. Thus, you save £31 per
month (5372 per year)by participating in the pr�tax premium plan. The Table below illustrates this savings.
' With Cafeteria Plan Without Cafeteria Plan
Gross Monthly Pay 52,500 $2,500
Pr�Tax Coverage Under Plan 140 --
Taxable Income 2 360 2 500
Estimated Federal Tax(15%) 354 375
FICA Tax 181 191
After-tax Coverage — 140
Take Home Pay 1,825 � 1,794
Mon[hly Savings: $31.00
�-8. How are my contributions under the Benefi[Plans or Policies made?
When you become a Participant, your share of [he contributions for the elected Benefit Plan or Policy(ies) will be paid
with Pre-tax Contributions elected on the SRA. Pre-tax Contnbutions are amounts wiihheld from your gross inwme
before any applicable federal and state taxes have been deducted (some state tax laws do not recognize Pre-tax
Contributions). In addition, all or a portion of the cost of Ihe 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 "Nonelechve
Contributions"). The amount of Nonelective Contribution that is applied towards the cost of [he Benefit Plan(s) or
4 SPD
10-84
Folicy(ies)for each Participant and/or level of coverage is subject to the sole discretion of ihe Employer, and it mzy be
adjusted upward or downward in the Employer's sole discretion. The Nonelective Contribution amount will be calculated
for each Plan Year in a uniform and nondiscriminatory manner and m2y be based upon your Dependent s�tus, -
commencement or termination date of your employment during the Plan Year, and such other faciors ihat the Employer
deems relevant. In no event will any Nonelective Contribution be disbursed to you in ihe form of additional, ta�ble
Compensation except as otherwise provided in the enrollment material. To the extent set forth in the enrollment
material, the Employer may make availabie a certain amount of Nonelective Con:ributions and then allow you to
allocate the Nonelective Contributions among the various Benefit Plan(s) or Policy(ies) that you choose (subject to
restrictions described in the enrollment material). � �
Q-9. Can I ever change my election during the Plan Year?
Generally, you cannot change your election to participate in the Plan or vary the Pre-taz Contribution amounts although
your election will tertninate if you are no longer working for the Empioyer or no longer eligible under the terms oi the
Plan. Oiherwise, you may change your elections for Pre-Tax Coniributions only during the Mnual Enrollment Period,
and then, only for Ihe coming Plan Year. There are several important exceptions to this general rule: You may change
or revoke your previous election during ihe Plan Year if you file a written request for change wiih the Plan Adminisirator
(or its designated Gaims administrator)within 30 days of any of the following events:
1. Change in Status. If one or more of[he 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 oi and correspond with the
Change in Status (as described below). Those occurrences thai qualify as a Change in Status indude the events
described below, as well as any o[her events thai the Plan Administretor detertnines are permitted under
subsequent IRS regulations: _ _
• a change in your legal marital status(such as marriage, legal separation, annulment, or divorce or death ef
your Spouse);
• a change in the number of your tax Dependents (such as the birth of a child, adopiion or placement for
adoption of a Dependent,or death of a Dependent);
• any of the following events thai change the employment status of you, your Spouse, or your Dependent thal
affect benefit eligibility under a cafeteria plan (induding this Plan and the Plan of another employer) or other
employee benefit plan of yours, your Spouse, or your Dependents. Such events indude any of the following
changes in employment status: termination or commencement of employment, a sirike or lockout, a
commencement of or retum from an unpaid leave of absence, a change in worksite, switching from salaried to
hourty-paid, union to non-union, or part-time to full-time; incurring a reduciion 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 goveming election changes when you take a leave of
. absence are described in Q-13 of this SPD);
• an eveni that causes your Dependent to satisfy or cease to satisfy an eligibility requirement for a particuiar
benefii(such as attaining a specified age, getting married,or ceasing to be a studeni);
• a change in your, your Spouse's or your DependenYs place of residence. �
If a Change in Status occurs and you want to make a corresponding election change, yo� must infortn the Plan
Administrator and complele 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 ihe
exception of special enrollment resuliing from birth, placemeni for adoption or adoption, all election changes are
prospective.
As a general ru�e, a desired election change will be found to be consistent wi[h a Change in Status event if the event
affects eligihility for coverage. A Change in Status affects eligibiiity tor coverage if it results in an increase or
decrease in the number of Dependenis who may benefit under the plan. In addition, you must also satisfy the
foliowing specific requirements in order to alter your election base�i on ihat Change in Status:
• Loss of Dependent Eligib�Trty. For accident and health benefits (e.g., health, dental and vision coverage, and
Medical Care Reimbursement Plan), a special rule govems which types of election changes are consistent wiih
ihe Change in Status. For a Change in Status inyolving your divorce, annulment or legal separa:ion from your �
Spouse, the death of your Spouse or your Dependent, or your Dependent ceasing to satisfy the eligibili;y
' requirements for coverage, your election to cancel accident or health benefts for any individual other than your
Spouse involved in the divorce, annulmeni, or legal separetion, your deceased Spouse or Dependent, or your
Dependent tFat ceased to satisfy the eligibiliry requirements, would fail to correspond with ihat Change in
Status. Hence,you may only cancel accident or healih coverage for the affected Spo�se or Dependent.
Example: Employee Mike is married to Sharon, and ihey have one child. The employer offers a calendar year
cafeteria plan that allows employees to elect no health coverege, employee-oniy coverage,
� employee-plusone-Dependent coverage, or family coverage. Before the plan year, Mike elects f2mily
coverage for himself, his wife Sharon, and their child. Mike and Sharon subsequentiy divorce during the plan
year; Sharon loses eligibili!y for coverage under ihe plan, while ihe chiid is still eligible for coverage under:he
plan. Mike now wishes to cancel his previous election and elect no health coverage. The divorce behveen Mike
5 SPD
10-85
and Sharon constitutes a Change in Status. An election to cancel coverage for Sharon is consistent with this
Change in Status. However, an election to cancel coverage for Mike and/or the child is not consistent with this
Change in Status. In contrast, an election to change to employee-plus-one-Dependent coverage would be
consistent with this Change in Status. However, there are instances in which you may be able to increase your
Pre-taz Contributions to pay for COBRA coverage of a Dependent child or yourself.
• Gain of Coverage Eligibilrty Under Another Employer's Plan. For a Change in Status in which you, your Spouse,
or your Dependent gain eligibility for coverage under another employer's cafeteria plan (or Benefit Plan or
Policy) as a result of a change in your mantal status or a change in your, your Spouse's, or your DependenPs
employment status, your election to cease or decrease coverage for that individual under the Plan would
correspond wiih that Change m Status ony if coverege for that individual becomes effective or is increased
under the other employer's plan.
• Dependent Care Reimbursement Plan Benef'ds (d offered under the Plan. See the list of BenefR Plans or
Policies offered unde� the Plan in the Plan Information Summary). With respect to the Dependent Care
Reimbursement Plan beneft(ii 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 affecis eligibility for
coverege 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 ezpenses 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 52,000 during a plan year to fund Dependent care coverage for his daughter. In the middle of the
plan year when the daughter turns 13 years old, however, she is no longer eligible to participate in the
Dependent care program. This event constitutes a Change in Status. Mike's election to cancel coverage under
the Dependent care program would be consistent with this Change in Status.
• Group Term LBe Insurance, Disability Income, or Dismemberment Benefds (if oNered under the Plan. See the
list of 8enef"rt Plans or Policies offered under the Plan in the Plan Information SummaryJ. For group term life
insurance, disability income, and accidental death and dismemberment benefits, if you experience any Change
in Status (as described above), you may elect either to increase or decrease coverage.
Example: Employee Mike is married to Sharon, and they have one child. The employer's plan offers a
cafeteria plan which funds group-term life insurance coverage (and other benefts) through salary reduction.
Before the plan year Mike elects $10,000 of group-term life insurance. Mike and Sharon subsequently divorce
during the plan year. The divorce constitutes a Change in Status. An election by Mike either to increase or to
decrease his group-term life insurance coverage would each be consistent with this Change in Stalus.
2. Special Enrollment Rights. If you, your Spouse, and/or a Dependent are entitled to special enroliment rights under a
Benefit Plan or Policy that is a group heallh plan, you may change your election to correspond with the special
enrollment right. Thus, for ezample, 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 [o certain
reasons (i.e., due to legal separation, divorce, death, termination of employment, reduction in hours, or exhaustion of
COBRA period), you may be able to elect medical coverage under the Beneft Plan or Policy for yourself and your
eligible Dependents wtio lost such coverage. Furthermore, if you have a new Dependent as a result of marriage, birth,
adopiion, or placement for adoption, you may also be able to enroll yourself, your Spouse, and your newly acquired
Dependents, provided that you request enrollment within the Election Change Period. An election change that
corresponds with a special enrollment must be prospective, unless the special enrollment is attributable to the birth,
adoption, or placement for adoption of a child, which may be retroactive up to 30 days. Please refer to the group health
plan description for an explanation of special enrollment rights. '
Effective April 1, 2009, if you or your eligible Dependent (1) lose coverage under a Medicaid Plan under Title XIX of the
Social Security Act; (2) lose coverage under a State Children's Health Insurance Program (SCHIP)under Title XXI of the
Social Security Act; or(3) become eligible for group health plan premium assistance under Medicaid or SCHIP and you
are entitled to special enrollment rights under a Benefit Plan or Policy that is a group health plan, you may change your
election to correspond with the special enrollment right. Thus, for example, if you declined enrollment in medical
coverage for yourself or your eligible Dependent(s)because of inedical coverage under Medicaid or SCHIP and eligibiliry
for such coverage is subsequently lost, you may be eligible to elect medical coverage under a Benefit Plan or Policy(or
yourself and your Dependent(s). You must request an election change to enroll in group plan coverage within 60 days
from the date (�) the coverage terminates under the Medicaid or SCHIP 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)[o be covered under
this Plan, you may change your election to provide coverage for[he Dependent child identified in the order. If the order
requires that ano[her 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, sub�ect to the terms of the underlying plan, elect to
begin or increase that person's accident or health coverage.
6 SPD
� 0-86
5. Change in Cost. If you are notified ihat the cosl of your Benefit Plan or �olicy coveraoe under the Plan sign;,-�cantly
inueases or decreases during the Plan Year, you may make cerain election chanaes. If the cost significantly
increases, you may choose eifher to make an increase in your contributions, revoke your election and receive coverage
under another Benefii Plan or Policy that provides similar coverage, or drop coverage altogether if no similar coverage
ebsts. If the cost significantly decrezses, you may revoke your elec;ion and elect to receive coverage provided under
the option that decreased in cost. For insgnil'icant increases or decreases in the cost oi Benefit Plans or Polides,
however, your Pre-tax Contributions will automatically be adjusted to re�ect [he minor change in cost. The Plan
Administrator wili have final authority to detertnine whether the requirements of this section are met. (Please note that
none of the above "Change in CosY exceptions are applica6le to a Medical Care Reimbursement Plan, to the extent
offered under ihe Plan.) � �
Example: Employee Mike is covered under an indemnity opiion of his employer's accident and health insurance
coverage. If the cost of this option significan[ly increases during a period of coverage, ihe Employee may make a
corresponding increase in his paymenis or may instead revoke his election and elect coverage under an HMO option.
6. Change in Coverege. If you are notified that your Benefit Plan or Policy coverege under the Plan is significantly
curtailed, you may revoke your election and elect covuage under another Benefit Plan or Policy thai provides similar
coverege. If the significant curtaiimeni amounts to a complete loss of coverage, you may also�rop coverage if no other
similar coverage is available. Further, if the Plan adds or significantly improves a benefit option during the Plan Year,
you may revoke your election and elect to receive on a prospective basis coverage provided by the newly added or
significanily improved option, so long as ihe nevAy 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 2nother
employer plan (including a plan of the Employer or anofher 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
difrerent from the Plan Year of the other employer plan. Finally, you may chang�your election to add coverage under
this Plan for yourself, your Spouse, or your Dependent if such individual(s) loses coverage under any group health
coverage sponsored by a governmental or educational institution. The Plan Administrator will have fnal discretion to
determine whether ihe requirements of this section are met. (Please note that none of the above"Change in Coverage'
exceptions are applicable to the Medical Care Reimbursemeni Plan, to the eutent offered under ihe 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 Intemal Revenue Code), if necessary to prevent ihe Plan from becoming
discriminatory wi:hin the meaning of the federal income tax law.
Q-10. How long will the Plan remain in effect9
� Although the Employer ezpects to mainiain the Plan indefinitely, it has the right to modify or terminate the program at
any time for any reason. It is also possible that future changes in state or federal tax laws may require that the Plan be
amended accordingly.
Q-11. What happens if my claim for benefts under this Plan is denied?
This SPD describes the basic features of the Plan. If your Gaim is for a benefit under one of the component Beneft
" Plans or Policies, you will generally proceed under the Gaims procedures applicable under the component Benefit Plan
� or Policy(see[he plan summary for each of[he Benefit Plans or Policies that you elect). However, i(you are denied a
benefit under this Plan, the claims procedure under this Plan will apply. You will be notified if your daim under[he Plan
is denied. The notice of deniai will be f�mished to you within 30 days after receiving your daim. However, if additional
time is needed to process your ciaim you will be notified before ihe initial 30-day period has expired. The notice will
explain why an e�ctension is necessary and the date a decision is expected to be rendered.--In no event will an ex;ension
go beyond 75 days after the end of the initial 30.day period. The notice of;he denial will include the specific reasons for
the denial and the relevant plan provisions on which the denial was based.
If your claim is denied in whole or in part, you may appeal by requesting a review of[he denied claim, as set forth in the
notice of denial, within 780 days after you receive notice of the denial. If there are iwo levels of appeal (as indicated in
the notice of denial), you will have a reasonable amouni of time in which to requesi a second review and such time
period will be ideniified in the notice of denial. As part of the appeal process (wheiher there is one or hvo appeals), you
or your authorized representative may examine documents, records, and other information relevant to your daim and
submit issues, documenis and comments in writing. Within 60 days after the request for review is received, you will be
notifled in writing of the decision on review.
� The notice of denial will indicate whether ihere are one�or two levels of appeals and will coniain the same rype of
information provided to you in the first notice of denial. If there are two levels of Plan appeals, ihe decisions on appeal
� will be made within 30 days after the request for each review is received. The Plan Administrator is the Gaims fiduciary
for making the final decision under the plan. �
In the event of your death, your beneficiary has the same rights and is subject to ihe same time limits and other
restrictions ihat would othenvise apply to you under the daims procedures explained above.
Q-12. What effect will Plan participation have on Social Security and other benefits?
Plan participztion wili reduce the amount of your taxable compensation. Accordingly, there could be a decrease in your
Social Securi.y benefits andlor o:her benefits (e.g., pension, disability and life insurance) ihat are based on taxable
compensation.
7 SPD
� �'87
�
Q-13. What happens if I take a leave of absence?
(a) If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), to the extent
required by the FMLA, the Employer will continue to maintain your Beneft Plans or Policies providing health
coverage on the same terms and conditions as though you were still active (e.g., the Employer will continue to pay �
its share oi the contribution to the ex[ent 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 paid leave are required to continue coverage). If so, you will pay your share of the
contributions by the method normally used during any paid leave (for ezample, 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 coniinued), 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 pr�pay all or a portion of your share of the contribution for the expecied
duration of the leave with Pr�tax Contributions from your pre-leave compensation by making a special election to
that effect before the date such compensation would normally be made available to you provided, however, that
pre-payments of Pre-tax Contributions may not be utilized ro fund coverage during the next Plan Year, or by other
arrangements agreed upon between you and the Plan Administrator(for example, the Plan Administrator may fund
coverage during the leave and withhold amounts from your compensation upon your return from leave). The
payment options provided by the Employer will be established in accordance with Code Section 125, FMLA and the
Employer's internal policies and procedures regarding leaves of absence. Alternatively, the Employer may require
all Participants to continue coverege during the leave. If so, you may elect to discontinue your share of the required
contributions unhl you retum from leave. Upon retum from leave, you will be required to repay Ihe contribution not
paid during the leave in a manner agreed upon with the Administretor. " • �
(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 ihe Plan
prior to the leave, or as othenvise required by the FMLA. Your coverage under the Benefit Plans or Policies
providing health coverage may be automatically reinstated provided that coverage for Employees on non-FMLA
leave is automatically reinstated upon relurn(rom 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 ihe required contribution. Upon return from leave, you will be required to repay
the contribution in a manner agreed upon by you and Employer.
(f) If you are commencing or returning from unpaid FMLA leave, your election under this Plan for Benefit Plans or
Policies providing non-health benefits shall be treated in the same manner that elections for non-health Beneft
Plans or Policies are treated wi[h respect to Participants commencing and returning from unpaid non-FMLA leave.
(g) If you go on an unpaid non-FMLA leave of absence (e.g., personal leave, sick leave, etc.) that does not affect
eligibility in this Plan or a Benefit Plan or Policy offered under this plan, then you will continue to participate and the
contribution due will be paid by pr�payment before going on leave, by after-tax contributions while on leave, or with
catch-up contributions after the leave ends, as may be determined by the Administrator. If you go on an unpaid
leave that affects eiigibility under this Plan or a Benefit Plan or Policy, the election change rules in Q-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 Plan?
Participation in the Plan does not give any Participant the right to be retained in the employ of his or her Employer or
any other right not speafed in the Plan. The Plan Administrator's name, address and telephone number appear in the
Plan Information Summary attached to [he 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 inierpret 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.
8 SPD
� �-88
`rrA1n.
�»�
cm oF
CHULA VI57A
EXHIBIT C
EMPLOYEE ASS�STANCE
PROGRAM
AETNA RESOURCES FOR
LIVING
(dba Horizon Health EAP -
Behavioral Services)
PLAN DOCUMENT
Amended and Restated as of January 1, 2014
Human Resources Deparnnent
City of Chula Vista
10-89
HORIZON HEALTH EAP-BEHAVIORAL SERVICES
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
TABLE OF CONTENTS
I. DEFINITIONS..............................................................................................................................................2
II. HOW TO OBT4I\BE\EFITS...................................................................................................................3
III. EMERGENCS'SERVICES..........................................................................................................................4
IV. CRISISINTERVEh"CION...........................................................................................................................4
V. PERIODIC FEES..........................................................................................................................................4
VI. OTHER CfiARGES........................��---.........................................................................................................5
VII. PREPA1'n4E\T OF FEES....................................................................................................................�---...5
�'III. C}IOICE OF EAP PROVIDERS.................................................................................................................5
Lt. FACILITIES..................................................................................................................................................5
X. LIABILITI'OF HORIZON HEALTH E_AP-BEHAVIORAL SERVICES/ME1fBERS.....................5
�� A. LIABILI7YOFHORIZONHEALTHEAP-BEHAVIORALSERVICES..................................................:...........5
B. LIABILITY OF I��IEMBERS...........................................................................................................................S
C. MEMBER LIABILITY TO NON-EAP PROVIDERS.........................................................................................6
�I. PROV[DERCOMPENSATION..................................................................................................................6
tilI. SECO\DOPI\IONPOLICY........................................:............................................................................6
RIIi. ELIGBILiTY/EnROLLMENT/EFFECTIVE DATE OF COVERAGE...............................................7
XI�'. TER11tINATION OF BENEFITS................................................................................................................7
A. CANCELLATION OF THE GROUP CONTRACT FOR NONPAYMENT OF PREMNAIS.........................................7
B. REIhSTATFbfEI.70FTHECOMRACTAFTERCANCELLATION....................................................................8
C. MEMBERI�RMWATIONFORNON-ELIGIBIL[Tl'........................................................................................8
D. TERhiL\ATION FOR GOOD CAUSE..............................................................................................................8
1V. CONT[NUITI'OF CARE............................................................................................................................9
A. NEW MEMBERS.........................................................................................................................................9
I) Eli�ibilitv. ..................._...... ..........._... .... ...... ....... ... . . ............. ... .. ... ...... .. . ....._.... ......9
2) Access....... ..... ... ........................ .. .... ... .... ............. ............................ ... ....... ........... ... . . .....9
B. TERhf�ATEDEAPPROVmERS...............................................................................................................10
i Eridence ofCorerage
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\"�"I. CO\'II\UATIO�OF GROliP COVER4GE.........................................................................................10
A. COBRA CO\7L\'UATION OF COb'ERAGE..................................................................................._............10
B. CAL-COBR4 CO\TCNUnT10\OF CO\'ERAGE........................................................................................11
1) Eli�ibilirvforCal-COBR9CantinuationCorerage..........._................... .._........................ ..._. ...11
?) :\'otificaiion of Oualifi�ing Everus ....................................................................................11
3) Ca!-COBR.1 Enro(lment and Premium Informmion.......................................................................l?
4) TerminarionofCal-COBR4ContinuationCorerage.....................................................................12
\1"LI. COil1PL.�T A,\D GRIE�'.+.NCE PROCEDURE.................................................................................13
a"VIII. �fISCELLATEOUS....................................................................................................................................15
.4. COr'F[DE'""f[ALITS'POLICY......................................................................................................................1 J
B. METfBERCO\SEYT.................................................................................................................................1�
C. HORIZON HEALTH E.4P-BEHA��OR4L SERVICES'POLIGIES...................................................................16
D. HoR¢o�IiEn�.ni E.aP-B�u.�TOa.u.SEav�cES'Pti�suc PoL�ct'ConmcrrrEe.....................................16
E. TERI.IA\'DRF'�EW.4LPROVLSIO\$..........................................................................................................16
F. LA�ORTAN!IKFOFNIATIO�ABOUT ORGAN.4\D 7iS5GE DONATIORS .....................................................16
ESHIBIT a-SCHEDGLE OF BE\"EFITS,LL1iITAT10\S,A\D ERCLUSIO\5........................................17
A. BEI�EFI'fS................................................................................................................................................17
B. LIMITATIO\5.....................................................................................ERROR!BOOI:.\LaRli\OT DEFL�ED.
C. EXCLUSIOt:s...........................................................................................................................................18
� ESfIIBIT B-CO�IPARISO\ OF BE\EFITS.......................°----°--.....-----.....................................--°-.°--.........._.19
ii Evidence oJCoveraae
� 0-9�
HEALTH AND HUMAN RESOURCE CENTER
(dba HORIZON HEALTH EAP-BEHAVIORAL SERVICES)
7676 Hazard Center Drive, Suite 1100
San Diego, CA 92108
1-800-342-8ll I
EMPLOYEE ASSIST.ANCE PROGRAM
COMBINED EVIDENCE OF COVERAGE AND DISCLOSURE FORM
The Employee Assistance Pro�ram (EAP) is bein� offered by your employer to provide you�vith
confidential assistance from licensed mental health professionals. These professionals can help
with problems affecting your life at �vork 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 ���ill conduct a thorough assessment of your problem and together u=ith 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 esact
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
' covera�e. It also provides you with important information on how to obtain Benefits and the
circumstances under n�hich Benefits will be provided to you. PLEASE READ .IT
CAREFiTLLY. Individuals with special health care needs should read carefully those sections
that apply to them.
Keep this publication in a safe place ��here you can easily refer to it when you are in need of
Benefits.
Contact Horizon Health EAP-Behavioral Services at 1-800-342-8] I1 to receive additional
information about Benefits.
Enclosed as Exhibit B is Horizon Health EAP-Behavioral Services' matrix of covered services.
1 Evidence ofCoverage
� �-92
III. EbiERGENCl' SER�TCES
Emereency services are medicalh� necessan� ambulance and ambulance transport sen�ices
provided throueh the 911 emergency response system and medical screenine, examination,
and evaluation by a physician; or other personneL to the estent provided by la�ti�, to determine
if an Emereenc}� �4edical Condition or ps}�chiatric emereenc�- medical condition exisu; and,
if it does; the care, veatment; and/or surgery b}� a ph��sician necessary to relieve or eliminate
the Emereency D4edical Condition or psychiatric emeraenc}� medical condition ���ithin the
capabilities of the facility.
R'hat To Do �Vhen You Require Emergenc�� Sen�icc
If you believe that you need Emeraency Sen�ices; you should call 911 or go to the nearest
emereencv medical facilirv for veatment. The Plan does not cover emereencv medical
services. -
It is appropriate for ��ou to use the 911 emereency response spstem: or altemative emergency
svstem in vour area, for assistance in an emereencv situation described above ���hen
ambulance transport services are required and ��ou reasonably believe that your condition is
immediate and serious and requires emereency ambulance transport sen�ices to transpoR you
to an appropriate facility
IV. CRISIS INTERVENTION
If you need crisis intervention or problem solvine; call Horizon Health EAP-Behavioral
Services at 1-800-342-8111. Horizon Health EAP-Behavioral Semices provides crisis
intemention both durins and afrer business hours at this numbec A member who is currentiv
ouuide the Plan sen�ice area and requires this sen�ice can call 1-800-342-8111. T4embers
can obtain care if the}� are temporarit}�outside of the Plan semice azea. D4embers 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 E.�P-Behavioral Sen�ices bills the Group for Periodic Fees and the Group
remiu such fees to Horizon Health EAP-Behavioral Services each month durins the term of
the EAP Services Asreement for D4embers entitled to receive Benefits durine such month.
Horizon Health E,4P-Behavioral Services mav chanee the Periodic Fees and/or Benefiu
under the EAP Sen�ices Aareement effective thim (30) days afrer receipt by the Group of
�ariaen notice from Horizon Heal[h EAP-Behavioral Sen-ices settins for�h am such chanee.
but in no e��ent during the then-existina thim-six (36) month term of the EAP Services
Aareement. There are no co-pa}�ments, deductibles, or charees co ��ou for Benefiu.
4 Evidence of Covera�e
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VI. OTHER CH_ARGES
The Plan «�ill bill the Group for additional sen�ices or benefits provided under the
Aareement. The Group �i�ill remit payment to the Plan within thirty (30) da}�s of receipt of
im�oice.
VII. PREPAYNIENT OF FEES
The D4ember does not pa}� co-pa��nents, deductibles, or fees for the Plan. All fees are paid
b} the Group.
VIIL CHOICE OF EAP PROVIDERS
PLEASE READ THE FOLLOWING INFORMATION SO YOU R'ILL Kl�'O�i'
'FROM WHOM OR WHAT GROUP OF PROVIDERS BENEFITS A�IAY 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 1-800-342-81 1 1 to deteimine the names and locations of EAP Providers.
EAP contracted providers include licensed psychologists, licensed clinical social workers,
and licensed marria�e and family therapists. Psychiatrists are not provided througl� the EAP.
Members are �iven names of contracted providers in their area with knowledoe in the
problem area that is indicated. You may also request a list of providers, and this will be
provided for tbe geographic area, customized by specialty, if}�ou prefer.
IX. FACILITIES
The location of Providers is obtained by calling Horizon Health EAP-Behavioral Sen�ices at
1-800-342-8111. If you prefer, a customized list of providers will be provided upon request.
This is arran�ed by zip code in the area specialty that you reouest.
X. LI�BILTTY 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
Benefits provided to you; you shall not be liable to EAP Providers for any sums o�ved by
Horizon Health EAP-Behavioral Services.
B. Liabilit}� of Members
It is not contemplated that A4embers would make payment to Plan providers for benefits.
If this has occuned, the A4ember may contact the Plan at 1-500-342-8111 to be
reimbursed. There is no restriction on assignment of sums pa}�able to the Member by the
health plan.
5 Evidence oJCoverage
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C. A4ember Liabilih� to Non-E_AP Pro��iders
I'ou may be liable to non-EAP Providers for the cost of services rendered �vhen such
semices are not authorized or referred by Horizon Health E_�1P-Behavioral Szrvices.
\I. PROVIDER CO�iPENSATION
Horizon Health EAP-Beha��ioral Sen�ices compensates EAP Providers t}uough an agreement
b}� w�hich thev are paid a fised amount of mone}� based on hours worked, number of
Members seen, or number of sessions provided. Providers are compensated �vithin thim�
(30) da}�s afrer claim is recei��ed.
Horizon Health EAP-Behavioral Services does not distribute financial bonuses or use anv
other incenti��e proaram to compensate iu EAP Pro��iders other than the methods of
compensation defined abo��e. -_
Members may request fur[her information about Horizon Healch EAP-Beha��ionl Services
EAP Provider reimbursement policies and procedures by contactins Horizo� Health EAP-
Behavioral Sen�ices' n4anager, Provider Relations. at 1-800-342-8111 or the �4ember's Er1P
Pro��ider.
%II. SECO\� OPL��ION POLICY
You may request a second opinion resardine both veatment rzcommended by the treatine
EAP Provider and treatment desired by you.�Horizon Health E.4P-Behacioral Sen�ices w�ill
au[horize second opinions ���here the second opinion is consistent with professionally
recognized standards of practice. The second opinion request will not result in a chanee in
what is and is not a Benefit as described in the E,4P Sen�ices Aereement and this Combined
Evidence of Coveraoe and Disclosure Form. Horizon Health E.�P-Behavioral Sen�ices may
deny coverage for second opinion requesu for services not listed as Benefiu in the EAP
Services Asreement and this Combined Evidence of Co��eraee and Disclosure Form. If
Horizon Health EAP-Behavioral Sen�ices denies such a request, you will bear the financial
responsibility for anp self-directed second opinion. There ��=ill be no cost to ��ou if the second
opinion is received from an EAP Provider under contract ���i[h the Plan. If you request a
second opinion from a pro��ider not under contract with Horizon Health E.4P-Behavioral
� Sen�ices, you must provide an explanation as to «°hy an EAP Provider cannot render such an
opinion. The Horizon Health E_AP-Beha��ioral Sen�ices T4edical Director shall revie�v the
request to determine whe[her there is an EAP Provider qualified to render a second opinion.
Requesu for second opinions may be made by contacting the Director, Clinical Quality
Improvement at (1-800-342-3111) or in writine to 7676 Hazard Center Dri��e, Suite 1100,
San Dieeo, CA 92108. All requesu for second opinions shall be processed and approved or
denied by Horizon Health EAP-Behavioral Sen�ices within fi��e (�) business da}�s of receipt.
Requesu related to ur�ent care or crisis intervention shall be processed and approved or
denied���ithin fom=-eiaht (48) hours of receipt.
6 Eoedence ojCocerage
10-95
XIIL ELIGIBILITY/ENROLLA�NT/EFFECTIVE DATE OF COVERAGE
All Enrollees identified by the Group prior to the effective date of the EAP Sen�ices
A�reement and all persons covered under the identified Enrollee's health benefit plan or
residing �i�ith the identified Enrollee shall be entitled to Benefits as of such effective date.
The Group shall be responsible for notif}�ing Horizon Health EAP-Behavioral Sen�ices of
any Enrollee who becomes newly eligible after the effective date of the EAP Services
A�reement Horizon Health EAP-Behavioral Services shall rely upon the determination by
the Group as to �i�hich Enrollees are eligible for Benefits under the EAP Services Agreement.
Any disputes or inquiries re�ardin� eligibilit}�, including rights re�arding renewal,
reinstatement and the like, shall be referred b}� Horizon Health EAP-Behavioral Sen�ices to
the Group, which shall then advise Horizon Health EAP-Behavioral Services of iu
determination �vith respect to the matter.
XIV. TERMIYATION OF BENEFITS - -
Usually; your enrollment in the Plan terminates when the Group or Enrollee is no lon�er
eligible for covera�e under the employer's EAP Plan. In most instances, the Group
determines the date in �vhich covera�e will terminate. Coverage can be terminated, however,
because of other circumstances as ���ell; which are described befow.
A. Cancellation of the Group Cootract for Nonpayment oSPremiums
Continuin� coverage under this EAP Plan is subject to the terms and conditions of the
Group's EAP Sen�ices Agreement with the Plan. If the EAP Services A�reement is
cancelled because the Group failed to pay the required premiums when due, then
covera�e for you and all your dependents will end 15 days afrer the Group mails you the
Notice Confirming Termination of Coverage.
The Plan will mail your Group a notice at least 30 da}�s before any cancellation of
covera�e. This Prospecti��e Notice of Cancellation will provide information to your
Group regardin� the consequences of your Group's failure to pay [he premiums due
���ithin 15 da}�s of the date the notice �vas mailed.
lf 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 �vill
provide you with the following information:
1) That the Group Contract has been cancelled for nornpa}�ment ofpremiums;
2) The specific date and time when your Group covera�e ends, which �vill be no sooner
than I S days afrer the Notice Confirmin� Termination of Coveraee is mailed to you.
7 Ee�idence ofCovera�e
� 0-96
B. Reinstatement of the Contract after Cancellation
If the Group A�reement is cancelled for the Group's nonpayment of premiums, then the
Plan will permit reinstatement of the Group A�reement if [he Group pa}�s the amounrs
o�ved within 1� days of the date of the \otice Confirming Termination is mailed to the
Group.
C. Alember Termination for\on-Elisibilih�
In addition to terminatino the EAP Semices Aoreement; the Plan mav terminate a
D4ember s coveraee for anv of the follo«�ins reasons:
• The D4ember no loneer meeu the eligibility requirements established by the Group
and/or Plan: �
• The A4ember lives or worls outside the Plan Sen ice Area and does not work inside
the Plan Service Area (except for a child who is co<<ered as a dependent).
Endine Coreraee— Sqecial Circumstances for Enrolled Familv Members.
Enrolled Famil�� �4embers terminate on the same date of termination as the Group. If
there is a divorce; the Spouse loses eliQibility at the end of the month in �vhich a final
judgment or decree of dissolution of marriaee is entered. Dependent children lose their
eliQibilit�� �ti�hen they reach the Limitina Aee of 26 and do not qualify for extended
coveraae as a disabled dependent.
D. Termivation for Good Ca'use
The Plan has the risht to terminate vour co��eraee under this Er1P Plan in the follo���ine
siruation: V � �
• Fraud or Misrepresentation. Your coverase ma}� be terminated if }�ou (:nowingly
provide false information (or misrepresent a meanin�ful fact) on your enrollment
form or fraudulently or decepti��eh� use seroices or facilities of the Plan, its
Participating Providers (or l:no���inely allo��� another person to' do the same).
Termination is effective immediatelv on the date the Plan mails the \iotice of
Termination; unless the Plan has specified a later date in that notice.
If coveraee is terminated for the above reason. vou forfeit all riahu to enroll in the
COBRA Plan. . . y
Under no circumstances will a�4ember be terminated due to health status or the need for
E.AP Sen�ices. P.nv Member who believes his or her enrollment has been terminated due
to the Member`s health status or requirements for EAP Sen�ices ma}� reques[ a revie�v of
the termination by the California Department of A4anaaed Health Care. For more
information; contact our Customer Sen�ice Depar[ment. y
8 Eridence ojCovera�e
� 0-9�
I
NOTE: If the EAP Sen�ices Agreement is terminated by the Plan, reinstatement with the
Plan is subject to all terms and conditions of the EAP Services A�reement behveen the Plan
and the employer.
XV. CONTINUITY OF CARF,
A. New Members
1) Eligibility
Any newly covered Member with an acute, serious, chronic, or other mental health
condition ���ho has been receivin� 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 �vill be offered the option of continued care with your non-plan provider through
the EAP. The Mana�er of Provider Relations or the Director of Clinical Sen�ices �=ill
review all requests for continued care with a non-plan provider. Consideration will
be �iven to the potential clinical effect that a change of provider would have on }�our
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, }�ou ��ill be notified in writing.
2) Access
You may access the sen�ices of the provider by calling Horizon Health EAP-
Behavioral Services and indicating to the Intake person that you ha��e 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 aaree to continue until one of the followine occurs:
a. The episode of care is completed.
b. Your benefit is exhausted, in which case you will be transitioned to other on�oin�
care.
c. A reasonable transition period is determined on a case-by-case basis, durin�
which time you �vould 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 �vill 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 n4edical Director will be consulted on these decisions.
The followin� conditions must be met to receive continuin� 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 aud�orize the continuine care.
9 Evidence oJCoverage
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b. The requested treatment must be a cor•ered benefit.
c. The non-plan provider must aaree in ���riting to the same contractual terms as a
plan pro�ider, which includes payment rates.
d. Ihe A4ember must be new to Horizon Health EAP-Behavioral Services.
B. Terminated EAP Pro��iders
Should Horizon Health E_4P-Behavioral Services terminate an EAP Pro<<ider for
reasons other than a disciplinary cause, fraud, or other criminal activity; you may be
able to continue receivina Benefiu from the terminated pro�=ider followine the
termination, if the provider aarees in writing to continue to pro��ide Benefiu under the
terms and conditions of his/her aereement with Horizon Health EAP-Behavioral
Semices. To inquire about continued care, you should contact the D4ember Sen�ices
Department. -
XVI. CONTI\tiATIO\' OF GROtiP COVERaGE
A. COBR�Continuation of Cocerase
If the Group is subject to the Consolidated Omnibus Budset Reconciliation Act
(COBR.�) of 198�, as amended, you may be entitled to continuation of Group coveraQe
under that act (COBRA Coveraee). You may qualify for COBRA Coverage if you lose
Group coveraQe due to the occurrence of certain qualifyin� 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 elieibili[��of a spouse due to divorce or le�al separation.
• Termination of eli�ibilirv of a dependent child.
• Covered dependent if D4ember becomes eligible for A4edicare
COBRA Coveraee extends up to thirty-six (36) months; dependin� upon your qualifying
event. COBRr� Co��eraee mav be terminated on the occurrence of certain e��ents,
includins �'ou becomine elieible for coveraee under D4edicare. In addition. COBRA
Co��eraee is not available to certain D4embers includine those \�fembers �vho have cerrain
other coveraQe at the time of the qualifyine event. You mav obtain complete information
on COBRA qualifying events, COBRA Coveraoe termination circumstances. and
ineligibility for COBR4 Coverage from the Group.
The Group is responsible for providin� you �vith notice of��our rieht to receive COBRr1
Co�eraQe. You must provide Horizon Health EAP-Behavioral Sen�ices; or the Group;
with a written request for COBRA Coveraoe within si�t}� (60) days of elieibility for such
co��erage or receipt of notice of the qualifying even[. Qualified Members must make
pa}�ment of Periodic Fees to the Group or COBRA administrator �vithin foR}�-five (��)
10 Eriaence oj Covera�2
10-99
days of such written request. Members whose continuation of coverase under COBRA
�i�ill 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 Califomia Continuing Benefits Replacement Act (Cal-
COBRA); Members may be entitled to continuation of Group covera�e under that act
(Cal-COBRA Coverage). A Group is subject to Cal-COBRA continuation coveraee
if it: a) employs Z — 19 employees on at least 50% of its working days durino the
precedin� calendar year; or if the employer�vas not in business durin� any part of the
pre�-ious year and employed 2 — 19 eli�ible employees on at least �0% of its workin�
days during the previous calendar quarter; b) is ❑ot subject to the federal
Consolidated Omnibus Bud�et Reconciliation Act of 1985, as amended (COBRA). If
the emplo}�er is subject to Cal-COBRA, you and your depzndants ma}� qualify for
Cal-COBRA if you would lose coverage due to one of the following Qualifying
Events:
• Termination of emplo��ment or reduction in work hours for reasons other than
eross misconduct.
• Death of Enrollee.
• Termination of eli�ibility of a spouse due to divorce or le�al separation.
• Termination of eli�ibility of a dependent child.
• Covered dependant if A4ember is entitled to Medicare.
• Member whose COBRA covera�e �vill espire.
Cal-COBRA Coverage extends for up to thirty-six (36) months from the Qualifyin�
Event unless earlier terminated b}�the occurrence of certain events.
The Group is responsible for providin� A4embers with notice of their ri�ht to receive
Cal-COBRA Covera�e. The D4ember must provide the Group or COBRA
administrator���ith a written request for Cal-COBRA Coverage within sixty (60) days
of eli�ibility for such coverage or receipt of notice of the Qualifying E��ent. Eligible
Members must make payment of Periodic Fees to Horizon Health EAP-Behavioral
Services within forty-five (45) days of such written request.
2) Notitication of Qualifyins 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 �vithin sixty
(60) days. The Qualif��in� Events that the Member is responsible for notifyin�
include:
• Subscribers death.
ll ' Ev�dence oJCoverage
� �—� ��
• Spouse ceases to be eliaible due to di�orce or leoal separation.
• Loss of dependent starus b}� a Dependent enrolled in the aroup benefit plan.
• \Vith respect to a co�=ered Dependent onh�, the Subscriber's entitlement to
Medicare.
The Group must notif}� Horizon Health E.AP-Beha��ioral Services ���ithin thirq� (30)
davs of a termination of employment or reduction in work hours, which would result
in ending coveraQe under the A4ember's group benefit plan. Failure to notify Horizon
Health EAP-Beha��ioral Sen�ices w�ithin sixty (60) days of the occurrence of a
Qualifyine Event will disqualify the A4ember from recei�ins continuation coverase.
I�'otifications of a Qualif}�ins Event are generally made to the Group or the Group's
COBRA �dministra[or. If the D4ember has questions; he/she may contact the Group,
or Horizon Health EAP-Beha��ioral Services at 1-800-342-8111.
3) Cal-COBR4 Enrollment and Premium Information
�'��ithin fourteen (14) days of receiving notification of a Qualifyin� Event, Horizon
Health E_4P-Beha��ioral Ser��ices N�ill send enrollment and premium information, ,
including a Cal-COBRA Election Form. The A4ember must rerum the compfeted
Cal-COBRA Etection 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 coverase under the Plan was tertninated or will terminate due [o a
Qualifi�in2 Event; or
• The date the r4ember was sent the Cal-COBRr1 enrollment and premium
information.
Horizon Health EAP-Behavioral Sen�ices must recei��e the first Cal-COBR4
premium payment �vithin forty-five 4� da��s of the da[e the D4embers Cal-COBRA
Election Form ���as recei��ed. Failure to send the correct premium amount with fom�-
five (4�) da}�s will disqualify the A4ember from continuation coveraee under Cal-
COBRA. I�he first premium payment equals the amount of all premiums due from
the first month follo«ine the Qualifi�ing Event throuoh the current mon[h. Afrer the
initial payment, Cal-COBRA premiums are due on the first dav of each month. The
Cal-COBRA premium is aenerally 110% of the premium charged to the Group for
emplo}�ees. The A4ember's enroliment in Cal-COBRA H�ill not occur until Horizon
Heal�h EAP-Beha��ioral Sen�ices receives both the Cal-COBRA Election Form and
the first Cal COBR.�.premium pa}�ment. ,
A) Termination of Cal-COBRr1 Continuation Co��erage
lisually. a D4embers Cal-COBR4 continuation covera�e will last up to [him�-sis (36)
months. The continuation coveraae shall end automatically if the individual becomes
eliQible for Medicare or becomes covered under any group health plan not maintained
12 Eridence oj'Covera�e
� �—� 0�
by the emplo}�er or an}� other health plan, regardless of whether that coveraQe is less
valuable. The Members Cal-COBRA continuation covera�e may terminate earfy if
the n4ember moves out of Horizon Health EAP-Behavioral Services' service area,
does not pay the required premium within fifteen (IS) days of it being due, or
commits fraud or deception in using Horizon Health EAP-Behavioral Sen�ices
services, or obtains other group coverage.
If the �roup benefit plan is terminated prior to the date that the Member's Cal-
COBRA continuation coverage would expire, the D�ember's covera�e with Horizon
Health EAP-Behavioral Sen�ices will expire. The Member has the opportunity to
continue coverage under the any �roup benefit plan purchased by the Group. If the
Group purchases a new plan, that plan �aill send the Member premium information
and enrollment forms. The n4ember 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 fhere are any changes of
address. The Cal-COBRA continuation co��erage will terminate if the Member fails
to enroll and pay premiums to the new group benefit plan within thirty (30) days afrer
receiving notification of the termination of the Horizon Health EAP-Behavioral
Semices group benefit plan.
If the �roup chan�es its EAP benefit to another plan, the Members coveraQe with
Horizon Health EAP-Behavioral Services will expire, and you will be given the
opportunity to continue covera�e with the new plan. The new plan is required to
provide covera�e for the balance of the Cal-COBRA continuation coverage period.
XVIL COMPLAINT AND GRIEVANCE PROCEDURE
A a ievance is a ���ritten or oral expression of dissatisfaction regarding Horizon Health EAP-
Behavioral Services and/or an EAP Provider, includino 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 processin� and resolvin� your complaints and �rievances.
Should }�ou desire to register a complaint or grievance with Horizon Health EAP-Behavioral
Services concernin� Benefits; you can either call Horizon Health EAP-Behavioral Services at
the toll-free telephone number 1-800-342-8111, or access the ���ebsite at
w�tiv.horizoncarelink.com to either do���nload the complaint form or to fill it out online. To
reques[ a copy of the Horizon Health EAP-Behavioral .Services Complaint Form, write
directly to Horizon Health EAP-Behavioral Sen�ices at 7676 Hazard Center Drive, Suite
1100, San Diego, CA 92108. The telephone call or letter should be addressed to the Director,
Clinical Qualiry Improvement Horizon Health EAP-Behavioral Services will acknowledse
each complaint and �rievance within five (5) days of receipt. The Director, Clinical Quality
13 Evidence ojCoverage
10-102
Improvement mill receive and investigate all A4ember complaints and grievances. The
Director, Clinical Quality Improvement �uill rzspond to you statine the disposition and the
rationale within thim= (30) davs of receipt of the grievance. If the arievance is not resol��ed
to ��our satisfaction, a second le��el of re��ie«� ma}� be requested within ten (10) days of
notification of such disposition. Any such request will be reviewed by the Medical Director
and responded to ��=ithin seventy-nvo (72) hours of receipt.
Lineuistic and cultural needs �t�ill be addressed b�� translation of erie�•ance fortns and
procedures into laneuaees other than Enelish. Using TTI' lines and van�ing the means b}�
which an Enrollee may submit a grievance; including ��erball}� to Horizon Health EAP-
Beha��ioral Sen ices' staff(bi-lin�ual capabilit}�), on website (Spanish and Enalish), verball}�
by provider (multi-languaQe capabilirv); or interpreter. This allows Enrollees to submit
grievances in a linwisticall} appropriate manner. Nhen you are seen ���ith the aid of an
interpreter; the interpreter or counselor readin� this statement will_explain the information
that is normally provided in a��ritten formaz. - '
Lf you have a complaint or grie��ance about the services you ha��e received; or will receive in
the future, you may notify your counselor (or interpreter); who �ill suppl�� them with a
erievance form and a description of the process. If you wish to submit the arievance through
your counselor or interpreter; ��ou ma}�do so.
Visually impaired clients ma��phone the Director of Quality Improvement directly at 1-800-
342-8111. The Director of Quality Improvement n�ill describe the grievance procedure, and
take the �rievance information. In this case; the appropriate letters would be sent and the
client conracted by telephone so that the letter can be read. Hearina impaired clien[s may file
a erievance usin� the telephone number 8�8-712-1080 to contact Horizon Health Er1P-
Behavioral Sen=ices.
If the complaint or grievance invoh�es a delay, modification, or denial of sen�ice related to a
clinically emersent or uraent situation, the review �i�ill be expedited and a response provided
in ��Titins to }�ou within three (3) days from receip[ of the complaint or grie��ance. There is
no requirement that you participate in Horizon Health E.aP-Behavioral Seraices grievance
process before requesting a revie�v b;� the California Department of A4anaeed Care
(Department) in the case of an waent or emersent grievance. The criteria for determinine
emergent situations are H�hether you are assessed to be at imminent risk to seriously harm
yourself or another person, or are so impaired in judgment as to destroy propeny or be unable
to care for eour o�vn basic needs. The criteria for determinine ureent siruations are whether
vou are assessed to be sienificantiv disvessed, and aze in anv medical daneer due [o [he level
of the problem, or are esperiencins a reduced level of functionins due to more than a
moderate impairment resultina in an inability to function in kev familyh��ork roles.
You, or [he aQent acting on your behalf; ma}� also request voluntan� mediation �rith Horizon
Health EAP-Behavioral Services prior to e�ercisina the rieht to submit a arievance to the
Deparvnent. The use of inediation sen�ices w ill not preclude your rieht to submit a grievance
to the Department upon completion of the mediation. In order to initiate mediation, you; or
the aaent actina on your behalf, and Horizon Health EAP-Behavioral Services will
lA E.•ider,ce ojCorera�e
10-103
voluntarily agree to mediation. Expenses for the mediation will be borne equally b}� the
parties. The Department ���ill have no administrative or enforcement responsibilities in
connection with the voluntary mediation process. Mediations will take place in San Dieao.
California unless other«ise determined by the parties.
Pursuant to Section 136�(b) of the Act, any Member who alleges his enrollment has been
canceled or not rene��,�ed because of his health status or requirement for services may request
revie«�by the Department.
The Califomia Department of A4ana�ed Health Care is responsible for reQulating health care
sen�ice plans. If you have a �rievance a�ainst your health plan, you should first telephone
your plan at (1-800-342-8111) and use the plads grievance process (or locate their grievance
form on Horizon Health EAP-Behavioral Services' website at www.horizoncarelink.com)
before contactin� the Department. Utilizing this grievance procedure does not prohibit any
potential leeal ri�hts or remedies that may be available to you. �If you need help with a
grievance invoh�in� an emergency; a grievance that has not been satisfactorily resolved by
your plan, or a grievance that has remained unresolved for more than thim� (30) days, you
may call the Department for assistance. You may also be eliaible for an Independent
Medical Review (IMR). lf }�ou are eligible for IMR, the IMR process will provide an
impartial review of inedical decisions made by a health plan related to the medical necessiry
of a proposed service or treatment, covera�e decisions for treatments that are experimental or
investisational in nature and payment disputes for emer�ency or urgent medical services.
The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The Department's internet �veb site
http:/h�����.hmohelp.ca.gov has complaint forms, IMR application forms and instructions
online. The Plan's �rievance 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. Confidentialitv Polic��
A STATEMENT DESCRIBII�'G HORIZON HEALTH EAP-BEHAVIORAL
SERVICES' POLICIES AND PROCEDLJRES FOR PRESERVII�rG THE
CONFIDENTIALITY OF A4EDICAL RECORDS IS AVAILABLE AND WILL BE
FURNISHED TO A MEMBER UPON REQUEST.
B. Member Consent
Under the EAP Services Asreemeot, the Group makes Benefits which are consistent with
professionally reco�nizedVstandards of practice, available to D7embers. The EAP
Services Agreement is subject to amendment, modification or termination, in accordance
�i-ith the provisions thereof, or by mutual agreement behveen Horizon Health EAP-
Behavioral Services and the Group, without the consent or concurrence of Members. By
accepting Benefiu hereunder; all A4embers ]e�ally capable of contracting, and the legal
IS Evidence oJCoverage
10-104
representatices of all Alembers incapable of conuactina; a�ee to all terms; conditions
and pro��isions of the E.4P Sen�ices Agreement.
C. Horizon Health EAP-Behavioral Sen�ices' Policies
Horizon Health EAP-Beha��ioral Sen�ices may adopt reasonable policies, procedures;
rules and interpretations to promote orderl}� and efficient administration of the E.4P
Sen�ices A�eement.
D. Horizon Health EAP-Beha��ioral Sen•ices' Public Polic�� Committee
Horizon Health Er1P-Beha��ioral Services has established a Public Policv Committee that
includes; amona others; b4embers of Groups that have contracted with Horizon Health
EAP-Behavioral Services for Benefits. This committee meets quarterl}= and the Horizon
Health EAP-Behavioral Services Board of Directors reviews the repotts and
recommendations of the committee. Anv Member desirine more information about this
committee should contact Hori2on Health E_AP-Behavioral Services at 1-300-342-8ll 1.
E. Term and Renewal Procisions
The initial term of the EAP Sen�ices .Agreement is thim�-six (36) months. Thereafrer the
aareement is automatically rene���ed 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 ���ith a variety of problems.
The need for donated orQans. corneas. skin. bone and tissue continues to erow bevond the
supph�. Organ and tissue donation pro��ides you with an opportunitv to help others.
Almost anvone can become a donor. There is no ase limit. If }�ou have questions or
concems you may���ish to discuss them with }�our doctor, your family, or your cleroy.
Resources for Information:
• For infortnation and donor cazd call 1-800-3»-SH.4RE.
• Request donor information from the Department of\4otor\'ehicles.
• On the Intemet, contact All About Transplantation and Donation (���ti�v.uansveb.org).
• Department of Health and Human Services; contact http:/h»«v.oraandonor.gov.
Share vour decision with familv.
If��ou decide to become a donor:
• Sign the donor card in the presence of famil}�members.
• • Have }�our famih° sian as ���imesses and pledge to cam�out �our wishes.
16 Evidence ofCoL•erage
10-105
E�HIBIT A
EXHIBIT A- SCHEDULE OF BENEFITS, LIMITATIONS, AND EXCLUSIONS
Emplo��ee Assistance Program
A. Benefits.
1) Individual, couple, or family assessment and brief counselin� for personal, marital,
family, relationship; work-related, and alcohol or substance abuse problems. Brief
counselin� is provided when, in the judgment of the EAP provider, the issues meet
communit}� standards of practice for brief counselin� within eight (8) private
counseling sessions per separate incident. A "session" is de5ned as either an in-
person or telephone consultation with the Member, of approximately one hour in
duration. Sessions are used to identify or „�ork on resolvin� the issues or conditions
that the Member is experiencin�. A new incident for the same Member would
invoh�e different issues or conditions. Benefits will be consistent �yith professionally
recognized standards of practice. A separate incident involves a sin�le underlying
issue or condition, re�ardless of the number of same or different events im�olving 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 ei�ht (8) sessions per separate incident. The EAP Provider ���orks „�ith the
Member to identify resources of an appropriate type and level of care beyond the
benefit.
I3) Referrals to other resources are offered to Members if the type of care is outside of
the scope ofpractice ofthis benefit. ,
4) 24-hour crisis hotline, 7 dayshveek. �
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 narure as described in sections 1-8 above.
2) Horizon Health EAP-Beha��ioral 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.
17 Evide�rce oJCoverage
� �-� �6
C. Eiclusions.
1) Inpatient ueatment of an�� l:ind, or outpatient treatment for am medicall�� treated
illness.
2) Ps��chiavist sen�ices.
3) Prescription drugs.
4) Counseling services be��ond the number of sessions co��ered by the benefi[.
�) Sen ices bv counselors n-ho aze not Panicipating Pro��iders.
6) Court ordered treavnent or therap}�, or any treatment or therapy ordered as a condition
of parole, probation. custody; or visitation evaluations; or paid for by �\'orkers'
Compensation.
7) Formal ps��chological evaluations ���hich normally involve psycholoQical testing and
result in a��zitten repon. �
S) Fimess for duty evaluations ���hich are used to evaluate ���hether an emplo}�ee is safely
able to perform his or her duties. This mpically inctudes ps}�choloaical testing and a
�vritten report
9) Investment advice (nor does Horizon Health EAP-Behavioral Sen�ices loan money or
pa}� bills).
10)LeQal represen[ation in coun, preparation of leQal documents, or advice in the areas
of taxes. patenu; or immiaration.
18 Eridence ojCoverage
� �—� ��
EXHIBIT B
HEALTH AND HUMAN RESOURCE CENTER
(dba HORiZON HEALTH EAP-BEHAVIORAL SERVICES)
EMPLOYEE ASSISTANCE PROGRAD4
E�HIBIT B - COMPARISON OF BENEFITS
The Employee Assistance Proaram (EAP) is being offered by your employer to provide }�ou ���ith
confidential assistance from licensed mental health professionals. These professionals can help
���ith problems affectin� your life at work as well as at home. Such problems include marital issues,
family relationships, depression and anxiet}�, alcohol and drug issues, and/or problems within the
workplace.
THIS DIATRI�IS IIVTENDED 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 AGREEMEl�`T SHOULD'BE CONSULTED FOR A DETAILED
DESCRIPTION OF BENEFITS,LIMITATIOA'S AND EXCLUSIONS.
A. Deductible � Not applicable
B. Lifetime Ma�imum Not applicable
C. Professional Services The EAP provides:
Psvchosocial Assessment
Treatment Referrals and Resources for Psychosocial Problems
24-hour Crisis Telephone Access
Eight(8) Caunseling Sessions Per Inciden[
Le�al Referrals
Financial Counseling Referrals
Identity Thefr Consultation
D. Outpatient Services Please see Item C: Professional Services
E. Hospitalization Services None
F. Emergencv Health Co��era�e 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: Professior,al Services
L. Home Health Services None
M. Other None
Members pa�� no co-payment. Coverase is limited to: a) eli�ible employees; b) the eligible
employee's children under the ase of 26; c) persons covered under the eli�ible employee s health
benefit plan; d)persons residin�with the eligible employee, including domestic parcners.
19 Evidence ojCoverage
� �—� �8
L DEFLITTIONS
The followine terms have the follou�ing meanings for purposes of this Combined E��idence of
Coveraee and Disclosure Form.
A. "Act" means the Iu�ox-Keene Health Care Sen�ice Plan Act of 197�. as amended
(California Health and Safet}° Code, Sections 1340 et seq.).
B. "Be�efiu" means the services to which ?�4embers are entitled under an E,4P Sen�ices
Aereement. and �vhich are described in Exhibit A to this Combined Evidence of
Co��erase and Disclosure Form.
C. "EAP Pro��ider" means the licensed assessment and shoa-tzrm counseline mental health
professionals emplo��ed by, or under contract ���ith. Horizon Health EAP-Behavioral
Services to provide Benefiu to D4embers. - �
D. "EAP Sen�ices Asreement" means the Employee Assistance Program (E_AP) Sen�ices
Agreement benveen Horizon Health EAP-Behavioral Sen�ices and a Group, ��fiich
establishes the terms and conditions �ovemino the provision of Benefiu to �4embers b��
Horizon Health EAP-Behavioral Sen�ices.
E. "Esclusiod' means any provision of an E.AP Sen�ices A�reement ���herebv coverage for
Benefits is entirely eliminated; and ���hich is set forth in Eshibit A to this Combined
Evidence of Coverase and Disclosure Form.
F. "GrOUp„ means the compan}� that has entered into an EAP Services Agreement «ith
Horizon 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 Sen�ices.
H. "Limitation" means an}� provision of an Er1P Services Asreement, other than an
Exclusion, �rhich restricts Benefits, and which is set forth in Exhibit A to this Combined
Evidence of Coverase and Disclosure Form.
I. "Enrollee ` means any eli�ible employee of Group ���ho (l) resides in Califomia and (2)
mav be covered under the Act.
J. "Member" means an Enrollee covered b}� the Group, as defined above, the Enrollee`s
children under the a�e of 26, persons covered under the Enrollee's health benefit plan;
ar�d persons residin�with the Enrollee; includino domestic partners.
K. "Periodic Fees° means the mon[hl}� amounes due and pa��able to Horizon Health'E.4P-
Behavioral Services by a Group for providing Benefits to Members.
2 Eridence ofCoveraoe
� �-� �9
L. "Emersencv Sen�ices" means medically necessary transport usin� the 911 system or
medical screenin�, esamination and evaluation by a physician to determine if an
emer�ency medical condition or psychiatric emergency medical condition exists.
M. "Crisis Intervention ' means assessment and problem solving in situations �rliich }�ou 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. "Emereencv Medical Condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity (includin� severe pain) such that the absence of
immediate medical attention could reasonably be expected by the Member to result in
an}�of the follo���ing:
• Placin�the A4ember's health in serious jeopardy;
• Serious impairment to bodily functions;
• Serious dysfunction of any bodily or�an or part; or
• Active labor, meanin� 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 unbom child.
II. HOW TO OBTAIN BENEFITS
Unless otherwise provided herein, you are entided to Benefits from an EAP Provider. You
must obtain Benefits by calling I-800-342-8111. Upon contact, Horizon Health EAP-
Behavioral Services will determine your eligibility for Benefts and arran�e for Benefits.
All Benefits must be provided by Horizon Health EAP-Behavioral Services or by an EAP
Provider referred to b�� 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-ei�ht(48) hours of contact.
Horizon Health EAP-Behavioral Services does not directly provide specialry 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 necessar}� and
appropriate levels of care; usually under your group health plan. Your EAP Provider will
assist you in securing potential referral resources.
Durin� or afrer business hours; any Member may access a licensed mental health prefessionaf
for a telephone assessment The telephone assessor may provide crisis inten�ention over the
telephone, arran�e a same-day appointment with an EAP Provider in your area, or assist you
in obtainin� more intensive, acute care services.
3 Evidence ofCoverage
10-110