RES 2012-15 APPROVING CAFETERIA PLAN FOR EMPLOYEESRESOLUTION NO. 2012 -15
A RESOLUTION of the City Council of Bainbridge Island,
Washington, approving an amended Cafeteria Plan for City
Employees.
WHEREAS, the City adopted a flexible benefits plan on November 9, 2005
pursuant to Resolution No. 2005 -38; and -_
WHEREAS, the
flexible benefits plan has
been
amended, effective January 1,
2013, in accordance with
the Affordable Care Act of
2010,
now, therefore,
THE CITY COUNCIL OF THE CITY OF BAINBRIDGE ISLAND DOES
RESOLVE AS FOLLOWS.
Section 1. The form of amended Cafeteria Plan, including a Dependent Care
Flexible Spending Account and Health Flexible Spending Account effective January 1,
2013 and attached as Exhibit A (the "Plan ") is hereby approved and adopted.
Section 2. The Finance and Administrative Services Director of the City is
hereby authorized and directed to execute and deliver to the Administrator of the Plan
one or more counterparts of the Plan.
Section 3. The Administrator shall be instructed to take such actions that are
deemed necessary and proper in order to implement the Plan, and to set up adequate
accounting and administrative procedures to provide benefits under the Plan.
Section 4. The Finance and Administrative Services Director of the City shall act
as soon as possible to notify the employees of the City of the adoption of the Plan by
delivering to each employee a copy of the summary description of the Plan in the form
attached as Exhibit B, which form is hereby approved.
PASSED by the City Council this 12"' day of December, 2012.
APPROVED by the Mayor this 12"' day of December, 2012.
By: �! 01" A�tq 1140�-
Debbi Lester, Mayor
ATTEST /AUTHENTICATE:
FILED WITH THE CITY CLERK: December 7, 2012
PASSED BY THE CITY COUNCIL: December 12, 2012
RESOLUTION NO. 2012 -15
CITY OF BAINBRIDGE ISLAND
FLEXIBLE BENEFITS PLAN
AND ALL SUPPORTING FORMS HAVE BEEN PRODUCED FOR
BENEFIT ADMINISTRATION COMPANY LLC
Copyright 2012 SunGard
All Rights Reserved
Exhibit A
CITY OF BAINBRIDGE ISLAND
FLEXIBLE BENEFITS PLAN
TABLE OF CONTENTS
ARTICLE I
DEFINITIONS
ARTICLE II
2.1
ELIGIBILITY 2
............................... 3
3.2
2.2
APPLICATION OF CONTRIBUTIONS ...................................................................................................
EFFECTIVE DATE
OF PARTICIPATION ...............................................................................................
............................... 2
2.3
............................... 4
APPLICATION TO
PARTICIPATE ..........................................................................................................
............................... 3
2.4
4.5
TERMINATION OF
PARTICIPATION .....................................................................................................
............................... 3
2.5
TERMINATION OF
EMPLOYMENT .......................................................................................................
............................... 3
2.6
DEATH 3
ARTICLE III
CONTRIBUTIONS TO THE PLAN
3.1
SALARY REDIRECTION ........................................................................................................................
............................... 3
3.2
APPLICATION OF CONTRIBUTIONS ...................................................................................................
............................... 4
3.3
PERIODIC CONTRIBUTIONS ................................................................................................................
............................... 4
ARTICLE IV
BENEFITS
4.1
BENEFIT OPTIONS ...............................................................................................................................
............................... 4
4.2
HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT ..........................................................................
............................... 4
4.3
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT .......................................................
............................... 4
4.4
HEALTH INSURANCE BENEFIT ...........................................................................................................
............................... 4
4.5
OTHER INSURANCE BENEFIT.. ........................ -- .............. ...............................................................................................
4
4.6
NONDISCRIMINATION REQUIREMENTS ............................................................................................
............................... 5
ARTICLE V
PARTICIPANT ELECTIONS
5.1 INITIAL ELECTIONS .............................................................................................................................. ............................... 5
5.2 SUBSEQUENT ANNUAL ELECTIONS .................................................................................................. ............................... 5
5.3 FAILURE TO ELECT .............................................................................................................................. ............................... 5
5.4 CHANGE IN STATUS ............................................................................................................................ ............................... 6
ARTICLE VI
HEALTH FLEXIBLE SPENDING ACCOUNT
6.1 ESTABLISHMENT OF PLAN ................................................................................................................. ............................... 7
6.2 DEFINITIONS .......................................................................................................................................... ..............................7
6.3 FORFEITURES .................................................. ................ ............ .... ............................... ......... ................. 8
6.4 LIMITATION ON ALLOCATIONS ........................................................................................................... ............................... 8
6.5 NONDISCRIMINATION REQUIREMENTS ............................................................................................ ............................... 8
6.6 COORDINATION WITH CAFETERIA PLAN .......................................................................................... ............................... 8
6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS ........................................................................... ............................... 9
6.8 DEBIT AND CREDIT CARDS.. ....... ........... ............... ...... ............................................................. ..................................... 9
6.9 QUALIFIED RESERVIST DISTRIBUTIONS ........................................................................................... ............................... 10
ARTICLE VII
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
7.1
ESTABLISHMENT OF ACCOUNT .........................................................................................................
............................... 11
7.2
DEFINITIONS ...........................................................................................................................................
.............................11
7.3
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS .....................................................................
............................... 11
7.4
INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS ...........................................
............................... 11
7.5
DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS .........................................
............................... 12
7.6
ALLOWABLE DEPENDENT CARE REIMBURSEMENT ........................................................................
............................... 12
7.7
ANNUAL STATEMENT OF BENEFITS ..................................................................................................
............................... 12
7.8
FORFEITURES ......................................................................................................................................
............................... 12
7.9
LIMITATION ON PAYMENTS ................... _._. ._...... ......_......- ._.. -- _
12
7.10
NONDISCRIMINATION REQUIREMENTS ............................................................................................
............................... 12
7.11
COORDINATION WITH CAFETERIA PLAN ..........................................................................................
............................... 12
7.12
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS, .............................................. ........................................
12
ARTICLE VIII
BENEFITS AND RIGHTS
8.1
CLAIM FOR BENEFITS .........................................................................................................................
............................... 13
8.2
APPLICATION OF BENEFIT PLAN SURPLUS ....................................... .._...................................
....................................... 14
ARTICLE IX
ADMINISTRATION
9.1
PLAN ADMINISTRATION .......................................................................................................................
............................... 14
9.2
EXAMINATION OF RECORDS ..............................................................................................................
............................... 15
9.3
PAYMENT OF EXPENSES ....................................................................................................................
............................... 15
9.4
INSURANCE CONTROL CLAUSE .........................................................................................................
............................... 15
9.5
INDEMNIFICATION OF ADMINISTRATOR ...........................................................................................
............................... 15
ARTICLE X
AMENDMENT OR TERMINATION OF PLAN
10.1
AMENDMENT ..........................................................................................................................................
.............................15
10.2
TERMINATION .........................................................................................................................................
.............................15
ARTICLE XI
MISCELLANEOUS
11.1
PLAN INTERPRETATION ......................................................................................................................
............................... 16
,11.2
GENDER AND NUMBER .......................................................................................................................
............................... 16
11.3
WRITTEN DOCUMENT .........................................................................................................................
............................... 16
11.4
EXCLUSIVE BENEFIT ...........................................................................................................................
............................... 16
11.5
PARTICIPANT'S RIGHTS ......................................................................................................................
............................... 16
11.6
ACTION BY THE EMPLOYER ...............................................................................................................
............................... 16
11.7
EMPLOYER'S PROTECTIVE CLAUSES ...............................................................................................
............................... 16
11.8
NO GUARANTEE OF TAX CONSEQUENCES ......... ... .... ............................. . .................. ................
... ... I...... I....................... 16
11.9
INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS .....................................................................
............................... 16
11.10
FUNDING 16
11.11
GOVERNING LAW ................................................................................................................................. ...............................
17
11.12
SEVERABILITY ........................................................................................................................................ .............................17
11.13
CAPTIONS 17
11.14
CONTINUATION OF COVERAGE (COBRA) ......................................................................................... ...............................
17
11.15
FAMILY AND MEDICAL LEAVE ACT (FMLA) ............ ......... ......... ......... ......... .... .........
.................. 17
11.16
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ..................................... ...............................
17
11.17
UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) ............. ...............................
17
11.18
COMPLIANCE WITH HIPAA PRIVACY STANDARDS ........................................................................... ...............................
17
11.19
COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS ................................................. ..................0............
18
11.20
MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT ................................................................. ...............................
19
11.21
GENETIC INFORMATION NONDISCRIMINATION ACT (GINA) ........................................................... ...............................
19
11.22
WOMEN'S HEALTH AND CANCER RIGHTS ACT ................................................................................ ...............................
19
11.23
NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT .............................................................. .........................0.....
19
CITY OF BAINBRIDGE ISLAND
FLEXIBLE BENEFITS PLAN
INTRODUCTION
The Employer has amended this Plan effective January 1, 2013, to recognize the contribution made to the Employer by its
Employees. Its purpose is to reward them by providing benefits for those Employees who shall qualify hereunder and their
Dependents and beneficiaries. The concept of this Plan is to allow Employees to choose among different types of benefits based on
their own particular goals, desires and needs. This Plan is a restatement of a Plan which was originally effective on December 30,
2006. The Plan shall be known as City of Bainbridge Island Flexible Benefits Plan (the "Plan ").
The intention of the Employer is that the Plan qualify as a "Cafeteria Plan" within the meaning of Section 125 of the Internal
Revenue Code of 1986, as amended, and that the benefits which an Employee elects to receive under the Plan be excludable from
the Employee's income under Section 125(a) and other applicable sections of the Internal Revenue Code of 1986, as amended.
The Employer also intends that, for purposes of the annual report requirement (Form 5500), this document is considered a
"wrap" plan and the terms of the underlying plans for which Participants are making contributions through this Plan are hereby
innnrnnroforl by rofc ronr•o
ARTICLE I
DEFINITIONS
1.1 "Administrator" means the Employer unless another person or entity has been designated by the Employer
pursuant to Section 9.1 to administer the Plan on behalf of the Employer. If the Employer is the Administrator, the Employer may
appoint any person, including, but not limited to, the Employees of the Employer, to perform the duties of the Administrator. Any
person so appointed shall signify acceptance by filing written acceptance with the Employer. Upon the resignation or removal of any
individual performing the duties of the Administrator, the Employer may designate a successor.
1.2 "Affiliated Employer" means the Employer and any corporation which is a member of a controlled group of
corporations (as defined in Code Section 414(b)) which includes the Employer; any trade or business (whether or not incorporated)
which is under common control (as defined in Code Section 414(c)) with the Employer; any organization (whether or not incorporated)
which is a member of an affiliated service group (as defined in Code Section 414(m)) which includes the Employer; and any other
entity required to be aggregated with the Employer pursuant to Treasury regulations under Code Section 414(0).
1.3 "Benefit" or "Benefit Options" means any of the optional benefit choices available to a Participant as outlined in
Section 4.1.
1.4
"Cafeteria Plan Benefit Dollars" means the amount
available
to Participants to purchase Benefit Options as
provided under
Section 4.1. Each dollar contributed to this Plan shall be
converted
into one Cafeteria Plan Benefit Dollar.
1.5 "Code" means the Internal Revenue Code of 1986, as amended or replaced from time to time.
1.6 "Compensation" means the amounts received by the Participant from the Employer during a Plan Year.
1.7 "Dependent" means any individual who qualifies as a dependent under an Insurance Contract for purposes of
coverage under that Contract only or under Code Section 152 (as modified by Code Section 105(b)).
"Dependent" shall include any Child of a Participant who is covered under an Insurance Contract, as defined in
the Contract, or under the Health Flexible Spending Account or as allowed by reason of the Affordable Care Act.
For purposes of the Health Flexible Spending Account, a Participant's "Child" includes his natural child, stepchild,
foster child, adopted child, or a child placed with the Participant for adoption. A Participant's Child will be an eligible Dependent until
reaChi;�y^ the lim ,gin ^y age of 26, VJ hoist regard to student status, irnaritai Statics, fiiianCial dependency or residency status with the
Employee or any other person. When the child reaches the applicable limiting age, coverage will end at the end of the calendar year.
The phrase "placed for adoption" refers to a child whom the Participant intends to adopt, whether or not the
adoption has become final, who has not attained the age of 18 as of the date of such placement for adoption. The term "placed"
means the assumption and retention by such Employee of a legal obligation for total or partial support of the child in anticipation of
adoption of the child. The child must be available for adoption and the legal process must have commenced.
1.8 "Effective Date" means December 30, 2006.
1.9 "Election Period" means the period immediately preceding the beginning of each Plan Year established by the
Administrator, such period to be applied on a uniform and nondiscriminatory basis for all Employees and Participants. However, an
Employee's initial Election Period shall be determined pursuant to Section 5.1.
1.10 "Eligible Employee" means any Employee who has satisfied the provisions of Section 2.1.
An individual shall not be an "Eligible Employee" if such individual is not reported on the payroll records of the
Employer as a common law employee. In particular, it is expressly intended that individuals not treated as common law employees by
1
the Employer
on its payroll records are
not "Eligible Employees" and
are
excluded from Plan
participation
even if a court or
administrative
agency determines that
such individuals are common
law
employees and not
independent
contractors.
1.11
"Employee" means
any person who is employed by the Employer. The term Employee shall include leased
employees
within
the meaning of Code
Section 414(n)(2).
1.12 "Employer" means City of Bainbridge Island and any successor which shall maintain this Plan, and any
predecessor which has maintained this Plan. In addition, where appropriate, the term Employer shall include any Participating,
1.13 "Grace Period" means, with respect to any Plan Year, the time period ending on the fifteenth day of the third
calendar month after the end of such Plan Year, during which Medical Expenses and Employment - Related Dependent Care Expenses
incurred by a Participant will be deemed to have been incurred during such Plan Year.
114 "Insurance Contract" means any contract issued by an Insurer underwriting a Benefit.
1.15 "Insurance Premium Payment Plan" means the plan of benefits contained in Section 4.1 of this Plan, which
provides for the payment of Premium Expenses.
1.16 "Insurer" means any insurance company that underwrites a Benefit under this Plan.
1.17 "Key Employee" means an Employee described in Code Section 416(1)(1) and the Treasury regulations
thereunder.
1.18
"Participant" means any Eligible Employee
who elects to become a Participant pursuant to Section 2.3 and has
not for any
reason
become ineligible to participate further in the
Plan.
1.19 "Plan" means this instrument, including all amendments thereto.
1.20 "Plan Year" means the 12 -month period beginning January 1st and ending December 31st. The Plan Year shall
be the coverage period for the Benefits provided for under this Plan. In the event a Participant commences participation during a Plan
Year, then the initial coverage period shall be that portion of the Plan Year commencing on such Participant's date of entry and ending
on the last day of such Plan Year.
1.21 "Premium Expenses" or "Premiums" mean the Participant's cost for the Benefits described in Section 4.1.
1.22 "Premium Expense Reimbursement Account" means the account established for a Participant pursuant to this
Plan to which part of his Cafeteria Plan Benefit Dollars may be allocated and from which Premiums of the Participant shall be paid or
reimbursed. If more than one type of insured Benefit is elected, sub - accounts shall be established for each type of insured Benefit.
1.23 "Salary Redirection" means the contributions made by the Employer on behalf of Participants pursuant to Section
3.1. These contributions shall be converted to Cafeteria Plan Benefit Dollars and allocated to the funds or accounts established under
the Plan pursuant to the Participants' elections made under Article V.
1.24 "Salary Redirection Agreement" means an agreement between the Participant and the Employer under which
the Participant agrees to reduce his Compensation or to forego all or part of the increases in such Compensation and to have such
amounts contributed by the Employer to the Plan on the Participant's behalf. The Salary Redirection Agreement shall apply only to
Compensation that has not been actually or constructively received by the Participant as of the date of the agreement (after taking this
Plan and Code Section 125 into account) and, subsequently does not become currently available to the Participant.
1.25 "Spouse" means "spouse" as defined in an Insurance Contract for purposes of coverage under that Contract only
or the "spouse," as defined under Federal law, of a Participant, unless legally separated by court decree.
ARTICLE II
PARTICIPATION
ft�i1•��[eiL]l�r�'1
Any Eligible Employee shall be eligible to participate hereunder as of the date he satisfies the eligibility conditions for the
Employer's group medical plan, the provisions of which are specifically incorporated herein by reference. However, any Eligible
Employee who was a_Participant in the Plan on the effective date of this amendment shall continue to be eligible to participate in the
Plan.
2.2 EFFECTIVE DATE OF PARTICIPATION
An Eligible Employee shall become a Participant effective as of the entry date under the Employer's group medical plan, the
provisions of which are specifically incorporated herein by reference.
4
2.3 APPLICATION TO PARTICIPATE
An Employee who is eligible to participate in this Plan shall, during the applicable Election Period, complete an application to
participate in a manner set forth by the Administrator. The election shall be irrevocable until the end of the applicable Plan Year unless
the Participant is entitled to change his Benefit elections pursuant to Section 5.4 hereof.
An Eligible Employee shall also be required to complete a Salary Redirection Agreement during the Election Period for the
Plan Year during which he wishes to participate in this Plan. Any such Salary Redirection Agreement shall be effective for the first pay
period beginning on or after the Employee's effective date of participation pursuant to Section 2.2.
Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who is covered by the Employer's
insured Benefits under this Plan shall automatically become a Participant to the extent of the Premiums for such insurance unless the
Employee elects, during the Election Period, not to participate in the Plan.
2.4 TERMINATION OF PARTICIPATION
A Participant shall no longer participate in this Plan upon the occurrence of any of the following events:
(a) Termination of employment. The Participant's termination of employment, subject to the provisions of
Section 2.5:
(b) Death. The Participant's death, subject to the provisions of Section 2.6; or
(c) Termination of the plan. The termination of this Plan, subject to the provisions of Section 10.2.
2.5 TERMINATION OF EMPLOYMENT
If a Participant's employment with the Employer is terminated for any reason other than death, his participation in the Benefit
Options provided under Section 4.1 shall be governed in accordance with the following:
(a) Insurance Benefit. With regard to Benefits which are insured, the Participant's participation in the Plan
shall cease, subject to the Participant's right to continue coverage under any Insurance Contract for which premiums have
already been paid.
(b) Dependent Care FSA. With regard to the Dependent Care Flexible Spending Account, the Participant's
participation in the Plan shall cease and no further Salary Redirection contributions shall be made. However, such
Participant may submit claims for employment related Dependent Care Expense reimbursements for claims incurred
through the remainder of the Plan Year in which such termination occurs and submitted within 90 days after the end of the
Plan Year, based on the level of the Participant's Dependent Care Flexible Spending Account as of the date of termination.
(c) COBRA applicability. With regard to the Health Flexible Spending Account, the Participant may submit
claims for expenses that were incurred during the portion of the Plan Year before the end of the period for which payments
to the Health Flexible Spending Account have already been made. Thereafter, the health benefits under this Plan including
the Health Flexible Spending Account shall be applied and administered consistent with such further rights a Participant and
his Dependents may be entitled to pursuant to Code Section 4980B and Section 11.14 of the Plan.
Eile�T :rm4l
If a Participant dies, his participation in the Plan shall cease. However, such Participant's spouse or Dependents may submit
claims for expenses or benefits for the remainder of the Plan Year or until the Cafeteria Plan Benefit Dollars allocated to each specific
benefit are exhausted. in no event may reimbursements be paid to someone who is not a spouse or Dependent. If the Plan is subject
to the provisions of Code Section 4980B, then those provisions and related regulations shall apply for purposes of the Health Flexible
Spending Account.
ARTICLE III
CONTRIBUTIONS TO THE PLAN
3.1 SALARY REDIRECTION
Benefits under the Plan shall be financed by Salary Redirections sufficient to support Benefits that a Participant has elected
hereunder and to pay the Participant's Premium Expenses. The salary administration program of the Employer shall be revised to
allow each Participant to agree to reduce his pay during a Plan Year by an amount determined necessary to purchase the elected
Benefit Options. The amount of such Salary Redirection shall be specified in the Salary Redirection Agreement and shall be
applicable for a Plan Year. Notwithstanding the above, for new Participants, the Salary Redirection Agreement shall only be
applicable from the first day of the pay period following the Employee's entry date up to and including the last day of the Plan Year.
These contributions shall be converted to Cafeteria Plan Benefit Dollars and allocated to the funds or accounts established under the
Plan pursuant to the Participants' elections made under Article IV.
Any Salary Redirection shall be determined prior to the beginning of a Plan Year (subject to initial elections pursuant to
Section 5.1) and prior to the end of the Election Period and shall be irrevocable for such Plan Year. However, a Participant may
revoke a Benefit election or a Salary Redirection Agreement after the Plan Year has commenced and make a new election with
3
respect to the remainder of the Plan Year, if both the revocation and the new election are on account of and consistent with a change
in status and such other permitted events as determined under Article V of the Plan and consistent with the rules and regulations of
the Department of the Treasury. Salary Redirection amounts shall be contributed on a pro rata basis for each pay period during the
Plan Year. All individual Salary Redirection Agreements are deemed to be part of this Plan and incorporated by reference hereunder.
3.2 APPLICATION OF CONTRIBUTIONS
As soon as reasonably practical after each payroll period, the Employer shall apply the Salary Redirection to provide the
Benefits elected by the affected Participants. Any contribution made or withheld for the Health Flexible Spending Account or
Dependent Care Flexible Spending Account shall be credited to such fund or account. Amounts designated for the Participant's
Premium Expense Reimbursement Account shall likewise be credited to such account for the purpose of paying Premium Expenses.
3.3 PERIODIC CONTRIBUTIONS
Notwithstanding the requirement provided above and in other Articles of this Plan that Salary Redirections be contributed to
the Plan by the Employer on behalf of an Employee on a level and pro rata basis for each payroll period, the Employer and
Administrator may implement a procedure in which Salary Redirections are contributed throughout the Plan Year on a periodic basis
that is not pro rata for each payroll period. However, with regard to the Health Flexible Spending Account, the payment schedule for
the required contributions may not be based on the rate or amount of reimbursements during the Plan Year.
ARTICLE IV
BENEFITS
4.1 BENEFIT OPTIONS
Each Participant may elect any one or more of the following optional Benefits:
(1) Health Flexible Spending Account
(2) Dependent Care Flexible Spending Account
In addition, each Participant shall have a sufficient portion of his Salary Redirections applied to the following Benefits unless
the Participant elects not to receive such Benefits:
(3) Health Insurance Benefit
(4) Other Insurance Benefit
4.2 HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT
Each Participant may elect to participate in the Health Flexible Spending Account option, in which case Article VI shall apply.
4.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT
Each Participant may elect to participate in the Dependent Care Flexible Spending Account option, in which case Article VII
shall apply.
4.4 HEALTH INSURANCE BENEFIT
(a) Coverage for Participant and Dependents. Each Participant may elect to be covered under a health
Insurance Contract for the Participant, his or her Spouse, and his or her Dependents.
(b)
Employer selects
contracts. The
Employer may select suitable health Insurance Contracts for use in
providing this
health insurance benefit,
which policies
will provide uniform benefits for all Participants electing this Benefit.
(c) Contract incorporated by reference. The rights and conditions with respect to the benefits payable
from such health Insurance Contract shall be determined therefrom, and such Insurance Contract shall be incorporated
herein by reference.
4.5 OTHER INSURANCE BENEFIT
(a) Employer selects contracts. The Employer may select additional health or other policies allowed under
Code Section 125 or allow the purchase of additional health or other policies by and for Participants, which policies will
provide uniform benefits for all Participants electing this Benefit.
(b) Contract incorporated by reference. The rights and conditions with respect to the benefits payable
from any additional Insurance Contract shall be determined therefrom, and such Insurance Contract shall be incorporated
herein by reference.
J
4.6 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory. It is the intent of this Plan to provide benefits to a classification of
employees which the Secretary of the Treasury finds not to be discriminatory in favor of the group in whose favor
discrimination may not occur under Code Section 125.
(b) 25% concentration test. It is the intent of this Plan not to provide qualified benefits as defined under
Code Section 125 to Key Employees in amounts that exceed 25 % of the aggregate of such Benefits provided for all Eligible
Employees under the Plan. For purposes of the preceding sentence, qualified benefits shall not include benefits which
(without regard to this paragraph) are includible in gross income.
(c) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination or
possible taxation to Key Employees or a group of employees in whose favor discrimination may not occur in violation of
Code Section 125, it may, but shall not be required to, reduce contributions or non - taxable Benefits in order to assure
compliance with this Section. Any act taken by the Administrator under this Section shall be carried out in a uniform and
nondiscriminatory manner. If the Administrator decides to reduce contributions or non - taxable Benefits, it shall be done in
the following manner. First, the non - taxable Benefits of the affected Participant (either an employee who is highly
nmm�onco #orl nr n ILA.. C111VIr....,.. .d;1.11..vul 1 .. C.... L. L.\ ..d... 110. mu L.:...fl.. L
....+....,. w...,. �. ,wy ullNlvycc, vv nlcnc vcl IJ apNnt,a vlc/ vvnV Ilya Inc nll�jnCM alilVlll llt VI IIVII- tdxdble DellClltS IVf tnC t'lan
Year shall have his non - taxable Benefits reduced until the discrimination tests set forth in this Section are satisfied or until
the mmnunt of hic nnn- taxahlp Rpnpfits prnlalc the nnn_tavahlo Rpnafitc of tho �ffnn +cA Pnr+irinnn+ k.,#,n h�C +ho � ^nA
highest amount of non - taxable Benefits. This process shall continue until the nondiscrimination tests set forth in this Section
are satisfied. With respect to any affected Participant who has had Benefits reduced pursuant to this Section, the reduction
shall be made proportionately among Health Flexible Spending Account Benefits and Dependent Care Flexible Spending
Account Benefits, and once all these Benefits are expended, proportionately among insured Benefits. Contributions which
are not utilized to provide Benefits to any Participant by virtue of any administrative act under this paragraph shall be
forfeited and deposited into the benefit plan surplus.
ARTICLE V
PARTICIPANT ELECTIONS
C 1 1 I l r�rl ur�nn
V. INITIAL ELEC I
IOIVJ
An
Employee who meets
the eligibility requirements of Section 2.1
on the first day of, or during, a Plan Year may elect to
participate in
this Plan for all or the
remainder of such Plan Year, provided
he elects to do so on or before his effective date of
participation
pursuant to Section 2.2.
the next
Plan Year;
Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who is covered by the Employer's
insured benefits under this Plan shall automatically become a Participant to the extent of the Premiums for such insurance unless the
Employee elects, during the Election Period, not to participate in the Plan.
5.2 SUBSEQUENT ANNUAL ELECTIONS
During the Election Period prior to each subsequent Plan Year, each Participant shall be given the opportunity to elect, on
an election of benefits form to be provided by the Administrator, which spending account Benefit options he wishes to select. Any
such election shall be effective for any Benefit expenses incurred during the Plan Year which follows the end of the Election Period.
With regard to subsequent annual elections, the following options shall apply:
(a) A Participant or Employee who failed to initially elect to participate may elect different or new Benefits
under the Plan during the Election Period;
(b)
A Participant
may terminate his participation in
the
Plan by
notifying the Administrator in writing during
the Election Period
that he does
not want to participate in the Plan
for
the next
Plan Year;
(c)
An
Employee who elects not to
participate for
the Plan Year following the Election
Period will
have to wait
until the next
Election
Period before again electing
to participate
in the Plan, except as provided for in
Section 5.4.
5.3 FAILURE TO ELECT
With regard to Benefits available under the Plan for which no Premium Expenses apply, any Participant who fails to
complete a new benefit election form pursuant to Section 5.2 by the end of the applicable Election Period shall be deemed to have
elected not to participate in the Plan for the upcoming Plan Year. No further Salary Redirections shall therefore be authorized or made
for the subsequent Plan Year for such Benefits.
With regard to Benefits available under the Plan for which Premium Expenses apply, any Participant who fails to complete a
new benefit election form pursuant to Section 5.2 by the end of the applicable Election Period shall be deemed to have made the
same Benefit elections as are then in effect for the current Plan Year. The Participant shall also be deemed to have elected Salary
Redirection in an amount necessary to purchase such Benefit options.
5
5.4 CHANGE IN STATUS
(a) Change in status defined. Any Participant may change a Benefit election after the Plan Year (to which
such election relates) has commenced and make new elections with respect to the remainder of such Plan Year if, under the
facts and circumstances, the changes are necessitated by and are consistent with a change in status which is acceptable under
rules and regulations adopted by the Department of the Treasury, the provisions of which are incorporated by reference.
Notwithstanding anything herein to the contrary, if the rules and regulations conflict, then such rules and regulations shall
control.
In general, a change in election is not consistent if the change in status is the Participant's divorce, annulment or legal
separation from a Spouse, the death of a Spouse or Dependent, or a Dependent ceasing to satisfy the eligibility requirements
for coverage, and the Participant's election under the Plan is to cancel accident or health insurance coverage for any individual
other than the one involved in such event. In addition, if the Participant, Spouse or Dependent gains or loses eligibility for
coverage, then a Participant's election under the Plan to cease or decrease coverage for that individual under the Plan
corresponds with that change in status only if coverage for that individual becomes applicable or is increased under the family
member plan.
Regardless of the consistency requirement, if the individual, the individual's Spouse, or Dependent becomes eligible
for continuation coverage under the Employer's group health plan as provided in Code Section 4980B or any similar state law,
then the individual may elect to increase payments under this Plan in order to pay for the continuation coverage. However, this
does not apply for COBRA eligibility due to divorce, annulment or legal separation.
Any new election shall be effective at such time as the Administrator shall prescribe, but not earlier than the first pay
period beginning after the election form is completed and returned to the Administrator. For the purposes of this subsection, a
change in status shall only include the following events or other events permitted by Treasury regulations:
(1) Legal Marital Status: events that change a Participant's legal marital status, including marriage, divorce,
death of a Spouse, legal separation or annulment;
(2)
Number of
Dependents:
Events that change a Participant's number of Dependents, including birth,
adoption,
placement
for adoption,
or death of a Dependent;
(3) Employment Status: Any of the following events that change the employment status of the Participant,
Spouse, or Dependent: termination or commencement of employment, a strike or lockout, commencement or return
from an unpaid leave of absence, or a change in worksite. In addition, if the eligibility conditions of this Plan or other
employee benefit plan of the Employer of the Participant, Spouse, or Dependent depend on the employment status of
that individual and there is a change in that individual's employment status with the consequence that the individual
becomes (or ceases to be) eligible under the plan, then that change constitutes a change in employment under this
subsection;
(4) Dependent satisfies or ceases to satisfy the eligibility requirements: An event that causes the Participant's
Dependent to satisfy or cease to satisfy the requirements for coverage due to attainment of age, student status, or
any similar circumstance; and
(5) Residency: A change in the place of residence of the Participant, Spouse or Dependent, that would lead to
a change in status (such as a loss of HMO coverage).
For the Dependent Care Flexible Spending Account, a Dependent becoming or ceasing to be a "Qualifying
Dependent" as defined under Code Section 21(b) shall also qualify as a change in status.
Notwithstanding anything in
this
Section to the contrary, the gain of
eligibility or
change
in eligibility of a child, as
allowed under Code Sections 105(b)
and
106, and IRS Notice 2010 -38, shall
qualify as a
change
in status.
(b) Special enrollment rights. Notwithstanding subsection (a), the Participants may change an election for
accident or health coverage during a Plan Year and make a new election that corresponds with the special enrollment rights
provided in Code Section 9801(0, including those authorized under the provisions of the Children's Health Insurance
Program Reauthorization Act of 2009 (SCHIP); provided that such Participant meets the sixty (60) day notice requirement
imposed by Code Section 9801(f) (or such longer period as may be permitted by the Plan and communicated to
Participants). Such change shall take place on a prospective basis, unless otherwise required by Code Section 9801(f) to be
retroactive.
(c)_ Qualified Medical Support Order. Notwithstanding subsection (a), in the event of a judgment, decree,
or order (including approval of a property settlement) ( "order ") resulting from a divorce, legal separation, annulment, or
change in legal custody which requires accident or health coverage for a Participant's child (including a foster child who is a
Dependent of the Participant):
(1) The Plan may change an election to provide coverage for the child if the order requires coverage under the
Participant's plan; or
(2) The Participant shall be permitted to change an election to cancel coverage for the child if the order
requires the former Spouse to provide coverage for such child, under that individual's plan and such coverage is
actually provided.
L
(d) Medicare or Medicaid. Notwithstanding subsection (a), a Participant may change elections to cancel
accident or health coverage for the Participant or the Participant's Spouse or Dependent if the Participant or the Participant's
Spouse or Dependent is enrolled in the accident or health coverage of the Employer and becomes entitled to coverage (i.e.,
enrolled) under Part A or Part B of the Title XVIII of the Social Security Act (Medicare) or Title XIX of the Social Security Act
(Medicaid), other than coverage consisting solely of benefits under Section 1928 of the Social Security Act (the program for
distribution of pediatric vaccines). If the Participant or the Participant's Spouse or Dependent who has been entitled to Medicaid
or Medicare coverage loses eligibility, that individual may prospectively elect coverage under the Plan if a benefit package
option under the Plan provides similar coverage.
(e) Cost increase or decrease. If the cost of a Benefit provided under the Plan increases or decreases
during a Plan Year, then the Plan shall automatically increase or decrease, as the case may be, the Salary Redirections of
all affected Participants for such Benefit. Alternatively, if the cost of a benefit package option increases significantly, the
Administrator shall permit the affected Participants to either make corresponding changes in their payments or revoke their
elections and, in lieu thereof, receive on a prospective basis coverage under another benefit package option with similar
coverage, or drop coverage prospectively if there is no benefit package option with similar coverage.
co„ ncrease or
UccJeOSC
ICIC1s
to
an IlllaeClJe Ur decrease iii the arnourit of
elective contributions under the
Plan, whether resulting from
an action
taken
by
the Participants or an
action taken by the
Employer.
(f) Loss of coverage. if the coverage under a Benefit is significantly curtailed or ceases during a Plan Year,
affected Participants may revoke their elections of such Benefit and, in lieu thereof, elect to receive on a prospective basis
coverage under another plan with similar coverage, or drop coverage prospectively if no similar coverage is offered.
(g) Addition of a new benefit. If, during the period of coverage, a new benefit package option or other
coverage option is added, an existing benefit package option is significantly improved, or an existing benefit package option
or other coverage option is eliminated, then the affected Participants may elect the newly -added option, or elect another
option if an option has been eliminated prospectively and make corresponding election changes with respect to other benefit
package options providing similar coverage. In addition, those Eligible Employees who are not participating in the Plan may
opt to become Participants and elect the new or newly improved benefit package option.
(h) Loss of coverage under certain other plans. A Participant may Make a prospective election change to
add group health coverage for the Participant, the Participant's Spouse or Dependent if such individual loses group health
coverage sponsored by a governmental or educational institution, including a state children's health insurance program
under the Social Security Act, the Indian Health Service or a health program offered by an Indian tribal government, a state
health benefits risk pool, or a foreign government group health plan.
(i) Change of coverage due to change under certain other plans. A Participant may make a prospective
election change that is on account of and corresponds with a change made under the plan of a Spouse's, former Spouse's
or Dependent's employer if (1) the cafeteria plan or other benefits plan of the Spouse's, former Spouse's or Dependent's
employer permits its participants to make a change; or (2) the cafeteria plan permits participants to make an election for a
period of coverage that is different from the period of coverage under the cafeteria plan of a Spouse's, former Spouse's or
Dependent's employer.
Q) Change in dependent care provider. A Participant may make a prospective election change that is on
account of and corresponds with a change by the Participant in the dependent care provider. The availability of dependent
care services from a new childcare provider is similar to a new benefit package option becoming available. A cost change is
allowable in the Dependent Care Flexible Spending Account only if the cost change is imposed by a dependent care provider
who is not related to the Participant, as defined in Code Section 152(a)(1) through (8).
(k) Health FSA cannot change due to insurance change. A Participant shall not be permitted to change
an election to the Health Flexible Spending Account as a result of a cost or coverage change under any health insurance
benefits.
ARTICLE VI
HEALTH FLEXIBLE SPENDING ACCOUNT
6.1 ESTABLISHMENT OF PLAN
This Health Flexible Spending Account is intended to qualify as a medical reimbursement plan under Code Section 105 and
shall be interpreted in a manner consistent with such Code Section and the Treasury regulations thereunder. Participants who elect to
participate in this Health Flexible Spending Account may submit claims for the reimbursement of Medical Expenses. All amounts
reimbursed shall be periodically paid from amounts allocated to the Health Flexible Spending Account. Periodic payments reimbursing
Participants from the Health Flexible Spending Account shall in no event occur less frequently than monthly.
6.2 DEFINITIONS
For the purposes of this Article and the Cafeteria Plan, the terms below have the following meaning:
7
(a) "Health Flexible Spending Account" means the account established for Participants pursuant to this
Plan to which part of their Cafeteria Plan Benefit Dollars may be allocated and from which all allowable Medical Expenses
incurred by a Participant, his or her Spouse and his or her Dependents may be reimbursed.
(b) "Highly Compensated Participant" means, for the purposes of this Article and determining
discrimination under Code Section 105(h), a participant who is:
(1) one of the 5 highest paid officers;
(2)
a shareholder who
owns
(or is considered to own applying the rules of Code Section 318) more than 10
percent
in value of the stock
of the
Employer; or
(3) among the highest paid 25 percent of all Employees (other than exclusions permitted by Code Section
105(h)(3)(B) for those individuals who are not Participants).
(c) "Medical Expenses" means any expense for medical care within the meaning of the term "medical care"
as defined in Code Section 213(d) and the rulings and Treasury regulations thereunder, and not otherwise used by the
Participant as a deduction in determining his tax liability under the Code. "Medical Expenses" can be incurred by the
Participant, his or her Spouse and his or her Dependents. "Incurred" means, with regard to Medical Expenses, when the
Participant is provided with the medical care that gives rise to the Medical Expense and not when the Participant is formally
billed or charged for, or pays for, the medical care.
A
Participant may not
be
reimbursed for the cost of any medicine or drug that is not "prescribed" within the
meaning of
Code Section 106(f)
or
is not insulin.
A Participant may not be reimbursed for the cost of other health coverage such as premiums paid under plans
maintained by the employer of the Participant's Spouse or individual policies maintained by the Participant or his Spouse or
Dependent.
A Participant may not be reimbursed for "qualified long -term care services" as defined in Code Section 7702B(c).
(d) The definitions of Article I are hereby incorporated by reference to the extent necessary to interpret and
apply the provisions of this Health Flexible Spending Account.
The amount in the Health Flexible Spending Account as of the end of any Plan Year (and after the processing of all claims
for such Plan Year pursuant to Section 6.7 hereof) shall be forfeited and credited to the benefit plan surplus. In such event, the
Participant shall have no further claim to such amount for any reason, subject to Section 8.2.
6.4 LIMITATION ON ALLOCATIONS
Notwithstanding any provision contained in this Health Flexible Spending Account to the contrary, the maximum amount that
may be allocated to the Health Flexible Spending Account by a Participant in or on account of any Plan Year is $2,500 as adjusted for
COLA.
6.5 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory. It is the intent of this Health Flexible Spending Account not to
discriminate in violation of the Code and the Treasury regulations thereunder.
(b) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination under
this Health Flexible Spending Account, it may, but shall not be required to, reject any elections or reduce contributions or
Benefits in order to assure compliance with this Section. Any act taken by the Administrator under this Section shall be
carried out in a uniform and nondiscriminatory manner. If the Administrator decides to reject any elections or reduce
contributions or Benefits, it shall be done in the following manner. First, the Benefits designated for the Health Flexible
Spending Account by the member of the group in whose favor discrimination may not occur pursuant to Code Section 105
that elected to contribute the highest amount to the fund for the Plan Year shall be reduced until the nondiscrimination tests
set forth in this Section or the Code are satisfied, or until the amount designated for the fund equals the amount designated
for the fund by the next member of the group in whose favor discrimination may not occur pursuant to Code Section 105
who has elected the second highest contribution to the Health Flexible Spending Account for the Plan Year. This process
shall continue until the nondiscrimination tests set forth in this Section or the Code are satisfied. Contributions which are not
utilized to provide Benefits to any Participant by virtue of any administrative act under this paragraph shall be forfeited and
credited to the benefit plan surplus.
6.6 COORDINATION WITH CAFETERIA PLAN
All Participants under the
Cafeteria Plan are eligible to receive Benefits
under this Health Flexible Spending Account. The
enrollment under the Cafeteria Plan
shall constitute enrollment under
this Health
Flexible Spending Account. In addition, other matters
concerning contributions, elections
and the like shall be governed by
the general
provisions of the Cafeteria Plan.
Is]
6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS
(a) Expenses must be incurred during Plan Year. All Medical Expenses incurred by a Participant, his or
her Spouse and his or her Dependents during the Plan Year including the Grace Period shall be reimbursed during the Plan
Year subject to Section 2.5, even though the submission of such a claim occurs after his participation hereunder ceases; but
provided that the Medical Expenses were incurred during the applicable Plan Year. Medical Expenses are treated as having
been incurred when the Participant is provided with the medical care that gives rise to the medical expenses, not when the _
Participant is formally billed or charged for, or pays for the medical care.
(b) Reimbursement available throughout Plan Year. The Administrator shall direct the reimbursement to
each eligible Participant for all allowable Medical Expenses, up to a maximum of the amount designated by the Participant
for the Health Flexible Spending Account for the Plan Year. Reimbursements shall be made available to the Participant
throughout the year without regard to the level of Cafeteria Plan Benefit Dollars which have been allocated to the fund at any
given point in time. Furthermore, a Participant shall be entitled to reimbursements only for amounts in excess of any
payments or other reimbursements under any health care plan covering the Participant and /or his Spouse or Dependents.
(c) Payments. Reimbursement payments under this Plan shall be made directly to the Participant. However,
in +hc Arlminic +rn+nr1n rlin. rnti.... ..+.. . L. ... .a:___u.. Lk-_
.II I o wo�.icuvi[I payiiiUI na iii &'y uc mauo un ou]y to LI IC JCI VII:C p1UVlde1. I he application for payment or
reimbursement shall be made to the Administrator on an acceptable form within a reasonable time of incurring the debt or
navin0 for thP. AP.NICP. ThP annlicatinn ¢hall inrlllrlo n Wriffen etofn Mnnf frnm nn inrlen,nnAl n ++hirt4 r.-.r +.... +..ti.... +".. Jf .
_._ - -. _.__. ..._ _.,_,_..__..._ .. ..............."._ .- .1. 1..,, I. II. „WI I1 .,11 p...I I.. I I L ti uI4 Nai.y ow uny uiaa LI Ic
Medical Expense has been incurred and the amount of such expense. Furthermore, the Participant shall provide a written
statement that the Medical Expense has not been reimbursed or is not reimbursable under any other health plan coverage
and, if reimbursed from the Health Flexible Spending Account, such amount will not be claimed as a tax deduction. The
Administrator shall retain a file of all such applications.
(d) Grace Period. Notwithstanding anything in this Section to the contrary, Medical Expenses incurred
during the Grace Period, up to the remaining account balance, shall also be deemed to have been incurred during the Plan
Year to which the Grace Period relates.
(e) Claims for reimbursement. Claims for the reimbursement of Medical Expenses incurred in any Plan
Year shall be paid as soon after a claim has been filed as is administratively practicable; provided however, that if a
Participant fails to submit a claim within 90 days after the end of the Plan Year, those Medical Expense claims shall not be
considered for reimbursement by the Administrator.
6.8 DEBIT AND CREDIT CARDS
Participants may, subject to a procedure established by the Administrator and applied in a uniform nondiscriminatory
manner, use debit and /or credit (stored value) cards ( "cards ") provided by the Administrator and the Plan for payment of Medical
Expenses, subject to the following terms:
(a) Card only for medical expenses. Each Participant issued a card shall certify that such card shall only
be used for Medical Expenses. The Participant shall also certify that any Medical Expense paid with the card has not already
been reimbursed by any other plan covering health benefits and that the Participant will not seek reimbursement from any
other plan covering health benefits.
(b) Card issuance. Such card shall be issued upon the Participant's Effective Date of Participation and
reissued for each Plan Year the Participant remains a Participant in the Health Flexible Spending Account. Such card shall
be automatically cancelled upon the Participant's death or termination of employment, or if such Participant has a change in
status that results in the Participant's withdrawal from the Health Flexible Spending Account.
(c) maximum dollar amount available. The dollar amount of coverage available on the card shall be the
amount elected by the Participant for the Plan Year. The maximum dollar amount of coverage available shall be the
maximum amount for the Plan Year as set forth in Section 6.4.
(d)
Only available for use with certain service
providers. The cards
shall
only be accepted by such
merchants and
service providers as have
been approved by the
Administrator following
IRS
guidelines.
(e) Card use. The cards shall only be used for Medical Expense purchases at these providers, including, but
not limited to, the following:
(1) Co- payments for doctor and other medical care;
(2) Purchase of drugs prescribed by a health care provider, including, if permitted by the Administrator, over -
the- counter medications as allowed under IRS regulations;
(3) Purchase of medical items such as eyeglasses, syringes, crutches, etc.
(f) Substantiation. Such purchases by the cards shall be subject to substantiation by the Administrator,
usually by submission of a receipt from a service provider describing the service, the date and the amount. The
Administrator shall also follow the requirements set forth in Revenue Ruling 2003 -43 and Notice 2006 -69. All charges shall
be conditional pending confirmation and substantiation.
9
(g) Correction methods. If such purchase is later determined by the Administrator to not qualify as a
Medical Expense, the Administrator, in its discretion, shall use one of the following correction methods to make the Plan
whole. Until the amount is repaid, the Administrator shall take further action to ensure that further violations of the terms of
the card do not occur, up to and including denial of access to the card.
(1) Repayment of the improper amount by the Participant,
Withholding the improper payment from the Participant's wages or other compensation to the extent
t with applicable federal or state law;
(3) Claims substitution or offset of future claims until the amount is repaid; and
(4)
if subsections
(1) through (3) fail to recover
the amount, consistent with the Employer's business
practices,
the Employer
may treat the amount as any
other business indebtedness.
6.9 QUALIFIED RESERVIST DISTRIBUTIONS
(a) Qualified Reservist Distribution. A Participant may request a Qualified Reservist Distribution, provided
the following provisions are satisfied. "Qualified Reservist Distribution" means any distribution to a Participant of all or a
portion of the balance in the Participant's Health Flexible Spending Account if:
(1)
Such Participant was an
individual who was (by reason of being a
member of a reserve component (as
defined
in Section 101 of Title 37,
United States Code)) ordered or called to
active duty for a period of 180 days or
more or
for an indefinite period.
ordered
or called to duty.
(2)
A Participant may
have been called prior to June 18, 2008,
provided the individual's active duty continues
after
June 18, 2008 and the
period of duty complies with subsection
(a).
(3) The distribution is made during the period beginning on the date of the order or call that applies to the
Participant and ending on the last day of the Plan Year (or Grace Period) which includes the date of such order or
call.
(4) The Qualified Reservist Distribution option is offered to all Participants who qualify under this Article.
(5) Qualified Reservist Distributions may only be made if the Participant is ordered or called to active duty,
not the Participant's spouse or dependents.
(6) Under Section 101 of the Title 37 of the United States Code, "reserve component" means: (1) the Army
National Guard, (2) the Army Reserve, (3) the Navy Reserve, (4) the Marine Corps Reserve, (5) the Air National
Guard, (6) the Air Force Reserve, (7) the Coast Guard Reserve, or (8) the Reserve Corps of the Public Health
Service.
(b) Conditions: The following conditions apply:
(1) The
Employer must
receive a copy
of the
order or
call to active duty and may rely on the order or call to
determine the
period that the
Participant has
been
ordered
or called to duty.
(2) Eligibility for a Qualified
Reservist Distribution is not affected if
the order or call is for
180 days or more or
is indefinite, but the actual period
of active duty is less than 180 days or
is changed otherwise
from the order or
call.
(3) If the original order is less than 180 days, then no Qualified Reservist Distribution is allowed. However, if
subsequent calls or orders increase the total days of active duty to 180 or more, then a Qualified Reservist
Distribution will be allowed.
(c) Amount: The amount a Participant may be reimbursed from the Health Flexible Spending Account is the
amount contributed by the Participant to the Health Flexible Spending Account as of the date of the distribution request, less
any reimbursements received as of the date of the distribution request.
(d) Procedure. The Employer must specify a process for requesting the distribution. The Employer may limit
the number of distributions processed for a Participant to 1 per Plan Year. The distribution request must be made on or after
the call or order and before the last day of the Grace Period. The QRD shall be paid within a reasonable time but in no event
more than 60 days after the date of the request.
(e) Claims. Claims incurred prior to the date of the request of the distribution shall be paid as any other
claim. Claims incurred after the date of the distribution shall not be paid and the Participant's right to submit a claim shall be
terminated as of the date of the distribution request.
10
ARTICLE VII
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
7.1 ESTABLISHMENT OF ACCOUNT
This Dependent Care Flexible Spending Account is intended to qualify as a program under Code Section 129 and shall be
- interpreted in a manner consistent with such C ode Section. Participants who elect to participate in this program may submit claims for
the reimbursement of Employment - Related Dependent Care Expenses. All amounts reimbursed shall be paid from amounts allocated
to the Participant's Dependent Care Flexible Spending Account,
7.2 DEFINITIONS
For the purposes of this Article and the Cafeteria Plan the terms below shall have the following meaning:
(a) "Dependent Care Flexible Spending Account" means the account established for a Participant
pursuant to this Article to which part of his Cafeteria Plan Benefit Dollars may be allocated and from which
Employment - Related Dependent Care Expenses of the Participant may reimbursed for the care of the Qualifvina
Dependents of Participants. V
(b)
"Earned
Income" means
earned income as defined under Code Section 32(c)(2), but excluding such
amounts paid
or incurred by
the Employer for
dependent care
assistance to the Participant.
(c) "Employment- Related Dependent Care Expenses" means the amounts paid for expenses of a
Participant for those services which if paid by the Participant would be considered employment related expenses under
Code Section 21(b)(2). Generally, they shall include expenses for household services and for the care of a Qualifying
Dependent, to the extent that such expenses are incurred to enable the Participant to be gainfully employed for any period
for which there are one or more Qualifying Dependents with respect to such Participant. Employment - Related Dependent
Care Expenses are treated as having been incurred when the Participant's Qualifying Dependents are provided with the
dependent care that gives rise to the Employment - Related Dependent Care Expenses, not when the Participant is formally
billed or charged for, or pays for the dependent care. The determination of whether an amount qualifies as an
Employment - Related Dependent Care Expense shall be made subject to the following rules:
(1) If such amounts are paid for expenses incurred outside the Participant's household, they shall constitute
Employment - Related Dependent Care Expenses only if incurred for a Qualifying Dependent as defined in Section
7.2(d)(1) (or deemed to be, as described in Section 7.2(d)(1) pursuant to Section 7.2(d)(3)), or for a Qualifying
Dependent as defined in Section 7.2(d)(2) (or deemed to be, as described in Section 7.2(d)(2) pursuant to Section
7.2(d)(3)) who regularly spends at least 8 hours per day in the Participant's household;
(2) If the expense is incurred outside the Participant's home at a facility that provides care for a fee,
payment, or grant for more than 6 individuals who do not regularly reside at the facility, the facility must comply
with all applicable state and local laws and regulations, including licensing requirements, if any; and
(3) Employment - Related Dependent Care Expenses of a Participant shall not include amounts paid or
incurred to a child of such Participant who is under the age of 19 or to an individual who is a Dependent of such
Participant or such Participant's Spouse.
(d) "Qualifying Dependent" means, for Dependent Care Flexible Spending Account purposes,
(1) a Participant's Dependent (as defined in Code Section 152(a)(1)) who has not attained age 13;
(2)
a Dependent or the Spouse
of a Participant
who is physically or mentally incapable of caring for himself
or herself
and has the same principal
place of abode
as the Participant for more than one -half of such taxable
year; or
(3) a child that is deemed to be a Qualifying Dependent described in paragraph (1) or (2) above, whichever
is appropriate, pursuant to Code Section 21(e)(5).
(e) The definitions of Article I are hereby incorporated by reference to the extent necessary to interpret and
apply the provisions of this Dependent Care Flexible Spending Account.
7.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
The Administrator shall establish a Dependent Care Flexible Spending Account for each Participant who elects to apply
Cafeteria Plan Benefit Dollars to Dependent Care Flexible Spending Account benefits.
7.4 INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
A Participant's Dependent Care Flexible Spending Account shall be increased each pay period by the portion of Cafeteria
Plan Benefit Dollars that he has elected to apply toward his Dependent Care Flexible Spending Account pursuant to elections made
under Article V hereof.
11
7.5 DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
A
Participant's Dependent Care Flexible
Spending
Account
shall
be reduced by the amount of any
Employment - Related
Dependent
Care Expense reimbursements paid or
incurred
on behalf
of a
Participant pursuant to Section 7.12
hereof.
7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT
Subject to limitations contained in Section 7.9 of this Program, and to the extent of the amount contained in the Participant's
Dependent Care Flexible Spending Account, a Participant who incurs Employment - Related Dependent Care Expenses shall be
entitled to receive from the Employer full reimbursement for the entire amount of such expenses incurred during the Plan Year or
portion thereof during which he is a Participant.
7.7 ANNUAL STATEMENT OF BENEFITS
On or before January 31st
of each calendar year, the Employer shall furnish to
each Employee who was a Participant and
received benefits under Section 7.6
during the
prior calendar year, a statement of all such
benefits paid to or on behalf of such
Participant during the prior calendar
year. This
statement is set forth on the Participant's
Form W -2.
7.8 FORFEITURES
The
amount in a Participant's Dependent Care
Flexible Spending Account as of the
end of any Plan Year (and
after
the
processing of
all claims for such Plan Year pursuant to Section 7.12 hereof) shall be forfeited
and credited to the benefit
plan
surplus.
In such event,
the Participant shall have no further claim
to such amount for any reason.
7.9 LIMITATION ON PAYMENTS
(a) Code limits. Notwithstanding any provision contained in this Article to the contrary, amounts paid from a
Participant's Dependent Care Flexible Spending Account in or on account of any taxable year of the Participant shall not
exceed the lesser of the Earned Income limitation described in Code Section 129(b) or $5,000 ($2,500 if a separate tax
return is filed by a Participant who is married as determined under the rules of paragraphs (3) and (4) of Code Section
21(e)).
7.10 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory. It is the intent of this Dependent Care Flexible Spending Account that
contributions or benefits not discriminate in favor of the group of employees in whose favor discrimination may not occur
under Code Section 129(d).
(b) 25% test for shareholders. It is the intent of this Dependent Care Flexible Spending Account that not
more than 25 percent of the amounts paid by the Employer for dependent care assistance during the Plan Year will be
provided for the class of individuals who are shareholders or owners (or their Spouses or Dependents), each of whom (on
any day of the Plan Year) owns more than 5 percent of the stock or of the capital or profits interest in the Employer.
(c) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination or
possible taxation to a group of employees in whose favor discrimination may not occur in violation of Code Section 129 it
may, but shall not be required to, reject any elections or reduce contributions or non - taxable benefits in order to assure
compliance with this Section. Any act taken by the Administrator under this Section shall be carried out in a uniform and
nondiscriminatory manner. If the Administrator decides to reject any elections or reduce contributions or Benefits, it shall be
done in the following manner. First, the Benefits designated for the Dependent Care Flexible Spending Account by the
affected Participant that elected to contribute the highest amount to such account for the Plan Year shall be reduced until the
nondiscrimination tests set forth in this Section are satisfied, or until the amount designated for the account equals the
amount designated for the account of the affected Participant who has elected the second highest contribution to the
Dependent Care Flexible Spending Account for the Plan Year. This process shall continue until the nondiscrimination tests
set forth in this Section are satisfied. Contributions which are not utilized to provide Benefits to any Participant by virtue of
any administrative act under this paragraph shall be forfeited.
7.11 COORDINATION WITH CAFETERIA PLAN
All Participants under the Cafeteria Plan are eligible to receive Benefits under this Dependent Care Flexible Spending
Account. The enrollment and termination of participation under the Cafeteria Plan shall constitute enrollment and termination of
participation under this Dependent Care Flexible Spending Account. In addition, other matters concerning contributions, elections and
the like shall be governed by the general provisions of the Cafeteria Plan.
7.12 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS
The Administrator shall direct the payment of all such Dependent Care claims to the Participant upon the presentation to the
Administrator of documentation of such expenses in a form satisfactory to the Administrator. However, in the Administrator's
discretion, payments may be made directly to the service provider. In its discretion in administering the Plan, the Administrator may
utilize forms and require documentation of costs as may be necessary to verify the claims submitted. At a minimum, the form shall
include a statement from an independent third party as proof that the expense has been incurred during the Plan Year including the
Grace Period and the amount of such expense. In addition, the Administrator may require that each Participant who desires to receive
12
reimbursement under this Program for Employment - Related Dependent Care Expenses submit a statement which may contain some
or all of the following information:
(a) The Dependent or Dependents for whom the services were performed,
(b) The nature of the services performed for the Participant, the cost of which he wishes reimbursement;
(c) The relationship, if any, of the person performing the services to the Participant,
(d) If the services are being performed by a child of the Participant, the age of the child;
(e) A statement as to where the services were performed;
(f)
If
any of the services were performed outside the
home, a statement as to whether the Dependent for
whom such
services
were performed spends
at least 8 hours a day in
the Participant's household;
(g) If the services were being performed in a day care center, a statement:
(1) that the day care center complies with all applicable laws and regulations of the state of residence,
(2) that the day care center provides care for more than 6 individuals (other than individuals residing at the
center), and
(3) of the amount of fee paid to the provider.
(h) If the Participant is married, a statement containing the following:
(1) the Spouse's salary or wages if he or she is employed, or
(2) if the Participant's Spouse is not employed, that
(I) he or she Is Incapacitated, or
(ii) he or she is a full -time student attending an educational institution and the months during the year which
he or she attended such institution.
0) Grace Period. Notwithstanding anything in this Section to the contrary, Employment - Related Dependent
Care Expenses incurred during the Grace Period, up to the remaining account balance, shall also be deemed to have been
incurred during the Plan Year to which the Grace Period relates.
Q)
Claims for reimbursement.
If a
Participant fails to
submit a claim within 90 days after the end of the
Plan Year, those
claims shall not be considered
for
reimbursement by
the Administrator.
ARTICLE VIII
BENEFITS AND RIGHTS
8.1 CLAIM FOR BENEFITS
(a)
Insurance claims. Any
claim for Benefits underwritten
by Insurance Contract(s) shall be
made to the
Insurer. If the
Insurer denies any claim, the
Participant or beneficiary shall
follow the Insurer's claims review
procedure.
(b) Dependent Care Flexible Spending Account or Health Flexible Spending Account claims. Any
claim for Dependent Care Flexible Spending Account or Health Flexible Spending Account Benefits shall be made to the
Administrator. For the Health Flexible Spending Account, if a Participant fails to submit a claim within 90 days after the end
of the Plan Year, those claims shall not be considered for reimbursement by the Administrator. For the Dependent Care
Flexible Spending Account, if a Participant fails to submit a claim within 90 days after the end of the Plan Year, those claims
shall not be considered for reimbursement by the Administrator. If the Administrator denies a claim, the Administrator may
provide notice to the Participant or beneficiary, in writing, within 90 days after the claim is filed unless special circumstances
require an extension of time for processing the claim. The notice of a denial of a claim shall be written in a manner
calculated to be understood by the claimant and shall set forth:
(1) specific references to the pertinent Plan provisions on which the denial is based;
(2) a description of any additional material or information necessary for the claimant to perfect the claim and
an explanation as to why such information is necessary; and
(3) an explanation of the Plan's claim procedure.
(c) Appeal. Within 60 days after receipt of the above material, the claimant shall have a reasonable
opportunity to appeal the claim denial to the Administrator for a full and fair review. The claimant or his duly authorized
representative may:
13
(1) request a review upon written notice to the Administrator,
(2) review pertinent documents; and
(3) submit issues and comments in writing.
(d) Review of appeal. A decision on the review by the Administrator will be made not later than 60 days
after receipt of a request for review, unless special circumstances require an extension of time for processing (such as the
need to hold a hearing), in which event a decision should be rendered as soon as possible, but in no event later than 120
days after such receipt. The decision of the Administrator shall be written and shall include specific reasons for the decision,
written in a manner calculated to be understood by the claimant, with specific references to the pertinent Plan provisions on
which the decision is based.
(e) Forfeitures. Any balance remaining in the Participant's Dependent Care Flexible Spending Account or
Health Flexible Spending Account as of the end of the time for claims reimbursement for each Plan Year and Grace Period
(if applicable) shall be forfeited and deposited in the benefit plan surplus of the Employer pursuant to Section 6.3 or Section
7.8, whichever is applicable, unless the Participant had made a claim for such Plan Year, in writing, which has been denied
or is pending; in which event the amount of the claim shall be held in his account until the claim appeal procedures set forth
above have been satisfied or the claim is paid. If any such claim is denied on appeal, the amount held beyond the end of the
Plan Year shall be forfeited and credited to the benefit plan surplus.
8.2 APPLICATION OF BENEFIT PLAN SURPLUS
Any forfeited amounts credited to the benefit plan surplus by virtue of the failure of a Participant to incur a qualified expense
or seek reimbursement in a timely manner may, but need not be, separately accounted for after the close of the Plan Year (or after
such further time specified herein for the filing of claims) in which such forfeitures arose. In no event shall such amounts be carried
over to reimburse a Participant for expenses incurred during a subsequent Plan Year for the same or any other Benefit available
under the Plan; nor shall amounts forfeited by a particular Participant be made available to such Participant in any other form or
manner, except as permitted by Treasury regulations. Amounts in the benefit plan surplus shall be used to defray any administrative
costs and experience losses or used to provide additional benefits under the Plan.
ARTICLE IX
ADMINISTRATION
9.1 PLAN ADMINISTRATION
The Employer shall be the Administrator, unless the Employer elects otherwise. The Employer may appoint any person,
including, but not limited to, the Employees of the Employer, to perform the duties of the Administrator. Any person so appointed shall
signify acceptance by filing written acceptance with the Employer. Upon the resignation or removal of any individual performing the
duties of the Administrator, the Employer may designate a successor.
If the Employer elects, the Employer shall appoint one or more Administrators. Any person, including, but not limited to, the
Employees of the Employer, shall be eligible to serve as an Administrator. Any person so appointed shall signify acceptance by filing
written acceptance with the Employer. An Administrator may resign by delivering a written resignation to the Employer or be removed
by the Employer by delivery of written notice of removal, to take effect at a date specified therein, or upon delivery to the Administrator
if no date is specified. The Employer shall be empowered to appoint and remove the Administrator from time to time as it deems
necessary for the proper administration of the Plan to ensure that the Plan is being operated for the exclusive benefit of the
Employees entitled to participate in the Plan in accordance with the terms of the Plan and the Code.
The operation of the Plan shall be under the supervision of the Administrator. It shall be a principal duty of the Administrator
to see that the Plan is carried out in accordance with its terms, and for the exclusive benefit of Employees entitled to participate in the
Plan. The Administrator shall have full power and discretion to administer the Plan in all of its details and determine all questions
arising in connection with the administration, interpretation, and application of the Plan. The Administrator may establish procedures,
correct any defect, supply any information, or reconciles any inconsistency in such manner and to such extent as shall be deemed
necessary or advisable to carry out the purpose of the Plan. The Administrator shall have all powers necessary or appropriate to
accomplish the Administrator's duties under the Plan. The Administrator shall be charged with the duties of the general administration
of the Plan as set forth under the Plan, including, but not limited to, in addition to all other powers provided by this Plan:
(a) To make and enforce such procedures, rules and regulations as the Administrator deems necessary or
proper for the efficient administration of the Plan;
(b) To interpret the provisions of the Plan, the Administrator's interpretations thereof in good faith to be final
and conclusive on all persons claiming benefits by operation of the Plan;
(c) To decide all questions concerning the Plan and the eligibility of any person to participate in the Plan and
to receive benefits provided by operation of the Plan;
(d) To reject elections or to limit contributions or Benefits for certain highly compensated participants if it
deems such to be desirable in order to avoid discrimination under the Plan in violation of applicable provisions of the Code;
14
(e)
To provide Employees
with a reasonable notification
of their benefits available by operation of the Plan
and to assist
any Participant regarding the
Participant's rights, benefits
or elections under the Plan;
(f) To keep and maintain the Plan documents and all other records pertaining to and necessary for the
administration of the Plan,
(g) To review and settle all claims against the Plan, to approve reimbursement requests, and to authorize the
payment of benefits if the Administrator determines such shall be paid if the Administrator decides in its discretion that the
applicant is entitled to them. This authority specifically permits the Administrator to settle disputed claims for benefits and
any other disputed claims made against the Plan;
(h) To appoint such agents, counsel, accountants, consultants, and other persons or entities as may be
required to assist in administering the Plan.
Any procedure, discretionary act, interpretation or construction taken by the Administrator shall be done in a
nondiscriminatory manner based upon uniform principles consistently applied and shall be consistent with the intent that the Plan shall
continue to comply with the terms of Code Section 125 and the Treasury regulations thereunder.
9.2 EXAMINATION OF RECORDS
The Administrator shall make available to each Participant, Eligible Employee and any other Employee of the Employer such
records as pertain to their interest under the Plan for examination at reasonable times during normal business hours.
9.3 PAYMENT OF EXPENSES
Any reasonable administrative expenses shall be paid by the Employer unless the Employer determines that administrative
costs shall be borne by the Participants under the Plan or by any Trust Fund which may be established hereunder. The Administrator
may impose reasonable conditions for payments, provided that such conditions shall not discriminate in favor of highly compensated
employees.
9.4 INSURANCE CONTROL CLAUSE
In the event of a conflict between the terms of this Plan and the terms of an Insurance Contract of an independent third party
Insurer whose product is then being used in conjunction with this Plan, the terms of the Insurance Contract shall control as to those
Participants receiving coverage under such Insurance Contract. For this purpose, the Insurance Contract shall control in defining the
persons eligible for insurance, the dates of their eligibility, the conditions which must be satisfied to become insured, if any, the
benefits Participants are entitled to and the circumstances under which insurance terminates.
9.5 INDEMNIFICATION OF ADMINISTRATOR
The Employer agrees to indemnify and to defend to the fullest extent permitted by law any Employee serving as the
Administrator or as a member of a committee designated as Administrator (including any Employee or former Employee who
previously served as Administrator or as a member of such committee) against all liabilities, damages, costs and expenses (including
attorney's fees and amounts paid in settlement of any claims approved by the Employer) occasioned by any act or omission to act in
connection with the Plan, if such act or omission is in good faith.
ARTICLE X
AMENDMENT OR TERMINATION OF PLAN
10.1 AMENDMENT
The Employer, at any time or from time to time, may amend
any or all of the provisions of the
Plan without the consent of
any Employee or Participant. No
amendment shall
have the effect of
modifying any
benefit election of any Participant in effect at the
time of such amendment, unless
such amendment
is made to comply
with Federal,
state or local laws,
statutes or regulations.
10.2 TERMINATION
The Employer reserves the right to terminate this Plan, in whole or in part, at any time. In the event the Plan is terminated,
no further contributions shall be made. Benefits under any Insurance Contract shall be paid in accordance with the terms of the
Insurance Contract.
No further additions shall be made to the Health Flexible Spending Account or Dependent Care Flexible Spending Account,
but all payments from such fund shall continue to be made according to the elections in effect until 90 days after the termination date
of the Plan. Any amounts remaining in any such fund or account as of the end of such period shall be forfeited and deposited in the
benefit plan surplus after the expiration of the filing period.
15
ARTICLE XI
MISCELLANEOUS
11.1 PLAN INTERPRETATION
All provisions of this Plan shall be interpreted and applied in a uniform, nondiscriminatory manner. This Plan shall be read in
its entirety and not severed except as provided in Section 11.12.
11.2 GENDER AND NUMBER
Wherever any words are used herein in the masculine, feminine
or neuter gender, they shall
be construed
as though they
were also used in another gender in all cases where they would so apply,
and whenever any words are used herein
in the singular or
plural form, they shall be construed as though they were also used in the
other form in all cases where
they would so apply.
11.3 WRITTEN DOCUMENT
This Plan,
in conjunction
with
any
separate written document which may be required by law, is intended to satisfy the written
Plan requirement of
Code Section
125
and
any Treasury regulations thereunder relating to cafeteria plans.
This Plan shall be maintained for the exclusive benefit of the Employees who participate in the Plan.
11.5 PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute an employment contract between the Employer and any Participant or to be a
consideration or an inducement for the employment of any Participant or Employee. Nothing contained in this Plan shall be deemed to
give any Participant or Employee the right to be retained in the service of the Employer or to interfere with the right of the Employer to
discharge any Participant or Employee at any time regardless of the effect which such discharge shall have upon him as a Participant
of this Plan.
11.6 ACTION BY THE EMPLOYER
Whenever the Employer
under the terms of the
Plan is permitted or required to do or perform any act or matter or thing, it
shall be done and performed by a
person duly authorized
by its
legally constituted authority.
11.7 EMPLOYER'S PROTECTIVE CLAUSES
(a) Insurance purchase. Upon the failure of either the Participant or the Employer to obtain the insurance
contemplated by this Plan (whether as a result of negligence, gross neglect or otherwise), the Participant's Benefits shall be
limited to the insurance premium(s), if any, that remained unpaid for the period in question and the actual insurance
proceeds, if any, received by the Employer or the Participant as a result of the Participant's claim.
(b) Validity of insurance contract. The Employer shall not be responsible for the validity of any Insurance
Contract issued hereunder or for the failure on the part of the Insurer to make payments provided for under any Insurance
Contract. Once insurance is applied for or obtained, the Employer shall not be liable for any loss which may result from the
failure to pay Premiums to the extent Premium notices are not received by the Employer.
11.8 NO GUARANTEE OF TAX CONSEQUENCES
Neither the Administrator nor the Employer makes any commitment or guarantee that any amounts paid to or for the benefit
of a Participant under the Plan will be excludable from the Participant's gross income for federal or state income tax purposes, or that
any other federal or state tax treatment will apply to or be available to any Participant. It shall be the obligation of each Participant to
determine whether each payment under the Plan is excludable from the Participant's gross income for federal and state income tax
purposes, and to notify the Employer if the Participant has reason to believe that any such payment is not so excludable.
Notwithstanding the foregoing, the rights of Participants under this Plan shall be legally enforceable.
11.9 INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS
If any Participant receives one or more payments or reimbursements under the Plan that are not for a permitted Benefit,
such Participant shall indemnify and reimburse the Employer for any liability it may incur for failure to withhold federal or state income
tax or Social Security tax from such payments or reimbursements. However, such indemnification and reimbursement shall not
exceed the amount of additional federal and state income tax (plus any penalties) that the Participant would have owed if the
payments or reimbursements had been made to the Participant as regular cash compensation, plus the Participant's share of any
Social Security tax that would have been paid on such compensation, less any such additional income and Social Security tax actually
paid by the Participant.
11.10 FUNDING
Unless otherwise
required by law, contributions to
the Plan need
not be placed in trust or dedicated to
a specific Benefit, but
may instead be considered
general assets of the Employer.
Furthermore,
and unless otherwise required by law,
nothing herein shall
be construed to require the
Employer or the Administrator to
maintain any
fund or segregate any amount for the
benefit of any
16
Participant, and no Participant or other person shall have any claim against, right to, or security or other interest in, any fund, account
or asset of the Employer from which any payment under the Plan may be made.
11.11 GOVERNING LAW
This Plan is governed by the Code and the Treasury regulations issued thereunder (as they might be amended from time to
time). In no event shall the Employer guarantee the favorable tax treatment sought by this Plan. To the extent not preempted by
Federal law, the provisions of this Plan shall be construed, enforced and administered according to the laws of the State of
Washington.
11.12 SEVERABiLITY
If any provision of the Plan is held invalid or unenforceable, its invalidity or unenforceability shall not affect any other
provisions of the Plan, and the Plan shall be construed and enforced as if such provision had not been included herein.
11.13 CAPTIONS
Tho nnnfinnc r• n ;ninon horc;m ;m. pri A .... L..... . w...iL..r , 4 .. A t,......, c_.._... ,,., _,-I :_ __
I uv uN.wlw vvl nw l 1� n�1i ]II a I G uwcl mU VI IIy UO a nlaucl VI UVI IV UI IIUI IVV qI IU IVI ICICI CI IUC, d IU III IIU Wdy UCIIIIC, Illllll,
enlarge or describe the scope or intent of the Plan, nor in any way shall affect the Plan or the construction of any provision thereof.
11.14 CONTINUATION OF COVERAGE (COBRA)
Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan subject to the continuation
coverage requirement of Code Section 4980B becomes unavailable, each Participant will be entitled to continuation coverage as
prescribed in Code Section 4980B, and related regulations. This Section shall only apply if the Employer employs at least twenty (20)
employees on more than 50% of its typical business days in the previous calendar year.
11.15 FAMILY AND MEDICAL LEAVE ACT (FMLA)
Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan becomes subject to the
requirements of the Family and Medical Leave Act and regulations thereunder, this Plan shall be operated in accordance with
Regulation 1.125 -3.
11.16 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Notwithstanding anything in this Plan to the contrary, this Plan shall be operated in accordance with HIPAA and regulations
thereunder.
11.17 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)
Notwithstanding any provision of this Plan to the contrary, contributions, benefits and service credit with respect to qualified
military service shall be provided in accordance with the Uniform Services Employment And Reemployment Rights Act (USERRA) and
the regulations thereunder.
11.18 COMPLIANCE WITH HIPAA PRIVACY STANDARDS
(a) Application. If any benefits under this Cafeteria Plan are subject to the Standards for Privacy of
Individually Identifiable Health Information (45 CFR Part 164, the "Privacy Standards "), then this Section shall apply.
(b) Disclosure of PHI. The Plan shall not disclose Protected Health Information to any member of the
Employer's workforce unless each of the conditions set out in this Section are met. "Protected Health Information" shall have
the same definition as set forth in the Privacy Standards but generally shall mean individually identifiable information about
the past, present or future physical or mental health or condition of an individual, including information about treatment or
payment for treatment.
(c) PHI disclosed for administrative purposes. Protected Health Information disclosed to members of the
Employer's workforce shall be used or disclosed by them only for purposes of Plan administrative functions. The Plan's
administrative functions shall include all Plan payment functions and health care operations. The terms "payment" and
"health care operations" shall have the same definitions as set out in the Privacy Standards, but the term "payment"
generally shall mean activities taken to determine or fulfill Plan responsibilities with respect to eligibility, coverage, provision
of benefits, or reimbursement for health care. Genetic information will not be used or disclosed for underwriting purposes.
(d) PHI disclosed to certain workforce members. The Plan shall disclose Protected Health information
only to members of the Employer's workforce who are authorized to receive such Protected Health Information, and only to
the extent and in the minimum amount necessary for that person to perform his or her duties with respect to the Plan.
"Members of the Employer's workforce" shall refer to all employees and other persons under the control of the Employer.
The Employer shall keep an updated list of those authorized to receive Protected Health Information.
(1) An authorized member of the Employer's workforce who receives Protected Health Information shall use
or disclose the Protected Health Information only to the extent necessary to perform his or her duties with respect
to the Plan.
17
(2) In the event that any member of the Employer's workforce uses or discloses Protected Health Information
other than as permitted by this Section and the Privacy Standards, the incident shall be reported to the Plan's
privacy officer. The privacy officer shall take appropriate action, including:
(i) investigation of the incident to determine whether the breach occurred inadvertently, through
negligence or deliberately; whether there is a pattern of breaches; and the degree of harm caused by the
breach;
appropriate sanctions
against the persons
causing the breach
which, depending upon the nature
of the breach, may include oral
or written reprimand,
additional training,
or termination of employment;
(iii) mitigation of any harm caused by the breach, to the extent practicable; and
(iv) documentation of the incident and all actions taken to resolve the issue and mitigate any
damages.
(e) Certification. The Employer must provide certification to the Plan that it agrees to:
(1) Not use or further disclose the information other than as permitted or required by the Plan documents or
as required by law;
(2) Ensure that any agent or subcontractor, to whom it provides Protected Health Information received from
the Plan, agrees to the same restrictions and conditions that apply to the Employer with respect to such
information;
(3) Not use or
disclose Protected Health
Information
for
employment - related actions and decisions or in
connection with any
other benefit or employee
benefit plan
of
the Employer;
(4)
Report to
the
Plan
any
use or disclosure of the
Protected Health
Information
of
which it becomes aware
that is
inconsistent
with
the
uses
or disclosures permitted
by this Section,
or required
by
law,
(5) Make available Protected Health Information to individual Plan members in accordance with
Section 164.524 of the Privacy Standards;
(6) Make available Protected Health Information for amendment by individual Plan members and incorporate
any amendments to Protected Health Information in accordance with Section 164.526 of the Privacy Standards;
(7)
Make
available
the Protected
Health Information required
to provide an accounting of disclosures to
individual
Plan
members
in accordance
with Section 164.528 of the
Privacy Standards,
(8) Make its internal practices, books and records relating to the use and disclosure of Protected Health
Information received from the Plan available to the Department of Health and Human Services for purposes of
determining compliance by the Plan with the Privacy Standards;
(9) If feasible, return or destroy all Protected Health Information 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 purpose for which
disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to
those purposes that make the return or destruction of the information infeasible; and
(10)
Ensure the adequate separation
between
the Plan and members of the Employer's workforce, as
required
by Section 164.504(f)(2)(iii) of the
Privacy
Standards and set out in (d) above.
11.19 COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS
Under the Security Standards for the Protection of Electronic Protected Health Information (45 CFR Part 164.300 et. seq.,
the "Security Standards "):
(a) Implementation. The Employer agrees to implement reasonable and appropriate administrative,
physical and technical safeguards to protect the confidentiality, integrity and availability of Electronic Protected Health
Information that the Employer creates, maintains or transmits on behalf of the Plan. "Electronic Protected Health
Information" shall have the same definition as set out in the Security Standards, but generally shall mean Protected Health
Information that is transmitted by or maintained in electronic media.
(b) Agents or subcontractors shall meet security standards. The Employer shall ensure that any agent
or subcontractor to whom it provides Electronic Protected Health Information shall agree, in writing, to implement reasonable
and appropriate security measures to protect the Electronic Protected Health Information.
(c) Employer shall ensure security standards. The Employer shall ensure that reasonable and
appropriate security measures are implemented to comply with the conditions and requirements set forth in Section 11.18.
ILL
11.20 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Mental Health Parity and Addiction Equity Act
and ERISA Section 712.
11.21 GENETIC INFORMATION NONDISCRIMINATION ACT (GINA)
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Genetic Information Nondiscrimination Act.
11.22 WOMEN'S HEALTH AND CANCER RIGHTS ACT
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Women's Health and Cancer Rights Act of
1998.
11.23 NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Newborns' and Mothers' Health Protection
19
ADOPTING RESOLUTION
The undersigned Principal of City of Bainbridge Island (the Employer) hereby certifies that the following resolutions were
duly adopted by the Employer on and that such resolutions have not been modified or rescinded as of the
date hereof:
RESOLVED, that the form of amended Cafeteria Plan including a Dependent Care Flexible Spending Account and Health
Flexible Spending Account effective January 1, 2013, presented to this meeting is hereby approved and adopted and that the duly
authorized agents of the Employer are hereby authorized and directed to execute and deliver to the Administrator of the Plan one or - more counterparts of the Plan.
RESOLVED,
that
the Administrator shall be instructed to take such
actions that
are deemed necessary and proper in order
to implement the Plan,
and
to set up adequate accounting and administrative
procedures
to provide benefits under the Plan.
RESOLVED, that the duly authorized agents of the Employer shall act as soon as possible to notify the employees of the
Employer of the adoption of the Cafeteria Plan by delivering to each employee a copy of the summary description of the Plan in the
form of the Summary Plan Description presented to this meeting, which form is hereby approved.
The undersigned further certifies that attached hereto as Exhibits A and B, respectively, are true copies of City of Bainbridge
Island Flexible Benefits Plan as amended and restated and the Summary Plan Description approved and adopted in the foregoing
resolutions.
Principal
Date:
IN WITNESS WHEREOF, this Plan document is hereby executed this day of
City of Bainbridge Island
By _
P
EMPLOYER
Exhibit B
CITY OF BAINBRIDGE ISLAND
FLEXIBLE BENEFITS PLAN
SUMMARY PLAN DESCRIPTION
TABLE OF CONTENTS
I
ELIGIBILITY
1.
When
can I become a participant in the Plan ? ......... ...... ............ ............... ...............................
__ . 1
2.
What
are the eligibility requirements for our Plan? ..................................................................................
............................... 1
3.
When
is my entry date? ..........................................................................................................................
............................... 1
4.
What
must I do to enroll in the Plan? ......................................................................................................
............................... 1
11
OPERATION
1. How does this Plan operate? .................................................................................................................. ............................... 1
III
CONTRIBUTIONS
1. How much of my pay may the Employer redirect? .................................................................................. ............................... 2
2. What happens to contributions made to the Plan? ................................................................................. ............................... 2
3. When must I decide which accounts I want to use? ................................................................................ ............................... 2
4. When is the election period for our Plan? ............................................................................................... ............................... 2
5. May I change my elections during the Plan Year? .................................................................................. ............................... 2
6. May I make new elections in future Plan Years? .................................................................................... ............................... 3
IV
BENEFITS
1. What benefits are offered under the Plan? ............................................................................................. ............................... 3
2. Health Flexible Spending Account .......................................................................................................... ............................... 3
3. Dependent Care Flexible Spending Account .......................................................................................... ............................... 4
4. Premium Expense Account .................................................................................................................... ............................... 4
V
BENEFIT PAYMENTS
1. When will I receive payments from my accounts? .................................................................................. ............................... 4
2. What happens if I don't spend all Plan contributions during the Plan Year? ........................................... ............................... 5
3. Family and Medical Leave Act (FMLA) ................................................................................................... ............................... 5
4. Uniformed Services Employment and Reemployment Rights Act ( USERRA) ......................................... ............................... 5
5. What happens if I terminate employment? .............................................................................................. ............................... 5
6. Will my Social Security benefits be affected? ......................................................................................... ............................... 5
7. Qualified Reservist Distributions ............................................................................................................. ............................... 5
VI
HIGHLY COMPENSATED AND KEY EMPLOYEES
1. Do limitations apply to highly compensated employees?.,.,, ............................... .. ........ .. .......... ........................................ 6
VII
PLAN ACCOUNTING
1. Periodic Statements ............................................................................................................................... ............................... 6
Vin
GENERAL INFORMATION ABOUT OUR PLAN
IX
ADDITIONAL PLAN INFORMATION
1. Claims Process ...................................................................................................................................... ............................... 7
X
CONTINUATION COVERAGE RIGHTS UNDER COBRA
1.
What is COBRA continuation coverage? ................................................................................................ ...............................
7
2.
Who can become a Qualified Beneficiary? ............................................................................................. .............6.................
8
3.
What is a Qualifying Event?. ...................................................................... ................................................... .......................
8
4.
What factors should be considered when determining to elect COBRA continuation coverage? ............ ...............................
8
5.
What is the procedure for obtaining COBRA continuation coverage? ..................................................... ...............................
9
6.
What is the election period and how long must it last? ........................................................................... ...............................
9
7.
Is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator of the
occurrenceof a Qualifying Event? .......................................................................................................... ...............................
9
8.
Is a waiver before the end of the election period effective to end a Qualified Beneficiary's election rights ? ...........................
10
9.
Is COBRA coverage available if a Qualified Beneficiary has other group health plan coverage or Medicare ? .......................
10
10.
When may a Qualified Beneficiary's COBRA continuation coverage be terminated? ............................. ...............................
10
11.
What are the maximum coverage periods for COBRA continuation coverage? ...................................... ...............................
11
12.
Under what circumstances can the maximum coverage period be expanded? ....................................... ...............................
11
13.
How does a Qualified Beneficiary become entitled to a disability extension? ......................................... ...............................
11
14.
Does the Plan require payment for COBRA continuation coverage? ...................................................... ...............................
11
15.
Must the Plan allow payment for COBRA continuation coverage to be made in monthly installments? .. ...............................
11
16.
What is Timely Payment for COBRA continuation coverage? ................................................................. ...............................
11
17.
Must a Qualified Beneficiary be given the right to enroll in a conversion health plan at the end of the maximum
coverage period for COBRA continuation coverage? ............................................................................. ...............................
12
18.
How is my participation in the Health Flexible Spending Account affected? ........................................... ...............................
12
XI
SUMMARY
CITY OF BAINBRIDGE ISLAND
FLEXIBLE BENEFITS PLAN
INTRODUCTION
We have amended the "Flexible Benefits Plan" that we previously established for you and other eligible employees. Under this
Plan, you will be able to choose among certain benefits that we make available. The benefits that you may choose are outlined in this
Summary Plan Description. We will also tell you about other important information concerning the amended Plan, such as the rules
you must satisfy before you can join and the laws that protect your rights.
One of the most important features of our Plan is that the benefits being offered are generally ones that you are already paying
for, but normally with money that has first been subject to income and Social Security taxes. Under our Plan, these same expenses
will be paid for with a portion of your pay before Federal income or Social Security taxes are withheld. This means that you will pay
less tax and have more money to spend and save.
Read this Summary Plan Description carefully so that you understand the provisions of our amended Plan and the benefits you
will receive. This SPD describes the Plan's benefits and obligations as contained in the legal Plan document, which governs the
c '
this SPD and the technical, legal language of the Plan document conflict, the document always governs. Also i f there s ae in
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control. If you wish to receive a copy of the legal Plan document, please contact the Administrator
This SPD describes the current provisions of the Plan which are designed to comply with applicable legal requirements. The Plan
is subject to federal laws, such as the Internal Revenue Code and other federal and state laws which may affect your rights. The
provisions of the Plan are subject to revision due to a change in laws or due to pronouncements by the Internal Revenue Service
(IRS) or other federal agencies. We may also amend or terminate this Plan. If the provisions of the Plan that are described in this SPD
change, we will notify you.
We have attempted to answer most of the questions you may have regarding your benefits in the Plan. If this SPD does not
answer all of your questions, please contact the Administrator (or other plan representative). The name and address of the
Administrator can be found in the Article of this SPD entitled "General Information About the Plan."
I
ELIGIBILITY
1. When can 1 become a participant in the Plan?
Before you become a Plan member (referred to in this Summary Plan Description as a "Participant "), there are certain rules
which you must satisfy. First, you must meet the eligibility requirements and be an active employee. After that, the next step is to
actually join the Plan on the "entry date" that we have established for all employees. The "entry date" is defined in Question 3 below.
You will also be required to complete certain application forms before you can enroll in the Health Flexible Spending Account or
Dependent Care Flexible Spending Account.
2. What are the eligibility requirements for our Plan?
You will be eligible to join the Plan once you have satisfied the conditions for coverage under our group medical plan. Of course,
if you were already a participant before this amendment, you will remain a participant.
3. When is my entry date?
You can join the Plan on the same day you can enter our group medical plan.
4. What must I do to enroll in the Plan?
Before you can join the Plan, you must complete an application to participate in the Plan. The application includes your personal
choices for each of the benefits which are being offered under the Plan. You must also authorize us to set some of your earnings
aside in order to pay for the benefits you have elected.
However, if you are
already covered
under any
of
the
insured benefits, you will automatically participate in this Plan to the extent
of your premiums unless
you elect not to
participate
in
this
Plan.
OPERATION
1. How does this Plan operate?
Before the start of each Plan Year, you will be able to elect to have some of your upcoming pay contributed to the Plan. These
amounts will be used to pay for the benefits you have chosen. The portion of your pay that is paid to the Plan is not subject to Federal
income or Social Security taxes. In other words, this allows you to use tax -free dollars to pay for certain kinds of benefits and
expenses which you normally pay for with out -of- pocket, taxable dollars. However, if you receive a reimbursement for an expense
1
under the Plan, you cannot claim a Federal income tax credit or deduction on your return. (See the Article entitled "General
Information About Our Plan" for the definition of "Plan Year. ")
III
CONTRIBUTIONS
1. How much of my pay may the Employer redirect?
Each year, we will automatically contribute on your behalf enough of your compensation to pay for the insurance coverage
provided unless you elect not to receive any or all of such coverage. You may also elect to have us contribute on your behalf enough
of your compensation to pay for any other benefits that you elect under the Plan. These amounts will be deducted from your pay over
the course of the year.
2. What happens to contributions made to the Plan?
Before each Plan Year begins, you will select the benefits you want and how much of the contributions should go toward each
benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered benefit or
expense during the Plan Year. Later, they will be used to pay for the expenses as they arise during the Plan Year.
3. When must I decide which accounts I want to use?
You are required by Federal law to decide before the Plan Year begins, during the election period (defined below). You must
decide two things. First, which benefits you want and, second, how much should go toward each benefit.
If you are already covered by any of the insured benefits offered by this Plan, you will automatically become a Participant to the
extent of the premiums for such insurance unless you elect, during the election period (defined below), not to participate in the Plan.
4. When is the election period for our Plan?
You will make your initial election on or before your entry date. (You should review Section I on Eligibility to better understand the
eligibility requirements and entry date.) Then, for each following Plan Year, the election period is established by the Administrator and
applied uniformly to all Participants. It will normally be a period of time prior to the beginning of each Plan Year. The Administrator will
inform you each year about the election period. (See the Article entitled "General Information About Our Plan" for the definition of Plan
Year.)
5. May I change my elections during the Plan Year?
Generally, you cannot change the elections you have made after the beginning of the Plan Year. However, there are certain
limited situations when you can change your elections. You are permitted to change elections if you have a "change in status" and
you make an election change that is consistent with the change in status. Currently, Federal law considers the following events to be
a change in status:
Marriage, divorce, death of a spouse, legal separation or annulment;
Change in the number of dependents, including birth, adoption, placement for adoption, or death of a dependent;
Any of the following events for you, your spouse or dependent: termination or commencement of employment, a strike or
lockout, commencement or return from an unpaid leave of absence, a change in worksite, or any other change in employment
status that affects eligibility for benefits;
-- One of your dependents satisfies or ceases to satisfy the requirements for coverage due to change in age, student status, or
any similar circumstance; and
-- A change in the place of residence of you, your spouse or dependent that would lead to a change in status, such as moving out
of a coverage area for insurance.
In addition, if you are participating in the Dependent Care Flexible Spending Account, then there is a change in status if your
dependent no longer meets the qualifications to be eligible for dependent care.
There are detailed rules on when a change in election is deemed to be consistent with a change in status. In addition, there are
laws that give you rights to change health coverage for you, your spouse, or your dependents. If you change coverage due to rights
you have under the law, then you can make a corresponding change in your elections under the Plan. If any of these conditions apply
to you, you should contact the Administrator.
If the cost of a benefit provided under the Plan increases or decreases during a Plan Year, then we will automatically increase or
decrease, as the case may be, your salary redirection election. If the cost increases significantly, you will be permitted to either make
corresponding changes in your payments or revoke your election and obtain coverage under another benefit package option with
similar coverage, or revoke your election entirely.
If the coverage under a Benefit is significantly curtailed or ceases during a Plan Year, then you may revoke your elections and
elect to receive on a prospective basis coverage under another plan with similar coverage. In addition, if we add a new coverage
2
option or eliminate an existing option, you may elect the newly -added option (or elect another option if an option has been eliminated)
and make corresponding election changes to other options providing similar coverage. If you are not a Participant, you may elect to
join the Plan. There are also certain situations when you may be able to change your elections on account of a change under the plan
of your spouse's, former spouse's or dependent's employer.
These rules on
change due to
cost or coverage do
not
apply to
the Health Flexible
Spending Account, and you may not change
your election to the
Health Flexible
Spending Account if
you
make a
change due to cost
or coverage for insurance.
You may not change your election under the Dependent Care Flexible Spending Account if the cost change is imposed by a
dependent care provider who is your relative.
6. May I make new elections in future Plan Years?
Yes, you may. For each new Plan Year, you may change the elections that you previously made. You may also choose not to
participate in the Plan for the upcoming Plan Year. If you do not make new elections during the election period before a new Plan
Year begins, we will assume you want your elections for insured benefits only to remain the same and you will not be considered a
Participant for the non - insured benefit options under the Plan for the upcoming Plan Year.
IV
RGNGFITC
1. What benefits are offered under the Plan?
Under our Plan, you can choose to receive your entire compensation or use a portion to pay for the following benefits or
expenses during the year.
2. Health Flexible Spending Account
The Health Flexible Spending Account enables you to pay for expenses allowed under Sections 105 and 213(d) of the Internal
Revenue Code which are not covered by our insured medical plan and save taxes at the same time. The Health Flexible Spending
Account allows you to be reimbursed by the Employer for expenses incurred by you and your dependents.
Drug costs, including insulin, may be reimbursed.
You may be reimbursed for "over the counter" drugs only if those drugs are prescribed for you. You may not, however, be
reimbursed for the cost of other health care coverage maintained outside of the Plan, or for long -term care expenses. A list of covered
expenses is available from the Administrator.
The most that you can contribute to your Health Flexible Spending Account each Plan Year is $2,500 as adjusted for COLA. In
order to be reimbursed for a health care expense, you must submit to the Administrator an itemized bill from the service provider. We
will also provide you with a debit or credit card to use to pay for medical expenses. The Administrator will provide you with further
details. Amounts reimbursed from the Plan may not be claimed as a deduction on your personal income tax return. Reimbursement
from the fund shall be paid at least once a month. Expenses under this Plan are treated as being "incurred" when you are provided
with the care that gives rise to the expenses, not when you are formally billed or charged, or you pay for the medical care.
You may be reimbursed for expenses for any child until the end of the calendar year in which the child reaches age 26. A child is
a natural child, stepchild, foster child, adopted child, or a child placed with you for adoption. If a child gains or regains eligibility due to
these new rules, that qualifies as a change in status to change coverage.
Newborns' and Mothers' Health Protection Act: Group health plans generally may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn 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 newborn's
attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case, plant and issuers may nor, under Federal law, requuire 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).
Women's Health and Cancer Rights Act: This plan, as required by the Women's Health and Cancer Rights Act of 1998, will
reimburse up to plan limits for benefits for mastectomy - related services including reconstruction and surgery to achieve symmetry
between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). Contact your Plan
Administrator for more information.
3
3. Dependent Care Flexible Spending Account
The Dependent Care Flexible Spending Account enables you to pay for out -of- pocket, work - related dependent day -care cost with
pre -tax dollars. If you are married, you can use the account if you and your spouse both work or, in some situations, if your spouse
goes to school full -time. Single employees can also use the account.
An eligible dependent is
someone for whom you can
claim expenses on Federal
Income Tax Form 2441 "Credit for Child and
Dependent Care Expenses."
Children must be under age
13. Other dependents must
be physically or mentally unable to care for
themselves. Dependent Care
arrangements which qualify
include:
(a) A Dependent (Day) Care Center, provided that if care is provided by the facility for more than six individuals, the facility
complies with applicable state and local laws;
(b) An Educational Institution for pre - school children. For older children, only expenses for non - school care are eligible; and
(c) An "Individual" who provides care inside or outside your home: The "Individual" may not be a child of yours under age 19 or
anyone you claim as a dependent for Federal tax purposes.
You should make sure that the dependent care expenses you are currently paying for qualify under our Plan.
The law places limits on the amount of money that can be paid to you in a calendar year from your Dependent Care Flexible
Spending Account. Generally, your reimbursements may not exceed the lesser of: (a) $5,000 (if you are married filing a joint return or
you are head of a household) or $2,500 (if you are married filing separate returns); (b) your taxable compensation; (c) your spouse's
actual or deemed earned income (a spouse who is a full time student or incapable of caring for himself /herself has a monthly earned
income of $250 for one dependent or $500 for two or more dependents).
Also, in order to have the reimbursements made to you from this account be excludable from your income, you must provide a
statement from the service provider including the name, address, and in most cases, the taxpayer identification number of the service
provider on your tax form for the year, as well as the amount of such expense as proof that the expense has been incurred. In
addition, Federal tax laws permit a tax credit for certain dependent care expenses you may be paying for even if you are not a
Participant in this Plan. You may save more money if you take advantage of this tax credit rather than using the Dependent Care
Flexible Spending Account under our Plan. Ask your tax adviser which is better for you.
4. Premium Expense Account
A Premium Expense Account allows you to use tax -free dollars to pay for certain premium expenses under various insurance
programs that we offer you. These premium expenses include:
-- Health care premiums under our insured group medical plan.
-- Other insurance coverage that we may provide.
Under our Plan, we will establish sub - accounts for you for each different type of insurance coverage that is available. Also,
certain limits on the amount of coverage may apply.
The Administrator may terminate or modify Plan benefits at any time, subject to the provisions of any insurance contracts
providing benefits described above. We will not be liable to you if an insurance company fails to provide any of the benefits described
above. Also, your insurance will end when you leave employment, are no longer eligible under the terms of any insurance policies, or
when insurance terminates.
Any benefits to
be
provided by insurance
will be provided only
after (1) you have provided the Administrator the necessary
information to apply
for
insurance, and (2) the
insurance is in effect
for you.
If you cover your children up to age 26 under your insurance, you can pay for that coverage through the Plan.
V
BENEFIT PAYMENTS
1. When will I receive payments from my accounts?
During the course of the Plan Year, you may submit requests for reimbursement of expenses you have incurred. Expenses are
considered "incurred'.' when the service is performed, not necessarily when it is paid for. The Administrator will provide you with
acceptable forms for submitting these requests for reimbursement. If the request qualifies as a benefit or expense that the Plan has
agreed to pay, you will receive a reimbursement payment soon thereafter. Remember, these reimbursements which are made from
the Plan are generally not subject to federal income tax or withholding. Nor are they subject to Social Security taxes. Requests for
payment of insured benefits should be made directly to the insurer. You will only be reimbursed from the Dependent Care Flexible
Spending Account to the extent that there are sufficient funds in the Account to cover your request.
0
2. What happens if 1 don't spend all Plan contributions during the Plan Year?
If you have not spent all the amounts in your Health Flexible Spending Account or Dependent Care Flexible Spending Account by
the end of the Plan Year, you may continue to incur claims for expenses during the "Grace Period." The "Grace Period" extends 2 1/2
months after the end of the Plan Year, during which time you can continue to incur claims and use up all amounts remaining in your
Health Flexible Spending Account or Dependent Care Flexible Spending Account.
Any monies left at the end of the Plan Year and the Grace Period will be forfeited. Obviously, qualifying expenses that you incur
late in the Plan Year or during the Grace Period for which you seek reimbursement after the end of such Plan Year and Grace Period
will be paid first before any amount is forfeited. For the Health Flexible Spending Account, you must submit claims no later than 90
days after the end of the Plan Year. For the Dependent Care Flexible Spending Account, you must submit claims no later than 90
days after the end of the Plan Year. Because it is possible that you might forfeit amounts in the Plan if you do not fully use the
contributions that have been made, it is important that you decide how much to place in each account carefully and conservatively.
Remember, you must decide which benefits you want to contribute to and how much to place in each account before the Plan Year
begins. You want to be as certain as you can that the amount you decide to place in each account will be used up entirely.
3. Family and Medical Leave Act (FMLA)
If you take leave under the Family and Medical Leave Act, you may revoke or change your existing elections for health insurance
and the_ Health Flaxihle gnPnr4inn Arrnl Inf If vnl Ir rnvorcinn in fhoen knnnfifo formin n+� AI in t. , ....H.... . S aL.,. L.,.. T:t ...L.;I . ..
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leave or due to your non - payment of contributions, you will be permitted to reinstate coverage for the remaining part of the Plan Year
upon your return. For the Health Flexible Spending Account, you may continue your coverage or you may revoke your coverage and
resume it when you return. You can resume your coverage at its original level and make payments for the time that you are on leave. For
example, if you elect $1,200 for the year and are out on leave for 3 months, then return and elect to resume your coverage at that level,
your remaining payments will be increased to cover the difference - from $100 per month to $150 per month. Alternatively your maximum
amount will be reduced proportionately for the time that you were gone. For example, if you elect $1,200 for the year and are out on leave
for 3 months, your amount will be reduced to $900. The expenses you incur during the time you are not in the Health Flexible Spending
Account are not reimbursable.
If you continue your coverage during your unpaid leave, you may pre -pay for the coverage, you may pay for your coverage on an
after -tax basis while you are on leave, or you and your Employer may arrange a schedule for you to "catch up" your payments when you
return.
4. Uniformed Services Employment and Reemployment Rights Act (USERRA)
If you are going into or returning
from military service,
you may have special rights to health care coverage under your Health
Flexible Spending Account under the
Uniformed Services
Employment
and Reemployment Rights Act of 1994. These rights can include
extended health care coverage. If you
may be affected by
this
law, ask
your Administrator for further details.
5. What happens if 1 terminate employment?
If you terminate employment during the Plan Year, your right to benefits will be determined in the following manner:
(a) You will remain covered by insurance, but only for the period for which premiums have been paid prior to your termination of
employment.
(b) You will still be able to request reimbursement for qualifying dependent care expenses incurred during the remainder of the
Plan Year from the balance remaining in your dependent care account at the time of termination of employment. However, no
further salary redirection contributions will be made on your behalf after you terminate. You must submit claims within 90 days
after the end of the Plan Year in which termination occurs.
(c) For health benefit coverage and Health Flexible
Article entitled "Continuation Coverage Rights Under
Health Flexible Spending Account. will cease, and no
However, you will be able to submit claims for health
payments to the Health Flexible Spending Account h
"Continuation Coverage Rights Under COBRA."
6. Will my Social Security benefits be affected?
Spending Account coverage on termination of employment, please see the
COBRA." Upon your termination of employment, your participation in the
further salary redirection contributions will be contributed on your behalf.
care expenses that were incurred before the end of the period for which
3ve already been made. Your further participation will be governed by
Your Social Security benefits may be slightly reduced because when you receive tax -free benefits under our Plan, it reduces the
amount of contributions that you make to the Federal Social Security system as well as our contribution to Social Security on your
behalf.
7. Qualified Reservist Distributions
If you are a member of a reserve unit and if you are ordered or called to active duty, then you may request a Qualified Reservist
Distribution (QRD). A Qualified Reservist Distribution is a distribution of all or a portion of the amounts remaining in your Health
Flexible Spending Account. You can only request this distribution if you are called to active duty for a period of 180 days or more or
for an indefinite period. The distribution must be made during the period beginning on the date of the call and ending on the last date
that reimbursements could otherwise be made under the Plan for the Plan Year which includes the date of the call.
5
You can receive the amount you have actually contributed minus any reimbursements you have already received (or are in
process). The amount you request may be adjusted if needed to conform with your actual account balance. You must request the
QRD before the last day of the Grace Period. Any claims that you submit after the date you request the QRD will not be processed.
You can only request 1 QRDs for a Plan Year.
VI
HIGHLY COMPENSATED AND KEY EMPLOYEES
1. Do limitations apply to highly compensated employees?
Under the Internal Revenue Code, highly compensated employees and key employees generally are Participants who are
officers, shareholders or highly paid. You will be notified by the Administrator each Plan Year whether you are a highly compensated
employee or a key employee.
If you are within these categories, the amount of contributions and benefits for you may be limited so that the Plan as a whole
does not unfairly favor those who are highly paid, their spouses or their dependents. Federal tax laws state that a plan will be
considered to unfairly favor the key employees if they as a group receive more than 25% of all of the nontaxable benefits provided for
under our Plan.
Plan experience will dictate whether contribution limitations on highly compensated employees or key employees will apply. You
will be notified of these limitations if you are affected.
VII
PLAN ACCOUNTING
1. Periodic Statements
The
Administrator will provide you with a statement of your account periodically during the Plan
Year that shows your account
balance.
It is important to
read these statements carefully so you understand the balance remaining
to pay for a benefit. Remember,
you want
to spend all the
money you have designated for a particular benefit by the end of the Plan
Year.
VIII
GENERAL INFORMATION ABOUT OUR PLAN
This Section contains certain general information which you may need to know about the Plan.
1. General Plan Information
City of Bainbridge Island Flexible Benefits Plan is the name of the Plan.
Your Employer has assigned Plan Number 501 to your Plan.
The provisions of your amended Plan become effective on January 1, 2013. Your Plan was originally effective on December 30,
2006.
Your Plan's
records
are maintained on
a twelve -month period of time.
This is known as the Plan Year. The Plan Year begins on
January 1st and
ends on
December 31st.
2. Employer Information
Your Employer's name, address, and identification number are:
City of Bainbridge Island
280 North Madison Avenue
Bainbridge Island, Washington 98110
91- 6001663
3. Plan Administrator Information
The name, address and business telephone number of your Plan's Administrator are:
City of Bainbridge Island
280 North Madison Avenue
Bainbridge Island, Washington 98110
(206) 780 -8619
The Administrator keeps the records for the Plan and is responsible for the administration of the Plan. The Administrator will also
answer any questions you may have about our Plan. You may contact the Administrator for any further information about the Plan.
4. Service of Legal Process
The name and address of the Plan's agent for service of legal process are:
Director of Finance & Administrative Services
280 North Madison Avenue
Bainbridge Island, Washington 98110
5. Type of Administration
The type of Administration is Employer Administration.
6. Claims Submission
Claims for expenses should be submitted to:
Benefit Administration Company LLC
on Box 5F^
Seattle, Washington 98111 -0550
IX
ADDITIONAL PLAN INFORMATION
1. Claims Process
You
should submit
all reimbursement
claims during the Plan Year. For the
Health Flexible Spending Account, you must submit
claims no
later than 90
days after the end
of the Plan Year.
For the Dependent
Care Flexible Spending Account, you must submit
claims no
later than 90
days after the end
of the Plan
Year.
Any claims submitted after that time will not be considered.
Claims that are insured will be handled in accordance with procedures contained in the insurance policies. All other general
requests should be directed to the Administrator of our Plan. If a dependent care or medical expense claim under the Plan is denied in
whole or in part, you or your beneficiary will receive written notification. The notification will include the reasons for the denial, with
reference to the specific provisions of the Plan on which the denial was based, a description of any additional information needed to
process the claim and an explanation of the claims review procedure. Within 60 days after denial, you or your beneficiary may submit
a written request for reconsideration of the denial to the Administrator.
Any such request should be accompanied by documents or records in support of your appeal. You or your beneficiary may
review pertinent documents and submit issues and comments in writing. The Administrator will review the claim and provide, within 60
days, a written response to the appeal. (This period may be extended an additional 60 days under certain circumstances.) In this
response, the Administrator will explain the reason for the decision, with specific reference to the provisions of the Plan on which the
decision is based. The Administrator has the exclusive right to interpret the appropriate plan provisions. Decisions of the Administrator
are conclusive and binding.
X
CONTINUATION COVERAGE RIGHTS UNDER COBRA
Under federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), certain employees and their families
covered under health benefits under this Plan will be entitled to the opportunity to elect a temporary extension of health coverage
(called "COBRA continuation coverage ") where coverage under the Plan would otherwise end. This notice is intended to inform Plan
Participants and beneficiaries, in summary fashion, of their rights and obligations under the continuation coverage provisions of
COBRA, as amended and reflected in final and proposed regulations published by the Department of the Treasury. This notice is
intended to reflect the law and does not grant or take away any rights under the law.
The Plan Administrator or its designee is responsible for administering COBRA, continuation coverage. Complete instructions on
COBRA, as well as election forms and other information, will be provided by the Plan Administrator or its designee to Plan
Participants who become Qualified Beneficiaries under COBRA. While the Plan itself is not a group health plan, it does provide health
benefits. Whenever "Plan" is used in this section, it means any of the health benefits under this Plan including the Health Flexible
Spending Account.
1. What is COBRA continuation coverage?
COBRA continuation coverage is the temporary extension of group health plan coverage that must be offered to certain Plan
Participants and their eligible family members (called "Qualified Beneficiaries ") at group rates. The right to COBRA continuation
coverage is triggered by the occurrence of a life event that results in the loss of coverage under the terms of the Plan (the "Qualifying
Event "). The coverage must be identical to the coverage that the Qualified Beneficiary had immediately before the Qualifying Event, or
if the coverage has been changed, the coverage must be identical to the coverage provided to similarly situated active employees
who have not experienced a Qualifying Event (in other words, similarly situated non -COBRA beneficiaries).
VA
2. Who can become a Qualified Beneficiary?
In general, a Qualified Beneficiary can be:
(a) Any individual who, on the day before a Qualifying Event, is covered under a Plan by virtue of being on that day either a
covered Employee, the Spouse of a covered Employee, or a Dependent child of a covered Employee. If, however, an individual
who otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under the Plan under circumstances in which
the denial or failure to offer constitutes a violation of applicable law, then the individual will be considered to have had the
coverage and will be considered a Qualified Beneficiary if that individual experiences a Qualifying Event.
(b) Any child who is born to or placed for adoption with a covered Employee during a period of COBRA continuation coverage,
and any individual who is covered by the Plan as an alternate recipient under a qualified medical support order. If, however, an
individual who otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under the Plan under
circumstances in which the denial or failure to offer constitutes a violation of applicable law, then the individual will be considered
to have had the coverage and will be considered a Qualified Beneficiary if that individual experiences a Qualifying Event.
The term "covered Employee" includes any individual who is provided coverage under the Plan due to his or her performance of
services for the employer sponsoring the Plan. However, this provision does not establish eligibility of these individuals. Eligibility for
Plan coverage shall be determined in accordance with Plan Eligibility provisions.
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is attributable to a period in which the
individual was a nonresident alien who received from the individual's Employer no earned income that constituted income from
sources within the United States. If, on account of the preceding reason, an individual is not a Qualified Beneficiary, then a Spouse or
Dependent child of the individual will also not be considered a Qualified Beneficiary by virtue of the relationship to the individual. A
domestic partner is not a Qualified Beneficiary.
Each Qualified Beneficiary (including a child who is born to or placed for adoption with a covered Employee during a period of
COBRA continuation coverage) must be offered the opportunity to make an independent election to receive COBRA continuation
coverage.
3. What is a Qualifying Event?
A Qualifying Event is any of the following if the Plan provided that the Plan participant would lose coverage (i.e., cease to be
covered under the same terms and conditions as in effect immediately before the Qualifying Event) in the absence of COBRA
continuation coverage:
(a) The death of a covered Employee.
(b) The termination (other than by reason of the Employee's gross misconduct), or reduction of hours, of a covered Employee's
employment.
(c) The divorce or legal separation of a covered Employee from the Employee's Spouse. If the Employee reduces or eliminates
the Employee's Spouse's Plan coverage in anticipation of a divorce or legal separation, and a divorce or legal separation later
occurs, then the divorce or legal separation may be considered a Qualifying Event even though the Spouse's coverage was
reduced or eliminated before the divorce or legal separation.
(d) A covered Employee's enrollment in any part of the Medicare program.
(e) A Dependent child's ceasing to satisfy the Plan's requirements for a Dependent child (for example, attainment of the
maximum age for dependency under the Plan).
If the Qualifying Event causes the covered Employee, or the covered Spouse or a Dependent child of the covered Employee, to
cease to be covered under the Plan under the same terms and conditions as in effect immediately before the Qualifying Event, the
persons losing such coverage become Qualified Beneficiaries under COBRA if all the other conditions of COBRA are also met. For
example, any increase in contribution that must be paid by a covered Employee, or the Spouse, or a Dependent child of the covered
Employee, for coverage under the Plan that results from the occurrence of one of the events listed above is a loss of coverage.
The taking of leave under the Family and Medical Leave Act of 1993 ( "FMLA ") does not constitute a Qualifying Event. A
Qualifying Event will occur, however, if an Employee does not return to employment at the end of the FMLA leave and all other
COBRA continuation coverage conditions are present. If a Qualifying Event occurs, it occurs on the last day of FMLA leave and the
applicable maximum coverage period is measured from this date (unless coverage is lost at a later date and the Plan provides for the
extension of the required periods, in which case the maximum coverage date is measured from the date when the coverage is lost.)
Note that the covered Employee and family members will be entitled to COBRA continuation coverage even if they failed to pay the
employee portion of premiums for coverage under the Plan during the FMLA leave.
4. What factors should be considered when determining to elect COBRA continuation coverage?
You should take into account that a failure to continue your group health coverage will affect your rights under federal law. First,
you can lose the right to avoid having pre- existing condition exclusions applied by other group health plans if there is more than a
63 -day gap in health coverage and election of COBRA continuation coverage may help you avoid such a gap. Second, if you do not
elect COBRA continuation coverage and pay the appropriate premiums for the maximum time available to you, you will lose the right
W
to convert to an individual health insurance policy, which does not impose such pre- existing condition exclusions. Finally, you should
take into account that you have special enrollment rights under federal law (HIPAA). You have the right to request special enrollment
in another group health plan for which you are otherwise eligible (such as a plan sponsored by your Spouse's employer) within 30
days after Plan coverage ends due to a Qualifying Event listed above. You will also have the same special right at the end of COBRA
continuation coverage if you get COBRA continuation coverage for the maximum time available to you.
5. What is the procedure for obtaining COBRA continuation coverage? _
The Plan has conditioned the availability of COBRA continuation coverage upon the timely election of such coverage. An election
is timely if it is made during the election period.
6. What is the election period and how long must it last?
The election period is the time period within which the Qualified Beneficiary must elect COBRA continuation coverage under the
Plan. The election period must begin no later than the date the Qualified Beneficiary would lose coverage on account of the Qualifying
Event and ends 60 days after the later of the date the Qualified Beneficiary would lose coverage on account of the Qualifying Event or
the date notice is provided to the Qualified Beneficiary of her or his right to elect COBRA continuation coverage. If coverage is not
eieuted within the 60 day period, all rights to elect CO13HA continuation coverage are forfeited.
Ivvc. Ir a VV VCIGU 1_I 111JIVyCG VVIIV IIdJ UCCII ICI II IIIId ICU UI CXIJCIICIIGeU 'd reUUCllon of Hours qualifies for a traoe readjustment
allowance or alternative trade adjustment assistance under a federal law called the Trade Act of 2002, and the employee and his or
her covered dependents have not elected COBRA coverage within the normal election period, a second opportunity to elect COBRA
coverage will be made available for themselves and certain family members, but only within a limited period of 60 days or less and
only during the six months immediately after their group health plan coverage ended. Any person who qualifies or thinks that he or
she and /or his or her family members may qualify for assistance under this special provision should contact the Plan Administrator or
its designee for further information.
The Trade Act of 2002 also created a tax credit for certain TAA- eligible individuals and for certain retired employees who are
receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) (eligible individuals). Under the new tax
provisions, eligible individuals can either take a tax credit or get advance payment of a part of the premiums paid for qualified health
insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Coverage
Tax Credit Consumer Contact Center toll -free at 1- 866 - 628 -4282. TTDf TITY callers may call toll -free at 1- 866 - 626 -4282. More
information about the Trade Act is also available at www.doleta.gov /tradeact.
7. is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator of the occurrence of a
Qualifying Event?
The Plan will offer COBRA continuation coverage to Qualified Beneficiaries only after the Plan Administrator or its designee has
been timely notified that a Qualifying Event has occurred. The Employer (if the Employer is not the Plan Administrator) will notify the
Plan Administrator or its designee of the Qualifying Event within 30 days following the date coverage ends when the Qualifying Event
is:
(a) the end of employment or reduction of hours of employment,
(b) death of the employee,
(c) commencement of a proceeding in bankruptcy with respect to the Employer, or
(d) entitlement of the employee to any part of Medicare.
IMPORTANT:
For the other Qualifving Events (divorce or legal separation of the employee and spot or a dependent child's losing
eligibility for coverage as a dependent child), you or someone on your behalf must notify the Plan Administrator or its
designee in writing within 60 days after the Qualifying Event occurs, using the procedures specified below. If these
procedures are not followed or if the notice is not provided in writing to the Plan Administrator or its designee during the
60 -day notice period, any spouse or dependent child who loses coverage will not be offered the option to elect continuation
coverage. You must send this notice to the Plan Administrator or its designee.
NOTICE PROCEDURES:
Any notice that you
provide must
be in wrifinq. Oral
notice,
including notice
by
telephone, is not acceptable. You must mail,
fax or hand - deliver your
notice to the
per
or firm
listed below, at
the
following address:
City of Bainbridge Island
280 North Madison Avenue
Bainbridge Island, Washington 98110
E
If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice you provide must
state:
• the name of the plan or plans under which you lost or are losing coverage,
• the name and address of the employee covered under the plan,
• the name(s) and address(es) of the Qualified Beneficiary(ies), and
• the Qualifying Event and the date it happened.
If the Qualifying Event is a divorce or legal separation, your notice must include a copy of the divorce decree or the legal
separation agreement.
Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability extension.
Once the Plan Administrator or its designee receives timely notice that a Qualifying Event has occurred, COBRA continuation
coverage will be offered to each of the qualified beneficiaries. Each Qualified Beneficiary will have an independent right to elect
COBRA continuation coverage. Covered employees may elect COBRA continuation coverage for their spouses, and parents may
elect COBRA continuation coverage on behalf of their children. For each Qualified Beneficiary who elects COBRA continuation
coverage, COBRA continuation coverage will begin on the date that plan coverage would otherwise have been lost. If you or your
spouse or dependent children do not elect continuation coverage within the 60 -day election period described above, the right to elect
continuation coverage will be lost.
8. Is a waiver before the end of the election period effective to end a Qualified Beneficiary's election rights?
If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the waiver can be revoked at any
time before the end of the election period. Revocation of the waiver is an election of COBRA continuation coverage. However, if a
waiver is later revoked, coverage need not be provided retroactively (that is, from the date of the loss of coverage until the waiver is
revoked). Waivers and revocations of waivers are considered made on the date they are sent to the Plan Administrator or its
designee, as applicable.
9. Is COBRA coverage available if a Qualified Beneficiary has other group health plan coverage or Medicare?
Qualified Beneficiaries who are entitled to elect COBRA continuation coverage may do so even if they are covered under another
group health plan or are entitled to Medicare benefits on or before the date on which COBRA is elected. However, a Qualified
Beneficiary's COBRA coverage will terminate automatically if, after electing COBRA, he or she becomes entitled to Medicare or
becomes covered under other group health plan coverage (but only after any applicable preexisting condition exclusions of that other
plan have been exhausted or satisfied).
10. When may a Qualified Beneficiary's COBRA continuation coverage be terminated?
During
the election period, a Qualified
Beneficiary may
waive COBRA continuation coverage. Except for an interruption of
coverage in
connection with a waiver, COBRA
continuation
coverage that has been elected for a Qualified Beneficiary must extend for
at least the
period beginning on the date of
the Qualifying Event
and ending not before the earliest of the following dates:
(a) The last day of the applicable maximum coverage period.
(b) The first day for which Timely Payment is not made to the Plan with respect to the Qualified Beneficiary.
(c) The date upon which the Employer ceases to provide any group health plan (including a successor plan) to any employee.
(d) The date, after the date of the election, that the Qualified Beneficiary first becomes covered under any other Plan that does
not contain any exclusion or limitation with respect to any pre- existing condition, other than such an exclusion or limitation that
does not apply to, or is satisfied by, the Qualified Beneficiary.
(e) The date, after the date of the election, that the Qualified Beneficiary first becomes entitled to Medicare (either part A or part
B, whichever occurs earlier).
(f) In the case of a Qualified Beneficiary entitled to a disability extension, the later of:
(1) (i) 29 months after the date of the Qualifying Event, or (ii) the first day of the month that is more than 30 days after the
date of a final determination under Title II or XVI of the Social Security Act that the disabled Qualified Beneficiary whose
disability resulted in the Qualified Beneficiary's entitlement to the disability extension is no longer disabled, whichever is
earlier: or
(2) the end of the maximum coverage period that applies to the Qualified Beneficiary without regard to the disability
extension.
The Plan can terminate for cause
the coverage of a Qualified Beneficiary on
the same basis
that the Plan terminates for cause
the coverage of similarly situated non -COBRA
beneficiaries, for example, for the
submission of a
fraudulent claim.
IT111
In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under the Plan solely because of the
individual's relationship to a Qualified Beneficiary, if the Plan's obligation to make COBRA continuation coverage available to the
Qualified Beneficiary ceases, the Plan is not obligated to make coverage available to the individual who is not a Qualified Beneficiary.
11. What are the maximum coverage periods for COBRA continuation coverage?
The maximum coverage periods are based on the type of the Qualifying Event and the status of the Qualified Beneficiary, as
shown below.
(a) In the case of a Qualifying Event that is a termination of employment or reduction of hours of employment, the maximum
coverage period ends 18 months after the Qualifying Event if there is not a disability extension and 29 months after the Qualifying
Event if there is a disability extension.
(b) In the case of a covered
Employee's
enrollment in the Medicare
program before experiencing a Qualifying Event that is a
termination of employment or
reduction of
hours of employment, the
maximum coverage period for Qualified Beneficiaries ends
on the later of:
LIIIFIIVYQQ
UCVVIIICJ eIIILAICU III
ule IVIUUIGdle prUyrarn. 1 his extension aces not
11\ 4R
11
mnn+kn •.Firer
Hk. An4. 4L.... ..... A
C...,.., L.. .., .,
L,___.v _., a -� :_
u__ nn- _c____ vi. -
\ vv
nwnuw and
Ulc Uaic ulc VVVCIUU
LIIIFIIVYQQ
UCVVIIICJ eIIILAICU III
ule IVIUUIGdle prUyrarn. 1 his extension aces not
apply to
the covered
Employee; or
(2) 18 months (or 29 months, if there is a disability extension) after the date of the covered Employee's termination of
employment or reduction of hours of employment.
(c) In the case of a Qualified Beneficiary who is a child born to or placed for
adoption with
a covered Employee
during a period
of COBRA continuation coverage, the maximum coverage period is the maximum coverage
period applicable to
the Qualifying
Event giving rise to the period of COBRA continuation coverage during which
the child was
born or placed for adoption.
(d) In the case of any other Qualifying Event than that described above, the maximum coverage period ends 36 months after
the Qualifying Event.
12. Under what circumstances can the maximum coverage period be expanded?
If a Qualifying Event that gives rise to an 18 -month or 29 -month maximum coverage period is followed, within that 18- or
29 -month period, by a second Qualifying Event that gives rise to a 36- months maximum coverage period, the original period is
expanded to 36 months, but only for individuals who are Qualified Beneficiaries at the time of and with respect to both Qualifying
Events. In no circumstance can the COBRA maximum coverage period be expanded to more than 36 months after the date of the first
Qualifying Event. The Plan Administrator must be notified of the second qualifying event within 60 days of the second qualifying event.
This notice must be sent to the Plan Administrator or its designee in accordance with the procedures above.
13. How does a Qualified Beneficiary become entitled to a disability extension?
A disability extension will be granted if an individual (whether or not the covered Employee) who is a Qualified Beneficiary in
connection with the Qualifying Event that is a termination or reduction of hours of a covered Employee's employment, is determined
under Title II or XVI of the Social Security Act to have been disabled at any time during the first 60 days of COBRA continuation
coverage. To qualify for the disability extension, the Qualified Beneficiary must also provide the Plan Administrator with notice of the
disability determination on a date that is both within 60 days after the date of the determination and before the end of the original
18 -month maximum coverage. This notice must be sent to the Plan Administrator or its designee in accordance with the procedures
above.
14. Does the Plan require payment for COBRA continuation coverage?
For any period of COBRA continuation coverage under the Plan, Qualified Beneficiaries who elect COBRA continuation coverage
may be required to pay up to 102% of the applicable premium and up to 150% of the applicable premium for any expanded period of
COBRA continuation coverage covering a disabled Qualified Beneficiary due to a disability extension. Your Plan Adminlistrator will
inform you of the cost. The Plan will terminate a Qualified Beneficiary's COBRA continuation coverage as of the first day of any period
for which timely payment is not made.
15. Must the Plan allow payment for COBRA continuation coverage to be made in monthly installments?
Yes. The Plan is also permitted to allow for payment at other intervals.
16. What is Timely Payment for COBRA continuation coverage?
Timely Payment means a payment made no later than 30 days after the first day of the coverage period. Payment that is made to
the Plan by a later date is also considered Timely Payment if either under the terms of the Plan, covered Employees or Qualified
Beneficiaries are allowed until that later date to pay for their coverage for the period or under the terms of an arrangement between
the Employer and the entity that provides Plan benefits on the Employer's behalf, the Employer is allowed until that later date to pay
for coverage of similarly situated non -COBRA beneficiaries for the period.
11
Notwithstanding
the above
paragraph, the Plan does
not require payment for any period of COBRA continuation coverage for a
Qualified Beneficiary
earlier than
45 days after the date on
which the election of COBRA continuation coverage is made for that
Qualified Beneficiary.
Payment
is considered made on the
date on which it is postmarked to the Plan.
If Timely Payment is made to the Plan
in an amount that is not significantly less than the amount the Plan requires
to be paid for
a period of coverage, then the amount paid
will be deemed to satisfy
the Plan's requirement for the amount to be paid,
unless the Plan
notifies the Qualified Beneficiary of the amount of the deficiency and
grants a reasonable period of time for payment of
the deficiency
to be made. A "reasonable period of time" is 30 days after the notice
is provided. A shortfall in a Timely Payment is not
significant if it
is no greater than
the
lesser of
$50 or 10%
of the required amount.
17. Must a Qualified Beneficiary be given the right to enroll in a conversion health plan at the end of the maximum coverage
period for COBRA continuation coverage?
If a Qualified Beneficiary's COBRA continuation coverage under a group health plan ends as a result of the expiration of the
applicable maximum coverage period, the Plan will, during the 180 -day period that ends on that expiration date, provide the Qualified
Beneficiary with the option of enrolling under a conversion health plan if such an option is otherwise generally available to similarly
situated non -COBRA beneficiaries under the Plan. If such a conversion option is not otherwise generally available, it need not be
made available to Qualified Beneficiaries.
18. How is my participation in the Health Flexible Spending Account affected?
You can elect to continue your participation in the Health Flexible Spending Account for the remainder of the Plan Year, subject
to the following conditions. You may only continue to participate in the Health Flexible Spending Account if you have elected to
contribute more money than you have taken out in claims. For example, if you elected to contribute an annual amount of $500 and, at
the time you terminate employment, you have contributed $300 but only claimed $150, you may elect to continue coverage under the
Health Flexible Spending Account. If you elect to continue coverage, then you would be able to continue to receive your health
reimbursements up to the $500. However, you must continue to pay for the coverage, just as the money has been taken out of your
paycheck, but on an after -tax basis. The Plan can also charge you an extra amount (as explained above for other health benefits) to
provide this benefit.
IF YOU HAVE QUESTIONS
If you have questions about your COBRA continuation coverage, you should contact the Plan Administrator or its designee. For
more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA),
and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's
Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are
available through EBSA's website at www.dol.gov /ebsa.
KEEP YOUR PLAN ADMINISTRATOR INFORMED OF ADDRESS CHANGES
In
order to protect your family's rights, you
should keep the
Plan Administrator
informed of
any changes in the
addresses of
family
members. You should also keep a copy,
for your records,
of any notices you
send to the
Plan Administrator
or its designee.
XI
SUMMARY
The money you earn is important to you
and your
family. You need it
to pay your bills, enjoy recreational activities and save for
the future. Our flexible benefits plan will help
you keep
more of the money
you earn by lowering the amount of taxes you pay. The
Plan is the result of our continuing efforts to find ways
to help you get the
most for your earnings.
If you have any questions, please contact the Administrator.
12