2000 - P & A Administrative Services - Flexible Benefits Plan• •
FLEXIBLE BENEFITS ADMINISTRATION
SERVICES AGREEMENT
This Agreement made effective as of August 1, 2008 (the "Effective Date"), by and between the
CITY OF ROSEMEAD, 8838 East Valley Boulevard, Rosemead, CA 91770 (the "Employer"), and P&A
ADMINISTRATIVE SERVICES, INC., 17 Court Street, Suite 500, Buffalo, NY 14202-3294 ("P&A").
WI TNESSETH:
WHEREAS, the Employer desires to establish a cafeteria plan as defined in Section 125 of the
Internal Revenue Code (the "Plan"); and
WHEREAS, the Employer desires to retain P&A to provide administrative services with respect to
the Plan, and P&A desires to provide such services upon certain terms and conditions;
NOW, THEREFORE, in consideration of the mutual covenants and agreements contained herein
and for other good and valuable consideration, receipt of which is hereby acknowledged, the parties
hereto, with the intention of being legally bound hereby, covenant and agree as follows:
1. Services. P&A shall provide the following services with respect to the Plan:
a. prepare such Plan documents as shall be necessary to properly establish the Plan as
of the Effective Date, including but not limited to a Plan document, a summary of the Plan for
distribution to employees eligible to participate in the Plan ("Participants'), and an enrollment
form. At the time forwarded to the Employer, all such documents shall conform in all
respects with all relevant provisions of the Internal Revenue Code and federal income tax
regulations;
b. with the assistance of the Employer, enroll Participants in the Plan;
C. provide Participants who have elected flexible spending account benefits under the
Plan with a form to use in submitting flexible spending account claims;
d. receive, review and, when authorized by the Plan and by applicable law, approve
flexible spending account claims;
e. from time to time, notify the Employer of the aggregate amount of funds needed from
the Employer to pay pending approved claims and receive said funds as transmitted by the
Employer;
f. pay approved flexible spending account claims from funds made available by the
Employer for that purpose. Claims shall be paid by check or, where authorized by a
claimant, by direct electronic deposit to a bank account of the claimant.
g. provide with each flexible spending account claim paid by check a statement of the
Participant's remaining account balance under the flexible spending account from which the
payment has been made;
h. provide such other services as shall be reasonably necessary to process flexible
spending account claims under the Plan;
i. before the end of each Plan Year of the Plan as described in the Plan document (the
"Plan Year"), provide to each Participant who elected any flexible spending account benefits
for that Plan Year a statement setting forth each of his or her flexible spending account
balances and advise of the potential forfeiture of any balances not used to reimburse the
Participant for eligible expenses incurred prior to the end of the Plan Year;
j. perform such benefits discrimination testing as P&A shall deem necessary to assure
the Plan's continuing compliance under Code Section 125; and
k. prepare any annual return (Form 5500 Series or equivalent) required by applicable
federal law with respect to the Plan for filing by the Employer with respect to each Plan Year
ending prior to the termination of this Agreement.
P&A shall use it best efforts to perform the above services in accordance with applicable law, in
accordance with the Plan document pursuant to which the Plan is maintained by the Employer and any
amendments thereto, and in accordance with an administrative manual detailing its claims procedures that
will be provided to the Employer by P&A following the execution of this Agreement.
P&A further shall use its best efforts to perform the above services in a competent and professional
manner. If P&A becomes aware of any error that has occurred in the performance of any of these
services, P&A shall take any actions necessary to correct said error as soon as is practicable.
2. Compensation. As compensation for the services rendered hereunder, the Employer shall
pay P&A such fees as are set forth in Schedule A attached hereto and made a part hereof. P&A may
modify this fee schedule as of the beginning of any Plan Year commencing on or afterthe initial term of the.
Agreement (as described in Section 6 hereof). P&A shall notify the Employer in writing of any modification
to the fee schedule not less than ninety (90) days before the beginning of the Plan Year in which the
modification is to become effective. Should the Employer be unwilling to accept any such modification, it
may exercise its right to terminate the Agreement in accordance with Section 6 below.
3. The Employer Responsibilities.
a. The Employer shall notify P&A in writing of any event or occurrence that affects the
group of employees who are eligible for reimbursement of expenses under the Plan (e.g.,
hiring of a new employee, termination of an employee, change in hours worked) as soon as
is reasonably practicable.
b. The Employer shall provide P&A on a timely basis with such other information as P&A
reasonably shall request in furtherance of its responsibilities hereunder as soon as is
reasonably practicable.
C. The Employer shall provide P&A with the funds necessary to pay all claims that
qualify for reimbursement under the Plan. P&A shall not be obligated to advance funds to
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the Employer for this purpose.
d. The Employer shall be responsible for assuring that withholding from its payroll is
consistent in all respects with salary reduction elections made under the Plan and for
preparing Forms W-2 that reflect benefits that were received by Participants during the
reporting year to the extent required by law.
4. Relationship and Responsibilities of the Parties and Indemnification. The legal
relationship between the Employer and P&A shall be exclusively that of principal and agent. The
responsibilities and liabilities of P&A are only those set forth herein, and no others shall be implied. P&A
shall have no duty or authority to make, or to compel the Employer to make payment of any benefit under
the Plan. Except for its own misconduct or negligence, P&A shall not indemnify the Employer or any other
provider of benefits under the Plan, with respect to its liability to pay benefits to Participants.
Except for its own misconduct or negligence, neither P&A nor any of its officers, directors, or
employees, nor any agent of or counsel for any of the foregoing, shall be liable to anyone at any time
interested in the Plan, for any act or omission in providing services hereunder. P&A shall indemnify and
hold harmless the Employer from any claim, liability, obligation or charge arising out of P&A's misconduct,
negligence or other wrongdoing in connection with activities or responsibilities arising out of or relating to
this Agreement. The Employer shall indemnify and hold harmless P&A from any claim, liability, obligation
or charge arising out of the Employer's misconduct, negligence or other wrongdoing in connection with
activities or responsibilities arising out of or relating to this Agreement.
5. Assignment. Neither party may assign this Agreement without the written consentof
the other. Should P&A assign the Agreement without the Employer's written consent or should the
Employer decline to consent to any such assignment, the Employer may cause this Agreement to be
terminated by giving P&A not less than sixty (60) days notice of its intention to terminate the Agreement.
6. Term; Termination. The initial term of this Agreement shall commence on the Effective Date
and shall end on the last day of the first twelve-month Plan Year commencing on or after that date.
Thereafter, this Agreement automatically shall be renewed for each additional Plan Year unless one of the
parties hereto gives the other party notice in writing of its desire to terminate the Agreement as of the end
of a specified Plan Year not less than sixty (60) days prior to the end of that Plan Year. Notwithstanding
the foregoing, this Agreement shall terminate (a) automatically if either party is adjudicated a bankrupt or
suffers appointment of a temporary or permanent receiver, trustee or custodian for all or a substantial part
of their assets, which shall not be discharged within thirty days of appointment, or makes an assignment for
the benefit of creditors, or (b) after written notice by one party of the other party's material breach of, or
material failure to perform, its obligations hereunder unless such breach or failure is cured within ten days
of said notice. Any notice of breach must provide all such details as are known to the non-breaching party
regarding the nature of the other party's alleged breach, the specific obligation hereunder to which the
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alleged material breach relates, the approximate date on which the alleged breach occurred and the
identity of any personnel of the other party that were involved. Failure to provide such detail shall render
said notice null and void for purposes of this Agreement.
Should the Employer cause this Agreement to be terminated other than in accordance with the
preceding paragraph, the Employer immediately shall become obligated to pay P&A as liquidated damages
an amount equal to seventy-five percent of the fees that would have been due had the Agreement
remained in effect for the period (i) commencing on the date next following the date on which the
Agreement prematurely was or will become terminated, and (ii) ending on the earliest date as of which the
Employer properly could have terminated the Agreement by giving the advance notice prescribed
hereunder on the date the Employer first notified P&A in writing of the Employer's intention to terminate the
Agreement. For purposes of calculating this liquidated damages amount, the fees due to P&A hereunder
for services it provided in the month preceding the month within which P&A first was notified of the
premature termination of the Agreement shall be the fees due for each month during the period described
in the preceding sentence.
7. Confidentiality. All books and records, including the data therein, pertaining to each party
which may come into the hands of the other are to be treated as confidential and private records, and the
other party shall not disclose information from such records unless it is required by law or authorized by the
initial party in writing prior to such disclosure. Both parties reserve the right to control the use of any of
their symbols, trademarks, computer programs and service marks currently existing or hereafter
established. Both parties agree that they will not use the computer programs work, symbols, trademarks,
service marks, or other devices of the other in advertising, promotional material, or otherwise and will not
advertise or display such devices without the prior written consent of the other party. In addition, both
parties further agree that any such work, symbols, trademarks, service marks, or other devices furnished
by one party to the other shall remain the property of the initial party and shall be returned by the other
party upon demand of the initial party upon termination of this Agreement.
The medical records and related information of and pertaining to Participants and their dependents,
which P&A may be given or obtain as a result of performing services underthis Agreement, are at all times
proprietary to the Employer and confidential and shall not be disclosed or disseminated without the written
consent of the Employer or as otherwise contemplated in accordance with P&A's responsibilities underthis
Agreement. In addition, all documents, records, reports, and data (including, but not limited to, data
recorded in P&A's data processing systems) related to the receipt, processing and payment of Plan claims
are at all items proprietary to the Employer and confidential and shall not be disclosed or disseminated
without written consent of the Employer or as otherwise contemplated in accordance with P&A's
responsibilities under this Agreement. P&A may possess and use any of the foregoing information for
purpose of performing its obligations under this Agreement during the term of the Agreement and any post-
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termination period during which it may have obligations related to the Agreement. P&A shall exercise the
same degree of care in protecting the confidential nature of such Information as it exercises to prevent the
disclosure of its own confidential information, including, without limitation, taking steps that a prudent party
would take to safeguard the confidentiality of such Information and to prevent unauthorized disclosure of
the Information by P&A's employees, contractors or agents.
B. HIPAA Compliance. With respect to any personal medical information that it obtains
pursuant to this Agreement ("Participant Information"), P&A shall act in conformance with the Health
Insurance Portability and Accountability Act of 1996 and all regulations issued from time to time pursuant
thereto (collectively "HIPAA"). The obligations under HIPAA include, but are not limited to the following:
a. P&A shall not use or further disclose Participant Information other than as permitted or
required by the Agreement.
b. P&A shall not use or further disclose Participant Information in a way that would
violate the privacy regulations set forth in HIPAA.
C. P&A shall implement appropriate safeguards to prevent use or disclosure of
Participant Information other than as provided for pursuant to the Agreement.
d. P&A shall ensure that any agents to whom it provides protected Participant
Information will abide by the requirements of HIPAA with respect to disclosure of such
information.
e. P&A shall report to the Employer any uses or disclosures of Participant Information
not provided for pursuant to the Agreement of which P&A becomes aware.
f. P&A shall make available protected Participant Information in accordance with the
provisions of HIPAA relating to an individual's right to receive an accounting of uses and
disclosures of their health information.
g. P&A shall make its internal practices, books and records relating to the use and
disclosure of protected Participant Information received from the Employer or Participants
available to the Secretary of Health and Human Services for purposes of determining
compliance with the HIPAA regulations.
h. P&A shall return to the Employer all protected Participant health information at the
termination or expiration of the Agreement.
i. P&A shall incorporate any amendments or corrections to protected Participant health
information when the Employer or Participants notify P&A of such changes.
Individuals from whom "protected health information" (i.e., individually identifiable health information
that is or has been electronically maintained or electronically transmitted, as well as such information
transmitted or maintained in any other form or medium) is obtained by P&A pursuant to the Agreement
shall be intended third-party beneficiaries of the Agreement.
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9. Binding Effect. This Agreement shall inure to the benefit of and be binding upon the parties,
their legal representatives, contractors, agents, successors and assigns.
10. Integration. By their making of this Agreement, the parties hereto hereby acknowledge that
this Agreement supersedes any previous understandings between them with respect to all matters
contained herein and contains the entire understanding and agreement between them with respect to all
matters contained herein and cannot be amended, modified or supplemented except by a subsequent
written agreement entered into by both parties.
11. Subcontracting. P&A shall not subcontract any portion of this Agreement without the prior
written approval of the Employer.
12. Non-Exclusive Arrangement. Nothing contained herein shall be construed to prevent either
party from independently operating or participating in any other agreement concerning plan administration
services independent and unrelated to the services and obligations of the parties pursuant to this
Agreement.
13. Waiver of Breach. The waiver by either party of a breach or violation of any provision of this
Agreement shall not operate as or be construed as a waiver of a breach or violation of any other provision
of this Agreement or of any subsequent breach or violation thereof.
14. Severability. In the event any provision of this Agreement is rendered invalid or
unenforceable, the remaining provisions of this Agreement shall remain in full force and effect.
15. Governing Law. This Agreement is made in and shall be construed pursuant to the laws of
the State of New York, to the extent that the law of the State of New York is not superseded by federal law.
16. Enforcement. If any action at law or in equity (including arbitration) is necessary to enforce
or interpret any one or more of the terms of this Agreement, the prevailing party shall be entitled to
reasonable attorneys' fees, costs and necessary disbursements in addition to any other relief to which such
party may be entitled.
17. Notice. Any notice hereunder by either party shall be deemed to have been duly given three
(3) business days after mailing, and shall be given by fax and by being mailed in any post office or post
office box maintained by the United States Postal Service, enclosed in a postage paid envelope, registered
or certified mail, return receipt requested, addressed to the party to whom orwhich notice is intended to be
given at such party's address as stated above or to such other address as each party shall specify in
writing to the other.
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IN WITNESS WHEREOF, the parties have executed this Agreement as of the Effective Date.
CITY OF ROSEMEAD
BY: a_
P&A ADMINISTRATIVE SERVICES, INC.
c
BY:
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The Employer will pay to P & A:
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SCHEDULE A-FEES
1. INSTALLATION FEE. A fee of $500.00 at the time this Agreement is signed for all of those services relating to the
installation of the Plan, including preparation of Plan documents, data entry and processing of enrollment forms.
2. MONTHLY ADMINISTRATION FEES. Administration fees for each calendar month or portion of a calendar month
during the duration of this Agreement. A Minimum Annual Fee amount of $600.00 per Plan Year shall be due and payable by the
first day of each Plan Year commencing during the term of this Agreement. Once paid, this Minimum Annual Fee shall be
credited against the Employer's monthly fees as hereinafter described. The fees for a given month shall equal $4.00 for each
individual who was eligible for the reimbursement of expenses under any of the Plan's Flexible Spending Account options as of
the first day of the preceding month on account of a salary reduction agreement in effect on that date or otherwise, including (i)
any individual who, on that date, would have been eligible for reimbursement under any Flexible Spending Account option but for
the fact that he or she previously was reimbursed for the full amount of his or her benefit election for the Plan Year; (ii) any
individual whose eligibility to make additional salary reduction contributions to the Plan had terminated priorto that date but who,
on that date, remained eligible to submit post-termination run-out claims under the terms of the Plan; and (iii) any individual who
had elected COBRA coverage prior to that date and whose COBRA coverage remained in effect on that date, provided, however,
the fees for the first month of the Agreement shall be based on the number of persons enrolling during the Plan's initial
enrollment. P&A shall not invoice for any monthly fees otherwise due under this Agreement until the aggregate fees otherwise
due for a Plan Year exceed the Minimum Annual Fee paid for the Plan Year. Monthly fees hereunder shall be due and payable
within thirty days of receipt by the Employer of P&A's invoice with respect to same.
3. ANNUAL REPORT PREPARATION. $300.00 for each annual return (Form 5500 Series or equivalent) that is prepared
by P&A pursuant to Section 1 of this Agreement.
4. REQUESTED ADDITIONAL SERVICES AND MATERIALS. For such services and materials requested by the
Employer that are in addition to the services and materials described in Section 1 of this Agreement, including but not limited to
the customization of notices or other documentation to accommodate the individual circumstances of the Employer, additional
compensation based on the time expended in providing the requested services (applying an hourly rate varying between $75.00
and $195.00, depending on the position of the P&A employee providing those services) and the out-of pocket cost to P&A of
providing the requested materials.
5. MAILING EXPENSES. The cost of any mailing required under the Agreement the rate for which exceeds the first class
rate charged by the U.S. Post Office.
6. RECOUPMENT OF PENALTIES AND FEES. The amount of any penalty or like fee that is imposed on P&A as a result
of any action or inaction by the Employer or by the employees or other agents of the Employer with respect to the administration
of the Plan, including but not limited to returned check charges or ACH rejection fees. P&A shall be entitled to immediately
recoup any such penalty or fee from the Employer after giving the Employer written notice that P&A has paid such amount.
Note: Should the Employer elect to change the terms of the Plan or should changes in applicable laws necessitate changes to
the Plan documents, P & A will provide the Employer with a quote as to the cost of having P & A make the document changes.
CITY OF ROSEMEAD FLEXIBLE BENEFITS PLAN
PLAN SUMMARY
CITY OF ROSEMEAD FLEXIBLE BENEFITS PLAN
PLAN SUMMARY
The City of Rosemead maintains the City of Rosemead Flexible Benefits Plan (the "Plan ") for the benefit of
its eligible employees. The terms of the Plan are contained in a lengthy, legally worded document. This Plan
Summary is intended to acquaint you with the provisions of the Plan that apply to you by summarizing them in
language that is easier to understand.
The format for the Summary is a series of questions and answers that cover such key areas as: when you
become eligible; what benefits you may receive; and how your benefits are paid for. The Summary is merely
intended to describe the Plan in a condensed fashion, not to change it or to add to it. Should the Plan and Summary
be inconsistent in any way, the provisions of the Plan will overrule the Summary.
IDENTIFYING INFORMATION
1. Plan Name:
City of Rosemead Flexible Benefits Plan.
2. Employer Name and Address:
City of Rosemead
8838 East Valley Boulevard
Rosemead, CA 91770
3. Plan Administrator:
City of Rosemead
8838 East Valley Boulevard
Rosemead, CA 91770
626 569 -2145
4. Claims Administrator:
Your Employer has retained P &A Administrative Services, Inc. to assist in Plan Administration. All claim
forms should be submitted to:
P &A Administrative Services, Inc.
17 Court Street - Suite 500
Buffalo, New York 14202
Claims may be faxed to 716 855 -7105.
5. Plan Year -End: December 31
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THE FLEXIBLE BENEFITS PLAN
OVERVIEW
The Plan gives you the opportunity to avoid taxes on money that you spend on certain expenses, many of
them commonly occurring. The expenses that you may pay under the Plan are: your share of the cost of insurance
coverage you receive through the Employer; health care expenses that are not covered by insurance; expenses for
the care of your children or other dependents so that you are able to work; the cost of health or disability coverage
other than the cost of coverage under the Employer's insurance plans; and the cost of adopting a child. So that you
and other eligible employees can enjoy the tax savings the Plan is intended to provide, the Plan is operated
according to certain rules contained in the federal tax laws and regulations.
If you want to take advantage of the tax savings potential that the Plan offers, you will need to figure out the
types and amounts of covered expenses that you will have each year. Then, you will need to complete an election
form based on your determination. When you complete an election form, you will instruct the Employer to withhold
enough money from your pay to cover your anticipated expenses. The monies withheld will be set aside to pay
these expenses in the manner described below.
Unless you file an election with the Plan Administrator to the contrary (on a form available from the
Administrator), you will be treated as having elected to have your compensation reduced to the extent
necessary to pay through the Plan your share of the cost of the employer- sponsored insurance coverage you
are receiving.
The following is a list of some of the more commonly asked questions regarding your Plan.
PLAN YEAR
WHAT IS THE EFFECTIVE DATE OF THE PLAN?
The Plan started on August 1, 2008. It was updated as of January 1, 2009 to increase the maximum amount
of benefits that may be elected under the Plan's Medical Expense Reimbursement Account option.
WHAT IS THE PLAN YEAR?
"Plan Year" refers to the accounting period that is used for purposes of maintaining the Plan's records, which
is the twelve -month period beginning on January 1 and ending on the following December 31.
ELIGIBILITYAND PARTICIPATION
WHEN AM I ELIGIBLE FOR PLAN PARTICIPATION?
To be eligible for the Plan, you must be regularly scheduled to work at least 32 hours a week for the
Employer. If you are an eligible type of employee, you qualify to elect benefits under the Plan by becoming a
"Participant' ' on the first day of the month after you start working for the Employer.
HOW DO I PARTICIPATE?
When you become a Participant in the Flexible Benefits Plan, you will receive a form that you can use to
elect the benefits that you desire.
PLAN CONTRIBUTIONS
HOW ARE BENEFITS PAID FOR?
Any benefits that you elect are paid for with money that is withheld from your pay. These pay reductions do
not count as income for income tax or Social Security tax purposes. This means that the Plan allows you to use tax -
free dollars to pay for expenses that would otherwise have to be paid with money that you've already paid taxes on.
WHEN ARE CONTRIBUTIONS MADE TO THE PLAN?
Unless the Employer tells you otherwise, the cost of your benefits will be withheld each pay period on a pro
rata basis over the course of the Plan Year.
WILL MY SOCIAL SECURITY BENEFITS BE AFFECTED BY MY CONTRIBUTIONS TO THE PLAN?
Your Social Security benefits may be slightly reduced because, when your pay is reduced to cover your
benefits under the Plan, the amount of contributions that are made to the federal Social Security system to provide
you Social Security benefits also are reduced.
PLAN BENEFITS
WHAT BENEFITS MAY I CHOOSE UNDER THIS PLAN?
The benefits under the Plan consist of the various categories of expenses that you may elect to pay for on a
non - taxable basis, using your salary withholdings. If you want to pay for your share of the cost of insurance
coverage you receive from the Employer through the Plan, elect the Insurance Premium Pre -tax Payment Option
described below; if you want to pay for your uninsured health care expenses through the Plan, elect the Medical
Expense Reimbursement Plan option described below; if you want to pay for day care costs through the Plan, elect
the Dependent Care Assistance Program option described below; if you want to pay for the cost of medical or
disability coverage other than coverage under the Employer's insurance plans through the Plan, elect the Individual
Premium Reimbursement Plan described below; and, if you want to pay for adoption expenses through the Plan,
elect the Adoption Assistance Program described below.
If you elect benefits under the Medical Expense Reimbursement Plan, the Dependent Care Assistance
Program, the Individual Premium Reimbursement Plan or the Adoption Assistance Plan (together called the
"Flexible Spending Account Plans "), your contributions to pay for your expenses covered by that option will be
credited to an account in your name. This "Account" is for record - keeping purposes only and does not involve any
actual segregation of funds.
WHAT BENEFITS ARE AVAILABLE UNDER THE INSURANCE PREMIUM PRE -TAX PAYMENT
OPTION?
You may elect under the Insurance Premium Pre -tax Payment Option to have premiums for coverage under
the medical and dental insurance plans of the Employer paid from your salary reductions. The portion of the
premiums for that coverage that you elect to pay through salary reduction is deducted from your gross pay, thereby
reducing your taxable income.
Unless you file an election with the Plan Administrator before the beginning of a Plan Year on a form
that is provided to you, you automatically will be enrolled in the Insurance Premium Pre -tax Payment Option
portion of the Plan. This means that the amounts that are taken from your pay during that Plan Year to
cover your share of the cost of your insurance coverage will not be subject to taxes.
WHAT BENEFITS ARE AVAILABLE UNDER THE MEDICAL EXPENSE REIMBURSEMENT PLAN?
If you elect the Medical Expense Reimbursement Plan option, you will be reimbursed for the cost of medical
care for yourself, your Spouse or Dependents that is not covered under any other plan or policy. "Medical care" for
this purpose means care for the diagnosis, cure, treatment or prevention of disease. Expenses for medical care
include expenses for routine and extraordinary medical and dental examinations, vision exams and eye -wear,
surgery, psychiatric care, hospitalization, prescription and over - the - counter drugs and medicines, therapeutic,
orthopedic and prosthetic aids and devices, and transportation primarily for essential medical care.
You may elect to pay up to $5,000 per Plan Year in covered expenses through this Medical Expense
Reimbursement Plan option. The lowest amount that you may elect is $100.
WHAT BENEFITS ARE AVAILABLE UNDER THE DEPENDENT CARE ASSISTANCE PROGRAM?
If you select the Dependent Care Assistance Program option, you will be reimbursed for your qualified
Dependent care expenses. Under the Plan, you will be reimbursed only for Dependent care expenses that meet all
the following conditions:
1. The Expenses were incurred for services rendered after the date you became a Participant.
2. Each individual for whom you incur the expense:
(a) is either (i) a Dependent under age 13 whom you are entitled to claim as a Dependent on
your federal income tax return or (ii) a Spouse or other Dependent for tax purposes who is physically
or mentally incapable of caring for himself or herself, and
(b) lived with you for most of the calendar year.
3. The expenses are incurred for the care of a Dependent described above, or for related household
services, and are incurred to enable you to be gainfully employed.
4. If the expenses are incurred for services provided by a Dependent care center (i.e., a facility that
provides care for more than 6 individuals not residing at the facility), the center complies with all
applicable state and local laws and regulations.
5. The expenses are not paid or payable to a child of yours who is under age 19 at the end of the year in
which the expenses are incurred.
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6. The expenses are not paid or payable to an individual for whom you or your Spouse is entitled to a
personal tax exemption as a Dependent.
WHAT EFFECT WILL PARTICIPATION IN THE DEPENDENT CARE ASSISTANCE PROGRAM
HAVE ON MY RIGHT TO THE DEPENDENT CARE CREDIT ON MY TAX RETURN?
The amount of your expenses that are eligible for the federal dependent care credit must be reduced, dollar
for dollar, by the amount of expenses that you pay through the Dependent Care Assistance Program option under
this Plan. Before choosing that benefit option, you should determine if you would save more money by choosing
instead to use the full, unreduced tax credit amount.
ARE THERE ANY LIMITS ON THE AMOUNT THAT MAY BE EXCLUDED FROM MY PAY FOR
DEPENDENT CARE ASSISTANCE?
Yes. In general, the amount of expenses that you may pay through the Dependent Care Assistance option is
limited to $5,000 per calendar year ($2,500 if you are single or are married but you and your Spouse file separate
tax returns). However, the amount of expenses can never exceed your earnings for the year or the earnings of your
Spouse, whichever is lower. Special rules apply in determining the earnings of a Spouse who is a student or
incapable of caring for himself or herself.
WHAT BENEFITS ARE AVAILABLE UNDER THE INDIVIDUAL PREMIUM REIMBURSEMENT
PLAN?
If you elect benefits under the Individual Premium Reimbursement Plan, you will be reimbursed for the
costs of health or disability coverage for you, your Spouse or your Dependent other than your coverage under your
Employer's insurance plans. The coverage may be provided through insurance contracts owned individually by you
or a family member or through an insured or self - insured benefit plan of a family member's employer. For example,
you could use this benefit option if you purchase and pay for a health insurance policy for a child who is no longer
eligible for coverage under your Employer's health insurance plan but is still a Dependent of yours for tax purposes.
You may elect to pay an amount up to $10,000 per Plan Year in covered expenses through this Individual
Premium Reimbursement Plan option.
WHAT BENEFITS ARE AVAILABLE UNDER THE ADOPTION ASSISTANCE PROGRAM?
The Adoption Assistance Program option provides reimbursement to you for the reasonable and necessary
expenses that you incur in the process of legally adopting an eligible child, including adoption fees, court costs and
attorney fees. Expenses that are not eligible for reimbursement include expenses incurred in violation of state or
federal law, expenses incurred in carrying out a surrogate parenting arrangement, and expenses in connection with
the adoption of a step - child. An "eligible child" is a child who has not yet reached age 18 or is physically or
mentally incapable of caring for himself or herself. The maximum amount of reimbursement that you may receive
in connection with the adoption of any one child is $12,150 (this $12,150 will be adjusted for inflation in years after
2009). This is a total rather than an annual amount, even if the expenses occur over a period of years.
WHAT ARE THE TAX BENEFITS OF REIMBURSEMENT UNDER THE ADOPTION EXPENSE
REIMBURSEMENT PLAN?
If your adjusted gross income (together with that of your Spouse if you are married and filing a joint tax
return) is $182,180 (this $182,180 will be adjusted for inflation in years after 2009) or less, you can exclude from
your gross income in computing your income tax liability the entire amount of adoption expense reimbursement you
receive under this Plan (subject to the $12,150 cap). However, if your adjusted gross income exceeds $182,180, the
portion of adoption expense reimbursement that may be excluded is reduced from $12,150 based on the following
formula:
$12,150 x [(adjusted gross income - $182,180) / $40,000]
If, for example, your adjusted gross income were $192,180, and you incurred $12,150 or more in expenses to
adopt a child, your maximum exclusion would be $3,037.50, calculated as follows:
$12,150 x ($10,000 / $40,000), or $12,150 x.25 = $3,037.50
$12,150 total expenses - $3,037.50 pre -tax reduction = $9,112.50 of expenses that may be reimbursed pre -tax
Generally, any amounts paid to reimburse you for eligible adoption expenses would be excluded from your
income for the year of the reimbursement. However, should you adopt a child who is not a citizen or resident of the
United States, all amounts reimbursed to you would be excludable from your income only in the year in which the
adoption becomes final.
While the amount of your salary that is withheld to pay adoption expenses is excluded from your income in
determining your income tax liability, FICA (Social Security) and FUTA (Unemployment) taxes still apply.
WHAT AFFECT WILL PARTICIPATION IN THE ADOPTION ASSISTANCE PROGRAM HAVE ON
MY RIGHT TO THE ADOPTION EXPENSES CREDIT ON MY TAX RETURN?
The federal tax laws also provides a tax credit (reducing federal tax liability) for adoption expenses that are
not reimbursed by an employer or paid under a state or federal grant program. The maximum amount of the credit is
$12,150 per adoption (subject to inflation adjustments after 2009). You may claim the credit and receive
nontaxable reimbursements from an Adoption Assistance Account in connection with the same adoption, but you
may not take a credit and receive reimbursement for the same expense. Because any election for benefits under the
Adoption Assistance Program should be coordinated with the use of the credit, the Administrator strongly
recommends that you seek advice from your own tax adviser before electing benefits under the Adoption Assistance
Program.
WHO IS CONSIDERED A SPOUSE? A DEPENDENT?
Under the Plan, only the expenses of a Participant, a Participant's Spouse or a Participant's Dependent
qualify for pre -tax treatment. According to the rules that apply to the Plan, an individual is the "Spouse" of a
Participant only if the individual is of the opposite sex and is considered to be married to the Participant under the
laws of the state where the Participant and the other individual live.
Even though a partner of the same sex cannot qualify as a Spouse, he or she may still qualify as a
"Dependent ". To qualify as a Dependent, a same sex partner (or any other person who is not related to a Participant)
must:
receive over 50% of his or her financial support from the Participant for the calendar year;
have the same principal residence as the Participant for the entire calendar year; and
be a member of the Participant's household (which is not possible if their living together violates the
law of the state where they live).
A Participant's relative will be considered to be his or her Dependent if the Participant provided over half of
the relative's financial support for the calendar year. If the relative is a child, grandchild, brother, sister, niece or
nephew of the Participant who is under age 19 (age 24 in the case of a full -time student), it is not necessary for the
Participant to have provided over half of the relative's support if the relative lived with the Participant for more than
half of the calendar year and the relative did not provide more than one -half of his or her own support.
A special rule applies to the reimbursement under the Medical Reimbursement Expense Plan of the health
expenses of children of divorced parents. The child of divorced parents or legally separated parents is considered to
be a Dependent of both parents if both parents together provide more than 50% of the child's support and have
custody of the child for more than half the year.
FLEXIBLE SPENDING ACCOUNT CLAIMS
HOW DO I RECEIVE FLEXIBLE SPENDING ACCOUNT BENEFITS?
You obtain reimbursement for expenses allowed under the Flexible Spending Account Plans by submitting
reimbursement claim forms and documentation from the provider of the services you received (e.g., a receipted bill,
an unpaid bill, or a signed affidavit) stating the nature, date and amount of the expense. A claim for dependent care
benefits must include the name, address and taxpayer identification number of the dependent care service provider.
In the case of a babysitter, the taxpayer identification number is the babysitter's Social Security number. It is your
responsibility to maintain adequate records to verify these expenses. You must apply for reimbursement by
March 31st of the following Plan Year (See below for special rules that apply for submitting claims if you
become ineligible).
To insure timely reimbursement, please submit your claims directly to the Claims Administrator.
WHAT IS THE MAXIMUM AMOUNT I CAN RECEIVE?
If, for any Plan Year, you make an election under the Medical Expense Reimbursement Account option, the
amount that you elect will be immediately credited to a Medical Expense Reimbursement Account in your name.
Starting on the first day of that Plan Year, you will be entitled to be reimbursed for claims up to the entire elected
amount (reduced by the amount of Medical Expense claim payments you already received for that year) at any time
during the Plan Year, even if the total salary reduction contributions that you have made to your Medical Expense
Reimbursement Account are less that the total amount of claims that you have submitted.
For claims under the any of the other Flexible Spending Account options, the largest amount that you will be
entitled to be reimbursed for at any point will be the amount that is in your Flexible Spending Account at the time a
claim is filed.
WHAT HAPPENS IF MY CLAIM FOR BENEFITS IS DENIED?
When a Claim is Denied.
You will be notified in writing by the Claims Administrator if a claim that you submitted has been denied.
As a general rule, you will receive notification of a claim denial within 30 days of the date you submitted your
claim. However, the 30 -day period may be extended for an additional 15 days due to circumstances beyond the
Claims Administrator's control. This would be the case if, for example, you did not include enough information
about a particular claim for the Claims Administrator to either allow or deny the claim.
The Claims Administrator will provide you with written notice if it becomes necessary to extend the 30 -day
period with regard to any claim that you file. The written notice will tell you the reason for the extension and when
the Claims Administrator expects to make its decision. If the reason for the extension is that your claim was
incomplete, you will also be notified of what additional information the Claims Administrator needs to allow or
deny your claim, and you will be given 45 days after you receive the notice to provide the information during which
time the claims submission deadline will be suspended.
Any notification that you receive from the Claims Administrator denying a claim that you have submitted
will include:
the reason or reasons that your claim was denied;
2. the specific Plan provision on which the denial was based; and
3. a description of any additional material or information that you would need to have your claim
approved and an explanation of why that additional material or information is needed.
Appealing a Claim Denial.
If the Claims Administrator denies your claim or any part of your claim, you or an authorized representative
of yours may apply to the Claims Administrator's Benefits Manager for the Plan to review the denial. Your appeal
must be made in writing within 180 days after you received notification from the Claims Administrator that your
claim was denied. If you do not appeal on time, you will lose the right to appeal the denial and the right to sue in
court. Your written appeal should state the reasons that you feel your claim should not have been denied. It should
include any additional facts or documents that you believe to support your claim. You will have the opportunity to
ask additional questions and make written comments, and you may review, upon request and for no charge,
documents and other information relevant to your appeal.
Decision on Review.
The Claims Administrator's Benefits Manager will review and decide your appeal in a reasonable time not
later than 60 days after he or she receives your request for review. The Claims Administrator's Benefits Manager
may, in his or her discretion, hold a hearing of the denied claim. Any medical expert consulted in connection with
your appeal will be different from and not subordinate to any expert consulted in connection with the initial claim
denial. You will be informed of the identity of any medical expert consulted in connection with your appeal. If the
decision on review affirms the initial denial of your claim, you will be furnished with a notice of adverse benefit
determination on review that will include:
the specific reasons for the decision on review;
2. the specific Plan provision or provisions on which the decision is based;
a statement of your right to review, upon request and at no charge, relevant documents and other
information; and
4. if an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision
on review, then a description of the specific rule, guideline, protocol, or other similar criterion or a
statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy
of such rule, guideline, protocol, or other similar criterion will be provided to you free of charge
upon request.
WHAT HAPPENS TO MONEY LEFT IN MY FLEXIBLE SPENDING ACCOUNT?
Any amounts in a Flexible Spending Account at the end of the permissible reimbursement period for a Plan
Year will be forfeited and used by the Employer to offset administrative expenses and future costs. Because your
salary reduction contributions not used to reimburse you for expenses incurred in the Plan Year will be forfeited, it
is important that you carefully determine the proper amount of your compensation to allocate to each account.
MID -YEAR CIIANGES
WHAT HAPPENS IF I TAKE A LEAVE OF ABSENCE?
If you take a leave of absence from your employment with the Employer, your election of benefits under the
Plan will remain in effect if your compensation from the Employer will continue to be paid during that leave. If, on
the other hand, your leave is unpaid, you will have the opportunity, before the leave starts, to revoke your election
and, if desired, make a new election in accordance with the rules discussed below at the Section entitled, "May I
Change My Benefit Election ?"
If you take a leave of absence to which the Family Medical Leave Act of 1993 ( "FMLA ") applies, during the
period of such leave you will have the option of continuing your coverage under the Employer's medical insurance
plan and Medical Expense Reimbursement Plan on the same terms and conditions as though you were still an active
Employee (i.e., the Employer will continue to pay its share of the premium to the extent you elect to continue you
coverage). You may do so by either paying your share of the premium with after -tax dollars while on leave (or pre-
tax dollars to the extent you receive compensation during the leave), or by prepaying all or a portion of your share
of the premium for the anticipated duration of the leave on a pre -tax salary reduction out of your pre -leave
compensation by making a special election to that effect prior to the date such compensation normally would be
made available to you (provided, however, that pre -tax dollars may not be utilized to fund coverage during the next
year), or through other arrangements agreeable to the Administrator. Upon return from FMLA leave, you will be
permitted to reenter the Plan on the same basis on which you were participating prior to taking leave.
MAY I CHANGE MY BENEFIT ELECTION?
While you may change your election before the beginning of a new Plan Year, as a rule, you may not change
an election of benefits during the Plan Year. However, if you experience any of the following events, you may
revoke your election after the Plan Year has commenced and make a new election for the balance of the Plan Year:
Change in Status.
(a) A change in your legal status (e.g., marriage, death of your Spouse, divorce, legal separation
or annulment).
(b) A change in the number of your dependents due to events such as birth, adoption, placement
for adoption or death.
10
(c) A termination or commencement of employment by your Spouse or Dependent.
(d) A reduction or increase in the hours that you, your Spouse or your Dependent works,
including a switch between part-time and full -time status and commencement or return from an
unpaid leave of absence. In addition, if the eligibility conditions of this Plan or of any other
employee benefit plan that you, your Spouse or your Dependent depend on the employment status of
the individual and a change in that individual's employment status causes that individual either to
become eligible or cease to be eligible under the plan, that change constitutes a Change in Status.
(e) An event that causes your Dependent to satisfy or cease to satisfy the eligibility requirements
for a certain benefit (e.g., due to attainment of a certain age).
(f) A change in the place where you, your Spouse or your Dependent work or reside.
(g) For purposes of adoption assistance provided through the Plan, the commencement or
termination of an adoption proceeding.
If you wish to change your election based on a Change in Status, the change must be consistent with
that Change in Status, under the following rules:
Your change of election will be considered to be consistent with a Change in Status only if the
Change in Status results in you, your Spouse or your Dependent gaining or losing eligibility for a
benefit (or particular benefit option) under a plan of the Employer or under a plan of your Spouse's
or Dependent's employer, and the change of election corresponds with that gain or loss of coverage,
or, if the Change in Status affects Dependent care expenses described in Code Section 129 or Code
Section 137.
If the Change of Status is your divorce, annulment or legal separation, the death of your Spouse or
Dependent, or your Dependent ceasing to satisfy the eligibility requirements for coverage, your
election under the Plan to cancel accident or health coverage for any individual other than your
Spouse involved in the divorce, annulment or legal separation, your deceased Spouse or Dependent
or the Dependent that ceased to satisfy the eligibility requirements for coverage, as the case may be,
fails to correspond with that Change in Status. In addition, if you or your Spouse or Dependent gains
eligibility for coverage under this Plan, another cafeteria plan or any other plan providing benefits
that are nontaxable benefits under Code Section 125 as a result of a change in marital status or a
change in employment status described above, an election under this Plan to cease or decrease
coverage for that individual corresponds with that Change in Status only if coverage for that
individual becomes available or is increased under the plan from which eligibility for coverage has
been gained.
If you, your Spouse or your Dependent become eligible for COBRA continuation coverage, you may
elect to increase payments under this Plan to pay for that coverage.
2. Special Enrollment Rights. You may change your election for the balance of the Plan Year and file a
new election that corresponds with any special enrollment rights you may have under a group health
plan.
Certain Judgments and Orders. If a judgment, decree or order from a divorce, legal separation,
annulment or custody change requires that your child, or a foster child who is your Dependent, be
covered under the Employer's health plan or the health plan of your former Spouse's employer, you
11
may change your election to provide coverage for the child under the Employer's plan if the order
requires it or change your election to cancel coverage for the child under the Employer's plan if the
order requires your Spouse or former Spouse, or any other individual, to provide the coverage.
4. Entitlement to Medicare or Medicaid. If you, your Spouse or your Dependent becomes entitled to
coverage under Medicare or Medicaid, you may cancel that person's coverage under the Employer's
accident or health plan. In addition, if you, your Spouse or your Dependent loses eligibility for
Medicare or Medicaid coverage, you may make an election to commence or to increase that person's
coverage under the Employer's accident or health plan.
5. Change in Cost or Coverage. A change of cost or change of coverage with respect to non -cash
benefits that may be elected under this Plan may be the basis for a change of election based on the
following rules:
(a) These rules do not apply to benefits under the Medical Expense Reimbursement Plan.
(b) If the cost of any of your benefits increases or decreases during a period of coverage and, as a
result, you are required to increase or decrease your payments for those benefits, your salary
reductions contributions under this Plan will be adjusted accordingly, unless you make a change
to your election under (c) below.
(c) If the cost of any of your benefits significantly increases during a period of coverage, you
may elect either to increase your contributions to pay for the increased cost or to revoke your
election and to receive instead coverage under another benefit option of the plan providing the
benefits. If the cost of any benefit or benefit option significantly decreases during a period of
coverage for which you have not elected that benefit or benefit option, you may make a new
election of that type of benefit or benefit option. If you have an election in effect at that time for
that type of benefit (e.g., medical insurance coverage) but under a benefit option other than the
one the cost of which has significantly decreased, you may revoke that existing election and elect
the benefit option that has significantly decreased in cost.
(d) You may only change your election due to an increase in the cost of Dependent care
assistance benefits if your Dependent care provider is not your relative.
(e) If your coverage under any benefit plan is significantly reduced or stops, you may make a
new election going forward of any other coverage option available under that plan. Coverage
under an accident or health plan is considered to be reduced only if there is an overall reduction
in coverage provided under the plan so as to constitute reduced coverage to Participants
generally.
(f) You may make an election change that is on account of and corresponds with a change made
under a benefit plan of your Spouse, former Spouse or Dependent if that plan allows for election
changes based on a change in cost or coverage consistent with the foregoing rules and if that plan
permits participants to make an election for a period of coverage under the cafeteria or other plan
that is different than that under this Plan.
6. Changes in Coverage Attributable to Spouse's Employment. You may revoke a prior election and
make a new election where there has been a significant change in benefit plan coverage for you,
your Spouse or your Dependent related to your employment or the employment of your Spouse or
12
Dependent, if that change of election is determined by the Administrator to be consistent with the
change in benefit plan coverage.
Even if you are permitted to change your election under these rules, you may not change your election for
Flexible Spending Account benefits below the amount of such benefits already reimbursed for the Plan Year.
IMPORTANT NOTE. Remember, unless you experience one of the limited circumstances allowing for election
changes during the Plan Year, you will not be able to reduce or increase the amounts designated on your enrollment
form, nor will you be able to change amounts from one account to another. This is why you are encouraged to plan
carefully before you enroll in this Plan.
The Administrator must be notified within 30 days of any such event to make a change.
If you fail to submit a new election form for any new Plan Year, your election under the Insurance Premium
Payment Option will remain the same as for the prior Plan Year, but you will be considered not to have elected any
Flexible Spending Account benefits for the new Plan Year.
MAY MY ELECTION BE CHANGED WITHOUT MY CONSENT?
If the Plan Administrator determined before or during any Plan Year that the Plan may fail to satisfy any
nondiscrimination requirements imposed by the Internal Revenue Code, the Administrator may take action to assure
compliance with any requirements or limitations. This action may include a modification of any elections with or
without the consent of the Employee.
WHAT HAPPENS IF I STOP WORKING FOR THE EMPLOYER OR I BECOME INELIGIBLE FOR
THE PLAN FOR ANOTHER REASON?
You will lose eligibility for the Plan if you stop being regularly scheduled to work at least 32 hours a week
for the Employer. When you lose eligibility for the Plan:
1. Your contributions for benefits will cease.
2. You will be permitted to submit claims for reimbursement of medical expenses that you had in the
current Plan Year before you lost eligibility.
3. You will be permitted to submit claims for reimbursement of other types of expenses that you have
any time during the current Plan Year, even after you lost eligibility.
4. Your remaining claims must be submitted by March 31 st of the following Plan Year.
CONTINUATION COVERAGE
ARE THERE ANY CIRCUMSTANCES UNDER WHICH I MAY CONTINUE TO RECEIVE
COVERAGE AFTER MY EMPLOYMENT TERMINATES?
This section contains important information about your right to COBRA continuation coverage, which is a
temporary extension of coverage under a group health plan. The right to COBRA coverage was created by a federal
law, the Consolidated Omnibus Budget Reconciliation Act of 1985 ( "COBRA "). COBRA coverage can become
13
available to you and to other members of your family who are covered under a plan when you would otherwise lose
coverage.
The COBRA law generally applies to all "group health plans' maintained by an employer. However, the
purpose of this section of the Summary is limited to explaining the COBRA rules that could allow you to
continue your coverage in the Medical Expense Reimbursement Plan portion of the Flexible Benefits Plan if
you have a Medical Expense Reimbursement Account at the time you lose eligibility for the Flexible Benefits
Plan (the "Plan ").
COBRA Coverage
COBRA coverage is a continuation of plan coverage when coverage would otherwise end because of a life
event known as a "qualifying event." After a qualifying event, COBRA coverage must be offered to each person
who is a "qualified beneficiary." You and your Spouse and Dependents, if any, all could become qualified
beneficiaries if coverage under the Plan is lost because of a qualifying event.
If you elect COBRA coverage, you will receive the same coverage as active employees who have coverage
under the Plan. You will also have the same rights that active employees have, including open enrollment and
special enrollment rights.
As an employee, you will have a qualifying event if:
1. Your hours of employment are reduced, or
2. Your employment ends for any reason other than your gross misconduct.
Your Spouse will have a qualifying event if:
1. You die;
2. Your hours of employment are reduced;
3. Your employment ends for any reason other than gross misconduct;
4. You become enrolled in Medicare (Part A, Part B or both); or
5. The two of you become divorced or legally separated.
Your Dependent will have a qualifying event if:
You die;
2. Your hours of employment are reduced;
Your employment ends for any reason other than gross misconduct;
4. You become enrolled in Medicare (Part A, Part B or both);
5. You and your Spouse become divorced or legally separated; or
6. He or she stops being eligible for coverage under the Plan as a "Dependent ".
14
Special Eligibility Rules Apply
Under special rules that apply to a "health flexible spending arrangement' like the Medical Expense
Reimbursement Plan, the Plan may only be required to offer COBRA coverage if you have a positive Account
balance in your Medical Expense Reimbursement Account at the time the qualifying event occurs. You will have a
positive Medical Expense Reimbursement Account balance at the time a Qualifying Event occurs if your total
contributions to the Account for the Plan Year to date are more than your total reimbursements from the Account
(including for this purpose, any claims that have been submitted but not paid) for the Plan Year.
Notifying the Plan Administrator of Qualifying Events
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan
Administrator has been timely notified that a qualifying event has occurred. When the qualifying event is the end of
employment or reduction of hours of employment, death of the employee or enrollment of the employee in
Medicare (Part A, Part B or both), the Employer must notify the Plan Administrator of the qualifying event within
30 days after the event occurs.
When the qualifying event is divorce, legal separation or your child's loss of eligibility for coverage as a
Dependent, you must notify the Plan Administrator in writing within 60 days after the qualifying event occurs.
Failure to do so will result in a loss of eligibility for COBRA continuation coverage.
How to Provide Notice
Any notice that you provide regarding COBRA continuation coverage must be in writing. Notice of a
qualifying event must include the name of the Plan, the name and address of the employee covered by the Plan, and
the name and address of any qualified beneficiary. Your notice must also specify the qualifying event and the date it
happened. If the qualifying event is divorce or legal separation, your notice must include a copy of the decree of
divorce or legal separation.
The Plan's form titled, "Notice of Qualifying Event', should be used to notify the Plan Administrator of a
qualifying event. A copy of this form can be obtained from the Plan Administrator.
You must mail your notice to the Plan Administrator unless you are otherwise instructed by the Plan
Administrator. If mailed, your notice must be postmarked no later than the last day of the 60 -day notice period.
See the information below regarding how the occurrence of a second qualifying event may affect the length
of COBRA continuation coverage that is available. Any notice that you provide of a second qualifying event must
include the same type of information that was included in your notice of the first qualifying event. The Plan's form
titled, "Notice of Second Qualifying Event ", should be used to notify the Plan Administrator of a second qualifying
event. A copy of this form can be obtained from the Plan Administrator. Your notice must be mailed within 60
days after the second qualifying event occurs.
See the information below regarding how a determination by the Social Security Administration that a
qualified beneficiary is disabled may affect the length of COBRA continuation coverage that is available. Any
notice of disability that you provide must include the name of the disabled qualified beneficiary, the date when the
qualified beneficiary became disabled and the date the Social Security Administration made its determination that
he or she is disabled. Your notice of disability must include a copy of the Social Security Administration's
determination.
15
The Plan's form titled, "Notice of Disability Determination ", should be used to notify the Plan Administrator
of a disability determination. A copy of this form can be obtained from the Plan Administrator.
Your notice must be mailed within 60 days after the Social Security Administration makes its determination and
before the end of the first 18 months of COBRA continuation coverage.
Electing COBRA Coverage
Once the Plan Administrator receives timely notice that a qualifying event has occurred, COBRA coverage
will be offered to each of the qualified beneficiaries. COBRA coverage will begin on the date that Plan coverage
would otherwise have been lost.
Each qualified beneficiary has an independent right to elect COBRA coverage. For example, you and your
Spouse may elect coverage separately. Also, you or your Spouse may elect coverage for your minor children.
A qualified beneficiary must elect coverage in writing within 60 days after it is offered, using the Plan's
election form and following the procedures specified on the election form. Your election form must be provided to
the Plan Administrator at the address indicated on the form. If you mail your form, it must be postmarked no later
than the last day of the 60 -day election period.
Even if you first reject COBRA coverage, you may change you mind and elect the coverage before the end
of the 60 -day election period.
Length of COBRA Coverage
When the qualifying event is your death, your enrollment in Medicare (Part A, Part B or both), your divorce
or legal separation or your Dependent losing eligibility as a Dependent, COBRA coverage lasts for up to 36 months.
When the qualifying event is the end of your employment or a reduction in your work hours and you became
entitled to Medicare benefits less than 18 months before that qualifying event, COBRA coverage for other family
members lasts until 36 months after the date of Medicare entitlement. Otherwise, when the qualifying event is the
end of your employment or reduction in your work hours, COBRA coverage generally lasts for up to 18 months.
There are three ways in which this 18 -month period of COBRA coverage can be extended.
Second qualifying event extension of 18 -month period of COBRA coverage
An 18 -month extension of coverage will be available to other family members if a second qualifying event
occurs during the first 18 months of their continuation coverage. The maximum amount of total COBRA coverage
available when a second qualifying event occurs is 36 months. Such second qualifying events include your death,
your divorce, your enrollment in Medicare or a child losing status as a Dependent.
If a second qualifying event occurs, you must notify the Plan Administrator in writing within 60 days to
obtain the extension.
Medicare extension for Spouse and Dependents
If your employment ends or your work hours are reduced within 18 months after you become entitled to
Medicare, the maximum coverage period for your Spouse and Dependents will end three years from the date you
enrolled in Medicare.
Disability extension of 18 -month period of COBRA coverage
16
An 11 -month extension of coverage may be available if you or another family member receiving COBRA is
disabled. For the extension to be available, the Social Security Administration ( "SSA ") must determine that the
family member was disabled during the first 60 days of COBRA coverage, and you must notify the Plan
Administrator of that fact in writing within 60 days after the SSA's determination and before the end of the first 18
months of continuation coverage. If the disability extension is available, it will apply to the COBRA coverage of all
family members, not just the disabled family member.
You must notify the Plan Administrator within 30 days if the SSA determines that the family member has
stopped being disabled at any time before the extension coverage period ends. COBRA coverage for all qualified
beneficiaries will terminate when this occurs. The plan reserves the right to retroactively cancel COBRA coverage
and to require reimbursement of all benefits paid after the first day of the month that is more than 30 days after the
SSA's determination that the qualified beneficiary is no longer disabled.
Special Rules May Shorten Your COBRA Continuation Coverage
Under special rules that apply to a "health flexible spending arrangement" like the Medical Expense
Reimbursement Plan, the Plan may only be required to offer COBRA coverage to you or your family members until
the end of the Plan Year in which you lose coverage under the Flexible Benefit Plan's normal eligibility provisions.
Termination of COBRA Coverage before the End of the Maximum Coverage Period
Your COBRA coverage may be terminated before the end of the maximum period if (1) you fail to make any
premium on time; (2) you become covered under another group health plan; (3) you enroll in Medicare; or (4) the
Employer ceases to provide any coverage under the Plan.
You must notify the Plan Administrator in writing within 30 days, if, after electing COBRA coverage, you or
another family member becomes covered under another group health plan or enrolls in Medicare Part A or B. The
Plan reserves the right to retroactively cancel COBRA coverage and to require reimbursement of all benefits paid
after the date of commencement of other group health plan coverage or Medicare entitlement.
Cost of COBRA coverage
The amount that you may be required to pay may not exceed 102% of the cost to the Plan of providing your
coverage (150% during any disability extension).
Payment for COBRA coverage -First payment
If you elect COBRA coverage, you do not have to send any payment with your election form. Your first
payment will be due within 45 days after the date of your election (This is the date your election form is post-
marked, if mailed). If you do not make your first payment for COBRA coverage within 45 days, you will lose all of
your rights to COBRA coverage.
Your first payment must cover the cost of COBRA coverage from the time your coverage under the Plan
would have otherwise terminated through the month before you make your first payment. You are responsible for
making sure that the amount of your first payment is enough to cover this entire period. You may contact the Plan
Administrator to confirm the correct amount of your first payment.
Payment for COBRA coverage- Periodic payments
1 7
After you make your first payment for COBRA coverage, you will be required to pay for each subsequent
month of coverage. These payments are due on the first day of each month of coverage. If you make a payment on
or before its due date, your coverage under the Plan will continue for that coverage period without any break.
The plan will notify you of the payments due for these coverage periods. A notice is only a reminder to you to pay.
It is not a bill. You must make your payment by the due date or within the grace period (discussed below) whether
or not you receive a notice.
Grace periods for periodic payments
Although monthly payments are due on the dates shown above, you will be given a grace period of 30 days
to make each payment. Your COBRA coverage will be provided for each coverage period so long as payment for
that coverage period is made before the end of the grace period for that payment. However, if you make a monthly
payment later than its due date but during its grace period, your coverage under the Plan will be suspended as of the
due date and then retroactively reinstated (going back to the due date) when the payment is made. This means that
any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted
once your coverage is reinstated.
If You Have Questions
If you have questions about your COBRA coverage, you should contact the Plan Administrator, or you may
contact the nearest Regional or Employer Office of the U.S. Department of Labor's Employee Benefits Security
Administration (EBSA). Addresses and phone numbers of Regional and Employer EBSA Offices are available
through EBSA's website at www.dol.gov /ebsa.
Keep Your Plan Informed of Address Changes
To protect your rights, you should notify the Plan Administrator if you change your address. You should
also keep a copy, for your records, of any notices you send to the Plan Administrator.
A federal law known as " USERRA" may require that Participants who cease to be eligible to receive health
care coverage because of duty in the uniformed services be given the right to buy continued health coverage on an
after -tax basis for up to twenty -four months. USERRA also requires that for Participants who are expected to
perform service in the uniformed services for less than 31 days, the Employer may not require the Participant to pay
more than his or her share, if any, of the premium. With respect to non - health plans, USERRA requires that
Participants be given the right to continue participation in the plan on the same basis as any Participant on a non-
military leave of absence. To the extent required by applicable federal laws, the Administrator will implement and
administer the procedures designed to comply with federal laws requiring the provision of continued coverage and
plan participation and will give you notice of your rights under these laws.
MISCELLANEOUS
WHAT HAPPENS IF MY EXPENSES ARE ELIGIBLE FOR REIMBURSEMENT UNDER A HEALTH
REIMBURSEMENT ARRANGEMENT ( "HRA ")?
m
If you have a health care expense that is considered an eligible expense for purposes of an HRA or a similar
supplemental medical reimbursement plan as well as this plan, the expense must be reimbursed by the other plan to
the extent that you have not exceeded your benefit limit under the other plan.
CAN MY EMPLOYER TERMINATE OR CHANGE THE PLAN?
The Employer has the right at any time to amend in whole or in part any or all of the provisions of the Plan.
However, no amendment may be passed which authorizes or permits any part of your account to be used or diverted
for a purpose other than providing benefits to you and your beneficiaries.
The Employer also has the right at any time to terminate the Plan.
WHO PAYS THE COSTS OF THE PLAN?
The cost of administering the Plan is paid by the Employer.
IS MY MEDICAL INFORMATION CONFIDENTIAL?
The Claims Administrator for the Plan may come into possession of certain information about you and your
family members that is considered "protected" under the HIPAA law. The Claims Administrator will treat this
information as confidential and will disclose this type of information only for the specific purposes of your health
care treatment, paying for your health care and for "health care operations" as that term is defined under HIPAA.
The Claims Administrator will disclose your protected health information to the Employer only after the
Employer certifies that the Plan documents have been amended to provide that the Employer will:
1. Not use or disclose protected health information other than as permitted or required by the Plan
document or as required by law;
2. Ensure that any agents, including a subcontractor, to whom the Employer provides protected health
information received from the Claims Administrator agree to the same restrictions and conditions
that apply to the Employer regarding the use and disclosure of protected health information;
3. Not use or disclose protected health information for employment - related actions and
decisions unless you have authorized it;
4. Not use or disclose protected health information in connection with any of the Employer's other
benefit plans unless you have authorized it;
Report to the Claims Administrator any use or disclosure of protected health information that the
Employer becomes aware of,
6. Make your protected health information available to you according to HIPAA's access requirements;
Make protected health information available for amendment and incorporate any amendments to
protected health information in accordance with HIPAA;
8. Make available the information required to provide an accounting of disclosures; make internal
practices, books and records relating to the use and disclosure of protected health information
19
received from the Claims Administrator available to the Secretary of the U.S. Department of Health
and Human Services for purposes of determining the Plan's compliance with HIPAA; and
9. If possible, return or destroy all protected health information received from the Claims
Administrator that the Employer still maintains in any form, and retain no copies of that protected
health information when no longer needed for the purpose for which it was disclosed (or, if return or
destruction is not possible, limit further uses and purposes that make it impossible to return or
destroy the information).
In compliance with HIPAA, only a select group of employees are permitted to receive protected health
information on behalf of your Employer. As of January 1, 2009, the only employee permitted to receive this type of
information for the Employer is the Employer's Assistant City Manager. Any protected health information that
these employees receive may be used only for purposes of administering this Plan. Your Employer will provide a
mechanism for resolving issues regarding whether the designated individuals have violated the limitations that
apply, including possible disciplinary sanctions.
THIS SUMMARY IS NOT MEANT TO INTERPRET, EXTEND OR CHANGE THE PLAN IN ANY WAY.
IN CASE OF A CONFLICT BETWEEN THIS SUMMARY AND THE ACTUAL PROVISIONS OF THE
PLAN, THE PROVISIONS OF THE PLAN WILL ALWAYS GOVERN YOUR RIGHTS AND BENEFITS.
20
FLEXIBLE BENEFITS PLAN
CITY OF ROSEMEAD FLEXIBLE BENEFITS PLAN
1.1 Cafeteria Plan Status. This Plan is intended to qualify as a "cafeteria plan" under Section 125 of the
Internal Revenue Code of 1986, as amended, and is to be interpreted in a manner consistent with the
requirements of Section 125. This document restates and amends, as of the Effective Date, the cafeteria plan
heretofore maintained by the Employer.
1.2 Purpose of Plan. The purpose of this Plan is to provide employees of the Employer with a choice
between cash and certain non -cash benefits under the benefit plans and arrangements of the Employer.
ARTICLE 11: DEFINITIONS
Whenever used herein, the following terms have the following meanings unless a different meaning is
clearly required by the context:
2.1 "Administrator" means the Employer or such other person or committee as may be appointed from
time to time by the Employer to supervise the administration of the Plan.
2.2 "Code" means the Internal Revenue Code of 1986, as amended from time to time. Reference to any
section or subsection of the Code includes reference to any comparable or succeeding provisions of
any legislation that amends, supplements or replaces such section or subsection.
2.3 "Compensation" means any wages, salary or other amounts paid in cash by the Employer and
reportable on a Participant's Form W -2.
2.4 "Component Plans" means the Insurance Plans and Flexible Spending Account Plans of the
Employer.
2.5 "Deemed Election" means the election of benefits that a Participant will be deemed to have made
if he or she fails to file a completed election form for any Period of Coverage on or before the
deadline set by the Administrator. A Participant's failure to timely file a completed election form for
his or her initial Period of Coverage under the Plan shall constitute an election of all benefits under
the Insurance Premium Pre -Tax Payment Option (and a corresponding agreement to a reduction in
the Participant's share of the cost during such Period of Coverage of each such benefit) and an
election not to receive any benefits under any of the Flexible Spending Account Plans. A
Participant's failure to timely file a completed election form for any subsequent Period of Coverage
shall constitute (a) a re- election of the same benefits, if any, as the Participant had elected (including
any benefits elected pursuant to a Deemed Election) under the Insurance Premium Pre -Tax Payment
Option for the immediately preceding Period of Coverage and a corresponding agreement to a
reduction in the Participant's Compensation during the Period of Coverage equal to the Participant's
share of the cost of such benefits, and (b) an election to not receive any benefits under any of the
Flexible Spending Account Plans.
2.6 "Dependent" means any individual who is a dependent of the Participant as defined in Code §152,
with the following exceptions:
(a) for purposes of accident or health coverage including the Medical Expense Reimbursement Plan,
(1) a dependent is defined as in Code §152, determined without regard to subsections (b)(1), (b)(2),
and (d)(1)(B) thereof; and (2) any child to whom Code §152(e) applies (regarding a child of divorced
parents, etc., where one or both parents have custody of the child for more than half of the calendar
year and where the parents together provide more than half of the child's support for the calendar
year) is treated as a Dependent of both parents. Notwithstanding the foregoing, the Medical Expense
Reimbursement Plan will provide benefits in accordance with the applicable requirements of any
qualified medical support order (as defined under applicable federal law) even if the child does not
meet the definition of "Dependent ".
(b) For purposes of the Dependent Care Assistance Program, a Dependent means a "qualifying
individual" as defined in Code §21(b)(1) with respect to the Participant, and in the case of divorced
parents, a qualifying individual who is a child shall, as provided in Code §21(e)(5), be treated as a
qualifying individual of the custodial parent (within the meaning of Code §152(e)(1)) and shall not be
treated as a qualifying individual with respect to the non - custodial parent.
2.7 "Dependent Care Service Provider" means a person who provides dependent care, but shall not
include (a) a Dependent care center (as defined in Section 21(b)(2)(D) of the Code), unless the
requirements of Code Section 21(b)(2)(C) are satisfied, or (b) a related individual described in
Section 129(c) of the Code.
2.8 "Effective Date" means January 1, 2009.
2.9 "Eligible Child" means any individual who: (a) has not attained age eighteen, or (b) is physically or
mentally incapable of caring for himself or herself.
2.10 "Eligible Employee" means an Employee who is of the type, category or classification that is eligible
to make an election of benefits under the Plan upon satisfying the Minimum Service Requirement, if
any, and the Minimum Age Requirement, if any, under the Plan. All Employees are Eligible
Employees, except for Employees who are not regularly scheduled to perform at least thirty -two
hours of services per week for the Employer.
2.11 "Employee" means an individual that the Employer classifies as a common -law employee and who
is on the Employer's W -2 payroll, but does not include any leased employee (including, but not limited
to those individuals defined in Code Section 414(n)), or an individual classified by the Employer as a
contract worker, independent contractor, temporary employee, short-term employee or casual
employee, whether or not any such persons are on the Employer's W -2 payroll, or any individual who
performs services for the Employer but is paid by a temporary or other employment agency such as
"Kelly," "Manpower," etc.
For purposes of this Plan, the following individuals shall not be considered Employees:
(a) If the Employer is an S Corporation, any "2- percent shareholder" of the Employer, as that term is
defined by Code Section 1372(b),
(b) If the Employer is a partnership or is taxed as a partnership under federal tax law, any partner,
member or owner in the Employer.
(c) If the Employer is a sole proprietorship, the owner of the Employer.
2.12 "Employer" means the City of Rosemead and any other corporation, partnership, firm or business
which, with the permission of the City of Rosemead, adopts the Plan, provided, however, that when
the Plan provides that the Employer has a certain power (e.g., the appointment of a Plan
Administrator, entering into a contract with a third party insurer, or amendment or termination of the
Plan), the term "Employer" shall mean only the City of Rosemead. Other parties that adopt the Plan
shall be bound by the Plan as adopted and subsequently amended unless they clearly withdraw from
participation therein.
2.13 "Flexible Spending Account Plan" means the Medical Expense Reimbursement Plan, the
Dependent Care Assistance Program, the Individual Premium Reimbursement Plan or the Adoption
Assistance Plan of the Employer, as established under Article V of this Plan.
2.14 "Inactive Participant" means an individual whose status as a Participant in a Flexible Spending
Account Plan has terminated, but who continues to have certain rights to reimbursement under that
Plan, in accordance with Article V of the Plan.
2.15 "Insurance Plan" means any of the plans, programs and arrangements made available by or
through the Employer pursuant to which Employees may obtain insurance (or Health Maintenance
Organization) coverage of the following types: medical and dental.
2.16 "Insurance Premium Pre -tax Payment Option" means the option afforded a Participant under the
Plan to elect to pay, on a pre -tax basis, his or her share of the cost of coverage under the Insurance
Plans.
2.17 "Key Employee" means any person who is a key employee, as defined in Section 416(1)(1) of the
Code, with respect to the Employer.
2.18 "Minimum Age Requirement" means the age, if any, that an Eligible Employee must attain as a
condition to becoming a Participant. The Plan does not have a Minimum Age Requirement.
2.19 "Minimum Service Requirement" means the period of continuous employmentwith the Employer,
if any, that an Eligible Employee must complete as a condition to becoming a Participant. The Plan
does not have a Minimum Service Requirement.
2.20 "Participant" means any Eligible Employee who has satisfied the Minimum Service Requirement, if
any, and the Minimum Age Requirement, if any, and whose Participant Commencement Date has
occurred.
2.21 "Participation Commencement Date" means the date on which an Eligible Employee becomes a
Participant, which is the date on which he or she satisfies the Minimum Service Requirement.
2.22 "Period of Coverage" means the Plan Year, except as follows: (i) The Period of Coverage for a first -
time Participant shall be the period commencing on his or her Participation Commencement Date and
ending on the last day of the Plan Year within which his or her Participation Commencement Date
occurs, and (ii) The Period of Coverage for a Participant whose participation ceases in accordance
with Section 3.2 shall be the period from the first day of the Plan Year within which his or her
participation ceases and ending on the date his or her participation ceases.
2.23 "Plan" means the City of Rosemead Flexible Benefits Plan as set forth herein, together with any and
all amendments and supplements hereto.
2.24 "Plan Year" means the period on which the records of the Plan are based, which is the twelve -month
period beginning on January 1 and ending on the following December 31.
2.25 "Qualifying Adoption Expense" means an expense incurred for reasonable and necessary
adoption fees, court costs, attorney fees, and any other expense that: (a) is directly related to, and
the principal purpose of which is for, the legal adoption of an Eligible Child by the Participant; (b) is
not incurred in violation of state or federal law or in carrying out any surrogate parenting
arrangement: and (c) is not an expense in connection with the adoption of a child who is the child of
the Participant's Spouse.
2.26 "Qualifying Dependent Care Expense" mean an expense incurred by a Participant which (a) is
incurred for the care of a Qualifying Individual orfor related household services, (b) is paid or payable
to a Dependent Care Service Provider, and (c) is incurred to enable the Participant to be gainfully
employed for any period for which there are one or more Qualifying Individual with respect to the
Participant. "Qualifying Dependent Care Expense" shall not include an expense incurred for (i)
services outside the Participant's household for the care of a Qualifying Individual, unless such
Qualifying Individual is described in "(a)" above or regularly spends at least eight hours each day in
the Participant's household, or (ii) services at a camp where the Qualifying Individual stays overnight.
2.27 "Qualifying Expense" means a Qualifying Adoption Expense, Qualifying Individual Premium
Expense, Qualifying Dependent Care Expense or Qualifying Medical Care Expense.
2.28 "Qualifying Individual" means (a) a Participant's Dependent who is under the age of thirteen (and
meets other conditions imposed by the definition of Dependent, such as a requirement that he or she
have the same principal place of abode as the Participant); (b) a Participant's Dependent who is
physically or mentally incapable of self -care, has the same principal place of abode as the Participant
for more than half of the year, and meets other conditions imposed by the definition of Dependent
and (c) a Participant's Spouse who is physically or mentally incapable of self -care, and who has the
same principal place of abode as the Participant for more than half of the year.
2.29 "Qualifying Individual Premium Expense" means the cost of accident or health coverage for a
Participant or his or her Spouse or Dependent that is provided under a contract or policy that is
owned by the Participant, the Spouse or the Dependent or under a benefit plan maintained by the
employer of the Spouse or Dependent.
2.30 "Qualifying Medical Care Expense" means an expense incurred by a Participant, or by the Spouse
or Dependent of such Participant, for medical care as defined in Section 213(d) of the Code
(including, without limitation, amounts paid for hospital bills, doctor, dental or vision care bills and
drugs), but only to the extent that the Participant or other person incurring the expense is not
reimbursed (or entitled to reimbursement) for the expense through insurance or otherwise (other than
under the Plan); provided, however, "Qualifying Medical Care Expense" shall not include any
premium paid for health coverage.
2.31 "Spouse" means an individual who is legally married to a Participant under applicable state law and
who is treated as a spouse under the Code.
ARTICLE///: PARTICIPATION
3.1 Commencement of Participation. An Eligible Employee shall become a Participant, thus entitling him
or her to make an election of benefits under the Plan, on his or her Participation Commencement Date.
3.2 Cessation of Participation. A Participant shall cease to be a Participant as of the earlier of (a) the
date on which the Plan terminates or (b) the date on which he or she ceases to be an Eligible Employee.
Except to the limited extent provided at Article V, any election made under this Plan (including any Deemed
Election) shall automatically terminate on the date on which the Participant ceases to be a Participant in the
Plan, although coverage or benefits under a Component Plan may continue if and to the extent provided by
such Plan.
3.3 Reinstatement of Former Participant. A former Participant will become a Participant again if and
when he or she becomes an Eligible Employee. However, in the case of a former Participant whose election
terminates due to separation from service with the Employer, if such person should return to service within
thirty days thereafter, he or she will be prohibited from making a new benefit election for the remainder of the
Plan Year.
3.4 Leaves of Absence. Subject to any specific limitations for any particular benefit which the Participant
has elected:
(a) A Participant's election shall remain in force during a paid leave of absence, i.e., one for which
the Participant continues to receive Compensation from the Employer.
(b) A Participant who takes an unpaid leave of absence may revoke his or her existing election and
execute a new election for the remainder of the Plan Year to the extent permitted by Section 4.6 below.
(c) Notwithstanding any provision to the contrary in the Plan, if a Participant goes on a qualifying
unpaid leave under the Family and Medical Leave Act of 1993 ( "FMLA "), to the extent required by FMLA, the
Employer shall continue to maintain the Participant's benefits under any "group health plan" as defined in Code
Section 5000(b)(1) on the same terms and conditions as though he or she were still an active Employee (i.e.,
the Employer must continue to pay its share of the premium to the extent the Employee elects to continue his
or her coverage). If the Employee elects to continue his or her coverage, the Employee may pay his or her
share of the premium with after -tax dollars while on leave (or pre -tax dollars to the extent the Employee
receives Compensation during the leave), or the Employee may be given the option to prepay all or a portion of
the Employee's share of the premium for the anticipated duration of the leave through a pre -tax salary
reduction out of the Employee's pre -leave Compensation by making a special election to that effect prior to the
date such Compensation normally would be made available to him (provided, however, that pre -tax dollars may
not be utilized to fund coverage during the next year), or through other arrangements agreed upon by the
Employee and the Administrator (e.g., the Administrator may fund coverage during the leave and withhold
amounts upon the Employee's return). Upon return from such leave, the Employee will be permitted to reenter
the Plan and to participate on the same basis as prior to taking leave or as otherwise required by the FMLA,
and shall have whatever rights as shall be applicable under Section 4.5.
ARTICLE IV. BENEFIT OPTIONS
4.1 Benefit Options. Each Participant may choose among the non -cash options and cash options
available under the Plan. The non -cash options shall consist of benefits under one or more of the Component
Plans, as described below. The cash benefits shall consist of the Participant's Compensation, without reduction
to pay for non -cash benefits.
4.2 Insurance Premium Pre -Tax Payment Option; Description of Benefits under the Insurance Plans.
The benefits directly available to Participants under this Plan relative to the Insurance Plans are limited to the
Insurance Premium Pre -Tax Payment Option. The types and amounts of insurance benefits available, the
eligibility requirements and the other terms and conditions of coverage under the Insurance Plans are as set
forth from time to time in those Plans and in the group insurance contracts and prepaid health plan contracts
that may constitute (or may be incorporated by reference in) those Plans.
4.3 Election Procedure.
(a) New Participants. The Administrator shall provide an Eligible Employee with a Flexible
Compensation Enrollment Form and Salary Deduction Agreement (or "election form ") before, or as soon as
practicable after, his or her Participation Commencement Date (or he or she qualifies to make a new election of
benefits pursuant to Section 3.3). The Eligible Employee shall specify on the election form those benefits he or
she elects for the Period of Coverage to which the election form relates and shall indicate the aggregate
amount to be allocated to each of the Component Plans with respect to the Period of Coverage.
5
(b) Annual Enrollment and Election Changes. Before the beginning of each Plan Year, the
Administrator shall provide an election form to each Eligible Employee who is scheduled to be a Participant on
the first day of that Plan Year. This election form shall enable the Participant to make a new election of benefits
under the Plan as of the first pay period commencing on or after the first day of the Plan Year. The Participant
shall specify on the election form those benefits that he or she elects for the Plan Year and shall agree to a
reduction in his or her Compensation to the extent necessary to pay for the cost on benefits elected under the
Component Plans.
(c) Deadline for Return of Election Form. Each election form must be completed and returned to the
Administrator on or before such date as the Administrator shall specify, which date shall be no later than the
beginning of the first pay period to which the election form is to apply.
(d) Failure to Return Election Forms - Deemed Election. A Participant's failure to return a completed
election form to the Administrator on or before the specified due date shall constitute a Deemed Election of
benefits under the Plan.
4.4 Election of Component Plan Benefits in Lieu of Cash. If a Participant elects benefits for a Period of
Coverage under any of the Component Plans, his or her Compensation for the Period of Coverage shall be
reduced to pay for those benefits in accordance with his or her election form. In the case of benefits elected
under any Insurance Plan, the Compensation reduction shall equal the Participant's share of the cost of
coverage under that Plan. In the case of benefits elected under any Flexible Spending Account Plan, the
Compensation reduction shall equal the amount of benefits elected by the Participant under that Plan.
4.5 Irrevocability of Elections. A Participant may not revoke any election made under the Plan during the
Period of Coverage to which it pertains, except as follows.
(a) A Participant may change his or her election for the balance of the Period of Coverage if, under
the facts and circumstances, a Change in Status occurs and the change of election satisfies the applicable
consistency requirement, as set forth below. For this purpose, a "Change in Status" consists of one of the
following events:
(1) A change in the Participant's legal status, including marriage, death of the Participant's Spouse,
divorce, legal separation or annulment.
(2) A change in the number of Dependents that the Participant has for federal income tax purposes,
as determined under Code Section 152, due to events that include birth, adoption, placement for
adoption or death.
(3) A termination or commencement of the employment of the Participant or of the Spouse or
Dependent of the Participant.
(4) A reduction or increase in the hours of employment of the Participant or the Spouse or Dependent
'of the Participant, including a switch between part-time and full -time, a strike or lockout and
commencement or return from an unpaid leave of absence. In addition, if the eligibility conditions of
this Plan, of any other employee benefit plan of the Employer or of any cafeteria plan or other
employee benefit plan of the employer of the Participant's 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, that change
constitutes a Change in Status.
(5) 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 as provided in the
accident or health plan under which the Participant receives coverage.
(6) A change in the place of residence or work of the Participant or of the Spouse or Dependent of
the Participant.
(7) For purposes of adoption assistance provided through the Plan, the commencement or
termination of an adoption proceeding.
A Participant's change of election is consistent with a Change in Status only if, (i) the Change in
Status results in the Participant or the Participant's Spouse or Dependent gaining or losing eligibility
under an employee benefit plan, and (ii) the change of election corresponds with that gain or loss of
coverage, or if the Change of Status affects Qualifying Dependent Care Expenses or Qualifying
Adoption Expenses.
If the Change of Status is a Participant's divorce, annulment or legal separation, the death of a
Participant's Spouse or Dependent, or a Dependent ceasing to satisfy the eligibility requirements for
coverage, the Participant's election under the Plan to cancel accident or health coverage for any
individual other than the Spouse involved in the divorce, annulment or legal separation, the deceased
Spouse or Dependent or the Dependent that ceased to satisfy the eligibility requirements for
coverage, as the case may be, fails to correspond with that Change in Status. Thus, if a Dependent
dies or ceases to satisfy the eligibility requirements for coverage, the election to cancel accident or
health coverage for any other person fails to correspond with that Change in Status. In addition, if a
Participant, Spouse or Dependent gains eligibility for coverage under this Plan, another cafeteria plan
or any other plan providing benefits that are qualified benefits under Code Section 125 as a result of
a change in marital status or a change in employment status described above, an election under this
Plan to cease or decrease coverage for that individual corresponds with that Change in Status only if
coverage for that individual becomes applicable or is increased under the plan from which eligibility
for coverage has been gained.
If the Participant or the Spouse or Dependent of a Participant becomes eligible for continuation
coverage under a group health plan of the Employer as provided in Section 49808 of the Code or any
similar state law, the Participant may elect to increase payments under this Plan to pay for the
continuation coverage.
(b) A Participant may change his or her election for the balance of the Period of Coverage and file a
new election that corresponds with special enrollment rights that the Participant exercises under Section
9801(f) of the Code.
(c) In the event of a judgment, decree or order resulting from a divorce, legal separation, annulment
or change in legal custody, including a qualified medical child support order that requires accident or health
coverage for a Participant's child or for a foster child who is a Dependent of a Participant, the Participant may:
(1) change his or her election to provide coverage for the child if the judgment, decree or order
requires coverage under the Employer's accident or health plan; or
(2) make a change of election to cancel coverage for the child if the order requires the Spouse or any
other person to provide coverage for the child.
(d) If a Participant who is enrolled in an accident or health plan of the Employer or the Spouse of
Dependent of such a Participant becomes entitled to coverage under Part A or Part B of Title XVI II 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), the
Participant may make a prospective change of election to cancel the coverage under the accident or health
plan of the Employer of such person. In addition, if a Participant, Spouse or Dependent who has been entitled
to coverage under Medicare or Medicaid loses eligibility for such coverage, the Participant may make a
prospective change of election to commence or to increase coverage for that person under the accident or
health plan of the Employer.
(e) A change of cost or change of coverage with respect to benefits under any Component Plan may
be the basis for a change of election in accordance with the following:
(1) The rules under this Section "(e)" shall not apply to benefits under the Medical Expense
Reimbursement Plan.
(2) If the cost of a Participant's benefits under any Component Plan increases or decreases
during a Period of Coverage and, under the terms of that Component Plan, Employees are required
to make a corresponding change in their payments, a corresponding adjustment shall be made to the
Participant's elective contributions under this Plan, subject, however, to (3) below.
(3) If the cost of a Participant's benefits under a Component Plan significantly increases during a
period of coverage, the Participant may elect either to increase his or her contributions to pay for the
increased cost or may revoke his or her election and, in lieu thereof, receive on a prospective basis,
coverage under another benefit option available under the Component Plan. If the cost of any benefit
or benefit option significantly decreases during a period of coverage for which a Participant has
elected that benefit or benefit option, a Participant may make a new election of that benefit or benefit
option. If a Participant has an election in effect at that time for that type of benefit (e.g., medical
insurance coverage) but under a benefit option other than the one the cost of which has significantly
decreased, he or she may revoke that existing election and elect that benefit option that has
significantly decreased in cost.
(4) Notwithstanding the foregoing, a cost change shall only provide the basis for an election
change with respect to dependent care assistance benefits if the cost change is imposed by a
dependent care provider who is not a "relative" of the Participant as that term is defined under Code
Section 152.
(5) If a Participant's coverage under any Component Plan is significantly curtailed or ceases
during a Period of Coverage, the Participant may revoke his or her existing election of the coverage
and may make a new election on a prospective basis of any other coverage option available under
that Component Plan. Coverage under an accident or health plan shall be considered as curtailed
only if there is an overall reduction in coverage provided under the plan so as to constitute reduced
coverage to Participants generally.
(6) A Participant may make a prospective election change that is on account of and corresponds
with a change made under the plan of the Participant's Spouse, former Spouse or Dependent if that
plan allows for election changes based on a change in cost or coverage consistent with the foregoing
rules and if that plan permits participants to make an election for a period of coverage under the
cafeteria or other plan that is different than that under this Plan.
(f) A Participant may revoke a prior election and make a new election where there has been a
significant change in the benefit plan coverage of the Participant, the Spouse of the Participant or a Dependent
of the Participant that is attributable to the employment of the Spouse or Dependent, provided such change of
election is determined by the Administrator to be consistent with the change in benefit plan coverage.
(g) A Participant taking leave under the FMLA may revoke an existing election of group health plan
coverage and make such other election for the remaining portion of the period of coverage as may be provided
for under the FMLA.
(h) The Change in Status rules do not apply with respect to elective contributions under a qualified
cash or deferred arrangement as defined in Code Section 401(k).
Notwithstanding any provision herein to the contrary, no Participant may reduce his or her election for
benefits under any Flexible Spending Account Plan below the amount already reimbursed under such Plan for
the Period of Coverage.
Any revocation and new election under this Section shall be effective at such time as the
Administrator shall prescribe, but not earlier than the first pay period beginning after the revocation and new
election.
Any election under this Section must be filed within thirty days of the occurrence of the Change in
Status to which the election relates.
4.6 Changes by Administrator. If the Administrator determines, before or during any Plan Year, that the
Plan may fail to satisfy for such Plan Year any nondiscrimination requirement imposed by the Code or any
limitation on benefits provided to Key Employees, the Administrator shall take such action as the Administrator
deems appropriate, under rules uniformly applicable to similarly situated Participants, to assure compliance
with such requirement or limitation. Such action may include, without limitation, a modification of elections by
highly compensated Employees (as defined by the Code for purposes of the nondiscrimination requirement in
question) or Key Employees without the consent of such Employees.
4.7 Maximum Employer Contributions. The maximum amount of employer contributions under the Plan
for any Participant shall be the sum of (i) the costs from time to time of the most expensive benefits available to
the Participant under the Insurance Premium Pre -Tax Payment Option, and (ii) the maximum amount that may
be contributed for benefits under the Flexible Spending Account Plans.
ARTICLE V: FLEXIBLE SPENDING ACCOUNT BENEFITS
5.1 Flexible Spending Account Plans
(a) Health Care. There is hereby created a "self- insured medical expense reimbursement plan" as
defined at Section 105(h) of the Code (the "Medical Expense Reimbursement Plan "). The purpose of the
Medical Expense Reimbursement Plan shall be to provide Participants with reimbursements of Qualifying
Medical Care Expenses that are excludable from income.
(b) Dependent Care. There is hereby created a "Dependent Care Assistance Program" as defined at
Section 129 of the Code. The purpose of the Dependent Care Assistance Program shall be to provide
Participants with reimbursements of Qualifying Dependent Care Expenses that are excludable from income.
(c) Accident and Health Insurance Premiums. There is hereby created an Individual Premium
Reimbursement Plan pursuantto Rev. Rul. 61 -146, 1961 -2 C.B. 25 and Code Section 106. The purpose ofthe
Individual Premium Reimbursement Plan shall be to provide Participants with reimbursements of Qualifying
Individual Premium Expenses that are excludable from income.
(d) Adoption. There is hereby created an "Adoption Assistance Program" as defined at Section 137
of the Code. The purpose of the Adoption Assistance Program is to provide Participants with reimbursements
of Qualified Adoption Expenses that are not subject to income taxation.
5.2 Status as Flexible Spending Arrangements. Each Flexible Spending Account Plan shall operate in all
respects in accordance with the rules applicable to a "flexible spending arrangement' as set forth in Proposed
Income Regulation Section 125 -5(a) and any successor IRS regulations and guidance.
M
5.3 Establishment of Accounts. If a Participant elects benefits under a Flexible Spending Account Plan
for any Period of Coverage, the Administrator shall establish an Account on the books of the Plan with respect
to his or her election and shall maintain the Account in accordance with the rules set forth below in this Article
V. Any such Account is for record - keeping purposes only and does not involve any actual segregation of
assets.
5.4 Crediting of Accounts.
(a) Medical Expense Reimbursement Account. The Account of a Participant that is established on
account of an election of benefits under the Medical Expense Reimbursement Plan (a "Medical Expense
Reimbursement Account ") shall be credited with an amount equal to his or her benefit election for that Period of
Coverage. This amount shall be credited to the Participant as of the first day of the Period of Coverage.
(b) Other Accounts. The Account of a Participant that is established on account of an election of
benefits under any other Flexible Spending Account Plan shall be credited with the amount of contributions that
are made to that Account in accordance with Article IV at the time the contributions occur.
5.5 Maximum Electable BenefitAmounts. The maximum (and minimum, where applicable) amount of
benefits for a Period of Coverage that a Participant may elect to pay for through the mechanism of
Compensation reductions is as follows:
(a) Medical Expense Reimbursement Plan: $5,000 maximum and $100 minimum.
(b) Dependent Care Assistance Program: The legal limit applicable to the Participant, as described
below, multiplied by the number of calendar years fully or partially included in the Plan Year.
(c) Individual Premium Reimbursement Plan: $10,000.
(d) Adoption Assistance Program: The legal limit per adopted child as described below, multiplied by
the number of children to be adopted.
5.6 Code Limits on Dependent Care Assistance. The maximum amount that a Participant may receive
for reimbursement of Qualifying Dependent Care Expenses in any calendar year shall be the least of (a) the
Participant's earned income for the calendar year (after all reductions in compensation including the reduction
related to dependent care assistance), (b) the actual or deemed earned income of the Participant's Spouse for
the calendar year, if the Participant is married, or (c) $5,000 (or, if the Participant does not certify to the
Administrator's satisfaction that he or she is either unmarried or will file a joint Federal income tax return for the
year, $2,500). In the case of a Spouse who is a full -time student at an educational institution or is physically or
mentally incapable of caring for himself or herself, such Spouse shall be deemed to have earned income of not
less than $250 per month if the Participant has one Qualifying Individual and $500 per month if the Participant
has two or more Qualifying Individuals. In the case of two Participants who are married to each other and who
file a joint Federal income tax return for the calendar year, the $5,000 limit in (c) above shall be reduced for
each such Participant by the amount received for the year under this Plan by the Participant's Spouse. For
purposes of this Section, "earned income" shall have the meaning given it by Section 32(c)(2) of the Code, and
a Participant shall not be treated as married if the Participant is not considered as married under the special
rules of Code Section 21(e)(3) and (4).
5.7 Code Limits on Adoption Expense Reimbursement. The maximum amount that a Participant may
receive for reimbursement of Qualifying Adoption Expenses with respect to the adoption of an Eligible Child
shall be $10,000, increased by such cost -of- living adjustments to that amount as shall be made from time to
time pursuant to Code Section 137(f).
10
5.8 Debiting of Accounts. A Participant's Account under a Flexible Spending Account Plan shall be
reduced by the amount of claims paid from the Account.
5.9 Claims for Reimbursement. A Participant shall obtain reimbursement of a Qualifying Expense by
submitting a claim on a form provided by the Plan. Each claim must include:
(a) a description of the Qualifying Expense, the amount of the Expense and the date on which the
Expense was incurred.
(b) the person paid or to be paid.
(c) the name of the person who incurred the Expense.
(d) bills, invoices, receipts or other documentation showing the amounts of the expenses incurred.
(e) if the expense is a Qualifying Medical Care Expense, a certification that the expense has not
already been reimbursed by another health plan and is not eligible for reimbursement under any other health
plan.
(f) if the expense is a Qualifying Dependent Care Expense, the name, address and taxpayer
identification number of the dependent care provider.
(g) if the expense is a Qualifying Adoption Expense, the name, age, taxpayer identification number
and place of residence of the Eligible Child.
5.10 When an Expense is Incurred. A claim may be submitted before or after the Participant has paid a
Qualifying Expense, but not before the Expense has been incurred. A Qualifying Expense shall be deemed
incurred at the time the services giving rise to the Expense are rendered.
5.11 Direct Payment Option. The Administrator may, at its option, pay any Qualifying Expense directly to
the person providing or supplying the services that gave rise to the Expense, lieu of reimbursing the Participant.
5.12 Amount Available For Payment of Claims.
(a) Medical Expense Reimbursement Plan Claims. The amount available to reimburse a Participant
for Qualifying Medical Care Expenses shall, at all times during a Period of Coverage, be equal to the amount of
his or her benefit election for that Period of Coverage reduced by the amount of previous reimbursements.
(b) Claims under other Flexible Spending Account Plans. The amount available to reimburse a
Participant for Qualifying Expenses under any other Flexible Spending Account Plan shall be limited to his or
her Account balance.
5.13 Deadline for Claims Submission. Any claim for reimbursement of a Qualifying Expense must be
submitted to the Administrator by March 31st of the Plan Year following the Plan Year within which the
Qualifying Expense was incurred. The Administrator shall not pay any claim submitted after that date.
5.14 Code Limitations on Reimbursements to Certain Participants.
(a) Nondiscriminatory Benefits. Each of the Flexible Spending Account Plans is intended not to
discriminate as to eligibility to participate or benefits in favor of highly compensated individuals or highly
compensated employees, as the case may be as those terms are defined in the applicable provisions of the
Code. If, in the judgment of the Administrator, the operation of the Plan in any Plan Year would result in such
11
discrimination, the Administrator may take such shall remedial action as the Administrator deems necessary or
appropriate to assure that the Plan does not discriminate, including but not limited to, restricting the amounts
reimbursed to such persons or excluding such persons altogether from participation. Such remedial actions
may be taken whether or not to do so would result in a forfeiture of any Account balance.
(b) Dependent Care Assistance Program. The following rules shall apply to the operation of the
Dependent Care Assistance Program:
(1) Not more than twenty -five percent of the total amount reimbursed under the Dependent Care
Assistance Program during any Plan Year may be reimbursed with respect to Participants who own
more than five percent of the stock or of the capital or profits interest of the Employer (or their
Spouses or Dependents).
(2) The average benefits provided to Participants who are not highly compensated employees must
be at least fifty -five percent of the average benefits provided to highly compensated employees
(within the meaning of Code Section 414(q)) under all dependent care assistance plans of the
Employer. For purposes of this limitation, in the case of any benefits provided through a salary
reduction agreement, any Participant whose compensation is less than $25,000 maybe disregarded.
Also, for the purposes of the foregoing, there shall be excluded from consideration employees who
are described in Code Section 129(d)(9).
(c) Adoption Assistance Program. No more than five percent of the total amount reimbursed under
the Adoption Assistance Program for any Plan Year may be reimbursed with respect to Participants who own
more than five percent of the stock or of the capital or profits interest of the Employer (or their Spouses or
Dependents).
5.15 Forfeiture of Unused Account Balances. If any balance remains in a Participant's Flexible Spending
Account for a Period of Coverage after all authorized reimbursements have been made, such balance shall not
be carried over to reimburse the Participant for Qualifying Expenses incurred during a subsequent Period of
Coverage and shall not be available to the Participant in any other form or manner, but shall remain the
property of the Employer, and the Participant shall forfeit all rights with respect to such balance. The Employer
may use any forfeited account balances to pay any administrative expenses of the Plan or in any other manner
that does not violate any applicable law or regulation. For this purpose, "administrative expense" shall include
any amount by which the benefits paid to any Participant under the Medical Expense Reimbursement Plan for
any Period of Coverage exceeded the Participant's contributions to the Medical Expense Reimbursement Plan
for that Period of Coverage.
5.16 Inactive Participant Status. Except as hereinafter provided, an individual shall cease being a
Participant in a Flexible Spending Account Plan and become an Inactive Participant in that Flexible Spending
Account Plan when he or she ceases to be a Participant under the Flexible Benefits Plan pursuant to Section
3.2 or when his or her election for benefits under that Flexible Spending Account Plan expires, whichever first
occurs. An individual who has the status of Inactive Participant with respect to any Flexible Spending Account
Plan may submit further claims for reimbursement of Qualifying Expenses under that Flexible Spending
Account Plan only in accordance with the following:
(a) An Inactive Participant who had an election for benefits under the Medical Expense
Reimbursement Plan on the date that he or she became an Inactive Participant may submit claims for any
Qualifying Medical Care Expenses incurred during the Period of Coverage ending on the date that he or she
became an Inactive Participant. Any such claims must be submitted by March 31 st of the Plan Year following
the Plan Year within which that Period of Coverage ends.
(b) An Inactive Participant who had an election for benefits under any other Flexible Spending
Account on the date that he or she became an Inactive Participant may submit claims for any Qualifying
12
Expenses incurred at any time during the Plan Year within which he or she became an Inactive Participant.
Any such claims must be submitted by March 31st of the following Plan Year.
5.17 Continuation Coverage under the Consolidated Omnibus Reconciliation Act of 1985 ( "COBRA'). The
Plan shall comply with the requirements of COBRA or any other applicable federal or state law granting
continuation benefits upon termination of coverage to the extent applicable.
ARTICLE VI: ADMINISTRATION OF PLAN
6.1 Plan Administrator. The Administrator shall administer the Plan in accordance with its terms without
discriminating among the Participants. The Administrator shall have full power to administer the Plan in all of
its details, subject to applicable requirements of law. For this purpose, the Administrator's powers shall include,
but shall not be limited to, the following authority, in addition to all other powers provided by this Plan:
(a) To make and enforce such rules and regulations as it deems necessary or proper for the efficient
administration of the Plan;
(b) To interpret the Plan, its interpretation thereof in good faith to be final and conclusive on all
persons claiming benefits under the Plan;
Plan;
(c) To decide all questions concerning the Plan and the eligibility of any persons to participate in the
(d) To appoint such agents, counsel, accountants, consultants and other persons as maybe required
to assist in administering the Plan; and
(e) To allocate and delegate its responsibilities under the Plan and to designate other persons to
carry out any of its responsibilities under the Plan, any such allocation, delegation or designation to be in
writing.
Notwithstanding the foregoing, any claim which arises under any of the Insurance Plans shall not be
subject to review under this Plan, and the Administrator's authority under this Section 6.1 shall not extend to
any matter as to which an administrator under any such other plan is empowered to make determinations
under such plan.
6.2 Examination of Records. The Administrator shall make available to each Participant such of his or
her records under the Plan as pertain to the Participant, for examination at reasonable times during normal
business hours.
6.3 Reliance on Tables, etc. In administering the Plan, the Administrator shall be entitled, to the extent
permitted by law, to rely conclusively on all tables, valuations, certificates, opinions and reports which are
furnished by, or in accordance with the instructions of, the administrators of the Component Plans, or by
accountants, counsel or other experts employed or engaged by the Administrator.
6.4 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 formerly 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 an act or omission to act in
connection with the Plan, if such act or omission is in good faith and was not the product of gross negligence.
ARTICLE VII: CLAIMS
13
7.1 Filing of Claims. The Employer has retained P &A Administrative Services, Inc. of Buffalo, New York
(the "Claims Administrator') to process all claims. Information regarding incurred expenses eligible for
reimbursement under this Plan shall be submitted directly to the Claims Administrator to determine the amount
of any benefits payable hereunder.
7.2 Scope of Claims Review under this Plan. Except to the extent otherwise specifically provided herein,
any claim for benefits under an Insurance Plan shall be governed by the claims procedures that are included in
the plan documents pursuant to which that Plan is maintained. The claims procedures in this Article shall apply
to (i) any partial or total denial of benefits under any Flexible Spending Account Plan, and (ii) any denial of
benefits due to an issue germane to the claimant's coverage under the Flexible Benefits Plan (e.g., whether an
Eligible Employee has satisfied any Minimum Service Requirement or whether a Change in Status has
occurred).
7.3 Claims Procedure.
(a) Any person who believes that he or she is entitled to a benefit shall have the right to file with the
Claims Administrator a written notice of claim for such benefit. The Claims Administrator shall either grant or
deny such claim within thirty days after the receipt of such written notice of claim (or within such other period as
may be mutually agreed to by the parties); provided, however, if circumstances beyond its control so dictate.
The Claims Administrator may extend that time by a maximum of fifteen days by giving the claimant written
notice of such extension within the initial thirty -day period. Such notice shall identify the reason for the
extension and the date by which the Claims Administrator expects to make its decision. If the reason is a lack
of complete information, the notice shall identify the additional information needed, shall grant the claimant
forty -five days from the date of the extension notice to furnish that information, and further shall advise the
claimant that the tolling of the limitation period for the Claims Administrator's response shall be suspended until
the Claims Administrator receives the information. Any delay on the part of the Claims Administrator in arriving
at a decision shall not adversely affect benefits payable under a granted claim.
(b) In the case of a denied claim, the Claims Administrator shall provide written notice to the claimant
setting forth:
(1) The specific reason for such denial;
(2) Specific reference to the pertinent Plan provisions on which the denial is based;
(3) A description of any additional material or information necessary for the claimant to
perfect the claim and an explanation of why such material or information is necessary;
and
(4) An explanation of the Plan's claim review procedures described below.
7.4 Review of Denied Claim.
(a) Any person whose claim is denied may appeal in writing to the Benefits Manager of the Claims
Administrator at any time within one hundred eighty days after the claimant receives written notice of such
denial. The appeal should include the reason or reasons the claimant believes the Claims Administrator's claim
denial to have been in error. In the event of such appeal, the Benefits Manager of the Claims Administrator
shall afford the claimant or his duly authorized representative the opportunity:
(1) To review documents pertinent to the claim;
(2) To submit issues and comments in writing; and
1XII
(3) To discuss such documents and issues with the Benefits Manager of the Claims
Administrator.
(b) The final decision of Benefits Manager of the Claims Administrator shall be made not later than
sixty days after its receipt from the claimant of a request for review, unless there are special circumstances,
such as the need to hold a hearing, or an extension of time for processing, in which case a decision shall be
made as soon as possible but not later than one hundred twenty days after receipt of a request for review. If
the decision on appeal affirms the initial denial, the claimant shall be furnished with a written notice to that
effect that shall include the following:
(1) The specific reasons for decision on appeal;
(2) The specific Plan provisions on which the decision is based;
(3) Statement of the right to review, upon request and at no charge, such Plan documents as
the claimant shall deem relevant; and
(4) A description of any internal rule, guideline, protocol or similar criterion that was relied on
in reaching the decision and a statement that a copy of same is available upon request
and at no charge.
ARTICLE Vlll: AMENDMENT AND TERMINATION OF PLAN
The Plan may at any time be amended or terminated by:
(a) If the Employer is a corporation, an action of the Board of Directors of the Employer (or ar
equivalent governing body) or a written instrument executed by the President of the Employer
(b) If the Employer is a partnership, a written instrument executed by the Managing Partner.
(c) If the Employer is a sole proprietorship, the owner of the Employer.
ARTICLE IX: MISCELLANEOUS PROVISIONS
9.1 Information to be Furnished. Participants shall provide the Employer and Administrator with such
information and evidence, and shall sign such documents, as may reasonably be requested from time to time
for the purpose of administration of the Plan.
9.2 Limitation of Rights. Neither the establishment of the Plan nor any amendment thereof, nor the
payment of any benefits, will be construed as giving to any Participant or other person any legal or equitable
right against the Employer or Administrator, except as provided herein.
9.3 Benefits Solely From General Assets. Except as may otherwise be required by law:
(a) Any amount by which a Participant's Compensation is reduced under this Plan will remain part of
the general assets of the Employer;
(b) Nothing herein will be construed to require the Employer or the Administrator to maintain any fund
or segregate any amount for the benefit of any Participant; and
(c) 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.
15
9.4 Use and Disclosure of Protected Health Information. This Plan (and its agents) will use information
that is "protected health information" ( "PHI ") for purposes of the privacy rules issued pursuant to the Health
Insurance Portability and Accountability Act of 1996 ( "HIPAA ") only as permitted by HIPAA. Specifically, the
Plan will use and disclose PHI only for purposes related to health care treatment, payment for health care and
health care operations as defined under HIPAA.
The Plan will disclose PHI to the Employer only upon receipt of a certification from the Employer that
the Plan documents have been amended to provide that the Employer will:
by law;
(a) Not use or disclose PHI other than as permitted or required by the Plan document or as required
(b) Ensure that any agents, including a subcontractor, to whom the Employer provides PHI received
from the Plan agree to the same restrictions and conditions that apply to the Employer regarding the use and
disclosure of PHI;
(c) Not use or disclose PHI for employment - related actions and decisions unless authorized by an
individual;
(d) Not use or disclose protected health information in connection with any of the Employer's other
benefit plans unless authorized by an individual;
(e) Report to the Plan any use or disclosure of PHI that the Employer becomes aware of;
(f) Make PHI available to an individual in accordance with HIPAA's access requirements;
(g) Make PHI for amendment and incorporate any amendments to PHI in accordance with HIPAA;
(h) Make available the information required to provide an accounting of disclosures; make internal
practices, books and records relating to the use and disclosure of PHI received from the Plan available to the
Secretary of the U.S. Department of Health and Human Services for purposes of determining the Plan's
compliance with HIPAA; and
(i) If feasible, return or destroy all PHI received from the Plan that the Employer still maintains in any
form, and retain no copies of that PHI when no longer needed for the purpose for which it disclosure was made
(or, if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the
return or destruction infeasible).
In accordance with HIPAA, only those employees designated by the Employer shall be given access
to PHI. As of the Effective Date, the only employee so designated is the Assistant City Manager of the
Employer. Those employees may use and disclose PHI only for Plan Administration functions that the
Employer performs with respect to the Plan. The Employer shall provide a mechanism for resolving issues of
noncompliance (i.e., allegations that authorized employees have failed to comply with this Section 9.4),
including disciplinary sanctions.
9.5 Governing Law. This Plan shall be construed, administered and enforced according to the laws of the
State wherein the principal office or place of business of the Employer is located.
9.6 Complete Document. This document contains all of the operative provisions of this Plan. Any conflict
between the provisions of this document and any other Employer document purporting to explain the rights,
benefits, or obligations of the parties hereunder shall be resolved in favor of this Plan document. In the event
16
that a tribunal of competent jurisdiction shall determine in a final judgment or decree that one or more of the
provisions of this Plan is invalid due to the provisions of applicable law, this Plan shall be interpreted as if the
offending language had been stricken from its provisions, and the remainder of the Plan document shall
continue in full force and effect.
9.7 Coordination of Benefits. Notwithstanding any other provision herein to the contrary, should a
Participant incur an eligible expense for purposes of both this Plan and any Health Reimbursement
Arrangement or similar type of supplemental self- insured medical expense reimbursement plan of arrangement
( "HRA "), he or she shall be obligated to submit a claim for reimbursement of that expense by the HRA and may
only submit the expense for reimbursement by this Plan if the HRA fails to fully reimburse him or her for the
expense.
9.8 Effect of Mistake. If a mistake occurs as to the eligibility or participation of an Employee, the
allocations made to the account of any Participant, or the amount of benefits paid or to be paid to a Participant
or other person, the Administrator shall, to the extent that it deems administratively feasible and otherwise
permissible under Code Section 125 or the regulations issued thereunder, cause to be allocated or cause to be
withheld or accelerated or otherwise make adjustment of, such amounts as it will in its judgment accord to
such Participant or other person the credits to the account or distributions to which he or she is properly
entitled under the Plan. Such action by the Administrator may include withholding of any amounts due to the
Plan or the Employer from Compensation paid by the Employer.
IN WITNESS WHEREOF, the Employer has caused this Plan to be executed in its name and on its
behalf as of the Effective Date.
CITY OF ROSEMEAD
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