HomeMy WebLinkAboutR-2012-094 Section 125 Benefit Plan Document (2) RESOLUTION NO. R-2012-094
A RESOLUTION ADOPTING AND RATIFYING A 5ECTION 125 FLEXIBLE BENEFIT PLAN
DOCUMENT FOR TME CITY OF RIVERSIDE
WHEREAS, the Board of Aldermen previously approved the Cafeteria Plan, Flex
Spending Account, and Dependent Care Assistance Plan on January 15 2001, as amended;
and
WHEREAS, the Board of Aldermen find there is a need to update the Section 125
Cafeteria Plan, Flex Spending Account and Dependent Care Assistance Plan as set forth in the
Section 125 Flexible Benefit Plan and to further modify the plan year to run from July 1 through
June 30; and
WHEREAS, the Board of Aldermen further find it in the best interest to approve and
ratify the plan and related servicing agreements attached hereto as Exhibit A and Exhibit B for
services provided by American Fidelity Assurance Company;
NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF ALDERMEN OF THE
CITY OF RIVERSIDE, MISSOURI, AS FOLLOWS:
THAT the Section 125 Flexible Benefits Plan Adoption Agreement effective as of July ',
1, 2012 is hereby approved, adopted, and ratified, and that the Mayor and/or City Administrator
are hereby authorized and directed to execute and deliver such agreement to American Fidelity
Assurance Company as the third party administrator to assist in the administration of the Plan;
and '
FURTHER THAT the Statement of Terms and Conditions of Flex Spending Account
Recordkeeping by American Fidelity Assurance Company attached hereto as Exhibit B is '
hereby approved and ratified; and
FURTHER THAT the City Administrator, Mayor and/or Finance Director are hereby
authorized to execute all such other documents necessary to implement the Plan and to set up
adequate accounting and administrative procedures to provide benefits under the Plan.
FURTHER THAT the proper officers of City of Riverside shali act as soon as possible to
notify the employees of the group of the adoption of the Cafeteria Plan by delivering to each
employee a copy of the summary description of the Plan in the form of the Summary Plan
Description presented to this meeting, which form is hereby approved.
PASSED AND ADOPTED b t�e Board of Aldermen and APPROVED by the Mayor of
the City of. Rivsrside, Missouri, the �-day of July, 2012.
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. • Mayor Kathleen L. ose
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Robin LittreA, ty•Clerk
. . App as to form:
hom son, City Attomey
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STATEMENT OF TERMS AND CONDITIONS
FLEX SPENDING ACCOUNT RECORDKEEPING
BY
AMERICAN FIDELITY ASSURANCE COMPANY
CITY OF RIVERSIDE MI550URI '
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� TABLE OF CONTEN b
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� PREAMBLE
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� ARTICLE I DEFINITiONS
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� 1.01 Account
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� 1.02 Plan Aclministrator
1.03 Agreement
� 1.04 Code
� 1.05 Employer
� 1.06 Participant
� 1.07 New Participant
� 1.08 Plan
;� 1.09 Policy
_� 110 Recordkeeper
� ARTICLE II POWERS AND DUT'�S OF RECO DKEEPER
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`� 2.01 Recordkeeper
� 2.02 Powers of the Recordkee �r
� 2.03 Claim Procedure
� 2.04 Debit Card Procedure
� 2.05 Duties of the Recordkeep i
� ARTICLE III RESPONSIBILITIES OF EMPLO � AS PLAN ADMINISTRATOR
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=� 3A1 Responsibilities Concemi �g Recordkeeper
� 3.02 Indemnification of Recor keeper
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ARTtCLE N ESTABLISHMENT OF ACCOUN i
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� 4.01 Account to Hold Contrib '�ons
;� 4.02 Account to Remain Prop ty of Empbyer
� 4.03 Status of Recordkeeper
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4.04 Account Not to Earn Inte Dst
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� ARTICLE V TERM OF STATEMENT
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=� 5.01 Termination
� 5.02 Termination Upon Writt � Notice
.� ARTICLE VI FEES FOR SERVICES
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6.01 Fees
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ARTICLE VII EXCEPTION TO ELECTION CHANGES
7.0] Exception to Election Changes
ARTICLE VIII COMPLIANCE WITH HIPAA REQUIREMENTS AS A
BUSINESS ASSOCIATE OF THE EMPLOYER
8.01 Recordkeeper as Business Associate
8.02 Definitions
8.03 Use and Disclosure
8.04 Further Limitations or Restrictions
8.05 Use for Management and Administration
8.06 Other Services
8.07 Safeguards
8.08 Assignment
8.09 Standard Transactions
8.10 Access
8.11 Amendment of PHI
812 Accounting
8.13 Breach of Obligations
814 Return of PHT
8.l 5 Compliance by Employer
816 Amendments to HIPAA
8.17 Effective Date
8.18 ARRA Compliance
8.19 Compliance with Breach Notification Rule
ARTICLE IX MISCELLANEOUS :
9.01 Action by the Employer
9.02 Notices
9.03 Applicable Law
9.04 Amendment
9.05 Titles
9.06 Severability
9.07 Controlling Agreement
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s PREAMBLE
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� This Statement of Terms and Conditions of Gex Spending Account Recordkeeping
� will be effective as of the date of the first remittance of flex ale spending account contributions for
�. the Plan Sponsor/Employer's (the "Employer") plan, and co �rs the services provided by American
� Fidelity Assurance Company (the "Recordkeeper") for the iployer's Section 125 Flexible Benefit
5 Plan (the "Plan").
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� ARTICLE I
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� DEFWITIONS
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� Capitalized terms used herein and not othe 'tse defined herein shall have the same
> meaning as set forth in the Plan. The masculine gender sh � include botl� sexes; the singular shall
� include plural and the plural the singular, unless the context jherwise requires.
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� 1.01 "Account" shall mean the account es blished by the Recordkeeper on behalf
� of the Employer from which benefits are to be paid in accor �.nce with the terms of the Plan and this
� Statement of Terms and Conditions.
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!� 1.02 "Plan Administrator" shall mean th Employer or its appointed delegate,
� which includes the perso�, persons or group appointed to ac �S Administrator under the Pian.
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'� 1.03 "Terms " shall mean this Statemen pf Terms and Conditions of the Flex
:� Spending Account Recordkeeping, as set forth herein, wi any and all further supplements and
� amendments thereto, which supplements and amendments hall be effective as to Empioyer upon
?� written notice to Employer.
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� 1.04 "Code" shall mean the Internal Re nue Code of 1986, as amended from
$ time to time, and successor t� laws.
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' 1.05 "Employer" shall mean the Plan Spo aor/Employer and its successors.
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? ].06 "Participant" shail mean an Emplo � of an Employer who participates in
:� the Plan under the participation provisions thereof. ir purposes of the medical expense
� reimbursement account, "Participant" does not include i �ployees who participated during the
� current plan year, left the plan by discontinuing contribution to the plan, and who then are rehired.
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� 1.07 "New Participant" shall mean an Em Iloyee newly hired during the plan year
= and who has not previously participated in the flexible sp ►ding accounts dttring the current plan
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{ 1.08 "Plan" shall mean the Employer's section 125 Flexible Benefit Plan as
hereafter amended from time to time.
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1.09 "Policy" shall mean the medical expense reimbursement insurance risk
coverage contract issued to the Employer by American Fidelity Assurance Company. The
Employer has either (a) applied for coverage under the Policy and the Trust Subscription
Agreement, as required by the Recordkeeper, has been submitted to the Recordkeeper (See Article
ViI for limitations of election), (b) not applied for the Policy and will assume the uniform coverage
risk for the medical expense reimbursement and has signed and submitted a Flexible Spending
Account Agreement), or (c) has not submitted any signed Agreement because the Plan either does
not include medical expense reimbursement and only includes dependent daycare reimbursement.
1.10 "Recordkeeper" shall mean American Fidelity Assurance Company as duly
appointed by the Employer pursuant to khe terms of the Plan.
ARTICLE II
POWERS AND DUTTES OF TT� RECORDKEEPER
2.01 Recordkeeper. The Recordkeeper shall provide the recordkeeping and other
ministerial services as the Recordkeeper appoi�ted by the Employer as such under the terms of the
Plan. T'he duties of the Recardkeeper shalt be only as provided under this Statement of Terms and '
Conditions, the Policy, or as otherwise agreed to, in writing by the Recordkeeper. '
2.02 Powers of the Recordkeeper. The Recordkeeper shall have such powers as
are necessary for the proper payment of claims for medical expense reimbursement and dependent
care expense reimbursement benefits under the Plan, including, but not limited to, the following:
(a) To prescribe procedures to be followed by Participants in filing
applications for benefits under the Plan and for furnishing evidence necessary to ,
establish their rights to benefits under the Plan;
(b) To apply the provisions of the Plan (including the provision allowing
no election changes by participants for the medical e�cpense reimbursement account
during the plan year unless otherwise agreed to in writing by the Employer and the
Recordkeeper) as interpreted by the Plan Administrator in determining the rights of
any Participant who applies for benefits u�der the Plan and to notify any such
Participant of any such determination;
(c) To obtain from the Employer, Participants, and others, information
as shall be necessary for proper accounting of expense reimbursement benefit
payments made pursuant to the terms of the Plan, the Policy, and the d'uections of
the Plan Administrator; and
(d) To receive from and hold on behalf of the Plan Admi�istrator those
sums of monies in the Account as determined by the Plan Administrator which (i) ?
represent contributions made under the Plan (by Participants or the Employer) and
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� (ii) will be held and administered in accord �ce with the Plan, the Policy and this
� Statement of Terms and Conditions to p benefits (or to be returned to the
� Employer).
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;� Provided, the faregoing notwithstanding, the Recordkeeper s Rll have no power to add to or subtract
� from or to modify any of the provisions of the Plan, or to c�nge or add to any benefit provided in
� the Plan.
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� 2.03 C1aim Procedure. The Recordke per shall pay or deny claims for
reimbursement of inedical expenses and dependent care ex �nses in accordance with the terms of
� the Plan, where applicable. The Recordkeeper shall refer t�he Plan Administrator any request for
� review of a denial of bene6ts pursuant to the provisions of claim pmcedures set forth in the Plan.
� In accordance with the terms of the Plan, the Plan Admini �ator (and not the Recordkeeper) sha11
, have the final and absolute authority to determine the validi � of claims and whether claims should
� be paid or denied. Claims will be retained by the Recordk �per for a period of six years plus the
� current year, after which they will be purged.
� � No reimbursement will be made to the participant under �e dependent day care and/or medical
expense reimbursement account until the first contributi 1 is received from the employer and
!� posted to the participant's account.
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� 2.04 Debit Card Procedure. The Recor Keeper sha11 pay or deny claims in the
� event that the Employer elects to allow the use of debit car ("Debit Cards") for reimbursement of
�; Eligible Medical Expenses under the Medical Expense R�nbursement Plan, in accordance with
� 3ection 8.05 of the Plan.
� 2.05 Duties of the Recordkeener. The R sordkeeper shall provide the following
� recordkeeping services to the Plan Administrator:
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;� (a) At the direction of the Plan Administrator, make expense
,� reimbursement benefit payments from Account to or for the benefit of
� Participants entitled to such henefits under Plan;
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� (b) Provide to the Plan Admini trator by January 15 of each yeaz, if
requested, annual statements of monies fro Participants received and posted who
:� participated in the Dependent Care Expens �°lan as set forth in the Plan during the
:� preceding calendaz year;
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`=� (c) Prepare a monthly recon liation of allocations and expense
`� reimbursement benefit payments made from he Account, if requested;
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:� (d) Retum unused reimbursem �t amounts which may be due to the
� Employer under the terms of the Plan and t Policy on a timely basis following the
-� runoff period after the end of the Plan year.
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ARTTCLE III
RE5PONSIBILITIES OF EMPLOYER AS PLAN ADMIN [STRATOR
3.O1 Responsibilities Concernin� Recordkeeper. The Employer sha11 take the
following actions in connection with its delegation of recordkeeping duties to the Recordkeeper:
(a) Deliver to the Recordkeeper all contributions (both by Participants
and the Employer) received by the Employer under the Plan;
(b) Provide any and all cost, claims, contribution and participation
information in the format and frequency that the Recordkeeper determines is
necessary to perform its recordkeeping duties;
(c) Interpret the Plan and provide written directions to the Recardkeeper
concerning (i) the proper interpretation of the terms of the Plan or any �pense
reimbursement provision thereunder and (ii) payment of benefits; and
(d) Complete and file an annual 5500 report, if necessary.
3.02 Indemnification of Recordkeeper. Notwithstanding any other provision of
this Statement of Terms and Conditions or the Policy, the Employer agrees to indemnify and hold
the Recordkeeper hannless from and against any liability, damage, expense (including attorney
fees) or cost that it may incur in serving as Recordkeeper under this Statement of Terms and '
Conditions, including but not limited to any claim arising from damage experienced by the ,
Employer, the Plan Administrator or a Participant in connection with the adoption or maintenance ',
or administration of the Plan, unless arising from tt�e Recordkeeper's own negligent or wi11fW
breach of the provisions of this Statement of Terms and Conditions. '
ARTICLE N
ESTABLISHMENT OF ACCOUNTS '
4.O1 Account to Hold Contributions. Pursuant to the Plan and Policy, the
Employer is required to collect contributions. The Employer does not desire to retain physical
custody of such contributions and has requested that the Recordkeeper hold and administer such
contributions as agent of the Employer, for the benefit of the Participants in the Plan. Accordingly,
the Employer hereby requests the Recordkeeper to establish the Account for and on behalf of tk�e
Employer and the Participants in the Plan. In accordance with the terms and provisions of the Plan,
the Employer shall collect and remit to the Recordkeeper all amounts collected by it under the Plan.
All amounts received by the Recordkeeper will be credited to the Account which has bee�
established in the name of the Employer by the Recordkeeper. The Employer will deliver all such
contributions as soon as reasonably possible following receipt by the Employer in accordance with
the terms of the Plan in order that such amounts may be available to pay benefits. No credits for
adjustments on previous billings are allowed; any necessary adjustment will be resolved separately
from the monthly contributions upon written agreement between Employer and Recordkeeper.
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� 4.02 Account to Remain Pro e of th Emplover. All contributions to the
` Account (and the Account itsel� shall be deemed to be an remain the e�cclusive property of the
� Employer until payment of benefits has occurred. The R�ordkeeper shall have no proprietary
� interest in or title to any amounts held in the Account, its dut �s hereunder being solely to administer
= the Account for and on behalf of the Employer and the P Xcipants in accordance with the terms
� and provisions of the Plan and this Statement of Terms and "-onditions. Further, the Account shall
in no manner whatsoever be considered as a trust or other s' ilar entity.
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; 4.03 Status of Recordkeever. The duties F the Recordkeeper hereunder shall be
� performed in its capacity as t1�e agent of the Employer �r the purposes of administering the
� Account. Due solely to the fact that the Recordkeeper is Idministering the Account for and on
� behalf of the Employer, this fact in no manner whatsoever hould be considered as a guarantee to
� either the Employer or the Participants that all funds wh h need to be made available for the
� payment of benefits under the plan are in the Account. The Recordkeeper does not warrant
� payment of any amounts otherwise due to be paid under �e Plan except with respect to those
amounts which the Employer has delivered to the Recordke �er for payment of benefits as provided
� under the Plan and the Policy. The maximum amount of ?imbursement elected by a Participant
� under the medical expense reimbursement account is avai �ble at all times during the period of
� coverage, as required under Prop. Treas. Reg. Section 1.125 �d).
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4.04 Account Not to Earn Interest. The �rnployer has specifically requested of
� and the Recordkeeper has agreed that the contributions wi not be maintained in interest bearing
'� accounts or investrnents; accordingly, the contributions he G in the Account will be held only in
� non-interest bearing accounts and investments.
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:� ARTICLE V
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� TERM OF STATEMENT OF TERMS I�TD CONDITIONS
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� 5.01 Tertnination. Unless earlier termin �d pursuant to the provisions of 5.02,
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� this Statement of Terms and Conditions shall remain in �ect for one Plan year following the
`� effective date. At the end of one Plan yeaz, this Statement o Terms and Conditions will continue in
.� full force and effect until terminated. Further, this Sta !tnent of Terms and Conditions will
;.� automatically terminate upon termination of the Plan if the ?mployer certifies to the Recordkeeper
� that no further benefits are to be paid to Participants. In the �ent of termination of this Statement of
;� Terms and Conditions, any and all amounts held in the Acc Ftnt will be returned to the Employer in
� accordance with the terms of the Policy, and the Employe rovill then be solely responsible for the
� performance of the duties othenvise required ta be perfo bed by the Recordkeeper hereunder or
� under the Plan.
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`� 5.02 Termination Upon Written Nodce. ais Statement of Terms and Conditions
:i� may be terminated with or without cause by eitt�er party u in no less than thirty (30) days written
notice to the other party. In addition, the Statement of T ms and Conditions may be terminated
'€ immediately by written notice specifying a termination �ate by any party should any of the
� following events occur: (a) a party fails to comply with the btatement of Terms and Conditions, or
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(b) an act of dishonesty or fraud is committed by any party, or (c) any other reason deemed by
American Fidelity to be a legitimate business reason. If American Fidelity insures the uniform
coverage risk, the risk policy will also terminate and all risk reverts back to the Employer. This
would include instances where the Employer consolidates with another entity during the plan
year and does not allow the flexible spending accounts to run the full length of the plan year. If
American Fidelity's recordkeeping services are terminated, or if Employer terminates either the
Section 125 Plan or the flexible spending accounts, a runoff period will only be honored if
Employer immediately provides funds to pay any outstanding claims.
ARTICLE Vl
FEES FOR SERVICES
6.01 Fees. In consideration of the Recordkeeper performing the services
described herein for the Employer, the Employer will pay a fee of $0.00 per month for participation
in one or both flexible spending accounts for each Participant in the Plan during such month.
Payment of a(1 required fees will be made each month during the term of this Statement of Terms
and Conditions following the month in which such services are performed. If the debit card is
allowed by the Employer in the Medical Expense Reimbursement Account, there will be an
additional fee of $0.00 per month per participant electing the debit card. '
ARTTCLE VII '
EXCEPTION TO ELECTiON CHANGES
7.01 Excention to Electio� Chan�es. If the employer applies for the Medical
Expense Reimbursement Policy, Participants may not make election changes under said Policy
except in the case of termination of employment unless otherwise agreed to in writing by Employer
and Recordkeeper, or otherwise stipulated by amendment to this Statement of Terms and
Conditions. This stipulation does not affect election changes under a dependent care account.
ARTICLE VIiI
COMPLIANCE WITH HIPAA REQUIREMENTS AS A
BUSINESS ASSOCIATE OF THE EMPLOYER
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8.01 Recardkeeper as Business Associate. In connection with Recordkeeper's
performance of services pursuant to this Statement of Terms and Conditions, Recordkeeper may
create, receive or have access to Pmtected Health Information. Since HIPAA regulates the use and
disclosure of Protected Health Information ("PHI"), Employer and Recordkeeper want to address
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� and ensure in this Article VIII their respective complian p with HIPAA's applicable business
� associate provisions and requirements in connection wi i the services performed under this
� Statement of Terms and Conditions. Wherever the term "E �ployer" is used in this Article VIII, it
; shall mean "Plan Administrator" and "Employer", as those t tms are defined in Paragraphs number
� 1.02 and 1.05 of this Statement of Terms and Conditions.
� 8.02 Definitions. When used in this Arti � VIII, the following terms shall have
the meanings specified adjacent to them:
� (a) "ARRA" means the American Reco �ry and Reinvestment Act of 2009.
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� (b) `Breach" means the acquisition, a�ess, use, or disclosure of PHI in a
� manner not permitted under 45 IC.F.R., Part 164, Part E, which
� compromises the security or privacy fF the PHT.
� (c) "Breach Notification Rule" means �e regulations set forth at 45 C.F.R.
� Part 164, Subpart D, as hereafter �ended, which implement the Breach
� notificatio� requirements set forth in 3IPAA.
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; (d) "Data Aggregation," "Designated R cord Set," "Secretary" and "Standard
� Transaction" shall each have the mea ng provided for that term in HIPAA.
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� (e) `Blectronic PHI" rrieans any inform �on that comes within or satisfies the
� definition of "protected health info �ation" at 45 C.F.R. §160.103, and is
� disclosed to, or created, obtained, ma ltained or received in electronic media
';� by Recordkeeper in connection Ith, or in any manner related to,
`� Recordkeeper's performance of servi �s pursuant to this Statement of Terms
:� and Conditions, or otherwise for or o behalf of Employer or any Plan.
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;g (fl "HIPAA" means the Health Insuran Portability and Accountability Act of
� 1996, and all rules and regulations p,�mulgated thereunder, as either or both
>a are amended and revised from time t kime.
;� (g) "Law" means any and all statutes, le siation, rules, regulations, codes, laws,
;� orders, decrees, decisions, and ordin �ces enacted, issued or promulgated by
:� any federal, state or local governmen 1 authority, agency, body, commission,
� board, court or legislature.
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:� (t�) "Person" means any natural person, -orporation, limited liability company,
,� partnership, tntst, or other legal enti �r organization.
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� (i) "Plan" means all individual or group �ealth plans, cafeteria plans, and similar
employee benefit plans sponsored b the Employer that provide, reimburse
;� or pay the cost of inedical care or si (ar services and to which Recordkeeper
'� now or hereafter provides services.
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(j) "Privacy Rule" means the regulations set forth at 45 C.F.R. Part 160 and
Part 164, subparts A and E, as hereafter amended, which implement the
privacy requirements set forth in the Administrative Simplification
provisions of HIPAA.
(k) "Protected Health Information" or "PHI" shall mean any information
constituting "protected health information," as that term is defined in HIPAA,
that is disclosed to, or created, obtained, maintained or received by,
Recordkeeper in connection with or in any manner related to, Recordkeeper's
performance of services pursuant to this Statement of Terms and Conditions,
or otherwise for or on behalf of Employer or any Plan.
(1) "Secretary" means the Secretary of Health and Human Services, or his or her
duly authorized designee.
(m) "Security IncidenY' has the same meaning as the term "security incidenY' in
45 C.F.R. § 164.304.
(n) "Security Rule" means the regulations set forth at 45 C.F.R. Part 164,
subpart C, as hereafter amended, which implement the security
requirements set forth in the Administrative Simplification provisions of
HIPAA.
8.03 Use and Disclosure. Recordkeeper shall neither use nor disclose PHI except '
as provided in this Article or permitted by applicable law. Except as otherwise specified in this ,
Article, Recordkeeper may make any and all uses of PHI that are reasonably necessary to perform
its undertakings with respect to the services under this Statement of Tertns and Conditions. Neither
Employer nor any Plan shall request Recordkeeper to use or disclose PHI in any manner that would
violate HIPAA. '
8.04 Further Limitations or Restrictions. Recordkeeper shall also comply with all
further limitations and restrictions on the privacy or any use or disclosure of PHI agreed by
Employer ar any Plan in accordance with 45 C.F.R. §164.522 to the extent they may affect
Recordkeeper's use or disclosure of PHI provided that Recardkeeper has received prior written ;
notification of those limitations and restrictions from Employer or the applicable Plan. Neitt�er
Employer nor any Plan will commit Recordkeeper to any such limitations or restrictions, including,
but not limited to, restrictions on the use or disclosure of PHI as provided for or limitations in 45
C.F.R. §164.522, unless those limitations or restrictions are required by applicable law or, in all
other instances, without first obtaining Recordkeeper's written approval, which approval will not be
unreasonably withheld or delayed. Employer shall immediately notify Recordkeeper of any
changes in, or revocation of, any authorization or consent of any participant of or beneficiary under
any Plan with respect to the use or disclosure of PHI, to the extent same may affect Recordkeeper.
8.05 Use for Manaeement and Administration. Recordkeeper may use PHI as
necessary for the proper management and administration of Recordkeeper or to carry out the legal
responsibilities of Recordkeeper. Recordkeeper may disclose PHI as necessary for the proper
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F inanagement and administration of Recordkeeper or to Irry out the legal responsibilities of
� Recordkeeper if (a) the disclosure is required by law or (b �rior to the disclosure, Recordkeeper
; obtains a binding written agreement from each Person to wh m Recordkeeper will disclose t1�e PHI
' which provides that each such Person will (i) hold the PHI i ponfidence and use or further disclose
a the PHI only as required by law or for the lawful purpose fo �vhich Recordkeeper disclosed it to the
� Person, and (ii) notify Recordkeeper of each instance of wh' � the Person becomes aware in which
� the confidentiality of the PHI is breached and/or a Security �ident occurs.
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; 8.06 Other Services. Recordkeeper may �se PHI, as permitted by HLPAA, to
� provide Data Aggregation services relating to the health car pperations of Employer or any Plan as
�; permitted under HiPAA. Recordkeeper may use PHI to rep k a violation of Law to the Secretary in
� accordance with HIPAA.
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� 8.07 Safe uards. Recordkeeper will use 3ppropriate, commercially reasonable
� safeguards to ensure the confidentiality of PHI permitte under this Statement of Terms and
� Conditions. Recordkeeper will implement administrative, Ihysical and technical safeguards that
; reasonably and appropriately protect the confidentiality, int grity and availability of the Electronic
� PHI that Recordkeeper creates, receives, maintains or trans �ts on behalf of Employer or any Plan.
'= Recordkeeper shall promptly notify Employer in writing a�r Recordkeeper has actual lmowledge
'� of any use or disclosure of PHI not permitted by this Articl Recordkeeper's obligation to protect
� the privacy of the PHI it created or received for or from E�loyer will be continuous and survive
,;; the termination of the Statement of Terms and Conditi Cs. Recordkeeper will report to the
`� applicable Plan and Employer any Security Incident of whic it becomes aware.
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+� 8.08 Assi n�ent. In each instance that R�ordkeeper provides PHI to any agent,
� sulrcontractor, assignee or delegatee and/or assigns or deleg kes (if such assignme�t or delegation is
:� permitted hereunder) any of its undertakings with respect � the services under this 5tatement of
'� Terms and Conditions to any other Person, then Recor �eeper shall obtain a binding written
�= agreement from each such agent, subcontractor, assignee nd delegatee requiring that Person to
� comply with the provisions of this Article with respect to ►e use, disclosure and safeguarding of
:j PHI including, without limitation, the implementation of r�sonable and appropriate safeguards to
* protect Electronic PHI and the reporting of Security Incide s involving such Person of which such
�;� Person becomes aware.
'� 8.09 Standard Transactions. If Recordk per conducts in whole or in part any
> Standard Transaction for or on behalf of Employer or an Plan, Recordkeeper will comply, and
� Recordkeeper will require any of its subcontractors or ag �ts involved with the conduct of such
� Standard Transaction to comply, with each applicable r �uirement of HIPAA as respects that
� Standard Transaction, as follows:
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' (a) When either party provides, transmits or exchan �es data and information electronically
� to the other pariy with respect to any Plan, Gat party shall transfer the data and
information in the code sets, data elements, utd formats reasonably specified by
'` Recordkeeper. To the extent required by HIP , Recordkeeper shall only specify and
'r use the code sets, data elements and formats th comply with HIPAA. All electronic
'< transmissions between the parties shall be to �e address provided by the receiving
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party to the transmitting party. Plan Administrator authorizes Recordkeeper to submit
such data and information to Plan Administrator in the specified electronic format after
completion of successful testing thereof. If Plan Administrator is unable or unwilling
to transfer data in the specified legal electronic format proposed by Recordkeeper, the�
Recordkeeper shall be under no obligation to receive or transmit data in any other
: format.
(b) Recordkeeper shall use its reasonable efforts to provide Plan Administrator with at
least sixty (60) days' prior wrirten notice of any proposed change by Recordkeeper to
any code sets, data elements or segments, and formats then being used by the parties
hereto for purposes of the electronic exchange of data and information concerning any
Plan.
(c) Each party will take reasonable measures to ensure that its data transmissions
conceming the Policy or containing any PHI are timely, accurate, complete, and
secure, and will take reasonable precautions to prevent unauthorized access to the other
party's data transmission or operating system. If either party receives data from the
other pariy that was not intended for it, the receiving party will immediately notify the
sender to arrange for, at the sender's sole election, the return, re-transmission or
destruction of that data. '
(d) Each party will obtain and maintain, at its own expense, its own operating system
necessary for timely, complete, accurate, and secure data transmission pursuant to this
Statement of Terms and Conditions. Each party will pay its own costs related to data
transmission under this Statement of Terms and Conditions, including, without
limitation, charges for the party's own operating system equipment, software and '
services, maintaining an electronic mailbox, connection time, terminals, connections, '
telephones, internet service providers, modems, and applicable minimum use charges,
except as otherwise provided in this Statement of Terms and Conditions or any other
agreement between the parties. Each party will be responsible for its own expenses
incurred in connection wit1� translating, formatting, and sending or receiving ;
communications over the electronic network to any electronic mailbox of the other
party, except as otherwise provided in this Statement of Terms and Conditions or any
- other agreement between the parties. ;
(e) Each party will provide the other party with all information (including, without
limitation, access and security codes) reasonably necessary to allow access to the other
paMy's operating system in order to successfully complete data transmissions and
satisfy the transmission and security requirements provided in this Statement of Terms
and Conditions. Each party shall test, and cooperate with the other party in testing,
each party's operating system to reasonably ensure the accuracy, timeliness,
completeness, and confidentiality of each data transmission made in connection with
any Plan.
(fl Each party shall use its reasonable efforts in accordance with prudent business
practices to provide uninterrupted access to the operating system of the other party for
purposes of electronic transmissions concerning any Plan.
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� (g) The parties shall use their good faith efforts t incorporate herein such applicable
� requirements of HIPAA khat are hereafter ado �d concerning the privacy, security,
� standardization or encryption of electronic data psmissions involving any Plan.
� � 8.10 Access. Upon Employer's reasona e written request, Recordkeeper will
make available to Employer or, at Employer's direction, to � individual participant in any Plan (or
� the individual's personal representative) any PHT (in its pos pssion or under its reasonable control)
;� conceming the individual in a Designated Record Set for hi pr her inspection and obtaining copies
� for so long as the PHI is so maintained by Recordkeeper. he PHI shall be made available in the
� format requested by the individual, unless the PHI is not rea �y producible in such format, in which
� case it shall be produced in a readable hard copy format. Rewrdkeeper shall have the right to
� F charge the individual a reasonable cost-based fee, as permitted by 45 C.F.R. §164.524.
Recordkeeper does not assume any obligation to coordi � access to PHT maintained by other
� business associates of Employer or any Plan. Recordk �per shall make its internal policies,
�t
� procedures, practices, books and records relating to its s�eguarding, use or disclosure of PHI
'� available to the Secretary, in a time and manner reasonably �ignated by the Secretary for purposes
'� of determining Employer or any Plan's compliance with 1A.
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';� 8.11 Amendment of PHI. Upon Employe s request, Recordkeeper will promptly
� amend, or provide Employer with reasonable access to pro ptly amend, any portion of the PHI or
� any record in a Designated Record Set in accordance with IS C.F.R. §164.526 for as long as the
� PHI is maintained in a Designated Record Set in the posse �on or under the reasonable control of
� Recordkeeper.
� 8.12 Accounting. Recordkeeper will m Rtain a record for each disclosure of
:� PHI, which is not excepted ftom disclosure accounting unde HIPAA, including, without limitation,
:� 45 C.F.R. § 164.528, that Recordkeeper makes to any rson. Tl�at record shall include all
� '' inforrr►ation that Employer would be required under HIPAA o respond to a request by a participant
in any Plan (or his or her personal representative) for accounting of disclosures of PHI in
`� accordance with HIPAA, including, without limitation, e information required by 45 C.F.R.
� § 164.528(b)(2)•
�
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� 8.13 Breach of Obligations. If Emplo �r determines that Recordkeeper has
;� breached the provisions of this Article in any material res �t and Recordkeeper has not remedied
-� or cannot remedy that breach within fifteen (15) days after ¢ receipt of written notification thereof
� from Employer, Employer may terminate the recordkeep' �g arrangement and this Statement of
� Terms and Conditions or, if termination is not feasible, repo the breach to the Secretary.
�
a�
# 8.14 Return of PHI. Upon termination o khe recordkeeping arrangement or this
-� 5tatement of Terms and Conditions and as to the ext permitted by applicable law and as
`� consistent with its other obligations and undertakings provi :d in this Article, Recordkeeper will, if
� feasible, return to Employer or destroy all PHI that Rec rdkeeper still maintains in any form,
$ including all copies of any data or compilations derived �m and allowing identification of any
� individual who is a subject of the PHI. Recordkeeper will Complete such return or destruction as
;� promptly as possible. Recordkeeper will identify the condi pns that make the return or destruction
of any PHI infeasible and any PHI that Recordkeeper canno feasibly return to Employer or destroy.
;� Recordkeeper will limit its further use or disclosure of th t PHI to those purposes that make its
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return ar destruction of tt�at PHI infeasible, and extend the safeguards and protections of this
Statement of Terms and Conditions to that PHI.
8.15 Compliance By Employer. As between Employer and Recordkeeper,
Employer shall be solely responsible for compliance with the applicable plan sponsar disclosure
rules of 45 C.F.R. §164.504(fl and other requirements of HIPAA applicable to Employer as the
sponsor and/or administrator of any Plan. As between a Plan and Recordkeeper, such Plan shall be
solely responsible for its compliance with the applicable obligations and requirements under HIPAA
applicable to that Plan as a covered entity. To the extent that Recardkeeper provides PHI (other
than `sununary health information," within the meaning of 45 C.F.R. §164.504(a), or enrollment
information) to Employer in connection with the services performed under this Statement of Terms
and Conditions or otherwise, Employer will ensure compliance with the requirements of HIPAA
including 45 C.F.R. §164.504(fl with respect to that PHI. To the extent that Employer is relying
upon the "summary health information" exception to the foregoing plan sponsor disclosure
requirements, Empbyer will ensure, consistent with the provisions of 45 C.F.R. § 164.504( fl(ii), that
the information in question meets the requirements of that defmition and that the informa6on is
sought for the purpose of obtaining premium bids or for modifying, amending or terminating the
group health plan or any other legally permissible purpose.
8.16 Amendments to HIPAA. Upon the effective date of any fmal regulation or
amendment to H�AA that conflicts witt� any term of this Article or which imposes any
requirement, condition or obligation upon Recordkeeper, Employer or any Plan conceming the
subject matter hereof that is not imposed by this Article, then this Article will be automatically
amended to incorporate the applicable terms and conditions of that regulation or amendment such
that this Article contractually imposes those terms upon the party or parties hereto to which they
apply. Any ambiguity in this Article shall be resolved in favor of a meaning that results in the '
parties complying with HIPAA.
8.17 Effective Date. This Article shall be effective on the effective date of this
5tatement of Terms and Conditions, except with respect to the applicable requirements of the
HIPAA security standards for the pmtection of Electronic PHI set forth at Subpart C of Part 164 of
Title 45 of the Code of Federal Regulations, which shall be ef�ective on the later of the effective
date of this Statement of Terms and Conditions or April 20, 2005. The Employer or any Plan's
engagement of Recordkeeper to perform any services during which Recordkeeper may create or
have access to PHI shall constitute Employer and that Plan's acceptance of, and agreement tq all
the terms and provisions of this Article. '
8.18 ARRA Compliance. Recordkeeper acknowledges and agrees, as of the
applicable effective dates for such provisions, Recordkeeper shall comply with each provision of the
American Recovery and Reinvestment Act of 2009 ("ARRA") that extends HIPAA Privacy or
Security Rule requirements to Business Associates of Covered Entities. The term `Business
Associate" and "Covered Entity" shall have the meanings given such terms at 45 C.F.R. § 160.103.
8.19 Comnliance with Breach Notification Rule. Recordkeeper shall report any
Breach to Employer and Plan as soon as possible, but in no event later than 30 days after
Recordkeeper becomes aware of any Breach. Recordkeeper shall, at the direction of the Plan,
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� cooperate and assist in investigating the Breach, perfo iing a risk assessment, determining
� � whether the Breach is reportable under the Breach N�fication Rule, and taking steps to
� minimize any adverse consequences resulting from th Breach. Recordkeeper shall take
appropriate disciplinary action against any of its employ �s that were involved in the Breach.
Recordkeeper shall not report the Breach to any individua the Secretary or the media and shall
� keep the investigation strictly confidential. 1'he Plan sha i, make the determination of whether
� the Breach is a reportable Breach under khe Breach Not ication Rule and shall comply with
� applicable reporting requirements.
�
SECTION IX
�
' MISCELLANEOUS
�
� � 9.01 Ac6on bv the Emplover. Whenev r under the Statement of Tercns and
Conditions the Employer is permitted or required to do or �form any act or thing, it shall be done
� and performed by an officer or a proper authority of the Em oyer.
� 9.02 Notices. All notices, advice, directi � or reports required or permitted to be
� given under this Statement of Terms and Conditions shall b in writing and shall be mailed postage
� prepaid or delivered by hand and acknowledged by signed r'�eipt, addressed as follows:
�
�
� To Recordkeeper:
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� American Fidelity Assurance Company
� AWD Section 125 Administration
� 2000 Classen Center
� P O Box 268887
;� Oklahoma City, OK 73125-0640
�
'� To Employer at last known address
�
� 9.03 Applicable Law. The provisions of iis Statement of Terms and Conditions
� shall be construed, administered, and enforced according to ie laws of the State of Oklahoma.
� 9.04 Amendment. This Statement of Te Is and Conditions may be amended by
� Recordkeeper by written notice to Employer.
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n 9.05 Titles. The title of the Articles 3 Paragraphs hereof are included for
� convenience only and shall not be construed as a part of thi Statement of Terms and Conditions or
;:� in any respect affecting or modifying its provisions.
�
� 9.06 Severabilitv. If any provision or p�isions of this Statement of Terms and
� Conditions shall be held illegal or invalid for any reason, s� illegality or invalidity shall not affect
°� the remaining provisions of this Statement of Terms and Co ditions, but shall be fully severable and
.-3 the Statement of Terms and Conditions shall be constrved nd enforced as if said illegal or invalid
'; provisions had never been inserted herein.
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9.07 Controlling Agreement. This Statement of Terms and Canditions supersedes
and replaces any prior agreement between the parties with respect to the subject matter contained
herei�.
THIS STATEMENT IS NULL AND VOID IFALTERED INANY WAY.
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SECTION 125 FLEXIBLE BENEFIT PLAN
ADOPTION AGREEMENT
The undersigned Employer hereby adopts the Section I25 Flexible Beneftt Plan jor those
Employees who shall qualify as Participants hereunder. The E►nployer hereby selects the
following Plan specifications:
A. EMPLOYER INFORMATION
Name of Employer: CITY OF RNERSIDE MISSOURI
Address: 2950 NW VNION RD
RNERSIDE, MO 64150
Employer ldentification Number: 44-6005867
Nature of Business: MUNICIPALITY
Name of Plan: CITY OF RNERSIDE MTSSOURI
FLEXTBLE BENEFIT PLAN
Plan Number: 501
B. EFFECTIVE DATE
Original effective date of the Plan: January 15, 2001
If Amendment to existing plan,
effective date of amendment: July 1, 2012
C. ELIGIBILITY REOUIREMENTS FOR PARTICIPATION
Eligibility requirements for each component plan under this Section 125 document will
be applicable and, if different, will be listed in Item F.
Length of Service: First day of the month following
employment.
Minimum Hours: All employees with 40 hours of service or
more each week. An hour of service is each
hour for which an employee receives, or is
entitled to receive, payment for performance
of duties for the Employer. :
Age: Minimum age of 0 years.
D. PLAN YEAR The current plan year will begin on July l,
2012 and end on June 30, 2013. Each
subsequent plan year will begin on July 1
and end on June 3Q
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� E. EMPLOYER CONTRIBUTIONS
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' Noo-Elective Contributions:
� The hployer may at its sole discretion
� provid a non-elective contribution to
� provid benefits for each Participant under
the Pl R. This amount will be set by the
� Empl er each Plan Year in a uniform and
� non-di Criminatory manner. If this non-
� electiv contribution amount exceeds the
� cost o benefits elected by the Participant,
� excess amounts will not be paid to the
� Partici �ar►t as taxable cash.
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� Elective Contributions
� (Salary Reduction): The �ximum amount available to each
� Partic' !ant for the purchase of elected
� benefi � through salary reduction will be:
� 100% if compensation per entire plan year.
:� � Each Participant may authorize the
�
� Empl !er to reduce his or her compensation
� by th amount needed for the purchase of
� benefi t elected, less the amount of non-
,� electi - contributions. An election for
;� salary �duction will be made on the benefit
electi ► form.
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F. AVAILABLE BENEFITS: Each of the following components should be considered a
plan that comprises this Plan.
1. Grouo Medical Insurance -- The terms, conditions, and
limitations for the Group Medical Insurance will be as set forth in the
insurance policy or policies described below: (See Section V of the Plan
Document)
Humana
Cigna
American Fidelity Assurance Company Accident Only Plan
Eli�ibilitv Renuirements for Participatio�, if different than Item C.
2. Disabilitv Income Insurance -- The terms, conditions, and limitations for the
Disability Income Insurance will be as set forth in the insurance policy or policies
described below: (See Section VI of the Plan Document)
N/A
Eligibilit�equirements for Particination, if different thari Ttem C.
3. Cancer Coveraee -- The terms, conditions, and limitations for the Cancer '
Coverage will be as set forth in the insurance policy or policies described below:
(See 5ection V of the Plan Document) '
American Fidelity Assurance Company C-12 and subsequent
policies
Eligibility Requirements for Participation, if different than Item C.
4. DentaUVision Insurance -- The terms, conditions, and limitations for the
DentalNision Insurance will be as set forth in the insurance policy or policies
described below: (See Section V of the Plan Document)
Detta Dental
Vision Service Plan
Eligibility Reyuirements for Participation, if different than Item C.
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� 5. Grouo Life Insurance which will be com ised of Group-term life insurance
$ and Individual term life insurance under Sec ion 79 of the Code.
�
� The terms, conditions, and limitations for � Group Life Insurance will be as set
; forth in the insurance policy or policies des ribed below: (See Section VII of the
� . Plan Document)
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� American Fidelity Assurance Co pany
�
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� Individual life coverage under Section 79 � available as a benefit, and the face
� amount when combined with the group-te life, if any, may not exceed $50,000.
�
� Eli ibili Re uirements for Partici ation i different than Item C.
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� 6. Deaendent Care Assistance Plan -- The te hs, conditions, and
; limitations for the Dependent Care Assistan e Plan will be as set
� forth in Section IX of the Plan Document l described below:
;�
� Minimum Contribution -$120.00 p r Plan Year
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-� Maximum Contribution -$ 5000.00 �er Plan Year
�
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;� Recordkeeper: American Fidelity surance Company
�
� Eli ibili Re uirements for Partici ation i�iifferent than Item C.
� N/A
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� 7. Medical Exaense Reimbursement Plan -- [1�e terms, conditions, and
'� limitations for the Medical Expense Reimb �sement Plan will be as set
� forth in Section VIII of the Plan Document hd described below:
';� Minimum Coverage -$120.00 per lan Year
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'� Maximum Coverage -$ 2500.00 pe Plan Year
,:� Recordkeeper: American Fidelity surance Company
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3� Restrictions: N/A
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� Grace Period: The provisions in Se ion 8.06 of the Plan to permit a Grace
;� Period with respect to the Medic I Expense Reimbursement Plan are
� elected.
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HEART: The provisions in Section 8.07 of the Plan to permit the
Qualified Reservist Distribution of the Heroes Earnings Assistance and
Relief Tax Act (HEART) are elected.
Debit Card: The provisions in Section 8.05 of the Plan to permit the offer
of the Debit Card with respect to the Medical Expense Reimbursement
; Plan are elected.
Eligibilitv Requirements for Participatio�, if different than Item C.
8. Health Savings Accounts — The Plan permits contributions to be made to a
Health Savings Account on a preta�r basis in accordance with 3ection X of the
Plan and the following provisions:
HSA Trustee — As designated by the employee and mutually agreed
upon by the employer.
Maacimum Contribution — As indexed annually by the IRS.
Limitation on Eligible Medical Expenses — For purposes of the Medical
Reimbursement Plan, Eligible Medical Expenses of a Participant that is eligible
for and elects to participate in a Health Savings Account shall be limited to
expenses for:
Dental and Vision
Eligibility Reguirements for Participation, if different than Item C.
a. An Employee must complete a Certification of Health Savings Account
Eligibility which confirms that the Participant is an eligible individual who
is entitled to establish a Health Savings Account in accordance with Code
Section 223(c)(1).
b. Eligibility for the Health Savings Account shall begin on the later of (i)
first day of the month coinciding with or next following the Employee's
commencement of coverage under the High Deductible Health Plan, or (ii)
the first day following the end of a Grace Period available to tk�e Employee
with respect to the Medical Reimbursement Accounts that are not limited
to vision and denial expenses (unless the participant has a$0.00 balance
on the last day of the plan year).
c. An Employee's eligibility for the Health Savings Account shall be ,
determined monthly.
6
The Plan shall be wnstrued, enforced, administered, and the validity determined in
accordance with the applicable provisions of t6e Employee Retirement Income Security Act
of 1974, (as amended) if applicable, the Internal Revenue Code of 1986 (as amended), and
the laws of the State of Missouri. Should any provision be determined to be void, invalid,
or unenforceable by any court of competent jurisdiction, the Plan will continue to operate,
and for purposes of the jurisdiction of the court only, will be deemed not to include the
provision determined to be void.
This Plan is hereby adopted this �� p day of w� , 20 l�
CITY OF RIV�RSIDE MISSOURI
(Name qf.�i mployer) �
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. Witn By.; �. __. --
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1 � .� Title• t� � 11a � `��A �e Q_„
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APPENDIX A
Related Employers that have adopted this Plan
Name(s):
N/A
THI5 DOCUMENT IS NOT COMPLETE WITHOUT SECTIONS I THROUGH XIII
PDOSiIsw 23661 5/30/2012 12:27 AM
7
SECTION 125 FLEXIBLE BENEFI'I' PLAN
; SECTION I
PURPOSE
The Employer is establishing this Flexible Benefit Plan in order to make a broader range of benefits available to
its Employees and their Beneficiaries. This Plan allows Employees to choose among different types of benefits
and select the combination best suited to their individual goals, desires, and needs. T'hese choices include an
option to receive certain benefits in lieu of taa�able compensation.
In establishing this Plan, the Employer desires to attract, reward, and retain highly qualified, competent
Employees, and believes this Plan will help achieve that goal.
It is the intent of the Employer to establish this Plan in conformity with Section 125 of the Intemal Revenue
Code of 1986, as amended, and in compliance with applicable rules and regulations issued by the Internal
Revenue Service. This Plan will grant to eligible Employees an opportunity to purchase qualified benefits
which, when purchased alone by the Employer, would not be ta�Lable.
SECTION II
DEFINITIONS
The following words and phrases appear in this Plan and will have the meaning indicated below unless a
different meaning is plainly required by the context: '
2A1 Administrator The Employer unless another has been designated in writing by the
Employer as Administrator within the meaning of Section 3(16) of ERISA
(if applicable).
2.02 Beneficiary Any person or persons designated by a participating Employee to receive
any benefit payable under the Plan on account of the Employee's death.
2.03 Code Internal Revenue Code of 1986, as amended. '
2.04 Dependent Any of the following:
(a) Tax Dependent: A Dependent includes a Participant's spouse and
any other person who is a Participant's dependent within the
meaning of Code Section 152, provided that, with respect to any
plan that provides benefits that are excluded from an Employee's
income under Code Section 105, a Participant's dependent (i) is
any person within the meaning of Code Section 152, determined
without regard to Subsections (b)(1), (b)(2), and (d)(1)(B) ;
thereof, and (ii) includes any child of the Participant to whom ,
Code Section 152(e) applies (such child will be treated as a
dependent of both divorced parents).
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� � (b) Student on a Medicall ,Necessarv Leave of Absence: With
� respect to any plan that is onsidered a group health plan under
� Michelle's Law (and not a HIPAA excepted benefit under Code
� 5ections 9831(b), (c) and 98 �(c)) and to the extent the Employer is
required by Michelle's La to provide continuation coverage, a
� Dependent includes a chil who qualifies as a Ta�c Dependent
� (defined in Section 2.04(a)) iecause of his or her full-time student
� status, is enrolled in a gro a health plan, and is on a medically
� necessary leave of absence �m school. The child will continue to
� be a Dependent if the idically necessary leave of absence
commences while the child is suffering from a serious illness or
� injury, is medically necess ', and causes the child to lose student
� status far purposes of the roup health plan's benefits coverage.
; Written physician certi6cat �n that the child is suffering from a
� serious illness or injury and that the leave of absence is medically
� necessary is required at the dministrator's request. The child will
� no longer be considered a D pendent as of the earliest date that the
;� child is no longer on a me lcally necessary leave of absence, the
� date that is one year after t� first day of the medically necessary
� leave of absence, ar the d C benefits would otherwise terminate
� under either the group heal t plan or this Plan. Terms related to
� Michelle's Law, and not ot prwise defined, will have the meaning
� provided under the Michel .'s Law provisions of Code Section
9813.
�
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� (c) Adult Children: With re pect to any plan that provides benefits
:� that are excluded from an hployee's income under Code Section
� 105, a Dependent includes a�hild of a Participant who as of the end
;� of the calendar year has not lttained age 27. A`child' for purpose
� of this Section 2.04(c) mea ' an individual who is a son, daughter,
stepson, or stepdaughter ' the Participant, a legally adopted
individual of the Participan an individual who is lawfully placed
� with the Participant for le tl adoption by the Participant, or an
� eligible foster child who � placed with the Participant by an
� authorized placement agenc or by judgment, decree, or otk►er order
� of any court of competent j'isdictioo. An adult child deacribed in
';� this Section 2.04(c) is onl a Dependent with respect to benefits
',� provided after March 30, 2 l0 (subject to any other limitations of
� the Plan).
�
� Depe�dent for purposes of � Dependent Care Reimbursement Plan
� is defined in Section 9.04(a)
�
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� 2.05 Effective Date The effective date of this 'lan as shown in Item B of the Adoption
� Agreement.
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2.06 Elective Contribution The amount the Participant authorizes the Employer to reduce
compensation for the purchase of benefits elected.
2.07 Eligible Employee Employee meeting the eligibility requirements for participation as shown
in Item C of the Adoption Agreement.
2.08 Employee Any person employed by the Employer on or after the Effective Date.
2.09 Employer The entity shown in Item A of the Adoption Agreement, and any Related
Employers authorized to participate in the Plan with the approval of the
Employer. Related Employers who participate in this Plan are listed in
Appendix A to the Adoption Agreement. For the purposes of Section
11.01 and 11.02, only the Employer as shown in Item A of the Adoption
Agreement may amend or terminate the Plan.
2.10 Employer Contributions Amounts that have not been actually received by the Participant and are
available to the Participant for the purpose of selecting benefits under the
Plan. This term includes Non-Elective Contributions and Elective
Contributions through salary reduction.
2.11 Entry Date The date that an Employee is eligible to participate in ttie Plan.
2.12 ERISA The Employee Retirement Income Security Act of 1974, Public Law 93-
406 and all regulations and rulings issued thereunder, as amended (if
applicable).
2.13 Fiduciary The named fiduciaty shall mean the Employer, the Administrator and
other parties designated as such, but only with respect to any specific
duties of each for the Plan as may be set forth in a written agreement.
2.14 Health Savings Account A"health savings accounY' as defined in Section 223(d) of the Internal
Revenue Code of 1986, as amended established by the Participant with the '
HSA Trustee.
2.15 HSA Trustee The Trustee of the Health Savings Account which is designated in Section '
F.8 of the Adoption Agreement. '
2.16 Highly Compensated Any Employee who at any time during the Plan Year is a"highly
compensated employee" as defined in Section 414(q) of the Code.
2.17 High Deductible Health A health plan that meets the statutoty requirements for annual deductibles
Plan and out-of-pocket expenses set forth in Code section 223(c)(2).
2.15 HIPAA The Health Insurance Portability and Accountability Act of 1996, as
amended.
2.l 9 Insurer Any insurance company that has issued a policy pursuant to the terms of
this Plan.
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� 2.20 Key Employee Any Participant who is a"k r employee" as defined in Section 4l6(i) of
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the Code.
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�
� 2.21 Non-Elective A contribution amount made �vailable by the Employer for tt�e
s Contribution purchase of benefits elected r the Participant.
�
� 2.22 Participant An Employee who has quali ed for Plan participatio� as provided in Item
� C of the Adoption Agreeme
�
� 2.23 Plan The Plan referred to in ite A of the Adoption Agreement as may be
� amended from time to time.
�
�
� 2.24 Plao Year The Plan Year as specified i Item D of the Adoption Agreement.
�
� 2.25 Policy An insurance policy issued a a part of this Plan.
�
� 2.26 Preventative Care Medical expenses which me t the safe harbor definition of "preventative
`� care" set forth in IRS Notic 2004-23, which includes, but is not limited
� to, the following: (i) periodi health evaluations, such as annual physicals
£ (and the tests and diagnostic �rocedures ordered in conjunction with such
� evaluations); (ii) well-baby td/or well-child care; (iii) immunizations for
'� adults and children; (iv) �bacco cessation and obesity weight-loss
� programs; and (v) screening evices. However, preventative care does not
generally include any servi e or benefit intended to treat an existing
� illness, injury or condition.
�
�
x 2.27 Recordkeeper The person designated by ie Employer to perform recordkeeping and
� other ministerial duties 4ith respect to the Medical Expense
II� Reimbursement Plan and/or �e Dependent Care Reimbursement Plan.
:�
�
� 2.28 Related Employer Any employer that is a me ber of a related group of organizations with
the Employer shown in It � A of the Adoption Agreement, and as
� specified under Code Sectio 414(b), (c) or (m).
:�
'>�
�
;;
�
'� 5ECTION III
:�
:�
;� ELIGIBILITY, ENROLLMENT, AN PARTICIPATION
`� •
`� 3.01 ELIGIBILITY: Each Employee of the Employer who ha h�et the eligibility requirements of Item C of
� the Adoption Agreement will be eligible to participate i the Plan on the Entry Date specified or the
:;�
� Ef�'ective Date of the Plan, whichever is later. Depend it eligibility to receive benefits under any of
� the plar►s listed in Item F of the Adoption Agreement 11 be described in the documents governing
`e those benefit plans. To the extent a Dependent is eligible o receive benefits under a plan listed in Item
� F, an Eligible Employee may elect coverage under �is Plan with respect to such Dependent.
' Notwithstanding the foregoing, life insurance coverage o the life of a Dependent may not be elected
;�
� under this Plan.
� 11
�
3A2 ENROLLMENT: An eligible Employee may enroll (or re-enroll) in the Plan by submitting to the
Employer, during an enrollment period, �n Election Form which specifies his or her benefit elections for
the Plan Year and which meets such standards for completeness and accuracy as the Employer may
establish. A Participant's Election Form shall be completed prior to the beginning of the Plan Year, and
shall not be effective prior to the date such form is submitted to the Employer. Any Election Form
submitted by a Participant in accordance with this Section shall remain in effect until the earlier of the
following dates: the date the Participant terminates participation in the Plan; or, the effective date of a
subsequently filed Election Form.
A Participant's right to elect certain benefit coverage shall be limited hereunder to the extent such rights
are limited in the Policy. Furthermore, a Participant will not be entitled to revoke an election after a
period of coverage has commenced and to make a new election with respect to the remainder of the
period of coverage unless both the revocation and the new election are on account of and consistent with
a change in status, or other allowable events, as determined by Section 125 of the Intemal Revenue
Code and the regulations thereunder.
3.03 TERMINATION OF PARTICIPATION: A Participant shall continue to participate in the Plan until the
earlier of the following dates:
(a) The date the Participant terminates employment by death, disability, retirement or other '
separation from service; or
(b) The date the Participant ceases to work for the Employer as an eligible Employee; or
(c) The date of termination of the Plan; or
(d) The first date a Participant fails to pay required contributions while on a leave of absence.
3.05 SEPARATiON FROM SERVICE: The existing elections of an Employee who separates from the '
employment service of the Employer shall be deemed to be automatically terminated and the Employee
will not receive benefits for the remaining portion of the Plan Year.
3.06 QUALIFYING LEAVE UNDER FAMILY LEAVE ACT: Notwithstanding any provision to the
contrary in this Plan, if a Participant goes on a qualifying unpaid leave under the Family and Medical
Leave Act of 1993 (FMLA), to the extent required by the FMLA, the Employer will continue to
maintain the Participant's existing coverage under the Plan with respect to benefits under Section V and
Section Viil of the Plan on the same terms and conditions as though he were still an active Employee. If
the Employee opts to continue his coverage, the Employee may pay his Elective Co�tribution with after-
tax dollars while on leave (or pre-tax dollars to the extent he receives compensation during the leave),
or the Employee may be given the option to pre-pay all or a portion of his Elective Contribution for the
expected duration of the leave on a pre-tax salary reduction basis out of his pre-leave compensation
(including unused sick days or vacation) by making a special election to that effect prior to the date such
compensation would normally be made available to him (provided, however, that pre-taaL dollars may
not be utilized to fund coverage during the next plan year), or via other arrangements agreed upon
between 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 on the same basis the Employee was participating in the Plan prior
to his leave, or as otherwise required by the FMLA.
12
7
�
,�
a
g
�
�
�
� SECTION IV
I�Y
N
1
� CONTRIBUTION
i �
� 4.01 EMPLOYER CONTRIBUTIONS: The Employer may p' the costs of the benefits elected under the
,� Plan with funds from the sources indicated in Item E' the Adoption Agreement. The Employer
� Contribution may be made up of Non-Elective Contributi �ts and/or Elective Contributions authorized
� by each Participant on a salary reduction basis.
� 4.02 IRREVOCABILITY OF ELECTIONS: A Participant �ay file a written election form with the
� Administrator before the end of the cunent Plan Ye revising the rate of his contributions or
a discontinuing such contributions effective as of the first day of the next following Plan Year. The
� Participant's Elective Contributions will automatically �erminate as of the date his employment
_� terminates. Except as provided in this Section 4.02 and S ation 4.03, a Participant's election under the
� Plan is irrevocable for the duration of the plan year � which it relates. The exceptions to the
� irrevocability requirement which would permit a mid-ye r election change in benefits and the salary
� reduction amount elected are set out in the Treasury regu �tions promulgated under Code 5ection 125,
;� which include the following:
�
�
;� (a) Change in Status. A Participant may change or �oke his election under the Plan upon the
;� occurrence of a valid change in status, but only if such :hange or termination is made on account of,
� and is consistent with, the change in status in accord �e with the Treasury regulations promulgated
under Section 125. The Employer, in its sole discretio as Administrator, shall determine whether a
� requested cha�ge is on account of and consistent with ohange in status, as follows:
:�
� (1) Change in Employee's legal marital status, inclu ing marriage, divorce, death of spouse, legal
� separation, and annulment;
� (2) Change in number of Dependents, including birth 4doption, placement for adoption, and death;
;� (3) Change in employment status, including any �nployment status change affecting benefit
; eligibility of the Employee, spouse or Depende , such as termination or commencement of
„ employment, change in hours, strike or lockout a commencement or return from an unpaid
� leave of absence, and a change in work site. If th eligibility for either the cafeteria Plan or any
t underlying benefit plans of the Employer of the . mployee, spouse or Dependent relies on the
;� employment status of that individual, and there s a change in that individual's employment
� � status resulting in gaining or losing eligibility un er the Plan, this constitutes a valid change in
status. This category only applies if benefit eligi iliry is lost or gained as a result of the event.
:� if an Employee terminates and is rehired within � days, the Employee is required to step back
'' into his previous election. Lf the Employee t tminates and is rehired after 30 days, the
,;� Employee may either step back into the previous ection or make a new electio�;
,� (4) Dependent satisfies, or ceases to satisfy, Depen nt eligibility requirements due to attaintnent
� of age, gain or loss of stude�t status, marriage or 1y similar circumstances; and
:� (5) Residence change of Employee, spouse or Depe �ent, affecting the Employee's eligibility for
� coverage.
� (b) Snecial Enrollment Ri�ts. If a Participant or his or er spouse or Dependent is entitled to special
� enrollment rights under a group health plan (other tha an excepted benefit), as required by HIPAA
':� . under Code Section 9801(fl or Section 2701(fl of the �ublic Health Service Act, then a Participant
� may revoke a prior election for group health plan cov kage and make a new election, provided that
� the election change corresponds with such HIPAA spe 'lal enrollment right. As required by HIPAA,
� a special enrollment right wili arise in the following :ircumstances: (i) a Participant or his or her
;� 13
'�
�
spouse or Dependent declined to enroll in group health plan coverage because he or she had
coverage, and eligibility for such coverage is subsequently lost because the coverage was provided
under COBRA and the COBRA coverage was exhausted, or the coverage was non-COBRA
coverage and the coverage terminated due to loss of eligibility for coverage or the employer
contributions for the coverage were terminated; (ii) a new Dependent is acquired as a result of
marriage, birtl�, adoption, or placement for adoption; (iii) the Participant's or his or her spouse's or
Dependent's coverage under a Medicaid plan or under a children's health insurance program (CHIP)
is terminated as a result of loss of eligibility for such coverage and the Participant requests coverage
under the group health plan not later than 60 days after the date of termination of such coverage; or
(iv) the Participant, his or her spouse or Dependent becomes eligible for a state premium assistance
subsidy from a Medicaid plan or through a state children's insurance program with respect to
coverage under the group health plan and the Participant requests coverage under the group health
plan not later than 60 days after the date the Participant, his or her spouse or Dependent is
determined to be eligible for such assistance. An election change under (iii) or (iv) of this provision
must be requested within 60 days after the termination of Medicaid or state health plan coverage or
the determination of eligibility for a state premium assistance subsidy, as applicable. Special
enrollment rights under the health insurance plan will be determined by the terms of the health
insurance plan.
(c) Certain Jud�ments. Decrees or Orders. If a judgment, decree or order resulting from a divorce, legal
separation, annulment or change in legal custody (including a qualified medical child support order
[QMCSO]) requires accident or health coverage for a Participant's child or for a foster child who is
a dependent of the Participant, the Participant may have a mid-year election change to add or drop
coverage consistent with the Order. ',
(d) Entitlement to Medicare or Medicaid. If a Participant, Participant's spouse or Participant's
Dependent who is enrolled in an a.ccide�t or health plan of the Employer becomes entitled to
Medicare or Medicaid (other than coverage consisting solely of benefits under Section 1928 of the
Social Security Act providing for pediatric vaccines), the Participant may cancel or reduce health '
coverage under the Employer's Plan. Loss of Medicare or Medicaid entitlement would allow the
Participant to add health coverage under the Employer's Plan.
(e) Family Medical Leave Act. If an Employee is taking leave under the rules of the Family Medical
Leave Act, the Employee may revoke previous elections and re-elect benefits upon return to work.
(fl COBRA Oualifying Event. If an Employee has a COBRA qualifying event (a reduction in hours of
the Employee, or a Dependent ceases eligibility), the Employee may increase his pre-tax
contributions for coverage under the Employer's Plan if a COBRA event occurs with respect to the
Employee, the Employee's spouse ar Dependent. The COBRA rule does not apply to COBRA
coverage under another Employer's Plan.
(g) Chan�es in Eli ig bilitv for Adult Children. To the extent the Employer amends a plan listed in Item
F of the Adoption Agreement that provides benefits that are excluded from an Employee's income
under Code Section 105 to provide that Adult Children (as defined in Section 2.04(c)) are eligible to
receive benefits under the plan, an Eligible Employee may make or change an election under this
Plan to add coverage for the Adult Child and to make any conesponding change to the Eligible
Employee's coverage that is consistent with adding coverage for the Adult Child.
(h) Notwithstanding anything to the contrary in this Section 4.02, the change in election rules in this
. Section 4.02 do not apply to the Medical Expense Reimbursement Plan, or may not be modified
14
�
� �
�
� �
�
�
�
�
� with respect to the Medical Expense Reimbursement Plan if the Plan is being administered by a
� Recordkeeper other than the Employer, unless the Em loyer and the Recordkeeper otherwise agree
€
� in writing.
t
� 4.03 OTHER EXCEPTIONS TO IItREVOCABILITY OF �LECTIONS. Other exceptions to the
� irrevocability of election requirement permit mid-year lection changes and apply to all qualified
� benefits except for Medical Expense Reimbursement Plan as follows:
,
�
� (a) Change in Cost. If the cost of a benefit package optio luider the Plan significantly increases during
�
� the plan year, Participants may (i) make a correspond �g increase in their salary reduction amount,
� (ii) revoke their elections and make a prospective el �tion under another benefit option offering
a similar coverage, or (iii) revoke election completely if to similar coverage is available, including in
� spouse or dependent's plan. If the cost significantly d Creases, employees may elect coverage even
� if they had not previously participated and may drop ►eir previous election for a similar coverage
� option in order to elect the benefit package option tha has decreased in cost during the year. If the
� increased or decreased cost of a benefit package ption under the Plan is insignificant, the
� participant's salary reduction amount shall be automati ally adjusted.
'�
# (b) Sipnificant curtailment of coveraee.
�:�
;
3
� (i) With no loss of covera�e. If the coverage un �r a benefit package option is significantly
� curtailed or ceases during the Plan Year, affected �rticipants may revoke their elections for the
� curtailed coverage and make a new prospective �lection for coverage under another benefit
�
� package option providing similar coverage.
,,
'� (ii) With loss of covera�e. If there is a significant c ttailment of coverage with loss of coverage,
:� affected Participants may revoke election for cu ailed coverage and make a new prospective
!� election for coverage under another benefit packa � option providing similar coverage, or drop
�
� coverage if no similar benefit package option is a ilable.
;�
�
'� (c) Addition or Si ificant Im rovement of Benefit Pac t,�e Option. If during the Plan Year a new
� benefit package option is added or significantly im �ved, eligible employees, whether cunently
:� participating or not, may revoke their existing election tnd elect the newly added or newly improved
Y
� option.
�
�
;� (d) Chan e in Covera e of a S ouse or De endent Un rr Another Employer's Plan. If there is a
� change in coverage of a spouse, former spouse, or . lependent under another emptoyer's plan, a
'� Participant may make a prospective election change ►at is on account of and corresponds with a
'� change made under the plan of the spouse or Depende t. This rule applies if (1) mandatory changes
� in coverage are initiated by either the insurer of spo e's plan or by the spouse's employer, or (2)
; optional changes are initiated by the spouse's employe or by the spouse through open enrotlment.
,�
:;
'� (e) Loss of coverage under other rg�oup health coveraee. f during the Plan Year coverage is lost under
ii� any group health coverage sponsored by a governmen ! or educational institution, a Participant may
'`� prospectively change his or her election to add group �ealth coverage for the affected Participant or
'� his or her spouse or dependent.
;
';� 4.04 CASH BENEFIT: Available amounts not used for the �urchase of benefits under this Plan may be
;� considered a cash benefit under the Plan payable to th participant as t�able income to the extent
� indicated in Item E of the Adoption Agreement.
� 15
;i
:4
�
�
:n
4.05 PAYMENT FROM EMPLOYER'S GENERAL ASSETS: Payment of benefits under this Plan shall be
made by the Employer ftom Elective Contributions which shall be held as a part of its general assets.
4.06 EMPLOYER MAY HOLD ELECT7VE CONTRIBUTIONS: Pending payment of benefits in
accordance with the terms of this Plan, Elective Contributions may be retained by the Employer in a
separate account or, if elected by the Employer and as permitted or required by regulations of the
' Internal Revenue Service, Departrnent of' Labor or other governmental agency, such amounts of Elective
Contributions may be held in a trust pending paytnent.
4.07 MAXIMiJM EMPLOYER CONTRIBUTIONS: With respect to each Participant, the m�imum
amount made available to pay benefits for any Plan Year shall not exceed the Employer's Contribution
specified in the Adoption Agreement and as provided in this Plan.
SECTION V
GROUP MEDICAL INSURANCE BENEFIT PLAN
SA1 PURPOSE: These benefits provide the group medical insurance benefits to Participants.
5.02 ELIGIBILITY: Eligibility will be as required in Items F(1), F(3), and F(4) of the Adoption Agreement.
5.03 DESCRIPTION OF BENEFITS: The benefits available under this Plan will be as defined in Items F(1),
F(3), and F(4) of the Adoption Agreement.
5.04 TERMS. CONDITIONS AND LIMITATTONS: The terms, conditions and limitations of the benefits
offered shall be as specifically described in the Policy identified in the Adoption Agreement.
5.05 COBRA: To the extent required by Section 4980B of the Code and Sections 601 through 607 of
ERISA, Participants and Dependents shall be entitled to continued participation in this Group Medical
Insurance Benefit Plan by contributing monthly (from their personal assets previously subject to
taxation) ]02% of the amount of the premium for the desired benefit during the period that such
individual is entitled to elect continuation coverage, provided, however, in the event the continuation
period is extended to 29 months due to disability, the premium to be paid for continuation coverage for
the 11 month extension period shall be 150% of the applicable premium.
5.06 SECTION 105 AND 106 PLAN: It is the intention of the Employer that these benefits shall be eligible
for exclusio� from the gross income of the Participants covered by this benefit plan, as provided in Code
Sections 105 and 106, and all provisions of this benefit plan shall be construed in a manner consistent ',
with that intention. It is also the intention of the Employer to comply with the provisions of the
Consolidated Omnibus Budget Reconciliation Act of 1985 as outlined in the policies identified in the
Adoption Agreement. '
5.07 CONTRIBUTIONS: Contributions for these benefits will be provided by the Employer on behalf of a
Participant as provided for in Item E of the Adoption Agreement.
5.08 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT:
Notwithstanding anyt6ing to the contrary herein, the Group Medical Insurance Benefit Plan shall
16
f
� �
�
�
�
5
� comply with the applicable provisions of the Uniforme Services Employment and Reemployment
, Rights Act of 1994 (Public Law 103-353).
�
� � 5ECTION VI
�
� DI5ABILITY INCOME BE P'IT PLAN
;� 6.01 PURPOSE: This benefit provides disability insurance signated to provide income to Participants
� during periods of absence from employment because of dis bility.
�
a
� 6.02 ELIGIBILITY: Eligibility will be as required in ltem F(2) f the Adoption Agreement.
g 6.03 DESCRIPTION OF BENEFITS: The benefits available u der this Plan will be as defined in Item F(2)
� of the Adoption Agreement.
�
� 6.04 TERMS. CONDITIONS AND LIMITATIONS: The te , conditions and limitations of the Disability
� Income Benefits offered shall be as specifically describ d in the Policy identified in the Adoption
Agreement.
� 6.05 SECTION 104 AND 106 PLAN: It is the intention of th Employer that the premiums paid for these
� benefits shall be eligible for exclusion from the gross inc 1e of the Participants covered by this benefit
� plan, as provided in Code Sections 104 and 106, and �Il provisions of this benefit plan shall be
construed in a manner consistent with that intention.
�
� 6.06 CONTRIBUTIONS: Contributions for this benefit will e provided by the Employer on behalf of a
� Participant as provided for in Item E of the Adoption Agre ment.
�
�
� � SECTION VII
GROUP AND INDIVIDUAL LIFE I sURANCE PLAN
:�
�
�; 7.01 PURPO5E: T'his benefit provides group life insurance b!�fits to Participants and may provide certain
� individual policies as provided for in Item F(5) of the Ado tion Agreement.
�
� 7.02 ELIGIBILIT'Y: Eligibility will be as required in Item F(5) if the Adoption Agreement.
�
:� 7.03 DESCRIPTION OF BENEFITS: The benefits available �der this Plan will be as defined in Item F(5)
af the Adoption Agreement.
�
� 7.04 TERMS. CONDITIONS, AND LIMITATIONS: The te �, conditions, and limitations of the group life
� insurance are specifically described in the Policy identifie in the Adoption Agreement.
� 7.05 SECTION 79 PLAN: It is the intention of the Empl 'er that the premiums paid for the benefits
� described in Item F(5) of the Adoption Agreement shall b eligible for exclusion from the gross income
� of the Participants covered by this benefit plan to the ttent provided in Code Section 79, and all
� provisions of this benefit plan shall be construed in a m �r consistent with that intention.
�
�
� 17
�
�
7.06 CONTRTBUTIONS: Contributions for this benefit will be provided by the Employer on behalf of a
Participant as provided for in Item E of the Adoption Agreement. Any individual policies purchased by
the Employer for the Participant will be owned by the Participant.
SECTION VIII
MEDICAL EXPENSE REIMBURSEMENT PLAN
8.01 PURPOSE: The Medical Expense Reimbursement Plan is designed to provide for reimbursement of
Eligible Medical Expenses (as defined in Section 8.04) that are not reimbursed under an insurance plan,
through damages, or from any other source. It is the intention of the Employer that amounts allocated
for this benefit shall be eligible for exclusion ftom gross income, as provided in Code 5ections 105 and
106, for Participants who elect this benefit and all provisions of this Section VID shall be construed in a
manner consistent with that intention.
8.02 ELIGIBILITY: The eligibility provisions are set forth in Item F(7) of the Adoption Agreement.
8.03 TERMS. CONDITIONS. AND LIMITATIONS:
(a) Accounts. The Reimbursement Recordkeeper shall establish a recordkeeping account for each
Participant. The Reimbursement Recordkeeper shall maintain a record of each account on an on-
going basis, increasing the balances as contributions are credited during the yeaz and decreasing the
balances as Eligible Medical Expenses are reimbursed. No interest shall be payable on amounts
recorded in any Participant's account.
(b) Maacimum benefit. The maximum amount of reimbursement for each Participant shall be limited to
the atnount of the Participant's Elective Contribution allocated to the program during the Plan Year, '
not to exceed the ma�cimum amount set forth in Item F(7) of the Adoption Agreement.
(c) Claim Procedure. Tn arder to be reimbursed for any medical expenses incurred during the Plan Year, '
the Participant shall complete the form(s) provided for such purpose by the Reimbursement
Recordkeeper. The Participant shall submit the completed form to the Reimbursement
Recordkeeper with an original bill or other proof of the expense acceptable to the Reimbursement
Recordkeeper. No reimbursement shall be made on the basis of an incomplete form or inadequate
evidence of expense as determined by the Reimbursement Recordkeeper. Forms for reimbursement '
of Eligible Medical Expenses must be submitted no later than the ninetieth (90th) day following the
last day of the Plan Year during which the Eligible Medical Expenses were incurred.
Reimbursement payments shall only be made to the Participant, or the Participant's legal
representative in the event of incapacity or death of the Participant. Forms for reimbursement shall
be reviewed in accordance with the claims procedure set forth in Section XIL
(d) Fundine. T'he funding of the Medical Reimbursement Plan shall be through contributions by the
Employer from its general assets to the extent of Elective Contributions directed by Participants.
Such contributions shall be made by the Employer when benefit payments and account
administrative expenses become due and payable under this Medical Expense Reimbursement Plan.
(e) Forfeiture. Any amounts remaining to the credit of the Participant at the end of the Plan Year and
not used for Eligible Medical Expenses incuned during the Participant's participation during the
Plan Year shall be forfeited and shall remain assets of the Plan. With respect to a Participant who
l8
E
¢
� .
e
3
e
�
�
�
I
�
� terminates employment with the Employer and who h'� not elected to continue coverage under this
� Plar► pursuant to COBRA rights referenced under Sec on 8.03(fl herein, such Participant shall not
s be entitled to reimbursement far Eligible Medical tpenses incurred after his termination date
� regardless if such Participant has any amounts of Em ioyer Contributions remaining to his credit.
� Upon the death of any Participant who has any amoun of Employer Contributions remaining to his
� credit, a dependent of the Participant may elect to c htinue to claim reimbursement for Eligible
�
Medical Expenses in the same manner as the Particip could have for the balance of the Plan Year.
�
:t
,,
�
' (� COBRA. To the extent required by Section 4980B 'the Code and Sections 601 through 607 of
� ERISA (`COBRA"), a Participant and a Participant's Dpendents shall be entitled to elect continued
� participation in this Medical Expense Reimbursement �lan only through the end of the plan year i�
� which the qualifying event occurs, by contributing m�nthly (from their personal assets previously
� subject to ta�cation) to the Employer/Administrator, 1 e% of the amount of desired reimbursement
a through the end of the Plan Year in which the qualifyi ; event occurs. Specifically, such individuals
� will be eligible for COBRA continuation coverage o ly if they have a positive Medical Expense
� Reimbursement Account balance on the date of the qu• ifying event. Participants who have a deficit
; balance in their Medical Expense Reimbursement Acc l�nt on the date of their qualifying event shall
� not be entitled to elect COBRA coverage. In lieu f COBRA, Participants may continue their
'� coverage through the end of the current Plan Year �y paying those premiums out of their last
� paycheck on a pre-tax basis.
<
� (g) Nondiscrimination. Benefits provided under this Med� al Expense Reimbursement Plan shall not be
;; provided in a manner that discriminates in favor o Employees or Dependents who are highly
� compensated individuals, as provided under Section 1�(h) of the Code and regulations promulgated
� thereunder.
„
�
�
!� (h) Uniform Covera�e Rule. Notwithstanding that a Parti pant has not had withheld and credited to his
� account all of his contributions elected with respect t a particulaz Plan Year, the entire aggregate
',� annual amount elected with respect to this Medical Ex �ense Reimbursement Plan, shall be available
-� at all times during such Plan Year to reimburse the p rticipant for Eligible Medical Expenses with
; respect to this Medical Expense Reimbursement Pl To the extent contributions with respect to
;� this Medical Expense Reimbursement Plan are insuffi ient to pay such Eligible Medical Expenses,
`� it shall be the Employer's obligation to provide ade ltate funds to cover any short fall for such
� Eligible Medical Expenses for a Participant; provided Cubsequent contributions with respect to this
'ry Medical Expense Reimbursement Plan by the P �ipant shall be available to reimburse the
'� Employer for funds advanced to cover a previous sho Fall.
:�
:r
;� (i) Uniformed Services Em lo ent and Reem lo ent ' hts Act. Notwithstanding anything to the
* contrary herein, this Medical Expense Reimburse �nt Plan shall comply with the applicable
� provisions of the Uniformed Serviees Employment 1 Reemployment Rights Act of 1994 (Public
!� Law 103-353).
� (j) Proration of Limit. In the event that the Employer �s purchased a uniform coverage risk policy
:� from the Recordkeeper, then the Maximum Cover �e amount specified in Section F.7 of the
� Adoption Agreement sha(1 be pro rated with respect t(i) an Employee who becomes a Participant
and enters the Plan during the Plan Year, and (ii) sho t p(an years initiated by the Employer. Such
i� Maximum Coverage amount will be pro rated by div ling the annual Maximum Coverage amount
� by 12, and multiplying the quotient by the number of maining months in the Plan Year for the new
'� Participant or the number of months in the short Pla� . ear, as applicable.
� 19
;�
,�
(k) Continuation Coverage for Certain Dependent Children. In the event that benefits under the Medical
Expense Reimbursement Plan does not qualify for the exception from the portability rules of
HIPAA, then, effective for Plan Years beginning on or after October 9, 2009, notwithstanding the
foregoing provisions, coverage for a Dependent child who is enrolled in the Medical Expense
Reimbursement Plan as a student at a post-secondary educational institution will not terminate due
to a medically necessary leave of absence before a date that is the earlier of:
• the date that is one year after the first day of the medically necessary leave of absence; or
• the date on which such coverage would otherwise terminate under the terms of the Plan.
For purposes of this paragraph, "medically necessary teave of absence" means a leave of absence of
the child from a post-secondary educational institution, or any other change in enrollment of the
child at the institution, that: (i) commences while the child is suffering from a serious illness or
injury; (ii) is medically necessary; and (iii) causes the child to lose student status for purposes of
coverage under the terms of the Plan. A written certification must be provided by a treating
physician of the dependent child to the Plan in order for the continuation coverage requirement to
apply. The physician's certification must state that the child is suffering from a serious illness or
injury and tt�at the leave of absence (or other change in enrollment) is medically necessary.
8.04 ELIGIBLE MEDICAL EXPENSES
(a) (a) Eligible Medical Expense in General. The phrase `Eligible Medical Expense' means any
expense incurred by a Participant or any of his Dependents (subject to the restrictions in Sections
8.04(b) and (c)) during a Plan Year that (i) qualifies as an expense incurred by the Participant or
Dependents for medical care as defined in Code Section 213(d) and meets the requirements '
outlined in Code Section 125, (ii) is excluded from gross income of the Participant under Code
Section 105(b), and (iii) has not been and will not be paid or reimbursed by any other insurance
plan, through damages, or from any other source. Notwithstanding the above, capital
expenditures are not Eligible Medical Expenses under this Plan. Further, notwithstanding the
above, effective January 1, 2011, only the following drugs or medicines will constitute Eligible
Medical Expenses: '
(i.) Drugs or medicines that require a prescription;
(ii.) Drugs or medicines that are available without a prescription ("over-the-counter
drugs or medicines") and the Participant or Dependent obtains a prescription; and '
(iii.) Tnsulin.
(b) Expenses Incurred After Commencement of Participation. Only medical care expenses incurred by
a Participant or the ParticipanYs Dependent(s) on or after the date such Participant commenced
participation in the Medical Expense Reimbursement Plan shall constitute an Eligible Medical
Expense.
(c) Eli ibg le Expenses Ineuned bv Dependents. For purposes of this Section, Eligible Medical Expenses
incurred by Dependents defined in Section 2.04(c) are eligible for reimbursement if incurred after
March 30, 2010; Eligible Medical Expenses incurred by Dependents defined in Sections 2.04(a) and
(b) are eligible for reimbursement if incurred either before or after March 30, 2010 (subject to the
restrictions of Section 8.04(b)).
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; (d) Health Savings Accounts. If the Employer has electe in Item F.8 of the Adoption Agreement to
� allow Eligible Employees to contribute to Health S�ings Accounts under the Plan, then for a
� Participant who is eligible for and elects to contrib te to a Health Savings Accounts, Eligible
� Medical Expenses shall be limited as set forth in Item B of the Adoption Agreement.
�
; 8.05 USE OF DEBIT CARD: In the event that the Employer lects to allow the use of debit cards ("Debit
� Cards") for reimbursement of Eligible Medical Expe '�es (other than over-the-counter drugs or
; medicines) under the Medical Expense Reimbursement an, the provisions described in this Section
� shall apply. However, beginning January 1, 2011, a Debi Card may not be used to purchase drugs or
� medici�es over-the-counter.
�
�
� (a) Substantiation. The following procedures shall be a�lied for purposes of substantiating claimed
� Eligible Medical Expenses after tt�e use of a Debit Card to pay the claimed Eligible Medical
� Expense:
�
� (i) If the dollar amount of the transaction at a ealth care provider equals the dollar amount
� of the co-payment for that service under �he Employer's major medical plan of the
� specific employee-cardholder, the charge s fully substantiated without the need for
;� submission of a receipt or further review.
:�
� (ii) if the merchant, service provider, or other i lependent third-party (e.g., pharmacy benefit
� manager), at the time and point of s�, provides information to verify to the
,�
� Recordkeeper (including electronically by e hiail, the internet, intranet, or telephone) that
'� the charge is for a medical expense, the ch ge is fully substantiated without the need for
� submission of a receipt or further review.
:�
;�
;� (b) Status of Char� All charges to a Debit Card, other t an co-payments and real-time substantiation
� as described in Subsection (a) above, are treated as co: ditional pending confirmation of the charge,
-� and additional third-party information, such as merch it or service provider receipts, describing the
� service or product, the date of the service or sale, and �e amount, must be submitted for review and
r
substantiation.
�
;� (c) Correction Procedures for Improper Pa, m� In the Vent that a claim has been reimbursed and is
� subsequently identified as not qualifying for reimburs ment, one or all of the following procedures
� shall apply:
�
�
� (i) First, upon the Recordkeeper's identifica on of the improper payment, the Eligible
� Employee will be required to pay back t the Plan an amount equal to the improper
,� payment.
�
�
� r (ii) Second, where the Eligible Employee doe not pay back to the Plan the amount of the
improper payment, the Employer will have le amount of the improper payment withheld
!,; from the Eligible Employee's wages or oth r compensation to the extent consistent with
� applicable law.
�
'� (iii) Third, if the improper payment still rema' �s outstanding, the Plan may utilize a claim
'� substitution or offset approach to resolve ' oroper claims paytnents.
`� (iv) If the above correction efforts prove un �ccessful, or are otherwise unavailable, the
'� Eligible Employee will remain indebted to he Employer for the amount of the improper
fl 1
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payment. In that event and consistent with its business practices, the Employer may treat
the payment as it would any other business indebtedness.
(v) In addition to the above, the Employer and the Plan may take other actions they may
deem necessary, in their sole discretion, to ensure that further violations of the terms of
' the Debit Card do not occur, including but not limited to, denial of access to the Debit
Card until the indebtedness is repaid by the Eligible Employee.
(d) Intent to Complv with Rev. Rul. 2003-43. It is the Employer's intent that any use of Debit Cards to
pay Eligible Medical Expenses shall comply with the guidelines for use of such cards set forth in
Rev. Rul. 2003-43, and this Section 8.05 shall be construed and interpreted in a manner necessary to
comply with such guidelines.
8.06 GRACE PERIOD: If the Employer elects in Section FJ of the Adoption Agreement to permit a Grace
Period with respect to the Medical Reimbursement Plan, the provisions of this Section 8.06 shall apply.
Notwithstanding anything to the contrary herein and in accordance witki Intemal Revenue Service Notice
2005-42, a Participant who has unused contributions relating to the Medical Reimbursement Plan from
the immediately preceding Plan Year, and who incurs Eligible Medical Expenses for such qualified
benefit during the Grace Period, may be paid or reimbursed for those Eligible Medical Expenses from
the unused contributions as if the expenses had been incurred in the immediately preceding Plan Year.
For purposes of this Section, `Grace Period' shall mean the period extending to the 15�' day of the third
calendar month after the end of the immediately preceding Plan Year to which it relates. Eligible
Medical Expenses incurred during the Grace Period shall be reimbursed first from unused contributions
allocated to the Medical Reimbursement Plan for the prior Plan Year, and then from unused
contributions for the current Plan Year, if participant is enrolled in current Plan Year.
8.07 QUALTFiED RESERVIST DISTRIBUTIONS: Notwithstanding anything in the Plan to the
contrary, an individual who, by reason of being a member of a reserve component (as defined in
37 U.S.C. § 101), is ordered or called to active duty for a period in excess of 179 days or for an
indefinite period may elect to receive a distribution of all or a portion of the unused Elective
Co�tributions in his or her Account relating to the Medical Expense Reimbursement Plan if the
distribution is made during the period beginning on the date of such order or call and ending on '
the last date that reimbursements could otherwise be made under the Plan for the Plan Year that
includes the date of such order or call. If the distribution is for the entire amount of unused
Elective Contributions available in the Medical Expense Reimbursement Plan, then no additional
reimbursement requests will be processed for the remainder of the Plan Year. '
5ECTION IX
DEPENDENT CARE REIII�IBURSEMENT PLAN '
9.01 PURPOSE: The Dependent Care Reimbursement Plan is designed to provide for reimbursement of
certain employment-related dependent care expenses of the Participant. It is the intention of the
Employer that amounts allocated for this benefit shall be eligible for exclusion from gross income, as
provided in Code 5ection 129, for Participants who elect this benefit, and all provisions of this Section
IX shall be construed in a manner consistent with that intention. '
9.02 ELIGIBILITY: The eligibility provisions are set forth in Item F(6) of the Adoption Agreement. ,
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� 9.03 TERMS, CONDITIONS. AND LIMITATIONS:
;
� (a) Accounts. The Reimbursement Recordkeeper shall ;stablish a recordkeeping account for each
� Participant. The Reimbursement Recordkeeper shall #aintain a record of each account on an on-
� going basis, increasing the balances as contributions ; credited during the year and decreasing the
balances as Eligible Dependent Care Expenses are r Irnbursed. No interest shall be payable on
;� amounts recorded in any Participant's account.
� (b) Maximum Benefit. Tl�e maximum amount of reimbur �ment for each Participant shall be limited to
� the amount of the Participant's allocation to the pro Am during the Plan Year not to exceed the
� m�imum amount set forth in Item F(6) of the adoptio egeement.
:�
(c) For purpose of this Section iX, the phtase "earned inco �e" shall mean wages, salaries, tips and other
� employee compensation, but only if such amounts includible in gross income for the taYable
� year. A Participant's spouse who is physically or m ltally incapable of self-care as described in
Section 9.04(a)(ii) or a spouse who is a full-time s �dent within the meaning of Code Section
'� 21(e)(7) shall be deemed to have earned income for e h month in which suc h spouse is so disa b le d
� (or a full-time student). The amount of such deemed lrned income shall be $250 per month in the
� case of one Dependent and $500 per month in the case �f two or more Dependents.
',� (d) Claim Procedure. In order to be reimbursed for any �ependent care expenses incurred during the
� Plan Year, the Participant shall complete the f m(s) provided for such purpose by the
� Reimbursement Recordkeeper. The Participant �all submit the completed form to the
;� Reimbursement Recordkeeper with an original bil or other proof of the expense from an
:� independent third party acceptable to the Reimbursem �t Recordkeeper. No reimbursement shall be
,� made on the basis of an incomplete fortn or inadequa evidence of the expense as determined by the
� Reimbursement Recordkeeper. Claims for reimburs ment of Eligible Dependent Care Expenses
� must be submitted no later than the ninetieth (90th) lay following the last day of the Plan Year
� during which the Eligible Dependent Care Expenses Cre incurred. Reimbursement payments shall
� only be made to the Participant, or the Participant's leg l representative in the event of the incapacity
:� or death of the Participant. Forms for reimburseme k shall be reviewed in accordance with the
� claims procedure set forth in Section XII.
� (e) Fundine. 'The funding of the Dependent Care Reimbu 'ement Plan shall be through contributions by
� the Employer from its general assets to the extent of �ctive Contributions directed by Participants.
Such contributions shall be made by the Empl yer when benefit payments and account
;� administration expenses become due and paya e under this Dependent Care Expense
Reimbursement Plan.
� (fl Forfeiture. Any amounts remaining to the credit of : Participant at the end of the Plan Year and
� � not used for Eligible Dependent Care Expenses incurr d during the Plan Year shall be forfeited and
remaio assets of the Plan.
�
� (g) Nondiscrimination. Benefits provided under this Dep hdent Care Reimbursement Plan shall not be
provided in a manner that discriminates in favor of ghly Compensated Employees (as defined in
� Code Section 414(c�) or their dependents, as provide in Code 5ection 129. In addition, no more
:�
� than 25 percent of the aggregate Eligible Dependent �are Expenses shall be reimbursed during a
� Plan Year to five percent owners, as provided in Code �ection 129.
'� 9.04 DEFINITIONS
3 23
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(a) "Dependent" (for purposes of this Section IX) means any individual who is:
(i) a Participant's qualifying child (as defined in Code Section 152 (c)) who has not attained
the age of 13; or
(ii) a dependent (qualifying child or qualifying relative, as defined in Code Section 152 (c)
and (d), respectively) or the spouse of a Participant who is physically or mentally
incapable of self-care, and who has the same principal place of abode as the t�payer for
more than half of the taacable year. For purposes of this Dependent Care Reimbursement
Plan, an individual shall be considered physically or mentally incapable of self-care if, as
a result of a physical or mental defect, the individual is incapable of caring for his or her
hygienic or nutritional �eeds, or requires full-time attention of another person for his or
her own safety or the safety of others.
(b) "Dependent Care Center" (for purposes of this Section IX) shall be a facility which:
(i) provides care for more than six individuals (other than individuals who reside at the
facility);
(ii) receives a fee, payment, or grant for providing services for any of the individuals
(regardless of whether such facility is operated for profit); and
(iii) satisfies all applicable laws and regulations of a state or unit of local government.
(c) "Eligible Dependent Care Expenses° (for purposes of this Section IX) shall mean expenses incurred
by a Participant which are:
(i) incurred for the caze of a Dependent of the Participant or for related household services;
(ii) paid or payable to a Dependent Care Service Provider; and
(iii) incuned to enable the Participant to be gainfully employed for any period for which there
are one or more Dependents with respect to the Participant.
"Eligible Dependent Care Expenses" shall not include expenses incurred for services outside the
Participant's household for the care of a Dependent unless such Dependent is (i) a qualifying
child (as defined in Code Section 152 (c)) under the age of 13, or (ii) a dependent (qualifying
child or qualifying relative, as defined in Code Section 152 (c) and (d), respectively)), 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 taxable year, or (iii) the spouse of a Participant 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 taxable year. Eligible Dependent Care Expenses shall
be deemed to be incurred at the time the services to which tl�e expenses relate are rendered.
(d) "Dependent Care Service Provider" (for purposes of this Section I� means:
(i) a Dependent Care Center, or
(ii) a person who provides care or other services described in Section 9.04(b) and who is not
a related individual described in Section 129(c) of the Code.
SECTION X
HEALTH SAVINGS ACCOUNTS
24
SECTION XII
ADMINISTRATION
12.01 NAMED FIDUCIARIES: The Administrator shall be the fiduciary of the Plan.
12.02 APPOINTMENT OF RECORDKEEPER: The Employer may appoint a Reimbursement Recordkeeper
which shall have the power and responsibility of performing recordkeeping and other ministerial duties
arising under the Medical Expense Reimbursement Plan and the Dependent Care Reimbursement Plan
provisions of this Plan. The Reimbursement Recordkeeper shall serve at the pleasure of, and may be
removed by, the Employer without cause. The Recordkeeper shall receive reasonable compensation for
its services as shall be agreed upon from time to time between the Administrator and the Recordkeeper.
12.03 POWERS AND RESPONSIBILITIES OF ADMINISTRATOR
(a) General. The Administrator shall be vested with all powers and authority necessary in order to
amend and administer the Plan, and is authorized to make such rules and regulations as it may deem
necessary to carry out the provisions of the Plan. The Administrator shall determine any questions
arising in the administration (including all questions of eligibility and determination of amouot, time
and manner of payments of benefits), construction, interpretation and application of the Plan, and the
decision of the Admi�istrator shall be final and binding on all persons.
(b) Recardkeeping. The Administrator shall keep full and complete records of the administration of the
Plan. The Administrator shall prepare such reports and such information concerning the Plan and
the administration thereof by the Administrator as may be required under the Code or ERISA and
the regulations promulgated thereunder.
(c) Inspection of Records. The Administrator shall, during normal business hours, make available to
each Participant for examination by the Participant at the principal office of the Administrator a
copy of the Plan and such records of the Administrator as may pertain to such Participant. No
Participant shall have the right to inquire as to or inspect the accounts or records with respect to
other Participants.
12.04 COMPENSATION AND EXPEN3ES OF ADMINISTRATOR The Administrator shall serve without
compensation for services as such. All expenses of the Administrator shall be paid by the Employer.
Such expenses shall include any expense incident to the functioning of the Plan, including, but not
limited to, attorneys' fees, accounting and clerical chazges, actuary fees and other costs of administering
the Plan. ,
12.05 LIABIL,ITY OF ADMINISTRATOR: Except as prohibited by law, the Administrator shall not be liable
personally for any loss or damage or depreciation which may result in connection with the exercise of
duties or of discretion hereunder or upon any other act or omission hereunder except when due to willful
misconduct. In the event the Administrator is not covered by fiduciary liability insurance or simi(ar '
insurance arrangements, the Employer shall indemnify and hold harmless the Administrator from any
and all claims, losses, damages, expenses (including reasonable counsel fees approved by the
Administrator) and liability (including any reasonable amounts paid in settlement with the Employer's
approval) arising from any act or omission of the Administrator, except when the same is determined to
be due to the willful misconduct of the Administrator by a court of competent jurisdiction.
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� 12.06 DELEGATIONS OF RESPONSIBILITY: The Administr Qr shall have the authority to delegate, from
� time to time, all or any part of its responsibilities under ie Plan to such person or persons as it may
deem advisable and in the same manner to revoke any s�h delegation of responsibilities which shall
� have the same force and effect for all purposes hereun :r as if such action had been taken by the
� Administrator. T'he Administrator shall not be liable for tny acts or omissions of any such delegate.
� The delegate shall report periodically to the Administrat � concerning the discharge of the delegated
responsibilities.
� 12.07 RIGHT TO RECENE AND RELEASE NECESSARY [NFORMATION: The Administrator may
� release or obtain any information necessary for the appli �tion, implementation and determination of
� this Plan or other Plans without consent or notice to any p�on. This. information may be released to or
� obtained from any insurance company, organization, person subject to applicable law. Any
� individual claiming benefits under this Plan shall furnish � the Administrator such information as may
� be necessary to implement this provision.
�
� 12.08 CLAIM FOR BENEFITS: To obtain payment of any ben �ts under the Plan a Participant must comply
� with the rules and procedures of the particular benefit pro �cn elected pursuant to this Plan under which
� the Participant claims a benefit.
�
�
� 12.09 GENERAL CLAIMS REVIEW PROCEDURE: This p vision shall apply only to the extent that a
� claim for benefits is not governed by a similar provision ' a benefit program available under this Plan
� or is not govemed by 5ection 12.10.
(a) Initial Claim for Benefits. Each Participant may sub k a claim for benefits to the Administrator as
"' provided in Section 12.08. A Participant shall have no ight to seek review of a denial of benefits, or
to bring any action in any court to enforce a claim for tnefits prior to his filing a claim for benefits
� and e�austing his rights to review under this section.
,n
:�
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� When a claim for benefits has been filed properly, suc claim for benefits shall be evaluated and the
� claimant shall be notified of t6e approval or the den �l within (90) days after the receipt of such
`; claim unless special circumstances require an extensio of time for processing the claim. If such an
'� extension of time for processing is required, written n ice of the extension shall be furnished to the
,�
� claimant prior to the termination of the initial ninety ( D) day period which shall specify the special
�� circumstances requiring an extension and the date by �hich a final decision will be reached (which
,� date shall not be later than one hundred and eighty (1 �) days after the date on which the claim was
� filed.) A claimant shall be given a writte� notice i which the claimant shall be advised as to
� whether the claim is granted or denied, in whole or in �art. If a claim is denied, in whole or in pazt,
� the claimant shall be given written notice which shall ontain (a) the specific reasons for the denial,
� (b) references to pertinent plan provisions upon whic the denial is based, (c) a description of any
`� additional material or infortnation necessary to perfe l the claim and an explanation of why such
� material or information is necessary, and (d) the claim It's rights to seek review of the denial.
� (b) Review of Claim Denial. If a claim is denied, in whol or in part, the claimant shall have the right to
request that the Administrator review the denial, provi ed that the claimant files a written request for
� review with the Administrator within sixty (60) days fter the date on which the claimant received
� written notification of the de�ial. A claimant (or hi duly authorized representative) may review
� pertinent documents and submit issues and comments h writing to the Administrator. Within sixty
,, (60) days after a request is received, the review shall �e made and the claimant shall be advised in
`� writing of the decision on review , unless special ci :umstances require an extension of time for
� processing the review, in which case the claimant sh l be give� a written notification within such
� 27
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initial sixty (60) day period specifying the reasons for the extension and when such review shall be
completed (provided that such review shall be completed within one hundred and twenty (120) days
after the date on which the request for review was filed.) The decision on review shall be forwarded
to the claimant in writing and shall include specific reasons for the decision and references to plan
provisions upon which the decision is based. A decision on review shall be final and binding on all
persons.
(c) Exhaustion of Remedies. If a claimant fails to file a request for review in accordance with the
procedures herein outlined, such claimant shall have no rights to review and shall have no right to
bring action in any court and the denial of the claim shall become final and binding on all persons
for all purposes.
1210 SPECIAL CLAIMS REVIEW PROCEDURE: The provisions of this Section 12.10 shall be applicable
to claims under the Group Medical Reimbursement Plan and the Group Medical Insurance Plan,
effective on the first day of the first Plan Year beginning on or after July 1, 2002, but in no event later
than January 1, 2003, provided such plans are subject to ERISA.
(a) Benefit Denials: The Administrator is responsible for evaluating all claims for reimbursement under
the Medical Expense Reimbursement Plan and the Group Medical Insurance Plan.
The Administrator will decide a Participant's claim within a reasonable time not longer than 30 days
after it is received. This time period may be extended for an additional 15 days for matters beyond
the control of the Administrator, including in cases where a claim is incomplete. The Participant
' will receive written notice of any extension, including the reasons for the extension and information
on the date by which a decision by the Administrator is expected to be made. The Participant will
be given 45 days in which to complete an incomplete claim. The Administrator may secure
independent medical or other advice and require such other evidence as it deems necessary to decide
the claim.
If the Administrator denies the claim, in whole or in part, the Participant will be furnished with a
written notice of adverse benefit determination setting forth:
1. the specific reason or reasons for the denial;
2. reference to the specific Plan pmvision on which the denial is issued;
3. a description of any additional material or information necessary for the Participant to '
complete his claim and an explanation of why such material or information is necessary,
and
4. appropriate information as to the steps to be taken if the Participant wishes to appeal the
Administrator's determination, including the participant's right to submit written
comments and have them considered, his right to review (on request and at no charge)
relevant documents and other information, and his right to file suit under ERISA with
respect to any adverse determination after appeal of his claim.
(b) Appealing Denied Claims: If the Participant's claim is denied in whole or in part, he may appeal to
the Administrator for a review of the denied claim. 1'he appeal must be made in writing within 180
days of the Administrator's initial notice of adverse benefit determination, or else the participant will
lose the right to appeal the denial. If the Participant does not appeal on time, he will also lose his
28
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� right to ftle suit in court, as he will have failed to ex �ust his internal administrative appeal rights,
� which is generally a prerequisite to bringing suit.
�
� A Participant's written appeal should state the re 'bns that he feels his claim should not have
been denied. It should include any additional fac ' and/or documents that the Participant feels
'£ support his claim. The Participant may also sk additional questions and make written
� comments, and may review (on request and at � charge) documents and other information
� relevant to his appeal. The Administrator will �view all written comment the Participant
� submits with his appeal.
�
�
� (c) Review of Appeal: The Administrator will review hd decide the Participant's appeal within a
� reasonable time not longer than 60 days after it is s�tnitted and will notify the Participant of its
� decision in writing. The individual who decides the tppeal will not be the same individual who
� decided the initial claim denial and will not be that i dividual's subordinate. The Administrator
;� may secure independent medical or other advice � require such other evidence as it deems
necessary to decide the appeal, except that any med �al expert consulted in connection with the
� appeal will be different from any expert consulted in c hnection with the initial claim. (The identity
� of a medical expert consulted in connection with the �rticipant's appeal will be provided.) If the
decision on appeal affirms the initial denial of the participant's claim, the Participant will be
:� fumished with a notice of adverse benefit determinatia on review setting forth:
1. The specific reason(s) for the denial,
2. The specific Plan provision(s) on which the �ecision is based,
� 3. A statement of the Participant's right to r View (on request and at no charge) relevant
� documents aod other information,
'� 4. If the Administrator relied on an "intem � rule, guideline, protocol, or other similar
� criterion" in making the decision, a descri kion of the specific rule, guideline, protocol,
� or other similar criterion or a statement t�t such a rule, guideline, protocol, or other
similar criterion was relied on and that a c py of such rule, guideline, protocol, or other
criterion will be provided free of charge to �e Participant upon request," and
5. A statement of the Participant's right to bri � suit under ERISA § 502(a).
�
� 12.11 PAYMENT TO REPRESENTATIVE: In the event �at a guardian, conservator or other legal
representative has been duly appointed for a Participant e itled to any payment under the Plan, any such
payment due may be made to the legal representative mak tg claim therefar, and such payment so made
shall be in complete discharge of the liabilities of Plan therefor and the obligations of the
Administratar and the Employer.
� 12.12 PROTECTED HEALTH INFORMATION. The provis' �ns of this Section will apply only to those
portions of the Plan that are considered a group health pl � for purposes of 45 CFR Parts 160 and 164.
The Plan may disclose PHI to employees of the Employ � or to other persons, only to the extent such
disclosure is required or permitted pursuant to 45 CFR P tts 160 and 164. T'he Plan has implemented
� administrative, physical, and technical safeguards to rea nably and appropriately protect, and restrict
� access to and use of, electronic PHI, in accordance witt► lbpart C of 45 CFR Part 164. The applicable
� claims procedures under the Plan shall be used to res lve any issues of non-compliance by such
;� individuals. The Employer will:
� 29
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• not use or disclose PHI other than as permitted or required by the plan documents and permitted or
required by law;
• reasonably and appropriately safeguard electronic PHI created, received, maintained, or transmitted
to or by it on behalf of the Plan, in accordance with Subpart C of 45 CFR Part 164;
, • implement administrative, physical, and technical safeguards that reasonably and appropriately
protect the confidentiality, integrity, and availability of the electronic PHT that it creates, receives,
maintains, or transmits on behalf of the Plan;
• ensure that any agents including a subcontractors to whom it provides PHI received from the Plan
agree to the same restrictio�s and conditions that apply to the Employer with respect to such
information;
• not use or disclose PHI for employment-related actions and decisions or in connection with any
other employee benefit plan of the Employer;
• report to the Plan any use or disclosure of the information that is inconsistent with the permitted uses
or disclosures provided for of which it becomes aware;
• make available PHI in accordance with 45 CFR Section 164.524;
• make available PHI for amendment and incorporate any amendments to PHI in accordance with 45
CFR Section 164.526;
• make available the information required to provide an accounting of disclosures in accordance with
45 CFR Section 164.528;
• make its internal practices, books, and records relating to the use and disclosure of PHI received
from tl�e Plan available to the Secretary of Health and Human Services or his designee upon request
for purposes of determining compliance with 45 CFR Section 164.504(fl;
• if feasible, return or destroy all PHI received from the Plan that the Employer still maintains in any
form and retain no copies of such information when no longer needed for the purposes for which t�e
disclosure was made, except that, if such return or destruction is not feasible, limit further uses and
disclosures to those purposes that make the retum or destruction of the information infeasible; and,
• ensure that the adequate separation required in paragraph (fl(2)(iii) of 45 CFR Section 164.504 is
established.
For purposes of this Section, "PHI" is "Protected Health Information" as defined in 45 CFR Section
160.103, which �is means individually identifiable health information, except as provided in paragraph
(2) of the definition of "Protected Health Information" in 45 CFR Section 160.103, that is transmitted by
electronic media; maintained in electronic media; or transmitted or maintained in any other form or
medium by a covered entity, as defined in 45 CFR Section 164.104.
SECTION XIII
NIlSCELLANEOUS PROVISIONS
13.01 INABILITY TO LOCATE PAYEE: If the Plan Administrator is unable to make payment to any
Participant or other person to whom a payment is due under the Plan because it cannot ascertain the
identity or whereabouts of such Participant or other person after reasonable efforts have been made to
identify or locate such person, then such payment ar�d all subsequent payments otherwise due to such
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� .
�
� •
a
Participant or other person shall be forfeited following 3 reasonable time after the date any such
� payment first became due.
� 13.02 FORMS AND PROOF5: Each Participant or Participan � Beneficiary eligible to receive any benefit
� hereunder shall complete such forms and furnish such pro Fs, receipts, and releases as shall be required
� by the Administrator.
:�
� 13.03 NO GUARANT'EE OF TAX CONSEOUENCES: Neith the Administrator nor the Company makes
any commitment or guarantee that any amounts paid to or �r the benefit of a Participant or a Dependent
under the Plan will be excludable from the Participant's or �ependent's gross income for federal or state
� income tax purposes, or that any other federal or state tax reatment will apply to or be available to any
� Participant or Dependent.
� 13.04 PLAN NOT CONTRACT OF EMPLOYMENT: The Pla will not be deemed to constitute a contract
� of employment between the Employer and any Partic �ant nor will the Plan be considered an
� i�ducement for the employment of any Participant or em �yee. Nothing contained in the Plan will be
� deemed to give any Participant or employee the right to be etained in the service of the Employer nor to
� interfere with the right of the Employer to discharge any uticipant or employee at any time regardless
� of the effect such discharge may have upon that individual s a Participant in the Plan.
�
� 13.05 NON-ASSiGNABILITY: No benefit under the Plan s!t be liable for any debt, liability, contract,
' engagement or tort of any Participant or his Beneficiary, nor be subject to charge, anticipation, sale,
� assignment, transfer, encumbrance, pledge, attachment, trnishment, execution or other voluntary or
involuntary alienation or other legal or equitable process, �r transferability by operation of law.
13.06 SEVERABILITY: If any provision of the Plan will be h d by a court of competent jurisdiction to be
� invalid or unenforceable, the remaining provisions hereof ill co�tinue to be fully effective.
� 13.07 CONSTRUCTION
� (a) Words used herein in the masculine or feminine g �der shall be construed as the feminine or
� masculine gender, respectively where appropriate.
(b) Words used herein in the singular or plural shall be co strued as the plural or singular, respectively,
,� where appropriate.
�
13.08 NONDISCRTMINATION: In accordance with Code S ction 125(b)(1), (2), and (3), this Plan is
' intended not to discriminate in favor of Higl�ly Compens led Participants (as defined in Code Section
� 125(e)(1)) as to contributions and benefits nor to provide pre than 25% of all qualified benefits to Key
� Employees. if, in the judgment of the Administrator, mor than 25% of the total nontaxable benefits are
� provided to Key Employees, or the Plan discriminates i any other manner (or is at risk of possible
� discrimination), then, notwithstanding any other provisi 1 contained herein to the contrary, and, in
� accordance with the applicable provisions of the Code, tl�e Administrator shall, after written notification
to affected Participants, reduce or adjust such contribuf ins and benefits under the Plan as shall be
necessary to insure that, in the judgment of the Administra �r, the Plan shall not be discriminatory.
� 13.09 ERISA. The Plan shall be construed, enforced, and Iministered and the validity determined in
� accordance with the applicable provisions of the Employe Retirement Income Security Act of 1974 (as
� amended), the Internal Revenue Code of 1986 (as amend i), and the laws of the Sta.te indicated in the
Adoption Agreement. Notwithstanding anything to the c ptrary hetein, the provisions of ERiSA will
� not apply to this Plan if the Plan is exempt from covera e under ERISA. Should any provisions be
determined to be void, invalid, or unenforceable by any �urt of competent jurisdiction, the Plan will
� 31
�
continue to operate, and for purposes of the jurisdiction of the court o�ly will be deemed not to include
the provision determined to be void.
PD 0511
32