HomeMy WebLinkAboutCC RES 01-087l0
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RESOLUTION NO. 01-87
A RESOLUTON OF THE CITY COUNCIL OF THE CITY OF TUSTIN, CALIFORNIA,
ADOPTING A NEW FLEXIBLE BENEFITS PLAN
WHEREAS, the City adopted a Cafeteria Flexible Benefits Plan in 1994
within the context of Section 125 of the Internal Revenue Code for the benefit of
eligible City employees; and
WHEREAS, such Plan as been amended when appropriate; and
WHEREAS, the City Council wishes to adopt a new and revised Cafeteria
Flexible Benefits Plan within the context of Section 125 of the Internal Revenue Code
for the benefit of eligible City employees.
NOW, THEREFORE, the City Council of the City of Tustin, California does
hereby adopt the Flexible Benefits Plan (consisting of the flexible benefits plan
document, the Adoption Agreement, and component benefit plans and policies) for
the City of Tustin effective January 1, 2002.
Resolved further, that the City Manager or his designee may, without a
further Resolution, execute the Adoption Agreement and any related documents or
amendments which may be necessary or appropriate to adopt the plan or maintain its
compliance with applicable federal, state and local law.
Passed and adopted by the City Council of the City of Tustin at a regular
meeting held on the 4th day of September, 2001.
S WORL
CITY CLERK
S:\City Council Agenda Items\CAFETERIAPLANRESO2001.DOC
PREAMBLE
TABLE OF CONTENTS
FLEXIBLE BENEFITS PLAN
ARTICLE I - DEFINITIONS
1.01
1.02
1.03
1.04
1.05
1'.06
1.07
1.08
1.09
1,10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
1.21
1.22
1.23
1.24
1.25
1.26
1.27
1.28
1.29
1.30
1.31
1.32
1 .$3
1.34
1.35
"Affiliated Employer"
"After-tax Premium(s)"
"Anniversary Date"
"Benefit Plan(s) or Policy(les)"
"Board of Directors"
"Change in Status"
"Code"
"Compensation"
"Dependent"
"Dependent Care Expense Reimbursement"
"Earned Income"
"Effective Date"
"Eligible Employment Related Expenses','
"Eligible Medical Expenses"
"Employee"
"Employer"
"ERISA"
"Highly compensated Individual"
"Key Employee"
"Medical Care Expense Reimbursement"
"Nonelective Contributions"
"Participant"
"Plan"
"Plan Administrator" or "committee"
"Plan Year"
"Pre-tax Premium(s)"
"Qualified Benefit"
"Qualifying Employment-Related Expenses"
"Qualifying Individual"
"Qualifying Services"
"Reimbursement Account(s) or Account(s)"
"Salary Redirection Agreement"
"Spouse"
"Student"
"Trustee"
ARTICLE II- ELIGIBILITY AND PARTICIPATION
2.01
2.02
2.03
2.04
2.05
Eligibility to Participate
Entry Date
Termination of Participation
Eligibility to Participate in Reimbursement Benefits
Qualifying Leave Under Family Leave Act
ARTICLE ill- PREMIUM ELECTIONS
3.01
3.02
3.03
3.04
3.05
Election of l~'remiums
Initial Election Period
Annual E[?ction Period
Change 87~remium Election
Termination of Election
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PROC2g7B.4
ARTICLE X.- GENERAL PROVISIONS
10.01
10.02
10.03
10.04
10.05
10.06
10.07
10.08
10.09
10.10
10.11
10.12
10.13
10.14
Not an Employment Contract
Applicable Laws
Post-Mortem Payments
Nonalienation of Benefits
Mental or Physical Incompetency
Inability to Locate Payee
Requirement for Proper Forms
Source of Payments
Multiple Functions
Tax Effects
Gender and Number
Headings
Incorporation by Reference
Severability
10.15. Effect of Mistake
10.16 Provisions Relating.to Insurers
10.17 Forfeiture of Unclaimed Reimbursement Account Benefits
ARTICLE XI-.CONTINUATION' COVERAGE UNDER COBRA
11.01
11.02
11.03
11.04
11.05
11.06
11.07
11.08
11.09
11.10
Continuation Coverage After Termination of Normal Participation
Who is a "Qualified Beneficiary"
Who is not a "Qualified Beneficiary"
What is a "Qualifying Event"
COBRA not applicable to Certain Health Care Expense Account Participants
What Benefit is Available Under Continuation Coverage
Notice Requirements
Election Period
Duration of Continuation Coverage
Automatic Termination of Continuation Coverage
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PROC297B.4
PREAMBLE
The Employer hereby establishes a Flexible Benefits Plan ("Plan") for its .Employees for
purposes of providing eligible Employees with the opportunity to choose from among the fringe benefits
available under the Plan, The Plan is intended to qualify as a cafeteria plan under the provisions of
Code Section 125. The Dependent Care Expense Reimbursement Plan ("DDO") is intended to qualify
as a Code Section 129 dependent care assistance plan, and the Medical Care Expense Reimbursement
Plan ("Health FSA") is intended to qualify as a Oode Section 105 medical, expense reimbursement
plan. Although printed within this document, the DDO and Health FSA Plans are separate written plans
for purposes of administration and all reporting and nondiscrimination requirements imposed by Sections
105 and 129 of the Code and all applicable provisions of ERISA. The DDC and Medical Care-Expense
Reimbursement Plans are available only if designated on the Adoption Agreement.
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PROC297B.4
FLEXIBLE BENEFITS PLAN
ARTICLE i
DEFINITIONS
1.01 "Affiliated Employer" means any Employer within the context of Code Section 414(b),
(c),or (m) of the Code which will be treated as single employer for purposes of Code Section 125.
1.02 "After-tax Premium(s)" means amounts withheld from an Employee's Compensation
pursuant to a Salary Redirection Agreement to purchase coverages available under the Adoption
Agreement on an after-tax basis. ·
1.03 "Anniversary Date" means the first day of any Plan Year;
1.04 "Benefit Plan(s) or Policy(les)" means those Qualified Benefits available to a Participant
under the Adoption Agreement. Where a Benefit Plan' or Policy is made available through, an individual
insurance policy, the insurer(s) and policy form numbers shall be listed in Appendix A.
1.05 "Board of Directors" means the Board of Directors of the Employer. The. Board of
Directors, upon adoption of this Plan appoints the Committee to act on the Employer's behalf in all
matters regarding the Plan.
1.06 "Change in Status" means any of the events, described below, as well as any other
events included under subsequent changes to Code Section. 12'5 or regulations issued under Code
Section 125 which the Plan Administrator (in its sole discretion) decides to recognize on a uniform, and
consistent basis:
(a) Legal Marital Status: A change in a Participant's legal marital status, including marriage,
death of a Spouse, divorce, legal separation or annulment; '
(b) Change in Number of Tax Dependents (as defined in Section 1.09): A change in the
Participant's number of tax Dependents, including the birth of a child,, the adoption or placement for
adoption of a Dependent, or the death of a Dependent.
(c) Change in Employment Status: Any change in employment status of the Participant,
the Participant's Spouse or the Participant's Dependents that affects, benefit eligibility under a cafeteria
plan (including this Plan) or other employee benefit plan (including the Benefit Plan(s) or Policy(ies) of
the employer of the Participant, the Spouse or Dependents, such. as: termination or commencement of
employment; a strike or lockout; a commencement of or return from an unpaid leave of absence; a
change in worksite; switching from salaried to hourly paid; union to. non. union; or part-time to full time;
incurring a reduction or increase in hours of employment; or any other similar change which makes the
individual become (or cease to be) eligible for a particular employee, benefit.
(d) Dependent Eligibility Requirements: An event that' .causes a Participant:s Dependent to
satisfy or cease to satisfy the Dependent eligibility requirements for a particular benefit, such as
attaining a specified age, getting married, or ceasing to be a Student;
(e) Change in Residence: A change in the place of residence of the Participant, the
Participant's Spouse or the Participant's Dependent.
Note: See Section 3.04 for requirements that must be met to permit certain mid-year election changes
on account of a Change in Status.
1.07 "Code" means the Internal Revenue Code of 1986, as amended:
1.08 "Compensation" means the cash wages or satary paid to. an Employee by the Employer.
1.09 "Dependent" means any individual who is a tax dependent of the Participant as. defined in
Code Section 152(a), or who is determined to be an alternative recipient of a Plan Participant under an
order determined to be a qualified medical child support order (QM¢SO) by the Plan Administrator,
provided however, that in the case of a divorced Employee: i) Dependent shall be defined as in Code
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PROC297B.4
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1.19 "Key Employee" means an individual who is a "key employee" as defined in Code
Section 125(b)(2), as amended.
1.20 "Medical Care Expense Reimbursement" shall have the meaning assigned to it by
Section 5.01 (b) of the Plan..
1.21 "Nonelective Contribution(s)" means any amount which the Employer in its sole
discretion may contribute on behalf of each Participant to provide benefits for such Participant and his
or her Dependents, if applicable under the Plan. The amount of Nonelective Contribution for each
Participant may be adjusted upward or downward in the contributing Employer's sole discretion. The
amount shall be disclosed in Participant enrollment materials and shall be calculated for each Plan Year
in a uniform and nondiscriminatory manner based upon the Participant's dependent status,
commencement or termination date of 'the Participant's employment during the Plan Year, and such
other factors as the Employer shall prescribe. Except as otherwise provided in the Adoption Agreement
in no event will any Nonelective Contribution be disbursed to a Participant if the cost of the benefit(s)
elected is less than the Nonelective Contribution allocable thereto. Any excess shall be returned to the
Employer.
1.22 "Participant" means an Employee who becomes a Participant pursuant to Article II.
1.23 "Plan" means the Adoption Agreement, the Flexible Benefits Plan and (if applicable) the
related Trust created by this document.
1.24 "Plan Administrator" "or committee" means the-person(s) appointed by the Employer
with authority and responsibility to manage and direct'the operation and administration of the Plan. If no
such person is named, the Plan Administrator shall be the Employer.
1.25 "Plan Year" means the twelve month period specified in the Adoption Agreement
provided, however, that a period of less than twelve months may be a Plan Year for the initial Plan Year,
the final Plan .Year, and a transition period to a different Plan Year.
1.26 "Pre-tax Premium(s)" means any amount withheld from the Employee's Compensation
pursuant to a Salary Redirection Agreement which is intended to be paid on a pre-tax basis. This
amount shall not exceed the premiums attributable to the most costly Benefit Plan of Policy options
afforded hereunder, and for purposes of Code Section 125, shall be treated as an Employer contribution
(this amount may, however, be treated as an Employee contribution for purposes of state insurance
laws).
1.27 "Qualified Benefit" means any benefit excluded from the Employee's taxable income
under Chapter 1 of the Code (other than Sections 106(b),117, 124, 127, or 132), and any other benefit
permitted by' the Income Tax Regulations (i.e., any group-term life insurance coverage that is includable
in gross income by virtue of exceeding the dollar limitation on nontaxable coverage under Code Sec.
79). Long-term care insurance is not a "Qualified Benefit".
1.28 "Qualifying Employment-Related Expenses" means those expenses that would be
considered to be employment-related expenses under Section 21(b)(2) of the Code (relating to
expenses for household and dependent care services necessary for gainful employment) if paid for by
the Employee to provide Qualifying Services.
1.29 "Qualifying Individual" means:
(a) a Dependent of the Participant who is under the age of thirteen (13);
(b) a Dependent of a Participant who is mentally or physically incapable of caring for himself or
herself; or
(c). the Spouse of .a Participant who is mentally or physically incapable of caring for himself or
herself. 3.
PROC297B.4
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2.03 Termination of Participation. Participation shall terminate on the earliest of: i) the date
an Employee ceases to be an Employee (except as otherwise provided in Section 3.05 for "COBRA
coverage"); ii) when an Employee ceases to meet the eligibility requirements of Section 2.01 of this
Plan, iii) the date this Plan is amended to exclude the Employee or is terminated: iv) the effective date
of the Employee's election not to participate pursuant to Sections 3.03 or 3.04.
Subject to any specific limitations for any particular benefit which the Participant has elected, (a)
participation shall be continued during a leave, of absence for which the Participant continues to receive
a salary from his or her employer and (b) participation shall be suspended during an unpaid leave of
absence.
2.04 Eligibility to Participate in Reimbursement' Benefits. An Employee, who is otherwise
an Eligible Participant pursuant to Sections 2.01 and 2.02 shall be eligible to receive Medical and/or
Dependent Care Expense Reimbursements (if. selected by the', Employer in the Adoption Agreement) if;
i) the additional Eligibility criteria (if any)~ set forth in the Adoption Agreement for the Reimbursement
benefits have been satisfied; and ii) a Salary Redirection Agreement is properly executed and submitted
on which the aforementioned benefit(s) have been selected.
2.05 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 medical coverage (as defined in. Code 5000) on the same terms and conditions as
though he were still an active Employee (i.e., the Employer will' continue to pay its share of the premium
to the extent the. Employee opts to continue his coverage), if the. Employee opts to continue his
coverage, the Employee may pay his share of the premium 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 share of the premium for the expected duration of the leave on a
pre-tax salary reduction basis out of his pre-leave Compensation 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-tax 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.
ARTICLE I!!
PREMIUM ELECTIONS
3.01 Election of Premiums. A Participant may elect any combination of Pre-tax Premiums or
After-tax Premiums to fund any Benefit Plan or Policy available under the Adoption Agreement, provided
however, that only Qualified Benefits (other than group, term life insurance coverage in excess of
$50,000) may be funded with Pre-tax Premiums. Participants may also be permitted to elect additional
cash compensation by opting out of certain coverages to the. extent described in the Adoption
Agreement under "Opt-Out Option".
3.02 Initial Election Period.
(a) Currently Eligible Employees. An Employee who is eligible to become' a Participant in this
Flexible Benefits Plan as of the Effective Date must complete, sign. and file a Salary Redirection
Agreement with the Plan Administrator during the election period' (as specified by the Plan
Administrator) immediately preceding the Effective Date in order to become a Participant on the
Effective Date. The elections made by the Participant on this initial Salary Redirection Agreement shall
be effective, subject to Section 3.04,.for the Plan Year beginning on the Effective Date.
(b) New Employees and Employees Who Have Not Yet Satisfied The Flexible Benefit Plan's
Waiting Period. An Employee who becomes' eligible to become a Participant in this Flexible Benefits
Plan after the Effective Date must complete, sign and file a Salary Redirection Agreement with the Plan
PROC297B.4
(2) Gain of Coverage Eligibility Under Another Employer's Plan. For a Change in Status in
which a Participant, a Participant's Spouse or a Participant's Dependent gains eligibility for coverage
under another employer's cafeteria plan (or another employer's qualified benefit plan) as a result of a
change in marital status or a change in employment status, a Participant may elect to cease or
decrease coverage for that individual only if coverage for that individual becomes effective or is
increased under the other employer's plan.
(3) Dependent Care Expense Reimbursement benefits. With respect to the Dependent Care
Expense Reimbursement benefit, a Participant may change or terminate his or her election only if i)
such change or termination is .made on account of and corresponds with a Change in Status that affects
eligibility for coverage under an employer's plan; or ii) the election change is on account of and
corresponds with a Change in Status that affects eligibility of dependent care assistance expenses for
the tax exclusions available under Code Section 129;
(4) Group term life insurance and disability income coverage. For a Ohange in Status involving
a Participant's legal marital status or the employment status of a Participant's Spouse or Dependent
(disregarding the requirement that the event caused a gain or loss of eligibility), a Participant may elect
either to increase or to decrease group-term life insurance or disability income coverage offered under
the Plan.
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(b) Special HIPAA Enrollment Rights. If a Participant, a Participant's Spouse or a Participant's
Dependent is entitled to special enrollment rights under a group health plan, as required by Section
9801(f) of the Code, and medical coverage was. declined under the group health plan because of
outside medical coverage and. eligibility for such coverage is subsequently lost due to legal separation,
divorce, death, termination of employment, reduction in hours, or exhaustion of the maximum COBRA
period, or a new Dependent is acquired as a result of marriage, birth, adoption, or placement for
adoption, then a Participant may revoke a prior election for health or accident coverage and make a new
election (including salary redirection election), provided that. the election corresponds with such special
enrollment right. For purposes of this provision: i) an. election to add previously eligible Dependents as
a result of the acquisition of a new Spouse or Dependent child shall be considered to be consistent with
the special enrollment right; and ii) a HIPAA special' enrollment election attributable, to the birth or
adoption of a new Dependent child may, subject to the provisions, of the underlying group health plan,
be effective retroactively (up to 30 days).
(c) Certain Judgments, Decrees and Orders.. If a judgment, .decree, or orde~ (an "Order")
resulting from a divorce, legal separation, annulment or change, in legal custody(including a qualified
medical child support order) requires accident or health coverage for a Participant's Dependent child
(including a foster child who is a Dependent of the Participant), a Participant may: i) change his or her
election to provide coverage for the Dependent child' (provided that the Order requires the Participant to
provide coverage), or ii) change his or' her election to revoke coverage for the Dependent child if the
Order requires that another individual (including the Participant's Spouse or former Spouse) provide
coverage under that individuaJ.'s' plan.
(d) Medicare and Medicaid. If a Participant, a Participant's Spouse, or a Participant's Dependent
who is enrolled in a health or accident benefit under this Plan 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 prospectivelY reduce or Cancel the health or
accident coverage of the person becoming entitled to Medicare or Medicaid. Further, if a Participant, a
Participant's Spouse, or a Participant's Dependent who has,. been entitled to Medicare or Medicaid loses
eligibility for such coverage, the Participant may prospectively elect to commence or increase the health
or accident coverage of the individual.
(e) Change in Cost. The following, rules
Reimbursement accounts under the Plan.
are not applicable to Health Care Expense
PROC297B.4
Any change in an election effecting annual Plan Contribution to the Medical or Dependent Care Expense
Reimbursement Plans pursuant to this Section also wilt change the Maximum Reimbursement Benefits
for the period of coverage remaining in the Plan Year. Such Maximum Reimbursement Benefits for the
period of coverage following an election change shall be calculated by adding, the balance. (if any)
remaining in each of the' Participant's Reimbursement Accounts as of the end of the portion of the Plan
Year immediately preceding, the change in election, to the total Plan'Contdbutions scheduled to be
made by the Participant during the remainder of such Plan Year to such Account(s).
An Employee who is eligible' to become a Participant but declined, to become a Participant during the
initial election period pursuant to Section 3.02(a) or (b) may become a Participant and file a Pre-tax
Contribution election within thirty (30) days of the occurrence of an event described in Section 3.04
above, but only if the election under the new Salary Redirection Agreement is made on account of and
corresponds with the event (as described above). A participant otherwise, entitled to make a new
election under this Section must do so within 30 days of the event (e.g., Change in Status, significant
change in cost or coverage, Medicare or Medicaid. eligibility, special enrollment right or judgment,
decree or order). Subject to the provisions of the underlying group health plan, elections made to add
medical coverage for a newborn, or newly adopted Dependent child pursuant to a HIPAA special
enrollment right may be retroactive for up to 30 days. All other new elections shall be effective
immediately following the date the Participant files his new Salary Redirection Agreement with the Plan
Administrator. Elections made pursuant to this Section. shall be effective for the balance of the Plan
Year in which the election is made unless a subsequent event (described' above) allows a further
election change.
3.05 Termination of Election.. Except as otherwise provided in Section 2.03, Termination of
employment shall automatically revoke any Salary Redirection Agreement. Except as provided below, if
revocation occurs under this Section 3.05, no new election with respect to Pre-tax Premiums may be
made by such Participant during the remainder of the. Plan Year. Except as otherwise provided in the
applicable Benefit. Plans or Policies, former Participants who. are rehired within 30 days or less of the
date of termination of employment will be reinstated with the same election(s) such individuals had
before termination, if a former Participant is rehired more than .30 days' following termination of
employment and is otherwise eligible to participate in the Plan, the individual may make a new election.
ARTICLE IV
PREMIUM PAYMENTS AND CREDITS AND. DEBITS TO ACCOUNTS
4.01 Source of Premium Payments. The Employer shall withhold from a Participant's
Compensation on a Pre-tax or After-tax basis (as elected on the Salary Redirection Agreement) an
amount equal to the contributions required from the. Participant (less any applicable Nonelective
Contribution) for coverage of the Participant, or the Participant's Spouse or Dependents, under the
Benefit Plans or Policies elected by the Participant and maintained by the Employer as noted in the
Adoption Agreement under this Plan. The component Benefit Plans. or Policies, and required Employee
contributions thereunder shall be set forth on an annual schedule and/or disclosed to Participants in
enrollment material. Amounts withheld from a Participant's Compensation as Pre-tax Premiums' or
After-tax Premiums shall be applied to fund benefits as soon as: administratively feasible. The maximum
amount of Pre-tax Premiums plus any Nonelective Contribution made available by the Employer for the
benefit of each Plan Participant shall not exceed the aggregate cost of the benefits elected'.
4.02 Allocations Irrevocable During PI'an Year. Except as provided in. Sections 3.04, 3.05,
4.03, and 4.04, neither (.i) the insurance coverages no~. amounts withheld therefore elected under
Section 5.01(a), nor (ii) the amount to be credited to a.. Participant Account during the Plan Year
pursuant to Sections 4.04 and 4.05, nor (iii) the. allocation of such amounts to the appropriate
Account(s) of the Participant, can be changed during the Plan Year.
4.03 Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator
determines, before or during any Plan Year, that the Plan may fail to satisfy for such Plan Year any
requirement imposed by the Code or any limitation on Pre-tax Premiums allocable to Key Employees or
to Highly Compensated Individuals, the Plan Administrator shall' take such action(s) as he deems
PROC297B.4
(b) Source of Payments. All Dependent Care Expense Reimbursement benefits derived
hereunder shall be paid exclusively from the amounts in each. Employee's Dependent Care Expense
Reimbursement Account funded by amounts withheld from the Employee's wages pursuant to the
Salary Redirection Agreement for "Dependent Care Expense .Reimbursement, and any Nonelective
Contributions allocable thereto.
ARTICLE V
BENEFITS
5.01 Qualified Benefits. The maximum benefit, a Participant may elect under this Plan shall
not exceed the Sum of i) the Aggregate Premium for all Insurance Premium Payments under 5.01 (a);ii)
the' Maximum Medical Care Expense Reimbursement under 5.01(b); and iii) the Maximum Dependent
Care Reimbursement under 5.01(c). The Qualified Benefits available for election are one or more of the
following:
(a) Insurance Premium Payment. The Employer shall withhold from a Participant's
Compensation an amount equal to the contributions required from the Participant (less any applicable
Nonelective contribution) for coverage of the Participant, or the dependent coverage of the Participant's
spouse or Dependents, under the Benefit Plans or Policies elected by the Participant and maintained by
the Employer as noted in the Adoption Agreement. The 'benefits are subject to the terms and conditions
of the applicable Benefit Plans. or Policies specifically referred to in the Adoption Agreement .and
incorporated herein into this Plan.
(b) Medical Care Expense Reimbursement. if pursuant to the Adoption Agreement, the
Employer has elected to maintain a Medical Care Expense Reimbursement Plan, payment shall be
made to the Participant in. cash as reimbursement for Eligible Medical Expenses-incurred by the
Participant or his Dependents while he is an Employee, during the Plan Year for which the Participant's
election is effective. These expenses must' also be expenses which--
(1)
(2)
(3)
(4)
(5)
(6)
are not covered, paid or reimbursed' from any other source; and
meet the criteria of tax-deductibility as a medical or dental expense under Section 213
of the Code, as amended and' the .regulations thereunder, and
meet any limitations imposed by applicable regulations promulgated under Code Section
125; and
will not be taken as a deduction from income on the Participant's federal income tax
return in any tax year; and
do not exceed the lesser of (a) the maximum annual amount allocable to Medical Care
Expense Reimbursement specified' in the Adoption Agreement, or (b) the annual amount
that the Employee has elected to have withheld for Medical Care Expense
Reimbursement,, less previous Medical Care Expense Reimbursements made during the
Plan Year; and.
are verified in writing to the satisfaction of the Administrator that a covered expense has
occurred and the reimbursement for which meet' the substantiation requirements of
Section 6.11.
(c) Dependent Care Expense Reimbursement. If pursuant to the Adoption Agreement, the
Employer has elected to maintain, a Dependent Care Expense Reimbursement Plan, payment shall be
made to the Participant in cash as reimbursement for Eligible Employment Related Expenses incurred
by him or her while an Employee, during, the Plan Year for which, the 'Participant's election is effective,
provided that the substantiation requirements of Section 6.11 have been complied with. No payment
otherwise due a Participant hereunder' shall exceed the smallest of:
the Participant's Earned Income for the applicable month; or
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PROC297B.4
~. TICLE VI
PLAN ADMINISTRATION
6.01 Allocation of Authority. Except as to those ~nctions reserved within the Plan to the
Employer, the Plan Administrator appointed pursuant to the Adoption Agreement shall control and
manage the operation and adh~inistration of the Plan. The. Plan Administrator shall have the exclusive
right to interpret the Plan and to. decide all matters arising thereunder, including the right to make
determinations of fact. and construe and interpret possible ambiguities, inconsistencies, or omissions in
the Plan and the Summary Plan Description issued" in connection with the Plan. All determinations of
the Plan Administrator with respect to any matter hereunde~ shall be conclusive and binding on all
persons. Without limiting the generality of the foregoing, the Plan. Administrator shall have the following
powers and duties:
(a)
To require any.person to furnish such reasonable, information as he may request for the
purpose of the proper administration of the Plan as a condition to receiving any benefits
under the Plan;
(b)
To make and enfOrce such rules and regulations and prescribe the use of such forms
as he shall deem necessary for the efficient administration-of the Plan;
(c)
To decide on questions concerning the Plan and the eligibility of any Employee to
participate in the Plan and, to make or revoke elections under the Plan, in accordance
with the provisions of the Plan;
(d)
To determine the amount of benefits which shall be payable to any person in
accordance with the provisions of' the Plan; to inform the Employer, insurer or Trustee
(if any), as appropriate, of the amount of such benefits; and to provide a full and fair
review to any Participant whose claim for benefits has been denied in whole or in part;
(e)
To designate other persons'to carry out any duty or power which may or may not
otherwise be a fiduciary responsibility of the Plan Administrator, under the terms of the
Plan;
(f)
To keep records of all acts, and determinations, and to keep all such records, books of
account, data and other documents as may be necessary for the proper administration
of the Plan;
(g)
(h)
To prepare and distribute to alt Employees information concerning the Plan and their
rights under the Plan;
,
To' do all things necessary, to. operate and administer the Plan in accordance with its
provisions.
6.02 Provision for Third-Party Plan Service, Providers. The Plan Administrator, subject to
approval of the Employer, may employ the services of. such persons as it may deem necessary or
desirable in connection with the operation of the Plan and to rely. upon all tables, valuations, certificates,
reports and opinions furnished thereby. Unless otherwise provided' in the service agreement, obligations
under this Plan shall remain the obligation of'the Employer.
6.03 Fiduciary Liability. To the extent: permitted by law, neither the Plan Administrator nor any
other person shall incur any liability' for any, acts or for failure to act except for their own willful
misconduct or willful breach of this Plan~
6.04 Compensation of Plan Administrator. Unless otherwise determined by the Employer
and permitted by law, any Plan Administrator who is also an employee of the Employer shall serve
without compensation for services rendered in such capacity, but all reasonable expenses incurred in
the performance of their duties shall be paid' by the Employer.
PROC297B.4
6.13 Annual Statements. The Plan Administrator shall furnish each Participant with an annual
statement, showing the amounts paid' or expenses incurred by the Employer in providing Medical and/or
Dependent Care Expense Reimbursement during, the previous calendar year and the respective
Reimbursement Account balance(s)on or before January 31 following the close of the applicable Plan
Year.
ARTICLE Vii.
FUNDING AGENT
7.01 Funding of the Plan. The Plan shall be funded with amounts withheld from
Compensation pursuant to Salary Redirection Agreements and by Nonelective Contributions by the
Employer.
7.02 The Employer as. Funding Agent. If the Employer is designated the Funding Agent in
the Adoption Agreement, the Employer will immediately apply all such amounts, without regard to their
source, to pay for the welfare benefits provided in the Adoption Agreement and shall comply with all
applicable regulations promulgated by the. Department of Labor ("D.O.L.") taking into consideration any
enforcement procedures adopted by the D.O~L.
7.03 Trust as Funding Agent. If a Trust is designated Funding Agent in the Adoption
Agreement, an appropriate Trust Agreement shall be attached at the end of this 'Plan.
AR?ICLE Vlll
CLAIMS: PROCEDURES
8.01 Application to Plan Benefits. The. provisions of this Article do not apply to: i) claims for
benefits under individual policies or ii) claims for benefits under group policies, not subject to ERISA. In
the event a claim arises with respect to. benef'~ under' such. policies, the insurer shall be the appropriate
named fiduciary for purposes of benefit determinations,, and with regard to benefits under such policies,
shall have the discretionary authority to construe and interpret the policies and make factual
determinations thereunder, if applicable, these provisions apply to claims for benefits only to the extent
that no claims procedure is specified for' such benefit in the applicable Benefit Plan or Policy. If a
claims procedure is otherwise available under the applicable Benefit Plan or Policy, this Article shall not
apply to benefits under the component Benefit Plan or Policy, but shall only apply to issues germane to
the pre-tax benefits available under, this Plan (i'..e., such as a determination of: a Change in Status;
significant change in premiums charged.; or eligibility and participation matters under this Flexible
Benefits Plan document). This Article shall be the claims procedure applicable to the Medical Care
Expense Reimbursement and the Dependent' Care Expense Reimbursement Plan(s).
8.02 Procedure if Benefits. are Denied Under the Plan. Any Employee, beneficiary, or his
duly authorized representative may file a claim for a benefit to which the claimant believes that he is
entitled, but that has been previously denied by' the Plan Administrator. Such a claim must be in writing
and delivered to the Plan Administrator' in person, or by mail, postage paid. Within ninety (90) days after
receipt of such claim, the Plan Administrator shall' send to the claimant, by mail, postage prepaid, notice
of the granting or denying, in whole or in part, of such claim, unless special circumstances require an
extension of time for processing the claim. In' no. event may the extension exceed ninety (90) days from
the end of the initial period. If such extension is necessary, the claimant will be given a written notice to
this effect prior to the expiration of the initial: 90-day period. The Plan Administrator shall 'have full
discretion to deny or grant a claim, in whole or in. part: If notice of the denial of a claim is not furnished
in accordance with this Section. 8.02, the claim shall,' be. deemed denied and the claimant shall be
permitted to exercise his right to review pursuant to Sections 8.04 and $.05.
8.03 Requirement for written Notice. of Claim. Denial. The Plan Administrator shall provide a
written notice to every claimant who is' denied a claim for benefits under this Article. Such written
notice shall set forth in a manner calculated to. be understood by the claimant, the following information:
(a)
The specific reason' or reasons for the denial;
15
PROC297B.4
..~
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ARTICLE X
GENERAL PROVISIONS
10.01 Not an Employment Contract. Neither this Plan nor any action taken with respect to it
shall confer upon any person the right to continue employment, with any Employer.
10.02 Applicable Laws. The provisions of the Plan shall be construed, administered and
enforced according to applicable Federal law and the laws of the State of the principal place of business
of the Employer to the extent not preempted.
10.03 Post-Mortem Payments. Any benefit payable under the Plan after the death of a
Participant shall be paid to his surviving spouse (if any), otherwise, to his estate. If there is doubt as to
the right of any beneficiary to receive any amount, the Plan. Administrator may retain such amount until
the rights thereto are determined., without liability for any interest thereon.
10.04 Nonallenation of Benefits. Except as expressly provided by the Plan Administrator, no
benefit under the Plan shall be subject in any manner to anticipation, alienation, sale, transfer,
assignment, pledge, encumbrance or charge, and any attempt' to do so shall be void. No benefit under
the Plan shall in any. manner be liable for' or subject to the debts, contracts, liabilities, engagements or
torts of any person..
10.05 Mental or Physical Incompetency. Every person receiving or claiming benefits under
the Plan shall be presumed to be mentally and. physically competent and of age until the Plan
Administrator receives a written notice, in a form and. manner acceptable to it, that such person is
mentally or physically incompetent or a minor, and that a guardian, conservator or other person legally
vested with the care of his estate has been appointed.
10.06 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 Participants or other person after reasonable efforts have been made to
identify or locate such person' such payment and all subsequent payments otherwise due to such
Participant or other person shall be forfeited one year after' the date any such payment first became
due.
10.07 Requirement for Proper Forms.. Ail communications in connection with the Plan made
by a Participant shall become effective only when duly executed on any forms as may be required and
furnished by, and filed with, the Plan Administrator.
·
10.08 Source of Payments'. The Employer, the Trust fund (if selected as Funding Agent), and
any insurance company contracts purchased or held by the Employer or funded pursuant to this Plan
shall be the sole sources of benefits under the Plan.. No. Employee or beneficiary shall have any right
to, or interest in, any assets of the Employer upon termination of' employment or otherwise, except as
provided from time to time under the Plan, and then only to the extent of the benefits payable under the
Plan to such Employee or beneficiary.
10.09 Multiple Functions. Any person or group of persons may serve in more than one
fiduciary capacity with respect to the Plan.
10.10 Tax Effects.. Neither the Employer, its agents, the Plan Administrator, nor the Trustee
makes any warranty or other representation as to whether any Pre-tax Premiums made to or on behalf
of any Participant hereunder will be treated as excludable from gross income for local, state, or federal
income tax purposes, if" for any reason it is determined that any amount paid for the benefit of a
Participant or Beneficiary is includable in an Employee's gross income for local, federal, or state income
tax purposes, then under' no circumstances shall the recipient have any recourse against the Plan
Administrator or the Employer with respect to any increased taxes or other losses or damages suffered
by the Employees as a result thereof. The Plan is designed and is intended to be operated as a
"cafeteria plan" under Section 125 of the Code.
17"
PROC297B.4
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11.02 Who is a "Qualified Beneficiary". A "Qualified Beneficiary" is any person who is, as of
the day before a Qualifying Event, (a) an Employee of the Employer. (including persons who are
considered to be "employees" within Code Sec. 401(c), directors and independent contractors) Covered
under a health plan offered under the Plan as of such day (such persons are called "Covered
Employees"), (b) the Spouse of the Covered Employee, or (c) a Dependent of the Covered Employee.
A Covered Employee can be.a Qualified Beneficiary only if the Qualifying Event censists of termination
of employment (for any reason other than gross misconduct) or reduction of hours of the Covered
Employee's employment. A child born to or placed for adoption with a Covered Employee during
Continuation Coverage will also be a. Qualified Beneficiary. A retiree or other former Employee actively
participating in the Plan by reason' of a previous period of employment will be .treated as a "Qualified
Beneficiary".
11,03 Who is not a "Qualified Beneficiary". A person is not a Qualified Beneficiary if, as of
such day, either the individual is covered under the Medical Care Expense Reimbursement Plan (or
other group health plan=, subject to COBRA) by virtue of the election of Continuation Coverage by
another person and is not already a Qualified Beneficiary by reason of a prior Qualifying Event, or is
.entitled to Medicare coverage under Title XVII! of the Social Security Act. Furthermore, an individual
who fails to elect Continuation Coverage within the election period, provided in Section 11.07, below,
shall not be considered to be a Qualified Beneficiary.
Event"'
11.04 What is a. "Qualifying Event". Any of the following shall be considered as a "Qualifying
(a).
death of a Covered Employee; or
(b)
termination (other than by 'reason of gross misconduct) of the Covered Employee's
employment or reduction of hours of employment; or
(c)
divorce or legal separation of a Covered Employee from the employee's spouse; or
(d)
a Covered Employee's becoming entitled to receive Medicare benefits under Title XVIIi
of the Social Security Act; or
(e)
a dependent child of a Covered Employee ceasing to be a Dependent.
In the case of any person treated as a Covered "Employee" but who is not a common-law
employee, termination of "employment" means termination of the relationship that originally gave rise to
eligibility to participate in the Medical Care Expense Reimbursement Plan (or other group health plan
subject to COBRA.)
11.05 COBRA Not Applicable to Certain Health Care Expense Account Participants. In
accordance with IRS regulations, .COBRA continuation coverages will not be offered to Medical Care
Expense Account Plan participants under certain circumstances:
(a) Unavailability of COBRA in Plan Year in Which Qualifying Event Occurs. COBRA
continuation coverage will not- be offered to a Qualified Beneficiary in the Plan Year in w~ich the
Qualifying Event occurred of:
(1) Conditions i'n111.05(b) are Satisfied. The Medical Care Expense Account Plan
satisfies, the conditions set forth in Section 11.05(b); and
(2) Health Care Expense Account has a Deficit at the Time of the Qualifying
Event. Tak!ng into account all claims, submitted on or before the date of the Qualifying
Event, the Qualified Beneficiary's remaining Medical Care Expense Account balance for
the Plan Year is less than the maximum, required COBRA premiums for the rest of the
year (i.e., the Medical Care Expense Account is in a deficit position).
19'
PROC297B.4
11.08 Election Period. Any Qualified Beneficiary entitled to Continuation Coverage shall have
60 days from the date of the notice required by Section 11.06, in the case of occurrence of a Qualifying
Event, in which to return a signed election to the Plan Administrator indicating the choice to continue
benefits under this Plan.
11.09 Duration of Continuation Coverage. Except as otherwise provided in this Plan,
Continuation Coverage shall extend for a period of 18 months after the date that regular coverage
ceased due to occurrence of the initial Qualifying Event described in Section 11.04(b), unless .during
such 18-month period a subsequent, Quali~ing 'Event occurs, in which case, another election to extend
coverage for 18 months shall be available to the Beneficiary. Except as otherwise provided in this
Section, in the. case of a Qualifying Event not described in Section 11.04(b), Continuation Coverage
shall extend for a period of 36 months after the. date that regular coverage ceased due to the
occurrence of the Qualifying Event. In the case of a Qualified Beneficiary who is determined, under title
!1 or XVI of the Social Security Act to have been disabled within 60 days of a Qualihting Event described
in Section 11.04 (b), Continuation Coverage with respect to such event shall extend for a period of 29
months after the date that regular coverage ceased due to the occurrence of the Quali~ing Event if the
Qualified Beneficiary has provided notice of such determination within sixty (60) days after the date of
such determination and before the end of the initial 18 month Continuation Coverage period. In the
event a Covered Employee becomes entitled to Medicare coverage, the period of Continuation
Coverage for a Qualified Beneficiary, other than the Covei'ed Employee for such Qualifying Event or any
subsequent Qualifying Event, shall not terminate for a period of. 36 months from the date the Covered
Employee becomes entitled to Medicare benefits. In no event, however, shall Continuation Coverage
extend more than 36 months beyond the date of the original Qualihting Event.
11.10 Automatic Termination of Continuation Coverage. Continuation Coverage shall
automatically cease if (a) the Employer no longer offers the particular group health coverage to any of
its employees (b) the required premium for Continuation Coverage for a particular coverage is not paid
within 30 days of the date due or within 45 days after the initial olection of Continuation Coverage made
pursuant to Section 11.08 (whichever is later), (c) an electing Qualified Beneficiary becomes Covered
under another group health plan other than a group health plan which may limit a Qualified Beneficiary's
coverage because it involves a pre-existing condition, or (d) an electing Qualified Beneficiary becomes
eligible to receive benefits under Medicare.
IN WITNESS WHEREOF, the Employer has executed this Flexible Benefits Plan, Medical Care
Expense Reimbursement .Plan, and/or Dependent Care Expense Reimbursement Plan (as noted in the
Adoption Agreement), the date and year first written below, to be effective as set forth in the Adoption
Agreement.
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WITNESS:
Corporate Officer
Employer:
By: ....
Title:
Date:
.
21
PROC297B.4
FLEXIBLE BENEFITS PLAN SUMMARY PLAN .DESCRIPTION FOR:
CITY OF TUSTIN
FLEXIBLE BENEFITS 'PLAN
· EMPLOYER INFORMATION
i i i i
i)
Name and Address of Employer/
Plan Administrator:
2) Employer's Telephone Number:.
3)
4)
Employer's Federal Tax
Identification Number:
Plan number assigned to cafeteria
plan (e.g., 501 if this is the first ERISA
plan number assigned)
5) 125 Start Date:
6) Effective Date of this Plan:
7)
8)
9)
Last Day of the Plan Year:
Subsequent Plan Years:
Name and Address of
Plan Service Provider:
Name and Address of registered
agent for service of legal
process:
· CITY OF TUSTIN
ARLENE MARKS
·
300 'CENTENNIAL WAY
TUSTIN, CA 92780
95-6000804
O1/01/02
01/01/02
12/31/02
01/01-'1~1
CLAIMS PROCESSOR: FLEX ONE
1932 WYNNTON ROAD
COLUMBUS, GA 3 i999
WlLUAM A HUSTON
CITY MANAGER
06/10/00 version
SPD97
10) Affiliated Employers which will participate in the Plan:
11) Employer's Type of Business:
OTHER
2, SPD97
ELIGtBiUT~
Ali Employees employed by the Employer shall be eligible to .participate under the Plan ,,e, xcept the following:
TEMPORARY OR SEASONAL OR .NON-REGULAR,PART-.TIME
An eligible Employee may become a Participant in the 'plan:
( )
( )
(x)
( )
Immediately, upon his first day of 'employment '(but nOt'prior to [he Effective Date of the Plan).
On the day following .commencement of employme~nt.
On the first day of the month following 30 days of .employment.
OTHER
provided the Employee completes a salary Red'~rection Agreement. 'However, eligibility for coverage under
any given Benefit Plan or Policy shall be determined by the terms of that Benefit Plan of Policy, and
reductions of the Employee's Compensation to pay Pre-tax or After-tax .Premiums shall commence when the
Employee becomes covered under the applicable Benefit 'Plan or Policy.
An eligible Employee may become a Partici~nt in the Dependent Care and/or Medical Expense Reimbursement
Plan(s) (if elected below):
( ) On the same day such Employee ~s eligible for lhe Pm-Tax .Premium benefits under the Plan.
( ) On the day following commencement.of employment.
( ) On the first day of the month following days of employment.
( ) OTHER
provided the 'Employee completes a Salary Redirection .Agreement selecting such benefits.
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BENEFITS PROVIDED UNDER THE PLAN
ii ii ii i
The following Benefit Plans and Policies subject to the terms and conditions of the Plan are available for election by
eligible Employees. The maximum a Participant can contribute via the Salary Redirection Agreement is the
maximum aggregate cost of the Benefit Plans or Policies elected minus any Nonelective Contribution made by the
Employer. It is intended that suoh Pm-tax Premium amounts shall, for tax purposes, constitute an Employer
contribution, but may constitute 'EmpE!yee .contributions for state insurance law purposes. Copies of the Benefit
Plans or Policies (or a list of eligible 'Policy numbers.) shall be ~tached as an appendix to this Plan.
(x)
(x)
( )
(x)
(x)
(x)
( )
(x)
(x)
(x)
( )
(x)
(x)
Group Medical Insurance
Vision Care Insurance
Disability Income-Short Term (A&S) ~
Cancer Insurance
Group Dental Coverage
Group Term Life Insurance
Disability Income-Long Term (LTD}
Intensive Care Insurance
Accident Insurance
Hospital Indemnity Insurance (HIP)
Specified Health Event
Medical Care Expense Reimbursement described in Section 5.01(b).of the Plan, not to exceed 3,000
per Plan Year'pursuant to the CITY OF TUSTIN
Medical Care Expense Reimbursement Plan.
Dependent Care Expense Reimbursement described in Sec~on 5.01(c) of the Plan not to exceed $5,000 per
Plan Year or $2,500 for :married fi'ling separate returns pursuant to the
CITY OF TUSTIN
Dependent Care Expense Reimbursement Plan.
Opt-out Option: See enrollment msterial.
SPD97
THE FUNDING AGENT
The Employer selects the following Funding Agent for the Plan (check one):
The Employer, which will comply with the requirements of Section 7.02 of the Plan.
.The Flexible Benefits Trust created concurrently with the execution of the Plan, which shall receive
contributions under the Plan in accordance with Section 7.03 of the Plan.
ADMINISTRATIVE EXPENSES
ii , I .....
Administrative Expenses incurr, ed in operating the Plan shall be paid by (check one)'
The Employer, except as otherwise noted in the Plan.'
The Participants, except as otherwise noted in the Plan.
SPD97
FLEXIBLE .BENEFITS PLAN SUMMARY PLAN DESCRIPTION
IRtroduction
Your employer (the '"Employer") is pleased 'to Sponsor an employee benefit program known as a "Flexible
Benefits Plan" (the "Plan")'.for you and your fellow emP' Ioyees. Under federal tax laws, it is also known as a
"cafeteria plan". It is so .called because it lets ,you choose from several different insurance and fringe benefit
programs according to your ~ndivicl. ual needs. The 'Employer l~mvides 'you with the opportunity to use pre-tax dollars
to pay for them by entering into a salary redirection arra~ement instead of a corresponding amount of your regular
pay. This arrangement helps you because the benefits you elect are nontaxable; you save social security and
income taxes on the amount of your salary redirection. Ntematively, your employer may allow you to pay for any of
the available benefits with after-tax .contributions on a .sa~ deduction basis.
·
This Summary Plan ;Description describes the?~ic features of the Plan, how it operates, and how you can
get the maximum advantage .iTom .,it. The booldet ,is ,.only s summary' of the key parts of the Plan, and a brief
description of your rights as a participant. It .is not a'part of ~ officia~ plan documents. If there is a conflict between
them and this booklet, the plan document will apply.
By enrolling in the Flexible ~Spending Account (FSA.)Ol~ion and submitting FSA claims you specifically
authorize the Plan, AFl_AC and Rex One, and their respeC~ve :agents, employees, sub-contractors, and assigns to
use your personal information in ~eir possession to 'adm[aister the :Plan (including the evaluation of eligibility for.
reimbursement under the .'PJaa) and '.to detect or 'prevent'~:l .or misrepresentation, and to further disclose such
information as is reasonably required 'for those purposes, .You further authorize any provider, insurer, or other entity
to release any health or treatment information for 'the .~se of determining eligibility .for Plan benefits or for
detecting or preventing fraud or misrepresentation. You 'fur~er waive and release any claims related to the use,
disclosure, or release of .suCh .information so tong .as ~the [W[orm~tion .is used-in furtherance of administering the Plan
(including processing or eva~uating a claim for 'benefits under t~e Plan) or to detect or prevent fraud or
misrepresentation. This authorization does not and is net [nten(~d .to in any way limit any right the Plan, AFLAC and
Flex One, or their respective agents, employees, sub-co~ctors, and .assigns may. have under applicable state or
federal law or regulation regarding .the use of such .information.
· PART !
:General Information about ~e .Flexible Benefits Plan
Questier~s & Answers
'I
Q-1. What is the purpose of the Plan?
The purpose of the Plan .is to allow eligible employees to use funds provided by the Employer through
employee salary redirection, to choose one ,or more of the 'Benefit 'Plans or Policies offered through the Plan, and
enable them to pay for the .selected coverage(s) wifl~ pre-tax.do[lam,
Q-2. What Benefits can i purchase on a pre-tax baals through the Plan?
You will be able to .choose .to participate in the. :Ptan':s pm-tax program options by filling out any required
enrollment form(s) for the component Benefit Plan ,or Poi'~. :..The ~P[en may also permit you to select Unreimbursed
Medical Care Expense Reimbursement or Dependent Care :Expense Reimbursement on a pre-tax basis. To the
extent described on enrollment .materials, employees Who ep~-out of certain benefits may be entitled to additional
cash compensation. The .various benefit options ~avaitabie w. fll':be, described to you in information materials distributed
prior to each enrollment :period. For the details regan~ag eligibitity .provisions, benefit amounts, 'and premium
schedules, please refer to the plan summary of each of the above programs. Ask the Plan Administrator for copies.
Q-3. Who can participate in the Plan?
Each employee ..'of the Employer is eligib.[e to participate .in the Plan who meets the description of eligible
Employee in the Employor Information Section. Those empioyoos ..~o-actually participate in the Plan are called
"Participants". An employee, continues to participate until he or she: i).elects not to participate in accordance with
Q-7; or ii) is no longer Om'pio~od by 'the Employer, or ~uation Coverage (as described below) is no longer in
effect.
06/10/00 version COPYRIGHT JANUARY 1, 1990
SPD97
Q-4. What tax advantages are available through the Plan?
The Plan permits you to pay for insurance and fringe benefit programs with pre-tax dollars through salary
redirection rather than regular pay. You should note, however, that paying for coverage on a pre-tax basis may
cause, insUrance claim payments under health and medical coverage to be subject to federal and state taxes if claim
payments from ali health and medical policies/plans are in. excess of medical expenses relating to the condition
which triggers the payment. You will be responsible for including such excess amounts (if any) in your tax return.
Paying for disability income policies with pre-tax premiums will cause the benefits payable thereunder to be taxable.
Alternatively, you may be permitted to pay for the same benefits with after-tax dollars on a salary deduction
basis. The Plan may also permit you to select Unreimbursed Medical Care Expense Reimbursement or Dependent
Care Expense Reimbursement on a pre-tax basis if these benefits are selected by your Employer as noted in the
Employer Information Section.
Q-5. HOw do i become a participant?
You bebome a Participant by signing an individual Salary Redirection Agreement on which you elect one or
more .of the benefits available under the Plan, as well as agree to a salary redirection to pay for those benefits so
elected. You will be provided a Salary Redirection Agreement when you first become eligible to participate. You
must complete the form and turn it in to the Personnel Office within the time period specified by the Plan
Administrator. If you are eligible on the initial Effective Date of the Plan, you will be able to enter .the Plan during the
Initial Enrollment Period and shall become a Participant on the date set'forth in the Employer Information Section.
Otherwise, you will be able to enter the Plan on the effective date of your coverage under the component Benefit
Plans or Policies.
In future years, a new Salary Redirection Agreement will be made available to you by the first day of the
Annual Enrollment Period, and you will be given the opportunity to confirm or change your choices made for the
previous 12-month period for the coming 12 months beginning on the first day of the next Plan Year. This twelve
month period is called the "Plan Year". A Participant who fails to complete, sign and file a Salary Redirection
Agreement as required shall be deemed to have elected to continue participation in the Plan, with the same benefit
elections as during the prior Plan Year (adjusted to reflect any increase/decrease in applicable premiums), and
except for a Change in Status, will not be permitted to modify his election until the next Annual Enrollment Period.
Notwithstanding the foregoing, annual elections for participation in the Medical Care and Dependent Care Expense
Reimbursement Plans must be made by submitting a Salary Redirection Agreement prior to the beginning of each
Plan Year -- no deemed elections shall occur with respect .to such benefits.
Q-6. What are the enrollment periods for entering the Plan?
The initial period for enrolling in the 'Plan is the period specified by the Plan Administrator immediately
preceding the Plan's Effective Date. Thereafter, the Enrollment Period will be specified by the Plan Administrator
and will begin prior to the Anniversary. Date and end on the Anniversary Date.
Q-7. Can I change my election during the Plan Year?
Generally, you cannot change your election to participate in the Pre-tax Premium payment option or vary the
Pre-Tax Premiums you have selected, during the Plan Year, although your election will terminate if you are no longer
working for the Employer. Otherwise, you may change your elections for Pre-Tax Premiums only during the Annual
Enrollment Period, and then, only for the coming Plan Year.
There are several important exceptions to this general rule: You may change or revoke your previous
election for Pre-Tax Premiums during the Plan Year if you file a written request for change with the Plan
Administrator within 30 days of any of the following events:
1. Change in Status. If one or more of the following Changes in Status occur, you may revoke your old
election and make a new election, provided that both the revocation and new election are on account of and
correspond with the Change in Status (as described below). Those occurrences which qualify as a Change in Status
include the events described below, as well as any other events which the Plan Administrator determines are
permitted under subsequent IRS regulations:
SPDg7
(a)
a change in your legal marital status (such as marriage, legal separation, annulment,' divorce or
death of your Spouse).
(b)
a change in the number of your tax Dependents (such as the birth of a child, adoption or placement
for adoption of a Dependent, or death of a Dependent).
(c)
any of the following events that change the employment status of you, your Spouse, or your
Dependent that affects benefit eligibility under a cafeteria plan (including this Plan) or other employee
benefit plan of yours, your Spouse or your Dependents. Such events include any of the following
changes in the employment status: termination or commencement of employment, a strike or
lockout, a commencement of or return from an unpaid leave of .absence, a change in worksite,
switching from salaried to hourly-paid, union to non-union, or :part-time 'to full time; incurring a
reduction or increase in hours of employment; or any other similar change which makes the
individual become (or cease to be) eligible for a particular employee benefit.
(d)
an event that causes your Dependent to satisfy or cease to satisfy an .eligibility requirement for a
particular benefit (such as attaining a specified age, getting married, or ceasing to be a student).
(e)
a change in your, your Spouse's or.your Dependent's place of residence.
If a Change in Status occurs, you must inform the Plan Administrator and complete a new election for Pre-
tax premiums within 30 days of the occurrence.
If you wish to change your election based on a Change in Status, you must establish that the revocation is
on account of and corresponds with the Change in Status. The Plan Administrator (in its sole discretion) shall
determine whether a requested change is on account' of and corresponds with a Change in Status. As a general
rule, a desired election change will be found to be consistent with a Change in Status event if the event affects
coverage eligibility (for Dependent Care Expense reimbursement, the event may also affect eligibility for the
dependent care exclusion). In addition, you must also satisfy the following specific :requirements in order to alter
your election based on that Change in Status:
(a)
Loss of Dependenl~ Eligibility. For accident and health benefits (e.g., 'health, dental and vision
coverage, accidental death and dismemberment coverage, and Health .Care Expense
Reimbursement benefits), a special rule governs which type of election changes are consistent with
the Change in Status. For a Change in Status involving your divorce, annulment or legal separation
from your Spouse, the death of your Spouse or your Dependent, or your Dependent ceasing to
satisfy the eligibility requirements for coverage, your election 'to cancel accident or health benefits for
any individual other than your Spouse involved in the divorce, annulment, or legal separation, your
deceased Spouse or Dependent, or your Dependent that ceased to satisfy the eligibility
requirements, would fail to correspond with that Change in Status. Hence, you may only cancel
accident or health coverage for the affected Spouse or Dependent.
m
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oD
Example: Employee Mike is married to Sharon and they have one Child. The ,employer offers a calendar
year cafeteria plan that allows employees to elect no health coverage, employee-only coverage, employee-'
plus-one-dependent coverage, or family coverage. Before the plan year, Mike elects family coverage for
himself, his wife Sharon and their child. Mike and Sharon subsequently divorce during the plan year; Sharon
loses eligibility for coverage under the plan, while the child is still eligible for coverage under the plan. Mike
now wishes to cancel his previous election and elect no health coverage. The divorce between Mike and
Sharon constitutes a Change in Status.. An election to cancel coverage for Sharon is consistent with this
Change in Status. However, an election to cancel coverage for Mike and/or the child is not consistent with
this Change in Status. In contrast, an election to change to employee-plus-one-dependent coverage would
be consistent with this Change in Status.
However, if you, your Spouse, or a Dependent' elect COBRA continuation coverage under the Employer's
plan, you may be able to increase your contribution to pay for such coverage.
(b)
Gain of Coverage Eligibility Under Another Employer's Plan. For a Change in Status in which you,
your Spouse, or your Dependent gain eligibility for coverage under another employer's cafeteria plan
(or qualified benefit plan) as a result of a change in your marital status or a change in your, your
Spouse's, or your Dependent's employment status, your election to cease or decrease coverage
7 SPD97
for that .individual under the Plan would correspond with that Change in Status only if coverage for
that individual becomes effective or is increased under the other employer's plan.
(c)
Dependent Care Expense Reimbursement Benefits. With respect to the Dependent Care Expense
Reimbursement benefit, you may change .or terminate your election only if: (1) such change or
termination is made on account of and conforms with a Change in Status that affects eligibility for
coverage under the Plan; or (2) your election change is on account of and conforms with a Change
in Status that affects the eligibility of dependent care or adoption assistance expenses for the
available tax exclusion.
Example: Employee Mike is married to Sharon, and they have a 12 year old daughter. The employer's plan
offers a dependent care expense reimbursement pro, ram as part of its cafeteria plan. Mike elects to reduce
his salary by $2,000 during a plan year to fund dependent care coverage for his daughter. In the middle of
the plan year when the daughter turns 13 years old, however, she is no longer eligible to participant in the
dependent care program. This event constitutes a Change in Status. Mike's election to cancel coverage
under the dependent care program would be consistent with this Change in Status.
(d)
For group term life insurance benefits and disability income coverage, if you have a change in your
marital status, or if you, your Spouse or ;your Dependent has a change in employment status, you
may elect either to increase or decrease coverage (without regard to the requirement that the event
affect coverage eligibility). '
Example: Employee Mike is married to Sharon and they have one child, The employer's plan offers a
cafeteria plan which funds group-term life' insurance coverage (and other benefits) through salary redirection.
Before the plan year Mike elects $10,000 of group-term 'life insurance. Mike and Sharon subsequently
divorce during the plan year. The divorce constitutes a Change in Status. An election by Mike either to
increase or to decrease his group-term life insurance coverage would both be consistent with this Change in
Status.
..
2. Special Enrollment Rights. If you, your Spouse arid/or a Dependent are entitled to special enrollment
rights under a group health plan, you may change your election to correspond with the special enrollment right.
Thus, for example, if you declined enrollment in medical coverage for yourself or your eligible dependents because
of outside 'medical coverage and eligibility for such coverage is subsequently lost due to certain reasons (i.e., due to
legal separation, divorce, death, termination of employment, reduction in hours, or exhaustion of the maximum
COBRA period), you may be able to elect medical coverage under the Plan' for yourself and your eligible dependents
who lost such coverage. Furthermore, if you have a new dependent as a result of marria~ge, birth, adoption, or
placement for adoption, you may also be able to enroll yourself, your Spouse, and your newly acquired dependents,
provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.
Please refer to the group health plan description for an explanation of special enrollment rights.
3. Certain Judgments and Orders. If a judgment, decree or order from a divorce, separation, annulment
or custody change requires your Dependent child (including a foster child who is your tax Dependent) to be covered
under this Plan, you may change your election to provide coverage for the Dependent child. If the order requires
that another individual (such as your former spouse) cover the Dependent child, you may change your election to
revoke coverage for the Dependent child.
4. Entitlement to Medicare or Medicaid. if you, your Spouse, or a Dependent becomes entitled to
Medicare or Medicaid, you may cancel that person's accident or health coverage. Similarly, if you, your Spouse, or
a Dependent who has been entitled to Medicare or Medicaid loses eligibility for such, you may, subject to the terms
of the underlying plan, elect to begin or increase that person's accident or health coverage. Medicaid may require
that benefits under accident or health policies be assigned to Medicaid. Therefore, employees or dependents eligible
for Medicaid may receive nd benefits and may wish not to elect coverage. Employees eligible for Medicaid should
check with Medicaid authorities to determine whether to continue supplemental health insurance.
5. Change in Cost. If the Plan Administrator notifies you that the cost of your coverage under the Plan
significantly increases during the Plan Year, you may choose either to make an increase in your contributions or
revoke your election and receive coverage under another Plan option which provides similar coverage. For
insignificant increases or decreases in the cost of benefits, however, the Plan Administrator will automatically adjust
your election contributions to reflect the minor change in cost. (This "change in Cost" exception is not applicable to
Health Care Expense Reimbursement accounts under the Plan).
8 SPD97
Example' Employee Mike is covered under an iindemnity.option of his employer's accident and health
insurance coverage. If the cost of this option significantly increases during a period of coverage, the
Employee may make a corresponding increase in .his payments .or may instead revoke his election and elect
coverage under an HMO option.
6. Change in Coverage. If the Plan Administrator notifies you that your coverage under the Plan is
significantly curtailed you may revoke' your election ..and elect coverage under another Plan option which provides
similar coverage. Also, if during the Plan Year the Plan adds er eliminates a coverage option, you may elect the
newly-added option or elect another Plan option (when a Plan option :has been eliminsted), and may do so on a pre-
tax basis by making a corresponding election change under another .Ptan option which provides similar coverage.
Further, you may make an election change that is on account efand :corresponds with a change made under the
plan of your Spouse's, former Spouse's, or Dependent's employer, so long as: (a) his or her employer's plan permits
its participants to make an .election change permitted under the IRS regulations; or (b) this Plan permits you to make
an election for a period of coverage which is different ~.rom-the .period .of coverage under his or her employer's plan.
(This "Change in Coverage" exception is not applicable ~ Health Care Expense Reimbursement accounts under the
Plan.)
Additionally, the Plan's Administrator may modify your election{s) downward during the Plan Year if you are a
Key employee or Highly Compensated Individual (as defined '1~ ~e.lntm'~a! Revenue Code), if necessary to prevent
the Plan from becoming discriminatory within the meaning .~.~the federal ir, come tax'law.
.o
Q-8. How are my Premium Payments Made?
When you become a Participant your premiums ~il! be paid with that portion of gross income that you have
elected to redirect through pre-tax salary redirection. Theroa~ter, your promiums will be paid with that portion of"
gross income that you have elected to forego through pre-tax salary.
Benefit Elected
Depender~t Medical Insurance
Cancer Insurance
Total Annual Cost
Ntnual Cost
_
,,,,,
750.00
276.00
1026.00
Assuming you are paid twice a month, the cost of the above benefits per paycheck would be $42.75. The tax-free
total of $1026 would be spread equally over 24 paychecks, or $85.50 per month. Thus, each pay period, the
corresponding amounts would be as follows: .
Dependent Medical Insurance Premium
Cancer Insurance
Total Withheld per"Pay Period.
$ 31.25
$ 11.50
.$ 42.75
The maximum aggregate level of benefits which may be .elected is the cost of any Benefit Plan or Policy
coverages elected less any Nonelective Contribution allocable thereto.
After-tax Premium coverages will be funded by an .amm~t deducted from your normal compensation which is
sufficient to pay for the elected' coverages after Withho. Eiing .ar~y applicable state, federal, or local income,
unemployment, or social security taxes.
Q-9. What benefit(s) do i get from participating in the"~?
Suppose your monthly gross pay is $2,500 ,,per.'month and ..your cost 'for coverage is $140.00 per month.
Also, suppose your total withholdings (income tax and Social Security) are 22.65%. After paying for coverage from
your after-tax pay, your take home pay is $1,793.75. :,However, under the pre-tax premium plan, you will be
considered to have received $2,360.00 gross pay rather than $2,~ 'for tax purposes with $140.00 contributed for
dependent coverage. This means your take home pay will be $1,825.4~ with the pre-tax premium plan rather than
$1,793.75 without it. Thus, you save $31.71 per month ($380.52 per year) by participating in the pre-tax premium
plan. The following table illustrates this savings:
SPD97
Gross Monthly Pay
Pre-Tax Insurance Under Plan
Taxable Income
Estimated Federal Tax (15%)
FICA Tax
After-Tax Insurance
Take Home Pay
With Cafeteria' Plan Without Cafeteria Plan
2,500.00
140.00
2,360.00
354.00
180.54
.1,825;46
2,500.00
2,500.00
375.00
191.25
140.00
1,793.75-
Of course, your actual tax-savings will vary depending on your circumstances.
Q-10. What if ! terminate my emploYment during the Plan Year?
If your employment with the Employer is terminated during the Plan Year, your active participation in the Plan
will cease, and' you will not be able to make any more contributions to the Plan. See the insurance booklets for
information on your right to continued or converted coverage after termination of your employment. If you are
rehired within the same Plan Year and are eligible for the Plan, you may make new elections, provided that you are
rehired more than 30 days after you terminated employment. If you are rehired within 30 days or less, your prior
elections shall remain in effect for the remainder of the Plan Year.
Q-11. Will I have any administrative costs under the Plan?
Unless otherwise indicated in the Employer Information Section, the Employer is bearing the entire cost of
administering the Plan.
Q-12. How.long will the Plan remain in effect?
Although the Employer expects to maintain the Plan indefinitely, it has the right to modify or terminate the
program at any time. It is also possible that future changes in state or federal' tax laws may require that the Plan be
amended accordingly.
Q-13. What happens if a Request for Reimbursement is denied?
If your request is for a benefit under one of the component Benefit Plans or Policies, you will generally
proceed under the reimbursement procedure applicable under the component Benefit Plan or Policy. However, if
you are denied a benefit under this Plan (such as the ability to pay for premiums on a pre-tax basis) due to an issue
germane to your coverage under this Plan (i.e., such as a determination of: a Change in Status; a "significant"
change in premiums charged; or eligibility and participation matters under the Flexible Benefits Plan document), the
reimbursement procedure under this Plan will apply, and you will be notified in writing by the Plan's Administrator
within 90 days of the date you submitted your request if the request is denied. Such notification will set out the
reasons your request was denied, and further advise you of what steps, if any, you might take to validate the claim
request. It will further advise you of your right to request an administrative review of the denial of the request; you
may request a review any time within the 60-day period after you have received notice that the request was denied.
You or your authorized representative will have the opportunity to review any important documents held by the
Administrator, and to submit comments and other supporting information. In most cases, a decision will be reached
within 60 days of the date of your request for a review.
Q-14. What is "Continuation Coverage" and how does it work?
"Continuation Coverage" means your right, or your .spouse and dependents' right, to continue to be covered
under any of the component medical benefit plans if the Employer is subject to COBRA (i.e., typically employs 20 or
more employees) and participation by you (including your spouse and dependents) otherwise would end due to the
occurrence of a "Qualifying Event." A Qualifying Event is:
termination of your employment (other than by reason of gross misconduct);
or reduction of your work hours;
your death;
divorce or legal separation from your spouse;
your becoming entitled to receive Medicare benefits;
when a dependent of yours ceases to be a dependent.
10
SPD97
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·
For a Qualifying Event, other than a change in your employment ,status, it will be your obligation to inform the
appropriate Plan Administrator of each medical benefit plan you ha~e elected o,f its occurrence within 60 days of the
occurrence. The appropriate Plan Administrator, in turn, .has a legal obligation to furnish you, or your spouse, as the
case may be, with separate, written options to ~continue the coverages provided at stated premium costs with respect
to each health plan in which you are a participant. 'The notification you will receive will explain all the rest of the
terms and conditions of the continued coverage.
Certain Medical Care Expense Reimbursement 'Expense Account Participants will be eligible for COBRA
Continuation Coverage if they have a positive Medical Care Expense Reimbursement Account balance at the time of
a Qualifying Event (taking into account all .claims submitted before the date of the qualifying event). You will be
notified if you are eligible for COBRA Continuation Coverage. 'Ho~ever, even .if COBRA is offered for the year in
which the .qualifying event occurs, COBRA coverage for the Medical Cam Expense Reimbursement Account will
cease at the 'end of the year and cannot be continued for the next .plan year.
·
Q-15. What effect will Plan participation have on Social Security and other benefits?
Plan participation will reduce the amount of your taxable compensation. Accordingly, there could be a slight
decrease in your Social Security benefits and/or other 'benefits (e.g., pension, disability and life insurance) which are
based on taxable compensation.
Q-16. What is the Family and Medical Leave Act?
If your Employer is subject to the Family and Medical 'Leave Act ("FMLA").(generally, employers with at least
50 employees) and you are on eligible leave under .FMLA, you may continue to pay for your Health Insurance
coverages on an after-tax basis. If your Employer pays a portion 'of your Heal~ Insurance premiums, it must
continue those payments.. However, if you do not return from .FMLA, you may be required to repay the Employer-
paid portion of the Health Insurance premiums, ff your Employer is subjec~ 'to FMLA, you should be provided with a
complete explanation of your FMLA rights and responsibilities.
PART II
Medical Care Expense Reimbursement Benefits
if offered as a benefit under the Flexible .Benefits Plan you will .have the opportunity to elect to receive
income tax-free reim. bursement for some or all of your unreimbursed medical expenses under the Medical Care
Expense Reimbursement Plan. Under this P{an, you purchase a specific level of Medical Care Expense
Reimbursement benefits, paying for coverage ltl'rough the Salary Redirection Agreement with the Employer, in lieu of
a corresponding amount of current pay, which .means the premiums you pay Will be with pre-tax funds. This
arrangement helps you because the level of coverage you elect is nontaxable, 'and you save social security and
income taxes on the amount of the premiums you .pay.
QUESTIONS & ANSWERS
Q-1. Who can participate in the Medical Care 'Ex~ense Reimbursement Plan?
Each employee of the Employer who is eligible to participate in the related Flexible Benefits Plan and has
satisfied any additional eligibility criteria set forth 'in the Adoption agreement for Medical Care Expense
Reimbursement benefits.
How do ! become a Participant?
·
By electing Medical Care Expense Reimbursement beneffiS during the Initial or Annual Enrollment Periods.
Q-3. What is my "Medical Care Expense Reimbursement Account"?
If you elect benefits under this portion of the Plan, a bookkeeping Account ("Account")' will be set up in your
~ name to keep a record of the reimbursem*nts you are entitled to, 'as well as tho premiums you have paid for such
~ benefits during the Plan Year. This Account will be maintained by your Employer, and will be subject to the claims of
· --~.. its general creditors. You should note that this benefit is not insurod, and that 'all 'benefits are payable from the
~ employer's general assets (even though a third-party may actually process claims 'payments).
·
1 1._ SPD97
, .
Q-4. What annual benefits are available under the Medical Care Expense Reimbursement Plan, and how
much will they cost?
You may. choose any amount of annual reimbursement you desire subject to the maximum reimbursement
amount set forth in the Employer Information Section. You will be required to pay the annual premium equal to the
coverage level you have chosen.
Q-5. How is my Medical Care Expense Reimbursement benefit paid for?
When' you complete the Salary Redirection Agreement,' you specify the amount of Medical Care Expense
Reimbursement you wish to pay for with your salary redirection. Thereafter, you must pay a premium for such
coverage by having an equal portion of the annual premium deducted from each paycheck. Your employer will
distribute benefit payments from its general assets. The full amount of the coverage you have elected will be
available to reimburse you for your out-of-pocket medical expenses at any time during the Plan Year, so long as you
continue to pay the premiums.
For example, suppose you have elected to be reimbursed for up to $1,000 per year for Eligible Medical
Expenses, and you have chosen no other benefits under the Flexible Benefits Plan. Your Account would be credited '
(and funded) with a total of $1,000 during the Plan Year. Moreover, if you are paid semi-monthly, your Account
would reflect that you have paid $83.33 per month in premiums for the benefit you have elected.
Q-6. What amounts will be available for Medical Care Expense Reimbursement at any particular time
during the Plan Year?
Provided that you have continued to pay the periodic contributions due for this benefit, the full, annual
amount of coverage you have elected will be available at any time during the Plan Year, reduced however by the
amount of prior reimbursements received during the Year.
Q-7. How do ! receive reimbursement under the Plan?
If you elect to participate in this Plan, you will have to take certain steps to be reimbursed for your Eligible
Medical Expenses. When you incur an expense that is eligible for payment, you submit a request to the Plan's
Administrator on a Request for Reimbursement form that will be supplied, to you. You must include written
statement(s)/bill(s) from an independent third party(les) stating that the medical expenses have been incurred, and
the amount of such expense(s) along with the Request for Reimbursement form. In addition, you must include an
Explanation of Benefits (EOB) form(s) from any primary medical and/or dental insurance carrier(s) indicating the
amount(s) which you are obligated to pay.
In addition, you will have 90 days after the end of the Plan Year in which to submit a Request for
Reimbursement for Eligible Expenses incurred during the previous Plan Year. You will be notified in writing if any
request is denied. To have your reimbursement processed as soon as possible, please read the Request for
Reimbursement instructions you have been furnished. Please note that it is not necessary that you have actually
paid an amount due for an Eligible Medical Expense -- only that you have !nCurred the expense, and that it is not
being paid for or reimbursed from any other source.
Q-8. What is an "Eligible Expense?"
An "Eligible Expense" generally means any item for which you could have claimed a medical expense
deduction on an itemized federal income tax return (without regard to any threshold limitation) for which you have not
otherwise been reimbursed from insurance, or some other, source. You should note, however, that Section 125 of
the Internal Revenue Code places additional restrictions on such expenses. For example, premiums for accident or
health insurance are not Eligible Medical Expenses. Aisc, expenses for long-term care services are not eligible.
You are encouraged to consult your perso.nal tax advisor or IRS Publication 17 "Your Federal Income Tax"
for further guidance as to what' is or is not an eligible expense if you have any doubts. Additional information may be
obtained in the Flexible Spending Account Participant's Handbook.
17., SPD97
Q-9. When must the expenses be incurred .that i..,may .be reimbursed for?
Eligible Expenses must :have been :incurred .during the Plan Year. You may not be reimbursed for any
expenses arising before the Plan became effective, before your Salary Redirection Agreement becomes effective, or
for any expenses incurred after the close of the Plan Year, or, except for Continuation Coverage, after a separation
from service.
In addition, IRS regulations require that a medical .sewice be actually rendered prior to the time that the
medical expense is reimbursed. Therefore, even if your doctor .requires that an expense be. paid in advance, you
cannot be reimbursed until the service relating to the expense has been rendered. In order to ensure compliance
with this IRS requirement, you (and/or your doctor) may be required :to submit additional substantiation (such as a
proposed treatment plan) with .respect to certain 'long-term treatments (e.g., orthodontic or obstetric expenses).
Failure to submit the required ~orms could :result in your reimbursement being pended and/or denied.
Q-10. What if the medical expenses I ~ncur during 'the .'Plan Year am less than the annual amount I have
elected for Medical Care Expense Reimbursement?
You will not be entitled to ,receive any direct or .indirect .payment of any amount that represents the difference
between the actual medical expertses you have incurred, on 'the one hand, and the annual coverage level you have
elected and paid for, on the other. Any amount allocated to .an ,Acc~t shall be forfeited by the Participant and
restored to the Employer if it has .not been applied 'to ,¢rovide the elected benefit for any Plan Year by the ninetieth
(90th) day following the end of the Plan Year for which the election was effective. Amounts so forfeited shall be
used to offset administrative expenses and future costs.
Q-11. Forfeiture of Unclaimed 'Reimbursement Account Benefits
Any Reimbursement Account benefit payments that are unclaimed (e.g., uncashed benefit checks), by the
close of the Plan Year following the 'Plan Year in which the Medical Care Expense was incurred shall be forfeited.
PART .111
Dependent Care ..Expense Reimbursement Benefits
If offered as a benefit under your Employer's Re)~ible Benefit.Plan, you may elect to receive income tax-free
reimbursement for some or all of your work-related .'dependent .cam expenses under the Dependent Care Expense
Reimbursement Plan ("DDC"). Under these provisions, you .provide a source of pre-tax funds to reimburse yourself
for your Eligible Dependent Care .Expenses by .entering into a Salary 'Redirection Agreement with your Employer in
lieu of a corresponding amount of your regular pay. This arrangement ~helps you because the" coverage you elect is
nontaxable; you save social security and income taxes 'on ff~e amount of your salary conversion.
Questions & Answers
~.~
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Q-1. Who can Participate in the Dependent 'Care Expense Reimbursement Plan?
Each Employee of the Employer who is eligible ~ participate in the related Flexible Benefits Plan and has
satisfied any additional eligibility criteda set 'forth in ~.the Adoption Agreement for Dependent Care Expense
Reimbursement benefits. Married :participants .must generally file a'joint return to be eligible.
Q-2. How do I become a Participant?
By electing DDC benefits during the .initial or Annual Enrot[meat Periods.
Q-3. What is my "Dependent Care Expense Reimbursement Account"?
If you elect benefits under this portion 'of the ~Plan, a non.~interest bearing Dependent Care Expense
Reimbursement Account ("Account") will be set up in your name to keep a record of the reimbursements you are
entitled to.
13
SPD97
Q-4. What is the maximum DDC benefit ! may elect?
This is set forth in the Employer Information Section, however, this amount cannot .exceed the maximum
amount specified in Section 129 of the Internal Revenue Code. The maximum amount is currently $5,000 per Plan
Year if you --
are married and file a joint return; or
are married, but you furnish more than one-half the cost of maintaining those Dependents for whom you. are
eligible to receive tax-free reimbursements under the DDO, your Spouse maintains a separate residence for
the last 6 months of the calendar year, and you file a separate tax return; or
are single, or a head of household for tax purposes.
If you are married, reside together, but file a separate federal income tax return, the maximum DDC benefit
you may elect 'is $2,500.
Q-5. How is my Account funded?
When. you complete the Salary Redirection Agreement, you specify the amount of DDC benefits for which
you wish to pay with your salary redirection. Thereafter, your Account will be credited with that portion of your gross
income you have elected to forego through salary redirection. These portions will be credited as of each pay period.
For example, suppose you have elected to be reimbursed for $2,400 per year for Eligible EmPloyment
Related Expenses, and you have chosen no other benefit under the Employer's Flexible Benefits Plan. Your
Account would .be credited (and funded) with a total of $2,400 during the Plan Year. Thus, if you are paid semi-
monthly, you would have a total of $100.00 credited to your Account each payday to pay reimbursements under this
Plan. The .amount that is available to your Account at any particular time will be whatever.has been credited to such
Account less any reimbursements already paid.
Q-$. What is an "Eligible Expense" for which I can request a reimbursement?
You may be reimbursed for work-related expenses incurred on behalf of any individual in. your family who is
· under age 13 who resides with you and for whom you cOuld claim as a Dependent exemption on your federal income
tax return; any other Dependent who is mentally or physically incapable of caring for himself or herself; or your
Spouse, if the Spouse is likewise physically or mentally incapacitated.
Generally, these expenses must meet all of the following conditions for them to be Eligible Dependent Care
Expenses:
.
.
1
=
The expenses are incurred for services rendered after the date of your election to receive
Dependent Care Expense Reimbursement, and during the calendar year to which it applies.
Each individual for whom you incur the expenses is
(a) Dependent under age 13 whom you are entitled to a personal tax exemption as a dependent,
or
(b) a Spouse or other tax dependent who is physically or mentally incapable of caring for himself
or herself.
The expenses are incurred for the care of a Dependent (as described above), or for related
household services, and are incurred to enable you to be gainfully employed.
If the expenses are incurred for services outside your household and such expenses are incurred for
the care of a Dependent who is age 13 or older, such Dependent regularly spends at least 8 hours
per day in your home.
If the expenses are incurred for services provided by a dependent care center (i.e., a facility that
provides care for more' than 6 individuals not residing at the facility), the center comPlies with all
applicable state and local laws and regulations,
The expenses are not paid or payable to a child, of yours who is under .age 19 at the end of the year
in which the expenses are incurred or an individual for whom you or your spouse is entitled to a
personal tax exemption as a dependent.
]. ~ SPD97
,
This reimbursement (when aggregated with all other Dependent Care Reimbursements during the
same year) may not exceed the least of the .following limits'
(a) $5,000
(b) $2,500, if y~)u are married but you .and your Spouse file separate tax returns.
(c) Your taxable .compensation (after ...your sala~ reduction under the Plan),
(d) If you are 'married, 'your Spouse:s actual .or.deemed Earned Income,
For purposes of (d),above, your' Spouse .~11 .be deemed to have Earned Income of $200 ($400 if you have
two or more Dependents described ~.in paragraph 2 above), for .each month in which your spouse is (i)
physically or mentally incapable Of caring for himself'or herself, .or (ii) a full-time Student,
You are encouraged to consult your personal tax advisor or 'IRS .Publication 17 "Your Federal Income Tax" for
further guidance as to what is oris.not.an Elig~ie Expense if you have .any doubts.
'Q-7, How do I receive reimbursement under ~e :Plan?
if you have elected to :participate .in this portion of the Plan, you will have to take certain steps, to be
reimbursed for your Eligible Employment Related :Expenses. VVhen you incur an expense that is eligible for payment,
you submit a Request for-Reimbursement to the .~'s Administrator on a Request for Reimbursement form that will
be supplied to you. if there are .enough credits to ;the 'Dependent Care Expense Reimbursement Account, you will
be reimbursed for your eligible expenses .in ~e month :that follows the month you submitted the Request for
Reimbursement.
if your reimbursement'was'for an amount :that ~ras more than your current Account balance, the excess part
of the reimbursement will be carried .over into following months, to be paid out as your balance becomes adequate.
Remember, though, that you can't be reimbursed for any total expenses .above your available, annual credits to your
Account. You may not be reimbursed for any '.expenses .that arise before your Salary Redirection Agreement
becomes effective, or for any .expense .incurred affer:lfle close of the Plan Year.
To have your Request-for Reimbursements .pmcess~ as soon .as possible, please read the reimbursement
instructions you have been furnished. 'Please note that.it is not necessary that you. have actually paid an amount
due. for Eligible Employment Related Expenses- only that you have incurred the expense, and that it is not being
paid for or reimbursed from any other source.
In addition, you will have 90 days after the end of the Plan .Year in which to submit a Request for
Reimbursement form for Eligible 'Expenses incurred eluding .the previous Plan Year. You will be notified in writing if
any Request for Reimbursement is dertied.
Q-8. What if the Eligible Employment Related Expenses ! incur during the Plan Year are less than the
annual amount of coverage ! have elected for Dependent Care Expense Reimbursement?
You will not be entitled to receive any direct or indirect payment of any amount that represents the difference
between the actual Eligible Employment Related :Expeases you have incurred, on the one hand, and the annual
coverage you have elected ..and '.paid for, on the other, Any amount allocated to an Account shall be forfeited by the
Participant and restored to the Employer if .it has .~ot :been applied to 'provide the elected reimbursement for any Plan
Year by the ninetieth (90th) day follo~ng the end of':the.Pian Year for which the election was effective. Amounts so
forfeited shall be used to offset reasonable administrative.expenses and future costs.
= ~ Q-9. Will I be taxed on the'DDC benefits .! receive..,?
You will not normally be taxed on your .DDC benefits, 'up to the limits set out in Q-4. However, to qualify for
tax-free treatment, you will be required to 'list the names and taxpayer identification numbers on your annual tax
return of any persons who 'provided you with dependent care services during the calendar year for which you have
claimed a tax-free reimbursement,
~' ,~ Q-10. If ! participate in the 'DDC, Wal ! .still be able to claim the household and dependent care credit on my
-.-- o federal income tax return?
i
~ C. You may not claim any Other tax benefit for the tax-free amounts received by you under this Plan, although
~ ~ the balance of your qualified dependent care expensos may be eligible for the dependent care credit.
SPD97
Q-11. What is the household and dependent care credit?
The household and dependent care credit is an allowance for a percentage of your annual, Eligible
Employment Related Expenses as a credit against your federal income tax liability under the U.S. Tax Code. In
determining what the tax credit would be, you may take into account only $2,400 of such expenses for one
Dependent, or $4,800 for two or more Dependents. Depending on your adjusted gross income, the .percentage
could be as much as 30% of your qualifying expenses. (to a maximum credit amount of $720 "for one Dependent or
$1,420 for two or more Dependents,) to a minimum of 20% of 'such expenses (producing a maximum credit of $480
for one Dependent or $960 for two or more Dependents.) The maximum' 30% rate must be reduced, by 1% (but not
below 20%) for each $2,000 portion (or any fraction of $2,000) of your adjusted gross incomes over $10,000.
·
Illustration' Assume you have one Dependent for whom you have incurred Eligible Expenses of $3,600, and. that
your adjusted gross income is $20,000. Since only one Dependent is involved, the credit will be calculated by
applying the appropriate percentage to the first $2,400 of the expenses. The percentage is, in turn, arrived at by
subtracting one .percentage point from 30% for each $2,000 of your adjusted gross income over $10,000. The
calculation is: 30% -- [($20,000 '- 10,000)/$2,000 X 1%] = 25%. Thus, your tax credit would be $2,400 X 25% =
$600. If you had incurred the same expenses for two or more Dependents, your credit would have been $3,600 ×
25% = $900, because the entire expense would have been taken into account, not just the first $2,400.
Q-12. When would ! be better off to include the reimbursements in my income and claim the credit, rather
than to treat the reimbursements as tax-free.
Generally, if your income tax bracket is 15% or less, you will probably come out ahead by including the DDC
benefits in income, and claiming the credits for dependent care. On the other, hand, it will generally be better to treat
DDC benefits as .tax-free the more income taxes you. are required to pay. Because the actual determination of the
preferable method for treating benefit payments depends on a number of factors such as one's tax filing status (e.g.,
married, single, head of household), number of Dependents, etc., each Participant will have to determine his or her
tax position individually in order to make the decision between taxable and tax-free benefits.
Q-13. Forfeiture of Unclaimed Reimbursement Account Benefits.
Any Reimbursement Account benefit payments that are unclaimed (e.g., uncashed benefit checks) by the
close of the Plan Year following the Plan Year in which the Dependent Care Expense was incurred shall be forfeited.
PART IV
Premium Benefits
You will be able to choose to participate in one or more of the component insurance or fringe benefit
programs designated in the Employer Information Section by separately filling out any required enrollment form(s) for
the component Benefit Plan or Policy. You should then select your chosen method for funding the coverage(s) (pre-
tax or after-tax) by indicating your choice or choices on the Salary Redirection Agreement, and financing your share
of the cost by pre-tax salary, redirection or after-tax salary deduction, as described earlier.
For the details regarding eligibility provisions, benefit amounts, and premium schedules, please refer to the
plan summary of each, separate plan that will be furnished to you by the Plan Administrator.
PART V
Electing Less Than The Maximum Annual Benefit
Any portion of your Compensation .that you do not choose to apply toward the purchase of the benefits
described above will be paid to you as regular, taxable Compensation.
PART V!
ERISA Rights
The Flexible Benefits Plan is not an ERISA welfare benefit plan. However, certain component Benefit Plans
or Policies may be subject to .ERISA. As a participant in an ERISA-covered Plan, you are entitled to certain rights
and protections under the Employee Retirement Income Security Act ("ERISA"). ERISA provides that all plan
participants shall be entitled to:
]. 6 SPD97
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work-
sites and union halls, ali plan documents, including insurance contracts, collective bargaining agreements and copies
of all documents filed by the Plan with the U.S. Department of Labor, such as detailed annual reports and plan
descriptions.
Obtain copies of all plan documents and other plan information upon
Administrator. The Plan Administrator may make a reasonable charge for the copies.
written request to the Plan'
Receive a summary .of the Plan's annual financial report.
furnish each participant with a copy of this summary annual report.
The Plan Administrator is required by law to
In .addition .to creating .rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation Of the employee benefit plan. The people who operate your plan, called "fiduciaries" of
the plan, have a duty to do 'so prudently and in the interest of the, plan participants and beneficiaries. No one,
including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any
way to prevent you from obtaining a benefit from the plan, or from exercising your rights under ERISA.
If your Request for a benefit under the' ERISA-covered plan is denied in whole or in part, you must receive a
written explanation of the' mason 'for the denial. You have the right to have the Plan review and reconsider your
Request for Reimbursement. Under ERISA, there are steps you can take to enforce the above rights. For instance,
if you request materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In
such a case, the court may require tlie Plan Administrator to provide the materials and pay you up to $100 a day
until you receive the materials, unless the materials were not sent because of reasons beyond the control of the
Administrator. if you .have a request for benefits which is denied or ignored in whole or part, you may file suite in a
state or federal court. If 'it should happen that plan fiduciaries misuse the Plan's money, or if you are discriminated
against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suite
in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court
may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay
these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about the Plan, yqu
should contact the Plan .Administrator. If you have any questions about this Part of the Summary Plan Description or
about your rights under 'ERISA, you should contact the nearest office of the U.S. Department of Labor, Pension and
Welfare Benefits Administration .'.listed in .your telephone directory, or the Division of Technical Assistance and
Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution Ave., N.W.,
Washington, D.C., 2021'0.
1 7 SPD97
L.
REIMBURSEMENT SERVICES AGREEMENT
This Agreement, effective upon execution for
CITY OF TUSTIN
and American Family Life .Assurance Company ..{"AFl. AC")
WITNESSETH:
the Plan Year, ~by and between
WHEREAS, the Employer has adopted .a Medical Care .Expense Reimbursement ("URM") Plan
and/or a Dependent Care Expense 'Reimbursement ("DDC") Plan for its Employees in
conjunction with its Flexible Benefits Plan (collectively Ceferred to as the "Plan" and attached
hereto) to be adopted and administered in accordance .with Sections t05, 125, and 129 of the
Internal Revenue Code of 1986, as amended (the "Code"); and
WHEREAS, the Employer will serve as 'the Plan Administrator; and
WHEREAS, the Employer desires that .^FLAC, as its agent, furnish ~eimbursement services
within a framework of policies, interpretations, rules, practices and procedures (the
"reimbursement practices and procedures") made and established bY the Employer in (i)
receiving and processing requests for benefits under the Plan ("Requests"') and (ii) disbursing
benefit payments from Employer funds (as provided for in Section Il.A) for eligible expenses
under the flexible spending account provisions of the Plan; (if Self-Pay Option is selected in
Section II.A. below, AFl_AC shall convey its initial .benefit determinations to Employer so
Employer can disburse reimbursement payments for-eligible expenses under the Flexible
Spending Agreement provisions of the Plan); and
WHEREAS, the Employer is to pay all plan benefits owed'or established under the Plan to its
Participants, and AFl_AC is to provide the agreed upon services to the Plan without assuming
any such liability;
NOW, THEREFORE, in consideration of the mutual :promises and covenants contained herein,
it is herebY agreed as follows:
~.ec.t. ion I. Enrollment ,and Dete,,r, mination of Eligibility
A.
The Employer shall'
(1)
(2)
be responsible for interpreting the Plan and .its provisions, its terms, conditions and
operation; and
·
notify Plan Participants of their ability to apply for reimbursement benefits and supply
them with Request forms (to be provided by AFLAC) and Request filing instructions;
and
(3)
provide AFLAC with the names, addresses, Social Security Numbers,
amounts of all participants in the P[an; and
and elected
(4)
(5)
upon the occurrence of events that would change ~ Participant's status under the Plan
(e.g. termination, Change in Status, Change in Cost or Coverage for DDC, etc.)
immediately provide AFl_AC with updates (via Telefax) which identify eligible Participants
in each of the respective reimbursement Plans and/or the amount of reimbursement
benefits for which they are eligible; and
immediately inform 'AFl_AC (via Telefax) as to any new Participants in either of the
reimbursement Plans, any Change in Status affecting a Participant's election, or any
Qualified Beneficiary elec,ting,_.coverage under COBRA and the amount of such election
(if COBRA applies-to the Employer), or of any other change ..which will affect AFLAC's
responsibilities hereunder.
]. RSA97.2
Bi
in determining any person's right to benefits under the Plan, AFLAO shall rely on the eligibility
information furnished by the Employer, and any signed statements by Participants regarding the
eligibility of their Requests under the respective Plan. It is mutually understood that the
effective performance of this Agreement by AFLAC will require that it be advised on a timely
basis by the Employer during the continuance of this Agreement of the identity of individuals
eligible for benefits under each of the respective reimbursement Plans. Information modifying a
Participant's eligibility or status/election under either reimbursement Plan shall identify the
effective date of eligibility and the termination date of eligibility and shall be provided to AFLAC
(via Telefax) prior to the effective date of such modification in order to be considered by AFLAC
in making benefit determinations hereunder. AFLAC shall not be responsible for Requests paid
in error where the Employer has failed to inform AFLAO (in a form and with such information as
may reasonably be required by AFLAO) of a Participant's .eligibility or status change prior, to the
release of the benefit payment.
Section II. Funding and Payment of Re. quests for the Plan Benefi.t...S.
A. Select one below:
r--} Daily Processing Option. The Employer shall:
(i)
make sufficient funds available from its general assets for amounts allocable to
eligible reimbursement benefits under its plan by depositing a "Maintenance
Deposit" (in amounts specified by AFLAC from time to time) in an Employer-owned
and named account (the "Account") in a financial institution selected by Employer
and AFLAC to facilitate the timely processing of Requests under the Plan. [Note:
the Account should not be opened in the Plan's name]; and
(ii)
grant AFLAC withdrawal authority over the Account sufficient to enable it to pay
benefits under the Employer's FSA Plans; and
(iv)
(v)
deposit additional funds (at the request of AFLAO) in order to reestablish the
Maintenance Deposit at the end of each Request processing cycle (or such .earlier
time specified by AFLAO); and
telefax copies of all deposit Verification receipts, Account Statements, and other
correspondence relating to the Account to AFLAC upon receipt of such
correspondence from the financial institution; and
during the term of this Agreement, the Employer ~hall not withdraw funds from the
Account; except at the request of, or to the extent approved by AFLAC. The
Employer bears sole responsibility for any fees imposed with respect to the Account
by the financial institution, including, but not limited to: Account maintenance fees,
insufficient funds fees, fees with respect to voided checks, etc.; and
(vi)
authorize AFLAC to access the Account by:
entering into a Withdrawal Agreement with CB&T; or
if a Financial Institution other than CB&T is designated below, the Employer
hereby authorizes AFLAO to: a) draw benefit checks directly on the
Account; b) electronically transfer benefit payments 'from the Account; c)
electronically access Account information; and d) execute the financial
institution's standard Deposit/Account Agreement on Employer's behalf
(subject to the terms and conditions set forth herein and as AFLAC may
otherwise establish). Name, address and contact person at other financial
institution:
RSA97.2
Standard Option. The Employer shall:
(i)
(ii)
make sufficient funds available from its general assets for amounts allocable to
eligible reimbursement benefits under its ;.Plan; and
draw an amount equal to the aggregate amount of all Requests payable under the
Employer's :Plan and electro~c~ly .traosfer it to AFLAC (within three (3) business
days of receipt of a request'for ..such funds from AFLAC) for which there are eligible
Outstanding Requests (pursuant to the terms of the Plan).
Self-Pay Option, The Employer shaJl:
(i)
(ii)
make sufficient funds available from 'its general assets for amounts allocable to
eligible reimbursement benefits underits .Plan; and
review AFLAC's initial reimbursements .determinations and issue reimbursement
checks from .its general .assets within seven days of the receipt thereof for those
Requests.which are reimbursable 'pursuant .to the terms of its Plan; and
upon request, provide AFLAC with ..proof of ljmely benefit check disbursements in a
form and .manner deemed acceptable ..by AFLAC (e.g., bank issued account
statements or check register).
If, at any time, the .amount of reimbursement beneffis payable under the applicable Plan
provisions exceeds the .amount. deposited by the 'Employer in the Account, the Employer shall
transfer an amount necessary to the Account .:to fulfill its reimbursement obligations under the
applicable Plan before ,,any further ..reimbursement benefit payment is made. AFLAC is under no
obligation to advance funds on behalf of the Employer.
B=
In accordance with the terms and conditions of .the 'Plan, and any reimbursement practices and
procedures prescribed .by the Employer, AFLAC, as ..agent for the Employer shall'
(1)
(2)
provide Employer with a cafeteria plan ..document, including a medical care expense
reimbursement .("URM") Plan and a..dependent care expense reimbursement ("DDC")
Plan to be reviewed by the Employer and its legal counsel; and
provide the Employer with. a .flexible benefits summary plan description for distribution to
each Plan Participant; and
mmmm
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(3)
(4)
(5)
(6)
(7)
(8)
assist the Employer in explaining 'the URM ancFor DDC features of the cafeteria plan to
employees; and
provide the Employer with salary redirection agreement forms to be used during the
enrollment process for current and new ,employees and where may be required by a
Change in Status; and
process for the Employer executed .salary redirection agreements as they relate to the
URM and DDC components of the Employer's flexible spending account; and
prepare an enrollment confirmation "letter and send it to the Employer to verify URM and
DDC elections; and
provide each Participant with mimbu.rsement forms and instructions for filing URM and
DDC reimbursement requests; and
provide each Participant with a URM and/or DDC statement on a quarterly basis; and
3 RSA97.2
(9)
('~0)
(11)
(~2)
(13)
(14)
(15)
provide the Employer with written monthly reports summarizing the previous period's
URM and/or DDC Account activities; and
upon receiving instructions from the Employer on a Change in Status, AFLAO, Will make
the change requested by the Employer; and
receive Requests for, and expeditiously review such Requests to determine what
amount, if any is due and payable with respect thereto; and
disburse the benefit payments it determines to be due (provided the Employer transfers
sufficient funds to AFLAO or has sufficient funds in the Account) or if Self-Pay is elected
above, notify Employer of the benefit determination in accordance with the .provisions of
the Plan and the following procedure(s):
(i)
valid reimbursement for URM and/or DDC benefits shall be paid by AFLAO on
the date funds are received from the Employer (with respect to such Requests)
by mailing a check in the appropriate amount(s) directly to the Participants at
their home addresses; and
(ii)
if the amount of the (otherwise) reimbursable DDC request exceeds the amount
the Participant had withheld for DDO benefits, the excess shall be carried
forward (within the same Plan Year) and treated as an Eligible Employment
Related Expense for that month; and
if the amount of the reimbursable URM Request exceeds the amount the
Participant has had withheld for URM benefits, the entire amount shall be
processed (provided the Employer makes available sufficient funds for AFLAC
to satisfy the Request); and
(iv)
Requests of less than $1'5.00 maY be carried forward and aggregated with
future Requests until the reimbursable amount is greater than $15.00, provided,
however, that the entire amount of the reimbursable Requests shall be paid
after the close of the Plan Year without regard to the $15.00 threshold; and
.(v)
under the Daily Processing Option, checks of $2,000 or more
forwarded to the Employer for countersignature and disbursement.
shall be
(vi)
unless otherwise specified in writing by the Employer, Health FSA claims
following a Change in' Status impacting the Health FSA election shall be
processed using a "blended approach" (i.e., the maximum Health FSA benefit
for a period of coverage following a Change in Status will be limited to the
lesser of): a) the annual Health FSA maximum set forth in the Plan document
less any benefit payments made prior to the Change in Status; and b) the sum
of the Participant's Health FSA Account balance immediately before the Change
in Status and any additional contributions made during the remaining period of
coverage.
notify claimants as to any Requests which are denied because of inadequate Request
substantiation or improper Request form submission and give affected claimants the
opportunity to resubmit their Requests; and
provide to the claimant within ninety (90) days following, receipt of a Request, written
notification (a) as to the disposition of the Request, or (b) of an anticipated delay
beyond ninety (90) days in the disposition of the Request together with an explanation
of the delay; and
notify the claimant and refer to the Employer (with an analysis of the issues affecting
the Request) for final decision any Requests which AFLAC deems not to be
reimbursable pursuant to the terms of the Plan and/or the reimbursement practices and
RSA97.2
mmm
mm
mm
mmmmm
m
procedures :established .by ~he Employer, .setting forth the applicable review procedure
available to the claimant .through .the Employer; and
(16) provide the Employer with written monthly .and year-end reports summarizing the
previous period's .URM and/or DDC Account :activities with sufficient detail to provide for
the audit and control of funds used; and
(17) provide the .Employer with the .information needed with respect to the URM and/or DDC
Plans for fulfilling annual reporting requirements and the preparation and submission of
a Form 5500 Series Annual Report by'the Employer to the Department of Labor.
In providing services, AFLAC shall assume that ERISA and COBRA apply to the Employer's
Plan unless .the Employer gives AFLAO written direction otherwise.
AFLAC shall not be obligated.or responsible for .any duty with regard to the administration of the
Plan (imposed by the Plan or otherwise) except as specifically provided' above. It shall be the
Employer's sole responsibility and duty to:
(1)
comply with the applicable pro.visions of the Consolidated Omnibus Budget
Reconciliation Act of 1985 (".COBRA"), as amended including, but not limited to,
providing Covered Employees and Quatified Beneficiaries covered by the URM with
initial COBRA notices, nOtices upon a Qualifying Event, and other information
concerning COBRA elections; and
(2)
perform nondiscrimination tes~ required by the .Internal Revenue Code (including, but
not limited to.: ensuring .that'a nondiscriminatory classification of employees is eligible for
the Plan, that contributions .and benefits do not discriminate in favor of highly
compensated employees, and that no more than 25% of the total pre-tax benefits is
received by officers and owners).. Additional nondiscrimination testing may be required
for the component benefits offered through 'the Plan (including insurance and URM/DDC
benefits). Nondiscrimination testing should be ~erformed shortly after enrollment and
again if there is a significant change in employee participation. AFLAC does not
automatically pedorm nondiscrimination testing. Upon written request submitted to
AFLAO's Rex One Department, AFLAC may .provide limited assistance with certain of
the nondiscrimination tests in accordance wit~ the terms and conditions (including
applicable fees) of an additional written agreement .provided by AFLAO and signed by
the Employer.
(3)
amend the Pla~ as necessary to .comply with future changes in applicable Internal
Revenue or 'Labor statutes and regulations or .other federal, state, or local statutes or
regulations; and
(4)
determine if, and when, a var~f Change in Status has occurred,
appropriate election change, and convey such information to AFl_AC; and
determine the
(5)
make a full and fair .review 'of any :unpaid Requests as described in II.B.15, above, and
required by ..the :Plan, ~and notify ~e claimant .in writing of its decision on review; and
(6)
(7)
prepare and submit summary :.plan descriptions and summary descriptions of material
modifications to each Employee .and to the extent ERISA applies, to the U.S.
Department of Labor as 'may from lime to time be required; and
file an annual Form 550.0 Return for the Plan Within seven months after the end of each
Plan Year. "In .addition, Employers subject to ERISA may be required to file Form 5500
Annual Returns for the component benefits offered 'through the cafeteria plan. AFLAC
does not 'automatically prepare .the Form 5500 Return. Upon written request submitted
to AFLAC's Flex One Department, AFl_AC may :assist with the preparation of Form 5500
for the Plan. Such requests' must ,be made within 120 days after the end of each Plan
Year, and :services will .only be performed in accordance with the terms and conditions
(including applicable fees) of an additional written agreement provided by AFLAC and
signed by the Employer; and
~ ,. RSA97.2
Di
(8) submit annual statements to Plan Participants showing the amounts paid and/or
expenses incurred as required .by the Plan Document and the Code; and
(9) take all other actions necessary to maintain and' operate the Plan in compliance with
applicable provisions of the Plan, ERISA, the Code, and. any other applicable state
and/or federal law; and
(10) retain documentation relating to Plan operations that may be requested in an IRS or
Department of Labor audit of Plan operations including, but not limited to
nondiscrimination testing information, executed copies of the Plan, Salary Redirection
Agreements, Plan amendments, resolutions adopting the Plan, and Form 5500s for
seven years after the close of each Plan Year; and
(11) execute and return Additional Adoption Agreement to Flex One Administration; and
(12) allow AFLAC, by and through independent associates, a reasonable opportunity to meet
with each employee to discuss AFLAC Supplemental benefits and the URM and DDC
Plans.
in the event AFLAC pays any person less than the .amount to which he or she is entitled under
the Plan, AFLAC will adjust th, e underpayment at the end of the next reimbursement period for
which a total payment of $15.00 would result or at the end of the Plan Year. In the event that
AFLAC overpays any person entitled to benefits under the Plan, or pays benefits to any person
who is not entitled to them, AFLAC shall take ali reasonable steps to recover the overpayment
except that AFLAC shall not be required to initiate court proceedings to recover an
overpayment. AFLAC shall promptly notify the Employer if it is unsuccessful in recovering any
overpayment.
E~
AFLAO will optically scan and maintain electronic copies of all FSA Reimbursement Requests
and supporting documentation for a period of seven (7) years after the claim is processed.
Copies of FSA claim documents can be reproduced upon written request at AFLAC's currently
prevailing rate.
Section .!!.!....Liability and Indemnity
A,
In performing its obligations under this Agreement, AFLAC neither assumes nor underwrites any
liability of the Employer under the Plan, but, with respect to the Employer, acts only as provider
of those services specifically described in Section II.B of this Agreement and with respect to
Plan Participants, acts only as the agent of the Employer. The services to be performed by
AFLAO shall be ministerial in nature and shall be performed within the framework of policies,
interpretations, rules, practices, and procedures made or established by the Employer. AFLAC
shall have no discretionary authority or discretionary control over any assets of the Employer,
the Plan, or Plan Participants.
B.
AFLAC shall have no duty or obligation to defend any'legal action or proceeding brought to
recover a Request for Plan Benefits. AFLAC shall, however, make available to the Employer
and its counsel, such evidence relevant to such action or proceeding as AFLAC may have as a
result of its processing of the contested benefit determination.
Cg
Except as otherwise explicitly provided in this Agreement, the Employer shall retain the liability.
for all Plan benefit Requests and ali expenses incident to the Plan and for any and. all violations
of the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), if applicable, and
agrees to indemnify AFLAC for and hold it, its directors, officers, and employees, harmless from
all amounts and-expenses (including reasonable attorneys' fees and court costs) for which
AFLAC may become liable:
For any state premium, or similar tax, however, denominated, including any
penalties and interest payable with respect thereto, assessed against AFl_AC on
the basis of and/or measured by the amount of Plan'benefit funds handled by
AFLAC pursuant to this Agreement;
RSA97.2
In consequence of any acts or omissions by AFLAC or the Employer (and their
employees, agents, or 'affiliates) arising out of this Agreement, or the'
administration Of the Plan (including those alleged to be a breach of fiduciary
duty under ERISA iif applicable), unless such act or omission is attributable to
willful and inte.n.tional .miscor~duct by AFl_AC;
Arising from any iega!..aClJon or proceeding to recover benefits under the Plan;
or
For any cost, charge, ta~, fine, .penalty, or interest, however denominated, that
may be assessed .ag~nst..AR. AC, the Pia~ Administrator, or the Employer for
any violation of :ERISA, ~(~f applicable)..or ,the Code (including COBRA and/or any
COBRA-related -provisions if applicable)..
D.
This indemnity shall survive the .termi~~ of this Agreement.
AFLAC shall use Ordinary and reasonable care 'in the performance of its duties, but shall not be
liable to the Employer for mistakes of judgmer~ or other actions taken in good faith unless such
error results directly from an i.nten~nally, wrongful or grossly negligent act of AFl_AC, its officers
or employees.
Em
F.
AFLAC shall have no duty or o.bligat[on ~th respect to Request incurred prior to the effective
date of this Agreement (hereafter "Prior Reimbursement Requests") and/or Plan Administrator
(or other) services arising prior to ,the ..effectfve date of this Agreement regardless of whether
such services were/are to be ~performed prier to or after the effective date of this Agreement
(hereafter "Prior Administration"'). ~'.Employer specifically acknowledge(s) and agree(s) that:
(i) AFLAC has no responsibHi.ty or .obligation with respect to Prior Reimbursement Requests
and/or Prior Administration; (ii).the Employer will be responsible for processing Prior
Reimbursement Requests (including :any mn-off 'Requests submitted after the effective date of
this Agreement) and maintaining .teg~y ,m~l~ .records of ali Prior Reimbursement Requests
and Prior Administration sufficient .~ comply with applicable legal (e.g., IRS substantiation)
requirements and (iii) the Empl~..er agrees to indemnify .and hold AFLAC harmless for any
liability relating to Prior Reimbursement.~Requests and/or Prior Administration.
Employer agrees that AFLAC may commu,icate confidential, protected, privileged or Otherwise
sensitive information to Employer'tflrough ~he Named Contact (as designated on the Plan
Document Request Form) and s.pecfficaUy 'agrees to indemnify AFLAC and hold it harmless: i)
for any such communications .directed to Employer through the Named Contact attempted via
telefax, mail, telephone, e-mail or any other media, acknowledging the possibility that such
communications may be inadv~~ misrouted or intercepted; and ii) from any claim for the
improper use or disclosure of any heatf~ information by AR.AC where such information is used
or disclosed in a manner consistent ~vith its duties and ,responsibilities under this Agreement.
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.Section' IV; Reimbu, rsement RequesT P,, ,,ssing':Service Fee
A,
The Employer shall pay AF,~C a fee for services performed under this Agreement in the
amount of $ 0.00 per Participan~ per FSA benefit (DDC or URM) per month (max per
Participant of $ 0.00) with a minimum :monthly fee of $ 0.00 for the reimbursement Plans
(URM and/or DDC) for which services are rendered. This amount shall be due by the tenth
(10th) of each month (or portion'thereof)for which this Agreement is in effect and is in addition
to and separate from (i) any Account Establishment (or ".Set Up") fee assessed by AFLAC of
$ 0.00 to initiate the reimbursement .arrangement: .and (ii) the Employers obligation to make
available sufficient funds to satisfy ,its obligations under the Plan and to make benefit
disbursement in accordance with section II.A. above. The Employer is responsible for paying
the Service Fee to AFl_AC. AFLAC "is not authorized .,to withdraw the Service Fee from the
Account. Failure to pay any applicable monthly Service Fee by the next monthly Requests
processing cycle shall result in a cessation of Request processing services until such fees are
RSA97.2
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received by AFLAC. If Request processing, services' are pended for an entire monthly
processing cycle, AFLAC may terminate this Agreement in accordance with Section VI.
AFLAC may revise the Service Fee for services performed under this Agreement effective on
each Anniversary Date of this Agreement by giving, the Employer written notice of the revised
rate at least thirty (30) days prior to the applicable Anniversary Date.
Notwithstanding any other agreement between the parties (and/or their agents), AFLAC may
revise the Service Fee set forth above at any time if revision is deemed necessary by AFLAC
by reason of: i) modification or amendment of the Plan by the Employer; ii) a significant
decrease in the number of AFLAC policies purchased by Participants under the Plan below the
number initially included in the Plan after the Service Fee was established (or if later, when the
Service Fee was last revised); or iii) a suspension, limitation, or revocation of the right' of
Employees or Participants to purchase AFLAC policies under the Plan. AFLAC shall advise the
Employer of the revised Service Fee at least thirty (30) days prior to its implementation. If the
Employer does not terminate this Agreement (by written notification pursuant to Section VI.A.3.)
within thirty (30) days after the 'receipt of a notice of such revision, the Employer shall be
deemed to have agreed to such revision for the remainder .of the term of the Agreement.
Thereafter, the Service Fee on and after the implementation date shall be made on the basis of
such revised Service Fee.
AFLAC may revise the Service Fee set forth above at any time if any change in law or
regulations imposes on AFLAO greater duties or obligations than contemplated by the
Agreement in force at the time of such change.
Section .,,V. Term Of, Ag. reement
The initial term of this Agreement shall be the initial Plan Year commencing on the effective date hereof,
thereafter, this Agreement will automatically renew for successive periods of twelve (12) months unless,
at least thirty (30) days prior to the end of the then current term, the Employer or AFLAC gives written
notice to the other of its intention not to renew the Agreement. In the event of a short plan year (other
than the first plan year) this Agreement shall automatically renew for an additional twelve (12) months
unless the Employer or AFLAC gives written notice to the other of its intention not to renew the
Agreement within three (3) days after the Employer notifies AFLAC of the short plan year..
..S.,ection VI.. Terminatio..n. of Ag.re,e..ment
Al
This Agreement shall terminate upon the earliest of the following dates:
(1) The end of a term of the.Agreement following the delivery of written notice of
termination pursuant to Section V.
(2)
At the option of AFLAC, the date upon which the Employer fails to transfer sufficient
funds to AFLAC (upon request by AFLAO) i) to pay all valid Requests pending under the
Plan; or ii) to pay the Service Fee (as provided in Section II.A and IV.A., above).
AFLAC shall promptly communicate its election of this option to the Employer.
(3)
Upon the implementation date for a proposed Service Fee increase deemed to be
Unacceptable by the Employer (after delivery of written notice of termination by the
Employer) pursuant to Section lV.O.
(4)
(5)
At the option of AFLAC, if no Plan Participan.t' is an AFLAC policyholder or if the
Employer denies AFLAC a reasonable opportunity (as determined by AFLAC in its sole
discretion) to meet with .Employees. AFLAO shall immediately communicate its election
of this option to the Employer.
Any other date mutually agreeable to the Employer and AFLAC.
RSA97.2
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Upon termination of this Agreement, AFLAC shall cease the processing of all Requests then in
its possession, return any undistributed funds to the Employer, and make all records relating to
Requests in process reasonably available to the Employer; If the termination occurs pursuant to
VI.A. 1. (above), AFLAC shall process all run-off claims provided any Service fee(s) is current.
Thereafter, the Employer and/or 'Plan Administrator shall be responsible for all aspects of
Reimbursement Requests processing and Plan administration.
Section VII. Miscellaneous
....
(1) Notices. Any notice requi~ed to be given hereunder to AFLAC shall be sufficient if in
writing and delivered .personally or by prepaid first class mail to AFLAC, Flexible
Benefits Division, 1932 Wynnton Road, .Columbus, GA 31999, or if to Employer, at the
address of the Employer denoted on .the signature page attached hereto.
(2)
Applicable Law. This Agreement shall be governed by, and shall be construed in
~ccordance' wi{J~ the laws ~ the State of Georgia, to the extent they are not preempted
by ERISA, the Code, or any other federal law.
(3)
.Legal and Tax Stoat_us. The Employer .acknowledges that neither AFLAC nor its agents is
providing legal or tax advice, and .that 'neither AFLAC nor its agents serves as the plan
administrator or a plan adm~~t'or or a fiduciary under the Plan. The Employer shall
be the sole party responsible for determining the legal and tax status of the Plan under
applicable law. AFl_AC .shati have no power or authority to waive, alter, breach or
modify any terms or conditiorts of the 'Plan.
(4)
Assignmen..t,. This Agreement may be assigned by AFLAC to any other party, including
any successor to the business of AFLAO by merger, consolidation, purchase of assets,
or otherwise, without the prior consent of the Employer. This Agreement shall be
binding upon any corporation into which the Employer may be merged or with which it
may be consolidated, or .any .corporation succeeding to all or substantially ali of the
business of the Employer.
(5)
Entire Contract. This Agreement constitutes the entire contract between the parties and
~o"m'o~iifi(~tion or amendment hereto shall be valid unless in writing and signed by' an
officer of the Employer .and an Officer or duly authorized representative of AFLAC.
(6)
· Tax R.e.p.orting and Withhoid.~ngs. The Employer has ultimate control, over the payment of
Plan benefits and shall be the sole party responsible for income and employment tax
reporting and withholding obligations imposed as a result of the includability of such
payments in the gross income of recipients: AFLAC is a mere agent of the Employer '
for the prOcessing of benefit Requests. .
(7)
Confidential Information. The term "Confidential Information" as used in this Agreement
means confidential or proprietary information of any party that is not generally known to
the public, including, but not limi{ed to compilations, lists of actual or potential
customers or suppliers, hardware systems, software, or other documentation of any
type, whether in printed or machine readable form, computer data bases, forms and
form lettersl contracts, information regarding specific transaction and marketing and
business plans. For the purposes .of this subsection, Confidential Information shall not
include the personally identirable information relating to any of Employer's employees.
The term "Trade Secrets" as used in this Agreement shall mean Confidential
Information that: (1).derives economic value, actual or potential, from not being
generally known to, and ..~ot being readily ascertainable by proper means by, other
persons who can obtain economic value from its disclosure or use; and (2) is the
subject of efforts that are reasonable under the circumstances to maintain its secrecy.
The terms "Confidential Information" and "Trade Secrets" do not include information
that: (a) is known to the receiving ~party prior to its disclosure by the disclosing party, as
evidence by the receiving party's written records; (b) is developed by the receiving
party independently of any of the Confidential Information or Trade Secrets received in
confidence from disclosing party, evidenced by the receiving party's written records; (c)
0 RSA97.2
(8)
(9)
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is rightfully received by the receiving party from a third party without restriction and
without breach of any obligation of confidentiality running to the disclosing party.
Each party agrees that it shall not disclose to others or use for any purpose other than
performance of the Agreement any of the other party's Confidential Information or Trade
Secrets any time during or after the term of this Agreement. Each party further agrees
that it will disclose Confidential Information or Trade Secrets to its employees only as
necessary for the performance of the Agreement, and only to employees with a need to
know. Each party to this Agreement agrees that all Confidential Information and Trade
Secrets are the property of the party disclosing it, and each agrees to promptly return to
the disclosing party, upon demand, any Confidential Information or Trade Secrets
furnished under this Agreement which is either received in or reduced to material form,
and all copies thereof. Employer agrees that AFl_AC may make lawful references to
Employer in its marketing activities.
Individual Information. Each party acknowledges that performance of the Agreement
~nay involve the ~USe and disclosure of personal information relating to Employer's
employees (including but not limited to names, addresses, benefit elections, claims and
health information). AFl_AC agrees that it will not use any such information disclosed to
it by Employer except as authorized by the individual to whom the information relates or
as otherwise permitted by applicable state or federal law or regulation. Employer
agrees that it will not use any such information disclosed to it by AFl_AC except' for the
purpose for which it received the information and will not further disclose such
information without the written authorization of the individual to whom the information
relates. This provision is not intended to create any third party beneficiary rights (in
favor of Employer's employees or any other party).
C~apitalized Ter. ms shall have the same meaning as in the Plan documents.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed in duplicate
and signed by an Officer of the Employer and an Officer or duly authorized. Worldwide Headquarters
Employee of AFLAC to do so.
Dated at
American Family Life Assurance Company
.....
This
,
day of ,
By:
Robert M. Ottman
Second Vice President
Flex One Administration
Dated at
This
.............
By:
Street Address:
. day of_
10 RSA97.2
City of Tustin
RESOLUTION CERTIFICATION
STATE OF CALIFORNIA )
COUNTY OF ORANGE ) SS
CITY OF TUSTIN )
RESOLUTION NO. 01-87
I, PAMELA STOKER, City Clerk and ex-officio Clerk of the City Council of the City of Tustin,
California, hereby certifies that the whole number of the members of the City Council of the
City of Tustin is five; and that the above and foregoing Resolution No. 01-87 was adopted
at a regular meeting of the City Council' held on the 4"~ day of September, 2001, by the
following vote:
COUNCILMEMBER AYES: Worley, Thomas, Bone, Doyle, Kawashima
COUNCILMEMBER NOES: None
COUNCILMEMBER ABSTAINED' None
COUNCILMEMBER ABSENT: None
Pamela Stoker, City Clerk