Cafeteria Plan/Medical Expense
""
OJOO3r ZS').3?
CAFETERIA PLAN
AND
MEDICAL EXPENSE
FLEXIBLE SPENDING ACCOUNT
AND
DEPENDENT CARE
FLEXIBLE SPENDING ACCOUNT PLAN
FOR
CITY OF MIAMI BEACH
STANDARD REIMBURSEMENT PLAN
Table of Contents
ARTICLE I. Introduction. .... ............ ....... ..... ............... ............. ........ ...... ........ ....... ................ .....1
1.1 Establishment of Plan ..................................................................................................1
1.2 Legal Status ............ .................... ............. ............ ............ ... ................. .............. ... ....... ...1
ARTICLE II. Definitions ........ ....... .................. ........ .... ...... ........ ................ .......... ............... .... ....2
2.1 Definitions.. .................... ............... ........ .......................... ............. ........ ......... ............ ....2
ARTICLE III. Eligibility and Participation.............................................................................6
3.1 Eligibility to Participate ...............................................................................................6
3.2 Termination of Participation ........... ..... ............... ........ ................ ....... ........ ... ..............6
3.3 Participation Following Termination of Employment or Loss of Eligibility ............6
3.4 FMLA Leaves of Absence ...........................................................................................7
3.5 Non-FMLA Leaves of Absence....................................................................................8
ARTICLE IV. Method and Timing of Elections ...................................................................9
4.1 Elections When First Eligible ......................................................................................9
4.2 Elections During Open Enrollment Period ................................................................9
4.3 Failure of Eligible Employee to File an Election Form/
Salary Reduction Agreement ......... ..... .............. ........ ... ...................... ........ ......... ..........9
4.4 Irrevocability of Elections .........................................................................................1 0
ARTICLE V. Benefits Offered and Method of Funding.....................................................ll
5.1 Benefits Offered ..........................................................................................................11
5.2 Employer and Participant Contributions ..................................................................11
The Standard Reimbursement Plan
Page ii
[Revised 315/03]
5.3 Using Salary Reductions to Make Contributions ......................................................11
5.4 Funding This Plan .......................................................................................................12
ARTICLE VI. Premium Payment Component.......................................................................... 13
6.1 Benefits .......................................................................................................................13
ARTICLE VII. Medical FSA Component ..................................................................................14
7.1 Benefits ........................................................................................................................14
7.2 Benefit Premiums (a/k/a Cost of Coverage) .............................................................14
7.3 Eligible Medical Care Expenses..................................................................................14
7.4 Maximum and Minimum Benefits ..............................................................................15
7.5 Establishment of Account .........................................................................................16
7.6 Forfeiture of Accounts; Use-It-or-Lose-It Rule .......................................................16
7.7 Reimbursement Procedure..........................................................................................17
7.8 Reimbursements After Termination; COBRA...........................................................17
7.9 Named Fiduciary; Compliance With ERISA, COBRA, HIPAA, etc. .......................18
ARTICLE VIII. Dependent Care FSA Component ..................................................................19
8.1 Benefits .......................................................................................................................19
8.2 Benefit Premiums (a/k/a Cost of Coverage) ............................................................19
8.3 Eligible Dependent Care Expenses ............................................................................19
8.4 Maximum and Minimum Benefits ..............................................................................20
8.5 Establishment of Account ..........................................................................................22
8.6 Forfeiture of Accounts; Use-It-or-Lose-It Rule .......................................................22
8.7 Reimbursement Procedure .. ................................ .................... ..................... ..... ....... ..23
8.8 Reimbursements After Termination ..........................................................................23
The Standard Reimbursement Plan
Pageiii
[Revised 3/5/03]
ARTICLE IX. HIPAA ....................................................................................................................24
9.1 HIP AA Compliance ...................................................................................................24
AR TI CLES X-XI. [Reserved] .............. ....... ............................................ .... ................................25
ARTICLE XII. Irrevocability of Elections; Exceptions .........................................................25
12.1 Irrevocability of Elections ........... ......... ...... ............. .................... ...................................25
12.2 Procedure for Making New Election If Exception to Irrevocability Applies .............25
12.3 Change in Status Defined ................................................................................................25
12.4 Events Permitting Exception to Irrevocability Rule .....................................................26
12.5 Election Modifications Required by Administrator ......................................................27
12.6 Overall Limitation on Changes in Contribution Amounts ...........................................28
ARTICLE XIII. Recordkeeping and Administration..............................................................29
13.1 Administrator ................ ......................... ....... ................................... .............. ......... ........29
13.2 Powers of the Administrator ..........................................................................................29
13.3 Reliance on Participant, Tables, etc. ..............................................................................30
13.4 Provision for Third-Party Plan Service Providers ........................................................30
13.5 Fiduciary Liability .... ...... ...... .......... ..... .................................. ....... ................ .................... 30
13.6 Compensation of Plan Administrator ............................................................................30
13.7 Bonding ............................................................................................................................ 30
13.8 Insurance Contracts ....... ................ .................. ............... ........ ............. ........................... 31
13.9 Inability to Locate Payee ................................................................................................31
13.10 Effect of Mistake .............................................................................................................31
The Standard Reimbursement Plan
Page iv
[Revised 3/5/03]
ARTICLE XIV. General Provisions ............................................................................................32
14.1 Expenses......................................................................... ..... .......... ..................................32
14.2 No Contract of Employment..........................................................................................32
14.3 Amendment and Termination ........................................................................................32
14.4 Governing Law .......................................... .............. .......... ..... ...... ...................................32
14.5 Code and ERISA Compliance ........................................................................................32
14.6 No Guarantee of Tax Consequences .............................................................................32
14.7 Indemnification of Employer ................ ......................................................................... 33
14.8 N on-Assignability of Rights ............................................................................................ 33
14.9 Headings........................................................................... ............... ..... ............................ 33
14.10 Plan Provisions Controlling ............................................................................................33
14.11 Severability .... ............ ............ ............... ..................... ........................................................ 33
Exhibit A ........................................................................................................... ..................... Employer
Exhibit B . ............ ...................... ......... ................... .................. .............................. Eligible Employees
Exhibit C ....................................................................................................... Change in Status Matrix
Exhibit D.............. ......... ............. ............... ..... ................................. ......... ............ Appeals Procedures
The Standard Reimbursement Plan
Page v
[Revised 3/5/03]
The Cafeteria Plan, Medical Expense FSA
and
Dependent Care FSA Plans
Adopted October 1, 2003
ARTICLE 1.
INTRODUCTION
1.1 Establishment of Plan
The Employer identified in Exhibit A (hereinafter the "Employer") hereby establishes
this flexible benefits plan (the "Plan") effective October 1, 2003 (the "Effective Date").
Capitalized terms used in this Plan that are not otherwise defined shall have the
meanings set forth in Article II.
This Plan is designed to permit Eligible Employees to select between Medical Expense
Flexible Spending Account Plan and Dependent Care Flexible Spending Account Plan
benefits, and to pay for certain Benefits with Employee contributions. Employee
contributions will be paid on a pre-tax Salary Reduction basis.
1.2 Legal Status
The Medical FSA Component of this Plan is intended to qualify as a "self-insured
medical reimbursement plan" under Code ~ 105, and the Medical Care Expenses
reimbursed thereunder are intended to be eligible for exclusion from the participating
Employees' gross income under Code ~ 105(b). The Dependent Care FSA Component
of this Plan is intended to qualify as a "dependent care assistance plan" under Code ~
129, and the Dependent Care Expenses reimbursed thereunder are intended to be
eligible for exclusion from the participating Employees' gross income under Code ~
129(a).
Although set forth together within this document, the Medical FSA Component and the
Dependent Care FSA Component are separate plans for the purposes of administration
and all reporting and nondiscrimination requirements imposed by Code ~ ~ 105 and 129.
The Medical FSA Component is also a separate plan for purposes of applicable
provisions of ERISA and COBRA, to the extent applicable.
Page 1
ARTICLE II.
DEFINITIONS
2.1 Definitions
"Account(s)" means the Medical FSA Accounts and the Dependent Care FSA
Accounts described in Sections 7.5 and 8.5, respectively.
"Benefits" means the Employer's Medical FSA and Dependent Care FSA Benefits and
the employee contributions for certain other employee benefit plans including Medical
Dental, Life, Short Term Disability and Critical Life. The Employer may substitute, add,
subtract or revise at any time the menu of such plans and/or the benefits, terms and
conditions of any such plans. Any such substitution, addition, subtraction or revision will
be communicated to Participants and will automatically be incorporated by reference
under this Plan.
"Administrator" means Fringe Benefits Management Company.
"Change in Status" has the meaning described in Section 12.3.
"COBRA" means the Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended.
"Code" means the Internal Revenue Code of 1986, as from time-to-time amended.
"Compensation" means the wages or salary paid to an Employee by the Employer,
determined prior to (a) any Salary Reduction election' under this Plan, (b) any salary
reduction election under any other cafeteria plan, and (c) any compensation reduction
under any Code ~ 132(f)(4) plan; but determined after (d) any salary deferral elections
under any Code ~ 401(k), 403(b), 408(k) or 457(b) plan or arrangement. Thus,
"Compensation" generally means wages or salary paid to an Employee by the Employer,
as reported in Box I of Form W-2, but adding back any wages or salary forgone by virtue
of any election described in (a), (b) or (c) of the prior sentence.
"Dependent Care FSA" means the Employer's dependent care assistance program.
"Dependent Care FSA Account" means the account described in Section 8.5.
"Dependent Care FSA Benefits" has the meaning described in Section 8.1.
"Dependent Care FSA Component" means the Component of this Plan described in
Article VIII.
"Dependent" means any individual who is a tax dependent of the Participant as defmed
in Code ~ 152, with the following exceptions: (a) for purposes of accident or Medical
coverage (to the extent such is an Insured Benefit under the Plan, and for purposes of
the Medical FSA Component), any child to whom Code ~ 152(e) applies (regarding a
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child of divorced parents, etc., where one or both parents have custody of the child for
more than half of the calendar year and where the parents together provide more than
half of the child's support for the calendar year) is treated as a dependent of both
parents; and (b) for purposes of the Dependent Care FSA Component, a dependent
means a qualifying individual as defined in Code ~ 21 (b) (1) with respect to the
Participant, and in the case of divorced parents, the child shall, as provided in Code ~
21 (e) (5), be treated as a qualifying individual of the custodial parent (within the meaning
of Code ~ 1 52(e)(1)) and shall not be treated as a qualifying individual with respect to the
noncustodial parent. Notwithstanding the foregoing, the Medical FSA Component will
provide benefits in accordance with the applicable requirements of any QMCSO, even if
the child does not meet the definition of "Dependent."
"Dependent Care FSA Expenses" has the meaning described in Section 8.3.
"Earned Income" means all income derived from wages, salaries, tips, self-
employment, and other Compensation (such as disability or wage continuation benefits),
but only if such amounts are includible in gross income for the taxable year. Earned
income does not include (a) any amounts received pursuant to any Dependent Care FSA
established under Code ~ 129; or (b) any other amounts excluded from earned income
under Code ~ 32(c)(2), such as amounts received under a pension or annuity, or pursuant
to workers' compensation. "Effective Date" of this Plan has the meaning described in
Section 1.1.
"Election Form/Salary Reduction Agreement" means the form provided by the
Administrator for the purpose of allowing an Eligible Employee to participate in this
Plan by electing Salary Reductions to pay for any of the following: Medical FSA Benefits
and/ or Dependent Care FSA Benefits. It includes an agreement pursuant to which an
Eligible Employee or Participant authorizes the Employer to make Salary Reductions.
"Eligible Employee" means an Employee eligible to participate in this Plan, as
provided in Exhibit B. "Employee" means an individual that the Employer classifies as a
common-law employee and who is on the Employer's W-2 payroll, but does not include
the following: (a) any leased employee (including but not limited to those individuals
defined as leased employees in Code ~ 414(n)) or an individual classified by the
Employer as a contract worker, independent contractor, temporary employee or casual
employee for the period during which such individual is so classified, whether or not any
such individual is on the Employer's W-2 payroll or is determined by the IRS or others
to be a common-law employee of the Employer; (b) any individual who performs
services for the Employer but who is paid by a temporary or other employment or
staffIng agency for the period during which such individual is paid by such agency,
whether or not such individual is determined by the IRS or others to be a common-law
employee of the Employer; and (c) any employee covered under a collective bargaining
agreement. The term "Employee" does include "former Employees" for the limited
purpose of allowing continued eligibility for benefits under the Plan for the remainder of
the Plan Year in which an Employee ceases to be employed by the Employer.
"Employer" means the City of Miami Beach, Florida.
Page 3
"Employment Commencement Date" means the first regularly-scheduled working
day on which the Employee first performs an hour of service for the Employer for
Compensation.
"ERISA" means the Employee Retirement Income Security Act of 1974, as amended.
"FMLA" means the Family and Medical Leave Act of 1993, as amended.
"HIPAA" means the Health Insurance Portability and Accountability Act of 1996, as
amended.
"Medical Care Expenses" has the meaning defined in Section 7.3.
"Medical FSA" means the Medical flexible spending arrangement made a part hereof.
"Medical FSA Account" means the account described in Section 7.5.
"Medical FSA Benefits" has the meaning described in Section 7.1.
"Medical FSA Component" means the Component of this Plan described in Article
VII.
"Medical Insurance Benefits" means the Employee's Medical Insurance Plan coverage
for purposes of this Plan.
"Open Enrollment Period" with respect to a Plan Year means the month occurring
two months preceding the start of each Plan Year, or such other period as may be agreed
to by the parties.
"Participant" means a person who is an Eligible Employee and who is participating in
this Plan in accordance with the provisions of Article III. Participants include those who
elect Medical FSA or Dependent Care Benefit and to pay for same via Salary Reductions.
"Period of Coverage" means the Plan Year, with the following exceptions: (a) for
Employees who first become eligible to participate, it will mean the portion of the Plan
Year following the date participation commences, as described in Section 3. I ; and (b)
for Employees who terminate participation, it will mean the portion of the Plan Year
prior to the date participation terminates, as described in Section 3.2.
"Plan" means the Plan as set forth herein and as amended from time to time. "Plan
Year" means the fiscal year (i.e., the 12-month period commencing October 1 and
ending on September 30).
"QMCSO" means a qualified medical child support order, as defined in ERISA ~
609(a).
"Qualifying Dependent Care Services" has the meaning described in Section
8.3.
Page 4
"Qualifying Individual" has the meaning described in Section 8.3.
"Salary Reduction" means the amount by which the Participant's Compensation is
reduced and applied by the Employer under this Plan to pay for one or more of the
Benefits, as permitted for the applicable benefit, before any applicable state and/or
federal taxes have been deducted from the Participant's Compensation (i.e., on a pretax
basis).
"Spouse" means an individual who is legally married to a Participant as determined
under applicable state law (and who is treated as a spouse under the Code).
Notwithstanding the above, for purposes of the Dep~!1dent Care FSA Component, the
term "Spouse" will not include (a) an individual legally separated from the Participant
under a divorce or separate maintenance decree; or (b) an individual who, although
married to the Participant, ftles a separate federal income tax return, maintains a
principal residence separate from the Participant during the last six months of the
taxable year, and does not furnish more than half of the cost of maintaining the principal
place of abode of the Participant.
"Student" means an individual who, during each of five or more calendar months
during the Plan Year, is a full-time student at any educational organization that normally
maintains a regular faculty and curriculum and normally has an enrolled student body in
attendance at the location where its educational activities are regularly carried on.
Page 5
ARTICLE III.
ELIGIBILITY AND PARTICIPATION
3.1 Eligibility to Participate
Eligibility to participate is set forth in Exhibit B, as from time-to-time amended by the
Employer.
3.2 Termination of Participation
A Participant will cease to be a Participant in this Plan upon the earlier of:
. the expiration of the Period of Coverage for which the Employee has elected to
participate (unless during the Open Enrollment Period for the next Plan Year the
Employee elects to continue participating);
. the termination of this Plan;
. the date on which the Employee ceases (because of retirement, termination of
employment, layoff, reduction in hours, or any other reason) to be an Eligible
Employee, provided that eligibility may continue beyond such date for purposes
of pre-taxing COBRA coverage, as may be permitted by the Administrator on a
uniform and consistent basis (but not beyond the end of the current Plan Year);
or
. the date the Participant revokes his or her election to participate under a
circumstance when such change is permitted under the terms of this Plan.
Termination of participation in this Plan will automatically revoke the Participant's
elections and terminate the benefits as of the applicable dates specified in the
insurance Plans. Reimbursements from the Medical FSA and Dependent Care
FSA Accounts after termination of participation will be made pursuant to Sections
7.8 and 8.8.
3.3 Participation Following Termination of Employment or Loss of Eligibility
If a former Participant is rehired following termination of employment and is otherwise
eligible to participate in the Plan, then the individual may make new elections as a new
hire as described in Section 3.1. If an Employee (whether or not a Participant) ceases to
be an Eligible Employee for any reason (other than for termination of employment),
including (but not limited to) a reduction in hours, and then becomes an Eligible
Employee again, the Employee must complete the waiting period described in Section
3.1 before again becoming eligible to participate in the Plan.
Page 6
3.4 FMLA Leaves of Absence
(a) Medical Benefits. Notwithstanding any provision to the contrary in this Plan, if a
Participant goes on a qualifying leave under the FMLA, then to the extent required
by the FMLA, the Employer will continue to maintain the Participant's Medical FSA
Benefits on the same terms and conditions as if the Participant were still an active
Employee. That is, if the Participant elects to continue his or her coverage while on
leave, the Employer will continue to pay its share of the premium.
A Participant may elect to continue his or her coverage for Medical FSA Benefits
during the FMLA leave. If the Participant elects to continue coverage while on leave,
then the Participant may pay his or her share of the premium in one of the following
ways:
. with after-tax dollars, by sending monthly payments to the Employer by the
due date established by the Employer;
. with pretax dollars, by pre-paying all or a portion of the premium for the
expected duration of the leave on a pre-tax Salary Reduction basis out of pre-
leave Compensation. To pre-pay the premium, the Participant must make a
special election to that effect prior to the date that such Compensation would
normally be made available (pre-tax dollars may not be used to fund coverage
during the next Plan Year); or
. under another arrangement agreed upon prior to the commencement of leave
between the Participant and the Employer (e.g., the Employer may fund
coverage during the leave and withhold "catch-up" amounts upon the
Participant's return).
If a Participant's coverage ceases while on FMLA leave, the Participant will be
permitted to re-enter the Plan upon return from such leave on the same basis as the
Participant was participating in the Plan prior to the leave or otherwise required by
the FMLA.
(b) Non-Medical Benefits. If a Participant goes on a qualifying leave under the FMLA,
entitlement to Dependent Care FSA Plan Benefits, is to be determined by the
Employer's policy for providing such Benefits when the Participant is on non-FMLA
leave (as agreed to by both the Participant and Employer prior to the
commencement of leave as described in Section 3.5.)
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3.5 Non-FMLA Leaves of Absence
If a Participant goes on an unpaid leave of absence that does not affect eligibility, then
the Participant will continue to participate and the premium due for the Participant will
be paid by pre-payment before going on leave, by after-tax contributions while on leave,
or with catch-up contributions after the leave ends, as may be determined by the
Employer.
If a Participant goes on an unpaid leave that affects eligibility, the election change rules
in Section 12.4 will apply.
Page 8
ARTICLE IV.
METHOD AND TIMING OF ELECTIONS
4.1 Elections When First Eligible
An Employee who ftrst becomes eligible to participate in the Plan may commence
participation on the ftrst day after the eligibility requirements have been satisfied,
provided that an Election Form/Salary Reduction Agreement is submitted to the
Administrator within 30 days of the date of eligibility. This election will remain in effect
from year-to-year until the employee revokes the election either at Open Enrollment or a
recognized change in status. An employee who does not elect to participate when ftrst
eligible may not enroll until the next Open Enrollment Period, unless an event occurs
that would justify a mid-year election change, as described under Section 12.4.
4.2 Elections During Open Enrollment Period
During each Open Enrollment Period with respect to a Plan Year, the Administrator will
permit each Employee who is eligible to participate in this Plan the opportunity to make
a new election under this Plan. Employees who wish to make a change must request and
complete the Election Form/Salary Reduction Agreement to authorize the necessary
Salary Reductions to pay for the beneftts elected. The Election Form/Salary Reduction
Agreement must be returned to the Administrator on or before the last day of the Open
Enrollment Period. If an Eligible Employee makes an election to participate during an
Open Enrollment Period, then the Employee will become a Participant on the first day
of the next Plan Year. If an Eligible Employee fails to return the Election Form/Salary
Reduction Agreement during the Open Enrollment Period, then the Employee's
elections currently in effect will remain in effect for the next plan year. The Employee
will not be permitted to make a change in the elections until the next Open Enrollment
Period, unless an event occurs that would justify a midyear election change, as described
under Section 12.4.
4.3 Failure of Eligible Employee to File an Election Form/Salary Reduction
Agreement
If an Eligible Employee fails to ftle an Election Form/Salary Reduction Agreement
within the time period described in Sections 4.1, then the Employee will not receive his
or her core beneftts from the Employer. The Employee will not be permitted to make a
change in the elections until the next Open Enrollment Period, unless an event occurs
that would justify a midyear election change, as described under Section 12.4.
Such Employee may not make a different election to participate in the Plan: (a) until the
next Open Enrollment Period; or (b) until an event occurs that would justify a mid-year
election change, as described under Section 12.4.
Page 9
4.4 Irrevocability of Elections
Unless an exception applies (as described in Article XII), a Participant's election under
the Plan is irrevocable for the duration of the Period of Coverage to which it relates.
Page 10
ARTICLE V.
BENEFITS OFFERED AND METHOD OF FUNDING
5.1 Benefits Offered
When fIrst eligible or during the Open Enrollment Period as described under Article IV,
Participants will be given the opportunity to elect from (a) Medical FSA BenefIts, as
described in Article VII; and (b) Dependent Care FSA BenefIts, as described in Article
VIII. In no event shall BenefIts under the Plan be provided in the form of deferred
compensation.
5.2 Participant Contributions
The Employer shall withhold from a Participant's Compensation on a pre-tax Salary
Reduction basis an amount equal to the contributions required from the Participant for
the BenefIts elected by the Participant under this Plan. Amounts withheld from a
Participant's Compensation shall be applied to fund BenefIts as soon as administratively
feasible. The maximum amount of Salary Reductions shall not exceed the aggregate cost
of the BenefIts elected. Participants who elect any of the BenefIts may pay for their
required contributions on a pre-tax Salary Reduction basis by completing an Election
Form/Salary Reduction Agreement.
5.3 Using Salary Reductions to Make Contributions
(a) Salary Reductions per Pqy Period. The Salary Reduction for a pay period for a Participant
is, for the BenefIts elected, an amount equal to (1) the annual premium for such
BenefIts (as described in Section 6.2 for Premium Payment BenefIts, Section 7.2 for
Medical FSA BenefIts, and Section 8.2 for Dependent Care FSA BenefIts), divided by
(2) the number of pay periods in the Period of Coverage, or an amount otherwise
agreed upon between the Employer and the Participant. If a Participant who is
making Salary Reductions increases his or her election under the Medical FSA
Component or Dependent Care FSA Component as permitted under Section 12.4,
the Salary Reductions per pay period will be equal to (x) the new reimbursement limit
elected pursuant to Section 12.4. less the aggregate premiums for the period prior to
such election change, divided by (y) the number of pay periods in the balance of the
Period of Coverage commencing with the election change.
(b) Considered Emplqyer Contributions for Certain Purposes. Salary Reductions are applied by the
Employer to pay for the Participant's premiums for the Medical FSA BenefIts and
the Dependent Care FSA BenefIts and, for the purpose of this Plan and the Code,
are considered to be Employer contributions.
Page II
(c) Salary Reduction Balance Upon Termination of Coverage. If, as of the date that any elected
coverage under this Plan terminates, a Participant's year-to-date Salary Reductions
exceed or are less than the Participant's required contributions for the coverage, then
the Employer will, as applicable, either rerum the excess to the Participant as
additional taxable wages or recoup the due Salary Reduction amounts from any
remaining Compensation.
5.4 Funding This Plan
All of the amounts payable under this Plan shall be paid from the general assets of the
Employer. Nothing herein will be construed to require the Employer or the Administrator
to maintain any fund or to segregate any amount for the benefit of any Participant, and no
Participant or other person shall have any claim against, right to, or security or other
interest in any fund, account or asset of the Employer from which any payment under this
Plan may be made. There is no trust or other fund from which Benefits are paid. While the
Employer has complete responsibility for the payment of Benefits out of its general assets
(except for Premium Payment Benefits paid as provided in the applicable insurance
policy), it has contracted with the Administrator to make Benefit payments on its behalf.
The maximum contributions that may be made under this Plan for a Participant is the total
of the maximums that may be elected under Sections 7.4(b) and 8A(b) for Medical FSA
and Dependent Care FSA Benefits.
Page 12
ARTICLE VI.
PAYMENT
6.1 Benefits
The benefits that can be elected under the Plan are the Medical FSA and the Dependent
Care FSA and medical dental, life, short term disability, critical life insurance -- Benefits
elected will be funded by Employer and! or Participant contributions as provided in
Section 5.2.
Unless an exception applies (as described in Article XII), such election is irrevocable for
the duration of the Period of Coverage to which it relates.
Page 13
ARTICLE VII.
MEDICAL FSA COMPONENT
7.1 Benefits
An Eligible Employee can elect to participate in the Medical FSA Component by electing
to receive benefits in the form of reimbursements for Medical Care Expenses (Medical
FSA Benefits). Benefits elected will be funded by Employer and/or Participant
contributions as provided in Section 5.2. Unless an exception applies (as described in
Article XII), such election is irrevocable for the duration of the Period of Coverage to
which it relates. The Employer may elect, on a Plan Year to Plan Year basis, to contribute
an amount to the Participant's Account for the reimbursement of Eligible Expenses.
7.2 Benefit Premiums (a/k/a Cost of Coverage)
The annual premium for a Participant's Medical FSA Benefits is equal to the annual
benefit amount elected by the Participant (for example, if the maximum annual benefit
amount is $2,400 and such amount is elected, then the annual premium amount is also
$2,400). The maximum annual benefit amount will be determined by the Employer on
a year-to-year basis.
7.3 Eligible Medical Care Expenses
Under the Medical FSA Component, a Participant may receive reimbursement for
Medical Care Expenses incurred during the Period of Coverage for which an election is
in force.
(a) Incurred. A Medical Care Expense is incurred at the time the medical care or service
giving rise to the expense is fumished, and not when the Participant is formally
billed for, is charged for, or pays for the medical care.
(b) Medical Care Expenses. "Medical Care Expenses" means expenses incurred by a
Participant or his or her Spouse or Dependents for medical care, as defined in
Code ~ 213 (including, for example, amounts for certain hospital bills, doctor and
dental bills and prescription drugs) and certain over-the-counter drugs and
medicines as otherwise approved by the Intemal Revenue Service as determined by
the Administrator, but only to the extent that the Participant or other person
incurring the expense is not reimbursed for the expense (nor is the expense
reimbursable) through any other insurance, or any other accident or Medical plan.
If only a portion of a Medical Care Expense has been reimbursed elsewhere (e.g.,
because the Medical Insurance Plan imposes co-payment or deductible limitations),
the Medical FSA can reimburse the retraining portion of such Expense if it
otherwise meets the requirements of this Article.
Page 14
7.4 Maximum and Minimum Benefits
(a) Maximum Reimbursement Available; Uniform Coverage. The maximum dollar amount
elected by the Participant for reimbursement of Medical Care Expenses incurred
during a Period of Coverage" (reduced by prior reimbursements during the Period
of Coverage) shall be available at all times during the Period of Coverage,
regardless of the actual amounts credited to the Participant's Medical FSA Account
pursuant to Section 7.5. Notwithstanding the foregoing, no reimbursements will be
available for Medical Care Expenses incurred after coverage under this Plan has
terminated, unless the Participant has elected COBRA as provided in Section 7.8.
Payment shall be made to the Participant in cash as reimbursement for Medical
Care Expenses incurred during the Period of Coverage for which the Participant's
election is effective, provided that the other requirements of this Article VII have
been satisfied.
(b) Maximum and Minimum Dollar Limits. The maximum annual benefit amount that a
Participant may elect to receive under this Plan in the form of reimbursements for
Medical Care Expenses incurred in any Period of Coverage shall be determined by
the Employer on a year-to-year basis, subject to Section 7.5 (c) below. The
minimum annual benefit amount that a Participant may elect to receive under this
Plan in the form of reimbursements for Medical Care Expenses is $130.00 per Plan
Year. Reimbursements due for Medical Care Expenses incurred by the Participant's
Spouse or Dependents shall be charged against the Participant's Medical FSA
Account.
(c) Changes; No Proration. For each Plan Year, the maximum and minimum dollar limit
may be changed by the Employer and Administrator and shall be communicated to
Employees through the Election Form/Salary Reduction Agreement or another
document. If a Participant enters the Medical FSA Component mid-year, or wishes
to increase his or her election mid-year as permitted under Section 12A, there will be
no proration rule - i.e., the Participant may elect coverage up to the maximum dollar
limit or may increase coverage to the maximum dollar limit, as applicable.
(d) Effict on Maximum Benifits lfElection Change Permitted. Any change in an election under
Article XII affecting annual contributions to the Medical FSA Component also will
change the maximum reimbursement benefits for the balance of the Period of
Coverage commencing with the election change. Such maximum reimbursement
benefits for the balance of the Period of Coverage shall be calculated by adding (1)
the aggregate premium for the period prior to such election change to (2) the total
premium for the remainder of such Period of Coverage to the Medical FSA Account,
reduced by (3) all reimbursements made during the entire Period of Coverage.
Page 15
7.5 Establishment of Account
The Administrator will establish and maintain a Medical FSA Account with respect to
each Participant who has elected to participate in the Medical FSA Component, but will
not create a separate fund or otherwise segregate assets for this purpose. The Account so
established will merely be a record keeping account with the purpose of keeping track of
contributions and determining forfeirures under Section 7.6.
(a) Crediting of Accounts. A Participant's Medical FSA Account will be credited periodically
during each Period of Coverage with an amount equal to the Participant's Salary
Reductions elected to be allocated to such Account.
(b) Debiting of Accounts. A Participant's Medical FSA Account will be debited during each
Period of Coverage for any reimbursement of Medical Care Expenses incurred
during the Period of Coverage.
(c) Available Amount Not Based on Credited Amount. As described in Section 7A, the amount
available for reimbursement of Medical Care Expenses is the Participant's annual
benefit amount, reduced by prior reimbursements during the Period of Coverage; it
is not based on the amount credited to the Medical FSA Account at a particular point
in time. Thus, a Participant's Medical FSA Account may have a negative balance
during a Period of Coverage, but any such negative amount shall never exceed the
maximum dollar amount of annual benefits elected by the Participant under this
Plan.
7.6 Forfeiture of Accounts; Use-It-or-Lose-It Rule
If any balance remains in the Participant's Medical FSA Account for a Period of
Coverage after all reimbursements have been made for the Period of Coverage, such
balance shall not be carried over to reimburse the Participant for Medical Care
Expenses incurred during a subsequent Plan Year. The Participant shall forfeit all rights
with respect to such balance. All forfeitures under this Plan shall be used as follows: (a)
first, to offset any losses experienced by the Employer during the Plan Year as a result
of making reimbursements (i.e., providing Medical FSA Benefits) with respect to any
Participant in excess of the premiums paid by such Participant through Salary
Reductions; (b) second, to reduce the cost of administering the Medical FSA
Component during the Plan Year or the subsequent Plan Year (all such administrative
costs shall be documented by the Administrator); and (c) third, to provide increased
benefits or compensation to Participants in subsequent years in any weighted or
uniform fashion that the Administrator deems appropriate, consistent with applicable
regulations. In addition, any Medical FSA Account benefit payments that are unclaimed
(e.g., uncashed-benefit checks) by the close of the Plan Year following the Period of
Coverage in which the Medical Care Expense was incurred shall be forfeited and
applied as described above.
Page 16
7.7 Reimbursement Procedure
(a) Timing. Within 30 days (or such shorter period as may occur through implementation
of a debit card or as may be contracrually agreed to by Employer and Administrator)
after receipt by the Administrator of a reimbursement claim from a Participant, the
Administrator will reimburse the Participant for the Participant's Medical Care
Expenses (if the Administrator approves the claim), or the Administrator will notify
the Participant that his or her claim has been denied. This time period may be
extended for an additional period for matters beyond the control of the
Administrator, including cases where a reimbursement claim is incomplete or where a
debit card transaction is deemed ineligible.
(b) Claims Substantiation. A Participant who has elected to receive Medical FSA Benefits
for a Period of Coverage may apply for reimbursement by submitting an application
in writing to the Administrator in such form as the Administrator may prescribe, by
no later than ninety (90) days following the close of the Plan Year in which the
Medical Care Expense was incurred, setting forth:
. the person or persons on whose behalf Medical Care Expenses have been
incurred;
. the narure and date of the Expenses so incurred;
. the amount of the requested reimbursement; and
. a statement that such Expenses have not otherwise been reimbursed and are
not reimbursable through any other source.
The application shall be accompanied by bills, invoices, or other statements from an
independent third party showing that the Medical Care Expenses have been incurred
and the amounts of such Expenses, together with any additional documentation that
the Administrator may request. Except for the final reimbursement claim for a
Period of Coverage, no claim for reimbursement may be made unless and until the
aggregate claims for reimbursement is at least $5.
(c) Claims Denied. For reimbursement claims that are denied see the appeals procedure in
Article XIII.
7.8 Reimbursements After Termination; COBRA
When a Participant ceases to be a Participant under Section 3.2, the Participant's Salary
Reductions will terminate, as will the Participant's election to receive reimbursements.
The Participant will not be able to receive reimbursements for Medical Care Expenses
incurred after his or her participation terminates. However, such Participant (or the
Participant's estate) may claim reimbursement for any Medical Care Expenses incurred
during the Period of Coverage prior to termination, provided that the Participant (or the
Participant's estate) f1les a claim no later than ninety (90) days following the close of the
Plan Year in which the Medical Care Expense was incurred.
Page 17
Notwithstanding any provision to the contrary in this Plan, to the extent required by
COBRA, a Participant and his or her Spouse and Dependents, whose coverage
terminates under the Medical FSA Component because of a COBRA qualifying event,
shall be given the opporrunity to continue on a self-pay basis the same coverage that he
or she had under the Medical FSA Component the day before the qualifying event for
the periods prescribed by COBRA (subject to all conditions and limitations under
COBRA), with premiums for such coverage to be paid on an after-tax basis, unless
permitted otherwise by the Administrator on a uniform and consistent basis (but not
beyond the current Plan Year). Specifically, such individuals will be eligible for COBRA
continuation coverage only if, under Section 7.5, they have a positive Medical FSA
Account balance at the time of a COBRA qualifying event (taking into account all claims
submitted before the date of the qualifying event). Such individualswill be notified if
they are eligible for COBRA continuation coverage. If COBRA is elected, it will be
available only for the remainder of the Plan Year in which the qualifying event occurs;
such COBRA coverage for the Medical FSA Component will cease at the end of the Plan
Year and cannot be continued for the next Plan Year.
7.9 Named Fiduciary; Compliance With ERISA, COBRA, HIPAA, etc.
(a) Named Fiduciary. The Employer is the named fiduciary for the Medical FSA
Component for purposes of ERISA ~ 402(a), if applicable.
(b) Laws Applicable to Group Medical Plans. Medical FSA Benefits shall be provided in
compliance with ERISA, COBRA, HIP AA, etc.
(c) Coordination of Benefits. Medical FSA Benefits are intended to pay benefits solely
for Medical Care Expenses not previously reimbursed or reimbursable elsewhere.
Accordingly, the Medical FSA shall not be considered a group Medical plan for
coordination of benefits purposes, and Medical FSA Benefits shall not be taken into
account when determining benefits payable under any other plan.
Page 18
ARTICLE VIII.
DEPENDENT CARE COMPONENT
8.1 Benefits
An Eligible Employee can elect to participate in the Dependent Care FSA Component by
electing to receive benefits in the form of reimbursements for Dependent Care Expenses.
Benefits elected will be funded by Employer and/ or Participant contributions as provided
in Section 5.2. Unless an exception applies (as described in Article XII), such election is
irrevocable for the duration of the Period of Coverage to which it relates.
8.2 Benefit Premiums (a/k/a Cost of Coverage)
The annual premium for a Participant's Dependent Care FSA Benefits is equal to the
annual benefit amount elected by the Participant (for example, if the maximum $5,000
annual benefit amount is elected, the annual premium amount is also $5,000).
8.3 Eligible Dependent Care Expenses
Under the Dependent Care FSA Component, a Participant may receive reimbursement for
Dependent Care Expenses incurred during the Period of Coverage for which an election is
in force.
(a) Incurred. A Dependent Care Expense is incurred at the time the Qualifying
Dependent Care Services giving rise to the expense is furnished, and not when the
Participant is formally billed for, is charged for, or pays for the Qualifying
Dependent Care Services (e.g., services rendered for the month of June are not fully
incurred until June 30 and cannot be reimbursed in full until then).
(b) Dependent Care Expenses. "Dependent Care Expenses" means expenses that are
considered to be employment-related expenses under Code ~ 21 (b) (2) (relating to
expenses for the care of a Qualifying Individual necessary for gainful employment of
the Employee and Spouse, if any), and expenses for incidental household services, if
paid for by the Eligible Employee to obtain Qualifying Dependent Care Services, but
only to the extent that the Participant or other person incurring the expense is not
reimbursed for the expense (nor is the expense reimbursable) through insurance or
any other plan. If only a portion of a Dependent Care Expense has been reimbursed
elsewhere (e.g. because the Spouse's Dependent Care FSA imposes maximum benefit
limitations), the Dependent Care FSA can reimburse the remaining portion of such
Expense if it otherwise meets the requirements of this Article VIII.
(c) Qualifying IndividuaL "Qualifying Individual" means:
. a Participant's Dependent who is under the age of thirteen (13);
Page 19
. a Participant's Dependent who is mentally or physically incapable of self-
care; or
. a Participant's Spouse who is mentally or physically incapable of self-
care.
(d) Qualifying Dependent Care Services. "Qualifying Dependent Care Services" means the
following services that both (1) relate to the care of a Qualifying Individual that
enable the Participant and his or her Spouse to remain gainfully employed after the
date of participation in the Dependent Care FSA Component and during the Period
of Coverage; and (2) are performed:
. in the Participant's home;
or
. outside the Participant's home for (1) the care of a Participant's Dependent
who is under age 13; or (2) the care of any other Qualifying Individual who
regularly spends at least eight hours per day in the Participant's household. In
addition, if the expenses are incurred for services provided by a dependent
care center (i.e., a facility that provides care for more than six individuals not
residing at the facility and that receives a fee, payment or grant for such
services), then the center must comply with all applicable state and local laws
and regulations.
(e) Exclusion. Dependent Care Expenses do not include amounts paid to:
. an individual with respect to whom a personal exemption is allowable under
Code ~ 151 (c) to a Participant or his or her Spouse;
. a Participant's Spouse; or
. a Participant's child who is under 19 years of age at the end of the year in
which the expenses were incurred.
8.4 Maximum and Minimum Benefits
(a) Maximum Reimbursement Available; Statutory Limitations.
The maximum dollar amount elected by the Participant for reimbursement of
Dependent Care Expenses incurred during a Period of Coverage (reduced by prior
reimbursements during the Period of Coverage) shall only be available during the
Period of Coverage to the extent of the acrual amounts credited to the Participant's
Dependent Care FSA Account pursuant to Section 8.5. Payment shall be made to the
Participant in cash as reimbursement for Dependent Care Expenses incurred during
the Period of Coverage for which the Participant's election is effective, provided that
the other requirements of this Article VIII have been satisfied. Notwithstanding the
foregoing, no payment otherwise due to a Participant hereunder shall exceed the
smallest of.
Page 20
. the year-to-date amount that has been withheld from the Participant's
Compensation for reimbursement for Dependent Care Expenses for the Period of
Coverage, less any prior reimbursements for Dependent Care Expenses incurred
during the Period of Coverage;
. the Participant's Eamed Income for the calendar year;
. the Eamed Income of the Participant's Spouse for the calendar year (a Spouse who
(1) is not employed during a month in which the Participant incurs a Dependent
Care Expense, and (2) is either physically or mentally incapable of self-care or a
Srudent shall be deemed to have Earned Income in the amount of $200 per month
__ per Qualifying Individual for whom the Participant incurs Dependent Care
Expenses, up to a maximum amount of $400 per month); or
. Either (1) $5,000 for the calendar year if one of the following applies:
(A) the Participant is married and f1les a joint return;
(B) the Participant is married, but (1) furnishes more than one-half the cost of
maintaining the Dependent for whom the Participant is eligible to receive
reimbursements under the Dependent Care FSA; (2) the Participant's Spouse
maintains a separate residence for the last six months of the calendar year; and
(3) the Participant f1les a separate tax rerum; or
(C) the Participant is single or is the head of the household for tax purposes;
or
(2) $2,500 for the calendar year if the Participant is married and resides with the
Spouse, but files a separate federal income tax rerum.
(b) Maximum and Minimum Dollar Limits. The maximum annual benefit amount that a
Participant may elect to receive under this Plan in the form of reimbursements for
Dependent Care Expenses incurred in any Period of Coverage shall be the maximum
amount allowed by law (subject to the other limitations described above, and subject to
Section 8A(c)). The minimum annual benefit amount that a Participant may elect to
receive under this Plan in the form of reimbursements for Dependent Care Expenses
incurred in any Period of Coverage shall be $130.00.
(c) Changes, No Proration. For subsequent Plan Years, the maximum and minimum dollar
limit may be changed by the Administrator and shall be communicated to Employees
through the Election Form/Salary Reduction Agreement or other document. If a
Participant enters the Dependent Care FSA Component mid-year, or wishes to
increase his or her election mid-year as permitted under Section 12A, there will be no
proration rule - i.e., the Participant may elect coverage up to the maximum dollar limit
or may increase coverage up to the maximum dollar limit, as applicable.
Page 21
(d) Effict on Maximum Benifits lfElection Change Permitted. Any change in an election under
Article XII affecting annual contributions to the Dependent Care FSA Component
also will change the maximum reimbursement benefits for the balance of the Period
of Coverage (commencing with the election change), as further limited by Section
8A(a). Such maximum reimbursement benefits for the balance of the Period of
Coverage shall be calculated by adding (1) the aggregate premium for the period prior
to such election change to (2) the total premium for the remainder of such Period of
Coverage to the Dependent Care FSA Account, reduced by (3) reimbursements
during the Period of Coverage.
8.5 Establishment of Account
The Administrator will establish and maintain a Dependent Care FSA Account with
respect to each Participant who has elected to participate in the Dependent Care FSA
Component, but will not create a separate fund or otherwise segregate assets for this
purpose. The Account so established will merely be a recordkeeping account with the
purpose of keeping track of contributions and determining forfeirures under Section 8.6.
(a) Crediting of Accounts. A Participant's Dependent Care FSA Account will be credited
periodically during each Period of Coverage with an amount equal to the Participant's
Salary Reductions elected to be allocated to such Account.
(b) Debiting of Accounts. A Participant's Dependent Care FSA Account will be debited
during each Period of Coverage for any reimbursement of Dependent Care Expenses
incurred during the Period of Coverage.
(c) Available Amount Based on Credited Amount. As described in Section 8A, the amount
available for reimbursement of Dependent Care Expenses may not exceed the year-
to date amount credited to the Participant's Dependent Care FSA Account, less any
prior reimbursements; i.e., it is based on the amount credited to the Dependent Care
FSA Account at a particular point in time. Thus, a Participant's Dependent Care FSA
Account may not have a negative balance during a Period of Coverage.
8.6 Forfeiture of Accounts; Use-It-or-Lose-It Rule
If any balance remains in the Participant's Dependent Care FSA Account for a Period of
Coverage after all reimbursements have been made for the Period of Coverage, such
balance shall not be carried over to reimburse the Participant for Dependent Care
Expenses incurred during a subsequent Plan Year. The Participant shall forfeit all rights
with respect to such balance. All forfeirures under this Plan may, at the choice of the
Employer, be used as follows: first, to reduce the cost of administering this Plan during
the Plan Year or the subsequent Plan Year (all such administrative costs shall be
documented by the Administrator); and second, to provide increased benefits or
compensation to Participants in subsequent years in any fashion the Administrator
deems appropriate, consistent with applicable regulations. In addition, any Dependent
Care FSA Account benefit payments that are unclaimed (e.g., uncashed benefit checks)
by the close of the Plan Year following the Period of Coverage in which the Dependent
Care Expense was incurred shall be forfeited and applied as described above.
Page 22
8.7 Reimbursement Procedure
(a) Timing. Within 30 days after receipt by the Administrator of a reimbursement claim
from a Participant, the Administrator will reimburse the Participant for the
Participant's Dependent Care Expenses (if the Administrator approves the claim), or
the Administrator will notify the Participant that his or her claim has been denied.
This time period may be extended for an additional 15 days for matters beyond the
control of the Administrator, including in cases where a reimbursement claim is
incomplete. The Administrator will provide written notice of any extension,
including the reasons for the extension, and will allow the Participant 45 days in
which to complete an incomplete reimbursement claim.
(b) Claims Substantiation. A Participant who has elected to receive Dependent Care FSA
Benefits for a Period of Coverage may apply for reimbursement by submitting an
application in writing to the Administrator in such form as the Administrator may
prescribe, by no later than ninety (90) days following the close of the Plan Year in
which the Dependent Care Expense was incurred, setting forth:
. the person or persons on whose behalf Dependent Care Expenses have been
incurred;
. the nature and date of the Expenses so incurred;
. the amount of the requested reimbursement;
the name of the person, organization or entity to whom the Expense was or is to be
paid, and taxpayer identification number (Social Security number, if an individual); and a
statement that such Expenses have not otherwise been paid and are not expected to be
paid through any other source.
The application shall be accompanied by bills; invoices, or other statements from an
independent third party showing that the Dependent Care Expenses have been incurred
and the amounts of such Expenses, together with any additional documentation that the
Administrator may request. Except for the final reimbursement claim for a Period of
Coverage, no claim for reimbursement may be made unless and until the aggregate
claims for reimbursement is at least $25.
(c) Claims Denied. For reimbursement claims that are denied, see the appeals procedure
in Article X111.
8.8 Reimbursements After Termination
When a Participant ceases to be a Participant as defined under Section 3.2, the
Participant's Salary Reductions will terminate, however the participant may spend down
or use up any remaining account balance to pay for pre-termination eligible expenses
that are incurred during the plan year in which the participant's employment terminated.
Eligible expenses must be submitted prior to the end of the grace period (90 days
following the close of the year.)
Page 23
ARTICLE IX.
HIPAA
9.1. HIPAA Compliance.
The Employer will:
a. not use or further disclose protected health information (PHI) other than as permitted
or required by the plan documents or as required by law;
b. ensure that any agents, including subcontractors, to whom it provides PHI received
from Health Plan agree to the same restrictions and conditions that apply to Plan
Sponsor with respect to such information;
c. not use or disclose PHI for employment-related actions or decisions;
d. not use or disclose PHI in connection with any other benefit or employee benefit plan
or plan sponsor;
e. report to Health Plan's designee any PHI use or disclosure that it becomes aware of
which is inconsistent with the uses or disclosures provided for;
f. make PHI available to an individual based on HIPAA's access requirements;
g. make PHI available for amendment and incorporate any PHI amendments based on
HIPAA's amendment requirements;
h. make available the information required to provide an accounting of disclosures;
1. make its intemal practices, books and records relating to the use and disclosure of PHI
received from the Health Plan available to the Secretary of the U.S. Department of
Health and Human Services to determine the health plan's compliance with HIPAA;
J. ensure that adequate separation between the group health plan and the Employer is
established as required by HIP AA; and
k. if feasible, rerum or destroy all PHI received from the Health Plan that Employer still
maintains in any form and retain no copies of such PHI when no longer needed for
the specified disclosure purpose. If rerum or destruction is not feasible, Employer will
limit further uses and disclosures to those purposes that make the return or destruction
infeasible.
Page 24
ARTICLE X-XI
[RESERVED]
ARTICLE XII.
IRREVOCABILITY OF ELECTIONS: EXCEPTIONS
12.1 Irrevocability of Elections
Except as described in this Article XII, a Participant's election under the Plan is
irrevocable for the duration of the Period of Coverage to which it relates. In other
words, unless an exception applies, the Participant may not change any elections for the
duration of the Period of Coverage regardi1Jg:
. participation in this Plan; or
. Salary Reduction amounts.
12.2 Procedure for Making New Election If Exception to Irrevocability Applies
(a) Timingfor When New Election Must Be Made. A Participant (or an Eligible Employee
who, when first eligible under Section 3.1 or during the Open Enrollment Period
under Section 3.2, declined to be a Participant) may make a new election within 30
days of the occurrence of an event described in Section 12A, as applicable, but only
if the election under the new Election Form Salary Reduction Agreement is made on
account of and is consistent with the event, and the election is made within any
specified time period (e.g., for subsections 12A(4) through (i), within 30 days of the
events described in such subsections).
(b) Effictive Date of New Election. Elections made pursuant to this Section 12.2 shall be
effective for the balance of the Period of Coverage following the change of election
unless a subsequent event allows for a further election change. Except as provided in
Section 12A(e) for HIP AA special enrollment rights in the event of birth, adoption,
or placement for adoption, all election changes shall be effective on a prospective
basis only (i.e., election changes will become effective no earlier than the first day of
eligibility.)
(c) Effict of New Election Upon Amount ofBenifits. For the effect of a changed election upon
the maximum and minimum benefits under the Medical FSA and Dependent Care
FSA Components, see Sections 7A and 8A respectively.
12.3 Change in Status Defined
A Participant may make a new election upon the occurrence of certain events as
described in Section 12.4, including a Change in Status, for the applicable Component.
"Change in Starus" means any of the events described below, as well as any other events
included under subsequent changes to Code ~ 125 or regulations issued thereunder,
which the Employer or designee., in its sole discretion and on a uniform and consistent
basis, determines are permitted under IRS regulations and under this Plan:
Page 25
(a) Legal Marital Status. A change in a Participant's legal marital starus, including marriage,
death of a Spouse, divorce, legal separation or annulment;
(b) Number of Dependents. Events that change a Participant's number of Dependents,
including birth, death, adoption, and placement for adoption;
(c) Emplqyment Status. Any of the following events that change the employment starus of
the Participant or his or her Spouse or Dependents: (1) a termination or
commencement of employment; (2) a strike or lockout; (3) a commencement of or
retum from an unpaid leave of absence; (4) a change in worksite; and (5) if the
eligibility conditions of this Plan or other employee benefit plan of the Participant or
his or her Spouse or Dependents depend on the employment status of that individual
and there is a change in that individual's starus with the consequence that the
individual becomes (or ceases to be) eligible under this Plan or other employee
benefit plan, such as if a plan only applies to salaried employees and an employee
switches from salaried to hourly-paid, union to nonunion, or full-time to part-time
(or vice versa), with the consequence that the employee ceases to be eligible for the
Plan;
(d) Dependent Eligibility Requirements. An event that causes a Dependent to satisfy or cease
to satisfy the Dependent eligibility requirements for a particular benefit, such as
attaining a specified age, Student status, or any similar circumstance; and
(e) Change in Residence. A change in the place of residence of the Participant or his or her
Spouse or Dependents.
12.4 Events Permitting Exception to Irrevocability Rule
A Participant may change an election as described below upon the occurrence of the
stated events for the applicable Component of this Plan:
(a) Open Enrollment Period. (Applies to both Medical FSA and Dependent Care FSA Benifits). A
Participant may change an election during the Open Enrollment Period in
accordance with Section 3.2.
(b) Termination of Emplqyment (Applies to both Medical FSA and Dependent Care FSA
Benifits). A Participant's election will terminate under the Plan upon termination of
employment in accordance with Sections 3.3 and 3A, as applicable.
(c) FMIA (Applies to both Medical FSA and Dependent Care FSA Benifits). A Participant may
change an election under the Plan upon FMLA leave in accordance with Section 3A.
(d) Change in Status (Applies to both Medical FSA Benifits as Limited Below, and Dependent Care
FSA Benifits as Limited Below). A Participant may change his or her actual or deemed
election under the Plan upon the occurrence of a Change in Starus (as defined in
Section 12.3), but only if such election change is made on account of and
Page 26
corresponds with a Change in Starus that affects eligibility for coverage under a plan
of the Employer or a plan of the Spouse's or Dependent's employer (referred to as
the general consistency requirement). A Change in Status that affects eligibility for
coverage under a plan of the Employer or a plan of the Spouse's or Dependent's
employer includes a Change in Starus that results in an increase or decrease in the
number of an Employee's family members (i.e., a Spouse and/ or Dependents) who
may benefit from the coverage. Refer to Exhibit C for specific change is status
elections.
(e) Increase or Decrease for Insignificant Cost Changes. Participants are required to increase
their elective contributions (by increasing Salary Reductions) to reflect
insignificant increases in their required contribution forJheir Benefit Package
Option(s), and to decrease their elective contributions to reflect insignificant
decreases in their required contribution. The Administrator, in its sole discretion
and on a uniform and consistent basis, will determine whether an increase or
decrease is insignificant based upon all the surrounding facts and circumstances,
including, but not limited to, the dollar amount or percentage of the cost change.
The Administrator, on a reasonable and consistent basis, will automatically
effecruate this increase or decrease in affected employees' elective contributions
on a prospective basis.
(1) Limitation on Change in Cost Provisions for Dependent Care FSA Benifits. The
above "Change in Cost" provisions (Sections 12A(h)(I)-(3)) apply to
Dependent Care FSA Benefits only if the cost change is imposed by a
dependent care provider who is not a "relative" of the Employee. For
this purpose, a relative is an individual who is related as described in
Code ~ 152(a)(1) through (B), incorporating the rules of Code ~~
152(b)(1) and (2).
(f) Change in Coverage (Applies to Dependent Care FSA Benifits, but Not to Medical FSA Benifits).
Dependent Care FSA Coverage Changes. A Participant may make a prospective election
change that is on account of and corresponds with a change by the Participant in the
dependent care service provider. For example: (a) if the Participant terminates one
dependent care service provider and hires a new dependent care service provider, the
Participant may Change coverage to reflect the cost of the new service provider; and
(b) if the Participant terminates a dependent care service provider-because a relative
becomes available to take care of the child at no charge, the Participant may cancel
coverage.
12.5 Election Modifications Required by Administrator
The Administrator may, at any time, require any Participant or class of Participants to
amend the amount of them Salary Reductions for a Period of Coverage if the
Administrator determines that such action is necessary or advisable in order to (a) satisfy
any of the Code's nondiscrimination requirements applicable to this Plan or other
cafeteria plan; (b) prevent any Employee or class of Employees from having to recognize
Page 27
more income for federal income tax purposes from the receipt of benefits hereunder
than would otherwise be recognized; (c) maintain the qualified status of benefits received
under this Plan; or (d) satisfy Code nondiscrimination requirements or other limitations
applicable to the Employer's qualified plans. In the event that contributions need to be
reduced for a class of Participants, the Administrator will reduce the Salary Reduction
amounts for each affected Participant, beginning with the Participant in the class who
had elected the highest Salary Reduction amount, continuing with the Participant in the
class who had elected the next highest Salary Reduction amount, and so forth, until the
defect is corrected.
12.6 Overall Limitation on Changes in Contribution Amounts.
No Participant will be allowed to reduce his or her election for a Medical Expense
Flexible Spending Account or Dependent Care Flexible Spending Account to a point
where the total allotment for the Plan Year for such benefit is less than the amount
already reimbursed for that Plan Year. In addition, any change in an election affecting
the Participant's annual allotments to such plans pursuant to this section also will change
the Participant's benefits for the period of coverage remaining in the Plan Year. The
Participant's benefits following an election change will be calculated by adding any
balance (including a negative balance) remaining in the Participant's Medical Expense
Flexible Spending Account or Dependent Care Flexible Spending Account as of the end
of the portion of the Plan Year immediately preceding the change in election, to the total
allotments scheduled to be made by the Participant during the remainder of such Plan
Year to each account, respectively.
Page 28
ARTICLE XIII.
RECORDKEEPING AND ADMINISTRATION
13.1 Administrator
The administration of this Plan shall be under the supervision of the Administrator. It is
the principal duty of the Administrator to see that this Plan is carried out, in accordance
with its terms, for the exclusive benefit of persons entitled to participate in this Plan
without discrimination among them.
13.2 Powers of the Administrator
The Administrator shall have such duties and powers, as it considers necessary or
appropriate to discharge its duties. It shall have the exclusive right to interpret the Plan
and to decide all matters thereunder, and all determinations of the Administrator with
respect to any matter hereunder shall be conclusive and binding on all persons. Without
limiting the generality of the foregoing, the Administrator shall have the following
discretionary authority:
(a) to construe and interpret this Plan, including all possible ambiguities, inconsistencies
and omissions in the Plan and related documents, and to decide all questions of fact,
questions relating to eligibility and participation, and questions of benefits under this
Plan (provided that, notwithstanding the ftrst paragraph in this Section 14.2, the
Committee shall exercise such exclusive power with respect to an appeal of a claim
under Section 14.1);
(b) to prescribe procedures to be followed and the forms to be used by Employees and
Participants to make elections pursuant to this Plan;
(c) to prepare and distribute information explaining this Plan and the benefits under this
Plan in such manner as the Administrator determines to be appropriate;
(d) to request and receive from all Employees and Participants such information as
the Administrator shall from time to time determine to be necessary for the
proper administration of this Plan;
(e) to furnish each Employee and Participant with such reports with respect to the
administration of this Plan as the Administrator determines to be reasonable
and appropriate, including appropriate statements setting forth the amounts by
which a Participant's Compensation has been reduced in order to provide
benefits under this Plan;
(f) to receive, review and keep on f1le such reports and information concerning the
benefits covered by this Plan as the Administrator determines from time to time to
be necessary and proper;
Page 29
(g) to appoint and employ such individuals or entities to assist in the administration of
this Plan as it determines to be necessary or advisable, including legal counsel and
benefit consultants;
(h) to sign documents for the purposes of administering this Plan, or to designate an
individual or individuals to sign documents for the purposes of administering this
Plan;
(i) to secure independent medical or other advice and require such evidence as it deems
necessary to decide any claim or appeal; and
G) to maintain the books of accounts, records, and other data in the manner necessary
for proper administration of this Plan and to meet any applicable disclosure and
reporting requirements.
13.3 Reliance on Participant, Tables, etc.
The Administrator may rely upon the direction, information or election of a Participant
as being proper under the Plan and shall not be responsible for any act or failure to act
because of a direction or lack of direction by a Participant. The Administrator will also
be entitled, to the extent permitted by law, to rely conclusively on all tables, valuations,
certificates, opinions and reports that are furnished by accountants, attorneys, or other
experts employed or engaged by the Administrator.
13.4 Provision for Third-Party Plan Service Providers
The 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. Unless otherwise provided in the service agreement, obligations under this Plan
shall remain the obligation of the Employer.
13.5 Fiduciary Liability
To the extent permitted by law, the Administrator shall not incur any liability for any acts
or for failure to act except for their own willful misconduct or willful breach of this Plan.
13.6 Compensation of Plan Administrator
Unless otherwise determined by the Employer and permitted by law, any 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
then duties shall be paid by the Employer.
13.7 Bonding
The Administrator shall be bonded to the extent required by ERISA.
Page 30
13.8 Insurance Contracts
The Employer shall have the right (a) to enter into a contract with one or more insurance
companies for the purposes of providing any benefits under the Plan; and (b) to replace
any of such insurance companies or contracts. Any dividends, retroactive rate adjustments
or other refunds of any type that may become payable under any such insurance contract
shall not be assets of the Plan but shall be the property of, and be retained by, the
Employer, to the extent that such amounts are less than aggregate Employer contributions
toward such insurance.
13.9 Inability to Locate Payee
If the Administrator is unable to make payment to any Participant or other person to
whom a payment is due under the Plan because it cannot ascertain the identity or
whereabouts of such Participant or other person after reasonable efforts have been made
to identify or locate such person, then such payment and all subsequent payments
otherwise due to such Participant or other person shall be forfeited following a reasonable
time after the date any such payment first became due.
13.10 Effect of Mistake
In the event of a mistake as to the eligibility or participation of an Employee, or the
allocations made to the account of any Participant, or the amount of benefits paid or to be
paid to a Participant or other person, the Administrator shall, to the extent it deems
administratively possible and otherwise permissible under Code ~ 125 or the regulations
issued thereunder, cause to be allocated or cause to be withheld or accelerated, or
otherwise make adjustment of, such amounts as it will in its judgment accord to such
Participant or other person the credits to the account or distributions to which he or she is
properly entided under the Plan. Such action by the Administrator may include
withholding of any amounts due the Plan or the Employer from Compensation paid by the
Employer.
Page 31
ARTICLE XIV.
GENERAL PROVISIONS
14.1 Expenses
All reasonable expenses incurred in administering the Plan are currently paid by forfeitures
to the extent provided in Sections 7.6 and 8.6, and then by the Employer.
14.2 No Contract of Employment
Nothing herein cont~ed is intended to be or shall be construed as constiruting a contract
or other arrangement between any Employee and the Employer to the effect that such
Employee will be employed for any specific period of time. All Employees are considered
to be employed at the will of the Employer.
14.3 Amendment and Termination
This Plan has been established with the intent of being maintained for an indefinite
period of time. Nonetheless, the Employer may amend or terminate all or any part of
this Plan at any time for any reason by decision of the appropriate authority to take such
action.
14.4 Governing Law
This Plan shall be construed. administered and enforced according to the laws of the
State of Florida to the extent not superseded by the Code, ERISA or any other federal
law.
14.5 Compliance with the Code
It is intended that this Plan meet all applicable requirements of the Code and of all
regulations issued thereunder. This Plan shall be construed, operated and administered
accordingly, and in the event of any conflict between any part, clause or provision of this
Plan and the Code, the provisions of the Code shall be deemed controlling, and any
conflicting part, clause or provision of this Plan shall be deemed superseded to the
extent of the conflict.
14.6 No Guarantee of Tax Consequences
Neither the Administrator nor the Employer makes any commitment or guarantee that
any amounts paid to or for the benefit of a Participant under this Plan will be excludable
from the Participant's gross income for federal, state or local income tax purposes. It
shall be the obligation of each Participant to determine whether each payment under this
Plan is excludable from the Participant's gross income for federal, state and local income
tax purposes, and to notify the Administrator if the Participant has any reason to believe
that such payment is not so excludable.
Page 32
14.7 Indemnification of Employer
If any Participant receives one or more payments or reimbursements under this Plan on
a pretax Salary Reduction basis, and such payments do not qualify for such treatment
under the Code, such Participant shall indemnify and reimburse the Employer for any
liability it may incur for failure to withhold federal income taxes, Medicare (if applicable)
taxes, or other taxes from such payments or reimbursements.
14.8 Non-Assignability of Rights
The right of any Participant to receive any reimbursement under this Plan shall not be
alienable by the Participant by assignment or any other method and shall not be subject
to claims by the Participant's creditors by any process whatsoever. Any attempt to cause
such right to be so subjected will not be recognized, except to such extent as may be
required by law.
14.9 Headings
The headings of the various Articles and Sections (but not subsections) are inserted for
convenience of reference and are not to be regarded as part of this Plan or as indicating or
controlling the meaning or construction of any provision.
14.10 Plan Provisions Controlling
In the event that the terms or provisions of any summary or description of this Plan, or of
any other instrument, are in any construction interpreted as being in conflict with the
provisions of this Plan as set forth in this document, the provisions of this Plan shall be
controlling.
14.11 Severability
Should any part of this Plan subsequently be invalidated by a court of competent
jurisdiction, the remainder of the Plan shall be given effect to the maximum extent
possible.
Page 33
IN WITNESS WHEREOF, Employer has caused this Plan to be executed in its name and on
its behalf, on this ~1ctay of October , 200~.
FRINGE BENEFITS MANAGEMENT COMPANY
~ .c->
By: . '\~. -
By: ~~~ {\ ,~~~/, Sr. Vi(l€ ~r6(den('
(Print Name andt'fitle)
~
EMPLOYER
City of Miami Beach
By:
CITY CLE~
BY:~ {Ll~
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
J1 JJ w[},IJ - J ~u1
~
Page 34
EXHIBIT A
NAME AND ADDRESS OF EMPLOYER/PLAN
City of Miami Beach
1700 Convention Center Drive
Miami Beach, FL 33139
305-673-7524
EXHIBIT B
DEFINITION OF EliGIBLE EMPLOYEE
Definition of Eligible Employee for Medical, Dental, Life and Identified Voluntary Benefits:
~ Full time Unclassified employees are eligible to participate on their date of employment. Full
time Classified employees are eligible to participate upon completion of 90 days of
employment.
Definition of Eligible Employee for FSA:
~ Full time Unclassified employees and the Classified group known as
"others" .
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EXHIBIT D
APPEALS PROCEDURES
Procedures If Benefits Are Denied Under This Plan. If (a) a claim for reimbursement under
the Health FSA or DCAP Components of the Plan is wholly or partially denied, or (b) a
Participant is denied a benefit under the Plan (such as the ability to pay for premiums on a pre-
tax basis) due to an issue germane to coverage under the Plan (for example, a determination of:
a Change in Starus; or eligibility and participation matters under the Flexible Benefits Plan
Document), then the clain).s procedure described below will apply.
A. Notification. If a claim is denied in whole or in part, the Participant will be notified in
writing by the Administrator within 30 days of the date the Administrator received the
claim. (This time period may be extended for circumstances beyond the control of the
Administrator, including in cases where a claim is incomplete. The Administrator will
provide written notice of any extension, including the reasons for the extension and the
date by which a decision by the Administrator is expected to be made. Where a claim is
incomplete, the extension notice will also specifically describe the required information,
will allow 45 days from receipt of the notice in which to provide the specified
information, and will have the effect of suspending the time for a decision on the claim
until the specified information is provided.)
B. Notification Requirements. Notification of a denied claim will set out:
. a specific reason or reasons for the denial;
. the specific Plan provision on which the denial is based;
. a description of any additional material or information necessary to validate the
claim and an explanation of why such material or information is necessary;
. appropriate information on the steps to be taken to appeal the Administrator's
decision, including the right to submit written comments and have them
considered, the right to review (upon request and at no charge) relevant
documents and other information, and, if applicable, the right to flle suit under
ERISA with respect to any adverse determination after appeal of the claim.
C. Appeals 1?J Participant. If the claim is denied in whole or part, the Participant (or his or her
authorized representative) may request review upon written application to the
Administrator. The appeal must be made in writing within 180 days of receipt of the
notice that the claim was denied. If the Participant fails to appeal on time, he or she will
lose the right to appeal the denial and the right to f1le suit in court. The written appeal
EXHIBIT D
Page I of2
EXHIBIT D
APPEALS PROCEDURES
should state the reasons that the claim should not have been denied. It should include
any additional facts and/or documents that support the claim. The Participant will
have the opporrunity to ask additional questions and make written comments, and may
review (upon request and at no charge) documents and other information relevant to
the appeal.
D. Decision on Review. The appeal will be reviewed and decided by the Administrator or
other entity designated in the Planin a reasonable time not later than 60 days after the
Administrator receives the request for review. The Administrator may, in its discretion,
hold a hearing on the denied claim. Any medical expert consulted in connection with
the appeal will be different from and not subordinate to any expert consulted in
connection with the initial claim denial. The identity of a medical expert consulted in
connection with the appeal will be provided. If the decision on review affIrms the
initial denial of the claim, the Participant will be furnished with a notice of adverse
benefit determination on review setting forth:
a. the specific reason(s) for the decision on review; and
b. the specific Plan provision(s) on which the decision is based.