HomeMy WebLinkAbout5.E.2. Adoption of Revised Section 125 Cafeteria Plan-Res. No. 6743 s~.z.
City of Shakopee
MEMORANDUM
TO: Mayor and City Council
Mark McNeill, City Administrator 0i'~
FROM: Kris Wilson, Assistant City Administrator~W-''"
SUBJECT: Adoption of Revised Section 125 Plan
DATE: March 14, 2008
Introduction
The Council is asked to adopt the attached Section 125 Cafeteria Plan, which outlines the
employee benefits provided on a pre-tax basis and brings us into compliance with IRS
Regulations.
Background
The City currently provides a number of benefits to our employees on a pre-tax basis.
Employees selecting two-party or family medical and dental insurance pay their share of the
monthly premium through payroll deduction with pre-tax dollars. Employees also have the
option of contributing to a Health Savings Account (HSA), Health Flexible. Spending Account
(FSA) or a Dependent Care Flexible Spending Account through payroll deduction with pre-tax
dollars.
The City currently has a Section 125 Plan in place that was adopted in 1990. A recent training
session attended by our HR Technician Jessica Nikunen stressed the importance of keeping your
.written plan documents up-to-date and noted that the IRS is doing increased enforcement in this
area. The resulting review of our Section 125 plan document suggested it was time to re-write
the document to reflect the City's current benefit offerings and the policies and procedures used
to administer those benefits. The attached document was prepared for us by Alliance Benefit
Group, the company that administers our Health Savings Accounts and Flexible Spending
Accounts.
The document reflects current practice in regards to all of our 125 benefits. This is simply a
matter of making-sure our written documentation is up-to-date with our current benefit offerings
and all IRS regulations.
Relationship to Vision
Ensuring that the City is in compliance with all IRS regulations related to payroll and benefits
contributes to Goal E - a financially strong City.
Budgetary Impact.
None.
Requested Action
The Council is asked to offer Resolution No. 674, a resolution adopting a revised Section 125
Cafeteria Plan for the City of Shakopee, and move its adoption.
RESOLUTION No. 6743
A RESOLUTION ADOPTING A REVISED SECTION 125 CAFETERIA PLAN
FOR THE CITY OF SHAKOPEE
BE IT RESOLVED BY THE CITY COUNCIL OF THE.CITY OF SHAKOPEE,
MINNESOTA, that the City of Shakopee, Minnesota (the "Employer") hereby adopts the
attached City of Shakopee Section 125 Cafeteria Plan as amendedand restated and the attached
Summary Plan Description and declares them both effective retroactively to January 1, 2008. .
BE IT FURTHER RESOLVED, that the duly authorized agents of the Employer are
.hereby authorized and directed to execute and deliver to the Administrator of the Plan, as defined
in the plan document, one or more counterparts of the Plan.
BE IT FURTHER RESOLVED, that the Administrator of the Plan shall be instructed to
take such actions that are deemed. necessary and .proper in order to implement the Plan, and to set
up adequate accounting and administrative procedures to provide benefits under the Plan.
BE IT FURTHER RESOLVED, that the duly authorized agents of the Employer shall act
as soon as possible to notify the employees of the Employer of the adoption of the Cafeteria Plan
by delivering to each employee a copy of the summary description of the Plan in the form of the
Summary Plan Description presented to this meeting,.
BE IT FURTHER RESOLVED, that Resolution No. 3315, 5246, 5404 and all-other
Resolutions in conflict with this resolution are hereby repealed and terminated effective January
1, 2008.
Adopted in adjourned regular session of the City Council of the City of Shakopee,
Minnesota, held this 18th day of March, 2008.
Mayor of the City of Shakopee
ATTEST:
City Clerk
CITY OF SHAKOPEE
SECTION 125 CAFETERIA PLAN
Copyright 2008 SunGard
A!I Rights Reserved
TABLE OF CONTENTS
ARTICLE
DEFINITIONS
ARTICLE II
PARTICIPATION
2.1 ELIGIBILITY ....3
2.2 EFFECTIVE DATE OF PARTICIPATION ..:..............:..................................................................:...:.3
2.3 APPLICATION TO PARTICIPATE .................................................:...........:......................:....................3
2.4 TERMINATION OF PARTICIPATION .........................................:.............:...........:................................3
' 2.5 CHANGE OF EMPLOYMENT STATUS ............................:.:.................................................................3
2.6 TERMINATION OF EMPLOYMENT............: ...:................:................:.............................4
2.7 DEATH .......................................:.............:...................................,....................:.......................4
ARTICLE ill
CONTRIBUTIONS'TO THE PLAN
3.1 EMPLOYER CONTRIBUTION .........................::....:...:...........................................................................4
3.2 SALARY REDIRECTION :...............................:.................................................................:....................4
3:3 APPLICATION OF CONTRIBUTIONS ...................:....:..............................::......:.....:.............................5
3.4 PERIODIC CONTRIBUTIONS...:..........: ...5
ARTICLE IV
BENEFITS .
4.1 BENEFIT OPTIONS: 5
4.2 HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT 5
4.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT ......................:.........:...........,........5
4.4 HEALTH INSURANCE BENEFIT ...............................................:...,..........:.....,.....,...............................5
4:5 DENTAL INSURANCE BENEFIT .........................................................................................6
4.6 HEALTH SAVINGS ACCOUNT BENEFIT ........................................................:....................................6
4.7 CASH BENEFIT .....................................................................:...................................:...........................6
4.8 NONDISCRIMINATION.REQUIREMENTS ..........................................................................................:6
ARTICLE V
PARTICIPANT ELECTIONS
5.1 INITIAL ELECTIONS ................................:..............................................................................._.............7
5.2 SUBSEQUENT ANNUAL ELECTIONS 7
5.3 FAILURE TO ELECT 7
5.4 CHANGE IN STATUS .......................................................................................:....................................7
ARTICLE V1
HEALTH FLEXIBLE SPENDING ACCOUNT
6.1. ESTABLISHMENT OF PLAN .............:.......:......................::....................................:............................10
6.2 DEFINITIONS .............................................................:.................:...................................:..........,....10
6.3 FORFEfTURES .................................:..:.........:..........:.............................:.........:.::.............:............:....11
6.4 LIMITATION ON ALLOCATIONS .......:.....:.............:.....:.....................:...:.........:..........:.....:............11
6.5 NONDISCRIMINAT?ON REQUIREMENTS ........:....:.........:............:...................:.:..............................11
6.6 COORDINATION WITH CAFETERIA.PLAN ................................:.....:................,...:............................11
6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS .......:................,..........:..........:........:................11
ARTICLE Vit
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
7.1 ESTABLISHMENT OF ACCOUNT ...............:.............:...............:......................................................12
7.2 DEFINITIONS .......................:.:....::.....................................:..........................:..........:.......:..................12
7.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS ....................:........:...................................13
7.4 INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING RCCOUNTS .......................:...............13
7.5 .DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS:.......... .............:............13
7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT ......................:....................:.........................13
7.7 ANNUAL STATEMENT OF BENEFITS .............................................................................:.....::.::::.....13
7.8 FORFEITURES ...........:............:..:....:..........................:..................:...................:............:.....:..............14
7.9 LIMITATION ON PAYMENTS .....::...................:.......:..:......................:.................................................14
7.10 NONDISCRIMINATION REQUIREMENTS .....................:...........:.....:........,...................:.:..................14
7.11 COORDINATION WITH CAFETERIA PLAN t4
7.i2 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS.........:.:...: ..................................:..14
ARTICLE VIII
BENEFITS AND RIGHTS
8.1 CLAIM FOR BENEFITS...........: ........................:.......:...................:..........................:...........................15
8.2 APPLICATION OF BENEFIT PLAN SURPLUS.:.........:..:.:........ ....................:.......:...........:.................16
ARTICLE IX
ADMINISTRATION
9.1 PLAN ADMINISTRATION ........................................:.:......................17
9.2 EXAMINATION OF RECORDS .........................................................................................................17
9.3 PAYMENT OF EXPENSES ...:............................................................:..............:.................................17
9.4 INSURANCE CONTROL CLAUSE .............................:...................................:..........:..............:..........17 .
9.5 INDEMNiFICATiON OF ADMINISTRATOR ...................:.....................................:..........:...................18
ARTICLE X
AMENDMENT OR TERMINATION OF PLAN
10.1 AMENDMENT ..............................:.......................................................................................................18
10.2 TERMINATION ................................................................:.............:......:...........................:..................18
ARTICLE XI
MISCELLANEOUS
11.1 PLAN 1NTERPRETATION ....................................................:..................::.:.:......................................18
11.2 GENDER AND NUMBER .................................................:.:...............................:.................................18
11.3 WRITTEN DOCUMENT ..................:.....................................:..............................................................18
11.4 EXCLUSIVE BENEFIT ...:...........:.................18
11.5 PARTICIPANT'S. RIGHTS ......:.....:..,............................:............................................1$
11.6 ACTION BY THE EMPLOYER............::..: .................................19
11.7 ~ EMPLOYER'S PROTECTIVE CLAUSES ................:..:............................:.:..........:.:............................19
11.8 NO GUARANTEE DF TAX CONSEQUENCES.........: ................19
11.9 FNDEMNIFICATION OF EMPLOYER BY PARTICIPANTS:.:.......:.....:...: ............................................19
t1:10 FUNDING.: ..........:..................:............:......:...............:......................................19
11.11 GOVERNING LAW .......:..:.......,.................................::.:.....:....................:.::...................:..................19
11.12 SEVERABILITY........,..:.: ......................................:...............:..:.........:..........:.................................:.....20
1 t.13 CAPTIONS ................:...:...........................:.......................................:..........._......20
. 11.14 CONTINUATION OF COVERAGE (COBRA) ..........:...:............................................................20
11.15 FAMILY AND MEDICAL LEAVE ACT (FMLA)...........:.:...: .......................:..........:................:...............20
11.16 HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) ...:.............................20
11.17 UNIFORM SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) ..............20
11.18 COMPLIANCE WITH HIPAA PRIVACY STANDARDS ........:........:....:..........:...........................20
11.19 COMPLIANCE WITH HIPAA ELECTRONIC SECURITY STANDARDS .............................................22
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CITY OF SHAKOPEE
SECTION 125 CAFETERIA PLAN
INTRODUCTION !
The Employer has amended this Plan effective January 1, 2008, to recognize the contribution '
made to the Employer by its Employees. Its purpose is to reward Them by providing benefits for those
Employees who shall qualify hereunder and their Dependents and beneficiaries. The concept of this Plan is to
allow Employees to choose among different types of benefits based on their own particular goals, desires and
needs. This Plan is a restatement of a Plan which was originally effective on January 1, 1991. The Plan shall
be known as City. of Shakopee Section 125 Cafeteria Plan (the "Plan").
The intention of the Employer is that the Plan qualify as a "Cafeteria Plan" within the meaning
of Section 125 of the Internal Revenue Code of 1986, as amended, and that the benefits which an Employee
elects to receive under the Plan be excludable from the Employee's income under Section 125(a) and other
applicable sections of the Internal Revenue Code of 1.986, as amended.
ARTICLE
DEFINITIONS
1.1 "Administrator" means the individual(s) or.corporation appointed by the Employer to carry
out the administration of the Plan.. The Employer shall be empowered to appoint and remove the Administrator
from time to time as it deems necessary for 4he proper administration of the Plan. In the event the Administrator
has not been appointed, or resigns from a prior appointment, the Empioyer shall be deemed to be the
Administrator.
1.2 "Affiliated Employer" means the Employer and any corporation which is a member of a
controlled group of corporations (as defined in Code Section 414(b)) which includes the Employer; any trade or
business. (whether or not incorporated) which is under common control (as defined in Code Section 414(c)) with
the .Employer; any organization (whether or not incorporated) which is a member of an affiliated service group.
(as defined in Code Section 414(m)) which includes the Employer; and any other entity required to be
aggregated with the Employer pursuant to Treasury regulations under Code Section 414(0).
1.3 "Benefit" or "Benefit Options" means any of the optional benefit choices available to a
Participant as outlined in Section 4.1.
1.4 "Cafeteria Plan Benefit Dollars" means the amount available to Participants to'purchase
Benefit Options as provided under Section 4.1. Each dollar contributed to this Plan shaA be converted into one
Cafeteria Plan Benefit Dollar.
1.5 "Code" means the Internal Revenue Code of 1986, as amended or replaced from time to
time.
1.6 "Compensation" means the amounts received by the Participant from the Employer during a
Plan Year.
1.7 "Dependent" means any individual who qualifies as a dependent under an Insurance
Contract for purposes of that Contract or under Code Section 152 (as modified by Code Section 105(b)).
1.8 "Effective Date" means January 1, 1991.
1.9 "Election Period" means the period immediately preceding the. beginning of each Plan Year
established by the Administrator, such period to be applied on a uniform and nondiscriminatory basis for all
Employees and Participants. However, an Employee's initial Election Period shall be determined- pursuant to
.Section 5.1.
1.10 "Eligible Employee" means any Employee who has satisfied the provisions of Section 2. T.
An individual shall not be an "Eligib(e Employee" if such individual is not reported on the
.payroll records of the Employer as a common law employee. In particular, if is expressly intended that
individuals not treated as common law employees by the Employer on its payroll records are not "Eligible
Employees" and are excluded from Plan participation even if a court or administrative agency determines that
such individuals are common law employees and not independent contractors.
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However, .any Employee who is a "part-time" .Employee shall not be eligible to participate in
this Plan: A "part-time" Employee is any Employee who works, or is expected to work on a regular basis, less
than 30, hours a week .and is designated as a part-time Employee on the' Employer's personnel records.
1.11 "Employee" means any person who is employed by the Employer. The term Employee shall
includeleased employees within the meaning of Code Section 414(n)(2).
1.12 ' "Employer" means City of Shakopee, Minnesota and any. successor which shall maintain this
Plan; and any predecessor which has maintained this Pfan. In addition, where.. appropriate, the term Employer
shall include any Participating, Affiliated or Adopting Employer.
1.13 "Employer Contribution" means the contributions made by the Employer pursuant to
Section 3.1 to enable a Participant to purchase .Benefits. These contributions shall be converted to Cafeteria
Plan Benefit Dollars and allocated to the funds or accounts established under the Plan pursuant to the
Participants' elections made under Article V and as set forth in Section 3.1.
1.14 "Insurance Contract" means any contract issued by an Insurer underwriting a Benefit..
1.15 "Insurance Premium Payment Plan" means the plan of benefits contained in Section 4.1 of
this P{an, which provides for the payment of Premium Expenses.
1.16 "Insurer" means any insurance company that underwrites a Benefit under this Plan.
1.17 "Key Employee" means an Employee described in Code Section 416(1)(1) and the Treasury
regulations thereunder.
1..18 "Participant" means any Eligible Employee who elects to become a Participant pursuant to
Section 2.3 and has not for any reason become.ineligibleto participate further in the Plan.
1.19 "Plan" means this instrument, including al! amendments thereto.
1.20. "Plan Year" means the 12-month period beginning January i and ending December 31. The
Plan Year shall be-the coverage period for the Benefits provided for under this Plan. fn .the event a Participant
commences participation during a Plan Year, then the initial coverage period shalt be that portion of the Plan
Year commencing on such Participant's date of entry and ending on-the last day of such Plan Year.
1.21 "Premium Expenses" or "Premiums" mean the Participant's cost for-the Benefits described
in Section 4.1.
1.22 "Premium .Expense Reimbursement Account" means the account established for a
Participant pursuant to this Plan to which part of his Cafeteria Plan Benefit Dollars may be allocated and from
which Premiums of the Participant shall be paid or reimbursed. If more than one type of insured Benefit is
elected, sub-accounts shall be established for each type of insured Benefit.
1.23 "Salary Redirection" means the contributions made by the Employer on behalf of
Participants pursuant to Section 3.2. These contributions shall be converted to Cafeteria P{an Benefit Dollars
and allocated to the funds or accounts established under the Plan pursuant to the Participants' elections made
under Article V.
1.24 "Salary .Redirection Agreement" means an agreement between the Participant and the
Employer under which the Participant agrees to reduce his Compensation or to forego all or part of the
increases in such Compensation and to have such amounts contributed by the Employer to the Plan on the
Participant's behalf. The Salary Redirection Agreement shall apply only to Compensation that has not been
actually or constructively received by the Participant as of the date of the agreement (after taking this Plan and
Code Section 125 into account) and, subsequently does not become currently available to the Participant.
1.25 "Spouse" means "spouse" as defined in an Insurance Contract for purposes of that Contract
or the legally married husband or wife of a Participant, unless legally separated by court decree.
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.ARTICLE II
.PARTICIPATION
2.1 ELIGIBILITY
Any Eligible Employee shall be eligible to participate hereunder as of the date he satisfies the
eligibility conditions for the Employer's group medical plan, the provisions of which. are specifically incorporated
herein by reference. However, any Eligible Employee who was a Participant in the Plan on the effective date of
this amendment shall continue to be eligible to participate in the Plan. -
2.2 EFFECTIVE DATE OF PARTICIPATION
An Eligible Employee shall become a Participant effective as of the entry date. under the
Employer's group medical plan, the provisions of which are specifically incorporated herein by reference.
2.3 ~ APPLICATION TO PARTICIPATE
An Employee who is eligible to participate in this Plan shall, during the applicable .Election
- Period, complete an application to participate and election of benefits form which the Administrator shall furnish
to the Employee. The election made on such form shall be irrevocable until the end of the applicable Plan Year
unless the Participant is entitled to change his Benefit elections pursuant to Section 5.4 hereof.
An Eligible Employee shall also be requiredto execute'a Salary Redirection Agreement during
the Election Period for the Plan Year during which he wishes to participate in this .Plan. Any such Salary"
Redirection Agreement shall be effective for the first pay. period beginning on or after the Employee's effective.
date of participation pursuant to Section 2.2.
Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who
is covered by the Employer's- insured Benefits. under this Plan shall automatically become a Participant to the
extent of the Premiums for such insurance unless the Employee elects, during the Election Period, not to
participate inthe Plan.
2.4 TERMINATION OF PARTICIPATION
A Participant shall no longer. participate. in this Plan upon the occurrence of any of the
following events:
(a) Termination of employment.-The Participant's termination of employment,
subject to the provisions of'Section 2.6;
(b) Change in employment status.. The end. of the Plan Year during which the
Participant became a limited Participant because of a change in employment status pursuant
to Section 2.5;
(c) Death. The Participant's death, subject to the provisions of Section 2.7; or
(d) Termination of the plan. The termination of this Plan,: subject to the
provisions of Section 10.2.
2.5 CHANGE OF EMPLOYMENT STATUS
If a Participant ceases to be eligible to participate because of a change in employment status.
or classification (other than through termination of employment), the Participant shall become a limited.
Participant in this Plan for the remainder of the Plan Year in which such change of employment status occurs.
As a limited Participant, no further Salary Redirection may be made on behalf of the Participant, and, except as
otherwise provided herein, all. further Benefit elections shall cease, subject to the limited Participant's right #o
continue coverage under any Insurance Contracts. However, any. balances in the limited Participant's
Dependent Care Flexible Spending Account may be used during such Plan Year to reimburse the limited
Participant for any allowable Employment-Related Dependent Care incurred during the Plan Year. Subject to
the provisions of Section 2.6, if the limited Participant later becomes an Eligible Employee, then the limited
Participant may again- become a full Participant in this Plan, provided he otherwise satisfies the participation
requirements set forth in this Article LI as if hE were a new Employee -and made an election in accordance with
Section 5.1.
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2.6 TERMINATION OF EMPLOYMENT
If a Participant's employment with the Employer is terminated-for any reason other than death,
his participation in the Benefit: Options provided under Section 4.T shall be governed in accordance with the
following:
(a) Insurance Benefit..With regard to Benefits. which -are insured, the -
Participant's participation in the Plan shall cease, subject to the Participants right to continue
coverage under any Insurance. Contract for which premiums have already been paid.
(b) Dependent Care FSA. With regard to the.. Dependent Care Flexible
Spending Account, the Participant's participation in the Plan shall cease and no further Salary
Redirection- contributions shall be made. However, .such. Participant may submit claims for
- employment related Dependent Care Expense reimbursements for claims incurred through
.the remainder of the-Plan Year in which such termination occurs and submitted within 90 days
. after the end of the Plan Year, based on the level of the Participant's Dependent Care Flexible
,Spending Account as of the date of termination.
(c) COBRA applicability. With regard to the Health Flexible Spending Account,
the Participant may submit claims for expenses that were incurred during the portion of the
Plan Year before the end of the period for which payments to the Health Flexible Spending
.Account have already been. made. Thereafter, the health benefits under this Plan including the
Health Flexible. Spending Account shall be applied and administered consistent with such
further rights a Participant and his Dependents may be entitled to pursuant to Code Section
49808 and Section 11..14 of the Plan.
2.7 DEATH
If a Participant dies, his participation in .the Plan shall cease. However, such Participant's
spouse or Dependents may. submit claims for expenses or benefits for the remainder of the Plan Year or until
he Cafeteria .Plan Benefit Dollars allocated to ..each specific benefit are exhausted. In no event. may
reimbursements be paid to someone who is not a spouse or Dependent. If the Plan is subject to the provisions
of Code Section 49806, then those provisions. and related regulations shall apply for. purposes of the Health
Flexible Spending Account..
ARTICLE III
CONTRIBUTIONS TO THE PLAN
3.1 EMPLOYER CONTRIBUTION
The Employer .shall make .available to each Participant an Employer 'Contribution to the
Participant's Health. Savings Account in an amount to be determined by the Employer prior to the beginning of
each Plan Year.. Each Participant's Employer Contribution shall be converted to Cafeteria Plan Benefit Dollars
and be available to purchase Benefits asset forth above. The Employer's Contribution shall be made available
at the beginning of the Plan Year. If no Benefits are selected, there shall be no Employer Contribution.
3.2 SALARY REDIRECTION
If a Participant's Employer Contribution is not sufficient to cover .the cost of Benefits or
:Premium Expenses he elects pursuant to Section 4.1, his Compensation will be reduced in an amount equal to
the difference between the cost of Benefits he elected and the amount of Employer Contribution available to
him. Such reduction shall be his Salary Redirecfion, which the Employer will use on his behalf, together with his
Employer Contribution,. to pay for the Benefits he elected. The amount of such Salary Redirection shall be
specified in the Salary. Redirection Agreement and shall be applicable for a Plan Year. Notwithstanding the
above, for new Participants, the Salary Redirection Agreement shall only be applicable from the first day of the
pay. period following. the Employee's entry date up to and .including the last day of the Plan Year. These
contributions shall be 'converted to Cafeteria Plan Benefit Dollars and allocated to the .funds or accounts
established under the Plan pursuant to the Participants' elections made under Article V and as set forth in
Section 3.1.
Any Salary Redirection shall be determined prior to the beginning of a Plan Year (subject to
initial elections pursuant to Section 5.1) and prior to the .end of the Election Period and shall be irrevocable for
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such Plan Year. However, a Participant may revoke a Benefit election or a Salary Redirection Agreement after
the Pian Year has commenced and make a new election with respect to the remainder of the Plan Year, if both
the revocation and the new election are on account of and consistent with a change in status and such other
permitted events as determined under Article V of the Plan and consistent with the rules and. regulations of the
Department of the Treasury. Salary Redirection amounts shall be contributed on a pro rata basis for each pay.
period during the Plan Year. All individual Salary Redirectioh Agreements are deemed to be part of .this Plan
and incorporated by reference hereunder.
3.3 APPLICATION OF CONTRIBUTIONS
As soon as reasonably practical after each .payroll period, the Employer shat( apply .the
Employer Contribution and Salary Redirection to provide the Benefits .elected by the affected Participants. Any
contribution made or withheld for the Health Flexible Spending Account or Dependent Care Flexible Spending
Account shalt be credited to such fund or account. Amounts designated-for the Participant's Premium Expense
Reimbursement Account shall .likewise be credited to such account for the purpose of paying Premium
Expenses.
3.4 PERIODIC CONTRIBUTIONS
.Notwithstanding the requirement provided above and in other Articles of this Pian that Salary
Redirections be contributed to the Plan by the Employer on behalf of an Employee on a level and pro rata basis
for :each payroll period, the .Employer and Administrator may implement a procedure in which Salary
Redirections are contributed- throughout the Plan Year on a periodic basis. that is not pro rata for each payroll
period. However, :with regard to the Health Flexible Spending Account, the payment schedule for the required
contributions may not be based on the rate or amount of reimbursements during the Plan Year.
ARTICLE IV
..:BENEFITS
4.1 BENEFIT OPTIONS
Each Participant. may elect any one or more of .the following optional Benefits:
(1) Health Flexible Spending Account
(2) Dependent Care Flexible Spending Account
(3) Health Savings Account Benefit
In addition, except for the Health .Savings Account Benefit, each Participant shall have a
sufficient portion of his Employer Contributions and Salary Redirections applied to the following Benefits unless
the Participant elects not to receive such Benefits:
(4) Health. Insurance Benefit
(5) Dental Insurance Benefit
4.2 HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT
-Each Participant may elect to participate in the. Health Flexible Spending Account option, in
which case Article VI shall apply.
4.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT
Each Participant may elect to participate in the Dependent Care .Flexible Spending Account
optioh, in which case Article VII shall apply.
4.4 HEALTH INSURANCE BENEFIT
(a) Coverage for AarEicipant and Dependents. Each Participant may elect to
be covered under a health Insurance Contract for the Participant, his or her Spouse, and his
or her Dependents.
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(b) Employer selects contracts. The Employer may select suitable health
Insurance Contracts for use in providing this health insurance benefit, which policies will
provide uniform benefits for all Participants electing this Benefit:
(c) Contract incorporated by reference. The rights and conditions with respect
to the benefits payable from such health Insurance. Contract shall be determined therefrom,
- and such Insurance Contract shall be incorporated herein by reference.
4.5 DENTAL MSURANCE BENEFIT
(a) Coverage for Participant and/or Dependents. Each Participant may elect
to be covered under the .Employer's dental Insurance Contract for the .Participant, his or her
Spouse, and his or her Dependents.
(b), Employer selects contracts. The Employer may select suitable dental
Insurance Contracts for use in-providing this- dental insurance: benefit, which policies .will
provide uniform benefits for all Participants electing this Benefit.
(c) Contract incorporated by reference. The rights and conditions with respect
to the benefits payable from such dental Insurance Contract shall be determined therefrom,
and such dental Insurance Contract shall be incorporated herein by reference.
4.6 HEALTH SAVINGS ACCOUNT BENEFIT
Each Participant may elect to have a portion of his Salary Redirections contributed to a Health
Savings Accouht, as defined in Code Section 223. In addition, Participants electing. coverage under the Health
Savings Account will receive an Employer Contribution to such account.. The amounts contributed shall be
subject to the terms of'the Health Savings Account as established.
4.7 CASH BENEFIT
Ifi a Participant does not elect any Salary Redirections, such Participant shall be deemed to
have chosen the Cash Benefit as his sole Benefit'Option. However, ~if a Participant fails to make any election of
Benefit Option, then the Employer Contribution will be deemed to be waived.
4.8 NONDISCRIMINATION REQUIREMENTS
(a} Intent to be nondiscriminatory. It is the intent of this Plan to .provide
berefits to a classification of employees which the Secretary of the Treasury finds not to be
discriminatory in favor of the group in whose favor discrimination may not occur under Code
Section 125.
(b) 25% concentration test. It is the intent of this Plan not to provide qualified
benefits as defined under Code Section 125 to Key Employees in amounts that exceed 25%
of the aggregate of such Benefits provided for all Eligible Employees under the Plan. For
purposes of the preced+ng sentence, qualified benefits shall not include benefits which
(without regard to this paragraph) are includible in gross income.
(c) Adjustment to avoid test failure. If the Administrator deems it necessary to
avoid discrimination or possible taxation to Key Employees or a group of employees in whose
`favor discrimination may not occur in violation of Code Section .125, it may, but shall not be
required to, reduce contributions or non-taxable .Benefits in order to assure compliance with
this Section. Any act taken bythe Administrator under this Section shall be carried out in a
uniform and nondiscriminatory manner. If the Administrator. decides to reduce contributions or
non-taxable Benefits, it shat{ be done in the following manner. First, the non-taxable Benefits
of the affected Participant (either an employee. who is highly compensated or a Key
Employee, whichever is applicable) who has the highest amount of non-taxable Benefits for
.the Plan Year shall have his. non-taxable Benefits reduced until the discrimination tests set
..forth in this Section are satisfied or until the amount of his non-taxable Benefits equals the
non-taxable Benefits of the affected Participant who has the. second highest amount of
non-taxable Benefits. This process shall continue until the nondiscrimination tests set forth in
this Section are satisfied. With respect to any affected Participant who has had Benefits
reduced pursuant to this Section, the reduction shall be made proportionately among. Health
6
Flexible Spending Account Benefits and Dependent Care Flexible Spending Account Benefits,
and once all these Benefits are expended, proportionately among insured Benefits..
Contributions which are not utilized to provide Benefits to any Participant by virtue of any
administrative act under this paragraph. shall be forfeited and deposited into the benefit plan
surplus.
ARTICLE V
PARTICIPANT ELECTIONS
5.1 .INITIAL ELECTIONS
An Employee who meets the eligibility requirements of Section 2.1 on the first day ot, or
during, a Plan Year may elect to participate in this Plan for all or the remainder of such Plan -Year, provided he
elects to do so on or before his effective date of participation .pursuant to Section 2.2.
:Notwithstanding the foregoing, an Employee who•is eligible to participate in this Plan arid who
is covered by the. Employer`s insured benefits under this Plan shall automatically become a Participant to the
extent of the Premiums #or such insurance unless the Employee elects, during the Election Period, not to
participate in the Plan.
5.2 SUBSEQUENT ANNUAL ELECTIONS
During the Election Period. prior to each subsequent Plan Year, each Participant shall be
given the. opportunity to elect, on an election of benefits form to be provided by the Administrator, which.
spending account Benefit options he wishes to select. Any such election shall be effective-for .any Benefit
expenses incurred during the Plan Year which .follows the end of ahe Election Period. With regard to
subsequent annual elections; the following options shall apply:
(a) A Participant or Employee who. failed to initially elect to .participate may elect.
different. or new Benefits under the Plan during the Election Period;
{b) A Participant may terminate his participation in the Plan by notifying the
Administrator in writing during the Election Period that he does not want fo participate in the
Plan for the next Plan Year;
(c) An .Employee who elects not to participate for the Pfan Year following the
Electioh Period will have to wait until the next Election Period before- again electing to
participate in the Plan, except as provided for in Section 5.4.
5.3 FAILURE TO ELECT
With regard to Benefits available under the Plan for which no Premium Expenses apply, any
Participant who fails to complete a new benefit election form pursuant to Section 5.2 by the end of the
applicable Election Period shall be deemed to have elected not to participate in the Plan for the upcoming Plan
.Year. No further. Salary Redirections shall therefore be authorized or made for the subsequent Plan Year for
such Benefits.
With regard to .Benefits available under the Plan for which Premium Expenses apply,. any
Participant who fails to complete a new. benefit election form pursuant to Section 5.2 by the end of the
applicable Election Period shall be deemed to have made the same Benefit elections as are then in effect for
the current Plan Year. 1"he Participant shall also be deemed to have elected Salary. Redirection in an amount.
necessary to purchase such Benefit options.
5.4 CHANGE IN STATUS
(a} Change in status defined. Any Participant may change a Benefit election
after the Plan Year. (to which such election relates) has commenced and make new elections
with respect to the remainder of such- Plan Year if, under the facts and circumstances, the
changes. are necessitated by and .are consistent with a change in status which is acceptable
under rules and regulations adopted by the Department of the Treasury, the provisions of which
are incorporated by reference. Notwithstanding anything herein to the contrary, if the rules and
regulations conflict, then such rules and regulations shall control
7
In general,. a change in electioh is not consistent if the .change. in status is .the
Participant's. divorce, annulment or legal. separation. from a Spouse, the death of a Spouse or
Dependeht, or a Dependent ceasing to satisfy the eligibility requirements for coverage, and the
Participant's election under the .Plan is to cancel accident or health insurance coverage for any.
individual other than the one involved in such event. In .addition, if the Participant, Spouse or
Dependent gains or loses' eligibility for coverage, then a Participant's election under the Plan to
cease or decrease coverage for that individual .under the Plan correspohds with that change in
status only if coverage for that individual becomes applicable or is increased under the family
member plan.
Regardless of the consistency requirement, if.the individual, the individuaPs Spouse, or
Dependent becomes eligible for continuation coverage under the Employer's group health plan
as provided in Code Section 49808 or any similar state law, then the individual may elect to
increase payments under this Plan in order to pay for the continuation coverage. However, this
does not apply for COBRA eligibility due to divorce, annulment or legal separation.
Any new election shall be effective at such time as the Administrator shall prescribe, but
not earlier than the first pay period beginning after the election form is completed and returned to
the Administrator. For the purposes of this subsection, a change in status shall only include the
following events or other events permitted by Treasury regulations:
(1) Legal Marital Status: events that change a Participant's legal marital status,
including marriage, divorce, death of a Spouse, {egat separation or annulment;
(2) :Number of Dependents: Events that change a Participant's number of
Dependents, including .birth, adoption, .placement for adoption, or death of a
Dependent;
(3) Employment .Status: Any of the following events that change the employment
status ' of the :Participant, Spouse, or Dependent: termination or commencement of
employment, a strike or lockout; commencement or return from an unpaid leave of
..absence, or a change in worksite. In addition, if he eligibility conditions of this Plan or
.other. employee benefit plan ofi the Employer of the Participant, Spouse, or Dependent
`depend on the employment status of that individual and there is a change in that
individual's employment status with the consequence that the individual becomes (or
ceases to be) eligible under the plan, then that change constitutes a change in
employment under this subsection;
(4) Dependent satisfies or ceases to satisfy the eligibility requirements: An event
that- causes the Participant's Dependent to satisfy or cease to satisfy the requirements
for coverage due to attainment of age, student status, or any similar circumstance; and
(5) Residency: A change in the place of residence of the Participant, Spouse or
Dependent, that would lead to a change in status (such as a loss of HMO coverage).
For the Dependent Care Flexible Spending Account, a Dependent becoming or ceasing
to be a "Qualifying Dependent" as defined under Code Section 21 (b) shall also qualify as a
change in status..
(b) Special enrollment rights. Notwithstanding subsection (a), the Participants
may change an election for accident or health coverage during a Plan Year and make a new
election that corresponds with the special enroNment rights provided in Code Section 9801(f).
Such change shall take place on a prospective basis, unless otherwise required by Code
Section 9801 (f) to be retroactive.
(c) Qualified Medical Support Order. Notwithstanding subsection (a), in the
event of a judgment, decree, or order (including approval of a property settlement) ("order")
resulting from a divorce, legal separation, annulment, or change in legal custody which
- requires accident or health coverage for a Participant's child (including a foster child who is a
Dependent of the .Participant):
{i) The Plan may change an election to provide coverage for the child if the order
requires coverage under the Participaht's plan; or
8
(2) The Participant shall be permitted to change an election to cancel coverage
for the .child if the 'order requires the .former Spouse to provide coverage for such
child, under that individual's plan and- such coverage is actually provided.
(d) Medicare or Medicaid. Notwithstanding subsection (a), a Participant may
change elections to cancel accident or health coverage for the Participant or the Participant's
Spouse or Dependent if the Participant or the Participant's Spouse or Dependent is enrolled in
the accident or health coverage of the Employer and becomes entitled to coverage (i.e.,
enrolled) under Part A or Part 6 of the Title XVlll of the Social Security .Act (Medicare) or Title
XIX of the Social Security Act (Medicaid), other than coverage consisting solely. of benefits under
Section 1928 of the Social Security Act (the program for distribution of pediatric vaccines). ff the
Participant or the Participant's Spouse or Dependent who has been .entitled to Medicaid or
Medicare coverage loses e(igibifity, that individual may prospectively elect coverage under. the
Plan if a benefit package option under the Plan provides similar coverage;
(e) Cost increase or decrease. If the cost of a Benefit provided under the.Plan
increases or decreases during a Plan Year, then the Plan shall automatically increase or
decrease, as the case may be, the -Salary Redirections of all affected Participants for such
.Benefit. Alternatively, if the cost of a .benefit package option increases. significantly,. the
Administrator shall permit the affected Participants to either make corresponding. changes in
...their payments or revoke their elections. and, in lieu thereof, .receive on a prospective basis
,:coverage. under another. benefit package option with similar coverage, or drop. coverage
prospectively,if there is no benefit package option with similar coverage.
A cost increase or decrease refers to an increase or decrease in the .amount of
elective' contributions .under .the Plan, whether resulting from .an action taken by the
Participants or an action taken bythe,Employer.
(f) Loss of coverage. If-the coverage under a Benefit is significantly curtailed
or ceases during a Plan Year, .affected Participants may revoke their; elections of such Benefit
and,. in lieu thereof, -elect to receive: on a prospective basis coverage under another plan with
similar coverage., ordrop-coverage prospectively if no similar coverage is offered.
(g) Addition of a new benefit. If, during the, period of coverage, a new benefit
.package option or other coverage option is added, an existing 'benefit package .option is
significantly improved, or an existing benefit package option or .other coverage option is
eliminated, then the affected Participants may elect the. newly-added option, or elect another
option if an option has been eliminated prospectively..and make corresponding election
'changes-with respect to other benefit package options providing similar coverage. In addition,
those Eligible Employees who are not participating in the Plan may opt to become Participants
and elect the new or newly improved benefit package option.
(h) Loss of coverage under certain other plans. A Participant may make.a
prospective election change to add group health coverage for the Participant, the Participant's
Spouse or Dependent if such individual loses group- health .coverage sponsored by a
governmental or educational institution, including a state children's health insurance program
under the Social Security. Act, the Indian .Health Service or a health program offered by an
Indian .tribal government, a state health benefits risk pool,. or a foreign government group
health plan..
{i) Change of coverage due to change under .certain other plans. A
Participant may make a prospective election change that is do account of and corresponds
with a change made under the plan of a :Spouse's, former Spouse's or Dependent's employer
if (1) the cafeteria plan or other benefits plan of the Spouse's, former Spouse's or Dependent's
employer, permits its participants to make a change; or (2) the cafeteria .plan .permits
participants to make an election for a period of coverage that. is different from the period of
coverage under the cafeteria plan of a Spouse's, former Spouse's or Dependent's employer.
Q) Change in dependent care provider. A Participant may make a
prospective election change that is on account of and corresponds. with a change. by the
Participant in the dependent care. provider. The availability of dependent care services from a
new childcare provider is similar to a new benefit package option becoming available. A cost
change is allowable in the Dependent Care Flexible Spending Account only if the cost change
9
is imposed by a dependent care provider who is not related to the Participant, as defined in
:Code Section 152(a)(1) through (8).
(k) Health FSA cannot change due to insurance<change. A Participant shall
not be permitted to change an election to the Health Flexible Spending Account as a result of a
cost or coverage change under any health insurance benefits.
{I) Health Savings Account changes. With regard to .the' Health Savings
Account Benefit specified in Section. 4.6, a Participant who has.. elected to make elective
contributions under such arrangement may modify or revoke the election prospectively,
provided such change is consistent with Code Section: 223 and the Treasury regulations
thereunder.
ARTICLE VI
.HEALTH FLEXIBLE SPENDING ACCOUNT
6.1 ESTABLISHMENT OF PLAN
:This Health Flexible Spending Account is intended to qualify as a medical reimbursement plan
under Code Section 105 and shall be interpreted in a manner consistent with such Code Section and the
Treasury regulations thereunder. Participants who elect to participate in this Health Flexible Spending Account
may submit claims for the reimbursement of Medical Expenses. All amounts reimbursed shall be periodically
.paid from amounts .allocated to the Health Flexible Spending Account.- Periodic payments reimbursing
Participants fromthe Health Flexible Spending Account shall in no event occurlessfrequently than monthly.
6.2 DEFINITIONS
For the purposes of this Article and the Cafeteria Plan, the terms below have the following
meaning:
(a) "Health Flexible Spending Account" means the account established for
Participants pursuant to this Plah to which part of their Cafeteria Plan Benefif Dollars may be
allocated and from which all allowable Medical Expenses incurred by a Participant, his or her
Spouse and his or her Dependents may be reimbursed.
(b) "Highly Compensated Participant" means, for the purposes of this Article
and determining. discrimination under Code Section 105(h), a participant who is:
(1) one of the 5 highest paid officers;
(2) a shareholder who owns (or is considered to own applying the rules of Code
Section 318) more than 10 percent in value of the stock of the Employer; or
(3) among the highest paid 25 percent of all Employees (other than exclusions
permitted by. Code -Section 105(h)(3)(B) for those individuals who are not
Participants).
(c) "Medical Expenses" means any .expense. for medical care within the
meaning of the term. "medical care" as defined in :Code Section 213(d) and as allowed under
Code Section 105 and the rulings and Treasury regulations thereunder, and not otherwise
used by the Participant as a deduction in determining his tax liability under the Code. "Medical
Expenses" can be incurred by the Participant, his or her Spouse and his or her Dependents.
A Participant who .contributes to a Health Savings Account may only be reimbursed
for medical expenses that are considered to be for dental, vision and/or "preventative care" or
other expenses as allowed under Code Section 223.
A Participant may not be reimbursed for the cost of other health coverage such as
premiums paid under plans maintained by the employer of the Participant's Spouse or
individual policies maintained by the Participant or his Spouse or Dependent.
A Participant may not be reimbursed for "qualified long-term care services" as defined
in Code Section 7702B(c).
10
(d} The definitions of Article I are. hereby incorporated by referehce to the extent
necessary to interpret ahd apply the provisions of this Health_Flexible Spending Account.
8.3 FORFEITURES "
The amount inthe Health Flexible Spending Account as of the end of any Plan Year (and after
the processing of all claims for such Plan Year pursuant to Section 6.7 hereof) shall be forfeited and credited to
the benefit plan surplus. In such event, the Participant shalt have no further .claim to such amount. for any
reason, subject to Section 8.2:
6.4 LIMITATION ON ALLOCATIONS
Notwithstanding any provision contained in this Health Flexible Spending Account to the
contrary, no more than $2,000 may be allocated to the Health Flexible Spending`Account by a Participant in or
on account of any Plan Year.
6.5 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory, it is the intent of this Health Flexible
Spending Account not to discriminate in violation of the Code and, the Treasury. regulations
thereunder.
(b) Adjustment to avoid test failure. If the Administrator deems it necessary to
avoid discrimination. under this Health Flexible Spending Account, it .may, but shall not. be
required to, reject any elections-or reduce contributions or Benefits in order to .assure.
compliance with this Section.- Any. act taken by the Administrator under this Section shall be
.carried out in a uniform and. nondiscriminatory manner. If the Administrator decides to reject
any elections or reduce. contributions or Benefits,-it shall,be done in the following manner..
first, the Benefits designated for the Health Flexible Spending Account by the member of the
group in whose favor discrimination may not occur pursuant to Code Section 105 that elected
to contribute he highest amount o ..the fund for the. Plan Year shall. be reduced until the
nondiscrimination tests set forth in'this Section or the Code are satisfied, or until the amount
designated for the fund equals the amount designated for the fund by the next member of the
group in whose favor discrimination-may not occur pursuant to Code Section 105 who has
elected the second highest contribution to the Health Flexible-Spending Account for the Plan
Year. This process shall continue until the nondiscrimination tests set forth in this Section or
the -Code are satisfied. Contributions which are not utilized to .provide Benefits to any
Participant by virtue of any administrative act under this paragraph shall be forfeited and
credited to;the benefit plan. surplus..
6.6 COORDINATION WITH CAFETERIA PLAN
All Participants under the Cafeteria Plan are eligible to receive Benefits under this Health
Flexible Spending Account. The enrollment under the Cafeteria Plan .shall .constitute enrollment under: this
Health Flexible Spending Account. In ..addition, other matters concerning contributions, elections and the like
shall be governed. by the general provisions of the Cafeteria Plan.
6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS
(a) Expenses must be ,incurred during Plan Year. All Medical Expenses
incurred by a Participant, his or her Spouse and his or her Dependents shall be reimbursed
during the Plan Year subject to Section 2.6, even though the submission of such a claim
occurs after his participation hereunder ceases; but provided that the Medical Expenses were
incurred during the applicable Plan Year. Medical Expenses are treated as having been
incurred when the Participant is provided with the medical care that gives rise to the medical
expenses, not when the Participant is formally billed or charged for, or pays for the medical
.care.
(b) Reimbursement available throughout Plan Year. The Administrator shall
direct the reimbursement to each eligible Participant for all allowable Medical Expenses, up to
a maximum of the amount designated by the .Participant for the Health Flexible Spending.
Account for the Plan Year. Reimbursements shall be made available to the .Participant
throughout the year without regard to the Jevel of Cafeteria Plan Benefit Dollars which have
11
-been allocated to the fund at any given. point in time: Furthermore, a Participant shall be
entitled to reimbursements. only for ..amounts in excess of any payments or other
reimbursements under any health care plan covering the Participant and/or his Spouse or .
Dependents:
°(c) Payments. Reimbursement payments under this Plan shall be made directly
to the Participant. The application for, payment or reimbursement. shall be made to the
Administrator on ari acceptable form within a reasonable time of incurring the debt or paying
for the service. The application shall include a written statement from an independent third
party stating that the Medical Expense has been incurred and the amount of such expense.
Furthermore, the Participant shall provide a written statement that the Medical.. Expense has
not been reimbursed or is not. reimbursable .under any other health .plan coverage and, if
reimbursed from the Health Flexible Spending Account, such amount will not be claimed as a
tax deduction. The Administrator shall retain a file of all such applications:
(d) Claims for reimbursement. Claims for .the reimbursement of Medical
Expenses incurred in `any Plan Year shall be paid as soon after a claim has been filed as is
administratively practicable; provided however, that if a Participant fails to submit a claim
within 90 days after the end of the Plan Year, those Medical Expense claims shall not be
consideredfor reimbursement by the Administrator.
ARTICLE VII
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
7.1 _ESTABtISHMENT OF ACCOUNT
This Dependent Care Flexible Spending Account is intended to qualify as a program under
Code Section 129 and shall be interpreted in a manner consistent with such Code Section. Participants who
elect to .participate in this program may submit :claims for the reimbursement of Employment-Related
Dependent Care Expenses. All amounts reimbursed shall be paid from amounts allocated to the Participant's
Dependent Care Flexible Spending Account.
7.2 DEFINITIONS
For the purposes of this Article and the .Cafeteria Plan the terms below shall have the
following meaning:
(a) "Dependent Care Flexible Spending Account" means the accounf
established for a Participant pursuant to this Articleto which part of his Cafeteria Plan Benefit
Dollars. maybe allocated and from which Employment-Related Dependent Care Expenses of
the Participant may be reimbursed for the. care of the Qualifying Dependents of Participants.
(b) "Earned Income" means earned income as defined under Code Section
32(c)(2), but .excluding such amounts paid or incurred by the Employer for dependent care
assistance to the Participant.
(c) "Employment-Related .Dependent Care Expenses" means the amounts
paid. for expenses df a Participant for those services which. if paid by the Participant would be
considered employment related expenses under Code Section 21(b)(2). Generally, they shall
include expenses for household services and for the care of a Qualifying Dependent, to the
extent that such expenses are incurred to enable the Participant to be gainfully employed for
any period for which there are one or more Qualifying .Dependents with respect to such
..Participant. Employment-Related Dependent. Care Expenses are treated as having been
incurred when the Participant's Qualifying Dependents are provided with the dependent care
that gives ..rise to the Employment-.Related .Dependent Care Expenses, not when the
Participant is formally billed or charged for, or pays for the dependent care. The determination
of whether an amount qualifies as an Employment-Reiated Dependent Care Expense shall be
made subject to the following rules:
(1) If such amounts are paid .for expenses incurred outside the Participant's
household, .they .shall constitute .Employment-Related Dependent Care Expenses
only if incurred for a Qualifying Dependent. as defined in Section 7.2(d)(1) (or deemed
12
to be, as described in Section 7.2(d)(1) pursuant to Section 7.2(d)(3)),"or for a
Qualifying Dependent as defined in .Section 7.2(d)(2) (or deemed to be, as described
in Section 7.2(d)(2) pursuant to Section-7.2(d)(3)) who regularly. spends at least 8
hours per. day in the Participant's household;
(2) If the expense is incurred outside the :Participant's home at a facility that
provides care for a fee, payment; or grant for .more than 6 individuals who do not
regularly reside... at the facility, the facility must comply with all applicable state. and
local laws and regulations, including licensing requirements; if any; and
(3) Employment-Related .Dependent Care Expenses of a Participant shall not
inciude amounts paid or incurred to a child of such Participant who is under the age
of 19 or to an individual who is a Dependent of such Participant or such.Participants
Spouse.
(d) "Qualifying Dependent" means, for Dependent Care Flexible. Spending.
Account purposes,
(1) a Participant's Dependent (as defined in Code Section.152(a)(1)) who has
not attained age 13;
(2) a Dependent or the .Spouse of a Participant who is physically or mentally.
incapable of caring for himself or herself and has the same principaF place of abode
as the Participant for more than one-half of such taxable year; or
(3) a child that is deemed to be a Qualifying Dependent described in paragraph
(1) or (2) above, whichever is appropriate, pursuant to Code Section 21(e)(5).
{e) The definitions of Article I are hereby incorporated py reference to the extent
necessary to ihterpret and- apply the provisions of this. Dependent. Care Flexible Spending.
Account.
7.3 DEPENDENT CAREPLEXIBLE SPENDING ACCOUNTS
The Administrator, shall establish a Dependent Care Flexible Spending Account- for each
Participant who elects to apply Cafeteria Plan Benefit Dollars'to Dependent Care Flexible Spending Account
benefits..
7.4 INCREASESIN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
A Participant's Dependent Care .Flexible Spending Account shall be increased each pay
period by the portion of Cafeteria Plan Benefit Dollars that he has elected to apply toward his Dependent Care
Flexible Spending Account pursuant#o elections made under Article V_hereof.
7.5 DECREASES 1N DEPENDENT CARE fLEXIBtE SPENDING ACCOUNTS
A Participant's Dependent Care Flexible Spending Account shall be reduced by the amount of
any Employment-Related Dependent Care Expense reimbursements paid or incurred on behalf of a Participant
pursuant to Section 7.12 hereof.
7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT
Subject to limitations contained in Section 7.9 of this Program, and to the extent of the amount
contained in the Participant's Dependent Care .:Flexible Spending. Account,. a .Participant who incurs
Employment-Related Dependent Care Expenses shall be entitled to receive from the Employer full
reimbursement for the entire amount of such expenses incurred during the Plan Year or portion thereof during
which he is a Participant.
7.7 ANNUAL STATEMENT OF BENEFITS -
On or before January 31st of each calendar year, the Employer shall furnish to each
Employee who was a Participant and received benefits under Section 7.6 during the prior calendar year, a
statement of all suchbenefits-paid to or on behalf of such Parficipantduring the prior calendar year.
13
7.8 FORFEITURES
The amount in a Participants Dependent Care .Flexible Spending Account as of the end of
any Pian_Year (and after the processing of .all claims for such Plan Year pursuant to Section 7.12 hereof) shall
be forfeited and credited to the benefit plan surplus: In such event, the. Participant shall. have no furtherciaim to
such amount for any,reason. '
7.9 LIMITATION ON PAYMENTS
Notwithstanding any provision contained ih this. Article to the contrary, amounts paid from a
Participant's Dependent Care Flexible Spending Account in or on account of any taxable year of the Participant
shall not exceed the lesser of the Earned Income. limitation described in Code Section 129(b) or $5,000 ($2,500
if a separate tax return is filed by a Participant who is married as determined under the rules of paragraphs (3)
and (4) of Code Section 21(e)).
..7.10 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory.. It is the intent of this Dependent Care
Flexible Spending Account that contributions or benefits not. discriminate in favor of the group
of employees irrvvhose favor discrimination may not occur under Code Section 129(d).
(b) 25% test for shareholders. It is the intent of this Dependent Care Flexible
:Spending Account that not more than 25 percent of the amounts paid by the Employer for
dependent care assistance during the Plan Year will be provided for the class of individuals
who are shareholders or owners (or their Spouses or Dependents), each of whom (on any day
of the Plan'Year) owns more #han 5 percent of the stock or of the capital or profits interest in
-the Employer.
(c) Adjustment to avoidtest failure. If the'Administrator deems it necessary to
avoid discrimination or possible .taxation to a -group of employees in whose favor
discrimihation may not occur irr violation of Code-Section 129 it may, but shall not be required
to, reject any elections or reduce contributions or non-taxable benefits in order. to assure
compliance with this Section. Any act taken by the Administrator under this Section shall be
carried out in a uniform andnondiscriminatory manner. If the Administrator decides to reject
any elections or reduce contributions or Benefits, it shall be done in the following manner.
first, the Benefits. designated for the .Dependent Care :Flexible Spending Account by the
affected Participant that elected to contribute the. highest amount to such account for the Plan
-Year shall be reduced until the nondiscrimination tests set forth in this Section are satisfied, or
until the amount designated for the account equals the amount designated for the account of
-the affected Participant who has elected the second highest contribution to the Dependent
:Care Flexible Spending Account for the Plan Year. This process shall continue until the
nondiscrimination tests set forth in his Section- are satisfied. Contributions which are not
utilized to provide Benefits to any Participant by virtue of any administrative act under this
paragraph shall be forfeited.
7.11 COORDINATION WITH CAFETERIA PLAN
All Participants underthe Cafeteria Plan are eligible to receive Benefits under this Dependent
Care Flexible Spending Account. The enrollment and termination of .participation under the Cafeteria Plan shall
constitute enrollment and termination,of participation under this Dependent Care Flexible Spending. Account. In
`addition, other matters-concerning .contributions, elections and .the like shall be governed by the general
provisions of the Cafeteria Plan:.
7.12 , DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS
The Administrator. shat( .direct the payment of all such Dependent Care claims to the
Participant upon the presentation. to the Administrator of documentation of such .expenses in a form satisfactory
to the Administrator. However,. in the Administrator's discretion, .payments may be made directly to the service
provider. In its discretion in administering the Plan, the Administrator may utilize forms and require
documentation of costs as may be necessary to verify the claims submitted. At a minimum, -the form shall
include a statement from an independent third party as proof that the expense has been :incurred and the
amount of such expense. In addition, the Administrator may require .that each .Participant who desires to
receive reimbursement-under this .Program for Employment-Related Dependent Care Expenses submit a
statement which may contain some or all of the following information:
14
(a) The Dependent or Dependents for whom the services were .performed;
(b) The nature of the services performed for the Participant, the cost of which he
swishes reimbursement;
(c) The relationship, if any, of the` person. performing the services to the
Participant;
(d) If the services are being. performed by a child of the Participant, the age of
the child; _
(e) A statement as to where the services were performed;
(f} If any of the services were performed outside the home, a statement as to
. whether the Dependent for whom such services were performed spends at least 8 hours a
day in the Participants household; -
(g) If the services were being performed in a day care center, a statement:
(1} that the day care center complies with all applicable laws and regulations of
the state of residence;
(2) that the day care center provides. care for. more than 6 individuals (other than.
individuals- residing at the. center), and
(3) of the amount of fee paid to the provider.
(h) -1f the Participant is married, a statement containing the following:
{1) the Spouse's salary or wages if he or sheds employed, or
{2) if the Participant's .Spouse is not employed, that
(i) ~he or she is incapacitated, or
(ii) he or she is a full-time student attending an educational
institution. and the .months during the year which he or she attended such
institution..
- (i) Claims for reimbursement. If a Participant fails to submit a claim within 90
days after the end of the Plan Year, those claims shall nofi be considered for reimbursement
by the Administrator.
ARTICLE VIII
BENEFITS AND RIGHTS
8.1, CLAIM FOR BENEFITS
(a) Insurance claims. Any .claim for Benefits underwritten by Insurance
Contract(s) shall be made to the Insurer. If the Insurer deniesany claim, the'Participant or
beneficiary shall follow the Insurer's claims review procedure.
{b) Dependent Care Flexible Spending Account or Health Flexible
Spending Account claims. Any claim for Dependent Care Flexible Spending Account or
Health Flexible Spending Account Benefits shall be made to the Administrator. For the Health
Flexible Spending Account, if a Participant fails to submit a claim within 90 days after the end
of the. Plan Year, those claims shall not be considered for reimbursement by the
Administrator, For the Dependent Care Flexible Spending Account, if a Participant fails to
submit a claim within 90 days after the end of the. Plan Year, those claims shall not be
considered for reimbursement by the Administrator. If the .Administrator denies a claim, the
Administrator may provide notice to the Participant or beneficiary, in writing, within 90-days
after the claim is filed unless special circumstances. require an extension of time for.
15
_processingthe claim. The notice of a denial of a claim shall be written ih a manner calculated
to be understood by the. claimant and shall set forth::
(1) specific references. to the pertinent Plan provisions on which the denial is
.based;
(2) a description of any additional- material or information .necessary for the
claimant to .perfect the claim and an explanation as to why ouch .information is
°necessary; and .
(3) 'an explanation of the Plan's claim procedure.
(c) Appeal Within 60 days after receipt of the above material, the claimant shall
have a reasonable opportunity to appeal the claim. denial to the Administrator for a full and fair
review. The claimant or his duly authorized represehtative may:
(1) request a review upon written notice to the Administrator;
(2) review pertinent documents; and
(3) submit issues and comments ih writing.
(d) Review ofi appeal. A decision on the review by the Administrator will be
made not1ater than 60 days after receipt of a request for review, unless special circumstances
require an extension of time for..processing (such as the need to hold a hearing), in which
event a decision should be rendered as soon. as possible, but in no event laterthan 120 days
-after such receipt. The decision. of the Administrator shall be written and shall include specific
.reasons for the decision, written in a manner calculated to be understood by the claimant, with
specific references to the pertinent Plan provisions'on which the decision is based.
(e) Forfeitures. Any balance remaining in the Participant's .Dependent Care
Flexible Spending Account or Health. Flexible: Spending Account as of the end of the #ime for
claims reimbursement for each Plan Year shall be forfeited and deposited in the benefit plan
surplus of the .Employer. pursuant to Section`6:3 or Section 7.8, whichever is applicable,
unless the Participant had made a claim for such Plan Year, in writing, which has been denied
or is .pending; in which .event the amount of the claim shall be held in his. account until the
claim appeal procedures set?orth above. have been satisfied or the claim is paid. If any such
claim is denied on appeal, the amount held beyond the end of the Plan Year shalt be forfeited.
and credited to the benefit plan surplus.
S.2 APPLICATION OF BENEFIT .PLAN SURPLUS
Any forfeited amounts credited to the 'benefit .plan surplus by virtue of the failure of a
Participant to incur a qualified expense or seek reimbursement in a timely manner may, but heed not be,
separately accounted for after the close of the Plan Year (or after. such further time specified herein for the filing
of claims) in which such forfeitures arose. In no event shall such amounts be carried over to reimburse a
Participant for expenses incurred :during a subsequent Plan Year for'the same or any other Benefit available
..under the Plan; nor shall amounts forfeited by a particular Participant be made available to such Participant in
:any other form or manner, except as permitted by Treasury regulations. Amounts in the benefit plan surplus
shall be used to defray any administrative costs and experience losses or used to provide additional benefits
under the Plan. No amounts attributable-to the Health Savings Account shall be subject to the benefit plan
surplus.
16
.ARTICLE IX
ADMINISTRATION
9.1 PLAN ADMINISTRATION
The .operation of the Plan shall be under the supervision of the Administrator. It shall be a
principal duty of the Administrator to see that the Plan is carried out in accordance with its Perms, and for the
exclusive .benefit of Employees entitled to participate in the Plana The Administrator shall have .full... power to
administer the Plan in -all of .its details, subject, however, to thee pertinent provisions of the Code. The
Administrator's powers shall include, but shall not be limited to the following authority, in addition to all other
powers provided by this Plan:
(a) To make and enforce such rules and regulations as the Administrator deems
necessary: or proper for the efficient .administration of the Plan;
(b) To interpret the Plan, the Administrator's interpretations thereof in good faith
to be final and conclusive on all persons claiming benefits by operation of the Plan;
(c) To decide all questions concerning the Plan and the eligibility of any person
to participate in the Plan and to receive benefits provided by operation of the Plan;
(d) To reject elections or to limit .contributions or Benefits for certain highly
compensated participants if it deems such to be desirable in order.#o avoid discrimination
under the Plan in violation of applicable. provisions otthe Code; -
(e) To `provide Employees with a .reasonable notification of their :benefits
available by operation of the-Plan;
(f) To approve reimbursement requests and to authorize.. the payment of
benefits;
_ (g) To appoint such. agents, counsel, accountants, consultants, and actuaries as
may be required to assistin administering the Plan.
Any. procedure, discretionary-act, interpretation or construction taken by the Administrator
-shall be done in a nondiscriminatory manner based upon uniform principles consistently applied and shall be
.consistent with .the intent that the Plan shall contiriue to .comply with. the terms of Code Section 125 and the.
Treasury regulations thereunder.
9.2 EXAMINATION. OF RECORDS
"The Administrator shall make available to each Participant, Eligible Employee and any other
Employee' of the Employer such records as pertain to their interest under the Plan -for examination, at
reasonable times during normal business hours.
9.3 PAYMENT OF EXPENSES
Any reasonable administrative expenses shall be paid by the Employer unless the Employer
determines that administrative. costs shall be borne by the Participants under the Plan or by any Trust Fund
which may be established hereunder. The Administrator may impose reasonable conditions. for payments,
providedthat such conditions shall not discriminate in favor of highly compensated employees.
9.4 INSURANCE CONTROL CLAUSE
In the event of a conflict between the terms of this Plan and the terms of an Insurance
Contract of an independent third party insurer whose product is then being used in conjunction with this Plan,
the terms of the Insurance Contract shalt control as to those Participants receiving coverage'-under such
Insurance Contract.. For this purpose, the Insurance Contract shall control in defining the persons eligible for
insurance, the dates of their eligibility, the conditions which must be satisfied to become insured, if any, he
benefits Participants are entitled to and the circumstances under which insurance terminates.
17
9.5 INDEMNIFICATION DF ADMINISTRATOR
The Employer agrees to indemnify and to defend to the"fullest extent permitted by law any
Employee serving as the Administrator or as a member of a committee designated as Administrator (including
any Employee orformer Employee who previously served as Administrator or as a member. of such committee)
against all liabilities, damages, costs and expenses (including attorney's fees and amounts paid in settlement of
any claims approved by the Employer) .occasioned by any actor omission. to act in connection with the Plan, if
such. act-or omission is in good faith.
ARTICLE X
.AMENDMENT OR TERMINATION OF-PLAN.
10.1 `...AMENDMENT
- The Employer, at any time or from time to time, may amend any or all of the provisions of the
Plan without the consent of any Employee or `Participant. No amendment shall have the .effect. of modifying any
":benefit election of any Participant in effect at the time of such amendment, unless such amendment is made to
comply with. Federal, state orlocal laws, statutes or regulations.
10.2 TERMINATION
The Employer is establishing this Plan with the intent that it will be maintained for an indefinite
period of time. Notwithstanding the foregoing, the Employer reserves the right to terminate this Plan, in whole
or in part, at any time. In the event the Plan is #erminated, no further .contributions shall be made. Benefits
under any Insurance Contract shall be paid in accordance with the terms of the Insurance Contract.
No further additions shall be made to the Health Flexible Spending Account or Dependent
Care Flexible.Spending Account; but all payments from such fund shall continue to be made according to the
elections in effect until 90 days after the termination date of the Plan. Any amounts remaining in any such fund
or account as of the end of such period shall be forfeited and deposited in the benefit plan surplus after the
expiration of the filing period.
ARTICLE XI
MISCELLANEOUS
11.1 PLAN INTERPRETATION
All provisions of this Plan shall be interpreted-and applied in a uniform, nondiscriminatory
manner. This Plan shall be read in its entirety and not severed except as provided in Section 11.12.
_11.2 GENDER AND NUMBER
Wherever any words are used herein in the masculine, feminine or neuter gender, they shall
be construed as though they were also used in another gender in all cases where they would so apply, and
whenever any words are used herein in the singular or plural form, they shall be construed as though they were
also used in the other form in all cases where they would so apply.
11.3 WRITTEN DOCUMENT
This Plan, in conjunction with any'separate written document which may be required bylaw, is
intended to satisfy the written Plan requirement of Code Section 125 and any Treasury regulations thereunder
relating to cafeteria plans.
:11.4 EXCLUSIVE BENEFIT .
This Plan shall be maintained forthe exclusive benefit of the Employees who participate in the.
Plan.....
11.5 PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute an employment contract between the Employer
and any Participant or to be a consideration or an inducement .for the employment of any Participant or
_ _ 18
Employee. Nothing contained in this. Plan shall be deemed to give any Participant,or-Employee the right to be
retained in the service of the Employer or to interfere with the right of he Employer to discharge .any Participant
or Employee-at any time regardless of the effect which such discharge shall have upon him as a Participant of
this Plana
11.6 ACTIONBY THE:EMPLOYER '
Whenever the Employer under the terms of the Plan is permitted or required to do or perform
any act or matter or thing, it shall be done and performed by a person duly authorized by its legally constituted
authority.
T1 :7 EMPLOYER'S"PROTECTIVE CLAUSES
(a) Insurance purchase.. Upon the failure of either the Participant or the
Employer to .obtain the insurance contemplated by .this Plan (whether as a result of
negligence, gross. neglect or otherwise), the Participant's Benefits shall' be limited to the
- insurance premium(s), if any, that remained unpaid for the period irr question and the actual
insurance proceeds, if any, .received by the Employer or the Participant as a result of the-
Participant's claim.
(b) Validity of insurance contract. The Employer shall not be responsible for
the validity. of any Insurance Contract issued hereunder or for the failure on the-part of the
.Insurer to make payments provided for under any Insurance Contract Once insurance is
applied for or obtained, the Employer shall not be liable for any. loss which may result from the
failure to pay Premiums to the extent Premium .notices are not received by the Employer..
11.8 NO GUARANTEE OF TAX CONSEQUENCES
Neither the 'Administrator nor the. Employer makes-any commitment or guarantee that any
amounts paid to or for the beriefit of a Participant under the-Plan will be excludable from the Participant's gross
income for federal or state income tax purposes, or that any other federal or state tax treatment will apply to .or
be available to -any Participant. It shall be the obligation of each Participant to determihe whether each payment
under the Plan is excludable from the Participant's gross income for federal and state income tax. purposes,
and to notify the Employer if the Participant has reason to believe that any such payment is not so excludable.
_ Notwithstanding the foregoing, the rights of Participants-under this Plan: shall be legally enforceable.
11.9 INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS
If any Participant receives one or more payments or reimbursements under the Plan that are
not for a permitted Benefit, such Participant shall indemnify,and reimburse the Employer for any liability it may
incur for failure to withhold federal or state income tax or Social .Security tax from .such payments or
reimbursements. However, such indemnification and reimbursement shah. not exceed the amount of additional
federal and state income tax {plus any .penalties) that the Participant would have owed if :the payments or
reimbursements had been made to the Participant as regular cash compensation, plus the Participant's share
of any Social Security tax that would have been paid on such compensation, -less any such additional income.
..and Social Security tax actually paid by the Participant.
11.10:.. FUNDING
Unless otherwise required by law, contributions to the Plan need not be placed in trust or '
dedicated to a specific Benefit, but may instead be considered general assets of the Employer. Furthermore,
and unless otherwise required by law, nothing .herein shall be construed to require the Employer or the
Administrator.to maintain any fund or segregate any .amount for the: benefit of any Participant, and no
Participant or other person shall have any claim against, right to, or security or other interest in, any fund,-
account or asset of the Employer. from .which any payment under the Plan may. be .made..
11.11 GOVERNING LAW
Thin Plan is governed by the Code .and the Treasury regulations issued thereunder (as they
might be amended from dime to time). In no event shall .the Employer;guarantee the favorable tax treatment
sought by this Plan. To the extent not preempted by Federal law, the provisions of this Plan shall be construed,.
enforced and administered according to the laws of the State of Minnesota.
19'
-11.12 SEVERABILITY
If any provision of the Plan is held invalid. or unenforceable, its invalidity or unenforceability
shall -not affect any other ,provisions of the Plan, and the -Plan shall be construed and enforced as if such
provisionhad not been included herein.;
11.13 CAPTIONS
The captions contained herein are inserted only as a matter ofi convenience and fior reference,
and in no way define, limit, enlarge or describe the scope or intent of the Plan, nor. in any way shall affect the
Plan orthe cohstruction of any provision thereof.
11.14 CONTINUATION OF COVERAGE (COBRA)
Notwithstanding anything in the Plan to the contrary,. in the event any benefit under this Plan
subject to the `continuation coverage requirement of Code Section 4980B becomes unavailable, each
.Participant will be entitled to continuation .coverage as prescribed in Code Section 49808, and. related
regulations. If during the Plan Year,,-the Employer employs fewer than twenty (20) employees on a typical
business day, this Section shall not apply.
11.15 FAMILY AND MEDICAL LEAVE ACT (FMLA)
Notwithstanding anything in the Plan to the contrary, ih the event any benefit under this Plan
becomes subject to .the requirements of the Family and Medical Leave Act and regulations thereunder, this
Plan shall be operated in accordance with Regulation 1.125-3.
11.16 HEALTH INSURANCE PORTABILITY'AND ACCOUNTABILITY ACT (HIPAA)
Notwithstanding anything in this Plan to the contrary, this Plan shall be operated in accordance
with: HIPAA and regulations thereunder.
11.17 UNIFORM SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)
.Notwithstanding any provision of this.Plan to the contrary, contributions, benefits and service '
credit with respect to qualified military. service shall be provided in .accordance -with the Uniform Services
Employment-And Reemployment Rights Act (USERRA) and the regulations thereunder.
11.18 :COMPLIANCE WITH HIPAA PRIVACY STANDARDS
(a) Application. If the Health Flexible Spending Account under this Cafeteria
Plan is subject to the Standards for Privacy of Individually Identifiable Health Information (45
CFR Part 164, the "Privacy Standards"), then this Section shall apply.
(b) Disclosure of PHI. The Plan shall not disclose Protected Health Information
to any member of the Employer's workforce unless each of the conditions set out in this
Section are met. "Protected Health. Information" shall have the same definition as set forth in
the Privacy Standards but generally-shall mean individually identifiable information about the
...past, .present or future physical or mental health or condition of an individual, including
information about treatment or payment for treatment.
(c) PHI-disclosed for administrative purposes. Protected Health Information
disclosed to members of the Employer's workforce shall be used or disclosed by them only for
purposes of Plan administrative functions. The .Plan's administrative functions shall include all
Plan payment functions and health care operations. The terms. "payment" and "health care
operations"shall have the same definitions asset out-in the Privacy Standards, but the term
"payment" generally shall mean activities taken to determihe or fulfill. Plan responsibilities with
respect to eligibility,<coverage, provision of benefits, or reimbursement for health care.
(d) PHI disclosed to certain workforce members. The Plan shall disclose
Protected Health Information only to members of the Employer's workforce who are
authorized to .receive such Protected Health Information, and only to the extent and in the
minimum amount necessary fior that-person to perform his or her duties with respect to the
Plan. "Members of the Employer's workforce" shall refer to all employees and other persons
20
j
i
under the control of the Employer. The Employer shalt keep an updated list of those
authorized to receive Protected Health Information.
(1) An authorized member of the Employer's workforce who receives Protected
Health Information shall use or disclose the Protected Health Information only to the
extent necessary to perform his or her duties with respect to the Plan.
(2) In the event that any member of the Employer's workforce uses or discloses
Protected Health Information other than as permitted by this Section and the Privacy
Standards, the incident shall be reported to the Plan's privacy officer. The privacy,
officer shall-take appropriate action, including::
(i) investigation of the incident to determine whether the breach
occurred inadvertently, through negligence ordeliberately; whetherthere is a
pattern of breaches; and the degree of harm caused by the breach;
(ii) appropriate sanctions against .the persons causing the breach
which, depending upon the nature of the breach, may include oral or written
..reprimand, additional training, or termination of employment;
(iii) mitigation of any harm caused by the breach, to the extent.
practicable; and
{iv) documentation of the .incident and all actions taken to resolve
the issue and mitigate any damages.
(e) Certification. The Employee must provide certification: to the Plan that. it
agrees to:
(1) Not use or further disclose the information other than as permitted or
required by the Plan documents or as required by law;
(2) Ensure that any agent or subcontractor, to whom it provides `Protected
Health Information. received from the Plan, agrees to the same restrictions and
conditions that apply to the Employer with respect to such information;
' (3) Not use or disclose Protected Health `Information for employment-related.
actions and decisions or in connection with any other benefit or employee benefit
-plan of the Employer;
(4) Report to the Plan .any use or disclosure. of the Protected Health Information
of which it becomes aware that is inconsistent with the uses or disclosures permitted
by this Section, or required bylaw;
(5) Make available Protected Health Information to individual Plan members in
accordance with Section 164.524 of the Privacy Standards;
(6) Make available Protected Health Information for amendment by individual
Plan members and incorporate any amendments to Protected Health Information in
accordance with Section 164.526 of the Privacy Standards;
(7) Make available -the Protected Health Information required to provide an
.accounting of disclosures to individual Plan members in accordance with
Section 164:528 of the Privacy Standards;
(8) Make its internal practices, books and records relating to the use. and
..disclosure of Protected Health Information received from the Plan available to the
Department of Health and Human Services for purposes of determining compliance
by,the Plan with the Privacy Standards;
(9) If feasible, return or destroy all Protected Health Jnformation received from
the Plan that the .Employer still maintains in any form; and retain no copies of such
information when no longer needed for the purpose-for which disclosure was made,
except: that, if such return or destruction _is not feasible, Iimif further uses and
21
disclosures to those purposes that make the. return or destruction of the information
infeasible; and -
(10) Ensure the adequate separation between the Plan and members of the
Employer's workforce, as required by -Section 164.504(f)(2)(iii) of the Privacy
Standards and set out in (d) above.
11.19 COMPLIANCE WITH HIPAA ELECTRONIC SECURITY.STANDARDS
Under the Security Standards for-the Protection of Electronic .Protected Health Information (45 CFR
Part 164.300 et, seq., the "Security Standards"):
(a) Implementation. The Employer agrees to implement reasonable and
appropriate .administrative, physical .and technical safeguards to protect the confidentiality,
integrity and availability of Electronic Protected Health Information that the Employer creates,
maintains or transmits on behalf of the .Plan.."Electronic Protected Health Information" shall
have the same definition as sef out in the Security Standards, but generally shall mean
Protected Health Information that is transmitted by or maintained in electronic media..
(b) Agents or subcontractors shall meet security standards. The Employer
shall ensure .that any agent or subcontractor to whom it provides Electronic Protected Health
Information shall agree, in writing; to implement reasonable and appropriate security
measures to protect the Electronic Protected Health Information..
(c) Employer shall ensure security standards. The Employer shall ensure
-chat reasonable and appropriate security measures are implemented to comply with the
conditions and requirements set forth in Section 11.18.
IN 'WITNESS WHEREOF, this .Plan document is hereby executed this day of
2008.
City of Shakopee, Minnesota
By
WITNESS AS TO EMPLOYER EMPLOYER
22
ADOPTING RESOLUTION
The undersigned Principal of City of Shakopee, Minnesota (the Employer) hereby certifiesthat
the followingresolutions were duly adopted by the Employerand made effective. on January`1, 2008, and that
.such resolutions~have not been modified or rescinded as of the date hereof:
- RESOLVED, that the form of amended Cafeteria Plan including a Dependent Care Flexible
Spending Account and Health Flexible Spending Account effective January 1, 2008, presented to this meeting
is hereby approved and adopted and that the duly authorized agents of the Employer are hereby authorized
and directed to execute-and deliver to the Administrator of the-Plan one or more counterparts. of the Plan.
RESOLVED, that the Administrator shall be instructed to take such actions that are deemed
necessary and proper in order to implement the Plan,: and to setup adequate accounting and administrative
procedures to provide benefits under the Pian. .
RESOLVED, that the duly authorized agents of the Employer shall act as soon as possible to
notify the employees of the Employer of the adoption of the Cafeteria Plan by delivering to each employee a
copy of .the summary description of the Plan in the form of the Summary Plan Description presented to this
.meeting, which form is hereby approved.
The undersigned further certifies: that attached hereto. as Exhibits A and 6, respectively, are
true copies of City of Shakopee Section 125 Cafeteria Plan as amended and restated and the Summary Plan
Description approved and adopted in the foregoing resolutions.
.Principal
Date;
CITY OF SHAKOPEE
SECTION 125 CAFETERIA PLAN
SUMMARY PLAN DESCRIPTION
January, 2008
.TABLE OF CONTENTS
. ELIGIBILITY
1. When can I become a participant in the plan? ...............................................................................................1
2. What are the eligibility requirements for our Plan? .........................................................................................1
3. When is my entry date? ............................................................:..............................................................:......1
4. Are there any employees who are not eligible? 2
5. What must I do to enroll in the Plan? 2
II
OPERATION
1. How does this Plan operate? .........................................................................................................................2
III
CONTRIBUTIONS
1. How much of my pay may the Employer redirect? .........................................................:...............................2
2. How much will the Employer contribute each year? .......................................................................................2
3. What happens to contributions made to the Plan?...........: ..................................................................:..........2
4. When must I decide which accounts I want to use? ..................................................:....................................2
5. When is the election period for our Plan? 3
6. May I change my elections during the Plan Year? ....................................................................................:....3
7. May I make new elections in future Plan Years? ............................................................:..............................4
IV
BENEFITS
1. What benefits are available? .........................:................................................................................................4
2. May I direct Plan contributions to my Health Savings Account? ....................................................................5
V
BENEFIT PAYMENTS
1. When will I receive payments from my accounts? .........................................................................................5
2. What happens if I don't spend all Plan contributions during the Plan Year? ..................................................5
3. Family and Medical Leave Act (FMLA) 6
4. Uniformed Services Employment and Reemployment Rights Act .................................:...............................6
5. What happens if I terminate employment? ........................................:............................................................6
6. Will my Social Security benefits be affected? .....................................:..........................................:............:...6
VI
HIGHLY COMPENSATED AND KEY EMPLOYEES
1. Do limitations apply to highly compensated employees? 7
VII
PLAN ACCOUNTING
1. Periodic Statements .......................................................................................................................................7
VIII
GENERAL INFORMATION ABOUTOURPLAN
1. General Plan Information ...............................................................................................................................7
2. Employer Information ..................................................................................................................................:..7
3. Plan Administrator Information .......................................................................................................................7
4. Service of Legal Process 8
5. Type of Administration 8
6. Claims Submission .........................................................................................................................................8
IX
.ADDITIONAL PLAN INFORMATION
1. Claims Process ..............................................................................................................................................8
X
CONTINUATION COVERAGE RIGHTS UNDER COBRA
1. What is COBRA continuation coverage? 9
2. Who can become a Qualified Beneficiary? 9
3. .What is a Qualifying Event? ...........................................................................................................................9
4. .What factors should be considered when determining to elect COBRA continuation coverage? ................10
5. What is the procedure for obtaining COBRA continuation coverage? .........................................................10
6. What is the election period and how long must it last? ................................................................................10
7. Is a covered Employee or Qualified Beneficiary responsible for informing the Plan Administrator of
the occurrence of a Qualifying Event? .........................................................................................................11
8. Is a waiver before the end of the election period effective to end a Qualified Beneficiary's-election
rights? ...........................................................................................................................................................12
9. Is COBRA coverage available if a Qualified Beneficiary has other group health plan coverage or
Medicare? .....................................................................................................................................................12
10. When may a Qualified Beneficiary's COBRA continuation coverage be terminated? ..................................12
11. What are the maximum coverage periods for COBRA continuation coverage? 13
12. Under what circumstances can the maximum coverage period be expanded? 13
13. How does a Qualified Beneficiary become entitled to a disability extension? ..............................................13
14. Does the Plan require payment for COBRA continuation coverage? ..........................................:................13
15. Must the Plan allow payment for COBRA continuation coverage to be made in monthly
installments? .:.....................:........................................................................................................................14
16. What is Timely Payment for COBRA continuation coverage? 14
17. Must a Qualified Beneficiary be given the right to enroll in a conversion health plan at the end of
the maximum coverage period for COBRA continuation coverage? .....................................:......................14
18. How is my participation in the Health Flexible Spending Account affected? ................................................14
CITY OF SHAKOPEE
SECTION 125 CAFETERIA PLAN
INTRODUCTION
We have amended the "Flexible Benefits Plan" that we previously established for you .and other
eligible employees. Under this Plan, you will be able to choose among certain benefits that we make available.
The benefits that you may choose are outlined in this Summary Plan Description. We will also tell you about
other important information concerning the amended Plan, such as the rules you must satisfy before you can
join and the laws that protect your rights.
One of the most important features of our Plan is that the benefits being offered are generally ones
that you are already paying for, but normally with money-that has first been subject to income and Social
Security taxes. Under our Plan, these same expenses will be paid for with a portion of your pay before Federal
_ -
income or Social Security taxes are withheld. This means that you will pay less tax and have more money to
spend and-save.
Read this Summary Plan Description carefully so that you understand the provisions of our amended
Plan and the benefits you will receive. This SPD describes the Plan's benefits and obligations as contained in
the legal Plan document, which governs the operation of the Plan. The Plan document is written in much more
technical and precise language. If the non-technical language in this SPD and the technical, legal language of
the Plan document conflict, the Plan document always governs. Also, if there is a conflict between an insurance
contract and either the Plan document or this Summary Plan Description, the insurance contract will control. If
you wish to receive a copy of the legal Plan document, please contact the Administrator.
This SPD describes the. current provisions of the Plan which are designed to comply with applicable
legal requirements. The Plan is subject to federal laws, such as the Internal Revenue Code and otherfederal
and state laws which may affect your rights: The provisions of the Plan are subject to revision due to a change
in .laws or due to pronouncements by the Internal Revenue Service (IRS) or other federal agencies. We may
also amend or terminate this Plan. If the provisions of the Plan that are described irrthis SPD change, we will
notify you.
We have attempted to answer most of the questions you may have regarding your benefits in the Plan.
If this SPD does not answer all of your questions, please contact the Administrator (or other plan
representative). The name and address of the Administrator can be found in the Article of this SPD entitled
"General Information. About the Plan."
I
ELIGIBILITY
1. When can I become a participant in the Plan?
Before you become a Plan member (referred to in this Summary Plan Description as a "Participant"),
there are certain rules which you must satisfy. First, you must meet the eligibility requirements and be an active
employee. After that, the next step is to actually join the Plan on the "entry date" that we have established for
all employees. The "entry date" is defined in Question 3 below. You will also be required to complete certain
application forms before you can. enroll in the Health Flexible Spending Account or Dependent Care Flexible
Spending Account.
2. What are the eligibility requirements for our Plan?
You will be eligible to join the Plan once you have. satisfied the conditions for coverage under our
group medical plan. Of course, if you were already a participant before this amendment, you will remain a
participant.
3. When is my entry date?
You can join the Plan on the same day you can enter our group medical plan.
1
4. Are there any employees who are not eligible?
Yes, there are certain employees who are not eligible to join the Plan. They are:
Employees who are part-time. Apart-time employee is someone who works, or is expected to work,
less than 30 hours a week.
5. What must I do to enroll in the Plan?
Before you can join the Plan, you must complete an application to participate in the Plan. The
application includes your personal choices #or each of the benefits which are being offered under the Plan. You
must also authorize us to set some of your earnings aside in order to pay for a portion of the benefits you have
elected.
However, if you are already covered under any of the insured .benefits, you will automatically
participate in this Plan to the extent of your premiums unless you elect not to participate in this Plan.
II
OPERATION
1. How does this Plan operate?
Before the start of each Plan Year, you will be able to elect to have some of .your upcoming pay
contributed to the P{an. These amounts will be used to pay for the benefits you have chosen. The portion of
your pay that is paid to the Plan is not subject to Federal income or Social Security taxes. In other. words, this
allows you to use tax-free dollars to pay for certain kinds of benefits and expenses which you normally pay for
with ou~of-pocket, taxable dollars. Also, we will make additional Employer contributions to the Plan that you
.may use to increase the. amounts used to pay benefits: However, if you receive a reimbursement for an
expense under the Plan, you cannot claim a Federal income tax credit or deduction on your return. (See the
Article entitled "General Information About Our Plan" for the definition of "Plan Year.")
III
CONTRIBUTIONS
1. How. much of my,pay may the Employer redirect?
Each year, we will automatically contribute on your behalf enough of your compensation to pay for the
insurance coverage provided unless you elect not to receive any or all of such coverage. You may also elect to
have us contribute on your behalf enough of .your compensation to pay. for any other benefits that you elect
under the Plan. These amounts will be deducted from your pay over the course of the year.
2. How much will the Employer contribute each year?
We may contribute a discretionary amount which we will determine prior to the beginning of each Plan
Year. This contribution is made only to your Health Savings Account and will be made at the beginning of the
Plan Year. If you elect not to participate, the Employer will not contribute to the Plan on your behalf..
3. What happens to contributions made to the Plan?
Before each Plan Year begins, you will select the benefits you want and how much of the contributions.
should go toward each benefit. It is very important that you make these. choices carefully based on what you
expect to spend on each covered benefit or expense during the Plan Year. Later, they will be used to pay for
.the expenses as they arise. during the Plan Year.
4. When must I decide which accounts I want to use?
You are required by Federal law to decide before the Plan Year begins, during the election period
(defined below). You must decide two things. First, which benefits you want and, second, how much should go
toward each benefit.
If you are already covered by any of the insured benefits offered by this Plan, you will automatically
become a Participant to the extent of the premiums for such insurance unless you elect, during the election
period (defined below), not to participate in the Plan.
2
5. When is the election period for our Plan?
You will make your initial election on or before your entry date. (You should review Section I on
Eligibility to better understand the eligibility requirements and entry date.) Then, for each following Plan Year,
..the election period is established by the Administrator and applied uniformly to all Participants. It will normally
be a period of time prior to the beginning of each Plan Year. The Administrator will. inform you each year about
the election. period. {See the Article entitled "General Information About Our Plan" for the definition of Plan
Year. )
6. May I change my elections during the Plan Year?
Generally, you cannot change the elections you have made after the beginning of the Plan Year.
However, there are certain limited situations when you can change your elections. You are permitted to change
elections if you have a "change in status" and you make an election change that is consistent with the change
in status. Currently, Federal law considers the following events to be a change in status:
-Marriage, divorce, death of a spouse, legal separation or annulment;
- Change in the number of dependents, including birth, adoption, placement for adoption, or death of a
dependent;
- Any of the following events for you, your spouse or dependent: termination or commencement of
employment, a strike or lockout, commencement or return from an unpaid leave of absence, a change in
worksite, or any other change in employment status that affects eligibility for benefits,.
- One of your dependents satisfies or ceases to satisfy the requirements for coverage due to change in
.age, student status, or any similar circumstance; .and
- A change in the place of residence of you, your spouse or dependent that would lead to a change in
status, such as moving out of a coverage area for insurance.
In addition, if you are participating in the Dependent .Care Flexible Spending Account, then there is a
change in status if your dependent no longer meets the qualifications to be eligible for dependent care.
However, with respect to the Health Savings Account, .you may modify or revoke your elections without
having to have. a change in status.
There are detailed rules on when a change in election is deemed to be consistent with a change in
status. In addition, there are laws'thaf give you rights to change °health coverage for you, your spouse, or your.
dependents. If you change coverage due to rights you have under the law, then you can make a corresponding
change in .your elections under the Plan. If any of these conditions apply to you, you should contact the
Administrator.
If the cost of a benefit provided under the Plan increases or decreases during a Plan Year, then we wil(
automatically increase or decrease, as the case may be, your salary redirection election. If the cost increases
significantly, you will be permitted to either make corresponding changes iri your payments or revoke your
election and obtain coverage under another benefit package option with similar coverage, or revoke your
election entirely.
If the coverage under a Benefit is significantly curtailed or ceases during a Plan Year, then you may
revoke your elections and elect to receive on a prospective basis coverage under another plan with similar
coverage. In addition, if we add a new coverage option or eliminate an existing option; you may elect the newly-
added option (or elect another option if an option has been eliminated) and make corresponding election
changes to other options providing similar coverage. If you are not a Participant, you may elect to join the Plan.
There are also certain situations when you may be able to change your elections on account of a change under
the plan of your spouse's, former spouse's or dependent's employer.
These rules on change due to cost or coverage do not apply to the Health Flexible Spending Account,
and you may not change your election to the Health Flexible Spending Account if you make a change due to
cosh or coverage for insurance or if you decide to participate in the Health Savings Account.
You may not change your election under the Dependent Care Flexible Spending Account if the cost
change is imposed by a dependent care provider who is your relative.
3
7. May I make new elections in future Pian Years?
Yes, you may. For each new Plan Year, you may change the elections that you previously made. You
may also choose not to participate in the Plan for the upcoming Plan Year. if you do not make new elections
during the election period before a new Plan Year begins, we will assume you want your elections for insured
benefits only to remain the same and you will not be considered a Participant for the non-insured benefit
options underthe Plan for the upcoming Plan Year.
IV
BENEFITS
1. What benefits are available?
Under our Plan, you can choose to receive your entire compensation or use a portion to pay forthe
following benefits or expenses during the year:
Health Flexible Spending Account:
-The Health Flexible Spending Account enables you to pay for expenses allowed under Sections 105
and 213(d) of the Internal Revenue Code which are. not covered by our insured medical plan and save taxes at
the same time. If you. participate in a Health Savings Account, the Health Flexible Spending Account allows you
to be reimbursed by the Employer for out-of-pocket preventative care,. dental andlor vision expenses incurred
by you and your dependents.
If you are an HSA participant, drug costs, including "over-the-counter" drugs may be reimbursed if they
are considered for dental, vision or preventative care. You may not, however, be reimbursed for the cost of
other health care coverage maintained outside of the Plan, or #or .long-term care expenses. A list of covered
.expenses is available from the Administrator.
The most that you can contribute to your Health Flexible Spending Account each-Plan Year is $2,000.
In order#o be reimbursed for a health care expense, you must submit to the Administrator an itemized bill from
the service provider. Amounts reimbursed .from the Plan may not be claimed as a deduction on your personal
income tax return. Reimbursement from the fund shall. be paid at least once a month.
Newborns' and Mothers' Health Protection Act: Group health plans generally may not, under Federal
law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child
to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However,
Federal law generally does not prohibit the mother's or newborn's attending, provider, after consulting with the
mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any
case, plans and issuers may not, under Federal law, require that a .provider obtain authorization from the plan
or the issuer for prescribing a length of stay. not in excess of 48 hours (or 96 hours).
Dependent Care Flexible Spending Account:
The Dependent Care Flexible Spending Account enables you to pay for out of-pocket, work-related
dependent day-care cost with pre-tax. dollars. If you are married, you can use the account if you and your
spouse both work or, in some situations, if your spouse goes to school full-time. Single employees can also use
.the account.
An eligible dependent is someone for whom you can claim expenses on Federal Income Tax Form
2441 "Credit for Child .and Dependent Care Expenses." Children must be under age 13. Other dependents
must be physically or mentally unable to care for themselves. Dependent Care arrangements which qualify
include:
(a) A Dependent{Day) Care Center, provided that if care is provided by the facility for more than
six individuals, the facility complies with applicable state and local laws:
(b) An Educational Institution for pre-school children. For older children, only expenses for
norrschool care are eligible; and
(c) An "Individual" who provides care inside or outside your home: The "IndividuaP' may not be a
child of yours under age 19 or anyone you claim as a dependent for Federal tax purposes.
4
You should make sure thatthe dependent care expenses you are currently .paying :for qualify under our
Plan. The law places limits on the amount of money that can be paid to you in a calendar year from. your
Dependent Care Flexible Spending Account Generally, your reimbursements may not exceed the lesser of: (a)
$5,000 {if you are married filing a joint return or you are head of a household) or $2,500 (if you are married
filing separate returns); (b) your taxable compensation; {c) your spouse's actual or deemed earned income (a
spouse who is a full time student or incapable of caring for himself/herself has a monthly. eamed income of
$250 for one dependent or $500 for two or more dependents). Also, in order to have the reimbursements made
to you from this account be excludable from your income, you must provide a statement from the service
.provider including the name, address, and in most cases, the taxpayer identification number of the service
provider on your tax form for the year, as well as the amount of such expense. as proof that the expense has
been incurred. In addition, Federal tax. laws permit a tax credit for certain dependent care expenses you may
be paying for even if you are not a Participant in this Plan. You may save more money if you take advantage of
this tax credit rather than using the Dependent Care Flexible Spending Account under our Plan. Ask your tax
adviser which is better for you.
Premium Expense Account:
A Premium Expense Account allows you to use tax-free dollars to pay for certain. premium expenses
under various insurance programs that we offer you. These premium expenses include:
--Health care premiums under our insured group. medical. plan.
--Dental insurance premiums.
Under our Plan, we will establish sub-accounts for you for each different type of insurance coverage
that is available. Also, certain limits on the amount of coverage may apply.
The Administrator may terminate or modify Plan benefits at any time, subject to the .provisions of any
insurance contracts providing benefits described above. We will not be liable to you if an insurance company
fails to provide any of the benefits described above. Also, your insurance will end when you leave employment,
are no longer eligible under the terms of any insurance policies, or when insurance terminates..
Any benefits to be provided by insurance will be provided only after (1) ,you have provided -the
Administrator the necessary information to apply for insurance, and (2) the insurance is in effect for you.
2. May I direct Plan contributions to my Health Savings Account?
Yes. Any monies that you do not apply toward available benefits can be contributed to your Health
.Savings Account, 'which enables you to pay for expenses which are. not covered by our insured medical plan
and save taxes at the same time. Please see your Plan Administrator for further details.
V
BENEFIT PAYMENTS
1. When will I receive payments from my accounts?
During the course of the Plan Year, you may submit requests for reimbursement of expenses you have
incurred. Expenses are considered "incurred" when the service is performed, not necessarily when it is paid for.
The Administrator will provide you with acceptable forms for submitting these requests for reimbursement. If the
request qualifies as a benefit or expense that the Plan has agreed to pay, you will receive a reimbursement
payment soon thereafter. Remember, these reimbursements which are made from the Plan are generally not
subject. to federal income tax or withholding. Nor are they subject to Social Security taxes. Requests for
payment of insured benefits should be made directly. to the insurer. You wil( only be reimbursed from the
Dependent Care Flexible Spending Account to the extent that there are sufficient funds in the Account to cover
your request.
2. What happens ifl don't spend all Plan contributions during the Plan Year?
Any monies left at the end of the Plan Year will be forfeited, except for amounts. contributed to your
.Health Savings Account. Obviously, qualifying expenses that you incur late in the Plan Year for which you seek
reimbursement after the end of such Plan Year will be paid firsf before any amount is forfeited. For the Health
Flexible Spending Account, you must submit claims no later than 90 days after the end of the Plan Year: For
the Dependent Care Flexible Spending Account, you must submit claims no later than 90 days after the end of
the Plan Year. Because it is possible that you. might forfeit amounts in the .Plan if you do not fully use .the
5
contributions that have been made, it is important that you decide how much to place irr each account carefully
and conservativeiy..Remember, you must decide which benefits you-want to contribute to and how much to
place in each account before the Plan Yearbegins.You want to be as certain as you can that the amount you
decide to place in each accouritwill be used up entirely.
3. Family and Medical Leave Act (FMLA)
If you take leave .under the Family and Medical Leave Act, you may revoke or change your existing
elections for health insurance and the Health Flexible Spending Account. If your coverage in these benefits
terminates, due to yourrevocation of the benefit while on leave or due to your non-payment of contributions, you
will be permitted to reinstate coverage for the remaining part of the Plan Year upon your return. For the Health
Flexible Spending Account, you may continue your coverage or you. may revoke your coverage and resume it
.when you return. You can resume your coverage at its original level and make payments for the time that you are
on leave. For example., if you elect $1,200 for the year and are out on leave for 3 months; then return and elect to
resume your coverage at that level, your remaining payments will be increased to cover the difference -from $100
.per month to $150 per month. Alternatively yourmaximum amount will be reduced proportionately forthe time that
you were gone. For example, if you. elect $1,200 forthe year and are out on leave for 3 months, your amount will
- be reduced to $900. The expenses you incur during the time you are not in the Health flexible Spending Account
-are not reimbursable.
If you continue your coverage during your unpaid leave, you may pre-pay for the coverage,. you may pay
for your coverage on an after-tax basis while you are on leave, or you. and your Employer may arrange a schedule
.for you to "catch up" your payments when you return:
4. Uniformed Services Employment and Reemploymenf Rights Act (USERRA)
-If you are going into or returning from military service, you may have special rights #o health care
coverage under your Health Flexible Spending Account .under the Uniformed. Services Employment .and
Reemployment Rights Act of 1994. These rights can include extended health care coverage. If .you may be
affected by this law, askyour Administrator for further details.
5. What happens if l terminate employment?
If you terminate employment during the Plan .Year, your .right to benefits will be determined in the
following manner.
(a) You will remain covered by insurance, but only. for the period for which premiums have been
paid prior to yourtermination of employment.
(b) You will still be able to request reimbursement for qualifying dependent care. expenses for the
remainder of the Plan Year from the balance remaining in your dependent care account at the time of
termination of employment. However, no further salary redirection and contributions will be made on
your behalf after you terminate. You must submit claims within 90 days after the end of the Plan Year
in which termination occurs.
(c) Your Health .Savings Account amounts will. remain yours .even after your termination of
employment.
(d) For health benefit coverage and Health Flexible Spending Account coverage on termination of
employment, please see the Article entitled "Continuation Coverage Rights Under COBRA." Upon your
termination of employment, your participation in the Health Flexible Spending Account will cease, and
no further salary redirection and contributions will be contributed on your behalf. However, you will be
able to submit claims for health care expenses that were incurred before the end of the period for
which payments to the Health Flexible Spending Account have already been made. Your further
participation will be governed by "Continuation Coverage Rights Under COBRA."
6. Will my Social Security benefits be affected?
Your Social Security benefits may be slightly reduced because when you receive tax-free benefits
under our Plan, it reduces the amount of contributions that you make to the Federal Social Security system as
well as our contribution to Social Security on yourbehalf.
6
VI
HIGHLY COMPENSATED,AND KEY. EMPLOYEES
1. Do limitations apply to highly compensated employees?
Under the Internal Revenue Code, highly compensated employees and key employees generally are
Participants who are officers, shareholders or highly .paid. You will be notified by the Administrator each .Plan
Year whether you are a highly compensated employee or a key employee.
If you are within these categories, the amount of contributions and benefits for you may be limited so
that the Plan as a whole does not unfairly favor those who are highly paid, their spouses or their dependents.
Federal tax laws state that a plan will be considered to unfairly favor the key employees if they as a group
receive. more than 25% of all of the nontaxable benefits provided for under our Plan.
Plan experience. will dictate whether contribution limitations on highly compensated employees or key
employees will apply. You will be notified of these limitations if you are affected.
VII
PLAN ACCOUNTING
1. Periodic Statements
The. Administrator will provide you with a statement ofyour account periodically during the Plan Year.
that shows your account balance. It is important to read these statements carefully so you understand the
.balance remaining to pay for a benefit. Remember, .you want to spend. all the money you have designated for a
particular benefit by the end of the Plan Year.
VIII
GENERAL INFORMATION ABOUT OUR PLAN
This Section contains certain general information whichyou may need to know about thePlan.
1. General.Plan information
City of Shakopee Section 1~5 Cafeteria Plan is the name of the Plan.
Your Employer has assigned Plan Number 505 to your. Plan.
The provisions of your amended. Plan become effective on January 1, 2008. Your Plan was originally
effective on January 1, 1991.
Your Plan's records are maintained on a twelve-month period of time. This is known. as the Plan Year.
The Plan Year begins on January 1 and ends on December 31.
2. Employer Information
:Your Employer's name, address, and identification number are:
City ofShakopee, Minnesota
129 Holmes Street South
Shakopee, Minnesota 55379
41-6005539
3. Plan Administrator Information
The name, address and business telephone number of your Plan's Administrator are:
City of Shakopee, Minnesota
129 Holmes Street South
Shakopee, Minnesota 55379
(952)233-9300
7
The Administrator keeps the records for the Plan and is responsible for the administration of the Plan.
- The Administrator. will -also .answer any questions .you may have about our Plan. You may contact the
Administrator for any further information about the Plan.
4. .Service of LegaF Process
The name and address of the Plan's agent for service of legal process are:
City of Shakopee, Minnesota
129 Holmes Street South
Shakopee, Minnesota 55379
5. Type of Administration
The type of Administration is Employer Administration.
6. Claims Submission
Claims for expenses should be submitted to:
Alliance Benefit Group
PO Box 1226
Albert Lea, MN 56007
IX
ADDITIONAL PLAN INFORMATION
1. Claims Process
You should submit all reimbursement claims during the Plan Year. For the Health Flexible Spending
Account, you must submit claims no later than 90 days after the end of the Plan Year. For the Dependent Care
Flexible Spending Account, you must submit claims no later than 90 days after the end of-the Plan Year. Any
claims submitted after that time will not be considered.
Claims that are insured will be handled in .accordance with .procedures contained in the insurance
policies. All other general-requests. should be directed to the Administrator of our Plan. If a dependent care or
medical expense claim under the Plan is denied in whole or in part, you or your beneficiary will receive-written
notification. The notification will include the reasons. for the denial, with .reference to the specific provisions of
the Plan on which the denial was based, a description of any additional information needed to process the
claim and an explanation of the claims review procedure. Within 60 days after denial, you or your beneficiary
may submit a written request for reconsideration of the denial to the Administrator.
Any such request should be accompanied by documents or records in support of your appeal. You or
your beneficiary may review pertinent documents and submit issues and comments in writing. The
Administrator will review the claim and provide, within 60 days, a written response to the appeal. (This period
may be extended an additional 60 days under certain circumstances.) In this response, the Administrator will
explain the reason for the decision, with specific reference to the provisions of the Plan on which the decision is
based. The Administrator has the exclusive right to interpret the appropriate plan provisions. Decisions of the
Administrator are conclusive and binding.
X
CONTINUATION COVERAGE RIGHTS UNDER COBRA
Under federal (aw, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), certain
employees and theirfamilies covered under health benefits under this Plan will be entitled to the opportunity to
elect a temporary extension of health coverage (called "COBRA continuation coverage") where coverage under
the Plan would otherwise end. This notice isintended to inform Plan Participants and beneficiaries, in summary
fashion, of their rights and obligations under the continuation coverage provisions of COBRA, as amended and
reflected in final and proposed regulations published by the Department of the Treasury. This. notice is intended.
to reflect the law and does not grant or take away, any rights under the law.
The Plan Administrator or its designee is responsible for administering COBRA continuation coverage.
Complete instructions on COBRA, as well as election forms and other information, will be provided by the Plan
Administrator or its designee to Plan Participants who become Qualified Beneficiaries under COBRA. While the
8
Plan itself is not a group health plan, it does provide health benefits. Whenever "Plan" is used in this section, it
means any of the health benefits under this Plan including the Health Flexible Spending Account
1. What is COBRA continuation coverage?
COBRA continuation coverage is the temporary extension of group health plan coverage that must be
offered to .certain Plan Participants and their eligible family members (called "Qualified Beneficiaries") at group
rates. The right to COBRA continuation coverage is triggered by the occurrence of a fife event that results in
- the loss of coverage under the terms of the Plan (the "Qualifying Event"). The coverage must be identical to the
coverage that the Qualified Beneficiary had immediately before the Qualifying Event, or if the coverage has
been changed, the coverage must be identical to the coverage provided to similarly situated active employees
who: have not experienced a Qualifying Event (in other words, similarly situated non-COBRA beneficiaries}.
2. Who can become a Qualified Beneficiary?
In general, a Qualified Beneficiary can be:
(a) Any individual who, on the day before a Qualifying Event, is covered .under a Plan by virtue of
.being on that day either a covered Employee, the Spouse of a covered Employee, or a Dependent
child of a covered Employee. If, however, an individual who otherwise qualifies as a Qualified
.Beneficiary is denied or not offered coverage under the Plan under circumstances in which the denial
or failure to offer constitutes a violation of applicable law, then the individual will. be considered to have
-had the coverage and will be considered a Qualified Beneficiary- if that individual experiences a
Qualifying Event.
(b) Any child who is bom to or placed for adoption with a covered Employee during a period of
COBRA continuation coverage, and any individual who is covered by the_Plan as an alternate recipient
under a qualified .medical support order..If, .however, an individual who otherwise qualifies as a
Qualified Beneficiary is denied: or not offered coverage-under the Plan under circumstances in which
the .denial or failure o offer constitutes a violation of applicable law, then the individual will be
considered to have had the coverage and will be considered a Qualified Beneficiary if that individual
experiences a Qualifying. Event.
The term "covered Employee" includes any individual who is provided coverage under the Plan due to
his or her performance of services for the employer, sponsoring the Plan. However, this provision- does not
establish eligibility of these individuals. Eligibility for Plan coverage shall be determined. in accordance with Plan..
Eligibility provisions.
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is
,attributable to a period in which fihe individual was a nonresident alien who received .from. the individual's
Employer no earned income that constituted income from sources within the United States. If, on account of the
preceding reason, an individual is not a Qualified Beneficiary, then a Spouse or Dependent. child of the
individual will also not be considered a Qualified Beneficiary by virtue of the relationship to the. individual. A
domestic partner is not a Qualified Beneficiary.
Each Qualified Beneficiary (including a child who is born to or placed for adoption with a covered
Employee during a period of COBRA continuation coverage) must be offered the opportunity to make an
independent election to receive COBRA continuation coverage.
3. What is a Qualifying Event?
A Qualifying Event is any of the following if the Plan- provided that the Plan participant would lose
coverage (i.e., cease to be covered under. the same terms and conditions as in effect immediately before the
Qualifying Event) in the absence of COBRA continuation coverage:
(a) The death of a covered.Employee.
(b) The termination (other than by reason of the Employee's gross misconduct), or reduction of
:hours, of a covered f mployee's employment.
(c) The divorce or legal separation of a covered Employee from the Employee's Spouse. If the
Employee reduces or eliminates the Employee's Spouse's Plan coverage in anticipation of a divorce or
9
legal separation, and a divorce or legal separation later occurs, #hen the divorce or legal separation
may be considered a Qualifying Event even though the Spouse's coverage was reduced or eliminated
before the divorce or legal separation.
(d) A covered Employee's enrollment in any part of the Medicare program.
(e) A Dependent child's ceasing to satisfy the Plan's requirements for a Dependent child (for
example, attainment of the maximum age for dependency under the Plan).
If the Qualifying Event causes the covered Employee, or the covered Spouse or a Dependent child of
the covered Employee, to cease to be covered under the Plan under the same terms and conditions as in effect
.immediately before the Qualifying Event, the persons .losing such coverage become .Qualified Beneficiaries
under COBRA if all the other conditions of COBRA are also met. For example, any increase in contribution that
must be paid by a covered Employee, or the Spouse, or a Dependent child of the covered Employee, for
coverage under the. Plan that results from the occurrence of one of the events listed above is a loss of
coverage.
The taking of leave under the Family and Medical Leave Act of 1993 ("FMLA") does not constitute a
Qualifying Event. A Qualifying_Event will occur, however, if an Employee does not return to employment at the
end of the FMLA leave and all other COBRA continuation coverage conditions are present. If a Qualifying
Event occurs, it occurs on the last day of FMLA leave and the applicable maximum: coverage period is
measured from this date (unless coverage is lost at a laterdate and he Plan provides for the extension of the
required periods,. in which case the maximum coverage date is measured from the date when the coverage is
lost.) Note that the covered Employee and family members will be entitled to COBRA-continuation coverage
even if they failed to pay the employee portion of premiums for. coverage under the Plan during the FMLA
leave.
4. What factors should be considered when determining to elect COBRA continuation coverage?
You should lake into account that a failure `to continue your group health coverage will affect your
rights under federal law. First, you can lose the right to avoid having pre-existing condition exclusions applied
by other group health plans if there is more than a 63-day gap in health coverage and election of COBRA
continuation coverage. may help you avoid such a gap. Second, if you do not elect COBRA continuation
coverage and .pay the appropriate premiums for the maximum time available to you; you will lose the right to
convert to an individual health instarance policy, which does not impose such pre-existing condition exclusions.
Finally, you should take into account that you have special enrollment rights under federal law (HIPAA). You
-have the right to request special enrollment in another group health plan .for which you are otherwise eligible
(such as a plan sponsored by your Spouse's employer) within 30 days after Plan coverage ends due to a
Qualifying Event listed above.. You will also have the same especial right at the end of COBRA continuation
-..coverage if you get COBRA continuation coverage for the maximum time available to you.
5. What is the procedure for obtaining COBRA continuation coverage?
The Plan has conditioned the availability of COBRA continuation coverage upon the timely election of
such coverage. An election is timely if it is made during the election period.
6. What is the election period and how long must it last?
The .election period is the `time period within which the Qualified Beneficiary must elect COBRA
continuation coverage under the Plan. The election period must begin not- later than the date the Qualified
Beneficiary would lose coverage on account of the Qualifying Event and ends 60 days after the later of the date
the .Qualified Beneficiary would lose coverage on account of the .Qualifying Event or the date notice is provided
to the Qualified Beneficiary of her or his right to elect COBRA continuation coverage. If coverage is not elected
within the 60 day period, all rights to elect COBRA continuation coverage are forfeited.
Note: If a covered Employee who has been terminated or experienced a reduction of hours qualifies
for a trade readjustment allowance or alternative trade adjustment assistance under a federal law called the.
Trade Act of 2002, and the employee and his or her covered dependents have not elected COBRA coverage
within the normal election period, a second opportunity to elect COBRA coverage will be made available for
themselves and certain family members; but only within a limited period of 60 days or less and only during the
six months immediately after their group health plan coverage ended. Any person who qualifies or thinks that
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he or she and/or his or her family members -may qualify for assistance under this special provision should
contact the Plan Administrator or its designee forfurther information.
The Trade Act of 2002 also created a newtax credit for certain TAA eligible individuals and for certain
retired employees who are receiving pension. payments from the .Pension Benefit Guaranty Corporation
(PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or
get advance payment of 65% of premiums paid #or qualified health insurance, including continuation coverage.
If you have questions about these new tax provisions, you may call the Health Coverage Tax Credit Consumer
Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More
information about the Trade Act is also available at www.doleta.gov/tradeact.
7. Is a covered Employee or Qualified Beneficiary .responsible for informing the Plan.
Administrator of the occurrence of a Qualifying Event?
The Plan will offer .COBRA continuation coverage to Qualified Beneficiaries only after .the Plan.
' Administrator or its designee has been timely notified that a Qualifying Event has occurred. The Employer (if
the Employer is not the Plan Administrator) will notify the Plan Administrator or its designee of the Qualifying
Event within 30 days following the date coverage ends when the Qualifying Event is:
(a) the end of employment or reduction of hours of employment,
(b) death of the employee, '
(c) commencement, of a proceeding in bankruptcy with respect to the Employer, or
(d) enrollment of the employee in any part of Medicare.
IMPORTANT:
For the other. Qualifying Events (divorce or legal separation of the employee and. spouse or a
dependent child's losing eligibility for coverage as a dependent child), you or someone on your behalf
must notify the Plan Administrator or its designee in writing within 60 days after the Qualifying Event
occurs, using the procedures specified below. If these procedures are not followed or if the notice is
.not provided in writing to the Plan Administrator or its designee during the 60-day notice .period, any
spouse or dependent child who loses coverage wilt not be offered the option to -elect continuation
coverage. You must send this notice to the Plan Administrator or its designee.
NOTICE PROCEDURES:
Any notice that you provide must be in writing. Oral notice, including notice by telephone, is not acceptable. You
must mail, fax or hand-deliver your notice to the person, department or firm listed below, at the #oflowing address:
City of Shakopee, Minnesota
129 Holmes Street South
Shakopee, Minnesota-55379
If mailed, your notice must be postmarked no later than the last day of the required notice period. `Any notice you
provide must state:
• the name of the plan or plans under which you lost or are losing coverage,
• the name and address of the employee covered under the plan,
• the name(s) and address(es) of the Qualified Beneficiary(iesj, and
• the Qualifying Event and the date. it happened.
Ifthe Qualifying Event is a divorce or legal separation, your notice must include a copy of the divorce decree or
the legal separation agreement
Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability
extension.
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Once the Plan Administrator or its designee receives timely notice that a Qualifying Event has
occurred, COBRA continuation coverage-will be offered to each of the qualified beneficiaries. Each Qualified
Beneficiary vvill have an independent right to elect COBRA continuation coverage. Covered employees may
elect COBRA continuation coverage for their spouses, and parents may elect COBRA continuation coverage
on behalf of their children. For each Qualified Beneficiary .who elects .COBRA continuation coverage,.
COBRA continuation coverage will begin on the date. that plan coverage would otherwise have been lost. If
you or your spouse or dependent children do not elect continuation coverage within the 60-day election period
described above, the right to elect continuation coverage will be lost.
8. Is a waiver before .the end of the election period effective #o end- a Qualified Beneficiary's
election rights?
If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the waiver
can be revoked at any time before the end of the election period. Revocation of the waiver is an election of
COBRA continuation coverage. However, if a waiver is .later revoked, coverage need not be provided
retroactively (that is, from the date. of the loss of coverage until the waiver is revoked). Waivers and. revocations
of waivers are considered made on the date they are sent to the Plan Administrator or its designee, as
applicable.
9. Is COBRA coverage available if a Qualified Beneficiary has other group health plan coverage or
.Medicare?
Qualified Beneficiaries who are entitled to elect COBRA continuation coverage may do so .even if they
are covered under another group health plan or are entitled to Medicare benefits on or before the date on which
COBRA is elected. However, a Qualified Beneficiary's COBRA coverage will terminate automatically if, after
electing COBRA, he' or she becomes entitled to Medicare or becomes. covered. under other group health plan
coverage (but only after any applicable preexisting condition exclusions of that other-plan have been exhausted
or satisfied).
10. When may a Qualified Beneficiary's COBRA continuation coverage be terminated?
During the election period, a Qualified Beneficiary may waive COBRA' continuation coverage. Except
for an interruption of coverage in connection with a waiver, COBRA continuation coverage that has been
elected for a Qualified Beneficiary must extend for at least the period beginning on the date of the Qualifying
.Event and .ending not. before the earliest of the following dates:
(a) The last day of the applicable maximum coverage period.
(b) The first day for which Timely Payment is not made to the Plan with respect to the Qualified
Beneficiary.
(c) The date upon which the Employer ceases to provide any group health plan (including a
successor plan) to any employee.
(d) The date, after the date of the election, that the-Qualified Beneficiary first becomes covered
under any other Plan that does not contain any exclusion or limitation with respect to any pre-existing
condition, other than such an exclusion or limitation that does .not apply to, or is satisfied by, .the
Qualified Beneficiary.
(e) The date, after. the date of the election, that the Qualified Beneficiary first enrolls. in the
Medicare program (either part A or part B, whichever occurs. earlier).
(f) In the case of a Qualified Beneficiary entitled to a disability extension, the later of:
(1) (i) 29 months after the. date of the Qualifying Event, or (ii) the first day of the month
that is more than 30 days after the date of a final determination under Title II or XVI of the
Social Security Act that the disabled Qualified Beneficiary .whose disability resulted in the
Qualified Beneficiary's entitlement to the disability extension is no longer disabled, whichever
is earlier; or
(2) the end of the maximum coverage period that applies to the Qualified Beneficiary
without regard to the disability extension.
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The Plan can terminate for cause the coverage of a Qualified Beneficiary on the same basis that the
Plan terminates for cause the coverage of similarly situated non-COBRA beneficiaries, for example, .for the
submission of a fraudulent claim.
In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under the
Plan solely because of the individual's relationship to a Qualified Beneficiary, ;if the Plan's obligation to make
COBRA continuation coverage available to the. Qualified Beneficiary ceases, he Plan is not obligated to make
coverage available to the individual who is not a Qualified Beneficiary:
11. What are the maximum coverage periods for COBRA continuation coverage?
The maximum coverage periods are based on the type of the Qualifying .Event and the status of the
Qualified Beneficiary, as shown. below.
(a) In the case of a Qualifying .Event that is a termination of employment or reduction of hours of
employment, the maximum coverage period ends 18 months after the. Qualifying Event if there is not a
disability extension and 29 months after the Qualifying Event if there is a disability extension.
(b) In the case of a covered Employee's enrollment in the Medicare program before experiencing
a Qualifying Event that is a termination of employment or reduction of hours ofi employment, the
maximum coverage._period for Qualified Beneficiaries other than the covered Employee ends on the
later of:
(1) 36 months after the date the covered Employee becomes enrolled in the Medicare
program; or
(2) 18 months (or 29 months, if there is a disability extension) after the .date of the
covered Employee's termination of employment or reduction of hours of employment.
(c) In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a
covered Employee during a period of COBRA continuation coverage, the maximum coverage period is
the maximum coverage period applicable to the Qualifying Event giving rise to the period of-COBRA
continuation coverage during which the child was bom or placed for adoption.
(d) In the case of any other Qualifying Event than that described above, the maximum coverage
period ends 36 months after the Qualifying Event.
12. Under what circumstances can the maximum coverage period be expanded?
If a Qualifying Event that gives rise to an 18-month or 29-month maximum coverage period is followed,
within .that 18- or 29-month. period, by a second Qualifying Event that gives rise to a 36-months maximum
coverage .period, the original period is expanded to 36 months, but only for individuals who .are Qualified
Beneficiaries at the time of and with respect to both Qualifying Events. !n no circumstance can the COBRA
maximum coverage period be expanded to more than 36 months after the date of the first Qualifying Event.
The Plan Administrator must be notified of the second qualifying .event within 60-days of the second qualifying
,event. This .notice must be sent to the Plan Administrator or its designee in accordance with the procedures
above.
13. How does a Qualified Beneficiary become entitled to a disability extension?
A disability extension will be granted if an individual (whether or not the covered Employee) who is a
Qualified Beneficiary in connection with the Qualifying Event that is a termination or reduction of hours of a
covered Employee's employment, is determined under Title II or XVI of the Social Security Act to have been
disabled of any time during the first 60 days of COBRA continuation coverage. To qualify for the disability
extension, the Qualified Beneficiary must also provide the Plan Administrator with notice of the disability
determination on a date that is both within 60 days after the date of the determination and before the end of the
original 18-month maximum coverage. This notice must be sent to the. Plan Administrator or its designee in
accordance with the procedures above.
14. Does the Plan require payment for COBRA continuation coverage?
For any period of COBRA continuation coverage under the Plan, Qualified Beneficiaries who elect
COBRA continuation coverage may be required to pay up to 102% of the applicable premium and up to 150%
of the applicable premium for any expanded period of COBRA continuation .coverage covering a disabled
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Qualified Beneficiary due to a disability extension. Your Plan Administrator will inform. you of the cost. The Plan
wily terminate a Qualified Beneficiary's COBRA continuation coverage as of the first day of any period for which
timely payment is not made.
15. Must the Plan allow payment. for COBRA continuation .coverage to ; be made in monthly
installments?
Yes. The Plan is also permitted to allow for payment at other intervals.
16. What is Timely Payment for COBRA continuation coverage?
Timely Payment means a payment made no later than 30 days after the first day of the coverage
period. Payment that is made to the Plan by a later date is also considered Timely. Payment if either under the
terms of the Plan, covered. Employees or Qualified Beneficiaries are allowed until that later date to pay for their
coverage for the period or under the terms of an arrangement between the Employer and .the entity that
provides Plan benefits on the Employer's behalf, .the Employer is allowed until that .later date to pay for
coverage of similarly situated non-COBRA beneficiaries for the period.
Notwithstanding the above paragraph, the Plan does not require payment for any period of COBRA
continuation coverage for a Qualified Beneficiary earlier than 45 days after the date on which the election of
COBRA continuation coverage is made for that Qualified Beneficiary. Payment is considered made on the date
on which it is postmarked to the Plan.
If Timely Payment is made to the Plan in an amount that is not significantly less than the amount the
Plan requires to be paid for a period of coverage, then the amount paid will be deemed to satisfy the Plan's
.requirement for the amount to be paid, unless the Plan notifies the Qualified Beneficiary of the amount of the
deficiency and grants a reasonable period of time for .payment. of the deficiency to be made. A "reasonable
period of time" is 30 days after the notice is_provided. A shortfall in a Timely Payment is not significant if it is no
greater than the lesser of $50 or 10% of the required amount.
17. Must a Qualified Beneficiary be given the right to enroll in a conversion health plan at the end
of the maximum coverage period for-COBRA continuation coverage?
If a Qualified Beneficiary's COBRA continuation coverage under a group health plan ends as a result
of the expiration of the applicable maximum coverage period, the Plan will, during the 180-day period that ends
on that expiration .date, provide the Qualified Beneficiary with the option of enrolling under a conversion health
plan if such an option is otherwise generally available to 'similarly situated non-COBRA beneficiaries under the
Plan. If such a conversion option is not otherwise generally available, it need not be made available to Qualified
Beneficiaries.
18. How is my participation in the Health Flexible Spending Account affected?
You-can elect to continue your participation in the Health Flexible Spending Account for the remainder
of the Plan Year, subject to the following conditions. You may only continue to participate in the Health Flexible
Spending Account if you have elected to contribute more money than -you have taken out in claims. For
example, if you elected to contribute an annual amount of $500 and, at the time you terminate employment,
you have contributed $300 but only claimed $150, ..you may elect to continue coverage under the Health
Flexible Spending Account. If you elect to continue coverage, then you would be able to continue to receive
your health reimbursements up to the $500. However, you must continue to pay for the coverage, just as-the
money has been taken out of your paycheck, but on an after-tax basis. The Plan can also charge you an extra
amount (as explained above for other health benefits) to provide this benefit.
IF YOU HAVE QUESTIONS
if you have questions about your COBRA continuation coverage, you should contact the Plan
Administrator or its designee. For more information -about your rights under ERISA, including COBRA, the
Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans,
contact the nearest Regional or District Office of the U.S. Department of. Labor's Employee Benefits Security
Administration (EBSA). Addresses .and phone numbers of Regional and District EBSA Offices are available
through EBSA's website at www.dol.gov/ebsa.
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KEEP YOUR PLAN ADMINISTRATOR INFORMED OF ADDRESS CHANGES
In order to protect your family's ..rights,. you should keep the Plan Administrator informed of any
changes in the addresses of family members.. You should also keep a copy, for your records, of any
notices you send to the Plan Administrator or its designee.
XI
.SUMMARY.
The money you earn is important to you and your family. You need it to pay your bills, enjoy
recreational activities and save for the future. Our flexible benefits plan will help you keep more of the. money
you earn by lowering the amount of taxes you pay. The Plan. is the result of our continuing efforts to find ways
to help you get the mosf for your earnings.
If you .have any questions, please contactthe Administrator.
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