HomeMy WebLinkAbout20083202.tiff RESOLUTION
RE: APPROVE WELD COUNTY GOVERNMENT CAFETERIA PLAN AND AUTHORIZE
CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with the Weld County Government Cafeteria
Plan for the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Human Resources, commencing
January 1, 2009, with further terms and conditions being as stated in said plan, and
WHEREAS, a hearing before the Board was held on the 8th day of December, 2008, at
which time the Board deemed it advisable to continue said matter to December 10, 2008, to allow
adequate time for Don Warden, Director of Finance and Administration, to further review the
proposed plan, and
WHEREAS, at said meeting on December 10, 2008, after review, the Board deems it
advisable to approve said plan, a copy of which is attached hereto and incorporated herein by
reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Weld County Government Cafeteria Plan for the County of Weld, State
of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Department of Human Resources be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said plan.
2008-3202
PE0025
fin ; / L (27 -O7-Ci %
WELD COUNTY GOVERNMENT CAFETERIA PLAN
PAGE 2
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 10th day of December, A.D., 2008.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: atezni EL,3' ,
Wi '.m Jerke, Chair
Weld County Clerk to the r•ar. ;1861 p�
. ; :+0I
bert .r asdPro-Tem
BY: Co �• �� � �I �
Deputy Clerk to the Bo. . (/J N.
WiI�F. Ga cia
,Piti2ZED ASST M: Ecj
David E. Long
County Attorney r - <• .n°=���
Douglas emacher
Date of signature: 4'�/�y/°F
2008-3202
PE0025
WELD COUNTY GOVERNMENT CAFETERIA PLAN
With Premium Payment, Health FSA and DCAP Components
Effective:January 1, 2009
WELD COUNTY GOVERNMENT CAFETERIA PLAN
With Premium Payment, Health FSA and DCAP Components
TABLE OF CONTENTS
ARTICLE I
Introduction 1
1.1 Establishment of Plan 1
1.2 Legal Status 1
ARTICLE II
Definitions 2
ARTICLE III
Eligibility and Participation 6
3.1 Eligibility to Participate 6
3.2 Termination of Participation 6
3.3 Participation Following Termination of Employment or Loss of Eligibility 6
3.4 FMLA Leaves of Absence 6
3.5 Non-FMLA Leaves of Absence 8
ARTICLE IV
Method and Timing of Elections 9
4.1 Elections When First Eligible 9
4.2 Elections During Open Enrollment Period 9
4.3 Failure of Eligible Employee to File an Election Form/Salary Reduction 9
Agreement
4.4 Irrevocability of Elections 9
ARTICLE V
Benefits Offered and Method of Funding 10
5.1 Benefits Offered 10
5.2 Participant Contributions 10
5.3 Funding This Plan 10
5.4 Maximum Contribution 10
ARTICLE VI
Premium Payment Component 12
6.1 Benefits 12
6.2 Contributions for Cost of Coverage 12
6.3 Events Permitting Exception to Irrevocability Rule 12
6.4 Insurance Benefits Provided Under the Plan 13
6.5 Medical Insurance Benefits, COBRA 13
6.6 Premium Insurance Benefits Grace Period 13
ARTICLE VII
Health FSA Component 14
7.1 Health FSA Benefits 14
7.2 Contributions for Cost of Coverage of Health FSA Benefits 14
7.3 Eligible Medical Care Expenses for Health FSA 14
7.4 Events Permitting Exception to Irrevocability Rule 14
7.5 Maximum Benefits for Health FSA 15
7.6 Health FSA Benefits Grace Period 15
7.7 Establishment of Health FSA Account 16
7.8 Forfeiture of Health FSA Accounts, Use-It-or-Lose-It Rule 16
7.9 Reimbursement Claims Procedure for Health FSA 16
7.10 Reimbursements From Health FSA After Termination of Participation, 17
COBRA
7.11 Named Fiduciary for Health FSA 18
7.12 Coordination of Benefits with Other Plans 18
ARTICLE VIII
DCAP Component 19
8.1 DCAP Benefits 19
8.2 Contributions for Cost of Coverage for DCAP Benefits 19
8.3 Eligible Dependent Care Expenses 19
8.4 Events Permitting Exception to Irrevocability Rule 20
8.5 Maximum and Minimum Benefits for DCAP 20
8.6 Establishment of DCAP Account 21
8.7 DCAP Benefits Grace Period 22
8.8 Forfeiture of DCAP Accounts, Use-It-or-Lose-It Rule 22
8.9 Reimbursement Claims Procedure for DCAP 22
8.10 Reimbursements From DCAP After Termination of Participation 23
8.11 Report to DCAP Participants 23
ARTICLE IX
HIPAA Provisions for Health FSA 24
9.1 Provision of Protected Health Information to Employer 24
9.2 Permitted Disclosure of EnrollmenUDisenrollment Information 24
9.3 Permitted Uses and Disclosure of Summary Health Information 24
9.4 Permitted and Required Uses and Disclosure of PHI 24
9.5 Conditions of Disclosure for Plan Administration Purposes 24
9.6 Adequate Separation Between Plan and Employer 25
9.7 Certification of Plan Sponsor 25
ARTICLE X
Irrevocability of Elections, Exceptions 26
10.1 Irrevocability of Elections 26
10.2 Procedure for Making New Election If Exception to Irrevocability 26
Applies
10.3 Change in Status Defined 26
10.4 Election Modifications Required by Plan Administrator 30
ARTICLE XI
Appeals Procedure 31
11.1 Procedure If Benefits Are Denied Under This Plan 31
11.2 Claims Procedures for Medical Insurance Benefits 32
ARTICLE XII
Recordkeeping and Administration 33
12.1 Plan Administrator 33
12.2 Powers of the Plan Administrator 33
12.3 Reliance on Participant, Tables, etc. 34
12.4 Provision for Third-Party Plan Service Providers 34
12.5 Fiduciary Liability 34
12.6 Compensation of Plan Administrator 34
12.7 Bonding 34
12.8 Insurance Contracts 34
12.9 Inability to Locate Payee 34
12.10 Effect of Mistake 35
ARTICLE XIII •
General Provisions 36
13.1 Expenses 36
13.2 No Contract of Employment 36
13.3 Amendment and Termination 36
13.4 Governing Law 36
13.5 Code and ERISA Compliance 36
13.6 No Guarantee of Tax Consequences 36
13.7 Indemnification of Employer 36
13.8 Non-Assignability of Rights 36
13.9 Headings 36
13.10 Plan Provisions Controlling 37
13.11 Severability 37
Appendix A 38
Weld County Government Cafeteria Plan
(With Premium Payment, Health FSA and DCAP Components)
ARTICLE I
Introduction
1.1 Establishment of Plan
Weld County Government, ("the Employer")hereby establishes the Weld County Government Cafeteria
Plan ("the Plan")effective January 1,2009("the Effective Date").
Capitalized terms used in this Plan that are not otherwise defined shall have the meanings set forth in
Article II,Definitions.
This Plan is designed to permit an Eligible Employee to pay for his or her share of Contributions on a pre-
tax salary reduction basis under the Premium Component and to the reimbursement benefit(s).
1.2 Legal Status
This Plan is intended to qualify as a"cafeteria plan"under Code section 125 and the regulations issued
thereunder and shall be interpreted to accomplish that objective.
The Health FSA Component is intended to qualify as a"self-insured medical reimbursement plan"under
Code section 105, and the Medical Care Expenses reimbursed thereunder are intended to be eligible for
exclusion from participating Employees'gross income under Code section 105(b).Although reprinted
within this document,the Health FSA Component is a separate plan for purposes of administration and all
reporting and nondiscrimination requirements imposed by Code section 105.The Health FSA Component
is also a separate plan for purposes of applicable provisions of ERISA and COBRA.
The DCAP Component is intended to qualify as a"dependent care assistance program"under Code
section 129, and the Dependent Care Expenses reimbursed thereunder are intended to be eligible for
exclusion from participating Employees'gross income under Code section 129(a).Although reprinted
within this document,the DCAP Component is a separate plan for purposes of administration and all
reporting and nondiscrimination requirements imposed by Code section 129.
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ARTICLE II
Definitions
"Account(s)" means the Health FSA Accounts described in Article VII and the DCAP Accounts described
in Article VIII.
"Appeals Committee"means the Committee appointed by the Employer that acts on behalf of the Plan
Administrator with respect to appeals.
"Benefits"mean cash,flex credits and the various qualified benefits under Section 125(f)of the Code
sponsored by the Employer and made available by the Employer through the Plan, including, but not
limited to, premium insurance benefits as described in Section 6.1, medical reimbursement as described in
Section 7.1 and dependent care reimbursement as described in Section 8.1.
"Benefit Package Option"means a qualified benefit under Code section 125(f)that is offered under a
cafeteria plan or an option for coverage under an underlying accident or health plan.
"Change in Status"has the meaning described in Section 10.3.
"COBRA"means the Consolidated Omnibus Budget Reconciliation Act of 1985,as amended.
"Code"means the Internal Revenue Code of 1986,as amended.
"Compensation"means all the earned income, salary,wages and other earnings paid by the Employer to
a Participant during a Plan Year, including any amounts contributed by the Employer pursuant to a salary
reduction agreement which are not includable in gross income under sections 125, 132(f)(4),401(k),
403(b),408(k)or 457(b)of the Code. all the earned income,salary,wages and other earnings except
bonuses and overtime paid by the Employer to a Participant during a Plan Year, including any amounts
contributed by the Employer pursuant to a salary reduction agreement which are not includable in gross
income under sections 125, 132(f)(4), 401(k),403(b),408(k)or 457(b)of the Code.
"Contributions"means the amount contributed to pay for the cost of Benefits(including self-funded
Benefits as well as those that are insured),as calculated under Section 6.2 for Premium Payment Benefits,
Section 7.2 for Health FSA Benefits and Section 8.2 for DCAP Benefits.
"DCAP"means dependent care assistance program.
"DCAP Component"means the benefits of this Plan described in Article VIII.
"Dependent"means any individual who is a tax dependent of the Participant as defined in Code section
152.The following exceptions apply:(a)for purposes of the Health FSA component,and(b)for purposes
of coverage funded by the Premium Payment component,a dependent is defined under code section 152,
but without use of subsections b(1), b(2)and d(1)(B)and any child to whom IRS Rev. Proc.2008-48
applies(regarding certain children of divorced or separated parents who receive more than half of their
support for the calendar year from one or both parents and are in the custody of one or both parents for
more than half of the calendar year)is treated as a dependent of both parents.Also,the Health FSA will
provide benefits in accordance with any QMCSO,even if the child does not otherwise meet the definition of
"Dependent". For purposes of the DCAP component,a dependent means a qualifying individual as defined
elsewhere.
"Dependent Care Expenses"has the meaning described in Section 8.3.
"Earned Income"means all income derived from wages, salaries,tips,self-employment,and other
Compensation(such as disability or wage continuation benefits),but only if such amounts are includible in
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gross income for the taxable year. Earned income does not include(a)any amounts received pursuant to
any DCAP established under Code section 129; or(b)any other amounts excluded from earned income
under Code section 32(c)(2), such as amounts received under a pension or annuity or pursuant to workers'
compensation.
"Effective Date"of this Plan has the meaning described in Section 1.1.
"Election Form/Salary Reduction Agreement"means the agreement by an Employee authorizing the
Employer to reduce the Employee's Compensation while a Participant during the Plan Year for purposes of
obtaining Benefits under the Plan.
"Electronic Payment Card"means a debit card, stored value card,or credit card that allows a Participant
to access funds in a flexible reimbursement arrangement to pay the service provider at the point-of-sale
(i.e.,the time a service or item is provided).
"Electronic Protected Health Information"has the meaning described in 45 C.F.R.Section 160.103 and
generally includes Protected Health Information that is transmitted by electronic media or maintained in
electronic media. Unless otherwise specifically noted, Electronic Protected Health Information shall not
include enrollment/disenrollment information and summary health information.
"Eligible Employee"means any Employee who is employed by a participating Employer other than:
(a)An Employee covered by a collective bargaining agreement as to which retirement benefits were
the subject of good faith bargaining, unless such agreement expressly provides for participation in
the Plan;
(b)A non-resident alien with no US source of income;
(c)A"leased employee"within the meaning of Section 414(n);
(d) Employees who regularly work less than 20 hours per week;
(e) Employees who regularly work less than 6 months per year;
(f) Employees who are self-employed individuals as defined in section 401(c)of the Internal
Revenue Code(including sole proprietors and partners in a partnership);
(g) Employees who own(or are considered to own within the meaning of section 318 of the Internal
Revenue Code)more than two percent(2%)of the outstanding stock of an S corporation or stock
possessing more than two percent(2%)of the total combined voting power of all stock of such
corporation.
In the event an individual who is not characterized or treated by the Participating Employer as a common
law employee of a Participating Employer is reclassified as a common law employee of a Participating
Employer who meets the definition of an Eligible Employee,the individual shall continue to be excluded
from the Plan until the Plan is amended to classify such individual as an Eligible Employee(to the extent
such individual otherwise qualifies as an Eligible Employee hereunder). In no event shall such individual be
eligible to participate in the Plan prior to the effective date of such Amendment.
The Plan Administrator shall have full and complete discretion to determine eligibility for participation and
benefits under this Plan, including,without limitation,the determination of those individuals who are
deemed Employees of the Employer(or any controlled group member.)The Plan Administrator's decision
shall be final, binding, and conclusive on all parties having or claiming a benefit under this Plan.This Plan
is to be construed to exclude,and the Plan Administrator is authorized to exclude,all individuals who are
not considered Employees for purposes of the Employer's payroll system.
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"Employee"means a person who is currently or hereafter employed by the Employer and any Related
Employers that have adopted the Plan. Former Employees are also considered"Employees"of the
Employer strictly for the limited purpose of allowing continued eligibility for benefits under the Plan for the
remainder of the Plan Year in which an Employee ceases to be employed by the Employer, but only to the
extent specifically provided elsewhere under this Plan.
"Employer"means Weld County Government
"Employment Commencement Date"means the first regularly-scheduled working day on which the
Employee first performs an hour of service for the Employer for Compensation.
"ERISA"means the Employee Retirement Income Security Act of 1974,as amended.
"Entry Date"means the date that an Eligible Employee actually becomes a Participant in the Plan.
Eligibility requirements are defined in Section 3.1 and the specific Entry Dates for the Plan are listed in
Section 3.1.
"FMLA"means the Family and Medical Leave Act of 1993,as amended.
"General-Purpose Health FSA Option"has the meaning described in Section 7.3(b).
"Grace Period"means the period that begins immediately following the close of a Plan Year and ends on
the day specified under the Component plan's Grace Period provision.
"Health FSA"means health flexible spending arrangement which consists of one(1)option:the General-
Purpose Health FSA Option.
"Health FSA Component"means the benefits of this Plan described in Article VII.
"High Deductible Health Plan"means the high deductible health plan offered by the Employer that is
intended to qualify as a high deductible health plan under Code section 223(c)(2),as described in
materials provided separately by the Employer.The High Deductible Health Plan may or may not be the
sole Medical Insurance Plan eligible for pre-tax salary reduction funding hereunder.
"HIPAA"means the Health Insurance Portability and Accountability Act of 1996,as amended.
"Medical Care Expenses"has the meaning defined in Section 7.3.
"Medical Insurance Plan"means the plan(s)that the Employer maintains for its Employees(and for their
Spouses and Dependents that may be eligible under the terms of such plan), providing major medical type
benefits through a group insurance policy or policies, dental care,vision care,etc.The Employer may
substitute,add,subtract,or revise at any time the menu of such plans and/or the benefits,terms, and
conditions of any such plans.Any such substitution,addition,subtraction,or revision will be communicated
to Participants and will automatically be incorporated by reference under this Plan.
"Open Enrollment Period"means with respect to a Plan Year the month preceding the Plan Year, or
such other period as may be prescribed by the Plan Administrator.
"Participant"means a person who is an Eligible Employee and who enters the Plan after meeting the
eligibility requirements of Section 3.1. Participants include those who elect any benefit(s)offered under the
Plan including those covered through COBRA and their respective beneficiaries.
"Period of Coverage"means the Plan Year,with the following exceptions: (a)for Employees who first
become eligible to participate,it shall mean the portion of the Plan Year following the date on which
participation commences,as described in Section 3.1;and(b)for Employees who terminate participation, it
shall mean the portion of the Plan Year prior to the date on which participation terminates,as described in
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•
Section 3.2.
"Plan"means the Weld County Government Cafeteria Plan as set forth herein and as amended from time
to time.
"Plan Administrator"means Weld County Government or such other person or committee as may be
appointed by the Employer to administer the Plan.
"Plan Year"means the 12-month period commencing January 1st and ending on December 31st.
"Premium Payment Component"means the benefits of this Plan described in Article VI.
"Protected Health Information"(PHI)shall have the meaning described in 45 C.F.R.Section 160.103
and generally includes individually identifiable health information held by,or on behalf of,the Plan.
"QMCSO"means a qualified medical child support order, as defined in ERISA Section 609(a).
"Qualifying Dependent Care Services"has the meaning described in Section 8.3.
"Qualifying Individual"has the meaning described in Section 8.3.
"Related Employer"means any employer affiliated with Weld County Government that,under Code
Sections 414(b), (c), or(m), is treated as a single employer with Weld County Government for purposes of
Code section 125(g)(4).
"Run-Out Period"means a period after the close of a Plan Year or other period during which Participants
in a flexible spending arrangement(FSA)may request reimbursement for expenses incurred during the
Period of Coverage.
"Salary Reduction"means the amount by which the Participant's Compensation is reduced and applied
by the Employer under this Plan to pay for one or more of the Benefits,as permitted for the applicable
Component, before any applicable state and/or federal taxes have been deducted from the Participant's
Compensation(i.e.,on a pre-tax basis).
"Spouse"means an individual who is legally married to a Participant as determined under applicable state
law(and who is treated as a spouse under the Code).
Notwithstanding the above,for purposes of the DCAP Component the term "Spouse"shall not include(a)
an individual legally separated from the Participant under a divorce or separate maintenance decree; or(b)
an individual who, although married to the Participant,files a separate federal income tax return, maintains
a principal residence separate from the Participant during the last six months of the taxable year,and does
not furnish more than half of the cost of maintaining the principal place of abode of the Participant.
"Student"means an individual as defined in Section 152(f)(2)who,during each of five calendar months
during the calendar year in which the taxable year of the taxpayer begins,(a)is a full-time student at an
educational organization described in section 170(b)(1)(A)(ii)or;(b)is pursuing a full-time course of
institutional on-farm training under the supervision of an accredited agent of an educational organization
described in section 170(b)(1)(A)(ii)or of a State or political subdivision of a State.
"Timely Submitted"means, unless the Plan Administrator has specific and special cause to alter the
definition of this phrase,within 30 calendar days of event that has triggered the Change in Status as
described in Section 10.2(a).
"USERRA"means the Uniformed Services Employment and Reemployment Rights Act of 1994,as
amended.
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ARTICLE III
Eligibility and Participation
3.1 Eligibility to Participate
An individual is eligible to participate in this Plan, including the Premium Payment Component,the Health
FSA Component and the DCAP Component if the individual satisfies all of the following:
(a)is an Eligible Employee;
Once an Employee has met the Plan's eligibility requirements,the Eligible Employee may commence
participation on the date the eligibility requirements have been met or for any subsequent Plan Year, in
accordance with the procedures described in Article IV,Method and Timing of Elections.
3.2 Termination of Participation
A Participant will cease to be a Participant in this Plan upon the earlier of:
- the date on which the Plan terminates;
- the date on which the Employee ceases(because of retirement,termination of employment, layoff,
reduction of hours,or any other reason)to be an Eligible Employee;
- the date on which the Employee fails to make a contribution required under the terms of the Plan; or
- the end of the Plan Year,as extended by the Grace Period coverage,for Eligible Employees;
Termination of participation in this Plan will automatically revoke the Participant's elections.
The Premium Insurance Benefits will terminate as of the date specified in the Premium Plan.
Reimbursements from the Health FSA Account after termination of participation will be made pursuant to
Section 7.10 for Health FSA Benefits.
Reimbursements from the DCAP Account after termination of participation will be made pursuant to
Section 8.10 for DCAP Benefits.
3.3 Participation Following Termination of Employment or Loss of Eligibility
If a Participant terminates his or her employment for any reason, including, but not limited to,disability,
retirement, layoff,or voluntary resignation,and then is rehired within 30 days or less after the date of
termination of employment, but within the same plan year and is otherwise eligible to participate in the
Plan,the Employee will immediately rejoin the Plan and be reinstated with the same elections that the
individual had before termination.
If a former Participant is rehired more than 30 days following termination of employment and is otherwise
eligible to participate in the Plan,then the Employee will be treated as a new hire and must resatisfy
(complete the waiting period)Plan eligibility requirements to rejoin the Plan.
Notwithstanding the above, an election to participate in the Premium Payment Component will be
reinstated only to the extent that coverage under the Premium Insurance Benefits is reinstated.
If an Employee(whether or not a Participant)ceases to be an Eligible Employee for any reason(other than
for termination of employment),including, but not limited to,a reduction of hours,and then becomes an
Eligible Employee again,the Employee must re-satisfy(complete the waiting period)Plan eligibility
requirements to rejoin the Plan as described in Section 3.1 (or before becoming eligible to participate in the
Plan).
3.4 FMLA Leaves of Absence
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(a)Health Benefits.Notwithstanding any provision to the contrary in this Plan, if a Participant goes
on a qualifying leave under the FMLA,then to the extent required by the FMLA,the Employer will
continue to maintain the Participant's Premium Insurance Benefits and Health FSA Benefits on the
same terms and conditions as if the Participant were still an active Employee.That is, if the
Participant elects to continue his or her coverage while on leave,the Employer will continue to pay
its share of the Contributions.An Employer may require participants to continue all Premium
Insurance Benefits and Health FSA Benefits coverage for Participants while they are on paid leave,
provided that Participants on non-FMLA paid leave are required to continue coverage. If so,the
Participant's share of the Contributions shall be paid by the method normally used during any paid
leave(e.g.,on a pre-tax salary reduction basis). In the event of unpaid FMLA leave(or paid FMLA
leave where coverage is not required to be continued),a Participant may elect to continue his or her
Premium Insurance Benefits or Health FSA Benefits during the leave. If the Participant elects to
continue coverage while on FMLA leave,then the Participant may pay his or her share of the
Contributions in one of the following ways:
- with after-tax dollars,by sending monthly payments to the Employer by the due date
established by the Employer;
- Pre-Pay with pre-tax dollars, by having such amounts withheld from the Participant's ongoing
Compensation, if any, including unused sick days and vacation days,or pre-paying all or a
portion of the Contributions for the expected duration of the leave on a pre-tax salary reduction
basis out of pre-leave Compensation.To pre-pay the Contributions,the Participant must make
a special election to that effect prior to the date that such Compensation would normally be
made available(pre-tax dollars may not be used to fund coverage during the next Plan Year);
- Pay-as-you-go with their share of premium payments on the same schedule as payments
would be made if the Employee were not on leave,or under another schedule permitted under
Department of Labor regulations and in a manner approved by the Plan Administrator;or
- under another arrangement agreed upon between the Participant and the Plan Administrator
(e.g.,the Plan Administrator may fund coverage during the leave and withhold"catch-up"
amounts from the Participant's Compensation on a pre-tax or after-tax basis)upon the
Participant's return.
If the Employer requires all Participants to continue Premium Insurance Benefits or Health FSA
Benefits during an unpaid FMLA leave,then the Participant may elect to discontinue payment of the
Participant's required Contributions until the Participant returns from leave. Upon returning from
leave,the Participant will be required to repay the Contributions not paid by the Participant during the
leave. Payment shall be withheld from the Participant's Compensation either on a pre-tax or after-tax
basis,as agreed to by the Plan Administrator and the Participant through a written notice to the
Employer.
If a Participant's Premium Insurance Benefits or Health FSA Benefits coverage ceases while on
FMLA leave(e.g.,for non-payment of required contributions),then the Participant is permitted to re-
enter the Premium Insurance Benefits or Health FSA Benefits as applicable, upon return from such
leave on the same basis as when the Participant was participating in the Plan prior to the leave,or
as otherwise required by the FMLA. In addition,the Plan may require Participants whose Premium
Insurance Benefits or Health FSA Benefits coverage terminated during the leave to be reinstated in
such coverage upon return from a period of unpaid leave, provided that Participants who return from
a period of unpaid, non-FMLA leave are required to be reinstated in such coverage.
Notwithstanding the preceding sentence,with regard to Health FSA Benefits a Participant whose
coverage ceased will be permitted to elect whether to be reinstated in the Health FSA Benefits at the
same coverage level as was in effect before the FMLA leave(with increased contributions for the
remaining Period of Coverage)or at a coverage level that is reduced pro rata for the period of FMLA
leave during which the Participant did not pay Contributions.If a Participant elects a coverage level
that is reduced pro rata for the period of FMLA leave,then the amount withheld from a Participant's
Compensation on a pay-period-by-pay-period basis for the purpose of paying for reinstated Health
FSA Benefits will be equal to the amount withheld prior to the period of FMLA leave.
(b) Non-Health Benefits.If a Participant goes on a qualifying leave under the FMLA,then
entitlement to non-health benefits(such as DCAP Benefits)is to be determined by the Employer's
policy for providing such Benefits when the Participant is on non-FMLA leave, as described in
Section 3.5.
3.5 Non-FMLA Leaves of Absence
If a Participant goes on an unpaid leave of absence that does not affect eligibility,then the Participant will
continue to participate and the Contributions due for the Participant will be paid in one of the following
ways:
- with after-tax dollars,by sending monthly payments to the Employer by the due date established
by the Employer;
- Pre-pay with pre-tax dollars, by having such amounts withheld from the Participant's ongoing
Compensation,if any, including unused sick days and vacation days,or pre-paying all or a portion
of the Contributions for the expected duration of the leave on a pre-tax salary reduction basis out of
pre-leave Compensation.To pre-pay the Contributions,the Participant must make a special
election to that effect prior to the date that such Compensation would normally be made available
(pre-tax dollars may not be used to fund coverage during the next Plan Year);
- Pay-as-you-go with their share of premium payments on the same schedule as payments would
be made if the Employee were not on leave,or under another schedule permitted under
Department of Labor regulations;or
- under another arrangement agreed upon between the Participant and the Plan Administrator(e.g.,
the Plan Administrator may fund coverage during the leave and withhold"catch-up"amounts from
the Participant's Compensation on a pre-tax or after-tax basis)upon the Participant's return.
If a Participant goes on an unpaid leave that affects eligibility,then the election change rules in Section
10.3 will apply.
8
ARTICLE IV
Method and Timing of Elections
4.1 Elections When First Eligible
Once an Employee has met the Plan's eligibility requirements,the Employee may enter the plan on the
date the eligibility requirements have been met provided that an Election Form/Salary Reduction
Agreement is submitted to the Plan Administrator before the first day of the month in which participation will
commence.
An Employee who does not elect benefits when first eligible may not enroll until the next Open Enrollment
Period unless an event occurs that would justify a mid-year election change, as described under Section
10.3. Eligibility for Premium Payment Benefits shall be subject to the additional requirements,if any,as
specified by the insurance benefits provider(s).The provisions of this Plan are not intended to override any
exclusions,eligibility requirements,or waiting periods specified by the insurance benefits provider(s).
4.2 Elections During Open Enrollment Period
During each Open Enrollment Period with respect to a Plan Year,the Plan Administrator shall provide an
Election Form/Salary Reduction Agreement to each Eligible Employee.The Election Form/Salary
Reduction Agreement shall enable the Employee to elect to participate in the various Components of this
Plan for the next Plan Year and to authorize the necessary salary reductions to pay for the Benefits
elected.The Election Form/Salary Reduction Agreement must be returned to the Plan Administrator on or
before the last day of the Open Enrollment Period,and it shall become effective on the first day of the next
Plan Year.
4.3 Failure of Eligible Employee to File an Election Form/Salary Reduction Agreement
If an Eligible Employee fails to file an Election Form/Salary Reduction Agreement within the time period
described in Sections 4.1 and 4.2,then the Employee shall continue with the same elections as the prior
year for insured/premium benefits.
•
If an Employee who fails to file an Election Form/Salary Reduction Agreement is eligible for Premium
Insurance Benefits and has made an effective election for such Benefits,then the Employee's share of the
Contributions for such Benefits will be paid with after-tax dollars outside of this Plan until such time as the
Employee files,during a subsequent Open Enrollment Period(or after an event occurs that would justify a
mid-year election change as described under Section 10.4)a timely Election Form/Salary Reduction
Agreement to elect Premium Payment Benefits. Until the Employee files such an election,the Employer's
portion of the Contribution will also be paid outside of this Plan.
4.4 Irrevocability of Elections
Unless an exception applies, as described in Article X,a Participant's election under the Plan is irrevocable
for the duration of the Period of Coverage to which it relates.
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•
ARTICLE V
Benefits Offered and Method of Funding
5.1 Benefits Offered
When first eligible or during the Open Enrollment Period as described under Article IV,Participants will be
given the opportunity to elect specific Benefits offered under this Plan:
(a) Premium Payment Benefits,as described in Article VI;
(b) Health FSA Benefits, as described in Article VII;
(c) DCAP Benefits, as described in Article VIII;
In no event shall Benefits under the Plan be provided in the form of deferred compensation.
5.2 Participant Contributions
Participants who elect Benefits under the Plan may pay for the cost of that coverage on a pre-tax salary
reduction basis by completing an Election Form/Salary Reduction Agreement.
(a)Salary Reductions.The salary reduction for a pay period for a Participant is,for the Benefits
elected,an amount equal to(1)the annual Contributions for such Benefits(elected under the Plan
as applicable),divided by the number of pay periods in the Period of Coverage; (2)an amount
otherwise agreed upon between the Employer and the Participant;or(3)an amount deemed
appropriate by the Plan Administrator(i.e.,in the event of shortage in reducible Compensation,
amounts withheld and the Benefits to which salary reductions are applied may fluctuate). If a
Participant increases his or her election under the benefits elected under the Plan to the extent
permitted under Section 10.4,the salary reductions per pay period will be,for the Benefits affected,
an amount equal to: (1)the new reimbursement limit elected pursuant to Section 10.4, less the
salary reductions made prior to such election change,divided by the number of pay periods in the
balance of the Period of Coverage commencing with the election change; (2)an amount otherwise
agreed upon between the Employer and the Participant;or(3)an amount deemed appropriate by
the Plan Administrator(i.e., in the event of shortage of reducible Compensation,amounts withheld
and the benefits to which salary reductions are applied may fluctuate).
(b)Considered Employer Contributions for Certain Purposes.Salary reductions are applied by
the Employer to pay for the Participant's share of the Contributions for the benefits elected under the
Plan and,for the purposes of this Plan and the Code, are considered to be Employer contributions.
(c)After-Tax Contributions for Premium Payment Benefits.For those Participants who elect to
pay their share of the Contributions for any of the Premium Insurance Benefits with after-tax
deductions, both the Employee and Employer portions of such Contributions will be paid outside of
this Plan.
5.3 Funding This Plan
All of the amounts payable under this Plan may be paid from the general assets of the Employer, but
Premium Payment Benefits are paid as provided in the applicable insurance policy. Nothing herein will be
construed to require the Employer or the Plan Administrator to maintain any fund or to segregate any
amount for the benefit of any Participant,and no Participant or other person shall have any claim against,
right to,or security or other interest in any fund, account, or asset of the Employer from which any payment
under this Plan may be made.There is no trust or other fund from which Benefits are paid.While the
Employer has complete responsibility for the payment of Benefits out of its general assets(except for
Premium Payment Benefits paid as provided in the applicable insurance policy),it may hire an unrelated
third-party paying agent to make Benefit payments on its behalf.
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5.4 Maximum Contribution
The maximum contribution that may be made under this Plan for a Participant is the total of the maximums
that may be elected as Employer and Participant Contributions,as described under each Component.
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ARTICLE VI
Premium Payment Component
6.1 Benefits
The premium insurance benefits that may be offered under the Premium Payment Component for
premium-type benefits pursuant to an insurance policy issued by an insurance company,or a contract with
a point of service organization are medical,dental,vision,or other qualified benefits under Section 125.
Notwithstanding any other provision in this Plan,the premium insurance benefits are subject to the terms
and conditions of the respective insurance policy. No changes can be made with respect to such premium
insurance benefits under this Plan (such as mid-year changes in election)if such changes are not
permitted under the applicable insurance policy. Unless an exception applies, as described in ArticleX,
such election is irrevocable for the duration of the Period of Coverage to which it relates.
6.2 Contributions for Cost of Coverage
The annual Contribution for a Participants Premium Payment Benefits is equal to the amount as set by the
Employer,which may or may not be the same amount charged by the insurance provider.
6.3 Events Permitting Exception to Irrevocability Rule
A Participant may make a new election upon the occurrence of certain events, including a Change in
Status as described in Section 10.3, but only if such election change is made on account of and
corresponds with a Change in Status that affects eligibility for coverage under a plan of the Employer or a
plan of the Spouse's or Dependent's employer(referred to as the general consistency requirement).A
Change in Status that affects eligibility for coverage under a plan of the Employer or a plan of the Spouse's
or Dependent's employer includes a Change in Status that results in an increase or decrease in the
number of an Employee's family members(i.e.,a Spouse and/or Dependents)who may benefit from the
coverage.
Change in Status means any of the events described below,as well as any other events included under
subsequent changes to Code section 125 or regulations issued thereunder,which the Plan Administrator,
in its sole discretion and on a uniform and consistent basis,determines are permitted under IRS
regulations and under this Plan.
A Participant may change an election under the regulations for the Premium Component of this Plan as
described below upon the occurrence of the stated events:
(a)Open Enrollment Period
(b) Change in Status:
(b.1)Change in Employee's Legal Marital Status
(b.2)Change in the Number of Employee's Dependents
(b.3)Change in Employment Status of Employee,Spouse or Dependent that Affects Eligibility
(b.4) Event Causing Employee's Dependent to Satisfy or Cease to Satisfy Eligibility
Requirements
(b.5)Change in Place of Residence
(c)Cost Changes with Automatic Increase/Decrease in Elective Contributions
(d)Significant Cost Increase or Significant Cost Decrease
(e)Significant Curtailment of Coverage(With or Without Loss of Coverage)
(f)Addition or Significant Improvement of a Benefit Package Option
(g)Change in Coverage Under Another Employer Cafeteria Plan or Qualified Benefits Plan
(h) Loss of Coverage Under Other Group Health Coverage
(i)HIPAA Special Enrollment Rights
(j)COBRA Qualifying Events
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(k)Certain Judgments, Decrees and Orders(QMCSO)
(I)Medicare and Medicaid Eligibility
(m) FMLA Leaves of Absence
6.4 Insurance Benefits Provided Under the Plan
Insurance benefits will be provided by the insurance provider(s), not this Plan.The types and amounts of
insurance benefits,the requirements for participating in each insurance plan,and the other terms and
conditions of coverage and benefits of the insurance plan(s)are set forth by the insurance provider.All
claims to receive benefits under the insurance plan shall be subject to and governed by the terms and
conditions of the insurance plan and the rules,regulations, policies,and procedures adopted in
accordance therewith,as may be amended from time to time.
6.5 Medical Insurance Benefits; COBRA
Notwithstanding any provision to the contrary in this Plan,to the extent required by COBRA,a Participant
and his or her Spouse and Dependents,as applicable,whose coverage terminates under the medical
insurance plan because of a COBRA qualifying event(and who is a qualified beneficiary as defined under
COBRA), shall be given the opportunity to continue on a self-pay basis the same coverage that he or she
had under the medical insurance plan the day before the qualifying event for the periods prescribed by
COBRA. Such continuation coverage shall be subject to all conditions and limitations under COBRA.
Contributions for COBRA coverage for medical insurance benefits may be paid on a pre-tax basis for
current Employees receiving taxable compensation(as may be permitted by the Plan Administrator on a
uniform and consistent basis, but may not be prepaid from contributions in one Plan Year to provide
coverage that extends into a subsequent Plan Year)where COBRA coverage arises either(a)because the
Employee ceases to be eligible because of a reduction in hours;or(b)because the Employee's
Dependent ceases to satisfy the eligibility requirements for coverage. For all other individuals(e.g.,
Employees who cease to be eligible because of retirement,termination of employment,or layoff),
Contributions for COBRA coverage for medical insurance benefits shall be paid on an after-tax basis
(unless may be otherwise permitted by the Plan Administrator on a uniform and consistent basis,but may
not be prepaid from contributions in one Plan Year to provide coverage that extends into a subsequent
Plan Year).
6.6 Premium Insurance Benefits Grace Period
No grace period applies to the Premium Component of this Plan.
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ARTICLE VII
Health FSA Component
7.1 Health FSA Benefits
An Eligible Employee can elect to participate in the Health FSA Component by electing (a)to receive
benefits in the form of reimbursements for Medical Care Expenses from the Health FSA(Health FSA
Benefits);and(b)to pay the Contribution for such Health FSA Benefits on a pre-tax salary reduction basis.
Unless an exception applies(as described in Article X),any such election is irrevocable for the duration of
the Period of Coverage to which it relates.
Once an Employee has met the Plan's eligibility requirements,the Eligible Employee may commence
participation on the date the eligibility requirements have been met.
7.2 Contributions for Cost of Coverage of Health FSA Benefits
The annual Contribution for a Participant's Health FSA Benefits is equal to the annual benefit amount
elected by the Participant, if applicable.
7.3 Eligible Medical Care Expenses for Health FSA
Under the Health FSA Component,a Participant may receive reimbursement for Medical Care Expenses
incurred during the Period of Coverage for which an election is in force.
(a)Incurred.A Medical Care Expense is incurred at the time the medical care or service giving rise
to the expense is furnished and not when the Participant is formally billed for, is charged for, or pays
for the medical care.
(b) Medical Care Expenses."Medical Care Expenses"will vary depending on which Health FSA
coverage option the Participant has elected.
- General-Purpose Health FSA Option.For purposes of this Option,"Medical Care Expenses"
means expenses incurred by a Participant or his or her Spouse or Dependents for medical
care, as defined in Code section 213(d),provided, however,that this term does not include
expenses that are excluded under Appendix A to this Plan, nor any expenses for which the
Participant is reimbursed for the expense through the Medical Insurance Plan, other insurance,
or any other accident or health plan. If only a portion of a Medical Care Expense has been
reimbursed elsewhere(e.g., because the Medical Insurance Plan imposes co-payment or
deductible limitations),then the Health FSA can reimburse the remaining portion of such
Expense if it otherwise meets the requirements of this Article.
7.4 Events Permitting Exception to Irrevocability Rule
A Participant may make a new election upon the occurrence of certain events, including a Change in
Status as described in Section 10.3, but only if such election change is made on account of and
corresponds with a Change in Status that affects eligibility for coverage under a plan of the Employer or a
plan of the Spouse's or Dependent's employer(referred to as the general consistency requirement).A
Change in Status that affects eligibility for coverage under a plan of the Employer or a plan of the Spouse's
or Dependent's employer includes a Change in Status that results in an increase or decrease in the
number of an Employee's family members(i.e.,a Spouse and/or Dependents)who may benefit from the
coverage.
"Change in Status"means any of the events described below,as well as any other events included under
subsequent changes to Code section 125 or regulations issued thereunder,which the Plan Administrator,
in its sole discretion and on a uniform and consistent basis,determines are permitted under IRS
regulations and under this Plan.
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A Participant may change an election under the regulations for the Health FSA Component of this Plan as
described below upon the occurrence of the stated events:
(a)Open Enrollment Period
(b)Change in Status:
(b.1)Change in Employee's Legal Marital Status
(b.2)Change in the Number of Employee's Dependents
(b.3)Change in Employment Status of Employee,Spouse or Dependent that Affects Eligibility
(b.4)Event Causing Employee's Dependent to Satisfy or Cease to Satisfy Eligibility
Requirements
(c)HIPAA Special Enrollment Rights(only if plan is subject to HIPAA)
(d)COBRA Qualifying Events
(e)Certain Judgments, Decrees and Orders(QMCSO)
(f)Medicare and Medicaid Eligibility
(g) FMLA Leaves of Absence
7.5 Maximum Benefits for Health FSA
(a) Maximum Reimbursement Available; Uniform Coverage.The maximum dollar amount
elected by the Participant for reimbursement of Medical Care Expenses incurred during a Period of
Coverage(reduced by prior reimbursements during the Period of Coverage)shall be available at all
times during the Period of Coverage, regardless of the actual amounts credited to the Participant's
Health FSA Account pursuant to Section 7.7. Notwithstanding the foregoing, no reimbursements will
be available for Medical Care Expenses incurred after coverage under this Plan has terminated,
unless the Participant has elected COBRA as provided in Section 7.10 or is entitled to submit
expenses incurred during a Grace Period as provided in Section 7.6. Payment shall be made to the
Participant in cash as reimbursement for Medical Care Expenses incurred during the Period of
Coverage for which the Participant's election is effective(or during a Grace Period, if applicable
under Section 7.6), provided that the other requirements of this Article have been satisfied.
Reimbursements due for Medical Care Expenses incurred by the Participant's Spouse or
Dependents shall be charged against the Participant's Health FSA Account.
(b) Changes to Dollar Limits.For subsequent Plan Years,the maximum dollar limit may be
changed by the Plan Administrator and shall be communicated to Employees through the Election
Form/Salary Reduction Agreement or another document. If a Participant enters the Health FSA
Component mid-year or wishes to increase his or her election mid-year as permitted under Section
7.4,then the Participant's maximum dollar limit will be prorated based on a percentage of the Plan
Year remaining.
(c)Monthly Limits on Reimbursing OTC Drugs.
Only reasonable quantities of over-the-counter(OTC)drugs or medicines of the same kind may be
reimbursed from a Participant's Health FSA Account in a single calendar month(even assuming
that the drug otherwise meets the requirements of this Article, including that it is for medical care
under Code section 213(d)); stockpiling is not permitted.
7.6 Health FSA Benefit Grace Period
Special Rules for Claims Incurred During a Grace Period. The Health FSA Component has a grace period
which allows for an additional period of time of 2.5 month(s)following the end of each Plan Year to incur
expenses before the"use it or lose it"forfeiture rule applies. Thus,expenses incurred within2.5 month(s)
after the close of the Plan Year can be reimbursed with funds carried over from the prior Plan Year.
However,any unused amounts from the prior Plan Year that are not used to reimburse expenses by the
end of the run-out-period remain subject to the"use it or lose it"rule and must be forfeited.
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Notwithstanding any contrary provision in this Plan and subject to the conditions of Section 7.5(b),an
individual may be reimbursed for Medical Care Expenses incurred during a Grace Period from amounts
remaining in his or her Health FSA Account at the end of the Plan Year to which that Grace Period relates
("Prior Plan Year Health FSA Amounts")if he or she is either: (1)a Participant with Health FSA coverage
that is in effect on the last day of that Plan Year; or(2)a qualified beneficiary(as defined under COBRA)
who has COBRA coverage under the Health FSA Component on the last day of that Plan Year.
7.7 Establishment of Health FSA Account
The Plan Administrator will establish and maintain a Health FSA Account with respect to each Participant
for each Plan Year or other Period of Coverage who has elected to participate in the Health FSA
Component, but it will not create a separate fund or otherwise segregate assets for this purpose.The
Account so established will merely be a recordkeeping account with the purpose of keeping track of
contributions and determining forfeitures under Section 7.8.
(a)Crediting of Accounts.A Participant's Health FSA Account for a Plan Year or other Period of
Coverage will be credited periodically during such period with an amount equal to the Participants
salary reductions elected to be allocated to such Account.
(b)Debiting of Accounts.A Participants Health FSA Account for a Plan Year or other Period of
Coverage will be debited for any reimbursement of Medical Care Expenses incurred during such
period(or for reimbursement of Medical Care Expenses incurred during any Grace Period to which
he or she is entitled as provided in Section 7.6).
(c)Available Amount Not Based on Credited Amount.As described in Section 7.5,the amount
available for reimbursement of Medical Care Expenses is the Participant's annual benefit amount,
reduced by prior reimbursements for Medical Care Expenses incurred during the Plan Year or other
Period of Coverage(or during the Grace Period, if applicable); it is not based on the amount credited
to the Health FSA Account at a particular point in time except as provided in Section 7.6.Thus,a
Participant's Health FSA Account may have a negative balance during a Plan Year or other Period
of Coverage,but the aggregate amount of reimbursement shall in no event exceed the maximum
dollar amount elected by the Participant under this Plan.
7.8 Forfeiture of Health FSA Accounts and Use-It-or-Lose-It Rule
(a) Use-It-or-Lose-It Rule.Except as otherwise provided in Section 7.6(regarding certain individuals
who may be reimbursed from Prior Plan Year Health FSA Amounts for expenses incurred during a
Grace Period), if any balance remains in the Participant's Health FSA Account for a Period of
Coverage after all reimbursements have been made for the Period of Coverage,then such balance
shall not be carried over to reimburse the Participant for Medical Care Expenses incurred during a
subsequent Plan Year.The Participant shall forfeit all rights with respect to such balance.
(b) Use of Forfeitures.All forfeitures under this Plan shall be used as follows:first,to offset any
losses experienced by the Employer during the Plan Year as a result of making reimbursements
(i.e., providing Health FSA Benefits)with respect to all Participants in excess of the Contributions
paid by such Participants through salary reductions;second,to reduce the cost of administering the
Health FSA Component during the Plan Year or the subsequent Plan Year(all such administrative
costs shall be documented by the Plan Administrator);and third,to provide increased benefits or
compensation to Participants in subsequent years in any weighted or uniform fashion that the Plan
Administrator deems appropriate,consistent with applicable regulations. In addition,any Health FSA
Account benefit payments that are unclaimed(e.g., uncashed benefit checks)by the close of the
Plan Year following the Run-Out Period in which the Medical Care Expense was incurred shall be
forfeited and applied as described above.
7.9 Reimbursement Claims Procedure for Health FSA
(a) Claims Substantiation.A Participant who has elected to receive Health FSA Benefits for a
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Period of Coverage may apply for reimbursement by submitting a request in writing to the Plan
Administrator in such form as the Plan Administrator may prescribe, by no later than 90 days
following the close of the Plan Year in which the Medical Care Expense was incurred(except that for
a Participant who ceases to be eligible to participate,this must be done no later than 90 days after
the date that eligibility ceases, as described in Section 7.10)setting forth:
- the person(s)on whose behalf Medical Care Expenses have been incurred;
- the nature and date of the Expenses so incurred;
- the amount of the requested reimbursement;
- a statement that such Expenses have not otherwise been reimbursed and that the Participant
will not seek reimbursement through any other source; and
- other such details about the expenses that may be requested by the Plan Administrator in the
reimbursement request form or otherwise(e.g., a statement from a medical practitioner that the
expense is to treat a specific medical condition,or a more detailed certification from the
Participant).
The application shall be accompanied by bills, invoices,or other statements from an independent
third party showing that the Medical Care Expenses have been incurred and showing the amounts of
such Expenses, along with any additional documentation that the Plan Administrator may request.
If the Health FSA is accessible by an electronic payment card (e.g.,debit card,credit card,or similar
arrangement),the Participant will be required to comply with substantiation procedures established
by the Plan Administrator in accordance with Rev. Rul.2003-43, IRS Notice 2006-69,or other IRS
guidance.
(b)Timing.Within 30 days after receipt by the Plan Administrator of a reimbursement claim from a
Participant,the Employer will reimburse the Participant for the Participant's Medical Care Expenses
(if the Plan Administrator approves the claim),or the Plan Administrator will notify the Participant that
his or her claim has been denied.This time period may be extended by an additional 15 days for
matters beyond the control of the Plan Administrator,including in cases where a reimbursement
claim is incomplete.The Plan Administrator will provide written notice of any extension, including the
reasons for the extension, and will allow the Participant 45 days in which to complete the previously
incomplete reimbursement claim.
(c) Claims Denied.For reimbursement claims that are denied, see the appeals procedure in Article
XI.
(d)Claims Ordering.
Medical Care Expenses incurred during a Grace Period and approved for reimbursement in
accordance with the Claims Substantiation procedures will be reimbursed first from any available
Prior Plan Year Health FSA Amounts and then from any amounts that are available to reimburse
expenses that are incurred during the current Plan Year.
If a claim is made for Medical Care Expenses incurred during a Grace Period,and approved for
reimbursement in accordance with the Claims Substantiation procedures,the claim shall be paid in
the order in which it is adjudicated and shall be irrevocable,except that if the Health FSA is
accessible by an electronic payment card (e.g.,debit card,credit card,or similar arrangement),
Medical Care Expenses incurred during the Grace Period may need to be submitted manually in
order to be reimbursed from Prior Plan Year Health FSA Amounts if the card is unavailable for such
reimbursement.
7.10 Reimbursements From Health FSA After Termination of Participation;COBRA
When a Participant ceases to be a Participant under Section 3.2,the Participant's salary reductions and
election to participate will terminate. Except as otherwise provided in Section 7.6(regarding certain
individuals who may be reimbursed from Prior Plan Year Health FSA Amounts for expenses incurred
during a Grace Period),the Participant will not be able to receive reimbursements for Medical Care
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Expenses incurred after the end of the day on which the Participants employment terminates or the
Participant otherwise ceases to be eligible. However, such Participant(or the Participant's estate)may
claim reimbursement for any Medical Care Expenses incurred during the Period of Coverage prior to the
date that the Participant ceases to be eligible(or during any Grace Period to which he or she is entitled as
provided in Section 7.6), provided that the Participant(or the Participant's estate)files a claim within 90
days after the date that the Participant ceases to be a Participant.
Notwithstanding any provision to the contrary in this Plan,to the extent required by COBRA,a Participant
and his or her Spouse and Dependents,as applicable,whose coverage terminates under the Health FSA
Component because of a COBRA qualifying event(and who is a qualified beneficiary as defined under
COBRA)shall be given the opportunity to continue on a self-pay basis the same coverage that he or she
had under the Health FSA Component the day before the qualifying event for the periods prescribed by
COBRA.
Specifically, such individuals will be eligible for COBRA continuation coverage only if, under Section 7.7,
they have a positive Health FSA Account balance at the end of the applicable Period of Coverage(taking
into account all claims submitted before the date of the qualifying event).
Such individuals will be notified if they are eligible for COBRA continuation coverage. If COBRA is elected,
it will be available only for the remainder of the applicable Period of Coverage; such COBRA coverage for
the Health FSA Component will cease at the end of the Plan Year and cannot be continued for the next
Plan Year. Such continuation coverage shall be subject to all conditions and limitations under COBRA.
Notwithstanding the foregoing, a qualified beneficiary(as defined under COBRA)who has COBRA
coverage under the Health FSA Component on the last day of a Plan Year may be entitled to
reimbursement of Medical Care Expenses incurred during the Grace Period following that Plan Year in
accordance with the provisions of Section 7.6.
Contributions for coverage for Health FSA Benefits may be paid on a pre-tax basis for current Employees
receiving taxable compensation(as may be permitted by the Plan Administrator on a uniform and
consistent basis,but may not be prepaid from contributions in one Plan Year to provide coverage that
extends into a subsequent Plan Year)where COBRA coverage arises either(a)because the Employee
ceases to be eligible because of a reduction of hours or(b)because the Employee's Dependent ceases to
satisfy the eligibility requirements for coverage. For all other individuals(e.g., Employees who cease to be
eligible because of retirement,termination of employment,or layoff), Contributions for COBRA coverage
for Health FSA Benefits shall be paid on an after-tax basis(unless permitted otherwise by the Plan
Administrator on a uniform and consistent basis, but may not be prepaid from contributions in one Plan
Year to provide coverage that extends into a subsequent Plan Year).
7.11 Named Fiduciary for Health FSA
Your Human Resources Rep is the named fiduciary for the Health FSA Component for purposes of ERISA
Section 402(a).
7.12 Coordination of Benefits with Other Plans
Health FSA Benefits are intended to pay benefits solely for Medical Care Expenses for which Participants
have not been previously reimbursed and will not seek reimbursement elsewhere.Accordingly,the Health
FSA shall not be considered to be a group health plan for coordination of benefits purposes,and Health
FSA Benefits shall not be taken into account when determining benefits payable under any other plan.
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ARTICLE VIII
DCAP Component
8.1 DCAP Benefits
An Eligible Employee can elect to participate in the DCAP Component by electing to receive benefits in the
form of reimbursements for Dependent Care Expenses and to pay the Contribution for such benefits on a
pre-tax salary reduction basis. Unless an exception applies(as described in Article X),such election of
DCAP Benefits is irrevocable for the duration of the Period of Coverage to which it relates.
Once an Employee has met the Plan's eligibility requirements,the Eligible Employee may commence
participation on the date the eligibility requirements have been met.
8.2 Contributions for Cost of Coverage for DCAP Benefits
The annual Contribution for a Participant's DCAP Benefits is equal to the annual benefit amount elected by
the Participant subject to the dollar limits set forth in Section 8.5(b).
8.3 Eligible Dependent Care Expenses
Under the DCAP Component,a Participant may receive reimbursement for Dependent Care Expenses
incurred during the Period of Coverage for which an election is in force.
(a)Incurred.A Dependent Care Expense is incurred at the time the Qualifying Dependent Care
Services giving rise to the expense is furnished, not when the Participant is formally billed for, is
charged for,or pays for the Qualifying Dependent Care Services(e.g., services rendered for the
month of June are not fully incurred until June 30 and cannot be reimbursed in full until then).
(b) Dependent Care Expenses."Dependent Care Expenses"are expenses that are considered to
be employment-related expenses under Code section 21(b)(2)(relating to expenses for the care of
a Qualifying Individual necessary for gainful employment of the Employee and Spouse, if any),and
expenses for incidental household services, if paid for by the Eligible Employee to obtain Qualifying
Dependent Care Services, provided, however,that this term shall not include any expenses for
which the Participant or other person incurring the expense is reimbursed for the expense through
insurance or any other plan. If only a portion of a Dependent Care Expense has been reimbursed
elsewhere(e.g., because the Spouse's DCAP imposes maximum benefit limitations),the DCAP can
reimburse the remaining portion of such expense if it otherwise meets the requirements of this
Article.
(c)Qualifying Individual."Qualifying Individual"means:
- a tax dependent of the Participant as defined in Code section 152 who is under the age of 13
and who is the Participant's qualifying child as defined in Code section 152(a)(1);
- a tax dependent of the Participant as defined in Code section 152 who is physically or mentally
incapable of self-care and who has the same principal place of abode as the Participant for
more than half of the year;or
- a Participant's Spouse who is physically or mentally incapable of self-care,and who has the
same principal place of abode as the Participant for more than half of the year.
Notwithstanding the foregoing, in the case of divorced parents,a Qualifying Individual who is a child
shall, as provided in Code section 21(e)(5), be treated as a Qualifying Individual of the custodial
parent(within the meaning of Code section 152(e)(3)(A))and shall not be treated as a Qualifying
Individual with respect to the non-custodial parent.
(d)Qualifying Dependent Care Services."Qualifying Dependent Care Services"means the
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following:services that both(1)relate to the care of a Qualifying Individual that enable the
Participant and his or her Spouse to remain gainfully employed after the date of participation in the
DCAP Component and during the Period of Coverage;and (2)are performed:
- in the Participant's home; or
- outside the Participant's home for(1)the care of a Participant's qualifying child who is under
age 13;or(2)the care of any other Qualifying Individual who regularly spends at least eight
hours per day in the Participant's household. In addition,if the expenses are incurred for
services provided by a dependent care center(i.e., a facility that provides care for more than six
individuals not residing at the facility and that receives a fee, payment,or grant for such
services),then the center must comply with all applicable state and local laws and regulations.
(e) Exclusions.Dependent Care Expenses do not include amounts paid to:
- an individual with respect to whom a personal exemption is allowable under Code section
151(c)to a Participant or his or her Spouse;
- a Participant's Spouse;or
- a Participant's child(as defined in Code section 152(f)(1))who is under 19 years of age at the
end of the year in which the expenses were incurred.
8.4 Events Permitting Exception to Irrevocability Rule
A Participant may make a new election upon the occurrence of certain events, including a Change in
Status as described in Section 10.3,but only if such election change is made on account of and
corresponds with a Change in Status that affects eligibility for coverage under a plan of the Employer or a
plan of the Spouse's or Dependent's employer(referred to as the general consistency requirement).A
Change in Status that affects eligibility for coverage under a plan of the Employer or a plan of the Spouse's
or Dependent's employer includes a Change in Status that results in an increase or decrease in the
number of an Employee's family members(i.e.,a Spouse and/or Dependents)who may benefit from the
coverage.
"Change in Status"means any of the events described below, as well as any other events included under
subsequent changes to Code section 125 or regulations issued thereunder,which the Plan Administrator,
in its sole discretion and on a uniform and consistent basis,determines are permitted under IRS
regulations and under this Plan.
A Participant may change an election under the regulations for the DCAP Component of this Plan as
described below upon the occurrence of the stated events:
(a)Open Enrollment Period
(b)Change in Status:
(b.1)Change in Employee's Legal Marital Status
(b.2)Change in the Number of Employee's Dependents
(b.3)Change in Employment Status of Employee,Spouse or Dependent that Affects Eligibility
(b.4) Event Causing Employee's Dependent to Satisfy or Cease to Satisfy Eligibility
Requirements
(c)Significant Cost Changes: Significant Cost Increase or Significant Cost Decrease
(d)Significant Curtailment of Coverage(With or Without Loss of Coverage)
(e)Addition or Significant Improvement of a Benefit Package Option
(f)Change in Coverage Under Another Employer Cafeteria Plan or Qualified Benefits Plan
(g) FMLA Leaves of Absence
8.5 Maximum Benefits for DCAP
(a) Maximum Reimbursement Available.The maximum dollar amount elected by the Participant
for reimbursement of Dependent Care Expenses incurred during a Period of Coverage(reduced by
prior reimbursements during the Period of Coverage)shall only be available during the Period of
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Coverage to the extent of the actual amounts credited to the Participant's DCAP Account pursuant to
Section 8.6. No reimbursement will be made to the extent that such reimbursement would exceed
the balance in the Participant's Account(that is,the year-to-date amount that has been withheld
from the Participant's Compensation for reimbursement for Dependent Care Expenses for the
Period of Coverage, less any prior reimbursements). Payment shall be made to the Participant in
cash as reimbursement for Dependent Care Expenses incurred during the Period of Coverage for
which the Participant's election is effective, provided that the other requirements of this ArticleVlll
have been satisfied.
(b)Maximum Dollar Limits. The maximum annual benefit amount that a Participant may elect to
receive under this Plan in the form of reimbursements for Dependent Care Expenses incurred in any
Period of Coverage shall be the maximum limit as indexed under Code section 129(a)(2). Or if
lower,the maximum amount that the Participant has reason to believe will be excludable from his or
her income at the time the election is made as a result of the applicable statutory limit for the
Participant.The applicable statutory limit for a Participant is the smallest of the following amounts:
- the Participant's Earned Income for the calendar year;
- the Earned Income of the Participant's Spouse for the calendar year(Note:A Spouse who(1)
is not employed during a month in which the Participant incurs a Dependent Care Expense;and
(2)is either physically or mentally incapable of self-care or a Student shall be deemed to have
Earned Income in the amount indexed under Code section 129(b)(2)per Qualifying Individual
for whom the Participant incurs Dependent Care Expenses,up to a maximum amount indexed
under Code section 129(b)(2));or
- either the maximum statutory limit indexed under Code section 129(a)(2)for the calendar year,
as applicable:
(1)Statutory maximum amount as indexed under Code section 129(a)(2)for the calendar
year if one of the following applies:
- the Participant is married and files a joint federal income tax return;
- the Participant is married,files a separate federal income tax return, and meets the
following conditions:(1)the Participant maintains as his or her home a household that
constitutes(for more than half of the taxable year)the principal abode of a Qualifying
Individual(i.e.,the Dependent for whom the Participant is eligible to receive reimbursements
under the DCAP);(2)the Participant furnishes over half of the cost of maintaining such
household during the taxable year;and(3)during the last six months of the taxable year,the
Participant's Spouse is not a member of such household(i.e.,the Spouse maintained a
separate residence);or
- the Participant is single or is the head of the household for federal income tax purposes;or
(2)Statutory maximum amount indexed under Code section 129(a)(2)for the calendar year if
the Participant is married and resides with the Spouse but files a separate federal income tax
return.
(c)Changes.For subsequent Plan Years,the maximum dollar limit may be changed by the Plan
Administrator and shall be communicated to Employees through the Election Form/Salary
Reduction Agreement or another document. If a Participant enters the DCAP Component mid-year
or wishes to increase his or her election mid-year as permitted under Section 8.4,then the
Participant's maximum dollar limit will be prorated based on a percentage of the Plan Year
remaining.
8.6 Establishment of DCAP Account
The Plan Administrator will establish and maintain a DCAP Account with respect to each Participant for
each Plan Year or other Period of Coverage who has elected to participate in the DCAP Component, but it
will not create a separate fund or otherwise segregate assets for this purpose.The Account so established
will merely be a recordkeeping account with the purpose of keeping track of contributions and determining
forfeitures under Section 8.8.
(a) Crediting of Accounts.A Participant's DCAP Account for a Plan Year or other Period of
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Coverage will be credited periodically during such period with an amount equal to the Participants
salary reductions elected to be allocated to such Account.
(b)Debiting of Accounts.A Participant's DCAP Account will be debited during each Period of
Coverage for any reimbursement of Dependent Care Expenses incurred during the Period of
Coverage.
(c)Available Amount Is Based on Credited Amount.As described in Section 8.5,the amount
available for reimbursement of Dependent Care Expenses may not exceed the year-to-date amount
credited to the Participant's DCAP Account, less any prior reimbursements(i.e.,it is based on the
amount credited to the DCAP Account at a particular point in time).Thus,a Participant's DCAP
Account may not have a negative balance during a Period of Coverage.
8.7 DCAP Benefits Grace Period
This benefit has a grace period which allows for an additional period of time of 2 month(s)following the
end of each Plan Year to incur expenses before the"use it or lose it"forfeiture rule applies.Thus,
expenses incurred within 2 month(s)after the close of the Plan Year can be reimbursed with funds carried
over from the prior Plan Year. However,any unused amounts from the prior Plan Year that are not used to
reimburse expenses by the end of the grace period remain subject to the"use it or lose it"rule and must be
forfeited.
8.8 Forfeiture of DCAP Accounts; Use-It-or-Lose-It Rule
If any balance remains in the Participant's DCAP Account for a Period of Coverage after all
reimbursements have been made for the Period of Coverage,then such balance shall not be carried over
to reimburse the Participant for Dependent Care Expenses incurred during a subsequent Plan Year.The
Participant shall forfeit all rights with respect to such balance.All forfeitures under this Plan shall be used
as follows:first,to offset any losses experienced by the Employer during the Plan Year as a result of
making reimbursements(i.e., providing DCAP Benefits)with respect to all Participants in excess of the
Contributions paid by such Participants through salary reductions;second,to reduce the cost of
administering the DCAP during the Plan Year or the subsequent Plan Year(all such administrative costs
shall be documented by the Plan Administrator);and third,to provide increased benefits or compensation
to Participants in subsequent years in any weighted or uniform fashion the Plan Administrator deems
appropriate,consistent with applicable regulations. In addition,any DCAP Account benefit payments that
are unclaimed (e.g., uncashed benefit checks)by the close of the Plan Year following the Period of
Coverage in which the Dependent Care Expense was incurred shall be forfeited and applied as described
above.
8.9 Reimbursement Claims Procedure for DCAP
(a)Claims Substantiation.A Participant who has elected to receive DCAP Benefits for a Period of
Coverage may apply for reimbursement by submitting a request for reimbursement in writing to the
Plan Administrator in such form as the Plan Administrator may prescribe, by no later than the90
days following the close of the Plan Year in which the Dependent Care Expense was incurred
(except for a Participant who ceases to be eligible to participate, by no later than 90 days after the
date that eligibility ceases, as described in Section 8.10),setting forth:
- the person(s)on whose behalf Dependent Care Expenses have been incurred;
- the nature and date of the Expenses so incurred;
- the amount of the requested reimbursement;
- the name of the person,organization or entity to whom the Expense was or is to be paid,and
taxpayer identification number(Social Security number, if the recipient is a person);
- a statement that such Expenses have not otherwise been reimbursed and that the Participant
will not seek reimbursement through any other source;
- the Participant's certification that he or she has no reason to believe that the reimbursement
requested, added to his or her other reimbursements to date for Dependent Care Expenses
incurred during the same calendar year,will exceed the applicable statutory limit for the
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Participant as described in Section 8.5(b);and
- other such details about the expenses that may be requested by the Plan Administrator in the
reimbursement request form or otherwise(e.g., a more detailed certification from the
Participant).
The application shall be accompanied by bills, invoices,or other statements from an independent
third party showing that the Dependent Care Expenses have been incurred and showing the
amounts of such Expenses, along with any additional documentation that the Plan Administrator
may request.
(b)Timing.Within 30 days after receipt by the Plan Administrator of a reimbursement claim from a
Participant,the Employer will reimburse the Participant for the Participant's Dependent Care
Expenses(if the Plan Administrator approves the claim),or the Plan Administrator will notify the
Participant that his or her claim has been denied.This time period may be extended by an additional
15 days for matters beyond the control of the Plan Administrator, including in cases where a
reimbursement claim is incomplete.The Plan Administrator will provide written notice of any
extension, including the reasons for the extension, and will allow the Participant45 days in which to
complete the previously incomplete reimbursement claim.
(c)Claims Denied.For reimbursement claims that are denied, see the appeals procedure in Article
XI.
(d)Claims Ordering. If a claim is made for Dependent Care Expenses incurred during a Grace
Period,and approved for reimbursement in accordance with the Claims Substantiation procedures,
the Participant may designate,at the time a claim is presented to the Plan Administrator,against
which Plan Year(s)the claim shall be adjudicated.Once a claim is adjudicated in this manner, it
shall be irrevocable.
If the Participant either chooses to have the claim adjudicated against all applicable Plan Years,or
fails to designate against which Plan Year(s)each particular claim is to be paid, such claim(s)shall
first be charged to the Participants Account that relates to the Plan Year associated with the Grace
Period. If any part of a claim for a Dependent Care Expense remains unpaid it shall next be charged
to the Account relating to the Plan Year in which such Dependent Care Expense was incurred.Once
a claim is adjudicated in this manner, it shall be irrevocable.
8.10 Reimbursements From DCAP After Termination of Participation
When a Participant ceases to be a Participant under Section 3.2,the Participant's salary reductions and
election to participate will terminate.
The Participant will not be able to receive reimbursements for Dependent Care Expenses incurred after the
end of the day on which the Participant's employment terminates or the Participant otherwise ceases to be
eligible.
8.11 Report to DCAP Participants
On or before January 31 of each year,the Plan Administrator shall furnish to each Participant who has
received reimbursement for Dependent Care Expenses during the prior calendar year a written statement
showing the Dependent Care Expenses paid during such year with respect to the Participant,or showing •
the salary reductions for the year for the DCAP Component,as the Plan Administrator deems appropriate.
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ARTICLE IX
HIPAA Provisions for Health FSA
9.1 Provision of Protected Health Information to Employer
Members of the Employer's workforce have access to the individually identifiable health information of Plan
participants for administrative functions of the Health FSA.When this health information is provided from
the Health FSA to the Employer, it is Protected Health Information(PHI).The Health Insurance Portability
and Accountability Act of 1996(HIPAA)and its implementing regulations restrict the Employer's ability to
use and disclose PHI.The following HIPAA definition of PHI applies for purposes of this Article:
Protected Health Information.Protected health information means information that is created or
received by the Plan and relates to the past, present,or future physical or mental health or condition
of a participant;the provision of health care to a participant;or the past, present,or future payment
for the provision of health care to a participant;and that identifies the participant or for which there is
a reasonable basis to believe the information can be used to identify the participant. Protected health
information includes information of persons living or deceased.The Employer shall have access to
PHI from the Health FSA only as permitted under this Article or as otherwise required or permitted
by HIPAA.
9.2 Permitted Disclosure of Enrollment/Disenrollment Information
The Health FSA may disclose to the Employer information on whether the individual is participating in the
Plan.
9.3 Permitted Uses and Disclosure of Summary Health Information
The Health FSA may disclose Summary Health Information to the Employer, provided that the Employer
requests the Summary Health Information for the purpose of modifying,amending,or terminating the
Health FSA.
"Summary Health Information"means information(a)that summarizes the claims history, claims
expenses,or type of claims experienced by individuals for whom a plan sponsor had provided health
benefits under a health plan; and(b)from which the information described at 42 CFR Section
164.514(b)(2)(i)has been deleted,except that the geographic information described in 42 CFR Section
164.514(b)(2)(i)(B)need only be aggregated to the level of a five-digit ZIP code.
9.4 Permitted and Required Uses and Disclosure of PHI for Plan Administration Purposes
Unless otherwise permitted by law,and subject to the conditions of disclosure described in Section9.5 and
obtaining written certification pursuant to Section 9.7,the Health FSA may disclose PHI to the Employer,
provided that the Employer uses or discloses such PHI only for Plan administration purposes."Plan
administration purposes"means administration functions performed by the Employer on behalf of the
Health FSA,such as quality assurance,claims processing,auditing,and monitoring. Plan administration
functions do not include functions performed by the Employer in connection with any other benefit or
benefit plan of the Employer,and they do not include any employment-related functions. Notwithstanding
the provisions of this Plan to the contrary, in no event shall the Employer be permitted to use or disclose
PHI in a manner that is inconsistent with 45 CFR Section 164.504(f).
9.5 Conditions of Disclosure for Plan Administration Purposes
The Employer agrees that with respect to any PHI (other than enrollmenUdisenrollment information and
Summary Health Information,which are not subject to these restrictions)disclosed to it by the Health FSA,
the Employer shall:
- not use or further disclose the PHI other than as permitted or required by the Plan or as required
by law;
-24-
- ensure that any agent, including a subcontractor,to whom it provides PHI received from the Health
FSA agrees to the same restrictions and conditions that apply to the Employer with respect to PHI;
- not use or disclose the PHI for employment-related actions and decisions or in connection with any
other benefit or employee benefit plan of the Employer;
- report to the Plan any use or disclosure of the information that is inconsistent with the uses or
disclosures provided for of which it becomes aware;
- make available PHI to comply with HIPAA's right to access in accordance with 45 CFR Section
164.524;
- make available PHI for amendment and incorporate any amendments to PHI in accordance with
45 CFR Section 164.526;
- make available the information required to provide an accounting of disclosures in accordance with
45 CFR Section 164.528;
- make its internal practices, books,and records relating to the use and disclosure of PHI received
from the Health FSA available to the Secretary of Health and Human Services for purposes of
determining compliance by the Health FSA with HIPAA's privacy requirements;
- if feasible, return or destroy all PHI received from the Health FSA 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, limit further
uses and disclosures to those purposes that make the return or destruction of the information
infeasible; and
- ensure that the adequate separation between the Health FSA and the Employer(i.e.,the
"firewall"), required in 45 CFR Section 504(f)(2)(iii), is satisfied.
The Employer further agrees that if it creates, receives,maintains,or transmits any electronic PHI (other
than enrollment/disenrollment information and Summary Health Information,which are not subject to
these restrictions)on behalf of the Health FSA, it will implement administrative, physical,and technical
safeguards that reasonably and appropriately protect the confidentiality, integrity,and availability of the
electronic PHI,and it will ensure that any agents(including subcontractors)to whom it provides such
electronic PHI agrees to implement reasonable and appropriate security measures to protect the
information.The Employer will report to the Health FSA any security incident of which it becomes aware.
9.6 Adequate Separation Between Plan and Employer
The Employer shall allow the following persons access to PHI:the Plan Administrator,and any other
Employee who needs access to PHI in order to perform Plan administration functions that the Employer
performs for the Health FSA(such as quality assurance,claims processing, auditing, monitoring, payroll,
and appeals). No other persons shall have access to PHI.These specified employees(or classes of
employees)shall only have access to and use PHI to the extent necessary to perform the plan
administration functions that the Employer performs for the Health FSA. In the event that any of these
specified employees does not comply with the provisions of this Section,that employee shall be subject to
disciplinary action by the Employer for non-compliance pursuant to the Employer's employee discipline and
termination procedures.
The Employer will ensure that the provisions of this Section are supported by reasonable and appropriate
security measures to the extent that the designees have access to electronic PHI.
9.7 Certification of Plan Sponsor
The Health FSA shall disclose PHI to the Employer only upon the receipt of a certification by the Employer
that the Plan has been amended to incorporate the provisions of 45 CFR Section 164.504(f)(2)(ii),and that
the Employer agrees to the conditions of disclosure set forth in Section 9.5.
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ARTICLE X
Irrevocability of Elections; Exceptions
10.1 Irrevocability of Elections
Except as described in this Article,a Participant's election under the Plan is irrevocable for the duration of
the Period of Coverage to which it relates. In other words, unless an exception applies,the Participant may
not change any elections for the duration of the Period of Coverage regarding:
- participation in this Plan;
- salary reduction amounts; or
- election of particular Benefit Package Options(including the various Health FSA Options).
10.2 Procedure for Making New Election If Exception to Irrevocability Applies
(a)Timeframe for Making New Election.A Participant(or an Eligible Employee who,when first
eligible under Section 3.1 or during the Open Enrollment Period under Section 4.2,declined to be a
Participant)may make a new election within 30 days of the occurrence of an event described in
Section 10.3, as applicable, but only if the election under the new Election Form/Salary Reduction
Agreement is made on account of and is consistent with the event and if the election is made within
any specified time period. Notwithstanding the foregoing,a Change in Status(e.g.,a divorce or a
dependent's losing student status)that results in a beneficiary becoming ineligible for coverage
under the Medical Insurance Plan shall automatically result in a corresponding election change,
whether or not requested by the Participant within the normal 30-day period.
(b) Effective Date of New Election.Elections made pursuant to this Section shall be effective for
the balance of the Period of Coverage following the change of election unless a subsequent event
allows for a further election change. Except as provided in Section 10.3 for HIPAA special
enrollment rights in the event of birth,adoption,or placement for adoption,all election changes shall
be effective
(c) Effect of New Election Upon Amount of Benefits.For the effect of a changed election upon
the maximum and minimum benefits under the Health FSA, see Section 7.5 and DCAP Component,
see Section 8.5.
10.3 Change in Status Defined
A Participant may make a new election upon the occurrence of certain events as described below,
including a Change in Status,for the applicable Component, but only if such election change is made on
account of and corresponds with a Change in Status that affects eligibility for coverage under a plan of the
Employer or a plan of the Spouse's or Dependent's employer(referred to as the general consistency
requirement).A Change in Status that affects eligibility for coverage under a plan of the Employer or a plan
of the Spouse's or Dependent's employer includes a Change in Status that results in an increase or
decrease in the number of an Employee's family members(i.e., a Spouse and/or Dependents)who may
benefit from the coverage.
"Change in Status"means any of the events described below,as well as any other events included under
subsequent changes to Code section 125 or regulations issued thereunder,which the Plan Administrator,
in its sole discretion and on a uniform and consistent basis,determines are permitted under IRS
regulations and under this Plan:
(a)Open Enrollment Period.A Participant may change an election during the Open Enrollment
Period in accordance with Section 4.2.
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(b)Termination of Employment.A Participant's election will terminate under the Plan upon
termination of employment in accordance with Sections 3.2 and 3.3, as applicable.
(c)Legal Marital Status.A change in a Participant's legal marital status,including marriage,death
of a Spouse,divorce, legal separation,or annulment;
(d) Number of Dependents.Events that change a Participant's number of Dependents,including
birth, death,adoption,and placement for adoption;
(e) Employment Status.Any of the following events that change the employment status of the
Participant or his or her Spouse or Dependents:(1)a termination or commencement of
employment;(2)a strike or lockout; (3)a commencement of or return from an unpaid leave of
absence; (4)a change in worksite;and(5)if the eligibility conditions of this Plan or other employee
benefits plan of the Participant or his or her Spouse or Dependents depend on the employment
status of that individual and there is a change in that individual's status with the consequence that the
individual becomes(or ceases to be)eligible under this Plan or other employee benefits plan,such
as if a plan only applies to salaried employees and an employee switches from salaried to hourly-
paid, union to non-union,or full-time to part-time(or vice versa),with the consequence that the
employee ceases to be eligible for the Plan;
(f) Dependent Eligibility Requirements.An event that causes a Dependent to satisfy or cease to
satisfy the Dependent eligibility requirements for a particular benefit,such as attaining a specified
age, student status,or any similar circumstance;and
(g) Change in Residence.A change in the place of residence of the Participant or his or her
Spouse or Dependents that causes the gain or loss of eligibility for coverage option.
(h) Leaves of Absence.A Participant may change an election under the Plan upon FMLA leave in
accordance with Section 3.4 and upon non-FMLA leave in accordance with Section 3.5.
Assuming that the general consistency requirement is satisfied,a requested election change must
also satisfy the following specific consistency requirements in order for a Participant to be able to
alter his or her election based on the specified Change in Status:
(h.1) Loss of Spouse or Dependent Eligibility; Special COBRA Rules.For a Change in
Status involving a Participant's divorce,annulment or legal separation from a Spouse,the death
of a Spouse or a Dependent,or a Dependent's ceasing to satisfy the eligibility requirements for
coverage,a Participant may only elect to cancel accident or health insurance coverage for(a)
the Spouse involved in the divorce,annulment, or legal separation;(b)the deceased Spouse or
Dependent;or(c)the Dependent that ceased to satisfy the eligibility requirements.Canceling
coverage for any other individual under these circumstances would fail to correspond with that
Change in Status. Notwithstanding the foregoing, if the Participant or his or her Spouse or
Dependent becomes eligible for COBRA(or similar health plan continuation coverage under
state law)under the Employer's plan (and the Participant remains a Participant under this Plan in
accordance with Section 3.2),then the Participant may increase his or her election to pay for
such coverage(this rule does not apply to a Participant's Spouse who becomes eligible for
COBRA or similar coverage as a result of divorce,annulment,or legal separation).
(h.2)Gain of Coverage Eligibility Under Mother Employer's Plan.For a Change in Status in
which a Participant or his or her Spouse or Dependent gains eligibility for coverage under a
cafeteria plan or qualified benefit plan of the employer of the Participant's Spouse or Dependent
as a result of a change in marital status or a change in employment status,a Participant may
elect to cease or decrease coverage for that individual only if coverage for that individual
becomes effective or is increased under the Spouse's or Dependent's employer's plan.The Plan
Administrator may rely on a Participant's certification that the Participant has obtained or will
obtain coverage under the Spouse's or Dependent's employer's plan, unless the Plan
-27-
Administrator has reason to believe that the Participant's certification is incorrect.
(i) HIPAA Special Enrollment Rights.If a Participant or his or her Spouse or Dependent is entitled
to special enrollment rights under a group health plan (other than an excepted benefit),as required
by HIPAA under Code section 9801(f),then a Participant may revoke a prior election for group
health plan coverage and make a new election(including,when required by HIPAA,an election to
enroll in another benefit package under a group health plan), provided that the election change
corresponds with such HIPAA special enrollment right.As required by HIPAA,a special enrollment
right will arise in the following circumstances:
(i.1)a Participant or his or her Spouse or Dependent declined to enroll in group health plan
coverage because he or she had coverage,and eligibility for such coverage is subsequently lost
because:(1)the coverage was provided under COBRA and the COBRA coverage was
exhausted;or(2)the coverage was non-COBRA coverage and the coverage terminated due to
loss of eligibility for coverage or the employer contributions for the coverage were terminated; or
(i.2)a new Dependent is acquired as a result of marriage, birth, adoption,or placement for
adoption.
An election to add previously eligible Dependents as a result of the acquisition of a new Spouse or
Dependent child shall be considered to be consistent with the special enrollment right.An election
change on account of a HIPAA special enrollment attributable to the birth,adoption,or placement
for adoption of a new Dependent child may,subject to the provisions of the underlying group health
plan, be effective retroactively(up to 30 days).
0)Certain Judgments, Decrees and Orders.If a judgment,decree, or order(collectively, an
"Order")resulting from a divorce, legal separation,annulment,or change in legal custody(including
a QMCSO)requires accident or health coverage for a Participant's child(including a foster child who
is a Dependent of the Participant),then a Participant may(1)change his or her election to provide
coverage for the child (provided that the Order requires the Participant to provide coverage); or(2)
change his or her election to revoke coverage for the child if the Order requires that another
individual(including the Participant's Spouse or former Spouse)provide coverage under that
individual's plan and such coverage is actually provided.
(k) Medicare and Medicaid.If a Participant or his or her Spouse or Dependent who is enrolled in a
health or accident plan under this Plan becomes entitled to(i.e., becomes enrolled in)Medicare or
Medicaid(other than coverage consisting solely of benefits under Section 1928 of the Social
Security Act providing for pediatric vaccines),then the Participant may prospectively reduce or
cancel the health or accident coverage of the person becoming entitled to Medicare or Medicaid.
(I)Change in Cost.For purposes of this Section, "similar coverage"means coverage for the same
category of benefits for the same individuals(e.g.,family to family or single to single). For example,
two plans that provide major medical coverage are considered to be similar coverage. For purposes
of this definition,(1)a health FSA is not similar coverage with respect to an accident or health plan
that is not a health FSA; (2)an HMO and a PPO are considered to be similar coverage;and(3)
coverage by another employer,such as a Spouse's or Dependent's employer, may be treated as
similar coverage if it otherwise meets the requirements of similar coverage.
(m)Increase or Decrease for Insignificant Cost Changes.Participants are required to increase
their elective contributions(by increasing salary reductions)to reflect insignificant increases in their
required contribution for their Benefit Package Option(s),and to decrease their elective contributions
to reflect insignificant decreases in their required contribution.The Plan Administrator will determine
whether an increase or decrease is insignificant based upon all the surrounding facts and
circumstances,including but not limited to the dollar amount or percentage of the cost change. The
Plan Administrator,on a reasonable and consistent basis,will automatically effectuate this increase
or decrease in affected employees'elective contributions on a prospective basis.
-28-
(n) Significant Cost Increases.If the Plan Administrator determines that the cost charged to an
Employee of a Participant's Benefit Package Option(s)significantly increases during a Period of
Coverage,then the Participant may(a)make a corresponding prospective increase in his or her
elective contributions(by increasing salary reductions);(b)revoke his or her election for that
coverage,and in lieu thereof,receive on a prospective basis coverage under another Benefit
Package Option that provides similar coverage(such as an HMO, but not the Health FSA); or(c)
drop coverage prospectively if there is no other Benefit Package Option available that provides
similar coverage.
(o) Significant Cost Decreases.If the Plan Administrator determines that the cost of any Benefit
Package Option significantly decreases during a Period of Coverage,then the Plan Administrator
may permit the following election changes:(a)Participants who are enrolled in a Benefit Package
Option(such as an HMO,but not the Health FSA)other than the Benefit Package Option that has
decreased in cost may change their election on a prospective basis to elect the Benefit Package
Option that has decreased in cost(such as the PPO for the Medical Insurance Plan); and(b)
Employees who are otherwise eligible under Section 3.1 may elect the Benefit Package Option that
has decreased in cost(such as the PPO)on a prospective basis,subject to the terms and limitations
of the Benefit Package Option.
(p)Limitation on Change in Cost Provisions for DCAP Benefits.The"Change in Cost"
provisions apply to DCAP Benefits only if the cost change is imposed by a dependent care provider
who is not a"relative"of the Employee.For this purpose,a relative is an individual who is related as
described in Code section 152(d)(2)(A)through(G), incorporating the rules of Code section
152(f)(1)and 152(f)(4).
(q)Change in Coverage.For purposes of this Section, "similar coverage"means coverage for the
same category of benefits for the same individuals(e.g.,family to family or single to single). For
example,two plans that provide major medical coverage are considered to be similar coverage. For
purposes of this definition, (1)a health FSA is not similar coverage with respect to an accident or
health plan that is not a health FSA;(2)an HMO and a PPO are considered to be similar coverage;
and (3)coverage by another employer, such as a Spouse's or Dependent's employer, may be
treated as similar coverage if it otherwise meets the requirements of similar coverage.
(r)Significant Curtailment.If coverage is"significantly curtailed"(as defined below), Participants
may elect coverage under another Benefit Package Option that provides similar coverage. In
addition,as set forth below, if the coverage curtailment results in a"Loss of Coverage"(as defined
below),then Participants may drop coverage if no similar coverage is offered by the Employer.
(r.1)Significant Curtailment Without Loss of Coverage.If the Plan Administrator determines
that a Participant's coverage under a Benefit Package Option under this Plan(or the Participant's
Spouse's or Dependent's coverage under his or her employer's plan)is significantly curtailed
without a Loss of Coverage during a Period of Coverage,the Participant may revoke his or her
election for the affected coverage,and in lieu thereof,prospectively elect coverage under
another Benefit Package Option that provides similar coverage(such as the HMO, but not the
Health FSA). Coverage under a plan is deemed to be"significantly curtailed"only if there is an
overall reduction in coverage provided under the plan so as to constitute reduced coverage
generally.
(r.2) Significant Curtailment With a Loss of Coverage.If the Plan Administrator determines
that a Participant's Benefit Package Option coverage under this Plan (or the Participant's
Spouse's or Dependent's coverage under his or her employer's plan)is significantly curtailed,
and if such curtailment results in a Loss of Coverage during a Period of Coverage,then the
Participant may revoke his or her election for the affected coverage and may either prospectively
elect coverage under another Benefit Package Option that provides similar coverage(such as
the HMO,but not the Health FSA)or drop coverage if no other Benefit Package Option providing
-29-
similar coverage is offered by the Employer.
(r.3)Definition of Loss of Coverage.For purposes of this Section,a"Loss of Coverage"means
a complete loss of coverage(including the elimination of a Benefit Package Option,an HMO
ceasing to be available where the Participant or his or her Spouse or Dependent resides,or a
Participant or his or her Spouse or Dependent losing all coverage under the Benefit Package
Option by reason of an overall lifetime or annual limitation).In addition,the Plan Administrator
may treat the following as a Loss of Coverage:
- a substantial decrease in the medical care providers available under the Benefit Package
Option(such as a major hospital ceasing to be a member of a preferred provider network or
a substantial decrease in the number of physicians participating in the PPO for the Medical
Insurance Plan or in an HMO);
- a reduction in benefits for a specific type of medical condition or treatment with respect to
which the Participant or his or her Spouse or Dependent is currently in a course of
treatment;or
- any other similar fundamental loss of coverage.
(s)Addition or Significant Improvement of a Benefit Package Option.If during a Period of
Coverage the Plan adds a new Benefit Package Option or significantly improves an existing Benefit
Package Option,the Plan Administrator may permit the following election changes: (a)Participants
who are enrolled in a Benefit Package Option other than the newly added or significantly improved
Benefit Package Option may change their elections on a prospective basis to elect the newly added
or significantly improved Benefit Package Option;and(b)Employees who are otherwise eligible
under Section 3.1 may elect the newly added or significantly improved Benefit Package Option on a
prospective basis, subject to the terms and limitations of the Benefit Package Option.
(t) Loss of Coverage Under Other Group Health Coverage.A Participant may prospectively
change his or her election to add group health coverage for the Participant or his or her Spouse or
Dependent,if such individual(s)loses coverage under any group health coverage sponsored by a
governmental or educational institution.
(u)Change in Coverage Under Mother Employer Plan.A Participant may make a prospective
election change that is on account of and corresponds with a change made under an employer plan
(including a plan of the Employer or a plan of the Spouse's or Dependent's employer), so long as
(a)the other cafeteria plan or qualified benefits plan permits its participants to make an election
change that would be permitted under applicable IRS regulations;or(b)the Plan permits
Participants to make an election for a Period of Coverage that is different from the Plan Year under
the other cafeteria plan or qualified benefits plan.
10.4 Election Modifications Required by Plan Administrator
The Plan Administrator may,at any time, require any Participant or class of Participants to amend the
amount of their salary reductions for a Period of Coverage if the Plan Administrator determines that such
action is necessary or advisable in order to(a)satisfy any of the Code's nondiscrimination requirements
applicable to this Plan or other cafeteria plan; (b)prevent any Employee or class of Employees from
having to recognize more income for federal income tax purposes from the receipt of benefits hereunder
than would otherwise be recognized; (c)maintain the qualified status of benefits received under this Plan;
or(d)satisfy Code nondiscrimination requirements or other limitations applicable to the Employer's
qualified plans. In the event that contributions need to be reduced for a class of Participants,the Plan
Administrator will reduce the salary reduction amounts for each affected Participant,beginning with the
Participant in the class who had elected the highest salary reduction amount and continuing with the
Participant in the class who had elected the next-highest salary reduction amount, and so forth, until the
defect is corrected.
-30-
ARTICLE XI
Appeals Procedure
11.1 Procedure If Benefits Are Denied Under This Plan
If a claim for reimbursement or benefit under this Plan is wholly or partially denied,they shall be
administered in accordance with the procedure set forth below and in the summary plan description of this
Plan.The Appeals Committee,separate and distinct from the individual(s)that adjudicate the claims, shall
act on behalf of the Plan Administrator with respect to appeals.
Claims Under the Health FSA or DCAP Components.
If(a)a claim for reimbursement under the Health FSA or DCAP Components of the Cafeteria Plan is
wholly or partially denied,or(b)Participant is denied a benefit under the Plan due to an issue germane to
said coverage under the Plan,then the procedure described below will apply.
If a claim is denied in whole or in part, Participant will be notified in writing by the Plan Administrator within
30 days after the date the Plan Administrator received the claim. (This time period may be extended for an
additional 15 days for matters beyond the control of the Plan Administrator,including in cases where a
claim is incomplete.The Plan Administrator will provide written notice of any extension, including the
reasons for the extension and the date by which a decision by the Plan Administrator is expected to be
made.Where a claim is incomplete,the extension notice will also specifically describe the required
information,will allow the Participant 45 days from receipt of the notice in which to provide the specified
information and will have the effect of suspending the time for a decision on the claim until the specified
information is provided.)
Notification of a denied claim will include:
- a statement of the specific reason(s)for the denial;
- reference(s)to the specific Plan provision(s)on which the denial is based;
- a description of any additional material or information necessary for Participant to validate the
claim and an explanation of why such material or information is necessary;
- appropriate information on the steps to be taken if Participant wishes to appeal the Plan
Administrator's decision, including their right to submit written comments and have them
considered,their right to review(upon request and at no charge)relevant documents and other
information,and their right to file suit under ERISA(where applicable)with respect to any adverse
determination after appeal of their claim.
Appeals.
If a claim is denied in whole or part,then Participant(or authorized representative)may request review
upon written application to the Appeals Committee.The appeal must be made in writing within 180 days
after Participant's receipt of the notice that the claim was denied. If Participant does not appeal on time,
Participant will lose the right to appeal the denial and the right to file suit in court. Participant's written
appeal should state the reasons that they feel their claim should not have been denied. It should include
any additional facts and/or documents that they feel support their claim. Participant will have the
opportunity to ask additional questions and make written comments,and Participant may review(upon
request and at no charge)documents and other information relevant to their appeal.
Decision on Review.
Participant's appeal will be reviewed and decided by the Appeals Committee within a reasonable time not
later than 60 days after the Appeals Committee receives Participant's request for review.The Appeals
Committee may, in its discretion, hold a hearing on the denied claim.Any medical expert consulted in
connection with their appeal will be different from and not subordinate to any expert consulted in
connection with the initial claim denial.The identity of a medical expert consulted in connection with the
-31-
appeal will be provided. If the decision on review affirms the initial denial of the claim, Participant will be
furnished with a notice of adverse benefit determination on review setting forth:
- a statement of the specific reason(s)for the decision on review;
- reference(s)to the specific Plan provision(s)on which the decision is based;
- a statement of Participant's right to review(upon request and at no charge)relevant documents
and other information;
- if an "internal rule,guideline,protocol,or other similar criterion"is relied on in making the decision
on review,then a description of the specific rule,guideline, protocol,or other similar criterion or a
statement that such a rule,guideline, protocol, or other similar criterion was relied on and that a
copy of such rule,guideline,protocol, or other criterion will be provided free of charge to
Participant upon request;and
- a statement of Participant's right to bring suit under ERISA Section 502(a)(where applicable).
11.2 Claims Procedures for Medical Insurance Benefits
Claims and reimbursement for Medical Insurance Benefits shall be administered in accordance with the
claims procedures for the Medical Insurance Benefits,as set forth by the provider.
-32-
ARTICLE XII
Recordkeeping and Administration
12.1 Plan Administrator
The administration of this Plan shall be under the supervision of the Plan Administrator. It is the principal
duty of the Plan Administrator to see that this Plan is carried out, in accordance with its terms,for the
exclusive benefit of persons entitled to participate in this Plan without discrimination among them.
12.2 Powers of the Plan Administrator
The Plan Administrator shall have such duties and powers as it considers necessary or appropriate to
discharge its duties. It shall have the exclusive right to interpret the Plan and to decide all matters
thereunder,and all determinations of the Plan Administrator with respect to any matter hereunder shall be
conclusive and binding on all persons.Without limiting the generality of the foregoing,the Plan
Administrator shall have the following discretionary authority:
(a)to construe and interpret this Plan, including all possible ambiguities,inconsistencies,and
omissions in the Plan and related documents,and to decide all questions of fact,questions relating
to eligibility and participation,and questions of benefits under this Plan(provided that,
notwithstanding the first paragraph in this Section the Appeals Committee shall exercise such
exclusive power with respect to an appeal of a claim as outlined in the Appeals Procedure Section);
(b)to prescribe procedures to be followed and the forms to be used by Employees and Participants
to make elections pursuant to this Plan;
(c)to prepare and distribute information explaining this Plan and the benefits under this Plan in such
manner as the Plan Administrator determines to be appropriate;
(d)to request and receive from all Employees and Participants such information as the Plan
Administrator shall from time to time determine to be necessary for the proper administration of this
Plan;
(e)to furnish each Employee and Participant with such reports with respect to the administration of
this Plan as the Plan Administrator determines to be reasonable and appropriate, including
appropriate statements setting forth the amounts by which a Participant's Compensation has been
reduced in order to provide benefits under this Plan;
(f)to provide the Employer with such tax or other information it may require in connection with the
Plan;
(g)to receive, review,and keep on file such reports and information regarding the benefits covered
by this Plan as the Plan Administrator determines from time to time to be necessary and proper;
(h)to employ any agents, attorneys,accountants or other parties(who may also be employed by the
Employer)and to allocate or delegate to them such powers or duties as is necessary to assist in the
proper and efficient administration of the Plan, provided that such allocation or delegation and the
acceptance thereof is in writing;
(i)to appoint and employ such individuals or entities to assist in the administration of this Plan as it
determines to be necessary or advisable, including legal counsel and benefit consultants;
0)to sign documents for the purposes of administering this Plan, or to designate an individual or
individuals to sign documents for the purposes of administering this Plan;
-33-
(k)to secure independent medical or other advice and require such evidence as it deems necessary
to decide any claim or appeal; and
(I)to maintain the books of accounts, records,and other data in the manner necessary for proper
administration of this Plan and to meet any applicable disclosure and reporting requirements.
(m)to report to the Employer,or any party designated by the Employer,after the end of each Plan
Year regarding the administration of the Plan,and to report any significant problems as to the
administration of the Plan and to make recommendations for modifications as to procedures and
benefits,or any other change which might insure the efficient administration of the Plan.
However,nothing in this Section is meant to confer upon the Plan Administrator any powers to amend the
Plan or change any administrative procedure or adopt any other procedure involving the Plan without the
express written approval of the Employer regarding any amendment or change in administrative
procedure,or Benefit Provider. Notwithstanding the preceding sentence,the Plan Administrator is
empowered to take any actions he or she sees fit to assure that the Plan complies with the
nondiscrimination requirements of Section 125 of the Code.
12.3 Reliance on Participant,Tables,etc.
The Plan Administrator may rely upon the direction, information,or election of a Participant as being proper
under the Plan and shall not be responsible for any act or failure to act because of a direction or lack of
direction by a Participant.The Plan Administrator will also be entitled,to the extent permitted by law,to rely
conclusively on all tables,valuations,certificates,opinions,and reports that are furnished by accountants,
attorneys,or other experts employed or engaged by the Plan Administrator.
12.4 Provision for Third-Party Plan Service Providers
The Plan Administrator,subject to approval of the Employer,may employ the services of such persons as
it may deem necessary or desirable in connection with the operation of the Plan. Unless otherwise provided
in the service agreement,obligations under this Plan shall remain the obligation of the Employer.
12.5 Fiduciary Liability
To the extent permitted by law,the Plan Administrator shall not incur any liability for any acts or for failure
to act except for their own willful misconduct or willful breach of this Plan.
12.6 Compensation of Plan Administrator
Unless otherwise determined by the Employer and permitted by law,any Plan Administrator that is also an
Employee of the Employer shall serve without compensation for services rendered in such capacity,but all
reasonable expenses incurred in the performance of their duties shall be paid by the Employer.
12.7 Bonding
Fiduciaries shall be bonded to the extent required by ERISA.
12.8 Insurance Contracts
The Employer shall have the right to:(a)enter into a contract with one or more insurance companies for
the purpose of providing any benefits under the Plan; and(b)replace any of such insurance companies or
contracts.Any dividends, retroactive rate adjustments,or other refunds of any type that may become
payable under any such insurance contract shall not be assets of the Plan but shall be the property of and
be retained by the Employer,to the extent that such amounts are less than aggregate Employer
contributions toward such insurance.
12.9 Inability to Locate Payee
If the Plan Administrator is unable to make payment to any Participant or other person to whom a payment
is due under the Plan because it cannot ascertain the identity or whereabouts of such Participant or other
person after reasonable efforts have been made to identify or locate such person,then such payment and
all subsequent payments otherwise due to such Participant or other person shall be forfeited following a
-34-
reasonable time after the date any such payment first became due.
12.10 Effect of Mistake
In the event of a mistake as to the eligibility or participation of an Employee,the allocations made to the
account of any Participant,or the amount of benefits paid or to be paid to a Participant or other person,the
Plan Administrator shall,to the extent that it deems administratively possible and otherwise permissible
under Code section 125 or the regulations issued thereunder,cause to be allocated or cause to be
withheld or accelerated,or otherwise make adjustment of, such amounts as it will in its judgment accord to
such Participant or other person the credits to the account or distributions to which he or she is properly
entitled under the Plan.Such action by the Plan Administrator may include withholding of any amounts due
to the Plan or the Employer from Compensation paid by the Employer.
-35-
ARTICLE XIII
General Provisions
13.1 Plan Expenses
All reasonable expenses incurred in administering the Plan are currently paid by the Employer.The
Employer has the discretion to decide upon an appropriate expense amount to offset experience gains.
13.2 No Contract of Employment
Nothing herein contained is intended to be or shall be construed as constituting a contract or other
arrangement between any Employee and the Employer to the effect that such Employee will be employed
for any specific period of time.All Employees are considered to be employed at the will of the Employer.
13.3 Amendment and Termination
This Plan has been established with the intent of being maintained for an indefinite period of time.
Nonetheless,the Employer may amend or terminate all or any part of this Plan at any time for any reason
by resolution of the Employer's Board of Directors or by any person or persons authorized by the Board of
Directors to take such action,and any such amendment or termination will automatically apply to the
Related Employers that are participating in this Plan.
13.4 Governing Law
This Plan shall be construed,administered,and enforced according to the laws of the State of Colorado,to
the extent not superseded by the Code, ERISA,or any other federal law.
13.5 Code and ERISA Compliance
It is intended that this Plan meet all applicable requirements of the Code and ERISA and of all regulations
issued thereunder.(ERISA applies to the Medical Insurance Plan and the Health FSA Component or the
DCAP Component.)This Plan shall be construed,operated,and administered accordingly,and in the
event of any conflict between any part,clause, or provision of this Plan and the Code and/or ERISA,the
provisions of the Code and ERISA shall be deemed controlling,and any conflicting part,clause,or
provision of this Plan shall be deemed superseded to the extent of the conflict.
13.6 No Guarantee of Tax Consequences
Neither the Plan Administrator nor the Employer makes any commitment or guarantee that any amounts
paid to or for the benefit of a Participant under this Plan will be excludable from the Participant's gross
income for federal, state,or local income tax purposes. It shall be the obligation of each Participant to
determine whether each payment under this Plan is excludable from the Participant's gross income for
federal,state,and local income tax purposes and to notify the Plan Administrator if the Participant has any
reason to believe that such payment is not so excludable.
13.7 Indemnification of Employer
If any Participant receives one or more payments or reimbursements under this Plan on a tax-free basis
and if such payments do not qualify for such treatment under the Code,then such Participant shall
indemnify and reimburse the Employer for any liability that it may incur for failure to withhold federal
income taxes,Social Security taxes,or other taxes from such payments or reimbursements.
13.8 Non-Assignability of Rights
The right of any Participant to receive any reimbursement under this Plan shall not be alienable by the
Participant by assignment or any other method and shall not be subject to claims by the Participant's
creditors by any process whatsoever.Any attempt to cause such right to be so subjected will not be
recognized, except to the extent required by law.
13.9 Headings
-36-
The headings of the various Articles and Sections are inserted for convenience of reference and are not to
be regarded as part of this Plan or as indicating or controlling the meaning or construction of any provision.
13.10 Plan Provisions Controlling
In the event that the terms or provisions of any summary or description of this Plan are in any construction
interpreted as being in conflict with the provisions of this Plan as set forth in this document,the provisions of
this Plan shall be controlling.
13.11 Severability
Should any part of this Plan subsequently be invalidated by a court of competent jurisdiction,the remainder
of the Plan shall be given effect to the maximum extent possible.
< * r
IN WITNESS WHEREOF,and as conclusive evidence of the adoption of the foregoing instrument
comprising the Weld County Government Cafeteria Plan,Weld County Government has caused this Plan
to be executed in its name and on its behalf,on this 1st day of January,2009.
Employer:
Weld County Government
At,-
Authorized-Signer
DEC 1 0 2008
-37-
aooY 3 2c
Appendix A
Exclusions-Medical Expenses That Are Not Reimbursable From the Health FSA
The Weld County Government Cafeteria Plan document contains the general rules governing what
expenses are reimbursable.This Appendix A, as referenced in the Plan document,specifies certain
expenses that are excluded under this Plan with respect to reimbursement from the Health FSA-that is,
expenses that are not reimbursable,even if they meet the definition of"medical care"under Code section
213(d)and may otherwise be reimbursable under the regulations governing Health FSAs.
Exclusions:The following expenses are not reimbursable from the Health FSA,even if they meet the
definition of"medical care"under Code section 213(d)and may otherwise be reimbursable under
regulations governing Health FSAs: (subject to change per IRS)
- Health insurance premiums for any other plan (including a plan sponsored by the Employer).
- Long-term care services.
- Cosmetic surgery or other similar procedures,unless the surgery or procedure is necessary to
ameliorate a deformity arising from, or directly related to,a congenital abnormality, a personal
injury resulting from an accident or trauma,or a disfiguring disease. "Cosmetic surgery"means
any procedure that is directed at improving the patient's appearance and does not meaningfully
promote the proper function of the body or prevent or treat illness or disease.
- The salary expense of a nurse to care for a healthy newborn at home.
- Funeral and burial expenses.
- Household and domestic help(even if recommended by a qualifie d physician due to an
Employee's or Dependent's inability to perform physical housework).
- Custodial care.
- Costs for sending a problem child to a special school for benefits that the child may receive from
the course of study and disciplinary methods.
- Social activities,such as dance lessons(even if recommended by a physician for general health
improvement).
- Bottled water.
- Cosmetics,toiletries,toothpaste,etc.
- Uniforms or special clothing, such as maternity clothing.
- Automobile insurance premiums.
- Marijuana and other controlled substances that are in violation of federal laws, even if prescribed
by a physician.
- Any item that does not constitute"medical care"as defined under Code section 213(d).
- Any item that is not reimbursable under Code section 213(d)due to the rules in Prop.Treas. Reg.
Section 1.125-2,Q-7(b)(4)or other applicable regulations.
-38-
Weld County Government Cafeteria Plan
SUMMARY PLAN DESCRIPTION
Effective January 1,2009
Summary Plan Description
With Premium Payment, Health FSA, and DCAP Components
Table of Contents
Article I 1
INTRODUCTION 1
Article II 2
PARTICIPATION IN YOUR PLAN 2
How can I participate in the Cafeteria Plan? 2
What are the Eligibility Requirements to participate in the Plan? 2
Are there any Employees who are not eligible to participate in the Plan? 2
How do I become a Participant and when is my Entry Date? 2
What is the"Open Enrollment Period"and the "Plan Year"? 2
What happens if my employment ends during the Plan Year or I lose eligibility 3
for other reasons?
What is"Continuation Coverage"and how does it work? 3
How does a leave of absence (such as under FMLA)affect my benefits? 4
Article III 6
PAYING FOR YOUR BENEFITS UNDER YOUR PLAN 6
How do employees pay for benefits on a pre-tax basis? 6
Will I pay any administrative costs under the Cafeteria Plan? 6
Can I change my elections under the Cafeteria Plan during the Plan Year? 6
When Can I Change Elections Under the Cafeteria Plan During the Plan 6
Year?
Article IV 11
WHAT BENEFITS ARE PROVIDED UNDER THE PLAN 11
What benefits may be elected under the Cafeteria Plan? 11
Article V 12
WHAT HOW BENEFITS ARE TAXED 12
What tax savings are possible under the Cafeteria Plan? 12
How will participating in the Cafeteria Plan affect my Social Security benefits? 12
Will I be taxed on the Health FSA Benefits that I receive? 12
Will I be taxed on the DCAP Benefits that I receive? 13
Article VI 14
PREMIUM INSURANCE BENEFIT ACCOUNT 14
What are "Premium Payment Benefits"? 14
How are my Premium Payment Benefits paid? 14
Article VII 15
HEALTH FSA REIMBURSEMENT ACCOUNT 15
What are "Health FSA Benefits"? 15
What is my"Health FSA Account"? 15
How are my Health FSA Benefits paid for under the Cafeteria Plan? 15
What amounts will be available for Health FSA reimbursement at any 16
particular time during the Plan Year?
What are"Medical Care Expenses"that may be reimbursed from the Health 16
FSA?
When must the Medical Care Expenses be incurred for the Health FSA? 17
Can I Continue Health FSA Coverage After Terminating Employment or 18
Incurring a COBRA Event?
What must I do to be reimbursed for Medical Care Expenses from the Health 18
FSA?
Is there any risk of losing or forfeiting the amounts I elect for Health FSA 20
Benefits?
What are the time limits that affect forfeiture of my Health FSA Benefits (and 20
what happens to amounts that are forfeited)?
Will I be taxed on the Health FSA Benefits that I receive? 20
Article VIII 21
DEPENDENT CARE REIMBURSEMENT ACCOUNT 21
What are "DCAP Benefits"? 21
What is my"DCAP Account"? 21
What are the maximum and minimum DCAP Benefits that I may elect under 21
the Cafeteria Plan?
How are my DCAP Benefits paid for under the Cafeteria Plan? 22
What amounts will be available for DCAP reimbursement at any particular 22
time during the Plan Year?
What are"Dependent Care Expenses"that may be reimbursed? 22
When must the Dependent Care Expenses be incurred? 24
Can I Continue DCAP Coverage After Terminating Employment? 24
What must I do to be reimbursed for my Dependent Care Expenses? 24
Is there any risk of losing or forfeiting the amounts that I elect for DCAP 25
Benefits?
What are the time limits that affect forfeiture of my DCAP Benefits? 26
Will I be taxed on the DCAP Benefits I receive? 26
If I elect DCAP Benefits, can I still claim the Dependent Care Tax Credit on 26
my federal income tax return?
What is the Dependent Care Tax Credit? 27
Would it be better to include the DCAP Benefits in my income and claim the 27
Dependent Care Tax Credit, instead of treating the reimbursements as tax
free?
Article IX 28
CLAIMS PROCEDURE 28
What happens if my claim for benefits is denied? 28
Article X 30
FUNDING 30
Funding This Plan 30
How long will the Cafeteria Plan remain in effect? 30
Article XI 31
STATEMENT OF ERISA RIGHTS 31
What are my ERISA Rights? 31
Article XII 33
GENERAL INFORMATION 33
What other general information should I know? 33
Weld County Government Cafeteria Plan
With Premium Payment, Health FSA, and DCAP Components
Summary Plan Description
Article I
INTRODUCTION
Weld County Government, (the"Employer")sponsors the Weld County Government Cafeteria Plan(with
Premium Payment, Health FSA,and DCAP Components)(the"Cafeteria Plan")that allows Eligible
Employees to choose from a menu of different benefits to suit their needs and to pay for those benefits with
pre-tax dollars.Alternatively, Eligible Employees may choose to pay for any of the benefits with after-tax
contributions on a payroll-reduction basis.
This Summary Plan Description(SPD)describes the basic features of the Cafeteria Plan,how it operates,
and how to get the maximum advantage from it.This Summary does not describe every detail of the
Cafeteria Plan and is not meant to interpret or change the provisions of your Plan.A copy of your Plan is on
file at your Employer's office and may be read by you,your Beneficiaries,or your legal representatives at
any reasonable time. In the event of any inconsistencies or conflict between the actual provisions of the
Cafeteria Plan document and this Summary,the Cafeteria Plan Document shall govern.
-1-
Article II
PARTICIPATION IN YOUR PLAN
How can I participate in the Cafeteria Plan?
Once an Employee has met the Plan's eligibility requirements,and provided that the election procedures
outlined under'How do I become a Participant and when is my Entry Date?'section are followed,the
Eligible Employee may participate in the Plan.
What are the Eligibility Requirements to participate in the Plan?
Employees who are employed by a participating Employer may participate in the Plan provided that the
election procedures outlined under'How do I become a Participant and when is my Entry Date?'section
are followed.
Eligibility for the Premium Insurance Benefits is also subject to the additional eligibility requirements,if any,
specified in the Medical Insurance Plan.
Are there any Employees who are not eligible to participate in the Plan?
The following Employees are excluded from participating in the Plan: Employees covered by a collective
bargaining agreement as to which retirement benefits were the subject of good faith bargaining,unless
such agreement expressly provides for participation in the Plan, Non-resident aliens with no US source of
income,"Leased employees"within the meaning of Section 414(n), Part-time employees who regularly
work less than 20 hours per week,Seasonal employees who regularly work less than 6 months per year,
and self-employed individuals,partners in a partnership,or more-than-2%shareholders in a Subchapter S
corporation.
How do I become a Participant and when is my Entry Date?
After you satisfy the eligibility requirements described under'What are the Eligibility Requirements to
participate in the Cafeteria Plan?',you may enter the plan on the date the eligibility requirements have
been met by signing an individual Election Form/Salary Reduction Agreement.The Election Form/Salary
Reduction Agreement will be available by the first day of the Open Enrollment Period. You must complete
the Election Form/Salary Reduction Agreement and return it to Your Human Resources Rep within the
time period specified in the enrollment materials. (If you have not received the enrollment materials and/or
the Election Form/Salary Reduction Agreement, ask Your Human Resources Rep for copies.)An Eligible
Employee who fails to complete,sign,and return an Election Form/Salary Reduction Agreement,as
required,shall continue with the same elections as the prior year for insured/premium benefits.
Employees who actually participate in the Cafeteria Plan are called"Participants."An Employee continues
to participate in the Cafeteria Plan until: (a)termination of the Cafeteria Plan;or(b)the date on which the
Participant ceases to be an Eligible Employee(because of retirement,termination of employment, layoff,
reduction of hours,or any other reason).
However,for purposes of pre-taxing COBRA coverage for Premium Insurance Benefits and Health FSA
Benefits,certain Employees may be able to continue eligibility in the Cafeteria Plan for certain periods. See
'What is Continuation Coverage and how does it work?,and'What happens if my employment ends
during the Plan Year or I lose eligibility for other reasons?for information about how termination of
participation affects your Benefits.
What is the"Open Enrollment Period"and the"Plan Year"?
The Open Enrollment Period is the period during which you have an opportunity to participate under the
Cafeteria Plan by signing and returning an individual Election Form/Salary Reduction Agreement.
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You will be notified of the timing and duration of the Open Enrollment Period prior to the beginning of the
new Plan Year.The Plan Administrator will inform all Participants of the applicable dates for each annual
enrollment period.
What happens if my employment ends during the Plan Year or I lose eligibility for other reasons?
If your employment with the Employer is terminated during the Plan Year,then your active participation in
the Cafeteria Plan will cease and you will not be able to make any more contributions to the Cafeteria Plan
for the Premium insurance benefits, Health FSA,and DCAP benefits.
The Premium Insurance Benefits will terminate as of the date specified in the Medical Insurance Plan.
See What is Continuation Coverage and how does it work?and the booklets for the Medical
Insurance Plan for information on your right to continued or converted group health coverage after
termination of your employment.
For reimbursement of expenses from the Health FSA Account after termination of employment, see What
must I do to be reimbursed for Medical Care Expenses from the Health FSA?.
For reimbursement of expenses from the DCAP Account after termination of employment, see What must
I do to be reimbursed for my Dependent Care Expenses?.
For purposes of pre-taxing COBRA coverage for Premium Insurance Benefits and Health FSA Benefits,
certain Employees may be able to continue eligibility in the Cafeteria Plan for certain periods.See What is
Continuation Coverage and how does it work?.
If you are rehired within 30 days or less during the same Plan Year and are eligible for the Cafeteria Plan,
then your prior elections will be reinstated.
If you are rehired more than 30 days after you terminated employment,but within same Plan Year and are
eligible for the Cafeteria Plan, you will be treated as a new hire and must re-satisfy(complete the waiting
period)Plan eligibility requirements to rejoin the Plan.Any unused reimbursement benefit account balance
prior to the initial separation of service date will be forfeited.
If you cease to be an Eligible Employee for reasons other than termination of employment, such as a
reduction of hours,then you must complete the waiting period described under'How can I participate in
the Cafeteria Plan?'before again becoming eligible to participate in the Plan.
What is "Continuation Coverage"and how does it work?
To the extent required by COBRA,a Participant and his or her Spouse and Dependents,as applicable,
whose coverage terminates under the medical insurance plan because of a COBRA qualifying event(and
who is a qualified beneficiary as defined under COBRA), may be given the opportunity to continue on a self-
pay basis the same coverage that he or she had under the medical insurance plan the day before the
qualifying event for the periods prescribed by COBRA. Such continuation coverage shall be subject to all
conditions and limitations under COBRA. Contributions for COBRA coverage for medical insurance
benefits may be paid on a pre-tax basis for current Employees receiving taxable compensation(as may be
permitted by the Plan Administrator on a uniform and consistent basis,but may not be prepaid from
contributions in one Plan Year to provide coverage that extends into a subsequent Plan Year)where
COBRA coverage arises either:(a)because the Employee ceases to be eligible because of a reduction in
hours;or(b)because the Employee's Dependent ceases to satisfy the eligibility requirements for coverage.
For all other individuals(e.g., Employees who cease to be eligible because of retirement,termination of
employment,or layoff), Contributions for COBRA coverage for medical insurance benefits shall be paid on
an after-tax basis(unless may be otherwise permitted by the Plan Administrator on a uniform and
consistent basis, but may not be prepaid from contributions in one Plan Year to provide coverage that
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extends into a subsequent Plan Year).
To the extent required by COBRA,a Participant and his or her Spouse and Dependents,as applicable,
who has a separation from service or whose coverage terminates under the Health FSA Benefit because
of a COBRA qualifying event(and who is a qualified beneficiary as defined under COBRA)may be given
the opportunity to continue on a self-pay basis the same coverage that he or she had under the Health FSA
Benefit the day before the qualifying event for the periods prescribed by COBRA.
Specifically, such individuals may be eligible for COBRA continuation coverage only if they have a positive
Health FSA Account balance at the end of the applicable Period of Coverage(taking into account all
claims submitted before the date of the qualifying event).
Such individuals will be notified if they are eligible for COBRA continuation coverage. If COBRA is elected,
it will be available only for the remainder of the applicable Period of Coverage; such COBRA coverage for
the Health FSA Benefit will cease at the end of the Plan Year and cannot be continued for the next Plan
Year.Such continuation coverage shall be subject to all conditions and limitations under COBRA.
Notwithstanding the foregoing,a qualified beneficiary(as defined under COBRA)who has COBRA
coverage under the Health FSA Benefit on the last day of a Plan Year may be entitled to reimbursement of
Medical Care Expenses incurred during the Grace Period following that Plan Year as described under'
When must the Medical Care Expenses be incurred for the Health FSA?.
Contributions for coverage for Health FSA Benefits may be paid on a pre-tax basis for current Employees
receiving taxable compensation(as may be permitted by the Plan Administrator on a uniform and
consistent basis,but may not be prepaid from contributions in one Plan Year to provide coverage that
extends into the new Plan Year)where COBRA coverage arises either: (a)because the Employee ceases
to be eligible because of a reduction of hour;or(b)because the Employee's Dependent ceases to satisfy
the eligibility requirements for coverage. For all other individuals(e.g., Employees who cease to be eligible
because of retirement,termination of employment,or layoff), Contributions for COBRA coverage for
Health FSA Benefits may be paid on an after-tax basis(unless permitted otherwise by the Plan
Administrator on a uniform and consistent basis, but may not be prepaid from contributions in one Plan
Year to provide coverage that extends into the new Plan Year).
USERRA
Continuation and reinstatement rights may also be available if you are absent from employment due to
service in the uniformed services pursuant to the Uniformed Services Employment and Reemployment
Rights Act of 1994(USERRA). More information about coverage under USERRA is available from the Plan
Administrator.
How does a leave of absence(such as under FMLA)affect my benefits?
FMLA Leaves of Absence
If you go on a qualifying leave under the Family and Medical Leave Act of 1993(FMLA),then to the extent
required by the FMLA your Employer will continue to maintain your Premium insurance benefits,and
Health FSA benefits on the same terms and conditions as if you were still active(that is,your Employer will
continue to pay its share of the contributions to the extent that you opt to continue coverage).Your
Employer may require you to continue all Premium Insurance Benefits and Health FSA Benefits coverage
while you are on paid leave(so long as Participants on non-FMLA paid leave are required to continue
coverage). If so,you will pay your share of the contributions by the method normally used during any paid
leave(for example,on a pre-tax salary-reduction basis).
If you are going on unpaid FMLA leave(or paid FMLA leave where coverage is not required to be
continued)and you opt to continue your Premium Insurance Benefits and Health FSA Benefits,then you
may pay your share of the contributions in one of the following ways:(a)with after-tax dollars while on
leave;(b)with pre-tax dollars to the extent that you receive compensation during the leave, or by pre-
paying all or a portion of your share of the contributions for the expected duration of the leave on a pre-tax
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salary reduction basis out of your pre-leave compensation, including unused sick days and vacation days
(to pre-pay in advance,you must make a special election before such compensation normally would be
available to you(but note that prepayments with pre-tax dollars may not be used to pay for coverage during
the next Plan Year);or(c)by other arrangements agreed upon by you and the Plan Administrator(for
example,the Plan Administrator may pay for coverage during the leave and withhold amounts from your
compensation upon your return from leave).
If your Employer requires all Participants to continue Premium Insurance Benefits and Health FSA Benefits
during the unpaid FMLA leave,then you may discontinue paying your share of the required contributions
until you return from leave. Upon returning from leave,you must pay your share of any required
contributions that you did not pay during the leave.Payment for your share will be withheld from your
compensation either on a pre-tax or after-tax basis,depending on what you and the Plan Administrator
agree to. If your Premium Insurance Benefits or Health FSA Benefits coverage ceases while you are on
FMLA leave(e.g.,for non-payment of required contributions),you will be permitted to re-enter such
Benefits,as applicable, upon return from such leave on the same basis as when you were participating in
the Plan before the leave or as otherwise required by the FMLA.You may be required to have coverage for
such Benefits reinstated so long as coverage for Employees on non-FMLA leave is required to be
reinstated upon return from leave.
But despite the preceding sentence,with regard to Health FSA Benefits, if your coverage ceased you will
be permitted to elect whether to be reinstated in the Health FSA Benefit at the same coverage level as was
in effect before the FMLA leave(with increased contributions for the remaining period of coverage)or at a
coverage level that is reduced pro rata for the period of FMLA leave during which you did not pay
contributions. If you elect the pro rata coverage,the amount withheld from your compensation on a payroll-
by payroll basis for the purpose of paying for reinstated Health FSA Benefits will equal the amount withheld
before FMLA leave.
If you are commencing or returning from FMLA leave,then your election for non-health benefits(such as
DCAP Benefits)will be treated in the same way as under your Employer's policy for providing such Benefits
for Participants on a non-FMLA leave(see below). If that policy permits you to discontinue contributions
while on leave,then upon returning from leave you will be required to repay the contributions not paid by
you during leave. Payment will be withheld from your compensation either on a pre-tax or after-tax basis,
as agreed to by the Plan Administrator and you or as the Plan Administrator otherwise deems appropriate.
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Article III
PAYING FOR YOUR BENEFITS UNDER YOUR PLAN
How do employees pay for benefits on a pre-tax basis?
An Employee's election to pay for benefits on a pre-tax or after-tax basis is made by entering into an
Election Form/Salary Reduction Agreement with the Employer(askYour Human Resources Rep for a
copy if you have not received one).Under that Agreement, if you elect to pay for benefits on a pre-tax
basis,you agree to a salary reduction to pay for your share of the cost of coverage(also known as
contributions)with pre-tax funds instead of receiving a corresponding amount of your regular pay that
would otherwise be subject to taxes.From then on,you must pay contributions for such coverage by having
that portion deducted from each paycheck on a pre-tax basis(generally an equal portion from each
paycheck,or an amount otherwise agreed to or as deemed appropriate by the Plan Administrator).
Will I pay any administrative costs under the Cafeteria Plan?
No.The cost of the plan includes administrative expenses and is paid entirely by the Employer.The cost of
the plan includes administrative expenses and is paid in part by the use of forfeitures, if any. (See Health
FSA See What are the time limits that affect forfeiture of my Health FSA Benefits?and What are the
time limits that affect forfeiture of my DCAP Benefits?)The rest of the cost of administering the
Cafeteria Plan is paid entirely by the Employer.
Can I change my elections under the Cafeteria Plan during the Plan Year?
You generally cannot change your election to participate in the Cafeteria Plan or vary the salary reduction
amounts that you have selected during the Plan Year(known as the irrevocability rule). Of course,you can
change your elections for benefits and salary reductions during the Open Enrollment Period, but those
election changes will apply only for the following Plan Year.
During the Plan Year, however,there are several important exceptions to the irrevocability rule. See the
various"Change in Election Events"that are described under When Can I Change Elections Under the
Cafeteria Plan?'.The Plan Administrator may also reduce your salary reductions(and increase your
taxable regular pay)during the Plan Year if you are a key employee or highly compensated individual as
defined by the Internal Revenue Code("the Code"), if necessary to prevent the Cafeteria Plan from
becoming discriminatory within the meaning of the federal income tax law.Additionally,if a mistake is
made as to your eligibility or participation,the allocations made to your account,or the amount of benefits
to be paid to you or another person,then the Plan Administrator shall,to the extent that it deems
administratively possible and otherwise permissible under the Code and other applicable law, allocate,
withhold,accelerate,or otherwise adjust such amounts as will in its judgment accord the credits to the
account or distributions to which you are or such other person is properly entitled under the Cafeteria Plan.
Such action by the Plan Administrator may include withholding of any amounts due from your
compensation.
When can I change elections under the cafeteria plan during the Plan Year?
Participants can change their elections under the Cafeteria Plan during a Plan Year if an event occurs that
is a Change in Election Event and certain other conditions are met, as described below. For details, see the
various'Change in Election Events'headings below for the specific type of Change in Election Event:
Leaves of absence, including FMLA leave(defined under How do leaves of absence(such as under
FMLA)affect my benefits7);Changes in Status;Special Enrollment Rights; Certain Judgments, Decrees,
and Orders; Medicare or Medicaid;Changes in Cost;Changes in Coverage;and Changes in HSA
Elections.Note also that no changes can be made with respect to Medical Insurance Benefits if they are
not permitted under the Medical Insurance Plan.
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If any Change in Election Event occurs,you must inform the Plan Administrator and complete a new
Election Form/Salary Reduction Agreement within 30 days after the occurrence.
If the change involves a loss of your Spouse's or Dependent's eligibility for Medical Insurance Benefits,then
the change will be deemed effective as of the date that eligibility is lost due to the occurrence of the
Change in Election Event,even if you do not request it within 30 days.
1. Leaves of Absence
(Applies to Medical Insurance Benefits, Health FSA,and DCAP Benefits)
You may change an election under the Cafeteria Plan upon FMLA and non-FMLA leave only as described
under How do leaves of absence(such as under FMLA)affect my benefits?
2.Change in Status.
(Applies to Medical Insurance Benefits,Health FSA, and DCAP Benefits)If one or more of the following
Changes in Status occur,you may revoke your old election and make a new election, provided that both
the revocation and new election are on account of and correspond with the Change in Status(as described
in item 3 below).Those occurrences that qualify as a Change in Status include the events described
below,as well as any other events that the Plan Administrator,in its sole discretion and on a uniform and
consistent basis,determines are permitted under IRS regulations:
• a change in your legal marital status(such as marriage,death of a Spouse,divorce,legal
separation,or annulment);
• a change in the number of your Dependents(such as the birth of a child,adoption or
placement for adoption of a Dependent,or death of a Dependent);
• any of the following events that change the employment status of you,your Spouse,or your
Dependent and that affect benefits eligibility under a cafeteria plan(including this Cafeteria
Plan)or other employee benefit plan of you,your Spouse,or your Dependents. Such events
include any of the following changes in employment status:termination or commencement of
employment;a strike or lockout;a commencement of or return from an unpaid leave of
absence;a change in worksite; switching from salaried to hourly-paid, union to non-union,or
full-time to part-time(or vice versa); incurring a reduction or increase in hours of employment;
or any other similar change that makes the individual become(or cease to be)eligible for a
particular employee benefit;
* an event that causes your Dependent to satisfy or cease to satisfy an eligibility requirement for
a particular benefit(such as attaining a specific age,ceasing to be a student,or a similar
circumstance);or
• a change in your,your Spouse's,or your Dependent's place of residence.
3.Change in Status-Other Requirements.
(Applies to Medical Insurance Benefits,Health FSA, and DCAP Benefits)
If you wish to change your election based on a Change in Status,you must establish that the revocation is
on account of and corresponds with the Change in Status.The Plan Administrator,in its sole discretion and
on a uniform and consistent basis,shall determine whether a requested change is on account of and
corresponds with a Change in Status.As a general rule, a desired election change will be found to be
consistent with a Change in Status event if the event affects coverage eligibility(for DCAP Benefits,the
event may also affect eligibility of Dependent Care Expenses(as defined under What are"Dependent
Care Expenses"that may be reimbursed?)for the dependent care tax exclusion).
Election changes may not be made to reduce Health FSA coverage during a Plan Year; however,election
changes may be made to cancel Health FSA coverage completely due to the occurrence of any of the
following events: death of your Spouse,divorce, legal separation, or annulment;death of your Dependent;
change in employment status such that you become ineligible for Health FSA coverage;or your
Dependent's ceasing to satisfy eligibility requirements for Health FSA coverage(e.g.,on account of
attaining a specific age). But if you cancel coverage, it cannot result in your contributions for the year being
less than the amount for which you have already been reimbursed. For example,assume that you elected
to contribute$100 per month to the Health FSA and in February you were reimbursed for expenses in the
amount of$700. If a Change in Status Event occurs in March that allows you to cancel coverage,your
cancellation will not take effect until you have contributed a total of$700 for the year. (See also'How are
my Health FSA Benefits paid for under the Cafeteria Plan?'and'What amounts will be available for
Health FSA reimbursement at any particular time during the Plan Year?'.)
In addition,you must satisfy the following specific requirements in order to alter your election based on that
Change in Status:
Loss of Spouse or Dependent Eligibility; Special COBRA Rules.For accident and health
benefits(the Medical Insurance Plan and the Health FSA Benefits),a special rule governs
which type of election changes are consistent with the Change in Status. For a Change in
Status involving your divorce,annulment,or legal separation from your Spouse,the death of
your Spouse or your Dependent,or your Dependent's ceasing to satisfy the eligibility
requirements for coverage,you may elect only to cancel the accident or health benefits for
the affected Spouse or Dependent.A change in election for any individual other than your
Spouse involved in the divorce,annulment, or legal separation,your deceased Spouse or
Dependent,or your Dependent that ceased to satisfy the eligibility requirements would fail to
correspond with that Change in Status.
Example: Employee Mike is married to Sharon,and they have one child.The employer offers
a calendar-year cafeteria plan that allows employees to elect any of the following: no medical
coverage,employee-only coverage,employee-plus-one-dependent coverage,or family
coverage. Before the plan year, Mike elects family coverage for himself, his wife Sharon,and
their child. Mike and Sharon subsequently divorce during the plan year;Sharon loses eligibility
for coverage under the plan,while the child is still eligible for coverage under the plan. Mike
now wishes to revoke his previous election and elect no medical coverage.The divorce
between Mike and Sharon constitutes a Change in Status.An election to cancel medical
coverage for Sharon is consistent with this Change in Status. However,an election to cancel
coverage for Mike and/or the child is not consistent with this Change in Status.In contrast,an
election to change to employee-plus-one dependent coverage would be consistent with this
Change in Status.
However, if you,your Spouse, or your Dependent elects COBRA continuation coverage under
the Employer's plan because you ceased to be eligible because of a reduction of hours or
because your Dependent ceases to satisfy eligibility requirements for coverage, and if you
remain a Participant under the terms of this Cafeteria Plan,then you may in certain
circumstances be able to increase your contributions to pay for such coverage. See What is
"Continuation Coverage"and how does it work?.
* Gain of Coverage Eligibility Under Another Employer's Plan.For a Change in Status in which
you,your Spouse,or your Dependent gains eligibility for coverage under another employer's
cafeteria plan(or qualified benefit plan)as a result of a change in your marital status or a
change in your,your Spouse's,or your Dependent's employment status,your election to
cease or decrease coverage for that individual under the Cafeteria Plan would correspond
with that Change in Status only if coverage for that individual becomes effective or is
increased under the other employer's plan.
DCAP Benefits.With respect to the DCAP Benefits,you may change or terminate your
election with respect to a Change in Status event only if(a)such change or termination is
made on account of and conforms with a Change in Status that affects eligibility for coverage
under the DCAP; or(b)your election change is on account of and conforms with a Change in
Status that affects the eligibility of Dependent Care Expenses for the available tax exclusion.
Example: Employee Mike is married to Sharon,and they have a 12-year-old daughter.The
employer's plan offers a DCAP as part of its cafeteria plan. Mike elects to reduce his salary by
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$2,000 during a plan year to fund dependent care coverage for his daughter. In the middle of
the plan year when the daughter turns 13 years old, however,she is no longer eligible to
participate in the DCAP.This event constitutes a Change in Status. Mike's election to cancel
coverage under the DCAP would be consistent with this Change in Status.
4.Special Enrollment Rights.(Applies to Medical Insurance Benefits)In certain circumstances,
enrollment for Medical Insurance Benefits may occur outside the Open Enrollment Period,as explained in
materials provided to you separately describing the Medical Insurance Benefits. (The Employer's Special
Enrollment Notice also contains important information about the special enrollment rights that you may
have, a copy of which was previously furnished to you. Contact the Human Resources Manager if you need
another copy.)When a special enrollment right explained in those separate documents applies to your
Medical Insurance Benefits,you may change your election under the Cafeteria Plan to correspond with the
special enrollment right.
5.Certain Judgments, Decrees,and Orders.(Applies to Medical Insurance Benefits and Health FSA
Benefits) If a judgment, decree,or order from a divorce,separation,annulment, or custody change
requires your child (including a foster child who is your Dependent)to be covered under the Medical
Insurance Benefits or Health FSA Benefits,you may change your election to provide coverage for the child.
If the order requires that another individual(such as your former Spouse)cover the child,then you may
change your election to revoke coverage for the child,provided that such coverage is,in fact, provided for
the child.
6. Medicare or Medicaid.(Applies to Medical Insurance Benefits and Health FSA Benefits) If you,your
Spouse,or your Dependent becomes entitled to(i.e., becomes enrolled in)Medicare or Medicaid,then you
may reduce or cancel that person's accident or health coverage under the Medical Insurance Plan, and/or
your Health FSA coverage may be canceled completely but not reduced. Similarly, if you,your Spouse,or
your Dependent who has been entitled to Medicare or Medicaid loses eligibility for such coverage,then you
may elect to commence or increase that person's accident or health coverage(here, Medical Insurance
Benefits and/or Health FSA Benefits,as applicable).
7. Change in Cost. (Applies to Medical Insurance Benefits and DCAP Benefits) If the cost charged to you
for your Medical Insurance Benefits or DCAP Benefits significantly increases during the Plan Year,then you
may choose to do any of the following:(a)make a corresponding increase in your contributions;(b)revoke
your election and receive coverage under another benefit package option(if any)that provides similar
coverage,or elect similar coverage under the plan of your Spouse's employer;or(c)drop your coverage,
but only if no other benefit package option provides similar coverage. (Note that,for purposes of this
definition,(a)the Health FSA is not similar coverage with respect to the Medical Insurance Benefits; (b)an
HMO and a PPO are considered to be similar coverage(the Employer currently offers an HMO and a
PPO); and (c)coverage under another employer plan,such as the plan of a Spouse's or Dependent's
employer, may be treated as similar coverage if it otherwise meets the requirements of similar coverage.)
For insignificant increases or decreases in the cost of benefits,however,the Plan Administrator will
automatically adjust your election contributions to reflect the minor change in cost.The Plan Administrator
generally will notify you of increases in the cost of Medical Insurance benefits;you generally will have to
notify the Plan Administrator of increases in the cost of DCAP benefits.The change in cost provision
applies to DCAP Benefits only if the cost change is imposed by a dependent care provider who is not your
relative.
8. Change in Coverage.(Applies to Medical Insurance Benefits and DCAP Benefits)You may also
change your election if one of the following events occurs:
Significant Curtailment of Coverage. If your Medical Insurance Benefits and DCAP Benefits
coverage is significantly curtailed without a loss of coverage(for example,when there is an
increase in the deductible under the Medical Insurance Benefits),then you may revoke your
election for that coverage and elect coverage under another benefit package option that
provides similar coverage.(Coverage under a plan is significantly curtailed only if there is an
-9-
overall reduction of coverage under the plan generally-loss of one particular physician in a
network does not constitute significant curtailment)If your Medical Insurance Benefits and
DCAP Benefits coverage is significantly curtailed with a loss of coverage(for example,if you
lose all coverage under the option by reason of an overall lifetime or annual limitation),then
you may either revoke your election and elect coverage under another benefit package option
that provides similar coverage,elect similar coverage under the plan of your Spouse's
employer,or drop coverage,but only if there is no option available under the plan that
provides similar coverage.(The Plan Administrator generally will notify you of significant
curtailments in Medical Insurance Benefits coverage.)you generally will have to notify the
Plan Administrator of significant curtailments in DCAP Benefits coverage.)
* Addition or Significant Improvement of Cafeteria Plan Option.If the Cafeteria Plan adds a new
option or significantly improves an existing option,then the Plan Administrator may permit
Participants who are enrolled in an option other than the new or improved option to elect the
new or improved option.Also,the Plan Administrator may permit eligible Employees to elect
the new or improved option on a prospective basis,subject to limitations imposed by the
applicable option.
Loss of Other Group Health Coverage.You may change your election to add group health
coverage for you,your Spouse,or your Dependent,if any of you loses coverage under any
group health coverage sponsored by a governmental or educational institution(for example, a
state children's health insurance program or certain Indian tribal programs).
Change in Election Under Another Employer Plan.You may make an election change that is
on account of and corresponds with a change made under another employer plan(including
a plan of the Employer or a plan of your Spouse's or Dependent's employer),so long as(a)
the other cafeteria plan or qualified benefits plan permits its participants to make an election
change permitted under the IRS regulations;or(b)the Cafeteria Plan permits you to make an
election for a period of coverage(for example,the Plan Year)that is different from the period
of coverage under the other cafeteria plan or qualified benefits plan,which it does. For
example, if an election to drop coverage is made by your Spouse during his or her employer's
open enrollment,you may add coverage under the Cafeteria Plan to replace the dropped
coverage.
DCAP Coverage Changes.You may make a prospective election change that is on account
of and corresponds with a change by your dependent care service provider. For example:(a)
if you terminate one dependent care service provider and hire a new dependent care service
provider,then you may change coverage to reflect the cost of the new service provider;and
(b)if you terminate a dependent care service provider because a relative becomes available
to take care of the child at no charge,then you may cancel coverage.
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Article IV
WHAT BENEFITS ARE PROVIDED UNDER THE PLAN
What benefits may be elected under the Cafeteria Plan?
The Cafeteria Plan includes the following benefit plans:
Premium Payment Component(currently including Premium Insurance Benefits)-permits an Employee to
pay for his or her share of contributions for the Medical Insurance Plan with pre-tax dollars."Medical
Insurance Plan"means the major medical plan that your Employer maintains for Employees,their
Spouses,and Dependents, providing major medical type benefits through a group insurance policy.
Here,these benefits include Basic Health, Dental,Vision,and Individual Voluntary Benefit Plans options.
Benefits provided under the Medical Insurance Plan are called"Premium Insurance Benefits."Benefits
provided generally under the Premium Payment Component(including any benefits that may be added at
a later date)are called"Premium Payment Benefits";
Other Premium Benefits: Individual Voluntary Benefit Plans, as described in a separate document entitled
Health Flexible Spending Arrangement(Health FSA)also called a medical expense reimbursement plan-
permits an Employee to pay for his or her qualifying Medical Care Expenses(defined under What are
Medical Care Expenses that may be reimbursed from the Health FSA?)that are not otherwise
reimbursed by insurance with pre-tax dollars. Benefits provided under the Health FSA are called"Health
FSA Benefits."As described under What are Medical Care Expenses that may be reimbursed from the
Health FSA?',the Health FSA election maybe for:
General-Purpose Health FSA Coverage.
Dependent Care Assistance Program(DCAP)also called a dependent care flexible spending account-
permits an Employee to pay for his or her qualifying Dependent Care Expenses(defined under What are
Dependent Care Expenses that may be reimbursed7)with pre-tax dollars. Benefits provided under the
DCAP are called"DCAP Benefits."
If you select one or more of the above benefits,you will pay all or some of the contributions;the Employer
may contribute some or no portion of them.The applicable amounts will be described in documents
furnished separately to you.
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Article V
HOW BENEFITS ARE TAXED
What tax savings are possible under the Cafeteria Plan?
You may save both federal income tax and FICA(Social Security)taxes by participating in the Cafeteria
Plan. Here is an example of the possible tax savings of paying for your share of the contributions for
Premium Insurance Benefits under the Cafeteria Plan. Suppose that you are married and have one child
and that your share of the required contributions for Premium Insurance Benefits for family coverage is an
annual total of$6,400.Suppose also that your gross pay is$75,000 and your Spouse(a student)earns no
income and that you file a joint tax return.
As illustrated in detail by the Table below,if you elect to salary-reduce$6,400 to pay for the Premium
Insurance contributions,then your annual take-home pay would be$56,732. If instead you elect to pay the
contributions on an after-tax basis,then your annual take-home pay would be only$55,282.This is
because by participating in the Cafeteria Plan for Premium Insurance contributions,you will be considered
for tax purposes to have received$68,600 in gross pay,so you save$1,450 per year. How much an
employee actually saves will depend on what family members are covered and the contributions for the
coverage,the total family income, and the tax deductions and exemptions claimed.There may be state tax
savings,too.And salary reductions also lower earned income,which can impact the earned income credit
for eligible taxpayers.
Caution:The amount of the contributions used in this example is not meant to reflect your actual
contributions-the actual contribution amounts will be determined by you.
Cafeteria No
Plan* Cafeteria
Plan
1.Adjusted Gross Income $75,000 $75,000
2. Salary Reductions for Premiums ($6,400) $0
3.W-2 Gross Wages $68,600 $75,000
4. Standard Deduction ($10,000) ($10,000)
5. Exemptions ($9,600) ($9,600)
6.Taxable Income(line 3 minus lines 4&5) $49,000 $55,400
7.W-2 Gross Wages $68,600 $75,000
8. Federal Income Tax(line 6 @ tax schedule) ($6,620) ($7,850)
9. FICA Tax(7.65%of line 3) ($5,248) ($5,738)
10.After-Tax Premium Payments $0 ($6,400)
11. Pay After Taxes and Premium Payments(line 7 minus lines 8, 9& 10) $56,732 $55,282
*The standard deduction,exemptions,and federal income tax rates for 2007 are found in IRS Rev. Proc.
2004-71,2004-50 I.R.B.970.The FICA tax rate is found at
http://www.ssa.gov/pressoffice/factsheets/colafacts2007.htm(as visited March 23,2007).
How will participating in the Cafeteria Plan affect my Social Security and other benefits?
Participating in the Cafeteria Plan will reduce the amount of your taxable compensation.Accordingly,there
could be a decrease in your Social Security benefits and/or other benefits(e.g.,pension,disability,and life
insurance),which are based on taxable compensation. However,the tax savings that you realize through
Cafeteria Plan participation will often more than offset any reduction in other benefits.
Will I be taxed on the Health FSA Benefits that I receive?
Generally,you will not be taxed on your Health FSA Benefits. However,the Employer cannot guarantee
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that specific tax consequences will flow from your participation in the Plan.The tax benefits that you receive
depend on the validity of the claims that you submit. For example,to qualify for tax-free treatment,your
Medical Care Expenses must meet the definition of"medical care"as defined in the Code. If you are
reimbursed for a claim that is later determined to not be for Medical Care Expenses,then you will be
required to repay the amount.
Will I be taxed on the DCAP Benefits I receive?
Generally,you will not be taxed on your DCAP Benefits,up to the limits set forth under What are the
maximum and minimum DCAP Benefits that I may elect under the Cafeteria Plan?. However,the
Employer cannot guarantee that specific tax consequences will flow from your participation in the DCAP.
The tax benefits that you receive depend on the validity of the claims that you submit.For example,to
qualify for tax-free treatment,you will be required to file IRS Form 2441 ("Child and Dependent Care
Expenses")with your annual tax return(Form 1040)or a similar form.You must list on Form 2441 the
names and taxpayer identification numbers(TINs)of any entities that provided you with dependent care
services during the calendar year for which you have claimed a tax-free reimbursement. If you are
reimbursed for a claim that is later determined to not be for Dependent Care Expenses,then you will be
required to repay the amount.
Ultimately,it is your responsibility to determine whether any reimbursement under the DCAP constitutes
Dependent Care Expenses that qualify for the federal income tax exclusion.Ask the Plan Administrator if
you need further information about which expenses are, and are not likely to be reimbursable.
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Article VI
PREMIUM INSURANCE BENEFIT ACCOUNT
What are"Premium Payment Benefits"?
As described under'How do employees pay for benefits on a pre-tax basis?, if you elect Premium
Payment Benefits you will be able to pay for your share of contributions for Premium Insurance Benefits
with pre-tax dollars by entering into an Election Form/Salary Reduction Agreement with your Employer.
Because the share of the contributions that you pay will be with pre-tax funds,you may save both federal
income taxes and FICA(Social Security)taxes.See How Benefits Are Taxed?.
The only Premium Payment Benefits offered under your Plan are for Premium Insurance Benefits,this is
major medical insurance,including Basic Health, Dental,Vision,and Individual Voluntary Benefit Plans
options.
How are my Premium Payment Benefits paid?
As described under'How do employees pay for benefits on a pre-tax basis?and'What are"Premium
Payment Benefits?, if you select the Medical Insurance Plan described under What are Premium
Payment Benefits?',then you may be required to pay a portion of the contributions.When you complete
the Election Form/Salary Reduction Agreement, if you elect to pay for benefits on a pre-tax basis you agree
to a salary reduction to pay for your share of the cost of coverage(also known as contributions)with pre-tax
funds instead of receiving a corresponding amount of your regular pay that would otherwise be subject to
taxes. From then on,you must pay a contribution for such coverage by having that portion deducted from
each paycheck on a pre-tax basis(generally an equal portion from each paycheck,or an amount
otherwise agreed to or as deemed appropriate by the Plan Administrator).
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Article VII
HEALTH FSA REIMBURSEMENT ACCOUNT
What are"Health FSA Benefits"?
As described under What benefits may be elected under the Cafeteria Plan7, a Health FSA permits
Eligible Employees to pay for coverage with pre-tax dollars that will reimburse them for Medical Care
Expenses not reimbursed elsewhere(for example,you cannot be reimbursed for the same expense from
the Medical Insurance Plan).
As described under'How do employees pay for benefits on a pre-tax basis?, if you elect Health FSA
Benefits,then you will be able to provide a source of pre-tax funds to reimburse yourself for your eligible
Medical Care Expenses by entering into an Election Form/Salary Reduction Agreement with your
Employer. Because the share of the contributions that you pay will be with pre-tax funds,you may save
both federal income taxes and FICA(Social Security)taxes. See What tax savings are possible under
the Cafeteria Plan?'for an example dealing with pre-tax payment of Premium Insurance contributions.
Health FSA Benefits are intended to pay benefits solely for Medical Care Expenses not reimbursed
elsewhere.Accordingly,the Health FSA shall not be considered to be a group health plan for coordination
of benefits purposes,and Health FSA Benefits shall not be taken into account when determining benefits
payable under any other plan.
After you satisfy the eligibility requirements described above,you may participate in the Health FSA on the
date the eligibility requirements have been met by signing an individual Election Form/Salary Reduction
Agreement as described under'How do I become a Participant and when is my Entry Date?
What is my"Health FSA Account"?
If you elect Health FSA Benefits,then an account called a "Health FSA Account"will be set up in your
name to keep a record of the reimbursements that you are entitled to,as well as the contributions that you
have paid for such benefits during the Plan Year.Your Health FSA Account is merely a recordkeeping
account; it is not funded(all reimbursements are paid from the general assets of the Employer),and it
does not bear interest.
A Health FSA election may be for:
General-Purpose Health FSA Coverage.
In addition, because the Health FSA includes a grace period,if you have an election for Health FSA
Benefits(other than the Limited(Vision/Dental/Preventive Care)Health FSA Coverage Option)that is in
effect on the last day of a Plan Year,you cannot elect HSA Benefits or otherwise make contributions to an
HSA for any of the first three calendar months following the close of that Plan Year unless the balance of
your Health FSA Account is zero at the end of that Plan Year.
Additionally, unless you have elected Employee-Only or Employee-Plus-Children Health FSA Coverage,
your spouse(if you are married)will also be unable to make HSA contributions during this period. See'
What amounts will be available for Health FSA reimbursement at any particular time during the Plan
Year?'for more information.
How are my Health FSA Benefits paid for under the Cafeteria Plan?
When you complete the Election Form/Salary Reduction Agreement,you specify the amount of Health
FSA Benefits that you wish to pay for with your salary reduction. From then on,you must pay a contribution
for such coverage by having that portion deducted from each paycheck on a pre-tax basis(generally an
equal portion from each paycheck or an amount otherwise agreed to or as deemed appropriate by the
Plan Administrator). For example,suppose that you have elected to be reimbursed up to$1,000 per year
15
for Medical Care Expenses and that you have chosen no other benefits under the Cafeteria Plan. If you pay
all of your contributions,then your Health FSA Account would be credited with a total of$1,000 during the
Plan Year. If you are paid bi-weekly,then your Health FSA Account would reflect that you have paid$38.46
($1,000 divided by 26)each pay period in contributions for the Health FSA Benefits that you have elected.
The Employer makes no contribution to your Health FSA Account.
If a Participant enters the Health FSA mid-year,then the Participant's maximum reimbursement dollar limit
will be prorated based on a percentage of the Plan Year remaining.
What amounts will be available for Health FSA reimbursement at any particular time during the Plan
Year?
The full amount of Health FSA coverage that you have elected (reduced by prior reimbursements made
during the same Plan Year)will be available to reimburse you for qualifying Medical Care Expenses
incurred during the Plan Year, regardless of the amount that you have contributed when you submitted the
claim (so long as you have continued to pay the contributions). For example, suppose that you elected
$1,000 of coverage and contributed to your Health FSA Account(as described under How are my Health
FSA Benefits paid for under the Cafeteria Plan7)during January and February-that means that by
February 24 you would have contributed$153.84($38.46 times four pay periods).You haven't made any
prior claims for reimbursement during the calendar year, but on February 26 you incur a Medical Care
Expense in the amount of$300. You submit that claim for reimbursement on February 27.So long as the
claim meets all applicable requirements,the$300 would be available to you for that expense, even though
you have only contributed$153.84 to your Health FSA Account at that point.
However,only reasonable quantities of over-the-counter(OTC)drugs will be reimbursed from your Health
FSA account in a single calendar month,even if the drugs otherwise meet the requirements for
reimbursement, including that they are for medical care under Code§213(d). Stockpiling is not permitted.
You may also be able to be reimbursed from unused amounts remaining in your Health FSA Account at
the end of a Plan Year for Medical Care Expenses incurred during a"grace period"following the end of the
Plan Year. (See When must the Medical Care Expenses be incurred for the Health FSA?)
What are"Medical Care Expenses"that may be reimbursed from the Health FSA?
Your Health FSA election may be for:
General-Purpose Health FSA Coverage.
Each of these Health FSA coverage options is described in detail below.
The eligible"Medical Care Expenses"vary according to the type of Health FSA coverage option that is
elected, as described below.
(a) General-Purpose Health FSA Coverage Option.
For purposes of the General-Purpose Health FSA Coverage Option,"Medical Care Expense"
means expenses incurred by you,your Spouse,or your Dependents for"medical care"as defined
in Code§213(d). Under the tax laws,"Medical Care Expenses"include expenses for OTC drugs
and medicines as well as expenses for prescription drugs. However,as described above, only
reasonable quantities of over-the-counter(OTC)drugs will be reimbursed from your Health FSA
account in a single calendar month.The following list specifies certain expenses that are not
reimbursable,even if they meet the definition of"medical care"under Code§213(d)and may
otherwise be reimbursable under regulations governing Health FSAs. Note that many expenses
that are not on the list of exclusions below will still not be reimbursable if such expenses do not
meet the definition of"medical care"under Code§213(d)and other requirements for
-16-
reimbursement under the Health FSA.
EXCLUSIONS:
health insurance premiums for any other plan(including premiums for a plan sponsored by
the Employer,such as the Medical Insurance Plan);
• long-term care services;
• cosmetic surgery or other similar procedures,unless the surgery or procedure is necessary to
ameliorate a deformity arising from or directly related to a congenital abnormality,a personal
injury resulting from an accident or trauma,or a disfiguring disease."Cosmetic surgery"
means any procedure that is directed at improving the patient's appearance and that does not
meaningfully promote the proper function of the body or prevent or treat illness or disease;
• the salary expenses of a nurse to care for a healthy newborn at home;
• funeral and burial expenses;
• household and domestic help(even if recommended by a qualified physician due to an
Employee's or Dependent's inability to perform physical housework);
• custodial care;
costs for sending a problem child to a special school for benefits that the child may receive
from the course of study and disciplinary methods;
* social activities,such as dance lessons(even if recommended by a physician for general
health improvement);
* bottled water;
• cosmetics,toiletries,toothpaste,etc.;
• uniforms or special clothing, such as maternity clothing;
• automobile insurance premiums;
• marijuana and other controlled substances that are in violation of federal law, even if
prescribed by a physician;
• any item that doesn't constitute"medical care"under Code§213(d);and
• any item that isn't reimbursable under applicable regulations.
Ask the Plan Administrator if you need further information regarding which expenses are
reimbursable under your plan.
For purposes of the Health FSA and its Coverage Options, "Spouse"means the person who is
legally married to you and is treated as a spouse under the Code. "Dependent"means your
tax dependent under the Code,except that an individual's status as a Dependent is
determined without regard to the gross income limitation for a"qualifying relative"and certain
other provisions of the Code's definition.See the Plan Administrator for more information
about which individuals will qualify as your Dependents.
Note: Because of recent changes in the Code,some individuals'Medical Care Expenses may no
longer qualify for tax-free reimbursement under a Health FSA.Your child(and in some cases,
your stepchild,grandchild, brother, sister, stepbrother, stepsister, niece,or nephew)may no
longer be considered to be your Dependent if he or she has the same principal place of
abode with another person for more than half the year. For example, if you provide more than
half of your child's support, but he or she lives with a grandparent all year,then your child
could be the grandparent's tax dependent instead of yours(if other conditions are met). If you
have children (or stepchildren,grandchildren,etc.)who do not reside with you and who are
affected by this change,their expenses will no longer be eligible for tax-free reimbursement
under the Health FSA.Other changes may apply as well to individuals who were previously
eligible for tax-free Health FSA coverage.
When must the Medical Care Expenses be incurred for the Health FSA?
For Medical Care Expenses to be reimbursed to you from your Health FSA Account for the Plan
Year,they must have been incurred during that Plan Year.The Plan Year for the Health FSA
is the same as the Plan Year for the Cafeteria Plan, a 12-month period beginning on January
-17-
1st and ending on December 31st.
In addition,as discussed below,you may be able to be reimbursed from unused amounts remaining
in your Health FSA Account at the end of a Plan Year for Medical Care Expenses incurred
during a"grace period"following the end of the Plan Year.Grace periods will begin
immediately following the last day of the plan year and will end 2.5 months later.
A Medical Care Expense is incurred when the service that causes the expense is provided, not when
the expense was paid. If you have paid for the expense but the services have not yet been
rendered,then the expense has not been incurred. For example,if you prepay on the first day
of the month for medical care that will be given during the rest of the month,the expense is
not incurred until the end of that month(and cannot be reimbursed until after the end of that
month). You may not be reimbursed for any expenses arising before the Health FSA or the
Cafeteria Plan became effective,before your Election Form/Salary Reduction Agreement
became effective,for any expense incurred after the close of the Plan Year(except for certain
expenses incurred during a grace period,as discussed below),or after a separation from
service(except for Continuation Coverage, as described under What is"Continuation
Coverage"and how does it work?').
In order to take advantage of the grace period,you must be:
a Participant in the Plan with Health FSA coverage that is in effect on the last day of the Plan
Year to which the grace period relates(December 31st);or
a qualified beneficiary who has COBRA coverage under the Health FSA on the last day of the
Plan Year to which the grace period relates(December 31st).
See What must I do to be reimbursed for Medical Care Expenses from the Health FSA?regarding
certain rules that apply to claims for reimbursement for Medical Care Expenses that are incurred during a
grace period.
Can I Continue Health FSA Coverage After Terminating Employment or Incurring a COBRA Event?
The only way a Participant and his or her Spouse and Dependents,as applicable, may continue the same
coverage that he or she had under the Health FSA Benefit before the qualifying event,is to elect COBRA
either on a self-pay basis or, if applicable, or to continue with salary reductions.
Please note that this only applies if you have a positive Health FSA Account balance at the end of the
applicable Period of Coverage(taking into account all claims submitted before the date of the qualifying
event).
Such individuals will be notified if they are eligible for COBRA continuation coverage. If COBRA is elected,
it will be available only for the remainder of the applicable Period of Coverage. COBRA coverage generally
ends for the Health FSA Benefit at the end of the Plan Year and cannot be continued for the next Plan
Year. Such continuation coverage shall be subject to all conditions and limitations under COBRA. Please
refer to your COBRA Notice for further explanation regarding your specific situation.
Contributions for COBRA continuation for Health FSA Benefits may be paid on a pre-tax basis for current
Employees receiving taxable compensation, but may not be prepaid from contributions in one Plan Year to
provide coverage that extends into a subsequent Plan Year.Generally for Employees who have incurred a
COBRA qualifying event as a result of no longer being actively employed, payments must be made on an
after-tax basis.
What must I do to be reimbursed for Medical Care Expenses from the Health FSA?
When you incur an expense that is eligible for payment,you must submit a claim to the Plan Administrator
on a Health FSA Reimbursement Request Form that will be supplied to you.You must include written
statements and/or bills from independent third parties stating that the Medical Care Expenses have been
-18-
incurred and stating the amount of such Medical Care Expenses,along with the Health FSA
Reimbursement Request Form.Generally,this requires including an Explanation of Benefits(EOB)Form
from the insurance provider(or a bill from a doctor's office)indicating the amounts that you are obligated to
pay.Further details about what must be provided are contained in the Health FSA Reimbursement
Request Form. If you have paid the contributions for the Health FSA coverage that you have elected,then
you will be reimbursed for your eligible Medical Care Expenses within 90 days after the date you submitted
the Health FSA Reimbursement Request Form(subject to a 15 day extension for matters beyond the Plan
Administrator's control-see What happens if my claim for benefits is denied?).Claims will be paid in
the order in which they are approved. Remember,though,that you can't be reimbursed for any total
expenses above the annual reimbursement amount that you have elected.
You will have until the 90th day after the end of the Plan Year in which to submit a claim for reimbursement
for Medical Care Expenses incurred during the previous Plan Year.However,if you have ceased to be
eligible as a Participant,you will only have until 90 days after the date you ceased to be eligible in which to
submit claims for reimbursement for Medical Care Expenses incurred prior to the date on which you
ceased to be eligible(or during any applicable grace period).You will be notified in writing if any claim for
benefits is denied. (See What happens if my claim for benefits is denied?)
The Health FSA Benefit has a grace period which allows for an additional period of time of 2.5 months
following the end of each Plan Year to incur expenses before the"use it or lose it"forfeiture rule applies.
Thus,expenses incurred within 2.5 months after the close of the Plan Year can be reimbursed with funds
carried over from the prior Plan Year.
The following additional rules will apply to Medical Care Expenses that are incurred during a grace period
or are submitted after the close of the Plan Year in which they were incurred:
• Medical Care Expenses incurred during a grace period and approved for reimbursement will
be paid first from available amounts that were remaining at the end of the preceding Plan
Year and then from any amounts that are available to reimburse expenses incurred during the
current Plan Year. For example, assume that$200 remains in your Health FSA Account at
the end of the current Plan Year and that you have also elected$2,400 of Health FSA
coverage for new Plan Year. If you submit a$500 Medical Care Expense that was incurred on
January 15,new Plan Year, $200 of your claim will be paid out of the unused amounts
remaining in your Health FSA Account from the current Plan Year and the remaining$300
will be paid out of the amounts that are available to reimburse you for Medical Care Expenses
incurred in the new Plan Year.
* Once paid,a claim will not be reprocessed or otherwise re-characterized so as to change the
Plan Year from which funds are taken to pay it. For example, using the same facts as in the
example in the preceding paragraph,assume that a few days after being reimbursed for the
$500 grace period expense,you discover$200 of 2007 Medical Care Expenses that have not
been submitted for reimbursement.You cannot be reimbursed for the newly discovered
expenses because no amounts remain to reimburse you for 2008 expenses.The Plan will not
reprocess the$500 grace period expense so as to pay it entirely from your 2008 Health FSA
amounts. For this reason, if you also have Health FSA coverage for the current year,you may
want to wait to submit Medical Care Expenses you incur during the grace period until you are
sure you have no remaining unreimbursed expenses from the prior Plan Year.
• Expenses incurred during a grace period must be submitted by the 90 day(s)following the
close of the Plan Year to which the grace period relates in order to be reimbursed from
amounts remaining at the end of that Plan Year. (As discussed above,90 days is also the
deadline for submitting any claims for reimbursement of Medical Care Expenses incurred
during the preceding Plan Year.)
To have your claims processed as soon as possible, please read What happens if my claim for benefits
is denied?'. Note that it is not necessary for you to have actually paid the amount due for a Medical Care
Expense, only for you to have incurred the expense(as defined under When must the Medical Care
Expenses be incurred for the Health FSA?)and that it is not being paid for or reimbursed from any other
source.
-19-
If the Employer implements an electronic payment card program(debit card,credit card,or similar
method)to pay expenses from the Health FSA,some expenses may be validated at the time the expense
is incurred(like co-pays for medical care). For other expenses,the card payment is only conditional and
you will still have to submit supporting documents. In addition, Medical Care Expenses incurred during a
Grace Period may need to be submitted manually in order to be reimbursed from unused amounts in your
Health FSA Account from the preceding Plan Year if the card is unavailable for such reimbursement.You
will receive more information from the Employer about what you must do to obtain reimbursement if such a
system is implemented.
Is there any risk of losing or forfeiting the amounts that I elect for Health FSA Benefits?
Yes. If the Medical Care Expenses that you incur during the Plan Year or during the grace period
immediately following the Plan Year(if you are eligible for the grace period-see When must the Medical
Care Expenses be incurred for the Health FSA?)are less than the annual amount that you elected for
Health FSA Benefits,you will forfeit the rest of that amount-this is called the"use-it-or-lose-it"rule under
applicable tax laws. In other words,you cannot be reimbursed for(or receive any direct or indirect payment
of)any amounts that were not incurred for Medical Care Expenses during the Plan Year or its grace period,
if applicable,even if amounts are still left in your Health FSA Account. The difference between what you
elected and what Medical Care Expenses were reimbursed will be forfeited at the end of the time limits
described under What are the time limits that affect forfeiture of my Health FSA Benefits?.
What are the time limits that affect forfeiture of my Health FSA Benefits(and what happens to
amounts that are forfeited)?
You will forfeit any amounts in your Health FSA Account that are not applied to pay expenses submitted by
the 90th day following the end of the Plan Year for which the election was effective(except that if you have
ceased to be eligible as a Participant,you may forfeit such amounts at an earlier date-see What must I do
to be reimbursed for Medical Care Expenses from the Health ESA?). Forfeited amounts will be used
as follows:first,to offset any losses experienced by the Employer as a result of making reimbursements in
excess of contributions paid by all Participants;second,to reduce the cost of administering the Health FSA
during the Plan Year and subsequent Plan Year;and third,to provide increased benefits or compensation
to Participants in subsequent years in any weighted or uniform fashion that the Plan Administrator deems
appropriate, consistent with applicable regulations.Also,any Health FSA Account benefit payments that
are unclaimed(for example, uncashed benefit checks)by the close of the Plan Year following the Plan
Year in which the Medical Care Expense was incurred shall be forfeited and applied as described above.
Will I be taxed on the Health FSA Benefits that I receive?Generally,you will not be taxed on your
Health FSA Benefits, up to the limits set forth under What are the maximum and minimum Health FSA
Benefits that I may elect?'. However,the Employer cannot guarantee that specific tax consequences will
flow from your participation in the Plan.The tax benefits that you receive depend on the validity of the
claims that you submit. For example,to qualify for tax-free treatment,your Medical Care Expenses must
meet the definition of"medical care"as defined in the Code. If you are reimbursed for a claim that is later
determined to not be for Medical Care Expenses,then you will be required to repay the amount.
Ask the Plan Administrator if you need further information about which expenses are and are not likely to
be reimbursable.
-20-
Article VIII
DEPENDENT CARE REIMBURSEMENT ACCOUNT
What are"DCAP Benefits"?
As described under What benefits may be elected under the Cafeteria Plan?, a DCAP permits eligible
Employees to pay for coverage with pre-tax dollars that will reimburse them for Dependent Care Expenses
not reimbursed elsewhere(for example,you cannot be reimbursed for the same expense from your
Spouse's DCAP).As described under How do employees pay for Benefits on a pre-tax basis?, if you
elect DCAP Benefits,then you will be able to provide a source of pre-tax funds to reimburse yourself for
your eligible Dependent Care Expenses by entering into an Election Form/Salary Reduction Agreement
with your Employer. Because the share of the contributions that you pay will be with pre-tax funds,you may
save both federal income taxes and FICA(Social Security)taxes. See What tax savings are possible
under the Cafeteria Plan?for an example dealing with pre-tax payment of Premium Insurance
contributions.
After you satisfy the eligibility requirements described above,you may participate in the DCAP on the date
the eligibility requirements have been met by signing an individual Election Form/Salary Reduction
Agreement as described under'How do I become a Participant and when is my Entry Date?
What is my"DCAP Account"?
If you elect DCAP Benefits,an account called a"DCAP Account"will be set up in your name to keep a
record of the reimbursements that you are entitled to,as well as the contributions that you have paid for
such benefits during the Plan Year.Your DCAP Account is merely a recordkeeping account;it is not
funded (all reimbursements are paid from the general assets of the Employer),and it does not bear
interest.
What are the maximum DCAP Benefits that I may elect under the Cafeteria Plan?
You may choose any amount of Dependent Care Expenses reimbursement that you desire under the
DCAP,subject to the maximum reimbursement amount described below.You must commit to a salary
reduction to pay the annual DCAP contribution equal to the coverage level that you have chosen(e.g., if
you elect$3,000 in DCAP Benefits,you'll pay for the benefits with a$3,000 salary reduction).The amount
of Dependent Care Expense reimbursement that you choose cannot exceed$5,000 for a calendar year or,
if lower,the maximum amount that you have reason to believe will be excludable from your income under
Code§ 129 when your election is made.The$5,000 maximum will apply to you if:
• you are married and file a joint federal income tax return;
• you are married and file a separate federal income tax return,and meet the following
conditions:(1)you maintain as your home a household that constitutes(for more than half of
the taxable year)the principal place of abode of a Qualifying Individual(i.e.,the Dependent
for whom you are eligible to receive reimbursements under the DCAP); (2)you furnish over
half of the cost of maintaining such household during the taxable year;and(3)during the last
six months of the taxable year,your Spouse is not a member of such household(i.e.,your
Spouse maintained a separate residence);or
• you are single or the head of the household for federal income tax purposes. If you are
married and reside with your Spouse but you file a separate federal income tax return,then
the maximum DCAP Benefit that you may exclude from your income under Code§ 129 is
$2,500 for a calendar year.These maximums($5,000 or$2,500 for a calendar year,as
applicable)are just the largest amount that is possible;the maximum amount that you are
able to exclude from your income may be less because of other limitations,as described
under'What are"Dependent Care Expenses"that may be reimbursed?'(for example, note
that you cannot exclude more than the amount of your or your Spouse's earned income for
the calendar year).
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If a Participant enters the DCAP mid-year,then the Participants maximum reimbursement dollar limit will
be prorated based on a percentage of the Plan Year remaining. •
How are my DCAP Benefits paid for under the Cafeteria Plan?
When you complete the Election Form/Salary Reduction Agreement,you specify the amount of DCAP
Benefits that you wish to pay with your salary reduction. From then on,you must pay a contribution for such
coverage by having that portion deducted from each paycheck on a pre-tax basis(generally an equal
portion from each paycheck or an amount otherwise agreed to or as deemed appropriate by the Plan
Administrator). If you pay all of your contributions,then your DCAP Account will be credited with the portion
of your gross income that you have elected to give up through salary reduction.These portions will be
credited as of each pay period.
For example,suppose that you have elected to be reimbursed for$2,600 per year for Dependent Care
Expenses and that you have chosen no other benefits under the Cafeteria Plan.Your DCAP Account
would be credited with a total of$2,600 by the end of the Plan Year. If you are paid bi-weekly,then your
DCAP Account would reflect that you have paid$100($2,600 divided by 26)each pay period in
contributions for the DCAP Benefits that you have elected.The Employer makes no contribution to your
DCAP Account.
What amounts will be available for DCAP reimbursement at any particular time during the Plan
Year?
The amount of coverage that is available for reimbursement of qualifying Dependent Care Expenses at any
particular time during the Plan Year will be equal to the amount credited to your DCAP Account at the time
your claim is paid, reduced by the amount of any prior reimbursements paid to you during the Plan Year.
Using the example under'How are my DCAP Benefits paid for under the Cafeteria Plan?', suppose that
you incur$1,500 of Dependent Care Expenses by the end of March.At that time,your DCAP Account
would only have been credited with$700($100 times seven pay periods), so only$700 would be available
for reimbursement at the end of March(assuming that you had not received any prior reimbursements).
You would have to wait to submit the remaining$800 in Dependent Care Expenses until after you had
received the appropriate credits to your DCAP Account(you could request a$100 reimbursement after
each of the next eight pay periods).
You may also be able to be reimbursed from unused amounts remaining in your DCAP Account at the end
of a Plan Year for Dependent Care Expenses incurred during a"grace period"following the end of the Plan
Year. (See When must the Dependent Care Expenses be incurred for the DCAP?)
What are"Dependent Care Expenses"that may be reimbursed?
"Dependent Care Expenses"means employment-related expenses incurred on behalf of a person who
meets the requirements to be a"Qualifying Individual,"as defined in the first bulleted item below.All of the
following conditions must be met for such expenses to qualify as Dependent Care Expenses that are
eligible for reimbursement:
Each person for whom you incur the expenses must be a Qualifying Individual,that is, he or
she must be:
a person under age 13 who is your"qualifying child"under the Code(in general,the
person must: (1)have the same principal abode as you for more than half the year; (2)
be your child or stepchild(by blood or adoption),foster child,sibling or stepsibling,or a
descendant of one of them; and(3)not provide more than half of his or her own
support for the year); or
your Spouse or a person who is your dependent under federal tax law, but only if he or
she is physically or mentally incapable of self-care and has the same principal abode
as you for more than half the year.
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Under a special rule for children of divorced or legally separated parents, a child is a Qualifying Individual
with respect to the custodial parent,even if that parent is not entitled to claim the dependency exemption
for the child.See the Plan Administrator for more information which individuals will qualify as your
Qualifying Individuals.
Note that recent legislation has changed the tests that apply for a child,Spouse,or other person to be a
Qualifying Individual. For example,to be a Qualifying Individual based on being physically or mentally
incapable of self-care,a dependent's gross income must be less than the exemption amount(for 2005,
$3,200(before phase-out)).This requirement does not apply to a Spouse or qualifying child (of any age)
who is physically or mentally incapable of self-care.
(For this purpose,a qualifying child is a person who meets the requirements described above and is under
19, under 24 and a full-time student,or permanently and totally disabled.)Other changes may apply as
well to persons who were previously Qualifying Individuals.
• No reimbursement will be made to the extent that such reimbursement would exceed the
balance in your DCAP Account.
• The expenses are incurred for services rendered after the date of your election to receive
DCAP Benefits and during the Plan Year to which the election applies.
The expenses are incurred in order to enable you(and your Spouse, if you are married)to be
gainfully employed,which generally means working or looking for work.There is an
exception: If your Spouse is not working or looking for work when the expenses are incurred,
he or she must be a full-time student or be physically or mentally incapable of self-care.
* The expenses are incurred for the care of a Qualifying Individual or for household services
attributable in part to the care of a Qualifying Individual.
• If the expenses are incurred for services outside of your household,they are incurred for the
care of(a)a person under age 13 who is your qualifying child;or(b)your Spouse or a person
who is your dependent under federal tax law, is physically or mentally incapable of self-care,
and regularly spends at least eight hours per day in your household.
• If the expenses are incurred for services provided by a dependent care center(that is,a
facility that provides care for more than six individuals not residing at the facility),the center
complies with all applicable state and local laws and regulations.
* The person who provided care was not your Spouse or a person for whom you are entitled to
a personal exemption under Code§ 151(c). If your child provided the care,then he or she
must be age 19 or older at the end of the year in which the expenses are incurred.
• The expenses are not paid for services outside of your household at a camp where the
dependent stays overnight.
Ask the Plan Administrator if you need further information about which expenses are, and are not, likely to
be reimbursable.
You will also be asked to certify that you have no reason to believe that the requested reimbursement,
when added to your other reimbursements to date for Dependent Care Expenses incurred during the same
calendar year,will exceed the applicable statutory limit.Your statutory limit is the smallest of the following
amounts:
your earned income for the calendar year(after your salary reductions under the Cafeteria
Plan);
• the earned income of your Spouse for the calendar year(your Spouse will be deemed to
have earned income of$250($500 if you have two or more Qualifying Individuals)for each
month in which your Spouse is(a)physically or mentally incapable of self-care;or(b)a full-
time student); or
* either$5,000 or$2,500 for the calendar year, depending on your marital and tax filing status,
as described further under What are the maximum and minimum DCAP Benefits that I may
elect under the Cafeteria Plan?.
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Any reimbursements that the Employer has reason to believe will exceed your statutory limit will be subject
to FICA and income tax withholding. Note that if you are married and your Spouse also participates in a
DCAP,the maximum amount that you and your Spouse together can exclude from income is$5,000.
When must the Dependent Care Expenses be incurred?
For Dependent Care Expenses to be reimbursed to you from your DCAP Account for the Plan Year,the
expenses must have been incurred during that Plan Year.The Plan Year for the DCAP is the same as the
Plan Year for the Cafeteria Plan, a 12-month period beginning on January 1st and ending on December
31st.
In addition,as discussed below,you may be able to be reimbursed from unused amounts remaining in
your DCAP Account at the end of a Plan Year for Dependent Care Expenses incurred during a"grace
period"following the end of the Plan Year.Grace periods will begin immediately following the last day of
the plan year and will end 2. months later.
A Dependent Care Expense is incurred when the service that causes the expense is provided, not when the
expense is paid. If you have paid for the expense but the services have not yet been rendered,then the
expense has not been incurred. For example, if you prepay on the first day of the month for dependent
care that will be given during the rest of the month,then the expense is not incurred until the end of that
month (and cannot be reimbursed until after the end of that month).You may not be reimbursed for any
expenses arising before the DCAP or Cafeteria Plan became effective,for any expenses arising before
your Election Form/Salary Reduction Agreement became effective,for any expenses incurred after the
close of the Plan Year,or after a separation from service(except as described under What must I do to
be reimbursed for my Dependent Care Expenses?).
Can I Continue DCAP Coverage After Terminating Employment?
When you cease to be a Participant under the DCAP Benefit,your salary reductions and election to
participate will terminate also.Therefore,the Participant will not be able to receive reimbursements for
Dependent Care Expenses incurred after the end of the day on which the Participant's employment
terminates or the Participant otherwise cease to be eligible.
What must I do to be reimbursed for my Dependent Care Expenses?When you incur an expense that
is eligible for payment,you must submit a claim to the Plan Administrator on a DCAP Reimbursement
Request Form that will be supplied to you.You must include written statements and/or bills from
independent third parties stating that the Dependent Care Expenses have been incurred and stating the
amount of such Dependent Care Expenses,along with the DCAP Reimbursement Request Form. Further
details about what must be provided are contained in the DCAP Reimbursement Request Form.
If there are enough credits to your DCAP Account,then you will be reimbursed for your eligible DCAP
Expenses within 30 days after the date you submitted the DCAP Reimbursement Request Form (subject to
a 45-day extension for matters beyond the Plan Administrator's control-see What happens if my claim
for benefits is denied?). If a claim is for an amount larger than that remaining in your current DCAP
Account balance,then the excess part of the claim will be carried over into the following months,to be paid
out as your balance becomes adequate. Remember,though,that you can't be reimbursed for any total
expenses above your available annual credits to your DCAP Account.
You will have until 90 days after the end of the Plan Year in which to submit a claim for reimbursement for
Dependent Care Expenses incurred during the previous Plan Year. However, if you have ceased to be
eligible as a Participant,you will only have until 90 days after the date you ceased to be eligible in which to
submit a claim for reimbursement for Dependent Care Expenses incurred prior to the date you ceased to
be eligible;you can also be reimbursed for expenses incurred in the month following your termination of
participation if such month is in the current Plan Year and your claim is submitted by the 90 day deadline.
You will be notified in writing if any claim for benefits is denied.(See What happens if my claim for
-24-
benefits is denied7.)
The DCAP Benefit has a grace period which allows for an additional period of time of 2. months following
the end of each Plan Year to incur expenses before the"use it or lose it"forfeiture rule applies.Thus,
expenses incurred within 2. months after the close of the Plan Year can be reimbursed with funds carried
over from the prior Plan Year.
The following additional rules will apply to Dependent Care Expenses that are incurred during a grace
period or are submitted after the close of the Plan Year in which they were incurred:
* If a claim is made for Dependent Care Expenses incurred during a grace period and
approved for reimbursement,you may designate,at the time a claim is presented to the Plan
Administrator, against which Plan Year(s)you want the claim paid against. Once paid, a claim
will not be reprocessed or otherwise re-characterized so as to change the Plan Year from
which funds are taken to pay it. For example, using the same facts as in the example in the
preceding paragraph,assume that a few days after being reimbursed for the$500 grace
period expense,you discover$200 of 2007 Dependent Care Expenses that have not been
submitted for reimbursement.You cannot be reimbursed for the newly discovered expenses
because no amounts remain to reimburse you for 2008 expenses.The Plan will not
reprocess the$500 grace period expense so as to pay it entirely from your 2008 Dependent
Care amounts. For this reason, if you also have Dependent Care coverage for the current
year,you may want to wait to submit Dependent Care Expenses you incur during the grace
period until you are sure you have no remaining unreimbursed expenses from the prior Plan
Year.
If you either choose to have the claim adjudicated against all applicable Plan Years, or fail to
designate against which Plan Year(s)each particular claim is to be paid,such claim(s)will
first be charged to the Account that relates to the Plan Year associated with the Grace Period.
If any part of a claim for a Dependent Care Expense remains unpaid it will next be charged to
the Account relating to the Plan Year in which such Dependent Care Expense was incurred.
Once a claim is adjudicated in this manner, it shall be irrevocable and cannot be reprocessed
against a different Plan Year.
Expenses incurred during a grace period must be submitted by the 90 day(s)following the
close of the Plan Year to which the grace period relates in order to be reimbursed from
amounts remaining at the end of that Plan Year. (As discussed above,90 days is also the
deadline for submitting any claims for reimbursement of Dependent Care Expenses incurred
during the preceding Plan Year.)
To have your claims processed as soon as possible, please read What happens if my claim for benefits
is denied?'. Note that it is not necessary for you to have actually paid the bill in an amount due for a
Dependent Care Expense, only for you to have incurred the expense(as defined under When must the
Dependent Care Expenses be incurred7)and that it is not being paid for or reimbursed from any other
source.
If the Employer implements an electronic payment card program(debit card, credit card,or similar
method)to pay expenses from the Dependent Care Account,some expenses may be validated at the time
the expense is incurred. For other expenses,the card payment is only conditional and you will still have to
submit supporting documents. In addition, Dependent Care Expenses incurred during a Grace Period may
need to be submitted manually in order to be reimbursed from unused amounts in your Dependent Care
Account from the preceding Plan Year if the card is unavailable for such reimbursement.You will receive
more information from the Employer about what you must do to obtain reimbursement if such a system is
implemented.
Is there any risk of losing or forfeiting the amounts that I elect for DCAP Benefits?
Yes. If the Dependent Care Expenses that you incur during the Plan Year are less than the annual amount
that you elected for DCAP Benefits,you will forfeit the rest of that amount in your DCAP Account-this is
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called the"use-it-or-lose-it"rule under applicable tax laws.
This benefit has a grace period which allows for an additional period of time of 2. months following the end
of each Plan Year to incur expenses before the"use it or lose it"forfeiture rule applies.Thus, expenses
incurred within 2. months after the close of the Plan Year can be reimbursed with funds carried over from
the prior Plan Year. However,any unused amounts from the prior Plan Year that are not used to reimburse
expenses by the end of the grace period remain subject to the"use it or lose it"rule and must be forfeited.
In other words, you cannot be reimbursed for(or receive any direct or indirect payment of)any amounts
that were not incurred for Dependent Care Expenses during the Plan Year, even if amounts are still left in
your DCAP Account.The difference between what you elected and what Dependent Care Expenses were
reimbursed will be forfeited at the time periods described under What are the time limits that affect
forfeiture of my DCAP Benefits?.
What are the time limits that affect forfeiture of my DCAP Benefits?
You will forfeit any amounts in your DCAP Account that are not applied to DCAP Benefits for any Plan Year
by the 90th day following the end of the Plan Year for which the election was effective(except that if you
have ceased to be eligible as a Participant,you will forfeit such amounts if they have not been applied
within days after the date you ceased to be eligible-see What must I do to be reimbursed for my
Dependent Care Expenses?). Forfeited amounts will be used as follows:first,to offset any losses
experienced by the Employer as a result of making reimbursements in excess of contributions paid by all
Participants;second,to reduce the cost of administering the DCAP during the Plan Year and the
subsequent Plan Year; and third,to provide increased benefits or compensation to Participants in
subsequent years in any weighted or uniform fashion that the Plan Administrator deems appropriate,
consistent with applicable regulations.Also, any DCAP Account benefit payments that are unclaimed (for
example, uncashed benefit checks)by the close of the Plan Year following the Plan Year in which the
Dependent Care Expense was incurred shall be forfeited and applied as described above.
Will I be taxed on the DCAP Benefits I receive?
Generally, you will not be taxed on your DCAP Benefits, up to the limits set forth under What are the
maximum and minimum DCAP Benefits that I may elect under the Cafeteria Plan?. However,the
Employer cannot guarantee that specific tax consequences will flow from your participation in the DCAP.
The tax benefits that you receive depend on the validity of the claims that you submit. For example,to
qualify for tax-free treatment,you will be required to file IRS Form 2441 ("Child and Dependent Care
Expenses")with your annual tax return(Form 1040)or a similar form. You must list on Form 2441 the
names and taxpayer identification numbers(TINs)of any entities that provided you with dependent care
services during the calendar year for which you have claimed a tax-free reimbursement. If you are
reimbursed for a claim that is later determined to not be for Dependent Care Expenses,then you will be
required to repay the amount.
Ultimately, it is your responsibility to determine whether any reimbursement under the DCAP constitutes
Dependent Care Expenses that qualify for the federal income tax exclusion.Ask the Plan Administrator if
you need further information about which expenses are, and are not likely to be reimbursable, but
remember that the Plan Administrator is not providing legal advice.
If I elect DCAP Benefits,can I still claim the Dependent Care Tax Credit on my federal income tax
return?
You may not claim any other tax benefit for the amount of your pre-tax salary reductions under the DCAP,
although your Dependent Care Expenses in excess of that amount may be eligible for the Dependent Care
Tax Credit(see What is the Dependent Care Tax Credit?). For example, if you elect$3,000 in coverage
under the DCAP and are reimbursed$3,000, but you had Dependent Care Expenses totaling$5,000,then
you could count the excess$2,000 when calculating the Dependent Care Tax Credit if you have two or
more Dependents.
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What is the Dependent Care Tax Credit?
The Dependent Care Tax Credit is a credit against your federal income tax liability under the Code. It is a
non-refundable tax credit,which means that any portion of it that exceeds your federal income tax liability
will be of no value to you.The credit is calculated as a percentage of your annual Dependent Care
Expenses. In determining what the tax credit would be,you may take into account$3,000 of such expenses
for one Dependent or$6,000 for two or more Dependents. Depending on your adjusted gross income,the
percentage could be as much as 35%of your qualifying expenses(to a maximum credit amount of$1,050
for one Dependent or$2,100 for two or more Dependents),to a minimum of 20%of such expenses
(producing a maximum credit of$600 for one Dependent or$1,200 for two or more Dependents).The
maximum 35%rate is reduced by 1%(but not below 20%)for each$2,000 portion(or any fraction of
$2,000)by which your adjusted gross incomes exceeds$15,000.
Example:Assume that you have one Dependent for whom you have incurred Dependent Care Expenses
of$3,600,and that your adjusted gross income is$20,000.Since only one Dependent is involved,the
credit will be calculated by applying the appropriate percentage to the first$3,000 of the expenses.The
percentage is 32%.Thus,your tax credit would be$3,000 x 32%=$960. If you had incurred the same
expenses for two or more Dependents,your credit would have been$3,600 x 32%=$1,152, because the
entire expense would have been taken into account,not just the first$3,000.
For more information about how the Dependent Care Tax Credit works, see IRS Publication No. 503
("Child and Dependent Care Expenses").
Would it be better to include the DCAP Benefits in my income and claim the Dependent Care Tax
Credit, instead of treating the reimbursements as tax free?
For most individuals,participating in a DCAP will produce the greater federal tax savings, but there are
some for whom the opposite is true. Because the preferable method for treating benefits payments
depends on certain factors such as a person's tax filing status(e.g., married, single, head of household),
number of Dependents,earned income,etc.,each Participant will have to determine his or her tax position
individually in order to make the decision. Use IRS Form 2441 ("Child and Dependent Care Expenses")to
help you.
Ask the Plan Administrator if you need further information about the DCAP or the Dependent Care Tax
Credit, but remember that the Plan Administrator is not providing legal advice.Your Employer may also be
able to provide you with a worksheet or tax calculator to help you make the comparison, ask the Human
Resources Manager if you would like to use one or both of these.
-27-
Article IX
CLAIMS PROCEDURE
What happens if my claim for benefits is denied?
Premium Insurance Benefits
The applicable insurance company will decide your claim in accordance with its claims procedures. If your
claim is denied,you may appeal to the insurance company for a review of the denied claim. If you don't
appeal on time,you will lose your right to file suit in a state or federal court,as you will not have exhausted
your internal administrative appeal rights(which generally is a prerequisite to bringing a suit in state or
federal court). For more information about how to file a claim and for details regarding the medical
insurance company's claims procedures,consult the claims procedure applicable under that plan or policy,
as described in the plan document or summary plan description for the Medical Insurance Plan.
Claims Under the Cafeteria Plan
However, if(a)a claim for reimbursement under the Health FSA or DCAP Components of the Cafeteria
Plan is wholly or partially denied, or(b)you are denied a benefit under the Cafeteria Plan(such as the
ability to pay for Premium insurance benefits, Health FSA,and DCAP benefits on a pre-tax basis)due to an
issue germane to your coverage under the Cafeteria Plan (for example,a determination of a Change in
Status;a"significant"change in contributions charged; or eligibility and participation matters under the
Cafeteria Plan document),then the claims procedure described below will apply. If your claim is denied in
whole or in part,you will be notified in writing by the Plan Administrator within 30 days after the date the
Plan Administrator received your claim. (This time period may be extended for an additional 15 days for
matters beyond the control of the Plan Administrator,including in cases where a claim is incomplete.The
Plan Administrator will provide written notice of any extension, including the reasons for the extension and
the date by which a decision by the Plan Administrator is expected to be made.Where a claim is
incomplete,the extension notice will also specifically describe the required information,will allow you 45
days from receipt of the notice in which to provide the specified information and will have the effect of
suspending the time for a decision on your claim until the specified information is provided.)
Notification of a denied claim will set out:
• a specific reason or reasons for the denial;
• the specific Plan provision on which the denial is based;
• a description of any additional material or information necessary for you to validate the claim
and an explanation of why such material or information is necessary;
• appropriate information on the steps to be taken if you wish to appeal the Plan Administrator's
decision, including your right to submit written comments and have them considered,your
right to review(upon request and at no charge)relevant documents and other information,
and your right to file suit under ERISA(where applicable)with respect to any adverse
determination after appeal of your claim.
Appeals
If your claim is denied in whole or part,then you(or your authorized representative)may request review
upon written application to the"Appeals Committee".Your appeal must be made in writing within 180 days
after your receipt of the notice that the claim was denied. If you do not appeal on time, you will lose the
right to appeal the denial and the right to file suit in court.Your written appeal should state the reasons that
you feel your claim should not have been denied. It should include any additional facts and/or documents
that you feel support your claim.You will have the opportunity to ask additional questions and make written
comments, and you may review(upon request and at no charge)documents and other information
relevant to your appeal.
Decision on Review
Your appeal will be reviewed and decided by the Committee or other entity designated in the Plan in a
reasonable time not later than 60 days after the Committee receives your request for review.The
Committee may, in its discretion, hold a hearing on the denied claim.Any medical expert consulted in
-28-
connection with your appeal will be different from and not subordinate to any expert consulted in
connection with the initial claim denial.The identity of a medical expert consulted in connection with your
appeal will be provided.
If the decision on review affirms the initial denial of your claim,you will be furnished with a notice of adverse
benefit determination on review setting forth:
• the specific reason(s)for the decision on review;
the specific Plan provision(s)on which the decision is based;
• a statement of your right to review(upon request and at no charge)relevant documents and
other information;
• if an"internal rule,guideline,protocol,or other similar criterion"is relied on in making the
decision on review,then a description of the specific rule,guideline,protocol,or other similar
criterion or a statement that such a rule,guideline, protocol, or other similar criterion was
relied on and that a copy of such rule,guideline, protocol, or other criterion will be provided
free of charge to you upon request;and
• a statement of your right to bring suit under ERISA§502(a)(where applicable).
Duty of Beneficiary/Third Party Recoveries
Any Beneficiary under the Plan that receives a payment,whether by lawsuit, settlement,or otherwise,from
third parties for costs associated with sickness or injury resulting from the acts or omissions of another
person or party must reimburse the Plan to the extent the Beneficiary has received payments from the Plan
for such sickness or injury. The Plan has a first lien upon any such recovery.Any recovery by the Plan
Administrator from such payments is subject to a deduction for reasonable attorney fees and court costs
incurred by the Beneficiaries in securing the third-party payments,and shall be prorated,to reflect that
portion of the total recovery reimbursed to the Plan Administrator for the benefits it had paid from the Plan.
However,the Plan's share of the recovery will not be reduced because the Beneficiary has not received the
full damages claimed, unless the Plan Administrator agrees in writing to such a reduction.
The Plan further requires covered Beneficiaries promptly advise the Plan Administrator of third-party claims
and to execute any assignments, liens,or other documents the Plan Administrator requests.The Plan may
withhold Benefits until such documents are received.
Subrogation/Acts of Third Parties
The Plan Administrator,on behalf of the Plan, has the right to recover any payments made to Beneficiaries,
whether by lawsuit, settlement,or otherwise, by third parties for costs associated with sickness or injury
resulting from the acts or omissions of another person or party.The Plan has a first lien upon any such
recovery.Any recovery by the Plan Administrator from such payments is subject to a deduction for
reasonable attorney fees and court costs incurred by the Beneficiaries in securing the third-party payments,
and shall be prorated,to reflect that portion of the total recovery reimbursed to the Plan Administrator for
the benefits it had paid from the Plan. However,the Plan's share of the recovery will not be reduced
because the Beneficiary has not received the full damages claimed, unless the Plan Administrator agrees
in writing to such a reduction.
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Article X
FUNDING
Funding This Plan
All of the amounts payable under this Plan may be paid from the general assets of the Employer,but
Premium Payment Benefits are paid as provided in the applicable insurance policy. Nothing herein will be
construed to require the Employer or the Plan Administrator to maintain any fund or to segregate any
amount for the benefit of any Participant,and no Participant or other person shall have any claim against,
right to,or security or other interest in any fund,account,or asset of the Employer from which any payment
under this Plan may be made.There is no trust or other fund from which Benefits are paid.While the
Employer has complete responsibility for the payment of Benefits out of its general assets(except for
Premium Payment Benefits paid as provided in the applicable insurance policy),it may hire an unrelated
third-party paying agent to make Benefit payments on its behalf.
How long will the Cafeteria Plan remain in effect?
Although the Employer expects to maintain the Cafeteria Plan indefinitely,it has the right to amend or
terminate all or any part of the Cafeteria Plan at any time for any reason. It is also possible that future
changes in state or federal tax laws may require that the Cafeteria Plan be amended accordingly.
-30-
Article XI
STATEMENT OF ERISA RIGHTS
What are my ERISA Rights?
The Cafeteria Plan and the HSA Component are not ERISA welfare benefit plans under the Employee
Retirement Income Security Act of 1974(ERISA).However,the Health FSA Component and the Medical
Insurance Plan are governed by ERISA.
Note:This Summary Plan Description does not describe the Medical Insurance Plan.Consult the Medical
Insurance Plan document and the separate Summary Plan Description for the Medical Insurance Plan.
Your Rights.As a participant in the Cafeteria Plan,you are entitled to certain rights and protections under
ERISA.ERISA provides that all participants shall be entitled to:
• Examine,without charge,at the Plan Administrator's office and at other specified locations
(such as worksites)all documents governing the Plan, including insurance contracts,and a
copy of the latest annual report(Form 5500 Series), if any,filed by the Plan with the U.S.
Department of Labor and available at the Public Disclosure Room of the Employee Benefits
Security Administration;
• Obtain, upon written request to the Administrator,copies of documents governing the
operation of the Plan,including insurance contracts and collective bargaining agreements,
and copies of the latest annual report(Form 5500 Series)and updated summary plan
description.The Plan Administrator may make a reasonable charge for the copies);and
* Receive a summary of the Plan's annual financial report, if any.The Plan Administrator is
required by law to furnish each participant with a copy of this summary annual report.
COBRA and HIPAA Rights.You have a right to continue your Medical Insurance Plan coverage(and,in
some cases,your Health FSA coverage)for yourself if there is a loss of coverage under the plan as a
result of a qualifying event.You or your dependents may have to pay for such coverage. Review this
summary plan description and the documents governing the plan on the rules governing your COBRA
continuation coverage rights.
You have rights regarding reduction or elimination of exclusionary periods of coverage for preexisting
conditions under your group health plan, if you have creditable coverage from another plan.You should be
provided a certificate of creditable coverage,free of charge,from your group health plan or health
insurance issuer when you lose coverage under the plan,when you become entitled to elect COBRA
continuation coverage,when your COBRA continuation coverage ceases, if you request it before losing
coverage,or if you request it up to 24 months after losing coverage.Without evidence of creditable
coverage,you may be subject to a preexisting condition exclusion for 12 months(18 months for late
enrollees)after your enrollment date in your coverage.(Note:This does not apply to the Health FSA,which
is an "excepted benefit"under HIPAA.)
HIPAA Privacy Rights.Under another provision of HIPAA,group health plans(including the Health FSA)
are required to take steps to ensure that certain"protected health information"(PHI)is kept confidential.
You may receive a separate notice from the Employer(or medical insurers)that outlines its health privacy
policies.
Fiduciary Obligations.In addition to creating rights for participants, ERISA imposes duties upon the
people who are responsible for the operation of the employee benefits plan.The people who operate your
plan,called"fiduciaries"of the plan, have a duty to do so prudently and in the interest of you and other
participants.
No Discrimination.No one, including your employer or any other person, may fire you or otherwise
discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights
under ERISA.
-31-
Right to Review.If your claim for a benefit is denied or ignored in whole or in part,you have a right to
know why this was done,to obtain copies of documents relating to the decision without charge,and to
appeal any denial,all within certain time schedules.
Enforcing Your Rights.Under ERISA,there are steps that you can take to enforce these rights. For
instance,if you request a copy of plan documents or the latest annual report(if any)from the plan and do
not receive them within 30 days,you may file suit in a federal court. In such a case,the court may require
the Plan Administrator to provide the materials and pay you up to$110 a day until you receive them, unless
the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a
claim for benefits that is denied or ignored in whole or in part,then you may file suit in a state or federal
court(but only if you have first filed your claim under the plan's claims procedures and, if applicable,filed a
timely appeal of any denial of your claim). If it should happen that plan fiduciaries misuse the plan's money,
or if you are discriminated against for asserting your rights,you may seek assistance from the U.S.
Department of Labor,or you may file suit in a federal court.The court will decide who should pay court
costs and legal fees. If you are successful the court may order the person you have sued to pay these
costs and fees. If you lose,the court may order you to pay these costs and fees,for example, if it finds your
claim is frivolous.
Assistance With Your Questions.If you have any questions about your plan,you should contact the Plan
Administrator. If you have any questions about this statement or about your rights under ERISA or HIPAA,
or if you need assistance in obtaining documents from the Plan Administrator,you should contact the
nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your
telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security
Administration, U.S. Department of Labor, 200 Constitution Avenue N.W.,Washington,D.C. 20210.You
may also obtain certain publications about your rights and responsibilities under ERISA by calling the
publications hotline of the Employee Benefits Security Administration.
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Article XII
GENERAL INFORMATION
What other general information should I know?
This question contains certain general information that you may need to know about the Plan. Note:This
Summary Plan Description does not describe the Medical Insurance Plan. Consult the Medical Insurance
Plan documents and the separate Summary Plan Description for the Medical Insurance Plan.
General Plan Information
Name: Weld County Government Cafeteria Plan
• Plan Number: 501
• Effective Date:January 1, 2009
• Plan Year:January 1st to December 31st.Your Plan's records are maintained on this 12-
month period of time.
• Type of Plan: Fringe Benefit and Welfare plan providing Benefits
• Your plan shall be governed by the Laws of the State of Colorado
Employer/Plan Sponsor Information
Name and Address: Weld County Government
915 10th Street
Greeley,CO 80632
(970)356-4000
• Federal Employer Tax Identification Number(EIN):84-6000813
Plan Administrator Information
Name, address, and business telephone number:
Weld County Government
915 10th Street
Greeley,CO 80632
(970)356-4000
The Plan Administrator appoints the Benefits Administrator to keep the records for the Plan and to be
responsible for the administration of the Plan. However,the Appeals Committee acts on behalf of the Plan
Administrator with respect to appeals.The Benefits Administrator will answer any questions that you may
have about our Plan.You may contact the Benefits Administrator at the above address for any further
information about the Plan.
Funding and Type of Plan Administration
A third-party administrator processes claims for the Plan,but the Employer pays all claims out of its
general assets.A health insurance issuer is not responsible for the financing or administration(including
payment of claims)of the Plan.
All of the amounts payable under this Plan may be paid from the general assets of the Employer, but
Premium Payment Benefits are paid as provided in the applicable insurance policy.
Nothing herein will be construed to require the Employer or the Plan Administrator to maintain any fund or
to segregate any amount for the benefit of any Participant,and no Participant or other person shall have
any claim against,right to, or security or other interest in any fund,account,or asset of the Employer from
which any payment under this Plan may be made.There is no trust or other fund from which Benefits are
paid.While the Employer has complete responsibility for the payment of Benefits out of its general assets
(except for Premium Payment Benefits paid as provided in the applicable insurance policy),it may hire an
unrelated third-party paying agent to make Benefit payments on its behalf.
Named Fiduciary
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The named fiduciary for the Health FSA Component is:Your Human Resources Rep
Agent for Service of Legal Process
The name and address of the Plan's agent for service of legal process is:
Weld County Government
Attn: Legal
915 10th Street
Greeley,CO 80632
(970)356-4000
Qualified Medical Child Support Order
The Medical Insurance Plan and the Health FSA will provide benefits as required by any qualified medical
child support order(QMCSO),as defined in ERISA§609(a).The Plan has detailed procedures for
determining whether an order qualifies as a QMCSO.Participants and beneficiaries can obtain,without
charge,a copy of such procedures from the Plan Administrator.
Newborns'and Mothers'Health Protection Act of 1996(NMPHA)
Group health plans and health insurance issuers 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 to less than 96 hours following a cesarean section. However,federal
law generally does not prohibit the mother's or newbom'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).
Women's Health and Cancer Rights Act of 1998(WHCRA)
The Women's Health and Cancer Rights Act of 1998(WHCRA)is a federal law that provides protections to
patients who choose to have breast reconstruction in connection with a mastectomy.This law applies
generally both to persons covered under group health plans and persons with individual health insurance
coverage.But WHCRA does NOT require health plans or issuers to pay for mastectomies. If a group
health plan or health insurance issuer chooses to cover mastectomies,then the plan or issuer is generally
subject to WHCRA requirements.
Medical Insurance Plan Documents and Information
This Summary Plan Description does not describe the Medical Insurance Plan. Consult the Medical
Insurance Plan document and the separate Summary Plan Description for the Medical Insurance Plan.
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