R-2014-14 CITY OF CLERMONT
RESOLUTION NO. 2014-14
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CLERMONT, LAKE COUNTY, FLORIDA, ADOPTING A SECTION 125
CAFETERIA PLAN FOR THE CITY OF CLERMONT, RESCINDING
THE CURRENT SECTION 125 CAFETERIA PLAN IN EFFECT AND
PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the Clermont City Council adopted the current Section 125 Cafeteria Plan
on April 10, 2012; and
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
Clermont, Florida, Lake County, Florida as follows:
Section 1
The current Section 125 Cafeteria Plan is hereby rescinded.
Section 2
The Section 125 Cafeteria Plan document attached to this Resolution is hereby adopted
by the City Council of the City of Clermont.
Section 3
This resolution shall take effect immediately upon its adoption.
1
CITY OF CLERMONT
RESOLUTION NO. 2014-14
DONE AND RESOLVED by the City Council of the City of Clermont, Lake County,
Florida, this 13`h day of May, 2014.
III ,L` b�5 r 1
CITY OF CLERMONT
p r - n %��I
�c6r r �, aro d S. Turville, Jr., Ma or
"CtflA ti
- :�P0au4...cra
- ' 'AT-TE T:-
�. .//i' /1A1
Tracy Ac ;.yd, City Cle�•
Appro - as to form an. le_ality:
-/
I
Dames • antzans, • = orne
ADOPTION AGREEMENT FOR THE
CODE SECTION 125—CAFETERIA PLAN
GENERAL INFORMATION
1. Name of the Plan:
City of Clermont Cafetena Plan with Flexible Spending Account
(e g "ABC Cafetena Plan"or"ABC Cafetena Plan with Flexible Spending Accounts")
2. Sponsoring Employer's Name, Address and Telephone Number [Drafting Note. the Sponsoring
Employer also is the Plan Administrator,Plan Sponsor and Named Fiduciary for the Plan]:
City of Clermont
Employer Name
Susan Irby,Human Resources Director
Contact Person Name
685 West Montrose Street#240
Street Address
Clermont,FL 34711
City,State and Zip Code
(352)241-7380
Telephone Number
3. Sponsoring Employer's Federal Employer Identification Number: 59-6000290
4. Agent for Service of Legal Processing: Same
(List the Name and Address of Agent,or indicate if the same as the contact person listed in Item 2 above)
5. Original Effective Date of the Plan: 1/1/1990
6. Effective Date of the Amendment and Restatement of the Plan: 1/1/2014
(Month/Day/Year)
7. Plan Number: 501
8. Plan Year: January 1 to December 31
PARTICIPATING EMPLOYERS
9. The following Participating Employers (and its eligible Employees) are authorized by the
Sponsoring Employer to participate in the Plan (only employers who are related entities of the
Sponsoring Employer can participate in the Plan):
Name of Employer Date of Termination Date
Participation of Participation
N/A
[USE FOR CLIENTS ADOPTING HYLANT CAFETERIA/FSA PLAN ONLY]
CAFETERIA BENEFIT PLAN OPTIONS
10. The Employer hereby elects that the following Qualified Benefits are available to Cafeteria Plan
Participants(check all that apply):
® The Employee's pre-tax premium payment for coverage under the Employer's Medical Plan.
❑ The Employee's pre-tax premium payment for COBRA continuation coverage offered under a
group health plan sponsored by the Employer.
❑ The Employee's pre-tax premium payment for COBRA continuation coverage offered under a
group health plan sponsored by a different employer.
® The Employee's pre-tax premium payment for Employer's Dental Plan.
® The Employee's pre-tax premium payment for Employer's Vision Plan.
® The Employee's pre-tax premium payment for coverage under the Employer's Group Term Life
Insurance Plan.
❑ The Employee's choice between pre-tax or after-tax premium payment for coverage under the
Employer's Long Term Disability Plan.
❑ The Employee's choice between pre-tax or after-tax premium payment for coverage under the
Employer's Short Term Disability Plan.
® The Employee's pre-tax contnbution (or Employer's non-taxable contribution on behalf of the
Employee) to a Health Care Flexible Spending Account (FSA) described m Article XIII of the
Basic Cafeteria Plan document
❑ The Employee's pre-tax contribution (or Employer's non-taxable contribution on behalf of the
Employee) to a Dependent Care Flexible Spending Account (FSA) described m Article XII of
the Basic Cafeteria Plan document.
❑ The Employee's pre-tax contribution (or Employer's non-taxable contribution on behalf of the
Employee)to a Health Savings Account.
® The Employee's pre-tax contribution for coverage under the Cancer, Accident and Hospital
Indemnity Plans.
11. The Employer hereby offers an Opt-Out Cash Payment to any Employee who waives coverage
under one or all of the following plans(check all that apply):
❑ The Employer's Medical Plan.
❑ The Employer's Dental Plan.
❑ The Employer's Vision Plan.
® No Opt-Out Cash Payment is available.
The amount of Opt-Out Cash Payment will be determined each Plan Year m the sole discretion of the Employer,
which amount may be zero.
2
12. If a newly eligible Participant fails to timely elect benefits under this Plan, he or she will be
deemed to have elected the following benefit elections(check all that apply):
❑ No default elections apply for newly eligible Participants(i.e.he or she will not participate in
Employer's benefit programs for the remainder of the Plan Year).
❑ Single coverage under the Employer's Medical Plan.
El Single coverage under the Employer's Dental Plan.
❑ Single coverage under the Employer's Vision Plan.
13. The Participant generally may not revoke or change a Benefit election under the Plan during a
Plan Year, except under the limited circumstances permitted under the Code and Treasury
Regulations referred to as "change in status events." The Employer has the discretion to decide
which, if any, of the change of status events will be recognized and made available to Participants
under the Plan. The Employer elects the following change in status events to apply under the
Plan.
® All of the change in status events permitted under the Code and Treasury Regulations, as set
forth m Section 6.07 of the Basic Cafeteria Plan document.
❑ " The change in status events permitted under the Code and Treasury Regulations, as set forth in
Section 6.07 of the Basic Cafeteria Plan document, except:
14. The Employer hereby elects the following additional payment methods to be offered to an
Employee during his FMLA, USERRA or Employer-Approved Leave of Absence [Drafting Note:
The Pay-As-You Go Payment Method will always be offered to Employees, and the Employer may elect one,
_ both or neither of the following additional options]:
El Pre-Payment Method
❑ ,Catch-Up Payment Method
AVAILABLE TAX-ADVANGATED ACCOUNTS
If the Employer indicates in Item 10 above that a Health Savings Account ("HSA") or Flexible Spending
Accounts are available, complete Items 15 through 18 as applicable. Skip Items 15 through 18 below if NO tax-
advantaged accounts(i.e. HSA and/or FSA)are being offered as part of the Employer's Cafetena Plan design.
15. Eligible Employees have access to(check all that apply):
El An HSA that is linked to the Employer's High Deductible Health Plan. The Eligible Employee
shall be permitted to: (select one):
❑ Direct the Employer through its Cafetena Plan to salary reduce his/her payroll and
remit such pay as a pre-tax contribution to his/her HSA;
❑ Direct the Employer to salary reduce his/her payroll and remit such pay as an after-
tax contnbution to his/her HSA.
❑ Make his/her own after-tax contributions to his/her HSA; the Employer does not
• permit payroll deductions for these purposes.
3
® A Health Care Flexible Spending Account that reimburses eligible health expenses that qualify
as(select one):
® A General Purpose FSA that allows for unrestricted reimbursements of Eligible
Health Expenses;
❑ A Restricted Purpose FSA that restricts reimbursement to the following eligible
health expenses(select one or more as applicable).
❑ Dental expenses;
❑ Vision expenses; and/or
El Post-deductible health expenses mcurred after the deductible has been paid under
the HDHP-HSA option.
El Both, a General Purpose FSA for Participants who do not elect coverage under a
HDHP-HSA option and a Restricted Purpose FSA for participants electing
coverage under a HDHP-HSA option, restricting reimbursements under such
Restncted Purpose FSA to the item(s)listed below:
El Dental expenses;
❑ Vision expenses; and/or
El Post-deductible health expenses mcurred after the deductible has been paid under
the HDHP-HSA option.
16. Health Care FSA Special Features: If the Employer indicates m Items 10 that a Health Care Flexible
Spendmg Account is offered, the following features shall apply to such Health FSA effective on and
after January 1 , 2014 :
® A Carryover Feature
El A Grace Penod Feature
El No Carryover Feature and No Grace Period Feature
17. Additional Health Care FSA Features: If the Employer indicates in Item 10 that a Health Care
Flexible Spending Account is offered,the following features and conditions apply to such Health FSA:
® The Claims Submission Deadline for the Health Care FSA is March 31st.
® List any other special features for or restrictions on Health Care FSA
reimbursements
M Legal spouse as defined by Florida State Law
18. Dependent Care FSA Features: If the Employer indicates in Item 10 that a Dependent Care Flexible
Spending Account is offered,the following features apply to such FSA(s):
El A Grace Penod [0 shall] /[0 shall not] be offered
El The Claims Submission Deadline for the Dependent Care FSA is
4
FSA ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE
If the Employer indicates in Item 10 that healthcare and/or dependent care FSAs are available, complete Items
19 to 21 below. Otherwise skip Items 19 to 21 below if the employer offers NO FSAs.
19. An Eligible Employee for purposes of eligibility to participate in the health care or dependent
care FSAs include the following(check all that apply):
0 Except as otherwise provided in Item 20 below, all Employees of the Employer (as defined in
Article II of the Basic Plan Document).
fl Except as otherwise provided in Item 20 below, all full-time Employees of the Employer. For
this purpose, a full-time Employee is an individual who is classified by the Employer as
employed in a job position that regularly requires a or more hour work week.
M Except as otherwise provided in Item 20 below, any Employees of the Employer who are
Benefits Eligible.
0 Other
20. Notwithstanding the foregoing, the following categories of Employees are not eligible to
participate in the Plan (noting that the Basic Plan Document automatically excludes independent
contractors, leased employees, and union employees (unless the terms of the collective bargaining
agreement expressly requires participation), and thus you do not need to specify such categories
as excluded below):
N/A
21. An Eligible Employee's initial participation in the Plan will become effective on the date set forth
below, provided he or she timely enrolls by the deadline established by the Plan Administrator
(check one):
0 On the first day of employment as an Eligible Employee.
fl On the first day of the calendar month following the Eligible Employee's employment
commencement date
M. On the first day immediately following, or M of the calendar month following] 60 (e.g. 30,
45, 60, 90) calendar days as an Eligible Employee for all benefits, except for Flexible Spending
Account.
0 Other. For Flexible Spending Account, on January 1 s`following one year of employment
5
APPLICABLE STATE LAW
22. To the extent not preempted by ERISA,the laws of the following state shall apply:
O Michigan
O Ohio
M Flonda
O Indiana
p Other:
HIPAA PRIVACY AND SECURITY OFFICERS
23. The appointed HIPAA Privacy and Security Officers are:
Privacy Officer: Human Resources Director
Security Officer: Human Resources Specialist
This Employer hereby executes this Adoption Agreement,which is incorporated by reference and is made
part of the Basic Plan Documents for the Cafeteria Plan with FSAs. Nothing in this Adoption Agreement
shall be intended to override the terms of the Basic Plan Documents to which this Adoption Agreement is
attached.
Adoptmg Employer: City of Clermont
Plan Adoption Restatement Date: 01/01/2014
6
Approved and adopted by the City Council of the City of Clermont on May ,2014
1111 11111HH„liel 411110
Harold S.Turville,Jr,Mayor
Attest:
L /
/rAL....64111-14.-
11 -
Tracy,Acicroyd,City Clerk
ir
_
7
BASIC PLAN DOCUMENT FOR THE
CODE SECTION 125 - CAFETERIA PLAN WITH
FLEXIBLE SPENDING ACCOUNT OPTIONS
(Generally Restated Effective for the Plan Year Beginning On and After January 1, 2014, Except
as Otherwise Provided Herein)
**Although Hylant has worked with its outside legal counsel in drafting this Basic Plan Document for
a Code Section 125- Cafeteria Plan and accompanying Adoption Agreement(the "Plan"), we cannot
guarantee that this Plan accurately reflects your particular benefit program or unique plan design.
Nor can Hylant make any representations as to the legality or sufficiency of this Plan document,
particularly if you modify it in any way. Nothing in this document is to be considered as the rendering
of legal advice, and, as a result,you are strongly recommended to consult with legal counsel before
using this Plan document. We also have attempted to incorporate recent law changes and IRS
guidance, including the Patient Protection and Affordable Care Act of 2010; but caution that the
document may need further modification as subsequent guidance is issued for such new laws and may
need to be tailored to reflect your specific facts. This Plan is available for your use solely with the
express permission of Hylant. Any attempt to duplicate or use this Plan in a manner not expressly
permitted by Hylant is strictly prohibited.
'USE FOR CLIENTS ADOPTING HYLANT CAFETERIA/FSA PLAN ONLY]
TABLE OF CONTENTS
Page
ARTICLE I PREAMBLES 1
Section 1.01 Adoption of Plan 1
Section 1.02 Purpose 1
Section 1.03 Interpretation and Law 1
ARTICLE II DEFINITIONS 1
ARTICLE III ELIGIBILITY 5
ARTICLE IV PARTICIPATION 5
Section 4.01 Commencement of Participation 5
Section 4.02 Meaning of Participation 5
Section 4.03 Spouses and Beneficiaries 5
ARTICLE V TERMINATION OF PARTICIPATION 6
Section 5.01 Termination of Participation 6
Section 5.02 COBRA Continuation Coverage 6
ARTICLE VI ELECTION OF•BENEFITS 6
Section 6.01 Available Benefits 6
Section 6.02 Notification 7
Section 6.03 Election of Benefits 7
Section 6.04 Minimum Benefits 7
Section 6.05 Failure to Elect 8
Section 6.06 Involuntary Election Modifications 8
Section 6.07 Other Election Modifications 8
ARTICLE VII SALARY REDUCTION CONTRIBUTIONS 12
Section 7.01 Salary Reduction 12
Section 7.02 Substantiation of Claims 13
Section 7.03 Payments to Insurer 13
Section 7.04 Funding Benefits 13
ARTICLE VIII CLAIMS FOR BENEFITS 13
Section 8.01 Claims for Benefits 13
Section 8.02 Insurance 13
Section 8.03 Claims Relating to Plan Administration 13
Section 8.04 Claim Administrator's Initial Determination 14
Section 8.05 Claimant's Deadline for Filing an Appeal of a Denied Claim 14
Section 8.06 Appeal Procedures 15
Section 8.07 Claims Administrator's Deadline for Deciding an Appeal 15
Section 8.08 Notice of Adverse Benefit Determinations 15
Section 8.09 General Claim Provisions 16
ARTICLE IX LEAVE OF ABSENCE 17
Section 9.01 In General 17
Section 9.02 Payment for Coverage 18
Section 9.03 Cessation of Coverage 18
Section 9.04 Restoration 19
ARTICLE X PROVISIONS RELATING TO ADMINISTRATION AND FIDUCIARIES 19
Section 10.01 Plan Administration 19
Section 10.02 Finality of Decisions 20
Section 10.03 Fiduciaries and Other Duties 20
Section 10.04 Employment of Advisers 21
Section 10.05 Delegation to Officers or Employees 21
Section 10.06 Fees and Expenses 21
ARTICLE XI GENERAL 21
Section 11.01 Amendment and Termination 21
Section 11.02 Non-Alienation of Benefits 21
Section 11.03 Employer's Rights 21
Section 11.04 Construction 22
Section 11.05 Tax Consequences 22
Section 11.06 Law Governing 22
Section 11.07 Exclusive Benefit - 22
Section 11.08 Binding Effect 22
ARTICLE XII DEPENDENT CARE Flexible SPENDING ACCOUNT PLAN 22
Section 12.01 Dependent Care Flexible Spending Account Plan Authority 22
Section 12.02 Definitions 22
Section 12.03 Eligibility 24
Section 12.04 Effective Date an Election Procedure 24
Section 12.05 Amount 24
Section 12.06 Benefit Limitations 24
Section 12.07 Benefits Limited to Expenses Incurred During Plan Year 24
Section 12.08 Restrictions on Payments 25
Section 12.09 Forfeiture 25
Section 12.10 Involuntary Election Modifications 25
Section 12.11 Reimbursements 26
Section 12.12 Establishment of Accounts 26
Section 12.13 Crediting of Accounts 26
Section 12.14 Debiting of Accounts 26
Section 12.15 Statement of Account 26
Section 12.16 Reimbursement Procedure 26
Section 12.17 Claims Procedure 27
Section 12.18 Refund of Duplicate Reimbursement 27
ii
Section 12.19 Termination of Participation 27
Section 12.20 Effect of Termination of Participation 27
Section 12.21 Leave of Absence 27
ARTICLE XIII HEALTH CARE Flexible SPENDING ACCOUNT PLAN 28
Section 13.01 Health Care Flexible Spending Account Plan Authority 28
Section 13.02 Definitions 28
Section 13.03 Eligibility 29
Section 13.04 Effective Date and Election Procedure 29
Section 13.05 Amount 29
Section 13.06 Benefits Limited to Expenses Incurred During Plan Year 29
Section 13.07 Forfeiture 30
Section 13.08 Involuntary Election Modifications 31
Section 13.09 Reimbursements 31
Section 13.10 Establishment of Accounts 31
Section 13.11 Crediting of Accounts 31
Section 13.12 Debiting of Accounts 31
Section 13.13 Statement of Account 31
Section 13.14 Reimbursement Procedure 31
Section 13.15 Payment Limitations 32
Section 13.16 Refund of Duplicate Reimbursement 32
Section 13.17 Termination of Participation 32
Section 13.18 Effect of Termination of Participation 33
Section 13.19 COBRA Continuation Coverage 33
Section 13.20 Claims Procedure 34
Section 13.21 Qualified Medical Child Support Orders 34
Section 13.22 Restricted Purpose Health Care Spending Account 34
Section 13.23 HIPAA Privacy and Security Laws 34
ARTICLE XIV 38
Health Savings Account Contributions and Participation 38
iii
•
ARTICLE I
PREAMBLES
Section 1.01 Adoption of Plan. Effective as of the date set forth in and by executing
the Adoption Agreement, the Employer adopts the Basic Plan Document for the Code Section
125 -Cafeteria Plan with Flexible Spending Account Options (the"Plan").
Section 1.02 Purpose. The purpose of this Plan, in conjunction with the Adoption
Agreement, is to establish the formal and official written terms of a cafeteria plan meeting the
requirements of Code Section 125, 105 and 129, as well as the summary to be furnished to
eligible employees. This Plan provides eligible Employees with the opportunity to select among
various combinations of taxable and non-taxable Benefits and taxable compensation. As
specifically selected in the Adoption Agreement, the Plan may allow a Participant to set aside
"before-tax" dollars from his or her gross pay to be used for reimbursement of certain medical
and dependent care expenses (see Article XII and XIII),to make pre-tax contributions to a health
savings account and/or to pay, on a pre-tax basis, his or her share of the premium payments
under certain Benefit Plans. The Employer, in its sole discretion, also may adopt an Opt-Out
Cash Payment feature under which a Participant would be allowed to elect, in writing, to waive
coverage under certain Benefit Plans and, in lieu thereof, receive a taxable Opt-Out Cash
Payment. The Employer, in its sole discretion, will determine the elections offered under this
Plan, including the amount of an Opt-Out Cash Payment, if any, and Participants will be
informed of such availability and amount during their initial enrollment period or during the
Open Enrollment Period.
Section 1.03 Interpretation and Law. The Plan is intended to comply with Section
125 of the Internal Revenue Code of 1986, as amended, and with the regulations promulgated
thereunder. Where not governed or preempted by federal law,the Plan shall be administered and
construed in accordance with the State identified in the Adoption Agreement. The Plan is not
intended to nor shall it be construed to be an amendment or interpretation of the provisions of
any benefit plan maintained by the Employer, except to the extent that this Plan permits
Employees who participate in this Plan to elect to participate in any such benefit plan. It is the
intention of the Employer that the Plan be maintained for the exclusive benefit of eligible
Employees.
ARTICLE II
DEFINITIONS
Throughout the Plan, various terms are used repeatedly. These terms have specific and
definite meanings when capitalized in the text. For convenience, capitalized terms are collected
and defined in this Article. Whenever capitalized terms appear in the Plan, they shall have the
meanings specified in this Article. Where necessary or appropriate to the context, the masculine
shall include the feminine, the singular shall include the plural and vice versa.
Section 2.01 "Adoption Agreement" means the agreement under which the Employer
duly adopts this Plan document, which agreement is incorporated by reference herein.
1
Section 2.02 "Affiliated Employer" means any entity who is considered with the
Employer to be a single employer in accordance with Code Section 414(b), (c)or(m).
Section 2.03 "Benefit" means the Permitted Taxable Benefits (e.g. cash) and
nontaxable Qualified Benefits made available to Participants from time to time under this Plan.
Such Benefits shall be determined by the Plan Administrator each Plan Year, a list of which will
be provided to Participants during each initial enrollment period or Open Enrollment Period (see
the Adoption Agreement). The specific provisions of Qualified Benefits shall be set forth in
separate plan documents, agreements, or contracts, which may include Employees' substantiated
individual health insurance policies, and are incorporated by reference into this Plan (referred to
as"Benefit Plan(s)").
Section 2.04 "Code" means the Internal Revenue Code of 1986, as amended, together
with its related rules and regulations. References to any Section of the Code shall include any
successor provision.
Section 2.05 "Dependent" means any individual who is deemed a "Dependent" under
the terms of the applicable Benefit Plan. However, a Participant can pay premiums on a pre-tax
basis under this Plan only for the Participant's Spouse or for the P
Participant's Dependents who
meet the Code Section 152 definition of
"dependent" (without regard to the earnings limit under
§152(d)(1)(B); the special exclusions
under §152(b)(1) or (2); or the age or student status
requirements under §152(c)(3), provided that such qualifying child is age 26 or under during the
entire Plan Year), even if a Benefit Plan allows coverage for individuals who do not qualify as
such. If the Employee is eligible and enrolls an individual who is not the Employee's Spouse or
a tax-qualified Dependent (e.g. the Employee's Domestic Partner) under a Benefit Plan listed in
_ the Adoption Agreement, the Employer may payroll deduct the Employee's share of the cost of
such coverage on a pre-tax basis, and then impute income to Employee for the Plan Year equal to
value of such pre-tax payments for such individual's coverage under the Plan.
Section 2.06 "Dependent Care Flexible Spending Account Plan" means the
dependent care spending account covered by this Plan, as described in Article XII below, if
offered by the Employer as selected in the Adoption Agreement.
Section 2.07 "Effective Date"of the Plan means the original effective date specified in
the Adoption Agreement on which this Plan was first established and adopted by the Employer.
Section 2.08 "Eligible Employee" means, for purposes of the Health and Dependent
Care Spending Accounts, an Employee who is hired and designated by the Employer in a benefit
eligible position as specified in the Adoption Agreement. All other Employees of the Employer
are not eligible to participate in the Plan.
Section 2.09 "Eligible Individual" means a Participant who can establish and make
contributions to a Health Savings Account pursuant to Code Section 223 and related IRS
regulations and guidance.
Section 2.10 "Employee" means any individual who is a common law employee
directly and actively employed in the regular business of, and compensated for services by, the
Employer. However, the term "Employee" will not include:
2
• any self-employed individual (e.g. a sole proprietor, partner or 2% shareholder of
an S corporation);
• any individual whose employment is covered under and subject to a collective
bargaining agreement, unless such agreement expressly requires and provides for
coverage under this Plan; and/or
• any individual for whom the Employer designates as an independent contractor,
leased or contract employee, or casual or temporary employee (regardless of the finding
by any third party as to the common law employment status of any such person).
Section 2.11 "Employer" means the Employer identified in the Adoption Agreement
as the sponsoring employer and any Affiliated Employer who adopts the Plan pursuant to
authorization provided by the sponsoring Employer. However, whenever the Plan indicates that
the Employer may or shall take any action under the Plan, the Employer identified in the
Adoption Agreement as the sponsoring Employer shall have sole authority to take such action for
itself and as agent for any such Affiliated Employer. The Adoption Agreement identifies a
current listing of Participating Employers.
Section 2.12 "Employer-Approved Leave of Absence" shall include any leave of
absence of the Employee that the Employer has, in writing, approved and agreed to continue the
coverage of such Employee under the applicable Benefits Plan during such leave period.
Section 2.13 "ERISA" means the Employee Retirement Income Security Act of 1974,
as presently enacted and as it may be amended from time to time, together with its related rules
and regulations.
Section 2.14 "Grace Period" means the additional period of time for a Participant to
incur Medical or Dependent Care Expenses beyond the last day of the current Plan Year. A
Grace Period shall apply to the Dependent Care and/or Health Care Spending Account Plans
only if the Employer makes an election under the Adoption Agreement to grant a Grace Period,
which may extend no later than two and one-half(2-1/2)months immediately following the close
of the Spending Account's Plan Year.
Section 2.15 "Health Care Flexible Spending Account Plan" means the health care
spending account covered by this Plan as described in Article XIII below, if offered by the
Employer as selected in the Adoption Agreement.
Section 2.16 "Health Savings Account ("HSA")" means the health savings account
established in accordance with Code Section 223 and related regulations and IRS guidance. For
purposes of this Plan, the term "HSA" shall include only those HSAs that are linked to the
Employer's High Deductible Plan(s) and provided through the trustee or custodian chosen by the
Employer(see the Adoption Agreement).
Section 2.17 Open Enrollment Period means a period during which a Participant may
enroll in or change coverage under the Plan. The Open Enrollment Period will begin and end on
3
dates determined by the Plan Administrator, which will be prior to the beginning of the next Plan
Year.
Section 2.18 Opt-Out Cash Payment means the taxable cash payment benefit
available to a Participant if he or she declines and waives in writing coverage under certain
Benefit Plans for a Plan Year. The Plan Administrator shall annually determine, in its sole
discretion, which Benefit Plans will offer an Opt-Out Cash Payment and the amount of any such
Opt-Out Cash Payment, which may be zero. A Participant is eligible for the Opt-Out Cash
Payment only if he or she is eligible to participate in the particular Benefit Plan that offers such
an Opt-Out Cash Payment.
Section 2.19 "Participant" means an Employee who has met the eligibility
requirements specified in Article III, who has commenced participation in the Plan pursuant to
Article IV, and whose participation has not terminated under other applicable provisions of the
Plan.
Section 2.20 "Permitted Taxable Benefits" mean cash and certain other taxable
benefits treated as cash for purposes of Code Section 125, including any Opt-Out Cash Payments
and any other benefits attributable to Employer contributions that are currently taxable to the
Employee upon receipt and benefits purchased with after-tax employee contributions.
Section 2.21 "Plan" means this Cafeteria Plan, as set forth in this plan document.
Section 2.22 "Plan Administrator" ' means the person(s) or organization(s)
specifically designated by Article X as the administrator of the Plan.
Section 2.23 "Plan Year" means the 12-month period set forth in the Adoption
Agreement.
Section 2.24 "Qualified Benefit" means any benefit excluded from the Employee's
taxable income pursuant to an express provision of the Code which is specifically recognized as
a "qualified benefit" under Code Section 125 and related Treasury Regulations. Generally,
qualified benefits include group term life insurance benefits (Code Section 79), accident and
health plan benefits, including through a Participant's substantiated individual health insurance
policy, (Code Sections 105 and 106); premiums for COBRA continuation coverage under the
Employer's group health plan or under a group health plan sponsored by a different employer;
accidental death and dismemberment insurance benefits (Code Section 106); long-term or short-
term disability benefits (Code Section 106); dependent care assistance benefits (Code Section
129); adoption assistance benefits (Code Section 137); qualified cash or deferred arrangement
that is part of a qualified defined contribution (401(k)) plan; and contributions to a Health
Savings Accounts.
Notwithstanding the foregoing, Qualified Benefits do not include and thus cannot be offered
under the Plan the following: scholarship benefits (Code Section 117); employer-provided meals
and lodging benefits (Code Section 119); educational assistance benefits (Code Section 127);
fringe benefits (Code Section 132); long-term care insurance benefits or services (Code section
106); group-term life insurance benefits on the life of any individual other than an employee;
health reimbursement arrangement benefits; contributions to Archer MSA (Code Section 106(b)
4
and 220); elective deferrals to a section 403(b) plan; or group-term life insurance benefits that
offer a permanent benefit, or any other benefits prohibited by treasury regulations or other IRS
guidance.
Section 2.25 "Spouse" means an Eligible Employee's husband or wife to whom the
Eligible Employee is legally married as recognized by the laws of the State or jurisdiction in
which the marriage was validly performed. The term spouse shall not include common law
marriages, even if common-law marriages are recognized under the laws of your State of
domicile. The legal married status between the Eligible Employee and Spouse must have existed
at the time that the expense was incurred for which reimbursement is claimed, but shall not
include an individual who is legally separated from the Employee under a decree of divorce or of
separate maintenance (except to the extent required by COBRA). This definition of"Spouse"
applies only: (i) for the purposes of providing a definition of Spouse as that term is used under
Article XII (Dependent Care Spending Account) and Article XIII (Health Care Spending
Account) and (ii) with respect to permitting a Participant to use pre-tax dollars to pay the
premium cost of a covered Spouse. The definition of Spouse in this document shall not govern
or dictate spousal eligibility conditions for the underlying Benefit Plan.
ARTICLE III
ELIGIBILITY
An Employee who has properly enrolled in coverage under one or more of the Benefit
Plans will be eligible to participate in this Plan. Each Benefit Plan will set forth its own
eligibility requirements for participation, including the Spending Account Plans.
ARTICLE IV
PARTICIPATION
Section 4.01 Commencement of Participation. An Employee shall commence
participation in the Plan as of the first payroll period following the date he or she has met the
eligibility requirements of Article III above, provided such Employee timely elects Benefits for
the remainder of the Plan Year pursuant to Article VI below. In no event may participation in
the Plan commence as of a date prior to the Effective Date of this Plan.
Section 4.02 Meaning of Participation. Participation entitles a Participant to elect
among the Benefits made available by the Employer under the Plan for each Plan Year. Each of
the Benefit Plans incorporated in this Plan may have its own eligibility requirements for
participation which differ from those set forth in this Plan. The eligibility and participation
requirements set forth in this Plan relate only to participation in this Plan and shall have no effect
on any eligibility or participation requirements set forth under the applicable Benefit Plan.
Section 4.03 Spouses and Beneficiaries. The Participant's Dependents may not
participate actively in the Plan (i.e., a Dependent may not be given the opportunity to select or
purchase Benefits offered under the Plan), but the Participant's Dependent may benefit from the
Participant's election of Benefits. Further, upon the Participant's termination of Plan
participation under Section 5.01 below, no rights under the Plan will inure to a Dependent,
except as provided under a specific Benefit Plan.
5
ARTICLE V
TERMINATION OF PARTICIPATION
Section 5.01 Termination of Participation. Except as provided in Section 5.02
(COBRA Coverage) and Article IX (Leave of Absence), participation in the Plan shall terminate
upon the earliest of:
(a) termination of the Plan;
(b) termination of a Participant's employment with the Employer (including
voluntary or involuntary termination of employment, layoffs, death, retirement, or
unapproved leave of absence);
(c) ' failure to meet the eligibility requirements of Article III;
(d) failure to timely pay required contributions under the Plan;
(e) failure by a Participant to return to work after an approved leave of
absence period; or
(0 any other event causing termination as described in the Plan.
A Participant who terminates participation in the Plan may be able to continue coverage
under a Benefit Plan to the extent that the terms and conditions of such Benefit permit continued
coverage.
Section 5.02 COBRA Continuation Coverage. Notwithstanding the provisions of
Section 5.01, continuation coverage under any Benefit Plan which is a "group health plan" as
that term is defined in Code Section 5000 shall be provided under the group health plan to
Participants, their covered spouses and dependents to the extent required under ERISA Sections
601 through 608, and Code Section 4980B ("COBRA"). The terms of such COBRA
continuation coverage, if any, shall be described in the group health plan or plans identified in
the Adoption Agreement. If a Participant elects COBRA coverage under an applicable Benefit
Plan, the Participant may continue participation under this Plan to pay for required contributions
under such Benefit Plan.
- ARTICLE VI
ELECTION OF BENEFITS
Section 6.01 Available Benefits. Prior to the beginning of each Plan Year, the
Employer shall designate the Benefits, including any Opt-Out Cash Payments, that are available
for Participant election under the Plan for the following Plan P g a Year and the cost to Participants of
each such Benefit and the amount of each such Opt-Out Cash Payments (available Benefits will
be specified in the Employer's Adoption Agreement). In determining such costs or amounts, the
Employer shall consider all relevant data including, but not limited to, the cost of insurance to
fund the benefit, the direct and indirect expense to the Employer if the benefit is paid directly
from the general assets of the Employer, and the value of the coverage to the Participant.
Further, the Employer may consider the age, pay, length of service, employment status, coverage
6
status, and number of dependents of a Participant in determining the cost of a Benefit or the
amount of an Opt-Out Cash Payment to each Participant, provided the Employer makes such
determination on an equitable and nondiscriminatory basis.
The Employer may impose such conditions on allowing a Participant to decline Benefits
coverage as it determines are appropriate, in its discretion; including, but not limited to, requiring
that a Participant provide proof of other, comparable coverage that is then in effect with respect
to the Participant(e.g., through a spouse's employer, etc.).
Section 6.02 Notification. Prior to the beginning of each Plan Year, the Employer will
notify (electronically or otherwise) each Employee who is eligible for participation in the Plan
for the following Plan Year of the Benefits available for selection under the Plan for such
following Plan Year. The notice may include:
(a) A description of each Benefit available under the Plan for the Plan
Year and whether the Benefit is taxable or non-taxable;
(b) The maximum amount of salary reduction that a Participant may
direct to be used on his or her behalf to provide Benefits;
(c) The available minimum and maximum levels of coverage under
each Benefit; and
(d) The cost to the Participant of each Benefit provided under the Plan
for the Plan Year.
Section 6.03 Election of Benefits. Prior to the beginning of each Plan Year, and in
conjunction with the notice materials as provided in Section 6.02, the Employer will provide
enrollment instructions to each Employee who is eligible for participation in the Plan for the
following Plan Year. For new Participants, the Employer shall provide the enrollment
instructions as soon as practicable before an Employee becomes a Participant.
The Employee must complete the enrollment process with the Employer in a manner
designated by the Employer and at any time up to and including a date specified by the
Employer, but, in any event, prior to the beginning of the following Plan Year or, for newly
eligible Participants, within 30 days of first becoming eligible to participate in the Plan. The
completed enrollment process will specify the amount which the Employer will reduce the
Employee's salary in order to pay for Benefits for the following Plan Year.
A Participant may not revoke or modify any election under this Section 6.03 for the Plan
Year, except as provided in Section 6.07.
Section 6.04 Minimum Benefits. Section 6.03 notwithstanding, the Employer may
require Employees to elect, with respect to a specified Benefit, a minimum level of such Benefit
for the Plan Year. Minimum benefits shall be determined by the Employer from the Benefits
available under the Plan for the Plan Year, and each Employee shall be notified in writing of the
identity and amount of minimum benefits for the Plan Year. Such notification will be in
conjunction with the notification of available Benefits pursuant to Section 6.02 and will be given
7
prior to the beginning of the Plan Year or participation. If a Participant fails to elect at least the
minimum amount of a specified Benefit, he or she will not be permitted to elect that Benefit or
will be deemed to have elected the minimum default elections as described in this Plan or as
established by the Plan Administrator and described in open enrollment materials.
Section 6.05 Failure to Elect. If an Employee fails to complete the enrollment process
with the Plan Administrator(either during the Open Enrollment Period for an existing Participant
or the initial enrollment period for a newly eligible Employee) on or before the specified due
date established by the Plan Administrator, such Employee generally will not be a Participant for
the new Plan Year, or any remainder thereof, with respect to any Benefit.
Notwithstanding the foregoing, the Plan Administrator, under the Adoption Agreement, may
establish a default election procedure under which the Employee may be deemed to have elected
one or more Benefits for a Plan Year(or remainder thereof).
For example, the Plan Administrator may establish a default election procedure for existing
Participants that provides they will be deemed to have elected the same elections in effect for the
prior Plan Year with respect to all Benefit Plans other than the Dependent Care Flexible
Spending Account Plan and/or Health Care Flexible Spending Account Plan, or that a Participant
has elected single coverage under a specified benefit option. If the Plan Administrator decides to
implement such a default election procedure or is otherwise required by law to do so, the Plan
Administrator will notify Participants in writing (e.g. in the initial or open enrollment materials)
of such default election procedures, including a description of the default elections, the amount
of the salary reduction, the period of time for which the election is effective, the procedures to
decline coverage and the deadline for making elections.
Section 6.06 Involuntary Election Modifications. At any time prior to or during the
Plan Year, the Employer may require some or all Participants to modify their Benefit,elections
under the Plan if the Employer determines to its satisfaction that such modifications are
necessary in order to preserve the tax-preferred status of this Plan under Code Section 125 or of
any Benefit available under the Plan under any other applicable provision of the Code.
Specifically, such modifications may be required in order to enable the Plan or any Benefit
available under the Plan to satisfy the nondiscrimination requirements of applicable provisions of
the Code. The Employer shall adopt and follow uniform and nondiscriminatory rules for
purposes of this section and its decisions regarding involuntary election modifications shall be
final and binding.
Section 6.07 Other Election Modifications. Under the circumstances specified below,
but subject to any limitations set forth in the Adoption Agreement, the Employer may permit or
require a Participant to revoke a Benefit election under the Plan during a Plan Year, and, in some
cases, to make a new election with respect to the remainder of the Plan Year. All such election
modifications shall be consistent with Code Section 125 and applicable Treasury Regulations.
(a) Cost or Coverage Changes. This Section 6.07(a)(1) through (4)
explains the circumstances under which a Participant's election may be modified as a
result of certain cost or coverage changes to a Benefit or a benefit package option
8
available under the applicable Benefit Plan (other than a flexible medical spending
account plan):
(1) Cost Changes. In the event that the cost of a Benefit
increases or decreases during a Plan Year, the Plan automatically may increase or
decrease, as applicable, all affected Participants' salary reduction contributions
for such Benefits on a reasonable and consistent basis.
If the cost charged to an Employee for a Benefit significantly increases or
decreases during the Plan Year, the Participant may make a corresponding change
in his or her salary reduction contributions under the Plan. Changes that may be
made include electing to participate in the Plan with respect to the Benefit with
the decreased cost or in the case of an increase in cost, revoking an election for
that coverage and, in lieu thereof, either receiving similar coverage or dropping
coverage if no other benefit package option providing similar coverage is
available. The Plan Administrator in its sole discretion shall determine if the
increase or decrease is significant.
A cost increase or decrease refers to an increase or decrease in the amount of
salary contributions under the Plan, whether the increase or decrease results from
an action taken by the employee (such as switching from full-time to part-time) or
from action taken by the Employer (such as increasing or decreasing the amount
of employer contributions for Employees).
(2) Coverage Changes. If an Employee (or his or her
dependents) has a significant curtailment of coverage (i.e. an overall reduction in
coverage) under a Benefit which does not result in a loss of coverage (as defined
below) (e.g. a significant increase in the deductible, co-pay or out-of-pocket cost
sharing limit), an Employee receiving such coverage may revoke his or her
election for such coverage and, in lieu thereof, elect to receive on a prospective
basis coverage under another benefit package option with respect to the applicable
Benefit which provides similar coverage. The Plan Administrator in its sole
discretion shall determine if the curtailment is significant.
If an Employee (or his or her dependents) has a significant curtailment of
coverage under a Benefit that is a loss of coverage, the Employee may revoke his
or her election for such coverage and, in lieu thereof, elect to receive on a
prospective basis coverage under another benefit package option with respect to
the applicable Benefit which provides similar coverage or completely drop
coverage if no other benefit package option providing similar coverage is
available. A loss of coverage means a complete loss of coverage under the
benefit package option with respect to a Benefit, a substantial decrease in medical
providers available under a benefit package option or a reduction in benefits for a
specific type of medical condition or treatment with respect to which the
Employee (or his or her dependents) is currently in a course of treatment.
9
I
If the Plan(adds a new Benefit Plan or benefit package option, or an existing
benefit package option is significantly improved during the Plan Year, an
Employee may revoke his or her election under the Plan and, in lieu thereof, make
an election on a prospective basis for coverage under the new or improved Benefit
or benefit package option.
(3) Change In Coverage Under Another Employer Plan. An
Employee may make a prospective election change that is on account of and
corresponds with a change made under another employer plan (including a plan of
the same employer or of another employer), if the other employer plan permits
participants to make an election change under the same circumstances described
under this Section 6.07.
(4) Loss Of Coverage Under Another Group Health Plan. If
an Employee (or his or her Dependents) loses coverage under any group health
coverage sponsored by a governmental or educational institution, the Employee
may make a corresponding election change under this Plan to add coverage for
himself or herself(or for his or her Dependents), on a prospective basis, under the
applicable Benefit plan.
(b) Special Enrollment Events of HIPAA. If the Benefit is a "group
health plan" subject to the Health Insurance Portability and Accountability Act
("HIPAA") (as codified under Code Section 9801 and related regulations) and to the
extent permitted by the applicable plan document or insurance policy for such Benefit, a
Participant may revoke an election during a period of coverage and make a new election
that corresponds with the special enrollment rights provided in Code Section 9801(f) and
related regulations.
Under Code Section 9801(f) and related regulations, special enrollment rights
allow an Employee to enroll in group health plan coverage, upon the occurrence of an
"Enrollment Event." For example, an Employee and/or his or her Dependent will have
an Enrollment Event if, when the Employee declined coverage under the applicable
group health plan, he or she certified that he or she was covered by another group health
plan or health coverage and he or she (his or her spouse or child) loses eligibility for
coverage under that other health plan for reasons such as legal separation, divorce,
annulment of marriage, death, termination of employment, reduction in number of hours
of employment (e.g., leave of absence, transfer from full-time to part-time status, strike),
change in place of residence or work, failure to elect COBRA coverage on termination of
employment, cessation of the other employer's contributions for health coverage, or
exhaustion of COBRA coverage. The Employee will not be considered to have lost
coverage under this provision if he or she failed to pay the required premiums for such
other coverage or such other coverage was terminated for cause. An Employee and/or
his Dependent also may experience an Enrollment Event if he or she loses coverage
under Medicaid or a State's Child Health Insurance Program (CHIP). Finally, an
Employee may experience an Enrollment Event under HIPAA upon acquiring a new
Dependent through marriage, birth or adoption.
10
(c) Change in Status. To the extent permitted by the applicable plan
document or insurance policy for the Benefit, an Employee may revoke a benefit election
during a Plan Year and make a new election with respect to the remainder of the Plan
Year provided that both the revocation and new election are on account of and
correspond with a change in status that affects eligibility for coverage under a Benefit
(i.e. the new election is consistent with the reason that such change is permitted). The
following events are "changes in status" for purposes of this subsection:
(1) Legal Marital Status. Events that change an Employee's
legal marital status, including marriage, death of a spouse, divorce, legal
separation or annulment.
(2) Number of Dependents. Events that change an Employee's
number of Dependents, including birth, adoption, placement for adoption (as
defined in regulations under Code Section 9801), or death of a Dependent.
(3) Employment Status. A termination or commencement of
employment by the Employee, spouse, or Dependent.
(4) Work Schedule. A reduction or increase in hours of
employment by the Employee, spouse, or Dependent, including a switch between
part-time and full-time employment, a strike or lockout, or commencement or
return from an unpaid leave of absence.
(5) Dependent Satisfies or Ceases to Satisfy the Requirements
for Unmarried Dependents. An event that causes an Employee's Dependent to
satisfy or cease to satisfy the requirements for coverage due to attainment of age,
student status, or any similar circumstance as provided under the applicable
Benefit.
(6) Residence or Worksite. A change in the place of residence
or work of the Employee, spouse or Dependent resulting in his or her becoming
covered under another plan which provides the applicable Benefit.
(d) QMCSO. If a Qualified Medical Child Support Order requires
coverage for a child under the applicable Benefit Plan, the Employee's election under the
Plan may be revised to provide coverage to such child. If a Qualified Medical Child
Support Order requires a former spouse to provide coverage and such coverage is in fact
provided,the Employee's election may be revised to cancel coverage for the child.
(e) Entitlement to Medicare or Medicaid. If an Employee (or his or
her Dependent) is enrolled in a Benefit which is a group health plan and he or she
becomes enrolled in coverage under Part A or B of Medicare or Medicaid (other than a
program for distribution of pediatric vaccines), the Employee may make a prospective
election change to cancel or reduce coverage of that Employee (or Dependent) under
such Benefit Plan. In addition, if an Employee (or Dependent) who has been entitled to
such Medicare or Medicaid coverage loses eligibility for such coverage, the Employee
11
may make a prospective election to commence or increase,coverage of that Employee (or
Dependent) under the Benefit which is a group health plan.
(f) Automatic Termination of Election. Except as provided in
Section 5.02 (COBRA Continuation Coverage), a Participant's elections under this Plan
shall automatically terminate on the date the Participant ceases to be a Participant in this
Plan or in one of the Benefit Plans.
(g) Failure to Make Contribution. In the event a Participant fails to
make the required contributions with respect to a Benefit elected under the Plan, his or
her receipt of such Benefit under the Plan for the remainder of the Plan Year shall be
terminated and he or she shall not be permitted to make a new benefit election under the
Plan during the remainder of that Plan Year.
(h) Election Changes for HSA Contributions. If the Employer
indicates in the Adoption Agreement that a Participant may make pre-tax contributions to
his or her Health Savings Account, the Participant may prospectively elect to increase,
decrease or completely revoke the amount of his or her salary reduction election for such
HSA contribution with respect only to salary that has not become currently available to
the Participant.
Any change in election permitted under Section 6.07(a), (b), (c) and (e) above must be made no
later than the last business day falling on or before 31 days (or within 60 days for Medicaid or
CHIP circumstances) following the date on which one of the events described in such paragraph
occurs.
Notwithstanding the foregoing, a Participant shall not revoke an election and make a new
election that would cause him or her to maintain less than the minimum benefits, if any, required
with respect to any Benefit for a Plan Year. The Employer shall adopt and follow uniform and
nondiscriminatory rules for purposes of this Section and its decisions regarding voluntary
election modifications shall be final and binding.
ARTICLE VII
SALARY REDUCTION CONTRIBUTIONS
Section 7.01 Salary Reduction. The Participant may direct the Employer to reduce his
or her compensation each pay period over the Plan Year in an amount equal to the cost of his or
her elected Qualified Benefits. Such salary reduction amounts shall be designated and
authorized by each Participant on his or her benefit election form and such form shall constitute a
salary reduction agreement between the Participant and the Employer. The amount of salary
reduction available to a Participant under the Plan for a Plan Year shall be equal to a portion of
the cost necessary for the Employer to purchase the elected Qualified Benefit. Such amount
shall be determined by the Employer prior to the beginning of each Plan Year. In the event of
increases or decreases in the cost of providing Qualified Benefits during a Plan Year, a
Participant's salary reduction amount may be automatically adjusted to reflect such increase or
decrease.
12
Section 7.02 Substantiation of Claims. A Participant must satisfy the substantiation
requirements set forth in this section and in Treasury Regulations §1.125-6(b) before the Plan
can pay or reimburse a Participant for the expense of Qualified Benefits listed in the Employer's
Adoption Agreement. Expenses must be substantiated by information from a third-party that is
independent of the Participant and his or her spouse or dependents. The independent third-party
must provide information describing the service or product, the date of service or sale and the
amount.
Section 7.03 Payments to Insurer. The Employer shall maintain separate
bookkeeping records of a Participant's salary reduction amounts and shall apply such amounts
on behalf of a Participant for the sole purpose of paying premiums or reimbursements to the
appropriate party in accordance with a Participant's Benefit elections.
Section 7.04 Funding Benefits. All Participant salary reduction amounts contributed
to the Plan shall be used to provide Benefits in accordance with Participants' Benefit elections
pursuant to Section 6.03. Benefits shall be funded from the general assets of the Employer or,
alternatively, through the direct payment of insurance premiums to an insurer from the general
assets of the Employer. The Plan shall not utilize a trust fund or other separately maintained
fund for accumulation of Plan assets or the provisions of other benefits, unless required by law.
ARTICLE VIII
CLAIMS FOR BENEFITS
Section 8.01 Claims for Benefits. Each Participant shall submit claims for Benefits in
accordance with the rules and procedures established under and applicable to each particular
Benefit Plan. In the event of a dispute regarding eligibility for participation in a Benefit Plan,the
right to receive a Benefit or the amount of benefit payable with respect to a claim, such dispute
shall be resolved in accordance with the rules and procedures applicable under the Benefit Plan
in question. There shall be no liability for the payment of Benefits imposed upon the officers,
directors, employees, or stockholders of the Employer.
Section 8.02 Insurance. To the extent that a Benefit is provided through insurance, a
Participant's right to receive benefits will be governed by the terms and conditions of the
applicable insurance contract, and the amount of such benefits will be limited to the amount
payable under such Insurance Contract. The Employer will have no obligation or duty to provide
Benefits to Participants to the extent such benefits are provided through insurance.
Section 8.03 Claims Relating to Plan Administration. Except as otherwise set forth
in the documents which evidence a particular Benefit Plan, the Plan Administrator (or its
designated claims administrator) shall determine the right of each Employee to participate in the
Plan, the identity and amount of Benefits subject to a Participant's election under the Plan for the
Plan Year, and the right of a Participant to be reimbursed for Dependent Care or Medical Care
Expenses under Articles XII and XIII. If an Employee or Participant disputes the determination
of the Plan Administrator with respect to any such rights, the Employee or Participant (or his or
her authorized representative) (the "claimant") may request a review by the Plan Administrator
of the disputed question. All such claims must be in writing or other electronic format and
13
furnished to the Plan Administrator (via personal delivery, U.S. mail or electronically). A claim
shall set forth the following:
(a) The name and address of the claimant;
(b) The specific basis for the claim;
(c) A specific reference to the pertinent Plan provision upon which the claim
is based; and
(d) Any additional material or information which the claimant desires to
submit in justification of the claim.
Any claims for reimbursement of Dependent Care or Medical Care Expenses must be submitted
in accordance with the reimbursement procedures outlined in Sections 12.16 and 13.14 below.
Section 8.04 Claim Administrator's Initial Determination. The Plan Administrator,
or its designated claims administrator, (collectively referred throughout this Article as "Claims
Administrator") shall promptly review submitted claims. If any written claim for reimbursement
under the Plan is denied in whole or in part, the Plan Administrator shall provide the claimant a
written notice of denial. Such notice of denial shall be delivered or mailed to the claimant
within:
• 30 days after receipt of the claim involving a request for reimbursement of
Health Care Spending Account benefits; or
• 90 days after receipt of all other types of claims.
However, if special circumstances require an extension of time for processing the claim, written
notice of the extension shall be furnished to the claimant prior to the termination of the
applicable initial 30 or 90-day period.
Section 8.05 Claimant's Deadline for Filing an Appeal of a Denied Claim. A
claimant may request, either in writing or electronically, a full and fair review of an initial
decision denying his or her claim, but such a request must be in writing and must be submitted to
the Plan Administrator within:
• 180 days after the claimant's receipt of the notice of denial of a claim
involving a request for reimbursement of Health Care Spending Account benefits;
or
• 60 days following receipt of the notice of denial for all other types of
claims.
The claimant shall be entitled to submit such issues or comments, in writing or otherwise, as he
or she shall consider relevant to a determination of his or her claim and may include a request for
a hearing in person before the Plan Administrator. Prior to submitting his or her request, the
14
claimant shall be entitled to review such documents as the Plan Administrator shall agree are
pertinent to his or her claim.
The review of a claim which has been denied shall be made by the Plan Administrator and a
written decision delivered or mailed to the claimant within 60 days of the Plan Administrator's
receipt of the request for review, unless the Employer determines that special circumstances,
such as the need to hold a hearing, require additional time, in which case a decision shall be
rendered and delivered (via U.S. mail, personal delivery or electronically) to the claimant not
later than 120 days after the Employer's receipt of the request for review. In no case, shall there
be liability for the payment of benefits imposed upon the officers, directors, or employees of the
Employer.
Section 8.06 Appeal Procedures. On appeal, the following procedures will apply:
(a) During the review, a claimant may represent himself or herself or
will have the right to appoint a representative, provided that the claimant is responsible
for all of fees and expenses of such representative.
(b) A claimant will have reasonable access (free of charge and upon
request) to copies of all documents, records and other information relevant to his or her
claim for benefits.
(c) A claimant will be provided the opportunity to submit, and any
review will take into account, all comments, documents, records, and other information
relating to the claim, without regard to whether such information was submitted or
considered in the initial benefit determination.
Section 8.07 Claims Administrator's Deadline for Deciding an Appeal. The Claims
Administrator will notify the claimant of its decision regarding the claimant's appeal within a
reasonable period of time, but not later than 60 calendar days after receipt of the claim for
review, unless the Claims Administrator determines that special circumstances require an
extension of time for processing the claim. If the Claims Administrator determines that an
extension of time for processing is required, a claimant will receive written notice of the
extension prior to the expiration of the initial 60 day period. In no event will the extension
exceed a period of 60 days from the end of the initial period. The extension notice will indicate
the special circumstances requiring an extension of time and the date by which the Claims
Administrator expects to render the determination of a claimant's appeal.
4
Section 8.08 Notice of Adverse Benefit Determinations. Any notice of a denied
claim by the Claims Administrator will set forth:
(a) the specific reasons for the Administrator's decision;
(b) references to specific Benefit Plan and provisions of the Plan upon
which the decision is based; and
(c) for a notice involving the Claims Administrator's initial decision
on a claim -- a description of any additional 'material or information necessary for the
15
claimant to perfect his or her claim along with an explanation of why such material or
information is necessary, and an explanation of claim review procedures under the plan
and the time limits applicable to such procedures.
(d) the specific rule, guideline, or protocol, if any, that was relied on in
making any adverse benefit determination relating to health- or disability-based claims,
or a statement that the rule, guideline, or protocol will be provided to the claimant free of
charge;
(e) if the adverse benefit determination is based on a medical necessity
or an experimental treatment limit or exclusion, either an explanation of the scientific or
clinical judgment for the determination that applies the Plan to the claimant's medical
circumstances or a statement that the explanation will be provided free of charge on
request; and
(f) the identity of any medical or vocational experts whose advice was
obtained by the Claims Administrator in the process of deciding the claim, regardless of
whether Claims Administrator relied upon such advice.
Section 8.09 General Claim Provisions. Notwithstanding anything to the contrary, the
following provisions will apply to all claims:
(a) Finality of Decisions. The Claims Administrator has full
discretion in determining any matter regarding a claim for Benefits or other claims
involving the Plan. The decision of the Claims Administrator upon review of any claim
shall be binding upon a claimant, his or her heirs and assigns, and all other persons
claiming by, through or under a claimant.
(b) Limitation of Claims Procedure. Except as otherwise required
under and subject to the terms of a Plan (including Sections 12.16 and 13.14 regarding
spending account reimbursements), any claim under this claims procedure must be
submitted within 12 months from the earlier of:
(1) the date on which the claimant learned of facts sufficient to
enable him to formulate such claim, or
(2) the date on which the claimant reasonably should have
been expected to learn of facts sufficient to enable him to formulate such claim.
(c) Limitation on Court Action. Any suit brought to contest or set
aside a decision of the Claims Administrator is to be filed in a court of competent
jurisdiction within one year from the date of the receipt of written or electronic notice of
the Claims Administrator's final decision. Service of legal process shall be made upon
the Plan by service upon the agent for service of legal process or upon the Claims
Administrator.
(d) Legal Action. No legal action to recover Plan benefits or to
enforce or clarify rights under the Plan shall be commenced under any federal or state
16
provision of law, whether or not statutory, until a claimant first exhausts the claims and
review procedures available to him or her hereunder.
(e) Forfeiture of Uncashed Checks. If the Plan (through the Employer,
or its third party administrator or insurer) makes payment to a Participant (and/or to
his/her dependents or to a provider on his/her behalf) of an approved benefit claim and
the check for such benefit claim remains uncashed (regardless of the reason) for a period
of more than one (1) year after the issue date of the check, then the Participant will forfeit
all rights for reimbursement or payment of such Benefit claim under the terms of Plan
and the Participant will not be entitled to reinstate his/her rights with respect to such
Benefit claim at any time thereafter. Also, the Plan requires that a Participant submit
his/her initial claim for P a Y ment within 12 months after the date of service for Benefit
claims. If a Participant submits his/her claim after this 12-month period, then a
Participant (or his/her dependents or the provider acting on the Participant's behalf) will
forfeit all rights to payment or reimbursement under the Plan, and the Plan will deny such
Benefit claim.
(f) Special Rulings. In order to resolve problems concerning the Plan
and to apply the Plan in unusual factual circumstances, the Claims Administrator may
make special rulings. Such special rulings will be in writing on a form to be developed
by the Claims Administrator. In making its rulings, the Claims Administrator may
consult with third party administrators, legal, accounting, investment, and other counsel
or advisers. Once made, special rulings shall be applied uniformly, except that the
Claims Administrator will not be bound by such rulings in future cases unless the factual
situation of a particular case is identical to that involved in the special ruling. Special
rulings shall be made in accordance with all applicable law and in accordance with the
Plan. It is not intended that the special ruling procedure will be a frequently used device,
but that it should be followed only in extraordinary situations. The Claims Administrator
at all times will have the final decision as to whether resort will be made to this special
ruling feature.
ARTICLE IX
LEAVE OF ABSENCE
Section 9.01 In General. Except as otherwise provided in a Benefit Plan, if a
Participant is absent from work due to (i) an approved medical or family leave of absence which
is covered under the Family and Medical Leave Act of 1993 ("FMLA") (to the,extent FMLA
applies to the Employer); (ii) a military leave of absence which is covered under the Uniformed
Services Employment and Reemployment Rights Act of 1994 ("USERRA"), or (iii) an
Employer-Approved Leave of Absence, the Participant shall have the following rights:
(a) To revoke his or her election with respect to any Benefit under the
Plan for the remainder of the Plan Year.
(b) To continue, in accordance with Section 9.02 below, his or her
election of Benefit coverage during the leave period, but only to the extent permitted by
the Employer and under a Benefit Plan.
17
(c) To suspend his or her election during the leave period with respect
to any Benefit Plan and to reinstate such election upon his or her return to work with the
Employer in accordance with Section 9.04 below.
Section 9.02 Payment for Coverage. If the Participant elects to continue his or her
election of coverage during an FMLA leave, a USERRA leave or an Employer-Approved Leave
(to the extent permitted by the Employer and under a Benefit Plan), the Participant's share of the
cost of continued coverage for such Benefit will be paid as follows:
(a) Paid Leave. If the leave is a paid leave, the Participant's share of
the cost of coverage shall be paid by'a reduction in the Participant's cash compensation
under this Plan.
(b) Unpaid Leave. If the leave is unpaid, the Participant may elect to
pay his or her share of the cost of coverage due during the leave pursuant to any of the
payment methods made available to him or her by the Employer as indicated in the
Adoption Agreement. The Employer may elect, under the Adoption Agreement, one or
more of the following payment options:
(1) Pay-As-You Go Option. The Participant may elect to make
payments to the Employer on an after-tax basis on the same schedule as if the
Participant were not on a leave;
(2) Pre-Payment Option. If elected by the Employer in the
Adoption Agreement, the Participant may elect to make payments to the
Employer on a pre-payment basis from any taxable compensation payable to the
Participant (including the cashing out of sick days or vacation days); provided,
however, that no pre-payment may be made in a manner that will permit a pre-tax
payment to be made in one taxable year of the Participant that will be applied to a
subsequent taxable year of the Participant.
(3) Catch-Up Payment. If elected by the Employer in the Adoption
Agreement, the Employer may agree to permit the Participant to make payments
to the Employer on a catch-up basis from compensation payable to the Participant
upon his or her return to work with the Employer from leave; provided, however,
that the Employer and the Participant agree in advance of the leave that:
(A) The Participant elects to continue coverage while on an
unpaid leave;
(B) The Employer will assume responsibility for advancing
payment of the Participant's contributions during the leave; and
(C) The advance amounts must be paid by the Participant when
he returns from the leave.
Section 9.03 Cessation of Coverage. If a Participant fails to timely make any
scheduled payments, coverage under the Plan during a leave will cease retroactively to the date
the required payment was due, provided the Employer has given the Participant at least 15 days
advance written notice that if payment is not received by the;30th day after the required due date,
18
coverage will be dropped on the that date retroactive to the date the required payment is due. If
the notice is not timely sent, coverage will cease 15 days after the required notice is given or the
date specified in the notice, if later, unless the payment-has been received by that date:
Section 9.04 Restoration. If a Participant suspends his or her election under the Plan
during a leave and then returns to work with the Employer within the same Plan Year the leave
commenced, he or she automatically will resume participation in the Plan without any change in
his or her prior elections under the Plan for such Plan Year, except as otherwise permitted under
Section 6.07 (Voluntary Election Modifications) above. The Participant's cash compensation
will be reduced to the rate in effect on the day before the leave commenced and an amount equal
to the reduction will be credited by the Employer in accordance with the Benefit Plan.
With respect to the Health Care Spending Account Plan, a Participant may: (i) resume
coverage at the level in effect before the leave plus make-up the unpaid contribution payments
for the period of leave, or (ii) resume coverage at a level that is reduced by only resuming
contribution payments at the level in effect before the leave with no make-up contributions. In
both of these cases, the coverage level for a Participant who resumes participation is reduced by
prior reimbursements to such Participant. If a Participant chooses to resume coverage at a level
that is reduced, the coverage is prorated for the period during the leave for which no
' contributions were paid. Regardless of the Participant's choice, the Participant is not entitled to
reimbursement for claims incurred during the period when his or her coverage was terminated
under this Plan.
With respect to other Benefit Plans, if the Participant elected (or is required by the Plan)
to discontinue or suspend his or her coverage during, or fails to pay the required premiums for, a
leave period, the Participant is not entitled (i) to reimbursement for claims incurred during the
period when his or her coverage was terminated, nor (ii) to greater benefits upon restoration for
the remainder of the Plan Year relative to premiums or contributions paid by an Employee who
is continuously employed during the Plan Year.
A Participant who returns from a leave in a Plan Year subsequent to the year the leave
commenced will be required to complete and submit a new election form as specified in Section
6.03 if he or she is to resume participation in the Plan. Participation in this Plan shall commence
as of the first pay period immediately following receipt of a Participant's completed election
form by the Employer.
ARTICLE X
PROVISIONS RELATING TO ADMINISTRATION AND FIDUCIARIES
Section 10.01 Plan Administration. The Employer (or such person or entity as it shall
designate) shall be the Plan Administrator and shall administer the Plan in accordance with its
terms. The Plan Administrator shall have such powers and duties as may be necessary to
discharge its functions under the Plan, including, but not limited to the following:
(a) Construction. To have full discretionary and binding authority to
construe and interpret the Plan and decide all questions of eligibility to participate in and
for benefit under the Plan;
19
■
(b) Forms. To require Participants (1) to complete and file with it
such forms as the Plan Administrator finds necessary or desirable for the administration
of the Plan, and (2) to furnish all pertinent information requested by the Plan
Administrator, and to rely upon all such forms and information furnished, including each
Participant's mailing address;
(c) Procedures. To prescribe procedures to be followed by Participants
in electing Benefits and filing claims for Benefits;
(d) Rules. To promulgate uniform rules and regulations whenever in
the opinion of the Plan Administrator such rules and regulations are required by the terms
of the Plan or would facilitate the effective operation of the Plan;
(e) Information. To prepare and distribute, in such manner as the Plan
Administrator determines to be appropriate, information explaining the/Plan, and to
receive from Participants such information as ' shall be necessary for the proper
administration of the Plan;
(f) Annual Reports. To prepare, furnish, and file such annual reports
with respect to the administration of the Plan as are required by law or as are reasonable
and appropriate;
(g) Insurers. To appoint and remove insurance carriers;
(h) Records. To prepare, receive, review, and keep on file (as it deems
convenient and proper) records of benefit payments and disbursements for expenses; and
(i) Appointments. To appoint and remove fiduciaries, fix their
compensation, if any, and exercise general supervisory authority over them.
Notwithstanding any provision of this Plan to the contrary, the Plan Administrator in its
sole discretion may enroll Participants in the Plan over the telephone, may furnish notices and
other disclosures via electronic transmission and may otherwise administer the Plan in a
paperless manner.
Section 10.02 Finality of Decisions. All determinations of the Plan Administrator or the
Employer or any of its delegates shall be final and binding on all persons except as otherwise
expressly provided herein.
Section 10.03 Fiduciaries and Other Duties. The Employer shall be a "named
fiduciary" of this Plan and of any Benefit Plan available under the Plan only to the extent they
are considered "employee welfare benefit plans," as those terms are described in ERISA. The
Employer shall have only those duties, responsibilities, and obligations (referred to collectively
as "fiduciary duties") as specifically are given it under the Plan, under any Benefit Plan available
under the Plan, or as otherwise are imposed by applicable law. The Employer shall have the sole
responsibility for making contributions or purchasing insurance in order to provide the Benefits
available under the Plan. The Employer may allocate or delegate its fiduciary duties under the
20
Plan to other Plan fiduciaries by written agreement between the Employer and such other
fiduciaries.
Section 10.04 Employment of Advisers. The Employer shall have the authority to
employ such legal, accounting, and financial counsel and advisers as it shall deem necessary in
connection with the performance of its duties under the Plan, and to act in accordance with the
advice of such counsel and advisers. In administering the Plan and to the extent permitted by
law, the Employer may rely conclusively on all tables, valuations, certificates, opinions and
reports which are furnished by accountants, counsel or other experts employed or engaged by the
Employer.
Section 10.05 Delegation to Officers or Employees. The Employer shall have the
power to delegate its fiduciary duties under the Plan or under any Benefit available under the
Plan to officers or employees of the Employer and to other persons, all of whom, if employees of
the Employer, shall serve without compensation other than their regular remuneration from the
Employer. The Employer agrees to indemnify and to defend to the fullest extent permitted by
law any delegated employee or officer against all liabilities, damages, costs and expenses
(including attorneys' fees and amounts paid in settlement of any claims approved by the
Employer), occasioned by any act or omission to act in connection with the Plan, if such act or
omission is in good faith.
Section 10.06 Fees and Expenses. All expenses incurred in the operation and
administration of the Plan, including the fees and expenses of counsel and other advisors and the
compensation, if any,of the fiduciaries, agents, and administrators shall be paid or reimbursed by
the Employer unless the Employer shall determine that such fees and expenses shall be paid in
whole or in part by the Plan or by Participants.
ARTICLE XI
GENERAL
Section 11.01 Amendment and Termination. The Plan and all Benefits available
under the Plan shall be subject to alteration, amendment, or termination in whole or in part, at
any time by action by the Board of Directors of the Employer (which power may be delegated,
through resolutions of the Board of Directors, to another person or organization selected by the
Employer).
Section 11.02 Non-Alienation of Benefits. No right or benefit provided for under the
Plan or under any Benefit available under the Plan shall be subject in any manner to anticipation,
alienation, sale, transfer, assignment, pledge, encumbrance, or charge, and any attempt to
anticipate, alienate, sell,transfer, assign, pledge, encumber, or charge the same shall be void.
Section 11.03 Employer's Rights. While the Employer believes in the benefits, policies
and procedures described in the Plan, the language used in the Plan is not intended to create, nor
is it to be construed to constitute, a contract of employment between the Employer and any of its
Employees. The Employer retains all of its rights to discipline or discharge Employees or to
exercise its rights as to incidents and tenure of employment. Employees retain the right to
21
terminate their employment at any time and for any reason, and the Employer retains a similar
right.
Section 11.04 Construction. Whenever any words are used in the Plan in the masculine
gender, they shall be construed as though they are also used in the feminine gender, where
applicable. Similarly, words used in the single form shall be construed as though they are also in
the plural form, where applicable. Headings of sections and paragraphs of this document are
inserted for convenience of reference. They constitute no part of the Plan and are not to be
considered in the construction of the Plan.
Section 11.05 Tax Consequences. Neither the Employer nor the Plan makes any
representations or warranties regarding the federal, state, local or other tax treatment of benefits
provided pursuant to the Plan and a Participant shall have no rights against the Employer or the
Plan if any tax consequences contemplated by any Participant are not achieved.
Section 11.06 Law Governing. This Plan is made pursuant to, and shall be governed
by, construed under and enforced in accordance with federal law and, to the extent not
preempted, the laws of the State identified in the Adoption Agreement to the extent not
preempted by ERISA.
Section 11.07 Exclusive Benefit.e efit. All contributions made under this Plan and all benefits
received shall inure to the exclusive benefit of the Participants and their beneficiaries, and such
contributions and benefits shall not be used for nor diverted to purposes other than for the
exclusive benefit of the Participant and their beneficiaries (including the costs of maintainin g and
administering the Plan).
Section 11.08 Binding Effect. The Employer hereby adopts the Plan (and amendments
thereto) through the proper execution of the Adoption Agreement. The Plan and such Adoption
Agreement (including any amendments thereto), and all actions and decisions hereunder, shall be
binding on the Employer and any and all Participants, present and future.
ARTICLE XII
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT PLAN
Section 12.01 Dependent Care Flexible Spending Account Plan Authority. The
benefit plan described in this Article XII is intended to qualify as a separate, nontaxable
employee benefit plan under Code Section 129 which provides dependent care assistance
benefits to Participants and is to be interpreted in a manner consistent with the requirements of
Code Section 129. This Article XII shall apply only to the extent the Employer offers a
Dependent Care Spending Account to its eligible employees as selected under the Adoption
Agreement.
Section 12.02 Definitions. The following definitions shall apply for purposes of this
Article XII:
(a) "Dependent" means any individual who would be a "qualifying
individual"within the meaning of Section 21(b)(1)of the Code, including:
22
Y
(1) A Participant's dependent who is a qualifying child within the
meaning of Code Section 152 who has not attained age 13; or
(2) A Participant's dependent (as defined under Code Section 152,
without regard to 152(b)(1) and (2) or 152(d)(1)(B)) or Spouse, if such dependent
or Spouse is physically or mentally incapable of self-care and has the same
principal place of abode as the Participant for more than one-half of the taxable
year.
(b) "Dependent Care Center" means a Dependent Care Center as defined in
Code Section 21. Generally, a Dependent Care Center is any facility which:
(1) provides care for more than 6 individuals (other than individuals
who reside at the facility); and
(2) receives a fee, payment or grant for providing services for any of
the individuals(regardless of whether such facility is operated for profit).
,(c) "Dependent Care Expenses" means amounts which if paid for by the
Participant would constitute "employment-related expenses" within the meaning of Code
Section 21(b)(2). Generally, Dependent Care Expenses are those expenses incurred for
the care of a Dependent or for household services with respect to the care of a Dependent
that are incurred to enable the Participant to be gainfully employed for any period for
which there are one or more Dependents with respect to such Participant.
(d) "Dependent Care Spending Account" means an account described in
Section 12.12 below.
(e) "Earned Income" means:
(1) with respect to a Participant, all income derived from wages,
salaries, tips, self-employment (with regard to the deduction allowed under Code
Section 164(f)), and other Employee compensation as defined in Code Section
32(c)(2), but excluding amounts paid or incurred by the Employer for dependent
care assistance to the Participant;
(2) with respect to a Participant's spouse, all wages, salaries, tips, and
other employee compensation, plus the amount of net earnings from self-
employment; provided, however, in the case of a spouse who is a full-time student
at an educational institution or is physically or mentally incapable of caring for
himself or herself, such spouse shall be deemed to have Earned Income of not less
than $200 per month if the Participant has l Dependent and $400 per month if the
Participant has 2 or more Dependents.
(f) "Spouse" shall have the meaning ascribed under Article II above,
and shall include a Participant's same-sex Spouse effective on and after January 1, 2013.
23
Section 12.03 Eligibility. In order to be eligible for reimbursement of Dependent Care
Expenses incurred within any Plan Year (or its Grace Period to the extent applicable under the
Adoption Agreement), an individual must be an Eligible Employee of the Employer (as defined
in the Adoption Agreement).
Section 12.04 Effective Date an Election Procedure. An Eligible Employee's election
to allocate salary reductions to his or her Dependent Care Spending Account shall become
effective as of the first payroll period coincident with or next following the date set forth in the
Adoption Agreement; provided that the Employee timely completes the enrollment process
pursuant to Article VI. An election to participate in the Dependent Care Spending Account Plan
shall be irrevocable during the Plan Year, except as otherwise permitted under this Plan.
Section 12.05 Amount. Each Participant shall be entitled to receive for each Plan Year,
reimbursement of Dependent Care Expenses which are incurred during the Plan Year (or its
Grace Period to the extent applicable under the Adoption Agreement) up to the lesser of the
dollar amount of the Dependent Care Expenses or the dollar amount of the Participant's
Dependent Care Spending Account balance. If the Participant's Dependent Care Expenses
exceed the dollar amount in his or her Dependent Care Spending Account as of the date of the
request for reimbursement, the Plan Administrator will make a partial reimbursement of such
request equal to the amount in such Participant's Account at that time, and then reimburse the
remaining portion of such request at the time that the Account has sufficient funds credited to it.
Section 12.06 Benefit Limitations. Notwithstanding any provision to the contrary in
this Plan, the maximum amounts paid from a Participant's Dependent Care Spending Account
for any taxable year of the Participant may not exceed the lesser of(a)or(b) below.
(a) Such amounts may not exceed $5,000 ($2,500 if a separate income tax
return is filed by a Participant who is married as determined under the rules of Code
Section 21(e)).
(b) Such amounts may not exceed (i) the Participant's Earned Income for the
Plan Year or (ii) the actual or deemed Earned Income of the Participant's Spouse, if less,
for the Plan Year.
This maximum amount may be automatically increased under the Plan if the Plan Administrator
elects to apply an increase that is permitted under Code Section 129.
The Plan Administrator may establish a minimum contribution amount that a Participant
may elect to credit to his or her Dependent Care Spending Account for a Plan Year, which
amount, if any, shall be set forth in the initial and open enrollment materials or in the Adoption
Agreement.
Section 12.07 Benefits Limited to Expenses Incurred During Plan Year. The
coverage elected by a Participant for a Plan Year is only available to reimburse expenses which
are incurred during the Plan Year (or its Grace Period to the extent applicable under the
Adoption Agreement) and for periods during which the Participant made contributions to the
Plan. An expense is incurred during the Plan Year if the services giving rise to the expense are
performed during the Plan Year (or its Grace Period to the extent applicable under the Adoption
24
Agreement). An expense shall not be deemed to be incurred merely because a Participant
receives a bill for the expense or pays for the expense during the Plan Year.
Section 12.08 Restrictions on Payments.
(a) In no event shall a Participant ,be reimbursed for Dependent Care
Expenses paid to a related individual:
(1) for whom the Participant or his or her Spouse is entitled to a
deduction under Code Section 151(c), or
(2) who is a child of the Participant under the age of 19 years.
1
(b) Services performed outside the household of a Participant for the care of a
Dependent shall be reimbursable only if such Dependent regularly spends at least 8 hours
each day in the Participant's household or the Dependent is under age 13.
(c) Dependent Care Expenses that are incurred for services performed by a
Dependent Care Center shall be reimbursable hereunder only if such center complies with
all applicable laws and regulations of the state and political subdivision in which it is
located.
Section 12.09 Forfeiture. If, during a Plan Year, a Participant incurs aggregate
Dependent Care Expenses in an amount which is less than the dollar amount of coverage he or
she has elected for a Plan Year, any remaining amount in his or her Dependent Care Spending
Account shall be forfeited as of the end of the Plan Year(or as of the last day of the Grace Period
if applicable under the Adoption Agreement). Any unused amount of coverage elected by a
Participant for a Plan Year resulting from the Participant's failure to timely submit proper claims
for reimbursement (in accordance with Section 12.16) shall be forfeited in the`same manner.
Subject to applicable law and regulations, such forfeitures shall be retained by the Employer or
applied toward the payment of reasonable Plan administrative expenses, provided, however that
the Employer shall have discretion to allocate the forfeitures on a reasonable and uniform basis
to Participants. In no event, however, shall any such forfeitures be allocated among Participants
based on their individual claims experience, be used for other benefits under the Plan, or be
carried over and applied to qualifying Dependent Care Expenses incurred more than 12 months
after the year in which such amount was forfeited. Upon Plan termination, forfeitures shall occur
as provided in Section 10.01.
Section 12.10 Involuntary Election Modifications. In no event shall more than 25%of
the amounts paid or incurred by the Employer for dependent care assistance and all other
qualified benefits (within the meaning of Code Section 125(b)(2)) under the Plan during the Plan
Year be provided to key employees (within the meaning of Code Section 416(i)(1)).
The average benefits provided to Employees who are not highly compensated employees
(within the meaning of Code Section 414(q)) shall at all times equal at least 55% of the average
benefits provided to highly compensated employees under the Dependent Care Spending
, Account Plan. For purposes of this paragraph, in the case of any benefits provided through a
25
•
salary reduction agreement, there may be disregarded any employees whose compensation
(within the meaning of Code Section 414(q)(7)) is less than $25,000.
If any of the limitations on benefits to key employees or highly compensated employees
under the preceding paragraphs would be exceeded but for this paragraph, the Employer may
reduce or cancel the compensation reduction of 1 or more highly compensated employees or
otherwise modify the salary reduction agreement or agreements of 1 or more highly compensated
employees to satisfy these limitations.
Section 12.11 Reimbursements. All reimbursements made under the Dependent Care
Spending Account Plan shall be payable directly to Participants and solely from the general
assets of the Employer. Funds contributed by the Employer represent salary reduction amounts
elected by Participants pursuant to the provisions of the Plan under Code Sections 125 and 129.
Section 12.12 Establishment of Accounts. The Employer shall establish and maintain
on its books a Dependent Care Spending Account for each Plan Year with respect to each
Participant who has elected to receive reimbursement of Dependent Care Expenses incurred
during the Plan Year (or its Grace Period to the extent applicable under the Adoption
Agreement).
Section 12.13 Crediting of Accounts. There shall be credited to each Participant's
Dependent Care Spending Account, as of each pay date, the amount designated on the
_ Participant's election and salary reduction agreement under the Plan. All amounts credited to
each such Dependent Care Spending Account shall be the property of the Employer until paid
out pursuant to Section 12.16.
Section 12.14 Debiting of Accounts. A Participant's Dependent Care Spending
Account for each Plan Year shall be debited in the amount of any payment made under Section
12.16 to or for the benefit of the Participant.
Section 12.15 Statement of Account. On or before January 31 of each year, the Plan
Administrator shall issue each Participant a written statement showing the amounts paid or
expenses incurred under such Participant's dependent care account during the-previous calendar
year.
Section 12.16 Reimbursement Procedure.
(a) Each Participant who applies for reimbursement for Dependent Care
Expenses under the Plan shall submit to the Plan Administrator a properly completed
claim form prescribed and provided by the Plan Administrator which shall include:
(1) the amount of the expense;
(2) the name of the Dependent(s) for whom the expense was incurred;
and
(3) a statement as to when and where or by whom the services were
performed.
26
Additional information may be requested if deemed necessary by the Plan
Administrator. Each such claim form shall be signed by the Participant and accompanied
by relevant bills, statements, or receipts relating to the claim. All properly submitted
claims shall be reimbursed monthly, on such date as shall be designated by the Plan
Administrator.
(b) A Participant only may submit claims to the Plan Administrator for
those Dependent Care Expenses that are incurred during the Plan Year (or its Grace
Period to the extent applicable under the Adoption Agreement), which claims must be
submitted in accordance with this Article XII.
(c) Participants may submit such claims for Dependent Care Expenses
only up to the claim submission deadline set forth in the Adoption Agreement.
Section 12.17 Claims Procedure. Subject to the rules for a claim of reimbursement
under Section 12.16 above, a claimant shall follow the rules set forth in Article VIII for the
submission and appeal of a claim.
Section 12.18 Refund of Duplicate Reimbursement. If a Participant receives a
reimbursement under this Plan and reimbursement for the same Dependent Care Expense is
made from another source, he or she shall be required to refund the reimbursement to the
Employer.
Section 12.19 Termination of Participation. A Participant will cease to be a
Participant as of the earliest of:
(a) the date on which the Plan terminates;
(b) the date on which his or her election to receive Dependent Care Expense
Reimbursements expires or is terminated under the Plan; or
(c) the date on which he or she terminates employment with the.Employer.
Section 12.20 Effect of Termination of Participation. In the event that a Participant
ceases to be a Participant in the Plan for any reason during a Plan Year(or its Grace Period to the
extent applicable under the Adoption Agreement), the Participant's salary reduction agreement
relating to the Plan shall terminate. The Participant shall be entitled to reimbursement only for
Dependent Care Expenses incurred before the Participant ceased participation in the Plan. Such
reimbursement shall be made in accordance with Section 12.16.
Section 12.21 Leave of Absence. If a Participant is absent from work due to an unpaid
leave of absence, the Participant will have the right to revoke his or her coverage under the
Dependent Care Spending Account Plan for the remainder of the Plan Year. In any event, the
Participant's coverage under such Plan will be suspended during an unpaid leave period. If the
Participant does not elect to revoke his or her coverage for the remainder of the Plan Year,
coverage will be reinstated upon his or her return to work with the Employer and will resume
without any change in the Participant's prior elections under such Plan for such Plan Year. The
27
Participant's cash compensation will be reduced to the rate in effect on the day before the leave
commenced.
In no event is a Participant entitled to (i) reimbursement for claims incurred during the
period when coverage was suspended or revoked, nor (ii) greater benefits upon restoration for
the remainder of the Plan Year relative to contributions paid by a Participant who is continuously
employed during the Plan Year.
If the Participant returns from an unpaid leave in a Plan Year subsequent to the year the
leave commenced, the Participant will be required to complete and submit a new election form
under the Plan if he or she wants to resume participation in the Dependent Care Spending
Account Plan. Participation in the Dependent Care Spending Account Plan will commence as of
the first pay period immediately following receipt of the Participant's completed election form
by the Employer(as long as made within 30 days of the Participant's return to work).
ARTICLE XIII
HEALTH CARE FLEXIBLE SPENDING ACCOUNT PLAN
Section 13.01 Health Care Flexible Spending Account Plan Authority. The benefit
plan described in this Article XIII is intended to qualify as a separate, nontaxable employee
benefit plan under Code Section 105, providing health care benefits to Participants and is to be
interpreted in a manner consistent with the requirements of Code Section 105. This Article XIII
shall apply only to the extent the Employer offers a Health Care Spending Account to its
eligible employees as selected under the Adoption Agreement.
Section 13.02 Definitions. The following definitions shall apply for purposes of this
Article XIII:
(a) "Dependent" means any individual who is:
(1) the legal Spouse of an Employee; or
(2) any individual who falls within the definition of dependent under
Code Section 152 (without regard to the earnings limit under §I52(d)(1)(B); the
special exclusions under §152(b)(1) or (2); or the age or student status
requirements under §152(c)(3), provided that such qualifying child is age 26 or
under during the entire Plan Year).
(b) "Health Care Spending Account" means an account described in Plan
Section 13.10 below.
(c) "Medical Care" shall have the meaning set forth in Code Section 213, but
only to the extent that the Participant or other person incurring the expense is not
reimbursed for the expense through insurance or otherwise (other than under this Plan).
Under the Plan, however, Medical Care does not include Participants' premium payments
for health coverage. Medical Care also includes insulin or over-the-counter (OTC)
medicines and drugs that are prescribed by a physician.
28
(d) "Medical Care Expenses" means amounts which are expended
for the Medical Care of a Participant or his or her Dependents during the Plan Year(or its
Grace Period to the extent applicable under the Adoption Agreement).
(e) "Spouse" shall have the meaning ascribed under Article II above,
and shall include a Participant's same-sex Spouse effective on and after January 1, 2014,
unless otherwise provided in the Adoption Agreement.
Section 13.03 Eligibility. In order to be eligible for reimbursement of Medical Care
Expenses incurred within any Plan Year (or its Grace Period to the extent applicable under the
Adoption Agreement), an individual must be an Eligible Employee of the Employer (as defined
in the Adoption Agreement).
Section 13.04 Effective Date and Election Procedure. An Eligible Employee's
election to allocate salary reductions to his or her Health Care Spending Account shall become
effective as of the first payroll period coincident with or next following the date set forth in the
Adoption Agreement; provided that the Employee timely completes the enrollment process
pursuant to Article VI. An election to participate in the Health Care Spending Account Plan
shall be irrevocable during the Plan Year, except as otherwise permitted under this Plan.
Section 13.05 Amount Each Participant shall be entitled to receive for each Plan Year,
reimbursement of Medical Care Expenses which are incurred during the Plan Year (or its Grace
Period to the extent applicable under the Adoption Agreement), but only if such expenses are not
reimbursed by any other source as provided in Section 13.15. The maximum reimbursement to a
Participant shall be the annual dollar amount of coverage elected under the Plan by the
Participant to be contributed to his or her Health Care Spending Account for that Plan Year.
The Plan Administrator may establish a minimum contribution amount that a Participant
may elect to credit to his or her Health Care Spending Account for a Plan Year, which amount, if
any, shall be set forth in the initial and open enrollment materials (or in the Adoption
Agreement). The maximum amount that a Participant may elect to contribute to the Plan for a
Plan Year is set forth in the Adoption Agreement, which amount may not exceed the statutory
limitation (e.g. $2,500 for the 2013 Plan Year), and is subject to the Employer's decision to
decrease or increase such maximum amount,to the extent permitted or required by law.
At all times during the Plan Year (or its Grace Period to the extent applicable under the
Adoption Agreement), the maximum dollar amount of coverage the Participant has elected for
the Plan Year, less any Medical Care Expenses previously reimbursed during such Plan Year,
shall be available for reimbursement for qualifying Medical Care Expenses, regardless of
whether a Participant's Medical Care Expenses exceed the total dollar amount in his or her
Health Care Spending Account at any time a particular request for reimbursement is made.
Section 13.06 Benefits Limited to Expenses Incurred During Plan Year The
coverage elected by a Participant for a Plan Year is only available to reimburse expenses that are
incurred during the Plan Year (or its Grace Period to the extent applicable under the Adoption
Agreement) and for periods during which the Participant made contributions to the Plan. An
expense is incurred during the Plan Year (or its Grace Period to the extent applicable under the
29
■
Adoption Agreement) if the services giving rise to the expense are performed,during such Plan
Year or Grace Period. An expense shall not be deemed to be incurred merely because a
Participant receives a bill for the expense or pays for the expense during the Plan Year (or its
Grace Period to the extent applicable under the Adoption Agreement).
Section 13.07 Forfeiture If, during a Plan Year, a Participant incurs aggregate Medical
Care Expenses in an amount which is less than the dollar amount of coverage he or she has
elected for a Plan Year, any remaining amount in his or her Health Care Spending Account shall
be forfeited as of the end of the Plan Year, subject to the Employer's election under the Adoption
Agreement to include either the carryover feature or the grace period feature for a Plan Year, as
follows:
(a) Carryover Feature. Effective on and after the date set forth in the
Adoption Agreement (but in no event earlier than the first day of the Plan Year that
begins in 2013), up to $500 of the unused balance existing in a Participant's Health Care
Spending Account as of the last day of the Plan Year may be carried over to reimburse
such Participant for eligible Medical Care Expenses that are incurred during the
subsequent Plan Year. Unused dollars in a Participant's account in excess of$500 may
not be carried over to the next year and shall be forfeited.
The Participant's unused balance at the end of the prior Plan Year may be used (i) for
expenses incurred in the prior Plan Year, but only if claimed during the Plan's claims
submission period specified under the Adoption Agreement that begins at the end of the
prior Plan Year (in effect retroactively reducing the unused amount as of the end of the
prior Plan Year) or (ii) to the extent of the permitted carryover amount of up to $500
from the final prior Plan Year's unused amount, for expenses that are incurred at any time
in the current Plan Year. For administrative ease, the Plan may treat reimbursements of
all claims for expenses that are incurred in the current Plan Year as reimbursed first from
unused amounts credited for the current Plan Year and, only after exhausting these
current Plan Year amounts, as then reimbursed from unused amounts carried over from
•
the preceding Plan Year. Any unused amounts from the prior Plan Year that are used to
reimburse a current year expense (x) reduce the amounts available to pay prior Plan Year
expenses during the claims submission period, (y) must be counted against the permitted
carryover of up to $500, and (z)cannot exceed the permitted carryover.
(b) Grace Period Feature. Effective on and after the date set forth in
the Adoption Agreement, the Participant has an additional two and one-half (2-1/2)
months immediately following the close of the Plan Year to incur Medical Care Expenses
and spend down account balances from the current Plan Year. Unused dollars in a
Participant's account after the close of the Grace Period for a Plan Year shall be forfeited.
1
The Plan may not offer both the carryover feature and the grace period feature for the
same Plan Year. Unused dollars existing in the Participant's account for a Plan Year resulting
from the Participant's failure to timely submit proper claims for reimbursement (pursuant to
Section 13.14) shall be forfeited in the same manner. Subject to applicable law and regulations,
such forfeitures shall be retained by the Employer or applied toward the payment of reasonable
Plan administrative expenses, provided, however that the Employer shall have discretion to
30
allocate the forfeitures on a reasonable and uniform basis to Participants. In no event, however,
shall any such forfeiture be allocated among Participants based on their individual claims
experience, be used for other Benefits under the Plan, or be carried over and applied to Medical
Care Expenses incurred more than 12 months after the end of the Plan Year in which the
forfeiture occurred. Upon termination of the Plan, forfeitures shall occur as provided in Section
10.01.
Section 13.08 Involuntary Election Modifications. At any time prior to or during the
Plan Year, the Employer may require some or all Participants to modify their elections under the
Plan if the Employer determines to its satisfaction that such modifications are necessary in order
to preserve the tax-preferred status of this Plan under Code Sections 125 or 105(h) or under any
other applicable provision of the Code and the regulations promulgated thereunder. Specifically,
such modifications may be required in order to enable the Plan to satisfy the nondiscrimination
requirements of applicable provisions of the Code. The Employer shall adopt and follow
uniform and nondiscriminatory rules for purposes of this section and its decisions regarding
involuntary election modifications shall be final and binding.
Section 13.09 Reimbursements All reimbursements made under this Plan shall be
payable directly to Participants and solely from the general assets of the Employer. Funds
contributed by the Employer represent salary reduction amounts elected by Participants pursuant
to the p rovisions of the Plan.
Section 13.10 Establishment of Accounts. The Employer shall establish and maintain
on its books a Health Care Spending Account for each Plan Year with respect to each Participant
who has elected under the Plan to receive reimbursement of Medical Care Expenses incurred
during the Plan Year (or its Grace Period to the extent applicable under the Adoption
Agreement).
Section 13.11 Crediting of Accounts There shall be credited to each Participant's
Health Care Spending Account as of each pay date the amount designated on the Participant's
election and salary reduction agreement under the Plan. All amounts credited to each such
Health Care Spending Account shall be the property of the Employer until paid out pursuant to
Section 13.14.
Section 13.12 Debiting of Accounts A Participant's Health Care Spending Account for
each Plan Year shall be debited in the amount of any payment made under Section 13.14 to or
for the benefit of the Participant for Medical Care Expenses incurred during such Plan Year (or
its Grace Period to the extent applicable under the Adoption Agreement).
Section 13.13 Statement of Account. The Plan Administrator may issue each
Participant a written statement showing the amounts paid or expenses incurred under such
Participant's Health Care Spending Account during the previous calendar year.
Section 13.14 Reimbursement Procedure.
(a) Each Participant who applies for reimbursement for Medical Care
Expenses under the Plan shall submit to the Plan Administrator a properly completed
claim on a form prescribed and provided by the Plan Administrator which shall include:
31
(1) the amount and•purpose of each expense and the date incurred;
(2) the name of the individual for whom the expense was incurred and,
if applicable, the relationship to the Participant; and -
(3) the name of the individual or entity to whom the expense was, or is
to be, paid.
Each such claim form shall be signed by the Participant, shall certify that the
expense has not been paid by, and that the Participant is not entitled to reimbursement or
payment from, another source pursuant to this Article, and shall be accompanied by
relevant bills, statements, or receipts from an independent third party that relate to the
claim. The Plan Administrator, in its sole discretion, may provide Participants with a
..) Flex Debit Card to be used for reimbursement of Medical Care Expenses (in lieu of a
r Participant submitting a claim form for reimbursement). The terms of any such Flex
Debit Card program will be established by the Plan Administrator and communicated to
Participants. The Plan Administrator, if it deems necessary, may require that a
Participant submit additional information for the Plan Administrator's consideration of a
Participant's request for reimbursement or for the Plan Administrator to substantiate
charges on a Flex Debit Card. Properly submitted claims will be reimbursed, on such
date as designated by the Plan Administrator.
(b) A Participant may submit claims to the Plan Administrator only for
those Medical Care Expenses incurred during the Plan Year (or its applicable Grace
Period if made available under the Adoption Agreement), which claims must be
submitted in accordance with this Article XIII.
(c) Participants may submit such claims for Medical Care Expenses
only up to the claim submission deadline set forth in the Adoption Agreement.
Section 13.15 Payment Limitations Reimbursement or payment under the Plan shall
be made by the Employer only to the extent that the claim for reimbursement has not been paid
by and is not payable from another source, including but not limited to (a) any insurance policy,
whether owned by the Employer, by the Participant, by an employer of the Participant's Spouse
or Dependents, or by any other person or entity, (b) any other health or-accident plan, whether
insured or self-insured, or(c) any government program or plan.
Section 13.16 Refund of Duplicate Reimbursement. If a Participant receives a
reimbursement under this Plan and reimbursement for the same Medical Care Expense is made
from another source, he or she shall be required to refund the reimbursement to the Employer.
Section 13.17 Termination of Participation. Subject to Sections 13.18 and ,13.19, a
Participant will cease to be a Participant as of the earliest of the date on which:
(a) the Health Care Spending Account Plan terminates;
(b) his or her election to receive reimbursement of Medical Care Expense
expires or is terminated under the Plan; or
32
(c) he or she terminates employment with the Employer.
Section 13.18 Effect of Termination of Participation. In the event that a Participant
ceases to be a Participant in the Health Care Spending Account Plan for any reason during a Plan
Year,the Participant's salary reduction agreement relating to the Plan shall terminate.
The Participant shall be entitled to reimbursement only for Medical Care Expenses
incurred before the Participant ceased participation in the Plan, except:
(a) As otherwise provided under Section 13.19 (COBRA Continuation Coverage); or
(b) If the individual was a Participant as of the last day of the Plan Year but he or she
terminated employment during the Grace Period, such Participant will be permitted to receive
reimbursement from his or her Health Care Spending Account for any medical expenses incurred
through the end of the Grace Period.
Section 13.19 COBRA Continuation Coverage. To the extent the Employer is subject
to COBRA, this Section 13.19 shall apply. If a Participant of the Health Care Spending Account
Plan terminates employment with the Employer, or he or she (or his or her Spouse or dependent
child) experiences another qualifying event under COBRA (e.g. reduced hours in employment,
divorce, death, loss of dependent status, entitlement to Medicare, etc.), the Participant (or his or
her spouse or dependent-child) may be offered a limited opportunity to continue coverage under
the Health Care Spending Account Plan as follows:
(a) COBRA continuation coverage under the Health Care Spending Account
Plan will be offered to such a Participant (or his or her Spouse or Dependent child) only
if the maximum amount available to the Participant under the Health Care Spending
Account Plan for the remainder of the Plan Year is more than the maximum amount that
the Employer may charge such individual to maintain COBRA continuation coverage
under the Health Care Spending Account Plan.
(b) Any available COBRA continuation coverage will be offered to such a
Participant (or his or her Spouse or Dependent child) only for the remainder of the Plan
Year in which the qualifying event occurred.
(c) In most cases, this means that the Participant would continue to contribute
to his or her Health Care Spending Account not by salary reductions, but by after-tax
payments. The after-tax cost for COBRA continuation of coverage would be 102% of
the level of coverage in effect prior to COBRA.
(d) If the Participant elects COBRA coverage, he or she could continue to be
reimbursed for medical expenses from his or her Health Care Spending Account for the
remainder of that Plan Year. The advantage of electing COBRA coverage under the
Health Care Spending Account Plan is the Participant's ability to be reimbursed out of his
or her account for medical expenses incurred after the date of termination or other
qualifying event. r
33
(e) When a qualifying event occurs, the Plan Administrator will provide the
Participant with more information regarding COBRA rights, if any, including election
requirements, procedures and duration of COBRA coverage. Note: in the ,event of a
divorce, legal separation or a child's losing dependent status, the Participant or his or her
family member must notify the Plan Administrator within 60 days of such event. Failure
to do so will forfeit the Participant and his or her spouse's or dependent-child's COBRA
rights, if any.
Section 13.20 Claims Procedure. , Subject to the rules for a claim of reimbursement
under Section 13.14 above, a claimant shall follow the rules set forth in Article VIII for the
submission and appeal of a claim.
Section 13.21 Qualified Medical Child Support Orders. The Plan Administrator has
established procedures to be followed if the Health Care Spending Account Plan receives a
medical child support order that requires you to provide health care coverage for your child
under such Plan. Please contact the Employer (Attn: Human Resources) to obtain, without
charge, a copy of the Plan procedures governing Qualified Medical Child Support Orders.
Section 13.22 Restricted Purpose Health Care Spending Account. If a Participant in
the Health Care Spending Account Plan also is an "eligible individual" " who is covered under a
High Deductible Health Plan and making contributions to a Health Savings Account (as defined
in Code Section 223), then reimbursement from such Participant's Health Care Spending
Account for the Plan Year is restricted to the expenses set forth in the Adoption Agreement,
which may include:
(a) The Participant will be reimbursed from his or her Account for Eligible
Medical Expenses that are incurred only for (i) dental or vision benefits (including deductible,
co-insurance or co-payment amounts); (ii) the cost of"permitted coverage" (i.e. coverage for a
specific disease or illness or that provides a fixed amount per day or other period of
hospitalization, but not through insurance or for long-term care services); or (iii) preventive care
benefits (as defined in IRS Notice 2004-23); and
(b) The Participant will be reimbursed for other Eligible Medical Care
Expenses (including deductible, co-insurance or co-payment amounts) that he incurs only after
the date on which the Participant has met, under the High Deductible Health Plan, the minimum
annual deductible amount as specified under Code Section 223(c)(2)(A)(i).
The Plan Administrator retains sole discretion in determining whether a Participant is
eligible for reimbursement for limited purpose expenses from his or her Health Care Spending
Account in accordance with IRS guidance (including Revenue Ruling 2004-45).
Section 13.23 HIPAA Privacy and Security Laws.
(a) Introduction. To the extent that the Employer has more than 50 Eligible
Employees, or to the extent the Employer outsources administration of the Health Care Spending
L Account to a third party administrator (regardless of the number of employees), the privacy and
security laws of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA")
shall apply to such Health Care Spending Account.
34
The Health Insurance Portability and Accountability Act of 1996, as amended, and its
implementing privacy and security regulations (collectively referred to as "HIPAA") restrict the
Employer's and Plan's ability to use and disclose certain health information known as "protected
health information" ("PHI") under the Health Care Spending Account Plan. It is the Employer's
policy that the Plan and the Employer will comply with HIPAA requirements.
Throughout this Article, various terms are used repeatedly. These terms have specific
and definite meanings and generally have been capitalized throughout this Article. Whenever
capitalized terms appear, they shall have the meanings specified in HIPAA.
(b) Protected Health Information (PHI). PHI includes information that the Plan
creates or receives that relates to the past, present, or future health or medical condition of an
individual that could be used to identify the individual. Electronic PHI is PHI that is transmitted
by or maintained in electronic media (e.g. memory devices in computers,
removable/transportable digital memory medium, etc.).
(c) Use and Disclosure of PHI. The Plan can use or disclose PHI only in a manner
consistent with HIPAA, which generally is for purposes of Payment and Health Care Operations.
Payment means activities to obtain and provide reimbursement for the health care provided to an
individual, including determinations of eligibility and coverage under the Plan, and other health
care utilization review activities. Health Care Operations means the support functions related to
treatment and payment, such as quality assurance activities, case management, receiving and
responding to patient complaints, physician reviews, compliance programs, audits, business
planning,development, management, and administrative activities.
(1) ,PHI also may be used or disclosed as specifically permitted by HIPAA, including
the following examples:
(2) The Plan may share PHI with government or law enforcement agencies when
required to do so or when required to in a court or other legal proceeding;
(3) The Plan may share PHI to obey Workers' Compensation laws; and
(4) The Plan may share PHI with the individual if the individual requests access to
PHI as described below.
(5) In other situations, the Plan will ask for the individual's written authorization
before using or disclosing PHI.
(d) Plan Sponsor Certification. The Plan may disclose PHI to the Plan Sponsor
(including certain members of the Plan Sponsor's workforce) only to perform administrative
functions on behalf of the Plan in a manner consistent with HIPAA requirements. In this regard,
the Plan Sponsor, by executing this plan document, hereby provides certification to the Plan that
the Plan Sponsor will appropriately safeguard and limit the use and disclosure of PHI that it
receives from the Plan only to perform plan administration functions. Specifically, the Plan
Sponsor agrees to:
35
(1) use or further disclose PHI only as permitted by and consistent with this Plan
Document and HIPAA;
(2) ensure that any agents, including a subcontractor, to whom it provides PHI
received from the Plan agree to the same restrictions and conditions that apply to Plan
Sponsor with respect to such information;
(3) not use or disclose PHI for employment related actions and decisions or in
connection with any other benefit or employee benefit plan;
(4) report to the Plan any use or disclosure of the PHI that is inconsistent with the
uses or disclosures permitted by the HIPAA Rule of which it becomes aware;
(5) make available information in accordance with the HIPAA Rules regarding
individual access to PHI;
(6) make available PHI for amendment in accordance with the HIPAA Rules;
(7) make available the information required under the HIPAA Rules to provide an
accounting of non-routine disclosures to the individual;
(8) make internal practices, books, and records relating to PHI available to the
Department of Health and Human Services for purposes of determining compliance as
required by the HIPAA Rules;
(9) if feasible, return or destroy all PHI received from the Plan that Plan Sponsor 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;
(10) ensure adequate separation between the Plan and Plan Sponsor and
(11) To the extent required by HIPAA, ensure compliance with the safeguard and
other requirements specified under 45 CFR 164.105(a) relating to hybrid entities and the
healthcare component of the Plan.
The Plan Sponsor further agrees that if it creates, receives, maintains or transmits any
electronic PHI on behalf of the Plan, 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 agree to implement reasonable and appropriate security measures to
protect the information. The Plan Sponsor will report to the appointed Security Official any
security incident of which it becomes aware and it will implement reasonable and appropriate
security measures for electronic PHI to ensure that the adequate separation provisions of
Section 12.7 are satisfied.
36
(e) Workforce of the Plan. The Plan has designated a Privacy and Security Official
-as identified in the Adoption Agreement. The Privacy and Security Official is the privacy and
security fiduciary responsible for the Plan's compliance with the HIPAA Privacy and Security
Rules. Compliance includes ensuring that appropriate administrative, physical and technical
procedures and safeguards are in place to protect PHI and to reasonably and appropriately protect
the integrity, confidentiality and availability of any electronic PHI that the Plan Sponsor creates,
receives, maintains or transmit on behalf of the Plan. This also includes ensuring that certain
members of the Employer's Workforce comply with, are trained in and appropriately handle PHI
and electronic PHI under the HIPAA Privacy and Security Rules, and understand the sanctions
for HIPAA violations.
Certain employees of the Plan Sponsor whose duties include administrative and
management functions on behalf of the Plan also are considered part of the Workforce of the
Plan and thus privacy and security fiduciaries of the Plan. Their access to PHI is limited to the
minimum necessary information needed to perform administrative functions on behalf of the
Plan, including using or disclosing summary health information for the purpose of obtaining
premium bids (including bids in connection with the placement of stop loss coverage) or making
decisions to modify, amend or terminate the Plan, or enrollment or disenrollment information
about participants. Please contact the Privacy Official for a complete listing of the designated
employees who serve as members of the workforce with access to PHI or electronic PHI.
(f) Adequate Separation between the Plan and Plan Sponsor. The Plan Sponsor
shall allow access to PHI received from the Plan only to those employees who have been
specifically designated by Plan Sponsor as employees authorized to access PHI pursuant to the
Plan's HIPAA Privacy and Security Policies and Procedures.
No other persons shall have access to PHI. These employees who have authorized access
to PHI only shall use and disclose PHI to the extent necessary to perform the plan administration
functions that Plan Sponsor performs for the Plan. These employees generally may not use or
disclose PHI for purposes of payment, operation or other administrative functions of the Plan
Sponsor's non-group health benefit plans (e.g. disability, life insurance, workers compensation,
supplemental plans, etc.) or of any other non-plan activity such as employment related decisions
without individual authorization. The Plan Sponsor will ensure that the adequate separation
between the Plan and Plan Sponsor is supported by reasonable and appropriate security measures
to the extent that the designees have access to electronic PHI.
(g) Violations of Privacy or Security Rules. If Plan Sponsor becomes aware of
violations of these HIPAA privacy or security rules, it shall arrange for the HIPAA Privacy or
Security Officer appointed by Plan Sponsor to consult with the person who has violated the
privacy or security rules with respect to his or her obligations under the privacy or security rules.
A person who violates these privacy or security rules may be subject to discipline up to and
including discharge. The Employer also shall comply with any notice requirements regarding
breach of Unsecured PHI, as set forth in the Employer's HIPAA Privacy and Security Policies
and Procedures.
(h) Individual Rights. You can learn more about these HIPAA Privacy and Security
laws or your legal rights regarding your medical information by reviewing a copy of the Plan's
37
Notice of Privacy Practice that is attached as an Appendix or by contacting the HIPAA Privacy
or Security Official.
ARTICLE XIV
HEALTH SAVINGS ACCOUNT CONTRIBUTIONS AND PARTICIPATIONThis Article
shall apply for any Plan Year during which the Employer offers a High Deductible Health Plan
(HDHP) option with a Health Savings Account (HSA) feature (the Adoption Agreement sets
forth if a HDHP-HSA is available). If you are an Eligible Individual otherwise eligible to
establish and make contributions to a HSA pursuant to Code Section 223, you may be able to
make pre-tax employee contributions through the Employer's Cafeteria Plan to the HSA that is
linked to the Employer's HDHP and provided through the trustee or custodian chosen by the
Employer. Any pre-tax employee contributions to your HSA under the Cafeteria Plan shall
relate to your taxable year during which such contributions are deducted from your
compensation (regardless of your ability to make such contributions for a given taxable year at
any time prior to the time prescribed by (without extensions) for filing your federal income tax
return for that year). Your election to make pre-tax employee contribution to your HSA will
remain in effect until the earliest of the date on which you change your pre-tax contribution
election; you are no longer eligible for participation in the Employer's HDHP option; or you are
no longer receiving a paycheck from the Employer.
In the sole discretion of the Employer, an employer contribution may be made to your HSA,
which also may be made through the Employer's Cafeteria Plan. The amount and terms of such
employer contribution shall be governed by the Benefits Guide, but employer contributions to
your HSA shall cease after the date you no longer are receiving a paycheck from the Employer.
While the HDHP option is an ERISA-governed plan sponsored by the Employer, any Health
Savings Account linked to the Employer's HDHP option or independently established by you or
your Eligible Dependent is not sponsored or maintained by the Employer and is not subject to or
governed by ERISA. You are the owner of such HSA and solely responsible for(i) determining
if you are an Eligible Individual who can establish, and make or receive contributions to an HSA,
(ii) determining the amount of contributions that may be made or received under your HSA each
taxable year, (iii) requesting distributions and determining if they are qualifying or non-
qualifying expenses under the HSA; and (iv) all tax consequences arising under or connection
with your HSA.
Please review the restrictions set forth above in this Article regarding coordination of the Health
Care Spending Account Plan with Health Savings Accounts. The Employer also has prepared
"Frequently Asked Questions About HDHP-HSA Option." Please review this FAQ carefully to
fully understand how the HSA works and your tax considerations.
38
APPENDIX
NOTICE OF PRIVACY PRACTICES FOR GROUP HEALTH PLANS
This Notice Describes How Medical Information About You May Be Used And
Disclosed And How You Can Get Access To This Information. Please Review It
Carefully.
Introduction
The Employer sponsors and maintains the group health plans identified in the Adoption Agreement
(collectively referred to as the "Plan") The Privacy Rules under the Health Insurance Portability and
Accountability Act ("HIPAA") generally restrict the ability to use and disclose certain health or medical
information about you that is created or received by the Plan with respect to these health care benefit
programs or by the Employer in connection with such health care benefit programs
The Plan is required to provide this Notice of Privacy Practice (the "Notice") to you pursuant to HIPAA
This Notice describes how medical information about you may be used or disclosed by the Plan or by
others that assist in the administration of Plan claims This Notice also describes your legal rights
regarding your medical information held by the Plan References to the Plan throughout this Notice
taking certain actions also shall mean the Employer, as plan sponsor of the Plan
Contact Person
If you have any questions about this Notice, please contact the HIPAA Officer identified in the Adoption
Agreement.
Protected Health Information
The HIPAA Privacy Rules protect only certain medical information known as"protected health information
("PHI") Generally, PHI is individually identifiable health information, including demographic information,
collected from you or received by a health care provider, a health care clearinghouse, a health plan or
your employer on behalf of a group health plan, that relates to
• your past, present or future physical or mental health or condition,
• the provision of health care to you, or
• the past, present or future payment for the provision of health care to you
Effective Date
This Notice has been amended and restated on several occasions, most recently effective September 23,
2013
Our Pledge and Responsibilities Regarding PHI
We understand that PHI about you and your health is personal and the Plan is committed to protecting
PHI The Plan is required by law to satisfy the following responsibilities with respect to any PHI created or
received by the Plan
• Maintain the privacy of your PHI,
• - Provide you with certain rights with respect to your PHI,
• Give you this Notice of the Plan's legal duties and privacy practices with respect to your
PHI, and
• Follow the terms of the Notice that is currently in effect
How the Plan May Use and Disclose Medical Information About You
Under law, the Plan may use or disclose your PHI under certain circumstances without your permission
The following categories describe different ways that the Plan may use and disclose PHI For each
39
category of uses or disclosures we will explain what we mean and present some examples Not every
use or disclosure in a category is listed However, all of the ways the Plan is permitted to use and
disclose PHI will fall within one of the categories
For Treatment. The Plan may use or disclose your PHI to facilitate medical treatment or services by
providers The Plan may disclose PHI about you to providers, including doctors, nurses, technicians,
medical students or other hospital personnel, who are involved in taking care of you For example, the
Plan might disclose information about your prior prescriptions to a pharmacist to determine if prior
prescriptions contra indicate a pending prescription
For Payment The Plan may use and disclose PHI about you to determine eligibility for Plan benefits, to
facilitate payment for the treatment and services you receive from health care providers, to determine
benefit responsibility under the Plan, or to coordinate Plan coverage For example,the Plan may tell your
health care provider about your medical history to determine whether a particular treatment is
experimental, investigational or medically necessary or to determine whether the Plan will cover the
treatment The Plan also may share PHI with a utilization review or precertification service provider
Likewise, the Plan may share PHI with another entity to assist with the adjudication or subrogation of
health claims or to another health plan to coordinate benefit payments
The Plan may release PHI about you that is directly relevant to the involvement of a family member, close
personal friend or other person in your medical care or payment for your medical care, unless you tell us
not to release such information to such person
For Health Care Operations. The Plan may use and disclose PHI about you for other Plan operations
These uses and disclosures are necessary to run the Plan For example, the Plan may use PHI in
connection with conducting quality assessment and improvement activities, underwriting, premium rating,
and other activities relating to Plan coverage, submitting claims for stop-loss (or excess loss) coverage,
conducting or arranging for medical review, legal services, audit services, and fraud and abuse detection
programs, business planning and development such as cost management, and business management
and general Plan administrative activities
However,the Plan may not use or disclose any PHI that is genetic information for underwriting purposes
To Business Associates The Plan may contract with individuals or entities known as Business
Associates to perform various functions or to provide certain types of services on the Plan's behalf In
order to perform these functions or provide these services, Business Associates will receive, create,
maintain, use and/or disclose your PHI, but only if they agree in writing with the Plan to implement
appropriate safeguards regarding your PHI For example, the Plan may disclose your PHI to a Business
Associate to administer claims or provide support services, such as utilization, management, pharmacy
benefit management or subrogation, but only after the Business Associate enters into a Business
Associate Agreement with the Plan
As Required by Law. The Plan will disclose PHI about you when required to do so by federal, state or
local law For example, the Plan may disclose PHI when required by a court order in a litigation
proceeding, such as a malpractice action
To Avert a Serious Threat to Health or Safety. The Plan may use and disclose PHI about you when
necessary to prevent a serious threat to your health and safety or the health and safety of the public or
another person Any disclosure, however, would only be to someone able to help prevent the threat For
example,the Plan may disclose PHI about you in a proceeding regarding the licensure of a physician
To Plan Sponsor(i.e. the Employer). For the purpose of administering the Plan, PHI may be disclosed
to certain employees of the Employer However, those employees will use or disclose that PHI only as
necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have
authorized further uses or disclosures Your PHI cannot be used for employment related purposes
without your specific, written authorization Information also may be disclosed to another health plan
maintained by the Employer for purposes of facilitating claim payments under that health plan
40
Special Situations
In addition to the above, the following categories describe other possible ways that the Plan may use and
disclose your PHI For each category of uses or disclosures, we will explain what we mean and present
some examples Not every use or disclosure in a category will be listed However, all of the ways we are
permitted to use and disclose information will fall within one of the categories
Organ and Tissue Donation. If you are an organ donor, the Plan may release PHI to organizations that
handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as
necessary to facilitate organ or tissue donation and transplantation
Military and Veterans. If you are a member of the armed forces, the Plan may release PHI about you as
required by military command authorities The Plan also may release PHI about foreign military
personnel to the appropriate foreign military authority
Workers' Compensation. The Plan may release PHI about you for worker's compensation or similar
programs These programs provide benefits for work-related injuries or illness
Public Health Risks. The Plan may disclose PHI about you for public health activities The activities
generally include the following
• To prevent or control disease, injury or disability,
• To report births and deaths,
• To report child abuse or neglect,
• To report reactions to medications or problems with products,
• To notify people of recalls of products they may be using,
• To notify a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition,
• To notify the appropriate government authority if we believe a patient has been the victim
of abuse, neglect or domestic violence The Plan will only make this disclosure if you
agree or when required or authorized by law
Health Oversight Activities. The Plan may disclose PHI to a health oversight agency for activities
authorized by law These oversight activities include, for example, audits, investigations, inspections, and
licensure These activities are necessary for the government to monitor the health care system,
government programs, and compliance with civil rights laws
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, the Plan may disclose PHI about
you in response to a court or administrative order The Plan also may disclose PHI about you in
response to a subpoena, discovery request, or other lawful process by someone else involved in the
dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting
the information requested
Law Enforcement. The Plan may release PHI if asked to do so by a law enforcement official
• In response to a court order, subpoena,warrant, summons or similar process,
• To identify or locate a suspect, fugitive, material witness, or missing person,
• About the victim of a crime if, under certain limited circumstances, we are unable to
obtain the person's agreement,
• About a death we believe may be the result of criminal conduct, and
• About criminal conduct
Coroners, Medical Examiners and Funeral Directors. The Plan may release PHI to a coroner or
medical examiner This may be necessary, for example, to identify a deceased person or determine the
cause of death The Plan may also release medical information about patients to funeral directors, as
necessary to carry out their duties
41
National Security and Intelligence Activities. The Plan may release PHI about you to authorized
federal officials for intelligence, counterintelligence, and other national security activities authorized by
law
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement
official,the Plan may release PHI about you to the correctional institution or law enforcement official This
release would be necessary (1) for the institution to provide you with health care, (2) to protect your
health and safety or the health and safety of others, or (3) for the safety and security of the correctional
institution
Required Disclosures
The following is a description of disclosures of your PHI the Plan is required to make
9 Y q
Government Audits The Plan is required to disclose your PHI to the Secretary of the United States
Department of Health and Human Services when the Secretary is investigating or determining the Plan's
compliance with the HIPAA Privacy rule
Disclosures to You When you request, the Plan is required to disclose to you the portion of your PHI
that contains medical records, billing records, and any other records used to make decisions regarding
your health care benefits The Plan also is required, when requested, to provide you with an accounting
of most disclosures of your PHI where the disclosure was for reasons other than for payment, treatment
'or health care operations, and where the PHI was not disclosed pursuant to your individual authorization
Other Disclosures
Personal Representatives The Plan will disclose your PHI to individuals authorized by you, or to an
individual designated as your personal representative, attorney in fact, etc , as long as you provide the
Plan with a written notice/authorization and any supporting documents (e g durable power of health care
attorney) Note that under HIPAA privacy rule, the Plan does not have to disclose PHI to a personal
representative if we have a reasonable belief that
• you have been, or may be, subjected to domestic violence, abuse or neglect by such
person,
• treating such person as your personal representative could endanger you, or
• in the exercise or professional judgment, it is not in your best interest to treat the person
as your personal representative
Spouses and Other Family Members. With only limited exceptions, the Plan will send all mail to the
employee This includes mail relating to the employee's spouse and other family members who are
covered under the Plan, and includes mail with information on the use of Plan benefits by the employee's
spouse and other family members and information on the denial of any Plan benefits to the employee's
spouse and other family members If a person covered under the Plan has requested Restrictions or
Confidential Communications (see below"Your Rights"), and the Plan has agreed to the request, the Plan
will send mail as provided by the request for Restrictions or Confidential Communications
Authorizations Other uses or disclosures of your PHI not described above will only be made with your
written authorization Additionally, most uses and disclosures of psychotherapy notes (where
appropriate), uses and disclosures of PHI for marketing purposes and disclosures that constitute a sale of
PHI require your authorization You may revoke written authorization at any time, as long as the
revocation is in writing Once we receive your written revocation, it will only be effective for future uses
and disclosures It will not be effective for any information that may have been used or disclosed in
reliance upon the written authorization and prior to receiving your written revocation
Your Rights
You have the following rights regarding PHI that the Plan maintains about you
Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make
decisions about your Plan benefits To inspect and copy PHI that may be used to make decisions about
you, you must submit your request in writing to the Contact Person listed above If you request a copy of
42
the information, you may be charged a reasonable fee for the costs of copying, mailing or other supplies
associated with your request
You generally shall have the right, upon written request, to obtain from the Plan an electronic copy of PHI
that is maintained electronically in one or more Designated Record Sets, and, if you choose, to direct the
Plan to transmit such copy to an entity or person designated by you, provided that any such choice is
clear, conspicuous and specific The Plan will provide the requested PHI in the format requested by you,
if it is readily producible in such form or format, or, if not, in a readable hard copy form or such other form
or format as agreed to by the Plan and you You also may direct the Plan, in a written statement signed
by you, to transmit a paper or electronic copy of your PHI to an entity or person designated by you,
provided that any such choice is clear, conspicuous and specific (e g clearly identifies the designated
person and where to send a copy of your PHI)
' The Plan may deny your request to inspect and copy PHI under very limited circumstances If you are
denied access to PHI, you may request that the denial be reviewed by submitting a written request to the
Contact Person listed above
Right to Amend. If you believe that PHI the Plan has about you is incorrect or incomplete, you may ask
us to amend the information You have the right to request an amendment for as long as the information
is kept by or for the Plan
To request an amendment, your request must be made in writing and submitted to the Contact Person
listed above In addition, you must provide the reason that supports your request
The Plan may deny your request for an amendment if it is not in writing or does not include a reason to
support the request In addition, the Plan may deny your request if you ask us to amend information that
Is not part of the PHI kept by or for the Plan,
• P P Y
• Was not created by the Plan, unless the person or entity that created the information is
no longer available to make the amendment,
• Is not part of the information which ou would be permitted to inspect and co
Y P copy, or
• Is already accurate and complete
If the Plan denies your request, you have the right to file a statement of disagreement with the Plan and
any future disclosure of the disputed information will include your statement File this statement with the
Contact Person listed above
Right to an Accounting of Disclosures. You have the right to request an "accounting" of certain
disclosures of your PHI The accounting generally will not include (1) disclosures made for purposes,of
treatment, payment or health care operations, (2) disclosures made to you, (3) disclosures made
pursuant to your authorization, (4) disclosures made to friends or family in your presence or because of
an emergency, (5) disclosures for national security purposes, and (6) disclosures incidental to otherwise
permissible disclosures However, to the extent required under HITECH, certain disclosures to carry out
treatment, payment or health care operations which are maintained in electronic health records may need
to be included in the accounting of disclosures beginning on the effective date set forth in HITECH
(please call the Contact Person if you would like additional information regarding such accounting rights
under the applicable guidance)
To request this list of accounting of disclosures, you must submit your requests in writing, to the Contact
Person listed above Your request must state a time period which may not be longer than six years and
may not include dates before April 14, 2004 Your request should indicate in what form you want the list
(for example, paper or electronic) The first list you request within a 12-month period will be free For
additional lists, the Plan may charge you for the costs of providing the list The Plan will notify you of the
cost involved and you may choose to withdraw or modify your request at that time before any costs are
incurred
Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI the
Plan uses or discloses about you for treatment, payment or health care operations You also have the
right to request a limit on the PHI the Plan discloses about you to someone who is involved in your care
43
or the payment for your care, such as a family member or friend For example, you could ask that we not
use or disclose information about a surgery you had
The Plan generally is not required to agree to your request Note that you have the right to request that
your health care provider not disclose certain PHI to this Plan in the event that the PHI pertains solely to
health care items or services that you pay for out of pocket and in full
To request restrictions, you must make your request in writing to the Contact Person listed above In your
request, you must tell us (1) what information you want to limit, (2) whether you want to limit our use,
disclosure or both, and (3)to whom you want the limits to apply,for example, disclosures to your spouse
The Plan may terminate a restriction that it previously agreed to with respect to your PHI provided that the
Plan informs you that it is terminating its agreement to the restriction and such termination is not effective
for PHI that is described in the first two paragraphs of this section and only effective with respect to PHI
created or received after you have been informed of such termination
Right to Request Confidential Communications You have the right to request that the Plan
communicate with you about medical matters in a certain way or at a certain location For example, you
can ask that we only contact you at work or by mail
To request confidential communications, you must make your request in writing to the Contact Person
listed above The Plan will not ask you the reason for your request The Plan will accommodate all
reasonable requests if you clearly provide information that the disclosure of all or part of your PHI could
endanger you Your request must specify how or where you wish to be contacted
Right to be Notified of a Breach. You have the right to be notified in the event that we discover, or a
Business Associate discovers, a breach of unsecured PHI
Right to a Paper Copy of This Notice You have the right to a paper copy of this Notice You may ask
the Plan to give you a copy of this Notice at any time Even if you have agreed to receive this Notice
electronically, you are still entitled to a paper copy of this Notice
To obtain a paper copy of this Notice, contact the Contact Person listed above
Changes to This Notice
The Plan reserves the right to change the terms of this Notice and to make new provisions regarding your
protected health information that the Plan maintains, as allowed or required by law The Plan reserves
the right to make the revised or changed Notice effective for PHI the Plan already has about you as well
as any information the Plan receives in the future If the Plan makes any material change to this Notice,
you will be provided with a copy of a revised Notice of Privacy Practices either by mail or electronically
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Plan or with the
Office of Civil Rights Complaints to the Plan must be submitted in writing to the Contact Person listed
above
A complaint to the Office of Civil Rights should be sent to Office for Civil Rights, U S Department of
Health & Human Services, 233 N Michigan Ave - Suite 240, Chicago, IL 60601, (312) 886-2359, (312)
353-5693 (TDD), (312) 886-1807 (fax) You also may visit OCR's website at
http//www hhs gov/ocr/privacy/hipaa/complaints/for more information
You will not be penalized, or in any other way retaliated against, for filing a complaint with the Plan or the
Office of Civil Rights
44