Resolution No. 2023-053RCITY OF CLERMONT
C� RESOLUTION NO.2023-053R
Chose ach-p —
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF
CLERMONT, LAKE COUNTY, FLORIDA AMENDING AND
RESTATING THE SECTION 125 CAFETERIA PLAN FOR THE CITY OF
CLERMONT; PROVIDING FOR CONFLICT, SEVERABILITY,
ADMINISTRATIVE CORRECTION OF SCRIVENERS ERROR,
PUBLICATION AND AN EFFECTIVE DATE.
WHEREAS, the City Council of the City of Clermont deems it advisable and in the best
interest of the City, to amend and restate the Section 125 Cafeteria Plan;
NOW, THEREFORE, BE IT RESOLVED, that the Section 125 Cafeteria Plan is
hereby amended as follows:
SECTION 1:
The City Council does hereby adopt the Section 125 Cafeteria Plan as set forth in Attachment A,
attached hereto and incorporated herein.
SECTION 2: CONFLICT
All Resolutions or parts of resolutions in conflict with any of the provisions of this Resolution
are hereby repealed.
SECTION 3: SEVERABILITY
If any portion of this Resolution is declared invalid, the invalidated portion shall be severed from
the remainder of the Resolution, and the remainder of the Resolution shall continue in full force
and effect as if enacted without the invalidated portion, except in cases where such continued
validity of the remainder would clearly and without doubt contradict or frustrate the intent of the
Resolution as a whole.
SECTION 4: ADMINISTRATIVE CORRECTION
This Resolution may be re -numbered or re -lettered, and/or corrected for typographical and/or
scrivener's errors which do not affect the intent of said resolution, as authorized by the City
Manager or designee, without need of public hearing, by filing a corrected copy of same with the
City Clerk.
SECTION 5: PUBLICATION AND EFFECTIVE DATE
This Resolution shall take effect immediately upon its adoption.
CITY OF CLERMONT
C� RESOLUTION NO.2023-053R
Chute dCh—p—
DONE AND RESOLVED by the City Council of the City of Clermont, Lake County,
Florida this 12th day of December, 2023.
CITY OF CLERMONT
Tim M or
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ATTEST: 7�'''`
Tracy Ackroyd Hove, MMC
City Clerk
Approv form and legality:
6niNian&ns, 1ty Attorney
Attachment A
Plan Document and Summary Plan Description
for the City of Clermont
Section 125 Cafeteria Plan with Flexible
Spending Account
• Medical and Prescription Drug Benefits
• Dental Benefits
• Vision Benefits
• Health Care Flexible Spending Account ("FSA")
• Voluntary Life and AD&D
Restated Effective Date: 01 /01 /2024
Introduction
The City of Clermont (the "Employer" or "City') is pleased to offer you this benefit plan. It is a
valuable and important part of your overall compensation package.
This booklet describes your cafeteria plan and health care flexible spending account and
serves as the Summary Plan Description (SPD) and Plan document for the City of Clermont
Cafeteria Plan with Flexible Spending Account ("the Plan').
Note: A separate SPD has been issued that describes information for the following Benefit
Program(s):
MEDICAL SUMMARY PLAN DESCRIPTION
FSA SUMMARY PLAN DESCRIPTION
DENTAL SUMMARY PLAN DESCRIPTION
VISION SUMMARY PLAN DESCRIPTION
VOLUNTARY LIFE AND AD&D
This document sets forth the provisions of the Plan that provide for payment or
reimbursement of Plan benefits.
This document contains information on the standard provisions and administration of the
Plan. From time to time, applicable law may require the City to temporarily make adjustments
to how it administers the Plan due to unforeseen circumstances, such as public health
emergencies, natural disasters or other emergency situations. In those situations, the
Employer intends to comply with all applicable legal requirements, including deadline
extensions, maintenance to benefits and other changes to coverage. Unless they are
addressed in specific plan amendments, any such changes required by law are incorporated
herein by reference to the extent necessary for the Plan to be in compliance.
We encourage you to read this booklet and become familiar with your benefits. You may also
wish to share this information with your enrolled family members.
This Plan and SPD replace the previous cafeteria plan booklets you may have in your files.
Be sure to keep this booklet in a safe and convenient place for future reference.
Table of Contents
Introduction..................................................................................................................................... ii
PlanOverview.................................................................................................................................
1
YourEligibility ...............................................................................................................................
1
EligibleDependents.....................................................................................................................
2
WhenCoverage Begins...............................................................................................................
2
Enrollingfor Coverage.................................................................................................................
2
NewHire Enrollment...............................................................................................................
2
AnnualOpen Enrollment.........................................................................................................
2
Code Section 125 Status of Plan.................................................................................................
3
Effect of Tax Regulations on this Plan.........................................................................................
3
PermittedElection Changes........................................................................................................
3
WhenCoverage Ends.................................................................................................................
5
Cancellationof Coverage............................................................................................................
5
Rescission of Coverage...............................................................................................................
5
CoverageWhile Not at Work.......................................................................................................
6
If You Take a Leave of Absence(FMLA)......................................................................................
6
Your Flexible Spending Account Benefits...................................................................................
7
Your Health Care Flexible Spending Account.............................................................................
7
HealthCare Expense Account....................................................................................................
7
Maximum Annual Amount............................................................................................................
7
EligibleMedical Expenses...........................................................................................................
7
Payment of Health Care Expense Account Claims.....................................................................
8
Continuation Coverage Upon Termination..................................................................................
8
Coordinationwith HRA................................................................................................................
8
Submitting a Claim for Reimbursement.......................................................................................
8
Claims Submission and Cut-Off..................................................................................................
9
Forfeitures....................................................................................................................................
9
Administrative Information..........................................................................................................10
Plan Sponsor and Administrator................................................................................................
10
PlanYear...................................................................................................................................
10
Typeof Plan................................................................................................................................11
IdentificationNumbers................................................................................................................11
Plan Funding and Type of Administration...................................................................................11
ClaimsAdministrators.................................................................................................................11
Agent for Service of Legal Process............................................................................................11
No Obligation to Continue Employment....................................................................................
12
Severability................................................................................................................................
12
Paymentof Benefits...................................................................................................................
12
Paymentof Benefits to Others...................................................................................................
12
Expenses...................................................................................................................................
12
Fraud..........................................................................................................................................
12
Indemnity...................................................................................................................................
12
Compliance with State and Federal Mandates..........................................................................
13
Refund of Premium Contributions.............................................................................................
13
No Guarantee of Tax Consequences........................................................................................
13
Non-discrimination.....................................................................................................................
13
Futureof the Plan......................................................................................................................
14
Claims and Appeal Procedure....................................................................................................
15
Time Frames for Processing Health -Related Claims................................................................
15
Time Frames for Processing All Other Claims..........................................................................
16
ExhaustionRequired.................................................................................................................
16
Your HIPAAICOBRA Rights.........................................................................................................17
Health Insurance Portability and Accountability Act(HIPAA)....................................................
17
Continuing Your Health Care FSA through COBRA..................................................................
20
Definitions.....................................................................................................................................
22
Adoptionof the Plan....................................................................................................................
22
AppendixA....................................................................................................................................
25
Plan Overview
The Plan provides benefits to eligible employees and their dependents through qualified
Benefit Programs. These Benefit Programs may be summarized in an insurance contract, a
Summary Plan Description ("SPD"), and/or other governing documents. You will receive a
separate SPD, where required, that describes the features of each Benefit Program included
under each Benefit Program and this Plan.
Your Eligibility
You are eligible for benefits if you are:
• A full-time active employee normally scheduled to work a minimum of 30 hours per
week;
• On the regular payroll of the City; and
• In a class of employees eligible for coverage.
Unless otherwise communicated to you in writing by the City, the following individuals are not
eligible for benefits: part-time employees, employees of a temporary or staffing firm, payroll
agency or leasing organization, part-time persons hired on a limited duration, seasonal or
temporary basis, independent contractors and other individuals who are not on the City
payroll, as determined by the City, without regard to any court or agency decision
determining common-law employment status.
Eligible Dependents
The definition of eligible dependents and other provisions, such as whether you may enroll
your eligible dependents in a Benefit Program, are defined in the governing documents for
each Benefit Program.
Unless otherwise defined by the insurance certificate for a Benefit Program, your eligible
dependents include:
• your legal spouse;
• your child under age 26 regardless of financial dependency, residency with you,
marital status, or student status;
• your unmarried child of any age who is principally supported by you and who is not
capable of self-support due to a physical or mental disability that began while the
child was covered by the Plan;
• your unmarried child of any age who is not capable of self-support due to a physical
or mental disability that occurred before age 26, whose disability is continuous, and
who is principally supported by you.
For purposes of the Plan, your child includes:
• your biological child;
• your legally adopted child (including any child lawfully placed for adoption with you);
• your stepchild;
• a foster child who has been placed with you by an authorized placement agency or by
judgment decree or other court order;
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• a grandchild for whom you are in a parent -child relationship who resides with you;
• a child for whom you are the court -appointed legal guardian;
• an eligible child for whom you are required to provide coverage under the terms of a
Qualified Medical Child Support Order (QMCSO) or a National Medical Support
Notice (NMSN).
If you have any questions regarding dependent coverage under a Benefit Program, check
with the Insurer or Claims Administrator for that program.
When Coverage Begins
On or before the time you become eligible to participate in the Plan, you will be provided
information for electronic enrollment, which provides your elections to be pre -taxed. Your
election will not be effective unless you complete the electronic election that authorizes your
pre-tax deductions to your salary. Your election will then continue until you change or
discontinue it or become ineligible to participate in the Plan or a Benefit Program.
Unless otherwise stated in the governing documents for a Benefit Program, your coverage
begins the first of the month following 60 days of employment. Coverage for your eligible
dependents begins on the same day as your initial eligibility provided you enroll your
dependents within 30 days of eligibility.
For the Health Care Flexible Spending Account, you are eligible for coverage the plan year
following One Year of employment and after you meet all eligibility requirements.
If you terminate employment and are subsequently rehired within 30 days, coverage under
the Plan will begin as of your rehired date. If you are rehired within 13 consecutive weeks
and were enrolled in medical coverage, that coverage will be reinstated first of the month
following reinstatement.
Enrolling for Coverage
New Hire Enrollment
As a newly eligible employee, you will receive enrollment information when you first become
eligible for benefits. To enroll in coverage, you will need to make your coverage elections by
the deadline shown in your enrollment materials. When you enroll in the Plan, you authorize
the City to deduct any salary reduction contributions from your pay.
The elections you make will remain in effect until the next December 31, unless you have a
qualifying change in status. After your initial enrollment, you will enroll during the designated
annual open enrollment period. If you do not enroll for coverage when initially eligible, you
will have no coverage for the remainder of the plan year.
Annual Open Enrollment
Each year during a designated open enrollment period, you will be given an opportunity to
make your elections for the upcoming year. Your enrollment materials and online enrollment
will provide your share of the premium cost, as well as any default coverage you will be
deemed to have elected if you do not make an election by the specified deadline. You must
make a new election each year to participate in the Health Care Flexible Spending Accounts.
Current year elections will not automatically continue in the new Plan year. The elections you
2
make will take effect on the following January 1 and stay in effect through December 31,
unless you have a qualifying change in status.
Code Section 125 Status of Plan
This Plan is designed and administered in accordance with Section 125 of the Internal
Revenue Code and underlying regulations. This enables you to pay your share of premiums
for certain Benefit Programs on a pre-tax basis, as permitted by the Employer. Pre-tax dollars
come out of your pay before federal income and Social Security taxes are withheld (and, in
most states, before state taxes are withheld). This gives your contributions a special tax
advantage and lowers the actual cost of participating in the Plan to you. Neither the Employer
nor any fiduciary under the Plan will in any way be liable for any taxes or other liability
incurred by you by virtue of your participation in the Plan.
Because of this favorable tax -treatment, there are certain restrictions on when you can make
changes to your elections. Generally, your elections stay in effect for the Plan Year (or other
12-month period of coverage for an insured benefit, as designated in your enrollment
materials and election form) and you can make changes only during an annual open
enrollment period. However, if permitted by the Plan, you can make changes to your
elections during the Plan Year (or other 12-month coverage period) if a permitted election
change event occurs (as described below) that allows the election change, as determined by
the Plan Administrator.
Effect of Tax Regulations on the Health Care Flexible Spending Account Plan
This Plan is designed and administered in accordance with Sections 125 of the Internal
Revenue Code. These code sections enable you to pay your share of the cost for coverage
on a pre-tax basis. Neither the City nor any fiduciary under the Plan will in any way be liable
for any taxes or other liability incurred by you by virtue of your participation in the Plan.
Because of this favorable tax -treatment, there are certain restrictions on when you can make
changes to your elections. Generally, your elections stay in effect for the Plan Year and you
can make changes only during each annual open enrollment. However, at any time
throughout the year, you can make changes to your coverage within 30 days of the date you
have a qualifying change in status as described below.
Permitted Election Change Events
The elections you make under the Plan are generally irrevocable during the Plan Year (or
other 12-month coverage period that applies to a Benefit Program, as indicated in your
enrollment and election materials). This means, for example, that once you have elected how
much pre-tax income you will use to pay for the Plan's Benefit Programs, you are locked into
that election until the next annual enrollment period. However, there are certain limited
situations that allow you to change your Plan elections outside of the annual enrollment
period, depending on the Plan's eligibility rules for a Benefit Program. You may change your
elections if a "permitted election change event" occurs and you make an election change that
is consistent with the event, as determined by the Plan Administrator.
This Plan allows participants to change their elections to extent permitted by applicable law
and approved by the Plan Administrator. Depending on the Plan's eligibility rules for a Benefit
Program, a "permitted election change event" that may allow you to change your election
includes the following events:
3
• a change in your legal marital status, including marriage, divorce, death of spouse,
legal separation or annulment
• a change in the number of dependents, including birth, adoption, placement for
adoption or death of a dependent
• a change in employment status of the you, your spouse, or dependent, including a
termination or commencement of employment; a strike or lockout; a commencement
of or return from an unpaid leave of absence that affects eligibility
• a change in a dependent child's eligibility
• a change in the residency for you, your spouse or dependent that would impact
eligibility (for example, moving out of a plan's coverage area)
• the cost of a Benefit Program significantly changes
• coverage under a Benefit Program is significantly curtailed or ceases
• a new Benefit Program or other coverage option is added or coverage under an
existing Benefit Program is significantly improved
• your spouse's or dependent's plan has a different enrollment period and you need to
make a change to account for that other coverage
• you, your spouse or your dependent loses group coverage sponsored by a
governmental or educational institution
• your change corresponds with a HIPAA special enrollment right (described above)
• you, a spouse or dependent is eligible for COBRA continuation coverage under the
Plan (if applicable) and you need to increase your payments for the coverage
• a court order, such as a QMCSO or NMSN, mandates coverage for an eligible
dependent child
• you, a spouse or a dependent enrolls in Medicare or Medicaid
• you take an FMLA leave (if applicable)
• a change in your employment status to less than 30 hours of service per week on
average even if the reduction does not result in loss of Plan eligibility
• eligibility for a special enrollment period to enroll in a qualified health plan (QHP)
through the Marketplace or seeking to enroll in a QHP during the Marketplace's
annual open enrollment period
• any other election change event recognized by the IRS and permitted by the Plan
Administrator
Also, if the cost of a Benefit Program changes by an insignificant amount during a coverage
period, the Plan Administrator may automatically make a corresponding change to your
election.
Additionally, your Health Care Flexible Spending Account election(s) may be modified
downward during the plan year if you are a Key Employee or Highly Compensated Individual
(as defined by the Internal Revenue Code) if necessary, to prevent the Plan from becoming
discriminatory. If you experience a change in certain family or employment circumstances,
you can change your coverage. Changes must be consistent with status changes as
described above.
2
You should report a status change to the Plan Administrator as soon as possible, but no later
than 30 days after the event occurs. Contact the Plan Administrator if you have questions
about when you can change your elections.
Keep in mind that certain mid -year election change events do not apply to health Flexible
Spending Accounts (FSAs), such as cost or coverage changes. Contact the Plan
Administrator if you have questions about when you can change your elections.
When Coverage Ends
Except as otherwise provided in the insurance certificate, your coverage under coverage
under a Benefit Program ends on the last day of the month in which your employment
terminates or upon your death, unless benefits are extended, such as when you take an
approved leave of absence.
Coverage for your covered dependents ends on the date your coverage ends, or, if earlier, on
the last day of the month in which your dependent is no longer eligible for coverage under
the Plan.
Coverage will also end for you and your covered dependents as of the date the Employer
terminates this Plan or, if earlier, the effective date you request coverage to be terminated for
you and/or your covered dependent.
If your coverage under the Health Care Flexible Spending Account ends due to a COBRA
qualifying event, you will be given the opportunity to continue your coverage the same
coverage you had in effect the day before the qualifying event on a self -pay basis. However,
you will be eligible for COBRA Continuation Coverage only if you have a positive Health Care
Expense Account balance at the time of the COBRA qualifying event (taking into account all
claims submitted by you before the date of the qualifying event). If COBRA is elected, it will
be available only for the remainder of the Plan Year (and any extended period) in which the
qualifying event occurs, and coverage will cease at the end of the Plan Year. Coverage will
not be continued for the next Plan Year.
Cancellation of Coverage
If you fail to pay any required premium for coverage under a Benefit Program, coverage for
you and your covered dependents will be canceled for that Benefit Program and no claims
incurred after the effective date of cancellation will be paid.
Rescission of Coverage
Coverage under the Plan may be rescinded (canceled retroactively) if you or a covered
dependent performs an act, practice or omission that constitutes fraud, or you make an
intentional misrepresentation of material fact as prohibited by the terms of the Plan. A
rescission of coverage is an adverse benefit determination that you may dispute under the
Plan's claims and appeals procedures. If your coverage is being rescinded due to fraud or
intentional misrepresentation of material fact, you will receive at least 30 days' advance
written notice of the rescission. This notice will outline your appeal rights under the Plan.
Benefits under the Plan that qualify as "excepted benefits" under HIPAA are not subject to
these restrictions on when coverage may be rescinded. Some types of retroactive
terminations of coverage are permissible even when fraud or intentional misrepresentation
5
are not involved. Coverage may be retroactively terminated for failure to timely pay required
premiums or contributions as required by the Plan.
Also, coverage may be retroactively terminated to the date of your divorce if you fail to notify
the Plan of your divorce and you continue to cover your ex -spouse under the Plan. Coverage
will be canceled prospectively for errors in coverage or if no fraud or intentional
misrepresentation was made by you.
The Plan reserves the right to recover from you and/or your covered dependents any benefits
paid as a result of the wrongful activity that are in excess of the contributions paid. In the
event the Plan terminates or rescinds coverage for gross misconduct on your behalf,
continuation coverage under COBRA may be denied to you.
Coverage While Not at Work
In certain situations, coverage may continue for you and your dependents when you are not
at work, so long as you continue to pay your share of the cost. If you take an unpaid leave of
absence, you will need to make payment arrangements prior to the start of your leave.
Generally, your payments will be made on an after-tax basis, unless you are on paid leave, in
which case your premium payments will continue to be deducted on a pre-tax basis. You
should discuss with Human Resources or your supervisor what options are available for
paying your share of costs while you are absent from work.
If You Take a Leave of Absence (FMLA)
If you take an approved FMLA leave of absence, your coverage will continue for the duration
of your leave, as long as you continue to pay your share of the cost as required under the
Employer's FMLA Policy. Coverage for other benefits can be found in the insurance
certificates for the respective Benefit Programs in which you have enrolled.
C:
Your Flexible Spending Account Benefits
Your Health Care Flexible Spending Account
The Health Care Flexible Spending Account offers you a convenient way to pay for eligible,
unreimbursed health care expenses using pre-tax dollars. You "fund" your account by
directing a portion of your pay to your Flexible Spending Account.
Health Care Expense Account
If you elect to participate in the Health Care Flexible Spending Account, a Health Care
Expense Account will be established for you. This account will be maintained for
bookkeeping purposes only to keep track of contributions and reimbursements, and to
determine forfeitures. It will not be funded.
Your Health Care Expense Account will be credited with the amount you authorize to be
deducted from your pay and debited with any amount reimbursed to you for allowable
medical care expenses.
Maximum Annual Amount
The maximum annual benefit amount that you may elect under the Health Care Flexible
Spending Account for a calendar year is stated in your benefit guide.
The Plan Administrator has discretion to change the maximum and/or minimum contributions
in subsequent years.
Eligible Medical Expenses
The Health Care Flexible Spending Account will pay only claims incurred during the year that
are for eligible "Medical Expenses", as that term is defined in Code Section 213(d), but only
to the extent that the expense has not been reimbursed through insurance or otherwise.
Expenses may be submitted for you, your spouse, and your "qualified dependents", as such
term is defined in Internal Revenue Code Section 152.
The following expenses do not qualify for reimbursement:
• any expense you claim as an itemized deduction on your Federal income tax return;
• premium payments for other health care coverage, including COBRA premiums;
• weight loss programs or dietary supplements;
• hair replacement treatments;
• over-the-counter drugs or medicines unless the purchase was obtained by
prescription;
• cosmetic surgery or dentistry procedures, unless related to a congenital abnormality,
a personal injury resulting from accident or trauma, or a disfiguring disease; or
• any expense determined to be ineligible as determined by the Plan Administrator.
For a list of eligible expenses, contact the Claims Administrator. Allowable Medical Expenses
may also be found in IRS Publication 502 Medical and Dental Expenses or on the IRS Web
site at www.irs.gov.
7
Payment of Health Care Expense Account Claims
The maximum amount available to you for reimbursement will be the lesser of:
• The amount of allowable medical expenses submitted for reimbursement; or
• The total annual Salary Reduction Contribution you elected for the year, less any prior
reimbursements.
The Plan will reimburse only those allowable medical expenses which have been incurred by
you and/or your dependents that are in excess of any payments or other reimbursements
made under any other health care plan. Advance reimbursement will not be made for
projected or future expenses.
If you are participating in the Health Care Flexible Spending Account on the last day of the
Plan Year and you have an unused amount remaining in your FSA, refer to the Employee
Benefit Guide to provide you guidance on the amount that may be carried forward to be used
in the following Plan Year. Carry forward amounts from the previous plan year may:
• reduce your amount available to pay previous plan year expenses during the run -out
period,
• will be counted against the permitted carryover amount, and
• cannot exceed the carryover amount.
Continuation Coverage Upon Termination
If your Employer is covered by COBRA and your coverage in the Health Care Flexible
Spending Account terminates due to a COBRA qualifying event, you will be given the
opportunity to continue (on a self -pay basis) the same coverage you had in effect on the day
before the qualifying event, as prescribed by COBRA. However, you may not be eligible for
COBRA if you "overspent" your Health Care Flexible Spending Account at the time of the
COBRA qualifying event. Your account is overspent if your remaining annual benefit
(maximum annual benefit minus the total amount of reimbursable claims submitted before
the date of the qualifying event) is less than the maximum COBRA premium that can be
charged for the rest of the year. If COBRA is elected, it will be available only for the
remainder of the year in which the qualifying event occurs and will cease at the end of that
year. Your Health Care Flexible Spending Account coverage cannot be continued for the next
year.
Coordination with Health Reimbursement Arrangement (HRA)
Since the City offers a medical Health Reimbursement Arrangement ("HRA") medical option,
certain qualified health care expenses are eligible for reimbursement by the HRA and the
Health Care FSA. Eligible health care expenses covered by both the Health Care FSA and
the HRA will automatically be deducted from your HRA (to the extent possible), then from
your Health Care FSA. See the City's Employee Benefit Guide for details.
Submitting a Claim for Reimbursement
There are a few possible reimbursement methods for FSAs. The methods that are available
to you depend on how your FSA is administered. These methods may include, for example,
submitting manual or electronic claim forms or allowing you to use an FSA debit card. When
you are enrolled in the FSA, your Employer will provide you with more specific information on
0
how your FSA reimburses eligible expenses. Keep in mind that an expense can be
reimbursed only after it is incurred. Expenses are incurred at the time the service is received,
not when the care or service is billed, charged or paid. In general, prepayment is not
permitted. Your FSA can only be used to reimburse eligible expenses. In some
circumstances, the Claims Administrator may ask you to provide additional documentation to
show that an expense is eligible for reimbursement from your FSA. If you do not provide this
information, your claim for reimbursement may be denied.
Claims Submission and Cut -Off
The Plan Administrator will establish and communicate to all participants the cut-off date by
which all claims for the year must be submitted. Claims submitted after that date will not be
eligible for reimbursement and will be forfeited.
Forfeitures
After processing all claims for a Plan Year, any amount credited to your Expense Account as
of the end of that Plan Year will no longer be available for further claims and will be forfeited
unless the plan allows for a carry-over. Refer to the FSA Plan Document for details.
E
Administrative Information
The following sections contain legal and administrative information you may need to contact
the right person for information or help. Although you may not use this information often, it
can be helpful if you want to know:
• how to contact the Plan Administrator;
• how to contact the Claims Administrators;
• what to do if a benefit claim is denied; and
• your rights under Federal laws such as COBRA.
Plan Sponsor and Administrator
City of Clermont is the Plan Sponsor and the Plan Administrator for this Plan. You may
contact the Plan Administrator at the following address and telephone number:
City of Clermont
685 W. Montrose St
Clermont, FL 34711
352-241-7380
The Plan Administrator will have control of the day-to-day administration of this Plan and will
serve without additional remuneration if such individual is an employee of the City. The Plan
Administrator will have the following duties and authority with respect to the Plan:
• To prepare and file with governmental agencies all reports, returns, and all documents
and information required under applicable law;
• To prepare and furnish appropriate information to eligible employees and Plan
participants;
• To prescribe uniform procedures to be followed by eligible employees and participants
in making elections, filing claims, and other administrative functions in order to
properly administer the Plan;
• To receive such information or representations from the City, eligible employees, and
participants necessary for the proper administration of the Plan and to rely on such
information or representations unless the Plan Administrator has actual knowledge
that the information or representations are false;
• To properly administer the Plan in accordance with all applicable laws governing
fiduciary standards;
• To maintain and preserve appropriate Plan records.
In addition, the Plan Administrator has the discretionary authority to determine eligibility
under all provisions of the Plan; correct defects, supply omissions, and reconcile
inconsistencies in the Plan; ensure that all benefits are paid according to the Plan; interpret
Plan provisions for all participants and beneficiaries; and decide issues of credibility
necessary to carry out and operate the Plan. Benefits under the Plan will be paid only if the
Plan Administrator decides in its discretion that the applicant is entitled to them.
Plan Year
The Plan Year is January 1 through December 31.
10
Note: An insured benefit may use a policy year that differs from the Plan Year, with deductible
and out-of-pocket expenses based on the policy year. Please refer to the insurance
certificate and other materials provided by the Insurer to determine how the policy year
impacts your benefits.
Type of Plan
This Plan is called a "welfare plan", which includes group health plans; they help protect you
against financial loss in case of sickness or injury.
Identification Numbers
The Employer Identification Number (EIN) and Plan number for the Plan is:
EIN: 59-6000290 PLAN NUMBER: 501
Plan Funding and Type of Administration
Funding and administration of the Plan is as follows.
Type of The Plan is administered by the Employer
Administration through an arrangement with Insurers and third -
party (claims) administrators. Insured benefits
will be payable solely by the Insurer. Self -funded
benefits are administered through contracts with
third -party administrators
Funding The Employer and employees both contribute to
the Plan. Premiums are paid to the Insurers for
fully insured Benefit Programs and benefits will
be paid by the Insurer in accordance with the
applicable insurance contract/policy. The City
fully funds the cost of the self -funded benefits.
Benefits will be paid solely from the general
assets of the City.
Claims Administrators
The Plan Administrator has contracted with several Companies to administer benefits and
pay claims. You may contact the appropriate Claims Administrator directly, using the
information listed in your Benefit Guide.
Agent for Service of Legal Process
If any disputes arise under the Plan, papers may be served upon:
City of Clermont
685 W. Montrose St
Clermont, FL 34711
352-394-7380
Service of legal process also can be made upon the Plan Administrator.
11
No Obligation to Continue Employment
The Plan does not create an obligation for the City to continue your employment or interfere
with the City's right to terminate your employment, with or without cause.
Severability
If any provision of this Plan is held by a court of competent jurisdiction to be invalid or
unenforceable, the remaining provisions shall continue to be fully effective.
Payment of Benefits
All benefits are payable when the Plan Administrator receives written proof of loss. Benefits
will be payable to the covered participant, unless otherwise assigned. If you receive care
from a non -network provider, it is your responsibility to pay the non -network provider for the
charges you incurred, including any difference between what you were billed and what the
Plan paid. You may not assign your benefits under the Plan to a non -network provider without
the City's consent. The City (or a Claims Administrator) reserves the right, in its discretion, to
pay a non -network provider directly for services rendered to you. Direct payment to a non -
network provider shall not be deemed to constitute consent by the City or waive the consent
requirement for assigning benefits.
Payment of Benefits to Others
The Plan Administrator, in its discretion, may authorize any payments due to be paid to the
parent or legal guardian of any individual who is either a minor or legally incompetent and
unable to handle his or her own affairs.
Expenses
All expenses incurred in connection with the administration of the Plan, are Plan expenses
and will be paid from the general assets of the City.
Fraud
No payments under the Plan will be made if the participant or the provider of services
attempts to perpetrate a fraud upon the Plan with respect to any such claim. The Plan
Administrator will have the right to make the final determination of whether a fraud has been
attempted or committed upon the Plan or if a misrepresentation of fact has been made. The
Plan will have the right to recover any amounts, with interest, improperly paid by the Plan by
reason of fraud. Any employee or his or her covered dependent who attempts or commits
fraud upon the Plan may have their coverage terminated and may be subject to disciplinary
action by the City, up to and including termination of employment.
Indemnity
To the full extent permitted by law, the City will indemnify the Plan Administrator and each
other employee who acts in the capacity of an agent, delegate, or representative ("Plan
Administration Employee") of the Plan Administrator against any and all losses, liabilities,
costs and expenses incurred by the Plan Administration Employee in connection with or
arising out of any pending, threatened, or anticipated action, suit or other proceeding in which
the Employee may be involved by having been a Plan Administration Employee.
12
Compliance with State and Federal Mandates
Each Benefit Program will comply to the extent possible with the requirement of all applicable
laws, including but not limited to: COBRA, USERRA, HIPAA, the Newborns' and Mothers'
Health Protection Act of 1996 (NMHPA), the Women's Health and Cancer Rights Act of 1998,
FMLA, the Mental Health Parity and Addiction Equity Act of 2008, PPACA, HITECH,
Michelle's Law (if applicable), and Title I of GINA (prohibiting the use of genetic information to
discriminate with respect to health insurance premiums, contributions or other restricted
purposes).
Refund of Premium Contributions
The Plan will comply with DOL guidance regarding refunds (e.g., dividends, demutualization,
experience adjustments, and/or medical loss ratio rebates) of insurance premiums. Where
any refund is determined to be a plan asset to the extent amounts are attributable to
participant contributions, such assets will be: 1) distributed to current plan participants within
90 days of receipt, 2) used to reduce participants' portion of future premiums under the Plan
(e.g., premium holiday); or 3) used to enhance future benefits under the Plan. Such
determination will be made by the Plan Administrator, acting in its fiduciary capacity, after
weighing the costs to the Plan and the competing interest of participants, provided such
method is reasonable, fair, and objective.
Nondiscrimination
The Plan is intended to be nondiscriminatory under Code Section 125. Code Section 125
prohibits discrimination in favor of highly compensated individuals with respect to eligibility to
participate, highly compensated participants with respect to benefits and contributions and
key employees with respect to total Plan contributions. If the Plan Administrator determines,
at any time, that the Plan may fail to satisfy these nondiscrimination requirements, the Plan
Administrator may take such action as it deems appropriate to comply with the
nondiscrimination requirements. This action may include, for example, modifying the
elections of highly compensated or key employees without their consent.
The Health Care Flexible Spending Account shall not discriminate in favor of "highly
compensated individuals" as to eligibility to participate or benefits available. The Health Care
Flexible Spending Account shall be operated consistently with Code Section 105(h),
regulations promulgated thereunder, and guidance issued by the Department of Labor or the
Internal Revenue Service relating to discrimination testing.
No Guarantee of Tax Consequences
Neither the Plan Administrator nor the Employer makes any representation, guarantee or
warranty that any amount paid as premiums or distributed as benefits under the Plan will be
excludable from your gross income for federal or state income tax purposes (or that any
other state or federal tax treatment will apply or be available to you). It is your responsibility
to determine whether payments are excludable from your gross income for federal and state
income tax purposes.
13
Future of the Plan
The City expects that the Plan will continue indefinitely. However, the City has the sole right
to amend, modify, suspend, or terminate all or part of the Plan at any time.
The City may also change the level of benefits provided under the Plan at any time. If a
change is made, benefits for claims incurred after the date the change takes effect will be
paid according to the revised Plan provisions. In other words, once a change is made, there
are no rights to benefits based on earlier Plan provisions.
14
Claims and Appeal Procedure
The claims procedures, including the time frames for submitting claims are set forth in the
governing documents for each benefit plan. This section describes what you must do to file
or appeal a claim for services.
Time Frames for Processing Health -Related Claims
Health -related claims are divided into urgent care claims, concurrent care claims, pre -service
health claims, and post -service health claims with different time frames applicable to each.
For purposes of the Health Care FSA, claims are treated as post -service health claims.
If an initial claim is denied in whole or in part, you or your representative will receive written
notice from the Claims Administrator that your claim is denied as soon as reasonably
possible, but no later than 30 days after receipt of the claim. For reasons beyond their
control, the Claims Administrator may take up to an additional 15 days to review your claim.
You will be provided written notice of the need for additional time prior to the end of the 30-
day period. If the reason for the additional time is that you need to provide additional
information, you will have 45 days from the notice of the extension to obtain that information.
The time period during which the Claims Administrator must make a decision will be
suspended until the earlier of the date that you provide the information or the end of the 45-
day period.
Once you have received your notice from the Claims Administrator, review it carefully. This
notice will include the reasons for denial, the specific Plan provision involved, an explanation
of how claims are reviewed, the procedure for requesting a review of the denied claim, a
description of any additional material or information that must be submitted with the appeal,
and an explanation of why it is necessary. If you disagree with this decision, you or your
representative may file a written appeal for review of a denied claim with the Claims
Administrator within 180 days after receipt of a notice of denial.
You will have the right to submit for review, written comments, documents, records, and other
information related to the claim as well as any additional information you believe would
support your claims. You also have the right to request, free of charge, reasonable access to,
and copies of, all documents, records and other information relevant to the claim.
If after such review the Claims Administrator continues to deny the validity of the claim in full
or in part, you may file a 2nd level appeal with the Plan Administrator. This appeal must be
filed within 60 days of the first level appeal denial notice from the Claims Administrator. You
should include any information necessary to perfect your claim and any other information that
you believe supports your claim.
You will be notified of the Plan Administrator's decision in writing. If your claim is denied, the
Plan Administrator will give you in writing the specific reason(s) that your claim was denied,
the specific reference to the Plan provisions on which the denial was based, any internal
rules, guidelines, protocols, or similar criteria used as basis for the decision, a statement that
you will be provided, upon request and free of charge, reasonable access to, and copies of,
all documents, records, and other information relevant to your claim.
Each level of appeal will be independent from the previous level (i.e., the same persons
involved in a prior level of appeal would not be involved in the next level). On each level of
appeal, the claims reviewer will review relevant information that you submit even if it is new
information.
15
The final decision of the Plan Administrator shall be final and conclusive on all persons
claiming benefits under the Plan, subject to applicable law.
Time Frames for Processing All Other Claims
For all non -health -related claims, you may file a claim with the Claims Administrator. The
Claims Administrator will notify you of its decision in writing within 90 days after the claim is
received.
Special circumstances may require an extension of this period up to 180 days for non -
disability claims, but if an extension is required, you will be notified of any extension within
the initial 90-day period. If an extension is necessary because you failed to submit necessary
information, the days from the date the Claims Administrator sends you the extension notice
until you respond to the request for additional information are not counted as part of the claim
determination period.
If your claim is denied, you will receive in writing the specific reasons that your claim was
denied, the specific reference to the Plan provision(s) on which the denial was based, a
description of any additional material or information necessary for you to perfect the claim
and why such material or information is necessary, a statement that you will be provided,
upon request and free of charge, reasonable access to, and copies of, all documents,
internal rules, guidelines, protocol, records and information relevant to your claim, and
information regarding the Plan's appeal procedures and time frames, including what steps
you need to take to appeal your claim.
To appeal a denied claim, you or your representative must send a written request for review
to the Plan Administrator within 60 days after the denial is received. You should state the
reason why you believe your claim should be reviewed and submit for review any written
comments, documents, records, or other information that is relevant to your claim.
The Plan Administrator will conduct a review and make a final decision within 60 days after
receipt of your request for review (or within 120 days if special circumstances warrant an
extension, provided you are notified of the extension within the initial 60-day period).
You will be notified of the Plan Administrator's decision in writing. If your claim is denied, the
Plan Administrator will give you in writing the specific reason(s) that your claim was denied,
the specific reference to the Plan provisions on which the denial was based, any internal
rules, guidelines, protocols, or similar criteria used as basis for the decision, a statement that
you will be provided, upon request and free of charge, reasonable access to, and copies of,
all documents, records, and other information relevant to your claim.
The final decision of the Plan Administrator shall be final and conclusive on all persons
claiming benefits under the Plan, subject to applicable law.
Exhaustion Required
If you do not file a claim, follow the claims procedures, or appeal a claim within the
timeframes permitted, you will give up all legal rights, including your right to file suit in
Federal court, as you will not have exhausted your internal administrative appeal rights.
Participants or claimants must exhaust all remedies available to them under the Plan before
bringing legal action. You cannot take any other steps or file any other claims or suits for
benefits unless and until you have exhausted all administrative appeals.
W-1
Your HIPAA/COBRA Rights
Health Insurance Portability and Accountability Act (HIPAA)
Title II of the Health Insurance Portability and Accountability Act of 1996, as amended, and
the regulations at 45 CFR Parts 160 through 164 (HIPAA) contain provisions governing the
use and disclosure of Protected Health Information (PHI) by group health plans, and provide
privacy rights to participants in those plans. These rules are called the HIPAA Privacy Rules.
You will receive a "Notice of Privacy Practices" from the Administrator(s) and/or Insurer(s)
that contains information about how your individually identifiable health information is
protected under the HIPAA Privacy Rules and who you should contact with questions or
concerns.
The HIPAA Privacy Rules apply to group health plans. These plans are commonly referred to
as "HIPAA Plans" and are administered to comply with the applicable provisions of HIPAA.
PHI is individually identifiable information created or received by HIPAA Plans that relates to
an individual's physical or mental health or condition, the provision of health care to an
individual, or payment for the provision of health care to an individual. Typically, the
information identifies the individual, the diagnosis, and the treatment or supplies used during
treatment. It includes information held or transmitted in any form or media, whether
electronic, paper or oral. When PHI is in electronic form it is called "ePHI."
The HIPAA Plans may disclose PHI to the Plan Sponsor only as permitted under the terms of
the Plan, or as otherwise required or permitted by HIPAA. The Plan Sponsor agrees to use
and disclose PHI only as permitted or required by the HIPAA Privacy Rules and the terms of
the Plan.
The HIPAA Plans (or an Insurer with respect to the HIPAA Plans) may disclose enrollment
and disenrollment information to the Plan Sponsor. Also, the HIPAA Plans (or an Insurer with
respect to the HIPAA Plans) may disclose Summary Health Information to the Plan Sponsor if
the Plan Sponsor requests the information for the purposes of (1) obtaining premium bids
from health plans for providing health insurance coverage under the Plan; or (2) modifying,
amending or terminating the Plan. "Summary Health Information" means information that
summarizes the claims history, claims expenses or types of claims experienced by
individuals covered under the HIPAA Plans and has almost all individually identifying
information removed. The HIPAA Plans may also disclose PHI to the Plan Sponsor pursuant
to a signed authorization that meets the requirements of the HIPAA Privacy Rules.
In addition, the HIPAA Plans (or an Insurer with respect to the HIPAA Plans) may disclose
PHI to the Plan Sponsor for plan administration purposes. Plan administration purposes
means administration functions performed by the Plan Sponsor on behalf of the HIPAA Plans,
such as claims processing, coordination of benefits, quality assurance, auditing and
monitoring. Plan administration purposes do not include functions performed by the Plan
Sponsor in connection with any other benefit or benefit plan of the Plan Sponsor or any
employment -related actions or decisions.
The Plan Sponsor agrees that with respect to any PHI (other than enroll ment/disenrollment
information, Summary Health Information and information disclosed pursuant to a valid
HIPAA authorization) disclosed to it by the HIPAA Plans (or an Insurer with respect to the
HIPAA Plans), the Plan Sponsor will:
17
• Not use or further disclose the information other than as permitted or required by the
Plan or as required by law;
• Ensure that any agents, including subcontractors, to whom it provides PHI received
from the HIPAA Plans agree to the same restrictions and conditions that apply to the
Plan Sponsor with respect to PHI;
• Not use or disclose the information for employment -related actions and decisions or
in connection with any other benefit or employee benefit plan of the Plan Sponsor;
• Report to the HIPAA Plans any use or disclosure of PHI of which it becomes aware
that is inconsistent with the permissible uses or disclosures;
• Make PHI available in accordance with the individual rights of access under the
HIPAA Privacy Rules;
• Make an individual's PHI available for amendment, and incorporate any amendments,
as required by the HIPAA Privacy Rules;
• Make available the information required to provide an accounting of disclosures to
individuals, as required by the HIPAA Privacy Rules;
• Make its internal practices, books and records relating to the use and disclosure of
PHI received from the HIPAA Plans available to the Secretary of the Department of
Health and Human Services for purposes of determining compliance with HIPAA's
requirements;
• If feasible, return or destroy all PHI received from the HIPAA Plans that the Plan
Sponsor still maintains in any form and retain no copies of this information when no
longer needed for the purpose for which disclosure was made, except that, if this
return or destruction is not feasible, limit further uses or disclosures to those purposes
that make the return or destruction of the information infeasible; and
• Ensure adequate separation between the HIPAA Plans and the Plan Sponsor is
established.
In addition, the Plan Sponsor will reasonably and appropriately safeguard ePHI (other than
enrollment/disenrollment information, Summary Health Information and information disclosed
pursuant to a valid HIPAA authorization) that is created, received, maintained or transmitted
to or by the Plan Sponsor on behalf of the HIPAA Plans. The Plan Sponsor will:
• Implement administrative, physical and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity, and availability of the ePHI that it
creates, receives, maintains or transmits on behalf of the HIPAA Plans;
• Ensure that adequate separation between the HIPAA Plans and the Plan Sponsor is
supported by reasonable and appropriate security measures;
• Ensure that any agent, including a subcontractor, to whom it provides ePHI agrees to
implement reasonable and appropriate security measures to protect the information;
and
• Report to the HIPAA Plans any security incident of which it becomes aware.
The Plan Sponsor allows HR Director, HR Manager and HR Advocates access to the PHI. No
other persons have access to PHI. These specified employees (or classes of employees)
only have access to and use of PHI to the extent necessary to perform the plan
administration functions that the Plan Sponsor performs for the HIPAA Plans. In the event
f.
that a specified employee does not comply with these HIPAA provisions, the employee will be
subject to disciplinary action by the Plan Sponsor for non-compliance pursuant to the Plan
Sponsor's employee discipline and termination procedures.
19
Continuing Your Health Care FSA through COBRA
This section provides an overview of COBRA continuation coverage. The coverage described
may change as permitted or required by applicable law. When you first enroll in coverage,
you will receive from the Plan Administrator/COBRA Administrator your initial COBRA notice.
This notice and subsequent notices you receive will contain current requirements applicable
for you to continue coverage.
If your coverage under the Health Care Flexible Spending Account ends due to a COBRA
qualifying event, you will be given the opportunity to continue the same coverage you had in
effect the day before the qualifying event on a self -pay basis.
COBRA Continuation Coverage will be available to you only if you have a positive Health
Care Expense Account balance at the time of the COBRA qualifying event (taking into
account all claims submitted by you before the date of the qualifying event). If COBRA is
elected, it will be available only for the remainder of the Plan Year (and any extended period)
in which the qualifying event occurs, and coverage will cease at the end of the Plan Year.
Coverage will not be continued for the next Plan Year.
COBRA Notifications
If you lose coverage under the Plan because your employment status changes, you become
entitled to Medicare, or you die, the Plan Administrator (or its designated COBRA
administrator) will automatically provide you with additional information about COBRA
continuation coverage, including what actions you must take by specific deadlines.
Cost of COBRA Coverage
You or your eligible dependent pay the full cost for healthcare coverage under COBRA, plus
any required administrative fee up to two percent, or up to 102 percent of the full premium
cost, except in the case of an 11-month disability extension where you may be required to
pay up to 150 percent of the full premium cost for coverage.
COBRA Continuation Coverage Payments
You must elect COBRA coverage by completing and returning your COBRA enrollment form
as instructed in your enrollment materials within 60 days of the date you receive information
about your COBRA rights or, if later, the date of your qualifying event.
The first COBRA payment is due no later than 45 days from the date COBRA coverage is
elected. Although COBRA coverage is retroactive to the date of the initial qualifying event, no
benefits will be paid until the full payment is received. Each month's premium is due prior to
the first day of the month of coverage. You are responsible for making timely payments.
If you fail to make the first payment within 45 days of the COBRA election, or subsequent
payments within 30 days of the due date (the grace period), COBRA coverage will be
canceled permanently, retroactive to the last date for which premiums were paid. COBRA
coverage cannot be reinstated once it is terminated. Other important information you need to
know about the required COBRA coverage payments follows.
COBRA premium payments that are returned by the bank for insufficient funds will result in
termination of your COBRA coverage if a replacement payment in the form of a cashier's
check, certified check, or money order is not made within the grace period.
COBRA premium payments must be mailed to the address indicated on your premium notice.
Even if you do not receive your premium notice, it is your responsibility to contact the COBRA
cl
administrator. Your COBRA coverage will end if payment is not made by the due date on your
notice. It is your responsibility to ensure that your current address is on file.
21
Definitions
COBRA
The Consolidated Omnibus Budget Reconciliation Act. This Federal law allows a continuation
of health care coverage in certain circumstances.
Dependent
The definition of a dependent is defined in the insurance certificate and other governing
documents provided for each Benefit Program.
Employee
A person who works for the City in an employer -employee relationship, who is a full-time
employee and who is regularly scheduled to work for the Employer in an employer -employee
relationship. The definition of an eligible employee is defined in the Plan Overview.
Election Form
The form used by employees to elect to participate in a Benefit Program and to authorize
salary reduction for payment of premiums for such Benefit Program, where applicable.
Family and Medical Leave Act
The Family and Medical Leave Act (FMLA) is a Federal law that provides for an unpaid leave
of absence for up to 12 weeks per year for:
• the birth or adoption of a child or placement of a foster child in a participant's home;
• the care of a child, spouse or parent (not including parents -in-law), as defined by
Federal law, who has a serious health condition;
• a participant's own serious health condition; or
• any qualifying exigency arising from an employee's spouse, son, daughter, or parent
being a member of the military on "covered active duty". Additional military caregiver
leave is available to care for a covered service member with a serious injury or illness
who is the spouse, son, daughter, parent, or next of kin to the employee.
Generally, you are eligible for coverage under FMLA if you have worked for your City for at
least one year; you have worked at least 1,250 hours during the previous 12 months; your
City has at least 50 employees within 75 miles of your worksite; and you continue to pay any
required premium during your leave as determined by the City. You should contact the City
with any questions you have regarding eligibility for FMLA coverage or how it applies to you.
H I PAA
Health Insurance Portability and Accountability Act of 1996, as amended.
Insurer
Any insurance City that fully insures (or partially insures) any benefit provided by this Plan or
any Benefit Program.
Leased Employee
Leased employee as defined in the Internal Revenue Code, section 414(n), as amended.
Participant
An eligible employee who elects to participate in the Plan by completing the necessary
Election Form on a timely basis, as provided by the Plan Administrator.
22
Uniformed Services Employment and Reemployment Rights Act of 1994
(USERRA)
A Federal law covering the rights of participants who have a qualified uniformed services
leave.
WHCRA
The Women's Health and Cancer Rights Act of 1998, as amended. Your medical coverage
under the Plan includes coverage for a medically necessary mastectomy and patient -elected
reconstruction after the mastectomy. Specifically, for you or your covered dependent who is
receiving mastectomy -related benefits, coverage will be provided in a manner determined in
consultation with the attending physician and the patient for: 1) All stages of reconstruction of
the breast on which the mastectomy was performed; 2) Surgery and reconstruction of the
other breast to produce a symmetrical appearance; 3) Prostheses; and 4) Treatment of
physical complications at all stages of mastectomy, including lymphedema.
23
Adoption of the Plan
The City of Clermont Section 125 Cafeteria Plan with Flexible Spending Account, effective
01/01/1990, as amended and restated herein, is hereby adopted as of 01/01/2024. This
document constitutes the basis for administration of the Plan.
IN WITNESS WHEREOF, the parties have caused this document to be executed on this
Utk day of 2023.
BY:
TITLE:
24
APPENDIX A
Benefit Programs Available
You will be able to choose to participate in one or more of the following Benefit Programs by
indicating your choice or choices through the online enrollment system, which provides your
agreement to pre-tax your portion through salary reductions.
The specific benefits available under each Benefit Program will be determined by the
respective governing documents. A Benefit Program may vary from year to year. For details
regarding eligibility, benefit amounts, and premium schedules, you should refer to the
materials provided for each Benefit Program. The Plan Administrator will provide you with
information on each of the applicable Benefits Programs prior to your decision to elect to pay
for a Benefit Program through salary reduction.
The qualified Benefit Programs offered under the Plan are:
• Group Health Insurance (includes Prescription Drug coverage)
• Group Dental Insurance
• Group Vision Insurance
• Flexible Spending Account (FSA)
• Voluntary Life and AD&D
25