HomeMy WebLinkAboutResolution - 2017-R0476 - Texas Master Welfare Benefit Plan - 12_18_2017Resolution No. 2017-RO476
Item No. 6.15
December 18, 2017
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute for
and on behalf of the City of Lubbock, Texas Master Welfare Benefit Plan, summary plan
description, and related documents. Said Master Benefit Plan is attached hereto and incorporated
in this resolution as if fully set forth herein and shall be included in the minutes of the City Council.
THAT in cases where a Participant requests an exception to the Plan and the cost to the
Plan is less than $325,000, approval or rejection of the request shall be determined by the Plan
Administrator.
THAT in cases where a Participant requests an exception to the Plan and the cost to the
Plan is $325,000 or more, the Plan Administrator shall submit the request to the Lubbock City
Council for approval or rejection.
Passed by the City Council on _ December 18, 2017
DANIEL M. POPE, MAYOR
ATTEST:
Re T
cca Garza, City Secr tar
APPROVED AS TO CONTENT:
f
Leisa Hutcheson
Director of Human Resources and Risk Management
First Assistant City Attorney
RES.Master Welfare Benefit Plan 2018
12.04.2017
Resolution No. 2017-R0476
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
PLAN DOCUMENT AND
SUMMARY PLAN DESCRIPTION
Amended and Restated Effective as of January 1, 2018
The Plan Sponsor reserves the right to amend this Plan, in its sole
discretion, at any time without the consent of any employee, former
employee, or participant. The benefits provided under the Plan are not
guaranteed benefits for covered persons or for their dependents. The Plan
Sponsor reserves the right, in its sole discretion, to terminate the Plan or
any Plan feature or component at any time and for any reason without
The terms "you" and "your" as used in this document refer to an individual
who is otherwise eligible to participate in the Plan. Receipt of this document
does not guarantee that the recipient is in fact eligible to participate in the
Plan or any Plan feature or component.
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TABLE OF CONTENTS
GENERAL INFORMATION ABOUT THE PLAN.............................................................. l
General Plan Information.....................................................................................................1
Employer Information..........................................................................................................2
Plan Administrator Information...........................................................................................2
Serviceof Legal Process......................................................................................................2
Typeof Welfare Plan............................................................................................................2
Typeof Administration........................................................................................................2
Amendment and Termination...............................................................................................3
ELIGIBILITY AND BENEFITS............................................................................................3
Employee Eligibility Requirements.....................................................................................3
Dependent Eligibility Requirements....................................................................................5
SpecialEnrollment Rights....................................................................................................7
Qualified Medical Child Support Orders.............................................................................7
PlanBenefits.........................................................................................................................8
Lossof Benefits....................................................................................................................8
PlanCosts.............................................................................................................................8
NOTICES AND DISCLOSURES...........................................................................................8
Special Rule for Maternity and Infant Coverage..................................................................8
Special Rule for Women's Health Coverage........................................................................8
Notice Regarding Lifetime and Annual Dollar Limits.........................................................9
Patient Protection Disclosure...............................................................................................9
Nondiscrimination and Accessibility Requirements............................................................
9
RESPONSIBILITIES FOR PLAN ADMINISTRATION....................................................10
PlanAdministrator..............................................................................................................10
Duties of the Plan Administrator........................................................................................11
Plan Administrator Compensation.....................................................................................
I I
FiduciaryDuties.................................................................................................................11
TheNamed Fiduciary .........................................................................................................11
Uniformed Services Reemployment Rights..........................................................................11
Leave under Family Medical Leave Act...............................................................................12
COBRA.................................................................................................................................12
Introduction........................................................................................................................12
COBRA Continuation Coverage........................................................................................13
FUNDINGPOLICY..............................................................................................................16
SUBROGATION AND RIGHTS OF RECOVERY.............................................................17
PLAN IS NOT AN EMPLOYMENT CONTRACT.............................................................19
HIPAA PRIVACY AND SECURITY PROVISIONS..........................................................20
Disclosure of Information...................................................................................................20
Certification of the Plan Sponsor.......................................................................................21
Separation of Plan and the Plan Sponsor............................................................................21
Security of Electronic Protected Health Information.........................................................21
Claims Procedure for the Plan...............................................................................................22
Claims Procedure for a Group Health Plan.....................................................................23
City Government Authority and Responsibility .................................................................29
APPENDIX A
Look -Back Measurement Method.................................................................................................30
A. DEFINITIONS......................................................................................................................30
B. ELIGIBILITY...................................................................................................32
APPENDIX B
Qualified Medical Child Support Order Procedures....................................................34
APPENDIX C
Health Flexible Spending Arrangement and Dependent Care Assistance Plan Components......36
APPENDIX D
Premium Conversion Cafeteria Plan.......................................................................69
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION
Amended and Restated Effective as of January 1, 2018
This document, together with the provider contracts identified in Schedule A, and their
respective policies, descriptions and other materials (either written or electronic), constitute the
written plan and the summary plan description for the City of Lubbock, Texas Master Welfare
Benefit Plan (the "Plan').
The policies, contracts or booklets for each underlying Plan feature govern the benefits
to be provided and include more details on how the Plan features operate. If there is any
conflict between this plan document and such policies, contracts or booklets, then such other
documents will control, unless otherwise specified herein. Participants and beneficiaries
should not rely on any oral description of the Plan because the written terms of the Plan will
always govem.
A. GENERAL INFORMATION ABOUT THE PLAN
This section contains general information that you may need to know about the Plan.
General Plan Information
The name of the Plan is the City of Lubbock, Texas Master Welfare Benefit Plan.
The Plan Sponsor has assigned Plan Number 502 to the Plan.
The Plan Year is the twelve-month period ending each December 3151
The Plan includes the following Plan features:
• Group Medical Benefits (the "Group Medical Feature")
• Group Dental Benefits (the "Group Dental Feature")
• Group Vision Benefits (the "Group Vision Feature")
• Group Life/AD&D Benefits (the "Group Life/AD&D Feature")
• Group Long Term Disability Benefits (the "Group LTD Feature")
• Group Short Term Disability Benefits (the "Group STD Feature")
• Flexible Benefits Plan (the "Flexible Benefits Feature"), which includes health
care and dependent care flexible spending accounts
• Premium Conversion Cafeteria Plan
2. Employer Information
The Plan Sponsor's name, address, and employer identification number are:
City of Lubbock, Texas
1625 13" Street, Room 104
Lubbock, Texas 79401
Plan Administrator Information
The Plan Administrator is:
The Insurance Committee
City of Lubbock, Texas
1625 131 Street, Room 104
Lubbock, Texas 79401
As Plan Administrator, the Insurance Committee keeps the records for the Plan and is
responsible for the administration of the Plan. As of the amended and restated effective date,
the Insurance Committee shall consist of the City Manager, City Attorney, Chief Financial
Officer, Director of Human Resources, and Director of Electric Utilities or their designees.
Any person appointed to be a member of the committee shall signify his acceptance in writing
by the City. Any member of the committee may recuse by delivering written notice to the City
Manager. The City Manager shall have the ability to appoint an alternate member to serve
during the recusal. In the event one of the Insurance Committee positions is vacant, or
abolished through the budget process, the City Manager shall have the ability to appoint a
replacement.
4. Service of Legal Process
The name and address of the Plan's agent for service of legal process is:
The Insurance Committee
City of Lubbock, Texas
1625 131h Street, Room 104
Lubbock, Texas 79401
5. Type of Welfare Plan
The Plan is intended to be an "employee welfare benefit plan" exempt from the
Employee Retirement Income Security Act of 1974 ("ERISA") pursuant to the governmental
plan exemption in ERISA §4(b)(1). To the extent not preempted by federal law, the provisions
of this Plan shall be construed, administered, and enforced according to the laws of the State of
Texas.
6. Type of Administration
Benefits furnished under the Plan are administered by the providers from which benefits
are purchased, or in the case of certain self -funded benefits, by the Plan Administrator (or a
third -party administrator, as may be designated by the Plan Administrator from time to time).
The name of each provider is set out in Schedule A. Unless otherwise indicated, all benefits
furnished under the Plan are provided under the insurance policies, administrative contracts
and/or plan documents identified in Schedule A, and the respective providers identified therein
provide all necessary administrative services.
7. Amendment and Termination
The Plan Sponsor reserves the right to amend any one or more of the underlying Plan
features or component benefits of the Plan at any time and for any reason, in its sole discretion,
without the consent of any employee or former employee or participant. The benefits provided
under the Plan are not guaranteed benefits for covered persons or for their dependents. The Plan
Sponsor reserves the right, in its sole discretion, to terminate the Plan or any Plan feature at any
time and for any reason, without liability. Upon the termination of the Plan or a Plan feature,
as the case may be, all elections and reductions in compensation relating to the Plan or the
applicable Plan feature will terminate.
B. ELIGIBILITY AND BENEFITS
1. Employee Eligibility Requirements
Subject to each Plan feature's eligibility requirements that are set forth in the provider
contracts or other plan documents identified in Schedule A, and their respective policies,
descriptions, plan materials and participant communications, and all regular full-time
employees and of the Plan Sponsor, are eligible to participate in the Plan upon the completion
of one full two -week pay period, except for employees in the following categories:
• employees covered by a collective bargaining agreement to which the Plan Sponsor
is a party and which does not provide for participation in the Plan;
• "leased employees" within the meaning of Section 414(n) of the Internal Revenue
Code;
• individuals who are classified by the Plan Sponsor as temporary workers, interns,
co-ops, independent contractors, or consultants;
• individuals from whom the Plan Sponsor does not withhold federal income and
employment taxes from such person's compensation;
• nonresident aliens who receive no earned income (within the meaning of Code
Section 911(d)(2)) from their employer that constitutes income from sources within
the United States, as defined in Code section 861(a)(3); or
• employees who are not regularly scheduled to work at least 40 hours per week for
Group Vision Benefits, Group Long Term Disability Benefits, Group Short Term
disability Benefits, and Group Life/AD&D Benefits, and at least 30 hours per week
for all other Plan benefits.
Notwithstanding the foregoing, if you are ineligible to participate in the Plan because
you are not regularly scheduled to work at least 30 hours per week, you will become eligible
for the Group Medical Feature in the future if you are treated as full-time under the "look -back"
eligibility definition set forth in Appendix A.
Retirees under age 65 who are eligible for Medicare benefits due to a disability may
remain on the plan until age 65. Retirees who meet age and service requirements are eligible to
participate in Group Medical Benefits, Group Dental Benefits, and Group Life/AD&D Benefits
until they reach age 65. Eligibility for this retiree coverage requires either (1) at least 20 years
of employment with the Plan Sponsor, regardless of age, or (2) at least 5 years of employment
with the Plan Sponsor and attaining age 60, on or before the termination of employment with
the Plan Sponsor. This retiree coverage is available under the Group Life/AD&D Feature only
to the degree the retiree was enrolled in such coverage as an active employee on the day before
termination of employment with the Plan Sponsor.
To the extent that the Plan and/or a Plan feature's provider contracts and/or other plan
documents refer to the eligibility of "employees," only individuals classified as "employees" by
the Plan Sponsor are eligible to participate in such Plan feature. Independent contractors,
consultants and individuals hired through staffing firms shall not be eligible even if they are
subsequently determined to be common law employees for any purpose, including without
limitation, for wage, labor or tax purposes by the Internal Revenue Service, the Department of
Labor or any other Federal or state agency, administrative body or court. Any such
determination should have a prospective effect only.
NOTE: The Plan Administrator reserves the right to terminate your health care
coverage prospectively without notice for cause (as determined by the Plan Administrator), or
if you or a dependent are otherwise determined to be ineligible for coverage under the Plan. In
addition, if you or your dependent commits fraud or intentional misrepresentation of a material
fact (including, for example, in an application for health coverage under the Plan, in connection
with a benefit claim or appeal, or in response to any request for information by the Plan
Sponsor or its delegees (including the Plan Administrator or a claims administrator), the Plan
Administrator may terminate your coverage retroactively upon 30 days' notice. Failure to
inform any such persons that you or your dependent is covered under another group health plan
(if required by the Plan) or knowingly providing false information in order to obtain coverage
for an ineligible dependent are examples of actions that constitute fraud under the Plan.
Coverage may also be terminated retroactively and without notice (unless required by law) if
the Plan Administrator or its delegee determines that a spouse or dependent is ineligible for
coverage under the Plan and such retroactive termination would not be considered a rescission
under the Affordable Care Act. If coverage is terminated retroactively, you must reimburse the
Plan and/or its delegee for the costs associated with providing coverage to any ineligible
persons (including benefit claims, processing fees, administrative charges and all other costs),
plus interest and any attorneys' fees incurred by them in order to collect such amounts.
Additionally, you may be subject to further disciplinary action from the Plan Sponsor,
including, but not limited to, termination of employment.
2. Dependent Eligibility Requirements
Subject to each Plan feature's eligibility requirements that are set forth in the provider
contracts or other plan documents identified in Schedule A, and their respective policies,
descriptions, plan materials and participant communications, you may also enroll the following
members of your family in the Plan ("Eligible Dependents"):
(a) Your spouse. "Spouse" means the individual to whom you are legally married as
determined under state law. The Plan Sponsor shall have the sole discretion to
determine the legal status of a Participant's marriage for purposes of coverage under the
Plan.
(b) Your children. Each of your children who is:
• under age 26, whether married or unmarried, regardless of his or her student or
employment status and regardless of whether your home is his or her principal place
of abode or whether you support him or her financially;
• over the age of 26 and are unmarried and (i) primarily dependent on you for support
because of a mental or physical disability; and (ii) for whom you give the Plan
Sponsor satisfactory proof of such mental or physical disability within 31 days after
the later of the commencement of such mental or physical disability or the date you
first become an eligible employee under this Plan; or
• for purposes of any Plan features that are subject to state -mandated benefits, over
the age 26 to the extent required to be covered by such state law.
For purposes of this definition, "Child" and "Children" means the following: your
biological children, your stepchildren, your legally adopted children, your foster
children, any children placed with you for adoption, any children for whom you are
responsible under court order, and children for whom you are appointed legal
guardianship.
You may be required to verify the eligibility of your eligible dependents for coverage
(e.g., by providing a birth or marriage certificate). If you fail to timely provide the
documentation upon request to prove the eligibility of any of your eligible dependents
or the Plan Administrator (or its delegee) is unable to verify the submitted
documentation, your dependent (or dependents) will lose coverage under the Plan,
whether or not they are otherwise eligible for benefits under the respective plan.
In order to enroll your eligible dependents in any Plan feature, you must also enroll in
that coverage under the Plan.
(c) Your domestic partner. As of the amended and restated effective date, no Plan feature
includes domestic partner coverage. If a Plan feature in the future includes domestic
partner coverage, to enroll your domestic partner and/or his or her eligible dependents,
you and your domestic partner must be at least 18 years or older and:
• Your partner must not be a blood relation who is close enough to bar marriage in the
state you reside;
• Your partner must not be eligible for coverage through the Plan Sponsor as an
employee;
• You and your partner have lived together in a committed personal relationship for at
least six consecutive months before applying for coverage, and you expect to
continue living together in a personal relationship in which you have joint and
reciprocal financial responsibilities; and
• You and your partner are not married nor have other domestic partners.
In addition, you must present two forms of documentation showing your shared
financial responsibilities, such as:
• A joint lease or mortgage;
• A joint bank account statement;
• Joint ownership of a motor vehicle; or
• Designation of your partner as the primary beneficiary of your will, life insurance or
retirement benefits.
(d) For purposes of health coverage to the extent funded under the Flexible Benefits
Feature and for health care flexible spending account purposes, any individual who is a
tax dependent of yours as defined in Code Section 152 (determined without regard to
Sections 152(b)(1), (b)(2) and (d)(1)(B), or your child (as defined in Code Section
152(f)(1)) who has not attained age 26 by the end of the calendar year.
(e) For dependent care flexible spending account purposes, any individual who is (i) a
dependent (within the meaning of Code Section 152) of yours who is under the age of
13; (ii) if you are divorced or separated, a child of yours if you are the child's custodial
parent, even if you cannot claim an exemption for the child, subject to the conditions of
Code Section 21(e)(5), or (iii) a dependent (within the meaning of Code Section 152,
determined without regard to subsections (b)(1), (b)(2), and (d)(1)(B) thereof) or
Spouse of yours who is physically or mentally incapable of caring for himself or
herself, who has the same principal place of abode as you for more than one-half of the
Plan Year and who regularly spends at least eight (8) hours each day in your household.
A person under the dependent care flexible spending account shall cease being an
eligible dependent at any time during the Plan Year that such person ceases to satisfy
these requirements.
3. Special Enrollment Rights
If you do not enroll yourself and your dependents in a group health plan after you
become eligible or during annual enrollment, you may be able to enroll under the special
enrollment rules under the Health Insurance Portability and Accountability Act of 1996
("HIPAA") that apply when an individual declines coverage and later wishes to elect it.
Generally, special enrollment is available if (i) you declined coverage because you had other
health care coverage that you have now lost through no fault of your own (or employer
contributions to your other health care coverage terminate); or (ii) you have acquired a new
dependent (through marriage or the birth or adoption of a child) and wish to cover that person.
In either case, as long as you meet the necessary requirements, you can enroll both yourself and
all eligible dependents in the group health plan if you provide notice to the Plan Administrator
within 30 days after you lose your alternative coverage (or employer contributions to your
alternative coverage cease) or the date of your marriage or the birth, adoption, or placement for
adoption of your child.
You may also enroll yourself and your dependents in a group health plan if your or one
of your eligible dependent's coverage under Medicaid or the state Children's Health Insurance
Program (CHIP) is terminated as a result of loss of eligibility, or if you or one of your eligible
dependents become eligible for premium assistance (that could be used toward the Plan costs)
under a Medicaid or state child health plan under CHIP. Under these two circumstances, the
special enrollment period must be requested within 60 days of the loss of Medicaid/CHIP
coverage or of the determination of eligibility for premium assistance under Medicaid/CHIP.
See the Plan Administrator for details about special enrollment.
4. Qualified Medical Child Support Orders
A Qualified Medical Child Support Order ("QMCSO") is an order by a court for a
parent to provide Your child or children with health insurance under a group health plan. The
Plan Administrator (unless otherwise delegated) will comply with the terms of any QMCSO it
receives, and will:
• Establish reasonable procedures to determine whether medical child support orders
are qualified medical child support orders;
• Promptly notify you and any alternate recipient of the receipt of any medical child
support order, and the Plan's procedures for determining whether medical child
support orders are qualified medical child support orders; and
Within a reasonable period of time after receipt of such order, the Plan
Administrator will determine whether such order is a qualified medical child
support order and will notify you and each alternate recipient of such determination.
The Plan Administrator has developed procedures to determine whether a medical
child support order is qualified and for complying therewith. The QMCSO procedures are
provided in Appendix B.
5. Plan Benefits
The Plan provides for (i) group medical benefits, (ii) group dental benefits, (iii) group
vision benefits, (iv) group life and AD&D insurance benefits, (v) group long term disability
benefits, (vi) group short term disability benefits, and (vii) health care and dependent care
flexible spending account benefits, all as more fully described (and subject to the limitations
contained) in the provider contracts, plan documents and related materials referred to in
Schedule A.
6. Loss of Benefits
As noted above, the Plan Sponsor reserves the right to change or eliminate any Plan
feature under the Plan and may amend or terminate the Plan at any time. Except in the case of
certain health care continuation rights under Federal law and certain retiree benefits as
referenced in the Eligibility section above (Section B.1.), all benefits terminate when your
active employment terminates or when you are no longer eligible for benefits or when the
group insurance policy terminates, whichever occurs first.
7. Plan Costs
The Plan provides for cost sharing between the Plan Sponsor and employees. The
dollar values of the participant contributions will be communicated to you prior to any initial,
open, or special enrollment period. Upon the terms and conditions set forth in the Plan
Sponsor's Flexible Benefits Feature, Participants may also elect to contribute to their health
and/or dependent care flexible spending accounts.
C. NOTICES AND DISCLOSURES
1. Special Rule for Maternity and Infant Coverage
Group health plans and health insurance issuers generally may not, under Federal law,
restrict benefits for any hospital length of stay in connection with childbirth for the mother or
newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a cesarean section. However, Federal law generally does not prohibit the attending
provider or physician, after consulting with the mother, from discharging the mother or her
newborn earlier than 48 hours (or 96 hours, as applicable). In any case, plans and issuers may
not, under Federal law, require that a provider obtain authorization from the plan or the
insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
2. Special Rule for Women's Health Coverage
The Women's Health and Cancer Rights Act of 1998 ("WHCRA") requires group
health plans, insurance issuers and HMOs who already provide medical and surgical benefits
for mastectomy procedures to provide insurance coverage for reconstructive surgery following
mastectomies. This expanded coverage includes (i) reconstruction of the breast on which the
mastectomy has been performed, (ii) surgery and reconstruction of the other breast to produce a
symmetrical appearance, and (iii) prostheses and physical complications at all stages of
mastectomy, including lymphedemas. These procedures may be subject to annual deductibles
and coinsurance provisions that are similar to those applying to other medical or surgical
benefits provided under the Group Medical Feature. For answers to specific questions
regarding WHCRA benefits, contact the Plan Administrator. Additional state laws may be
applicable as more fully described in other materials detailing your medical benefits.
3. Notice Regarding Lifetime and Annual Dollar Limits
In accordance with applicable law, any lifetime or annual dollar limits set forth in the
Group Medical feature shall not apply to "essential health benefits," as such term is defined
under Section 1302(b) of the Affordable Care Act. The law defines "essential health benefits"
to include, at a minimum, items and services covered within certain categories including
emergency services, hospitalization, prescription drugs, rehabilitative and habilitative services
and devices, and laboratory services.
The restrictions regarding lifetime and annual dollar limits under the Group Medical
Feature do not apply to services (even services for essential health benefits) which are limited
by the number of visits or other criteria. For example, a medical plan may provide that
coverage for a physical therapist is limited to up 30 visits per year per covered person.
4. Patient Protection Disclosure
If the Group Medical Feature in which you are enrolled requires the designation of a
primary care provider, you have the right to designate any participating primary care provider
who is available to accept you or your family members (for children, you may designate a
pediatrician as the primary care provider). For information on how to select a primary care
provider and for a list of participating primary care providers, contact the Plan Administrator.
You do not need prior authorization from the Plan or from any other person, including your
primary care provider, in order to obtain access to obstetrical or gynecological care from a
health care professional; however, you may be required to comply with certain procedures,
including obtaining prior authorization for certain services, following a pre -approved treatment
plan, or procedures for making referrals. For a list of participating health care professionals
who specialize in obstetrics or gynecology, contact the Plan Administrator.
5. Nondiscrimination and Accessibility Requirements
The Plan complies with applicable federal civil rights laws and does not discriminate on
the basis of race, color, national origin, age, disability or sex. The Plan does not exclude people
or treat them differently because of race, color, national origin, age, disability or sex. The Plan:
Provides free aids and services to people with disabilities to communicate
effectively with us, such as:
o Qualified sign language interpreters; and
o Written information in other formats (large print, audio, accessible electronic
formats, other formats);
• Provides free language services to people whose primary language is not English,
such as:
o Qualified interpreters; and
o Information written in other languages.
If you need these services, contact the Plan Administrator. If you believe that the Plan
has failed to provide these services or discriminated in another way on the basis of race, color,
national origin, age, disability or sex, you can file a grievance with the Plan Administrator. You
can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the
Plan Administrator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and
Human Services, Office for Civil Rights, electronically through the Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal!lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room
509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at h_LV:/lwww.hhs.gov/ocr/office/file/index.html.
D. RESPONSIBILITIES FOR PLAN ADMINISTRATION
1. Plan Administrator
The Plan Administrator has (i) the power and authority in its sole, absolute and
uncontrolled discretion to control and manage the operation and administration of the Plan and
(ii) all powers necessary to accomplish these purposes.
The Plan Administrator will administer the Plan in accordance with established policies,
interpretations, practices, and procedures and in accordance with the requirements of applicable
laws. With respect to the Plan, the Plan Administrator has discretion (i) to interpret the terms
of the Plan, (ii) to determine factual questions that arise in the course of administering the Plan,
(iii) to adopt rules and regulations regarding the administration of the Plan, (iv) to determine
the conditions under which benefits become payable under the Plan and (v) to make any other
determinations that the Plan Administrator believes are necessary and advisable for the
administration of the Plan. Subject to any applicable claims procedure, any determination
made by the Plan Administrator will be final, conclusive and binding on all parties. The Plan
Administrator may delegate all or any portion of its authority to any person or entity. For
example, for benefits that are fully insured, the applicable insurance company is delegated
certain administrative authority.
DESPITE ANY PLAN PROVISION TO THE CONTRARY, THE POLICIES,
CONTRACTS OR BOOKLETS FOR EACH UNDERLYING PLAN FEATURE
GOVERN THE BENEFITS TO BE PROVIDED, AND THE PROVIDERS FOR EACH
10
PLAN FEATURE ARE RESPONSIBLE FOR MAKING BENEFIT
DETERMINATIONS UNDER EACH SUCH PLAN FEATURE, NOT THE PLAN
ADMINISTRATOR. IF THERE IS ANY CONFLICT BETWEEN THIS PLAN
DOCUMENT AND SUCH POLICIES, CONTRACTS OR BOOKLETS, THEN SUCH
OTHER DOCUMENTS WILL CONTROL.
2. Duties of the Plan Administrator
The Plan Administrator will (i) administer the Plan in accordance with its terms,
(ii) decide disputes which may arise relative to a Plan participant's rights, (iii) keep and
maintain the Plan documents and all other records pertaining to the Plan, (iv) pay or arrange for
the payment of claims, (v) with respect to each group health plan covered under the Plan,
establish and communicate procedures to determine whether a medical child support order is
qualified, and (vi) perform all necessary reporting.
3. Plan Administrator Compensation
All expenses for administration, including compensation for hired services, will be paid
by the Plan unless paid by the Plan Sponsor.
4. Fiduciary Duties
A fiduciary must carry out his or her duties and responsibilities for the purpose of
providing benefits to the participants and their dependents and defraying reasonable expenses
of plan administration. These duties must be carried out with the care, skill, prudence and
diligence under the given circumstances that a prudent person, acting in a like capacity and
familiar with such matters, would use in a similar situation and in accordance with Plan
documents.
5. The Named Fiduciary
The Plan Administrator is a "named fiduciary" with respect to the Plan. A named
fiduciary can appoint others to carry out fiduciary responsibilities (other than as a trustee) under
the Plan. These other persons become fiduciaries themselves and are responsible for their acts
under the Plan. To the extent that the named fiduciary allocates its responsibility to other
persons, the named fiduciary will not be liable for any act or omission of such person unless
either (i) the named fiduciary has violated its legal duties in appointing the fiduciary,
establishing the procedures to appoint the fiduciary or continuing to monitor the fiduciary or
(ii) the named fiduciary breached its fiduciary responsibility under applicable law.
E. Uniformed Services Reemployment Rights
Your right to continued participation in a group health plan during leaves of absence for
active military duty is protected by the Uniformed Services Employment and Reemployment
Rights Act (USERRA). Accordingly, if you are absent from work due to a period of active
duty in the military for less than 31 days, your plan participation will not be interrupted. If the
absence is for more than 30 days and not more than 12 weeks, you may continue to maintain
your coverage under a group health plan by paying premiums in the manner specified by the
Plan Sponsor.
If you do not elect to continue to participate in a group health plan during an absence
for military duty that is more than 30 days, or if you revoke a prior election to continue to
participate for up to 12 weeks after your military leave began, you and your covered family
members will have the opportunity to elect continuation coverage under a group health plan for
up to the 24-month period that begins on the first day of your leave of absence. You must pay
the premiums for continuation coverage with after-tax funds, subject to the rules that are set out
in the applicable Plan features.
USERRA continuation coverage is considered alternative coverage for purposes of
COBRA. Therefore, if you elect USERRA continuation coverage, COBRA coverage will
generally not be available.
F. Leave under Family Medical Leave Act
If you take a leave of absence (i) for your own serious health condition, (ii) to care for
family members with a serious health condition, (iii) to care for a newborn or adopted child,
(iv) to care for an injured or ill covered service member of the Armed Forces or (v) due to a
qualifying exigency arising out of a covered service member's active duty, you may be able to
continue your health coverage under the Plan. If you drop your health coverage during the
leave, you can also have your health coverage reinstated on the date you return to work
assuming you pay any contributions required for the coverage. See the Plan Administrator for
more information about your FMLA rights.
G. COBRA
1. Introduction
"COBRA continuation coverage' for purposes of this Plan means the continuation of
group health care coverage within the meaning of Sections 2201 through 2208 of the Public
Health Services Act. COBRA continuation coverage can become available to you and to other
members of your family who are covered under the Plan when you would otherwise lose your
group health coverage. The following generally explains COBRA continuation coverage,
when it may become available to you and your family, and what you need to do to protect
the right to receive it. This notice gives only a summary of your COBRA continuation
coverage rights. For more information about your COBRA rights and obligations under the
Plan and under Federal law, you should ask the Plan Administrator.
The Plan Administrator is responsible for administering COBRA continuation coverage,
but the Plan Administrator may delegate its administrative duties to a third party administrator
from time to time. The Plan Administrator has delegated authority for administering COBRA
continuation coverage to the COBRA administrator referenced in the Schedule of Benefits.
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2. COBRA Continuation Coverage
COBRA continuation coverage is a continuation of group health plan coverage when
coverage would otherwise end because of a life event known as a "qualifying event." COBRA
applies to each group health plan Specific qualifying events are listed later. COBRA
continuation coverage must be offered to each person who is a "qualified beneficiary." A
qualified beneficiary is someone who will lose coverage under the Plan because of a qualifying
event. Depending on the type of qualifying event, employees, spouses of employees, and
dependent children of employees may be qualified beneficiaries. Qualified beneficiaries who
elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you will lose your
coverage under a group health plan because either one of the following qualifying events
happens:
• Your hours of employment are reduced; or
• Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you
will lose your coverage under a group health plan because any of the following qualifying
events happens:
• Your spouse dies;
• Your spouse's hours of employment are reduced;
• Your spouse's employment ends for any reason other than his or her gross
misconduct;
• Your spouse becomes entitled to Medicare (Part A, Part B, or both); or
• You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they will lose coverage
under a group health plan because any of the following qualifying events happens:
• The parent -employee dies;
• The parent -employee's hours of employment are reduced;
• The parent -employee's employment ends for any reason other than his or her gross
misconduct;
• The parent -employee becomes entitled to Medicare (Part A, Part B, or both);
13
• The parents become divorced or legally separated; or
• The child stops being eligible for coverage under the plan as a "dependent child."
Each group health plan under the Plan will offer COBRA continuation coverage to
qualified beneficiaries only after the Plan Administrator (or third -party COBRA administrator,
as applicable) has been notified that a qualifying event has occurred. When the qualifying
event is the end of employment or reduction of hours of employment, death of the employee, or
entitlement of the employee to Medicare (Part A, Part B, or both), the Plan Sponsor must notify
the Plan Administrator (or third -party COBRA administrator, as applicable) of the qualifying
event within 30 days of the date the event occurs or the date you would otherwise lose coverage
under the group health plan due to a qualifying event, whichever is later.
For the other qualifying events (divorce or legal separation of the employee and spouse
or a dependent child's losing eligibility for coverage as a dependent child), you must notify the
Plan Administrator (or third -party COBRA administrator, as applicable). Each group health
plan covered under the Plan requires you to notify the Plan Administrator (or third -party
COBRA administrator, as applicable) within 60 days after the qualifying event occurs or the
date you would otherwise lose coverage under the group health plan due to a qualifying event,
whichever is later.
Within 14 days of the Plan Administrator (or third -party COBRA administrator, as
applicable) receiving notice (in accordance with the procedures set forth below under
"Furnishing Notice to Administrator") that a qualifying event has occurred, the Plan
Administrator (or third -party COBRA administrator, as applicable) will send out an election
notice, offering COBRA continuation coverage to each of the qualified beneficiaries. For each
qualified beneficiary who elects COBRA continuation coverage, COBRA continuation
coverage will begin on the date that coverage under the group health plan would otherwise
have been lost.
COBRA continuation coverage is a temporary continuation of coverage. When the
qualifying event is the death of the employee, enrollment of the employee in Medicare (Part A,
Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as a
dependent child, COBRA continuation coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the employee's
hours of employment, COBRA continuation coverage lasts for up to 18 months. However,
with respect to the extension of coverage under the healthcare flexible spending account of the
Cafeteria Plan, continuation coverage will extend only until the end of the calendar year in
which the qualifying event occurs.
There are two ways in which this 18-month period of COBRA continuation coverage
can be extended.
14
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under a group health plan is determined by the
Social Security Administration to be disabled at any time during the first 60 days of COBRA
continuation coverage and you notify the Plan Administrator (or third -party COBRA
administrator, as applicable) in a timely fashion, you and your entire family can receive up to
an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months.
You must make sure that the Plan Administrator (or third -party COBRA administrator,
as applicable) is notified of the Social Security Administration's determination within 60 days
of the latest of the date of the determination, the date of the qualifying event or the date you
would otherwise lose coverage under the group health plan due to a qualifying event, and
before the end of the 18-month period of COBRA continuation coverage.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving COBRA
continuation coverage, and such event would result in loss of health coverage if the first
qualifying event had not already occurred, the spouse and dependent children in your family
can get additional months of COBRA continuation coverage, up to a maximum of 36 months.
This extension is available to the spouse and dependent children if the former employee dies,
becomes entitled to Medicare (Part A, Part B, or both), or gets divorced or legally separated.
The extension is also available to a dependent child when that child stops being eligible for
coverage under the group health plan as a dependent child. In all of these cases, you must
make sure that the Plan Administrator (or third -party COBRA administrator, as applicable) is
notified of the second qualifying event within 60 days of the second qualifying event or the
date you would otherwise lose coverage under the group health plan due to a qualifying event,
whichever is later.
Furnishing Notice to Administrator
Unless the Plan has a third -party COBRA administrator, in which case qualified
beneficiaries should follow the notice procedures established by the third -party COBRA
administrator, when furnishing a notice to the Plan Administrator with respect to the occurrence
of a qualifying event or with respect to a disability determination by the Social Security
Administration, such notices will be delivered to the human resources department of the Plan
Administrator (i) by hand -delivery, (ii) via facsimile, followed by written confirmation by first
class mail, or (iii) by registered or certified mail, return receipt requested. Such notices will
include the name(s) of the covered employee and/or qualified beneficiaries, as applicable, a
general description of, and circumstances surrounding, the qualifying event or disability
determination, and the date of such qualifying event or disability determination. Once the Plan
Administrator receives such notice, it reserves the right to make further inquiry to verify the
circumstances surrounding such qualifying event or disability determination.
End of Continuation Coverage
Continuation coverage will end earlier than the period elected if:
15
• Timely payment of premiums for the continuation coverage is not made;
• The qualified beneficiary first becomes covered under any other group health plan,
after the COBRA election, as an employee or otherwise;
• The qualified beneficiary first becomes entitled to benefits under Medicare, after the
COBRA election;
• The Plan Sponsor ceases to provide any group health plan to any employee;
• You, as the covered employee, cease to be disabled, if continuation coverage is due
to your disability; or
• The period of continuation coverage expires.
Health Insurance Marketplace
You may have other options available to you when you lose group health coverage. For
example, you may be eligible to buy an individual plan through the Health Insurance
Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower
costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify
for a 30-day special enrollment period for another group health plan for which you are eligible
(such as a spouse's plan), even if that plan generally doesn't accept late enrollees. For more
information about the Marketplace, visit www.healthcare.gov.
If you have questions
If you have questions about your COBRA continuation coverage, you should contact
the Plan Administrator or you may contact the nearest regional or district office of the U.S.
Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and
phone numbers of regional and district EBSA offices are available through EBSA's website at
www.dol.gov/ebsa.
Keep your plan informed of address changes
In order to protect your family's rights, you should keep the Plan Administrator (and
third -party COBRA administrator, if applicable) informed of any changes in the addresses of
family members. You should also keep a copy for your records of any notices you send to the
Plan Administrator (or third -party COBRA administrator, as applicable).
H. FUNDING POLICY
Benefits furnished hereunder are provided through the purchase of insurance policies
and other provider contracts, or funded by the Plan Sponsor and self-administered or
administered by a third party claims administrator, as indicated in Schedule A. The Plan
Sponsor will collect the applicable employee premiums and will pay when due all premiums
16
required to keep such policies and contracts in force. Funding is derived from the funds of the
Plan Sponsor and contributions made by the employees and retirees. To the extent you are
required to make contributions toward the cost of a particular benefit feature, your
contributions will be used in their entirety prior to using Plan Sponsor contributions to pay for
the cost of such benefit. Accordingly, any claims experience dividends, refunds or other
adjustments in premiums, fees or other Plan costs related to benefits provided under the Plan
may be used to reduce the amount of contributions made by the Plan Sponsor. The level of any
employee and retiree contributions is set by the Plan Sponsor, which will be communicated to
you when you first enroll in the Plan, and during each open and special enrollment period. The
Plan Sponsor reserves the right to modify employee and retiree contribution amounts.
Employee and retiree contributions will be used to fund, or reimburse the Plan Sponsor for
funding, the cost of the Plan benefits as soon as practicable after they have been received from
the employee or retiree or withheld from the employee's pay through payroll deduction.
Contributions by Participants
(a) With respect to each underlying component Welfare Benefit provided under the
Plan, Participants shall make contributions with respect to each Welfare Benefit, if any, in the
amounts specified and adjusted from time to time by the Employer for particular groups of
Participants. At least annually, the Employer shall provide to individuals eligible to participate
in the Plan with respect to a given Welfare Benefit a schedule of the required contributions, if
any, for such Welfare Benefits
(b) Unless the Plan documentation referenced in Appendix A with respect to a given
component Welfare Benefit expressly provides to the contrary or is otherwise impermissible
under applicable law, each Participant required to make contributions under this Section 4.1
who is an Employee of the Employer shall authorize payment of his contributions by payroll
deduction pursuant to the terms of the premium conversion -only cafeteria plan as set forth in
Appendix D.
SUBROGATION AND RIGHTS OF RECOVERY
The Plan is designed to only pay covered expenses under each Plan feature for which
payment is not available from anyone else, including any insurance company or any other
health or welfare plan. In order to help you and your covered dependents in a time of need,
however, the Plan may pay covered expenses that may be or become the responsibility of
another person, provided that the Plan later receives reimbursement for those payments
(hereinafter called "Reimbursable Payments").
Therefore, by enrolling in the Plan, as well as by applying for payment of covered
expenses, you and your dependents are subject to, and agree to, the following terms and
conditions with respect to the amount of covered expenses paid by the Plan.
Assignment of Rights (Subrogation)
You and your dependents automatically assign to the Plan any rights (or causes of
action) you and/or your dependents may have to recover all or part of the same covered
17
expenses from any party, including an insurer or any other group health or welfare program,
but limited to the amount of Reimbursable Payments made by the Plan. This assignment
includes, without limitation, the assignment of a right to (or causes of action for) any funds paid
by a third party to you and/or any of your dependents or paid to another for your benefit (or the
benefit of one of your dependents). This assignment applies on a first -dollar basis (i.e., has
priority over other rights), applies whether the funds paid to (or for the benefit of) you and/or
one of your dependents constitute a full or a partial recovery, and even applies to funds paid for
non -medical or non -disability charges, attorney fees, or other costs and expenses. This
assignment also allows the Plan to pursue any claim that you and/or any of your dependents
may have, whether or not you or such dependent chooses to pursue that claim. By this
assignment, the Plan's right to recover from insurers includes, without limitation, such recovery
rights against no-fault auto insurance carriers in a situation where no third party may be liable,
and from any uninsured or underinsured motorist coverage, homeowner's plan, renter's plan, or
any other insurance policy under which you or your dependents are insured.
The Plan will not be responsible for expenses or attorney's fees incurred by you or your
dependents in connection with any recovery. Accordingly, you and your dependents must pay
your own legal fees.
Equitable Liens/Equitable Remedies
The Plan shall also have an equitable lien against any rights (or causes of action) you
and/or your dependents may have to recover the same covered expenses from any party,
including an insurer or any other group health or welfare program, but limited to the amount of
Reimbursable Payments made by the Plan. The equitable lien also attaches to any right to
payment from workers' compensation, whether by judgment or settlement, where the Plan has
paid covered expenses prior to a determination that the covered expenses arose out of and in the
course of employment. Payment by workers' compensation insurers or the employer will be
deemed to mean that such a determination has been made.
This equitable lien shall also attach to any money or property that is obtained by anyone
(including, but not limited to, you or your dependent, your or your dependent's attorney, and/or
a trust) as a result of an exercise of your and/or your dependent's rights of recovery (sometimes
referred to as "proceeds"). The Plan shall also be entitled to seek any other equitable remedy
against any party possessing or controlling such proceeds. At the discretion of the Plan
Administrator, the Plan may reduce any future covered expenses otherwise available to you
and/or your dependents under the Plan by an amount up to the total amount of Reimbursable
Payments made by the Plan that is subject to the equitable lien.
Assisting Reimbursement Activities
You and your covered dependents have an obligation to assist the Plan to obtain
reimbursement of the Reimbursable Payments that it has made on your behalf (and on behalf of
your dependents), and to provide the Plan with any information concerning your and/or your
dependent's other insurance coverage (whether through automobile insurance, other group
health or welfare program, or otherwise) and any other person or entity (including their
18
insurer(s)) that may be obligated to provide payments or benefits on your behalf (or on behalf
of one of your dependents). You and/or your dependents are required to: (a) cooperate fully in
the Plan's exercise of its right to subrogation and reimbursement; (b) not do anything to
prejudice those rights (such as settling a claim against another party without including the Plan
as a co -payee for the amount of the Reimbursable Payments and notifying the Plan); (c) sign
any document deemed by the Plan Administrator to be relevant to protecting the Plan's
subrogation, reimbursement or other rights; and (d) provide relevant information when
requested. The term "information" includes any documents, insurance policies, police reports,
or any reasonable request by the Plan Administrator to enforce the Plan's rights.
Failure by you or your dependents to follow the above terms and conditions may result,
at the discretion of the Plan Administrator, in a reduction from future benefit payments
available to you or your dependents under the Plan of an amount up to the aggregate amount of
Reimbursable Payments that has not been reimbursed to the Plan.
The Plan's rights hereunder shall not be construed to interfere or conflict in any way
with the provisions of any insurance policies or other provider contracts that are made part of
the Plan. Rather, the Plan's rights under this Section I shall run concurrent with any such
similar right provided to any such insurer, vendor or provider under the Plan, but in no event
shall you, or any of your dependents, as the case may be, be obligated to make payments to the
Plan in excess of the Reimbursable Payments.
4. Recovery of Overpayments
Whenever a payment has been made under any Plan Feature in a total amount, at any
time, in excess of the maximum amount payable under the Plan's provision ("Overpayment"),
you or any other participant must refund to the Plan the applicable Overpayment and help the
Plan obtain the refund of the Overpayment from another person or organization. This includes
any Overpayments resulting from retroactive awards received from any source, fraud, or any
error made in processing your claim.
In case of a recovery from a source other than the Plan, Overpayment recovery will not
be more than the amount of the payment.
The Plan Administrator may, at its option, recover the Overpayment by reducing or
offsetting against any future benefits payable under the Plan; stopping future benefit payments
that would otherwise be due under the Plan (payments may continue when the Overpayment
has been recovered); or demanding an immediate refund of the Overpayment.
J. PLAN IS NOT AN EMPLOYMENT CONTRACT
The Plan will not be construed as a contract for or of employment.
19
K. HIPAA PRIVACY AND SECURITY PROVISIONS
1. Disclosure of Information
(a) The Plan Sponsor may only use and/or disclose Protected Health Information (as
such term is defined in 45 C.F.R. § 160.103) as permitted by the "Standards for
Privacy of Individually Identifiable Health Information" under the Health Insurance
Portability and Accountability Act of 1996, P.L.104-191, as amended by the Health
Information Technology for Economic and Clinical Health Act ("HITECH Act")
portion of the American Recovery and Reinvestment Act of 2009, and applicable
guidance (the "Privacy Rule").
(b) The Plan will disclose Protected Health Information to the Plan Sponsor only upon
its receipt of a certification by the Plan Sponsor that the Plan Sponsor agrees to:
• Not use or further disclose the information other than as permitted or required
by the Plan documents or as required by law;
• Ensure that any agents, including subcontractors, to whom it provides Protected
Health Information and electronic Protected Health Information received from
the Plan agree to the same restrictions and conditions that apply to the Plan
Sponsor with respect to such information;
• Not use or disclose the Protected Health 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 Plan any use or disclosure of the Protected Health Information that
is inconsistent with the uses or disclosures permitted by the Privacy Rule of
which it becomes aware;
• Make available Protected Health Information based on HIPAA's access
requirements in accordance with 45 C.F.R. § 164.524;
• Make available Protected Health Information for amendment and incorporate
any amendments to Protected Health Information in accordance with 45 C.F.R.
§ 164.526;
• Make available the information required to provide an accounting of disclosures
in accordance with 45 C.F.R. § 164.528, including an accounting of disclosures
of any electronic health record (as defined in HIPAA);
• Make its internal practices, books, and records relating to the use and disclosure
of Protected Health Information received from the Plan available to the
Secretary of Health and Human Services for purposes of determining
compliance by the Plan with the Privacy Rule;
20
If feasible, return or destroy all Protected Health Information received from the
Plan that the 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; and
• Ensure that adequate separation of the Plan and the Plan Sponsor is established
as required by 45 C.F.R. 164.504(f)(2)(iii) as described below.
2. Certification of the Plan Sponsor
The Plan (or a health insurance issuer or HMO with respect to the Plan, if applicable)
will disclose Protected Health Information to the Plan Sponsor only upon the receipt of a
certification by the Plan Sponsor that the Plan has been amended to incorporate the provisions
of 45 C.F.R. § I64.504(f)(2)(ii), and that the Plan Sponsor agrees to the conditions of disclosure
set forth in Section K.1. The Plan will not disclose and may not permit a health insurance
issuer or HMO to disclose Protected Health Information to the Plan Sponsor as otherwise
permitted herein unless the statement required by 45 C.F.R. § 164.520(b)(1)(iii)(C) is included
in the appropriate notice.
3. Separation of Plan and the Plan Sponsor
• Only the Insurance Committee and designated employees in the Human Resources
Department of the Plan Sponsor ("Permitted Employees") will be given access to the
Protected Health Information. Despite the foregoing, any employee or person not
described above who receives Protected Health Information relating to payments under,
health care operations of, or other matters pertaining to the Plan in the ordinary course
of business, will also be included in the definition above of Permitted Employees.
Members of the Insurance Committee and designated employees in the Human
Resources Department will be required to sign an Confidentiality Agreement.
• The Permitted Employees may only use the Protected Health Information for Plan
administrative functions that the Plan Sponsor performs for the Plan.
4. Security of Electronic Protected Health Information
In accordance with 45 C.F.R. § 164.314(b)(2), to the extent as may be required by law,
the Plan Sponsor agrees to:
• Implement administrative, physical, and technical safeguards that reasonably and
appropriately protect the confidentiality, integrity, and availability of the electronic
Protected Health Information that the Plan Sponsor may create, receive, maintain, or
transmit on behalf of the Plan;
21
Ensure that the adequate separation required by 45 C.F.R. § 164.504(f)(2)(iii) is
supported by reasonable and appropriate security measures;
Ensure that any agents, including subcontractors, to whom it provides electronic
Protected Health Information agrees to implement reasonable and appropriate
security measures to protect the information; and
• Report to the Plan any security incident of which it becomes aware with respect to
electronic Protected Health Information.
L. Claims Procedure for the Plan
Except as provided in Paragraph 1 below, claims for benefits under each Plan
feature will be reviewed in accordance with procedures contained in the policies,
contracts, summary plan descriptions or other written materials for such Plan features
("Component Documents"). However, all issues or disputes solely regarding eligibility for
coverage or participation and all other general inquiries or requests should be directed to the
Plan Administrator. If a non -insurance related claim under the Plan is denied in whole or in
part, you or your beneficiary will receive written notification. The notification will include the
reasons for the denial, with reference to the specific provisions of the Plan on which the denial
was based, a description of any additional information needed to process the claim and an
explanation of the claims review procedure. If the Plan Administrator fails to respond within
90 days, your claim is treated as denied. (This period may be extended to 180 days under
certain circumstances.) Within 60 days after denial, if you want to appeal such denial, you or
your beneficiary may submit a written request for reconsideration of the application to the Plan
Administrator.
Any such request should be accompanied by documents or records in support of your
appeal. You or your beneficiary may review pertinent documents and submit issues and
comments in writing. The Plan Administrator will review the claim and provide, within 60
days, a written response to the appeal. (This period may be extended to 120 days under certain
circumstances.) In this response, the Plan Administrator will explain the reason for the
decision, with specific reference to the provisions of the Plan on which the decision is based.
The Plan Administrator has the exclusive right to interpret the provisions of the Plan.
Decisions of the Plan Administrator are final, conclusive and binding. The Plan Administrator
has final claims adjudication authority under the Plan. However, the Plan Administrator may
delegate duties and authority to others to accomplish those duties. For instance, the applicable
administrator listed in the table in Schedule A is the claims administrator for the respective plan
feature; each has sole and complete discretionary authority to determine claims and appeals in
accordance with the terms of the documents or instruments governing the plan in which you are
enrolled.
The insurer of each "insured" plan sponsored by the Employer has sole and complete
discretionary authority to administer and interpret the provisions of the plan it insures. Please
see the table in Schedule A to determine whether a plan is insured and for corresponding
contact information for the applicable insurer or claims administrator.
22
Authorized Representatives
If you wish to designate an authorized representative to act on your behalf with respect
to your claim for benefits, you must do so in writing. Please be advised that no rights under the
Plan, including but not limited to the right to receive any benefit or any right to pursue a claim
or cause of action, are assignable. Any payment by the Plan directly to a provider pursuant to a
written election or purported assignments submitted by a participant or a dependent is provided
at the discretion of the Plan Administrator as a convenience to the participant or dependent and
does not imply an enforceable assignment of any benefits or the right to pursue a claim or cause
of action.
Please be further advised that no rights under the Plan, including but not limited to the right
to receive any benefit or any right to pursue a claim or cause of action, are assignable. Any
payment by the Plan directly to a provider pursuant to a written election or purported
assignments submitted by a participant or a dependent is provided at the discretion of the Plan
Administrator as a convenience to the participant or dependent and does not imply an
enforceable assignment of any benefits or the right to pursue a claim or cause of action.
1. Claims Procedures for a Group Health Plan
The following claims procedure will apply specifically to claims made under any group
health plan covered under the Plan. To the extent that this procedure is inconsistent with
the claims procedures contained in the policies, contracts, summary plan descriptions or
other written materials for a group health plan covered under the Plan, the claims
procedures in such other policies, contracts, summary plan descriptions, or other written
materials will supersede this procedure as long as such other claims procedures comply
with applicable law.
Benefit Determinations
Post -Service Claims
Post -Service Claims are those claims that are filed for payment of benefits after health
care has been received. If your Post -Service Claim is denied, you will receive a written notice
from the Plan Administrator within 30 days of receipt of the claim, as long as all needed
information was provided with the claim. The Plan Administrator will notify you within this
30- day period if additional information is needed to process the claim, and may request a one-
time extension not longer than 15 days and hold your claim until all information is received.
Once notified of the extension, you then have 45 days to provide this information. If all
of the needed information is received within the 45-day time frame and the claim is denied, the
Plan Administrator will notify you of the denial within 15 days after the information is
received. If you don't provide the needed information within the 45-day period, your claim
will be denied.
f3
Pre -Service Claims
Pre -Service Claims are those claims that require notification or approval prior to
receiving health care. If your claim is a Pre -Service Claim, and it is submitted improperly, the
Plan Administrator will notify you of the improper filing and how to correct it within 5 days. If
your Pre -Service Claim is submitted properly with all needed information, you will receive
written notice of the claim decision from the Plan Administrator within 15 days of receipt of
the claim. The Plan Administrator will notify you within this 15-day period if additional
information is needed to process the claim, and may request a one-time extension not longer
than 15 days and hold your claim until all information is received. Once notified of the
extension, you then have 45 days to provide this information. If all of the needed information
is received within the 45-day time frame, the Plan Administrator will notify you of the
determination within 15 days after the information is received. If you don't provide the needed
information within the 45-day period, your claim will be denied.
Urgent Claims
Urgent Care Claims are those claims that require notification or approval prior to
receiving medical care, where a delay in treatment could seriously jeopardize your life or health
or the ability to regain maximum function or, in the opinion of a doctor with knowledge of your
health condition, could cause severe pain. In these situations:
You will receive notice of the benefit determination in writing or electronically
within 72 hours after the Plan Administrator receives all necessary information,
taking into account the seriousness of your condition.
Notice of denial may be oral with a written or electronic confirmation to follow
within 3 days.
If you file an Urgent Care Claim improperly, the Plan Administrator will notify you of
the improper filing and how to correct it within 24 hours after the Urgent Care Claim is
received. If additional information is needed to process the claim, the Plan Administrator will
notify you of the information needed within 24 hours after the claim was received. You then
have 48 hours to provide the requested information.
You will be notified of a determination no later than 48 hours after:
The Plan Administrator's receipt of the requested information; or
The end of the 48-hour period within which you were to provide the additional
information.
Concurrent Care Claims
If an on -going course of treatment was previously approved for a specific period of time
or number of treatments, and your request to extend the treatment is an Urgent Care Claim as
defined above, your request will be decided within 24 hours, provided your request is made at
least 24 hours prior to the end of the approved treatment. The claims administrator will make a
24
determination on your request for the extended treatment within 24 hours from receipt of your
request. If your request for extended treatment is not made at least 24 hours prior to the end of
the approved treatment, the request will be treated as an Urgent Care Claim and decided
according to the timeframes described above.
If an ongoing course of treatment was previously approved for a specific period of time
or number of treatments, and you request to extend treatment in a non -urgent circumstance,
your request will be considered a new claim and decided according to post -service or pre -
service timeframes, whichever applies.
Benefits Determination Notice
A denial notice for a group health plan will include:
• the specific reason(s) for your adverse benefit determination;
• reference to the specific Plan provision on which the determination is based;
• a description of any additional material or information necessary for you to fix your
claim and an explanation of why such material or information is necessary;
• a description of the review procedures, including a statement of your right to bring a
lawsuit following an adverse benefit determination on review;
• either the specific rule or guideline used in making your benefits determination or a
statement that such a rule or guideline was relied upon in making the determination
and that a copy of such rule or guideline will be provided free of charge upon
request;
• if the adverse benefit determination is based on a medical judgment, either an
explanation of such judgment, or a statement that such explanation will be provided
to you free of charge upon request; and
• in the case of an Urgent Care Claim, a description of the expedited review process
to which you may be entitled.
In addition to the notice standards described above, to the extent required by the
Affordable Care Act, all adverse benefit determination notices will include the following: (a)
information identifying the claim involved, including the date of service, the health care
provider, the claim amount, the diagnosis code, the treatment code, and the corresponding
meaning of those codes; (b) the reason or reasons for the adverse benefit determination that
includes the denial code and its corresponding meaning and a description of the Plan's
standard, if any, that was used to deny the claim (for notices of final internal adverse benefit
determinations, the description will include a discussion of the decision); (c) a description of
available internal appeals and external review processes, including how to initiate an appeal;
and (d) contact information for any applicable office of health insurance consumer assistance or
25
ombudsman established under the Affordable Care Act to assist individuals with the internal
claims and appeals and external review processes.
How to Appeal a Claim Decision
If you disagree with a claim determination, you can contact the Plan Administrator in
writing to formally request an appeal. If the appeal relates to a claim for payment, your request
should include:
• The patient's name and the identification number from the ID card.
• The date(s) of health care service(s).
• The provider's name.
• The reason you believe the claim should be paid.
• Any documentation or other written information to support your request for claim
payment.
Your first appeal request must be submitted to the Plan Administrator within 180 days
after you receive the claim denial.
Appeal Process
A qualified individual who was not involved in the decision being appealed will be
appointed to decide the appeal. If your appeal is related to clinical matters, the review will be
done in consultation with a health care professional with appropriate expertise in the field who
was not involved in the prior determination. The Plan Administrator may consult with, or seek
the participation of, medical experts as part of the appeal resolution process. You consent to
this referral and the sharing of pertinent health claim information. Upon request and free of
charge you have the right to reasonable access to and copies of, all documents, records, and
other information relevant to your claim for benefits.
Appeals Determinations
Pre -Service and Post -Service Claim Appeals
You will be provided with written or electronic notification of the decision on your
appeal as follows:
For appeals of Pre -Service Claims, the first level appeal will be conducted and you will
be notified by the Plan Administrator of the decision within 15 days from receipt of a request
for appeal of a denied claim. The second level appeal will be conducted and you will be
notified by the Plan Administrator of the decision within 15 days from receipt of a request for
review of the first level appeal decision.
26
For appeals of Post -Service Claims, the first level appeal will be conducted and you will
be notified by the Plan Administrator of the decision within 30 days from receipt of a request
for appeal of a denied claim. The second level appeal will be conducted and you will be
notified by the Plan Administrator of the decision within 30 days from receipt of a request for
review of the first level appeal decision.
For procedures associated with Urgent Claims, see "Urgent Claim Appeals" below.
If you are not satisfied with the first level appeal decision of the Plan Administrator,
you have the right to request a second level appeal from the Plan Administrator. Your second
level appeal request must be submitted to the Plan Administrator within 60 days from receipt of
first level appeal decision.
Please note that the Plan Administrator's decision is based only on whether or not
benefits are available under the group health plan for the proposed treatment or procedure. The
determination as to whether the pending health service is necessary or appropriate is between
you and your doctor.
Urgent Claim Appeals
Your appeal may require immediate action if a delay in treatment could significantly
increase the risk to your health or the ability to regain maximum function or cause severe pain.
In these urgent situations, the appeal does not need to be submitted in writing. You or your
doctor should call the Plan Administrator as soon as possible, and provide the Plan
Administrator with the information identified above under "How to Appeal a Claim Decision."
The Plan Administrator will provide you with a written or electronic determination within 72
hours following receipt of your request for review of the determination taking into account the
seriousness of your condition.
Appeal Determination Notice
Your review decision on appeal will include:
• the specific reason(s) for the adverse determination;
• reference to the specific Plan provision on which the benefit determination is based;
a statement that you are entitled to receive, without charge, reasonable access to any
document (i) relied on in making the determination, (ii) submitted, considered or
generated in the course of making the benefit determination, (iii) that demonstrates
compliance with the administrative processes and safeguards required in making the
determination, or (iv) that constitutes a statement of policy or guidance with respect
to the Plan concerning the denied treatment without regard to whether the statement
was relied on;
27
• either the specific rule or guideline used in making your benefits determination or a
statement that such a rule or guideline was relied upon in making the determination
and that a copy of such rule or guideline will be provided free of charge upon
request;
• if the adverse determination is based on medical necessity or experimental treatment
or a similar exclusion or limit, either an explanation of the scientific or clinical
judgment applying the terms of the Plan to your medical condition, or a statement
that such explanation will be provided without charge on request;
• a statement describing the Plan's optional appeals procedures, and your right to
receive information about such procedures, as well as your right to bring a lawsuit;
and
• the following statement: "You and your Plan may have other voluntary alternative
dispute resolution options, such as mediation. One way to find out what may be
available is to contact your local U.S. Department of Labor Office and your State
insurance regulatory agency."
If you file an internal appeal for medical benefits, you will continue to be covered
pending the outcome of the internal appeal. This means that the Plan shall not terminate or
reduce any ongoing course of treatment without providing advance notice and the opportunity
for review.
Voluntary External Review
If the Group Medical Feature in which you are enrolled is not subject to a State external
review process and is not a "grandfathered" plan for purposes of the Affordable Care Act, and
your internal appeal of a claim for benefits (not related to employee classifications or non -
covered benefits) under such plan is denied, you will have the right to request an external (i.e.,
independent) review if you do so within four months after receiving notice of an adverse
benefit determination or final internal adverse benefit determination. Within five business days
after receiving your request, a preliminary review will be completed to determine whether: (i)
you are/were covered under the Plan; (ii) the denial was based on your ineligibility under the
terms of the Plan; (iii) you have exhausted the Plan's internal process, if required; and (iv) you
provided all information necessary to process the external review. Within one business day
after completing the preliminary review, you will be notified in writing if your appeal is not
eligible for an external review or if it is incomplete. If your appeal is complete but not eligible,
the notice will include the reason(s) for ineligibility. If your appeal is not complete, the notice
will describe any information needed to complete the appeal. You will have the remainder of
the four -month filing period or 48 hours after receiving the notice, whichever is greater, to cure
any defect. If eligible for an external review, your appeal will be assigned to an independent
review organization (IRO). If the IRO reverses the Plan's denial, the IRO will provide you
written notice of its determination.
28
In addition, you will have the right to an expedited external review in the following
situations:
Following an adverse benefit determination involving a medical condition for which the
timeframe for completion of an expedited internal appeal would seriously jeopardize
your life or health or would jeopardize your ability to regain maximum function and
you have filed a request for an expedited internal appeal.
Following a final internal adverse benefit determination involving (i) a medical
condition for which the timeframe for completion of a standard external review would
seriously jeopardize your life or health or would jeopardize your ability to regain
maximum function or (ii) an admission, availability of care, continued stay, or health
care item or service for which you received emergency services but have not been
discharged from a facility.
The IRO will provide notice of its final external review decision as expeditiously as
your medical condition or circumstances require, but not more than 72 hours after the IRO
receives the request.
2. City Government Authority and Responsibility
The Plan Administrator has the exclusive right to interpret the provisions of the Plan.
Decisions of the Plan Administrator are final, conclusive and binding. The Plan Administrator
has final claims adjudication authority under the Plan.
2sr
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
APPENDIX A
Look -Back Measurement Method
This Appendix, effective January 1, 2018, describes the Group Medical Feature's
eligibility provisions applicable to employees who are not eligible to participate in the Group
Medical Feature solely because they are not regularly scheduled to work at least 30 hours per
week. In the event there is a conflict between Appendix A and another Plan provision, the Plan
terms will control; provided that it is the intention of the Employer that this Appendix A be
given effect to the fullest extent possible.
A. DEFINITIONS
Terms defined in the Plan shall have the same meanings when used in this Appendix,
except as provided below. In addition, the following words and phrases shall have the
meanings stated:
1. "Break in Service" means a period of.
• Thirteen (13) consecutive weeks (or more) during which an Employee has no, and is
not credited with any, Hours of Service, or
• At the Plan Administrator's discretion, four (4) consecutive weeks (or more) during
which an Employee has no, and is not credited with any, Hours of Service, if the
period with no Hours of Service is greater than the immediately preceding period of
employment.
2. "Code" means Internal Revenue Code of 1986, as amended, and regulations issued
thereunder or pursuant thereto.
3. "Employee" means a person currently performing services under the Employer's
control, except for employees excluded under section B.1. Employee Eligibility
Requirements.
4. "Employer" means the Plan Sponsor.
5. "Hours of Service" means an hour for which an Employee is (A) paid, or entitled to
payment, for the performance of duties for the Employer, or (B) entitled to payment by
the Employer due to vacation, holiday, illness, incapacity (including disability), layoff,
jury duty, military duty or leave of absence. Notwithstanding the foregoing, hours paid
through disability benefits from coverage purchased by employees on an after-tax basis
or hours paid solely to comply with a workers' compensation law will not be treated as
hours of service.
30
6. "Initial Administrative Period" means the one (1) month period beginning immediately
after the end of the Initial Measurement Period and ending immediately before the start
of the Initial Stability Period. The Initial Administrative Period also includes the period
between a new Employee's hire date and the beginning of the Initial Measurement
Period, to the extent that the Initial Measurement Period does not begin on the new
Employee's date of hire.
7. "Initial Measurement Period" means the period beginning on the first day of the
calendar month following the Employee's start date and ending twelve (12) months
later. The Employer shall measure the Employee's Hours of Service during the Initial
Measurement Period as described in Paragraph B of this Appendix.
8. "Initial Stability Period" means the period of time beginning immediately after the
Initial Administrative Period, and ending twelve (12) months later.
9. "Ongoing Employee" means an Employee who has been employed by the Employer for
at least one complete Standard Measurement Period.
10. "Part-time Employee" means a new Employee who is not regularly scheduled to work
30 hours per week or more, and whom the Employer reasonably expects at the time of
hire to work on average less than 30 Hours of Service per week during the Initial
Measurement Period.
11. "Seasonal Employee" means an Employee who is hired into a position for which the
Employer determines that the customary annual employment is six months or less and
at approximately the same time each year.
12. "Standard Administrative Period" means the period beginning immediately after the end
of the Standard Measurement Period and ending immediately before the start of the
Standard Stability Period.
13. "Standard Measurement Period" means the twelve (12) month period beginning
October 7 and ending October 6. The Employer shall measure an Ongoing Employee's
Hours of Service during the Standard Measurement Period as described in Section B of
this Appendix.
14. "Standard Stability Period" means the Plan Year immediately following the end of a
Standard Measurement Period and Standard Administrative Period.
15. "Variable Hour Employee" means a new Employee who is not regularly scheduled to
work 30 hours or more per week, and with respect to whom, based on the facts and
circumstances at the Employee's start date, the Employer cannot reasonably determine
whether the Employee will average at least 30 Hours of Service per week over the
Initial Measurement Period because the Employee's hours are variable or otherwise
uncertain.
3I
B. ELIGIBILITY
1. An Employee not otherwise eligible for the Group Medical Feature solely because he or
she is not regularly scheduled to work at least 30 hours per week shall be eligible for
Plan participation on:
• For an Ongoing Employee, the first day of the Plan Year following the end of the
Standard Measurement Period in which the Employee averaged at least 30 Hours of
Service per week.
For Part-time, Variable Hour and Seasonal Employees, if the Employee averages at
least 30 Hours of Service per week during the Initial Measurement Period, such
Employee will be eligible as of the first day of the Initial Stability Period, which
shall be no later than the first of the month following 13 consecutive months after
the Employee's date of hire. However, if the Employee experiences a change in
employment status during the Initial Measurement Period such that, had the
Employee begun employment in the new position or status, the Employee would
have been expected to work at least 30 Hours of Service per week (and would not
have been a Seasonal Employee), the Employee will be eligible for Plan benefits as
soon as administratively practicable, but no later than the first day of the fourth full
calendar month following the change, or, if earlier, the first day of the Initial
Stability Period after an Initial Measurement Period during which the Employee
averages at least 30 Hours of Service.
The Employer intends to use the look -back measurement method in Treas. Reg.
§54.4980H-3(d) to determine which Ongoing, Part -Time, Variable Hour, and Seasonal
Employees are eligible for benefits under the Group Medical Feature. However, the
Employer retains its discretion to determine who is eligible for benefits. A person that
the Employer classifies as not a full-time employee shall not be eligible to participate in
the Plan's benefits, regardless of whether such person is determined by a court, the IRS
or other regulatory authority to be full-time under Treas. Reg. §54.4980H.
3. To the extent that the eligibility rules in this Appendix A do not address a specific
eligibility issue, the Employer shall have discretion to make eligibility determinations
consistent with applicable law and regulations, including special rules for changes in
employment status and special unpaid leaves of absence.
Part -Time, Variable Hour, or Seasonal Employees who have not averaged at least 30
Hours of Service per week during the Initial Measurement Period are not eligible to
participate in the Group Medical Feature under the look -back measurement method.
Notwithstanding the foregoing, if an Employee returns to work after an unpaid leave of
absence without a Break in Service, the Employee will be eligible for benefits upon
return if the Employee returns during an Initial Stability Period or Standard Stability
Period in which the Employee is eligible for Plan benefits under Paragraph B of this
Appendix A. If the Employee returns to work after a Break in Service, the Employee
will be treated as an Employee who has not worked an entire Standard Measurement
Period to the extent permissible by law, except that the Employee will not be treated as
32
an Employee who has not worked an entire Standard Measurement Period if the
Employee is returning to work after a leave that is for jury duty, FMLA leave,
USERRA leave, state mandated or job projected leave, or any approved leave of
absence.
To the extent that the Plan and/or a Plan feature's provider contracts and/or other plan
documents refer to the eligibility of "employees," only individuals classified as
"employees" by the Plan Sponsor are eligible to participate in such Plan feature.
Independent contractors, freelancers and individuals hired through staffing fines shall
not be eligible even if they are subsequently determined to be common law employees
for any purpose, including without limitation, for wage, labor or tax purposes by the
Internal Revenue Service, the Department of Labor or any other Federal or state agency,
administrative body or court. Any such determination should have a prospective effect
only.
5. If an Employee in an Initial Stability Period or Standard Stability Period fails to pay the
Employee's share of the cost of coverage on a timely basis, coverage under the Group
Medical Feature shall terminate on the date that payment is due, provided that the
employee will have a grace period of 30 days from the date the payment is due to remit
payment.
33
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
APPENDIX B
QUALIFIED MEDICAL CHILD SUPPORT ORDER PROCEDURES
1.1 General
In the case of any medical child support order ("Order") that is received with respect to the
Plan, its status shall be determined in accordance with the provisions set forth in this Exhibit.
1.2 Notification of Receipt.
Promptly upon receipt of an Order, the Plan Administrator will notify in writing each person
named therein, at the address specified in the Order (if applicable), of the receipt by the Plan
of the Order and forward to them notification of the procedures set forth in this Exhibit. If
the Plan Administrator is able to determine whether an Order is qualified promptly upon
receipt of such Order, the Plan Administrator may send one notice which informs each
person named therein both of the receipt of the Order and of the Plan Administrator's
determination, as provided in Sections 1.5 and 1.6.
1.3 Review of Order.
The Plan Administrator will ascertain, with the assistance of legal counsel, as appropriate,
whether:
(1) The Order is a judgement, decree, or order (including approval of a property settlement
agreement) issued either by a court of competent jurisdiction, or through an
administrative process established under state law that has the force and effect of law
under applicable state law, which:
(a) provides for child support with respect to a child of a Participant under a
group health plan or provides for health benefit coverage to such a child
under this Plan, made pursuant to a state domestic relations law (including
a community property law), or
(b) enforces a state medical child support law enacted under the Social Security
Act with respect to a group health plan;
(2) The Order specifies the name and the last known full mailing address (if any) of the
Participant and each alternate recipient covered by the Order, or if not, that the
information is available from the records of the Plan or Employer;
(3) The Order clearly identifies the Plan or plan(s) to which it applies;
34
(4) The Order clearly specifies a reasonable description of the type of coverage to be
provided by the Plan to each alternate recipient, or the manner in which such type of
coverage is to be determined;
(5) The Order does not require the Plan to provide any type or form of benefit, or any option,
not otherwise provided under the Plan, except to the extent necessary to meet the
requirement of a law relating to medical child support under Social Security Act; and
(6) The Order clearly specifies the period to which it applies
Provided, however, any appropriately completed National Child Support Notice, issued pursuant
to the Child Support Performance and Incentive Act of 1998, shall be deemed satisfy the
requirements to be a "qualified medical support order."
1.4 Suspension of Claims.
Claims for a proposed alternate recipient shall be suspended until the Plan Administrator has
determined whether the order in question is qualified.
1.5 Notification of Status.
When the Plan Administrator determines whether the Order satisfies the requirements to be a
"qualified medical child support order," the Plan Administrator shall notify in writing all
persons named in the Order and any representatives designated in writing by such persons
("Interested Parties") of the determination as soon as practicable following such
determination.
(1) If no Interested Party disputes this determination within thirty (30) days of receipt of
such notice or if all Interested Parties agree in writing not to dispute the Plan
Administrator's determination, then the Plan Administrator shall proceed with
implementing the Order as a "qualified medical child support order."
(2) If any Interested Party disputes this determination within thirty (30) days of receipt of
such notice, then the suspension of claims provided in Section 1.4 shall continue and the
Interested Party disputing the determination may request a review of the determination in
accordance with the claims procedures set forth in the Plan.
1.6 Notification of Non -Qualified Status.
If the Plan Administrator determines that the Order is not a "qualified medical child
support order," the Plan Administrator shall notify in writing all Interested Parties of its
determination, and such notice will state the reasons for such determination. Following such a
determination, any Interested Parties may re -submit a revised Order to the Plan Administrator.
35
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
APPENDIX C
HEALTH FLEXIBLE SPENDING ARRANGEMENT AND
DEPENDENT CARE ASSISTANCE PLAN COMPONENTS
ARTICLE I
INTRODUCTION
The City of Lubbock (hereinafter referred to as the "City") hereby establishes the the City of
Lubbock Health Flexible Spending Arrangement, ("Health FSA") and Dependent Care
Assistance Plan ("DCAP").
This Plan is intended to qualify as a cafeteria plan under section 125 of the Internal Revenue
Code of 1986, as amended ("Code). The Health FSA component is intended to qualify as a self -
insured medical reimbursement plan under section 105 of the Code. The DCAP component is
intended to qualify as a dependent care assistance program under section 129 of the Code. The
Plan shall be construed and interpreted in a manner that is consistent with the requirements of
these sections and any implementing regulations (including proposed implementing
regulations) and is to be interpreted in a manner consistent with the requirements of the Code.
The Plan has two (2) components which Eligible Employees can pay on a pre-tax Salary
Reduction basis: (i) a Health FSA, for an Eligible Employee's qualifying medical expenses,
and (ii) a Dependent Care Assistance Plan ("DCAP"), for an Eligible Employee's qualifying
Dependent Care Expenses.
Employer expects to continue the Plan but reserves the right to amend or terminate it at any
time and for any reason.
Although reprinted within this document, the Health FSA and DCAP components are separate
plans for purposes of administration and all non-discrimination and reporting requirements
imposed by Code § 105 and Code § 129. The Health FSA component is a separate plan for
purposes of applicable provisions of COBRA.
36
ADMINISTRATIVE INFORMATION
Plan Name The City of Lubbock Health Flexible Spending Arrangement
("Health FSA") and Dependent Care Assistance Plan
("DCAP")
Type of Plan Welfare Benefit Plan
The Plan Sponsor The City of Lubbock, Texas
1625 131h Street
Post Office Box 2000
Lubbock, TX 78457-
2000
Phone: (806) 775-2303
Fax: (806) 775-3316
Employer ID (EIN) 75-600059
Plan Administrator The Insurance Committee
And Named Fiduciary The City of Lubbock, Texas
1625 131h Street
Post Office Box 2000
Lubbock, TX 78457-
2000
Phone: (806) 775-2277
Type of Funding Benefits under the Health FSA and DCAP shall be paid
from Employer's general assets. There is no trust or other fund,
no independent source of funds, or any insurance contract that
guarantees the payment of Health FSA or DCAP benefits
under the Plan. Eligible Employees who elect any of the
benefits requiring Participant contributions will contribute at a
fixed rate toward the cost of the Plan through payroll
deductions as specified in the Election Form or as otherwise
specified by the Plan Administrator.
2.1. Assignment of Duties
(a) The Plan Administrator has the discretionary authority to administer the
Plan in all of its details, including determining eligibility for benefits and
construing all terms of the Plan. The Plan Administrator has the exclusive
right and discretion to interpret the Plan and to determine all questions of
fact and/or law that may arise in connection with the administration of the
Plan. All actions, decisions, determinations and interpretations by the Plan
Administrator are final and binding.
37
(b) The Plan Administrator may assign its duties to others. The Plan
Administrator has designated ConnectYourCare, LLC ("CYC") at 307
International Circle, Suite 200, Hunt Valley, Maryland 21030 the "Claims
Administrator" for the Health FSA and DCAP components of the Plan. The
ministerial function of claims administration, in accordance with the terms of
the Plan documentation, has been assigned to the Claims Administrator.
2.2. Future of the Plan
Employer intends to continue this Plan indefinitely. However, Employer reserves the right
to change or terminate the Plan at any time without Your consent or the consent of Your
Spouse or Dependents. Employer or any authorized officer or representative of Employer
can make changes to or terminate the Plan by a written instrument signed or approved by
such duly authorized officer or duly authorized representative of Employer. You will be
notified if any changes are made. Nothing in this Plan is intended to entitle You to vested
benefits. No vested benefits are provided under the Plan.
2.3. Not an Employment Contract
Neither this Plan nor any action taken with respect to it will confer upon any person the
right to continued employment with Employer.
ARTICLE III
DEFINITIONS
In this document, there are some words and phrases that have specific meanings within the
context of the Plan. To help the reader understand these words, they are defined here and
capitalized in this document.
3.1. Account means the Health FSA and DCAP recordkeeping accounts described
herein.
3.2. Calendar Year means the twelve month period beginning January 1 and ending
December 31.
3.3. Cardholder Agreement means the agreement that governs the use of an
electronic payment card.
3.4. Change in Status has the meaning described in Article V.
3.5. Claims Administrator means ConnectYourCare, LLC and any entities designated
by ConnectYourCare as working on behalf of ConnectYourCare, LLC with respect
to services provided by ConnectYourCare under thisAgreement.
3.6. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended
38
3.7. Code means the Internal Revenue Code of 1986, as amended.
3.8. Compensation means the wages or salary paid to an employee prior to any Salary
Reduction election under the Plan.
3.9. DCAP means dependent care assistance Flexible Spending Account program as
described in Article XI.
3.10. Dependent:
(a) For purposes of the Health FSA, Dependent means (i) any person who is a
dependent of the Eligible Employee as a Qualifying Child or a Qualifying
Relative under Section 152 of the Code determined without regard to
subsections (b)(1), (b)(2), and (d)(1)(B) thereof and (ii) any child (as
defined in Section 152(0(1) of the Code) of the Eligible Employee who as
of the end of the taxable year has not attained age 26.
(b) For purposes of the DCAP, Dependent means (i) a dependent of the
Eligible Employee as a Qualifying Child as defined in Section 152(a)(1) of
the Code who has not attained age 13 or (ii) a dependent of the Eligible
Employee as a Qualifying Relative as defined in Section 152 of the Code,
determined without regard to subsections (b)(1),(b)(2) and (d)(1)(B)
thereof who is physically or mentally incapable of caring for himself or
herself and who has the same principal place of abode as the Eligible
Employee for more than one-half of the taxable year.
(c) For purposes of any medical, dental or vision plan benefits referred to in
Section 8.2, Dependent means a person (i) who is eligible as a Dependent
of the Eligible Employee under the Dependent eligibility requirements of
such medical, dental and vision plans and (ii) whose coverage and benefits
under such medical, dental and vision plans are nontaxable to the Eligible
Employee under Sections 105(b) and 106 of the Code. In accordance with
Section 8.2, eligibility under such medical, dental and vision plans shall be
determined solely by the terms of such plans and nothing in this Plan shall
modify the eligibility requirements of such plans.
3.11. Dependent Care Expense means a Dependent Care Expense as defined under
Code section 129.
3.12. Earned Income means all income derived from wages, salaries, tips, self-
employment and other compensation included in gross income for the taxableyear.
3.13. Election Form means the form or other method that Employer provides to the
Eligible Employee to elect benefits under the Plan and specify Salary Reduction
amounts. This form may be delivered and completed online.
3.14. Eligible Employee means an individual that Employer classifies as a common-law
39
employee, is on Employer's W-2 payroll and regularly works 30 or more hours per
week, but does not include any of the following:
(a) Any leased employee or anyone classified by Employer as a contract
worker, independent contractor or temporary employee, whether or not
such employee is on Employer's W-2 payroll;
(b) Any individual who performs services for Employer but is paid by a
temporary or other staffing agency;
(c) Any self-employed individual;
(d) Any partner in apartnership;
(e) Any more than 2% shareholder in a Subchapter S corporation; and
(f) Any member of an LLC.
To the extent You are an Eligible Employee of Employer, this document will refer directly
to "You" as an "Employee."
3.15. Employer means The City of Lubbock and any related employer that adopts this
Plan with the approval of The City ofLubbock.
3.16. ERISA means the Employee Retirement Income Security Act of 1974, as amended.
3.17. Fiduciary means a person who has discretionary authority over the administration
of the Plan (CYC is not a Fiduciary).
3.18. Flexible Spending Account means the Health FSA and DCAP Plan.
3.19. FMLA means the Family and Medical Leave Act of 1993, as amended.
3.20. Grace Period means the period beginning immediately following the close of a
Plan Year and ends on the day that is two months and 15 days following the close
of that Plan Year.
3.21. Health FSA means Health Flexible Spending Account as described in ArticleX.
3.22. HIPAA means Health Insurance Portability and Accountability Act of 1996, as
amended.
3.23. Incurred means the date on which the service, care or product giving rise to an
expense has been furnished without regard to the date when You are formally
billed for, are charged with, or pay for the service, care orproduct.
3.24. Medical Expense means medical care expenses as defined under Code section
213(d) that are Incurred by You, Your Spouse and Dependents that will not be
40
taken as a deduction from income on the Participant's federal income tax return in
any tax year (and will not be reimbursable under any other plan or insurance
coverage), which include medical expenses described in Article X. In accordance
with Section 106(f) of the Code, a medicine or drug expense shall qualify as a
Medical Expense only if such medicine or drug is a prescribed drug (determined
without regard to whether such drug is available without a prescription) or is
insulin.
3.25. Named Fiduciary means a named fiduciary within the meaning of ERISA section
402(a)(2), if applicable, and listed in Section 13.3. The Employer is the Named
Fiduciary. CYC is not a Named Fiduciary.
3.26. Participant means a person who is an Eligible Employee and who is participating
in this Plan. To the extent You are a Participant in this Plan, this document will
refer directly to "You" as a "Participant."
3.27. Plan means the The City of Lubbock Cafeteria Plan as described herein and as
amended from time to time.
3.28. Qualifying Child means an individual who in accordance with Section 152 of the
Code
(a) Is the son, daughter, stepson, stepdaughter or eligible foster child of the
Employee or a descendent of any such child, a sibling or step -sibling of the
Employee or a descendant of any such relative;
(b) Has the same principal abode as the Employee for more than half the year;
(c) Is under age 19 as of the end of the calendar year, is a full-time student
under age 24 at the end of the calendar year, or is permanently and totally
disabled; and
(d) Has not provided more than half of his own support for the year.
3.29. Qualifying Individual has the meaning described in Article XI.
3.30. Qualifying Relative is an individual who in accordance with Section 152 of the
Code
(a) Is the son, daughter, stepson, stepdaughter or eligible foster child of the
Employee or a descendent of any such child, a sibling or step -sibling of the
Employee or a descendent of any such relative, the father, mother,
stepfather or stepmother of the Employee or the sibling of any such
relative, the son-in-law, daughter-in-law, father-in-law, mother-in-law,
brother-in-law or sister-in-law of the Employee, or
an individual (other than the Employee's Spouse) who has the same
principal abode as the Employee for the entire calendar year and whose
relationship with the Employee is not in violation of local law;
41
(b) Receives over half of his support from the Employee; and
(c) Is not anyone else's Qualifying Child.
3.31. Salary Reduction means the amount Your Compensation is reduced and applied
by Employer under this Plan before any applicable federal and/ or state taxes have
been deducted from Your Compensation. Salary Reductions are applied by
Employer to pay the Participant's share of the contributions for benefits under the
Plan and, for purposes of this Plan and the Code, are considered to be Employer
contributions.
3.32. Spouse means the individual to whom you are legally married as determined
under state law. The Plan Sponsor shall have the sole discretion to determine the
legal status of a Participant's marriage for purposes of coverage under the Plan.
ARTICLE IV
ELIGIBILITY TO PARTICIPATE
4.1 Participation
You may elect to participate in the Plan on the later of this Plan's Effective Date or the first
day of the calendar month on or after the date You meet all of the following criteria and the
first day of any subsequent Plan Year in accordance with the annual enrollment period
described in Article V, provided that an Election Form is submitted to the Plan
Administrator before the first day participation will commence:
(a) You are an Eligible Employee ofEmployer;
(b) You have been employed by Employer for one full pay period.
4.3. Qualified Medical Child Support Order
A Qualified Medical Child Support Order ("QMCSO") is a type of order that is issued: (i)
by a court of competent jurisdiction, or (ii) through an administrative process established
under state law and which has the force and effect of law under applicable state law. The
order is usually issued as part of a settlement agreement or divorce decree that provides for
child support or health care coverage for Your child. The Plan Administrator will establish
requirements for honoring a QMCSO.
ARTICLE V
5.1. Period of Coverage; Election Form Generally Irrevocable
Subject to Section 5.4, the election specified on Your Election Form or specified in some
42
other manner required by the Plan Administrator is irrevocable during the Plan Year,
except as provided in Sections 5.3 through 5.6.
5.2. Limits on Salary Reduction Amounts Elected
The total Salary Reduction amount that You may elect on an Election Form for all benefits
under this Plan cannot exceed Your Earned Income for the Plan Year. The limits on Salary
Reduction amounts for each individual benefit are as follows:
(a) Premium Payment. The amount you may elect to salary reduce as your
portion of the cost for medical, dental or vision plans offered by Employer
is equal to the amount set by Employer, which may or may not be the same
amount charged by the insurance carrier. Your election for Salary
Reduction is further limited to Your portion of the cost for You, Your
Spouse, Your Qualifying Children, Your child ( as defined in Section
152(f)(1) of the Code) who as of the end of the taxable year has not
attained age 26 and Your Qualifying Relatives only. Your portion of the
cost of the medical, dental or vision plans may include Your payment of
the full cost of such plans without any contribution by the Employer. In
accordance with Section 8.2, eligibility for such medical, dental and vision
plans shall be as set forth in those plans and nothing in this Plan shall
modify the eligibility requirements of those plans
(b) Health FSA. The minimum amount that you may elect to salary reduce
under the Health FSA for the Plan Year is $100 and the maximum amount
is $2,650.
(c) Dependent Care FSA. The minimum amount that You may elect to salary
reduce under the DCAP for the Plan Year is $100 and the maximum
amount is equal to the least of:
i) Your Earned Income for the Plan Year (after all reductions in
Compensation including the reduction related to dependent care
assistance);
ii) the actual or deemed Earned Income of Your Spouse for the Plan
Year; or
iii) an amount such that the portion You elect to salary reduce in any
Calendar Year (which may be different from the Plan Year) is no
more than $5,000 ($2,500 if You are married filing a separate
federal income tax return).
If Your Spouse 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 $250 per month if You have one Dependent and $500 per
month if You have two or more Dependents. If both You and Your Spouse participate in
Dependent Care FSAs of different employers, the $5,000 limit described in (d)(iii) above
43
applies on a combined basis. Consequently, the maximum combined amount that You and
Your Spouse could contribute under both employers' Dependent Care FSAs would be
$5,000, not $10,000. Hence, if You contributed $5,000 under this Plan's Dependent Care
FSA, Your Spouse could not make any eligible contributions under the dependent care FSA
of his or her employer.
5.3. Annual Enrollment Period
An annual enrollment period will be scheduled by Employer prior to the beginning of each
Plan Year. At that time, You will receive enrollment instructions describing the Plan.
In order to participate in the Plan, You must complete an Election Form, where required by
the Plan Administrator, specifying the total amount of Your annual Compensation that You
wish to reduce on a pre-tax basis each Plan Year to apply toward each benefit under the
Plan. The amount You elect to reduce will be deducted prorated (in equal amounts) or in
such other amounts as the Plan Administrator may require from Your salary beginning the
first payday of the Plan Year (or the first payday after Your participation commences if
Your participation commences after the Plan Year has begun). Where required by the Plan
Administrator, an Election Form must be returned to the Plan Administrator on or before
the last day of the annual enrollment period, and it will become effective on the first day of
the next Plan Year.
If You do not become an Eligible Employee until after the first day of a Plan Year, You
may file an Election Form with the Plan Administrator during the 30-day period following
the first day on which You become an Eligible Employee. The Plan Administrator will
provide You an Election Form at the time Your employment commences or as soon as
administratively feasible after You become an Eligible Employee.
5.4. Change in Election
Treasury Regulations require that generally, Your election must remain the same for the
entire Plan Year. However, the regulations provide that in limited circumstances You may
be allowed to change Your election if the change is "on account of and corresponds with" a
Change in Status event that affects eligibility for coverage under the Plan. The
determination of whether a requested change is "on account of and corresponds with" a
Change in Status event will be made by the Plan Administrator in its sole discretion in
accordance with the Plan Administrator's interpretation of the applicable regulations.
To change an election, You must complete and return an Election Form to the Plan
Administrator within 30 days of the occurrence of the Change in Status event.
Notwithstanding the foregoing, a Change in Status that results in a person becoming
ineligible for coverage under the Plan will automatically result in a corresponding election
change, whether or not requested by the Participant within the normal 30-day period.
(a) Change in Status Events: Valid Change in Status Events consist of thefollowing:
i) Change in Your Legal Marital Status: marriage, divorce, annulment,
legal separation or death of Spouse;
ii) Change in Number of Dependents: events that change Your number of
Dependents, such as birth, adoption, placement for adoption or death;
iii) Change in Employment Status of You, Your Spouse or Dependent: any
of the following that change the employment status of You, Your
Spouse, or Your Dependent: termination or commencement of
employment, strike or lockout, beginning or returning from an unpaid
leave of absence, change in worksite that also affects benefit eligibility,
or a change from an eligible to an ineligible employment status or
classification;
iv) Dependent Satisfies (or Ceases to Satisfy) Dependent Eligibility
Requirements: events that cause Your Dependent to satisfy or cease to
satisfy eligibility requirements for coverage, such as due to age, student
status, or similar circumstances;
v) Change in Residence: A change in the place of residence of the
Participant or his Spouse or Dependents;
vi) Termination of Employment: All Salary Reduction elections under the
Plan will terminate upon termination of employment in accordance with
Article VI as applicable.
vii) Leave of Absence: All Salary Reduction elections under the Plan will
terminate upon the commencement of an unpaid leave that is not
designated leave under the FamilyMedical Leave Act.
(b) Other Changes That May Allow Changes under the Premium Payment Benefit:
i) HIPAA Special Enrollment Right: If a Participant or his Spouse or
Dependent is entitled to special enrollment rights under a group health
plan (other than excepted benefits such as the Health FSA), as required
by HIPAA under Code section 9801(f), then a Participant may revoke a
prior election for group health coverage and make a new election,
provided the election change corresponds with such HIPAA special
enrollment rights. As required by HIPAA, a special enrollment right
will arise in the following circumstances:
a) A Participant or his Spouse or Dependent declined to enroll in a
group health plan coverage because he had other coverage, and
eligibility for such coverage is subsequently lost because (1) the
coverage was provided under COBRA and the COBRA
coverage was exhausted, or (2) the coverage was non -COBRA
coverage and the coverage terminated due to loss of eligibility
for coverage or Employer contributions for coverage were
terminated; or
45
b) A new Dependent is acquired as a result of marriage, birth,
adoption or placement for adoption.
ii) Change in Employment Altering Employee's Eligibility under the
Medical, Dental or Vision Plan: any of the following that change Your
eligibility under the medical, dental or vision plan: a significant
curtailment in coverage or elimination or addition of a new benefit
option under the medical, dental or vision plan, or a significant change
in the coverage or cost of coverage for the medical, dental or vision
plan, but only to the extent permitted under Section 125 of the Code
and the regulations thereunder.
iii) Change in Coverage Under Another Employer's Cafeteria Plan: You
may make an election change that is on account of and corresponds
with a change made under another employer plan if (a) the other
cafeteria plan or qualified benefits plan permits its participants to make
election changes permitted under the rulings and regulations under
Code Section 125 or (b) the period of coverage under the other cafeteria
plan or qualified benefits plan is different from the Plan Year of this
Plan.
(c) Other Events That May Allow Changes under the Premium Payment and
Health FSA:
i) Judgment, Decree, or Order: If a judgment, decree, or order
(collectively called "order") resulting from a divorce, legal separation,
annulment, or change in legal custody (including a Qualified Medical
Child Support Order under the Employee Retirement Income Security
Act) requires You to cover a child for accident or health coverage,
including an election for the Health FSA, You may increase Salary
Reduction amounts for coverage under the Premium Payment or Health
FSA benefit to provide coverage for of the child. Likewise, if the order
requires another individual to provide coverage for the child, and that
coverage is in fact provided, You may reduce Salary Reduction
amounts.
ii) Medicare and Medicaid: If You, Your Spouse, or Dependent becomes
entitled to Medicare or Medicaid (other than coverage only for pediatric
vaccines), You may make a change to reduce Salary Reduction amounts
for coverage under the Premium Payment or Health FSA benefit to take
into account Medicare or Medicaid. Likewise, if You, Your Spouse, or
Dependent loses eligibility for coverage under Medicare or Medicaid,
You may increase Salary Reduction amounts to take into account loss
of that coverage.
iii) Special requirements relating to the Family and Medical Leave Act
FMLA .
46
a) If You take paid leave under FMLA, You must continue
your existing election under the Premium Payment and
Health FSA benefit.
b) If You take unpaid leave under the Family and Medical
Leave Act (FMLA), You may continue your existing
election under the Premium Payment and Health FSA
benefit. If You elect to continue coverage while on an
unpaid FMLA leave, You must pay Your share with after-
tax dollars, by sending monthly payments to Employer by
the due date established by Employer or utilize another
payment arrangement agreed upon between You and
Employer. Alternately, You may revoke an existing election
under the Premium Payment and Health FSA benefit for the
remaining portion of the period of coverage as may be
provided for under the FMLA. You will not be considered a
Participant in the Plan, and You will not receive Health FSA
reimbursement for expenses Incurred during the time You
were not a Participant. When You return from FMLA leave,
You can elect to be reinstated in the Premium Payment and
Health FSA benefit on the same terms as existed prior to the
FMLA leave (unless those terms were changed in the
meantime for other Plan Participants). Upon reinstatement
to the Health FSA, You have the right to resume coverage at
the level in effect before the FMLA leave and make up the
unpaid Health FSA premium payments or resume coverage
at a level that is reduced and resume Health FSA premium
payments at the level in effect before the FMLA leave.
(d) Other Events That May Allow Changes underDCAP:
i) Change in dependent care service provider: You will be allowed to
make a change in Your DCAP election due to a change in cost or
coverage of the service provider. For example, if You terminate one
dependent care service provider and hire a new dependent care
service provider, then You may change Your election to reflect the
cost of the new service provider. Similarly, if You terminate a
dependent care service provider because a relative becomes
available to take care of the child at no cost, then You may cancel
coverage. However, You may not increase Your election to pay the
increased cost of a service provider if such service provider is a
relative as defined in Code section 152(d)(2).
You will not be allowed to reduce Your election for the Health FSA or DCAP to a
point where the total allotment for the Plan Year for such benefit is less than the
amount already reimbursed for that Plan Year. In addition, any change in election
affecting Your annual election to the Health FSA or DCAP allowed under this
47
section will also change Your benefits for the period of coverage remaining in the
Plan Year. Your benefits following an election change will be calculated by adding
any balance (including a negative balance) remaining in the Health FSA or DCAP
as of the end of the portion of the Plan Year immediately preceding the change in
election, to the total allotments scheduled to be made by You during the remainder
of the Plan Year to each account, respectively.
5.5. Changes Required for Non-discrimination Compliance
The Plan Administrator retains the authority to modify or revoke Your election without
Your consent if the Plan Administrator deems it necessary in order to comply with non-
discrimination rules under the Code. For example, the Plan Administrator may find it
necessary to reduce DCAP elections to comply with nondiscrimination requirements under
the Code.
ARTICLE VI
K _ ; 1►`wY[i7�i11��TI�IYL�1�ll_YC��
Participation will terminate on the earliest of:
(a) The date You cease to be an Employee, except as otherwise allowed under
COBRA coverage;
(b) The date on which You no longer meet the definition of an Eligible
Employee, except as provided under COBRA;
(c) The date the Plan is terminated or amended to exclude You;
The date of Your election not to participate during the Annual Enrollment Period or due to a
qualifying Change in Status.
BENEFITS
7.1. Benefits Offered
You may elect one or more of the following Benefits:
(a) Health FSA Benefits
(b) DCAP Benefits
Each Benefit is described in more detail within separate Articles in this document.
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48
ARTICLE IX
HEALTH FSA BENEFITS
9.1. Contributions
You contribute to the Health FSA through pre-tax dollars. You select the amount of Your
contributions, up to authorized limits set by Employer. [Employer does not contribute to
the Health FSA.] The Account established for You will be a recordkeeping account for the
purpose of keeping track of contributions and available reimbursement amounts as benefits
are paid from Employer's general assets.
9.2. Grace Period
The Health FSA includes a Grace Period following the close of the Plan Year. Expenses
Incurred during the Grace Period can be reimbursed from amounts remaining in Your
Health FSA at the end of the preceding Plan Year. Any unused amounts in Your Health
FSA at the end of the Grace Period will be forfeited. You must be a Participant with Health
FSA coverage that is in effect on the last day of the Plan Year to be eligible for the Grace
Period extension. If You elect to participate in the Health FSA for the following Plan Year,
qualifying expenses Incurred during the Grace Period will be applied to the amounts
remaining in Your Health FSA at the end of the preceding Plan Year.
9.3. Reimbursements Under a Health FSA
(a) Reimbursements shall only be made for Medical Expenses Incurred during
the Plan Year or Grace Period by You, Your Spouse and Dependents
while You are participating in the Health FSA that are not covered, paid
or reimbursed from any other source. Each Medical Expense must be
substantiated by You in accordance with Section 10.2. and all IRS
requirements.
(b) Medical Expenses that may be reimbursed under the Health FSA are
expenses that meet the criteria of medical, dental or vision expenses under
Code section 213 (d), including those for:
i) The diagnosis, cure, mitigation, treatment, or prevention of any
disease, or for the purpose of affecting any structure or function of
the body; and
ii) Transportation primarily for and essential to obtaining medical care.
A partial listing of examples of eligible expenses includes the
following:
• Alcohol or chemical dependency treatment
• Cosmetic surgery that is medically necessary (e.g., to cure deformity
that is the result of an accident)
49
• Dental expense, including routine and preventive care
• Diabetic supplies, including insulin and testing strips
• Hearing aids, including batteries and repairs
• Medical equipment
• Mental health services (excluding marriage and family counseling)
• For medicine or drug expenses Incurred on or after January 1, 2011, the
expense will be an eligible expense only if it is a prescribed drug
(determined without regard to whether such drug is available without a
prescription) or is insulin.
• Physical, speech or occupational therapy
• Physician services, including surgeons, acupuncturists, chiropractors
and other medical providers
• Prescription drugs
• Smoking cessation program
• Transportation primarily for and essential to obtaining medical care
• Vision care, including exam, prescription glasses and contact lenses and
supplies
• Vision correction surgery, such as RK orLasik
• Weight loss program medically necessary to treat obesity as
recommended by a physician.
(c) Not all medical expenses are eligible for reimbursement under the Health
FSA.
Reimbursements under the Health FSA may not be made for:
i) Long-term care services as defined under Code section 770213;
ii) Premiums for healthcare or long-term care insurance;
iii) Expenses Incurred for cosmetic purposes;
iv) A Medical Expense that is:
50
a) Attributable to a deduction allowed under Code section 213 for
any prior taxable year;
b) Incurred before the effective date of this Health FSA or Incurred
before You became a Participant in the Health FSA;
c) Not Incurred during the Plan Year or Grace Period; or
d) Reimbursed from any other source.
Here are some examples of expenses not eligible for reimbursement:
• Cosmetic expenditures (for example, teeth whitening, chemical peels)
• General wellness expenses (for example, health club dues, special foods
and dietary supplements, vitamins, exercise programs and equipment)
• Insurance premiums
• Long term care expenses
• Other charges: missed appointment, late payment or interest charges
• Expenses for over the counter drugs or medicines not accompanied by a
prescription (except for insulin) as explained above.
• You Incurred a medical expense on January 2 of Year X but did not
commence participation in the Health FSA until July 1 of Year X when
You became an Eligible Employee. The medical expense Incurred on
January 2 is not reimbursable.
• You Incurred a medical expense on July 1 of Year Y but Your participation
ended on June 30 of Year Y when Your employment terminated and You
did not elect COBRA for the Health FSA for the remainder of
Year Y. The medical expense Incurred on July 1 is not reimbursable.
(d) The annual amount elected for the Plan Year minus any amounts already
reimbursed for that Plan Year will be available at all times with respect to
qualifying Medical Expenses Incurred during that Plan Year (and Grace
Period, if applicable) while You are covered under the Plan, regardless of
the actual amounts deposited to Your Health FSA. (Example: You elect
$1200 for Plan Year (of January 1 to December 31). At the end of January
You have contributed only $100 to Your Health FSA. On January 31 You
Incur a qualifying Medical Expense of $200. You are eligible to be
reimbursed for that $200 qualifying Medical Expense and Your maximum
reimbursement under the Health FSA for the rest of the Plan Year would
51
be reduced to $1,000 ($1200 annual amount elected minus $200
reimbursement). You would, of course, continue to contribute $100 per
month to Your Health FSA for the remainder of the Plan Year.)
(e) Any unused amounts remaining in Your Health FSA after the deadline for
filing claims expires cannot be carried forward to any subsequent Plan
Year, cannot be cashed out and will be forfeited to Employer.
9.4. Termination of Employment
(a) Coverage under the Health FSA shall cease upon tennination from
employment. However, You may submit claims for reimbursement for
Medical Expenses Incurred before the termination date in accordance with
ArticleXI.
(b) Unless a COBRA election is made, You, shall not be entitled to receive
reimbursement for Medical Expenses Incurred after coverage ceases
under this Plan.
(c) Any unused amounts held in Your Health FSA shall be forfeited and
returned to Employer.
9.5. Repayment of Excess Reimbursements
If it is determined that You have received payments under the Health FSA that exceed the
amount of Medical Expenses that have been substantiated by You, the Plan Administrator
shall give You prompt written notice of any such excess amount, and You shall repay the
amount of such excess to the Plan in accordance with procedures established by the Plan
Administrator. If repayment is not made, the Plan Administrator shall direct Employer to
withhold such excess reimbursement from Your Compensation to the extent permitted by
law. If that is not successful, the Plan Administrator may offset future benefits by an
amount equal to the excess reimbursement in accordance with IRS rules. If all attempts to
recover the excess reimbursement are unsuccessful, the Plan Administrator may direct
Employer to include such amounts in Your gross income.
If it is determined that You have received payments under the Health FSA for Medical
Expenses that do not meet the criteria for eligible expenses as defined in this
Article, the Plan Administrator shall give You prompt written notice of any such
ineligible amount, and You shall repay the ineligible amount to the Plan in accordance with
procedures established by the Plan Administrator. If repayment is not made, the Plan
Administrator shall direct Employer to withhold such excess reimbursement from Your
Compensation to the extent permitted by law. If that is not successful, the Plan
Administrator may offset future benefits by an amount equal to the excess reimbursement in
accordance with IRS rules. If all attempts to recover the excess reimbursement are
unsuccessful, the Plan Administrator may direct Employer to include such amounts in Your
gross income.
52
10.1. Contributions
You contribute to the DCAP through pre-tax dollars. You select the amount of Your
contributions, up to authorized limits set by Employer. The maximum annual benefit
amount You can deposit into Your DCAP during a calendar year cannot exceed the
statutory limit described in Section 5.2. Employer does not contribute to the DCAP. The
DCAP established for you will be a recordkeeping account for the purpose of keeping track
of contributions and available reimbursement amounts as benefits are paid from Employer's
general assets.
10.2. Grace Period
The DCAP includes a Grace Period following the close of the Plan Year. Expenses
Incurred during the Grace Period can be reimbursed from amounts remaining in Your
DCAP at the end of the preceding Plan Year. Any unused amounts in Your DCAP at the
end of the Grace Period will be forfeited. You must be a Participant with DCAP coverage
that is in effect on the last day of the Plan Year to be eligible for the Grace Period
extension. If You elect to participate in the DCAP for the following Plan Year, qualifying
expenses Incurred during the Grace Period will be applied to amounts remaining in Your
DCAP at the end of the preceding P1anYear.
10.3. Qualifying Individual
A "Qualifying Individual" under the DCAP means a person who is a Qualifying Individual
under Section 21(b)(1) of the Code having the same principal place of abode as You for
more than one- half the year and is one of the following:
(a) Your Dependent who is Your Qualifying Child (as defined under Section
152(a)(1)of the Code) under age 13;
(b) Your Dependent who Your Qualifying Relative as defined under Section
152 of the Code, determined without regard to subsections (b)(1),(b)(2)
and (d)(1)(13) thereof, who is mentally or physically incapable of caring for
himself or herself and who has the same principal place of abode as You
for more than one-half of the tax year; or
(c) Your Spouse who is mentally or physically incapable of self -care care and
has the same principal place of abode as You for more than one-half of the
tax year. In the case of divorced parents, a Qualifying Individual who is a
child will be treated as the Qualifying Individual of the custodial parent
and will not be treated as a Qualifying Individual of the non -custodial
parent. If the parents share custody and the child is in the custody of both
parents for more than one-half the year, the child is treated as having been
53
in the custody of the parent who had custody for the greater portion of that
year.
10.4. Reimbursements Under the DCAP
(a) Reimbursements shall only be made for eligible Dependent Care Expenses
that relate to the care of a "Qualifying Individual" that enable You and
Your Spouse to remain gainfully employed and are Incurred during the
Plan Year or Grace Period while You are participating under the DCAP
and cannot be reimbursed through any other arrangement. Each Dependent
Care Expense must be substantiated by You in accordance with Section
11.2. and all IRS requirements as determined by the Plan Administrator.
Those IRS requirements include the name, address and taxpayer
identification number (i.e., Social Security number for individuals) of the
person or entity providing the services for which reimbursement is being
requested.
A partial listing of examples of eligible expenses includes the following (assuming they
meet the requirements discussed in Section 10.4(a) above):
• Au pair services
• After -school care
• Before -school care
• Dependent care center (if the center complies with all state and local
regulations, if any, that apply to the center)
• Nursery school
(b) Not all Dependent Care Expenses are eligible for reimbursement from the
DCAP.
Eligible Dependent Care Expenses do not include amounts
i) Paid to Your Spouse or Your child who is under age 19;
ii) That are claimed as a Dependent Tax Credit under Code § 21; or
iii) Reimbursed by insurance or any otherplan.
Here are some examples of other expenses not eligible for reimbursement:
• Housekeeping services separate from child care duties
• Kindergarten
54
• Medical care
• Overnight camps
• You Incurred a dependent care expense in January of Year X but did
not commence participating in the DCAP until July 1 of Year X when
You became an Eligible Employee. The expense Incurred in January is
not reimbursable
• You Incurred a dependent care expense on July 1 of Year Y but ceased
participating in the DCAP on June 30 of Year Y when Your
employment terminated. The expense Incurred on July 1 is not
reimbursable.
(c) Any unused amounts remaining in Your DCAP after the deadline for filing
claims expires cannot be carried forward to any subsequent Plan Year,
cannot be cashed- out and will be forfeited to Employer.
(d) The maximum amount of reimbursement under this Plan shall not exceed
the amount You have contributed to Your DCAP, and which is currently
remaining in Your DCAP when Your claim for reimbursement is
submitted. Example: As of January 31, You have contributed $416 to Your
DCAP. Consequently, as of January 31, the maximum amount available for
reimbursement at that time for qualifying expenses is $416. Hence, if You
submitted a claim on January 31 for $500 of qualifying dependent care
expenses, Your maximum reimbursement at that time would be $416, not
$500.
10.5. Termination of Employment
(a) Coverage under the DCAP shall cease upon termination from employment.
However, You maysubmit claims for reimbursement for expenses Incurred
before the termination date in accordance with Article XI.
(b) You shall not be entitled to receive reimbursement for expenses Incurred
after coverage ceases under this Plan Any unused amounts held in Your
DCAP shall be forfeited and returned to Employer.
10.6. Repayment of Excess Reimbursements
If it is determined that You have received payments under the DCAP that exceed the
amount of Dependent Care Expenses that have been substantiated by You, the Plan
Administrator shall give You prompt written notice of any such excess amount, and You
shall repay the amount of such excess to the Plan in accordance with procedures
established by the Plan Administrator. If repayment is not made, the Plan Administrator
shall direct Employer to withhold such excess reimbursement from Your Compensation to
55
the extent permitted by law. If that is not successful, the Plan Administrator may offset
future benefits by an amount equal to the excess reimbursement in accordance with IRS
rules. If all attempts to recover the excess reimbursement are unsuccessful, the Plan
Administrator may direct Employer to include such amounts in Your gross income.
If it is determined that You have received payments under this Plan for Dependent Care
Expenses that do not meet the criteria for eligible expenses as defined in this Article, the
Plan Administrator shall give You prompt written notice of any such ineligible amount, and
You shall repay the ineligible amount to the Plan in accordance with procedures established
by the Plan Administrator. If repayment is not made, the Plan Administrator shall direct
Employer to withhold such excess reimbursement from Your Compensation to the extent
permitted by law. If that is not successful, the Plan Administrator may offset future benefits
by an amount equal to the excess reimbursement in accordance with IRS rules. If all
attempts to recover the excess reimbursement are unsuccessful, the Plan Administrator may
direct Employer to include such amounts in Your gross income.
ARTICLE XI
HEALTH FSA AND DCAP CLAIMS PROCEDURES
As a Participant in the Health FSA, You will automatically be provided with an electronic
payment card, which is linked to Your Account. Rather than paying a provider upfront and
waiting to be reimbursed, You can use the payment card to electronically access funds to
pay providers that accept VISA® or MasterCard®. You should treat it like cash and secure
it carefully. The Cardholder Agreement contains terms between You and the card issuer.
In addition, You can submit claims online, through fax or mail.
11.1. Submission of Claims
(a) You should use the payment card to pay expenses at any qualified medical
provider in accordance with IRS requirements who accepts VISA® or
MasterCard®. Each time the card is used, funds are automatically deducted
from Your Account. If it cannot be clearly determined that the funds were
used for eligible expenses per IRS guidelines, You will be notified to
submit any applicable receipts in the time and manner specified. It is
important that You retain receipts for all payment card purposes.
(b) If You cannot or choose not to use the payment card for an eligible
expense, You can submit a claim to request reimbursement. You will enter
claim information online through a secure web site, print out a claim
submission cover sheet to fax in or email with required documentation.
Alternatively, You can enter claim information on a paper claim form that
can be faxed or mailed with the required documentation.
(c) You can continue to submit claims for expenses Incurred during the Plan
Year or Grace Period for 90 days after the end of the Grace Period.
Requests for reimbursement received after that time will not be honored.
56
11.2. Substantiation of Expenses
(a) When submitting a claim, You must attach a copy of the original itemized
bill or receipt for the expense. The bill, receipt or other statements from an
independent third party should clearly show the person Incurring the
expenses, the nature of the expenses, the date the expense was Incurred, the
amount of the requested reimbursement and other details that may be
requested by the Plan Administrator.
(b) If the Account was accessed by an electronic payment card, You will be
required to comply with the level of substantiation required under IRS
rules regarding the use of electronic payment cards. In the event that
additional documentation is needed, a notification and request will be sent
to You. You will have 45 days to submit the required documentation. If the
additional documentation is not received in the time frame specified or if it
is received but it is determined by the Plan Administrator that the charge
was not for an eligible expense, then, in accordance with IRS rules, You
will be required to refund the reimbursed amount to the Plan, and the
electronic payment card's usage will be suspended. If Your card is
suspended, You will need to submit online or paper claims for future
requests for reimbursement, and the reimbursements for paper claim
requests may be held and applied to the outstanding payment card
transaction.
11.3. Initial Claims Decision For FSA Claims (Post -Service Claims)
(a) While many claims will be processed sooner than 30 days, the law
provides that a 30-day period to process a Health FSA claim is generally
reasonable. The law also provides that if there are special circumstances,
the 30-day period can be extended to 45 days. If an extension of time from
30 days is needed for processing, written notice of the extension will be
furnished before the end of the initial 30-day period. The extension notice
will indicate the special circumstances requiring an extension of time and
the date by which a decision on the claim is expected to be given. If the
extension is necessary to request additional information, the extension
notice will describe the required information, and You will be given at
least 45 days to submit the information. The Claims Administrator then
will make its determination within 15 days from the date the Plan receives
the additional information, or, if earlier, the deadline to submit the
additional information. All actions of the Claim Administrator are on
behalf of Employer.
(b) If a claim under the Health FSA or DCAP is denied in whole or in part, the
Claims Administrator will notify the claimant of the decision by written
notice, in a manner calculated to be understood by the claimant. The notice
will set forth:
57
i) The specific reasons for the denial of the claim;
ii) A reference to specific provisions of the Plan on which the denial is
based;
iii) A description of any additional material or information necessary
to perfect the claim and an explanation of why such material or
information is necessary;
iv) For the Health FSA only:
a) An explanation of the procedure for review of the denied or
partially denied claim, including the claimant's right to
bring a civil action following an adverse benefit
determination on review;
b) A disclosure of any internal rule, guideline, or protocol
relied on in making the adverse determination (or statement
that such information is available free of charge upon
request); and
c) If the denial is based on a medical necessity or experimental
treatment or similar limit, an explanation of the scientific or
clinical judgment for the determination (or statement that
such information will be provided free of charge upon
request).
11.4. Appealing a Denied Claim
If a claim is denied in whole or in part, You or Your authorized representative have the
right to request the Plan Administrator to review the claim. This request must be submitted
in writing. You may appeal the denial by using the following procedure:
(a) Within 180 days of receipt of a notice of denial on the claim, You or Your
authorized representative must send a written request for a review of the
claim. The request should be sent to the Claims Administrator, which will
forward the request for review to the Plan Administrator. You have the
right to submit written comments, documents, records and other
information relating to the claim for benefits. These actions must be taken
at Your own expense. If You fail to file a request for review within 180
days of the denial notification, the claim is deemed abandoned and You are
precluded from reasserting it.
(b) Within 60 days after the request for review is received, the Plan
Administrator will make a decision. The decision on review will be in
writing and will include:
58
i) The specific reason or reasons for the denial of the claim;
ii) A reference to specific Plan provisions on which the adverse
determination was made;
iii) A statement that the claimant is entitled to receive, upon
request and free of charge, reasonable access to, and copies
of, all documents, records, and other information relevant to
the claimant's claim for benefits;
iv) For the Health FSA only:
a) A statement describing any voluntary appeal
procedures offered by the Plan and the claimant's
right to obtain the information about such procedures
and a statement of the claimant's right to bring a civil
action under Texas law;
b) A disclosure of any internal rule, guideline, or
protocol relied on in making the adverse
determination (or statement that such information is
available free of charge upon request); and
c) If the denial is based on a medical necessity or
experimental treatment or similar limit, an
explanation of the scientific or clinical judgment for
the determination (or statement that such information
will be provided free of charge upon request).
The Plan Administrator has the final discretionary authority to make benefit decisions, and its
decision will be final and binding.
ARTICLE Xii
12.1. Amendment or Termination
Although Employer intends to continue this Plan indefinitely, Employer expressly and
specifically reserves the sole and exclusive right at any time to amend or terminate the
Plan. Any amendment or termination will be evidenced by a written instrument duly
executed or approved by a duly authorized officer or duly authorized representative of
Employer.
12.2. Plan Administrative Expenses
(a) Except as otherwise provided in this Plan document or required by
Employer, all reasonable expenses incurred in administering the Plan will
be paid by Employer for Participants in the Plan but Employer reserves the
W
right at any time to have such expenses paid for by Participants in the Plan.
If any such administrative expenses are charged to You (for example, the
charge associated with requesting a replacement or second electronic
payment card), notification will be provided.
(b) All forfeitures will be retained by Employer and used by Employer in any
manner authorized by relevant law.
12.3. Named Fiduciaries
The Named Fiduciary of the Health FSA is the City of Lubbock Insurance Committee,
which may designate other Named Fiduciaries of the Health FSA. (CYC is not a Named
Fiduciary). The obligations under Sections 12.4 and 12.5 apply to Employer solely with
respect to the Health FSA.
12.4. Fiduciary Duties
Each Fiduciary must discharge its duties with respect to the Health FSA:
(a) Solely in the interest of Participants and for the exclusive purpose of
providing benefits to them and defraying reasonable expenses of
administering the Health FSA.
(b) With the care, skill, prudence, and diligence under the circumstances that a
prudent person acting in a like capacity and familiar with like matters
would use in the conduct of an enterprise of like character and with like
aims; and
(c) In accordance with the documents and instruments governing the Health
FSA insofar as the documents and instruments are consistent with the
provisions of applicable law.
12.5. Fiduciary Liability
(a) For Fiduciary's Own Actions. No Fiduciary is liable for its own act, or
failure to act, unless the Fiduciary causes actual loss to the Health FSA or
to a Participant by failing properly to discharge a fiduciary duty or
responsibility expressly imposed upon the Fiduciary by the Health FSA or
by law.
(b) For Actions of Other Fiduciaries. No Fiduciary is liable for the act, or
failure to act, of another Fiduciary unless the first Fiduciary commits one
or more of the following breaches of his fiduciary responsibilities:
i) If he participates knowingly in, or knowingly undertakes to
conceal, an act or omission of another Fiduciary, knowing the act or
omission is a breach;
60
ii) If, by his failure to observe applicable standards in the
administration of his specific responsibilities which give rise to his
status as a Fiduciary, he enables the other Fiduciary to commit a
breach; or
iii) If he has actual knowledge of a breach by the other Fiduciary,
unless he makes reasonable efforts under the circumstances to
remedy the breach.
12.6. Inability to Locate Payee
If the Plan Administrator is unable to make a payment to You, Your Spouse and
Dependents because the Plan Administrator cannot ascertain Your identity or the identity
of Your Spouse or Dependents or the Plan Administrator cannot ascertain Your
whereabouts or the whereabouts of Your Spouse or Dependents after reasonable efforts
have been made, then such payments will be forfeited following a reasonable time after the
date any such payment first becomes due.
12.7. Indemnification of Employer
If You receive one or more payments or reimbursements under this Plan on a tax-free basis
that do not qualify for tax-free treatment under the Code, then You will indemnify and
reimburse Employer for any liability it may incur for failure to withhold federal income
taxes, Social Security taxes, or other taxes from the payments or reimbursements.
12.8. Code and HIPAA Compliance
It is intended that this Plan meet all applicable requirements of the Code and all regulations
issued thereunder. In addition, it is intended that the Health FSA meet all applicable
requirements of HIPAA and all regulations issued thereunder. In the event of any conflict
between any provisions of the Plan and the Code or HIPAA, the applicable provisions of
the Code and/or HIPAA will control, and any conflicting provision of this Plan will be
superseded to the extent of the conflict.
12.9. Applicable Laws
The provisions of the Plan will be construed, administered and enforced according to
applicable Federal law and the laws of the State of the principal place of business of
Employer to the extent not preempted by federal law.
12.10. Gender
Any masculine pronouns used in the document include the feminine as well.
c�
12.11. Effect of Mistake
Clerical errors or omissions in information provided to You do not deprive You of Your
right to receive a benefit, and do not affect the amount of Your benefit. Conversely, clerical
errors or omissions do not cause You to have the right to receive a benefit to which You are
not entitled and if You receive an overpayment by mistake, You must repay the
overpayment, if requested to do so. Employer, through the Claims Administrator, reserves
the right to correct any mistake in any reasonable manner, including but not limited to,
adjusting the amount of future benefit payments, repaying to the Plan any overpayment, or
making catch-up payments to You for an underpayment. The failure to enforce any
provision of the Plan does not affect the Plan's right thereafter to enforce such provision,
nor does such failure affect its right to enforce any other Plan provision.
12.12. Headings
The headings of the various sections are inserted for the convenience of reference and are
not to be regarded as part of this Plan or as indicating or controlling the meaning of any
provision.
ARTICLE XIII
HIPAA PRIVACY AND SECURITY
The below information describes restrictions on Plan information under the Health FSA
due to HIPAA. This information generally explains HIPAA and what information about
Your Health FSA can be provided to Employer.
14.1. Permitted Uses and Disclosures of PHI by Employer
The Plan may only disclose protected health information to Employer, to enable Employer
to carry out Plan administration functions or as otherwise permitted by the Standards for
Privacy of Individually Identifiable Health Information ("HIPAA Privacy Rule"). Only
persons involved with Plan administration functions may have access to any Health FSA
information disclosed under this Article. If the persons to whom information is disclosed
violate this section, or applicable law, the Plan shall cease disclosing such information.
14.2. Definitions
Unless otherwise indicated, any definitions under this Article shall have the meaning given
them under the HIPAA Privacy Rule.
14.3. Certification
The Plan will only disclose information to Employer under this Article upon a certification
by Employer of the following:
(a) Further Disclosure. Employer agrees not to use or further disclose the
information obtained under this Article other than as permitted or required
62
by the Plan document, or as required by law.
(b) Agents. Employer will require that any agents, including any
subcontractors, to whom it provides protected health information received
under this Article agree to the same restrictions and conditions that apply to
Employer with respect to such information.
(c) Employment Actions. Employer agrees not to use or disclose any
information received under this Article for employment -related actions and
decisions, or in connection with any other benefit or employee benefit plan
sponsored by Employer.
(d) Duty to Report. Employer will report to the Plan any use or disclosure of
information that is inconsistent with the uses or disclosures provided for
under this Article of which it becomes aware.
(e) Access. Employer will make available any information it holds under this
Article in order for the Plan to comply with the access requirements under
the HIPAA Privacy Rule.
(f) Amendment. Employer will make available any information it holds under
this Article in order for the Plan to comply with the amendment
requirements under the HIPAA Privacy Rule, and will incorporate any
amendments to Protected Health Information it holds, as required under the
HIPAA Privacy Rule.
(g) Accounting. Employer agrees to document and provide a description of
any disclosures of protected health information, and information related to
such disclosures, as would be required for the Plan to respond to a request
by an individual for an accounting of disclosures of protected health
information in accordance with the HIPAA Privacy Rule.
(h) Internal Books. Employer agrees to make its internal practices, books, and
records relating to the use and disclosure of protected health information
received from the Plan available to the Secretary of Health and Human
Services, for purposes of the Secretary determining the Plan's compliance
with the HIPAA Privacy Rule.
(i) Return of Information. Employer will, if feasible, return or destroy all
protected health information received from the Plan that Employer
maintains in any form, and retain no copies of such information, when it is
no longer needed for the purpose for which the disclosure was made,
except that, if such return or destruction is not feasible, Employer will limit
further uses or disclosures of the information to those purpose that make
the return or destruction of the information infeasible.
(j) Adequate Separation. Employer will establish adequate separation between
Employer and the Plan, as required under the HIPAA Privacy Rule, and
63
Employer will limit access to protected health information to those
employees or classes of employees entitled to use or disclose such
information and will require that these employees only may use or disclose
such information for the Plan administration functions. Such employees
shall be limited to those employees involved in the administration of the
Health FSA, with such Health FSA administration including arranging for
the payment of Health FSA claims, conducting quality assurance
(including audits) relating to the Health FSA, evaluating Health FSA
claims and deciding appeals of denied Health FSA claims.
(k) Noncompliance. Employer will resolve issues of noncompliance with the
terms of this Article by persons entitled to use or disclose protected health
information in a timely manner, including taking appropriate disciplinary
actions against the individuals responsible for such noncompliance.
14.4. HIPAA Security Standards
(a) Safeguards. Employer will implement administrative, physical, and
technical safeguards that reasonably and appropriately protect the
confidentiality, integrity, and availability of the electronic protected health
information, as defined in the HIPAA Security Standards, 45 CFR Parts
160, 162 and 164, that it creates, receives, maintains, or transmits on
behalf of the Plan, as required in the HIPAA Security Standards.
(b) Agents. Employer will ensure that any agent, including a subcontractor, to
whom it provides electronic protected health information agrees to
implement reasonable and appropriate safeguards to protect such
information.
(c) Security Incidents. Employer will report to the Plan any security incident
under the HIPAA Security Standards of which it becomesaware.
(d) Adequate Separation. Employer will establish reasonable and appropriate
security measures to ensure adequate separation between the Plan and
Employer, in support of the requirements described in this Article.
CONTINUATION COVERAGE RIGHTS UNDER COBRA
The below information describes your right to COBRA continuation coverage under the
Health FSA, which is a temporary extension of coverage under the Health FSA. This
information only applies if this Health FSA is subject to COBRA. Generally, COBRA
applies to all private -sector group health plans maintained by employers that have at least
20 employees on more than 50% of its typical business days in the previous calendar year.
COBRA also applies to certain plans sponsored by some state and local governments, but
not to plans sponsored by the federal government or by churches or certain church -related
organizations. This information generally explains COBRA continuation coverage,
64
when it may become available to You under the Health FSA, and what You need to do
to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985. COBRA continuation coverage is a
continuation of Health FSA coverage when coverage would otherwise end because of a life
event known as a "qualifying event." Specific qualifying events are listed below. After a
qualifying event, COBRA continuation coverage must be offered to each person who is a
"qualified beneficiary." You, Your Spouse and Your Dependent children could become
qualified beneficiaries if coverage under the Health FSA is lost because of the qualifying
event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage
must pay for COBRA continuation coverage.
If You are an Employee, You will become a qualified beneficiary if You lose Your
coverage under the Health FSA because either one of the following qualifying events
happens:
• Your hours of employment are reduced, or
• Your employment ends for any reason other than Your gross misconduct.
If You are the Spouse of an Employee, You will become a qualified beneficiary if You lose
Your coverage under the Health FSA because any of the following qualifying events
happens:
• Your Spouse dies;
• Your Spouse's hours of employment arereduced;
• Your Spouse's employment ends for any reason other than his gross misconduct;
• Your Spouse becomes entitled to Medicare benefits (under Part A, Part B, or both);
or
• You become divorced or legally separated from YourSpouse.
Your Dependent children will become qualified beneficiaries if they lose coverage under
the Health FSA because any of the following qualifying events happens:
• the parent -Employee dies;
• the parent -Employee's hours of employment are reduced;
• the parent -Employee's employment ends for any reason other than his gross
misconduct;
65
• the parent -Employee becomes entitled to Medicare benefits (Part A, Part B, or
both);
• the parents become divorced or legally separated; or
• the child stops being eligible for coverage under the plan as a "Dependent child."
15.1. COBRA Coverage Notification
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the
Plan Administrator has been notified that a qualifying event has occurred. When the
qualifying event is the end of employment or reduction of hours of employment, death of
the Employee, or the Employee's becoming entitled to Medicare benefits (under Part A,
Part B, or both), Employer will notify the Plan Administrator of the qualifying event.
You Must Give Notice of Some Qualifying Events. For the other qualifying events
(divorce or legal separation of the Employee and Spouse or a Dependent child's losing
eligibility for coverage as a Dependent child), You must notify Employer in writing within
60 days after the qualifying event occurs.
15.2. Rights to COBRA Coverage
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each qualified
beneficiary will have an independent right to elect COBRA continuation coverage. Covered
Employees may elect COBRA continuation coverage on behalf of their Spouses, and
parents may elect COBRA continuation coverage on behalf of their children. If You are
electing COBRA continuation coverage, You must notify the Plan Administrator within 60
days of the date the COBRA election notice was provided to You at the time of the
qualifying event. You must provide this notice in writing to Employer following the notice
procedures specified in the COBRA election notice.
COBRA coverage under the Health FSA will be offered only to qualified beneficiaries
losing coverage who have under -spent accounts. A qualified beneficiary has an under -spent
account if the annual limit elected by the covered employee, reduced by reimbursements up
to the time of the qualifying event, is equal to or more than the amount of the premiums for
Health FSA COBRA coverage that will be charged for the remainder of the Plan Year.
COBRA coverage will consist of the Health FSA coverage in force at the time of the
qualifying event. The use -it -or -lose -it rule and all other Plan rules will continue to apply,
so any unused amounts will be forfeited at the end of the Grace Period, and COBRA
coverage will terminate at the end of the Plan Year.
Unless otherwise elected, all qualified beneficiaries who were covered under the Health
FSA will be covered together for the Health FSA COBRA coverage.
66
15.3. Length of COBRA Coverage
COBRA continuation coverage is a temporary continuation of coverage and is made
available for a limited period of time. COBRA continuation coverage for the Health FSA
will not continue past the end of the Plan Year during which the qualifying event occurred.
COBRA coverage will automatically end before the end of the Plan Year if.
(a) Any required premium is not paid in full on time;
(b) A qualified beneficiary becomes covered under another group health plan
after electing COBRA (as long as that other plan doesn't impose an
exclusion or limitation with respect to a pre-existing condition on the
qualified beneficiary);
(c) A qualified beneficiary becomes entitled to Medicare benefits after electing
COBRA; or
(d) Employer ceases to provide a Health FSA for its employees.
15.4. Payments for COBRA Coverage
Each qualified beneficiary is required to pay the entire cost of COBRA coverage. The
amount the qualified beneficiary is required to pay may not exceed 102% of the cost of the
Health FSA for coverage of a similarly situated plan Participant who is not receiving
COBRA continuation. All COBRA premiums must be paid by check, money order, or
another form of payment acceptable to the Administrator. Your first payment and all
monthly payments for COBRA coverage must be mailed or hand delivered to the payment
address specified in the election notice. If mailed, your payment is considered to have been
made on the date it is postmarked. If hand delivered, your payment is considered to have
been made on the date it is received at the payment address. You will not be considered to
have made any payment if Your check is returned for insufficient funds or otherwise.
If You elect COBRA, you do not have to send any payment with the election form.
However, you must make Your first payment no later than 45 days after the date of Your
election. Your first payment must cover the cost of COBRA coverage from the time your
coverage under the Plan would have otherwise terminated up through the end of the month
in which You make Your first payment. You are responsible for making sure the amount of
Your first payment is correct. Claims for reimbursement will not be processed and paid
until You have elected COBRA and made Your first payment for it. If You fail to make
Your first payment in full within 45 days of the date of Your election, You will lose all
rights to COBRA coverage under the Plan.
After You make Your first payment for COBRA coverage, You will be required to make
monthly payments for each subsequent month of COBRA coverage. Under the Plan,
each of these monthly payments for COBRA coverage is due on the first day of the month
for that month's COBRA coverage. If You make a monthly payment on or before the first
day of the month to which it applies, Your COBRA coverage under the Plan will continue
67
for that month without a break. Employer will not send periodic notices of payment due
for these coverage periods. It is Your responsibility to pay Your COBRA premiums
on time.
Although monthly payments are due on the first day of the month for that month's COBRA
coverage, You will be given a grace period of 30 days after the first day of the month to
make each monthly payment. Your COBRA coverage will be provided for each month as
long as payment for that month is made before the grace period for payment. However, if
You pay a monthly payment later than the first day of the month to which it applies but
before the end of the grace period for that month, Your coverage under the Plan will be
suspended as of the first day of the month and reinstated retroactively when the monthly
payment is received. If You fail to make a monthly payment in full before the end of the
grace period for that month, You will lose all rights to COBRA coverage under the Plan.
15.5. Changes in Your Contact Information
In order to protect Your family's rights, You should keep the Plan Administrator informed of
any changes in the addresses of family members. You should also keep a copy, for Your
records, of any notices You send to the Plan Administrator.
68
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
APPENDIX D
PREMIUM CONVERSION CAFETERIA PLAN
The Employer hereby establishes, and intends to maintain, this Exhibit as a cafeteria plan
consistent with the requirements of Section 125 of the Internal Revenue Code of 1986 (the
"Code"), as amended. The purpose of the Exhibit is to provide eligible Employees of the
Employer with the opportunity to choose among those benefits available to them under the
Plan.
ARTICLE I
DEFINITIONS
The following words and phrases as used in this Exhibit shall have the following
meanings, unless a different meaning is plainly required by the context:
1.1 "Administrator" means the City, or such other entity, person, or committee as
may be appointed by the City from time to time to administer the Plan in accordance with
Article VI.
1.2 "Benefit Election Form" means the form promulgated by the Administrator by
which an eligible Employee enrolls in the Plan and makes a choice between the premium
benefits described in Article IV and an equivalent amount of cash.
1.3 "Benefits" means those benefits available to an Employee who has not elected to
receive cash under Article IV.
1.4 "Code" means the Internal Revenue Code of 1986, as amended.
1.5 "City" means the City of Lubbock, a governmental subdivision of the State of
Texas.
1.6 "Effective Date" means January 1, 2018.
1.7 "Employee" means an employee of an Employer.
1.8 "Employer" means the City or any of its affiliates and any other persons, firms, or
organizations which the City determines to include in accordance with the Policies.
1.9 "ERISA" means the Employee Retirement Income Security Act of 1974, as
amended.
69
1.10 "FMLA" means the Family and Medical Leave Act of 1993 (29 USCS §2601 et
seq.).
1.11 "FMLA Leave" means a leave of absence that the City is required to extend to an
Employee under the provisions of the FMLA.
1.12 "Insurer" means any insurance company that provides coverage for an Employee
under Section 4.01 and, where applicable, a qualified health maintenance organization.
1.13 "Medical expense reimbursement plan" means an arrangement under which an
Employee- Participant may become eligible to be reimbursed for certain out-of-pocket
medical expenses incurred on behalf of himself or his family members.
1.14 "Participant" means an Employee who participates in the Plan under Article II.
1.15 "Period of Coverage" means the time interval of coverage purchased through a
Participant's election of coverage under a particular insurance plan.
1.16 "Plan" means the City of Lubbock, Texas Premium Conversion Cafeteria Plan.
1.17 "Plan Year" means the twelve (12) consecutive month period beginning each
January 1st and ending the following December 31st.
1.18 "Policy" means any group insurance contract maintained by the City for the
benefit of Employees that provides medical, life, or disability income insurance coverage
to Employees.
1.19 "Uniformed Services" means the Armed Forces, the Army National Guard, and
the Air National Guard when engaged in active duty for training, inactive duty training, or
full-time National Guard duty, the commissioned corps of the Public Health Service, and
any other category of persons designated by the President of the United States in time of
war or emergency.
ARTICLE II
ELIGIBILITY AND PARTICIPATION
2.1 Eligibility. With respect to any of the Benefits available under the Plan, each
Employee shall be eligible to participate in the Plan as to such Benefits upon the
Employee's satisfaction of the conditions for eligibility set forth in the Policy providing the
Benefits.
2.2 Participation. With respect to each of the Benefits available under the Plan, each
eligible Employee shall become a Participant for a Plan Year when he properly files with
the Administrator a Benefit Election Form in accordance with Article III.
70
2.3 Termination of Participation. Except as provided in Section 2.04, participation
during a Plan Year shall terminate on the date an Employee ceases to be an Employee or
fails to meet the eligibility requirements in Section 2.01.
2.4 Participation During FMLA and Uniformed Service Leaves of Absence. Any
Employee who is absent from work due to (a) an FMLA leave or (b) a period of duty in
the Uniformed Services shall have the right to continue to participate in any insurance
program offered through this Plan that does not limit continued participation on the basis
of a requirement that an insured must be actively at work. The Employee's right to
maintain insurance coverage while on a leave of absence —other than COBRA
continuation coverage under Article V, which makes separate provision for continuation of
health insurance under certain circumstances —is conditioned on the Employee's (a)
continuing to have an employment relationship with the City, and (b) making the required
premium contributions, as provided in Section 4.03.
An Employee who is absent from work on an FMLA leave may continue to participate in
the Plan for a maximum of 12 weeks. If the Employee has not returned to active
employment at the end of the 12-week period, his participation in the Plan shall cease.
However, the Employee and his insured dependents shall be given the right to elect to
continue any group health insurance coverage maintained through this Plan, as provided
under Article V.
An Employee, who is absent from work due to a period of duty in the Uniformed Services,
may continue to participate in the Plan for a maximum of 12 weeks. If such Employee has
not returned to active employment at the end of the 12-week period, his participation in the
Plan shall cease. Provided, however, an Employee who is absent due to duty in the
Uniformed Services shall be given the right to elect to continue any group health insurance
coverage maintained through this Plan for himself and on behalf of his covered
dependents for a maximum of 18 months, measured from the first day of the Employee's
absence for duty in the Uniformed Services. Provided further, however, that such
continuation coverage may extend indefinitely as long as the Employee is entitled to
receive differential pay from the Employer on account of his duty in the Uniformed
Services pursuant to the Employer's leave policy.
ARTICLE III
BENEFIT ELECTIONS
Election of Benefits. Each Employee must, under this Article III, make an election to
receive either the premium benefits available under Article IV, or an equivalent amount of
cash.
Initial Election Period.
An Employee who is eligible to participate as of the Effective Date and who wishes to
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receive the premium benefits under the Plan in lieu of the equivalent amount of cash must
elect such premium benefits before the Effective Date. The required election is made by
completing, signing, and returning a Benefit Election Form to the Administrator.
An Employee who becomes eligible to participate after the Effective Date and who wishes to
participate in the Plan's available premium benefits shall complete, sign, and file a Benefit
Election Form with the Administrator prior to the date the Employee is eligible to become
covered under the Plan. The Benefit Election Form filed by the Employee shall be effective,
subject to Section 3.04, for the period beginning on the first day of the month coinciding
with or next following the date as of which the Benefit Election Form is filed and ending on
the last of the Plan Year.
An eligible Employee who fails to complete and file a Benefit Election Form with the
Administrator under Section 3.02(a) or (b) with respect to the first Plan Year of his most
recent period of participation in the Plan shall be deemed to have elected to receive cash in
lieu of the premium benefits available under Article IV, and shall not be eligible to elect
premium benefits until the next Annual Election period, or until the Employee experiences a
change in status described in Sections 3.05, 3.06, or 3.07, if sooner.
Annual Elections. Each eligible Employee shall be entitled to reform his election for the
next Plan Year by filing a new Benefit Election Form with the Administrator during the 30-
day period preceding the beginning of the new Plan Year. During this re -enrollment period,
the Employee may elect any combination of premium benefits or cash otherwise available
under the Plan. However, if the Employee does not complete a Benefit Election Form during
the 30-day period, it is presumed that his previous year's election is valid and applicable to
the next Plan Year and any succeeding Plan Year until the Employee reforms it.
Altering Benefit Elections Due to Changes in Status.
A Participant shall be entitled to prospectively change a previous benefit election by
revocation or modification during a Plan Year in the event that the Participant experiences a
"Change of Status."
For this purpose, a "Change of Status" is a change in an individual's eligibility for coverage
under a qualified insurance benefit plan sponsored by the Participant's Employer or another
employer's plan due to at least one of the following:
the birth, death, adoption, and placement for adoption of one of a Participant's dependents;
the Participant's marriage, divorce, legal separation, annulment or the death of the
Participant's spouse;
a change in the Participant's employment status or the employment status of the Participant's
spouse or a dependent (including, but not limited to, commencement or termination of
employment, reduction or increase in work hours, strike or lock -out, and commencement of
or return from an unpaid leave of absence);
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a change in an employee's residency or the residency of an employee's spouse or a
dependent; or
a change in the status of one of an employee's dependents under a plan's eligibility criteria
(attainment of a specified maximum age, enrollment or graduation in school, and any similar
circumstance).
The status changes enumerated in Section 3.04(b) may justify election changes with respect
to any qualified insurance benefit offered under this Plan. Furthermore, for purposes of this
Plan, the commencement or termination of adoption proceedings is treated as a change in
status for purposes of adoption assistance benefits.
A Participant otherwise entitled to implement a new prospective election because of having
experienced a Change in Status must do so within 30 days before or after the date of the
status change. However, any such election change is subject to the following restrictions.
A Participant may not cancel coverage for an individual who has become eligible for
coverage under another plan unless the individual actually becomes covered under the other
plan.
With respect to group term life or disability income insurance coverage, an election change
following a change in marital status must correspond to either a resulting need to satisfy a
coverage deficiency or to eliminate unnecessary coverage.
If a Participant, his spouse, or a dependent loses coverage under the health insurance plan
sponsored by the Participant's Employer and elects coverage continuation under the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), the Participant may
increase any health insurance contribution election under this Plan to pay for such coverage.
A Participant's termination of employment for more than 30 days during a Plan Year will be
deemed to be a bona fide termination that would permit the Participant to cancel coverage
for the remainder of the plan year, reinstate his prior elections, or make a new election
without regard to his prior elections.
Altering Benefit Elections Due to Changes in Participant's Coverage.
If coverage under any benefit option offered under this Plan is significantly curtailed or
terminated during the Plan Year, an affected Participant shall be permitted to change to
coverage under another option providing similar coverage. In this context, coverage under an
accident or health plan is significantly curtailed only if there is an overall reduction in
coverage that affects all Participants.
If the Plan adds or eliminates a benefit package or coverage option during the Plan Year,
affected Participants may elect the new option or a replacement for a cancelled option and
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make corresponding election changes with respect to other options providing similar
coverage.
Altering Benefit Elections Due to Coverage Changes Under a Family Member's Plan.
A Participant may make a mid -Plan Year prospective election change on account of (and
consistent with) a coverage change under a Code § 125 cafeteria plan sponsored by the
employer of the Participant's spouse, former spouse, or dependent that results from:
a permissible election change (for any of the reasons set forth in Section 3.04 and 3.05); or
if the Participant's and the family member's cafeteria plans have different plan years, such
family member's new election during an open enrollment period.
Altering Benefit Elections Due to Changes in Coverage Costs.
If the cost of a qualified benefit option (other than a health FSA under a medical expense
reimbursement plan, but including a self -insured arrangement providing conventional health
insurance benefits) increases or decreases during a Plan Year, and so affects participants'
premiums for such benefit plan, the Administrator will automatically make a prospective
adjustment, on a reasonable and consistent basis, in affected Participants' pretax premiums.
If the cost that is charged to all Participants with respect to a benefit package option is
significantly increased, each affected Participant shall be given the choice of either making a
corresponding
increase in his premiums for that option or electing another benefit package option providing
similar coverage on a prospective basis.
If coverage under a qualified benefit option offered under this Plan is significantly curtailed
or ceases during a Plan Year, affected Participants shall be allowed to change to coverage
under another option providing similar coverage. Coverage under an accident or health plan
is significantly curtailed only if there is an overall reduction in coverage that affects all
participants in that program.
Altering Elections for Court Ordered Coverage. If a Participant's child who is the subject
of a qualified medical child support order (QMCSO) gains or losses coverage under any
employer's plan, the participant may change his elections in a manner that is consistent with
an increase or decrease in the Participant's responsibility to provide health care coverage for
such child. For these purposes, a QMCSO is a judgment, decree, or order issued by a court
or a state administrative process with the force of law under which a child for whom an
individual must provide child support is entitled to benefits under such individual's health
plan.
Altering Elections for HIPAA Special Enrollments. If a Participant, his spouse, or any of
his dependents become covered under a group health insurance plan maintained by the
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Employer by reason of special enrollment rights arising under federal law, the Participant
shall be permitted to make a prospective change to his health benefit election under this Plan
consistent with the financial effect of the special enrollment.
Altering Elections Upon Medicare or Medicaid Entitlement. If a Participant, his spouse,
or a dependent becomes enrolled for general benefits under Medicare or Medicaid (i.e.,
benefits in addition to pediatric vaccinations), the Participant shall be allowed to cancel
coverage for such individual. Alternatively, if the Participant, spouse, or dependent loses
coverage under Medicare or Medicaid, the Participant may make a prospective election to
begin or increase coverage of that individual under the Participant's accident or health plan.
Altering Elections Due to FMLA Leaves. A Participant who takes an FMLA leave
described in Section 1.16 shall have the right to make any election change under an
Employer -sponsored group health plan option as may be provided for under FMLA.
Termination of Election. A Participant may revoke a prior election upon terminating
employment or taking an unpaid leave of absence. Likewise, failure to make required
contributions for any benefit elected under this Plan shall automatically terminate any prior
election with respect to such benefit, unless delinquent contributions are brought current
within 30 days of the date that they became delinquent. If revocation occurs under this
Section 3.12, no new election may be made by such Participant during the remaining
coverage period of the Plan Year.
ARTICLE IV
BENEFITS
4.1 Benefits. Those Employees who elect to receive the Benefits available under this
Article IV by properly filing a Benefit Election Form with the Administrator under
Article III shall have their taxable salaries reduced by an amount equal to the Employee
contribution amounts required for coverage of the Employees and, if applicable, the
Employees' respective spouses and dependents, with respect to the underlying Policies, and
the full premium payment with respect to such coverage shall be made by the City to the
appropriate Insurer. The annual employee contribution amounts by which an Employee's
salary is to be reduced in order to fund the cost of the Benefits available under this Section
4.01 is equal to the amount as set by the Employer, which may or may not be the same
amount charged by the Insurer.
4.2 Insurance Contracts. The City shall have the right to enter into a contract with
one or more Insurers for the purpose of providing Benefits under the Plan and to replace
any Insurer. The terns of the Policies shall supersede the terms of the Plan. Any
dividends, retroactive rate credits, or other refunds which may become payable under any
agreement with an Insurer shall be retained by the City.
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4.3 Premium Payments by Employees of FMLA and Uniformed Service Leaves
of Absence.
(a) Any employee who elects to maintain coverage while on an FMLA leave
of absence or is absent from work for more than 31 days for duty in the
Uniformed Services (as provided in Section 2.04, above) must continue to
make any required contributions specified in Section 4.01. During the
absence, an Employee may choose to make these contributions by:
(i) remitting payment to the City on or before each pay period for
which the contributions would have been deducted from the
Employee's paycheck if leave had not been taken, provided that any
delinquent payments must be made within 30 days of their due date,
or
(ii) at the Employee's request, prepaying the amounts that will become
due during the leave out of one or more of the Employee's
paychecks preceding the leave.
(b) An Employee who is absent from work for any paid leave of absence may
continue any and all benefits elected under this Plan not prohibited by any
insurance policy provision requiring an insured to be actively at work, and
Employee contributions for those benefits that the Employee chooses to
continue while on the leave of absence will continue to be deducted from
the Employee's paychecks during the absence. Provided, however, for
Employees who are absent from work due to duty in the Uniformed
Services, Employee contributions will be deducted from the Employee's
differential pay paid by the Employer on a pre-tax basis and any shortfall
may be made up with the Employee's personal funds on an after-tax basis.
ARTICLE V
CONTINUATION COVERAGE
5.01 Continuation Coverage. An Employee or a Qualified Beneficiary who loses
coverage under the underlying group health insurance plan or plans covered by this Plan
generally will have the opportunity to elect Continuation Coverage under that plan in
accordance with the COBRA continuation coverage provisions contained in that plan.
ARTICLE VI
ADMINISTRATION
6.1 The Administrator. Except as to those functions reserved within the Plan to the
City, the Administrator shall control and manage the operation and administration of the
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Plan. The Administrator shall be the City, or such other entity, person, or committee as
may be appointed from time to time to serve as Administrator by the City. If a committee
is appointed to serve as Administrator, any member of the committee may resign or be
removed by the City and new members may be appointed by the City. The City also shall
designate from time to time one or more individuals to act on behalf of the Administrator.
Committee Members. The Insurance Committee keeps the records for the Plan and
is responsible for the administration of the Plan. As of the amended and restated effective
date, the Insurance Committee shall consist of the City Manager, City Attorney, Chief
Financial Officer, Director of Human Resources and Director of Electric Utilities or their
designees. Any person appointed to be a member of the committee shall signify his
acceptance in writing by the City. Any member of the committee may recuse by delivering
written notice to the City Manager. The City Manager shall have the ability to appoint an
alternate member to serve during the recusal. In the event one of the Insurance Committee
positions is vacant, or abolished through the budget process, the City Manager shall have
the ability to appoint a replacement.
6.2 Rules of Administration. Subject to the limitations of the Plan, the Administrator
shall establish rules for the Administration of the Plan and the transaction of its business.
It shall have the exclusive right (except as to matters reserved to the City or an Employer
by the Plan or that the City or an Employer may reserve to itself) to interpret the Plan and
to decide all matters arising under the Plan, including the right to remedy possible
ambiguities, inconsistencies, or omissions. All determinations of the Administrator as to
any matter under the Plan shall be conclusive and binding on all persons. Without limiting
the generality of the foregoing, the Administrator shall have the following powers and
duties:
(a) To require any person to furnish information that it may request for the
purpose of the proper administration of the Plan and as a condition to
receiving any Benefits under the Plan;
(b) To make and enforce rules and regulations and prescribe the use of forms
that it deems necessary for the efficient administration of the Plan;
(c) To decide questions concerning the Plan and the eligibility of any Employee
to participate in the Plan;
(d) To determine the cost of Benefits available to any person under the
provisions of the Plan and to provide a full and fair review to any
Participant whose claim for Benefits has been denied in whole or in part;
(e) To allocate any of its powers and duties to or among individual members of
the committee; and
(f) To designate persons other than the committee members to carry out any
duty or power which would otherwise be a fiduciary responsibility of the
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Administrator under the terms of the Plan.
6.3 Employment of Others. The Administrator, subject to approval of the City, may
employ the services of those persons that it may deem necessary or desirable in
connection with the Plan.
6.4 Liability. To the extent permitted by law, neither the Administrator nor any other
person shall incur any liability for any acts or for any failure to act except for their or his
own willful misconduct or willful breach of the Plan.
6.5 Expenses. All expenses incurred prior to the termination of the Plan that shall
arise in connection with the administration of the Plan, including, without limitation,
administrative expenses and compensation and other expenses and charges of any actuary,
counsel, accountant, specialist, or other person who shall be employed by the
Administrator in connection with the administration of the plan, shall be paid by the City.
ARTICLE VII
CLAIMS PROCEDURE
Any Employee, beneficiary, or duly authorized representative may file a claim for Benefits
to which the claimant believes he is entitled. The claims procedure applicable to any
Benefits shall be determined in accordance with the Policies under which the Benefits are
provided.
ARTICLE VIII
AMENDMENT OR TERMINATION OF PLAN
8.1 Plan Amendment or Modification. The City reserves the power at any time and
from time to time (and retroactively, if necessary or appropriate to meet the requirements
of the Code) to modify or amend, in whole or in part, any or all provisions of the Plan,
provided, however, that no modification or amendment shall divest an Employee of a
right to those Benefits to which he has become entitled under the Plan. Any amendments
to this Plan may be effected by a written resolution adopted by the governing body of the
City, or its delegate.
8.2 Plan Termination. This Plan may be terminated by a written resolution adopted
by a majority of the governing body of the City. Furthermore, the Plan will also
automatically terminate if the City (1) is legally dissolved; (2) makes a general
assignment for the benefit of its creditors; (3) files for liquidation under the Bankruptcy
Code; or (4) merges or consolidates with any other entity and it is not the surviving entity,
or if it sells or transfers substantially all of its assets, or goes out of business, unless the
City's successor in interest agrees to assume the liabilities under this Plan as to the
Participants and Eligible Dependents. The City reserves the right and power to
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discontinue or terminate the Plan at any time.
8.3 Effective Date of Amendment or Termination. Any amendment, discontinuance
or termination of the Plan shall be effective as of the date that the City determines.
ARTICLE IX
GENERAL INFORMATION
9.1 Right to Continued Employment. Neither the Plan nor any action taken with
respect to it shall confer upon any person the right to continue in the employ of an
Employer.
9.2 Assignment. No benefit under the Plan shall be subject in any manner to
anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, or charge, and any
attempt to do so shall be void.
9.3 Written Communications. All communications in connection with the Plan made
by an Employee shall become effective only when duly executed and filed with the
Administrator.
9.4 Fiduciaries. Any person or group of persons may serve in more than one fiduciary
capacity with respect to the Plan.
9.5 Governing Laws. The provisions of the Plan shall be construed, administered and
enforced according to applicable Federal law and the laws of the State of Texas.
9.6 Severability. The provisions of the Plan are severable. If any provision of the Plan
is deemed legally or factually invalid or unenforceable to any extent or in any application,
then the remainder of the provision and the Plan, except to such extent or in such
application, shall not be affected, and each and every provision of the Plan shall be valid
and enforceable to the fullest extent and in the broadest application permitted by law.
79
IN WITNESS WHEREOF, we have executed this Plan Agreement the date and
year first written above.
ATTEST:
By:
Title: A Secretary
APPROVED '.a T4 CONTENT:
Title: Human Resources Director
City of Lubbock
sn
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
Schedule A
As of January 1, 2018
I. Group Medical Feature
Carrier/Administrator Contract/Group No.
Blue Cross Blue Shield of Texas 10097 11
II. Group Dental Feature
Carrier Cont act/Group No.
Blue Cross Blue Shield of Texas 10097 11
III. Group Vision Feature
Carrier Cont act/Group No.
Davis Vision 501988-A
IV. Group Life/AD&D Feature
Carrier Contract/Group No.
Fort Dearborn Life Insurance Company GFZ03192-0001
V. Group LTD Feature
Carrier Contract/Group No.
Fort Dearborn Life Insurance Company GFZ03192-0001
81
VI. Flexible Benefits Feature
Claims Administrator Benefit Reference
City of Lubbock Health Flexible Spending
Arrangement and Dependent Care
Assistance Plan Components
(Appendix C)
VII. COBRA Administrator
Health Care Service Corporation
P.O. Box 1180
Marion, Illinois 62959-7680
Telephone: (888) 541-7107
Premium Conversion Cafeteria Plan
(Appendix D)
92