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Home My WebLink AboutResolution - 2014-R0386 - Texas Master Welfare Benefit Plan - 11/20/2014Resolution No. 2014-RO386 Item No. 6.13 November 20, 2014 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 and 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. Passed by the City Council on November 20. 2014'. _ GLBK C. R76BERTSON, MAYOR ATTEST: ebe a Garza, City Secret APPROVED AS TO CONTENT: Leisa utcheson Director of Human Resourses and Risk Management APPROVED AS TO FORM: i c ell Satter" ite, First A istant City Attorney RES.Master Welfare Benefit Plan November 4, 2014 Resolution No. 2014-RO386 CITY OF LUBBOCK, TEXAS MASTER WELFARE BENEFIT PLAN AND SUMMARY PLAN DESCRIPTION Effective: January 1, 2004 Amended and Restated: January 1, 2015 This document, together with the documents referenced in Appendix A and Appendix B, constitutes BOTH the formal written plan document and the Summary Plan Description of such plan. TABLE OF CONTENTS ARTICLE I ESTABLISHMENT AND PURPOSE OFTHE PLAN.......................................................................................... 1 ARTICLEII DEFINITIONS...........................................................................................1 ARTICLE III ELIGIBILITY, PARTICIPATION, AND BENEFITS .......................... 4 ARTICLE IV CONTRIBUTIONS AND FUNDING ...................................................... 6 ARTICLE V ARTICLE VI EXHIBITS: EXHIBIT I EXHIBIT II EXHIBIT III EXHIBIT IV EXHIBIT V EXHIBIT VI APPENDICES: PLAN ADMINISTRATION.................................................................... 7 MISCELLANEOUS................................................................................10 CONTINUATION COVERAGE QUALIFIED MEDICAL CHILD SUPPORT ORDER PROCEDURES SUBROGATION AND REIMBURSEMENT OF PAYMENTS BY PLAN CLAIMS AND REVIEW PROCEDURES PROVISION OF PROTECTED HEALTH INFORMATION TO PLAN SPONSOR PREMIUM CONVERSION CAFETERIA PLAN APPENDIX A WELFARE BENEFITS PROVIDED UNDER PLAN APPENDIX B SUMMARY PLAN DESCRIPTION SUPPLEMENT CITY OF LUBBOCK, TEXAS MASTER WELFARE BENEFIT PLAN Effective: January 1, 2004 Amended and Restated: January 1, 2015 The City of Lubbock, Texas (hereinafter referred to as the "City") hereby amends and restates the City of Lubbock, Texas Master Welfare Benefit Plan (the "Plan"), effective as of January 1, 2015. ARTICLE I ESTABLISHMENT AND PURPOSE OF THE PLAN 1.1 Establishment of Plan. The City has established the Plan for the exclusive benefit of its employees, employees of certain related businesses, retirees, elected officials and their respective dependents and beneficiaries, as applicable, to provide certain welfare and fringe benefits to such individuals. 1.2 Plan Document. This document, together with the specific documents (or portions thereof) (i) set forth opposite the name of each of the component welfare or fringe benefits identified in Appendix A, or (ii) the successor documents to such referenced documents, shall constitute the written plan document for this Plan and for each underlying component Welfare Benefit provided under the Plan, and each of the separate documents (or portions thereof) referenced in Appendix A are hereby incorporated by reference. 1.3 Grandfathered Group Health Care Plan Disclosure. The City believes that this group health plan is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that the plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. 1.4 Questions Regarding Grandfathered Health Plans. Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the City Manager at 1-806-775-2003 or www. ci.lubbock. tx. us. You may also contact the U.S. Department of Health and Human Services at wwnl. healthreform.gov. ARTICLE II DEFINITIONS The following words and phrases when used with initial capitals herein shall have the following meanings unless the context requires otherwise. All other defined terms in this Plan shall have the meanings specified in the documentation with respect to the given underlying component Welfare Benefit in which they appear. 2.1 Code. "Code" means the Internal Revenue Code of 1986, as amended. 2.2 Contract. "Contract" means any contract, other than a Policy, entered into by the Employer that is being used in conjunction with providing any underlying component Welfare Benefits referenced in Appendix A. 2.3 City. "City" means the City of Lubbock, Texas, or any successors and assigns thereto. 2.4 Employee. "Employee" means any person who is employed by the Employer as a common-law employee and who is compensated from the Employer's payroll. Provided, however, unless specifically included under the documentation with respect to an underlying component Welfare Benefit provided under the Plan set forth in Appendix A, "Employee" does not include any of the following: (a) Temporary or seasonal employees classified as such on the Employer's payroll records; (b) Persons classified and treated by the Employer as independent contractors, contract worker, or any other individual who is not designated as of the initial date of the relationship as a common law employee of the Employer; if someone so classified and treated is subsequently determined by the Employer or any governmental agency or court to be a common law employee of the Employer, such person shall not be considered an Employee until the day after the final determination that such person is a common law employee of the Employer; (c) Individuals characterized as leased employees (as defined by Code Section 414(n)) or any individuals who would be leased employees but for the fact they are common law employees of the Employer; and (d) Individuals included in a unit covered by a collective bargaining agreement if Welfare Benefits were the subject of good faith bargaining. In the event a person listed in one or more of the subsections (a) through (e) above is specifically included as an "Employee" under the documentation with respect to an underlying component Welfare Benefit provided under the Plan set forth in Appendix A, he shall be considered an Employee under this Plan only with respect to that specific underlying component Welfare Benefit, and not with respect to other any benefits provided under this Plan. 2.5 Employer. "Employer" means, collectively, (i) the City, and (ii) any other affiliated or related entity which has adopted this Plan for the benefit of its Employees in a manner satisfactory to such entity and the City, and which is set forth in Appendix B attached hereto, as amended from time to time. 2.6 ERISA. "ERISA" means the Employee Retirement Income Security Act of 1974, as amended. 2.7 Funded Welfare Benefit. "Funded Welfare Benefit" means a Welfare Benefit that is provided through a trust or other segregation of assets from the Employer's general assets and income. 2.8 Insured Welfare Benefit. "Insured Welfare Benefit" means a Welfare Benefit that is provided through a Policy obtained by the Employer. 2.9 Insurer. "Insurer" means the entity that issues any Policy utilized under the Plan. 2.10 Participant. "Participant" means any individual who is eligible for, and becomes covered with respect to, any component Welfare Benefit provided under the Plan. 2.11 Plan. "Plan" means, collectively, this document, including all amendments thereto, together with the separate documentation (or portions thereof) with respect to the various underlying component Welfare Benefits referenced in Appendix A attached hereto that is incorporated by reference. With respect to a given underlying component Welfare Benefit referenced in Appendix A, the term "Plan" also means the Policy, plan document, or other governing document prepared by the City relating to such underlying Welfare Benefit. When the Plan refers to a Policy, it also refers to any attachments to such contract, as well as documents incorporated by reference into such contract (such as the application and the certificate of insurance booklet). This document, together with the documentation referenced in Appendix A, shall constitute the formal written plan document. 2.12 Plan Administrator. "Plan Administrator" means, except as otherwise set forth in any Policy or Contract incorporated by reference into this Plan with respect to a given component Welfare Benefit, the City, or such other entity, person, or committee as may be appointed from time to time to act as Plan Administrator by the City. The City also shall designate from time to time one or more individuals to act on behalf of the Plan Administrator. 2.13 Plan Year. "Plan Year" means the Plan's accounting year of twelve months commencing on January 1 st of each year and ending the following December 31 st. 2.14 Policy. "Policy" means any policy of insurance or health maintenance organization contract which involves the shifting of the risk to an Insurer, health maintenance organization, or other third -party unrelated to the Employer that is being used in conjunction with providing any underlying component Welfare Benefit referenced in Appendix A. 2.15 Unfunded Welfare Benefit. "Unfunded Welfare Benefit" means a component Welfare Benefit that is provided solely from the general assets of the Employer. 2.16 Welfare Benefit. "Welfare Benefit" means (i) any benefit specified in the definition of "employee welfare benefit plan" in ERISA Section 3(1) and its corresponding regulations, and (ii) a cafeteria plan within the meaning of Code Section 125. 3 ARTICLE III ELIGIBILITY, PARTICIPATION, AND BENEFITS 3.1 Eligibility and Participation. (a) An individual who is eligible with respect to the Plan will be an Employee (or eligible dependent thereof) who is eligible to participate in and receive benefits under one or more of the component Welfare Benefits provided under the Plan. The specific terms and conditions regarding eligibility and participation under the Plan with respect to any given component Welfare Benefit provided under the Plan, including any applicable enrollment procedures and when such coverage commences, are set forth in the Plan documentation with respect to such Welfare Benefit referenced in Appendix A. (b) The Plan shall comply with the special enrollment provisions of the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), with respect to those underlying component Welfare Benefits provided under the Plan that are subject to HIPAA. (c) Notwithstanding anything to the contrary, any Employee (or eligible dependent thereof) is eligible for coverage with respect to a given component Welfare Benefit provided under the Plan only if any contributions required by Participants, in accordance with Section 4.1, with respect to such coverage have been made for the period for which coverage is claimed. (d) The Plan shall comply with the provisions of the Patient Protection and Affordable Care Act of 2010, as amended, such that the Plan will maintain its status as a "grandfathered" group health plan. 3.2 Termination of Participation. (a) The terms and conditions regarding when an Employee's (and his eligible dependent's) participation under the Plan ceases with respect to any given component Welfare Benefit provided under the Plan are set forth in the Plan documentation with respect to such Welfare Benefit referenced in Appendix A. (b) In any event, all benefits shall cease upon the termination of the Plan. (c) Any other circumstances that may result in the termination, reduction, or denial of benefits under the Plan (including, but not limited to, annual or lifetime caps, and costs incurred within an exclusionary period) with respect to any given component Welfare Benefit provided under the Plan are set forth in the Plan documentation with respect to such Welfare Benefit referenced in Appendix A, to the extent applicable or not otherwise exempt. (d) The Plan shall comply with the provisions of the Patient Protection and Affordable Care Act of 2010, as amended, such that no Participant who is 0 otherwise eligible to receive benefits will have coverage under the Plan rescinded except in the case of fraud or intentional misrepresentation. 3.3 Benefits. (a) The terns and conditions of the benefits provided to Participants under this Plan with respect to a particular underlying component Welfare Benefit are described in the underlying Plan documents with respect to such benefit, and shall be subject to various limitations and exclusions set forth in the Plan with respect to such underlying component Welfare Benefit. (b) No Participant shall be entitled to any benefits under this Plan except as expressly provided in the Plan with respect to its underlying component Welfare Benefits, with all Insured Welfare Benefits being the direct financial obligation of the applicable Insurer, and all Funded Welfare Benefits and Unfunded Welfare Benefits, directly or indirectly, being the financial obligation of the Employer. 3.4 Continuation Coverage. (a) The provisions set forth in Exhibit I concerning continuation coverage shall apply to any component Welfare Benefit referenced in Appendix A that is a group health plan which is subject to the (i) Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA); (ii) Uniform Services Employment and Reemployment Rights Act of 1994, as amended (USERRA); or (iii) Family and Medical Leave Act of 1993, as amended (FMLA); or (iv) The Patient Protection and Affordable Care Act of 2010, as amended; unless the Plan documentation referenced in Appendix A with respect to such Welfare Benefit otherwise specifically provides for continuation coverage with respect to such Welfare Benefit in a legally sufficient manner. (b) Unless otherwise expressly provided to the contrary in Appendix A, all component Welfare Benefits referenced in Appendix A that provide health care benefits shall be treated as a single plan for purposes of COBRA; provided, however, any Welfare Benefit referenced in Appendix A that is a health flexible spending account arrangement shall be treated as a separate plan. 3.5 Qualified Medical Child Support Orders. With respect to any component Welfare Benefits that are group health plans, the Plan shall provide benefits as required by any qualified medical child support order (QMCSO), but only to the extent it is documented as a National Medical Child Support Notice. The provisions of Exhibit II attached hereto set forth the procedures for determining whether an order qualifies as a QMCSO; provided, however, any correctly completed National Medical Child Support Notice is automatically deemed to be a valid QMCSO. Participants and beneficiaries can obtain a copy without charge, a copy of such procedures from the Plan Administrator. 5 ARTICLE IV CONTRIBUTIONS AND FUNDING 4.1 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 Benefit, provided, however, that the Employee's contribution rate shall not be increased if the increase would constitute a "significant change" under the Patient Protection and Affordable Care Act of 2010, as amended. (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 Exhibit VI. 4.2 Contributions by the Employer. The Employer shall provide funds that, when combined with the contributions made by Participants, are at least sufficient (as determined in the Employer's sole discretion) to provide for the underlying component Welfare Benefits provided under this Plan. Participant contributions toward the cost of a particular Welfare Benefit will be used in their entirety prior to using Employer contributions to pay for the cost of such benefit. 4.3 Funding. Any Insured Welfare Benefit provided under the Plan shall be funded by the corresponding Policies; provided, however, any dividends credited to the Employer under any such Policy are reserved by, and to the benefit of, the Employer to the extent that the total of such dividends does not exceed the total of Employer contributions under the policy or contract for such premium year and to such extent such dividends shall not constitute an asset of the Plan. Any Unfunded Welfare Benefits provided under the Plan shall be funded by the general assets of the Employer. Any Funded Welfare Benefits provided under the Plan shall be funded through a funding vehicle that is segregated from the Employer's general assets and liabilities. Nothing herein shall be construed to require the Employer to maintain any fund or segregate any amount for the benefit of any particular Participant, and no Participant or other person shall have any claim against, right to, or security or other interest in, any fund, account, or asset of the Employer from which any payment under the Plan may be made. 4.4 Subrogation and Reimbursement of Payments Made by Plan. The provisions of Exhibit III attached hereto shall apply to any underlying component Welfare Benefit provided under the Plan (other than any Insured Welfare Benefit), unless the Plan documentation referenced in Appendix A with respect to such Welfare Benefit otherwise specifically includes provisions with respect to the assignment of rights (subrogation), equitable liens, and other equitable remedies that provide rights and remedies that are more favorable to the Plan than those set forth in Exhibit III. ARTICLE V PLAN ADMINISTRATION 5.1 Principal Duty. The Plan shall be administered by the Plan Administrator, who is the named fiduciary under the Plan. The principal duty of the Plan Administrator is to determine that the provisions of the Plan are carried out in accordance with its terms, for the exclusive benefit of persons entitled to participate in the Plan. The administrative provisions set forth in this Article V shall govern the administration of the Plan; provided, however, the administrative provisions (including, but not limited to any administrative claims and review procedures) set forth in the Plan documentation with respect to any Insured Welfare Benefit referenced in Appendix A shall control with respect to such benefits. 5.2 Plan Administrator's General Powers, Rights, and Duties. The Plan Administrator shall have full discretionary power to administer the Plan in accordance with its terms and intended meaning, subject to any applicable requirements of law. For this purpose, the Plan Administrator is given the powers, rights, and duties specifically stated elsewhere in the Plan, and in addition, is given, but not limited to, the following powers, rights, and duties: (a) To determine all questions arising under the Plan, including the power to determine the rights or eligibility of Employees or Participants and any other persons, and the amounts of their contributions or benefits under the Plan; (b) To make any findings of fact needed in the administration of the Plan; (c) To interpret and construe the Plan, and to remedy ambiguities, inconsistencies, or omissions in any fashion it deems to be appropriate in its sole judgment (including, but not limited to, interpreting any Plan provision that due to errors, omissions, or delays in drafting does not accurately reflect its intended meaning, as demonstrated by consistent interpretations or other evidence of intent); (d) To make and enforce such rules and regulations as it deems necessary for the proper and efficient administration of the Plan; (e) To direct payments or distributions from the Plan in accordance with the provisions of the Plan; (f) To develop such information as may be required by it for tax or other purposes as respects the Plan; and (g) To employ agents, attorneys, accountants, or other persons (who also may be 7 employed by the Employer), and allocate or delegate to them such powers, rights and duties as the Plan Administrator may consider necessary or advisable to properly carry out the administration of the Plan. (h) To ensure that the Plan is administered in such a way as to maintain the Plan's status as a grandfathered group health plan in accordance with the Patient Protection and Affordable Care Act of 2010, as amended. 5.3 Exercise of Authority. To the extent the Plan Administrator has been granted discretionary authority under the Plan, the Plan Administrator's prior exercise of such authority shall not obligate it to exercise its authority in a like fashion thereafter. Moreover, the validity of any findings of fact, interpretation, construction, or decision by the Plan Administrator shall not be given de novo review if challenged in court or in any other forum, and shall be upheld unless clearly arbitrary or capricious. Thus, subject to the claims and review procedures set forth in Section 5.6, all actions taken and all determinations made in good faith by the Plan Administrator pursuant to this Article V shall be final and binding upon all persons claiming any interest in or under the Plan. 5.4 Indemnification of Administrator. The City agrees to indemnify and to defend to the fullest extent permitted by law any Employee serving as a delegate or agent of the Plan Administrator (including any Employee or former Employee who is serving or formerly served as a delegate or agent of the Plan Administrator) against all liabilities, damages, costs, and expenses (including attorney's fees and amounts paid in settlement of any claims approved by the Employer) occasioned by any act or omission to act in connection with the Plan, if such act or omission is or was in good faith. 5.5 Information Required by Plan Administrator. The Plan Administrator has the right to obtain such data and information as the Plan Administrator may deem necessary or desirable in order to administer the Plan, including but not limited to independent medical advice. The records of the Employer as to an Employee's or Participant's period or periods of employment, termination of employment and the reason therefore, leave of absence, re-employment, and earnings will be conclusive on all persons unless determined by independent agents or delegates of the Plan Administrator to be incorrect. Participants and other persons entitled to benefits under the Plan also shall furnish the Plan Administrator with such evidence, data, or information, as the Plan Administrator considers necessary or desirable to administer the Plan. 5.6 Claims and Review Procedures. To obtain benefits from any component Welfare Benefit under this Plan, a Participant must complete and submit to the Plan Administrator a claim for benefits in the form and manner specified by the Plan Administrator. The Plan Administrator will decide a Participant's claim in accordance with reasonable claims procedures. If the Plan Administrator denies a claim in whole or in part, then the Participant will receive a written notification setting forth the reason(s) for the denial. If a claim is denied, the Participant may appeal to the Plan Administrator for a review of the denied claim. The Plan Administrator will decide the appeal in accordance with reasonable claims review procedures. If a Participant does not file his claim or appeal in a timely manner, then the Participant will lose his right to file legal action in state or federal court because he will not have exhausted the internal administrative claims procedures (which generally is a prerequisite to bringing a legal action in state or federal court). The specific terms of the Plan's claims and review procedures are set forth in Exhibit IV attached hereto. 5.7 Furnishing Information or Providing Other Reports. To the extent required by the Code or applicable state or local law, the Employer shall provide Employees with: (a) a summary description of the Plan, and (b) any other required information or notices with respect to the Plan. After payment by the Employee of a reasonable charge (which charge may be waived by the Plan Administrator), the Plan Administrator shall provide the Employee with a copy of this Plan upon written request by the Employee. The City or Plan Administrator, as appropriate or as required by law, shall also file with government authorities any reports or returns required. 5.8 Expenses. Unless specified otherwise in the Plan documentation with respect to a given underlying component Welfare Benefit provided under the Plan referenced in Appendix A, the Employer shall pay all reasonable expenses that are necessary to operate and administer the Plan. 5.9 Bonding and Fiduciary Liability Insurance. To the extent required by law, with respect to Welfare Benefits provided under the Plan, every fiduciary of the Plan and every person handling Plan funds shall be bonded. The Plan Administrator shall take such steps as are necessary to assure compliance with the applicable bonding requirements. In addition, the Plan Administrator may apply for and obtain fiduciary liability insurance, at the Employer's expense, insuring the Plan against damages by reason of breach of fiduciary responsibility and insuring each fiduciary against liability to the extent permissible by law. 5.10 Nondiscrimination Rules. (a) The Plan Administrator shall not take any action or direct any action with respect to any of the benefits provided hereunder that would be impermissibly discriminatory in favor of Employees who are officers or highly compensated Employees of the Employer, or that would result in benefiting one Participant or group of Participants at the expense of another, or in the application of different rules to substantially similar sets of facts. (b) The Plan shall comply with all applicable nondiscrimination rules under the Code. Should the Plan be subject to nondiscrimination testing under the Code or any other applicable law, the Plan Administrator may make any decisions or elections, whether voluntary or required by law, necessary to facilitate such testing. Any elections required to be in writing shall be stated from time to time in Plan documentation with respect to the applicable underlying component Welfare Benefit referenced in Appendix A. 0 ARTICLE VI MISCELLANEOUS 6.1 Amendment and Termination of Plan. The City, as Plan sponsor, has the right to amend or terminate all or a portion of the Plan at any time; provided, however, no such action shall adversely affect any claims that have actually been incurred by a Participant (or beneficiary) that would otherwise be eligible for payment under the Plan as in effect when the expense is incurred. Where an amendment of the Plan requires the consent or approval of any Insurer, such amendment shall be subject to a condition that such consent or approval is obtained. Notice of any amendment or termination shall be given to the Plan Administrator. No amendment or modification of the Plan shall be interpreted to relinquish the Plan's "grandfathered" status under the Patient Protection and Affordable Care Act of 2010, as amended, unless the intent to relinquish "grandfathered" status is expressly stated in clear and unambiguous language. 6.2 Privacy of Health Information. The provisions set forth in Exhibit V concerning the use of protected health information by any Employees of the Employer, in its capacity as Plan sponsor, and/or any of its agents or subcontractors, shall apply with respect to any group health care benefits subject to the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) and its implementing regulations. 6.3 Information to be Furnished. Participants shall provide the Employer and Plan Administrator with such information and evidence, and shall sign such documents, as may reasonably be requested from time to time for the purpose of administration of the Plan. The Plan, at its own expense, shall have the right and opportunity (i) to have the person of any individual whose injury or sickness is the basis of a claim under the Plan, examined by a physician designated by the Plan Administrator, when and as often as it may reasonably require during the pendency of a claim under the Plan, and (ii) to make an autopsy in case of death, where it is not forbidden by law. 6.4 No Guaranty of Tax Treatment. Neither the Employer nor the Plan Administrator makes any representation, commitment, or guaranty that the value of any coverage and any amounts paid to or for the benefit of a Participant under this Plan will be excludable from the Participant's gross income for federal or state income tax purposes, or that any specific federal or state tax treatment will apply or be available to any Participant. 6.5 Incapacity. If a Participant is, in the judgment of the Plan Administrator, legally, physically, or mentally incapable of personally receiving any payment due under the Plan, the Plan Administrator, in its sole discretion, may direct payments due to such other person or institution who, in the opinion of the Plan Administrator, are then maintaining or having custody of such Participant until claim is made by a duly appointed guardian or other legal representative of such Participant. Such payment shall constitute a full discharge of liability of the Plan to the extent of such payment. 6.6 Alienation of Interests. Unless the Plan documentation referenced in Appendix A with respect to a given Welfare Benefit expressly provides to the contrary, benefits provided under this Plan may not be assigned or alienated. 10 6.7 Unclaimed Payments. Unless the Plan documentation referenced in Appendix A with respect to a given Welfare Benefit expressly provides to the contrary, checks that are issued by the Plan for benefit payments and are not cashed within 90 days may be voided. A new check will be issued upon request of the party entitled to payment. 6.8 Beneficiary Designations. Unless the Plan documentation referenced in Appendix A with respect to a given Welfare Benefit expressly provides to the contrary, a Participant must designate a beneficiary in the form and manner specified by the Plan Administrator. If there is no beneficiary designation form on file with the Plan Administrator, benefits will be paid to the Participant's estate. 6.9 Recovery of Benefits. If a Participant (or beneficiary) receives a benefit payment under the Plan in excess of the benefit payment that should have been made, the Plan or its agent shall have the right to recover such excess from the Participant (or beneficiary). The Plan may, however, at its option, deduct the amount of such excess from any subsequent benefits payable to or for such Participant (or beneficiary). 6.10 Scope of Legal Rights. Except as provided herein, neither the establishment nor maintenance of the Plan nor any amendment thereof, nor the payment of any benefits, will be construed as giving any Participant, or other person any legal or equitable right against the Employer or Plan Administrator. Furthermore, the adoption and maintenance of the Plan shall not be deemed to constitute or modify a contract between the Employer and any Employee or Participant, or to be consideration, inducement for, or condition of the performance of services by any person. Nothing contained herein or in any document incorporated herein shall be deemed to give any Employee or Participant the right to continue in the service of the Employer, to interfere with the right of the Employer to discharge any Employee or Participant at any time, or to give the Employer the right to require an Employee or Participant to remain in its service or to interfere with his right to terminate his service at any time. 6.11 Gender and Number. Wherever any words are used herein in the masculine, feminine, or neuter gender, they shall be construed as though they were also used in another gender in all cases where they would so apply, and whenever any words are used herein in the singular or plural form, they shall be construed as though they were also used in the other form in all cases where they would so apply. 6.12 Action by the Employer. Whenever the Employer under the terms of the Plan is permitted or required to do or perform any act or matter or thing, it shall be done and performed by an officer of the Employer or person authorized to act on behalf of the Employer by its legally constituted authority. 6.13 Compliance with State and Federal Mandates. With respect to each component Welfare Benefits provided under this Plan, the Plan will comply, to the extent applicable, with the requirements of all applicable laws (as amended), including but not limited to the Uniform Services Employment and Reemployment Rights Act of 1994 (USERRA); Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA); Health Insurance Accountability 11 and Portability Act of 1996 (HIPAA); Newborns' and Mothers' Health Protection Act of 1996 (NMHP); Women's Health and Cancer Rights Act of 1998 (WHCRA), Mental Health Parity Act (MHPA), and Family and Medical Leave Act of 1993 (FMLA); Patient Protection and Affordable Care Act of 2010, as amended. With respect to any self-insured group health benefits that are provided under this Plan, the City may elect to not comply with the health care portability provisions of HIPAA, NMHP, and/or WHCRA, provided they comply with the applicable opt -out requirements. 6.14 Insurance Policy or Governing Document Controls. Each component Welfare Benefit provided under this Plan is provided pursuant to Policies or pursuant governing plan documents adopted by the City, as referenced in Appendix A. If the terms of this document conflict with the terms of any Policy or governing plan document, then the terms of the Policy or governing plan document will control, rather than this document, unless otherwise required by law. No amendment or modification of the Policies or governing plan documents shall be interpreted to relinquish the Plan's "grandfathered" status under the Patient Protection and Affordable Care Act of 2010, as amended, unless the intent to relinquish "grandfathered" status is expressly stated in clear and unambiguous language. 6.15 Severability. If any provision of the Plan is held invalid or unenforceable, its invalidity or unenforceability shall not affect any other provisions of the Plan, and the Plan shall be construed and enforced as if such provision had not been included herein. 6.16 Captions. The captions contained herein are inserted only as a matter of convenience and for reference, and in no way define, limit, enlarge or describe the scope or intent of the Plan, nor in any way shall affect the Plan or the construction of any provision thereof. 6.17 Governing Law. This Plan is governed by the Code, the Public Health Service Act, Patient Protection and Affordable Care Act of 2010, as amended, and the regulations issued thereunder (as they might be amended from time to time). 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. 12 IN WITNESS WHEREOF, this Plan document November 20, 2014 ATTEST: By: R . -5K--- Title: Reb ca Garza City SecretAry Lubbock, Texas is hereby executed on City By: -'4 Title: nRobertlon, Mayor APPRO D AS -CONTENT: 7 Title: Leisa utcheson, Human Resources Director APPR S FORM: Title: D. Mitchell Satterwhite, Assistant City Attorney 13 EXHIBIT I CONTINUATION COVERAGE 1.1 Scope. The provisions set forth in this Exhibit shall apply to any Welfare Benefit referenced in Appendix A that provides group health care benefits subject to Sections 2201 through 2208 of the Public Health Services Act, unless the Plan documentation referenced in Appendix A with respect to such Welfare Benefit otherwise specifically provides for such group health plan continuation coverage with respect to such Welfare Benefit. 1.2 Definitions. For purposes of this Article, the following definitions shall apply: (a) "Covered Employee" means an Employee enrolled in the Plan as of the day before a Qualifying Event. (b) "COBRA Continuation Coverage" means the continuation of group health care coverage within the meaning of Sections 2201 through 2208 of the Public Health Services Act. (c) "Entitled" means, with respect to Medicare coverage, notification by the Social Security Administration that Medicare Part A coverage is in effect. (d) "Qualified Beneficiary" means any person who, as of the day before a Qualifying Event, is (i) a Covered Employee, (ii) a Dependent of the Covered Employee, including the spouse of the Covered Employee, (iii) a child is born to, adopted, or placed for adoption with a Qualified Beneficiary any time while COBRA Continuation Coverage is in effect. Provided, however, a Covered Employee can be a Qualified Beneficiary only in the event of the Qualifying Event described in Section 1.2(e)(1) below. Provided, further that, in the event of a Qualifying Event described in Section 1.2(e)(6), a Covered Employee who had retired on or before the date of substantial elimination of coverage and any other individual who, on the day before such Qualifying Event, is a beneficiary under the Plan as the spouse, surviving spouse, or dependent child of the Covered Employee shall be considered a Qualified Beneficiary. A person who fails to elect COBRA Continuation Coverage within the applicable election period shall not be considered a Qualified Beneficiary. (e) "Qualifying Event" means, any of the following events which, but for COBRA Continuation Coverage, would result in the loss of coverage of a Qualified Beneficiary: (1) the termination (other than by reason of the Employee's gross misconduct), or reduction of hours, of the Covered Employee; (2) the death of the Covered Employee; 1 (3) the divorce or legal separation of the Covered Employee from the Covered Employee's spouse; (4) the Covered Employee becoming Entitled to Medicare benefits under Title XVII of the Social Security Act; (5) a dependent child ceasing to be a dependent child under the generally applicable requirements of the Plan; or (6) a bankruptcy proceeding under Title 11 of the United States Code with respect to the Employer from whose employment an Employee retired. 1.3 COBRA Continuation Coverage Benefits (a) Upon a Qualifying Event, each Qualified Beneficiary may elect to continue the level of benefits coverage in effect under the Plan for such Qualified Beneficiary on the day before the Qualifying Event; provided, however, each Qualified Beneficiary may change the level of benefits coverage during any open and/or annual enrollment period to the same extent that a Participant to whom a Qualifying Event has not occurred may under the terms of the Plan. In addition, if a Qualified Beneficiary of another group health plan maintained by the Employer is prevented from receiving the previous level of benefits due to a change in plan benefits or termination of such other Employer-sponsored group health plan, such individual shall be entitled to elect any level of coverage available under this Plan. (b) Coverage may continue for a period of thirty-six (36) months from the date of any Qualifying Event described in Sections 1.2(e)(2) through (e)(6) (i.e., death, divorce or legal separation, Medicare entitlement, loss of dependent child status, and employer bankruptcy). Coverage may continue for a period of 18 months from the date of the Qualifying Events described in Section 1.2(e)(1) (i.e., termination of employment or reduction in hours); provided, however, if the Qualified Beneficiary is determined to be disabled under Title II or Title XVI of the Social Security Act, coverage may continue (with respect to all Qualified Beneficiaries) for a period of twenty-nine (29) months from the date of the Qualifying Event. To qualify for such 29 -month coverage, however, the Qualified Beneficiary must (i) be determined under the Social Security Act to have been disabled at any time before or within the first sixty (60) days of COBRA continuation coverage, and (ii) must notify the Plan Administrator of such determination within eighteen (18) months from the Qualifying Event and in accordance with the terms of Section 1.4(e). (c) If a Qualifying Event (other than the Qualifying Event described in Section 1.2(e)(6)) occurs during the eighteen (18) months after the date of the Qualifying Event described in Section 1.2(e)(1), then coverage may continue for up to thirty-six (36) months after the date of the Qualifying Event described in Section 1.2(e)(1). 0j (d) The Qualified Beneficiary must elect coverage on or prior to the later of: (1) sixty (60) days after the date on which coverage terminates under the Plan by reason of a Qualifying Event, or (2) sixty (60) days after the Qualifying Beneficiary is notified by the Plan Administrator of the Qualifying Beneficiary's right to elect continuation coverage pursuant to the terms of Section 1.4(d). (e) Notwithstanding the maximum continuation periods set forth in Sections 1.3(b) and (c), COBRA Continuation Coverage will automatically cease after any of the following: (1) thirty (30) days after the date on which any premium for COBRA continuation coverage was due and not paid; (2) the date on which Qualified Beneficiary first becoming Entitled, after the date of his or her election of COBRA continuation coverage, to Medicare benefits under Title XVIII of the Social Security Act; (3) the date on which Qualified Beneficiary first becoming covered, after the date of his or her election of COBRA continuation coverage, under another group health care plan that contains no exclusion or limitation based on a preexisting condition, or that has a limitation based on a preexisting condition that is satisfied or rendered inoperative by virtue of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). There are limitations on plans imposing a pre-existing condition exclusion and such exclusions will become prohibited beginning in 2014 under the Patient Protection and Affordable Care Act of 2010, as amended; (4) the date on which the Employer terminates this Plan and all other group health care plans maintained by the Employer; or (5) in the case of a disabled Qualified Beneficiary who has elected extended COBRA continuation coverage, the month that begins more than thirty (30) days after the date of the final determination under Title II or Title XVI of the Social Security Act that the Qualified Beneficiary is no longer disabled. 1.4 Notice Requirements. (a) When an Employee becomes covered under this Plan, the Plan Administrator shall inform the Participant (and any dependent of the Participant who also becomes covered under the Plan) in writing, of the rights to continuation coverage under this Article VI. (b) The Employer shall give the Plan Administrator written notice of a Qualifying 3 Event described in Sections 1.2(e)(1), (e)(2), (e)(4), and (e)(6) within thirty (30) days of the occurrence of such event. (c) In the case of a Qualified Event described in Sections 1.2(e)(3) or (e)(5), a Covered Employee or a Qualified Beneficiary who is a spouse or dependent of such Employee must notify the Plan Administrator within sixty (60) days of the occurrence of such event. (d) Within fourteen (14) days of the Plan Administrator's receipt of the notice provided for in Section 1.4(b) or Section 1.4(c), the Plan Administrator shall furnish each Qualified Beneficiary with written notification of the termination of regular coverage under the Plan, as well a recital of the rights of any such Qualified Beneficiary to elect continuation coverage under this Exhibit. (e) Each Qualified Beneficiary who is determined to be disabled, consistent with the terms of Section 1.3(b), must notify the Plan Administrator of such determination within sixty (60) days after the latest of: (i) the date of the Social Security disability determination; (ii) the date of the Qualifying Event; and (iii) the date on which the Qualified Beneficiary loses (or would lose) coverage under the Plan as a result of the Qualifying Event. (f) Each Qualified Beneficiary who has been determined to be disabled, consistent with the terms of Section 1.3(b), must notify the Plan Administrator within thirty (30) days of the date of any final determination by the Social Security Administration that the Qualified Beneficiary is no longer disabled. (g) The Plan Administrator should notify each Qualified Beneficiary if their respective COBRA continuation coverage terminates before its maximum coverage period. Notwithstanding any of the foregoing, notification to a Qualified Beneficiary who is a spouse of a Covered Employee is treated as notification to all other Qualified Beneficiaries residing with that person at the time notification is made. 1.5 Premium Requirements. (a) A Qualified Beneficiary who has elected continuation coverage under this Exhibit must pay a premium designated by the Employer of up to 102% of the applicable premium for the period of coverage otherwise charged to similarly situated Participants (or dependents) with respect to whom a Qualifying Event has not occurred for the same type of coverage. In the case of an individual who is determined to have been disabled, consistent with the terms of Section 1.3(b), the premium for continuation coverage shall not exceed 150% of the applicable premium for any month after the eighteenth (18th) month of continuation coverage as described in Section 1.3(b). (b) The required premium for continuation coverage under this Exhibit, if any, may, at the Qualified Beneficiary's election, be paid in monthly installments. As noted 4 in Section 1.3(e)(1), there is a thirty (30) day grace period following the due date of any required premium before such premium payment is considered untimely. (c) Provided, however, no later than forty-five (45) days after the day on which the Qualified Beneficiary makes the initial election for continuation coverage hereunder, the Qualified Beneficiary must make the premium payment for the initial period of continuation coverage retroactively back to date that coverage otherwise would have been lost. 1.6 Special Continuation Coverage for Uniformed Services Leaves. Notwithstanding any other Plan provision regarding termination of coverage, an Employee who is absent from work due to "uniformed service duty" as defined under the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended (USERRA), shall be considered to have experienced a Qualifying Event as of the first day of such individual's absence for such duty. Such an individual (and any of that individual's dependents covered under the Plan) shall be treated as any other Qualified Beneficiaries for all purposes concerning continuation coverage provided under this Exhibit; provided, however, the maximum period of coverage available to such an individual is the lesser of (i) 18 months (24 months for coverage elected on or after December 10, 2004) beginning on the date the individual's uniformed service duty begins, or (ii) the day after the date on which the individual fails to apply for or return to active employment with the Employer. Provided, further, coverage will continue only as long as any required Participant contributions for continuation coverage as set forth in this Exhibit are timely made, except that any individual who performs uniformed services for less than thirty-one (3 1) days will not be required to pay more than any required Participant contribution applicable for active Employees for the comparable level of coverage. 1.7 Special Continuation for FMLA. Notwithstanding any other Plan provision regarding termination of coverage, in the event participation in a health benefit offered through this Plan would terminate due to a Participant taking a leave of absence pursuant to the terms of the Family and Medical Leave Act of 1993, as amended (FMLA), such benefits shall be continued for the lesser of. the period of such leave, or 12 weeks. Provided, however, coverage will continue only as long as any required Participant contributions are timely made. Employees on leave must make the same contribution as is required for active Participants. Coverage under other Welfare Benefits (other than health benefits) provided under the Plan shall continue or terminate during a period of a FMLA leave to the same extent as such benefits continue or terminate during periods of leave under similar circumstances (i.e., paid or unpaid leave, as the case may be) that is not a FMLA leave. 5 EXHIBIT II QUALIFIED MEDICAL CHILD SUPPORT ORDER PROCEDURES 1.1 In 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 judgment, 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; 1 (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. 2 EXHIBIT III SUBROGATION AND REIMBURSEMENT OF PAYMENTS MADE BY PLAN 1.1 Payment Condition (1) The Plan, in its sole discretion, may elect to conditionally advance payment of benefits in those situations where an Injury, Sickness, Disease or disability is caused in whole or in part by, or results from the acts or omissions of Participants, and/or their Dependents, beneficiaries, estate, heirs, guardian, personal representative, or assigns (collectively referred to hereinafter in this section as "Participant(s)") or a third party, where any party besides the Plan may be responsible for expenses arising from an incident, and/or other funds are available, including but not limited to no-fault, uninsured motorist, underinsured motorist, medical payment provisions, third party assets, third party insurance, and/or guarantor(s) of a third party (collectively "Coverage"). (2) Participant(s), his or her attorney, and/or legal guardian of a minor or incapacitated individual agrees that acceptance of the Plan's conditional payment of medical benefits is constructive notice of these provisions in their entirety and agrees to maintain 100% of the Plan's conditional payment of benefits or the full extent of payment from any one or combination of first and third party sources in trust, without disruption except for reimbursement to the Plan or the Plan's assignee. By accepting benefits the Participant(s) agrees the Plan shall have an equitable lien on any funds received by the Participant(s) and/or their attorney from any source and said funds shall be held in trust until such time as the obligations under this provision are fully satisfied. The Participant(s) agrees to include the Plan's name as a co -payee on any and all settlement drafts. (3) In the event a Participant(s) settles, recovers, or is reimbursed by any Coverage, the Participant(s) agrees to reimburse the Plan for all benefits paid or that will be paid by the Plan on behalf of the Participant(s). If the Participant(s) fails to reimburse the Plan out of any judgment or settlement received, the Participant(s) will be responsible for any and all expenses (fees and costs) associated with the Plan's attempt to recover such money. (4) If there is more than one party responsible for charges paid by the Plan, or may be responsible for charges paid by the Plan, the Plan will not be required to select a particular party from whom reimbursement is due. Furthermore, unallocated settlement funds meant to compensate multiple injured parties of which the Participant(s) is/are only one or a few, that unallocated settlement fund is considered designated as an "identifiable" fund from which the plan may seek reimbursement. 3 1.2 Subrogation (1) As a condition to participating in and receiving benefits under this Plan, the Participant(s) agrees to assign to the Plan the right to subrogate and pursue any and all claims, causes of action or rights that may arise against any person, corporation and/or entity and to any Coverage to which the Participant(s) is entitled, regardless of how classified or characterized, at the Plan's discretion. (2) If a Participant(s) receives or becomes entitled to receive benefits, an automatic equitable lien attaches in favor of the Plan to any claim, which any Participant(s) may have against any Coverage and/or party causing the Sickness or Injury to the extent of such conditional payment by the Plan plus reasonable costs of collection. (3) The Plan may, at its discretion, in its own name or in the name of the Participant(s) commence a proceeding or pursue a claim against any party or Coverage for the recovery of all damages to the full extent of the value of any such benefits or conditional payments advanced by the Plan. (4) If the Participant(s) fails to file a claim or pursue damages against: (A) The responsible party, its insurer, or any other source on behalf of that party; (B) Any first party insurance through medical payment coverage, personal Injury protection, no-fault coverage, uninsured or underinsured motorist coverage; (C) Any policy of insurance from any insurance company or guarantor of a third party; (D) Workers' compensation or other liability insurance company; or (E) Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage; the Participant(s) authorizes the Plan to pursue, sue, compromise and/or settle any such claims in the Participant(s)' and/or the Plan's name and agrees to fully cooperate with the Plan in the prosecution of any such claims. The Participant(s) assigns all rights to the Plan or its assignee to pursue a claim and the recovery of all expenses from any and all sources listed above. 1.3 Right of Reimbursement (1) The Plan shall be entitled to recover 100% of the benefits paid, without deduction for attorneys' fees and costs or application of the common fund doctrine, make whole doctrine, or any other similar legal theory, without regard to whether the Participant(s) is fully compensated by his/her recovery from all sources. The Plan shall have an equitable lien which supersedes all common law or statutory rules, doctrines, and laws of any State prohibiting assignment of rights which interferes with or compromises in any way the Plan's equitable lien and right to reimbursement. The obligation to reimburse the Plan in full exists regardless of how the judgment or settlement is classified and whether or not the judgment or settlement specifically designates the recovery or a portion of it as including medical, disability, or other expenses. If the Participant(s)' recovery is less than the benefits paid, then the Plan is entitled to be paid all of the recovery achieved. (2) No court costs, experts' fees, attorneys' fees, filing fees, or other costs or expenses of litigation may be deducted from the Plan's recovery without the prior, expressed written consent of the Plan. (3) The Plan's right of subrogation and reimbursement will not be reduced or affected as a result of any fault or claim on the part of the Participant(s), whether under the doctrines of causation, comparative fault or contributory negligence, or other similar doctrine in law. Accordingly, any lien reduction statutes, which attempt to apply such laws and reduce a subrogating Plan's recovery will not be applicable to the Plan and will not reduce the Plan's reimbursement rights. (4) These rights of subrogation and reimbursement shall apply without regard to whether any separate written acknowledgment of these rights is required by the Plan and signed by the Participant(s). (5) This provision shall not limit any other remedies of the Plan provided by law. These rights of subrogation and reimbursement shall apply without regard to the location of the event that led to or caused the applicable Sickness, Injury, Disease or disability. 1.4 Excess Insurance If at the time of Injury, Sickness, Disease or disability there is available, or potentially available any Coverage (including but not limited to Coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of Coverage, except as otherwise provided for under the Plan's Coordination of Benefits section. The Plan's benefits shall be excess to: (1) The responsible party, its insurer, or any other source on behalf of that party; 5 (2) Any first party insurance through uninsured or underinsured motorist coverage; (3) Any policy of insurance from any insurance company or guarantor of a third party; (4) Workers' compensation or other liability insurance company; or (5) Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage. 1.5 Separation of Funds Benefits paid by the Plan, funds recovered by the Participant(s), and funds held in trust over which the Plan has an equitable lien exist separately from the property and estate of the Participant(s), such that the death of the Participant(s), or filing of bankruptcy by the Participant(s), will not affect the Plan's equitable lien, the funds over which the Plan has a lien, or the Plan's right to subrogation and reimbursement. 1.6 Wrongful Death In the event that the Participant(s) dies as a result of his or her Injuries and a wrongful death or survivor claim is asserted against a third party or any Coverage, the Plan's subrogation and reimbursement rights shall still apply, and the entity pursuing said claim shall honor and enforce these Plan rights and terms by which benefits are paid on behalf of the Participant(s) and all others that benefit from such payment. 1.7 Obligations (1) It is the Participant(s)' obligation at all times, both prior to and after payment of medical benefits by the Plan: (A) To cooperate with the Plan, or any representatives of the Plan, in protecting its rights, including discovery, attending depositions, and/or cooperating in trial to preserve the Plan's rights; (B) To provide the Plan with pertinent information regarding the Sickness, Disease, disability, or Injury, including accident reports, settlement information and any other requested additional information; (C) To take such action and execute such documents as the Plan may require to facilitate enforcement of its subrogation and reimbursement rights; (D) To do nothing to prejudice the Plan's rights of subrogation and reimbursement; (E) To promptly reimburse the Plan when a recovery through settlement, judgment, award or other payment is received; and 31 (F) To not settle or release, without the prior consent of the Plan, any claim to the extent that the Participant may have against any responsible party or Coverage. (2) If the Participant(s) and/or his or her attorney fails to reimburse the Plan for all benefits paid or to be paid, as a result of said Injury or condition, out of any proceeds, judgment or settlement received, the Participant(s) will be responsible for any and all expenses (whether fees or costs) associated with the Plan's attempt to recover such money from the Participant(s). (3) The Plan's rights to reimbursement and/or subrogation are in no way dependent upon the Participant(s)' cooperation or adherence to these terms. 1.8 Minor Status (1) In the event the Participant(s) is a minor as that term is defined by applicable law, the minor's parents or court-appointed guardian shall cooperate in any and all actions by the Plan to seek and obtain requisite court approval to bind the minor and his or her estate insofar as these subrogation and reimbursement provisions are concerned. (2) If the minor's parents or court-appointed guardian fail to take such action, the Plan shall have no obligation to advance payment of medical benefits on behalf of the minor. Any court costs or legal fees associated with obtaining such approval shall be paid by the minor's parents or court-appointed guardian. 1.9 Language Interpretation The Plan Administrator retains sole, full and final discretionary authority to construe and interpret the language of this provision, to determine all questions of fact and law arising under this provision, and to administer the Plan's subrogation and reimbursement rights. The Plan Administrator may amend the Plan at any time without notice. 1.10 Severability In the event that any section of this provision is considered invalid or illegal for any reason, said invalidity or illegality shall not affect the remaining sections of this provision and Plan. The section shall be fully severable. The Plan shall be construed and enforced as if such invalid or illegal sections had never been inserted in the Plan. 1 *94:1l: f1 ] CLAIMS AND REVIEW PROCEDURES 1.1 Benefit Determinations. All claims for eligibility to participate or for the payment of benefits under this Plan shall be first made to the Plan Administrator, or to such other person as the Plan Administrator may designate (a "claims administrator"), in such manner and in such form as the Plan Administrator (or claims administrator) may reasonably require. The Plan Administrator (or claims administrator) shall, subject to the review procedures set forth below, have the responsibility and authority to interpret the provisions of the Plan with respect to the underlying benefit involved, to decide the rights of the claimant to the claimed benefit (including, but not limited to, eligibility determinations), to determine the amount of any such benefit, and to inform the claimant of his decision with respect to the claim for benefits. Any Participant or beneficiary (or a duly authorized representative thereof) (collectively, a "claimant") may file a claim for benefits under the Plan to which the claimant believes he is entitled. Upon receipt of a properly documented claim for benefits, the Plan Administrator (or claims administrator) shall inform the claimant of its decision with respect to such claim. Except in the case of legal incapacity, claims not properly submitted and received by the Plan Administrator (or claims administrator) within twelve (12) months after the date the applicable costs were incurred will not be considered for payment of benefits. The claimant shall be notified of the Plan's benefit determination within a reasonable period of time (but in no event in excess of the applicable maximum response time) after the claim is received by the Plan Administrator (or claims administrator), unless the claimant has failed to submit sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such a failure, the Plan Administrator (or claims administrator) shall notify the claimant as soon as possible of the specific information necessary to complete the claim. If circumstances beyond the control of the group health plan require an extension of time for processing a claim, then the Plan Administrator (or claims administrator) may be granted such an extension of a specified limited duration, provided the claimant is given notice of such special circumstances and the length of the extension prior to the expiration of the applicable maximum response time. If the claimant is not notified of the determination of his claim for benefits within the applicable maximum response time (including any extensions), then the claim shall be deemed denied as of the last day of such period. For purposes of this section, the applicable maximum response period of time is 90 days, and the maximum extension of such period in the event of special circumstances is another 90 days beyond the initial response time. Provided, however, with respect to benefits provided under a group health plan or a claim for disability benefits, the applicable maximum response time (and any extension thereof) are subject to the following special rules depending on the type of claim involved: 1 (1) Urgent Care Claims. The applicable maximum response time for a decision with respect to an urgent care claim under a group health plan is 72 hours. If the claim is incomplete, the Plan Administrator (or claims administrator) must notify the claimant of the deficiency and specify what information is necessary to complete the claim within 24 hours of receipt of the claim, and the claimant has at least 48 hours to provide such specified additional information. The decision on the claim must be provided not later than 48 hours after the earlier of the plan's receipt of the specified additional information, or the end of the additional period of time provided to the claimant to submit such information. For purposes of this Exhibit, an urgent care claim is any claim for medical care or treatment under a group health plan with respect to which the application of the time periods for making non -urgent care determinations (i) could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function, or (ii) in the opinion of a physician with knowledge of the claimant's medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. The determination of whether a claim is an urgent care claim generally will be determined by the Plan Administrator (or claims administrator) acting on behalf of the group health plan and applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine; provided, however, any claim that a physician with knowledge of the claimant's medical condition determines to be urgent will be treated as an urgent care claim. (2) Pre -Service Claims. The applicable maximum response time for a decision with respect to a pre -service claim under a group health plan is 15 days. A single extension of up to 15 days is permitted. If the extension is due to insufficient information, the notice provided to the claimant must specify the information required and allow the claimant 45 days to submit the required information. For purposes of this Exhibit, a pre -service claim is any claim for a benefit under a group health plan with respect to which the terms of the plan condition receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. (3) Concurrent Care Claims. The Plan Administrator (or claims administrator) must notify the claimant of an adverse benefit determination with respect to any concurrent care claim far enough ahead of the reduction or termination of the ongoing course of treatment to allow for an appeal of the decision and obtain a determination on review of such decision before the benefit is reduced or terminated. Any request by a claimant for an extension of any concurrent care claim that involves urgent care must be decided within 24 hours, provided the request was made at least 24 hours prior to the prescribed period of time or number of treatments. For purposes of this Exhibit, a concurrent care claim is any claim under a group 2 health plan with respect to any reduction or termination (other than by amendment or termination of the group health plan) of an ongoing course of treatment to be provided over a period of time or number of treatments previously approved by the group health plan. (4) Post -Service Claim. The applicable maximum response time for a post -service claim under a group health plan is 30 days. A single extension of up to 15 days is permitted. If the extension is due to insufficient information, the notice provided to the claimant must specify the information required and allow the claimant 45 days to submit the required information. For purposes of this Exhibit, a post -service claim is any claim for a benefit under a group health plan that is not a pre -service claim or concurrent care claim. (5) DisabilityClaim. The applicable maximum response time for a disability claim is 45 days. Two separate extensions of up to 30 days each are permitted. 1.2 Manner and Content of Adverse Benefit Determination Notifications. In the event of a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit provided under the Plan (an "adverse benefit determination"), notice of such adverse benefit determination shall be written (or provided electronically, consistent with the applicable legal standards for electronic notifications) in a manner calculated to be understood by the claimant and shall set forth: (i) the specific reasons for the denial, (ii) references to the specific pertinent Plan provisions, (iii) a description of any additional material or information necessary for the claimant to perfect the claim and an explanation as to why such information is necessary, and (iv) a description of the Plan's claims and claims review procedure and the time limits applicable to such procedure (including the claimant's right to pursue a civil legal action following an adverse benefit determination on review). Provided, however, with respect to benefits under a group health plan or a plan providing disability benefits, the following additional rules shall apply: (i) upon request, a claimant shall be provided free of charge with a copy of any rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse benefit determination, (ii) upon request, a claimant shall be provided free of charge with an explanation applying the terms of the plan to the claimant's medical circumstances if the adverse benefit determination is based on medical necessity, experimental treatment, or other similar exclusion or limitation, and (iii) in the case of an adverse benefit determination with respect to an urgent care claim under a group health plan, the claimant shall be provided with a description of the expedited review procedures set forth below in Section 1.3, and all adverse benefit determination notification information may be provided to the claimant orally if written (or electronic) notification is furnished to the claimant no later than three (3) days after the oral notification. 1.3 Review Procedure. Within 60 days after receipt of the notice of an adverse benefit determination (or, if applicable, the date on which an adverse benefit determination is considered to have occurred), the claimant shall have a reasonable opportunity to appeal such adverse benefit determination to a designated named Plan fiduciary for a full and fair review. A claimant (i) may request such a review upon written notice to the designated named Plan fiduciary; (ii) may submit written comments, documents, records, and other information relating to the claim; (iii) shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim; and (iv) shall be provided with a review that takes into account all comments, documents, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. Provided, however, if the claim under review is with respect to benefits under a group health plan, then the procedures set forth above shall apply but with the following modifications and additions: (i) a claimant shall have at least 180 days after the date on which the claimant receives a written notice of a denied claim (or, if applicable, the date on which an adverse benefit determination is considered to have occurred) to file a written request with the Plan Administrator for a review of the adverse benefit determination; (ii) such review shall not afford deference to the initial claim denial and shall be conducted by a designated named Plan fiduciary who is neither the individual who made the initial claim denial or is a subordinate of such individual; (iii) with respect to an adverse benefit determination that is based, in whole or in part, on a medical judgment, the named fiduciary conducting the review shall consult with a health care professional with appropriate training and experience in the field of medicine involved in the medical judgment, provided that such professional was not consulted with respect to the initial claim denial or is a subordinate of any such individual who was so consulted; (iv) a claimant shall be provided with the identification of any medical or vocational experts whose advice was obtained by the Plan in connection with a claimant's initial claim denial; and (v) in the case of an urgent care claim, a claimant shall be provided with an expedited review process pursuant to which the appeal of an adverse benefit determination may be submitted orally or in writing by a claimant, and all necessary information, including the Plan's benefit determination on review, may be transmitted between the Plan and the claimant by telephone, facsimile, or other available similarly expeditious method. The claimant shall be notified of the Plan's benefit determination on review within a reasonable period of time (but in no event in excess of the applicable maximum response time) after receipt of the claimant's request for review. Under special circumstances, then the designated named Plan fiduciary may be granted an extension (or extensions) of a specified limited duration, provided the claimant is given notice of such special circumstances and the length of the extension prior to the expiration of the applicable maximum response time. If the claimant is not notified of the determination of the review of his claim for benefits within the applicable maximum response time (including any extensions), then the appeal of the claim shall be deemed denied as of the last day of such period. For purposes of the review of appeals of adverse benefit determinations, the applicable maximum response time is 60 days, and the maximum extension of such period is another 60 days beyond the initial response time. 0 Provided, however, with respect to benefits under a group health plan or a claim for disability benefits, the applicable maximum response time are subject to the following special rules depending on the type of claim involved: (1) Urgent Care Claims. The applicable maximum response time for the review of an appeal of an adverse benefit determination with respect to an urgent care claim under a group health plan is as soon as possible, taking into account the medical exigencies, but in no event later than 72 hours. (2) Pre -Service Claims. The applicable maximum response time for the review of an appeal of an adverse benefit determination with respect to a pre -service claim under a group health plan is 30 days. (3) Post -Service Claims. The applicable maximum response time for the review of an appeal of an adverse benefit determination with respect to a post -service claim under a group health plan is 60 days. (4) Disability Claims. The applicable maximum response time is 60 days. 1.4 Manner and Content of Notification of Benefit Determination on Review. In the case of an adverse benefit determination of a claim on review, such adverse benefit determination shall be written (or provided electronically, consistent with the applicable legal standards for electronic notifications) in a manner calculated to be understood by the claimant and shall set forth: (i) the specific reasons for the denial; (ii) references to the specific pertinent Plan provisions; (iii) a statement that the claimant is entitled to receive, upon request free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim; and (iv) a statement of any voluntary appeal procedures offered by the Plan and the claimant's right to obtain information concerning any such procedures and his right to bring a civil action with respect to the claim. Provided, however, with respect to benefits under a group health plan or a plan providing disability benefits, the following additional rules shall apply: (i) upon request, a claimant shall be provided free of charge with a copy of any rule, guideline, protocol, or other similar criterion that was relied upon in making the adverse benefit determination, (ii) upon request, a claimant shall be provided free of charge with an explanation applying the terms of the plan to the claimant's medical circumstances if the adverse benefit determination is based on medical necessity, experimental treatment, or other similar exclusion or limitation, and (iii) the notification shall include a statement indicating that other voluntary alternative dispute resolution options, such as mediation, may be available. 5 EXHIBIT V PROVISION OF PROTECTED HEALTH INFORMATION TO PLAN SPONSOR 1.1 Scope and Purpose. The City (hereinafter the "Plan Sponsor") sponsors the Plan, which includes certain group health benefits (hereinafter the "Plan"). This Exhibit shall apply only with respect to any group health benefits that are provided to individuals participating under the Plan ("Health Plan Participants") that are subject to the administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 ("HIPAA"). In order for the Plan to operate effectively and efficiently, Plan Sponsor, using its own employees and/or agents and subcontractors, needs access to the individually identifiable health information of Health Plan Participants to perform certain administrative functions with respect to the Plan. When such health information is provided from the Plan to the Plan Sponsor, it is Protected Health Information ("PHI"). In turn, HIPAA and its implementing regulations restrict Plan Sponsor's ability to use and disclose PHI. For purposes of this Exhibit, PHI is individually identifiable health information related to a Health Plan Participant's past, present, or future health condition, the health care services provided to a Health Plan Participant, or the past, present, or future payments made for a Health Plan Participant's health care, which is created or received by a health care provider that electronically transmits such information, a health care clearinghouse, or a health plan. Plan Sponsor shall have access to PHI from the Plan only as permitted under this Exhibit, or as otherwise required or permitted by HIPAA. 1.2 Permitted Disclosure of Enrollment/Disenrollment Information The Plan (or a health insurance issuer or HMO with respect to the Plan) may disclose to Plan Sponsor information on whether the individual is participating in the Plan, or is enrolled in or has disenrolled from a health insurance issuer or HMO offered by the Plan. 1.3 Permitted Uses and Disclosures of Summary Health Information The Plan (or a health insurance issuer or HMO with respect to the Plan) may disclose Summary Health Information to Plan Sponsor, provided Plan Sponsor requests the Summary Health Information for the purpose of (a) obtaining premium bids from health plans for providing health insurance coverage under the Plan; or (b) modifying, amending, or terminating the Plan. For purposes of this Exhibit, "Summary Health Information" means information that (a) summarizes the claims history, claims expenses, or type of claims experienced by individuals for whom Plan Sponsor has provided health benefits under the Plan (or ro predecessor health care arrangement); and (b) from which various identifying elements described in 45 C.F.R. § 164.514(b)(2)(i) has been deleted, except that the geographic information described in 45 C.F.R. § 164.514(b)(2)(i)(B) need only be aggregated to the level of a five -digit zip code. 1.4 Permitted Uses and Disclosure of PHI for Certain Other Plan Administration Functions Unless otherwise permitted by law, and subject to the conditions of disclosure described in Section 1.5 and obtaining written certification pursuant to Section 1.7, the Plan (or a health insurance issuer or HMO on behalf of the Plan) may disclose PHI to Plan Sponsor, provided Plan Sponsor uses or discloses such PHI only for certain Plan Administration Functions. "Plan Administration Functions" means certain administration functions performed by Plan Sponsor on behalf of the Plan, such as claims processing, quality assurance, auditing of the Plan and its vendors, and management of carve -out health plans (such as vision or dental). In no event, however, shall Plan Administration Functions include functions performed by Plan Sponsor in connection with any other benefit or benefit plan of Plan Sponsor, or any employment-related functions. For purposes of this section, "claims processing" shall include investigating, auditing, and otherwise administering and facilitating the payment of Plan claims with respect to health benefits from payers of such claims (including, but not limited to, providing advocacy and troubleshooting assistance to Health Plan Participants and beneficiaries, the coordination of benefits, determination of cost sharing amounts, and subrogation of health benefit claims), and obtaining payment on behalf of Plan Sponsor under a contract for stop -loss or reinsurance being utilized with respect to the health care benefits being provided under the Plan. Notwithstanding the provisions of this Plan to the contrary, in no event shall Plan Sponsor be permitted to use or disclose PHI in a manner that is inconsistent with 45 C.F.R. § 164.504(o. 1.5 Conditions of Disclosure for Certain Other Plan Administration Functions Plan Sponsor agrees that with respect to any PHI (other than enrollment / disenrollment information and Summary Health Information, which are not subject to these restrictions) disclosed to it by the Plan (or a health insurance issuer or HMO on behalf of the Plan) Plan Sponsor shall: (a) Not use or further disclose the PHI other than as permitted or required by the Plan or as required by law. (b) Ensure that any agent, including a subcontractor, to whom it provides PHI received from the Plan, agrees to the same restrictions and conditions that apply to Plan Sponsor with respect to PHI. (c) Not use or disclose the PHI for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of Plan Sponsor. (d) Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware. (e) Make available PHI to comply with HIPAA's right to access in accordance with 45 7 C.F.R. § 154.524. (f) Make available PHI for amendment and incorporate any changes to PHI in accordance with 45 C.F.R. § 164.526. (g) Make available the information required to provide an accounting of disclosures in accordance with 45 C.F.R. § 164.528. (h) Make its internal practices, books, and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of the United States Department of Health and Human Services for purposes of determining compliance by the Plan with HIPAA's privacy requirements. (i) If feasible, return or destroy all PHI received from the Plan that Plan Sponsor still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible. (j) Ensure that the adequate separation between the Plan and Plan Sponsor (i.e., the "firewall"), required in 45 C.F.R. §504(f)(2)(iii), is satisfied. 1.6 Adequate Separation Between Plan and Plan Sponsor Plan Sponsor shall allow only the following employees or other persons (including third parties) access to PHI: Director of Human Resources and Risk Management Benefits and Wellness Manager Insurance Specialists Deputy City Manager or Assistant City Manger over Human Resources City Manager City Council No other persons shall have access to PHI. These specified persons (or classes of persons) shall only have access to and use PHI to the extent necessary to perform the plan administration functions that Plan Sponsor performs on behalf of the Plan. In the event that any of these specified persons do not comply with the provisions of this Section 1.5, then (a) if such person is an employee of Plan Sponsor, that person shall be subject to disciplinary action by Plan Sponsor for non-compliance pursuant to Plan Sponsor's employee discipline and termination procedures, and (b) if such person is not an employee of Plan Sponsor, that person shall be subject to disciplinary action by Plan Sponsor pursuant to the terms of the business associate agreement that shall be in place between such person and the Plan and Plan Sponsor. 1.7 Certification of Plan Sponsor The Plan (or a health insurance issuer or HMO with respect to the Plan) shall disclose PHI to Plan Sponsor only upon the receipt of a certification by Plan Sponsor that the Plan has been amended to incorporate the provisions of 45 C.F.R. § 164.504(f)(2)(ii), and that the Plan Sponsor agrees to the conditions of disclosure set forth in Section 1.5. 1.8 Security Safeguards 0 The Plan Sponsor shall: (a) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of any electronic PHI that it receives, maintains, or transmits on behalf of the Plan. (b) Ensure that adequate separation between the Plan and Plan Sponsor is supported by reasonable and appropriate security measures. (c) Ensure that any agent, including a subcontractor, to whom it provides electronic PHI agrees to implement reasonable and appropriate security measures to protect the information; and (d) Report to the Plan any security incident of which the Plan Sponsor becomes aware; provided, however, (i) the Plan Sponsor will report the aggregate number of unsuccessful, unauthorized attempts to access, use, disclose, modify, or destroy electronic PHI or to interfere with system operations in an information system containing electronic PHI, including pings, at the frequency requested by the Plan (but in no event more often than once per calendar quarter); and (ii) the Plan Sponsor will report to the Plan any successful, unauthorized access, use, disclosure, modification, or destruction of electronic PHI or any successful interference with system operations in an information system containing electronic PHI, in writing, as soon as feasible. EXHIBIT VI 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, 2007. 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. 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 H. 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 1 st and ending the following December 31 st. 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 I11. 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 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 3.1 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. 3.2 Initial Election Period. (a) An Employee who is eligible to participate as of the Effective Date and who wishes to 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. 3 (b) 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. (c) 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. 3.3 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. 3.4 Altering Benefit Elections Due to Changes in Status. (a) 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." (b) 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: (1) the birth, death, adoption, and placement for adoption of one of a Participant's dependents; (2) the Participant's marriage, divorce, legal separation, annulment or the death of the Participant's spouse; FJ (3) 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); (4) a change in an employee's residency or the residency of an employee's spouse or a dependent; or (5) 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). (c) 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. (d) 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. (1) 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. (2) 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. (3) 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. (4) 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. 5 3.5 Altering Benefit Elections Due to Changes in Participant's Coverage. (a) 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. (b) 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 make corresponding election changes with respect to other options providing similar coverage. 3.6 Altering Benefit Elections Due to Coverage Changes Under a Family Member's Plan. (a) 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: (1) a permissible election change (for any of the reasons set forth in Section 3.04 and 3.05); or (2) 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. 3.7 Altering Benefit Elections Due to Changes in Coverage Costs. (a) 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. (b) 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 T 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. 3.8 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. 3.9 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 Employer by reason of special enrollment rights arising under ERISA § 701(f) (or the parallel provision in the Public Health Services Act), 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. 3.10 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. 3.11 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. 3.12 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 7 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 terms 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. 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 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. 6.2 Committee Members. Any person appointed to be a member of the committee shall signify his acceptance in writing to the City. Any member of the committee may resign by delivering his written resignation to the City and the resignation shall become effective upon delivery or upon any later date specified in the written resignation. 6.3 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 (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 Administrator under the terms of the Plan. 6.4 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. 6.5 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. 6.6 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. 10 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 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. I IN WITNESS WHEREOF, this Plan document is hereby executed on November 20 2014 ATTEST: By: Title: Re cca Garza Ci Secreta APPRAVED AS TO CONTENT: Title: Leisa Hutcheson, Human Resources Director Lubbock, Texas City By: Tit]4 n Robertson, Mayor APPROVED AS TO F Title: D. Mitc ell Satterwhite, First Assistant City Attorney 15 I i Q X EN Lo O cd bA .0 .� ° 'p •p 'fl E E LL O. 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Name of Plan City of Lubbock, Texas Mauer Welfare Benefit Plan Plan Number 502 Plan Sponsor City of Lubbock 1625 13th Street Lubbock, Texas 79457 (806) 775-3000 Employer Identification Number: 75-600059 Plan Year The Plan Year begins on January 1 st and ends on the following December 31 st, and Plan records are maintained on that basis. Effective Date The initial Effective Date of the Plan was January 1, 2004. Plan Administrator City Manager City of Lubbock and Named 1625 13th Street Fiduciary Lubbock, Texas 79457 (806) 775-3000 The Plan Administrator is responsible for maintaining records on Participants, determining eligibility for benefits, and interpreting and administering the provisions of the Plan. Type of In cases where a Participant request an exception to the Plan and the cost Administration / to the Plan is less than twenty-five thousand dollars (U.S. Dollars), the Funding Medium / Participant shall secure the approval or rejection from the Plan Source of Administrator. Contributions In cases where a Participant requests an exception to the Plan and the cost to the Plan is for twenty-five thousand dollars (U.S. Dollars) or more, the Plan Administrator shall submit the request to the City Council for approval or rejection. Benefits under the Plan are paid from the general funds of the Employer and are self-administered by the Employer (or a third -party administrator). The Plan is funded through employer and employee contributions. Agent for Service of The Plan Administrator is the agent for service of legal process. Legal Process Request for Plan Requests to review Plan documents, requests for copies of Plan Information documents, and questions regarding plan operations should be directed to Plan Administrator at the address and telephone number provided above. NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT OF 1996 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 caesarean section. However, Federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours for vaginal deliveries (or 96 hours for caesarean sections 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 for vaginal deliveries (or 96 hours for caesarean sections). WOMEN'S HEALTH AND CANCER RIGHTS ACT OF 1998 If you have had or going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy -related services, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • All stages of reconstruction of the breast on which the mastectomy was performed; • Surgery and reconstruction of the other breast to produce a symmetrical appearance; • Prostheses; and • Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the Plan. Contact your Plan Administrator for more information. SPECIAL ENROLLMENT RIGHTS If you decline enrollment for yourself or for an eligible dependent (including your spouse) while other health insurance or group health plan coverage is in effect, you may be able to enroll yourself and your dependents if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward the cost of your or your dependents' coverage). However, you must request enrollment within 31 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the cost of the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents. However, you must request enrollment within 31 days (or within 60 days in the event of birth, adoption, or placement for adoption). REQUESTS FOR PLAN INFORMATION You have the right to inspect all Plan documents and to make copies of the documents. All Plan documents can be reviewed and copied during normal business hours at the Employer's Human 3 Resources Department at 1625 13th Street, Lubbock, Texas. In accordance with Internal Revenue Service regulations, the Employer may charge a reasonable fee for copies. Any such request or other requests regarding Plan operation should be directed to Plan Administrator as indicated on page 1 of this Appendix B.