HomeMy WebLinkAboutResolution - 2006-R0589 - Authorizes Employee Benefit Plan - BCBS Texas - Changes To Employee Benefit Plan - 12/19/2006Resolution No. 2006-80589
December 19, 2006
Item No. 5.13
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock, an Employee Benefit Plan
between the City of Lubbock and Blue Cross Blue Shield of Texas, for changes to the
employee benefit plan, and related documents. Said plan is attached hereto and
incorporated in this Resolution as if fully set forth herein and shall be included in the
minutes of the Council.
Passed by the City Council this 19th day of December , 2006,
ATTEST:
Rebkca Garza, City Secretary
OVED AS TO CONTENT:
Leisa Hutchenson, Risk Manager
APPROVED AS TO FORM:
City Attorney
Igs/cedocs/Blue Cross Blue -res
November 9. 2006
DAVID A. MILLER, MAYOR
Resolution No. 2006-RO589
CITY OF LUBBOCK, TEXAS
MASTER WELFARE BENEFIT PLAN
AND
SUN AIRY PLAN DESCRIPTION
Amended and Restated
Effective as of January 1, 2007
This document, together with the documents referenced in Appendix A, constitutes BOTH the
formal written plan document and the Summary Plan Description of such plan.
Rev. 1-07
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......................................................5
ARTICLE V PLAN ADMINISTRATION.....................................................................6
ARTICLEVI MISCELLANEOUS........................................................................................9
EXHIBIT I
CONTINUATION COVERAGE
EXHIBIT II
QUALIFIED MEDICAL CHILD SUPPORT
ORDER PROCEDURES
EXIIIBIT III
SUBROGATION AND REIMBURSEMENT OF
PAYMENTS BY PLAN
EXHIBIT IV
CLAIMS AND REVIEW PROCEDURES
EXHIBIT V
PROVISION OF PROTECTED HEALTH
INFORMATION TO PLAN SPONSOR
EXHIBIT VI
PREMIUM CONVERSION CAFETERIA PLAN
APPENDICES:
APPENDIX A WELFARE BENEFITS PROVIDED
UNDER PLAN
APPENDIX B SUMMARY PLAN DESCRIPTION SUPPLEMENT
Rev. ]-Q7
CITY OF LUBBOCK, TEXAS]
MASTER WELFARE BENEFIT PLAN
Amended and Restated
Effective as of January 1, 2007
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, 2007.
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, 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.
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
Rev. 1-07
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 workers 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;
(d) Individuals included in a unit covered by a collective bargaining agreement if
Welfare Benefits were the subject of good faith bargaining; and
(e) Nonresident aliens who receive no United States source income from the Employer.
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.
Rev. 1-07 2
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 1st of each year and ending the following December 31st.
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.
Rev. 1-07 3
3.1
ELIGIBILI'
Eligibility and Participa
(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.
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, preexisting condition
limitations, 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.
3.3 Benefits.
(a) The terms 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
Rev. 1-07 4
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); 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 Il 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.
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
Rev. 1-07 5
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.
(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
Rev. 1-07 6
determine that the provisions of the Plan
the exclusive benefit of persons entitled lu yai Lic iliac ui u,a. x ict".
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
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.
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
Rev. 1-Q7
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
Rev. 1-47 8
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.
59 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.
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.
Rev. 1-07 9
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.
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
Rev. 1-07 10
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
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). 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.
Rev. 1-07 11
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, 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.
IN WITNESS WHEREOF, this Plan document is
December 19. 2006
Lubbock
City
hereby executed on
00,
w
David . Miller
Title: Mayor
ATTEST:
By:,Q;:g,
Re ecca Garza
Title: City Secretary
APPROV .,.AS TO7 CONTENT:
utcheson
Director of Risk Management
PPR " %FORM:
044W4I*,/rol, lrrzi W1
■Ah�rt:
r I�/ItI MA. ,ENEEMMIr - . s •r �;
Assistant City Attorney
Rev. 1-07 12
IWaso 11:11lil
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;
(3) the divorce or legal separation of the Covered Employee from the Covered
Employee's spouse;
Exhibit I — Continuation Coverage 1
Rev. 1-47
(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).
Exhibit T — Continuation Coverage 2
Rev. 1-07
(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");
(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
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.
Exhibit I — Continuation Coverage 3
Rev. 1-07
(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 13(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 terns 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
in Section 13(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.
Exhibit I — Continuation Coverage 4
Rev. 1-07
(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.
Exhibit I — Continuation Coverage 5
Rev. 1-a7
EXIIIBIT 1�
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;
Exhibit II -- Qualified Medical Child
Support Order Procedures
Rev. 1-07
(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 1948, 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.
Exhibit II - Qualified Medical Child 2
Support Order Procedures
Rev. 1-03
EXHIBIT III
SUBROGATION AND REIMBURSEMENT
OF PAYMENTS MADE BY PLAN
Ll Scope. With respect to any Welfare Benefits that provide group health benefits, the Plan is
designed to only pay covered expenses for which payment is not available from anyone else,
including any insurance company or another health plan. In order to help a covered person
in a time of need, however, the Plan may advance the payment of covered expenses that
may be or become the responsibility of another person, provided that the Plan later receives
reimbursement for those payments (hereinafter called "Reimbursable Payments").
Therefore, by enrolling in the Plan, as well as by applying for payment of covered expenses,
a covered person (and any person or entity acting on behalf of a covered person) is subject
to, and agrees to, the terms and conditions set forth in this Exhibit with respect to the amount
of covered expenses paid by the Plan.
1.2 Assignment of Rights (Subrogation). The covered person automatically assigns to the
Plan any rights the covered person may have to recover all or part of the same covered
expenses from any party, including an insurer or another group health program, but limited
to the amount of Reimbursable Payments made by the Plan. This assignment includes,
without limitation, the assignment of a right to any funds paid by a third party to a covered
person or paid to another for the benefit of the covered person. This assignment (i) applies
on a first -dollar basis (i.e., has priority over other rights to such funds), (ii) applies whether
the funds paid to (or for the benefit of) the covered person constitute a full or a partial claim
or recovery, (iii) applies regardless of how such funds, claims, or recoveries are classified or
characterized by the courts or any other entity, and (iv) even applies to funds paid for non-
medical or dental charges, attorney fees, or other costs and expenses. This assignment also
allows the Plan to purse any claim that the covered person may have, whether or not the
covered person chooses to pursue that claim. In cases where the Plan pursues the collection
of a claim (e.g., by suing a third party), the costs of collection incurred by the Plan shall be
considered as part of the claim. By this assignment, the Plan's right to recover from insurers
includes, without limitation, such recovery rights against no-fault auto insurance carriers in a
situation where no third party may be liable, and from any uninsured or underinsured
motorist coverage.
1.3 Equitable Lien and Other Equitable Remedies (Reimbursement). If payments are made
by the Plan and the covered person receives a settlement or is otherwise compensated by a
third party as a result of illness or injury of the covered person, the covered person is
required to reimburse the Plan for the Reimbursable Payments advanced from the Plan.
Moreover, the Plan shall have an equitable lien against any rights the covered person may
have to recover the same covered expenses from any party, including an insurer or another
group health program, but limited to the amount of Reimbursable Payments made by the
Plan. Such an equitable lien also attaches to any right to payment from workers'
compensation, whether by judgment or settlement, where the Plan has paid covered
expenses prior to a determination that the covered expenses arose out of and in the curse of
Exhibit III — Subrogation and Reimbursement
of Payments Made By Plan
Rev, 1-D7
employment. Payment by workers' compensation insurers or the employer will be deemed
to mean that such a determination has been made.
This equitable lien shall also attach to any and all money or property that is obtained by
anybody (including, but not limited to, the covered person, the covered person's attorney,
and/or a trust) as a result of an exercise of the covered person's right of recovery (sometimes
referred to as "proceeds"). The Plan shall also be entitled to seek any other equitable
remedy against any party possessing or controlling such proceeds. Thus, the Plan will not
pay, offset any recovery, or in any way be responsible for any fees or costs associated with
pursuing a claim unless the Plan agrees to do so in writing.
This and any other provisions of the Plan concerning subrogation, equitable liens, and other
equitable remedies are intended to supersede the applicability of the federal common law
doctrines commonly referred to as the "make whole" rule and the "common fund" rule, but
while also meeting the standards for enforcement under ERISA that were enunciated in the
United States Supreme Court's decision, Great -West Life & Annuity Insurance Co. v.
Knudson, 534 U.S. 204 (January 8, 2002).
1.4 Assisting in Plan's Reimbursement Activities. The covered person has an obligation to
assist the Plan to obtain reimbursement of the Reimbursable Payments that it has made on
behalf of the covered person, and to provide the Plan with any information concerning the
covered person's other insurance coverage (whether through automobile insurance, other
group health program, or otherwise) and any other person or entity (including their
insurer(s)) that may be obligated to provide payments or benefits to or for the benefit of the
covered person. The covered person is required to (i) cooperate fully in the Plan's exercise
of its right to subrogation and reimbursement, (ii) not do anything to prejudice those rights
(such as settling a claim against another party without including the Plan as a co -payee for
the amount of the Reimbursable Payments and notifying the Plan), (iii) sign any document
deemed by the Plan Administrator to be relevant to protecting the Plan's subrogation,
reimbursement, or other rights within 30 days of receipt by the covered person, and (iv)
promptly provide relevant information when requested. The term "information" includes
any documents, insurance policies, police reports, or any reasonable request by the Plan
Administrator to enforce the Plan's rights.
1.5 Consequences of Failure to Follow Terms and Conditions. Failure by a covered person
to follow the terms and conditions set forth in this Exhibit may result, at the discretion of the
Plan Administrator, in a reduction from future benefit payments available to the covered
person under the Plan of an amount up to the aggregate amount of Reimbursable Payments
that has not been reimbursed to the Plan.
Exhibit III — Subrogation and Reimbursement 2
of Payments Made By Plan
Rev. 1-07
EXHIBIT IV
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
fust 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:
Exhibit IV — Ciaims and Review Procedures
Rev. 1-07
(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
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
Exhibit IV — Claims and Review Procedures 2
Rev. 1-07
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.
(4) Disability Claim. 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)
Exhibit W — Claims and Review Procedures 3
Rev. 1-07
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.
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:
Exhibit TV — Claims .and Review Procedures 4
Rev. 1-07
(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.
Exhibit IV _ Claims and Review Procedures 5
Rev. 1-Q7
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 HM0 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
predecessor health care arrangement); and (b) from which various identifying elements
Exhibit V — Premium Conversion Cafeteria Plan 1
Rev. 1-07
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
rovidedPlan 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(f).
1.5 Conditions of Disclosure for Certain Other Plan Administration Functions
Pian Sponsor agrees that with respect to any PHI (other than enrollment / disenrolhment
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
C.F.R. § 154.524.
Exbibit V — Premium Conversion Cafeteria Plan 2
Rev. 1-07
(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 CY 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 Risk Management
Benefits Coordinator
Benefits Specialists
City Manager
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
The Plan Sponsor shall:
Exhibit V — Premium Conversion Cafeteria Pian 3
Rev. 1-a7
(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 V — Premium Conversion Cafeteria Plan 4
Re%. ]-D'
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 19$6
(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:
1.01 "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.
1.02 "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.
1.03 "Benefits" means those benefits available to an Employee who has not elected to
receive cash under Article IV.
1.04 "Code" means the Internal Revenue Code of 1986, as amended.
1.05 "City" means the City of Lubbock, a governmental subdivision of the State of
Texas.
1.06 "Effective Date" means January 1, 2007.
1.07 "Employee" means an employee of an Employer.
1.08 "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.
1.09 "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.).
Exhibit V — Premium Conversion Cafeteria Plan
Rev. 4-07
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 1I.
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
2.01 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.
2.02 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 I1I.
2.03 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.
Exhibit V — Premium Conversion Cafeteria Plan 2
Rev. 407
2.04 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 4.103.
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 fust 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
3.01 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.
3.02 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.
Exhibit V— Premium Conversion Cafeteria Plan
Rev. 4-07
(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 N, 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.
3.03 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.
3.04 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;
Exhibit V — Premium Conversion Cafeteria Plan 4
Rev. 4-07
(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.
Exhibit V — Premium Conversion Cafeteria Plan
Rev. a-07
3.05 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.
3.06 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.
3.07 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.
Exhibit V — Premium Conversion Cafeteria Plan
Rev. 4-Q7
similar coverage. Coverage under an accident c
significantly curtailed only if there is an overal
affects all participants in that program.
3.08 Altering Elections for Court Ordered Coverage. If
the subject of a qualified medical child support order (QMCSO) gains or loses 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.
3.09 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
4.01 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
Exhibit V — Premium Conversion Cafeteria Plan
Rev. 4-07
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.
4.02 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.
4.03 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.
Exhibit V — Premium Conversion Cafeteria Plan
Rev. 4-07
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
6.01 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.
6.02 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.
6.03 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;
Exhibit V - Premium Conversion Cafeteria Plan 9
Rev. 4-07
(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.
6.04 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.
6.05 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.
6.06 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
8.01 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.
Exhibit V — Premium Conversion Cafeteria Plan 10
Rev. 4-07
8.02 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.
8.03 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
9.01 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.
9.02 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.
9.03 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.
9.04 Fiduciaries. Any person or group of persons may serve in more than one
fiduciary capacity with respect to the Plan.
9.05 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.
9.06 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.
Exhibit V — Premium Conversion Cafeteria Plan 11
Rev. 4-07
IN WITNESS WHEREOF, we have executed this Plan Agreement the date and
year first written above.
Lubbock
city
By
Davi A./Miller
Title: Mayor
ATTEST:
By:
4Recca Garza
Title: City Secretary
APPRQVED AS TO CONTENT
Leisa Hutcheson
Director of Risk Management
-
Assistant City Attorney
Exhibit V — Premium Conversion Cafeteria Plan 12
Rev. 4-07
APPENDIX A
WELFARE BENEFITS PROVIDED UNDER PLAN
Effective as of January 1, 2007
The underlying Welfare Benefits maintained by the Employer under this Plan are listed in the first column below; a general description of such
benefits is listed in the second column below; any associated documents relating to such benefits that are officially are cross-referenced and
incorporated in this Plan are listed in the third column below (e.g., separate plan documents, descriptions of benefits, certificates of insurance,
insurance policies, TPA/ASO agreements, etc.); the policy or contract identification number along with the contact information of any insurer or
service provider are listed in the fourth column below; and a basic summary of the eligibility provisions of such benefits are listed in the remaining
columns below, as follows:
Underlying
Welfare Benefit
General Description of
Benefits Provided
Associated Documents
Policy Number, Contact
Information of insurer or
Service Provider
if applicable)
Employee Eligibility
Classification
Employee
Effective Date
(Dependent
Effective Date
Coverage
Termination
Date
Major Medical
Comprehensive health,
City of Lubbock (Group #10097)
ASO/TPA:
Full-time (40
Date of hire as full-
First day of
Benefits
medical, surgical, and
Managed Health Care benefits
Group # 10097
hours/week) active
time employees
month following
hospitalization coverage
booklet (drafted by BCBS)
Blue Cross Blue Shield of
employees and
(same for
date of eligibility
Texas
retirees
dependents)
is lost
Employee Policy Manual (but
14643 Dallas Parkway,
(dependents
limited to just those portions
Suite 850
generally lose
relating to employee classification
Dallas, TX 75254-8800
coverage when
procedures used with respect to
(972) 855-9019
employee sloes,
the Plan administration)
except coverage
terminates
immediately upon
marriage,
divorce, or death
of dependent, but.
shall continue if
covered as of date
employee dies or
is killed in the
line of duty)
Appendix A — Welfare Benefits Provided Under Plan
Rev. t-07
Underlying
General Description of
Associated Documents
Policy Number, Contact
Employee Eligibility
Employee
Coverage
Welfare Benefit
Benefits Provided
Information of Insurer or
Classification
Effective Date
Termination
Service Provider
(Dependent
Date
if applicable)
Effective Date
Retirees following 20
Retiree coverage
Retiree coverage
years of service
commences on first
terminates on first
regardless of age, or
day of month
day of month
following attaining
following
following date of
age 60 and 5 years of
retirement (same for
eligibility is lost
service
dependents)
(dependents
generally lose
coverage when
retiree does,
except coverage
terminates
immediately upon
marriage,
divorce, or death,
but shall continue
if covered on date
retiree dies, then
coverage
continues)
Dental Benefits
Dental coverage
City of Lubbock (Group #10097)
ASWTPA:
Full-time (40
Date of hire as full-
First day of
Dental Benefits benefits booklet
Blue Cross Blue Shield of
hours/week) active
time employees
month following
(drafted by BCBS)
Texas
employees and
(same for
date of eligibility
14643 Dallas Parkway,
retirees
dependents)
is lost
Employee Policy Manual (but
Suite 850
(dependents
limited to just those portions
Dallas, TX 75254-8800
generally lose
relating to employee classification
(972) 855-9019
coverage when
procedures used with respect to
employee does,
the Plan administration)
except coverage
terminates
immediately upon
marriage,
divorce, or death
of dependent, but
shall continue if
covered as of date
Exhibit VI — Premium Conversion Cafeteria Plan
Rev. 4-07
Underlying
Welfare Benefit
General Description of
Benefits Provided
Associated Documents
Policy Number, Contact
Information of Insurer or
Service Provider
if applicable)
Employee Eligibility
Classification
Employee
Effective Date
(Dependent
Effective Date
Coverage
Termination
Date
employee dies or
is killed in the
line of duty)
Retirees following 20
Retiree coverage
(dependents
years of service
commences on first
generally lose
regardless of age, or
day of month
coverage when
following attaining
following
retiree does,
age 60 and S years of
retirement (same for
except coverage
service
dependents)
terminates
immediately upon
marriage,
divorce, or death,
but shall continue
if covered on date
retiree dies, then
coverage
continues)
Exhibit VI — Premium Conversion Cafeteria Plan
Rv,, 4-07
APPENDIX B
SUMMARY PLAN DESCRIPTION SUPPLEMENT
The following information, along with the information contained in the attached Plan document,
is intended to constitute the Summary Plan Description.
Name of Plan City of Lubbock, Texas Master Welfare Benefit Plan
Plan Number 502
Plan Sponsor City of Lubbock
1625 13th Street
Lubbock, Texas 79457
(806) 775-2277
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 Lee Ann Dumbauld, City Manager
and Named City of Lubbock
Fiduciary 1625 13th Street
Lubbock, Texas 79457
(806) 775-2277
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 Benefits under the Plan are paid from the general funds of the Employer
Administration / and are self-administered by the Employer (or a third -party administrator.
Funding Medium / The Plan is funded through employer and employee contributions.
Source of
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.
Appendix B — Summary Plan Supplement 1
Rev. 1-07
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
Appendix B - Summary Plan Supplement 2
Rev. 1-07
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 C.
Appendix B — Summary Plan Supplement
Rev. 1-07