MARCICOPA COUNTY BENEFITS PLAN 11TH EXHIBIT B.PDF
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Maricopa County
The Maricopa County Benefits Plan
(Eleventh Amendment and Restatement)
This plan document, when executed, will constitute a legal
instrument with important tax and legal implications. Before
you adopt it, you should verify its accuracy, and your legal
advisor(s) should confirm and approve it.
“KW
C.- B)-ale OOS
PREAMBLE AND EXECUTION
WHEREAS, Maricopa County (“the County") maintains The Maricopa County Benefits Plan
(Tenth Amendment and Restatement), the Maricopa County Dependent Care Flexible Spending
Account Plan (Fifth Amendment and Restatement), the Maricopa County Health Care Flexible
Spending Account Plan (Fifth Amendment and Restatement), and the Maricopa County Limited
Scope Flexible Spending Account Plan (Second Amendment and Restatement); and
WHEREAS, the County desires to amend, restate, consolidate, and supersede the above listed
plans Into this Maricopa County Benefits Plan (Eleventh Amendment and Restatement);
NOW, THEREFORE, by virtue and in exercise of the power reserved to the Maricopa County
Board of Supervisors, this Maricopa County Benefits Plan (Eleventh Amendment and
Restatement) (the “Maricopa County Benefits Plan” or the Plan) is hereby approved and
adopted effective September 2, 2020.
IN WITNESS WHEREOE, the Countyha the Plan to be executed by its duly authorized
te
representative this ol day of ei , 2020.
MARICOPA COUNTY
OCT 29 2020
HAE
Chairman, Bodrd of Superdsors Date
ATTEST:
OCT 29 2020
ROY Ve AAs
~Glerk of the Board 040220 | Date
APPROVED AS TO FORM:
Sus , nw re [o/28[1020
Deputy County Attorney Date
TABLE OF CONTENTS
1 Ethene Behe saris eke ok
ho
1 Purpose ‘and: History. ses en aac ok
1 QQUAMICARION o.oo... cece cscs cee cscs cceceesesssnseessesseuaeesessessecessceaaeaaeaeseesnnnseuaeessuseeaeeaenas oe
Bu
1 DIUPERION wos... cceeeeessccceseeensesescoeesscccuceeeeeeenseneeeesnneuusseseaaaauausessceaaeaannnnnnnaneeeesnssneasseess Bo
ARTICLE I! DEFINITIONS
2.1 PS REPS ccc cate arse cocnaincveaeseteneesevucuuzents verdeeact edacwesaseceetemeatenesaeuecusanenseenucresecnceeesand oe
ra Benefits Titast oe: ccctocnrsescccecnccescay ncugeceressscccs segedeties cen decbosalicaucdesasedeervieeeeveies csueceas oe
2.3 Board of Su perviss ic: sciictececc ce cecsik cniies. acta eee
oo
2.4 Boardbot; Trustees icc. ee
2.9 (Cheep In: Stee sss Sa eae Ro ee
2.6 Claim ACMinisStrator ...........ccecccseeeescceeeccesneeeecccsseeeusesssennneeeesececssseenersssennerseseeeareess oo
a | oe | eee
2.8 COBRA...
2.9 County ...
2.10 Covered Employes...
SAHOO
2.11 Covered Person.. OOOO
2.12 Dependent...
2.13 Dependent Care Account Plan...
Spending
2.14 Effective Date ..
2.15
2.16 a a
aca
2.17 ERISA...
2.18 FMLA.. si
2.19 Health Care Spending Account Plan...
2.20 Health Savings ACCOUNE......cscssoteesectneee naomi ae
2.21 i gare ea rs OO oe EN TaN NOSE Ler ORME ene aN REST eT aes Pec Od
2.22 Incorporated Document............. oo
2.23 Limited Purpose Health Care ‘Spending Account Plan...
2.24 Outbreak Period. mmo
2.25 Participating trib
2.26 Plan...
2.27 Plan Administrator ..
2.28 Plan Sponsor ... coonoonmnmoa
2.29 Plan Year...
2.30 Salary Deduction .. ;
2.31 Salary Deduction Contributions ..
2.32 Salary Reduction ..
2.33 Salary Reduction Contributions ..
2.34 Spouse... dns sticesazecastea neues
ARTICLE II] ELIGIBILITY, PARTICIPATION AND COVERAGE...
3.1 Eligibility...
3.2 Participation...
3.3 Coverage...
3.4 under the and Medical Leave Act and ‘Section 609 of
te Family
ERISA...
3.5 Uniformed Services Employment and Reemployment Act... aid
ee enane
3.6 Health Insurance Portability and Act of 1996 .. 14
_ratmiomen
3.7 Coordination with State Medicaid Program ...
3.8 Mental Health Parity and Addiction Equity Act. 14
3.9 Women’s Health and Cancer Rights Act 2 15
3.10 Newborns’ and Mothers’ Health Protection Act..
3.11 Genetic Information Nondiscrimination Act of 2008 ..
us
3.12 Children’s Health Insurance Program Reauthorization ‘Act ot 2009 .. lS
soe
3.13 Patient Protection and Affordable Care Act and Health Care and Education
Reconcsialion Avet .c3eeccee sect oes ee te ee 16
Vf
4.4 Benefits...
4.2 Options ... .
4.3 Unreduced Benefi t...
Compensation
4.4 Elective Benefits ..
4.5 Non-Elective Benefits ..
4.6 Limits for Certain Employees...
47 Notification of Premium Amounts...
Payment
4.8 Application of Other Plans.. ee,
ARTICLE V ELECTIONS..
5.1 Enrollment ‘for Non- Elective Benefi ts. ed
aie
5.2 Enrollment for Elective Booth eoseemea enero 2d
5.3 Salary Reductions/De@ductions..w............ ccc cece ceseseeeesseesesaeeeceessnnsseeeeceeseseeees 2d
5.4 Forms and a tintunuias nr sinantin easiensinagensaciens aehthensnnrnnninsd ccsemdcinn nase nveednsshsinneiienninn as)
one
5.5 Default Benefits ..
5.6 Deadlines... a
5.7 Validity of Election Forms.
5.8 Changing Elections... 2D
5.9 Waiver of RE -asceessensecearesrrnernnray wre nrecuesreueraummurmsnonaetst 30
31
6.1 Applicability...
6.2 COB Defi nitions ..
6.3 Order of Benefit Determination Rules... wae
6.4 Effect on the Benefits of this PLA ooo eeocccccceseeeeeeceeeeee eects a4
6.5 Disagreement on Order of Bamefits «oo... 0... cece cceeseeceesceeeguaseeeeescecesceees 35
6.6 Limitation of Benefits .. si
6.7 Right to Receive and Release Necessary COB information ..
6.8 Facility of Payment as wd
6.9 Right of Pai eee cae 36
6.10 Goveming Provisions: ic3: isis ae eS 36
ARTIGLE VIl COBRA CONTINUATION COVERAGE ...........-..ceccecceccceeceeeceseeeeeeeeeeseeseeeeeeneeneeeeees 37
fA Eligibility for Continuation Coverage. ............ccccceesecceeerscrnerreeeesseenseeteneensnnneeneess af
f.2 Definitions...
7.3 Loss of Eligibility for Continuation Coverage ...
7.4 Termination of COBRA Continuation Coverage.
7.5 Notice Requirements ... wig
7.6 Coverage Available for Continuation .. ..--40
ta Ee CURT PRINS ccc ceseapeipinis asian sattecie aenatadsaintnaenee vont dhiaiedaa Siac ard iueidelddel ce oebioc 44
7.8 Required: Premium sccscccccsss: ocssssers acucaees pence ry. seater bemsten uencreeecees cece 42
4.3 Governing: Provisions iccececceeccorec cess eee ee ee ce 42
ARTICLE VIII CONTRIBUTIONS, FUNDING AND PLAN ASSETS 43
8.1 Ia TEMA Sai a ge a a 43
8.2 Funding...
8.3 Plan Assets...
.
5.4 Treatment of Certain Policy Payments ... 44
..
ARTICLE IX CLAIM AND PAYMENT PROCEDURES ..............:c:ccceececeesesenecceesceerersesserenreesseeterenes 45
9.1 General Claims Proceduresy............0....ccccc0ssscccceceessessveceessecetescseseecenaaeeeeeees 45
9.2 Chaim Ae inisttator sceicssccssesesues atieeeteec ect ate 45
9.3 Claims Adiministrantiony ii..c.sc2.c5ccc.005c000se sev sceeveesveccicedeeessilicaladocsesdcanesnstebeeesseauclens 46
9.4 Claimants...
9.5 Claim Forms ..
9.6 Deadline for Filing a Claim...
9.7 Proof of Claim..
9.8 Decision on the Claim...
9.9 Right to Appeal... “i
9.10 Right to an External Review of Claims ..
9.11 Legal Remedy... 0d
9.12 Subrogation, Reimbursement and for Third Liabi 58
Recovery fe Party L ADI
9.13 Payment Procedures .. d
62
10.1 Plan AGmMiniStrator .............ccccsssssseseeeennneeceeeeesuneereneeesusscueueeeeseeeeeeennnuseeeessanannneess 62
10.2 Plan Administrator's Duties... 2.00. ce. ccc cece eeeecceeeeeneeseeeeeeensreeeeenesteereeseessvenes 62
10.3 Pian AGMInSWAaLOIS POWBIS.......50sescc00ctscesecssiesecsssssevsssssaveessiesconeccocccseactensssacesees 63
10.4 Finality of Decisions... -
10.5 Compensation and Bonding of Plan Administrator... 64
_...
10.7 Reserved Powers .. j
10.8 Intergovernmental Agreements ... 64
.
ARTICLE Xl AMENDMENT, TERMINATION OR MERGER OF PLAN..........00...200.00002:ec eee 66
11.1 Right to Amend the Plan...
11.2 Right to Terminate or Merge the Plan... ..-66
11.3 Effect of Amendment, Termination or Merger... ba Skceuucabren ev eveunet cunnnnua eanwensdan coil 66
67
12.1 Nia: Eniployrmient Fights cssesccs scscccscessscesceeeseceeestnneuitineennnr tannic ei a 67
12.2 Esecdunsives Rig libs eiee iss sccccsccncsecccrcennci increas ca a 67
12.3 No Property Rights ... .
12.4 No Assignment of Benefits Hp Po ee eo ep a sep se a
12.5 Eanes te Wis cad incompeteis..
12.6 Right to Offset Future Payments ... BB
12.7 Right to Recover Payments ..0..0.00.......cccccccecceecceccecensceeeeecercicecensseerenecnnsaeees 68
12.8 Misrepresentation Or Fraud... ccc ilk ese sceeeeesceseeeceeesnesedeeeesneee 68
12.9 LOB ASTON cccsccssaserese. crstormzceceiasceriiuisin ane cinitsteness peta ean reaEeE .. 69
12.10 (S0VONNND LAW? is csicsscasascenetens ecnuanaaitiesyeeasisli e tec as, 69
12.11 FORUM S@leGHOM sateen: 3: casci ec Re ee ee 69
iii
12.12 Govemiing Instrunnbeni si. ics. .cecsasssvececciess. cteccccaeets danke seerakestasteviea cde. stexadesienesscte 69
12.13 aw NS Alaa Ses ccseg ce iecees sect aaa aie ae ee 69
12.14 and carr 69
<a Lin.
12.15 Notices...
12.16 Waiver...
12.17 Parties’ Reliance... tO
12.18 DISCIAITON ooccecco ses ecoccoccccsssccccccsesevesceccsoveveveeccccceeveveeseecevtececeteveecceeevveeeneees 70
12.19 Expenses ...
12.20 Indemnifi cation...
—
12.21 Employees’ Tax Obligations ..
12.22 Unknown Whereabouts .. ree a
2
13.1 Scope...
13.2 Definitions.
.
13.3 Uses and Disclosures of PHI.
.
13.4 Privacy Agreements of the Plan Sponsor...
13.5 Security Agreements of the Plan Sponsor... de
APPENDIX A MARICOPA COUNTY DEPENDENT CARE SPENDING ACCOUNT PLAN............
ee
ee Etiectnns: Babes csc y eens, seme eee eed
ho Purpose ..
ee
ee to Qualification...
ee es
ff sie Reference... ee
ela By
tn Duration .. cececeeaeeeee
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2.1 Covered Employee...
2.2 Dependent Care Expenses..... aa
2.3 Dependent Care Account Plan.
napCrnN
24 Effective Date .. WNMNNNRR
2.5 Exclusions... iy
2.6 Maximum Annual Benefit.
ra Plan... oF
2.8 Qualifying Individual...
ARTICLE lll PARTICIPATION ..
3.1 Participation... AAR
wa
3.2 Termination of Participation...
ARTICLE IV DEPENDENT CARE REIMBURSEMENT BENEFIT ................::cccesssssesseeeseeeesnseenens
4.1 Right to: Bene besscscsssesscoc.cruacaeeses ene
4.2 Maintenance of Accounts «...c5c.5.c062c ees ie ee eee eee
Aoannnin
4.3 Amount Payable ...
4.4 Care Expenses...
reas
4.5 Limits ..
oOo
5.1 Gemeral RUIGS.......c.cccccccccccsssseecccesseenneceeseeesseseceueeeeeesseeeseuseetucceeeseaueceessuneeseeaueess
5.2 Specie Excision ssc icccsis cctsdscac ia an a aes
5.3 Conditional Exclusions. .....22206.0005.06.000c. cccecsceceeecenccebvs ccccusiectecededeveesssdecellicdeciecees
ARTICLE VI PROCEDURES...
ee
6.1 Enrollment and Flection Procedures .. i
6.2 Claim PROCOGUICS oooccsccccccsssssecssscccseseccecsssesscssreseccssseessestvesestivisesiseeesestieseesieesse 11
6.3 Claim Administrator w...cccc cece esses eeeeeeeeeeeseeeeeeouuuaeeeeeeueuuuuueeues 11
6.4 Claims ACMInistration wo. eeceeccceeeesesssueeeesesssseceeecuuuuseeeaususuuuueseuss 11
6.5 FASO OT. Od CSB A ssssisaitsar cwaanewenncecensmaetas ncsiacuni saincleaisnias dasaptaamsatnadeawieeictsbambtuhuaavaanunafesiies 12
APPENDIX B MARICOPA COUNTY HEALTH CARE SPENDING ACCOUNT PLAN.......00..000..
ee
4 Effective: Dabesnisciscueriee eases area ae a eats Se ea
| he Purpose ... ee
1 bo Qualifi cation... we
1 ip vl Reference.
agi By
1 in Duration .. ee
ARTICLE Il DEFINITIONS Suivcun dato uien ey sobeaadeite entueeeabur sp aadeich souk eusetneshtetumedeny mepeaemeentes bo
ae Employes. ho
2.2 Dependent... ho
2.0 Effective Date .
hh
2.4 Exclusions... ae
2.5 Health Care Spending Account ..
hh
2.6 Maximum Annual Benefit...
2.7 Plan... .
2.6 Qualifying Medical Expenses... ww
ARTICLE Ill PARTICIPATION ..
3.1 Participation... as
3.2 Termination of Participation...
tn
4.4 Right to Benefit: 2c:50s eee a ea ass oe on
4.2 Maintenance Of ACCOUNTS ........ccccccccccesssssecececescseeccessuseseeeeecesaseeueeeeuseeeeeeeeeeeaueeess en
43 Amount Payable .. tm
44 Medica steerer jesne temene emote on
Qualifying Expenses.
4.5 Limits .. =I
5.1 Grenetal Rikes was: cence nee ei
5.2 SPO CHC: EXGHISIMISs sce eee
ARTICLE VI PROCEDURES... .
6.1 Enrollment and Election Procedures ..
6.2 Claim PROCOAUIOS oooccs-ccccossssecssssecsesevecccstvesccoreeccteteooviteccbheeeseteesesteseesteeeen
6.3 Claim Administrator 0.000.000.0000 ccc cece ces eeeeeeeeeececeeeeeeuweeeeeeeueuuuueeeeees
6.4 Claims Administration ....0000000cccc cece cece css eeeeeeeseeesceeeceuuueeesesuunuueeeeeess
6.5 PANG OE CEG EAE ssccscises scaicenaaseite ctiestcarcacteaneacanatiainisuis subuadiatawsdStadivanttdaanmidneanetemedewnecs
APPENDIX C MARICOPA COUNTY LIMITED PURPOSE HEALTH CARE SPENDING
ACCOUNT PLAN... =
1 o FETT RSMIE DIPS cn cerecerancnesicccscsaaceccseneessucereiehe aueqspundavvnqansalevcselasenediescieuerianescnae
1 Purpose ..
hohe Qualification ..
1 wens
1 Reference...
eae By
4 mn Duration ..
2.1 Covered Employee vscccccccetatcciincnnkiinass cee a ehh
2.2 ES
FEE ior
2.3 Effective Date ..
2.4 Exclusions...
2.5 Limited Purpose Health Care AGCOUNL oo esevcccccsseccecsssssesssessveseseveses
Spending wwhhyye
2.6 Maximum Annual Benefit.. e
20 Plan... ”
2.6 Qualifying Medical Expenses...
ARTICLE II] PARTICIPATION ..
3.1 Participation... BRB
3.2 Termination of Participation ...
tn
4.1 Right to Benefit .. om
42 Maintenance of Accounts ... tn
MO
43 Amount Payable 0... tn
4.4 Medical Expenses...
a
4.5 Limits .. | wsteiess
5.1 (oeneral:- PUGS ose ce tae uuntecrice cea ~~~
5.2 Speci: EXGIISIONG:s: csninnnaititonn scion a ae a a
ARTICLE Vl PROCEDURES... oa oD
6.1 Enrollment and Election Procedures .. Oo
6.2 Claim PHOCEMUIES -ssssssssssesesssssssssssssstssssssesevssssssssssssssssssssesvssssesssssssssssissssseeeseeeee oo
6.3 Claim AGMINISHIALOL oo... ccsssesessssuuceeeeesuuueeeeesesessceuuuasseeeseeereeausuneeeessuuenereeeeees Go
6.4 ClaiIMS ACIMIMISTIATION ...........cccccccccssssseececeeeseeeeeeesessesseeeeeseeseeeeecenueneeeeessasaeeeeeetess 09
6.5 PROF OE LE cece cc ccocsesvsccdenaaeeveseresncueuneeesaanacaues eeidmeccnese veauebnnd eye aceemmecareanaeenteeeas to
vi
APPENDIX D APPLICABLE INCORPORATED DOCUMENTS. ............:.::c:cccccccssesseescueesssesssseeeeenes
APPENDIX E EMPLOYEES OF THE EMPLOYER APPROVED TO HAVE ACCESS TO
APPENDIX G MARICOPA COUNTY HEALTH SAVINGS ACCOUNT...............0..000.000: cece:
ARTICLE | PLAN ESTABLISHMENT ..
14
n
1.2 Health Savings Account Not Intended to be an ERISA Plan.
1.3 Incorporation BY REPRPENGCE ............-cececeseseeeieeesicecseenansereseteaaeenesiausernsacnens
ARTICLE Il DEFINITIONS..
= bles 2
es
22 Health Savings Account (HSA).....
3.1 sae 14 Le RSPR en err me OR ee Ey oe So eae DE
ARTICLE IV HEALTH SAVINGS ACCOUNT BENEFIT
............cccccesscssecsecsssssesecesesesaeeeseusseseeresseees
vii
ARTICLE I
PLAN ESTABLISHMENT
1.1 Effective Date
The Maricopa County Benefits Plan ("the Plan") is amended and restated effective
upon execution.
1.2 Purpose and History
Effective January 1, 1985, the Board of Supervisors of Maricopa County, Arizona
(the “County"), adopted The Maricopa County Cafeteria Plan, pursuant to section
125 of the Code, in order to establish a “cafeteria plan” to provide to the County’s
employees certain health, welfare and other benefits. The County also adopted
and established certain other benefit plans (previously referred to as “Benefits")
which, subject to the eligibility requirements set forth in each plan, became
available to the County's employees for the purpose of providing the benefits
described therein. Effective as of January 1, 1988, the County also amended and
restated the Dependent Health Care Payment Plan in its entirety by adopting The
Maricopa County Accident and Health Insurance Plan (the “A&H Plan”). Effective
as of January 1, 2006, the Cafeteria Plan and the A&H Plan were amended and
restated to incorporate all prior amendments made to those Plans since their
original Effective Date, and to make such other amendments as determined by the
County to be in the best interests of those Plans and their participants. Effective
June 22, 2011, the Second Amendment and Restatement of the Cafeteria Plan
and Third Amendment and Restatement of the A&H Plan were implemented.
Effective July 1, 2013, the Maricopa County Benefits Plan (Third Amendment and
Restatement) was amended and consolidated the Maricopa County Cafeteria Plan
(Second Amendment and Restatement) and the A&H Plan (Third Amendment and
Restatement) into one plan. The Plan has since been amended fram time to time.
The Plan is now amended effective as of the Effective Date to incorporate all prior
amendments and to make additional amendments required to comply with federal
and state laws and/or amendments which have been determined by the County to
be in the best interests of the Plan and its Covered Persons. The Plan is also
intended to give Covered Employees, as defined in Article Il, means to exchange
all or part of their compensation for other Plan benefits they select in order to allow
Covered Employees to maximize their tax savings to the greatest extent permitted
by law, as contemplated by sections 105, 106 and 125 of the Internal Revenue
Code of 1986, as amended (the “Code’).
1.3 Qualification
The Plan is not subject to the Employee Retirement Income Security Act of 1974,
as amended ("ERISA"). Any references in this document to sections of ERISA, or
statutes or rules commonly understood to be related to ERISA, are for
administrative ease, and do not subject the Plan to ERISA's jurisdiction.
To the extent this Plan provides permitted taxable benefits and qualified benefits
under Section 125 of the Code, it is intended to qualify as a cafeteria plan under
Section 125 of the Code. This document is intended to satisfy the written plan
document requirements of Department of Treasury Proposed Regulations
section 1.125-1(c). The portions of the plan that constitute the cafeteria plan and
the term Cafeteria
5 1 2 1 3 4 1002 474 99 33 82.217430 Plan”
5 1 2 1 3 5 1116 474 87 33 95.241776 shall
5 1 2 1 3 6 1218 483 105 24 95.241776 mean
5 1 2 1 3 7 1341 477 105 33 96.642715 those
5 1 2 1 3 8 1464 477 192 39 96.562592 provisions
5 1 2 1 3 9 1671 477 39 33 96.358551 of
5 1 2 1 3 10 1719 477 69 33 95.379395 this
5 1 2 1 3 11 1803 477 192 33 95.379395 document
5 1 2 1 3 12 2010 477 72 33 95.935768 that
5 1 2 1 3 13 2094 486 63 24 95.935768 are
4 1 2 1 4 0 621 525 1551 45 -1
5 1 2 1 4 1 621 531 198 36 96.376251 necessary
5 1 2 1 4 2 831 534 39 24 95.739998 or
5 1 2 1 4 3 885 525 219 42 95.739998 appropriate
5 1 2 1 4 4 1119 528 33 30 96.276390 to
5 1 2 1 4 5 1167 525 60 33 96.276390 the
5 1 2 1 4 6 1242 525 297 42 96.159302 implementation
5 1 2 1 4 7 1554 528 69 33 96.462242 and
5 1 2 1 4 8 1641 528 270 33 96.661514 administration
5 1 2 1 4 9 1929 528 36 33 96.788635 of
5 1 2 1 4 10 1977 528 195 42 96.185455 Employee
4 1 2 1 5 0 618 576 1527 45 -1
5 1 2 1 5 1 618 576 174 33 96.357208 elections
5 1 2 1 5 2 804 585 132 33 96.409164 among
5 1 2 1 5 3 951 576 60 33 96.599403 the
5 1 2 1 5 4 1026 576 168 42 96.449821 following
5 1 2 1 5 5 1209 576 99 36 96.882591 listed
5 1 2 1 5 6 1326 579 153 33 96.359306 benefits
5 1 2 1 5 7 1491 579 36 33 96.376228 to
5 1 2 1 5 8 1542 579 60 33 96.376228 the
5 1 2 1 5 9 1614 579 120 33 96.621582 extent
5 1 2 1 5 10 1749 582 135 39 96.621582 pre-tax
5 1 2 1 5 11 1899 579 171 33 96.294525 elections
5 1 2 1 5 12 2085 588 60 24 96.995140 are
4 1 2 1 6 0 618 627 1539 45 -1
5 1 2 1 6 1 618 627 183 33 96.537415 available:
5 1 2 1 6 2 816 627 60 33 92.799522 the
5 1 2 1 6 3 891 627 204 33 91.309273 unreduced
5 1 2 1 6 4 1110 627 273 42 96.033775 compensation
5 1 2 1 6 5 1401 630 138 36 96.245216 benefit,
5 1 2 1 6 6 1554 630 60 33 96.465363 the
5 1 2 1 6 7 1632 630 147 33 96.277802 Medical
5 1 2 1 6 8 1797 630 171 33 96.165955 Premium
5 1 2 1 6 9 1986 630 171 42 96.447670 Payment
4 1 2 1 7 0 618 678 1494 45 -1
5 1 2 1 7 1 618 678 144 39 96.720673 Benefit,
5 1 2 1 7 2 780 678 123 33 95.468506 Dental
5 1 2 1 7 3 921 678 171 33 95.468506 Premium
5 1 2 1 7 4 1110 678 171 42 96.535706 Payment
5 1 2 1 7 5 1296 678 144 39 95.308716 Benefit,
5 1 2 1 7 6 1458 678 117 33 95.974480 Vision
5 1 2 1 7 7 1590 681 174 33 96.054428 Premium
5 1 2 1 7 8 1779 681 174 42 96.302971 Payment
5 1 2 1 7 9 1968 681 144 39 96.430176 Benefit,
4 1 2 1 8 0 618 729 1611 45 -1
5 1 2 1 8 1 618 729 123 33 96.220177 Health
5 1 2 1 8 2 756 729 93 33 95.988098 Care
5 1 2 1 8 3 864 729 183 42 95.988098 Spending
5 1 2 1 8 4 1062 729 159 33 95.455727 Account
5 1 2 1 8 5 1236 729 174 33 95.455727 Premium
5 1 2 1 8 6 1425 729 174 42 96.511955 Payment
5 1 2 1 8 7 1614 732 141 39 96.421730 Benefit,
5 1 2 1 8 8 1776 732 138 33 95.707108 Limited
5 1 2 1 8 9 1929 732 162 42 95.971695 Purpose
5 1 2 1 8 10 2106 732 123 33 96.335358 Health
4 1 2 1 9 0 618 780 1536 45 -1
5 1 2 1 9 1 618 780 93 33 95.856804 Care
5 1 2 1 9 2 726 780 183 42 96.262360 Spending
5 1 2 1 9 3 921 780 162 33 95.630447 Account
5 1 2 1 9 4 1098 780 171 33 96.203423 Premium
5 1 2 1 9 5 1287 780 171 42 96.351151 Payment
5 1 2 1 9 6 1473 780 144 39 96.274719 Benefit,
5 1 2 1 9 7 1635 783 213 39 96.752396 Dependent
5 1 2 1 9 8 1863 783 93 33 95.252800 Care
5 1 2 1 9 9 1971 783 183 42 96.218292 Spending
4 1 2 1 10 0 615 828 1452 45 -1
5 1 2 1 10 1 615 828 159 36 96.189949 Account
5 1 2 1 10 2 789 831 174 33 96.691154 Premium
5 1 2 1 10 3 978 831 174 42 96.597054 Payment
5 1 2 1 10 4 1164 831 144 39 96.392403 Benefit,
5 1 2 1 10 5 1326 831 69 33 96.334915 and
5 1 2 1 10 6 1413 831 123 33 96.593704 Health
5 1 2 1 10 7 1554 831 153 42 96.810699 Savings
5 1 2 1 10 8 1719 834 162 33 95.769753 Account
5 1 2 1 10 9 1896 834 171 33 96.232346 Premium
4 1 2 1 11 0 618 879 1566 45 -1
5 1 2 1 11 1 618 879 171 42 96.218231 Payment
5 1 2 1 11 2 804 882 144 33 94.891998 Benefit.
5 1 2 1 11 3 963 882 84 33 97.014099 This
5 1 2 1 11 4 1062 882 84 33 96.800804 Plan
5 1 2 1 11 5 1161 882 30 33 96.366135 is
5 1 2 1 11 6 1206 882 78 33 96.074432 also
5 1 2 1 11 7 1299 882 165 33 96.304810 intended
5 1 2 1 11 8 1479 885 36 30 96.819603 to
5 1 2 1 11 9 1530 882 126 42 96.580246 qualify
5 1 2 1 11 10 1671 891 42 24 96.410454 as
5 1 2 1 11 11 1728 891 45 24 96.410454 an
5 1 2 1 11 12 1791 885 177 33 96.410156 “accident
5 1 2 1 11 13 1983 885 69 33 95.886398 and
5 1 2 1 11 14 2070 885 114 33 95.886398 health
4 1 2 1 12 0 618 930 1581 45 -1
5 1 2 1 12 1 618 930 93 42 72.840370 plan”
5 1 2 1 12 2 729 933 210 33 95.801636 maintained
5 1 2 1 12 3 957 933 111 33 96.554443 under
5 1 2 1 12 4 1080 933 165 33 96.554443 Sections
5 1 2 1 12 5 1263 933 69 33 96.202400 105
5 1 2 1 12 6 1347 933 72 33 96.202400 and
5 1 2 1 12 7 1437 933 69 33 95.573158 106
5 1 2 1 12 8 1521 933 36 33 95.573158 of
5 1 2 1 12 9 1569 933 60 33 96.693619 the
5 1 2 1 12 10 1644 933 102 36 95.576645 Code
5 1 2 1 12 11 1761 936 69 33 95.576645 and
5 1 2 1 12 12 1848 936 213 39 94.279610 regulations
5 1 2 1 12 13 2076 936 123 33 96.212570 issued
4 1 2 1 13 0 615 981 1569 39 -1
5 1 2 1 13 1 615 981 213 36 95.742790 thereunder
5 1 2 1 13 2 840 984 72 33 95.742790 and
5 1 2 1 13 3 927 984 33 33 95.869354 to
5 1 2 1 13 4 978 984 87 33 96.080017 offer
5 1 2 1 13 5 1080 984 150 33 96.277596 benefits
5 1 2 1 13 6 1245 993 45 24 96.277596 on
5 1 2 1 13 7 1305 993 21 24 96.880829 a
5 1 2 1 13 8 1341 984 150 33 96.683113 tax-free
5 1 2 1 13 9 1506 984 99 33 96.360489 basis
5 1 2 1 13 10 1620 984 30 33 95.725479 in
5 1 2 1 13 11 1665 987 228 33 95.725479 accordance
5 1 2 1 13 12 1905 987 78 33 96.798531 with
5 1 2 1 13 13 1998 987 60 33 96.828941 the
5 1 2 1 13 14 2073 987 111 33 96.718239 Code.
4 1 2 1 14 0 615 1032 1518 42 -1
5 1 2 1 14 1 615 1032 81 33 96.798019 This
5 1 2 1 14 2 714 1032 81 33 95.981148 Plan
5 1 2 1 14 3 813 1035 87 33 95.981148 shall
5 1 2 1 14 4 915 1035 45 33 95.542351 be
5 1 2 1 14 5 978 1035 216 39 95.542351 interpreted,
5 1 2 1 14 6 1212 1035 189 33 96.741989 construed
5 1 2 1 14 7 1419 1035 69 33 96.132431 and
5 1 2 1 14 8 1506 1035 246 33 96.132431 administered
5 1 2 1 14 9 1770 1035 30 33 96.751564 in
5 1 2 1 14 10 1815 1038 228 33 96.192406 accordance
5 1 2 1 14 11 2055 1038 78 33 96.838531 with
4 1 2 1 15 0 615 1083 1587 39 -1
5 1 2 1 15 1 615 1083 90 33 96.404274 such
5 1 2 1 15 2 723 1083 114 33 94.839714 intent.
5 1 2 1 15 3 867 1083 33 33 95.733200 In
5 1 2 1 15 4 915 1092 45 24 95.733200 no
5 1 2 1 15 5 975 1086 108 33 94.892632 event
5 1 2 1 15 6 1095 1086 87 33 96.380363 shall
5 1 2 1 15 7 1197 1086 69 33 96.673805 this
5 1 2 1 15 8 1281 1086 84 33 96.018524 Plan
5 1 2 1 15 9 1383 1086 45 33 96.018524 be
5 1 2 1 15 10 1443 1086 249 33 96.381668 administered
5 1 2 1 15 11 1707 1095 39 24 96.152679 or
5 1 2 1 15 12 1758 1089 192 30 96.592926 construed
5 1 2 1 15 13 1965 1089 36 33 96.678406 to
5 1 2 1 15 14 2016 1089 186 33 96.187363 constitute
4 1 2 1 16 0 615 1134 1527 45 -1
5 1 2 1 16 1 615 1143 21 24 95.081932 a
5 1 2 1 16 2 651 1134 81 42 96.264313 plan
5 1 2 1 16 3 747 1134 36 33 96.286911 of
5 1 2 1 16 4 795 1134 162 36 96.716949 deferred
5 1 2 1 16 5 972 1137 282 39 94.792999 compensation.
5 1 2 1 16 6 1272 1137 75 33 96.552376 The
5 1 2 1 16 7 1362 1137 165 33 96.534515 cafeteria
5 1 2 1 16 8 1545 1137 78 42 96.386520 plan
5 1 2 1 16 9 1641 1137 27 33 96.386520 is
5 1 2 1 16 10 1683 1137 51 33 96.489853 for
5 1 2 1 16 11 1746 1137 165 33 95.947060 Covered
5 1 2 1 16 12 1929 1140 213 39 96.083298 Employees
4 1 2 1 17 0 615 1185 87 42 -1
5 1 2 1 17 1 615 1185 87 42 96.368843 only.
2 1 3 0 0 0 612 1284 1587 198 -1
3 1 3 1 0 0 612 1284 1587 198 -1
4 1 3 1 1 0 612 1284 1587 42 -1
5 1 3 1 1 1 612 1284 75 33 95.965538 The
5 1 3 1 1 2 705 1284 213 42 95.925072 Dependent
5 1 3 1 1 3 930 1284 96 33 95.536827 Care
5 1 3 1 1 4 1038 1287 183 39 95.536827 Spending
5 1 3 1 1 5 1236 1287 159 33 95.785660 Account
5 1 3 1 1 6 1410 1287 96 39 96.264816 Plan,
5 1 3 1 1 7 1524 1296 42 24 96.309113 as
5 1 3 1 1 8 1581 1287 141 33 96.452644 defined
5 1 3 1 1 9 1740 1287 30 33 95.271500 in
5 1 3 1 1 10 1782 1287 123 33 96.876915 Article
5 1 3 1 1 11 1923 1287 18 33 59.711868 Il
5 1 3 1 1 12 1956 1290 72 30 95.989815 and
5 1 3 1 1 13 2043 1290 57 33 96.984230 set
5 1 3 1 1 14 2112 1290 87 33 96.588455 forth
4 1 3 1 2 0 615 1335 1560 45 -1
5 1 3 1 2 1 615 1335 30 33 95.044022 in
5 1 3 1 2 2 657 1335 186 42 94.964806 Appendix
5 1 3 1 2 3 855 1335 39 39 96.758949 A,
5 1 3 1 2 4 912 1335 27 33 96.876686 is
5 1 3 1 2 5 957 1338 72 39 96.220856 part
5 1 3 1 2 6 1044 1338 36 33 96.220856 of
5 1 3 1 2 7 1092 1338 66 33 96.894310 this
5 1 3 1 2 8 1173 1338 84 33 96.912201 Plan
5 1 3 1 2 9 1275 1338 69 33 96.645523 and
5 1 3 1 2 10 1362 1338 27 33 96.361473 is
5 1 3 1 2 11 1404 1338 165 33 96.265457 intended
5 1 3 1 2 12 1584 1338 36 33 96.837372 to
5 1 3 1 2 13 1635 1338 126 42 96.720848 qualify
5 1 3 1 2 14 1776 1347 42 24 95.921036 as
5 1 3 1 2 15 1833 1347 21 24 95.997871 a
5 1 3 1 2 16 1872 1338 207 42 96.451836 dependent
5 1 3 1 2 17 2091 1347 84 27 95.892120 care
4 1 3 1 3 0 612 1386 1521 45 -1
5 1 3 1 3 1 612 1386 207 33 96.180870 assistance
5 1 3 1 3 2 834 1395 162 33 95.737816 program
5 1 3 1 3 3 1011 1389 111 30 95.737816 under
5 1 3 1 3 4 1137 1389 144 33 96.216080 Section
5 1 3 1 3 5 1299 1389 69 33 96.572723 129
5 1 3 1 3 6 1383 1389 36 33 96.365379 of
5 1 3 1 3 7 1431 1389 60 33 96.592888 the
5 1 3 1 3 8 1506 1389 111 33 96.253059 Code.
5 1 3 1 3 9 1632 1389 186 42 96.371178 Appendix
5 1 3 1 3 10 1823 1382 18 54 96.903503 A
5 1 3 1 3 11 1875 1389 27 33 96.903503 is
5 1 3 1 3 12 1920 1389 162 33 96.360733 intended
5 1 3 1 3 13 2097 1392 36 33 96.524857 to
4 1 3 1 4 0 612 1437 1419 45 -1
5 1 3 1 4 1 612 1437 126 42 89.705093 satisfy
5 1 3 1 4 2 750 1437 60 33 96.749153 the
5 1 3 1 4 3 822 1437 129 33 96.678474 written
5 1 3 1 4 4 966 1437 81 42 96.746407 plan
5 1 3 1 4 5 1062 1437 192 33 96.071968 document
5 1 3 1 4 6 1269 1437 234 42 96.191437 requirement
5 1 3 1 4 7 1518 1440 36 33 96.421188 of
5 1 3 1 4 8 1566 1440 102 33 96.258446 Code
5 1 3 1 4 9 1683 1440 144 33 92.170845 Section
5 1 3 1 4 10 1848 1440 183 42 82.203751 129(d)(1).
2 1 4 0 0 0 609 1536 1605 246 -1
3 1 4 1 0 0 609 1536 1605 246 -1
4 1 4 1 1 0 612 1536 1545 42 -1
5 1 4 1 1 1 612 1536 75 33 96.498497 The
5 1 4 1 1 2 702 1536 123 33 95.828636 Health
5 1 4 1 1 3 840 1536 93 33 96.010727 Care
5 1 4 1 1 4 948 1536 183 42 96.663338 Spending
5 1 4 1 1 5 1146 1536 159 33 96.371742 Account
5 1 4 1 1 6 1320 1539 96 36 96.419952 Plan,
5 1 4 1 1 7 1431 1545 45 24 96.359962 as
5 1 4 1 1 8 1491 1539 141 33 96.703903 defined
5 1 4 1 1 9 1650 1539 30 33 95.166000 in
5 1 4 1 1 10 1692 1539 123 33 92.843872 Article
5 1 4 1 1 11 1833 1539 18 33 66.091988 ||
5 1 4 1 1 12 1869 1539 69 33 96.346909 and
5 1 4 1 1 13 1953 1542 57 30 96.696465 set
5 1 4 1 1 14 2025 1539 84 33 96.306984 forth
5 1 4 1 1 15 2127 1539 30 33 95.412880 in
4 1 4 1 2 0 609 1587 1467 45 -1
5 1 4 1 2 1 609 1587 186 42 92.250969 Appendix
5 1 4 1 2 2 810 1587 36 39 91.698845 B,
5 1 4 1 2 3 864 1587 27 33 96.182312 is
5 1 4 1 2 4 906 1590 75 39 96.411079 part
5 1 4 1 2 5 996 1587 36 33 96.411079 of
5 1 4 1 2 6 1044 1587 66 33 96.324562 this
5 1 4 1 2 7 1128 1587 93 33 96.118980 Plan.
5 1 4 1 2 8 1236 1590 75 30 96.118980 The
5 1 4 1 2 9 1329 1587 123 36 96.733307 Health
5 1 4 1 2 10 1467 1590 93 33 95.757401 Care
5 1 4 1 2 11 1575 1590 183 42 96.624191 Spending
5 1 4 1 2 12 1770 1590 162 33 96.283012 Account
5 1 4 1 2 13 1947 1590 84 33 96.478523 Plan
5 1 4 1 2 14 2046 1590 30 33 96.530144 is
4 1 4 1 3 0 612 1638 1596 45 -1
5 1 4 1 3 1 612 1638 165 33 95.987778 intended
5 1 4 1 3 2 792 1638 36 33 96.828445 to
5 1 4 1 3 3 843 1638 126 42 95.809875 qualify
5 1 4 1 3 4 984 1647 42 24 95.809875 as
5 1 4 1 3 5 1041 1647 21 24 96.788963 a
5 1 4 1 3 6 1080 1638 114 33 96.152382 health
5 1 4 1 3 7 1212 1638 78 42 95.550613 plan
5 1 4 1 3 8 1308 1638 111 33 95.550613 under
5 1 4 1 3 9 1431 1638 144 36 92.798798 Section
5 1 4 1 3 10 1596 1641 120 39 92.414719 105(e)
5 1 4 1 3 11 1731 1641 39 33 96.846489 of
5 1 4 1 3 12 1779 1641 60 33 96.180191 the
5 1 4 1 3 13 1854 1641 114 33 96.680138 Code.
5 1 4 1 3 14 1983 1641 183 42 93.227112 Appendix
5 1 4 1 3 15 2181 1641 27 33 93.227112 B
4 1 4 1 4 0 612 1689 1602 45 -1
5 1 4 1 4 1 612 1689 30 33 96.147141 is
5 1 4 1 4 2 657 1689 78 33 95.660645 also
5 1 4 1 4 3 750 1689 165 33 95.660645 intended
5 1 4 1 4 4 930 1692 36 30 96.573128 to
5 1 4 1 4 5 978 1689 126 42 96.207359 satisfy
5 1 4 1 4 6 1116 1689 60 33 96.932304 the
5 1 4 1 4 7 1188 1689 129 33 96.395340 written
5 1 4 1 4 8 1335 1689 78 42 96.585457 plan
5 1 4 1 4 9 1428 1689 192 36 96.037178 document
5 1 4 1 4 10 1635 1692 234 39 95.334778 requirement
5 1 4 1 4 11 1884 1692 36 33 96.279541 of
5 1 4 1 4 12 1935 1692 225 42 96.095589 Department
5 1 4 1 4 13 2175 1692 39 33 96.968971 of
4 1 4 1 5 0 609 1740 885 42 -1
5 1 4 1 5 1 609 1740 174 42 95.487350 Treasury
5 1 4 1 5 2 798 1740 189 42 49.292595 regulation
5 1 4 1 5 3 1005 1740 144 33 93.204666 Section
5 1 4 1 5 4 1167 1740 327 42 73.909775 1.105-11(b)(1)(i).
2 1 5 0 0 0 609 1839 1596 246 -1
3 1 5 1 0 0 609 1839 1569 144 -1
4 1 5 1 1 0 609 1839 1569 42 -1
5 1 5 1 1 1 609 1839 75 33 96.667404 The
5 1 5 1 1 2 699 1839 138 33 96.069649 Limited
5 1 5 1 1 3 855 1839 162 42 96.464386 Purpose
5 1 5 1 1 4 1032 1839 123 33 96.222122 Health
5 1 5 1 1 5 1170 1839 93 33 96.290550 Care
5 1 5 1 1 6 1278 1839 183 42 93.031075 Spending
5 1 5 1 1 7 1476 1839 159 36 96.557709 Account
5 1 5 1 1 8 1650 1842 96 39 96.108864 Plan,
5 1 5 1 1 9 1761 1851 45 24 96.544334 as
5 1 5 1 1 10 1821 1842 141 33 96.705017 defined
5 1 5 1 1 11 1980 1842 30 33 96.178291 in
5 1 5 1 1 12 2022 1842 123 33 95.939384 Article
5 1 5 1 1 13 2163 1842 15 33 72.754196 II
4 1 5 1 2 0 612 1890 1533 42 -1
5 1 5 1 2 1 612 1890 69 33 96.027336 and
5 1 5 1 2 2 696 1896 45 27 96.235985 as
5 1 5 1 2 3 756 1890 57 33 96.358383 set
5 1 5 1 2 4 825 1890 87 33 96.466469 forth
5 1 5 1 2 5 927 1890 30 33 96.134399 in
5 1 5 1 2 6 972 1890 183 42 93.139114 Appendix
5 1 5 1 2 7 1170 1890 39 39 92.999992 C,
5 1 5 1 2 8 1227 1890 27 33 96.906235 is
5 1 5 1 2 9 1272 1893 72 39 96.859566 part
5 1 5 1 2 10 1359 1890 39 33 96.613724 of
5 1 5 1 2 11 1407 1890 66 33 96.474663 this
5 1 5 1 2 12 1491 1890 93 33 96.547882 Plan.
5 1 5 1 2 13 1602 1890 75 33 95.526566 The
5 1 5 1 2 14 1692 1893 138 33 95.728348 Limited
5 1 5 1 2 15 1845 1893 162 39 91.717667 Purpose
5 1 5 1 2 16 2025 1893 120 33 95.029182 Health
4 1 5 1 3 0 609 1938 1431 45 -1
5 1 5 1 3 1 609 1938 96 33 96.729797 Care
5 1 5 1 3 2 720 1938 180 42 96.802139 Spending
5 1 5 1 3 3 915 1941 162 33 96.298592 Account
5 1 5 1 3 4 1089 1941 84 33 96.237198 Plan
5 1 5 1 3 5 1191 1941 27 33 96.237198 is
5 1 5 1 3 6 1236 1941 162 33 96.371788 intended
5 1 5 1 3 7 1413 1944 36 30 96.172440 to
5 1 5 1 3 8 1464 1941 126 42 96.172440 qualify
5 1 5 1 3 9 1605 1950 42 24 96.472511 as
5 1 5 1 3 10 1662 1950 21 24 96.857338 a
5 1 5 1 3 11 1701 1941 117 36 96.586723 health
5 1 5 1 3 12 1833 1944 81 39 95.641197 plan
5 1 5 1 3 13 1929 1944 111 33 95.641197 under
3 1 5 2 0 0 609 1989 1596 96 -1
4 1 5 2 1 0 609 1989 1596 48 -1
5 1 5 2 1 1 609 1989 144 36 93.279816 Section
5 1 5 2 1 2 771 1992 123 42 85.149841 105(e)
5 1 5 2 1 3 909 1992 39 33 96.228340 of
5 1 5 2 1 4 957 1992 60 33 96.207413 the
5 1 5 2 1 5 1032 1992 114 33 96.609161 Code.
5 1 5 2 1 6 1161 1992 183 42 93.271172 Appendix
5 1 5 2 1 7 1351 1985 20 56 93.259239 C
5 1 5 2 1 8 1404 1992 27 33 96.907654 is
5 1 5 2 1 9 1446 1992 78 33 97.000908 also
5 1 5 2 1 10 1542 1992 165 33 96.672562 intended
5 1 5 2 1 11 1722 1995 33 33 97.011696 to
5 1 5 2 1 12 1770 1995 123 42 96.973335 satisfy
5 1 5 2 1 13 1908 1995 60 33 96.514847 the
5 1 5 2 1 14 1980 1995 129 33 96.863945 written
5 1 5 2 1 15 2127 1995 78 42 96.609161 plan
4 1 5 2 2 0 609 2040 1470 45 -1
5 1 5 2 2 1 609 2040 192 36 96.502831 document
5 1 5 2 2 2 816 2043 234 39 94.916359 requirement
5 1 5 2 2 3 1065 2043 36 33 96.463188 of
5 1 5 2 2 4 1116 2043 225 42 95.493149 Department
5 1 5 2 2 5 1356 2043 36 33 96.385483 of
5 1 5 2 2 6 1404 2043 174 42 96.071663 Treasury
5 1 5 2 2 7 1593 2043 189 42 96.530388 regulation
5 1 5 2 2 8 1797 2046 144 30 93.167274 Section
5 1 5 2 2 9 1959 2046 120 33 62.735111 1.105-
2 1 6 0 0 0 609 2091 204 132 -1
3 1 6 1 0 0 609 2091 204 132 -1
4 1 6 1 1 0 612 2091 201 42 -1
5 1 6 1 1 1 612 2091 201 42 0.000000 11(b)(1)(0.
4 1 6 1 2 0 609 2190 177 33 -1
5 1 6 1 2 1 609 2190 177 33 96.536301 Duration
2 1 7 0 0 0 606 2289 1551 198 -1
3 1 7 1 0 0 606 2289 1551 198 -1
4 1 7 1 1 0 606 2289 1512 45 -1
5 1 7 1 1 1 606 2289 75 33 96.517227 The
5 1 7 1 1 2 699 2292 81 30 96.731094 Plan
5 1 7 1 1 3 798 2292 27 33 95.779984 is
5 1 7 1 1 4 840 2292 222 33 96.174561 established
5 1 7 1 1 5 1077 2292 75 33 96.586494 with
5 1 7 1 1 6 1167 2292 60 33 96.037254 the
5 1 7 1 1 7 1242 2292 162 33 96.436897 intention
5 1 7 1 1 8 1422 2292 36 33 96.125107 of
5 1 7 1 1 9 1470 2292 105 42 96.213326 being
5 1 7 1 1 10 1590 2292 213 33 96.307251 maintained
5 1 7 1 1 11 1818 2292 51 33 96.587143 for
5 1 7 1 1 12 1881 2301 48 24 96.610764 an
5 1 7 1 1 13 1944 2295 174 33 96.924599 indefinite
4 1 7 1 2 0 609 2340 1548 45 -1
5 1 7 1 2 1 609 2340 117 42 96.915558 period
5 1 7 1 2 2 744 2340 36 33 96.975792 of
5 1 7 1 2 3 792 2340 90 39 96.356567 time;
5 1 7 1 2 4 900 2343 174 36 96.405632 however,
5 1 7 1 2 5 1089 2343 63 33 96.175331 the
5 1 7 1 2 6 1164 2343 147 42 96.324730 County,
5 1 7 1 2 7 1329 2352 45 24 96.365486 as
5 1 7 1 2 8 1389 2343 141 33 96.984886 defined
5 1 7 1 2 9 1548 2343 27 33 95.882568 in
5 1 7 1 2 10 1590 2343 123 33 96.711143 Article
5 1 7 1 2 11 1728 2343 30 39 69.191628 II,
5 1 7 1 2 12 1776 2343 30 33 95.283119 in
5 1 7 1 2 13 1824 2343 39 33 95.283119 its
5 1 7 1 2 14 1881 2346 78 30 96.966415 sole
5 1 7 1 2 15 1971 2346 186 33 96.475769 discretion
4 1 7 1 3 0 609 2391 1536 45 -1
5 1 7 1 3 1 609 2391 69 33 96.272820 and
5 1 7 1 3 2 696 2391 27 33 96.272820 in
5 1 7 1 3 3 741 2391 225 33 96.256905 accordance
5 1 7 1 3 4 978 2394 78 30 96.812920 with
5 1 7 1 3 5 1071 2394 60 30 96.643951 the
5 1 7 1 3 6 1146 2394 195 39 96.643951 provisions
5 1 7 1 3 7 1356 2394 39 33 96.629440 of
5 1 7 1 3 8 1404 2394 123 33 96.519989 Article
5 1 7 1 3 9 1539 2394 39 33 69.643684 Xl
5 1 7 1 3 10 1596 2403 78 33 96.234276 may
5 1 7 1 3 11 1689 2394 132 33 96.299431 amend
5 1 7 1 3 12 1836 2403 39 24 96.977379 or
5 1 7 1 3 13 1887 2394 183 33 96.514786 terminate
5 1 7 1 3 14 2085 2397 60 33 96.152397 the
4 1 7 1 4 0 609 2442 870 45 -1
5 1 7 1 4 1 609 2442 84 33 95.228989 Plan
5 1 7 1 4 2 708 2451 39 24 95.518509 or
5 1 7 1 4 3 759 2451 69 33 95.518509 any
5 1 7 1 4 4 843 2445 174 39 95.989388 provision
5 1 7 1 4 5 1032 2442 36 33 96.920929 of
5 1 7 1 4 6 1080 2445 60 33 96.731697 the
5 1 7 1 4 7 1155 2445 84 33 96.939049 Plan
5 1 7 1 4 8 1254 2445 36 33 96.488068 at
5 1 7 1 4 9 1305 2454 69 33 96.803993 any
5 1 7 1 4 10 1386 2445 93 33 95.979675 time.
1.4
ARTICLE Il
DEFINITIONS
The following words and phrases, when capitalized, shall have the following
meanings. Words and phrases not defined in this Article shall have the meaning
set forth in an applicable Incorporated Document, and if not defined in an
applicable Incorporated Document, then such words and phrases shall have the
meaning customarily given them by the applicable insurance company, third party
administrator, or other service provider, as the case may be.
2.1 Benefits
Benefits mean the health and welfare coverages provided under the Plan and as
described in the Incorporated Documents. Certain benefits are provided to any
Employee who meets the eligibility requirements of Section 3.1, while certain other
benefits are provided only upon selection by an Employee who meets the eligibility
requirements of Section 3.1.
2.2 Benefits Trust
Benefits Trust refers to the Maricopa County, Arizona Self-Insured Benefits Trust
Fund authorized under A.R.S. § 11-981 and established by the Board of
Supervisors pursuant to the Revised and Restated Declaration of Trust for
Maricopa County, Arizona Self-Insured Benefits Trust Fund, for purposes of
collecting and maintaining contributions from Employees, the County, and
authorized Participating Employers, and funding the Plan.
2.3 Board of Supervisors
Board of Supervisors means the Board of Supervisors of Maricopa County.
2.4 Board of Trustees
Board of Trustees means the Trustees described in and appointed pursuant to the
Revised and Restated Declaration of Trust for Maricopa County, Arizona Self-
Insured Benefits Trust Fund.
2.5 Change in Status
Change in Status means:
A. A“special enrollment” event under HIPAA,
B. The Covered Employee's marriage, divorce, legal separation, or annulment,
C. The birth, adoption, placement for adoption, or change in dependency or
custody of a Covered Employee's child,
D. The death of the Employee's Spouse or Dependent child,
A change in employment status by the Covered Employee, Spouse or
Dependent child, including commencement or termination of employment, a
change in work shift, a change in worksite, a reduction or increase in hours of
employment including changing from part-time to full-time employment
status, a strike or lockout,
Commencement or return from an unpaid leave of absence by the Employee,
Spouse or Dependent child,
A change in worksite or personal residence resulting in eligibility or loss of
eligibility of coverage for the Covered Employee, Spouse or Dependent child
under any health maintenance organization offered through the Plan,
A change in legal custody/guardianship (including the issuance of a Qualified
Medical Child Support Order) that affects a child's eligibility for coverage
under this Plan or the plan of the child's other parent,
Entitlement or loss of entitlement to Medicare or Medicaid by the Employee,
Spouse or Dependent child,
Attainment by a Dependent child of limiting age for a benefit provided under
this Plan,
Loss of “qualifying individual’ status, as defined in Article II of the Dependent
Care Spending Account Plan,
Experiencing a change in employment that does not otherwise affect
eligibility for coverage under the Plan, after which the Covered Employee is
reasonably expected to average less than 30 hours of service per week, if
the Covered Employee (and any Dependents also revoking coverage)
intend(s) to enroll in another plan that provides minimum essential coverage
effective no later than the first day of the second month after the date that
Plan coverage is revoked. This rule permits the Covered Employee to revoke
group health plan Benefits only, for the Covered Employee and his or her
Dependents, and does not apply to Health Care Spending Account or Limited
Purpose Health Care Spending Account elections,
Eligibility for special enrollment in a qualified health plan (QHP) through the
public Marketplace, or seeking to enroll in a QHP offered through the public
Marketplace during the Marketplace’s annual open enrollment. This rule
permits the Covered Employee to revoke group health plan Benefits only, for
the Covered Employee and his or her Dependents, and must correspond
with the intended enrollment of the Covered Employee and his or her
Dependents in a QHP effective beginning no later than the day immediately
following the last day of the of the Plan coverage that is revoked. This rule
does not apply to Health Care Spending Account or Limited Purpose Health
Care Spending Account elections, or
Any other event the Plan Administrator determines permits revocation of an
election without violating the Code.
2.6 Claim Administrator
Claim Administrator means the person(s) or entity (or entities) authorized and
responsible for receiving and reviewing claims for benefits under the Plan;
determining what amount, if any, is due and payable; making appropriate
disbursements to persons entitled to benefits under the Plan; and reviewing and
determining denied claims and appeals.
2.7 Code
Code means Internal Revenue Code of 1986, as amended, and regulations issued
thereunder or pursuant thereto by the United States Internal Revenue Service
(IRS).
2.8 COBRA
COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985
(Public Law 99-272, Title X), as amended, and the regulations issued thereunder
or pursuant thereto.
2.9 County
County means Maricopa County, Arizona.
2.10 Covered Employee
Covered Employee means an Employee who satisfies the eligibility, participation,
and coverage requirements of Article Ill and who has made an election to
participate in the benefits described in Article IV.
2.11 Covered Person
Covered Person means a Covered Employee or Dependent who has satisfied the
eligibility and enrollment provisions of Article Ill or, if applicable, the provisions of
Article VII.
A Covered Person may have Plan coverage with respect to certain benefits, but
not all benefits, as hereinafter described in the Plan.
2.12 Dependent
Dependent means a Spouse or dependent child of an Employee who is a Covered
Person as determined under the applicable Incorporated Document.
Regardless of whether a Dependent is eligible for a Benefit under this Plan, a
Covered Employee may only make Salary Reduction Contributions for Benefits for
an Employee's dependent who is a Covered Person as follows:
A. Spouse,
B. dependent as defined in Code Section 152 (without regard to (b)(1), (b)(2),
and (d)(1)(B)), or
C. for health Benefits for the Covered Employee's child as defined in Code
Section 152(f)(1) who has not attained age 27 as of the end of the taxable
year.
“Dependent’ will be construed in accordance with applicable federal, state, and
local law, including, but not limited to, surviving spouses and dependents of law
enforcement officers killed in the line of duty or that died from injuries suffered
while in the line of duty and who are eligible pursuant to Arizona Statute.
A Dependent may be eligible for coverage with respect to certain benefits, but not
all benefits, as hereinafter described in the Plan.
2.13 Dependent Care Spending Account Plan
Dependent Care Spending Account Plan means the plan set forth in Appendix A,
which amends, restates, and supersedes the Maricopa County Dependent Care
Flexible Spending Account Flan (Fifth Amendment and Restatement) as of the
Effective Date.
2.14 Effective Date
Effective Date means the date the Plan becomes operative, as set forth in Article |.
2.15 Employee
For purposes of this Plan only, the term Employee means a common law
employee of the Employer or the Superior Court in and for Maricopa County
(whose compensation is paid by the County or through the County payroll).
Employee shall also mean an individual or group of individuals eligible for
employee benefits coverage offered by the County to its employees pursuant to
the terms of a contract with the County (including Intergovernmental Agreements
such as those described in Section 10.7).
The term Employee includes, but is not limited to, a person who is:
A. aleased employee, as defined in Code Section 414(n),
B. a nonresident alien who receives earned income (within the meaning of Code
Section 911(d)(2)) from an Employer that constitutes income from sources
within the United States, as defined in Code Section 861(a)(3), or
CG. acollectively bargained employee.
Subject to the above, the term Employee does not mean:
D. aself-employed individual, as defined in Code Section 401(c)(1)(A),
E. aperson whom the Plan Administrator determines has been engaged by the
Employer as an independent contractor, or
F. aperson whom the Plan Administrator determines has been engaged by the
Employer as a consultant or advisor on a retainer or fee basis.
A person the Plan Administrator determines is not an “Employee” as defined
above shall not be eligible to participate in the Plan regardless of whether such
determination is upheld by a court or tax or regulatory authority having jurisdiction
over such matters. However, a person the County determines is not an
“Employee” as defined above and who later is required to be reclassified as an
Employee shall be eligible to participate in the Plan benefits under the Plan
prospectively only, provided that the Employee is otherwise eligible pursuant to
Section 3.1.
2.16 Employer
Employer means the County and its elected officials and any subsidiary or
affiliated organization and any successor(s) of any of them which, with the
approval of the County, and subject to such conditions as the County may impose,
adopts the Plan, including any Participating Employer.
For purposes of satisfying the nondiscrimination requirements of Code
Section 125(b), Sections 105(h) and 129(d), the term “Employer” shall include any
other corporation or other business entity which must be aggregated with the
Employer under Sections 414(b), (c), (m) or (0) of the Code, but only for such
period of time when the Employer or such other corporation or other business
entity must be aggregated as aforesaid.
2.17 ERISA
ERISA means the Employee Retirement Income Security Act of 1974, as
amended, and the regulations issued thereunder or pursuant thereto. As stated in
Section 1.3, the Plan is not subject to ERISA. Any references to ERISA are for
administrative ease and do not subject the Plan in any way to ERISA's jurisdiction.
2.18 FMLA
FMLA means the Family and Medical Leave Act of 1993, as amended, and the
regulations issued thereunder or pursuant thereto.
2.19 Health Care Spending Account Plan
Health Care Spending Account Plan means the plan set forth in Appendix B, which
amends, restates, and supersedes the Maricopa County Flexible Spending
Account Plan (Fifth Amendment and Restatement) as of the Effective Date.
2.20 Health Savings Account
Health Savings Account means an individual savings account described in
Appendix G.
2.21 HIPAA
HIPAA means the Health Insurance Portability and Accountability Act of 1996, as
amended, and the regulations issued thereunder or pursuant thereto.
2.22 Incorporated Document
Incorporated Document means any insurance policy, administrative services
agreement, plan, trust, certificate of coverage, evidence of coverage, summary
plan description or other document incorporated by reference, together with any
exhibits, supplements, addendums or amendments thereto. The Incorporated
Documents are listed in Appendix D, which may be updated from time to time by
the County and/or Plan Administrator.
2.23 Limited Purpose Health Care Spending Account Plan
Limited Purpose Health Care Spending Account Plan means the plan set forth in
Appendix C, which amends, restates, and supersedes the Maricopa County
Limited Scope Flexible Spending Account Plan (Second Amendment and
Restatement) as of the Effective Date.
2.24 Outbreak Period
Outbreak Period means the period from March 1, 2020, through 60 days after the
announced end of the COVID-19 “National Emergency” (or such other time as the
applicable agencies may announce in the future) as described in relevant federal
quidance issued in response to the COVID-19 National Emergency.
2.25 Participating Employer
Participating Employer means an Employer who has adopted the Plan pursuant to
Section 10.7 and as listed in Appendix F.
2.26 Plan
Plan means The Maricopa County Benefits Plan as herein set forth and as
amended from time to time.
2.27 Plan Administrator
The County is the Plan Administrator. An employee(s) who serves in the position
of Benefits Manager and is authorized to perform day-to-day management and
administration of this Plan, including oversight of the administration of the direct
payment of benefits, losses, and claims pursuant to this Plan and in accordance
with the Benefits Trust. Certain administrative functions may be delegated to third-
party administrators under contract with the County.
2.28 Plan Sponsor
Plan Sponsor means the County.
2.29 Plan Year
Plan Year means the 12-month period beginning July 1 and ending June 30.
2.30 Salary Deduction
Salary Deduction means the authorization to the Employer by the Employee to
reduce such Employee’s compensation by an amount on an after-tax basis for
selected Plan benefits.
2.01 Salary Deduction Contributions
Salary Deduction Contributions means the contributions taken from the Covered
Employee's compensation on an after-tax basis, pursuant to a Salary Deduction.
2.32 Salary Reduction
salary Reduction means the authorization to the Employer by the Employee to
reduce such Employee's compensation by an amount on a before-tax basis for
selected Plan benefits.
Z.da Salary Reduction Contributions
Salary Reduction Contributions means the contributions taken from the Covered
Employee's compensation on a before-tax basis, pursuant to a Salary Reduction.
2.34 Spouse
Spouse means, for purposes of this Plan only, a person recognized as married to
the Covered Employee by a state, possession, or territory of the United States in
which the marriage is entered into, regardless of domicile, provided such person is
not legally separated fram the Employee. Where the marriage was entered into in
a foreign jurisdiction, a person is recognized as married to the Covered Employee
if the relationship is recognized as marriage under the laws of at least one state,
possession or territory of the United States, regardless of domicile.
ARTICLE Ill
ELIGIBILITY, PARTICIPATION AND COVERAGE
3.1 Eligibility
An Employee who is classified by the Employer as regularly scheduled to work at
least 20 hours per week shall become eligible for Plan participation in the benefits
identified in Article IV on the later of the Effective Date or the first of the month next
following his or her date of hire.
The following Employees are not eligible to participate in the Plan:
A. Employees regularly scheduled to work fewer than 20 hours per week;
B. Employees who are hired on a femporary basis, with the classification
temporary meaning any Employee hired to fill a job vacancy for a limited
time, as designated by the Plan Administrator;
C. Employees who are hired on a seasonal basis, with the classification
seasonal meaning hired to fill a job vacancy relating to or occurring during a
particular season, as designated by the Plan Administrator:
D. Leased employees, as defined in Code Section 414(n);
E. Employees in an employee unit covered by a collective bargaining
agreement between Employee representatives and one or more Employers if
this Plan’s benefits were the subject of good faith bargaining between the
Employee representatives and the Employer, unless such agreement
provides for coverage for such bargaining employees in the Plan;
F. Nonresident aliens who receive no earned income (within the meaning of the
Code Section 911(d)(2)) from an Employer that constitutes income from
sources within the United States, as defined in Code Section 861(a)(3); and
G. Employees employed pursuant to a contract that does not permit
participation in the Plan.
Specific eligibility requirements for certain benefits shall be set forth in Article IV or
in the applicable Incorporated Documents.
3.2 Participation
Employees become Covered Employees with respect to non-elective Benefits
(Section 4.5) on the date they satisfy the eligibility requirements of Section 3.1.
Employees become Covered Employees with respect to elective Benefits on the
date they also satisfy the enrollment and election requirements of Section 5.4.
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3.3 Coverage
A. Date Coverage Begins
The provisions and requirements describing when and how Employees and
Dependents become Covered Persons, the conditions and limitations to coverage,
and the circumstances wherein coverage terminates shall be set forth as
applicable in the Incorporated Documents by reference under Section 4.1. In
addition, coverage is governed by the rules stated below and in Section 5.8.
B. Coverage During Leave of Absence
1. Paid Leave
During a paid leave of absence, a Covered Employee continues to
participate in all benefits—except that participation in the Dependent Care
spending Account Plan is suspended on the last day of the pay period in
which the Covered Employee's paid leave began.
2. Unpaid Leave
For Plan benefits not requiring Employee contributions, a Covered
Employee remains covered for such benefits during an unpaid leave of
absence for four (4) pay periods, unless otherwise required by the FMLA.
Except as otherwise provided below, for Plan benefits requiring an
Employee contribution, coverage for a Covered Employee on an approved
unpaid leave of absence is suspended on the last date of coverage for
which a premium payment benefit has been paid. The terms of the plan to
which the Covered Person's selected premium payment benefits were paid
control whether and to what extent coverage and benefits under that plan
continue. Coverage is otherwise suspended after four (4) pay periods of
unpaid leave.
To the extent the Covered Employee may continue coverage during an
unpaid leave, and except as required below, the Covered Employee is
required to pay for coverage on an after-tax basis.
lf the unpaid leave of absence is taken pursuant to FMLA, Covered
Employees continue participation in all premium payment benefits
described in Sections 4.4 except 4.4(D), (E), (F), and (K) by either
(i) paying premium payment benefits during the FMLA leave on an after-tax
basis, or to the extent possible on a before-tax basis, or (ii) paying on a
before-tax basis upon return from the leave the premium payment benefits
for coverage during the leave, and adjusting the Salary Reduction
Contribution accordingly for the balance of the Plan Year. Benefits
described in Section 4.4(D), (E), (F), and (K) are suspended.
With respect to premium payment benefits described in Section 4.4(D), (E),
and (F), no expenses incurred during the leave shall be reimbursed. Upon
return from leave, the Employee can either: i) elect to be reinstated in the
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