4.3 FY 2020-21 HCFSA PLAN EXHIBIT C.PDF

exh1,11
C-31- (7-610 --1•11-00
THE
MARICOPA COUNTY HEALTH CARE FLEXIBLE SPENDING ACCOUNT PLAN
(FIFTH AMENDMENT AND RESTATEMENT)
ARTICLE I
ESTABLISHMENT OF PLAN
1.1 Purpose. The purpose of this Plan is to allow Employees who become
Participants in this Plan to obtain reimbursement for certain Covered Health Expenses on a tax
free basis, as provided under section 105(b) of the Code. This Plan is intended to qualify as a
"self-insured medical expense reimbursement plan" maintained under section 105 of the Code
and regulations issued thereunder, and as a Benefit Plan as that term is defined in the Maricopa
County Benefits Plan, and this Plan shall be interpreted and construed in accordance with that
intention. In no event shall this Plan be administered or construed to constitute a plan of deferred
compensation and in no event shall this Plan be administered in a manner that is inconsistent
with the Maricopa County Benefits Plan.
1.2 Effect Upon Other Plans. Nothing in this Plan shall be construed to affect the
provisions of the Maricopa County Benefits Plan or any other Health Plan maintained by the
County which is intended to comply with the requirements of any other provision of the Code.
1.3 Effect of Amendment and Restatement. This Maricopa County Health Care
Flexible Spending Account Plan (Fifth Amendment and Restatement) is amended effective July
1, 2017 to incorporate all prior amendments and to make additional amendments required to
comply with federal and state laws and/or amendments. The purpose of this amendment and
restatement is to make such amendments as determined by the County to be in the best interests
of the Plan and its Participants.

ARTICLE II
DEFINITIONS
2.1 Application of Definitions. Unless otherwise required by context, the capitalized
terms used in this Plan shall have the meanings set forth this Article. If not defined in this
Article, then capitalized terms shall have the meanings set forth in the Maricopa County Benefits
Plan. The masculine gender, when used herein, shall include the feminine and, unless context
indicates otherwise, the singular shall include the plural and the plural the singular, where
context requires.
2.2 Covered Health Expense. Any expense incurred by a Participant or his
Dependents for Health Care, as defined in section 2.5.
2.3 Dependent. Any individual who is a dependent of a Participant as defined in the
Maricopa County Benefits Plan. Any child to whom section 152(e) of the Code applies may be
treated as a Dependent of either parent for purposes of this Plan.
2.4 Health Care. Amounts paid for:
(a) The diagnosis, cure, mitigation, treatment, or prevention of disease, or any
treatment or action taken for the purpose of affecting any structure or function of the body; and
(b) Transportation for and essential to Health Care as defined in paragraph (a)
above; and
(c) Amounts paid for lodging (not lavish or extravagant under the
circumstances) while away from home primarily for and essential to Health Care referred to in
paragraph (a) above shall be treated as amounts paid for Health Care if: (i) the Health Care
referred to in paragraph (a) above is provided by a Physician in a licensed hospital (or a medical
care facility which is related to, or the equivalent of a licensed hospital); and (ii) there is no
significant element of personal pleasure, recreation, or vacation in the travel away from home.
The amount taken into account under this paragraph (c) shall not exceed $50 for each night for
each individual; and
(d) Except as provided in paragraph (e) below, the definition of "Health Care"
shall be limited to all items of "medical care" described in section 213(d)(1) of the Code, and any
regulations issued thereunder, including, without limitation, hospital services, nursing services,
medical, dental and any other diagnostic or health related service, including x-rays, medicine,
drugs, artificial teeth or limbs, and vision and hearing care; provided that, effective January 1,
2011, "Health Care" shall include amounts paid for medicine or drugs only if the medicine or
drug is a prescribed drug (determined without regard to whether such drug is available without a
prescription) or is insulin.
(e) The term "Health Care" shall not include:
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(i) cosmetic surgery or other similar procedures, unless the surgery or
procedure is necessary to ameliorate a deformity arising from, or directly related to, a congenital
abnormality, a personal injury resulting from an accident or trauma or disfiguring disease. For
purposes of this paragraph (e), the term "cosmetic surgery" shall mean any procedure which is
directed at improving the patient's appearance and does not meaningfully promote the proper
function of the body or prevent or treat illness or disease; and
(ii) coverage for qualified long-term care services as defined in section
7702B(c) of the Code.
2.5 LCFSA Plan. The Maricopa County Limited Scope Flexible Spending Account
Plan (as amended).
2.6 Participant. An Employee who is eligible to participate in the Maricopa County
Benefits Plan and who has executed a Benefits Purchase Order as provided in section 3.2 of this
Plan.
2.7 Plan or HCFSA Plan. This Maricopa County Health Care Flexible Spending
Account Plan (Fifth Amendment and Restatement).
2.8 Maricopa County Benefits Plan. The Maricopa County Benefits Plan (as
amended).
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ARTICLE III
ELIGIBILITY AND PARTICIPATION
3.1 Eligibility. All Employees who are eligible to participate in the Maricopa County
Benefits Plan are eligible to participate in this Plan except those Employees who have elected to
participate in a high deductible health plan (HDHP) sponsored by the County and who have also
elected to participate in a health savings account (HSA) for all or any portion of the Plan Year
(HDHP/HSA Participants). HDHP/HSA Participants are only eligible to participate in the
LSFSA Plan for reimbursement of benefits which constitute Limited Scope Covered Health
Expenses incurred by the Participant or his Dependents during the Plan Year.
3.2 Benefits Purchase Order.
(a) An Employee eligible to participate in this Plan may participate hereunder
by executing a Benefits Purchase Order authorizing the County to reduce his Compensation by
the dollar amount specified in such Benefits Purchase Order. The amount of Compensation to be
reduced must be specified as a whole dollar amount of Compensation. The amount of the
Participant's Compensation specified in the Benefits Purchase Order shall be credited to the
Participant's Benefits Funding Account. The Participant's Benefits Purchase Order shall be
governed by Article IV of the Maricopa County Benefits Plan.
(b) The minimum and maximum Compensation a Participant may elect to
contribute to his Benefits Funding Account during any Plan Year shall not exceed the amount set
by the Board for the Plan Year or the permissible amounts under the Code. In no event shall a
Participant's total reduction of Compensation under a Benefits Purchase Order for any Plan Year
exceed the Participant's Compensation for that Plan Year.
3.3 Benefits Unfunded. The credit balance of any Participant's Benefits Funding
Account at any time shall evidence only an unfunded obligation of the County in accordance
with the terms of this Plan. The interest of any Participant, Dependent or COBRA Beneficiary
under a Benefit Plan or in any benefits provided through such Benefit Plans shall be only that of
a general, unsecured creditor of the County, and no greater. No Participant, Spouse, Dependent
or Beneficiary of a Participant (or any other person claiming through any such person) shall have
any right or claim to any specific property of the County to satisfy any claim for benefits
hereunder. Notwithstanding the foregoing, the County may, in the County's sole discretion,
elect to transfer all or any portion of a Participant's Benefits Funding Account to the Benefits
Trust or other trust fund the County has created pursuant to Arizona Revised Statutes § 11-981.
Any amounts transferred to such trust shall be held under the provisions of the trust, but shall be
subject to the payment of benefits under this Plan and the Benefit Plans maintained hereunder.
Any amounts transferred to such trust shall not be considered "funded" for purposes of the Code,
this Plan or any Benefit Plan since the County can terminate such trust at any time and revert all
funds held thereunder to the County, subject only to the payment of benefits by the County as
required under this Plan and the Benefit Plans.
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3.4 Effect of Termination of Employment.
(a) A Participant may elect to revoke his Benefits Purchase Order and cease to
participate in this Plan effective as of the termination of his employment.
(b) If a Participant's employment is terminated, the Participant may continue
to make contributions to his Benefits Funding Account. Contributions must be paid directly by
the Participant to the COBRA Administrator on such terms as set forth by the Administrator not
to exceed the Participant's Plan Year elections.
(c) If a Participant fails to make any required contribution to the HCFSA Plan
following his termination of employment, the Participant shall cease to be eligible to participate
in the HCFSA Plan effective as of the date such failure to contribute occurs and the Participant
will not be entitled to submit for reimbursement any claims for Covered Health Expenses under
,Article IV which were incurred after the effective date that the Participant's participation in this
Plan terminated.
(d) If a Participant resumes employment within 30 days following his
Severance Date and without any other intervening event(s) that would permit a change in the
Participant's Benefits Purchase Order, such Participant shall return to the elections in effect prior
to his Severance Date and benefits coverage shall be retroactive to the Severance Date. If more
than 30 days have elapsed, Participant shall make new benefits elections and a new Benefits
Purchase Order in accordance with the Maricopa County Benefits Plan.
(e) Anything in this Plan to the contrary notwithstanding, the continuation of
coverage rules described in section 10003 of the Consolidated Omnibus Budget Reconciliation
Act of 1985 ("COBRA") which were added to the Public Health Service Act, as amended (the
"Act"), shall apply, and a Participant who terminates employment for any reason shall be eligible
to continue to participate in this HCFSA Plan (and the Maricopa County Benefits Plan) only to
the extent and for the minimum period (including no period) provided in the Act as interpreted
by the Internal Revenue Service under corresponding provisions of the Code and the Treasury
Regulations issued thereunder.
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ARTICLE IV
PAYMENT OF PLAN BENEFITS
4.1 Submission of Claims.
(a) Each Participant shall file with the Plan Administrator, at such time as the
Plan Administrator may prescribe by rule or regulation, but not later than November 30 th
following the close of a Plan Year, a claim statement on a form provided by the Plan
Administrator, setting forth all Covered Health Expenses incurred by the Participant for such
Plan Year, as of the date of such filing and for which the Participant seeks reimbursement under
this Plan. As part of any such claim statement, each Participant shall submit a written statement
from an independent third party stating that the expense for Health Care has been incurred and
the amount of such expense and a written statement signed by the Participant to the effect that
the expense for which reimbursement is sought has not been reimbursed or is not reimbursable
under any other plan. Benefits under this Plan shall be paid if the Covered Health Expenses were
incurred while the Employee was a Participant in this Plan and to the extent they were incurred
during the Plan Year to which they relate. In addition, any claim for Health Care Expenses that
are incurred on or before September 15 th following the close of a Plan Year may be submitted for
payment from the Participant's Benefits Funding Account for the preceding Plan Year and, if
that account balance is exhausted, may be submitted for payment for the current Plan Year. For
purposes of this Plan, an expense is treated as having been incurred by the Participant when the
Participant is provided with the service or product that gives rise to the expense and not when the
Participant is finally billed, charged for, or pays the expense.
(b) The Plan Administrator shall determine which expenses qualify as
Covered Health Expenses for purposes of reimbursement. Upon making a determination that all
or part of the benefit claimed is for Covered Health Expenses, the Plan Administrator shall
authorize reimbursement to the Participant in an amount equal to the amount determined by the
Plan Administrator to constitute Covered Health Expenses.
(c) Section 4.1(a) notwithstanding, if a Participant terminates employment
and has not elected COBRA, such Participant must submit a claim for reimbursement of Covered
Health Expenses no later than 60 calendar days following the Participant's Benefits Termination
Date. Only Covered Health Expenses incurred on or prior to the Participant's Benefits
Termination Date are reimbursable.
(d) COBRA Beneficiaries participating in this HCFSA Plan continue to be
eligible to submit claims for reimbursement in accordance with paragraph (a) provided they
continue to make the required contributions to the HCFSA Plan as set forth in Section 3.4.
4.2 Reimbursement of Expenses.
(a) Section 4.1 notwithstanding, the benefits payable to a Participant under
this Plan shall not exceed the amount of Compensation a Participant has elected to contribute to
his Benefits Funding Account for such Plan Year.
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(b) If for any reason, including, without limitation, mathematical or
administrative error, the aggregate charges made to a Participant's Benefits Funding Account
under this Plan at any time during a Plan Year, exceed the total amount to be contributed to the
Benefits Funding Account during the Plan Year, such negative balance shall constitute an
indebtedness of the Participant to the Benefits Trust. Such indebtedness shall be payable to the
Trust by the Participant, upon demand, and each Employee, by becoming a Participant in this
Plan, authorizes the County to withhold amounts from such Participant's current Compensation
and reimburse such amounts to the Trust. If due to an administrative or mathematical error or
otherwise, the amount of Compensation deposited to the Participant's Benefits Funding Account
is greater than the amount authorized by the Participant's Benefits Purchase Order, the County
shall reimburse to the Participant the amount of Compensation erroneously deducted subject to
applicable taxes and withholdings.
(c) Forfeiture of Unused Accounts. Following each Plan Year after the time for
submitting claims for the Plan Year has expired as provided under the terms of this Plan, the Plan
Administrator shall aggregate the total amount of credits standing in the Participants' Benefits
Funding Accounts and, after all proper adjustments have been made in such Plan Year as
provided in this Plan and the Maricopa County Benefits Plan, all such amounts shall be forfeited
by the Participants and they shall have no grounds claiming thereto. The forfeited amounts shall
become the property of the Benefits Trust, so long as it exists, and the County may use such
amounts for any purpose authorized by the Trust; otherwise such amounts shall revert to the
County.
(d) If a Participant who is enrolled in this HCFSA Plan chooses to become an
HDHP/HSA Participant during the Plan Year, such Participant shall terminate participation in
this Plan and shall only be eligible for reimbursement of Covered Health Expenses incurred prior
to enrollment in the HDHP/HSA plan. If a Participant in this HCFSA Plan chooses during Open
Enrollment to change to an HDHP/HSA plan for the succeeding Plan Year, such Participant shall
only be eligible to seek reimbursement of Covered Health Expenses incurred through June 30 of
that Plan Year and not for Covered Health Expenses incurred from July 1 to September 15 th
unless such expenses would be eligible for reimbursement under the LSFSA Plan.
4.3 Covered Health Expenses; Coordination of Benefits. Payments under this Plan
shall be made to Participants only to the extent that (i) payments are for Covered Health
Expenses and (ii) such Covered Health Expenses are not subject to reimbursement under any
similar plan or program maintained by any other employer of a Participant or Dependent, or
under any federal, state or other governmental program or under any policy of insurance under
which a Participant or Dependent is an insured. If, in accordance with the terms of the Maricopa
County Benefits Plan, the Participant adds a new Dependent to be covered hereunder during a
Plan Year on account of a Change in Status which relates to birth, adoption or placement for
adoption, payments for Covered Health Expenses shall be effective as of the date of such birth,
adoption or placement for adoption.
4.4 Time for Payment. The benefits which are payable hereunder shall be paid as
soon as is reasonably practicable after the Plan Administrator has obtained all information from
the Participant necessary to establish that the charges for which payment or reimbursement is
sought are Covered Health Expenses.

4.5 Reimbursements in the Event of Incompetency of a Participant. If a Participant
entitled to receive any benefits hereunder is adjudged by a court of competent jurisdiction to be
legally incapable of giving valid receipt and discharge for benefits provided under this Plan, such
benefits may be paid to the duly appointed guardian or conservator of such Participant or may be
held by the Trust for the benefit of such Participant until distribution can be made to a duly
appointed guardian or conservator or is ordered to be made by a court of competent jurisdiction.
Such payment shall, to the extent made, discharge the Benefits Trust and the County of any
liability for such payment under the Plan.
4.6 Qualified Reservist Distribution. Notwithstanding any other provision of the Plan
to the contrary, a Participant may elect to receive a distribution of certain funds from his or her
Benefits Funding Account for a Plan Year (a "Qualified Reservist Distribution") in accordance
with the terms of this Section.
(a) A Participant who meets each of the following requirements may
elect to receive a Qualified Reservist Distribution of certain funds from his or her Benefits
Funding Account for a Plan Year:
(i) The Participant's contributions to his or her Health Care
Account for the Plan Year as of the date of the request for a Qualified Reservist Distribution
exceed the reimbursements he or she has received from his or her Health Care Account for the
Plan Year as of that date;
(ii) The Participant is ordered or called to active military duty
for a period of at least 180 days or for an indefinite period by reason of being a member of the
Army National Guard of the United States, the Army Reserve, the Navy Reserve, the Marine
Corps Reserve, the Air National Guard of the United States, the Air Force Reserve, the Coast
Guard Reserve, or the Reserve Corps of the Public Health Service;
(iii) The Participant has provided the Plan Administrator with a
copy of the order or call to active duty. An order or call to active duty of less than 180 days
duration must be supplemented by subsequent calls or orders to reach a total of 180 or more
days;
(iv) The Participant is ordered or called to active military duty
on or after July 1, 2008; and
(v) During the period beginning on the date of the order or call
to active duty and ending on September 15 th following the close of the Plan Year during which
the order or call occurred, the Participant delivers a written election to the Plan Administrator in
such form as the Plan Administrator may prescribe, requesting a Qualified Reservist
Distribution.
(b) The Plan Administrator will review all requests for Qualified
Reservist Distributions on a uniform and consistent basis. Requests for Qualified Reservist
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Distributions that are approved by the Plan Administrator shall be paid within a reasonable time,
not to exceed 60 days after the date of the Participant's request.
(c) The amount of any Qualified Reservist Distribution made under
this provision shall be equal to the Participant's contributions to his or her Benefits Funding
Account for the Plan Year as of the date of the request for a Qualified Reservist Distribution,
minus the reimbursements he or she has received from his or her Benefits Funding Account for
the Plan Year as of that date. Notwithstanding any other provision of the Plan to the contrary,
this portion of the Participant's balance may be distributed without regard to whether Covered
Health Expenses have been incurred. Any portion of the distribution that is not a reimbursement
for Covered Health Expenses will be included in the Participant's gross income as wages for the
calendar year of distribution and will be subject to employment taxes and federal and state
income tax withholding.
(d) A Participant who has requested a Qualified Reservist Distribution
shall forfeit the right to receive reimbursements for Covered Health Expenses incurred during the
Plan Year and on or after the date of the distribution request. However, a Participant may claim
reimbursement for Covered Health Expenses incurred during the Plan Year and before the date
of the distribution request, even if such claims are submitted after the date of his or her
distribution, so long as the total dollar amount of such claims does not exceed the amount of
Compensation the Participant has elected to contribute to his or her Health Care Account for the
Plan Year, less the sum of his or her Qualified Reservist Distribution under this provision and the
reimbursements he or she have received from his or her Health Care Account for the Plan Year.
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ARTICLE V
ADMINISTRATION OF THE PLAN
5.1 Administration. The Plan shall be administered by the County, the Board of
Trustees and the Plan Administrator as provided in the Benefits Trust.
5.2 Suspension, Termination and Amendment. The County shall have:
(a) The sole power to suspend or partially terminate or completely discontinue
the benefits provided under the terms of the Plan; and
(b) The power to amend the Plan as specified in Section 6.1.
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ARTICLE VI
GENERAL PROVISIONS
6.1 Amendments. The County reserves the right to, from time to time, make any
amendments to this Plan it determines to be necessary or desirable, with or without retroactive
effect, to maintain the qualifications of the Plan under sections 105 and 125 of the Code; and any
regulations thereunder, or to ensure the successful administration and operation of the Plan. The
County shall make all amendments in writing. Each amendment shall state the date to which it is
either retroactively or prospectively effective.
6.2 Right to Terminate. The County reserves the right to terminate or partially
terminate the Plan in its discretion in accordance with applicable laws.
6.3 No Guarantee of Employment. Neither the Plan nor any provisions contained in
the Plan shall be construed to be a contract between the County and an Employee, or to be a
consideration for, or an inducement of, the employment of any Employee. Nothing contained in
the Plan shall grant any Employee the right to continued employment or shall limit in any way
the right of the COurity to discharge or to terminate the service of any Employee at any time.
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6.4\ Right t6 BefiefitL No Participant, or person claiming through such Participant,
shall have any right to, or interest in, any benefits provided under this Plan upon termination of
his employment or otherwise, except as provided under this Plan and the Maricopa County
Benefits Plan.
6.5 Nonalienation of Benefits. The County has created this Plan to provide certain
"cafeteria" benefits to eligible Employees and their Dependents, in accordance with the terms of
the Maricopa County Benefits Plan and this Plan. Except as provided in section 4.2(b), no
interest in or benefit payable under the Plannshall be subject in any manner to anticipation,
alienation, sale, transfer, assignment, pledge, encumbrance or charge, except as the Plan
Administrator may otherwise permit by rule or regulation; and any action by a Participant to
anticipate, alienate, sell, transfer, assign, pledge, encumber or charge the same shall be void and
of no effect, nor shall any interest in or benefit payable under the Plan be in any way subject to
any legal or equitable process, including, but not limited to, garnishment, attachment, levy or
seizure or to the lien of any, person. -This provision shall be , construed to provide each
Participant, or other person claiming any interest or benefit in this Plan through a Participant
with the maximum protection against alienation, encumbrance and any legal and equitable
process, including, but not limited to, attachment, garnishment, levy, seizure or other lien,
afforded his interest in the Plan (and the benefits provided thereunder) by law and any applicable
regulations.
6.6 Unknown Whereabouts. It shall be the affirmative duty of each Participant to
inform the Plan Administrator, and to keep on file with the Plan Administrator, his current
mailing address. If a Participant fails to inform the Plan Administrator of his current mailing
address, neither the Plan Administrator, the Board of Trustees or the County shall be responsible
for any late payment of or loss of benefits.
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6.7 Construction. The Plan shall be construed, enforced and administered according
to the laws of the State of Arizona and the terms of the Maricopa County Benefits Plan. In case
any provision of the Plan is held to be illegal or invalid for any reason, it shall not affect the
remaining provisions of the Plan, but the Plan shall be construed and enforced as if such illegal
or invalid provision had not been included therein.
IN WITNESS WHEREOF, the County has caused this Plan to be signed by its duly
authorized representative.
DATED this day of t-A‘viC)A ,2017.
MARICOPA COUNTY, ARIZONA
By MAR 0 1 2017
Chairman, Board of Sup 1SOTS
ATTEST:
MAR 0 1 2017
APPROVED AS TO FORM:
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