4.4 FY 2020-21 LSFSA EXHIBIT D.PDF

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THE
MARICOPA COUNTY LIMITED SCOPE FLEXIBLE SPENDING ACCOUNT PLAN
(SECOND 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 Limited Scope 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. This Plan is available only to those employees who have a Health
Savings Account (HSA) and are therefore ineligible to participate in the Maricopa County Health
Care Flexible Spending Account Plan (HCFSA , 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 Limited Scope
Flexible Spending Account Plan (Second 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 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.
2.3 HCFSA Plan. The Maricopa County Health Care Flexible Spending Account
Plan (as amended). .
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 hot 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 (c), 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 Limited Scope Covered Health Expense. Expense incurred by the Participant or
his Dependents only for dental or vision care, which otherwise meets the definition of Health
Care in section 2.4.
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 3.1 of this
Plan.
2.7 Plan or LSFSA Plan. This Maricopa County Limited Scope Flexible Spending
Account Plan (Second 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. Only 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 (NSA) for all or any portion of the Plan Year are eligible to participate in this
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 in accordance with this Plan 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.
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 in accordance with this Plan.
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 LSFSA Plan
following his termination of employment, the Participant shall cease to be eligible to participate
in the LSFSA 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 Limited Scope 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 LSFSA 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.

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 th
Plan Administrator may prescribe by rule or regulation, but not later than November 30
following the close of a Plan Year, a claim statement on a form provided by the Plan
Administrator, setting forth all Limited Scope 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 eligible
Limited Scope Health Care reimbursement 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 Limited Scope 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 Limited Scope 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 Limited
Scope Covered Health Expenses for purposes of reimbursement. Upon making a determination
that all or part of the benefit claimed is for Limited Scope 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 Limited Scope 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 Limited
Scope Covered Health Expenses no later than 60 calendar days following the Participant's
Benefits Termination Date. Only Limited Scope Covered Health Expenses incurred on or prior
to the Participant's Benefits Termination Date are reimbursable.
(d) COBRA Beneficiaries participating in this LSFSA 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 LSFSA Plan as set forth in Section 3.3.
4.2 Reimbursement of Expenses.
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(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 this purpose for such Plan Year.
(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 in this Plan was previously enrolled in the HCFSA Plan
during the preceding Plan Year, such Participant shall only be eligible to seek reimbursement of
Limited Scope Covered Health Expenses incurred from July 1 to September 15 th and not
reimbursement of other Covered Health Expenses (as defined in the HCFSA Plan) incurred
during that time.
4.3 Limited Scope Covered Health Expenses; Coordination of Benefits. Payments
under this Plan shall be made to Participants only to the extent that (i) payments are for Limited
Scope Covered Health Expenses and (ii) such Limited Scope 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 Limited Scope 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
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the Participant necessary to establish that the charges for which payment or reimbursement is
sought are Limited Scope 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 Benefits
Funding 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 Benefits Funding
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
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 Limited
Scope Covered Health Expenses have been incurred. Any portion of the distribution that is not a
reimbursement for Limited Scope 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 Limited Scope 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 Limited Scope 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 Benefits Funding 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 Benefits Funding 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.

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 &Instrued be a contract between the County and an Employee, or to be a
, ,c9nsiderationlioRoVm indAespent of, the employment of any Employee. Nothing contained in
the Plan shal grant anyWmPlOethe right to continued employment or shall limit in any way
the right of the County to discharge or to terminate the service of any Employee at any time.
6.4 Right to Benefits. 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, The7gonnty has created this Plan to provide certain
"cafeteria" behefits 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 Plan shall 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 an 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 fairs 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 14( day of 11\-4irr-Ifl , 2017.
MARICOPA COUNTY, ARIZONA
By
Chairman, Board of Suptrvisors
ATTEST:
MAR 01 10i7
DEPUTi Clerk of the Board o nem
APPROVED AS TO FORM:
Deputy County Attorney
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