MARICOPA COUNTY - CONSOLIDATED PLAN (THIRTEENTH AMENDMENT)_EXHIBIT B.PDF
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Maricopa County
The Maricopa County Benefits Plan
(Thirteenth 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.
PREAMBLE AND EXECUTION
WHEREAS, Maricopa County (“the County”) maintains The Maricopa County Benefits Plan
(Twelfth 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 (Thirteenth 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 (Thirteenth Amendment and
Restatement) (the “Maricopa County Benefits Plan” or the "Plan") is hereby approved and
adopted effective July 1, 2022.
IN WITNESS WHEREOF, the County has caused the Plan to be executed by its duly authorized
representative this ______ day of __________________, 2021.
MARICOPA COUNTY
Chairman, Board of Supervisors Date
ATTEST:
Clerk of the Board Date
APPROVED AS TO FORM:
Deputy County Attorney Date
8th
December
i
TABLE OF CONTENTS
ARTICLE I PLAN ESTABLISHMENT ............................................................................................ 1
1.1
Effective Date .................................................................................................... 1
1.2
Purpose and History .......................................................................................... 1
1.3
Qualification ...................................................................................................... 1
1.4
Duration ............................................................................................................ 2
ARTICLE II DEFINITIONS ............................................................................................................ 3
2.1
Benefits ............................................................................................................. 3
2.2
Benefits Trust .................................................................................................... 3
2.3
Board of Supervisors ......................................................................................... 3
2.4
Board of Trustees .............................................................................................. 3
2.5
Change in Status ............................................................................................... 3
2.6
Claim Administrator ........................................................................................... 5
2.7
Code ................................................................................................................. 5
2.8
COBRA ............................................................................................................. 5
2.9
County ............................................................................................................... 5
2.10
Covered Employee ............................................................................................ 5
2.11
Covered Person ................................................................................................ 5
2.12
Dependent ........................................................................................................ 5
2.13
Dependent Care Spending Account Plan .......................................................... 7
2.14
Effective Date .................................................................................................... 7
2.15
Employee .......................................................................................................... 7
2.16
Employer ........................................................................................................... 8
2.17
ERISA ............................................................................................................... 8
2.18
FMLA ................................................................................................................ 8
2.19
Health Care Spending Account Plan ................................................................. 8
2.20
Health Savings Account .................................................................................... 8
2.21
HIPAA ............................................................................................................... 8
2.22
Incorporated Document ..................................................................................... 9
2.23
Limited Purpose Health Care Spending Account Plan ....................................... 9
2.24
Outbreak Period ................................................................................................ 9
2.25
Participating Employer ...................................................................................... 9
2.26
Plan ................................................................................................................... 9
2.27
Plan Administrator ............................................................................................. 9
2.28
Plan Sponsor ..................................................................................................... 9
2.29
Plan Year .......................................................................................................... 9
2.30
Salary Deduction ............................................................................................. 10
2.31
Salary Deduction Contributions ....................................................................... 10
2.32
Salary Reduction ............................................................................................. 10
2.33
Salary Reduction Contributions ....................................................................... 10
2.34
Spouse ............................................................................................................ 10
ARTICLE III ELIGIBILITY, PARTICIPATION AND COVERAGE ................................................. 11
3.1
Eligibility .......................................................................................................... 11
3.2
Participation .................................................................................................... 11
3.3
Coverage ........................................................................................................ 12
3.4
Coverage under the Family and Medical Leave Act and Section 609 of
ERISA ............................................................................................................. 14
ii
3.5
Uniformed Services Employment and Reemployment Rights Act .................... 14
3.6
Health Insurance Portability and Accountability Act of 1996 ............................ 15
3.7
Coordination with State Medicaid Program ...................................................... 15
3.8
Mental Health Parity and Addiction Equity Act ................................................. 15
3.9
Women’s Health and Cancer Rights Act .......................................................... 16
3.10
Newborns’ and Mothers’ Health Protection Act ................................................ 16
3.11
Genetic Information Nondiscrimination Act of 2008 ......................................... 16
3.12
Children’s Health Insurance Program Reauthorization Act of 2009 ................. 16
3.13
Patient Protection and Affordable Care Act and Health Care and Education
Reconciliation Act ............................................................................................ 17
ARTICLE IV BENEFITS .............................................................................................................. 18
4.1
Benefits ........................................................................................................... 18
4.2
Options ............................................................................................................ 18
4.3
Unreduced Compensation Benefit ................................................................... 18
4.4
Elective Benefits .............................................................................................. 18
4.5
Non-Elective Benefits ...................................................................................... 22
4.6
Limits for Certain Employees ........................................................................... 22
4.7
Notification of Premium Payment Amounts...................................................... 23
4.8
Application of Other Plans ............................................................................... 23
ARTICLE V ELECTIONS ............................................................................................................ 24
5.1
Enrollment for Non-Elective Benefits ............................................................... 24
5.2
Enrollment for Elective Benefits ....................................................................... 24
5.3
Salary Reductions/Deductions......................................................................... 24
5.4
Forms and Agreements ................................................................................... 24
5.5
Default Benefits ............................................................................................... 25
5.6
Deadlines ........................................................................................................ 25
5.7
Validity of Election Forms ................................................................................ 25
5.8
Changing Elections ......................................................................................... 26
5.9
Waiver of Coverage ......................................................................................... 31
ARTICLE VI COORDINATION OF BENEFITS ............................................................................ 32
6.1
Applicability ..................................................................................................... 32
6.2
COB Definitions ............................................................................................... 32
6.3
Order of Benefit Determination Rules .............................................................. 33
6.4
Effect on the Benefits of this Plan .................................................................... 35
6.5
Disagreement on Order of Benefits ................................................................. 36
6.6
Limitation of Benefits ....................................................................................... 36
6.7
Right to Receive and Release Necessary COB Information ............................ 36
6.8
Facility of Payment .......................................................................................... 36
6.9
Right of Recovery ............................................................................................ 37
6.10
Governing Provisions ...................................................................................... 37
ARTICLE VII COBRA CONTINUATION COVERAGE ................................................................. 38
7.1
Eligibility for Continuation Coverage ................................................................ 38
7.2
Definitions ....................................................................................................... 38
7.3
Loss of Eligibility for Continuation Coverage.................................................... 39
7.4
Termination of COBRA Continuation Coverage ............................................... 39
7.5
Notice Requirements ....................................................................................... 40
7.6
Coverage Available for Continuation ............................................................... 41
iii
7.7
Election Rules ................................................................................................. 42
7.8
Required Premium .......................................................................................... 43
7.9
Governing Provisions ...................................................................................... 43
ARTICLE VIII CONTRIBUTIONS, FUNDING AND PLAN ASSETS ............................................. 44
8.1
Contributions ................................................................................................... 44
8.2
Funding ........................................................................................................... 45
8.3
Plan Assets ..................................................................................................... 45
8.4
Treatment of Certain Policy Payments ............................................................ 45
ARTICLE IX CLAIM AND PAYMENT PROCEDURES ................................................................ 46
9.1
General Claims Procedures ............................................................................ 46
9.2
Claim Administrator ......................................................................................... 46
9.3
Claims Administration ...................................................................................... 47
9.4
Claimants ........................................................................................................ 47
9.5
Claim Forms .................................................................................................... 47
9.6
Deadline for Filing a Claim .............................................................................. 47
9.7
Proof of Claim ................................................................................................. 47
9.8
Decision on the Claim ..................................................................................... 47
9.9
Right to Appeal ................................................................................................ 52
9.10
Right to an External Review of Claims ............................................................. 59
9.11
Legal Remedy ................................................................................................. 59
9.12
Subrogation, Reimbursement and Recovery for Third Party Liability ............... 59
9.13
Payment Procedures ....................................................................................... 62
ARTICLE X ADMINISTRATION .................................................................................................. 63
10.1
Plan Administrator ........................................................................................... 63
10.2
Plan Administrator’s Duties ............................................................................. 63
10.3
Plan Administrator’s Powers ............................................................................ 64
10.4
Finality of Decisions ........................................................................................ 65
10.5
Compensation and Bonding of Plan Administrator........................................... 65
10.7
Reserved Powers ............................................................................................ 65
10.8
Intergovernmental Agreements ....................................................................... 65
ARTICLE XI AMENDMENT, TERMINATION OR MERGER OF PLAN........................................ 67
11.1
Right to Amend the Plan.................................................................................. 67
11.2
Right to Terminate or Merge the Plan .............................................................. 67
11.3
Effect of Amendment, Termination or Merger .................................................. 67
ARTICLE XII MISCELLANEOUS ................................................................................................ 68
12.1
No Employment Rights .................................................................................... 68
12.2
Exclusive Rights .............................................................................................. 68
12.3
No Property Rights .......................................................................................... 68
12.4
No Assignment of Benefits .............................................................................. 68
12.5
Payments to Minors and Incompetents ............................................................ 69
12.6
Right to Offset Future Payments ..................................................................... 69
12.7
Right to Recover Payments ............................................................................. 69
12.8
Misrepresentation or Fraud ............................................................................. 69
12.9
Legal Action .................................................................................................... 70
12.10
Governing Law ................................................................................................ 70
12.11
Forum Selection .............................................................................................. 70
iv
12.12
Governing Instrument ...................................................................................... 70
12.13
Savings Clause ............................................................................................... 70
12.14
Captions and Headings ................................................................................... 70
12.15
Notices ............................................................................................................ 71
12.16
Waiver ............................................................................................................. 71
12.17
Parties' Reliance ............................................................................................. 71
12.18
Disclaimer ....................................................................................................... 71
12.19
Expenses ........................................................................................................ 71
12.20
Indemnification ................................................................................................ 71
12.21
Employees' Tax Obligations ............................................................................ 72
12.22
Unknown Whereabouts ................................................................................... 72
ARTICLE XIII HIPAA PRIVACY AND SECURITY ....................................................................... 73
13.1
Scope .............................................................................................................. 73
13.2
Definitions ....................................................................................................... 73
13.3
Uses and Disclosures of PHI ........................................................................... 74
13.4
Privacy Agreements of the Plan Sponsor ........................................................ 74
13.5
Security Agreements of the Plan Sponsor ....................................................... 76
APPENDIX A MARICOPA COUNTY DEPENDENT CARE SPENDING ACCOUNT PLAN ........... 1
ARTICLE I PLAN ESTABLISHMENT ............................................................................................ 1
1.1
Effective Date .................................................................................................... 1
1.2
Purpose ............................................................................................................. 1
1.3
Qualification ...................................................................................................... 1
1.4
Incorporation By Reference ............................................................................... 1
1.5
Duration ............................................................................................................ 1
ARTICLE II DEFINITIONS ............................................................................................................ 2
2.1
Covered Employee ............................................................................................ 2
2.2
Dependent Care Expenses ............................................................................... 2
2.3
Dependent Care Spending Account Plan .......................................................... 2
2.4
Effective Date .................................................................................................... 2
2.5
Exclusions ......................................................................................................... 2
2.6
Maximum Annual Benefit ................................................................................... 2
2.7
Plan ................................................................................................................... 2
2.8
Qualifying Individual .......................................................................................... 3
ARTICLE III PARTICIPATION ....................................................................................................... 4
3.1
Participation ...................................................................................................... 4
3.2
Termination of Participation ............................................................................... 4
ARTICLE IV DEPENDENT CARE REIMBURSEMENT BENEFIT ................................................. 5
4.1
Right to Benefit .................................................................................................. 5
4.2
Maintenance of Accounts .................................................................................. 5
4.3
Amount Payable ................................................................................................ 5
4.4
Dependent Care Expenses ............................................................................... 5
4.5
Limits ................................................................................................................. 6
ARTICLE V EXCLUSIONS............................................................................................................ 9
5.1
General Rules ................................................................................................... 9
v
5.2
Specific Exclusions ............................................................................................ 9
5.3
Conditional Exclusions .................................................................................... 10
ARTICLE VI PROCEDURES ...................................................................................................... 11
6.1
Enrollment and Election Procedures ............................................................... 11
6.2
Claim Procedures ............................................................................................ 11
6.3
Claim Administrator ......................................................................................... 11
6.4
Claims Administration ...................................................................................... 11
6.5
Proof of Claim ................................................................................................. 11
APPENDIX B MARICOPA COUNTY HEALTH CARE SPENDING ACCOUNT PLAN ................... 1
ARTICLE I PLAN ESTABLISHMENT ............................................................................................ 1
1.1
Effective Date .................................................................................................... 1
1.2
Purpose ............................................................................................................. 1
1.3
Qualification ...................................................................................................... 1
1.4
Incorporation By Reference ............................................................................... 1
1.5
Duration ............................................................................................................ 1
ARTICLE II DEFINITIONS ............................................................................................................ 2
2.1
Covered Employee ............................................................................................ 2
2.2
Dependent ........................................................................................................ 2
2.3
Effective Date .................................................................................................... 2
2.4
Exclusions ......................................................................................................... 2
2.5
Health Care Spending Account ......................................................................... 2
2.6
Maximum Annual Benefit ................................................................................... 2
2.7
Plan ................................................................................................................... 3
2.8
Qualifying Medical Expenses ............................................................................ 3
ARTICLE III PARTICIPATION ....................................................................................................... 4
3.1
Participation ...................................................................................................... 4
3.2
Termination of Participation ............................................................................... 4
ARTICLE IV MEDICAL EXPENSE BENEFIT ............................................................................... 5
4.1
Right to Benefit .................................................................................................. 5
4.2
Maintenance of Accounts .................................................................................. 5
4.3
Amount Payable ................................................................................................ 5
4.4
Qualifying Medical Expenses ............................................................................ 5
4.5
Limits ................................................................................................................. 7
ARTICLE V EXCLUSIONS............................................................................................................ 8
5.1
General Rules ................................................................................................... 8
5.2
Specific Exclusions ............................................................................................ 8
ARTICLE VI PROCEDURES ...................................................................................................... 10
6.1
Enrollment and Election Procedures ............................................................... 10
6.2
Claim Procedures ............................................................................................ 10
6.3
Claim Administrator ......................................................................................... 10
6.4
Claims Administration ...................................................................................... 10
6.5
Proof of Claim ................................................................................................. 10
vi
APPENDIX C MARICOPA COUNTY LIMITED PURPOSE HEALTH CARE SPENDING
ACCOUNT PLAN .............................................................................................. 1
ARTICLE I PLAN ESTABLISHMENT ............................................................................................ 1
1.1
Effective Date .................................................................................................... 1
1.2
Purpose ............................................................................................................. 1
1.3
Qualification ...................................................................................................... 1
1.4
Incorporation By Reference ............................................................................... 1
1.5
Duration ............................................................................................................ 1
ARTICLE II DEFINITIONS ............................................................................................................ 2
2.1
Covered Employee ............................................................................................ 2
2.2
Dependent ........................................................................................................ 2
2.3
Effective Date .................................................................................................... 2
2.4
Exclusions ......................................................................................................... 2
2.5
Limited Purpose Health Care Spending Account ............................................... 2
2.6
Maximum Annual Benefit ................................................................................... 2
2.7
Plan ................................................................................................................... 3
2.8
Qualifying Medical Expenses ............................................................................ 3
ARTICLE III PARTICIPATION ....................................................................................................... 4
3.1
Participation ...................................................................................................... 4
3.2
Termination of Participation ............................................................................... 4
ARTICLE IV MEDICAL EXPENSE BENEFIT ................................................................................ 5
4.1
Right to Benefit .................................................................................................. 5
4.2
Maintenance of Accounts .................................................................................. 5
4.3
Amount Payable ................................................................................................ 5
4.4
Qualifying Medical Expenses ............................................................................ 6
4.5
Limits ................................................................................................................. 6
ARTICLE V EXCLUSIONS............................................................................................................ 7
5.1
General Rules ................................................................................................... 7
5.2
Specific Exclusions ............................................................................................ 7
ARTICLE VI PROCEDURES ........................................................................................................ 8
6.1
Enrollment and Election Procedures ................................................................. 8
6.2
Claim Procedures .............................................................................................. 8
6.3
Claim Administrator ........................................................................................... 8
6.4
Claims Administration ........................................................................................ 8
6.5
Proof of Claim ................................................................................................... 8
vii
APPENDIX D APPLICABLE INCORPORATED DOCUMENTS .................................................... 1
APPENDIX E EMPLOYEES OF THE EMPLOYER APPROVED TO HAVE ACCESS TO
PROTECTED HEALTH INFORMATION ........................................................... 1
APPENDIX F PARTICIPATING EMPLOYERS .............................................................................. 1
APPENDIX G MARICOPA COUNTY HEALTH SAVINGS ACCOUNT .......................................... 1
ARTICLE I PLAN ESTABLISHMENT ............................................................................................ 1
1.1
Trustee/Custodial Agreement ............................................................................ 1
1.2
Health Savings Account Not Intended to be an ERISA Plan .............................. 1
1.3
Incorporation By Reference ............................................................................... 1
ARTICLE II DEFINITIONS ............................................................................................................ 2
2.1
Covered Employee ............................................................................................ 2
2.2
Health Savings Account (HSA) .......................................................................... 2
ARTICLE III PARTICIPATION ....................................................................................................... 3
3.1
Participation ...................................................................................................... 3
ARTICLE IV HEALTH SAVINGS ACCOUNT BENEFIT ................................................................ 4
1
ARTICLE I
PLAN ESTABLISHMENT
1
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 from 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 II, 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
2
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 Plan” shall mean those provisions of this document that are
necessary or appropriate to the implementation and administration of Employee
elections among the following listed benefits to the extent pre-tax elections are
available: the unreduced compensation benefit, the Medical Premium Payment
Benefit, Dental Premium Payment Benefit, Vision Premium Payment Benefit,
Health Care Spending Account Premium Payment Benefit, Limited Purpose Health
Care Spending Account Premium Payment Benefit, Dependent Care Spending
Account Premium Payment Benefit, and Health Savings Account Premium
Payment Benefit. This Plan is also intended to qualify as an “accident and health
plan” maintained under Sections 105 and 106 of the Code and regulations issued
thereunder and to offer benefits on a tax-free basis in accordance with the Code.
This Plan shall be interpreted, construed and administered in accordance with
such intent. In no event shall this Plan be administered or construed to constitute
a plan of deferred compensation. The cafeteria plan is for Covered Employees
only.
The Dependent Care Spending Account Plan, as defined in Article II and set forth
in Appendix A, is part of this Plan and is intended to qualify as a dependent care
assistance program under Section 129 of the Code. Appendix A is intended to
satisfy the written plan document requirement of Code Section 129(d)(1).
The Health Care Spending Account Plan, as defined in Article II and set forth in
Appendix B, is part of this Plan. The Health Care Spending Account Plan is
intended to qualify as a health plan under Section 105(e) of the Code. Appendix B
is also intended to satisfy the written plan document requirement of Department of
Treasury regulation Section 1.105-11(b)(1)(i).
The Limited Purpose Health Care Spending Account Plan, as defined in Article II
and as set forth in Appendix C, is part of this Plan. The Limited Purpose Health
Care Spending Account Plan is intended to qualify as a health plan under
Section 105(e) of the Code. Appendix C is also intended to satisfy the written plan
document requirement of Department of Treasury regulation Section 1.105-
11(b)(1)(i).
1.4
Duration
The Plan is established with the intention of being maintained for an indefinite
period of time; however, the County, as defined in Article II, in its sole discretion
and in accordance with the provisions of Article XI may amend or terminate the
Plan or any provision of the Plan at any time.
3
ARTICLE II
DEFINITIONS
2
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,
4
E.
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,
F.
Commencement or return from an unpaid leave of absence by the Employee,
Spouse or Dependent Child,
G.
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,
H.
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,
I.
Entitlement or loss of entitlement to Medicare or Medicaid by the Employee,
Spouse or Dependent Child,
J.
Attainment by a Dependent Child of limiting age for a benefit provided under
this Plan,
K.
Loss of “qualifying individual” status, as defined in Article II of the Dependent
Care Spending Account Plan,
L.
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,
M.
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
N.
Any other event the Plan Administrator determines permits revocation of an
election without violating the Code.
5
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 III 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 III 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,
6
B.
Dependent Child(ren)
For the purposes of this Plan, a Dependent Child is any of the employee’s
children listed below who are under the age of 26 whether married or
unmarried:
•
natural children (son or daughter),
•
foster children,
•
stepchildren (who are the natural, adopted, foster or legal
guardianship children) of the employee’s legal spouse
•
legally adopted child(ren) or children placed for adoption,
•
child(ren) for whom the employee is the legal guardian,
•
child named in a qualified medical child support order (QMCSO) or
other court ordered dependent is also an eligible Dependent Child
under this Plan.
A Disabled Adult Child may continue coverage if they are an unmarried
Dependent Child (as defined above) age 26 or older who is permanently
and totally disabled with a disability that existed prior to the attainment of
the Plan’s age limit. “Disabled” means physical or mental impairment that
substantially limits one or more of that person’s major life activities as the
result of a mental or physical condition, illness or injury such as mental
retardation, cerebral palsy, epilepsy or another neurological disorder or
psychosis. Major life activities typically refer to employment, caring for
oneself, walking, learning, breathing, speaking, hearing, or seeing. The
Plan will require initial and periodic proof of disability. Proof of Social
Security Disability may be required for Disabled Adult Children over age
26. A Dependent Child who is not covered under the Plan but becomes
disabled after reaching the Plan's Dependent age limit is not eligible to
enroll as a Dependent under this Plan.
It is the employee’s obligation to inform the Plan promptly if any of the
requirements set out in this definition of a Dependent Child are NOT met
with respect to any child for whom coverage is sought or is being provided.
Coverage of a Dependent Child ends at the end of the month in which that
child:
1. reaches his or her 26th birthday unless the child is a Disabled
Adult Child (as described above), or
2. fails to pay required contributions for coverage, or
3. no longer meets the definition of a Dependent child or Disabled
Adult Child.
7
“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 Plan (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 I.
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.
a leased 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
C.
a collectively bargained employee.
Subject to the above, the term Employee does not mean:
D.
a self-employed individual, as defined in Code Section 401(c)(1)(A),
E.
a person whom the Plan Administrator determines has been engaged by the
Employer as an independent contractor, or
F.
a person whom the Plan Administrator determines has been engaged by the
Employer as a consultant or advisor on a retainer or fee basis.
8
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 (o) 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.
9
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
guidance 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 January 1 and ending December
31, with the exception of the current plan year which begins on July 1, 2022 and
ends on December 31, 2022.
10
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.
2.31 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.
2.33 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 from 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.
11
ARTICLE III
ELIGIBILITY, PARTICIPATION AND COVERAGE
3
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 temporary 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.
12
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
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.
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.
If 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
13
prior election amount, reduced by the dollar amount of the annual election
not contributed during the unpaid leave, or ii) elect to be reinstated to the
full annual election amount, with the Salary Reduction Contribution
adjusted accordingly for the balance of the Plan Year.
C.
Date Coverage Ceases
Coverage for a specific benefit offered under the Plan ceases on the earliest
of:
1.
the last day of the month in which the Covered Employee last satisfies
the eligibility and participation requirements of Sections 3.1 and 3.2,
respectively,
2.
except where participation continues during an unpaid leave of
absence, the last day of the month for which a Covered Employee
makes a Salary Reduction Contribution or Salary Deduction
Contribution with respect to an elective Benefit;
3.
the effective date of a Plan amendment that terminates coverage for the
Covered Employee's job category, or
4.
the date the Plan terminates.
A Covered Employee’s Dependent shall cease to be a Covered Person if the
Employee ceases to be a Covered Person, except as otherwise provided in
Article VII and in Section 2.12.
D.
Effect of Terminated Coverage
Termination of coverage automatically cancels a Covered Employee's Salary
Reduction and Salary Deduction on the date coverage terminates. Coverage
and benefits may continue in effect to the extent provided in an applicable
Incorporated Document.
E.
Reinstatement of Coverage
If Previously Suspended
A Covered Employee who returns to an Employer's service during the
same Plan Year that he or she took an unpaid leave of absence will
have reinstated automatically the Benefits in effect when Plan coverage
was suspended provided such benefits continue to be provided by the
County. If an unpaid leave of absence was taken in accordance with
FMLA, such Covered Employee may reinstate his or her election and
Salary Reduction for the remainder of the Plan Year if participation has
not continued pursuant to Section 3.3(B). In all other cases, the
Covered Employee may only make any new benefit elections for the
remainder of the Plan Year, as described in Section 5.8.
14
If Previously Terminated
A Covered Employee who returns to an Employer's service shall be
eligible to participate in the Plan and make new benefit elections,
provided such Employee satisfies the eligibility requirements of
Section 3.1. Notwithstanding the foregoing, if a former Covered
Employee returns to service within 30 days of the date prior
participation ended, his or her elections for Benefits described in
Section 4.4(A), (B), (C), (D), (E), (F), and (K) shall be reinstated, except
as described in Section 5.8. The above rule shall not apply and the
rehired Employee shall be eligible to make new elections for Benefits
described in Section 4.4(G), (H), (I), and (J) for the balance of the Plan
Year, if it is determined to the satisfaction of the Plan Administrator that
the prior termination of employment and reinstatement was bona fide
and not an attempt to avoid the irrevocable rule described in
Section 5.8(A). This section does not apply to Headstart teachers on a
yearly contract.
3.4
Coverage under the Family and Medical Leave Act and Section 609 of ERISA
A.
Family and Medical Leave Act of 1993
If not otherwise provided for herein, the Plan shall provide coverage for a
Covered Employee solely to the extent necessary to comply with FMLA, and
the Plan shall be interpreted and administered as necessary to comply with
FMLA and the rulings and regulations issued thereunder.
B.
Section 609 of ERISA
If not otherwise provided for herein, the Plan shall voluntarily provide
coverage to a child solely to the extent required by a qualified medical child
support order defined under Section 609(a) of ERISA or to an adoptive child
or child placed for adoption solely to the extent required by Section 609(c) of
ERISA, even though it is not otherwise subject to ERISA.
C.
Coverage Contingent Upon Contribution
Any coverage provided as a result of this Section 3.4 shall be conditioned
upon payment of applicable contributions by the Employee.
3.5
Uniformed Services Employment and Reemployment Rights Act
Solely to the extent required by the Uniformed Services Employment and
Reemployment Rights Act (hereafter the “Uniformed Services Act”), a Covered
Person who is an Employee who enters military service shall have the right to
continue coverage under the Plan for the period prescribed under the Uniformed
Services Act. Continuation of coverage shall be conditioned upon payment of the
required premiums, if any.
15
This Section 3.5 shall be interpreted and applied to give an Employee only those
rights as are prescribed under the Uniformed Services Act and rulings and
regulations issued thereunder.
3.6
Health Insurance Portability and Accountability Act of 1996
A.
HIPAA Title I
Solely to the extent required by the Health Insurance Portability and
Accountability Act of 1996 (hereinafter “HIPAA”), an Employee shall be a
Covered Person under the Plan no later than such time as required under
HIPAA, and the Plan shall be subject to the special enrollment and
nondiscrimination in health status provisions of HIPAA. This Section 3.6 shall
be interpreted and applied to give a Covered Person only those rights as
prescribed under HIPAA and the rulings and regulations issued thereunder.
B.
HIPAA Title II
The Plan
shall comply with the privacy and security regulations of HIPAA, in
accordance with the provisions set forth in Article XIII.
3.7
Coordination with State Medicaid Program
The fact that a Covered Person is eligible for coverage by, or is covered by, a
State Medicaid program shall not affect the Covered Person’s eligibility to
participate in the Plan or to receive benefits. While a Covered Person’s purported
assignments are void under Section 12.4 in all other cases, the payment of
benefits under the Plan with respect to any Covered Person shall be made in
accordance with any assignment of rights made by or on behalf of the Covered
Person or a beneficiary of the Covered Person as and to the extent required by
any State Medicaid program. To the extent a payment has been made to or with
respect to a Covered Person pursuant to a State Medicaid program and the
amount so paid is for a medical expense that the Plan has a legal liability to pay,
the Plan will pay such expense in accordance with any State law that provides that
the State has acquired the right with respect to the Covered Person to receive
payment for such expense.
3.8
Mental Health Parity and Addiction Equity Act
Solely to the extent required by the Mental Health Parity and Addiction Equity Act
of 2008, as amended, the Plan shall provide mental health benefits to the same
extent as other medical benefits.
This Section 3.8 shall be interpreted and applied to give Covered Persons only
those rights as prescribed under the Mental Health Parity and Addiction Equity Act,
and the rulings and regulations issued thereunder.
16
3.9
Women’s Health and Cancer Rights Act
Solely to the extent required under the law of the Women's Health and Cancer
Rights Act (hereinafter “WHCRA”), the Plan shall provide certain benefits related to
benefits received in connection with a mastectomy.
In the case of a Covered Person who is receiving benefits under the Plan in
connection with a mastectomy and who elects breast reconstruction, the coverage
shall be provided in a manner determined in consultation with the attending
physician and the patient for reconstruction of the breast on which the mastectomy
was performed; surgery and reconstruction of the other breast to produce a
symmetrical appearance; and prostheses and treatment of physical complications
at all stages of the mastectomy, including lymphedemas.
Such reconstructive benefits are subject to annual plan deductibles and
coinsurance provisions such as other medical and surgical benefits covered under
the Plan.
This Section 3.9 shall be interpreted and applied to give Covered Persons only
those rights as prescribed under WHCRA, and the rulings and regulations issued
thereunder.
3.10 Newborns’ and Mothers’ Health Protection Act
Solely to the extent required by the Newborns’ and Mothers’ Health Protection Act
(hereinafter “NMHPA”), the Plan shall provide that coverage for childbirth may not
be limited to a hospital stay of less than 48 hours for normal delivery, or less than
96 hours for cesarean section, or require the provider to obtain approval for shorter
hospital stays. The requirement shall not apply if the attending provider, in
consultation with the mother, decides to discharge the mother or newborn earlier
than the time prescribed by the NMHPA.
This Section 3.10 shall be interpreted and applied to give Covered Persons only
those rights as prescribed under the NMHPA, and the rulings and regulations
issued thereunder.
3.11 Genetic Information Nondiscrimination Act of 2008
The Plan shall also comply with the Genetic Information Nondiscrimination Act of
2008 (hereinafter “GINA”).
This Section 3.11 shall be interpreted and applied to give Covered Persons only
those rights as prescribed under GINA, and the rulings and regulations issued
thereunder.
3.12 Children’s Health Insurance Program Reauthorization Act of 2009
The Plan shall also comply with the Children’s Health Insurance Program
Reauthorization Act of 2009 (hereinafter “CHIP”).
17
This Section 3.12 shall be interpreted and applied to give Covered Persons only
those rights as prescribed under CHIP, and the rulings and regulations issued
thereunder.
3.13 Patient Protection and Affordable Care Act and Health Care and Education
Reconciliation Act
The Plan shall also comply with the applicable provisions of the Patient Protection
and Affordable Care Act (hereinafter “PPACA”) as amended by the Health Care
and Education Reconciliation Act (hereinafter “HCERA”).
This Section 3.13 shall be interpreted and applied to give Covered Persons only
those rights as prescribed under PPACA as amended by HCERA, and the rulings
and regulations issued thereunder.
18
ARTICLE IV
BENEFITS
4
4.1
Benefits
The benefits provided under the Plan are described as set forth below and as
further described in any applicable Incorporated Document. Any such applicable
Incorporated Document is hereby incorporated by reference as if set forth in full
herein. Pursuant to Section 8.1(B), any Salary Reductions and/or Salary
Deductions issued in conjunction with the Plan are incorporated by reference.
4.2
Options
Covered Employees must elect one of the following:
A.
to receive the full unreduced compensation benefit described in Section 4.3,
and receive automatic coverage under Benefits described in Section 4.5;
B.
to forego all or part of the unreduced compensation benefit described in
Section 4.3 and make before- or after-tax contributions in exchange for one
or a combination of Benefits described in Section 4.4 and receive automatic
coverage under Benefits described in Section 4.5;
Employee contributions for Benefits described in Sections 4.4(A), (B), (C), (D), (E),
(F), and (K) must be made on an entirely before-tax basis through a Salary
Reduction. Employee contributions for Benefits described in Section 4.4(G), (H),
(I), and (J) may be made only on an after-tax basis through a Salary Deduction.
There are no Employee Contributions for Benefits described in Sections 4.5.
4.3
Unreduced Compensation Benefit
In lieu of all or some of the Benefits described in Section 4.4 that a Covered
Employee otherwise could elect, he or she may elect to receive unreduced
compensation in an amount equal to the value of the Benefits available for election
that are not elected. The unreduced compensation benefit is subject to the
Employer's regular payroll practices; applicable local, state, and federal income tax
withholding; and other applicable deductions. The unreduced compensation
benefit is not additional compensation; it is the amount by which a Covered
Employee's compensation is not reduced each pay period by not electing a
premium payment benefit. The unreduced compensation benefit shall cease
whenever the Covered Employee commences an unpaid leave of absence,
terminates employment, or the Covered Employee's Employer determines, in its
sole discretion, that compensation is not payable to such Employee.
4.4
Elective Benefits
By electing one or more premium payment benefits, an Employee converts a
portion of his or her compensation for the Plan Year into contributions for the
Benefits selected. Covered Employees may elect one or more of these premium
payment benefits:
19
A.
Medical Premium Payment Benefit
Covered Persons shall have the right to the medical benefits described in the
applicable Incorporated Document. Such benefits shall be subject to the
terms, conditions, and limitations set forth in such applicable Incorporated
Document. A description of such benefits, including the amount payable,
required deductibles, co-payments, maximums, conditions precedent to
payment, limitations and exclusions shall be as set forth in the applicable
Incorporated Document.
If an Employee is eligible for medical benefits, he or she may elect any of the
medical plan options as the medical premium payment benefit.
B.
Dental Premium Payment Benefit
Covered Persons shall have the right to the dental benefits described in the
applicable Incorporated Document. Such benefits shall be subject to the
terms, conditions, and limitations set forth in such applicable Incorporated
Document. A description of such benefits, including the amount payable,
required deductibles, co-payments, maximums, conditions precedent to
payment, limitations and exclusions shall be as set forth in the applicable
Incorporated Document.
If an Employee is eligible for dental benefits, he or she may elect any of the
dental plan options as the dental premium payment benefit.
C.
Vision Premium Payment Benefit
Covered Persons shall have the right to the vision benefits described in the
applicable Incorporated Document. Such benefits shall be subject to the
terms, conditions, and limitations set forth in such applicable Incorporated
Document. A description of such benefits, including the amount payable,
required deductibles, co-payments, maximums, conditions precedent to
payment, limitations and exclusions shall be as set forth in the applicable
Incorporated Document.
If an Employee is eligible for vision benefits, he or she may elect any of the
vision plan options as the vision premium payment benefit.
D.
Health Care Spending Account Premium Payment Benefit
Employees who are Covered Persons shall have the right to the health care
spending account benefits described in the applicable Incorporated
Document. Such benefits shall be subject to the terms, conditions and
limitations set forth in such Incorporated Document. A description of such
benefits, including the amount payable, maximums, conditions precedent to
payment, limitations and exclusions shall be as set forth in the applicable
Incorporated Document.
If an Employee is eligible for the health care spending account benefits, he or
she may elect any whole dollar annual contribution amount of not less than
20
$10 and not more than an amount to be communicated annually by the Plan
Administrator, which amount shall not exceed the IRS annual limit.
E.
Limited Purpose Health Care Spending Account Premium Payment Benefit
Employees who are Covered Persons shall have the right to the limited
purpose health care spending account benefits described in the applicable
Incorporated Document. Such benefits shall be subject to the terms,
conditions and limitations set forth in such Incorporated Document. A
description of such benefits, including the amount payable, maximums,
conditions precedent to payment, limitations and exclusions shall be as set
forth in the applicable Incorporated Document.
If an Employee is eligible for the limited purpose health care spending
account benefits, he or she may elect any whole dollar annual contribution
amount of not less than $10 and not more than an amount to be
communicated annually by the Plan Administrator, which amount shall not
exceed the IRS annual limit.
F.
Dependent Care Spending Account Premium Payment Benefit
Employees who are Covered Persons shall have the right to the dependent
care spending account benefits described in the applicable Incorporated
Document. Such benefits shall be subject to the terms, conditions and
limitations set forth in such Incorporated Document. A description of such
benefits, including the amount payable, maximums, conditions precedent to
payment, limitations and exclusions shall be as set forth in the applicable
Incorporated Document.
If an Employee is eligible for dependent care spending account benefits, he
or she may elect any whole dollar annual contribution amount of not less
than $10 and not more than $5,000 as the dependent care spending account
premium payment benefit.
G.
Short-Term Disability Premium Payment Benefit
Employees who are Covered Persons shall have the right to the short term
disability benefits described in the applicable Incorporated Document. Such
benefits shall be subject to the terms, conditions and limitations set forth in
such Incorporated Documents. A description of such benefits, including the
amount payable, maximums, conditions preceded to payment, limitations and
exclusions shall be as set forth in the applicable Incorporated Document.
If an Employee is eligible for short-term disability benefits, he or she may
elect any of the supplemental short-term disability coverage options as the
short-term disability premium payment benefit.
H.
Supplemental Life Premium Payment Benefit
Employees who are Covered Persons shall have the right to the
supplemental life insurance benefits described in the applicable Incorporated
21
Document. Such benefits shall be subject to the terms, conditions, and
limitations set forth in such Incorporated Document. A description of such
benefits, including the amount payable, maximums, conditions precedent to
payment, limitations and exclusions, the procedure for naming beneficiaries
and consequences for failure to name a beneficiary, shall be as set forth in
the applicable Incorporated Document.
If an Employee is eligible for supplemental life benefits, he or she may elect
any of the supplemental life coverage options as the supplemental life
premium payment benefit.
I.
Dependent Life Premium Payment Benefits
Covered Persons shall have the right to the dependent life insurance benefits
described in the applicable Incorporated Document. Such benefits shall be
subject to the terms, conditions, and limitations set forth in such Incorporated
Document. A description of such benefits, including the amount payable,
maximums, conditions precedent to payment, limitations and exclusions, the
procedure for naming beneficiaries and consequences for failure to name a
beneficiary, shall be as set forth in the applicable Incorporated Document.
If an Employee is eligible for dependent life benefits, he or she may elect any
of the dependent life options as the dependent life premium payment benefit.
J.
Supplemental AD&D Premium Payment Benefit
Employees who are Covered Persons shall have the right to the
supplemental AD&D insurance benefits described in the applicable
Incorporated Document. Such benefits shall be subject to the terms,
conditions, and limitations set forth in such Incorporated Document. A
description of such benefits, including the amount payable, maximums,
conditions precedent to payment, limitations and exclusions, the procedure
for naming beneficiaries and consequences for failure to name a beneficiary,
shall be as set forth in the applicable Incorporated Document.
If an Employee is eligible for supplemental AD&D benefits, he or she may
elect any of the supplemental AD&D coverage options as the supplemental
AD&D premium payment benefit.
K.
Health Savings Account Premium Payment Benefit
Employees who are Covered Persons and who participate in an Employer-
sponsored high deductible health plan that meets the requirements of
Section 223 of the Code shall have the right to the health savings account
benefits described in Appendix G. Such benefits shall be subject to the
terms, conditions and limitations set forth in Appendix G. A description of
such benefits, including the amount payable, maximums, conditions
precedent to payment, limitations and exclusions shall be as set forth in
Appendix G.
22
Employees who participate in an Employer-sponsored high deductible health
plan that meets the requirements of Section 223 of the Code and who are
eligible to contribute to a Health Savings Account under Section 223 of the
Code, may elect any whole dollar annual contribution amount of not more
than the maximum allowed under Section 223 of the Code as the health
savings account premium payment benefit.
4.5
Non-Elective Benefits
A.
Basic Life Benefits
Employees who are Covered Persons shall have the right to the basic life
benefits provided under the applicable Incorporated Documents. Such
benefits shall be subject to the terms, conditions, and limitations set forth in
such applicable Incorporated Documents. A description of such benefits,
including the amount payable, maximums, conditions precedent to payment,
limitations, exclusions, and the procedure for naming beneficiaries and
consequences for failure to name a beneficiary, shall be as set forth in the
applicable Incorporated Document.
B.
Basic AD&D Benefits
Employees who are Covered Persons shall have the right to the basic AD&D
benefits provided under the applicable Incorporated Documents. Such
benefits shall be subject to the terms, conditions, and limitations set forth in
such Incorporated Documents. A description of such benefits, including the
amount payable, maximums, conditions precedent to payment, limitations,
and exclusions shall be set forth in the applicable Incorporated Documents.
C.
Employee Assistance Plan Benefits
Covered Persons shall have the right to the employee assistance plan
benefits provided under the applicable Incorporated Document. Such
benefits shall be subject to the terms, conditions, and limitations set forth in
such applicable Incorporated Document. A description of such benefits,
including the amount payable, maximums, conditions precedent to payment,
limitations, and exclusions shall be set forth in the applicable Incorporated
Document.
4.6
Limits for Certain Employees
Benefits payable under the Plan to each highly compensated participant, as
defined in Code Section 125(e)(1) or highly compensated individual, as defined in
Code Section 125(e)(2), shall be limited to the extent necessary to avoid violating
Code Section 125(b)(1), as applicable.
Benefits payable under the Plan to each key employee, as defined in Code
Section 416(i)(1), shall be limited to the extent necessary to avoid violating Code
Section 125(b)(2), as applicable.
23
Benefits payable under the Plan to each highly compensated individual, as defined
in Code Section 105(h)(5) shall be limited to the extent necessary to avoid
violating Code Section 105(h)(l) as applicable.
Benefits payable under the Dependent Care Spending Account Plan to a highly
compensated employee, as defined in Code Section 414(q), are limited to the
extent necessary to avoid violating Code Section 129(d)(8). The Employer may
determine prior to or during a Plan Year that the salary reductions contributions of
a highly compensated employee must be reduced to avoid violating Code Section
129(d)(8). Any amounts that are in excess of the Code Section 129(d)(8) limit and
have not been used shall be returned to a highly compensated employee in the
form of taxable compensation.
4.7
Notification of Premium Payment Amounts
The County shall provide written notification to eligible Employees of the amount of
the premium payment benefits prior to the initial and annual enrollment/election
period. The amount of the premium payment benefits shall be the contributions
required of the Employee to participate in the group health or welfare benefit
plan(s) for which a premium payment benefit is available under the Plan. Any such
written notification is hereby incorporated by reference and made part of the Plan.
4.8
Application of Other Plans
Notwithstanding any other provision of the Plan, Covered Employees electing one
or more premium payment benefits under the Plan shall be subject to the
provisions, conditions, limitations, and exclusions of each Benefit listed in Article IV
for which they elect the premium payment benefit.
24
ARTICLE V
ELECTIONS
5
5.1
Enrollment for Non-Elective Benefits
All Employees meeting the eligibility requirements of Section 3.1 shall be
automatically covered for Benefits described in Section 4.5 and such benefits shall
not be subject to the remaining provisions of this Article V. Covered Employees
who have more than one source of eligibility for enrollment (for example, an
Employee married to another Employee) are limited to one enrollment.
5.2
Enrollment for Elective Benefits
A.
Initial Enrollment/Election
Employees meeting the eligibility requirements of Section 3.1 shall be eligible
to elect Benefits described in Section 4.4. Covered Employees who have
more than one source of eligibility for enrollment (for example, an Employee
married to another Employee) are limited to one enrollment.
B.
Annual Enrollment/Election
Approximately 60 to 90 days before each Plan Year begins, the Plan
Administrator shall conduct an enrollment during which Employees may
make new elections or change existing ones for the next Plan Year.
5.3
Salary Reductions/Deductions
During the applicable election period determined by the Employer, an Employee
shall enter into a Salary Reduction with the Employer if such Employee selects
Benefits requiring Employee pre-tax contributions. The Salary Reduction shall
authorize the Employer to reduce the Employee’s compensation by the amount of
required Employee contributions. All elections of Benefits shall be null and void if
the Covered Employee fails to execute a Salary Reduction as provided for herein.
During the applicable election period determined by the Employer, an Employee
shall enter into a Salary Deduction with the Employer if such Employee selects
Benefits requiring Employee after-tax contributions. The Salary Deduction shall
authorize the Employer to deduct the amount of required Employee contributions
from the Employee’s compensation on an after-tax basis. All elections of Benefits
shall be null and void if the Covered Employee fails to execute a Salary Deduction
as provided for herein.
5.4
Forms and Agreements
Employees make elections, and direct the County to make Salary Reduction
Contributions and/or Salary Deduction Contributions only by enrolling in the online
enrollment system or filing the appropriate, completed forms or agreements with
the Plan Administrator before the deadline described in Section 5.6.
25
5.5
Default Benefits
The Plan Administrator shall conduct an enrollment during which Employees may
make new elections or change existing ones for the next Plan Year. For any year
in which the Plan Administrator allows a passive enrollment, unless the Plan
Administrator approves a supplemental election, as described in Section 5.8(B), a
Covered Employee who fails to submit a valid enrollment/election and Salary
Reduction and/or Salary Deduction, as required in Section 5.4, is deemed to have
reelected benefits in effect for the prior year, except that the Covered Employee
will be deemed to have declined participation in the Health Care Spending
Account, Limited Purpose Health Care Spending Account, Dependent Care
Spending Account and Health Savings Account.
An Employee enrolling for the first time who fails to submit a valid
enrollment/election and Salary Reduction and/or Salary Deduction, as required in
Section 5.4, is deemed to have waived all elective benefits in Section 4.4.
Contributions required for the default coverage shall be deducted from the
Employee’s pay as Salary Reduction Contributions, as permitted under the Code,
or as Salary Deduction Contributions.
5.6
Deadlines
A.
Initial Enrollment/Election
For Employees who become eligible after the Effective Date but before the
annual enrollment described in Section 5.2(B), the deadline for enrolling and
making initial elections is within 30 days of the Employee’s date of hire.
Salary Reductions and/or Salary Deductions completed by Eligible
Employees shall be effective as of the first day of the month following the
Employee's date of hire.
B.
Annual Enrollment/Election
For Covered Employees and Employees who become eligible as of the first
day of a Plan Year, the deadline for enrolling and making elections is the
date the Plan Administrator specifies, but no later than the day preceding the
first day of the Plan Year to which the enrollment, elections, and Salary
Reduction and/or Salary Deduction apply.
5.7
Validity of Election Forms
A.
Plan Administrator Approval
Enrollments, elections, and Salary Reductions and/or Salary Deductions take
effect only if valid, as determined by the Plan Administrator. Except for
supplemental elections described in Section 5.8(B), the Plan Administrator
shall substitute the unreduced compensation benefit, described in
Section 4.3, for any invalid premium payment benefit election.
26
B.
Remedial Modification or Rejection
The Plan Administrator may modify or reject any enrollment or election
and/or Salary Reduction and/or Salary Deduction or take other action the
Plan Administrator deems appropriate under rules uniformly applicable to
similarly situated persons to satisfy nondiscrimination requirements of Code
Section 125(b). The Plan Administrator may divide Covered Employees into
two or more classes for purposes of administering this section, provided that
any such classification shall be nondiscriminatory. Any remedial modification,
rejection, or other action the Plan Administrator takes must be on a
reasonable basis that does not discriminate in favor of highly compensated
individuals or participants, as defined in Code Section 125(e)(1) and (2),
respectively, or key employees, as defined in Code Section 416(i)(1).
5.8
Changing Elections
A.
General Rule
All elections and Salary Reductions and/or Salary Deductions stay in force
during the entire Plan Year to which they apply unless changed or revoked
as provided in this Section 5.8. During annual enrollment, however, Covered
Employees may make new benefit elections or change existing ones for the
forthcoming Plan Year. Notwithstanding the foregoing, elections and Salary
Deductions for Benefits described in Section 4.4(G), (H), (I), and (J) are not
subject to the rules of this Section 5.8.
The above general rule does not apply to the Health Savings Account. With
respect solely to the Health Savings Account, a Covered Employee who
makes an election to contribute Salary Reduction Contributions to his or her
Health Savings Account may change such election on a prospective basis at
least once per month. Such election change is effective no later than the first
day of the next calendar month following the date that the election was filed.
B.
Supplemental Elections
Section 5.8(A) notwithstanding, the Plan Administrator may approve a
supplemental election to correct an enrollment or election form or Salary
Reduction or Salary Deduction that is invalid for any reason if approval would
not violate Code Section 125.
C.
Revocation of Elections
Except as provided in Section 3.3(C), Covered Employees may revoke
elections (including default elections) and Salary Reductions and Salary
Deductions during a Plan Year only in accordance with the provisions
described in this Section 5.8(C). Except for changes made in accordance
with Section 5.8(C)(7) and, changes made pursuant to a HIPAA special
enrollment due to initial entitlement to state premium assistance under
Medicaid or CHIP or loss of entitlement to Medicaid or a state children’s
health insurance program (CHIP), a Covered Employee must make the
change within 30 days of the event giving rise to the election change. In the
27
event of a HIPAA special enrollment due to the loss of Medicaid or a state
children's health insurance program (CHIP) or initial entitlement to state
premium assistance by an Employee, Spouse or Dependent a Covered
Employee will have 60 days from the date of the event to make an election
change. Notwithstanding the provisions of this Section 5.8(C), an Employee’s
or Covered Employee’s ability to elect or revoke certain benefit option mid-
year may be restricted by the terms of the plan governing that benefit option.
The Plan will disregard the Outbreak Period for purposes of calculating any
30 or 60-day HIPAA special enrollment periods.
Separation from Service
Covered Employees may revoke elections and Salary Reductions or
Salary Deductions on separating from the Employer's service.
Regardless of previous claims or reimbursements, the Plan
Administrator must reimburse a Covered Employee for any amounts
the Covered Employee already paid for coverage relating to the period
after the effective date of termination of coverage.
Change in Status
A Covered Employee may revoke any election and make a new one if
such revocation and new election are both on account of and
necessary or appropriate because of a Change in Status.
Election and Salary Reduction changes must be consistent with the
Change in Status, except for elections:
a. Made pursuant to the special enrollment provisions of HIPAA, or
b. Made pursuant to a Change in Status event expressly identified in
Article II as not requiring that Plan eligibility be affected, and only to
the extent permitted under applicable law or guidance, or
c. Made to increase Salary Reduction Contributions in the event the
Employee or Dependent elects COBRA coverage.
For purposes of this paragraph (2), the term “consistent” means that the
Change in Status event must cause the Employee or Employee’s
Spouse or Dependent Child(ren) to gain or lose eligibility under an
employer-sponsored benefit offered through this Plan or the plan of the
Spouse or Dependent, including a Change in Status that results in an
increase or decrease in the number of an Employee’s Dependents who
may benefit from coverage under the Plan. Coverage may be
retroactive to the date of the event, to the extent permitted by the
applicable Incorporated Document; in no event will the Employee pay
for retroactive coverage on a pre-tax basis unless permitted under
Section 125 of the Code. In general, Salary Reduction Contributions will
begin as soon as administratively practicable following receipt by the
Plan Administrator of the election change. With respect to an election
made pursuant to a birth, adoption or placement for adoption of a child,
28
the election change shall take effect as of the birth, adoption or
placement for adoption.
The Plan Administrator may require such evidence as it deems
necessary to satisfy the consistency requirement imposed by
Section 125 of the Code. An Employee who adds a Dependent to
coverage must submit verification to the Plan Administrator, or
authorized third party administrator, of the Dependent’s eligibility
subject to the foregoing. Satisfactory verification must be submitted not
later than forty-five (45) calendar days from the date of the Change in
Status. The Dependent will be added to coverage retroactively to the
date of the Change in Status upon satisfactory verification submission
and approval. Any request to extend this time limit due to exceptional
circumstances (such as severe health condition causing incapacitation
of the Employee, acts of God, or natural disaster) must be directed to
the Plan Administrator, who shall approve or deny the request in his or
her sole discretion, such discretion to be applied in a uniform and
nondiscriminatory manner in accordance with such rules, regulations or
procedures as it may adopt. Decisions of the Plan Administrator to
grant or deny an extension are final. An Employee shall not be
permitted to re-add such Dependent to coverage until the Plan’s next
open enrollment period or until there is a Change in Status that allows
for the Dependent to be re-added to coverage and satisfactory
verification of eligibility is submitted.
Cost Changes
If the cost of a premium payment benefit increases or decreases during
a Plan Year, the Plan may, on a reasonable and consistent basis,
automatically make a prospective change to Covered Employees'
contributions to reflect the cost of this change.
If the Plan Administrator determines that the increase in cost of such
premium payment benefit is significant, however, Covered Employees
who have elected that premium payment benefit may either change
their Salary Reduction correspondingly or revoke their premium
payment benefit election and — in lieu thereof — elect, prospectively, a
premium payment benefit with similar coverage, or may revoke the
existing premium payment benefit if no other option providing similar
coverage is available. Employees who previously waived participation
may elect benefits if the cost of the coverage significantly decreases
during the Plan Year.
This opportunity for making new elections does not apply to the Health
Care Spending Account Plan Premium Payment Benefit or Limited
Purpose Health Care Spending Account Plan Premium Payment
Benefit and applies to the Dependent Care Spending Account Plan only
if a cost change is imposed by a dependent care provider who is not a
relative of the Covered Employee. For purposes of this subparagraph
(c), a “relative” is an individual who is related as described in Code
29
Section 152(d)(2) (A) through (G), incorporating the rules of Code
Sections 152(f)(1)(B) and 152(f)(4).
Coverage Changes
This subparagraph does not apply to the Health Care Spending
Account Plan or Limited Purpose Health Care Spending Account Plan.
a. Significant curtailment without a loss of coverage
If coverage offered under the Plan is significantly curtailed without
a loss of coverage during a Plan Year, affected Covered
Employees may revoke their election and make a new election on
a prospective basis for coverage under another option providing
similar coverage. For purposes of this subsection, a significant
curtailment occurs if there is an overall reduction in coverage
generally.
b. Significant curtailment with loss of coverage
If coverage offered under the Plan is significantly curtailed to the
extent that the Covered Employee experiences a loss of
coverage, affected Covered Employees may revoke their election
and make a new election on a prospective basis for coverage
under another option providing similar coverage, or may revoke
existing coverage if no other option providing similar coverage is
available. For purposes of this subsection, a loss of coverage
means a complete loss of coverage under the benefit option and
shall include the elimination of a benefit option, an HMO ceasing
to be available where the individual resides, the individual losing
all coverage under the option by reason of an overall lifetime or
annual limitation, or other fundamental loss of coverage as
determined by the Plan Administrator.
c. Significantly improved or new benefit option
If the coverage offered under the Plan is significantly improved or
if a new benefit option is made available under the Plan, then: (A)
a Covered Employee who is enrolled in a benefit option other than
the new or significantly improved benefit option may change their
election on a prospective basis to elect the new or significantly
improved benefit option, or (B) a Eligible Employee who had
previously elected to waive coverage under a benefit option may
elect to enroll on a prospective basis in the new or significantly
improved benefit option. The Plan Administrator, in its sole
discretion, will determine whether there has been an addition of,
or a significant improvement in, a benefit option in accordance
with Internal Revenue Service guidance.
Change in Coverage of Employee, Spouse or Dependent under Another
Employer’s Plan
30
This subparagraph does not apply to the Health Care Spending
Account Plan or Limited Purpose Health Care Spending Account Plan.
If the Employee or the Employee’s Spouse or Dependent is covered
under another plan of the Employer or a plan of the employer of the
Employee’s Spouse or Dependent, the Employee may make an
election change under this Plan in the following situations, provided
such election change is on account of and corresponds with a change
under the other plan:
a. if the plan year of such other employer plan is different than the
Plan Year of this Plan, or
b. if the other employer plan permits the Employee, Spouse or
Dependent to make changes for any of the situations described in
this Section 5.8(C).
Loss of Coverage under Another Health Plan
This subparagraph does not apply to the Health Care Spending
Account Plan or Limited Purpose Health Care Spending Account Plan.
If an Employee, Spouse or Dependent loses coverage under any group
health coverage sponsored by a governmental or educational
institution, the Employee may make a new election on a prospective
basis for health coverage provided under this Plan, provided such
Employee, Spouse or Dependent is otherwise eligible for coverage
under this Plan. For purposes of this subsection, a governmental or
educational institution shall include the following:
a. A state children’s health program (CHIP) under Title XXI of the
Social Security Act,
b. A medical program of an Indian Tribal government (as defined in
Section 7701(a)(40) of the Code), the Indian Health Service, or a
tribal organization,
c. A state health benefits risk pool, or
d. A foreign government group health plan.
Automatic Adjustment of Election
The election and Salary Reduction of a Covered Employee who loses a
Spouse or Dependent due to death or other loss of eligibility for
purposes of a premium payment benefit described in Section 4.4 but
fails to make a timely election in accordance with Section 5.8(C)(2)—
shall be automatically adjusted in accordance with this subsection 5.8.
In addition, the Plan Administrator may seek redress pursuant to any
and all available remedies afforded under PPACA and other applicable
state and federal law.
31
5.9
Waiver of Coverage
An Employee may choose to waive coverage under this Plan. Any waiver of
coverage must be made by the Employee in the same manner and at the same
time specified by the County pursuant to Section 5.4.
32
ARTICLE VI
COORDINATION OF BENEFITS
6
6.1
Applicability
Except as provided in Section 6.10, the following Coordination of Benefits (“COB”)
provisions apply to this Plan, as outlined in this Article VI, when a Covered Person
has health care coverage under more than one Health Care Arrangement.
6.2
COB Definitions
A.
“Health Care Arrangement” means any of the following coverages which
provides benefits or services to the Covered Person for, or because of,
medical, dental, surgical or hospital care treatment:
Group or nongroup coverage, whether insured or uninsured, including
HMOs;
The medical care component of long-term care contracts, such as
skilled nursing care
Coverage under a labor-management trusteed plan, a union welfare
plan, an employer organization plan or an employee benefits plan;
Coverage under federal government programs, except that coverage
under a federal government program may be limited to hospital, medical
and surgical benefits of the governmental program. Coverage does not
include Medicare supplemental policies or Medicaid policies;
The medical benefits coverage in group or individual automobile “fault”
or “no-fault” coverage.
The term Health Care Arrangement shall be construed separately with
respect to each policy, contract, or other arrangement for benefits or services
and separately with respect to that portion of any such policy, contract, or
other arrangement which reserves the right to take the benefits or services of
other Health Care Arrangements into consideration in determining its benefits
and that portion which does not.
B.
“Allowable Expense” means an expense for health care, when the item of
expense is covered at least in part by one or more Health Care
Arrangements covering the individual for whom the claim is made.
When a Health Care Arrangement provides benefits in the form of services
instead of cash payments, the reasonable cash value of each service
rendered will be considered both an Allowable Expense and a benefit paid.
33
6.3
Order of Benefit Determination Rules
This Plan determines its order of paying benefits using the first of the following
rules which applies:
A.
COB/Non-COB Provision
The benefits of a Health Care Arrangement which does not contain a COB
provision always shall be determined before the benefits of a Health Care
Arrangement which does contain a COB provision.
B.
No Fault Auto Insurance
The benefits of the Health Care Arrangement which covers the person as a
beneficiary under a no-fault automobile insurance policy required by law shall
be determined prior to this Plan, regardless of whether the no-fault policy has
been selected as secondary.
C.
Non-Dependent/Dependent
Subject to paragraph I, the benefits of the Health Care Arrangement which
covers the person as an employee, member or subscriber (that is, other than
as a dependent) shall be determined before those of the Health Care
Arrangement which covers the person as a dependent.
D.
Dependent Child/Parents not Separated or Divorced
Except as stated in Paragraph (E) below, when this Plan and another Health
Care Arrangement cover the same child as a dependent of different persons,
called “parents”:
the benefits of the Health Care Arrangement of the parent whose
birthday falls earlier in a year are determined before those of the Health
Care Arrangement of the parent whose birthday falls later in that year;
but
if both parents have the same birthday, the benefits of the Health Care
Arrangement which covered the parent longer are determined before
those of the Health Care Arrangement which covered the other parent
for a shorter period of time.
However, if the other Health Care Arrangement does not have the rule
described in (1) immediately above, but instead has a rule based upon the
gender of the parent, and if, as a result, the Health Care Arrangements do
not agree on the order of benefits, the rule in the other Health Care
Arrangement will determine the order of benefits.
For a dependent who has coverage under either or both parents and also
has coverage as a dependent under a spouse’s plan, the rule in paragraph H
applies.
34
E.
Dependent Child/Separated or Divorced Parents
If two or more Health Care Arrangements cover a person as a Dependent
Child of divorced or separated parents, benefits for the child are determined
in this order:
first, the Health Care Arrangement of the parent with custody of the
child;
then, the Health Care Arrangement of the spouse of the parent with
custody of the child;
then, the Health Care Arrangement of the parent not having custody of
the child; and
finally, the Health Care Arrangement of the spouse of the parent not
having custody of the child.
However, if the specific terms of a court decree state that one of the parents
is responsible for the health care expenses of the child, and the entity
obligated to pay or provide the benefits of the Health Care Arrangements of
that parent has actual knowledge of those terms, the benefits of that Health
Care Arrangement are determined first. This paragraph does not apply with
respect to any Plan Year starting before the Plan is given notice of the court
decree.
This Plan will not cover the expenses of any child who does not meet the
Plan’s definition of Dependent as defined in Article II, except as the Plan may
voluntarily cover pursuant to a qualified medical child support order under
Section 609(a) of ERISA.
F.
Active/Inactive Employee
The benefits of a Health Care Arrangement which covers a person as an
employee who is neither laid off nor retired (or as that employee’s
dependent) are determined before those of a Health Care Arrangement
which covers that person as a laid off or retired employee (or as that
employee’s dependent). If the other Health Care Arrangement does not have
this rule, and if, as a result, the Health Care Arrangements do not agree on
the order of benefits, this rule is ignored.
G.
Continuation Coverage
If an individual is covered under a continuation plan as a result of the
purchase of coverage as provided under federal or state law, and also under
another group plan, the following shall be the order of benefit determination:
First, the benefits of a plan covering the person as an employee (or as
the dependent of an employee);
Second, the benefits of coverage under the continuation plan.
35
If the other plan does not have the rule described above, and if, as a result,
the plans do not agree on the order of benefits, this rule is ignored.
H.
Longer-Shorter Length of Coverage
If none of the above rules determines the order of benefits, the benefits of the
Health Care Arrangement which has covered the person longer are
determined before those of the Health Care Arrangement which has covered
that person for the shorter time.
The start of a new plan does not include:
A change in the amount or scope of a plan’s benefits;
A change in the entity that pays, provides or administers the plan’s
benefits; or
A change from one type of plan to another, such as from a single
employer plan to a multiple employer plan.
I.
Medicare Coordination
Employees and/or Spouses Entitled to Medicare Due to Age
Unless an active Employee entitled to Medicare due to age gives the
Plan notice, in the form and manner requested by the Plan
Administrator, waiving his or her right to Plan benefits, the Plan is
Primary. With respect to the spouse who is entitled to Medicare due to
age of an active Employee, unless the Employee gives the Plan notice,
in the form and manner requested by the Plan Administrator, waiving
Plan benefits, the Plan is primary.
Medicare Disabled Covered Persons
If required by law, the Plan is primary with respect to a Covered Person
who is also entitled to Medicare because of disability. Otherwise, the
Plan is secondary.
Covered Persons with End-Stage Renal Disease
For the period required by law, if any, the Plan is primary with respect
to a Covered Person entitled to Medicare because of end-stage renal
disease. Otherwise, the Plan is secondary.
6.4
Effect on the Benefits of this Plan
A.
When this Section Applies
This Section 6.4 applies when, in accordance with Section 6.3, “Order of
Benefit Determination Rules”, this Plan is a secondary payor of benefits to
one or more other Health Care Arrangements. In that event, the benefits of
this Plan may be reduced under this Section. Such other Health Care
36
Arrangement or Arrangements are referred to as “the other Arrangements” in
(B) immediately below.
B.
Reduction in this Plan’s Benefits
The benefits that would be payable under this Plan in the absence of the
COB provisions specified in this Article VI will be reduced by the benefits
payable under the other Arrangements for the expenses covered in whole or
in part under this Plan. This applies whether or not claim is made under a
Health Care Arrangement.
When a Health Care Arrangement provides benefits in the form of services,
the reasonable cash value of each service rendered will be considered both
an expense incurred and a benefit payable.
C.
This Plan shall credit against its plan deductible any amounts it would have
credited to its deductible in the absence of the other Health Care
Arrangement.
6.5
Disagreement on Order of Benefits
If the Plan and other Health Care Arrangement(s) cannot agree on the order of
benefits within thirty (30) calendar days after the plans have received all of the
information needed to pay the claim, the Plan shall immediately pay half of the
claim and will determine its liability following payment, except that the Plan shall be
required to pay no more than it would have paid had it been the primary plan.
6.6
Limitation of Benefits
In applying this Article’s provisions, the Plan does not pay health care benefits in
an amount greater than it would have if it were primary.
6.7
Right to Receive and Release Necessary COB Information
The County has the right to obtain any information necessary to apply the COB
provisions of this Article VI. The County has the right to obtain COB information
from or give that information to any other organization or person involved in the
administration of the COB provisions of this Plan or any other Health Care
Arrangement. The County need not tell, or get the consent of, any person prior to
obtaining that information. Each person claiming benefits under this Plan must give
the County any information it needs to process the claim.
6.8
Facility of Payment
A payment made under another Health Care Arrangement may include an amount
which should have been paid under this Plan. If it does, the County may pay that
amount to the organization which made that payment. That amount will then be
treated as though it were a benefit paid under this Plan. The County will not have
to pay that amount again. The term “payment made” includes providing benefits in
the form of services, in which case “payment made” means reasonable cash value
of the benefits provided in the form of services.
37
6.9
Right of Recovery
If the amount of the payments made by the County is more than it should have
paid under the COB provisions specified in this Article VI, it may recover the
excess from one or more of:
A.
the persons it has paid or for whom it has paid;
B.
insurance companies; or
C.
other Health Care Arrangements, including Workers’ Compensation.
The “amount of the payments made” includes the reasonable cash value of any
benefits provided in the form of services.
6.10 Governing Provisions
When the provisions describing coordination of benefits are set forth in an
applicable Incorporated Document, such Incorporated Document shall govern
except to the extent the provisions fail to establish order of responsibility, in which
case the provisions of this Article VI shall govern.
38
ARTICLE VII
COBRA CONTINUATION COVERAGE
7
7.1
Eligibility for Continuation Coverage
The provisions contained in this Article VII apply only to Section 4.4(A), (B), (C),
(D), and (E) benefits provided under the Plan. The provisions of this Article VII do
not govern to the extent provided in Section 7.9.
Certain Employees and Dependents shall have the right to purchase continuation
coverage under this Plan in accordance with the provisions of the Consolidated
Omnibus Budget Reconciliation Act of 1985, Public Law 99-272, Title X (COBRA),
provided such individuals were Covered Persons under the Plan on the date
immediately preceding the date of a Qualifying Event or become Covered Persons
during the continuation period because such Dependent is born to or placed for
adoption with the Employee.
7.2
Definitions
For purposes of this Article VII, the following terms have the following meanings:
A.
“Employee” means a person who is (or was) covered under the Plan by
virtue of the person’s performing services for the Employer on the day before
the occurrence of the event giving rise to the right to elect COBRA
continuation coverage.
B.
“Dependent” means, with respect to an Employee as defined in this Section
7.2, any individual who, on the day before the occurrence of the event giving
rise to the right to elect COBRA continuation coverage, is covered under the
Plan as (1) the Spouse of such Employee or (2) the Dependent Child of such
Employee. The term Dependent shall include any child born to or placed for
adoption with the Employee during the continuation period.
C.
“Qualified Beneficiary” means an Employee or Dependent as defined in this
Section 7.2 but shall not mean Dependents defined in Section 7.7(B), except
that the term Qualified Beneficiary shall include Dependents born to or
placed for adoption with the Employee during the continuation period.
D.
“Qualifying Event” means any of the following, the occurrence of which would
result in loss of coverage under the Plan were it not for the right to purchase
COBRA continuation coverage:
for Employees, termination of employment for any reason other than
gross misconduct, or loss of eligibility due to reduction in hours worked
by the Employee;
for Dependents:
a. death of the Employee;
39
b. divorce of the Employee and Spouse;
c. legal separation of the Employee and Spouse;
d. reduction in hours worked by the Employee or termination of
employment by the Employee for any reason other than gross
misconduct;
e. entitlement of the Employee to benefits under Title XVIII of the
Social Security Act (relating to Medicare); or
f. ceasing to qualify as a Dependent Child under the Plan.
The Qualifying Event shall be deemed to occur the date coverage ends
because of the Qualifying Event— not on the date of the Qualifying Event.
7.3
Loss of Eligibility for Continuation Coverage
A Qualified Beneficiary shall not be eligible for COBRA continuation coverage
unless:
A.
the County or Plan Administrator is notified of the election of COBRA
continuation coverage, on a form provided for that purpose, within 60 days of
the later of:
the date the Qualified Beneficiary’s coverage under the Plan would
otherwise terminate by reason of an event described in Section 7.2(D);
or
the date notice of eligibility is sent to the individual in accordance with
Section 7.5(C); and
B.
the Qualified Beneficiary pays the initial required premium, as set forth in
Section 7.8, no later than the date 45 days after the date on which COBRA
continuation coverage was elected.
Notwithstanding the foregoing, the Outbreak Period shall be disregarded for
determining the 60- and 45-day deadlines in this Section.
Until expiration of the election period, a Qualified Beneficiary may change or
revoke any election. Failure to elect COBRA continuation coverage within the
prescribed election period shall result in a waiver of the right to COBRA
continuation coverage.
7.4
Termination of COBRA Continuation Coverage
COBRA continuation coverage shall terminate on the date on which the earliest of
the following occurs:
A.
the last day of the month preceding the date the Qualified Beneficiary fails to
pay a subsequent required premium within 30 days of the date it is due;
40
B.
the date the Qualified Beneficiary first becomes, after the date of making a
COBRA election, entitled to Medicare;
C.
the date the Qualified Beneficiary first becomes, after the date of making a
COBRA election, covered under another group health plan, as defined in
Code Section 5000(b)(1), not containing a limitation or exclusion as to any
pre-existing condition of such individual (other than such an exclusion or
limitation which does not apply to, or is satisfied by, such beneficiary by
reason of the Health Insurance Portability and Accountability Act of 1996);
D.
36 months from the date on which a Qualifying Event described in Sections
7.2(D)(2)(a), 7.2(D)(2)(b), 7.2(D)(2)(c), 7.2(D)(2)(e), or 7.2(D)(2)(f) occurs;
E.
18 months from the date on which a Qualifying Event described in Sections
7.2(D)(1) or 7.2(D)(2)(d) occurs. If a Qualifying Event described in Sections
7.2(D)(2)(a), 7.2(D)(2)(b), 7.2(D)(2)(c), or 7.2(D)(2)(f) occurs subsequent to a
Qualifying Event described in Section 7.2(D)(2)(d), an additional period of
coverage shall be allowed for Dependents who have properly and timely
elected and paid for COBRA continuation coverage; but, in no event shall
the sum of the first and second periods of coverage exceed 36 months from
the date of the first Qualifying Event giving rise to the Qualified Beneficiary’s
eligibility for COBRA continuation coverage;
F.
the date the County terminates all group health plans;
G.
in the case of a Qualified Beneficiary who is determined under Title II or XVI
of the Social Security Act to have been disabled (i) at the time of the
Qualifying Event or (ii) at any time during the first 60 days of continuation
coverage, the 18-month period set forth in Section 7.4(E) shall be extended
to 29 months; provided that such individual notifies the Plan Administrator of
such determination in accordance with Section 7.5(D) before the end of such
18-month period; and provided further that if the Qualified Beneficiary does
not remain disabled during the extended period, coverage shall cease with
the month that begins more than 30 days after the date of the final
determination under Title II or XVI of the Social Security Act that the
Qualified Beneficiary is no longer disabled;
H.
in the case of a Qualifying Event described in Section 7.2(D)(2)(d) that
occurs less than 18 months after the date the Employee becomes entitled to
Medicare, 36 months from the date the Employee becomes entitled to
Medicare; or
I.
for the Health Care Spending Account Plan or Limited Purpose Health Care
Spending Account Plan, the last day of the Plan Year in which the Qualifying
Event occurs (subject to any applicable grace period).
7.5
Notice Requirements
A.
The Employer shall notify the Plan Administrator of the occurrence of an
event described in Sections 7.2(D)(1), 7.2(D)(2)(a), 7.2(D)(2)(d), and
7.2(D)(2)(e) within 30 days of the date of the described event.
41
B.
The Qualified Beneficiary shall be responsible for notifying the Plan
Administrator of the occurrence of an event described in Sections
7.2(D)(2)(b), 7.2(D)(2)(c), or 7.2(D)(2)(f) within 60 days of the date of the
described event. The Outbreak Period shall be disregarded for determining
this 60-day deadline.
C.
The Plan Administrator shall provide notice to Qualified Beneficiaries of their
COBRA continuation coverage rights within 14 days of the date it receives
the notice described in Sections 7.5(A) and (B).
D.
A Qualified Beneficiary, who is determined under Title II or XVI of the Social
Security Act to have been disabled at any time within the first 60 days of the
continuation period, shall be responsible for notifying the Plan Administrator
of such determination within 60 days after the date of such determination,
but in no event later than the end of the 18-month period set forth in Section
7.4(E). Such Qualified Beneficiary further shall be responsible for notifying
the Plan Administrator of any final determination under such Title(s) that he
or she is no longer disabled, within 30 days of the date of such
determination. The Outbreak Period shall be disregarded for determining
these 30- and 60-day deadlines.
E.
At the commencement of coverage under the Plan, the Plan Administrator
shall provide each Employee or Spouse who is a Covered Person with
notice of their rights under COBRA.
F.
The Plan Administrator shall provide notice to each Qualified Beneficiary of
any termination of COBRA continuation coverage that takes effect earlier
than the end of the maximum period of COBRA continuation coverage
applicable to the Qualified Beneficiary.
G.
The Plan Administrator shall provide notice to each Employee, Spouse or
Dependent of the unavailability of COBRA continuation coverage if the Plan
Administrator determines after receiving notice of a Qualifying Event that the
Employee, Spouse or Dependent is not entitled to COBRA continuation
coverage.
7.6
Coverage Available for Continuation
A Qualified Beneficiary may elect to continue receiving the health care coverage
(as defined in COBRA regulations) he or she was receiving immediately before the
event giving rise to the right to elect COBRA continuation coverage. If coverage
provided to similarly situated active Employees is changed or eliminated, COBRA
continuation coverage also shall be changed or eliminated. If the County
terminates the Plan but continues to maintain one or more other group health
plans, as defined in Code Section 5000(b)(l), COBRA continuation coverage
recipients may elect coverage under one of those other group health plans. A
Qualified Beneficiary may elect to continue to receive coverage for the level of
reimbursement, if any, that the individual had in effect under his or her Health Care
Spending Account or Limited Purpose Health Care Spending Account immediately
before the Qualifying Event after reflecting debits for health care reimbursements
made up to the Qualifying Event.
42
7.7
Election Rules
A.
Scope of Election
Each affected Qualified Beneficiary generally shall have an independent right to
elect or reject COBRA continuation coverage under this Article VII; provided,
however, that in the event an Employee or his or her Spouse makes an election to
continue coverage on behalf of the other or on behalf of any other Qualified
Beneficiary, such election shall be binding on such other party; and provided
further, that in the event the Qualified Beneficiary is a minor or an incapacitated
person, the parent or legal guardian of such minor or the legal representative of
such incapacitated person shall have the right to elect or reject continuation
coverage on behalf of such minor or incapacitated person, and any such election
or rejection of coverage shall be binding on such minor or incapacitated person.
Each Qualified Beneficiary is entitled to a separate election with respect to any
choice of coverages available under the Plan.
B.
After Acquired Dependents
A Qualified Beneficiary eligible for COBRA continuation coverage may elect to
cover Dependents (as defined in Section 7.2(B)) acquired after the date of
eligibility described under Section 7.3 to the same extent as Covered Persons,
provided the County or Plan Administrator is notified of the election to cover such
Dependent(s) in the manner and within the time set forth in an applicable
document incorporated by reference under the Plan, except that in no event shall
notice be required within a period of less than 30 days. (Notwithstanding the
foregoing, the Plan shall disregard the Outbreak Period for purposes of this 30
days.) Such newly acquired Dependent(s), other than Qualified Beneficiaries
defined in Section 7.2(C), shall have no independent right to COBRA continuation
coverage. Failure to notify the County or Plan Administrator within the prescribed
time shall result in a waiver of the right to elect COBRA continuation coverage for
such newly acquired Dependent(s).
C.
Open Enrollment Periods
During an open enrollment period occurring during the COBRA coverage period, a
Qualified Beneficiary may elect to cover Dependents not previously covered,
subject to the terms and conditions set forth in the applicable document
incorporated by reference under the Plan. This subsection (C) shall not apply to
Health Care Spending Account or Limited Purpose Health Care Spending Account
benefits.
43
7.8
Required Premium
In order to receive COBRA continuation coverage, Qualified Beneficiaries shall
agree, on forms furnished by the Plan Administrator, to pay any required premiums
to the Plan and shall make such premium payments when and as required. All
premiums other than the initial premium shall be due on the first day of the
calendar month. The amount of the premium shall be no more than 102 percent of
the cost of coverage. In the case of a Qualified Beneficiary who is determined
under Title I or XVI of the Social Security Act to have been disabled at any time
within the first 60 days of continuation coverage, the cost of coverage for the 19th
month through the 29th month of coverage shall be no more than 150 percent of
the cost of coverage. Notwithstanding the foregoing, the cost of coverage shall not
exceed the maximum, nor be changed more frequently than, permitted by law.
7.9
Governing Provisions
When the provisions for COBRA continuation coverage are set forth in an
applicable Incorporated Document, such applicable Incorporated Document shall
govern except to the extent such language fails to comply with requirements of
applicable law or fails to determine the right or liability of the party, in which case
the provisions of this Article VII shall govern.
44
ARTICLE VIII
CONTRIBUTIONS, FUNDING AND PLAN ASSETS
8
8.1
Contributions
A.
Employer Contributions
The Employer shall pay premiums for Benefits listed in Section 4.4 to the
Employer-sponsored plans to which such benefits are payable provided that the
Covered Employee shall authorize Salary Reduction Contributions and/or Salary
Deduction Contributions in a corresponding amount pursuant to Section 8.1(B)(2).
The Employer shall make Employer contributions for benefits listed in Section 4.5
to the Employer-sponsored plans to which such benefits are payable.
The Employer shall make the required contribution to a Health Savings Account for
Employees who elect such premium payment benefit under Article IV.
Notwithstanding any contrary Plan provision, the Employer is not obligated to
contribute to the Plan after it is terminated except to the extent required to pay
benefits outstanding on the date the termination is adopted or, if later, effective.
B.
Salary Reduction and/or Salary Deduction Contributions
As a condition of Plan participation, Employees must agree to direct the Employer
to:
not reduce their compensation and not provide premium payment
benefits pursuant to Section 4.4, or
reduce their compensation and make Salary Reduction Contributions
and/or Salary Deduction Contributions to the plan(s) governing their
selected premium payment benefits.
Any election of premium payment benefits shall be null and void unless the
Employee authorizes a Salary Reduction and/or a Salary Deduction as provided
for herein. An Employer must take Salary Reduction Contributions and/or Salary
Deduction Contributions and apply them as directed, except that the Employer
may not apply a Salary Reduction Contribution or a Salary Deduction Contribution
for a selected premium payment benefit to any other premium payment benefit nor
may a Salary Reduction Contribution or a Salary Deduction Contribution be
applied during a subsequent Plan Year to any participating plan that provides
benefits or coverage. Any such Salary Reductions and/or a Salary Deductions are
hereby incorporated by reference into the Plan as if set forth in full herein.
45
C.
Priority of Contributions
Contributions shall be deemed to come first from amounts contributed by Covered
Employees and then from amounts contributed by the Employer.
D.
COBRA Contributions
To the extent a former Covered Employee, Dependent or Spouse has exercised
his or her continuation rights under the Consolidated Omnibus Reconciliation Act
of 1985 (COBRA) with respect to benefits described in Section 7.1, the Plan shall
accept contributions from such individuals as COBRA premiums.
8.2
Funding
A.
Funding Policy
The Employer shall establish and carry out, and may revise from time to time, the
funding policy for the Plan.
B.
Funding Mechanism
Contributions from the Employer, Employees, Dependents, and/or Spouses may
be held under or paid to one or more of the following vehicles: insurance policies
or arrangements, arrangements with health maintenance organizations, or the
Benefits Trust, which is hereby incorporated by reference, or other trust funds
established by the Employer. Any amounts held under or paid to such vehicle shall
be subject to the payment of benefits under the Plan. In addition, benefits may be
paid directly from the general fund or other assets of the Employer. Benefits
provided through insurance or pursuant to an arrangement with a health
maintenance organization shall be only paid by the Insurance Company issuing
the insurance policy or by the health maintenance organization. The Employer
shall have no liability for benefits provided through insurance or pursuant to an
agreement with a health maintenance organization.
8.3
Plan Assets
Plan assets shall be maintained in the Benefits Trust. The Employer shall make
payments provided for in Section 8.1(A) from its general fund or other assets. The
Employer shall make payments provided for in Section 8.1(B) and (D) by collecting
Employee contributions and COBRA contributions and transmitting such amounts
to the applicable benefits described in Article IV.
8.4
Treatment of Certain Policy Payments
Where an insurance policy provides for payment of premiums directly from the
Employer, unless the insurance policy states otherwise, payable dividends,
retroactive rate adjustments, rebates or experience refunds are not plan assets.
These dividends, retroactive rate adjustments, rebates or experience refunds are
Employer property, which the Employer may retain to the extent they do not
exceed the Employer’s aggregate contributions to Plan cost made from its own
funds, except as required by law.
46
ARTICLE IX
CLAIM AND PAYMENT PROCEDURES
9
9.1
General Claims Procedures
Except as hereinafter provided, the provisions of this Section shall apply to every
claim for a benefit under the Plan regardless of the basis asserted for the claim
and regardless of when the act or omission upon which the claim is based
occurred.
These provisions shall not apply to the extent that claims and appeals procedures
are set forth differently in an Incorporated Document, except to the extent that
claims and appeals procedures set forth in an Incorporated Document fail to
comply with requirements of applicable law, in which case the provisions of this
Article IX shall govern. In addition, the provisions of this Article IX shall not be
interpreted so as to override applicable state laws that are more protective of
Covered Persons’ rights with respect to these claims and appeals provisions.
Solely with respect to the Benefits described in Section 4.4(A), notwithstanding
any other Plan provision to the contrary, the Plan intends to comply with Section
2719 of the Public Health Service Act, as set forth in the Patient Protection and
Affordable Care Act, and all regulations and guidance issued thereunder.
Claim procedures for the Dependent Care Spending Account shall be as modified
in Article VI of Appendix A.
Claim procedures for the Health Care Spending Account shall be as modified in
Article VI of Appendix B.
Claim procedures for the Limited Purpose Health Care Spending Account shall be
as modified in Article VI of Appendix C.
Claim procedures for the Health Savings Account shall not be subject to this
Article IX, but shall be subject to the terms set forth by the trustee/custodian for the
Health Savings Account.
9.2
Claim Administrator
The Board of Supervisors shall have the authority to appoint, remove, and replace
one or more Claim Administrators. A Claim Administrator shall have the duties,
powers, and responsibilities set forth herein.
Claims with respect to benefits provided on an insured basis shall be determined
by the insurance company issuing the policy or agreement as Claim Administrator,
except that, if the County and insurance company so agree in writing, the Plan
Administrator shall retain final authority over the disposition of any review pursuant
to Section 9.9.
With respect to claims for benefits provided on a self-funded basis, the Plan
Administrator shall retain final authority over the disposition of any review pursuant
47
to Section 9.9 unless otherwise delegated to a Claim Administrator in an
Incorporated Document.
9.3
Claims Administration
The Claim Administrator shall have the duty to receive and review claims for
benefits under the Plan; to determine what amount, if any, is due and payable
under the terms and conditions of the Plan; to make or authorize appropriate
disbursements of benefit payments to persons entitled thereto; to inform the
County or any other third party, as appropriate, of the amount of such benefits; to
make claims decisions under the terms of the Plan; and to provide a full and fair
review to any individual whose claim for benefits has been denied in whole or in
part, except as described in Section 9.2 as applied to self-funded benefits.
9.4
Claimants
A Covered Person (or his or her duly authorized representative) may file a claim
for benefits to which such claimant believes he or she is entitled.
9.5
Claim Forms
The Claim Administrator shall furnish to a claimant, upon request, the form(s)
required for filing a claim for benefits under the Plan.
9.6
Deadline for Filing a Claim
No claim for benefits shall be payable unless a properly completed claim form,
including all necessary documentation of services or supplies received, is received
by the Plan Administrator within the timeframe set forth in the applicable
Incorporated Document. Failure to submit a properly completed claim form within
the prescribed period shall neither invalidate nor reduce a claim if it is shown that it
was not reasonably possible to furnish the claim form within that time and that the
claim form was submitted as soon as reasonably possible.
9.7
Proof of Claim
As a condition of receiving a Plan benefit and as often as the Plan Administrator
determines is reasonably necessary, a claimant must submit such evidence as the
Plan Administrator shall require that a claim is reimbursable under the terms of the
Plan.
9.8
Decision on the Claim
Unless otherwise specified in an applicable Incorporated Document, these claim
procedures will apply to any Benefit under the Plan. An “adverse benefit
determination” is a denial, reduction or termination of a benefit, failure to provide or
pay for (in whole or in part) a benefit, a denial to participate in the Plan, or a claim
adverse benefit determination on the grounds that the treatment is experimental,
investigational or not medically necessary. This also includes concurrent care
determinations. With respect to claims for disability benefits and claims for benefits
under Section 4.4(A), certain retroactive terminations of coverage will be
48
considered adverse benefit determinations, whether or not there is an adverse
effect on any particular benefit at that time, to the extent required by applicable
regulations and by guidance from the relevant government agencies.
A.
Any time a claimant receives an adverse benefit determination for benefits,
other than group health plan and disability benefits as described in
paragraphs B and C below, the claimant shall be given written notice of such
action within a reasonable period of time but not later than 90 days after the
claim is received by the plan, unless special circumstances require an
extension of time for processing. If there is an extension, the claimant shall
be notified of the extension and the reason for the extension within the initial
90-day period. The extension shall not exceed 180 days after the claim is
filed.
If a claim is denied, in whole or in part, the claimant shall be notified of the
adverse benefit determination in writing. The notice of adverse benefit
determination shall contain the following information:
the specific reason(s) for the adverse benefit determination;
a reference to the specific provision(s) in the Plan on which the adverse
benefit determination is based;
a description of additional material or information necessary to perfect
the claim and an explanation of why the material or information is
needed; and
a description of the Plan’s claim and appeal procedures and applicable
timeframes.
B.
Any time a claimant receives an adverse benefit determination for disability
benefits, the claimant shall be given written notice of such action within a
reasonable period of time, no later than 45 days after the claim is received
by the plan, unless the Claim Administrator determines that an extension of
up to 30 days is necessary due to matters beyond the Plan’s control. If there
is an extension, the claimant shall be notified, before the initial 45-day period
of time expires, of the circumstances requiring the extension of time and the
date by which the Plan expects to render a decision. The 30-day extension
period is tolled until the claimant responds to any information request. A
second 30-day extension is also permitted if the Claim Administrator
determines that, due to matters beyond the Plan’s control, a decision cannot
be rendered within the first extension period. In that case, the claimant shall
be notified, before the end of the expiration of the first 30-day extension
period, of the circumstances requiring the extension and the date as of which
the plan expects to render a decision. Such extension notices shall
specifically explain the standards on which entitlement to a benefit is based,
the unresolved issues that prevent a decision on the claim, and the
additional information needed to resolve those issues. The claimant shall be
afforded at least 45 days within which to provide the specified information.
49
If a claim is denied, in whole or in part, the claimant shall be notified of the
adverse benefit determination in writing. The notice of adverse benefit
determination shall contain the following information:
the specific reason(s) for the adverse benefit determination;
a reference to the specific provision(s) in the Plan on which the adverse
benefit determination is based;
a description of additional material or information necessary to perfect
the claim and an explanation of why the material or information is
needed;
a description of the Plan’s claim and appeal procedures and applicable
timeframes;
for disability claims, a discussion of the decision, including an
explanation of the basis for disagreeing with or not following:
a. the views of health care professionals treating the claimant and
vocational professionals who evaluated the claimant;
b. the views of medical or vocational experts obtained by the plan,
without regard to whether the advice was relied upon for the
adverse benefit determination; and
c. any Social Security Administration disability determination regarding
the claimant presented to the Plan;
for adverse benefit determinations based on medical necessity,
experimental treatment, or other similar exclusions or limits, an
explanation of the scientific or clinical judgment used in the decision, or
a statement that an explanation will be provided free of charge upon
request;
for disability claims, either the specific rule, guideline, protocol,
standards, or other similar criteria relied upon in making the adverse
benefit determination, or a statement that such rules, guidelines,
protocols, standards or other similar criteria do not exist; and
for disability claims, a statement that reasonable access to and copies of
all documents, records, and other information relevant to the claimant’s
claim for benefits are available free of charge, upon request.
C.
The following rules shall apply to medical, dental, vision, employee
assistance plan or health care spending account or limited purpose health
care spending account benefits except that claims for health care spending
account or limited purpose health care spending account benefits shall be
considered “post-service” only.
50
Urgent Care Claims – Claims for which the application of non-urgent
care time frames could seriously jeopardize the life or health of the
patient or the ability of the patient to regain maximum function, or, in the
judgment of a physician, would subject the patient to severe pain that
cannot be adequately managed otherwise. The Plan shall defer to an
attending provider to determine if a medical claim under Section 4.4(A)
is urgent.
The Claim Administrator shall notify the claimant of the Plan’s
determination not later than 72 hours after receipt of the claim, unless
the claimant fails to provide sufficient information to determine whether,
or to what extent, benefits are covered or payable under the Plan. In the
case of such a failure, the Claim Administrator shall notify the claimant
as soon as possible, but not later than 24 hours after receipt of the claim
by the Plan, of the specific information necessary to complete the claim.
The claimant shall be afforded a reasonable amount of time, taking into
account the circumstances, but not less than 48 hours, to provide the
specified information. The Claim Administrator shall notify the claimant
of the Plan’s benefit determination as soon as possible, but no later than
48 hours after the earlier of the Plan’s receipt of the specified
information or the end of the period afforded the claimant to provide the
specified additional information.
Pre-service Claims – Claims which must be decided before a patient will
be afforded access to health care (e.g., preauthorization requests).
The Claim Administrator shall notify the claimant of the Plan’s
determination not later than 15 days after receipt of the claim. This
period may be extended by 15 days, provided the Claim Administrator or
its delegate determines that an extension is necessary due to matters
beyond the control of the Plan and notifies the claimant within the initial
period of the circumstances requiring the extension and the date by
which the Plan expects to render a decision. If such an extension is
necessary due to the claimant’s failure to submit the information
necessary to decide the claim, the notice of extension shall specifically
describe the required information. The claimant shall be afforded at least
45 days from receipt of the notice within which to provide the specified
information.
If the claim is improperly filed, the Claim Administrator shall notify the
claimant as soon as possible, but not later than five (5) days after receipt
of the claim by the Plan, of the specific information necessary to
complete the claim.
Post-service Claims – Claims involving the payment or reimbursement
of costs for medical care which has already been provided.
For non-urgent post-service health claims, the Plan has up to 30 days,
to evaluate and process claims for benefits. The 30-day period begins
on the date the claim is first filed. This period may be extended by 15
days provided the Claim Administrator or its delegate determines that
51
an extension is necessary due to matters beyond the control of the Plan
and notifies the claimant within the initial period, of the circumstances
requiring the extension and the date by which the Plan expects to
render a decision. The claimant shall be afforded at least 45 days from
receipt of the notice within which to provide the specified information.
Concurrent Care Claims – Claims where the Plan has previously
approved a course of treatment over a period of time or for a specific
number of treatments, and the Plan later reduces or terminates
coverage for those treatments.
Concurrent care claims may fall under any of the other three
categories, depending on when the appeal is made. However, the Plan
must give the claimant sufficient advance notice to appeal the claim
before a concurrent care decision takes effect.
Notification of Adverse Benefit Determination - applicable to all health
claims
In the event of an adverse benefit determination, the claimant will
receive notice of the determination.
If a claim is denied, in whole or in part, the claimant shall be notified of
the adverse benefit determination in writing. The notice of adverse
benefit determination shall contain the following information:
a. the specific reason(s) for the adverse benefit determination;
b. a reference to the specific provision(s) in the Plan on which the
adverse benefit determination is based;
c. a description of additional material or information necessary to
perfect the claim and an explanation of why the material or
information is needed;
d. a description of the Plan’s claim and appeal procedures and
applicable timeframes;
e. if any internal rules, guidelines, protocols or similar criteria were
used as a basis for the adverse benefit determination, either the
specific rule, guideline, protocol, or other similar criteria or a
statement that a copy of such information will be made available
free of charge upon request;
f. for adverse benefit determinations based on medical necessity,
experimental treatment, or other similar exclusions or limits, an
explanation of the scientific or clinical judgment used in the
decision, or a statement that an explanation will be provided free of
charge upon request; and
52
g. For adverse determinations involving urgent care (for medical
claims only), the notice will also include a description of the
expedited review process for such claims. This notice can be
provided orally within the timeframe for the expedited process, as
long as written notice is provided no later than 3 days after the oral
notice.
For medical claims only, the notice of adverse benefit determination
shall include information sufficient to identify the claim involved,
including:
h. the date of service;
i.
the health care provider;
j.
the claim amount (if applicable);
k. the denial code and its corresponding meaning;
In addition, for medical claims only, the notice of adverse benefit
determination shall include the following information:
l.
a statement that diagnosis and treatment codes (and their
meanings) shall be provided upon request;
m. description of the Plan’s standard used in denying the claim;
n. a description of the external review processes; and
o. the availability of, and contact information for, any applicable office
of health insurance consumer assistance or ombudsman to assist
enrollees with the internal claims and appeals and external review
processes.
9.9
Right to Appeal
A claimant who has received an adverse benefit determination, shall have the right
to appeal the adverse benefit determination.
The following rules shall apply to claims filed with respect to any Benefit under the
Plan, unless otherwise specified in an applicable Incorporated Document.
A.
A claimant who has received an adverse benefit determination for benefits,
other than the group health plan and disability benefits as described in
paragraphs B and C below, or is otherwise adversely affected by action of
the Claim Administrator, shall have the right to request review of the claim.
Such request must be in writing and must be made within 60 days after such
claimant is advised of the Claim Administrator’s action. The requested
review must take into account all comments, documents, records, and other
information submitted by the claimant relating to the claim, without regard to
whether such information was submitted or considered in the initial benefit
53
determination. If written request for review is not made within the 60-day
period, the claimant shall forfeit his or her right to review. The claimant or a
duly authorized representative of the claimant may review all relevant
information and submit issues, comments, documents, records, and other
information in writing.
The Claim Administrator or Plan Administrator or its delegate, as applicable, shall
then review the claim. It may hold a hearing if it deems it necessary and shall issue
a written decision reaffirming, modifying, or setting aside its former action within a
reasonable period of time, but not later than 60 days after receipt of the written
request for review, unless the Plan Administrator determines that special
circumstances, such as a hearing, require an extension. The claimant shall be
notified in writing of any such extension within 60 days following the request for
review, and such extension shall not exceed 60 days from the end of the initial
period.
A copy of the review determination shall be furnished to the claimant. If the claim is
denied, the review determination notice shall contain the following information:
the specific reason(s) for the adverse benefit determination;
a reference to the specific provision(s) in the Plan on which the adverse
benefit determination is based;
a statement that the claimant is entitled to receive, upon request and
free of charge, reasonable access and copies of all relevant information;
a description of any voluntary appeals procedures offered by the Plan, if
any; and
a statement that the claimant has the right to obtain information about
the voluntary appeals process, if any.
The decision shall be final and binding upon the claimant and all other persons or
entities involved, except to the extent that the Plan provides for a voluntary
appeals procedure subsequent to this appeals process, or the decision is subject
to judicial review.
B.
A claimant who has received an adverse benefit determination for disability
benefits or is otherwise adversely affected by action of the Claim
Administrator shall have the right to request review of the claim. Such
request must be in writing and must be made within 180 days after such
claimant is advised of the Claim Administrator’s action. If written request for
review is not made within the 180-day period, the claimant shall forfeit his or
her right to review. The claimant or a duly authorized representative of the
claimant may review all relevant information and submit issues and
comments in writing.
The Claim Administrator or Plan Administrator or its delegate, as applicable, shall
then review the claim. It shall issue a written decision reaffirming, modifying, or
setting aside its former action within a reasonable period of time, but not later than
54
45 days after receipt of the written request for review, or an additional 45 days if
the Plan Administrator determines that special circumstances require an
extension. The claimant shall be notified in writing of any such extension before
the initial period of time expires, and such notice shall indicate the special
circumstances requiring an extension of time and the date by which the Plan
expects to render the determination on review. The extension period is tolled until
the claimant responds to any information request.
A copy of the review determination shall be furnished to the claimant. If the claim is
denied, the review determination notice shall contain the following information:
the specific reason(s) for the adverse benefit determination;
a reference to the specific provision(s) in the Plan on which the adverse
benefit determination is based;
a statement that the claimant is entitled to receive, upon request and
free of charge, reasonable access and copies of all relevant information;
a description of any voluntary appeals procedures offered by the Plan, if
any;
for disability claims, a statement that the claimant has the right to obtain
information about the voluntary appeals process, if any;
for disability claims, a discussion of the decision, including an
explanation of the basis for disagreeing with or not following:
a. the views of health care professionals treating the claimant and
vocational professionals who evaluated the claimant;
b. the views of medical or vocational experts obtained by the plan,
without regard to whether the advice was relied upon for the
adverse benefit determination; and
c. any Social Security Administration disability determination regarding
the claimant presented to the Plan;
for disability claims, a description of any applicable contractual
limitations period, including the date on which the claim expires;
for disability claims, either the specific rule, guideline, protocol,
standards, or other similar criteria relied upon in making the adverse
benefit determination, or a statement that such rules, guidelines,
protocols, standards or other similar criteria do not exist; and
for adverse benefit determinations based on medical necessity,
experimental treatment, or other similar exclusions or limits, an
explanation of the scientific or clinical judgment used in the decision, or
a statement that an explanation will be provided free of charge upon
request.
55
The Plan will provide for the identification of experts whose advice was obtained
on behalf of Plan in connection with an adverse determination, without regard to
whether the advice was relied on in making the determination.
In deciding an appeal of any adverse benefit determination based in whole or in
part on a medical judgment, the Plan Administrator will consult with a health care
professional who has appropriate training and experience in the field of medicine
involved in the medical judgment, and such individual shall not have been
consulted in connection with the adverse benefit determination that is the subject
of the appeal nor the subordinate of any such individual. In deciding an appeal, no
deference will be afforded to the initial adverse benefit determination and the
review of the appeal will be conducted by an appropriate named fiduciary of the
Plan who is neither the individual who made the adverse benefit determination that
is the subject of the appeal nor the subordinate of such individual.
The Claims Administrator will ensure that all claims and appeals for disability
benefits are handled impartially. The Claims Administrator shall ensure the
independence and impartiality of the persons involved in making the decision.
Accordingly, decisions regarding hiring, compensation, termination, promotion, or
other similar matters with respect to any individual (such as a claims adjudicator or
medical expert) must not be made based upon the likelihood that the individual will
support an adverse benefit determination of benefits. The Claims Administrator
shall ensure that health care professionals consulted are not chosen based on the
expert’s reputation for outcomes in contested cases, rather than based on the
professional’s qualifications.
For disability claims, a claimant shall be able to review his or her file and present
information as part of the appeal. Before making a benefit determination on review,
the Claims Administrator shall provide the claimant with any new or additional
evidence considered or generated by the Plan, as well as any new or additional
rationale to be used in reaching the decision. The claimant shall be given this
information in advance of the date on which the notice of final appeal decision is
made to give such claimant a reasonable opportunity to respond.
If the Plan fails to strictly adhere to the requirements in this subsection with respect
to the claim, the claimant is deemed to have exhausted the Plan’s administrative
remedies and may pursue any other available remedies under applicable law.
However, this shall not apply if the error was de minimis, if the error does not
cause harm to the claimant, if the error was due to good cause or to matters
beyond the Plan’s control, if it occurs in context of good faith exchange of
information, or if the error does not reflect a pattern or practice of noncompliance.
If a court rejects the claimant’s demand for immediate review based on the
exceptions above, the claim will be considered as refiled on appeal upon receipt of
the court’s decision, and the plan will notify the claimant of the resubmission.
The decision shall be final and binding upon the claimant and all other persons or
entities involved, except to the extent that the Plan provides for a voluntary
appeals procedure subsequent to this appeals process, or the decision is subject
to judicial review.
56
C.
A claimant who has received an adverse benefit determination for medical,
dental, vision, employee assistance plan, health care spending account or
limited purpose health care spending account benefits or is otherwise
adversely affected by action of the Claim Administrator, shall have the right
to request review of the claim. Such request must be in writing and must be
made within 180 days after such claimant is advised of the Claim
Administrator’s action. If written request for review is not made within the
180-day period, the claimant shall forfeit his or her right to review. The
claimant or a duly authorized representative of the claimant may review all
relevant information and submit issues and comments in writing.
The Claim Administrator or Plan Administrator or its delegate, as applicable, shall
then review the claim. It shall issue a written decision reaffirming, modifying, or
setting aside its former action within a reasonable period of time, but not later
than:
for urgent health claims, as soon as possible considering the medical
situation, but no later than 72 hours.
for pre-service claims, within a reasonable period of time given the
medical situation, but no later than 30 days (or 15 days following each
appeal if there are two mandatory appeals).
for post-service claims, within a reasonable period of time, but not later
than sixty (60) days after receipt of the request for review (or 30 days
following each appeal if there are two mandatory appeals).
If a claim for medical benefits is an urgent health claim or a claim requiring an
ongoing course of treatment, the claimant may begin an expedited external review,
as described in Section 9.10, before the Plan’s internal appeals process has been
completed.
Medical coverage as described in Section 4.4(A) shall continue pending the
outcome of an internal appeal.
A copy of the review determination shall be furnished to the claimant. If the claim is
denied, the review determination notice shall contain the following:
the specific reason(s) for the adverse benefit determination;
reference to the specific provision(s) in the Plan on which the adverse
benefit determination is based;
a statement that the claimant is entitled to receive, upon request and
free of charge, reasonable access and copies of all relevant information;
a description of any voluntary appeals procedures offered by the Plan, if
any;
a statement that the claimant has the right to obtain information about
the voluntary appeals process, if any, and information as to how the
57
claimant may obtain information about alternative dispute resolution
options from the Department of Labor or state regulators;
if any internal rules, guidelines, protocols or similar criteria were used as
a basis for the adverse benefit determination, either the specific rule,
guideline, protocol, or other similar criteria or a statement that a copy of
such information will be made available free of charge upon request;
for adverse benefit determinations based on medical necessity,
experimental treatment, or other similar exclusions or limits, an
explanation of the scientific or clinical judgment used in the decision, or
a statement that an explanation will be provided free of charge upon
request; and
for adverse determinations involving urgent care, the notice will also
include a description of the expedited review process for such claims
(for medical claims only). This notice can be provided orally within the
timeframe for the expedited process, as long as written notice is
provided no later than 3 days after the oral notice.
For claims for medical benefits, the notice of adverse benefit
determination shall include information sufficient to identify the claim
involved, including:
a.
the date of service;
b.
the health care provider;
c.
the claim amount (if applicable);
d.
the denial code and its corresponding meaning;
e.
In addition, for medical claims only, the notice of adverse benefit
determination shall include the following information:
f.
a statement that diagnosis and treatment codes (and their
meanings) shall be provided upon request;
g.
description of the Plan’s standard used in denying the claim;
h.
a description of the external review processes; and
i.
the availability of, and contact information for, any applicable office
of health insurance consumer assistance or ombudsman to assist
enrollees with the internal claims and appeals and external review
processes.
Upon request by the claimant, the Plan will provide for the identification of experts
whose advice was obtained on behalf of Plan in connection with an adverse
determination, without regard to whether the advice was relied on in making the
determination.
58
In deciding an appeal of any adverse benefit determination based in whole or in
part on a medical judgment, the Plan Administrator shall consult with a health care
professional who has appropriate training and experience in the field of medicine
involved in the medical judgment, and such individual shall not have been
consulted in connection with the adverse benefit determination that is the subject
of the appeal nor the subordinate of any such individual. In deciding an appeal, no
deference shall be afforded to the initial adverse benefit determination and the
review of the appeal shall be conducted by an appropriate named fiduciary of the
Plan who is neither the individual who made the adverse benefit determination that
is the subject of the appeal nor the subordinate of such individual.
The Claims Administrator will ensure that all claims and internal appeals for
medical benefits are handled impartially. The Claims Administrator shall ensure
the independence and impartiality of the persons involved in making the decision.
Accordingly, decisions regarding hiring, compensation, termination promotion, or
other similar matters with respect to any individual (such as a claims adjudicator or
medical expert) must not be made based upon the likelihood that the individual will
support an adverse benefit determination of benefits. The Claims Administrator
shall ensure that health care professionals consulted are not chosen based on the
expert’s reputation for outcomes in contested cases, rather than based on the
professional’s qualifications.
In connection with an internal appeal of a medical claim, a claimant shall be able to
review his or her file and present information as part of the review. Before making
a benefit determination on review, the Claims Administrator shall provide the
claimant with any new or additional evidence considered or generated by the Plan,
as well as any new or additional rationale to be used in reaching the decision. The
claimant shall be given this information in advance of the date on which the notice
of final appeal decision is made to give such claimant a reasonable opportunity to
respond.
For medical claims only, if the Plan fails to strictly adhere to all the requirements of
the internal claims and appeals process with respect to the claim, the claimant is
deemed to have exhausted the internal claims and appeals process and may
request an expedited external review before the Plan’s internal appeals process
has been completed. However, this shall not apply if the error was de minimis, if
the error does not cause harm to the claimant, if the error was due to good cause
or to matters beyond the Plan’s control, if it occurs in context of good faith
exchange of information, or if the error does not reflect a pattern or practice of
noncompliance. In that case, the claimant may resubmit the claim for internal
review and the claimant may ask the Plan to explain why the error is minor and
why it meets this exception.
The decision shall be final and binding upon the claimant and all other persons or
entities involved, except to the extent that the Plan provides for a voluntary
appeals procedure subsequent to this appeals process, or the decision is subject
to judicial review.
59
9.10 Right to an External Review of Claims
To the extent required by PPACA, as amended by HCERA and as interpreted by
applicable guidance and regulations from the relevant government agencies, the
following rules shall apply to claims filed with for benefits under Section 4.4(A) of
the Plan. This Section 9.10 shall not be interpreted to give claimants any rights to
external review beyond what is expressly required under PPACA, as amended by
HCERA and as interpreted by applicable guidance and regulations from the
relevant government agencies. This Section 9.10 is not applicable to any other
benefits offered under the Plan.
The claimant shall be entitled to request an external review of a medical claim
involving medical judgment, as determined by the external reviewer, or a coverage
rescission, provided the claimant requests the external review within four (4)
months of the date of receipt of an adverse benefit determination. If the claimant’s
request for an external review is determined eligible for such a review, an
independent organization shall review the Claims Administrator’s decision and
provide the claimant with a written determination, as described in the Incorporated
Documents.
The external review decision is binding on the claimant and the Plan, except to the
extent that other remedies are available under federal law.
The external review process does not apply to an adverse benefit determination or
final internal adverse benefit determination that is not related to medical judgment
or coverage rescission.
9.11 Legal Remedy
Before pursuing a legal remedy, a claimant shall first exhaust all claims, review,
and appeals procedures required under the Plan.
9.12 Subrogation, Reimbursement and Recovery for Third Party Liability
This Section shall govern with respect to Plan benefits for injuries or illnesses of
Covered Persons related to a third party’s actions or inactions.
With respect to benefits provided on a fully-insured basis, to the extent that
conflicting subrogation, reimbursement or recovery provisions exist in an
Incorporated Document, such provisions in the Incorporated Document shall
govern.
With respect to benefits provided on a self-insured basis, to the extent that any
Incorporated Document also contains subrogation, reimbursement, or recovery
provisions, this subsection and the applicable Incorporated Document will both
apply so as to grant the Plan the greatest possible rights with respect to
subrogation, reimbursement, and recovery.
A.
Subrogation
60
If a Covered Person becomes injured or ill because of the actions or inactions of a
third party, the Plan shall have the right to pursue a claim against the third party for
expenses paid by the Plan related to such injury or illness to the fullest extent
permitted by law, including, but not limited to, the right of recovery of the cost of
medical care and treatment afforded to the County pursuant to A.R.S. § 12-961 et
seq. The Plan’s right of recovery applies to the extent the Plan has paid expenses
related to the injury or illness, regardless of whether any related settlement or
other third-party payment states that the payment (all or part of it) is for health care
expenses or of any allocation or itemization of such recovery to specific types of
injuries.
By accepting Plan benefits to pay for treatments, devices or other products or
services related to such injury or illness, the Covered Person agrees to place such
third-party payments in Covered Person’s separate identifiable account (in an
amount equal to related expenses paid by the Plan or, if less, the full third-party
payment amount) and that the Plan has an equitable lien on such funds, without
regard to whether the Covered Person has been made whole or fully compensated
for the injury or illness. The Covered Person also agrees to serve as a constructive
trustee over the funds until the time they are paid to the Plan. The Covered Person
further agrees to cooperate with the Plan’s recovery efforts and do nothing to
prejudice the Plan’s recovery rights.
The Plan’s right of subrogation will apply to the first dollar of any recovery obtained
from the third-party, without regard to whether the Covered Person has been made
whole or fully compensated for the injury or illness, and shall not be subject to the
principles of unjust enrichment, assertion of a “common fund” doctrine or its
equivalent or any other equitable defenses unless required by law. At its option,
the Plan may file suit or intervene in any pending lawsuit to secure and protect its
rights on any third-party recovery. The Plan is not required to participate in or
contribute to any expenses or fees (including attorney’s fees and costs) incurred in
obtaining the funds.
B.
Plan’s Right of Recovery
If a Covered Person becomes injured or ill because of the actions or inactions of a
third party, the Plan shall have the right to recover related Plan expenses out of
any payments made by (or on behalf of) the third party (whether by lawsuit,
settlement, no-fault automobile insurance statute or otherwise) to or on behalf of a
Covered Person to the fullest extent permitted by law, including, but not limited to,
the right of recovery of the cost of medical care and treatment afforded to the
County pursuant to A.R.S. § 12-961 et seq. The Plan’s right of recovery applies to
the extent the Plan has paid expenses related to the injury or illness, regardless of
whether any related settlement or other third-party payment states that the
payment (all or part of it) is for health care expenses, regardless of the label
assigned to the recovery and regardless of the allocation or itemization of such
recovery to specific types of injuries. The Plan may require the Covered Person to
sign a reimbursement agreement in a form acceptable to the Plan Administrator,
but whether or not such an agreement is executed, in the event that the Plan
provides benefits and the Covered Person receives a third-party payment as
described in this paragraph, the Covered Person shall immediately reimburse the
Plan for the full amount of all benefits paid by the Plan.
61
By accepting Plan benefits to pay for treatments, devices or other products or
services related to such injury or illness, the Covered Person agrees to place such
third-party payments in Covered Person’s separate identifiable account (in an
amount equal to related expenses paid by the Plan or, if less, the full third-party
payment amount) and that the Plan has an equitable lien on such funds, without
regard to whether the Covered Person has been made whole or fully compensated
for the injury or illness. The Covered Person also agrees to serve as a constructive
trustee over the funds until the time they are paid to the Plan. Covered Person
further agrees to cooperate with the Plan’s recovery efforts and do nothing to
prejudice the Plan’s recovery rights.
The Plan is not required to participate in or contribute to any expenses or fees
(including attorney’s fees and costs) incurred in obtaining the funds.
C.
Cooperation
If so requested by the Claim Administrator, the Covered Person (or if a minor, his
or her parent or legal guardian) shall:
provide proof, satisfactory to the Claim Administrator, that no right,
claim, interest or cause of action against a third party has been, or will
be, discharged or released without the written consent of the Claim
Administrator;
execute a written agreement assigning to the Plan all rights, claims,
interests, and causes of action that the Covered Person has against a
third party in connection with the expenses paid by the Plan;
notify the Plan within 30 days of the date any notice is given by any
party, including an attorney, of an intent to pursue or investigate a claim
to recover damages or obtain compensation due to sustained injuries or
illness;
provide all information requested by the Plan, the Claims Administrator,
or their representatives;
authorize the Plan, in writing, to sue, compromise or settle, in the
Covered Person’s name or otherwise, all rights, claims, interests, or
causes of action to the extent of benefits paid by the Plan and shall do
nothing to prejudice the rights given to the Plan under this section; and
agree, in writing, to assist the Plan in prosecuting any rights, interests,
claims, or causes of action that have been assigned to the Plan against
a third party, including, if requested by the Claim Administrator or Plan
Administrator, the institution of a formal proceeding against a third party.
B.
Enforcement of Plan’s Subrogation and Recovery Rights
Should it be necessary for the Plan to institute proceedings against the Covered
Person for failure to reimburse the Plan or to otherwise honor the Plan’s equitable
interest in obtaining amounts described in this Section, the Covered Person shall
62
be liable for the costs of collection relating to such failure, including reasonable
attorney’s fees.
The Plan shall have the right to terminate a Covered Person’s participation in the
Plan or offset future benefits to which a claimant (or a Covered Person through
whom the claimant derives his or her claim) may be entitled, until the amount
otherwise due the Plan under this Section, plus interest, has been received by the
Plan.
The Plan’s rights under this Section shall be enforceable regardless of whether the
third party admits liability for the injury or illness to a Covered Person, and shall
remain enforceable against the heirs and estate of any Covered Person.
9.13 Payment Procedures
A.
Payment of Claim
Subject to Section 12.4, benefits shall be payable to the claimant upon
establishment of the right thereto.
B.
Facility of Payment
If a claimant dies before all amounts payable under the Plan have been paid, or if
the Plan Administrator determines that the claimant is a minor or is incompetent or
incapable of executing a valid receipt and no guardian or legal representative has
been appointed, or if the claimant fails to provide the Plan with a forwarding
address, the amount otherwise payable to the claimant may be paid to any other
person or institution reasonably determined by the Plan Administrator to be entitled
equitably thereto and without prejudice therefor. Any payment made in accordance
with this provision shall discharge the obligation of the Plan hereunder to the
extent of such payment.
C.
Forfeiture
The Plan Administrator shall take reasonable steps to ascertain the whereabouts
of a claimant so as to affect delivery of benefits payable under the Plan. If a
claimant has not collected benefits payable to him or her within 15 months from
the date the claim was filed, the Plan Administrator may, three months after
sending by certified mail a written notice of benefits to the last known address of
such claimant as shown on the records of the Administrator, deem the claimant’s
right to such benefit waived. Upon such waiver, the Plan shall have no liability for
payment of the benefit otherwise payable.
63
ARTICLE X
ADMINISTRATION
10
10.1 Plan Administrator
The County shall appoint a person, entity or committee to serve as Plan
Administrator. In the absence of such appointment, the County shall be the Plan
Administrator.
10.2 Plan Administrator’s Duties
The Plan Administrator shall:
A.
manage and carry out the Plan's operation and administration according to
the Plan's terms and for Covered Employees' exclusive benefit;
B.
maintain:
whatever records and data are necessary or desirable for the Plan's
proper operation and administration, and
the Plan's most current governing documentation, including the
Incorporated Documents, for inspection by anyone who participates or is
eligible to participate in the Plan;
C.
notify Employees eligible to participate in the Plan of:
the Plan's availability and terms,
the premium payment benefits available for election,
the maximum annual Salary Reduction Contribution and/or Salary
Deduction Contribution amounts for each available premium payment
benefit, and
the procedures for enrolling and making and changing elections;
D.
supply eligible Employees with any forms and agreements they must
complete;
E.
prepare and file all annual reports or returns, plan descriptions, financial
statements, and other documents required by law or under the Plan's terms;
and
F.
record its and the Employer's acts and determinations regarding the Plan
and preserve these records in its custody.
64
10.3 Plan Administrator’s Powers
Except as expressly limited or reserved in the Plan or the Benefits Trust to the
County, the Board of Supervisors, the Board of Trustees, or an Employer, the Plan
Administrator shall have the right to exercise, in a uniform and nondiscriminatory
manner, full discretion with respect to the administration, operation, and
interpretation of the Plan. Without limiting the generality of the foregoing rights, the
Plan Administrator shall have full power and discretionary authority to:
A.
require any person to furnish such information as the Plan Administrator may
request from time to time and as often as the Plan Administrator determines
reasonably necessary for the purpose of proper administration of the Plan
and as a condition to the individual's receiving benefits under the Plan;
B.
make and enforce such rules and prescribe the use of such forms as the
Plan Administrator determines reasonably necessary for the proper
administration of the Plan;
C.
interpret the Plan and decide all matters arising under the Plan, including the
right to remedy possible ambiguities, inconsistencies, administrative errors,
or omissions;
D.
determine all questions concerning the eligibility of any individual to
participate in, be covered by, and receive benefits under the Plan pursuant
to the provisions of the Plan;
E.
determine whether objective criteria set forth in the Plan have been satisfied
respecting any term, condition, limitation, exclusion, and restriction or waiver
thereof;
F.
determine the amount of benefits payable, if any, to any person or entity in
accordance with the provisions of the Plan; to inform the Employer or any
other third party, as appropriate, of the amount of such benefits; to make
claims decisions under the terms of the Plan; and to provide a full and fair
review to any individual whose claim for benefits has been denied in whole
or in part;
G.
delegate to other person(s) any duty that otherwise would be a fiduciary
responsibility of the Plan Administrator under the terms of the Plan;
H.
engage the services of such person(s) and entity or entities as it deems
reasonably necessary or appropriate in connection with the administration of
the Plan;
I.
make such administrative or technical amendments to the Plan as may be
reasonably necessary or appropriate to carry out the intent of the County,
including such amendments as may be required or appropriate to satisfy the
requirements of the Code and the rules and regulations from time to time in
effect under any such laws, or to conform the Plan with other governmental
regulations or policies; and
65
J.
pay all reasonable and appropriate expenses incurred in connection with the
management and administration of the Plan including, but not limited to,
premiums or other considerations payable under the Plan and fees and
expenses of any actuary, accountant, legal counsel, or other specialist
engaged by the Plan Administrator.
10.4 Finality of Decisions
The Plan Administrator shall have full power, authority and discretion to enforce,
construe, interpret and administer the Plan. All decisions and determinations of the
Plan Administrator with respect to any matter hereunder shall be conclusive and
binding on Covered Persons and all other interested parties.
10.5 Compensation and Bonding of Plan Administrator
Unless otherwise agreed to by the County, the Plan Administrator shall serve
without compensation for services as such, but all reasonable expenses incurred
in the performance of the Plan Administrator's duties shall be paid as specified in
Article XII. Unless otherwise determined by the County or unless required by
federal or state law, the Plan Administrator shall not be required to furnish bond or
other security in any jurisdiction.
10.1 Reserved Powers
The County reserves the powers, among others:
A.
to adopt the Plan;
B.
to amend, terminate, or merge the Plan according to Article XI; and
C.
to appoint and remove any Claim Administrator or Plan Administrator.
10.2 Intergovernmental Agreements
The Board of Supervisors may allow a special district or other employer performing
governmental functions within the County, such as, without limitation, providing
health services, housing, libraries, flood control, parks and sporting facilities, and
judicial functions to adopt this Plan to provide cafeteria plan and certain welfare
benefits to the employees of the special district or other employer. The special
district or other employer may adopt this Plan pursuant to the terms of an
intergovernmental agreement (IGA) entered into between the County and the
special district or other employer on such terms as may be approved by the Board
of Supervisors. In all events, the special district or other employer shall be a
governmental employer so that this Plan shall each be a “governmental plan” as
defined in Section 3(32) of ERISA. By adopting this Plan, the special district or
other employer delegates to the Board of Supervisors the authority to terminate
this Plan and the Benefits at any time and to make such amendments and take
such action as the Board of Supervisors deems necessary, and further delegates
to the Plan Administrator the power to take all actions required or permitted of the
Plan Administrator under this Plan. The County, Board of Supervisors, Board of
Trustees and Plan Administrator shall have no liability or responsibility to any
66
special district or other employer or any of its or their employees for any action
taken or not taken under this Plan. The employees of the County and each special
district or other employer shall be treated as employed by a separate employer for
all purposes under this Plan and any transfer of employment of an employee
among the County and the special districts or other employer adopting this Plan
shall be deemed termination of employment by such employee with the former
employer and a new hire by the other employer but such change shall not be
considered a qualifying Change in Status. At any time following the adoption of this
Plan, the special district or other employer may withdraw and terminate its
adoption of this Plan. Any action taken by a special district hereunder shall be
evidenced by resolution of the governing board of such special district.
67
ARTICLE XI
AMENDMENT, TERMINATION OR MERGER OF PLAN
11
11.1 Right to Amend the Plan
Except as provided in Section 11.3, the County reserves the unlimited right to
amend the Plan in any way. Any amendment to the Plan shall be in writing and
shall be adopted by the Board of Supervisors in accordance with its normal
procedures. However, the Plan Administrator shall have the authority to amend the
Plan to comply with applicable law or regulation or to reflect the County’s intent.
11.2 Right to Terminate or Merge the Plan
Notwithstanding that the Plan is established with the intention that it be maintained
indefinitely, the County reserves the unlimited right to terminate or merge the Plan.
Any termination or merger of the Plan shall be in writing and shall be adopted by
the Board of Supervisors in accordance with its normal procedures.
11.3 Effect of Amendment, Termination or Merger
Any amendment, termination or merger of the Plan shall be effective at such date
as the County shall determine except that no amendment, termination or merger
may be retroactive unless remedial to comply with a law or regulatory requirement
the County or the Plan is subject to.
68
ARTICLE XII
MISCELLANEOUS
12
12.1 No Employment Rights
The Plan is a voluntary undertaking of the Employer and does not constitute a
contract with any person. The Plan is not an inducement or condition of an
Employee's employment with any Employer. Neither the establishment of the Plan,
nor any modification thereof, nor any payments hereunder, shall be construed as
giving to any Employee or any other person, any legal or equitable rights against
his or her Employer, the County, Board of Supervisors, Board of Trustees, Plan
Administrator, or the Employer’s officers, employees or agents, or as giving any
person the right to be retained in the employ of the Employer.
12.2 Exclusive Rights
No individual shall have a right to benefits under the Plan except as specified
herein; and in no event shall any right to benefits under the Plan be or become
vested. This Plan is not a guarantee of continuation of any benefits or coverage
offered through the Plan.
12.3 No Property Rights
No one has any right, title, or interest in the property of the County or the Employer
by virtue of the Plan, nor is any person entitled to interest on any benefit amounts
that may be allocated or available to him or her.
12.4 No Assignment of Benefits
Except when the Plan is required by law or applicable guidance to recognize an
assignment of Benefits to a State Medicaid program, Benefits payable under the
Plan and the right to assert legal rights, including but not limited to bringing an
administrative claim for benefits or filing a lawsuit against the Plan, the Plan
Administrator, a Claim Administrator, or any Plan fiduciary, or the County and
Participating Employers, or officers, employees, or agents thereof, shall not be
subject in any manner to anticipation, alienation, sale, transfer, assignment,
pledge, encumbrance or charge of any kind, and any attempt to effect same shall
be void. This includes, but is not limited to, any attempt by a Covered Person to
assign his or her right to receive Plan benefits and legal rights relating to the
Plan—including any rights to bring an administrative claim or lawsuit—to any
health care provider; such assignment is not permitted under the Plan and is void.
The Plan reserves the right to make payment directly to the Covered Person, or,
solely at the discretion of the Plan Administrator or the Claim Administrator,
directly to a doctor, hospital, or other provider of health care. Where payments are
made directly to a doctor, hospital, or other provider of health care, such direct
payments are provided at the discretion of the Plan Administrator or Claims
Administrator and do not imply or create an enforceable assignment of benefits or
the right to receive such benefits or the right to assert any legal rights, or to bring
any administrative claim or lawsuit against the Plan, the Plan Administrator, a
Claim Administrator, or any Plan fiduciary, or the County and Participating
69
Employers, or officers, employees, or agents thereof, under any federal or state
law.
12.5 Payments to Minors and Incompetents
Notwithstanding anything to the contrary in this Plan, if a Covered Person entitled
to receive any benefits hereunder is a minor or is determined by the Plan
Administrator, in its sole discretion to be incompetent, or 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 person, or may be paid to any third
party who is eligible to receive any benefit under the Plan for the account of such
Covered Person, or may be held in trust by the County for the benefit of such
person 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 Plan Administrator and the County of any liability
for such payment under the Plan.
12.6 Right to Offset Future Payments
In the event a payment or the amount of a payment is made erroneously to an
individual, the Plan shall have the right to reduce future payments payable to or on
behalf of such individual by the amount of the erroneous or excess payment. This
right to offset shall not limit the right of the Plan to recover an erroneous or excess
payment in any other manner.
12.7 Right to Recover Payments
Whenever a payment has been made by the Plan, including erroneous payments,
in a total amount in excess of the amount payable under the Plan, irrespective of
to whom paid, the Plan shall have the right to recover such payments, to the extent
of the excess, from the person to or for whom the payment was made.
12.8 Misrepresentation or Fraud
A Covered Person who receives benefits under the Plan as a result of false,
incomplete, or incorrect information or a misleading or fraudulent representation
may be required to repay all amounts paid by the Plan and may be liable for all
costs of collection, including attorney's fees and court costs. The Plan
Administrator shall decide such matters on a case by case basis. An Employee
may be asked to provide proof of eligibility for his or her Dependents. If a Covered
Person makes any intentional misrepresentation or uses fraudulent means
concerning eligibility for coverage, changing existing coverage, or benefits under
the Plan, the Employee’s and his or her Dependents’ coverage may be terminated
irrevocably (retroactively to the extent permitted by law), and could be grounds for
Employee discipline up to and including termination. Failure to provide timely
notice of loss of eligibility will be considered intentional misrepresentation.
70
12.9 Legal Action
Before pursuing legal action, a person claiming Plan benefits or seeking redress
related to the Plan must first exhaust the Plan's claim, review, and appeal
procedures. Unless otherwise provided by law, the County and the Plan
Administrator are the only necessary parties to any action or proceeding that
involves the Plan or its administration. No Employee, Employer, or other person or
entity is entitled to notice of any legal action, unless a court with appropriate
jurisdiction orders otherwise.
Unless an Incorporated Document specifies a shorter timeframe, no action at law
or in equity in any court or agency shall be brought to recover benefits under the
Plan prior to the exhaustion of the claims and appeals procedures set forth in
Article IX, nor shall an action be brought at all unless within 36 months after the
date a claim is incurred under the Plan.
12.10 Governing Law
The provisions of the Plan shall be administered, and all questions pertaining to
the validity or construction of the Plan and the acts and transactions of the parties
shall be determined, construed, and enforced, in accordance with applicable and,
to the extent not preempted, the laws of the State of Arizona.
12.11 Forum Selection
Any legal action, whether in law or in equity, must be brought in the U.S. District
Court for the District of Arizona.
12.12 Governing Instrument
This document, together with any documentation incorporated by reference herein,
is the legal instrument governing the Plan. In case of conflict between this
document and any other writing or evidence, the terms of this document shall
govern.
12.13 Savings Clause
If a provision of the Plan or the application of a provision of the Plan to any person,
entity, or circumstance is held invalid under governing law by a court of competent
jurisdiction, the remainder of the Plan and the application of the provision to any
other person, entity, or circumstance shall not be affected.
12.14 Captions and Headings
The captions and headings of an Article, Section or provision of the Plan are for
convenience and reference only and are not to be considered in interpreting the
terms and conditions of the Plan.
71
12.15 Notices
No notice or communication in connection with the Plan made by a claimant or an
Employee shall be effective unless duly executed on a form provided or approved
by, and filed with, the appropriate Plan Administrator (or his or her representative).
12.16 Waiver
No term, condition, or provision of the Plan shall be deemed waived unless the
purported waiver is in a writing signed by the party to be charged. No written
waiver shall be deemed a continuing waiver unless so specifically stated in the
writing, and only for the stated period, and such waiver shall operate only as to the
specific term, condition, or provision waived.
12.17 Parties' Reliance
The County, the Board of Supervisors, the Board of Trustees, the Employer, the
Plan Administrator and anyone to whom the Plan's operation or administration is
delegated may rely conclusively on any advice, opinion, valuation, or other
information furnished by any actuary, accountant, appraiser, legal counsel, or
physician the Plan engages or employs. A good faith action or omission based on
this reliance is binding on all parties, and no liability can be incurred for it except as
the law requires. No liability shall be incurred for any other action or omission of
the Board of Supervisors, the Board of Trustees, the County, the Employer or their
employees, except for willful misconduct or willful breach of duty to the Plan.
12.18 Disclaimer
The County makes no assertion or warranty about:
A.
health care services and supplies that Covered Persons obtain
reimbursement for as Plan benefits, or
B.
whether Plan benefits are or will be excludable from a Covered Employee's
gross income for federal or state income tax purposes, or
C.
whether any other tax treatment is or will be applicable.
12.19 Expenses
All expenses of the Plan shall be paid from forfeitures, Employee contributions, or
by the Plan, unless otherwise paid by the Employer. The Employer may advance
expenses to the Plan, subject to reimbursement, without obligating itself to pay
such expenses.
12.20 Indemnification
The Employer, to the extent permitted by law, shall indemnify and hold harmless
the Board of Supervisors, the Board of Trustees, any employee or officer or
shareholder of the County or the Employer from and against all loss, damages,
liability and reasonable costs and expenses incurred in carrying out his or her
72
responsibilities under the Plan, unless due to the bad faith or willful misconduct of
such person, provided that such individual's attorney's fees and any amount paid
in settlement shall be approved by the County.
12.21 Employees' Tax Obligations
A.
Excludability Determination
Covered Employees themselves must determine whether Plan benefits are
excludable for tax purposes, and must notify the Plan Administrator if they have
reason to believe a payment is not excludable.
B.
Liability and Payment
If the Plan Administrator determines at any time after a Plan Year's end that
Employees' Salary Reduction Contributions or Salary Deduction Contributions or
other Employer contributions exceeded limits allowed by law for any reason
including, but not limited to, erroneous information, administrative error, or a final
determination that the Plan does not qualify as a cafeteria plan under Code
Section 125 for the Plan Year, then Covered Employees must:
pay any local, state, and federal income taxes and related penalties and
interest due with respect to the excess Salary Reduction Contributions
or other Employer contributions for which the Covered Employee is
liable, and
reimburse the Employer for the Employee's share of any local, state,
and federal tax contributions the Employer would have withheld or other
applicable deductions the Employer would have taken had the excess
Salary Reduction Contributions or other Employer contributions been
treated as taxable income.
12.22 Unknown Whereabouts
It shall be the affirmative duty of each Covered Person to inform the Plan
Administrator, and to keep on file with the Plan Administrator, his or her current
mailing address. If a Covered Person fails to inform the Plan Administrator of his
or her current mailing address, neither the Plan Administrator, the Board of
Trustees, the Board or the County shall be responsible for any late payment of or
loss of benefits.
73
ARTICLE XIII
HIPAA PRIVACY AND SECURITY
13
13.1 Scope
The provisions of this Article XIII shall apply to the medical, dental, vision,
employee assistance plan, wellness plan, health care spending account, and
limited purpose health care spending account.
13.2 Definitions
For purposes of this Article XIII, the following terms have the following meanings:
A.
“Business Associate” means a person or entity that performs a function or
activity regulated by HIPAA on behalf of the group health plans provided
under the Plan and involving individually identifiable health information.
Examples of such functions or activities are claims processing, legal,
actuarial, accounting, consulting, data aggregation, management,
administrative, accreditation and financial services. A Business Associate
may be a Covered Entity. However, Insurers and HMOs are not Business
Associates of the plans they insure. A person or entity that transmits PHI to a
covered entity (or its business associate) and routinely requires access to
that PHI may also be a business associate. Examples of such entities
include health information exchange organizations, regional health
information organizations and e-prescribing gateways. Vendors that contract
with covered entities offering certain personal health records to individuals
may also be considered business associates, and vendors that contract with
Business Associates (“subcontractors”) and require or have access to PHI or
ePHI on a routine basis may also be Business Associates with respect to the
Plan.
B.
“Covered Entity” means a group health plan (including an employer plan,
Insurer, HMO and government coverage such as Medicare); a health care
provider (such as a doctor, hospital or pharmacy) that electronically
transmits any health information in connection with a transaction for which
the U.S. Department of Health and Human Services has established an
electronic data interchange standard; and a health care clearinghouse (an
entity that translates electronic information between nonstandard and HIPAA
standard transactions).
C.
“Protected Health Information or PHI” means individually identifiable health
information transmitted by electronic media, maintained in electronic media,
or transmitted or maintained in any other form or medium. Information is
“individually identifiable” if it names the individual person or there is a
reasonable basis to believe components of the information could be used to
identify the individual. “Health Information” means information, including
genetic information, whether oral or recorded in any form or medium, that (i)
is created by a health care provider, health care plan, employer, life insurer,
public health authority, health care clearinghouse, or school or university;
and (ii) relates to the past, present, or future physical or mental health or
74
condition of a person, the provision of health care to a person; or the past,
present or future payment for health care.
13.3 Uses and Disclosures of PHI
The Plan may disclose a Covered Employee’s PHI or ePHI to the Plan Sponsor (or
to the agent of the Plan Sponsor) for the plan administration functions under 45
CFR 164.504(a), to the extent not inconsistent with the HIPAA regulations. The
Plan will not disclose PHI or ePHI to the Plan Sponsor except upon receipt of a
certification by the Plan Sponsor that the Plan incorporates the agreements of
Sections 13.4 and 13.5, except as otherwise permitted or required by law.
13.4 Privacy Agreements of the Plan Sponsor
As a condition for obtaining PHI from the Plan and its Business Associates the
Plan Sponsor agrees it will:
A.
Not use or further disclose such PHI other than as permitted by Section 13.3,
as permitted by 45 CFR 164.508, 45 CFR 164.512, and other sections of the
HIPAA regulations, or as required by law;
B.
Ensure that any of its agents, including a subcontractor, to whom it provides
the PHI agree to the same restrictions and conditions that apply to the Plan
Sponsor with respect to such information;
C.
Not use or disclose the PHI for employment-related actions and decisions or
in connection with any other benefit or employee benefit plan of the Plan
Sponsor;
D.
Report to the Plan any use or disclosure of the PHI that is inconsistent with
the uses or disclosures provided for of which the Plan Sponsor becomes
aware, including reporting any breach of unsecured PHI;
E.
Make the PHI of a particular Covered Person available for purposes of the
Covered Person's requests for inspection, copying, and amendment, and
carry out such requests in accordance with HIPAA regulation 45 CFR
164.524 and 164.526;
F.
Make the PHI of a particular Covered Person available for purposes of
required accounting of disclosures by the Plan Sponsor pursuant to the
Covered Person’s request for such an accounting in accordance with HIPAA
regulation 45 CFR 164.528;
G.
Make the Plan Sponsor’s internal practices, books, and records relating to
the use and disclosure of PHI received from the Plan available to the
Secretary of the U.S. Department of Health and Human Services for
purposes of determining compliance by the Plan with HIPAA;
H.
If feasible, return or destroy all PHI received from the Plan that the Plan
Sponsor still maintains in any form and retain no copies of such information
when no longer needed for the purpose for which disclosure was made,
75
except that, if such return or destruction is not feasible, the Plan Sponsor
agrees to limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible; and
I.
Ensure that there is adequate separation between the Plan and the Plan
Sponsor by implementing the terms of subparagraphs (1) through (3), below:
Employees With Access to PHI: The employees, classes of former
employees or other individuals under the control of the Plan Sponsor
listed in Appendix E are the only individuals that may access PHI
received from the Plan.
Use Limited to Plan Administration: The access to and use of PHI by the
individuals described in (1), above, is limited to plan administration
functions as defined in HIPAA regulation 45 CFR 164.504(a) that are
performed by the Plan Sponsor for the Plan.
Mechanism for Resolving Noncompliance: If the Plan Sponsor or the
persons listed in Appendix E who are responsible for monitoring
compliance determine that any person described in (1), above, has
violated any of the restrictions of this Article XIII, then such individual
shall be disciplined in accordance with the policies of the Plan Sponsor
established for purposes of privacy and security compliance, up to and
including dismissal from employment. The Plan Sponsor shall arrange to
maintain records of such violations along with the persons involved, as
well as disciplinary and corrective measures taken with respect to each
incident.
J.
Notify Covered Person(s) of an unauthorized acquisition, access, use or
disclosure of PHI that compromises the security or privacy of the information
(a “Breach”) without unreasonable delay in a report which includes the
following information:
the circumstances surrounding the Breach;
the date of the Breach and the date of its discovery;
the information Breached;
any steps the impacted individuals should take to protect themselves;
the steps the County is taking to investigate the Breach, mitigate losses,
and protect against future Breaches; and
a contact person who can provide additional information about the
Breach.
The County will cooperate with Covered Person(s) in the investigation of, and
response to, the Breaches it reports to Covered Person(s). For this purpose, the
76
term “Breach” means an unauthorized acquisition, access, use or disclosure of
PHI that compromises the security or privacy of the information.
Notwithstanding the foregoing, the terms of this Article XIII shall not apply to uses
or disclosures of Enrollment, Disenrollment, and Summary Health Information
made pursuant to 45 CFR 164.504(f)(1)(ii) or (iii); of PHI released pursuant to an
Authorization that complies with 45 CFR 164.508; or in other circumstances as
permitted by the HIPAA regulations.
13.5 Security Agreements of the Plan Sponsor
As a condition of obtaining e-PHI from the Plan, its Business Associates, Insurers
and HMOs, the Plan Sponsor agrees it will:
A.
Implement administrative, physical, and technical safeguards that
reasonably and appropriately protect the confidentiality, integrity, and
availability of the electronic protected health information that it creates,
receives, maintains, or transmits on behalf of the Plan;
B.
Ensure that the adequate separation between the Plan and the Plan
Sponsor as set forth in 45 CFR 164.504(f)(2)(iii) is supported by reasonable
and appropriate security measures;
C.
Ensure that any agent, including a subcontractor, to whom it provides this
information agrees to implement reasonable and appropriate security
measures to protect the information;
D.
Report to the Plan any security incident of which it becomes aware. For
purposes of this Amendment, security incident shall mean successful
unauthorized access, use, disclosure, modification or destruction of, or
interference with, the e-PHI; and
E.
Upon request from the Plan, the Plan Sponsor agrees to provide information
to the Plan on unsuccessful unauthorized access, use, disclosure,
modification or destruction of the e-PHI to the extent such information is
available to the Plan Sponsor.
Appendix A, Article I
A-1
APPENDIX A
MARICOPA COUNTY DEPENDENT CARE SPENDING ACCOUNT PLAN
ARTICLE I
PLAN ESTABLISHMENT
1
1.1
Effective Date
This Maricopa County Dependent Care Spending Account Plan ("the Plan")
amends, restates, and supersedes the Maricopa County Dependent Care Flexible
Spending Account Plan (Fifth Amendment and Restatement) as of the Effective
Date in Article I of The Maricopa County Benefits Plan.
1.2
Purpose
The Plan is created exclusively for Employees, as defined in Article II of the
Cafeteria Plan. The Plan's purpose is to reimburse Covered Employees, as
defined in Article II of this Appendix, for Dependent Care Expenses, as defined in
Article II of this Appendix.
1.3
Qualification
The Plan is intended to qualify as a dependent care assistance program under
Section 129 of the Internal Revenue Code of 1986, as amended (the "Code"). The
Plan's reimbursements of Dependent Care Expenses are intended to be eligible
for exclusion from Covered Employees' gross income under Code Section 129(a).
This document is intended to satisfy the written plan document requirement of
Code Section 129(d)(1).
1.4
Incorporation By Reference
The term Cafeteria Plan as used in this Appendix means the Cafeteria Plan as
defined in Section 1.3 of The Maricopa County Benefits Plan. The terms of the
Cafeteria Plan are incorporated by reference wherever they apply to this Plan's
operation to the extent such provisions do not conflict with the terms of this Plan.
1.5
Duration
The Plan is established with the intention of being maintained for an indefinite
period of time; however, the County, as defined in Article II of the Cafeteria Plan, in
its sole discretion and in accordance with the provisions of Article XI of the
Cafeteria Plan may amend or terminate the Plan or any provision of the Plan
Appendix A, Article II
A-2
ARTICLE II
DEFINITIONS
2
When capitalized in this document, these words and phrases have the following meanings:
2.1
Covered Employee
Covered Employee means an Employee who satisfies the participation
requirements of Article III.
2.2
Dependent Care Expenses
Dependent Care Expenses means expenditures for dependent care as described
in Section 4.4.
2.3
Dependent Care Spending Account Plan
Dependent Care Spending Account Plan means the notational account
established on behalf of each Covered Employee who elects the dependent care
spending account premium payment benefit under the Cafeteria Plan to which the
Covered Employee allocates Salary Reduction Contributions for the
reimbursement of Dependent Care Expenses.
2.4
Effective Date
Effective Date means the date this Plan becomes operative, which is the effective
date identified in Article I of The Maricopa County Benefits Plan.
2.5
Exclusions
Exclusions means the exclusions in Article V.
2.6
Maximum Annual Benefit
Maximum Annual Benefit means the total Salary Reduction Contributions a
Covered Employee authorizes to his or her Dependent Care Spending Account,
according to the election requirements of Article VI, for Dependent Care Expense
reimbursement, which amount must be not more than $5,000, except as otherwise
limited under Section 4.5(B).
2.7
Plan
Plan means the Maricopa County Dependent Care Spending Account Plan as
herein set forth and as amended from time to time.
Appendix A, Article II
A-3
2.8
Qualifying Individual
Qualifying Individual means an individual who is either:
A.
The Covered Employee’s child under age 13 and claimable as a personal
exemption deduction under Code Section 152(a)(1) on the Covered
Employee’s federal income tax return; or
B.
The Spouse of a Covered Employee who is physically or mentally incapable
of caring for him or herself, and who resides with the Employee for more
than half of the year; or
C.
Any other relative or household member who is physically or mentally
incapable of caring for him or herself and is a qualifying relative under
Section 152 of the Code (without regard to subsections (b)(1), (b)(2) and
(d)(1)(B)) and who resides with the Employee for more than half of the year.
Physically or mentally incapable of caring for him or herself means:
D.
incapable of caring for one's own hygienic or nutritional needs, or
E.
requiring another person's full-time attention for one's own safety or the
safety of others.
Whether a person is physically or mentally incapable of caring for him or herself is
determined on a daily basis.
Appendix A, Article III
A-4
ARTICLE III
PARTICIPATION
3
3.1
Participation
An Employee is a Covered Employee and participates in the Plan during those
periods in which the Employee:
A.
participates in the Cafeteria Plan, and
B.
has allocated an amount to his or her Dependent Care Spending Account.
Except for Dependent Care Expenses incurred before Plan coverage ceases and
subject to satisfying the procedural requirements of Article VI, no Plan benefits are
payable after coverage terminates.
3.2
Termination of Participation
A Covered Employee shall cease to participate in the Plan when he or she no
longer participates in the Cafeteria Plan, when the Covered Employee revokes his
or her election to participate in the Plan, or when the Covered Employee
terminates employment, retires or dies.
Appendix A, Article IV
A-5
ARTICLE IV
DEPENDENT CARE REIMBURSEMENT
BENEFIT
4
4.1
Right to Benefit
Subject to the following terms and limits and the Exclusions, Covered Employees
are entitled to reimbursement for Dependent Care Expenses.
4.2
Maintenance of Accounts
The Plan Administrator shall maintain a Dependent Care Spending Account for
each Employee who elects the dependent care spending account premium
payment benefit. The dependent care spending account premium payment benefit
that the Employee elected under the Cafeteria Plan shall be credited to the
Employee's Dependent Care Spending Account on a pro-rata basis over the
period for which the Employee's election is effective.
4.3
Amount Payable
Subject to the procedural requirements of Article VI, payable Dependent Care
Expenses may not exceed the dependent care spending account premium
payment benefit the Covered Employee authorized and which was credited in
accordance with Section 4.2, less any payments previously made during the Plan
Year — up to the Maximum Annual Benefit.
If any balance remains in a Covered Employee’s Dependent Care Spending
Account at the end of the Plan Year after all reimbursements have been made,
such balance shall not be carried over to reimburse the Covered Employee for
Dependent Care Expenses incurred during a subsequent Plan Year nor returned
to the Covered Employee and the Covered Employee shall forfeit all rights with
respect to such balance. Any amounts forfeited under this Section 4.3 shall not be
segregated or invested in an interest bearing account, but shall remain the
property of the Employer to be used to pay administrative expenses, to cover
expense losses, or used in any other manner as the Employer in its discretion,
exercised in a uniform and nondiscriminatory manner, directs.
4.4
Dependent Care Expenses
Dependent Care Expenses means employment-related expenses that a Covered
Employee incurs — while employed — for:
A.
Household services, and
B.
Care of a Qualifying Individual.
Employment-related, as defined in Code Section 21(b), means incurred to enable
a Covered Employee to be gainfully employed. In the case of a married Covered
Employee, to be employment-related, the expense must also enable the Covered
Appendix A, Article IV
A-6
Employee's Spouse to: be gainfully employed, actively seek gainful employment,
or be a full-time student, unless the Spouse is described in Section 2.8(B).
Incurs refers to the date services resulting in employment-related expenses are
provided — not the date charged, billed, or paid.
Household services means services ordinarily necessary to maintain a Covered
Employee's home and rendered as part of a Qualifying Individual's care.
Care means services primarily to assure the well-being and protection of at least
one Qualifying Individual.
Full-time student means a person enrolled at and attending an educational
institution during at least part of each of five calendar months of the Covered
Employee's tax year for the number of course hours that the institution considers
to be a full-time course of study.
4.5
Limits
A.
On What the Plan Pays
For Care Furnished Outside Covered Employee's Household
Dependent Care Expenses for care provided outside a Covered
Employee's home or in a Qualified Dependent Care Center is reimbursed
only if such care is furnished for a Qualifying Individual:
a.
described in Section 2.8(A), or
b.
described in Section 2.8(B) or (C) who regularly spends at least
8 hours each day in the Covered Employee's home.
Qualified Dependent Care Center means a facility:
c.
in compliance with all applicable state and local laws and
regulations, and
d.
providing care for more than 6 persons (other than facility residents)
on a regular, compensation-for-service basis.
To Certain "Highly Compensated" Employees
Benefits payable under the Plan to each highly compensated employee, as
defined in Code Section 414(q), are limited to the extent necessary to avoid
violating Code Section 129(d)(8).
Appendix A, Article IV
A-7
B.
On Exclusion from Gross Income
Individual Exclusion Limit
Plan reimbursement for Dependent Care Expenses is excludable from a
Covered Employee's gross income only to the extent the Dependent Care
Expense does not exceed:
a.
the sum of the Covered Employee's actual Salary Reduction
Contributions for the Plan Year,
or, if less,
b.
the Maximum Annual Benefit.
Gross Income Exclusion Limit
The amount of dependent care expenses reimbursed during a Covered
Employee's taxable year by all plans, including the Plan, that qualify as
dependent care plans under Code Section 129 may not exceed:
a.
$5,000 (or $2,500 for a married Covered Employee filing a separate
federal income tax return),
or, if less,
b.
the Covered Employee's earned income (or if less, the Covered
Employee's Spouse's earned income, if the Covered Employee was
married at the end of his or her tax year).
Earned income means wages, salaries, tips, and other
compensation, to the extent such amounts are includible in taxable
income for the year, like strike benefits, disability pay reported as
wages, and net earnings from self-employment.
Earned income does not include pensions, annuities, social security
payments, workers' compensation, unemployment compensation,
or a nonresident alien's income not connected with United States
business.
Earned income is computed without considering community
property laws.
Earned income of a Spouse who is a full-time student, as defined in
Section 4.4, or who is physically or mentally incapable of caring for
him or herself, as defined in Article II of this Appendix, is deemed to
be not less than $250 per month for Covered Employees with one
Qualifying Individual or $500 per month for Covered Employees
with two or more Qualifying Individuals.
Appendix A, Article IV
A-8
Reporting Identifying Information Limit
Plan reimbursement for Dependent Care Expenses is excludable from a
Covered Employee's gross income only if the Covered Employee reports
on the federal income tax return to which the exclusion relates, the
name, address, and taxpayer identification number (or other information
acceptable to comply with federal reporting requirements) of each
dependent care service provider furnishing dependent care services to
the Covered Employee during the year.
Appendix A, Article V
A-9
ARTICLE V
EXCLUSIONS
5
5.1
General Rules
A.
The Plan pays only those Dependent Care Expenses incurred by an
Employee:
during the current Plan Year, except that the Plan will allow a grace
period of two and one half months following the end of the Plan Year in
which Covered Employees may incur Dependent Care Expenses for
reimbursement from amounts remaining unused at the end of the
immediately preceding Plan Year. This reimbursement will be treated as
if the expenses had been incurred in the prior year,
while the Employee is a Covered Employee, and
to allow the Covered Employee (and Spouse, if married) to continue
gainful employment (or, if married and the Spouse is unemployed, to
allow the Covered Employee's Spouse to actively seek gainful
employment or be a full-time student, as defined in Section 4.4, unless
the Spouse is described in Section 2.8(B) of this Appendix).
B.
Except as provided in Section 5.1(A)(3), the Plan does not reimburse
amounts paid for Dependent Care Expenses incurred while a Covered
Employee (or Spouse, if married) is off work for any reason, including illness
or vacation. However, if Dependent Care Expenses are paid to the
dependent care services provider on a weekly or longer basis, Dependent
Care Expenses incurred during a temporary absence from work for illness or
vacation will not be subject to this exclusion.
5.2
Specific Exclusions
The Plan does not reimburse amounts paid in connection with:
A.
a Qualifying Individual's overnight camp;
B.
services rendered by:
a Covered Employee's (and if married, the Covered Employee's
Spouse's) child (within the meaning of Code Section 152(c)(3)) under
age 19 at the Plan Year's end,
a Covered Employee’s Spouse or parent of the Covered Employee’s
child, or
a person for whom the Covered Employee (or if married, the Covered
Employee's Spouse) is entitled to a federal income tax deduction under
Code Section 151(c) for the Covered Employee's tax year.
Appendix A, Article V
A-10
5.3
Conditional Exclusions
Unless incidental, minimal, and inseparable from the cost of caring for a Qualifying
Individual, the Plan shall not pay any charges in connection with a Qualifying
Individual's:
A.
food,
B.
clothing,
C.
entertainment,
D.
education (kindergarten and above), or
E.
transportation between the Covered Employee's home and the place where
dependent care is provided unless such transportation is furnished by the
dependent care provider
Appendix A, Article VI
A-12
ARTICLE VI
PROCEDURES
6
6.1
Enrollment and Election Procedures
Employees may enroll and make elections only by filing the appropriate,
completed forms with the Plan Administrator within prescribed time limits. Rules
and deadlines for enrolling and making or changing elections are stated in the
Cafeteria Plan.
6.2
Claim Procedures
No claim for benefits shall be payable unless a properly completed claim, including
all necessary documentation of services received, is received by the Claim
Administrator within 5 months following the close of the Plan Year to which the
claim relates. In addition, any claim for benefits that are incurred within 2.5 months
following the close of a Plan year may be submitted for payment for the preceding
Plan year and, if that account balance is exhausted, may be submitted for payment
for the current Plan year, if the claim for benefits is also incurred during the current
Plan Year. For purposes of this Plan, an expense is treated as having been
incurred by the Covered Employee when the Covered Employee is provided with
the service that gives rise to the expense and not when the Covered Employee is
finally billed, charged for, or pays the expense. Notwithstanding the foregoing, if a
Covered Employee terminates employment, such Covered Employee must submit
a claim for benefits no later than 60 calendar days following the Covered
Employee’s termination date.
6.3
Claim Administrator
The Plan Administrator and/or the County shall have the authority to appoint,
remove, and replace one or more Claim Administrators. A Claim Administrator
shall have the duties, powers, and responsibilities set forth herein. In the absence
of such an appointment and except as hereinafter provided, the Plan Administrator
shall also be the Claim Administrator.
6.4
Claims Administration
The Claim Administrator shall have the duty to receive and review claims for
benefits under the Plan, to determine what amount, if any, is due and payable
under the terms and conditions of the Plan, and to make appropriate
disbursements of benefit payments to persons entitled thereto.
6.5
Proof of Claim
As a condition of receiving Plan benefits, claimants must:
A.
submit to the Plan Administrator:
a properly completed and timely filed claim form,
Appendix A, Article VI
A-12
a written declaration stating the dependent care expense has not been
reimbursed and is not reimbursable under any other dependent care
plan, and
a written declaration from an independent third party stating the
Covered Employee has incurred the dependent care expense and the
amount of such expense; and
B.
prove any claimed status.
Appendix B, Article I
B-1
APPENDIX B
MARICOPA COUNTY HEALTH CARE SPENDING ACCOUNT PLAN
ARTICLE I
PLAN ESTABLISHMENT
1
1.1
Effective Date
This Maricopa County Health Care Spending Account Plan ("the Plan") amends, restates,
and supersedes the Maricopa County Flexible Spending Account Plan (Fifth Amendment
and Restatement) effective as of the Effective Date, as defined in Article I of The Maricopa
County Benefits Plan.
1.2
Purpose
The Plan is created exclusively for Employees, as defined in Article II of the Cafeteria
Plan. The Plan's purpose is to reimburse Covered Employees, as defined in Article II of
this Appendix, for Qualifying Medical Expenses, as defined in Article II of this Appendix.
1.3
Qualification
The Plan is intended to qualify as a health plan under Section 105(e) of the Internal
Revenue Code of 1986, as amended ("the Code"). The Plan's Qualifying Medical Expense
reimbursements are intended to be eligible for exclusion from Covered Employees' gross
income under Code Section 105(b). This document is intended to satisfy the written plan
document requirement of Treasury regulations Section 1.105-11(b)(1)(i).
1.4
Incorporation By Reference
The term Cafeteria Plan as used in this Appendix means the Cafeteria Plan as defined in
Section 1.3 of The Maricopa County Benefits Plan. The terms of the Cafeteria Plan are
incorporated by reference wherever they apply to this Plan's operation, to the extent such
provisions do not conflict with the provisions of this Plan.
1.5
Duration
The Plan is established with the intention of being maintained for an indefinite period of
time; however, the County, as defined in Article II of the Cafeteria Plan, in its sole
discretion and in accordance with the provisions of Article XI of the Cafeteria Plan may
amend or terminate the Plan or any provision of the Plan.
Appendix B, Article II
B-2
ARTICLE II
DEFINITIONS
2
When capitalized in this document, these words and phrases have the following meanings:
2.1
Covered Employee
Covered Employee means an Employee who satisfies the participation
requirements of Article III.
2.2
Dependent
Dependent means a Covered Employee's:
A.
Spouse, and
B.
dependent(s) as defined in Code Section 152, (without regard to (b)(1),
(b)(2), and (d)(1)(B)), and
C.
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.
2.3
Effective Date
Effective Date means the date this Plan becomes operative, which is the effective
date identified in Article I of The Maricopa County Benefits Plan.
2.4
Exclusions
Exclusions means the exclusions in Article V.
2.5
Health Care Spending Account
Health Care Spending Account means the notational account established on
behalf of each Covered Employee who elects the Health Care Spending Account
premium payment benefit under the Cafeteria Plan to which the Covered
Employee allocates Salary Reduction Contributions for the reimbursement of
Qualifying Medical Expenses.
2.6
Maximum Annual Benefit
Maximum Annual Benefit means the total Salary Reduction Contributions a
Covered Employee authorizes to his or her Health Care Spending Account,
according to the election procedures of Section 6.1, for Qualifying Medical
Expense reimbursement, which amount must be not more than an amount to be
communicated annually by the Plan Administrator, which amount shall not exceed
the IRS annual limit.
Appendix B, Article II
B-3
2.7
Plan
Plan means the Maricopa County Health Care Spending Account Plan as herein
set forth and as amended from time to time.
2.8
Qualifying Medical Expenses
Qualifying Medical Expenses means a Covered Employee's and a Dependent's
expenses incurred during the Plan Year for medical care, as defined in Code
Section 213(d)(1)(A) and (B). However, the Plan will allow a grace period of two
and one half months following the end of the Plan Year in which Covered
Employees and Dependents may incur Qualifying Medical Expenses to be
reimbursed under the current Plan Year’s election. To be a Qualifying Medical
Expense, the medical care must be essential to diagnose, cure, mitigate, treat, or
prevent a disease or disorder or to affect an unsound structure or function of the
mind or body. Incurred refers to the date the medical care is provided — not to the
date charged, billed, or paid.
Appendix B, Article IV
B-4
ARTICLE III
PARTICIPATION
3
3.1
Participation
An Employee is a Covered Employee and participates in the Plan during those
periods in which the Employee:
A.
participates in the Cafeteria Plan, and
B.
has allocated an amount to his or her Health Care Spending Account.
Except for Qualifying Medical Expenses incurred before Plan coverage ceases
and subject to satisfying the procedural requirements of Article VI, no Plan benefits
are payable after coverage terminates.
3.2
Termination of Participation
A Covered Employee shall cease to participate in the Plan when he or she is no
longer eligible to participate in the Cafeteria Plan, when the Covered Employee
revokes his or her election to participate in the Plan, or when the Covered
Employee terminates employment, retires or dies.
Appendix B, Article IV
B-5
ARTICLE IV
MEDICAL EXPENSE BENEFIT
4
4.1
Right to Benefit
Subject to the following terms and limits and the Exclusions, Covered Employees
are entitled to reimbursement for Qualifying Medical Expenses.
4.2
Maintenance of Accounts
The Plan Administrator shall maintain a Health Care Spending Account for each
Employee who elects the health care spending account premium payment benefit.
The health care spending account premium payment benefit elected by the
Employee shall be credited to his or her Health Care Spending Account as of the
first day that the Employee's election is effective.
4.3
Amount Payable
Subject to the procedural requirements of Article VI, payable Qualifying Medical
Expenses may not exceed the health care spending account premium payment
benefit the Covered Employee elected to be credited to his or her Health Care
Spending Account for the Plan Year, less any payments previously made during
the Plan Year — up to the Maximum Annual Benefit.
4.4
Qualifying Medical Expenses
Qualifying Medical Expenses, as defined in Article II of this Appendix, that are not
covered by any other health plan include, for example, expenses for:
A.
abortion, if legal where performed
B.
acupuncture
C.
ambulance service
D.
birth control pills
E.
breast pumps and supplies that assist lactation
F.
capital expenses for home improvements and special equipment installed in
the car or home, if the main reason for the improvement or equipment is for
medical care, but only to the extent the expenditure exceeds any increase in
the improved property's value
G.
Christian Science practitioners
H.
crutches
I.
dental treatment
Appendix B, Article IV
B-6
J.
doctor's fees including, but not limited to: anesthesiologists, gynecologists,
chiropodists, chiropractors, dermatologists, neurologists, obstetricians,
occupational therapists, ophthalmologists, osteopaths, podiatrists,
pediatricians, physical therapists, psychiatrists, psychologists, and speech
therapists
K.
eye examinations, eyeglasses, and contact lenses
L.
hearing examinations and hearing aids
M.
hospital services
N.
laboratory fees and diagnostic testing
O.
mental health treatment
P.
nursing home services, including meals and lodging
Q.
nursing services
R.
organ transplant expenses
S.
over-the-counter drugs or items only as permitted under applicable law or
regulation
T.
oxygen and oxygen equipment
U.
prescription drugs
V.
prostheses
W.
smoking cessation products
X.
special schooling and equipment for the mentally or physically handicapped
Y.
sterilization
Z.
substance abuse treatment
AA. surgery
BB. therapy
CC. transportation for medical reasons
DD. wheelchairs
EE. X-ray fees
Appendix B, Article IV
B-7
4.5
Limits
The Plan reimburses Qualifying Medical Expenses only to the extent the charge is
not compensated for by any prepaid health coverage, group health plan, medical
insurance, or otherwise. Qualifying Medical Expenses include deductibles and co-
payments if not reimbursed through coordination of benefits with a secondary
payor.
Appendix B, Article V
B-8
ARTICLE V
EXCLUSIONS
5
5.1
General Rules
A.
The Plan pays only those Qualifying Medical Expenses incurred by an
Employee or the Employee's Dependent:
during the current Plan Year, except that the Plan will allow a grace
period of two and one half months following the end of the Plan Year in
which Covered Employees may incur Qualifying Medical Expenses for
reimbursement from amounts remaining unused at the end of the
immediately preceding Plan Year. This reimbursement will be treated as
if the expenses had been incurred in the prior year, and
while the Employee is a Covered Employee.
B.
The Plan does not reimburse amounts paid for services or supplies that
merely improve health or morale generally.
5.2
Specific Exclusions
Unless specifically permitted under applicable law or regulation, the Plan does not
reimburse amounts paid in connection with:
A.
cosmetic surgery or similar procedure 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 a disfiguring disease,
B.
custodial or domiciliary care,
C.
diaper service,
D.
funeral and burial expenses,
E.
health club membership fees and dues,
F.
household and domestic help,
G.
illegal services and supplies,
H.
insurance premiums of any kind including those for health maintenance
organizations, life insurance, long term care, loss of earnings, accidental
death or dismemberment, automobile insurance, and group medical or other
health insurance,
I.
meals and lodging at a nonmedical facility,
J.
maternity clothes or uniforms,
Appendix B, Article V
B-9
K.
nursing services for a normal, healthy newborn baby, except for breast
pumps and supplies that assist lactation,
L.
over-the-counter or nonprescription drugs or items unless specifically
permitted under applicable law or regulation,
M.
personal use items like cosmetics, toiletries, and items for personal hygiene
or beautification,
N.
schooling or tuition for scholastic improvement or discipline,
O.
social activities like dancing or swimming lessons,
P.
special foods or dietary supplements like vitamins, minerals, bottled water,
and diet foods,
Q.
transportation for nonmedical reasons,
R.
trips or vacations, and
S.
long term care expenses.
Appendix B, Article VI
B-10
ARTICLE VI
PROCEDURES
6
6.1
Enrollment and Election Procedures
Employees may enroll and make elections only by filing the appropriate,
completed forms with the Plan Administrator within prescribed time limits. Rules
and deadlines for enrolling and making or changing elections are stated in the
Cafeteria Plan.
6.2
Claim Procedures
No claim for benefits shall be payable unless a properly completed claim, including
all necessary documentation of services received, is received by the Claim
Administrator within 5 months following the close of the Plan Year to which the
claim relates. In addition, any claim for benefits that are incurred within 2.5 months
following the close of a Plan year may be submitted for payment for the preceding
Plan year and, if that account balance is exhausted, may be submitted for payment
for the current Plan year, if the claim for benefits is also incurred during the current
Plan Year. For purposes of this Plan, an expense is treated as having been
incurred by the Covered Employee when the Covered Employee is provided with
the service that gives rise to the expense and not when the Covered Employee is
finally billed, charged for, or pays the expense.
6.3
Claim Administrator
The Plan Administrator and/or the County shall have the authority to appoint,
remove, and replace one or more Claim Administrators. A Claim Administrator
shall have the duties, powers, and responsibilities set forth herein. In the absence
of such an appointment and except as hereinafter provided, the Plan Administrator
shall also be the Claim Administrator.
6.4
Claims Administration
The Claim Administrator shall have the duty to receive and review claims for
benefits under the Plan, to determine what amount, if any, is due and payable
under the terms and conditions of the Plan, and to make appropriate
disbursements of benefit payments to persons entitled thereto.
6.5
Proof of Claim
As a condition of receiving Plan benefits, claimants must:
A.
submit to the Plan Administrator:
a properly completed and timely filed claim form,
a written declaration stating the Qualifying Medical Expense has not
been reimbursed and is not reimbursable under any other health plan,
and
Appendix B, Article VI
B-11
a written declaration from an independent third party stating the
Covered Employee has incurred the medical expense and the amount
of such expense; and
B.
prove any claimed status.
Appendix C, Article I
C-1
APPENDIX C
MARICOPA COUNTY LIMITED PURPOSE HEALTH CARE SPENDING ACCOUNT PLAN
ARTICLE I
PLAN ESTABLISHMENT
1
1.1
Effective Date
This Maricopa County Limited Purpose Health Care Spending Account Plan ("the Plan")
amends, restates, and supersedes the Maricopa County Limited Scope Flexible Spending
Account Plan (Second Amendment and Restatement) effective as of the Effective Date,
as defined in Article I of The Maricopa County Benefits Plan.
1.2
Purpose
The Plan is created exclusively for Employees, as defined in Article II of the Cafeteria
Plan. The Plan's purpose is to reimburse Covered Employees, as defined in Article II of
this Appendix, for Qualifying Medical Expenses, as defined in Article II of this Appendix.
1.3
Qualification
The Plan is intended to qualify as a health plan under Section 105(e) of the Internal
Revenue Code of 1986, as amended ("the Code"). The Plan's Qualifying Medical Expense
reimbursements are intended to be eligible for exclusion from Covered Employees' gross
income under Code Section 105(b). This document is intended to satisfy the written plan
document requirement of Treasury regulations Section 1.105-11(b)(1)(i).
1.4
Incorporation By Reference
The term Cafeteria Plan as used in this Appendix means the Cafeteria Plan as defined in
Section 1.3 of The Maricopa County Benefits Plan. The terms of the Cafeteria Plan are
incorporated by reference wherever they apply to this Plan's operation, to the extent such
provisions do not conflict with the provisions of this Plan.
1.5
Duration
The Plan is established with the intention of being maintained for an indefinite period of
time; however, the County, as defined in Article II of the Cafeteria Plan, in its sole
discretion and in accordance with the provisions of Article XI of the Cafeteria Plan may
amend or terminate the Plan or any provision of the Plan.
Appendix C, Article II
C-2
ARTICLE II
DEFINITIONS
2
When capitalized in this document, these words and phrases have the following meanings:
2.1
Covered Employee
Covered Employee means an Employee who satisfies the participation requirements of
Article III.
2.2
Dependent
Dependent means a Covered Employee's:
A.
Spouse, and
B.
dependent(s) as defined in Code Section 152, (without regard to (b)(1), (b)(2), and
(d)(1)(B)), and
C.
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.
2.3
Effective Date
Effective Date means the date this Plan becomes operative which is the effective date
identified in Article I of The Maricopa County Benefits Plan.
2.4
Exclusions
Exclusions means the exclusions in Article V.
2.5
Limited Purpose Health Care Spending Account
Limited Purpose Health Care Spending Account means the notational account established
on behalf of each Covered Employee who elects the Limited Purpose Health Care
Spending Account premium payment benefit under the Cafeteria Plan to which the
Covered Employee allocates Salary Reduction Contributions for the reimbursement of
Qualifying Medical Expenses.
2.6
Maximum Annual Benefit
Maximum Annual Benefit means the total Salary Reduction Contributions a Covered
Employee authorizes to his or her Limited Purpose Health Care Spending Account,
according to the election procedures of Section 6.1, for Qualifying Medical Expense
reimbursement, which amount must be not more than an amount to be communicated
annually by the Plan Administrator, which amount shall not exceed the IRS annual limit.
Appendix C, Article II
C-3
2.7
Plan
Plan means the Maricopa County Limited Purpose Health Care Spending Account Plan as
herein set forth and as amended from time to time.
2.8
Qualifying Medical Expenses
Qualifying Medical Expenses means a Covered Employee's and a Dependent's expenses
incurred during the Plan Year for medical care, as defined in Code Section 213(d)(1)(A)
and (B). The Plan will allow a grace period of two and one half months following the end of
the Plan Year in which Covered Employees and Dependents may incur Qualifying Medical
Expenses to be reimbursed under the current Plan Year’s election.
Notwithstanding any other Plan provision, medical expenses that are not dental, vision or
preventive care expenses are not considered Qualifying Medical Expenses under this
Plan. To be a Qualifying Medical Expense, the medical care must be essential to
diagnose, cure, mitigate, treat, or prevent a disease or disorder or to affect an unsound
structure or function of the mind or body. Incurred refers to the date the medical care is
provided — not to the date charged, billed, or paid.
Appendix C, Article IV
C-4
ARTICLE III
PARTICIPATION
3
3.1
Participation
An Employee is a Covered Employee and participates in the Plan during those periods in
which the Employee:
A.
participates in the Cafeteria Plan, and
B.
has allocated an amount to his or her Limited Purpose Health Care Spending
Account.
Except for Qualifying Medical Expenses incurred before Plan coverage ceases and
subject to satisfying the procedural requirements of Article VI, no Plan benefits are
payable after coverage terminates.
3.2
Termination of Participation
A Covered Employee shall cease to participate in the Plan when he or she is no longer
eligible to participate in the Cafeteria Plan, when the Covered Employee revokes his or
her election to participate in the Plan, or when the Covered Employee terminates
employment, retires or dies.
Appendix C, Article IV
C-5
ARTICLE IV
MEDICAL EXPENSE BENEFIT
4
2
4.1
Right to Benefit
Subject to the following terms and limits and the Exclusions, Covered Employees are
entitled to reimbursement for Qualifying Medical Expenses.
4.2
Maintenance of Accounts
The Plan Administrator shall maintain a Limited Purpose Health Care Spending Account
for each Employee who elects the limited purpose health care spending account premium
payment benefit. The limited purpose health care spending account premium payment
benefit elected by the Employee shall be credited to his or her Limited Purpose Health
Care Spending Account as of the first day that the Employee's election is effective.
4.3
Amount Payable
Subject to the procedural requirements of Article VI, payable Qualifying Medical Expenses
may not exceed the limited purpose health care spending account premium payment
benefit the Covered Employee elected to be credited to his or her Limited Purpose Health
Care Spending Account for the Plan Year, less any payments previously made during the
Plan Year — up to the Maximum Annual Benefit.
Appendix C, Article IV
C-6
4.4
Qualifying Medical Expenses
Qualifying Medical Expenses, as defined by Article II, must be dental, vision, or preventive
care expenses. The following are examples of Qualifying Medical Expenses to the extent
they are not covered by any other health plan and meet the limitations described below:
A.
Vision Expenses
1.
Eyeglasses
2.
Contact lenses
3.
Ophthalmologist fees
4.
The cost of a guide dog for the blind and special education devices for the
blind (such as an interpreter)
B.
Dental Expenses
1.
Anesthesia
2.
Cleaning
3.
Charges in excess of Usual and Prevailing Fee Limits
4.
Drugs and their administration
5.
Experimental procedures
6.
Extra sets of dentures or other Dental appliances
7.
Medically Necessary orthodontia expenses for adults or dependents
8.
Myofunctional therapy
9.
Replacement of dentures or bridgework
10.
Replacement of lost, stolen, or missing dentures or orthodontic devices
C.
Preventive Care Expenses
4.5
Limits
The Plan reimburses Qualifying Medical Expenses only to the extent the charge is not
compensated for by any prepaid health coverage, group health plan, medical insurance,
or otherwise. Qualifying Medical Expenses may include certain deductibles and co-
payments if not reimbursed through coordination of benefits with a secondary payor.
Appendix C, Article V
C-7
ARTICLE V
EXCLUSIONS
5
2
5.1
General Rules
A.
The Plan pays only those Qualifying Medical Expenses incurred by an Employee
or the Employee's Dependent:
1.
during the current Plan Year, except that the Plan will allow a grace period
of two and one half months following the end of the Plan Year in which
Covered Employees may incur Qualifying Medical Expenses for
reimbursement from amounts remaining unused at the end of the
immediately preceding Plan Year. This reimbursement will be treated as if
the expenses had been incurred in the prior year, and
2.
while the Employee is a Covered Employee.
B.
The Plan does not reimburse amounts paid for services or supplies that merely
improve health or morale generally.
5.2
Specific Exclusions
The Plan does not reimburse amounts that are not paid for dental, vision, or preventive
services.
Appendix C, Article VI
C-8
ARTICLE VI
PROCEDURES
6
6.1
Enrollment and Election Procedures
Employees may enroll and make elections only by filing the appropriate, completed forms
with the Plan Administrator within prescribed time limits. Rules and deadlines for enrolling
and making or changing elections are stated in the Cafeteria Plan.
6.2
Claim Procedures
No claim for benefits shall be payable unless a properly completed claim, including all
necessary documentation of services received, is received by the Claim Administrator
within 5 months following the close of the Plan Year to which the claim relates. In addition,
any claim for benefits that are incurred within 2.5 months following the close of a Plan
year may be submitted for payment for the preceding Plan year and, if that account
balance is exhausted, may be submitted for payment for the current Plan year, if the claim
for benefits is also incurred during the current Plan Year. For purposes of this Plan, an
expense is treated as having been incurred by the Covered Employee when the Covered
Employee is provided with the service that gives rise to the expense and not when the
Covered Employee is finally billed, charged for, or pays the expense.
6.3
Claim Administrator
The Plan Administrator and/or the County shall have the authority to appoint, remove, and
replace one or more Claim Administrators. A Claim Administrator shall have the duties,
powers, and responsibilities set forth herein. In the absence of such an appointment and
except as hereinafter provided, the Plan Administrator shall also be the Claim
Administrator.
6.4
Claims Administration
The Claim Administrator shall have the duty to receive and review claims for benefits
under the Plan, to determine what amount, if any, is due and payable under the terms and
conditions of the Plan, and to make appropriate disbursements of benefit payments to
persons entitled thereto.
6.5
Proof of Claim
As a condition of receiving Plan benefits, claimants must:
A.
submit to the Plan Administrator:
1.
a properly completed and timely filed claim form,
2.
a written declaration stating the Qualifying Medical Expense has not been
reimbursed and is not reimbursable under any other health plan, and
Appendix C, Article VI
C-9
3.
a written declaration from an independent third party stating the Covered
Employee has incurred the medical expense and the amount of such
expense; and
B.
prove any claimed status.
Appendix D
D-1
APPENDIX D
APPLICABLE INCORPORATED DOCUMENTS
APPLICABLE
BENEFIT
APPLICABLE BENEFIT
Medical Benefits
Administrator Services Only Agreement between the
County and Cigna Health (Group #3205496) effective
July 1, 2014 [Network Medical benefits]
Administrator Services Only Agreement between the
County and UnitedHealthcare (Group #901632)
effective July 1, 2014 [UnitedHealthcarePPO ]
Administrator Services Only Agreement between the
County and Cigna Health (Group #3205496) effective
July 1, 2014 [Cigna HDHP with HSA Plan]
Administrator Services Only Agreement between the
County and UnitedHealthcare (Group #901632)
effective July 1, 2014 [UnitedHealthcare HDHP with
HSA]
Prescription Benefits
Contract for Pharmacy Benefit Manager Services
between the County and OptumRx Inc. (Group
#512229) effective January 1, 2017
Dental Benefits
Administrator Services Only Agreement between the
County and Cigna Dental (Group #2465354) effective
July 1, 2012 [Cigna Dental Preferred Provider
Insurance]
Vision Benefits
Administrator Services Only Agreement between
County and EyeMed effective July 1, 2015 [EyeMed
Vision Care Service]
Employee Assistance
Plan
Group Policy and certificate of coverage issued by
Magellan Health Services effective June 20, 2012
Group Term Basic Life
Benefits
Group Policy #70334 and certificate of coverage issued
by Securian effective July 1, 2018
Accidental Death &
Dismemberment
Benefits
Group Policy #70335 and certificate of coverage issued
by Securian effective July 1, 2018
Appendix D
D-2
Short Term Disability
Benefits
Administrator Services Only Agreement between the
County and Sedgwick effective July 1, 2012 [Maricopa
County Group Short-Term Disability Plan Description]
This Appendix D shall be subject to modification without formal amendment of the Plan.
Appendix E
E-1
APPENDIX E
EMPLOYEES OF THE EMPLOYER APPROVED TO HAVE ACCESS TO
PROTECTED HEALTH INFORMATION
Analysts:
Benefits Analysts
Finance Analyst
Quality Assurance Analyst
Coordinators - Wellness and Fitness
Deputy Director of Employee Benefits and Wellness
Employee Benefits Managers – Operations, Administration and Finance
Employee Benefits Supervisors – Operations, Administration, Finance, and Wellness
Human Resource Director
Specialists:
Accounting Specialists
Benefits Specialists
Appendix F
F-1
APPENDIX F
PARTICIPATING EMPLOYERS
In addition to Maricopa County, the following entities are Participating Employers in this Plan:
As of Effective Date: None.
The list of Participating Employers shall be subject to modification without formal amendment of
the Plan.
Appendix G, Article I
G-1
APPENDIX G
MARICOPA COUNTY
HEALTH SAVINGS ACCOUNT
ARTICLE I
PLAN ESTABLISHMENT
1
1.1
Trustee/Custodial Agreement
Health Savings Account benefits under the Cafeteria Plan consist solely of the
ability to make contributions to the Health Savings Account pursuant to the Salary
Reduction. Terms and conditions of coverage and benefits (e.g., eligible medical
expenses, claims procedures, etc.) will be provided by the applicable
trustee/custodian for the Health Savings Account, not this Cafeteria Plan. The
terms and conditions of each Covered Employee’s Health Savings Account trust or
custodial account are described in the Health Savings Account trust or custodial
agreement provided by the applicable trustee/custodian to each electing Covered
Employee and are not a part of this Plan.
1.2
Health Savings Account Not Intended to be an ERISA Plan
The Health Savings Account is not an employer-sponsored employee benefits
plan. It is a savings account that is established and maintained by a Health
Savings Account trustee/custodian outside this Plan to be used primarily for
reimbursement of “qualified medical expenses” as set forth in Code Section
223(d)(2). The Employer has no authority or control over the funds deposited in a
Health Savings Account. This Cafeteria Plan may allow contributions to a Health
Savings Account through salary reductions.
1.3
Incorporation By Reference
The term Cafeteria Plan as used in this Appendix means the Cafeteria Plan as
defined in Section 1.3 of The Maricopa County Benefits Plan. The terms of the
Cafeteria Plan are incorporated by reference wherever they apply to this Plan's
operation, to the extent such provisions do not conflict with the provisions of this
Plan.
Appendix G, Article II
G-2
ARTICLE II
DEFINITIONS
2
In this Appendix, references to an Article or Section refer to an Article or Section of this Appendix,
unless otherwise specified. When capitalized in this document, these words and phrases have
the following meanings:
2.1
Covered Employee
Covered Employee means an Employee who satisfies the participation
requirements of Article III.
2.2
Health Savings Account (HSA)
An individual trust or custodial account established under Code Section 223 by a
Covered Employee with a trustee/custodian that has contracted with the County to
receive pre-tax salary reduction contributions.
Appendix G, Article III
G-3
ARTICLE III
PARTICIPATION
3
3.1
Participation
An Employee is a Covered Employee and participates in the Health Savings
Account during those periods in which the Employee:
A.
participates in the Cafeteria Plan and an Employer-sponsored high
deductible health plan that meets the requirements of Section 223; and
B.
has elected the Health Savings Account Premium Payment Benefit as
described in Article IV of the Cafeteria Plan.
Appendix G, Article IV
G-4
ARTICLE IV
HEALTH SAVINGS ACCOUNT BENEFIT
4
4.1
Contributions for Cost of Coverage for HSA/Maximum Limits
The annual contribution for a Covered Employee’s Health Savings Account is equal to
the annual benefit amount elected by the Health Savings Account, but in no event shall
the amount elected exceed the statutory maximum amount for HSA contributions
applicable to the Covered Employee’s high-deductible health plan coverage option (i.e.,
single or family) for the calendar year in which the contribution is made. An additional
catch-up contribution of up to $1,000 may be made for Covered Employees who are age
55 or older as of the end of the taxable year.
In addition, the maximum annual contribution shall be:
A.
reduced by any Employer contribution made on the Covered Employee’s behalf;
and
B.
prorated for the number of months in which the Covered Employee is an HSA-
eligible individual, unless the Covered Employee chooses to use the full-year
contribution rule described in Section 223(b)(8).
Because HSAs are individual accounts, complying with the maximum annual
contribution is the responsibility of the Covered Employee.
4.2
Recording Contributions for HSA
As described in Article I, the HSA is not an employer-sponsored employee benefit plan—
it is an individual trust or custodial account separately established and maintained by a
trustee/custodian outside the Plan. Consequently, the HSA trustee/custodian, not the
Employer, will establish and maintain the HSA. The Employer, however, reserves the
right to limit the HSA provider to whom it will forward Employer contributions and
contributions that the Covered Employee makes via Salary Reduction.
The Plan Administrator will maintain records to track HSA contributions a Covered
Employee makes pursuant to the Salary Reduction, but it will not create a separate fund
or otherwise segregate assets for this purpose. The County has no authority or control
over the funds deposited in an HSA.
4.3
Tax Treatment of HSA Contributions and Distributions
The federal income tax treatment of the HSA (including contributions and distributions) is
governed by Code Section 223.