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RESOLUTION N0.2006 -10
FOR THE AMENDMENT OF CITY OF REXBURG CAFETERIA PLAN
On this date, the City Council of the CITY OF REXBURG did meet to discuss the
amendment of the CITY OF REXBURG CAFETERIA PLAN to be effective July 1st,
2006. Let it be known that the following resolutions were duly adopted by the City Council
of CITY OF REXBURG and that such resolutions have not been modified or rescinded as
of the date hereof;
RESOLVED, that the form of Cafeteria Plan, as authorized under Section 125 of the
Internal Revenue Code of 1986, presented to this meeting is hereby adopted and approved
and that the proper officers of the Employer are hereby authorized and directed to execute
and deliver to the Plan Administrator one or more copies of the Plan.
RESOLVED, that the short Plan Year shall begin on July 1st, 2006 and end on December
31st, 2006. Each subsequent Plan Year shall begin on January 1st and end on December
31st.
RESOLVED, that the proper officers of the Employer shall act as soon as possible to notify
employees of the amendment of the Cafeteria Plan by delivering to each Employee a copy of
the Summary Plan Description presented to this meeting, which form is hereby approved.
The undersigned certifies that attached hereto as Exhibits A and B respectively are true
copies of the Plan Document, and Summary Plan Description for CITY OF REXBURG
CAFETERIA PLAN approved and adopted in the foregoing resolutions.
The undersigned further certifies and attests that the above resolutions were made with the
consent of the City Council of the City of Rexburg on this date September 6, 2006.
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Shawn Larsen, Mayor
Attest:
Blair D. Kay, Ciry Clerk
CITY OF REXBURG CAFETERIA PLAN
TABLE OF CONTENTS
ARTICLE I -INTRODUCTION
1.1 Creation and Title 3
1.2 Effective Date 3
1.3 Purpose 3
ARTICLE II -DEFINITIONS
ARTICLE III -PARTICIPATION
4
3.1 Eligibility 7
3.2 Commencement of Participation 7
3.3 Term of Participation 7
3.4 Treatment of Rehired Employees 8
3.5 HIPAA Portability 8
3.6 COBRA Continuation Coverage 8
3.7 Family Medical Leave Act 8
ARTICLE IV -CONTRIBUTIONS
4.1 Source of Contributions 12
4.2 Change in Participant's Benefits Enrollment 12
4.3 Increases or Decreases in Premiums 12
4.4 Maximum Contribution 12
4.5 Nondiscrimination 12
ARTICLE V -PARTICIPANTS' ACCOUNTS AND PAYMENT OF
BENEFITS
5.1 Participants' Benefit Accounts 14
5.2 Premium Account 14
5.3 Reimbursement Account 14
5.4 Payment of Benefits 14
ARTICLE VI -PLAN ADMINISTRATION
6.1 Plan Administrator 15
6.2 Plan Administrator's Duties 15
6.3 Information to be Provided to Plan Administrator 16
6.4 Decision of Plan Administrator Final 16
6.5 Review Procedures 16
6.6 Extensions of Time 17
6.7 Rules to Apply Uniformly 17
6.8 Indemnity 17
ARTICLE VII -GENERAL PROVISIONS
7.1 Amendment and Termination 18
7.2 Nonassignability 18
7.3 Medical Child Support Orders 18
7.4 Not an Employment Contract 19
7.5 Participant Litigation 19
7.6 Addresses, Notice and Waiver of Notice 19
7.7 Required Information 19
7.8 Severability 19
7.9 Applicable Law 19
CITY OF REXBURG CAFETERIA PLAN
ARTICLE I
INTRODUCTION
1.1 Creation and Title. The Employer hereby amends its cafeteria plan under the
terms and conditions set forth in this document. The Plan is to be known as CITY OF REXBURG
CAFETERIA PLAN.
1.2 Effective Date. The provisions of the Plan, as amended, shall be effective as of
July 1st, 2006. The Plan was originally effective July 1st, 1985.
1.3 Purpose. The purpose of the Plan is to allow employees to select among cash
compensation and certain nontaxable benefits, namely coverage under one or more benefits
programs maintained by the Employer. The Employer intends that the Plan qualify as a cafeteria
plan under Section 125 of the Code, and that the benefits provided under the Plan be eligible for
exclusion from Federal income tax.
ARTICLE II
DEFINITIONS
As used in this Plan document, the following terms shall have the following meanings:
2.1 "Benefit Entry Date" means for each Eligible Employee the day that the
Employee becomes eligible to participate in each of the Plan's Benefits. If the Plan does not have
different eligibility requirements for each benefit, the Benefit Entry Date will be the same as the
Plan Entry Date.
2.2 "Benefits" mean cash and the various qualified benefits under Section 125(f) of
the Code sponsored by the Employer and made available by the Employer through the Plan,
including, but not limited to, health insurance, group term life insurance, disability insurance,
medical reimbursement and dependent care reimbursement.
2.3 "Benefits Accounts" mean the accounts established by the Plan Administrator
under the Plan for each Participant's Benefits for purposes of administering the Plan.
2.4 "Benefits Enrollment Form" means the form or forms, including a Salary
Reduction Agreement, evidencing an Eligible Employee's selections from among the various
Benefits and the amount to be contributed towards various Benefits for a Plan Year or portion of a
Plan Year.
2.5 "Change in Status"
(a) With regard to the election to participate in the Plan and elections for Medical
Flexible Spending Account benefits, Change in Status shall mean the marriage or divorce
of the Participant; the adoption, birth, or death of a child or other Dependent of the
Participant or the Participant's Spouse; the emancipation or coming of age of a child of the
Participant so that the child is no longer eligible as a Dependent under the Plan; the
employment of the Participant or Participant's Spouse; change in the Participant's
residence; the Participant beginning or ending adoption proceedings, or; Medicare or
Medicaid entitlement.
(b) With regard to the election to participate in the Plan and elections for all other
Plan Benefits, Change in Status shall mean the marriage or divorce of the Participant; the
adoption, birth, or death of a child or other Dependent of the Participant or the
Participant's Spouse; the emancipation or coming of age of a child of the Participant so
that the child is no longer eligible as a Dependent under the Plan; the employment of the
Participant or Participant's Spouse; change in the Participant's residence; the Participant
beginning or ending adoption proceedings; automatic changes upon cost increases or
decreases; significant cost increases; significant curtailment of coverage; addition or
elimination of similar benefit package option allowing (prohibiting) employees that
previously opted out of other benefits to make an election change; change in coverage
under employer plan of spouse or dependent; FMLA leaves; changes in 401(k)
contributions; HIPAA special enrollment rights; a COBRA qualifying event; a judgment,
decree or order, or; Medicare or Medicaid entitlement.
2.6 "Code" means the Internal Revenue Code of 1986, as amended from time to time.
2.7 "Compensation" means all the earned income, salary, wages and other earnings
paid by the Employer to a Participant during a Plan Year, including any amounts contributed by
the Employer pursuant to a salary reduction agreement which are not includable in gross income
under Sections 125, 402(g)(3), 402(h), 403(b) or 457(b) of the Code.
2.8 "Dependent" means an individual who is a dependent within the meaning of
Section 152(a) without regard to 152(b)(1, (b)(2), and (d)(1)(B) thereof of the Code of a
Participant or a former Participant in the Plan.
2.9 "Effective Date" shall be July 1st, 2006.
2.10 "Eligible Employee" means an Employee, as defined in Section 2.11 below,
who is eligible to participate in the Employer's health care program, except for employees who
works less than 30 hours per week and has been employed less than 6 months. except for: (1)
Employees who are self-employed individuals as defined in section 401(c) of the Internal
Revenue Code (including sole proprietors and partners in a partnership), (2) Employees who own
(or are considered to own within the meaning of section 318 of the Internal Revenue Code) more
than 2 percent of the outstanding stock of an S corporation or stock possessing more than 2
percent of the total combined voting power of all stock of such corporation.
2.11 "Employee" means a person who is currently or hereafter employed by the
Employer, or by any other employer aggregated under sections 414(b), (c), (m), (n) or (o) of the
Code and the regulations there under, including a Leased Employee subject to section 414(n) of
the Code. Excluding individuals who are not contemporaneously classified as Employees of the
Employer for purposes of the Employer's payroll system (including, without limitation,
individuals employed by temporary help firms, technical help firms, staffing firms, employee
leasing firms, professional employer organizations or other staffing firms whether or not deemed
to be "common law" Employees or "Leased Employees" within the meaning of section 414(n) (o)
of the Code) are not considered to be Eligible Employees of the Employer and shall not be
eligible to participate in the Plan. In the event any such individuals are reclassified as Employees
for any purpose, including without limitation, common law or statutory employees, by any action
of any third party, including, without limitation, any government agency, or as a result of any
private lawsuit, action, or administrative proceeding, such individuals shall notwithstanding such
reclassification, remain ineligible for participation hereunder. Notwithstanding foregoing, the
exclusive means for individuals who are not contemporaneously classified as an Employee of the
Employer on the Employer's payroll system to become eligible to participate in this Plan is
through an amendment to this Plan, duly executed by the Employer, which specifically renders
such individuals eligible for participation hereunder.
The Plan Administrator shall have full and complete discretion to determine eligibility for
participation and benefits under this Plan, including, without limitation, the determination of
those individuals who are deemed Employees of the Employer (or any controlled group member).
The Plan Administrator's decision shall be final, binding and conclusive on all parties having or
claiming a benefit under this Plan. This Plan is to be construed to exclude all individuals who are
not considered Employees for purposes of the Employer's payroll system, and the Plan
Administrator is authorized to do so, despite the fact that its decision may result in the loss of the
Plan's tax qualification.
2.12 "Employer" means CITY OF REXBURG or any of its affiliates, successors or
assignors which adopt the Plan.
2.13 "Participant" means any Employee who has met the eligibility requirements of
Section 3.1 of the Plan and has elected to participate in the Plan by providing the Plan
Administrator with an executed Benefits Enrollment Form.
2.14 "Plan" means CITY OF REXBURG CAFETERIA PLAN, as described herein.
2.15 "Plan Administrator" Human Resource Director or such other person or
committee as may be appointed by the Employer to administer the Plan.
2.16 "Plan Entry Date" means for each Eligible Employee, the first day of the
month coincident with or next following the day that the Employee becomes eligible to
participate in the Plan.
2.17 "Plan Year" means the 12-consecutive month period beginning on January 1st
and ending on December 31st, except for a short Plan Year beginning on July 1st, 2006 and
ending on December 31st, 2006.
2.18 "Salary Reduction Agreement" means the agreement by an Employee
authorizing the Employer to reduce the Employee's Compensation while a Participant during the
Plan Year for purposes of making contributions toward Benefits under the Plan.
2.19 "Spouse" means an individual who is legally married to a Participant but shall
not include an individual separated from a Participant under a decree of legal separation.
2.20 "Timely Submitted" means, unless the Plan Administrator has specific and
special cause to alter the definition of this phrase, within 30 calendar days of event that has
triggered the Change in Status.
ARTICLE III
PARTICIPATION
3.1 Eligibility. Each Employee, as defined in section 2.11 above, shall be eligible to
participate in the Plan upon the latter of the following dates:
(a) the date the Employee attains age 21;
(b) the date the Employee completes 6 months of service with the Employer and
works no less than 30 hours per week.
3.2 Commencement of Participation. An Eligible Employee shall become a
Participant in the Plan after providing the Plan Administrator with an executed Benefits
Enrollment Form setting forth the Benefits to be made available to the Eligible Employee for the
immediately following Plan Year or remaining portion of the Plan Year. As part of the Benefits
Enrollment Form, the Participant shall also execute a Salary Reduction Agreement, which
authorizes the Employer to withhold from the Participant's Compensation an amount the
Participant elects to have contributed to the Plan. The Participant must, before the end of the first
Plan Year of participation and, before the end of each subsequent Plan Year, provide the Plan
Administrator with a newly executed Benefits Enrollment Form. Each new Benefits Enrollment
Form shall specify the type and amount of Benefits to be made available to the Participant for the
immediately following Plan Year or remaining portion of the Plan Year. For the initial Plan Year
only, if a Participant fails to execute a valid Benefits Enrollment Form before the Plan's original
Effective Date, the Participant shall be ineligible to participate in the Plan for the initial Plan
Year. Should a Participant fail to execute a valid Benefit Enrollment Form for any Plan Year
before the start of the Plan Year, the Participant shall be ineligible to participate in the Plan for
that Plan Year.
3.3 Term.of Participation. Each Participant shall be a Participant in the Plan for the
entire Plan Year or the portion of the Plan Year remaining after the Participant's Entry Date, if
later than the first day of the Plan Year. A Participant shall cease to be a Participant in the Plan on
the earliest of:
(a) the date the Participant dies, resigns or terminates employment with the
Employer, subject to the provisions of Section 3.4;
(b) the date the Participant fails to make required contributions under the Plan;
(c) the date the Participant ceases to be an Employee; or
(d) the date the Plan terminates.
3.4 Treatment of Reliired Employees. A Participant whose employment
terminates and who is subsequently re-employed with less than 30 days separation of service will
immediately rejoin the Plan with the same Benefit elections. Should the Participant return to
service during the following Plan Year, the Participant would be allowed to elect new Benefits
prior to returning to service.
A Participant whose employment terminates and who is subsequently re-employed with
more than 29 days separation of service may immediately rejoin the Plan and may make new
benefit elections. Any unused reimbursement Benefits Accounts balance prior to the initial
separation of service date will be forfeited.
3.5 HIPAA Portability. Notwithstanding any other provisions in this Article III, any
Employee who becomes eligible under the Health Portability and Accountability Act of
1996("HIPAA") for coverage by an Accident or Health benefit under the Plan shall be allowed to
participate in the Plan, so long as such Employee complies with the provisions set out in HIPAA.
3.6 COBRA Continuation Coverage. Subject to any provision in the Code,
Regulations or Contract governing COBRA Continuation Coverage to the contrary,. COBRA type
continuation shall be available to all participants. Notwithstanding any other provisions in this
Article III, any Participant, Spouse or Dependent eligible for continuation coverage under the
Plan under the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA") as
amended from time to time, shall be allowed to continue to participate in the Plan, so long as such
Participant, Spouse or Dependent complies with the provisions set out in COBRA.
The Employer shall adopt rules relating to continuation coverage, as provided under Section
4980B of the Code or applicable state law, as may be required from time to time, and shall advise
affected individuals of the terms and conditions of such continuation coverage.
3.7 Family Medical Leave Act. Subject to any provision in the Code, Regulation or
Contract governing FMLA leave coverage to the contrary, FMLA type continuation coverage
shall be available to all participants.
Payment Options for coverage while on unpaid Family Medical Leave Act leave for group
plans:
(a) Pre-pay before commencement of leave through pre-tax or after-tax Salary
Reduction Agreement from any taxable compensation, including cashing out of unused
sick or vacation days, provided all other plan requirements are met.
(b) Pay-as-you-go. Employees may pay their share of premium payments on the
same schedule as payments would be made if the employee were not on leave, or under
another schedule permitted under Department of Labor regulations.
The Employer shall not be required to continue the health coverage of an Employee who
fails to make required premium payments while on FMLA leave. However, if the
Employer chooses to continue the health coverage of an Employee who fails to make
required premium payment while on FMLA leave, the Employer is entitled to recoup
those payments after the Employee returns from FMLA leave.
(C) Catch-up-option. Under this payment option the Employer shall advance the
Employee's share of group health premiums while the Employee is on FMLA leave and
thereafter shall be entitled to recover such advanced amounts when the Employee Returns
from FMLA leave.
(d) An "Eligible Employee" is an Employee of a covered Employer who:
(1) Has been employed by the Employer for at least 12 months, and
(2) Has been employed for at least 1,250 hours of service during the 12-
month period immediately preceding the commencement of the leave, and
(3) Is employed at a worksite where 50 or more Employees are employed by
the Employer within 75 miles of that worksite. (See Section 825.105(a) regarding
Employees who work outside the U.S.)
(e) The 12 months an Employee must have been employed by the Employer need
not be consecutive months. If an Employee is maintained on the payroll for any part of a
week, including any periods of paid or unpaid leave (sick, vacation) during which other
benefits or compensation are provided by the Employer (e.g., workers' compensation,
group health plan benefits, etc.), the week counts as a week of employment. For purposes
of determining whether intermittent/occasional/casual employment qualifies as "at least 12
months," 52 weeks is deemed to be equal to 12 months.
(f) Whether an Employee has worked the minimum 1,250 hours of service is
determined according to the principles established under the Fair Labor Standards Act
(FLSA) for determining compensable hours of work (see [29 CFR 785]). The determining
factor is the number of hours an Employee has worked for the Employer within the
meaning of the FLSA. The determination is not limited by methods of recordkeeping, or
by compensation agreements that do not accurately reflect all of the hours an Employee
has worked for or been in service to the Employer. Any accurate accounting of actual
hours worked under FLSA's principles may be used. In the event the Employer does not
maintain an accurate record of hours worked by an Employee, including for Employees
who are exempt from FLSA's requirement that a record be kept of their hours worked
(e.g., bona fide executive, administrative, and professional employees as defined in FLSA
Regulations, [29 CFR 541]), the Employer has the burden of showing that the Employee
has not worked the requisite hours. In the event the Employer is unable to meet this burden
the Employee is deemed to have met this test. See also 29 CFR Section 825.500(F). For
this purpose, full-time teachers (see 29 CFR Section 825.800 for definition) of an
elementary or secondary school system, or institution of higher education, or other
educational establishment or institution are deemed to meet the 1,250 hour test. An
Employer must be able to clearly demonstrate that such an Employee did not work 1,250
hours during the previous 12 months in order to claim that the Employee is not "Eligible"
for FMLA leave.
(g) The determinations of whether an Employee has worked for the Employer for
at least 1,250 hours in the past 12 months and has been employed by the Employer for a
total of at least 12 months must be made as of the date leave commences. If an Employee
notifies the Employer of need for FMLA leave before the Employee meets these eligibility
criteria, the Employer must either confirm the Employee's eligibility based upon a
projection that the Employee will be eligible on the date leave would commence or must
advise the Employee when the eligibility requirement is met. If the Employer confirms
eligibility at the time the notice for leave is received, the Employer may not subsequently
challenge the Employee's eligibility. In the latter case, if the Employer does not advise the
Employee whether the Employee is eligible as soon as practicable (i.e., two business days
absent extenuating circumstances) after the date Employee eligibility is determined, the
Employee will have satisfied the notice requirements and the notice of leave is considered
current and outstanding until the Employer does advise. If the Employer fails to advise the
Employee whether the Employee is eligible prior to the date the requested leave is to
commence, the Employee will be deemed eligible. The Employer may not, then, deny the
leave. Where the Employee does not give notice of the need for leave more than two
business days prior to commencing leave, the Employee will be deemed to be eligible if
the Employer fails to advise the Employee that the Employee is not eligible within two
business days of receiving the Employee's notice.
(h) The period prior to the FMLA's effective date must be considered in
determining Employee's eligibility.
(i) Whether 50 Employees are employed within 75 miles to ascertain an
employee's eligibility for FMLA benefits is determined when the Employee gives notice
of the need for leave. Whether the leave is to be taken at one time or on an intermittent or
reduced leave schedule basis, once an Employee is determined eligible in response to that
notice of the need for leave, the Employee's eligibility is not affected by any subsequent
change in the number of Employees employed at or within 75 miles of the Employee's
worksite, for that specific notice of the need for leave. Similarly, an Employer may not
terminate employee leave that has already started if the Employee-count drops below 50.
For example, if an Employer employs 60 Employees in August, but expects that the
number of Employees will drop to 40 in December, the Employer must grant FMLA
benefits to an otherwise Eligible Employee who gives notice of the need for leave in
August for a period of leave to begin in December.
ARTICLE IV
CONTRIBUTIONS
4.1 Source of Contributions. The Employer shall contribute amounts deemed
necessary to meet its obligations under the Plan. Contributions to the Plan for the Plan Year shall
be limited to the amounts determined by the Benefits Enrollment Form entered into by
Participants for the Plan Year. Contributions to the Plan shall be made to, and all Plan assets shall
be held in such accounts or funds as the Employer deems appropriate.
4.2 Change in Participant's Benefits Enrollment. No Participant in the Plan
shall be allowed to alter or discontinue the Participant's elected Benefits under the Plan during a
Plan Year except when due to and consistent with a Change in Status.
Upon the occurrence of a Change in Status, the Participant may file a new Benefits
Enrollment form, which will serve to revoke the Participant's previous Benefits Enrollment Form.
The new Benefits Enrollment Form, if determined by the Plan Administrator to be timely
submitted and consistent with the Status Change, shall be effective prospectively and apply only
to those Benefits accruing to the Participant, the Participant's Spouse or the Participant's
Dependents after the effective date of the new Benefits Enrollment Form.
With respect to an election change under the special enrollment period provisions of
HIPAA, "timely submitted" shall mean submitted no later than the last day of such special
enrollment period. With respect to any other change in election, the Plan Administrator shall
determine if the new Benefits Enrollment Form has been timely submitted consistent with the
nature of the Change in Status.
The Participant's Benefits Enrollment Form for a given Plan Year shall terminate and
Benefits under the Plan shall cease upon the date a Participant is no longer eligible to participate
under the terms of this Plan.
4.3 Increases or Decreases in Premiums. Should a third party benefit provider,
such as an Insurance Company, increase or decrease premiums for any health benefits being
offered under this Plan during the Plan Year, any Participant participating in such benefit shall
have his contributions increased or decreased automatically in an amount sufficient to pay for
such increase or decrease. However, in the case of an increase in premium, if there is a similar
benefit offered under the Plan at the time of said increase, the Participant may select such similar
benefit rather than pay the increase.
4.4 Maximum Contribution. Notwithstanding any other provisions of this Plan, no
Participant shall be allowed to contribute more than $15,000 per Plan Year to this Plan.
4.5 Nondiscrimination. The Plan is intended to not discriminate in favor of highly
compensated individuals as to eligibility to participate, contributions and benefits in accordance
with applicable provisions of the Code. The Plan Administrator may take such actions as
excluding certain highly compensated individuals from participation in the Plan or limiting the
contributions made with respect to certain highly compensated participants if, in the Plan
Administrator's judgment, such actions serve to assure that the Plan does not violate applicable
nondiscrimination rules.
ARTICLE V
PARTICIPANTS' ACCOUNTS AND PAYMENT OF BENEFITS
5.1 Participants' Benefit Accounts. The Plan Administrator shall establish
separate Benefits Accounts based on the Benefits selections made by each Participant.
Contributions shall be credited to the proper Benefits Accounts of each Participant. Each Benefits
Account shall be designated as a "Premium Account" or as a "Reimbursement Account".
5.2 Premium Account. A "Premium Account" is an account established with the
intent of paying for premium-type Benefits pursuant to an insurance policy issued by an insurance
company to provide medical, vision, psychological or psychiatric, prescription drugs, group-term
life insurance, disability insurance, or other qualified benefits under Section 125.
5.3 Reimbursement Account. A "Reimbursement Account" is an account
established with the intent of providing reimbursement of allowable insurance expenses not
accounted for under the premium account in 5.2.
5.4 Payment of Benefits. The Plan Administrator shall pay the Benefits authorized
under the Plan other than insurance benefits administered by a third-party benefit provider.
Payment shall be made by the Employer, (or the designated Plan Administrator), in a timely
manner upon receipt of a Premium Notice from the Benefit Provider providing such benefit. In
the event of the death of the Participant prior to the payment of any claims, payment shall be
made in the following priority:
(a) Executor of the Estate of the deceased Participant,
(b) Spouse,
(c) Family member held responsible for payment of deceased's medical bills,
(d) Spouse of dependent with COBRA continuation rights.
ARTICLE VI
PLAN ADMINISTRATION
6.1 Plan Administrator. The Plan Administrator shall be responsible for the
administration of the Plan.
6.2 Plan Administrator's Duties. In addition to any rights, duties or powers
specified throughout the Plan, the Plan Administrator shall have the following rights, duties and
powers:
(a) to interpret the Plan, to determine the amount, manner and time for payment of
any benefits under the Plan, and to construe or remedy any ambiguities, inconsistencies or
omissions under the Plan;
(b) to adopt and apply any rules or procedures to insure the orderly and efficient
administration of the Plan;
(c) to determine the rights of any Participant, Spouse, Dependent or beneficiary to
benefits under the Plan;
(d) to develop appellate and review procedures for any Participant, Spouse,
Dependent or designated beneficiary denied benefits under the Plan;
(e) to provide the Employer with such tax or other information it may require in
connection with the Plan;
(f) to employ any agents, attorneys, accountants or other parties (who may also be
employed by the Employer) and to allocate or delegate to them such powers or duties as is
necessary to assist in the proper and efficient administration of the Plan, provided that
such allocation or delegation and the acceptance thereof is in writing;
(g) to report to the Employer, or any party designated by the Employer, after the
end of each Plan Year regarding the administration of the Plan, and to report any
significant problems as to the administration of the Plan and to make recommendations for
modifications as to procedures and benefits, or any other change which might insure the
efficient administration of the Plan.
However, nothing in this section 6.2 is meant to confer upon the Plan Administrator any
powers to amend the Plan or change any administrative procedure or adopt any other
procedure involving the Plan without the express written approval of the Employer
regarding any amendment or change in administrative procedure, or Benefit Provider.
Notwithstanding the preceding sentence, the Plan Administrator is empowered to take any
actions he sees fit to assure that the Plan complies with the nondiscrimination
requirements of Section 125 of the Code.
6.3 Information to be Provided to Plan Administrator. The Employer, or any
of its agents, shall provide to the Plan Administrator any employment records of any employee
eligible to participate under the Plan. Such records shall include, but will not be limited to, any
information regarding period of employment, leaves of absence, salary history, termination of
employment, or any other information the Plan Administrator may need for the proper
administration of the Plan. Any Participant or Dependent or any other person entitled to benefits
under the Plan shall furnish to the Plan Administrator his correct post office address, his date of
birth, the names, correct addresses and dates of birth of any designated beneficiaries, with proper
proof thereof, or any other data the Plan Administrator might reasonably request to insure the
proper and efficient administration of the Plan.
6.4 Decision of Plan Administrator Final. Subject to applicable State or Federal
law, and the provisions of Section 6.5, below, any interpretation of any provision of this Plan
made in good faith by the Plan Administrator as to any Participant's rights or benefits under this
Plan is final and shall be binding upon the parties. Any misstatement or other mistake of fact shall
be corrected as soon as reasonably possible upon notification to the Plan Administrator and any
adjustment or correction attributable to such misstatement or mistake of fact shall be made by the
Plan Administrator as he considers equitable and practicable.
6.5 Review Procedures. In cases where the Plan Administrator denies a benefit
under this Plan for any Participant, Spouse or Dependent or any other person eligible to receive
benefits under the Plan, the Plan Administrator shall furnish in writing to said party the reasons
for the denial of benefits. The written denial shall be provided to the party within 30 days of the
date the benefit was denied by the Plan Administrator. The written denial shall refer to any Plan
or section of the Code upon which the Plan Administrator relied in making such denial. The
denial may include a request for any additional data or material needed to properly complete the
claim and explain why such data or material is necessary, and explain the Plan's claim review
procedures. If requested in writing, and within 180 days of the claim denial, the Plan
Administrator shall afford any claimant whose request for claim was denied a full and fair review
of the Plan Administrator's decision, and within 60 days of the request for review of the denied
claim, the Plan Administrator shall notify the claimant in writing of his final decision on the
reviewed claim.
With respect to the denial of any claim for benefits from an insurance company or other third-
party benefit provider, paid for as a premium-type Benefit under the Plan, the review procedures
of the insurance company or other third-party benefit provider shall apply.
6.6 Extensions of Time. In any case where the Plan Administrator determines special
circumstances apply, the Plan Administrator may extend the amount of time any Participant,
Spouse, Dependent or designated beneficiary may need to appeal a claim, upon proper application
to the Plan Administrator.
6.7 Rules to Apply Uniformly. The Plan Administrator shall perform his duties in a
reasonable manner and on a nondiscriminatory basis and shall apply uniform rules to all
Participants similarly situated under the Plan.
6.8 Indemnity. The Employer does hereby agree to indemnify and hold harmless, to
the extent allowed by law and over and above any liability coverage contracts or directors and
officers insurance, any sole proprietor, member, partner, officer or director of the Employer,
designated by the Employer or the Plan Administrator who has been employed, hired or
contracted to assist in the fulfillment of the administration of this Plan. In addition, the Employer
agrees to pay any costs of defense or other legal fees incurred by any of the above parties over
and above those paid by any liability or insurance contract.
ARTICLE VII
GENERAL PROVISIONS
7.1 Amendment and Termination. The Employer may amend or terminate this
Plan at any time by legal action of the authorized agents of the Employer, subject to the limitation
that no amendment shall change the terms and conditions of payment of any benefit a Participant,
Spouse, Dependent or designated beneficiary was or might have been entitled to under the Plan at
the time of the amendment or termination. The Employer may also make amendments apply
retroactively to the extent necessary so that the Plan remains in compliance with Section 125 of
the Code or any other provision of the Code applicable to the Plan.
7.2 Nonassi~nability. Any benefits to any Participants under this Plan shall be
nonassignable and for the exclusive benefit of Participants, Spouses, Dependents and designated
beneficiaries. No benefit shall be voluntarily or involuntarily assigned, sold or transferred.
7.3 Medical Child Support Orders. The Plan Administrator shall adhere to the
terms of any judgment, decree, or court order (including a court's approval of a domestic relations
settlement agreement) which
(i) relates to the provision of child support related to health benefits for a child of a
Participant of a group health plan
(ii) is made pursuant to a state domestic relations law and
(iii) which creates or recognizes the right of an alternate recipient to, or assigns to
an alternate recipient the right to receive benefits under the group health plan under which
a Participant or other beneficiary is entitled to receive benefits.
The Plan administrator shall promptly notify the Participant and each alternate recipient
named in the medical child support order of the Plan's procedures for determining the qualified
status of the medical child support orders. Within a reasonable period after receipt of a medical
child support order, the Plan Administrator shall determine whether such order is a qualified
medical child support order and shall notify the Participant and each alternate recipient of such
determination. If the Participant or any affected alternate payee objects to the determinations of
the Plan Administrator, the disagreeing party shall be treated as a claimant and the claims
procedure of the Plan shall be followed. The Plan Administrator may bring an action for a
declaratory judgment in a court of competent jurisdiction to determine the proper recipient of the
benefits to be paid by the Plan.
Any such Qualified Medical Child Support Order (QMCSO) must clearly specify the
name and last known mailing address of the Participant, name and address of each alternate
recipient covered by the order, a description of the coverage to be provided by the group health
plan or the manner in which such coverage is to be determined, the period of coverage that must
be provided, and each plan to which such order applies.
Any such QMCSO shall not require the Plan to provide any type or form of benefit, or any
option, that it is not already offering except as necessary to meet the requirements of a state
medical child support law described in Section 1908 of the Social Security Act as added by
Section 13822 of the Omnibus Reconciliation Act of 1993 (OBRA'93).
Upon determination of a Qualified Medical Child Support Order, the Plan must recognize
the QMCSO by providing benefits for the Participant's child in accordance with such order and
must permit the parent to enroll under the family coverage any such child who is otherwise
eligible for coverage without regard to any enrollment season restrictions.
7.4 Not an Em to ment Contract. By creating this Plan and providing benefits
under the Plan, the Employer in no way guarantees employment for any employee or Participant
under this Plan. Participation in this Plan shall in no way assure continued employment with the
Employer.
7.5 Participant Litigation. In any action or proceeding against the Plan, or the
administration thereof, employees or former employees of the Employer or any other person
having or claiming to have an interest under the Plan shall not be necessary parties to such action
or proceeding. The Employer, the Plan Administrator, or their registered representatives shall be
the sole source for service of process against the Plan. Any final judgment which is not appealed
or appealable shall be binding on the Employer and any interested party to the Plan.
7.6 Addresses, Notice and Waiver of Notice. Each Participant shall furnish the
Employer with his correct post office address. Any communication, statement or notice addressed
to a Participant at his last post office address as filed with the Employer will be binding on such
person. The Employer or Plan Administrator shall be under no legal obligation to search for or
investigate the whereabouts of any person benefiting under this Plan. Any notice required under
the Plan may be waived by such person entitled to such notice.
7.7 Required Information. Each Participant, Spouse or Dependent shall furnish to
the Employer such documents, evidence or information as the Employer considers necessary or
desirable to ensure the efficient operation and administration of the Plan and for the protection of
the Employer.
7.8 Severability. In any case where any provision of this Plan is held to be illegal or
invalid, such illegality or invalidity shall apply only to that part of the Plan and shall not apply to
any remaining provisions of the Plan, and the Plan shall be construed as if such illegal or invalid
provision had never existed under the Plan.
7.9 Applicable Law. The Plan shall be construed under the laws of the State of
IDAHO, to the extent not preempted by any Federal law.
Executed this day of
Employer: CITY OF REXBURG
CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT
TABLE OF CONTENTS
ARTICLE I -INTRODUCTION
1.1 Creation and Title 3
1.2 Effective Date 3
1.3 Purpose 3
ARTICLE II -DEFINITIONS
ARTICLE III -PARTICIPATION
4
3.1 Eligibility 7
3.2 Commencement of Participation 7
3.3 Term of Participation 7
3.4 Treatment of Rehired Employees 8
3.5 HIPAA Portability 8
3.6 COBRA Continuation Coverage 8
3.7 Family Medical Leave Act 18
ARTICLE IV -BENEFITS
4.1 Provision of Benefits 12
4.2 Amount of Reimbursement 11
4.3 Change in Participant Election 12
4.4 Nondiscriminatory Benefits 12
4.5 Maximum Benefits 12
ARTICLE V -FUNDING AND PAYMENT OF BENEFITS
5.1 Funding 12
5.2 Participants' Accounts 14
5.3 Payment of Benefits 14
5.4 Forfeiture of Benefits 14
ARTICLE VI -PLAN ADMINISTRATION
6.1 Plan Administrator 14
6.2 Plan Administrator's Duties 15
6.3 Information to be Provided to Plan Administrator 15
6.4 Decision of Plan Administrator Final 16
6.5 Review Procedures 16
6.6 Extensions of Time 16
6.7 Rules to Apply Uniformly 17
6.8 Indemnity 17
ARTICLE VII -GENERAL PROVISIONS
7.1 Amendment and Termination 17
7.2 Nonassignability 18
7.3 Medical Child Support Orders 8
7.4 Not an Employment Contract 18
7.5 Participant Litigation 19
7.6 Addresses, Notice and Waiver of Notice 19
7.7 Required Information 19
7.8 Severability 19
7.9 Applicable Law 19
CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT
ARTICLE I
INTRODUCTION
1.1 Creation and Title. The Employer hereby amends its welfare benefit plan under
the terms and conditions set forth in this document. The Plan is to be known as CITY OF
REXBURG FLEXIBLE SPENDING ACCOUNT.
1.2 Effective Date. The provisions of the Plan, as amended, shall be effective as of
July 1st, 2006. The Plan was originally effective July 1st, 1985.
1.3 Purgose. The purpose of the Plan is to provide reimbursement for certain medical
expenses of Participants not otherwise covered by insurance or by the Employer. The Employer
intends that the Plan qualify as an accident and health plan under Section 105(e) of the Code, and
that the nontaxable benefits provided under the Plan be eligible for exclusion from Participants'
income under Section 105(b) of the Code.
ARTICLE II
DEFINITIONS
As used in this Plan document, the following terms shall have the following meanings:
2.1 "Agreement to Participate" means the agreement evidencing an Eligible
Employee's election to participate in the Plan and setting forth the amount of Medical
Reimbursement Benefits to be made available to the Participant for a Period of Coverage or
portion of a Plan Year as reimbursement for Qualified Expenses.
2.2 "Benefit Entry Date" means for each Eligible Employee the day that the
Employee becomes eligible to participate in each of the Plan's Benefits. If the Plan does not have
different eligibility requirements for each benefit, the Benefit Entry Date will be the same as the
Plan Entry Date.
2.3 "Cafeteria Plan" means CITY OF REXBURG CAFETERIA PLAN.
2.4 "Code" means the Internal Revenue Code of 1986, as amended from time to time.
2.5 "Compensation" means all the earned income, salary, wages and other earnings
paid by the Employer to a Participant during a Plan Year, including any amounts contributed by
the Employer pursuant to a salary reduction agreement which are not includable in gross income
under Sections 125, 402(g)(3), 402(h), 403(b) or 457(b) of the Code.
2.6 "Dependent" means an individual who is a dependent within the meaning of
Section 152(a) without regard to 152(b)(1, (b)(2), and (d)(1)(B) thereof of the Code of a
Participant in the Plan.
2.7 "Effective Date" shall be July 1st, 2006.
2.8 "Eligible Employee" means an Employee, as defined in Section 2.9 below, who
is eligible to participate in the Employer's health care program, and shall include employees who
regularly works at least 30 hours per week, and at least 6 months per year. except for: (1)
employees who are self-employed individuals as defined in section 401(c) of the Internal
Revenue Code(including sole proprietors and partners in a partnership), and (2) employees who
own (or are considered to own within the meaning of section 318 of the Internal Revenue Code)
more than 2 percent of the outstanding stock of an S corporation or stock possessing more than 2
percent of the total combined voting power of all stock of such corporation
2.9 "Employee" means a person who is currently or hereafter employed by the
Employer, or by any other employer aggregated under sections 414(b), (c), (m), (n) or (o) of the
Code and the regulations there under, including a Leased Employee subject to section 414(n) of
the Code. Excluding individuals who are not contemporaneously classified as Employees of the
Employer for purposes of the Employer's payroll system (including, without limitation,
individuals employed by temporary help firms, technical help firms, staffing firms, employee
leasing firms, professional employer organizations or other staffing firms whether or not deemed
to be "common law" Employees or "Leased Employees" within the meaning of section 414(n) (o)
of the Code) are not considered to be Eligible Employees of the Employer and shall not be
eligible to participate in the Plan. In the event any such individuals are reclassified as Employees
for any purpose, including without limitation, common law or statutory employees, by any action
of any third party, including, without limitation, any government agency, or as a result of any
private lawsuit, action, or administrative proceeding, such individuals shall notwithstanding such
reclassification, remain ineligible for participation hereunder. Notwithstanding foregoing, the
exclusive means for individuals who are not contemporaneously classified as an Employee of the
Employer on the Employer's payroll system to become eligible to participate in this Plan is
through an amendment to this Plan, duly executed by the Employer, which specifically renders
such individuals eligible for participation hereunder.
The Plan Administrator shall have full and complete discretion to determine eligibility for
participation and benefits under this Plan, including, without limitation, the determination of
those individuals who are deemed Employees of the Employer (or any controlled group member).
The Plan Administrator's decision shall be final, binding and conclusive on all parties having or
claiming a benefit under this Plan. This Plan is to be construed to exclude all individuals who are
not considered Employees for purposes of the Employer's payroll system, and the Plan
Administrator is authorized to do so, despite the fact that its decision may result in the loss of the
Plan's tax qualification.
2.10 "Emplo_yer" means CITY OF REXBURG or any of its affiliates, successors or
assignors which adopt the Plan.
2.11 "Grace Period" means a 2.5 months period immediately following the last day
of the Plan Year. The Grace Period will not be available to Participants who terminate before the
end of the Plan Year unless they comply with the provisions set out in COBRA.
2.12 "Medical Reimbursement Benefits" means, for any Period of Coverage,
the amount available to a Participant as benefits in the form of reimbursements of Qualified
Expenses.
2.13 "Medical Reimbursement Benefits Account" means the account
established by the Plan Administrator under the Plan for each Participant from which benefits in
the form of reimbursements of Qualified Expenses shall be paid.
2.14 "Participant" means any Employee who has met the eligibility requirements of
Section 3.1 of the Plan and has elected to participate in the Plan by providing the Plan
Administrator with an executed Agreement to Participate and Salary Reduction Agreement.
2.15 "Period of Coverage" begins with the later of the 1st day of the plan year or
the Participant's Entry Date, and extends to the earlier of the date the employee is no longer a
participant in the plan (as described in Section 3.3), or the last day of the Plan Year plus the Grace
Period.
2.16 "Plan" means CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT, as
described herein.
2.17 "Plan Administrator" means the Human Resource Director or such other
person or committee as may be appointed by the Employer to administer the Plan.
2.18 "Plan Entry Date" means for each Eligible Employee, the first day of the
month coincident with or next following the day that the Employee becomes eligible to
participate in the Plan.
2.19 "Plan Year" means the 12-consecutive month period beginning on January 1st
and ending on December 31st, except for a short Plan Year beginning on July 1st, 2006 and
ending on December 31st, 2006.
2.20 "Qualified Expenses" mean the medical expenses as defined in Section 213(d)
of the Code incurred during a Period of Coverage by a Participant, the Participant's Spouse or the
Participant's Eligible Dependents while the Participant remains a Participant. For purposes of the
Plan, an expense is incurred on the date when the underlying service(s) giving rise to the medical
expense(s) is/are performed and not on the date that the service(s) is/are billed by the service-
provider or paid by the Participant.
2.21 "Salary Reduction Agreement" means the agreement by an Employee
authorizing the Employer to reduce the Employee's Compensation while a Participant during the
Plan Year for purposes of obtaining Medical Reimbursement Benefits under the Plan.
2.22 "Spouse" means an individual who is legally married to a Participant but shall
not include an individual separated from a Participant under a decree of legal separation.
2.23 "Timely Submitted" means, unless the Plan Administrator has specific and
special cause to alter the definition of this phrase, within 30 calendar days of event that has
triggered the Change in Status.
ARTICLE III
PARTICIPATION
3.1 Eligibility. Each Employee, as defined in section 2.9 above, shall be eligible to
participate in the Plan upon the later of the following dates:
(a) the date the Employee attains age 21;
(b) the date the Employee completes 6 months of service with the Employer and
works no less than 30 hours per week.
3.2 Commencement of Participation. An Eligible Employee shall become a
Participant in the Plan after providing the Plan Administrator with an executed Benefits
Enrollment Form setting forth the amount of Medical Reimbursement Benefits to be made
available to the Eligible Employee for the immediately following Plan Year or remaining portion
of the Plan Year. The Participant must, before the end of the first Plan Year of participation and,
before the end of each subsequent Plan Year, provide the Plan Administrator with a newly
executed Benefits Enrollment Form. Each such new agreement shall specify the amount to be
made available to the Participant for the immediately following Plan Year or remaining portion of
the Plan Year covered by the agreement. For the initial Plan Year only, if a Participant fails to
execute a valid Benefits Enrollment Form before the Plan's original Effective Date, the
Participant shall be ineligible to participate in the Plan for the initial Plan Year. Should a
Participant fail to execute a valid Benefits Enrollment Form for any Plan Year before the start of
the Plan Year, the Participant shall be ineligible to participate in the Plan for that Plan Year.
3.3 Term of Participation. Each Participant shall be a Participant in the Plan for the
entire Period of Coverage or the portion of the Period of Coverage remaining after the
Participant's Entry Date, if later than the first day of the Plan Year. A Participant shall cease to be
a Participant in the Plan on the earliest of:
(a) the date the Participant dies, resigns or terminates employment with the
Employer, subject to the provisions of Section 3.4;
(b) the date the Participant fails to make required contributions under the Plan;
(c} the date the Participant ceases to be an Employee; or
(d) the date the Plan terminates.
3.4 Treatment of Rehired Employees. A Participant whose employment
terminates and who is subsequently re-employed with less than 30 days separation of service will
immediately rejoin the Plan with the same Benefit elections. Should the Participant return to
service during the following Plan Year, the Participant would be allowed to elect new Benefits
prior to returning to service.
A Participant whose employment terminates and who is subsequently re-employed with
more than 29 days separation of service may immediately rejoin the Plan and may make new
benefit elections. Any unused reimbursement Benefits Accounts balance prior to the initial
separation of service date will be forfeited.
3.5 HIPAA Portability. Notwithstanding any other provisions in this Article III, any
Employee who becomes eligible under the Health Portability and Accountability Act of
1996("HIPAA") for coverage by an Accident or Health benefit under the Plan shall be allowed to
participate in the Plan, so long as such Employee complies with the provisions set out in HIPAA.
3.6 COBRA Continuation Coverage. Subject to any provision in the Code,
Regulations or Contract governing COBRA Continuation Coverage to the contrary, COBRA type
continuation shall be available to all participants. Notwithstanding any other provisions in this
Article III, any Participant, Spouse or Dependent eligible for Continuation coverage under the
Plan under the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA") as
amended from time to time, shall be allowed to continue to participate in the Plan, so long as such
Participant, Spouse or Dependent complies with the provisions set out in COBRA.
The Employer shall adopt rules relating to continuation coverage, as provided under Section
4980B of the Code or applicable state law, as may be required from time to time, and shall advise
affected individuals of the terms and conditions of such continuation coverage.
A terminated Participant or the Beneficiary or Dependent of a terminated Participant shall be
eligible for Grace Period continuation coverage so long as such Participant, Spouse or Dependent
complies with the provisions set out in COBRA.
3.7 Family Medical Leave Act. Subject to any provision in the Code, Regulation or
Contract governing FMLA leave coverage to the contrary, FMLA type continuation coverage
shall be available to all participants.
Payment Options for coverage while on unpaid Family Medical Leave Act leave for group
plans:
(a) Pre-pay before commencement of leave through pre-tax or after-tax Salary
Reduction Agreement from any taxable compensation, including cashing out of unused
sick or vacation days, provided all other plan requirements are met.
(b) Pay-as-you-go. Employees may pay their share of premium payments on the
same schedule as payments would be made if the employee were not on leave, or under
another schedule permitted under Department of Labor regulations.
The Employer shall not be required to continue the health coverage of an Employee who
fails to make required premium payments while on FMLA leave. However, if the
Employer chooses to continue the health coverage of an Employee who fails to make
required premium payment while on FMLA leave, the Employer is entitled to recoup
those payments after the Employee returns from FMLA leave.
(c) Catch-up-option. Under this payment option the Employer shall advance the
Employee's share of group health premiums while the Employee is on FMLA leave and
thereafter shall be entitled to recover such advanced amounts when the Employee Returns
from FMLA leave.
(d) An "Eligible Employee" is an Employee of a covered Employer who:
(1) Has been employed by the Employer for at least 12 months, and
(2) Has been employed for at least 1,250 hours of service during the 12-
month period immediately preceding the commencement of the leave, and
(3) Is employed at a worksite where 50 or more Employees are employed by
the Employer within 75 miles of that worksite. (See Section 825.105(a) regarding
Employees who work outside the U.S.)
(e) The 12 months an Employee must have been employed by the Employer need
not be consecutive months. If an Employee is maintained on the payroll for any part of a
week, including any periods of paid or unpaid leave (sick, vacation) during which other
benefits or compensation are provided by the Employer (e.g., workers' compensation,
group health plan benefits, etc.), the week counts as a week of employment. For purposes
of determining whether intermittent/occasional/casual employment qualifies as "at least 12
months," 52 weeks is deemed to be equal to 12 months.
(f) V~hether an Employee has worked the minimum 1,250 hours of service is
determined according to the principles established under the Fair Labor Standards Act
(FLSA) for determining compensable hours of work (see [29 CFR 785]). The determining
factor is the number of hours an Employee has worked far the Employer within the
meaning of the FLSA. The determination is not limited by methods of recordkeeping, or
by compensation agreements that do not accurately reflect all of the hours an Employee
has worked for or been in service to the Employer. Any accurate accounting of actual
hours worked under FLSA's principles may be used. In the event the Employer does not
maintain an accurate record of hours worked by an Employee, including for Employees
who are exempt from FLSA's requirement that a record be kept of their hours worked
(e.g., bona fide executive, administrative, and professional employees as defined in FLSA
Regulations, [29 CFR 541]), the Employer has the burden of showing that the Employee
has not worked the requisite hours. In the event the Employer is unable to meet this burden
the Employee is deemed to have met this test. See also 29 CFR Section 825.500(F). For
this purpose, full-time teachers (see 29 CFR Section 825.800 for definition) of an
elementary or secondary school system, or institution of higher education, or other
educational establishment or institution are deemed to meet the 1,250 hour test. An
Employer must be able to clearly demonstrate that such an Employee did not work 1,250
hours during the previous 12 months in order to claim that the Employee is not "Eligible"
for FMLA leave.
(g) The determinations of whether an Employee has worked for the Employer for
at least 1,250 hours in the past 12 months and has been employed by the Employer for a
total of at least 12 months must be made as of the date leave commences. If an Employee
notifies the Employer of need for FMLA leave before the Employee meets these eligibility
criteria, the Employer must either confirm the Employee's eligibility based upon a
projection that the Employee will be eligible on the date leave would commence or must
advise the Employee when the eligibility requirement is met. If the Employer confirms
eligibility at the time the notice for leave is received, the Employer may not subsequently
challenge the Employee's eligibility. In the latter case, if the Employer does not advise the
Employee whether the Employee is eligible as soon as practicable (i.e., two business days
absent extenuating circumstances) after the date Employee eligibility is determined, the
Employee will have satisfied the notice requirements and the notice of leave is considered
current and outstanding until the Employer does advise. If the Employer fails to advise the
Employee whether the Employee is eligible prior to the date the requested leave is to
commence, the Employee will be deemed eligible. The Employer may not, then, deny the
leave. Where the Employee does not give notice of the need for leave more than two
business days prior to commencing leave, the Employee will be deemed to be eligible if
the Employer fails to advise the Employee that the Employee is not eligible within two
business days of receiving the Employee's notice.
(h) The period prior to the FMLA's effective date must be considered in
determining Employee's eligibility.
(i) Whether 50 Employees are employed within 75 miles to ascertain an
employee's eligibility for FMLA benefits is determined when the Employee gives notice
of the need for leave. Whether the leave is to be taken at one time or on an intermittent or
reduced leave schedule basis, once an Employee is determined eligible in response to that
notice of the need for leave, the Employee's eligibility is not affected by any subsequent
change in the number of Employees employed at or within 75 miles of the Employee's
worksite, for that specific notice of the need for leave. Similarly, an Employer may not
terminate employee leave that has already started if the Employee-count drops below 50.
For example, if an Employer employs 60 Employees in August, but expects that the
number of Employees will drop to 40 in December, the Employer must grant FMLA
benefits to an otherwise Eligible Employee who gives notice of the need for leave in
August for a period of leave to begin in December.
ARTICLE IV
BENEFITS
4.1 Provision of Benefits. Benefits under the Plan shall take the form of
reimbursement of Qualified Expenses incurred by a Participant, the Participant's Spouse and the
Participant's Dependents during the Period of Coverage. A Participant, or former Participant, shall
be entitled to benefits under the Plan for Qualified Expenses incurred only while a Participant.
4.2 Amount of Reimbursement. A Participant shall be entitled to benefits under
the Plan for a Period of Coverage in an amount that does not exceed the Participant's Medical
Reimbursement Benefits. The amount of a Participant's Medical Reimbursement Benefits shall be
uniformly available during the Period of Coverage.
If a claim is made for Qualified Expenses incurred during a Grace Period, the Participant
may designate, at the time a claim is presented to the Plan Administrator, against which Plan
Year(s) the claim shall be adjudicated. Such election shall be made on a form provided by the
Plan Administrator and shall be irrevocable.
If the Participant either chooses to have the claim adjudicated against all applicable Plan
Years, or fails to designate against which Plan Year(s) each particular claim is to be paid, such
claim(s) shall first be charged to the Participant's Account that relates to the Plan Year associated
with the Grace Period. If any part of a claim for a Qualified Expense remains unpaid it shall next
be charged to the Account relating to the Plan Year in which such Qualified Expense was
incurred. Once a claim is adjudicated in this manner it shall not be re-adjudicated.
4.3 Change in Participant Election. A Participant may not change the amount of
Medical Reimbursement Benefits to be made available for a Period of Coverage during that Plan
Year, except in accordance with the rules for changes in elections due to a change in status in the
Cafeteria Plan.
4.4 Nondiscriminatory Benefits. The Plan is intended to not discriminate in favor
of highly compensated individuals as to eligibility to participate, contributions and benefits in
accordance with applicable provisions of the Code. The Plan Administrator may take such actions
as excluding certain highly compensated employees from participation in the Plan if, in the Plan
Administrator's judgment, such actions serve to assure that the Plan does not violate applicable
nondiscrimination rules.
4.5 Maximum Benefits. Notwithstanding any other provisions of this Plan, no
Participant shall receive Medical Reimbursement Benefits in excess of $20,000 per Plan Year.
ARTICLE V
FUNDING AND PAYMENT OF BENEFITS
5.1 Funding. Contributions to the Plan for the Plan Year shall be limited to the
amounts determined by the Salary Reduction Agreements entered into by Participants for the Plan
Year. Contributions to the Plan shall be made to, and all Plan assets shall be held in, such
accounts or funds as the Employer deems appropriate.
5.2 Participants' Accounts. The Plan Administrator shall establish a separate
Medical Reimbursement Benefits Account for each Participant in the Plan. The Plan
Administrator shall credit a Participant's Medical Reimbursement Benefits Account with the
amount of Medical Reimbursement Benefits to be made available to the Participant pursuant to
the Agreement to Participate. The Plan Administrator shall charge a Participant's Medical
Reimbursement Benefits Account in the amount of any reimbursements made to the Participant.
The Plan Administrator may also establish a minimum reimbursement amount below which
requests for reimbursement shall not be made during the Period of Coverage, but which must be
made by the end of the Period of Coverage (including the period set forth in Section 5.4).
5.3 Payment of Benefits. Reimbursement shall only be made under the Plan on the
basis of Qualified Expenses incurred by the Participant, the Participant's Spouse or the
Participant's Dependents, as presented to the Plan Administrator on a written form specified by
the Plan Administrator and as evidenced by a written statement from a third party. It shall be the
duty of the Plan Administrator to construe what are and what are not Qualified Expenses subject
to reimbursement from a Participant's Medical Reimbursement Benefits Account. If the Plan
Administrator determines that an expense is a Qualified Expense subject to reimbursement, the
Plan Administrator shall reimburse the Participant for the Qualified Expense within a reasonable
time. To make the determination that a Qualified Expense subject to reimbursement has been
incurred, the Plan Administrator may require proper evidence of any or all of the following:
(a) the name of the person or persons for whom the expenses have been incurred;
(b) the nature of the expenses incurred;
(c) the date the expenses were incurred;
(d) the amount of the requested reimbursement; or
(e) that the expenses have not been otherwise paid through an insurance program
offered by the Employer or any other employer, or reimbursed from any other source.
The Plan Administrator shall be the sole arbiter of what constitutes a Qualified Expense
subject to reimbursement under the Plan.
In the event of the death of the Participant prior to the payment of any claims, payment
shall be made in the following priority:
(a) Executor of the Estate of the deceased Participant,
(b) Spouse,
(c) Family member held responsible for payment of deceased's medical bills,
(d) Spouse of dependent with COBRA continuation rights.
5.4 Forfeiture of Benefits. A Participant forfeits any amount of Medical
Reimbursement Benefits under the Plan for a Plan Year if a claim for reimbursement is not
provided to the Plan Administrator within 90 days after the last day of the Plan Year or the last
day of the Period of Coverage or the last day of participation in the Plan, if earlier. Upon such
forfeiture, the Participant's Medical Reimbursement Benefits Account shall be reduced to zero. At
the discretion of the Employer, forfeitures of benefits under the Plan may be reallocated to
Participants in any reasonable manner. Forfeitures of benefits may also be applied towards the
cost of administering the Plan. Forfeitures of benefits shall become the sole property of the
Employer.
ARTICLE VI
PLAN ADMINISTRATION
6.1 Plan Administrator. The Plan Administrator shall be responsible for the
administration of the Plan.
6.2 Plan Administrator's Duties. In addition to any rights, duties or powers
specified throughout the Plan, the Plan Administrator shall have the following rights, duties and
powers:
(a) to interpret the Plan, to determine the amount, manner and time for payment of
any benefits under the Plan, and to construe or remedy any ambiguities, inconsistencies or
omissions under the Plan;
(b) to adopt and apply any rules or procedures to insure the orderly and efficient
administration of the Plan;
(c) to determine the rights of any Participant, Spouse, Dependent or beneficiary to
benefits under the Plan;
(d) to develop appellate and review procedures for any Participant, Spouse,
Dependent or beneficiary denied benefits under the Plan;
(e) to provide the Employer with such tax or other information it may require in
connection with the Plan;
(f~ to employ any agents, attorneys, accountants or other parties (who may also be
employed by the Employer) and to allocate or delegate to them such powers or duties as is
necessary to assist in the proper and efficient administration of the Plan, provided that
such allocation or delegation and the acceptance thereof is in writing;
(g) to report to the Employer, or any party designated by the Employer, after the
end of each Plan Year regarding the administration of the Plan, and to report any
significant problems as to the administration of the Plan and to make recommendations for
modifications as to procedures and benefits, or any other change which might insure the
efficient administration of the Plan.
However, nothing in this section 6.2 is meant to confer upon the Plan Administrator any
powers to amend the Plan or change any administrative procedure or adopt any other
procedure involving the Plan without the express written approval of the Employer
regarding any amendment or change in administrative procedure, or Benefit Provider.
Notwithstanding the preceding sentence, the Plan Administrator is empowered to take any
actions he sees fit to assure that the Plan complies with the nondiscrimination
requirements of Section 105 of the Code.
6.3 Information to be Provided to Plan Administrator. The Employer, or any
of its agents, shall provide to the Plan Administrator any employment records of any employee
eligible to participate under the Plan. Such records shall include, but will not be limited to, any
information regarding period of employment, leaves of absence, salary history, termination of
employment, or any other information the Plan Administrator may need for the proper
administration of the Plan. Any Participant or Dependent or any other person entitled to benefits
under the Plan shall furnish to the Plan Administrator his correct post office address, his date of
birth, the names, correct addresses and dates of birth of any designated beneficiaries, with proper
proof thereof, or any other data the Plan Administrator might reasonably request to insure the
proper and efficient administration of the Plan.
6.4 Decision of Plan Administrator Final. Subject to applicable State or Federal
law, and the provisions of Section 6.5, below, any interpretation of any provision of this Plan
made in good faith by the Plan Administrator as to any Participant's rights or benefits under this
Plan is final and shall be binding upon the parties. Any misstatement or other mistake of fact shall
be corrected as soon as reasonably possible upon notification to the Plan Administrator and any
adjustment or correction attributable to such misstatement or mistake of fact shall be made by the
Plan Administrator as he considers equitable and practicable.
6.5 Review Procedures. In cases where the Plan Administrator denies a benefit
under this Plan for any Participant, Spouse or Dependent or any other person eligible to receive
benefits under the Plan, the Plan Administrator shall furnish in writing to said party the reasons
for the denial of benefits. The written denial shall be provided to the party within 30 days of the
date the benefit was denied by the Plan Administrator. The written denial shall refer to any Plan
or section of the Code upon which the Plan Administrator relied in making such denial. The
denial may include a request for any additional data or material needed to properly complete the
claim and explain why such data or material is necessary, and explain the Plan's claim review
procedures. If requested in writing, and within 180 days of the claim denial, the Plan
Administrator shall afford any claimant whose request for claim was denied a full and fair review
of the Plan Administrator's decision, and within 60 days of the request for review of the denied
claim, the Plan Administrator shall notify the claimant in writing of his final decision on the
reviewed claim.
With respect to the denial of any claim for benefits from an insurance company or other third-
party benefit provider, paid for as a premium-type Benefit under the Plan, the review procedures
of the insurance company or other third-party benefit provider shall apply.
6.6 Extensions of Time. In any case where the Plan Administrator determines special
circumstances apply, the Plan Administrator may extend the amount of time any Participant,
Spouse, Dependent or designated beneficiary may need to appeal a claim, upon proper application
to the Plan Administrator.
6.7 Rules to Apply Uniformly. The Plan Administrator shall perform his duties in a
reasonable manner and on a nondiscriminatory basis and shall apply uniform rules to all
Participants similarly situated under the Plan.
6.8 Indemnity. The Employer does hereby agree to indemnify and hold harmless, to
the extent allowed by law and over and above any liability coverage contracts or directors and
officers insurance, any sole proprietor, member, partner, officer or director of the Employer,
designated by the Employer or the Plan Administrator who has been employed, hired or
contracted to assist in the fulfillment of the administration of this Plan. In addition, the Employer
agrees to pay any costs of defense or other legal fees incurred by any of the above parties over
and above those paid by any liability or insurance contract.
ARTICLE VII
GENERAL PROVISIONS
7.1 Amendment and Termination. The Employer may amend or terminate this
Plan at any time by legal action of the authorized agents of the Employer, subject to the limitation
that no amendment shall change the terms and conditions of payment of any benefit a Participant,
Spouse, Dependent or beneficiary was entitled to under the Plan at the time of the amendment or
termination. The Employer may also make amendments apply retroactively to the extent
necessary so that the Plan remains in compliance with Section 105 of the Code or any other
provision of the Code applicable to the Plan.
7.2 Nonassignability. Any benefits to any Participants under this Plan shall be
nonassignable and for the exclusive benefit of Participants, Spouses, Dependents and
beneficiaries. No benefit shall be voluntarily or involuntarily assigned, sold or transferred.
7.3 Medical Child Support Orders. The Plan Administrator shall adhere to the
terms of any judgment, decree, or court order (including a court's approval of a domestic relations
settlement agreement) which
(i) relates to the provision of child support related to health benefits for a child of a
Participant of a group health plan
(ii) is made pursuant to a state domestic relations law and
(iii) which creates or recognizes the right of an alternate recipient to, or assigns to
an alternate recipient the right to receive benefits under the group health plan under which
a Participant or other beneficiary is entitled to receive benefits.
The Plan administrator shall promptly notify the Participant and each alternate recipient
named in the medical child support order of the Plan's procedures for determining the qualified
status of the medical child support orders. Within a reasonable period after receipt of a medical
child support order, the Plan Administrator shall determine whether such order is a qualified
medical child support order and shall notify the Participant and each alternate recipient of such
determination. If the Participant or any affected alternate payee objects to the determinations of
the Plan Administrator, the disagreeing party shall be treated as a claimant and the claims
procedure of the Plan shall be followed. The Plan Administrator may bring an action for a
declaratory judgment in a court of competent jurisdiction to determine the proper recipient of the
benefits to be paid by the Plan.
Any such Qualified Medical Child Support Order (QMCSO} must clearly specify the
name and last known mailing address of the Participant, name and address of each alternate
recipient covered by the order, a description of the coverage to be provided by the group health
plan or the manner in which such coverage is to be determined, the period of coverage that must
be provided, and each plan to which such order applies.
Any such QMCSO shall not require the Plan to provide any type or form of benefit, or any
option, that it is not already offering except as necessary to meet the requirements of a state
medical child support law described in Section 1908 of the Social Security Act as added by
Section 13822 of the Omnibus Reconciliation Act of 1993 COBRA '93).
Upon determination of a Qualified Medical Child Support Order, the Plan must recognize
the QMCSO by providing benefits for the Participant's child in accordance with such order and
must permit the parent to enroll under the family coverage any such child who is otherwise
eligible for coverage without regard to any enrollment season restrictions.
7.4 Not an Employment Contract. By creating this Plan and providing benefits
under the Plan, the Employer in no way guarantees employment for any employee or Participant
under this Plan. Participation in this Plan shall in no way assure continued employment with the
Employer.
7.5 Participant Litigation. In any action or proceeding against the Plan, or the
administration thereof, employees or former employees of the Employer or any other person
having or claiming to have an interest under the Plan shall not be necessary parties to such action
or proceeding. The Employer, the Plan Administrator, or their registered representatives shall be
the sole source for service of process against the Plan. Any final judgment which is not appealed
or appealable shall be binding on the Employer and any interested party to the Plan.
7.6 Addresses, Notice and Waiver of Notice. Each Participant shall furnish the
Employer with his correct post office address. Any communication, statement or notice addressed
to a Participant at his last post office address as filed with the Employer will be binding on such
person. The Employer or Plan Administrator shall be under no legal obligation to search for or
investigate the whereabouts of any person benefiting under this Plan. Any notice required under
the Plan may be waived by such person entitled to such notice.
7.7 Required Information. Each Participant, Spouse or Dependent shall furnish to
the Employer such documents, evidence or information as the Employer considers necessary or
desirable to ensure the efficient operation and administration of the Plan and for the protection of
the Employer.
7.8 Severability. In any case where any provision of this Plan is held to be illegal or
invalid, such illegality or invalidity shall apply only to that part of the Plan and shall not apply to
any remaining provisions of the Plan, and the Plan shall be construed as if such illegal or invalid
provision had never existed under the Plan.
7.9 Applicable Law. The Plan shall be construed under the laws of the State of
IDAHO, to the extent not preempted by any Federal law.
Executed this day of
Employer: CITY OF REXBURG
CITY OF REXBURG DEPENDANT CARE
TABLE OF CONTENTS
ARTICLE I -INTRODUCTION
1.1 Creation and Title 3
1.2 Effective Date 3
1.3 Purpose 3
ARTICLE II -DEFINITIONS
ARTICLE III -PARTICIPATION
4
3.1 Eligibility 7
3.2 Commencement of Participation 7
3.3 Term of Participation 7
3.4 Treatment of Rehired Employees 8
ARTICLE IV -BENEFITS
4.1 Provision of Benefits 12
4.2 Amount of Reimbursement 11
4.3 Change in Participant Election 12
4.4 Nondiscriminatory Benefits 12
4.5 Maximum Benefits 12
ARTICLE V -FUNDING AND PAYMENT OF BENEFITS
5.1 Funding 12
5.2 Participants' Accounts 14
5.3 Payment of Benefits 14
5.4 Forfeiture of Benefits 14
5.5 Annual Report to Participants 14
ARTICLE VI -PLAN ADMINISTRATION
6.1 Plan Administrator 15
6.2 Plan Administrator's Duties 15
6.3 Information to be Provided to Plan Administrator 16
6.4 Decision of Plan Administrator Final 16
6.5 Review Procedures 16
6.6 Extensions of Time 17
6.7 Rules to Apply Uniformly 17
6.8 Indemnity 17
ARTICLE VII -GENERAL PROVISIONS
7.1 Amendment and Termination
7.2 Nonassignability
7.3 Not an Employment Contract
7.4 Participant Litigation
7.5 Addresses, Notice and Waiver of Notice
7.6 Required Information
7.7 Severability
7.8 Applicable Law
18
18
19
19
19
19
19
19
CITY OF REXBURG DEPENDANT CARE
ARTICLE I
INTRODUCTION
1.1 Creation and Title. The Employer hereby amends its welfare benefit plan under
the terms and conditions set forth in this document. The Plan is to be known as CITY OF
REXBURG DEPENDANT CARE.
1.2 Effective Date. The provisions of the Plan, as amended, shall be effective as of
July 1st, 2006. The Plan was originally effective July 1st, 1985.
1.3. Purpose. The purpose of the Plan is to provide reimbursement for certain
dependent care expenses of Participants not otherwise covered by insurance or by the Employer.
The Employer intends that the Plan qualifies as a dependent care assistance plan under Section
129(d) of the Code, and that the benefits provided under the Plan be eligible for exclusion from
Participants' income under Section 129 of the Code.
ARTICLE II
DEFINITIONS
As used in this Plan document, the following terms shall have the following meanings:
2.1 "Agreement to Participate" means the agreement evidencing an Eligible
Employee's election to participate in the Plan and setting forth the amount of Dependent Care
Reimbursement Benefits to be made available to the Participant for a Period of Coverage or
portion of a Plan Year as reimbursement for Dependent Care Expenses.
2.2 "Benefit Entry Date" means for each Eligible Employee the day that the
Employee becomes eligible to participate in each of the Plan's Benefits. If the Plan does not have
different eligibility requirements for each benefit, the Benefit Entry Date will be the same as the
Plan Entry Date.
2.3 "Cafeteria Plan" means CITY OF REXBURG CAFETERIA PLAN.
2.4 "Code" means the Internal Revenue Code of 1986, as amended from time to time.
Z.5 "Compensation" means all the earned income, salary, wages and other earnings
paid by the Employer to a Participant during a Plan Year, including any amounts contributed by
the Employer pursuant to a salary reduction agreement which are not includable in gross income
under Sections 125, 402(a)(8), 402(h), 403(b) or 457(b) of the Code.
2.6 "Dependent" means an individual who is a dependent within the meaning of
Section 152(a) without regard to 152(b)(1, (b)(2), and (d)(1)(B) thereof of the Code of a
Participant in the Plan.
2.7 "Dependent Care Expenses" means expenses incurred by a Participant for the
care of a Dependent or Spouse of the Participant or for related household services which would be
considered employment-related expenses under Section 21(b)(2) of the Code.
2.8 "Dependent Care Reimbursement Benefits" means, for any Period of
Coverage, the amount available to a Participant as benefits in the form of reimbursements of
Dependent Care Expenses.
2.9 "Dependent Care Reimbursement Benefits Account" means the account
established by the Plan Administrator under the Plan for each Participant from which benefits in
the form of reimbursements of Dependent Care Expenses shall be paid.
2.10 "Effective Date" shall be July 1st, 2006.
2.11 "Eligible Employee" means an Employee, as defined in Section 2.12 below,
who is eligible to participate in the Employer's health care program, and shall include employees
who regularly works at least 30 hours per week, and at least 6 months per year,
2.12 "Employee" means a person who is currently or hereafter employed by the
Employer, or by any other employer aggregated under sections 414(b), (c), (m), (n) or (o) of the
Code and the regulations there under, including a Leased Employee subject to section 414(n) of
the Code. Excluding individuals who are not contemporaneously classified as Employees of the
Employer for purposes of the Employer's payroll system (including, without limitation,
individuals employed by temporary help firms, technical help firms, staffing firms, employee
leasing firms, professional employer organizations or other staffing firms whether or not deemed
to be "common law" Employees or "Leased Employees" within the meaning of section 414(n) (o)
of the Code) are not considered to be Eligible Employees of the Employer and shall not be
eligible to participate in the Plan. In the event any such individuals are reclassified as Employees
for any purpose, including without limitation, common law or statutory employees, by any action
of any third party, including, without limitation, any government agency, or as a result of any
private lawsuit, action, or administrative proceeding, such individuals shall notwithstanding such
reclassification, remain ineligible for participation hereunder. Notwithstanding foregoing, the
exclusive means for individuals who are not contemporaneously classified as an Employee of the
Employer on the Employer's payroll system to become eligible to participate in this Plan is
through an amendment to this Plan, duly executed by the Employer, which specifically renders
such individuals eligible for participation hereunder.
The Plan Administrator shall have full and complete discretion to determine eligibility for
participation and benefits under this Plan, including, without limitation, the determination of
those individuals who are deemed Employees of the Employer (or any controlled group member).
The Plan Administrator's decision shall be final, binding and conclusive on all parties having or
claiming a benefit under this Plan. This Plan is to be construed to exclude all individuals who are
not considered Employees for purposes of the Employer's payroll system, and the Plan
Administrator is authorized to do so, despite the fact that its decision may result in the loss of the
Plan's tax qualification.
2.13 "Employer" means CITY OF REXBURG or any of its affiliates, successors or
assignors which adopt the Plan.
2.14 "Grace Period" means a 2.5 months period immediately following the last day
of the Plan Year. The Grace Period will not be available to Participants who terminate before the
end of the Plan Year unless they comply with the provisions set out in COBRA.
2.15 "Participant" means any Employee who has met the eligibility requirements of
Section 3.1 of the Plan and has elected to participate in the Plan by providing the Plan
Administrator with an executed Agreement to Participate and Salary Reduction Agreement.
2.16 "Period of Coverage" begins with the later of the 1st day of the plan year or
the Participant's Entry Date, and extends to the earlier of the date the employee is no longer a
participant in the plan (as described in Section 3.3), or the last day of the Plan Year plus the Grace
Period.
2.17 "Plan" means CITY OF REXBURG DEPENDANT CARE, as described herein.
2.18 "Plan Administrator" means the Human Resource Director or such other
person or committee as may be appointed by the Employer to administer the Plan.
2.19 "Plan Entry Date" means for each Eligible Employee, the first day of the
month coincident with or next following the day that the Employee becomes eligible to
participate in the Plan.
2.20 "Plan Year" means the 12-consecutive month period beginning on January 1st
and ending on December 31st, except for a short Plan Year beginning on July 1st, 2006 and
ending on December 31st, 2006.
2.21 "Salary Reduction Agreement" means the agreement by an Employee
authorizing the Employer to reduce the Employee's Compensation while a Participant during the
Plan Year for purposes of obtaining Dependent Care Reimbursement Benefits under the Plan.
2.22 "Spouse" means an individual who is legally married to a Participant but shall
not include an individual separated from a Participant under a decree of legal separation.
2.23 "Timely Submitted" means, unless the Plan Administrator has specific and
special cause to alter the definition of this phrase, within 30 calendar days of event that has
triggered the Change in Status.
ARTICLE III
PARTICIPATION
3.1 Eligibility. Each Employee, as defined in section 2.12 above, shall be eligible to
participate in the Plan upon the later of the following dates:
(a) the date the Employee attains age 21;
(b) the date the Employee completes 6 months of service with the Employer and
works no less than 30 hours per week.
3.2 Commencement of Participation. An Eligible Employee shall become a
Participant in the Plan after providing the Plan Administrator with an executed Benefits
Enrollment Form setting forth the amount of Dependent Care Reimbursement Benefits to be
made available to the Eligible Employee for the immediately following Plan Year or remaining
portion of the Plan Year. The Participant must, before the end of the first Plan Year of
participation and, before the end of each subsequent Plan Year, provide the Plan Administrator
with a newly executed Benefits Enrollment Form. Each such new agreement shall specify the
amount to be made available to the Participant for the immediately following Plan Year or
remaining portion of the Plan Year covered by the agreement. For the initial Plan Year only, if a
Participant fails to execute a valid Benefits Enrollment Form before the Plan's original Effective
Date, the Participant shall be ineligible to participate in the Plan for the initial Plan Year. Should a
Participant fail to execute a valid Benefits Enrollment Form for any Plan Year before the start of
the Plan Year, the Participant shall be ineligible to participate in the Plan for that Plan Year.
3.3 Term of Participation. Each Participant shall be a Participant in the Plan for the
entire Period of Coverage or the portion of the Plan Year remaining after the Participant's Entry
Date, if later than the first day of the Plan Year. A Participant shall cease to be a Participant in the
Plan on the earliest o£
(a) the date the Participant dies, resigns or terminates employment with the
Employer, subject to the provisions of Section 3.4;
(b) the date the Participant fails to make required contributions under the Plan;
(c) the date the Participant ceases to be an Employee; or
(d) the date the Plan terminates.
3.4 Treatment of Rehired Employees. A Participant whose employment
terminates and who is subsequently re-employed with less than 30 days separation of service will
immediately rejoin the Plan with the same Benefit elections. Should the Participant return to
service during the following Plan Year, the Participant would be allowed to elect new Benefits
prior to returning to service.
A Participant whose employment terminates and who is subsequently re-employed with
more than 29 days separation of service may immediately rejoin the Plan and may make new
benefit elections. Any unused reimbursement Benefits Accounts balance prior to the initial
separation of service date will be forfeited.
ARTICLE IV
BENEFITS
4.1 Provision of Benefits. Benefits under the Plan shall take the form of
reimbursement of Dependent Care Expenses incurred by a Participant, the Participant's Spouse
and the Participant's Dependents during the Period of Coverage. A Participant, or former
Participant, shall be entitled to benefits under the Plan for Dependent Care Expenses incurred
only while a Participant.
4.2 Amount of Reimbursement. A Participant shall be entitled to benefits under
the Plan for a Period of Coverage in an amount that does not exceed the Participant's Dependent
Care Reimbursement Benefits. The amount of a Participant's Dependent Care Reimbursement
Benefits shall be available during the Period of Coverage in accordance with the provisions of
Section 5.2.
If a claim is made for Dependent Care Expenses incurred during a Grace Period, the
Participant may designate, at the time a claim is presented to the Plan Administrator, against
which Plan Year(s) the claim shall be adjudicated. Such election shall be made on a form
provided by the Plan Administrator and shall be irrevocable.
If the Participant either chooses to have the claim adjudicated against all applicable Plan
Years, or fails to designate against which Plan Years} each particular claim is to be paid, such
claim(s) shall first be charged to the Participant's Account that relates to the Plan Year associated
with the Grace Period. If any part of a claim for a Dependent Care Expense remains unpaid it
shall next be charged to the Account relating to the Plan Year in which such Dependent Care
Expense was incurred.
4.3 Change in Participant Election. A Participant may not change the amount of
Dependent Care Reimbursement Benefits to be made available for a Period of Coverage during
that Plan Year, except in accordance with the rules for changes in elections due to a change in
status in the Cafeteria Plan.
4.4 Nondiscriminatory Benefits. The Plan is intended to not discriminate in favor
of highly compensated individuals as to eligibility to participate, contributions and benefits in
accordance with applicable provisions of the Code. The Plan Administrator may take such actions
as excluding certain highly compensated employees from participation in the Plan if, in the Plan
Administrator's judgment, such actions serve to assure that the Plan does not violate applicable
nondiscrimination rules.
4.5 Maximum Benefits. Notwithstanding any other provisions of this Plan, no
Participant shall receive Dependent Care Reimbursement Benefits in excess of $5,000 (or $2,500
in the case of a married Participant filing a separate Federal income tax return) in a calendar year,
not withstanding reimbursements made during the grace period for the previous calendar year.
ARTICLE V
FUNDING AND PAYMENT OF BENEFITS
5.1 Funding. Contributions to the Plan for the Plan Year shall be limited to the
amounts determined by the Salary Reduction Agreements entered into by Participants for the Plan
Year. Contributions to the Plan shall be made to, and all Plan assets shall be held in, such
accounts or funds as the Employer deems appropriate.
5.2 Participants' Accounts and Account Balances. The Plan Administrator
shall establish a separate Dependent Care Reimbursement Benefits Account for each Participant
in the Plan. The Plan Administrator shall credit a Participant's Dependent Care Reimbursement
Benefits Account with the amount of Dependent Care Reimbursement Benefits to be made
available to the Participant pursuant to the Agreement to Participate as those amounts are actually
contributed to the Plan. The Plan Administrator shall charge a Participant's Dependent Care
Reimbursement Benefits Account in the amount of any reimbursements made to the Participant.
The amount of any reimbursement of Dependent Care Expenses may not exceed the balance of
the Participant's Dependent Care Reimbursement Account at the time of the reimbursement. The
Plan Administrator may also establish a minimum reimbursable amount below which
reimbursements shall not be made during the Period of Coverage, but which must be made by the
end of the Period of Coverage (including the period set forth in Section 5.4).
5.3 Payment of Benefits. Reimbursement shall only be made under the Plan on the
basis of Dependent Care Expenses incurred by the Participant or the Participant's Spouse, as
presented to the Plan Administrator on a written form specified by the Plan Administrator. It shall
be the duty of the Plan Administrator to construe what are and what are not Dependent Care
Expenses subject to reimbursement from a Participant's Dependent Care Reimbursement Benefits
Account. If the Plan Administrator determines that an expense is a Dependent Care Expense
subject to reimbursement, the Plan Administrator shall reimburse the Participant for the
Dependent Care Expense within a reasonable time. To make the determination that a Dependent
Care Expense subject to reimbursement has been incurred, the Plan Administrator may require
proper evidence of any or all of the following:
(a) the name of the person or persons for whom the expenses have been incurred;
(b) the nature of the expenses incurred;
(c) the date the expenses were incurred;
(d) the amount of the requested reimbursement; or
(e) that the expenses have not been otherwise paid through a program offered by
the Employer or any other employer, or reimbursed from any other source.
The Plan Administrator shall be the sole arbiter of what constitutes a Dependent Care
Expense subject to reimbursement under the Plan.
In the event of the death of the Participant prior to the payment of any claims, payment
shall be made in the following priority:
(a) Executor of the Estate of the deceased Participant,
(b) Spouse,
(c) Family member held responsible for payment of deceased's medical bills,
(d) Spouse of dependent with COBRA continuation rights.
5.4 Forfeiture of Benefits. A Participant forfeits any amount of Dependent Care
Reimbursement Benefits under the Plan for a Plan Year if a claim for reimbursement is not
provided to the Plan Administrator within 90 days after the last day of the Plan Year or the last
day of the Period of Coverage or the last day of participation in the Plan, if earlier. Upon such
forfeiture, the Participant's Dependent Care Reimbursement Benefits Account shall be reduced to
zero. At the discretion of the Employer, forfeitures of benefits under the Plan may be reallocated
to Participants in any reasonable manner. Forfeitures of benefits may also be applied towards the
cost of administering the Plan. Forfeitures of benefits shall become the sole property of the
Employer.
5.5 Annual Report to Participants. On or before each January 31, the Plan
Administrator shall provide a written statement to each Participant (or former Participant) of the
amount of reimbursements of Dependent Care Expenses paid to the Participant (or former
Participant) for the immediately preceding calendar year.
ARTICLE VI
PLAN ADMINISTRATION
6.1 Plan Administrator. The Plan Administrator shall be responsible for the
administration of the Plan.
6.2 Plan Administrator's Duties. In addition to any rights, duties or powers
specified throughout the Plan, the Plan Administrator shall have the following rights, duties and
powers:
(a) to interpret the Plan, to determine the amount, manner and time for payment of
any benefits under the Plan, and to construe or remedy any ambiguities, inconsistencies or
omissions under the Plan;
(b) to adopt and apply any rules or procedures to insure the orderly and efficient
administration of the Plan;
(c) to determine the rights of any Participant, Spouse, Dependent or beneficiary to
benefits under the Plan;
(d) to develop appellate and review procedures for any Participant, Spouse,
Dependent or beneficiary denied benefits under the Plan;
(e) to provide the Employer with such tax or other information it may require in
connection with the Plan;
(f) to employ any agents, attorneys, accountants or other parties (who may also be
employed by the Employer) and to allocate or delegate to them such powers or duties as is
necessary to assist in the proper and efficient administration of the Plan, provided that
such allocation or delegation and the acceptance thereof is in writing;
(g) to report to the Employer, or any party designated by the Employer, after the
end of each Plan Year regarding the administration of the Plan, and to report any
significant problems as to the administration of the Plan and to make recommendations for
modifications as to procedures. and benefits, or any other change which might insure the
efficient administration of the Plan.
However, nothing in this section 6.2 is meant to confer upon the Plan Administrator any
powers to amend the Plan or change any administrative procedure or adopt any other
procedure involving the Plan without the express written approval of the Employer
regarding any amendment or change in administrative procedure, or Benefit Provider.
Notwithstanding the preceding sentence, the Plan Administrator is empowered to take any
actions he sees fit to assure that the Plan complies with the nondiscrimination
requirements of Section 129 of the Code.
6.3 Information to be Provided to Plan Administrator. The Employer, or any
of its agents, shall provide to the Plan Administrator any employment records of any employee
eligible to participate under the Plan. Such records shall include, but will not be limited to, any
information regarding period of employment, leaves of absence, salary history, termination of
employment, or any other information the Plan Administrator may need for the proper
administration of the Plan. Any Participant or Dependent or any other person entitled to benefits
under the Plan shall furnish to the Plan Administrator his correct post office address, his date of
birth, the names, correct addresses and dates of birth of any beneficiaries, with proper proof
thereof, or any other data the Plan Administrator might reasonably request to insure the proper
and efficient administration of the Plan.
6.4 Decision of Plan Administrator Final. Subject to applicable State or Federal
law, and the provisions of Section 6.5, below, any interpretation of any provision of this Plan
made in good faith by the Plan Administrator as to any Participant's rights or benefits under this
Plan is final and shall be binding upon the parties. Any misstatement or other mistake of fact shall
be corrected as soon as reasonably possible upon notification to the Plan Administrator and any
adjustment or correction attributable to such misstatement or mistake of fact shall be made by the
Plan Administrator as he considers equitable and practicable.
6.5 Review Procedures. In cases where the Plan Administrator denies a benefit
under this Plan for any Participant, Spouse or Dependent or any other person eligible to receive
benefits under the Plan, the Plan Administrator shall furnish in writing to said party the reasons
for the denial of benefits. The written denial shall be provided to the party within 30 days of the
date the benefit was denied by the Plan Administrator. The written denial shall refer to any Plan
or section of the Code upon which the Plan Administrator relied in making such denial. The
denial may include a request for any additional data or material needed to properly complete the
claim and explain why such data or material is necessary, and explain the Plan's claim review
procedures. If requested in writing, and within 180 days of the claim denial, the Plan
Administrator shall afford any claimant whose request for claim was denied a full and fair review
of the Plan Administrator's decision, and within 60 days of the request for review of the denied
claim, the Plan Administrator shall notify the claimant in writing of his final decision on the
reviewed claim.
With respect to the denial of any claim for benefits from an insurance company or other third-
party benefit provider, paid for as a premium-type Benefit under the Plan, the review procedures
of the insurance company or other third-party benefit provider shall apply.
6.6 Extensions of Time. In any case where the Plan Administrator determines special
circumstances apply, the Plan Administrator may extend the amount of time any Participant,
Spouse, Dependent or beneficiary may need to appeal a claim, upon proper application to the Plan
Administrator.
6.7 Rules to Apply Uniformly. The Plan Administrator shall perform his duties in a
reasonable manner and on a nondiscriminatory basis and shall apply uniform rules to all
Participants similarly situated under the Plan.
6.8 Indemnity. The Employer does hereby agree to indemnify and hold harmless, to
the extent allowed by law and over and above any liability coverage contracts or directors and
officers insurance, any sole proprietor, member, partner, officer or director of the Employer,
designated by the Employer or the Plan Administrator who has been employed, hired or
contracted to assist in the fulfillment of the administration of this Plan. In addition, the Employer
agrees to pay any costs of defense or other legal fees incurred by any of the above parties over
and above those paid by any liability or insurance contract.
ARTICLE VII
GENERAL PROVISIONS
7.1 Amendment and Termination. The Employer may amend or terminate this
Plan at any time by legal action of the authorized agents of the Employer, subject to the limitation
that no amendment shall change the terms and conditions of payment of any benefit a Participant,
Spouse, Dependent or beneficiary was entitled to under the Plan at the time of the amendment or
termination. The Employer may also make amendments apply retroactively to the extent
necessary so that the Plan remains in compliance with Section 129 of the Code or any other
provision of the Code applicable to the Plan.
7.2 Nonassignability. Any benefits to any Participants under this Plan shall be
nonassignable and for the exclusive benefit of Participants, Spouses, Dependents and
beneficiaries. No benefit shall be voluntarily or involuntarily assigned, sold or transferred.
7.3 Not an Employment Contract. By creating this Plan and providing benefits
under the Plan, the Employer in no way guarantees employment for any employee or Participant
under this Plan. Participation in this Plan shall in no way assure continued employment with the
Employer.
7.4 Participant Litigation. In any action or proceeding against the Plan, or the
administration thereof, employees or former employees of the Employer or any other person
having or claiming to have an interest under the Plan shall not be necessary parties to such action
or proceeding. The Employer, the Plan Administrator, or their registered representatives shall be
the sole source for service of process against the Plan. Any final judgment which is not appealed
or appealable shall be binding on the Employer and any interested party to the Plan.
7.5 Addresses, Notice and Waiver of Notice. Each Participant shall furnish the
Employer with his correct post office address. Any communication, statement or notice addressed
to a Participant at his last post office address as filed with the Employer will be binding on such
person. The Employer or Plan Administrator shall be under no legal obligation to search for or
investigate the whereabouts of any person benefiting under this Plan. Any notice required under
the Plan may be waived by such person entitled to such notice.
7.6 Required Information. Each Participant, Spouse or Dependent shall furnish to
the Employer such documents, evidence or information as the Employer considers necessary or
desirable to ensure the efficient operation and administration of the Plan and for the protection of
the Employer.
7.7 Severability. In any case where any provision of this Plan is held to be illegal or
invalid, such illegality or invalidity shall apply only to that part of the Plan and shall not apply to
any remaining provisions of the Plan, and the Plan shall be construed as if such illegal or invalid
provision had never existed under the Plan.
7.8 Applicable Law. The Plan shall be construed under the laws of the State of
IDAHO, to the extent not preempted by any Federal law.
Executed this day of
Employer: CITY OF REXBURG
CITY OF REXBURG CAFETERIA PLAN
SUMMARY PLAN DESCRIPTION
Summary Plan Description
Table of Contents
Article Section Page
I INTRODUCTION TO YOUR PLAN 3
II GENERAL INFORMATION 3
III PARTICIPATION IN YOUR PLAN 3
IV PAYING FOR BENEFITS UNDER YOUR PLAN 4
V ADMINISTRATION OF YOUR PLAN 7
VI BENEFITS UNDER YOUR PLAN 7
VII STATEMENT OF ERISA RIGHTS 8
COBRA NOTICE 8
HIPAA PRIVACY NOTICE 12
Article I
INTRODUCTION TO YOUR PLAN
CITY OF REXBURG offers a "Cafeteria Plan" as part of your employee benefits program. This
Plan was most recently amended on July 1st, 2006 and was instituted on July 1st, 1985. This Plan
is intended to qualify under Section 125 of the Internal Revenue Code (IRC). Under IRC Section
125, you can take advantage of the tax-free benefits offered under the Plan, as described in this
summary.
Your Plan is a "Salary (or wage) Reduction" plan. This means that you pay the cost of your
benefits by electing to have your compensation reduced. To Participate, you must file a Benefits
Enrollment Form which contains a "Salary (or wage) Reduction Agreement" with the Plan
Administrator. This form lists both the benefits selected plus the amount you have agreed to
contribute to pay for those benefits. Then, the Employer will deduct from your paycheck, an
amount sufficient to pay for your portion of your benefits.
Any money you contribute to pay for your benefits is not subject to Federal income, Social
Security or Unemployment taxation. Therefore, your benefit costs are quite low, and in some
cases, can even result in a net increase in spendable income to you, after paying for your benefits.
This can be illustrated by the following example:
With
Your Plan
Gross Taxable Wages $25,000.
Pre-tax Contribution $1,800.
Taxable Wages $23,200.
Estimated Taxes* $3,480.
After-tax Contribution N/A
Take-home Pay $19,720.
* Joint Return, 15% marginal tax rate
Without
Your Plan
$25,000.
N/A
$25,000.
$3,750.
$1,800.
$19,450.
By paying for benefits before taxes are calculated, estimated taxes are reduced by $270, which is
$22.50 per month more in take-home pay for our example person. In other words, paying for
benefits without a Cafeteria Plan costs this person $22.50 more per month. Please consult your
tax advisor for a more accurate estimate for your situation.
This Summary Plan Description is a brief description of the Plan and your rights, benefits and
obligations under the Plan which was amended on July 1st, 2006. This Summary Plan Description
is not meant to interpret, extend or change any provision contained in the main Plan Document.
The provisions of CITY OF REXBURG CAFETERIA PLAN can only be accurately understood
by reading the Plan Document. This Document is on file with the Employer and may be read by
you or your dependents or your legal representative by contacting the Benefits Coordinator. The
Benefits Coordinator's office will make the Document available to you at any reasonable time.
You may request a copy of the Plan from the Plan Administrator, who may charge you a fee for
copying the Plan for you.
Article II
GENERAL INFORMATION
You may need the following information if you have any questions about your Plan.
1. GENERAL PLAN INFORMATION
The name of this Plan is CITY OF REXBURG CAFETERIA PLAN.
Your Employer has assigned Plan Number 501 to this Plan.
The provisions of your amended Plan became effective on July 1st, 2006.
This Plan's records are maintained on a 12-month period known as the Plan Year. The Plan Year
for your Plan is January 1st through December 31st.
Your Plan shall be governed by the Laws of the State of IDAHO.
2. EMPLOYER INFORMATION
The name, address and tax identification number of the Employer are:
CITY OF REXBURG
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
82-6000250
3. PLAN ADMINISTRATOR INFORMATION
The name, address and telephone number of your Plan Administrator are:
CITY OF REXBURG
HUMAN RESOURCE DIRECTOR
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
Your Plan Administrator is responsible for the administration of your Plan. Should you need to
see any records or have any questions regarding the Plan, contact the Plan Administrator.
4. BENEFITS COORDINATOR
CITY OF REXBURG, HUMAN RESOURCE DIRECTOR has been named as the Plan's Benefits
Coordinator. If you need additional information about the plan or the benefits offered, the
Benefits Coordinator will be able to assist you.
5. LEGAL REPRESENTATIVE
The following person has been named your Plan's agent for service of legal process:
CITY OF REXBURG
HUMAN RESOURCE DIRECTOR
12 N. CENTER
REXBURG, ID 83440
Service of process can also be made upon the Plan Administrator.
Article III
PARTICIPATION IN YOUR PLAN
All employees who meet the participation requirements are eligible to participate in this Plan.
To qualify as a participant under this Plan, you must meet the following requirements:
- You must have reached the age 21.
- You must have completed 6 months of service with the employer.
Employees who fall into the following groups are excluded from participating in the Plan:
- Part-Time Regular Employees who work less than 30 hours per week.
- Seasonal Employees.
If you become eligible under the Health Insurance Portability and Accountability Act of 1996
(HIPAA) for coverage by an Accident or Health Benefit available under the Plan you shall be
allowed to participate in the Plan, so long as you comply with the provisions set out in HIPAA.
See your Plan Administrator for details.
Your Plan Entry Date, the date you may actually join the Plan, is on the first day of the month
following, or coincident with, the date you meet all of the above eligibility requirements.
BENEFITS ENROLLMENT FORM
You will be required to file a Benefits Enrollment Form before either one of two dates. If your
plan has different eligibility requirements, you will have different benefit entry dates for each
benefit. If your plan has one set of eligibility requirements, the benefit entry dates will be the
same as the plan entry dates. The benefits enrollment form needs to be filed before any applicable
benefit or plan entry dates. The Benefits Enrollment Form is an agreement between you and your
Employer, where your Employer lists the benefits offered for the Plan Year. It will also specify
the amount you have agreed to contribute towards the cost of these benefits, in the Salary (or
Wage) Reduction Agreement part of the form. This is an agreement between you and your
Employer, which states that you agree to have your compensation reduced by the amount
necessary to pay for the benefits. Any money you contribute to this Plan will not be subject to
Federal income taxation.
If you do not file a new Benefits Enrollment Form with the Plan Administrator before the start of
the new Plan Year, it will be assumed that you do not wish to participate in the Plan for the new
Plan Year, and the Employer will stop taking contributions from your compensation when the
new Plan Year begins. For purposes of the Plan's first Plan Year only, if you do not file a Benefits
Enrollment Form with the Plan Administrator before the Plan's Effective Date, you will not be
able to participate in the Plan during that first Plan Year.
LIMITATIONS ON CONTRIBUTIONS
You are limited to a maximum of $40,000 (Insurance premium = $15,000; Flexible Spending
Account = $20,000; Dependant Care = $5,000) per Plan Year in salary (or wage) reductions to
pay for your portion of benefits selected under this Plan.
CHANGE IN ELECTIONS/CHANGE IN STATUS
The laws governing Cafeteria Plans generally do not allow you to change the terms of your
Benefits Enrollment Form during a Plan Year. There are, however, a few exceptions to this rule.
You may change your benefit elections if there is a change in your status. If you are enrolled in
the CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT, these changes are limited to: the
marriage or divorce of the Participant; the adoption, birth, or death of a child or other Dependent
of the Participant or the Participant's Spouse; the emancipation or coming of age of a child of the
Participant so that the child is no longer eligible as a Dependent under the Plan; the employment
of the Participant or Participant's Spouse; change in the Participant's residence; the Participant
beginning or ending adoption proceedings, or; Medicare or Medicaid entitlement. If you are
enrolled in the other benefits provided by the Plan, your changes would be limited to: the
marriage or divorce of the Participant; the adoption, birth, or death of a child or other Dependent
of the Participant or the Participant's Spouse; the emancipation or coming of age of a child of the
Participant so that the child is no longer eligible as a Dependent under the Plan; the employment
of the Participant or Participant's Spouse; change in the Participant's residence; the Participant
beginning or ending adoption proceedings; automatic changes upon cost increases or decreases;
significant cost increases; significant curtailment of coverage; addition or elimination of similar
benefit package option allowing (prohibiting) employees that previously opted out of other
benefits to make an election change; change in coverage under employer plan of spouse or
dependent; FMLA leaves; changes in 401(k) contributions; HIPAA special enrollment rights; a
COBRA qualifying event; a judgment, decree or order, or; Medicare or Medicaid entitlement.
You do need to submit any changes to your election within 30 days of any applicable event.
Also, you (or your estate) will not be required to make further contributions to the Plan once you
have died, retired, terminated employment, or have a change in job status so that you are no
longer eligible to participate under this Plan.
Note that the new benefit elections can start only after your change in status has taken place and
the new form has been filed. For example, assume that you have a change in status from the list
above. You could request a change in your benefits ahead of time to be effective on the date of
the event. However, making other unrelated changes or changes that are effective before the date
of the event would not be approved.
Also, you may be required to increase your contribution if the Plan's cost for a particular benefit
should increase during the Plan Year. If, for example, premiums for health insurance offered
under the Plan are raised during the year, you will have the option of either paying your share of
the increased premiums or selecting another health insurance option offered under the Plan.
ENDING PLAN PARTICIPATION AND LEAVES OF ABSENCE
Because you contribute to this plan on a pre-tax basis, you must be receiving pay from your
employer in order to make those contributions. Usually, your participation in the plan will end
when you stop making pre-tax contributions. The rest of this section explain the rules regarding
suspending or ending your participation in the plan.
Ending Plan Participation
A Participant whose employment terminates and who is subsequently re-employed with less than
30 days separation of service will immediately rejoin the Plan with the same Benefit elections.
Should the Participant return to service during the following Plan Year, the Participant would be
allowed to elect new Benefits prior to returning to service.
A Participant whose employment terminates and who is subsequently re-employed with more
than 29 days separation of service may immediately rejoin the Plan and may make new benefit
elections. Any unused reimbursement Benefits Accounts balance prior to the initial separation of
service date will be forfeited.
Continuing Plan Participation Under COBRA and FMLA
Special rules, called COBRA provisions, apply to certain health or medical plans. If you
terminate employment or have another "qualifying event" that affects your health plan, your
Benefits Coordinator will give you an explanation of COBRA and your rights to continued
coverage, if COBRA applies to your plan.
The Family and Medical Leave Act ('the FMLA') requires employers with 50 or more employees
to provide unpaid leave for eligible employees at the time of the birth or adoption of a child or at
the time of a serious health condition affecting the employee or a family member.
If you are on an unpaid leave under the FMLA rules, you may continue to participate in the plan,
by making contributions under one of the options elected by your employer.
The payment options for coverage while on unpaid Family Medical Leave Act leave for group
health plans are:
i) Pre-pay. Under this option, you will pay your share of premium payments that will be due
during your leave, before your FMLA leave begins. The payments may be either pre-tax or
after-tax, according to the terms of your Salary Reduction Agreement.
ii) Pay-as-you-go. Under this option, you will pay your share of premium payments on the
same schedule as if you were not on leave, or under another schedule according to
Department of Labor regulations. If you fail to make payments under this Pay-as-you-go
option, your Employer is not required to continue coverage. However, if your Employer
chooses to continue coverage, your employer is entitled to collect these amounts from you
after you return from the FMLA leave.
(iii) Catch-up-option. Under this payment option your Employer will pay your share of
group health premiums while you are on FMLA leave. When you return from FMLA leave,
you will reimburse your employer for the amount of these premiums.
Ending your participation in a reimbursement benefit affects the way the Plan Administrator will
handle your requests for reimbursement, too. These rules for reimbursement benefits are
explained in Article VI.
Article IV
PAYING FOR BENEFITS UNDER YOUR PLAN
INTRODUCTION
There are two basic types of benefits offered under your plan: Premium benefits and
Reimbursement benefits.
Premium benefits are insurance benefits, such as health, life and disability insurance.
Reimbursement benefits are benefits where you designate a portion of your salary (or wage)
reduction contributions to be placed in an account for you. You can later have the Plan reimburse
you when you have expenses to pay that are considered "Qualified Expenses" under the Plan.
Your Plan offers reimbursement for certain medical and dependent care expenses, as authorized
under the Internal Revenue Code.
PAYMENT OF PLAN EXPENSES
The cost of the plan includes administrative expenses and the amount paid to provide benefits
such as premium payments to insurance companies and reimbursement benefits. The amount
needed to provide your benefits depends on the selections you made on the Benefits Enrollment
Form. You pay the cost of the benefits under your Plan through salary (or wage) reductions.
Article V
ADMINISTRATION OF YOUR PLAN
The Plan Administrator is responsible for the administration of your Cafeteria Plan. The duties of
the Plan Administrator include determining who is eligible to participate, interpreting laws and
regulations and how they apply to your Plan and whether or not certain expenses should be
allowed under the Plan.
When you are ready to enter the Plan, you must file a Benefits Enrollment Form and Salary (or
Wage) Reduction Agreement with the Plan Administrator. After becoming a participant in the
Plan, file all change requests and requests for reimbursement with the Plan Administrator. The
Plan Administrator will determine, in accordance with the various laws that apply to Cafeteria
Plans, whether or not to grant your requests.
The Plan Administrator can demand any documents or evidence deemed necessary to properly
administer your Plan. If the Plan Administrator feels that you have submitted insufficient data to
make a determination, or that the request made is not allowed under the Plan, the Plan
Administrator can deny your request. After the request has been denied, you will be allowed an
opportunity to appeal. The Plan Administrator must furnish you in writing the reasons for the
denial of your claim for benefits. The written denial must be provided to you within 30 days of
the date the claim for benefits was received by the Plan Administrator. The written denial must
refer to the Plan provision, or section of the Internal Revenue Code upon which the Plan
Administrator relied in making such denial. The denial may include a request for any additional
data or material needed to properly complete the claim and explain why such data or material is
necessary, and explain the Plan's claim review procedures. If requested in writing, and within 180
days of the claim denial, the Plan Administrator is required to give you a full and fair review of
the Plan Administrator's decision, and within 60 days of the request for review of the denied
claim, the Plan Administrator shall notify you in writing of his final decision on the reviewed
claim.
With respect to the denial of any claim for benefits from an insurance company or other third-
party benefit provider, paid for as a premium-type Benefit under the Plan, the review procedures
of the insurance company or other third-party benefit provider shall apply.
If your request was denied because the Plan Administrator felt your request is not covered under
the Plan, you will be given the chance to show why it should have been allowed under the Plan. If
the Plan Administrator rejects your reasons, you will not be able to appeal again.
You may, however, feel that you were treated unfairly. The Employee Retirement Income
Security Act of 1974 (ERISA) provides all plan participants with certain rights. If you feel the
Plan Administrator violated these rights, you may be able to take legal action in a court of law.
Generally, this type of action can be taken only if you can prove that the Plan Administrator did
not act in accordance with the terms of your Plan, or that the Plan Administrator acted in bad faith
when making its decision.
In addition to interpreting the plan and making sure that benefits are properly paid, the Plan
Administrator also keeps all the records of the Plan. Should you need a copy of anything filed
with the Plan Administrator, contact the Plan Administrator directly.
Article VI
BENEFITS UNDER YOUR PLAN
INTRODUCTION
Your Cafeteria Plan offers several benefit options. It is very important that you make benefit
choices that fit your benefit needs. You should not, for example, choose a benefit just because it is
the least expensive if that benefit will not fit your needs. When making your decision as to what
benefits are best for you, you should consider factors such as whether you have benefits from
another source (such as coverage under a similar plan by your spouse's employer), the number of
dependents you are covering and the amount you can afford to spend. Your Benefits Coordinator
will be glad to assist you in making the best benefit choices for your particular situation.
HEALTH INSURANCE BENEFITS
Your Plan offers basic health insurance -with deductibles and co-payments as its health insurance
option. You can choose benefits for your dependents, as well, at an additional charge.
The basic health insurance program has a deductible and co-payments. A "deductible" is the
amount you must pay out of your own pocket before the health insurance company will begin
paying its portion of the benefits.
Remember, you can have your deductibles and co-payments paid out of the Medical
Reimbursement Program. For specific coverages and deductibles and co-payments, consult the
Summary Plan Description of the basic health insurance policy, available from the Benefits
Coordinator.,
Also, deductibles, co-payments and other fees will vary among health care alternatives. Consult
each health alternative's enrollment materials or Summary Plan Description for a description of
the benefits, limitations and costs. This information can be obtained from your Benefits
Coordinator.
GROUP TERM LIFE INSURANCE
Your Cafeteria Plan offers group term life insurance as one of your benefit options.
Group term life insurance provides a cash benefit to your beneficiary, such as your spouse, should
you die unexpectedly. Unlike whole life insurance, group term life does not build a cash fund (or
cash values) during its term. Thus, group term life insurance does not help you accumulate
additional money for retirement. However, the price of a group term life insurance policy is
considerably less than that of other life insurance.
Ask to see the Summary Plan Description for the group term life insurance benefits available
under this Plan. It is on file with the Benefits Coordinator and has information about specific
coverages, limitations and restrictions concerning the group term life insurance policy available
under your Cafeteria Plan.
DISABILITY BENEFITS
Your Cafeteria Plan offers disability insurance as one of your benefit options.
Disability insurance helps to preserve a substantial part of your income in case you become
severely ill or injured and are unable to work. Should you become severely injured or are unable
to work, a determination will be made as to whether or not you qualify for disability coverage
under the Plan. If it is determined that you are disabled, you will begin receiving disability
benefits. You should be aware that there is a waiting period between the time you become sick or
injured and the time you can begin receiving disability benefits.
Also, some disability insurance policies require that your disability benefits be reduced by a
portion of any money you receive from Social Security for disability benefits.
Ask to see the Summary Plan Description for the disability benefits available under the Plan. It is
on file with the Benefits Coordinator and has information about specific coverages, limitations,
restrictions and waiting periods concerning disability benefits being offered under your Cafeteria
Plan.
REIMBURSEMENT PROGRAMS
INTRODUCTION
Your Cafeteria Plan allows you to direct some of your salary (or wage) reductions so that this
money can later be returned to you, tax free, to pay for certain allowed expenses, called qualified
expenses.
Assume that your enrollment is effective as of March 1. If you saw the doctor on February 28,
that expense would not be eligible for reimbursement, even if you received an invoice dated after
March 1.
If your participation in the reimbursement program ends, perhaps because you terminate
employment, your period of coverage ends on the day you terminate employment. Any expenses
incurred after that date are ineligible for reimbursement. If you have not incurred expenses equal
to the amounts deposited to your account BEFORE that date, you forfeit the unused amount.
ONCE YOU HAVE ELECTED TO DEFER MONEY TO ONE OF THE PROGRAMS BELOW,
YOU CANNOT CHANGE THAT ELECTION, SUBJECT TO THE EXCEPTION
REGARDING A CHANGE IN STATUS. ANY MONEY LEFT OVER AT THE END OF THE
PLAN YEAR IN THESE PROGRAMS BECOMES THE PROPERTY OF THE EMPLOYER.
THE PLAN ADMINISTRATOR WILL FINISH THE ACCOUNTING FOR THE PLAN YEAR
90 DAYS AFTER THE LAST DAY OF THE PLAN YEAR. YOU MUST SUBMIT ANY
REMAINING CLAIMS FOR REIMBURSEMENT BEFORE THAT DATE. SHOULD YOU
FAIL TO SPEND ALL THE MONEY YOU DEFER TO A REIMBURSEMENT PROGRAM
BEFORE THE END OF A PLAN YEAR, YOU CANNOT CARRY THAT MONEY OVER TO
THE NEXT PLAN YEAR. IT IS, THEREFORE, VERY IMPORTANT THAT YOU
DETERMINE AS ACCURATELY AS POSSIBLE HOW MUCH YOU WISH TO DEFER TO
A REIMBURSEMENT PROGRAM. THE BENEFITS COORDINATOR WILL BE GLAD TO
ASSIST YOU IN MAKING AN ACCURATE ASSESSMENT OF YOUR NEEDS UNDER
THESE PROGRAMS.
CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT
Money directed into the Medical Reimbursement Program will be returned to you, tax free, to pay
for any qualified medical expenses that are not covered by medical insurance. The maximum
amount you may defer to this program is $20,000 per Plan Year.
Qualified expenses under the Medical Reimbursement Program might include medical expenses
that are not covered under your medical insurance program. Thus, co-payments, deductibles,
certain excluded coverages, expenses for prescriptions or medical supplies that are not paid for by
insurance could be considered expenses that can be reimbursed under your Medical
Reimbursement Program.
Examples of expenses eligible for reimbursement under this Program would include:
hospitalization and clinical care; prescription and over-the-counter drugs; transportation expenses
(such as an ambulance) incurred to get medical services; home improvement costs that are
recommended by a doctor and necessary for treatment or rehabilitation, to the extent such
improvement does not increase the value of your home.
The following examples would usually not qualify as expenses eligible for reimbursement, even
though recommended by a doctor: expenses for cosmetic surgery or cosmetic items, maternity
items or wigs (unless ordered by a doctor as essential to health); vacation or travel expenses, even
if for rehabilitation or prescribed by a doctor; meals and lodgings (unless included as part of a
hospital bill or while traveling between distant hospitals) at a location away from home, even if
prescribed by a doctor or received as an outpatient.
The Plan is required to pay you any benefits you incur, up to the maximum you elected, at any
time. For example, assume that you have elected to establish a Medical Reimbursement account
of $600 for the Plan Year, $50 each month. During the first month when there is only $50 in your
account, you have qualified medical expenses of $300. The Plan must reimburse you the full $300
and take the risk that you might terminate employment before the full $300 has been contributed.
CITY OF REXBURG DEPENDANT CARE
Qualified expenses under the Dependent Care Assistance Program include any expenses that you
could take as a credit against tax on your income tax form for the care of a dependent. A
dependent eligible for these expenses includes a child or any other relative for whom you take a
tax deduction on your tax form. A person is a dependent of yours if you provide them with at least
50% of their living expenses over the course of the year.
Dependents eligible under this program include children under the age of 13, and physically or
mentally incapacitated individuals who are in need of supervised care.
Before deciding to participate in the Dependent Care Assistance Program, you should know that
there is a provision in the Federal Income Tax Code that allows you to take a credit against taxes
for Dependent Care Assistance Expenses. Section 21 of the Internal Revenue Code allows
taxpayers to take a credit against tax of up to $3,000 per qualified dependent, up to a maximum of
$6,000, per year for dependent care assistance expenses. These amounts are for 2003 and may
vary from year to year. This allowable tax credit may be more advantageous for lower-paid
Participants in this Plan. Consult your tax advisor to determine if participating in this Program or
taking the tax credit under Internal Revenue Code Section 21 would be better for you.
Also, the tax laws further limit how much you can contribute to this Program. Under the law and
the terms of the Plan, you can defer no more than the lesser of your actual (or, if you are married
and if less, your spouse's) income for the year or $5000 per year to this Program.
Generally, you can't receive reimbursements under this Program if you are married and your
spouse doesn't work. However, if your spouse is a full-time student or unable to work, then your
spouse is deemed to have a monthly income of $250, if you have one dependent, $500 if you have
two or more dependents.
You can apply for reimbursement for household service expenses, including payments to baby-
sitters, maids, nurses and cooks who work in your house, at least to the extent their services are
for the care of a qualified individual. Household service expenses would not include payments to
a gardener or chauffeur.
Out-of--home expenses would include payments for well-being and protection of qualified
individuals. This would include nursery school, day-care centers, and certain summer camp
expenses. This does not include expenses for educational expenses for children in kindergarten or
beyond, or food, clothing and transportation expenses.
In order to qualify as a day care center, the center must care for at least six individuals who do not
live on the premises, and comply with all applicable state and local laws.
Out-of--home care expenses for your spouse or dependents over the age of 12 who are unable to
care for themselves qualify under this Program only if those individuals regularly spend at least
eight hours each day in your home. Therefore, nursing home expenses do not qualify under this
Program. However, in-house expenses for these individuals would.
You cannot receive reimbursement for dependent care services provided BY your child under the
age of 19, even if that child is providing you with otherwise-qualified dependent care assistance.
The law requires that you give the name, address and taxpayer identification number for any
person or organization that you use for dependent care assistance on your tax return. If you fail to
get this information from any party who provided dependent care assistance to you, you will have
to include any amounts you paid through reimbursement under the Dependent Care Assistance
Program (or had paid directly by the Dependent Assistance Program) to that party in your gross
income for the year. Thus, it is very important that you get this information as soon as possible
from those parties providing dependent care assistance to you or your family. It is your
responsibility to get this information. The Plan Administrator will not be liable for any additional
taxable income to you that might have been avoided if the proper information had been furnished.
BENEFITS DUE TO A MEDICAL CHILD SUPPORT ORDER
CITY OF REXBURG established CITY OF REXBURG CAFETERIA PLAN for your benefit as
an employee who participates in the plan. Under certain circumstances, your child might be
treated as a Participant, also, even if you do not have custody of your child or the child is not your
dependent. Those circumstances must be established through a Qualified Medical Child Support
Order (QMCSO).
A QMCSO is a decree or order issued by a court that obligates you to provide health benefits for
your child. If you incur this type of obligation as a result of a court ordered medical child support
order, you must inform the Plan Administrator. The Plan Administrator can provide you with a
copy of the Qualified Medical Child Support Order Procedure. This procedure explains the rules
that the Plan Administrator must follow to properly handle a QMCSO.
The Plan Administrator will determine if a medical child support order is a Qualified Medical
Child Support Order in accordance with the provisions of the Procedure, the Plan Document and
Section 609(a)(3) of ERISA. If a medical child support order is found to be a QMCSO, the Plan
may be obligated to provide coverage or benefits to the child under any medical benefit offered to
you under the Plan.
Article VII
STATEMENT OF ERISA RIGHTS
As a participant in CITY OF REXBURG CAFETERIA PLAN you are entitled to certain rights
and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA
provides that all plan participants shall be entitled to:
Examine, without charge, at the plan administrator's office and at other specified locations, such
as worksites and union halls, all plan documents, including insurance contracts, copies of the
latest annual report (Form 5500 series if applicable), updated Summary Plan Description,
collective bargaining agreements and copies of all documents filed by the plan with the
Department of Labor, such as detailed annual reports and plan descriptions.
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your plan,
called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of you and other
participants and beneficiaries. No one, including your employer, union or any other person, may
fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare
benefit or exercising your rights under ERISA. If your claim for a welfare benefit is denied in
whole or in part you must receive a written explanation of the reason for denial. You have the
right to have the plan review and reconsider your claim. Under ERISA, there are steps you can
take to enforce the above rights. For instance, if you request materials from the plan and do not
receive them within 30 days, you may file a suit in federal court. In such a case, the court may
require the plan administrator to provide the materials and pay you up to $110 a day until you
receive the materials, unless the materials were not sent because of reasons beyond the control of
the administrator. If you have a claim for benefits, which is denied or ignored, in whole or in part,
you may file suit in a state or federal court. If it should happen that plan fiduciaries misuse the
plan's money, or if you are discriminated against for asserting your rights, you may file suit in a
federal court. The court will decide who should pay court costs and legal fees. If you are
successful, the court may order the person you have sued to pay these costs and fees. If you lose,
the court may order you to pay these costs and fees, for example, if it finds your claim frivolous.
If you have any questions about this statement or about your rights under ERISA, you should
contact the nearest office of the Pension and Welfare Benefits Administration, U.S. Department
of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries,
Pension and Welfare Benefit Administration, U.S. Department of Labor, 200 Constitution
Avenue N.W., Washington, D.C. 20210.
CONTINUATION COVERAGE RIGHTS UNDER COBRA
Introduction
You are receiving this notice because you have recently become covered under CITY OF
REXBURG CAFETERIA PLAN. This notice contains important information about your right to
COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This
notice generally explains COBRA continuation coverage, when it may become available to
you and your family, and what you need to do to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can
become available to you when you would otherwise lose your group health coverage. It can also
become available to other members of your family who are covered under the Plan when they
would otherwise lose their group health coverage. For additional information about your rights
and obligations under the Plan and under federal law, you should either review the Plan's
Summary Plan Description or contact the Plan Administrator.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would
otherwise end because of a life event known as a "qualifying event." Specific qualifying events
are listed later in this notice. After a qualifying event, COBRA continuation coverage must be
offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent
children could become qualified beneficiaries if coverage under the Plan is lost because of the
qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation
coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you will lose your coverage
under the Plan because either one of the following qualifying events happens:
(1) Your hours of employment are reduced, or
(2) Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you will lose
your coverage under the Plan because any of the following qualifying events happens:
(1) Your spouse dies;
(2) Your spouse's hours of employment are reduced;
(3) Your spouse's employment ends for any reason other than his or her gross misconduct;
(4) Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
(5) You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they will lose coverage under the
Plan because any of the following qualifying events happens:
(1) The parent-employee dies;
(2) The parent-employee's hours of employment are reduced;
(3) The parent-employee's employment ends for any reason other than his or her gross
misconduct;
(4) The parent-employee becomes entitled to Medicare benefits (under Part A, Part B, or
both);
(5) The parents become legally separated; or
(6) The child stops being eligible for coverage under the plan as a "dependent child"
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan
Administrator has been notified that a qualifying event has occurred. When the qualifying event is
the end of employment or reduction of hours of employment, death of the employee, or the
employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer
must notify the Plan Administrator of the qualifying event.
You Must Give Notice of Some Qualifying Events
For the other qualifying events divorce or legal separation of the employee
and spouse or a dependent child's losing eligibility for coverage as a dependent
child), you must notify the Plan Administrator within 60 days after the
qualifying event occurs. This notice must be provided, in writing, to the Plan
Administrator at the address listed at the end of this document.
How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each qualified
beneficiary will have an independent right to elect COBRA continuation coverage. Covered
employees may elect COBRA continuation coverage on behalf of their spouses, and parents may
elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying
event is the death of the employee, the employee's becoming entitled to Medicare benefits (under
Part A, Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as
a dependent child, COBRA continuation coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the employee's hours of
employment, and the employee became entitled to Medicare benefits less than 18 months before
the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the
employee lasts until 36 after the date of Medicare entitlement. For example, if a covered
employee becomes entitled to Medicare 8 months before the date on which his employment
terminates, COBRA continuation coverage for his spouse and children can last up to 36 months
after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying
event (36 months minus 8 months). Otherwise, when the qualifying event is the end of
employment or reduction of the employee's hours of employment, COBRA continuation coverage
generally lasts for only up to a total of 18 months. There are two ways in which this 18-month
period of COBRA continuation coverage can be extended.
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security
Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and
your entire family may be entitled to receive up to an additional 11 months of COBRA
continuation coverage, for a total maximum of 29 months. The disability would have to have
started at some time before the 60th day of COBRA continuation coverage and must last at least
until the end of the 18-month period of continuation coverage.
You must make sure that the Plan Administrator is notified, in writing, of the Social Security
Administration's determination within 60 days of the date of determination and before the end of
the 18-month period of COBRA continuation coverage. This notice should be sent to the Plan
Administrator at the address listed at the end of this document.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA
continuation coverage, the spouse and dependent children in your family can get up to an
additional 18 months of COBRA continuation coverage, for a maximum of 36 months, if notice
of the second qualifying event is properly given to the Plan. This extension may be available to
the spouse and any dependent children receiving continuation coverage if the employee or former
employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets
divorced or legally separated, or if the dependent child stops being eligible under the Plan as a
dependent child, but only if the event would have caused the spouse or dependent child to lose
coverage under the Plan had the first qualifying event not occurred.
In all of these cases, you must make sure that the Plan Administrator is notified, in writing, of the
second qualifying event within 60 days of the second qualifying event. This notice must be sent to
the Plan Administrator at the address listed at the end of this document.
If You Have Questions
Questions concerning your Plan or your COBRA continuation rights should be addressed to the
contact identified below. For more information about your rights under ERISA, including
COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws
affecting group health plans, contact the nearest Regional or District Office of the U.S.
Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit
the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District
EBSA Offices are available through EBSA's website.)
Keep your Plan Informed of Address Changes
In order to protect your family's rights, you should keep the Plan Administrator informed of any
changes in the addresses of family members. You should also keep a copy, for your records, of
any notices you send to the Plan Administrator.
Plan Contact Information
CITY OF REXBURG
HUMAN RESOURCE DIRECTOR
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
CITY OF REXBURG CAFETERIA PLAN
NOTICE OF PRIVACY PRACTICES
Pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") Originally
Effective July 1st, 2006, Revised July I st, 2006.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR PERSONAL AND HEALTH
INFORMATION IS IMPORTANT.
CITY OF REXBURG is committed to protecting the privacy of health information maintained by
the health plans it sponsors. This Notice is provided to you as required by the Health Insurance
Portability and Accountability Act and the HIPAA Privacy Regulations (collectively, "HIPAA").
It applies to employees and covered dependents enrolled in the Medical Reimbursement Benefit
under the CITY OF REXBURG CAFETERIA PLAN, hereinafter "the Plan".
This Notice describes how the Plan may use health information about you and your covered
dependents and when such information may be used and disclosed. This notice also describes
how you may have access to this information.
WHAT HEALTH INFORMATION IS COLLECTED?
The Plan considers personal health information to be confidential. The Plan will protect the
privacy of that information in accordance with federal and state privacy laws, as well as the Plans'
privacy policies. "Health Information" is used to mean information that identifies you and relates
to your medical history, such as the health care you receive and or the amounts paid for that care.
Health information subject to the provisions explained in this Notice is information maintained by
the Plan. The provisions do not extend to similar information, which may be on file with CITY
OF REXBURG as an Employer in its normal course of doing business. The type of health
information typically received and maintained by the Plan, which is subject to this Notice,
includes enrollment and claims information, benefit determinations, appeals information,
eligibility, and case management information.
SUMMARY OF
PERMISSIBLE USES AND DISCLOSURES AND YOUR RIGHTS
REGARDING YOUR HEALTH
INFORMATION WHICH DO NOT REQUIRE YOUR AUTHORIZATION
In order to provide and administer your benefits, the Plans may use your and disclose your health
information in various ways without your express authorization. These include:
Payment: The Plan may use and disclose your health information for purposes of paying for
your health care services or to obtain premiums/contributions from you. The Plan may also
use and disclose your health information to make determinations about your eligibility for
benefit plan coverage, for coordination of benefits with other benefit plans, to perform claims
management and collection activities, to review the medical necessity or the appropriateness
of the care you received, and to conduct utilization reviews such as pre-authorizations, or
reviews, of services.
Health Care Operations: The Plan may use and disclose your health information as necessary
to operate and manage their business operations. For example, CITY OF REXBURG, on
behalf of the Plan, has contracts with an outside firm called a "third party administrator"
(TPA) to provide administrative services to the Plan. The Plan may use your health
information to evaluate the performance of the TPA in managing and providing you with
health care benefits. The Plan might use and disclose your health information to contract for
reinsurance or to investigate the validity of benefits claims. In addition, the Plan may share
your health information with another company that performs certain services, such as billing
or compiling information to help the Plan determine how the Plan is doing relative to other
plans. Whenever the Plan has such an arrangement, they will have a written confidentiality
agreement to ensure that the company that performs these services will protect the privacy of
your health information, maintain its confidentiality and limit the uses or further disclosures
to the purpose for which the information was disclosed or as required by law.
Benefits and Services: As a part of health care operations, the Plan may use your health
information to contact you regarding benefits or services that may be of interest to you, such
as benefits that are included in the Plan, your medical treatment, case management and
coordination of benefits, recommendations for alternative treatments, therapies, health care
providers or settings of care.
Employer: The Plan may disclose certain health information to CITY OF REXBURG since it
is the Employer, which sponsors the Plan. Upon a request from CITY OF REXBURG, the
Plan may disclose health information about enrolled employees and their covered dependents
to enable the Employer to obtain premium bids from other health plans, or to modify, amend,
or terminate the Plan; however, the information the Plan discloses in such situations will not
include any information that explicitly identifies individuals. The Plan may disclose to the
Employer information on whether you are participating in, enrolled in, or unenrolled from the
Plan. The Plan also may disclose health information about you, including information that
identifies you, only if it is necessary for the Employer to administer the Plan. For example,
CITY OF REXBURG may need such information to process health benefits claims, to audit
or monitor the business operations of the Plans, or to ensure that the Plans are operating
effectively and efficiently. The Plan may also disclose information to the Employer with
respect to workers' compensation and the Family and Medical Leave Act. The Plan, however,
will restrict their use of your information to purposes related only to Plan administration. The
Plan prohibits the Employer from using your information for uses unrelated to Plan
administration. Under no circumstances will the Plan disclose your health information to the
Employer for the purpose of employment-related actions or decisions. The Employer will
only disclose the health information it received from the Plan to third parties, such as to
consultants or advisors, if the Plan has first obtained a confidentiality agreement from the
person or organization which will receive your health information.
- Disclosures to Friends and Family Involved in Your Care and Payment for Your Care:
The Plans may share information about your health benefits to a person involved in your care
such as a family member unless you object. If you have provided a friend or family member
with copies of your claim and other relevant identifying information, the Plan will assume
that you do not object.
- Emergencies or Public Need: The Plan may use or disclose your health information in an
emergency or for important public needs. For example, the Plan may share your information
with public health officials authorized to investigate and control the spread of diseases. The
Plan may have information to prevent or lessen a serious and imminent threat to health or
safety.
- As Required By Law: The Plan may use or disclose your health information if the Plan is
required by law to do so. The Plan will notify you of these uses and disclosures if notice is
required by law.
- Business Associates: The Plan may share information with service providers who provide
administrative services for the Plans.
USES AND DISCLOSURES OF HEALTH INFORMATION WHICH
REQUIRE YOUR WRITTEN AUTHORIZATION
Except as otherwise described in this Notice, the Plan, through their third party administrator, will
generally obtain your written authorization before using your health information or disclosing it
outside the Plan. If you provide the Plan with such a written authorization, you may revoke that
authorization at any time, except to the extent that the Plans have already relied on it. To revoke
an authorization, write to the Plan Administrator or Privacy Officer.
Access and Control of Your Health Information
The Plan must provide you certain rights with respect to access and control of your health
information in your health claims file. You have the following rights to access and control your
health information:
You generally have the right to inspect and copy your health information which the Plan
maintains.
You have the right to request that the Plan amend your protected health information if you
believe it is inaccurate or incomplete. You must submit your request in writing to the third
party administrator of the Plan in which you are enrolled.
You have the right to receive from the Plan an accounting of disclosures of protected health
information. Your request must be in writing to the Privacy Officer. Many routine disclosures
the Plan makes, including disclosures to your Employer for Plan administration, will not be
included in the accounting; the accounting will identify only non-routine disclosures.
You have the right to request further restrictions on the way the Plan uses your health
information or shares it with others. The Plan is not required to agree to the restriction you
request, but if the Plan does, the Plan will be bound by the agreement until such agreement is
revoked by the Plan and you are notified in writing of such revocation.
You have the right to request that the Plan contact you in a way that is more confidential for
you, such as at work instead of at home, if disclosure of your health information could put
you in danger and you clearly state that in your request. The Plans will accommodate all
reasonable requests.
To Have Someone Act on Your Behalf
You have the right to name a personal representative who may act on your behalf to control the
privacy of your health information. This authorization must be in writing and delivered to the
Privacy Officer for the Plan.
Special Protections for HIV, Substance Abuse, and Mental Health Information
Special privacy protections may apply to HIV-related information, substance abuse information,
and mental health information. Some parts of this Notice may not apply to these types of
information.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Plan or
with the Secretary of the Department of Health and Human Services. To file a complaint with the
Plan, please contact the Privacy Officer listed at the end of this notice:
No one will retaliate or take action against you for filing a complaint.
Right to Revise
The Plan may change its privacy practices from time to time. If that happens, the Plan will revise
this Notice so you will have an accurate summary of the Plans' practices. The revised Notice will
apply to all of your health information. If you received this Notice electronically, you have the
right to obtain a paper copy of the Notice. To request a paper copy of this Notice or any revised
Notice, please contact the Plan's Privacy Officer. If this Notice is substantially revised, a new
Notice will be mailed to you within 60 days.
The Plan is required by law to abide by the terms of the Notice currently in effect.
Contact Information
For further information, please contact the Plans' Privacy Officer (payroll clerk):
CITY OF REXBURG
PAYROLL CLERK
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT
Summary of Material Modification
To: Participants of CITY OF REXBURG FLEXIBLE SPENDING ACCOUNT
From: CITY OF REXBURG
Date: August 17, 2006
This is a summary of a recent change to your Plan.
Please file this "Summary of Material Modification" with your Summary Plan Description (the
booklet that explains your Plan). If you would like to see the full text of the changes, you may
inspect the Plan Document or receive a copy of the changes as explained in the "ERISA Rights"
section of your Summary Plan Description.
The Plan has been amended to allow an additional period of time (or "grace period") of 2,5
months following the end of each plan year to incur expenses before the "use it or lose it"
forfeiture rule applies. Thus, expenses incurred within 2.5 months after the close of the plan year
can be reimbursed with funds carried over from the prior plan year. However, any unused
amounts from the prior plan year that are not used to reimburse expenses by the end of the grace
period remain subject to the "use it or lose it" rule and must be forfeited.
Example #1: In the 2005 calendar plan year, Sally elects to contribute $2,000 for reimbursement
of eligible medical expenses under the employer's Health FSA. On December 31, 2005, Sally has
only incurred $1,000 in expenses; therefore, she has a $1,000 Temporary Carry-over amount
following the 2005 plan year. For 2006, Sally again elects to contribute $2,000. Sally incurs a
$3,000 expense on January 15, 2006. Under the new rule, the $1,000 Temporary Carry-over
amount may be applied to the $3,000 expense incurred on January 15, 2006. The remaining
$2,000 would be available for reimbursement under her 2006 election.
Example #2: Same facts as Example #1, except assume that Sally only incurs a $500 expense on
January 15, 2006 and she incurs no other expenses during the grace period. In this example, $500
of the $1,000 Temporary Carry-over amount may be applied to $500 expense and the remaining
$500 is forfeited.
The grace period will not be available to Participants who terminate before the end of the plan
year unless they comply with the provisions set out in COBRA.
If you have any questions on this Summary or the amendment to your Plan, contact your Plan
Administrator:
CITY OF REXBURG.
HUMAN RESOURCE DIRECTOR
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
CITY OF REXBURG DEPENDANT CARE
Summarv of Material Modification
To: Participants of CITY OF REXBURG DEPENDANT CARE
From: CITY OF REXBURG
Date: August 17, 2006
This is a summary of a recent change to your Plan.
Please file this "Summary of Material Modification" with your Summary Plan Description (the
booklet that explains your Plan). If you would like to see the full text of the changes, you may
inspect the Plan amendment.
The Plan has been amended to allow an additional period of time (or "grace period") of 2.5
months following the end of each plan year to incur expenses before the "use it or lose it"
forfeiture rule applies. Thus, expenses incurred within 2.5 months after the close of the plan year
can be reimbursed with funds carried over from the prior plan year. However, any unused
amounts from the prior plan year that are not used to reimburse expenses by the end of the grace
period remain subject to the "use it or lose it" rule and must be forfeited.
Example #1: In the 2005 calendar plan year, Sally elects to contribute $2,000 for reimbursement
of eligible expenses under the employer's Dependent Care Plan. On December 31, 2005, Sally has
only incurred $1,000 in expenses; therefore, she has a $1,000 Temporary Carry-over amount
following the 2005 plan year. For 2006, Sally again elects to contribute $2,000. Sally incurs a
$3,000 expense on January 15, 2006. Under the new rule, the $1,000 Temporary Carry-over
amount may be applied to the $3,000 expense incurred on January 15, 2006. The remaining
$2,000 would be available for reimbursement under her 2006 election.
Example #2: Same facts as Example #1, except assume that Sally only incurs a $500 expense on
January 15, 2006 and she incurs no other expenses during the grace period. In this example, $500
of the $1,000 Temporary Carry-over amount may be applied to $500 expense and the remaining
$500 is forfeited.
If you have any questions on this Summary or the amendment to your Plan, contact your Plan
Administrator:
CITY OF REXBURG
HUMAN RESOURCE DIRECTOR.
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
CITY OF REXBURG RESOLUTION NO.
FOR THE AMENDMENT OF CITY OF REXBURG CAFETERIA PLAN
On this date, the City Council of the CITY OF REXBURG did meet to discuss the amendment of
the CITY OF REXBURG CAFETERIA PLAN to be effective July 1st, 2006. Let it be known that
the following resolutions were duly adopted by the City Council of CITY OF REXBURG and
that such resolutions have not been modified or rescinded as of the date hereof;
RESOLVED, that the form of Cafeteria Plan, as authorized under Section 125 of the Internal
Revenue Code of 1986, presented to this meeting is hereby adopted and approved and that the
proper officers of the Employer are hereby authorized and directed to execute and deliver to the
Plan Administrator one or more copies of the Plan.
RESOLVED, that the short Plan Year shall begin on July 1st, 2006 and end on December 31st,
2006. Each subsequent Plan Year shall begin on January 1st and end on December 31st.
RESOLVED, that the proper officers of the Employer shall act as soon as possible to notify
employees of the amendment of the Cafeteria Plan by delivering to each Employee a copy of the
Summary Plan Description presented to this meeting, which form is hereby approved.
The undersigned certifies that attached hereto as Exhibits A and B respectively are true copies of
the Plan Document, and Summary Plan Description for CITY OF REXBURG CAFETERIA
PLAN approved and adopted in the foregoing resolutions.
The undersigned further certifies and attests that the above resolutions were made with the
consent of the City Council of the City of Rexburg on this date September 6, 2006.
Mayor
Attest:
City Clerk
CONTINUATION COVERAGE RIGHTS UNDER COBRA
Introduction
You are receiving this notice because you have recently become covered under CITY OF
REXBURG CAFETERIA PLAN. This notice contains important information about your right to
COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This
notice generally explains COBRA continuation coverage, when it may become available to
you and your family, and what you need to do to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can
become available to you when you would otherwise lose your group health coverage. It can also
become available to other members of your family who are covered under the Plan when they
would otherwise lose their group health coverage. For additional information about your rights
and obligations under the Plan and under federal law, you should either review the Plan's
Summary Plan Description or contact the Plan Administrator.
What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would
otherwise end because of a life event known as a "qualifying event." Specific qualifying events
are listed later in this notice. After a qualifying event, COBRA continuation coverage must be
offered to each person who is a "qualified beneficiary." You, your spouse, and your dependent
children could become qualified beneficiaries if coverage under the Plan is lost because of the
qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation
coverage must pay for COBRA continuation coverage.
If you are an employee, you will become a qualified beneficiary if you lose your coverage under
the Plan because either one of the following qualifying events happens:
(1) Your hours of employment are reduced, or
(2) Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your
coverage under the Plan because any of the following qualifying events happens:
(1) Your spouse dies;
(2) Your spouse's hours of employment are reduced;
(3) Your spouse's employment ends for any reason other than his or her gross misconduct;
(4) Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
(5) You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan
because any of the following qualifying events happens:
(1) The parent-employee dies;
(2) The parent-employee's hours of employment are reduced;
(3) The parent-employee's employment ends for any reason other than his or her gross
misconduct;
(4) The parent-employee becomes entitled to Medicare benefits (under Part A, Part B, or
both);
(5) The parents become divorced or legally separated; or
(6) The child stops being eligible for coverage under the plan as a "dependent child".
When is COBRA Coverage Available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan
Administrator has been notified that a qualifying event has occurred. When the qualifying event is
the end of employment or reduction of hours of employment, death of the employee, or the
employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer
must notify the Plan Administrator of the qualifying event.
You Must Give Notice of Some Qualifying Events
For the other qualifying events divorce or legal separation of the employee
and spouse or a dependent child's losing eligibility for coverage as a dependent
child), you must notify the Plan Administrator within 60 days after the
qualifying event occurs. This notice must be provided, in writing, to the Plan
Administrator at the address listed at the end of this document.
How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each qualified
beneficiary will have an independent right to elect COBRA continuation coverage. Covered
employees may elect COBRA continuation coverage on behalf of their spouses, and parents may
elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying
event is the death of the employee, the employee's becoming entitled to Medicare benefits (under
Part A, Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as
a dependent child, COBRA continuation coverage lasts for up to 36 months.
When the qualifying event is the end of employment or reduction of the employee's hours of
employment, and the employee became entitled to Medicare benefits less than 18 months before
the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the
employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered
employee becomes entitled to Medicare 8 months before the date on which his employment
terminates, COBRA continuation coverage for his spouse and children can last up to 36 months
after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying
event (36 months minus 8 months). Otherwise, when the qualifying event is the end of
employment or reduction of the employee's hours of employment, COBRA continuation coverage
generally lasts for only up to a total of 18 months. There are two ways in which this 18-month
period of COBRA continuation coverage can be extended.
Disability extension of 18-month period of continuation coverage
If you or anyone in your family covered under the Plan is determined by the Social Security
Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and
your entire family may be entitled to receive up to an additional 11 months of COBRA
continuation coverage, for a total maximum of 29 months. The disability would have to have
started at some time before the 60th day of COBRA continuation coverage and must last at least
until the end of the 18-month period of continuation coverage.
You must make sure that the Plan Administrator is notified, in writing, of the Social Security
Administration's determination within 60 days of the date of determination and before the end of
the 18-month period of COBRA continuation coverage. This notice should be sent to the Plan
Administrator at the address listed at the end of this document.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event while receiving 18 months of COBRA
continuation coverage, the spouse and dependent children in your family can get up to an
additional 18 months of COBRA continuation coverage, for a maximum of 36 months, if notice
of the second qualifying event is properly given to the Plan. This extension may be available to
the spouse and any dependent children receiving continuation coverage if the employee or former
employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets
divorced or legally separated, or if the dependent child stops being eligible under the Plan as a
dependent child, but only if the event would have caused the spouse or dependent child to lose
coverage under the Plan had the first qualifying event not occurred.
In all of these cases, you must make sure that the Plan Administrator is notified, in writing, of the
second qualifying event within 60 days of the second qualifying event. This notice must be sent to
the Plan Administrator at the address listed at the end of this document.
If You Have Questions
Questions concerning your Plan or your COBRA continuation rights should be addressed to the
contact identified below. For more information about your rights under ERISA, including
COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws
affecting group health plans, contact the nearest Regional or District Office of the U.S.
Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit
the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District
EBSA Offices are available through EBSA's website.)
Keep your Plan Informed of Address Changes
In order to protect your family's rights, you should keep the Plan Administrator informed of any
changes in the addresses of family members. You should also keep a copy, for your records, of
any notices you send to the Plan Administrator.
Plan Contact Information
CITY OF REXBURG
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
CITY OF REXBURG CAFETERIA PLAN
NOTICE OF PRIVACY PRACTICES
Pursuant to the Health Insurance Portability and Accountability Act ("HIPAA") Originally
Effective July 1st, 2006, Revised July 1st, 2006.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR PERSONAL AND HEALTH
INFORMATION IS IMPORTANT.
CITY OF REXBURG is committed to protecting the privacy of health information maintained by
the health plans it sponsors. This Notice is provided to you as required by the Health Insurance
Portability and Accountability Act and the HIPAA Privacy Regulations (collectively, "HIPAA").
It applies to employees and covered dependents enrolled in CITY OF REXBURG CAFETERIA
PLAN, hereinafter "the Plan".
This Notice describes how the Plan may use health information about you and your covered
dependents and when such information may be used and disclosed. This notice also describes
how you may have access to this information.
WHAT HEALTH INFORMATION IS COLLECTED?
The Plan considers personal health information to be confidential. The Plan will protect the
privacy of that information in accordance with federal and state privacy laws, as well as the Plans'
privacy policies. "Health Information" is used to mean information that identifies you and relates
to your medical history, such as the health care you receive and or the amounts paid for that care.
Health information subject to the provisions explained in this Notice is information maintained by
the Plan. The provisions do not extend to similar information which may be on file with CITY OF
REXBURG as an Employer in its normal course of doing business. The type of health
information typically received and maintained by the Plan which is subject to this Notice includes
enrollment and claims information, benefit determinations, appeals information, eligibility, and
case management information.
SUMMARY OF
PERMISSIBLE USES AND DISCLOSURES AND YOUR RIGHTS
REGARDING YOUR HEALTH
INFORMATION WHICH DO NOT REQUIRE YOUR AUTHORIZATION
In order to provide and administer your benefits, the Plans may use and disclose your health
information in various ways without your express authorization. These include:
Payment: The Plan may use and disclose your health information for purposes of paying for
your health care services or to obtain premiums/contributions from you. The Plan may also
use and disclose your health information to make determinations about your eligibility for
benefit plan coverage, for coordination of benefits with other benefit plans, to perform claims
management and collection activities, to review the medical necessity or the appropriateness
of the care you received, and to conduct utilization reviews such as pre-authorizations, or
reviews, of services.
Health Care Operations: The Plan may use and disclose your health information as necessary
to operate and manage their business operations. For example, CITY OF REXBURG, on
behalf of the Plan, has contracts with an outside firm called a "third party administrator"
(TPA) to provide administrative services to the Plan. The Plan may use your health
information to evaluate the performance of the TPA in managing and providing you with
health care benefits. The Plan might use and disclose your health information to contract for
reinsurance or to investigate the validity of benefits claims. In addition, the Plan may share
your health information with another company that performs certain services, such as billing
or compiling information to help the Plan determine how the Plan is doing relative to other
plans. Whenever the Plan has such an arrangement, they will have a written confidentiality
agreement to ensure that the company that performs these services will protect the privacy of
your health information, maintain its confidentiality and limit the uses or further disclosures
to the purpose for which the information was disclosed or as required by law.
Benefits and Services: As a part of health care operations, the Plan may use your health
information to contact you regarding benefits or services that may be of interest to you, such
as benefits that are included in the Plan, your medical treatment, case management and
coordination of benefits, recommendations for alternative treatments, therapies, health care
providers or settings of care.
Employer: The Plan may disclose certain health information to CITY OF REXBURG since it
is the Employer which sponsors the Plan. Upon a request from CITY OF REXBURG, the
Plan may disclose health information about enrolled employees and their covered dependents
to enable the Employer to obtain premium bids from other health plans, or to modify, amend,
or terminate the Plan; however, the information the Plan discloses in such situations will not
include any information that explicitly identifies individuals. The Plan may disclose to the
Employer information on whether you are participating in, enrolled in, or unenrolled from the
Plan. The Plan also may disclose health information about you, including information that
identifies you, only if it is necessary for the Employer to administer the Plan. For example,
CITY OF REXBURG may need such information to process health benefits claims, to audit
or monitor the business operations of the Plans, or to ensure that the Plans are operating
effectively and efficiently. The Plan may also disclose information to the Employer with
respect to workers' compensation and the Family and Medical Leave Act. The Plan, however,
will restrict their use of your information to purposes related only to Plan administration. The
Plan prohibits the Employer from using your information for uses unrelated to Plan
administration. Under no circumstances will the Plan disclose your health information to the
Employer for the purpose of employment-related actions or decisions. The Employer will
only disclose the health information it received from the Plan to third parties, such as to
consultants or advisors, if the Plan has first obtained a confidentiality agreement from the
person or organization which will receive your health information.
- Disclosures to Friends and Family Involved in Your Care and Payment for Your Care:
The Plans may share information about your health benefits to a person involved in your care
such as a family member unless you object. If you have provided a friend or family member
with copies of your claim and other relevant identifying information, the Plan will assume
that you do not object.
- Emergencies or Public Need: The Plan may use or disclose your health information in an
emergency or for important public needs. For example, the Plan may share your information
with public health officials authorized to investigate and control the spread of diseases. The
Plan may have information to prevent or lessen a serious and imminent threat to health or
safety.
- As Required By Law: The Plan may use or disclose your health information if the Plan is
required by law to do so. The Plan will notify you of these uses and disclosures if notice is
required by law.
- Business Associates: The Plan may share information with service providers who provide
administrative services for the Plans.
USES AND DISCLOSURES OF HEALTH INFORMATION WHICH
REQUIRE YOUR WRITTEN AUTHORIZATION
Except as otherwise described in this Notice, the Plan, through their third party administrator, will
generally obtain your written authorization before using your health information or disclosing it
outside the Plan. If you provide the Plan with such a written authorization, you may revoke that
authorization at any time, except to the extent that the Plans have already relied on it. To revoke
an authorization, write to the Plan Administrator or Privacy Officer.
Access and Control of Your Health Information
The Plan must provide you certain rights with respect to access and control of your health
information in your health claims file. You have the following rights to access and control your
health information:
You generally have the right to inspect and copy your health information which the Plan
maintains.
You have the right to request that the Plan amend your protected health information if you
believe it is inaccurate or incomplete. You must submit your request in writing to the third
party administrator of the Plan in which you are enrolled.
You have the right to receive from the Plan an accounting of disclosures of protected health
information. Your request must be in writing to the Privacy Officer. Many routine disclosures
the Plan makes, including disclosures to your Employer for Plan administration, will not be
included in the accounting; the accounting will identify only non-routine disclosures.
You have the right to request further restrictions on the way the Plan uses your health
information or shares it with others. The Plan is not required to agree to the restriction you
request, but if the Plan does, the Plan will be bound by the agreement until such agreement is
revoked by the Plan and you are notified in writing of such revocation.
You have the right to request that the Plan contact you in a way that is more confidential for
you, such as at work instead of at home, if disclosure of your health information could put
you in danger and you clearly state that in your request. The Plans will accommodate all
reasonable requests.
To Have Someone Act on Your Behalf
You have the right to name a personal representative who may act on your behalf to control the
privacy of your health information. This authorization must be in writing and delivered to the
Privacy Officer for the Plan.
Special Protections for HIV, Substance Abuse, and Mental Health Information
Special privacy protections may apply to HIV-related information, substance abuse information,
and mental health information. Some parts of this Notice may not apply to these types of
information.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with the Plan or
with the Secretary of the Department of Health and Human Services. To file a complaint with the
Plan, please contact the Privacy Officer listed at the end of this notice:
No one will retaliate or take action against you for filing a complaint.
Right to Revise
The Plan may change its privacy practices from time to time. If that happens, the Plan will revise
this Notice so you will have an accurate summary of the Plans' practices. The revised Notice will
apply to all of your health information. If you received this Notice electronically, you have the
right to obtain a paper copy of the Notice. To request a paper copy of this Notice or any revised
Notice, please contact the Plan's Privacy Officer. If this Notice is substantially revised, a new
Notice will be mailed to you within 60 days.
The Plan is required by law to abide by the terms of the Notice currently in effect.
Contact Information
For further information, please contact the Plans' Privacy Officer:
CITY OF REXBURG
CITY OF REXBURG
12 N. CENTER
REXBURG, ID 83440
(208)359-3020
CITY OF REXBURG CAFETERIA PLAN
HIPAA Privacy Plan Amendment
Article 1. Introduction
CITY OF REXBURG ("the Plan Sponsor") sponsors CITY OF REXBURG CAFETERIA PLAN
("the Plan"). Certain employees of the Company have access to the individually identifiable
health information of Plan participants for administrative functions of the Plan. When this health
information is provided from the Plan to the Plan Sponsor, it is Protected Health Information
(PHI).
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the regulations
implementing it, limit the Plan Sponsor's ability to use and disclose PHI. The following HIPAA
definition of PHI shall apply to this plan amendment:
Protected Health Information. Protected health information means information that is created
or received by the Plan and relates to the past, present, or future physical or mental health or
condition of a participant; the provision of health care to a participant; or the past, present, or
future payment for the provision of health care to a participant; and that identifies the
participant or for which there is a reasonable basis to believe the information can be used to
identify the participant. Protected health information includes information of persons living
or deceased.
The Plan Sponsor shall have access to PHI from the Plan only as permitted under this plan
amendment or as otherwise required or permitted by HIPAA.
Provision of Protected Health Information to Plan Sponsor
Article 2. Permitted Disclosure of Enrollment Information
The Plan, or any insurance carrier under the plan, may disclose to the Plan Sponsor information
on whether the individual is participating in the Plan, or is enrolled in or has unenrolled from any
benefit offered by the Plan.
Article 3. Permitted Uses and Disclosure of Summary Health Information
The Plan, or any insurance carrier under the plan, may disclose Summary Health Information to
the Plan Sponsor, provided that the Plan Sponsor requests the Summary Health Information for
the purpose of (1) obtaining premium bids from health plans for providing health insurance
coverage under the Plan; or (2) modifying, amending, or terminating the Plan.
"Summary Health Information" means information (1) that summarizes the claims history, claims
expenses or type of claims experienced by individuals for whom a plan sponsor had provided
health benefits under a Health Plan; and (2) from which the information described at 42 CFR
164.514(b)(2)(i) has been deleted, except that the geographic information described in 42 CFR
164.514(b)(2)(i)(B) need only be aggregated to the level of a five-digit ZIP code.
Article 4. Permitted and Required Uses and Disclosure of PHI for Plan
Administration Purposes:
Unless otherwise permitted by law, and subject to the conditions of disclosure described in
Article 5 and obtaining written certification pursuant to Article 7, the Plan or any insurance
carrier under the Plan may disclose PHI to the Plan Sponsor, provided that the Plan Sponsor uses
or discloses such PHI only for Plan administration purposes. "Plan administration purposes"
means administration functions performed by the Plan Sponsor on behalf of the Plan, such as
quality assurance, claims processing, adjudication, appeal, payment, auditing, and monitoring.
Plan administration functions do not include functions performed by the Plan Sponsor in
connection with any other benefit or benefit plan of the Plan Sponsor, nor to any employment-
related functions.
Notwithstanding the provisions of this Plan to the contrary, in no event shall the Plan Sponsor be
permitted to use or disclose PHI in a manner that is inconsistent with 45 CFR 164.504(f).
Article 5. Conditions of Disclosure for Plan Administration Purposes
Plan Sponsor agrees that with respect to any PHI, other than enrollment information and
Summary Health Information which are not subject to these restrictions, disclosed to it by the
Plan or health insurance carrier under the Plan, Plan Sponsor shall:
a. Not use or further disclose the PHI other than as permitted or required by the Plan or as
required by law;
b. Ensure that any agent, including a subcontractor, to whom it provides PHI received from
the Plan agrees to the same restrictions and conditions that apply to the Plan Sponsor
with respect to PHI;
c. Not use or disclose the PHI for employment-related actions and decisions or in
connection with any other benefit or employee benefit plan of the Plan Sponsor;
d. Report to the Plan any use or disclosure of the information that is inconsistent with the
uses or disclosures provided for of which it becomes aware;
e. Make available PHI to comply with HIPAA's right to access in accordance with 45 CFR
164.524;
f. Make available PHI for amendment and incorporate any amendments to PHI in
accordance with 45 CFR 164.526;
g. Make available the information required to provide an accounting of disclosures in
accordance with 45 CFR 164.528;
2
h. Make its internal practices, books, and records relating to the use and disclosure of PHI
received from the Plan available to the Secretary of Health and Human Services for
purposes of determining compliance by the Plan with HIPAA's privacy requirements;
i. If feasible, return or destroy all PHI received from the Plan that 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, except that, if such return or destruction
is not feasible, limit further uses and disclosures to those purposes that make the return or
destruction of the information infeasible; and
j. Ensure that the adequate separation between Plan and Plan Sponsor required in 45 CFR
504(f)(2)(iii), is satisfied.
Article 6. Adequate Separation Between Plan and Plan Sponsor
The Plan Sponsor shall allow HUMAN RESOURCE access to the PHI. No other persons shall
have access to PHI. The specified employees, or classes of employees, shall only have access to
and use PHI to the extent necessary to perform the plan administration functions that the Plan
Sponsor performs for the Plan. In the event the above named individuals or groups are
unavailable to carry out their duties with respect to the Plan, the Plan Sponsor may appoint other
persons as necessary to carry out plan administration functions. The Plan Sponsor shall promptly
notify the Privacy Officer of such occurrence.
In the event that any named individual does not comply with the provisions of this article, that
employee shall be subject to disciplinary action by the Plan Sponsor pursuant to the Plan
Sponsor's employee disciplinary and termination procedures.
Article 7. Plan Sponsor Certification
The Plan shall disclose PHI to the Plan Sponsor only upon the receipt of a certification by the
Plan Sponsor that the Plan has been amended to incorporate the provisions of 45 CFR
164.504(f)(2)(ii), and that the Plan Sponsor agrees to the conditions of disclosure set forth in
Article 5 of this amendment.
This Plan Amendment is effective the 1st day of July, 2006, and has been adopted by:
Plan Sponsor Representative Signature
Plan Sponsor Representative Name
Plan Sponsor Representative Title
Date