HomeMy Public PortalAboutRES-CC-2017-60RESOLUTION #60-2017
A RESOLUTION ADOPTING THE CITY OF MOAB HEALTH REIMBURSEMENT ARRANGEMENT PLAN
AND SUMMARY PLAN DESCRIPTION DOCUMENTS
WHEREAS, the City of Moab is desirous of offering a Health Reimbursement Arrangement to our
classified employees and elected officials; and
WHERAS, Health Reimbursement Arrangement Plans and Summary Plan Description Documents
(referred to as the "Plan") should be approved by the Governing Body;
NOW, THEREFORE, we, the Governing Body of the City of Moab do herby resolve the following:
RESOLVED, that the form of amended Health Reimbursement Arrangement effective
January 1, 2018 , presented to this meeting is hereby approved and adopted and that the proper
officers of the Corporation are hereby authorized and directed to execute and deliver to the
Administrator of the Plan one or more counterparts of the Plan.
RESOLVED, that the Administrator shall be instructed to take such actions that are deemed
necessary and proper in order to implement the Plan, and to set up adequate accounting and
administrative procedures to provide benefits under the Plan.
RESOLVED, that the proper officers of the Corporation shall act as soon as possible to notify the
employees of the Corporation of the adoption of the Health Reimbursement Arrangement Plan
by delivering to each employee a copy of the summary description of the Plan in the form of the
Summary Plan Description presented to this meeting, which form is hereby approved.
The undersigned further certifies that attached hereto are true copies of the
Health Reimbursement Arrangement Plan as amended and restated and the Summary Plan
Description approved and adopted in the foregoing resolutions.
This resolution shall take effect immediately upon passage.
Passed and adopted by action of the Governing Body of the Cyfy'pf Moab in open session this
14th day of November, 2017.
Bv:
ATTEST:
Rachel Stenta
City Recorder
David L. Sakrison
Mayor
Resolution #60-2017
ADOPTION AGREEMENT
HEALTH REIMBURSEMENT PLAN
The undersigned adopting employer hereby adopts this Plan. The Plan is intended to qualify as a health reimbursement
arrangement under Code sections 106 and 105. The Plan shall consist of this Adoption Agreement, its related Basic Plan
Document and any related Appendix and Addendum to the Adoption Agreement. Unless otherwise indicated, all Section
references are to Sections in the Basic Plan Document.
COMPANY INFORMATION
1. Name of adopting employer (Plan Sponsor): Moab City
2. Address: 217 E Center St.
3. City: Moab 4.State: Utah 5. Zip: 84532
6. Phone number: 435-259-2683 7. Fax number: 435-259-0600
8. Plan Sponsor EIN: 87-6000248
9. Plan Sponsor fiscal year end: 12/31
10a. Plan Sponsor entity type:
i. J C Corporation
ii. ] S Corporation
iii. ] Non Profit Organization
iv. ] Partnership
v. ] Limited Liability Company
vi. I Limited Liability Partnership
vii. I Sole Proprietorship
viii. I Union
ix. X I Government Agency
x. I Other:
10b. If 10a.viii (Union) is selected, enter name of the representative of the parties who established or maintain the Plan:
11. State of organization of Plan Sponsor: Utah
I2a. The Plan Sponsor is a member of an affiliated service group:
[ I Yes [XI No
12b. If 12a is "Yes", list all members of the group (other than the Plan Sponsor):
13a. The Plan Sponsor is a member of a controlled group:
1 I Yes I X I No
13b. If 13a is "Yes", list all members of the group (other than the Plan Sponsor):
PLAN INFORNATION
A. GENERAL INFORMATION.
1. Plan Number: 502
2. Plan name: a. Moab Citv
b. Active Emnlovee Exemnt Health Reimbursement Plan.
3. Effective Date:
3a. Original effective date of Plan: 01/01/2018
3b. Is this a restatement of a previously -adopted plan:
I X J Yes I I No
3c. IfA.3b is "Yes", effective date of Plan restatement: 01/01/2018.
NOTE: If A.3b is "No", the Effective Date shall be the date specified in A.3a, otherwise the date specified in A.3c:
provided, however, that when a provision of the Plan states another effective date. such stated specific effective date
shall apply as to that provision.
4a. Plan Year means each 12-consecutive month period ending on 12/31 (e.g. December 31). If the Plan Year changes,
any special provisions regarding a short Plan Year should be placed in the Addendum to the Adoption Agreement.
4b. The Plan has a short plan year:
I J Yes 1 X 1 No
4c. If A.4b is "Yes", the short plan year begins and ends on
5. Is the Plan Subject to ERISA?
I] Yes 1 X I No
B. ELIGIBILITY.
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Other Company Benefit Plan
1 a. An Employee is eligible to participate in the Plan under the same terms and conditions as under the Company benefit
plan(s) specified in B.lb:
i. I ] Yes - without limitation
ii. [ 1 Yes - with limitations and modifications described in B.1c
iii. I X ] No — Only Full Time employee who waive the employer sponsored group health plan but retain coverage
under an ACA compliant spousal/partner plan are eligible to participate.
lb. if B.1 a is not "No", enter name of other Company benefit plan(s):
lc. If B.la is " Yes - with limitations and modifications", describe limitations and/or modifications:
NOTE: If B.la is not "No", the remainder of Section B is disregarded.
Exclusions/Modifications
If B.la is "No", the term "Eligible Employee" shall not include (Check items B.2 - B.6a as appropriate):
2. I I Union. Any Employee who is included in a unit of Employees covered by a collective bargaining agreement, if
benefits were the subject of good faith bargaining, and if the collective bargaining agreement does not provide for
participation in this Plan.
3. I X J Any leased employee.
4. I X ] Non -Resident Alien. Any Employee who is a non-resident alien who received no earned income (within the
meaning of Code section 911(d)(2)) which constitutes income from services performed within the United States (within
the meaning of Code section 86I(a)(3)).
5. 1 X J Part-time. Any Employee who is expected to work less than 30 hours per week.
6a. 1 I Other. Other Employees described in B.6b.
6b. If B.la is "No", and B.6a is selected, describe other Employees excluded from definition of Eligible Employee:
NOTE: The Plan may not discriminate in favor of highly compensated employees (within the meaning of Code section
105(h)(5)) as to benefits provided or eligibility to participate.
7a. If B.la is "No", allow immediate participation for all Eligible Employees employed on the date specified in B.7b:
I I Yes I X I No
7b. If B.la is "No" and B.7a is "Yes". all Eligible Employees employed on shall become eligible to participate
in the Plan as of such date.
8a. If B.la is "No", indicate whether the Plan will make any other revisions to the term "Eligible Employee":
1 1 Yes 1 X I No
8b. If B.la is "No" and B.8a is "Yes", describe any further modifications to the term "Eligible Employee":
Service Requirements
10. If B.la is "No", minimum age requirement for an Eligible Employee to become eligible to be a Participant in the Plan:
None
11. If B.la is "No", minimum service requirement for an Eligible Employee to become eligible to be a Participant in the
Plan:
i. I X I None.
ii. I 1 Completion of hours of service.
iii. [ 1 Completion of days of service.
iv. [ 1 Completion of months of service.
v. [ 1 Completion of years of service.
12a. If B.la is "No", frequency of entry dates:
i. [ 1 An Eligible Employee shall become a Participant in the Plan as soon as administratively feasible upon
meeting the requirements of B.10 and B.I 1.
ii. I X I first day of each calendar month.
iii. I I first day of each plan quarter.
iv. [ I first day of the first month and seventh month of the Plan Year.
v. [ ] first day of the Plan Year.
12b. If B.la is "No" and B.12.a.i (immediate entry) is not selected, an Eligible Employee shall become a Participant in the
Plan on the entry date selected in B.l2a that is:
i. [ X 1 coincident with or next following
ii. I ] next following
the date the requirements of B.10 and B.11 are met.
13a. If B.la is "No", indicate whether the Plan will make any other revisions to the eligibility rules specified in B.10 - B.12:
IIYes 1XINo
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13b. 1f B.Ia is "No" and B.13a is "Yes", describe any further modifications to the eligibility rules specified in B.10 - B.12:
Former Employees
15a. Permit Eligible Employees to participate in the Plan after Termination (Section 3.03; See item C.10 to describe benefits
available to former employees):
i. I I Yes - all Eligible Employees are eligible to participate in the Plan after Termination.
ii. l 1 Yes - selected Eligible Employees are eligible to participate in the Plan after Termination.
iii. l X l No.
15b. If B.15a is "Yes - selected Eligible Employees are eligible to participate in the Plan after Termination'. describe the
Employees:
NOTE: The election in B.15 does not have an effect on COBRA coverage.
C. BENEFITS
Eligible Expenses
la. Coverage under the Plan for Covered Persons is available for the following Eligible Expenses (Section 4.01):
i. I X ] All allowable medical expenses. All medical expenses that are excludable from income under Code section
105(b).
ii. I I Listed medical expenses. All medical expenses that are listed on an appendix to the Adoption Agreement and
that are excludable from income under Code section 105(b).
iii. I I l•lealth plan deductibles. Only health plan deductible amounts that are otherwise payable by the Participant
under a Company -sponsored medical plan covering the Participant.
iv. I 1 Health plan coinsurance. Only health plan coinsurance amounts that are otherwise payable by the Participant
under a Company -sponsored medical plan covering the Participant.
v. [ I Health plan deductibles and coinsurance. Only health plan deductibles and coinsurance amounts that arc
otherwise payable by the Participant under a Company -sponsored medical plan covering the Participant.
vi. I I Schedule of expenses. A schedule of allowable medical expenses under a Company -sponsored medical
plan(s) (current or former) as provided in an appendix to the Adoption Agreement.
NOTE: If C.1a.vi. is selected, the terms listed in the schedule of expenses shall be defined as provided in the relevant
Company -sponsored medical plan.
Ib. Are there any other modifications to the definition of Eligible Expenses:
[ 1 Yes I X I No
1 c. If C.1 b is "Yes", describe modifications to the definition of Eligible Expenses:
NOTE: The modifications listed in C.l c may not be inconsistent with expenses that are excludable from income under
Code section 105(b).
Covered Person
2a. The definition of Covered Person under the Plan shall include the following persons:
i. I X I Participant, spouse and dependents. The Participant. his or her spouse and all dependents within the
meaning of Code section 152 as modified by Code section 105(b), and any child (as defined in section 152(f)(1))
of the Participant until his or her 26th birthday.
ii. l I Persons covered under Company medical plan. The Participant, his or her spouse and all dependents within
the meaning of Code section 152 as modified by Code section I 05(b), and any child (as defined in section
152(f)( I)) of the Participant until his or her 26th birthday, but only if such persons are also covered under the
Company -sponsored benefit plan specified in C.2b.
iii. [ 1 Participants Only. No spousal or dependent coverage.
iv. [ I Other. The persons described in C.2c.
NOTE: The Plan Administrator may extend coverage for children until the end of the calendar year in which a child
tums age 26.
2b. If C.2a is "Persons covered under Company medical plan', indicate the name of the Company -sponsored benefit plan:
NOTE: If i) the Plan constitutes a group health plan as defined in Treas. Reg. section 54.9801-2 or if the Plan
Administrator determines that the Plan is subject to FIIPAA portability rules, ii) the Plan is not a grandfathered health
plan under the Patient Protection and Affordable Care Act, and iii) children are covered undcr this Plan. all children up
to their 26th birthday must be covered.
2c. If C.2a is "Other", indicate the definition of Covered Person:
NOTE: The definition in C.2c may not include anyone other than the Participant, his or her spouse and all dependents
within the meaning of Code section 152 as modified by Code section 105(b). and any child (as defined in section
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152(f)(1)) of the Participant until his or her 26th birthday. If i) the Plan constitutes a group health plan as defined in
Treas. Reg. section 54.9801-2 or if the Plan Administrator determines that the Plan is subject to FIIPAA portability
rules, ii) the Plan is not a grandfathered health plan under the Patient Protection and Affordable Care Act, and iii)
children are covered under this Plan, all children up to their 26th birthday must be covered.
Health Reimbursement Account - Maximum Benefit
3a. If C.1a.vi is selected are the maximum annual amounts specified in the schedule of benefits?
I I Yes 1 1 No
NOTE: if the maximum annual amount credited to a Participant's Health Reimbursement Account depends on the
Company -sponsored benefit plan the Participant is enrolled in or the particular type of Eligible Expense, C.1a.vi
(schedule of expenses) should be selected and C.3a should be "Yes" (the maximum annual amounts entered in the
schedule of benefits apply to this Plan).
3b. Enter the maximum annual amount that will be credited to a Participant's Health Reimbursement Account in any Plan
Year for the applicable coverage category (Section 4.01):
i. One Covered Person (Participant only): Single Coverage - $6697.00 + S 1206.28 Wellness Incentive.
ii. Two Covered Persons (Participant plus one other Covered Person): Member + Spouse - $13,984.59 + S 2518.96
Wellness Incentive : Member + Child - S12.988.27 + S 2339.49 Wellness Incentive.
iii. More than two Covered Persons (Family coverage):.Familv - S20,347.25 + S S3665.03 Wellness Incentive.
NOTE: If the Plan only provides for a single coverage level for all Participants, enter that coverage level in C.3b.i.-
C.3b.iii.
NOTE: The maximum annual amount is determined after any deductibles and coinsurance are calculated. For example.
if the HRA pays the last $750 of a $1,000 plan deductible (after the Participant pays $250). C.3b.i should be "$750".
3c. FSA Failsafe. Limit the maximum annual benefit to 5 times the value of coverage and exclude long term care services:
I I Yes I X 1 No
NOTE: If C.3c is "Yes", the Plan is intended to be a flexible spending arrangement under Code section I06(c).
Qualified long term care services as defined in Code section 7702B(c) arc not an Eligible Expense under the plan and
the maximum amount of reimbursement available must be less than 5 times the value of such coverage.
Health Reimbursement Account - Deductible
4. Enter the annual Health Reimbursement Account deductible in any Plan Year for the applicable coverage category:
a. One Covered Person (Participant only): $0
b. Two Covered Persons (Participant plus one other Covered Person): $0
c. More than two Covered Persons (Family coverage): $0
NOTE: If the Plan only provides for a single deductible for all Participants. enter that coverage level in C.4a.- C.4c.
NOTE: If the Participants are also covered by a Company -sponsored medical plan, enter the deductible that applies to
this plan (the Health Reimbursement Plan), not the deductibles of the Company -sponsored plan. Any expenses covered
by a Company -sponsored plan are not an Eligible Expense under this Plan (Section 4.01(c)).
NOTE: If C.1 a.vi (schedule of benefits) is selected, enter 0 (zero) if no annual deductible applies before the schedule
of benefits is implemented.
NOTE: WO the Plan constitutes a group health plan as defined in Treas. Reg. section 54.9801-2 or if the Plan
Administrator determines that the Plan is subject to HIPAA portability rules and ii) the Plan is not a grandfathered
health plan under the Patient Protection and Affordable Care Act, then the Plan must provide coverage without cost -
sharing requirements for preventative care to the extent required under Treas. Reg. 54.9815-2713T (and any
superseding guidance; up to the amount available under a Participant's Health Reimbursement Account).
Health Reimbursement Account - Coinsurance
5. If C.1a.vi is not selected, once the HRA deductible is met (if any), indicate the level of coverage provided under the
HRA until the annual amount under C.3 is met: 100% (for example, "50% of coinsurance/copayment amounts" or
"100%ofEligible Expenses").
NOTE: If C.5 is left blank, once the HRA deductible is met (if any), the Plan will provide coverage for 100%of
Eligible Expenses until the annual amount under C.3 is met, unless otherwise provided in the Adoption Agreement.
NOTE: If i) the Plan constitutes a group health plan as defined in Treas. Reg. section 54.9801-2 or if the Plan
Administrator determines that the Plan is subject to HIPAA portability rules and ii) the Plan is not a grandfathered
health plan under the Patient Protection and Affordable Care Act, then the Plan must provide coverage without cost -
sharing requirements for preventative care to the extent required under Treas. Reg. 54.9815-2713T (and any
superseding guidance; up to the amount available under a Participant's Health Reimbursement Account).
Health Reimbursement Account - Procedures
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6a. The amounts in C.3 shall be credited to the Participant's Health Reimbursement Account at the following times:
i. [ X I Beginning of Plan Year. The entire amount shall be credited at the beginning of the Plan Year.
ii. I 1 Semi annually. One half of the amount shall be credited at the beginning of the Plan Year and on the first day
of the seventh month of the Plan Year.
I I Quarterly. One fourth of the amount shall be credited at the beginning of each plan quarter.
iv. [ ] Monthly. One twelfth of the amount shall be credited at the beginning of each calendar month during the Plan
Year.
v. [ J Per payroll period. Amounts are credited each payroll period in an amount equal to the entire amount divided
by the number of payroll periods.
vi. 1 ] Claims dependent. Accounts are credited and reimbursements are made as claims are made.
6b. If C.6a.vi is not selected and a Participant enters the Plan at a time other than the beginning of a period described in
C.6a, the amounts credited to the Participant's Health Reimbursement Account for such period shall be reduced to
reflect the time of actual participation in the applicable period:
1 X I Yes I 1 No
6c. l f C.6a.vi is not selected and if a change to the number of Covered Persons under C.2 affects the amount(s) credited to
the Health Reimbursement Account at times other than that selected in C.6a, contributions to the Participant's Health
Reimbursement Account will be prorated to accommodate the change:
I X 1 Yes [ I No - only future contributions affected
NOTE: if you select "Yes", this may result in a forfeiture from a Participant's Account, or, if amounts have been
credited from a Participant's Account in excess of prorated amounts, future contributions may be discontinued until the
correct contribution amount is attained.
7a. The Plan allows a carryover of the balance in a Participant's Health Reimbursement Account to the next Plan Year:
I 1 Yes.
ii. I 1 Yes - but limited to the dollar amount specified in C.7b.
iii. [ ] Yes - but limited to the multiple specified in C.7b of the maximum annual benefit specified in C.3.
iv. I X ] No.
7b. If C.7a is "Yes with limitations". enter the maximum dollar amount (or multiple of the maximum annual amount
specified in C.3) that may be carried over to the next Plan Year:
NOTE: Enter a percentage if C.7a.iii is selected and the multiple is less than I.
Coordination with Other Plans
8. Describe method to coordinate coverage in the Plan with a Health Care Reimbursement Account ("HCRA") in a
Company -sponsored cafeteria plan for expenses that are reimbursable under both this Plan and the cafeteria plan
(Section 6.01(e)):
i. [ X J None. Plan is not used in conjunction with a Company -sponsored HCRA.
ii. 1 1 HRA first. A Participant shall not be entitled to payment/reimbursement under the HCRA until the Participant
has received his or her maximum reimbursement under the Plan.
iii. I 1 Cafeteria plan first. A Participant shall not be entitled to payment/reimbursement under this Plan until the
Participant has received his or her maximum reimbursement under the HCRA.
9a. Describe method to coordinate coverage in the Plan with Health Savings Accounts (Section 6.01(j)):
i. [ X 1 None. Coverage in the Plan is not limited or the Plan is not used in conjunction with a Health Savings
Account.
ii. I 1 Permitted Coverage. Coverage in the Plan is only provided for permitted insurance and other specified
coverage (e.g., coverage for accidents, disability, dental care, vision care or preventive care within the meaning of
Code section 223(c)(I ). Rev. Rul. 2004-45 and Notice 2008-59).
iii. 1 ] Post Deductible Coverage. The Plan will not pay or reimburse any medical expense incurred before the
minimum annual deductible under Code section 223(c)(2)(A)(i) is satisfied pursuant to Notice 2008-59.
iv. I I Both Permitted and Post Deductible Coverage. Until the minimum annual deductible under Code section
223(c)(2)(A)(i) is satisfied. coverage in the Plan is only provided for permitted insurance and other specified
coverage (e.g., coverage for accidents, disability, dental care, vision care or preventive care within the meaning of
Code section 223(c)(1) and Rev. Rul. 2004-45). The Plan will pay or reimburse all medical expenses otherwise
allowed by the Plan incurred after the minimum annual deductible under Code section 223(c)(2)(A)(i) is satisfied.
v. I I Suspended HRA. A Participant may elect to forego coverage in the Plan except for permitted insurance and
other specified coverage (e.g., coverage for accidents, disability, dental care, vision care or preventive care within
the meaning of Code section 223(c)(I) and permitted by Rev. Rul. 2004-45).
9b. If C.9a is not "None", the limitations shall apply to:
i. [ 1 All Participants.
ii. I I Only Participants who are also eligible to participate in the high deductible health plan.
iii. I I Only Participants who are also enrolled in the high deductible health plan.
NOTE: If C.9a is "None" or C.9b is not "All Participants", eligibility for a Health Savings Account may be limited.
Copyright 2002-2017 E Benefits Administration 5
Former Employees
10a. IfB.15a is "Yes" (Eligible Employees may participate in the Plan after Termination). select what benefits the
Employees described in B.15 are eligible for after Termination:
i. I J Plan Year spend -down. Former employees may spend down the amount remaining in their Account through
the end of the Plan Year or 90 days after Termination, whichever is later.
ii. I J Other. As specified in C.IOb.
NOTE: If C.10a.i is selected, no new benefits will apply to Terminated participants. If you want to provide new
benefits for Terminated Participants or other spend -down periods, select C.10a.ii and indicate what benefits
Terminated Participants will receive and any restrictions on Eligible Expenses in C.10b.
10b. IfC.10a.ii is selected, describe any unique Plan features that apply to the Employees described in B.1S:
NOTE: The elections in C.10 will apply irrespective of whether employees are eligible for or elect COBRA coverage.
NOTE: Unless otherwise specified in C.10b, Eligible Expenses, benefits and other Plan provisions will apply in the
same manner to former employees as other Plan Participants.
D. PLAN OPERATIONS
Claims
1. Claims for reimbursement for an active Participant must be filed with the Plan Administrator (Section 6.01):
i. I X ] within 90 days following the last day of each Plan Year.
ii. I I by
2a. The Plan provides for an earlier deadline for claims submission for Terminated Participants:
[ I Yes I X I No
2b. If D.2a is Yes, claims for reimbursement for a Terminated Participant must be filed with the Plan Administrator
(Section 6.01):
i. I I within days following Termination of employment.
ii. I I by
3. Indicate whether the Company will provide debit, credit, and/or other stored -value cards (Section 6.01(i)):
[ X I Yes [ J No
Plan Administrator
4a. Designation of Plan Administrator (Section 7.01):
i. [ X I Plan Sponsor
ii. I I Committee appointed by Plan Sponsor
iii. I I Other
4b. If D.4a.iii is selected, Name of Plan Administrator:
5a. Type of indemnification for the Plan Administrator (Section 7.02):
i. [ I None - the Company will not indemnify the Plan Administrator.
ii. I X ] Standard as provided in Section 7.02.
iii. I I Custom.
5b. If D.Sa.iii (Custom) is selected, indemnification for the Plan Administrator is provided pursuant to an Addendum to the
Adoption Agreement.
State Law Rules
10a. IfA.5 is No (non-ERISA Plan), is the Plan subject to other state law rules?:
[ ] Yes [ X I No
10b. If A.5 is "No" (non-ERISA Plan) and D.10a is "Yes", enter any State law rules that apply to the Plan:
E. EFFECTIVE DATES
Use this Section to provide any effective dates for Plan provisions other than the Effective Date specified in A.3.
The Active Employee Exempt HRA plan is an exempt Health Reimbursement Plan available solely to active Full time
employee working 30 + hours a week employees who waive the Moab City Group Health Medical plan but are enrolled
in an ACA compatible plan via their spouse or domestic partner's group health plan.
The Employee will provide documentation of enrollment in said plan within 30 days after their effective date in The
Moab City Active Employee Exempt HRA plan. If the employee fails to provide proof either by a certificate of
coverage from the carrier or letter of coverage from the spouse/domestic partner's employer, then their enrollment in
Copyright 2002-2017 E Benefits Administration 6
the Active Employee Exempt 14RA plan will be terminated and no claims will be allowed to pay from the Active
Employee Exempt HRA plan for the employee until such proof is provided to the FIR Department of Moab City.
F. EXECUTION PAGE
Failure to properly fill out the Adoption Agreement may result in the failure of the Plan to achieve its intended tax consequences.
The Plan shall consist of this Adoption Agreement, its related Basic Plan Document #HRA and any related Appendix and
Addendum to the Adoption Agreement.
Additional participating employers may be specified in an addendum to the Adoption Agreement.
The undersigned agree to be bound by the terms of this Adoption Agreement and Basic Plan Document and acknowledge receipt
of same.
The Plan Sponsor caused this Plan to be executed this •46-
day of NO v-e44A-142v1— , 2017.
MOAB CITY:
Signature:
Print Name:
�4-�1%� >54,� rw
Title/Position:
Ci I
Copyright 2002-2017 E Benefits Administration 7
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INTEGRATION ADDENDUM
This addendum to the Plan is adopted to reflect "PAQs about Affordable Care Act Implementation Part Xl," IRS Notice
2013-54, the Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act (collectively, the
Affordable Care Act). This addendum is intended as good faith compliance with the requirements of the Affordable Care Act and
is to be construed in accordance with same. This addendum shall supersede the provisions of the Plan to the extent those
provisions are inconsistent with the provisions of this addendum and the Affordable Care Act.
NOTE: This addendum shall not mode the Plan with respect to former employees unless specifically noted below.
I. Other Company Group Health Plan —Spouse / Domestic Partner l Iealth Plan
a. The Company offers an ACA compliant group health plan: The Company -sponsored Group I lealth Plan does not
consist solely of excepted benefits.
b. Does the Company -sponsored Group Health Plan offer minimum value?
i. ] X I Yes, the Company -sponsored Group Health Plan provides minimum value.
ii. [ I No, the Company -sponsored Group Health Plan does not provide minimum value.
NOTE: "A/inimum value" means minimum vahte as defined in Code section 36B(c)(2)(C)(ii) and any superseding guidance
(generally means the Company -sponsored Group Health Plan covers at least 60% of total costs).
2. Eligible Employee and Enrollment
a. An Employee is eligible to participate in the Plan if enrolled in (choose one)
i. I 1 the Company -sponsored Group Health Plan
ii. 1 X 1 a group health plan that offers minimum value
iii. 1 1 a group health plan even if that plan does not offer minimum value
b. An Eligible Employee will enter the plan and become a Participant in this Plan at the same time as the Company -
sponsored Group Health Plan.
[ X ] The following modifications apply: The employee must provide proof of coverage in spousal/domestic partner
plan.
d. An Eligible Employee (or former employee) may opt out of the HRA during the same enrollment periods as the
Company -sponsored Group I lealth Plan (choose at least one)
i. [X 1 on an annual basis
ii. 1 1 permanently and waive all future reimbursements from the HRA
3. Eligible Expenses
Coverage under the Plan for Covered Persons is available for the following Eligible Expenses:
a. [ X I All allowable medical expenses. All medical expenses that are excludable from income under Code section
105(b).
b. I I Selected expenses. Choose one or more options below.
i. [ ] Health plan deductibles. Only health plan deductible amounts that are otherwise payable by the Participant
under a group health plan covering the Participant.
ii. [ 1 Health plan coinsurance. Only health plan coinsurance/copay amounts that are otherwise payable by the
Participant under a group health plan covering the Participant.
iii. I I Group health plan premiums
iv. [ 1 Non -pediatric dental benefits
v. [ ] Non -pediatric vision benefits
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SPD MODIFICATIONS FOR THE INTEGRATION ADDENDUM
Eligible Employee
You are an "Eligible Employee" if you are enrolled in another group health plan as long as that health plan provides
minimum value / or enrolled in another group health plan].
Date of Participation
You will become a Participant eligible to receive benefits from the Plan when enrollment in the Company health plan
would occur if you are enrolled in another group health plan. The following terms and conditions apply: You must provide
proof of coverage in the other group health plan to your HR Department within 30 days of enrollment.
Opt Out/Dis-enrollment
You may elect to opt out of Participation in this Plan on an annual basis. Any election to opt out must be returned to
the Plan Administrator by the date specified on the form.
if a change in group health plan coverage results in you no longer qualifying as an Eligible Employee for this Plan,
your participation in this plan will cease as of the effective date of such coverage change
Eligible Expenses
The Plan will reimburse all medical expenses for Covered Persons that are excludable from income under the federal
tax code / the following expenses]:
llealth plan deductibles. Only health plan deductible amounts that are otherwise payable by the Participant
under a group health plan covering the Participant.
* Health plan coinsurance. Only health plan coinsurance/copay amounts that are otherwise payable by the
Participant under a group health plan covering the Participant.
* Group health plan premiums
* Non -pediatric dental benefits
* Non -pediatric vision benefits
Dollar limits on reimbursements and other limitations on reimbursements described in the Summary Plan Description
continue to apply.
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Itloab City Active Employee HRA
SUMMARY OF MATERIAL MODIFICATIONS AND NOTICE
The purpose of this Summary of Material Modifications is to inform you of a change that has been made to the Moab
City Active Employee Exempt HRA plan.
This change has affected the information previously provided to you in the Plan's Summary Plan Description. The
Summary Plan Description is modified as described below.
You are entitled to receive reimbursement from your Moab City Active Employee Exempt HRA plan for Eligible
Expenses incurred by you, your spouse, or your dependents. A dependent is generally someone who you may claim as a
dependent on your federal tax return and also includes a child who is under the age of 27 through the end of the calendar year.
Eligible Expenses
Effective January Is' 2018, your Employer will contribute the following for expenses for medical care as defined by
Code section 213(d):
One Covered Person (Participant only):
Single Coverage - S6697.00 + S 1206.28 Wellness incentive if elected
Two Covered Persons (Participant plus one other Covered Person):
Member+ Spouse - S13,984.59 + S 2518.96 Wellness incentive if elected
Member+ Child - S12,988.27 + S 2339.49 Wellness incentive if elected.
More than two Covered Persons (Family coverage):
Family - S20,347.25 + S S3665.03 Wellness incentive if elected.
Proof of Coverage
You must submit proof that you have been enrolled in a health care plan that provides minimum essential coverage to
be eligible to participant in the Moab City Active Employee Exempt HRA plan. Proof of Coverage must be submitted to the Plan
Administrator by January 31a, 2018.
The Moab City Active Employee Exempt }IRA plan is not considered minimum essential coverage for purposes of the
ACA's individual mandate. Unless you are also enrolled in minimum essential coverage as defined by Code section 5000A(f),
you could be subject to the individual mandate tax and the amounts reimbursed under the Moab City Active Employee Exempt
HRA plan may be included in taxable income for any month you are not covered under minimum essential coverage.
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Copyright 2002-2017 E Benefits Administration 11
MOAB CITY ACTIVE EMPLOYEE EXEMPT HRA
PLAN HIGHLIGHTS
Effective date: Moab City (the "Company") established the Moab City Active Employee
exempt HRA (the "Plan") effective 01/01/2018. The following highlights
describe the Plan as amended and restated effective 01/01/2016.
Eligibility: The following employees are eligible for the Plan
Full time (30 hours or more per week) Employees who waive the
Moab City Group health plan and have coverage under a spouse/domestic
partner's Employer's Group Health Plan.
Enrollment
Periods:
Benefits
If you are an Eligible Employee, you may enter the Plan at any time specified
in the "Enrollment Periods" specified below.
On the first day of the calendar month coincident with or next following the
time you meet the eligibility criteria specified above.
Health Reimbursement Account. You will be entitled to receive
reimbursement from this account for Eligible Expenses incurred by you, your
spouse and dependents, if any (Covered Persons).
The annual limit on reimbursement is
One Covered Person (Participant only):
• Single Coverage - $6697.00 + $ 1,206.28 Wellness incentive.
Two Covered Persons (Participant plus one other Covered Person)
• Member + Spouse - $13,984.59 + $ 2,518.96 Wellness incentive:
Member + Child - $12,988.27 + $ 2,339.49 Wellness Incentive.
More than two Covered Persons (Family coverage):
• Family - $20,347.25 + $3,665.03 Wellness Incentive
The Plan will reimburse all medical expenses for Covered Persons that are
excludable from income under the federal tax code. The Plan will not
reimburse you for the cost of over the counter drugs unless such medicine or
drug is a prescribed drug (determined without regard to whether such drug is
available without a prescription) or is insulin.
Claims/deadlines: You must submit claims for reimbursement within 90 days after the end of the
Plan Year.
You will receive a Debit Card upon enrollment to use for out of pocket
medical expenses.
t
Copyright 2002-2017 E Benefits Administration
MOAB CITY ACTIVE EMPLOYEE EXEMPT HRA
PLAN HIGHLIGHTS
Any Manual Claims must be submitted to
E Benefits Administration
Mail: PO Box 190466, Boise, ID. 83719
email claims 'ri&wilelitsaClminsltation.com
Fax: 888-876-1058
Note: These plan highlights are intended to be a very concise overview of plan features. For a
detailed description of plan features, please review the Summary Plan Description or contact the
Plan Administrator for more information. The plan features described in these plan highlights are
subject to change and in the event of a discrepancy between the legal plan document and these
highlights (or any other summary of plan features), the Plan document shall control.
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Copyright 2002-2017 E Benefits Administration