HomeMy Public PortalAboutRES-CC-2014-06RESOLUTION #06-2014
A RESOLUTION AMENDING THE CITY OF MOAB HEALTH REIMBURSEMENT ACCOUNT (HRA)
PLAN
WHEREAS, the City of Moab has previously adopted an HRA Plan; and
WHEREAS, certain changes are now desirable to integrate the HRA Plan with the Affordable Care
Act (ACA);
NOW, THEREFORE, we, the Governing Body of the City of Moab do hereby amend the HRA Plan
as attached.
FURTHER, the effective date of this amendment is January 28, 2014.
Passed and adopted by action of the Governing Body of the City of Moab in open session this
28th day of January, 2014.
By:
C-P
ATTEST: �1Cu_
2.Q t,_
Rachel E. Stenta
City Recorder
David L. Sakrison
Mayor
Resolution #06-2014 January 28, 2014
MOAB CITY CORPORATION HRA PLAN
SUMMARY PLAN DESCRIPTION
Restated January 6, 2014
TABLE OF CONTENTS
I 4
ELIGIBILITY 4
1. What Are the Eligibility Requirements for Our Plan? 4
2. When is My Entry Date? 4
3. Are There Any Employees Who Are Not Eligible? 4
II 5
BENEFITS 5
1. What Benefits Are Available? 5
2. When Must Expenses Be Incurred? 5
3. When Will I Receive Payments From the Plan? 6
4. What Happens If I Terminate Employment, 6
5. Family and Medical Leave Act (FMLA) 6
6. Uniformed Services Employment and Reemployment Rights Act (USERRA) 6
7. Newborn and Mothers Health Protection Act 6
8. Women's Health and Cancer Rights Act- 7
9. Qualified Medical Child Support Order 7
III 7
GENERAL INFORMATION ABOUT OUR PLAN 7
1. General Plan Information 7
2. Employer Information 7
3. Plan Administrator Information 8
4. Third Party Claims Administrator Information 8
5. Service of Legal Process 8
6. Type of Administration 8
IV 8
ADDITIONAL PLAN INFORMATION 8
1. Your Rights Under ERISA 8
2. How to Submit a Claim 10
V 11
CONTINUATION COVERAGE RIGHTS UNDER COBRA 11
1. What is COBRA Continuation Coverage? 12
2. Who Can Become a Qualified Beneficiary? 12
3. What is a Qualifying Event? 13
4. What Factors Should Be Considered When Determining to Elect COBRA Continuation
Coverage? 14
5. What is the Procedure for Obtaining COBRA Continuation Coverage? 14
6. What is the Election Period and How Long Must It Last? 14
7. Is a Covered Employee or Qualified Beneficiary Responsible for Informing the Plan
Administrator of the Occurrence of a Qualifying Event? 15
8. Is a Waiver Before the End of the Election Period Effective to End a Qualified Beneficiary's
Election Rights? 16
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HRA SPD (01/14)
9. Is COBRA Coverage Available If a Qualified Beneficiary Has Other Group Health PIan
Coverage or Medicare? 16
10. When May a Qualified Beneficiary's COBRA Continuation Coverage Be Terminated? 17
11. What Are the Maximum Coverage Periods for COBRA Continuation Coverage? 18
12. Under What Circumstances Can the Maximum Coverage Period Be Expanded? 18
13. How Does a Qualified Beneficiary Become Entitled to a Disability Extension? 18
14. Does the Arrangement Require Payment for COBRA Continuation Coverage? 19
15. Must the Arrangement Allow Payment for COBRA Continuation Coverage to Be Made in
Monthly Installments? 19
16. What is Timely Payment for Payment for COBRA Continuation Coverage? 19
17. Must a Qualified Beneficiary Be Given the Right to Enroll in a Conversion Health Plan at the
End of the Maximum Coverage Period for COBRA Continuation Coverage? 19
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HRA SPD (01/14)
HEALTH REIMBURSEMENT ARRANGEMENT
INTRODUCTION
We are pleased to establish this Health Reimbursement Arrangement to provide you with additional
health coverage benefits. The benefits available under this Plan are outlined in this summary plan
description. We will also tell you about other important information concerning the Plan, such as the
rules you must satisfy before you become eligible and the laws that protect your rights.
Read this summary plan description carefully so that you understand the provisions of our Plan and the
benefits you will receive. You should direct any questions you have to the Administrator. There is a plan
document on file, which you may review if you desire. In the event there is a conflict between this
summary plan description and the plan document, the plan document will control.
I
ELIGIBILITY
1. What Are the Eligibility Requirements for Our Plan?
You will be eligible to join the Plan as of your date of employment with us; and upon providing a
signed statement that you are covered under an outside employer's group health plan (such as one
sponsored by the employer of your spouse).
2. When is My Entry Date?
Once you have met the eligibility requirements, your entry date will be the first day of the month
coinciding with or following the date you met the eligibility requirements.
3. Are There Any Employees Who Are Not Eligible?
Yes, there are certain employees who are excluded from participating in the Plan. They are:
-- Employees who are leased employees.
-- Employees who are part-time. A part-time employee is someone who works, or is expected to
work, less than 30 hours a week.
-- Certain non-resident aliens whose income is not considered income earned within the United
States under Federal tax laws.
4. Can I opt out of receiving any future benefit under the plan? A Participant under the Plan is
permitted to permanently opt out of and waive future reimbursements from the HRA at least
annually and upon termination of employment.
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HRA SPD (01/14)
II
BENEFITS
1. What Benefits Are Available?
The plan allows you to be reimbursed for certain out-of-pocket medical, dental and vision
expenses which are incurred by you and your dependerits. These would include drugs obtained
through a prescription. The expenses, which qualify, are those permitted by Section 213 of the
Internal Revenue Code. A list of some of the expenses that qualify is available from the
Administrator.
The plan also allows you to be reimbursed by the Employer for qualified insurance premiums,
which are incurred by you or your dependents. Insurance Premiums under a spouse's Employer
can qualify unless such coverage is currently reimbursed before tax under a Section 125 or
comparable benefit plan (including Dental and Vision Insurance).
The maximum Employer contribution allowed each year is:
Any Employee who opts -out of the Employer sponsored Group Health Insurance and is currently
enrolled in a Qualifying Health Plan shall receive the following annual amount:
(1) ($420.35/month) $5,044.18 per year per Participant;
(2) ($876.81/month) $10,521.70 per year Participant and Child;
(3) ($885.99/month) $10,631.85 per year per 2 Party; or
(4) ($1,281.69/month) $15,380.26 per Family.
We will provide you with a debit or credit card to use to pay for your medical expenses. The debit
card that is issued to be used in conjunction with the Plan cannot be used to purchase "over-the-
counter" drugs even with a prescription. "Over-the-counter" drugs prescribed to treat a medical
condition, can only be reimbursed if you have a prescription from a doctor and only by completing
a manual claim form and submitting a copy of the prescription with the form. The Administrator
will provide you with further details.
Expenses are considered "incurred" when the service is performed, not necessarily when it is paid
for. Any amounts reimbursed to you under the Plan may not be claimed as a deduction on your
personal income tax return nor reimbursed by other health plan coverage including our health
flexible spending account.
2. When Must Expenses Be Incurred?
You may submit expenses that you incur each "Coverage Period." A new "Coverage Period"
begins each January 1st and ends December 31st.
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HRA SPD (01/14)
3. When Will I Receive Payments From the Plan?
During the course of the Coverage Period, you may submit requests for reimbursement of
expenses you have incurred. However, you must make your requests for reimbursements no later
than 90 days after the end of the Coverage Period. The Administrator will provide you with
acceptable forms for submitting these requests for reimbursement. In addition, you must submit to
the Administrator proof of the expenses you have incurred and that they have not been paid by
any other health plan coverage. If the request qualifies as a benefit or expense that the Plan has
agreed to pay, you will receive a reimbursement payment soon thereafter. Remember,
reimbursements made from the Plan are generally not subject to federal income tax or withholding.
Nor are they subject to Social Security taxes.
4. What Happens If I Terminate Employment?
If your employment is terminated during the Plan Year for any reason, your participation in the
Plan will cease and any unused amounts are forfeited. Terminated Employees will have 60 days to
file claims for services through date of termination.
Your Plan is subject to COBRA, please see ARTICLE V.
5. Family and Medical Leave Act (FMLA)
If you take leave under the Family and Medical Leave Act, you remain entitled to coverage under
the Plan unless you permanently opt out of the coverage and waive future reimbursements to
become eligible for certain federal benefits under the Affordable Care Act.
6. Uniformed Services Employment and Reemployment Rights Act (USERRA)
If you are going into or returning from military service, you may have special rights to health care
coverage under the Plan under the Uniformed Services Employment and Reemployment Rights
Act of 1994. These rights can include extended health care coverage. If you may be affected by this
law, ask your Administrator for further details.
7. Newborn and Mothers Health Protection Act
Group health plans generally may not, under Federal law, restrict benefits for any hospital length
of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal
law generally does not prohibit the mother's or newborn's attending provider, after consulting with
the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case, plans and issuers may not, under Federal law, require that a provider
obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48
hours (or 96 hours).
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HRA SPD (01/14)
8. Women's Health and Cancer Rights Act:
This plan, as required by the Women's Health and Cancer Rights Act of 1998, will reimburse up to
plan limits for benefits for mastectomy -related services including reconstruction and surgery to
achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy
(including lymphedema). Contact your Plan Administrator for more information.
9. Qualified Medical Child Support Order
A medical child support order is a judgment, decree or order (including approval of a property
settlement) made under state law that provides for child support or health coverage for the child of
a participant. The child becomes an "alternate recipient" and can receive benefits under the health
plans of the Employer, if the order is determined to be "qualified." You may obtain, without
charge, a copy of the procedures governing the determination of qualified medical child support
orders from the Plan Administrator.
III
GENERAL INFORMATION ABOUT OUR PLAN
This Section contains certain general information, which you may need to know about the Plan.
1. General Plan Information
Moab City Corporatioin HRA Plan is the name of the Plan.
Your Employer has assigned Plan Number 502 to your Plan.
The provisions of your Plan become effective on January 1, 2014. The original effective date of the
Plan is September 1, 2010.
2. Employer Information
Your Employer's name, address, and identification number are:
Moab City Corporation
217 East Center Street Moab, UT 84532
87-6000248
The Plan allows other employers to adopt its provisions. You or your beneficiaries may examine or
obtain a complete list of employers, if any, who have adopted your Plan by making a written
request to the Administrator.
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HRA SPD (01/14)
3. Plan Administrator Information
The name, address and business telephone number of your Plan's Administrator are:
Moab City Corporation
217 East Center Street Moab, UT 84532
(435)259-2683
The Plan Administrator keeps the records for the Plan and is responsible for the administration of
the Plan. The Administrator will also answer any questions you may have about our Plan. The Plan
Administrator has the exclusive right to interpret the appropriate plan provisions. Decisions of the
Administrator are conclusive and binding. You may contact the Administrator for any further
information about the Plan.
4. Third Party Claims Administrator Information
The name, address and business telephone number of the Third Party Claims Administrator are:
National Benefit Services, LLC
P.O. Box 6980
West Jordan, UT 84084
(800)274-0503
The Third Party Claims Administrator is responsible for the actual processing of claims on behalf
of the Plan Administrator.
5. Service of Legal Process
The Employer is the Plan's agent for service of legal process.
6. Type of Administration
The Plan is a health reimbursement arrangement and the administration is provided through a
Third Party Claims Administrator. The Plan is not funded or insured. Benefits are paid from the
general assets of the Employer.
IV
ADDITIONAL PLAN INFORMATION
1. Your Rights Under ERISA
Plan Participants, eligible employees and all other employees of the Employer may be entitled to
certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA)
and the Internal Revenue Code. These laws provide that Participants, eligible employees and all
other employees are entitled to:
(1) Examine, without charge, at the Administrator's office, all Plan documents, including
insurance contracts, collective bargaining agreements, and a copy of the latest annual
report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor, and
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HRA SPD (01/14)
available at the Public Disclosure Room of the Employee Benefits Security
Administration.
(2) Obtain copies of all Plan documents and other Plan information upon written request
to the Administrator. The Administrator may charge a reasonable fee for the copies.
(3)
Continue health care coverage for a Plan Participant, Spouse, or other dependents if
there is a loss of coverage under the Plan as a result of a qualifying event. Employees
or dependents may have to pay for such coverage.
(4) Review this summary plan description and the documents governing the Plan on the
rules governing COBRA continuation coverage rights.
If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why
this was done, to obtain copies of documents relating to the decision without charge, and to appeal
any denial, all within certain time schedules.
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.
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 thirty (30) days, you may file suit in a
Federal court. In such a case, the court may request the 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.
In addition, if a Plan Participant disagrees with the Plan's decision or lack thereof concerning the
qualified status of a medical child support order, he or she may file suit in federal court.
In addition to creating rights for Plan Participants, ERISA imposes obligations upon the individuals
who are responsible for the operation of the Plan. The individuals who operate the Plan, called
"fiduciaries" of the Plan, have a duty to do so prudently and in the interest of the Plan Participants
and their beneficiaries. No one, including the Employer or any other person, may fire a Plan
Participant or otherwise discriminate against a Plan Participant in any way to prevent the Plan
Participant from obtaining benefits under the Plan or from exercising his or her rights under
ERISA.
If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated
against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or
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 is frivolous.
If you have any questions about the Plan, you should contact the Administrator. If you have any
questions about this statement, or about your rights under ERISA or the Health Insurance
Portability and Accountability Act (HIPAA), or if you need assistance in obtaining documents from
the Administrator, you should contact the nearest office of the Employee Benefits Security
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HRA SPD (01/14)
Administration, U.S. Department of Labor, listed in the telephone directory or the Division of
Technical Assistance and Inquiries, Pension and Welfare Benefits Administration, U.S. Department
of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210. You may also obtain certain
publications about your rights and responsibilities under ERISA by calling the publications hotline
of the Employee Benefits Security Administration.
2. How to Submit a Claim
When you have a Claim to submit for payment, you must:
(1) Obtain a claim form from the Plan Administrator.
(2)
(3)
Complete the Employee portion of the form.
Attach copies of all bills from the service provider for which you are requesting
reimbursement.
A Claim is defined as any request for a Plan benefit, made by a claimant or by a representative of a
claimant that complies with the Plan's reasonable procedure for making benefit Claims. The times
listed are maximum times only. A period of time begins at the time the Claim is filed. Decisions
will be made within a reasonable period of time appropriate to the circumstances. "Days" means
calendar days.
Notification of whether Claim is accepted or denied
Extension due to matters beyond the control of the Plan
Insufficient information on the Claim:
Notification of
Response by Participant
Review of Claim denial
30 days
15 days
15 days
45 days
60 days
The Plan Administrator will provide written or electronic notification of any Claim denial. The
notice will state:
(1) The specific reason or reasons for the denial.
(2) Reference to the specific Plan provisions on which the denial was based.
(3)
A description of any additional material or information necessary for the claimant to
perfect the Claim and an explanation of why such material or information is
necessary.
(4) A description of the Plan's review procedures and the time limits applicable to such
procedures. This will include a statement of your right to bring a civil action under
Section 502 of ERISA following a denial on review.
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HRA SPD (01/14)
(5)
A statement that the claimant is entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records, and other information
relevant to the Claim; and
(6) If the denial was based on an internal rule, guideline, protocol, or other similar
criterion, the specific rule, guideline, protocol, or criterion will be provided free of
charge. If this is not practical, a statement will be included that such a rule, guideline,
protocol, or criterion was relied upon in making the denial and a copy will be
provided free of charge to the claimant upon request.
When you receive a denial, you will have 180 days following receipt of the notification in which to
appeal the decision. You may submit written comments, documents, records, and other
information relating to the Claim. If you request, you will be provided, free of charge, reasonable
access to, and copies of, all documents, records, and other information relevant to the Claim.
The period of time within which a denial on review is required to be made will begin at the time an
appeal is filed in accordance with the procedures of the Plan. This timing is without regard to
whether all the necessary information accompanies the filing.
A document, record, or other information shall be considered relevant to a Claim if it:
(1) was relied upon in making the Claim determination;
(2) was submitted, considered, or generated in the course of making the Claim
determination, without regard to whether it was relied upon in making the Claim
determination;
(3)
demonstrated compliance with the administrative processes and safeguards
designed to ensure and to verify that Claim determinations are made in accordance
with Plan documents and Plan provisions have been applied consistently with
respect to all claimants;
(4) or constituted a statement of policy or guidance with respect to the Plan concerning
the denied Claim.
The review will take into account all comments, documents, records, and other information
submitted by the claimant relating to the Claim, without regard to whether such information was
submitted or considered in the initial Claim determination. The review will not afford deference to
the initial denial and will be conducted by a fiduciary of the Plan who is neither the individual who
made the adverse determination nor a subordinate of that individual.
V
CONTINUATION COVERAGE RIGHTS UNDER COBRA
Under federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), certain
employees and their families covered under this Arrangement will be entitled to the opportunity to elect
a temporary extension of health coverage (called "COBRA continuation coverage") where coverage
under the Arrangement would otherwise end. This notice is intended to inform Participants and
beneficiaries, in summary fashion, of their rights and obligations under the continuation coverage
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HRA SPD (01/14)
provisions of COBRA, as amended and reflected in final and proposed regulations published by the
Department of the Treasury. This notice is intended to reflect the law and does not grant or take away
any rights under the law.
The Plan Administrator or its designee is responsible for administering COBRA continuation coverage.
Complete instructions on COBRA, as well as election forms and other information, will be provided by
the Plan Administrator or its designee to Participants who become Qualified Beneficiaries under COBRA.
The Arrangement itself can provide group health benefits and may also be used to provide health
benefits through insurance. Whenever "Arrangement" is used in this section, it means any of the health
benefits under this Plan.
1. What is COBRA Continuation Coverage?
COBRA continuation coverage is the temporary extension of group health plan coverage that must
be offered to certain Participants and their eligible family members (called "Qualified
Beneficiaries") at group rates. The right to COBRA continuation coverage is triggered by the
occurrence of a life event that results in the loss of coverage under the terms of the Arrangement
(the "Qualifying Event"). The coverage must be identical to the coverage that the Qualified
Beneficiary had immediately before the Qualifying Event, or if the coverage has been changed, the
coverage must be identical to the coverage provided to similarly situated active employees who
have not experienced a Qualifying Event (in other words, similarly situated non -COBRA
beneficiaries).
2. Who Can Become a Qualified Beneficiary?
In general, a Qualified Beneficiary can be:
(1) Any individual who, on the day before a Qualifying Event, is covered under the
Arrangement by virtue of being on that day either a covered Employee, the Spouse of a
covered Employee, or a Dependent child of a covered Employee. If, however, an individual
who otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under
the Arrangement under circumstances in which the denial or failure to offer constitutes a
violation of applicable law, then the individual will be considered to have had the coverage
and will be considered a Qualified Beneficiary if that individual experiences a Qualifying
Event.
(2) Any child who is born to or placed for adoption with a covered Employee during a period of
COBRA continuation coverage, and any individual who is covered by the Arrangement as an
alternate recipient under a qualified medical support order. If, however, an individual who
otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under the
Arrangement under circumstances in which the denial or failure to offer constitutes a
violation of applicable law, then the individual will be considered to have had the coverage
and will be considered a Qualified Beneficiary if that individual experiences a Qualifying
Event.
The term "covered Employee" includes any individual who is provided coverage under the
Arrangement due to his or her performance of services for the employer sponsoring the
Arrangement. However, this provision does not establish eligibility of these individuals. Eligibility
for Plan coverage shall be determined in accordance with Plan Eligibility provisions.
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HRA SPD (01/14)
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is
attributable to a period in which the individual was a nonresident alien who received from the
individual's Employer no earned income that constituted income from sources within the United
States. If, on account of the preceding reason, an individual is not a Qualified Beneficiary, then a
Spouse or Dependent child of the individual will also not be considered a Qualified Beneficiary by
virtue of the relationship to the individual. A domestic partner is not a Qualified Beneficiary.
Each Qualified Beneficiary (including a child who is born to or placed for adoption with a covered
Employee during a period of COBRA continuation coverage) must be offered the opportunity to
make an independent election to receive COBRA continuation coverage.
3. What is a Qualifying Event?
A Qualifying Event is any of the following if the Arrangement provided that the participant would
lose coverage (i.e., cease to be covered under the same terms and conditions as in effect
immediately before the Qualifying Event) in the absence of COBRA continuation coverage:
(1) The death of a covered Employee.
(2) The termination (other than by reason of the Employee's gross misconduct), or reduction of
hours, of a covered Employee's employment.
(3)
The divorce or legal separation of a covered Employee from the Employee's Spouse. If the
Employee reduces or eliminates the Employee's Spouse's Plan coverage in anticipation of a
divorce or legal separation, and a divorce or legal separation later occurs, then the divorce or
legal separation may be considered a Qualifying Event even though the Spouse's coverage
was reduced or eliminated before the divorce or legal separation.
(4) A covered Employee's enrollment in any part of the Medicare program.
(5) A Dependent child's ceasing to satisfy the Arrangement's requirements for a Dependent
child (for example, attainment of the maximum age for dependency under the Arrangement).
If the Qualifying Event causes the covered Employee, or the covered Spouse or a Dependent child
of the covered Employee, to cease to be covered under the Arrangement under the same terms and
conditions as in effect immediately before the Qualifying Event (or in the case of the bankruptcy of
the Employer, any substantial elimination of coverage under the Arrangement occurring within 12
months before or after the date the bankruptcy proceeding commences), the persons losing such
coverage become Qualified Beneficiaries under COBRA if all the other conditions of COBRA are
also met. For example, any increase in contribution that must be paid by a covered Employee, or
the Spouse, or a Dependent child of the covered Employee, for coverage under the Arrangement
that results from the occurrence of one of the events listed above is a loss of coverage.
The taking of leave under the Family and Medical Leave Act of 1993 ("FMLA") does not
constitute a Qualifying Event. A Qualifying Event will occur, however, if an Employee does not
return to employment at the end of the FMLA leave and all other COBRA continuation coverage
conditions are present. If a Qualifying Event occurs, it occurs on the last day of FMLA leave and
the applicable maximum coverage period is measured from this date (unless coverage is lost at a
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HRA SPD (01/14)
later date and the Arrangement provides for the extension of the required periods, in which case
the maximum coverage date is measured from the date when the coverage is lost.) Note that the
covered Employee and family members will be entitled to COBRA continuation coverage even if
they failed to pay the employee portion of premiums for coverage under the Arrangement during
the FMLA leave.
4. What Factors Should Be Considered When Determining to Elect COBRA Continuation
Coverage?
You should take into account that a failure to continue your group health coverage will affect
your rights under federal law. First, you can lose the right to avoid having pre-existing condition
exclusions applied by other group health plans if there is more than a 63-day gap in health
coverage and election of COBRA continuation coverage may help you avoid such a gap. Second,
if you do not elect COBRA continuation coverage and pay the appropriate premiums for the
maximum time available to you, you will lose the right to convert to an individual health
insurance policy, which does not impose such pre-existing condition exclusions. Finally, you
should take into account that you have special enrollment rights under federal law (HIPAA). You
have the right to request special enrollment in another group health plan for which you are
otherwise eligible (such as a plan sponsored by your Spouse's employer) within 30 days after
Plan coverage ends due to a Qualifying Event listed above. You will also have the same special
right at the end of COBRA continuation coverage if you get COBRA continuation coverage for
the maximum time available to you.
5. What is the Procedure for Obtaining COBRA Continuation Coverage?
The Arrangement has conditioned the availability of COBRA continuation coverage upon the
timely election of such coverage. An election is timely if it is made during the election period.
6. What is the Election Period and How Long Must It Last?
The election period is the time period within which the Qualified Beneficiary must elect COBRA
continuation coverage under the Arrangement. The election period must begin not later than the
date the Qualified Beneficiary would lose coverage on account of the Qualifying Event and must
not end before the date that is 60 days after the later of the date the Qualified Beneficiary would
lose coverage on account of the Qualifying Event or the date notice is provided to the Qualified
Beneficiary of her or his right to elect COBRA continuation coverage.
Note: If a covered employee who has been terminated or experienced a reduction of hours qualifies
for a trade readjustment allowance or alternative trade adjustment assistance under a federal law
called the Trade Act of 2002, and the employee and his or her covered dependents have not elected
COBRA coverage within the normal election period, a second opportunity to elect COBRA
coverage will be made available for themselves and certain family members, but only within a
limited period of 60 days or less and only during the six months immediately after their group
health plan coverage ended. Any person who qualifies or thinks that he or she and/or his or her
family members may qualify for assistance under this special provision should contact the Plan
Administrator or its designee for further information.
The Trade Act of 2002 also created a new tax credit for certain TAA-eligible individuals and for
certain retired employees who are receiving pension payments from the Pension Benefit Guaranty
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HRA SPD (01/14)
Corporation (PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can
either take a tax credit or get advance payment of 65% of premiums paid for qualified health
insurance, including continuation coverage. If you have questions about these new tax provisions,
you may call the Health Coverage Tax Credit Consumer Contact Center toll -free at 1-866-628-4282.
TTD/TTY callers may call toll -free at 1-866-626-4282. More information about the Trade Act is also
available at www.doleta.gov/tradeact/2002act_index.asp.
7. Is a Covered Employee or Qualified Beneficiary Responsible for Informing the Plan
Administrator of the Occurrence of a Qualifying Event?
The Arrangement will offer COBRA continuation coverage to Qualified Beneficiaries only after the
Plan Administrator or its designee has been timely notified that a Qualifying Event has occurred.
The Employer will notify the Plan Administrator or its designee of the Qualifying Event within 30
days following the date coverage ends when the Qualifying Event is:
(1) the end of employment or reduction of hours of employment,
(2) death of the employee,
(3) commencement of a proceeding in bankruptcy with respect to the Employer, or
(4) enrollment of the employee in any part of Medicare,
IMPORTANT:
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 or someone on your behalf
must notify the Plan Administrator or its designee in writing within 60 days after the Qualifying
Event occurs, using the procedures specified below. If these procedures are not followed or if the
notice is not provided in writing to the Plan Administrator or its designee during the 60-day notice
period, any spouse or dependent child who loses coverage will not be offered the option to elect
continuation coverage. You must send this notice to the Plan Administrator or its designee.
NOTICE PROCEDURES:
Any notice that you provide must be in writing. Oral notice, including notice by telephone, is not acceptable.
You must mail, fax or hand -deliver your notice to the person, department or firm listed below, at the
following address:
Moab City Corporation
217 East Center Street
Moab, UT 84532
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HRA SPD (01/14)
If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice
you provide must state:
• the name of the plan or plans under which you lost or are losing coverage,
• the name and address of the employee covered under the plan,
• the name(s) and address(es) of the Qualified Beneficiary(ies), and
• the Qualifying Event and the date it happened.
If the Qualifying Event is a divorce or legal separation, your notice must include a copy of the divorce
decree or the legal separation agreement.
Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a
disability extension.
Once the Plan Administrator or its designee receives timely 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 for their spouses, and parents may elect COBRA continuation
coverage on behalf of their children. For each Qualified Beneficiary who elects COBRA continuation
coverage, COBRA continuation coverage will begin on the date that coverage would otherwise have
been lost (if under your coverage the COBRA period begins on the date of the Qualifying Event, even
though coverage actually ends later (e.g., at the end of the month) substitute the appropriate language,
e.g. "on the date of the Qualifying Event"). If you or your spouse or dependent children do not elect
continuation coverage within the 60-day election period described above, the right to elect continuation
coverage will be lost.
8. Is a Waiver Before the End of the Election Period Effective to End a Qualified Beneficiary's
Election Rights?
If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the
waiver can be revoked at any time before the end of the election period. Revocation of the waiver is
an election of COBRA continuation coverage. However, if a waiver is later revoked, coverage need
not be provided retroactively (that is, from the date of the loss of coverage until the waiver is
revoked). Waivers and revocations of waivers are considered made on the date they are sent to the
Plan Administrator or its designee, as applicable.
9. Is COBRA Coverage Available If a Qualified Beneficiary Has Other Group Health Plan
Coverage or Medicare?
Qualified Beneficiaries who are entitled to elect COBRA continuation coverage may do so even if
they are covered under another group health plan or are entitled to Medicare benefits on or before
the date on which COBRA is elected. However, a Qualified Beneficiary's COBRA coverage will
terminate automatically if, after electing COBRA, he or she becomes entitled to Medicare or
becomes covered under other group health plan coverage (but only after any applicable preexisting
condition exclusions of that other plan have been exhausted or satisfied).
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HRA SPD (01/14)
10. When May a Qualified Beneficiary's COBRA Continuation Coverage Be Terminated?
During the election period, a Qualified Beneficiary may waive COBRA continuation coverage.
Except for an interruption of coverage in connection with a waiver, COBRA continuation coverage
that has been elected for a Qualified Beneficiary must extend for at least the period beginning on
the date of the Qualifying Event and ending not before the earliest of the following dates:
(1) The last day of the applicable maximum coverage period.
(2) The first day for which Timely Payment is not made to the Arrangement with respect to the
Qualified Beneficiary.
(3) The date upon which the Employer ceases to provide any group health plan (including a
successor plan) to any employee.
(4) The date, after the date of the election, that the Qualified Beneficiary first becomes covered
under any other Plan that does not contain any exclusion or limitation with respect to any
pre-existing condition, other than such an exclusion or limitation that does not apply to, or is
satisfied by, the Qualified Beneficiary.
(5)
The date, after the date of the election that the Qualified Beneficiary first enrolls in the
Medicare program (either part A or part B, whichever occurs earlier).
(6) In the case of a Qualified Beneficiary entitled to a disability extension, the later of:
(a) (i) 29 months after the date of the Qualifying Event, or (ii) the first day of the month
that is more than 30 days after the date of a final determination under Title II or XVI
of the Social Security Act that the disabled Qualified Beneficiary whose disability
resulted in the Qualified Beneficiary's entitlement to the disability extension is no
longer disabled, whichever is earlier; or
(b) the end of the maximum coverage period that applies to the Qualified Beneficiary
without regard to the disability extension.
The Arrangement can terminate for cause the coverage of a Qualified Beneficiary on the same basis
that the Arrangement terminates for cause the coverage of similarly situated non -COBRA
beneficiaries, for example, for the submission of a fraudulent claim.
In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under
the Arrangement solely because of the individual's relationship to a Qualified Beneficiary, if the
Arrangement's obligation to make COBRA continuation coverage available to the Qualified
Beneficiary ceases, the Arrangement is not obligated to make coverage available to the individual
who is not a Qualified Beneficiary.
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HRA SPD (01/14)
11. What Are the Maximum Coverage Periods for COBRA Continuation Coverage?
The maximum coverage periods are based on the type of the Qualifying Event and the status of the
Qualified Beneficiary, as shown below.
(1) In the case of a Qualifying Event that is a termination of employment or reduction of hours of
employment, the maximum coverage period ends 18 months after the Qualifying Event if
there is not a disability extension and 29 months after the Qualifying Event if there is a
disability extension.
(2) In the case of a covered Employee's enrollment in the Medicare program before experiencing
a Qualifying Event that is a termination of employment or reduction of hours of
employment, the maximum coverage period for Qualified Beneficiaries other than the
covered Employee ends on the later of:
(3)
(a) 36 months after the date the covered Employee becomes enrolled in the Medicare
program; or
(b) 18 months (or 29 months, if there is a disability extension) after the date of the
covered Employee's termination of employment or reduction of hours of
employment.
In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a
covered Employee during a period of COBRA continuation coverage, the maximum coverage
period is the maximum coverage period applicable to the Qualifying Event giving rise to the
period of COBRA continuation coverage during which the child was born or placed for
adoption.
(4) In the case of any other Qualifying Event than that described above, the maximum coverage
period ends 36 months after the Qualifying Event.
12. Under What Circumstances Can the Maximum Coverage Period Be Expanded?
If a Qualifying Event that gives rise to an 18-month or 29-month maximum coverage period is
followed, within that 18- or 29-month period, by a second Qualifying Event that gives rise to a
36-months maximum coverage period, the original period is expanded to 36-months, but only for
individuals who are Qualified Beneficiaries at the time of and with respect to both Qualifying
Events. In no circumstance can the COBRA maximum coverage period be expanded to more than
36-months after the date of the first Qualifying Event. The Plan Administrator must be notified of
the second qualifying event within 60 days of the second qualifying event. This notice must be sent
to the Plan Administrator or its designee and in accordance with the procedures above.
13. How Does a Qualified Beneficiary Become Entitled to a Disability Extension?
A disability extension will be granted if an individual (whether or not the covered Employee) who
is a Qualified Beneficiary in connection with the Qualifying Event that is a termination or reduction
of hours of a covered Employee's employment, is determined under Title II or XVI of the Social
Security Act to have been disabled at any time during the first 60 days of COBRA continuation
coverage. To qualify for the disability extension, the Qualified Beneficiary must also provide the
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HRA SPD (01/14)
Plan Administrator with notice of the disability determination on a date that is both within 60 days
after the date of the determination and before the end of the original 18-month maximum coverage.
This notice must be sent to the Plan Administrator or its designee and in accordance with the
procedures above.
14. Does the Arrangement Require Payment for COBRA Continuation Coverage?
For any period of COBRA continuation coverage under the Arrangement, Qualified Beneficiaries
who elect COBRA continuation coverage may be required to pay up to 102% of the applicable
premium and up to 150% of the applicable premium for any expanded period of COBRA
continuation coverage covering a disabled Qualified Beneficiary due to a disability extension. Your
Plan Administrator will inform you of any costs. The Arrangement will terminate a Qualified
Beneficiary's COBRA continuation coverage as of the first day of any period for which timely
payment is not made.
15. Must the Arrangement Allow Payment for COBRA Continuation Coverage to Be Made in
Monthly Installments?
Yes. The health coverage is also permitted to allow for payment at other intervals.
16. What is Timely Payment for Payment for COBRA Continuation Coverage?
Timely Payment means a payment made no later than 30 days after the first day of the coverage
period. Payment that is made to the Arrangement by a later date is also considered Timely
Payment if either under the terms of the Arrangement, covered employees or Qualified
Beneficiaries are allowed until that later date to pay for their coverage for the period or under the
terms of an arrangement between the Employer and the entity that provides benefits on the
Employer's behalf, the Employer is allowed until that later date to pay for coverage of similarly
situated non -COBRA beneficiaries for the period.
Notwithstanding the above paragraph, the Arrangement does not require payment for any period
of COBRA continuation coverage for a Qualified Beneficiary earlier than 45 days after the date on
which the election of COBRA continuation coverage is made for that Qualified Beneficiary.
Payment is considered made on the date on which it is postmarked to those providing coverage.
If Timely Payment is made to the Arrangement in an amount that is not significantly less than the
amount the Arrangement requires to be paid for a period of coverage, then the amount paid will be
deemed to satisfy the Arrangement's requirement for the amount to be paid, unless the
Arrangement notifies the Qualified Beneficiary of the amount of the deficiency and grants a
reasonable period of time for payment of the deficiency to be made. A "reasonable period of time"
is 30 days after the notice is provided. A shortfall in a Timely Payment is not significant if it is no
greater than the lesser of $50 or 10% of the required amount.
17. Must a Qualified Beneficiary Be Given the Right to Enroll in a Conversion Health Plan at the
End of the Maximum Coverage Period for COBRA Continuation Coverage?
If a Qualified Beneficiary's COBRA continuation coverage under a group health plan ends as a
result of the expiration of the applicable. maximum coverage period, the Arrangement will, during
the 180 day period that ends on that expiration date, provide the Qualified Beneficiary with the
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HRA SPD (01/14)
option of enrolling under a conversion health plan if such an option is otherwise generally
available to similarly situated non -COBRA beneficiaries under the Arrangement. If such a
conversion option is not otherwise generally available, it need not be made available to Qualified
Beneficiaries.
IF YOU HAVE QUESTIONS
If you have questions about your COBRA continuation coverage, you should contact the Plan
Administrator or its designee. 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). Addresses and phone numbers of Regional and District EBSA Offices
are available through EBSA's Web site at www.dol.gov/ebsa.
KEEP YOUR PLAN ADMINISTRATOR 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 or its designee.
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HRA SPD (01/14)
MOAB CITY CORPORATION HRA PLAN
PLAN DOCUMENT
TABLE OF CONTENTS
ARTICLE I 4
DEFINITIONS 4
ARTICLE II 6
PARTICIPATION 6
2.1 Eligibility 6
2.2 Effective Date of Participation 6
2.3 Termination of Participation 7
2.4 Opt -out and Waiver 7
ARTICLE III 7
BENEFITS 7
3.1 Establishment of Plan 7
3.2 Nondiscrimination Requirements 8
3.3 Health Reimbursement Arrangement CIaims 8
3.4 Debit and Credit Cards 8
ARTICLE IV 9
ERISA PROVISIONS 9
4.1 Claim for Benefits 9
4.2 Named Fiduciary 11
4.3 General Fiduciary Responsibilities 11
4.4 Nonassignability of Rights 11
ARTICLE V 12
ADMINISTRATION 12
5.1 Plan Administration 12
5.2 Examination of Records 12
5.3 Indemnification of Administrator 12
ARTICLE VI 13
AMENDMENT OR TERMINATION OF PLAN 13
6.1 Amendment 13
6.2 Termination 13
ARTICLE VII 13
MISCELLANEOUS 13
7.1 Plan Interpretation 13
7.2 Gender and Number 13
7.3 Written Document 13
7.4 Exclusive Benefit 13
7.5 Participant's Rights 13
7.6 Action by the Employer 14
7.7 No Guarantee of Tax Consequences 14
7.8 Indemnification of Employer by Participants 14
7.9 Funding 14
7.10 Governing Law 14
7.11 Severability 14
7.12 Headings 14
7.13 Continuation of Coverage 15
7.14 Family and Medical Leave Act 15
7.15 Health Insurance Portability and Accountability Act 15
7.16 Uniformed Services Employment and Reemployment Rights Act 15
7.17 HIPAA Privacy Standards 15
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HRA Document (12/13)
7.18 HIPAA Electronic Security Standards 17
7.19 Mental Health Parity And Addiction Equity Act (USERRA) 19
7.20 Genetic Information Nondiscrimination Act (GINA) 19
7.21 Women's Health and Cancer Rights Act 19
7.22 Newborn's and Mothers' Health Protection Act 19
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HRA Document (12/13)
HEALTH REIMBURSEMENT ARRANGEMENT
As used in this Plan, the following words and phrases shall have the meanings set forth herein unless a
different meaning is clearly required by the context:
ARTICLE I
DEFINITIONS •
1.1 "Administrator" means the individual(s) or committee appointed by the Employer to carry out
the administration of the Plan. In the event the Administrator has not been appointed, or
resigns from a prior appointment, the Employer shall be deemed to be the Administrator.
1.2 "Affiliated Employer" means any corporation which is a member of a controlled group of
corporations (as defined in Code Section 414(b)) which includes the Employer; any trade or
business (whether or not incorporated) which is under common control (as defined in Code
Section 414(c)) with the Employer; any organization (whether or not incorporated) which is a
member of an affiliated service group (as defined in Code Section 414(m)) which includes the
Employer; and any other entity required to be aggregated with the Employer pursuant to
Treasury regulations under Code Section 414(o).
1.3 "Affordable Care Act" means the Patient Protection and Affordable Care Act, as amended by
the Health Care and Education Reconciliation Act of 2010, and as further amended by the
Department of Defense and Full -Year Continuing Appropriations Act, 2011.
1.4 "Code" means the Internal Revenue Code of 1986, as amended.
1.5 "Coverage Period" or "Plan Year" means the 12-month period commencing on January 1st and
ending on December 31"t
1.6 "Dependent" means any individual who qualifies as a dependent under Code Section 152 (as
modified by Code Section 105(b)). Any child of a Participant who is an "alternate recipient"
under a qualified medical child support order under ERISA Section 609 shall be considered a
Dependent under this Arrangement.
Notwithstanding anything in the Plan to the contrary, Qualifying Medical Expenses incurred
by a Participant's child prior to the end of the calendar year in which the child attains age 26
may be reimbursed under the Plan. A Participant's child includes his natural child, and
adopted child, or a child placed with the Employee for adoption. It may also include step
children and/or foster children if elected on the Adoption Agreement. A Participant's child will
be an eligible Dependent until reaching the limiting age of 26, without regard to student
status, marital status, financial dependency or residency status with the Employee or any other
person.
The phrase "placed for adoption" refers to a child whom the Employee intends to adopt,
whether or not the adoption has become final, who has not attained the age of 18 as of the date
of such placement for adoption. The term "placed" means the assumption and retention by
such Employee of a legal obligation for total or partial support of the child in anticipation of
adoption of the child. The child must be available for adoption and the legal process must
have commenced.
1.7 "Effective Date" of the Plan means September 1, 2010. The effective date of this amendment
and restatement is January 1, 2014.
1.8 "Eligible Employee" means any Eligible Employee as stated in Section 2.1 and as provided
herein. An individual shall not be an "Eligible Employee" if such individual is not reported on
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HRA Document (12/13)
the payroll records of the Employer as a common law employee. In particular, it is expressly
intended that individuals not treated as common law employees by the Employer on its
payroll records are not "Eligible Employees" and are excluded from Plan participation even if
a court or administrative agency determines that such individuals are common law employees
and not independent contractors. Furthermore, Employees of an Affiliated Employer will not
be treated as "Eligible Employees" prior to the date the Affiliated Employer adopts the Plan as
a Participating Employer.
However, a self-employed individual as defined under Code Section 401(c) or a 2-percent
shareholder as defined under Code Section 1372(b) shall not be eligible to participate in this
Plan.
1.9 "Employee" means any person who is employed by the Employer. The term "Employee" shall
also include any person who is an employee of an Affiliated Employer and any Leased
Employee deemed to be an Employee as provided in Code Section 414(n) or (o).
1.10 "Employer" means Moab City Corporation any successor which shall maintain this Plan and
any predecessor which has maintained this Plan. In addition, unless the context means
otherwise, the term "Employer" shall include any Participating Employer which shall adopt
this Plan.
1.11 "Employer Contribution" means the amounts contributed to the Plan by the Employer.
1.12 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended from time
to time.
1.13 "Leased Employee" means, effective with respect to Plan Years beginning on or after January
1, 1997, any person (other than an Employee of the recipient Employer) who, pursuant to an
agreement between the recipient Employer and any other person or entity ("leasing
organization"), has performed services for the recipient (or for the recipient and related
persons determined in accordance with Code Section 414(n)(6)) on a substantially full time
basis for a period of at least one year, and such services are performed under primary
direction or control by the recipient Employer. Contributions or benefits provided a Leased
Employee by the leasing organization which are attributable to services performed for the
recipient Employer shall be treated as provided by the recipient Employer. Furthermore,
Compensation for a Leased Employee shall only include Compensation from the leasing
organization that is attributable to services performed for the recipient Employer.
A Leased Employee shall not be considered an employee of the recipient Employer if: (a) such
employee is covered by a money purchase pension plan providing: (1) a nonintegrated
employer contribution rate of at least ten percent (10%) of compensation, as defined in Code
Section 415(c)(3), but for Plan Years beginning prior to January 1, 1998, including amounts
contributed pursuant to a salary reduction agreement which are excludable from the
employee's gross income under Code Sections 125, 402(e)(3), 402(h)(1)(B), 403(b), or for Plan
Years beginning on or after January 1, 2001 (or as of a date, no earlier than January 1, 1998, as
specified in Section 1.6 of the Plan),132(f)(4), (2) immediate participation, and (3) full and
immediate vesting; and (b) leased employees do not constitute more than twenty percent
(20%) of the recipient Employer's non -highly compensated workforce.
1.14 "Participant" means any Eligible Employee who has satisfied the requirements of Section 2.1
and has not for any reason become ineligible to participate further in the Plan.
1.15 "Plan" means Moab City Corporation HRA Plan as set forth herein adopted by the Employer,
including all amendments thereto. "Plan" means the "Health Reimbursement Arrangement."
1.16 "Premiums" mean the Participant's cost for any health plan coverage.
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HRA Document (12/13)
1.17 "Qualifying Health Plan" means coverage which does not consist solely of "excepted benefits"
as described in 26 C.F.R. § 54.9831-1(c)(3) which is a group health plan which is not sponsored
by the Employer which provides "minimum value" pursuant to Code section 36B(c)(2)(C)(ii)
for which the Plan has received an attestation signed by an Employee certifying coverage
under the group health plan.
1.18 "Qualifying Medical Expenses" means any expense eligible for reimbursement under the
Health Reimbursement Arrangement which would qualify as a "medical expense" (within the
meaning of Code Section 213(d) and as allowed under Code Section 105 and the rulings and
Treasury regulations thereunder) of the Participant, the Participant's spouse or a Dependent
and not otherwise used by the Participant as a deduction in determining the Participant's tax
liability under the Code or reimbursed under any other health coverage, including a health
Flexible Spending Account. Qualifying Medical Expenses covered by this Plan are limited to
all medical expenses within the meaning of Code Section 213 and qualifying insurance
premiums. A Participant may not be reimbursed for the cost of any medicine or drug that is
not "prescribed" as defined in Code Section 106(f). Furthermore, a Participant may not be
reimbursed for "qualified long-term care services" as defined in Code Section 7702B(c). If the
Employer provides Health Savings Accounts for Participants, Qualifying Medical Expenses
reimbursed shall be limited to those allowed under Code Section 223. "Incurred" means when
the Participant is provided with the medical care that gives rise to the Qualifying Medical
Expense and not when the Participant formally billed or charged for, or pays for, the medical
care.
ARTICLE II
PARTICIPATION
2.1 Eligibility
Any Eligible Employee will be eligible to participate in the Health Reimbursement
Arrangement upon satisfaction of the following: (a) Date of Hire (No service required); (b)
Employee is scheduled to work at least 30 hours per week; and (c) Employee opts -out of the
Employer sponsored Group Health Insurance but must currently be enrolled in a Qualifying
Health Plan. The following Employees are excluded: Non-resident aliens and Leased
Employees.
2.2 Effective Date of Participation
An Eligible Employee who has satisfied the conditions of eligibility pursuant to Section 2.1
shall become a Participant effective as of the first day of the month coinciding with or
following the date on which such requirements are satisfied.
If an Employee, who has satisfied the Plan's eligibility requirements and would otherwise
have become a Participant, shall go from a classification of a noneligible Employee to an
Eligible Employee, such Employee shall become a Participant on the date such Employee
becomes an Eligible Employee or, if later, the date that the Employee would have otherwise
entered the Plan had the Employee always been an Eligible Employee.
If an Employee, who has satisfied the Plan's eligibility requirements and would otherwise
become a Participant, shall go from a classification of an Eligible Employee to a noneligible
class of Employees, such Employee shall become a Participant in the Plan on the date such
Employee again becomes an Eligible Employee, or, if later, the date that the Employee would
have otherwise entered the Plan had the Employee always been an Eligible Employee.
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HRA Document (12/13)
2.3 Termination of Participation
This Section shall be applied and administered consistent with any rights a Participant and the
Participant's Dependents may be entitled to pursuant to Code Section 4980B, Section 7.13 of the
Plan. A former Participant has 60 days following termination of participation to file claims for
services performed prior to this date. In the case of the death of the Participant, any remaining
balances may only be paid out as reimbursements for Qualifying Medical Expenses and shall
not constitute a death benefit to the Participant's estate and/or the Participant's beneficiaries.
2.4 Opt -out and Waiver
A Participant under the Plan is permitted to permanently opt out of and waive future
reimbursements from the HRA at least annually and upon termination of employment.
ARTICLE III
BENEFITS
3.1 Establishment of Plan
(a) This Health Reimbursement Arrangement is intended to qualify as a Health
Reimbursement Arrangement under Code Section 105 and shall be interpreted in a
manner consistent with such Code Section and the Treasury regulations thereunder.
(b)
Beginning with the plan year which begins on or after January 1, 2014, to the extent that
this Health Reimbursement Arrangement ("HRA") does not constitute an "excepted
benefit" as described in 26 C.F.R. § 54.9831-1(c)(3)(v); or according to its terms may be
used to reimburse essential health benefits as defined in § 1302(b) of the Affordable Care
Act; this Plan is intended by the Employer to constitute an "integrated" HRA as that
term is used in the Affordable Care Act and regulatory guidance issued thereunder
("ACA").
(c) The Employer maintains a group health plan which does not consist solely of "excepted
benefits" as described in 26 C.F.R. § 54.9831-1(c)(3) which provides "minimum value"
pursuant to Code section 36B(c)(2)(C)(ii).
(d) The Employer does maintain a Health Flexible Spending Account and/or Cafeteria Plan.
Participants in this Health Reimbursement Arrangement may submit claims for the
reimbursement of Qualifying Medical Expenses for services that were incurred during
the Coverage Period. The HRA Plan will reimburse you in conjunction with the
Cafeteria Plan, if applicable. Separate accounts are held for the HRA and Cafeteria Plan.
The funds from the HRA and Cafeteria plan will not be co -mingled.
The Employer shall make available to each Participant an Employer Contribution for the
reimbursement of Qualifying Medical Expenses. The Employer shall contribute the following
annual amount:
Any Employee who opts -out of the Employer sponsored Group Health Insurance and is
currently enrolled in a Qualifying Health Plan shall receive the following annual amount:
(1) ($420.35/month) $5,044.18 per year per Participant;
(2) ($876.81/month) $10,521.70 per year Participant and Child;
(3) ($885.99/month) $10,631.85 per year per 2 Party; or
(4) ($1,281.69/month) $15,380.26 per Family.
No salary reductions may be made to this Health Reimbursement Arrangement.
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HRA Document (12/13)
(e) This Plan shall not be coordinated or otherwise connected to the Employer's cafeteria
plan (as defined in Code Section 125), except as permitted by the Code and the Treasury
regulations thereunder, to the extent necessary to maintain this Plan as a Health
Reimbursement Arrangement.
3.2 Nondiscrimination Requirements
(a) It is the intent of this Health Reimbursement Arrangement not to discriminate in
violation of the Code and the Treasury regulations thereunder.
(b)
If the Administrator deems it necessary to avoid discrimination under this Health
Reimbursement Arrangement, it may, but shall not be required to reduce benefits
provided to "highly compensated individuals" (as defined in Code Section 105(h)) in
order to assure compliance with this Section. Any act taken by the Administrator under
this Section shall be carried out in a uniform and nondiscriminatory manner.
3.3 Health Reimbursement Arrangement Claims
(a) The Administrator shall direct the reimbursement to each eligible Participant for all
Qualifying Medical Expenses. All Qualifying Medical Expenses eligible for
reimbursement pursuant to Section 3.1(b) shall be reimbursed during the Coverage
Period, even though the submission of such a claim occurs after his participation
hereunder ceases; but provided that the Qualifying Medical Expenses were incurred
during a Coverage Period. Claims must include receipts or documentation that the
expense being incurred is eligible for reimbursement, in order to claim reimbursement.
Expenses may be reimbursed up to 90 days after the end of the Coverage Period; and
Section 3.3(c) below. However, a Participant may not submit claims incurred prior to
beginning participation in the Plan and/or the Effective Date of the Plan, whichever is
earlier.
(b) Notwithstanding the foregoing, Qualifying Medical Expenses shall not be reimbursable
under this Plan if eligible for reimbursement and claimed under the Employer's Health
Flexible Spending Account or Health Savings Account, if applicable.
(c) Claims for the reimbursement of Qualifying Medical Expenses incurred in any Coverage
Period shall be paid as soon after a claim has been filed as is administratively practicable.
However, if a Participant fails to submit a claim within 90 days immediately following
the end of the Coverage Period, those Medical Expense claims shall not be considered for
reimbursement by the Administrator.
(d) Reimbursement payments under this Plan shall be made directly to the Participant.
(e) If the maximum amount available for reimbursement for a Coverage Period is not
utilized in its entirety, such remainder shall be forfeited.
3.4 Debit and Credit Cards
(a) Participants may, subject to a procedure established by the Administrator and
applied in a uniform nondiscriminatory manner, use debit and/or credit (stored value)
cards ("cards") provided by the Administrator and the Plan for payment of Qualifying
Medical Expenses, subject to the following terms:
(b) Each Participant issued a card shall certify that such card shall only be used for Medical
Expenses. The Participant shall also certify that any Medical Expense paid with the card
has not already been reimbursed by any other plan covering health benefits and that the
Participant will not seek reimbursement from any other plan covering health benefits.
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HRA Document (12/13)
(c) Such card shall be issued upon the Participant's Effective Date of Participation and
reissued for each Coverage Period the Participant remains a Participant in the Health
Reimbursement Arrangement. Such card shall be automatically cancelled upon the
Participant's death or termination of employment, or if such Participant withdraws from
the Health Reimbursement Arrangement.
(d) The maximum dollar amount of coverage available shall be the maximum amount for
the Plan Year as set forth in Section 3.1(c).
(e) The cards shall only be accepted by such merchants and service providers as have been
approved by the Administrator.
(0
(g)
The cards shall only be used for Medical Expense purchases at these providers,
including, but not limited to, the following:
(i) Co -payments for doctor and other medical care;
(ii) Purchase of prescription drugs;
(iii) Purchase of medical items such as eyeglasses, syringes, crutches, etc.
(iv) Effective January 1, 2011, "over-the-counter" drugs obtained under a
prescription to treat a medical condition may not be purchased with the
debit card that has been issued to be used in conjunction with the Plan.
A manual claim must be submitted and a copy of the prescription for the
"over-the-counter" medicine must be included with the claim in order
for it to be a reimbursable expense.
Such purchases by the cards shall be subject to substantiation by the Administrator,
usually by submission of a receipt from a merchant or service provider describing the
service or product, the date of the purchase and the amount. Some charges shall be
considered substantiated at the time of charge by the nature of the charge, such as co -
payments. Some charges shall be considered substantiated due to their "recurring"
nature, in which the expenses match expenses previously approved as to amount,
provider, and time period. At point of sale, the service provider or merchant can provide
information to the Administrator to substantiate the charge. All charges shall be
conditional pending confirmation and substantiation.
(h) If such purchase is later determined by the Administrator to not to be a Qualifying
Medical Expense, the Administrator, in its discretion, shall use the one of the following
correction methods to make the Plan whole. Until the amount is repaid, the
Administrator shall take further action to ensure that further violations of the terms of
the card do not occur, up to and including denial of access to the card.
(i) Repayment of the improper amount by the Participant;
(ii) Withholding the improper payment from the Participant's wages or
other compensation to the extent consistent with applicable federal or
state law;
(iii) Claims substitution or offset of future claims until the amount is repaid.
ARTICLE IV
ERISA PROVISIONS
4.1 Claim for Benefits
Any claim for Benefits shall be made to the Administrator. The following timetable for claims
and rules below apply:
9
HRA Document (12/13)
Notification of whether claim is accepted or denied 30 days
Extension due to matters beyond the control of the Plan 15 days
Insufficient information on the Claim:
Notification of 15 days
Response by Participant 45 days
Review of claim denial 60 days
The Administrator will provide written or electronic notification of any claim denial. The
notice will state:
(1) The specific reason or reasons for the denial.
(2) Reference to the specific Plan provisions on which the denial was based.
(3)
A description of any additional material or information necessary for the
claimant to perfect the claim and an explanation of why such material or
information is necessary.
(4) A description of the Plan's review procedures and the time limits applicable to
such procedures. This will include a statement of the right to bring a civil action
under section 502 of ERISA following a denial on review.
(5)
A statement that the claimant is entitled to receive, upon request and free of
charge reasonable access to, and copies of, all documents, records, and other
information relevant to the Claim.
(6) If the denial was based on an internal rule, guideline, protocol, or other similar
criterion, the specific rule, guideline, protocol, or criterion will be provided free
of charge. If this is not practical, a statement will be included that such a rule,
guideline, protocol, or criterion was relied upon in making the denial and a copy
will be provided free of charge to the claimant upon request.
When the Participant receives a denial, the Participant shall have 180 days following receipt of
the notification in which to appeal the decision. The Participant may submit written comments,
documents, records, and other information relating to the Claim. If the Participant requests, the
Participant shall be provided, free of charge, reasonable access to, and copies of, all documents,
records, and other information relevant to the Claim.
The period of time within which a denial on review is required to be made will begin at the
time an appeal is filed in accordance with the procedures of the Plan. This timing is without
regard to whether all the necessary information accompanies the filing.
A document, record, or other information shall be considered relevant to a Claim if it:
(1) was relied upon in making the claim determination;
(2) was submitted, considered, or generated in the course of making the claim
determination, without regard to whether it was relied upon in making the claim
determination;
10
HRA Document (12/13)
(3) demonstrated compliance with the administrative processes and safeguards
designed to ensure and to verify that claim determinations are made in
accordance with Plan documents and Plan provisions have been applied
consistently with respect to all claimants; or
(4) constituted a statement of policy or guidance with respect to the Plan concerning
the denied claim.
The review will take into account all comments, documents, records, and other information
submitted by the claimant relating to the Claim, without regard to whether such information
was submitted or considered in the initial claim determination. The review will not afford
deference to the initial denial and will be conducted by a fiduciary of the Plan who is neither
the individual who made the adverse determination nor a subordinate of that individual.
4.2 Named Fiduciary
The "named Fiduciaries" of this Plan are (1) the Employer and (2) the Administrator. The
named Fiduciaries shall have only those specific powers, duties, responsibilities, and
obligations as are specifically given them under the Plan including, but not limited to, any
agreement allocating or delegating their responsibilities, the terms of which are incorporated
herein by reference. In general, the Employer shall have the sole responsibility for providing
benefits under the Plan; and shall have the sole authority to appoint and remove the
Administrator; and to amend the provisions of the Plan or terminate, in whole or in part, the
Plan. The Administrator shall have the sole responsibility for the administration of the Plan,
which responsibility is specifically described in the Plan. Furthermore, each named Fiduciary
may rely upon any such direction, information or action of another named Fiduciary as being
proper under the Plan, and is not required under the Plan to inquire into the propriety of any
such direction, information or action. It is intended under the Plan that each named Fiduciary
shall be responsible for the proper exercise of its own powers, duties, responsibilities and
obligations under the Plan. Any person or group may serve in more than one Fiduciary
capacity.
4.3 General Fiduciary Responsibilities
The Administrator and any other fiduciary under ERISA shall discharge their duties with
respect to this Plan solely in the interest of the Participants and their beneficiaries and
(a) for the exclusive purpose of providing Benefits to Participants and their beneficiaries and
defraying reasonable expenses of administering the Plan;
(b) with the care, skill, prudence and diligence under the circumstances then prevailing that
a prudent man acting in like capacity and familiar with such matters would use in the
conduct of an enterprise of a like character and with like aims; and
(c) in accordance with the documents and instruments governing the Plan insofar as such
documents and instruments are consistent with ERISA.
4.4 Nonassignability of Rights
The right of any Participant to receive any reimbursement under the Plan shall not be alienable
by the Participant by assignment or any other method, and shall not be subject to the rights of
creditors, and any attempt to cause such right to be so subjected shall not be recognized, except
to such extent as may be required by law.
11
HRA Document (12/13)
ARTICLE V
ADMINISTRATION
5.1 Plan Administration
The operation of the Plan shall be under the supervision of the Administrator. It shall be a
principal duty of the Administrator to see that the Plan is carried out in accordance with its
terms, and for the exclusive benefit of Employees entitled to participate in the Plan. The
Administrator shall have full power to administer the Plan in all of its details, subject, however,
to the pertinent provisions of the Code. The Administrator's powers shall include, but shall not
be limited to the following authority, in addition to all other powers provided by this Plan:
(a) To make and enforce such rules and regulations as the Administrator deems necessary or
proper for the efficient administration of the Plan;
(b)
To interpret the Plan, the Administrator's interpretations thereof in good faith to be final
and conclusive on all persons claiming benefits under the Plan;
(c) To decide all questions conceming the Plan and the eligibility of any person to
participate in the Plan and to receive benefits provided under the Plan;
(d) To limit benefits for certain highly compensated individuals if it deems such to be
desirable in order to avoid discrimination under the Plan in violation of applicable
provisions of the Code;
(e) To approve reimbursement requests and to authorize the payment of benefits; and
(f) To appoint such agents, counsel, accountants, consultants, and actuaries as may be
required to assist in administering the Plan.
(g)
To establish and communicate procedures to determine whether a medical child support
order is qualified under ERISA Section 609.
Any procedure, discretionary act, interpretation or construction taken by the Administrator
shall be done in a nondiscriminatory manner based upon uniform principles consistently
applied and shall be consistent with the intent that the Plan shall continue to comply with the
terms of Code Section 105(h) and the Treasury regulations thereunder.
5.2 Examination of Records
The Administrator shall make available to each Participant, Eligible Employee and any other
Employee of the Employer such records as pertain to their interest under the Plan for
examination at reasonable times during normal business hours.
5.3 Indemnification of Administrator
The Employer agrees to indemnify and to defend to the fullest extent permitted by law any
Employee serving as the Administrator or as a member of a committee designated as
Administrator (including any Employee or former Employee who previously served as
Administrator or as a member of such committee) against all liabilities, damages, costs and
expenses (including attorney's fees and amounts paid in settlement of any claims approved by
the Employer) occasioned by any act or omission to act in connection with the Plan, if such act
or omission is in good faith.
12
HRA Document (12/13)
ARTICLE VI
AMENDMENT OR TERMINATION OF PLAN
6.1 Amendment
The Employer, at any time or from time to time, may amend any or all of the provisions of the
Plan without the consent of any Employee or Participant.
6.2 Termination
The Employer is establishing this Plan with the intent that it will be maintained for an
indefinite period of time. Notwithstanding the foregoing, the Employer reserves the right to
terminate the Plan, in whole or in part, at any time. In the event the Plan is terminated, no
further reimbursements shall be made.
ARTICLE VII
MISCELLANEOUS
7.1 Plan Interpretation
All provisions of this Plan shall be interpreted and applied in a uniform, nondiscriminatory
manner. This Plan shall be read in its entirety and not severed except as provided in Section
7.11.
7.2 Gender and Number
Wherever any words are used herein in the masculine, feminine or neuter gender, they shall be
construed as though they were also used in another gender in all cases where they would so
apply, and whenever any words are used herein in the singular or plural form, they shall be
construed as though they were also used in the other form in all cases where they would so
apply.
7.3 Written Document
This Plan, in conjunction with any separate written document which may be required by law, is
intended to satisfy the written Plan requirement of Code Section 105 and any Treasury
regulations thereunder.
7.4 Exclusive Benefit
This Plan shall be maintained for the exclusive benefit of the Employees who participate in the
Plan.
7.5 Participant's Rights
This Plan shall not be deemed to constitute an employment contract between the Employer and
any Participant or to be a consideration or an inducement for the employment of any
Participant or Employee. Nothing contained in this Plan shall be deemed to give any
Participant or Employee the right to be retained in the service of the Employer or to interfere
with the right of the Employer to discharge any Participant or Employee at any time regardless
of the effect which such discharge shall have upon him as a Participant of this Plan.
13
HRA Document (12/13)
7.6 Action by the Employer
Whenever the Employer under the terms of the Plan is permitted or required to do or perform
any act or matter or thing, it shall be done and performed by a person duly authorized by its
legally constituted authority.
7.7 No Guarantee of Tax Consequences
Neither the Administrator nor the Employer makes any commitment or guarantee that any
amounts paid to or for the benefit of a Participant under the Plan will be excludable from the
Participant's gross income for federal or state income tax purposes, or that any other federal or
state tax treatment will apply to or be available to any Participant. It shall be the obligation of
each Participant to determine whether each payment under the Plan is excludable from the
Participant's gross income for federal and state income tax purposes, and to notify the
Employer if the Participant has reason to believe that any such payment is not so excludable.
Notwithstanding the foregoing, the rights of Participants under this Plan shall be legally
enforceable.
7.8 Indemnification of Employer by Participants
If any Participant receives one or more payments or reimbursements under the Plan that are
not for a permitted Medical Expense such Participant shall indemnify and reimburse the
Employer for any liability it may incur for failure to withhold federal or state income tax or
Social Security tax from such payments or reimbursements. However, such indemnification
and reimbursement shall not exceed the amount of additional federal and state income tax
(plus any penalties) that the Participant would have owed if the payments or reimbursements
had been made to the Participant as regular cash compensation, plus the Participant's share of
any Social Security tax that would have been paid on such compensation, less any such
additional income and Social Security tax actually paid by the Participant.
7.9 Funding
Unless otherwise required by law, amounts made available by the Employer need not be placed
in trust, but may instead be considered general assets of the Employer. Furthermore, and unless
otherwise required by law, nothing herein shall be construed to require the Employer or the
Administrator to maintain any fund or segregate any amount for the benefit of any Participant,
and no Participant or other person shall have any claim against, right to, or security or other
interest in, any fund, account or asset of the Employer from which any payment under the Plan
may be made.
7.10 Governing Law
This Plan and Trust shall be construed and enforced according to the Code, ERISA, and the
laws of the state or commonwealth in which the Employer's principal office is located, other
than its laws respecting choice of law, to the extent not pre-empted by ERISA.
7.11 Severability
If any provision of the Plan is held invalid or unenforceable, its invalidity or unenforceability
shall not affect any other provisions of the Plan, and the Plan shall be construed and enforced
as if such provision had not been included herein.
7.12 Headings
The headings and subheadings of this Plan have been inserted for convenience of reference and
are to be ignored in any construction of the provisions hereof.
14
HRA Document (12/13)
7.13 Continuation of Coverage
Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan
subject to the continuation coverage requirement of Code Section 4980B becomes unavailable,
each qualified beneficiary (as defined in Code Section 4980B) will be entitled to continuation
coverage as prescribed in Code Section 4980B.
7.14 Family and Medical Leave Act
Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan
becomes subject to the requirements of the Family and Medical Leave Act and regulations
thereunder, this Plan shall be operated in accordance with Regulation 1.125-3.
7.15 Health Insurance Portability and Accountability Act
Notwithstanding anything in this Plan to the contrary, this Plan shall be operated in accordance
with HIPAA and regulations thereunder.
7.16 Uniformed Services Employment and Reemployment Rights Act
Notwithstanding any provision of this Plan to the contrary, contributions, benefits and service
credit with respect to qualified military service shall be provided in accordance with USERRA
and the regulations thereunder.
7.17 HIPAA Privacy Standards
(a) If this Plan is subject to the Standards for Privacy of Individually Identifiable Health
Information (45 CFR Part 164, the "Privacy Standards"), then this Section shall apply.
(b) The Plan shall not disclose Protected Health Information to any member of Employer's
workforce unless each of the conditions set out in this Section are met. "Protected Health
Information" shall have the same definition as set forth in the Privacy Standards but
generally shall mean individually identifiable information about the past, present or
future physical or mental health or condition of an individual, including information
about treatment or payment for treatment.
(c) Protected Health Information disclosed to members of Employer's workforce shall be
used or disclosed by them only for purposes of Plan administrative functions. The Plan's
administrative functions shall include all Plan payment functions and health care
operations. The terms "payment" and "health care operations" shall have the same
definitions as set out in the Privacy Standards, but the term "payment" generally shall
mean activities taken to determine or fulfill Plan responsibilities with respect to
eligibility, coverage, provision of benefits, or reimbursement for health care.
(d) The Plan shall disclose Protected Health Information only to members of the Employer's
workforce, who are authorized to receive such Protected Health Information, and only to
the extent and in the minimum amount necessary for that person to perform his or her
duties with respect to the Plan. "Members of the Employer's workforce" shall refer to all
employees and other persons under the control of the Employer. The Employer shall
keep an updated list of those authorized to receive Protected Health Information.
(1) An authorized member of the Employer's workforce who receives
Protected Health Information shall use or disclose the Protected Health
Information only to the extent necessary to perform his or her duties with
respect to the Plan.
15
HRA Document (12/13)
(2) In the event that any member of the Employer's workforce uses or
discloses Protected Health Information other than as permitted by this
Section and the Privacy Standards, the incident shall be reported to the
Plan's privacy officer. The privacy officer shall take appropriate action,
including:
(i)
investigation of the incident to determine whether the breach
occurred inadvertently, through negligence or deliberately;
whether there is a pattem of breaches; and the degree of harm
caused by the breach;
(ii) appropriate sanctions against the persons causing the breach
which, depending upon the nature of the breach, may include oral
or written reprimand, additional training, or termination of
employment;
(iii) mitigation of any harm caused by the breach, to the extent
practicable; and
(iv) documentation of the incident and all actions taken to resolve the
issue and mitigate any damages.
(e) The Employer must provide certification to the Plan that it agrees to:
(1) Not use or further disclose the information other than as permitted or
required by the Plan documents or as required by law;
(2) Ensure that any agent or subcontractor, to whom it provides Protected
Health Information received from the Plan, agrees to the same
restrictions and conditions that apply to the Employer with respect to such
information;
(3)
Not use or disclose Protected Health Information for employment -related
actions and decisions or in connection with any other benefit or employee
benefit plan of the Employer;
(4) Report to the Plan any use or disclosure of the Protected Health
Information of which it becomes aware that is inconsistent with the uses or
disclosures permitted by this Section, or required by law;
. (5)
Make available Protected Health Information to individual Plan members
in accordance with Section 164.524 of the Privacy Standards;
(6) Make available Protected Health Information for amendment by
individual Plan members and incorporate any amendments to Protected
Health Information in accordance with Section 164.526 of the Privacy
Standards;
(7)
Make available the Protected Health Information required to provide an
accounting of disclosures to individual Plan members in accordance with
Section 164.528 of the Privacy Standards;
(8) Make its internal practices, books and records relating to the use and
disclosure of Protected Health Information received from the Plan
available to the Department of Health and Human Services for purposes of
determining compliance by the Plan with the Privacy Standards;
16
HRA Document (12/13)
(9)
If feasible, return or destroy all Protected Health Information received
from the Plan that the Employer 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
(10) Ensure the adequate separation between the Plan and members of the
Employer's workforce, as required by Section 164.504(f)(2)(iii) of the
Privacy Standards and set out in (d) above.
7.18 HIPAA Electronic Security Standards
If this Plan is subject to the Security Standards for the Protection of Electronic Protected Health
Information (45 CFR Part 164.300 et. seq., the "Security Standards"), then this Section shall apply
as follows:
(a) The Employer agrees to implement reasonable and appropriate administrative, physical
and technical safeguards to protect the confidentiality, integrity and availability of
Electronic Protected Health Information that the Employer creates, maintains or transmits
on behalf of the Plan. "Electronic Protected Health Information" shall have the same
definition as set out in the Security Standards, but generally shall mean Protected Health
Information that is transmitted by or maintained in electronic media.
(b)
The Employer shall ensure that any agent or subcontractor to whom it provides Electronic
Protected Health Information shall agree, in writing, to implement reasonable and
appropriate security measures to protect the Electronic Protected Health Information.
(c) The Employer shall ensure that reasonable and appropriate security measures are
implemented to comply with the conditions and requirements set forth in Section 7.17.
(d) The Plan shall not disclose Protected Health Information to any member of Employer's
workforce unless each of the conditions set out in this Section are met. "Protected Health
Information" shall have the same definition as set forth in the Privacy Standards but
generally shall mean individually identifiable information about the past, present or
future physical or mental health or condition of an individual, including information
about treatment or payment for treatment.
(e) Protected Health Information disclosed to members of Employer's workforce shall be
used or disclosed by them only for purposes of Plan administrative functions. The Plan's
administrative functions shall include all Plan payment functions and health care
operations. The terms "payment" and "health care operations" shall have the same
definitions as set out in the Privacy Standards, but the term "payment" generally shall
mean activities taken to determine or fulfill Plan responsibilities with respect to
eligibility, coverage, provision of benefits, or reimbursement for health care.
(0
The Plan shall disclose Protected Health Information only to members of the Employer's
workforce, who are authorized to receive such Protected Health Information, and only to
the extent and in the minimum amount necessary for that person to perform his or her
duties with respect to the Plan. "Members of the Employer's workforce" shall refer to all
employees and other persons under the control of the Employer. The Employer shall
keep an updated list of those authorized to receive Protected Health Information.
(1) An authorized member of the Employer's workforce who receives
Protected Health Information shall use or disclose the Protected Health
17
HRA Document (12/13)
(g)
Information only to the extent necessary to perform his or her duties with
respect to the Plan.
(2) In the event that any member of the Employer's workforce uses or
discloses Protected Health Information other than as permitted by this
Section and the Privacy Standards, the incident shall be reported to the
Plan's privacy officer. The privacy officer shall take appropriate action,
including:
(i)
investigation of the incident to determine whether the breach
occurred inadvertently, through negligence or deliberately;
whether there is a pattern of breaches; and the degree of harm
caused by the breach;
(ii) appropriate sanctions against the persons causing the breach
which, depending upon the nature of the breach, may include oral
or written reprimand, additional training, or termination of
employment;
(iii) mitigation of any harm caused by the breach, to the extent
practicable; and
(iv) documentation of the incident and all actions taken to resolve the
issue and mitigate any damages.
The Employer must provide certification to the Plan that it agrees to:
(1) Not use or further disclose the information other than as permitted or
required by the Plan documents or as required by law;
(2) Ensure that any agent or subcontractor, to whom it provides Protected
Health Information received from the Plan, agrees to the same
restrictions and conditions that apply to the Employer with respect to such
information;
(3)
Not use or disclose Protected Health Information for employment -related
actions and decisions or in connection with any other benefit or employee
benefit plan of the Employer;
(4) Report to the Plan any use or disclosure of the Protected Health
Information of which it becomes aware that is inconsistent with the uses or
disclosures permitted by this Section, or required by law;
(5) Make available Protected Health Information to individual Plan members
in accordance with Section 164.524 of the Privacy Standards;
(6) Make available Protected Health Information for amendment by
individual Plan members and incorporate any amendments to Protected
Health Information in accordance with Section 164.526 of the Privacy
Standards;
(7)
Make available the Protected Health Information required to provide an
accounting of disclosures to individual Plan members in accordance with
Section 164.528 of the Privacy Standards;
18
HRA Document (12/13)
a'I..�.�. ti��
CERTIFICATE OF CORPORATE RESOLUTION
The undersigned Authorized signer of Moab City Corporation (the Corporation) hereby certifies
that the following resolutions were duly adopted by the Employer on 3av, • 243, ao N , and that
such resolutions have not been modified or rescinded as of the date hereof:
RESOLVED, that the form of amended Health Reimbursement Arrangement effective January 1,
2014, 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, 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.
Moab
Empl
Corporation
�r
Authorized Signer
Date:
l'a8- I Lt
fir: et t - Eco,2.r��-ram
21
HRA Document (12/13)
(8)
(9)
Make its internal practices, books and records relating to the use and
disclosure of Protected Health Information received from the Plan
available to the Department of Health and Human Services for purposes of
determining compliance by the Plan with the Privacy Standards;
If feasible, return or destroy all Protected Health Information received
from the Plan that the Employer 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
(10) Ensure the adequate separation between the Plan and members of the
Employer's workforce, as required by Section 164.504(f)(2)(iii) of the
Privacy Standards and set out in (d) above.
7.19 Mental Health Parity And Addiction Equity Act (USERRA)
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Mental Health Parity and Addition Equity Act and ERISA Section 712.
7.20 Genetic reformation Nondiscrimination Act (GINA)
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Genetic Information Nondiscrimination Act.
7.21 Women's Health and Cancer Rights Act
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Women's Health and Cancer Rights Act of 1998.
7.22 Newborn's and Mothers' Health Protection Act
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Newborns' and Mothers' Health Protection Act.
19
HRA Document (12/13)
IN WITNESS WHEREOF, this HRA Plan document is hereby executed this U� day of
"SanIu4,‘3 a o I �.
20
Moab City Corporation
By
/Yt
Title:
Date: (o ' I I
HRA Document (12/13)
NATIONAL BENEFIT S RVICES, LLC
Customer Care • Knowledge and Expertise Organizational Excellence
January 6, 2014
Rachel Stenta
Moab City Corporation
217 East Center Street
Moab, UT 84532
RE: Restatement of Plan Document to add Affordable Care Act Requirements
Dear Rachel Stenta,
We have completed a Plan restatement to keep your documents in compliance. This restatement updates
the document to include the provisions of the Affordable Care Act that affect HRA Plans in 2014.
Attached are the following:
1. The Highlight Page: This document gives a general description of the plan and should be
copied and distributed to all Participants in the Plan.
2. The Plan Document: Please print, sign and return a copy of the last two pages to National
Benefit Services, LLC by January 20, 2014(fax to (801) 823-2207 or mail is acceptable).
3. Summary Plan Description: An updated Summary Plan Description has been provided. This
should be copied and distributed to all Participants in the Plan.
If you have any questions regarding these forms or if we may be of further assistance please feel free to
call Steve Sandal! at (801) 532-4000 ext. 152 or toll free (800) 274-0503.
Cordially,
Sheri Angell
Document Specialist
Enclosures
8523 S. Redwood Road, West Jordan, UT 84088 • (801) 532-4000, (800) 274-0503 • www.NBSbeuefits.com