HomeMy Public PortalAboutRES-CC-2014-29RESOLUTION #29-2014
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;
NOW, THEREFORE, we, the Governing Body of the City of Moab do herby amend the HRA Plan in
the following particulars only:
FURTHER, the effective date of this amendment is June 1, 2014.
ARTICLE III BENEFITS — SECTION 3.1 ESTABLISHMENT OF PLAN (c) is amended to read as follows:
SECTION 3.1:
Benefit. Section 3.1(e) has been amended to read:
The Employer shall make available to each Participant an Employer Contribution for the
reimbursement of Qualifying Medical Expenses. The Employer shall contribute a discretionary
amount reviewed semi-annually for any Employee who opts -out of the Employer sponsored
Group Health Insurance and is currently enrolled in a Qualifying Health Plan.
Passed and adopted by action of the Governing Body of the City of Moab in open session this
loth day of June, 2014.
ATTEST:
Rachel E.-Stent6
City Recor-d�r
Resolution #29-2014
BY:
David L. Sakrison
Mayor
June 10, 2014
HEALTH REIMBURSEMENT ARRANGEMENT
MOAB CITY CORPORATION
SUMMARY PLAN DESCRIPTION
Updated June 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? 5
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. Newborns' and Mothers' Health Protection Act 6
8. Qualified Medical Child Support Order 6
III 7
GENERAL INFORMATION ABOUT OUR PLAN 7
1. General Plan Information 7
2. Employer Information 7
3. Plan Administrator Information 7
4. Third Party Claims Administrator Information 7
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 9
V 11
CONTINUATION COVERAGE RIGHTS UNDER COBRA 11
1. What is COBRA Continuation Coverage? 11
2. Who Can Become a Qualified Beneficiary? 12
3. What is a Qualifying Event? 12
4. What Factors Should Be Considered When Determining to Elect COBRA Continuation
Coverage? 13
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? 14
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 Plan
Coverage or Medicare? 16
10. When May a Qualified Beneficiary's COBRA Continuation Coverage Be Terminated? 16
11. What Are the Maximum Coverage Periods for COBRA Continuation Coverage? 17
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? 18
15. Must the Arrangement Allow Payment for COBRA Continuation Coverage to Be Made in
Monthly Installments? 18
16. What is Timely Payment for Payment for COBRA Continuation Coverage? 18
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 dependents. 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 Employer shall make available to each Participant an Employer Contribution for the
reimbursement of Qualifying Medical Expenses. The Employer shall contribute a discretionary
amount reviewed semi-annually for any Employee who opts -out of the Employer sponsored
Group Health Insurance and is currently enrolled in a Qualifying Health Plan.
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.
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.
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HRA SPD (01/14)
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. Newborns' 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).
8. 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.
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HRA SPD (01/14)
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 Corporation 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 June 1, 2014. The original effective date of the
Plan is September 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.
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
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HRA SPD (01/14)
(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
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.
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HRA SPD (01/14)
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
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
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HRA SPD (01/14)
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.
(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.
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HRA SPD (01/14)
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
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?
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HRA SPD (01/14)
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.
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?
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HRA SPD (01/14)
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
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. (These
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HRA SPD (01/14)
pre-existing condition exclusions will only apply during Plan Years that begin before January 1,
2014.) 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
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.
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HRA SPD (01/14)
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
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 Qualifi ed
Beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees
15
HRA 5PD (01/14)
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).
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.
16
HRA SPD (01/14)
(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.
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
17
HRA SPD (01/14)
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
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
18
HRA SPD (01/14)
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
Employers 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
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.
19
HRA SPD (01/14)
HRA PLAN
Moab City Corporation
HIGHLIGHTS
Moab City Corporation has established a
"HRA Plan" to help you pay for your out-of-
pocket medical expenses. If you received a
reimbursement for an expense under the
Plan, you cannot claim a Federal income tax
credit or deduction on your return.
GENERAL PLAN INFORMATION
Plan Name:
Moab City Corporation HRA Plan
Address: 217 East Center Street
Moab, UT 84532
Telephone: (435)259-2683
Tax I.D. Number: 87-6000248
Plan Number: 502
Plan Effective Date- 9/1/2010
Amended- 6/1/2014
Coverage Period End- December 31st
Plan Administrator:
Moab City Corporation
Company Contact: Rachel Stenta
QUALIFIED EXPENSES
The plan allows you to be reimbursed for
certain out-of-pocket medical, dental and
vision expenses which are incurred by you
and your dependents. 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).
ELIGIBILITY
If you work 30 hours or more each week for
the company, 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).
You will enter the Plan on the first day of
the month following your date of
employment.
BENEFIT
The Employer shall make available to each
Participant an Employer Contribution for
the reimbursement of Qualifying Medical
Expenses. The Employer shall contribute a
discretionary amount reviewed semi-
annually for any Employee who opts -out of
the Employer sponsored Group Health
Insurance and is currently enrolled in a
Qualifying Health Plan.
BENEFITS PAYMENT
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.
Expenses are considered "incurred" when
the service is performed, not necessarily
when it is paid for. You can get a claim form
at www.nbsbenefits.com for
reimbursement.
Any monies left at the end of the Coverage
Period will be forfeited. You must submit
claims no later than 90 days after the end of
the Coverage Period.
HIGHLY COMPENSATED & KEY
EMPLOYEES
Under the Internal Revenue Code, "highly
compensated employees" and "key
employees" generally are Participants who
are officers, shareholders or highly paid.
If you are within these categories, the
amount of contributions and benefits for you
may be limited so that the Plan as a whole
does not unfairly favor those who are highly
paid, their spouses or their dependents.
Please refer to your Summary Plan
Description for more information. You will
be notified of these limitations if you are
affected.
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 of 1993
and regulations thereunder, this Plan shall be
operated in accordance with proposed
Regulation 1.125-3.
ADDITIONAL PLAN INFORMATION
As a participant in the Plan, you are entitled
to certain rights and protections under the
Employee Retirements Income Security Act
of 1974 (ERISA). Please refer to your
Summary Plan Description for more
information on your ERISA rights.
Updated June 6, 2014
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NATIONAL BENEFIT SERVICES, LLC
(801) 532-4000 - Salt Lake City, UT