HomeMy Public PortalAboutORD11521 W 00
BILL NO. 90-133
SPONSORED BY COUNCILMAN SCHEULE14
ORDINANCE NO
AN ORDINANCE OF THE CITY OF JEFFERSON, MISSOURI RATIFYING THE
FLEXIBLE BENEFITS P LAN, ADDING A COVERED ITEM AND APPROVING
INSURANCE INVOLV ED IN THE PLAN.
Benefits Plan
r• ,gig WHEREAS, The city has previously adopted a
(hereinafter the "Plan") under the provisions of Section 125 of the
Internal Revenue Code of 1954 ; and
WHEREAS, Certain amendments to the Plan have been implemented from
time to time; and
ntire plan as it
WHEREAS, It is appropriate to place on record the e
currently ex ists; and
o been
WHEREAS, An added eligible charge for mammography has requested by employees extra ;cause a need for
will not
which
funding; and
WHEREAS, Insuran ce coverages and premiums need to be put in place.
NOW, THEREFORE, BE IT ENACTED BY THE COUNCIL OF THE CITY OF
JEFFERSON, MISSOURI, AS FOLLOWS:
Section 1. The Plan a ttached hereto as Exhibit 1 is hereby
ratified and adopted as the city's Flexible Benefits Plan.
Section 2 . The following provisions concerning mammography
shall be added to the Major Medical Benefits of the City Of
Jefferson Employee Health Care Plan as eligible charges:
Charges fo r low-dose mammography screening (x
-ray examination
of the breast using equipment specifically designed and
dedicated for mammography, ray tube, filter,
hy, including the x
,?4�k compression device, films, and cassettes, with an average
AW. radiation exposure delivery of less than one rad mid-breast,
fee charged by a
each breast) and any f
with two views for
radiologist or other physician f interpreting or
or reading,
diagnosing based on such x-ray.
Eligible charges for low-dose mammography screening shall
be limited to the following fre quency limitations:
A baseline mammogram for covered
women age thirty-five to thirty
nine, inclusive;
(2) a mammogram for covered women age
forty to forty-nine, inclusive,
every two years or more frequent
based on the recommendation of the
patient's physician;
(3) a mammogram every year for co vered
women age fifty and over.
Eligible charges for low dose mammography shall be
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SECTION 125 FLEXIBLE BENEFITS
TABLE OF CONTENTS
PAGE
i Definitions
a'k9i7 w
vs''v';o-,aG
.ty 45y t,.,•;,-��
Administration of
Health Plan Continuation Coverage (COBRA) * . . 00 . 0 . . 12-13
I'','Yy� �•'�`c�i is t�
Amendment or • of • , .i 1rS
Dependent Care Assistance Plan and Medical
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INTRODUCTION
Purpose of Plan. The purpose of this Plan is to provide
employees of the City of Jefferson a choice between cash and
benefits under the dependent care, life insurance, medical
care and medical reimbursement plans maintained by the City
of Jefferson.
Cafeteria Plan Status. This Plan is intended to qualify as
a "cafeteria plan" under section 125 of the Internal Revenue
Code of 1986, as amended, and is to be interpreted in a
manner consistent with the requirements of Section 125.
DEFINITIONS
Wherever used herein, the following terms have the following
meanings unless a different meaning is clearly required by
the context:
Administrator means the company or such other person or P
committee, as may be appointed from time to time by the
Company, to supervise the administration of the Plan.
Code means the Internal Revenue Code of 1986, as amended
from time to time. Reference to any section or subsection
of the Code includes reference to any comparable or
succeeding provisions of any legislation which amends,
supplements or replaces such section or subsection*.
Company means the City of Jefferson, a municipality
organized under the laws of Missouri.
Dependent means any individual who is:
(a) a dependent of the participant who is under the age of
15 and with respect to whom the participant is entitled
to an exemption under Section 151 (c) of the Code, or
(b) a dependent or spouse of the participant who is
physically or mentally incapable 'of caring for himself.
Dependent Care Assistance Account means the account
established by the Company to maintain, on its books, a
Dependent Care Assistance Account for each plan year with
respect to each participant who has elected to receive
dependent care assistance for the plan year.
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Dependent Care are Assistance
Assistance Plan amended Y from Jefferson
to7.
Dependent C
time.
by a
Expenses mean expenses incurred
Dependent Care x
participant which: t
(a) are incurred for the care of a dependent of the
participant or for related household services, f
able to a dependent care services
(b) are paid or. pay
provider, and
e participant to be gainful , :. afirF? °r•
(c) are incurred to enable th gainfully
for any period for which there are one or more a ' rntis
dependents with respect to the partici ant. 'r,� �,r ,.•;
expenses incurred ,.'ifif :-V
Dependent care expenses shall not include exp incurr w! r;; };
for services outside the participant's household for the ;;a.
r t x
care of a dependent unless such dependent meets the .
definition of a dependent in this Plan or regularly spends ; ,
at least 8 hours each day in the participant's household.
t :x
Dependent care expenses shall be deemed to be incurred at
the time the services to which the related expenses are
rendered.
{ }� Dependent Care Service Provider means a parson who provides
,P1
care or other services described above (under Dependent Care n,
Expenses) , but shall not include: k
(a) a dependent care renter (as defined in Section 21 (b) ,
(2) (D) of the Code, unless the requirements of Code
Section 21 (b) (2) (C) are satisfied, or
k
(b) a related individual described in Section 129 (c) of the
Code.
Effective Date means March 1, 1988.
Employee means any individual employed by the Company or by
any other entity which is treated, along with the Company,
as a single employer, in accordance with the provisions of
Section 414 (b) , (c) or (m) of the Code.
ERISA means the Employee Retirement Income Security Act of
t 1974 .
person who is a key employee as
Key Employee means any p of the Code.
defined in S.ection 416(i) (1)
�,.
Life Insurance Plan means the City of Jefferson Life :ry
Insurance Plan, as amended from time to time.
2
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Medical Care Plan mean s the City of Jefferson Medical Plan,
as amended from time to time.
Medical. Reimbursement Account means the accoun t established
by the Company to maintain, on its books, a Medical
Reimbursement Account for each plan year with respect to
each participant who has elected to receive reimburseme nt of
qualifying medical care expenses in curred during the plan
year.
Medical Reimbursement Plan means the City of Jefferson
Medical Reimbursement Plan, as amended from time to time.
ticipates in the Plan
Participant means each employee who par
in accordance with t he section entitled "Participation" .
Plan means the Section 125 Plan as set forth herein,
together with any and all amendments and supplements hereto.
Plan Year means the period beginning on the effective date
989, and the 12 month period
and ending on February 28 , 1
ending on each February 28 thereafter.
Qualifying Medical Care Expense means any expense in curred
by a participant, or by the spouse or dependent of such
participant, for medical care as defined in Section 213 of
COE the Code ( including without limitation amounts paid for
hospital bills, doctor and dental bills, drugs, and premiums
for accident and health insurance) , but only to the extent
that the participant or other person incurring the expense
is not reimbursed for the expenses through insurance or
otherwise (other than under the Plan) .
A pronoun or adjective in the masculine gender includes the
feminine gender, and the singular includes the plural,
unless the context clearly indicates otherwise.
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+., PARTICIPATION
Commencement of Participation. Each employee whose
customary employmentr excluding overtime work, is working
the hours per week required by the Company will be eligible {
` to participate in the Plan. An employee will become a
" f:participant on the later o
err
{ a the effective date, or
r 5:Y
,,, •, (b) the first day of the month following the date he
becomes eligible to participate under the preceding ,
sentence.
. " Cessation of Participation. A participant will cease to be
' a participant as of the earlier of: } `'
r1n
rf ' •' r�Y1-�
(a) the date on which the Plan terminates, or
(b) the date on which he ceases to be an employee eligible 4;
to participate as describes' in the section
"Commencement of Participation" above. k'I
4
Reinstatement of Former Participant. A former participant
i.
will become a participant again if and when he meets the
eligibility requirements as described in the section
e "Commencement of Participation" above.
OPTIONAL BENEFITS
Benefit options. A participant may choose under this plan
to receive his full compensation for any plan year in cash
'�:• ��• or to have a portion of it applied by the Company toward the
` cost of one or more of the following optional benefits.: "
(a) Benefits available to the participant under. the Cancer
Premium benefit;
(b) Benefits available to the participant under the
r : z Dependent Care Assistance Plan;
, t (c) Benefits available to the participant under the
retirement supplement benefit;
(d) Benefits available to the participant under the Life
Insurance Plan;
k'f.
r' (e) Benefits available to the participant under the Medical
°n Care Plan; and
f.
}
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f Benefits available to the participant under the Medical
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Description of Benefits other than Cash. While the election asfr'r
to receive one or more of the optional benefits describeda
above may be made under this Plan, the benefits will be
provided not by this Plan but by the Dependent Care ,Y '
Assistance Plan, Life Insurance Plan, Medical Care Plan, ao � ;Y
Medical Reimbursement Plan. The types and amounts
benefits available under each option described above the a? ,
requirements for participating in such option, and the other
terms and conditions of coverage and benefits under such
option are as set forth from time to time in the Dependent
SfiA r .Y;
Care Assistance Plan, Life Insurance Plan, Medical Care
Plan, and in the group
Plan, and Medical Reimbursement
insurance contracts and prepaid health plan contracts that
constitute (or are incorporated by reference in) certain of c''` A;''.'f
those plans . The benefit descriptions in such plans and
contracts, as in effect from time to time, are hereby
incorporated by reference into this Plan.
y;.' . Election of optional Benefits in lieu of Cash. A ,Irr ,
I r,T ti21 al?t�.rojt{f}i:;':l
participant may elect, under this Plan, to receive one or
more of the optional benefits described in "Benefit Options"
.. "Election
in accordance with the pro
If a participant described in
Procedure" . ant elects dependent care
p p
z,.
assistance or medical reimbursement, the participant's cashk ;:
compensation will be reduced, and an amount equal to the ."�
reduction will be credited by the Company to a reimbursement
r account in accordance with the Dependent Care Assistance is
Plan or Medical Reimbursement Plan, as the case may be. If
a participant elects life insurance, or medical care, the R,
participant's cash compensation will be reduced, and an
t ' amount equal to the reduction will be contributed by the
Company under the Life Insurance or Medical Care Plan in
question to cover the participant's share of the cost of
g such benefit as determined by the Company. The balance of
the cost of each such benefit shall be paid by the Company
under this Plan with nonelective Company contributions.
Election Procedure. Approximately 30 days prior to the
commencement of each plan year, the Administrator shall
} ' provide one or more written election forms and compensation
reduction agreements to each participant and to each other
i=. employee who is expected to become a participant at the
' F beginning of the plan year. The election forms shall be
r> " effective as of the first day of the plan year. Each
r,r ra
stx participant who desires one or more optional benefit
coverages described in "Benefit options" for the plan year
4: shall so specify on the appropriate election form or forms
and shall agree to a reduction in his compensation. The `
amount of the reduction in the participant's compensation
{F`
for the plan year for each optional benefit: life insurance `
or medical care; that is elected by the participant shall
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.xr ict��hTlilkYa rl$�i>�����s..i,x�ay.`..,�,`�}('�' ."•aM;;+r 3:.3e..,,...,...._.,..,.._..__.�..,,,W�, sr,.:.E�;t. ...5;.".2;x.��.1zs°`lh?�:,..`�f,�h.,.a.s�cs>xi ��....�.u�3�r `,��-�t�... ..
equal the participant's share of the cost of such optional ;=yt
benefit, and shall be adjusted automatically in the event of u
a change in such cost. The amount of the reduction in the
ems,.,pry
participant' s compensation for the plan year for each
optional benefit: dependent care assistance or medical ';
reimbursement, shall be the amount elected by the
participant, subject to the limitations of the Dependent
Care Assistance Plan and the Medical Reimbursement Plan. zr :°.
.,, Existing participants in the Plan must complete and return `..
their election forms to the Administrator on or before such t
`r date as the Administrator shall specify, which date shall in
no event be later than the beginning of the plan year to sh `
`
which the election relates . New participants in the Plan
must complete and return their election forms to the
g. Administrator on or before such date as the Administrator
shall specify, which date shall be no later than the
whi ch the
beginning of the first pay period for
k r fr
participant's compensation reduction agreement will apply.
New Participants. As soon as practicable before an employee `;;" as r
becomes a participant as described under "Commencement of 'i
Participation" or "Reinstatement of Former Participant" , the ; ifz' K,t;';
Administrator shall provide the written election forms and
compensation reduction agreements described in Election
Procedure" to the employee. If the employee desires one or '�t'' '" '``
-,� more optional benefit coverages described in "Benefit
options" for the balance of the plan year, he shall so
specify on the election forms and shall agree to a reduction rtlr, }
in his compensation as provided in "Election Procedure" . ry '�
The election forms must be completed and returned to the
r
Administrator on or before such date as the Administrator
shall specify, which date shall be not later than he
beginning of the first pay period for which the
:PW
participant's compensation reduction agreements will apply. ='
S Failure to Elect. A participant failing to return a
completed election form to the Administrator on or before '
the specified due date for the initial plan year of the
plan, or for the plan year in which be became a participant, •
41' shall be deemed to have elected to receive his full
compensation in cash. A participant failing to return a
' completed election form to the administrator relating to the
a optional benefits; life insurance or medical care, on or
before the specified due date for any subsequent plan year
' shall be deemed to have made the same election as was in
effect as to such optional benefits just prior to the end of
the preceding plan year. The participant shall also be
deemed to have agreed to a reduction in his compensation for
the subsequent plan year equal to the participant's share of
the cost from time to time during such plan year of each
such optional benefit he is deemed to have elected for such
.•, plan year . A participant failing to return a completed w
election form to the Administrator relating to the optional
xt benefits; dependent care assistance or medical
ur.
x
6
t s tf Sv t a ✓ ; � k j 1, ' 'S '
7 t i
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� j
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ii .r {�` 1
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4 ta.
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aR{ rr atr eta + . t P s k K
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r 1 �
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5,NM
a� ";i f �. '.�sF"5. S i •'lt "xi+ .�� w t.. !$ /,r tA' .{ "7 j , "){:"'..
y,+4i�c ��.r; "£p'���
6 r �..t..1::.;..»s...W,++ra,:a,;+lvimt litYt.�'dLt#R'�.'`�4{'SS,i,:t..f3t��tm.ri,3..-..t K..`..�;1„.t...:si. ....,>,rt..r.-._',�e.t?,..i.�.,.,.. ..:.. �4,^.:.l..:i;•iF.�v?t.. ,u.v;7�i±F�<.�Te.,.e, �..�+ T} A�'fi?
reimbursement, on or before the specified due date for any
plan year shall be deemed to have elected cash compensation
in lieu of such optional benefit, regardless of the election
in effect during the preceding p lan year. i
Changes by Administrator. If the Administrator determines, v .,
before or during any plan year, that the Plan may fail. to
satisfy for such plan year any nondiscrimination requirement ,
>' imposed by the Code or any limitation on benefits provided
to key employees, the Administrator shall take such action
� 5
as the Administrator deems appropriate, under rules
uniformly applicable to similarly situated participants, to
assure compliance with such requirement or limitation. suchr� ,5,3,.,
, � +
:, �
action may include without limitation a modification of iKt � "
� elections by highly compensated employees or key employees
with or without the consent of such employees.
'fir. -'�(`-'";'St1'i•`,:
Irrevocability of Election by the Participant during the6 +;1; M`,,
Plan Year. Elections made under the Plan (or deemed to be
made under "Failure to Elect") shall be irrevocable by ther ?5`
participant during the plan year, subject to a change in }g.,1,v, r
family status. A participant may revoke a benefit election
for the balance of a plan year and file a new election only
if both the revocation and new election are on account of `-:= "
and consistent with a change in family status. a change in
family status for this purpose includes marriage, divorce,
death of a spouse or child, birth or adoption of a child/
It termination of employment of a spouse and such other events
that the Administrator determines will permit a change or
during revocation of an election ?
g a plan year under
regulations and rulings of the Internal Revenue Service. t
Any new election under this section shall be effective at
>` such time as the Administrator shall prescribe, but not
earlier than the first pay period beginning after the
r�
election form is completed and returned to the
Administrator.
Automatic Termination of Election. Elections made under 'i
this Plan (or deemed to be made under "Failure to Elect")
k' shall automatically terminate on the date on which the z
u; participant ceases to be a participant in the Plan, although
coverage or benefits under the Life Insurance, Medical Care,
Dependent Care Assistance and Medical Reimbursement Plan may
continue if and to the extent provided by such plans.
Maximum Employer Contributions. The maximum amount of
t employer contributions under the plan for any participant
shall be the sum of:
(a) the maximum amounts which the participant may receive
in the form of dependent care assistance under the
s;71ilt Dependent Care Assistance Plan and as medical
reimbursements under the Medical Reimbursement Plan, as
set forth in such plans, and
t
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rr¢ Al
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�t
w
n
a (b) the costs from time to time of the most expensive
benefits available to the participant under the Life
Insurance and Medical Care Plan ( including the portion f
of such costs payable with nonelective company r
contributions) .
tet.a
ADMINISTRATION OF PLAN
`i Plan Administrator. The administration of the Plan shall bebu. -�
' under the supervision of the Administrator. It shall be a `''
#:• 1
principal duty of the Administrator to see that the Plan is ', °t
Ws
carried out, in accordance with its terms, for the exclusive 4,`." z' }' _.'
benefit of persons entitled to participate in the plan srh '
s.
'
without discrimination among them. The Administrator will
in all of its
x- have full power to administer the plan , xak'�t
' details subject to applicable requirements of law. For
this purpose, the Administrator's powers will include, but ;, ,,,,��<•4
will not be limited to, the following authority, in addition $g;y;firjr1a <
to all other powers provided by this Plan:
(a) To make and enforce such rules and regulations as it ,.ttl+ q,ksf,
deems necessary or proper for the efficient
`. administration of the Plan, including the establishment
f} t' of any claims procedures that may be required by
g applicable provisions of law;
' (b) To interpret the Plan, its interpretation thereof, in1f;
good faith to be final and conclusive on all persons Y ;
claiming benefits under the plan; ,
1' (c) To decide all questions concerning the Plan and the
eligibility of any person to participate in the Plan;
1Y
(d) To compute the amount of benefits which will be payable
to any participant or other person in accordance with ,
the provisions of the Plan, and to determine the person
or persons to whom such benefits will be paid;
(e) To authorize the payment of benefits;
(f) To appoint such agents, counsel, accountants,
consultants and other persons as may be required to
assist in administering the Plan; and
(g) To allocate and delegate its responsibilities under the
;x. Plan and to designate other persons to carry out any of
i` its responsibilities under the Plan, any such
allocation, delegation or designation to be by written
a .:
instrument and in accordance with applicable
requirements of law.
off•'
.i
8
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,I lF`•i
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X97
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f
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V
!� �tt r'. � 7�y tk�ktw`:y4�t.t£��'�t,f�5 tit ..t :r'. ` :t•;. .t' � rf�,a �[{frki;,. ' g;
F1 � � �JW,'t..rf q �1 i° t`i.:w �` .t'��s � . . :• �' .�y,; ,: .: . .'., .: ;: 1 t ..it'�, �,.i.t :':➢.t�i.,l�^i... le
r
y_
Notwithstanding the foregoing, any claim which arises under
the Dependent Care Assistance Plan, Life Insurance Plan, #
Medical Reimbursement Plan or any Medical Care Plan shall nil
not be subject to review under this Plan, and the
shall not
t this section _
Administrator's authority under
extend to any matter as to which an administrator under any
such other plan is empowered to make determinations under r' w ,
�i such plan.
t ' Examination of Records. The Administrator will make
fP
available to each participant such of his records under thef4x;:
plan as pertain to him, for examination at reasonable times t{t • �f�{
!{. during normal business hours.
ster in the Plan the
Reliance on Tables , etc. In administering
Administrator will be entitled, to the extent permitted by ;
r ,
` law, to rely conclusively on all tables valuations,
certificates, opinions and reports which are furnished by,
or in accordance with the instructions Off the 47+'.�x
administrators of the Dependent Care Assistance, Life
Insurance, Medical Care and Medical Reimbursement Plans or
WYl <? :j JI
r 'p
by accountants, counsel or other experts employed or engaged
by the Administrator.
Named Fiduciary. The Administrator will be a "named . rJ,
r ? fiduciary" for purposes of Section 402 (a) (1) of ERISA with
authority to control and manage the operation and v'
administration of the Plan, and will be responsible for r.
complying with all of the reporting and disclosure
t
requirements of Part 1 of Subtitle B of Title 1 of ERISA. ;,t
Nondiscriminatory Exercise of Authority. Whenever, in the 4,q
administration of the Plan, and discretionary action by the
Administrator is required, the Administrator shall exercise Yt
its authority in a nondiscriminatory manner so that all
persons similarly situated will received substantially the
same treatment.
1
Indemnification of Administrator. The Company agrees to
indemnify and to defend to the fullest extent permitted by
' law any employee serving as the Administrator or as a member
�Y .• '1
, r. of a committee designated as Administrator (including any
employee or former employee who formerly served as V
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 Company) occasioned by any act or omission
�X to act in connection with the Plan, if such act or omission
is in good faith.
! 1
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;{ t rat ,t�S it r r.:1r� t1 YET i ,. .�.. �_. t,.: ria �isu}`�`FS'�+�M'}yy �,''Y��sr,,r� ► �, _.t
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��A
r;
INSURANCE :
Plan. Once an employee is 3: ts
Responsibility for Implementing
eligible to be a participant, it shall be the participant's
l to any insurance carrier for any .
responsibility to apply anw { `1':
-�. the P1
ti insurance contemplated by
}' on the f a i lure of
�- Limit on Obligation to obtain or the r Company to obtain the
z° either the
participant
the Plan (whether as a result of '.,# '
insurance contemplated by the
'r gross neglect or otherwise) ,
circumstances, negligence, g ,.
participant's benefit shall be limited toUe �on nandathe
unpaid for. the period in g
premium, if any , received by the Companyf; ,
r. roceeds, if any, zw <,
actual insurance p participant' s claim.
par
a result of the .;< '
G., or the p pant as
T company. The Company's liability to
Receipt of Benefit by P Y• 'ts> s=4:
extend to and shall be limited to
x� the articipant shall only from the
p received by the Company
an payment actually r&y' '
Y
i y ,
insurance company. In the event that the full insurance � . .',.
#'t^ the company ..
benefit contemplated is not promptly received by hen
within a reasonable time after submission of a claim,
shall notify the participant of such facts and
the Company er have any legal obligation
the Company shall no long
N
.K. whatsoever (except to execute any do Hutment The participant
settlement reached by the participant) . ursue the '
,
shall be free to settle, compromise or refuse to psr see
f claim as the participant, in his sole discretion,
fit. ,
� shall not
Limit on Duty to Maintain Policies. The Company
be liable for any loss or obligation with respect to any
itation shall include but not
insurance coverage. igations which pertain to the
' be limited to, losses or obl' following
e% lied for or obtained, the Company
(a) Once insurance is app loss which may result from
shall not be liable for any
premium
to the extent premium r'^
the failure to pay
P
the company. '
" notices are not received by
premium notices are received by
the
(b) To the extent p
the Company's liability for the payment of
Company,
such pre
and shall be limited to the amount of
such premiums and shall not include liability for or such
`�Hfiy other loss which may result from failure to pay
premiums.
payment of any
�N (c) The Company
shall not be liable for the
'& insurance premium or any loss which may result from the
a an insurance prem
fa ium if the benefits
failure to pay
"} SS available under this plan are insufficient to provide
for the amount of such premium cost at the time it is
.. r • 1 J s #� •.
`i kr;pE{}cid��iL;t�'�'i5'+`a FZ>s��' }�` °'P 't4�, �. r. tl{ if '� rs t rr.}i ?i�` 1. 4r�'s �•;;�tr.�.
W,
gill o mil
s��. � i F1 �=,`tt ry E�Y.„4�cr 7 ff' '` a I i t. 'i r. t .1: 'J^.' �t•a r qs. L .tt,} y
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t 1
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1 � 1
y � F•I ks �;` k fJ,Si t ,ar a �'',LV{1 I{ _ ,.t r r ° ( � i+j t.�' }i f,`�? { �' �}t� � fi d� .
•'.4'. f `.t. A.. �xl ite++:..'..L:,.ai..,..r:u.::iLir ° t..
x.
zf Lt
s'
dj"t Y�
r' due. In such circumstances the participant shall be
responsible for and to see to the payment of such
premiums. The company shall undertake to notify a
participant if available benefits under this Plan are
insufficient to provide for an insurance premium but
shall not be liable for any failure to make such
notification.
{< (d) Upon termination of employment by a participant, the
` Company shall have no liability to take any step to
maintain any policy in force. The company shall not be fir'
liable for or responsible to see to the payment of any
premium after termination of employment.
r Selection of Beneficiaries. In the case of any insurance
policy which permits or requires the naming of a '
beneficiary, it shall be the responsibility of the
' participant to see that this is done. The company shall not
x be liable for any loss or cost which may result from such
failure. The Company's responsibility shall be limited to
joining in the execution of any documents as requested to a n t! r
participant or insurance carrier in order to carry out the y
purpose of this Plan. I
zX;
ht�,
Master Insurance Agreement Controls. A participant shall .
not be eligible for an insured benefit under this plan until
the insurance contemplated by this Plan is actually
obtained. In the event of a conflict between the terms of
k this plan and the terms of the policy of a particular
,y.
insurance company, if any, whose product is then being used s'
' in conjunction with this Plan, the terms of the insurance
policy master agreement shall control as to those '
participants receiving coverage under such master agreement
in defining the persons eligible for insurance, the dates of
their eligibility, the conditions which must be satisfied to
become insured, if any, and the benefits and circumstances
under which insurance terminates. '
t�
:I
( 11
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it
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i'k�1� ��t`N
I
'/�p � ' ,h9j�,r, „�,f 4�h1,-•,vi° �.��1;§.{. ����fiXt`�r..t �i��S, r �Yi.�''C t. rr 'i , �Ffl}i } r .ik �f�k'. r.r'rs} 7�,;c�4iG�r� '1���° �a`�as`ft.
♦ I' XI 1 �i,��}, F""''�� It C��fIF/'I �1. .t�r���f YI' l_t r i.! l: � JF..' � 7' .0 t {,y � t s�ll' f� ��! i
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f
HEALTH PLAN CONTINUATION COVERAGE (COBRA)
x!•
General Requirements on Continuation coverage. Pursuant to r `r
the Consolidated Omnibus Budget Reconciliation Act (COBRA) � z
if the Company had twenty (2 0) or more employees on a
typical business day during the preceding calendar year, the
hro Company is required to make available continuation coverage,
at group rates, if a participant lof-.es group health coverage
because of reduction in hours of employment or the `lLL
termination of their employment (for reasons other than `
. !
gross misconduct on their part) . To determine the twenty
(20) employee test, employees of all employers in a ';'
controlled group of affiliated service group are counted. } rah•." s
Spouses of employees covered by such plans have the right to ; �„,rJ, .
L choose continuation coverage for themselves if they lose
group health coverage for any of the following four reasons: .+; �
(a) Death of the spouse; ,'yar,•,s,�` Uk;
(b) Termination of the spouse's employment (for reasons
other than gross misconduct) or reduction in the
t` spouse's hours of employment;
(c) Divorce or legal separation from the spouse; or
C211, (d) The spouse becomes eligible for Medicare.
Dependent children of a covered employee have the right to
kt' continuation coverage if group health coverage under the
't Plan is lost for and of the following reasons:
�. (a) Death of a parent;
f:
P:
(b) Termination of a parent's employment (for reasons other
�`. than gross misconduct) or reduction of a parent's hours
of employment with the covered employer;
r4 (c) Parents' divorce or legal separation;
(d) A parent becomes eligible for Medicare; or
(e) The dependent ceases to be a dependent child under the
Plan.
If the Plan is extended by the employer to provide benefits' !
! after retirement, continuation coverage shall be available
K, if the Company undergoes reorganization under federal
.t.
bankruptcy law.
Notification Requirements. When the Plan is notified that
fr one of the events described in the section 10General
Requirements on Continuation Coverage's has happened, it will
in turn notify the covered person(s) if the right to choose
i�
3'
12
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t 4,4Y �: t,)"s�y'��? 4 "��.5'�{.�•.lY �v �,� �ti�; :51 tst F�, i t t r ' r �. .1jry,?r k,3"t a•..t�ln,J}' +:,t�i�3J
q hX .r, _ +[;.Jy� y'$J+4' �ax..11:rnt?;. }f':k1{ .C`. r• it k.= .,,y + , ,17 t Jr:;t.•,",::,.� r..:: h',n .'1" ,�' t
•f
continuation coverage. The law allows at least sixty (GO) n
``'' days from the date you would lose coverage because of one of
if'`i...
the events described above to inform the Plan Administrator e
` that you want continuation coverage. The employer or a
family member has the responsibility to inform the Plan of a
divorce, legal separation, or a child losing dependent
status under the Plan, within sixty (60) days of that event.
' The Company has a responsibility to notify the Plan of the
`i
employee's death, termination of employment or reduction in k
hours, or Medicare eligibility. If covered individuals
` change their marital status, or their spouses have changed
addresses, they should notify the Plan Administrator.
An person electing
�sb Cost of Continuation Coverage. y
' continuation coverage may be required to bear the cost of
such coverage. However, the cost of coverage may not exceed
102% of the cost of the Plan for "similarly situated" n;
^' employees or family members. ;.
Termination of Continuation Coverage. The right to
continuation coverage shall continue for eighteen (18)
r.,.
months for a participant who has lost coverage because of ;
termination of employment or reduction of hours. Spouses or
dependents who would otherwise lose coverage because of any
events listed in the section "General Requirements on
Continuation Coverage" , may continue coverage for a period
;. .. '� of three (3) years. However, this continuation coverage
y
may be terminated, as provided by federal law, for reasons E;
: . such as failure to pay continuation coverage cost,
eligibility for coverage under another employer's plan
'y (whether as an employee or otherwise) , this Company
terminates its health plan, or the beneficiary becomes
entitles to Medicare benefits. 1
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's ,.!7fgg,�y '�.i t� ylg5''4.�S���t�}�, s�I�4i�;ttN�t li{}-trkt'�l1iz�S s�r{t�i �(t'+4 .+f•;�"r1�715y r.i�4`�.�^t����ssi S,����t�4�aa���['�{ts ,`.. t
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YN
rt
AMENDMENT OR TERMINATION OF PLAN
1�rtiri
Amendment of Plan. The Company reserves the power at any
N...Ar S,•'r' i•.,
time or times to amend the provisions of the Plan to any :r � :!•
extent and in any manner that it may deem advisable, by aM: x;F
written instrument signed by an officer (Trustee) of thex }
Company.
Termination of the Plan. The Company has established the
s< Plan with the bona fide intention and expectation that it
will be continued indefinitely, but the Company will have no
y p y : .
obligation whatsoever to maintain the Plan for any given ;rN _ '
length of time any may discontinue or terminate the Plan at jr ,
' liability. Upon termination or
any time without t'tt
discontinuance of the Plan, all elections and reductions in
" compensation relating to the Plan shall terminate, and ,, ., r ,.°a
t reimbursements shall be made only in accordance with the
,17>J.Ri`1"..•'-.er...,',fie.
section under the Dependent Care Assistance Plan and the
, d
fr
Medical Reimbursement Plan, entitled "Termination ofA: Y :',
Participation" . „
4 }•yea'Fi54t.
MISCELLANEOUS PROVISIONS
Communication to Employees. Promptly after the Plan is ;h=
1: '•
adopted the Company will notify all employees of the
availability and terms of the Plan.
t. ..
Information to be Furnished. Participants shall provide the
Company and Administrator with such information and
evidence, and shall sign such documents, as may reasonably .'.
be requested from time to time for the purpose of
administration of the Plan. .
Limitation of Rights. Neither the establishment of the Plan
nor ant amendment thereof, nor the payment of any benefits,
b ' will be construed as giving to any participant or other
person any legal or equitable right against the Company or
Administrator, except as provided herein, and in no event u
will the terms of employment or service of any participant ,.
be modified or in any way be affected hereby.
Benefits solely from General Assets. The benefits provided
hereunder will be paid solely from the general assets of the
`re Company. Nothing herein will be construed to require the
` Company or the Administrator to maintain any fund or
f segregate any amount for the benefit of any participant, and ; .
:f 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 Company from which any payment under
the Plan may be made .
2Sr•F
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riet..t 3��ft� t ir,�drtvj�,4l"t r s i � r. r1 E � �r 3 t.'1�rx.. .4 t ..v ¢t .�1�ftl.��h yT��L^}y 1�'?-°",� ,.�.; t � •,
`ir i i•. �. .f� + ,� .• j r t jt.,:`. i t `` } ) 't1 , •! 1 +•.. r;' > ,*1 i,t.; 4 I 6�S"Lf ,f^�'e,�i
x
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i
S r + s 'i'�` r� � Tt k'1'ii y yi�+"�y9 >f 3ryP ✓z4!' , :'r. r ., ,�1 ,,�,y *y1e�. y.,,�txr qk� Y�E4t
a., �k .ti rd, t�n'ii.S f.,.m ..S.snvlyk..4Y',y'Mer+....., .......,w.+.i;L++.KeCC!•.vatdLS'XC'' 'a7: exAY .f.iTte7Ja
.a•. .....,;.i iF..,..,r..
�,• feel:
t to�'n:j
ssignability of Rights. The right of any participant to
Nona
'fiFx;
receive ant reimbursement under the Plan shall not be 3e""
alienable by the participant by assignment or any other
method, and will not be subject to be taken by his creditors
by any process whatsoever, and any attempt to cause suchr ri�.JJ
right to be so subjected will not be recognized, except to ``= ::;,'
,r
such extent as may be required by law.
No Guarantee of Tax Consequences . Neither the Administrator `�'H?'''
nor the Company makes any commitment or guarantee that any
amounts paid to or for the benefit of a participant will be
excludable from the participant' s gross income or federal orx
«r
state income tax purposes, or that any other federal or £
state tax treatment will apply to or be available to an a`=k}• f`'
participant. It shall be the obligation of each participants'
to determine whether each payment is excludable form the
r; participant's gross income for federal or state income tax
purposes, and to notify the Company if the participant has
reason to believe that any such payment is not so
k excludable .
Indemnification of Company by Participants. If any
participant receives one or more payments or reimbursements .} ?ark
that are not for dependent care expenses or qualifying
medical care expenses, such participant shall indemnify andjt.�;:r.p,
reimburse the Company for any liability it may incur for ,
,- S.i
failure to withhold federal or state income tax or sociali
security tax from such payments or reimbursements. However,
'r such indemnification and reimbursement shall not exceed the
amount of additional federal and state income tax that the t'
..,. 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
P ' security tax actually paid by the participant. T
Governing Law. This Plan shall be construed administered
and enforced according to the laws of Missouri .
IN WITNESS WHEREOF, the Company has caused this Plan to be N
executed in its name and behalf this day of
191 by its officer (Trustee) thereunto duly
authorized.
Reimbursement or Payment of Expenses. The Company shall
reimburse the participant from the Participant's Dependent
Care Assistance
},z
By !
15
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L� 1`
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'.iil� 5r 't�itaGyda3.'s4tct irifik �"
A
�ar•.
i�
DEPENDENT CARE ASSISTANCE PLAN r.
AND
MEDICAL REIMBURSEMENT PLAN .
A
r,
;,. INTRODUCTION _
Dependent Care Assistance Plan. This Plan is intended to
qualify as a dependent care assistance program under Section
129 of the Internal Revenue Code of 1986, as amended, and is
to be interpreted in a manner consistent with the
requirements of Section 129 . The purpose of the Plan is to
enable participants to elect to receive
p p payments or
reimbursements of their dependent care expenses that are
excludable form the participants' gross income under Sectionu �
r 129 of the Code. �F
f�
Medical Reimbursement Plan. This Plan is intended to t �
qualify as a medical reimbursement plan under Section 105 rr
(b) of the Internal Revenue Code of 1986 , as amended, and is
p. to be interpreted in a manner consistent with the k '>
requirements of Section 105 (b) . The purpose of the Plan is
to enable participants to elect to receive payments or
A` reimbursements of qualifying medical care expenses that are
excludable form the participants' gross income under Section
105 (b) of the Code.
r,. MAXIMUM AMOUNTS
Dependent Care Assistance Plan. The maximum amount which '
qa.
s. the participant may receive in any taxable year in the form
$. of dependent care assistance under this Plan shall be the
least of:
r
(a) the participant's earned income for the taxable year
(after all reductions in compensation including the
reduction related to dependent care assistance) ,
•y. (b) the actual or deemed earned income of the participant's
spouse for the taxable year, or
(c) $5, 000. 00.
tb�
In the case of a spouse who is a full-time student at an
educational institution or is physically or mentally
incapable of caring for himself, such spouse shall be deemed
to have earned income of not less than $200 per month if the
y: participant has one dependent and $400 per month if the
participant has two or more dependents.
Medical Reimbursement P1a.n. The maximum amount which the
participant may receive under this Plan in the form of
�i
r
16
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<�1�,f ti.y i kv.t,: h.`.1 � 'Ilprn t t r it• 7 , t itl .. ttn .:JaSi.Mt � 4 v ro�� f` ,�/i t
• �V ��t �?`�SZU '�I. t ,�, }� JS�4?iyA .`.++c�r-aa. ���S�Y .}i
... ,....�r..s... .._�.�..--�..r--•r' "/' t a 1�2{.NtPF`'t" ',
;s� -rtA�+�o a �,i k`it,»�. S�rmc` ti!?^J.".s $r.-S.'t?19.fsM.+w>;'a-„..-,....,.. un.i+.,l:,i•,>tir j r� �.r;r.;'�l{..'t
G
payments of reimbursements for qualifying medical care
expenses incurred in any plan year shall be
DEPENDENT CARE ASSISTANCE ACCOUNTS z
AND
MEDICAL REIMBURSEMENT. ACCOUNTS
k
Establishment of Accounts. The company will establish and
maintain on its books a Dependent Care Assistance Account or
Medical Reimbursement Account for each plan year with
respect to each participant who has elected to receive
dependent care assistance or reimbursement of qualifying
{' medical care expenses incurred during the plan year.
?. F:
Crediting of Accounts. There shall be credited to a
participant's Dependent Care Assistance Account for each
•l,,t . u.,�l
P
lan year, as of each date compensation is paid to the
5
participant in such plan year, an amount equal to the ,,I,i,,�/f,;�,,r,..s•f;.
reduction, if any, to be made in such compensation in
accordance with the participant's election and compensation
aF: reduction agreement under the Plan. All amounts Y � '
. .aat.
credited to each such Dependent Care Assistance Account ors{a .
Medical Reimbursement Account shall be the property of the
Company until paid out pursuant to the section entitled4Y'�� jy,
are Assistance or Medical Care
"Payment of Dependent C
Expense Reimbursements" . ;
' Debiting of Accounts. A participants Dependent Care '
Assistance Account or Medical Reimbursement Account for each
plan year shall be debited from time to time in the amount +
of any payment under the section entitled "Payment of
Dependent Care Assistance or Medical Care Expense
i
Reimbursements" to, or for the benefit of, the participant
for dependent care expenses or qualifying medical care
expenses incurred during such plan year. Amounts debited to
'.: each such Dependent Care Assistance Account or Medical
Reimbursement Account shall be treated as payments of the
earliest amounts credited to the Account and not yet treated
as paid under this sentence, under a "first-in/first-out”
�i
approach .
3 F.
Forfeiture of Accounts. The amount credited to a .{
participant's Dependent Care Assistance Account or Medical M.
Reimbursement Account for any plan year shall be used only p
to reimburse the participant for dependent care expenses or
Y=; qualifying medical care expenses incurred during such plan
r � year, and only if the participant applies for reimbursement ;
on or before the 90th day following the close of the plan
year. If any balance remains in the participant's Dependent
Care Assistance Account or Medical Reimbursement Account for
any plan year after all reimbursements hereunder, such
balance shall not be carried over to reimburse the
..1
17
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SY `f
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,.fin;:,ty.l 1?z N 0
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+ 7 tf !r 'f .i� ..rt + ,t,t .r; y44 , b {�h dYS��;^ ,a`�«it �etA ,�. • ': ;�'
.$t. ���k a�F� ta` c a t+t. t .�ss„ ., .,,, . . �, ., �;.�t-.v t�42.:�•�,�[[�{�iy« iw' i� err.
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.,���{• r+.4i, .:t'�i' v 45. .'f,• a. !.'. ..,� .4� ,.a3 . t�'YS3�k �.�...�s. -Sr '.'1 •
r
a
ED medical for dependent care expenses or qualifying ='
medical care expenses incurred during a subsequent plan
A
year, and shall not be available to the participant in any f '
other form or manner, but shall remain the property of the
Company, and the participant shall forfeit all rights withfi.;
,.
respect to such balance. haa < `
PAYMENT OF
DEPENDENT CARE ASSISTANCE ;
AND
HEDICAh CARE EXPENSE REIMBURSEMENTS
Claims for Reimbursement. A participant who has elected tot .y
receive dependent care assistance or medical care � v ;x
Eav
F reimbursements for a plan year may apply to the Company for
reimbursement of dependent care expenses or qualifying4jx4 .r =:
medical care expenses incurred by the participant during thek
plan year by submitting an application in writing to the
y, 7Rx4�h�
Company, in such form as the Company may prescribe, settingxt' ,
forth: ,.; .,
(a) the amount, date and nature of the expense with respect A
to which a benefit is requested; 1
(b) the name of the person, organization or entity to which
the expense was or is to be paid; f
(c) such other information as the Company may from time to
3 time require;
(d) for Dependent Care Expense Reimbursements, the social
security number of the day care provider; s
(e) for Medical Care Expense Reimbursements, the name of
the person for whom the expense was incurred and, if
such person is not the participant requesting the
benefit, the relationship of such person to the '
participant; and
!a' (f) for Medical Care Expense Reimbursements, the amount
recovered or expected to be recovered, under any
insurance arrangement or other plan, with respect to }
the expense.
Such application may be accompanied by bills, invoices,
receipts, cancelled checks or other statements showing the
r
A' amounts of such expenses, together with any additional
k:
.. documentation which the Company may request.
18
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y 1
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4 :!� �ilu�q:Y� �}lr�,�X<"'ffI{ i�rXJ,:J( try.,. i ff, r 4� i�A^.r }•'• Ir` r�'' t f 1- •
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t
`i•. l%fit
y
Reimbursement or Payment of Expenses. The Company shall
reimburse the participant from the Participant' s Dependent '.
Care Assistance Account for dependent care expenses or
Medical Reimbursement Account for qualifying medical care r
,.
expenses incurred during the plan year for which the
participant submits a written application and documentation " • :
' in accordance with the section entitled "Claims for
' .
Reimbursement" .
No reimbursement or payment under this
•'
,. , section of expenses incurred during a plan year shall at any
�.:.
. ;• time exceed the annual election amount of the participant' s
Sir
Dependent Care Assistance Account for the plan year. v,r
f;.:. .r
r` Report to Participants on or before January 31 of each Year. fit;
On or before January 31 of each year, the Administrator . , ;
f..
shall furnish to each participant who has received dependent
care assistance during the prior calendar year a written
:, ...,
' statement showing the amount of such assistance paid during
such year with respect to the participant. fr<
TERMINATION OF PARTICIPATION jJ`{
. , In the event that a participant ceases to be a participant
in this Plan for any reason, the participant's compensation i
reduction agreement relating to dependent care assistance or
F.
qualifying medical care expenses shall terminate. The
r, y
participant (or his estate) shall be entitled to
reimbursement only for dependent care expenses or qualifying ?
medical care expenses incurred within the same plan year and
prior to the 90th day after the date participation is r, ,
terminated, and only if the participant (or his 'estate)
applies for such reimbursement in accordance with the r
section entitled "Claims for Reimbursement" on or before the
#` earlier of:
(1) the 180th day following the date participation is
terminated, or
2 the 90th day after the close of the plan year.
No such reimbursement shall exceed the remaining balance, if
x any, in the participant's Dependent Care Assistance Account
or Medical Reimbursement Account for the plan year in which
the expenses were incurred.
t Y,
}
= x
�Ne. ,
i zf4: c
19
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t:
PROCEDURES
CLAIMS AND REVIEW ,t
FOR
MEDICAL REIMBURSEMENT PLAN
t 5 2Ys $
`: Claims Procedure. If any per believes he is being denied
person may file
: ,.. any rights or benefits under the Plan, such p
ex}, claim in writing with the Administrator. If any such claim
F'
is wholly or partially denied, the Administrator will notify
person of its decision in writing. Such notification K,t
such p
'" will be written in a manner calculated to be understood y
such person and will contain: `
denial,
the
(a) specific reasons for
pertinent Plan provisions,
specific references top
. .rye
(c) a description of any additional
son to e fect suchrclaim rand lan
necessary for such per P
explanation of why such material or information is Y �
necessary, and
(d) information as to the steps to be taken- if the person
wishes to submit a request for review.
SY r
Such notif ication will be given within 90 days after the
the Administrator (or within 180 days,
if special circumstances require an extension of
claim is received by time for
processing the claim, and if written notiersonf within
d ; extension and circumstances is given to such p
the initial 90 day period) . If such notification is not
given within such p
eriod, the claim will be considered
denied as of the last day of such period and such person may
request a review of his claim.
') 'i]{•
Review Procedure. Within 60 days after the date on which a
if r.
,•, t person receives a written notice of a denied claim (or, �.
applicable, within 60 days after the date mtt which
such
erson (or his
? denial is considered to have occurred) such p k
duly authorized representative) may:
£.: . ,.
F, .
(a) file a written request with the Administrator for a
pertinent documents,
review of his denied claim and of p
and
•, (b)' submit written issues and comments to the
Administrator.
The Administrator will notify such 1 Pbeswritten sine aismanner
,y writing. Such no
Pt calculated to be understood by such person and will contain
specific reasons for the decision as well as specific
:. provisions.
The decision on
references to pertinent Plan p
review will. be made within 60 days after the request for
�jx#
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THE CITY OF JEFFERSON
BALANCE SHEET
- AS OF 10/31/90
E
mom
ASSETS
, sf
4. CHECKING ACCOUNT $11 ,864 .87
SAVINGS ACCOUNT
INVESTMENTS $25,952 .96 t
TOTAL $37,817.83
LIABILITIES
FICA WITHHELD
ti RETAINED EARNINGS $16,809.78
CURRENT YEARS GAIN OR LOSS $21 ,008 .05
TOTAL $37,817 .83
Fx.
RECEIPTS AND DISBURSEMENTS
A, RECEIPTS MONTH TO DATE YEAR TO DATE
CO NP RIBUTIONS $69,152.91 $684,738 .74
a'} k
INVEST. EARNINGS $ 161.18 $ 1,493 .92
REINSURANCE REFS. $ 30,495 .85
TOTAL $69 ,314.09 $716,728 .51
In .
� DISBURSEMENTS
'1 BENEFITS $27 ,464 .01 $541,736 .18
ADMIN. FEE $1 ,530.12 $ 15,458 .71
' REINSURANCE EXP $10 ,415.15 $102,041 .19
PRINTING EXPENSE $ 48.30 $ 622 .60
LIFE INS PREMIUMS $ 2,918.86 $ 28,574 .08
MISC: EXPENSE $ $ 21 .70
POSITIVE CARE $ 718.00 $ 7,266 .00
Aii TOTAL $43 ,094 .44 $695,720 .46
NET GAIN OR LOSS (—) $26.,219.65 $ 21,008 .05
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City of Jefferson
Plan Year Cost Summar.,y
x, ( 1/1/90 - 10/31/90)
kh
During this period the group averaged 217 with Single coverage
and 146 with Family coverage.
J
TOTAL COST: $695,720.46 d
Less Investment earnings: ( $ 1,493 .92)
Less Reinsurance refunds: ($ 30,495 .85)
Less Life Ins. . ($ 28 ,574 .08)
Net Cost: $635,156 .61
4, Average Monthly composite cost per employee: $ 174 .97 t
'. Average monthly cost based on Single/Family ratio: $110.30 single
$160.81 dependent:
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$271.1.2 family x
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COST PROJECTIONS AT PLAIT YEAR BEGINNING 1
Projected Maximum ,
$106.64 single $137.45 single
E; $1.55.48 dependent $200.40 dependent
`.. $262.12 family $337.85 family
`k SL
CURRENT FUNDING
Medical: $107.00 single
$156.00 dependent
$263.00 family
r Life: .40 Per $1 ,000
Dependent. Life: $1 .07
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Cite of Jefferson
Annual Cost Comparison
a:^ (Based on 223 single / 134 family)
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; ' Current Renewal Option I Option II
,.�. Stop 'Loss Level: ($30,000) ($30 ,000) ($30,000) ($35,000)
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Carrier: Ohio National Ohio National Gerber Life Ohio National
r�•a;1 w
Specific Stop
Loss Premium: $ 109,242. 00 $ 135,417.24 $ 129,282.96 $ 115,239.60 4
Aggregate Stop
Loss Premium: $ 6,456.00 $ 7,404 . 00 $ 10,752.84 $ 7 ,404. 00
` Administration and
Precert Fee: $ 26,775. 00 $ 26 775.00 $ 26 775.00 $ 26,775. 00 '
Conversion: included above $ 2,570.40 $ 2,998 .80 $ 2,570. 40
:. TOTAL FIXED COST: $ 142 ,473.00 $ 172,166.64 $ 169,809 .60 $ 151 ,989. 00
Aggregate Attachment
;- Point: $ 792,711 .36 $ 965,534.20 $ 985,534 .20 $1, 003 ,269. 96
TOTAL MAXIMUM COST: $ 935,184 .36 $1 ,157,700.84 $1 ,173,079 .56 $1 ,137 ,523 .20
3.
: - - - - -- - - - - - - - - - - - -
r'`:. Projected Self-Funded
Utz, t
Claims: $ 652,951 .50 $ 652,951.50 $ 662 ,523 .72
' 'DOTAL PBOJECTED COST: $ �.r 2 r ,118 .14 $ 822,761 .10
$ 814 ,5
12 .72
rr'
- - - - - - - - - - - - - - - - - - - - - - - - - -- r
"Y Suggested Medical Contribution Rates:
MR�Y r
Maximum Employee: $174 .66 $176.98 $171.61
Dependent: $254 ,65 $258.03 $250.22
Family: $429 .31 $435.01
$421 .83
j ;. Projected Employee: $124 .48 $1.24 .13 $122.88
Dependent: $181 .49 $180.97
6 . $179 .16
Family: $305 .97 $305.10 $302 . 04
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t �
i
i
v ' RENEWAL
SPECIFIC AGGREGATE PREMIUM r
9 ].34 family)
�. (Based an 223 single / ;kf
, k Date: 1/1/91
Effective
7'
Carrier blame= Ohio National
r ,
$30,000 t
Specific Deductible: $31,61 per employee per month G
Composite Rate: $11 ,2x4.77
r R eci_fic Premium: $135 ,417 .24
: Monthly .gip•- '
Annual Specific Premium:
rk' ' $ 617 .00
.,; Monthly Aggregate Premium: $ 7 ,404 .00
Annual Aggregate Premium:
Factor: $230.05
Composite Aggregate $82 ,127 .85
monthly Attachment Point: $985,534 .20
Annual Attachment Point:
Specific contract Basis: Incurred in 12 months, Paid. in 15 months
Contract Basis: paid in 12 months
Aggregate
Definitions
individual.
» .az; Specific
$30,000 Specific Stop Loss is provided on each indi.
�r ;5 'n excess of $30,000 are reimbursed a 100%
fY' Claim amount. i
'`
to a $1 ,000 ,000 Lifetime Maximum Benefit. Specific
reimbursements are made at the time of claim.
l"'t
A.ygregate
Aggregate Stop Loss is provided on al]_ claims under $30 ,00
:a combined to a $1,000 ,000 maximum benefit annually.
Aq re ate Attachment Point (Maximum Self-funded Claims per
Plan Year) y the
In arrivincs .o a Maximum
Carrier Annual Claim
develops iabiclaim cost
uncles-griting Strap Los.. Ca
jo ecLi.on ba..�cd on the croup' s average age, location, past
,. p _ 3
claims r_xpari.ence, fixture medical inflation, and other
factors. To this cost is added an additional erx'arrier layer
of 25%, boi:}� as protection to the Reinsurance
adequate reserves.
as an incentive for the gro pbrokenl d wn into a per employee
This final COsti g y the number of
"Aggregate Factor" which is multiplied by
participating employees each month to arrive at a cumulative
"Aggregate ALtachment Point" .
-4-
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•�.. .}!�, F,'r� t�g�ti: ��N�r hjft�'FV�j`3C'y',r?.�,A,{�}�r���t��1�'uF4�8yN� .aF + :'j't�f , rfk...17i �� r �� � r f :.
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A;,1}i
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ti �'�' ° ���� �t'aJ3a .tk.�,' da. ,4v r is �t C� •� f iv s 3 as i,e12tY T,^,}li n r T5�{x'tiyi.�S'' ,,
}a,
OPTION I
SPECIFIC / AGGREGATE PREMIUM
..: (Based on 223 single / 134 family)
Effective Date: 1/1/91
Carrier Name: Gerber Life Insurance
.w Specific Deductible: $30 ,000
' Single Rate: $18 .82
Family Rate: $49 .08
Monthly Specific Premium: $10,773 .58
Annual Specific Premium: $ 129 ,282.96 '
Aggregate Pr.P.miunl/Ee/Month: $2. 51 +�
{'. Monthly Aggregate Premium: $ 896 .07 i
Annua.l .Aggregate Premium: $ 10,752.84
Composite Aggregate Factor: $234.19
{L Monthly Attachment Point: $83,605 .83 : `
F�. Annual Attachment Point: $1, 003 ,269.96
Specific Contract Basis: Incurred in 12 months, Paid in 15 months
Aggregate Contract Basis: paid in 12 months (run-in limited to 60
: b days prior to effective date)
- - - - - - - - - - - - - - - - - - - - - - - -
?`{,` Definitions
4 " Sy�ecific
$30,000 Specific Stop Loss is provided on each individual,
;f� R
Claim amounts in excess of $30,000 are reimbursed a 100$
to a $1, 000 ,000 Lifetime Maximum Benefit. Specific
reimbursements are made at the time of claim, �r
Aggregate
A re. ate Stop Loss is ,
gg �I p provided on all claims under $30 000
combined to a $1 ,000,000 maximum benefit annually.
Aggregate Attachment Point (Maximum Self-Funded Claims per
Plan Year)
Iii arriving at a Maximum Annual Claim Liability, the
underwriting Stop Loss Carrier first develops a claim cost
projection based on the group' s average age, location, past
claims experience, future medical inflation, and other
factors. To this cost is added an additional excess layer
of 25%, both as protection to the Reinsurance Carrier and
as an incentive for the group to build up adequate reserves.
This final costing is then broken down into a per employee
,Y "Aggregate Factor" which is multiplied by the number of
E participating employees each month to arrive at a cumulative
"Aggregate Attachment Point" .
' � x
F . w". �w1all,u �vN qTl~�"u��tkl�t i y'�}.�'k tar,r I's n'��'AaVt •�V Rs�,�.-j"ai°(sa tn f x'++�t�v"�),>Ii li�t�,{�r1�N�t`elin^y �M r.z°+3,
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Y
} ,: k.' � :`` >'�`'�����°t�i,J f° �i $4,i�x a �a�*rF`��tr�rcl•�) �'� ri�r;,�3+�t�M?�4�
*f 'I
..l.Sl F�a , �`.]n n� fir°;. lcr,#��}� �p•�, j
(� 1. �" ( v�� F��nigavf rtMA. t tirilf{� t" hige1 1 �
t� '�1k�
S'f�i"r
��, at ' ��„ 'Luc :���+»L'tt try .,..�.�� r.�.r:r..:.;+�ury.rtfr.t.'� 1a(: 'r�c � v. Sip�'t �� �t°+ 0 � ��a`•t r
t s. 1',�}� d .,r+' +.•'K l?°tv(° ep;r� i 1 bt M j� 4 r i w° 4r 1.S ir`,r t } sl k It r r° P P �} {
° �� i i gg l t ��,,,, �t iY .J,..• ; .;t�...t� S.P n,, wr ,t 33 i S) °�)t'4 3( �4)i � .4r:...:. � $ Flj
) U'K,� .�. "t2 ,Y^' t ;:t9-Y •.i .t .. 43t ✓.: .1 r/
W.1 i.G.t j t` Y'�tf d!t It(.L} Sy k,'.Ij Y J.ft"Rf•N+. :"'i!'2!�'
r
fi+� �'��� "f �° •Y�'C`+7 'd k�r 1 �t�' .n� �.p4 �r� �slt rj 'tt+. tff>, 4 !fir'�� +J�.i�?t�'r
OPTION II
. SPECIFIC / AGGREGATE PREMIUM
(Based on 223 single / 134 family)
Effective Date: 1/1/91
r.
Carrier Name: Ohio National
Specific Deductible: $35,000
Composite Rate: $26 .90
Monthly Specific Premium: $9,603 .30
: l Annual Specific Premium; $115,239 .60
Monthly Aggregate Premium: $ 617 .00
Annual Aggregate Premium: $ 7,404 .00
" J
Composite Aggregate Factor: $230.05
Monthly Attachment Point: $82,127 .85
Annual Attachment Point: $985,534 .20
a
Specific Contract Basis: Incurred in 12 months, Paid in 15 months
Aggregate Contract Basis: paid
- - - - - - - - - - - - - - - - - - -
Definitions
S :s Specific
$3 ',000 Specific Stop Loss is provided on each individual.
Claim amounts in excess of $35,000 are reimbursed a 100%
to a $1,O00 ,000 Lifetime Maximum Benefit. Specific
reimbursements are made at the time of claim.
7�
Aggregate
Aggregate Stop Loss is provided on all claims under $35,000
combined to a $1 ,000,000 maximum benefit annually.
tai
a ' Aggreca1:e Attachment Point (Maxi Self-Funded Claims per
Plan Year)
+ In arriving at a Maximum Annual Claim Liability, the
underwriting Stop Loss Carrier f first develops a claim cost
projection based on the group' s average age, location, past
" claims experience, future medical inflation, and other
factors. To this cost is added an additional excess layer
of 25%, bath as protection to the Reinsurance Carrier and
as an incentive for the group to build up adequate reserves.
? This final costing is then broken down into a per employee
"Aggregate Factor" which is multiplied by the number of
participating employees each month to arrive at a cumulative
"Aggregate Attachment Point" .
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