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HomeMy Public PortalAboutExhibit MSD 71 - BeneFLEX HR Resources, Inc.Exhibit MSD 71 BUSINESS ASSOCIATE AGREEMENT Date: rg l-e- ZL, Zo[I Business Associate: BeneFLEX HR Resources, Inc. 10805 Sunset Office Dr., Suite 401 St. Louis, MO 63127 This Agreement is entered into as of the Covered Entity and the Business Associate. Covered Entity: Name: Me}ro l,-6a" 61-_ 1--00 <1 )psr 14E d Address:Z35e 6i-.Los date set forth above, by and between the A. Definitions. Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in the Privacy and Security Rules. 1. "Agreement" shall mean this Business Associate Agreement. 2. "Breach" shall have the same meaning as the term "breach" in 45 C.F.R. section 164.402 and shall be limited to those events that compromise the security or privacy of Protected Health Information as determined by Business Associate in its sole discretion. 3. "Business Associate" shall mean the business associate set forth above. 4. "Covered Entity" shall mean the covered entity set forth above. 5. "HIPAA" shall mean the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, and the regulations promulgated thereunder. 6. "HITECH Act" shall mean the Privacy provisions of the Health Information Technology for Economic and Clinical Health Act of 2009, and the regulations promulgated thereunder. 7. "Individual" shall have the same meaning as "individual" in 45 C.F.R section 160.103 and shall include a person who qualifies as a personal representative in accordance with 45 C.F.R. section 164.502(g). 8. "Privacy and Security Rules" shall mean the Standards for Privacy of Individually Identifiable Health Information and the Security Standards for the Protection of Electronic Health Information at 45 C.F.R. parts 160 and 164, as amended and supplemented by the HITECH Act. 9. "Protected Health Information" shall have the same meaning as the term "protected health information" in 45 C.F.R. section 160.103, limited to the information created, received, maintained or transmitted by Business Associate from or on behalf of Covered Entity. 10. "Required by Law" shall have the same meaning as the term "required by law" in 45 C.F.R. section 164.103. 11. Services. "Secretary" shall mean the Secretary of the Department of Health and Human 12. "Security Incident" shall have the same meaning as the term "security incident" in 45 C.F.R. section 164.304, limited to Information Systems (as defined in 45 C.F.R. 164.304) maintained by Business Associate that contain Protected Health Information, but shall not include trivial incidents that occur on a daily basis such as scans, "pings," or routine unsuccessful attempts to penetrate computer networks or servers maintained or utilized by Business Associate. 13. "Service Agreement" shall mean the underlying agreement(s) for services between Business Associate and Covered Entity under which Protected Health Information may be disclosed to Business Associate. 14. "Unsecured Protected Health Information" shall have the same meaning as "unsecured protected health information" in 45 C.F.R. section 164.402, limited to Protected Health Information as defined herein. B. Obligations and Activities of Business Associate. 1. Privacy and Security Rules. Business Associate will comply with the provisions of the Privacy and Security Rules and the HITECH Act that are applicable to a "business associate" (as such term is defined in the Privacy and Security Rules) and such provisions shall be incorporated herein by reference. 2. Protected Health Information. Business Associate agrees to not use or disclose Protected Health Information other than as permitted or required by this Agreement or as Required By Law. 3. Safeguards. Business Associate agrees to implement and use appropriate safeguards to prevent use or disclosure of Protected Health Information other than as provided for by this Agreement, including administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of Protected Health Information. 4. Mitigation. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of Unsecured Protected Health Information by Business Associate in violation of the requirements of this Agreement. 5. Breach Notification. Business Associate agrees to promptly provide written notice to the Covered Entity of a Breach of Unsecured Protected Health Information by Business Associate or any of its employees, officers and agents of which it becomes aware. 6. Security Incident Reporting. Business Associate agrees to promptly provide written notice to the Covered Entity of a Security Incident of which it becomes aware. 7. Agents. Business Associate agrees to obtain assurances from any agent, including a subcontractor, to whom it provides Protected Health Information that such agent agrees to the 2 same restrictions and conditions that apply through this Agreement and the Privacy and Security Rules to Business Associate with respect to such Protected Health Information. 8. Access. Business Associate agrees to provide to Covered Entity or to the Individual, as requested by Covered Entity, prompt access to Protected Health Information in a Designated Record Set to meet the requirements under 45 C.F.R. section 164.524 and the Privacy and Security Rules. To the extent that such Protected Health Information is maintained in an Electronic Health Record, Business Associate agrees to produce a copy of such Protected Health Information in electronic format upon Covered Entity's request in accordance with the Privacy and Security Rules. 9. Amendments. Business Associate agrees, at the request of Covered Entity or an Individual, to promptly make any amendment(s) to Protected Health Information in a Designated Record Set that the Covered Entity directs or agrees to pursuant to 45 C.F.R. section 164.526. 10. Audit. Business Associate agrees promptly to make internal practices, books, and records, including policies and procedures and Protected Health Information, relating to the use and disclosure of Protected Health Information available to the Secretary, in a time and manner mutually agreed to by Business Associate and the Secretary, for purposes of the Secretary determining Covered Entity's or Business Associate's compliance with the Privacy and Security Rules. 11. Accounting. Business Associate agrees to document disclosures of Protected Health Information and information related to such disclosures as would be required for Covered Entity or Business Associate to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 C.F.R. section 164.528 and the Privacy and Security Rules. 12. Restrict Use/Disclosure. Business Associate agrees to provide promptly to Covered Entity or an Individual, information collected in accordance with Section B.11 above, to permit Covered Entity to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 C.F.R. section 164.528 and the Privacy and Security Rules. 13. No Sale of Protected Health Information. Except as otherwise allowed under the HITECH Act, Business Associate shall not directly or indirectly receive remuneration in exchange for Protected Health Information unless Covered Entity or Business Associate obtains the Individual's authorization and written permission, including a specification of whether the Protected Health Information can be further exchanged for remuneration by the entity receiving the Individual's Protected Health Information, in accordance with the Privacy and Security Rules. 14. Marketing Limits. To the extent Protected Health Information is maintained in an Electronic Health Record, Business Associate agrees to comply with the prohibition on the sale of Protected Health Information without an Individual's authorization in accordance with the Privacy and Security Rules. 3 C. Permitted Uses and Disclosures by Business Associate; General Use and Disclosure Provisions. Except as otherwise limited in this Agreement, Business Associate may use or disclose Protected Health Information to provide services to or perform functions, activities, or services for, or on behalf of, Covered Entity as specified in the Service Agreement, provided that such use or disclosure would not violate the Privacy and Security Rules if done by Covered Entity or Business Associate. Any use or disclosure of Protected Health Information shall be limited to a Limited Data Set or the Minimum Necessary to accomplish the intended purpose of such use or disclosure, or otherwise comply with guidance on "minimum necessary" as promulgated by the Secretary in accordance with section 13405(b) of the HITECH Act, codified at 42 U.S.C. section 17935(b). D. Specific Use and Disclosure Provisions. Except as otherwise limited in this Agreement, Business Associate may: (a) Use Protected Health Information for the proper management and administration of the Business Associate or to carry out the legal responsibilities of Business Associate; (b) Disclose Protected Health Information for the proper management and administration of Business Associate, provided that disclosures are Required By Law, or Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as Required By Law or for the purpose for which it was disclosed to the person, and the person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached; (c) Use Protected Health Information to provide Data Aggregation services to Covered Entity upon Covered Entity's request as permitted by 45 C.F.R. section 164.504(e)(2)(i)(B); and (d) Use Protected Health Information to report violations of law to appropriate Federal and state authorities, consistent with 45 C.F.R. section 164.502(j)(I). E. Obligations of Covered Entity. 1. Covered Entity shall notify affected Individuals, the Secretary, or the media, as applicable, upon a Breach of Unsecured Protected Health Information in accordance with the Privacy and Security Rules and the HITECH Act. 2. Covered Entity shall provide Business Associate written notification of any: (a) Limitation(s) in Covered Entity's notice of privacy practices in accordance with 45 C.F.R. section 164.520, to the extent that such limitation may affect Business Associate's use or disclosure of Protected Health Information; 4 (b) Changes in, or revocation of, permission by an Individual to use or disclose Protected Health Information, to the extent that such changes may affect Business Associate's use or disclosure of Protected Health Information; or (c) Restriction to the use or disclosure of Protected Health Information that Covered .Entity has agreed to in accordance with 45 C.F.R. section 164.522 or section 13405(a) of the HITECH Act, as codified at 42 U.S.C. section 17935(a), to the extent that such restriction may affect Business Associate's use or disclosure of Protected Health Information. 3. Except as provided above regarding data aggregation and management and administrative activities of Business Associate, Covered Entity shall not request Business Associate to use or disclose Protected Health Information in any manner that would not be permissible under the Privacy and Security Rules. F. Term and Termination. 1. Term. The Term of this Agreement shall be effective as of the date set forth above and shall terminate when all of the Protected Health Information in Business Associate's possession is destroyed or returned to Covered Entity, or, if it is infeasible to return or destroy Protected Health Information, protections are extended to such information, in accordance with the termination provisions in this Section. 2. Termination for Cause. Upon Covered Entity's knowledge of a material breach of this Agreement by Business Associate, Covered Entity has the right to: (a) Provide an opportunity for Business Associate to cure the breach or end the violation and terminate this Agreement and demand return of Protected Health Information in accordance with Section F.3(a) below if Business Associate does not cure the breach or end the violation within the time specified by Covered Entity; (b) Immediately terminate this Agreement and demand return of Protected Health Information in accordance with Section F.3(a) below if Business Associate has breached a material term of this Agreement and cure is not possible; or (c) If neither termination nor cure are feasible, report the violation to the Secretary. 3. Effect of Termination. (a) Except as provided in paragraph (b) of this Section, upon termination of this Agreement for any reason, Business Associate shall return or destroy all Protected Health Information. This provision shall apply to Protected Health Information that is in the possession of employees, subcontractors or agents of Business Associate. Business Associate shall retain no copies of the Protected Health Information. 5 (b) In the event that Business Associate determines that returning or destroying the Protected Health Information is infeasible, Business Associate shall provide to Covered Entity written notification of the conditions that make return or destruction infeasible. Upon determining that return or destruction of Protected Health Information is infeasible, Business Associate or its subcontractor or agent shall extend the protections of this Agreement and the Privacy and Security Rules to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Business Associate or such subcontractor or agent maintains such Protected Health Information. G. Miscellaneous. 1. Survival. The respective rights and obligations of Business Associate under Sections B.5 and F.3 of this Agreement shall survive the expiration or termination of this Agreement. The respective rights and obligations of Covered Entity under Sections E.1 and E.2 of this Agreement shall survive the expiration or termination of this Agreement. 2. Interpretation. Any ambiguity in this Agreement shall be resolved to permit Covered Entity to comply with the Privacy and Security Rules. 3. No Third Party Beneficiaries. This Agreement shall not confer any benefit or rights upon any person other than the parties hereto, and no third party shall be entitled to enforce any obligation, responsibility, or claim of either party to this Agreement, unless expressly provided otherwise in this Agreement. 4. Choice of Law. The law of the State of Missouri shall govern this Agreement. 5. Binding Nature and Assigmnent. This Agreement and the rights and obligations of a party hereto may be assigned only upon the prior written approval of the other party. The rights and obligations of the parties will inure to the benefit of, will be binding upon, and will be enforceable by the parties and their lawful successors, authorized assigns, and representatives. 6. Notices. Any notices required or permitted under this Agreement shall be deemed effective (a) on the day when personally delivered to a party, or (b) if sent by registered or certified mail, return receipt requested, on the third business day after the day on which mailed, postage prepaid, to such party at the address listed at the beginning of this Agreement. Either party may only change its address for notices under this Section by a written amendment to this Agreement made in accordance with Section G.8 below. 7. Waiver. No waiver or discharge of obligations arising under this Agreement shall be valid unless in writing and executed by the party against whom such waiver or discharge is sought to be enforced. The waiver by either party to this Agreement of a breach of any provisions of this Agreement shall not operate or be construed as a waiver of any subsequent breach of the same or any other provision of this Agreement. 6 8. Change in Law: Amendments. (a) A reference in this Agreement to a provision of HIPAA, the HITECH Act or each of their implementing regulations means such provision as in effect or as amended and all formal guidance issued thereunder. (b) No amendment or modification of this Agreement will be effective except by a written amendment executed by the party against whom such amendment or modification is sought to be enforced. (c) The parties acknowledge that it may be necessary to amend this Agreement from time to time as required by the provisions of the Privacy and Security Rules, or other applicable law, to ensure that this Agreement is consistent with all such laws and regulations. The parties agree to take such action to amend this Agreement from time to time as is necessary for Covered Entity and Business Associate to comply with the requirements of the Privacy and Security Rules and other applicable laws and regulations. This Agreement may be terminated by either party upon thirty (30) days prior written notice to the other party, or upon such lesser notice as required by applicable law, if the parties fail to reach written agreement on modifications to this Agreement needed to comply with the provisions of applicable law. 9. Counterparts. This Agreement may be executed in one or more counterparts, all of which shall be considered one and the same agreement. In witness whereof, the parties have executed this Agreement as of the day and date set forth above. Covered Entity: Business Associate: BeneFLEX HR Resources, Inc. By: ByC Title: Date: APPROVED AS TO FORM #521015;.1 7 Title fterc) Date: IZI 2 c> I yZ osu3oi2oio EMPLOYER INFORMATION 2. Name of Employer: (exactlyasit is to appear withlpunctuation) a. Ne+rr� c I t"Tu -. L-fJo f S b. Se,l,J2.r Cafeteria Flexible Spending Account (with or without Premium Conversion) Checklist/Transmittal Form 3. Employer's Address: a. Z3 5723 c)f a+- 3 +rQ_ (Street —Physical not P.O. Box) 4. 5. 6. b. -�- - >J + 5 c. d. 63! D3 (CItY) (State) (Zip} e. Telephone (3 ) - Za t) Employer's Tax ID No.: a. 43- by 1" Plan Number (clrcle one): a. 501 502 503 504 505 Plan Administrator shall be: a. IXEmployer, using Employer's address OR b. ❑ Other, AND, if Other selected c. ❑ Use Employers address d. ❑ Use address below... (Sheet —Physical not P.O. Box) 2. 3. 4. (City) (Sue) (Zip) 5. Telephone ( ) 7. Plan's Agent for service of legal process is: a. ❑ Employer, using Employers address b. ❑ Plan Administrator c. ❑ Other (Name) AND WU d.se Employers address (automatically selected if 7a chosen) e.se address below,.. 1. 2. (Slreet—Physical not P.O. Box) (City) Employer's Principal Office: a. 9. Plan Information: a. New Plan b. Amendment and Restatement (State) PP) (State) AND, is this Plan a'wrap' plan for Form 5500 filing purposes? c. Yes d. jg. No d. R NIA 12. Effective Date(s): a. Initial Effective Date b. This Restatement 10. Plan Name/Title of Document: (exactly as it is to appear with punctuation) a -roP ear, -. Licv L5 b. mower NN-�-r i c -�� c. 1Z5 11. Plan Year: a. Begins b. Ends zr ( (month) (day) 13( (month) (day) Is first year a short Plan Year? c. ❑ Yes, beginning (month) (day) ( nth) (day) (Year) 2—I 1 13 (month) (day) (year) 13. Employer Entity: a. 0 S Corporation (2% shareholders not eligible) b. ❑ Corporation c. ❑ Partnership (self-employed (partners) not eligible) d. ❑ Sole Proprietorship (self-employed not eligible) e. Govemmental Entity or Church f. ❑ Non -Profit Organization g. ❑ limited Liability Company (members not eligible) Note: 13a, c., d., & g., add a provision that excludes the group in parentheses from participating in the plan. ELIGIBILITY 14. Eligible Class of Employees: a. nAll Employees who satisfy eligibility requirements b. ❑ Salaried Employees only c. ❑ Hourly Employees only d. ❑ All Employees except: 1. ❑ Commissioned Employees 2. ❑ Union Employees 3. ❑ Leased Employees 4. ❑ Part-time Employees, expected to work less than hours per week 5. ❑ Nonresident Aliens 6. ❑ Employees not eligible under the Employers group medical plan 7. ❑ Those who have not completed Hours of Service (if left blank, default will be 1 Year of Service (1000 hours)) 8. ❑ Those who have not attained age (cannot exceed 21; if left blank, default will be age 21) 9. ❑ Other Note: If using Simple Cafeteria Provisions, only 2, 5, 7 and 8 can be selected. 15. C nditions for Eligibility: a. Same as Employer's group medical plan O b. ❑ For first Plan Year only, anyone employed on the effective date of the Plan is eligible, thereafter: (choose one from e. - g. below) FLEX-CKL-4 SUNGARD® Cafeteria ©2010 Cafeteria Flexible Spending Account (with or without Premium Conversion) ChecklistJTransmittal Form 09/30/2010 OR c. ❑ For all years, eligibility is as follows: (choose one horn d. - g. below) d. ❑ Date of hire (no service required) e. 0 years after date of hire f. ❑ days after date of hire 9. ❑ months after date of hire AND For Health Flexible Spending Account only, eligibility is as follows: h. No Health Flexible Spending Account, or eligibility is the same as above for ail benefits i. ❑ days after date of hire 1 ❑ months after date of hire k. ❑ years after date of hire Note: If option i., j. or k. selected, 211 must be selected. 16. En Date: a. D First day of the pay period next following date requirements were met b. 0 Date conditions for eligibility are met c. 0 Dual entry (lstday of Plan Year & 6 months later) d. 0 First day of Plan Year following date requirements were met e. ❑ First day of month following date requirements were met f. 'Same as Employer's group medical plan 17. Family and Medical Leave Act: Is the Employer subject to these provisions? a. ❑ No b. j4Yes CONTRIBUTIONS 18. Ctions. Plan will provide for... a. Salary reduction contributions ONLY (no Employer contributions) (gip m 20) b. ❑ Employer contributions ONLY (no salary reductions) (answer 19, then skip to 21) C. ❑ Both salary reductions AND Employer contributions 1. ❑ Simple Cafeteria provisions ONLY (skip 19, answer 40) 2. D Simple Cafeteria provisions AND additional Employer contributions. (answer 19 and 40) Note: Salary reduction contributions are set at the amount sufficient to cover a Participants benefit elections. Note: If Employer contributions are only paying a portion of the cost of insurance with no cash option, select 18a 19. Employer Contributions. For each Plan Year, Employer will contribute... 0 N/A a. ❑ % of compensation per Participant b. ❑ $ per Partidpant c. 0 Discretionary d. ❑ Other e. ❑ "Opt Out" (payment thealmcoverage waived) AND, the contributions shall be made... f. ❑ At beginning of Plan Year g. ❑ Pro rata each pay period AND, the contributions are convertible to cash h. 0 Yes f. 0 No Note: Option i. may not be selected with 18b or 19e Cafeteria (D2010 AND, the contributions are to be made to (select j. or all that apply from k. - m.) j. 0 All accounts k. 0 Health FSA (must answer 24) I. ❑ Health Savings Account (mustanswer 25) M. ❑ Dependent Care FSA (must answer21m) BENEFIT OPTIONS 20. Benefit Options. Plan to provide... k. ® Flexible Spending Accounts. (automatically selected) 21. Flexible Spending Accounts will be established for... (select . that apply) I, Health Flexible Spending Account m. ►i' a ependent Care Flexible Spending Account n, 0 Adoption Assistance Flexible Spending Account Note: The terms of the Health Flexible Spending Account are set below at 24. For the Dependent Care Flexible Spending Account and Adoption Assistance Flexible Spending Account, statutory maximums and terms are standard in the Flexible Spending Account Plan. AND include account for insurance premium payments o. ayes, include Premium Payment Account — must check options a. through k. below p. ❑ No (skip to 24) Premium Payments may be elected for... aa.. Health insurance (individual AND dependent coverage) b. ❑ Dependent health insurance ONLY OR c. ❑ No group health insurance AND d. ❑ Group -term fife insurance e. ❑ Disability insurance f. I Dental insurance g. ❑ Cancer insurance h. ❑ Vision insurance ❑ Accidental Death and Dismemberment insurance j. ❑ Prescription Drug Coverage k. ❑ Other insurance Coverage Note: k. adds language that allows for other types of health coverage not listed above. 22. Are the health premium payments elected above self -insured b th Employer? a. Yes b. 0 No 23. For Health and Disability Insurance, may Participants seek reimbursement for individual policies through the Premium Conversion Plan? a. 0 N/A b. [,Yes, at the Administrator's discretion No 24. Health Flexible Spending Account (Health FSA) Options: (select as app) a. NIA (No Health Flexible Spending Account skip to 25) b $ —7 SOO is the maximum amount to be contributed to the Health Flexible Spending Account (Health FSA) SUNGARD® FLEX-CKL-5 09/30/2010 Cafeteria Flexible Spending Account (with or without Premium Conversion) Checklist/Transmittal Form AND, further restrictions shall apply: (select all that apply) 1. ❑ the minimum amount to be contributed shall be: 2; 0 for a short Plan Year, $ is the maximum amount to be contributed to the Health Flexible Spending Account 3. ❑ if an Eligible Employee enters the Plan mid year, $ is the maximum amount to be contributed to the Health Flexible Spending Account AND, Terminated Employees shall.., (select one) c. g N/A —COBRA applies d. ❑ Continue contributions and reimbursements for the remainder of the Plan Year e. ❑ Cease contributions and reimbursements upon termination f. ❑ Continue or cease at Participant's election AND, new election due to change in status permitted? (select one) g. ❑ No h. ` 1, Yes i. 0 Yes, only if salary redirections to the Health FSAs are increased AND, to accommodate Health Savings Accounts (HSAs), the Health FSA will be limited to the following types of medical expenses... (select all that j. ►A N/A k. 0 certain types of expenses only: (select all that apply) 1. 0 dental expenses 2. ❑ vision expenses 3. 0 preventive expenses I. ❑ only expenses in excess of the HDHP deductible FOR m. ❑ all Participants n. 0 only HSA contributing Participants AND, claims for medical expenses can only be submitted for. o. ❑ the Participant p. jkthe Participant and all dependents Note: If medical expenses are not limited, HSA eligibility may be affected. -Qualified HSA Distribution. A Qualified HSA Distribution can be made: (also select Grace Period at 32) q. ❑ Yes r. lallo MISCELLANEOUS PROVISIONS 25. Health Savings Account provided by Employer? a. ❑ Yes b. TSLNo 26. Benefit Election Period shall be... a. ❑ The day period prior to each Plan Year b. ❑ From the day to 1. day period prior to each Plan Year c. Established by Administrator in nondiscriminatory manner 27. Is automatic enrollment for insured benefits provided under this PI n? a. aiL.Yes b. ❑ No 28. Participants who fail to sign a new election form shall... a. 0 Be considered to have elected not to participate for upcoming Plan Year (may not be selected wrh 27a) b. Continue same elections as prior year only for insured benefits (may any be selected with 21o) 29. Witnesses to Employer's signature: a. ❑ Yes b. ZNo Note: State law may require witnesses to the Employer's signature. SunGard does not have this information. 30. Is a 401(k) Plan a benefit under this Cafeteria Plan? a. ❑ Yes, name of Plan: b. `R:[ No or N/A 31. May Participants convert vacation days into Cafeteria Plan benefit dollars? a. ❑ Yes b. ta No 32. "Grace Period" Extend the time to incur expenses past the end of the PIn Year: a. aYes b. ❑ No AND, extend the time period by how long? (serest one) C. -75 days (maximum 75) d. 21 /2 months after the end of the Plan Year (March 15 for a calendar year plan) ANDJIIow up to what amount? (select one) e. ntire remaining account balance f. ❑ $ AND, for which accounts? g. Et. Health FSA h. ❑ Dependent Care FSA I. ❑ Adoption Assistance FSA 33. Claims for Reimbursement must be filed within Health FSA: (must select a. or b.; c. is optional in addition to a. or b.) a. ❑ days following each Plan Year (e.g., 60) b. IX (,-4-1 days following the Grace Period (e.g., so) (may not be selected with 32.b.) AND, for Participants who terminate employment, will a different filing des line apply? (optional, lean blank 1 WA) c. 3 (2:, days following termination of employment (e.g., 60) Dependent Care FSA: (must select d. or e.; f. is optional in addition to d. or e.) d. ❑ days following each Plan Year (e.g., 60) e. '®""•• days following the Grace Period (e.g., 60) (may not be selected with 326) AND, for Participants who terminate employment, will a different filing deadline a,pppply? (optional, leave blank if WA} f. j gig? _ days following termination of employment (e.g., so) Adoption Assistance FSA: (must select g. or h.; i. Is optional In addition to g. or h.) g. ❑ days following each Plan Year (e.g. so) h. ❑ days following the Grace Period (e.g., so) (may not be selected with 32b) FLEX CKL-6 SUNGARD® Cafeteria 02010 Cafeteria Flexible Spending Account (with or without Premium Conversion) O9/3012O10 Checklist/Transmittal Form AND, for Participants who terminate employment, will a different filing deadline apply? (optional, leave blank If NIA) i. D days following termination of employment (e.g., 60) 34. Claims should be submitted to: a. ❑ Employer, using Employer's address b• P.C) l 2ac at address below: 1. (Street --Physical not P.D. Box) 2. (CitY) (State) (Zip) 35. Are employer provided debit or credit cards used for expenses thro h Flexible Spending Accounts? a. Yes AND, for which accounts? 1. ealth FSA (may only be selected with 211) 2. ❑ Dependent Care FSA (may only he selected with 21m) b. 0 No 36. Add COBRA? (a. must be selected if 24c chosen, b. must be selected if 24d, e, or f. chosen) a N.Yes b. ❑ No 37. Is the Plan subject to HIPAA? a. � Yes b. ❑ No 38. HEART Act. Add Qualified Reservist Distribution (QRD) provisions for Health FSA: a. ❑ ► lA or No (skip to 3s) b. ►� Yes AND, select distribution amount (all amounts minus reimbursements paid) (select one): c. ❑ the beginning of year FSA amount d. 'amount contributed up to point of distribution request e. ❑ $ (cannot exceed beginning of the year FSA amount) AND, how many distributions per year? f. ) � per year AND, claims submitted after QRD (select one): g. ❑ be paid on submission as any other daim h. shall not be paid 39. Dependent Care and Adoption Assistance Flexible Spending Account Maximums. The statutory maximums for Dependent Care andlor Adoption Assistance will be the maximums for Plan unless elected below. Options b. - d. may beadded if the statutory maximums are selected. (select all that apply: leave blank if not applicable) a. ❑ The statutory maximum is replaced by the amount below: 1. ❑ $ for Dependent Care FSA 2. ❑ $ for Adoption Assistance FSA AND, will there be a minimum? b. ❑ Yes 1. ❑ $ for Dependent Care FSA 2. 0 $ for Adoption Assistance FSA AND, for a short Plan Year, will there be a different maximum? c. 0 Yes 1. ❑ $ for Dependent Care FSA 2. ❑ $ for Adoption Assistance FSA AND, if an Eligible Employee enters the Plan mid -year, will there be a different maximum? d. ❑ Yes 1. ❑ $ for Dependent Care FSA 2. ❑ $ for Adoption Assistance FSA HEALTH CARE REFORM PROVISIONS 40. Simple Cafeteria plan (for employers with 100 or fewer em Ioyees): a. D] Yes, effective b. El No AND, the Employer Contribution shall be... (select one) C. ❑ _% (not less than 2%) of a Participants Compensation d. ❑ Matching contribution equal to _% of compensation but in no event more than _% (cannot be less than 6% of compensation) AND, the contributions are convertible to cash e. 0 Yes f. ❑ No 41. Coves_ a for Children provided in Health FSA? a. es b. 0 No (may only be selected if Health FSA limited to participant only) Skip to 60 ADOPTING EMPLOYERS 60. Will Adopting Employers execute this Plan? Note: Selecting 'Yes' will generate a Supplemental Participation Agreement. /A or No Yes First Adopting Employer 1. 2. 3. 4. (Sue) (City) (Slate) (Zip} (ID No.) ...AND, the first Adopting Employer is? c. ❑ S Corporation (2% shareholders not eligible) d. ❑ Corporation e. ❑ Partnership (self-employed (partners) not *tie) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Governmental Entity or Church h. ❑ Non -Profit Organization I. ❑ Limited liability Company (members not etlglble) Cafeteria ®2D10 SUNGARD® FLEX-CKL-7 09/30/2010 61. Will there be a second Adopting Employer? a ❑ No b. ❑ Yes 1. 2. 3. 4. (Name) (Street) (City) (State) Cafeteria Flexible Spending Account (with or without Premium Conversion) Checklist/Transmittal Form ...AND, the fourth Adopting Employer is? c. ❑ S Corporation {2% shareholders not eligible) d. ❑ Corporation e. ❑ Partnership {self-employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Governmental Entity or Church h. ❑ Non -Profit Organization i. ❑ Limited Liability Company (members not eligible) 64. Will there be a fifth Adopting Employer? a. ❑ No b. ❑ Yes (ID No.) ...AND, the second Adopting Employer is? c. ❑ S Corporation (2% shareholders not ergible) d. 0 Corporation e. ❑ Partnership (self-employed (partners) not ergible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Govemmental Entity or Church h. 0 Non -Profit Organization i. ❑ Limited Liability Company (members not elgIble) 62. Will there be a third Adopting Employer? a. ❑ No b. ❑ Yes 1. 2. 3. 4. (Name) (Street) (City} (State) (ID No.) ...AND, the third Adopting Employer is? c. ❑ S Corporation (2% shareholders not eligible) d. ❑ Corporation e. 0 Partnership (self-employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. 0 Governmental Entity or Church h. 0 Non -Profit Organization I. ❑ Limited Liability Company (members not eligible) 63. Will there be a fourth Adopting Employer? a. ❑ No b. ❑ Yes (N) (Street) 3. (CAM (State) 4. (ID No.) 1. 2. 3. 4. (Name) (Street) (City) (Stale) {Zip) (ID No.) ...AND, the fifth Adopting Employer is? c. ❑ S Corporation (2% shareholders not eligible) d. ❑ Corporation e. 0 Partnership (set -employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Govemmental Entity or Church h. ❑ Non -Profit Organization I. ❑ Limited Liability Company (members not eligible) 65. Will there be a sixth Adopting Employer? a. 0 No b. ❑ Yes 1. 2. 3. 4. (Name) (Street) (City) (State) (Zp) (ID No.) ...AND, the sixth Adopting Employer is? c. ❑ S Corporation (2% shareholders not eligible) d. ❑ Corporation e. ❑ Partnership (self-employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Govemmental Entity or Church h. 0 Non -Profit Organization i. ❑ Limited Liability Company (members not eligible) FLEX-CKL-8 SUNGARD® Cafeteria ®2010 Cafeteria Flexible Spending Account (with or without Premium Conversion) 0913012010 ChecklistlTransrnittal Form 66. Will there be a seventh Adopting Employer? a. ❑ No b. ❑ Yes 1. 2. 3. 4. (Name) (Sheet) (City) {State} (ID No.) ...AND, the seventh Adopting Employer is? c. ❑ S Corporation (2% shareholders notergible) d. ❑ Corporation e. ❑ Partnership (self-employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Governmental Entity or Church h. ❑ Non -Profit Organization i, ❑ Limited Liability Company (members not eitgitte) 67. Will there be an eighth Adopting Employer? a. ❑ No b. ❑ Yes 2. 3. 4. (Name) (Street) (City) (State) (ID No.) ...AND, the eighth Adopting Employer is? c. ❑ S Corporation (2%6shareholders not eligible) d. ❑ Corporation e. ❑ Partnership (self-employed (partners) not agile) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Governmental Entity or Church h. ❑ Non -Profit Organization i. ❑ Limited Liability Company (members notergble) 68. Will there be a ninth Adopting Employer? a. D No b. ❑ Yes (Name) 2. 3. (City) (State) (Zip) 4. (Sheet) (ID No.) ...AND, the ninth Adopting Employer is? c. ❑ S Corporation (2% shareholders not eligible) d. ❑ Corporation e. ❑ Partnership (self employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Governmental Entity or Church h. ❑ Non -Profit Organization i. ❑ Limited Liability Company (members not eligible) 69. Will there be a tenth Adopting Employer? a. ❑ No b. ❑ Yes 1. 2. 3. (Name) (Street) (City) (Slate) (Zip) 4. (ID No.) ...AND, the tenth Adopting Employer is? C. ❑ S Corporation (2% shareholders not eligible) d. ❑ Corporation e. ❑ Partnership (self-employed (partners) not eligible) f. ❑ Sole Proprietorship (self-employed not eligible) g. ❑ Governmental Entity or Church h. 0 Non -Profit Organization i. ❑ Limited Liability Company (members riot eligible) Cafeteria @2010 SUNGARD® FLEX-CKL-9 09130/2010 Cafeteria Flexible Spending Account (with or without Premium Conversion) Checklist/Transmittal Form These documents are being printed by SunGard at the direction of the person named on the transmittal form, who is either a professional authorized to practice before the Internal Revenue Service or acting under the direction of such a professional. It is understood that SunGard is not engaged in the practice of law. Any unanswered questions may result in errors in the Plan produced by using the information from this worksheet. I understand that in preparing the document requested, SunGard is utilizing information shown on this checklist to produce documents using a format which has been designed by SunGard and programmed by SunGard on its Relius® Documents system. SunGard has made NO REPRESENTATION OR WARRANTY OF ANY KIND, expressed or implied, including no warranties of MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, nor is any opinion, expressed or implied, rendered by its attorneys as to the legal effect, sufficiency or tax qualification of any document utilizing SunGard's format If a check is not enclosed, the undersigned agrees to pay SunGard upon receipt of such documents at the prices in effect when this order is received by SunGard. The practitioner shall be exclusively responsible for carefully reviewing and editing all documents to confirm their accuracy and client suitability. 1 hereby RELEASE SunGard from any and all liability attributable to any legal or other defect in the requested documents. I understand that I am responsible for the payment of any applicable taxes, including sales and/or use taxes, that may be due upon purchase of services provided herein. SIGNED Required) FLEX-CKL-10 SUNGARD® Cafeteria 42010 Health Reimbursement Arrangement HEALTH REIMBURSEMENT ARRANGEMENT PLAN APPLICATION The undersigned Employer adopts Health Reimbursement Arrangement and elects the following provisions: EMPLOYER INFORMATION 1. EMPLOYER'S NAME, ADDRESS AND TELEPHONE NUMBER Name: ,=?1 1 5 Address: Z3 sc.> 1\--10..rke.-1- S---rime-+ Street Li.5 i.--tO 63io.3 City State Telephone: 314 - -7 i ,2c O Fax: L4 � 2. EMPLOYER'S TAXPAYER IDENTIFICATION NUMBER: 9..3 ". VA I l cH 3. TYPE OF ENTITY a. [ ] Corporation (including Tax-exempt or Non-profit Corporation) b. [ ] Professional Service Corporation c. [ ] S Corporation d. [ ] Limited Liability Company that is taxed as: 1. [ ] a partnership or sole proprietorship 2. [ ] a Corporation 3. [ ] an S Corporation e. [ ] Sole Proprietorship or Non-profit Corporation f. [ ] Partnership (including Limited Liability) g. p Governmental Entity h. [ ] Other: NOTE: S Corporation shareholders, partners, sole proprietors, and members of a Limited Liability Company generally cannot participate in the Heath Reimbursement Arrangement. r� Total number of employees Number of covered employees —i 50 PLAN INFORMATION 4. PLAN NAME: Hp-F-r-c.)ed (fir-N Lc s 5e er ack) -i- i-N n, k-NrSe.rrer\-- f rr mac- m e# f I c r 5. EFFECTIVE DATE a. [ ] This is a new Health Reimbursement Arrangement effective as of the "Effective Date"). b. i4 This is an amendment and restatement of a previously established Health Reimbursement Arrangement of the Employer which was originally effective 0(�) %1 (hereinafter called the "Effective Date'). The effective date of this amendment and restatem nt is Z1 1 I i 3 6. PLAN YEAR — The first plan year for the HRA will be: a. a 12-consecutive-month period beginning (date) 4—f i and ending (date) b. [ ] a short plan year beginning (date) and ending (date) ® Copyright 2005 SunGard Inc. 1 (hereinafter called Rev. 04192011 Health Reimbursement Arrangement PLAN INFORMATION (continued) 7. CONSECUTIVE PLAN YEARS (if first year is short plan year) a. n/a b. [ ] a 12 month period beginning (date) and ending (date) 8. NUMBER assigned by the Employer a. [ ] 501 b. [ ] 502 c. [ ] 503 d. [ ] Other: 9. PLAN ADMINISTRATOR'S NAME, ADDRESS AND TELEPHONE NUMBER: (If none is named, the Employer will become the Administrator.) a. Employer (Use Employer address and telephone number). b. [ ] Use name, address and telephone number below: Name: Address: Telephone: Street City 10. CLAIMS ADMINISTRATOR'S NAME, ADDRESS AND TELEPHONE NUMBER: (If none is named, the Employer will serve as the Claims Administrator.) a. [ ] Employer (Use Employer address and telephone number). b. t>er Use name, address and telephone number below: Name: 4-1 Address: Telephone: Street City State Zip ELIGIBILITY REQUIREMENTS 11. ELIGIBLE EMPLOYEES a. [ ] N/A. No exclusions. b. The following are excluded (select all that apply): 1. [ ] Union Employees 2. [ ] Non-resident aliens 3. Employees who are not eligible for the Employer's group medical plan 4. [ ] Salaried Employees 5. [ ] Hourly Employees 6. [ ] Leased Employees 7. [ ] Part -Time Employees scheduled to work at least hours per week. 8. [ ] Other: 12. THE FOLLOWING AFFILIATED EMPLOYERS will adopt this Health Reimbursement Arrangement as Participating Employers (if there is more than one, or if Affiliated Employers adopt this after the date the Adoption Agreement is executed, attach a list to this Adoption Agreement of such Affiliated Employers including their names, addresses and taxpayer identification numbers): a. 14 N/A b. [ ] Name of Affiliated Employer (s): ® Copyright 2005 SunGard Inc. Revised 02/15/07 (Updated 4-2010) 2 13. CONDITIONS OF ELIGIBILITY Any Eligible Employee will be eligible to participate in the Health following: a. [ ] Date of Hire (No service required) b. ,P'Q Same conditions as Employer's group medical plan c. [ ] years after date of hire d. [ ] months after date of hire e. [ ] days after date of hire f. [ ] Other: Health Reimbursement Arrangement Reimbursement Arrangement upon satisfaction of the 14. EFFECTIVE DATE OF PARTICIPATION An Eligible Employee who has satisfied the eligibility requirements will become a Participant on a. [ ] the day on which such requirements are satisfied. b. [ ] the first day of the month coinciding with or next following the date on which such requirements are satisfied. c. [ ] the first day of the calendar quarter coinciding with or next following the date on which such requirements are satisfied. d. [ ] the first day of the pay period coinciding with or next following the date on which such requirements are met. e. [ ] the first day of the Coverage Period coinciding with or next following the date on which such requirements are satisfied. f. same date as Employer's group medical plan. g. [ ] Other: BENEFITS 15. MAXIMUM BENEFIT AVAILABLE PER COVERAGE PERIOD: a. [ ] Employee Only $ CC, Employee Plus One $ Family $ EE or ER pays r` $ How are out -of -network claims paid? [ ] HRA does not cover out -of -network claims [ ] HRA pays out -of -network claims up to the in -network amount [ ] HRA pays ail out -of -network claims FAdditional plan information: r +Y� -�-o Prri C' iems- or. 1 l i)nCdS � be_ .-6 l d 4-0c r�rylA f7-1 klj- ,cm C� b. Should HRA claims be paid from the deductible accumulated total on the EOB? c. [ ] Other (please list details): 16. Medical plan renewal date: 1 i 17. COVERAGE PERIOD is: a. [ ] monthly b. [ ] quarterly c. [X( yearly d. [ ] Other: 18. THIS ARRANGEMENT SHALL REIMBURSE: (select all that apply) a. [ ] co -payments under the Employer's group medical plan b. [ ] deductibles under the Employer's group medical plan c. [ ] all medical expenses within the meaning of Code Section 213, including non-prescription drugs d [ ] medical insurance premiums e [ ] the following types of medical expenses ONLY: f. c>4 Other: V l 5,00r1 LaT, Ord. (C SS e5 0-on-1- caNd 19. IF THE EMPLOYER MAINTAINS A HEALTH FLEXIBLE SPENDING ACCOUNT, WHICH PLA SHALL PAY EXPENSES FIRST? a. [ ] N/A. The Employer does not maintain a Health Flexible Spending Account and/or Cafeteria Plan. b.).4, This Plan (Heath Reimbursement Arrangement). ® Copyright 2005 SunGard Inc. 3 Rev. 04192011 Health Reimbursement Arrangement c. [ ] The Health Flexible Spending Account under the Employer's Cafeteria Plan. 20. IS THE EMPLOYER SUBJECT TO THE FAMILY AND MEDICAL LEAVE ACT? If b. Is selected, FMLA will not apply a. >Yes. b. [ ] No. 21. IS THE PLAN SUBJECT TO COBRA? If b. is selected, COBRA will not apply a.. Yes. b. [ ] No. 22. CARRY FORWARD: Amounts not used during a Coverage Period shall: % CC) a. be carried forward to the next Coverage Period, in an amount up _ $' However, the maximum accumulation limit for a Coverage Period is $ b. [ ] be forfeited. 23. RETIREES OR OTHER TERMINATED EMPLOYEES SHALL: a. [ ] Shall continue to be eligible for reimbursement of any remaining balances. b. May not participate and any unused amounts are forfeited. 24. A CLAIM may be submitted up to 60 days after a, q the end of the Coverage Period b. [ ] the end of each calendar year c. [ ] Other: 25. DEBIT/CREDIT CARDS shall be provided by the Employer for Medical Expenses: a. [ ] Yes b. 4 No 26. Disbursements of funds: a. [ ] Disbursement Register b. f>1 Check Register on BeneFLEX's Account — ACH Employer's Account Authorized Signature Date Fax this completed form to BeneFLEX HR Resources, Inc.: (314) 909-6983 10805 Sunset Office Dr., Suite 401 • St. Louis, MO 63127. 314-909-6979 ® Copyright 2005 SunGard Inc. Revised 02/15/07 (Updated 4-2010) 4 RESOLUTION NO. 3176 WHEREAS, Ordinance No. 13559, adopted December 13, 2012, authorized the Executive Director and Secretary -Treasurer on behalf of The Metropolitan St. Louis Sewer District to enter into a contract with BeneFlex HR Resources Inc. to administer the District's Flexible Benefit Plan and Prescriptive Eyewear Plan, and WHEREAS, said contract will expire on January 31, 2015, and WHEREAS, the District desires to exercise it option to renew said contract for an additional one-year term, commencing on February 1, 2015, NOW, THEREFORE, BE IT ORDAINED BY THE BOARD OF TRUSTEES OF THE METROPOLITAN ST. LOUIS SEWER DISTRICT THAT, the Executive Director and Secretary -Treasurer are hereby authorized on behalf of The Metropolitan St. Louis Sewer District to exercise the District's option to renew for an additional one-year term commencing on February 1, 2015, the contract with BeneFlex HR Resources Inc. whereby BeneFlex HR Resources Inc. would administer the District's Flexible Benefit Plan and Prescriptive Eyewear Plan, said contract renewal shall be comprised of such terms and conditions as are approved by the Office of the General Counsel of the District. The foregoing Resolution was adopted on November 13, 2014.