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Home My Public Portal AboutRES-CC-2006-10RESOLUTION #10-2006 A RESOLUTION OF THE GOVERNING BODY OF MOAB CITY ADOPTING THE FLEXIBLE BENEFIT PLAN ELECTION FORM/CONTRACT DOCUMENT WHEREAS, Resolution #13-93 established a medical reimbursement policy for the City of Moab; and WHEREAS, the Governing Body of Moab City has a need to modify that policy; NOW, THEREFORE, BE IT RESOLVED BY THE GOVERNING BODY OF MOAB CITY THAT THE ATTACHED FLEXIBLE BENEFIT PLAN ELECTION FORM/CONTRACT IS HEREBY ADOPTED AND WILL BE EFFECTIVE AS OF MAY 31, 2006. PASSED AND APPROVED in open Council by a majority vote of the Governing Body of Moab City Council this 25TH day of April, 2006 ATTEST: Rachel Ellison, Recorder SI ED: David L. S . ison, Mayor Resolution#10-2006 Page 1 of 1 CITY OF MOAB FLEXIBLE BENEFITS PLAN ELECTION FORM/CONTRACT AND COMPENSATION REDUCTION AGREEMENT FOR PREMIUM REIMBURSEMENT EMPLOYEES Employee Name: Employee Address: 217 EAST CENTER STREET Plan Year: JANUARY TO DECEMBER 2006 Employee Number: As an eligible employee in the above plan, I acknowledge that I have received the Summary Plan Description, I have read the Summary Plan Description, and I understand the benefits available to me a well as the other rights and obligations which I have under the plan. ELECTION OF MEDICAL REIMBURSEMENTS (X) I elect to receive medical reimbursements for the plan year. (X) The City contribution amount for Deductible Offset will be - $ _for the plan year. ( ) The City contribution amount for Exempt Deductible offset will be - $ for the plan year. The City contribution amount for Medical Reimbursement will be - $ for the plan year. The amount of Compensation Redirection (monies withheld from your check) will be - $ for the plan year. I understand the following: • The maximum medical and dental expense subject to reimbursement during any plan year for any Participant shall not exceed the greater of 1/26 of Participant's annual income or $2,000. • Reimbursements will be available only for qualifying medical care expenses. Generally, qualifying medical care expenses are those medical expenses normally deductible on my federal income tax return (without regard to the percentage of adjusted gross income limitation). Qualifying medical care expenses include expenses incurred for the following: • Medicines, drugs, birth control pills, vaccines, and vitamins prescribed by a doctor. • Medical doctors, dentists, eye doctors, chiropractors, osteopaths, podiatrists, psychiatrists, psychologists, physical therapists, acupuncturists, and psychoanalysts (medical care only). • Medical examinations, X-ray and laboratory services and insulin treatments. • Nursing help. If you pay someone to do both nursing and housework, you can be reimbursed only for the cost of the nursing help. • Hospital care including meals and lodging, clinic costs, and lab fees. • Medical treatments at a center for substance abuse. 1 " Medical aids such as hearing aids (and batteries), false teeth, eyeglasses, contact lenses, braces, orthopedic shoes, crutches, wheelchairs, guide dogs and the cost of maintaining them. " Ambulance services and other travel costs to get medical care. If you use your own car, you can claim 15 cents per mile. Add parking and tolls to the amount you claim. " Qualifying medical care expenses incurred for the following must be accompanied by a doctor's certification indicatinz the specific medical disorder, the specific treatment needed, and how this treatment will alleviate the medical condition: " Whirlpools " Tanning Bed for the treatment of psoriasis " Water Bed to be used in the aid of a special aliment and NOT for general well-being " Orthopedic Bed to be used in the aid of a special aliment and NOT for general well-being " Exercise Equipment to be used in the aid of a special aliment and NOT for general well-being " I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer on demand for any liability it may incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non -qualifying expense, up to the amount of additional tax actually owed by me. " This section of the agreement will automatically terminate if the Plan is terminated or discontinued. " I agree to provide the Plan Administrator with an explanation of benefits from the insurance company as proof of my monetary responsibility. " If I cease my employment with the Employer, my participation in the Plan will cease. No further contributions will be made to the Plan on my behalf, although I may be entitled to reimbursements for claims incurred prior to my date of termination. " I cannot seek reimbursement from this account for a medical expense which I intend on taking as a deduction or credit on my tax return. " You cannot obtain reimbursement for the following: " The basic cost of Medicare insurance (Medicare A). " Life insurance or income protection policies. " Accident insurance for you or members of your family. " Health insurance coverage for you or members of your family. " Hospital insurance benefits withheld from your pay as part of the Social Security tax or paid as part of Social Security self-employment tax. " Nursing care for a healthy baby. " Illegal operations or drugs. " Travel your doctor prescribed for you for rest or change. " Cosmetic Surgery. " Any Expense recommended for the bettering of general health is not eligible (example: health fitness clubs or classes) " Qualifying medical expenses include only those expenses incurred for the following individuals: " You " Your spouse " All dependents you list on your federal tax return. " Any person that you could have listed as a dependent on your return if that person had not received $2,450 or more of gross income or had not filed a joint return. This amount is adjusted each year for cost of living. 2 ELECTION OF DEPENDENT CARE REIMBURSEMENTS I elect to receive dependent care reimbursements for the plan year. The amount of compensation redirection will be $ for the plan year. I understand the following: • Reimbursement will be available only for qualifying dependent care expenses as described in the Internal Revenue Code Section 129, the Plan document, and the Summary Plan Description. • I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense. I also agree to indemnify and reimburse the Employer on demand for any liability it may incur for failure to withhold federal, state or local income tax or Social Security tax from any reimbursement I receive of a non -qualifying expense, up to the amount of additional tax actually owed by me. • I agree to provide the Plan Administrator with a statement from the service providers that includes the amount of the expense as proof that the expense has been incurred. • I agree to provide the Plan Administrator with the name, address, and if applicable, the taxpayer identification number of the service providers. • This section of the agreement will automatically terminate if the Plan is terminated or discontinued. I will, however, be entitled to be reimbursed for eligible expenses (to the extent funded) for the remainder of the Plan year. • I will only be reimbursed for amounts up to the balance in my account at the time of my request. • I cannot claim a dependent care tax credit on amounts I receive as reimbursements under this dependent care assistance program. • The worksheet on page 6 is to help you estimate your annual dependent care costs. The worksheet is not intended to be comprehensive but may be used as a guide. • Under the plan you will be reimbursed only for dependent care expenses meeting all of the following conditions: • The expenses are incurred for services rendered after the date of this election and during the Plan year to which it applies. • Each individual for whom you incur the expenses is either of the following: (1) a dependent under age 13 whom you are entitled to claim as a dependent (or a child or other dependent under age 13 whom you are supporting but are not entitled to claim as a dependent only because of a written declaration of decree of divorce) on your federal income tax return, or (2) a spouse or other tax dependent (or a child you are supporting but are not entitled to claim as a dependent only because of a written declaration or decree of divorce) who is physically or mentally incapable or caring for himself or herself • The expenses are incurred for the care of a dependent described above, or for related household services, and are incurred to enable you to be gainfully employed. • If the expenses are incurred for services outside your household, they are incurred for the care of a dependent as described above, or for an individual who regularly spends at least 8 hours per day in your household. • If the expenses are incurred for services provided by a dependent care center (i.e., facility that provides care for more than six individuals not residing at the facility), the center complies with all applicable state and local laws and regulation. • The expenses are not paid or payable to a child of yours who is under age 19 at the end of the year in which the expenses are incurred. • The expenses are not paid or payable to an individual for whom you or your spouse is entitled to a personal tax exemption as a dependent. ELECTION NOT TO PARTICIPATE I reject to following benefits offered me through the flexible benefits plan: 3 ( )Group health insurance coverage ( )Medical reimbursements ( ) Dependent care reimbursements OTHER TERMS AND CONDITIONS I understand the following: • I cannot change or revoke any of my elections or this compensation reduction agreement at any time during the plan year unless I have a change in family status. Such changes include marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of employment of a spouse, change in my or my spouses employment status from full-time to part-time or from part-time to full-time, my spouse or me taking an unpaid leave of absence, a substantial change in my family's health coverage due to a change in my spouses employer -sponsored health coverage, or such other events as the Plan Administrator determines will permit a change or revocation of an election. • The Plan Administrator may reduce or cancel my compensation reduction or otherwise modify this agreement in the event be believes it advisable in order to satisfy certain provisions of the Internal Revenue Code. • The reduction in my cash compensation under this agreement shall be in addition to any reductions under other agreements or benefit programs maintained by my Employer. • Any amounts that are not used during a Plan year to provide benefits will be forfeited and may not be paid to me in cash or used to provide benefits specifically for me in another Plan year. • Prior to the first day of each Plan year I will be offered the opportunity to change my benefit elections for the following Plan year. If I do not complete and return a new election form at that time, I will be treated as having elected not to participate for the following Plan year. • This agreement is subject to the terms of the Employers Flexible Benefits Plan, as amended, shall be governed by and construed in accordance with applicable laws, shall take effect as a sealed instrument under applicable laws, and revokes any prior election and compensation reduction agreement relating to such plan. Signature of Employee Date Signature of Employers Authorized Representative Date 4