HomeMy WebLinkAboutOPH FLEX TASC Standard Plan Document & Plan Adoption with FSA 2017
Plan Document
1 FlexSystem Plan Document
Article I: Table of Contents
Article I Table Of Contents Article VI Elections
6.01
Article II Purpose 6.02 Election Maximum Amounts
2.01 Creation and Title6.03 Failure to Elect
2.02 Effective Date6.04 Effective Periods for Elections
2.03 Purpose6.05 Change in Status Events
6.06 Non-Discrimination
Article III
3.01 Change in Status Event Article VII Contributions
3.02 Code7.01 Employer Contributions
3.03 Compensation7.02 Employee Salary Reductions
3.04 Dependent7.03 Administrative Fees
3.05 Effective Date7.04 Increases or Decreases in
3.06 Eligible EmployeePremium
3.07 Employee
3.08 Employer Article VIII Records and Reports
3.09 Enrollment Communication8.01 Responsibility
3.10 Participant8.02 Examination of Records
3.11 Plan Year
3.12 Article IX Plan Termination
3.13 Spouse9.01 Plan Termination
9.02 Rights to Terminate
Article IV Administration
4.01 Employers Duties Article X Plan Construction
4.02 Information to be Provided to 10.01 Taxation
the Employer10.02 Adoption by Related
4.03 Interpreting Plan TermsOrganizations
4.04 Misstatements10.03 Uniform Exercise of Powers
4.05 Review Procedures10.04 Construction
4.06 Rules Apply Uniformly10.05 Entire Document
4.07 Facility of Payment10.06 Severability
4.08 Information to be Furnished10.07 ovided through
4.09 Medical Child Support OrdersThird Parties
10.08 Rights Against the Employer
Article V Eligibility and Participation 10.09 Successor-Businesses
5.01 Eligibility Requirements
5.02 Current Employees at the Time Article XI Plan Adoption and Schedule
of Plan Inception11.01 Employer Adoption
5.03 New Employees11.02 Plan Year
5.04 Re-Employment of Former 11.03 Effective Date
Employees11.04 Eligible Employee
5.05 Becoming a Participant11.05 Commencement of Participa-
5.06 tion
5.07 Termination of Participation11.06 Plans
5.08 Family Medical Leave Act
5.09 Uniformed Services Employ-
ment & Reemployment Rights
Act (USERRA)
5.10 Layoff, Leave of Absences and
Sabbaticals
2 FlexSystem Plan Document
Article II: Purpose
2.01 Creation and Title. The Employer adopts 2.03 Purpose. The Plan allows Participants to
this Cafeteria Plan as indicated by the elect between cash Compensation or certain
Employer signature in Article XI - 11.01, and nontaxab
creates this Cafeteria Plan under the terms tained by the Emplo
and conditions set forth in this Plan Docu-Plan Schedule, see Article XI. The Employer
ment as well as through the Enrollment intends that this Plan qualify as a Cafeteria
Communications that are expressly incor-Plan under Section 125 of the Internal Rev-
porated by reference into this Plan Docu-enue Code. Notwithstanding any term in
ment and described in Article XI - 11.06. this Plan Document, if any term is found
w, the
2.02 Effective Date. The original Effective Date of term will automatically be amended to
this Cafeteria Plan and the Effective Date of comply with the federal or state law.
Plan Schedule, see Article XI.
Article III: Definitions
3.01 Change in Status Event. A Change in 3.04 Dependent. For the purpose of the tax
Status Event allows a Participant to revoke advantages available under this Plan, a
or change his/her pre-tax election during Dependent is an individual who is a depen-
the Plan Year, and outside of the scheduled dent of a Participant within the meaning of
open Enrollment period. The Employer al-Section 152(a) of the Internal Revenue Code,
lows all of the Change in Status Events and any child of the Participant to whom
published by the IRS for this type of Plan IRS Rev. Proc. 2008-48 applies (regarding
under 26 CFR 1.123-4, as amended. A certain children of divorced or separated
Participant who becomes eligible under parents who receive more than half of their
the Health Insurance Portability & Account-support for the calendar year from one or
ability Act of 1996 (HIPAA) for coverage both parents and are in the custody of one
or both parents for more than half of the
by the Employer will be allowed to make a calendar year). For the purposes of the tax
consistent election, or election change adv
under this Plan.Plans that provide accident and health
3.02 Code. The Internal Revenue Code of 1986, 106 of the Code, a Dependent is determined
as amended from time to time.without regard to Subsections (b)(1), (b)(2),
and (d)(1)(B) thereof and includes any child
3.03 Compensation. All the earned income, -
salary, wages and other earnings paid by the ticipant who at the end of the taxable year
Employer to a Participant during a Plan Year, has not attained age 27.
including any amounts contributed by the
Employer pursuant to a salary reduction 3.05 Effective Date.
agreement which are not includable in gross Plan Schedule, see Article XI, on which the
income under Sections 125, 402(g)(3), 402(h), ve, and the date that
403(b) or 457(b) of the Internal Revenue this Plan Document is in effect.
Code.
3 FlexSystem Plan Document
3.06 Eligible Employee. An Employee who is 3.08 Employer. The Employer adopting this
eligible to participate in the one or more Plan under Article XI,
y the subsidiary that, with the consent of the Em-
Employployer becomes an Employer, by adopting
below who meet the additional require-the Plan, or any successor business organi-
ments in the Plan Schedule, see Article XI, zation that assumes the obligations of the
and not including the following: Employer.
(a) Employees who are Non-Resident Aliens 3.09 Enrollment Communication. The Employer
(within the meaning of Section 7701(b)(1)(B) will provide a written Enrollment Commu-
of the Internal Revenue Code) who are de-nication at open Enrollment and during
riving no earned income (within the meanthe Plan Year for midyear enrollees. The
ing of Section 911(d)(2) of the Code) from Enrollment Communication will provide
the Employer which constitutes income ollment in the
from sources within the United States The Enrollment
(within the meaning of Section 861(a)(3) of Communication is expressly incorporated
the Code); and, by reference into this Plan Document.
(b) Employees who are self-employed indi-automatically enroll you in the Medical or
viduals (as described in Section 401(c) of the Medical-Related Premium Plan. There is no
Internal Revenue Code) including sole pro-separate Enrollment form for the Medical or
prietors, partners in a partnership, or more Medical-Related Premium Plan.
than 2% owners of subchapter S Corpora-
tions. This exclusion applies to the Spouse, 3.10 Participant. Any person who has been or is
children, parents, and grandparents under an Eligib
the Code Section 318 attribution rules.
An Eligible Employee will also meet any
3.11 Plan Year.
in the Enrollment Communication. the Plan Year and each anniversary thereof,
If an Employee is not eligible to participate period of fewer than twelve (12) consecu-
in this Plan and allowed to participate under tiv
then the Em-the Plan Schedule, see Article XI.
ployee cost will be paid with taxable in-
come, and the Compensation will not be 3.12 Employer-spon-
reduced by the Employer. sored plans that are allowed tax advantages
under this Plan pursuant to Section 125(f) of
3.07 Employee. An Employee is a person who the Internal Revenue Code.
is currently or hereafter employed by the 3.13 Spouse. An individual who is legally mar-
Employer, or by any other Employer aggre-ried to a Participant but is not separated
gated under Sections 414(b), (c), (m), (n), or from a Participant or under a decree of legal
(o) of the Internal Revenue Code and the separation.
regulations thereunder, including a leased
Employee subject to Section 414(n) of the
Code.
4 FlexSystem Plan Document
Article IV: Administration
4.01 Employers Duties. In addition to any but will not be limited to, any information
rights, duties or poregarding period of employment, leaves of
Plan Document, the Employer will have the absence, salary history, termination of
following rights, duties, and powers: employment, or any other information the
Employer may need for the proper admin-
(a) to interpret the Plan, to determine the istration of the Plan. A Participant will fur-
amount, manner and time for payment of nish the Employer the data the Employer
and to construe reasonably requests to ensure the proper
or remedy any ambiguities, inconsistencies
or omissions under the Plan; with documentation for items such as proof
of relationship as needed.
(b) to adopt and apply any rules or proce-
dures to ensur4.03 Interpreting Plan Terms. Any interpretation
administration of the Plan, and from time to of any provision of this Plan made in good
time, amend or supplement such rules and faith by the Employer as to the terms of this
regulations;
parties.
(c) to determine the rights of any Partici-
pant, Spouse4.04 Misstatements. Any misstatement or other
mistake of fact will be corrected as soon as
(d) to develop appellate and review pro-Employer and any adjustment or correction
cedures for any Participant, Spouse, or attributable to such misstatement or
mistake of fact will be made by the Employ-
er as he considers equitable and practicable.
(e) to maintain records it may require in
connection with the proper administration 4.05 Review Procedures. An Employee or his/
of the Plan;her authorized representative can appeal
a decision made to deny Enrollment in a
(f) to employ any agents, attorneys, accoun-
tants or other parties (who may also be low an election change by sending a written
employed by the Employer) and to allocate request for an appeal to the Employer
or delegate to them such powers or duties within 60 days of the decision to deny
as is necessary to assist in the proper and Enrollment or an election change. The ap
pro-peal will be performed in a manner that
vided that such allocation or delegation and does not afford deference to the initial de-
the acceptance thereof is in writing; termination and will be conducted by the
Employer or designee. A Participant can
(g) to correct any defect, supply any omis-request, free of charge, reasonable access to,
sion, or reconcile any inconsistency in the and copies of, all documents and records
Plan in such a manner and to such extent as
it shall be deemed expedient to administer denied claims are addr
the Plan;vided by the
Employer.
(h) to amend or terminate this Plan.
4.06 Rules Apply Uniformly. The Employer will
4.02 Information to be Provided to the Employ-perform assigned duties in a reasonable
er. The Employer, or any of its agents, will manner and on a nondiscriminatory basis,
collect employment records of Participants and will apply uniform rules to all Partici-
under the Plan. These records will include, pants similarly situated under the Plan.
5 FlexSystem Plan Document
4.07 Facility of Payment. Whenever a Partici-from time to time for the purpose of admin-
pant who is entitled to receiistering the Plan.
under this Plan is under legal disability
or is incapacitated to be unable to manage 4.09 Medical Child Support Orders. The Em-
yer may ployer will adhere to the terms of any judg-
make payments to the Participants legal ment, decree, or court order (including a
courts approval of a domestic relations
of such Participant in such manner as the settlement agreement) which complies with
Employer considers advisable. Any such federal or applicable state law. The Employer
dance with will comply with the administrative require-
the provisions of this document shall be a ments described under 29 USC Sec. 1169
complete discharge of any liability for the
making of such payment under the provi-Orders (QMCSO), including any federal
sions of this Plan.regulations or state laws relating to the
same. On the date coverage is provided
4.08 Information to be Furnished. Participants as directed by a QMCSO the Employee-par-
shall provide the Employer with such in-ent will become eligible to participate in
formation and evidence, and shall sign such this Plan in order to pay his/her share of the
documents, as may be requested reasonably cost of the coverage on a pre-tax basis.
Article V: Eligibility and Participation
5.01 Eligibility Requirements. Each Employee
Participant return within 30 days of his/her
must be eligible to participate in this Plan to separation of service during the following
receive the tax advantages made available Plan Year, the Participant will be allowed to
under this Plan. The eligibility for this Plan change elections through the Plan Enroll-
is set forth in the Plan Schedule, see Article XI.ment process. A Participant whose employ-
ment terminates and who is subsequently
5.02 Current Employees at the time of Plan re-employed with more than 30 days sepa-
inception. At the time of Plan adoption, all ration of service will need to re-satisfy Plan
non-excluded Employees who meet the eligibility requirements to rejoin the Plan.
eligibility requirements may participate.Any un
Account balance prior to the initial separa-
5.03 New Employees. New Employees engaged tion of service date will be forfeited.
for employment after the Plan adoption,
who meet the eligibility requirements, may 5.05 Becoming a Participant. To become a Par-
participate in the Plan the next following ticipant, an Eligible Employee shall enroll in
entry date as indicated in the Plan Schedule, y application,
see Article XI.agreements, or process as may be required
by the Employer at the time of Enrollment.
5.04 Re-employment of Former Employees. The Enrollment Communication provided
Unless the Employer provides differently in by the Employer at the time of Enrollment
the Enrollment Communications, the treat-
ment of re-employed former Employees shall Participant. By completing the Enrollment
be as follows. A Participant whose employ- process, the Employee shall be deemed for
ment terminates and is subsequently all purposes to have agreed to participate
re-employed within 30 days of his/her and to conform to the Plan requirements.
separation of service and within the same An Employee, electing to participate in the
Plan Year will immedi ately rejoin the Plan Plan, is choosing to participate for the entire
6 FlexSystem Plan Document
Plan Year. The annualized sum of salary or fewer Employees as counted in that Act.
For Plan Years in which the Employer has
a current obligation of the Employee to more than 50 Employees, the Employer is
the Employer. Such obligation may be required to make FMLA Leave available to
revoked or changed only when the Em-Eligible Employees under circumstances
ployee has experienced and documents a that are prescribed by applicable federal law,
Change in Status Event, when the request is including a period in which an Employee is
consistent with the event, and notice is off due to the FMLA shall be treated in
provided to the Plan within 30 days.accordance with the rules for a layoff or a
leave of absence and provided to the ex-
5.06 The Employer tent required by the FMLA (e.g., the Employ-
will communicate (in writing) to all Partici-er will continue to pay its share of the
pants the terms and conditions of this Plan contribution to the extent the Participant
through administrative communications opts to continue coverage). If the Employer
at the time of Enrollment and as needed is subject to the FMLA, a Participant may
during the Plan Year. These communications revoke or continue an election through
are expressly incorporated by reference into the Plan upon commencement of the FMLA
this Plan Document.Leave, whether such leave is paid or unpaid.
This provision applies in addition to any
5.07 Termination of Participation. A Participant other right to re
will automatically cease to be a Participant under the Plan. Upon return from FMLA
on the earliest of the following dates:Leave, a Participant may be reinstated to all
(a) the date on which this Plan or any Quali-pre-leave elections.
Employer;5.09 Uniformed Services Employment & Reem
(b) the end of the Plan Year, unless the ployment Rights Act (USERRA). The Em-
ployer shall permit Participants to continue
Plan for the next Plan Year;ed under the
(c) the date on which the Participant fails Uniformed Services Employment & Reem-
to pay any required premium (including ployment Rights Act and shall provide such
payment by salary reduction);reinstatement rights as required by such
(d) when the Participants employment law.
with Plan Sponsor is terminated this Plan
will terminate on the earlier of the day of 5.10 Layoff, Leave of Absences, and Sabbaticals.
the termination or the day using the rule Continuation under the Plan may occur in
stated in the SPD, whether termination one of the following ways:
is initiated by the Participant or the Plan (a) In the case of a planned layoff, an
Sponsor, however the Participants election Employee may be able to pre-fund a Quali-
can continue to be used for one or more of
planned leave or the end of the Plan Year.
period of time communicated in the SPD.(b) During the period which the Employee
is off and receiving a salary, the pre-tax
Plan is described in the materials provided deductions may continue. If the Employee is
by the Employer; see Article XI Section 11.6 not receiving a salary, he/she may continue
for a list of plans and literature available to fund his/her election with after-tax dol-
from the Employer.lars while on leave. (Payment schedule to
be agreed upon between the Employer and
5.08 Family Medical Leave Act. The Family & Employee prior to the commencement of
Medical Leave Act of 1993 (29 U.S.C. 2611) the leave.)
as amended, is referred to as FMLA. FMLA
Leave will not be available to Employees for
Plan Years in which the Employer has 50
7 FlexSystem Plan Document
Article VI: Elections
6.01 6.05 Change in Status Events. No Participant in
Plans offered under this Plan are listed on the Plan will be allowed to alter or discon-
the Plan Schedule; see Article XI. The option tinue the P
for an Employee to make after-tax contri-during a Plan Year except when due to and
consistent with a Change in Status Event.
will be communicated by the Employer at These Status Events include the Change in
the time of Enrollment. Status Events described in Notice 2014-55
that allow a Participant to revoke his/her
6.02 Election Maximum Amounts. Each Par-election of coverage under the group health
ticipant shall elect any combination of the plan to enroll in Exchange coverage. Enroll
ailable. No Participant ment requests must be made within 30 days
may cof the Change in Status Event and be
than the maximum amount, if any, as indi-consistent with the event. Notwithstand-
The ing, an Employee can make a prospective
maximum election amounts will be in-change to a Health Savings Account (HSA)
cluded in the Enrollment Communication election under this Plan during the Plan
and the literature available for each Quali-Year without having a Change in Status
Event.
6.03 Failure to Elect. A Participant failing to A Change in Status Event allows a Partici-
complete the Enrollment process on or pant to change his/her contribution election
during the Plan Year, and outside of the
Year, or a midyear enrollee during the Plan scheduled open Enrollment period. The
Year, shall be deemed to have elected to Employer has elected to allow all of the
receive his full Compensation in cash. The Change in Status Events published by the
Employer will communicate any applicable IRS for this type of plan. An unpermitted
Enrollment deadlines in writing at the time election change will cause the elected ben-
of Enrollment.s gross in-
come and can disqualify the Plan from tax
6.04 Effective Periods for Elections. The election preferred status.
must be made by each Participant prior to
the commencement of each Plan Year, Upon the occurrence of a Change in Status
and shall be irrevocable except as provided Event, the Participant will notify the
for in a Change in Status Event that would Employer within 30 days and complete the
allow an election change. Participants may forms provided by the Employer. The Em-
not carry over any unused contributions or ployer can require additional documenta-
tion for evidence of the event. The new
a subsequent Plan Year unless the Plan election will be effective prospectively and
Schedule indicates that the Plan has incor-will apply onl
porated the Grace Period or the Plan docu- the Participant, the Participants Spouse,
ment includes a limited Carryover for the or the Participants Dependents after the
Medical-Related Expense Reimbursement effective date of the election change. With
, Participants may not respect to an election change under the spe-
use any contributions from one Plan Year to cial Enrollment period provisions of HIPAA,
purc timely submitted will mean submitted no
provided in a subsequent Plan Year.later than the last day of such special En-
rollment period.
8 FlexSystem Plan Document
6.06 Non-Discrimination. The Plan is not judgment, such actions serve to assure that
intended to discriminate in favor of highly the Plan does not violate applicable nondis-
compensated individuals or key Employees crimination rules. The Employer can make
as to eligibility to participate or contribu-necessary adjustments to Employee contri-
ed by the Code. butions during the Plan Year to assure that
The Employer may exclude or limit certain the Plan passes the required discrimination
highly compensated individuals from par-tests.
ticipation in the Plan, in the Employers
Article VII: Contributions
7.01 Employer Contributions. The Employer assets of the Employer. A Participant has
will contribute out of its general assets the only an unsecured contractual right to
amounts necessary to meet its obligations
under the Plan. Unless the Employer pro-
vides differently in the Enrollment Commu-
nication or separate Plan Documents for 7.03 Administrative Fees. The Employer may
there charge the Employee reasonable cafeteria
are no segregated funds established to col-plan administrative fees. If any administra-
lect or maintain the contributions. Contri-tive fees are required, the Enrollment Com-
butions to the Plan for any Plan Year will munication will include the amount of the
be limited to the amounts necessary to pay administrative fee and whether it is with
held from the Employees salary reduction.
the Participants.
7.04 Increases or Decreases in Premium. The
The Employer may provide additional con-Employer reserves the right to increase the
tributions in the way of cash or spending Participants share of any Premiums and
credits that can be used for any Quali-decrease the Employers share by a like
amount. The Employer will notify Partici-
yer. The pants prior to raising the Participants
Employobligations. If the premium or required
The
Enrollment Communications will include Plan increases or decreases during the Plan
the amount of any Employer contribution, Year, a Participants contributions will
yer con-increase or decrease automatically in
tributions can be used by the Participants, h
and any limitations on the use of Employer increase or decrease. However, in the case of
contributions. Employer contributions will an increase in pr
continue to be provided while on approved is offered under the Plan at the time of said
FMLA Leave to the same extent provided to increase, the Participant may select such
an Employee actively at work.y the increase.
7.02 Employee Salary Reductions. The Partici-The Employer reserves the right to reduce
pant shall agree to reduce his/her Com-the Participants share of any Premiums
pensation from the Employer by such and increase the Employers share by a like
amounts as are necessary to provide for amount. The duration of this Premium
Holiday is at the Employers discretion and
Participant has elected. Employee salary will be communicated by the Employer. As
reduction amounts are Employer contribu-this is considered to be temporary, Partici-
tions for purposes of Internal Revenue Code pants are not considered to have incurred
Section 125 and its applicable regulations. a Change in Status should the Employer
No Participant shall have, by virtue of the invoke this option.
Plan, an
9 FlexSystem Plan Document
Article VIII: Records and Reports
8.01 Responsibility. The Employer shall exercise 8.02 Examination of Records. The Employer will
authority and responsibility to comply with make each Participants records under the
the Plan relating to Participant records, Plan available for his/her examination at
yable under this reasonable times and during normal busi-
Plan. The Employer also shall be respon-ness hours.
sible for all Plan reporting and disclosure
requirements.
Article IX: Plan Termination
9.01 Plan Termination. The Plan or any portion 9.02 Rights to Terminate. In accordance with
of the Plan shall be subject to termination the procedures set forth in this section, the
at any time by the Employer, provided how-Employer may terminate the Plan at any
ever, that such termination shall not affect time. In the event of a dissolution, merger
any right or claim arising under the Plan consolidation, or reorganization of the
prior to termination. Any unclaimed funds Employer, the Plan shall terminate unless
shall become payable as the Employer may the Plan is adopted and continued by a
direct. Such direction may include, but not successor to the Employer in accordance
be limited to a continuation of the Plan in with the resolution of its Board of Directors.
order to pay balances in accordance with
Article X: Plan Construction
10.01 Taxation. The Employer intends that this state income tax purposes, or that any other
Plan be in compliance with Section 125 of federal or state tax treatment will apply
the Internal Revenue Code, and therefore, to or be available to any Participant. It shall
the Employer may deduct the amount paid be the obligation of each Participant to
vided from federal in-determine whether each payment is exclud-
come and employment taxes. This Plan has able from the Participants gross income for
not been submitted to the Internal Rev-federal and state income tax purposes, and
enue Service, and there is no assurance to notify the Employer if the Participant has
reason to believe that any such payment
Plan will be realized. Neither the Employer is not so excludable. Any Participant, by
nor its designated representatives makes agrees
any commitment or guarantee that any to be liable for any tax penalties and inter-
est which may be imposed by the Internal
Participant will be excludable from the Revenue Service with respect to these
Participants gross income for federal or
10 FlexSystem Plan Document
10.02 Adoption by Related Organizations. Upon ployer can be subject to ERISA. Refer to the
the approval of the Employer, this Plan may
be adopted by an10.05 Entire Document. This document, including
with the Employer. For the purpose of this any appendices or supplements thereto,
anizations are described shall constitute the entire and complete
in Section 414(b), (c) or (m) of the Internal document, and as such shall govern the
Revenue Code. The adopting organizations rights, liabilities and obligations of the Plan,
shall execute and deliver to the Employer a
supplemental agreement providing for the
adoption of this Plan and such other docu-10.06 Severability. In the event any provisions
ments as the Employer deems necessary or of this document shall be held illegal or
desirable. The provisions of this Plan shall invalid for any reason by law or a court of
be applicable to such organization to the competent jurisdiction, said illegality or
extent provided in the supplemental agree-invalidity shall not affect the remaining
ment. provisions included herein either initially,
or bey
10.03 Uniform Exercise of Powers. In the exercise held to be illegal or invalid, provided the
of any of its powers, duties and discretion basic purposes hereof can be affected
under this Plan, and within the scope of its through the remaining valid and legal provi-
authority, and in all of its acts, decisions, sions.
and determinations hereunder, the Employ-
er shall at all times act in good faith and 10.07
in a non-discriminatory manner and shall ovided through
follow a consistent policy on comparable is-a third party, such as an insurance com-
sues. All Employer actions and determi-pany, pursuant to a contract or policy with
nations shall be duly recorded. All such such thir
records, together with such other docu-tency exists between the description of
ments as may be necessary for the admin-
istration of this Plan, shall be preserved. De-contract or policy, then the terms of such
cisions regarding any Employer-disputed contract or policy shall control.
questions relative to the rights of a Par-
ticipant hereunder and upon all matters 10.08 Rights Against the Employer. Neither the
within the scope of its authority shall be estab
tion thereof, nor any distribution hereunder,
shall be construed as giving to any Partici-
10.04 Construction. No provision of this Plan pant or any person whomsoever any legal or
equitable rights against the Employer, its
Treasury Department, Department of Labor, shareholders,
or Internal Revenue Service Regulation, Rul-or as giving any person the right to be
ing, Release, or Proposed Regulation or retained in the employ of the Employer.
other order which affect, or could affect, the
terms of the Plan. This Plan will be in 10.09 Successor-Businesses. Unless this Plan be
compliance with any changes related to the sooner terminated, a successor to the busi-
Internal Revenue Code. This 125 Plan is not ness of the Employer, by whatever form or
subject to the Employee Retirement Income manner resulting, may continue this Plan by
Security Act of 1974 (ERISA); however the appropriate supplemental agreement.
y the Em-
11 FlexSystem Plan Document
Article XI Plan Adoption and Schedule
11.01 Employer Adoption. By signing this Plan Description of Excluded Employees
Document, the EmploUnion. Employees who are included in the unit of
represents that it has formally adopted this Employees covered by a collective bargaining agree-
Cafeteria Plan.ment between the Employer and Employee represen-
CityofOakParkHeights
Employer: _________________________________faith bargaining and two percent or less of the Em-
ployees of the Employer who are covered pursuant
By: ________________________________________
Treasury regulation Section 1.410(b)-9). For this pur-
Printed: ___________________________________pose, the term Employee Representatives does not
include any organization more than half of whose
Title: ______________________________________
executives of the Employer.
11.02 Plan Year. The Plan Year is from _____ Excluded
X
_____ Eligible
January117
____________________, 20 _____ to _____ Not applicable
December3117
____________________, 20 _____. Seasonal Employees regularly working less than
There is a short Plan Year beginning _______ months within a year.
_____ Excluded
____________________, 20 _____ and ending _____ Eligible
X
_____ Not applicable
____________________, 20 _____.
Employees under _____ years of age.
(If left blank, there is no short Plan Year.)_____ Excluded
_____ Eligible
X
11.03 Effective Date. This Cafeteria Plan was _____ Not applicable
January1
originally effective on ____________________, 11.05 Commencement of Participation. An Eli-
gible Employee can enroll in this Plan at the
09
20 ___. This Cafeteria Plan has been annual open Enrollment period or upon
completion of the employment requirement
created or restated by this Plan Document
January1
17
effective ____________________, 20 _____._____ No wait, on the date of hire
_____ 30 days after the date of hire
11.04 Eligible Employee. An Employee who meets _____ 60 days after the date of hire
le Employee, 3.06, _____ 90 days after the date of hire
X
and the requirements in this part 11.04, can _____ First of the month after the date of hire
enroll in this Plan by completing the process _____ First of the month after 30 days of con-
outlined in the Enrollment Communica-tinuous employment
tions. _____ First of the month after 60 days of con-
tinuous employment
An Eligible Employee must be regularly _____ Other _________________________________
40
scheduled to work ________________ hours _______________________________________
per week in order to enroll in this Plan. Part-
time Employees working fewer hours are
not Eligible Employees.
12 FlexSystem Plan Document
11.06 The Plan Docu-
ments and Summary Plan Descriptions
w are expressly
incorporated by reference into this Plan
Document and pro
vailable through the
plan, including the periods during which
ovided (the periods of
coverage if different from the Plan Year for
this Plan), and the Plans rules governing
participation.
The following Plans are offered under this Cafeteria
Plan:
Check if offered Available Plan Documents or Summary
under this Plan:Plan Description (SPD)
X
_____Medical or Medical-Related Premium for A Medical or Medical-Related Premium SPD
a group health plan. (This can include an will be provided by the Employer within 90
imbedded or standalone dental/vision plan.) days of Enrollment and upon request.
X
_____Health Savings Account (HSA)* Details will be provided in the Enrollment
Communication.
_____Non-Employer-Sponsored Premium Account See Appendix A.
Plan for individual health plans (NESP).
X
_____Medical or Medical-Related Expense Reim-See Appendix B. A Medical or Medical-Relat-
be provided by the Employer within 90 days
of Enrollment and upon request.
_____Non-Excepted Medical or Medical-RelatedSee Appendix D. A non-excepted Medical
or Medical-Related Expense Reimburse-
FSA)
Employer within 90 days of enrollment and
upon request.
X
_____ See Appendix C.
X
_____Supplemental Insurance (Voluntary Indem-Details will be provided in the Enrollment
nity Plans). Communication.
x
_____Disability Insurance Premium (Employee
Details will be provided in the Enrollment
Only) - Pre-taxing Employee contributions Communication.
-
tion.
X
_____Voluntary/Group Term Life Insurance ** Details will be provided in the Enrollment
Communication.
13 FlexSystem Plan Document
NOTES
* A Participant is required to make an election
before the start of the Plan Year, or before the
verage, showing the
amount contributed to an HSA tax free under
this Plan. A Participant will be able to change
his/her HSA election for any month in the Plan
Year regardless of whether the Employee can
show a Change in Status Event.
** The cost of excess coverage as determined in
Table I, published by the IRS, a will be imputed
income. Excess coverage is any amount over a
14 FlexSystem Plan Document
COBRAToday COBRA Administration
DirectPay Health Reimbursement Arrangements (HRA)
FlexSystem Flexible Spending Accounts (FSA)
ERISAEdge ERISA Compliance
FMLAMatters FMLA Administration
Form 5500 Preparation
Funded HRA
GiveBack
HIPAA Compliance
Health Savings Accounts (HSA)
Medicare Part D
Non-Discrimination Testing
PayPath Payroll Services
PCORI
Total Administrative Services, Inc.
2302 International Lane, Madison, WI 53704-3140www.tasconline.com
800.422.4661
15 FlexSystem Plan Document
FX-4798-101414
Plan Document: Appendix C
Qualifying Person - All child and Dependent Care
Expenses must be for the care of one or more Quali-
All terms and conditions stated in the Plan Docu-
following:
ment and Appendix C are applicable to this Depen-
(a) A child whom is claimed as the Participants
by this Appendix C.
Dependent and who was under the age of
13 when the care was provided;
-
(b) A Participants Spouse who was physically
tions.
or mentally unable to care for himself/her-
self and lived with the Participant for more
This Plan is intended to provide reimbursement
than half of the year;
for certain Dependent Care Expenses incurred by
Participants. The Employer intends that the Plan
(c) A person who was physically or mentally
qualify as a dependent care assistance plan under
unable to care for himself or herself and
Section 129(d) of the Internal Revenue Code, and that
lived with the Participant for more than half
of the year, and either of the following:
eligible for exclusion from Participant incomes under
Section 129 of the Code. This Plan is not subject to
(1) Was the Participants Dependent; or
the Employee Retirement Income Security Act of
1974 (ERISA).
(2) Would have been the Participants
Dependent without the occurrence of
Maximum Contribution. A Participant can defer the
one of the following:
lesser of $5000, their earned income, or the Spouses
earned income, per plan Year. If a Spouse is disabled
i) He or she received gross income
or a full-time student with no income, then the
equal to or in excess of the exemp-
Spouse is deemed to have a monthly income of $250,
tion amount for Dependents under
if one dependent, $500 if two or more dependents. A
Internal Revenue Code § 151(d);
limited to $2,500 per year. Contributions to the Plan
ii)
are made and limited in accordance with the Partici-
pants annual election.
iii) The Participant, or the Participants
A Participant can never withdraw
claimed as a Dependent on some-
more funds than actually contributed on the date a
one elses federal tax return.
claim is submitted. If a Participant fails to use his/her
entire election at the end of the Plan Year or upon
Child of divorced or separated parents: Even if a
other termination of the Plan, the unused election
Participant cannot claim a child as a Dependent, he
cannot be cashed out and becomes the property of
or she is treated as a Qualifying Person if one of the
the Employer.
following applies.
Dependent Care Expenses. Expenses incurred by a
(a) The child was under the age of 13 or was
physically or mentally unable to care for
related household services which would be consid-
himself/herself; or
ered employment-related expenses under Section
21(b)(2) of the Internal Revenue Code.
(b1) The Participant was the childs custodial
parent (the parent with whom the child
lived for the greater part of the calendar
year), and
(b2) The non-custodial parent is entitled to In the event of the death of the Participant prior to
claim the child as a Dependent under the the payment of any claims, payment will be made in
special rules for a child of divorced or sepa-the following priority:
rated parents.
(a) Executor of the Estate of the deceased
If this applies, the non-custodial parent cannot treat Participant,
the child as a Qualifying Person.
(b) Spouse of decedent.
Amounts Paid in Error
Dependent Care Expenses that are incurred during made in error, the Employer will inform the Partici-
the Plan Year and during the period in which the pant that they are required to repay the amount that
has been paid to or on the behalf of a Participant in
the amount that has actually been withheld from the error. This includes and is not limited to amounts
Participants Compensation on the date the claim is over the Participants annual election, amounts for
processed.services that are determined not to be Dependent
Care Expense, or when a Participant does not provide
Reimbursement will be made under the Plan only on adequate documentation to substantiate a claim
the basis of Dependent Care Expenses incurred for upon request. The Employer may take reasonable
-steps to recoup such an amount including reducing
the Plan. Dependent Care Expenses requested for re-amount paid in error.
imbursement will be reviewed for eligibility prior to
reimbursement from a Participants dependent care Forfeiture (Use-it-or-lose-it Rule) - A Participant
forfeits any amount of his/her annual election that
that an expense is a Dependent Care Expense subject exceeds of the amount of claims reimbursed during
to reimbursement, the Participant will be reimbursed any Plan Year. A Participant who terminates coverage
for the Dependent Care Expense within a reasonable during the Plan Year has a run out period in which to
time. To make the determination that a Dependent submit eligible claims. A Participant who is covered
Care Expense subject to reimbursement has been through the end of the Plan Year will have a run out
incurred, proper evidence of any or all of the follow-period in which to submit eligible claims. The dura-
ing may be required:tion of these run out periods will be provided in the
Summary Plan Description provided by the Employer.
(a)
the expenses have been incurred; Upon such forfeiture, the Participants accrual will
be reduced to zero. Forfeited funds can be retained
(b) the nature of the services incurred;
by the Employer, or at the discretion of the Employer,
-
(c) the date the services were incurred; cated to Participants in any reasonable manner that
has no relation to prior claims history. Forfeitures
(d) the amount of the requested reimburse-
ment; and,
become the sole property of the Employer.
(e) that the expenses have not been otherwise
paid through a program offered by the Change in Enrollment. No Participant in the Plan
Employer or any other employer, or reim-will be allowed to alter or discontinue the Partici-
bursed from any other source. pants elections during a Plan Year except when due
to and consistent with a Change in Status. Change
in Status Event enrollment requests must be made
what constitutes a Dependent Care Expense subject within 30 days of the Change in Status Event and
to reimbursement under the Plan.be consistent with the actual Change in Status, as
the Employer to be submitted in a timely fashion and
consistent with the Status Change, will be effective
-
ing to the Participant, the Participants Spouse, or the
Participants Dependents after the effective date of
Nondiscrimination. The Plan is not intended to dis-
criminate in favor of highly compensated individuals
regarding eligibility to participate, contributions, and
the Code. The Employer may take such actions as
excluding certain highly compensated employees
from participation in the Plan or adjusting elections
midyear, if in the Employers judgment, such actions
serve to assure that the Plan does not violate appli-
cable nondiscrimination rules.
Any other use or disclosure is prohibited.
FX-4794-011314
Plan Document: Amendment
Limited or Limited Post-Deductible Health FSA
To the Medical or Medical-
Coverage. Any Employee who contributes to a Health
Related Expense Reimbursement
Savings Account and elects to participate in this
Health FSA will automatically be placed in a limited
or limited post-deductible Health FSA. Any other Em-
All terms and conditions stated in the Plan Docu-
ployee who contributes to a Health Savings Account
ment and Appendix B continue in effect unless spe-
and who elects to participate in this Health FSA may
to be placed in a limited or limited post-deductible
-
Health FSA
A limited or limited post-deductible Health FSA
-
ployer has arranged for a limited health FSA that will
Expenses that are described below, as allowed by the
accommodate persons who are making contributions
IRS. The limited or limited post-deductible Health
to a Health Savings Account (HSA) and enrolled in a
FSA will not provide reimbursement for any other
high deductible health plan (HDHP) option. An HSA
service or supply regardless of whether that service
is a tax advantaged savings account held in trust for
or supply is allowed under a Health FSA by the IRS,
the payment of medical expenses under Section 223
or allowed under the terms of a full Health FSA. All
to the Internal Revenue Code.
Amendment are applied to claims submitted.
Enrollment Restriction. An Employee who contrib-
utes to a Health Savings Account may participate in
Check below the type of Health FSA(s) offered under
a limited Health FSA only. A limited Health FSA pro-
this Plan (You may select one or more options; lim-
ited, limited post-deductible, and/or full health FSA.):
that are for dental, vision services, and services pro-
vided after the annual deductible under the High De-
4
_____ Limited Health FSA
Covered Dental and Vision Services. A Quali-
Health FSA will not provide reimbursement for any
other service or supply regardless of whether that
to dental and vision services or supplies that are
service or supply is allowed by the IRS as a medical
excluded from coverage under your high deductible
expense, or allowed under a full Health FSA. All other
health plan. Some dental and vision services may be
considered medical in nature and are covered under
Plan Document are applied to claims submitted.
your high deductible health plan. A dental or vision
service covered by your high deductible health plan
In order to contribute to an HSA through a salary
cannot be reimbursed under this Health FSA even
reduction agreement, the Employee must provide
if the cost for the service was credited towards your
the Employer with a newly executed Salary Reduc-
deductible.
tion Agreement before the beginning of any Plan Year
_____ Limited Post-Deductible Health FSA
enrollment is allowed during the Plan Year. Said em-
Services after the annual HDHP Deductible has
ployee must execute a Salary Reduction Agreement
that authorizes the Employer to reduce the Employ-
ees compensation in the amount elected to fund the
HSA. Employees may change their HSA election at
under the limited Health FSA. With the limited
any time during the Plan Year, limited to one change
post-deductible Health FSA, after the annual HDHP
per month, regardless of whether the Employee had
a change in status event.
are not covered by the HDHP can be submitted and
the insurance carrier that administers the HDHP
will be required to be submitted. The EOB needs to
portion of the expense that has been submitted for
reimbursement under this Plan was not applied to
the HDHP deductible.
4
_____ Full Health FSA (General Purpose)
A medical expense incurred
during a Plan Year, (or applicable Grace Period if
any) by a Participant, the Participants Spouse, or the
Participants Dependents while the Participant is cov-
ered under this Plan. Medical expenses are reimburs-
able only to the extent allowed as a medical expense
under Section 213(d) of the Internal Revenue Code.
For purposes of the Plan, an expense is incurred on
the date when the underlying services giving rise
to the medical expenses are performed and not on
the date that the services are billed by the service-
provider or paid by the Participant.
Any other use or disclosure is prohibited.
FX-4822-020514