Cafeteria Plan fr the Emplyees f Central Rivers Area Educatin Agency Plan Dcument and Summary Plan Descriptin Originally Effective July 1, 2003 Amended and Restated July 1, 2017 Summary Plan Descriptin This Plan Dcument als cnstitutes a Summary Plan Descriptin. 1
Sectin 1 Intrductin 1.1 Establishment f the Plan Central Rivers Area Educatin Agency (the Emplyer ) riginally established the Central Rivers Area Educatin Agency Cafeteria Plan (the Plan ) effective July 1, 2003. The Emplyer hereby amends and restates the Plan effective July 1, 2017 (the Effective Date ). 1.2 Purpse f the Plan This Plan allws an Emplyee t participate in the fllwing Benefit Optins: Premium Only Plan (POP) t make pre-tax Salary Reductin Cntributins t pay the Emplyee s share f the premium r cntributin fr the Insurance Plan(s). Health Flexible Spending Accunt (Health FSA) t make pre-tax Salary Reductin Cntributins t an accunt fr reimbursement f certain Health Care Expenses. Dependent Care Assistance Prgram (DCAP) t make pre-tax Salary Reductin Cntributins t an accunt fr reimbursement f certain Dependent Care Expenses. 1.3 Legal Status This Plan is intended t qualify as a cafeteria plan under the Cde 125, and regulatins issued thereunder and shall be interpreted t accmplish that bjective. The Health FSA is intended t qualify as a self-insured health reimbursement plan under Cde 105, and the Health Care Expenses reimbursed are intended t be eligible fr exclusin frm participating Emplyees grss incme under Cde 105(b). The DCAP is intended t qualify as a dependent care assistance prgram under Cde 129, and the Dependent Care Expenses reimbursed are intended t be eligible fr exclusin frm participating Emplyees grss incme under Cde 129(a). Althugh reprinted within this dcument, the Health FSA and the DCAP are separate plans fr purpses f administratin and all reprting and nndiscriminatin requirements impsed by Cde 105 and 129. The Health FSA is als a separate plan fr purpses f applicable prvisins f COBRA and HIPAA. 1.4 Capitalized Terms Many f the terms used in this dcument begin with a capital letter. These terms have special meaning under the Plan and are defined in the Glssary at the end f this dcument r in ther relevant Sectins. When reading the prvisins f the Plan, please refer t the Glssary at the end f this dcument. Becming familiar with the terms defined there will prvide a better understanding f the prcedures and Benefits described. 2
Sectin 2 General Infrmatin Name f the Cafeteria Plan Name f Emplyer Central Rivers Area Educatin Agency Cafeteria Plan Central Rivers Area Educatin Agency Address f Plan 3712 Cedar Heights Drive, Cedar Falls, IA 50613 Plan Administratr Plan Spnsr and its IRS Emplyer Identificatin Number Named Fiduciary & Agent fr Service f Legal Prcess Type f Administratin Central Rivers Area Educatin Agency Central Rivers Area Educatin Agency 16-1658584 Central Rivers Area Educatin Agency The Plan is administered by the Plan Administratr with Benefits prvided in accrdance with the prvisins f the Central Rivers Area Educatin Agency Cafeteria Plan. It is nt financed by an insurance cmpany and Benefits are nt guaranteed by a cntract f insurance. Central Rivers Area Educatin Agency may hire a third party t perfrm sme f its administrative duties such as claim payments and enrllment. Plan Number 501 Benefit Optin Year The twelve-mnth perid ending June 30. Plan Effective Date Originally effective July 1, 2003; Amended and restated effective July 1, 2017 Claims Administratr Applicatin Sftware Inc. Plan Renewal Date July 1 Internal Revenue Cde and Other Federal Cmpliance Discretinary Authrity It is intended that this Plan meet all applicable requirements f the Internal Revenue Cde f 1986 (the Cde ) and ther federal regulatins. In the event f any cnflict between this Plan and the Cde r ther federal regulatins, the prvisins f the Cde and the federal regulatins shall be deemed cntrlling, and any cnflicting part f this Plan shall be deemed superseded t the extent f the cnflict. The Plan Administratr shall perfrm its duties as the Plan Administratr and in its sle discretin, shall determine the apprpriate curses f actin in light f the reasn and purpse fr which this Plan is established and maintained. 3
In particular, the Plan Administratr shall have full and sle discretinary authrity t interpret all Plan dcuments, and make all interpretive and factual determinatins as t whether any individual is entitled t receive any Benefit under the terms f this Plan. Any cnstructin f the terms f any Plan dcument and any determinatin f fact adpted by the Plan Administratr shall be final and legally binding n all parties. Any interpretatin shall be subject t review nly if it is arbitrary, capricius, r therwise an abuse f discretin. Any review f a final decisin r actin f the Plan Administratr shall be based nly n such evidence presented t r cnsidered by the Plan Administratr at the time it made the decisin that is the subject f review. Accepting any Benefits r making any claim fr Benefits under this Plan cnstitutes agreement with and cnsent t any decisins that the Plan Administratr makes in its sle discretin and further cnstitutes agreement t the limited standard and scpe f review described by this Sectin. 4
Sectin 3 Benefit Optins and Methd f Funding 3.1 Benefits Offered Each Emplyee may elect t participate in ne r mre f the fllwing Benefits: Premium Only Plan (POP) as described in Schedule A. Health Flexible Spending Accunt (Health FSA) as described in Schedule B. Dependent Care Assistance Prgram (DCAP) as described in Schedule C. Benefits under the Plan shall nt be prvided in the frm f deferred Cmpensatin. 3.2 Emplyer and Participant Cntributins Emplyer Cntributins. The Emplyer may, but is nt required t, cntribute t any f the Benefit Optins. There are n Emplyer Cntributins fr the POP under this Plan; hwever, if the Participant elects the POP as described in Schedule A, the Emplyer may cntribute tward the Insurance Plan(s) as prvided in the respective plan r plicy f the Emplyer. Participant Cntributins. The Emplyer shall withhld frm a Participant s Cmpensatin by Salary Reductin n a pre-tax basis, r with after-tax deductins, an amunt equal t the Cntributins required fr the Benefits elected by the Participant under the Salary Reductin Agreement. The maximum amunt f Salary Reductins shall nt exceed the aggregate cst f the Benefits elected. 3.3 Cmputing Salary Reductin Cntributins Salary Reductins per Pay Perid. The Participant s Salary Reductin is an amunt equal t: The annual electin fr such Benefits divided by the number f pay perids in the Perid f Cverage; An amunt therwise agreed upn between the Emplyer and the Participant; r An amunt deemed apprpriate by the Plan Administratr. (Example: in the event f a shrtage f reducible Cmpensatin, amunts withheld and the Benefits t which Salary Reductins are applied may fluctuate.) Salary Reductins Fllwing a Change f Electins. If the Participant changes his r her electin under the POP, Health FSA r DCAP, as permitted under the Plan, the Salary Reductins will be, fr the Benefits affected, calculated as fllws: An amunt equal t: The new annual amunt elected pursuant t the Methd f Timing and Electins sectin belw; 5
Less the aggregate Cntributins, if any, fr the perid prir t such electin change; Payable ver the remaining term f the Perid f Cverage cmmencing with the electin change; An amunt therwise agreed upn between the Emplyer and the Participant; r An amunt deemed apprpriate by the Plan Administratr. (Example: in the event f a shrtage f reducible Cmpensatin, amunts withheld and the Benefits t which Salary Reductins are applied may fluctuate.) Salary Reductins Cnsidered Emplyer Cntributins fr Certain Purpses. Salary Reductins t pay fr the Participant s share f the Cntributins fr Benefit Optins elected fr purpses f this Plan and the Cde are cnsidered Emplyer Cntributins. Salary Reductin Balance Upn Terminatin f Cverage. If, as f the date that cverage under this Plan terminates, a Participant s year-t-date Salary Reductins exceed r are less than the required Cntributins necessary fr Benefit Optins elected up t the date f terminatin, the Emplyer will either return the excess t the Participant as additinal taxable wages r recup the amunt due thrugh Salary Reductin amunts frm any remaining Cmpensatin. After-Tax Cntributins fr POP. After-tax Cntributins fr the Insurance Plan will be paid utside f this Plan. 3.4 Funding This Plan Benefits Paid frm General Assets. All f the amunts payable under this Plan shall be paid frm the general assets f the Emplyer. Nthing herein will be cnstrued t require the Emplyer nr the Plan Administratr t maintain any fund r t segregate any amunt fr the Participant s benefit. Neither the Participant, nr any ther persn, shall have any claim against, right t, r security r ther interest in any fund, accunt r asset f the Emplyer frm which any payment under this Plan may be made. There is n trust r ther fund frm which Benefits are paid. While the Emplyer has cmplete respnsibility fr the payment f Benefits ut f its general assets, it may hire a third party administratr t perfrm sme f its administrative duties such as claims payments and enrllment. Participant Bkkeeping Accunt. While all Benefits are t be paid frm the general assets f the Emplyer, the Emplyer will keep a bkkeeping accunt in the name f each Participant. The bkkeeping accunt is used t track allcatin and payment f Plan Benefits. The Plan Administratr will establish and maintain under each Participant s bkkeeping accunt a subaccunt fr each Benefit Optin elected by each Participant. Maximum Cntributins. The maximum Cntributins that may be made under this Plan fr the Participant are the ttal f the maximums that may be elected fr the POP as described in Schedule A, Health FSA as described in Schedule B, and the DCAP as described in Schedule C. 6
Sectin 4 Eligibility and Participatin 4.1 Eligibility t Participate An individual is eligible t participate in this Plan if such individual meets the definitin f Emplyee as set frth in the Glssary. Eligibility requirements t participate in the individual Benefit Optins may vary frm the eligibility requirements t participate in this Plan. 4.2 Required Salary Reductin Agreement T participate in the Benefit Optin(s), an Emplyee must cmplete, sign and return t the Plan Administratr a Salary Reductin Agreement by the deadline designated by the Plan Administratr. If an Emplyee fails t return a Salary Reductin Agreement, the Emplyee is deemed t have elected cash and will nt be allwed t change such electin until the next Open Enrllment unless the Emplyee experiences an event permitting an electin change mid-year. The Emplyee may begin participatin n the 1st f the mnth cincident with r next fllwing the date n which the Emplyee has met the Plan s eligibility requirements r in accrdance with the Enrllment requirements each year. 4.3 Terminatin f Participatin A Participant will terminate participatin in this Plan upn the earlier f: The expiratin f the Perid f Cverage fr which the Emplyee has elected t participate unless during the Open Enrllment Perid fr the next Plan Year the Emplyee elects t cntinue participating; The terminatin f this Plan; r The end f the calendar mnth in which the Emplyee ceases t be an Emplyee because f retirement, terminatin f emplyment, layff, reductin in hurs, r any ther reasn. If the Emplyee is a cntract emplyee and such emplyee has fulfilled his/her cntract bligatins, then the Emplyee will cntinue t remain eligible fr this Plan until the end f his/her cntract. Eligibility may cntinue beynd such date fr purpses f COBRA cverage, where applicable as set frth in the respective Schedule attached heret, as may be permitted by the Plan Administratr n a unifrm and cnsistent basis, but nt beynd the end f the current Plan Year. False r Fraudulent Claims. The Plan Administratr has the authrity t terminate participatin in the Plan if it has been determined that a Participant has filed a false r fraudulent claim fr Benefits. Terminatin f participatin in this Plan will autmatically revke the Participant s participatin in the elected Benefit Optins, accrding t the terms theref. 7
4.4 Rehired Emplyees If a Participant terminates emplyment with the Emplyer fr any reasn, including, but nt limited t, disability, retirement, layff, leave f absence withut pay, r vluntary resignatin, and then is rehired within the same Plan Year and within 30 days r less f the date f terminatin f emplyment, the Emplyee may make new electins as a new hire. If the Emplyer rehires a frmer Participant within the same Plan Year but mre than 30 days fllwing terminatin f emplyment and the Participant is therwise eligible t participate in the Plan, then the individual may make new electins as a new hire. 4.5 Eligibility Rules Regarding the Health FSA An Emplyee enrlled in a Health Savings Accunt (HSA) is nt eligible t enrll in the Health FSA. 4.6 FMLA Leaves Of Absence Health Benefits. Ntwithstanding any prvisin t the cntrary in this Plan, if a Participant ges n a qualifying leave under FMLA then t the extent required by FMLA, the Participant will be entitled t cntinue the Benefits that prvide health cverage n the same terms and cnditins as if the Participant were still an active Emplyee. Fr example, the Emplyer will cntinue t pay its share f the Cntributin t the extent the Participant pts t cntinue cvereage. In the event f unpaid FMLA leave, a Participant may elect t cntinue such Benefits. If the Participant elects t cntinue cverage while n FMLA leave, then the Participant may pay his r her share f the Cntributin: With after-tax dllars, by sending mnthly payments t the Emplyer by the due date established by the Emplyer; With pre-tax dllars, by having such amunts withheld frm the Participant s nging Cmpensatin, if any, including unused sick days and vacatin days; r By pre-paying all r a prtin f the Cntributin fr the expected duratin f the leave n a pre-tax Salary Reductin basis ut f pre-leave Cmpensatin. T pre-pay the Cntributin, the Participant must make a special electin t that effect prir t the date that such Cmpensatin wuld nrmally be made available. Pre-tax dllars may nt be used t fund cverage during the next Plan Year. Cverage will terminate if Cntributins are nt received by the due date established by the Emplyer. If a Participant s cverage ceases while n FMLA leave fr any reasn, including fr nn-payment f Cntributins, the Participant will be entitled t re-enter upn return frm such leave n the same basis as the Participant was participating in the Plan prir t the leave, r as therwise required by the FMLA. A Participant whse cverage ceased under any f the afrementined plans will be entitled t elect whether t be reinstated in such plans at the same cverage level as in effect befre the FMLA leave with increased Cntributins fr the remaining Perid f Cverage, r at a cverage level that is reduced pr-rata fr the perid f FMLA leave during which the Participant did nt pay Cntributins. If a Participant elects a cverage level that is reduced pr-rata fr the perid f FMLA leave, the amunt 8
withheld frm a Participant s Cmpensatin n a payrll-by-payrll basis fr the purpse f paying fr his r her Cntributins will be equal t the amunt withheld prir t the perid f FMLA leave. Nn-Health Benefits. If a Participant ges n a qualifying leave under the FMLA, then entitlement t nn-health benefits (such as DCAP Benefits) is t be determined by the Emplyer s plicy fr prviding such Benefits when the Participant is n leave nt qualified as an FMLA leave f absence, as described belw. If such plicy permits a Participant t discntinue Cntributins while n leave, then the Participant will, upn returning frm leave, be required t repay the Cntributins nt paid by the Participant during the leave. Payment shall be withheld frm the Participant s Cmpensatin either n a pre-tax r after-tax basis, as may be agreed upn by the Plan Administratr and the Participant r as the Plan Administratr therwise deems apprpriate. 4.7 Nn-FMLA Leaves f Absence If a Participant ges n an unpaid leave f absence that des nt affect eligibility, then the Participant will cntinue t participate and the Cntributins due fr the Participant will be paid by pre-payment befre ging n leave, by after-tax Cntributins while n leave r with catch-up Cntributins after the leave ends, as may be determined by the Plan Administratr. If a Participant ges n an unpaid leave that affects eligibility, the electin change rules set frth by this Plan will apply. T the extent COBRA applies, the Participant may cntinue cverage under COBRA. 4.8 Death A Participant s beneficiaries r representative f the Participant s estate, may submit claims fr expenses that the Participant incurred thrugh the end f the mnth in which the Participant ceases t be eligible fr the Plan due t death. A Participant may designate a specific beneficiary fr this purpse. If n beneficiary is specified, the Plan Administratr r its designee may designate the Participant s Spuse, anther Dependent, r representative f the estate. Claims incurred by the Participant s cvered Spuse r any ther f the Participant s cvered Dependents prir t the end f the mnth in which the Participant dies may als be submitted fr reimbursement. 4.9 COBRA Under the COBRA rules, as discussed in the attached Schedules B and C, where applicable, the Participant s Spuse and Dependents may be able t cntinue t participate under the Health FSA thrugh the end f the Perid f Cverage in which the Participant dies. The Participant s Spuse and Dependents may be required t cntinue making Cntributins t cntinue their participatin. 4.10 USERRA Ntwithstanding any prvisin t the cntrary in this Plan, if a Participant ges n a qualifying leave under USERRA, then t the extent required by USERRA, the Emplyer will cntinue the Benefits that prvide health cverage n the same terms and cnditins as if the Participant were still an active Emplyee. In the event f unpaid USERRA leave, a Participant may elect t cntinue such Benefits during the leave. If the Participant elects t cntinue cverage while n USERRA leave, then the Participant may pay his r her share f the Cntributin with: 9
After-tax dllars, by sending mnthly payments t the Emplyer by the due date established by the Emplyer; r Pre-tax dllars, by having such amunts withheld frm the Participant s nging Cmpensatin, if any, including unused sick days and vacatin days. Cverage will terminate if Cntributins are nt received by the due date established by the Emplyer. If a Participant s cverage ceases while n USERRA leave fr any reasn, including fr nn-payment f Cntributins, the Participant will be entitled t re-enter such Benefit upn return frm such leave n the date f such resumptin f emplyment and will have the same pprtunities t make electins under this Plan as persns returning frm nn-userra leaves. Regardless f anything t the cntrary in this Plan, an Emplyee returning frm USERRA leave has n greater right t Benefits fr the remainder f the Plan Year than an Emplyee wh has been cntinuusly wrking during the Plan Year. 10
Sectin 5 Methd f Timing and Electins 5.1 Initial Electin An Emplyee must cmplete, sign and return a Salary Reductin Agreement within the electin-perid set frth therein t enrll in the Benefit Optins. Unless therwise specified by the Emplyer, an Emplyee wh first becmes eligible t participate in the Plan mid-year will cmmence participatin n the 1st day f the mnth cinciding with r after the date the Emplyee cmpletes, signs and returns a Salary Reductin Agreement r cmpletes a Salary Reductin Agreement using the electrnic system prduced by the Emplyer (if any), within the electin perid set frth therein. Eligibility fr Benefits shall be subject t the additinal requirements, if any, specified in the applicable Benefit Optin. The prvisins f this Plan are nt intended t verride any exclusins, eligibility requirements r waiting perids specified in the applicable Benefit Optins. 5.2 Open Enrllment During each Open Enrllment Perid, the Plan Administratr shall prvide a Salary Reductin Agreement t each Emplyee wh is eligible t participate in the Plan. The Salary Reductin shall enable the Emplyee t elect t participate in the Benefit Optins fr the next Plan Year, and t authrize the necessary Salary Reductins t pay fr the Benefits elected. The Emplyee must cmplete sign and return the Salary Reductin Agreement r cmplete an electin using the electrnic system prvided by the Emplyer, if any, t the Plan Administratr n r befre the last day f the Open Enrllment Perid. If an Emplyee makes an electin t participate during an Open Enrllment Perid, then the Emplyee will becme a Participant n the first day f the next Plan Year. The Emplyer may, in lieu f a Salary Reductin Agreement, prvide an electrnic methd fr Emplyees t use t make electins. The Emplyer may require Emplyees t use the electrnic system t make electins. Use f an electrnic system will have the same effect as a signed Salary Reductin Agreement. 5.3 Failure T Elect If an Emplyee fails t cmplete, sign and return a Salary Reductin Agreement r fails t cmplete an electin using the electrnic system (if any) prvided by the Emplyer within the time described in the Electins paragraphs as discussed immediately abve, then the Emplyee will be deemed t have elected t receive his r her entire Cmpensatin in cash. Where the Emplyer prvides fr an autmatic electin fr the POP, the Emplyee will have als agreed t a Salary Reductin fr such Emplyee s Cntributin t the POP. Such Emplyee may nt enrll in the Plan: Until the next Open Enrllment Perid; r 11
Until an event ccurs that wuld justify a mid-year electin change as described in the Irrevcability f Electin and Exceptins sectin belw. 12
6.1 Irrevcability f Electins Sectin 6 Irrevcability f Electins and Exceptins A Participant s electin under the Plan is irrevcable fr the duratin f the Perid f Cverage t which it relates, except as described in this Sectin. The rules regarding irrevcability f electins and exceptins are quite cmplex. The Plan Administratr will interpret these rules in accrdance with prevailing IRS guidance. 6.2 Prcedure fr Making New Electin If Exceptin t Irrevcability Applies Timing fr Making New Electin if Exceptin t Irrevcability Applies. A Participant may make a new electin within 30 days f the ccurrence f an event described in sectin 6.4 belw, if the electin under the new Salary Reductin Agreement is made n accunt f and crrespnds t the event. Pursuant t Iwa state law, a Participant may make a new electin within 60 days f the ccurrence f the birth f a child, eligibility changes fr the Title XIX/Hawk I prgram, r eligibility changes under Medicaid; any new electins due t such changes must be made n the accunt f and crrespnd t the event. A Change in Status, as defined belw, that autmatically results in ineligibility in the Insurance Plan(s) shall autmatically result in a crrespnding electin change, whether r nt requested. Effective Date f New Electin. Electins made pursuant t this Sectin shall be effective n the 1st f the mnth fllwing r cinciding with the Plan Administratr's receipt and apprval f the electin request fr the balance f the Perid f Cverage fllwing the change f electin unless a subsequent event allws fr a further electin change. Except as prvided in Certain Judgments, Decrees and Orders r fr HIPAA special enrllment rights in the event f birth, adptin, r placement fr adptin, all electin changes shall be effective n a prspective basis nly. Changes. Fr subsequent Plan Years, the maximum and minimum dllar limit may be changed by the Plan Administratr and shall be cmmunicated t Emplyees thrugh the Salary Reductin Agreement r ther dcument. Effect n Maximum Benefits. Any change in an electin affecting annual Cntributins t the Health FSA r DCAP als will change the maximum reimbursement Benefits fr the balance f the Perid f Cverage cmmencing with the electin change. Such maximum reimbursement Benefits fr the balance f the Perid f Cverage shall be calculated by adding: Any Cntributins made by the Participant as f the end f the prtin f the Perid f Cverage immediately preceding the change in electin; t The ttal Cntributins scheduled t be made by the Participant during the remainder f such Perid f Cverage t the Benefit Optin; reduced by All reimbursements made during the entire Perid f Cverage. 13
6.3 Change in Status Defined A Participant may make a new electin that crrespnds t a gain r lss f eligibility and cverage under this Plan r under any ther plan maintained by the Emplyer r a plan f the Spuse s r Dependent s emplyer that was caused by the ccurrence f a Change in Status. A Change in Status is any f the events described belw, as well as any ther events included under subsequent changes t Cde 125 r regulatins issued thereunder, which the Plan Administratr, in its sle discretin and n a unifrm and cnsistent basis, determines are permitted under IRS regulatins and under this Plan: Legal Marital Status. A change in a Participant s legal marital status including marriage, death f a Spuse, divrce, legal separatin r annulment; Number f Dependents. Events that change a Participant s number f Dependents, including birth, death, adptin, and placement fr adptin. In the case f the DCAP, a change in the number f Qualifying Individuals as defined in Cde 21(b)(1); Emplyment Status. Any f the fllwing events that change the emplyment status f the Participant, Spuse r Dependents: A terminatin r cmmencement f emplyment; A strike r lckut; A cmmencement f r return frm an unpaid leave f absence; A change in wrksite; r If the eligibility cnditins f this Plan r anther emplyee benefit plan f the Participant, Spuse r Dependent depend n the emplyment status f that individual and there is a change in that individual s status with the cnsequence that the individual becmes, r ceases t be, eligible under this Plan r anther emplyee benefit plan; Dependent Eligibility Requirements. An event that causes a Dependent t satisfy r cease t satisfy the Dependent eligibility requirements fr a particular Benefit; and Change in Residence. A change in the place f residence f the Participant, Spuse r Dependent(s). 6.4 Events Permitting Exceptin t Irrevcability Rule A Participant may change an electin as described belw upn the ccurrence f the stated events fr the applicable Benefit Optin. The fllwing rules shall apply t all Benefit Optins except where expressly limited belw. Open Enrllment Perid. A Participant may change an electin during the Open Enrllment Perid. 14
Terminatin f Emplyment. A Participant s electin will terminate upn terminatin f emplyment as described in the Eligibility and Participatin sectin abve. Leave f Absence. A Participant may change an electin upn a leave f absence as described in the Eligibility and Participatin sectin abve. Change in Status. (Applies t the POP and Health FSA as limited belw, and DCAP as limited belw.) A Participant may change the actual r deemed electin under the Plan upn the ccurrence f a Change in Status, but nly if such electin change crrespnds with a gain r lss f eligibility and cverage under a plan f the Emplyer r a plan f the Spuse s r Dependent s emplyer, referred t as the general cnsistency requirement. A Change in Status that affects eligibility fr cverage als includes a Change in Status that results in an increase r decrease in the number f an Emplyee s family members wh may benefit frm the cverage. The Plan Administratr, n a unifrm and cnsistent basis, shall determine, based n prevailing IRS guidance, whether a requested change satisfies the general cnsistency requirement. Assuming that the general cnsistency requirement is satisfied, a requested electin change must als satisfy the fllwing specific cnsistency requirements in rder fr a Participant t be able t alter electins based n the specified Change in Status: Lss f Spuse r Dependent Eligibility. Fr a Change in Status invlving a Participant s divrce, annulment r legal separatin, the death f a Spuse r a Dependent, r a Dependent s ceasing t satisfy the eligibility requirements fr cverage, a Participant may nly elect t cancel accident r health cverage fr: The Spuse invlved in the divrce, annulment, r legal separatin; The deceased Spuse r Dependent; r The Dependent that ceased t satisfy the eligibility requirements. Canceling cverage fr any ther individual under these circumstances fails t crrespnd with that Change in Status. Ntwithstanding the freging, if the Participant r his r her Spuse r Dependent becmes eligible fr COBRA r similar health plan cntinuatin cverage under the Emplyer s plan, then the Participant may increase his r her electin t pay fr such cverage. This rule des nt apply t a Participant s Spuse wh becmes eligible fr COBRA r similar cverage as a result f divrce, annulment, r legal separatin. Gain f Cverage Eligibility Under Anther Emplyer s Plan. When a Participant, Spuse r Dependent gains eligibility fr cverage under a cafeteria plan r qualified benefit plan f the emplyer f that Participant s Spuse r Dependent, a Participant may elect t terminate r decrease cverage fr that individual nly if cverage fr that individual becmes effective r is increased under the Spuse s r Dependent s emplyer s plan. The Plan Administratr may rely n a Participant s certificatin that the Participant has btained 15
r will btain cverage under the Spuse s r Dependent s emplyer s plan, unless the Plan Administratr has reasn t believe that the Participant s certificatin is incrrect. Special Cnsistency Rule fr DCAP Benefits. With respect t the DCAP, the Participant may change r terminate the Participant s electin upn a Change in Status if: Such change r terminatin is made n accunt f and crrespnds with a Change in Status that affects eligibility fr cverage under an Emplyer s plan; r The electin change is n accunt f and crrespnds with a Change in Status that affects eligibility f Dependent Care Expenses fr the tax exclusin under Cde 129. HIPAA Special Enrllment Rights (Applies t the POP nly). If the Participant, the Participant s Spuse r Dependent is entitled t special enrllment rights under a grup health plan as required by HIPAA, then the Participant may revke a prir electin fr grup health plan cverage and make a new electin prvided that the electin change crrespnds with such HIPAA special enrllment right. As mre specifially defined by HIPAA, a special enrllment right will arise in the fllwing circumstances: The Participant, Spuse r Dependent declined t enrll in grup health plan cverage because the Participant, the Participant s Spuse r Dependent had cverage, and eligibility fr such cverage is subsequently lst because the cverage was prvided under COBRA and the COBRA cverage was exhausted; r the cverage was nn-cobra cverage and the cverage terminated due t lss f eligibility fr cverage r the emplyer cntributins fr the cverage were terminated; The Participant acquired a new Dependent as a result f marriage, birth, adptin r placement fr adptin; r The Emplyee r Dependents wh are eligible but did nt enrll fr cverage when initially eligible and: The Emplyee r Dependent s Medicaid r Children s Health Insurance Prgram (CHIP) cverage terminated as a result f lss f eligibility and the Emplyee requests cverage under the Plan within 60 days after the terminatin; r The Emplyee r Dependent becmes eligible fr a premium assistance subsidy under Medicaid r CHIP, and the emplyee requests cverage under the Plan within 60 days after eligibility is determined. An electin t add previusly eligible Dependents as a result f the acquisitin f a new Spuse r Dependent child shall be cnsidered t be cnsistent with the special enrllment right. An electin change due t birth, adptin, r placement fr adptin f a new Dependent child may, subject t the grup health plan, be effective retractively fr up t 30 days. Certain Judgments, Decrees and Orders. (Applies t the POP and Health FSA, but des nt apply t the DCAP). If a judgment, decree, r rder resulting frm a divrce, legal separatin, annulment r change in legal custdy, including a Qualified Medical Child Supprt Order 16
(QMCSO) requires accident r health cverage, including an electin fr Health FSA Benefits fr a Participant s Dependent child, a Participant may: Change an electin t prvide cverage fr the Dependent child prvided that the rder requires the Participant t prvide cverage; r Change an electin t revke cverage fr the Dependent child if the rder requires that anther individual prvide cverage under that individual s plan and such cverage is actually prvided. Medicare and Medicaid. (Applies t the POP and Health FSA as limited belw, but des nt apply t the DCAP). If a Participant, Spuse r Dependent is enrlled in a Benefit under this Plan and becmes entitled t Medicare r Medicaid (ther than cverage cnsisting slely f benefits under Sectin 1928 f the Scial Security Act prviding fr pediatric vaccines), the Participant may prspectively reduce r cancel the Health Plan cvering the persn, and the Health FSA cverage may be cancelled but nt reduced. Hwever, such cancellatin will nt be effective t the extent that it wuld reduce future cntributins t the Health FSA t a pint where the ttal cntributins fr the Plan Year are less that the amunt already reimbursed fr the Plan Year. Further, if a Participant, Spuse, r Dependent wh has been entitled t Medicare r Medicaid lses eligibility fr such cverage, the Participant may prspectively elect t cmmence r increase the Health FSA cverage. Change in Cst. (Applies t the POP and DCAP as limited belw, but des nt apply t the Health FSA). Fr purpses f this Sectin, similar cverage means cverage fr the same categry f Benefits fr the same individuals. Insignificant Cst Changes. The Participant is required t increase his r her elective Cntributins t reflect insignificant increases in the required Cntributin fr the Benefit Optins, and t decrease the elective Cntributins t reflect insignificant decreases in the required Cntributin. The Plan Administratr, in its sle discretin and n a unifrm and cnsistent basis, will determine whether an increase r decrease is insignificant based upn all the surrunding facts and circumstances, including but nt limited t the dllar amunt r percentage f the cst change. The Plan Administratr, n a reasnable and cnsistent basis, will autmatically make this increase r decrease in affected Participants elective Cntributins n a prspective basis. Significant Cst Increases. If the Plan Administratr determines that the cst charged t an Emplyee fr a Benefit significantly increases during a Perid f Cverage, the Participant may: Make a crrespnding prspective increase t elective Cntributins by increasing Salary Reductins; Revke the electin fr that cverage, and in lieu theref, receive n a prspective basis cverage under anther Benefit Optin that prvides similar cverage; r Terminate cverage ging frward if there is n ther Benefit Optin available that prvides similar cverage. 17
The Plan Administratr, in its sle discretin and n a unifrm and cnsistent basis, will decide whether a cst increase is significant. Significant Cst Decreases. If the Plan Administratr determines that the cst f any Benefit (such as the premium fr the Health Plan) significantly decreases during a Perid f Cverage, then the Plan Administratr may permit the fllwing electin changes: Participants enrlled in that Benefit Optin may make a crrespnding prspective decrease in their elective cntributins by decreasing Salary Reductins; Participants wh are enrlled in anther benefit package ptin may change their electin n a prspective basis t elect the Benefit Optin that has decreased in cst; r Emplyees wh are therwise eligible may elect the Benefit Optin that has decreased in cst n a prspective basis, subject t the terms and limitatins f the Benefit Optin. The Plan Administratr, in its sle discretin and n a unifrm and cnsistent basis, will decide whether a cst decrease is significant. Limitatin n Change in Cst Prvisins fr DCAP Benefits. The abve Change in Cst prvisins apply t DCAP Benefits nly if the cst change is impsed by a dependent care prvider wh is nt a relative f the Emplyee. Change in Cverage. (Applies t the POP and DCAP, but nt t the Health FSA). The definitin f similar cverage applied in the Change f Cst prvisin abve als applies here. Significant Curtailment. Cverage under a Plan is deemed t be significantly curtailed nly if there is an verall reductin in cverage prvided under the Plan t cnstitute reduced cverage generally. If cverage is significantly curtailed, Participants may elect cverage under a Benefit Optin that prvides similar cverage. In additin, if the cverage curtailment results in a Lss f Cverage as defined belw, Participants may drp cverage if n similar cverage is ffered by the Emplyer. The Plan Administratr, in its sle discretin and n a unifrm and cnsistent basis, will decide whether a curtailment is significant, and whether a Lss f Cverage has ccurred in accrdance with prevailing IRS guidance. Significant Curtailment Withut Lss f Cverage. If the Plan Administratr determines that a Participant s cverage under a Benefit Optin (r the Participant s, Spuse s r Dependent s cverage under the respective emplyer s plan) is significantly curtailed withut a Lss f Cverage during a Perid f Cverage, the Participant may revke an electin fr the affected cverage and prspectively elect cverage under anther Benefit Optin if ffered, that prvides similar cverage. Significant Curtailment With a Lss f Cverage. If the Plan Administratr determines that a Participant s cverage under this Plan (r the Participant s, Spuse s r Dependent s cverage under the respective emplyer s plan) is significantly curtailed, and such curtailment results in a Lss f Cverage during a Perid f Cverage, the Participant may revke an electin fr the affected cverage, and may either prspectively elect cverage under anther Benefit Optin that prvides similar 18
cverage r drp cverage if n ther Benefit Optin prviding similar cverage is ffered by the Emplyer. Definitin f Lss f Cverage. Fr purpses f this Sectin, a Lss f Cverage means a cmplete lss f cverage. In additin, the Plan Administratr in its sle discretin and n a unifrm and cnsistent basis, may treat the fllwing as a Lss f Cverage: A substantial decrease in the health care prviders available under the Benefit Package Plan; A reductin in benefits fr a specific type f medical cnditin r treatment with respect t which the Participant r his r her Spuse r Dependent is currently in a curse f treatment; r Any ther similar fundamental lss f cverage. Additin r Significant Imprvement f a Benefit Optin. If during a Perid f Cverage, the Plan adds a new Benefit Optin r significantly imprves an existing Benefit Optin, the Plan Administratr may permit the fllwing electin changes: Participants wh are enrlled in a Benefit Optin ther than the newly-added r significantly imprved Benefit Optin that prvides similar cverage may change their electin n a prspective basis t cancel the current Benefit Optin and instead elect the newly added r significantly imprved Benefit Optin; and Emplyees wh are therwise eligible may elect the newly added r significantly imprved Benefit Optin n a prspective basis, subject t the terms and limitatins f the Benefit Optin. The Plan Administratr, in its sle discretin and n a unifrm and cnsistent basis, will decide whether there has been an additin f, r a significant imprvement in, a Benefit Optin. Lss f Cverage Under Anther Grup Health Cverage. A Participant may prspectively change an electin t add grup health cverage fr the Participant, Spuse r Dependent, if such individual(s) lses cverage under any grup health cverage spnsred by a gvernmental r educatinal institutin, including, but nt limited t, the fllwing: A children s health insurance prgram (CHIP) under Title XXI f the Scial Security Act; A health care prgram f an Indian Tribal gvernment (as defined in Cde 7701(a)(40)), the Indian Health Service, r a tribal rganizatin; A state health benefits risk pl; r A freign gvernment grup health plan, subject t the terms and limitatins f the applicable Benefit Optin. Change in Cverage Under Anther Emplyer Plan. A Participant may make a prspective electin change that is n accunt f and crrespnds with a change made under an 19
emplyer plan, including a plan f the Emplyer r a plan f the Spuse s r Dependent s emplyer, s lng as: The ther cafeteria plan r qualified benefits plan permits its participants t make an electin change that wuld be permitted under applicable IRS regulatins; r The Plan permits Participants t make an electin fr a Perid f Cverage that is different frm the plan year under the ther cafeteria plan r qualified benefits plan. The Plan Administratr, n a unifrm and cnsistent basis, will decide whether a requested change is because f, and crrespnds with, a change made under the ther emplyer plan. Enrllment in a Grup Health Plan that Offers Minimal Essential Cverage r in a Health Care Exchange r Marketplace. An Emplyee may make a prspective electin change that is n accunt f and crrespnds with a change t his/her POP electin, s lng as: The Emplyee s emplyment status changes frm an expectatin t wrk 30 hurs r mre per week t an expectatin t wrk less than 30 hurs per week (even if that change fails t make the Emplyee ineligible fr Emplyer-spnsred grup health plan cverage); AND the Emplyee enrlls in a grup health plan that ffers minimal essential cverage (as defined by the Affrdable Care Act) with a new cverage effective date n later than the first day f the secnd mnth fllwing the mnth that includes the date the riginal cverage is revked; r The Emplyee is eligible fr a Special Enrllment Perid t enrll in a Qualified Health Plan thrugh a Marketplace r the Emplyee seeks t enrll in a Marketplace during the Marketplace s annual pen enrllment perid; AND the Emplyee enrlls in the Marketplace with a new cverage effective date n later than the day immediately fllwing the last day the riginal cverage is revked. N such changes shall be made retractively. Change in Dependent Care Service Prvider. A Participant may make a prspective electin change that crrespnds with a change in the dependent care service prvider. Fr example: If the Participant terminates ne dependent care service prvider and hires a new dependent care service prvider, the Participant may change cverage t reflect the cst f the new service prvider; and If the Participant terminates a dependent care service prvider because a relative r ther persn becmes available t take care f the child at n charge, the Participant may cancel cverage. A Participant entitled t change an electin as described in this Sectin must d s in accrdance with the prcedures described this Sectin. 20
6.5 Electin Mdificatins Required by Plan Administratr The Plan Administratr may require, at any time, any Participant r class f Participants t amend their Salary Reductins fr a Perid f Cverage if the Plan Administratr determines that such actin is necessary r advisable in rder t: Satisfy any f the Cde s nndiscriminatin requirements applicable t this Plan r anther cafeteria plan; Prevent any Emplyee r class f Emplyees frm having t recgnize mre incme fr federal incme tax purpses frm the receipt f Benefits hereunder than wuld therwise be recgnized; Maintain the qualified status f Benefits received under this Plan; r Satisfy any f the Cde s nndiscriminatin requirements r ther limitatins applicable t the Emplyer s qualified Plans. In the event that Cntributins need t be reduced fr a class f Participants, the Plan Administratr will reduce the Salary Reductin amunts fr each affected Participant, beginning with the Participant in the class wh had elected the highest Salary Reductin amunt, and cntinuing with the Participant in the class wh had elected the next-highest Salary Reductin amunt, and s frth, until the defect is crrected. 21
Sectin 7 Claims and Appeals 7.1 Claims Under the Plan If a claim fr reimbursement under the Health FSA r DCAP is whlly r partially denied, r if the Participant is denied a Benefit under the Plan regarding the Participant s cverage under the Plan, then the claims prcedure described belw will apply. 7.2 Ntice frm ASI If a claim is denied in whle r in part, ASI will ntify the Participant in writing within 30 days f the date that ASI received the claim. This time may be extended fr an additinal 15 days fr matters beynd the cntrl f the ASI, including cases where a claim is incmplete. ASI will prvide written ntice f any extensin, including the reasn(s) fr the extensin and the date a decisin by ASI is expected t be made. When a claim is incmplete, the extensin ntice will als specifically describe the required infrmatin, and will allw the Participant at least 45 days frm receipt f the ntice t prvide the specified infrmatin, and will have the effect f suspending the time fr a decisin n the claim until the specified infrmatin is prvided. Ntificatin f a denied claim will include: The specific reasns fr the denial; The specific Plan prvisins n which the denial is based; A descriptin f any additinal material r infrmatin necessary t validate the claim and an explanatin f why such material r infrmatin is necessary; and Apprpriate infrmatin n the steps t take t appeal ASI s adverse benefits determinatin, including the right t submit written cmments and have them cnsidered, and the right t review, upn request and at n charge, relevant dcuments and ther infrmatin, and the right t file suit, where applicable, with respect t any adverse benefits determinatin after the final appeal f the claim. 7.3 First Level Appeal t ASI If a claim is denied in whle r in part, the Participant, r the Participant s authrized representative, may request a review f the adverse benefits determinatin upn written applicatin t ASI. The Participant, r the Participant s authrized representative, may request access t all relevant dcuments in rder t evaluate whether t request review f an adverse benefits determinatin and, if review is requested, t prepare fr such review. An appeal f an adverse benefits determinatin must be made in writing within 90 days upn receipt f the ntice that the claim was denied. If an appeal is nt made within the abve referenced timeframe all rights t appeal the adverse benefits determinatin and t file suit in curt will be frfeited. A written appeal shuld include: additinal dcuments, written cmments, and any ther infrmatin in supprt f the appeal. The review f the adverse benefits determinatin will take int accunt all new infrmatin, whether r nt presented r available at the initial determinatin. N deference will be affrded t the initial determinatin. 22
7.4 ASI Actin n Appeal ASI, within a reasnable time, but n later than 60 days after receipt f the request fr review, will decide the appeal. ASI may, in its discretin, hld a hearing n the denied claim. Any medical expert cnsulted in cnnectin with the appeal will be different frm and nt subrdinate t any expert cnsulted in cnnectin with the initial claim denial. The identity f any medical expert cnsulted in cnnectin with the appeal will be prvided. If the decisin n review affirms the initial denial f the claim, a ntice will be prvided which sets frth: The specific reasns fr the decisin n review; The specific Plan prvisins n which the decisin is based; A statement regarding the right t review, upn request and at n charge, relevant dcuments and ther infrmatin. If an internal rule, guideline, prtcl, r ther similar criterin is relied n in making the decisin n review, a descriptin f the specific rule, guideline, prtcl, r ther similar criterin r a statement that such a rule, guideline, prtcl, r ther similar criterin was relied n and that a cpy f such rule, guideline, prtcl, r ther criterin will be prvided free f charge upn request; and Apprpriate infrmatin n the steps t take t appeal ASI s adverse benefits determinatin, including the right t submit written cmments and have them cnsidered, and the right t review, upn request and at n charge, relevant dcuments and ther infrmatin, and the right t file suit, where applicable, with respect t any adverse benefits determinatin after the final appeal f the claim. 7.5 Secnd and Final Level Appeal t the Plan Administratr If the decisin n review affirms ASI s initial denial, the Participant may request a review f the adverse appeal determinatin upn written applicatin t the Plan Administratr. The Participant, r the Participant s authrized representative, may request access t all relevant dcuments in rder t evaluate whether t request review f an adverse benefits determinatin and, if review is requested, t prepare fr such review. An appeal f an adverse appeal determinatin must be made in writing within 90 days after receipt f the ntice that the claim was denied. If an appeal is nt made within the abve referenced timeframe all rights t appeal the adverse benefits determinatin and t file suit in curt will be frfeited. A written appeal shuld include: additinal dcuments, written cmments, and any ther infrmatin in supprt f the appeal. The review f the adverse benefits determinatin will take int accunt all new infrmatin, whether r nt presented r available at the initial determinatin. N deference will be affrded t the initial determinatin. 7.6 Plan Administratr Actin n Appeal The Plan Administratr, within a reasnable time, but n later than 60 days after receipt f the request fr review, will decide the appeal. The Plan Administratr may, in its discretin, hld a hearing n the denied claim. Any medical expert cnsulted in cnnectin with the appeal will be different frm and nt subrdinate t any expert cnsulted in cnnectin with the initial claim denial. The identity f any 23
medical expert cnsulted in cnnectin with the appeal will be prvided. If the decisin n review affirms the initial denial f the claim, a ntice will be prvided which sets frth: The specific reasn(s) fr the decisin n review; The specific Plan prvisin(s) n which the decisin is based; A statement regarding the right t review, upn request and at n charge, relevant dcuments and ther infrmatin. If an internal rule, guideline, prtcl, r ther similar criterin is relied n in making the decisin n review, a descriptin f the specific rule, guideline, prtcl, r ther similar criterin r a statement that such a rule, guideline, prtcl, r ther similar criterin was relied n and that a cpy f such rule, guideline, prtcl, r ther criterin will be prvided free f charge upn request; and A statement regarding the right t bring suit, where applicable. 7.7 Appeal Prcedure fr Eligibility r Salary Reductin Issues If the Participant is denied a Benefit under the Plan due t questins regarding the Participant s eligibility r entitlement fr cverage under the Plan r regarding the amunt the Participant wes, the Participant may request a review upn written applicatin t the Plan Administratr. The Participant, r the Participant s authrized representative, may request access t all relevant dcuments in rder t evaluate whether t request review f an adverse benefits determinatin and if review is requested, t prepare fr such review. An appeal f an adverse benefits determinatin must be made in writing within 90 days upn receipt f the ntice that the claim was denied. If an appeal is nt made within the abve referenced timeframe all rights t appeal the adverse benefits determinatin and t file suit in curt will be frfeited. A written appeal shuld include: additinal dcuments, written cmments, and any ther infrmatin in supprt f the appeal. The review f the adverse benefits determinatin will take int accunt all new infrmatin, whether r nt presented r available at the initial determinatin. N deference will be affrded t the initial determinatin. The Plan Administratr, within a reasnable time, but n later than 30 days after receipt f the request fr review, will decide the appeal. The Plan Administratr may, in its discretin, hld a hearing n the denied claim. Any medical expert cnsulted in cnnectin with the appeal will be different frm and nt subrdinate t any expert cnsulted in cnnectin with the initial claim denial. The identity f any medical expert cnsulted in cnnectin with the appeal will be prvided. If the decisin n review affirms the initial denial f the claim, a ntice will be prvided which sets frth: The specific reasns fr the decisin n review; The specific Plan prvisins n which the decisin is based; A statement regarding the right t review, upn request and at n charge, relevant dcuments and ther infrmatin. If an internal rule, guideline, prtcl, r ther similar criterin is relied n in making the decisin n review, a descriptin f the specific rule, guideline, prtcl, r ther similar criterin r a statement that such a rule, guideline, prtcl, r ther similar 24