HomeMy WebLinkAbout12-1403
RESOLUTION N0. 12-140
A RESOLUTION ADOPTING A REVISION TO THE EMPLOYEE FLEXIBLE BENEFITS
PLAN DOCUMENT AND THE SUMMARY PLAN DESCRIPTION THAT COMPLIES WITH
IRS NOTICE 2012-40 WHICH REDUCES THE AMOUNT OF PRE-TAX DOLLARS
EMPLOYEES MAY SET ASIDE IN THEIR HEALTH FLEXIBLE SPENDING ACCOUNT TO
$2,500 AND ADDS A NINETY DAY RUN-OUT-PERIOD AFTER THE END OF THE PLAN
YEAR DURING WHICH PLAN PARTICIPANTS MAY SUBMIT CLAIMS FOR
REIMBURSEMENT OUT OF THE PRIOR PLAN YEAR'S ACCOUNT.
WHEREAS, The Board of County Commissioners of St. Lucie County, Florida, has made the following
determinations:
That the County has previously adopted an IRS Compliant Section-125 Flexible Benefit Plan that includes a
Health Flexible Spending Account feature for employees and that the IRS has now changed the permissible
amount of dollars an employee may set aside in their Flexible Spending Accounts.
2. That the revised Flexible Benefits Plan and the Summary Plan Description that are attached hereto as Exhibits A
and B include the new IRS Health Flexible Spending Account limits and include a provision permitting employees
to use aninety-day Run-Out-Period to submit claims for reimbursement.
3. That the revised Flexible Benefits Plan and the Summary Plan Description that are attached hereto as Exhibits A
and B are hereby approved and adopted effective January 1, 2013 and County staff are hereby authorized and
directed to execute and deliver them to the Plan Administrator.
4. That the County staff is instructed to act as soon as possible to notify the employees of the Employer of the
adoption of the Revised Flexible Benefits Plan by making a copy of the Summary Plan Description attached
hereto as Exhibit B available to all employees.
NOW, THEREFORE, BE IT RESOLVED, by the Board of County Commissioners of St. Lucie County, Florida:
1. The Board does hereby approve and adopt the Revised Flexible Benefits Plan and the Revised Summary Plan
Description as presented to this meeting and as hereby attached.
PASSED AND DULY ADOPTED this 7th day of August, 2012.
ATTEST:
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"" DE UTY C ERK
BOARD OF COUNTY COMMISSIONERS
ST. LUCIE COUNTY, FLO
By:
CHAIRM N
AS TO LEGAL FORM AND
UNTY AT~'ORNEY
ST. LUCIE COUNTY BOARD OF COUNTY COMMISSIONERS
Section-125 -Cafeteria Plan
FLEXIBLE BENEFITS PLAN
Plan Number 507
Revised: 08/07/2012
Revised: 0 810 712 0 1 2 Page 1 of 28
ST. LUCIE COUNTY BOARD OF COUNTY COMMISSIONERS
FLEXIBLE BENEFITS PLAN
M
INTRODUCTION
1.0 DEFINITIONS
TABLE OF CONTENTS
.....................................
ARTICLE I
DEFINITIONS
..........................................
ARTICLE II
PARTICIPATION
........................................... 6
.. 6
2.1 ELIGIBILITY ..................................................................................................................8
2.2 EFFECTIVE DATE OF PARTICIPATION ..................................................................... 8
2.3 APPLICATION TO PARTICIPATE ............................................................................... 8
2.4 TERMINATION OF PARTICIPATION .......................................................................... 9
2.5 TERMINATION OF EMPLOYMENT ............................................................................. 9
2.6 DEATH ...........................................................................................................................9
ARTICLE III
CONTRIBUTIONS TO THE PLAN
3.1 SALARY REDIRECTION .............................................................................................. 9
3.2 APPLICATION OF CONTRIBUTIONS .......................................................................... 10
3.3 PERIODIC CONTRIBUTIONS ...................................................................................... 10
ARTICLE IV
BENEFITS
4.1 FLEXIBLE SPENDING ACCOUNT OPTIONS ............................................................. 10
4.2 PREMIUM REDIRECTION BENEFIT ............................................................................ 11
4.3 HEALTH INSURANCE BENEFIT ................................................................................... 11
4.4 DENTAL INSURANCE BENEFIT ...................................................................................11
4.5 VISION INSURANCE BENEFIT .................................................................................... 11
4.6 NONDISCRIMINATION REQUIREMENTS .................................................................... 12
ARTICLE V
PARTICIPANT ELECTIONS
5.1 INITIAL ELECTIONS .....................................................................................................12
5.2 SUBSEQUENT ANNUAL ELECTIONS .......................................................................... 12
5.3 FAILURE TO ELECT ......................................................................................................13
5.4 CHANGE IN STATUS .....................................................................................................13
Revised: 08/07/2012 Page 3 of 28
ARTICLE VI
HEALTH FLEXIBLE SPENDING ACCOUNT
6.1 ESTABLISHMENT OF PLAN ................................................................................ 16
6.2 DEFINITIONS ....................................................................................... .............. 16
6.3 LIMITATION ON ALLOCATIONS ........................................................... ............... 17
6.4 FORFEITURES ..................................................................................... ...............16
6.5 NONDISCRIMINATION REQUIREMENTS ............................................. ............... 17
6.6 COORDINATION WITH CAFETERIA PLAN ........................................... ............... 17
6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS ............................. ............... 17
6.8 DEBIT AND CREDIT CARDS ................................................................. ............... 18
ARTICLE VII
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
7.1 ESTABLISHMENT OF ACCOUNT .................................................................................. 19
7.2 DEFINITIONS ................................................................................................................. 19
7.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS ............................................. 20
7.4 INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS .................. 20
7.5 DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS ................ 21
7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT ............................................... 21
7.7 ANNUAL STATEMENT OF BENEFITS .......................................................................... 21
7.8 FORFEITURES ............................................................................................................... .21
7.9 LIMITATION ON PAYMENTS ......................................................................................... . 21.
7.10 NONDISCRIMINATION REQUIREMENTS ..................................................................... . 21
7.11 COORDINATION WITH CAFETERIA PLAN .................................................................. . 22
7.12 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS ................................. . 22
ARTICLE VIII
BENEFITS AND RIGHTS
8.1 CLAIM FOR BENEFITS ................................................................................................. 23
8.2 APPLICATION OF BENEFIT PLAN SURPLUS ............................................................. 24
ARTICLE IX
ADMINISTRATION
9.1 PLAN ADMINISTRATION ............................................................................................... 24
9.2 EXAMINATION OF RECORDS ....................................................................................... 25
9.3 PAYMENT OF EXPENSES ............................................................................................. 25
9.4 INSURANCE CONTROL CLAUSE .................................................................................. 251
9.5 INDEMNIFICATION OF ADMINISTRATOR .................................................................... 25 '
ARTICLE X
AMENDMENT OR TERMINATION OF PLAN
10.1 AMENDMENT .................................................................................................................25
10.2 TERMINATION ...............................................................................................................25
Revised: 08/07/2012 Page 4 of 28
ARTICLE XI
MISCELLANEOUS
11.1 PLAN INTERPRETATION ............................................................................................. 26
11.2 GENDER AND NUMBER ............................................................................................... 26
11.3 WRITTEN DOCUMENT ................................................................................................. 26
11.4 EXCLUSIVE BENEFIT ................................................................................................... 26
11.5 PARTICIPANT'S RIGHTS ............................................................................................. 26
11.6 ACTION BY THE EMPLOYER ....................................................................................... 26
11.7 EMPLOYER'S PROTECTIVE CLAUSES ....................................................................... 26
11.8 NO GUARANTEE OF TAX CONSEQUENCES .............................................................. 27
11.9 INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS ............................................ . 27
11.10 FUNDING ....................................................................................................................... ..27
11.11 OTHER VOLUNTARY EMPLOYEE BENEFIT OPTIONS ....................................... . 27
11.12 GOVERNING LAW ......................................................................................................... .. 27
11.13 SEVERABILITY ............................................................................................................. .. 27
11.14 CAPTIONS .................................................................................................................... .. 27
11.15 FAMILY AND MEDICAL LEAVE ACT (FMLA) .............................................................. .. 28
11.16 Uniform Services Employment & Reemployment Rights Act (USERRA) ................... . 28
11.17 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT ....................................... .. 28
11.18 GENETIC INFORMATION NONDISCRIMINATION ACT (GINA) .................................. .. 28
Revised: 0 810 712 0 1 2 Page 5 of 28
ST. LUCIE COUNTY BOARD OF COUNTY COMMISSIONERS
Section-125
FLEXIBLE BENEFITS PLAN
INTRODUCTION
St. Lucie County BOCC (Employer) has previously established aSection-125 Flexible Benefits Plan and to
comply with changes in Federal and State Regulations is now adopting this revised Plan with an effective date of
January 1, 2013, The plan is made to recognize the premium contributions made to the Employer by its Employees as
pre-tax dollars. The purpose of this plan is to reward employees by providing benefits for those that qualify hereunder
and their Dependents and beneficiaries. The concept of this Plan is to allow Employees to choose among different types
of benefits based on their own particular goals, desires and needs and to pay for those benefits with Pre-Tax dollars. The
Plan shall be known as St. Lucie County Board of County Commissioners Flexible Benefits Plan (the "Plan").
The intention of the Employer is that the Plan qualify as a "Cafeteria Plan" within the meaning of Section 125 of
the internal Revenue Code of 1986, as amended, and that the employees share of the premiums for benefits which an
Employee elects to receive under the Plan be excludable from the Employee's income under Section 125(a) and other
applicable sections of the Intemal Revenue Code of 1986, as amended.
This cafeteria plan permits employees to elect to pay their share of their benefit cost with pretax deferrals. This
cafeteria plans permits an employee to change their pre-tax deferral election only when certain specific event occurs
(other than during an enrollment period.) An eligible employee MUST submit a written request to their employer
regarding any such event(s) within 31 days from the date of the event.
ARTICLE I
DEFINITIONS
1.1 "Administrator" means the individual(s) or corporation appointed by the Employer to carry out the
administration of the Plan. The Employer shall be empowered to appoint and remove the Administrator from
time to time as it deems necessary for the proper administration of the Plan. In the event the Administrator has
not been appointed, or resigns from a prior appointment, the Employer shall be the Administrator.
1.2 "Affiliated Employer" means the Employer and any corporation which is a member of a controlled group of
corporations (as defined in Code Section 414(b)) which includes the Employer; any trade or business (whether
or not incorporated) which is under common control (as defined in Code Section 414(c)) with the Employer; any
organization (whether or not incorporated) which is a member of an affiliated service group (as defined in Code
Section 414(m)) which includes the Employer; and any other entity required to be aggregated with the Employer
pursuant to Treasury regulations under Code Section 414(0).
1.3 "Benefit" or "Benefit Options" means any of the optional benefit choices available to a Participant as outlined
in Section 4.1.
1.4 "Cafeteria Plan Benefit Dollars" means the amount available to Participants to purchase Benefit Options as
provided under Section 4.1. Each dollar contributed to this Plan shall be converted into one Cafeteria Plan
Benefit Dollar.
1.5 "Code" means the Internal Revenue Code of 1986, as amended or replaced from time to time.
1.6 "Compensation" means the amounts received by the Participant from the Employer during a Plan Year.
Revised: 08/07/2012 Page 6 of 28
1.7 "Dependent" means any individual who qualifies as a dependent under an Insurance Contract for purposes of
that Contract or under Code Section 152 (as modified by Code Section 105(b)).
For Health Benefits, a Dependent child includes dependent children through age 26 (until their 27~h birthday).
This includes children that may be married, and even if the child has other group coverage available.
Notwithstanding anything in the Plan to the contrary, the Plan will comply with Michelle's Law and any future
changes in the benefits laws or regulations affecting such plans.
1.8 "Effective Date" means January 1, 2013.
1.9 "Election Period" means the designated annual "Open Enrollment Period" or the 60 day period immediately
preceding the beginning of each Plan Year and/or an "Open Enrollment Period" as designated by the Plan
Administrator. However, an Employee's initial Election Period shall be determined pursuant to Section 5.1.
1.10 "Eligible Employee" means any Employee who has satisfied the provisions of Section 2.1.
An individual shall not be an "Eligible Employee" if such individual is not reported on the payroll
records of the Employer as a common law employee. In particular, it is expressly intended that individuals not
treated as common law employees by the Employer on its payroll records are not "Eligible Employees" and are
excluded from Plan participation even if a court or administrative agency determines that such individuals are
common law employees and not independent contractors.
1.11 "Employee" means any person who is employed by the Employer. The term Employee shall include leased
employees within the meaning of Code Section 414(n)(2).
1.12 "Employer" means St. Lucie County Board of County Commissioners and any successor which shall maintain
this Plan; and any predecessor which has maintained this Plan. In addition, where appropriate, the term
Employer shall include any Participating, Affiliated or Adopting Employer.
1.13 "Grace Period" means, with respect to any Plan Year, the time period ending on the fifteenth day of the third
calendar month after the end of such Plan Year, during which Medical Expenses incurred by a Participant will
be deemed to have been incurred during such Plan Year. The "Grace Period" is 2 and 'h months long and
ends on March 15 of each year.
1.14 "Insurance Contract" means any contract issued by an Insurer underwriting a Benefit.
1.15 "Insurance Premium Payment Plan" means the plan of benefits contained in Section 4.1 of this Plan, which
provides for the payment of Premium Expenses.
1.16 "Insurer" means any insurance company that underwrites a Benefit under this Plan.
1.17 "Key Employee" means an Employee described in Code Section 416(1)(1) and the Treasury regulations
thereunder.
1.18 "Participant" means any Eligible Employee who elects to become a Participant pursuant to Section 2.3 and
has not for any reason become ineligible to participate further in the Plan.
1.19 "Plan" means this instrument, including all amendments thereto.
1.20 "Plan Year" means the 12-month period beginning January 1 and ending December 31. The Plan Year shall be
the coverage period for the Benefits provided for under this Plan. In the event a Participant commences
participation during a Plan Year, then the initial coverage period shall be that portion of the Plan Year
commencing on such Participant's date of entry and ending on the last day of such Plan Year.
Revised: 08/07/2012 Page 7 of 28
1.21 "Premium Expenses" or "Premiums" mean the Participant's cost for Benefits described in Section 4.1.
1.22 "Premium Expense Reimbursement Account" means the account established for a Participant pursuant to
this Plan to which part of his Cafeteria Plan Benefit Dollars may be allocated and from which Premiums of the
Participant shall be paid or reimbursed. If more than one type of insured Benefit is elected, sub-accounts shall
be established for each type of insured Benefit.
1.23 "Run-out Period" means the first 90 days following the end of the plan year. The Run-out Period is the time in
which a participant has to submit claims for reimbursement out of the prior plan year's account. The plan Run-
out period ends on March 30 of each year.
1.24 "Salary Redirection" means the contributions made by the Employer on behalf of Participants pursuant to
Section 3.1. These contributions shall be converted to Cafeteria Plan Benefit Dollars and allocated to the funds
or accounts established under the Plan pursuant to the Participants' elections made under Article V.
1.25 "Salary Redirection Agreement" means an agreement between the Participant and the Employer under which
the Participant agrees to reduce his Compensation or to forego all or part of the increases in such
Compensation and to have such amounts contributed by the Employer to the Plan on the Participant's behalf.
The Salary Redirection Agreement shall apply only to Compensation that has not been actually or constructively
received by the Participant as of the date of the agreement (after taking this Plan and Code Section 125 into
account) and, subsequently does not become currently available to the Participant.
1.26 "Spouse" means "spouse" as defined in an Insurance Contract for purposes of that Contract or the legally
married husband or wife of a Participant, unless legally separated by court decree.
ARTICLE II
PARTICIPATION
2.1 ELIGIBILITY
Employee's shall be eligible to participate hereunder as of the date they satisfy the eligibility conditions for the
Employer's group medical plan, the provisions of which are specifically incorporated herein by reference.
2.2 EFFECTIVE DATE OF PARTICIPATION
An Eligible Employee shall become a Participant effective as of the entry date under the Employer's group
medical plan, the provisions of which are specifically incorporated herein by reference.
2.3 APPLICATION TO PARTICIPATE
An Employee who is eligible to participate in this Plan shall, during the applicable Election Period, complete an
application to participate and Election of Benefits Form which the Administrator shall furnish to the Employee. The
election made on such form shall be irrevocable until the end of the applicable Plan Year unless the Participant is
entitled to change his Benefit elections pursuant to Section 5.4 hereof.
An Eligible Employee shall also be required to execute a Salary Redirection Agreement during the Election
Period for the Plan Year during which he wishes to participate in this Plan. Any such Salary Redirection Agreement shall
be effective for the first pay period beginning on or after the Employee's effective date of participation pursuant to
Section 2.2.
Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who is covered by the
Employer's insured Benefits under this Plan shall automatically become a Participant to the extent of the Premiums for
such insurance unless the Employee elects, during the Election Period, not to participate in the Plan.
Revised: 08/07/2012 Page 8 of 28
2.4 TERMINATION OF PARTICIPATION
A Participant shall no longer be eligible to participate in this Plan following any of the following events:
(a) Termination of employment. The Participant's termination of employment, subject to the provisions
of Section 2.5;
(b) Death. The Participant's death, subject to the provisions of Section 2.6; or
(c) Termination of the plan. The termination of this Plan, subject to the provisions of Section 10.2.
2.5 TERMINATION OF EMPLOYMENT
If a Participant's employment with the Employer is terminated for any reason other than death, his participation
in the Benefit Options provided under Section 4.1 shall be governed in accordance with the following:
(a) Insurance Benefit. With regard to Benefits which are insured, the Participant's participation in the
Plan shall cease, subject to the Participant's right to continue coverage under any Insurance Contract
for which premiums have already been paid.
(b) Dependent Care FSA. With regard to the Dependent Care Flexible Spending Account, the
Participant's participation in the Plan shall cease and no further Salary Redirection contributions shall
be made. However, such Participant may submit claims for employment related Dependent Care
Expense reimbursements for claims incurred up to the date of termination and submitted within 90
days after termination, based on the level of the Participant's Dependent Care Flexible Spending
Account as of the date of termination.
(c) Health FSA. With regard to the Health Flexible Spending Account, the Participant's participation in the
Plan shall cease and no further Salary Redirection contributions shall be made. However, such
Participant may submit claims for expenses that were incurred during the portion of the Plan Year
before the end of the period for which payments to the Health Flexible Spending Account have already
been made for claims incurred up to the date of termination and submitted within 90 days after
termination.
(d) Health FSA treatment. In the event a Participant terminates his participation in the Health Flexible
Spending Account during the Plan Year, if Salary Redirections are made other than on a pro rata
basis, upon termination the Participant shall be entitled to a reimbursement for any Salary Redirection
previously paid for coverage or benefits relating to the period after the date of the Participant's
separation from service regardless of the Participant's claims or reimbursements as of such date.
2.6 DEATH
If a Participant dies, his participation in the Plan shall cease. However, such Participant's spouse or
Dependents may submit claims for expenses or benefits for the remainder of the Plan Year or until the Cafeteria Plan
Benefit Dollars allocated to each specific benefit are exhausted. In no event may reimbursements be paid to someone
who is not a spouse or Dependent.
ARTICLE III
CONTRIBUTIONS TO THE PLAN
3.1 SALARY REDIRECTION
Benefits under the Plan shall be financed by Salary Redirections sufficient to support Benefits that a Participant
has elected hereunder and to pay the Participant's Premium Expenses. The salary administration program of the
Revised: 08/07/2012 Page 9 of 28
Employer allows each Participant to agree to reduce his pay during a Plan Year by an amount determined necessary to
purchase the elected Benefit Options. The amount of such Salary Redirection shall be specified in the Salary Redirection
Agreement and shall be applicable for a Plan Year. For new Employees, the Salary Redirection Agreement shall only be
applicable from the first day of the pay period following the Employee's entry date up to and including the last day of the
Plan Year. These contributions shall be converted to Cafeteria Plan Benefit Dollars and allocated to the funds or
accounts based on the Participants' elections made under Article V.
Any Salary Redirection shall be determined prior to the beginning of a Plan Year (subject to initial elections
pursuant to Section 5.1) and prior to the end of the Election Period and shall be irrevocable for such Plan Year.
However, a Participant may revoke a Benefit election or a Salary Redirection Agreement after the Plan Year has
commenced and make a new election with respect to the remainder of the Plan Year, if both the revocation and the new
election are on account of and consistent with a change in status and such other permitted events as determined under
Article V of the Plan and consistent with the rules and regulations of the Department of the Treasury. Salary Redirection
amounts shall be contributed on a pro rata basis for each pay period during the Plan Year. All individual Salary
Redirection Agreements are part of this Plan and incorporated by reference hereunder.
3.2 APPLICATION OF CONTRIBUTIONS
As soon as reasonably practical after each payroll period, the Employer shall apply the Salary Redirection to
provide the Benefits elected by the affected Participants. Any contribution made or withheld for the Health Flexible
Spending Account or Dependent Care Flexible Spending Account shall be credited to such fund or account. Amounts
designated for the Participant's Premium Expense Reimbursement Account shall likewise be credited to such account for
the purpose of paying Premium Expenses.
3.3 PERIODIC CONTRIBUTIONS
Notwithstanding the requirement provided above and in other Articles of this Plan that Salary Redirections be
contributed to the Plan by the Employer on behalf of an Employee on a level and pro rata basis for each payroll period,
the Employer and Administrator may implement a procedure in which Salary Redirections are contributed throughout the
Plan Year on a periodic basis that is not pro rata for each payroll period. However, with regard to the Health Flexible
Spending Account, the payment schedule for the required contributions may not be based on the rate or amount of
reimbursements during the Plan Year. In the event Salary Redirections to the Health Flexible Spending Account are not
made on a pro rata basis, upon termination of participation, a Participant may be entitled to a refund of such Salary
Redirections pursuant to Section 2.5.
ARTICLE IV
BENEFITS
4.1 FLEXIBLE SPENDING ACCOUNT OPTIONS
Each Participant may elect any one or more of the following optional Benefits:
(a) HEALTH FLEXIBLE SPENDING ACCOUNT BENEFIT
Each Employee may elect to participate in the Health Flexible Spending Account option, in which case
Article VI shall apply.
(b) DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT BENEFIT
Each Employee may elect to participate in the Dependent Care Flexible Spending Account option, in
which case Article VII shall apply.
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4.2 Each Participant enrolling in the following benefits shall have a sufficient portion of their Salary
Redirected PRE-TAX and applied to the PREMIUM for the following Benefits unless the Participant
elects not to receive such Salary Redirection Benefits:
(a) Health Insurance Benefit
(b) Dental Insurance Benefit
(c) Vision Insurance Benefit
4.3 HEALTH INSURANCE BENEFIT
(a) Coverage for Participant and Dependents. Each Participant may elect to be covered under a health
Insurance Contract for the Participant, his or her Spouse, and his or her Dependents.
(b) Employer selects contracts. The Employer may select suitable health Insurance Contracts for use in
providing this health insurance benefit, which policies will provide uniform benefits for all Participants
electing this Benefit.
(c) Contract incorporated by reference. The rights and conditions with respect to the benefits payable
from such health Insurance Contract(s) shall be determined there from, and such Insurance
Contract(s) shall be incorporated herein by reference.
4.4 DENTAL INSURANCE BENEFIT
(a) Coverage for Participant and/or Dependents. Each Participant may elect to be covered under the
Employer's dental Insurance Contract. In addition, the Participant may elect either individual or family
coverage under such Insurance Contract.
(b) Employer selects contracts. The Employer may select suitable dental Insurance Contracts for use in
providing this dental insurance benefit, which policies will provide uniform benefits for all Participants
electing this Benefit.
(c) Contract incorporated by reference. The rights and conditions with respect to the benefits payable
from such dental Insurance Contract shall be determined there from, and such dental Insurance
Contract shall be incorporated herein by reference.
4.5 VISION INSURANCE BENEFIT
(a) Coverage for Participant and/or Dependents. Each Participant may elect to be covered under the
Employer's vision Insurance Contract. In addition, the Participant may elect either individual or family
coverage.
(b) Employer selects contracts. The Employer may select suitable vision Insurance Contracts for use in
providing this vision insurance benefit, which policies will provide uniform benefits for all Participants
electing this Benefit.
(c) Contract incorporated by reference. The rights and conditions with respect to the benefits payable
from such vision Insurance Contract shall be determined there from, and such vision Insurance
Contract shall be incorporated herein by reference.
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4.6 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory. It is the intent of this Plan to provide benefits to a classification of
employees which the Secretary of the Treasury finds not to be discriminatory in favor of the group in
whose favor discrimination may not occur under Code Section 125.
(b) 25% concentration test. It is the intent of this Plan not to provide qualified benefits as defined under
Code Section 125 to Key Employees in amounts that exceed 25% of the aggregate of such Benefits
provided for all Eligible Employees under the Plan. For purposes of the preceding sentence, qualified
benefits shall not include benefits which (without regard to this paragraph) are includible in gross
income.
(c) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination or
possible taxation to Key Employees or a group of employees in whose favor discrimination may not
occur in violation of Code Section 125, it may, but shall not be required to, reduce contributions or non-
taxable Benefits in order to assure compliance with this Section. Any act taken by the Administrator
under this Section shall be carried out in a uniform and nondiscriminatory manner. If the Administrator
decides to reduce contributions ornon-taxable Benefits, it shall be done in the following manner. First,
the non-taxable Benefits of the affected Participant (either an employee who is highly compensated or
a Key Employee, whichever is applicable) who has the highest amount of non-taxable Benefits for the
Plan Year shall have his non-taxable Benefits reduced until the discrimination tests set forth in this
Section are satisfied or until the amount of his non-taxable Benefits equals the non-taxable Benefits of
the affected Participant who has the second highest amount of non-taxable Benefits. This process
shall continue until the nondiscrimination tests set forth in this Section are satisfied. With respect to
any affected Participant who has had Benefits reduced pursuant to this Section, the reduction shall be
made proportionately among Health Flexible Spending Account Benefits and Dependent Care Flexible
Spending Account Benefits, and once all these Benefits are expended, proportionately among insured
Benefits. Contributions which are not utilized to provide Benefits to any Participant by virtue of any
administrative act under this paragraph shall be forfeited and deposited into the benefit plan surplus.
ARTICLE V
PARTICIPANT ELECTIONS
5.1 INITIAL ELECTIONS
An Employee who meets the eligibility requirements of Section 2.1 on the first day of, or during, a Plan Year
may elect to participate in this Plan for all or the remainder of such Plan Year, provided he elects to do so on or before
his effective date of participation pursuant to Section 2.2.
Notwithstanding the foregoing, an Employee who is eligible to participate in this Plan and who is covered by the
Employer's insured benefits under this Plan shall automatically become a Participant to the extent of the Premiums for
such insurance unless the Employee elects, during the Election Period, not to participate in the Plan.
5.2 SUBSEQUENT ANNUAL ELECTIONS
During the Election Period prior to each subsequent Plan Year, each Participant shall be given the opportunity to elect,
on an election of benefits form to be provided by the Administrator, which spending account Benefit options he wishes to
select. Any such election shall be effective for any Benefit expenses incurred during the Plan Year which follows the end
of the Election Period. With regard to subsequent annual elections, the following options shall apply:
(a) A Participant or Employee who failed to initially elect to participate may elect different or new Benefits
under the Plan during the Election Period;
Revised: 08/07/2012 Page 12 of 28
(b) A Participant may terminate his participation in the Plan by notifying the Administrator in writing during
the Election Period that he does not want to participate in the Plan for the next Plan Year;
(c) An Employee who elects not to participate for the Plan Year following the Election Period will have to
wait until the next Election Period before again electing to participate in the Plan, except as provided
for in Section 5.4.
5.3 FAILURE TO ELECT
With regard to Benefits available under the Plan for which no Premium Expenses apply, any Participant who
fails to complete a new benefit election form pursuant to Section 5.2 by the end of the applicable Election Period shall be
deemed to have elected not to participate in the Plan for the upcoming Plan Year. No further Salary Redirections shall
therefore be authorized or made for the subsequent Plan Year for such Benefits.
With regard to Benefits available under the Plan for which Premium Expenses apply, any Participant who fails
to complete a new benefit election form pursuant to Section 5.2 by the end of the applicable Election Period shall be
deemed to have made the same Benefit elections as are then in effect for the current Plan Year. The Participant shall
also be deemed to have elected Salary Redirection in an amount necessary to purchase such Benefit options.
5.4 CHANGES IN STATUS
(a) Change in status defined. Any Participant may change a Benefit election after the Plan Year (to
which such election relates) has commenced and make new elections with respect to the remainder of
such Plan Year if, under the facts and circumstances, the changes are necessitated by and are
consistent with a change in status which is acceptable under rules and regulations adopted by the
Department of the Treasury, the provisions of which are incorporated by reference.
Notwithstanding anything herein to the contrary, if the rules and regulations conflict, then such
rules and regulations shall control. In general, a change in election is not consistent if the change in
status is the Participant's divorce, annulment or legal separation from a Spouse, the death of a Spouse
or Dependent, or a Dependent ceasing to satisfy the eligibility requirements for coverage, and the
Participant's election under the Plan is to cancel accident or health insurance coverage for any
individual other than the one involved in such event. In addition, if the Participant, Spouse or
Dependent gains or losses eligibility for coverage, then a Participant's election under the Plan to cease
or decrease coverage for that individual under the Plan corresponds with that change in status only if
coverage for that individual becomes applicable or is increased under the family member plan.
Regardless of the consistency requirement, if the individual, the individual's Spouse, or
Dependent becomes eligible for continuation coverage under the Employer's group health plan as
provided in Code Section 49806 or any similar state law, then the individual may elect to increase
payments under this Plan in order to pay for the continuation coverage. However, this does not apply
for COBRA eligibility due to divorce, annulment or legal separation.
Any new election shall be effective at such time as the Administrator shall prescribe, but not
earlier than the first pay period beginning after the election form is completed and returned to the
Administrator. For the purposes of this subsection, a change in status shall only include the following
events or other events permitted by Treasury regulations:
(1) Legal Marital Status: events that change a Participant's legal marital status, including
marriage, divorce, death of a Spouse, legal separation or annulment;
(2) Number of Dependents: Events that change a Participant's number of Dependents, including
birth, adoption, placement for adoption, or death of a Dependent;
Revised: 08/07/2012 Page 13 of 28
(3) Employment Status: Any of the following events that change the employment status of the
Participant, Spouse, or Dependent: termination or commencement of employment, a strike or
lockout, commencement or return from an unpaid leave of absence, or a change in worksite.
In addition, if the eligibility conditions of this Plan or other employee benefit plan of the
Employer of the Participant, Spouse, or Dependent depend on the employment status of that
individual and there is a change in that individual's employment status with the consequence
that the individual becomes (or ceases to be) eligible under the plan, then that change
constitutes a change in employment under this subsection;
(4) Dependent satisfies or ceases to satisfy the eligibility requirements:
An event that causes the Participant's Dependent to satisfy or cease to satisfy the
requirements for coverage due to attainment of age, student status, or any similar
circumstance; and
(5) Residency: A change in the place of residence of the Participant, Spouse or Dependent, that
would lead to a change in status (such as a loss of HMO coverage).
For the Dependent Care Flexible Spending Account, a Dependent becoming or ceasing to be
a "Qualifying Dependent" as defined under Code Section 21(b) qualifies as a change in
status.
(b) Special enrollment rights. Notwithstanding subsection (a), the Participants may change an election
for accident or health coverage during a Plan Year and make a new election that corresponds with the
special enrollment rights provided in Code Section 9801(f), including those authorized under the
provisions of the Children's Health Insurance Program Reauthorization Act of 2009 (SCRIP); provided
that such Participant meets the sixty (60) day notice requirement imposed by Code Section 9801 (f) (or
such longer period as may be permitted by the Plan and communicated to Participants). Such change
shall take place on a prospective basis, unless otherwise required by Code Section 9801(f) to be
retroactive.
(c) Qualified Medical Support Order. Notwithstanding subsection (a), in the event of a judgment,
decree, or order (including approval of a property settlement) ("order") resulting from a divorce, legal
separation, annulment, or change in legal custody which requires accident or health coverage for a
Participant's child (including a foster child who is a Dependent of the Participant}:
(1) The Plan may change an election to provide coverage for the child if the order requires
coverage under the Participant's plan; or
(2) The Participant shall be permitted to change an election to cancel coverage for the child if the
order requires the former Spouse to provide coverage for such child, under that individual's
plan and such coverage is actually provided.
(d) Medicare or Medicaid. Notwithstanding subsection (a), a Participant may change elections to cancel
accident or health coverage for the Participant or the Participant's Spouse or Dependent if the
Participant or the Participant's Spouse or Dependent is enrolled in the accident or health coverage of
the Employer and becomes entitled to coverage (i.e., enrolled) under Part A or Part B of the Title XVIII
of the Social Security Act (Medicare) or Title XIX of the Social Security Act (Medicaid), other than
coverage consisting solely of benefits under Section 1928 of the Social Security Act (the program for
distribution of pediatric vaccines). If the Participant or the Participant's Spouse or Dependent who has
been entitled to Medicaid or Medicare coverage loses eligibility, that individual may prospectively elect
coverage under the Plan if a benefit package option under the Plan provides similar coverage.
Revised: 08!07/2012 Page 14 of 28
(e) Cost increase or decrease. If the cost of a Benefit provided under the Plan increases or decreases
during a Plan Year, then the Plan shall automatically increase or decrease, as the case may be, the
Salary Redirections of all affected Participants for such Benefit. Alternatively, if the cost of a benefit
package option increases significantly, the Administrator shall permit the affected Participants to either
make corresponding changes in their payments or revoke their elections and, in lieu thereof, receive
on a prospective basis coverage under another benefit package option with similar coverage, or drop
coverage prospectively if there is no benefit package option with similar coverage. A cost increase or
decrease refers to an increase or decrease in the amount of elective contributions under the Plan,
whether resulting from an action taken by the Participants or an action taken by the Employer.
(f) Loss of coverage. If the coverage under a Benefit is significantly curtailed or ceases during a Plan
Year, affected Participants may revoke their elections of such Benefit and, in lieu thereof, elect to
receive on a prospective basis coverage under another plan with similar coverage, or drop coverage
prospectively if no similar coverage is offered.
(g) Addition of a new benefit. If, during the period of coverage, a new benefit package option or other
coverage option is added, an existing benefit package option is significantly improved, or an existing
benefit package option or other coverage option is eliminated, then the affected Participants may elect
the newly-added option, or elect another option if an option has been eliminated prospectively and
make corresponding election changes with respect to other benefit package options providing similar
coverage. In addition, those Eligible Employees who are not participating in the Plan may opt to
become Participants and elect the new or newly improved benefit package option.
(h) Loss of coverage under certain other plans. A Participant may make a prospective election
change to add group health coverage for the Participant, the Participant's Spouse or Dependent if
such individual loses group health coverage sponsored by a governmental or educational institution,
including a state children's health insurance program under the Social Security Act, the Indian Health
Service or a health program offered by an Indian tribal government, a state health benefits risk pool, or
a foreign government group health plan.
(i) Change of coverage due to change under certain other plans. A Participant may make a
prospective election change that is on account of and corresponds with a change made under the plan
of a Spouse's, former Spouse's or Dependent's employer if (1) the cafeteria plan or other benefits plan
of the Spouse's, former Spouse's or Dependent's employer permits its participants to make a change;
or (2) the cafeteria plan permits participants to make an election for a period of coverage that is
different from the period of coverage under the cafeteria plan of a Spouse's, former Spouse's or
Dependent's employer.
Q) Change in dependent care provider. A Participant may make a prospective election change that is
on account of and corresponds with a change by the Participant in the dependent care provider. The
availability of dependent care services from a new childcare provider is similar to a new benefit
package option becoming available. A cost change is allowable in the Dependent Care Flexible
Spending Account only if the cost change is imposed by a dependent care provider who is not related
to the Participant, as defined in Code Section 152(a)(1) through (8).
(k) Health FSA cannot change due to insurance change. A Participant shall not be permitted to
change an election to the Health Flexible Spending Account as a result of a cost or coverage change
under any health insurance benefits.
Revised: 08/07/2012 Page 15 of 28
ARTICLE VI
HEALTH FLEXIBLE SPENDING ACCOUNT
6.1 ESTABLISHMENT OF PLAN
This Health Flexible Spending Account is intended to qualify as a medical reimbursement plan under Code
Section 105 and shall be interpreted in a manner consistent with such Code Section and the Treasury regulations
thereunder. Participants who elect to participate in this Health Flexible Spending Account may submit claims for the
reimbursement of Medical Expenses. All amounts reimbursed shall be periodically paid from amounts allocated to the
Health Flexible Spending Account. Periodic payments reimbursing Participants from the Health Flexible Spending
Account shall in no event occur less frequently than monthly.
6.2 DEFINITIONS
For the purposes of this Article and the Cafeteria Plan, the terms below have the following meaning:
(a) "Health Flexible Spending Account" means the account established for Participants pursuant to this
Plan to which part of their Cafeteria Plan Benefit Dollars may be allocated and from which all allowable
Medical Expenses incurred by a Participant, his or her Spouse and his or her Dependents may be
reimbursed.
(b) "Highly Compensated Participant" means, for the purposes of this Article and determining
discrimination under Code Section 105(h), a participant who is:
(1) One of the 5 highest paid officers;
(2) A shareholder who owns (or is considered to own applying the rules of Code Section 318)
more than 10 percent in value of the stock of the Employer; or
(3) Among the highest paid 25 percent of all Employees (other than exclusions permitted by
Code Section 105(h)(3)(B) for those individuals who are not Participants).
(c) "Medical Expenses" means any expense for medical care within the meaning of the term "medical
care" as defined in Code Section 213(4) and as allowed under Code Section 105 and the rulings and
Treasury regulations thereunder, and not otherwise used by the Participant as a deduction in
determining his tax liability under the Code. "Medical Expenses" can be incurred by the Participant, his
or her Spouse and his or her Dependents. "Incurred" means, with regard to Medical Expenses, when
the Participant is provided with the medical care that gives rise to the Medical Expense and not when
the Participant is formally billed or charged for, or pays for, the medical care. A Participant may not be
reimbursed for the cost of other health coverage such as premiums paid under plans maintained by
the employer of the Participant's Spouse or individual policies maintained by the Participant or his
Spouse or Dependent.
A Participant may not be reimbursed for "qualified long-term care services" as defined in Code Section
7702B(c).
(d) The definitions of Article I are hereby incorporated by reference to the extent necessary to interpret
and apply the provisions of this Health Flexible Spending Account.
(e) "Grace Period" While the "plan year" is defined as the calendar year participants may
obtain medical services and submit claims during the Grace Period of January 1 -March 15
of the following year. If participants do not submit all claims before the Run-Out Date of March 31
of the following year they will forfeit any remaining balance in the account.
Revised: 08/07/2012 Page 16 of 28
6.3 LIMITATION ON ALLOCATIONS
Notwithstanding any provision contained in this Health Flexible Spending Account to the contrary, effective with
the 2013 plan year, no more than $2,500 may be allocated to the Health Flexible Spending Account by a Participant in or
on account of any Plan Year.
6.4 FORFEITURES
The amount in the Health Flexible Spending Account as of the end of any Plan Year (and after the processing
of all claims for such Plan Year pursuant to Section 6.7 hereof) shall be forfeited and credited to the benefit plan surplus.
In such event, the Participant shall have no further claim to such amount for any reason, subject to Section 8.2.
6.5 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory. It is the intent of this Health Flexible Spending Account not to
discriminate in violation of the Code and the Treasury regulations thereunder.
(b) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination
under this Health Flexible Spending Account, it may, but shall not be required to, reject any elections
or reduce contributions or Benefits in order to assure compliance with this Section. Any act taken by
the Administrator under this Section shall be carried out in a uniform and nondiscriminatory manner. If
the Administrator decides to reject any elections or reduce contributions or Benefits, it shall be done in
the following manner. First, the Benefits designated for the Health Flexible Spending Account by the
member of the group in whose favor discrimination may not occur pursuant to Code Section 105 that
elected to contribute the highest amount to the fund for the Plan Year shall be reduced until the
nondiscrimination tests set forth in this Section or the Code are satisfied, or until the amount
designated for the fund equals the amount designated for the fund by the next member of the group in
whose favor discrimination may not occur pursuant to Code Section 105 who has elected the second
highest contribution to the Health Flexible Spending Account for the Plan Year. This process shall
continue until the nondiscrimination tests set forth in this Section or the Code are satisfied.
Contributions which are not utilized to provide Benefits to any Participant by virtue of any
administrative act under this paragraph shall be forfeited and credited to the benefit plan surplus.
6.6 COORDINATION WITH CAFETERIA PLAN
All Participants under the Cafeteria Plan are eligible to receive Benefits under this Health Flexible Spending
Account. The enrollment under the Cafeteria Plan shall constitute enrollment under this Health Flexible Spending
Account. In addition, other matters concerning contributions, elections and the like shall be governed by the general
provisions of the Cafeteria Plan.
6.7 HEALTH FLEXIBLE SPENDING ACCOUNT CLAIMS
(a) Expenses must be incurred during Plan Year or subsequent Run-out period. All qualified
Medical Expenses incurred by a Participant, his or her Spouse and his or her Dependents shall be
reimbursed during the Plan Year subject to Section 2.5, even though the submission of such a claim
occurs after his participation hereunder ceases; but provided that the Medical Expenses were incurred
during the applicable Plan Year or subsequent GRACE period as described further in sub-Para (d).
Medical Expenses are treated as having been incurred when the Participant is provided with the
medical care that gives rise to the medical expenses, not when the Participant is formally billed or
charged for, or pays for the medical care.
(b) Reimbursement available throughout Plan Year. The Administrator shall direct the reimbursement
to each eligible Participant for all allowable Medical Expenses, up to a maximum of the amount
designated by the Participant for the Health Flexible Spending Account for the Plan Year.
Revised: 08/07/2012 Page 17 of 28
Reimbursements shall be made available to the Participant throughout the year without regard to the
level of Cafeteria Plan Benefit Dollars which have been allocated to the fund at any given point in time.
Furthermore, a Participant shall be entitled to reimbursements only for amounts in excess of any
payments or other reimbursements under any health care plan covering the Participant and/or his
Spouse or Dependents.
(c) Payments. Reimbursement payments under this Plan shall be made directly to the Participant.
However, in the Administrator's discretion, payments may be made directly to the service provider. The
application for payment or reimbursement shall be made to the Administrator on an acceptable form
within a reasonable time of incurring the debt or paying for the service. The application shall include a
written statement from an independent third party stating that the Medical Expense has been incurred
and the amount of such expense. Furthermore, the Participant shall provide a written statement that
the Medical Expense has not been reimbursed or is not reimbursable under any other health plan
coverage and, if reimbursed from the Health Flexible Spending Account, such amount will not be
claimed as a tax deduction. The Administrator shall retain a file of all such applications.
(d) Grace Period. Notwithstanding anything in this Section to the contrary, Medical Expenses
incurred during the Grace Period, up to the remaining account balance, shall be deemed to
have been incurred during the Plan Year to which the Grace Period relates. Participants may
obtain medical services and submit claims during the Grace Period of January 1 -March 15 of
the following year. If participants do not submit all claims before the end of the Run-Out Period,
which is the March 30 that follows the end of the plan year, they will forfeit any remaining balance in
the account.
(e) Claims for reimbursement. Claims for the reimbursement of Medical Expenses incurred in any Plan
Year shall be paid as soon after a claim has been filed as is administratively practicable; provided
however, that if a Participant fails to submit a claim by the end of the Run•Out-Period, which ends 90
days after the end of the Plan Year, those Medical Expense claims shall not be considered for
reimbursement by the Administrator. However, if a Participant terminates employment during the Plan
Year, claims for the reimbursement of Medical Expenses must be submitted within 90 days after
termination of employment.
6.8 DEBIT AND CREDIT CARDS
Participants may, subject to a procedure established by the Administrator and applied in a uniform
nondiscriminatory manner, use debit and/or credit (stored value) cards ("cards") provided by the Administrator and the
Plan for payment of Medical Expenses, subject to the following terms:
(a) Card only for medical expenses. Each Participant issued a card shall certify that such card shall
only be used for Medical Expenses. The Participant shall also certify that any Medical Expense paid
with the card has not already been reimbursed by any other plan covering health benefits and that the
Participant will not seek reimbursement from any other plan covering health benefits.
(b) Card issuance. Such card shall be issued upon the Participant's Effective Date of Participation and
reissued for each Plan Year the Participant remains a Participant in the Health Flexible Spending
Account. Such card shall be automatically cancelled upon the Participant's death or termination of
employment, or if such Participant has a change in status that results in the Participant's withdrawal
from the Health Flexible Spending Account.
(c) Maximum dollar amount available. The dollar amount of coverage available on the card shall be the
amount elected by the Participant for the Plan Year. The maximum dollar amount of coverage
available shall be the maximum amount for the Plan Year as set forth in Section 6.4.
Revised: 08/07/2012 Page 18 of 28
(d) Only available for use with certain service providers. The cards shall only be accepted by such
merchants and service providers as have been approved by the Administrator.
(e) Card use. The cards shall only be used for Medical Expense purchases at these providers, including,
but not limited to, the following:
(1) Co-payments for doctor and other medical care;
(2) Purchase of drugs;
(3) Purchase of medical items such as eyeglasses, syringes, crutches, etc.
(f) Substantiation. Such purchases by the cards shall be subject to substantiation by the Administrator,
usually by submission of a receipt from a service provider describing the service, the date and the
amount. The Administrator shall also follow the requirements set forth in Revenue Ruling 2003-43 and
Notice 2006-69. All charges shall be conditional pending confirmation and substantiation.
(g) Correction methods. If such purchase is later determined by the Administrator to not qualify as a
Medical Expense, the Administrator, in its discretion, shall use one of the following correction methods
to make the Plan whole. Until the amount is repaid, the Administrator shall take further action to ensure
that further violations of the terms of the card do not occur, up to and including denial of access to the
card.
(1) Repayment of the improper amount by the Participant;
(2) Withholding the improper payment from the Participant's wages or other compensation to the
extent consistent with applicable federal or state law;
(3) Claims substitution or offset of future claims until the amount is repaid; and
(4) If subsections (1) through (3) fail to recover the amount, consistent with the Employer's
business practices, the Employer may treat the amount as any other business indebtedness.
ARTICLE VII
DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT
7.1 ESTABLISHMENT OF ACCOUNT
This Dependent Care Flexible Spending Account is intended to qualify as a program under Code Section 129
and shall be interpreted in a manner consistent with such Code Section. Participants who elect to participate in this
program may submit claims for the reimbursement of Employment-Related Dependent Care Expenses. All amounts
reimbursed shall be paid from amounts allocated to the Participant's Dependent Care Flexible Spending Account.
7.2 DEFINITIONS
For the purposes of this Article and the Cafeteria Plan the terms below shall have the following meaning:
(a) "Dependent Care Flexible Spending Account" means the account established for a Participant
pursuant to this Article to which part of his Cafeteria Plan Benefit Dollars may be allocated and from
which Employment-Related Dependent Care Expenses of the Participant may be reimbursed for the
care of the Qualifying Dependents of Participants.
(b) "Earned Income" means earned income as defined under Code Section 32(c)(2), but excluding such
amounts paid or incurred by the Employer for dependent care assistance to the Participant.
Revised: 08/07/2012 Page 19 Of 28
(b) "Employment•Related Dependent Care Expenses" means the amounts paid for expenses of a
Participant for those services which if paid by the Participant would be considered employment related
expenses under Code Section 21(b)(2). Generally, they shall include expenses for household services
and for the care of a Qualifying Dependent, to the extent that such expenses are incurred to enable the
Participant to be gainfully employed for any period for which there is one or more Qualifying
Dependents with respect to such Participant. Employment-Related Dependent Care Expenses are
treated as having been incurred when the Participant's Qualifying Dependents are provided with the
dependent care that gives rise to the Employment-Related Dependent Care Expenses, not when the
Participant is formally billed or charged for, or pays for the dependent care. The determination of
whether an amount qualifies as an Employment-Related Dependent Care Expense shall be made
subject to the following rules:
(1) If such amounts are paid for expenses incurred outside the Participant's household, they shall
constitute Employment-Related Dependent Care Expenses only if incurred for a Qualifying
Dependent as defined in Section 7.2(d)(1) (or deemed to be, as described in Section 7.2(4)(1)
pursuant to Section 7.2(d)(3)), or for a Qualifying Dependent as defined in Section 7.2(d)(2)
(or deemed to be, as described in Section 7.2(d)(2) pursuant to Section 7.2(4)(3)) who
regularly spends at least 8 hours per day in the Participant's household;
(2) If the expense is incurred outside the Participant's home at a facility that provides care for a
fee, payment, or grant for more than 6 individuals who do not regularly reside at the facility,
the facility must comply with all applicable state and local laws and regulations, including
licensing requirements, if any; and
(3) Employment-Related Dependent Care Expenses of a Participant shall not include amounts
paid or incurred to a child of such Participant who is under the age of 19 or to an individual
who is a Dependent of such Participant or such Participant's Spouse.
(d) "Qualifying Dependent" means, for Dependent Care Flexible Spending Account purposes,
(1) A Participant's Dependent (as defined in Code Section 152(a)(1)) who has not attained age
13;
(2) A Dependent or the Spouse of a Participant who is physically or mentally incapable of caring
for himself or herself and has the same principal place of abode as the Participant for more
than one-half of such taxable year; or
(3) A child that is deemed to be a Qualifying Dependent described in paragraph (1) or (2) above,
whichever is appropriate, pursuant to Code Section 21(e)(5).
(e) The definitions of Article I are hereby incorporated by reference to the extent necessary to interpret
and apply the provisions of this Dependent Care Flexible Spending Account.
7.3 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
The Administrator shall establish a Dependent Care Flexible Spending Account for each Participant who elects
to apply Cafeteria Plan Benefit Dollars to Dependent Care Flexible Spending Account benefits.
7.4 INCREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
A Participant's Dependent Care Flexible Spending Account shall be increased each pay period by the portion of
Cafeteria Plan Benefit Dollars that he has elected to apply toward his Dependent Care Flexible Spending Account
pursuant to elections made under Article V hereof.
Revised: 08/07/2012 Page 20 of 28
7.5 DECREASES IN DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS
A Participant's Dependent Care Flexible Spending Account shall be reduced by the amount of any
Employment-Related Dependent Care Expense reimbursements paid or incurred on behalf of a Participant pursuant to
Section 7.12 hereof.
7.6 ALLOWABLE DEPENDENT CARE REIMBURSEMENT
Subject to limitations contained in Section 7.9 of this Program, and to the extent of the amount contained in the
Participant's Dependent Care Flexible Spending Account, a Participant who incurs Employment-Related Dependent
Care Expenses shall be entitled to receive from the Employer full reimbursement for the entire amount of such expenses
incurred during the Plan Year or portion thereof during which he is a Participant.
7.7 ANNUAL STATEMENT OF BENEFITS
On or before January 31st of each calendar year, the Employer shall furnish to each Employee who was a
Participant and received benefits under Section 7.6 during the prior calendar year, a statement of all such benefits paid
to or on behalf of such Participant during the prior calendar year.
7.8 FORFEITURES
The amount in a Participant's Dependent Care Flexible Spending Account as of the end of any Plan Year (and
after the processing of all claims for such Plan Year pursuant to Section 7.12 hereof) shall be forfeited and credited to
the benefit plan surplus. In such event, the Participant shall have no further claim to such amount for any reason.
7.9 LIMITATION ON PAYMENTS
Notwithstanding any provision contained in this Article to the contrary, amounts paid from a Participant's
Dependent Care Flexible Spending Account in or on account of any taxable year of the Participant shall not exceed the
lesser of the Earned Income limitation described in Code Section 129(b) or $5,000 ($2,500 if a separate tax return is filed
by a Participant who is married as determined under the rules of paragraphs (3) and (4) of Code Section 21(e)).
7.10 NONDISCRIMINATION REQUIREMENTS
(a) Intent to be nondiscriminatory. It is the intent of this Dependent Care Flexible Spending Account
that contributions or benefits not discriminate in favor of the group of employees in whose favor
discrimination may not occur under Code Section 129(d).
(b) 25% test for shareholders. It is the intent of this Dependent Care Flexible Spending Account that not
more than 25 percent of the amounts paid by the Employer for dependent care assistance during the
Plan Year will be provided for the class of individuals who are shareholders or owners (or their
Spouses or Dependents), each of whom (on any day of the Plan Year) owns more than 5 percent of
the stock or of the capital or profits interest in the Employer.
(a) Adjustment to avoid test failure. If the Administrator deems it necessary to avoid discrimination or
possible taxation to a group of employees in whose favor discrimination may not occur in violation of
Code Section 129 it may, but shall not be required to, reject any elections or reduce contributions or
non-taxable benefits in order to assure compliance with this Section. Any act taken by the
Administrator under this Section shall be carried out in a uniform and nondiscriminatory manner. If the
Administrator decides to reject any elections or reduce contributions or Benefits, it shall be done in the
following manner. First, the Benefits designated for the Dependent Care Flexible Spending Account by
the affected Participant that elected to contribute the highest amount to such account for the Plan Year
shall be reduced until the nondiscrimination tests set forth in this Section are satisfied, or until the
Revised: 08/07/2012 Page 21 of 28
amount designated for the account equals the amount designated for the account of the affected
Participant who has elected the second highest contribution to the Dependent Care Flexible Spending
Account for the Plan Year. This process shall continue until the nondiscrimination tests set forth in this
Section are satisfied. Contributions which are not utilized to provide Benefits to any Participant by
virtue of any administrative act under this paragraph shall be forfeited.
7.11 COORDINATION WITH CAFETERIA PLAN
All Participants under the Cafeteria Plan are eligible to receive Benefits under this Dependent Care Flexible
Spending Account. The enrollment and termination of participation under the Cafeteria Plan shall constitute enrollment
and termination of participation under this Dependent Care Flexible Spending Account. In addition, other matters
concerning contributions, elections and the like shall be governed by the general provisions of the Cafeteria Plan.
7.12 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT CLAIMS
The Administrator shall direct the payment of all such Dependent Care claims to the Participant upon the
presentation to the Administrator of documentation of such expenses in a form satisfactory to the Administrator.
However, in the Administrators discretion, payments may be made directly to the service provider. In its discretion in
administering the Plan, the Administrator may utilize forms and require documentation of costs as may be necessary to
verify the claims submitted. At a minimum, the form shall include a statement from an independent third party as proof
that the expense has been incurred and the amount of such expense. In addition, the Administrator may require that
each Participant who desires to receive reimbursement under this Program for Employment-Related Dependent Care
Expenses submit a statement containing some or all of the following information:
(a) The Dependent or Dependents for whom the services were performed;
(b) The nature of the services performed for the Participant, the cost of which he wishes reimbursement;
(c) The relationship, if any, of the person performing the services to the Participant;
(d) If the services are being performed by a child of the Participant, the age of the child;
(e) A statement as to where the services were performed;
(f) If any of the services were performed outside the home, a statement as to whether the Dependent for
whom such services were performed spends at least 8 hours a day in the Participant's household;
(g) If the services were being performed in a day care center, a statement:
(1) That the day care center complies with all applicable laws and regulations of the state of
residence,
(2) That the day care center provides care for more than 6 individuals (other than individuals
residing at the center), and
(3) Of the amount of fee paid to the provider.
(h) If the Participant is married, a statement containing the following:
(1) The Spouse's salary or wages if he or she is employed, or
(2) If the Participant's Spouse is not employed, that
(i) He or she is incapacitated, or
Revised: 08/07/2012 Page 22 of 28
(ii) He or she is a full-time student attending an educational institution and the months
during the year which he or she attended such institution.
(i) Claims for reimbursement. If a Participant fails to submit a claim within 90 days after the end of the
Plan Year, those claims shall not be considered for reimbursement by the Administrator. However, if a
Participant terminates employment during the Plan Year, claims for reimbursement must be submitted
within 90 days after termination of employment.
ARTICLE VIII
BENEFITS AND RIGHTS
8.1 CLAIM FOR BENEFITS
(a) Insurance claims. Any claim for Benefits underwritten by Insurance Contract(s) shall be made to the
Insurer. If the Insurer denies any claim, the Participant or beneficiary shall follow the Insurer's claims
review procedure.
(b) Dependent Care Flexible Spending Account or Health Flexible Spending Account claims. Any
claim for Dependent Care Flexible Spending Account or Health Flexible Spending Account Benefits
shall be made to the Administrator. For the Health Flexible Spending Account, if a Participant fails to
submit a claim within 90 days after the end of the Plan Year, those claims shall not be considered for
reimbursement by the Administrator. However, if a Participant terminates employment during the Plan
Year, claims for the reimbursement of Medical Expenses must be submitted within 90 days after
termination of employment. For the Dependent Care Flexible Spending Account, if a Participant fails to
submit a claim within 90 days after the end of the Plan Year, those claims shall not be considered for
reimbursement by the Administrator. However, if a Participant terminates employment during the Plan
Year, claims for reimbursement must be submitted within 90 days after termination of employment. If
the Administrator denies a claim, the notice to the Participant or beneficiary, shall be sent in writing,
within 90 days after the claim is filed unless special circumstances require an extension of time for
processing the claim. The notice of a denial of a claim shall be written in a manner calculated to be
understood by the claimant and shall set forth:
(1) Specific references to the pertinent Plan provisions on which the denial is based;
(2) A description of any additional material or information necessary for the claimant to perfect
the claim and an explanation as to why such information is necessary; and
(3) An explanation of the Plan's claim procedure.
(c) Appeal. Within 60 days after receipt of the above material, the claimant shall have a reasonable
opportunity to appeal the claim denial to the Administrator for a full and fair review. The claimant or his
duly authorized representative may:
(1) Request a review upon written notice to the Administrator;
(2) Review pertinent documents; and
(3) Submit issues and comments in writing.
(d) Review of appeal. The Administrator shall make a decision on the review not later than 60 days after
receipt of a request for review, unless special circumstances require an extension of time for
processing (such as the need to hold a hearing), in which event a decision will be rendered as soon as
possible, but in no event later than 120 days after such receipt. The decision of the Administrator shall
be written and shall include specific reasons for the decision, written in a manner calculated to be
understood by the claimant, and shall refer to the Plan provisions on which the decision is based.
Revised: 0 810 712 0 1 2 Page 23 of 28
(e) Forfeitures. Any balance remaining in the Participant's Dependent Care Flexible Spending Account
or Health Flexible Spending Account as of the end of the time for claims reimbursement for each Plan
Year and Grace Period (if applicable) shall be forfeited and deposited in the benefit plan surplus of the
Employer pursuant to Section 6.3 or Section 7.8, whichever is applicable, unless the Participant had
made a claim for such Plan Year, in writing, which has been denied or is pending; in which event the
amount of the claim shall be held in his account until the claim appeal procedures set forth above have
been satisfied or the claim is paid. If any such claim is denied on appeal, the amount held beyond the
end of the Plan Year shall be forfeited and credited to the benefit plan surplus.
8.2 APPLICATION OF BENEFIT PLAN SURPLUS
Any forfeited amounts credited to the benefit plan surplus by virtue of the failure of a Participant to incur a
qualified expense or seek reimbursement in a timely manner may, but need not be, separately accounted for after the
close of the Plan Year (or after such further time specified herein for the filing of claims) in which such forfeitures arose.
In no event shall such amounts be carried over to reimburse a Participant for expenses incurred during a subsequent
Plan Year for the same or any other Benefit available under the Plan; nor shall amounts forfeited by a particular
Participant be made available to such Participant in any other form or manner, except as permitted by Treasury
regulations. Amounts in the benefit plan surplus shall be used to defray any administrative costs and experience losses
or used to provide additional benefits under the Plan.
ARTICLE IX
ADMINISTRATION
9.1 PLAN ADMINISTRATION
The operation of the Plan shall be under the supervision of the Administrator. It shall be a principal duty of the
Administrator to see that the Plan is carried out in accordance with its terms, and for the exclusive benefit of Employees
entitled to participate in the Plan. The Administrator shall have full power to administer the Plan in all of its details,
subject, however, to the pertinent provisions of the Code. The Administrator's powers shall include, but shall not be
limited to the following authority, in addition to all other powers provided by this Plan:
(a) To make and enforce such rules and regulations as the Administrator deems necessary or proper for
the efficient administration of the Plan;
(b) To interpret the Plan, the Administrator's interpretations thereof in good faith to be final and conclusive
on all persons claiming benefits by operation of the Plan;
(c) To decide all questions concerning the Plan and the eligibility of any person to participate in the Plan
and to receive benefits provided by operation of the Plan;
(d) To reject elections or to limit contributions or Benefits for certain highly compensated participants if it
deems such to be desirable in order to avoid discrimination under the Plan in violation of applicable
provisions of the Code;
(e) To provide Employees with a reasonable notification of benefits available through the Plan;
(f) To approve reimbursement requests and to authorize the payment of benefits;
(g) To appoint such agents, counsel, accountants, consultants, and actuaries as may be required to assist
in administering the Plan.
Any procedure, discretionary act, interpretation or construction taken by the Administrator shall be done in a
nondiscriminatory manner based upon uniform principles consistently applied and shall be consistent with the intent that
the Plan shall continue to comply with the terms of Code Section 125 and the Treasury regulations thereunder.
Revised: 08/07/2012 Page 24 of 28
9.2 EXAMINATION OF RECORDS
The Administrator shall make available to each Participant, Eligible Employee and any other Employee of the
Employer such records as pertain to their interest under the Plan for examination at reasonable times during normal
business hours.
9.3 PAYMENT OF EXPENSES
Any reasonable administrative expenses shall be paid by the Employer unless the Employer determines that
administrative costs shall be borne by the Participants under the Plan or by any Trust Fund which may be established
hereunder. The Administrator may impose reasonable conditions for payments, provided that such conditions shall not
discriminate in favor of highly compensated employees.
9.4 INSURANCE CONTROL CLAUSE
In the event of a conflict between the terms of this Plan and the terms of an Insurance Contract of an
independent third party Insurer whose product is then being used in conjunction with this Plan, the terms of the
Insurance Contract shall control as to those Participants receiving coverage under such Insurance Contract. For this
purpose, the Insurance Contract shall control in defining the persons eligible for insurance, the dates of their eligibility,
the conditions which must be satisfied to become insured, if any, the benefits Participants are entitled to and the
circumstances under which insurance terminates.
9.5 INDEMNIFICATION OFADMINISTRATOR
The Employer agrees to indemnify and to defend to the fullest extent permitted by law any Employee serving as
the Administrator or as a member of a committee designated as Administrator (including any Employee or former
Employee who previously served as Administrator or as a member of such committee) against all liabilities, damages,
costs and expenses (including attorney's fees and amounts paid in settlement of any claims approved by the Employer)
occasioned by any act or omission in connection with the Plan, if such act or omission is in good faith.
ARTICLE X
AMENDMENT OR TERMINATION OF PLAN
10.1 AMENDMENT
The Employer, at any time or from time to time, may amend any or all of the provisions of the Plan without the
consent of any Employee or Participant. No amendment shall have the effect of modifying any benefit election of any
Participant in effect at the time of such amendment, unless such amendment is made to comply with Federal, state or
local laws, statutes or regulations.
10.2 TERMINATION
The Employer is establishing this Plan with the intent that it will be maintained for an indefinite period of time.
Notwithstanding the foregoing, the Employer reserves the right to terminate this Plan, in whole or in part, at any time. In
the event the Plan is terminated, no further contributions shall be made. Benefits under any Insurance Contract shall be
paid in accordance with the terms of the Insurance Contract.
No further additions shall be made to the Health Flexible Spending Account or Dependent Care Flexible
Spending Account, but all payments from such fund shall continue to be made according to the elections in effect until 90
days after the termination date of the Plan -The Run-Out•Period. Any amounts remaining in any such fund or account
as of the end of such period shall be forfeited and deposited in the benefit plan surplus after the expiration of the filing
period.
Revised: 08/07/2012 Page 25 of 28
ARTICLE XI
MISCELLANEOUS
11.1 PLAN INTERPRETATION
All provisions of this Plan shall be interpreted and applied in a uniform, nondiscriminatory manner. This Plan
shall be read in its entirety and not severed except as provided in Section 11.12.
11.2 GENDER AND NUMBER
Wherever any words are used herein in the masculine, feminine or neuter gender, they shall be construed as
though they were also used in another gender in all cases where they would so apply, and whenever any words are
used herein in the singular or plural form, they shall be construed as though they were also used in the other form in all
cases where they would so apply.
11.3 WRITTEN DOCUMENT
This Plan, in conjunction with any separate written document which may be required by law, is intended to
satisfy the written Plan requirement of Code Section 125 and any Treasury regulations thereunder relating to cafeteria
plans.
11.4 EXCLUSIVE BENEFIT
This Plan shall be maintained for the exclusive benefit of the Employees who participate in the Plan.
11.5 PARTICIPANT'S RIGHTS
This Plan shall not be deemed to constitute an employment contract between the Employer and any Participant
or to be a consideration or an inducement for the employment of any Participant or Employee. Nothing contained in this
Plan shall be deemed to give any Participant or Employee the right to be retained in the service of the Employer or to
interfere with the right of the Employer to discharge any Participant or Employee at any time regardless of the effect
which such discharge shall have upon him as a Participant of this Plan.
11.6 ACTION BY THE EMPLOYER
Whenever the Employer under the terms of the Plan is permitted or required to door perform any act or matter
or thing, it shall be done and performed by a person duly authorized by its legally constituted authority.
11.7 EMPLOYER'S PROTECTIVE CLAUSES
(a) Insurance purchase. Upon the failure of either the Participant or the Employer to obtain the insurance
contemplated by this Plan (whether as a result of negligence, gross neglect or otherwise), the
Participant's Benefits shall be limited to the insurance premium(s), if any, that remained unpaid for the
period in question and the actual insurance proceeds, if any, received by the Employer or the
Participant as a result of the Participant's claim.
(f) Validity of insurance contract. The Employer shall not be responsible for the validity of any
Insurance Contract issued hereunder or for the failure on the part of the Insurer to make payments
provided for under any Insurance Contract. Once insurance is applied for or obtained, the Employer
shall not be liable for any losses which may result from the failure to pay Premiums to the extent
Premium notices are not received by the Employer.
Revised: 08/07/2012 Page 26 of 28
11.8 NO GUARANTEE OF TAX CONSEQUENCES
Neither the Administrator nor the Employer makes any commitment or guarantee that any amounts paid to or
for the benefit of a Participant under the Plan will be excludable from the Participant's gross income for federal or state
income tax purposes, or that any other federal or state tax treatment will apply to or be available to any Participant. It
shall be the obligation of each Participant to determine whether each payment under the Plan is excludable from the
Participant's gross income for federal and state income tax purposes, and to notify the Employer if the Participant has
reason to believe that any such payment is not so excludable. Notwithstanding the foregoing, the rights of Participants
under this Plan shall be legally enforceable.
11.9 INDEMNIFICATION OF EMPLOYER BY PARTICIPANTS
If any Participant receives one or more payments or reimbursements under the Plan that are not for a permitted
Benefit, such Participant shall indemnify and reimburse the Employer for any liability it may incur for failure to withhold
federal or state income tax or Social Security tax from such payments or reimbursements. However, such indemnification
and reimbursement shall not exceed the amount of additional federal and state income tax (plus any penalties) that the
Participant would have owed if the payments or reimbursements had been made to the Participant as regular cash
compensation, plus the Participant's share of any Social Security tax that would have been paid on such compensation,
less any such additional income and Social Security tax actually paid by the Participant.
11.10 FUNDING
Unless otherwise required by law, contributions to the Plan need not be placed in trust or dedicated to a specific
Benefit, but may instead be considered general assets of the Employer. Furthermore, and unless otherwise required by
law, nothing herein shall be construed to require the Employer or the Administrator to maintain any fund or segregate
any amount for the benefit of any Participant, and no Participant or other person shall have any claim against, right to, or
security or other interest in, any fund, account or asset of the Employer from which any payment under the Plan may be
made.
11.11 OTHER VOLUNTARY EMPLOYEE BENEFIT OPTIONS
From time to time the Employer may offer or otherwise make available to employees "Voluntary Benefits" that
may be construed as Health Benefits but do not meet the criterion of the IRS for inclusion in the Pre-Tax Section-125
Plan. Premiums or other costs for such plans will not qualify for Salary Redirection and the participants will pay for those
with Post-Tax dollars.
11.12 GOVERNING LAW
This Plan is governed by the Code and the Treasury regulations issued thereunder (as they might be amended
from time to time). In no event shall the Employer guarantee the favorable tax treatment sought by this Plan. To the
extent not preempted by Federal law, the provisions of this Plan shall be construed, enforced and administered
according to the laws of the State of Florida.
11.13 SEVERABILITY
If any provision of the Plan is held invalid or unenforceable, its invalidity or unenforceability shall not affect any
other provisions of the Plan, and the Plan shall be construed and enforced as if such provision had not been included
herein.
11.14 CAPTIONS
The captions contained herein are inserted only as a matter of convenience and for reference, and in no way
define, limit, enlarge or describe the scope or intent of the Plan, nor in any way shall affect the Plan or the construction of
any provision thereof.
Revised: 08/07/2012 Page 27 of 28
11.15 FAMILY AND MEDICAL LEAVE ACT (FMLA)
Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan becomes subject
to the requirements of the Family and Medical Leave Act and regulations thereunder, this Plan shall be operated in
accordance with Regulation 1.125-3.
11.16 UNIFORM SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA)
Notwithstanding any provision of this Plan to the contrary, contributions, benefits and service credit with respect
to qualified military service shall be provided in accordance with the Uniform Services Employment and Reemployment
Rights Act (USERRA) and the regulations thereunder.
11.17 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Mental Health Parity and
Addition Equity Act and ERISA Section 712.
11.18 GENETIC INFORMATION NONDISCRIMINATION ACT (GINA)
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the Genetic Information
Nondiscrimination Act.
IN WITNESS WHEREOF, this Plan document is hereby executed this ~ day of ~~' 2012.
EMPLOYER: St. Lucie Coun B out m' n
By: .~.
Title: < <..r,-
AS TO FORM
AND
COUNTY A'
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Revised: 08/07/2012 Page 28 of 28
ST. LUCIE COUNTY BOARD OF COUNTY COMMISSIONERS
Section-125 -Cafeteria Plan
FLEXIBLE BENEFITS PLAN
Plan Number 507
SUMMARY PLAN DESCRIPTION
- S.P.D. -
Revised: 08/07/2012
Revised: 08/07/2013 Page 1 of 14
ST. LUCIE COUNTY BOARD OF COUNTY COMMISSIONERS
FLEXIBLE BENEFITS PLAN
SUMMARY PLAN DESCRIPTION
SPD
TABLE OF CONTENTS
INTRODUCTION ............................................................................................ 5
I
ELIGIBILITY
1. When can I become a participant in the Plan? ....................................................................... 5
2. What are the eligibility requirements for our Plan? ............................................................... 6
3. When is my entry date? ........................................................................................................... 6
4. What must I do to enroll in the Plan? ..................................................................................... 6
II
OPERATION
1. How does this Plan operate? .................................................................................................. 6
III
CONTRIBUTIONS
1. How much of my pay may the Employer redirect? ................................................................ 6
2. What happens to contributions made to the Plan? .................................................................. 6
3. When must I decide which accounts I want to use? .............................................................. 6
4. When is the election period for our Plan? .............................................................................. 7
5. May I change my elections during the Plan Year? .................................................................. 7
6. May I make new elections in future Plan Years? .................................................................... 8
IV
BENEFITS
1. What benefits are available? ................................................................................................... 8
V
BENEFIT PAYMENTS
1. When will I receive payments from my accounts? ................................................................. 10
2. What happens if I don't spend all Plan contributions during the Plan Year? .......................... 10
3. Family and Medical Leave Act (FMLA) ................................................................................ 11
4. Uniformed Services Employment and Reemployment Rights Act ........................................ 11
5. What happens if I terminate employment? ............................................................................ 11
6. Will my Social Security benefits be affected? ....................................................................... 12
Revised: 08/07/2013 Page 3 of 14
VI
FIIGALY COMPENSATED AND KEY EMPLOYEES
1. Do limitations apply to highly compensated employees? .................................................... 12
VII
PLAN ACCOUNTING
1. Periodic Statements ............................................................................................................. 12
VIII
GENERAL INFORMATION ABOUT OUR PLAN
1. General Plan Information ...................................................................................................... 12
2. Employer Information ........................................................................................................... 13
3. Plan Administrator Information ........................................................................................... 13
4. Service of Legal Process ...................................................................................................... 13
5. Type of Administration ......................................................................................................... 13
6. Claims Submission ............................................................................................................... 13
IX
ADDITIONAL PLAN INFORMATION
1. Claims Process ...................................................................................................................... 13
X
SUMMARY
SUMMARY .................................................................................................... 14
Revised: 08/07/2013 Page 4 of 14
ST. LUCIE COUNTY BOARD OF COUNTY COMMISSIONERS
FLEXIBLE BENEFITS PLAN
SUMMARY PLAN DESCRIPTION
INTRODUCTION
Recent changes in the IRS laws and regulations affect employee benefits, including those in the
Federal "Affordable Care Act" and specifically, IRS Notice 2012-40. Those changes require that prior to
January 1, 2012, St. Lucie County REVISE the "Flexible Benefit Plan" for employees. These changes will
noticeably affect some individual employees. As such the County is moving to insure that our benefit plans
are in compliance. Under the Flexible Benefits Plan, employees are able to choose among certain benefits
that the employer makes available. The benefits that employees may choose from are outlined in this
Summary Plan Description. This description also tells you other important information concerning the Plan,
such as the rules you must satisfy before you can join and the laws that protect your rights.
The benefits listed in this plan are those that the employee pays for and may choose to pay for with
money that has not yet been subject to income and Social Security taxes. Under the Flexible Benefits Plan,
these premium expenses will be paid for with a portion of the employee's pay before Federal income or
Social Security taxes are withheld. This means that the employee pay less tax and as a result has more
money to spend and save.
Read this Summary Plan Description (SPD) carefully and understand the Plan and the benefits you
receive. This SPD describes the Plan's benefits and obligations as contained in the legal Plan document,
which governs the operation of the Plan. The Plan document is written in much more technical and precise
language. If the non-technical language in this SPD and the technical, legal language of the Plan document
conflict, the Plan document always governs. In addition, if there is a conflict between an insurance contract
and either the Plan document or this Summary Plan Description, the insurance contract will control. If you
wish to receive a copy of the legal Plan document, please contact the Plan Administrator.
This SPD describes the current provisions of the Plan which are designed to comply with applicable
legal requirements. The Plan is subject to federal laws, such as the Internal Revenue Code and other federal
and state laws which may affect your rights. The provisions of the Plan are subject to revision due to a
change in laws or due to pronouncements by the Internal Revenue Service (IRS) or other federal agencies.
We may also amend or terminate this Plan. If the provisions of the Plan that are described in this SPD
change, we will notify you.
We have attempted to answer most of the questions you may have regarding your benefits in the
Plan. If this SPD does not answer all of your questions, please contact the Administrator (or other plan
representative). The name and address of the Administrator can be found in the Article of this SPD entitled
"General Information about the Plan."
I
ELIGIBILITY
1. When can I become a participant in the Plan?
Before you become a Plan member (referred to in this Summary Plan Description as a "Participant"),
there are certain rules which you must satisfy. First, you must meet the eligibility requirements and be an
active employee. After that, the next step is to actually join the Plan on the "entry date" that we have
established for all employees. The "entry date" is defined in Question 3 below. You will also be required to
complete certain application forms before you can enroll in the Health Flexible Spending Account or
Dependent Care Flexible Spending Account.
Revised: 08/07/2013 Page 5 of 14
2. What are the eligibility requirements for our Plan?
You will be eligible to join the Plan when you are eligible for our group medical plan.
3. When is my entry date?
You can join the Plan on the same day you can enter our group medical plan.
4. What must I do to enroll in the Plan?
Before you can join the Plan, you must complete an application to participate in the Plan. The
application includes your choices for each of the benefits which are being offered under the Plan. You must
also authorize us to set some of your earnings aside in order to pay for the benefits you have elected.
However, if you are already covered under any of the insured benefits, you will automatically
participate in this Plan to the extent of your premiums unless you elect not to participate in this Plan.
II
OPERATION
1. How does this Plan operate?
Before the start of each Plan Year, you will be able to elect to have some of your upcoming pay
contributed to the Plan. These amounts will be used to pay for the benefits you have chosen. The portion of
your pay that is paid to the Plan is not subject to Federal income or Social Security taxes. In other words, this
allows you to use tax-free dollars to pay for certain kinds of benefits and expenses which you normally pay
for with out-of-pocket, taxable dollars. However, if you receive a reimbursement for an expense under the
Plan, you cannot claim a Federal income tax credit or deduction on your return. (See the Article entitled
"General Information About Our Plan" for the definition of "Plan Year.")
III
CONTRIBUTIONS
1. How much of my pay may the Employer redirect?
Each year, we will automatically contribute on your behalf enough of your compensation to pay for
the insurance coverage provided unless you elect not to receive any or all of such coverage. You may also
elect to have us contribute on your behalf enough of your compensation to pay for any other benefits that you
elect under the Plan. These amounts will be deducted from your pay over the course of the year.
2. What happens to contributions made to the Plan?
Before each Plan Year begins, you will select the benefits you want and how much of the
contributions should go toward each benefit. It is very important that you make these choices carefully based
on what you expect to spend on each covered benefit or expense during the Plan Year. Later, they will be
used to pay for the expenses as they arise during the Plan Year.
3. When must I decide which accounts I want to use?
You are required by Federal law to decide before the Plan Year begins, during the election period
(defined below). You must decide two things. First, which benefits you want and, second, how much should
go toward each benefit.
Revised: 08107!2013 Page 6 of 14
If you are already covered by any of the insured benefits offered by this Plan, you will automatically
become a Participant to the extent of the premiums for such insurance unless you elect, during the election
period (defined below), not to participate in the Plan.
4. When is the election period for our Plan?
You will make your initial election on or before your entry date. (You should review Section I on
Eligibility to better understand the eligibility requirements and entry date.) Then, for each following Plan
Year, the election period will be the 60 day period prior to the beginning of each Plan Year or a specific time
period before the start of the plan year as designated by the plan Administrator as the "Open Enrollment
Period". (See the Article entitled "General Information About Our Plan" for the definition of Plan Year.)
5. May I change my elections during the Plan Year?
Generally, you cannot change the elections you have made after the beginning of the Plan Year.
However, there are certain limited situations when you can change your elections. You are only permitted to
change elections during the plan year if you have a "change in status" or a "Change in Family Life Style" as
defined by the IRS. You make an election change that is consistent with the change in status. Currently,
Federal law considers the following events to be a change in status:
Marriage, divorce, death of a spouse, legal separation or annulment;
-- Change in the number of dependents, including birth, adoption, placement for adoption, or
death of a dependent;
-- Any of the following events for you, your spouse or dependent: termination or
commencement of employment, a strike or lockout, commencement or return from an
unpaid leave of absence, a change in worksite, or any other change in employment status that
affects eligibility for benefits;
-- One of your dependents satisfies or ceases to satisfy the requirements for coverage due to
change in age, student status, or any similar circumstance; and
-- A change in the place of residence of you, your spouse or dependent that would lead to a
change in status, such as moving out of a coverage area for insurance.
In addition, if you are participating in the Dependent Care Flexible Spending Account, then there is a
change in status if your dependent no longer meets the qualifications to be eligible for dependent care.
There are detailed rules on when a change in election is deemed to be consistent with a change in
status. In addition, there are laws that give you rights to change health coverage for you, your spouse, or your
dependents. If you change coverage due to rights you have under the law, then you can make a
corresponding change in your elections under the Plan. If any of these conditions apply to you, you should
contact the Administrator.
If the cost of a benefit provided under the Plan increases or decreases during a Plan Year, then we
will automatically increase or decrease, as the case may be, your salary redirection election. If the cost
increases significantly, you will be permitted to either make corresponding changes in your payments or
revoke your election and obtain coverage under another benefit package option with similar coverage, or
revoke your election entirely.
Revised: 08/07/2013 Page 7 of 14
If the coverage under a Benefit is significantly curtailed or ceases during a Plan Year, then you may
revoke your elections and elect to receive on prospective basis coverage under another plan with similar
coverage. In addition, if we add a new coverage option or eliminate an existing option, you may elect the
newly-added option (or elect another option if an option has been eliminated) and make corresponding
election changes to other options providing similar coverage. If you are not a Participant, you may elect to
join the Plan. There are also certain situations when you may be able to change your elections on account of
a change under the plan of your spouse's, former spouses or dependent's employer.
These rules on change due to cost or coverage do not apply to the Health Flexible Spending Account,
and you may not change your election to the Health Flexible Spending Account if you make a change due to
cost or coverage for insurance.
You may not change your election under the Dependent Care Flexible Spending Account if the cost
change is imposed by a dependent care provider who is your relative.
6. May I make new elections in future Plan Years?
Yes, you may. For each new Plan Year, you may change the elections that you previously made. You
may also choose not to participate in the Plan for the upcoming Plan Year. If you do not make new elections
during the election period before a new Plan Year begins, we will assume you want your elections for
insured benefits only to remain the same and you will not be considered a Participant for the non-insured
benefit options under the Plan for the upcoming Plan Year.
IV
BENEFITS
1. What benefits are available?
Under our Plan, you can choose to receive your entire compensation or use a portion to pay for the
following benefits or expenses during the year:
Health Flexible Spending Account:
The Health Flexible Spending Account enables you to pay for expenses allowed under Sections 105
and 213(d) of the Internal Revenue Code which are not covered by our insured medical plan and save taxes
at the same time. The Health Flexible Spending Account allows you to be reimbursed by the Employer for
out-of-pocket medical, dental and/or vision expenses incurred by you and your dependents.
Drug costs, including prescribed "over-the-counter" drugs may be reimbursed. You may not,
however, be reimbursed for the cost of other health care coverage maintained outside of the Plan, or for long-
term care expenses. A list of covered expenses is available from the Administrator.
Beginning with the 2013 Plan Year the most that you can contribute to your Health Flexible
Spending Account each Plan Year is $2,500. In order to be reimbursed for a health care expense, you must
submit to the Administrator an itemized bill from the service provider. We will also provide you with a debit
or credit card to use to pay for medical expenses, such as co-pays, deductibles, medical equipment and drug
costs. The Administrator will provide you with further details. Amounts reimbursed from the Plan may not
be claimed as a deduction on your personal income tax return. Reimbursement from the fund shall be paid at
least once a month. Expenses under this Plan are treated as being "incurred" when you are provided with the
care that gives rise to the expenses, not when you are formally billed or charged, or you pay for the medical
care.
Revised: 08/07/2013 Page 8 of 14
Newborns' and Mothers' Health Protection Act: Group health plans generally may not, under Federal
law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn
child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section.
However, Federal law generally does not prohibit the mother's or newborn's attending provider, after
consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain
authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96
hours).
Dependent Care Flexible Spending Account:
The Dependent Care Flexible Spending Account enables you to pay for out-of-pocket, work-related
dependent day-care cost with pre-tax dollars. If you are married, you can use the account if you and your
spouse both work or, in some situations, if your spouse goes to school full-time. Single employees can also
use the account.
An eligible dependent is someone for whom you can claim expenses on Federal Income Tax Form
2441 "Credit for Child and Dependent Care Expenses." Children must be under age 13. Other dependents
must be physically or mentally unable to care for themselves. Dependent Care arrangements which qualify
include:
(a) A Dependent (Day) Care Center, provided that if care is provided by the facility for more
than six individuals, the facility complies with applicable state and local laws:
(b) An Educational Institution for pre-school children. For older children, only expenses for
non-school care are eligible; and
(c) An "Individual" who provides care inside or outside your home: The "Individual" may not
be a child of yours under age 19 or anyone you claim as a dependent for Federal tax
purposes.
You should make sure that the dependent care expenses you are currently paying for qualify under
our Plan. The law places limits on the amount of money that can be paid to you in a calendar year from your
Dependent Care Flexible Spending Account. Generally, your reimbursements may not exceed the lesser of:
(a) $5,000 (if you are married filing a joint return or you are head of a household) or $2,500 (if you are
married filing separate returns); (b) your taxable compensation; (c) your spouse's actual or deemed earned
income (a spouse who is a full time student or incapable of caring for himself/herself has a monthly earned
income of $250 for one dependent or $500 for two or more dependents). Also, in order to have the
reimbursements made to you from this account be excludable from your income, you must provide a
statement from the service provider including the name, address, and in most cases, the taxpayer
identification number of the service provider on your tax form for the year, as well as the amount of such
expense as proof that the expense has been incurred. In addition, Federal tax laws permit a tax credit for
certain dependent care expenses you may be paying for even if you are not a Participant in this Plan. You
may save more money if you take advantage of this tax credit rather than using the Dependent Care Flexible
Spending Account under our Plan. Ask your tax adviser which is better for you.
Revised: 08/07/2013 Page 9 of 14
Premium Expense Account:
A Premium Expense Account allows you to use tax-free dollars to pay for certain premium expenses
under various insurance programs that we offer you. These premium expenses include:
-- Health care premiums under our insured group medical plan.
-- Dental insurance premiums.
-- Vision insurance premiums.
Under our Plan, we will establish sub-accounts for you for each different type of insurance coverage
that is available. Also, certain limits on the amount of coverage may apply.
The Administrator may terminate or modify Plan benefits at any time, subject to the provisions of
any insurance contracts providing benefits described above. We will not be liable to you if an insurance
company fails to provide any of the benefits described above. Also, your insurance will end when you leave
employment, are no longer eligible under the terms of any insurance policies, or when insurance terminates.
Any benefits to be provided by insurance will be provided only after (1) you have provided the
Administrator the necessary information to apply for insurance, and (2) the insurance is in effect for you.
V
BENEFIT PAYMENTS
1. When will I receive payments from my accounts?
During the course of the Plan Year, you may submit requests for reimbursement of expenses you
have incurred. Expenses are considered "incurred" when the service is performed, not necessarily when it is
paid for. The Administrator will provide you with acceptable forms for submitting these requests for
reimbursement. If the request qualifies as a benefit or expense that the Plan has agreed to pay, you will
receive a reimbursement payment soon thereafter. Remember, these reimbursements which are made from
the Plan are generally not subject to federal income tax or withholding. Nor are they subject to Social
Security taxes. Requests for payment of insured benefits should be made directly to the insurer. You will
only be reimbursed from the Dependent Care Flexible Spending Account to the extent that there are
sufficient funds in the Account to cover your request.
2. What happens if I don't spend all Plan contributions during the Plan Year?
If you have not spent all the amounts in your Health Flexible Spending Account by the end of the
Plan Year, you may continue to incur claims for expenses during the "Grace Period." The "Grace Period"
extends 2 1/2 months after the end of the Plan Year, during which time you can continue to incur claims and
use up all amounts remaining in your Health Flexible Spending Account.
Grace Period: Medical Expenses incurred during the Employer established Grace Period, which is
January 1 -March 15 of the following year, up to the remaining account balance shall also be deemed to
have been incurred during the Prior Plan Year. Participants may obtain medical services and submit claims
during the Grace Period of January 1 -March 15 of the following year.
Run-Out Period: If participants do not submit all claims before the end of the Run-Out Period,
which ends March 30 of the following year, they will forfeit any remaining balance in the account.
Revised: 08/07/2013 Page 10 of 14
Any monies left at the end of the Plan Year and the Grace Period will be forfeited. All qualifying
expenses that you incur late in the Plan Year or during the Grace Period for which you seek reimbursement
after the end of such Plan Year and Grace Period will be paid first before any amount is forfeited. For the
Health Flexible Spending Account, you must submit claims no later than 90 days after the end of the Plan
Year. For the Dependent Care Flexible Spending Account, you must submit claims no later than 90 days
after the end of the Plan Year. Because it is possible that you might forfeit amounts in the Plan if you do not
fully use the contributions that have been made, it is important that you decide how much to place in each
account carefully and conservatively. Remember, you must decide which benefits you want to contribute to
and how much to place in each account before the Plan Year begins. You want to be as certain as you can
that the amount you decide to place in each account will be used up entirely.
Family and Medical Leave Act (FMLA)
If you take leave under the Family and Medical Leave Act, you may revoke or change your existing
elections for health insurance and the Health Flexible Spending Account. If your coverage in these benefits
terminates, due to your revocation of the benefit while on leave or due to your non-payment of contributions,
you will be permitted to reinstate coverage for the remaining part of the Plan Year upon your return. For the
Health Flexible Spending Account, you may continue your coverage or you may revoke your coverage and
resume it when you return. You can resume your coverage at its original level and make payments for the
time that you are on leave. For example, if you elect $1,200 for the year and are out on leave for 3 months,
then return and elect to resume your coverage at that level, your remaining payments will be increased to
cover the difference -from $100 per month to $150 per month. Alternatively your maximum amount will be
reduced proportionately for the time that you were gone. For example, if you elect $1,200 for the year and
are out on leave for 3 months, your amount will be reduced to $900. The expenses you incur during the time
you are not in the Health Flexible Spending Account are not reimbursable. If you continue your coverage
during your unpaid leave, you may pre-pay for the coverage, you may pay for your coverage on an after-tax
basis while you are on leave, or you and your Employer may arrange a schedule for you to "catch up" your
payments when you return.
4. Uniformed Services Employment and Reemployment Rights Act (USERRA)
If you are going into or returning from military service, you may have special rights to health care
coverage under your Health Flexible Spending Account under the Uniformed Services Employment and
Reemployment Rights Act of 1994. These rights can include extended health care coverage. If you may be
affected by this law, ask your Administrator for further details.
5. What happens if I terminate employment?
If you terminate employment during the Plan Year, your right to benefits will be determined in the
following manner:
(a) You will remain covered by insurance, but only for the period for which premiums have
been paid prior to your termination of employment.
(b) You will still be able to request reimbursement for qualifying dependent care expenses from
the balance remaining in your dependent care account at the time of termination of
employment. However, no further salary redirection contributions will be made on your
behalf after you terminate. You must submit claims within 90 days after termination.
Revised: 08/07/2013 Page 11 of 14
(c) Your participation in the Health Flexible Spending Account will cease, and no further salary
redirection contributions will be contributed on your behalf. However, you will be able to
submit claims for health care expenses that were incurred before the end of the period for
which payments to the Health Flexible Spending Account have already been made. You
must submit claims within 90 days after termination.
6. Will my Social Security benefits be affected?
Your future Social Security benefits may be slightly reduced because when you receive tax-free
benefits under our Plan, it reduces the amount of contributions that you make to the Federal Social Security
system as well as our contribution to Social Security on your behalf.
VI
HIGHLY COMPENSATED AND KEY EMPLOYEES
1. Do limitations apply to highly compensated employees?
Under the Internal Revenue Code, highly compensated employees and key employees generally are
Participants who are officers, shareholders or highly paid. You will be notified by the Administrator each
Plan Year whether you are a highly compensated employee or a key employee.
If you are within these categories, the amount of contributions and benefits for you maybe limited so
that the Plan as a whole does not unfairly favor those who are highly paid, their spouses or their dependents.
Federal tax laws state that a plan will be considered to unfairly favor the key employees if they as a group
receive more than 25% of all of the nontaxable benefits provided for under our Plan.\
Plan experience will dictate whether contribution limitations on highly compensated employees or
key employees will apply. You will be notified of these limitations if you are affected.
VII
PLAN ACCOUNTING
1. Periodic Statements
The Administrator will provide you with a statement of your account periodically during the Plan
Year that shows your account balance. It is important to read these statements carefully so you understand
the balance remaining to pay for a benefit. Remember, you want to spend all the money you have designated
for a particular benefit by the end of the Plan Year.
VIII
GENERAL INFORMATION ABOUT OUR PLAN
This Section contains certain general information which you may need to know about the Plan.
1. General Plan Information
St. Lucie Coicnty Board of County Commissioners Flexible Benefits Plan is the name of the Plan.
Your Employer has assigned Plan Number 507 to your Plan.
The provisions of the revised Plan become effective on January 1, 2013, which is called the Effective
Date of the Plan.
Your Plan's records are maintained on a twelve-month period of time. This is known as the Plan
Year. The Plan Year begins on January 1 and ends on December 31.
Revised: 08/07/2013 Page 12 of 14
2. Employer Information
Your Employer's name, address, and identification number are:
St. Lucie County Board of County Commissioners
2300 Virginia Ave.
Ft. Pierce, Florida 34982-5632
59-6000835
3. Plan Administrator Information
The name, address and business telephone number of your Plan's Administrator are:
The Plan Administrator is the County Risk & Benefits Manager
St. Lucie County Board of County Commissioners
Attn: Risk & Benefits Manager
2300 Virginia Ave.
Ft. Pierce, Florida 34982-5632
(772) 462-1613
The Administrator keeps the records for the Plan and is responsible for the administration of the
Plan. The Administrator will also answer any questions you may have about our Plan. You may contact the
Administrator for any further information about the Plan.
4. Service of Legal Process
The name and address of the Plan's agent for service of legal process are:
St. Lucie County Board of County Commissioners
2300 Virginia Ave.
Ft. Pierce, Florida 34982-5632
Type of Administration
The type of Administration is Employer Administration.
6. Claims Submission
Claims for expenses should be submitted to:
TASC
PO Box 7308
Madison, WI 53707-7308
IX
ADDITIONAL PLAN INFORMATION
1. Claims Process
You should submit all reimbursement claims during the Plan Year. For the Health Flexible Spending
Account, you must submit claims no later than 90 days after the end of the Plan Year. However, if you
terminate employment during the Plan Year, you must submit your Health Flexible Spending Account claims
within 90 days after your termination of employment. For the Dependent Care Flexible Spending Account,
you must submit claims no later than 90 days after the end of the Plan Year. However, if you terminate
Revised: 08/07/2013 Page 13 of 14
employment during the Plan Year, you must submit your Dependent Care Flexible Spending Account claims
within 90 days after your termination of employment. Any claims submitted after that time will not be
considered.
Claims that are insured will be handled in accordance with procedures contained in the insurance
policies. All other general requests should be directed to the Administrator of our Plan. If a dependent care
or medical expense claim under the Plan is denied in whole or in part, you or your beneficiary will receive
written notification. The notification will include the reasons for the denial, with reference to the specific
provisions of the Plan on which the denial was based, a description of any additional information needed to
process the claim and an explanation of the claims review procedure. Within 60 days after denial, you or
your beneficiary may submit a written request for reconsideration of the denial to the Administrator.
Any such request should be accompanied by documents or records in support of your appeal. You or
your beneficiary may review pertinent documents and submit issues and comments in writing. The
Administrator will review the claim and provide, within 60 days, a written response to the appeal. (This
period may be extended an additional 60 days under certain circumstances.) In this response, the
Administrator will explain the reason for the decision, with specific reference to the provisions of the Plan on
which the decision is based. The Administrator has the exclusive right to interpret the appropriate plan
provisions. Decisions of the Administrator are conclusive and binding.
X
SUMMARY
The money you earn is important to you and your family. You need it to pay your bills, enjoy
recreational activities and save for the future. Our flexible benefits plan will help you keep more of the
money you earn by lowering the amount of taxes you pay. The Plan is the result of our continuing efforts to
find ways to help you get the most for your earnings.
If you have any questions, please contact the Plan Administrator.
IN WITNESS WHEREOF, this Plan document is hereby executed this / day of /~~' , 2012.
EMPLOYER: St. Luci
By:
Title
ES .
EI
APPRO ED AS TO FORM
AND C RR~,CTN,~S
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COUN Y ATTOR Y
Revised: 08/07/20'Lg
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14 of 14