Resolution - 2019 - 19-01 - Restated Health Reimbursement Arrangement - 01/08/2019RESOLUTION 19-01
The undersigned Authorized Signer of City of Eagle (the Employer) hereby certifies that the following
resolutions were duly adopted by the Employer on January 8, 2019, and that such resolutions have not
been modified or rescinded as of the date hereof:
RESOLVED, that the form of amended and restated Health Reimbursement Arrangement
effective nun pro tunc January 1, 2019, presented to this meeting is hereby approved and adopted and
that the duly authorized agents of the Employer are hereby authorized and directed to execute and
deliver to the Administrator of the Plan one or more counterparts of the Plan.
RESOLVED, that the Administrator shall be instructed to take such actions that are deemed
necessary and proper in order to implement the Plan, and to set up adequate accounting and
administrative procedures to provide benefits under the Plan.
RESOLVED, that the duly authorized agents of the Employer shall act as soon as possible to
notify the employees of the Employer of the adoption of the Health Reimbursement Arrangement Plan
by delivering to each employee a copy of the summary description of the Plan in the form of the
Summary Plan Description presented to this meeting, which form is hereby approved.
The undersigned further certifies that attached hereto are true copies of the Health Reimbursement
Arrangement Plan as amended and restated and the Summary Plan Description approved and adopted
in the foregoing resolutions.
ADOPTED THIS 8TH DAY OF JANUARY 2019.
Stan Ridgeway, Mayor
j.1\
ATTEST: Sharon K. Bergmann, City CLbrk/Treasurer
ORIGINAL
HEALTH REIMBURSEMENT ARRANGEMENT
CITY OF EAGLE
BASIC PLAN DOCUMENT
Effective January 1, 2019
TABLE OF CONTENTS
ARTICLE I 4
DEFINITIONS 4
ARTICLE II 6
PARTICIPATION 6
2.1 Eligibility 6
2.2 Effective Date of Participation 6
2.3 Termination of Participation 6
2.4 Opt -out and Waiver 7
ARTICLE III 7
BENEFITS 7
3.1 Establishment of Plan 7
3.2 Nondiscrimination Requirements 8
3.3 Health Reimbursement Arrangement Claims 8
ARTICLE 1V 8
ERISA PROVISIONS 8
4.1 Claim for Benefits 9
4.2 Named Fiduciary 10
4.3 General Fiduciary Responsibilities 10
4.4 Nonassignability of Rights 10
ARTICLE V 11
ADMINISTRATION 11
5.1 Plan Administration 11
5.2 Examination of Records 11
5.3 Indemnification of Administrator 11
ARTICLE VI 11
AMENDMENT OR TERMINATION OF PLAN 12
6.1 Amendment 12
6.2 Termination 12
ARTICLE VII 12
MISCELLANEOUS 12
7.1 Plan Interpretation 12
7.2 Gender and Number 12
7.3 Written Document 12
7.4 Exclusive Benefit 12
7.5 Participant's Rights 12
7.6 Action by the Employer 12
7.7 No Guarantee of Tax Consequences 13
7.8 Indemnification of Employer by Participants 13
7.9 Funding 13
7.10 Governing Law 13
7.11 Severability 13
7.12 Headings 13
7.13 Continuation of Coverage 13
7.14 Family and Medical Leave Act 14
7.15 Health Insurance Portability and Accountability Act 14
7.16 Uniformed Services Employment and Reemployment Rights Act 14
7.17 HIPAA Privacy Standards 14
7.18 HIPAA Electronic Security Standards 16
7.19 Mental Health Parity And Addiction Equity Act (USERRA) 18
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7.20 Genetic Information Nondiscrimination Act (GINA) 18
7.21 Women's Health and Cancer Rights Act 18
7.22 Newborn's and Mothers' Health Protection Act 18
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MRA Document (9/15)
HEALTH REIMBURSEMENT ARRANGEMENT
As used in this Plan, the following words and phrases shall have the meanings set forth herein unless a
different meaning is clearly required by the context:
1.1
ARTICLE I
DEFINITIONS
"Administrator" means the individual(s) or committee appointed by the Employer to carry out
the administration of the Plan. In the event the Administrator has not been appointed, or
resigns from a prior appointment, the Employer shall be deemed to be the Administrator.
1.2 "Affiliated Employer" means 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(o).
1.3 "Affordable Care Act" means the Patient Protection and Affordable Care Act, as amended by
the Health Care and Education Reconciliation Act of 2010, and as further amended by the
Department of Defense and Full -Year Continuing Appropriations Act, 2011.
1.4 "Code" means the Internal Revenue Code of 1986, as amended.
1.5 "Coverage Period" or "Plan 'Year" means the 12 -month period commencing on January 1st and
ending on December 31st.
1.6 "Dependent" means any individual who qualifies as a dependent under Code Section 152 (as
modified by Code Section 105(b)). Any child of a Participant who is an "alternate recipient"
under a qualified medical child support order under ERISA Section 609 shall be considered a
Dependent under this Arrangement.
Notwithstanding anything in the Plan to the contrary, Qualifying Medical Expenses incurred
by a Participant's child prior to the end of the calendar year in which the child attains age 26
may be reimbursed under the Plan. A Participant's child includes his natural child, and
adopted child, or a child placed with the Employee for adoption. It may also include step
children and/or foster children if elected on the Adoption Agreement. A Participant's child will
be an eligible Dependent until reaching the limiting age of 26, without regard to student status,
marital status, financial dependency or residency status with the Employee or any other
person.
The phrase "placed for adoption" refers to a child whom the Employee intends to adopt,
whether or not the adoption has become final, who has not attained the age of 18 as of the date
of such placement for adoption. The term "placed" means the assumption and retention by
such Employee of a legal obligation for total or partial support of the child in anticipation of
adoption of the child. The child must be available for adoption and the legal process must have
commenced.
1.7 "Effective Date" of the Plan means May 1, 2010. The effective date of this amendment and
restatement is January 1, 2019.
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1.8 "Eligible Employee" means any Eligible Employee as stated in Section 2.1 and as provided
herein. 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. Furthermore, Employees of an Affiliated Employer will not
be treated as "Eligible Employees" prior to the date the Affiliated Employer adopts the Plan as
a Participating Employer.
However, a self-employed individual as defined under Code Section 401(c) or a 2 -percent
shareholder as defined under Code Section 1372(b) shall not be eligible to participate in this
Plan.
1.9 "Employee" means any person who is employed by the Employer. The term "Employee" shall
also include any person who is an employee of an Affiliated Employer and any Leased
Employee deemed to be an Employee as provided in Code Section 414(n) or (o).
1.10 "Employer" means City of Eagle any successor which shall maintain this Plan and any
predecessor which has maintained this Plan. In addition, unless the context means otherwise,
the term "Employer" shall include any Participating Employer which shall adopt this Plan.
1.11 "Employer Contribution" means the amounts contributed to the Plan by the Employer.
1.12 "ERISA" means the Employee Retirement Income Security Act of 1974, as amended from time
to time.
1.13 "Leased Employee" means, effective with respect to Plan Years beginning on or after January
1, 1997, any person (other than an Employee of the recipient Employer) who, pursuant to an
agreement between the recipient Employer and any other person or entity ("leasing
organization"), has performed services for the recipient (or for the recipient and related
persons determined in accordance with Code Section 414(n)(6)) on a substantially full time
basis for a period of at least one year, and such services are performed under primary direction
or control by the recipient Employer. Contributions or benefits provided a Leased Employee
by the leasing organization which are attributable to services performed for the recipient
Employer shall be treated as provided by the recipient Employer. Furthermore, Compensation
for a Leased Employee shall only include Compensation from the leasing organization that is
attributable to services performed for the recipient Employer.
A Leased Employee shall not be considered an employee of the recipient Employer if: (a) such
employee is covered by a money purchase pension plan providing: (1) a nonintegrated
employer contribution rate of at least ten percent (10%) of compensation, as defined in Code
Section 415(c)(3), but for Plan Years beginning prior to January 1, 1998, including amounts
contributed pursuant to a salary reduction agreement which are excludable from the
employee's gross income under Code Sections 125, 402(e)(3), 402(h)(1)(B), 403(b), or for Plan
Years beginning on or after January 1, 2001 (or as of a date, no earlier than January 1, 1998, as
specified in Section 1.6 of the Plan), 132(0(4), (2) immediate participation, and (3) full and
immediate vesting; and (b) leased employees do not constitute more than twenty percent (20%)
of the recipient Employer's non -highly compensated workforce.
1.14 "Participant" means any Eligible Employee who has satisfied the requirements of Section 2.1
and has not for any reason become ineligible to participate further in the Plan.
1.15 "Plan" means City of Eagle HRA Plan as set forth herein adopted by the Employer, including
all amendments thereto. "Plan" means the "Health Reimbursement Arrangement."
1.16 "Premiums" mean the Participant's cost for any health plan coverage.
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1.17 "Qualifying Health Plan" means coverage which does not consist solely of "excepted
benefits" as described in 26 C.F.R. § 54.9831-1(c)(3) which is a group health plan which is not
sponsored by the Employer which provides "minimum value" pursuant to Code section
36B(c)(2)(C)(ii) for which the Plan has received an attestation signed by an Employee certifying
coverage under the group health plan.
1.18 "Qualifying Medical Expenses" means any expense eligible for reimbursement under the
Health Reimbursement Arrangement which would qualify as a "medical expense" (within the
meaning of Code Section 213(d) and as allowed under Code Section 105 and the rulings and
Treasury regulations thereunder) of the Participant, the Participant's spouse or a Dependent
and not otherwise used by the Participant as a deduction in determining the Participant's tax
liability under the Code or reimbursed under any other health coverage, including a health
Flexible Spending Account. Qualifying Medical Expenses covered by this Plan are limited to
deductibles under the Employer's group medical. A Participant may not be reimbursed for the
cost of any medicine or drug that is not "prescribed" as defined in Code Section 106(0.
Furthermore, a Participant may not be reimbursed for "qualified long-term care services" as
defined in Code Section 7702B(c). If the Employer provides Health Savings Accounts for
Participants, Qualifying Medical Expenses reimbursed shall be limited to those allowed under
Code Section 223. "Incurred" means when the Participant is provided with the medical care
that gives rise to the Qualifying Medical Expense and not when the Participant formally billed
or charged for, or pays for, the medical care.
ARTICLE II
PARTICIPATION
2.1 Eligibility
Any Eligible Employee will be eligible to participate in the Health Reimbursement
Arrangement upon satisfaction of the following: (a) 30 days after date of hire; (b) Employee is
scheduled to work at least 30 hours per week; and (c) Employee is currently enrolled in the
Employer's group health plan. The following Employees are excluded: Union Employees;
Non-resident aliens; Leased Employees.
2.2 Effective Date of Participation
An Eligible Employee who has satisfied the conditions of eligibility pursuant to Section 2.1
shall become a Participant effective as of the first day of the month coinciding with or
following the date on which such requirements are satisfied.
If an Employee, who has satisfied the Plan's eligibility requirements and would otherwise have
become a Participant, shall go from a classification of a noneligible Employee to an Eligible
Employee, such Employee shall become a Participant on the date such Employee becomes an
Eligible Employee or, if later, the date that the Employee would have otherwise entered the
Plan had the Employee always been an Eligible Employee.
If an Employee, who has satisfied the Plan's eligibility requirements and would otherwise
become a Participant, shall go from a classification of an Eligible Employee to a noneligible
class of Employees, such Employee shall become a Participant in the Plan on the date such
Employee again becomes an Eligible Employee, or, if later, the date that the Employee would
have otherwise entered the Plan had the Employee always been an Eligible Employee.
2.3 Termination of Participation
This Section shall be applied and administered consistent with any rights a Participant and the
Participant's Dependents may be entitled to pursuant to Code Section 4980B, Section 7.13 of the
Plan. A former Participant has 60 days following termination of participation to file claims for
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I -IRA Document (9/15)
services performed prior to this date. In the case of the death of the Participant, any remaining
balances may only be paid out as reimbursements for Qualifying Medical Expenses and shall
not constitute a death benefit to the Participant's estate and/or the Participant's beneficiaries.
2.4 Opt -out and Waiver
A Participant under the Plan is permitted to permanently opt out of and waive future
reimbursements from the HRA at least annually and upon termination of employment.
3.1 Establishment of Plan
(a)
ARTICLE III
BENEFITS
This Health Reimbursement Arrangement is intended to qualify as a Health
Reimbursement Arrangement under Code Section 105 and shall be interpreted in a
manner consistent with such Code Section and the Treasury regulations thereunder.
(b) Beginning with the plan year which begins on or after January 1, 2014, to the extent that
this Health Reimbursement Arrangement ("HRA") does not constitute an "excepted
benefit" as described in 26 C.F.R. § 54.9831-1(c)(3)(v); or according to its terms may be
used to reimburse essential health benefits as defined in § 1302(b) of the Affordable Care
Act; this Plan is intended by the Employer to constitute an "integrated" HRA as that term
is used in the Affordable Care Act and regulatory guidance issued thereunder ("ACA").
(c) The Employer maintains a group health plan which does not consist solely of "excepted
benefits" as described in 26 C.F.R. § 54.9831-1(c)(3) which provides "minimum value"
pursuant to Code section 36B(c)(2)(C)(ii).
(d) The Employer does not maintain a Health Flexible Spending Account and/or Cafeteria
Plan. Participants in this Health Reimbursement Arrangement may submit claims for the
reimbursement of Qualifying Medical Expenses for services that were incurred during
the Coverage Period.
(e) The Employer shall make available to each Participant an Employer Contribution for the
reimbursement of Qualifying Medical Expenses. The Employer shall contribute the
following annual amount for deductible expenses:
Single Participant:
Employee pays the first $300 of the $2,500 deductible. The remaining $2,200 of the
deductible will be paid out by the Employer at 70%. The maximum Employer
Contribution for a Single Participant will not exceed $1,540.
Participant and FamiIv:
The Employee and/or Dependents pay the first $300 of two separate deductibles before
the Employer will pay at 70% of any remaining deductible expenses up to $3,080. Once
one family member reaches $300 in expenses, the Employer will begin to pay for any
additional deductible expenses for that family member at 70% of remaining deductible.
The second $300 deductible can be reached by another individual or an aggregate of the
family. If no family member incurs $300 in deductible expenses but the family has an
aggregate of $600 in deductible expenses, then the Employer will pay at 70% any
remaining deductible expenses up to $3,080.
Maximum Employer Contribution for an individual is $1,540 and for the family is $3,080.
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FIRA Document (9/15)
(0
If the maximum Employer Contribution is not used in its entirety, such remainder will be
forfeited. •
Expenses are considered "incurred" when the service is performed, not necessarily when
it is paid for. Any amounts reimbursed to you under the Plan may not be claimed as a
deduction on your personal income tax return nor reimbursed by other health plan
coverage.
No salary reductions may be made to this Health Reimbursement Arrangement.
This Plan shall not be coordinated or otherwise connected to the Employer's cafeteria
plan (as defined in Code Section 125), except as permitted by the Code and the Treasury
regulations thereunder, to the extent necessary to maintain this Plan as a Health
Reimbursement Arrangement.
3.2 Nondiscrimination Requirements
(a) It is the intent of this Health Reimbursement Arrangement not to discriminate in
violation of the Code and the Treasury regulations thereunder.
(b) If the Administrator deems it necessary to avoid discrimination under this Health
Reimbursement Arrangement, it may, but shall not be required to reduce benefits
provided to "highly compensated individuals" (as defined in Code Section 105(h)) 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.
3.3 Health Reimbursement Arrangement Claims
(a)
The Administrator shall direct the reimbursement to each eligible Participant for all
Qualifying Medical Expenses. All Qualifying Medical Expenses eligible for
reimbursement pursuant to Section 3.1(b) shall be reimbursed during the Coverage
Period, even though the submission of such a claim occurs after his participation
hereunder ceases; but provided that the Qualifying Medical Expenses were incurred
during a Coverage Period. Claims must include receipts or documentation that the
expense being incurred is eligible for reimbursement, in order to claim reimbursement.
Expenses may be reimbursed up to 60 days after the end of the Coverage Period; and
Section 3.3(c) below. However, a Participant may not submit claims incurred prior to
beginning participation in the Plan and/or the Effective Date of the Plan, whichever is
earlier.
(b) Notwithstanding the foregoing, Qualifying Medical Expenses shall not be reimbursable
under this Plan if eligible for reimbursement and claimed under the Employer's Health
Flexible Spending Account or Health Savings Account, if applicable.
(c) Claims for the reimbursement of Qualifying Medical Expenses incurred in any Coverage
Period shall be paid as soon after a claim has been filed as is administratively practicable.
However, if a Participant fails to submit a claim within 60 days immediately following
the end of the Coverage Period, those Medical Expense claims shall not be considered for
reimbursement by the Administrator.
(d) Reimbursement payments under this Plan shall be made directly to the Participant.
(e) If the maximum amount available for reimbursement for a Coverage Period is not
utilized in its entirety, such remainder shall be forfeited.
ARTICLE IV
ERISA PROVISIONS
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HRA Document (9/15)
4.1 Claim for Benefits
Any claim for Benefits shall be made to the Administrator. The following timetable for claims
and rules below apply:
Notification of whether claim is accepted or denied 30 days
Extension due to matters beyond the control of the Plan 15 days
Insufficient information on the Claim:
Notification of 15 days
Response by Participant 45 days
Review of claim denial 60 days
The Administrator will provide written or electronic notification of any claim denial. The
notice will state:
(1) The specific reason or reasons for the denial.
(2) Reference to the specific Plan provisions on which the denial was based.
(3) A description of any additional material or information necessary for the
claimant to perfect the claim and an explanation of why such material or
information is necessary.
(4) A description of the Plan's review procedures and the time limits applicable to
such procedures. This will include a statement of the right to bring a civil action
under section 502 of ERISA following a denial on review.
(5)
A statement that the claimant is entitled to receive, upon request and free of
charge reasonable access to, and copies of, all documents, records, and other
information relevant to the Claim.
(6) If the denial was based on an internal rule, guideline, protocol, or other similar
criterion, the specific rule, guideline, protocol, or criterion will be provided free
of charge. If this is not practical, a statement will be included that such a rule,
guideline, protocol, or criterion was relied upon in making the denial and a copy
will be provided free of charge to the claimant upon request.
When the Participant receives a denial, the Participant shall have 180 days following receipt of
the notification in which to appeal the decision. The Participant may submit written comments,
documents, records, and other information relating to the Claim. If the Participant requests, the
Participant shall be provided, free of charge, reasonable access to, and copies of, all documents,
records, and other information relevant to the Claim.
The period of time within which a denial on review is required to be made will begin at the
time an appeal is filed in accordance with the procedures of the Plan. This timing is without
regard to whether all the necessary information accompanies the filing.
A document, record, or other information shall be considered relevant to a Claim if it:
(1) was relied upon in making the claim determination;
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HRA Document (9/15)
(2) was submitted, considered, or generated in the course of making the claim
determination, without regard to whether it was relied upon in making the claim
determination;
(3)
demonstrated compliance with the administrative processes and safeguards
designed to ensure and to verify that claim determinations are made in
accordance with Plan documents and Plan provisions have been applied
consistently with respect to all claimants; or
(4) constituted a statement of policy or guidance with respect to the Plan concerning
the denied claim.
The review will take into account all comments, documents, records, and other information
submitted by the claimant relating to the Claim, without regard to whether such information
was submitted or considered in the initial claim determination. The review will not afford
deference to the initial denial and will be conducted by a fiduciary of the Plan who is neither
the individual who made the adverse determination nor a subordinate of that individual.
4.2 Named Fiduciary
The "named Fiduciaries" of this Plan are (1) the Employer and (2) the Administrator. The
named Fiduciaries shall have only those specific powers, duties, responsibilities, and
obligations as are specifically given them under the Plan including, but not limited to, any
agreement allocating or delegating their responsibilities, the terms of which are incorporated
herein by reference. In general, the Employer shall have the sole responsibility for providing
benefits under the Plan; and shall have the sole authority to appoint and remove the
Administrator; and to amend the provisions of the Plan or terminate, in whole or in part, the
Plan. The Administrator shall have the sole responsibility for the administration of the Plan,
which responsibility is specifically described in the Plan. Furthermore, each named Fiduciary
may rely upon any such direction, information or action of another named Fiduciary as being
proper under the Plan and is not required under the Plan to inquire into the propriety of any
such direction, information or action. It is intended under the Plan that each named Fiduciary
shall be responsible for the proper exercise of its own powers, duties, responsibilities and
obligations under the Plan. Any person or group may serve in more than one Fiduciary
capacity.
4.3 General Fiduciary Responsibilities
The Administrator and any other fiduciary under ERISA shall discharge their duties with
respect to this Plan solely in the interest of the Participants and their beneficiaries and
(a) for the exclusive purpose of providing Benefits to Participants and their beneficiaries and
defraying reasonable expenses of administering the Plan;
(b) with the care, skill, prudence and diligence under the circumstances then prevailing that
a prudent man acting in like capacity and familiar with such matters would use in the
conduct of an enterprise of a like character and with like aims; and
(c) in accordance with the documents and instruments governing the Plan insofar as such
documents and instruments are consistent with ERISA.
4.4 Nonassignability of Rights
The right of any Participant to receive any reimbursement under the Plan shall not be alienable
by the Participant by assignment or any other method and shall not be subject to the rights of
creditors, and any attempt to cause such right to be so subjected shall not be recognized, except
to such extent as may be required by law.
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HRA Document (9/15)
ARTICLE V
ADMINISTRATION
5.1 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 under 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 under the Plan;
(d) To limit benefits for certain highly compensated individuals 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 approve reimbursement requests and to authorize the payment of benefits; and
(f) To appoint such agents, counsel, accountants, consultants, and actuaries as may be
required to assist in administering the Plan.
(g)
To establish and communicate procedures to determine whether a medical child support
order is qualified under ERISA Section 609.
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 105(h) and the Treasury regulations thereunder.
5.2 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.
5.3 Indemnification of Administrator
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 to act in connection with the Plan, if such act
or omission is in good faith.
ARTICLE VI
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HRA Document (9/15)
AMENDMENT OR TERMINATION OF PLAN
6.1 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.
6.2 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 the
Plan, in whole or in part, at any time. In the event the Plan is terminated, no further
reimbursements shall be made.
ARTICLE VII
MISCELLANEOUS
7.1 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
7.11
7.2 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.
7.3 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 105 and any Treasury
regulations thereunder.
7.4 Exclusive Benefit
This Plan shall be maintained for the exclusive benefit of the Employees who participate in the
Plan.
7.5 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.
7.6 Action by the Employer
Whenever the Employer under the terms of the Plan is permitted or required to do or perform
any act or matter or thing, it shall be done and performed by a person duly authorized by its
legally constituted authority.
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HRA Document (9/15)
7.7 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.
7.8 Indemnification of Employer by Participants
If any Participant receives one or more payments or reimbursements under the Plan that are not
for a permitted Medical Expense 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.
7.9 Funding
Unless otherwise required by law, amounts made available by the Employer need not be placed
in trust 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.
7.10 Governing Law
This Plan and Trust shall be construed and enforced according to the Code, ERISA, and the
laws of the state or commonwealth in which the Employer's principal office is located, other
than its laws respecting choice of law, to the extent not pre-empted by ERISA.
7.11 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.
7.12 Headings
The headings and subheadings of this Plan have been inserted for convenience of reference and
are to be ignored in any construction of the provisions hereof.
7.13 Continuation of Coverage
Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan
subject to the continuation coverage requirement of Code Section 4980B becomes unavailable,
each qualified beneficiary (as defined in Code Section 4980B) will be entitled to continuation
coverage as prescribed in Code Section 498013.
13
1 -JRA Document (9/15)
7.14 Family and Medical Leave Act
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.
7.15 Health Insurance Portability and Accountability Act
Notwithstanding anything in this Plan to the contrary, this Plan shall be operated in accordance
with HIPAA and regulations thereunder.
7.16 Uniformed Services Employment and Reemployment Rights Act
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 USERRA and
the regulations thereunder.
7.17 HIPAA Privacy Standards
(a) If this Plan is subject to the Standards for Privacy of Individually Identifiable Health
Information (45 CFR Part 164, the "Privacy Standards"), then this Section shall apply.
(b) The Plan shall not disclose Protected Health Information to any member of Employer's
workforce unless each of the conditions set out in this Section are met. "Protected Health
Information" shall have the same definition as set forth in the Privacy Standards but
generally shall mean individually identifiable information about the past, present or
future physical or mental health or condition of an individual, including information
about treatment or payment for treatment.
(c) Protected Health Information disclosed to members of Employer's workforce shall be
used or disclosed by them only for purposes of Plan administrative functions. The Plan's
administrative functions shall include all Plan payment functions and health care
operations. The terms "payment" and "health care operations" shall have the same
definitions as set out in the Privacy Standards, but the term "payment" generally shall
mean activities taken to determine or fulfill Plan responsibilities with respect to
eligibility, coverage, provision of benefits, or reimbursement for health care.
(d)
The Plan shall disclose Protected Health Information only to members of the Employer's
workforce, who are authorized to receive such Protected Health Information, and only to
the extent and in the minimum amount necessary for that person to perform his or her
duties with respect to the Plan. "Members of the Employer's workforce" shall refer to all
employees and other persons under the control of the Employer. The Employer shall
keep an updated list of those authorized to receive Protected Health Information.
(1) An authorized member of the Employer's workforce who receives
Protected Health Information shall use or disclose the Protected Health
Information only to the extent necessary to perform his or her duties with
respect to the Plan.
(2) In the event that any member of the Employer's workforce uses or
discloses Protected Health Information other than as permitted by this
Section and the Privacy Standards, the incident shall be reported to the
Plan's privacy officer. The privacy officer shall take appropriate action,
including:
(i)
HRA Document (9/15)
investigation of the incident to determine whether the breach
occurred inadvertently, through negligence or deliberately;
14
whether there is a pattern of breaches; and the degree of harm
caused by the breach;
(ii) appropriate sanctions against the persons causing the breach
which, depending upon the nature of the breach, may include oral
or written reprimand, additional training, or termination of
employment;
(iii) mitigation of any harm caused by the breach, to the extent
practicable; and
(iv) documentation of the incident and all actions taken to resolve the
issue and mitigate any damages.
(e) The Employer must provide certification to the Plan that it agrees to:
(1)
Not use or further disclose the information other than as permitted or
required by the Plan documents or as required by law;
(2) Ensure that any agent or subcontractor, to whom it provides Protected
Health Information received from the Plan, agrees to the same
restrictions and conditions that apply to the Employer with respect to such
information;
(3)
Not use or disclose Protected Health Information for employment-related
actions and decisions or in connection with any other benefit or employee
benefit plan of the Employer;
(4) Report to the Plan any use or disclosure of the Protected Health
Information of which it becomes aware that is inconsistent with the uses or
disclosures permitted by this Section, or required by law;
(5) Make available Protected Health Information to individual Plan members
in accordance with Section 164.524 of the Privacy Standards;
(6) Make available Protected Health Information for amendment by
individual Plan members and incorporate any amendments to Protected
Health Information in accordance with Section 164.526 of the Privacy
Standards;
(7) Make available the Protected Health Information required to provide an
accounting of disclosures to individual Plan members in accordance with
Section 164.528 of the Privacy Standards;
(8) Make its internal practices, books and records relating to the use and
disclosure of Protected Health Information received from the Plan
available to the Department of Health and Human Services for purposes of
determining compliance by the Plan with the Privacy Standards;
(9)
HRA Document (9/15)
If feasible, return or destroy all Protected Health Information received
from the Plan that the Employer still maintains in any form, and retain no
copies of such information when no longer needed for the purpose for
which disclosure was made, except that, if such return or destruction is not
feasible, limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible; and
15
(10) Ensure the adequate separation between the Plan and members of the
Employer's workforce, as required by Section 164.504(f)(2)(iii) of the
Privacy Standards and set out in (d) above.
7.18 HIPAA Electronic Security Standards
If this Plan is subject to the Security Standards for the Protection of Electronic Protected Health
Information (45 CFR Part 164.300 et. seq., the "Security Standards"), then this Section shall apply
as follows:
(a) The Employer agrees to implement reasonable and appropriate administrative, physical
and technical safeguards to protect the confidentiality, integrity and availability of
Electronic Protected Health Information that the Employer creates, maintains or transmits
on behalf of the Plan. "Electronic Protected Health Information" shall have the same
definition as set out in the Security Standards, but generally shall mean Protected Health
Information that is transmitted by or maintained in electronic media.
(b) The Employer shall ensure that any agent or subcontractor to whom it provides Electronic
Protected Health Information shall agree, in writing, to implement reasonable and
appropriate security measures to protect the Electronic Protected Health Information.
(c) The Employer shall ensure that reasonable and appropriate security measures are
implemented to comply with the conditions and requirements set forth in Section 7.17.
(d) The Plan shall not disclose Protected Health Information to any member of Employer's
workforce unless each of the conditions set out in this Section are met. "Protected Health
Information" shall have the same definition as set forth in the Privacy Standards but
generally shall mean individually identifiable information about the past, present or
future physical or mental health or condition of an individual, including information
about treatment or payment for treatment.
(e) Protected Health Information disclosed to members of Employer's workforce shall be
used or disclosed by them only for purposes of Plan administrative functions. The Plan's
administrative functions shall include all Plan payment functions and health care
operations. The terms "payment" and "health care operations" shall have the same
definitions as set out in the Privacy Standards, but the term "payment" generally shall
mean activities taken to determine or fulfill Plan responsibilities with respect to
eligibility, coverage, provision of benefits, or reimbursement for health care.
(f)
The Plan shall disclose Protected Health Information only to members of the Employer's
workforce, who are authorized to receive such Protected Health Information, and only to
the extent and in the minimum amount necessary for that person to perform his or her
duties with respect to the Plan. "Members of the Employer's workforce" shall refer to all
employees and other persons under the control of the Employer. The Employer shall
keep an updated list of those authorized to receive Protected Health Information.
(1) An authorized member of the Employer's workforce who receives
Protected Health Information shall use or disclose the Protected Health
Information only to the extent necessary to perform his or her duties with
respect to the Plan.
(2) In the event that any member of the Employer's workforce uses or
discloses Protected Health Information other than as permitted by this
Section and the Privacy Standards, the incident shall be reported to the
Plan's privacy officer. The privacy officer shall take appropriate action,
including:
16
I -IRA Document (9/15)
(g)
(i)
investigation of the incident to determine whether the breach
occurred inadvertently, through negligence or deliberately;
whether there is a pattern of breaches; and the degree of harm
caused by the breach;
(ii) appropriate sanctions against the persons causing the breach
which, depending upon the nature of the breach, may include oral
or written reprimand, additional training, or termination of
employment;
(iii) mitigation of any harm caused by the breach, to the extent
practicable; and
(iv) documentation of the incident and all actions taken to resolve the
issue and mitigate any damages.
The Employer must provide certification to the Plan that it agrees to:
(1) Not use or further disclose the information other than as permitted or
required by the Plan documents or as required by law;
(2) Ensure that any agent or subcontractor, to whom it provides Protected
Health Information received from the Plan, agrees to the same
restrictions and conditions that apply to the Employer with respect to such
information;
(3)
Not use or disclose Protected Health Information for employment-related
actions and decisions or in connection with any other benefit or employee
benefit plan of the Employer;
(4) Report to the Plan any use or disclosure of the Protected Health
Information of which it becomes aware that is inconsistent with the uses or
disclosures permitted by this Section, or required by law;
(9)
HRA Document (9/15)
Make available Protected Health Information to individual Plan members
in accordance with Section 164.524 of the Privacy Standards;
Make available Protected Health Information for amendment by
individual Plan members and incorporate any amendments to Protected
Health Information in accordance with Section 164.526 of the Privacy
Standards;
Make available the Protected Health Information required to provide an
accounting of disclosures to individual Plan members in accordance with
Section 164.528 of the Privacy Standards;
Make its internal practices, books and records relating to the use and
disclosure of Protected Health Information received from the Plan
available to the Department of Health and Human Services for purposes of
determining compliance by the Plan with the Privacy Standards;
If feasible, return or destroy all Protected Health Information received
from the Plan that the Employer still maintains in any form, and retain no
copies of such information when no longer needed for the purpose for
which disclosure was made, except that, if such return or destruction is not
feasible, limit further uses and disclosures to those purposes that make the
return or destruction of the information infeasible; and
17
(10) Ensure the adequate separation between the Plan and members of the
Employer's workforce, as required by Section 1b4.504(f)(2)(iii) of the
Privacy Standards and set out in (d) above.
7.19 Mental Health Parity And Addiction Equity Act (USERRA)
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.
7.20 Genetic Information Nondiscrimination Act (GINA)
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Genetic Information Nondiscrimination Act.
7.21 Women's Health and Cancer Rights Act
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Women's Health and Cancer Rights Act of 1998.
7.22 Newborn's and Mothers' Health Protection Act
Notwithstanding anything in the Plan to the contrary, the Plan will comply with the
Newborns' and Mothers' Health Protection Act.
18
HRA Document (9/15)
IN WI'T'NESS W1l1R OI., this 1 IRA Plan document is hereby executed on 01)d I ,)--01S
City of Eagle
19
11RA Document (9/15)
13%
Title: yV 1 a%li0i
0
Date: lZ -22--j'
ORIGINAL
HEALTH REIMBURSEMENT ARRANGEMENT
CITY OF EAGLE
SUMMARY PLAN DESCRIPTION
Effective January 1, 2019
TABLE OF CONTENTS
I 4
ELIGIBILITY 4
1. What Are the Eligibility Requirements for Our Plan? 4
2. Are There Any Employees Who Are Not Eligible? 4
3. Can I opt out of receiving any future benefit under the plan? 4
BENEFITS
1.
What Benefits Are Available?
2. When Must Expenses Be incurred?
3. What Happens If I Terminate Employment?
4. Family and Medical Leave Act (FMLA)
5. Uniformed Services Employment and Reemployment Rights Act (USERRA)
6. Newborns' and Mothers' Health Protection Act
7. Qualified Medical Child Support Order
III
GENERAL INFORMATION ABOUT OUR PLAN
1 General Plan Information
2. Employer Information
3. Plan Administrator Information
4. Third Party Claims Administrator Information
5. Service of Legal Process
6. Type of Administration
5
5
5
6
6
6
6
68
6
6
6
6
7
7
7
7
IV 7
ADDITIONAL PLAN INFORMATION 7
1. Your Rights Under ERISA 7
2. How to Submit a Claim 9
V 10
CONTINUATION COVERAGE RIGHTS UNDER COBRA 10
10
10
11
1. What is COBRA Continuation Coverage?
2. Who Can Become a Qualified Beneficiary?
3. What is a Qualifying Event?
4. What Factors Should Be Considered When Determining to Elect COBRA Continuation
Coverage?
5. What is the Procedure for Obtaining COBRA Continuation Coverage?
6. What is the Election Period and How Long Must It Last?
7. Is a Covered Employee or Qualified Beneficiary Responsible for Informing the Plan
Administrator of the Occurrence of a Qualifying Event? 12
8. Is a Waiver Before the End of the Election Period Effective to End a Qualified Beneficiary's
Election Rights? 13
9. Is COBRA Coverage Available If a Qualified Beneficiary Has Other Group Health Plan
Coverage or Medicare?
10. When May a Qualified Beneficiary's COBRA Continuation Coverage Be Terminated?
11. What Are the Maximum Coverage Periods for COBRA Continuation Coverage?
12. Under What Circumstances Can the Maximum Coverage Period Be Expanded?
13. How Does a Qualified Beneficiary Become Entitled to a Disability Extension?
14. Does the Arrangement Require Payment for COBRA Continuation Coverage?
15. Must the Arrangement Allow Payment for COBRA Continuation Coverage to Be Made in
Monthly Installments?
16. What is Timely Payment for Payment for COBRA Continuation Coverage?
12
12
12
14
14
15
15
15
15
2
HRA SPD 010416
16
16
Effective January 1, 2019
17. Must a Qualified Beneficiary Be Given the Right to Enroll in a Conversion Health Plan at
the End of the Maximum Coverage Period for COBRA Continuation Coverage? 16
3
HRA SPD 010416
Effective January 1, 2019
HEALTH REIMBURSEMENT ARRANGEMENT
INTRODUCTION
We are pleased to establish this Health Reimbursement Arrangement to provide you with additional health
coverage benefits. The benefits available under this Plan are outlined in this summary plan description. We will
also tell you about other important information concerning the Plan, such as the rules you must satisfy before
you become eligible and the laws that protect your rights.
Read this summary plan description carefully so that you understand the provisions of our Plan and the
benefits you will receive. You should direct any questions you have to the Administrator. There is a plan
document on file, which you may review if you desire. In the event there is a conflict between this summary
plan description and the plan document, the plan document will control.
I
ELIGIBILITY
1. What Are the Eligibility Requirements for Our Plan?
You will be eligible to join the Plan:
a. once you have completed 30 days of employment; and
b. Upon enrollment in our group medical plan.
2. When is My Entry Date?
Once you have met the eligibility requirements your entry date will be the first day of the month
coinciding with or following the date you met the eligibility requirements.
3. Are There Any Employees Who Are Not Eligible?
Yes, there are certain employees who are excluded from participating in the Plan. They are:
-- Employees who are leased employees.
-- Union employees.
-- Employees who are not eligible to receive medical benefits under our group medical plan.
- - Employees who are part-time. A part-time employee is someone who works, or is expected to work,
less than 30 hours a week.
- - Certain non-resident aliens whose income is not considered income earned within the United States
under Federal tax laws.
4. Can I opt out of receiving any future benefit under the plan?
A Participant under the Plan is permitted to permanently opt out of and waive future reimbursements
from the HRA at least annually and upon termination of employment.
4
HRA SPD 010416
Effective January 1, 2019
II
BENEFITS
1. What Benefits Are Available?
The plan allows you to be reimbursed by the Employer for any deductibles which you have to meet
under a group medical plan which are incurred by you or your dependents who are covered under a
group medical plan.
The maximum Employer contribution allowed each year deductible expenses is:
Single Participant:
Employee pays the first $300 of the $2,500 deductible. The remaining $2,200 of the deductible will be
paid out by the Employer at 70%. The maximum Employer Contribution for a Single Participant will not
exceed $1,540.
Participant and Family:
The Employee and/or Dependents pay the first $300 of two separate deductibles before the Employer
will pay at 70% of any remaining deductible expenses up to $3,080. Once one family member reaches
$300 in expenses, the Employer will begin to pay for any additional deductible expenses for that family
member at 70% of remaining deductible. The second $300 deductible can be reached by another
individual or an aggregate of the family. If no family member incurs $300 in deductible expenses but
the family has an aggregate of $600 in deductible expenses, then the Employer will pay at 70% any
remaining deductible expenses up to $3,080.
Maximum Employer Contribution for an individual is $1,540 and for the family is $3,080.
If the maximum Employer Contribution is not used in its entirety, such remainder will be forfeited.
Expenses are considered "incurred" when the service is performed, not necessarily when it is paid for.
Any amounts reimbursed to you under the Plan may not be claimed as a deduction on your personal
income tax return nor reimbursed by other health plan coverage.
If the maximum Employer Contribution is not used in its entirety, such remainder will be forfeited.
Expenses are considered "incurred" when the service is performed, not necessarily when it is paid for.
Any amounts reimbursed to you under the Plan may not be claimed as a deduction on your personal
income tax return nor reimbursed by other health plan coverage.
2. When Must Expenses Be Incurred?
You may submit expenses that you incur each "Coverage Period." A new "Coverage Period" begins
each January 1st and ends December 31st.
When Will I Receive Payments From the Plan?
During the course of the Coverage Period, you may submit requests for reimbursement of expenses
you have incurred. However, you must make your requests for reimbursements no later than 60 days
after the end of the Coverage Period. The Administrator will provide you with acceptable forms for
submitting these requests for reimbursement. In addition, you must submit to the Administrator proof of
the expenses you have incurred and that they have not been paid by any other health plan coverage.
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, reimbursements made from the Plan are
generally not subject to federal income tax or withholding. Nor are they subject to Social Security
taxes.
5
HRA SPD 010416
Effective January 1, 2019
4. What Happens If I Terminate Employment?
If your employment is terminated during the Plan Year for any reason, your participation in the Plan will
cease and any unused amounts are forfeited. Terminated Employees will have 60 days to file claims
for services through date of termination.
Your Plan is subject to COBRA, please see ARTICLE V. (Always if COBRA eligible)
5. Family and Medical Leave Act (FMLA)
If you take leave under the Family and Medical Leave Act, you remain entitled to coverage under the
Plan unless you permanently opt out of the coverage and waive future reimbursements to become
eligible for certain federal benefits under the Affordable Care Act.
6. 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 the Plan 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.
7. 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).
8. Qualified Medical Child Support Order
A medical child support order is a judgment, decree or order (including approval of a property
settlement) made under state law that provides for child support or health coverage for the child of a
participant. The child becomes an "alternate recipient" and can receive benefits under the health plans
of the Employer, if the order is determined to be "qualified." You may obtain, without charge, a copy of
the procedures governing the determination of qualified medical child support orders from the Plan
Administrator.
III
GENERAL INFORMATION ABOUT OUR PLAN
This Section contains certain general information, which you may need to know about the Plan.
1. General Plan Information
City of Eagle HRA Plan is the name of the Plan.
Your Employer has assigned Plan Number 501 to your Plan.
The provisions of your Plan become effective on January 1, 2019. The original effective date of the
Plan is May 1, 2010.
Your Plan Year is from January 15t to December 31st.
2. Employer Information
Your Employer's name, address, and identification number are:
6
HRA SPD 010416
Effective January 1, 2019
City of Eagle
660 East Civic Lane
Eagle, Idaho 83616
82-0304359
The Plan allows other employers to adopt its provisions. You or your beneficiaries may examine or
obtain a complete list of employers, if any, who have adopted your Plan by making a written request to
the Administrator.
3. Plan Administrator Information
The name, address and business telephone number of your Plan's Administrator are:
City of Eagle
660 East Civic Lane
Eagle, Idaho 83616
(208) 939-6813
The Plan 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. The Plan
Administrator has the exclusive right to interpret the appropriate plan provisions. Decisions of the
Administrator are conclusive and binding. You may contact the Administrator for any further
information about the Plan.
4. Third Party Claims Administrator Information
The name, address and business telephone number of the Third Party Claims Administrator are:
National Benefit Services, LLC
P.O. Box 6980
West Jordan, UT 84084
(800)274-0503
The Third Party Claims Administrator is responsible for the actual processing of claims on behalf of the
Plan Administrator.
5. Service of Legal Process
The Employer is the Plan's agent for service of legal process.
6. Type of Administration
The Plan is a health reimbursement arrangement and the administration is provided through a Third
Party Claims Administrator. The Plan is not funded or insured. Benefits are paid from the general
assets of the Employer.
IV
ADDITIONAL PLAN INFORMATION
1. Your Rights Under ERISA
Plan Participants, eligible employees and all other employees of the Employer may be entitled to
certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA)
and the Internal Revenue Code. These laws provide that Participants, eligible employees and all other
employees are entitled to:
(1) Examine, without charge, at the Administrator's office, all Plan documents, including
insurance contracts, collective bargaining agreements, and a copy of the latest annual report
(Form 5500 Series) filed by the Plan with the U.S. Department of Labor, and available at the
Public Disclosure Room of the Employee Benefits Security Administration.
7
HRA SPD 010416
Effective January 1, 2019
(2) Obtain copies of all Plan documents and other Plan information upon written request to the
Administrator. The Administrator may charge a reasonable fee for the copies.
(3) Continue health care coverage for a Plan Participant, Spouse, or other dependents if there is
a Toss of coverage under the Plan as a result of a qualifying event. Employees or dependents
may have to pay for such coverage.
(4) Review this summary plan description and the documents governing the Plan on the rules
governing COBRA continuation coverage rights.
If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating to the decision without charge, and to appeal any
denial, all within certain time schedules.
If you have a claim for benefits, which is denied or ignored, in whole or in part, you may file suit in a
state or Federal court.
Under ERISA there are steps you can take to enforce the above rights. For instance, if you request
materials from the Pian and do not receive them within thirty (30) days, you may file suit in a Federal
court. In such a case, the court may request the Administrator to provide the materials and pay you up
to $110 a day until you receive the materials, unless the materials were not sent because of reasons
beyond the control of the Administrator. If you have a claim for benefits, which is denied or ignored, in
whole or in part, you may file suit in a state or Federal court.
In addition, if a Plan Participant disagrees with the Plan's decision or lack thereof concerning the
qualified status of a medical child support order, he or she may file suit in federal court.
In addition to creating rights for Plan Participants, ERISA imposes obligations upon the individuals who
are responsible for the operation of the Plan. The individuals who operate the Plan, called "fiduciaries"
of the Pian, have a duty to do so prudently and in the interest of the Plan Participants and their
beneficiaries. No one, including the Employer or any other person, may fire a Plan Participant or
otherwise discriminate against a Plan Participant in any way to prevent the Plan Participant from
obtaining benefits under the Plan or from exercising his or her rights under ERISA.
If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against
for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file
suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are
successful, the court may order the person you have sued to pay these costs and fees. If you lose, the
court may order you to pay these costs and fees; for example, if it finds your claim is frivolous.
If you have any questions about the Plan, you should contact the Administrator. If you have any
questions about this statement, or about your rights under ERISA or the Health Insurance Portability
and Accountability Act (HIPAA), or if you need assistance in obtaining documents from the
Administrator, you should contact the nearest office of the Employee Benefits Security Administration,
U.S. Department of Labor, listed in the telephone directory or the Division of Technical Assistance and
Inquiries, Pension and Welfare Benefits Administration, U.S. Department of Labor, 200 Constitution
Avenue, N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights
and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security
Administration.
8
HRA SPD 010416
Effective January 1, 2019
2. How to Submit a Claim
When you have a Claim to submit for payment, you must:
(1) Obtain a claim form.
(2) Complete the Employee portion of the form.
(3) Attach copies of all bills from the service provider for which you are requesting
reimbursement.
(4) Claims can be submitted manually or through the online system.
A Claim is defined as any request for a Plan benefit, made by a claimant or by a representative of a
d aimant that complies with the Plan's reasonable procedure for making benefit Claims. The times listed
are maximum times only. A period of time begins at the time the Claim is filed. Decisions will be made
within a reasonable period of time appropriate to the circumstances. "Days" means calendar days.
Notification of whether Claim is accepted or denied 30 days
Extension due to matters beyond the control of the Plan 15 days
Insufficient information on the Claim:
Notification of 15 days
Response by Participant 45 days
Review of Claim denial 60 days
The Plan Administrator will provide written or electronic notification of any Claim denial. The notice will
state:
(1) The specific reason or reasons for the denial.
(2) Reference to the specific Plan provisions on which the denial was based.
(3) A description of any additional material or information necessary for the claimant to perfect the
Claim and an explanation of why such material or information is necessary.
(4) A description of the Plan's review procedures and the time limits applicable to such
procedures. This will include a statement of your right to bring a civil action under Section 502
of ERISA following a denial on review.
(5)
A statement that the claimant is entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records, and other information relevant to
the Claim; and
(6) If the denial was based on an internal rule, guideline, protocol, or other similar criterion, the
specific rule, guideline, protocol, or criterion will be provided free of charge. If this is not
practical, a statement will be included that such a rule, guideline, protocol, or criterion was
relied upon in making the denial and a copy will be provided free of charge to the claimant
upon request.
When you receive a denial, you will have 180 days following receipt of the notification in which to appeal
the decision. You may submit written comments, documents, records, and other information relating to
the Claim. If you request, you will be provided, free of charge, reasonable access to, and copies of, all
documents, records, and other information relevant to the Claim.
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HRA SPD 010416
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The period of time within which a denial on review is required to be made will begin at the time an appeal
is filed in accordance with the procedures of the Plan. This timing is without regard to whether all the
necessary information accompanies the filing.
A document, record, or other information shall be considered relevant to a Claim if it:
(1) was relied upon in making the Claim determination;
(2) was submitted, considered, or generated in the course of making the Claim determination,
without regard to whether it was relied upon in making the Claim determination;
(3) demonstrated compliance with the administrative processes and safeguards designed to
ensure and to verify that Claim determinations are made in accordance with Plan documents
and Plan provisions have been applied consistently with respect to all claimants;
(4) or constituted a statement of policy or guidance with respect to the Plan concerning the
denied Claim.
The review will take into account all comments, documents, records, and other information submitted
by the claimant relating to the Claim, without regard to whether such information was submitted or
considered in the initial Claim determination. The review will not afford deference to the initial denial
and will be conducted by a fiduciary of the Plan who is neither the individual who made the adverse
determination nor a subordinate of that individual.
V
CONTINUATION COVERAGE RIGHTS UNDER COBRA
Under federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), certain employees
and their families covered under this Arrangement will be entitled to the opportunity to elect a temporary
extension of health coverage (called "COBRA continuation coverage") where coverage under the Arrangement
would otherwise end. This notice is intended to inform Participants and beneficiaries, in summary fashion, of
their rights and obligations under the continuation coverage provisions of COBRA, as amended and reflected in
final and proposed regulations published by the Department of the Treasury. This notice is intended to reflect
the law and does not grant or take away any rights under the law.
The Plan Administrator or its designee is responsible for administering COBRA continuation coverage.
Complete instructions on COBRA, as well as election forms and other information, will be provided by the Plan
Administrator or its designee to Participants who become Qualified Beneficiaries under COBRA. The
Arrangement itself can provide group health benefits and may also be used to provide health benefits through
insurance. Whenever "Arrangement" is used in this section, it means any of the health benefits under this Plan.
1. What is COBRA Continuation Coverage?
COBRA continuation coverage is the temporary extension of group health plan coverage that must be
offered to certain Participants and their eligible family members (called "Qualified Beneficiaries") at
group rates. The right to COBRA continuation coverage is triggered by the occurrence of a life event
that results in the loss of coverage under the terms of the Arrangement (the "Qualifying Event"). The
coverage must be identical to the coverage that the Qualified Beneficiary had immediately before the
Qualifying Event, or if the coverage has been changed, the coverage must be identical to the coverage
provided to similarly situated active employees who have not experienced a Qualifying Event (in other
words, similarly situated non -COBRA beneficiaries).
2. Who Can Become a Qualified Beneficiary?
In general, a Qualified Beneficiary can be:
(1) Any individual who, on the day before a Qualifying Event, is covered under the Arrangement
by virtue of being on that day either a covered Employee, the Spouse of a covered Employee,
or a Dependent child of a covered Employee. If, however, an individual who otherwise
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HRA SPD 010416
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qualifies as a Qualified Beneficiary is denied or not offered coverage under the Arrangement
under circumstances in which the denial or failure to offer constitutes a violation of applicable
law, then the individual will be considered to have had the coverage and will be considered a
Qualified Beneficiary if that individual experiences a Qualifying Event.
(2) Any child who is born to or placed for adoption with a covered Employee during a period of
COBRA continuation coverage, and any individual who is covered by the Arrangement as an
alternate recipient under a qualified medical support order. If, however, an individual who
otherwise qualifies as a Qualified Beneficiary is denied or not offered coverage under the
Arrangement under circumstances in which the denial or failure to offer constitutes a violation
of applicable law, then the individual will be considered to have had the coverage and will be
considered a Qualified Beneficiary if that individual experiences a Qualifying Event.The term
covered Employee" includes any individual who is provided coverage under the Arrangement
due to his or her performance of services for the employer sponsoring the Arrangement.
However, this provision does not establish eligibility of these individuals. Eligibility for Plan
coverage shall be determined in accordance with Plan Eligibility provisions.
An individual is not a Qualified Beneficiary if the individual's status as a covered Employee is
attributable to a period in which the individual was a nonresident alien who received from the
individual's Employer no earned income that constituted income from sources within the United States.
If, on account of the preceding reason, an individual is not a Qualified Beneficiary, then a Spouse or
Dependent child of the individual will also not be considered a Qualified Beneficiary by virtue of the
relationship to the individual. A domestic partner is not a Qualified Beneficiary.
Each Qualified Beneficiary (including a child who is born to or placed for adoption with a covered
Employee during a period of COBRA continuation coverage) must be offered the opportunity to make
an independent election to receive COBRA continuation coverage.
3. What is a Qualifying Event?
A Qualifying Event is any of the following if the Arrangement provided that the participant would lose
coverage (Le., cease to be covered under the same terms and conditions as in effect immediately
before the Qualifying Event) in the absence of COBRA continuation coverage:
(1) The death of a covered Employee.
(2) The termination (other than by reason of the Employee's gross misconduct), or reduction of
hours, of a covered Employee's employment.
(3)
The divorce or legal separation of a covered Employee from the Employee's Spouse. If the
Employee reduces or eliminates the Employee's Spouse's Plan coverage in anticipation of a
divorce or legal separation, and a divorce or legal separation later occurs, then the divorce or
legal separation may be considered a Qualifying Event even though the Spouse's coverage
was reduced or eliminated before the divorce or legal separation.
(4) A covered Employee's enrollment in any part of the Medicare program.
(5) A Dependent child's ceasing to satisfy the Arrangement's requirements for a Dependent child
(for example, attainment of the maximum age for dependency under the Arrangement).
If the Qualifying Event causes the covered Employee, or the covered Spouse or a Dependent child of
the covered Employee, to cease to be covered under the Arrangement under the same terms and
conditions as in effect immediately before the Qualifying Event (or in the case of the bankruptcy of the
Employer, any substantial elimination of coverage under the Arrangement occurring within 12 months
before or after the date the bankruptcy proceeding commences), the persons losing such coverage
become Qualified Beneficiaries under COBRA if all the other conditions of COBRA are also met. For
example, any increase in contribution that must be paid by a covered Employee, or the Spouse, or a
Dependent child of the covered Employee, for coverage under the Arrangement that results from the
occurrence of one of the events listed above is a loss of coverage.
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4. What Factors Should Be Considered When Determining to Elect COBRA Continuation
Coverage?
You should take into account that a failure to continue your group health coverage will affect your
rights under federal law. First, you can lose the right to avoid having pre-existing condition exclusions
applied by other group health plans if there is more than a 63 -day gap in health coverage and election
of COBRA continuation coverage may help you avoid such a gap. (These pre-existing condition
exclusions will only apply during Plan Years that begin before January 1, 2014.) Second, if you do not
elect COBRA continuation coverage and pay the appropriate premiums for the maximum time
available to you, you will lose the right to convert to an individual health insurance policy, which does
not impose such pre-existing condition exclusions. Finally, you should take into account that you have
special enrollment rights under federal law (HIPAA). You have the right to request special enrollment in
another group health plan for which you are otherwise eligible (such as a plan sponsored by your
Spouse's employer) within 30 days after Plan coverage ends due to a Qualifying Event listed above.
You will also have the same special right at the end of COBRA continuation coverage if you get
COBRA continuation coverage for the maximum time available to you.
5. What is the Procedure for Obtaining COBRA Continuation Coverage?
The Arrangement has conditioned the availability of COBRA continuation coverage upon the timely
election of such coverage. An election is timely if it is made during the election period.
6. What is the Election Period and How Long Must It Last?
The election period is the time period within which the Qualified Beneficiary must elect COBRA
continuation coverage under the Arrangement. The election period must begin not later than the date
the Qualified Beneficiary would lose coverage on account of the Qualifying Event and must not end
before the date that is 60 days after the later of the date the Qualified Beneficiary would lose coverage
on account of the Qualifying Event or the date notice is provided to the Qualified Beneficiary of her or
his right to elect COBRA continuation coverage.
Note: If a covered employee who has been terminated or experienced a reduction of hours qualifies for
a trade readjustment allowance or alternative trade adjustment assistance under a federal law called
the Trade Act of 2002, and the employee and his or her covered dependents have not elected COBRA
coverage within the normal election period, a second opportunity to elect COBRA coverage will be
made available for themselves and certain family members, but only within a limited period of 60 days
or less and only during the six months immediately after their group health plan coverage ended. Any
person who qualifies or thinks that he or she and/or his or her family members may qualify for
assistance under this special provision should contact the Pian Administrator or its designee for further
information.
The Trade Act of 2002 also created a new tax credit for certain TM -eligible individuals and for certain
retired employees who are receiving pension payments from the Pension Benefit Guaranty
Corporation (PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either
take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance,
including continuation coverage. If you have questions about these new tax provisions, you may call
the Health Coverage Tax Credit Consumer Contact Center toll-free at 1-866-628-4282. TTD/TTY
callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also available at
www.doleta.gov/tradeact/2002act_index.asp.
7. Is a Covered Employee or Qualified Beneficiary Responsible for Informing the Plan
Administrator of the Occurrence of a Qualifying Event?
The Arrangement will offer COBRA continuation coverage to Qualified Beneficiaries only after the Plan
Administrator or its designee has been timely notified that a Qualifying Event has occurred. The
Employer will notify the Plan Administrator or its designee of the Qualifying Event within 30 days
following the date coverage ends when the Qualifying Event is:
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HRA SPD 010416
Effective January 1, 2019
(1) the end of employment or reduction of hours of employment,
(2) death of the employee,
(3) commencement of a proceeding in bankruptcy with respect to the Employer, or
(5) enrollment of the employee in any part of Medicare,
IMPORTANT:
For the other Qualifying Events (divorce or legal separation of the employee and spouse or a
dependent child's losing eligibility for coverage as a dependent child), you or someone on your behalf
must notify the Plan Administrator or its designee in writing within 60 days after the Qualifying Event
occurs, using the procedures specified below. If these procedures are not followed or if the notice is
not provided in writing to the Plan Administrator or its designee during the 60 -day notice period, any
spouse or dependent child who loses coverage will not be offered the option to elect continuation
coverage. You must send this notice to the Plan Administrator or its designee.
NOTICE PROCEDURES:
Any notice that you provide must be in writing. Oral notice, including notice by telephone, is not acceptable. You
must mail, fax or hand -deliver your notice to the person, department or firm listed below, at the following address:
City of Eagle
660 East Civic Lane
Eagle, Idaho 83616
If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice you
provide must state:
• the name of the plan or plans under which you lost or are losing coverage,
• the name and address of the employee covered under the plan,
• the name(s) and address(es) of the Qualified Beneficiary(ies), and
• the Qualifying Event and the date it happened.
If the Qualifying Event is a divorce or legal separation, your notice must include a copy of the divorce decree or
the legal separation agreement.
Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability
extension.
Once the Plan Administrator or its designee receives timely notice that a Qualifying Event has occurred,
COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each Qualified
Beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may
elect COBRA continuation coverage for their spouses, and parents may elect COBRA continuation coverage
on behalf of their children. For each Qualified Beneficiary who elects COBRA continuation coverage,
COBRA continuation coverage will begin on the date that coverage would otherwise have been lost (if under
your coverage the COBRA period begins on the date of the Qualifying Event, even though coverage actually
ends later (e.g., at the end of the month) substitute the appropriate language, e.g. "on the date of the Qualifying
Event"). If you or your spouse or dependent children do not elect continuation coverage within the 60 -day
election period described above, the right to elect continuation coverage will be lost.
8. Is a Waiver Before the End of the Election Period Effective to End a Qualified Beneficiary's
Election Rights?
If, during the election period, a Qualified Beneficiary waives COBRA continuation coverage, the waiver
can be revoked at any time before the end of the election period. Revocation of the waiver is an
election of COBRA continuation coverage. However, if a waiver is later revoked, coverage need not be
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HRA SPD 010416
Effective January 1, 2019
provided retroactively (that is, from the date of the loss of coverage until the waiver is revoked).
Waivers and revocations of waivers are considered made on the date they are sent to the Plan
Administrator or its designee, as applicable.
9. Is COBRA Coverage Available If a Qualified Beneficiary Has Other Group Health Plan
Coverage or Medicare?
Qualified Beneficiaries who are entitled to elect COBRA continuation coverage may do so even if they
are covered under another group health plan or are entitled to Medicare benefits on or before the date
on which COBRA is elected. However, a Qualified Beneficiary's COBRA coverage will terminate
automatically if, after electing COBRA, he or she becomes entitled to Medicare or becomes covered
under other group health plan coverage (but only after any applicable preexisting condition exclusions
of that other plan have been exhausted or satisfied).
10. When May a Qualified Beneficiary's COBRA Continuation Coverage Be Terminated?
During the election period, a Qualified Beneficiary may waive COBRA continuation coverage. Except
for an interruption of coverage in connection with a waiver, COBRA continuation coverage that has
been elected for a Qualified Beneficiary must extend for at least the period beginning on the date of
the Qualifying Event and ending not before the earliest of the following dates:
(1) The last day of the applicable maximum coverage period.
(2) The first day for which Timely Payment is not made to the Arrangement with respect to the
Qualified Beneficiary.
(3)
The date upon which the Employer ceases to provide any group health plan (including a
successor plan) to any employee.
(4) The date, after the date of the election, that the Qualified Beneficiary first becomes covered
under any other Plan that does not contain any exclusion or limitation with respect to any
pre-existing condition, other than such an exclusion or limitation that does not apply to, or is
satisfied by, the Qualified Beneficiary.
(5)
The date, after the date of the election that the Qualified Beneficiary first enrolls in the
Medicare program (either part A or part B, whichever occurs earlier).
(6) In the case of a Qualified Beneficiary entitled to a disability extension, the later of:
(a) (i) 29 months after the date of the Qualifying Event, or (ii) the first day of the month
that is more than 30 days after the date of a final determination under Title II or XVI of
the Social Security Act that the disabled Qualified Beneficiary whose disability
resulted in the Qualified Beneficiary's entitlement to the disability extension is no
longer disabled, whichever is earlier; or
(b) the end of the maximum coverage period that applies to the Qualified Beneficiary
without regard to the disability extension.
The Arrangement can terminate for cause the coverage of a Qualified Beneficiary on the same basis
that the Arrangement terminates for cause the coverage of similarly situated non -COBRA
beneficiaries, for example, for the submission of a fraudulent claim.
In the case of an individual who is not a Qualified Beneficiary and who is receiving coverage under the
Arrangement solely because of the individual's relationship to a Qualified Beneficiary, if the
Arrangement's obligation to make COBRA continuation coverage available to the Qualified Beneficiary
ceases, the Arrangement is not obligated to make coverage available to the individual who is not a
Qualified Beneficiary.
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HRA SPD 010416
Effective January 1, 2019
11. What Are the Maximum Coverage Periods for COBRA Continuation Coverage?
The maximum coverage periods are based on the type of the Qualifying Event and the status of the
Qualified Beneficiary, as shown below.
(1) In the case of a Qualifying Event that is a termination of employment or reduction of hours of
employment, the maximum coverage period ends 18 months after the Qualifying Event if
there is not a disability extension and 29 months after the Qualifying Event if there is a
disability extension.
(2) In the case of a covered Employee's enrollment in the Medicare program before experiencing
a Qualifying Event that is a termination of employment or reduction of hours of employment,
the maximum coverage period for Qualified Beneficiaries other than the covered Employee
ends on the later of:
(a) 36 months after the date the covered Employee becomes enrolled in the Medicare
program; or
(b) 18 months (or 29 months, if there is a disability extension) after the date of the
covered Employee's termination of employment or reduction of hours of employment.
(3) In the case of a Qualified Beneficiary who is a child born to or placed for adoption with a
covered Employee during a period of COBRA continuation coverage, the maximum coverage
period is the maximum coverage period applicable to the Qualifying Event giving rise to the
period of COBRA continuation coverage during which the child was born or placed for
adoption.
(4) In the case of any other Qualifying Event than that described above, the maximum coverage
period ends 36 months after the Qualifying Event.
12. Under What Circumstances Can the Maximum Coverage Period Be Expanded?
If a Qualifying Event that gives rise to an 18 -month or 29 -month maximum coverage period is followed,
within that 18- or 29 -month period, by a second Qualifying Event that gives rise to a 36 -months
maximum coverage period, the original period is expanded to 36 -months, but only for individuals who
are Qualified Beneficiaries at the time of and with respect to both Qualifying Events. In no
circumstance can the COBRA maximum coverage period be expanded to more than 36 -months after
the date of the first Qualifying Event. The Plan Administrator must be notified of the second qualifying
event within 60 days of the second qualifying event. This notice must be sent to the Plan Administrator
or its designee and in accordance with the procedures above.
13. How Does a Qualified Beneficiary Become Entitled to a Disability Extension?
A disability extension will be granted if an individual (whether or not the covered Employee) who is a
Qualified Beneficiary in connection with the Qualifying Event that is a termination or reduction of hours
of a covered Employee's employment, is determined under Title II or XVI of the Social Security Act to
have been disabled at any time during the first 60 days of COBRA continuation coverage. To qualify
for the disability extension, the Qualified Beneficiary must also provide the Plan Administrator with
notice of the disability determination on a date that is both within 60 days after the date of the
determination and before the end of the original 18 -month maximum coverage. This notice must be
sent to the Plan Administrator or its designee and in accordance with the procedures above.
14. Does the Arrangement Require Payment for COBRA Continuation Coverage?
For any period of COBRA continuation coverage under the Arrangement, Qualified Beneficiaries who
elect COBRA continuation coverage may be required to pay up to 102% of the applicable premium
and up to 150% of the applicable premium for any expanded period of COBRA continuation coverage
covering a disabled Qualified Beneficiary due to a disability extension. Your Plan Administrator will
inform you of any costs. The Arrangement will terminate a Qualified Beneficiary's COBRA continuation
coverage as of the first day of any period for which timely payment is not made.
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HRA SPD 010416
Effective January 1, 2019
15. Must the Arrangement Allow Payment for COBRA Continuation Coverage to Be Made in
Monthly Installments?
Yes. The health coverage is also permitted to allow for payment at other intervals.
16. What is Timely Payment for Payment for COBRA Continuation Coverage?
Timely Payment means a payment made no later than 30 days after the first day of the coverage
period. Payment that is made to the Arrangement by a later date is also considered Timely Payment if
either under the terms of the Arrangement, covered employees or Qualified Beneficiaries are allowed
until that later date to pay for their coverage for the period or under the terms of an arrangement
between the Employer and the entity that provides benefits on the Employer's behalf, the Employer is
allowed until that later date to pay for coverage of similarly situated non -COBRA beneficiaries for the
period.
Notwithstanding the above paragraph, the Arrangement does not require payment for any period of
COBRA continuation coverage for a Qualified Beneficiary earlier than 45 days after the date on which
the election of COBRA continuation coverage is made for that Qualified Beneficiary. Payment is
considered made on the date on which it is postmarked to those providing coverage.
If Timely Payment is made to the Arrangement in an amount that is not significantly Tess than the
amount the Arrangement requires to be paid for a period of coverage, then the amount paid will be
deemed to satisfy the Arrangement's requirement for the amount to be paid, unless the Arrangement
notifies the Qualified Beneficiary of the amount of the deficiency and grants a reasonable period of
time for payment of the deficiency to be made. A "reasonable period of time" is 30 days after the notice
is provided. A shortfall in a Timely Payment is not significant if it is no greater than the lesser of $50 or
10% of the required amount.
17. Must a Qualified Beneficiary Be Given the Right to Enroll in a Conversion Health Plan at the
End of the Maximum Coverage Period for COBRA Continuation Coverage?
If a Qualified Beneficiary's COBRA continuation coverage under a group health plan ends as a result
of the expiration of the applicable maximum coverage period, the Arrangement will, during the 180 day
period that ends on that expiration date, provide the Qualified Beneficiary with the option of enrolling
under a conversion health plan if such an option is otherwise generally available to similarly situated
non -COBRA beneficiaries under the Arrangement. If such a conversion option is not otherwise
generally available, it need not be made available to Qualified Beneficiaries.
IF YOU HAVE QUESTIONS
If you have questions about your COBRA continuation coverage, you should contact the Plan Administrator or
its designee. For more information about your rights under ERISA, including COBRA, the Health Insurance
Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest
Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration
(EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's
Web site at www.dol.gov/ebsa.
KEEP YOUR PLAN ADMINISTRATOR INFORMED OF ADDRESS CHANGES
In order to protect your family's rights, you should keep the Plan Administrator informed of any changes in the
addresses of family members. You should also keep a copy, for your records, of any notices you send to the
Plan Administrator or its designee.
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HRA SPD 010416
Effective January 1, 2019