HomeMy WebLinkAboutRestated and Revised Plan Document
RESTATED AND REVISED PLAN DOCUMENT
FOR
FLEXIBLE BENEFITS PLAN
FOR EMPLOYEES OF
CITY OF BOZEMAN
PLAN EFFECTIVE DATE:
AUGUST 1,1995
RESTATED AND REVISED PLAN DOCUMENT EFFECTIVE DATE:
December 19, 2005
SELECTED PROVISION RETROACTIVE EFFECTIVE DATE:
AUGUST 1, 1995
GROUP NUMBER:
0005783
EMPLOYER 10 NUMBER:
81-6001238
PLAN NUMBER:
501
TABLE OF CONTENTS
INTRODUCTION.......... ........... ...... ............................................. ,....... ........ ..................... 1
SCHEDULE OF AVAILABLE BENEFITS ........................................................................1
Before-Tax Premium Payments.................. ..... ...... ..... ..... .... ....... ..... ....... ...........,..1
Flexible Spending Accounts ....... .,................ .......... .......,........ .... ... ...... .... ........,....1
DE FIN IT IONS. . . ... .. . ... . .. . . . .... .... .. . . . . . .. .. . . . . . .. . .. . .. . . . . . . .. . . . .. . . .. . .. . . .. . .. .. . . . . . . . , . . .. .. .. . , . . . . . .., . . . . ... . . 2
ELIGIBILITY PROVISIONS AND ELECTION OF BENEFITS ..................................__. 6
Eligibility...................................................................................,....,................ __.....6
When Coverage Begins.................................................................................,,,.... 6
Elected Benefits...........,.,...................................................................................... 6
Benefit Cost and Funding ..............................................,......................................7
Maximum Employer Contributions.......................................,................................ 7
Funding by Employer Contributions....................................................,...."........... 8
Calculation of Benefit Credit.. ....... ................. .... ....................... .............. ..... ..,....,.8
Qualified Plan Expenses for Elected Benefits............."."""................................. 8
Benefit Credits Remaining When Coverage Ends,............................................... 8
BENEFIT ELECTION........ ............. ........................................................ .........................8
Benefit Election for New Participants.................................."....".......................... 8
Annual Election.. ...................... ............. ..,...,.,........ .................. .......,."... ."'" ....,.,..8
If A Participant Does Not Elect Annual Participation............................................. 9
BENEFIT ELECTION CHANGES.............................................................. ......................9
Changes in Elected Benefits Prohibited During the Plan Year "........................... 9
Family Status Changes...... .... ...................................... ..... ........... ...,......,............ 10
Employment Status Changes................................"........................................... 1 0
Insurance Cost or Coverage Changes ............................................................... 11
Other Situations Which May Permit Mid-Year Election Changes ......................, 11
Changes by the Plan Administrator ................"..................................................11
Benefit Summaries......,................. --............,...,..,............................................... 12
TERMINATION........................,..............................,.,.............,..,..........,........................ 13
When Participation Ends. .,.... ....... ........,..,... ,. ................................................,.,.. 13
Reinstatement....................................... ...... ................. .." .................., .. ....... ...,.. 13
CONTINUED COVERAGE AFTER TERMINATION .................,......__,.......................... 13
Notification Responsibilities..........................,....,....,..........,................................ 14
Election of Coverage.........................................................,.,.............................. 14
Monthly Contribution Payments..............................."......................................... 15
When COBRA Continuation Coverage Ends...................................................... 15
FAMILY AND MEDICAL LEAVE ACT OF 1993............................................................ 16
FLEXIBLE SPENDING ACCOUNTS ............ ........ ............ ............................................. 18
Flexible Spending Accounts ........ ......., '..",.. ...., ...... ..... ... ..,...,. ... ........... ... ....., .....18
Establishment of Accounts ............ .... ...... .... ............ ... ........ ,... ,..,.. ... .... .......,...,. ,.18
Period of Coverage .................... ......... ..,.., ..... .... ....,................... ... ... ...... .............18
Crediting of Accounts .... ..... ......................,.............. ........ ........................ ........... 18
Debiting of Accounts.................................,...,...,.,............................................... 18
Unused Contributions Forfeited...............,........,............................................... 19
No I nteres t .... .. .... ... .. .... .. .. . .. .... .. .. .. .. . , .. .. . . .. .."......,......".......,..,....."......"............ 19
DEPENDENT CARE ASSISTANCE PLAN .................."..............................................19
Eligible Dependent for Dependent Care Expenses............................................ 19
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City of Bozeman Full Flex Plan Document
Qualifying Dependent Care Expenses.......................................,...................... 19
Reimbursement of Dependent Care Expenses .... ........ .... ............ .... ..... ...... .......20
Annual Maximum Contribution for Dependent Care Assistance ......................... 20
Form 2441 ..........................................".................".....,.....,............,."............... 21
MEDICAL EXPENSE REIMBURSEMENT PLAN......_.................... _..............................21
Annual Benefit ........................................................,..................,................,...... 21
U nifo rm Coverage ..................................................,.............,....,.....,.,................ 21
Annual Maximum Reimbursements...................................................,................ 21
Reimbursement Requests ...... ...............,...... ................................."......,............21
REIMBURSEMENT REVIEW PROCEDURES...,...............,. ......................................... 22
Accounting for Contributions and Reimbursement Requests. .._.............. ........... 22
Reimbursement Processing....... .................,....... ............,...................................22
Den ial Of A Reimbursement Request........................................ __. __ ....................22
PLAN ADMINiSTRATION.........,.........,......,.......,.......,......,. ....................... .........,......... 23
Administration.................................. ......,......................, ......... .................,.......... 23
No Employment Contract...................,.. ........... ...................,.,.......,....,...............,24
Severability...,.. ..........,.......... ...............,........,. ..... ...............................................24
Plan Amendments, Modification or Termination By the Employer ............ .......24
Benefits Solely F rom Plan Assets... _.. .................... ......... ..............., .. .............. .... 25
Non-Assignability of Rights under a Flexible Spending Account ........................25
No Guarantees of Tax Consequences..............,................................................ 25
Indemnification of Company by Participants....................................................... 26
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City of Bozeman Full Flex Plan Document
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INTRODUCTION
Effective August 1, 1995, and revised and restated November 28, 2006. with a selective
provision retroactive effective date of August 1. 1995, City of Bozeman (Employer) adopts this
Cafeteria Plan to allow options to the Employees between cash and benefits as addressed
below and to retroactively recognize the Employees selection of such options in the past.
Purpose of Plan. The purpose of this Plan is to provide eligible Employees of City of Bozeman
a choice between taxable income (cash or taxable benefits) or before~tax benefits under the
Medical Related. Group Term Life Insurance, Dependent Care and Medical Expense
Reimbursement Plans maintained by City of Bozeman. if the same are available under this
Plan, and shown in the Schedule of Available Benefits, Additionally, this Plan provides
retroactive recognition of intended and effected Employee elections of before-tax benefits with
regard to Medical Related Plans from August 1, 1995 to present to the extent such formal
election was not previously made.
Cafeteria Plan Status. This Plan is intended to qualify as a "Cafeteria Plan" under Section 125
of the Internal Revenue Code of 1986, as amended, and shall be interpreted in a manner
consistent with the requirements of Section 125.
SCHEDULE OF AVAILABLE BENEFITS
The following benefits are available to become Elected Benefits under this Plan if elected by the
Participant:
Before~Tax Premium Payments For:
Medical Related Plan Benefits, which includes any group health care, dental or vision care plan
provided by premiums to and contract with an insurance carrier or group health plan.
Qualified Group Term Life Insurance. which is any policy of Life Insurance available as part of
the Employer's Group Term life Insurance benefit Plan, provided, however. that the qualified
face amount of any such policy is fifty thousand dollars ($50,000) or less. Premium for
coverage in excess of this maximum, if any, is not qualified.
Flexible Spendina Accounts For:
Dependent Care Assistance Plan. which is a benefit plan in which a Flexible Spending Account
is established from which specified Incurred expenses for dependent care may be reimbursed
(subject to reimbursement maximums and other reasonable conditions).
Medical Expense Reimbursement Plan, which is a benefit plan in which a Flexible Spending
Account is established from which specified Incurred expenses for health care may be
reimbursed (subject to reimbursement maximums and other reasonable conditions),
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City of Bozeman Full Flex Plan Document
DEFINITIONS
Except when otherwise indicated by context. any masculine terms used herein will also include
the feminine, and the definition of any term in the singular will include the plural.
"Annual Election Period" Of "Election Period" means the period from December 1 through
December 31 of each year, during which an Employee and the Employee's eligible Dependents
who are not covered under this Plan, may elect Participant or Dependent coverage on an
approved benefit election form provided by the Plan.
"Benefit Credit" means the amount the Participant elects to have deducted from his or her
compensation per pay period, as stated in the Compensation Reduction Agreement, to be used
for payment of the Premium for the Medical Related Plans and/or the Group Term Life
Insurance Plan under Employer's Plan(s). In no event will the Benefit Credit exceed the
Premium
"COBRA" means Title X of The Consolidated Omnibus Budget Reconciliation Act of 1985, as
amended.
"COBRA Continuation Coverage" means the coverage provided under the provisions of The
Consolidated Omnibus Budget Reconciliation Act of 1985 and its amendments.
"Code" means the Internal Revenue Code of 1986, and any applicable amendments and any
Treasury regulation applicable to the section or subsection.
"Compensation" means earned income, wages, fees, commissions, overtime pay, bonuses,
tips, extraordinary compensation and all other earnings of an Employee which are reportable on
Form W-2.
"Compensation Reduction Agreemene means the voluntary agreement of an Employee to
have deductions made from his or her compensation for the forthcoming Plan Year, (or portion
thereof. if the Employee becomes eligible after the beginning of the Plan Year), and to have the
compensation so deducted applied toward all or a portion of the benefits provided by this Plan.
The Compensation Reduction Agreement is incorporated into the benefit election form,
"Covered Person" means any Participant or Dependent of a Participant meeting the eligibility
requirements for coverage and properly enrolled for coverage as specified in the Plan,
"Dependent." For purposes of the Medical Related Plans or Group Term Life Insurance Plan,
Dependent means any eligible individual set out in the applicable plan document of the Medical
Related Plans or Group Term Ufe Insurance Plan of the Employer, as amended or replaced
from time to time. For purposes of the Medical Expense Reimbursement Plan, an eligible
Dependent means a Tax Dependent for the tax year during which expenses were Incurred. For
purposes of the Dependent Care Assistance Plan, an eligible Dependent means a Tax
Dependent for the tax year during which expenses were Incurred who is (a) a Dependent under
age of thirteen (13) with respect to whom a parent is entitled to a Dependent child exemption
under the Code or (b) a spouse or any other Dependent of the Participant who is incapable of
self-care due to a physical or mental handicap.
City of Bozeman Full Flex Plan Document
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"Dependent Care" means services and assistance and directly related expenses for the
supervision and custodial care of a Participant's Dependent. during any time that said
Dependent is not being directly cared for by the Participant, except when provided by a school
or other educational institution, which services, assistance or directly related expenses allow the
Participant or the Participant's spouse to be gainfully employed.
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"Dependent Care Assistance Account" means the custodial account maintained and utilized
for the sole purpose of accounting for funds and paying benefits in accordance with the terms
and conditions of the Dependent Care Assistance Plan.
"Dependent Care Assistance Plan" means the Employer's Dependent Care Assistance Plan
when in force and as amended from time to time.
"Dependent Care Expenses" mean expenses Incurred by the Participant which are Incurred for
the care of a Dependent of the Participant, or which are Incurred for services rendered by a
Dependent Care Service Provider, and are Incurred to enable the Participant to be gainfully
employed for any period during which a Participant has one or more Dependents. Dependent
Care Expenses will not include expenses Incurred for services outside the Participant's
household for the care of any person except a Dependent who is under the age of thirteen (13)
years, or any other Dependent who regularly spends at least eight (8) hours per day in the
Participant's home. Dependent Care Expenses will be deemed to be Incurred at the time when
the services to which the expenses relate are rendered, not when they are paid for.
"Dependent Care Service Provider" means a Qualifying Day Care Center or any person who
provides Dependent care except for a Participant's spouse, a Dependent of the Participant or
Participant's spouse, or a child of the Participant who is under the age of nineteen (19) years on
the ending date of the Plan Year during which the Dependent Care Expenses were Incurred,
"Elected Benefits" means whichever of the following benefits are in force under the Employer's
benefit plan, as amended from time to time, and elected by the Participant and shown on the
Schedule of Benefits:
(A) Benefits available under Medical Related Plans
(8) Benefits available under the Group Term Life Insurance Plan
(C) Benefits available under the Dependent Care Assistance Plan
(0) Benefits available under the Medical Expense Reimbursement Plan
"Employee" means an individual that the Employer classifies as a common-law employee and
who is paid by the Employer, but does not include any leased employee (including but not
limited to those individuals defined in Code 3414(n)), or any individual classified by the
Employer as a contract worker, independent contractor, temporary employee or casual
employee, whether or not any such persons are on the Employer's W-2 payroll, or any individual
who performs services for the Employer but who is paid by a temporary employment agency
under a professional employer arrangement as defined in 39-8-102(8)(a) MeA or other
employment agency, or any employee covered under a collective bargaining agreement.
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City of Bozeman Full Flex Plan Document
"Employer" means City of Bozeman, a governmental entity organized under the laws of the
State of Montana, or any affiliated agencies or boards that have adopted this Plan for its
Employees.
"Flexible Spending Account" means a custodial account established under a benefit plan in
which an amount specified by the Participant is contributed through a Compensation Reduction
Agreement on a before-tax basis (along with Employer funds, if the Employer contributes to the
account) into an account from which specified Incurred expenses may be reimbursed, subject to
reimbursement maximums and other reasonable conditions, in accordance with the terms and
conditions of the Employer's Dependent Care Assistance Plan and/or Medical Expense
Reimbursement Plan when in force and as amended or replaced from time to time.
"Group Term Life Insurance Plan" means the Employer's Group Term Ufe Insurance Plan,
when in force and as amended or replaced from time to time.
"HIPAA" means the Health Insurance Portability and Accountability Act of 1996 and any
applicable amendments.
"Incurred" means the date Covered Services are provided, regardless of the date payment is
rendered for the services.
"Medical Care Reimbursement Account" means the custodial account maintained and utilized
for the sole purpose of accounting for funds and paying benefits in accordance with the terms
and conditions of the Employer's Medical Expense Reimbursement Plan when in force and as
amended or replaced from time to time.
"Medical Expense Reimbursement Plan" means the Employer's Medical Expense
Reimbursement Plan, as amended from time to time.
"Medical Related Plan" means any group health care, dental or vision care plan provided by
premiums to and contract with a third party insurer that is in force for Employees of the
Employer and as may be amended or replaced from time to time at the discretion of the
Employer.
"Medicare" means the programs established by Title I of Public Law 89-98 (79 Statutes 291), as
amended, entitled "Health Insurance for the Aged Act," and which includes Parts A and Band
title XVIII of the Social Security Act (as amended by Public Law 89-97, 79) as amended from
time to time.
"Named Fiduciary" means the Plan Administrator which has the authority to control and
manage the operation and administration of the Plan, and will be responsible for complying with
all of the requirements of applicable law.
"Participant" means an Employee of the Company who is eligible for, enrolled in and covered
under the Plan
"Plan" or "Flex Plan" means City of Bozeman Flexible Benefits Plan as set forth herein,
together with any and all amendments, supplements and appendices and any other relevant
documents pertinent to its operation and maintenance,
CIty of Bozeman FUll Flex Plan Document
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"Plan Administrator" means the Employer and!or its designee which is responsible for the day.
to-day functions and management of the Plan. The Plan Administrator may employ persons or
firms to process claims and perform other Plan-connected services, The Employer will be
deemed to be the Plan Administrator of the Plan unless by action of the Board of Directors, the
Employer designates an individual or committee to act as Plan Administrator of the Plan.
"Plan Supervisor" means the person or firm employed by the Plan to provide consulting
services to the Plan in connection with the operation of the Plan and any other functions.
including the processing and payment of claims. The Plan Supervisor for this Plan is
Intermountain Administrators, Inc. The Plan Supervisor provides ministerial duties only,
exercises no discretion over Plan assets and will not be considered a fiduciary as defined by
applicable law.
"Plan Year" means a period of time commencing with the effective date of this Plan or the Plan
anniversary date, and terminating on the date of the next succeeding Plan anniversary date.
The Plan anniversary date will be January 1st of each year.
"Premium" means the amount that the Participant must pay as a requirement for participation in
the Employer's Medical Related Plans and/or Group Term Life Insurance Plan by Participant
and!or Participant's Dependents during any Plan Year or part thereof for which the Participant is
eligible for said Plan(s).
"Premium Payment Account" means a bookkeeping record established and maintained by the
Plan, setting forth a Participant's Benefit Credits for a Plan Year.
"QMCSO" means Qualified Medical Child Support Order.
"Qualified Beneficiary" means an employee, former employee or dependent of an employee or
former employee who is eligible to continue coverage under the Plan in accordance with
applicable provisions of Title X of COBRA in relation to QMCSQ's.
Qualified Beneficiary will also include a child born to, adopted by or placed for adoption with an
employee or former employee at any time during COBRA continuation coverage,
"Qualified Life Insurance" means any policy of Life Insurance available as part of the
Employer's Group Life Insurance benefit plan for Group Term Life Insurance, provided,
however. that the qualified face amount of any such policy must be fifty thousand dollars
($50,000) or less. Premium for coverage in excess of this maximum, if any, is not qualified
"Qualifying Day Care Center" means a day care center which provides full.time or part-time
care on a regular basis, for more than six (6) individuals. other than individuals who regularly
live at the day care location, and charges a fee or receives payment or grant funds for its
services, whether for profit or not. Said day care center must comply with all laws and
regulations of the jurisdictions in which it is located.
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City of Bozeman Full Flex Plan Document
"Qualifying Medical Care Expense" means an expense Incurred by a Participant or by the
Participant's spouse if said spouse files a joint federal income tax return (married filing jointly)
with Participant for the tax year in which the othelWise Qualifying Medical Care Expense is
Incurred, or which is Incurred by the Dependent of a Participant. for medical care as defined by
the Code, but only to the extent that the Participant or other person incurring the expense is not
reimbursed for the expense through insurance or otherwise (other than under the Plan).
Qualifying Medical Care Expense will also mean premium expenses for health coverage offered
through the Employer.
Qualifying Medical Care Expense will not mean/include premiums for health insurance or other
health coverage, which is not offered by the Employer; for medical care for a spouse who files a
federal income tax return separately from the Participant (married filing separately) for the tax
year during which the otherwise Qualifying Medical Care Expense is Incurred, or expenses
solely for elective cosmetic surgical procedures.
"Spouse" means a person of the opposite sex to whom the Participant is legally married
according to the laws of the state in which the Participant resides, during the time periods
relevant to the references to "spouse" contained in this Plan,
"Tax Dependent" means any person who can be claimed by the Participant for Federal Income
Tax purposes according to the Code.
ELIGIBILITY PROVISIONS AND ELECTION OF BENEFITS
Eligibility. For purposes of benefits under the Medical Related Plans and Group Term Life
Insurance Plan, if available, an Employee is eligible to participate in the benefits offered by this
Plan on the date that the Employee becomes eligible for benefjts under the terms of the
Employer's group health, and/or medical and/or life insurance plan, as amended or replaced
from time to time. For purposes of benefits under the Medical Expense Reimbursement Plan
and Dependent Care Assistance Plan, if available, an Employee is eligible to participate in the
benefits offered by this Plan on date of hire, and when he or she files the required election forms
and Compensation Reduction Agreement as a new Participant or during an Annual Election
Period in accordance with procedures established under the Plan.
When Coverage Begins. To become a Participant for Elected Benefits, the Employee must:
1. Be eligible as described in this Plan; and
2. Submit a completed benefit election form and Compensation Reduction Agreement
described in this Plan; and
3. Pay, when due, the pro-rata portion of the premium for that benefit by reduction of
compensation under a Compensation Reduction Agreement.
The period of coverage begins on the first day of participation and, as each pay-period's portion
of the premium is paid, extends to the end of the year after the full annual premium is paid.
Benefit coverage does not extend to a period for which no premium has been paid.
Elected Benefits. A Participant may choose, under this Plan, to receive his or her full
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City of Bozeman Full Flex Plan Document
compensation for any Plan Year in taxable income, which includes a taxable benefit with regard
to any Medical Related Plan Participant contributions if Participant does not elect to participate
in such plan on a .pre-tax basis, or to have a portion of his or her compensation applied by the
Employer on a pre-tax basis toward the Premium or contribution for Elected Benefits. If a
Participant chooses to have a portion of compensation applied to the Premium on a pre-tax
basis, which includes any deemed selection of pre-tax participation, the Participant's
Compensation will be reduced and the amount deducted will be applied by the Employer, on
behalf of the Participant, to pay the Participant's share of the costs (premiums) for Elected
Benefits on a pre-tax basis. The balance of said costs, if any, may be paid by the Employer, at
the Employer's option, with Employer contributions. If a Participant chooses not to participate in
any Medical Related Plan on a pre-tax basis said participant shall be considered to have elected
to participate in the Medical Related Plan on a post-tax basis and to make his or her respective
contributions toward said benefits on an after-tax basis,
The following, when made available by the Employer, are Elected Benefits:
1, Benefits available under Medical Related Plans;
2. Benefits available under the Group Term Life Insurance Plan;
3, Benefits available under the Dependent Care Assistance Plan; and/or
4. Benefits available under the Medical Expense Reimbursement Plan.
While the election to receive one or more of the benefits described above may be made under
this Plan, the benefits for the Medical Related Plans and the Group Term Life Insurance Plan
will be provided not by this Plan but by the plan provisions of the Medical Related Plans and the
Group Term Ufe Insurance Plan as set out and described in the respective Plan Documents or
insurance contracts, if applicable, The terms and conditions of the Dependent Care Assistance
Plan and the Medical Expense Reimbursement Plan are set out herein.
Benefit Cost and Funding. Before the beginning of each Plan Year, the Employer will
establish the Employees' Premium amounts which will be the amount of the Employee's share
of the annual cost for each Elected Benefit under the Employer's Medical Related and Group
Term Life Insurance Plans, Significant changes in these costs during the Plan Year may permit
a change of election, as described in this Plan, For the convenience of Participants, this annual
Premium will be pro~rated and deducted during designated pay periods. The full annual
Premium will be paid by the Participant according to the Compensation Reduction Agreement
unless the Plan or Elected Benefit is terminated by the Employer before the end of the Plan
Year, or the Participant terminates employment, or the Participant ceases to be eligible before
the end of the Plan Year.
At the discretion of the Employer, and with no guarantee of continuation, the Employer may
decide to make contributions on a nondiscriminatory basis to similarly situated PartiCipants.
Subject to the terms and conditions of the Elected Benefits, the Employer will determine the
method of funding each Elected Benefit during the Benefit election described in this Plan.
Maximum Employer Contributions. The amount of Employer contributions, if any, will be
established by the Employer no later than thirty (30) days prior to the first day of any Plan year.
If the Employer makes contributions under this Plan, the maximum amount of Employer
contributions under the Plan for any Participant will be the sum of (a) the maximum amounts
which the Participant may receive in the form of Dependent Care Assistance under this Plan
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City of Bozeman Full Fie. Plan Document
and as Medical Reimbursements under this Plan, and (b) the costs from time to time of the most
expensive benefits available to the Participant under the Medical Related and Group Term Life
Insurance Plans in force (including the portion of such costs payable with Employer
contributions). The sum of these Employer contributions cannot exceed the sum of
compensation reductions elected by the Participant under this Plan.
Funding by Employer Contributions. When the Employer makes contributions to fund, or
partially fund, the premiums for any Medical Related Plan coverage, such contribution will be
made directly to the applicable insurance carrier or group health plan administrator. If the
Employer makes contributions to fund, or partially fund, any Flexible Spending Account benefit
under this Plan, those contributions will be credited to a Participant's applicable benefit account
on each payday of each Plan Year for which the Employer contributions are established.
Employer contributions not used during the Plan Year in which contributed will be used for any
qualified purpose determined by the Employer. Employer contributions, if any, shall cease upon
termination of employment.
Calculation of Benefit Credit. The perNpay-period Benefit Credit will be established by dividing
the Participant's Premium by the number of pay periods during the Plan Year or part thereof
during which the Participant is eligible for and receiving benefits under this Plan, This amount
may be reduced by any Premium payments or contributions made by Employer on behalf of the
Participant during each applicable pay period,
Qualified Plan Expenses for Elected Benefits. The Benefit Credit may be used only for credit
against the Premium.
Benefit Credits Remaining When Coverage Ends. Any unused Benefit Credits that remain
after termination of benefits under this Plan will be refunded to the Participant who contributed
them.
BENEFIT ELECTION
Benefit Election for New Participants. When an Employee becomes eligible to be a
Participant under this Plan, the Plan Administrator will provide the written election forms and
Compensation Reduction Agreement(s) described in this Plan to the Employee. If the
Employee is eligible for and desires one or more of the benefits shown in the Schedule of
Available Benefits for the balance of the Plan Year, the Employee will so specify on the election
forms and will agree to a reduction in Compensation as provided in this Plan. The election
forms must be completed and returned to the Plan Administrator on or before the beginning of
the first pay-period for which the Participant's Compensation Reduction Agreement will apply.
Annual Election. Elections must be made annually to allow the Plan Participant to determine
the appropriate contribution amount for the following Plan Year.
Approximately thirty (30) days before the beginning of each Plan Year, the Plan Administrator
will provide any required election formes) and a Compensation Reduction Agreement to each
eligible Employee. The election formes) will be effective as of the first day of the Plan Year.
Each Participant who desires one or more of the benefits shown on the Schedule of Available
Benefits for the upcoming Plan Year must (1) decide which benefits to elect, (2) decide how
much compensation should go toward each benefit, and (3) complete the appropriate election
formes) and Compensation Reduction Agreement.
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City of Bozeman Full Flex Plan Document
If a Participant elects the Medical Related Plans and/or Group Term Life Insurance Plan, the
amount deducted under the Compensation Reduction Agreement will be applied by the
Employer, on behalf of the Participant to pay Participant's share of the costs (premiums), The
amount deducted will be equal to the premium for the Participant's share of the cost of the
optional benefit, and will be adjusted automatically in the event of a change in such cost. The
balance of said costs, if any, may be paid by the Employer, if the Employer so elects, with
Employer contributions.
If a Participant elects the Dependent Care Assistance Plan or Medical Expense Reimbursement
Plan, the amount deducted under the Compensation Reduction Agreement will be the amount
elected by the Participant, subject to the limitations of the Dependent Care Assistance Plan and
the Medical Expense Reimbursement Plan, and will be credited by the Employer to a
reimbursement account in accordance with the terms and conditions of the Dependent Care
Assistance Plan or Medical Expense Reimbursement Plan, respectively.
If A Participant Does Not Elect Annual Participation. An eligible Employee who does not
return a completed election form and Compensation Reduction Agreement to the Plan
Administrator on or before the specified due date for the Plan Year in which the Employee
becomes eligible as a Participant will be deemed to have elected to receive his or her full
compensation in taxable income which will include receipt of a taxable benefit regarding post-
tax contributions made through any Medical Related Plan and to have elected not to otherwise
participate for the Plan Year or part thereof for which the Employee failed to return a completed
election form, provided this failure to elect relates to an eligible Employee's initial election. To
the extent an eligible Employee does not return a completed election form and Compensation
Reduction Agreement in any year following the Employee's initial election, the Employee's most
recent election shall remain valid and carry-over to the following year, unless affirmatively
changed by the Employee.
Deemed Elections. To the extent any eligible Employee failed to formally elect to receive
benefits offered under any Medical Related Plan prior to the date this Restated Plan is adopted,
but actually received such benefits on a pre-tax basis, such objective indication of intent to elect
such benefits on a pre-tax basis shall be respected and said Employee shall be deemed to have
made a proper and timely election of such benefits on a pre-tax basis as opposed to electing to
receive such benefits on an after-tax basis.
BENEFIT ELECTION CHANGES
Changes in Elected Benefits Prohibited During the Plan Year. Except as provided below, a
Participant's election to participate in this Plan is irrevocable for the duration of the Plan Year to
which it relates. This means that except for the events described, once a PartIcipant has
elected to participate for the Plan Year and agreed under a Compensation Reduction
Agreement to have before-tax deductions for Elected Benefits, the Participant may not change
the following for the duration of the Plan Year:
1. The Participant's participation in this Plan,
2, The annual benefit amount Participant elected, or
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City of Bozeman Full Flex Plan Document
3, The Participant's Salary Reduction amount
A Participant may revoke or change a benefit election during a Plan Year and make a new
election for the remaining portion of the Plan Year effective as of the first day of the month
following the revocation, only if the revocation and new election are both on account of and
consistent with a Change in Family Status, a Change in Employment Status or an Insurance
Coverage Change (collectively called Change in Status Events) and made no more than thirty
(30) days after the change occurs. A benefit election change is consistent with a status or
coverage change only if it is necessary or appropriate as a result of the status or coverage
change. Status changes that increase the number of Tax Dependents must be consistent with
election changes that increase or expand insurance coverage, or add or increase the size of
Medical Reimbursement and Dependent Care Accounts. Changes that decrease the number of
Tax Dependents must be consistent with reduced insurance coverage and smaller
reimbursement accounts,
The Plan is not required to allow benefit election changes during the Plan Year; such benefit
election changes will be allowed at the Employer's discretion. Further, the Plan Administrator
may disallow benefit election changes that appear to be for the purpose of circumventing the
terms and conditions of this Plan, or which may cause the loss of any tax benefit secured by this
Plan.
Family Status Changes, The changes of status which affect the number of Tax Dependents of
the Participant, which may permit a Benefit election Change include:
1. A change in Employee's legal marital status including marriage, divorce, death of
spouse, legal separation, or annulment. Note with regard to marriage that a spouse's
future coverage must be funded prospectively from future pay periods.
2. A change in number of Tax Dependents for reasons including birth, adoption or
placement for adoption, or death.
3. An event that causes a Dependent to satisfy or cease to satisfy the eligibility
requirements for coverage due to attainment of age, gain or loss of student status,
marriage or any similar circumstances as are provided in the health benefit plan.
4. With regard to the Dependent Care Expense Benefits, an event which causes a
dependent to cease to be an eligible tax dependent for purposes of this benefit (such as
a Dependent child reaching age 13).
To comply with federal regulations applicable to mid~year election changes due to Changes in
Family Status, the Plan may require the employee to certify that a spouse or Dependent child
has other coverage before the Plan will permit coverage to be deleted for that individual.
Further, if coverage is being dropped for a dependent child due to a Qualified Medical Child
Support Order or National Medical Child Support Notice, proof of actual coverage for the child
under another plan may be required before coverage under this Plan can be dropped for the
child.
Employment Status Changes. The following are considered Change in Employment Status
Events:
1. Termination or commencement of employment by the Employee, Employee's Spouse, or
Employee's Dependent.
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City of Bozeman Full Flex Plan Document
2. A change in work schedule to include a reduction or increase in hours by the Employee,
Employee's Spouse, or Employee's Dependent, including a switch between parHime
and full~time, a strike or lockout, or commencement or return from unpaid leave of
absence.
3. A change in residence or work site of Employee, Employee's Spouse, or Employee's
Dependent which affects the Employee's eligibility for coverage.
Insurance Cost or Coverage Changes. The following changes in insurance cost or coverage
may allow election changes with regard to premium costs only:
1. Significant increases or decreases in the cost of health coverage or benefits under this
plan or another employer plan,
2. Significant improvement in coverage or benefits; for example, the addition of a new
benefit option (such as dental or vision) or a new benefit package.
3. Significant curtailment in coverage or benefits; for example, the complete loss of
coverage, elimination of a benefit option or coverage, loss of access to a managed care
network, or reaching the annual or lifetime benefit maximum.
4. Special enrollment rights an individual is entitled to under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA).
5. A judgment. decree or order, including a QMCSO,
6. Entitlement to Medicare or Medicaid, or loss of entitlement to Medicare or Medicaid.
Revocation will be permitted if the Participant preserves the intention of the original election by
enrolling in a similar plan. Only if no similar plan is available may a Participant revoke his or her
annual election in its entirety.
Other Situations Which May Permit Mid-Year Election Changes. Other changes that may
allow election changes include:
1. A change of residence of the Participant, or the Participant's spouse or dependent
child(ren).
2. With regard to life coverage, a Participant may increase or decrease such coverage for
any Change in Status Event regardless of whether eligibility under the Plan is gained or
lost as a result of the change of Status Event.
3. With regard to the Dependent Care Assistance Plan, a change of Qualified Dependent
Care Provider.
4, With regard to the Dependent Care Assistance Plan, a significant change in the cost of
Dependent Care, but only if the Dependent Care Provider is not a relative of the
Participant as outlined in the Code,
Changes by the Plan Administrator. In the event that the cost of group health benefits
increases or decreases during the Plan Year, the Plan Administrator may automatically make
11
City of Bozeman Full Flex Plan Document
reasonable adjustments to the Participant's pre-tax premium deduction corresponding to the
change in the required Employee contribution for such benefits.
If the Plan Administrator determines, before or during any Plan Year, that the Plan may fail to
satisfy any nondiscrimination requirement imposed by the Code or any limitation on benefits
provided to highly compensated individuals, or highly compensated or key Employees (as those
terms are defined in the Code) for that Plan Year, the Plan Administrator will take such action as
it deems appropriate, under rules uniformly applicable to similarly situated Participants, to
assure compliance with such requirement or limitation. Such action may include, without
limitation, a modification of elections by highly compensated Employees or key Employees with
or without the consent of such Employees
If, during the Plan Year, the operation of the Plan could result in discrimination, then the Plan
Administrator will select and exclude from coverage under the Plan such highly compensated
individuals, highly compensated Employees or key Employees who are Plan Participants, to the
extent necessary to assure that, in the judgment of the Plan Administrator and in compliance
with applicable law, the Plan does not discriminate.
Benefit Summaries. The Plan will provide Participants who received benefits under this Plan
with the following Flex Plan benefit summary information:
1. If the Participant's Flexible Spending Account reimbursements are deposited directly into
the Participant's bank account, the Participant will receive a monthly activity notice
showing amounts deposited and reimbursements made during the applicable month.
2. If the Participant's Flexible Spending Account reimbursements are paid to the Participant
by check, a summary of the account activity and remaining balance will be shown on the
check stub.
3. If funds remain in the Participant's Flexible Spending Account as of the tenth (10th)
month of the Plan Year, the Plan will send a notice to the Participant which shows the
account balance remaining along with a reminder that services must be Incurred by the
end of the Plan Year, as extended by the applicable grace period, to qualify for
reimbursement.
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City of Bozeman full Flex Plan Document
TERMINATION
When Participation Ends. Participation in the Plan is subject to meeting the Plan's eligibility
requirements and timely payment of any required Premium. Participation in the Plan will end
based on the occurrence of one of the events outlined below:
1. Termination of the Plan. Except as provided under Continuation of Coverage After
Termination, the date on which the Plan terminates; or
2, Benefit No Longer Available. With regard to any benefit shown on the Schedule of
Available Benefits, the date on which said benefit is no longer available; or
3. Loss of Eligibility. Except as provided under Continuation of Coverage After
Termination, in the event that a Participant ceases to be eligible to participate under this
Plan for any reason, any election for Elected Benefits will also automatically cease on
the date of such loss of eligibility; or
4. Non~payment of Premium. Participation will end at such time as the Participant fails to
make premium payments in lieu of compensation reduction, after any applicable grace
period for such payment has expired.
Reinstatement. A Participant who loses eligibility under this Plan may become a Participant
again when the Employee meets the eligibility requirements of the Plan, Terminated Employees
rehired after thirty (30) days may make a new election in the Plan upon meeting eligibility
requirements.
CONTINUED COVERAGE AFTER TERMINATION
THIS SECTION APPLIES ONLY IF EMPLOYER HAS TWENTY (20) OR MORE EMPLOYEES.
NOTE: IF EMPLOYER SPONSORS A HEALTH BENEFIT PLAN, AND A PERSON IS
COVERED UNDER THAT PLAN, COBRA CONTINUATION RIGHTS WILL NOT BE
PROVIDED UNDER THE TERMS OF THIS FLEX PLAN; COBRA RIGHTS WILL BE AS
DESCRIBED IN THE HEALTH BENEFIT PLAN.
Under Title X of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as
amended, Employees and their enrolled dependents may have the right to continue coverage
beyond the time coverage would ordinarily have ended, The law applies to employers who
normally employ twenty (20) or more Employees.
Continued Coverage under COBRA is available to any Qualified Beneficiary whose coverage
would otherwise terminate due to any Qualifying Event. With regard to Medical Care Expense
Reimbursement Flexible Spending Accounts, a Qualified Beneficiary will be given the
opportunity to continue participation in the Medical Care Reimbursement Account. on an after-
tax basis, only if the Qualified Beneficiary has a pOSitive Medical Care Reimbursement Account
balance at the time of the Qualifying Event (taking into account all claims submitted before the
date of the Qualifying Event),
Continued Coverage under this provision will begin on the first day immediately following the
13
City of Bozeman Full Flex Plan Document
date coverage under the Plan terminates or the date of the Qualifying Event, as elected by the
Company.
1, Qualifying Events for covered Employees, for purposes of this section, are the following
events. if such event results in a loss of eligibility or coverage under the Plan:
A. The termination (other than by reason of gross misconduct) of the covered
Employee's employment.
B. The reduction in hours of the covered Employee's employment.
2. Qualifying Events for covered dependents, for purposes of this section, are the following
events, if such event results in a loss of eligibility or coverage under the Plan:
A. Death of the covered Employee,
B. Termination of the covered Employee's employment.
C. Reduction in hours of the covered Employee's employment
D. The divorce or legal separation of the covered Employee from his or her spouse.
E, The covered Employee's entitlement to Medicare.
F. A covered dependent child ceases to be a Dependent as defined by the Plan,
3. Qualifying Events for retired covered Employees, for purposes of this section, are:
A, Bankruptcy, if the covered Employee retired on or before the date of any
substantial elimination of group health coverage due to bankruptcy.
4. Qualifying Events for the dependents of retired covered Employees, for purposes of this
section, are:
A Bankruptcy, if the Dependent was a covered Dependent of a covered retiree on
or before the day before the bankruptcy Qualifying Event.
Notification Responsibilities. The Covered Person has the responsibility to notify the
Employer of a Qualifying Event within sixty (60) days of the date of the event. The Employer
has the responsibility to notify the Plan Administrator of the Employee's death, termination of
employment, reduction in hours, Medicare entitlement or the Company's filing of bankruptcy
Election of Coverage. When the Plan Administrator is notified of a Qualifying Event, the Plan
Administrator will notify the Qualified Beneficiary of the right to elect continuation of coverage,
Notice of the right to Continued Coverage will be provided by the Plan no more than forty-four
(44) days from the date coverage under the Plan terminates or the date of the Qualifying Event,
as elected by the Company.
The Qualified Beneficiary has sixty (60) days from the date coverage would otherwise be lost or
sixty (60) days from the date of notification from the Plan Administrator, whichever is later. to
notify the Plan Administrator that he or she elects to continue coverage under the Plan. Failure
to elect continuation within that period will cause coverage to end.
14
City of Bozeman Full Flex Plan Document
Monthly Contribution Payments. The Qualified Beneficiary or covered dependent is
responsible for the full cost of continuation, Monthly contributions for continuation of coverage
must be paid in advance to the Plan Administrator. The contribution required under the
provision of COBRA for a Qualified Beneficiary will be one-twelfth (1/12th) of the Participant's
annual contribution election, plus any monthly administrative expense, plus two percent (2%) of
the total of those costs.
When COBRA Continuation Coverage Ends. Continued Coverage under COBRA and any
coverage under the Plan with respect to any Covered Person will cease on the earliest date as
outlined below:
1. On the date the Qualified Beneficiary becomes covered under another group health plan
or health insurance, unless the other group health plan contains a provision excluding or
limiting coverage for a pre-existing condition applicable to a condition of the Qualified
Beneficiary under this Plan, However, if the exclusionary period does not apply due to
prior creditable coverage, COBRA continued coverage ends, Coverage will not be
terminated as stated until the pre-existing exclusionary period of the other coverage is
no longer applicable.
This exception applies to all Qualified Beneficiaries.
2. On the date the Qualified Beneficiary becomes entitled to Benefits under Title XVIII of
the Social Security Act (Medicare), except when the individual is on continuation due to
bankruptcy.
3. On the date the Qualified Beneficiary fails to make timely payment of any premium
required under the Plan with respect to Continued Coverage for the covered Employee
or dependent.
4. On the date which the employer ceases to provide any group health plan coverage to
any Employee.
5. Upon written notice that the Qualified Beneficiary wishes to terminate coverage.
6. On the date which the maximum benefit period for Continued Coverage has expired,
which will be the end of the Plan Year in which the Qualifying Event occurs.
15
City of Bozeman Full Flex Plan Document
FAMILY AND MEDICAL LEAVE ACT OF 1993
THIS SECTION ONLY APPLIES IF THE EMPLOYER HAS FIFTY (50) OR MORE
EMPLOYEES WITHIN A SEVENTY ~FIVE (75) MILE RADIUS OF THE WORK SITE.
The FMLA requires covered employers to allow "eligible" employees to take unpaid,
job-protected leave, or to substitute appropriate paid (eave if the employee has earned or
accrued it, for up to twelve (12) work weeks in any twelve (12) month period, as determined by
the employer's company policy, for certain family and medical reasons, In certain cases, this
leave may be taken on an intermittent basis rather than all at once, or the employee may work a
part-time schedule,
Covered Employers. In general, an employer covered by the FMLA is any person engaged in
commerce or in any industry or activity affecting commerce who employs fifty (50) or more
employees within a seventy~five (75) mite radius of the work site for each working day during
each of twenty (20) or more calendar work weeks in the current or preceding calendar year.
Covered employer also includes persons acting directly or indirectly in the interest of any
employer to any of the employer's employees (as described in section 3(d) of the Fair Labor
Standards Act. 29 U.S.C. 203(d)), The FMLA applies to government entities, including
branches of the United States government, state governments and political subdivisions thereof.
Eligible Employees. Generally, employees are eligible for FMLA leave only if they satisfy all of
the following requirements as of the date on which any FMLA leave is to commence: (1) have
been employed by a covered employer for a total of at least twelve (12) months (whether
consecutive or not); (2) the employee worked (as defined under the Fair Labor Standards Act)
at least 1,250 hours during the twelve (12) month period immediately preceding the leave; (3)
the employee is employed in any state of the United States, the District of Columbia or any
Territories or possession of the United States; and (4) at the time the leave is requested, the
employee is employed at a work site where fifty (50) or more employees are employed by the
employer within seventy-five (75) surface miles of the work site.
Reasons for Taking Leave. Unpaid leave must be granted (1) to care for the employee's child
at, and immediately following, birth; (2) for placement of a child with the employee for purposes
of adoption or foster care; or (3) to care for the employee's spouse, son or daughter, or parent.
who has a serious health condition: or (4) because the employee's own serious health condition
makes the employee unable to peliorm the functions of his or her job.
Advance Notice and Medical Certification. Ordinarily, an employee must provide thirty (30)
days advance notice when the requested leave is "foreseeable." If the leave is not foreseeable,
the employee must notify the employer as soon as is practicable, generally within two (2)
Working Days. An employer may require medical certification to substantiate a request for
leave requested due to a serious health condition. If the leave is due to the employee's serious
health condition, the employer may require second or third opinions, at the employer's expense,
and a certification of fitness to return to work prior to allowing the employee to return to work.
16
City of Bozeman Fut! Flex Plan Document
Job Benefits and Protection. For the duration of FMLA leave, the employer must maintain the
employee's health coverage under any "group health plan" on the same conditions as coverage
would have been provided if the employee had been continuously employed during the entire
leave period. Generally, upon return from FMLA leave, employees must be restored to the
same or equivalent positions with equivalent pay. benefits and other working conditions as
existed at the time leave commenced. The taking of FMLA leave cannot result in the loss of any
employment benefit that accrued prior to the start of an employee's leave.
Unlawful Acts by Employers. The FMLA makes it unlawful for any employer to interfere with,
restrain or deny the exercise of any right provided under the FMLA or to manipulate events or
circumstances so as to avoid responsibilities under the FMLA. Further, the employer may not
discharge, or discriminate against, any person for opposing any practice made unlawful by the
FMLA or for involvement in any proceeding under or relating to the FMLA.
Enforcement. The U.S, Department of Labor is authorized to investigate and resolve
complaints of FMLA violations. An eligible employee may also bring a civil action against an
employer for FMLA violations. The FMLA does not supersede any federal or state law
prohibiting discrimination, and does not supersede any state or local law or collective bargaining
agreement which provides greater family or medical leave rights. For additional information,
contact the nearest office of Wage and Hour Division, listed in most telephone directories under
U,S. Government, Department of Labor,
Administration of FMLA For Cafeteria Plans. Three permissible methods to accommodate
the requirements of the FMLA and Section 125 of the Internal Revenue Code are allowed as
follows:
1. If the need for FMLA leave can be anticipated, the Plan Administrator may allow
Participants to choose to accelerate their Flex Plan deductions to fully fund (pre~pay)
coverage on a pre-tax basis before the leave begins, To pre-pay the premium, the
Participant must make a special election to that effect prior to the date that such
compensation would normally be made available (note, however, that pre-tax dollars
may not be used to fund coverage during the next Plan Year); or
2. The Plan Administrator may choose to collect the necessary contributions from
Participants during their FMLA leave. If the leave is paid, premiums may be made on a
pre-tax basis. If the leave is unpaid, premiums must be made on an after-tax basis; or
3. The Plan Administrator may continue the pre-leave coverage and recover contributions
from the Participant (pre-tax or after-tax) at the end of the FMLA leave.
17
City of Bozeman Full Flex Plan Document
FLEXIBLE SPENDING ACCOUNTS (FSAs)
Flexible Spending Accounts. A Flexible Spending Account is a custodial account established
under a benefit plan in which an amount specified by the Participant is contributed through a
Compensation Reduction Agreement on a before-tax basis (along with Employer funds, if the
Employer contributes to the account) from which specified Incurred expenses may be
reimbursed (subject to reimbursement maximums and other reasonable conditions) in
accordance with the terms and conditions of the Employer's Dependent Care Assistance Plan
and/or Medical Expense Reimbursement Plan when in force and as amended or replaced from
time to time. This Plan provides a Participant the opportunity to establish the Flexible Spending
Accounts shown in the Schedule of Available Benefits by filing an election and a Compensation
Reduction Agreement in accordance with the procedures established under this Plan. The
Flexible Spending Accounts shown in the Schedule of Available Benefits are described below.
Establishment of Accounts. The Plan will establish and maintain a Flexible Spending
Account for each Elected Benefit (Dependent Care Assistance and/or Medical Care
Reimbursement Plan) for each Plan Year with respect to each Participant who has elected to
receive such benefits for the Plan Year.
Period of Coverage. The Period of Coverage begins with the first day of participation and is
that portion of the Plan Year for which Flexible Spending Account Contributions have been paid.
Once the full annual contribution has been paid, coverage will extend through the end of the
Plan Year, plus the applicable grace period. Reimbursement requests will only be honored if
the expense has been Incurred within the Period of Coverage
Crediting of Accounts. The Employer will credit the amount of the before-tax deduction
elected by the Participant under the Compensation Reduction Agreement to the Participant's
corresponding Flexible Spending Account(s) as of each date compensation is paid to the
Participant during the applicable Plan Year. All amounts credited to each such Flexible
Spending Account will be the property of the Company until paid out according to the terms and
conditions of this Plan.
Debiting of Accounts. The amount of any reimbursement made to or for the benefit of the
Participant for Qualifying Dependent Care Expenses and/or Qualifying Medical Care Expenses
Incurred during the Period of Coverage will be subtracted from the Participant's Flexible
Spending Account from time to time during the applicable Plan Year as reimbursements are
made. Amounts subtracted from the applicable Flexible Spending Account will be for payments
of the earliest amounts credited to the account and not yet reimbursed, under a "first-in/first-out"
approach, which insures that reimbursements covering Qualifying Dependent Care Expenses
and/or Qualifying Medical Care Expenses Incurred during any applicable grace period come first
from any available funds in the Participant's respective Flexible Spending Accounts from the
immediately preceding Plan Year.
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City of Bozeman Full Flex Plan Document
Unused Contributions Forfeited. The amount of contributions credited to a Participant's
Flexible Spending Account(s) for any Plan Year will be used only to reimburse the Participant
for Qualified Dependent Care Expenses and/or Qualifying Medical Care Expenses Incurred
during such Plan Year's period of coverage, and only if the Participant applies for
reimbursement on or before the ninetieth (90th) day following the end of the Plan Year's period
of coverage, or within ninety (90) days after any loss of eligibility, which ever occurs first. If any
balance remains in the Participant's Flexible Spending Account for any Plan Year after all
eligible requested reimbursements are made, such balance must be forfeited by the PartiCipant
as provided in the Code and remain the property of the Plan.
Grace Period. Pursuant to IRS Notice 2005-42, which is hereby incorporated into this Plan, a
grace period immediately following the end of each Plan Year is hereby established during
which unused benefits or contributions to a Participant's respective Flexible Spending
Account{s) may be paid for Qualified Dependent Care Expenses and/or Qualifying Medical Care
Expenses Incurred during the grace period. Said grace period shall run up to and include the
fifteenth (15th) day of the third calendar month after the end of the immediately preceding Plan
Year to which it relates. As the Plan Year currently ends on December 31 of each year, the
grace period shall run up to and include March 15 of each year and shall expire thereafter.
No Interest. Interest will not be credited or paid on amounts in the Participant's Flexible
Spending Account(s) described in this Plan, Interest, if any, shalt be applied to payment of
administrative fees for this Plan.
DEPENDENTCAREASS~TANCEPlAN
Under the Plan, reimbursement will be made only for Qualified Dependent Care Expenses
which are Incurred during the Period of Coverage for an eligible Dependent or Dependents.
Eligible Dependent for Dependent Care Expenses. Each individual for whom the Participant
incurs the expense must be:
1. A Dependent of the Participant, and under age thirteen (13) who is entitled to be claimed
as a Dependent on Participant's federal income tax return for the tax year during which
the expense was Incurred; or
2. A spouse of the Participant or any other Dependent who the Participant can claim as a
Dependent exemption for federal income tax purposes, and who is physically or mentally
incapable of caring for himself or herself.
Qualifying Dependent Care Expenses. The expenses must be Incurred for the care of a
Dependent described above, and must be Incurred to enable the Participant or his or her
Spouse to be gainfully employed. Expenses for care for other purposes (such as overnight
camps, or private school as an alternative to public school) are not eligible: however, the fact
that a program has an educational component does not automatically disqualify the expense
under this benefit. To qualify as eligible, expenses are subject to the following:
1. If the expenses are Incurred for services outside the household of the Participant, then
they must be Incurred for the care of a Dependent who is less than thirteen (13) years of
age, or any other eligible Dependent who regularly spends at least eight (8) hours per
day in Participant's household: and
19
City of Bozeman Full Flex Plan Document
2, The expenses must be for the services of a Dependent Care Service Provider or a
Qualified Day Care Center.
The Participant must provide certification and/or documentation satisfactory to the Administrator
that the Dependent Care Expenses meet the above qualifications,
Reimbursement of Dependent Care Expenses. A Participant who has elected to receive
reimbursement for qualifying Dependent Care Expenses for a Plan Year plus the applicable
grace period may submit a reimbursement request in writing to the Plan Supervisor, along with
a reimbursement voucher form. Submission by facsimile (fax) is acceptable, The Plan
Supervisor will request independent third*party documentation of the following information
concerning the reimbursement request:
1, The name and tax identification number of the person, organization or entity to which the
expense was or is to be paid; and
2 The name of the person for whom the expense was Incurred; and
3. The reimbursement request must be accompanied by bills, invoices, or other statements
showing the amounts of such expenses, together with any additional documentation
which the Plan Supervisor requires to determine that the requested reimbursement is
eligible,
The Participant should retain for his or her records, the date, amount and nature of each
expense submitted and reimbursed under this benefit, for tax return purposes.
The Plan Administrator or its designee will make payments from the Dependent Care
Assistance Account of a Participant for claimed and qualified expenses within thirty (30) days of
the receipt of the qualified reimbursement request. to the extent funds have been credited to the
Participant's Dependent Care Assistance Account and are available in the Plan's
reimbursement account Total reimbursement(s) for qualified Dependent Care Expenses
Incurred during a Plan Year plus applicable grace period will not at any time exceed for any
Participant the total amount of premium validly elected and credited under the Participant's
Compensation Reduction Agreement for Dependent Care Expense reimbursement for the Plan
Year.
Annual Maximum Contribution for Dependent Care Assistance. The maximum amount
which the Participant may elect to receive in any Plan Year in the form of Dependent Care
Assistance under the Plan will be the least of:
1. The Participant's earned income for the Plan Year (after all reductions in compensation,
including the reduction related to Dependent Care Assistance);
2. The actual or deemed earned income of the Participant's spouse for the Plan Year;
3. Five thousand dollars ($5,000.00); or
4. Two thousand five hundred dollars ($2,500.00), if the Participant's earned personal
income tax filing status for the Plan Year is married, filing separately.
In the case of a spouse who is a full-time student at an educational institution, or who is
physically or mentally incapable of self-care, such spouse will be deemed to have earned
20
City of Bozeman Full Flex Plan Document
income of not less than two hundred dollars ($200.00) per month if the Participant has one
Dependent and four hundred dollars ($400,00) per month if the Participant has two (2) or more
Dependents (deemed earned income).
Form 2441. Each Participant that receives Dependent Care benefits or who files for child care
tax credit, must file IRS Form 2441. This form must be attached to any such Flex Participant's
1040. Failure to file this form could mean disallowance of the pre-tax exclusion provided to the
Participant through the Flex Plan. Code Section 129(e)(9) requires that the information on Form
2441 (the care giver's name, address, tax identification number, etc.) be included.
MEDICAL EXPENSE REIMBURSEMENT PLAN
The Plan will only reimburse the Participant for Qualifying Medical Care Expenses, as that term
is defined by the Plan and the Code.
Annual Benefit. The Annual Benefit under a Medical Reimbursement Account is the total
amount elected by the Participant under a Compensation Reduction Agreement along with
Employer contributions, if any, for the Plan Year or Period of Coverage, whichever is shorter,
subject to any maximums provided under the Code or applicable law.
Uniform Coverage. The full annual elected benefit will be available at all times during the
Period of Coverage to reimburse Qualifying Medical Care Expenses.
Annual Maximum Reimbursements. The maximum amount which the Participant may elect
to receive under this Plan in the form of payments or reimbursements for Qualifying Medical
Care Expenses Incurred in any Period of Coverage will be five thousand dollars ($5,000,00).
Reimbursement Requests. A Participant who has elected to receive qualifying Medical Care
reimbursements for a Plan Year plus applicable grace period may submit a reimbursement
request in writing to the Plan Supervisor, along with a reimbursement voucher form,
Submission by facsimile (fax) is acceptable. The Plan Administrator will request independent
third-party documentation of the following information concerning the reimbursement request
1, The amount, date and nature of the expense with respect to which a benefit is
requested; and
2. The name and tax identification number of the person, organization or entity to which the
expense was or is to be paid; and
3. The name of the person for whom the expense was Incurred; and
4. A statement that the expense has not been reimbursed in full or in part or is not
reimbursable In full or in part under any other health plan coverage (except as shown on
the accompanying documentation); and
5. The amount recovered or expected to be recovered, under any insurance arrangement
or other plan, with respect to the expense,
Such reimbursement requests shall be accompanied by bills, invoices, insurance "Explanation
21
City of BOl:eman Full Flex Plan Document
of Benefits," or other statements showing the amounts of such expenses, together with any
additional documentation which the Administrator may request
The Plan Administrator or its designee will make reimbursements from the Qualified Medical
Care Expense Account of a Participant for claimed and qualified expenses within thirty (30)
days of the receipt of the qualified reimbursement request, to the extent funds have been
credited to Participant's Qualifying Medica! Expense Account and are available in the Plan's
reimbursement account. Total reimbursement(s) or payments of Qualified Medical Care
Expenses Incurred during a Plan Year plus applicable grace period will not at any time exceed
for any Participant the total amount of contributions validly elected under a Compensation
Reduction Agreement by the Participant for Qualifying Medical Expense Reimbursement for the
Plan Year.
REIMBURSEMENT REVIEW PROCEDURES
Accounting for Contributions and Reimbursement Requests. During the processing and
payment of reimbursement requests under Flexible Spending Accounts, the Plan Supervisor will
generate a quarterly report within thirty (30) days following the end of the quarter. The report
will set forth all deposits made to each benefit account, reimbursement requests received and
reimbursements made. Said reports will be kept by the Plan Supervisor for a period of six (6)
years, and then destroyed.
Reimbursement Processing. Reimbursement requests will be considered according to the
Plan's terms and conditions, industry-standard reimbursement request processing guidelines
and administrative practices, The Plan may, when appropriate or when required by law, consult
with relevant professionals and access professional industry resources in making decisions
about reimbursement requests that involve specialized knowledge or judgment. Initial
reimbursement request decisions will be made within the time periods outlined below.
In most cases, reimbursement will be made within a few days of the Plan's receipt of the
reimbursement request. The Plan will provide timely reimbursement no later than thirty (30)
days after receiving the reimbursement request, once sufficient information is received. Upon
written notice to the Covered Person of the circumstances requiring an extension and the date
by which the Plan expects to render a decision, this time period may be extended fifteen (15)
days for reasons beyond the Plan's control. If the extension is necessary due to a failure of the
claimant to submit information necessary to process the reimbursement, the extension notice
will specifically describe the information needed, and the Covered Person will be afforded forty-
five (45) days from receipt of the notice within which to provide the specified information. Once
sufficient information is received, the Plan will provide reimbursement, or notice that
reimbursement cannot be made, no later than fifteen (15) days after receiving sufficient
information.
Denial Of A Reimbursement Request. If a request for reimbursement is denied in whole or in
part, the Covered Person will receive written notification delivered in the same fashion as for
reimbursement. If no part of the request can be reimbursed, the Covered Person will receive a
letter of explanation as to why reimbursement cannot be made, If partial reimbursement can be
made, the Covered Person will receive reimbursement for the portion which can be reimbursed
along with an Explanation of Benefits (EOB) form for the portion not reimbursed. The EOB will
show:
A. The reason reimbursement could not be made;
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City of Bozeman Full Flex Plan Document
S, Reference to the specific Plan provision(s) or rule(s) upon which the decision was based
which resulted in the denial;
C If the request could not be reimbursed due to insufficient information, any additional
information needed to process the reimbursement request and why such information is
needed; and
D. An explanation of the Covered Person's right to appeal the denied request for a full and
fair review and the right to bring a civil action under applicable law following an adverse
benefit determination on appeal.
If a Covered Person does not understand the reason the reimbursement request was denied, he
or she should contact the Plan Supervisor, at the address or telephone number shown on the
EOB form.
A Covered Person has not more than one hundred eighty (180) days after denial of a
reimbursement request to appeal the denial to the Plan Administrator. When appealing a
benefit denial, the Covered Person should include any additional information supporting the
reimbursement request or the information required by the Plan which was not initially provided
and forward it to the Plan Administrator within the permitted time period. Failure to appeal the
determination within the permitted time period will render the determination final; appeals
received after the permitted time period has expired will receive no further consideration.
The Plan Administrator will review the reimbursement request in question along with the
additional information submitted by the Covered Person. The Plan will conduct a full and fair
review of the request by the Named Fiduciary who is neither the original decision maker nor the
decisionmaker's subordinate. The Named Fiduciary cannot give deference to the initial benefit
determination. The Named Fiduciary may, when appropriate or if required by law, consult with
relevant professionals in making decisions about appeals that involve specialized judgment.
When necessary, the Named Fiduciary wifl consult with a professional with appropriate training
who was neither the professional consulted in the initial determination or his or her subordinate.
After a full and fair review of the Covered Person's appeal, the Plan will provide a written or
electronic notice of the final benefit determination which contains the same information as
notices for the initial determination, within a reasonable time, but no later than sixty (60) days
from the date the appeal is received by the Plan"
All reimbursements are based upon the terms and provisions contained in the Plan Document
which is on file with the Plan Administrator and the Plan Supervisor. The Covered Person may
examine the Plan Document and other instruments pertaining to the Plan upon written request
to the Plan Administrator or the Plan Supervisor. The Covered Person may also request, free of
charge, more detailed information, names of any professionals consulted and copies of relevant
documents, as defined in and required by law, which were used by the Plan to process the
request.
PLAN ADMINISTRATION
Administration. It is a principal duty of the Employer as Plan Administrator to see that the Plan
is carried out, in accordance with its terms, for the exclusive benefit of persons entitled to
23
City of Bozeman Full Flex Plan Document
participate in the Plan without discrimination among them. The Employer will have full power to
administer the Plan in all of its details subject, however, to the requirements of applicable law,
including compliance with all reporting and disclosure requirements. For this purpose, the
Employer's powers as Plan Administrator will include, but will not be limited to, the following
authority, in addition to all other powers provided by this Plan:
1, To make and enforce such rules and regulations as it deems necessary or proper for the
efficient administration of the Plan;
2. To interpret the Plan, its interpretation thereof in good faith to be final and conclusive on
all persons claiming benefits under the Plan, unless reversed or modified by the order of
a court or agency with competent jurisdiction;
3. To decide all questions concerning the Plan and the eligibility of any person to
participate in the Plan;
4. To compute the amount of benefits which will be payable to any Participant or other
person in accordance with the provisions of the Plan, and to determine the person or
persons to whom such benefits will be paid;
5. To authorize the payment of benefits;
6. To appoint such agents, counsel, accountants and actuaries as may be required to
assist in administering the Plan; and
7. To allocate and delegate its responsibilities under the Plan and to designate such other
persons as it deems necessary to carry out any of its responsibilities under the Plan.
Any such allocation, delegation or designation will be by written instrument and in
accordance with applicable law.
No Employment Contract. The Plan Document constitutes the primary authority for Plan
administration. The establishment, administration and maintenance of this Plan will not be
deemed to constitute a contract of employment, give any Employee of the Employer the right to
be retained in the service of the Employer, or to interfere with the right of the Employer to
discharge or otherwise terminate the employment of any Participant.
Severability. In the event any provision of this Plan is held to be illegal or invalid for any
reason, this illegality or invalidity will not affect the remaining provisions of this Plan, and such
remaining provisions will be fully severable and this Plan will, to the extent practicable, be
construed and enforced as if the illegal or invalid provision had never been inserted therein.
Plan Amendments, Modification or Termination By the Employer. The Employer has
established the Plan(s) with the bona fide intention and expectation that it will be continued
indefinitely. but the Employer will have no obligation whatsoever to maintain any such Plan for
any given length of time and may discontinue or terminate any Plan at any time without liability.
Upon termination or discontinuance of a Plan or Plans, all related elections and reductions in
compensation related to the discontinued Plan(s) will terminate, and reimbursements will be
made only in accordance with the provisions of the discontinued Plan(s).
The Plan Document contains all the terms of the Plan The Employer reserves the power to
amend or terminate the provisions of any Plan (including without limitation the Medical Related
Plans, Group Term Life Insurance Plan, Dependent Care Assistance Plan and Medical Expense
24
City of Bozeman Full Flex Plan Document
Reimbursement Plan) at any time and to any extent and in any manner that it may deem
advisable. Any changes will be binding on each Participant and on any other Covered Persons
referred to in this Plan Document.
The authority to amend the Plan is delegated by the Plan Administrator to the Human Resource
Manager or his or her equivalent, whichever is applicable, of the Company. Any such
amendment, modification, revocation or termination of the Plan will be authorized and signed by
the Human Resource Manager or his or her equivalent, whichever is applicable, of the
Company, pursuant to a policy granting that individual the authority to amend, modify, revoke or
terminate this Plan. A copy of the executed policy will be supplied to the Plan Supervisor.
Written notification of any amendments, modifications, revocations or terminations will be given
to Plan Participants within one hundred twenty (120) days of such decision, except for notices of
reduction of benefits.
Benefits Solely From Plan Assets. The benefits provided hereunder will be paid solely from
the assets of the Plan. Nothing herein will be construed to require the Employer or the Plan
Administrator to maintain any fund or segregate any amount for the benefit of any Participant,
except as required under the Code for Flexible Spending Accounts for Participant contributions,
and no Participant or other person will 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.
Non-Assignability of Rights under a Flexible Spending Account. The Participant may not
alienate, by assignment or any other method, his or her right to receive any reimbursement
under the Plan and reimbursements will not be subject to be taken by his creditors by any
process whatsoever. Any attempt to cause such right to be so subjected will not be recognized.
except to such extent as may be required by law,
No Guarantees of Tax Consequences. Neither the Plan Administrator nor the Employer
makes any commitment or guarantee that any amounts paid to or for the benefit of a Participant
under this Plan will be excluded 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 will be the obligation of each Participant to determine whether each payment
under its provisions is excluded 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 excluded.
25
City of Boz.eman Full Flex Plan Document
Indemnification of Company by Participants. If any Participant receives one or more
payments or reimbursements under this Plan that are not for Qualifying Medical Care Expenses
or qualifying Dependent Care Expenses, such Participant will indemnify the Employer for any
liability it may incur for failure to withhold Federal or State income tax or Social Security tax from
such payment. However, such indemnification will not exceed the amount of additional Federal
and State income tax 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.
IN WITNESS WHEREOF, the Employer has caused this Plan to be executed in its name and on
its behalf by its authorized agent on the days and year first written above.
CITY OF BOZEMAN
..'7
._1'1
..~. Y'
By: ~.. ,,/ )'---~
Title: Acting City Mana~er
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City of Bozeman Full Flex Plan Document