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Resolution Number 08-01-15-02IRESOLUTION NO. 08-01-15- 02 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN JUAN CAPISTRANO, CALIFORNIA, ADOPTING THE CITY OF SAN JUAN CAPISTRANO FLEXIBLE BENEFITS PLAN EFFECTIVE JANUARY 1, 2008 WHEREAS, Section 32706 of the Government Code requires the City Council to prescribe the time and method of paying salaries and wages of employees of the City; and, WHEREAS, employee benefits such as medical, dental and vision cove rage contribute to a total compensation package; and, WHEREAS, the City has contracted the administrative functions of the City of San Juan Capistrano Flexible Benefit Plan to a third party administrator since January 1, 2004; and, WHEREAS, the City wishes to continue contracting the administrative functions of the City of San Juan Capistrano Flexible Benefit Plan; and, WHEREAS, the Administrator has been instructed to take such actions that are deemed necessary and proper in order to execute the Plan, and to set up adequate ' accounting and administrative procedures to provide benefits under the Plan; and; WHEREAS, the City shall notify the employees of the Adoption of the Plan by delivering to each employee a copy of the summary description of the Plan in the form of the Summary Plan Description and Schedule of Benefit Options; and, WHEREAS, the premium amounts for health, dental, and vision insurance as well as the Flexible Benefits Plan fees may change annually, and based upon the City's Memorandum of Understanding with the Classified Employees Association and the Memorandum of Understanding with the Management and Professional Employees Association, the City desires that all increases in premiums and Plan fees be combined into the City of San Juan Capistrano Flexible Benefits Plan and Schedule of Benefit Options with any annual increases incorporated therein. NOW, THEREFORE, BE IT RESOLVED, that the City Council of the City of San Juan Capistrano does hereby: 1. Adopt the City of San Juan Capistrano Flexible Benefits Plan and the Schedule of Benefit Options, both effective January 1, 2008, hereto attached as Exhibit "A" and Exhibit "B" respectively. 2. Authorize the City Manager to adopt an annual update of the City.of San Juan Capistrano Flexible Benefits Plan and the Schedule of Benefit Options in January of each year based upon the City's Memoranda of Understanding with its employee organizations and increases in premiums and Plan fees, without further City Council review. PASSED, APPROVED, AND ADOPTED this 15TH day of January 2008. STATE OF CALIFORNIA ) COUNTY OF ORANGE ) ss. CITY OF SAN JUAN CAPISTRANO ) I, MARGARET R. MONAHAN, appointed City Clerk of the City of San Juan Capistrano, do hereby certify that the foregoing Resolution No. 08-01-15-02 was duly adopted bythe City Council of the City of San Juan Capistrano at a Regular meeting thereof, held the 15`h day of January 2008, by the following vote: AYES: COU IL MEMBERS: Allevato, Hribar, Uso and Mayor Soto NOES: 1I �Q IL MEMBER: None ABSENT: I / t% NCIL MEMBER: Nielsen CITY OF SAN -JUAN CAPISTRANO CITY OF SAN JUAN CAPISTRANO'S CAFETERIA PLAN SUMMARY PLAN DESCRIPTION For The Cafeteria Plan Healthcare Flexible Spending Account Dependent Care Flexible Spending Account F1ex-SPD-072005 EXHIBIT A TABLE OF CONTENTS GENERAL INFORMATION ABOUT THE PLAN CAFETERIA PLAN COMPONENT SUMMARY................................................................ 2 Q-1. What is the purpose of the Cafeteria Plan?............................................................................ 2 Q-2. Who can participate in the Cafeteria Plan?............................................................................ 2 Q-3. When does my participation in the Cafeteria Plan end? ......................................................... 2 Q-4. How do I become a participant?............................................................................................. 3 Q-5. What are the tax advantages and disadvantages of participating in the Cafeteria Plan?.....,.. 4 Q-6. What are the election periods for enrolling in the Cafeteria Plan? ........................................ 4 Q-7. How is my Benefit Plan Option coverage paid for under this Plan? ...................................... 5 Q-8, Under what circumstances can I change my electionduring the Plan Year? .......................... 6 Q-9, What happens to my participation under the Cafeteria Plan if I take a leave of absence?..... 6 Q-10. How long will the Cafeteria Plan remain in effect?............................................................... 8 Q-11. What happens if my request for a benefit under this Cafeteria Plan is denied? ..................... 8 HEALTHCARE FSA COMPONENT SUMMARY..._...............................................................9 Q-1. Who can participate in the Healthcare FSA?......................................................................... 9 Q-2. How do I become a Participant?............................................................................................. 9 -3. What is my"Health Care Account'?................................................................................ ..... 10 Q-4. When does coverage under the Healthcare FSA end?.......................................................... 10 Q-5. Can I Ever Change My Healthcare FSA election?............................................................... 10 Q-6. What happens to my Health Care Account if I take an approved leave of absence?........... I I Q-7. What is the maximum annual Health Care Reimbursement that I may elect under the Healthcare FSA, and how much will it cost?..................................................................... I I Q-8. How are Health Care Reimbursement benefits paid for under this Plan? ............................ I I Q-9. What amounts will be available for Health Care Reimbursement at any particular time duringthe Plan Year?........................................................................................................ I I Q-10. How do 1 receive reimbursement under the Healthcare FSA? ............................................. 12 Q-11. What is an "Eligible Medical Expense"?.............................................................................. 14 Q-12. When must the expenses be incurred in order to receive reimbursement? .......................... 15 Q-13. What if the Eligible Medical Expenses I incur during the Plan Year are less than the annual amount 1 have elected for Healthcare Reimbursement?.................................................... 15 Q-14 What happens if a Claim for Benefits under the Healthcare FSA is denied? ....................... 16 Q-15. What happens to unclaimed Health Care Reimbursements?................................................ 16 Q-16. What is COBRA continuation coverage?............................................................................. 16 Q-17. What happens if I receive erroneous or excess reimbursements? ........................................ 18 Q-18. Will my health information be kept confidential?................................................................ 18 Q-19. How long will the Healthcare FSA remain in effect?.......................................................... 19 Miscellaneous Rights Under the Healthcare FSA............................................................................... 20 DEPENDENT CARE FSA SUMMARY .......... .......... ..... ......... ....... ...-... ......... ........ ........................ 22 Q-1. Who can participate in the Plan?.......................................................................................... 22 Q-2. How do 1 become a Participant?........................................................................................... 22 Q-3. What is my ,Dependent Care Account"?.............................................................................. 22 Q-4. When does my coverage under the Dependent Care FSA end? ............................................ 22 Q-5. Can I ever change my Dependent Care FSA election?......................................................... 23 Rex -SPD -072005 ' Q-6. What happens to my Dependent Care Account if 1 take an unpaid leave of absence?......... 23 Q-7. What is the maximum annual Dependent Care Reimbursement that t may elect under the DependentCare FSA?........................................................................................................ 23 Q-8, How Do I Pay for Dependent Care Reimbursements?......................................................... 23 Q-9. What is an "Eligible Employment Related Expense" for which 1 can claim a reimbursement?.................................................................................................................. 24 Q-10. How do I receive reimbursement under the Dependent Care FSA? ..................................... 25 Q-11. When must the expenses be incurred in order to receive reimbursement? .......................... 25 Q-12. What if the Eligible Employment Related Expenses I incur during the Plan Year are less than the annual amount of coverage I have elected for Dependent Care Reimbursement? ............................................................................................................................................ 25 Q-13. Will 1 be taxed on the Dependent Care Reimbursement benefits I receive? ........................ 26 Q-14. If I participate in the Dependent Care FSA, will I still be able to claim the household and dependent care credit on my federal income tax return? ................................................... 26 Q-15, What is the household and dependent care credit?............................................................... 26 Q-16. What happens to unclaimed Dependent Care Reimbursements? ......................................... 27 Q-17. What happens if my claim for reimbursement under the Dependent Care FSA is denied?. 27 Q-18. What happens if 1 receive erroneous or excess reimbursements? ........................................ 27 Q-19. How long will the Dependent Care FSA remain in effect? .................................................. 27 PLAN INFORMATION SUMMARY...........................:.....:.............................................................28 APPENDIX 1. - CLAIMS REVIEW PROCEDURE CHART.- .................... .......... __ ........ ...................................... I APPENDIX 11. -TAX ADVANTAGES EXAMPLE..................:...............................................:................................I APPENDIX 111. - ELECTION CHANGE CHART_ ........................................................... .......... ...................... ...... I Flex -SPD -072005 CITY OF SAN JUAN CAPISTRANO CITY OF SAN JUAN CAPISTRANO'S CAFETERIA PLAN SUMMARY PLAN DESCRIPTION GENERAL INFORMATION ABOUT THE PLAN City of San Juan Capistrano (the "Employer") is pleased to sponsor an employee benefit program known as the City of San Juan Capistrano's Cafeteria Plan (the "Plan") for you and your fellow employees. It is so-called because it lets you choose from several different benefit programs (which we refer to herein as "Benefit Plan Options") according to your individual needs, and allows you to use Pre-tax Contributions to pay for the benefits by entering into a salary reduction arrangement with your Employer. This Plan helps you because the benefits you elect are nontaxable (i.e., you save social security and income taxes on the amount of your salary reduction). Alternatively, you may choose to pay for any of the available benefits with after-tax contributions on a salary deduction basis to the extent described in your enrollment materials. This Plan has three components: • A Cafeteria Plan Component. The Cafeteria Plan Component allows you to pay,your share of certain underlying welfare benefit plans (called "Benefit Plan Options) with Pre- tax Contributions. • The Healthcare Flexible Spending Account ("Healthcare FSA"). The Healthcare FSA allows you to elect to use a specified amount. of Pre-tax Contributions to be used for -- reimbursement of Eligible Medical Expenses. The Healthcare FSA is intended to qualify as a Code Section 105 self-insured medical reimbursement plan. • The Dependent Care Spending Account ("Dependent Care FSA"). The Dependent Care FSA allows you to elect to use a specified amount of Pre-tax Contributions to be used for reimbursement of Employment Related Expenses, The Dependent Care FSA is intended to qualify as a Code Section 129 dependent care assistance plan. Each of the three components is summarized in this document. Information relating to the Plan that is specific to your Employer is described in the Plan Information Summary. For example, you can find the identity of the Third Party Administrator, the Employer, and the Plan Administrator in the Plan Information Summary as well as the Plan Number and any applicable contact information. Each summary and the attached Appendices constitute the Summary Plan Description for the City of San Juan Capistrano's Cafeteria Plan. The SPD (collectively, the Summary Plan Description or "SPD") describes the basic features of the Plan, how it operates, and how you can get the maximum advantage from it. The Plan is also established pursuant to a plan document into which the SPD has been incorporated. However, if there is a conflict between the official plan document and the SPD, the plan document will govern. Certain terms in this Summary are capitalized. Capitalized terms reflect important terms that are specifically defined in this Summary or in the Plan Document into which this Summary is incorporated. You should pay special attention to these terms as they play an important role in defining your rights and responsibilities under this Plan Participation in the Plan does not give any Participant the right to be retained in the employ of his or her Employer or any other right not specified in the Plan. If you have any questions Flex -SPD -072005 ' regarding your rights and responsibilities under the Plan, you may also contact the Plan Administrator (who is identified in the Plan Information Summary). CAFETERIA PLAN COMPONENT SUMMARY Q-1. What is the purpose of the Cafeteria Plan? The purpose of the Cafeteria Plan is to allow eligible employees to pay for certain benefit plans (Benefit Plan Options) with pre-tax dollars ("Pre-tax Contributions"). The Benefit Plan Options to which you may contribute with Pre-tax Contributions under this Cafeteria Plan are described . in the Plan Information Summary. Pre-tax Contributions are described in more detail below. To the extent Health Savings Accounts are included as a Benefit Plan Option under this Plan as set forth in the Plan Information Summary attached to this SPD, you may be able to contribute to your personal Health Savings Account (as defined in Code Section 223) under this Plan. If you are permitted to contribute to a Health Savings Account under this Plan, the rules regarding Health Savings Account contributions will be set forth generally in Plan Information Summary, Q-2. Who can participate in the Cafeteria Plan? Each employee of the Employer (or an Affiliated Employer identified in the`Plan Information Summary) who satisfies the Cafeteria Plan Eligibility Requirements and is also eligible to participate in any of the Benefit Plan Options will be eligible to participate in this Cafeteria Plan. If you meet these requirements, you may become a Participant on the Cafeteria Plan Eligibility Date, The Cafeteria Plan Eligibility Requirements and'Eligibility Date are described in the Plan Information Summary. Those employees who actually participate in the Cafeteria Plan are called "Participants". (See below for instructions on how to become a Participant.) You may only pay for the coverage of yourself and your tax dependents as defined in Code Section 152 generally (except as otherwise defined in Code Section 105(6) and the regulations issued under Code Section 106) under this Plan and as set forth in the SPD. The terms of eligibility of this Cafeteria Plan do not override the terms of eligibility of each of the Benefit Plan Options. In other words, if you are eligible to participate in this Cafeteria Plan, it does not necessarily mean you are eligible to participate in the Benefit Plan Options. For details regarding eligibility provisions, benefit amounts, and premium schedules for each of the Benefit Plan Options, please refer to the plan summary for each Benefit Plan Option. If you do not have a summary for a Benefit Plan Option, you should contact the Plan Administrator for information on how to obtain a copy. Q-3. When does my participation in the Cafeteria Plan end? Your coverage under the Cafeteria Plan ends on the earliest of the following to occur: a) The date that you make an election not to participate in accordance with this Cafeteria Plan Summary; b) The date that you no longer satisfy the Eligibility Requirements of this Cafeteria Plan or all of the Benefit Plan Options; c) The date that you terminate employment with the Employer; or IFlex -SPD -072005 d) The date that the Cafeteria Plan is either terminated or amended to exclude you or the class of employees of which you are a member. If your employment with the Employer is terminated during the Plan Year or you otherwise cease to be eligible, your active participation in the Cafeteria Plan will automatically cease, and you will not be able to make any more Pre-tax Contributions under the Cafeteria Plan except as otherwise provided pursuant to Employer policy or individual arrangement (e.g., a severance arrangement where a former employee is permitted to continue paying for a Benefit Plan Option out of severance pay on a pre-tax basis). if you are rehired within the same Plan Year and are eligible for the Cafeteria Plan (or you become eligible again), you may make new elections if you are rehired or become eligible again more than 30 days after you terminated employment or lost eligibility (subject to any limitations imposed by the Benefit Plan Option(s)). If you are rehired or again become eligible within 30 days or less of your termination date, your Cafeteria Plan elections that were in effect when you terminated employment or stopped being eligible will be reinstated and remain in effect for the remainder of the Plan Year (unless you are allowed to change your election in accordance with the terms of the Plan). Q-4. How do I become a participant? If you have otherwise satisfied the Cafeteria Plan's eligibility requirements, you become a Participant by signing an individual Salary Reduction Agreement (sometimes referred to as an "Election Form") on which you agree to pay your share of the Benefit Plan Options that you choose with Pre-tax Contributions. You will be provided with a Salary Reduction Agreement on or before your Cafeteria Plan Eligibility Date. Youmustcomplete the form and submit it to the — Plan Administrator or the Third Parry Administrator (per the instructions provided on or with your Salary Reduction Agreement) during one of the election periods described in Q-8. below. You may also enroll during the year if you previously elected not to participate and you experience a change described below that allows you to become a participant during the year. If that occurs, you must complete an election change form during the Election Change Period described in Q-8, below. In no event can you become a Participant in this Cafeteria Plan prior to the date you complete and properly submit the Salary Reduction Agreement. The Third Party Administrator is identified in the Plan Information Summary. In some cases, the Employer may require you to pay your share of the Benefit Plan Option coverage that you elect with Pre-tax Contributions. If that is the case, your election to participate in the Benefit Plan Option(s) will constitute an election under this Cafeteria Plan. You may be required to complete a Salary Reduction Agreement via telephone or voice response technology, electronic communication, or any other method prescribed by the Plan Administrator. In order to utilize a telephone system or other electronic means, you may be required to sign an authorization form authorizing issuance of personal identification number ("PIN") and allowing such PIN to serve as your electronic signature when utilizing the telephone system or electronic means. The Plan Administrator and all parties involved with Plan administration will be entitled to rely on your directions through use of the PIN as if such directions were issued in writing and signed by you. Flex -SPD -072005 ' Q-5. What are tax advantages and disadvantages of participating in the Cafeteria Plan? You save both federal income tax and FICA (Social Security) taxes by participating in the Cafeteria Plan. There is an example in the Plan Information Summary that illustrates the tax savings you might experience as a result of participating in the Cafeteria Plan. Cafeteria Plan participation will reduce the amount of your taxable compensation. Accordingly, there could be a decrease in your Social Security benefits and/or other benefits (e.g., pension, disability and life insurance) that are based on taxable compensation. Q-6. What are the election periods for entering the Cafeteria Plan? The Cafeteria Plan basically has three election periods: (1) the "Initial Election Period," (2) the "Annual Election Period," and (3) the "Election Change Period, which is the period following the date you have a Change in Status Event (described below). The Plan Year is generally a 12 - month period (except during the initial or last Plan Year of the Plan). The beginning and ending dates of the Plan Year are described in the Plan Information Summary. The following is a summary of the Initial Election Period and the Annual Election Period. 6-a. What is the Initial Election Period? If you want to participate in the Cafeteria Plan when you are first hired, you must enroll during the "Initial Election Period" described in the enrollment materials you will receive. If you make an election during the Initial Election Period, your participation in this ' Cafeteria Plan will begin on the )ater of your Eligibility Date or the first pay period coinciding with or next following the date that your election is received. The effective date of coverage under the Benefit Plan Options will be effective on the date established in the governing documents of the Benefit Plan Options. The election that you make during the Initial Election Period is effective for the remainder of the Plan Year and generally cannot be changed during the Plan Year unless you have a Change in Status Event described in Q-8. below. If you do not make an election during the Initial Election Period, you will be deemed to have elected not to participate in this Cafeteria Plan for the remainder of the Plan Year. Failure to make an election under this Cafeteria Plan generally results in no coverage under the Benefit Plan Options; however, the Employer may provide coverage under certain Benefit Plan Options automatically. These automatic benefits are called "Default Benefits" Any Default Benefit provided by your Employer will be identified in the enrollment material. In addition, your share of the contributions for such Default Benefits may be automatically withdrawn from your pay on a pre-tax basis. You will be notified in the enrollment material whether there will be a corresponding Pre-tax Contribution for such default benefits. 6-b. What is the Annual Election Period? The Cafeteria Plan also has an "Annual Election Period" during which you may enroll if you did not enroll during the Initial Election Period or change your elections for the next Plan Year. The Annual Election Period will be identified in the enrollment material distributed to you prior to the Annual Election Period. The election that you make during the Annual Election Period is effective the first day of the next Plan Year and cannot be changed during the entire Plan Year unless you have a Change in Status Event described IFlex -SPD -072005 4 below. If you fail to complete, sign and file a Salary Reduction Agreement during the Annual Election Period, you may be deemed to have elected to continue participation in the Cafeteria Plan with the same Benefit Plan Option elections that you had on the last day of the Platt Year in which the Annual Election period occurred (adjusted to reflect any increase/decrease in applicable premium/contributions). This is called an "Evergreen Election." Alternatively, the Plan Administrator may deem you to have elected not to participate in the Cafeteria Plan for the next Plan Year if you fail to make an election during the Annual Election Period) . The consequences of failing to make an election under this Cafeteria Plan during the Annual Election Period are described in the Plan Information Summary. Special Rule for Reimbursement Accounts (and Health Savings Account contribution elections, if offered under the Plan): Evergreen Elections do not apply to Reimbursement Accounts (and Health Savings Account contribution elections) unless specifically stated by the employer in the enrollment material. Consequently, you generally must make an election each Annual Election Period in order to participate in the Reimbursement Accounts during the next Plan Year. Q-7. How is my Benefit Plan Option coverage paid for under this Plan? You may be required to pay for any Benefit Plan Option coverage that you elect with Pre-tax Contributions. Alternatively, the Employer may allow you to pay your share of the contributions with after-tax contributions. The enrollment material you receive will indicate whether you have to pay with Pre -Tax Contributions or whether you have an option to choose to pay with after-tax contributions. When you elect to participate both in a Benefit Plan Option and this Cafeteria Plan, an amount equal to your share of the annual cost of those Benefit Plan Options that you choose divided by the applicable number of pay periods you have during that Plan Year is deducted from each paycheck after, your election date. If you have chosen to use Pre-tax Contributions (or it is a plan requirement), the deduction is made before any applicable federal and/or state taxes are withheld. An Employer may choose to pay for a share of the cost of the Benefit Plan Options you choose with Nonelective Employer Contributions. The amount of Nonelective Employer Contributions that is applied by the Employer towards the cost of the Benefit Plan Option(s) for each Participant and/or level of coverage is subject to the sole discretion of the Employer and it may be adjusted upward or downward in the Employer's sole discretion at any time. The Nonelective Employer Contribution amount will be calculated for each Plan Year in a uniform and nondiscriminatory manner and may be based upon your dependent status, commencement or termination date of your employment during the Plan Year, and such other factors that the Employer deems relevant. In no event will any Nonelective Contribution be disbursed to you in the form of additional, taxable compensation except as otherwise provided in the enrollment material or in the Plan information Summary. The Employer may provide you with employer contributions over which you have discretion to choose how to apply to the various Benefit Plan Options available under the Cafeteria Plan. These elective employer contributions are called "Flexible Credits" or "Benefit Credits". The Flexible or Benefit Credit amounts provided by the Employer, if any, and any restrictions on their use, will be set forth in the enrollment material. Flex -SPD -072005 ' Q-8. Under what circumstances can I change my election during the Plan Year? Generally, you cannot change your election under this Cafeteria Plan during the Plan Year. There are, however, a few exceptions. First, your election will automatically terminate if you terminate employment or lose eligibility under this Cafeteria Plan or under all of the Benefit Plan Options that you have chosen. Second, you may voluntarily change your election during the Plan Year if you satisfy the following conditions (prescribed by federal law); • You experience a "Change in Status Event' that affects your eligibility under this Cafeteria Plan and/or a Benefit Plan Option; or • You experience a significant cost or coverage change; and • You complete and submit a written Election Change Form within the Election Change period described in the Plan Information Summary. Change in Status Events and Cost or Coverage Changes recognized by this Cafeteria Plan, and the rules surrounding election changes in the event you experience a Change in Status Event or Cost or Coverage Change are described in the Election Change Chart attached to this SPD. An election under this Cafeteria Plan may be modified during the Plan Year if you are a Key Employee or Highly Compensated Individual (as defined by the Internal Revenue Code), if necessary to prevent the Cafeteria Plan from becoming discriminatory within the meaning of the applicable federal income tax law. If coverage under a Benefit Plan Option ends, the corresponding Pre-tax Contributions for that ' coverage will automatically end. No election is needed to stop the contributions. Q-9. What happens to my participation under the Cafeteria Plan if I take a leave of absence? The following is a general summary of the rules regarding participation in the Cafeteria Plan (and the Benefit Plan Options) during a leave of absence. The specific election changes that you can make under this Cafeteria Plan following a leave of absence are described in the Election Change Chart and the rules regarding coverage under the Benefit Plan Options during a leave of absence will be described in the Benefit Plan Option summaries. If there is a conflict between the Election Change Chart/Benefit Plan Option Summaries and this Q-9, the Election Change Chart or Benefit Plan Option summary, whichever is applicable, controls. 1 Flex -SPD -072005 • If you go on a qualifying unpaid leave under the Family and Medical Leave Act of 1993 (FMLA), the Employer will continue to maintain your Benefit Plan Options that provide health coverage on the same terms and conditions as though you were still active to the extent required by FMLA (e.g., the Employer will continue to pay its share of the contribution to the extent you opt to continue coverage). • Your Employer may elect to continue all health coverage for Participants while they are on paid leave (provided Participants on non-FMLA paid leave are required to continue coverage). if so, you will pay your share of the contributions by the method normally used during any paid leave (for example, with Pre-tax Contributions if that is what was used before the FMLA leave began). • In the event of unpaid FMLA leave (or paid leave where coverage is not required to be continued), if you opt to continue your group health coverage, you may pay your share of the contribution in one of the following ways: (1) with after-tax dollars while you are on leave, (2) by pre -paying all or a portion of your share of the contribution for the expected duration of the leave with Pre-tax Contributions from your pre -leave compensation by making a special election to that effect before the date such compensation would normally be made available to you. However, pre -payments of Pre-tax Contributions may not be utilized to fund coverage during the next Plan Year; or (3) by other arrangements agreed upon between you and the Plan Administrator (for example, the Plan Administrator may fund coverage during the leave and withhold amounts from your compensation upon your return from leave). The payment options provided by the Employer will be established in accordance with Code Section 125, FMLA and the Employer's internal policies and procedures regarding leaves of absence and will be applied uniformly to all Participants. Alternatively, the Employer may require all Participants to continue coverage during the leave. If so, you may elect to discontinue your share of the required contributions until you return from leave. Upon return from leave, you will be required to repay the contribution not paid during the leave in a manner agreed upon with the Administrator. The Election Change Chart will let you know whether you are able to drop your coverage or whether you are required to continue coverage during the leave. • If your coverage ceases while on FMLA leave (e.g., for non-payment of required contributions), you will be permitted to re-enter the Cafeteria Plan and the Benefit Plan Option upon return from such leave on the same basis as you were participating in the plans prior to the leave, or as otherwise required by the FMLA. Your coverage under the Benefit Plan Options providing health coverage may be automatically reinstated provided that coverage for Employees on non-FMLA leave is automatically reinstated upon return from leave. • The Employer may, on a uniform and consistent basis, continue your group health coverage for the duration of the leave following your failure to pay the required contribution. Upon return from leave, you will be required to repay the contribution in a manner agreed upon by you and the Employer. • If you are commencing or returning from unpaid FMLA leave, your election under this Cafeteria Plan for Benefit Plan Options providing non -health benefits shall be treated in the same manner that elections for non -health Benefit Plan Options are treated with respect to Participants commencing and returning from unpaid non-FMLA leave. • If you go on an unpaid non-FMLA leave of absence (e.g., personal leave, sick leave, etc.) that does not affect eligibility in this Cafeteria Plan or a Benefit Plan Option offered Flex -SPD -072005 ' under this Cafeteria Plan, then you will continue to participate and the contribution due will be paid by pre -payment before going on leave, by after-tax contributions while on leave, or with catch-up contributions after the leave ends, as may be determined by the Administrator. If you go on an unpaid leave that affects eligibility under this Cafeteria Plan or a Benefit Plan Option, the election change rules described herein will apply. The Plan Administrator will have discretion to determine whether taking an unpaid non- FMLA leave of absence affects eligibility. Q-10. How long will the Cafeteria Plan remain in effect? Although the Employer expects to maintain the Cafeteria Plan indefinitely, it has the right to modify or terminate the Cafeteria Plan at any time and for any reason. Plan amendments and terminations will be conducted in accordance with the terms of the Plan Document. Q -I1. What happens if my request for a benefit under this Cafeteria Plan (e.g. an election change or other issue germane to Pre-tax Contributions) is denied? You will have the right to a full and fair review process. You should refer to Appendix 1 for a detailed summary of the Claims Procedures under this Plan. Flex -SPD -072005 HEALTHCARE FSA COMPONENT SUMMARY Q-1. Who can participate in the Healthcare FSA? Each employee who satisfies the Healthcare FSA Eligibility requirements is eligible to participate on the Healthcare FSA Eligibility Date. The Healthcare FSA Eligibility Requirements and Eligibility Date are described in the Plan Information Summary. Q-2. How do I become a Participant? If you have otherwise satisfied the Healthcare FSA's Eligibility requirements, you become a participant in the Healthcare FSA by electing Healthcare Reimbursement benefits during the Initial or Annual Election Periods described in the Cafeteria Plan Summary. Your participation in the Healthcare FSA will be effective on the date that you make the election or your Healthcare FSA Eligibility Date, whichever is later. If you have made an election to participate and you want to participate during the next Plan Year, you must make an election during the Annual Election Period, even if you do not change your current election. Evergreen elections do not apply to Healthcare FSA elections. You may also become a participant if you experience a change in status event or cost or coverage change that permits you to enroll mid year (see Q -S. of the Cafeteria Plan Summary for more details regarding mid year election changes and the effective date of those changes). Once you become a Participant, your "Eligible Dependents" also become covered. For purposes of the Healthcare FSA, Eligible Dependents are the following: a) Your legal Spouse (as determined by state law to the extent consistent with the federal Defense of Marriage Act); and b) Any other individual who would qualify as a tax Dependent under Code Section 105 and the regulations issued by Treasury under Code Section 106). If the Plan Administrator receives a qualified medical child support order (QMCSO) relating to the Healthcare FSA, the Healthcare FSA will provide the health benefit coverage specified in the order to the person or persons ("alternate recipients") named in the order to the extent the QMCSO does not require coverage the Healthcare FSA does not otherwise provide. "Alternate recipients" include any child of the participant who the Plan is required to cover pursuant to a QMCSO. A "medical child support order" is a legal judgment, decree or order relating to medical child support. A medical child support order is a QMCSO to the extent it satisfies certain conditions required by law. Before providing any coverage to an alternate recipient, the Plan Administrator must determine whether the medical child support order is a QMCSO. If the Plan Administrator receives a medical child support order relating to your Healthcare Account, it will notify you in writing, and after receiving the order, it will inform you of its determination of whether or not the order is qualified. Upon request to the Plan Administrator, you may obtain, without charge, a copy of the Plan's procedures governing qualified medical child support orders. NOTE: You may be able to elect to cover only yourself under the Healthcare FSA tothe extent chosen by your Employer in the Plan Information Summary. This would allow your spouse to Flex -SPD -072005 9 establish a Health Savings Account as defined in Code Section 223. If this option is available, it will be described in more detail in the Plan Information Summary. Q-3. What is my "Healthcare Account?" If you elect to participate in the Healthcare FSA, the Employer will establish a "Healthcare Account" to keep a record of the reimbursements you are entitled to, as well as the contributions you elected to withhold for such benefits during the Plan Year. No actual account is established; it is merely a bookkeeping account. Benefits under the Healthcare FSA are paid as needed from the Employer's general assets except as otherwise set forth in the Plan Information Summary. Q4. When does coverage under the Healthcare FSA end? Your coverage under the Healthcare FSA ends on the earlier of the following to occur: a) The date that you elect not to participate in accordance with the Cafeteria Plan Summary; b) The last day of the Plan Year unless you make an election during the Annual Election Period; c) The date that you no longer satisfy the Healthcare FSA Eligibility Requirements; d) The date that you terminate employment; or e) The date that the Plan is terminated or you or the class of eligible employees of which you are a member are specifically excluded from the Plan. You may be entitled to elect Continuation Coverage (as described in Q-16. below) under the Healthcare FSA once your coverage ends because you terminate employment or experience a reduction in hours of employment. Coverage for your Eligible Dependents ends on earliest of the following to occur: a) The date your coverage ends; b) The date that your dependents cease to be eligible dependents (e.g, you and your spouse divorce); c) The date the Plan is terminated or amended to exclude the individual or the class of Dependents of which the individual is a member from coverage under the Healthcare FSA. You and/or your covered dependents may be entitled to continue coverage if coverage is lost for certain reasons. The continuation of coverage provisions are described in more detail below. Q-5. Can I ever change my Healthcare FSA election? You can change your election under the Healthcare FSA in the following situations: a) For any reason during the Annual Election Period. You can change your election during the Annual Election Period for any reason. The election change will be effective the first day of the Plan Year following the end of the Annual Election Period. b) Following a Change In Status Event. You may change your Healthcare FSA election during the Plan Year only if you experience an applicable Change in Status Event. See Q-8. of the Cafeteria Plan Summary for more information on election changes. . Flex -SPD -072005 119 NOTE: You may not make Healthcare FSA election changes as a result of any cost or coverage changes. Q-6. What happens to my Healthcare Account if I take an approved leave of absence? Refer to the Cafeteria Plan Summary and the Election Change Chart to determine what, if any, specific changes you can make during a leave of absence. If your Healthcare FSA coverage ceases during an FMLA leave, you may, upon returning from FMLA leave, elect to be reinstated in the Healthcare FSA at either a) the same coverage level in effect before the FMLA leave (with increased contributions for the remaining period of coverage) or b) at the same coverage level that is reduced pro -rata for the period of FMLA leave during which you did not make any contributions. Under either scenario, expenses incurred during the period that your Healthcare FSA coverage was not in effect are not eligible for reimbursement under this Healthcare FSA. Q-7. What is the maximum annual Healthcare Reimbursement that I may elect under the Healthcare FSA, and how much will it cost? You may elect any annual reimbursement amount subject to the maximum annual Healthcare Reimbursement Amount and Minimum Reimbursement Amount described in the Plan Information Summary. You will be required to pay the annual contribution equal to the coverage level you have chosen reduced by any Nonelective Employer Contributions and/or Benefit Credits allocated to your Healthcare Account. Any change in your Healthcare FSA election also will change the maximum available reimbursement for the period of coverage after the election. Such maximum available reimbursements will be determined on a prospective basis only by a method determined by the Plan Administrator that is in accordance with applicable law. The Plan Administrator (or its designated claims administrator) will notify you of the applicable method when you make your election change. Q-8. How are Health Care Reimbursement benefits paid for under this Plan? When you complete the Salary Reduction Agreement, you specify the amount of Healthcare Reimbursement you wish to pay for with Pre-tax Contributions and/or Nonelective Employer Contributions (or Benefit Credits), to the extent available. Your enrollment material will indicate if Nonelective Contributions or Benefit Credits are available for Healthcare FSA coverage. Thereafter, each paycheck will be reduced by an amount equal to a pro -rata share of the annual contribution, reduced by any Nonelective Employer Contributions and/or Benefit Credits allocated to your Healthcare Account. Q-9. What amounts will be available for Healthcare Reimbursement at any particular time during the Plan Year? So long as coverage is effective, the full, annual amount of Healthcare Reimbursement you have elected, reduced by the amount of previous Healthcare Reimbursements received during the Year, will be available at any time during the Plan Year, without regard to how much you have contributed. Flex -SPD -072005 11 Q-10. How do I receive reimbursement under the Healthcare FSA? Under this Healthcare FSA, you have two reimbursement options. You can complete and submit a written claim for reimbursement (see "Traditional Paper Claims" below for more information). Alternatively, you can use an electronic payment card (see "Electronic Payment Card" below for more information) to pay the expense. In order to be eligible for the Electronic Payment Card, you must agree to abide by the terms and conditions of the Electronic Payment Card Program (the "Program") as set forth herein and in the Electronic Payment Cardholder Agreement (the "Cardholder Agreement") including any fees applicable to participate in the program, limitations as to card usage, the Plan's right to withhold and offset for ineligible claims, etc. The following is a summary of how both options work. Traditional Paper Claims: When you incur an Eligible Medical Expense, you may file a claim with the Plan's Third Party Administrator by completing and submitting a Request for Reimbursement Form. You may obtain a Request for Reimbursement Form from the Plan Administrator or the Third Party Administrator. You must include with your Request for Reimbursement Form a written statement from an independent third party (e.g., an itemized statement, EOB, etc.) associated with each expense that indicates the following: a) The nature of the expense (e.g. what type of service or treatment was provided). If the expense is for an over the counter drug, the written statement must indicate the name of the drug; b) The date(s) of service; c) The name of the provider; d) The amount of the expense; and e) The patient's name The Third Party Administrator will process the claim once it receives the Request for Reimbursement Form from you. Reimbursement for expenses that are determined to be Eligible Medical Expenses will be made as soon as possible after receiving the claim and processing it. If the expense is determined to not be an "Eligible Medical Expense" you will receive notification of this determination. You must submit all claims for reimbursement for Eligible Medical Expenses during the Plan Year in which they were incurred or during the Run Out Period. The Run Out Period is described in the Plan Information Summary, Electronic Payment Card: The Electronic Payment Card allows you to pay for Eligible Medical Expenses at the time that you incur the expense. Here is how the Electronic Payment Card works. a) You must make an electron to use the card. In order to be eligible for the Electronic Payment Card, you must agree to abide by the terms and conditions of the Program as set forth herein and in the Electronic Payment Cardholder Agreement (the "Cardholder Agreement") including any fees applicable to participate in the Program, limitations as to card usage, the Plan's right to withhold and offset for ineligible claims, etc. You must agree to abide by the terms of the Program both during the Initial Election Period and during each Annual Election Period. A Cardholder Agreement will be provided to you. The card will be turned off effective the first day of each Plan Year if you do not affirmatively agree. to abide by the terms of the Program during the preceding Annual Flex -SPD -072005 12 Election Period. The Cardholder Agreement is part of the terms and conditions of your Plan and this SPD. b) The card will be turned off when employment or coverage terminates. The card will be turned off when you terminate employment or coverage under the Plan, You may not use the card during any applicable COBRA continuation coverage period. c) You must cert proper use of the card. As specified in the Cardholder Agreement, you certify during the applicable Election Period that the amounts in your Healthcare FSA will only be used for Eligible Medical Expenses (i.e. medical care expenses incurred by you, your spouse, and your tax dependents) and that you have not been reimbursed for the expense and that you will not seek reimbursement for the expense from any other source. Failure to abide by this certification will result in termination of card use privileges. d) Healthcare FSA reimbursement under the card is limited to healthcare providers (including pharmacies). Use of the card for Healthcare FSA expenses is limited to merchants who are healthcare providers (doctors, pharmacies, etc.). As set forth in the Cardholder Agreement, you will not be able to use the card at a regular retail store — e.g., a supermarket, grocery store, or discount store with a pharmacy. e) You swipe the card at the health care provider like you do any other credit or debit card. When you incur an Eligible Medical Expense at a doctor's office or pharmacy, such as a co -payment or prescription drug expense, you swipe the card at the provider's office much like you would a typical credit or debit card. The provider is paid for the expense up to the maximum reimbursement amount available under.the Healthcare FSA (or as otherwise limited by the program) at the time that you swipe the card. Every time you swipe the card, you certify to the Plan that the expense for which payment under the Healthcare FSA is being made is an Eligible Medical Expense and that you have not been reimbursed from any other source nor will you seek reimbursement from another source. I) You must obtain and retain a receipt/third parry statement each time you swipe the card, You must obtain a third party statement from the healthcare provider (e.g,, receipt, invoice, etc.) that includes the following information each time you swipe the card: • The nature of the expense (e.g. what type of service or treatment was provided). If the expense is for an over the counter drug, the written statement must indicate the name of the drug; • The date(s) of service; • The name of the provider; • The amount of the expense; and • The patient's name You must retain this receipt for one year following the close of the Plan year in which the expense is incurred. Even though payment is made under the card arrangement, a written third party statement is required to be submitted (except as otherwise provided in the Cardholder Agreement). You will receive a letter from the Claims Administrator that a third party statement is needed. You must provide the third party statement to the Claims Administrator within 45 days (or such longer period provided in the letter from the Claims Administrator) of the request. g) There are situations where the third party statement will not be required to, be provided to the Claims Administrator. There may be situations in which you will not be required Flex -SPD -072005 13 to provide the written statement to the claims administrator. More detail as to which situations apply under your Plan is specified in the Cardholder Agreement: • Co -Pay Match: As specified in the Cardholder Agreement, no written statement is necessary if the Electronic Payment Card payment matches a specific co- payment you have under the component medical plan for the particular service that was provided. For example, if you have a $10 co -pay for physician office visits, and the payment was made to a physician office in the amount of $10, you will not be required to provide the third party statement to the Claims Administrator. • Previously Approved Claim Match: As specified in the Cardholder Agreement, no written statement is required if the expense is the same as the amount, duration and provider as a previously approved expense For example, the claims administrator approves a 30 count prescription with 3 refills that was purchased at ABC Pharmacy. Each time the card is swiped for subsequent refills at ABC Pharmacy the receipt need not be provided to the Claims Administrator if the expense incurred is the same amount. • Provider Match Program: As specified in the Cardholder Agreement, no third party statement is required to be submitted to the Claims Administrator if the electronic claim file is accompanied by an electronic or written confirmation from the healthcare provider (e.g., your prescription benefits manager) that identifies the nature of your expense and verifies the amount. Note: You should still obtain the third party receipt when you incur the expense and ' swipe the card, even if you think it will not be needed, so that you will have it in the event the Claims Administrator does request it. h) You must payback any improperly paid claims. If you are unable to provide adequate or timely substantiation as requested by the Claims Administrator, you must repay the Plan for the unsubstantiated expense as set forth below. In addition, your usage of the card may be terminated by the Employer. i) You can use either the payment card or the traditional paper claims approach. You have the choice as to how to submit your eligible claims. If you elect not to use the electronic payment card, you may also submit claims under the Traditional Paper Claims approach discussed above. Claims for which the Electronic Payment Card has been used cannot be submitted as Traditional Paper Claims. Q-11. What is an "Eligible Medical Expense'? lI-a. General Rule An "Eligible Medical Expense" is an expense that has been incurred by you and/or your eligible dependents that satisfies the following conditions: a) The expense is for "medical care" as defined by Code Section 213(d); and b) The expense has not been reimbursed by any other source and you will not seek reimbursement for the expense from any other source. Flex -SPD -072005 14 The Code generally defines "medical care" as any amounts incurred to diagnose, treat or prevent a specific medical condition or for purposes of affecting any function or structure of the body. This includes, but is not limited to, both prescription and over the counter drugs (and over the counter products & devices). Not every health related expense you or your eligible dependents incur constitutes an expense for "medical care." For example, an expense is not for "medical care", as that term is defined by the Code, if it is merely for the beneficial health of you and/or your eligible dependents (e.g. vitamins or nutritional supplements that are not taken to treat a specific medical condition) or for cosmetic purposes, unless necessary to correct a deformity arising from illness, injury, or birth defect. You may, in the discretion of the Third Party Administrator/Plan Administrator, be required to provide additional documentation from a healthcare provider showing that you have a medical condition and/or the particular item is necessary to treat a medical condition. Expenses for cosmetic purposes are also not reimbursable unless they are necessary to correct an abnormality caused by illness, injury or birth defect. In addition, certain expenses that might otherwise constitute "medical care" as defined by the Code are not reimbursable under any Healthcare FSA (per IRS regulations): a) Health insurance premiums; b) Expenses incurred for qualified long term care services; and c) Any other expenses that are specifically excluded by the Employer as set forth in the Plan Information Summary. ll -b. Limited Reimbursement Option You may be able to make a special election under this Healthcare FSA to limit the scope of reimbursement that will enable you or your spouse to participate in a Health Savings Account (as defined in Code Section 223). If that option is available, it will be described in more detail in the Plan Information Summary. Q-12. When must the expenses be incurred in order to receive reimbursement? Eligible Medical Expenses must be incurred during the Plan Year and while you are a participant in the Plan. "Incurred" means that the service or treatment giving rise to the expense has been provided. If you pay for an expense before you are provided the service or treatment, the expense may not be reimbursed until you have been provided the service or treatment. You may not be reimbursed for any expenses arising before the Healthcare FSA becomes effective, before your Salary Reduction Agreement or Election Form becomes effective, or for any expenses incurred after the close of the Plan Year, or, after a separation from service or loss of eligibility (except for expenses incurred during an applicable COBRA continuation period). Q-13. What if the Eligible Medical Expenses I incur during the Plan Year are less than the annual amount I have elected for Healthcare Reimbursement? You will not be entitled to receive any direct or indirect payment of any amount that represents the difference between the actual Eligible Medical Expenses you have incurred and the annual coverage level you have elected. Any amount allocated to a Healthcare Account will be forfeited by the Participant and restored to the Employer if it has not been applied to provide reimbursement for expenses incurred during the Plan Year that are submitted for reimbursement within the Run Out period described in the Plan Information Summary. Amounts so forfeited Flex -SPD -072005 15 shall be used to offset administrative expenses and future costs, and/or applied in a manner that is consistent with applicable rules and regulations (per the Plan Administrator's sole discretion). Q-14 What happens if a Claim for Benefits under the Healthcare FSA is denied? You will have the right to a full and fair review process. You should refer to Appendix I for a detailed summary of the Claims Procedures under this Plan. Q-15. What happens to unclaimed Healthcare Reimbursements? Any Healthcare Reimbursement benefit payments that are unclaimed (e.g., uncashed benefit checks) by the close of the Plan Year following the Plan Year in which the Eligible Medical Expense was incurred shall be forfeited. Q-16. What is COBRA continuation coverage? Federal law requires most private and governmental employers sponsoring group health plans to offer employees and their families the opportunity for a temporary extension of healthcare coverage (called "continuation coverage") at group rates in certain instances where coverage under the plans would otherwise end. These rules apply to this Healthcare FSA unless the Employer sponsoring the Healthcare FSA is not subject to these rules (e.g., the employer is a "small employer" or the Healthcare FSA is a church Plan). The Plan Administrator can tell you whether the Employer is subject to federal COBRA continuation rules (and thus subject to the following rules). These rules are intended to summari4e the continuation rights set forth under ' federal law. If federal law changes, only the rights provided under applicable federal law will apply. To the extent that any greater rights are set forth herein, they shall not apply. When Coverage Mav Be Continued Only "Qualified Beneficiaries" are eligible to elect continuation coverage if they lose coverage as a result of a Qualifying Event. A "Qualified Beneficiary" is the Participant, covered Spouse and/or covered dependent child at the time of the qualifying event. A Qualified Beneficiary has the right to continue coverage if he or she loses coverage (or should have lost coverage) as a result of certain qualifying events. The table below describes the qualifying events that may entitle a Qualified Beneficiary to continuation coverage: 111 1111MENIJIM111M Covered Employee Covered Spouse Covered Dependent 1. Covered Employee's Termination of employment or reduction in hours of employment 2. Divorce or Legal Separation 3. Child ceasing to be an eligible dependent 4. Death of the covered employee Flex -SPD -072005 16 TyRe of Continuation Coverage If you choose continuation coverage, you may continue the level of coverage you had in effect immediately preceding the qualifying event. However, if Plan benefits are modified for similarly situated active employees, then they will be modified for you and other Qualified Beneficiaries as well. After electing COBRA coverage, you will be eligible to make a change in your benefit election with respect to the Healthcare FSA upon the occurrence of any event that permits a similarly situated active employee to make a benefit election change during a Plan Year. If you do not choose continuation coverage, your coverage under the Healthcare FSA will end with the date you would otherwise lose coverage. Notice Requirements You or your covered Dependents (including your Spouse) must notify the COBRA Administrator (if a COBRA Administrator is not identified in the Plan Information Summary, then contact the Plan Administrator) in writing of a divorce, legal separation, or a child losing dependent status under the Pian within 60 days of the later of (i) date of the event (ii) the date on which coverage is lost because of the event. Your written notice must identify the qualifying event, the date of the qualifying event and the qualified beneficiaries impacted by the qualifying event. When the COBRA Administrator is notified that one of these events has occurred, the Plan Administrator will in turn notify you that you have the right to choose continuation coverage by sending you the appropriate election forms. Notice to an employee's Spouse is treated as notice to any covered Dependents who reside with the Spouse. You may be required to provide additional information/documentation to support that a particular qualifying event has occurred (e,g. divorce decree). An employee or covered Dependent is responsible for notifying the COBRA Administrator if he or she becomes covered under another group health plan. Election Procedures and Deadlines Each qualified beneficiary is entitled to make a separate election for continuation coverage under the Plan if they are not otherwise covered as a result of another Qualified Beneficiary's election. In order to elect continuation coverage, you must complete the Election Form(s) and return it to the COBRA Administrator identified in the Plan Information Summary within 60 days from the date you would lose coverage for one of the reasons described above or the date you are sent notice of your right to elect continuation coverage, whichever is later. Failure to return the election form within the 60 -day period will be considered a waiver of your continuation coverage tights. Cost You will have to pay the entire cost of your continuation coverage. The cost of your continuation coverage will not exceed 102% of the applicable premium for the period of continuation coverage. The first contribution after electing continuation coverage will be due 45 days after you make your election. Subsequent contributions are due the I' day of each month; however, you have a 30 -day grace period following the due date in which to. make your contribution. Failure to make contributions within this time period will result in automatic termination of your continuation coverage. Flex -SPD -072005 17 When Continuation Coverage Ends The maximum period for which coverage may be continued is the end of the Plan Year in which the qualifying event occurs. However, in certain situations, the maximum duration of coverage nuay be 18 or 36 months from the qualifying event (depending on the type of qualifying event and the level of Non -Elective contributions provided by the Employer). You will be notified of the applicable maximum duration of continuation coverage when you have a qualifying event. Regardless of the maximum period, continuation coverage may end earlier for any of the following reasons: a) If the contribution for your continuation coverage is not paid on time or it is significantly insufficient (Note: if your payment is insufficient by the lesser of 10% of the required premium, or $50, you will be given 30 days to cure the shortfall); b) If you become covered under another group health plan and are not actually subject to a pre-existing condition exclusion limitation; c) If you become entitled to Medicare; or d) If the employer no longer provides group health coverage to any of its employees. Q-17. What happens if I receive erroneous or excess reimbursements? If, as of the end of any Plan Year, it is determined that you have received payments under this Healthcare FSA that exceed the amount of Eligible Medical Expenses that have been properly substantiated during the Plan Year as set forth in this SPD or reimbursements have been made in ' error (e.g. reimbursements were made for expenses incurred for the care of an individual who was not a qualifying individual), the Plan Administrator may recoup the excess reimbursements in one or more of the following ways: a) The Plan Administrator will notify you of any such excess amount, and you will be required to repay the excess amount to the Employer within sixty (60) days of receipt of such notification; b) The Plan Administrator may offset the excess reimbursement against any other Eligible Medical Expenses submitted for reimbursement (regardless of the Plan Year in which submitted); and/or c) The Plan Administrator may withhold such amounts from your pay (to the extent permitted under applicable law). If the Plan Administrator is unable to recoup the excess reimbursement by the means set forth above, the Plan Administrator will notify the Employer that the funds could not be recouped and the Employer will treat the excess reimbursement as it would any other bad business debt. This could result in adverse income tax consequences to you. Q-18. Will my health information be kept confidential? Under the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") group health plans such as the Healthcare FSA and the third party service providers are required to take steps to ensure that certain "protected health information" iskept confidential. You may receive a separate notice that outlines the Employer's health privacy policies. IFlex -SPD -072005 18 a Q-19. How long will the Healthcare FSA remain in effect? Although the Employer expects to maintain the Plan indefinitely, it has the right to modify or terminate the program at any time and for any reason. Flex -SPD -072005 19 MISCELLANEOUS RIGHTS UNDER THE HEALTHCARE FSA ERISA Rights (not applicable to non -ERISA Plans) The Healthcare FSA Plan may be an ERISA welfare benefit plan if your employer is a private employer. If this is an ERISA Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act ("ERISA"). ERISA provides that all plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator's office and at other specified locations, such as work -sites and union halls, all documents governing the plan, 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. Obtain, upon written request to the plan administrator, copies of all documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 series) and updated SPD. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan's annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. ' Continue Group Health Plan Coverage You may continue healthcare coverage for yourself, Spouse or Dependent children if there is a loss of coverage under the Plan as a result of a qualifying event. You or your eligible Dependents will have to pay for such coverage. You should review Q-16. of this Healthcare FSA Summary for more information concerning your COBRA continuation coverage rights. (To the extent the Healthcare FSA is subject to HIPAA's portability rules) You may be eligible for a reduction or elimination of exclusionary periods of coverage for preexisting condition under your group health plan, if you move to another plan and you have creditable coverage from this Plan. If you are eligible for this reduction or elimination, you will he provided a certificate of creditable coverage, free of charge, from the Plan when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage in another plan. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called "fiduciaries" of the plan, have a duty to do so prudently and in the interest of the plan participants and beneficiaries. No one, including your employer, your union, or any other 1 Flex -SPD -072005 20 person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit from the plan, or from exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit under an ERISA -covered plan is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have the right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request materials from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan 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 that is denied or ignored in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the plan's decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. 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. Assistance with Your Questions If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance obtaining documents from the plan administrator, you should contact the nearest office of the U.S. Department of Labor, Employee Benefits Security Administration listed in your telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Ave., 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. Newborns' and Mothers' Health Protection Act of 1996 Group health plans and health insurance issuers 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). Flex -SPO -072005 21 DEPENDENT CARE FSA COMPONENT SUMMARY Q- 1. Who can participate in the Plan? Each employee who satisfies the Dependent C participate in the Dependent Care FSA on th Dependent Care FSA Eligibility Requirements Information Summary. Q-2. How do I become a Participant? ue.FSA Eligibility Requirements is eligible to Dependent Care FSA Eligibility Date. The and Eligibility Date are described in the Plan If you have otherwise satisfied the Dependent Care FSA's Eligibility Requirements, you become a participant in the Dependent Care FSA by electing Dependent Care Reimbursement benefits during the Initial or Annual Election Periods described in Q-8. of the Cafeteria Plan Summary. Your participation in the Dependent Care FSA will be effective on the date that you make the election or your Dependent Care FSA Eligibility Date, whichever is later. If you have made an election to participate and you want to participate during the next Plan Year, you must make an election during the Annual Election Period, even if you do not change your current election. Evergreen elections do not apply to Dependent Care FSA elections. You may also become a participant if you experience a change in status event or cost or coverage change that permits you to enroll mid year (see Q-8. of the Cafeteria Plan Summary for more details regarding mid year election changes and the effective date of those changes). Q-3. What is my "Dependent Care Account"? If you elect to participate in the Dependent Care FSA, the Employer will establish a "Dependent Care Account' to keep a record of the reimbursements you are entitled to, as well as the contributions you elected to withhold for such benefits during the Plan Year. No actual account is established; it is merely a bookkeeping account. Benefits under the Dependent Care FSA are paid as needed from the Employer's general assets except as otherwise set forth in the Plan Information Summary. Q-4. When does my coverage under the Dependent Care FSA end? Your coverage under the Dependent Care FSA ends on the earlier of the following to occur: a) The date that you elect not to participate in accordance with the Cafeteria Plan Summary; b) The last day of the Plan Year unless you make an election during the Annual Election Period; c) The date that you no longer satisfy the Dependent Care FSA Eligibility Requirements; d) The date that you terminate employment; or e) The date that the Plan is terminated or you or the class of eligible employees of which you are a member are specifically excluded from the Plan. If you terminate employment or you cease to be eligible during the Plan Year, you may submit for reimbursement Eligible Employment Related Expenses incurred after the date of separation Flex -SPD -072005 22 up to the amount of your Dependent Care Account to the extent set forth in the Plan Information Summary. Q-5. Can I ever change my Dependent Care FSA election? You can change your election under the Dependent Care FSA in the following situations: a) For any reason during the Annual Election Period You can change your election during the Annual Election Period for any reason. The election change will be effective the first day of the Plan Year following the end of the Annual Election Period. b) Following a Change In Status Event or Cost or Coverage Change. You may change your Dependent Care FSA election Anigg the Plan Year only if you experience an applicable Change in Status Event or there is a significant cost or coverage change. See Q-8. of the Cafeteria Plan Summary for more information on election changes. Q-6. What happens to my Dependent Care Account if I take an unpaid leave of absence? Refer to the Cafeteria Plan Summary and the Election Change Chart to determine what, if any, specific changes you can make during a leave of absence. Q-7. What is the maximum annual Dependent Care Reimbursement that I may elect under the Dependent Care FSA? The annual amount cannot exceed the maximum Dependent Care Reimbursement amount specified in Section 129 of the Internal. Revenue Code. The maximum annual amount is currently $5,000 per Plan Year if you are: a) Married and file a joint return; b) Married but your Spouse maintains a separate residence for the last 6 months of the calendar year, you file a separate tax return, and you furnish more than one-half the cost of maintaining those Dependents for whom you are eligible to receive tax-free reimbursements under the Dependent Care FSA; or c) Single. If you are married and reside together, but file a separate federal income tax return, the maximum Dependent Care Reimbursement that you may elect is $2,500. In addition, the amount of reimbursement that you receive on a, tax free basis during the Plan Year cannot exceed the lesser of your earned income (as defined in Code Section 32) or your spouse's earned income. Your Spouse will be deemed to have earned income of $250 if you have one Qualifying Individual and $500 if you have two or more Qualifying Individuals (described below), for each month in which your Spouse is: a) Physically or mentally incapable of caring forhimselfor herself; or b) A full-time student (as defined by Code Section 21). Q-8. How Do 1 Pay for Dependent Care Reimbursements? When you complete the Salary Reduction Agreement, you specify the amount of Dependent Care Reimbursement you wish to pay for with Pre-tax Contributions and/or Nonelective Employer Flex -SPD -072005 23 Contributions (or Benefit Credits), to the extent available. Your enrollment material will indicate if Nonelective Contributions or Benefit Credits are available for Dependent Care FSA coverage. Thereafter, each paycheck will be reduced by an amount equal to a pro -rata share of the annual contribution, reduced by any Nonelective Employer Contributions and/or Benefit Credits allocated to your Dependent Care Account, Q-9. What is an "Eligible Employment Related Expense" for which I can claim a reimbursement? You may be reimbursed for work-related dependent care expenses ("Eligible Employment Related Expenses"). Generally, an expense must meet all of the following conditions for it to be an Eligible Employment Related Expense: a) The expense is incurred for services rendered after the date of your election to receive Dependent Care Reimbursement benefits and during the calendar year to which it applies. b) Each individual for whom you incur the expense is a "Qualifying Individual." A Qualifying Individual is: An individual age 12 or under who is a "qualifying child" of the Employee as defined in Code Section 152(a)(1). Generally speaking, a "qualifying child" is child (including a brother, sister, step sibling) of the Employee or a descendant of such child (e.g. a niece, nephew, grandchild) who shares the same principal place of abode with you for more than' half the year and does not provide over half of his/her support. In addition, a child of an Employee who is also a Code Section 152 dependent of another individual cannot be a qualifying individual; or • A Spouse or other tax Dependent (as defined in Code Section 152) who is physically or mentally incapable of caring for himself or herself and who has the same principal place of abode as you for more than half of the year. Note: There is a special rule for children of divorced parents. The child is a qualifying individual of the "custodial parent', as defined in Code Section 152(e). c) The expense is incurred for the care of a Qualifying Individual (as described above), or for related household services, and is incurred to enable you (and your Spouse, if applicable) to be gainfully employed. Expenses for overnight stays or overnight camp are not eligible. Tuition expenses for kindergarten (or above) do not qualify. d) If the expense is incurred for services outside your household and such expenses are incurred for the care of a Qualifying Individual who is age 13 or older, such Dependent regularly spends at least 8 hours per day in your home. e) If the expense is incurred for services provided by a dependent care center (i.e., a facility that provides care for more than 6 individuals not residing at the facility), the center complies with all applicable state and local laws and regulations. f) The expense is not paid or payable to a "child" (as defined in Code Section 152(f)(1)) of yours who is under age 19 by the end of the year in which the expense is incurred or an individual for whom you or your Spouse is entitled to a personal tax exemption as a ' Dependent. Flex -SPD -072005 24 g) You must supply the taxpayer identification number for each dependent care service provider to the IRS with your annual tax return by completing IRS Form 2441. You are encouraged to consult your personal tax advisor or IRS Publication 17 "Your Federal Income Tax" for further guidance as to what is or is not an Eligible Employment Related Expense if you have any doubts. In order to exclude from income the amounts you receive as reimbursement for dependent care expenses, you are generally required to provide the name, address and taxpayer identification number of the dependent care service provider on your federal income tax return. Q-10. How do I receive reimbursement under the Dependent Care FSA? If you have elected to participate in the Dependent Care FSA, you will have to take certain steps to be reimbursed for your Eligible Employment Related Expenses. When you incur an Eligible Employment Related Expense, you may file a claim with the Plan's Third Party Administrator by completing and submitting a Request for Reimbursement Form. You may obtain a Request for Reimbursement Form from the Plan Administrator or the Third Party Administrator. If there are enough credits to your Dependent Care Account, you will be reimbursed for your Eligible Employment Related Expenses on the next scheduled processing date. If your claim was for an amount that was more than your current Dependent Care Account balance, the excess part of the claim will be carried over into following months, to be paid out as your balance becomes adequate. Remember, though, that you can't be reimbursed for any total expenses above your available, annual credits to your Dependent Care Account. You may not be reimbursed for any expenses that arise before your Salary Reduction Agreement becomes effective, or for any expense incurred after the close of the Plan Year. To have your claims processed as soon as possible, please read the claims instructions you have been furnished. Please note that it is not necessary that you have actually paid an amount due for Eligible Employment Related Expenses -- only that you have incurred the expense, and that it is not being paid for or reimbursed from any other source. Q-11. When must the expenses be incurred in order to receive reimbursement? Eligible Employment Related Expenses must be incurred during the Plan Year. You may not be reimbursed for any expenses arising before the Dependent Care FSA becomes effective, before your Salary Reduction Agreement or Election Form becomes effective, or for any expenses incurred after the close of the Plan Year and unless noted otherwise in the Plan Information Summary, after your participation in the Dependent Care FSA ends. Q-12. What if the Eligible Employment Related Expenses I incur during the Plan Year are less than the annual amount of coverage I have elected for Dependent Care Reimbursement? You will not be entitled to receive any direct or indirect payment of any amount that represents the difference between the actual Eligible Employment Related Expenses you have incurred, on the one hand, and the annual Dependent Care Reimbursement you have elected and paid for, on the other, Any amount credited to a Dependent Care Account shall be forfeited by the Flex -SPD -072005 125 ' Participant and restored to the Employer if it has not been applied to provide the elected reimbursement for any Plan Year by the end of the Run Out period following the end of the Plan Year for which the election was effective. Amounts so forfeited shall be used to offset reasonable administrative expenses and future costs or as otherwise permitted under applicable law. Q-13. Will I be taxed on the Dependent Care Reimbursement benefits I receive? You will not normally be taxed on your Dependent Care Reimbursement so long as your family's aggregate Dependent Care Reimbursement (under this Dependent Care FSA and/or another employer's dependent care fsa) does not exceed the maximum annual reimbursement limits described above. However, to qualify for tax-free treatment, you will be required to list the names and taxpayer identification numbers on your annual tax return of any persons who provided you with dependent care services during the calendar year for which you have claimed a tax-free reimbursement. Q-14. If I participate in the Dependent Care FSA, will 1 still be able to claim the household and dependent care credit on my federal income tax return? You may not claim any other tax benefit for the tax-free amounts received by you under this Dependent Care FSA, although the balance of your Eligible Employment Related Expenses may be eligible for the dependent care credit. Q-15. What is the household and dependent care credit? ' The household and dependent care credit is an allowance for a percentage of your annual, Eligible Employment Related Expenses as a credit against your federal income tax liability under the U.S. Tax Code. In determining what the tax credit would be, you may take into account only $3,000 of such expenses for one Qualifying Individual, or $6,000 for two or more Qualifying Individuals. Depending on your adjusted gross income, the percentage could be as much as 35% of your Eligible Employment Related Expenses (to a maximum credit amount of $1,050 for one Qualifying Individual or $2,100 for two or more Qualifying Individuals,) to a minimum of 20% of such expenses. The maximum 35% rate must be reduced by 1% (but not below 20%) for each $2,000 portion (or any fraction of $2,000) of your adjusted gross income over $15,000. Illustration: Assume you have one Qualifying Individual for whom you have incurred Eligible Employment Related Expenses of $3,600, and that your adjusted gross income is $21,000. Since only one Qualifying Individual is involved, the credit will be calculated by applying the appropriate percentage to the first $3,000 of the expenses. The percentage is, in tum, arrived at by subtracting one percentage point from 35% for each $2,000 of your adjusted gross income over $15,000. The calculation is: 35%-- [($21,000 - 15,000)/$2,000 X 1%] = 32%. Thus, your tax credit would be $3,000 X 32% _ $960. If you had incurred the same expenses for two or more Qualifying Individuals, your credit would have been $3,600 X 32% _ $1,152, because the entire expense would have been taken into account, notjust the first $3,000. Flex -SPD -072005 26 Q-16. What happens to unclaimed Dependent Care Reimbursements? Any Dependent Care Reimbursements that are unclaimed (e.g., uncashed benefit checks) by the close of the Plan Year following the Plan Year in which the Eligible Employment Related Expense was incurred shall be forfeited. Q-17. What happens if my claim for reimbursement under the Dependent Care FSA is denied? You will have the right to a full and fair review process. You should refer to Appendix IV for a detailed summary of the Claims Procedures under this Plan Q-18. What happens if I receive erroneous or excess reimbursements? If, as of the end of any Plan Year, it is determined that you have received payments under this Dependent Care FSA that exceed the amount of Eligible Employment Related Expenses that have been properly substantiated during the Plan Year as as set forth in this SPD or reimbursements have been made in error (e.g. reimbursements were made for expenses incurred for the care of an individual who was not a qualifying individual), the Plan Administrator may recoup the excess reimbursements in one or more of the following ways: (i) The Plan Administrator will notify you of any such excess amount, and you will be required to repay the excess amount to the Employer within sixty (60) days of receipt of such notification; (ii) The Plan Administrator may offset the excess reimbursement against any other eligible Employment Related Expenses submitted for reimbursement (regardless of the Plan Year in which submitted) or (iii) withhold such amounts from your pay (to the extent permitted under applicable law. If the Plan Administrator is unable to recoup the excess reimbursements by the means set forth in (i) — (iii), the Plan Administrator will notify the Employer that the funds could not be recouped and the Employer will treat the excess reimbursement as it would any other bad business debt. This could result in adverse tax consequences to you. Q-19. How long will the Dependent Care FSA remain in effect? Although the Employer expects to maintain the Plan indefinitely, it has the right to modify or terminate the program at any time for any reason. Flex -SPD -072005 27 L PLAN INFORMATION SUMMARY This Appendix provides information specific to the City of San Juan Capistrano's Cafeteria Plan. The Effective Date of this Plan Information Summary is January 1, 2006. This Plan Information Summary replaces and supersedes any other Plan Information Summary with an earlier effective date. I. EMPLOYERIPLAN SPONSOR/THIRD PARTY ADMINISTRATOR INFORMATION I . Name, address, and telephone number of the Employer/Plan Sponsor: City of San Juan Capistrano 32400 Paseo Adelanto San Juan Capistrano CA 92675 9494336313 2. Name, address, and telephone number of the Plan Administrator: Plan Administrator 32400 Paseo Adelanto Note: The Plan Administrator shall have the San Juan Capistrano CA 92675 exclusive right to interpret the Plan and to 9494336313 decide all matters arising under the Plan, including the right to make determinations of fact, and construe and interpret possible ambiguities, inconsistencies, or omissions in the Plan and the SPD issued in connection with the Plan. The agent for service of legal process is the Plan Administrator. 3. Employer's federal tax identification 95-6006666 number: 4. Plan Number: 501 5. ,Effective Date of the Plan: January 1, 2004 Note: This is the date that the Plan was first established. 6. Effective Date of this SPD: January 1, 2006 Note: This is the most recent date of the SPD other than the Plan Information Summary and the Appendices. 7. Plan Year: January I through December 31 Flex -SPD -072005 28 r II, CAFETERIA PLAN COMPONENT INFORMATION (a) Eligibility Requirements and Eligibility Date. Each Employee who is eligible for coverage or participation under any of the Benefit Plan Options will be eligible to participate in this Plan on the first of the month following date of employment ("Cafeteria Plan Eligibility Date"). The Employee's commencement of participation in the Plan is conditioned on the Employee properly completing and submitting a Salary Reduction Agreement as summarized in this SPD. Eligibility for coverage under any given Benefit Plan Option shall be determined not by this Plan but by the terms of that Benefit Plan Option. (b) Annual Election Rules. With respect to Benefit Plan Option elections (other than the Healthcare FSA and Dependent FSA elections), failure to make an election during the Annual Election Period will result in the one of following deemed election(s): (N/A) The employee will be deemed to have elected not to participate during the subsequent plan year. Coverage under the Benefit Plan Options offered under the Plan will end the last day of the Plan Year made. (X) The employee will be deemed to have elected to continue his or her Benefit Plan Option elections in effect as of the end of the Plan Year in which the Annual Election Period took place. This is called an "Evergreen election". (c) Change of Election Period. If you experience a Change in Status Event or Cost or Coverage Change as described in the Cafeteria Plan Summary and in the Election Change Chart, you may make the permitted election changes described in the Election Change Chart if you complete and submit an election change form within 30 days after the date of the event. If you are participating in an insured arrangement that provides a longer election change period, the election change period described in the insurance policy will apply. (d) Benefit Plan Options. The Employer elects to offer to eligible Employees the following Benefit Plan Option(s) subject to the terms and conditions of the Plan and the terms and conditions of the Benefit Plan Options. These Benefit Plan Option(s) are specifically incorporated herein by reference. The maximum Pre-tax Contributions a Participant can contribute via the Salary Reduction Agreement is the aggregate cost of the applicable Benefit Plan Options selected reduced any Noneleative Contributions made by the Employer. It is intended that such Pre-tax Contribution amounts will, for tax purposes, constitute an Employer contribution, but may constitute Employee contributions for state insurance law purposes. Flex -SPD -072005 29 8. Adopting Employers participating in the Plan: N/A 9. Third Party Administrator: CONEXIS Benefits Administrators, LP II, CAFETERIA PLAN COMPONENT INFORMATION (a) Eligibility Requirements and Eligibility Date. Each Employee who is eligible for coverage or participation under any of the Benefit Plan Options will be eligible to participate in this Plan on the first of the month following date of employment ("Cafeteria Plan Eligibility Date"). The Employee's commencement of participation in the Plan is conditioned on the Employee properly completing and submitting a Salary Reduction Agreement as summarized in this SPD. Eligibility for coverage under any given Benefit Plan Option shall be determined not by this Plan but by the terms of that Benefit Plan Option. (b) Annual Election Rules. With respect to Benefit Plan Option elections (other than the Healthcare FSA and Dependent FSA elections), failure to make an election during the Annual Election Period will result in the one of following deemed election(s): (N/A) The employee will be deemed to have elected not to participate during the subsequent plan year. Coverage under the Benefit Plan Options offered under the Plan will end the last day of the Plan Year made. (X) The employee will be deemed to have elected to continue his or her Benefit Plan Option elections in effect as of the end of the Plan Year in which the Annual Election Period took place. This is called an "Evergreen election". (c) Change of Election Period. If you experience a Change in Status Event or Cost or Coverage Change as described in the Cafeteria Plan Summary and in the Election Change Chart, you may make the permitted election changes described in the Election Change Chart if you complete and submit an election change form within 30 days after the date of the event. If you are participating in an insured arrangement that provides a longer election change period, the election change period described in the insurance policy will apply. (d) Benefit Plan Options. The Employer elects to offer to eligible Employees the following Benefit Plan Option(s) subject to the terms and conditions of the Plan and the terms and conditions of the Benefit Plan Options. These Benefit Plan Option(s) are specifically incorporated herein by reference. The maximum Pre-tax Contributions a Participant can contribute via the Salary Reduction Agreement is the aggregate cost of the applicable Benefit Plan Options selected reduced any Noneleative Contributions made by the Employer. It is intended that such Pre-tax Contribution amounts will, for tax purposes, constitute an Employer contribution, but may constitute Employee contributions for state insurance law purposes. Flex -SPD -072005 29 ' The following Benefit Plan Options are made available under the Plan to all those eligible Employees who make an appropriate election. 1. Health Flexible Spending Account 2. Dependent Care Assistance Plan 3. Health Insurance Flex -SPD -072005 30 1II. HEALTHCARE FSA COMPONENT INFORMATION (a) Healthcare FSA Eligibility Requirements and Eligibility Date. Each Employee who is eligible for coverage in the Healthcare FSA will be eligible to participate in the Healthcare FSA on the first of the month following date of employment ("Healthcare FSA Eligibility Date"). (b) Annual Healthcare Reimbursement Amounts. The Maximum Annual Reimbursement Amount each year may not exceed the lesser of Healthcare FSA reimbursement amount elected for that year or $3,500.00. The minimum reimbursement amount that may be elected under the Healthcare FSA is $0.00. (c) Run Out Period. The Run Out Period is the period during which expenses incurred during a Plan Year must be submitted to be eligible for reimbursement. The Run Out Period for active employees ends 90 days after the end of the Plan Year, The Run Out Period for terminated employees ends 90 days after the end of the Plan Year. (d) COBRA Administrator. The COBRA administrator for the Healthcare FSA City of San Juan Capistrano, (e) Method of Funding: Healthcare FSA Benefits are paid from general assets. Flex -SPD -072005 31 IV. DEPENDENT CARE FSA COMPONENT INFORMATION INEW (a) Dependent Care FSA Eligibility Requirements and Eligibility Dates. Each Employee who is eligible for coverage in the Dependent Care FSA will be eligible to participate in the Dependent Care FSA on the first of the month following date of employment ("Dependent Care FSA Eligibility Date"). (b). Run Out Period. The Run Out Period is the period during which expenses incurred during a Plan Year must be submitted to be eligible for reimbursement. The Run Out Period for active employees ends 90 days after the end of the Plan Year. The Run Out Period for terminated employees ends 90 days after the end of the Plan Year. (c) Expense incurred after termination of employment. You may be reimbursed for Eligible Employment Related Expenses incurred after you terminate employment up to the amount in your account balance, subject to the reimbursement rules set forth in the SPD. (d) Method of Funding. Dependent Care FSA Benefits are paid from general assets Flex -SPD -072005 32 APPENDIX I CLAIMS REVIEW PROCEDURE CHART The Effective Date of this Appendix I is January 1, 2006. It should replace and supersede any other Appendix I with an earlier date. The Plan has established the following claims review procedure in the event you are denied a benefit under this Plan. The procedure set forth below does not apply to benefit claims filed under the Benefit Plan Options other than the Healthcare FSA and Dependant Care FSA. Step 1: Notice is received from Third Party Administrator. If your claim is denied, you will receive written notice from the Third Party Administrator that your claim is denied as soon as reasonably possible but no later than 30 days after receipt of the claim. For reasons beyond the control of the Third Party Administrator, the Third Party Administrator may take up to an. additional 15 days to review your claim. You will be provided written notice of the need for additional time prior to the end of the 30 -day period. If the reason for the additional time is that you need to provide additional information, you will have 45 days from the notice of the extension to obtain that information. The time period during which the Third Party Administrator must make a decision will be suspended until the earlier of the date that you provide the information or the end of the 45 -day period. Step 2: Review your notice carefully. Once you have received your notice from the Third Party — Administrator, review it carefully. The notice will contain: a) The reason(s) for the denial and the Plan provisions on which the denial is based; b) A description of any additional information necessary for you to perfect your claim, why the information is necessary, and your time limit for submitting the information; c) A description of the Plan's appeal procedures and the time limits applicable to such procedures; and d) A right to request all documentation relevant to your claim. Step 3: V you disagree with the decision, file an Appeal. If you do not agree with the decision of the Third Party Administrator and you wish to appeal, you must file your appeal no later than 180 days after receipt of the notice described in Step I. You should submit all information identified in the notice of denial as necessary to perfect your claim and any additional information that you believe would support your claim. Step 4: Notice of Denial is received from Third Party Administrator. 1f the claim is again denied, you will be notified in writing as soon as possible but no later than 30 days after receipt of the appeal by the Third Party Administrator. Step 5: Review your notice carefully. You should take the same action that you took in Step 2 described above. The notice will contain the same type of information that is provided in the first notice of denial provided by the Third Party Administrator, Step 6: Lf you still disagree with the Third Party Administrator's decision, file a 2nd Level Appeal with the Plan Administrator. If you still do not agree with the Third Party Flex -SPD -072005 Appendix 1 - 1 ' Administrator's decision and you wish to appeal, you must file a written appeal with the Plan Administrator within the time period set forth in the first level appeal denial notice from the Third Party Administrator. You should gather any additional information that is identified in the notice as necessary to perfect your claim and any other information that you believe would support your claim. If the Plan Administrator denies your 2"" Level Appeal, you will receive notice within 30 days after the Plan Administrator receives your claim. The notice will contain the same type of information that was referenced in Step 1 above. Important Information Other important information regarding your appeals: • (Healthcare FSA Only) Each level of appeal will be independent from the previous level (i.e., the same person(s) or subordinates of the same person(s) involved in a prior level of appeal will not be involved in the appeal); • On each level of appeal, the claims reviewer will review relevant information that you submit even if it is new information; and • You cannot file suit in federal court until you have exhausted these appeals procedures. 1 Flex -SPD -072005 Appendix I - 2 APPENDIX II TAX ADVANTAGES EXAMPLE The Effective Date of this Appendix II is January 1, 2006. It should replace and supersede any other Appendix II with an earlier date. As indicated in the SPD, participating in the Plan can actually increase your take home pay. Consider the following example: You are married and have one child. The Employer pays for 80% of your medical insurance premiums, but only 40% for your family. You pay $2,400 in premiums ($400 for your share of the employee -only premium, plus $2,000 for family coverage under the Employer's major medical insurance plan). You earn $50,000 and your spouse (a student) earns no income. You file ajoint tax return. Flex -SPD -072005 Appendix 11- I If you participate in If you do not the cafeteria plan participate in the " cafeteria plan 1. Gross Income $50,000 $50,000 2. Salary Reductions $2,400 (pre-tax) $0 for Premiums 3. Adjusted Gross $47,600 $50,000 Income "4' 4. Standard ($9,700) ($9,700) Deduction 5. Exemptions (S9,300) $9,300 6. Taxable Income $28,600 $31,000 7. Federal Income ($3,590) ($3,950) Tax (Line 6 x applicable tax schedule 8. FICA Tax (7.65% ($3,641) ($3,825) x Line 3 Amount 9. After Tax ($0) ($2400) Contributions 10. Pay after taxes $40,365 ,';. $391821 and contributions 11. Take Home Pay $544 Difference Flex -SPD -072005 Appendix 11- I APPENDIX III ELECTION CHANGE CHART The Effective Date of this Appendix III is January 1, 2006. It should replace and supersede any other Appendix III with an earlier date. The following is a summary of the election changes that are permitted under this Plan. Also, election changes that are permitted under this Plan may not be permitted under the Benefit Plan Option (e.g., the insurance carrier may not allow a change). If a change is not permitted under a Benefit Plan Option, no election change is permitted under the Plan. Likewise, a Benefit Plan Option may allow an election change that is not permitted by this Plan. In that case, your pre-tax reduction may not be changed even though a coverage change is permitted. For a description of the election change rules for Health Savings Accounts (if made available through the Plan), see the Health Savings Account Contribution Appendix). First, we describe the general rules regarding election changes that are established by the IRS. Then, you should look to the chart to determine under what circumstances you'are permitted to make an election under this Plan and the scope of the changes you may make. a) Change in Status. Election changes may be allowed if a Participant or a Participant's Spouse or Dependent experiences one of the Change in Status Events set forth in the ' chart. The election change must be on account of and correspond with the Change in Status Event as determined by the Plan Administrator (or its designated Third Party Administrator). With the exception of enrollment resulting from birth, placement for adoption or adoption, all election changes are prospective (generally the first of the month following the date you make a new election with the Third Party Administrator but it may be earlier depending on the Employer's internal policies or procedures). As a general rule, a desired election change will be found to be consistent with a Change in Status Event if the event the Change in Status affects eligibility for coverage. A Change in Status affects eligibility for coverage if it results in an increase or decrease in the number of Dependents who may benefit under the Plan. In addition, you must also satisfy the following specific requirements in order to alter your election based on that Change in Status: • Loss of Dependent Eligibility. For accident and health benefits (e.g., health, dental and vision coverage), a special rule governs which types of election changes are consistent with the Change in Status. For a Change in Status involving a divorce, annulment or legal separation, the death of a Spouse or Dependent, or a Dependent ceasing to satisfy the eligibility requirements for coverage, an election to cancel accident or health benefits for any individual other than the Spouse involved in the divorce, annulment, or legal separation, the deceased Spouse or Dependent, or the Dependent that ceased to satisfy the eligibility requirements, would fail to correspond with that Change in Status. Hence, you may only cancel accident or health coverage for the affected Spouse or Dependent. However, there are instances in which you may be able to increase your Pre-tax Contributions to pay for COBRA coverage of -a Dependent. Contact the Third Parry Administrator for more information. Flex -SPD -072005 Appendix III - I Example: Employee Mike is married to Sharon, and they have one child. The employer offers a calendar year cafeteria plan that allows employees to elect no health coverage, employee -only coverage, employee -plus -one -dependent coverage, or family coverage. Before the plan year, Mike elects family coverage for himself, his wife Sharon, and their child. Mike and Sharon subsequently divorce during the plan year; Sharon loses eligibility for coverage under the plan, while the child is still eligible for coverage under the plan. Mike now wishes to cancel his previous election and elect no health coverage. The divorce between Mike and Sharon constitutes a Change in Status. An election to cancel coverage for Sharon is consistent with this Change in Status. However, an election to cancel coverage for Mike and/or the child is not consistent with this Change in Status. In contrast, an election to change to employee -plus -one - dependent coverage would be consistent with this Change in Status. Gain of Coverage Eligibility Under Another Employer's Plan. For a Change in Status in which a Participant or his or her Spouse or Dependent gain eligibility for coverage under another employer's cafeteria plan or benefit plan as a result of a change in marital status or a change in the Participant's, the Participant's Spouse's, or the Participant's Dependent's employment status, an election to cease or decrease coverage for that individual under the Plan would correspond with that Change in Status only if coverage for that individual becomes effective or is increased under the other employer's plan. Dependent Care Reimbursement Plan Benefits With respect to the Dependent Care FSA benefit, an election change is permitted only if (I) such change or termination is made on account of and corresponds with a Change in Status that affects eligibility for coverage under the Plan; or (2) the election change is on account of and corresponds with a Change in Status that affects the eligibility of Dependent Care FSA expenses for the available tax exclusion. Example: Employee Mike is married to Sharon, and they have a 12 year-old daughter. The employer's plan offers a dependent care expense reimbursement program as part of its cafeteria plan. Mike elects to reduce his salary by $2, 000 during a plan year to fund dependent care coverage for his daughter. In the middle of the plan year when the daughter turns 13 years old, however, she is no longer eligible to participate in the dependent care program. This event constitutes a Change in Status. Mike's election to cancel coverage under the dependent care program would be consistent with this Change in Status. Group Term Life Insurance, Disability Income, or Dismemberment Benefits (if offered under the Plan. See the list of Benefit Plan Options offered under the Plan). For group term life insurance, disability income and accidental death and dismemberment benefits only if a Participant experiences any Change in Status (as described above), an election to either increase or decrease coverage is permitted. Flex -SPD -072005 Appendix 111- 2 ' Example: Employee Mike is married to Sharon and they have one child. The employer's plan offers a cafeteria plan which funds group -term life insurance coverage (and other benefits) through salary reduction. Before the plan year Mike elects $10,000 of group -term life insurance. Mike and Sharon subsequently divorce during the plan year. The divorce constitutes a Change in Status. An election by Mike either to increase or to decrease his group -term life insurance coverage would each be consistent with this Change' in Status. b) Special Enrollment Rights. If a Participant, Participant's Spouse and/or Dependent are entitled to special enrollment rights under a Benefit Plan Option that is a group health plan, an election change to correspond with the special enrollment right is permitted. Thus, for example, if an otherwise eligible employee declined enrollment in medical coverage for the employee or the employee's eligible Dependents because of outside medical coverage and eligibility for such coverage is subsequently lost due to certain reasons (i.e., due to legal separation, divorce, death, termination of employment, reduction in hours, or exhaustion of COBRA period), the employee may be able to elect medical coverage under the Plan for the employee and his or her eligible Dependents who lost such coverage. Furthermore, if an otherwise eligible employee gains a new Dependent as a result of marriage, birth, adoption, or placement for adoption, the employee may also be able to enroll the employee, the employee's Spouse, and the employee's newly acquired Dependent, provided that a request for enrollment is made within the Election Change Period. An election change that corresponds with a special enrollment must be prospective, unless the special enrollment is attributable to the birth, adoption, or placement for adoption of a child, which may be retroactive up to 30 days. Please refer to the group health plan summary description for an explanation of special enrollment rights. c) Certain Judgments, Decrees and Orders. If a judgment, decree or order from a divorce, separation, annulment or custody change requires a Dependent child (including a foster child who is your tax Dependent) to be covered under this Plan, an election change to provide coverage for the Dependent child identified in the order is permissible. If the order requires that another individual (such as your former Spouse) cover the Dependent child, and such coverage is actually provided, you may change your election to revoke coverage for the Dependent child. d) Entitlement to Medicare or Medicaid. If a Participant or the Participant's Dependents become entitled to Medicare or Medicaid, an election to cancel that person's accident or health coverage is permitted. Similarly, if a Participant or Participant's Dependents who have been entitled to Medicare or Medicaid loses eligibility for such, you may elect to begin or increase that person's accident or health coverage. e) Change in Cost. if the cost of a Benefit Plan Option significantly increases, a Participant may choose either to make an increase in contributions, revoke the election and receive coverage under another Benefit Plan Option that provides similar coverage, or drop coverage altogether if no similar coverage exists. If the cost of a Benefit Plan Option significantly decreases, a Participant who elected to participant in another Benefit Plan Option may revoke the election and elect to receive coverage provided under the Benefit Plan Option that decreased in cost. In addition, otherwise eligible employees who elected not to participate in the Plan may elect to participate in the Benefit Plan Option that decreased in cost. For insignificant increases or decreases in the cost of Benefit Plan Option options, however, Pre-tax Contributions will automatically be adjusted to reflect the minor change in cost. The Plan Administrator will have final IFlex -SPD -072005 Appendix 111- 3 authority to determine whether the requirements of this section are met. (Please note that none of the above "Change in Cost" exceptions are applicable to a Healthcare FSA, to the extent offered under the Plan.) Example: Employee Mike is covered under an indemnity option of his employer's accident and health insurance coverage. If the cost of this option significantly increases during a period of coverage, the Employee may make a corresponding increase in his payments or may instead revoke his election and elect coverage under an HMO option. t) Change in Coverage. If coverage under a Benefit Plan Option is significantly curtailed, a Participant elect to revoke his or her election and elect coverage under another Benefit Plan Option that provides similar coverage. If the significant curtailment amounts to a complete loss of coverage, a Participant may also drop coverage if no other similar coverage is available. Further, if the Plan adds or significantly improves a benefit option during the Plan Year, a Participant may revoke his or her election and elect to receive, on a prospective basis, coverage provided by the newly added or significantly improved option, so long as the newly added or significantly improved option provides similar coverage. Also, a Participant may make an election change that is on account of and corresponds with a change made under another employer plan (including a plan of the Employer or another employer), so long as: (a) the other employer plan permits its participants to make an election change permitted under the IRS regulations; or (b) the Plan Year for this Plan is different from the Plan Year of the other employer plan. Finally, a Participant may change his or her election to add coverage under this Plan for the Participant, the Participant's Spouse or Dependents if such individual($) loses coverage under any group health coverage sponsored by a governmental or educational institution. The Plan Administrator will have final discretion to determine whether the requirements of this section are met. (Please note that none of the above "Change in Coverage" exceptions are applicable to the Healthcare FSA, to the extent offered under the Plan.) Flex -SPD -072005 Appendix III - 4 The following is a chart reflecting the election changes that may be made under the Plan with respect to each Benefit Plan Option. In addition, election changes that are permitted under this Plan are subject to any limitations imposed by the Benefit Plan Options. If an election change is permitted by this Plan but not by the Benefit Plan Option, no election change under this Plan is permitted. Event 1. Chanae in Status Major Medical Employee may Dental and Vision Same as previous Healthcare FSA Employee may Dependent Care FSA Employee may Employee Group Life, AD&D and Disability Coverage Employee may A. Change in Employee's Legal Marital Status enroll or increase column (Note: enroll or increase enroll or increase enroll, increase, election for newly- HIPAA special election for newly to accommodate decrease, or cease eligible spouse and enrollment rights eligible spouse or newly -eligible coverage even dependent children likely do not dependents, or dependents or when eligibility is (Note: Under IRS apply). likely decrease decrease or cease not impacted. "tag -along" election if coverage if new interpretation, new employee or spouse is not and preexisting dependents become employed or makes dependents may be an eligible a Dependent Care enrolled); coverage dependent under FSA coverage . option (e.g., HMO new spouse's election under to PPO) change health plan (Note: spouse's plan. may be made; HIPAA special employee may enrollment rights revoke or decrease likely do not employee's or apply), dependent's coverage only when such coverage becomes effective or is increased under the spouse's plan. Also, see HIPAA special enrollment role below. 2. Lose spouse (divorce, Employee may Same as previous Employee may Employee may Employee may legal separation, annulment, revoke election column (Note: decrease election enroll or increase enroll, increase, death of spouse) (See loss o only for spouse; HIPAA special for former spouse to accommodate decrease, or cease dependent eligibility below coverage option enrollment rights who loses newly eligible coverage even for discussion of dependent (e.g., HMO to likely do not eligibility (Note: dependents (e.g., when eligibility is eligibility loss following PPO) change may apply). HIPAA special due to death of not impacted. divorce, separation, etc.) be made: employee enrollment rights spouse) or decrease may elect coverage - likely do not Dr cease coverage i for self or apply). Employee eligibility is lost dependents who may enroll or (e.g.. because lose eligibility increase election dependent now under spouse's where coverage resides with ex. plan if such lost under spouse's spouse). individual loses health plan. eligibility as a result of the Flex -SPD -072005 Appendix III - 5 Event Major Medical Dental and Healthcare Dependent Employee Vision FSA .Care FSA Croup Life, AD&D and Disability Coverage divorce, legal separation, annulment, or death. (Note: Under IRS "tag- along" interpretation. any dependents may be enrolled so long as at least one dependent has lost coverage under the spouse's plan.) B. Change in the Number""i a --, of Employee's Dependents iJ;;" 1. Cain Dependent Employee may Same as previous Same as previous Employee may Employee may (birth, adoption) enroll or increase column (Note: column (Note: enroll or increase enroll, increase, coverage for HIPAA special HIPAA special to accommodate decrease, or cease newly -eligible enrollment rights enrollment rights newly eligible coverage even dependent (and,my likely do not likely do not dependents (and when eligibility is other dependents apply). apply). any other not impacted. who were not dependents who previously covered were not previous) under IRS "tag- covered under IRS along" rule): "tag -along" rule). coverage option (e.g., HMO to PPO) change may be made; employee may revoke or decrease employee's or dependent's coverage if employee becomes eligible under spouse's plan. Also, see HIPAA special enrollment rule below. 2. Lose Dependent (death) Employee may Same as previous Employee may Employee may Employee may drop coverage only column. decrease or cease decrease election enroll, increase, for the dependent election for for dependent who decrease, or cease who loses _ dependent who loses eligibility. coverage even eligibility; - loses eligibility. when eligibility is coverage option not impacted. (e.g., HMO to PPO) change may be made. Flex -SPD -072005 Appendix IH - 6 1 Event Major Medical Dental and Healthcare Dependent Employee Vision FSA - Care FSA Group Life, AD&D and Disability Coverage C. Change in Employment Status of Employee, " '- Spouse, or Dependent - -- - _ That Affects Eligibility 7 Commencement of Employment by Employee Ar 7,AN -- Spouse, or Dependent (or Other Change in Employment Status) That - -- - - Triggers Eligibility - - a. Commencement of Provided eligibility Same m previous Same as previous Same as previous Employee may Employment by Employee was gained for this column. column. column. enroll, increase, or Other Change in overage, cmployet decrease, or cease Employment Status (e.g., may add coverage coverage even PT to FT, hourly to for employee, when eligibility is salaried, etc.) Triggering spouse, or not impacted. Eligibility Under dependents and Component Plan coverage option (e.g., HMO to PPO) change may be made. b. Commencement of Employee may Same as previous Employee may Employee may Employee may Employment by Spouse or revoke or decrease column. apparently decretist make or increase enroll, increase, Dependent or Other election as to or cease FSA election to reflect decrease or cease Employment Event employee's, election if gains new eligibility coverage even Triggering Eligibility spouse's, or eligibility for (e.g., if spouse when spouse's or Under Their Employer's dependent's health coverage previously did not dependent's Plan coverage if under spouse's or work). Employee eligibility is not employee, spouse dependent's plan. may revoke impacted, or dependent is election as to added to spouse's dependent's or dependent's coverage if coverage; coverage dependent is added option (e.g., HMO to spouse's plan. to PPO) change ma be malt. 2. Termination of mi Employment by Employee, Spouse, or Dependent (or Other Change in Employment -Status) Tha--777 Causes Loss of Eligibility Employee may Same as previous Same m previous Employee may Employee may a. Termination of Employee's Employment revoke or decrease column. column. revoke or decrease enroll, increase, or Other Change in Employment Status (,g., election for employee, spouse election to reflect decrease or cease unpaid leave, FT to PT, or dependents who loss of eligibility. coverage even strike, salaried to hourly, lose eligibility when eligibility is etc.) Resulting in a Loss of under the plan. In not affected. Eligibility addition, other previously eligible - Flex -SPD -072005 Appendix Ill - 7 Event Major Medical Dental and Healthcare Dependent Employee Vision FSA Care FSA Croup Life, AD&D and Disability Coverage dependents may also be enrolled under "tag -along" rate. Coverage option (HMO to PPO) change may be made. I. Termination and Rehire Prior elections at Same as previous Sarin as previous Same as previous Same as previous Within 30 Days termination are column. column, column, column. reinstated unless another event has occurred that allows a change (as an alternative, employer may prohibit participation until next DIM ear. ii. Termination and Rehire Employee may Same as previous Same as previous Same as previous Same as previous After 30 Days make new column. column. column. column. elections. b. Termination of Spouse's Employee may Same as previous Employee may Employee may Employee may or Dependent's enroll or increase column (Note: enroll or increase enroll or increase if enroll, increase, Employment (or other election for HIPAA special FSA election if spouse or decrease or cease change in employment employee, spouse enrollment rights spouse or dependent loses even when status resulting in a loss of or dependents who likely do not dependent loses eligibility for eligibility is not eligibility under their lose eligibility apply). eligibility for Dependent Care affected. employer's plan) under spouse's or health coverage FSA. Employee dependent's (Note: HIPAA may decrease or employer's plan. In special enrollment cease Dependent addition, other rights likely do not Care FSA election previously eligible apply). if spouse's loss of dependents may employment also be enrolled renders dependents under "tag -along" ineligible. rule. Coverage option (e.g., HMO to PPO) change may be made; See HIPAA special enrollment rule below. D. Event Causing Employee's Dependent to Satisfy or Cease to Satisfy Eligibility Requirements (Also see discussion of gain/loss of eligibility under dependent or souse's employer's Wan Flex -SPD -072005 Appendix III - 8 Event 'a-' Major Medical - Dental and Healthcare Dependent Employee Vision FSA Care FSA Group Life, AD&D and Disability Coverage 1. Event by Which Employee may Same as previous Employee may Employee may Employee may Dependent Satisfies enroll or increase column. increase election or increase election or enroll, increase, Eligibility Requirements election for enroll only if enroll to take into decrease or cease Under Employer's Plan affected dependent. dependent gains account expenses even when (attaining a specified age, In addition, eligibility under of affected eligibility is not becoming single, becoming employee may Healthcare FSA. dependent. affected. a student, etc.) apparently add previously eligible (but not enrolled) dependents under "tag-along" rule; coverage option (e.g., HMO to PPO)change may be made. 2. Event by Which Employee may Same as previous Employee may Employee may Employee may Dependent Ceases to decrease or revoke column, decrease election to decrease or drop enroll, increase, Satisfy Eligibility election only for take into account election to take int decrease or cease Requirements Under affected dependent. ineligibility of account expenses coverage even Employer's Plan (attaining Coverage option expenses of of affected when eligibility is a specified age, getting (e.g., HMO to affected dependent, dependent. not affected. married, ceasing to be a PPO) change may but only if student, etc.) be made. eligibility is lost. E. Change in Place of Residence of Employee, Spouse, or Dependent I, Move Triggers Employee may Same as previous No change N/A. Dependent Employee may Eligibility enroll or increase column. allowed, even if care eligibility is increase or election for newly underlying health not generally decrease even if eligible employee, coverage change affected by place o spouse's or spouse, or occurs, residence (but see dependent's dependent. Also, change in coverage eligibility is not other previously below), affected, eligible dependents may be re-enrolled under "tag-along" rule; coverage option (e.g., HMO to PPO) change may be made. 2. Move Causes Loss of Employee may Same as previous No change N/A. Dependent Employee may Eligibility (e.g., employee revoke election or column. allowed, even if care eligibility is enroll, increase, or dependent moves make new election underlying health not generally decrease or cease outside HMO service area) if the change in coverage change affected by place ol even when residence affects - - occurs. residence (but see eligibility is not the employee's, change in coverage affected, spouse's or below). dependent's eligibility for coves e — Flex -SPD -072005 Appendix 111- 9 Event Major Medical Dental end Vision Healthcare FSA Dependent Care FSA Employee Group Life, AD&D and Disability Coverage IL Cost Changes With Automatic Plan may Same as No change Application is Same as Major Increase/Decrease in automatically previous permitted, unclear. Medical Elective Contributions increase or column. Presumably, column. (including employer decrease (on a plan may motivated changes and ieasonable and automatically changes in employee consistent basis) increasc.or contribution rates) affected decrease (on a employees' reasonable and elective consistent basis) contributions affected under the plan, employees' so long as the elective terms of the contributions plan require under the plan, - employees to so long as the make such terms of the corresponding plan require changes. employees to make such corresponding changes. 111. Significant Cost Significant Same as No change Same as Major Same as Major Changes Cost Increase: previous permitted. Medical column Medical Affected column. for significant column. employee may cost increase, increase except no election change can be correspondingly made when the OR revoke cost change is election and imposed by a elect coverage dcpendentcare under another provider who is benefit package a relative of the option employee. providing similar coverage. if no option providing similar coverage is available, employee may revoke election. Significant ^ Cost Decreasr Employees may elect coverage (even if had not participated before) with decreased cost, and may drop election for Ffex-SPD-072005 Appendix III - 10 fl 0 Event Major Medical Dental and Healthcare Dependent Employee vision FSA Care FSA Group Life, AD&D and Disability Coverage similar coverage option. Though unclear, it appears that tag -along concepts may apply. IV. Significant Coverage Without Loss Same as No change Same as Major Curtailment (With or of Coverage: previous permitted. Medical Without Loss of Affected column. Election change column. Coverage) participant may may apparently revoke election be made for curtailed - whenever there coverage and is a change in make new provider or a prospective change in hours election for of dependent coverage under care. another benefit package option which provides - -" similar coverage. With Loss of Coverage: Affected participant may revoke election for curtailed coverage and make new prospective election for coverage under another benefit package option which provides similar coverage OR drop coverage if no " similar benefit package option is available. V. Addition or Eligible Same as No change Eligible Same as Significant Improvement employees previous permitted, employees previous of Benefit Package (whether column, (whether column. Option currently currently Flex -SPD -072005 Appendix III - I 1 Event Major Medical Dental and Healthcare Dependent Employee Vision FSA Care FSA Croup Life, AD&D and Disability Coverage participating or participating or not) may revoke not) may revoke their existing their existing election and election and elect the newly elect the newly added (or newly added (or newly improved) improved) option. option. Though unclear, it appears that tag-along concepts may apply, VI. Change in Coverage Employee may Same as No change Employee may Same as Under Other Employer's decrease or previous permitted. decrease or previous Cafeteria Plan or revoke election column. revoke election column. Qualified Benefits Plan for employee, for employee, (In order for election spouse or spouse, or dependents if dependents if changes to be permitted employee, employee, under this exception, the election change must be spouse, or spouse, or dependents have dependents have on account of and elected or elected or correspond with the received _ . - received change in coverage under corresponding corresponding the other employer's increased increased cafeteria plan or qualified coverage under coverage under benefits plan, In addition, other employer other employer either(1)the plan of the plan. plan. other employer must permit elections specified under the Regulations and - an election must actually be made under such plan: or (2) the employee's cafeteria plan must permit elections for a period of coverage different from that under the other employer plan ("Election Lock" rule). A. Other Employer's Employee may Same as No change Employee may Same as Plan increases Coverage decrease or previous permitted. decrease or previous revoke election column. revoke election column. for employee, for employee, spouse, or spouse, or dependents if dependents if employee, employee, spouse, or spouse, or dependents dependents have elected or have elected or received received - corresponding corres ondin Flex -SPD -072005 Appendix III - 12 L Event Major Medical Dental and Healthcare Dependent Employee Vision FSA Care FSA Group Life, AD&D and Disability Coverage increased increased coverage under coverage under other other employer's employer's plan Plan. B. Other Employer's Employee may Same as No change Employee may Same as Plan Decreases or Ceases enroll or previous permitted. increase previous Coverage increase column. election for column. election for employee, employee, spouse, or spouse, or dependents if dependents if employee, employee, spouse, or spouse, or dependents dependents have elected or have elected or received received corresponding corresponding decreased decreased coverage under coverage under other other employer's employer's plan. plan. C. Open Enrollment Corresponding Corresponding No change Corresponding Corresponding Under Plan of Other changes can be changes can be permitted. changes can be changes can be Employer made under made under made under - made under employer's employer's _ employer's employer's plan. plan. plan. plan. VII, FMLA Leave (Employees can fund this coverage by (1) pre- ro-paying payingtheir contribution obligations on a pre-tax basis (so long as the leave does not straddle two plan years); (2) making contributions on a month -by -month basis (pre-tax if they are receiving salary continuation payments); or (3) catching up on their contributions upon returning from the leave.) Employee can Same as Same as Employee may Same as A. Employee's Commencement of make same previous previous revoke election previous FMLA Leave elections as column, column. and make - column. employee on another election Flex -SPD -072005 Appendix III - 13 Event Major Medical Dental and Vision Healthcare FSA Dependent Care FSA Employee Group Life, AD&D and Disability Coverage non-FMLA as provided leave. in under FMLA. addition, an employer must allow an employee on unpaid FMLA leave either to revoke coverage or to continue coverage but allow employce to discontinue payment of his or her share of the contribution during the leave (the employer may recover the employee's share of contributions when the employee _ returns to work). FMLA also allows an employer to require that employees on paid FMLA leave continue coverage if employees on non-FMLA paid leave are required to continue coverage. B. Employee's Return Employee may Same as Some as Employee may Same as from FMLA Leave make a new previous previous make a new previous election if column. column. Note election if columm coverage that, upon coverage terminated return, an terminated while on FMLA employee while on FMLA leave. In ' whose coverage leave. In addition, an has lapsed has addition, an employer may the right to employer may require an resume require an employee to be coverage at employee to be reinstated in his prior coverage reinstated in his or her election level (and make or her election upon return up unpaid upon return from leave ifpremiums) or at from leave if Flex -SPD -072005 Appendix III - 14 Event Major Medical Dental and Healthcare Dependent Employee Vision FSA Care FSA Group Life, AD&D and Disability Coverage employees who a level reduced employees who return from a prorate for the return from a non-FMLA paid missed non-FMLA leave are contributions. leave are required to be required to be reinstated in reinstated in their elections. their elections. IX. HIPAA Special Enrollment Rights (See related exception for addition of new dependents) Employee may No change No change No change No change A. Special Enrollment for Loss of Other Health elect coverage permitted, permitted, permitted. permitted. Coverage for employee, unless plan is unless spouse, or subject to healthcare FSA dependent who HIPAA. is subject to has lost other HIPAA. coverage (COBRA coverage -- exhausted or terminated, no longer eligible for non - COBRA coverage or employer contributions for non - COBRA coverage terminated, etc.) Though unclear, it appears that tag -along concepts may apply. B. Special Enrollment for Employee may No change No change No change No change Acquisition of New elect coverage permitted, permitted, permitted. permitted. Dependent by Birth, for employee, unless plan is unless Marriage, Adoption, or spouse, or subject to healthcare FSA Placement for Adoption dependent. HIPAA. is subject to (If newbom or newly Example HIPAA. adopted child is enrolled provides that under HIPAA's special election of rules, child's coverage coverage may may be retroactive to date also extend to ' of birth, adoption, or previously placement for adoption; Flex -SPD -072005 Appendix 111- 15 Event Major Medical Dental and Healthcare Dependent Employee Vision FSA Care FSA Group Life, AD&D and Disability Coverage employee may change eligible (but not salary reduction election yet enrolled) to pay for extra cost of dependents, child's coverage retroactive to date of birth, adoption, or placement for adoption. For marriage, coverage is effective ' prospectively. - X. COBRA Events Employee may Same as No change No change No change increase pre-tax previous permitted. permitted. permitted. contributions column. under employer's plan for coverage if COBRA event (or similar state law continuation coverage event) occurs with respect to the employee, spouse, or - dependents with respect to which the COBRA qualifying event occurred (such as a loss of eligibility for regular coverage due to loss of dependent status or a reduction in hours, etc.) and if applicable, the individual still qualifies as a in dependent of employee. XI. Judgment, Decree, or Order Employee may Same as Same as No change No change A. Order That Requires Coverage for the Child change election previous previous permitted. permitted. Under Employee's Plan to provide column. column, coverage for the child. Though unclear, Flex -SPD -072005 Appendix III - 16 Event Major Medical Dental sod Healthcare Dependent Employee vision FSA Care FSA Group Life, AD&D and Disability Coverage it appears that tag -along concepts may apply B. Order That Requires Employee may Same as. Same as No change No change Spouse, Former Spouse, change election previous previous permitted. permitted. or Other Individual to to cancel column. column. Provide Coverage for the coverage for the Child child. X11. Medicare or Medicaid A. Employee, Spouse, or Employee may Unlikely that Employee may No change No change Dependent Enrolled in elect to cancel employee can apparently permitted. permitted. Employer's Accident or or reduce elect to drop decrease or Health Plan Becomes coverage for dental or vision revoke election Entitled to Medicare or employee, coverage: or increase Medicaid (other than spouse, or presumably, election if coverage solely for dependent, as employee must Healthcare FSA pediatric vaccines) applicable, retain coverage, is dropped due to Medicare/Medic aid and prior employer coverage was more comprehensive. B. Employee, Spouse, or Employee may Unlikely that Employee may No change No change Dependent Loses elect to employee can apparently permitted. permitted. Eligibility for Medicare commence or elect to add increase or or Medicaid (other than increase dental or vision decrease or coverage solely for coverage for coverage; revoke election pediatric vaccines) employee, presumably, where employer spouse, or employee plan elected due dependent, as cannot. to loss of applicable. eligibility for Medicare/Medic Though unclear, aid is more it appears that comprehensive tag -along than concepts may Medicare/Medic apply. aid. IFlex -SPD -072005 Appendix III - 17 CITY OF SAN JUAN CAPISTRANO CITY OF SAN JUAN CAPISTRANO'S CAFETERIA PLAN This Document is effective January 1, 2006 125 -PD -072005 ' TABLE OF CONTENTS ARTICLEI - DEFINITIONS.................................................................................................................. 2 1.01 AFFILIATED EMPLOYER..........................................................................................................2 1.02 AFTER-TAX CONTRIBUTION(S).............................................................................................. 2 1.03 ANNIVERSARY DATE................................................................................................................ 2 1.04 BENEFIT PACKAGE OPTION(S)............................................................................................... 2 1.05 BOARD OF DIRECTORS............................................................................................................2 1.06 CHANGE IN STATUS................................................................................................................. 2 1.07 CODE.........................................................................................................................................2 1.08 COMPENSATION.......................................................................................................................2 1.09 DEPENDENT..............................................................................................................................2 1.10 EFFECTIVE DATE..................................................................................................................... 2 1.11 EMPLOYEE...............................................................................................................................2 1.12 EMPLOYER...............................................................................................................................3 1.13 ERISA......................................................................................................................................3 1.14 HIGHLY COMPENSATED INDIVIDUAL.....................................................................................3 1.15 KEY EMPLOYEE....................................................................................................................... 3 1.16 NONELECTIVE CONTRIBUTION(S)..........................................................................................3 1.17 PARTICIPANT ......................... .... -.............. ..... ...................................................... ................ ..3 1.18 PLAN.........................................................................................................................................3 1.19 PLAN ADMINISTRATOR...........................................................................................................3 1.20 PLAN YEAR..............................................................................................................................3 1.21 PRE-TAX CONTRIBUTION(S) ... I .::............................................................................................ 4 1.22 QUALIFIED BENEFIT................................................................................................................4 1.23 SALARY REDUCTION AGREEMENT......................................................................................... 4 1.24 SPOUSE..................................................................................................................................... 4 1.25 SUMMARY PLAN DESCRIPTION OR SPD................................................................................ 4 1.26 STUDENT...................................................................................................................................4 ARTICLE 11- ELIGIBILITY AND PARTICIPATION...................................................................... 4 2.01 ELIGIBILITY TO PARTICIPATE................................................................................................ 4 2.02 TERMINATION OF PARTICIPATION......................................................................................... 4 2.03 QUALIFYING LEAVE UNDER FAMILY LEAVE ACT................................................................ 5 2.04 NON-FMLA LEAVE................................................................................................................. 5 ARTICLE III - PREMIUM ELECTIONS............................................................................................. 5 3.01 ELECTION OF CONTRIBUTIONS..............................................................................................5 3.021 INITIAL ELECTION PERIOD..................................................................................................... 5 3.03 ANNUAL ELECTION PERIOD.................................................................................................... 6 3.04 CHANGE OF ELECTIONS.......................................................................................................... 6 3.05 IMPACT OF TERMINATION OF EMPLOYMENT ON ELECTION OR CESSATION OF ELIGIBILITY............................................................................................................................. 6 ARTICLE IV - PREMIUM PAYMENTS AND CREDITS AND DEBITS TO ACCOUNTS .......... 6 4.01 SOURCE OF BENEFIT FUNDING............................................................................................... 6 _ 4.02 REDUCTION OF CERTAIN ELECTIONS TO PREVENT DISCRIMINATION ................................ 7 ' 125 -PD -072005 I �. ARTICLEV - BENEFITS.....................................................................................................................................7 5.01 QUALIFIED BENEFITS.............................................................................................................. 7 5.02 CASH BENEFIT......................................................................................................................... 7 ARTICLE VI - PLAN ADMINISTRATION 6.01 ALLOCATION OF AUTHORITY.................................................................................................7 6.02 PROVISION FOR THIRD -PARTY PLAN SERVICE PROVIDERS ................................................. 8 6.03 FIDUCIARY LIABILITY............................................................................................................. 8 6.04 COMPENSATION OF PLAN ADMINISTRATOR.......................................................................... 8 6.05 BONDING..................................................................................................................................8 6.06 PAYMENT OF ADMINISTRATIVE EXPENSES...........................................................................8 6.07 FUNDING POLICY..................................................................................................................... 8 ARTICLE VII- CLAIMS PROCEDURES ARTICLE VIII - AMENDMENT OR TERMINATION OF PLAN.........................................................9 8.01 PERMANENCY..........................................................................................................................9 8.02 EMPLOYER'S RIGHT TO AMEND............................................................................................. 9 8.03 EMPLOYER'S RIGHT TO TERMINATE..................................................................................... 9 8.04 DETERMINATION OF EFFECTIVE DATE OF AMENDMENT OR TERMINATION ...................... 9 ARTICLE IX - GENERAL PROVISIONS.......................................................................................... 10 9.01 NOT AN EMPLOYMENT CONTRACT .................................................... ..... ................... I......... 10 9.02 APPLICABLE LAWS................................................................................................................ 10 9.03 REQUIREMENT FOR PROPER FORMS ............ ................ ........... ..................... I ......... I ...... ....... 10 9.04 MULTIPLE FUNCTIONS...............................................................................................I......... 10 9.05 TAX EFFECTS......................................................................................................................... 10 9.06 GENDERANDNUMBER.......................................................................................................... 10 9.07 HEADINGS.............................................................................................................................. 10 9.08 INCORPORATION BY REFERENCE......................................................................................... 10 9.09 SEVERABILITY....................................................................................................................... 10 9.10 EFFECT OF MISTAKE............................................................................................................. 10 125 -PD -072005 ' PREAMBLE Effective as of the date set forth below, City of San Juan Capistrano established the City of San Juan Capistrano's Cafeteria Plan (the "Plan" or "Cafeteria Plan") for its Employees for purposes of providing eligible Employees with the opportunity to choose from among the Benefit Package Options available under the Plan. The Plan is intended to qualify as a cafeteria plan under the provisions of Code Section 125. I125 -PD -072005 CITY OF SAN JUAN CAPISTRANO City of San Juan Capistrano's Cafeteria Plan ARTICLE I DEFINITIONS 1.01 "Affiliated Employer" means any entity who is considered with the Employer to be a single employer in accordance with Code Section 414(b), (c), or (m). 1,02 "After-tax Contribution(s)" means amounts withheld from an Employee's Compensation pursuant to'a Salary Reduction Agreement after all applicable state and federal taxes have been deducted. Such amounts are withheld for purposes of purchasing one or more of the Benefit Package Options available under the Plan. 1,03 "Anniversary Date" means the first day of any Plan Year, 1.04 "Benefit Package Option(s)" means those Qualified Benefits available to a Participant under this Plan as set forth in the Summary Plan Description, as amended and/or restated from time to time. 1.05 "Board of Directors" means the Board of Directors or other governing body of the Employer (the "Board"). The Board of Directors, upon adoption of this Plan, appoints the Plan Administrator to act on the Employer's behalf in all matters regarding the Plan. 1.06 "Change in Status" means any of the events described in the Summary Plan Description, as well as any other events included under subsequent changes to Code Section 125 or regulations issued under Code Section 125, that the Plan Administrator (in its sole discretion) decides to recognize on a uniform and consistent basis as a reason to change the election mid -year. Note: See the Summary Plan Description for requirements that must be met to permit certain mid -year election changes on account of a Change in Status. 1.07 "Code" means the Internal Revenue Code of 1986, as amended. 1.08 "Compensation" means the cash wages or salary paid to an Employee by the Employer. 1.09 "Dependent" means any individual who is a tax dependent of the Participant as defined generally in Code Section 152(a); however, that in the case of a health benefits, a Dependent shall be defined as set forth in Code Section 105(b) and the regulations issued under Code Section 106. For purposes of Dependent Care FSA (if offered under the Plan) a Dependent shall also be defined as in Code Section 21(e)(5) (i.e., dependent of the parent with custody for the greatest portion of the year). 1.10 "Effective Date" of the Plan means January I, 2004 This is the date the Plan was established. It will not necessarily coincide with the date of this document as set forth in the title page. 1.11 "Employee" means an individual who the Employer classifies as a common-law employee and who is on the Employer's W-2 payroll, but does not include any of the following: (a) any leased employee (including, but not limited to, those individuals defined in Code § 414(n)); (b) an individual classified by the Employer as a contract worker or independent contractor; (c) an individual classified by the Employer as a temporary employee or casual employee, whether or not any such persons are on the Employer's W-2 payroll; and (d) any individual who performs services for the Employer but who is paid 125 -PD -072005 -2- ' by a temporary or other employment agency such as "Kelly," "Manpower," etc., or any employee covered under a collective bargaining agreement, except as otherwise provided for in the collective bargaining agreement. 1.12 "Employer" means the City of San Juan Capistrano and any Affiliated Employer who adopts the Plan pursuant to authorization provided by the Employer. Notwithstanding the previous sentence when the Plan provides that the Employer has a certain power (e.g., the appointment of a third party administrator, entering into a contract with a third party insurer, or amendment or termination of the Plan) the term "Employer" shall mean only City of San Juan Capistrano Affiliated Employers who adopt the Plan shall be bound by the Plan as adopted and subsequently amended unless they clearly withdraw from participation herein. Affiliated Employers who have adopted the Plan are set forth in the Summary Plan Description. 1.13 "ERISA" shall mean the Employee Retirement Income Security Act of 1974, as amended. 1.14 "Highly Compensated Individual" means an individual defined under Code Section 125(e), as amended, as a "highly compensated individual" or a "highly compensated employee." 1.15 "Key Employee" means an individual who is a "key employee" as defined in Code Section 125(b)(2), as amended. 1.16 "Nonelective Contribution(s)" means any amount that the Employer, in its sole discretion, may contribute on behalf of each Participant to provide benefits for such Participant and his or her Dependents, if applicable, under one or more of the Benefit Package Option(s) offered under the Plan. ' The amount of employer contribution that is applied towards the cost of the Benefit Package Option(s) for each Participant and/or level of coverage shall be subject to the sole discretion of the Employer and may be adjusted upward or downward at any time in the contributing Employers sole discretion. The amount shall be calculated for each Plan Year in a uniform and nondiscriminatory manner and may be based upon the Participant's dependent status, commencement or termination date of the Participant's employment during the Plan Year, and such other factors as the Employer shall prescribe. To the extent set forth in the Summary Plan Description or enrollment material, the Employer may make Nonelective Contributions available to Participants and allow Participants to allocate the Nonelective Contributions among the various Benefit Package Options offered under the Plan in a manner set forth in the Summary Plan Description or enrollment material. In no event will any Nonelective Contribution be disbursed to a Participant in the form of additional, taxable Compensation except as otherwise provided in the Summary Plan Description or enrollment material. 1 1.17 "Participant" means an Employee who becomes a Participant pursuant to Article 11.. 1.18 "Plan" means this Cafeteria Plan, as set forth herein. 1.19 "Plan Administrator" means the person(s) or Committee identified in the Summary Plan Description that is appointed by the Employer, with authority, discretion, and responsibility to manage and direct the operation and administration of the Plan. If no such person is named, the Plan Administrator shall be the Employer. 1.20 "Plan Year" shall be the period of coverage set forth in the Summary Plan Description. 125 -Po -072005 - 3 - 1.21 "Pre-tax Contributiou(s)" means amounts withheld from an Employee's Compensation pursuant to a Salary Reduction Agreement before any applicable state and federal taxes have been deducted. The amounts are withheld for purposes of purchasing one or more of the Benefit Package Options available under the Plan. This amount shall not exceed the premiums or contributions attributable to the most costly Benefit Package Option afforded hereunder, and for purposes of Code Section 125, shall be treated as an Employer contribution (this amount may, however, be treated as an Employee contribution for purposes of state insurance laws). 1.22 "Qualified Benefit" means any benefit excluded from the Employee's taxable income under Chapter 1 of the Code other than Sections 106(b), 117, 124, 127, or 132, and any other benefit permitted by the Income Tax Regulations (i.e., any group -term life insurance coverage that is includable in gross income by virtue of exceeding the dollar limitation on nontaxable coverage under Code Sec. 79). Notwithstanding the previous sentence, long-term care insurance is not a "Qualified Benefit." 1.23 "Salary Reduction Agreement" means the actual or deemed agreement pursuant to which an eligible Employee or Participant elects to contribute his share of the cost of chosen Benefit Package Options with Pre-tax or After-tax Contributions and/or Benefit Credits (if offered under the Plan) in accordance with Article III herein. If the Employer utilizes an interactive voice response (IVR) system or web -based program for enrollment, the Salary Reduction Agreement may be maintained on an electronic database in accordance with all applicable federal and/or state laws. 1.24 "Spouse" means an individual who is legally married to a Participant (and who is treated as a spouse under the Code). 1.25 "Summary Plan Description" or "SPD" means the Flexible Benefits Plan SPD and all appendices incorporated into and made a part of the SPD that is adopted by the Employer and attached to this Plan Document as Attachment 1, as amended from time to time. The SPD and appendices are incorporated hereto by reference. 1.26 "Student" means an individual who, during each of five (5) or more calendar months during the Plan Year, is a full time student at any college or university, the primary function of which is the conduct of formal instruction, and which routinely maintains a regular faculty and curriculum and normally has an enrolled student body in attendance at the location where its educational activities are regularly presented. ARTICLE II ELIGIBILITY AND PARTICIPATION 2.01 Eligibility to Participate. Each Employee who satisfies the eligibility requirements set forth in the SPD shall be eligible to participate in this Plan as of the Eligibility Date set forth in the SPD. Eligibility to participate in this Plan means only that the Eligible Employee is entitled to contribute his share of the cost of applicable Benefit Package Options for which he is eligible with Pre-tax Contributions. The provisions of this Article are not intended to override any eligibility requirement(s) or waiting period(s) specified in the applicable Benefit Package Options and the terms of eligibility and participation for the Benefit Package Option(s) offered under the Plan shall be subject to the requirements specified in the governing documents of the Benefit Package Options. 2.02 Termination of Participation. Participation shall terminate on the earliest of the dates set forth in the SPD. 125 -PD -072005 - 4 - - 2.03 Qualifying Leave Under Family Leave Act. Notwithstanding any provision to the contrary in this Plan, if a Participant goes on a qualifying leave under the Family and Medical Leave Act of 1993 (the "FMLA"), then to the extent required by the FMLA, the Participant will be entitled to continue the Participant's Benefit Package Options that provide health coverage on the same terms and conditions as if the Participant were still an active Employee. The requirements for continuing coverage, procedures for FMLA leave and payment option(s) provided by the Employer (as described above) will be set forth in the SPD and will be administered in accordance with the regulations issued under Code Section 125 and in accordance with the FMLA. 2.04 Non-FMLA Leave. If a Participant goes on an unpaid leave of absence that does not affect eligibility under this Plan or ,the Benefit Package Options chosen by the Participant, then the Participant will continue to participate and the contributions due for the Participant will be paid by one or more of the payment options described in the SPD and implemented by the Employer on a uniform and consistent basis in accordance with the Employer's internal policy and procedure. If a Participant goes on an unpaid leave that affects eligibility under this Plan or the Benefit Package Options chosen by the Participant, the election change rules in Section 3.04, will apply. If such policy requires coverage to continue during the leave but permits a Participant to discontinue contributions while on leave, the Participant will, upon returning from leave, be required to repay the contributions not paid by the Participant during the leave. ARTICLE III PREMIUM ELECTIONS 3.01 Election of Contributions. A Participant may elect any combination of Pre-tax Contributions or After-tax Contributions (to the extent set forth in the enrollment material) to fund any Benefit Package Option available under the Plan, provided that only Qualified Benefits may be funded with Pre-tax Contributions. The Employer may, but is not required to, allocate Non -elective Contributions to one or more Benefit Package Options offered under the Plan and to the extent set forth in the SPD or enrollment material, may allow the Participants to allocate his allotted share of Nonelective Contributions among the various Benefit Package Options in a manner set forth in the SPD or enrollment material. 3.02 Initial Election Period. a) Currently Eligible Employees. An Employee who is eligible to become a Participant in this Plan as of the Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan Administrator (or its designated third party administrator as set forth on the Salary Reduction Agreement) during the election period (as specified by the Plan Administrator) immediately preceding the Effective Date of the Plan in order to become a Participant on the Effective Date. The elections made by the Participant on this initial Salary Reduction Agreement shall be effective, subject to Section 3.04, for the Plan Year beginning on the Effective Date. b) New Employees and Employees Who Have Not Yet Satisfied The Plan's Waiting Period. An Employee who becomes eligible to become a Participant in this Plan after the Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan Administrator (or its designated third party administrator as set forth on the Salary Reduction Agreement) during the Initial Election Period set forth in the SPD or the enrollment material. Participation will commence under this Plan as set forth in the SPD. Coverage under the component Benefit 125 -PD -072005 -5- Package Options will be effective in accordance with the governing provisions of such Benefit Package Options. c) Failure to Elect. An eligible Employee who fails to complete, sign and file a Salary Reduction Agreement in accordance with paragraph (a) or (b) above during an initial election period may become a Participant on a later date in accordance with Section 3.03, or 3.04. 3.03 Annual Election Period. Each Employee who is a Participant in this Plan or who is eligible to become a Participant in this Plan shall be notified, prior to each Anniversary Date of this Plan, of his right to become a Participant in this Plan, to continue participation in this Plan, or to modify or to cease participation in this Plan, and shall be given a reasonable period of time in which to exercise such right. Such period of time shall be known as the Annual Election Period. The date on which the Annual Election Period commences and ends will be set forth in the SPD or the enrollment material. An election is made during the Annual Election Period in the manner set forth in the SPD. The consequences of failing to make an election during the Annual Election Period will be set forth in the SPD. 3.04 Change of Elections. A Participant shall not make any changes to the Pre-tax Contribution amount or, where applicable, to the Participant's elected allocation of Nonelective Contributions except under the circumstances set forth in the SPD and for changes made during the Annual Election Period, changes caused by termination of employment or cessation of eligibility, and changes pursuant to the Family and Medical Leave Act. Except as provided in the SPD for HIPAA special enrollment rights arising from the birth, adoption, or placement for adoption of a child, all election changes shall be effective on a prospective basis only (i.e., election changes will become effective no earlier than the first day of the first pay period coinciding with or immediately following the date that the election change was filed) but, as determined by the Plan Administrator, election changes may become effective later to the extent the coverage in the applicable component plan commences later. 3.05 Impact of Termination of Employment on Election or Cessation of Eligibility. Termination of employment or cessation of eligibility shall automatically revoke any Salary Reduction Agreement. Except as provided below, if revocation occurs under this Section 3.05, no new election with respect to Pre -Tax Contributions may be made by such Participant during the remainder of the Plan Year except as set forth in the SPD. ARTICLE IV PREMIUM PAYMENTS AND CREDITS AND DEBITS TO ACCOUNTS 4.01 Source of Benefit Funding. The cost of coverage under the component Benefit Package Options shall be funded by Participant's Pre-tax and/or After-tax Contributions and/or any Nonelective Contributions provided by the Employer. The required contributions for each of the Benefit Package Options offered under the Plan shall be made known to employees in enrollment materials. Pre-tax or After-tax Contributions (as elected by the Employee on the Salary Reduction Agreement and permitted by the Employer) shall equal the contributions required from the Participant less any available Nonelective Contributions allocated thereto by the Employer, or where applicable, the Participant for coverage of the Participant or the Participant's Spouse or Dependents under the Benefit Package Options elected by the Participant under this Plan. Amounts withheld from a Participant's Compensation as Pre- tax Contributions or After-tax Contributions shall be applied to fund benefits as soon as administratively feasible. The maximum amount of Pre-tax Contributions, plus any Nonelective Contributions made available by the Employer, shall not exceed the aggregate cost of the Benefit Package Options elected. 125 -PD -072005 -6- _ 4.02 Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator determines, before or during any Plan Year, that the Plan may fail to satisfy for such Plan Year any requirement imposed by the Code or any limitation on Pre-tax Contributions allocable to Key Employees or to Highly Compensated Individuals, the Plan Administrator shall take such action(s) as he 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 or revocation of a Highly Compensated Individual's or Key Employee's election without the consent of such Employee. ARTICLE V BENEFITS 5.01 Qualified Benefits. The maximum benefit a Participant may elect under this Plan shall not exceed the sum of the aggregate maximum premium and/or contribution for all Benefit Package Option(s) set forth in the SPD. 5.02 Cash Benefit. To .the extent that a Participant does not elect to have the maximum amount of his Compensation contributed as a Pre-tax Contribution or After-tax Contribution hereunder, such amount not elected shall be paid to the Participant in the form of normal Compensation payments; provided, however, that any applicable Nonelective Contributions may not be received in the form of cash compensation, except as otherwise provided for in the SPD or the enrollment material. ARTICLE VI PLAN ADMINISTRATION 6.01 Allocation of Authority. The Board of Directors or applicable governing body (or an authorized officer of the Employer) appoints a Plan Administrator that keeps the records for the Plan and shall control and manage the operation and administration of the Plan. The Plan Administrator shall have the exclusive right to interpret the Plan and to decide all matters arising thereunder, including the right to make determinations of fact, and construe and interpret possible ambiguities, inconsistencies, or omissions in the Plan and the SPD issued in connection with the Plan. All determinations of the Plan Administrator with respect to any matter hereunder shall be conclusive and binding on all persons. Without limiting the generality of the foregoing, the Plan Administrator shall have the following powers and duties: a) To require any person to furnish such reasonable information as he may request for the purpose of the proper administration of the Plan as a condition to receiving any benefits under the Plan; b) To make and enforce such rules and regulations and prescribe the use of such forms as he shall deem necessary for the efficient administration of the Plan; c) To decide on questions concerning the Plan and the eligibility of any Employee to participate in the Plan and to make or revoke elections under the Plan, in accordance with the provisions of the Plan; d) To designate other persons to carry out any duty or power which may or may not otherwise be a fiduciary responsibility of the Plan Administrator, under the terms of the Plan. Such entity will be referred to as a third party administrator and shall be identified in the SPD; 125 -PD -072005 7- e) To keep records of all acts and determinations, and to keep all such records, books of account, data and other documents as may be necessary for the proper administration of the Plan; f) To do all things necessary to operate and administer the Plan in accordance with its provisions. 6.02 Provision for Third -Party Pian Service Providers. The Plan Administrator, subject to approval of the Employer, may employ the services of such persons, as it may deem necessary or desirable in connection with the operation of the Plan and may rely upon all tables, valuations, certificates, reports and opinions furnished thereby. Such entity will be identified in the SPD as a third party administrator. Unless otherwise provided in the service agreement, obligations under this Plan shall remain the obligation of the Employer. 6.03 Fiduciary Liability. To the extent permitted by law, the Plan Administrator shall not incur any liability for any acts or for failure to act except for their own willful misconduct or willful breach of this Plan. 6.04 Compensation of Plan Administrator. Unless otherwise determined by the Employer and permitted by law, any Plan Administrator who is also an employee of the Employer shall serve without compensation for services rendered in such capacity, but the Employer shall pay all reasonable expenses incurred in the performance of their duties. 6.05 Bonding. Unless otherwise determined by the Employer, or unless required by any federal or state law, the Plan Administrator shall not be required to give any bond or other security in any jurisdiction in connection with the administration of this Plan. — 6.06 Payment of Administrative Expenses. The Employer currently pays all reasonable expenses incurred in administering the Plan. 6.07 Funding Policy. The Employer shall have the right to enter into a contract with one or more insurance companies for the purposes of providing any Benefit Package Options offered under the Plan and to replace any of such insurance companies or contracts. Any dividends, retroactive rate adjustments or other refunds of any type that may become payable under any such insurance contract shall not be assets of the Plan but shall be the property of, and shall be retained by the Employer. The Employer will not be liable for any loss or obligation relating to any insurance coverage except as is expressly provided by this Plan. Such limitation shall include, but not be limited to, losses or obligations that pertain to the following: a) Once insurance is applied for or obtained, the Employer will not be liable for any loss which may result from the failure to pay premiums to the extent premium notices are not received by the Employer; b) To the extent premium notices are received by the Employer, the Employer's liability for the payment of such premiums will be limited to such premiums and will not include liability for any other loss which result from such failure; c) The Employer will not be liable for the payment of any insurance premium or any loss that may result from the failure to pay an insurance premium if the benefits available under this Plan are not enough to provide for such premium cost at the time it is due. In such circumstances, the Employee will be responsible for and see to the payment of such premiums. The Employer will 125 -PD -072005 - 8 - ' undertake to notify a Participant if available benefits under this Plan are not enough to provide for an insurance premium, but will not be liable for any failure to make such notification; d) When employment ends, the Employer will have no liability to take any step to maintain any policy in force except as may be specifically required otherwise in this Pian, and the Employer will not be liable for or responsible to see to the payment of any premium after employment ends. ARTICLE VII CLAIMS PROCEDURES The Plan has established procedures for reviewing claims denied under this Plan and those claims review procedures are set forth in the SPD. The Plan's claim review procedures set forth in the SPD shall only apply to issues germane to the pre-tax benefits available under this Plan (i.e., such as a determination of. a Change in Status; change in cost or coverage; or eligibility and participation matters under this Cafeteria Plan document), and to the extent offered under the Plan, claims for benefits under the Reimbursement Accounts. ARTICLE VIII AMENDMENT OR TERMINATION OF PLAN 8.01 Permanency. While the Employer fully expects that this Plan will continue indefinitely, due to unforeseen, future business contingencies, permanency of the Plan will be subject to the Employer's right to amend or terminate the Plan, as provided in Sections 8.02, and 8.03, below. Nothing in this Plan is intended to be or shall be construed to entitle any Participant, retired or otherwise, to vested or non - terminable benefits. 8.02 Employer's Right to Amend. The Employer reserves the right to amend at any time any or all of the provisions of the Plan. All amendments shall be made in writing and shall be approved by the Employer in accordance with its normal procedures for transacting business (e.g., by approval by the Board of Directors through a meeting or unanimous consent of all Board members). Such amendments may apply retroactively or prospectively as set forth in the amendment. Each Benefit Package Option shalt be amended in accordance with the terms specified therein, or, if no amendment procedure is prescribed, in accordance with this section. Any amendment made by the Employer shall be deemed to be approved and adopted by any Affiliated Employer. 8.03 Employer's Right to Terminate. The Employer reserves the right to discontinue or terminate the Plan without prejudice at any time and for any reason without prior notice. Such decision to terminate the Plan shall be made in writing and shall be approved by the Employer in accordance with its normal procedures for transacting business. Affiliated Employers may withdraw from participation in the Plan, but may not terminate the Plan. 8.04 Determination of Effective Date of Amendment or Termination. Any such amendment, discontinuance or termination shall be effective as of such date as the Employer shall determine. 125 -PD -072005 - 9 - ARTICLE IX GENERAL PROVISIONS 9.01 Not an Employment Contract. Neither this Plan nor any action taken with respect to it shall confer upon any person the right to continue employment with any Employer. 9.02 Applicable Laws. The provisions of the Plan shall be construed, administered and enforced according to applicable federal law and the laws ofthe State of California to the extent not preempted. 9.03 Requirement for Proper Forms. All communications in connection with the Plan made by a Participant shall become effective only when duly executed on any forms as may be required and furnished by, and filed with, the Plan Administrator. 9.04 Multiple Functions. Any person or group of persons may serve in more than one fiduciary capacity with respect to the Plan. 9.05 Tax Effects. Neither the Employer, nor the Plan Administrator makes any warranty or other representation as to whether any Pre-tax Contributions made to or on behalf of any Participant hereunder will be treated as excludable from gross income for local, state, or federal income tax purposes. If for any reason it is determined that any amount paid for the benefit of a Participant or Beneficiary are includable in an Employee's gross income for local, federal, or state income tax purposes, then under no circumstances shall the recipient have any recourse against the Plan Administrator or the Employer with respect to any increased taxes or other losses or damages' suffered by the Employees as a result thereof. The Plan is designed and is intended to be operated as a "cafeteria plan" under Section 125 of the Code. 9.06 Gender and Number. Masculine pronouns include the feminine as well as the neuter genders, and the singular shall include the plural, unless indicated otherwise by the context. 9.07 Headings. The Article and Section headings contained herein are for convenience of reference only, and shall not be construed as defining or limiting the matter contained thereunder. 9.08 Incorporation by Reference. The actual terms and conditions of the separate component Benefit Package Options offered under this Plan are contained in separate, written documents governing each respective benefit, and shall govern in the event of a conflict between the individual plan document, and this Plan as to substantive content. To that end, each such separate document, as amended or subsequently replaced, is hereby incorporated by reference as if fully recited herein. In addition, the SPD for this Plan contains many of the actual terms and conditions of this Plan. To that end, the SPD, as amended from time to time, is incorporated herein. 9.09 Severability. Should a court of competent jurisdiction subsequently invalidate any part of this Plan, the remainder thereof shall be given effect to the maximum extent possible. 9.10 Effect of Mistake. In the event of a mistake as to the eligibility or participation of an Employee, or the allocations made to the account of any Participant, or the amount of distributions made or to be made to a Participant or other person, the Plan Administrator shall, to the extent it deems possible, cause to be allocated or cause to be withheld or accelerated, or otherwise make adjustment of, such amounts as will in its judgment accord to such Participant or other person the credits to the account or distributions 125 -PD -072005 - to- ' to which he is properly entitled under the Plan. Such action by the Administrator may include withholding of any amounts due the Plan or the Employer from Compensation paid by the Employer. IN WITNESS WHEREOF, the Employer has executed this Cafeteria Plan as of the date set forth below. CITY OF SAN JUAN CAPISTRANO I125 -PD -072005 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT APPENDIX B TO THE CITY OF SAN JUAN CAPISTRANO'S CAFETERIA PLAN The Effective Date of this Document is January 1, 2006 DFSA-PD-072005 I TABLE OF CONTENTS ARTICLE IB — DEFINITIONS................................................................................................... 2 1.0111 Dependent...................................................................................................................2 1.02B Dependent Care Expense Reimbursement.............................................................. 2 1.03B Earned Income...........................................................................................................2 1.04E Effective Date.............................................................................................................. 2 1.05B Eligible Employment Related Expenses...................................................................2 1.06B Highly Compensated Individual...............................................................................2 1.07B Reimbursement Account(s) or Account(s)............................................................... 2 1.08B Qualifying Individual.................................................................................................3 1.09B Qualifying Services.................................................................................................... 3 ARTICLE IIB — ELIGIBILITY AND PARTICIPATION ... .................... . .......... I ... I................ 3 DFSA-PD-072005 2.018 Eligibility to Participate.............................................................................................3 2.02B Termination of Participation ....................................................................................3 2.03E Qualifying Leave Under Family Leave Act............................................................. 3 ARTICLE IIIB — ELECTION TO PARTICIPATE PARTICIPATION ................................ 4 3.01E Initial Election Period................................................................................................4 3.02B Annual Election Period..............................................................................................4 3.03B Change of Elections.................................................................................................... 4 3.04B Impact of Termination of Employment on Election or Cessation of Eligibility... 5 3.0511 Reduction of Certain Elections to Prevent Discrimination................:...................5 ' ARTICLE IVB — REIMBURSEMENTS.................................................................................... 5 4.0111 Dependent Care Reimbursement..............................................................................5 4.02B Receiving Dependent Care Reimbursement............................................................ 5 4.03B Substantiation of Expenses........................................................................................5 4.04B Repayment of Excess Reimbursements....................................................................5 4.05B Reimbursement Following Cessation of Participation ........................................... 6 4.06B Disbursement Reports...............................................................................................6 4.07B Reimbursement..........................................................................................................6 4.08B Statements...................................................................................................................6 4.09B Past -Mortem Payments.............................................................................................6 4.10B Non alienation of Benefits.......................................................................................... 6 4.11B Mental or Physical Incompetency............................................................................. 6 4.12B Inability to Locate Payee...........................................................................................7 4.13B Tax Effects of Reimbursements................................................................................7 4.14B Forfeiture of Unclaimed Reimbursement Account Benefits..................................7 ARTICLE VB — FUNDING AGENT..........................................................................................7 ARTICLE VIB — CLAIMS PROCEDURES..............................................................................7 DFSA-PD-072005 PREAMBLE Effective as of the date set forth below, City of San Juan Capistrano established this Dependent Care Spending Account (the Dependent Care FSA) to help provide dependent care assistance for those Employees who participate in the Employer's Cafeteria Plan ("Plan") and who, pursuant to the election procedures set forth in the Plan, choose to make contributions to a Dependent Care Reimbursement Account established pursuant to this Dependent Care FSA. This Dependent Care FSA is intended to provide reimbursement of certain Eligible Employment Related Expenses incurred by the Participant for care of a Qualifying individual. The Employer intends that the Dependent Care FSA qualify as a Code Section 129 dependent care assistance plan, and that the benefits provided under the Dependent Care FSA be eligible for exclusion from the Participant's income for federal income tax purposes under Section 129 of the Code. This Dependent Care FSA is a component of, and incorporated by reference into, the City of San Juan Capistrano's Cafeteria Plan ("Cafeteria Plan") and Articles VI, IX and X of the Cafeteria Plan document apply also to this Dependent Care FSA. DFSA-PD-072005 ' ARTICLE IB DEFINITIONS Unless otherwise specified, terms that are capitalized in this Appendix B to the Cafeteria Plan have the same meaning as the defined terms in the Cafeteria Plan. The definitions of terms defined in this Appendix B, but not defined in the Cafeteria Plan, shall be applicable only with respect to this Appendix B. To the extent a tern is defined both in the Cafeteria Plan and in this Appendix B, the term as defined in the Cafeteria Plan shall govern the interpretation of the Cafeteria Plan and the tern as defined in this Appendix B shall govern the interpretation of this Dependent Care FSA. LOW "Dependent" means any individual who is a tax dependent of the Participant as defined in Code Section 152 except that a child with respect to whom Code Section 21(e)(5) applies shall be considered a dependent of the custodial parent (as defined in Code Section 152(e)) for purposes of this Dependent Care FSA. . 1.02B "Dependent Care Reimbursement" shall have the meaning assigned to it by Section 4.01 B of this Dependent Care FSA 1.03B "Earned Income" means all income derived from wages, salaries, tips, self- employment, and other Compensation (such as disability or wage continuation benefits), but only if such amounts are includible in gross income for the taxable year. Earned income does not include any other amounts excluded from earned income under Code Section 32(c)(2), such as amounts received under a pension or annuity, or pursuant to workers' compensation. ' 1.04B "Effective Date" of this Dependent Care FSA means January 1, 2004. 1.05B "Eligible Employment Related Expenses" means those expenses that would be considered to be employment-related expenses under Section 21(bx2) of the Code (relating to expenses for household and dependent care services necessary for gainful employment) if paid for by the Employee to provide Qualifying Services other than amounts paid to: a) An individual with respect to whom a Dependent deduction is allowable under Code Section 15l(c) to the Participant or his Spouse; b) The Participant's Spouse; or c) A child (as defined in Code Section 152(0(1)) of the Participant who is under 19 years of age at the end of the taxable year in which the expenses were incurred. 1.06B "Highly Compensated Individual" means an individual defined under Code Section 414(q), as amended, as a "highly compensated individual" or a "highly compensated employee." 1.07B "Reimbursement Account(s)" shall be the funding mechanism by which amounts are withheld from an Employee's Compensation and retained for future Dependent Care Reimbursement (as defined in Section 1.028 herein). No money shall actually be allocated to any individual Participant Account(s); any such Account(s) shall be of a memorandum nature, maintained by the Administrator for accounting purposes, and shall not be representative of any identifiable trust assets. No interest will be credited to or paid on amounts credited to the Participant Account(s). I DFSA-PD-012005 1.088 "Qualifying Individual" means: a) An individual age 12 or under who is a "qualifying child" of the Participant as defined in Code Section 152(aXQ. Generally speaking, a "qualifying child" is a child (including a brother, sister, step sibling) of the Participant or a descendant of such child (e.g. a niece, nephew, grandchild) who shares the same principal place of abode with the Participant for more than half the year and does not provide over half of his/her support. In addition, a child of an Participant who is also a Code Section 152 dependent of another individual cannot be a Qualifying Individual; b) A Dependent of a Participant who is mentally or physically incapable of caring for himself or herself and who has the same principal place of abode as the employee for more than half the year; or c) The Spouse of a Participant who is mentally or physically incapable of caring for himself or herself and who has the same principal place of abode as the employee for more than half the year. A child of divorced parents will be considered a Qualifying Individual of the "custodial parent" as defined in Code Section 152(e). 1.09B "Qualifying Services" means services relating to the care of a Qualifying Individual that enable the Participant or his Spouse to remain gainfully employed which are performed: a) In the Participant's home; or b) Outside the Participant's home for (i) the care of a Dependent of the Participant who is under age 13, or (ii) the care of any other Qualifying Individual who resides at least eight (8) hours per day in the Participant's household. If the expenses are incurred for services provided by a dependent care center (i.e., a facility that provides care for more than 6 individuals not residing at the facility), the center must comply with all applicable state and local laws and regulations. ARTICLE IIB ELIGIBILITY AND PARTICIPATION 2.91E Eligibility to Participate. Each Employee who satisfies the eligibility requirements set forth in the SPD shall be eligible to participate in this Dependent Care FSA as of the Dependent Care Eligibility Date set forth in the SPD. 2.02B Termination of Participation. Participation shall terminate on the earliest of the dates set forth in the SPD. 2.03B Qualifying Leave under the Family and Medical Leave Act. Notwithstanding any provision to the contrary in this Dependent Care FSA, if a Participant goes on a qualifying leave under the Family and Medical Leave Act of 1993 (the "FMLA"), then to the extent required by the FMLA, the Participant will be entitled to continue the Participant's coverage under this Dependent Care FSA in accordance with the SPD. The requirements for continuing coverage, procedures for FMLA leave and payment option(s) provided by the Employer (as described above) will be set forth in the SPD and will be administered in accordance with the regulations issued under Code Section 125 and in accordance with the FMLA. DESA -PD -072005 ARTICLE IIIB ELECTION TO PARTICIPATE 3.0111 Initial Election Period. a) Currently Eligible Employees. An Employee who is eligible to become a Participant in this Dependent Care FSA as of the Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan Administrator (or its designated third party administrator as set forth on the Salary Reduction Agreement) during the election period (as specified by the Plan Administrator) immediately preceding the Effective Date of the Dependent Care FSA in order to become a Participant on the Effective Date. The elections made by the Participant on this initial Salary Reduction Agreement shall be effective, subject to Section 3.02B, for the Plan Year beginning on the Effective Date. b) New Employees and Employees Who Have Not Yet Satisfied The Dependent Care FSA's Waiting Period. An Employee who becomes eligible to become a Participant in this Dependent Care FSA after the Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan Administrator (or its designated third party administrator as set forth on the Salary Reduction Agreement) during the Initial Election Period set forth in the SPD or the enrollment material. Participation will commence under this Dependent Care FSA as set forth in the SPD (but in no event prior to the election). c) Failure to Elect. An eligible Employee who fails to complete, sign and file a Salary Reduction Agreement in accordance with paragraph (a) or (b) above during an initial election period may become a Participant on a later date in accordance with Section 3.02B or 3.03B. 3.02B Annual Election Period. Each Employee who is a Participant in this Dependent Care FSA or who is eligible to become a Participant in this Dependent Care FSA shall be notified, prior to each Anniversary Date of this Dependent Care FSA, of his right to become a Participant in this Dependent Care FSA, to continue participation in this Dependent Care FSA, or to modify or to cease participation in this Dependent Care FSA, and shall be given a reasonable period of time in which to exercise such right: such period of time shall be known as the Annual Election Period. The date on which the Annual Election Period commences and ends will be set forth in the SPD or the enrollment material. An election is made during the Annual Election Period in the manner set forth in the SPD. The consequences of failing to make an election during the Annual Election Period will be set forth in the SPD. 3.03B Change of Elections. A Participant shall not make any changes to his or her election except for election changes permitted under the SPD, and for changes made during the Annual Election Period, changes caused by termination of employment or cessation of eligibility and changes pursuant to the Family and Medical Leave Act. All election changes shall be effective on a prospective basis only (i.e., election changes will become effective no earlier than the first day of the first pay period coinciding with or immediately following the date that the election change was filed) but, as determined by the Plan Administrator, election changes may become effective later to the extent the coverage in the applicable component plan commences later. ' DFSA-PD-072005 4 3.04B Impact of Termination of Employment on Election or Cessation of Eligibility. Termination of employment or cessation of eligibility shall automatically revoke any Salary Reduction Agreement. Except as provided below, if revocation occurs under this Section 3.04B, no new election with respect to the Dependent Care FSA may be made during the remainder of the Plan Year except as set forth in the SPD. 3.05B Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator determines, before or during any Plan Year, that the Dependent Care FSA may fail to satisfy for such Plan Year any requirement imposed by the Code or any limitation on Highly Compensated Individuals, the Plan Administrator shall take such action(s) as he deems appropriate, under rules uniformly applicable to similarly situated Participants, to assure compliance with such requirement or limitation. ARTICLE IVB REIMBURSEMENTS 4.0113 Dependent Care Reimbursement. Each Participant's Dependent Care FSA will be credited for Dependent Care Reimbursement with amounts withheld from the Participant's Compensation, and any Nonelective Contributions allocated thereto by the Employer or where applicable, the Participant. The Dependent Care Account will be debited for Dependent Care Reimbursements disbursed to the Participant in accordance with Article IVB of this document. In the event that the amount in the Account is less than the amount of reimbursable claims at any time during the Plan Year, the excess part of the claim will be carried over into following months within the same Plan Year, to be paid out as the Dependent Care Account balance becomes adequate. In no event will the amount of Dependent Care Reimbursements exceed the amount credited to the Dependent Care Account for any Plan Year. Any amount allocated to the Dependent Care Account shall be forfeited by the Participant and restored to the Employer if it has not been applied to provide Dependent Care Reimbursement for the Plan Year within the run out period set forth in the SPD. Amounts so forfeited shall be used in a manner that is not prohibited by applicable federal or state law. The maximum annual reimbursement amount shall be set forth in the SPD. The Employer may establish a minimum annual reimbursement amount as set forth in the SPD. 4.02B Receiving Dependent Care Reimbursement. Payment shall be made to the Participant in cash as reimbursement for Eligible Employment Related Expenses incurred by him while a Participant, during the Plan Year for which the Participant's election is effective, provided that the substantiation requirements of Section 4.0313 herein.are satisfied. 4.03B Substantiation of Expenses. Each Participant must submit an expense for reimbursement in accordance with the terms of the SPD. 4.04B Repayment of Excess(Erroneous Reimbursements. If, as of the end of any Plan Year, it is determined that a Participant has received payments under this Dependent Care FSA that exceed the amount of Eligible Employment Related Expenses that have been properly substantiated by such Participant during the .Plan Year as required by Section 4.038 herein or reimbursements have been made in error (e.g. reimbursements were made for expenses incurred for the care of an individual who was not a qualifying individual), the Plan Administrator shall recoup the excess reimbursements in one or more of the following ways: DFSA-PD-072005 ' a) The Plan Administrator shall give the Participant prompt written notice of any such excess amount, and the Participant shall repay the amount of such excess to the Employer within sixty (60) days of receipt of such notification; b) The Plan Administrator may offset the excess reimbursement against any other Eligible Employment Related Expenses submitted for reimbursement (regardless of the Plan Year in which submitted); and/or c) The Plan Administrator may withhold such amounts from the Participant's pay (to the extent permitted under applicable law. If the Plan Administrator is unable to recoup the excess reimbursement through the means set forth above, the Plan Administrator will notify the Employer that the funds could not be recouped and the Employer will treat the excess reimbursement as it would any other bad business debt. 4.05B Reimbursement Following Cessation of Participation. Participants in the Dependent Care FSA may submit claims for reimbursement for Eligible Employment Related Expenses incurred during the Plan Year and before the date of participation in the Dependent Care FSA ceases so long as the claim is submitted prior to the end of the run out period set forth in the SPD. To the extent set forth in the SPD, Participants may submit claims for reimbursement of Eligible Employment -Related Expenses incurred during the Plan Year and after they cease participation so long as such claims are submitted prior to the end of the run out period. Any unused reimbursement benefits at the expiration of the Plan Year (as set forth in the SPD) shall be treated in accordance with Section 4.01 B. 4.06B Disbursement Reports. The Plan Administrator shall issue directions to the Employer concerning all benefits that are to be paid from the Employers general assets pursuant to the provisions of the Dependent Care FSA, 4.07B Timing of Reimbursements. Reimbursements shall be made as soon as administratively feasible after the required forms have been received by the Plan Administrator or its designee. 4.08E Statements. The Plan Administrator or its designated third party administrator may periodically furnish each Participant with a statement, showing the amounts paid or expenses incurred by the Employer in providing Dependent Care Reimbursement under the Dependent Care FSA, 4.09B Post -Mortem Payments. Any benefit payable under the Dependent Care FSA after the death of a Participant shall be paid to his surviving Spouse, otherwise, to his estate. If there is doubt as to the right of any beneficiary to receive any amount, the Plan Administrator may retain such amount until the rights thereto are determined, without liability for any interest thereon. 4.10B Non -Alienation of Benefits. Except as expressly provided by the Administrator, no benefit under the Dependent Care FSA shall be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance or charge, and any attempt to do so shall be void. No benefit under the Dependent Care FSA shall in any manner be liable for or subject to the debts, contracts, liabilities, engagements or torts of any person. 4.11B Mental or Physical Incompetency. Every person receiving or claiming benefits under the Dependent Care FSA shall be presumed to be mentally and physically competent and of age ' until the Plan Administrator receives a written notice, in a form and manner acceptable to it, that DFSA-PD-072005 6 such person is mentally or physically incompetent or a minor, and that a guardian, conservator or other person legally vested with the care of his estate has been appointed. 4.12B Inability to Locate Payee. If the Plan Administrator is unable to make payment to any Participant or other person to whom a payment is due under the Dependent Care FSA because he cannot ascertain the identity or whereabouts of such Participants or other person after reasonable efforts have been made to identify or locate such person, such payment and all subsequent payments otherwise due to such Participant or other person shall be forfeited after a reasonable time after the date any such payment first became due. 4.13B Tax Effects of Reimbursements. Neither the Employer, nor the Plan Administrator makes any warranty or other representation as to whether any reimbursements made under the Dependent Care FSA will be treated as excludable from gross income for local, state, or federal income tax purposes. If for any reason it is determined that any amount paid for the benefit of a Participant or Beneficiary are includable in an Employee's gross income for local, federal, or state income tax purposes, then under no circumstances shall the recipient have any recourse against the Plan Administrator or the Employer with respect to any increased taxes or other losses or damages suffered by the Employees as a result thereof. The Dependent Care FSA is designed and is intended to be operated as a dependent care assistance plan under Section 129 of the Code, 4.14B Forfeiture of Unclaimed Reimbursement Account Benefits, Any Dependent Care FSA Reimbursement Account benefit payments that are unclaimed (e.g., uncashed benefit checks) by the close of the Plan Year following the Plan Year in which the Eligible Employment Related Expense was incurred shall be forfeited. ARTICLE VB FUNDING AGENT The Dependent Care FSA shall be funded with amounts withheld from Compensation pursuant to Salary Reduction Agreements, and/or Nonelective Contributions provided by the Employer, if any. The Employer will apply ail such amounts, without regard to their source, to pay for the welfare benefits provided herein as soon as administratively feasible and shall comply with all applicable regulations. ARTICLE VIB CLAIMS PROCEDURES The Plan has established procedures for reviewing claims denied under this Dependent Care FSA and those claims review procedures are set forth in the SPD. DFSA-PD-072005 u IN WITNESS WHEREOF, the Employer has executed this Dependent Care FSA as of the date set forth below. DFSA-PD-072005 City of San Juan Capistrano 8 HEALTHCARE FLEXIBLE SPENDING ACCOUNT APPENDIX A TO THE CITY OF SAN JUAN CAPISTRANO'S CAFETERIA PLAN The Effective Date of this Document is January I, 2006 HFSA-PD-072005 1 TABLE OF CONTENTS ARTICLE IA - DEFINITIONS ................................................ I.01A Dependent...................................................................................................................2 1.02A Effective Date.............................................................................................................. 2 1.03A Eligible Medical Expenses.........................................................................................2 1.04A Healthcare Reimbursement...................................................................................... 2 1.05A Highly Compensated Individual...............................................................................2 1.06A Reimbursement Account or Account(s)...................................................................2 ARTICLE IIA - ELIGIBILITY AND PARTICIPATION....................................................... 2 2.01A Eligibility to Participate............................................................................................. 2 2.02A Termination of Participation.................................................................................... 2 2.03A Qualifying Leave Under Family Leave Act.............................................................2 ARTICLE IIIA - ELECTION TO PARTICIPATE PARTICIPATION ................................ 3 3.01A Initial Election Period................................................................................................3 3.02A Annual Election Period..............................................................................................3 3.03A Change of Elections.................................................................................................... 4 3.04A Impact of Termination of Employment on Election or Cessation of Eligibility... 4 3.05A Reduction of Certain Elections to Prevent Discrimination....................................4 ARTICLE IVA -REIMBURSEMENTS ...................................................................................4 4.01A Healthcare Reimbursement........................................................................................4 4.02A Receiving Healthcare Reimbursement.....................................................................5 ' 4.03A Substantiation of Expenses........................................................................................ 5 4.04A Repayment of Excess Reimbursements.................................................................... 5 4.05A Reimbursement Following Cessation of Participation ........................................... 5 4.06A Coordination of Benefits Under HCRA................................................................... 5 4.07A Disbursement Reports...............................................................................................6 4.08A Reimbursement..........................................................................................................6 4.09A Statements...................................................................................................................6 4.10A Post -Mortem Payments.............................................................................................6 4.11A Non alienation of Benefits.......................................................................................... 6 4.12A Mental or Physical Incompetency............................................................................. 6 4.13A Inability to Locate Payee........................................................................................... 6 4.14A Tax Effects of Reimbursements................................................................................ 6 4.15A Forfeiture of Unclaimed Reimbursement Account Benefits .................................. 6 ARTICLE VA -FUNDING AGENT..........................................................................................7 ARTICLE VIA -CLAIMS PROCEDURES.............................................................................7 ARTICLE VIIA -CONTINUATION COVERAGE UNDER COBRA..................................7 ARTICLE VIII - HIPAA Privacy............................................................................................... 7 8.01A, Scope and Purpose.....................................................................................................7 8.02A Effective Date.............................................................................................................. 7 8.03A Use and Disclosure of PHI.........................................................................................7 8.04A Conditions Imposed on Employer............................................................................8 8.05A Designated Employees Who May Receive PHI ....................................................... 8 ' HFSA-PD-092005 i 8.06A Restrictions on Employees with Access to PHI ....................................................... 8 8.07A 8.08A rocedures....................................................... 8 Policies and Procedures., ........... ...... Organized Healthcare Arrangement........................................................................ 8 8.09A 8.10A 8.11A 8.12A Privacy Official........................................................................................................... 8 Noncompliance...........................................................................................................9 Definitions...................................................................................................................9 Interpretations and Limited Authority......................................................:.............9 8.13A Services Performed for the Employer ................................ ............................. I...... 1.9 HFSA-PO-072005 it r PREAMBLE Effective as of the Effective Date set forth below, City of San Juan Capistrano established this Healthcare Flexible Spending Account (the Healthcare FSA) to help provide full and complete medical care for those Employees who participate in the Employer's Cafeteria Plan ("Plan") and who, pursuant to the election procedures set forth in the Plan, choose to contribute to a Healthcare Reimbursement Account established pursuant to this Healthcare FSA Plan. This Healthcare FSA is intended to provide reimbursement of certain Eligible Medical Expenses incurred by the Participant and his eligible Dependents. The Employer intends that the Healthcare FSA qualify as a Code Section 105 self-insured medical reimbursement plan, and that the benefits provided under the Healthcare FSA be eligible for exclusion from the Participant's income for federal income tax purposes under Section 105(b) of the Code. This Healthcare FSA is a component of, and incorporated by reference into, the Cafeteria Plan and Articles VI, VII, Vlll and IX of the Cafeteria Plan document apply also to this Healthcare FSA. t1FSA-PD-072005 1 ARTICLE IA DEFINITIONS Unless otherwise specified, terms that are capitalized in this Appendix A have the same meaning as the defined terms in the Cafeteria Plan. The definitions of terms defined in this Appendix A, but not defined in the Cafeteria Plan, shall be applicable only with respect to this Appendix A. To the extent a term is defined both in the Cafeteria Plan and in this Appendix A, the term as defined in the Cafeteria Plan shall govern the interpretation of the Cafeteria Plan and the term as defined in this Appendix A shall govern the interpretation of this Healthcare FSA, 1.01A "Dependent" means any individual who is a tax dependent of the Participant as defined in Code Section 105(b). 1.02A "Effective Date" of this Healthcare FSA means January 1, 2004. 1.03A "Eligible Medical Expenses" means those expenses that are eligible for reimbursement under this Healthcare FSA as set forth in the SPD. 1.04A "Healthcare Reimbursement" shall have the meaning assigned to it by Section 4.01 A of this Healthcare FSA. 1.05A "Highly Compensated Individual" means an individual defined under Code Section 105(h), as amended, as a "highly compensated individual" or a "highly compensated employee." 1.06A "Reimbursement Account" shall be the funding mechanism.by whichamounts are withheld from an Employee's Compensation and retained for future Healthcare Reimbursement (as defined in Section 1.04A herein). No money shall actually be allocated to any individual Participant Account(s); any such Account(s) shall be of a memorandum nature, maintained by the Administrator for accounting purposes, and shall not be representative of any identifiable trust assets. No interest will be credited to or paid on amounts credited to the Participant Account(s). ARTICLE IIA ELIGIBILITY AND PARTICIPATION 2.91A Eligibility to Participate. Each Employee who satisfies the eligibility requirements set forth in the SPD shall be eligible to participate in this Healthcare FSA as of the Healthcare FSA Eligibility Date set forth in the SPD. 2.02A Termination of Participation. Participation shall terminate on the earliest of the dates set forth in the SPD. 2.03A Qualifying Leave Under Family Leave Act. Notwithstanding any provision to the contrary in this Healthcare FSA, if a Participant goes on a qualifying leave under the Family and Medical Leave Act of 1993 (the "FMLA"), then to the extent required by the FMLA, the Participant will be entitled to continue the Participant's coverage under this Healthcare FSA on the same terms and conditions as if the Participant were stili an active Employee. The requirements for continuing coverage, procedures for FMLA leave and payment option(s) provided by the Employer (as described above) will be set forth in the SPD -and will be KFSA-PD-072005 ' administered in accordance with the regulations issued under Code Section 125 and in accordance with the FMLA. r 2.04A. Non-FMLA Leave. If a Participant goes on an unpaid leave of absence that does not affect eligibility under this Healthcare FSA, then the Participant will continue to participate and the contributions due for the Participant will be paid by one or more of the payment options described in the SPD and implemented by the Employer on a uniform and consistent basis in accordance with the Employer's internal policy and procedure. If a Participant goes on an unpaid leave that affects eligibility under this Healthcare FSA, the election change rules in Section 3.03A of this Healthcare FSA will apply. If such policy requires coverage to continue during the leave but permits a Participant to discontinue contributions while on leave, the Participant will, upon returning from leave, be required to repay the contributions not paid by the Participant during the leave. ARTICLE IIIA ELECTION TO PARTICIPATE 3.01A Initial Election Period. a) Currently Eligible Employees: An Employee who is eligible to become a Participant in this Healthcare FSA as of the Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan Administrator (or its designated third party administrator as set forth on the Salary Reduction Agreement) during the election period (as specified by the Plan Administrator) immediately preceding the Effective Date of the Healthcare FSA in order to become a Participant on the Effective Date. The elections made by the Participant on this initial Salary Reduction Agreement shall be effective, subject to Section 3.02A, for the Plan Year beginning on the Effective Date. b) New Employees and Employees Who Have Not Yet Satisfied the Healthcare FSA's Waiting Period. An Employee who becomes eligible to become a Participant in this Healthcare FSA after the Effective Date must complete, sign and file a Salary Reduction Agreement with the Plan Administrator (or its designated third party administrator as set forth on the Salary Reduction Agreement) during the Initial Election Period set forth in the SPD or the enrollment material. Participation will commence under this Healthcare FSA as set forth in the SPD (but in no event prior to the election). c) Failure to Elect. An eligible Employee who fails to complete, sign and file a Salary Reduction Agreement in accordance with paragraph (a) or (b) above during an initial election period may become a Participant on a later date in accordance with Section 3.02A or 3.03A. 3.02A. Annual Election Period. Each Employee who is a Participant in this Healthcare FSA or who is eligible to become a Participant in this Healthcare FSA shall be notified, prior to each Anniversary Date of this Healthcare FSA, of his right to become a Participant in this Healthcare FSA, to continue participation in this Healthcare FSA, or to modify or to cease participation in this Healthcare FSA, and shall be given a reasonable period of time in which to exercise such right: such period of time shall be known as the Annual Election Period. The date on which the Annual Election Period commences and ends will be set forth in the SPD or the enrollment material. An election is made during the Annual Election Period in the manner set forth in the HFSA.PD•072005 SPD. The consequences of failing to make an election during the Annual Election Period will be set forth in the SPD. 3.03A Change of Elections. A Participant shall not make any changes to his or her election except for election changes permitted under the SPD, and for changes made during the Annual Election Period, changes caused by termination of employment or cessation of eligibility and changes pursuant to the Family and Medical Leave Act. Except as provided in the SPD for HIPAA special enrollment rights arising from the birth, adoption, or placement for adoption of a child, all election changes shall be effective on a prospective basis only (i.e., election changes will become effective no earlier than the first day of the first pay period coinciding with or immediately following the date that the election change was filed) but, as determined by the Plan Administrator, election changes may become effective later to the extent the coverage in the applicable component plan commences later. 3.04A Impact of Termination of Employment on Election or Cessation of Eligibility. Termination of employment or cessation of eligibility shall automatically revoke any Salary Reduction Agreement. Except as provided below, if revocation occurs under this Section 3.04A, no new election with respect to the Healthcare FSA may be made during the remainder of the Plan Year except as set forth in the SPD. 3.05A Reduction of Certain Elections to Prevent Discrimination. If the Plan Administrator determines, before or during any Plan Year, that the Healthcare FSA may fail to satisfy for such Plan Year any requirement imposed by the Code or any limitation on Highly Compensated Individuals, the Plan Administrator shall take such action(s) as he deems appropriate, under rules uniformly applicable to similarly situated Participants, to assure compliance with such requirement or limitation. ARTICLE IVA REIMBURSEMENTS 4.01A Healthcare Reimbursement. Each Participant's Healthcare FSA Reimbursement Account will be credited with amounts withheld from the Participant's Compensation and any Nonelective Contributions allocated thereto by the Employer or where applicable, the Participant. The Account will be debited for Healthcare Reimbursements disbursed to the Participant in accordance with this Article IVA. The entire amount elected by the Participant on the Salary Reduction Agreement as an annual amount for the Plan Year for Healthcare Reimbursement less any Healthcare Reimbursements already disbursed to the participant for Expenses incurred during the Plan Year shall be available to the Participant at any time during the Plan Year without regard to the amount of contributions made (provided that the periodic contributions have been made). In no event will the amount of Healthcare Reimbursements in any Plan Year exceed the annual amount specified for the Plan Year in the Salary Reduction Agreement for Healthcare Reimbursement. Any amount credited to the Healthcare Account shall be forfeited by the Participant and restored to the Employer if it has not been applied to provide Healthcare Reimbursement within the run out period set forth in the SPD, Amounts so forfeited shall be used in a manner that is permitted within the applicable Department of Labor or Internal Revenue Service regulations. The maximum annual reimbursement under the Healthcare FSA shall be set forth in the SPD. The Employer may establish a minimum annual reimbursement amount as set forth in the SPD. tiFSA-PD-072005 ' 4.02A Receiving Healthcare Reimbursement. Payment shall be made to the Participant in cash as reimbursement for Eligible Medical Expenses incurred by the Participant or his Dependents while he is a Participant during the Plan Year for which the Participant's election is effective provided that the substantiation requirements of Section 4.03A herein are satisfied. However, if the employer so chooses, the participant may choose to make payment for eligible medical expense with an electronic payment card arrangement. The terms of the electronic payment card arrangement, if applicable, will be set forth in the SPD. 4.03A Substantiation of Expenses. Each Participant must submit an expense for reimbursement in accordance with the terms of the SPD and provide the required substantiation set forth in the SPD or as otherwise requested by the Plan Administrator (or its designee). 4.04A Repayment of Excess Reimbursements. If, as of the end of any Plan Year, it is determined that a Participant has received payments under this Healthcare FSA that exceed the amount of Eligible Medical Expenses that have been substantiated by such Participant during the Plan Year as required by Section 4.03A herein or reimbursements have been made in error (e.g. reimbursements were made for expenses incurred for the care of an individual who was not a qualifying individual), the Plan Administrator shall recoup the excess reimbursements in one or more of the following ways: a) The Plan Administrator shall give the Participant prompt written notice of any such excess amount, and the Participant shall repay the amount of such excess to the Employer within sixty (60) days of receipt of such notification; b) The Plan Administrator may offset the excess reimbursement against any *other Eligible ' Medical Expenses submitted for -reimbursement (regardless of the Plan Year in which submitted); and/or c) The Plan Administrator may withhold such amounts from the Participant's pay (to the extent permitted under applicable law). If the Plan Administrator is unable to recoup the excess reimbursement through the means set forth above, the Plan Administrator will notify the Employer that the funds could not be recouped and the Employer will treat the excess reimbursement as it would any other bad business debt. 4.05A Reimbursement Following Cessation of Participation. Participants in the Healthcare FSA may submit claims for reimbursement for Eligible Medical Expense incurred during the Plan Year and before the date of participation in the Healthcare FSA ceases so long as the claim is submitted prior to the end of the run out period set forth in the SPD. Unless a COBRA election is made as set forth in the SPD, Participants shall not be entitled to receive reimbursement for Eligible Medical Expenses incurred after employment and/or eligibility ceases under this Section. Any unused reimbursement benefits at the expiration of the Plan Year (as set forth in the SPD) shall be treated in accordance with Section 4.0 IA. 4.06A Coordination of Benefits under the Healthcare FSA. The Healthcare FSA is intended to pay benefits solely for otherwise unreimbursed medical expenses. Accordingly, it shall not be considered a group health plan for coordination of benefits purposes, and its benefits shall not be taken into account when determining benefits payable under any other plan. IHFSA-PD-072005 4.07A Disbursement Reports. The Plan Administrator shall issue directions to the Employer concerning all benefits that are to be paid from the Employer's general assets pursuant to the provisions of the Healthcare FSA. 4.08A Timing of Reimbursements. Reimbursements shall be made as soon as administratively feasible after the Plan Administrator or its designee has received the required forms. 4.09A Statements. The Plan Administrator or its designated third party administrator may periodically furnish each Participant with a statement, showing the amounts paid or expenses incurred by the Employer in providing Healthcare Reimbursement under the Healthcare FSA. 4.10A Post -Mortem Payments. Any benefit payable under the Healthcare FSA after the death of a Participant shall be paid to his surviving Spouse, or if no spouse, to his estate. If there is doubt as to the right of any beneficiary to receive any amount, the Plan Administrator may retain such amount until the rights thereto are determined, without liability for any interest thereon. 4.11A Non -Alienation of Benefits. Except as expressly provided by the Administrator, no benefit under the Healthcare FSA shall be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance or charge, and any attempt to do so shall be void. No benefit under the Healthcare FSA shall in any manner be liable for or subject to the debts, contracts, liabilities, engagements or torts of any person. - 4.12A Mental or Physical Incompetency. Every person receiving or claiming benefits under the Healthcare FSA shall be presumed to be mentally and physically competent and of age until the Plan Administrator receives a written notice, in a form and manner acceptable to it, that such person is mentally or physically incompetent or a minor, and that a guardian, conservator or other person legally vested with the care of his estate has been appointed. 4.13A Inability to Locate Payee. If the Plan Administrator is unable to make payment to any Participant or other person to whom a payment is due under the Healthcare FSA because he cannot ascertain the identity or whereabouts of such Participants or other person after reasonable efforts have been made to identify or locate such person, such payment and all subsequent payments otherwise due to such Participant or other person shall be forfeited after a reasonable time after the date any such payment first became due. 4.14A Tax Effects of Reimbursements. Neither the Employer, nor the Plan Administrator makes any warranty or other representation as to whether any reimbursements made under the Healthcare FSA will be treated as excludable from gross income for local, state, or federal income tax purposes. If for any reason it is determined that any amount paid for the benefit of a Participant or Beneficiary are includable in an Employee's gross income for local, federal, or state income tax purposes, then under no circumstances shall the recipient have any recourse against the Plan Administrator or the Employer with respect to any increased taxes or other losses or damages suffered by the Employees as a result thereof. The Healthcare FSA is designed and is intended to be operated as a self-insured medical reimbursement plan under Section 105 of the Code. 4.15A Forfeiture of Unclaimed Reimbursement Account Benefits. Any Healthcare FSA Reimbursement Account benefit payments that are unclaimed (e.g., uncashed benefit checks) by the close of the Plan Year following the Plan Year in which the Eligible Medical -Expense was incurred shall be forfeited. HFSA-PD-072005 6 ARTICLE VA FUNDING AGENT The Healthcare FSA shall be funded with amounts withheld from Compensation pursuant to Salary Reduction Agreements, and/or Nonelective Contributions provided by the Employer, if any. The Employer will apply all such amounts, without regard to their source, to pay for the welfare benefits provided herein as soon as administratively feasible and to the extent applicable, shall comply with all applicable regulations promulgated by the Department of Labor ("D.O.L.") taking into consideration any enforcement procedures adopted by the D.O.L. ARTICLE VIA CLAIMS PROCEDI. The Healthcare FSA has established procedures for reviewing claims denied under this Healthcare FSA and those claims review procedures are set forth in the SPD. ARTICLE VIIA CONTINUATION COVERAGE UNDER COBRA The SPD includes COBRA continuation of coverage provisions that shall be applicable to the Healthcare FSA, to the extent the plan sponsor is subject to COBRA (as it amended ERISA, the Code, and the Public Health Service Act). ARTICLE VIIIA ' HIPAA PRIVACY AND SECURITY 8.01A Scope and Purpose. The Healthcare FSA (the "Plan") will use protected health information ("PHP') to the extent of and in accordance with the uses and disclosures permitted by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). Specifically, the Plan will use and disclose PHI for purposes related to healthcare treatment, payment for healthcare and healthcare operations as set forth below. 8.02A Effective Date. This Article VIIIA is effective on April 14, 2003, or such later effective date of the Privacy Rules with respect to the client). 8.03A Use and Disclosure of PHI. a) General. The Plan will use PHI to the extent of and in accordance with the uses and disclosures permitted by HIPAA, including but not limited to healthcare treatment, payment for healthcare, healthcare operations and as required by law. The Privacy Notice will list the specific uses and disclosure of PHI that will be made by the Plan. b) Disclosure to the Employer. The Plan will disclose PHI to the Employer, or where applicable, an Affiliate only upon receipt of written certification from the Employer that: The Plan document has been amended to incorporate the provisions in this Article VIIIA; and The Employer agrees to implement the provisions in Section 8.04A herein. HFSA-PD-072005 8.04A Conditions Imposed on Employer. Notwithstanding any provision of the Plan to the contrary, the Employer agrees: a) Not to use or disclose PHI other than as permitted or required by this Article VIIIA or as required by law; b) To ensure that any agents, including a subcontractor, to whom the Employer provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Employer with respect to PHI received or created on behalf of the Plan; c) Not use or disclose an individual's PHI for employment-related purposes (including hiring, firing, promotion, assignment or scheduling) unless authorized by the Individual; d) Not to use or disclose an Individual's PHI in connection with any other non -health benefit program or employee benefit plan of the Employer unless authorized by the Individual; e) To report to the Plan any use or disclosureof PHI that is inconsistent with this Article Vlll, if it becomes aware of an inconsistent use or disclosure; f) To provide Individuals with access to PHI in accordance with 45 C.F.R. § 164.524; g) To make available PHI for amendment and incorporate any amendments to PHI in accordance with 45 C.F.R.§ 164.526; h) To make available the information required to provide an accounting of disclosures in accordance with 45 C.F.R. § 164.528; i) To make internal practices, books and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of Health and Human Services for purposes of determining the Plan's compliance with HIPAA; j) If feasible, to return or destroy all PHI received from the Plan that the Employer maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made. If return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible; and k) To ensure adequate separation between the Plan and Employer as required by 45 C.F.R. § 164.504(f)(2)(iii) and described in this Article VIIIA. 8.05A Designated Employees Who May Receive PHI. In accordance with the Privacy Rules, only certain Employees who perform Plan administrative functions may be given access to PHI. Those Employees who have access to PHI from the Plan are listed in the Privacy Notice, either by name or individual position. 8.06A Restrictions on Employees with Access to PHI. The Employees who have access to PHI listed in the Privacy Notice may only use and disclose PHI for Plan Administration functions that the Employer performs for the Plan, as set forth in the Privacy Notice, including but not limited to, quality assurance, claims processing, auditing, and monitoring. 8.07A Policies and Procedures. The Employer will implement Policies and Procedures setting forth operating rules to implement the provisions hereof. 8.08A Organized Healthcare Arrangement. The Plan Administrator intends the Plan to form part of an Organized Healthcare Arrangement along with any other Benefit under a covered health plan (under 45 C.F.R. § 160.103) provided by the Employer. 8.09A Privacy Official. The Plan shall designate a Privacy Official, who will be responsible for the Plan's compliance with HIPAA. The Privacy Official may contract with or otherwise utilize the services of attorneys, accountants, brokers, consultants, or other third party experts as HFSA-PD-072005 ' the Privacy Official deems necessary or advisable. In addition and notwithstanding any provision of this Plan to the contrary, the Privacy Official shall have the authority to and be responsible for: a) Accepting and verifying the accuracy and completeness of any certification provided by the Employer under this Article VIIIA; b) Transmitting the certification to any third parties as may be necessary to permit them to disclose PHI to Employer, c) Establishing and implementing policies and procedures with respect to PHI that are designed to ensure compliance by the Plan with the requirements of HIPAA; d)Establishing and overseeing proper training of the Plan, or Employer personnel who will have access to Protected Heath Information; and e) Any other duty or responsibility that the Privacy Official, in his or her sole capacity, deems necessary or appropriate to comply with the provisions of HIPAA and the purposes of this Article VIIIA. 8.10A Noncompliance. The Employer shall provide a mechanism for resolving issues of noncompliance, including disciplinary sanctions for personnel who do not comply with the provisions of this Article VIIIA. 8.11A Definitions. As used in this Article VIIIA, each of the following capitalized terms shall have the respective meaning given below: • "Individual" means the person who is the subject of the heath information created, received or maintained by the Plan or Employer. • "Organized Healthcare Arrangement" means the relationship of separate legal entities as defined in 45 C.F.R. §160.103. • "Privacy Notice" means the notice of the Plan's privacy practices distributed to Plan participants in accordance with 45 C.F.R. § 164.520, as amended from time to time. • "Privacy Rules" means the privacy provisions of HIPAA and the regulations in 45 C.F.R- Parts 160 and 164. • "Protected Health Information or PHI" means individually identifiable health information as defined in 45 C.F.R. § 160.103. 8.12A Interpretation and Limited Applicability. This Article VIII serves the sole purpose of complying with the requirements of HIPAA and shall be interpreted and construed in a manner to effectuate this purpose. Neither this Article Vllt nor the duties, powers, responsibilities, and obligations listed herein shall be taken into account in determining the amount or nature of the benefits provided to any person covered under this Plan, nor shall they inure to the benefit of any third parties. To the extent that any of the provisions of this Article VIII are no longer required by HIPAA, they shall be deemed deleted and shall have no further force or effect. 8.13A Services Performed for the Employer. Notwithstanding any other provision of this Plan to the contrary, all services performed by a business associate for the Plan in accordance with the applicable service agreement shall be deemed to be performed on behalf of the Plan and subject to the administrative simplification provisions of HIPAA contained in 45 C.F.R. parts 160 through 164, except services that relate to eligibility and enrollment in the Plan. If a business IHFSA-PD-072005 9 associate of the Plan performs any services that relate to eligibility and enrollment to the Plan, these services shall be deemed to be performed on behalf of the Employer in its capacity as Plan Sponsor and not on behalf of the Plan. IN WITNESS WHEREOF, the Employer has executed this Healthcare FSA as of the date set forth below. City of San Juan Capistrano HFSA-PD-072005 10 - •• ' EXHIBIT "B" CITY OF SAN JUAN CAPISTRANO FLEXIBLE BENEFITS PLAN SCHEDULE OF BENEFIT OPTIONS Effective January 1, 2008 A. Employer non -elective contribution based upon PEMHCA Medical Plan coverage: Coverage Emobver Contribution Employee only $ 502.99 Employee + 1 dependent 1011.67 Family 1340.18 B. Employer non -elective contribution based upon NON-PEMHCA Medical Plan coverage: Employee only, Employee +1 dependent, & Family: $325.00/month Exhibit B PEMHCA Health Plans Monthly Rates: ' Health Plan Employee Employee + 1 Family Blue Shield Net Value $401.98 $803.96 $1045.15 Blue Shield HMO 447.97 895.94 1164.72 Kaiser HMO 393.63 787.26 1023.44 PERS Select 444.05 888.10 1154.53 PERS Choice 458.59 917.18 1192.33 PERSCare 712.71 1425.42 1853.05 Aetna Dental Plan $40.04 $94.01 $136.51 VSP Vision Plan 14.98 $21.72 $38.95 Exhibit B