Resolution Number 00-10-3-2RESOLUTION NO. 00-10-3-2
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN JUAN
CAPISTRANO, CALIFORNIA, ADOPTING A FLEXIBLE BENEFITS PLAN
DOCUMENT (JULY 1, 2000 - DECEMBER 31, 2001)
WHEREAS, Section 37206 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 coverages
contribute to a total compensation package; and,
WHEREAS, the City enrolled its employees into the Public Employees'
Medical and Hospital Care Act Program through CAPERS for the provision of medical
benefits, effective July 1, 2000; and,
WHEREAS, the City enrolled its employees with Prudential Health Care and
Vision Services Plan, for the provision of dental and vision benefits, respectively, effective
July 1, 1998; and,
WHEREAS, contracting with CalPERS requires the establishment of a
cafeteria -style plan and Flexible Benefits Plan document, in accordance with Internal
Revenue Service Code Section 125; and,
WHEREAS, the City desires to adopt a Flexible Benefits Plan Document.
NOW, THEREFORE, BE IT RESOLVED, that the City Council of the City of
San Juan Capistrano does hereby adopt the City's Flexible Benefits Plan Document, to be
administered in accordance with the provisions of said Plan Document, hereto attached
as "Exhibit A."
ATTEST:
CITY CLERK U
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096
STATE OF CALIFORNIA
COUNTY OF ORANGE S s
CITY OF
,!i k JUAN LIY M ;k O
1, CHERYL JOHNSON, City Clerk of the City of San Juan Capistrano,
California, OO HEREBY CERTIFY that the foregoing is a true and correct copy of
Resolution No. 00-10-3-2, adopted by the City Council of the City of San Juan Capistrano,
California, at a regular meeting thereof held on the 3rd day of October, 2000, by the
following vote;
AYES: Council Members Bathgate, Greiner, Fart, Swerdlin
and Mayor Campbell
NOES: None
ABSENT: Done
(SEAL)
CHERYL JO O CITY CLERK
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Exhibit "A"
097
098
SAN RJAN CAPIS`I`RANO
Fl..,EXIL I..E BENFTITS PLAN
TABLE OI{ CON I LN'I 5
Page
ARTICLE I FOREWORD AND PURPOSE 1
ARTICLE II DEFINITIONS AND CONSTRUCTION I
ARTICLE III ELIGIBILITY, PARTICIPATION AND ENROLLMENT 3
ARTICLE IV CONTRIBUTIONS g
ARTICLE V ADMINISTRATION 7
ARTICLE VI AMENDMENT Oh TME PLAN 9
ARTICLE VII TERMINATION OF ` 111 PLAN 9
ARTICLE VIII MISCELLANEOUS IO
SCHEDULE A EMPLOYER CONTRIBUTION SCHEDULE A
DEPENDENT CARE REIMBURSEMENT COMPONENT PLAN SCHEDULE AI -I
MEDICAL, REIMBURSEMENT COMPONENT PLAN SCHEDULE A2-1
099
SAN JUAN CAPISTRANO
111)CIBLI B Nil TITS PLAN
ARTICLE I l`0RF'W()R.D AND PURP(I)SE
The ;pan Juan Capistrano Flexibly Berietits Plein permits eligible. Participants to elect to
receive compensation for coverage for themselves and their eligible l:)ependents under
various Corponent :Plans.
The Plan has been established for the exclusive benefit of its Participant; and is intended
to qualify under Section 125 of the Internal Revenue Code of 1986, as a "c&fr tcria plan",
.ARTICLE II DEFINITIONS AND CONSTRUCTION
2.1 Definitions: Where the following words and phrases appear in this Plan they shall
have the meaning set forth below, unless a different meaning is plainly required by the
context:
(a) Code: The Internal Revenue Code of 1986 and regulations and rulings issued
thereunder, as amended froze time to time.
(b) Component Plana: Any one of the plans listed in subsection (c) below. It is intended
that each of the Component Plans shall constitute a "qualified benefit" within the
meaning of Section 125 of the Code.
(c) Coverage Expenses: The insurance premiums or other costs for the benefit coverage
a Participant elects pursuant to Section 3.2, and which is provided under one or more of
the Component Plans which are attached hereto and incorporated herein by reference:
SEE SCHEDULE "A" "A I" & "A2"
(d) Covered Compensation: For each Plan Year, a Participant's Covered Compensation
shall mean the actual compensation (including bonuses and overtime) accrued or paid by
the Employer to the Employee for the period during which the Employee was a
Participant in this Plan.
(e) Dependent: A spouse or child of the participant as defined in the Code.
100
(f) Discrimination: This Plan shall not be operated in such a manner as to discriminate
in favor of highly compensated individuals pursuant to Code Section 105.
(g) Effective date: Me date upon which this Plan is effective is July 1, 2000.
(h) Employee Any person who is an employee (the term "employee" having its
customary, common law meaning) of the .Employer and who is receiving remuneration
for personal services rendered to the Employer on a full time employment basis and is
eligible for coverage in the various benefit plans offered by the Employer; including City
Councilmembers.
(i) Employer: City of San Juan Capistrano,
0) Employer Contribution: The Employer Contribution for each Plan Year shall be the
sum of (1) and (2) below:
(1) Non -elective contributions: The amount the Employer makes available for the
benefit of each Participant for the Plan Year pursuant to Section 4.1. for each Plan Ycar.
the maximum amount of Employer Contribution available under the Plan to any
Participant for application to his or her Coverage Expenses shall be that amount set forth
in Schedule A of the flan. For purposes of Section 125 of the Code, the amount set forth
in Schedule A shall constitute the maximum Employer Contribution available to any
Participant under the Plan during a Plan Year. The maximum amount shall be determined
by the Employer prior to the beginning of the Regular Enrollment Period for the ensuing
Plan Year and may be adjusted as necessary due to increases in cost of the coverage.
(2) Elective Contributions: The amount of Flexible Pay applied to a Participant's
Coverage Expenses under the Plan. It is intended hereunder that such amounts shall, for
tax purposes (including Section 125 of the Code), constitute an Employer Contribution.
(k) ERISA: Public Law 93-406, the Employee Retirement Income Security Act of
1974 and regulations and rulings issued thereunder as amended from time to time.
(1) Fiduciaries: The Named Fiduciaries who shall be the Employer and the Plan
Administrator, and other parties designated as Fiduciaries by such Named Fiduciaries in
accordance with the powers herein provided, but only with respect to the specific
responsibilities of each in connection with the Plan.
(m) Flexible Pay: The amount of Covered Compensation that, pursuant to Section 4.2,
is applied on behalf of a Participant to pay his or her Coverage Expenses or that (to the
extent not otherwise applied) he or she may elect to receive the balance as cash
compensation.
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(n) Highly Compensated Participant: See Key Employee below.
(o) Key Employee: A Participant who is ('1) an officer of" the Employer having at least
$80,000 annual compensation from the Employer or such other amount as is prescribed
by the Secretary of the Treasury from time to time, pursuant to Code `.lection 415
(d)(1)(B); provided however, that no more than. 50 employees, or if the number of
employees of the Employer is less than 500, the greater of three of .10% of the employees,
shall be treated as officers; (2) one of the 10 employees, having at least $30,000 annual
compensation :from the Employer (or such other amount as is prescribed by the Secretary
of the Treasury from time to time pursuant to Code Section 415 (d)(1 )(B).
(p) Participant: Any Officer, Director or Employee who has qualified under the, terms
of the flan for participation herein and who .remains so qualified.
(q) flan: The San Juan Capistrano Flexible Benefits flan set forth herein, as amended
from time to time.
(r) flan Administrator: The City Manager, or other person desi�g.nated by the City
Manager, which shall have authority to administer the Plan as provided in .Article V.
(s) Plan Year: The first Plan Year shall be the period commencing July 1, 2000 and
ending December 31, 2001. All subsequent Plan Years shall be the 12 -month period
commencing on January 1 and ending on December 31.
2.2 Construction: As used in this Plan, the ma,culine gender includes the feminine, and
the singular includes the plural, unless the context clearly indicates to the contrary. The
words "hereof', "hereunder" and other similar compounds of the word "here" mean and
refer to the entire flan, not to any particular provision or section.
ARTICLE III ELIGIBILITY, PARTICIPATION AND ENROLLMENT
3.1 Eligibility and Participation:
(a) Commencement of Participation: An eligible Participant, as defined in Section 2.1,
may commence (or recommence) participation in this Plan on the latest of the following
dates: (1) the Effective Date of the flan, (2) the first day of the month following the
Employee's date of employment or reemployemnt [may not exceed 37 months] as an
Employee; or (3) the date (as determined by the Plan Administrator) that the Election
Form is filed by the Participant.
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(b) Termination cif Participation: A Participant .shall continue to participate in this Plan
until the earlier of the following dates: (1) The day Participant ceases to qualify, as a
participant resulting from termination of employment or failure to make required
contributions, if any; (2) the day Participant terminates membership in a group or class of
employees eligible for Plan or Program benefits; (3) with respect to a covered dependent,
the date such person ceases to be a dependent, or (4) the date the Plan is terminated.
3.2 Enrollment:
(1) Each Participant who is eligible, as definr;d in Article 2.1 on July 1, 2000 shall have
an Initial Enrollment Period which shall begin on May 10. 2000 and shall terminate on
June 30, 2000. Each Employee who becomes eligible on or after July 1, 2000 shall have
an Initial Enrollment Period which shall begin on the first day of his or her employment
as a eligible employee and shall terminate, 60 days thereafter.
(2) Each participant shall have a Regular Enrollment Period during which to make
elections for the immediately ensuing Plan Year, For Plan Years beginning January 1,
2001 and thereafter, the Regular l;nrollment Period for such Plan Year shall commence
on October I prior to such Plan Year, and shall terminate 30 days thereafter, on October
31.
(3) A participant who incurs a change in Dependent status shall have a Special
Enrollment Period which shall begin on the date of his or her Dependent status changes
and shall terminate 45 days thereafter.
For purposes of this paragraph, a Participant's Dependent status shall change when his or
her Dependents change in number, identity, eligibility or employment.
(b) Enrolling Dependents: An eligible Employee may enroll in the Plan any or all of his
or her Dependents during his or her Initial Enrollment Period, Regular Enrollment Period,
or Special Enrollment Period. A Participant who incurs a Dependent status change may
enroll any new Dependents during the Special Enrollment Period commencing on the
date such individuals become Dependents of the Participant. Any Dependent not enrolled
during an Enrollment Period described in the two preceding sentences may be enrolled
thereafter for the current Plan Year only with the consent of the Plan Administrator. An
Employee shall enroll his or her Dependents by specifying, on such forms as the Plan
Administrator may require, the Dependents' names and birth dates, and by electing the
category of dependent coverage that corresponds to the number of Dependents the
Employee wishes to enroll.
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(c) Limitations on Enrollment Elections: A .Participant's right to elect certain benefit
coverage shall be limited hereunder to the extent such rights are .limited in a Component
Plan or in rules adopted by the Plan Administrator. Furthermore, a Participant shall not
be entitled to revoke an I'Mrollrnent Election after a period of coverage has cozrzmencecl
and to make a new IMrolIment Election with respect to the remainder of the period of
coverage unless both the revocation and the new election are on account of" and consistent
with a change in family status (e.g.. marriage, divorce. death of a spouse or child, birth or
adoption of child, and termination of employment of spouse).
(d) Notice of 1digibility: The Plan Administrator shall notify employees of their
eligibility to participate in. the .Pian and of,the terns of the flan. f^,ach Participant shall be
furnished with a copy of this Plan Description.
ARTICLE IV CONTRIBUTIONS
4.1 Non -elective Contributions: For each Plan Year, the .Employer in its sole discretion,
may make on behalf of each Participant a Non -elective Contribution to provide, benefits
for such Participant and his or her Dependents, if applicable, under the Plan. Me
amount of a Non -elective Contribution shall be calculated for each Plan Year in Ll
uniform and nondiscriminatory manner based on the Participant's Dependent status
category (as elected under Section 3.2), the commencement or termination date of the
Participant's employment during the Plan Year, and such other factors as the Employer
shall prescribe in Schedule A attached. if the amount of the Non -elective Contribution
exceeds the cost of the benefit coverage selected by the Participant, such excess amounts
will be currently paid to the Participant.
4.2 ELECTIVE CONTRIBUTIONS:
(a) FLEXIBLE PAY CONTRIBUTIONS: Each Participant may authorize the Plan
Administrator to withhold from his or her Covered Compensation for the Plan Year an
amount of flexible Pay equal to his or her Coverage Expenses in excess of his or her
Non -elective Contribution for such year. Any Flexible Pay which is withheld from a
Participant's Covered Compensation pursuant to this Section shall be withheld in
approximately equal installments frorn the amounts payable to the Participant for each
pay period during the Plan Year ( or such portion of the year as the Plan Administrator
may designate). For Employees whose salary during the year is paid to them over a
period of time less than a year, Flexible Pay amounts will be withheld in installments as
determined by the Plan Administrator. If an Employee becomes a Participant after the
beginning of the first pay period of the Plan Year, the amount withheld from his or her
Covered Compensation during such year shall be a pro rata share of the amount that
would have been withheld had he or she been a Participant in the Plan as of the beginning
of the Plan Year.
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(b) ELECTION: An election under subsection (a) to authorize withholding of Flexible
Pay shall be made on an Election form submitted in accordance with Section :3.2, an
election to have withheld an amount of Flexible pay which, in the determination of the
Plan Administrator, exceeds the limitation on Flexible Pay set firth in subsection (a) may
in the discretion of the Plan Administrator be treated as void or an election to have
withheld the maximum amount permissible under such limitation.
4.3 EF ECT OF CHANGE IN DEPENDENT STATUS: If a Participant's elections
change during the flan Year because of an election rnade during a Special Enrollment
Period, then in accordance with rules adopted by the flan Administrator appropriate
adjustments shall be made in the amount withheld from or added to the Participant's pay
for the balance of the year to reflect any changes in the Participant's Elective
Contributions and benefit elections.
ARTICLE V ADMINISTRATION
5.1 ALLOCATION OF RESPONSIBILITY AMONG FIDUCIARIES FOR PLAN
ADMINISTRATION: The Fiduciaries shall have only those powers, duties,
responsibilities, and obligations as are specifically given or delegated to them under this
Plan.
(a) The Employer shall have the sole responsibility for making the Employer
Contributions under the Plan as specified in Article IV.
(b) The Employer shall have the sole authority to appoint and remove the Plan
Administrator, and to amend or terminate this Plan in whole or in part.
(c) The Plan Administrator shall have the sole responsibility for the administration of
the Plan, which responsibility is specifically described herein.
(d) Each Fiduciary warrants that any directions given, information furnished, or action
taken by it shall be in accordance with the provisions of the Plan authorizing or providing
for such direction, information or action of another Fiduciary as being proper under the
Plan, and is not required under the Plan to inquire into the propriety of any direction,
information or action.
5.2 ADMINISTRATOR: The Plan shall be administered by the Plan Administrator
which may appoint or employ persons to assist in the administration of the Plan and may
appoint or employ any other agents it deems advisable, including legal counsel, actuaries,
auditors, bookkeepers and record keepers to serve at the Plan Administrator's direction.
All usual and reasonable expenses of the Plan and the Plan Administrator may be paid by
the Employer or this Plan.
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5_3 CLAIMS PRt)I,EDUIZE: The flan Administrator, or a party designated by the
Plan Administrator, shad make all determinations as to the right of a person to an
Employer Contribution under the Ilan. If an assertion of any such right by a Participant
or Dependent is wholly or partially denied. the Plan Administrator, or the designated
paj-ty, will provide such claillrant a comprelrensiblc; written notice within 90 clays after
receipt of the claim, unless circumstances warrant an extension of time not to exceed an
additional 90 days, setting; forth:
(a) The specific reason or reasons for such denial,
(b) Specific rel'erenc;e to pertinent flan provisions on which the denial is based;
(c) A description of any additional material or information necessary for the claimant to
submit pertinent to the claim and an explanation of why such material or information is
necessary;
{d) A description of' the Nan's clain-i review procedure. I'he review procedure is
available upon written request by the c,laimani lo tlac flan Administrator, or the
designated party, within 60 days sifter receipt by the claimant ol' written notice of denial
of the claim, and includes the right to examine pc!rt:inent documents and submit issues and
comments in writing to the Elan Administrator, or the designated party.
The decision on review shall be made within 60 days after receipt of request for review,
unless circumstances warrant an extension of time not to exceed an additional 60 days.
The decision shall be in writing and drafted in a manner calculated to be understood by
the claimant, and shall include specific reasons for the decision with references to the
specific flan provisions on which the decision is based.
5.4 ®THEM ADMINISTRATIVE POWERS AND DUTIES: The Plan administrator
shall have such powers and dirties as may be necessary to discharge its functions
hererrnder, including:
(a) to construe and interpret the Plan, decide all questions of eligibility and determine
the amount, mariner and time of payment of any reimbursements hereunder;
(b) to prescribe procedures to be followed by Participants electing benefit coverages or
filing applications for reimbursements;
(c) to prepare and distribute, in such mariner as the Plan Administrator determines to be
appropriate, information explaining the Plan;
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{d) to receive from Employees, agents and Participants such information as shall be
necessary for the proper administration of the Plan-,
(e) to receive, review and keep on file (as it deems convenient or proper) reports of the-
receipts
hereceipts and disbursements of the Plan;
(f} to appoint or employ individuals or other parties to assist in the administration of the
Plan and any other agents it deems advisable, including accountants, legal counsel,
bookkeepers and record keepers, and
(g) to designate or employ persons to carry out any of the Plan Administrator's fiduciary
duties or responsibilities under the Plan.
5.5 RULES AND DECISIONS: The Plan Administrator may adopt such rules and
procedures as it deems necessary, desirable, or appropriate for the administration of this
Plan. All rules, procedures and decisions of the Plan Administrator shall be unifor-nly
and consistently applied to all Participants in similar circumstances. When making a
determination or calculation, the Plan Administrator shall be entitled to rely upoal
information furnished by a Participant, a Dependent,. the duly authorized representative of
a Participant or Dependent or the legal counsel of the Plan Administrator.
5.6 DORMS AND REQUESTS FOR iNFORMAI`.ION: The Plan Administrator may
require a participant to complete and file such forms, as are provided for herein and all
other forms prescribed by the Plan Administrator, and to furnish all pertinent information
requested by the Plan Administrator. The Plan Administrator may rely upon all such
information, including the Participant's current mailing address.
5.7 RESPONSIBILITY FOR PLAN: The complete; authority to control and manage
the operation and administration of the Plan shall be placed in the Plan Administrator,
who shall be solely responsible for the operation of the Plan in accordance with its terms.
ARTICLE VI AMENDMENT OF THE PLAN
The Employer shall have the right at any time by instrument in writing, duly executed
and acknowledged, to modify, alter or amend this Plan in whole or in part, provided
however, that no such amendment shall diminish or eliminate any claire for any benefit to
which a Participant shall have become entitled prior to such amendment.
Notwithstanding the foregoing, the Employer shall have the limited right to amend the
Plan at any time, retroactively or otherwise, in such respects and to such extent as may be
necessary to fully qualify it as a "cafeteria plan" under existing and applicable laws and
regulations, including Section 125 of the Code, and if and to the extent necessary to
accomplish such purpose, may by such amendment decrease or otherwise affect benefits
to which Participants may have already become entitled.
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ARTICLE; VII TERMINATION OF THE PLAN
The Plan herein provided for has been established by the Employer with the bona fide -
intention that it shall be continued in operation indefinitely. however, the Employer
reserves the right at any time to terminate or partially terminate the Plan. Should the
E'rnployer decide to terminate or partially terminate the Plan, the Platy. Administrator shall
be notified of such termination in writing and shall proceed at the direction of the;
I:,mployer to tape such steps as are necessary to discontinue the operation of the Plan in
an appropriate and timely manner,
ARTICLE VIII MISCELLANFOUS
8.1 EMPLOYMENT RIGHTS: Under no circumstances shall the terms of employment
of any Participant be modified or in any way affected hereby. This Plan shall not
constitute a contract of employment nor afford any individual any right except as
contained herein nor to be retained in the employ of the Employer.
8.2 NONASSIGNABILITY: To the extent permitted by lave, Participants are
prohibited from anticipating, encumbering, alienating or assigning ally of their rights,
claims or interests in this Plan, and no undertaking or attempt to do so shall in any way
bind the Plan Administrator or be of any force or affect whatsoever. Furthermore, to the
extent permitted by law, no such rights, claims or interest of a Participant in this Plan,
shall in any way be subject to such Participant's debts, contracts or engagements, nor to
attachment, garnishment, levy or other legal or equitable process. Provided however,.
anything to the contrary herein notwithstanding, to the extent permissible under
applicable law, a Participant's interest hereunder is subject to all bona fide and existing
debts owed by such Participant to the Plan.
8.3 NO GUARAWEE ON NON -TAXABILITY: The Plan is designed and is intended
to be operated as a "cafeteria plan" under Section 125 of the Code. Nonetheless, neither
the Employer nor any Plan Fiduciary shall in any -xray be liable for any taxes or other
liability incurred by a Participant or anyone claiming through him or her by virtue of
Participation in this Plan. The Plan does not prohibit, and indeed contemplates, the
payment of taxable benefits under certain of the Component Plans.
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8.4 NONDISCRIMIiv'ATIOM In accordance: with Sections 1-105 & 125 (b) (1) and (2)
of the Code, the Plan is intended not to discriminate in favor of /Highly Compensated
Individuals as to eligibility to participate or as to contributions and benefits, nor to
provide more than 25% of all qualified benefits to Key Employees. If, in the operation of
the Platt, more than 25% of the total qualified benefits are found to be provided to Key
f.."tnploye;es; or the Plan discriminates in any other manner (or is in danger of so
discriminating), then notwithstanding any other provision contained herein, the flan
Administrator shall reduce or adjust such contributions and/or benefits under the Plan as
shall be necessary to assure that, in the judgment of the Plan Administrator, the Plant
thereafter will not discriminate- All rules, procedures and decisions of' the Plan
administrator shall be adopted, made and/or applied in such flashion that they do not
discriminate in favor of Highly Compensated Participants and Key Employees.
8.5 DELEGATION Of' AUTHORITY BY EMPLOYER: Whenever the Employer
under the terms of this Agreement is permitted or required to do or perforin any act or
matter or thing, it shall be done and performed by any officer or individual duly
authorized by the .Employer.
8.6 CONSTRUCTION OF AGREEMENT: This Plan shall be construed according to
the laws of the. State of California and all provisions hereof shall be administered
according to and its validity and enforceability shall be determined under the Taws of such
state, except where preempted by the Code; or EIRISA
8.7 HEADINGS: The headings of sections and subsections are for ease of reference
only any shall not be construed to limit or modify the detailed provisions hereof.
8.8 ENTIRE PLAN STATED: This document and attached schedules A, Al, and A2
sets forth the entire plan. No other employee benefit or employee benefit plan which is or
may hereafter be maintained by the Employer on a non -elective basis shall constitute a
part of this plan.
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ADOPTED BY THE CITY OF SAN JUAN CAPISTRANO EFFECTIVE JULY t, 2000
BY:
/s� oaf/e�Pa 12�a� /
COLLENE CAMPBELL, MAYOR
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S AN Jt'. N C'AP[SI"RAN() l l 1 II3I I; 13I NEFITS P1..,AN
SCHEDULE A 2000-2001
A. .Employer non -elective contribution based upon PEMI K'A Medical Plan coverage:
Effective Juiy 1, 2000
Employee only: 5363.32/mo.
Employee + I dependent: $455.70/mo.
Employee +2 t- dependents-. $608.31/mo
Effective .lanuary1.22001._. _..._-
E'rnployee:° only: $380.}7/a o_
IIrxaployec ,, I dependent: $491.00%o.
Employee _ 2 dependents: $654,19mo.
B. Employer nota -elective contribution based upon NO N-PEMI ICA Medical flan
Coverage. . efiective July 1, 2000:
Employee including all dependents: $250.00/mo.
PEMHCA HEAL, TH PLANS: -- MONTHLY RATE'S -1 PARTY
2 PARTY
FAMILY
(Selected examples
-Effective July 1, 2000)
201. I7
402,34
BLUE SHIELD ACCESS+ HMO
184.56
369.12
479.87
HEALTH NET
l 80.64
361.27
469.67
KAISER
184.06
368.12
478.56
PACIFICARE
174.52
349,04
453.73
PERS-CARE (INDEMNI`T'Y)
296.00
592.00
770.00
PERS-CHOICE (INDEMNITY-M/C)
176.00
352.00
458.00
(Selected examples ---Effective January 1, 2001)
KAISER
202.21
404.42
525.75
BLUE SHIELD ACCESS+ HMO
201. I7
402,34
523.04
HEALTH NEI'
197.26
394.52
512.88
PACIFICARE
188.17
376.34
489.24
PERS-CARE (INDEMNITY)
343.00
686.00
892.00
PERS-CHOICE (INDEMNITY -MIC)
214.00
428.00
556.00
PRUDENTIAL. HEALTH CARE DENTAL PLAN
28.32
66.48
96.55
VSP VISION PLAN
12.94
20.10
31.89
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SC"HEDULE Al
DEPENDENT CAI E ASSISTANCE
COMPONENT PIAN
ARTICLE 1. FORWARD AND PURPOSE
This Dependent Care Assistance Component flan is established for the exclusive benefit
of eligible full time employees and is intended to qualify as a dependent care assistance
program under Sections 125 and 129 of the Code. The purpose of the Plan is to enable
employee Participants to elect to receive payments or reimbursements of their dependent
care expenses in lieu of their compensation, which payments are incurred by Participants
in connection with their employment and are: excludable from the Participant's gross
income under Sections 125 and 129 of the Code.
ARTICLE II. DEFINITIONS AND CONSTRUCTION
2.1 Definitions. Where the following words and phrases appear in this Plan, they
shall have the following meanings, unless a different meaning is plainly required by the
context:
(a) Dependent: (1) General Rule: Any individual who is (i) a dependent of the
Participant who is under the age of 13 and with respect to whom the Participant is
entitled to an exemption under Section 151(c) of the Code, or (ii) a dependent or spouse
of the Participant who is physically or mentally incapable of caring for himself.
(2) Special Rule for Divorce or Separation of Parents: Notwithstanding subsection (1), if
(i) either Code Section 152(e)(2) (regarding the release by a custodial parent of a claim to
a dependency exemption) or Code Section 152(e)(4) (regarding various pre -1985 divorce
or separation agreements) is applicable to a child of an Employee, and (ii) such child is
under the age of 13 or is physically or mentally incapable of self-care, then such child
shall be deemed a dependent with respect to the Employee if such Employee is the
custodial parent (within the meaning of Code Section 152(e)(1) ) of the child.
(3) Other relatives by blood or marriage that are incapable of caring for themselves
meeting the requirements of both Sections 151 & 152 of the Code.
(b) Dependent Care Assistance Account: The account described in Article IV hereof.
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SF
(c) Dependent Care Expenses: Expenses incurred by a Participant which (1) are paid or
incurred for the care of a .Dependent of the: Participant or f'or related household services,
(2) are paid or incurred to a Dependent Care Service Provider, and (3) are incurred to
enable the Participant to be gainfully employed for any period for which there are one or
more Dependents with respect to the Participant. Dependent Care Expenses shall not
include expenses paid or incurred for services rendered outside the Participant's
household for the care of Dependent unless such Dependent is described in Section
2,1(a)(1), or such Dependent regularly speeds at least eight hours a day in the
Participant's household. Dependent care Expenses shall be deemed to be incurred at the
time the services to which the expenses relate are rendered.
(d) Dependent Care Service Provider: A person who provides care; or their services
described in Section 2. I (c)(1) above, but shall not include (1) a dependent care center (as
defined in Code Section 21(b)(2)(1)), unless the requirements of Code Section
21(b)(2)(C) are satisfied; or (2) a related individual described in Code Section 129 (c)
(e) Earned Income; All income derived from wa(yes, salaries, tips, self employment, and
other employee compensation described in (ode Section 32(c)(2) but excluding amounts
received under this Plan or under any other plan providing dependent care assistance,.
ARTICLE 111, DEPENDENT CARE ASSISTANCE
3.1 Maximum dependent care assistance. The maximum amount which the Participant
may receive in any Plan Year in the form of dependent care assistance under this Plan
shall be the least of (a) the Participant's Earned Income for the Plan Year, (b) the actual or
deemed Earned Income of the spouse for the Plan year, or (c) $ 5,000. Provided however,
that for taxable years beginning after December 31, 1986, the maximum amount that the
Participant may receive in any taxable year shall not exceed $5,000. The $5,000 limit
shall be reduced to $2,500 in the case of a separate return by a married individual. In the
case of a spouse who is a Student or is physically or mentally incapable of caring for
himself or herself, such spouse shall be deemed to have Earned Income of not less than
$200 per month if the Participant has one Dependent and $400 per month if the
Participant has two or more Dependents.
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3.2 Treatment of Onsite Facilities. Except to the extent provided in regulations,
effectivei for taxable years beginning; after December 31, 1986, the amount of dependent
care assistance any Participant may receive under this Flan with respect to an onsite -
facility maintained by the Employer shall be based on utilization of the facility by the
Dependent and the value of services provided.
ARTICLE 1V, DEPENDENT CARE ASSISTANC �'� ACCOUNTS
4.1 ll'stablishment of accounts. The Employer will establish and maintain on its books
a Dependent Care; Assistance Account for each Plan Year with respect to each Participant
who has elected under the Flexible benefits Plan to receive dependent care assistance for
the flan Year.
4,2 Crediting of accounts. "There shall be credited to a Participant's Dependent Care
Assistance Account for each .Plan Year, as of each date compensation is paid to the
Participant in such Plan Year, an amount equal to the reduction for dependent cart:
assistance, if any, to be made in such compensation in accordan.cc with the Participant's
election under the Flexible Benefits [Ilan. All amounts credited to each such Dependent
Care Assistance Account shall be the property of the Employer until paid out pursuant to
Article V.
4.3 Debiting of accounts. A Participant's Dependent Care Assistance Account for each
Plan Year shall be debited from time to time in the amount of any payment under Article
V to or for the benefit of the Participant for Dependent Care Expenses incurred during
such Plan Year. Amounts debited to each such Dependent Care Assistance Account shall
be treated as payments of those amounts first credited to the Account that have not yet
been treated as paid under this Section.
4.4 Forfeiture of accounts. The amount credited to a Participant's Dependent Care
Assistance Account for any Plan Year shall be used only to reimburse the Participant for
Dependent Care Expenses incurred during such Plan Year, and only if the Participant
applies for reimbursement on or before the 30th day following the close of the Plan Year.
If any balance remains in the Participant's Dependent Care Assistance Account for any
Plan Year after all reimbursements hereunder, such balance shall not be carried over to
reimburse the Participant for Dependent Care Expenses incurred during a subsequent
Plan Year, and shall not be available to the Participant in any other form. or ;manner, but
shall remain the property of the Employer and the Participant shall forfeit all rights with
respect to such balance.
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F
AR"11CLE V. PAYMENT OF DEPENDENT CARE ASSISTANCE
5.1 Claims for reimbursement. A Participant who has elected to receive. dependent care -
assistance for for a Placa Year may apply to the Employer for reimbursement of Dependent
Care Expenses incurred by the Participant daring the flan Year by submitting an
application in writing to the flan Administrator. setting forth; (a) the amount, date and
nature of the; expenses with respect to which a benefit is requested, (b) the: name of the
person, organization. or entity to which the expense was or is to Nc paid. and (c) such
other application shall be accompanied by bills, invoices, receipts, canceled checks or
other statements showing the amounts of such expenses, together with any additional
documentation which the Plan Administrator may request.
5.2 Reimbursement or payment of expenses. The Plan Administrator shall reimburse
the Participant's Dependent Care Expenses incurred during the Plan Year for which the
Participant submits documentation in accordance with Section 5.1. The Plan
Administrator may, at its option, pay any such Dependent Care Expenses directly to the
Dependent Care Service Provider in lieu of reimbursing the participant. No
reimbursement or payment under this Section 5.2 01'expenses incurred during a Plan Year
shall at any time exceed the balance of the Participant's Dependent Care Assistance
Account for the Plan Year at the time of the reimbursement or payment. The amount of
any Dependent Care Expenses not reimbursed or paid as a result of the preceding
sentence shall be carried over and reimbursed or paid only if and when the balance in
such Account permits such reimbursement or payment; provided however, that no
Dependent Care Expenses may be carried over froi:a one Plan Year to the next.
53 Report to Participants. On or before January 31 of each year, the Plan. Administrator
shall furnish to each Participant who has received dependent care assistance during the
prior calendar year a written statement showing the amount of such assistance paid or
incurred by the Employer during such calendar year with respect to the Participant.
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1.1.4
SCHEDULE A2
MEDICAL REIMBURSEMENT
COMPONENT PLAN
ARTICLE- I. FOREWORD AND PURPOSE
This Medical Reimbursement Component Plan is established for the exclusive; benefit of
eligible participants, and is intended to qualify under Sections 125 and 105(b) of the
Code, and is to be interpreted in a manner consistent with the requirements of the Code.
The purpose of this Component of the Plan is to enable eligible Participants to elect to
receive payments or reimbursements of Qualifying Medical Care Expenses, which
payments are excludable from the Participant's gross income under Sections 125 and
105(b) of'the Code.
ARTICLE II. DEFINITIONS
2.1 Definitions. Where the fallowing words and phrases appear in this plan, they shall
have the following; meanings, unless a different meaning; is plainly required by the
context:
(a) Qualifying Medical Care Expenses. An expense incurred by a Participant, or by the
spouse or Dependent of such Participant, for medical care as defined in Section 213(d) of
the Code (including amounts paid for eligible hospital bills, doctor and dental bills,
prescribed drugs, eligible medical equipment and supplies), but only to the extent that the
Participant or other eligible person incurring the expense is not reimbursed for the
expense through insurance or otherwise (other than under this Plan).
ARTICLE III. MEDICAL REIMBURSEMENTS
3.1 The maximum amount which a Participant may receive under this Plan in the form
of payments or reimbursements for Qualifying Medical Expenses incurred in any Plan
Year shall be $3,500.00 for all eligible expenses.
ARTICLE IV. MEDICAL REIMBURSEMENT ACCOUN I'S
4.1 Establishment of accounts. 'The Employer will establish and maintain on its books
a Medical Reimbursement Account for each flan Year with respect to each Participant
who has elected under the Flexible Benefits Plan to receive medical reimbursement for
the Plain Year.
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4.2 Crediting; of accounts. There shaIlbe credited to a Participant's Medical
Reimbursement Account at the beginning of each Plan Year, an amount equal to the
reduction for medical reimbursement, if any, to be made in such compensation for the
entire plan year in accordance with the Participant's election under the Flexible Benefits -
Plan. All amounts credited to each such Medical Reimbursement Account shall be the
property of the Employer until paid out pursuant to Article V°,
4.3 Debiting of accounts. A Participant's Medical Reirnbursement Account for each
Plan Year shall be debited from time to time In the amount of any payment under Article
V to or for the benefit of the Participant for eligible medical expenses incurred during
such Plan Year.
ARTICLE V. PAYMENT OF MEDICAL REIMBURSEMENTS
5.1 Claims for reimbursement. A Participant who has elected to receive medical
reimbursements for a Plan Year may apply to the; Plan Administrator for reimbursement
of Qualifying Medical Gare Expenses incurred by the Participant during the Plan Year by
submitting an application in writing to the Plan Administrator on or before the 90th day
following the close of the Plan Year, in such form as the Plan Administrator may
prescribe, setting forth: (a) the amount, date and nature of the expense with respect to
which a benefit is requested; (b) the name of the person, organization or entity to which
the expense was or is to be paid; (c) the name of the person for whom the expense was
incurred and, if such person is not the Participant requesting the benefit, the relationship
of such person to the Participant; and (d) the amount recovered, or expected to be
recovered, under any insurance arrangement or other plan, with respect to the expense.
Such application shall be accompanied by bills, invoices, receipts, canceled checks or
other statements showing the amounts of such expenses, together with any additional
documentation which the Plan Administrator may request.
5.2 Reimbursement or payment of expenses. The Plan Administrator shall reimburse
the Participant from the Participant's Medical Account for Qualifying Medical Care
Expenses incurred during the Plan Year, for which the Participant submits documentation
in accordance with Section 5. L The Plan Administrator may, at its option, pay any such
Qualifying Medical Care Expenses directly to the person providing or supplying medical
care in lieu of reimbursing Participant. No reimbursement- or payment under this Section
5.2 of expenses incurred during a Plan Year shall at any time exceed the total eligible
amount for the Plan Year. No Qualifying Medical Care Expenses may be carried over
from one Plan Year to the next.
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116
STATE OF CALIFORNIA )
COUNTY OF ORANGE } Ss AFFIDAVIT OF POSTING
CITY OF SAN JUAN CAPISTRANO j
I, CHERYL JOHNSON, declare as follows:
That I am the duly appointed and qualified City Clerk of the City of San Juan
Capistrano,
That in compliance with State laws of the State of California and in further
compliance with City Resolution No. 98-12-15-1 and on the 5th day of October, 2000, I
caused to be posted:
RESOLUTION NO. 00-10-3-2 , being
A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN JUAN
CAPISTRANO, CALIFORNIA, ADOPTING A FLEXIBLE BENEFITS PLAN
DOCUMENT (JULY 1, 2000 - DECEMBER 31, 2001)
in three (3) public places in the City of San Juan Capistrano, to wit: City Hall; Community
Center reception area, Orange County Public Library.
CHECK LIST
ORD. NO. RES. NO. 00 3 ~ 2,-
^,ff Mayor has signed
Clerk has signed
City Seal stamped
All blanks typed in
"Absent"
"Abstain"
Copies sent to post Ord. dist.
file _ _��. C--, 40
ma' certified
� L"L-
Legal Publication ordered to be published
(date)
No. Printed copies required
Remarks
, DI
CHERYL J NN, CITY CLERK
San Juan Capistrano, California
F