1 Summary Plan Description for the Health Reimbursement Arrangement Plan General Benefit Information Eligible Expenses All expenses that are eligible under Section 213(d) of the Internal Revenue Code, such medical, dental, vision and premium expenses, including the following: Copays Deductible expenses Coinsurance HRA Account Funding: HRA Accounts will be funded for Participants in monthly installments during the Period of Coverage in the amounts shown below: Employee Only Coverage $ $ Employee plus Dependent Coverage Expenses are considered eligible only if they are incurred while the individual is covered by this plan. Any expenses incurred after participation in the Plan ends are not eligible for reimbursement Plan Year The Plan Year is the 12 month period beginning on July 1st of each year. Health Plan The Health Plan is the medical plan sponsored by the North Las Vegas Fire Fighters Health and Welfare Trust. Participation Requirements Employees who are eligible for and who have elected to participate in the Health Plan are automatically covered under this Plan. Once enrolled, participation can continue in this Plan even after termination of Health Plan participation under the terms described in this SPD. Effective Date of Coverage Coverage will become effective for eligible Employees when participation in the Health Plan becomes effective, which is generally the first day of the month following the date of hire, if the Employee properly enrolls in the Health Plan. Coverage will become effective for a Dependent when the Dependent's coverage becomes effective under the Health Plan. Funding The Employer pays for the coverage under this Plan out of its general assets. Participants are not required to contribute to the cost of coverage. 1
2 Claims Submission Deadline This Plan does not have a Claims Submission Deadline. Claims Administrator IntegraFlex 225 N. 9th Street, Suite 530 Boise, ID (208)
3 Eligibility and Coverage Who is eligible for coverage under this Plan? Any employee of the Employer who is enrolled in the Health Plan is covered by this Plan. Dependents (including both the spouse and children of a participating employee) are also covered by this Plan if they are eligible to enroll in the Health Plan. Children include the biological children, step children, adopted children and foster children of the Participant. Adopted children include children who are placed for adoption with the Participant. Foster children include children who are placed with the Participant for adoption by a qualified foster agency or court. Coverage is available for children until they reach age 26. If an event occurs that triggers one of the HIPAA special enrollment rights, the Eligible Employee can enroll or a Participant can enroll any spouse or child within 30 days of the applicable date by making a corresponding enrollment in the Health Plan. HIPAA special enrollment is permitted when: The Eligible Employee or his or her spouse or child previously declined coverage that has now been lost because it was exhausted (COBRA) or terminated due to loss of eligibility or loss of employer contributions; A new dependent is acquired as a result of marriage, birth, adoption, placement for adoption or placement by a foster agency or court. There may be additional election rights contained in the Employer's cafeteria plan. See the Employer for details. Benefits How does the health reimbursement account work? The Health Reimbursement Account works like this: The Claims Administrator records the amount that is available in your Health Reimbursement Account, though the account exists only as a paper record; When you have an Eligible Expense, you will submit an Explanation of Benefits from the insurance company or a detailed receipt from the provider to the Claims Administrator; If the claim is eligible for reimbursement and there are sufficient funds in your Health Reimbursement Account, the Claims Administrator or Employer will send you a check and subtract the amount paid from your Reimbursement Account balance. NOTE: If you use the HRA Plan debit card to pay for eligible Medical Expenses, you will be required to submit documentation of the expense What expenses are eligible for reimbursement? Eligible Medical Expenses include all expenses that are eligible in accordance with Section 213(d) of the Internal Revenue Code. For a listing of ineligible items, you can refer to Publication 502 or you can view a list of eligible and ineligible items at To be considered "Eligible," the expense must also be incurred during the Period of Coverage for that individual. The Period of Coverage is the time during which an individual is covered under this Plan. An expense is incurred when the care is provided rather than when you are billed or when you pay for the service. If I am also enrolled in a health care flexible spending account, which plan pays first? Benefits under this Plan are intended to pay for Eligible Expenses that are not reimbursed or reimbursable by another plan. However, if an Eligible Expense is covered by both this Plan and a health care flexible spending account, then this Plan would not be available for reimbursement until any funds in the individual's flexible spending account have been exhausted. 3
4 How does Coordination of Benefits work if I am covered under a health plan sponsored by another employer? This plan is considered integrated with the Health Plan so that if the Health Plan is considered primary to another plan, then the benefits under this Plan will be treated as part of those primary benefits. What happens if I receive reimbursement for a qualifying medical expense and I receive reimbursement under this plan? If you receive a reimbursement under this Plan and reimbursement for the same expense is made under another plan, you will be required to refund the reimbursement to the Plan Administrator. Any amount not refunded becomes taxable income to the Participant. Carryover of HRA Funds Under the Plan, unused amounts in your HRA Account can remain available for claims, subject to the following terms and conditions: Any amount allocated to your HRA Account but not spent each month carries over from month to month at a rate of 100% and do not expire until used. If you voluntarily terminate coverage under the Health Plan, contributions to your HRA Account will stop as of the month of termination. Your continued access to the HRA Account is subject to the a Run- Out Option that allows you to continue to incur Medical Expenses that are eligible for reimbursement under this Plan, until your HRA Account balance is exhausted. If you retire, monthly contributions to your HRA Account will stop the month after retirement. Thereafter, you have two options for allocation of your remaining HRA funds: Retirement Run - Out Option: This option allows you and/or your eligible dependent(s) to continue to participate in this Plan and to continue to incur Medical Expenses that are eligible for reimbursement until your HRA Account balance is exhausted. HSA Rollover Option: This option allows you to rollover any unused funds to an HSA account. You would be responsible for the setup and administration of the HSA account at any banking facility of your choosing. You must initiate the HSA rollover, in writing, within 90 days of retirement. Any requests received after 90 days are not permitted by law. If you terminate employment, monthly contributions to your HRA Account will stop the month after termination. Thereafter, the Plan gives two options for HRA allocation. Termination Run - Out Option: This option allows retiree and/or eligible dependent(s) to continue to participate in this Plan and to continue to incur Medical Expenses that are eligible for reimbursement until your HRA Account balance is exhausted. You will be required to pay the administration fees associated with continued participation in this Plan. The amount of the fee will be deducted from the HRA Account on a monthly basis HSA Rollover Option: This option allows former Participants to rollover any unused funds to an HSA account. You are responsible for the setup and administration of the HSA account at any banking facility of your choosing. You must initiate the HSA rollover, in writing, within 90 days of termination. Any requests received after 90 days are not permitted in accordance with regulations under the Code. 4
5 Claim Submission How do Participants receive benefits under the Plan? When you have an Eligible Medical Expense you must complete the Claim Form and submit it to the Claims Administrator along with any Explanation of Benefits or a detailed receipt from the provider. If the claim is eligible for reimbursement, the Claims Administrator will send you a check All claims will be processed and paid (if eligible under the Plan) within 30 days of receipt of a completed Claim Form. However, the Claims Administrator may request a 15-day extension for matters beyond its control. What happens if a claim is denied? If a claim is denied because it is incomplete, the Claims Administrator will provide a description of any additional material or information necessary and an explanation of why this material or information is necessary. This notice will be provided within 5 days of receipt of the claim (or immediately for urgent care claims). After receipt of all the information needed to review a claim, if any claim for benefits under the Plan is wholly or partially denied, the Claims Administrator will give notice in writing of the denial within 30 days after the claim is filed. This notice will include the following information: Information that is sufficient to identify the claim involved (including date of service, name of health care provider, claim amount, diagnosis code and its meaning, and the treatment code and its meaning) The specific reason or reasons for the denial, including a description of the meaning of any denial code; Specific reference to pertinent Plan provision, internal rule, guideline, protocol or similar criteria on which the denial is based; A description of the available internal appeals and external review processes, including information on how to initiate an appeal; Information about the availability of any health insurance consumer assistance or ombudsman to assist with appeals, including contact information; and An explanation that a full and fair review of the decision denying the claim (including the right to present evidence and testimony) may be requested by you or your authorized representative by filing an appeal within 180 days after such notice of denial has been received. If you request a review of the claim denial, you may review pertinent documents and submit issues and comments in writing. The appeal will be reviewed by a committee or individual who was not involved in the initial denial. The decision of the Claims Administrator on review will be made promptly, but not later than 30 days after receipt of the request for review, unless special circumstances require an extension of time for processing. The decision on review will be made in writing and will include specific reasons for the denial, written in a manner that you can understand and will include references to the Plan provisions on which the denial is based. The notice of denial will include a discussion of the decision. The Claims Administrator will provide you with any new or additional information that was considered, relied upon or generated in connection with the claim. This information will be provided in advance of the final determination so that you have a reasonable opportunity to respond prior to that date. Upon exhaustion of the internal review process (or earlier if the Claims Administrator does not follow the requirements of the applicable law), you have the right to initiate an external review of the denial. The Claims Administrator will provide a description of the applicable external appeal process. Termination of Coverage When does coverage terminate under this plan? Coverage for a Participant or any spouse or child will terminate on the earlier of: the date of termination of this Plan; or the date that your HRA Account balance is exhausted 5
6 What happens to my coverage if I take an FMLA leave of absence? Your coverage (and the coverage of your spouse and children) will continue during an FMLA leave or other leave of absence in accordance with the requirements of the FMLA and the Employer's policies. If you fail to return to active employment with the Employer, your coverage will be considered a voluntary termination at the earlier of: (1) the end of the leave of absence, unless the leave resulted from your disability and continued coverage is considered an accommodation under the Americans with Disabilities Act and its regulations (as amended); or (2) the date you tell the Employer that you do not intend to return to active employment the required number of hours per week. Can I elect COBRA if I lose coverage under this plan? If a Participant's and/or Dependent's coverage under this Plan terminates because of a "qualifying event," each individual has a right to purchase continued coverage for a temporary period of time. COBRA coverage is available under this Plan, only if the individual also elects COBRA under the Health Plan and if COBRA is elected under the Health Plan, coverage under this Plan will continue under the same terms. NOTE: if a former Participant elects COBRA coverage, the Run-Out option is not available. Qualifying events include termination of employment, reduction in hours, divorce, death, or a child ceasing to meet the definition of Dependent. A participating Employee or Dependent must notify the Administrator of any divorce, legal separation, or a child ceasing to be considered a Dependent under the Plan within 60 days after the event. This notice must be in writing and addressed to the Administrator. In addition, if a second qualifying event occurs during COBRA continuation coverage or if the former Employee becomes entitled to Medicare or dies during the COBRA coverage, the former Employee or Dependent (as applicable) must notify the Administrator. Finally, an Employee must notify the Administrator of the start or end of any disability that is determined under the Social Security Act to be a covered disability. The Administrator will provide Employees and Dependents with the forms needed to make the required notifications. Any notice described in the above paragraph must be provided in writing to the Administrator within 60 days of the occurrence of the event (except that if there is a change in the Employee's disability status, notice must be given within 30 days). If the Employee or Dependent fails to provide notice within the required time period, he or she may no longer be eligible for COBRA continuation coverage. In this event, the Administrator may send Notice of Unavailability of COBRA Coverage upon receipt of the late notice. If you have any questions about your COBRA rights, please read the COBRA notice, which has been provided to you and your spouse (if covered) at the time of your enrollment in the Health Plan. You can contact the Administrator if you need another copy. You will need to follow the procedures set forth in the Notice that you will receive when your participation ends and you will be required to make premium payments for continued coverage. Can I continue coverage during a period of active military duty? Yes, you can continue coverage in accordance with USERRA for yourself and/or your covered spouse and children during a period of absence from employment due to military service. This extended coverage will be administered similar to COBRA coverage in accordance with the Employer's policies and can continue for up to 24 months. How long will the plan remain in effect? Although the Employer expects to maintain the Plan indefinitely, it has the right to amend or terminate all or any part of the Plan at any time for any reason. It is also possible that future changes in state or federal tax law may require that the Plan be amended accordingly. 6
7 Notices Newborns' and Mothers' Health Protection Act The Newborns' and Mothers' Health Protection Act of 1996 requires group health plans, insurance companies, and HMO's that cover hospital stays following childbirth to provide coverage for a minimum period of time. In general, hospital coverage for the mother and newborn must be provided for a minimum of 48 hours following normal delivery, or 96 hours following a cesarean section. Group health plans may not restrict benefits for a hospital stay in connection with childbirth for the mother or newborn to less than 48 hours following delivery, and less than 96 hours following a caesarean section, unless the attending provider, after consultation with the mother, discharges the newborn earlier. A group health plan cannot require that a provider obtain authorization from the plan or third party administrator for a length of stay not in excess of these periods, but precertification may be required to reduce out-of-pockets costs or to use a certain provider or facility. Also, under federal law, issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96- hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. The Plan provides coverage in compliance with The Newborns' and Mothers' Health Protection Act. Women's Health and Cancer Rights Protection Act The benefits of most health plans must include coverage for the following post-mastectomy services and supplies in a manner determined in consultation with the attending physician and the patient: all stages of reconstruction of the breast on which the mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; prostheses; and treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the Health Plan and the terms of this plan. General Plan Information Plan Name Health Reimbursement Arrangement Type of Plan Health reimbursement arrangement This HRA Plan is integrated with major medical coverage that is described in a separate SPD Period of Coverage The 12 month period beginning on July 1st of each year. Plan Number 501 Effective Date August 1, 2012 Plan Sponsor P.O. Box Las Vegas, NV (702) Plan Sponsor's Employer Identification Number
8 Plan Administrator P.O. Box Las Vegas, NV (702) Named Fiduciary P.O. Box Las Vegas, NV (702) Agent for Service of Legal Process Attention: Board P.O. Box North Las Vegas, NV (702) Statement of ERISA Rights As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants are entitled to: Receive Information about the Plan and its Benefits You are entitled to examine, without charge, at the Plan Administrator's office, and at other specified locations, all documents governing the Plan, including any insurance contracts, and if there are 100 or more participants, 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. You are entitled to obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements (if any), any updated summary plan description and, if there are 100 or more participants, a copy of the latest annual report (Form 5500 Series). The Plan Administrator may make a reasonable charge for the copies. If there are more than 100 participants in the Plan, you are entitled to 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 During any Plan Year in which the Employer is subject to COBRA, you are entitled to continue health care coverage for yourself, spouse or Dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your Dependents may have to pay for such coverage. You are also entitled to review this summary plan description and the documents governing your COBRA continuation coverage rights. 8
9 You are entitled to reduction or elimination of any exclusionary periods of coverage for pre-existing conditions under the Plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage, 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 any plan pre-existing condition exclusion which may be up to 12 months (or 18 months for late enrollees) after your enrollment date in your coverage. 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 the Plan, called "fiduciaries" of the Plan, have a duty to do so prudently in the interest of you and other Plan participants and beneficiaries. No one, including your Employer, your union (if any), or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. Enforce Participant's Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents from the Plan and do not receive them within 30 days, you may file suit in 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 Plan 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 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 federal court. The court shall 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 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 in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in the telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Ave., N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. 9
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