Camanche Community School Health Reimbursement Arrangement Plan Summary Plan Description Second Amendment effective 9/1/2014 1
Summary Plan Description Table of Contents Article Section Page I INTRODUCTION TO YOUR PLAN 2 II GENERAL INFORMATION 3 III PARTICIPATION IN YOUR PLAN 5 IV ADMINISTRATION OF YOUR PLAN 6 V BENEFITS UNDER YOUR PLAN 8 VI STATEMENT OF ERISA RIGHTS 9 Article I INTRODUCTION TO YOUR PLAN The Camanche Community School District (hereinafter referred to as the District ) offers this Health Reimbursement Arrangement Plan (hereinafter referred to as the HRA Plan ) as part of your employee benefits program. The purpose of the HRA Plan is permit each participating employee and his or her spouse and dependent children to obtain reimbursement of eligible qualified medical care expenses not otherwise covered by any other insurance or any other programs offered by the District or any other employer. The District intends that this HRA Plan qualify as an accident and health plan under Section 105 and 106 of the Code, and under IRS Notice 2002-45. The District also intends that the nontaxable benefits provided under the HRA Plan be eligible for exclusion from Participant s income under Section 105(b) of the Code. This HRA Plan is not part of the District s Cafeteria Plan. The HRA Plan is not funded in any way by salary reductions from your wages. The District is paying 100% of the HRA Plan benefits out of its general assets. The District, in cooperation with the Camanche Education Association, will designate 2
a maximum benefit that will be provided from the District s general assets on an annual basis beginning on the first day of any Plan Year. There is no trust established for this HRA Plan. This Summary Plan Description is a brief description of the Plan and your rights, benefits and obligations under the Plan. This Summary Plan Description is not meant to interpret, extend or change any provision contained in the written Plan Document. The provisions of the Camanche Community School Health Reimbursement Arrangement Plan can only be accurately understood by reading the Plan Document. Article II GENERAL INFORMATION You may need the following information if you have questions about your plan. GENERAL PLAN INFORMATION The name of this Plan is the Camanche Community School Health Reimbursement Arrangement Plan (the HRA Plan ). The District has included this HRA Plan under Plan Number 530. The provisions of this HRA Plan, second amendment, became effective on September 1, 2014. This Plan s records are maintained on a 12-month period known as the Plan Year. The Plan Year is from September 1 through August 31. Reimbursements under this HRA Plan are tax free and therefore governed by the Internal Revenue Service (IRS) Code. As a form of a health plan sponsored by the District, this HRA Plan is also subject to ERISA. Some of your basic rights under ERISA are described in this Summary Plan Description. EMPLOYER INFORMATION The name, address and tax identification number of the District are: Camanche Community School 702 13 th Avenue Camanche, IA 52730 Phone: 563-259-3000 EIN Number (Tax ID): 42-6016657 3
PLAN ADMINISTRATOR INFORMATION The name, address and telephone number of your Plan Administrator is: Camanche Community School 702 13 th Avenue Camanche, IA 52730 Phone: 563-259-3000 Your plan administrator is responsible for the administration of your Plan. Should you need to see any records or have any questions regarding the Plan, contact the Plan Administrator. The Plan Administrator has the discretionary authority to interpret the Plan in order to make eligibility and benefit determinations as it may determine. If a claim for reimbursement under this Plan is wholly or partially denied, and an appeal is entered by the Participant, a Plan committee shall have the authority to confirm or overturn the Plan Administrator s initial decision. The Plan committee shall consist of the District Superintendent, the District Business Director, plus one additional appointment from the Camanche Education Association. The Plan Administrator may, in its sole discretion, appoint a Service Provider to conduct one or more specified duties in operating the Plan. The District has appointed P.R.I.M.E. Benefit Systems, Inc. to be the Plan Service Provider. The name, address and telephone number of the Service Provider is: P.R.I.M.E. Benefit Systems, Inc. PO Box 2239 Cedar Rapids, IA 52406-2239 Phone: 319-294-4045. LEGAL REPRESENTATIVE The following entity has been named as your Plan s agent for service of legal process: Camanche Community School 702 13 th Avenue Camanche, IA 52730 Phone: 563-259-3000 MISCELLANEOUS PROVISIONS Termination and Amendment of the Plan The District expects to maintain the HRA Plan for so long as there are excess funds in the District s Hospital Expense Internal Service Fund. However, the District has the right, in its sole discretion, to terminate the Plan or to modify or amend any provision of the Plan at any time. Participants in the HRA Plan will receive no reimbursements after the HRA Plan has terminated or a partial HRA Plan termination affecting them, except with respect to covered events giving rise to benefits and occurring prior to the date of the HRA Plan termination or partial termination and except as otherwise expressly provided in this Plan Description, or provided in writing by the District. 4
No Continued Employment No provision of the HRA Plan or this Plan Description shall give any employee any rights of continued employment with the District or shall in any way prohibit changes in the terms of employment of any Employee covered by the HRA Plan. Non-Assignment of Benefits Except as may be required pursuant to a Qualified Medical Child Support Order which provides for HRA Plan coverage for an alternate recipient, or other applicable law, no Participant or beneficiary may transfer, assign or pledge any HRA Plan benefits. Excess Payments Upon any benefit payment made in error under this Plan, the District will inform you that you are required to repay the amount that has been paid under this Plan in error. This includes and is not limited to amounts over the annual maximum benefit allocation, amounts for services that are determined not to be Qualified Expenses, or when you did not provide adequate documentation to substantiate a paid claim upon request. The District may take reasonable steps to recoup such an amount including the withholding the amount from future salary or wages, and or reducing the amount of future benefit reimbursements by the amount paid in error. Article III PARTICIPATION IN YOUR PLAN ELLIGIBILITY In order to be eligible for this HRA Plan you must be (1) an active employee and (2) enrolled in the District s group health plan. Any event that causes you to no longer be covered under the District s group health plan, causes the loss of your active employment status will automatically terminate coverage under this HRA Plan. ENROLLMENT TO PARTICIPATE While the District will ask that you sign an Acknowledgement Form, enrollment into the HRA Plan will be automatic, contingent upon the fact that as of the first day of each new Plan year you are enrolled in the District s group health plan. While you are allowed to make changes to your group health plan during the Plan year, the contribution by the District to the HRA Plan is determined solely on the basis of whether you elected single or family health insurance coverage on September 1 of each new Plan year. If, for instance, you change from single coverage to family health coverage during the year does not mean that the District will contribute more to your HRA Plan. Likewise, if during the Plan year, you elect to change your family coverage to single health coverage, for whatever reason, does not mean that your HRA account will be reduced. WHEN ANNUAL CONTRIBUTIONS WILL CEASE You will no longer be a participant in the HRA Plan for purposes of new annual contributions on the earlier of 1) the termination of the Plan; 2) the end of the month following your termination from the District s group health plan; 3) the end of the month following your death; 4) the end of the month when you are no longer employed by the District, even if you elect to continue the District group health as a COBRA participant; 5) the end of the month in which you become a retiree, even if you continue the District group health plan as a retiree under the State of Iowa s Sec 509A.13 Continuation of Coverage rules; or 6) when you are classified by the District as no longer being an active employee on account of being disabled or not working due to the Family Medical Leave Act (FMLA), even if you elected to continue the District group health plan as a COBRA participant. For purposes of this plan retiree shall mean any former eligible employee who has reached the age of 55, and who states in a letter to the District school board that you will not be working for any other IPERS-eligible organization. If you are no longer a participant in the HRA Plan, it 5
means that the District will no longer contribute additional funds at the beginning of each subsequent Plan Year. PLAN BALANCE VESTING UPON TERMINATION OF PARTICIPATION In the event you are 1) no longer participating in the District group health plan; 2) you die; 3) are no longer employed by the District; or 4) no longer an active employee with the District, your plan account balance, if positive, will be vested and may be applied to reimburse you for eligible medical expenses with dates of service incurred by you or any member of your family not later than the last day of the calendar year in which your Plan termination occurred. Any balance that remains in your account on the last day of the year in which your participation terminated, including any unclaimed checks or benefit checks not cashed by the last day of following February will remain in the District s Hospital Expense Internal Service Fund. In the event you become a retiree, as defined by this Plan, your plan account balance, if positive, will remain fully vested, without time limit, until all account funds have been reimbursed to you. MILITARY LEAVE If you go on a leave of absence because of military service, you may continue coverage under this HRA Plan as required by the Uniformed Services Employment and Reemployment Rights Act of 1994 ( USERRA ). Your continued participation in the HRA Plan is not contingent on your continued coverage in the District s group health plan. Your participation in the HRA Plan will end on the earlier of: 1) the last day of the 24-month period beginning on the date your absence begins; or 2) the day after the date on which you fail to apply for or return to a position of employment with the District. The District can provide you with additional information if necessary. In the event of your termination of participation, the same run-out provisions will apply as stated in the Termination of Participation section, above. THE FAMILY AND MEDICAL LEAVE ACT The FMLA requires the District must provide unpaid leave for eligible employees under circumstances that are prescribed by applicable federal law, including the Family and Medical Leave Act of 1993 (29 U.S.C. 2611) as amended. If you are on unpaid leave under the FMLA rules, you may continue participation in the HRA plan, as long as you continue participation in the District s group health plan during the leave. If for any reason, your participation in District s group health plan ends, and therefore your participation in the HRA Plan ends while on FMLA leave, you will be entitled to resume participation in the HRA Plan upon return from leave on the same participation basis in effect prior to your leave, or as otherwise required under FMLA. If your HRA Plan participation ends due to your FMLA leave, and then you resume participation at the end of your leave, qualified medical expenses incurred during this period will not be covered. Article IV ADMINISTRATION OF YOUR PLAN The Plan Administrator is responsible for the administration of your HRA Plan. The duties of the Plan Administrator include determining who is eligible to participate, interpreting laws and regulations and how they apply to your Plan and whether or not certain expenses should be allowed under the Plan. 6
After becoming a participant in the HRA Plan, your requests for expense reimbursement will be processed by the Service Provider. The District has the final determination, in accordance with the various laws that apply to HRA Plans, whether or not to grant your requests. FUNDING MAXIMUM REIMBURSEMENT AMOUNTS Active employees enrolled in the District s group health plan will be eligible to receive reimbursements from the HRA Plan. The amounts stated below are available on the first day of the applicable Plan Year, or the first day of group health coverage for a late enrollee during the Plan year. On September 1 of each Plan Year, or the first of the month in which you became enrolled in the District s group health plan, $1,000.00 will be credited to your HRA account if you elect single group health coverage, or $2,000.00 will be credited to your HRA account if you elect family group health coverage. If you have a spouse and/or dependent children, and still elect to take only single group health coverage with the District, eligible medical expenses incurred by your spouse and/or dependent children may be reimbursed by the HRA Plan. PLAN YEAR BALANCE CARRY OVER Any unused benefit available at the end of each Plan Year will carry over to the next Plan Year. PLAN YEAR CLAIMS CARRY OVER Any eligible full or partial claim not paid during the Plan Year due to a lack of sufficient funds in your HRA account will be carried over to the next Plan Year, and paid as funds are deposited to your account by the District. FORFEITURES Funds remaining in your HRA account will only be subject to forfeiture in the event that a termination has occurred, as stated previously in Article III. Otherwise all plan balances and unpaid claims will be carried over from Plan year to Plan year. SUBMITTING CLAIMS Requests for reimbursement are to be submitted to the Service Provider, using the District s Section 125 Cafeteria Plan claim form. In addition to the form, you must submit independent proof or verification that the expense was performed by a licensed provider, including the date of service, and payments previously received from health/dental insurance companies and all other sources. In certain situations, such as contact lens solution, the original cash register receipt will be accepted. Medical expenses cannot be paid for using the District s Section 125 Cafeteria Benny debit card. When you submit a claim for reimbursement under this Plan, the Plan Administrator will notify you of an adverse benefit determination no later than 30 days after receipt of the claim. This period may be extended one time for up to 15 days, provided that the extension is necessary due to matters beyond the control of the Plan Administrator and the Plan Administrator notifies you, prior to the expiration of the initial 30-day period, of the circumstances requiring the extension of time and the date by which the plan expects to render a decision. If an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and you will be allowed at least 30 days from the receipt of the notice within which to provide the specified information. CLAIM DENIALS The denial notice you receive will state the reason(s) for the denial and refer to the Plan provision or section of the Internal Revenue Code upon which was relied in making the decision to deny the claim. The denial notice will include a description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary. It will describe the review procedures and the time limits applicable to such procedures. If an internal review, guideline, protocol, or other criterion was relied on in making the adverse determination, the notice will include the specific rule, or a statement that such a rule, guideline, protocol or other similar 7
criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to you on request. Your authorized representative can act on your behalf in pursuing a benefit claim or appeal of an adverse benefit determination. The District will have established reasonable procedures for determining whether an individual has been authorized to act on your behalf. There are no fees charged to appeal a denial of a claim for reimbursement. You must first file an appeal within the time limits stated below, with the Plan Administrator, in order to bring an item that can be appealed under this Plan. After a claim has been denied, you will be allowed an opportunity to appeal. If requested in writing, and within 30 days of the claim denial, the District will give you a full and fair review within 30 days from the date of your written appeal. The District s appeals committee will notify you in writing of the final decision. The decision to deny reimbursement will be reviewed in a manner that does not afford deference to the initial denial and will be conducted by the District s appeal committee, who is neither the individual who made the denial nor the subordinate of such individual. You will have the opportunity to submit written comments, documents, records, and other information relating to the claim. You can request free of charge reasonable access to and copies of all documents, records, and other information relevant to the claim. The review will take into account all comments, documents, records, and other information submitted by you related to the claim, regardless to whether the information was submitted or considered in the initial denial. Article V BENEFITS UNDER YOUR PLAN INTRODUCTION Benefits under this HRA Plan shall take the form of tax free reimbursements for eligible qualified medical expenses incurred by you, your spouse or your tax dependent children that are incurred during the period in which you are enrolled in this HRA Plan. Benefits are provided from the District s general assets. You are entitled under this HRA Plan up to the amount that has been allocated by the District on your behalf. REIMBURSEMENT FOR ELIGIBLE EXPENSES The HRA Plan will only provide reimbursements for qualified medical expenses approved by the Internal Revenue Service. Qualified medical expenses are expenses incurred during a Plan Year by you, your spouse and your tax-dependent children, while you are covered under the HRA Plan. For purposes of the HRA Plan, an expense is incurred on the date when the underlying services giving rise to the medical expenses are performed and not on the date that the services are billed by the service-provider or paid for by you. If the qualified medical expense is related to a premium due for an eligible group insurance expense sponsored by the District, reimbursement shall only be for the current month, and not for quarterly, semi-annual, or annual premiums paid in advance. Medical care expenses incurred before you first become covered by the HRA Plan are not eligible. A medical expense incurred in one Plan Year, and cannot be reimbursed in full due to an insufficient balance in your HRA Account may be paid in subsequent Plan Years, provided that you were a covered participant in the Plan Year that the medical care or service was incurred. 8
Qualified Medical Expenses means out-of-pocket medical, dental, hearing, and vision expenses incurred by you or a member of your family for medical care, as defined in Internal Revenue Code 213, including, for example: - Medical Insurance deductibles and co-insurance payments - Routine physicals - Prescription drugs, including Insulin - Physical and occupational therapy - Medical-related transportation (per mile rate established by the IRS) - Psychiatric and psychological care - Dental care, both preventive and restorative - Skilled nursing care - Vision exams and eye wear, including contact lens solution - Hearing care, audiologist testing visits, including hearing instruments and batteries Qualified Medical Expenses shall not include (1) health or dental insurance premiums for individual policies or for any group health or dental coverage sponsored by an employer other than Camanche Community School; (2) over-the-counter drugs and medicines, with or without a prescription; (3) expenses incurred for cosmetic surgery and cosmetic dentistry. A more complete list of covered as well as non-covered expenses is available from the Service Provider. Qualified Medical Expenses can only be reimbursed to the extent that your incurring the expense is not elsewhere reimbursed for the same expense, nor is the expense reimbursable through the District s group health plan, other insurance, or any other accident or health plan. If only a portion of a Qualified Medical Expense has been reimbursed elsewhere, your HRA Account may reimburse the remaining portion of such expense if it otherwise meets the requirements of this Article V. If you are currently enrolled in a Code Section 125 Cafeteria Plan (medical flexible spending account), the HRA Account shall not reimburse any Qualified Medical Expenses until the medical flexible spending account has been depleted to a zero balance. BENEFITS DUE TO A MEDICAL CHILD SUPPORT ORDER The HRA plan, under certain circumstances, will provide benefits for your child, even if you do not have custody of your child or the child is not claimed on your taxes as a dependent. Those circumstances must be established through a Qualified Medical Child Support Order (QMCSO). A QMCSO is a decree or order issued by a court that obligates you to provide health benefits for your child. If you incur this type of obligation as a result of a court ordered medical child support order, you must inform the Plan Administrator. The Plan Administrator can provide you with a copy of the QMCSO procedure. This procedure explains the rules that the Plan Administrator must follow to properly handle a QMCSO. The Plan Administrator will determine if a medical child support order is a qualified medical child support order in accordance with the provisions of the procedure, the Plan document. If a medical child support order is found to be a QMCSO, the Plan may be obligated to provide coverage or benefits to the child under any medical benefit offered to you under this Plan. 9
Article VI STATEMENT OF ERISA RIGHTS As a Participant in any Plan that is subject to the Employee Retirement Income Security Act of 1974 (ERISA), you are entitled to certain rights and protections under ERISA. This HRA Plan is subject to ERISA. ERISA provides that you are entitled to: RECEIVE INFORMATION ABOUT YOUR PLAN AND BENEFITS (1) Examine, without charge, at the Plan Administrator s office and at other specified locations, such as Service Provider, all documents governing the ERISA Plan. (2) Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the ERISA Plan, and any updated summary plan descriptions. The Plan Administrator may make a reasonable charge for the copies. PRUDENT ACTIONS BY PLAN FIDUCIARIES In addition to creating rights for Participants, ERISA imposes duties upon the people who are responsible for the operation of the HRA Plan. The people who operate the HRA Plan, called fiduciaries have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including the District, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. ENFORCE YOUR RIGHTS If your claim for an HRA Plan 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 fee or 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 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 which 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 o 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 fees. If you lose, the court may order you to pay those costs and fees, for example, it if finds your claim is frivolous. You must first file an appeal within the time limits stated in Article IV, with the Plan Administrator, in order to bring a lawsuit in federal court for an item that can be appealed under this Plan. ASSISTANCE WITH YOUR QUESTIONS If you have any questions about this HRA Plan, you should contact your 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 office in Kansas City, MO. Or you may contact the: 10
Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue N.W. Washington, DC 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 at 866-285-1800. 11