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HomeMy WebLinkAboutFD 2024-001 - Resolution RESOLUTION NO. FD 2024-001 A RESOLUTION OF THE BOARD OF DIRECTORS OF THE RANCHO CUCAMONGA FIRE PROTECTION DISTRICT, RANCHO CUCAMONGA, CALIFORNIA, APPROVING AN AMENDED AND RESTATED CAFETERIA PLAN AND EMPLOYEE PLAN SUMMARY FOR THE RANCHO CUCAMONGA FIRE PROTECTION DISTRICT WHEREAS, Section 125 of the Internal Revenue Code ("IRS Code") and the regulations thereunder permit an eligible employer to implement a Section 125 Plan ("Cafeteria Plan") for the benefit of its eligible employees; and WHEREAS, the Rancho Cucamonga Fire Protection District implemented a Cafeteria Plan on September 1, 2007, to provide its eligible employees with the opportunity to choose among qualified benefits available to them under the Cafeteria Plan; and WHEREAS, the Rancho Cucamonga Fire Protection District desires to update and reconfirm the Cafeteria Plan and has prepared an Amended and Restatement Cafeteria Plan document,which it believes complies with the IRS Code; and WHEREAS, the Board of Directors finds that adopting the Amended and Restated Cafeteria Plan is in the best interest and welfare of the Fire District as it allows for pre-tax benefits choices; and NOW, THEREFORE, by the BOARD OF DIRECTORS OF THE RANCHO CUCAMONGA FIRE PROTECTION DISTRICT, RANCHO CUCAMONGA, CALIFORNIA as follows: SECTION 1. Adoption of the Amended and Restated Cafeteria Plan.The staff for the Rancho Cucamonga Fire Protection District independently considered the Amended and Restated Cafeteria Plan Document and found that it adequately outlines the terms and conditions of the Cafeteria Plan. SECTION 2. Employee Plan Summary. The staff for the Rancho Cucamonga Fire Protection District independently considered the Employee Summary Plan Summary and found that it adequately summarizes the terms and conditions of the Cafeteria Plan. SECTION 3. Implementation. The Plan Administrator of the Cafeteria Plan is hereby authorized and directed to take any and all action necessary to implement the purposes of this Resolution and the Amended and Restated Plan. SECTION 4. Effective Date. This resolution shall take effect immediately upon its passage, with the Amended and Restated Plan's effective date to be January 1, 2024. Resolution No. FD 2024-001 — Page 1 of 2 PASSED, APPROVED AND ADOPTED this 17th day of January, 2024. L. D nnis Michael, President ATTEST: ��//2 nice C. Reynold ecretary I, Janice C. Reynolds , Secretary of the Rancho Cucamonga Fire Protection District, do hereby certify that the foregoing Resolution was duly passed, approved, and adopted by the Board of Directors of the Rancho Cucamonga Fire Protection District, at a Regular Meeting of said Board held on the 171h day of January, 2024. AYES: Hutchison, Kennedy, Michael, Scott, Stickler NOES: None ABSENT: None ABSTAINED: None Executed this 18th day of January, 2024, at Rancho Cucamonga, California. nice C. Reynolds—, Clerk / Resolution No. FD 2024-001 — Page 2 of 2 CITY OF RANCHO CUCAMONGA CAFETERIA PLAN i a n+ h.ti s xi�t �-� j �S_, t fl 4�`�cja'2�j�a } i •M � r: � { � A,: '� a 5 �:1 s- A j r� � 4 r t,^Y �� s ATTACHMENT 4 , �-+r s�s}t h'.� t�`��yv C 2F��.Mr� ��'B au h t �r 4 f,�f�,�t � T '� �^�'� x ✓ �, t j�� � �4 r IA ,�.,f #� r r TABLE OF CONTENTS PLANINFORMATION..........................................................................................................................................1 ENROLL TO STRETCH YOUR BENEFIT DOLLARS...........................................................................................2 Establishmentand Purpose...............................................................................................................................................................2 Advantages of Pre-Tax Contributions.............................................................................................................................................2 AccountOptions.................................................................................................................................................................................2 Useor Lose Rule..................................................................................................................................................................................2 Cash-In-Lieu Benefit Option.............................................................................................................................................................2 SalaryReduction Agreement.............................................................................................................................................................3 Pre-Tax Benefit Considerations........................................................................................................................................................3 ENROLLMENTAND PARTICIPATION...............................................................................................................4 Eligibility...............................................................................................................................................................................................4 EnrollmentProcedures.......................................................................................................................................................................4 AnnualOpen Enrollment..................................................................................................................................................................4 Irrevocabilityof Elections.................................................................................................................................'.................................5 PermissibleElection Changes...........................................................................................................................................................5 Cessationof Participation..................................................................................................................................................................5 PERMISSIBLE ELECTION CHANGES.................................................................................................................6 Changeof Status..................................................................................................................................................................................6 HIPAASpecial Enrollment Rights...................................................................................................................................................6 ACA Marketplace/Exchange Enrollment........................................................................................................................................7 Changein Cost or Coverage..............................................................................................................................................................7 OtherSituations....................................................................................................................................................................................8 COVERAGE DURING A LEAVE OF ABSENCE..................................................................................................9 Familyand Medical Leave Act..........................................................................................................................................................9 Employeeson Military Leave..........................................................................................................................................................10 ELECTIVEBENEFITS ..........................................................................................................................................11 PremiumContribution Benefits.....................................................................................................................................................11 HealthFSA Benefits..........................................................................................................................................................................11 DependentCare FSA Benefit...........................................................................................................................................................12 REIMBURSEMENT AND CLAIMS PROCEDURES...........................................................................................14 HealthFSA Reimbursements..........................................................................................................................................................14 Claimsfor Health FSA Benefits......................................................................................................................................................14 DependentCare FSA Reimbursements.........................................................................................................................................15 Dependent Care FSA Claims Procedures......................................................................................................................................16 CONTINUATION OF COVERAGE RIGHTS.....................................................................................................17 What is COBRA Continuation Coverage?....................................................................................................................................17 When is COBRA Coverage Available?...........................................................................................................................................17 You Must Give Notice of Some Events..........................................................................................................................................17 Howis COBRA Coverage Provided?.............................................................................................................................................18 Special COBRA Rule for Health FSAs...........................................................................................................................................18 IfYou Have Questions.....................................................................................................................................................................18 Keep Your Plan Informed of Address Changes...........................................................................................................................18 OTHER IMPORTANT INFORMATION .............................................................................................................19 PlanAdministration.........................................................................................................................................................................19 Amendmentand Termination........................................................................................................................................................19 Summary Plan Description a January 1, 2024 i ExperienceGains...............................................................................................................................................................................19 Changein Benefit Cost.....................................................................................................................................................................19 Privacy and Security of Information..............................................................................................................................................19 LegalActions......................................................................................................................................................................................19 Non-Assignment of Benefits...........................................................................................................................................................20 ControllingDocuments....................................................................................................................................................................20 APPENDIXA.......................................................................................................................................................21 Participation and Eligibility Requirements...................................................................................................................................21 APPENDIXB........................................................................................................................................................22 Summary of Benefits and Contribution Requirements...............................................................................................................22 APPENDIXC.......................................................................................................................................................24 Partial List of Qualified Health Care Expenses.............................................................................................................................24 ii City of Rancho Cucamonga Cafeteria Plan m SPD PLAN INFORMATION This Employee Plan Summary ("EPS") outlines your rights and responsibilities under the City of Rancho Cucamonga Cafeteria Plan ("Plan") and reflects the Plan's benefits ("Elective Benefits") as of January 1, 2024, which may change from time to time. For purposes of the Health FSA,this document,when incorporated with the benefit booklets and certificates,and provider contracts,policies,and descriptions("Benefit Documents"),constitutes this Plan's Employee Plan Sum- mary("EPS").You should keep this EPS with the Benefit Documents provided to you upon enrollment in each Elective Benefit. Plan Name: City of Rancho Cucamonga Cafeteria Plan,a component plan of the City of Rancho Cucamonga Health and Welfare Plan Type of Plan: The Plan is a Section 125 flexible benefits plan classified as a"cafeteria" plan by the Internal Revenue Code("Code").It includes a Code Section 105 Health Care Expense Account("Health FSA"),classified by the Department of Labor("DOL")as a"welfare"plan,and a Code Section 129 Dependent Care Expense Account("Dependent Care FSA"). Plan Year: January 1 through December 31 of the same calendar year Plan Number: 501 Effective Date of this EPS: January 1,2024 Original Effective Date of Plan: January 1,2008 Source of Contributions: From City of Rancho Cucamonga's general assets and employee contributions,when required by City of Rancho Cucamonga in its sole discretion Plan Sponsor and City of Rancho Cucamonga Plan Administrator: 10500 Civic Center Drive Rancho Cucamonga,CA 91730 909-477-2700 Plan Sponsor's Federal Employer 95-3213002 Identification Number: Agent for Service of The agent for the service of legal process for the Plan is the Plan Sponsor Legal Process: at the address set forth above Health FSA Claims Administrator: Sheakley Flexible Benefits Division One Sheakley Way Cincinnati,OH 45246 513-618-1100 www.sheakley.com For additional information regarding the Plan,contact City of Rancho Cucamonga's Human Resources Director at 909-477-2700.Copies of applicable Benefit Documents are available from City of Rancho Cucamonga on request. Summary Plan Description ® January 1, 2024 1 ENROLL TO STRETCH YOUR BENEFIT DOLLARS Establishment and Purpose Account Options City of Rancho Cucamonga ("The City") maintains the Under the Plan,you can enroll in any of the following City of Rancho Cucamonga Cafeteria Plan ("Plan") for Elective Benefits or elect to waive participation in all of the exclusive benefit of its eligible employees and the them. employees of its Affiliated Organizations. The Plan al- Premium Contribution Plan "Premium Contribu- lows you to save money by giving you the opportunity to ■ ( use pre-tax dollars: tion Benefits") that allows you to pay your share of premium contributions for the Benefit Plans listed ■ To pay your share of the cost for coverage under The on Appendix B on a pre-tax or after-tax basis. City's group health and welfare plan ("Benefit ■ Cash-in-Lieu Benefit that adds cash to your payroll Plans") on a pre-tax or after-tax basis through pay- for waiving Medical coverage under the Premium roll deductions;and, Contribution Plan. ■ To set-aside pre-tax dollars to pay for qualified ■ Health Care Expense Account ("Health FSA") that health care and dependent care expenses. reimburses you for a wide variety of health care costs not covered by your Benefit Plans. Advantages of Pre-Tax Contributions Dependent Care Expense Account ("Dependent Participation in any of the Elective Benefits under the Care FSA")that reimburses you for the cost of eligi- Plan is a way to stretch your paycheck by increasing your ble work-related dependent care expenses. take-home pay. The best way to understand how this works is through an example: Use or Lose Rule It's important to remember that you must use the Non- ; Participating full amounts you deposit into the Health FSA (in Married w/One Child Participant in the Plan j excess of the permissible carryover amount) and Gross Income $60,000 $60,000 Dependent Care FSA accounts to pay for eligible expenses incurred during the Plan Year, or you Pretax Benefits Cost NLA Ja 000 __ _ _. i will forfeit any remaining balance. In addition, 1 Adjusted Gross Income $60,000$60,000 $54,300 1 you have until 90 days following the end of a Plan r )— 25,1 0 Year to submit your claims. I Standard Deduction ($25,100 Taxable Income $34,900 $28,400 Please Note:You cannot convert unused funds to cash or transfer the funds from one Elective Bene- Federal Income Tax ($3,829) ($3,145) fit to another, so it's important to estimate your FICA Tax ($3,720) ($3,366) expenses carefully! I - After-Tax Contributions ($5,700) N/A Spendable Income $46,751 $47,789 Cash-In-Lieu Benefit Option Take Home Pay Difference: $1,038 If you have major medical insurance coverage under an- other group plan,for example through your spouse,you As you can see, the Plan's before-tax contributions will may apply for a cash payment in lieu of having The City reduce your taxable income and increase your spendable pay for your coverage.Refer to the enrollment materials income (by$1,038 in the above example). In addition, provided to you for the specific cash-in-lieu amounts depending on where you live, your state income taxes available during a Plan Year. The cash-in-lieu payment may be lower. is taxable and paid on your paycheck. To be eligible for this benefit,you must complete the In- surance Waiver Credit Program Form and provide evi- dence of your alternative coverage.The form is available 2 City of Rancho Cucamonga Cafeteria Plan SPD in the Human Resources Department and is provided to Security taxes are based. This means your future Social you when you are hired and again at each open enroll- Security earnings may be reduced.Your pre-tax contri- ment. butions may also reduce the earnings used to calculate your unemployment insurance benefits. Salary Reduction Agreement Highly Compensated Employees. Certain highly paid An employee's election to pay for benefits on a pre-tax employees may have their elections reduced in order for or after-tax basis is made by entering into a Salary Re- the Plan to comply with applicable federal laws prohib- duction Agreement with The City.Under that Salary Re- iting discrimination. If this applies to you, you will be duction Agreement, you agree to a salary reduction to notified. pay for your share of the cost of Plan coverage instead of receiving a corresponding amount of your regular pay Contributions for Non-Tax Dependents. If you elect that would otherwise be subject to taxes. For the rest of coverage for your eligible domestic partner who is not the Plan Year,you must pay contributions for such cov- your federal tax dependent you will be required to pay erage by having that portion deducted from each contributions for the partner coverage on an after-tax paycheck (generally an equal portion from each basis and the amount The City contributes toward your paycheck, or an amount otherwise agreed to or. as partner's coverage will be treated as imputed income. deemed appropriate by the Plan Administrator). The amount of your imputed income will be added to your paychecks each payroll period and will be subject to federal income tax withholding(the state of California Pre-Tax Benefit Considerations treats registered domestic partners the same as a spouse Social Security and Unemployment Insurance Bene- for purposes of Plan coverage). Before enrolling your fits. Because your contributions are made on a pre-tax domestic partner, you should talk to your tax advisor basis, they lower the earnings on which your Social about the federal tax implications for you. Summary Plan Description January 1, 2Q24 3 ENROLLMENT AND PARTICIPATION Eligibility Failure to Enroll When First Eligible.If you do not en- The Plan is available to any individual who meets the roll in any Elective Benefits when you first become eligi- Plan participation requirements specified in Appendix ble(either because you waive coverage or you fail to sub- A and whose relationship with The City is,under com- mit an election form within the required timeframe), mon law,that of an employee. you will not have an opportunity to elect coverage again until the next Plan Year (January 1 through December Eligible Dependents 31) unless you experience one of the "Qualifying Life In general, the definition of eligible dependents is the Events" described in the Permissible Election Changes same definition used under the particular Benefit Plan in section below. which you are enrolled and who qualifies for exclusion Default or Negative Coverage. Consistent with federal from your income for federal tax purposes.The City may regulations,The City at its discretion,may automatically impose additional restrictions that shall be described in enroll newly eligible employees in certain benefits for the your enrollment materials. remainder of their first Plan Year.In the event The City Note that the definition of"dependent"for purposes of adopts such enrollment procedures, it will provide you the Dependent Care FSA is detailed in the "Dependent with the opportunity to modify the default elections or Care FSA"section. to entirely waive participation in the Plan. Please familiarize yourself with the above definitions be- Annual Open Enrollment fore attempting to estimate your contributions to the The Plan's Plan Year runs from January 1 to December Plan. 31 of the same calendar year.New enrollment materials will be provided to you during the annual Open Enroll- Proof of Dependent Eligibility ment period held prior to the beginning of each Plan You may be required to provide proof of your covered Year.If you are already enrolled in the Plan and decide dependents'eligibility upon request.If you fail to timely you want to keep or modify your benefit choices, or provide the requested documentation, your dependent waive participation,you generally must make your elec- may lose coverage under the Plan whether or not he or tion changes pLior to the beginning of the Coverage Pe- she is otherwise eligible to participate. A dependent riod by following the annual enrollment procedures whose coverage is terminated due to lack of or insuffi- adopted by The City. cient documentation will not be eligible for COBRA cov- erage. If you are not covered under the Plan and fail to com- plete an election form during the next Open Enrollment Enrollment Procedures period, your waiver of participation will continue for subsequent Plan Years until a timely election form is re- If you are eligible for Plan benefits,you will receive en- ceived by The City(during an Open Enrollment period rolhnent materials with information about the Elective Benefits available to you,the cost for each benefit choice, or after experiencing a Qualifying Life Event) as de- scribed below. and instructions for completing your elections in a timely manner. Generally you must submit the com- Once you enroll in the Plan,you will need to complete a pleted election form (or any electronic enrollment ma- new election form for each subsequent Plan Year to con- terials)pLhor to your coverage date.The benefits you en- tinue Plan participation. If you fail to complete the re- roll in will take effect once you meet any applicable wait- quired election form in a timely manner,your coverage ing periods or other requirements. under the Plan will cease for the remainder of the next By completing the enrollment process, you authorize Plan Year(unless you experience a Qualifying Life Event The City to withhold, from your paycheck, the cost of that allows you to elect coverage.) the benefits you have selected. The amounts withheld from your pay for each pay period will be shown on your paycheck stub. 4 City of Rancho Cucamonga Cafeteria Plan ® SPD Irrevocability of Elections Cessation of Participation Except for the Qualifying Life Events described in the Unless otherwise stated in the applicable Benefit Docu- Permissible Election Changes section below,you gener- ments your coverage will cease upon the earliest of the ally cannot change your benefit elections for the dura- following: tion of the coverage period or Plan Year with regard to The date or end of the month in which you cease to participation in the Plan,salary reduction amounts,and satisfy the eligibility requirements for a particular elections of particular Benefit Options. Plan benefit. This may result from your death, re- duction in hours, or termination of active employ- In addition, if you do not enroll in the Plan when first ment,or it may result because you average less than eligible(either because you waive coverage or fail to sub- 130 hours of service per month during a Standard mit your election materials within the required Measurement Period and are not eligible for bene- timeframe), you will not have an opportunity to elect fits during the Standard Stability Period; coverage again until the next Plan Year unless you expe- rience a Qualifying Life Event. The end of the period for which you paid your re- quired contribution if the contribution for the next Permissible Election Changes period is not paid when due; ■ The date you report for active military service,un- Certain changes to your family or employment status less coverage is continued through the Uniformed ("Qualifying Life Event") may allow you a new 30-day Services Employment and Reemployment Rights window during which you may change your elections. Act of 1994 ("USERRA") as described in the "Em- The changes you make to your participation in the Plan ployees on Military Leave"section;or, must be made on account of, and consistent with, the The date that your coverage is terminated by change(s) in your family or employment status.In gen- ■ amendment of the Plan,by whole or partial termi- eral,you cannot make changes retroactively.And if you stop participating,you can't be reimbursed for expenses nation of the Plan, termination of the contract or agreement, or by discontinuance of contributions incurred after the coverage end date. by The City. See the "Permissible Election Changes" Section of this Depending on the reason for termination of coverage, EPS for a list of permissible Qualifying Life Events. To you and your covered spouse and dependent child(ren) make a change, contact The City's Human Resources may have the right to continue health coverage tempo- Director at 909-477-2700 to request the required rarily under COBRA. See the "Continuation Coverage change-in-enrollment materials. Rights"Section of this EPS for additional details. Summary Plan Description o January 1, 2024 5 PERMISSIBLE ELECTION CHANGES You generally cannot change your pre-tax benefit elections of employee's spouse, divorce, legal separation, and under the Plan or vary the salary reduction amounts that annulment. you have selected during the Plan Year.However,you may ■ Number of Dependents.Events that change the num- revoke a benefit election (including,but not limited to,an ber of employee's dependents, including following election not to receive benefits under the Plan) after the birth,death,adoption,placement for adoption. Plan Year has commenced and make a new election with respect to the remainder of the Plan Year if both the revo- ■ Employment status.Any of the following events that cation and new election are on account of and consistent change the employment status of the employee, the with a Qualifying Life Event(as described below). employee's spouse, or the employee's dependent: ter- mination or commencement of employment;strike or Election and salary reduction changes shall be effective on lockout;commencement of or return from an unpaid a prospective basis only(i.e.,election changes will generally leave of absence; or a change in worksite. In addition, become effective no earlier than the first day of the next if the eligibility conditions of this Plan or other em- calendar month following the date that the election change ployer-sponsored plan of the employee,spouse,or de- request was filed), except that an election change on ac- pendent depend on the employment status of that in- count of a HIPAA Special Enrollment Right,attributable to dividual and there is a change in that individual's em- the birth,adoption,or placement for adoption of a new de- ployment status with the consequence that the individ- pendent child may,subject to the provisions of the under- ual becomes (or ceases to be) eligible under the plan, lying group health plan, be effective retroactively back to then that change constitutes a change in employment the date of the qualifying event. under this subsection. ■ Dependent Satisfies or Ceases to Satisfy Eligibility If you undergo a Qualifying Life Event,you must inform Requirements. Events that cause an employee's de- the Plan Administrator and complete the required change-in-coverage enrollment materials within 30 days pendent to satisfy or cease to satisfy eligibility require- ments for coverage on account of attainment of age, after the occurrence of the Qualifying Life Event (or change in student status,or any similar circumstance. within 60 days in the case of a Special Enrollment Right due to loss of eligibility for Medicaid or Children's Residency Change.A change in the place of residence Health Insurance Program("CHIP")coverage). of the employee,spouse,or dependent that results in a loss of eligibility for coverage(e.g.relocates outside the In the event of a conflict between the following provisions current plan's service area). and the Internal Revenue Code ("IRC") Section 125 plan ■ Qualifying Dependent. For the Dependent Care As- adopted by The City, the IRC Section 125 plan shall con- sistance Plan only,a dependent becoming or ceasing to trol. The Plan Administrator reserves the right to deter- be a "Qualifying Dependent" as defined under Code mine whether an Employee has experienced a Qualifying Section 21(b) shall also qualify as a Qualifying Life Life Event and whether the Employee's requested election Event. is consistent with such event. HIPAA Special Enrollment Rights Change of Status An employee may change an election for group health cov- Qualifying Life Events include a change of status due to one erage during a Plan Year and make a new election that cor- of the following events permitted under the rules and reg- responds with HIPAA Special Enrollment Rights, includ- ulations adopted by the Department of the Treasury, but ing those authorized under the provisions of the Children's only if the Qualifying Life Event changes the individual's Health Insurance Program Reauthorization Act of 2009 eligibility for the applicable benefit.These change in status (CHIP),as long as the employee meets the notice require- rules apply to elections for all qualified benefits,except that ments.Special Enrollment Rights can occur when: election changes are generally not permitted for Health FSA or Dependent Care FSA benefits if the Qualifying Life You lose eligibility for coverage under a group health Event is a change in residence: plan or other health insurance coverage(such as if you and your dependents lose coverage under your ■ Legal Marital Status. Events that change an em- spouse's plan) or if your employer terminates contri- ployee's legal marital status,including marriage,death butions toward health coverage. 6 City of Rancho Cucamonga Cafeteria Plan © SPD ■ You gain a new dependent through marriage, birth, Change in Coverage under Another Employer's adoption,or being placed for adoption. Plan.You may make a new election if there is a change ■ You or your dependents lose coverage under a CHIP in coverage (for you,your spouse or your dependent) or Medicaid or become eligible to receive premium as- under a plan provided by another employer.Your new sistance under those programs for group health plan election must be on account of the change in the other coverage. employer's plan and correspond with that change. Among other things, this rule permits you to make election changes during another plan's open enroll- ACA Marketplace/Exchange Enrollment ment period. Qualifying Life Events include the opportunity to enroll in Significant Coverage Decrease with or without Loss the ACA Marketplace/Exchange or other plans that offer of Coverage.If your coverage under a benefit is signif- minimum essential coverage under the ACA.These Quali- icantly curtailed or ceases during a Plan Year,you may fying Life Events apply to elections for group health plan revoke your election of such benefit and, in its place, coverage that is not Health FSA benefit coverage and that elect to receive on a prospective basis coverage under provides minimum essential coverage under the ACA: another plan with similar coverage, or drop coverage prospectively if no similar coverage is offered. ■ ACA Marketplace/Exchange Election.You may elect ■ Significant Improvement or Addition of a New Ben- to cancel contributions for and payment of your por- efit.If,during the period of your coverage,a new ben- tion of the group health plan premiums if(1) you are efit package option or other coverage option is added, eligible for a special enrollment period to enroll in a an existing benefit package option is significantly im- "qualified health plan' through an ACA Marketplace proved,or an existing benefit package option or other or (2) you are seeking to enroll in a qualified health plan through a Marketplace during the Marketplace's coverage option is eliminated, then you may elect the annual open enrollment period. newly-added option, or elect another option if an op- tion has been eliminated prospectively and make cor- In addition, effective January 1, 2023, you may pro- responding election changes with respect to other ben- spectively drop some or all covered family members efit package options providing similar coverage.In ad- from the group health plan consistent with their en- dition, if you are not participating in the Plan when rollment or intended enrollment in an ACA Market- these options are added or changed, you may opt to place/Exchange. become a participant and elect the new or newly im- ■ ACA Reduction in Hours. You may elect to cancel proved benefit package option. contribution for and payment of the employee-paid ' Significant Cost Increase. If the cost of one of your portion of group health plan premiums if(1)you had benefit options increases significantlX,you may either been reasonably expected to average at least 30 hours make corresponding changes in your payments or re- of service per week and subsequently move to a posi- voke your elections and, in lieu thereof, receive on a tion in which you are reasonably expected to average prospective basis coverage under another benefit op- less than 30 hours of service per week,even if you con- tion with similar coverage,or drop coverage prospec- tinue to be eligible under your employer-sponsored tively if there is no benefit package option with similar group health plan;and(2)your revocation of the elec- coverage. tion of coverage under the group health plan corre- ■ Significant Cost Decrease. If the cost of your benefit sponds to your(and any dependents')intended enroll- option decreases significantly, you may make corre- ment in another plan that provides ACA minimum es- sponding changes in your payments. In addition, if sential coverage with the new coverage effective no you are not enrolled in the Plan and the cost of an op- later than the first day of the second month following tion decreases significantly, you may elect coverage the month in which the original coverage is revoked. under the corresponding benefit package. ■ In addition, if the expenses for a component plan in- Change in Cost or Coverage crease or decrease during a Plan Year,the Plan may au- tomatically increase or decrease accordingly your re- A change in cost or coverage,as follows,may allow an elec- quired periodic contribution for such health insurance tion change. The following Qualifying Life Events do not benefits. apply to the election of Health FSA benefits: Summary Plan Description - January 1, 2024 7 Other Situations group health coverage sponsored by a governmental or educational institution and loses such coverage, the Other situations that may permit an election change: employee may make an election change to add cover- ■ Court Order. A judgment, decree, or other order re- age under a corresponding The City plan. Group sulting from a divorce,legal separation,annulment,or health coverage sponsored by a governmental or edu- change in legal custody(including a Qualified Medical cational institution includes(but is not limited to)cov- Child Support Order) that requires accident or health erage under: a state children's health insurance pro- coverage for an employee's child or for a foster child gram (SCHIP); a medical care program of an Indian who is a dependent of the employee. The employee Tribal government, the Indian Health Service, or a may change his or her election to provide coverage for tribal organization; a state health benefits risk pool; the child if the order requires coverage for the child and a foreign government group health plan. under the Plan and may cancel coverage under the ■ FMLA Leaves of Absence. A participant may revoke Plan for the child if the order requires the employee's coverage or,if coverage is required,continue coverage spouse, former spouse, or other individual to provide but delay payment of his or her share of the cost for coverage for the child,and that coverage is,in fact,pro- group health plan coverage during the period of a leave vided. of absence under FMLA. An employee who revokes ■ Entitlement to Medicare or Medicaid.If an employee coverage shall be entitled to reinstate coverage upon or an employee's spouse or dependent who is enrolled returning from a leave of absence under FMLA. in an employer-sponsored accident or health plan be- COBRA Premiums.If the employee or the employee's comes enrolled under Part A or Part B of Medicare or spouse or dependent becomes eligible for continuation under Medicaid(other than coverage consisting solely coverage under an employer's group health plan as of benefits under the program for distribution of pedi- provided in Code section 4980B or any similar state atric vaccines), the employee may make an election law,the employee may elect to increase contributions change to cancel or reduce coverage of that employee, under the Plan in order to pay for the continuation spouse, or dependent under the accident or health coverage. component plan.In addition,if an employee or an em- ployee's spouse or dependent who has been enrolled in � Correcting Discrimination Issues under the Code.If such coverage under Medicare or Medicaid loses eligi- The City determines before or during a Plan Year that bility for such coverage, the employee may make an the Plan or one of its component plans will fail to sat- isfy any nondiscrimination requirement imposed by election to commence or increase his or her coverage or the coverage of his or her spouse or dependent, as the Code or any limitation on benefits provided to applicable,under The City's accident or health plan. highly compensated or key employees, The City may decrease or revoke the elections of affected highly com- ■ Loss of Coverage under Health Plan of a Govern- pensated or key employees to ensure compliance with mental or Educational Institution.If an employee or such nondiscrimination requirements or benefit limi- an employee's spouse or dependent is enrolled in a tation. 8 City of Rancho Cucamonga Cafeteria Plan SPD COVERAGE DURING A LEAVE OF ABSENCE You maybe eligible to continue certain Plan benefits for health care benefits on the same terms and condi- yourself and your covered dependents for a period of tions as though you were still an active employee by time during a leave of absence, subject to the leave paying any normally required contributions for policies and procedures adopted by The City and to the your health care benefits in accordance with The extent prescribed by law. The type of leave you take City's FMLA policies and applicable law. If you do determines the cost of your benefits (i.e., whether you not make such payments,or do not make them in a can continue to pay the same contribution amounts timely manner,your health care coverage may cease. toward your coverage or will need to pay the full At least 15 days before cessation of your health care premium cost).If you elect not to continue your benefits coverage, you will be provided with notice of the during your approved leave of absence or if you fail to cancellation. Unless The City has adopted a longer timely pay for your benefits,your benefits may terminate grace period,you will have 15 days from the date of for the duration of your leave. the notice to make the required payment. Please refer to The City's leave policies and procedures Any coverages that are terminated during your FMLA and the applicable Benefit Documents for a description leave will.be reinstated upon your return from leave of the different types of leaves of absence available, the without any evidence of good health or newly imposed maximum length and types of benefits available while on Waiting period so long as you make the required contri- a leave of absence, employee contributions require- butions, including any catch-up payments attributable ments,and the procedures for paying your share of pre- to the period prior to your return from leave,if applica- miums. ble.If you experience a change in status event while you are on leave, or upon your return from leave,you may Note that Dependent Care FSA Participants are not make appropriate changes to your elections. eligible to participate in the Dependent Care FSA while on leave of absence. If you do not return to work at the end of your FMLA leave you may be entitled to COBRA continuation cov- erage. You also may be required to reimburse The City Family and Medical Leave Act for the cost of coverage provided to you while you were In the event The City employs 50 or more individuals on unpaid FMLA leave(the cost equals the COBRA pre- within a 75-mile radius,The City will be subject to the mium,without a 2% add-on),unless your failure to re- Family and Medical Leave Act of 1993("FMLA").FMLA turn to employment is due to a serious health condition, generally allows eligible employees to take a specific the need to care for a servicemember,or because of other amount of job-protected,unpaid leave for certain family circumstances beyond your control. and medical reasons specified under the law and its reg- For additional information on FMLA leave,and for in- ulations,as amended from time to time. formation on participant contributions to Plan coverage If you take FMLA leave,you may continue your group during FMLA leave,please contact the Plan Administra- health care coverage under the Plan(e.g.medical,dental, tor. vision,Health FSA)for you and any covered dependents Special FMLA Rules for Health FSAs. If you partici- as long as you continue to pay your portion of the cost pated in the Health FSA prior to revoking or ceasing for your benefits during the leave. coverage during your leave of absence,you will have two ■ If you are being paid directly by The City and you coverage options upon return to active employment: 1) substitute accrued aid leave for some of your un- you may elect to reinstate a level of coverage that is pro- paid FMLA leave days (e.g.both types of leaves run rated (reduced by the amount of contributions missed concurrently), your share of premiums will con- during leave);or,2)You may elect to reinstate your orig- tinue to be deducted from your pay(on a pre-tax ba- inal coverage level. sis,if applicable). ■ If you take an unpaid leave of absence that qualifies under FMLA, you may continue to maintain your Summary Plan Description m January 1, 2024 9 Employees on Military Leave If you take a military leave,but your coverage under the Plan is terminated (e.g. you do not elect the extended Employees going into or returning from military service coverage),when you return to work with The City you will have Plan rights mandated by the Uniformed Ser- will be treated as if you had been actively employed dur- vices Employment and Reemployment Rights Act of ing your leave when determining whether an exclusion 1994 ("USERRA"). If you take a military leave under or waiting period applies to health care coverage under USERRA,whether for active duty or for training,you are the Plan. entitled to extend your health care coverage (e.g. medi- cal, dental,vision, Health FSA) for up to 24 months as If you do not return to work at the end of your military long as you give The City advance notice of the leave leave you may be entitled to continue coverage under (unless military necessity prevents this, or if providing COBRA continuation coverage for the remainder of the notice would be otherwise impossible or unreasonable). COBRA continuation period, if any. Any continuation Your total leave,when added to any prior periods of mil- of coverage under USERRA will reduce the maximum itary leave from The City, cannot exceed five years. COBRA continuation period for which you and/or your There are a number of exceptions, however, such as dependents may be eligible. types of service that are not counted toward the five-year limit. Additionally, the maximum time period may be These rights apply only to employees and their depend- extended due to your hospitalization or convalescence ents covered under the Plan before leaving for military following service-related injuries after your uniformed service. service ends. Applicable State or Municipal Law If the entire length of the leave is 30 days or less,you will The City shall permit you to continue participation in not be required to pay any more than the contributions the Plan as required under any applicable state or mu- required for active employees.If the entire length of the nicipal law to the extent that such law is not pre-empted leave is 31 days or longer,you may be required to pay up by federal law. to 102% of the full amount necessary to cover an em- ployee(and any amount for dependent coverage)who is not on military leave. 10 City of Rancho Cucamonga Cafeteria Plano SPD ELECTIVE BENEFITS Premium Contribution Benefits Maximum Contribution Amount The Premium Contribution Benefits available under the The IRS sets the maximum amount you can contribute Plan allow you to pay for your share of eligible premium to a Health FSA.See Appendix B for details. costs with pre-tax dollars through payroll deductions. The annual salary reduction amount you elect to con- The enrollment materials provided to you when you first tribute to your Health FSA (less any prior reimburse- became eligible and thereafter during the annual Open ments) will be available in full at all times during the Enrollment period contain a list of available Premium Plan Year: Contribution Benefits,as well as your cost for coverage in each benefit plan. Appendix B provides a brief sum- Uniform Coverage Rule mary of the Premium Contribution Benefits available. The "Uniform Coverage Rule" requires that the maxi- under the Plan and.the contribution requirements for mum amount of reimbursement from a Health FSA each benefit choice. must be available at all times during the period of cover- The terms and conditions of the underlying benefits,in- age(properly reduced as of any particular time for prior cluding eligibility for coverage,claims and appeals pro- reimbursements for the same period of coverage)." cedures,and details regarding the benefits.provided are stated in the applicable Benefit Plan's Benefit Docu- ments and are not governed by this Plan If any balance remains in your Health FSA after the end of any Plan Year after all reimbursement requests have The City, at its discretion,requires employee contribu- been processed, then such ending balance in excess of tions as a condition of participation in each Premium . permissible carryover amount shall be.forfeited.In such Contribution Benefit. Each year, The City will evaluate event, you will have no further claim to the forfeited all benefit costs and shall make adjustments for the fol- funds for any reason and the Plan Administrator will use lowing Plan Year.You will be notified of any changes in such funds as described in"Experience Gains"section. your enrollment materials prior to each Plan Year. The Plan Administrator will "carryover any unused balance of up to permissible carryover amount remain- Health FSA Benefits ing in your Health FSA at the end of a Plan Year and will. You can use a Health FSA for health care expenses that apply it to your Health FSA balance for the subsequent . your medical, dental, and vision Benefit Plans do not Plan Year.The carried over funds do not affect your sal- cover. You also can use it to pay for your share of the ary. reduction election for the subsequent Plan Year and cost of health care expenses,including copayments, co- may be used to reimburse healthcare expenses. insurance,and prescription drugs. Run-Out Period for Submitting Claims. In general, Eligible Health Care Expenses you will have 90 days from either the end of the Plan Your Health FSA contributions can be used to pay for a Year or your last day of Plan participation,whichever is wide variety of health care expenses defined as"deduct- earlier,to submit Health FSA claims for health care ex- penses incurred during the Plan Year. After.that time, ible"by tax law. The expenses cannot be payable under you will forfeit any funds remaining in your account. any other health plan and must be incurred by either you The rollover of the carryover funds will occur after the or your dependents who meet the eligibility require- 90-day run-out period is complete. ments. See Appendix C for a.partial list of allowable expenses. Continuation of Coverage Rights For the most up-to-date list of qualified health care ex- See the "Continuation of Coverage Rights" section of penses refer to IRS Publication 502. Please be advised this EPS for additional details on a participant's rights to that the IRS can amen_d this list at any time,with or with- continue Health FSA coverage under the Plan for a lim-. out prior notice. ited period after experiencing a loss of coverage due to a. qualifying event, such as voluntary or involuntary job Summaiy Plan Description ® January 1, 2024 11 loss,reduction in hours worked,death,divorce,or other Contribution Limits for Highly Compensated Em- life events. ployees. The Code has certain nondiscrimination rules which may require the Plan Administrator to limit the Under most circumstances, COBRA continuation cov- contribution amounts elected by highly compensated erage is provided to qualified individuals on an after-tax employees during a Plan Year.You will be notified if this basis.Individuals whose COBRA continuation coverage limitation applies to you. may be provided on a pre-tax basis are limited to cur- rent employees(as permitted by the Plan Administrator Use or Lose Rule on a uniform and consistent basis)whose COBRA con- If any balance remains in your Dependent Care FSA af- tinuation coverage arises either because of a reduction of ter the end of any Plan Year after all reimbursement re- hours or because the participant's dependent ceases to quests have been processed, then such ending balance satisfy the underlying Benefit Plan's eligibility require- shall be forfeited.In such event,you will have no further ments even though the dependent's COBRA continua- claim to the forfeited funds for any reason and the Plan tions coverage continues to qualify for exclusion from Administrator will use such funds as described in Ex- the participant's income. perience Gains"section. Dependent Care FSA Benefit Run-Out Period for Submitting Claims.You will have 90 days from the end of the Plan Year or your last day of Ifyou have young children or care for a disabled depend- Plan participation, whichever is earlier, to submit De- ent, you can use the Dependent Care FSA to pay for pendent Care FSA claims for dependent care expenses qualifying, work-related dependent care expenses with incurred during the Plan Year.After that time,you will pre-tax dollars. To be eligible for this benefit,you (and forfeit any funds remaining in your account. your spouse, if you are married and your spouse is not disabled or a full-time student) must be at work during Eligible Dependents the time your eligible dependent is receiving care. The definition of dependent under the Dependent Care FSA is an individual who is your qualifying child,quali- Dependent Care FSA vs. Dependent Care fying spouse,or qualifying relative,as follows: Tax Credit If you choose.to pay some or all of your dependent care A person under age 13 who is your qualifying child expenses through the Dependent Care FSA,you cannot under the Code (in general, the person must: (1) take advantage of the Federal Dependent Care Tax have the same principal abode as you for more than Credit for the same expenses. For some people, the tax half the year;(2)be your child or stepchild(by blood credit may result in greater savings than participation in or adoption),foster child,sibling or stepsibling,or a the Dependent Care FSA, especially if household earn- descendant of one of them; and (3) not .provide ings are less than$25,000 per year.You should compare more than half of his or her own support for the both options to determine which approach provides you year); with the greatest savings. If you have questions,refer to Your spouse who is physically or mentally incapable IRS Publication 503 or consult your tax advisor. of caring for himself or herself and has the same principal place of abode as you for more than half of Maximum Contribution Amount the year;or, If you elect to participate in the Dependent Care FSA, A person who is physically or mentally incapable of you can contribute up to$5,000($2,500 if married filing caring for himself or herself,has the same principal separately) per Plan Year toward your dependent care place of abode as you for more than half of the year, expenses. and is your tax dependent under the Code (for this Any amounts contributed to your account in excess of purpose, status as a tax dependent is determined the above limits during a Plan Year will be included in without regard to the gross income limitation for a your taxable income and wages. Unlike the Health FSA, qualifying relative and certain.other provisions of you can be reimbursed from your Dependent Care FSA the Code's.definition. only up to the amount that you have contributed to your Under a special rule for children of divorced or sep- Dependent Care FSA. arated parents, a child is a qualifying chld with re- spect to the custodial parent when the noncustodial 12 City of Rancho Cucamonga Cafeteria Plan SPD parent is entitled to claim the dependency exemp- spouse or if you or your spouse is a full-time student tion for the child. or incapable of self-care; Eligible Dependent Care Expenses Certified"away from home"facilities(providing not Eligible dependent care expenses that can be reimbursed more than 12 hours per day). from your Dependent Care FSA are expenses incurred Examples of ineligible expenses include for household and dependent care services that enable ■ Food or clothing; you and (if married) your spouse to be gainfully em- ployed,which generally means working or actively look- ' Costs for a dependent's education (other than edu- ing for work. Eligible dependent care expenses include, cation a nursery school provides); but are not limited to,the following expenses if not oth- Expenses for transportation of a dependent to and erwise excluded (review IRS Publication 503 for addi- from the provider of dependent care services except tional qualified dependent care expenses): where transportation is required to maintain gainful ■ Dependent care costs that you must pay to enable employment (such as a school bus to and from the you to work. If you are married, your spouse also dependent care provider); must be employed full-time, be a full-time student ■ Fees to a day care center that do not comply with all or incapable of self-care; laws applying to child care centers; ■ Dependent care for a dependent who is under 13 ■ Dependent care costs that are covered by the federal years of age—the IRS requires the provider to be a tax credit for dependent care on your federal tax re- qualified day care center or a person who is not your turns; dependent. A relative age 19 or older can provide ■ Costs for a nursery school,day care center or baby- qualified dependent care assistance if you do not sitter outside of scheduled working hours. claim him or her as a dependent for income tax pur- poses; Ineligible Expenses While on Leave ■ Non-nursing care for a dependent 13 years of age or If a Participant in the Dependent Care FSA takes a paid older who is physically or mentally incapable of self- or unpaid leave of absence lasting longer than 14 consec- care; utive calendar days,Dependent Care Expenses shall not ■ Nursery school,day care center that meets local reg- include expenses incurred after the fourteenth day of the ulations or babysitter fees only for purposes of leave and through the end of the leave. maintaining gainful employment for you and your Summary Plan Description m January 1, 2024 13 REIMBURSEMENT AND CLAIMS PROCEDURES The Plan Administrator will act as, or will designate, a ■ A statement that such expenses have not otherwise claims administrator to decide your claim ("Claimant") been reimbursed and that the Claimant will not seek in accordance with its reasonable claims procedures,as reimbursement through any other source;and, required by applicable law. If the claims administrator ■ Other such details about the expenses that may be denies your claim in whole or in part,you will receive a requested by the claims administrator in the reim- written notification setting forth the reason(s) for the bursement request form or otherwise (e.g., a state- denial.If your claim is denied,you may appeal for a re- ment from a medical practitioner that the expense is view of the denied claim. The claims administrator will to treat a specific medical condition,documentation decide your appeal in accordance with its reasonable that a medicine or drug was prescribed, or a more claims and appeal procedures,as required by applicable detailed certification from the Claimant). law. The reimbursement request must be accompanied by Premium Contribution Benefits bills,invoices,or other statements from an independent A Plan participant is neither required nor permitted to third party showing that the health care expenses have file Claims for Premium Contribution Benefits. If you been incurred and the amounts of such expenses,along have questions about this Benefit, please contact The with any additional documentation that the claims ad- City's Human Resources Director at 909-477-2700. To ministrator may request. file a claim or appeal for medical,dental,or vision bene- fits, a Claimant must follow the procedures set forth in Requests for reimbursement should be sent to: the Benefit Document for the applicable component Sheakley Flexible Benefits Division plan. One SheaMey Way Cincinnati,OH 45246 Health FSA Reimbursements 513-618-1100 Reimbursements under the Health FSA must be submit- www.sheakley.com ted pursuant to procedures established by the claims ad- ministrator. Claims for Health FSA Benefits Debit Card Payments.Payments from your Health FSA Within 30 days after receipt by the claims administrator for qualified health care expenses will occur automati- of a reimbursement request from Claimant, the claims cally if you pay your health care provider using a debit administrator will reimburse the Claimant for the health card provided by the claims administrator. You must care expenses (if the claims administrator approves the comply with the card substantiation procedures by claim),or the claims administrator will notify the Claim- providing any requested documentation that supports ant that his or her claim has been denied.This time pe- your reimbursement. riod may be extended by an additional 15 days for mat- ters beyond the control of the claims administrator,in- Manual Submissions. In general,a Health FSA partici- cluding in cases where a reimbursement claim is incom- pant may apply for reimbursement by submitting a re- plete.The claims administrator will provide written no- quest to the claims administrator in such.form as the tice of any extension, including the reasons for the ex- claims administrator may prescribe,by no later than 90 tension,and will allow the Claimant 45 days in which to. days following the close of the Plan Year in which the complete the previously incomplete reimbursement health care expense was incurred(or 90 days after the claim. date eligibility ceases).At minimum,the request for re- imbursement must include: If the claims administrator does not fully agree with the claim,the Claimant shall receive an adverse benefit de- 0 The name of the person or persons who incurred the termination ("Adverse Determination"). The Notice of health care expenses; Adverse Determination must be written in a manner cal- 0 The nature and date of the expenses so incurred; culated to be understood by the Claimant and shall in- clude the following information: ■ The amount of the requested reimbursement; 14 City of Rancho Cucamonga Cafeteria Plan SPD ■ The specific reason for the Adverse Determination; of documents,records,and other information rele- ■ References to the specific Plan provisions on which vant to the claim; the Adverse Determination is based; ■ A statement describing any additional, voluntary ■ A description of any additional information needed appeal procedures offered by the Plan and the to reconsider the claim and the reason this infor- Claimant's right to obtain information about such mation is needed; procedures; ■ A description of the Plan's review procedures and ' Specific references to the internal rules, guidelines, the applicable time limits; protocols,or other similar criteria on which the Ad- verse Determination is based. For Health Claims, ■ A statement that the Claimant is entitled to receive, such specific references may be made available to upon request and free of charge, reasonable access the Claimant by including a statement that the in- to,and copies of,all documents, records,and other formation is available free of charge upon the information relevant to the claim; Claimant's request;and, ■ If applicable,specific references to the internal rules, guidelines, protocols, or other similar criteria on Dependent Care FSA Reimbursements which the Adverse Determination is based. Such specific references may be made available to the Reimbursements under the Dependent Care FSA must Claimant by including a statement that the infor- be submitted pursuant to procedures established by the mation is available free of charge upon the Claim- claims administrator. ant's request;and, Debit Card Payments.Payments from your Dependent Health FSA Claims Appeal Procedures Care FSA for qualified dependent care expenses will oc- First Appeal.If the Claimant disagrees with an Adverse cur automatically if you pay your dependent care pro- Determination, the Claimant or the Claimant's ap- vider using a debit card provided by the claims adminis- pointed representative may formally request an appeal trator. You must comply with the card substantiation by following the claims administrator's appeal proce- Procedures by providing any requested documentation dures. The Claimant may appeal any Adverse Determi- that supports your reimbursement. nation within 180 days of receipt of such a denial by sub- Manual Submissions. In general, a Dependent Care mitting a written request for review to the Administra- FSA participant may apply for reimbursement by sub- tor.If the Claimant does not appeal in a timely manner, mitting a request to the claims administrator in such the Claimant will lose the right to later object to the ad- form as the claims administrator may prescribe, by no verse determination on review("Appeal Decision"). later than 90 days following the close of the Plan Year in If the claim on appeal is wholly or partially denied, the Which the Dependent Care Expense was incurred(or 90 claims administrator will provide the Claimant with a days after the date eligibility ceases). At minimum, the written notification of the Plan's Appeal Decision, request for reimbursement must include: within a reasonable period of time,but not later than 60 . The name of the person or persons on whose behalf days after receipt of the appeal by the Plan. Any deter- the dependent care expenses have been incurred; mination by the claims administrator or any authorized delegate shall be binding and final in the absence of clear The nature and date of the expenses so incurred; and convincing evidence that the claims administrator ■ The amount of the requested reimbursement; or delegate acted arbitrarily and capriciously.The notice . The name of the person, organization, or entity to of Appeal Decision shall include the following infor- whom the expense was or is to be paid,and taxpayer mation: identification number (Social Security number, if ■ The specific reason for the Appeal Decision; the recipient is a person); ■ References to the specific Plan provisions on which ' A statement that such expenses have not otherwise the Appeal Decision is based; been reimbursed and that the Claimant will not seek ■ A statement regarding the Claimant's right, on re- reimbursement through any other source; quest and free of charge,to access and receive copies ' The participant's certification that he or she has no reason to believe that the reimbursement requested, Summary Plan Description @ January 1,2024 15 added to his or her other reimbursements to date for calculated to be understood by the Claimant and shall dependent care expenses incurred during the same include the following information: calendar year, will exceed the applicable statutory limit for the participant as described in Section 9.3; References to the specific Plan provisions on which the Adverse Determination is based; and, ■ Other such details about the expenses that may be A description of any additional information needed requested by the claims administrator in the reim- to reconsider the claim and the reason this infor- bursement request form or otherwise (e.g., a more mation is needed;and, detailed certification from the participant). ■ An explanation of the Plan's claims procedures. The reimbursement request must be accompanied by bills,invoices,or other statements from an independent Claims Appeal Procedures third party showing that the dependent care expenses If the Claimant disagrees with an Adverse Determina- have been incurred and the amounts of such expenses, tion, the Claimant or the Claimant's appointed repre- along with any additional documentation that the claims sentative may formally request an appeal by following administrator may request. the claims administrator's appeal procedures. The Claimant may appeal any Adverse Determination within Requests for reimbursement should be sent to: 60 days of receipt of such a denial by submitting a writ- ten request for review to the Administrator.If the Claim- Sheakley Flexible Benefits Division ant does not appeal in a timely manner, the Claimant One Sheakley Way will lose the right to later object to the adverse determF Cincinnati,OH 45246 nation on review("Appeal Decision"). 513-618-1100 www.sheakley.com If the claim on appeal is wholly or partially denied, the claims administrator will provide the Claimant with a Dependent Care FSA Claims.Procedures written notification of the Plan's Appeal Decision, within a reasonable period of time,but not later than 60 Within 90 days after receipt by the claims administrator days after receipt of the appeal by the Plan. Any deter- of a reimbursement request from a Claimant,the claims mination by the claims administrator or any authorized administrator will reimburse the Claimant for the de- delegate shall be binding and final in the absence of clear pendent care expenses (if the claims administrator ap- and convincing evidence that the claims administrator proves the claim),or the claims administrator will notify or delegate acted arbitrarily and capriciously.The notice the Claimant that his or her claim has been denied. of Appeal Decision shall include the following infor- mation: If the claims administrator does not fully agree with the claim,the Claimant shall receive an adverse benefit de- ■ The specific reason for the Appeal Decision;and, termination ("Adverse Determination"). The Notice of ■ References to the specific Plan provisions on which Adverse Determination must be written in a manner the Appeal Decision is based. 16 City of Rancho Cucamonga Cafeteria Plan SPD . CONTINUATION COVERAGE RIGHT This Section applies only to the Health FSA provisions ■ Your spouse dies; of this Plan.If you have opted to contribute to a Health ■ Your spouse's hours of employment are reduced; FSA under this Plan, then read this entire notice care- ■ Your spouse's employment ends for any reason fully. other than his or her gross misconduct; This notice contains important information about your ■ Your spouse becomes entitled to Medicare benefits right to COBRA continuation coverage,which is a tem- (under Part A,Part B,or both);or porary extension of Health FSA coverage. This notice ■ You become divorced or legally separated from your generally explains COBRA continuation coverage,when spouse. it may become available to you and your family, and what you need to do to protect the right to receive it. four dependent children will become qualified benefi- ciaries if they lose Health FSA coverage because any of The right to COBRA continuation coverage was created the following qualifying events happens: by a federal law,the Consolidated Omnibus Budget Rec- ■ The parent-employee dies; onciliation Act of 1985(COBRA).COBRA continuation ■ The parent-employee's hours of employment are re- coverage can become available to you when you would duced; otherwise lose your group health coverage. It can also become available to other members of your family who The parent-employee's employment ends for any are covered under the Health FSA when they would oth- erwise lose that coverage. For additional information ' The parent-employee becomes entitled to Medicare about your rights and obligations under the Health FSA benefits(under Part A,Part B,or both); and under federal law, you should review this EPS or ■ The parents become divorced or legally separated; contact the Plan Administrator. or ■ The child stops being eligible for coverage under the What is COBRA Continuation Coverage? plan as a"dependent child." COBRA continuation coverage is a continuation of Health FSA coverage when coverage would otherwise When is COBRA Coverage Available? end because of a life event known as a"qualifying event." COBRA continuation coverage will be offered to quali- Specific qualifying events are listed later in this notice. fied beneficiaries only after the Plan Administrator has After a qualifying event,COBRA continuation coverage been notified that a qualifying event has occurred.When must be offered to each person who is a"qualified bene- the qualifying event is the end of employment or reduc- ficiary."You,your spouse,and your dependent children tion of hours of employment,death of the employee,or could become qualified beneficiaries if coverage under the employee's becoming entitled to Medicare benefits the Health FSA is lost because of the qualifying event. (under Part A,Part B,or both),the employer must notify Qualified beneficiaries who elect COBRA continuation the Plan Administrator of the qualifying event. coverage must pay for COBRA continuation coverage. If you are an employee,you will become a qualified ben- You (Must Give Notice of Some Events eficiary if you lose your Health FSA coverage because ei- ther one of the following qualifying events happens: For the other qualifying events (divorce or legal separa- tion of the employee and spouse or a dependent child's ■ Your hours of employment are reduced,or losing eligibility for coverage as a dependent child),you ■ Your employment ends for any reason other than must notify the Plan Administrator. The Plan requires your gross misconduct. you to notify the Plan Administrator within 60 days after If you are the spouse of an employee,you will become a the qualifying event occurs. You must provide this no- qualified beneficiary if you lose your Health FSA cover- tice to: age because any of the following qualifying events hap- pens: Summary Plan Description a January 1,2024 17. City of Rancho Cucamonga of the Plan Year and the Health FSA COBRA coverage Attn:Human Resources Director will be terminated. 10500 Civic Center Drive Rancho Cucamonga,CA 91730 Any carryover funds remaining in a Health FSA account 909-477-2700 after the end of the Plan Year in which a qualifying event occurred will continue to be available to reimburse qual- Note that you may lose your right to elect COBRA Cov- ified health care expenses until the end of the qualified erage if proper procedures are not followed. beneficiary's COBRA coverage period. How is COBRA Coverage Provided? If You Have Questions Once the Plan Administrator receives notice that a qual- Questions concerning your Plan or your COBRA con- ifying event has occurred, COBRA continuation cover- tinuation coverage should be addressed to the contact or age will be offered to each of the qualified beneficiaries. contacts identified below. For more information about Each qualified beneficiary will have an independent your rights under COBRA,the Health Insurance Porta- right to elect COBRA continuation coverage. Covered bility and Accountability Act (HIPAA), and other laws employees may elect COBRA continuation coverage on affecting group health plans, contact the nearest Re- behalf of their spouses, and parents may elect COBRA gional or District Office of the U.S. Department of La- continuation coverage on behalf of their children.Each bor's Employee Benefits Security Administration qualified beneficiary will receive an Election Notice, (EBSA) in your area or visit the EBSA website at which must be completed and returned within 60 days. www.dol.g_ov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available Special COBRA Rule for Health FBAs through EBSA'swebsite.) COBRA coverage under the Health FSA will be offered Keep Your Plan Informed of Address Changes only to qualified beneficiaries losing coverage who have underspent accounts.A qualified beneficiary has an un- In order to protect your family's rights,you should keep derspent account if the annual limit elected by the cov- the Plan Administrator informed of any changes in the ered employee,reduced by the reimbursable claims sub- addresses of family members. You should also keep a mitted up to the time of the qualifying event,is equal to copy, for your records, of any notices you send to the .or more than the amount of the premiums for Health Plan Administrator. FSA COBRA coverage that will be charged for the re- mainder of the Plan Year.Health FSA COBRA coverage. City of Rancho Cucamonga Cafeteria Plan will only last until the end of the Plan Year during which City of Rancho Cucamonga the qualifying event occurred. The use=it-or-lose rule 10500 Civic Center Drive will continue to apply,so any unused funds(in excess Rancho Cucamonga;CA 91730 of any carryover amount) will be forfeited at the end 909-477-2700 18 City of Rancho Cucamonga Cafeteria Plan SPD OTHER IMPORTANT INEO ATION Plan Administration obtain and/or maintain such status,The City may be re- quired to make subsequent amendments to the Plan. The City is the Plan Administrator of the Plan and a Some amendments might be made on a retroactive basis. Named Fiduciary within the meaning of such terms un- der applicable law. The City is the Plan's agent for ser- vice of legal process. Experience Gains The City has the duty and discretionary authority to in- If the Health FSA has an experience gain with respect to terpret and construe the Plan in regard to all questions a Plan Year,such experience gain may be used to pay ex- of eligibility,the status and rights of any Plan participant penses of the Health FSA,or for such other uses that are under the Plan, and the manner, time, and amount of determined by the Plan Administrator to be consistent payment of any benefits under the Plan.Each employee with applicable laws and regulations. If the Dependent shall,from time to time,upon request of The City,fur- Care FSA has an experience gain with respect to a Plan nish to The City such data and information as The City Year,such experience gain may be used to pay expenses shall require in the performance of its duties under the of the Dependent Care FSA,or for such other uses that Plan. are determined by the Plan Administrator to be con- sistent with applicable laws and regulations. The City may designate any individual,partnership, or other organization to carry out its duties and responsi- In no event shall experience gains be allocated among bilities with respect to the administration of the Plan. Participants based, directly or indirectly,on the level of Such designation shall be in writing and such writing their Health FSA or Dependent Care FSA reimburse- shall be kept with the records of the Plan. ment amounts. The City may adopt such rules and procedures as it Change in Benefit Cost deems desirable for the administration of the Plan,pro- vided that any such rules and procedures shall be con- If a Benefit Plan expense under this Plan increases or de- sistent with provisions of the Plan and applicable law. creases during a Plan Year,then the Plan may automat- ically increase or decrease, as the case may be, the re- The City will discharge its duties with respect to the Plan quired periodic contribution of all affected Participants (i)solely in the interest of persons eligible to receive ben- for such benefits. efits under the Plan, (ii) for the exclusive purpose of providing benefits to persons eligible to receive benefits Privacy and Security of Information under the Plan and of defraying reasonable expenses of administering the Plan,and(iii)with the care,skill,pru- Certain of the benefits provided by this Plan are health dence and diligence under the circumstances then pre- plans and thereby subject to the provisions of the Health vailing that a prudent person acting in a like capacity and Insurance Portability and Accountability Act of 1996 familiar with such matters would use in the conduct of ("HIPAA") including regulations affecting the mainte- an enterprise of like character and with like aims. nance, creation or use of Protected Health Information ("PHI") (as defined under HIPAA). Please refer to the Notice of Privacy Practices issued by the Plan for a de- Amendment and Termination scription of how your medical information may be used The City intends to maintain the Plan indefinitely but is and disclosed and how you can get access to this infor- under no obligation to continue the Plan and can termi- mation. nate the Plan without liability by providing written no- tice to all then current Plan participants.In amending or Legal Actions terminating the Plan, The City cannot retroactively re- duce the benefits to which you are entitled prior to the Any legal action relating to,arising out of,or involving, termination or amendment. the Plan shall be litigated in the state or federal court of proper jurisdiction in the State of California. The City intends to maintain the Plan as a tax-qualified plan under the Internal Revenue Code. In order to Summary Plan Description January 1,2024 19 The time limit for bringing any lawsuit that arises under Non-Assignment of Benefits or relates to the Health FSA is as follows: Except as otherwise specifically provided in the Plan or ■ Before bringing any lawsuit seeking benefits under required by law, benefits payable for you or your de- the Plan, a Claimant must complete the applicable pendents under the Plan may not be assigned to anyone. claims procedure set out in the Plan or Benefit Doc- Additionally,to the extent any assignment of benefits is uments (and comply with all applicable deadlines permitted under any Elective Benefit,the Plan Adminis- established as part thereof). Failure to properly ex- trator or the responsible fiduciary reserves the discre- haust the claims procedure will extinguish the tionary authority to determine whether any purported Claimant's right to file a lawsuit with respect to the assignment of Plan benefits to a provider is valid. As claim. such,the Plan does not guarantee that any purported as- ■ Any lawsuit seeking benefits related to the Health signment will be valid under the terms of the Plan or any FSA must be brought within the shorter of(i) one insurance contract. year from the date of the final appeal denial or (ii) three years from the date of the services giving rise Controlling Documents to the claim.All claims other than claims for bene- The information contained in this EPS is a general dis- fits(such as claims for penalties,equitable relief,in- cussion of the relevant provisions of the Plan found in terference with protected rights, or production of the official Plan and Benefit Documents. In all events, documents; claims arising under state law; claims the provisions of the official Plan document shall control against nonfiduciaries; and claims for breach of fi- with regard to all matters concerning the administration duciary duty that are not governed by Section 413 of and operation of the Plan. ERISA) must be brought within one year of the act or omission giving rise to the claim. 20 City of Rancho Cucamonga Cafeteria Plan SPD APPENDIX A CITY OF RANCHO CUCAMONGA CAFETERIA PLAN EMPLOYEE PLAN SUMMARY Participation and Eligibility Requirements Employee Eligibility An Employee who is determined to be benefit-eligible as of his or her start date shall be offered coverage as of the Effective Date of Eligibility specified below. Effective Date of Working Hours Employee Class Benefit Option Eligibility Requirement Full-Time City Employees All Elective Benefits listed First day of the month 40 hours per week on Appendix B following date of hire Full-Time Fire District All Elective Benefits listed First day of the month 40 hours per week or 122 Employees on Appendix B following date of hire hours over 2 weeks of shift Certain employees who are hired into positions that are not initially benefit-eligible may become participants in the Plan by achieving Full-Time Status ("ACA-FT") under special eligibility rules for variable hour,part-time, and sea- sonal employees. In the event The City adopts such rules,it intends to administer them in a manner consistent with the final regulations issued by the Department of Treasury related to the "Shared Responsibility" provisions of the ACA. Summary Plan Description ® January 1, 2024 21 APPENDIX B CITY OF RANCHO CUCAMONGA CAFETERIA PLAN EMPLOYEE PLAN SUMMARY Summary of Benefits and Contribution Requirements Effective as of January 1, 2024 benefits and Employee contribution requirements of the City of Rancho Cucamonga Cafeteria Plan are as follows: Elective Benefits The following Elective Benefits are available under the Plan: ■ Premium Contribution Benefits: 13 Group Medical L3 Voluntary Worksite Benefits ■ General-Purpose Health FSA ■ Dependent Care FSA The above Elective Benefits are described in the applicable Benefits Documents provided by each carrier, contract administrator,and HSA administrator,which are incorporated herein by reference. Premium Contribution Requirements Prior to the beginning of a Plan Year,The City,at its discretion,may make changes to the benefits and contribution requirements. The cost sharing requirements for Premium Contribution Benefits are detailed in the Annual Open Enrollment materials provided to eligible Employees,which are incorporated herein by reference. Copies of enroll- ment materials are available upon request by contacting: City of Rancho Cucamonga Attn:Human Resources Director 10500 Civic Center Drive Rancho Cucamonga,CA 91730 909-477-2700 Voluntary Worksite Benefits. If indemnity health benefits (e.g.hospital indemnity, cancer, critical illness) are paid by you with pretax salary reduction funds,benefits are excludable from income up to the amount of unreimbursed medical expenses(the excess amount paid above unreimbursed medical expenses is taxable).Employees covered un- der an indemnity health plan are responsible for determining the amount of any taxable benefits and including this amount on their personal income tax return. How disability benefits(e.g. accident)are taxed when an Employee becomes disabled depends on how the premiums are paid during the year of the disabling event. If premiums are paid entirely with pre-tax dollars,then the benefits that an Employee receives upon become disabled are taxable.If the premiums are paid entirely with after-tax dollars, then the benefits are not taxable. If premiums are paid with a combination of pre-tax and after-tax dollars,then the benefits are taxable on a pro rata basis. Cash-in-Lieu, Health FSA and Dependent Care FSA Limits and Deadlines Participants may make contributions to these accounts, subject to the account maximums specified below, in the manner determined by the Plan Administrator and may not exceed the full amount elected in any one Plan Year. 22 City of Rancho Cucamonga Cafeteria Plan SPD Details City Employees: $300 Fire District Employees: $200 to$500 depending on dependent status and bargaining group. 'Realth'FSA Account;Details Maximum Contribution Up to the statutory maximum limit per Plan Year in accordance with Code Amount per Plan Year: Section 125(i)(2) (cost of living adjustment). For example,for the 2024 Plan Year,the maximum limit is$3,200. Health FSA Carryover If funds remain in your Health FSA at the end of the Plan Year,up to 20%of Maximum: the current Plan Year's Maximum Contribution Amount will be carried over for your use in the subsequent Plan Year. For example,up to$640 of unused funds may rollover to your 2025 account. Run-Out Period for sending in 90 days after the end of the Plan Year in which the expense was incurred. Reimbursement Requests: Dgendent.Care,FSA Account Details Maximum Contribution Amount per Plan Year: ■ Single or married filing Up to$5,000 per plan year jointly ■ Married filing jointly and Up to spouse's earned income per plan year spouse's earned income is less than$5,000 per year ■ Married filing separately Up to$2,500 per plan year(spouse may also contribution$2,500 to a separate Dependent Care Assistance Program Run-Out Period for sending in 90 days after the end of the Plan Year in which the expense was incurred. Reimbursement Requests: Summary Plan Description January 1,2024 23 APPENDIX C CITY OF RANCHO CUCAMONGA CAFETERIA PLAN EMPLOYEE PLAN SUMMARY Partial List of Qualified Health Care Expenses IRS regulations require that you keep all receipts and any documentation for eligible health care expenses with your personal tax records.Generally,eligible expenses are those not covered by your medical,dental,or vision plans.They must be meant to diagnose,cure,mitigate,treat,or prevent illness or disease.For more details,refer to IRS Publication 502.Please be advised that the IRS can amend the list of eligible expenses at any time,with or without prior notice. The following is a partial list of qualified health care expenses for General-Purpose Health FSAs: ■ Acupuncture ■ Hearing devices and batteries ■ Physician-recommended ■ Alcoholism treatment ■ Home improvements moti- swimming pool or spa ex- ■ Ambulance service vated by medical considera- penses ■ Artificial limbs tions ■ Prescribed medicine and drugs ■ Artificial teeth Hospital bills ■ Psychiatric care ■ Birth.control pills Hospitalization insurance ■ Psychologist fees ■ Birth prevention surgery Insulin ■ Mentally-disabled persons' ■ Braces ■ Laboratory fees cost for special home ■ Braille reading material ' Laetrile by prescription ■ Routine physical and other ■ Care for mentally handicapped Lead-based paint removal non-diagnostic services or ■ Chiropractors Life fee to retirement home for treatments ■ Christian Science Practitioners medical care ■ "Seeing-eye"dog,and its up- Co-Insurance payments . ' Medical information plan keep ■ Contact lenses Membership fees in associa- ' Special communication equip- ■ COVID-19 Home Testing Kits tion furnishing medical ser- ment for the deaf ■ COVID-19 PPE vices,hospitalization,and din- ' Special education for the blind ical care Special plumbing for the hand- Crutches Deductibles ' Nurses'fees(including nurses' icapped board and Social Security tax Sterilization fees ■ Dental fees when paid by taxpayer) ■ Surgical fees ■ Dentures ■ Obstetrical expenses Therapeutic care for drug and ■ Diagnostic fees ■ Operations alcohol addiction ■ Eyeglasses ■ Orthodontia ■ Therapy treatment ■ Eye examination ■ Orthopedic shoes ■ Transportation for medical ■ Fee.for practical nurse 0 Over-the-Counter Medicines services ■ Fees for healing services and Drugs Tuition at special schools for ■ Fees for licensed osteopaths Over-the-Counter menstrual the handicapped ■ Handicapped persons'schools care products ■ Wheelchair (medical expenses) 0 Oxygen ■ Wigs ■ Hair transplants ■ Physicians'fees ■ X-rays 24 City of Rancho Cucamonga Cafeteria Plan © SOD Orthodontic Expenses.Because orthodontic treatment often requires that you pay some or all of the full cost upfront, these expenses are treated differently than other health care expenses.You may pay a lump sum up front or make pay- ments on a monthly basis provided that you submit proof of payment along with treatment start date and anticipated end date. Examples of Ineligible Expenses: ■ Insurance premiums ■ Personal use items(e.g.toothpaste,cosmetics) ■ Family or marriage counseling Summary Plan Description ® .January 1, 2024 25