HomeMy WebLinkAboutItem DI
AGENDA STAFF REPORT
C& 4
DATE: December 11, 2017
TO: Honorable Mayor and City Council
THRU: Jill R. Ingram, City Manager
FROM: Victoria L. Beatley, Director of Finance/City Treasurer
SUBJECT: RETIREE HEALTH SAVINGS PLAN ADOPTION
SUMMARY OF REQUEST:
That the City Council approve Resolution No. 6775 authorizing the City Manager
to sign agreements and documents related to the Retiree Health Savings Plan
implementation.
STRATEGIC PLAN GOAL:
Attract, Develop, Compensate, and Retain Quality Staff
BACKGROUND:
The City Council approved the implementation of a Retiree Health Savings
(RHS) Plan for the executive management team and the City Manager. This
benefit was approved by the City Council as part of the employment contracts for
the executive management team and the City Manager. Those management
employees' who are not otherwise eligible for retiree health benefits could, if they
leave the City, convert 25% of their accrued sick leave balances into a
contribution to a Retiree Health Savings Plan. The proposed Retiree Health
Savings Plan will be offered through ICMA-RC, the City's current deferred
compensation provider.
This plan is an employer-sponsored health savings benefit vehicle that allows for
the accumulation of assets to pay for certain medical expenses in retirement (or
other eligibility, including separation from employment) on a tax-free basis. The
RHS offers a number of benefits including tax-deferred accumulation of earnings
and, when the account assets are used to pay for tax -qualified medical benefits,
the additional benefit of tax-free withdrawals.
ENVIRONMENTAL IMPACT:
There is no environmental impact related to this item.
Agenda Item Q
LEGAL ANALYSIS:
The City Attorney has reviewed the proposed resolution and approved as to
form.
FINANCIAL IMPACT:
There was no additional sick time granted to any employee. The plan
participants will pay the administrative costs associated with the Plan. The
financial impact for the increase in the pay out of sick time to fund the RHS was
estimated to be $10,000 per departing department head if the individual's sick
time balance has reached the maximum number of hours. The cost of the
payout will be offset by the related reduction in the Compensated Absence
balance in the Financial Statements.
RECOMMENDATION:
That the City Council approve Resolution No. 6775 authorizing the City Manager
to sign agreements and documents related to the Retiree Health Savings Plan
implementation.
SUB"TT D BY: NOTED AND APPROVED:
Victoria L. Beatley Jil R. ngram, City a a er
Director of Finance/City Treas rer
Attachments:
A. Resolution for Adoption and Affirmative Statement of Adoption
B. Administrative Services Agreement
C. Vantagecare Retirement Health Savings Program Adoption Booklet
Page 2
Attachment "A"
Resolution No. 6775
SUGGESTED RESOLUTION FOR ADOPTION
��d
SUGGESTED AFFIRMATIVE STATEMENT OF ADOPTION
SUGGESTED RESOLUTION FOR ADOPTION OF THE
VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM
Plan Number.8 03694
Name of Employer: City Of Seal Beach _ a„_. Cal'tfomia
Resolution of the above -tamed Employer (the "Employer'):
WHEREAS, the Employer has employees rendering valuable services; and
WHEREAS, the establishment of a retiree health savings program for such employees serves rhe interests of the Employer by
enabling it w provide reasonable security regarding such employm health needs during retirement, by providing increased
flexibility in its personnel management system, and by assisting in the attraction and retention of competent personnel; and
WHEREAS, the Employer has determined that the establishment of the retiree health savings program (the "Program")
servo the above objectives;
NOW, THEREFORE BE IT RESOLVED, that the Employer hereby adopts she ICMA Retirement Corporation's
VantageCate Retirement Health Savings Program ('Program") through the Employer's integral part trust ('Trust") and the
Empbyer'a welfare benefit. plan ("Plan").
BE IT FURTHER RESOLVED that the mea of the Plan shall be held in tmar, with the following entity or individual
,ming as trust« (Select one):
0 the Employer
❑ the following position within the Employer:
(Ira, uk d itlMd„tlea � o,el
❑ the following group or committee within the Employer:
❑ the following third -Parry trustee
1� 6m4 m mmmim.a.i. rams)
1.—dwd. mel
for the exclusive benefit of Plan participants and their mrvivora, and the suets of the Plan shall not be diverted to any
other purpose prior m the satisfaction of all liabilities of the Plan. 'The Employer has executed the Declaration of Trust of
the Employers Integral Part Trust in the form of (Select one)
m The sample toast made available by rhe ICMA Retirement Corporation
❑ The tout provided by rhe Employer (arecuud copy attached hereto).
BE IT FURTHER RESOLVED, that the Au"0" d1etlam1°°°aar shall be the coordinamr and contact for the Program and
shall receive necessary reports, notices, etc.
1 Robin L. Roberta Gak of the City of Seal Beach to hereby certify that the foregoing
C' Council
resolution, propmed by RY .was duly passed and adopted in the � °ra°°i �tli of the County of Orange
. at a regular meeting thereof assnnbled this 11 day of 20 17 , 6T' the following vote:
AYES:
NAYS:
ABSENT:
(Seal) Clerks Signature.
Clerk's Tide: CityClerk
u:s
SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT
HEALTH SAVINGS (RHS) PROGRAM
Plat Number: g 03694
Name of Employer. CifY Of Seal Beach $race' CA
ARirmarive Statement of the above -maned Employer (the "Employer"):
WHEREAS, the Employer has employees rendering valuable services; and
WHEREAS, the establishment of mires, health savings progam serves the interests of the Employer by enabling it to
provide reasonable security, regarding such employed health needs during retirement, by providing increased Reaibility in its
Personnel management system, and by assisting in the attraction and retention of competent personnel; and
WHEREAS, the Employer has determined that the establishment of the red= health savings program (the "Program") serves
the above objectives;
NOW THEREFORE, at a duly authorized agent of the Employer, 1 hereby:
ESTABLISH the Employer's ICMA Retirement Corporation's VanmgeCare Retirement Health Savings Program through the
Employees integral pan trust ("Trust") and the Employer's welfare benefits plan ("Plan"); and
SPECIFY that the anew of the Plan that! be held in tout, with the following entity or individual serving as, trustee (Select ore):
® the Employer
❑ the following position within the Employer:
t��marim.wa..wu.mei
❑ the following group or committee within the Employer.
❑ the following third -parry trustee
(, -ad&,, „r mel
for the exclusive benefit of the Plan participants and their survivors, and the assts of the plan shall nor be dia med an any other
Purpose prior to the satisfaction of all liabilities of the Plan. The Employer has executed the Declaration of
trust of the Employers Integral Parc Trust in the form of. (Select one)
0 The sample sour made available by the ICMA Retirement Corporation
❑ The trust provided by the Employer (exauad copy attached herem).
SPECIFY dist the Finance Director/Treasurer
shall 6s, the coordimtor
and contatt for the Plan and shall receive necessary reports, notices, nc
DATE: 12/11/2017
Tide of Designated Agent
Signature
IIA
Attachment "B"
ADMINISTRATIVE SERVICES AGREEMENT
Between
ICMA Retirement Corpomdon
and
City of Seal Beach
Type: VantageCare RHS
Account Number: 803694
Plan # 803694
ADMINISTRATIVE SERVICES AGREEMENT
This Agreement, made as of theday of 20 (herein referred to as
the "Inception Date"), between The International City Management Association Retirement
Corporation ("ICMA-RC"), a nonprofit corporation organized and existing under the laws of the
State of Delaware; and the City of Seal Beach ("Employer") a local governmental instrumentality
organized and existing under the laws of the State of California with an office at 211 Eighth
Street, Seal Beach, California 90740.
RECITALS
Employer acts as a public plan sponsor for a retiree health plan with responsibility to obtain
investment alternatives and services for employees participating in that plan;
Employer desires to make the VantageCare Retirement Health Savings ("RHS") Program
provided by ICMA-RC available to its employees through the Employer's integral part trust
("Trust' and the Employer's welfare benefits plan ("Plan');
ICMA-RC acts as investment adviser to VantageTrust Company, LLC ("VTC"), the Trustee of
VantageTrust 11 Multiple Collective Investment Funds Trust ("VantageTrust II);
VantageTrust II is a group trust established and maintained in accordance with New Hampshire
Revised Statutes Annotated section 391:1 and Internal Revenue Service Revenue Rulings 81-100
and 2011-1, which provides for the collective investment and reinvestment of assets of certain
tax-exempt, governmental pension and profit sharing plans, and retiree welfare plans, and other
eligible investors;
VTC makes a series of separate funds (the "VT 11 Funds") available through VantageTrust II for
the investment of plan assets w referenced in VantageTrust II's Declaration of Trust and
Disclosure Memorandum ("Disclosure Materials");
VTC is a wholly owned subsidiary of ICMA-RC and has exclusive management and investment
authority with respect to the VT 11 Funds;
The VT II Funds are available only through adoption of VantageTrust II; and
In addition to serving as investment adviser to VTC, ICMA-RC provides a complete offering of
services to public employers for the operation of employee retirement and retiree health savings
plans including, but not limited to, communications concerning investment alternatives, account
maintenance, account record-keeping, investment and tax reporting, form processing, benefit
disbursement and asset management.
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Plan # 803694
AGREEMENTS
I. Acceptance of RHS Program
Employer agrees to make the RHS Program provided by ICMA-RC available to its employees.
The details of the RHS Program shall be as mutually agreed between the Employer and aCMA-
RC, and in general shall be as set forth in the RHS Program materials developed by ICMA-RC
and provided to Employer. The RHS Program materials are hereby incorporated by reference and
made a part of this Agreement, except that Employer and ICMA-RC may from time to time
mutually agree in writing to terms that vary from the RHS Program materials. RHS Program
materials shall include the VantageCare RHSEmployer Manual, available electronically through
the EZ Link System upon adoption of the RHS Program.
The functions to be performed by ICMA-RC and its agents include:
(a) allocation in accordance with participant direction of individual accounts to investment
funds ("Funds") made available to Plan participants;
(b) maintenance of individual accounts for participants reflecting amounts contributed,
income, gain, or loss credited, and amounts disbursed as benefits;
(c) provision of periodic reports to the Employer and participants of the status of Plan
investments and individual accounts;
(d) communication to participants of information regarding their rights and elections under
the Plan;
(e) disbursement of benefits as agent for the Employer in accordance with terms of the Plan;
and
(f) performance of tax withholding and reporting in conjunction with the Employer for each
RHS account.
2. Emplover Duty to Furnish Information
Employer agrees to furnish to ICMA-RC on a timely basis such information as is necessary for
ICMA-RC to carry out its responsibilities with respect to the Plan, including information needed
to allocate individual participant accounts to Fonds, and information as to the benefit eligibility
and employment status of participants, and participants' ages, addresses, dependents, spouses
and other identifying information (including tax identification numbers). Employer also agrees
that it will notify ICMA-RC in a timely manner regarding changes in staff as it relates to various
roles. This is to be completed through the online EZLink employer contact options. ICMA-RC
shall be entitled to rely upon the accuracy of any information that is famished to it by a
responsible official of the Employer or any information relating to an individual participant,
spouse or dependent that is famished by such participant, spouse or dependent, and ICMA-RC
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Plan # 803694
shall not be responsible for any error arising from its reliance on such information. ICMA-RC
will provide reports, statements and account information to the Employer through EZLink, the
online plan administrative tool.
3. ICMA-RC Representations and Warranties
ICMA-RC represents and warrants to Employer that:
(a) ICMA-RC is a non-profit corporation with full power and authority to enter into this
Agreement and to perform its obligations under this Agreement.
(b) ICMA-RC is an investment adviser registered as such with the Securities and Exchange
Commission under the Investment Advisers Act of 1940, as amended.
(c) ICMA-RC will handle participant information in the manner described in the Business
Associate Agreement to be executed between the Plan and ICMA-RC, a form of which is
provided as Exhibit A to this Agreement.
4. Employer Representations and Warranties
Employer represents and warrants to ICMA-RC that:
(a) Employer is organized in the form and manner recited in the opening paragraph of this
Agreement with full power and authority to enter into and perform its obligations under
this Agreement and to act for the Plan and participants in the manner contemplated in this
Agreement. Execution, delivery, and performance of this Agreement will not conflict
with any law, rule, regulation or contract by which the Employer is bound or to which it
is a party.
(b) Information required to be retained by the Employer shall be set forth in the RHS
Program materials developed by ICMA-RC and provided to the Employer.
(c) Employer agrees to send in contributions through EZLink, the online plan administration
tool provided by ICMA-RC.
(d) Employer is responsible for determining that there me no state or local laws that would
prohibit it from establishing the RHS Program. Employer is also responsible for
determining that the investments selected for the Plan fall within state or local
requirements. ICMA-RC shall not be responsible for monitoring state or local law or
for administering the Plan in compliance with local or state requirements unless
Employer notifies ICMA-RC of any such local or state requirements.
(e) Employer acknowledges that the RHS Plan is a "health plan' for Health Insurance
Portability and Accountability Act ("HIPAA") purposes and therefore is subject to
HIPAA privacy rules. Employer also acknowledges that the RHS Plan is a Health
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Plan # 803694
Reimbursement Arrangement, subject to applicable provisions of the Affordable Can
Act ("ACA"). An employer sponsoring the Plan is responsible for complying with the
HIPAA privacy and security rules with respect to all protected health information
created, maintained, received, or transmitted in relation to the Plan and is responsible for
complying with the ACA.
(f) Employer acknowledges that certain such services to be performed by ICMA-RC under
this Agreement may be performed by an affiliate or agent of ICMA-RC pursuant to one
or more other contractual arrangements or relationships, and that ICMA-RC reserves the
right to change vendors with which it has contracted to provide services in connection
with this Agreement without prior notice to Employer.
(g) Employer acknowledges and agrees that ICMA-RC does not assume any responsibility
with respect to the selection or retention of the Plan's investment options. Employer
shall have exclusive responsibility for the selection and retention of the Plan's investment
options, including the selection of the applicable mutual fund share class.
(h) Employer confirms that it has executed a Participation Agreement for VantageTrust II
and acknowledges that it has received the Disclosure Materials.
5. Participation in Certain Proceedings
The Employer hereby authorizes ICMA-RC to act as agent, to appear on its behalf, and to join
the Employer as a necessary party in all legal proceedings regarding the Plan involving the
garnishment of benefits or the transfer of benefits pursuant to a medical child support order.
Unless Employer notifies ICMA-RC otherwise, Employer authorizes ICMA-RC to determine
whether disbursement of benefits to a spouse or child pursuant to a medical child support order is
appropriate.
6. Compensation and Payment
Absent an explicit agreement to the contrary between ICMA-RC and Employer, participant fees
and expenses shall be payable from RHS assets, in accordance with the requirements of the RHS
Program as set forth below.
(a) Asset-based fees will be included in the daily unit value of each VT II Fond, and
no separate asset-based fees will be assessed.
(b) A $ 25 annual account administration fee will be charged quarterly to each
Accountholder's account.
(c) The account administration fee is subject to change with appropriate prior
notification.
(d) Compensation for Advisory and other Services to VT III Vantagepoint
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Plan # 803694
Funds. Employer acknowledges that ICMA-RC, including certain of its wholly
owned subsidiaries, receives compensation for advisory and other services
famished to the VT III Vantagepoint Funds, which are collective funds serving as
the underlying funds to certain VT R Funds.
7. Contribution Remittance
Employer understands that amounts contributed to the Plan are to be remitted directly to
Vantagepoint Transfer Agents in accordance with instructions provided to Employer in the RHS
Program materials and are not to be remitted to ICMA-RC. In the event that any check or wire
transfer is incorrectly labeled or transferred, ICMA-RC will return it to Employer with proper
instructions.
Responsibiliri
(a) ICMA-RC shall not be responsible for any acts or omissions of any person with respect
to the Plan, or related Trust, other than ICMA-RC in connection with the administration
or operation of the Plan or related Trust.
(b) The Employer understands that, as a general matter, the Internal Revenue Service ("IRS")
may decline to role on certain design features or provisions that the Employer may
request to have added to the RHS Program materials. The Employer agrees to hold
ICMA-RC harmless in connection with the addition and administration of any Plan
feature or provision requested by the Employer for which the IRS will not provide
express interpretive guidance,
9. Indemnification
Employer shall indemnify ICMA-RC against, and hold ICMA-RC harmless from, any and all
Ion, damage, penalty, liability, cost, and expense, including without limitation, reasonable
attorney's fees, that may be incurred by, imposed upon, or asserted against ICMA-RC by reason
of any claim, regulatory proceeding, or litigation arising from any act done or omitted to be done
by any individual or person with respect to the Plan or related Trust, excepting only any and all
loss, damage, penalty, liability, cost or expense resulting from ICMA-RC's negligence, bad faith,
or willful misconduct.
10. Term
This Agreement shall be in effect for an initial term beginning on the Inception Date and ending
5 years after the Inception Date. This Agreement will be renewed automatically for each
succeeding year unless written notice of termination is provided by either party to the other no
less than 60 days before the end of such Agreement year.
No
Plan # 803694
11 Amendments and Adiustments
(a) This Agreement may be amended by written instrument signed by the parties.
(b) The parties agree that only an adjustment to compensation or administrative and
operational services under this Agreement may be implemented by ICMA-RC through a
proposal to the Employer via correspondence or the Employer Bulletin. The Employer
will be given at least 60 days to review the proposal before the effective date of the
adjustment. Such adjustment shall become effective unless, within the 60 -day period, the
Employer notifies ICMA-RC in writing that it does not accept such adjustment, in which
event the parties will negotiate with respect to the adjustment.
(c) No failure to exercise and no delay in exercising any right, remedy, power or privilege
hereunder shall operate as a waiver of such right, remedy, power or privilege.
12. Notices
All notices required to be delivered under this Agreement shall be delivered electronically,
personally or by registered or certified mail, postage prepaid, term receipt requested, to (i)
Legal Department, ICMA Retirement Corporation, 777 North Capitol Street, N.E., Suite 600,
Washington, D.C, 200024240; (ii) Employer at the office set forth in the fust paragraph hereof,
or to any other address designated by the party to receive the same by written notice similarly
given.
13 Complete Agreement
This Agreement, with an executed Business Associate Agreement, shall constitute the sole
agreement between ICMA-RC and Employer relating to the object of this Agreement and
correctly sets forth the complete rights, duties and obligations of each party to the other as of its
date. Any prior agreements, promises, negotiations or representations, verbal or otherwise, not
expressly set forth in this Agreement are of no force and effect.
14. Governing Law
This agreement shall be governed by and construed in accordance with the laws of the
State/Commonwealth of California applicable to contracts made in that jurisdiction without
reference to its conflicts of laws provisions.
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Plan # 803694
In Witness Whereof, the parties hereto have executed this Agreement as of the Inception Date
first above written.
CITY OF SEAL BEACH
By
Signature/Date
By
Name and Title (Please Print)
INTERNATIONAL CITY
MANAGEMENT ASSOCIATION
RETIREMENT CORPORATION
By�/
Erica McFarquhar
Assistant Secretary
Please return an executed mov of the Aoreement either
(a) Electronically W PlanAdootionServicesAicmarc ore, or
(b) In paper form to ICMA-RC
ATTN: PLAN ADOPTION SERVICES
777 North Capitol Street NE
Suite 600
Washington DC 200024240
1.2
Exhibit A
RHS HIPAA BUSINESS ASSOCIATE AGREEMENT FOR 803694
This Business Associate Agreement ("BA Agreement") supplements and is made part of
the Administrative Services Agreement entered into between City of Seal Beach
Ry ("Covered Entity') and ICMA-RC ("Business Associate") on , and is
effective as of the effective date of the Administrative Services Agreement (the "Effective
Date").
RECITALS
Covered Entity is a group health plan that reimburses medical expenses for eligible
participants, their spouses, and their dependents. Under the Health Information Portability
and Accountability Act of 1996 ("HIPAA"), Covered Entity is required to enter into this BA
Agreement to obtain satisfactory assurances that Business Associate will appropriately
safeguard all Protected Health Information ("PHI"), as defined herein, that is created,
maintained, received, or transmitted by Business Associate on behalf of Covered Entity.
Business Associate is a record keeper providing administrative services to Covered Entity.
In general, Business Associate will not have access to information that would traditionally
be considered PHI because participant medical information used to substantiate
reimbursements is sent directly to and reviewed by a third -party claims processor. The
third -party claims processor has agreed to protect PHI that it creates, maintains, receives,
or transmits in a manner that is consistent with and as stringent as the terms agreed to by
Business Associate under this BA Agreement with respect to information that could be
considered PHI. Business Associate has access to information that might be interpreted
as PHI, including an individual's participation in the plan, reimbursement amounts, and the
timing of reimbursements.
In consideration of the mutual promises below and the exchange of information pursuant
to this BA Agreement and in order to comply with all legal requirements for the protection
of this information, Covered Entity and Business Associate agree as follows:
1. DEFINITIONS
a. The following terms used in this BA Agreement shall have the same meaning
as those terms are defined in the HIPAA Rules: Breach, Data Aggregations,
Designated Record Set, Disclosure, Health Care Operations, Minimum
Necessary, Notice of Privacy Practices, Secretary, Security Incident,
Subcontractor, Unsecured Protected Health Information, and Use.
b. "Administrative Services Agreement" refers to a separate agreement outlining
the services ICMA-RC will provide to Covered Entity and the terms and
conditions governing the provision of such services. The Administrative
Services Agreement is made between ICMA-RC and Citv of Seal Beach
RHS or its sponsor, acting on behalf of City of Seal Beach RHS
Plan # 803694
C. "Business Associate" shall have the same meaning as the term "business
associate" at 45 CFR 160.103, and in reference to this BA Agreement shall
mean ICMA-RC.
d. "Covered Entity" shall have the same meaning as the term "covered entity" at
45 CFR 160.103, and in reference this BA Agreement, shall mean City of
Seal Beach RHS .
e. "HIPAA Rules" shall mean the Privacy, Security, Breach Notification, and
Enforcement Rules at 45 CFR Part 160 and Part 164.
f. "Privacy Rule" shall mean the Privacy Standards and Implementation
Specifications at 45 CFR 170 and 164, Subparts A and E.
g. "Protected Health Information" ("PHI") shall have the same meaning as the
term "protected health information" in 45 CFR § 160.103, limited to the
information created, received, maintained, or transmitted by Business
Associate from or on behalf of Covered Entity pursuant to this Agreement.
h. "Security Rule" shall mean the Security Standards and Implementation
Specifications at 45 CFR Parts 160 and 164, Subparts A and C.
2. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
Business Associate agrees to:
a. Not Use or Disclose PHI other than as permitted or required by this BA
Agreement or as required by law.
b. Use appropriate safeguards to prevent Use or Disclosure of PHI other than as
provided for by this BA Agreement, and comply with subpart C of 45 CFR Part
164 with respect to electronic PHI in Business Associate's custody or control,
to prevent Use or Disclosure of PHI other than as provided for by this BA
Agreement.
C. Report to Covered Entity any Use or Disclosure of PHI not provided for by the
BA Agreement of which it becomes aware not more than 60 calendar days
after Business Associate discovers such non -permitted Use or Disclosure,
including Breaches of Unsecured PHI as required at 45 CFR 164.410, and any
Security Incident for which it becomes aware.
d. In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), if applicable,
ensure that any Subcontractors that create, receive, maintain, or transmit PHI
on behalf of the Business Associate agree to the same restrictions, conditions,
and requirements that apply to the Business Associate with respect to such
information.
e. Make available, within 30 calendar days of the request of Covered Entity, PHI
in a Designated Record Set in Business Associate's custody or control, to
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Plan # 803694
Covered Entity, or as Directed by Covered Entity, to an individual, so that
Covered Entity may meet its access obligations under 45 CFR § 164.524.
f. Make any amendment(s) to PHI in a Designated Record Set in Business
Associate's custody or control as directed in writing by the Covered Entity
pursuant to 45 CFR 164.526 no later than 60 days after receipt of such
request, so that Covered Entity may meet its amendment obligations under 45
CFR 164.526.
g. Maintain and make available the information required to provide an accounting
of Disclosures to the Covered Entity as requested by Covered Entity in writing
and as necessary to satisfy the Covered Entity's obligations under 45 CFR
164.528.
h. Make its internal practices, books, and records, available to the Secretary for
purposes of determining compliance with the HIPAA Rules.
I. Not directly or indirectly receive remuneration in exchange of PHI.
j. Comply with the administrative simplification rules applicable to standard
transactions, if Business Associate conducts such transactions under the
electronic data interchange rules on behalf of Covered Entity.
k. To the extent the parties agree that Business Associate will carry out directly
one or more of Covered Entity's obligations under the Privacy Rule, the
Business Associate will comply with the requirements of the Privacy Rule that
apply to the Covered Entity in the performance of such obligations.
3. PERMrTTEO USES AND DISCLOSURES BY BUSINESS ASSOCIATE
a. Business Associate may only Use or Disclose PHI as necessary to perform the
services set forth in the Administrative Services Agreement and as permitted
by this BA Agreement.
b. Business Associate may Use or Disclose PHI as required by law or to report
violations of law to appropriate Federal and State authorities, consistent with
45 CFR 164.5020)(i).
c. Except as otherwise limited by this BA Agreement, Business Associate agrees
to make Uses and Disclosures and requests for PHI consistent with the
Covered Entity's Minimum Necessary policies and procedures when such are
provided by the Covered Entity to Business Associate.
d. Business Associate is authorized to de -identify information in accordance with
45 CFR 164.514(a) -(c).
e. Business Associate may not Use or Disclose PHI in a manner that would
violate Subpart E of 45 CFR Part 164 If done by Covered Entity, except for the
specific Uses and Disclosures set forth below.
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Plan # 803694
f. Business Associate may Use PHI for the proper management and
administration of the Business Associate or to carry out the legal
responsibilities of the Business Associate.
g. Business Associate may provide Data Aggregation services relating to the
Health Care Operations of the Covered Entity.
4. OBLIGATIONS AND ACTIVITIES OF COVERED ENTITY
a. Covered Entity shall notify Business Associate of any limitations in the Notice
of Privacy Practices that Covered Entity provides to individuals pursuant to 45
CFR 164.520, to the extent that such limitation may affect Business
Associate's Use or Disclosure of PHI.
b. Covered Entity shall notify Business Associate of any changes in, or revocation
of, the permission by an individual to Use or Disclose his or her PHI, to the
extent that such changes may affect Business Associate's Use or Disclosure of
PHI.
c. Covered Entity shall notify Business Associate of any restrictions on the Use or
Disclosure of PHI that Covered Entity has agreed to or is required to abide by
under 45 CFR 164.522, to the extent that such restriction may affect Business
Associate's Use or Disclosure of PHI.
d. Covered Entity shall not request Business Associate to Use or Disclose PHI in
any manner that would not be permissible under Subpart E of 45 CFR Part 164
If done by Covered Entity, except to the extent that Business Associate will
Use or Disclose PHI for Data Aggregation or management and administration
and legal responsibilities of the Business Associate.
e. Covered Entity shall notify Business Associate of any confidential
communication requests with which the Covered Entity has agreed to in
accordance with 45 CFR 164.522, to the extent such requests would affect
Business Associate's Use or Disclosure of PHI.
5. TERM AND TERMINATION
a. This BA Agreement shall be effective as of the Effective Date, and shall
terminate upon the termination of the Administrative Services Agreement,
subject to the provisions below regarding the return or destruction of PHI.
b. Business Associate authorizes termination of this BA Agreement by Covered
Entity, if Covered Entity determines Business Associate has violated a material
term of the BA Agreement, and Business Associate has not cured the Breach
or ended the violation, following written notice to the Business Associate,
within a reasonable period of time not to exceed any reasonable cure period
defined in the Administrative Services Agreement.
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Plan # 803694
c. Upon termination of this BA Agreement for any reason, Business Associate,
with respect to PHI Received from Covered Entity, or created, maintained, or
received from Business Associate on behalf of Covered Entity, shall:
1. Retain only that PHI which is necessary for Business Associate to
continue its proper management and administration or to carry out its
legal responsibilities;
ii. Return to Covered Entity or, if agreed to by Covered Entity, destroy the
remaining PHI that the Business Associate still maintains in any form;
111. Continue to use appropriate safeguards and comply with Subpart C of
45 CFR Part 164 with respect to electronic PHI to prevent Use or
Disclosure of the PHI, other than as provided for in this Section, for as
long as Business Associate retains PHI;
Iv. Not Use or Disclose the PHI retained by Business Associate other than
for the purposes for which such PHI was retained and subject to the
same conditions set out at Paragraph 3(f);
v. Return to Covered Entity or, if agreed to Covered Entity, destroy the
PHI retained by Business Associate when it is no longer needed by
Business Associate for its proper management and administration or to
carry out its legal responsibilities;
vi. Notwithstanding any other provision of this BA Agreement, upon
termination, Business Associate may also transmit PHI to another
Business Associate of the Covered Entity upon the written request of
the Covered Entity.
d. The obligations of Business Associate under Section 5, Term and Termination,
shall survive the termination of this BA Agreement.
6. GENERAL PROVISIONS
a. A reference in this BA Agreement to a section in the HIPAA Rules means the
section as in effect or amended.
b. The parties agree to take such action as is necessary to amend this BA
Agreement from time to time as is necessary for compliance with the
requirements of the HIPAA Rules and any other applicable laws.
c. Any ambiguity in this BA Agreement shall be interpreted to permit compliance
with the HIPAA rules.
d. Nothing in this BA Agreement shall be construed as creating any rights or
benefits to any third parties.
e. The invalidity and unenforceability of any provision of this BA Agreement shall
not affect the enforceability of any other provision of this BA Agreement or the
Administrative Services Agreement, which shall remain in full force and effect.
13-
Plan # 803694
f. All notices and communications required by this BA Agreement shall be in
writing. Such notices and communications shall be given in one of the
following forms: (i) by delivery in person, (ii) by a nationally -recognized, next -
day courier service, (iii) by first-class, registered or certified mail, postage
prepaid, or (iv) by electronic mail to the address that each parry specifies in
writing.
g. This BA Agreement and the Administrative Services Agreement constitute the
entire agreement between the parties with respect to its subject matter and
constitute and supersede all prior agreements, representations, and
understandings of the parties, written or oral, with regard to the same subject
matter.
CITY OF SEAL BEACH RHS
By
Signature
Name and Title (Please Print)
Date
INTERNATIONAL CITY
MANAGEMENT ASSOCIATION
RETIREMENT CORPORATION
BY -
Erica McFarquhar
Assistant Secretary
Please return fully executed Agreement to: New Business Services
ICMA-RC
777 North Capitol Street NE
Suite 600
Washington DC 20002-4240
-14-
Attachment "C
�kk
VANTAGECARE
"SINGS PROGRA"
ADOPTION BOOKLET
ICM/ -KC
BUILDING PUBLIC SECTOR
RETIREMENT SECURITY
This adoption booklet contain. useful information to WE, employers establish a VanrageCare Retirement Health Savings, Program.
Section 1 includes information regarding key RHS features and instructions m adopt the Program. Section It includes the documents
Chu must be rcmtrted to ICMA-RC. Section III mad-dea documents that are nm required to be returned m ICMA-RC.
■ Section 1: Adoption Information
• E=blishing Your VantageGte RHS Program
• Description of V mmFCam RIES Adoption Materials
■ Section IT: VantageC ve RHS Adoption Documents to Remo m ICMA-RC
• Suggested Resolution for Adoption of the VaretageCam RHS Program OR Suggested Afl'irtvtive Statement for Adoption of
the VantageCate RHS Program
• VantageCa¢ RHS Adoption Agreement
• VantarTnut II Participation Agreement (ss, the RHS VantageTrust 11 Adoption Materials document)
• VmeageCate RHS Implementation Dan Form
• [CMA -RC EZU kAccess Form
• Administrative Services Agreement (provided separately)
• Sample Declaration of the Integral Part Trust
• Sample Retiree Welfare Benefits Plan
■ Section III: V ruageCarc RHS Adoption Documents to ReWn in Yom Fila
• IRS Private Inver Ruling on Integral Part Trust
• Important Information on Welfare Plan Nondiscrimination Rules
RHS EmollmendCmunbution Process
Plearc renin a copy of all VantageCarc RHS Adoption Documents for your records, including the documents that arc being
remrued m [CMA -RC.
PLEASE NOTE
The information in this booklet only akea into account the federal ax mics related to ICMA-RC's Vsm geCare
Retirement Health Sadogs Program. New to implementing an RHS Program, the employer ie rcapomibk for
determining that there are no nate or local laws that would prohibit the employer from offering the Program m in
employee. The employer mus, also determine that the op,lom it selects in the Ysnragcur Rm'rrmem Nra(rh Sarong
Adopeaa Agne., comply with sate and local requirements. The employer is empomible for determining tbar be
invermenu selected for the welfare henefies plan utilir d by the RHS Program fill within Sate and loeal requiremenu.
ICMA RETIREMENT CORPORATION 1 777 NOUN(APBOISTREFT, ME I WWINGTON,DC200024240
10:202962-1600 1 FAX:202-962-1601 I TOLL REEM669-7100 I INIERNR:WWWICMARLORG
1cmac
SECTION I:
INFORMATION AND INSTRUCTIONS
FOR ESTABLISHING YOUR
VANTAGECARE RETIREMENT HEALTH SAVINGS PROGRAM
INFORMATION AND INSTRUCTIONS FOR ESTABLISHING YOUR
VANTAGECARE RETIREMENT HEALTH SAVINGS PROGRAM
Congratulation, on yon decitwn to establish a
V-MWCare Retiremrnt Health Saving, Program ("RHS
Program." "RHS." or "rhe N.Seam") for your employer .
RHS allows governmental employers and employee[ to
accumulate auto to pay for health insurance and om-
of-poclret -.dual rap. in retirement. RHS has a
number of advantagn including ras-free rontdbutiom,
tax-free iuvertment earnings, and tact -free disbunertents
for eligible medical expenses for participants, their
spouse, and dependents. The R14S Program comp6o
with the harmal Rrvcnue Service guidance for Health
Reimbursement Arrangrments.
The steps n ." to establ'uh your RHS Program are
outlined below.
I. Review the materials in this booklet to become
familur with the option available through the
Program.
• Section I contain information and instructions
on establishing your VamageC., RHS Program.
• Section 11 contain documents that most be
completed and returned to ICMA-RC in order for
your RHS Program to be established, including
the VanrageCare RHS Adoption Agreement,
Implementation Data Form, and EZLink Access
Form.
• Section III comain documents that you retain fm
Your fibs, including a copy of the Private Letter
Ruling obtained by ICMA-RC in conjunction
with the original adopting RHS employer.
You have also been provided two copies of the
Administrative Smites Agreement: the contract
between you and ICMA-RC for administration of
the RHS Pmgorm. One copy of this Agreement
most be returned to ICMA-RC along with your
RHS adoption materials.
You may also want to review the materials indudd in
the V—MgeCam RHS Employer Folder, available from
Your Retirement Plans Specialist or by calling our Plan
Spmuor Services -1 800-326-7272. These materials
[rdude the Employ, Qaertion end Amour Brorbum
and the YantegeCnrr Retirement Health Seeing, Men
Fund Optim Sheet.
2. Decide on your RHS design features, such as
employee group cuveragq contribution sources,
1:2
funding levels, benefit eligibility timing, and type
of eligible medical expenses. You may need to
meet with covered employee groups, including
collectively bargained groups, as appropriate.
3. Prepare the required documents.
• Sample Declvad n of Integral Part Trust
• Sample Retires Welfare &nrfits Plan (if one don
not already Grist)
• VantageCare RHS Adoption Agreement
• VantageTrurt 11 Participation Agreemen,
• Implementation Data Form
• EZLink Access Form
• Administrative ServicesAgreement
• Governing Body Resolution or Affirmative
Sumurnt of Adoption
PLEASE NOTE
Ifyou would like [CMA -RC to review your adoption
maren.1, prior to formal exewa., please canracr your
Retirement Pum Sped2lu,. Thu review may make your
Adoption more efficient, as any onsunding iorations can
be disc sed prior to formal adolmon.
Addiriunl infrmufn on arh requird doamenr is
i luded utter in this booklet.
4. Return dx folk-ing eacmed documents m ICMA-RC.
s VmtageCare RHS Adoption Agreemen,
• Implementation Dara Form
• EZLink A. Form
s Administrative Services Agreement
• VantagrTi ut II Participation Agreement
• Governing Body Resolution or Affirmative
Searrarm of Adoption
• Sample Declaration of the Integral Part Trust
• Sample Retina Welfare Benefits Plan (if one does
not already exist)
5. ICMA-RC will set up your RHS Program in our
tecmdkeeping system and send you a New Plan
Confirmation letter. At that point, you may hold
employee education/enrollment meeting and help
your employees begin saving for their retiremene health
costs.
PLEASE NOTE
At any point m ehe RHS Program adoprien process,
you should feel free to contstr your fl,,,emenr plate
Specialist regarding deign lathes. You may be referred
W a member of ICMA-RC's RHS Product Tan for
questions of a team.] wmre.
For questions on the adaption proem itself, erns,[
ICMA-RC's RHS Ncw Bwinen Analyst at 800426-
7272hat assurance
Varaogocara MINS Adopllen materials
The fdlowing docoments arc required in order m
establish your RHS Program and most be returned to
ICMA-RC:
• Sample Declaration of lnrtgil Parr Trus,
• Sample Retiree Welfare Benefits Plan
• VanrageCare RHS Adoption Agreement
• VanagTmn 11 Participation Agreement
• Impkancm ion Data Form
• Mink A. Form
• Adruman ive Services Agreement
• Governing Body Resolution or Alfirmstive Sraementof
Adoption
VantageCare RHS Program Documents
The following three documents collectively comprise
your VanrageCam Retirement Health Savings Program.
S.arPl, D -Zoned,. ef1su llra[P m, True
The Sample Dm6miou of Integml Pan True u included
in Section 11.
Ifyou do no already have an applicable postemploymon,
benefit owt. the Sample Declaration of Integral Part
Trust onblishe the legal entity that will hold the assts
you ser aside to pay for your employee' retiree, health
benefits, and lays out the duties of the employer and
Trustee, with respect to the Trust.
draft an individually designed document in conjunction
with your human ¢sources or benefits counsel. Howeves,
if you do not use the sample trust document, or if you
make changes to the sample document, your individually,
designed document most be reviewed and accepted by
ICMA-RC prior to adoption of your RHS Program. This
will ensure that your document meets the requirements for
integral part musts, and that ICMA-RC can administer all
provisions of your RHS Program.
The sample [run document has been worded broadly
to encompass any employees RHS program. In mon
situations, as with your 457 and 401 retirement programs,
the employer will as as Tants. Some employers name
the jurisdiction (e.g.. City or County) as Trustee. Odusss
name a particular position (erg, Finance Director,
Human Routines Manager) or a group (e.g., Deferral
Compensation Committee, Reduce Health Committee)
within the jurisdiction When the employer is named as
Trusts. the terms Adminirmane and Truuee in the Trust
Declaration will refer to the employe. Each refeerre
to the employer, Administrator, or Truame refers to the
employer acting in the apprepriarc capacity.
• In some cases, the employer names a third -party
as Tnanec (eg., a bank). In chis rase, the ram
Administrator refer m the employer while Trusts refers
to that third -party Tomas, Employers intro ated in
using the services ofa thiel -party mime may contaer
your Retirement Plans Specialist or ICMA-RCS RHS
New Business Analyst for information.
PLEASE NOTE
lo res easean ICA/MRC as as Trams fes your True
The sample Declaration of Integral Art Trust is can an
agreement between you and ICMA-RC. The Declaration
gives the employer (acting as Administrator) the
ability to designate another entity (i.s., ICMA-RC) ro
perform administrative services for the RHS Program.
The Administrative Services Agreement ue, below)
constitutes the concoct between you and ICMA-RC for
these services -
Return the completed sample trun document or your
individually designed document to ICMA-RC.
SamPle Retiree Welfare Bensfier Pla.
Aaa,,Tk Resins Welfare Beefier Plan u included lo Serio,
1.
If you do not wish to use the ample Dedant on of The ample Resume Wdfare Benefits Plan doomwn
Integral Pan Trust provided by ICMA-RC, You may identifies the wdvlymg benefits; available to the rel. such
13
as medical, dermal, sod long-teni rare caserage. Yon may wish
mdisaw.0 withcosmidwhetheroistingpen 1policesor
memoranda of undemanding may qujWm a welfare berafin
Plan doahnnr ahuabk for use in mnjwation with your RHS
program.
Ifyou do scar already have -written retiree welfsse buufin plan
in pita, you may. dwample Rd. Welfare Benefits Plan
Document provided by [CMA -RC. If you wish, you may
also draft a welfare benefits plan m conjuration with your
human resourm or bnrefir counsel. It can be a simple
document. but it should be in writing in order far your
employees to enjoy rax -free tmtment of the bemfirs they
receive. Your individually designed document most be
reviewed and accepted by ICMA-RC prior to adoption of
your RHS Program.
Recons the completed ample Retiree Welface Benefits Plan
Document or your existing/individually designed document
to [CMA -RC.
ViWjrCtrr R!lSAdopti- AgrerArrt
The VantrgrCare RHS Adoption Agreement is included in
Section 11.
The Adoption Agreement specifies the derails of how your
welfare betafirs plan will work. For example, the Adoption
Agreement dmaih participant eligibility requircruents,
worm of conributans, any ocnricdom on mnribmicim,
vesting provisions (if any), the types of benefits that will be
funded by the Intregral Pan Trust, and procedures to be
followed in case of the death of the participant.
Specify instructions for completion of the Adoption
Agreement arc provided in Section [I.
Other RHS Adoption Materials
Additional document, required for RHS Program adoption
include the following.
VanwgeTists, ertiripation Agreement
The VanngeTrmt 11 (VT 11) Participation Agreement is
included in Semon 11. Review and eacone this agreement in
order to adopt Vf 11 and become digible to invert in VT If
Funds.
/mp/rmentation Dara Form
'Igse Gnplrmrntude- Dow Farm is included in Secvon IL
This fin. provides ICMA-RC with the necessary coma
information to set up your RHS Program.
1:4
EZE.kApplicotiro
The FZI,ink Application is included in Section II.
This form provides ICMA-RC with information occuury
to establish your account(s) on FZ[Jnk, [CMA -RC's web -
based employer plan administration poral.lf you already use
EZ13nk for your ICMA-RC provided 457 or 401 retirement
plan. you need only complete Section I of the form.
Admin(mative Srreiar.Agnerrwrnr
Two copies of the Administrative Services Agreement are
Provided separately with yourodor RHS adoption materials.
The Administrative Setvim Agreement u dic contract
between you and ICMA-RC for administration of the RHS
Program. One signed copy in= be resumed to ICMA-RC.
The other copy is for your filer. Your RHS program cannot
be implemented without an exemred Administrative Servim
Ag.t.
G—ing Body Rr ustsui n otAff .ti. Swtawi nt of
Adoption
A sample resolution and a sample affirmative sra¢mmmt of
adoption are included in Section It.
Your governing body may require the monition of a formal
Resolution to adopt the RHS Program. Other jusisi idom
may simply require an AlBrstative Statement of Adoption.
You may wish to speak with cormxi to determine which
action is required in your jurisdiction. ICMA-RC canmmt
make this determination for you.
PLEASE NOTE
The infomrC n in this Booklet only taker into actems
rhe feded sox risks related in ICMA-RC's Vamgce .
Red... Hmkh Savings Pmgom. Prior in implementing
an RHS Program, the employer is responsible for
determining that there are no rate or haat I.,k.,
would prohibit the employer frum offering the Prognm
to in employees. The employer mush also denrmine that
the options it select, in the VasurgeCrrr Renennent Heads
Savings Adrptwn Agreement comply with inn and local
requi... The employer is responsible for determining
rhos the investments selected for the welfare benefits plan
nuirzd in the RHS Program lag within m re ad load
requirements.
SPECIFIC INSTRUCTIONS FOR
VANTAGECARE RHS ADOPTION
MATERIALS
PLEASE NOTE
Ar any point in the RHS Program adoption process,
You should feel free to ronract your Ro nomorm Plam
Speciil'ut regarding design imus. You may be referred
ro a member of ICMA-RC's RHS Product Two for
quesdom ofa technical namrc.
For quesdons on the adunlon protea itself, contact
[CMA -RC'. RHS New Rud. Analyst at 88 326-
7272 Far assimuce.
INSTRUCTIONS FOR SECTION
11: ADOPTION DOCUMENTS
TO RETURN TO ICMA-RC
Sample Resolution and Sample
Affirmative Statement of Adoption
• Determine whether your jurisdiction requires a
resolution to adopt the RHS Program, or if a leu
formal affirmative statement may be Dred.
• Review the appropriate sample document to emote
that it meet, your local requireme m.
• Complete and execute the document.
• Your RHS Plan number can be found on the
Administrative Services Agreement.
• Return a cagy of the executed document m ICMA-RC
with your miter RHS adaption materials.
PLEASE NOTE
Ifyou do not we the nmple resolution or alhmnrive
surement of adoption, your individwlly designed adoption
evecurion mor include rhe following moernenn:
• Thu you ate -doping be ICMA-RC'-VanugcCare
Raircmmt Heath Saving program.
• That rhe a-xu ofymr, wdhte bvowfin plan shall be held
in mes, wih the-Vioox (orad. narned thiel parry
tnrnp+)"as Inver, for the exclaims barest of
plan um parurardd rnovne ,atd dist the num
dull on be diverted m., cher papse Poor m the
--faction ofall Ilabilaks fdie Plan.
• 11w you have esmrred a Declaration ofTme to
the form ofeither the Sample Declaration of the
Integral Part Tout provided by ICMA-RC or a
true povided by you!
• The tire, ofdic trustee for your Trwc
m IC41
dA-vReCf- mwuspmrourrmdosmAmpfjepapaeRHS
bPepma.
VantageCare RHS Adoption Agreement
• Review the features available in the RHS Program.
• Determine the features that you wish m include in
your Program.
• Complete the Adoption Agreement, ruing the derailed
in n neriom included in Section II.
You may wish m consult with your benefits counsel
and your ICMA-RC Renrcment Plans Specialist on the
various features available in the Adoption Agreement.
PLEASE NOTE
Ifyou arc amending an existing RHS Program, he
Adoption Agreement u rhe only docummr that you
need m mmphae and return ro ICMA-RC. Ple-re
1 -dude a summary oFcbanges you An, making ro your
RHS program in your cover letter when you mmro the
complercd amended Adoption Agrmnnt to ICMA-RC.
VantageCare RHS Implementation
Data Form
Complete the requested information regarding your
RHS Program mnnca. The following information
should help you in completing the Implementation Dan
Form.
PrsmaryCnmaa: Complete this section with
the information for the individual responsible for
day -today administration and processing of RHS
transactions. ICMA-RC will contact this im ividual
with general questions ergarding your RHS program,
u well As questions regarding EZLink transmiuion
of all items other than contributions (e.g., henefit
eligibility dans).
Contribution FruperecTs Check the boa for the frequency
you will use mon often. If contributions will be sent only
a separation from service m retirement, check "Other" and
write "At Separation" in the blank space.
Contribution Contact, Please provide the infomution for
the individual responsible for contribution remittances. If
there are discrepancies in the EFT, check or wire amount
remitted and the corresponding detail transmitted via
EZI-mk. ICMA-RC will contact this individual to maolve
the discrepancy. This individual should have a .�... to
all payroll/conribution information in emurc efficient
processing of comributiom and resolution of contribution
questiom.
Trustee Information The title of the individual or group
acting as Trustee for your Integral Part Trust is designated
in your adopting resolution or affirmative statement of
adoption. The individual you name in this section will
receive reports on behalf of the Trustee (e.g., quarterly
plan arcaunr statements, contribution confirmations,
and confirmations for all ranmtd dividends). See the
"VantageGrc RHS Program Doc est nts" section on
page 1:3 for detailed information regarding naming of
the Trustee, for your Integral Pan Trust. Y. may specify
in this Section whether you wish both the employer and
the Trustee to receive Plan reporting. If you wish only the
Touter to retrive the reports, check the ben as indicated. If
you do not check the boa, two ren of reports will he sent,
one to the Primary Contact named in Section 2 and ores to
the Trustee named in this Section.
EiRing (Pm) Contacts Please provide the information for
the individual in whom quenions regarding employer paid
lea, if any, should be directed.
Contribution Frequency: Check the box or the frequency,
you will use coma often. If contributions will be sent only
ar separation from service or retirement, chrck "Other" and
write "At Separation" in the blank space.
First Contribution Due Following Implementation:
Complete this blank with the expocted first contribution
remittance dam. This is for informational purposes only,
and does not need in be an exact due.
EZLink Across Form
EZLink is the required employer data milium for
employers who adopt a VaotageCam RHS Program.
If you already use EZLink for other ICMA-RC sponsored
Programs. you need only complete Section L RHS
rens will be added for the idividuah that already have
EZLink acerin for your other programa.
L6
If you arc new, m EZLink, complete the entire form,
following the instructions included on the form.
PLEASE NOTE
The VaaudvCrn RHS £arpkyn Moved mnesim dcuikit
Infomarion on processing RHS mnsactiom via Mink.
When your Program is established you will he contacted
by an EZLink Speeialim who an sower all questions
,Writing mormi ofit. m ICMAAC.
Administrative Services Agreement
You received two copies of a VanrageGre RHS
Administrative Services Agreement with your RHS
Adoption materials. This document is located in the front
cover booklet pricker.
Review the Administrative Services Agreement,
consulting with counsel if desired.
Sign both copies.
• Retain one copy for your RHS files. Rrmm the other
original m ICMA-RC with your other adopriou materials.
Upon receipt of all of your RHS adoption materials,
ICMA-RC wig review the docamcnts for complereness
and compliance with RHS Program requirements. Once
the review is complete, and any outstanding questions arc
answered, ICMA-RC will send you a written konfirms on
letter and a castumirable summary that may be provided in
your employees during enrollment.
Sample Declaration of Mlprol Port Trost
• Review, the sample Doclamrion of Integral Part Trust
document. You may with to review this docurncnt with
counsel.
• Complete the title page of the sample Dedaruion of
Integral Pan Trust document with the name of the
employer adopting the RHS Program.
• Complete the blanks on pages 11:30 and 11:32.
• Execute the Trost on page 11:37. The employer and
Trustee shoukt sign. If the employer has been named
Trustee, the employer should sign in both places u
indicated.
Remus the aekvted ample Declaration of Integral Part
Tout Document with your ether RHS materials.
PLEASE NOTE
Ifyw make revisions to he sample Declaration of
Integral Pan Trost Document and sample Retire,
Welfare Benefits Plan, you most provide a copy to ICMA.
RC for o vkw prior in adoption of put RHS Program.
This rev"ww will be espedited ifyou provide a'redlined"
.iun dthe document, indicating prwidom that have
been revised.
SatnPIG Retiree Welfare Benefits Plan
• Determine if you already have a welfare henefiu plan
in place that outline the hatcher available or your
employar/retirm covered by the RHS Program. You
may wish to mview this with counsel in determine
if existing personnel policies or memoranda of
understanding may be used.
• If you do not have a welfare benefits plan in place,
review the sample Retire Welfare Bettchu Plan. You
may wish to mica, this document with couael.
• Giw the sample Plan a name, such an, City of XYZ
Retiree Welfare Benefits Plan, and put this arae in the
RHS Adoption Agreement, Anite IV.
• Complete the blanks in the Preamble and Section 1.01.
• Complete the blanks in Section 2.09, "Plan Yme. For
purposes of RHS, mom employers use a calendar year
to coincide with the individual pamicipant's us year.
• Complete the blank in Section 9.12 with the name of
the Sure you arc located in.
• Execute the document by signing it a indicated.
• Returns the ex«utd sample Retiree Welfare Benefits
Plan Docmnent or your existing document with your
other RHS materiels.
INSTRUCTIONS FOR SECTION Ill:
ADOPTION DOCUMENTS TO RETAIN IN
YOUR FILES
Private Letter Ruling on Integral Part
Trust
[CMA -RC obtained a Privatr Lester Ruling (PLR) from
the Internal Revenue Service (IRS) approving the tax -
mention mato of the integral pare room. This PLR was
obtained in conjunction with the tint adopting RHS
employer in late 1999.
IPa
The PLR included in this Booklet is for your information.
Yon may want in keep it with your other RHS materials.
Your use of [CMA -RC's Sample Dahration of the
Integral Pan Tnut will provide you with comfort that
the trust for your RHS Program is also within die IRS'
requirements for integral pan trusts.
PLEASE NOTE
The information in this Booklet only, rakes J.
account he federal rare ruin related m ICMA-RC's
Wcuaag,Urc Retirement Health Saving, Program.
Prior no implementing an RHS Program, the employer
u r.pomibk for dnermming,hm there are no stare or
local laws that would prohibit the employer from offering
the Program to its employees. The employer must also
determine that rhe options it sclero in ,he VantagcC re
Retirement Health Savings Adoption Agreemen, comply
with sure and local requirements. The employer is
.Possible for determining that ,he morourems selma d
for the welfare bensfin plan utilitd in the RHS Program
611 within marc and local requirements.
A. ARC
ua
SECTION II:
ADOPTION DOCUMENTS TO RETURN TO ICMA-RC
64AC
SUGGESTED RESOLUTION FOR ADOPTION
AND
SUGGESTED AFFIRMATIVE STATEMENT OF ADOPTION
11:2
Resolution No. 6775
SUGGESTED RESOLUTION FOR ADOPTION
and
SUGGESTED AFFIRMATIVE STATEMENT OF ADOPTION
SUGGESTED RESOLUTION FOR ADOPTION OF THE
VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM
Plan Number: 8 03694
Name of Employer: City of Seal Beach Snrc: Califomia
Resolution of the above-named Employer (the "Employer"):
WHEREAS, the Employer has employees rendering valuable services: and
WHEREAS, the establishment of a mirce health savings program for such employees serves the interests of the Employer by
enabling it to provide reasonable security regarding such employcei health needs during retirement, by providing harnessed
flexibility in its personnel management system, and by assisting in the attraction and retention of competent personnel; and
WHEREAS, the Employer has determined that the establishment of the retiree health savings program (the "Program")
serves the above objectives;
NOW, THEREFORE BE IT RESOLVED, that the Employer hereby adopts the ICMA Retirement Corporation's
VatuageCare Retirement Health Savings Program ("Program") through the Employer's integral part trust ("Trust") and the
Employer's welfare benefits plan
BE IT FURTHER RESOLVED that the asseu of the Plan shall be held in trust, with the following entity or individual
serving u ons ee (Select one):
VI the Employer
❑ the following position within the Employer:
O.m ase d bA.d.l .sy. ewrI
❑ the following group or committee within the Employer.
❑ the following thud -party trustee:
ammmmdrYdru.rmm:l
for the exclusive benefit of Plan participants and their survivors, and the assets of the Plan shall not be diverted to any
other purpose prior to the satbfacdon of all liabilities of the Plan. The Employer has executed the Declaration of Trust of
the Employers Integral Part Trust in the form of (Select one)
W) The sample trust made available by the ICMA Retirement Corporation
❑ The tmrn provided by the Employer (.red copy amr hcd herein).
BE IT FURTHER RESOLVED, that the sl"°"rn rt1°oct?1V°a'r°r shall be the coordinator and contact for the Program and
shall receive ne seuary reports, notices, etc.
I, Robin L. Roberts , Clerk ofdhe City M Seal Beach 0 do hereby certify that the foregoing
reaslotico proposed by City Council ,was duly passed and adopted in the olyd sewtsofthe County oEOrange
, u a regular meeting thereof assembled this 11 day of a"�"` , 20 17 by the following votr.
AYES:
NAYS:
ABSENT
(Seal) Clerk's Signamm:
Clerk's Title: City Clerk
IL-3
SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT
HEALTH SAVINGS )RHS) PROGRAM
Plan Number. 8 03694
Name of Employer: CRY of Seal Beach Stare: CA
A6rmnive Sentiment of the above.named Employer (the `Employer');
WHEREAS, the Employer has employees rendering valuable service; and
WHEREAS, the establishment of a retiree health savings progam serve the interests of the Employer by enabling it to
provide reasonable security rep ding such empk i health needs during retirement, by providing increased flexibility in its
personnel management system, and by sunning in the artraction and retention of competent peva mi and
WHEREAS, the Employer has determined that the establishment of the retiree health savings program (the `Program') serve
the above objectives;
NOW THEREFORE. as a ddy suchosired age. of the Employer, l hereby:
ESTABLISH the Employer's ICMA Retirement Cotporationi VamageCare Retirement Health Savings program through the
Employers integral part trour C'Trusi) and the Employees welfare benefits plan ('Plan'); and
SPECIFY that the seven, of the Plan shall be held in trust, with the following many or individual serving as trustee (Select ore):
0 the Employer
❑ dw following position within the Employer.
❑ the following group or committer within the Employer.
❑ the following durd-Parry [nuts
I��dmdiMd.myw.vaxl
IL�n em d,Ydpgmiml
for the exclusive benefit of the Plan participants and their survivors, and the assea, of the plan shall not be diverted m any other
purpose prior to the satisfaction of all liabilities of the Plan. The Employer has escorted the Dedans ion of
.of the Employ— Integral Pan Trust in the from of. (Select o.)
IZI The ampk trust nude available by the ICMA Retirement Corporation
❑ The trust provided by the Employer (extend ropy a. , herein).
Finance Dire dorf treasurer
SPECIFY that the shall be the coorditamr
and motion for the Plan and shall receive necessary reporn,, undoes, etc
DATE 12/11/2017
Title of Designated Agent
Signature
IL-4
INSTRUCTIONS FOR COMPLETING THE
VANTAGECARE RETIREMENT HEALTH
SAVINGS ADOPTION AGREEMENT
the VamageCam Reummem Health Savings (RHS)
Adoption Agreement (pages 11:13 through IL18) specifies
rhe details of how your RHS Program will operate.
For example, the adoption agreement details employee
eligibility requirements, soured of contributions, the
level of contributions, vesting provisions (if any), the
types of benefits that will be funded by the Trust, and
procedures to be followed in case of the death of the
employee. The following instructions outline how the
adoption agreement should be completed. Any questions
regarding the adoption agreement can be directed to
your ICMA-RC Retirement Plans Specialist. You may
also wish In consult with your benefits counsel.
RHS Plan Number
Please insert your RHS Plan number. The Plan number
can be found on the front of your RHS Administrative
Smites Agreement included with your RHS adoption
materials.
New Plan or Amendment to Existing
Plan
Check the appropriate box to specify whether you are
establishing a new RHS Plan or amending an existing Plan.
PLEASE NOTE
If you are amending an existing RHS Plan, pkasc
complem the escirc Adoption Agreement, including
items flus arc nor being amended. When you send your
amended document to a, phase summame the changes
I. your cover knot.
1.6np1"m Name and State
Enna the official name of the employer sponsoring the
RHS Plan (e.g. City of City name) and your Sue.
III. Man Dates
A. Effective Date: Enter the dare your welfare
benefits plan will become effective. The
effective date determines the employ. that
may participate - employees that separate from
service prior to the effective due may not
Participate.
B. Plana Y... Enter the annual accounting period
for the RHS Program.
11:5
IV. Retiree Welfare Benefits Plan
Ener the .,m e(c) of nc, weitarc bamfir plan(s) that will
be funded through the Trust mg., City of City name
Retiree Welfare Benefits Plan). If you do not already have
s welfare benefice plan in place, a sample plan u provided
in Section Il of the buckler.
V. Eligible Groups, Participation, and
Participant Eligibility Requirements
A. Eligible Groups: This section is used to
designate the employee group(s) covered under
your welfare benefits plan. The coverage group
specified in your adoption agreement should
correspond m a group of the same designation
that is defined in the natutes, ardinanm,
rules, regulations, personnel manuals or other
documents in effect in your sate or locality.
Nota If you select different contribution
arrangements for different eligibility groups,
you arc responsible for ensuring your RHS
Program conforms with the welfare plan
nondiscrimination nolo.
One Pan m Mukok Nom If you intend ro
provide different program futures that crust
be administered diffcrcndy by ICMA-RC
for diff nt groups of employers, you must
establlsh distinct RHS Plans and complete a
separate adoption agreement for each grocp.
Features that require separate plans are as
follows
• Vesting Schedule (Section VILA.)
• Forfeit. Albotion Pnwitim (Semen VIIL)
• m_ .."_ Medical Bvd't Payments
(Secvms x)
PLEASE NOTE
You may want m esablish rcpuac RHs Plans den
ifseps. plum arc nm equated. For ccunpk, if you
establish differem ffnefit eligibility criteria m Section IX
of the Adoption "nun, for different employee groups,
you may want a establish repass plans for he. gaups
I. order to rake plan adrunistair m. Ampler.
If the only diffcerme in your plan is in the
contribution armature (rag., types of contributions
B. Direct Employer Contributions and
or contribution limitations), you may include all
Mandatory Employee Contributions
employee groups in one plan or establish separate
Plans. Somv employers prefer, to keep employee
You tory choose m include [he following
groups separate for Payroll processing or collectivr
contribution rype in your RHS Plan:
bargaining reasons.
• direct employer contributions
Welfare Plau Nondiscrimination Rvlm:
Please note that if the RHS Program roves non-
• mandatory contributions of employee
collectively bargained employees, AND it provides
Undated unused leave
for reimbursement of any medical expenses
• mandatory contributions of employee
other than insurance premiums, the welfare
compensation. or
Plan nondiscrimination rules will apply. More
information regarding these rules is available
• a combination of the above.
I- the ✓aaoegeC-m RHS Quatiom AndAtumn;
Employees participating in the RHS Plan will
Fsr EmPloy—, the lraamgeCam RHSEmPI%'e,
motive these contributions.
Manart[, and he Yam q Care RHS Fragmm
NandimHmmatim Requirement; included in this
1. Direct employer contributions
package
Direct employer contributions can be made
B. Particlpatiom In accordance with IRS rules,
as a
the RHS Program requires participation of all
• percentage of earnings (Note. If you
employees in the covered group (Mandatory
ilea contributions to be made based
Participation). Employees may not opt not of
on a percentage of earnings, you
Participation as long as they arc in the covered
should consult your benefits counsel
group(s) (current employee and future hires).
m ensure your Plan confoms with the
nondiscrimination odes.)
RHS employes may allow participants the
option m Permanently opt -out and waive future
specific dollar amount each Plan
s specyear per
reimbursemenn from their RHS arcaun[, as
participant, or
allowed under IRS Notice 201354. If you
wish to adopt this (canoe, please contact your
• a discretionary amount to be determined
Retirement Plan Specialist.
each year.
Direct employer contributions may be
C. Employee EBgibBityr If desired, you may
contributed in a lump men, each pay period,
specify a minimum period of service (e.g 6
or under any schedule determined by the
months) and/or minimum age (e.g. age 21)
employer.
requirement. Employees that have trot met
these requirements may nor join the plan under
No FICA (Social Security and Medicare
the Mandatory Participation.
rases) or federal income tax are payable ar
the time of contribution, and, if used for
YI. Contribution Sources and Amounts
medical anpenses of the participant. spouse or
dependent, no FICA or federal income tats arc
This section defines the amount and types of
payable at distribution. Where state follow
contributions to your RHS Program.
federal income res talc, ran, income taxes
A. Definition of Earnings
generally are not payable. Check with your
state income tax department for additional
The definition of Earnings specified in this section
information.
win be used for purposes of an contribution type
included in your RHS Plan:
2, Mandatory Employee Compensation
Contributions
• direct employer contributions made as a
Percentage of earnings
Mandatory contributions of employee
compensation can be used ar a wry m share
• mandatory contributions ofempl%ce
responsibility for funding your retirement
compeneumn
health� with
P Your employees.
Ih6
Ym an establish a compensation
contribution formula that best fin the
needs of you and your covaed employees.
For example, mandatory compensation
contributions may cake the form of either a
reduction in salary (e.g., 1% of compensation
is contributed to the Plan) or a decrease in the
annual pay plan or merit increase (e.g., 1%
of a 3% pay plan adjustment is contributed
to the Plan). Mandatory contributions of
employee con.palaation are established by
the employer— rmployeer may not chew,
ssb,dvn ormt Or mak, tbem eentNbsrtdrn,
and4sy map we revise du esstrlboden
amen tt.
No FICA (Social Security and Medicare
axes) or federal income era arc payable at
the ricer, of conrdbutiort, and, if used for
medical expenses of the participant, spouse or
dependent, no FICA or federal income rax are
Payable at distribution. Where am. follow
federal income tax rules, atarc income tam
generally arc not payable. Check with your
state income tax department for additional
information.
3. Mandatory Employee Leave Contributions
Mandatory contributions of employee lave
can be used as a wry to share responsibility
for funding your RHS Plan with your
employ..
You can establish an unwed leave
contribution formula that bat fit the needs
of you and your towered employees. For
example, you might require all accumulated
Is. in excess of. certain number of hour. to
be contributed to the RHS Plan on an annual
Mss. Mandatory contributions of employee
accred leave arc established by the employer
— employees may notthmum whsrdmr or not
to make these contribution. and they may
not moire the rontribntian ..aunt.
No FICA (Social Security and Medicare
rases) or federal income taxes arc payable
u the time of comribmion, and, if used for
medial expenses of the participant, rap.
or dependent, no FICA or federal income
aero are payable at distribution. Where
stares follow federal income tax rules, sum
income tam generally arc not payable. Check
with your sure income tax department for
additional information.
11:7
Diner employer counibueiom made as a pereenugc
ofeamings, mandatory conrdbutions ofemployee
compensation that arc made as a pereemage of
mings ora discretionary amoune that varies
from smplaym m employes, u well as mvd..q
contributions ofaecumulated have may be subject
.,he nandimrimim umn cobs. Sm he discussion in
the RHS ftram Nondbm.leam n R,gwnmeno
included in this package, or mmacr your benefits
counsel. RHS reimbursement char arc considered to
be "disermusumry" under these rub are reporable u
axubk income to the retiree. Sm the VanmgeCare RHS
£mp1g,Manaal for information an m mponing of
shoe payment.
C. limits on Comribtdooa
This rection is used to eublish an overall
limitation on tool contributions to each
individual participants RHS amount, if you wish
to do so. While this is not a requirement of the
Program, you may do so to ensure that the RHS
Program does not provide benefits in excess of
reasonable beorfit normally provided by such a
welfare benefits plan. You may wish to speak with
your benefits counsel.
You may limit mal contributions to a specific
percentage of earnings (u defiuod in this section)
or a speeifre dollar amount. If you choose to place
an overall limit on contributions, at the end of
each plan year, you will tat coal contributions
from all source, (direct employer and mandatory
employs) against your limit for each participant
ace .. Contributions in excess of the Rmiration
should be rcmmed to the Pa..leipant as
compensation or lens as the case may be, and
,he Participates Form W-2 should be adjusted
accordingly for the year the corepcoution is
resumed.
Limits on each individual type of contribution
(erg., mandatory employee) arc established within
section. VI.A. and B.
RECORDKEEPINO Of
CONTRIBUTION TYPES
Now that the IRS considers direct employer
emaributluns, mandatory accrued leave, and mandamry
compensation contributions or be employer contributions,
In he, words, 4U sarnrrlbntfarras an a araider'd to
liar-0*16Ysreantributtews. However, ICMA-RC will
reeordk.p rhe direct employer contributions as a distinct
source for participant reporting and vesting purpose.
All other types ofemplorece contributions -- marrdatory
accrued Ieave and mandamry employee compensation
— will be combined and shown su employee pre -.a
contributions on paaicipam satemma.
The VanrageCore RHS Employer Menvalixludou
directions on low m report your contribution detail
properly vu Murk.
VII. Vesiing for Direct En*A"ur
Caarfrilianiorrs
A. Vexing Schedule
You may place a vesting schedule on Direct
Employer Coomflaroam (Section VLR.I). There
is on minimum or maximum vesting period for
the RHS Program. Example of vetting sdudulet
include:
e 100% immediate voting
s cliff teasing (e.g., 100 voting after 5 Mn
of service)
a grdmadwaft(eg,10%vvdngforearls
year of service with I00%vowing afier 10 yeah)
a oaring at retirement or some other specified
event.
'16 RHS plan default is 100% starting for Direst
Employer Contributions.
ICMA-RC will nkulaw vesting for each
pas rticipanr account iFyou theme a vesting
achedu4 based on yea of service. If you choose
vetting se essiament or some other specified
event, you will notify [CMA -RC via EZLink
when 100%vadngocturs.
coundbutors ate always l00%
11:8
B. Vrating Upon Cassandra Evens s
A participant's Direct Employ. ContriMmmn
will sommariolly be—100%wswd upon dw
Parrkipatds
a death
s disability, (as defined in Section DLC)
a nemement (a defined in Section VII.B.), and
a armimnent of berwfir eligibility (as
determined in Section DQ.
You mrut define "retirement" for orating purposes
in this section.
PLEASE NOTE
Ifyou eswblinh berwfit eligibility. separation from
service, participants will become 100% vested in tbeh
Diwct Employer Contributions immedcardy upon
separnlon regardless of their yours of wrvice. if you
do not wish for full voting m occur a separation, you
should establish benefit eligibility. an const other than
wpaoutiun from auntoe (e.g., separation and a sp.lfic age,
ear one month after separation from service).
C. Rehired E npluyase
If an employee participating in RHS separatet
from service ands then rehired into a group
covered by RHS, the service completed pm m
the employee'. first sep ration will nor ..or for
vesting purpmes. The account balance, including
any Direct Employer Contributions that were
contributed prior m the fierr separation, will
be subject to vesting as if the employee had no
accumulated service.
If an employee became eligible m receive
winds esemena from the RHS Program upon
separation from services and is subsequently
rehired a an employee, the participant most
suspeed his or her acres. or benefits urrdcr the
RHS Program until he or she is again separated
from service. Rehited employee grn.ally are
unable to request disbursements.
VIII. Forfeiture PnyAdon
All RHS Plans moat contain a forfeitua provision,
even if there is no venting schedule on Direct
Employer Conttibutime.
be used in three situations:
• Yom RHS plan includes direct employer
contributions subject to vtating: when a
participant separaus from service prior m attaining
full voting, the uninvested assets will be forfeited
and used as you direct in this Section.
• Upon the death of a participant: if there am no
surviving spouse or dependents, remaining avers
will revert to your Trust to be utilized as you direct
in this Section. Note that ar long as these is a
surviving spouse or dependent, no f ntlensre will
Drat.
• Permvtent Opt Out and Waives: if a participant
pemutroody opts out and waive future
reimbursements, ar allowed under IRS Notice
1013-54, the Participant's account at the dose of
the waiver will be farfated as you direst in this
Section.
Them are four 16rfcimre.110 tion methods:
• Forfeited amounts will be used to off. your direct
employer concributinns for the nae and succeeding
contribution cycles until die forfeinues are depleted
• Fattened amouon will be "located on an equal
dollar basis among remaining plan participants.
• Fmfeitd amounts will be nalloord among remaining
plan participants based on account ba nice.
• Forfeited amounts will revert to the employer in
be used for arty purpose. It is anticipated that few
employers will rimose this option, in order that
RHS avers will continue to be used for the intended
purpose of die welfart benefits plan for remaining
Participants.
Regardless of which forfeiture allocation method
you choose, you most inform ICMA-RC at the time
you wish to use the fotfared funds u outlined in the
VanngeCare RHS Employer Manual.
IX. Eligibility Requirements to Receive Medical
Benefit Payments from the VantageCare
Retirensera Htsalth Savings Program
A. General Rencfit Eligibility
Thu section defines your primary benefit
eligibility provision(s). You may doignare,
eligibilityar.
• Redrement (as defined in this Section or in
11:9
Section VILE).
• Separation from service, with romalons
defined by the employer, if desired (e.g.,
separation from service and at rimncn[ of age
55). If no restrictions are desired, wdte'N/A"
at 'None" in the blank
• Attainment of a certain age. (Note Employers
selecting benefit eligibility to begin upon a
event other than scpantion from service or
retirement may violate the Affordable Can:
Acis ('ACA) prohibition on Annual and
Lifetime, Limits, union the RHS Program is
"integntod" with another health plan that
s dsfies the ACAs requiremenuJ
• A combination of retimmendseparation from
service and a rennin age.
B. Tominarion Paor ro C ,,d Bcnt fu Eligibduy
Use this section to specify benefit eligibility
criteria for employees that separate from service
prior to staining the general benefit eligibility
you have selected in Section A. For example, if
your general benefit eligibility criterion requires
employees to ".tire" before they become eligible
for benefits, you may have some employees that
separate from service prior m "retirement." in
this situation, you need to designatt a specific
time for [hose early- separating employees to
become eligible for benefits. Y mighr specify
immediate eligibility or a certain age (e.g. age 65
or the retirement age provided under your genenl
pension program). If you do not specify benefit
eligibility criteria in Section B., employees that
leave employment prim to attainment of your
geneml benefit eligibility may never atmin benefit
eligibility, and their account will not be available
for use until the employee's death.
C. Benefit Eligibility at Disability
Your RHSpanicipating employees will
automatically become eligible for medical benefit
payments if they are disabled according in the
definition chosen in this section. In all cases.
you most notify ICMA-RC via EZLink when a
participant is disabled under the definition you
provide in this Section.
D. Benefit Eligibility at Death
Upon the hath of the participaing employee,
the surviving spouse and dependents will
automatically become eligible for rax -free medical
expense reimbursement. If there are no surviving
spouse or dependents, the account balance
will revert to the employers RHS Trust to be
«allocated as forfeitures in sccurdance with
Section VIII of the VantageCare RHS Adoption
Agreement. See Section XI.
X. Permissible Medical Benefit Paymatts
Ihis section is used m de.ignare he medical expenses
that will qualify for reimbursement under your RHS
Plan. You may offer reimbursement for all qualifying
medical expenses u defimd in Internal Revenue Cade
Section 213 0.c medical ansa that would otherwise
be deductible to the employs on his w her individual
income tax rents.) who than (fi direct long-term care
expense, and (ii) epema paid afar December 31,
2010, for medidnes or drugs which are not prescribed
drug (other than insulin).
Alternatively, you may allow reimbursement of only
specific type of medical expenses. For example,
reimbursements may be made available only for
health imurance premiums, COBRA premiums,
Medicare supplemental intuance premiums, dental
insurance premiums, omrof-pocket medical cons,
qualified long-term mrc insurance, em. You may
allow reimbursement for only one benefit, or for any
combination of qualifying medical cents. Information
about what continue a qualifying medical eapense
can be found in IRS Publication 502, Medical and
Dental Expenses (available on the IRS website at
bapd)srasrJ-9-1).
Noce: Under count IRS rules, direct long -tam
care expenses may not be reimbursed through your
RHS Program. However, qualifying long to -in can
insurance premiums arc an allowable expense.
PLEASE NOTE
Fads of ibe medial cap. types lined undo the second
chek bor option an indudd m "AO Medical Expewa"
(the 6m cheh boa). if you intend to iwlude all qualifying
mod" expemn in your plank mimbumm eat rub, you
should check it. fine boa, rather than chehing every, its.
in the second check bot.
PLEASE NOTE
Ifyo s include any ran imurance eapemes a permissible
medial benefit payments, you may need to perform wdf.
plan nondiscrimination [ening See he discussion in the
Vamag,Core RHS Program Norducriminourn Requimnwa
induded in this package or contact your henefits cuumel.
XI. Benefits After the Death of the Participant
"Ihis section defines rhe treatment of the participant's
account balance at death.
A %midagSpome.&.Stuviviog DT dma
Upon the death of the parocipsut, the surviving
spouse and/or surviving eligible dependence arc
immediately eligible m maintain the account and
utilize it only for the purpose of reimbursing
eligible medical benefits.
When a participant dict, [CMA -RC mars[ be
notified by the filing of the VanrageCmr RHS
Decedent Inforramtion Form. [CMA -RC will
maintain the participants account for the benefit
of the spome and dependena and move all funds
into VT 11 Cash Management Fun& (or another
default investment Fund named by the employer).
The namferee may move the money into who-
immamem, on. the new account has been
established.
If the do-vtd puticipani s account balance is on,
fully deplered upon the deth of dhc surviving
spouse, remaining dependents may continue m use
the account. Upon the death of all eligible
dependents. the account balance will revert in
accordance with the employer's election under
Section Vlll of the VanngeCnm RHSAdapNma
Agreement.
B. No Surviving Spomear Dcpendmu
If there arc no surviving spouse or dependents, the
account balance will revert to the employer's RHS
Trus, to be reallocated as indeltne under Section
VIII.
'Refon unerring in the Fund you rhuu/dearfuRy emoder your inrxrescroloa4. mkn nee for ruk, lnowarear now /-man. adPenonel
nnumruncer 'There a mgworime dint the Fund will meed in lnwrdnenr ob)rrvivs andpu ma lore money. For a"ar ml infonvnon regarding
rhe Fund, inc/udinga dnniprien ofrhe pnnripal ruler, pkare mnralr the VanwpTmur 11 Fuodr Dim/nrum M nosdum awifusd Sac Am,
whish u anounb/e udmn you login ar www.hm rre.org or upon requerr by rolling liM-669-7400.
told. plant deyiwkjiirsdh nod doe VT Il Cath Managemem Farad Phare mad the duchnum naunah or prop.. spplkable a the d*uItfund.
11:10
When a participant dim, ICMA-RC must be
notified by the filing of the V n VeCnrc RHS
Decedent Information Form.
XII. ONax Providons
This section defines other provision, of he RHS
Program, including:
• RHS Program administration most be
accomplished is [CMA -RC', EZLink System.
• RHS program fee payment
• Definition of dependent.
• Employer resporuibilities for at reporting and
comitance for paymenu deemed rateable under the
nondiscrimination rules.
XIII. Employer AcknovA dpornoms
A. This section acknowledges that the employer
uvdemands the significance of completing
the Adoption Agreement properly to safeguard
the tate-fine status of the contribution, and
distributions from the Program.
B. If you have policies or procedures Goch as
Memoranda of Understanding or Personnel
Policia) rekrcnced in this document that you
wish m be a pan of the RHS program, you
should check the hot in this seniors, indicating
that you are attaching three documents as pan
of your Employer Signature Plat.
After you have completed the Adoption Agreement,
it should be signed and returned m ICMA-RC with
the other documents outlined in VantageCate RHS
Adoption Materials on page 1:3.
PLIASI NOII
The information in this Bonder only tale,, Imo mous,
the kderal us rale, rclaad m ICMA-RC's VanugcC m
Retirement Health Savings Progam. Prior m implementing
an RHS Program, the employer is responsible for
derermining that there arc no sure or local laws that
would prohibit the employer from offering the Program
m in employees. The employer must also determine that
the options it selecu in the VaruageCare Rm'mme, Heald
Savings Adverbs Agreement comply with sure and local
requiremma. Employer is responsible for dcrermiuing that
the investments selected for the welfare benefice plan utilized
by RHS fall within one and local regmmornn.
EMPLOYER VANTAGECARE
RETIREMENT HEALTH SAVINGS (RHS)
ADOPTION AGREEMENT
11:12
VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS)
ADOPTION AGREEMENT
Plan Number. 8
Scher u app0table: ❑ Standalone RHS ❑InvWated RHS ❑Amendment roExisting Plan ❑New Plan
1. Employer Name: Stare:
11. The Employer herebyatteste that kin a unit of arfataorloeal6overnraees or au agency or instrumemali, of one or
more units of ..tate or local government.
III. Plan Data:
A. Plan Effective Dam
R. Plan Year. Enter the annual accounting period for the RHS program.
W. The Employer intends to utilize the Trust ro fund only welfare benefits pursuant to the following welfare benefit
plan(.) sands] is urd by the Employe
V. Eligible Groups, Participation and Participant Eligibility Requiremeuu
A. Eligible Groups
The following group or groups of Employees arc eligible to participate in the Employers welfare benefits plan identified
in Section IV. (check all applicable bones):
❑
AN Employees
❑ Ali Full -Tune Employees
❑ Non -Union Employees
❑ Public Safety Employees — Police
❑ Public Safety Employees — Firefighters
❑ General Employees
❑ CoUretiY-Bargained Employ. (Specify mit(s))
❑ Other(spedfygresup(s))
The Employee group(.) specified mum correspond to a group(.) of the same designation shat is defined in the statutes,
ordinances, tele., regulations, personnel manuals or other documents or provisions in Mect in the stem or locality of
the Employer.
B. Participation
Afia fa ry ParNripatioru All Employees in the covered group(s) mm required to participate in
the Plan and shall «eeh,r contributions pursuant in Section VI.
If the Employer's underlying wel6m benefit plan is in whole or pan a non-coUo ively bargained plan that allows
reimbursement for medical expenses other than insurance premium., the rmndiscrimlnation requirements of
Internal Revenue Code (IRC) Section 105(h) will apply. These mks may impose taxation on the benefits teeeivcd
by highly compewted individuals if the Plan discriminates in favor of highly compensated individuals in mems of
eligibility or benefits. The Employer should discuss these rules with appropriate counsel.
11:13
C. Participant Eligibility Requirements
I. Minimum service: The minimum period of service required for participation is—(wrim N/A if m minimum
service is required).
2. Minimum age: The minimum age r.famod for eligibility to participate is— (write N/A if.. minimum age is
required).
VI. Contel6urioa Sources andAmoums
A. Definition of Earning,
The definition of Earnings will apply to all RHS Contribution Features that refi:mnce'Earningr", including Direct
Employer Contribution (Section VI.B.1.) and Mandatory Employee Compensation Contribution (Section V1.B.2.).
Definition of earnines:
B. Dirst Employer Contributions and Mandatory Comribution
L Direct Employer Conuibutions
The Employer shall contribute on behalf of each participant
❑ %of Earnings'
❑ S each Plan Year
A discretionary, amount to be determined =6 Plan Year
Other (durn'he):
2. Matdamry Employee Compensation Contributions
The Employer will make mandatory contribution of Employee compensation as follows:
❑ Reduction in Salary - —% of Earnings or 8 will be wntributcd for the Plan Year.
❑ Decreased Merit or Pry Plan Adjustment - All or a portion of the Employees' annual merit
or pay plan adjmtmenr will be contributed a follows:
An Employee shall pp(haw the right no discontinue or vary the rate of Mandatory Contribution of Employee
Compensation.
3. Mandatory Employee Leave Contribution
The Employer will make mandatory contributions of accrued eve as follows (provide formula for determining
Mandatory Employee Leave contributions):
❑ Atcnrod Silt leave
LFM
❑ ChM (specify type of 4ave) Arcned _have
M Employee shall naLhave the right m discontinue or vary the rare of mandatory leave contribution.
' Non-ea/&enve(y bargainedplam t/mr n,mult ar medical eapetna other d6m moeoare premismr ihou/d romrdt their benefln roume(
regarding—fare plan wndne"miooman ro&t ifthe employer a&m to make romributiom baud on a percentage ofeanungt.
11:14
C. Limits on Taal Contributions (d neck one bus)
The coral contribution by the Employer on behalf of each Participant (including Direct Employer and Mandatory
Employee Contributions) for each Plan Year shall not exceed the following limit(s) below. Limits on individual
contribution type are defined within the appropriate scion above.
❑ There is no Plan -defined limit on the percentage or dollar amount of earnings that may be cuntributed
❑ _%ofeamingt
Definition of earnings: ❑ Same as Section VIA ❑ Other
❑ S mor the Plan year.
VII. Vesting for Direct Employer Contributions
A. Vesting Schedule (check one bin)
❑ The account u 100% vested at all times.
❑ -flue following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VIAL:
Years of Service Vting
Completed Percentage
%
%
%
%
B. The account will hemme 100% vested upon the death, disability, retirement', or attainment of benefit
eligibility (ns outlined in Section DQ by a Participant.
'Definition of retirement includes a separation from servim component and u further defined by (check one):
❑ The primary retirement plan of the Employer
❑ Separation from service
❑ Other
C. Any period of service by a Participant prior to a rehire of the Participant by the Employer shall not coast
toward the vesting schedule outlined in A above.
Vlll. Forfeiture Provisions
If. Participant xp.. from service prior to full vesting. non -vested funds in the Participant's account shall be forfeited in
accordance with the ba checked under this action.
Upon the death of a participant, surviving spouse, and all surviving eligible dependents (w outlined in Section XI), fords
remaining in the Participants account shall be revert to the Trust in accordance with the bor checked under this section.
11:15
If a Participant permanently opts our and waives future reimbursements, u allowed under IRS Notice 2013-54, all funds in
the Participants acemtnt at the time of waives shall be forfeited in accordame with the but checked under this section.'
❑ Remain in the Trost m be n allocawd among all Plan Participmm with a bilin¢ at Direct Employer Contributions
for the oat and succeeding contribution cycle(s)."
❑ Remain in the Trust to be reallocated on an equal dollar basis among all Plan participants with a balanic."
❑ Remain in the Trmt to be rollocared among all Plan Participants based upon Participant account balurm."
❑ Revert m the Employer via check
OC. Eligibility Requirements ro Restive Medical Benefit Payments from the VamageCam Retirement Health Savings
Pragam
A. A Participam u eligible ro receive benefits:
❑ At retirement only (also complete Sidon B.)
Definition of rest . no . r,.
❑ Same as Section VII.B.
❑
Other
❑ M separation from servim with the following mmictiom
❑ No restrictions
❑
Other—
B.
thtt
B. Termination prior to general bemfit eligibility: In case where the general benefit eligibility as outlined in Section
IX.A includes. retirement component, a Participant who separates from service of the Employer prior on retirement
will be eligible to mreive benefits:
❑ Immediately upon separation from smite
❑ Other
C. A Partidpam thm become tomlly and perma ly diwbled
❑ as defined by he Social Security Administration
❑ as defined by test Employde primacy rmiremeat plan
❑ other
will became immediatdy eligible ro receive medical benefit payments from his/her account under the Employees
welfare benefits plan.
D. Upon the death of the participant, bemfit-.hall become payable as outlined in Section XI.
/fthe Emp/olvri RHS Ansgmm diner not Gmitehgibdur v a Partidpana who haat reP,,v,*dJrom rrnnn, the employer wiR/n ngaiad
to provide farther dlnrsom to [CMA -RC ngardhrg do trrol sent of ponibL ont iboo o, t/ut an ,q use ( m be made f flmoing t/u
participami waiver
"Iftbeforfekod balance or owdonirreby the r Ikcsonm amount to soh Plan Participant with a ba/anre u minimal, the amm vrcR
avert a MPloyerifaefeioaff accoantfar fother direction from the employrr. lftbere areMn,,sMna aithonta balance why ebvald
e'—foe/m— nons, Pk -e provide ak—Ure irtrnmts-ou a ICAM-RC on the fofeimn reaAcradon notice.
1130
X. Pee simeible Medical Benefit Payment
Bercfit eligible for reimbursement consist of.
❑ All Medical Expemo eligible under IRC Section 213 other dun (i) direct long-arm este aperua, and (ii)
expenses for medicines or drugs which are not prescribed drugs (other than imulin).
❑ The following Medical persons digible under IRC Seoion 213 other Haan (i) direct lungterm cart espenues, and (ii)
apert for medicines or drop} which see not prescribed drugs (other dun leash.). Select only the apemes you wish w
ewer under the Employer'. welfare benefit plan:
❑ Medical I.c, premiums
❑ Medic Otoof-Pocket Exprmo•
❑ Medicate Pan B Imurunce Premiums
❑ Medicare Pan D Inuurance Premiums
❑ Medicare Supplemcotl I.earaece Premiums
❑ Prescription Drug Imuran¢ Pnmi •m.
❑ COBRA Insurance Premlwv
❑ Dental Insurance Psemiunm
❑ Dents Outof-Pocket Expenses'
❑ Vision huurance Premiums
❑ Vision Outof-Pude[ Expensed
❑ Qualified lung -Term Care Insurance Premium.
❑ Non -Prescription medications allowed under IRS guidance'
❑ Osier qualifying medical open ses (describe)'
• Nan-ral/rrtivrfj/prgaixdp/aro dour rdmkunr maBra(nprxn cath. rimes imvraxrprcmiumrrhaulGronru[r rhrir ben �n
manic rrgari'rtg mdfarrp/an mn4iu'rmimeion rulm ifdxemp/yrrr4m to make ronniburiom based on a percrnmgr of
raining.
XI. Benefit After the Death of the Participant
In the event of a Paracipani s death, the following shall apply:
A. Surviving Spouse and/or Surviving Dependent
Upon the death of a participant, the surviving spouse and/or surviving eligible depetdnsn (as degtwd in Section XII.D.) of dw
dereard Participant are immediately digihk to maintain the Participants BUS scouter and utilizing the rwaining balance m
fund eligible medial heafit specified in Section X above.
Upon notification of a Participant's death, doe Participants sccomn balance will be uarufertad into Vr If Cash Ma..gcmenr
Fund— (or another fund sdetted by rhe Employer). The account balance may be reallocated by the surviving spouse or dependent.
'• &fan invertinif in he Fundyaushe ddmrrf.111y rom(drryour invormrnr pals, tokraxrfor'ark, eave uwnd roe, Aures, and
pmonallerumsmxrr. Tlxre u mgmmnrce r/nar rlx Ford uriR sent is in'rcamenro[ry'rrrim mdpu roes lou marry For o"cenel
i �nnwdon se8°rdng du Furn4 ixkdinga dacopdon edrc prixipal rub, pine,... rbc VanmpToue Pl Fundy Due",
Mewen'dum 4rdfwdfar1'beer,u4kb u arwimbla teben you log in at wurw. irmarc.erg or pen request by calling 800-66¢7400.
If the Plan i defaobfunda me rbc VT 11 Cada Mmmgrmenr Fund p4av read rix duc/aum marrriab o r p ropeene,appb.'64 ear rhe
deefaak fund
If a Participant's account balance has not been !idly utiliwd upon the death of the eligible spouse, the accent balance may
continue to be ut8ired w pay benefit of efigible dependent. Upon the death of dl eligible dependent, the eccoune will seven in
accordance with the Employer's election under Section Vill of the VanragrCam RHS Adoption Agmeoseer.
11:17
B. No Surviving Spouse or Surviving Dependents
If there are no living spouse or dependent at the time of death of the Participator, the account will revert in accordance
with the Employers election under Section V 111 of the ✓anugrCam RHSAdoption Agreement.
XII. The Plan will operate according w the following provisions:
A. Employer Rapoaaibilities
I. The Employer will submit all VantageCare, Rearmament Health Savings Man contribution data via eletvonic submission.
2. The Employer will submit all VantageCae Retirement Health Savings Plan Participant status updates or personal
infmrmuion updates via electronic submiuion. This includes but is not limited to termination notification, benefit
eligibility, and vesting notification.
B. Participant account administration and amm4aaed fees will be paid through the redemption of Participant account
shares, unless agreed upon otherwise in the Administrative Services Agreement.
C. Assignment of benefits is nor permitted. Rcoefita will be paid only to the Participant, his/her Survivor, the
Employer, or an insuran¢ provider (v allowed by the claims administrator). Payments to a third -parry payee (e.g..
medical service provider) are nor permitted with the exception of reimbursement to the Employer or iusurance
provider (as allowed by the claims admi.irtmu r).
D. An eligible dependent is (a) the Participants lawful spouse, (b) the Participants child under the age of 27, w defied
by IRC Section 152(f)(1) and Inretrul Revenue Service Notice 2010-38, or (c) any other individual who is a person
described in IRC Section 1524), as clarified by Internal Revenue Service Notes 2004-79.
E. The Employer will be responsible Far withholding, reporting and remitting any applicable rases for payments which
arc deemed to be discrimimwry under IRC Section 105(h), as outlined in the Van wCare Retirement Health Savings
Employer Manual.
XID. Employer Aduarwriedgements
A. The Employer hereby acknowledges it undermnds that failure to properly fill mut this ✓amagCar RM.em Health
Saving Adoption Agreement may result in the loss of tax exemption of the Trust and/or lou of tsyslefred sours for
Employer mntrihutiom.
B. ❑ Check this bus if you are including supporting documents that include plan provisions.
Darr.
Title•.
11:18
icMARRCC
RHS VANTAGETRUST II ADOPTION MATERIALS
1619
RHS VANTAGEMUST II ADOPTION MATERIALS
The VantageCare Retirement Health Savings ("RHS") Program makes available for imestmenr the
VantageTnut II Funds ("Vr II Funds"), a Collective Investment Trust ("CIT"). A CIT is designed m facilitate
investment management by combining assets from eligible investors into a single investment portfolio (or
fund) with a specific invesunent strategy.
To access the VT 11 Funds, you must adopt VT 11 by executing the VantageTrust 11 Participation Agreement
and resuming it along with the completed documents from the RHS Program Adoption Book.
Prior to executing the agreement, please review the following information:
• Vanta¢elfruat II Participation A¢rmment: Review and execute this agreement in order to adopt VT
11 and became eligible to invest in VF N Funds.
• VanmaeTruat It Declaration of Truer. The governing document for the operation of VT II. Please review
acrd retain a copy for your records.
• VaonaeTnut II Disclosure Memoraudum: Additional information regarding VT II and the operation of
rhe funds it makes available to investors.
The VT 11 Funds available for investment can be found on our website. VT II Fund Fact Sheets are available at
www.icmam.org/login or upon request by calling Plan Sponsor Services at 800-326-7272 and the
VantageTnut II Disclosure Memorandum is provided above.
II:20
icMARC
RHS IMPLEMENTATION DATA FORM
VantageCare Retirement Health Savings
ICNIn Implementation Data form — Page 1 of 3
Instructions to Employer: Provide necessary inlmmahon to establish your plan properly.
I� emu wiliu Im
highIr Plan Number: Employers Full Nome.
SOW Adkm
dl Store: Zip Code.
TmplgelshdmRlTm Nentificatim Number _.
❑� PRIMART CONTACT INFORMATION
The person is mspanible lar the day to day admineaction and processing of RNS tmessannere. Th,,,, the person we mil if gmmrol questions erne concerning your RHS plan.
Nor.. Rbe Primary (ruled will be used H may tMacr desipmtbms are left blank.
("par Nome:
TakpMm F In, 8:
1—_—) I---1----..
(mRNAMmm,
❑3 CLAIMS CONTACT INFORMATION
Ilia pawls) wdl be responsible for coordinating with the INS plan third -party clan administrator
1. (sow Nanm:
TNR:
Teipb�t. Fm F.
card Ai
t. Cantel Name'.
TMe:
Indianan. P: Em d:
Email Address:
m
Vantage(are Retirement Health Savings
IC.nanrRC Implementation Data Form — Page 2 of 3
Il]%MIBUTION/EZUNH CONTACT INFORMATION
Thn pawn n respmrsi6k for sending conbibutiom to I(MA-A(.
it there are discrepancies in the mnlribmion amount received and the corresponding detail personified via Uteri,
thin n the person we will acted to resolve the is,. This person should have access to all payroll/mnbibulloo entertainer.
Campo Now
TMe:
Telephone k: Fax p
Email Address:
u TRUSTEE CONTACT INFORMATION
If your slot, or laml law requires a rtschi ii the title of the person a designated in the resolution. If o dilferenr person obtains the same tiller you maY uu this I" m undone the
name damge. The perm -will receiveall quarterly statements as well as cunhrmmiom for ond contribution received and onfirmorlo.. for erg reinvened dividends.
Comet Name,'.
Tile:
Lhjnnl: Fax #:
fanglAYaax
C', BILLING (FEES) CONTACT INFORMATION
It IOIAAC charges any employer pod fees in Your account, this person will retrive the invoices
(paper Nomm.
Tale:
ideAMet. Fax #.-
how
:haml Ad*M
ICAM Refirement Corporation w P.O. Box 96220 w Washington, DC 200905220 w Toll Free 6800 6697100
11:23
Vantage(are Retirement Health Savings
ICM/ -RC Implementation Data Form — Page 3 of 3
7 DEFAULT INVESTMENT OPTION
Defoeft Pond Far Invesnormal Allocations:
The 414 fund dl be used it a parhipont does rat provide raid alaamen im rustems (i.e, no allomlion is provided, the alocmonn peranloges do nor tonal 100%or one or came bads that
ore not amdoble Is the plan me waded)
If you do at rake as election in the Wind, the V.rtegelast II Vamagepam MilesMe Fund with the target aide raw to o partkipam's 60e birthday teal be used at your plans dell
often.
Your may select the'(zinn Default" option N war would like to use o fund for funds) other then the Milesmer fords as your pions Moult ophan. Pease me ICMA-R('s Standard Nan Fund
Ones f. RHS of . kmmr an m mmpere this semen.
Note: Prior to seeRiag A. 'Carl.. Default" option, employers should carefully review the Department of Labors final regulations on qualified default investment
alternatives (ODIAs). Mare information is available online at www.dol.gov or www.icmorc.org/ppa.
Detauh Fund Far Investment Mountain, (ken one option).
J The Warfare Fmrds (Dash) witho legal retirement age of:
I Age60(Daeuhl
❑ Age __._..(irmt the target rem.nem age to be seed for your pion)
Word Default (List are Fund ame(s) lard pan ntoge(s) thin will be mind a the pon i dash imesimem optoN:
Fund Nome Perzemage
Target mleemere age lar cost. wastedatafunds Imlart one option):
Age 60 (Defaub)
Age (input the mrgel retirement age to he used or your plan)
® PLAN IMPLEMENTATION INFORMATION
(***Man Fre4uemy. Ideas mail:
❑ N+neNy ❑ monthly ❑ Duonedy
❑ needy ❑ seniaaday ❑ Mnuogy
Ta lrbaboto Depose Method;
❑ wire ❑ A(N
Frt (omrihution Dote Following Implementation: //____ Irmn/dd/VM).
Numb. of FigBk (mparree-e:
I(MA Retirement Corporation o P.O. Box 96220 a Washington, 0C 200906220 o Tall Free 1800 6697400
112,
iCAARRCC
FZLINK ACCESS FORM
1125
icM'—RC EZLink Access Form
EZLink gives you electronic access to a wide range of plan specific information, transaction processing capabilities and
keeps you up -m -dam on the latest in plan changes. As a user, you can access the information you need, when you need it.
To arras EZLink, visit www.icmaroorgledinh.
Who should ase the Mink Auess form?
Use this form to request a new user, and to update
or remove an existing user.
Instructions
1. Primary Contact Information:
Please provide the name of the person who is desig-
nated as the primary contact. This person will need
to sign this form to authorize arrest. if you want on
verify your primary contact, please all Plan Sponsor
Serviaa at 1-800-326-7272 between 8:30 a.m. and
7:30 p.m. EasternTame. Primary contact User ID
and password will be created with full screw.
2. EZUnk that Informalbn:
To request a new, User ID — check the Add New
User ID box and enter the user information. The
email address and access options are required.
To update an existing User ID — check the Update
User ID box, enter the User ID and select all the ac-
ceas the user should have.
To remre an existing User ID — check the Re-
move User ID box to remove all access.
Aeoess Options:
Balance Inquiry —This provides the user the
ability m view plan and participant information
including balances, investment allocations, state-
ment and report.
Fnvollmenr,/Rekine —Thu provides the oyer the
ability to manually enroll and rehire participant.
This is often used when enrolling or rehiring a few
participant.
IL26
Participant Changes —Thu provides the user the
ability to manually update participant information
such as name, address, marital starts, title, and
termination date. This is often used when enroll-
ing or hiring a few participant.
Fitt Traotfer—Thu provides the user the ability
to submit contributions and loan repayment on-
line using a prior payroll or ICMA-RC approved
pre -formatted file.
Participant Dam Transfer, —This provides the
user the ability to submit an ICMA-RC approved
pre -formatted file of participant indicative data,
which includes enrollment, rehires, maintenance
changes and terminations, and view a participant
tramartion derail report.
3. Primary Conlan Approval.
Please have the PHmary Conmer sign and date this
F.ZLinkAcren Form.
Please fax your completed EZI!nk Acow Form m the
Workflow Management Tam at 202-682-6439.
Plan Name: _
Plan Number(s):_
(AQpbn numbea cost be &Ads awidpmeaang &Zay d
HUNK ACCESS FORM — PAGE 1 OF 2
1 Primary Contact Name: _
?duty (wtoo Information Primary Contact Tide:
Email Address:
Daytime Phone Number: --
2 Select Ona O Add New User ID O Update User ID -I Remove User ID
Mink Uur Informahm
Name:
Trtle
Email Address:
Daytime Phone Number. (___)__--- __—
Alsace, Options (You matt alert admrya or no for each aaett option)
Ba6ma Inquiry O Yes
O No File Transfer O Yes O No
Enrollments/Rehire 0 Yes
0 No Participant Dara Transfers 0 Yes (71 No
...Parti v nt Chanes.,,, C7 Yes...
O No
Slot Otra O Add New User ID
O Updeoe User ID O ll u User ID
Name:
Trtle
Email Addnas:
Daytime Phone Number: (_ _ _) _ _ _ _
Arrest Options (You court alert eidwya or no for ea& array option)
Balance Inquiry O Yet
0 No File Transfer 0 Yea 0 No
Enrollments/Rehite 0 Yes
0 No Participant Data TrAnsfers 0 Yet 0 No
...iciPartt.Chatt.&er....❑Ya
...................................................................................................
0No
Select Ono 0 Add New User ID
(3 Updue User ID 0 Rm Uter ID
IMM
Title:
Daytime Phone Numbs: (—__)
A Optiome (You mutt start admr)w or no for rash arrest option):
Balance Inquiry 0 Yes 0 No File Transfer 0 Yes 0 No
Emolhnents/Rehirc 0 Yes 0 No Participant DataTransfers 0 Yes 0 No
Participant Changes 0 Yes 0 No
11:27
,A C Link HUNK ACCESS FORM — PAGE 2 OF 2
3
Select One: O Add New User ID 7 Update User ID 7 Remove User ID
" -
Name:
Tide:
Email Address:
Daytime Phone Number. (---- --- _--
Aare, Option, (Yon mrutselea eitheryer or no for each agar option):
Balance Inquiry O Yes O No File Transfer O Yes (3 No
Enrollmencs/Rehire O Yes O No Participant Data Transfers O Yes O No
Participant Changes O Ya O No
.............................................................................................................................................
Seim One: O Add New Ute ID O Updam User ID O Remose Use ID
Name:
Thtla
Emat Address:
Daytime Phone Number: (_ _ _ _ _ -
Aorm Option, (Ym msatte/at admr)a or no for each agar option):
Balance Inquiry O Ya O No File Transfer O Ya O No
Enrollments/Rehire O Ya O No Participant Data Transfers O Ya O No
Participant Changes O Ya O No
4
ICMA-RC considers participant information to be highly confidential, and we go m great kngdu
Pommy (amen Apprard
to avoid breaching that confidentiality. For this reason, ICMA-RC cannot be responsible far (i)
negligent or intentional misuse of the password by the municipality's officers, employees, agents or
contractors. (ii) a breach of confidentiality that may occur at a result of such negligent or intentional
misuse of the passtvord, or (iii) a breach of confidentiality that may oaur u a proximate result of the
municipality's access to the participant database. If the municipality uses EZlink online transaction
processing, please remember to review all financial information you have entered for your partici-
pants, as ICMA-RC is not mpomibk for incomes daa transmitted by the municipality. ICMA-RC
recommends that you encourage all participants to review confirmations for amrracy. M, Jain User
IDs that have not been used within a consecutive eighteen month period will be systematically
deleted to fiuther protect the security of your plan and participant data
ICMA-RC's website is normally available 24 hours a day, .seven days a week. However, service
availability is not guaranteed. Neither ICMA-RC or its afhliatea, the VmtageTnrat Company, nor
'Ihe Vanagepoint Funds will be responsible for any Ion (or forgone gain) you may incur as a result
of service being unavailable.
Please signify your agreement to these rams by signing in the space indicated below We will provide
you with User ID(s) and Password(;) m begin using EZLink. Should you have questions, please call
our EZLink Team at I-800-326-7272.
Agread: Darr.
Print your name:
For ICMA-RC Internal Use Only:
EZUnkPn..y NBS EZIinkQA DatsSoomy
11:28
DECLARATION OF TRUST OF THE
NAME OF EMPLOYER
INTEGRAL PART TRUST
11:29
22872MI5-1276
DECLARATION OF TRUST OF THE
(NAME OF EMPLOYER)
INTEGRAL PART TRUST
Declaration of Trust made as of the
20, by and between
the a
Urws d Fmsbprl )Hud Iles d faNryl
(Irndoafter referred m at the "Employer") and or its designee (hemm fter referred to as the "Trustee').
IFws n TFIh d Inrlxl
RECITALS
WHEREAS, the Employer is a political subdivision of the State of exempt from
ISmA
federal income ria under the Internal Revenue Code of 1996; and
WHEREAS, the Employer provides for the security and welfare of its eligible employees (hereinafter mkmod to as
"Participants"), their Spouses and Dependenu by the maintenance of one or more post-retirement welfare benefit plans,
programa or arrangements which provide for life, sickness, medical, disability, seveunce and other similar benefits through
insurance and self-funded reimbursement plans (collectively the "Plan"); and
WHEREAS, it is an essential function and integral pan of the exempt activities of the Employer to assist Participants,
their Spouse, and Dependents by nuking contributions to and accumulating assets in the trust, a segregated fund, for post-
retirement welfare benefits under the Plan; and
WHEREAS, the authority to conduct the general operation and administration of the Plan is vested in the Employer or its desigrree,
who has the authority and shall be subject to the ducts with respect to the mut specified in this sample Dm6 atlon of Tmrt; and
WHEREAS, the Employer wishes to establish this trust to hold suets and income of the Plan for the exclusive berrefir of Plan
Participants. their Spouses and Dependents;
NOW, THEREFORE, the patties here. do hereby esublidt this trust, by executing the ample
Declaration of Trust of the Integral Part Trust (hereinafter mkmed
IFrws sl Fgbryrl
to as the'Trust'), and agree that the following comritme the sample Declaration of Trust (hereinafter referred to as the
"Declaration"):
11;30
ARTICLE I
Definitions
1.1 Definitions. For the purposes of this Declaration, the following terms shall have the respective meanings set forth below
unless mherwiw expressly provided.
(a) "Armunt" means the individual recnrdkesping account maintained under the Plan to record the interest of a
Participant in the Plan in accordance with Section 7.3.
(b) "Administrator" means the Employer or she entity designated by the Employer m arty our administrative services
as are necessary to implement the Plan.
(c) "Beee6ciary" means the Spouse and Dependsms, who will receive any benefits payable hereunder in the event
of the Participants death. In the case where there is no Spouse or Dependents, any amount of contributions, plus
accrued earnings thereon, remaining in the Account most revert in accordance with the Employer's election under
Section VIII of the VantageCare RHS Adoption Agreement.
(d) "Code" mum she Internal Revenue Code of 1986, a amended from time m time.
(e) "Dependent" means (a) the Participani s lawful spouse, (b) the Partkip2an s child under the age of 27, a defined
by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010-38, or (c) airy other individual who is a penin
described in IRC Section 152(x), m clarified by Internal Revenue Service Notice 2004-79.
(f) "Imeatment Fund" means any separate investment option or vehicle selected by the Employer in which all or a
portion of the Trust asaeu may be separately invested as herein provided. The Tmsece shall not be required m select
any Investment Fund.
(g) "Nonforfdtable Interest" means the interest of the Participant or the Participants Spouse and Dependent
(whichever is applicable) in the percentage of Participant's Employers contribution which has vetted pursuant to
the voting schedule specified in the Employers Plan. A Participant shall, at all time, have a one hundred percent
(100%) Nonforfeitable Interest in she Participants own contributions.
(h) "Spouse" means the Participants lawful spouse a determined under the laws of the jurisdiction in which the
Paericipant was married.
(7 "Trott" means the trust established by this Declaration.
(I) "Trustee" meant the Employer or the person or persons appointed by the Employer to serve in dist capacity.
ARTICLE 11
Establishment of Trust
2.1 The Trus, is hemby established as of rhe dam set forth above for the exclusive benefit of Participants, their Spouses and
Dependents.
ARTICLE III
3.1 Thu Tms[ and its validity, conatrocrion and cff r shall be governed by the laws of he Stare of
3.2 Proununs and mher similar words used herein in the masculine gender shall he read as the feminine gender where
appropriate, and the singular form of words shall be read as the plural where appropriate.
3.3 If any provision of this Trust shall be held illegal or invalid for any reason, such determination shall nm affca the
remaining prwuiom, and such prwisiom shall be constnud to effectuate the purpose of this Trust.
ARTICLE IV
Benefits
4.1 Bawfics. This Trust may provide benefit to the Participant, the Participants Spouse and Dependents pursuant to the
terms of the Plan.
4.2 Form of Benefits. This Trust may reimburse the Participant, his Spouse and Dependents for insumnce premiums or
other payments expended for permissible benefits described under the Plan. This tract may reimburse the Employer, or
,he Administrator for insurance premiums.
ARTICLE V
_�FMgT
5.1 It shall be the dory of the Trustee to hold title to aucrs hell in respect of the Plan in the Trustee's name ar dirseuxi by the
Employer or" c aigtwes In writing. The Trustee shall not be under any duty to compute the amount of contributions
to he paid by the Employer m to take airy steps to "Ilea such amounts as may be due to be held in trust under the Plan.
The Tmstce shall out be responsible for the asmdy, investment, safekeeping or disposition of any asses comprising rhe
Trust, to the extent such functions are performed by the Employer or the Administrator, or both.
5.2 It shall be the duty of the Employer, subject m the provisions of the Plan, to pay ewer to the Administrator or other person
designated hereunder from time to time the Employers contributions and Participants' wmribu[ions under the Plan and
ro inform the Trustee in writing as to the identity and value of the assets titled in the Trustees mote hereuruder and to
kap accurate book. and record. with respect to the Participants of the Plan.
ARTICLE VI
6.1 The Employer may appoint one or more inveament managers to manage and control all or part of the assets of the Trust
and the Employer shall notify the Trus cce in writing of any such appointment.
6.2 The Trusts shall sur have any discretion or authority with regard to the imerment of the Truve and shall act solely as
a directed Trusrce of the sues of which it holds title. To the eaten[ directed by the Employer (or Participant, or their
Spouses and Dependents m the extent provided herein) the Trustee is authorized and empowered with the following
Possess, rights and dories, each of which the Trustor shall a mmisc in a nondiscretiomry manner.
(a) To cause stocks, bonds. securities, mother investments to be registered in its name as Trusts or in the name of a
romance, or to rake and keep the same unregistered;
1132
(b) To employ such agents and legal counsel as it deems advisable or proper in connection with in duties and m pay such
agents and legal mantel a ...able fee. The Tnsree shall our be liable for the acts of such agents and.... or
for the sera done in good faith and in reliance upon the advice of such agents and legal counmL provided it has used
reasonable ears in selecting such agents and legal counsel;
(c) To exercise where applicable and appropriate any rights of ownership in any contracts of insurance in which any pan
of the Trust may be invested and to pay the premiums thereon; and
(d) Ac the direction of the Employer (or Participant, their Spouses, their Deptrdenrs, or the investment manager, so the
ease may be) to sell, write options on, convey or transfer, invest and reinvest any part thereof in each and every kind of
property, whether real, personal or mixed, tangible or intangible whether income or nominmme producing and wherever
situs ed, iruludirg but not limited rte, time depocits (including rime deposits in rine Trustee or in affiliate, or any successor
ch... if the deposits bet a reasonable rate of instant), share of common and preferred stork, mortgage, bods, I.,
nate, debesturec, equipment or collateral trust certificares, rights, warrants, convertible or tuhangeable securities and
other corporate, individual or government securities or obligations, annuity, retirenem or other insurance contracts,
mutual funda (inckding funds for which the To. or in affiliates serve u investment dvi.. custodian or in a similar
or mlared capacity), m in units of any ether common, collective or commingled tort fund.
63 Notwithstanding anything to the contrary herein, the asters of the Plan shall be held by the Trustee so tide holder only.
persons holding custody or possession of assets titled to the Trust shall include the Employer, the Administrator. the
vestment manager, and any agents and subagents, but not the Truster. The Trustee shall rot be responsible or liable
for any lou or expense which may arise from or result from compliance with any direction from the Employer, the
Administrator, the imermens manager, or such agents to take rite to any saxes nor shall the Trustee be responsible or
lube for any loss or expense which may result from the Trustee's refusal or failure to comply with any direction m hold
title, except if the same shall involve or mulr from the Tmsree's negligence or intentional misconduct. The Tmstee may
refuse to comply with any direction from the Employer, the Administrator. the investment manager, or such agents in the
event aha[ the Tonsure, in in sole and absolute diseretion. deems such direction illegal.
6.4 The Employer hereby indemnifies and holds the Trustee karmles from any and all actions, claims, demands, liabilities,
losses, damage or reasonable expenses of wharseever kind and mrure in connection with or arising our of (i) any
action taken or omitted in good faith by the Trustee in accordance with the directions of the Employer or is agents
and subagent hereunder, or fid any disbursements of any pan of the Trus made by the Trustee in accordance with
the directions of the Employer, or (iii) any action taken by or omitted in good faith by the Trustee with respect to an
investment managed by an investment manager in accordance with any direction of the investment manager or any
inaction with respect to any such investment in the absence of directions from the im ormenr manager. Notwithstanding
anything to the contrary herein, the Employer shall have no responsibility to the Trustee under the foregoing
indemnification if the Trustee fails negligently, intentionally or recklessly to perform any of the duties undertaken by it
under the provisions of this Trust.
6.5 Notwithstanding anything to the contrary herein, the Employer or, if w designated by the Employer, the Administrator
and the investment manager or another agent of the Employ". will be responsible for valuing all asses w squired for
all purposes of the Trost and of holding, investing, trading and disposing of the same The Employer will indemnify
and hold the Trustee harmless against any and al l claims. actions, demands, liabilities, loses, damages, or expense
ofwharroever kind and nature, which arise from or are related to any use of such valmtion by the Trmree or holding,
trading, or disposition of such assets.
6.6 The Trustee shall and hereby does indemnify and hold hanmest the Employer from any and dl actions, claim, demands,
liabilities, losses, damages and mawnable, expenses of whatsoever kind and mrure in connection with or aching our of
(a) ch. Trustee. failure to follow the directions of the Employer, the Administrator, the investment manager, or agents
thereof, except as permitted by the last senteme of Section 6.3 above; (b) any disbursements made without the direction
of the Employer, the Administrator, the investment manager or agents thereof, and (c) the Trustee's negligence, willful
misconduct, or mckemness with respect to the Trustee's duties under this Declaration.
IL33
ARTICLE VII
Conh9btalons
71 Employer Contributions. The Employer shall contribute to the Trust such amounts as specified in the Plan or by
r<solufian.
72 Accessed lave. Contributions up to an amount equal w the value of setrued sick have, vacation Iesve or other type
of accrued leave, as permitted under the Plan. The Employer's Plan must provide a formula for determining the value of
the Participants contribution of accrued [cave. The Emplorr's Plan must contain a forki.te provision that will prevent
Participants from receiving the accrued have in cash in lim of a contribution m the Trost.
73 Accounts. Employer contributions, including mandatory Participant contributions, and contributions of accrued leave,
all investment intone and realized and unrealized gains and losses, and forfdtuees allocable thereto will be deposited
into an Account in the nnme of the Participant for the esclusive bene6r of the Participant, his Spouse and Dependrns.
The status in each Participant's Account may be invested in Investment Funds u directed by the Participant (or, after
the Participants doth, by the Spouu or Dependents) or the Employer, as required under the Plan, from among the
Investment Funds selected by the Employer.
7.4 Reocipt ofCesstsibadom. The Employer or, if so designated by the Employer, the Administrator or investment manager
or another agent of the Employer, shall receive all contributions paid or delivered to it hereunder and shall hold, invest,
reinvest and administer such contrib.ons pursuant Or this Declaration, without distinction between principal and
income.'the Trustee shall not be responsible for the calculation or collation of any contribution under the Plan, but shall
hold title to property received to respect of the Plan in the Truara's name as directed by the Employer or is designs,
pursuant to this Dedantion.
7.5 No amount in any Accounr maintained under this Trust shall be subject to tmnskr, assignment, or alienation, whether
voluntary or involuntary, in favor of any crod'nror, uunskree, or assignee of the Employer, the Trance, any Participant, hu
Spouse, . Depnndrnt.
7.6 Upon the satisfaction of all liabilities under the Plan m provide such bea6rs, any amount of Employer contributions,
phis accrued earnings thereon remaining in such "nor Accounts most, under the terms of the Plan, be returned to the
Employer.
ARTICLE VIII
C41w PIMs
If the Employer hereafter adopts one or more other plans providing life, sickness, accident, medical, disability, severance,
or Other benefits and deaigrutn the Trost hereby created as, part of such other plan, the Employer or, if so designated by the
Employer, the Administrator or an investment manager or anther agent of the Employer shall, subject to the terms of this
Declaration. accept and hold hereunder contributions m such other plans. In that event (a) the Employer or, if so designated
by the Employer, the Administrator or an investment manager or anther agent of the Employer, may commingle for
investment purposes the contributions received under such other plan or plans with the contributions previously received by
the 'I'mst, but the books and records of the Employer or, if w designated by the Employer, the Administrator or an investment
manager or another age. of the Employer, shall at all time show the portion of the Trust Fund allocable to each plan: (b) the
term "Pan". used herein shall be deemed m refer separately to each other plan; and (c) the term "Employer" as used herein
shall be deemed to refer to the person or group of persons which base been designated by the terms of such other pans as
hiring the authority to control and manage the operation and administration of such other plan.
1134
ARTICLE IX
Disbursements and Expenses
9.1 The Employer or its designr« shall nuke such payments From ch<Trust at such time co wch persons and to such amounts
as shall be authorized by the provisions of the Plan provided, however, that no payment shall be made, either during the
exisnnce of or upon the disenntinuance of the Plan (subject to Section 76), which would cmw any part of the Trust m
be used for or diverted m purposes ocher than the exclustve benefit of the Participants, their Spouses and Dependents
pursuant to the provisions of the Plan.
9.2 All payments of betrefits under the Phm shall be made exclusively form the assets of the Accounts of the Participants m
whom m to whose Spouse or Dependents such payments arc to be made, and no person shall be entitled to look to any
other source for such payments.
9.3 The Employer, Trustee and Administrator may be reimbursed for expenses reasonably incurred by them in the
administration of the Trust, All such expenses, including, without limitation, reasonable fres of accountants and legal
counsel to the eaten not otherwise reimbursed, shall constitute a charge against and shall be paid From the Trust upon
,he direction of the Employer.
ARTICLE X
10.1 The Trusre, shall rat be required to keep accounts of the investments, receipts, disbursements, and other transaction of
the Trust, except as necessary to perform in rick -holding function hereunder. All accounts, books, and records relating
the em shall be maintained by the Employer or in designer.
10.2 As promptly a potsibk following the dose of each year, the Trustee shall file with the Employer a written account setting
forth assets tided in the Trust as repotted to the Truster by the Employer or in designee.
fYt1scekr1 s Plovisiam
11.1 Neither the Trntec nor any aBrliam thereof shall be required to give any bond or in qualify before, be sppaintd by, or
account m any court of law in the exercise of in powers hereunder.
11.2 No person tmnsferting title or receiving a transfer of title from the Trusrce shall be obligated on look to the prop try of
the acts of the Troatee in connection therewith.
11.3 The Employer may engage the Trustee as in agent in the performance of any duties tequned of the Employe under the
Plan. bot such agency shall not be deemed to increase the responsibility or liability of the Trusom under this Declaration.
I IA The Employer shall have the right at all reasonable times during the term of this Declaration and for three (3) years
after he trrmin sumn of this Declaration to examine, audit, inspect, review, extract information from and copy all
books, records, accounts. and other documents of the Trustee relating m this Declaration and the Trusted perfomhame
hereunder.
11:35
ARTICLE XII
Amendment and Termination
12.1 The Employer reserves the right to alret, amend, or (subject to Section 9.1) terminate this Declaration at any time for any
reason without the ooment of the Trustecor any usher person, provided that no amendment affecting the rights, duties,
or responsibilities of the Trustee dull be adopted without the etecution of the'l navere to the amendment. Any such
amendment shall become effmtivc as of the dam provided in the amendment, if requiring the Tources esmution, or on
delivery of the amendment to the Trustee, if the Trwtees ersecutinn is nm required
12.2 Upon termination of this Declaration and upon the satisfaction of all liabilities under the plan to provide such benefits,
any amount of Employer contributions, plus secured earnings thereon, remaining in such separate Accounts must, under
the terms of the Plan, be returned to the Employer.
ARTICLE XIII
Successor Trustees
13.1 The Employer reserves the right to discharge the Trustee for any or no reason, at any time by giving ninety (90) days'
advance wriae r novice.
13.2 The Trust« reserves the right to resign at any time by giving ninety (90) days advance written notice m the Employer.
13.3 In the event of discharge or resignation of the Trustee, the Employer may appoint a successor Trustee who shall succeed
w 211 rights, duties, and responsibilities of the former Trustee under this Declaration, and the terminated Trusts shall be
rimmed discharged of all duties under this Declaration and responsibilities for the Tiut.
ARTICLE XIV
Limited Effect of Plan and Trost
Neirher the esnWnbracnr of the Plan and the Trust or any modification themof, the creation of any fund m account, nor
the payment of any benefits. shall be comtrued as giving in any person covered under the Plan or other person any legal
or equitable right against the Trus ec, the Administrator, the Employer or any officer or employee thereof, except as may
otherwise be expressly provided in the Plan or in this Declaration.
11:36
ARTICLE XV
Protective Clause
Neither the Administrator, the Employer, nor the Trusrec shall be respomible for the validity of any contract of insurance or
other arrangement maintained in connection with the Plan, or for the failure on the pan: of the inmrer or provider to make
payments provided by such contract, or for the action of any per s n which may delay payment or render a contract void or
unenforceable in whole or in part.
IN WITNESS WHEREOF, the Employer and the Trmree have acecuted this Dcclaradon by their respective duly authorised
officer, as of the dare fin, hereinabove mentioned.
EMPLOYER:
By
7RUSTEE(s):
1107
ICM C
NAME OF EMPLOYER
RETIREE WELFARE BENEFITS PLAN
RETIREE WELFARE BENEFITS PLAN
Table of Contents
ic4RC
Article I Preamble
I.OI Esublishment of Plan
1.02 Purpose of Plan
Article II DefiniYsons
2.01 "Benefits"
2.02 "Cade"
2.03 "Dependent"
2.04 "Eligible Medical or Denul Expenses"
2.05 "Employer"
2.06 "Entry Dare"
2.07 "Participant"
2.08 "Plan Adminuustem"
2.09 "Plan Year"
2.10 "Retiree"
2.11 "Spoure"
Article III Eligibility
3.01 General Requirements
Article IV Amount of Benefits
4.01 Annual Benefits Provided by the Plan
4.02 Coat of Coverage
Article V Payment of Benefits
5.01 Eligibility for Benefits
5.02 Claims for Benefits
Article VI Wan Administration
6.01 Allonrion ofAuthadty
6.02 Provision for'Ihird-Patty Plan Service Provide.
6.03 Several Fiduciary Liability
6.04 Compensation of Plan Administrator
6.05 Bonding
6.06 Paynomr ofAdminlstrative Expenses
6.07 Timeliness of Payments
6.08 Annual State...
11:39
Table of Contents (continued)
Article VII Claims Procedure
7.01 Procedure if Benefits an, Denied Uttder thr Plan
7.02 Requirement for Written Notice of Claim Denial
7,03 Right to Request Hearing on Benefit Denial
7.04 Disposition of Disputed Claim
7.05 Preurva,ion of Other Remedies
Article VIII Amendment or Termination of Plan
8.01 Permanent,
8.02 Employer's Right w Amend
8.03 Employer's Right to Tcrminare
Article IX General Prwisions
9.01 No Employment Rights Conferred
9.02 Payments to Survivor
9.03 Nmulieoation of Benefits
9.04 Mental or Physical Incompetency
9.05 Inability w l.oc w Pays
9.06 Requirement of Proper Forms
9.07 Source of Payments
9.08 Ta: Effect,
9.09 Multiple Functions
9.10 Gender and Number
9.11 Headings
9.11 Applicable Laws
9.13 Sewrabiliry
IL40
Name of Employer
RETIREE WELFARE BENEFITS PLAN
ARTICLE I
Preamble
THIS INSTRUMENT made and published by (ht.m fter called "Employer") an
the day of 20 � cretres the Retiree W86re Bernefins
Plan ("Man"), a follows:
1.01 Establishment of Plan
The Employer named above hereby establishes a Retiree Welfarc Bcncfis Ilan as of the _ day of
20
1.02 Purpose of flan
This Man has been established to rei buve the eligible Retirm of the Employer for medical and dental expenses inenrrcd by
them, their Spouses and l3q a Jena through the Employers VantageCare Retirement Health Savings (RHS) program.
ARTICLE II
Definitions
The following words and phrases as used herein shall have the following meanings, unless a different meaning is plainly
required by the contest.
2.01 "benefits" ma. any amounts paid to a Participant. Spouse or Depcndeus in the Plan as reimbursement for
Eligible Medical and Dental Expenses incurred by the Participant during a Plan Year by him, his Spouse or his Dependent.
2.02 "Cods" means the Internal Revenue Code of 1986, .amended.
2.03 "Dependent" means any individual who is a dependent of the Participant within the meaning of Code Sec. 152,
as amplified by Inrcr.l Revenue Service Notice 2004-79.2004-49 I.R.B.898 and Internal Revenue Service Notice 2010-38.
2.04 "Eligible Medical Expenses or Dental Expenses" mea. those expenses designated by the
Employer as eligible for reimbursement in the Vantagecare Retirement Health Savings Adoption Agreement.
2.05 "Employer" means the unit of stare or local government creating this 1`6n, or any affilcur or successor thereof
that likewise adopt this Man.
2.06 "Entry Data" means the first day the Participant mem the eligibility requirement of Amw k III as dsuch Dae.
2.07 "Participant" means any Retime who has met the eligibility requirements set forth in Article 111.
2.08 "Plan Administrator" mans the Employer. other person appointed by the Employer wM has the authority
and responsibility to manage and direct the operation and administration of the Plan.
2.09 'INan Year" mons the annual —coming period of the Plan, which begins cen the _day of
20 � and ends on the _ day of , 20 with respect to the first Plan Yeas, and thereafter at
long as; this Plan remains in effect, the period that begins on and ends on momh/day
2.10 `Retiree^ meas any individual who, while in the service of the Employer, was considered to be in a legal
employer-employee relationship with the Employer for federal withholding tax purposes, and who was pan of the
classification of employers designated as emceed by the Employer's VantageCaer Retirement Health Savings Program.
2.11 "Spouse" mos the Pa napmes lawful spouse ar determined under he lawt of the jurisdiction in which the
Participant was married All other defined terms in this Plan shall have the mornings specified in the variom Articles of the
Plan in which they appear.
ARTICLE 111
Eligibility
Each Retiree who meets the eligibility requirements outlined in she Employers V moirCarc Retirement Health Savings
Adoption Agreement shall be eligible m participate in this Plan.
ARTICLE IV
Amount of Benefits
4.01 Annual Benefits Provided by the Plan
Each Participant shall be entitled to reimbursement for his documented. Eligible Medical Expenses incurred during the Plan
Year in an annual amount not in exceed the participants account balance under the Plan.
4.02 Cost of Coverage
The expense of providing the be cku set out in Section 4.01 shall be contributed as m at ined in the Employer's V mageC re,
Retirement Health Savings Adoption Agmemau.
ARTICLE V
Payment of Benefits
5.01 Eligibility for benefits
a) Each Participant in the Plan dull be entitled to a berefir hereurder for all Eligible Medical Expenses material by dee
Participant on or after the Entry Dare of his or her participation (and after tine e(Yectme date of the Plan), object to the
barbarous; confined in this Addc V, raprdless whether the mend or physical condition for which due Participant maks
application for bnhefits under this Plan war derated, diagnosed, or rran 1 befo rc rhe Participant became cmered by the Plan.
b) In order m be eligible for benefits, the Participant most separate from service or separate from service and mst the benefit
eligibility criteria outlined in the Employer's VanageCare Retirement Health Savings Plan Adoption Agreement.
c) A Participant who becomes mdly and permanently disabled in defined by the Soda] Security Administration. by the
Employer's priory retirement plan, or otherwise by the Employer) will become imnudiaody rligiblc in naive medical bca efir
payments from the Plan. Pursuant to Section 9.02 of this Plan and Section )a of the Employer's Vanragrfaa generation
Hath Savings Adoption Agnomen, the surviving Spouse and Depe dots tell become immediately eligible m rcrewc or to
snrisim morning medical bene fir payments from the Plan upon the death of the Participant.
IL42
5.02 Claims for Benefits
No benefit dull be paid hereunder on" a Participant, his Spouse or Dependent has fine submitted a written claim for
bmefio to the Plan Administrator on a form specified by rhe Plan Administrator, and pursuant m the procedures set out in
Article V1, below. Upon receipt of a properly documented claim, the Plan Adminutemor shall pay the Participant, his Spouse
or Dependent the hawfis provided under this Plan as soon as is administratively l sible.
ARTICLE VI
Plan Administration
6.01 Allocation of Authority
The Employer shall control and manage the operation and Administration of the Plan. 7Le Employer shall have the eschuive
right to insane[ the Plan and to decide all mattes arising thereunder, including the right m remedy possible ambiguities,
imesuistencies, ce omiuiosu. All determinations of the Employer with respect m any matter hereunder shall be conclusive and
binding on all persons.
Without limiting the gcocrality of the foregoing, the Employer shah have the following powers, and duties:
a) To decide on questions concerning the Plus and the eligibility of any Employee to participate in the Plan, in accordance
with tine provisions of the Plan:
b) To desermine the amount of brMfits that shag be payable to any person in accordance with the provisions of the Plan; m
inform the Plan Administrator, ar apprespdaee, of die amount of such Benefiu; and to provide a full and fair review many
Participant whose claim for benefits has been denied in whole or in pato and
e) To doignsre otter pmam to carry om any duty or power which would otherwise be a fiduciary responsibility of the Plan
Adermistem r, under the reran, of the Plan.
d) To negww arty person to fomuh such reasonable information as it may request for the purpose of the proper administration
of the Plan as a condition to rneiving any benefits under the Plan;
e) To nuke and enf rat such odes and tegulatiom and prescribe the use of such forms as he shall deem n esawary for the
efficient administration of the Plan.
6.02 Prevision for Third -Party Plan Sorvice Providers
The Plan Administrator, subjmr to, approval of the Employer, may employ the services of such posom a, it may deem
necessary or desirable in connection with operation of the Plan. The Plan Administrator, the Employer (and any person
to whom is may delegate any duty or power in connection with the administration of the Plan), and all persons amnsecred
therewith may rely upon all cables, valuations, urtificsser, reports and opinions furnbhcd by any duly appointed actuary,
actoumane, (including Employss who arc actuaries or accountants), cesmuinnt, third party administration service provider.
legal ..ad. or Ochs specialist, and they shall be fully persecrod in respect to any action taken me permitted in good faith in
Mi.. thereon. All actions so caken or permitted shall be conclusive and binding ar to all pe..
6.03 Several Fiduciary Liability
76 the extent permitted by law, neither the Plan Administrator we any other person shall incur any liability for any aces or for
failure to act except for his awn willful misconduct or willfit breach of this Man.
11:43
6.04 Compensation of Plan Administrator
Unless otherwise agreed to by the Emphrycr, the Plan Administrator shall serve without compensation for services tendered in
such capacity, but all reasonable expenses incurred in dw performance of his duties shall be paid by the Employer.
6.05 Bonding
Unless otherwise determined by the Employer, or unlas required by any Federal or Sure law, the Plan Administrator shall no
he required to give any bond or other secu dry in any jurisdiction in connection with the administration of this Man.
6.06 Payment of Administrative Expenses
All reasonable expenses incurred in administering the Man, including but not limited to administrative tea and eapensa
owing to any third party administrative service provider, actuary, consultant, atmuntam, as mnry, specialist, or other person
Or organisation that may be employed by the Plan Administrator in connection with the administration thereof, shall be
paid by the Employer, permided, however that each Particpana shall bear [he monthly cots (if any) charged by a third party
administrator for maintenance of his Benefit Account unless m eesue paid by the Employer.
6.07 Timeliness of Payment for Benefits
Payment for Benefice shall be made as soon as administratively feasible after she requited forms and documentation have been
received by the Man Administrator.
6.08 Annual Statements
The Man Adaimismator shall furnish each Participant with an annual staacment of his medical aperue reimbursement
account within ninety (90) days after the close of each Man Year.
ARTICLE VII
Claims Procedure
7.01 Procedure if Benefits are Denied Under the Plan
Any Participant, Spouse, Deperrdenp or his duly authorized representative may file a claim for a plan benefit to which the
claimant believes that he h entitled, Such a claim must be in writing on a form provided by the Plan Administrator and
delivered to the Man Administrator, in person or by mail, postage paid. Within thirty (30) days after receipt of such claim,
the Plan Administrator shall send m the claimant, by mail, postage prepaid, notice of the granting or denying, in whole or
in pass, of such claim, unless special circumstances; require an attention of rime for processing the claim. In no event may
the er[emlon aceed forty-five (45) days from the end of the initial period. If such atemion is tsecewary, the claimant will
be given a written notice m this effect prior to the expimdon of the initial 30 -day period. Ifeuch execution is necessary due
on a failure of the Participant, Spouse or Dependent to submit the information oecon ary to decide the claim, the undo, of
earcusion shall describe she requited information and [k c6inum dull be afforded at least forty-five (45) days from receipt
of the notice within which to provide such information. The Plan Administrator shall have full disco tion m deny or grant a
claim in whole or in part. If notice of the denial of a claim is we furnished in accordance with this Station, the claim dull be
discord denied and the claimant shall be permitad to exercise his right [o review Pursuant to Sections 703 and 7.04.
M44
7.04 Requirement for Written Notice of Claim Denial
The Plan Admimstntor shall provide, m everyclaimant who u denied a claim fin benefits, written muco setting forth in a
manner calculated to be understood by the claimant.
a) The specific reason or reswum for the denial:
b) Specific reference to pertinent Plan provisions, including references to the VantageCire Retirement Health Savings
Adoption Agreement. on which the denial is bawd,
c) A description of any additional material of infomudon necessary for the claimant to perfect the claire and an explan sion
of why such material is necessary, and
d) An explanation of the Plan's claim review procedure.
7.03 Right to Request Hearing on Benefit Denial
Within one -hundred eighty (180) days after the receipt by the claimant of written notificaion of the denial (in whole m in
part) of his claim, the claimant or his duly authorised represmtuive, upon written application to the Plan Administrator, in
person or by certified mail, postage prepaid, may request a review of such denial, may review pertinent documents, and may
submit issues and comments in writing
7.04 Disposition of Disputed Claims
Upon m receipt of entice of a mgrus for rev'ow, the Plan Administrazor shall ma4e a pompe decision on sec review. Tire derision
on review shdl6cwritten in a mannec ralcolaod to be umdenmod by the claimant and shall include epaific masaru fm the hrisiar
and specific refn n to the pertircnt plan provisions on which the decision u based. The decision on nview shall he made not later
than vary (60) days afer the Plan Administrators «rcipt of request for a review, unless special circumstances require an exannon
of time far processing, in which ccs a decision shall be mndeced nor lam than arc hu dmd-twenty (120) days afre ncap, of a
request for review. If an summon is necessity, the claimant shill be given written notice of the extension prom to the expiration of
the initial sixty (60) dry pr i If notice of the decision on dw review is nor famished in accordance with this Sectim the claim
shall bedeemrd denial and the daitnum dull be permitted to ererds his right to legal remedy pursuers to Section 7.05.
7.05 Preservation of Other Remedies
Afrcr eshaustion of the claims procedures provided under this Plan, nothing shall prevent any penton from pursuing any who
legal or equitable remedy otherwise available.
ARTICLE Vlll
Amendment or Termination of Plan
8.01 Permanency
While the Employer fully expects that this Plan will continue indefinitely, due m unforeseen, future business contingencies,
permanency of the Plan will be subject: to the Employer's right to vnerd or terminate the Plan, as provided in Section; 8.02
and 8.03, below.
I[45
8.02 Employer's Right to Amend
Mac Employer reserves the right in amend the Plan ae any time and from rime-ro-rime, and retroactively if deemed necessary,
or appropriate to marc the requirements of the Code, or any similar provisions of suhsequent revenue or other laws, or the
mles and icgulatiom in effect under any of such laws or to conform with governmental regulations or other polities. in
modify or amend in whole or in part any in all of the provisions of the Plan.
8.03 Employer's Right to Terminate
The Employer reserves the right to discontinue or terminate the Plan at any time without prejudice
ARTICLE IX
General Provisions
9.01 No Employment Rights Conferred
Neither this flan nor any action taken with respect to it shall conkr upon any person the right ro be continued in the
employment of the Employer.
9.02 Payments After Death of Participant
Any benefiva otherwise payable to a Participant following the date of death of such Participant shall be paid as outlined in
Section XI of he Employer's VannrCare Retiminem Health Savings Plan Adoption Agreement.
9.08 Nonalienation of Benefits
No benefit under the Plan shall be subject in any manner in anticipation, alienation, sale, mmfer, assignment, pledge,
encumbrance or charge, and any attempt to do so shall be mid. No benefit under the Plan shall in any manner be liable for
or subject to the debts, contracts, liabilities, engagements or two of any person. If any person entitled to benefits under the
Plan becomes bankrupt or attempts to anticipate, alienate, sell, confer, assign, pledge, encumber or charge any benefit under
the Ilan, or if any attempt is made to subject any such benefit in the debts, contracts, liabilities, engagements or cons of the
person entitled in any such benefit, except as specifically provided in the Plan, then such benefit shall cease and ustainate
in the discretion of the Plan Administrator, and he may hold or apply the nine or any part thereof to the benefit of any
dependent of such person, in such manner and proportion as he may deem proper.
9.04 Mental or Physieal Incompetency
If the Plan Administrator determines that any person entitled in payments under the Plan is incompetem by rasun of physical
m mental disabiliry, he may cause all payments thereafter becoming due in such person to be made to any other person for
his benefit, without responsibility to follow the application of amounts ro paid. Payments made pursuant to this Section shall
completely discharge the Plan Adminiantor and the Employer.
9.05 Inability to Locate Payee
If the Plan Administrator is unable to make payment to any Participant or other person m whom a payment is due under
the Plan because he canmat sscertain the identity or whereabouts of such Participant or other pecan after reasonable efforts
have been made to identify or locate such Person (including a notice of the payment an due mailed to the hat known address
of such Participant or other person as shown on the records of the Employer), such payment and all subsequent payments
otherwise due in such Participant or other person shall be eacheated under the laws of the State of the last known address of
the Participant or other persons eligible for benefits.
9.06 Requirement of Proper Forms
All communications in connection with the Plan made by a Participant shall become effective only when duly executed on
forms provided by and filed with the Plan Administrator.
9.07 Source of Payments
The Employer shall be the sole source of benefits under the Plan. No Employee, Sponse or Depetdenn shall have any right m, or
insert in, any assets of the Employer upon rumination of employment or otherwise, un,,pr as provided from dot to time under
the Plan, and then only to the motor of the benefin payable under rhe Plan to such Employee, Spouse or Dependents.
9.08 Tax Effects
Neither the Employer nor the Plan Administrator makes any warranty or other representation as to whether any payments
received by a participant, his Spouse or Dependents hereunder will be neared v includible in grow income for federal or Stam
income ma purposes.
9.09 Multiple Functions
Any person or group of persons may serve in mos than one fiduciary capacity with respect to the Plan.
9.10 Gender and Number
Masculine pronouns include the feminine as well as the neuter gender, and the singular shall include the plural, unless
indicated otherwise by the conmxc.
9.11 Headings
The Article and Section headings contained herein arc for convenience of reference only, and shall nor be construed as
defining or linking the matter contained thermndcr.
9.12 Applkable Laws
The pewisions of the Plan shall be construed, administered and enforced according to the laws of the Stare of
9.13 Severability
Should any part of this Plan subsequently be invalidated by a court of competent jurisdiction, the remainder thereof shall be
given effect to the maximum resent pmAbk.
IN WITNESS WHEREOF, we have executed this plan Agreement the dam and year firs written above.
EMPLOYER
Title:
Signature of Authorised Official
ATTEST (if applicable)
Signature of Armour
11.47
icmARRC
SECTION III:
ADOPTION DOCUMENTS TO RETAIN IN YOUR FILES
PRIVATE LETTER RULING ON INTEGRAL PART TRUST
Internal Revenue Service Department of the Treasury
:index Numcer: .15,02-00 Wasanglnn' Dc 20224
contain Person:
Telephone Numeer
CCefF8'0'Y1&P:2 PLR -116685-99
Date
December 28, 1999
City =
Trust =
State
Dear
This is in response to a letter dated October 12, 1999, and
prior correspondence, requesting a private letter ruling that
Trust is an integral part cf City.
FACTS
City is a political subdivision of State. City currently
maintains one or more poet -retirement welfare benefit plans
(collectively, the "Plan") that provide its eligible employees
("Participants") and their beneficiaries ("Beneficiaries") with
life, sickness, medical, disability, severance and other similar
benefits through insurance and self-funded reimbursement plans.
City intends to establish Trust to hold assets and income of
the Plan for the exclusive benefit of Participants and their
Beneficiaries.
Trust's Declaration defines "Beneficiaries" tc 'nclude a
Participant's spouse, any child of the Participant or the
Participant's spouse who is a minor or a student within the
meaning of section '-Site) (4) of the Internal Revenue Code, any
ether minor child residing with the Participant, and any otxr
individual who is a person described in section 152(a) of the
Code. Death benefits may be provided to any Beneficiary
designated by a Participant under the terms of a death benef_t
program or an insurance contract forninc part co the Pian.
D L?
Hui
to
PLR -116685-99 z
may provide benefits by cash payment, and may reimburse a
Participant, City, or Trust's Administrator for insurance
premiums or other payments expended for permissible benefits
under the Plan.
Under Trust's Declaration, City will be the Administrator of
Trust. City may appoint one or more investment managers to
manage and control all or part of the assets of Trust. Under
Trust's Declaration, the Trustee will hold assets only as
titleholder. Persons having custody or possession of assets may
include City, the Administrator of Trust, the investment manager,
and their agents and subagents, but not the Trustee. The Trustee
will have no discretion or authority with regard to the
investments of Trust and will act solely as a directed Trustee
with respect to the assets to which it holds title.
The Trustee will not be responsible or liable for any lose
or expense that may arise or result from complying with any
direction from the City, the Administrator, the investment
manager, or such agents to take title to any assets, or from the
Trustee's refusal or failure to comply with any direction to hold
title, unless it involves or results from the Trustee's
negligence or intentional misconduct. The Trustee may refuse to
comply with any direction if it deems such direction illegal.
City indemnifies and holds the Trustee harmless from any
actions, claims, demands, liabilities, losses, damages or
reasonable expenses of any kind in connection with or arising out
of (i) any action taken or omitted in good faith in accordance
with its directions, (ii) any disbursements made in accordance
with directions, or (iii) any action taken by or omitted by the
Trustee with respect to an investment managed by an investment
manager in accordance with any direction of the investment
manager or any inaction regarding any investment in the absence
of directions from the investment manager. City, however, has no
responsibility to the Trustee under the indemnification if the
Trustee fails negligently, intentionally, or reckless to perform
its duties.
City will contribute to Trust such amounts as specified in
the Plan or by resolution. No other person or persons will be
Permitted to make any contributions.
The Plan must provide a formula for determining the value of
a Participant's accrued vacation leave, sick leave, or both, in
excess of a threshold number of hours of such leave. City :nay
contribute amounts so determined to Trust. The Plan will contain
a forfeiture provision that will prevent Participants and their
Beneficiaries from receiving cash in lieu of a contribution to
Trust in their behalf. Contributions, investment income,
.0
realized and unrealized cains and losses, and forfeitures •'1' :e
deposited into an account - in Trust in the name of t1e Part=c:cart
M=
PLR -116685-99 3
for the exclusive benefit of the Participant and his or her
Beneficiaries. A Participant may direct the investment of
amounts in her or his account among investments selected by City.
No amount in any account will be subject to transfer, assignment,
or alienation, whether voluntary or involuntary, in favor of any
creditor, transferee, or assignee of City, the Trustee,
Participant or Beneficiary.
City or the Administrator, investment manager, or other
agent designated by City will receive contributions and will
hold, invest, and administer contributions without distinction
between principal and income. The Trustee will not be
responsible for the calculation or collection of contributions,
but will hold title to property received as directed by City or
its designee. The Trustee will not be required to keep accounts
of the investments, receipts, disbursements, and other
transaction of Trust except as necessary to perform its title -
holding function. City or its designee will maintain all books
and records.
City reserves the right to alter, amend, or terminate Trust
at any time for any reason without the consent of any person. No
amendment affecting the Trustee is effective without the
Trustee's consent, and no termination can result in any part of
Trust's assets being used for or diverted to Purposes other than
the exclusive benefit of Participants and Beneficiaries.
If City adopts other plans providing life, sickness,
accident, medical, disability, severance, or other benefits and
designates Trust as part of such plan, City or its agent will
hold contributions to such plan in Trust. The contributions may
be commingled for investment purposes, but the books and record
Of Trust must show the portion of Trust allocable to each plan.
Upon the satisfaction of all liabilities under the Plan to
provide benefits, any amounts remaining in any account must be
returned to City.
LAW 6 ANALYSIS
Income of an integral part of a state or political
subdivision of a state is not taxable absent specific statutcry
authorization. ,&& Rev. Rul. 87-2, 1987-1 C.B. 18; section
512(a)(2)(B) of the Code, GCM 14407, C.B. XIV -1, 103 (1935),
superseded by Rev. Rul. 71-131, 1971-1 C.B. 28. Whether an
enterprise is an integral part depends on facts and circumstances
such as the state's degree of control over the enterprise and its
financial commitment to the enterprise. If an enterprise is an
integral part of a state or political subdivision of a state, it
will not be created as a separate entity for federal tax
purposes, though it may have been formed as a separate ent`-=-.
,f'Jd.:ld
PLR -116685-99
under state law. Section 301.7701-1(a)(3) of the Procedural and
Administrative Regulations.
City has made a substantial financial commitment to Trust by
providing all of its funding. City retains complete control over
Trust because it may amend or terminate Trust at any time. City
retains control over the daily operation of Trust by its power to
appoint or remove agents who manage daily operation. The Trustee
is merely a title holder with no power to manage Trust.
CONCLUSION
Provided that City is the only person that makes
contributions to Trust, and Trust accepts or holds only amounts
of money contributed by City, Trust will be an integral part of
City, and any income earned on amounts in Trust will not be
subject to federal income tax.
This ruling is directed only to the.taxpayer that requested
it. Section 6110(k)(3) of the Code provides that it may not be
used or cited as precedent.
Except as specifically provided otherwise, no opinion is
expressed on the federal income tax consequences of the
transaction described above.
In accordance with the terms of a power of attorney on file
in thin office, a copy of tt' letter is being sent to your
authorized representative.
Sincerely,
Assistant Chief Counsel
(Financial Institutions & Products)
By: William Coppersmith
William E. Coppersmith
Chief, Branch 2
111:6
ICAAC
IMPORTANT INFORMATION ON
WELFARE PLAN NONDISCRIMINATION RULES
4R
C Retiree Health Program
BUIC SECTOR
REIOING EMENT 0ECURITY Nondiscrimination
RETIREMENT SECURITY
Important Information on Welfare Plan
Nondiscrimination Rules
AN EMPLOYER'S RETIREE HEALTH PROGRAM
(LE., VANTAGECARE RETIREMENT HEALTH
SAVINGS (RHS) PIAN/4010-0 RETMEE
HEALTH ACCOON'I) will generally be covered
by nondiscrimination requirements that are already
applicable to the employers other health and welfare plans
(under Internal Revenue Code Section 105(h)).
However, please note that nondiscrimination
requirements will not adversely impact year Retiree
Health Program (Program) in the following scenarios:
A If the Program is limited to one or more collective
bargaining groups that bargained regarding health
benefits and the Program provides for fixed dollar
contributions for all employees.
B. If the Program limits reimbursements to insurance
premiums only (health insurance premiums,
Medicare supplemental insurance premiums,
Medicare Part B insurance premiums COBRA
insurance premiums, long-term cue insurance
premiums).
Premium -Only Programs are currently excluded
from nondiscrimination testing. However, under the
Affordable Care Act, Premium -Only Programs will likely
be subject to nondiscrimination testing upon home IRS
guidance.
If the Program does not fall into one of the two ster"mos
above, health and welfare nondiscrimination requirements
may adversely impact your Plan.
Generally speaking, if your program does not fall
under one of the two scenarios above, the following
requirements apply.
1. An IRS-appmved proportion of your employees
most be covered. For inamnce, coverage most
be extended m u Inst 70 percent of employees
irements
(excluding put -time and seasonal employees,
employers under age 25, employees with lets than
three years of service, and collectively bargained
employees), Once the employer identifies the
applicable coverage group, up to 30 percent of that
group an be excluded.'
2. Benefits most be provided on a substantially
equal basis to all covered employees. What this
means, in practical terms, is that contributions
must be substantially equal for each participant,
and thus cannot be determined as a percentage of
compensation or based on age or years of service. A
feed dollar contribution would comply.
Please note that "failure" to meet the nondiscrimination
requirements does not result in "disqualification" of
the Program. The ramifications of not meeting the
requirements are that "excess benefits" paid to "highly,
compensated individuals" that participate in the RHS
plan arc taxable as W-2 income to the participant.
An excess benefit is generally equal to the amount of
the benefit made available to the highly compensated
individuals but not made available to other employers.
Highly compensated individuals will generally comet of
the highest paid 25 percent of all employees.
What does all this aNaN?
Employers need to consider nondiscrimination
requirements when developing their Program. The
employer may want to consider talking to benefits counsel
to determine if these rules will impact its participants.
Should an employer establish a program that does not
fall under scenario A or B above and does not meet the
nondiscrimination requirements, the our -of -pock"
expenses paid to highly compensated employees may be
rumble.
You are encouraged to discus the results with a to or
benefits advisor because the IRS rules are complex.
!herr may hr eddt'tiowl assays thctyoar prof..vroddtatufy t& wtdnmmiurion .gairc.ene of/RCf 705(h).
4Zymeae/-2571-1015101"50
RBym6
ICMA REOROMENT CORPORATION 1 777 NORTH CAmOL STREET, NE I WASHINGTON, D[20002-4240
10,202.9624600 I FAX:202962-4601 I TOLL ERR: 800-6697400 I INTERNET: WWW.NMARCORG
1119
OLLMENT
1E
CONTRIBUTION PROCESS
RHS Enrollment/Contribution Process
ICMA-RC's Mink Team will assist the Employer through the RHS enrollment and contribution process.
Please follow the steps below after the plan has been established.
Contact the FZLmk Team (800-3267272) to conduct a teat
Testing mould take up m 2 weeks.
By ele(trani( fund transfer:
Receiving Bank:
Bank ABA for W'irce
Bank ABA for ACH:
Receiving Account Name:
Receiving Account J:
OBI Field (for wire[):•
Company ID (for ACH):
M8,T Bank
022-000-046
022-000-046
Vanragepoint Transfer Agents
89559029
80JODOC
80JOOLr
•T be ON Ftdd and Company ID it the six digit RHS plan number. Tau irsfurmaaon is required to properly
medit your account.
By dtedc
Make checks payable m Vantagepoint Transfer Agents and mail to lockbox address.
Vamagcpoint Tramfer Agents
c/o M&T Bank
P.O. Box 64636
Baltimore, MD 21264-4636
ICMA RETIREMENT CORPORATION
777 NORTH CAPITOL STREET, HE
WASHINGTON, OC 10002-4140
800669-7400
WWW.ICMARC.ORG
PKT000-02 29319 0516 8363 826
IFY 0016