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HomeMy WebLinkAboutAGMT - ICMA Retirement Corporation (VantageCare)0 ADMINISTRATIVE SERVICES AGREEMENT Between ICMA Retirement Corporation and City of Seal Beach • Type: VantageCare RHS Account Number: 803694 • Plan # 803694 ADMINISTRATIVE SERVICES AGREEMENT 41 This Agreement, made as of theday of Ow 4w , 20 )i (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 II 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 II Funds ") available through VantageTrust II for the investment of plan assets as 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 II 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. -2- E Plan # 803694 • AGREEMENTS 1. Acceptance of RES 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 ICMA- 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 RHS Employer 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. Employer 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 Funds, 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 furnished to it by a responsible official of the Employer or any information relating to an individual participant, spouse or dependent that is furnished by such participant, spouse or dependent, and ICMA -RC • -3- 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. Em lover 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 E —Link, the .,nlire pla ^, administration tool provided by ICMA -RC. (d) Employer is responsible for determining that there are 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 Ell • Reimbursement Arrangement, Act ( "ACA "). An employers HIPAA privacy and security created, maintained, received, complying with the ACA. Plan # 803694 subject to applicable provisions of the Affordable Care ponsoring the Plan is responsible for complying with the rules with respect to all protected health information or transmitted in relation to the Plan and is responsible for (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 Fund, 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 • -5- Plan # 803694 Funds. Employer acknowledges that ICMA -RC, including certain of its wholly owned subsidiaries, receives compensation for advisory and other services furnished to the VT III Vantagepoint Funds, which are collective funds serving as the underlying funds to certain VT II 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. 8. Responsibility (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 rule 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 loss, 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 dope 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. %� E Plan # 803694 • 11 Amendments and Adjustments (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, return receipt requested, to (i) Legal Department, ICMA Retirement Corporation, 777 North Capitol Street, N.E., Suite 600, Washington, D.C, 20002 -4240; (ii) Employer at the office set forth in the first 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. is -7- 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 TAI K. frl4ram, CITY MAJA(,E/2 Name and T' le (Please Print) INTERNATIONAL CITY MANAGEMENT ASSOCIATION RETIREMENT CORPORATION By Erica McFarquhar Assistant Secretary Please return an executed com of the Agreement either (a) Electronically to PlanAdoptionServicespicmarc.oro, or (b) In paper form to ICMA -RC ATTN: PLAN ADOPTION SERVICES 777 North Capitol Street NE Suite 600 Washington DC 20002 -4240 M 11 • 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 RHS ( "Covered Entity ") and ICMA -RC ( "Business Associate ") on 12• i i. Ui T 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 City of Seal Beach RHS or its sponsor, acting on behalf of City of Seal Beach RHS is 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 -10- 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. PERMITTED 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 bylaw 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. • - 11 - 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. -12- 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: I. 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; M. 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 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 party 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 ign ture ,J II 12• Irara(h, N MA0A66C Name and -Title (Please Print) Vcem�E- ZI Date INTERNATIONAL CITY MANAGEMENT ASSOCIATION RETIREMENT CORPORATION By U 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- SUGGESTED AFFIRMATIVE STATEMENT FOR ADOPTION OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM Plan Number: 803694 p Name of Employer: City of Seal Beach State: CA Affirmative Statement of the above -named Employer (the "Employer "): WHEREAS, the Employer has employees rendering valuable services; and WHEREAS, the establishment of a retiree health savings progam serves the interests of the Employer by enabling it to provide reasonable security regarding such employees' 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 ") serves the above objectives; NOW THEREFORE, as a duly authorized agent of the Employer, I hereby: ESTABLISH the Employer's ICMA Retirement Corporation's VantageCare Retirement Health Savings Program through the Employer's integral part trust ( "Trust ") and the Employer's welfare benefits plan ( "Plan "); and SPECIFY that the assets of the Plan shall be held in trust, with the following entity or individual serving as trustee (Select one): ❑ the Employer ® the following position within the Employer: Director of Finance /City Treasurer i�,.;� "findnn ��,u.�,Qi ❑ the following group or committee within the Employer: ❑ the following third -party trustee: (w...',p —mm �,nI.,.,a.) (in ....... ora;.a p . .,,.,...i for the exclusive benefit of the Plan participants and their survivors, and the assets of the plan shall not be diverted to 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 Part'Crust in the form of: (Select one) ® 71he sample trust made available by the ICMA Retirement Corporation ❑ The trust provided by the Employer (executed copy attached hereto). SPECIFY that the Finance Director /City Treasurer shall be the coordinator and contact for the Plan and shall receive necessary reports, notices, etc. DATE: 12/11/2017 11 :4 City Manager 'Title of Designated Agent s Sign ure VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) ADOPTION AGREEMENT Plan Number 8 03694 Select as applicable: ❑ Standalone RHS ❑ Integrated RHS []Amendment to Existing Plan ❑d New Platt I. Employer Nam« City of Seal Beach State: CA II. The Employer hereby attests that it is a unit of a state or local government or an agency or instrumentality of one or more units of a state or local government. III. Plan Dates: A. Plan Effectivc Datc 12 -11 -2017 B. Plan Year. Enter the annual accounting period for the RHS program. July 1 to .tulle 30 IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: Citv of Seal Beach RHS V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the Employer's welfare benefits plan identified in Section IV. (check all applicable boxes): ❑ All Employees ❑ All Full -'lime Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively- Bargained Employees (Specify unit(s)) Q Other (specify group(s)) City Manner and txecunve I eam The Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, ordinances, rules, regulations, personnel manuals or other documents or provisions in effect in the state or locality of the Employer. B. Participation Mandatory Participation: All Employees in the covered group(s) are required to participate in the Plan and shall receive contributions pursuant to Section VI. If the Employer's underlying welfare benefit plan is in whole or part a non - collectively bargained plan that allows reimbursement for medical expenses other than insurance premiums, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by highly compensated individuals if the Plan discriminates in favor of highly compensated individuals in terms of eligibility or benefits. The Employer should discuss these rules with appropriate counsel. 11:13 C. Participant Eligibility Requirements 1. Minimum service: The minimum period of service required for participation is -M (write N/A if no minimum service is required). 2. Minimum age: The minimum age required for eligibility to participate is NW (write N/A if no minimum age is required). VI. Contribution Sources and Amounts A. Definition of Earnings The definition of Earnings will apply to all RHS Contribution Features that reference "Earnings ", including Direct Employer Contributions (Section VI.B.1.) and Mandatory Employee Compensation Contributions (Section VLB.2.). Definition of earnings: 25% of Accrued Sick Leave at separation B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions The Employer shall contribute on behalf of each Participant ❑ % of Earnings' ❑ $ each Plan Year ❑ A discretionary amount to be determined each Plan Year ❑� Other (describe): 25% of Accrued Sick Leave at separation 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ❑ Reduction in Salary - —% of Earnings or $ will be contributed for the Plan Year. ❑ Decreased Merit or Pay Plan Adjustment -All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of Mandatory Contributions of Employee Compensation. 3. Mandatory Employee Leave Contributions The Employer will make mandatory contributions of accrued leave as follows (provide formula for determining Mandatory Employee Leave contributions): ❑ Accrued Sick Leave ❑ Accrued vacation Leave ❑ Other (specify type of leave) Accrued Leave An Employee shall not have the right to discontinue or vary the rare of mandatory leave contributions. Non - collectively bargained plain that reimburse medical expenses other than insurance premiums should consults their benefits counsel regarding welfare plan nondiscrimination rules if the employer elects to make contributions bared on a percentage ofearnings. 11:14 C. Limits on Total Contributions (check one box) The total 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 types are defined within the appropriate section above. Q There is no Plan-defined limit on the percentage or dollar amount of earnings that may be contributed. % of earnings Definition of earnings: ❑ Same as Section VIA. ❑ Other ❑ $ _for the Plan year. VII. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) 0 The account is 100% vested at all times. The following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VIR L: Years of Service Vesting Completed Percentage o/0 a� o� % % o� % o� B. The account will become 100% vested upon the death, disability, retirement', of attainment of benefit eligibility (as outlined in Section IX) by a participant. `Definition of retirement includes a separation from service component and is 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 count toward the vesting schedule outlined in A above. VIII. Forfeiture Provisions If a Participant separates from service prior to full vesting, non - vested funds in the Participant's account shall be forfeited in accordance with the box checked under this section. Upon the death of a participant, surviving spouse, and all surviving eligible dependents (as outlined in Section XI), funds remaining in the Participant's account shall be revert to the Trust in accordance with the box checked under this section. 11 :15 If a Participant permanently opts out and waives future reimbursements, as allowed under IRS Notice 2013 -54, all funds in the Participant's account at the time of waiver shall be forfeited in accordance with the Ism checked under this section.* ❑ Remain in the Trust to be reallocated among all Plan Participants with a balance as Direct Employer Contributions for the next and succeeding contribution cyde(s). ** ❑ Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants with a balance. ** ❑ Remain in the That to be reallocated among all Plan Participants based upon Participant account balances. ** Q Revert to the Employer via check. IX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Program A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Section B.) Definition of retirement: ❑ Same as Section VII.B. ❑ Other ❑a At separation from service with the following restrictions Q No restrictions Other B. Termination prior to general benefit eligibility: In case where the general benefit eligibility as outlined in Section 1X.A includes a retirement component, a Participant who separates from service of the Employer prior to retirement will be eligible to receive benefits: QImmediately upon separation from service ❑ Other C. A Participant that becomes totally and permanently disabled 0 as defined by the Social Security Administration ❑ as defined by the Employer's primary retirement plan ❑ other will become immediately eligible to receive medical benefit payments from his /her account under the Employer's welfare benefits plan. D. Upon the death of the Participant, benefits shall become payable as outlined in Section XI. * If the Employer 's RHS Program does not limit e[igibility to participants who have separated from service, the employer will be required to provide furtber direction to ICMA -RC regarding the treatment ofpossib4 contributions that are required to be made following the participants waiver. ** if the forfeited balance is small whereby the reallocation amount to each Plan Participant with a balance is minimal the assets will revert to employers forfeiture account for further direction from the employer. If them arc participants without a balance who should receive forfeiture assets, please provide alternative instructions to ICMA -RC on the forfeiture reallocation notice. 11:16 X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: Q AB Medical Expenses eligible under IRC Section 213 other than (i) direct long -term care expenses, and (ii) expenses for medicines or drugs which are not prescribed drugs (other than insulin). ❑ The following Medical Expenses eligible under IRC Section 213 other than (i) direct long -term care expenses, and (ii) expenses for medicines or drugs which are not prescribed drugs (other than insulin). Select only the expenses you wish to cover under the Employer's welfare benefits plan: ❑ Medical Insurance Premiums ❑ Medical Out-of- Pocket Expenses' ❑ Medicare Parr B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of- Pocket Expenses" ❑ Vision Insurance Premiums ❑ Vision Our- of- Pocker Expenses' ❑ Qualified Long -Term Care Insurance Premiums ❑ Non - Prescription medications allowed under IRS guidance" ❑ Other qualifying medical expenses (describe)` Non - collectively bargained plans that reimburse medical expenses other than insurance premiums should consult their benefits counsel regarding we #5replan nondiscrimination rules if the employer elects to make contributions basedon apercentage of earnings. XI. Benefits After the Death of the Participant In the event of a Participant's death, the following shall apply: A. Surviving Spouse and/or Surviving Dependents Upon the death of a Participant, the surviving spouse and/or surviving eligible dependents (as defined in Section XII.D.) of the deceased Participant are immediately eligible to maintain the Participant's RHS account and utilizing the remaining balance to Fund eligible medical benefits specified in Section X above. Upon notification of a Participant's death, the Participants account balance will be transferred into VT 11 Cash Management Fund" (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents " Before investing in the Fund you should carefully consideryour investment goals, tolerance for risk, investment time horizon, and personal circumstances. Tbere is no guarantee that the Fund will meet in investment objective and you can lose money. For additional information regarding the Fund, including a description of the principal risks, p"i, consult the Van tageTrust H Funds Disclosure Memorandum and fund fact sheet, which is available when you log in at www.icmaraorg or upon request by calling 800 -669 -7400. If the plan i default fund is not the VT II Cash Management Fund, please read the disclosure materiak or prospectus applicable to the default fund If a Participant's account balance has not been fully utilized upon the death of the eligible spouse, the account balance may continue to be utilized to pay benefits of eligible dependents. Upon the death of all eligible dependents, the account will revert in accordance with the Employer's election under Section VIII of the VamageCare RHSAdoption Agreement. II:17 B. No Surviving Spouse or Surviving Dependents If there are no living spouse or dependents at the time of death of the Participant, the account will revert in accordance with the Employer's election under Section VIII of the VantageCare RHSAdoption Agreement. XII. The Plan will operate according to the following provisions: A. Employer Responsibilities 1. The Employer will submit all VamageCam Retirement Health Savings Plan contribution data via electronic submission. 2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes but is not limited to termination notification, benefit eligibility, and vesting notification. B. Participant account administration and asset -based 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 not permitted. Benefits will be paid only to the Participant, his /her Survivors, the Employer, or an insurance provider (as allowed by the claims administrator). Payments to a third -party payee (e.g., medical service provider) are not permitted with the exception of reimbursement to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is (a) the Participant's lawful spouse, (b) the Participant's child under the age of 27, as defined by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010 -38, or (c) any other individual who is a person described in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004 -79, E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes for payments which are deemed to be discriminatory under IRC Section 105(h), as outlined in the VantageCare Retirement Health Savings Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it understands that failure to properly fill out this VaniageCare Retirement Health Savings Adoption Agreement may result in the loss of tax exemption of the Trust and /or loss of tax- deferred status for Employer contributions. B. ❑ Check this box if you are including supporting documents that include plan provisions. EMPLOYER SIGNATURE , By: Tide, na er Attest- Titl, City Clerk 11.18 Date: Date: I c7aIL� I J