Ed. B. Morris Assoc/Health Plan/HR APPROVED AS TO FORM BY ~) --
ADMINISTRATIVE AUTHORIZATION AGREEMENT_
The City of Carmel has established the Employee Health 13enefits Plan to pay medical,
dental and prescription drug expenses for the benefit of eligible participants, and has
engaged Edward 13. Morris Associates, Inc., to provide eligibility, claims processing and
other administrative services.
Prior to completion of the City's Plan Document, thc City of Carmel requests that
Edward B. Morris Associates, Inc., begin payment of benefits for medical, dental and
prescription drug claims eligible under the Plan, based on the Plan Document draft
prepared by Morris Associates on January 6, 2004, as revised by the City of Carmel on
January 7, 2004.
The City of Carmel understands that if any changes are made to the January 7, 2004,
Plan Document draft, which will be effective January 1, 2004, such changes will not
become effective until Edward B. Morris Associates, Inc., has received the final signed
Plan Document from City of Carmel.
The City of Carmel further understands that:
1. Edward B. Morris Associates, Inc., will not re-process claims processed pursuant to
this Agreement, and
2. should the final signed Plan Document contain a benefits reduction or exclusion or a
change in eligibility, effective date or termination provisions from those included in
the January 7, 2004, Plan Document draft effective January 1, 2004, all or a portion
of such claims paid based upon the January 7, 2004, drafi may not be covered under
a reinsurance contract, and
should a final signed Plan Document not be received by Morris Associates within 60
days following the date this Agreement is executed, Morris Associates may cease
processing claims until the final signed Plan Document is received.
and Safety
CITY OF CARMEL, INDIANA
By and t~hrough its Board ofCPublic Wg~ks
~fit~s Bra~nard, Presiding offic
Mary.
! Member
Date
l~]~a c~M~rea;urer D
A photocopy or facsimile of this Agreement shall be as valid as the original.
FIRST AMENDMENT TO
CITY OF CARMEL
FLEXIBLE BENEFIT PLAN
APPROVED AS TO FORM BY~'~
WHEREAS, the City of Cannel ("Employer"), by action of its governing go~y,
adopted the City of Carmel Flexible Benefit Plan ("Plan") effective January 1, 1990, and
subsequently modified the Plan by a full restatement effective August 1, 2002; and
WHEREAS, Employer wishes to further amend the restated Plan; and
WHEREAS, authority to amend the Plan is granted in Section 10.C. of said Plan.
NOW, THEREFORE, pursuant to the authority granted in said Section, effective
January 1, 2004, the Plan is amended as follows:
Section 2.J. is amended to read:
Health Care Expense means any medical, dental or vision expense
Incurred by you or your dependents that qualifies as "medical care" as
defined in Section 213(d) of the Code, or qualified over-the-counter
medications as specified in Revenue Ruling 2003-102. Health Care
Expense does not include any premium paid for health coverage or
qualified long-term care services (as defined in Code Section 7702(B)(c)),
or for coverage for any product that is advertised, marketed or offered as
long-term care insurance. To be eligible for reimbursement through this
Plan, a Health Care Expense must not be reimbursed or be entitled to
reimbursement through any insurance plan. Further, you or your
dependents must be legally obligated to pay for the Health Care Expense.
II.
Section 3.A. is amended to read:
A. When Coverage Begins. Your coverage under this Plan will be effective:
(i) the first payroll period following the date on which you submit
your election form to Human Resources, if you are enrolling when
you first become an Employee or when you experience a change of
status (election form must be submitted within 30 days of your
date of hire or change of status); or
(ii) January 1 of the following calendar year, if you are enrolling
during the annual election period.
III.
Section 5.C. is amended to read:
C. Annual Elections. For each calendar year after you first become an
Employee (your "annual election"), you may elect to:
(i) continue your current election;
(ii) change yom' current election;
(iii) stop your current election; or
(iv) begin coverage.
These elections are to be made by completing and turning in a payroll
reduction authorization form to Human Resources within the time period
communicated (this will be some time before the first day of the next
calendar year). Your election will be effective the first payroll period in
the next calendar year.
IV. Section 6.B. is amended to read:
Maximum Reimbursement. There will be credited to your Health Care
Reimbursement Account, as of the beginning of the calendar year (or as of
the later effective date of your election, if applicable), the annualized
amount that you have elected to have your Compensation reduced for the
calendar year. The minimum amount that ~ou may elect to have credited
to your Health Care Reimbursement Account is $5 per payroll period and
the maximum amount is $3,000 per calendar year. Any expenses paid out
of your Health Care Reimbursement Account during the calendar year will
be reflected in your Health Care Reimbursement Account balance.
V. Section 6.D. is amended to read:
Health Care Expenses. Health Care Expenses (as defined in Section 2.J.)
are expenses that can be reimbursed out of your Health Care
Reimbursement Account. Eligible expenses normally include deductibles,
copays, coinsurance and amounts in excess of plan maximums.
VI. Section 8 is amended to read:
8. PROVISIONS APPLICABLE TO HEALTH CARE AND DEPENDENT
CARE REIMBURSEMENT ACCOUNTS
Submission of Health Care Expenses.
(i) If you are enrolled in the City of Carmel Employee Health Benefit
Plan, any medical, dental or prescription drug claim, or portion
thereof, that is submitted for payment but is not paid by the
insurance plan will automatically be submitted for reimbursement
from your Health Care Reimbursement Account, after the medical,
dental or prescription drug claim is processed. (Expenses
(ii)
submitted automatically may or may not be eligible for
reimbursement.)
If you are not enrolled in the City of Carmel Employee Health
Benefit Plan, or if you Incur medical expenses that are not covered
by that plan, you must apply for reimbursement by submitting a
written claim form to the Claims Administrator not later than
March 3I after the end of the Plan Year in which the expenses
were Incurred. The claim for reimbursement may be made before
or after you have paid the Health Care Expense, but not before the
expense has been Incurred.
A claim form for Health Care Expenses must include the following
information and documentatmn.
amount, date and description of the expense;
name of the person for whom the expense was Incurred and, if
the person is not you, the relationship of the person to you;
name of the provider to which the expense was or is to be paid;
an Explanation of Benefits (EOB) for all expenses covered by
an_gy_ health insurance plan OR a fully itemized bill from a
provider whose services are not covered by anY. health
insurance plan OR an itemized store receipt for over-the-
counter medications (if the register receipt does not include the
name of the medication, you must obtain a handwritten receipt
from the store indicating the name of the medication and the
date purchased); and
any other information or documentation that the City or the
Claims Administrator reasonably requests.
Submission of Dependent Care Expenses.
You must apply for reimbursement of Dependent Care Expenses by
submitting a written claim form to the Claims Administrator not later than
March 31 after the end of the Plan Year in which the expenses were
Incurred. The claim for reimbursement may be made before or after you
have paid the Dependent Care Expense, but not before the expense has
been Incurred.
A claim form for Dependent Care Expenses must include the following
information and docrunentation:
· amount, dates of service and description of the expense;
· name of the dependent;
· name, address and taxpayer identification number of the
individual or organization to which the expense was or is to be
paid;
· itemized bills or receipts for the services (if your provider is a
daycare center, a printout is acceptable; if your provider is an
individual you must submit a receipt signed by the provider);
and
· any other information or documentation that the City or the
Claims Administrator reasonably requests.
Reimbursement. If you timely submit a claim form and all required
documentation, and your request for reimbursement is approved, yom'
claim will be reimbursed at such times as the City will prescribe, generally
as soon as administratively feasible. The amount of any reimbursement
will not exceed the amount credited to your applicable Accounts at the
time of the reimbursement.
Any dispute regarding a claim for benefits will be governed by the section
entitled Claims Procedure.
Forfeiture of Unused Amounts. Federal law requires that the amount
credited to your Accounts be used only to reimburse you for Health Care
Expenses or Dependent Care Expenses Incurred during the calendar year
for which your election is applicable, with any balance remaining in your
Accounts (after all allowable reimbursements for the calendar year have
been made) to be forfeited. Such amounts will be used to pay expenses
and fees of the Plan. In other words, if you do not use up the amounts
contained in your Health Care Reimbursement Account and/or Dependent
Care Reimbursement Account by the end of the calendar year, you will
lose those amounts. Therefore, it is very important to be conservative
when allocating amounts to these Accounts.
In all other respects, the terms of the Plan are unchanged.
CITY OF CARMEL, INDIANA
By and through its Board of Public Works and Safety
/~es Brainard, Presiding Officer Date
Mm:y A~oar//d~,~ ember D~e
Lori Watson, B d ember Date
! ~ts°n~~bb
AT~%T~.' /~ /r~ ~
/Diana Cordray, I~)~C, Clerk-Treasurer Date