Loading...
HomeMy WebLinkAboutGODINEZ, RAUL II (2)IASURANOC NOT REQUIRED ORK AWAY PROCEED & • CLERK OF GO NCIL. DATE:' 3C7 0, HPOI ICAARC BUILDING PUBLIC SECTOR RETIREMENT SECURITY Vantage(are Retirement Health Savings (RHS) PLAN AMENDMENT PACKET To amend your existing RHS flan, please complete the entire Adoption Agreement, including items that are not being amended. When you send your amendment to ICMA-RC, please summarize the changes in your cover letter. Please note that ICMA-RC does not require the use of a resolution to amend the plan. Should you require legislative action, you may use the Suggested Resolution for Amendment on the following page. If you do not require legislative action, you may complete the Suggested Affirmative Statement for Amendment which follows. Once the amendment is completed, retain a copy for your records and send the original with the cover letter and either the resolution or the affirmative statement to 1CMA--RC as follows: Via Mail ICMA-RC Arm — New Business Services Suite 600 777 North Capitol Street, NE Washington, DC 20002-4240 Via Facsimile 202-9624601 Atm — New Business Services You will receive notification that your amendment has been received and accepted. A030�6' 2-091CxW 1,2 r RETIREMENT HEALTH SAVINGS (RHS) ADOPTION AGREEMENT 11:12 VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) ADOPTION AGREEMENT Plan Number: g 03550 Select as applicable: ❑ Standalone RHS ❑ Integrated RHS ® Amendment to Existing Plan ❑ New Plan I. Employer. Namr City of Santa Ana State: CA II. The Employer hereby attests that it is a unit of a state or local government or as agency or instrumentality of one or more units of a state or local government. III. Plan Dates: A. Plan Effective Bate 12019 B. Plan Year: Enter the annual accounting period for the RHS program IV The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the EmploynnCily Of Santa Ana RP.tiPBe Wd 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 -Time Employees ❑ Non -Union Employees ❑ Public Safety Employees — Police ❑ Public Safety Employees — Firefighters ❑ General Employees ❑ Collectively -Bargained Employees (Specify unit(s)) ❑ Other (specify group(s)), it)(,MgInager 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 insurancepremiums, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 10$(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 benefirs. The Employer should discuss these rules with appropriate counsel II:13 C. Participant Eligibility Requirements t. Minimum service: The minimum period of service required for participation is -bW (write N/A if no minimum service is required). 2. Minimum age: The minimum age required for eligibility to participate is 1W (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 VLBA.) and Mandatory Employee Compensation Contributions (Section VI.B.2.). Definition ofeaminas:As defined by City Manager Empl® B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions The Employer shall contribute on behalf ofeach Participant ❑ %ofEamings* ❑ $ each Plan Year ❑ A discretionary amount to be determined each Plan Year ❑ Other (describe): 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - 5.Q0 % of Earnings or $ will he 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 100% of sick leave cash op_ p Accrued Vacation Leave 100% of Vacation and Management Van m Other (specify type of leave) Accrued— Leave 55% of all othercashout payments made at separation from emplovme�r tt An Employee shall not have the right to discontinue or vary the rate of mandatory leave contributions. *Nan -collectively bargained plans that reimburse medical expenses other than insurance premiums should consult their bencfrts counsel regarding welfare plan nondiscrimination rules ifthe employer elects to make contributions based on a percentage ofearnings. s e' 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 Yearshall not exceed the following limit(s) below. Limits on individual contribution types are defined within the appropriate section above. ® There is no Plan -defined limit on the percentage or dollar amount of earnings that may be contributed. ❑ z % of earnings Definition of earnings: (❑ Same as Section VI.A. ❑ Other ❑ $ _for the Plan year. VII. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) ® The account is 1004'6 vested at all rimes. ❑ The following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VIR I.: Years of Service Vesting Completed Percentage % % % % % % E. The account will become 100% vested upon the death, disability, retirement', or 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 Participants 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, wallowed under IRS Notice 2013-54, all funds in the Participants account at the time of waiver shall be forfeited in accordance with the box 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 cycle(s).** © Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants with a balance." ❑ Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances." ❑ 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 retaemena ❑ Same" Section VILB. ❑ Other 21 At sepatation from service with the following restrictions ❑ 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: ® Immediately upon separation from service ❑ Ocher C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security Administration ❑✓ as defined by the Employetss 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. *Ifthe Employer's RHS Program does not limit eligibility to participants who have separated from service, the employer will be required to provide further direction to ICMA-RC regarding the treatment of passible contributions that are required to be made following the participant's waiver. ** Ifthe forfeited balance is smallwhereby the reallocation amount to each Plan Participant with a balance is minima( tbeasseu will revert to employer's forfeiture account for further dimetiorh from the employer. Ifthere are participants without a balance who should receive forfeiture aceta, pleare provide altermaive instructions to ICW-RC on the forfeiture reallocation notice. 11:16 X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of All 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 otter 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 Employees welfare benefits plan: ❑ Medical Imurmcc Premiums ❑ Medical Outof-Pocket Expenses" ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Meditate Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of -Pocket Expenses` ❑ %ision Insurance Premiums ❑ Vision Ourof-Packet Expenses' ❑ Qualified Long -Term Care Insurance Premiums ❑ Non -Prescription medications allowed under IRS guidance ❑ Other qualifying medical expenses (describe)" • Non-cvllarrim4 burgained planar shot reimburse medical "peruesother class imumncepmmiumrsboubl consult rlieir benefiu counsel rcgardingwelfare plan nondisc munation rules ifthe employer elects to make contributions based on a percentage of earnings. Xi. Benefits After the Death of the Participant In the event ofa 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 die deceased Participant are immediately eligible to maintain the Participants 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 Participant's account balance will be transferred into VT II Cash Management Fund" (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents .. Before invouing in rhe Fundyau should carefully comideryour invesimentgoak, ro/erance far risk, investment rime horizon, and personal tirrumsmnca. There is noguaninsee chat the Fund will meet in investment objective and yon can lase money. For additional information regarding the Fund, inked inga description of the principal risks, please consuls the Van rage Trust II Funds Diselouere Mmwrandxm and fiend facrsheer, which is available when you log in at www, immreorg or upon request by calling 800-669-7400. Ifthe phrn I defaulr fmtd is not the VT II Cash Managemenr Fund, please read rhe disclosrne martriak or prospectus applicable in the defauh-find 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 VanmgeCare RHS Adoption Agreement. 11:17 A-2019-013-01 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 Vill of the lrantageCare RHS Adoption Agreement. XII. The Plan will operate according to the following ptuvisions: A. Employer Responsibilities 1. The Employer will submit all VantageCarc Retirement Health Savings Plan contribution data via electronic submission. 2. The ]employer will submit all VantageCarc Retirement Health Savings Plan Participant stains updates or personal information updates via eiecrrnnfc submission. This includes but is not limited to termfnatmn 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 -patty, payer (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 Participants child under the age of 27, as defined by IRC Section 152(f)(1) and Internal Revenue Service Notice 2010-38, or (e) any other individual who is a person described in IRC Section 152(x), 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 VamagrCare Retirement Health Savings EmployerManaal. X121. Employer Acknowledgements A. The Employer hereby acknowledges It understands that failure to properly fill our this VarnogeCare 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, 2SO I �i��1 Titles-Oy-�= � +-{- Attest: Tldc.._ Norma Mitre _ Acting Clerk of the Council Approved to Form R.,t��v Sonia R. Carvalho City Attorney 11:18 Date: _ y— }..— J SUGGESTED RESOLUTION FOR AMENDMENT OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM Plan Number. 03550 Name of Employer: City of Santa Ana State: CA Resolution of the above-named Employer (the "Employer"): WHEREAS, the Employer has employees rendering valuable services; and WHEREAS, the amendment of its existing retiree health savings plan for such employees serves the interests of the Employer and Employees. NOW, THEREFORE BE IT RESOLVED, that the Employer hereby amends the Plan in the form of the ICMA Retirement Corporation's VantageCare Retirement Health Savings program. Clerk of the —of do herebycertify that the foregoing resolution, proposed by was duly passed and adopted in the of rhe of at a regular meeting thereofassembled this day of 20�, by the following vote: AYES: NAYS: ABSENT: I (Seal) Clerks Clerk's Title: Date: AC 30662-0916-W411 SUGGESTED RESOLUTION FOR AMENDMENT OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM PlanNumber- 03550 Name of Employer. City Of Santa Ana State: CA Resolution of the above-named Employer (the "Employer"): WHEREAS, the Employer has employees rendering valuable services; and WHEREAS, the amendment of its existing retiree health savings plan for such employees serves the interests of the Employer and Employers. NOW, THEREFORE BE IT RESOLVED, that the Employer hereby amends the Plan in the form of the ICMA Retirement Corporation's VanageCare Retirement Health Savings program. 1, Clerk of the _ of , do herebycertify that the foregoing resolution, proposed by was duly passed and adopted in the_ of the of at a regular meeting thereof assembled this — day of .20—, by the following vote: AYES: NAYS: ABSENT: (Seal) Clerks Signature: Clerk's Tide: Date: e � AC: 30662-0916.7412 ,17 icmARC' BUILDING PUBLIC SECTOR RETIREMENT SECURITY SUGGESTED RESOLUTION FOR AMENDMENT mwo SUGGESTED AFFIRMATIVE STATEMENT FOR AMENDMENT Plan Number: SUGGESTED AFFIRMATIVE STATEMENT FOR AMENDMENT OF THE VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PROGRAM 03550 Name of Employer: City Of Santa Ana State: Affirmative Statement of the above-named Employer (the "Employer"): WHEREAS, the Employer has employees rendering valuable services; and CA WHEREAS, the amendment of its existing retiree health savings plan serves the interests of the Employer and its Employees; and NOW THEREFORE, as a duly authorized agent of the Employer, I hereby: AMEND the Employer's Plan in the form of the SCMA Retirement Corporation's VantageCare Retirement Health Savings program. DATE: Tide of Designated Agent Signature Afr 30662-091(rW412 /--N ocmARC BUILDING PUBLIC SECTOR RETIREMENT SECURITY SUGGESTED RESOLUTION FOR AMENDMENT SUGGESTED AFFIRMATIVE STATEMENT FOR AMENDMENT