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HomeMy WebLinkAboutICMA-RC RHS PLAN ADOPTION AGREEMENT (2))YER VANTAGECARE RETIREMENT HEALTH SAVINGS (RHS) PLAN ADOPTION AGREEMENT A -2011- 258 -02 Plan Number: 8 03237 Select as applicable: ❑ Standalone RHS ❑ Integrated RHS ❑ Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers only): Check here ® if you want ICMA -RC to use existing plan contact information for this new plan setup. Otherwise, if contact information has changed, please complete and return the Implementation Data Form found on pg. 11: 31 along with the adoption materials. ® Employer Retirement Health Savings Plan Name: CU I. Employer Name: City of Santa Ana State: CA _b 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. I1I. Effective Date of the Plan: October 1, 2014 IV. The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plans) established by the Employer: City of Santa Ana Retiree welfare Benefits Plan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups of Employees are eligible to participate in the VantageCare Retirement Health Savings Plan (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)) Police Management Association, Fire Management Association, ® Other (specify group(s)) Collectively- Bargained Employees continued: Santa Ana Management Association & Confidential Association of the City of Santa Ana 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 or funding under this VantageCare Retirement Health, Savings Plan is in whole or part a non - collectively bargained, self-insured plan, 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. C. Participant Eligibility Requirements 1. Minimum service: The minimum period of service required for participation is N/A (write N/A if no minimum service is required). 2. Minimum age: The minimum age required for eligibility to participate is NIA (write N/A if no minimum age is required). I t:21 Vf. 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 VI.B.2.). Definition of earnines: As defined by the MOU 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 Q Other (describe): See Attached 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: ® Reduction in Salary - see Anached % 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 See Attached ® Accrued Vacation Leave See Attached ® Other (specify type of leave) Accrued Leave See Attached An Employee shall not have the right to discontinue or vary the rate of mandatory leave contributions. 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. ® 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 VI.A.. ❑ Other ❑ $ for the Plan year. See Section V.B. for a discussion of nondiscrimination rules that may apply to non - collectively bargained self - insured Plans. VII. Vesting for Direct Employer Contributions A. Vesting Schedule (check one box) ® The account is 100% vested at all times. ❑ The following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VI.B.I.: Years of Service Vesting Completed Percentage B. 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 Upon separation from the service of the Employer prior to attainment of benefit eligibility (as outlined in Section IX), or upon reversion to the Trust of a Participant's account assets remaining upon the participants death (as outlined in Section XI), a Participant's non - vested funds shall (check one box): ❑ Remain in the Trust to be reallocated among all remaining Employees participating in the Plan as Direct Employer Contributions for the next and succeeding contribution cycle(s). V] Remain in the Trust to be reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Trust to be reallocated among all Plan Participants based upon Participant account balances. ❑ Revert to the Employer. 11:2j' IX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Plan A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Section B.) Definition of retirement: ❑ Same as Section VII.B. ❑ Other 0 At separation 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 IX.A includes a retirement component, a Participant who separates from service of the Employer prior to retirement will be eligible to receive benefits: Z Immediately upon separation from service ❑ Other C. A Participant that becomes totally and permanently disabled ❑ 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 VantageCare Retirement Health Savings Plan account. D. Upon the death of the Participant, benefits shall become payable as outlined in Section XI. 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* other than (1) 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 VantageCare Retirement Health Savings Plan: ❑ Medical Insurance Premiums ❑ Medical Out -of- Pocket Expenses* ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums 11:26 ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of- Pocket Expenses* ❑ Vision Insurance Premiums ❑ Vision Out -of- Pocket Expenses* ❑ Qualified Long -Term Care Insurance Premiums ❑ Non- Prescription medications allowed under IRS guidance* ❑ Other qualifying medical expenses (describe)* * See Section VA. for a discussion ofnondiscrimination ruler which may apply to non- collectively bargained, self - insured Plans. 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 The surviving spouse and /or surviving eligible dependents (as defined in Section XII.D.) of the deceased Participant are immediately eligible to maintain the account and utilize it 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 Dreyfus Cash Management fund* (or another fund selected by the Employer). The account balance may be reallocated by the surviving spouse or dependents. *An investment in the Dreyfus Cash Management money marketfund is not insured orguaranteed by the Federal Deposit Insurance Corporation or any other government agency. Although the fund seeks to preserve the value ofyour investment at $1.00 per share, it is possible to lose money by investing in the fund. Investors should consider the investment objectives, risks, charges, and expenses ofthe fund carefully before investing. You may visit us at www.icmarc. org or call 800- 669 -7400 to obtain a prospectus that contains this and other information about the fund. Read the prospectus carefully before investing 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 to the Plan to be applied as specified in Section VIII. 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 to the Plan to be applied as specified in Section VIII. XII. The Plan will operate according to the following provisions: A. Employer Responsibilities 1. The Employer will submit all VantageCare 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 and benefit eligibility 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. 11:27 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 an 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 Plan Employer Manual. XIII. Employer Acknowledgements A. The Employer hereby acknowledges it understands chat failure to properly fill out this Employer VantageCarc Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and /or loss of tax - deferred status for Employee contributions. B. Vj Check this box if you arc including supporting documents that include plan provisions. Accepted: VANTAGEPOINT TRANSFER AGENTS, LLC ; 6CA. C, i)I� - Assistant Secretary, ICMA -RC Date: 9/(3 l Date: City of Santa Ana RHS Plan #803237 Amended 10/1/2014 Eligible Group: Police Management Association Direct Employer Contribution: 1. A percent of earnings as defined by the MOU 2. A one -time lump sum contribution as a conversion from the existing PMA Medical Retirement Subsidy Plan Mandatory Employee Contribution from Compensation: A percent of earnings as defined by the MOU Mandatory Employee Leave Contribution: Accrued Sick Leave: Employees hired prior to 1990 who separate from service on or after July 1, 2011 will contribute 100% of eligible sick leave payout Accrued Vacation Leave: Employees hired prior to 1990 who separate from service on or after July 1, 2011 will contribute 100% of vacation leave payout Accrued Management Leave and Holiday Pay: Employees hired prior to 1990 who separate from service on or after July 1, 2011 will contribute 100% of holiday leave payout and 100% of management leave payout Eligible Group: Fire Management Association Direct Employer Contribution: A one -time lump sum contribution as a conversion from the existing FMA Medical Retirement Subsidy Eligible Group: Santa Ana Management Association & Confidential Association of the City of Santa Ana Direct Employer Contribution: 1. A percent of earnings as defined by the MOU 2. A one -time lump sum contribution as a conversion from the existing SAMA & CASA Medical Retirement Subsidy Plan Mandatory Employee Leave Contribution: Accrued Sick Leave: Employees who separate from service on or after July 1, 2014 will contribute 100% of eligible sick leave payout d o1/ - '�'2 -4'8 -- (-)I AII640R 7� CERTIFICATE OF LIABILITY INSURANCE GAp&R14 /20'4 THIS CERTIFICATE 1$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endoreemen s . PRODUCER, MARSH USA INC. SUITE 490 125523RD STREET, N.W. WASHINGTON, DC 20037 GENERAL LIABILITY X COMMERCIFU. GENERAL LIABILITY CLAIMS -MADE ®.00CUR X CONTRACTUAL COV.INCL. PHONE q..E.alh— IBC N Y E.p Aa, - ------ 08101014 Q 0810112015 / INSURERS AFFORDING COVERAGE NAIC4 INSURER A: Phcen"I"U"rance COmpsny 25623 040355- EO+Fbi415 INSURED RETIREMENT CORP, ATTN: UJUANA THOMAS INSURER a: NIA WA INSURER C TaMera Casultylnsuranm CD.OfAmedca 1904 6 777 NORTH CAPITOL ST., NE WASHINGTON, DC 20002 INSURER O: Federal Insurance Company 20281 INSURER E: St. Paul Fire 8 Marine insurance Co. 24787 W INSURERF: S COVERAGE$ CERTIFICATE NUMBER: CLE- W374312415 REVISION NUMBER:$ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NYSR TYRE OP INSURANCe O ML POLICY NUMBER POLICY M DOfYY DC EXP IDO LIMITS A GENERAL LIABILITY X COMMERCIFU. GENERAL LIABILITY CLAIMS -MADE ®.00CUR X CONTRACTUAL COV.INCL. 630BESS8375 �rrr n wy i7 p/•F 08101014 Q 0810112015 / EACHOCCURRENCE S 1'000,006 PREMISES (Ea �oceUMM $ 1'000'000 MED EXP (Any one Parson) $ 10,00 PERSONAL&AOVINJURY $ 1,006,009 GENERAL AGGREGATE $ 2,090,000 GEN'L AGGREGATE X POLICY LIMIT APPLIES PER: PRO- LOC JECT —1 PRODUCTS- COMPfOPAGG $ 2,000,000 S AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS HIRED AUTOS NON-OWNED h POP J k gSYSta�t G, I+ v RT`A�C`A .L tt® !� `a 8y COMB EU SINGLE LIMIT BODILY INJURY (Per person) $ BODILY INJURY (Per aaitlen9 $ FR e cR —DAMAGE S UMBRELLA LIAR excess LIAM OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE S $ DED I RETENTION$ $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICERMEMBER EXCLUDED4 ECUTIVE® (Mandatory9n NH) If yes, desalt* Under DESCRIPTION OF OPERATIONS below MIA I U86508MB04 0810112014 08101/2015 WC STATU- 0 EL EACH ACCIDENT 99- 0,000 $ E.L DISEASE EA EMPLOYE $ 1,000400 E.L.OISEASE- POUCYLIMiT $ 1,000,000 D E BANKERS PROF. LIA2. SIR: V,000,000 82114261 71W7549 0613012014 0613012014 0613012015 06012015 87,500,000 BIC312,500,000 $5,000,000 Po 112,500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ANach ACORD 101, Addidonet Remarks Schedule, if morn space Is required) CITY OF SANTA ANA ATTN: EXECUTIVE DIRECTOR OF PERSONNEL SVS 20 CIVIC CENTER PLAZA W34 SANTAANA, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manoshi Mukherjee - -+*•�� �,a -'-�- (J 7NBd3 -LU1U AtiOHU CUKPUKAI WN. All ngntS reserve9. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER In; 040356 LOCO: Washington ADDITIONAL REMARKS SCHEDULE page 2 of 2 AGENCY NAMED INSURED MARSH USA INC. ICMA RETIREMENT CORP. AT M' O'JUANA THOMAS 777 NORTH CAPITOL ST., NE POUCY NUMBER WASHINGTON, UC 20002 CARRIER NAIL CODS EFFECTIVE DATEt The # M name and logo are registered marks of '.i