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HomeMy WebLinkAboutEflexFSA2012 • eflexF - � Adoption and Service Agreement The employer listed below adopts the eflexgroup.com(eflex)plan(the plan)and engages eflex to provide services related Lu Lhe plan.The plan is a"cafeteria plan"as defined in Section 125 of the Internal Revenue Code.Important:eflex cannot process incomplete agreements. Please call eflex Sales at 1.877.933.3539,ext.300 with questions regarding this agreement. Fax completed form to the attention of your eflex Sales Associate at(608)237-3800 or email to efgsales @eflexgroup.com. Organization/Group Information Organization:City of Oshkosh Federal ID#: 39-6005563 Enter the name exactly as it appears on your tax returns and as you would like it to appear in your plan documents. Date Incorporated/Organized: Number of eligible employees:575 Mailing Address: PO Box 1130 City: Oshkosh State:WI ZIP: 54903 Street Address: 215 Church Ave State:WI ZIP: 54901 (lf different from mailing address) Organization Type(Check all that apply) ❑ Professional Association ❑Subchapter"S"Corporation* ❑Non-profit ❑Subchapter"C"Corporation ❑ Partnership/LLP** ❑Sole Proprietorship** fl Government Agency ❑ LLC(Limited Liability Company)** ❑Other: *Subchapter"5"Corporation shareholders above the 2%ownership level may not participate,but may sponsor a plan for its employees;immediate family members of Subchapter S owners may not participate. **LLC,LLP,Partnership,and Sole proprietors may not participate,but may sponsor a plan for the employees.However,if the spouse is a bona fide employee of the firm,he/she may participate and use the benefit for the entire family. The employer/organization entity is organized pursuant to the laws in the state of:Wisconsin Nature of the Business:Local Municipality Phone Number: (920)236-5110 SIC: Web Address: www.ci.oshkosh.wi.us Human Resources Contact(name and title):Jennifer Greeninger, Benefits Coordinator Phone: (920)236-5138 Fax: (920)236-5090 Email: jgreeninger@ci.oshkosh.wi.us Payroll Contact(name and title): Sarah Neubauer, Payroll Coordinator Phone: (920)236-5113 Fax: (920)236-5090 Email: sneubauer @ci.oshkosh.wi.us Plan Elections Plan Name IS Employer's Name:City of Oshkosh ❑Other: Plan Number ©501 ❑502 ❑Other: Plan Year Plan Begin Date: 01/01/2012 Plan End Date: 12/31/2012 .`t 11 O„ Nyje:I yo 11p1aE`nisao.,ems isle r4 burrs nj,-ti RSA a�nL 5d�ctible plan must be the same plan year. Is this a short plan year? ` ❑ Yes 0 No Is this a mid-year takeover?(if yes,complete original plan dates below) ❑ Yes 0 No Original Plan Begin Date: Original Plan End Date: 2.5-Month Extension IRS Regulation Notice 2005-42 allows employers to offer a 2.5 month extension that will immediately follow the end of the plan year.Unused benefits or contributions of employees may be paid or reimbursed to plan participants for qualified benefit expenses incurred during the 2.5 month grace period.Claims run-out will begin at the plan end date and stop 90 days later.This extension is an optional choice for the employer. ❑Elect 2.5-Month Extension GI Do not Elect 2.5-Month Extension ©2010 eflexgroup,Inc.1 2740 Ski Lane•Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -1- Eligibility Requirements To enroll in the Plan,an employee must timely complete an enrollment form for the applicable plan year.An employee must also satisfy eligibility rules for the various available benefits as follows(check one): ❑ All employees are eligible(including part time).For Group Medical Premiums and/or Cash in Lieu of Medical Premiums,an employee must be eligible for coverage under the terms of the applicable underlying plans.For Health FSA,Dependent FSA,and/or Individual Health Premium Account,all employees are eligible,regardless of how few hours they work. FA Only employees who work sufficient hours are eligible.For Group Medical Premiums and/or Cash in Lieu of Medical Premiums,an employee must be eligible for coverage under the terms of the applicable underlying plans. For Health FSA,Dependent FSA,and/or Individual Health Premium Account,an employee must be regularly scheduled to work at least: IS Hours per week: 24 ❑Other: 4 Other Requirements(e.g.,class,union).To participate in the Plan,an employee must: Be eliyible fur yruup healll!insurance. The following questions determine whether the Health FSA is an excepted benefit under HIPAA Portability Rules. The determination of whether the flex plan is excepted or non-excepted will determine if your plan must comply with applicable Public Health Service Act(PHSA)mandates and how COBRA should be administered for the FSA. Are all individuals who are eligible to participate in the FSA also eligible to participate in a major medical SI Yes ❑No plan sponsored by the employer? (Answer"no"if(a)or(b)below is the only coverage available;answer yes even if participants can decline coverage under your major medical plan and still participate in the FSA plan.) Please note the following plans do not qualify as a major medical plan: (a) A limited-scope vision or dental plan (b) Individual coverage under a voluntary plan not sponsored by the employer If you have a qualifying major medical plan,are individuals who opt out of coverage able to elect ❑Yes F4 No coverage at least once each year(i.e.,annual enrollment)? Are any employer contributions available for benefits under the FSA?(You should answer yes if employer ['Yes 0 No funds are available through flex credits,matching contributions or any other employer contributions.) If employer contributions are available,please check how the contributions are calculated. ❑Specified dollar amount ❑ Flex credits ❑ Matching contributions If employer contributions are available,what is the maximum amount of employer contributions an employee may receive under the plan? $ If employer contributions are available,does the employee have the option to receive all of the employer ❑Yes ❑No contributions in cash if the employee does not wish to use them for FSA benefits?(If Yes,skip to Plan Participation) If employees receive partial cash-out of employer contributions,please describe: Plan Participation Participation in the plan begins(check one): ❑ Date of hire First of the month following: ❑ Date of Hire ig 30 Days ❑60 Days ❑90 Days ❑Other: Q Other: Eligible to participate in flex benefits on the same date eligible for group health insurance Do you have other benefit plan administration with eflex?(Please check all that apply.) ❑POP ❑HSA ❑ HRA ❑COBRA IS Transit ©2010 eflexgroup,Inc. 1 2740 Ski Lane•Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -2- Benefits for the Cafeteria Plan 0 Pre-tax Premiums. Pre-tax payment of employee premiums for coverage under the following plans offered by the employer:(Check all that apply) NI Major Medical ❑ Dental ❑ Short-term Disability* ❑ Long-term Disability* ❑ Vision Care ❑ Other: ❑ Cancer Insurance(not a cash-back policy) ❑ Accidental Death or Dismemberment Insurance ❑ Group Term Life that is$ (Applies to Employee coverage only;Employer may need to impute income for benefit over$50,000.) *Note:If you include short-term and/or long-term disability in this account,benefits will be taxable to the employee. IS Health FSA.Pre-tax payment by salary reduction and reimbursement of qualifying health care expenses incurred by employees,subject to the following:(Check one) 0 Because an employee's annual Health FSA election amount is required by law to be available uniformly throughout the year,the plan shall limit the amount that an employee may annually elect up to$5000.00 ❑ The plan shall not limit the annual Health FSA election amount NI All 213d expenses included ❑ All 213d expenses with the exception of: ❑ Dental and Vision Only ❑ Health Savings Account(HSA). Pre-tax payment by salary reduction to a Health Savings Account. MI Dependent Care FSA.Pre-tax payment by salary reduction and reimbursement of qualifying dependent-care expenses incurred by employees. IS Individual Health Premium Account. Pre-tax payment by salary reduction and reimbursement of employee premiums for individual- billed health-related insurance. ❑ Premium Waiver Bonus.Instead of requiring employees to pay premiums for medical coverage,the employer pays cash as follows to employees who decline coverage: NI Debit Card.All participating employees will be offered the eflex Card.Your account will need to be pre-funded up to 1/12 of the total annual elections.Your eflex Account Manager will notify you of this amount upon completion of group set-up.This deposit will roll forward each plan year.Important:to reduce requests for substantiation and comply with IRS regulations,please provide the co-pay amounts from your group medical plan.Also provide a copy of your benefit plan summary. Office Visit Co-pay(s): Emergency Room Co-pay(s) Prescription Drug Co-pay(s)$5/$20/$40 Other Co-pays(please describe) ❑ Pharmacy Download:Our card vendor offers links to check prescription eligibility at the point of sale.If you would like to explore this option for your plan,please provide the name of your pharmacy vendor.Please note there is an additional one-time cost of$400 to set up this download.By providing the pharmacy vendor information,you agree to accept this cost.Vendor name: ❑ Claims Download.Check this box if you are affiliated with an eflex partner/affiliate and want auto claims download.Also check your eflex partner/affiliate: ❑ARISE Health Plan ❑Blue Shield of California(groups of 50+) ❑Mercy Health Care ❑ Midwest Security Administrator ❑Physicians Plus Health Care ❑WPS Health Insurance ❑UMR Enrollment Fl Spreadsheet enrollment.Employer enters enrollment data into an eflex spreadsheet;no charge. ❑ Download option. Electronic submission of enrollments from your HR system or enrollment company.(Please request data specifications from your eflex Sales consultant.) ❑ Internet.Employer provides a list of eligible employees and chooses timeframe for employees to enroll online.This option requires 14 business days for set up.Contact eflex Sales at efgsalesPeflexgroup.com to arrange online enrollment. ❑ Paper enrollment.$5 fee per form for manual enrollment;fee is waived if employer uses eflex spreadsheet enrollment. ©2010 eflexgroup,Inc.1 2740 Ski Lane-Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -3- Deductions and Payment Limitations Are all employees paid on the same schedule? G Yes ❑ No Employees are paid on the following schedule:(checkoll that apply) ❑ Weekly(48 pay periods) ❑ Weekly(52 pay periods) First pay date after effective date: ❑ Bi-weekly(24 pay periods) V Bi-weekly(26 pay periods) First pay date after effective date: l 15 1 2012 ❑ Semi-monthly First pay date after effective date: Second pay date after effective date: ❑ M• onthly First pay date after effective date: ❑ O• ther First pay date after effective date: Deductions are taken: ❑ Every time the employee is paid 151 Other: Every check except when there is a 3rd check in the month (deductions taken 24 times per year) (e.g.,Monthly payroll paid on the 15th and 30th of every month except when they fall on a weekend or holiday.) Funding(Choose one) ri Payroll Deduction Funding.Your Account Administrator will ❑ Claims Based Funding.Your Account Administrator will send send you a payroll deduction report three business days prior you a claims summary report based on your processing to your payroll. Please verify deductions and make any schedule.Funds will be drawn via EFT one business day after corrections. Return any corrections to your Account you(the employer)receive the report.Please make your Administrator prior to your payroll date.Funds are drawn via employees aware of the claims-based schedule you have electronic funds transfer(EFT)on the payroll date and occur chosen with your plan so they will know when to expect within 24 to 48 hours from the payroll date depending on bank reimbursements.Note:If opting for the debit card,funding clearing time. must be daily. If you offer and FSA and an HRA,funding for the FSA must Choose reimbursement schedule for claims-based funding: be claims based. ❑ Daily ❑ Semi-weekly(Tues/Thurs) ❑ Weekly(Fri) Discrimination Testing/Cooperation To perform required services for the plan,the employer shall timely provide eflex with information that eflex reasonably requests,including completed employee enrollment forms,employee census data/nondiscrimination testing data,and otherwise cooperate with eflex.All data submitted by the employer shall be in electronic format as specified by eflex. In the event such data is not provided as specified,the employer hereby holds eflex harmless from any claims or liability associated with employer's potential failure to remain in compliance.In the event the employer requests eflex to perform manual services,eflex may,at its discretion,charge the employer a fee comprising of time and materials,as determined by eflex. Tests included in Annual Fee(see Fees): •25%Key Concentration Test •55%Average Benefits Test(Dependent Care) •5%Owners Test(Dependent Care) • Eligibility and Contributions& Benefits Test • Dependent Care Eligibility Test and Contributions and Benefits Test Note:You're responsible for any other discrimination tests that may be required for your plans such as testing for your group medical,dental, or vision plans under 105(h)of the Internal Revenue Code. If you would like eflex to perform any other testing for your plans,please contact us at efgsales @eflexgroup.com for our proposed services and fees. ©2010 eflexgroup,Inc.1 2740 Ski Lane•Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -4- Fees — See a-Ebac ui eflex will electronically invoice monthly;fees will be debited on or around the 10th of each month. Annual Fee(Plan Document,Summary Plan Description,Discrimination Testing Fee,5500 Filing,Setup,2.5-month extension) $ Monthly Administration Fee(per participant per month) $ Minimum Monthly Billing $ Optional Fees Onsite employee meetings,presented by eflex $ Private-labeled Website $ Custom Debit Card(include one-color,high resolution logo) $ Company Name/Logo for Custom Card: Note:eflex may increase fees from year to year by an amount equivalent to the increase in the Consumer Price Index (all urban consumers,US city average,all items). Billing Information Billing Contact(name and rirle):Jennifer Greeninger, Benefits Coordinator email address for monthly invoices:jgreeninger@ci.oshkosh.wi.us Banking Arrangements Please attach voided check.Do not use a deposit slip as the number could be invalid.Your agreement will not be processed without a voided check. Bank Account Information Bank Name:Associated Bank Bank Contact: Peggy Steeno, Director of Finance Bank Address: 444N Sawyer Street • City: Oshkosh State: ZIP: 54901 Name on the Account:City of Oshkosh 075900575 Routing and 1186855 IohhandMaryDoe 3 1x3#ra�4 :, f Account#: !!! Account type:Checking By signing this Agreement and providing banking account information (above),we hereby authorize eflex,hereinafter called COMPANY,to °', �EBank Raub Number P3ease�on't _ .: initiate debit entries to our account indicated above and the depository j Your; �„Num�,) named above,hereinafter called DEPOSITORY,to debit the same to such €.: .. as0000aa r aeon, .iaaas«i 123� account.This authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written notification from either of us of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it. eflex Responsibilities eflex responsibilities are:1)provide customer service during normal business hours as contracted and provide electronic services 24 hours per day,seven days per week with the exception of situations beyond its reasonable control;2)provide benefits payment as set forth under terms of the Agreement;3)provide reporting as requested by Employer for payment history and summary of participant accounts;4)make initial determination as to participant allocation of claim reimbursements;5)perform enrollment,eligibility,and termination functions as provided by Employer;6)provide plan documents to include Summary Plan Description as contracted to the Employer;7)provide data necessary to enable Employer's preparation of Form 5500(if applicable);and 8)assist in performing nondiscrimination tests as contracted by Employer. ©2010 eflexgroup,Inc.1 2740 Ski Lane•Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -5- Employer/Group Responsibilities Employer has authority and responsibility for all Plan Operations except as otherwise noted under eflex Responsibilities. The Employer and/or other person or committee who has been so designated by the Employer shall control and manage the operation and administration of the Plan as the named fiduciary,with ultimate responsibility for:1)ensuring that the plan complies with all applicable provisions of the Plans,ERISA, HIPAA,Internal Revenue Code§125 and other federal,state and local laws,including COBRA;2)establishing, amending,terminating,and interpreting plan provisions to ensure ongoing compliance with applicable law;3)performing required nondiscrimination testing;4)filing of any required tax or governmental returns(i.e.,5500)relating to the Plan; 4)distributing Plan Documents to include Summary Plan Description;5)making all election change determinations;6)determining whether claims should be paid and handling claims appeals to include the external review process,which includes retention of Independent Review Organizations;7) providing non-English plan communications for relevant notices as required by Foreign Language Notices and Assistance;and 8)completing and keeping required Plan and claims documentation.Although the Employer has engaged eflex to provide certain documents and administrative services(including review and payment of qualified claims under the plan),eflex shall whenever possible,consistent with this agreement,act as directed by the Employer. ERISA All plans that are not government or church plans are ERISA plans. Effect of Agreement This agreement,along with the plan document and any addenda attached to the agreement,contains all provisions of an Internal Revenue Code§125"Cafeteria Plan"adopted by the employer.This agreement is also a contract between the Employer and eflex. Funding of Plan(please read carefully) The Employer shall provide eflex with all funds that eflex requires to pay benefit claims under the plan.If eflex pays a qualified benefit claim in advance in an amount greater than$100 of receipt of the corresponding funds from the Employer,the Employer shall,upon request, provide funds to eflex within 5 days notice of such payment by eflex. If the Employer has funded any overages,eflex will review the account on an annual plan-year basis,and any overages will be refunded with forfeitures. If the necessity arises for eflex to hold the overages in an account,the overages will be added at plan-year close with other applicable funds.If the Employer is under a PEO arrangement or other payroll service,by signing this agreement,the Employer authorizes the PEO/payroll service to forward funds to eflex as necessary. All debit card deposits will roll forward to the next plan year.Funds will be returned upon termination of the Employer plan or after claims run-out period has ended. Mutual Indemnification Each party shall indemnify the other party,its employees,directors,and agents(collectively,Indemnitees)and hold the Indemnitees harmless against all damages,losses,or other liabilities incurred by the Indemnitees arising from any act or failure to act by the Indemnitor, its employees,directors,or agents in connection with the plan.Such indemnification shall include(and not be limited to)liabilities arising from a failure to timely provide eflex with information.Such indemnification shall also include liabilities arising from administration or interpretation of the plan by either party in a manner contrary to law ' • - _ -. _ • , , S . . - nlaluStihskaindi.i c the above, -the Ci# ligbili-hi shall ltet -ia -the lln'►tA.i(rt,S aO(tctiine.d Sec. 843.80, Wes. Si-catde-SI ara 031)6 6 rc:►tar 5}ctj u}CS. ©2010 eflexgroup,Inc. 1 2740 Ski Lane•Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -6- Term and Termination The term of this Agreement shall be two years,and shall automatically renew indefinitely for like terms unless the employer gives to eflex notice of termination at least 90 days prior to the plan year end date.In any case of termination,the employer shall be responsible for 90 days of administrative fees to cover administration of claims run out. Other Termination by Employer: If the Employer terminates the agreement without giving the notice or terminates within the current plan year specified above,there shall be a termination fee of six months of administrative fees,measured by the administrative fees averaged over the prior three months,payable to eflex prior to the actual termination date.Additionally,the employer shall be responsible for reimbursing eflex$300 and any applicable material and labor costs,as well as any fees required to cover administration of run out claims. Other Termination by eflex:eflex may terminate the agreement effective 1)as of an end of term date witivaerthe 90-day notice or 2)on a date other than an end of term date,but only if the employer previously breached this agreement,such as by failing to pay eflex for its services,failing to provide funds for payment of claims,or failing to cooperate with eflex. The Employer and eflex executed this Agreement on the dates set forth below. Employer Company Name: City of Oshkosh Name: Mark Rohloff Signature: See Page 7A Date: eflexgroup.com Representative Name: 6'4L/Q O 2- '2 /C5/C C Jai I l Signature: 111.1.4 - ---� L ice-_ -L�� ' Date: / //3/�G /( Agent/Broker Company Name:-The_ \-\Oc-Vt.\ a-buy- ' c e . "ben(_11't 1Lk Name: Address:01(A \ c \O\ y-k\ T,Ive_rz5Lticca O'. City(( ,L\Y Q StateIt)Z/ Zip 58186 Email:(/. /ILL ' A.' I. - it' t♦ ' • 4' 'Phone Number: (' t a.) r L1OL¢ Signature: Lb% Date: Employer Authorization for Release of Information I Mark Rohloff, City Manager ,(Name,Title), an authorized representative/officer of City of Oshkosh (Company), P y), authorize The Horton Group (Broker/Agent) to discuss our company plan details and perform services on behalf of City of Oshkosh (Company) P Y) including the discussion of PHI as it relates to plan administration.In doing so, The Horton Group (Broker/Agent) will adhere to the provisions and understandings provided in the BAA. ID 2010 eflexgroup,Inc. 1 2740 Ski Lane•Madison,WI 53713 I Phone:877.933.3539 I Sales Fax:608.237.3800 I eflexgroup.com eflexgroup 00040-02-1110 -7- Signed for and in behalf of the City of Oshkosh Mark A. Rohloff, City Manager #f. 1 Or"' Pamela R. Ubrig, City Clerk ipf/4014.4- S!_-(2_01')/Q_ Peggy Steeno,60irector of Finance 7 Lynn Lorenson, City Attorney I hereby certify that the necessary provisions have been made to pay the liability which will accrue under this contract. 7A Associated Bank December 14,2010 City of Oshkosh P.O.Box 1130 Oshkosh,WI 54903 RE: City of Oshkosh Account Confirmation To Whom it May Concern: This letter confirms that the City of Oshkosh has a checking account with Associated Bank. It is identified as follows: Account#: 1186855 Routing#: 075900575 if you have any questions,please feel free to give me a call at 920-236-8131. Sincerely, Tex_194).j 464920---j\) Becky Holland Senior Sales Support Specialist Commercial Banking • .... a,: ,r,..-50,�sL::.. _: *, .�,•G..,. _"t ZS• ..►:a f . ? <,s +..•+,Yr".`.r Z ...r. .......` era'q ''y-i✓ _ .r : efiexgroup I. FLEXIBLE SPENDING ACCOUNT PLAN, FINANCIAL QUOTATION PAGE Implementation Fee(Specify if this is first year only or if it applies upon renewal): $300 annual(waived first year) *Monthly Administrative Fee: ./n Year: $3.75 per participant/mo in the health care reimbursement account only $3.75 per participant/mo in the dependent care reimbursement account only $3.75* per participant/mo if enrolled in both health&dependent care reimbursement accounts *Note:We do not charge separately for the FSA and Dependent Care accounts.The monthly PPPM is$4.10 whether participants choose to enroll in only one account or both the FSA and Dependent Care accounts. Transit/Parking is an additional$1 PPPM if elected in conjunction with an FSA/Dependent Care account($5.10 PPPM Total). For a Transit/Parking account only,the PPPM is$4.10. $NO CHARGE per participant/mo if debit card option is selected Fee for additional debit card(s) $INCLUDED-NO ADDITIONAL CHARGE Additional charge(if applicable)for mailing quarterly statements to the participants home: 51.00 EACH Minimum Monthly Billing: $50.00 Postage Charges(if applicable) $INCLUDED 2n°Year: SAME AS ABOVE—FEES GUARANTEED FOR THREE-YEAR CONTRACT 3'.4 Year: SAME AS ABOVE—FEES GUARANTEED FOR THREE-YEAR CONTRACT Flexible Benefits Administration Solutions for the City of Oshkosh eflexgroup Prepared for The Horton Group 1 I p a g e e !ex r u Optional Services and Fees (Please specify if you charge any additional fees that have not otherwise been stated on the Financial Quotation Page) There are no additional fees that have not been stated on the Financial Quotation Page. Date: September 1, 2011 Name of Company/Firm: eflexgroup, Inc. Address: 2740 Ski Lane, Madison WI 53713 Telephone Number: Nancy Dantzman Direct: 608-237-3015; Mobile: 608-206-7229 Authorized Signature: Nancy Dantzman Flexible Benefits Administration Solutions for the City of Oshkosh G fie cgroup Prepared for The Horton Group 2 1 p a g e