Appendix_A_-_Health_Reimbursement_Arrangement_Plan_Document_(new).pdf
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- Solicitation number
- 017-202406-MC
- Issued by
- Orange County, San Diego City, California
About this file
This document is a Health Reimbursement Arrangement (HRA) Plan Document for the County of Orange, California, initially established on June 24, 2008, and subsequently amended and restated on January 1, 2011, and June 1, 2016. The plan is designed to provide a pre-tax funding mechanism for eligible employees, participants, and retired participants to reimburse unsubstantiated and substantiated qualified medical expenses. The document outlines comprehensive administrative details including eligibility criteria, participation rules, contribution mechanisms, benefit payment procedures, and privacy provisions in compliance with HIPAA regulations.
The plan is exclusively for County of Orange employees, covering those employed in specific capacities such as peace officers and managers, with specific provisions for participation, contribution, and reimbursement. Contributions are made solely by the employer, and benefits are limited to reimbursing qualified medical expenses for participants, their spouses, and covered dependents. The document emphasizes strict administrative controls, including precise definitions of terms, detailed claims procedures, and robust privacy and security protocols for protecting individually identifiable health information. The plan is governed by the Internal Revenue Code and aims to provide tax-advantaged medical expense reimbursement for eligible individuals throughout their employment and retirement periods.
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AMENDMENT
TO THE
Administrative Services Agreement for Plan Number 803049
This Amendment to the April 1, 2019 Administrative Services Agreement (“Agreement”) for Plan number 803049 (the “Plan”) is entered by and between County of Orange (“Employer”) and ICMA Retirement Corporation (“ICMA-RC”), effective as of the date of execution by the Employer below (“Execution Date”).
WHEREAS, the Employer sponsors the Plan on behalf of its eligible employees and retirees;
WHEREAS, the Employer entered the Agreement to engage ICMA-RC to provide administrative services and investments for the Plan under the terms specified in the Agreement;
WHEREAS, the parties wish to amend the Agreement to add a new RHS plan number 800161 to the Agreement;
WHEREAS, Article 5 of the Agreement provides that the Agreement may be amended pursuant to a written instrument signed by the parties.
NOW, THEREFORE, the Agreement is hereby amended as follows:
AMENDMENT
The listed plan numbers are: 803049, 800161
In all other material respects, the Agreement is hereby ratified and affirmed.
DocuSign Envelope ID: 856B5154-946A-41FD-8B0F-2EA4FE73B2BE
Amendment 803049, 800161
CONTRACT SIGNATURE PAGE
IN WITNESS WHEREOF, The Parties hereto have executed this Agreement on the dates shown opposite their respective signatures below.
ICMA RETIREMENT CORPORATION:*
Thomas McAndrews Managing Vice President
Signature Date
Erica McFarquhar Assistant Secretary
Signature Date
*If the contracting party is a corporation, two (2) signatures are required: one (1) signature by the Chairman of the Board, the President or any Vice President; and one (I) signature by the Secretary, any Assistant Secretary, the Chief Financial Officer or any Assistant Treasurer. The signature of one person alone is sufficient to bind a corporation, as long as he or she holds corporate offices in each of the two categories described above. For County purposes, proof of such dual office holding will be satisfied by having the individual sign the instrument twice, each time indicating his or her office that qualifies under the above described provision.
In the alternative, a single corporate signature is acceptable when accompanied by a corporate resolution demonstrating the legal authority of the signature to bind the company.
COUNTY of ORANGE A political subdivision of the State of California
Print Name Title
Signature Date
Approved by the Board of Supervisors on: _________________
APPROVED AS TO FORM:
Deputy, Office of County Counsel Orange County, California
Please return an executed copy of the Agreement to a Delivery Address, either:
(a) Via DocuSign
(b) Electronically to PlanAdoptionServices@icmarc.org, or
(c) In paper form to ICMA-RC
ATTN: PLAN ADOPTION SERVICES
777 North Capitol Street NE Suite 600 Washington DC 20002-4240
DocuSign Envelope ID: 856B5154-946A-41FD-8B0F-2EA4FE73B2BE
7/22/2020
7/22/2020
Duane Bankey Senior Program Manager
| HRA Plan Document (Amended June 2016).pdf |
| ICMA Signed HRA Plan Amendment.pdf |
File details come from the government source that posted it. Updated .