Appendix A - Plan 125 Document Medical FSA_DCAP.pdf

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Appendix A

Amendment One

The Commonwealth of Pennsylvania

Section 125 Plan Document

Effective January 1, 2021, The Commonwealth of Pennsylvania Section 125 Plan Document, as previously amended and restated, for Dependent Care and Medicare Reimbursement Plan is amended further as follows.

1. As used in Section 1.01, Legal Status, of Article I, “participating Employees” shall be interpreted to mean Participant, as defined in Article II of the Plan Document.

2. Section 2.02 of Article II, Definitions, shall be deleted and replaced with the following:

2.02 “Benefits Package” means, for any Participant, the Pennsylvania State Police

Health Benefits Program, or a plan of health benefits described in the PEBTF Plan

Document which is available for election by an Eligible Employee with respect to himself, or himself and his Dependent(s).

3. Article II, Definitions, shall have the following added:

2.40 “Pennsylvania State Police Health Benefits Program” means the plan of health benefits offered by the Commonwealth of Pennsylvania to Pennsylvania State

Police Enlisted Members and their dependents, as may be amended or modified by the Commonwealth of Pennsylvania from time to time.

4. Section 3.03, Medical Reimbursement Plan, paragraph (a) is deleted in its entirety and replaced with the following:

(a) An Eligible Employee who is eligible for PEBTF benefits, or for benefits under the

Pennsylvania State Police Health Benefits Program, shall be eligible to participate in the Medical Reimbursement Plan beginning on the Effective Date; to participate he must submit Enrollment Forms under Section 4.03.

5. Section 5.01 (b) (2), Termination Date of Coverage, is deleted in its entirety and replaced with the following:

(2) The date the individual’s coverage terminates under the Benefits Package.

6. Section 5.02 (c), Medical Reimbursement Plan, is deleted in its entirety and replaced with the following:

(c) Medical Reimbursement Plan. If a Participant in the Medical Reimbursement Plan is on an unpaid leave of absence from his Participating Employer, the Participant may elect to discontinue coverage under the Medical Reimbursement Plan during the leave or continue such coverage.

(1) If the Participant elects to continue coverage during the leave of absence, the Participant has two options to pay the amount due for coverage during the leave: 1) increase the payroll reduction prior to the leave of absence, or 2) pay for the coverage through payroll reductions upon returning to work. Under option 2, the Participant’s per-pay contributions will be increased so the total amount contributed through the course of the year will equal the amount that the Participant had elected prior to the leave.

(2) If the Participant declines coverage for the period of the leave and returns within the same Plan Year, the Participant’s coverage will be reinstated at the same annual amount that the Participant had elected before the leave.

The Participant’s per-pay contributions will be increased so the total amount contributed in the remainder of the year will equal the amount that the Participant had elected prior to the leave. The Participant may elect a new annual contribution amount. The new annual contribution amount must be sufficient to cover all reimbursements paid out of the

Medical Reimbursement Plan prior to the leave. If the new annual contribution rate is less than the annual rate elected prior to the leave, then the new amount must be sufficient for the per-payroll contribution rates to be at least equal to the per-payroll contribution rates in effect before the leave. If the Participant returns in a subsequent Plan Year, participation will require the submission of a new Enrollment Form.

7. Section 7.03, Medical Reimbursement Plan, paragraph (f), Carryover Provision, is deleted in its entirety and replaced with the following:

(f) Carryover Provision. Any amount, up to a maximum of $300, that remains in a

Participant’s Medical Reimbursement Account after reimbursement has been made for all claims that are timely submitted for reimbursement for the Plan

Year will be automatically carried over to the following Plan Year. Any amount over the $300 maximum will be forfeited. The Participant may use the amount carried over at any time in the following Plan Year.

Executed this _6th_______ day of _November__, 2020.

COMMONWEALTH OF PENNSYLVANIA

By:

V. Reid Walsh

Deputy Secretary for Human Resources and Management

Amendment Two

Section 125 Plan Document

Effective January 1, 2021, The Commonwealth of Pennsylvania Section 125 Plan Document, as previously amended and restated, for Dependent Care and Medical Reimbursement Plan is amended further as follows.

1. Section 5.02, Coverage while on Leave with Benefits, paragraph (b), Dependent Care

Reimbursement Plan, is deleted in its entirety and replaced with the following:

(b) Dependent Care Reimbursement Plan. If a Participant in the Dependent Care

Reimbursement Plan is on an unpaid leave of absence from his Participating Employer, the Participant’s participation in the Plan will end. If the Eligible Employee returns to work, the Eligible Employee may re-enroll into the Dependent Care Reimbursement

Plan through the submission of required forms to the Administrator, if the return from leave or increase in compensation qualifies as a Change in Status and the change is consistent with that Change in Status. If the Eligible Employee’s return to work or increase in compensation occurs in a subsequent Plan Year, participation will require the submission of a new Enrollment Form.

2. Section 5.02, Coverage while on Leave with Benefits, paragraph (c), Medical

Reimbursement Plan, is deleted in its entirety and replaced with the following:

(c) Medical Reimbursement Plan.

(1) If a Participant in the Medical Reimbursement Plan is on an unpaid leave of absence from his Participating Employer, and such unpaid leave terminates coverage under the Benefits Package, then coverage in the Medical

Reimbursement Plan will be terminated effective the same date as the termination of coverage under the Benefits Package.

(2) If a Participant in the Medical Reimbursement Plan is on an unpaid leave of absence from his Participating Employer, and such unpaid leave continues coverage under the Benefits Package, then coverage under the Medical

Reimbursement Plan will continue during the unpaid leave.

(3) If coverage continues during unpaid leave, the Participant has two options to pay the amount due for coverage during the leave: 1) increase the payroll reduction prior to the leave of absence, or 2) pay for the coverage through payroll reductions upon returning to work. Under option 2, the Participant’s per-pay contributions will be automatically increased so the total amount contributed through the course of the year will equal the annual contribution amount that the Participant had elected prior to the leave.

(4) If coverage under the Medical Reimbursement Plan does not continue during unpaid leave and the Participant returns to work within the same Plan Year, the

Participant’s coverage under the Medical Reimbursement Plan will be reinstated effective the date of return to work at the same annual amount the Participant had elected before the leave. The Participant’s per-pay contributions will be increased so the total amount contributed in the remainder of the year will equal the amount that the Participant had elected prior to the leave. The Participant may elect a new annual contribution amount within 60 days of the return to work. The new annual contribution amount must be sufficient to cover all claims paid out of the Medical Reimbursement Plan prior to the leave. If the Participant returns to work in a subsequent Plan Year, participation will require the submission of a new Enrollment Form.

3. Section 7.03, Medical Reimbursement Plan, paragraph (f), Carryover Provision, is deleted in its entirety and replaced with the following:

(f) Carryover Provision. Any amount, up to a maximum of $300, that remains in a

Participant’s Medical Reimbursement Account after reimbursement has been made for all claims that are timely submitted for reimbursement for the Plan Year will be automatically carried over to the following Plan Year, if the Participant has enrolled in the following Plan Year. Any amount over the $300 maximum will be forfeited. The Participant may use the amount carried over at any time in the following Plan Year. The carryover of up to $300 is only available to Participants still covered by the Plan as of the last day of the Plan Year. If coverage under the

Plan did not continue due to unpaid absence, separation, or any other reason prior to the last day of the Plan Year, then any amount left in the Medical

Reimbursement Account will be forfeited.

Executed this 26th day of January 2021.

COMMONWEALTH OF PENNSYLVANIA

By: __________________________

V. Reid Walsh

Deputy Secretary for Human Resources and Management

Amendment Three

Commonwealth of Pennsylvania

Section 125 Plan Document

Effective January 1, 2021, The Commonwealth of Pennsylvania Section 125 Plan Document, as previously amended and restated, for Dependent Care and Medical Reimbursement Plan is amended further as follows.

1. The following is added to Article II, Definitions:

2.40 “QRD” means a qualified reservist distribution. A QRD is an allowable distribution to a Participant of all or a portion of the balance in the Participant’s

Medical Reimbursement Account that is not a reimbursement of eligible medical expenses.

2. The following is added to the end of Section 4.02, Dependent Care Reimbursement

Plan:

(g) One Time Enrollment/Increase Event. In calendar year 2021 only, a one-time event will be offered for Eligible Employees to enroll into the Dependent Care

Reimbursement Plan or for Participants to increase their annual elections. Such event will be a two-week period, during which an enrollment or an increase may be elected by submitting a properly completed Enrollment Form to the

Administrator. Any elections made during the event will be effective in Plan

Year 2021. Participants may not decrease their annual elections or terminate participation in the Plan during this event.

3. The following is added to the end of Section 4.03, Medical Reimbursement Plan:

(f) One Time Enrollment/Increase Event. In calendar year 2021 only, a one-time event will be offered for Eligible Employees to enroll into the Medical

Reimbursement Plan or for Participants to increase their annual elections. Such event will be a two-week period, during which an enrollment or an increase may be elected by submitting a properly completed Enrollment Form to the

Administrator. Any elections made during the event will be effective in Plan

Year 2021. Participants may not decrease their annual elections or terminate participation in the Plan during this event.

4. The following is added to the end of Section 7.02, Dependent Care Reimbursement

Plan:

(f) Carryover Provision. Participants in Plan Year 2020 of the Family Care Account

Program (FCAP), set forth in the Commonwealth of Pennsylvania Family Care

Account Program Plan Document, that have a remaining balance in the

Participant’s Family Care Reimbursement Account for Plan Year 2020 and that are participating the Dependent Care Reimbursement Plan during Plan Year

2021, shall have the remaining balance for the FCAP Plan Year 2020 automatically carried over into the Participant’s Dependent Care

Reimbursement Account for Plan Year 2021. Expenses incurred in Plan Year

2021 shall be eligible for reimbursement pursuant to the Dependent Care

Reimbursement Plan from the amount carried over from Plan Year 2020. There is no maximum amount that may be carried over. There will be no carry over for the Dependent Care Reimbursement Plan except for the FCAP balance from

Plan Year 2020 into Plan Year 2021 of the Dependent Care Reimbursement

Plan as set forth in this subsection.

5. The following is added to Section 7.03, Medical Reimbursement Plan, Paragraph (c), Restriction on Benefit Payments:

When a Participant has received a QRD and re-enrolls in the Medical

Reimbursement Plan upon return to work in the same Plan Year, the maximum amount the Participant may elect is the annual maximum contribution in that

Plan Year, minus the amount of the QRD and prior reimbursements in that Plan

Year. Such election shall be available during the remainder of the Plan Year, regardless of the actual amounts credited to the Participant’s Medical

Reimbursement Account.

6. The following is added to the end of Section 7.03, Medical Reimbursement Plan:

(g) Participants may receive a QRD payment from their Medical Reimbursement

Account. A QRD payment made to a Participant will be returned to the

Participant’s taxable earnings. Such payment will be the Participant’s balance in the Medical Reimbursement Account. In no case may the QRD exceed the amount contributed to the Medical Reimbursement Account as of the date of the QRD request minus the reimbursements received as of the date of the QRD request. Participants who receive a QRD may no longer receive reimbursements for claims after the QRD.

To receive a QRD, the Participant must be a member of a reserve component ordered or called to active duty for a period of at least 180 days or for an indefinite period. Furthermore, the request for the QRD must be made during the period beginning with the order or call to active duty and ending March

31st of the year following the plan year in which the order or call to active duty began. A Participant must request a QRD from the Plan Administrator, and such request must provide a copy of the order or call to active duty to the

Administrator before a distribution can be made.

A Participant that receives a QRD and returns to work with the Employer within the same Plan Year in which the QRD is received will be eligible to re-enroll in the Medical Reimbursement Plan upon their return. Upon such re-enrollment, the maximum enrollment permitted will be the annual maximum contribution minus the QRD received and minus the claims already reimbursed in the Plan

Year. If a Participant receives a QRD and returns to work with the Employer in a subsequent plan year, the return to work will be a Change in Status as defined in 2.04 and 4.02 (c) of this Plan Document.

7. Any Sections in The Commonwealth of Pennsylvania Section 125 Plan Document, as previously amended, not modified by this Amendment Three shall remain in full force and effect.

COMMONWEALTH OF PENNSYLVANIA

By: ____________________________

V. Reid Walsh

Deputy Secretary for Human Resources and Management

Amendment Four

Section 125 Plan Document

Effective January 1, 2022, The Commonwealth of Pennsylvania Section 125 Plan

Document, as previously amended and restated, for Dependent Care and Medical

Reimbursement Plan is amended further as follows.

1. Section 5.03, Ineligible or Terminated Employees, is deleted in its entirety and replaced with the following:

Section 5.03, Ineligible or Terminated Employees.

(a) A Participant who was enrolled in a Medical Reimbursement Plan or

Dependent Care Reimbursement Plan and has terminated employment or otherwise becomes ineligible to participate in the Plan during a Plan Year will be allowed to submit claims for reimbursement for expenses incurred during the Participant’s period of participation (Medical Reimbursement

Account) or through the end of the Plan Year (Dependent Care

Reimbursement Account) until no later than March 31 following the last day of the Plan Year.

(b) If a Participant under the Medical Reimbursement Plan terminates employment and is rehired with the Employer as an Eligible Employee within the same Plan Year, the Participant’s coverage under the Medical

Reimbursement Plan will be reinstated effective the date of the rehire at the maximum benefits amount elected by the Participant before the

Participant terminated employment. The Participant’s Compensation

Reduction Amount will be increased so the total amount contributed in the remainder of the Plan Year will equal the maximum benefits amount that the Participant had elected prior to the termination. The Participant may elect a new annual contribution amount within 60 days of the effective date of the rehire. The new annual contribution amount must be sufficient to cover all claims paid out of the Medical Reimbursement Plan prior to the termination. If the Participant is rehired in a subsequent Plan Year, participation will require the submission of a new Enrollment Form, as per

Section 4.03, Medical Reimbursement Plan.

(c) If a Participant under the Medical Reimbursement Plan terminates employment and is rehired with the Employer as an ineligible Employee within the same Plan Year, the Participant would not be reinstated under the Medical Reimbursement Plan. Should the Participant return to status as an Eligible Employee in the same Plan Year, the Participant would be reinstated at the amount elected prior to separation effective the date of when the Participant became an Eligible Employee.

Executed this 28th day of June 2022.

COMMONWEALTH OF PENNSYLVANIA

By: __________________________

V. Reid Walsh

Deputy Secretary of Human Resources and Management

Amendment Five

Section 125 Plan for Dependent Care and Medical Reimbursement Plans

Effective April 26, 2024, the Commonwealth of Pennsylvania Section 125 Plan for

Dependent Care and Medicare Reimbursement Plan is amended as follows.

1. Section 7.03 (f), Medical Reimbursement Plan, is deleted in its entirety and replaced with the following:

(f) Carryover Provision. Any Amount, up to a maximum of $300, that remains in a Participant’s Medical Reimbursement Account after reimbursement has been made for all claims that are timely submitted for reimbursement for the Plan Year will be automatically carried over to the following Plan Year, provided the Participant is covered under the Plan on the last day of the Plan

Year. Any amount over the $300 maximum carry over will be forfeited. If a

Participant does not reenroll, the carryover, up to a maximum of $300, is still available to the Participant from the prior Plan Year. Carryover funds remaining dormant for two full plan years will be forfeited.

Executed this 29th day of April 2024.

COMMONWEALTH OF PENNSYLVANIA

By: __ __________________________

Jason Swarthout

Deputy Secretary for Human Resources and Management

Amendment Six

Section 125 Plan for Dependent Care and Medical Reimbursement Plans

Effective January 1, 2025, The Commonwealth of Pennsylvania Section 125 Plan for

Dependent Care and Medicare Reimbursement Plan is amended as follows.

1. Section 7.03 (f), Medical Reimbursement Plan; Amendment Five, is deleted in its entirety and replaced with the following:

(f) Carryover Provision. Any Amount, up to a maximum of $600, that remains in a Participant’s Medical Reimbursement Account after reimbursement has been made for all claims that are timely submitted for reimbursement for the Plan Year will be automatically carried over to the following Plan Year, provided the Participant is covered under the

Plan on the last day of the Plan Year. Any amount over the $600 maximum carryover will be forfeited. Carryover funds will be forfeited if not used within two full Plan Years. If a Participant does not reenroll, the carryover, up to a maximum of $600, is still available to the

Participant from the prior Plan Year. Carryover funds remaining dormant for two full plan years will be forfeited.

Executed this __ _8th_____ day of __October___, 2024.

COMMONWEALTH OF PENNSYLVANIA

By: ____________________________

Jason Swarthout

Deputy Secretary for Human Resources and Management