Attachment_C_Flex_Plan_Document_effective_Jan_1_2015.pdf

ADMINISTRATIVE OFFICE OF THE U.S. COURTS

FLEXIBLE BENEFIT PROGRAM

(As Amended and Restated Effective January 1, 2015)

LEGAL02/32193587v l

ARTICLE I- DEFINITIONS ............. w . . . ............ . . . - .. "' ........................................... -l.01 AFFILIATED £,..[PLOVER

1.02 AFTER-TAX CONTRIBUTIONS

1.03 ANNIVERSARY DATE

1.04 BENEFIT PLAN(S)· OA POLICY(IES)

1.0S CHANGE JN STATUS .................................................................................................................................... l 1.06- Curr\i

1.07 CLAll\IA.NT ... ............ ................................... ............................................ ~ ............................................... -

1.08 CLAIMS Al»-11NISTRATOR

J.09 CODE

1.10 COMPENSATION

1.11 DEPENDENT

l . 12 DEPENDENT CARE EXPENSE R EIMBURSDlEl'lff

1.13 EARNED, INCOME

1.14 EFFECTrvE DAT£

1.15 EL1CIBLE EMPLOYMENT RELATED EXPENSES

1.16 ELIGIBLE DAY CAR£ CEl'frER

1.17 ELIGIBLE M ED1CAL EXPENSES ..................................................... .. ·•·•·•· l.l8 E.ftlPLOYEE

1.19 El'ttPLOYER ........................................................... ·•••••··

1.20 GRACE PERJOD

1.21 HEALTH CARE EXPENSE REIMBURSEMENT

t.22 HlCHLV Co;io..trENSATEO INDIVIDUAL

1.23 HEALTH SAVINGS ACCOUNT OR HSA

J.24 HIGH DEDVCT1BL£ HEALTH PLAN

1.2! KEV EMPLOYEE ......................................................................................................................................... S

1.26 NONELECTIYE CONTRl8UTION(S)

1.21 PARTic•rANJ' .............................................................................................................................................. s

1.28 Pl,.J\.N ........................................... . ' ............. I ........ . .................................... ....................... . . . ............... . . .... .... .............. . ...... .. ............ •+• • • s

1.29 'PLAN ADMINISTRATOR' ORCO!'ttMITI°££ ..................... , ................ .......................................................... S 1.Jo PLAN YEAR ................................................................................................................................................. s l .31 PRE·TAXCONTRIBOTION(S)

1.32 QuALIFIED BENEFIT .. .. ............................................ .. .. .... .. ................ .. .. .. .. ...... ................. .................. ....... s

1.33 QU i\LIFS ED RESERVIST DISTRIBUTION

1.34 QUALlfVtNG EMPLOVMENT•RELATED EXPENSES

1.35 Q UALIFYING INDIVIDUAL

1.36 QUALIFYING SERVICES

1.37 REIMBURSEMENT ACCOUl'fr(S) OR ACCOUNT(S)

1.38 SALARV REDUCTlON AGREEMENT

1.39 SPOUSE ...................................................................... .................................. , .... ,. ..... ~ ...... ........ ...... ~ ...... ......................... fl . .. . .............. ~-· · ····

1.40 STllOENT

1.41 SUJ\11\'lARY PLAN DESCRIPTIONS: OR SPD

ARTICLE II - ELIGtBtLITY AND PARTICIPATION ..................... - ..................... - . ._

2.01 ELIGIBILITY TO· PARTICIPATE

2.02 TERMlNAT•ON or PARTICIPATION

?.03 EUCIBILITYTO PARTICIPATE LN REll'tJBURSEMENT BENEFITS

2.04 QUALIFYING LEAVE UNDER FAMILY LEAVE ACT

2.05 NON-FMLA LEA VE .................................... ............................................................. ..................... ........... l 0

ARTICLE UI - BENEFIT ELECTIONS

3.01 PRE-TAx ELECTIONS ............................................................................................................................... to

3.02 INlTIAL ELECTION PERIOD ................................................................................................................. ..... t 0

- j - LECAL02132 l9'3S87v I

3.03 ANNUAL El£CT10N PERIOD ............. .. .. ............. ... ....... " .......... ................ ........ .... .. .. .. .. .. .. .. ...................... t I

3.04 CHANCE OF BENEFIT ELECTION .................................................................................. ............................ l 1

3.05 IMPACT OF TERf.tlNATION OF EMPLOYMENT OR C ESSATlON Of' li:LIGIBIL.lTV ON ELECTION

3.06 No COMPENSATION DEFERRAL ANO No CARRYOVER OF UNUSED PRE-TAX BENEFITS

3.07 HSA ELECT10NS

ARTICLE IV - BENEFIT PAYMENTS AND CREDITS AND DEBITS TO ACCOUNTS

4.01 SOURCEOFBENEFIT PAYMENTS

4.0l ALLOCATIONS lRR£VOCAPLE DURlNG PLAN YEAR ........ ...................................................................... . l 9

4.03 REDUCTION OF C ERTAIN ELECTIONS TO .PREVENT DISCRIMINATION

4.04 HEALTH CARE EXPENSE REIMDURSEMIENT

4.0S DEPENDENT CARE EXPENSE R £tM BURSEMENT

AR'TICLE v - BENEFlTS,ff ................................. .., ....... .., ........................................... H ........... .... .......... . .. _ ......... _ .... _ __ . , _ _ ... _ __ ... . ...... -

5.01 Q UALIFIED BENEFJTS .................................................................. H

5.02 CASH B·ENEftT

5.03 REPA VM.El"ft' OF EXCESS REI l\t8tJRSEM£NTS

5.(14 T ERMINATfON Of' REIMBURSEMENT BENEFITS

5.05 COORDINATION Of 8£NEFrTS UNDER HEALTH FSA

5.06 GRACE PERIOD FOR HCRA CLAIMS

5.07 Q UALIFIED RESERVIST DISTRIBUT10N

ARTICLE VI - PLAN ADl\tllNISTRA TION .. .. .. .............. - ........ "' . ........ - ............... -

6.01 ALLOCATION OF AUTHOiUT V

6.02 PROVISION FOR THIRD-PARTY .PLAN SERVICE PROVtDERS

6.1)3 FIDUCIARY LIABILITY

6.04 COMPENSATION OF PLAN ADMINISTRATOR

6 .. 05 BON,DING .......... ......... ..................... .............. ~ ....................... .. ................................................... ~ .••..•

6.06 PAYMENT OF AD~UNISTRAT'IVE EXPENSES

6.07 INDEMNIFICATION

6.08 Suesr ANTlATION OF txPENsES

6.09 REIMBURSEMENT

6.10 ~ ATDtENTS ................ ........ .............. ...... ··•·•· ·~ ..................................... ~· ·· · ..... .............................. ••+•+• ....... ~ .... . . . . •·• • • • • ........ r• r• •• •••••• '

.ARTICLE VII - CLAIMS PROCEDU.RE.S .,...,..,..,..,_.,,,.., ... ._, __ .._ ..... _ .......................... H .. .,. ....... . .. _ ."'."'""'""'""..,.,... . ... "

7.0l APPLICATION TO PLAN BENEFITS

7.02 CLAIMS PROC£DURE

7.03 PROCEDURE FOR APPEALS OF DENIED CLAIMS

ARTICLE VIII - HIPAA PRJV ACY PROVISIONS ........... _ .. _ _. . .................... ............ - •• ~-

8.01 APPLtC AT10N ... ..... ............ I . .. . .. .. ... . .. . .. . . . ... . . . . . . .. ... . ... . .. . .. . ................... ... ........ . . . . . .. . .. .. ............. ... .. . ...... . .. . .. . ... . .. .. . . . . .. . .. .. ............. . ....... . . .......... .. I . 28

8.01 USE AND DISCLOSURE OF PROTECTED H EALTH INFORMATION (PHI)

8.03 DESIGNA n'.D I NDIVliDUALS WHO MAY RECEt\liE PHI

8.04 R£STRtCTIONS ON INDIVIDUALS W1rn ACCESS TO PHI

8.05 POLICIES AND PROCEDURES

8.06 ORGANIZED HEALTH CAREARRAN<iEtlrlENT

8.07 PRJVACV OfFICtAL .................................................................................................................................. 3 l

8.08 SECtJRITV OFFTCL\L ................................................................................................................................ 3 l

8.09 NONCOiMPLIANCE ............................................................................... .................... .. .. .. ...... ...................... 3 2 8 .. 10 DEA NIT.IONS ...... <!~<! •• ••••••••• •• 1 ... •• ....... ,. • • •• •• •• • • •.o • • r• • • • • • • • • • ••+• • • t • • • + ;.-o • " ~• •+t1 J +•+ • 4 •• •• , ..... 1 .,. ... •.o . .. •••• .. •.a •.a •.o ...... • o • o • • • • " •••• •• t •• • 1 • • • +.; • 32

8.1 l INTERPR£TATION AND LIMITED APPLICABtLITY

8.12 SERVICES PERFORMED FOR THE EMPLOYER

8.13 HYBRID ENT1T\' DESIGNATION

ARTICLE IX-AMENDMENT OR TERMINATION OF PLAN ............. ........... .. ..... -

• ii - LEQAl.02132193587" l