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HomeMy WebLinkAbout5313Contract Number Vendor Sub� ect Department File Class Begin Date End Date Review Date Vault Date 5313 VEBA SERVICE GROUP Employer Adoption Agreement Human Resources LEG 12-1 10/21/2013 9/1/2014 Comments � �t� � - ���:� Employer Adoption Documents A fully completed and signed Employer Adoption Agreement must be received and accepted by HRA VEBA Trust prior to establrshing Particapant Accounts Please submit two orrgtnal, srgned copres of your Employer Adophon Agreement as per the Instructrons One countersigned copy wall be returned 10 you upon acceptance by HRA VEBA Trust Contents • Instructions • Employer Adoption Agreement - Employer Data Page - Provisions - Schedule A Formal Action and Plan Design Documentation - Schedule B Summary of Compliance Requirements Applicable to HRAs - Exhibit A Form of Annual Certification Regarding Integration • Plan Design Change Form Plan Consultant• VEBA Service Group, a Div�s�on of Gallagher Benefit Sennces, Inc Home Office 906 West 2nd Avenue, Suite 400 � Spokane, WA 99201 Phone 1-800-888-VEBA (8322) � Fax (509) 838-5613 HRA VEBA Employer Adoption Agreement Instructions Two fully completed and signed original copies of your Employer Adoption Agreement must be received and accepted by HRA VEBA Trust prior to establishing partiapant accounts and providing benefits on behalf of your eligible employees The Employer Adoption Agreement consists of six parts • Employer Data Page (page 5) • Provisions (pages 6 -11) • Schedule A Formal Action and Plan Design Documentation (pages 12 -15) • Schedule B Summary of Compliance Requirements Applicable to HRAs (pages 16 -17) • Exhibit A Form of Annual Certification Regarding Integration (page 18) • Plan Des�gn Change Form (page 19) Following these steps will be helpful when completing your Employer Adoption Agreement 1 Call your client consultant VEBA Service Group, a Division of Gallagher Benefit Services, Inc (VSG), has been engaged by the HRA VEBA Trust as the Plan Consultant VSG is available to help you avoid common mistakes and answer your questions Prior to completmg and submitting your Employer Adoption Agreement, all language and documentation related to your HRA VEBA plans that contains employee group-specific details, such as fundmg methods, contribution calculations, and eligibility requirements, should be reviewed by your VSG client consultant (e g coilective bargaining agreements, memorandums of understanding, other written agreements, Employer policies, etc ) This advance review will help avoid unexpected delays in getting your Employer Adoption Agreement accepted by HRA VEBA Trust 2 Complete all sections of the Employer Data Page (page 5� Employer contact information will be kept on file by VSG and the third-party admirnstrator (TPA), Meritain Health, Inc (Meritam Health) This will help these primary service providers communicate with the appropriate indiv�dual(s) when questions or issues arise Please immed�ately notify your VSG client consultant if your primary contact information changes 3 Complete the Partiapat�on section (page 6) In this section, please indicate whether you are a New Employer or a Renewing Employer PSE11(07 2313 PRC) Page 2 of 18 Instructions—contmued 4 Complete the Employer Plan Des�gn Selections (pages 7-9) These sections allow you to make plan design selections regarding participant accounts and forfeitures for each Plan 5 Complete the Employer Account sect�on (page 9) An Employer Account can be used to hold assets to offset other post-employment benefit (OPEB) liabilities under Governmental Accounting Standards Board Statement No 45 (GASB 45) 6 Complete and sign the Employer Adoption Agreement (page 11) Enter the requested information and provide an authorized signature Please read item 9 below for more details 7 Complete Schedule A To Employer Adoption Agreement (pages 12-15) Schedule A requires that you attach copies of a The formal Employer action which was executed to approve and adopt the Plans (e g resolution or other similar action, sample language available upon request) For renewing Employers, the Trust does not require any formal action for renewal, however, please provide cop�es of any such formal Employer action, if taken in connection with such renewal, in order for the Trust to maintain current records Please note that formal Employer action is separate and apart from collective bargaining agreements, memorandums of understanding, other written agreements, Employer polices, etc , which contain employee-group specific details such as fundmg methods and eligibility requirements b ALL applicable excerpts of collective bargaining agreements, memorandums of understanding, other written agreements, Employer policies, etc which define the agreed upon funding methods and corresponding eligibility requirements, and c ALL documentation language or prov�s�ons that describe the contribution formulas and eligibility definitions for the HRA VEBA contributions For example, if an Employee group's sick leave or vacation cash out amounts are being redirected to HRA VEBA in lieu of taxable income, ALL language which describes and defines the Employer's cash out program must be attached Additionally, if you are a renewmg Employer and will be making future contributions to the Post-separation HRA Plan on behalf of employees who were already enrolled in the Standard HRA Plan as of July 1, 2013, please attach a list of such participants to Schedule PSE11 (07 2313 PRC) Page 3 of 18 Instructions—cont►nued A prior to making your initial contribution to the Post-separation HRA Plan This is in lieu of you having to collect and submit new Enrollment Forms for such participants (see page 15 for more informat�on) 8 Complete and sign Exhibit A(page 18) Enter the requested information and provide an authorized signature to certify the provisions of Exhibit A on behalf of the employer 9 Return two original, signed paper copies Please mail two original copies of your completed and signed documents and any attachments to VSG's home office in Spokane VEBA Service Group, a Drvision of Gallagher Benefit Services, Inc 906 West 2nd Avenue, Suite 400 Spokane, WA 99201 VSG will review the submitted documents and, if in good form, accept and countersign the documents on behalf of HRA VEBA Trust Upon acceptance, one countersigned, original copy will be returned to you for your files VSG will keep the second countersigned, original copy on file for the benefit of HRA VEBA Trust and forward a copy to the TPA 10 After th�s irntial Plan adopt�on, provide future changes/renewals in advance Prior to adopting and implementing future changes that may occur after your imtial plan adoption, including any changes relatmg to part�cipant eligibdity or contnbution methods or policies, submit a fully-completed and signed Plan Design Change Form to VSG Also, when groups renew participation without making any changes, piease provide copies of applicable collective bargaining language or other documents to VSG If you have any questions or need assistance when completing your Employer Adoption Agreement, please contact your VSG client consultant Spokane 1-800-888-8322 Sumner Vancouver Richland 1-800-422-4023 1-877-695-3945 1-855-565-2555 PSE11 (07 2313 PRC) Page 4 of 18 HRA VEBA Employer Adoption Agreement Employer Data Page Employer contact information will be kept on file by VSG and the TPA, Meritain Health This wiil help these primary service providers communicate with the appropriate individual(s) when questions or issues arise Please immediately notify your VSG client consultant if your primary contact information changes SECTION 1 EMPLOYER INFORMATION Employer Name City of Bremerton Employer Address HR Department - 345 6th Street, Suite 600 - Bremerton, WA 98337 Employer Phone 360-473-5926 Employer Fax 360-473-2333 Estimated number of newly-enrolling employees within the next 12 months ? Plan Effective Date 01/01/2014 EmployerTax Identification Number 91-6001231 SECTION 2 CONTACT INFORMATION Total Number of FTEs 304 a) Contact for General Plan Commumcations Please idenUfy the pnmary busmess or admirnstrative contact who should receive official Plan communicadons (such as amendments) and other time sensitive admirnstrahve and operaUonal commurncations and informafion This person will receive your counter-signed AdopUon Agreement and Employer Welcome kit Contact Name Charlotte Belmore Contact Title Human Resources Manager Mailing Address (if different than above) Telephone 360-473-5926 E-mail charlotte belmore@ci bremerton wa us b) Contact for Enroliment/Payroll Contribution Matters Please idenUfy the person who �s generally responsible for facditaUng panc�ipant enrollment and Employer contnbuUon remittance Contact Name Lisa Garland Contact Title Human Resources Assistant Mailing Address (if different than above) Telephone 360-473-5347 E-mail lisa garland@G bremerton wa us SECTION 3 FOR INTERNAL USE ONLY—To be completed bY VSG VSG Client Consultant Phone E-mail PSE11 (07 23 13 PRC) Page 5 of 18 HRA VEBA EMPLOYER ADOPTION AGREEMENT VEBA TRUST FOR PUBLIC EMPLOYEES IN THE NORTHWEST Provisions 1 Panc�roahon [check one only] (a) [] New Employer Employer is a newly-adophng Employer, wrth a plan effective date of [enter mtended plan effective date] Tlus Employer Adoption Agreement may be amended only m wnring as executed by authonzed officers of all parties hereto or (b) �j(� Renewing Employer Employer is a currently-participatmg Employer and wants to renew and rahfy or amend rts panc�ipahon in the Plans and the Trust (as defined below) Tlus Employer Adoption Agreement supersedes all pnor Employer Adophon Agreements, if any, and may be amended only m wntmg as executed by authonzed officers of all parhes hereto Formal Authorizahon of Emqlover The Employer, by formal action of its governmg body or other authonzed achon, has formally established an employee benefit plan or arrangement pursuant to which it desues to make one or more contnbuhons to the followmg health reimbursement arrangement ("HRA") plans (as each may be amended or restated from tune to tune and refened to herem as a"Plan" or an"HRA VEBA Plan") offered by the Voluntary Employees' Beneficiary Associahon Trust for Public Employees u�► the Northwest ( as the same may be amended or restated from hme to time, the "Trust") (a) VOLLJNTARY EMPLOYEES' BENEFICIARY ASSOCIATION STANDARD HEALTH CARE REIMBURSEMENT PLAN FOR PUBLIC EMI'LOYEES IN THE NORTHWEST (also referred to as the "HRA VEBA Standard HRA Plan"), which is designed to be exempt from the annual lumts restnchons under the Public Health and Safety Act ("PHSA 2711"), as amended by the Parient Protechon, Affordability, and Care Act of 2012 ("PPACA"), based upon mtegrarion wrth the Employer's group health plan that is compliant wrth PHSA 2711 The HRA VEBA Standazd HRA Plan may accept only contnbuhons (i) made on behalf of participants who are enrolled in the Employer's group health plan that is compliant with PHSA 2711 or (ii) made after December 31, 2012 but before January 1, 2014 that are approved by the Trust as pernutted or "grandfathered" contnbuhons under PPACA and applicable PPACA regulahons and regulatory guidance (b) VOLUNTARY EMPLOYEES' BENEFICIARY ASSOCIATION POST-SEPARATION HEALTH CARE REIMBURSEMENT PLAN FOR PUBLIC EMPLOYEES IN THE NORTHWEST (also referred to as the "HRA VEBA Post-separation HRA Plan"), for which payment or reimbursement of benefits aze available only after an eligible parncipant has retired from employment or otherwise separated from service with his or her Employer The HRA VEBA Post-separation HRA Plan may accept contnbutions on PSE11 (07 23 13 PRC) Page 6 of 18 behalf of all panc�ipants, mcludmg panc�ipants who aze not enrolled m the Employer's group health plan, as directed by the Employer pursuant to (i) this Employer Adoption Agreement, (ii) a Plan Design Change Form, (iii) contnbution reports for the Post- sepazation HRA Plan submitted wrth panc�ipant contnbuhons, or (iv) other wntten mstructions from the Employer Contribuhons on behalf of panc�ipants who are not enrolled in the Employer's group health plan must be submitted by the Employer into the Post-separahon HRA Plan and included only m the Employer's contribution report for the Post-separahon HRA plan Through this Employer Adophon Agreement the Employer applies for participahon m each Plan and the Trust, to be effective with respect to either or both Plans only when both of the followmg have occurred wrth respect to such Plan (i) the Trust has accepted ttus Employer Adoption Agreement and (ii) the Employer has made a contnbuhon or transfer into such Plan on behalf of one or more panc�ipants With respect to each Plan, the Employer shall be considered to be a sponsor of such Plan with respect to its employees and shall have adopted and become sub�ect to the provisions of such Plan and the Trust only upon acceptance by the Trust and the funding by the Employer of any contnbuhons or transfer of assets mto such Plan The Employer acknowledges that it understands and agrees that (a) Neither the Plans, the Trust, nor the Plans/Trust's auditor performs audit work or otherwise exammes to assure that any contnbution from the Employer to the Trust is m accordance with the Employer's plan or arrangement and that ttus determmation is the sole responsibilrty of the Employer, (b) In the event the Employer's plan or arrangement for contnbutions is deternuned by the IRS to pernut mdividual employee elections and thereby results m taxable mcome to affected employees, the Employer shall hold harmless and indemmfy each Plan, Trust, and their agents for liability which may result therefrom 3 HRA VEBA Standard HRA Plan - Plan Design Selechons Pursuant to collechve bargammg agreements, other wntten agreements, or Employer benefits pohcies, whichever is apphcable, the Employer hereby elects the followmg options under the Plan (a) Participant Accounts [check one only, unless Employer is establislung more than one type of Panc�ipant Account,��� if no ophon is selected, the default elechon wdl be 3(a)(i) — In-serv�ce and post-separahon coverage, 100% vested] Commencement of Benefits shall be as du�ected below by Employer or, for Employees whose assets have been transferred by Employer from a pnor plan, Employer may additionally direct m wntmg that the commencement of Benefits shall comcide wrth the Employee's benefits eligibility date under the pnor plan, provided the Employee becomes a Participant as defined by the Plan (i) [x] In-service and post-separarion coverage, 100% vested Panc�ipants shall immediately be eligible to file clauns for qualified expenses and prexniums mcurred anytune after a Participant Account is established wrth respect to such Employee or (ii) [x] Post-separation coverage`y, 100% vested Participants shall be ehgible to file claims for qualified expenses and premiums mcurred after separation from PSE11 (07 23 13 PRC) Page 7 of 18 service Employer must nohfy the Third-party Admmistrator of such Employees' separanon dates by subrrutting a completed Participant Status Change Form or (iii) [] In-service and post-separahon covera�e, sub�ect to vestmg Parncipants shall be eligible to file claims for qualified expenses and prerruums mcurred wlule m- service and post-separahon after havmg met any vestu►g requirements Employer must notify the Tturd-party Admmistrator of such Employees' claims ehgibility dates, separation dates, and/or vested account percentages by subrruttmg a completed Participant Status Change Form or (iv) [] Post-separation covera�y, sub�ect to veshng Panc�ipants shall be eligible to file claims for qualified expenses and preiruums mcurred post- separahon and after havmg met any vestmg requirements Employer must notify the Th�rd-party Admmistrator of such Employees' separahon dates and vested account percentages by subrruttmg a completed Participant Status Chan e� (b) Forfeitures [check one only] If, pnor to January l, 2014, the balance credited to any Panc�ipant Account is forfeited because the Participant fails to sahsfy the vestmg requ�rements for such Participant Account, if any, or is forfeited as a result of a deceased Parncipant havmg no survivmg spouse or Dependents as descnbed in Section 5 3 of the Plan, the forferted amount will be reallocated as follows (i) 6(] Reallocate an equal amount to all Participant Accounts from this Employer that have a posrtive balance at the tune of the reallocation or (ii) [] Reallocate to an Employer Account established pursuant to pazagraph 5, to be applied as subsequently d�rected by the Employer Option 5(b) must be checked if this option is selected If such forfeiture reallocation occurs on or after January 1, 2014, such forfeited funds shall be applied agamst Plan expenses in a manner deternuned by the Trustees to be consistent with the goals of the Plan and the Trust 4 HRA VEBA Post-senarahon HRA Plan — Plan Desi�n Selechons Pursuant to collective bargauung agreements, other wntten agreements, or Employer benefits policies, whichever is applicable, the Employer hereby elects the following options under the Plan (a) Participant Accounts [check one only, unless Employer is establistung more than one type of Parncipant Account,�'� �f' no ophon is selected, the default elechon will be 4(a)(i) — Post-separahon coverage, 100% vested] Commencement of Benefits shall be as duected below by Employer or, for Employees whose assets have been transferred by Employer from a pnor plan, Employer may addirionally PSE11(O7 2313 PRC) Page 8 of 18 direct m wntmg that the commencement of Benefits shall comcide with the Employee's benefits eligibility date under the pnor plan, provided the Employee becomes a Participant as defined by the Plan (i) � Post-sepazation covera�e, 100% vested Participants shall be eligible to file clauns for qualified expenses and prermums incurred after separation from service Employer must notify the Tlurd-party Admmistrator of such Employees' separahon dates by subrrutting a completed PartlClpant Status Chan e�orm or (ii) [] Post-senaration covera�sub�ect to vestmg Participants shall be eligible to file claims for qualified expenses and premiums incurred post-separahon and after having met any vesring requirements Employer must notify the Tlurd-party Admmistrator of such Employees' separation dates and vested account percentages by subrruttmg a completed Participant Status Chan e� (b) Forfertures [check one only] If, pnor to January 1, 2014, the balance credited to any Panc�ipant Account is forfeited because the Participant fails to sahsfy the vestmg requirements for such Panc�ipant Account, if any, or is forferted as a result of a deceased Participant havmg no surviving spouse or Dependents as descnbed m Sechon 5 3 of the Plan, the forfeited amount v�nll be reallocated as follows (i) �j(� Reallocate an equal amount to all Participant Accounts from this Employer that have a posrtive balance at the hme of the reallocation or (ii) [] Reallocate to an Employer Account established pursuant to paragraph 5, to be applied as subsequently duected by the Employer Option 5(b) must be checked if this oprion is selected If such forfeiture reallocation occurs on or after January l, 2014, such forferted funds shall be applied against Plan expenses m a manner deternuned by the Trustees to be consistent with the goals of the Plan and the Trust 5 Emalover Account [check one only] An Employer Account can be used to hold assets to offset other post-employment benefits, such as OPEB liabilihes as defined by Governmental Accounring Standards Boazd Statement No 45 (GASB 45) accounring rules An Employer Account can also be estabhshed for the purpose of acceptmg Participant Account forfeitures due to a Parricipant's death or failure to meet vesring requirements, if any (a) (� Employer is not establishmg any Employer Account or (b) [] Employer is establishmg one or more Employer Accounts PSE11 (07 23 13 PRC) Page 9 of 18 6. Annual Comohance Cerhficahon The Employer acknowledges that the qualification of the HRA VEBA Standard HRA Plan as an employer-mtegrated HRA Plan depends m part upon the Employer's compliance with the contnbution restnctions under the Standard HRA Plan and descnbed m paragraph 2(a) above The Employer hereby agrees to execute and deliver herewith, and agrees to execute and deliver to the Trust annually, a certificate substantially m the form of Exhibit A hereto, as the same may be revised from time to time as requ�red by law m order to mamtam the qualification of the HRA VEBA Standard Plan as an employer-mtegrated HRA Plan [The remamder of this page is mtenhonally left blank ] ��� In almost all cases Employer �nll select only one Participant Account option However, more than one ophon may be selected if an Employer wants to (1) establish more than one type of Parhapant Acxount per Employee or (2) establish different types of Paficipant Accounts across multiple Employee groups Example 1—Employer wants to establish two types of Partiapant Accounts per employee within the Standab HRA plan one that permits in service and post separation benefits and is 100% vested, and one that permits post-separation benefits only sub�ect to vesting Example 2—Employer wants to establish different types of Par�cipant Acxounts for certain Employee groups For Employee group A Employer wants to establish Participant Accounts that are sub�ect to vesting For Employee group B, Employer wants to establish Participant Accounts that are 100% vested If Employer selects more than one Participant Account option, language must be attached that clearly descnbes, by Employee group, which type(s) of Parhapant Account(s) are to be established for each eligible Paficipant PSE11 (07 23 13 PRC) Page 10 of 18 IN WITNESS WHEREOF, the Employer has approved ttus Employer Adoption Agreement, as evidenced by the signature below of �ts authonzed officer, to be effectave when accepted by signature below on behalf of HRA VEBA Trust Employer Name Ciry of Bremerton By Cha�iotte Belmore Authonzed signature Pr►nted name Human Resources Manager October 21, 2013 Trtle Date Accented bv HRA VEBA Trust VEBA Sernce Group, a Division of Gallagher Benefit Sernces, Inc on behalf of the Voluntary Employees' Beneficiary Associarion Trust for Pubhc Employees m the Northwest By Mazk Wilkerson, Area President Authonzed stgnature Date PSE11(W-01 13-PRC) Page 11 of 18 SCHEDULE A: FORMAL ACTION AND PLAN DESIGN DOCUMENTATION Most rtems contamed in tlus Schedule A reqiure Employer to submit supportmg documentahon The most common and preferred method of providmg the reqwred mformahon is to sunply attach ALL apphcable excerpts from collechve bargammg agreements, memorandums of understandmg, other wntten agreements, Employer policies, etc that relate to the HRA VEBA Plans NOTE After Employer completes and submits its Employer AdopUon Agreement, Employer must complete and submit a Plan Design Change Form pnor to the adoption and implementation of future changes Future changes mclude addmg new par�Gpating employee groups, adding new fundmg methods, changing exisUng funding methods, adding an Employer Account, ,etc The reqwred form is supphed with the Employer Adopt�on Agreement, or it can be requested from your VSG chent consultant when needed Also, when groups renew or rat�fy partiapation without making any changes, piease send copies of such collective bargaimng language or other documents to VSG This wdl help keep current informa6on o file for you PLAN ADOPTION 1 Formal Emplover Action Attached to this Schedule A is a copy of the formal action taken by Employer to adopt the HRA VEBA Plans��� DESCRIPTION OF ELIGIBILITY PROVISIONS AND FUNDING METHODS 2 Participatm� Employee Groups [check one only] (a) X Attached to this Schedule A(preferred method), or (b) Set forth below is mformation wluch lists the name(s) of all Employee group(s) currently eligible or becomuig ehgible to participate in the Plans pursuant to collective bazgauung agreements, Employer policy, etc , whichever is applicable See attached Memo of Understandings ��� Formal Employer action is commonly a resolubon or simdar ac6on (sample language avadable upon request) which is separate and apart from collective bargaining agreements memorandums of understanding, other wntten agreements, Employer policies, etc , that contain employee group-specific detads such as fundmg methods and conesponding eligibdity requirements PSE11(07 2313 PRC) Page 12 of 18 Schedule A—continued 3 Emnloyer Contnburion Methods and Eli ig bility Requuements [check one only� (a) X Attached to this Schedule A(preferred method), or (b) Set forth below is mformation wluch (i) descnbes, by Employee group, the Employer contribuhon method(s) applicable to each, and (ii) defines the correspondmg eligibility reqwrements �z� In most cases Employers select option 3(a) and supply the reqwred information by attachmg the cover page and ALL applicable excerpts from collective bargairnng agreements, memorandums of understandmg, other wntten agreements, Employer policies, etc , which relate to the HRA VEBA Plans, and that contain clear descnphons of Employer contnbution methods and corresponding defimt�ons of eligibdity If such documents do not exist, select opbon 3(b) and complete the table on the next page by entenng the name, size contnbut�on method(s) and eligibdity requirements for each pafiapat�ng employee group Regardless of which option is selected option 3(a) or 3(b) Employer must attach copies of ALL language and documentation that descnbes the confibubon formulas and eligibdity defirntions that provide the basis for its HRA VEBA contnbutions For exampie, if an employee group's sick leave or vacation cash out amounts are being redirected to HRA VEBA in lieu of taxable income ALL language and documenta6on which descnbes and defines the Employer's cash out program must be attached PSE11(07 2313 PRC) Page 13 of 18 Schedule A—coniznued Complete the following table if option 3(b) is selected When enteruig the reqwred mformation, follow the example contamed in footnote 2 on page 8 I�:nipl��ycc Gruu�� Gruu�� Sir.c Contrihution Eli;ibilit�� �A`:imc (T' �if mcmbcr�) !�'Icthod(s) 12cc�uircn�cnqsl �� � 4 Vestmg Requirements [check one only] (a) X All Employer contnbutions are 100% vested at a11 times (most common), or (b) Attached to this Schedule A, or (c) Set forth below is mformation wtuch mcludes a descnpt�on, by Employee group, of any vestmg requirements appltcable to Participant Accounts which must be satisfied before a Participant becomes ehgible to file claxms for qual�fied expenses mcurred on or after the date upon which the Participant becomes vested If vestmg applies, Employer is responsible for tracking when an Employee becomes eligible to file claims after havmg met the Employer's vestmg requtrements and providmg such notification to the Th�rd-party Admmistrator Notification shall mclude what percentage of the ParticipanYs account balance is vested (e g 100% vested, 50% vested, 0% vested, etc ) A ParttciQant Status Chan eg Form for this purpose is required and is available onlme or can be requested from the Tlvrd-party Admmistrator PSE11(07-01 13-PRC) Page 14 of 18 5 Automaric Enrollment for Certam Previouslv Enrolled Panc�roants of Renewmg EmploYers [Applicable only for Renewing Employers who (a) previously adopted the HRA VEBA Plan prior to July 1, 2013 and (b) are adophng the Post-separahon HRA Plan for the first hme with this Adophon Agreement] Attached to tlus Schedule A is a list of pazhcipants ("Inihal Post-sepazation Participants") who were enrolled m the HRA VEBA Plan pnor to July 1, 2013, and for which the Employer wishes to establish a Post-separahon HRA parncipant account upon uunal adoption of the Post- sepazahon HRA Plan Upon receipt of this Adophon Agreement, the Trust will establish a panc�ipant account withm the Post-separahon HRA Plan for all Imhal Post-separation Participants, and such participants v�nll be automahcally enrolled in the Post-separation HRA Plan Thereafter, a Participant Enrollment Form will be requ�red for any other participant who is added to the Employer's contnbuhon report for the Post-separation HRA Plan (whether or not such panc�ipant was enrolled pnor to July 1, 2013) [The remamder of this page is mtenhonally left blank ] PSE11 (07 23 13 PRC) Page 15 of 18 SCHEDULE B: SUMMARY OF COMPLIANCE REQUIREMENTS APPLICABLE TO HRAs 1 HSA Panc�roahon (a) Employees/participants can have both a health savmgs account (HSA) and a health reimbursement arrangement (HRA), such as HRA VEBA But, for a participant or his or her spouse to become eligible to make or receive contnbutions to an HSA, the participant will need to elect liriuted purpose coverage (b) If you currently make HSA contnbunons on behalf of eligible employees, you may want to consider offenng HRA VEBA contnbuhons m lieu of HSA contnbutions for employees who are meligible for HSA contnbutions, such as those covered under their spouse's medical plan, health flexible spendmg account (FSA), etc (c) Your VSG client consultant is available to help you deternune what employee/participant educational commumcahon may be warranted regarding HSA participation and coordmahon of benefits 2 No Ind�vidual Choice (a) Applicable law governmg the tax-exemphon of the HRA VEBA Plans does not pernut mdividual choice with regards to participahon (eligibilrty) or confibution amounts All employee group members defined as eligible (m Schedule A of ttus Employer Adoption Agreement) must participate If an eligible employee refuses or fails to complete the requued Enrollment Form, the employee may receive no other remuneration m lieu of the HRA contnbuhon (b) Induect cafetena plan fundmg is not permitted Ttus means an employee's salary reduction election cannot affect (mcrease) the�r HRA contnbution (IRS Notice 2002-45) 3 Form W-2 Renorhn� Requirements (a) Form W-2 reportmg is not requued for HRAs Tlus is not expected to change unless the IRS publishes further guidance (IRS Notice 2012-9) 4 Summarv of Benefits and Covera�e Repuirements (a) Newly-enrollmg participants may access a Summary of Benefits and Coverage document on the HRA VEBA website (hraveba org) The HRA VEBA Participant Enrollment Kit directs enrollmg participants to the website, or they can contact the TPA and request a free, paper copy 5 Medical ont-outs (a) Employers may not drop/disconhnue offeruig the�r employer-sponsored group health plan and provide HRA contnbuhons mstead (HIPAA rules) (b) Employers may not provide medical opt-out HRA contnbutions to employees who opt out of employer-sponsored group coverage and purchase mdividual health msurance policies (HIPAA rules) (c) The only medical opt-out HRA contnbutions currently pemutted under HIPAA rules must requ�re that the employee be covered under another employer-sponsored group plan, PSE11 (07 23 13 PRC) Page 16 of 18 such as through theu spouse's employer, not an mdividual policy However, applicable PPACA rules that exempt the HRA VEBA Plans from the annual Lmits restnchons under PHSA 2711 require that permitted medical opt-out HRA contribuhons be contributed only to the HRA VEBA Post-separahon Plan To ensure HRA VEBA's compliance with and ezemphon from PHSA 2711, Employers will be required to submit separate contnbuhon reports for employees who are enrolled in the Employer's group health plan and employees who have opted-out of the Employer's group health plan More detailed mformahon about this issue is discussed under paragraph 7 below (d) Employers may not offer medical opt-out HRA contnburions to employees age 65 or older Medicare Secondary Payer (MSP) rules prohibrt Employers from providmg mcentives to employees to drop employer-sponsored coverage, which would otherwise be pnmary to Medicare (MSP rules) 6 PCOR Fee (a) Federal health care reform unposes the new Parient-Centered Outcomes Research (PCOR) fee on all group health plans, mcludmg the HRA VEBA Plan, to fund clmical effecriveness research (b) For the 2012-13 Plan year, the PCOR fee is $1 00 per panc�ipant The fee will mcrease to $2 00 per panc�ipant for the 2013-14 Plan year and go up each year thereafter through the 2019-20 Plan year based on mcreases m the pro�ected per capita amount of national health expenditures 7 Annual Limit Restrichons under PHSA 2711(and related PPACA �uidance) (a) The HRA VEBA Standazd HRA Plan has been re-designed to be exempt from the annual lunits restnchons under PHSA 2711, as an HRA plan that is mtegrated with the Employer's group health plan To qualify as an employer-mtegrated HRA plan, the HRA VEBA Standard HRA Plan may accept only contnbutions (i) made on behalf of employees who are enrolled m the Employer's group health plan that is compliant with the annual lirruts restnchons under PHSA 2711 or (ii) that are approved by the Trust as "grandfathered" confibutions under PPACA and applicable PPACA regulations and regulatory guidance Contnbuhons that do not quahfy for the Standard I-IRA Plan will be accepted mto the Post-separanon HRA Plan (b) The HRA VEBA Post-separation HRA Plan is designed to be exempt from the annual lunits restnctions under PHSA 2711, as an HRA plan that provides benefits to former employees only after retuement or other sepazahon from service from the Employer The HRA VEBA Post-separahon HRA Plan may accept contnbutions for any panc�ipant, includmg participants who are not enrolled m the Employer's group health plan at the time of such contnburion PSE11(07 2313 PRC) Page 17 of 18 MEMORANDUM OF UNDERSTANDING BETWEEN THE CITY OF BREMERTON AND THE BREMERTON POLICE OFFICER'S GUILD This Memorandum of Understanding is agreed to pursuant to Article 23, Section 23 2 of the Collective Bargairnng Agreement between the City of Bremerton and the Bremerton Police Officer's Guild The City of Bremerton (Employer) has adopted the HRA VEBA plans offered and admmistered by the Voluntary Employees' Beneficiary Association Trust for Public Employees m the Northwest (collectively the "plans") the Standard HRA Pian, which shall be mtegrated with the Employer's group medical plan and to which the Employer shall remit contributions only on behalf of eligible employees who are enrolled in or covered by the Employer's group medical plan, and the Post-Separation HRA Plan to which the Employer may remit contributions on behalf of eligible employees, mcluding eligible employees who are not enrolled m or covered by the Employer's group medical plan, and which shail provide benefits onty after a participant separates from service or retires Employer agrees to contribute to the Plans on behalf of all employees in the Bremerton Police O�cer's Guild (BPOG) defined as eligible to participate in the Plans Each eligible employee must submit a completed and signed Enrollment Form to become an eligible participant and become eligible for bene�ts under the Plans Contributions on behalf of each eligible employee shall be based on the following selected fundmg sources/formulas o Sick leave, cash-outs upon separation from service or retirement Eligibility is limited to employees who retire from service with leave cash-out rights durmg the term hereof Employer contributions shall include the entire cash-out value of (sick, 35�0 of the sick leave balance up to a maximum of 420 hours) accrued sick leave and available for cash-out upon retirement or separation from service per the Collective Bargaining Agreement o Mandatory employee contributions for BPOG Members (no individual permitted) The Employer and the BPOG agree that the BPOG's compensation package wdl be changed such that eligible employees shall receive additional bene�ts in the form of HRA VEBA Plan contributions equal to $60 00, which shall be contributed on a monthly basis, and each eligible employee's salary shall be reduced by an amount equal to $30 00 Such contributions shall be made on behalf of all BPOG employees defined as eligible and shall be considered and referred to as employer contributions All day The Jon Patty Le City of B provisions of the Collecnve Bazgammg Agreements apply m all respects Dated this �_ C�t�a1,�' , 2013 of this agreement shall be from January 1, 2014 to December 31, 2014 � r, Gudd President Police Officer's Gu�ld � � `} I � Date /a �4 �3 Date MEMORANDUM OF UNDERSTANDING BETWEEN THE CITI( OF BREMERTON AND THE BREMERTON POLICE MANAGEMENT ASSOCIATION This Memorandum of Understanding is agreed to pursuant to Article 22, Section 221 of the Collective Bargammg Agreement between the City of Bremerton and the B�emerton Police Management Assoaation The City of Bremerton (Employer) has adopted the HRA VEBA plans offered and administered by the Voluntary Employees' Beneficiary Association Trust for Public Employees in the Northwest (coliectively the "plans") the Standard HRA Plan, which shall be mtegrated with the Employers group medical plan and to which the Employer shall remit contributions only on behalf of eligible employees who,are enrolled in or covered by the Employers group medical plan, and the Post-Separation HRA Plan to which the Employer may remit contributions on behalf of eligible employees, including eligible employees who are not enrolled m or covered by the Employer's group medical plan, and which shall provide bene�ts only after a participant separates from service or retires Employer agrees to contribute to the Pians on behalf of all employees in the Bremerton Police Management Association (BPMA) defined as eligible to participate m the Plans Each eligible employee must submit a completed and signed Enrollment Form to become an eligible participant and become eligible for benefits under the Plans Contributions on behatf of each eligible empioyee shall be based on the followmg selected funding sources/formulas o Sick leave, cash-outs upon separation from service or retirement Eligibility is limited to empioyees who retire from service with leave cash-out rights during the term he�eof Employer contnbutions shall include the entire cash-out value of (sick, 35% of the sick leave balance up to a maximum of 420 hours) accrued sick leave and available for cash-out upon retirement or separation from service per the Collective Bargairnng Agreement o Mandatory employee contributions for BPMA Members (no indrviduai permitted) The Employer and the BPMA agree that the BPMA's compensation package wdl be changed such that eligible employees shall receive additional benefits in the form of HRA VEBA Plan contr�butions equai to $55 00, which shall be contributed on a monthly basis, and each eligible employee's salary shall be reduced by an amount equal to $25 00 Such contributions shall be made on behaif of ail BPMA employees defined as eligible and shall be cons�dered and referred to as employer contributions ����� � � All other rovisions of the Collechve Bargammg Agreements apply m all respects Dated this �o�. �� day of ��p�-ew►(9n�✓� , 2013 sEP 1 s znf � The term of this agreement shall be from January 1, 2014 to December 31, 2014 � D , ��d�'�tl�� Tom Wolfe, Bremerton Police Manage ent ociation atty lent, or City of Bre on � /��/3 Date � l � za�.� 0 e ����1��'��e Bremerton Police Management Assoc�ation Standard HRA Plan First Name Last Name Current Job Ciass Titie JAMES W BURCHETT POLICE CAPTAIN LEOFF II PETER WAYNE FISHER JR POLICE LIEUTENANT LUIS D OLAN POLICE LIEUTENANT THOMAS E WOLFE POLICE CAPTAIN LEOFF II Page 1 Bremerton Police Officer's Gudd Standard HRA Plan First Name BEAU TRAVIS SPENCER G JOHN F DANA GENE JOESEPH F KEVIN M RICHARD A KENNY D MICHAEL SC�TT ROBERT AUSTIN EJDE AARON D WILLIAM PAUL CHRISTOPHER RORY STEVEN M MARTIN DOUGLAS TIMOTHY J CRYSTAL D LAWRENCE BRANDON K BRYAN CASTLE RODNEY C RYAN MATTHEW RUSSELL L ALAN R DAVID W JEFFREY LANE FLOYD EARLE KENT A KELLY G JONATHAN A JAMES D MICHAEL HART RANDY D i RANDY D !STEVE MICHAEL 'WILLIAM R RODNEY LEE B�LLY FRANK JOHNNY DAHLE L DONPIELL CHARLES Last AYERS BERNTSEN BOGEN CLEVENGER COREY DAVIS DAVIS DAVIS DONNELLY JORDAN ELTON ENDICOTT FAIDLEY FORBRAGD GARLAND GARRITY GRAY GREEN GREENHILL HALL HARKER HEFFERNAN HOIT HORNBURG HUGHES INKLEBARGER MAY JR MAYFIELD MEADE MEADOR MILLER NELSON OLSON PLUMB POLONSKY PROUSE RAUBACK RENFRO RIVERA ROESSEL ROGERS Current Job Class Title POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE SERGEANT POLiCE SERGEANT POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE SERGEANT POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFiCER POLICE SERGEANT POLICE SERGEANT POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE SERGEANT POLICE OFFICER POLICE OFFICER POLICE OFFICER Page 1 Bremerton Police Officer's Gwld Standard HRA Plan KEITH A FRANK R MATTHEW A MARK R MATTHEW A JOHN B JASON A HAROLD P SARGENT SHAW STROMBACH THOMPSON THURING VAN SANTFORD VERTEFEUILLE WHATLEY POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE SERGEANT POLICE OFFICER POLICE OFFICER POLICE OFFICER POLICE OFFICER � Page 2 Bremerton Police Officer's Gudd Post Separation HRA Plan First Name Last Name Current Job Class Title FLOYD EARLE MAY JR POLICE OFFICER Page 1