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Home My WebLink AboutICMA-RC RHS PLAN ADOPTION AGREEMENT(CITY MANAGER)�J 1C v� s V� 5 C'J i A �i A- 2015 - 023 -01 EMPLOYER VANTAGECARE RETIREMENT HEALTH SAVINGS (RH5) PLAN ADOPTION AGREEMENT Plan Number: S 03550 Select as applicable: ❑ Standalone RHS ❑ bitegrateci RHS K Amendment to Existing Plan ❑ New Plan (see NOTE below) NOTE: (For existing employers only): Check here Z if you want ICMA -RC to use existing plan contact information for this new plan setup. Otherwise, if contact information has changed, please complete and return the Implementation Data Form found on pg. 11:31 alongwith the adoption materials. Employer Retirement Health Savings Plan Name:: 1. Employer Name: City of Santa Ana State: California 1I. The Employer hereby attests that it is aunt of a state or local government or an agency or instrumentality of one or more units of a state or local government. 11I. Effective Date of the Plan: 06/01/2015 IV The Employer intends to utilize the Trust to fund only welfare benefits pursuant to the following welfare benefit plan(s) established by the Employer: CRY of saotaAna Rati:aewerare aeneats elan V. Eligible Groups, Participation and Participant Eligibility Requirements A. Eligible Groups The following group or groups. of Employees are eligible to participate in the UantageCare Retirement Health Savings Plan (check all applicable boxes): ❑ All Employees ❑ Ali Full -Time Employees ❑. Non - Union. Employees ❑ Public Safety Employees:- Police ❑ Public .Safew Employees — Firefighters ❑ General Employees ❑ Collectively-Bargalned Employees (Specify unit(s)) ❑ Other (specify group(,)) City Manager the Employee group(s) specified must correspond to a group(s) of the same designation that is defined in the statutes, ordinances, rules, regulations, personnel manuals e or other documents or provisions in effect in the state or locality of the Employer. S. Participation Mandatory Participation., All Employees in the covered group(s) are required to participate in die Plan and shall receive contributions pursuant to Section VL If the Employer's underlying welfare benefit plan or feuding under this UantageCare Retirement Health Savings Plan is in -- whole or part a non collectively bargained, self- insured plan, the nondiscrimination requirements of Internal Revenue Code (IRC) Section 105(h) will apply. These rules may impose taxation on the benefits received by highly compensated individuals if the Plan disc, iminares in favor of highly compensated individuals in terms ofel'igibilay or benefits. The Employer should discuss these rules with appropriate counsel C. Participant Eligibility Requirements I. Minimum service: The minimum period of service required for participation is N/A (write N/A it no minimum service is required). 2. Minimum. age: The minimum age required for eligibility to participate is N/A (write N/A if no minimum age is required). VI. Contribution Sources and Amounts A. Definition of Earnings The definition of Earnings will apply to all RHS Contribution Features that reference "Earnings ", including Direct Employer Contributions (Section VI.B.1.) and Mandatory Employee Compensation Contributions (Section VI.B.2.). Definition of earnings: As defined by the City Manager Employment Agreement. B. Direct Employer Contributions and Mandatory Contributions 1. Direct Employer Contributions The Employer shall contribute on behalf of each Participant ❑ % of Earnings ❑ $ each Plan Year ❑ A discretionary amount to be determined each Plan Year p Other (describe): A one -time contribution as a conversion from the existing Medical Retirement Subsidy Plan. 2. Mandatory Employee Compensation Contributions The Employer will make mandatory contributions of Employee compensation as follows: 0 Reduction in Salary - 1.95 % of Earnings or $ will be contributed for the Plan Year ❑ Decreased Merit or Pay Plan Adjustment - All or a portion of the Employees' annual merit or pay plan adjustment will be contributed as follows: An Employee shall not have the right to discontinue or vary the rate of Mandatory Contributions of Employee Compensation. 3. Mandatory Employee Leave Contributions 'the Employer will make mandatory contributions of accrued leave as follows (provide formula for determining Mandatory Employee Leave contributions): ® Accrued Sick Leave 100% of sick leave cash out ❑ Accrued Vacation Leave ❑ Other (specify type of leave) Accrued Leave An Employee shall not have the right to discontinue or vary the rate of mandatory leave contributions. C. Limits on Total Contributions (check one box) The total contribution by the Employer on behalf of each Participant (including Direct Employer and Mandatory Employee Contributions) for each Plan Year shall not exceed the following limit(s) below. Limits on individual contribution types are defined within the appropriate section above. W1 There is no Plan- defined limit on the percentage or dollar amount of earnings that may be contributed. ❑ _. % of earnings* *Definition of earnings: ❑ Same" SectionVLA.. ❑. Other ❑ $ for the Plan year•. See Section V•B, for a discussion of nondiscrimination rules that may apply to non - collectively, bargained self-insured Plans. VII. Vesting for Direct. Employer Contributions A. Vesting Schedule (check one box) ® The account is 100% vested at all times. ❑ The following vesting schedule shall apply to Direct Employer Contributions as outlined in Section VI.B.I.; Years of Service Vesting Completed Percentage % % B. The account will become 100% vested upon the death, disability, retirement *, or attainment of benefit eligibility (as outlined in Section IX) by a Participant. 'Definition of retirement includes a separation from service component and is further defined by (check one): Wl The primary retirement plan of the Employer ❑ Separation from service ❑ Other C. Any period of service by a Participant prior to a rehire of the Participant by the Employer shall not count . toward the vesting schedule outlined in A above. VIII. Forfeiture Provisions Upon separation from the service of the Employer Prior to attainment of benefit eligibility (as outlined in Section IX), or upon reversion to the Trust of a Participant's accormt assets remaining upon the participant's death (as outlined in Section XI), a Participant's non- vested funds shall (check one box): ❑ Remain in the Trust to be reallocated among all remaining Employees participating in the Platt as Direct Employer Contributions for the next and succeeding contribution cyrle(s). (2yj Remain in the Trust to he reallocated on an equal dollar basis among all Plan Participants. ❑ Remain in the Trust to be reallocared among all Plan Participants based upon Participant account balances. ❑ Revert to the Employer. IX. Eligibility Requirements to Receive Medical Benefit Payments from the VantageCare Retirement Health Savings Plan A. A Participant is eligible to receive benefits: ❑ At retirement only (also complete Section B.) D6nition of retirement: ❑ Same as Section VIL &. ❑ Other 6Z7 At separation from service with the following restrictions 0 No restrictions ❑ Other.,,, __... S. Termination prior to general benefit eligibility: In case where the general benefit eligibility as outlined in Section IX.A includes a retirement component, a participant who separates from service of the Employer prior to retirement will be eligible to receive benefits: 0 Immediately upon separation from service ❑ Other C. A Participant that becomes totally and permanently disabled ❑ as defined by the Social Security Administration 10 as defined by the Employer's primary retirement plan ❑ other will become Immediately eligible to receive medical benefit payments from his /her VantageCare Retirement Health Savings Plan account. D. Upon the death of the Participant, benefits shall become payable as outlined in Section XL. X. Permissible Medical Benefit Payments Benefits eligible for reimbursement consist of: ® All Medical Expenses eligible under IRC Section 213* other than (i) direct long -term care expenses, and (ii) expenses for medicines or drugs which are not prescribed drugs (ocher than insulin). ❑ The following Medical Expenses eligible under IRC Section 213' other than (i) direct long -term care expenses, and (ii) expenses for medicines or drugs . which are not prescribed drugs (ocher than insulin). Select only the expenses you wish to cover under the VantageCare Retirement Health Savings Plan: ❑ Medical Insurance Premiums ❑ Medical Out-of- Pocket Expenses' ❑ Medicare Part B Insurance Premiums ❑ Medicare Part D Insurance Premiums ❑ Medicare Supplemental Insurance Premiums ❑ Prescription Drug Insurance Premiums ❑ COBRA Insurance Premiums ❑ Dental Insurance Premiums ❑ Dental Out -of- Pocket Expenses" ❑ Vision Insurance Premiums ❑ Vision Out -of- Pocket Expenses* ❑ Qualified Long -Term Care Insurance Premiums ❑ Non - Prescription medications allowed under IRS guidance" ❑ Other qualifying medical expenses (describe)" * See Section VA. for a discussion of nondiscrimination moles which ntay apply to non - collectively bargained, selfiaruurad Plans. XI. Benefits After the Death of the Participant In the event of a Participant's death, the following shall apply: A. Surviving Spouse and /or Surviving Dependents The surviving spouse and/or surviving eligible dependents (as defined in Section XILD.) of the deceased Participant are immediately eligible to maintain the account and utilize it to fund eligible medical benefits specified in Section X above. Upon notification of a Participant's death, the Participant's account balance will be transferred into Dreyfus Cash Management fund* (or another fund selected by the Employer),. The account balance may be reallocated by the surviving spouse or dependents: *An investment In the Dreyf s Cash Nlimgyement money marketfund it not hesured orguaranteed by the Toderal Deposit Insurance Corporation orany other-government agency. Alebotugh the fitedseekr to preserve the value ofyour investment at $1.00pershare, it is possible to lore money by investing in tbeRand. Investors should consider the investment objectives, risks, charges, and expenses gletbe fiend care(l y before btvesting. You may visit as at nuww.icmare.org m'call 800 -669-7400 to obtain a prorpectur that eomaim this andotber information about. the fund. Read tbeprorpectus carefrdly before investing If a partic'ipant's account balance has not been fully utilized upon the death of the eligible spouse; the account balance may continue to be utilized to pay benefits of eligible dependents_ Upon the death of all eligible dependents, the account will revert to the Plan to be applied as specified in Section VIII, B. No Surviving Spouse or Surviving Dependents If there are no living spouse or dependents at the time of death of the Participant, the account will revert to the Plan to be applied as specified in Section VIII. XII. The Plan will operate according to the following provisions: A. Employer Responsibilities L The Employer will submit all VanuageCare Retirement Health Savings Plan contribution data viaeleerrmuc submission. 2. The Employer will submit all VantageCare Retirement Health Savings Plan Participant status updates or personal information updates via electronic submission. This includes but is not limited to termination notification and benefit eligibility notification. B. Participant accomu administration and asset-based fees will be paid through the redemption of Participant account shares, unless agreed upon otherwise in the Administrative Services Agreement. C. Assignment of benefits is not permitted. Benefus will be paid only to the Participant, his/her Survivors, the Employer, or an Insurance provider (as allowed by the claims administrator). Payments to an third -party payee (e.g., medical service provider) are not permitted with the exception ofreimbursemem to the Employer or insurance provider (as allowed by the claims administrator). D. An eligible dependent is (a) the Participant's lawful spouse, (b) the Participam's child under the age o €27, as defined by IRC Section 1520(1) and Internal Revenue Service Notice 2010 -38, or (c) any other individual who is a person described in IRC Section 152(a), as clarified by Internal Revenue Service Notice 2004 -79. E. The Employer will be responsible for withholding, reporting and remitting any applicable taxes for payments which are deemed to be discriminatory under IRC Section 105(h), as outlined in the VamageCare Retirement Health Savings Plan Employer Manual, XIIi. Employer Acknowledgements A. The Employer hereby acknowledges it understands that failure to properly fill out this Employer VamageCare Retirement Health Savings Plan Adoption Agreement may result in the loss of tax exemption of the Trust and/or loss of tax - deferred status for Employer contributions. E. 0 Check this box if you are including supporting documents that include plan provisions. EMPLOYER SIGNATURE By: C Date: /C7 /o2o1 Title: Executive Director, Personnel Services Attest: %'Y 1. �/1"__. /� /Iv i%1 lr'' Date: Trrtd. Clerk of the Council Accepted: VANTAGEPOINT TRANSFER AGENTS, LLC n Assistant ecru nary ICMA -RC 41 LPPR 0 "OR M S1 Jose an o MARI D. HUI enior Assistant City Attorney CLE K OF THE CO C11L a