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HomeMy WebLinkAboutAgreement A-17-434 with Navia Benefit Solutions Inc..pdf Agreement No. 17-434 1 AGREEMENT 2 3 THIS AGREEMENT is made and entered into this 22nd day of August, 2017, by and 4 between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter 5 referred to as "COUNTY", and Navia Benefit Solutions, Inc., a Washington corporation, whose 6 address is 11400 SE 6th Street Suite 125, Bellevue WA, 98004, hereinafter referred to as 7 "CONTRACTOR". 8 WITNESSETH: 9 WHEREAS, the COUNTY intends to maintain an employee benefit plan that includes 10 an "Employee Flexible Spending Account" as defined by Internal Revenue Code Section 125, and 11 a "Mass Transit and Parking Plan", as defined by Internal Revenue Code section 132, hereinafter 12 called the "Plan", under which benefits may be acquired using pre-tax dollars by employees; and 13 WHEREAS, the COUNTY issued a request for proposal for the purpose of securing 14 recordkeeping and administrative services related to the Plan; and 15 WHEREAS, the CONTRACTOR is engaged in the business of performing such 16 recordkeeping and administrative services and responded to the request for proposal, 17 NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions 18 herein contained, the parties hereto agree as follows: 19 1. OBLIGATIONS OF THE CONTRACTOR 20 CONTRACTOR shall provide Flexible Spending Account administration 21 services as described in Exhibit A, COUNTY's Request for Proposal No. 17-073 (including 22 Addendum Number One (1)), attached hereto and incorporated herein by reference, and Exhibit B, 23 CONTRACTOR's response to COUNTY's Request for Proposal No. 17-073, attached hereto and 24 incorporated herein by reference. 25 Such services include, but are not limited to the following: 26 A. CONTRACTOR shall administer the County's Health Care, Dependent 27 Care, Parking and Transit Flexible Spending Account Programs in compliance with the terms of the 28 County of Fresno Cafeteria Plan Document and the County of Fresno Commuter Plan Document -1- 1 and all applicable laws, regulations, and IRS guidance. 2 B. CONTRACTOR shall accept claims submitted on CONTRACTOR'S website 3 or smart phone application, as well as via facsimile and U.S. Postal Service mail. All claims will be 4 processed in accordance with the terms of the County of Fresno Cafeteria Plan Document, the 5 County of Fresno Commuter Plan Document, Contractors standard operating procedures, and all 6 applicable laws, regulations, and IRS guidance. Reimbursements will be processed via check or 7 direct deposit, subject to availability of funds in each participant's account, on a daily basis. 8 C. CONTRACTOR shall maintain records of claims entered and claims paid for 9 each COUNTY participating employee and covered dependent including participants on unpaid 10 leave of absence and COBRA participants. 11 D. CONTRACTOR shall provide monthly or other periodic reports as follows: 12 1) CONTRACTOR shall prepare and distribute to each participating 13 COUNTY employee: 14 a. Quarterly Employee Statements, detailing quarterly account activity; 15 b. End-of-plan year forfeiture warning notices; and 16 c. Open Enrollment confirmation statements. 17 CONTRACTOR shall provide participating employees the opportunity to 18 elect hard copy or paperless statements and correspondence. 19 2) CONTRACTOR shall prepare and provide to COUNTY: 20 a. A monthly claim payment report detailing the daily reimbursement to each participant; 21 all applicable plan years will be included in the same report; 22 b. A daily listing of all debits from the COUNTY-owned bank account maintained for the 23 purpose of providing Flexible Spending Account reimbursements; and 24 c. A biweekly discrepancy report, detailing any discrepancies between a participant's 25 expected and actual biweekly contribution and annual election. 26 E. CONTRACTOR shall provide a dedicated account manager to assist County 27 staff. 28 F. CONTRACTOR shall provide an employer web portal where County staff -2- 1 may access such information and perform such functions as are necessary to administer the 2 Flexible Spending Account program. 3 G. CONTRACTOR shall provide immediate written notice to COUNTY of any 4 legally required changes to COUNTY'S Plan Documents, and shall, consistent with industry 5 standards, monitor and keep COUNTY informed of any pending or enacted legislation potentially 6 impacting its Plan Documents. The Plan Documents may be amended only upon the written 7 approval of COUNTY. 8 H. CONTRACTOR shall perform all non-discrimination tests required under 9 applicable laws and IRS guidance as needed. 10 I. CONTRACTOR shall maintain a fully automated claims adjudication system 11 in compliance with electronic transmission standards and security requirements and all other 12 regulations as required by HIPAA and applicable IRS guidance, including but not limited to Revenue 13 Ruling 2003-43 and Notice 2006-69. 14 J. CONTRACTOR shall offer a debit card to all Health Care FSA participants 15 and provide a minimum of two (2) debit cards to each participant who elects this option, at no 16 additional cost to the participant. 17 K. CONTRACTOR shall provide plan participants access to customer service 18 and claims processing staff for inquiries and problem resolution, to include but not be limited to, toll 19 free phone number, e-mail, and open enrollment fairs. The toll free phone number will be available, 20 at minimum, from 8.00 am to 5.00 pm Pacific Standard Time. CONTRACTOR shall provide, at 21 minimum, one (1) representative to COUNTY'S annual Open Enrollment fairs, which take place 22 over a 14 calendar day period each year. 23 L. CONTRACTOR shall provide a website and smart phone application where 24 participants may review their account information and submit claims and substantiating information. 25 M. CONTRACTOR agrees to keep full and accurate records and shall follow 26 generally accepted industry accounting methods and practices. Such records shall be maintained 27 electronically for a period of eight (8) years. The COUNTY or its duly authorized representatives 28 shall have full and free access to said records during normal working hours consistent with the -3- 1 Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 as amended, 2 including by the Health Information Technology for Economic & Clinical Health Act of the American 3 Recovery and Reinvestment Act of 2009 ('ARRA"), (collectively "HIPAX) and all other applicable 4 privacy and security laws. 5 N. CONTRACTOR shall provide administrative, technical, and physical 6 safeguards to protect any County information maintained in the CONTRACTOR'S custody, 7 consistent with current HIPAA requirements. 8 O. CONTRACTOR shall provide a backup system in the event of destruction of 9 the primary system so that administration and accounting for the flex plan would not be disrupted 10 by fire, equipment failure, or other catastrophe. 11 2. OBLIGATIONS OF THE COUNTY 12 A. COUNTY shall establish a bank account which CONTRACTOR shall debit 13 for reimbursement of claims paid to Flexible Spending Account participants and to provide benefits 14 to parking and mass transit participants. CONTRACTOR shall initiate direct debit of COUNTY's 15 bank account on the third (3rd) business day after CONTRACTOR sends the Initial Payroll 16 Deduction Report. 17 B. COUNTY shall provide CONTRACTOR with biweekly eligibility and 18 participation information. COUNTY will provide to CONTRACTOR timely, accurate and complete 19 information relating to the employees/participants and the Programs as is necessary for 20 CONTRACTOR to satisfy its obligations hereunder. 21 3. TERM 22 The term of this Agreement shall be for a period of three (3) years, commencing 23 on January 1, 2018 through and including December 31, 2020. This Agreement may be extended 24 for two (2) additional consecutive twelve (12) month periods upon written approval of both parties 25 no later than thirty (30) days prior to the first day of the next twelve (12) month extension period. 26 The Director of Human Resources or his or her designee is authorized to execute such written 27 approval on behalf of COUNTY based on CONTRACTOR'S satisfactory performance. 28 CONTRACTOR's obligation to reimburse outstanding claims for the last Plan -4- 1 year of this Agreement shall survive the expiration date of this Agreement for a period until all such 2 claims are paid, not to exceed one-hundred eighty (180) days. CONTRACTOR shall maintain 3 records of claims entered and claims paid for each COUNTY participating employee and covered 4 dependent, including participants on unpaid leave of absence and COBRA participants, as needed 5 in order to meet this obligation. 6 4. TERMINATION 7 A. Non-Allocation of Funds - The terms of this Agreement, and the services to 8 be provided hereunder, are contingent on the approval of funds by the appropriating government 9 agency. Should sufficient funds not be allocated, the services provided may be modified, or this 10 Agreement terminated, at any time by giving the CONTRACTOR thirty (30) days advance written 11 notice. 12 B. Breach of Contract By CONTRACTOR - The COUNTY may immediately 13 suspend or terminate this Agreement in whole or in part, where in the determination of the COUNTY 14 there is: 15 1) An illegal or improper use of funds; 16 2) A failure to comply with any term of this Agreement; 17 3) A substantially incorrect or incomplete report submitted to the 18 COUNTY; 19 4) Improperly performed service. 20 In no event shall any payment by the COUNTY constitute a waiver by the COUNTY 21 of any breach of this Agreement or any default which may then exist on the part of the 22 CONTRACTOR. Neither shall such payment impair or prejudice any remedy available to the 23 COUNTY with respect to the breach or default. The COUNTY shall have the right to demand of the 24 CONTRACTOR the repayment to the COUNTY of any funds disbursed to the CONTRACTOR 25 under this Agreement in the possession of CONTRACTOR, which in the judgment of the COUNTY 26 were not expended in accordance with the terms of this Agreement. The CONTRACTOR shall 27 promptly return any such funds upon demand. 28 C. Breach of Contract By COUNTY— CONTRACTOR may immediately -5- 1 terminate this Agreement in the event COUNTY fails to fund the benefits as set forth herein or fails 2 to cure a material breach (to the extent curable) within thirty (30) calendar days after written notice 3 of the breach and intent to terminate is provided. In the event funding is not received in a manner 4 permitting CONTRACTOR to administer benefits, then CONTRACTOR may suspend claim 5 processing (including debit cards) within ten (10) days of COUNTY's receipt of CONTRACTOR's 6 written request for such funding. 7 D. Without Cause— Under circumstances other than those set forth above, this 8 Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written 9 notice of an intention to terminate to CONTRACTOR. 10 5. COMPENSATION/INVOICING: COUNTY agrees to pay CONTRACTOR and 11 CONTRACTOR agrees to receive compensation as follows: 12 A. A biweekly administrative fee of one dollar and twenty cents ($1.20) for 13 employees who are enrolled in a Health Care and/or Dependent Care Flexible Spending Account; 14 or 15 B. A biweekly administrative fee of one dollar and twenty cents ($1.20) for 16 employees who are enrolled in a Mass Transit and/or Parking Flexible Spending Account; or 17 C. A biweekly administrative fee of two dollars and forty cents ($2.40) for 18 employees who are enrolled in one (1) or both options in 5.A above and one (1) or both options in 19 5.13 above. 20 CONTRACTOR shall submit monthly invoices to the County of Fresno Human 21 Resources Department. CONTRACTOR shall allow for a minimum of forty-five (45) days from date 22 of receipt of invoice by the COUNTY until payment of the invoice. 23 In no event shall services performed under this Agreement be in excess of 24 $400,000.00 during the term of this Agreement, including renewal periods. It is understood that all 25 expenses incidental to CONTRACTOR'S performance of services under this Agreement shall be 26 borne by CONTRACTOR. 27 6. INDEPENDENT CONTRACTOR: In performance of the work, duties and 28 obligations assumed by CONTRACTOR under this Agreement, it is mutually understood and -6- 1 agreed that CONTRACTOR, including any and all of the CONTRACTOR'S officers, agents, and 2 employees will at all times be acting and performing as an independent contractor, and shall act in 3 an independent capacity and not as an officer, agent, servant, employee, joint venturer, partner, or 4 associate of the COUNTY. Furthermore, COUNTY shall have no right to control or supervise or 5 direct the manner or method by which CONTRACTOR shall perform its work and function. However, 6 COUNTY shall retain the right to administer this Agreement so as to verify that CONTRACTOR is 7 performing its obligations in accordance with the terms and conditions thereof. 8 CONTRACTOR and COUNTY shall comply with all applicable provisions of law 9 and the rules and regulations, if any, of governmental authorities having jurisdiction over matters 10 the subject thereof. 11 Because of its status as an independent contractor, CONTRACTOR shall have 12 absolutely no right to employment rights and benefits available to COUNTY employees. 13 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its employees 14 all legally-required employee benefits. In addition, CONTRACTOR shall be solely responsible and 15 save COUNTY harmless from all matters relating to payment of CONTRACTOR'S employees, 16 including compliance with Social Security withholding and all other regulations governing such 17 matters. It is acknowledged that during the term of this Agreement, CONTRACTOR may be 18 providing services to others unrelated to the COUNTY or to this Agreement. 19 7. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 20 A. This section is intended to comply with the Business Associate Agreement 21 provisions set forth in 45 CFR §§ 164.314 and 164.504(e), and any other applicable provisions of 22 45 CFR parts 160 and 164, issued pursuant to the Health Insurance Portability and Accountability 23 Act of 1996, Public Law 104-191 as amended, including by the Health Information Technology for 24 Economic & Clinical Health Act of the American Recovery and Reinvestment Act of 2009 ('ARRA"), 25 (collectively"HIPAX). CONTRACTOR recognizes that in the performance of the Agreement it may 26 have access to, create, and/or receive from the benefit plan(s) or on its behalf Protected Health 27 Information ("PHI'). The parties to this Agreement shall be in strict conformance with all applicable 28 Federal and State of California laws and regulations, including but not limited to Sections 5328, -7- 1 10850, and 14100.2 et seq. of the Welfare and Institutions Code, Sections 2.1 and431.300 et seq. 2 of Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the California Civil Code, 3 Sections 11977 and 11812 of Title 22 of the California Code of Regulations, and the Health 4 Insurance Portability and Accountability Act (HIPAA), including but not limited to Section 1320 D et 5 seq. of Title 42, United States Code (USC) and its implementing regulations, including, but not 6 limited to Title 45, CFR, Sections 142, 160, 162, and 164, The Health Information Technology for 7 Economic and Clinical Health Act (HITECH regarding the confidentiality and security of patient 8 information, and the Genetic Information Nondiscrimination Act (GINA) of 2008 regarding the 9 confidentiality of genetic information. 10 Except as otherwise provided in this Agreement, CONTRACTOR, as a Business 11 Associate of COUNTY, may use or disclose Protected Health Information (PHI)to perform functions, 12 activities or services for or on behalf of COUNTY, as specified in this Agreement, provided that such 13 use or disclosure shall not violate the Health Insurance Portability and Accountability Act (HIPAA), 14 USC 1320d et seq. The uses and disclosures of PHI may not be more expansive than those 15 applicable to COUNTY, as the "Covered Entity" under the HIPAA Privacy Rule (45 CFR 164.500 et 16 seq.), except as authorized for management, administrative or legal responsibilities of the Business 17 Associate. 18 B. CONTRACTOR, including its subcontractors and employees, shall protect, 19 from unauthorized access, use, or disclosure of names and other identifying information, including 20 genetic information, concerning persons receiving services pursuant to this Agreement, except 21 where permitted in order to carry out data aggregation purposes for health care operations [45 CFR 22 Sections 164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)] This pertains to any and all 23 persons receiving services pursuant to a COUNTY funded program. This requirement applies to 24 electronic PHI. CONTRACTOR shall not use such identifying information or genetic information for 25 any purpose other than carrying out CONTRACTOR' s obligations under this Agreement. 26 C. CONTRACTOR, including its subcontractors and employees, shall not 27 disclose any such identifying information or genetic information to any person or entity, except as 28 otherwise specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 or -8- 1 other law, required by the Secretary, or authorized by the client/patient in writing. In using or 2 disclosing PHI that is permitted by this Agreement or authorized by law, CONTRACTOR shall make 3 reasonable efforts to limit PHI to the minimum necessary to accomplish intended purpose of use, 4 disclosure or request. 5 D. For purposes of the above sections, identifying information shall include, but 6 not be limited to name, identifying number, symbol, or other identifying particular assigned to the 7 individual, such as finger or voice print, or photograph. 8 E. For purposes of the above sections, genetic information shall include genetic 9 tests of family members of an individual or individual, manifestation of disease or disorder of family 10 members of an individual, or any request for or receipt of, genetic services by individual or family 11 members. Family member means a dependent or any person who is first, second, third, or fourth 12 degree relative. 13 F. CONTRACTOR shall provide access, at the written request of COUNTY, 14 and in the time and manner designated by COUNTY, to PHI in a designated record set (as defined 15 in 45 CFR Section 164.501), to an individual or to COUNTY in order to meet the requirements of 45 16 CFR Section 164.524 regarding access by individuals to their PHI. With respect to individual 17 requests, access shall be provided within thirty (30) days from request. Access may be extended if 18 CONTRACTOR cannot provide access and provides individual with the reasons for the delay and 19 the date when access may be granted. PHI shall be provided in the form and format requested by 20 the individual or COUNTY. 21 CONTRACTOR shall make any amendment(s) to PHI in a designated record 22 set at the request of COUNTY or individual, and in the time and manner designated by COUNTY in 23 accordance with 45 CFR Section 164.526. 24 CONTRACTOR shall provide to COUNTY or to an individual, in a time and 25 manner designated by COUNTY, information collected in accordance with 45 CFR Section 164.528, 26 to permit COUNTY to respond to a request by the individual for an accounting of disclosures of PHI 27 in accordance with 45 CFR Section 164.528. 28 G. CONTRACTOR shall report to COUNTY without unreasonable delay and -9- 1 in no case later than ten (10) business days upon becoming aware, in writing, any knowledge or 2 reasonable belief that there has been a Breach of unsecured PHI not permitted by this Agreement 3 of which it becomes aware. CONTRACTOR shall promptly report to COUNTY without 4 unreasonable delay and in no case later than ten (10) business days upon becoming aware of any 5 Security Incident involving Electronic Protected Health Information that results in actual 6 unauthorized access, use, disclosure, modification or destruction of PHI in electronic media or 7 interference with system operations of any system that contains PHI in electronic media. 8 CONTRACTOR shall report all other Security Incidents that do not result in unauthorized access, 9 use, disclosure, modification or destruction of PHI in the aggregate, upon the specific request of 10 the COUNTY, and no more frequently than on an annual basis. 11 H. Notification shall be made to COUNTY's Information Security Officer and 12 Privacy Officer and COUNTY's DPH HIPAA Representative. The notification shall include, to the 13 extent possible, the identification of each individual whose unsecured PHI has been, or is 14 reasonably believed to have been, accessed, acquired, used, disclosed, or breached. 15 CONTRACTOR shall take prompt corrective action to cure any deficiencies and any action 16 pertaining to such unauthorized disclosure required by applicable Federal and State Laws and 17 regulations. CONTRACTOR shall investigate such breach and is responsible for all notifications 18 required by law and regulation or deemed necessary by COUNTY and shall provide a written report 19 of the investigation and reporting required to COUNTY's Information Security Officer and Privacy 20 Officer and COUNTY's DPH HIPAA Representative. This written investigation and description of 21 any reporting necessary shall be postmarked within the thirty (30) working days of the discovery of 22 the breach to the addresses below: 23 County of Fresno County of Fresno County of Fresno 24 Dept. of Public Health Dept. of Public Health Dept. of Internal Services 25 HIPAA Representative Privacy Officer Information Security Officer 26 (559) 600-6439 (559) 600-6405 (559) 600-5800 27 P.O. Box 11867 P.O. Box 11867 2048 N. Fine Street 28 Fresno, CA 93775 Fresno, CA 93775 Fresno, CA 93727 -10- 1 I. CONTRACTOR shall make its internal practices, books, and records relating 2 to the use and disclosure of PHI received from COUNTY, or created or received by the 3 CONTRACTOR on behalf of COUNTY, in compliance with HIPAA's Privacy Rule, including, but not 4 limited to the requirements set forth in Title 45, CFR, Sections 160 and 164. CONTRACTOR shall 5 make its internal practices, books, and records relating to the use and disclosure of PHI received 6 from COUNTY, or created or received by the CONTRACTOR on behalf of COUNTY, available to 7 the United States Department of Health and Human Services (Secretary) upon demand. 8 CONTRACTOR shall cooperate with the compliance and investigation reviews 9 conducted by the Secretary. PHI access to the Secretary must be provided during the 10 CONTRACTOR's normal business hours, however, upon exigent circumstances access at any time 11 must be granted. Upon the Secretary's compliance or investigation review, if PHI is unavailable to 12 CONTRACTOR and in possession of a Subcontractor, it must certify efforts to obtain the information 13 to the Secretary. 14 J. Safeguards 15 CONTRACTOR shall implement administrative, physical, and technical 16 safeguards as required by the HIPAA Security Rule, Subpart C of 45 CFR 164, that reasonably and 17 appropriately protect the confidentiality, integrity, and availability of PHI, including electronic PHI, 18 that it creates, receives, maintains or transmits on behalf of COUNTY and to prevent unauthorized 19 access, viewing, use, disclosure, or breach of PHI other than as provided for by this Agreement. 20 CONTRACTOR shall conduct an accurate and thorough assessment of the potential risks and 21 vulnerabilities to the confidential, integrity and availability of electronic PHI. CONTRACTOR shall 22 develop and maintain a written information privacy and security program that includes 23 administrative, technical and physical safeguards appropriate to the size and complexity of 24 CONTRACTOR's operations and the nature and scope of its activities. Upon COUNTY's request, 25 CONTRACTOR shall provide COUNTY with information concerning such safeguards. 26 CONTRACTOR shall implement strong access controls and other security 27 safeguards and precautions in order to restrict logical and physical access to confidential, personal 28 (e.g., PHI) or sensitive data to authorized users only. Said safeguards and precautions shall include -11- 1 the following administrative and technical password controls for all systems used to process or store 2 confidential, personal, or sensitive data: 3 1) Passwords must not be: 4 a. Shared or written down where they are accessible or recognizable by anyone else; 5 such as taped to computer screens, stored under keyboards, or visible in a work area; 6 b. A dictionary word; or 7 c. Stored in clear text 8 2) Passwords must be: 9 a. Eight (8) characters or more in length; 10 b. Changed every ninety (90) days; 11 c. Changed immediately if revealed or compromised; and 12 d. Composed of characters from at least three (3) of the following four (4) groups from 13 the standard keyboard: 14 (1) Upper case letters (A-Z); 15 (2) Lowercase letters (a-z); 16 (3) Arabic numerals (0 through 9); and 17 (4) Non-alphanumeric characters (punctuation symbols). 18 CONTRACTOR shall implement the following security controls on each 19 workstation or portable computing device (e.g., laptop computer) containing confidential, personal, 20 or sensitive data: 21 1) Network-based firewall and/or personal firewall; 22 2) Continuously updated anti-virus software; and 23 3) Patch management process including installation of all operating 24 system/software vendor security patches. 25 CONTRACTOR shall utilize a commercial encryption solution that has received 26 FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable 27 electronic media (including, but not limited to, compact disks and thumb drives) and on portable 28 computing devices (including, but not limited to, laptop and notebook computers). -12- 1 CONTRACTOR shall not transmit confidential, personal, or sensitive data via e- 2 mail or other internet transport protocol unless the data is encrypted by a solution that has been 3 validated by the National Institute of Standards and Technology (NIST) as conforming to the 4 Advanced Encryption Standard (AES)Algorithm. CONTRACTOR must apply appropriate sanctions 5 against its employees who fail to comply with these safeguards. CONTRACTOR must adopt 6 procedures for terminating access to PHI when employment of employee ends. 7 COUNTY acknowledges and agrees that CONTRACTOR may disclose PHI in 8 its possession to COUNTY's workforce as necessary to administer the Plan(s). COUNTY shall 9 timely notify CONTRACTOR in writing of any terminations or changes of such employees. 10 K. Mitigation of Harmful Effects 11 CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that 12 is suspected or known to CONTRACTOR of an unauthorized access, viewing, use, disclosure, or 13 breach of PHI by CONTRACTOR or its subcontractors in violation of the requirements of these 14 provisions. CONTRACTOR must document suspected or known harmful effects and the outcome. 15 L. CONTRACTOR' s Subcontractors 16 CONTRACTOR shall ensure that any of its contractors, including 17 subcontractors, if applicable, to whom CONTRACTOR provides PHI received from or created or 18 received by CONTRACTOR on behalf of COUNTY, agree to the same restrictions, safeguards, and 19 conditions that apply to CONTRACTOR with respect to such PHI and to incorporate, when 20 applicable, the relevant provisions of these provisions into each subcontract or sub-award to such 21 agents or subcontractors. 22 M. Employee Training and Discipline 23 CONTRACTOR shall train and use reasonable measures to ensure compliance 24 with the requirements of these provisions by employees who assist in the performance of functions 25 or activities on behalf of COUNTY under this Agreement and use or disclose PHI and discipline 26 such employees who intentionally violate any provisions of these provisions, including termination 27 of employment. 28 N. Termination for Cause -13- 1 Upon COUNTY's knowledge of a material breach of these provisions by 2 CONTRACTOR, COUNTY shall either: 3 1) Provide an opportunity for CONTRACTOR to cure the breach or end 4 the violation and terminate this Agreement if CONTRACTOR does not cure the breach or end the 5 violation within the time specified by COUNTY; or 6 2) Immediately terminate this Agreement if CONTRACTOR has 7 breached a material term of these provisions and cure is not possible. 8 3) If neither cure nor termination is feasible, the COUNTY's Privacy 9 Officer shall report the violation to the Secretary of the U.S. Department of Health and Human 10 Services. 11 O. Judicial or Administrative Proceedings 12 COUNTY may terminate this Agreement in accordance with the terms and 13 conditions of this Agreement as written hereinabove, if: (1) CONTRACTOR is found guilty in a 14 criminal proceeding for a violation of the HIP AA Privacy or Security Laws or the HITECH Act; or(2) 15 a finding or stipulation that the CONTRACTOR has violated a privacy or security standard or 16 requirement of the HITECH Act, HIP AA or other security or privacy laws in an administrative or civil 17 proceeding in which the CONTRACTOR is a party. 18 P. Effect of Termination 19 Upon termination or expiration of this Agreement for any reason, 20 CONTRACTOR shall return or destroy all PHI received from COUNTY (or created or received by 21 CONTRACTOR on behalf of COUNTY) that CONTRACTOR still maintains in any form, and shall 22 retain no copies of such PHI. If return or destruction of PHI is not feasible, it shall continue to extend 23 the protections of these provisions to such information, and limit further use of such PHI to those 24 purposes that make the return or destruction of such PHI infeasible. This provision shall apply to 25 PHI that is in the possession of subcontractors or agents, if applicable, of CONTRACTOR. If 26 CONTRACTOR destroys the PHI data, a certification of date and time of destruction shall be 27 provided to the COUNTY by CONTRACTOR. 28 Q. Disclaimer -14- 1 COUNTY makes no warranty or representation that compliance by 2 CONTRACTOR with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will be 3 adequate or satisfactory for CONTRACTOR's own purposes or that any information in 4 CONTRACTOR's possession or control, or transmitted or received by CONTRACTOR, is or will be 5 secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR is solely 6 responsible for all decisions made by CONTRACTOR regarding the safeguarding of PHI. 7 R. Amendment 8 The parties acknowledge that Federal and State laws relating to electronic data 9 security and privacy are rapidly evolving and that amendment of these provisions may be required 10 to provide for procedures to ensure compliance with such developments. The parties specifically 11 agree to take such action as is necessary to amend this agreement in order to implement the 12 standards and requirements of HIPAA, the HIPAA regulations, the HITECH Act and other applicable 13 laws relating to the security or privacy of PHI. COUNTY may terminate this Agreement upon thirty 14 (30) days written notice in the event that CONTRACTOR does not enter into an amendment 15 providing assurances regarding the safeguarding of PHI that COUNTY in its sole discretion, deems 16 sufficient to satisfy the standards and requirements of HIPAA, the HIPAA regulations and the 17 HITECH Act. 18 S. No Third-Party Beneficiaries 19 Nothing express or implied in the terms and conditions of these provisions is 20 intended to confer, nor shall anything herein confer, upon any person other than COUNTY or 21 CONTRACTOR and their respective successors or assignees, any rights, remedies, obligations or 22 liabilities whatsoever. 23 T. Interpretation 24 The terms and conditions in these provisions shall be interpreted as broadly as 25 necessary to implement and comply with HIPAA, the HIPAA regulations and applicable State laws. 26 The parties agree that any ambiguity in the terms and conditions of these provisions shall be 27 resolved in favor of a meaning that complies and is consistent with HIP AA and the HIP AA 28 regulations. -15- 1 U. Regulatory References 2 A reference in the terms and conditions of these provisions to a section in the 3 HIPAA regulations means the section as in effect or as amended. 4 V. Survival 5 The respective rights and obligations of CONTRACTOR as stated in this Section 6 shall survive the termination or expiration of this Agreement. 7 W. No Waiver of Obligations 8 No change, waiver or discharge of any liability or obligation hereunder on any 9 one or more occasions shall be deemed a waiver of performance of any continuing or other 10 obligation, or shall prohibit enforcement of any obligation on any other occasion. 11 8. MODIFICATION: Any matters of this Agreement maybe modified from time to 12 time by the written consent of all the parties without, in any way, affecting the remainder. 13 9. NON-ASSIGNMENT: Neither party shall assign, transfer or sub-contract this 14 Agreement nor their rights or duties under this Agreement without the prior written consent of the 15 other party. 16 10. HOLD HARMLESS: CONTRACTOR agrees to indemnify, save, hold harmless, 17 and at COUNTY'S request, defend the COUNTY, its officers, agents, and employees from any and 18 all costs and expenses, damages, liabilities, claims, and losses occurring or resulting to COUNTY 19 in connection with the performance, or failure to perform, by CONTRACTOR, its officers, agents, or 20 employees under this Agreement, and from any and all costs and expenses, damages, liabilities, 21 claims, and losses occurring or resulting to any person, firm, or corporation who may be injured or 22 damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents, or 23 employees under this Agreement. 24 CONTRACTOR shall not be responsible for inaccurate and/or incomplete 25 information or data files received from COUNTY. CONTRACTOR shall not be responsible for any 26 delays in providing services under this Agreement and any financial or adverse consequences due 27 to the receipt of the inaccurate and/or incomplete information or data files or for COUNTY's failure 28 to send data files. -16- 1 11. INSURANCE 2 Without limiting the COUNTY's right to obtain indemnification from 3 CONTRACTOR or any third parties, CONTRACTOR, at its sole expense, shall maintain in full force 4 and effect, the following insurance policies or a program of self-insurance, including but not limited 5 to, an insurance pooling arrangement or Joint Powers Agreement (JPA) throughout the term of the 6 Agreement: 7 A. Commercial General Liability 8 Commercial General Liability Insurance with limits of not less than One 9 Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars 10 ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific 11 coverages including completed operations, products liability, contractual liability, Explosion- 12 Collapse-Underground, fire legal liability or any other liability insurance deemed necessary because 13 of the nature of this contract. 14 B. Automobile Liability 15 Comprehensive Automobile Liability Insurance with limits for bodily injury of 16 not less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred 17 Thousand Dollars ($500,000.00) per accident and for property damages of not less than Fifty 18 Thousand Dollars ($50,000.00), or such coverage with a combined single limit of Five Hundred 19 Thousand Dollars ($500,000.00). Coverage should include owned and non-owned vehicles used 20 in connection with this Agreement. 21 C. Professional Liability 22 If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., 23 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than 24 One Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual 25 aggregate. 26 D. Worker's Compensation 27 A policy of Worker's Compensation insurance as may be required by the 28 California Labor Code. -17- 1 CONTRACTOR shall obtain endorsements to the Commercial General Liability 2 insurance naming the County of Fresno, its officers, agents, and employees, individually and 3 collectively, as additional insured, but only insofar as the operations under this Agreement are 4 concerned. Such coverage for additional insured shall apply as primary insurance and any other 5 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be 6 excess only and not contributing with insurance provided under CONTRACTOR's policies herein. 7 This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance 8 written notice given to COUNTY. 9 Within Thirty (30) days from the date CONTRACTOR signs and executes this 10 Agreement, CONTRACTOR shall provide certificates of insurance and endorsement as stated 11 above for all of the foregoing policies, as required herein, to the County of Fresno, (Name and 12 Address of the official who will administer this contract), stating that such insurance coverage have 13 been obtained and are in full force; that the County of Fresno, its officers, agents and employees 14 will not be responsible for any premiums on the policies; that such Commercial General Liability 15 insurance names the County of Fresno, its officers, agents and employees, individually and 16 collectively, as additional insured, but only insofar as the operations under this Agreement are 17 concerned; that such coverage for additional insured shall apply as primary insurance and any other 18 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, shall be 19 excess only and not contributing with insurance provided under CONTRACTOR's policies herein; 20 and that this insurance shall not be cancelled or changed without a minimum of thirty (30) days 21 advance, written notice given to COUNTY. 22 In the event CONTRACTOR fails to keep in effect at all times insurance 23 coverage as herein provided, the COUNTY may, in addition to other remedies it may have, suspend 24 or terminate this Agreement upon the occurrence of such event. 25 All policies shall be issued by admitted insurers licensed to do business in the 26 State of California, and such insurance shall be purchased from companies possessing a current 27 A.M. Best, Inc. rating of A FSC VI or better. 28 12. AUDITS AND INSPECTIONS: The CONTRACTOR shall at any time during -18- 1 business hours, and as often as the COUNTY may deem necessary, make available to the 2 COUNTY for examination all of its records and data with respect to the matters covered by this 3 Agreement, consistent with HIPAA and any other applicable privacy and security laws. The 4 CONTRACTOR shall, upon request by the COUNTY, permit the COUNTY to audit and inspect all 5 of such records and data necessary to ensure CONTRACTOR'S compliance with the terms of this 6 Agreement. 7 If this Agreement exceeds ten thousand dollars ($10,000.00), CONTRACTOR 8 shall be subject to the examination and audit of the Auditor General for a period of three (3) years 9 after final payment under contract (Government Code Section 8546.7). 10 13. NOTICES: The persons and their addresses having authority to give and 11 receive notices under this Agreement include the following: 12 COUNTY CONTRACTOR COUNTY OF FRESNO NAVIA BENEFIT SOLUTIONS, INC. 13 Department of Human Resources 11400 SE 6t" St., Suite 125 14 2220 Tulare Street, 14t" Floor Bellevue, WA 98004 Fresno, CA 93721 15 All notices between the COUNTY and CONTRACTOR provided for or permitted 16 under this Agreement must be in writing and delivered either by personal service, by first-class 17 United States mail, by an overnight commercial courier service, or by telephonic facsimile 18 transmission. A notice delivered by personal service is effective upon service to the recipient. A 19 notice delivered by first-class United States mail is effective three COUNTY business days after 20 deposit in the United States mail, postage prepaid, addressed to the recipient. A notice delivered 21 by an overnight commercial courier service is effective one COUNTY business day after deposit 22 with the overnight commercial courier service, delivery fees prepaid, with delivery instructions given 23 for next day delivery, addressed to the recipient. A notice delivered by telephonic facsimile is 24 effective when transmission to the recipient is completed (but, if such transmission is completed 25 outside of COUNTY business hours, then such delivery shall be deemed to be effective at the next 26 beginning of a COUNTY business day), provided that the sender maintains a machine record of the 27 completed transmission. For all claims arising out of or related to this Agreement, nothing in this 28 section establishes, waives, or modifies any claims presentation requirements or procedures -19- 1 provided by law, including but not limited to the Government Claims Act (Division 3.6 of Title 1 of 2 the Government Code, beginning with section 810). 3 14. GOVERNING LAW: Venue for any action arising out of or related to this 4 Agreement shall only be in Fresno County, California. 5 The rights and obligations of the parties and all interpretation and performance 6 of this Agreement shall be governed in all respects by the laws of the State of California. 7 15. DISCLOSURE OF SELF-DEALING TRANSACTIONS 8 This provision is only applicable if the CONTRACTOR is operating as a 9 corporation (a for-profit or non-profit corporation) or if during the term of the agreement, the 10 CONTRACTOR changes its status to operate as a corporation. 11 Members of the CONTRACTOR's Board of Directors shall disclose any self- 12 dealing transactions that they are a party to while CONTRACTOR is providing goods or 13 performing services under this agreement. A self-dealing transaction shall mean a transaction to 14 which the CONTRACTOR is a party and in which one or more of its directors has a material 15 financial interest. Members of the Board of Directors shall disclose any self-dealing transactions 16 that they are a party to by completing and signing a Self-Dealing Transaction Disclosure Form, 17 attached hereto as Exhibit C and incorporated herein by reference, and submitting it to the 18 COUNTY prior to commencing with the self-dealing transaction or immediately thereafter. 19 16. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement 20 between the CONTRACTOR and COUNTY with respect to the subject matter hereof and 21 supersedes all previous Agreement negotiations, proposals, commitments, writings, 22 advertisements, publications, and understanding of any nature whatsoever unless expressly 23 included in this Agreement. In the event of any inconsistency in interpreting the documents which 24 constitute this Agreement, the inconsistency shall be resolved by giving precedence in the following 25 order of priority: (1) the text of this Agreement (excluding Exhibits A, B and C); (2) Exhibit A; and (3) 26 Exhibit B. 27 28 -20- I IN WITNESS WHEREOF,the parties hereto have executed this Agreement 2 as of the daw reinabove written. 3 OUNTY OF FRESNO 4 E (Authorized Signature) Brian Pacheco 5 Chairman, Board of Supervisors 6 Matt Aitken, Vice President ATTEST: Print Name&Title 7 BERNICE E.SEIDEL,Clerk 11400 SE 0-STREET SUITE 125 Board of Supervisors , 8 By SuSb�nn ���-- BELLEVUE,WA 98004 Deputy 9 Mailing Address 10 Br2'17 DATE: 8h/2017 DATE: 11 REVIEWED&RECOMMENDED I OR APPROVAL 12 �� v _ 13 Paul Nerland �J Director of Human Resources 14 APPROVED AS TO LEGAL.EO M APPROVED AS 1"O ACCOUNTING FORM 15 16 Danis tlerborg Oscar Garcia 17 Counter Counsel Auditor-Controllerfrreasurer-Tax Collector r 18 FOR ACCOUNTING USE ONLY: 19 ORG No.: Various Orgs Account No.: 6600 20 Requisition No.: 8921700171 21 FCMC 06111 G:1EB%OTHER SENEFITS%FLEX SPENDING ACCOUNTSV FPWSA RFP 201PAGREEMEN7WODELCONTRACT(1�DOC 22 23 24 25 26 27 28 -21- Exhibit A COUNTY OF FRESNO Co O� SRO FRE`' REQUEST FOR PROPOSAL NUMBER: 17-073 COUNTY FLEXIBLE SPENDING ACCOUNT ADMINISTRATOR Issue Date: April 13, 2017 Closing Date: May 15, 2017 at 2:00 PM All Questions and Proposals must be electronically submitted on the Bid Page on Public Purchase. For assistance, contact Nick Chin at Phone (559) 600-7110. Undersigned agrees to furnish the commodity or service stipulated in the attached response at the prices and terms stated in this RFP. Bid must be signed and dated by an authorized officer or employee. COMPANY ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER E-MAIL ADDRESS SIGNATURE PRINT NAME TITLE G:\Public\RFP\FY2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc PD-040(03/28/17) Proposal No. 17-073 Page 2 TABLE OF CONTENTS PAGE OVERVIEW..................................................................................................................... 3 KEYDATES ....................................................................................................................4 GENERAL REQUIREMENTS & CONDITIONS .............................................................. 5 INSURANCE REQUIREMENTS ..................................................................................... 8 BID INSTRUCTIONS ...................................................................................................... 9 SCOPEOF WORK ....................................................................................................... 11 SCOPE OF WORK PROPOSAL REQUIREMENTS..................................................... 14 COSTPROPOSAL........................................................................................................ 18 AWARD CRITERIA....................................................................................................... 19 PROPOSAL CONTENT REQUIREMENTS ..................................................................20 TRADE SECRET ACKNOWLEDGEMENT...................................................................22 DISCLOSURE - CRIMINAL HISTORY & CIVIL ACTIONS...........................................24 CERTIFICATION...........................................................................................................26 REFERENCE LIST........................................................................................................27 PARTICIPATION...........................................................................................................28 CHECKLIST .................................................................................................................29 EXHIBITS...................................................................................................................... 30 G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 3 OVERVIEW The County of Fresno (County) is requesting proposals from qualified vendors with a strong commitment to excellent customer service to administer the County's Health, Dependent Care, Parking, and Transit flexible spending account programs. The County is currently in the final year of a three-year agreement with our current administrator,ASI Flex. The County is conducting a request for proposals process pursuant to County policy to re-evaluate benefits vendors at the end of the three-year agreement. Election Limits Health: $2,600 Dependent Care: $5,000 Parking: $250 per month Transit: $130 per month Plan Basics • Please review Exhibit C for current FSA statistics, including the number of eligible employees, number of participants, claims information, and fees paid. • The County pays all costs associated with the plan. The current biweekly, per-participant rates are $1.29 per Health and/or Dependent Care participant, and $1.29 per Parking and/or Transit participant. Individuals enrolled in both Health and Dependent Care are subject to one fee. • We offer a debit card for Health transactions. The current debit card process is compliant with IRS regulations. Documentation is not required for copays. • The County offers high deductible health plan options;therefore, it is imperative that vendors are able to administer both standard and limited-purpose health FSA plans. Approximately 115 participants are enrolled in a high deductible health plan. • Health and Dependent Care elections must be renewed each plan year(see Plan Year 2018 Important Dates below), while parking and transit elections remain in effect until changed or terminated. • Approximately 1,797 employees pay on a pre-tax basis for parking on County-owned parking lots near their work locations. Plan Year 2018 Important Dates Open Enrollment: October 23— November 9, 2017 Plan Year: January 1 — December 31, 2018 Last day to incur expenses: March 15, 2019 Last day to submit claims: May 15, 2019 Payroll Frequency: Biweekly (26 Pay Periods) G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 4 KEY DATES RFP Issue Date: April 13, 2017 Bidders' Conference: April 24, 2017 at 10:00 AM County of Fresno - Purchasing 4525 E. Hamilton Avenue, 2nd Floor Fresno, CA 93702 Written Questions for RFP Due: April 26, 2017 at 10:00 AM. Questions must be submitted on the Bid Page. RFP Closing Date: May 15, 2017 at 2:00 PM Proposals must be electronically submitted on the Bid Page. BIDDERS' CONFERENCE &SITE INSPECTION: A bidders' conference will be held in which the scope of the project and proposal requirements will be explained. Addenda will be prepared and distributed to all bidders if questions are submitted. Bidders are to contact Nick Chin at County of Fresno - Purchasing, (559) 600-7110, if they are planning to attend. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 5 GENERAL REQUIREMENTS & CONDITIONS TERM: It is County's intent to contract with the successful bidder for a term of three years with the option to renew for up to two additional one year periods based on mutual written consent. The County reserves the right to terminate any resulting contract upon written notice. AWARD: The award will be made to the vendor offering the proposal that is deemed the most advantageous to the County. The award will be determined by factors other than price alone. Past performance and references may factor into the tentative awarding of a contract. The County will be the sole judge in making such determination. The County reserves the right to reject any and all proposals. Award Notices are tentative. Acceptance of an offer made in response to this RFP shall occur only upon execution of an agreement by both parties or issuance of a valid Purchase Order by Purchasing. After award, all bids shall be open to public inspection. The County assumes no responsibility for the confidentiality of information offered in a bid. Award may require approval by the County of Fresno— Board of Supervisors. PARTICIPATION: The bidder may agree to extend the terms of the resulting contract to other political subdivisions, municipalities, and tax-supported agencies. Such participating governmental bodies may make purchases in their own name, make payment directly to the bidder, and be liable directly to the bidder, holding the County of Fresno harmless. CONFIDENTIALITY: Services performed by the bidder shall be in strict conformance with all applicable Federal, State of California and/or local laws and regulations relating to confidentiality, including but not limited to, California Civil Code, California Welfare and Institutions Code, Health and Safety Code, California Code of Regulations, Code of Federal Regulations. The bidder shall submit to County's monitoring of said compliance. The bidder may be a Business associate of County, as that term is defined in the "Privacy Rule" enacted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As a HIPAA Business Associate, vendor may use or disclose protected health information ("PHI")to perform functions, activities or services for or on behalf of County, as specified by the County, provided that such use or disclosure shall not violate HIPAA and its implementing regulations. The uses and disclosures of PHI may not be more expansive than those applicable to County, as the "Covered Entity" under HIPAA's Privacy Rule, except as authorized for management, administrative or legal responsibilities of the Business Associate. The bidder shall not use or further disclose PHI other than as permitted or required by the County, or as required by law without written notice to the County. The bidder shall ensure that any agent, including any subcontractor, to which vendor provides PHI received from, or created or received by the vendor on behalf of County, shall comply with the same restrictions and conditions with respect to such information. SUBCONTRACTORS: If a subcontractor is proposed, complete identification of the subcontractor and his tasks should be provided. The primary contractor is not relieved of any responsibility by virtue of using a subcontractor. A specialty contractor cannot contract for work outside of their classification even if they are going to subcontract that work to another licensee who does hold the classification. The only classification that may do that is the B—General Building contractor. SELF-DEALING TRANSACTION DISCLOSURE: Contractor agrees that when operating as a corporation (a for-profit or non-profit corporation), or if during the term of the agreement the Contractor changes its status to operate as a corporation, members of the Contractor's Board of Directors shall disclose any self-dealing transactions that they are a party to while Contractor is providing goods or performing services under the agreement with the County. A self-dealing transaction shall mean a transaction to which the Contractor is a party and in which one or more of its directors has a material financial interest. Members of the Board of Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a Fresno County Self-Dealing Transaction Disclosure Form and submitting it to the County prior to commencing with the self-dealing transaction or immediately thereafter. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 6 LOCAL VENDOR PREFERENCE: The Local Vendor Preference does not apply to this Request for Proposal. CONFLICT OF INTEREST: The County shall not contract with, and shall reject any bid or proposal submitted by the persons or entities specified below, unless the Board of Supervisors finds that special circumstances exist which justify the approval of such contract: 1. Employees of the County or public agencies for which the Board of Supervisors is the governing body. 2. Profit-making firms or businesses in which employees described in Subsection (1) serve as officers, principals, partners or major shareholders. 3. Persons who, within the immediately preceding twelve (12) months, came within the provisions of Subsection (1), and who were employees in positions of substantial responsibility in the area of service to be performed by the contract, or participated in any way in developing the contract or its service specifications. 4. Profit-making firms or businesses in which the former employees described in Subsection (3) serve as officers, principals, partners or major shareholders. 5. No County employee, whose position in the County enables him to influence the selection of a contractor for this RFP, or any competing RFP, and no spouse or economic dependent of such employee, shall be employees in any capacity by a bidder, or have any other direct or indirect financial interest in the selection of a contractor. 6. In addition, no County employee will be employed by the selected vendor to fulfill the vendor's contractual obligations to the County. DISCLOSURE: The bidder is required to disclose if, within the three-year period preceding the proposal, their owners, officers, corporate managers and partners have been convicted of, or had a civil judgment rendered against them for: • fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; • violation of a federal or state antitrust statute; • embezzlement, theft, forgery, bribery, falsification, or destruction of records; or • false statements or receipt of stolen property Within a three-year period preceding their proposal, they have had a public transaction (federal, state, or local)terminated for cause or default. ORDINANCE 3.08.130— POST-SEPARATION EMPLOYMENT PROHIBITED: No officer or employee of the County who separates from County service shall for a period of one year after separation enter into any employment, contract, or other compensation arrangement with any County consultant, vendor, or other County provider of goods, materials, or services, where the officer or employee participated in any part of the decision making process that led to the County relationship with the consultant, vendor or other County provider of goods, materials or services. Pursuant to Government Code section 25132(a), a violation of the ordinance may be enjoined by an injunction in a civil lawsuit, or prosecuted as a criminal misdemeanor. TIE BIDS: In the event of a tie score between two or more proposals at the completion of the evaluation process, the evaluation team will break the tie by re-evaluating the proposals and coming to a consensus on which proposal to award. Additional information or interviews may be requested from bidders with the tied proposals. DATA SECURITY: Individuals and/or agencies that enter into a contractual relationship with the County for the purpose of providing services must employ adequate controls and data security measures, both internally and externally to ensure and protect the confidential information and/or data provided to contractor by the County, preventing the potential loss, misappropriation or inadvertent access, viewing, use or disclosure of County data including sensitive or personal client information; abuse of County resources; and/or disruption to County operations. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 7 Individuals and/or agencies may not connect to or use County networks/systems via personally owned mobile, wireless or handheld devices unless authorized by County for telecommuting purposes and provide a secure connection; up to date virus protection and mobile devices must have the remote wipe feature enabled. Computers or computer peripherals including mobile storage devices may not be used (County or Contractor device)or brought in for use into the County's system(s)without prior authorization from County's Chief Information Officer and/or designee(s). No storage of County's private, confidential or sensitive data on any hard-disk drive, portable storage device or remote storage installation unless encrypted according to advance encryption standards (AES of 128 bit or higher). The County will immediately be notified of any violations, breaches or potential breaches of security related to County's confidential information, data and/or data processing equipment which stores or processes County data, internally or externally. County shall provide oversight to Contractor's response to all incidents arising from a possible breach of security related to County's confidential client information. Contractor will be responsible to issue any notification to affected individuals as required by law or as deemed necessary by County in its sole discretion. Contractor will be responsible for all costs incurred as a result of providing the required notification. AUDITS & RETENTION: The Contractor shall maintain in good and legible condition all books, documents, papers, data files and other records related to its performance under this contract. Such records shall be complete and available to Fresno County, the State of California, the federal government or their duly authorized representatives for the purpose of audit, examination, or copying during the term of the contract and for a period of at least three (3)years following the County's final payment under the contract or until conclusion of any pending matter(e.g., litigation or audit), whichever is later. Such records must be retained in the manner described above until all pending matters are closed. E-PAYMENT OPTIONS: The County of Fresno provides an E-pay Program which involves payment of invoices by a secure Visa account number assigned to the supplier after award of contract. Notification of payments and required invoice information are issued to the supplier's designated Accounts Receivable contact by e-mail remittance advice at time of payment. To learn more about the benefits of an E-pay Program, how it works, and obtain answers to frequently asked questions, click or copy and paste the following URL into your browser: www.bankofamerica.com/epayablesvendors or call Fresno County Accounts Payable, 559-600-3609. DISPUTE RESOLUTION: The ensuing contract shall be governed by the laws of the State of California. Any claim which cannot be amicably settled without court action will be litigated in the U. S. District Court for the Eastern District of California in Fresno, CA or in a state court for Fresno County. ASSIGNMENTS: The ensuing proposed contract will provide that the vendor may not assign any payment or portions of payments without prior written consent of the County of Fresno. ASSURANCES: Any contract awarded under this RFP must be carried out in full compliance with The Civil Rights Act of 1964, The Americans With Disabilities Act of 1990, their subsequent amendments, and any and all other laws protecting the rights of individuals and agencies. The County of Fresno has a zero tolerance for discrimination, implied or expressed, and wants to ensure that policy continues under this RFP. The contractor must also guarantee that services, or workmanship, provided will be performed in compliance with all applicable local, state, or federal laws and regulations pertinent to the types of services, or project, of the nature required under this RFP. In addition, the contractor may be required to provide evidence substantiating that their employees have the necessary skills and training to perform the required services or work. LICENSES AND CERTIFICATIONS: Any license(s) and/or certification(s) required in this RFP must be obtained by the bidder prior to submitting a proposal and must be active and in good standing. Proposals submitted without the proper license(s) and/or certification(s)will be deemed non-responsive. PUBLIC CONTRACT CODE SECTION 7028.15: Where the State of California requires a Contractor's license; it is a misdemeanor for any person to submit a bid unless specifically exempted. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 8 INSURANCE REQUIREMENTS Without limiting the County's right to obtain indemnification from contractor or any third parties, contractor, at its sole expense, shall maintain in full force and effect, the following insurance policies or a program of self- insurance, including but not limited to, an insurance pooling arrangement or Joint Powers Agreement(JPA) throughout the term of the Agreement: A. Commercial General Liabilitv: Commercial General Liability Insurance with limits of not less than One Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific coverages including completed operations, products liability, contractual liability, Explosion-Collapse-Underground, fire legal liability or any other liability insurance deemed necessary because of the nature of this contract. B. Automobile Liabilitv: Comprehensive Automobile Liability Insurance with limits for bodily injury of not less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred Thousand Dollars ($500,000.00) per accident and for property damages of not less than Fifty Thousand Dollars ($50,000.00), or such coverage with a combined single limit of Five Hundred Thousand Dollars ($500,000.00). Coverage should include owned and non-owned vehicles used in connection with this Agreement. C. Professional Liabilitv: If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate. This coverage shall be issued on a per claim basis. Contractor agrees that it shall maintain, at its sole expense, in full force and effect for a period of three years following the termination of this Agreement, one or more policies of professional liability insurance with limits of coverage as specified herein. D. Worker's Compensation: A policy of Worker's Compensation insurance as maybe required by the California Labor Code. Contractor shall obtain endorsements to the Commercial General Liability insurance naming the County of Fresno, its officers, agents, and employees, individually and collectively, as additional insured, but only insofar as the operations under this Agreement are concerned. Such coverage for additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained by County, its officers, agents and employees shall be excess only and not contributing with insurance provided under Contractor's policies herein. This insurance shall not be cancelled or changed without a minimum of thirty(30)days advance written notice given to County. Within thirty(30) days from the date Contractor executes this Agreement, Contractor shall provide certificates of insurance and endorsement as stated above for all of the foregoing policies, as required herein, to the County of Fresno, Human Resources, David Joseph, 2220 Tulare Street, 14t' Floor, Fresno, CA 93721, stating that such insurance coverage have been obtained and are in full force; that the County of Fresno, its officers, agents and employees will not be responsible for any premiums on the policies; that such Commercial General Liability insurance names the County of Fresno, its officers, agents and employees, individually and collectively, as additional insured, but only insofar as the operations under this Agreement are concerned; that such coverage for additional insured shall apply as primary insurance and any other insurance, or self-insurance, maintained by County, its officers, agents and employees, shall be excess only and not contributing with insurance provided under Contractor's policies herein; and that this insurance shall not be cancelled or changed without a minimum of thirty(30)days advance, written notice given to County. In the event Contractor fails to keep in effect at all times insurance coverage as herein provided, the County may, in addition to other remedies it may have, suspend or terminate this Agreement upon the occurrence of such event. All policies shall be with admitted insurers licensed to do business in the State of California. Insurance purchased shall be purchased from companies possessing a current A.M. Best, Inc. rating of A FSC VII or better. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 9 BID INSTRUCTIONS • All prices and notations must be typed or written in ink. • Unless otherwise noted, prices shall remain firm for 180 days after the closing date of the bid. • Proposals must be electronically submitted on the forms provided in this RFP with all pages numbered. • Additional material may be submitted with the proposal as attachments. Any additional descriptive material that is used in support of any information in your proposal must be referenced by the appropriate paragraph(s)and page number(s). • Bidders must electronically submit their proposal in .pdf format, no later than the proposal closing date and time as stated on the front of this document, to the Bid Page on Public Purchase. The County will not be responsible for and will not accept late bids due to slow internet connection or incomplete transmissions. • County of Fresno will not be held liable for any costs incurred by vendors in responding to this RFP. • Bidders are instructed not to submit confidential, proprietary and related information within the request for proposal. If you are submitting trade secrets, it must be electronically submitted in a separate PDF file clearly named "TRADE SECRETS" and marked as Confidential, see Trade Secret Acknowledgement section. • If a bidder finds any discrepancies or has any questions, submit all inquiries to the Bid Page on Public Purchase or contact Nick Chin at(559)600-7110. Any change in the RFP will be made only by written addendum issued by the County. The County will not be responsible for any other explanations or interpretations. • Failure to respond to all questions or to not supply the requested information could result in rejection of your proposal. Merely offering to meet the specifications is insufficient and will not be accepted. Each bidder shall submit a complete proposal with all information requested. • Proposals received after the closing date and time will NOT be considered. • Proposals will be evaluated by an evaluation team led by County Purchasing and may consist of County of Fresno department staff, community representatives from advisory boards, and other members as appropriate. If a proposal does not respond adequately to the RFP or the bidder is deemed unsuitable or incapable of delivering services, the proposal may be eliminated from consideration. Upon review and evaluation, the evaluation team will make the final recommendation to the County department. • After the initial evaluation of proposals and reference checks, the evaluation team may invite the bidders deemed most qualified to present a demonstration as part of the final selection process. • Appeals must be submitted in writing within seven (7)working days after notification of proposed recommendations for award. A"Notice of Award" is not an indication of County's acceptance of an offer made in response to this RFP. Appeals shall be submitted to County of Fresno Purchasing, 4525 E. Hamilton Avenue 2nd Floor, Fresno, California 93702-4599 and in Word format to gcornuelle(cDco.fresno.ca.us. Appeals should address only areas regarding RFP contradictions, procurement errors, proposal rating discrepancies, legality of procurement context, conflict of interest, and inappropriate or unfair competitive procurement grievance regarding the RFP process. Purchasing will provide a written response to the complainant within seven (7)working days unless the complainant is notified more time is required. If the appealing bidder is not satisfied with the decision of Purchasing, he/she shall have the right to appeal to the County Administrative Office within seven (7) working days after Purchasing's notification; if the appealing bidder is not satisfied with CAO's decision, the final appeal is with the Board of Supervisors. Please contact Purchasing if the appeal will be going to the Board of Supervisors. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 10 • All communication regarding this RFP shall be directed to an authorized representative of County Purchasing. The specific Analyst managing this RFP is identified on the cover page, along with his or her contact information, and he or she should be the primary point of contact for discussions or information pertaining to the RFP. Contact with any other County representative, including elected officials, for the purpose of discussing this RFP, its content, or any other issue concerning it, is prohibited unless authorized by Purchasing. Violation of this clause, by the vendor having unauthorized contact(verbally or in writing)with such other County representatives, may constitute grounds for rejection by Purchasing of the vendor's quotation. The above stated restriction on vendor contact with County representatives shall apply until the County has awarded a purchase order or contract to a vendor or vendors, except as follows. First, in the event that a vendor initiates a formal appeal against the RFP, such vendor may contact the Purchasing Manager who manages that appeal as outlined in the County's established appeal procedures. All such contact must be in accordance with the sequence set forth under the appeal procedures. Second, in the event a public hearing is scheduled before the Board of Supervisors to hear testimony prior to its approval of a purchase order or contract, any vendor may address the Board at scheduled Board Meeting. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 11 SCOPE OF WORK The Scope of Work below is intended to inform bidders of the County's Flexible Spending Program Administration needs. If there are any services that a bidder is not able to provide, this should be noted and explained fully. Bidders must complete the Vendor Questionnaire contained in this RFP. Bidders are welcome to provide a detailed proposal for any service that is not addressed in the Scope of Work or Vendor Questionnaire. The Scope of Work includes providing services through the grace period and claims run-out for each plan year being administered through the end of the agreement at no additional cost. Administration 1. Administer the County's Health Care, Dependent Care, Parking and Transit Flexible Spending Account Programs and ensure that the plan design, plan documents, implementation, communication and reports are in compliance with all applicable laws and regulations. Reference Exhibits A and B for the Plan Documents. 2. Process Flexible Spending Account claims;claims will be processed and reimbursements to employees will be made, via check or direct deposit, at least two (2) times per week; currently, claims processing and reimbursements occur daily. 3. Maintain individual accounts for all participants crediting biweekly contributions to each account and debiting periodic payments against those accounts. This includes coordinating with the County and its third-party billing firm on payments from participants on unpaid leave of absence ("Pay As You Go")and tracking payments and claims of COBRA participants. 4. Accept claim forms online, via fax and by U.S. mail; in addition, claim filing via smart phone app is preferred. 5. Provide participants with quarterly account statements, end-of-plan year forfeiture warning notices and Open Enrollment confirmation statements. Employees will be given the opportunity to sign up for paperless statements/correspondence. 6. Provide a dedicated account manager to assist County staff. 7. Provide an employer portal where County staff can access reports, participant account information, etc. 8. The County maintains a separate bank account for Flexible Spending Account transactions. The current Administrator debits this account as needed to pay for claims reimbursement. The County prefers to maintain this process. 9. Provide biweekly reports detailing any discrepancies between a participant's expected and actual biweekly contribution and annual election. 10. Provide the County with daily and monthly claim payment reports. It is preferred that all claim types(e.g., Health, Dependent Care, Transportation) and all plan years be in one daily/monthly report, rather than separate reports by plan type/year. 11. Provide the County of Fresno with bank account reconciliation reports, at least monthly, in a format approved by the County. 12. Perform all non-discrimination tests required under applicable laws and IRS guidance, at least quarterly. 13. Provide notification of changes in regulations affecting the plans and advise the County on any amendments to the Plan Documents necessitated by changes in applicable laws or regulations. 14. Provide guidance to the County with regard to interpreting the County's existing Cafeteria Plan Document (IRC Sections 105, 125, 129, and 223) and Commuter Plan Document. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 12 15. Review requests by employees to participate in the Health or Dependent Care plans or make changes to their Health or Dependent Care elections outside of Open Enrollment. Determine whether such Change in Status or Qualifying Event requests, on a uniform and consistent basis, are permissible under IRS regulations and the County of Fresno Cafeteria Plan Document. 16. Provide a detailed plan for transitioning the County plans, including a timeline of key events and communication strategy. 17. All Flex Plan literature for plan year 2018 must be available for Open Enrollment by September 1, 2017. Dates for subsequent plan years will be consistent with the above time frame. Participant Services and Communication 18. Administrator will provide plan participants access to their staff for inquiries and problem resolution, to include but not be limited to,toll free phone number,e-mail,and open enrollment fairs. The toll free phone number will be available, at minimum, from 8:00 am to 5:00 pm Pacific Standard Time. 19. Customer service representatives will provide friendly,efficient service to plan participants with a focus on educating them regarding the various components of the plan when necessary. 20. Provide a website and smart phone application where participants may review their account information and submit claims and substantiating information. 21. Assist the County in educating employees on the benefits of the different plans,with particular emphasis on the Dependent Care and Parking/Commuter plans. 22. Typically,the County has one (1) major health and wellness fair and several satellite fairs over the course of a two-week period during the annual Open Enrollment period. Administrator is required to send, at minimum, one (1) representative to the health and wellness fair as well as all other satellite fairs to assist with plan enrollment(see Exhibit G for the 2016 OE fair schedule). Therefore,your Cost Proposal should account for attendance at all Open Enrollment fairs. Debit Card 23. Offer an optional FSA debit card to all Health Care FSA participants and provide a minimum of two(2)debit cards to each participant who elects this option, at no additional cost to the participant. 24. Provide clear communications regarding the features and functionality of the debit card, with particular emphasis on what is required to substantiate debit card transactions and clearly explain all instances when the card may be used (pharmacy, doctor's office, vision provider, etc.). 25. Maintain a fully automated claims adjudication system in compliance with electronic transmission standards and security requirements and all other regulations as required by HIPAA and applicable IRS guidance, including Revenue Ruling 2003-43 and Notice 2006-69. 26. Provide monthly and annual unsubstantiated/improper health flexible spending account claims report, detailing members with active unsubstantiated debit card claims, and assist County with correction procedures for improper health flexible spending account payments pursuant to IRS Memorandum number 201413006. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 13 Information Transmission and Security 27. The Administrator must be able to receive a biweekly census and deductions file with specifications approved by the County(see Exhibit H for the current file specifications). 28. The Administrator must provide a public key to allow for information to be encrypted and securely transmitted via SFTP (FTP over SSH) protocol. 29. Provide administrative,technical,and physical safeguards to protect any County information maintained in the contractor's custody, consistent with current HIPAA requirements. 30. Provide a backup system in the event of destruction of the primary system so that administration and accounting for the flex plan would not be disrupted by fire, equipment failure, or other catastrophe. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 14 SCOPE OF WORK PROPOSAL REQUIREMENTS Pursuant to instructions included in this RFP, Proposal Content Requirements, a bidder's proposal shall include a response to the following: Vendor Information 1. Please provide an organization overview including, but not limited to: a. Length of time processing FSA administration for clients b. Company location, claim office location as well as customer service location which will be responsible for servicing the County. c. Does FSA administration represent a core business unit or strategy or ancillary administrative product line? Please explain. d. Will you accept fiduciary responsibility of the plan? If not please explain. 2. Please provide an organization chart of employees who would be involved in this account along with their duties, titles, years of experience and physical locations. 3. In the table below, indicate the number of Public and Private FSA plans your company has in force as of January 1, 2017, by the number of eligible employees. What is the average tenure and average participation rate(i.e.,the percentage of eligible employees who actually participate)among your current FSA clients? Less than 1,000 1,000—5,000 5,001 — 10,000 10,000 + Public Private 4. What steps have you taken over the past two(2)years to improve your products and the experience of your customers? What changes do you plan during the next 12—24 months to enhance your member service and technology capabilities? Administration 5. Confirm your ability to administer the plan design exactly as stated in the Plan Documents in terms of benefit levels, covered services, exclusions, claims processing and claim appeal procedures. If not, please specify which provisions and why you are unable to administer them. 6. How often are claims processed and reimbursements made?Can participants submit claims online, by U.S. Mail,via fax, and by a mobile device/app? Do you require a minimum claim amount for submission and/or reimbursement? 7. What was your average claim turnaround time for reimbursements (number of days from receipt of a clean claim)for 2014, 2015, and 2016? 8. What steps do you take to ensure that a submitted FSA claim is a covered expense under applicable federal and state laws and regulations? 9. Will you require substantiation of a recurring eligible expense each time the expense is submitted or only the first time the expense is submitted? 10. Please confirm that you are able to debit the County-owned bank account as needed to pay for claims reimbursement as stated in #8 of the Scope of Work. If you are not able continue this process please describe the alternate process. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 15 11. Please confirm that a dedicated account manager for FSA program administration will be assigned to the County's account no later than thirty(30)days prior to Open Enrollment(scheduled to begin October 23, 2017). 12. Please confirm that it is your expectation that the account manager will respond to emails and phone calls within one(1)business day. If the County is not satisfied with the service or responsiveness of the current dedicated account manager, how will your firm work with the County to improve the performance of that account manager? If improvements are not made,will your firm assign a different manager to the County? 13. For each of the following functions,indicate whether the dedicated account manager will coordinate these functions or if the County will have designated contact people. a. Billing/Accounting b. Technical Support c. Customer Service d. Communications e. Legal/Compliance 14. Will you generate detailed quarterly account statements to participants,end-of-plan-year warning notices regarding forfeitures, and Open Enrollment confirmation statements? Are you able to provide paper statements and correspondence? Is there an additional cost for paper? If so, please note in your Cost Proposal. 15. Describe the capabilities of your employer portal. Does it allow for multiple County staff to have access to view and change information if needed? What daily functions are available? 16. Please attach samples of your standard reports and indicate which reports are available on-demand, monthly, quarterly, and annually at no charge. 17. Please confirm that you are able to provide biweekly reports detailing any discrepancies between a participant's expected and actual biweekly contribution and annual election. 18. Please confirm that you are able to provide daily and monthly claim payment reports. Will these reports include all plan types and plan years in the same report? 19. Please confirm that you are able to provide monthly bank account reconciliation reports in a format approved by the County. 20. Please confirm that you are able to perform all non-discrimination tests required under applicable laws and IRS guidance, at least quarterly, at no additional charge to the County. 21. Explain how you will keep the County informed of changes to applicable laws and regulations that affect the County's Plan Documents. Do you suggest changes to specific provisions in the Plan Documents? 22. Please confirm that you will assist the County in interpreting provisions of the County's Plan Documents. 23. Do you provide Change in Status or Qualifying Event request review and determination services (as stated in Scope of Work#15)for clients? Is there an additional cost for this service? If so, please note in your Cost Proposal. 24. How do you coordinate and communicate with clients and/or their third-party billing firm to: a. Identify COBRA-eligible participants who have separated from service and maintain a record of COBRA participants' contributions and claims? b. Manage the accounts of participants who are on unpaid leave of absence? 25. Please confirm that you have reviewed the Model County Contract(Exhibit E)and are able to comply with the terms and conditions, including:4.Termination,7. Health Insurance Portability and Accountability Act, 10. Hold Harmless, 11. Insurance, and 14. Governing Law. Please note any exceptions and provide a detailed remedy. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 16 Account Transition 26. Implementation a. Provide a sample implementation calendar detailing the work plan for implementation of FSA program administration, including the personnel required from vendor and County and what each entity is responsible for; assume a July 1, 2017 selection date and a January 1, 2018 effective date. b. Please provide copies of any informational brochures/guidelines you could provide for eligible employees and confirm that all materials will be available by September 1, 2017. c. Confirm that your implementation manager and account executive would meet with County benefits staff in Fresno for a kickoff meeting. 27. Describe how you would transition accounts, including any black-out periods involved: a. Include your capability to transition account history(contributions, claims, etc.). b. Describe the communication support you would provide. 28. Please explain how you would facilitate claims incurred prior to January 1,2018 but submitted to you for processing. How would you help with the run out period? 29. Will you be willing to put a dollar amount or percentage of fees at risk if implementation goals are not met? If so, please provide a detailed explanation and note in your Cost Proposal. Participant Services and Communication 30. Describe the structure and staffing of your customer service office: a. What are your member service hours of operation? b. What are your 24-hour customer service capabilities? c. How many CSR's will be assigned to the County of Fresno and what is their average tenure? 31. For 2016, provide the following customer service statistics: a. Total number of calls received b. Average hold/wait time c. Average hold/wait time between January and March d. Average phone call abandonment rate e. Percent of telephone inquiries resolved during initial call f. Will the County have access to these statistics for our participants? 32. Provide a complete description of your customer service procedures from receipt of a question or complaint to complete resolution. Do your customer service representatives record each call and are calls monitored for quality? Will you contact and communicate directly with participants as required to resolve problems or to respond to questions? 33. Describe your guidelines and requirements for continuing education among your staff for compliance and regulatory issues, customer service, and client-specific account information. 34. How often do you measure participant satisfaction with your program? Please attach a copy of the most recent survey with results, if available.Are you willing to conduct an annual employee satisfaction survey of County of Fresno participants?Will you be willing to put a dollar amount or percentage of fees at risk if participant satisfaction goals are not met? If so, please provide a detailed explanation and note in your Cost Proposal. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 17 35. Please confirm that you offer a website where participants may check the status of their account,submit a claim, and review requests for additional information for a pending claim. Please list any additional capabilities available and include any hardware or software requirements necessary to access the website. Please provide a sample web page and dummy account for the County to review. 36. Do you provide a smartphone application for participants? If yes, please explain what services are provided through the smartphone application and include any hardware or software requirements necessary to access the application. 37. Please describe your strategy for promoting the programs and educating employees on the benefits of the programs, with particular emphasis on the Dependent Care and Parking/Commuter programs. 38. Briefly describe the printed materials you offer employees regarding Flexible Spending Accounts(flyers, brochures, etc.)and the purpose of each one. Do you have separate communications for the Debit Card that detail the restrictions and responsibilities that come with using the Card, such as when and why substantiating information is needed? Do you provide hard-copy welcome kits,webinars and/or on-site seminars? Please provide sample communications materials and describe any additional cost associated with these services. 39. Please confirm that you are able to provide at least one (1) representative at the annual health and wellness fair as well as all other satellite fairs to assist with plan enrollment as stated in Scope of Work #22. Debit Card 40. Please confirm that you offer an optional debit card to Health Care FSA participants and that each participant will receive at least two(2)cards. Please also confirm that debit card participants are still able to submit manual claims and receive reimbursements. 41. Please confirm that you adhere to the claim substantiation rules contained in IRS Revenue Ruling 2003- 43 and IRS Notice 2006-69 and describe how the debit card distinguishes between valid FSA purchases and other goods that are not eligible for reimbursement. 42. How do you ensure the debit card is deactivated when a participant separates from service or fails to make a contribution? 43. Please describe your procedure(s)for assisting clients with correction procedures for improper health flexible spending account payments pursuant to IRS Memorandum number 201413006. a. What parts of the process do you manage, and what is the employer responsible for? b. What is the schedule for deactivating a card if a participant fails to provide substantiating documentation and how do you communicate with the participant that this is happening? What appeals process is in place for a participant whose debit card claim is denied? c. What is the timing and process for reactivating cards once a situation is resolved? Information Transmission, Retention and Security 44. Please confirm that you are able to use the current biweekly census file format(Exhibit H). If not,please provide your file specifications. 45. Please confirm that you are able to accommodate the data encryption and transmission protocols as stated in Scope of Work#28. If not, please explain. 46. How do you ensure client confidentiality consistent with current HIPAA requirements? Is your system HIPAA compliant for data security? Explain how. 47. Describe your information technology infrastructure including back-up, security, and disaster recovery procedures?Are files archived and stored at an off-site location? Have procedures been tested?When did you last perform a full-scale disaster recovery test and what were the results? 48. How long are records retained? In what manner are they retained? G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 18 COST PROPOSAL A. In the table below, indicate the biweekly per participant cost for each category—Health and/or Dependent Care, Transit and/or Parking, and Participants in both—and the total annual cost based upon the expected number of participants. Please state your proposed fees based on a three (3)year agreement with two (2) optional one-year renewals. Health and/or Transit and/or Participants in both Dependent Care Parking Health/DCAP and (1,691 Participants) (33 Participants) Parking/Transit Biweekly Per Participant Fee Total Annual Administration Cost B. Will your company guarantee pricing during the length the contract term, including renewals? C. Are fees higher if participants request paper statements? If so, please indicate the difference for each fee category in "A" above and the conditions which would trigger higher fees. D. Does your per participant rate decrease based on program enrollment milestones?If so, please indicate the difference for each fee category in"A"above. Please also indicate whether any of the proposed rates are tied to a minimum enrollment. E. Please confirm that non-discrimination testing, as requested in the Scope of Work, is included in the administrative fee. If not, please specify the additional cost. F. If applicable, please detail any fees your firm will put at risk for failing to meet stated goals. G. Please detail any and all other possible charges/expenses/fees applicable to the administration of the programs. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 19 AWARD CRITERIA Selection of the winning bidder will be based on the following criteria. Please note that the list below is not ordered by level of importance; proposals will be judged on how well they meet all of the criteria. COST • Cost, as submitted in the Cost Proposal section. Please note that the County intends to award the contract to the proposing firm whose proposal is determined to be most advantageous to the County, taking into account both technical merit and price. CAPABILITY AND QUALIFICATIONS • Quality, thoroughness, and clarity of proposal and the absence of exceptions to provisions in the RFP, including, but not limited to the inability to accept the terms and conditions of the model County of Fresno contract or the inability to perform services as stated in the Scope of Work. • The demonstrated ability, including staff, experience and resources, to provide the services requested in the Scope of Work for organizations similar in size to the County of Fresno. • The demonstrated ability to administer the County FSA programs, including the debit card feature, in compliance with applicable state and federal laws and regulations and the County's Plan Documents. • Demonstrated ability to successfully transition the County FSA programs within the proposed timeline. • Demonstrated commitment to delivering excellent customer service and administrative support to County staff and participating employees and their dependents. After initial evaluation of proposals and reference checks, the County may invite the bidders deemed most qualified to present a demonstration as part of the final selection process. If demonstrations are necessary, they will be held at: Fresno County Purchasing Department 4525 E. Hamilton Avenue, 2nd Floor Fresno, CA 93702-4599 G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 20 PROPOSAL CONTENT REQUIREMENTS It is required that the vendor submit his/her proposal in accordance with the format and instructions provided under this section. I. RFP PAGE 1 AND ADDENDUM(S) PAGE 1 (IF APPLICABLE) completed and signed by participating individual or agency. II. COVER LETTER: A one-page cover letter and introduction including the company name and address of the bidder and the name, address and telephone number of the person or persons to be used for contact and who will be authorized to make representations for the bidder. A. Whether the bidder is an individual, partnership or corporation shall also be stated. It will be signed by the individual, partner, or an officer or agent of the corporation authorized to bind the corporation, depending upon the legal nature of the bidder. A corporation submitting a proposal may be required before the contract is finally awarded to furnish a certificate as to its corporate existence, and satisfactory evidence as to the officer or officers authorized to execute the contract on behalf of the corporation. III. TABLE OF CONTENTS IV. CONFLICT OF INTEREST STATEMENT: The Contractor may become involved in situations where conflict of interest could occur due to individual or organizational activities that occur within the County. The Contractor must provide a statement addressing the potential, if any, for conflict of interest and indicate plans, if applicable, to address potential conflict of interest. This section will be reviewed by County Counsel for compliance with conflict of interest as part of the review process. The Contractor shall comply with all federal, state and local conflict of interest laws, statutes and regulations. V. TRADE SECRET: A. Sign where required. VI. CERTIFICATION—DISCLOSURE—CRIMINAL HISTORY& CIVIL ACTIONS VII. REFERENCES VIII. PARTICIPATION IX. EXCEPTIONS: This portion of the proposal will note any exceptions to the requirements and conditions taken by the bidder. If exceptions are not noted, the County will assume that the bidder's proposals meet those requirements. The exceptions shall be noted as follows: A. Exceptions to General Conditions. B. Exceptions to General Requirements. C. Exceptions to Specific Terms and Conditions. D. Exceptions to Scope of Work and/or Scope of Work Proposal Requirements. E. Exceptions to Proposal Content Requirements. F. Exceptions to any other part of this RFP. X. VENDOR COMPANY DATA: This section should include: A. A narrative which demonstrates the vendor's basic familiarity or experience with problems associated with this service/project. B. Descriptions of any similar or related contracts under which the bidder has provided services. C. Descriptions of the qualifications of the individual(s) providing the services. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 21 D. Any material (including letters of support or endorsement) indicative of the bidder's capability. E. A brief description of the bidder's current operations, and ability to provide the services. F. Copies of the audited Financial Statements for the last three (3)years for the agency or program that will be providing the service(s) proposed. If audited statements are not available, compiled or reviewed statements will be accepted with copies of three years of corresponding federal tax returns. This information is to be provided after the RFP closes, if requested. Do not provide with your proposal. G. Describe all contracts that have been terminated before completion within the last five (5) years: 1. Agency contract with 2. Date of original contract 3. Reason for termination 4. Contact person and telephone number for agency H. Describe all lawsuit(s)or legal action(s)that are currently pending; and any lawsuit(s) or legal action(s)that have been resolved within the last five (5)years: 1. Location filed, name of court and docket number 2. Nature of the lawsuit or legal action I. Describe any payment problems that you have had with the County within the past three (3) years: 1. Funding source 2. Date(s) and amount(s) 3. Resolution 4. Impact to financial viability of organization. XI. SCOPE OF WORK: A. Bidders are to use this section to describe the essence of their proposal. B. This section should be formatted as follows: 1. A general discussion of your understanding of the project, the Scope of Work proposed and a summary of the features of your proposal. 2. A detailed description of your proposal as it relates to each item listed under the "Scope of Work Proposal Requirements" section of this RFP. Bidder's response should be stated in the same order as are the "Scope of Work Proposal Requirements" items. Each description should begin with a restatement of the "Scope of Work Proposal Requirements" item that it is addressing. Bidders must explain their approach and method of satisfying each of the listed items. C. When reports or other documentation are to be a part of the proposal a sample of each must be submitted. Reports should be referenced in this section and submitted in a separate section entitled "REPORTS." D. A complete description of any alternative solutions or approaches to accomplishing the desired results. XI I. COST PROPOSAL: Quotations may be prepared in any manner to best demonstrate the worthiness of your proposal. Include details and rates/fees for all services, materials, equipment, etc. to be provided or optional under the proposal. XIII. CHECK LIST G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 22 TRADE SECRET ACKNOWLEDGEMENT All proposals received by the County shall be considered "Public Record" as defined by Section 6252 of the California Government Code. This definition reads as follows: "...Public records" includes any writing containing information relating to the conduct of the public's business prepared, owned, used or retained by any state or local agency regardless of physical form or characteristics"Public records"in the custody of,or maintained by,the Governor's office means anywriting prepared on or after January 6, 1975." Each proposal submitted is Public record and is therefore subject to inspection by the public per Section 6253 of the California Government Code. This section states that"every person has a right to inspect any public record". The County will not exclude any proposal or portion of a proposal from treatment as a public record except in the instance that it is submitted as a trade secret as defined by the California Government Code. Information submitted as proprietary, confidential or under any other such terms that might suggest restricted public access will not be excluded from treatment as public record. "Trade secrets" as defined by Section 6254.7 of the California Government Code are deemed not to be public record. This section defines trade secrets as: "...Trade secrets," as used in this section, may include, but are not limited to, any formula, plan, pattern, process, tool, mechanism, compound, procedure, production data or compilation of information that is not patented, which is known only to certain individuals within a commercial concern who are using it to fabricate, produce, or compound an article of trade or a service having commercial value and which gives its user an opportunity to obtain a business advantage over competitors who do not know or use it." Information identified by bidder as "trade secret"will be reviewed by County of Fresno's legal counsel to determine conformance or non-conformance to this definition. Such material should be electronically submitted in separate PDF file named "Trade Secret" and marked as Confidential. Examples of material not considered to be trade secrets are pricing, cover letter, promotional materials, etc. INFORMATION THAT IS PROPERLY IDENTIFIED AS TRADE SECRET AND CONFORMS TO THE ABOVE DEFINITION WILL NOT BECOME PUBLIC RECORD. COUNTY WILL SAFEGUARD THIS INFORMATION IN AN APPROPRIATE MANNER. Information identified by bidder as trade secret and determined not to be in conformance with the California Government Code definition shall be excluded from the proposal. Such information will be returned to the bidder at bidder's expense upon written request. Trade secrets must be electronically submitted in a separate PDF file that is plainly named "Trade Secrets" and marked as Confidential. The County shall not in any way be liable or responsible for the disclosure of any proposals or portions thereof, if they are not(1)electronically submitted in a separate PDF that is named "Trade Secret" and marked as Confidential; and (2) if disclosure is required or allowed under the provision of law or by order of Court. Vendors are advised that the County does not wish to receive trade secrets and that vendors are not to supply trade secrets unless they are absolutely necessary. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 23 TRADE SECRET ACKNOWLEDGEMENT I have read and understand the above "Trade Secret Acknowledgement." I understand that the County of Fresno has no responsibility for protecting information electronically submitted as a trade secret if it is not delivered in a separate PDF file named "Trade Secret' and marked as Confidential. I also understand that all information my company submits, except for that information electronically submitted in a separate PDF file named "Trade Secret' and marked as Confidential, are public records subject to inspection by the public. This is true no matter whether my company identified the information as proprietary, confidential or under any other such terms that might suggest restricted public access. Enter company name on appropriate line: Has submitted information identified as Trade Secrets in (Company Name) a separate marked binder.** Has not submitted information identified as Trade (Company Name) Secrets. Information submitted as proprietary confidential or under any other such terms that might suggest restricted public access will not be excluded from treatment as public record. ACKNOWLEDGED BY: Signature Telephone Print Name and Title Date Address City State Zip **Bidders brief statement that clearly sets out the reasons for confidentiality in conforming with the California Government Code definition. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 24 DISCLOSURE - CRIMINAL HISTORY & CIVIL ACTIONS In their proposal, the bidder is required to disclose if any of the following conditions apply to them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as "Bidder"): 1. Within the three-year period preceding the proposal, they have been convicted of, or had a civil judgment rendered against them for: a. fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local)transaction or contract under a public transaction; b. violation of a federal or state antitrust statute; c. embezzlement, theft, forgery, bribery, falsification, or destruction of records; or d. false statements or receipt of stolen property 2. Within a three-year period preceding their proposal, they have had a public transaction (federal, state, or local)terminated for cause or default. Disclosure of the above information will not automatically eliminate a Bidder from consideration. The information will be considered as part of the determination of whether to award the contract and any additional information or explanation that a Bidder elects to submit with the disclosed information will be considered. If it is later determined that the Bidder failed to disclose required information, any contract awarded to such Bidder may be immediately voided and terminated for material failure to comply with the terms and conditions of the award. Any Bidder who is awarded a contract must sign an appropriate Certification Regarding Debarment, Suspension, and Other Responsibility Matters. Additionally, the Bidder awarded the contract must immediately advise the County in writing if, during the term of the agreement: (1) Bidder becomes suspended, debarred, excluded or ineligible for participation in federal or state funded programs or from receiving federal funds as listed in the excluded parties list system (http://www.epls.gov); or(2) any of the above listed conditions become applicable to Bidder. The Bidder will indemnify, defend and hold the County harmless for any loss or damage resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification Regarding Debarment, Suspension, and Other Responsibility Matters. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 25 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at any time the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded, as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 26 CERTIFICATION (1)The prospective primary participant certifies to the best of its knowledge and belief, that it, its owners, officers, corporate managers and partners: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local)transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local)terminated for cause or default. (2)Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. Signature: Date: (Printed Name&Title) (Name of Agency or Company) G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 27 REFERENCE LIST VENDOR MUST COMPLETE AND RETURN WITH REQUEST FOR PROPOSAL Firm: Provide a list of at least five (5) customers for whom you have recently provided similar services. Be sure to include all requested information. Reference Name: Contact: Address: City: State: Zip: Phone No.: ( ) Project Date: Service Provided: Reference Name: Contact: Address: City: State: Zip: Phone No.: ( ) Project Date: Service Provided: Reference Name: Contact: Address: City: State: Zip: Phone No.: ( ) Project Date: Service Provided: Reference Name: Contact: Address: City: State: Zip: Phone No.: ( ) Project Date: Service Provided: Reference Name: Contact: Address: City: State: Zip: Phone No.: ( ) Project Date: Service Provided: Failure to provide a list of at least five (5) customers may be cause for rejection of this RFP. G:\Public\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 28 PARTICIPATION The County of Fresno is a member of the Central Valley Purchasing Group. This group consists of Fresno, Kern, Kings, and Tulare Counties and all governmental, tax supported agencies within these counties. Whenever possible, these and other tax supported agencies co-op (piggyback)on contracts put in place by one of the other agencies. Any agency choosing to avail itself of this opportunity, will make purchases in their own name, make payment directly to the contractor, be liable to the contractor and vice versa, per the terms of the original contract, all the while holding the County of Fresno harmless. If awarded this contract, please indicate whether you would extend the same terms and conditions to all tax supported agencies within this group as you are proposing to extend to Fresno County. * Note: This form/information is not rated or ranked for evaluation purposes. Yes, we will extend contract terms and conditions to all qualified agencies within the Central Valley 11-11 Purchasing Group and other tax supported agencies. IF] No, we will not extend contract terms to any agency other than the County of Fresno. (Authorized Signature) Title G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 29 CHECK LIST This Checklist is provided to assist vendors in the preparation of their RFP response. Included are important requirements the bidder is responsible to submit with the RFP package in order to make the RFP compliant. Check off each of the following (if applicable): 1. Signed cover page of Request for Proposal (RFP). 2. Check https://www2.co.fresno.ca.us/0440/Bids/BidsHome.aspx for any addenda. 3. Signed cover page of each Addendum. 4. Provide a Conflict of Interest Statement. Signed Trade Secret Form as provided with this RFP (Trade Secret Information, if provided, 5. must be electronically submitted in a separate PDF file and marked as Confidential). 6. Signed Criminal History Disclosure Form as provided with this RFP. 7. Signed Participation Form as provided with this RFP. 8. The completed Reference List as provided with this RFP. 9. Verification of Department of Industrial Relations Contractor Registration. Verification of Contractor's License and the Department of Consumer Affairs—Contractors' 10. State License Board Indicate all of bidder exceptions to the County's requirements, conditions and specifications 11. as stated within this RFP. Bidder's proposal, in PDF format, electronically submitted to the Bid Page on Public 12. Purchase. Return Checklist with your RFP response G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 30 EXHIBITS A. Cafeteria Plan B. Commuter Plan C. Flexible Spending Accounts Statistics D. Current Agreement E. Sample Agreement F. Current FSA Forms G. 2016 Open Enrollment Fair Schedule H. Current Biweekly Census File Specifications G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc EXHIBIT A Cafeteria Plan for the Employees of County of Fresno Plan Document and Summary Plan Description Originally Effective July 1, 1988 Restated and Amended January 1, 2016 Summary Plan Description This Plan Document also constitutes a Summary Plan Description. 1 Section 1 Introduction 1.1 Establishment of the Plan County of Fresno (the "Employer") originally established the County of Fresno Cafeteria Plan (the "Plan") effective July 1, 1988. County of Fresno hereby amends and restates the Plan effective January 1, 2016 (the "Effective Date"). 1.2 Purpose of the Plan This Plan allows an Employee to participate in the following Benefit Options: • Premium Payment Plan (PPP) to make pre-tax Salary Reduction Contributions to pay the Employee's share of the premium or contribution for the Insurance Plan(s). • Health Flexible Spending Account (Health FSA) to make pre-tax Salary Reduction Contributions to an account for reimbursement of certain Health Care Expenses. • Limited Scope Health Flexible Spending Account (Limited Scope Health FSA) to make pre-tax Salary Reduction Contributions to an account for reimbursement of certain Limited Scope Health Care Expenses. • Dependent Care Assistance Program (DCAP) to make pre-tax Salary Reduction Contributions to an account for reimbursement of certain Dependent Care Expenses. 1.3 Legal Status This Plan is intended to qualify as a "cafeteria plan" under the Code §125, and regulations issued thereunder and shall be interpreted to accomplish that objective. The Health FSA and the Limited Scope Health FSA are intended to qualify as self-insured health reimbursement plans under Code §105, and the Health Care Expenses reimbursed are intended to be eligible for exclusion from participating Employees'gross income under Code §105(b). The Limited Scope Health FSA is intended to be permissible coverage for purposes of determining eligibility for an HSA under§223 of the Code. The DCAP is intended to qualify as a dependent care assistance program under Code §129, and the Dependent Care Expenses reimbursed are intended to be eligible for exclusion from participating Employees' gross income under Code §129(a). Although reprinted within this document, the Health FSA, the Limited Scope Health FSA, and the DCAP are separate plans for purposes of administration and all reporting and nondiscrimination requirements imposed by Code §§105 and 129. The Health FSA and Limited Scope Health FSA are also separate plans for purposes of applicable provisions of COBRA and HIPAA. 2 1.4 Capitalized Terms Many of the terms used in this document begin with a capital letter. These terms have special meaning under the Plan and are defined in the Glossary at the end of this document or in other relevant Sections. When reading the provisions of the Plan, please refer to the Glossary at the end of this document. Becoming familiar with the terms defined there will provide a better understanding of the procedures and Benefits described. 3 Section 2 General Information Name of the Cafeteria Plan County of Fresno Cafeteria Plan Name of Employer County of Fresno Address of Plan 2220 Tulare Street, 141h Floor, Fresno, CA 93721 Plan Administrator County of Fresno Plan Sponsor and its IRS County of Fresno Employer Identification 94-6000512 Number Named Fiduciary&Agent for County of Fresno Service of Legal Process Type of Administration The Plan is administered by the Plan Administrator with Benefits provided in accordance with the provisions of the County of Fresno Cafeteria Plan. It is not financed by an insurance company, and Benefits are not guaranteed by a contract of insurance. County of Fresno may hire a third party to perform some of its administrative duties such as claim payments and enrollment. Benefit Option Year The twelve-month period ending December 31. Plan Effective Date Originally effective July 1, 1988; amended and restated effective January 1, 2016 Claims Administrator As of January 1, 2015, the Claims Administrator is Application Software Inc. The Claims Administrator is subject to change as determined by the Employer. Plan Renewal Date January 1 Internal Revenue Code and It is intended that this Plan meet all applicable requirements of the Other Federal Compliance Internal Revenue Code of 1986 (the "Code") and other federal regulations. In the event of any conflict between this Plan and the Code or other federal regulations, the provisions of the Code and the federal regulations shall be deemed controlling, and any conflicting part of this Plan shall be deemed superseded to the extent of the conflict. Discretionary Authority The Plan Administrator shall perform its duties as the Plan Administrator and in its sole discretion, shall determine the appropriate courses of action in light of the reason and purpose for which this Plan ® is established and maintained. 4 In particular, the Plan Administrator shall have full and sole discretionary authority to interpret all Plan documents, and make all interpretive and factual determinations as to whether any individual is entitled to receive any Benefit under the terms of this Plan. Any construction of the terms of any Plan document and any determination of fact adopted by the Plan Administrator shall be final and legally binding on all parties. Any interpretation shall be subject to review only if it is arbitrary, capricious, or otherwise an abuse of discretion. Any review of a final decision or action of the Plan Administrator shall be based only on such evidence presented to or considered by the Plan Administrator at the time it made the decision that is the subject of review. Accepting any Benefits or making any claim for Benefits under this Plan constitutes agreement with and consent to any decisions that the Plan Administrator makes in its sole discretion and further constitutes agreement to the limited standard and scope of review described by this Section. 5 Section 3 Benefit Options and Method of Funding 3.1 Benefits Offered Each Employee may elect to participate in one or more of the following Benefits: • Premium Payment Plan (PPP) as described in Schedule A. • Health Flexible Spending Account(Health FSA) as described in Schedule B. • Limited Scope Health Flexible Spending Account (Limited Scope Health FSA) as described in Schedule C. • Dependent Care Assistance Program (DCAP) as described in Schedule D. Benefits under the Plan shall not be provided in the form of deferred Compensation. 3.2 Employer and Participant Contributions • Employer Contributions. The Employer may, but is not required to, contribute to any of the Benefit Options. There are no Employer Contributions for the PPP under this Plan; however, if the Participant elects the PPP as described in Schedule A, the Employer may contribute toward the Insurance Plan(s) as provided in the respective plan or policy of the Employer. • Participant Contributions. The Employer shall withhold from a Participant's Compensation by Salary Reduction on a pre-tax basis, or with after-tax deductions, an amount equal to the Contributions required for the Benefits elected by the Participant under the Salary Reduction Agreement. The maximum amount of Salary Reductions shall not exceed the aggregate cost of the Benefits elected. 3.3 Computing Salary Reduction Contributions • Salary Reductions per Pay Period. The Participant's Salary Reduction is an amount equal to: o The annual election for such Benefits payable on a biweekly basis in the Period of Coverage; o An amount otherwise agreed upon between the Employer and the Participant; or o An amount deemed appropriate by the Plan Administrator. (Example: in the event of a shortage of reducible Compensation, amounts withheld and the Benefits to which Salary Reductions are applied may fluctuate.) • Salary Reductions Following a Change of Elections. If the Participant changes his or her election under the PPP, Health FSA, Limited Scope Health FSA or DCAP, as permitted under the Plan,the Salary Reductions will be,for the Benefits affected, calculated as follows: ® An amount equal to: 6 ■ The new annual amount elected pursuant to the Method of Timing and Elections section below; ■ Less the aggregate Contributions, if any, for the period prior to such election change; ■ Payable over the remaining term of the Period of Coverage commencing with the election change; o An amount otherwise agreed upon between the Employer and the Participant; or o An amount deemed appropriate by the Plan Administrator. (Example: in the event of a shortage of reducible Compensation, amounts withheld and the Benefits to which Salary Reductions are applied may fluctuate.) • Salary Reductions Considered Employer Contributions for Certain Purposes. Salary Reductions to pay for the Participant's share of the Contributions for Benefit Options elected for purposes of this Plan and the Code are considered Employer Contributions. • Salary Reduction Balance Upon Termination of Coverage. If, as of the date that coverage under this Plan terminates, a Participant's year-to-date Salary Reductions exceed or are less than the required Contributions necessary for Benefit Options elected up to the date of termination, the Employer will either return the excess to the Participant as additional taxable wages or recoup the amount due through Salary Reduction amounts from any remaining Compensation. • After-Tax Contributions for PPP. After-tax Contributions for the Insurance Plan(s) will be paid outside of this Plan. 3.4 Funding This Plan • Benefits Paid from General Assets. All of the amounts payable under this Plan shall be paid from the general assets of the Employer. Nothing herein will be construed to require the Employer nor the Plan Administrator to maintain any fund or to segregate any amount for the Participant's benefit. Neither the Participant, nor any other person, shall have any claim against, right to, or security or other interest in any fund, account or asset of the Employer from which any payment under this Plan may be made. There is no trust or other fund from which Benefits are paid. While the Employer has complete responsibility for the payment of Benefits out of its general assets, it may hire a third party administrator to perform some of its administrative duties such as claims payments and enrollment. • Participant Bookkeeping Account. While all Benefits are to be paid from the general assets of the Employer, the Employer will keep a bookkeeping account in the name of each Participant. The bookkeeping account is used to track allocation and payment of Plan Benefits. The Plan Administrator will establish and maintain under each Participant's bookkeeping account a subaccount for each Benefit Option elected by each Participant. • Maximum Contributions. The maximum Contributions that may be made under this Plan for the Participant are the total of the maximums that may be elected for the PPP as described in Schedule A, Health FSA as described in Schedule B, Limited Scope Health FSA as described in Schedule C, and the DCAP as described in Schedule D. 7 Section 4 Eligibility and Participation 4.1 Eligibility to Participate An individual is eligible to participate in this Plan if such individual meets the definition of Employee as set forth in the Glossary. Eligibility requirements to participate in the individual Benefit Options may vary from the eligibility requirements to participate in this Plan. 4.2 Required Salary Reduction Agreement To participate in the PPP, an Employee must complete, sign and return to the Plan Administrator a Salary Reduction Agreement by the deadline designated by the Plan Administrator. If an Employee fails to return a Salary Reduction Agreement, the Employee is deemed to have elected cash and will not be allowed to change such election until the next Open Enrollment unless the Employee experiences an event permitting an election change mid-year. The Employee may begin participation on the 1st day of the pay period coincident with or next following the date on which the Employee has met the Plan's eligibility requirements or in accordance with the Enrollment requirements each year. 4.3 Termination of Participation A Participant will terminate participation in this Plan upon the earlier of: • The expiration of the Period of Coverage for which the Employee has elected to participate unless during the Open Enrollment Period for the next Plan Year the Employee elects to continue participating; • The termination of this Plan; or • The date on which the Employee ceases to be an Employee because of retirement, termination of employment, layoff, reduction in hours, or any other reason. Eligibility may continue beyond such date for purposes of COBRA coverage, where applicable as set forth in the respective Schedule attached hereto, as may be permitted by the Plan Administrator on a uniform and consistent basis, but not beyond the end of the current Plan Year. False or Fraudulent Claims. The Plan Administrator has the authority to terminate participation in the Plan if it has been determined that a Participant has filed a false or fraudulent claim for Benefits. Termination of participation in this Plan will automatically revoke the Participant's participation in the elected Benefit Options, according to the terms thereof. 8 4.4 Rehired Employees If a Participant terminates employment with the Employer for any reason, including, but not limited to, disability, retirement, layoff, leave of absence without pay, or voluntary resignation, and then is rehired within the same Plan Year and the Participant is otherwise eligible to participant in the Plan, then the individual may make new elections as a new hire. A Participant will not be allowed to exceed the federally allowed maximum within a calendar year in any event. 4.5 Eligibility Rules Regarding the Health FSA and the Limited Scope Health FSA An Employee enrolled in a Health Savings Account (HSA) is not eligible to enroll in the Health FSA. However, such Employee is eligible to enroll and participate in the Limited Scope Health FSA. An Employee is not eligible to participate in both the Health FSA and the Limited Scope Health FSA. 4.6 FMLA Leaves Of Absence Health Benefits. Notwithstanding any provision to the contrary in this Plan, if a Participant goes on a qualifying leave under FMLA then to the extent required by FMLA, the Participant will be entitled to continue the Benefits that provide health coverage on the same terms and conditions as if the Participant were still an active Employee. For example, the Employer will continue to pay its share of the Contribution to the extent the Participant opts to continue coverage. In the event of unpaid FMLA leave, a Participant may elect to continue such Benefits. If the Participant elects to continue coverage while on FMLA leave, then the Participant may pay his or her share of the Contribution: • With after-tax dollars, by sending bi-weekly payments to the Employer by the due date established by the Employer; • With pre-tax dollars, by having such amounts withheld from the Participant's ongoing Compensation; or • By pre-paying all or a portion of the Contribution for the expected duration of the leave on a pre-tax Salary Reduction basis out of pre-leave Compensation. To pre-pay the Contribution, the Participant must make a special election to that effect prior to the date that such Compensation would normally be made available. Pre-tax dollars may not be used to fund coverage during the next Plan Year. Coverage will terminate if Contributions are not received by the due date established by the Employer. If a Participant's coverage ceases while on FMLA leave for any reason, including for non-payment of Contributions,the Participant will be entitled to re-enter upon return from such leave on the same basis as the Participant was participating in the Plan prior to the leave, or as otherwise required by the FMLA. A Participant whose coverage ceased under any of the aforementioned plans will be entitled to elect whether to be reinstated in such plans at the same coverage level as in effect before the FMLA leave with increased Contributions for the remaining Period of Coverage, or at a coverage level that is reduced pro-rata for the period of FMLA leave during which the Participant did not pay Contributions. If a 9 Participant elects a coverage level that is reduced pro-rata for the period of FMLA leave, the amount withheld from a Participant's Compensation on a payroll-by-payroll basis for the purpose of paying for his or her Contributions will be equal to the amount withheld prior to the period of FMLA leave. Non-Health Benefits. If a Participant goes on a qualifying leave under the FMLA, then entitlement to non-health benefits (such as DCAP Benefits) is to be determined by the Employer's policy for providing such Benefits when the Participant is on leave not qualified as an FMLA leave of absence, as described below. If such policy permits a Participant to discontinue Contributions while on leave, then the Participant may, upon returning from leave, be required to repay the Contributions not paid by the Participant during the leave if the Participant remains eligible to use the non-health benefit during the leave period. Payment shall be withheld from the Participant's Compensation either on a pre-tax or after-tax basis, as may be agreed upon by the Plan Administrator and the Participant or as the Plan Administrator otherwise deems appropriate. 4.7 Non-FMLA Leaves of Absence If a Participant goes on an unpaid leave of absence that does not affect eligibility, then the Participant will continue to participate and the Contributions due for the Participant will be paid by pre-payment before going on leave, by after-tax Contributions while on leave or with catch-up Contributions after the leave ends, as may be determined by the Plan Administrator. If a Participant goes on an unpaid leave that affects eligibility, the election change rules set forth by this Plan will apply. To the extent COBRA applies,the Participant may continue coverage under COBRA. 4.8 Death A Participant's beneficiaries or representative of the Participant's estate, may submit claims for expenses that the Participant incurred through the end of the month in which the Participant ceases to be eligible for the Plan due to death. A Participant may designate a specific beneficiary for this purpose. If no beneficiary is specified, the Plan Administrator or its designee may designate the Participant's Spouse, another Dependent, or representative of the estate. Claims incurred by the Participant's covered Spouse or any other of the Participant's covered Dependents prior to the end of the month in which the Participant dies may also be submitted for reimbursement. 4.9 COBRA Under the COBRA rules, as discussed in the attached Schedules B and C, where applicable, the Participant's Spouse and Dependents may be able to continue to participate under the Health FSA and the Limited Scope Health FSA through the end of the Period of Coverage in which the Participant dies. The Participant's Spouse and Dependents may be required to continue making Contributions to continue their participation. 4.10 USERRA Notwithstanding any provision to the contrary in this Plan, if a Participant goes on a qualifying leave under USERRA, then to the extent required by USERRA, the Employer will continue the Benefits that provide health coverage on the same terms and conditions as if the Participant were still an active Employee. In the event of unpaid USERRA leave, a Participant may elect to continue such Benefits during the leave. 10 If the Participant elects to continue coverage while on USERRA leave, then the Participant may pay his or her share of the Contribution with: • After-tax dollars, by sending monthly payments to the Employer by the due date established by the Employer; or • Pre-tax dollars, by having such amounts withheld from the Participant's ongoing Compensation. Coverage will terminate if Contributions are not received by the due date established by the Employer. If a Participant's coverage ceases while on USERRA leave for any reason, including for non-payment of Contributions, the Participant will be entitled to re-enter such Benefit upon return from such leave on the date of such resumption of employment and will have the same opportunities to make elections under this Plan as persons returning from non-USERRA leaves. Regardless of anything to the contrary in this Plan, an Employee returning from USERRA leave has no greater right to Benefits for the remainder of the Plan Year than an Employee who has been continuously working during the Plan Year. 11 Section 5 Method of Timing and Elections 5.1 Initial Election An Employee must complete, sign and return a Salary Reduction Agreement within the election-period set forth therein to enroll in the Benefit Options. Unless otherwise specified by the Employer, an Employee who first becomes eligible to participate in the Plan mid-year will commence participation on the 1st day of the pay period coinciding with or after the date the Employee completes, signs and returns a Salary Reduction Agreement or completes a Salary Reduction Agreement using the electronic system produced by the Employer (if any), within the election period set forth therein. Eligibility for Benefits shall be subject to the additional requirements, if any, specified in the applicable Benefit Option. The provisions of this Plan are not intended to override any exclusions, eligibility requirements or waiting periods specified in the applicable Benefit Options. 5.2 Open Enrollment During each Open Enrollment Period,the Plan Administrator shall provide a Salary Reduction Agreement to each Employee who is eligible to participate in the Plan. The Salary Reduction shall enable the Employee to elect to participate in the Benefit Options for the next Plan Year, and to authorize the necessary Salary Reductions to pay for the Benefits elected. The Employee must complete sign and return the Salary Reduction Agreement or complete an election using the electronic system provided by the Employer, if any,to the Plan Administrator on or before the last day of the Open Enrollment Period. If an Employee makes an election to participate during an Open Enrollment Period, then the Employee will become a Participant on the first day of the next Plan Year. The Employer may, in lieu of a Salary Reduction Agreement, provide an electronic method for Employees to use to make elections. The Employer may require Employees to use the electronic system to make elections. Use of an electronic system will have the same effect as a signed Salary Reduction Agreement. 5.3 Failure To Elect If an Employee fails to complete, sign and return a Salary Reduction Agreement or fails to complete an election using the electronic system (if any) provided by the Employer within the time described in the Elections paragraphs as discussed immediately above, then the Employee will be deemed to have elected to receive his or her entire Compensation in cash. Where the Employer provides for an automatic election for the PPP, the Employee will have also agreed to a Salary Reduction for such Employee's Contribution to the PPP. Such Employee may not enroll in the Plan: • Until the next Open Enrollment Period; or 12 • Until an event occurs that would justify a mid-year election change as described in the Irrevocability of Election and Exceptions section below. 13 Section 6 Irrevocability of Elections and Exceptions 6.1 Irrevocability of Elections A Participant's election under the Plan is irrevocable for the duration of the Period of Coverage to which it relates, except as described in this Section. The rules regarding irrevocability of elections and exceptions are quite complex. The Plan Administrator will interpret these rules in accordance with prevailing IRS guidance. 6.2 Procedure for Making New Election If Exception to Irrevocability Applies • Timing for Making New Election if Exception to Irrevocability Applies. A Participant may make a new election within 30 days of the occurrence of an event described in section 6.4 below, if the election under the new Salary Reduction Agreement is made on account of and corresponds to the event. A Change in Status, as defined below, that automatically results in ineligibility in the Insurance Plan(s) shall automatically result in a corresponding election change, whether or not requested. • Effective Date of New Election. Elections made pursuant to this Section shall be effective on the 1st day of the pay period following or coinciding with the Plan Administrator's receipt and approval of the election request for the balance of the Period of Coverage following the change of election unless a subsequent event allows for a further election change. Except as provided in "Certain Judgments, Decrees and Orders" or for HIPAA special enrollment rights in the event of birth, adoption, or placement for adoption, all election changes shall be effective on a prospective basis only. • Changes. For subsequent Plan Years, the maximum and minimum dollar limit may be changed by the Plan Administrator and shall be communicated to Employees through the Salary Reduction Agreement or other document. • Effect on Maximum Benefits. Any change in an election affecting annual Contributions to the Health FSA, Limited Scope Health FSA or DCAP also will change the maximum reimbursement Benefits for the balance of the Period of Coverage commencing with the election change. Such maximum reimbursement Benefits for the balance of the Period of Coverage shall be calculated by adding: o Any Contributions made by the Participant as of the end of the portion of the Period of Coverage immediately preceding the change in election; to o The total Contributions scheduled to be made by the Participant during the remainder of such Period of Coverage to the Benefit Option; reduced by o All reimbursements made during the entire Period of Coverage. 14 6.3 Change in Status Defined A Participant may make a new election that corresponds to a gain or loss of eligibility and coverage under this Plan or under any other plan maintained by the Employer or a plan of the Spouse's or Dependent's employer that was caused by the occurrence of a Change in Status. A Change in Status is any of the events described below, as well as any other events included under subsequent changes to Code §125 or regulations issued thereunder, which the Plan Administrator, in its sole discretion and on a uniform and consistent basis, determines are permitted under IRS regulations and under this Plan: • Legal Marital Status. A change in a Participant's legal marital status including marriage, death of a Spouse, divorce, legal separation or annulment; • Number of Dependents. Events that change a Participant's number of Dependents, including birth, death, adoption, and placement for adoption. In the case of the DCAP, a change in the number of Qualifying Individuals as defined in Code §21(b)(1); • Employment Status. Any of the following events that change the employment status of the Participant,Spouse or Dependents: o A termination or commencement of employment; o A strike or lockout; o A commencement of or return from an unpaid leave of absence; o A change in worksite; or o If the eligibility conditions of this Plan or another employee benefit plan of the Participant, Spouse or Dependent depend on the employment status of that individual and there is a change in that individual's status with the consequence that the individual becomes, or ceases to be, eligible under this Plan or another employee benefit plan; • Dependent Eligibility Requirements. An event that causes a Dependent to satisfy or cease to satisfy the Dependent eligibility requirements for a particular Benefit; and • Change in Residence. A change in the place of residence of the Participant, Spouse or Dependent(s). 6.4 Events Permitting Exception to Irrevocability Rule A Participant may change an election as described below upon the occurrence of the stated events for the applicable Benefit Option. The following rules shall apply to all Benefit Options except where expressly limited below. • Open Enrollment Period. A Participant may change an election during the Open Enrollment Period. 15 • Termination of Employment. A Participant's election will terminate upon termination of employment as described in the Eligibility and Participation section above. • Leave of Absence. A Participant may change an election upon a leave of absence as described in the Eligibility and Participation section above. • Change in Status. (Applies to the PPP, Health FSA, Limited Scope Health FSA as limited below, and DCAP as limited below.) A Participant may change the actual or deemed election under the Plan upon the occurrence of a Change in Status, but only if such election change corresponds with a gain or loss of eligibility and coverage under a plan of the Employer or a plan of the Spouse's or Dependent's employer, referred to as the general consistency requirement. A Change in Status that affects eligibility for coverage also includes a Change in Status that results in an increase or decrease in the number of an Employee's family members who may benefit from the coverage. The Plan Administrator, on a uniform and consistent basis, shall determine, based on prevailing IRS guidance, whether a requested change satisfies the general consistency requirement. Assuming that the general consistency requirement is satisfied, a requested election change must also satisfy the following specific consistency requirements in order for a Participant to be able to alter elections based on the specified Change in Status: o Loss of Spouse or Dependent Eligibility. For a Change in Status involving a Participant's divorce, annulment or legal separation, the death of a Spouse or a Dependent, or a Dependent's ceasing to satisfy the eligibility requirements for coverage, a Participant may only elect to cancel accident or health coverage for: ■ The Spouse involved in the divorce, annulment, or legal separation; ■ The deceased Spouse or Dependent; or ■ The Dependent that ceased to satisfy the eligibility requirements. Canceling coverage for any other individual under these circumstances fails to correspond with that Change in Status. Notwithstanding the foregoing, if the Participant or his or her Spouse or Dependent becomes eligible for COBRA or similar health plan continuation coverage under the Employer's plan, then the Participant may increase his or her election to pay for such coverage. This rule does not apply to a Participant's Spouse who becomes eligible for COBRA or similar coverage as a result of divorce, annulment, or legal separation. o Gain of Coverage Eligibility Under Another Employer's Plan. When a Participant, Spouse or Dependent gains eligibility for coverage under a cafeteria plan or qualified benefit plan of the employer of that Participant's Spouse or Dependent, a Participant may elect to terminate or decrease coverage for that individual only if coverage for that individual becomes effective or is increased under the Spouse's or Dependent's employer's plan. The Plan Administrator may rely on a Participant's certification that the Participant has obtained 16 or will obtain coverage under the Spouse's or Dependent's employer's plan, unless the Plan Administrator has reason to believe that the Participant's certification is incorrect. o Special Consistency Rule for DCAP Benefits. With respect to the DCAP, the Participant may change or terminate the Participant's election upon a Change in Status if: ■ Such change or termination is made on account of and corresponds with a Change in Status that affects eligibility for coverage under an Employer's plan; or ■ The election change is on account of and corresponds with a Change in Status that affects eligibility of Dependent Care Expenses for the tax exclusion under Code §129. • HIPAA Special Enrollment Rights (Applies to the PPP only). If the Participant, the Participant's Spouse or Dependent is entitled to special enrollment rights under a group health plan as required by HIPAA, then the Participant may revoke a prior election for group health plan coverage and make a new election provided that the election change corresponds with such HIPAA special enrollment right. As more specifially defined by HIPAA, a special enrollment right will arise in the following circumstances: o The Participant, Spouse or Dependent declined to enroll in group health plan coverage because the Participant, the Participant's Spouse or Dependent had coverage, and eligibility for such coverage is subsequently lost because the coverage was provided under COBRA and the COBRA coverage was exhausted; or the coverage was non-COBRA coverage and the coverage terminated due to loss of eligibility for coverage or the employer contributions for the coverage were terminated; o The Participant acquired a new Dependent as a result of marriage, birth, adoption or placement for adoption; or o The Employee or Dependents who are eligible but did not enroll for coverage when initially eligible and: ■ The Employee or Dependent's Medicaid or Children's Health Insurance Program (CHIP) coverage terminated as a result of loss of eligibility and the Employee requests coverage under the Plan within 60 days after the termination; or ■ The Employee or Dependent becomes eligible for a premium assistance subsidy under Medicaid or CHIP, and the employee requests coverage under the Plan within 60 days after eligibility is determined. An election to add previously eligible Dependents as a result of the acquisition of a new Spouse or Dependent child shall be considered to be consistent with the special enrollment right. An election change due to birth, adoption, or placement for adoption of a new Dependent child may, subject to the group health plan, be effective retroactively for up to 30 days. • Certain Judgments, Decrees and Orders. (Applies to the PPP, Health FSA and Limited Scope Health FSA, but does not apply to the DCAP). If a judgment, decree, or order resulting from a divorce, legal separation, annulment or change in legal custody, including a Qualified Medical 17 Child Support Order (QMCSO) requires accident or health coverage, including an election for Health FSA Benefits or Limited Scope Health FSA Benefits for a Participant's Dependent child, a Participant may: o Change an election to provide coverage for the Dependent child provided that the order requires the Participant to provide coverage; or o Change an election to revoke coverage for the Dependent child if the order requires that another individual provide coverage under that individual's plan and such coverage is actually provided. • Medicare and Medicaid. (Applies to the PPP, Health FSA and Limited Scope Health FSA as limited below, but does not apply to the DCAP). If a Participant, Spouse or Dependent is enrolled in a Benefit under this Plan and becomes entitled to Medicare or Medicaid (other than coverage consisting solely of benefits under Section 1928 of the Social Security Act providing for pediatric vaccines), the Participant may prospectively reduce or cancel the Health Insurance Plan covering the person, and the Health FSA coverage and Limited Scope Health FSA may be cancelled but not reduced. However, such cancellation will not be effective to the extent that it would reduce future contributions to the Health FSA or Limited Scope Health FSA to a point where the total contributions for the Plan Year are less that the amount already reimbursed for the Plan Year. Further, if a Participant, Spouse, or Dependent who has been entitled to Medicare or Medicaid loses eligibility for such coverage, the Participant may prospectively elect to commence or increase the Health FSA coverage and Limited Scope Health FSA coverage. • Change in Cost. (Applies to the PPP and DCAP as limited below, but does not apply to the Health FSA or Limited Scope Health FSA). For purposes of this Section, "similar coverage" means coverage for the same category of Benefits for the same individuals. o Insignificant Cost Changes. The Participant is required to increase his or her elective Contributions to reflect insignificant increases in the required Contribution for the Benefit Options, and to decrease the elective Contributions to reflect insignificant decreases in the required Contribution. The Plan Administrator, in its sole discretion and on a uniform and consistent basis, will determine whether an increase or decrease is insignificant based upon all the surrounding facts and circumstances, including but not limited to the dollar amount or percentage of the cost change. The Plan Administrator, on a reasonable and consistent basis, will automatically make this increase or decrease in affected Participants' elective Contributions on a prospective basis. o Significant Cost Increases. If the Plan Administrator determines that the cost charged to an Employee for a Benefit significantly increases during a Period of Coverage, the Participant may: ■ Make a corresponding prospective increase to elective Contributions by increasing Salary Reductions; ■ Revoke the election for that coverage, and in lieu thereof, receive on a prospective basis coverage under another Benefit Option that provides similar coverage; or 18 ■ Terminate coverage going forward if there is no other Benefit Option available that provides similar coverage. The Plan Administrator, in its sole discretion and on a uniform and consistent basis, will decide whether a cost increase is significant. o Significant Cost Decreases. If the Plan Administrator determines that the cost of any Benefit (such as the premium for the Insurance Plan(s)) significantly decreases during a Period of Coverage,then the Plan Administrator may permit the following election changes: ■ Participants enrolled in that Benefit Option may make a corresponding prospective decrease in their elective contributions by decreasing Salary Reductions; ■ Participants who are enrolled in another benefit package option may change their election on a prospective basis to elect the Benefit Option that has decreased in cost; or ■ Employees who are otherwise eligible may elect the Benefit Option that has decreased in cost on a prospective basis, subject to the terms and limitations of the Benefit Option. The Plan Administrator, in its sole discretion and on a uniform and consistent basis, will decide whether a cost decrease is significant. o Limitation on Change in Cost Provisions for DCAP Benefits. The above "Change in Cost" provisions apply to DCAP Benefits only if the cost change is imposed by a dependent care provider who is not a relative of the Employee. • Change in Coverage. (Applies to the PPP and DCAP, but not to the Health FSA or Limited Scope Health FSA). The definition of"similar coverage" applied in the Change of Cost provision above also applies here. o Significant Curtailment. Coverage under a Plan is deemed to be "significantly curtailed" only if there is an overall reduction in coverage provided under the Plan to constitute reduced coverage generally. If coverage is "significantly curtailed," Participants may elect coverage under a Benefit Option that provides similar coverage. In addition, if the coverage curtailment results in a "Loss of Coverage" as defined below, Participants may drop coverage if no similar coverage is offered by the Employer. The Plan Administrator, in its sole discretion and on a uniform and consistent basis, will decide whether a curtailment is "significant," and whether a Loss of Coverage has occurred in accordance with prevailing IRS guidance. ■ Significant Curtailment Without Loss of Coverage. If the Plan Administrator determines that a Participant's coverage under a Benefit Option (or the Participant's, Spouse's or Dependent's coverage under the respective employer's plan) is significantly curtailed without a Loss of Coverage during a Period of Coverage, the Participant may revoke an election for the affected coverage and prospectively elect coverage under another Benefit Option if offered,that provides similar coverage. ■ Significant Curtailment With a Loss of Coverage. If the Plan Administrator determines that a Participant's coverage under this Plan (or the Participant's, Spouse's or Dependent's coverage under the respective employer's plan) is significantly curtailed, 19 and such curtailment results in a Loss of Coverage during a Period of Coverage, the Participant may revoke an election for the affected coverage, and may either prospectively elect coverage under another Benefit Option that provides similar coverage or drop coverage if no other Benefit Option providing similar coverage is offered by the Employer. ■ Definition of Loss of Coverage. For purposes of this Section, a "Loss of Coverage" means a complete loss of coverage. In addition, the Plan Administrator in its sole discretion and on a uniform and consistent basis, may treat the following as a Loss of Coverage: ➢ A substantial decrease in the health care providers available under the Benefit Package Plan; ➢ A reduction in benefits for a specific type of medical condition or treatment with respect to which the Participant or his or her Spouse or Dependent is currently in a course of treatment; or ➢ Any other similar fundamental loss of coverage. o Addition or Significant Improvement of a Benefit Option. If during a Period of Coverage, the Plan adds a new Benefit Option or significantly improves an existing Benefit Option, the Plan Administrator may permit the following election changes: ➢ Participants who are enrolled in a Benefit Option other than the newly-added or significantly improved Benefit Option that provides similar coverage may change their election on a prospective basis to cancel the current Benefit Option and instead elect the newly added or significantly improved Benefit Option; and ➢ Employees who are otherwise eligible may elect the newly added or significantly improved Benefit Option on a prospective basis, subject to the terms and limitations of the Benefit Option. The Plan Administrator, in its sole discretion and on a uniform and consistent basis, will decide whether there has been an addition of, or a significant improvement in, a Benefit Option. o Loss of Coverage Under Another Group Health Coverage. A Participant may prospectively change an election to add group health coverage for the Participant, Spouse or Dependent, if such individual(s) loses coverage under any group health coverage sponsored by a governmental or educational institution, including, but not limited to,the following: ■ A children's health insurance program (CHIP) under Title XXI of the Social Security Act; ■ A health care program of an Indian Tribal government (as defined in Code §7701(a)(40)),the Indian Health Service, or a tribal organization; ■ A state health benefits risk pool; or ■ A foreign government group health plan, subject to the terms and limitations of the applicable Benefit Option. 20 o Change in Coverage Under Another Employer Plan. A Participant may make a prospective election change that is on account of and corresponds with a change made under an employer plan, including a plan of the Employer or a plan of the Spouse's or Dependent's employer, so long as: ■ The other cafeteria plan or qualified benefits plan permits its participants to make an election change that would be permitted under applicable IRS regulations; or ■ The Plan permits Participants to make an election for a Period of Coverage that is different from the plan year under the other cafeteria plan or qualified benefits plan. The Plan Administrator, on a uniform and consistent basis, will decide whether a requested change is because of, and corresponds with, a change made under the other employer plan. o Change in Dependent Care Service Provider. A Participant may make a prospective election change that corresponds with a change in the dependent care service provider. For example: ■ If the Participant terminates one dependent care service provider and hires a new dependent care service provider, the Participant may change coverage to reflect the cost of the new service provider; and ■ If the Participant terminates a dependent care service provider because a relative or other person becomes available to take care of the child at no charge, the Participant may cancel coverage. A Participant entitled to change an election as described in this Section must do so in accordance with the procedures described this Section. 6.5 Election Modifications Required by Plan Administrator The Plan Administrator may require, at any time, any Participant or class of Participants to amend their Salary Reductions for a Period of Coverage if the Plan Administrator determines that such action is necessary or advisable in order to: • Satisfy any of the Code's nondiscrimination requirements applicable to this Plan or another cafeteria plan; • Prevent any Employee or class of Employees from having to recognize more income for federal income tax purposes from the receipt of Benefits hereunder than would otherwise be recognized; • Maintain the qualified status of Benefits received under this Plan; or • Satisfy any of the Code's nondiscrimination requirements or other limitations applicable to the Employer's qualified Plans. In the event that Contributions need to be reduced for a class of Participants, the Plan Administrator will reduce the Salary Reduction amounts for each affected Participant, beginning 21 with the Participant in the class who had elected the highest Salary Reduction amount, and continuing with the Participant in the class who had elected the next-highest Salary Reduction amount, and so forth, until the defect is corrected. 22 Section 7 Claims and Appeals 7.1 Claims Under the Plan If a claim for reimbursement under the Health FSA, Limited Scope Health FSA, or DCAP is wholly or partially denied, or if the Participant is denied a Benefit under the Plan regarding the Participant's coverage under the Plan,then the claims procedure described below will apply. 7.2 Notice from Claims Administrator If a claim is denied in whole or in part, Claims Administrator will notify the Participant in writing within 30 days of the date that Claims Administrator received the claim. This time may be extended for an additional 15 days for matters beyond the control of the Claims Administrator, including cases where a claim is incomplete. Claims Administrator will provide written notice of any extension, including the reason(s) for the extension and the date a decision by Claims Administrator is expected to be made. When a claim is incomplete, the extension notice will also specifically describe the required information, and will allow the Participant at least 45 days from receipt of the notice to provide the specified information, and will have the effect of suspending the time for a decision on the claim until the specified information is provided. Notification of a denied claim will include: • The specific reasons for the denial; • The specific Plan provisions on which the denial is based; • A description of any additional material or information necessary to validate the claim and an explanation of why such material or information is necessary; and • Appropriate information on the steps to take to appeal Claims Administrator's adverse benefits determination, including the right to submit written comments and have them considered, and the right to review, upon request and at no charge, relevant documents and other information, and the right to file suit, where applicable, with respect to any adverse benefits determination after the final appeal of the claim. 7.3 First Level Appeal to Claims Administrator If a claim is denied in whole or in part, the Participant, or the Participant's authorized representative, may request a review of the adverse benefits determination upon written application to Claims Administrator. The Participant, or the Participant's authorized representative, may request access to all relevant documents in order to evaluate whether to request review of an adverse benefits determination and, if review is requested,to prepare for such review. An appeal of an adverse benefits determination must be made in writing within 180 days upon receipt of the notice that the claim was denied. If an appeal is not made within the above referenced timeframe all rights to appeal the adverse benefits determination and to file suit in court will be forfeited. A written appeal should include: additional documents, written comments, and any other information in support of the appeal. The review of the adverse benefits determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. 23 7.4 Claims Administrator Action on Appeal Claims Administrator, within a reasonable time, but no later than 60 days after receipt of the request for review, will decide the appeal. Claims Administrator may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection with the appeal will be different from and not subordinate to any expert consulted in connection with the initial claim denial. The identity of any medical expert consulted in connection with the appeal will be provided. If the decision on review affirms the initial denial of the claim, a notice will be provided which sets forth: • The specific reasons for the decision on review; • The specific Plan provisions on which the decision is based; • A statement regarding the right to review, upon request and at no charge, relevant documents and other information. If an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and • Appropriate information on the steps to take to appeal Claims Administrator's adverse benefits determination, including the right to submit written comments and have them considered, and the right to review, upon request and at no charge, relevant documents and other information, and the right to file suit, where applicable, with respect to any adverse benefits determination after the final appeal of the claim. 7.5 Second and Final Level Appeal to the Plan Administrator If the decision on review affirms Claims Administrator's initial denial, the Participant may request a review of the adverse appeal determination upon written application to the Plan Administrator. The Participant, or the Participant's authorized representative, may request access to all relevant documents in order to evaluate whether to request review of an adverse benefits determination and, if review is requested,to prepare for such review. An appeal of an adverse appeal determination must be made in writing within 180 days after receipt of the notice that the claim was denied. If an appeal is not made within the above referenced timeframe all rights to appeal the adverse benefits determination and to file suit in court will be forfeited. A written appeal should include: additional documents, written comments, and any other information in support of the appeal. The review of the adverse benefits determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. 7.6 Plan Administrator Action on Appeal The Plan Administrator, within a reasonable time, but no later than 60 days after receipt of the request for review, will decide the appeal. The Plan Administrator may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection with the appeal will be different from and not subordinate to any expert consulted in connection with the initial claim denial. The identity of any 24 medical expert consulted in connection with the appeal will be provided. If the decision on review affirms the initial denial of the claim, a notice will be provided which sets forth: • The specific reason(s)for the decision on review; • The specific Plan provision(s) on which the decision is based; • A statement regarding the right to review, upon request and at no charge, relevant documents and other information. If an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and • A statement regarding the right to bring suit,where applicable. 7.7 Appeal Procedure for Eligibility or Salary Reduction Issues If the Participant is denied a Benefit under the Plan due to questions regarding the Participant's eligibility or entitlement for coverage under the Plan or regarding the amount the Participant owes, the Participant may request a review upon written application to the Plan Administrator. The Participant, or the Participant's authorized representative, may request access to all relevant documents in order to evaluate whether to request review of an adverse benefits determination and if review is requested,to prepare for such review. An appeal of an adverse benefits determination must be made in writing within 180 days upon receipt of the notice that the claim was denied. If an appeal is not made within the above referenced timeframe all rights to appeal the adverse benefits determination and to file suit in court will be forfeited. A written appeal should include: additional documents, written comments, and any other information in support of the appeal. The review of the adverse benefits determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. The Plan Administrator, within a reasonable time, but no later than 30 days after receipt of the request for review, will decide the appeal. The Plan Administrator may, in its discretion, hold a hearing on the denied claim. Any medical expert consulted in connection with the appeal will be different from and not subordinate to any expert consulted in connection with the initial claim denial. The identity of any medical expert consulted in connection with the appeal will be provided. If the decision on review affirms the initial denial of the claim, a notice will be provided which sets forth: • The specific reasons for the decision on review; • The specific Plan provisions on which the decision is based; • A statement regarding the right to review, upon request and at no charge, relevant documents and other information. If an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar 25 criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and • Appropriate information on the steps to take to appeal the Plan Adminstrator's adverse benefits determination, including the right to submit written comments and have them considered, and the right to review, upon request and at no charge, relevant documents and other information, and the right to file suit, where applicable, with respect to any adverse benefits determination after the final appeal of the claim. If the decision on review affirms the Plan Administrator's initial denial, the Participant may request a review of the adverse appeal determination upon written application to the Plan Administrator. The Second and Final Level of Appeals Procedures described above will apply. 26 Section 8 Plan Administration 8.1 Plan Administrator The administration of this Plan shall be under the supervision of the Plan Administrator. It is the principal duty of the Plan Administrator to see that this Plan is carried out in accordance with the terms of the Plan document and for the exclusive benefit of persons entitled to participate in this Plan and without discrimination among them. 8.2 Powers of the Plan Administrator The Plan Administrator shall have such powers and duties as may be necessary or appropriate to discharge its functions hereunder. The Plan Administrator shall have final discretionary authority to make such decisions and all such determinations shall be final, conclusive and binding. The Plan Administrator shall have the exclusive right to interpret the Plan and to decide all matters hereunder. The Plan Administrator shall have the following discretionary authority: • To construe and interpret this Plan, including all possible ambiguities, inconsistencies and omissions in the Plan and related documents, and to decide all questions of fact, questions relating to eligibility and participation, and questions of Benefits under this Plan (provided that the Committee shall exercise such exclusive power with respect to an appeal of a claim); • To prescribe procedures to be followed and the forms to be used by Employees and Participants to make elections pursuant to this Plan; • To prepare and distribute information explaining this Plan and the Benefits under this Plan in such manner as the Plan Administrator determines to be appropriate; • To request and receive from all Employees and Participants such information as the Plan Administrator shall from time to time determine to be necessary for the proper administration of this Plan; • To furnish each Employee and Participant with such reports in relation to the administration of this Plan as the Plan Administrator determines to be reasonable and appropriate, including appropriate statements setting forth the amounts by which a Participant's Compensation has been reduced in order to provide Benefits under this Plan; • To receive, review and keep on file such reports and information concerning the Benefits covered by this Plan as the Plan Administrator determines from time to time to be necessary and proper; • To appoint and employ such individuals or entities to assist in the administration of this Plan as it determines to be necessary or advisable, including legal counsel and Benefit consultants; • To sign documents for the purposes of administering this Plan, or to designate an individual or individuals to sign documents for the purposes of administering this Plan; 27 • To secure independent medical or other advice and require such evidence as deemed necessary to decide any claim or appeal; and • To maintain the books of accounts, records, and other data in the manner necessary for proper administration of this Plan and to meet any applicable disclosure and reporting requirements. 8.3 Reliance on Participant,Tables,etc. The Plan Administrator may rely upon the Participant's direction, information or election as being proper under the Plan and shall not be responsible for any act or failure to act because of a direction or lack of direction by the Participant. The Plan Administrator will also be entitled, to the extent permitted by law, to rely conclusively on all tables, valuations, certificates, opinions and reports that are furnished by accountants, attorneys, or other experts employed or engaged by the Plan Administrator. 8.4 Outside Assistance The Plan Administrator may employ such counsel, accountants, claims administrators, consultants, actuaries and other person or persons as the Plan Administrator shall deem advisable. The Plan shall pay the compensation of such counsel, accountants, and other person or persons and any other reasonable expenses incurred by the Plan Administrator in the administration of the Plan. Unless otherwise provided in the service agreement, obligations under this Plan shall remain the obligations of the Employer and the Plan Administrator. 8.5 Insurance Contracts The Employer shall have the right to enter into a contract with one or more insurance companies for the purposes of providing any Benefits under the Plan; and to replace any of such insurance companies or contracts. Any dividends, retroactive rate adjustments or other refunds of any type that may become payable under any such insurance contract shall not be assets of the Plan but shall be the property of, and be retained by, the Employer, to the extent that such amounts are less than aggregate Employer Contributions toward such insurance. 8.6 Fiduciary Liability To the extent permitted by law, the Plan Administrator shall not incur any liability for any acts or for failure to act except for its own gross negligence, misconduct or willful breach of this Plan. 8.7 Compensation of Plan Administrator Unless otherwise determined by the Employer and permitted by law, any Plan Administrator that is also an employee of the Employer shall serve without compensation for services rendered in such capacity, but all reasonable expenses incurred in the performance of their duties shall be paid by the Employer. 8.8 Inability to Locate Payee If the Plan Administrator is unable to make payment to the Participant or another person to whom a payment is due under the Plan because it cannot ascertain the identity or whereabouts of the Participant or such other person after reasonable efforts have been made to identify or locate such 28 person, then such payment and all subsequent payments otherwise due to the Participant or such other person shall be forfeited one year after the date any such payment first became due. 8.9 Effect of Mistake In the event of a mistake as to the eligibility or participation of an Employee, or the allocations made to the Participant's account, or the amount of Benefits paid or to be paid to the Participant or another person, the Plan Administrator shall, to the extent administratively possible and otherwise permissible under Code §125 or the regulations issued thereunder, correct by making the appropriate adjustments of such amounts as necessary to credit the Participant's account or such other person's account or withhold any amount due to the Plan or the Employer from Compensation paid by the Employer. 29 Section 9 Amendment or Termination of the Plan 9.1 Permanency While the Employer fully expects that this Plan will continue indefinitely, due to unforeseen, future business contingencies, permanency of the Plan will be subject to the Employer's right to amend or terminate the Plan, as provided in the paragraphs below. 9.2 Right to Amend The Employer reserves the right to merge or consolidate the Plan and to make any amendment or restatement to the Plan from time-to-time, including those which are retroactive in effect. Such amendments may be applicable to any Participant. Any amendment or restatement shall be deemed to be duly executed by the Employer when signed by the Chair of the Board of Supervisors, and attested by the Clerk to the Board of Supervisors. 9.3 Right to Terminate The Employer reserves the right to discontinue or terminate the Plan in whole or in part at any time without prejudice. This Plan may be terminated by the Employer. This Plan also shall terminate automatically if the Employer is legally dissolved, makes a general assignment for the benefit of its creditors, files for liquidation under the Bankruptcy Code, merges or consolidates with any other entity and it is not the surviving entity, or if it sells or transfers substantially all of its assets, or goes out of business, unless the Employer's successor in interest agrees to assume the liabilities under this Plan as to the Participant and Dependents. 30 Section 10 General Provisions 10.1 Expenses All reasonable expenses incurred in administering the Plan are currently paid by forfeitures to the extent provided in Schedules B, C, and D and then by the Employer. 10.2 No Contract of Employment Nothing contained in the Plan shall be construed as a contract of employment with the Employer or as a right of any Employee to be continued in the employment of the Employer, or as a limitation of the right of the Employer to discharge any Employee,with or without cause. 10.3 Compliance with Federal Mandates To the extent applicable for each Benefit Option, the Plan will provide Benefits in accordance with the requirements of all federal mandates, including USERRA, COBRA, and HIPAA. This Plan shall be construed, operated and administered accordingly, and in the event of any conflict between any part, clause or provision of this Plan and the Code, the provisions of the Code shall be deemed controlling, and any conflicting part, clause or provision of this Plan shall be deemed superseded to the extent of the conflict. 10.4 Verification The Plan Administrator shall be entitled to require reasonable information to verify any claim or the status of any person as an Employee or Dependent. If the Participant does not supply the requested information within the applicable time limits or provide a release for such information, the Participant will not be entitled to Benefits under the Plan. 10.5 Limitation of Rights Nothing appearing in or done pursuant to the Plan shall be held or construed: • To give any person any legal or equitable right against the Employer, any of its employees, or persons connected therewith, except as provided by law; or • To give any person any legal or equitable right to any assets of the Plan or any related trust, except as expressly provide herein or as provided by law. 10.6 Non-Assignability of Rights The right of any Participant to receive any reimbursement under this Plan shall not be alienable by the participant by assignment or any other method and shall not be subject to claims by the Participant's creditors by any process whatsoever. Any attempt to cause such right to be so subjected will not be recognized, except to the extent required by law. 31 10.7 Governing Law This Plan is intended to be construed, and all rights and duties hereunder are governed, in accordance with the laws of the State of California, except to the extent such laws are preempted by any federal law. 10.8 Severability If any provision of the Plan is held invalid or unenforceable, its validity or unenforceability shall not affect any other provision of the Plan, and the Plan shall be construed and enforced as if such provision had not been included herein. 10.9 Captions The captions contained herein are inserted only as a matter of convenience and for reference and in no way define, limit, enlarge or describe the scope or intent of the Plan nor in any way shall affect the Plan or the construction of any provision thereof. 10.10 Federal Tax Disclaimer To ensure compliance with requirements imposed by the IRS to the extent this Plan Document or any Schedule contains advice relating to a federal tax issue, it is not intended or written to be used, and it may not be used, for the purpose of avoiding any penalties that may be imposed on the Participant or any other person or entity under the Internal Revenue Code or promoting, marketing or recommending to another party any transaction or matter addressed herein. 10.11 No Guarantee of Tax Consequences Neither the Plan Administrator nor the Employer make any commitment or guarantee that any amounts paid to the Participant or for the Participant's benefit under this Plan will be excludable from the Participant's gross income for federal, state or local income tax purposes. It shall be the Participant's obligation to determine whether each payment under this Plan is excludable from the Participant's gross income for federal, state and local income tax purposes, and to notify the Plan Administrator if the Participant has any reason to believe that such payment is not so excludable. 10.12 Indemnification of Employer If the Participant receives one or more payments or reimbursements under this Plan on a pre-tax Salary Reduction basis, and such payments do not qualify for such treatment under the Code, the Participant shall indemnify and reimburse the Employer for any liability the Employer may incur for failure to withhold federal income taxes, Social Security taxes, or other taxes from such payments or reimbursements. 32 Section 11 HIPAA Privacy and Security 11.1 Provision of Protected Health Information to Employer For purposes of this Section, Protected Health Information (PHI) shall have the meaning as defined in HIPAA. PHI means information that is created or received by the Plan and relates to the past, present, or future physical or mental health or condition of a Participant; the provision of health care to a Participant; or the past, present, or future payment for the provision of health care to a Participant; and that identifies the Participant or for which there is a reasonable basis to believe the information can be used to identify the Participant. PHI includes information of persons living or deceased. Members of the Employer's workforce have access to the individually identifiable health information of Plan Participants for administrative functions of the Health FSA and/or Limited Scope Health FSA, plus any other Benefit Option which might be subject to the privacy and security provisions of HIPAA (hereinafter referred to collectively as the Plan). When this health information is provided to the Employer, it is PHI. HIPAA and its implementing regulations restrict the Employer's ability to use and disclose PHI. The Employer shall have access to PHI from the Plan only as permitted under this Section or as otherwise required or permitted by HIPAA. 11.2 Permitted Disclosure of Enrollment/Disenrollment Information The Plan may disclose to the Employer information on whether the individual is participating in the Plan. 11.3 Permitted Uses and Disclosure of Summary Health Information The Plan may disclose Summary Health Information to the Employer, provided that the Employer requests the Summary Health Information for the purpose of modifying, amending, or terminating the Plan. Summary Health Information means information: • That summarizes the claims history, claims expenses, or type of claims experienced by individuals for whom a plan sponsor had provided health benefits under a health plan; and • From which the required information has been deleted, except that the geographic information need only be aggregated to the level of a five-digit ZIP code. 11.4 Permitted and Required Uses and Disclosure of PHI for Plan Administration Purposes Unless otherwise permitted by law, and subject to the conditions of disclosure and obtaining written certification described below, the Plan may disclose PHI to the Employer, provided that the Employer uses or discloses such PHI only for Plan Administration Purposes. Plan Administration Purposes means administration functions performed by the Employer on behalf of the Plan, such as quality assurance, claims processing, auditing, and monitoring. Plan Administration functions do not include functions performed by the Employer in connection with any other benefit or benefit plan of the Employer, and they do not include any employment-related functions. 33 Notwithstanding the provisions of this Plan to the contrary, in no event shall the Employer be permitted to use or disclose PHI in a manner that is inconsistent with 45 CFR § 164.504(f). 11.5 Conditions of Disclosure for Plan Administration Purposes Employer agrees that with respect to any PHI (other than enrollment/disenrollment information and Summary Health Information, which are not subject to these restrictions) disclosed to it, the Employer shall: • Not use or further disclose PHI other than as permitted or required by the Plan or as required by law; • Ensure that any agent, including a subcontractor, to whom it provides PHI received from the Plan agrees to the same restrictions and conditions that apply to the Employer with respect to PHI; • Not use or disclose the PHI for employment-related actions and decisions or in connection with any other for employee benefit plan of the Employer; • Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware; • Make available PHI to comply with HIPAA's right to access in accordance with 45 CFR §164.524; • Make available PHI for amendment and incorporate any amendments to PHI in accordance with 45 CFR §164.526; • Make available the information required to provide an accounting of disclosures in accordance with 45 CFR§164.528; • Make its internal practices, books, and records relating to the use and disclosure of PHI received from the Plan available to the Secretary of Health and Human Services for purposes of determining compliance with HIPAA's privacy and security requirements; • If feasible, return or destroy all PHI received from the Plan that the Employer still maintains in any form and retain no copies of such information when no longer needed for the purpose for which disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and • Ensure that the adequate separation between the Plan and the Employer (i.e., the "firewall"), required in 45 CFR §504(f)(2)(iii), is satisfied. The Employer further agrees that if it creates, receives, maintains, or transmits any electronic PHI (other than enrollment/disenrollment information and Summary Health Information, which are not subject to these restrictions) on behalf of the Plan, it will implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI, and it will ensure that any agents, including subcontractors, to whom it provides such 34 electronic PHI agrees to implement reasonable and appropriate security measures to protect the information.The Employer will report to the Plan any security incident of which it becomes aware. 11.6 Adequate Separation Between Plan and Employer The Employer shall designate such employees of the Employer who need access to PHI in order to perform Plan administration functions that the Employer performs for the Plan such as quality assurance, claims processing, auditing, monitoring, payroll, and appeals. No other persons shall have access to PHI. These specified employees, or classes of employees, shall only have access to and use of PHI to the extent necessary to perform the plan administration functions that the Employer performs for the Plan. In the event that any of these designated employees do not comply with the provisions of this Section, that employee shall be subject to disciplinary action by the Employer for non-compliance pursuant to the Employer's employee discipline and termination procedures. The Employer will ensure that the provisions of this Section are supported by reasonable and appropriate security measures to the extent that the designees have access to electronic PHI. 11.7 Certification of Plan Sponsor The Plan shall disclose PHI to the Employer only upon the receipt of a certification by the Employer that the Plan has been amended to incorporate the provisions of 45 CFR §164.504(f)(2)(ii), and that the Employer agrees to the conditions of disclosure set forth in Section 10.5. 11.8 Organized Health Care Arrangement The Plan Administrator intends the Plan to form part of an Organized Health Care Arrangement along with any other Benefit Option under a covered health plan under 45 CFR §160.103 provided by Employer. IN WITNESS WHEREOF, and as conclusive evidence of the adoption of the foregoing instrument comprising the County of Fresno Cafeteria Plan, County of Fresno has caused this Plan to be executed in its name and on its behalf, on this day of , 20_ County of Fresno By: Its: Attest: Its: 35 Glossary Capitalized terms used in the Plan have the following meanings: Benefit or Benefits means the Benefit Options offered under the Plan. Benefit Option means a qualified benefit under Code §125(f)that is offered under this Cafeteria Plan, or an option for coverage under an underlying accident or health plan. Cafeteria Plan means the County of Fresno Cafeteria Plan as set forth herein and as amended from time to time. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. Code means the Internal Revenue Code of 1986, as amended. Compensation means the wages or salary paid to an Employee by the Employer, determined prior to: any Salary Reduction election under this Plan; any Salary Reduction election under any other cafeteria plan; any compensation reduction under any Code §132(f)(4) plan; and any salary deferral elections under any Code §§401(k),408(k) or 457(b) Plan or arrangement. Contribution means the amount contributed to pay for the cost of Benefits as calculated under the Benefit Options. DCAP means Dependent Care Assistance Program. Dependent means any individual who is a tax dependent of the Participant as defined in Code §§105(b) and 152, with the following exceptions: • For purposes of accident or health coverage (to the extent funded under the PPP, and for purposes of the Health FSA and Limited Scope Health FSA: o A dependent is defined as in Code §§105(b) and 152, determined without regard to §152 subsections(b)(1), (b)(2), and (d)(1)(B)thereof; and o Any child whom IRS Rev. Proc. 2008-48 applies (regarding certain children of divorced or separated parents who receive more than half of their support for the calendar year from one or both parents and are in the custody of one or both parents for more than half of the calendar year) is treated as a dependent of both parents; and • For purposes of the DCAP, a dependent means a Qualifying Individual. Notwithstanding the foregoing, the Health FSA Component will provide Benefits in accordance with the applicable requirements of any QMCSO, even if the child does not meet the definition of"Dependent." Dependent Care Assistance Program means the dependent care assistance program component established by Employer under the Plan. It allows the Participant to use pre-tax dollars to pay for the care of the Participant's eligible Dependents while the Participant is at work. 36 Dependent Care Expenses has the meaning described in the DCAP Schedule below. Earned Income means all income derived from wages, salaries, tips, self-employment, and other compensation (such as disability or wage continuation Benefits), but only if such amounts are includible in gross income for the taxable year. Earned income does not include: any amounts received pursuant to any DCAP established under Code §129; or any other amounts excluded from earned income under Code §32(c)(2), such as amounts received under a pension or annuity, or pursuant to workers' compensation. Effective Date of this Plan shall be January 1, 2016. Employee means an individual who is permanently employed and regularly scheduled to work 20 hours or more per week and has been employed by the Employer for one pay period of work, counting the Participant's employment commencement date as the first day. The following classes of employees cannot participate in the County of Fresno Cafeteria Plan: • Leased employees (as defined by §414(n) of the Code); • Contract workers and independent contractors; • Temporary employees, casual employees, and employees hired short-term to meet specific needs of the Employer whether or not such persons are on the Employer's W-2 payroll; • Individuals paid by a temporary or other employment or staffing agency; • Self-employed individuals; and • Any more than 2%shareholders of S corporations. Employer means County of Fresno. FMLA means the Family and Medical Leave Act of 1993, as amended. HDHP means High Deductible Health Plan. Health Care Expenses has the meaning defined in the Health FSA Schedule below. Health Flexible Spending Account means the health flexible spending account component established by the Employer under the Plan. It allows a Participant to use pre-tax dollars to pay for most health and dental expenses not reimbursed under other programs. Health FSA means Health Flexible Spending Account. Health Plan means the health benefit plan sponsored by the Employer. Health Savings Account means the savings account Benefit Option established by the Employer under this Plan. 37 High Deductible Health Plan means the high deductible health plan offered by the Employer that is intended to qualify as a high deductible health plan under Code §223(c)(2), as described in materials provided separately by the Employer. HIPAA means the Health Insurance Portability and Accountability Act of 1996, as amended. HSA means a Health Savings Account established under Code §223. Such arrangements are individual trusts or custodial accounts, each separately established and maintained by an Employee with a qualified trustee/custodian. Insurance Plan(s) means the insurance group benefit plan(s) sponsored by the Employer, including medical, prescription drug, dental, vision, accidental death & dismemberment, and group term life plans. Limited Scope Health FSA means the flexible spending account Benefit Option that reimburses only dental,vision and preventive care expenses established by the Employer under this Plan. Limited Scope Health Care Expense means, unless otherwise limited, an expense incurred during the applicable Plan Year by a Participant or by the Spouse or Dependent of a Participant for dental,vision, or preventive care within the meaning of"medical care" as defined in Section 213 of the Code. However, a Participant may not be reimbursed for dental and vision care of the type covered under any health plan including the High Deductible Health Plan, and a Participant may not be reimbursed for the cost of other dental or vision coverage such as premiums paid under plans maintained by the employer of the Participant's Spouse or individual policies maintained by the Participant or his Spouse or Dependent. Open Enrollment Period with respect to a Plan Year means a period as described by the Plan Administrator preceding the Plan Year during which Participants may make Benefit elections for the Plan Year. Participant means a person who is an Employee and who is participating in this Plan in accordance with the provisions of the Eligibility and Participation Section. Participants include: (a) those that elect to receive Benefits under this Plan, and enroll for Salary Reductions to pay for such Benefits; and (b) those that elect instead to receive their full salary in cash and have not elected the Health FSA, Limited Scope Health FSA or DCAP. Period of Coverage means the Plan Year, with the following exceptions: for Employees who first become eligible to participate, it shall mean the portion of the Plan Year following the date participation commences, as described in the Eligibility and Participation Section; and for Employees who terminate participation, it shall mean the portion of the Plan Year prior to the date participation terminates, as described in the Eligibility and Participation Section. PHI means Protected Health Information. Plan means the County of Fresno Cafeteria Plan, as set forth herein and as amended from time to time. Plan Administrator means County of Fresno. Plan Year means the twelve-month period ending December 31. 38 PPP means the Premium Payment Plan. Premium Payment Plan means the Benefit Option in which an Employee can elect to participate and have Contributions for the Insurance Plan(s) paid on a pre-tax basis. Protected Health Information (PHI) means information that is created or received by County of Fresno Cafeteria Plan and relates to the past, present, or future physical, mental health or condition of a Participant; the provision of health care to a participant; or the past, present, or future payment for the provision of health care to a Participant; and that identifies the Participant or for which there is a reasonable basis to believe the information can be used to identify the Participant. Protected health information includes information of persons living or deceased. QMCSO means a Qualified Medical Child Support Order, as defined in ERISA§609(a). Qualifying Dependent Care Services has the meaning described in the DCAP Schedule below. Qualifying Individual means: • A tax dependent of the Participant as defined in Code §152 who is under the age of 13 and who is the Participant's qualifying child as defined in Code § 152(a)(1); • A tax dependent of the Participant as defined in Code §152, but determined without regard to subsections (b)(1), (b)(2), and (d)(1)(B) thereof, who is physically or mentally incapable of self- care and who has the same principal place of abode as the Participant for more than half of the year; or • A Participant's Spouse who is physically or mentally incapable of self-care, and who has the same principal place of abode as the Participant for more than half of the year. Notwithstanding the foregoing, in the case of divorced or separated parents, a Qualifying Individual who is a child shall, as provided in Code §21(e)(5), be treated as a Qualifying Individual of the custodial parent (within the meaning of Code §152(e)) and shall not be treated as a Qualifying Individual with respect to the non-custodial parent. Related Employer means any employer affiliated with County of Fresno that, under Code §414(b), (c), or (m), is treated as a single employer with County of Fresno for purposes of Code §125(g)(4), and which is listed in Appendix B. Salary Reduction means the amount by which the Participant's Compensation is reduced and applied by the Employer under this Plan to pay for one or more of the Benefit Options. Salary Reduction Agreement means the agreement, form(s) or Internet web site, which Employees use to elect one or more Benefit Options. The agreement and/or forms spell out the procedures used for allowing an Employee to participate in this Plan and will allow the Employee to elect Salary Reductions to pay for any Benefit Options offered under this Plan. Spouse means an individual who is legally married to a Participant as determined under applicable state law (and who is treated as a Spouse under the Code). Notwithstanding the above, for purposes of the DCAP, the term "Spouse" shall not include: an individual legally separated from the Participant under a 39 divorce or separate maintenance decree; or an individual who, although married to the Participant, files a separate federal income tax return, maintains a principal residence separate from the Participant during the last six months of the taxable year, and does not furnish more than half of the cost of maintaining the principal place of abode of the Participant. Student means an individual who, during five or more calendar months during the Plan Year, is a full- time student at any educational organization that normally maintains a regular faculty and curriculum and normally has an enrolled student body in attendance at the location where its educational activities are regularly held. USERRA means the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended. 40 Appendix A Exclusions—Medical Expenses That Are Not Reimbursable From the Health FSA or Limited Scope Health FSA The Plan Document contains the general rules governing what expenses are reimbursable under the Health FSA or Limited Scope Health FSA. This Appendix A, as referenced in the Plan Document, specifies certain expenses that are excluded under this Plan with respect to reimbursement from the Health FSA or Limited Scope Health FSA -- that is, expenses that are not reimbursable, even if such expenses meet the definition of "medical care" under Code §§213(d) and 106(f) and may otherwise be reimbursable under the regulations governing health flexible spending accounts: • Health insurance premiums for any other plan (including a plan sponsored by the Employer). • Long-term care services. • Cosmetic surgery or other similar procedures, unless the surgery or procedure is necessary to ameliorate a deformity arising from, or directly related to, a congenital abnormality, a personal injury resulting from an accident or trauma, or a disfiguring disease. "Cosmetic surgery" means any procedure that is directed at improving the patient's appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease. • The salary expense of a nurse to care for a healthy newborn at home. • Funeral and burial expenses. • Household and domestic help (even if recommended by a qualified physician due to an Employee's or Dependent's inability to perform physical housework). • Custodial care. • Costs for sending a problem child to a special school for Benefits that the child may receive from the course of study and disciplinary methods. • Social activities, such as dance lessons (even if recommended by a physician for general health improvement). • Bottled water. • Cosmetics,toiletries,toothpaste, etc. • Uniforms or special clothing, such as maternity clothing. • Automobile insurance premiums. • Marijuana and other controlled substances that are in violation of federal laws, even if prescribed by a physician. • Any item that does not constitute "medical care" as defined under Code §§213(d) and 106(f). 41 • Any item that is not reimbursable under Code §§213(d) and 106(f) due to the rules in Prop. Treas. Reg. §1.125-2, Q-7(b)(4) or other applicable regulations. 42 Appendix B Related Employers That Have Adopted This Plan With the Approval of County of Fresno. No Related Employers have adopted this plan. County of Fresno is the only employer participating in this Plan. 43 Schedule A Premium Payment Plan Unless otherwise specified, terms capitalized in this Schedule A shall have the same meaning as the defined terms in the Plan Document to which this Schedule is attached. A.1 Benefits If the Employee is an enrolled participant in the Insurance Plan(s) and timely submits an executed Salary Reduction Agreement, the Employee can either: • Option A: Elect Benefits under the PPP by electing to contribute his or her share for the Insurance Plan(s)on a pre-tax basis; or • Option B: Elect no Benefits under the PPP and to contribute his or her share, if any, for the Insurance Plan(s)with after-tax deductions outside of this Plan. If the Employee is an enrolled participant in the Insurance Plan(s) and does not timely submit an executed Salary Reduction Agreement,the Employee will be deemed to have elected Option A. Benefits elected under Option A will be funded by the Participant's Contributions as provided in the Eligibility and Participation section in the Plan Document. To determine when a Salary Reduction Agreement will be considered timely submitted, see the Method and Timing of Elections section in the Plan Document. Unless an exception applies, as described in the Irrevocability of Elections and Exceptions section in the Plan Document, such election is irrevocable for the duration of the Period of Coverage to which it relates. A.2 Benefit Contributions The annual Contribution for the PPP is equal to the amount as set by the Employer, which may or may not be the same amount charged under the Insurance Plan(s). A.3 Benefits Provided Under the Insurance Plan(s) Medical and other insured benefits will be provided by the Insurance Plan(s), not this Plan. The types and amounts of medical benefits, the requirements for participation, and other terms and conditions of coverage and benefits of the Insurance Plan(s) are set forth in the documents relating to that plan. No changes can be made under this Plan with respect to such Health Plan if such changes are not permitted under the applicable Insurance Plan(s). All claims to receive benefits under the Insurance Plan(s) shall be subject to and governed by the terms and conditions of the Insurance Plan(s) and the rules, regulations, policies and procedures adopted in accordance therewith, as may be amended from time to time. 44 A.4 COBRA To the extent required by COBRA, the Participant, Spouse and Dependent, as applicable, whose coverage terminates under the Insurance Plan(s) because of a COBRA qualifying event and who is a qualified beneficiary as defined under COBRA, shall be given the opportunity to continue the same coverage that the Participant, Spouse or Dependent had under the Insurance Plan(s)the day before the qualifying event for the periods prescribed by COBRA, on a self-pay basis. Such continuation coverage shall be subject to all conditions and limitations under COBRA. 45 Schedule B Health Flexible Spending Account Unless otherwise specified, terms capitalized in this Schedule B shall have the same meaning as the defined terms in the Plan Document to which this Schedule is attached. B.1 Benefits An Employee not enrolled in the Limited Scope Health FSA, can elect to participate in the Health FSA by electing to receive Benefits in the form of reimbursements for Health Care Expenses. If elected, the Benefit Option will be funded by Participant Contributions on a pre-tax Salary Reduction basis as provided in the Employer and Participant Contributions section in the Plan Document. Unless an exception applies as described in the Irrevocability of Elections and Exceptions section, such election is irrevocable for the duration of the Period of Coverage to which it relates. A Participant who has an election for the Health FSA (other than the Limited Scope Health FSA) that is in effect on the last day of a Plan Year cannot make or receive contributions made to an HSA for any of the first three calendar months following the close of that Plan Year, unless the balance in the Participant's Health FSA is$0 as of the last day of that Plan Year. For this purpose, a Participant's Health FSA balance is determined on a cash basis — that is, without regard to any claims that have been incurred but have not yet been reimbursed (whether or not such claims have been submitted). B.2 Benefit Contributions The annual Contribution for a Participant's Health FSA is equal to the annual Benefit amount elected by the Participant. B.3 Eligible Health Care Expenses Under the Health FSA, a Participant may receive reimbursement for Health Care Expenses incurred during the Period of Coverage for which an election is in force. • Incurred. A Health Care Expense is incurred at the time the medical care or service giving rise to the expense is provided, and not when the Participant is formally billed for, is charged for, or pays for the medical care. • Health Care Expenses. Health Care Expenses means expenses incurred by a Participant, or the Participant's Spouse or Dependent(s) covered under the Health FSA for medical care, as defined in Code §§213(d) and 106(f), other than expenses that are excluded by this Plan, but only to the extent that the Participant or other person incurring the expense is not reimbursed through any other accident or health plan. • Expenses That Are Not Reimbursable. Insurance premiums are not reimbursable from the Health FSA. Other expenses that are not reimbursable are listed in Appendix A to the Plan Document. 46 B.4 Maximum and Minimum Benefits • Maximum Reimbursement Available; Uniform Coverage Rule. The maximum dollar amount elected by the Participant for reimbursement of Health Care Expenses incurred during a Period of Coverage, reduced by prior reimbursements during the Period of Coverage, shall be available at all times during the Period of Coverage, regardless of the actual amounts credited to the Participant's Health FSA. Notwithstanding the foregoing, no reimbursements will be available for Health Care Expenses incurred after coverage under this Plan has terminated, unless the Participant has elected COBRA as provided below, or is entitled to submit expenses incurred during a Grace Period as provided below. • Payment shall be made to the Participant in cash as reimbursement for Health Care Expenses incurred during the Period of Coverage for which the Participant's election is effective, or during a Grace Period as provided below, provided that the other requirements of this Section have been satisfied. • Maximum and Minimum Dollar Limits. The maximum annual benefit amount that a Participant may elect to receive under this Plan in the form of reimbursements for Health Care Expenses incurred in any Period of Coverage shall be no greater than the federally allowed maximum. There is no minimum dollar limit. Reimbursements due for Health Care Expenses incurred by the Participant's Spouse or Dependent(s) shall be charged against the Participant's Health FSA. • Changes. For subsequent Plan Years, the maximum and minimum dollar limit may be changed by the Plan Administrator and shall be communicated to Employees through the Salary Reduction Agreement or another document. • No Proration. If a Participant enters the Plan mid-year or wishes to increase his or her election mid-year as permitted under this Plan, then the Participant may elect coverage or increase coverage respectively, up to the maximum annual benefit amount stated above. The maximum annual benefit amount will not be prorated. • Effect on Maximum Benefits If Election Change Permitted. Any change in an election affecting annual Contributions to the Health FSA will also change the maximum reimbursement benefits for the balance of the Period of Coverage commencing on the election change effective date. Such maximum reimbursement benefits for the balance of the Period of Coverage shall be calculated by adding: o The aggregate Contribution for the period prior to such election change;to o The total Contribution for the remainder of such Period of Coverage to the Health FSA; reduced by o All reimbursements made during the entire Period of Coverage. • FMLA Leave. Any change in an election for FMLA leave will change the maximum reimbursement benefits in accordance with FMLA or the regulations governing cafeteria plans. • Monthly Limits on Reimbursing OTC Drugs. Only reasonable quantities of over-the-counter (OTC) drugs or medicines of the same kind may be reimbursed from a Participant's Health FSA in 47 a single calendar month, even assuming that the drug otherwise meets the requirements of this Section, including that it is for medical care under Code §§213(d) and 106(f). Stockpiling is not permitted. B.5 Establishment of Account The Plan Administrator will establish and maintain a Health FSA with respect to each Participant who has elected to participate in the Health FSA, but will not create a separate fund or otherwise segregate assets for this purpose.The account established hereto will merely be a record keeping account with the purpose of keeping track of Contributions and determining forfeitures. • Crediting of Accounts. A Participant's Health FSA will be credited following each Salary Reduction actually made during each Period of Coverage with an amount equal to the Salary Reduction actually made. • Debiting of Accounts. A Participant's Health FSA will be debited during each Period of Coverage for any reimbursement of Health Care Expenses incurred during the Period of Coverage, or during a Grace Period described below. • Available Amount Not Based on Credited Amount. The amount available for reimbursement of Health Care Expenses is the amount as calculated according to the "Maximum Reimbursement Available" paragraph of this Section above. It is not based on the amount credited to the Health FSA at a particular point in time. B.6 Use It or Lose It Rule; Forfeiture Of Account Balance • Use It or Lose It Rule. Except for expenses incurred during an applicable Grace Period, if any balance remains in the Participant's Health FSA for a Period of Coverage after all reimbursements have been made for the Period of Coverage, then such balance shall not be carried over to reimburse the Participant for Health Care Expenses incurred during a subsequent Plan Year. The Participant shall forefeit all rights with respect to such balance. • Use of Forfeitures. All forfeitures under this Plan shall be used as follows: o First,to offset any losses experienced by Employer during the Plan Year as a result of making reimbursements with respect to any Participant in excess of the Contributions paid by such Participant through Salary Reductions; and o Second, to reduce the cost of administering the Health FSA during the Plan Year or the subsequent Plan Year (all such administrative costs shall be documented by the Plan Administrator). • Unclaimed Benefits. Any Health Care FSA benefit payments that remain unclaimed by the close of the Plan Year following the Period of Coverage in which the Health Care Expense was incurred shall be forfeited and applied as described above. 48 B.7 Grace Period • Special Rules for Claims Incurred During a Grace Period. The Employer has the discretion to establish a grace period following the end of the Plan Year, as follows: o An individual may be reimbursed for Health Care Expenses incurred during a Grace Period from amounts remaining in his or her Health FSA Account at the end of the Plan Year to which that Grace Period relates ("Prior Plan Year Health FSA Amounts") if the individual is either: ■ A Participant with Health FSA coverage that is in effect on the last day of that Plan Year; or ■ A qualified beneficiary as defined under COBRA who has COBRA coverage under the Health FSA Benefit Option on the last day of that Plan Year. o Prior Plan Year Health FSA Amounts may not be cashed out or converted to any other taxable or non-taxable Benefit Option. For example, Prior Plan Year Health FSA Amounts may not be used to reimburse Dependent Care Expenses. o Health Care Expenses incurred during a Grace Period and approved for reimbursement will be reimbursed first from any available Prior Plan Year Health FSA Amounts and then from any amounts that are available to reimburse expenses that are incurred during the current Plan Year. If the Health FSA is accessible by an electronic payment card, Health Care Expenses incurred during the Grace Period may need to be submitted manually in order to be reimbursed from Prior Plan Year Health FSA Amounts if the card is unavailable for such reimbursement. An individual's Prior Plan Year Health FSA Amounts will be debited for any reimbursement of Health Care Expenses incurred during the Grace Period that is made from such Prior Plan Year Health FSA Amounts. o Claims for reimbursement of Health Care Expenses incurred during a Grace Period must be submitted no later than May 15 of the year following the close of the Plan Year to which the Grace Period relates in order to be reimbursed from Prior Plan Year Health FSA Amounts. Any Prior Plan Year Health FSA Amounts that remain after all reimbursements have been made for the Plan Year and its related Grace Period shall not be carried over to reimburse the Participant for expenses incurred in any subsequent period. The Participant will forfeit all rights with respect to these amounts, which will be subject to the Plan's provisions regarding forfeitures. B.8 Reimbursement Procedure • Timing. Within 30 days after receipt by the Plan Administrator of a reimbursement claim from a Participant, the Employer will reimburse the Participant for the Participant's Health Care Expenses, or the Plan Administrator will notify the Participant that a claim has been denied. This time period may be extended for an additional 15 days for matters beyond the control of the Plan Administrator, including in cases where a reimbursement claim is incomplete. The Plan Administrator will provide written notice of any extension, including the reasons for the extension, and will allow the Participant 45 days from receipt of the written notice in which to complete an incomplete reimbursement claim. 49 • Claims Substantiation. A Participant who has elected to receive Health Care Reimbursement Benefits for a Period of Coverage may apply for reimbursement by submitting an application to the Plan Administrator by no later than the date set by the Plan Administrator each year, setting forth: o The person or persons on whose behalf Health Care Expenses have been incurred; o The nature and date of the expenses incurred; o The amount of the requested reimbursement; o A statement that such expenses have not otherwise been reimbursed and the Participant will not seek reimbursement through any other source; and o Other such details about the expenses that may be requested by the Plan Administrator in the reimbursement request form or otherwise. The application shall be accompanied by bills, invoices, or other statements from an independent third party showing that the Health Care Expenses have been incurred and the amounts of such expenses, together with any additional documentation that the Plan Administrator may request. Except for the final reimbursement claim for a Participant's Health FSA for a Plan Year or other Period of Coverage, no claim for reimbursement may be made unless and until the aggregate claim for reimbursement is at least $25. If the Health FSA is accessible by an electronic payment card, the Participant will be required to comply with substantiation procedures established by the Plan Administrator in accordance with the most current IRS guidance. • Claims Denied. For appeal of claims that are denied, see the Appeals Procedure in the Plan Document. • Claims Ordering; No Reprocessing. All claims for reimbursement will be paid in the order in which they are approved. Once paid, a claim will not be reprocessed or otherwise recharacterized solely for the purpose of paying it from amounts attributable to a different Plan Year or Period of Coverage. B.9 Reimbursements After Termination; Limited COBRA Continuation The Participant will not be able to receive reimbursements for Health Care Expenses incurred after participation terminates. However, except for expenses incurred during an appropriate Grace Period, such Participant, or the Participant's estate, may claim reimbursement for any Health Care Expenses incurred during the Period of Coverage prior to termination, provided that the Participant, or the Participant's estate, files a claim by the date established in the Reimbursement Procedure paragraphs above following the close of the Plan Year in which the Health Care Expense was incurred. Notwithstanding any provision to the contrary in this Plan, to the extent required by COBRA, a Participant and such Participant's Spouse and Dependent(s), whose coverage terminates under the Health FSA because of a COBRA qualifying event, shall be given the opportunity to continue the same coverage that the Participant had under the Health FSA the day before the qualifying event, subject to all conditions and limitations under COBRA. The Contributions for such continuation coverage will be 50 equal to the cost of providing the same coverage to an active employee taking into account all costs incurred by the Employee and the Employer plus a 2% administration fee. Specifically, an individual will be eligible for COBRA continuation coverage only if the Participant's remaining available amount is greater than the Participant's remaining Contribution payments at the time of the qualifying event, taking into account all claims submitted before the date of the qualifying event. Such individual will be notified if the individual is eligible for COBRA continuation coverage. If COBRA is elected, COBRA coverage will be subject to the most current COBRA rules. COBRA will be available only for the remainder of the Plan Year in which the qualifying event occurs. Such COBRA coverage for the Health FSA will cease at the end of the Plan Year, except for expenses incurred during an appropriate Grace Period, and cannot be continued for the next Plan Year. Coverage may terminate sooner if the Contributions for a Period of Coverage are not received by the due date established by the Plan Administrator for that Period of Coverage. Continuation coverage is only granted after the Plan Administrator has received the Contributions for that period of coverage. Contributions for coverage for Health FSA Benefits may be paid on a pre-tax basis for current Employees receiving taxable compensation, as may be permitted by the Plan Administrator on a uniform and consistent basis, but may not be prepaid from Contributions in one Plan Year to provide coverage that extends into a subsequent Plan Year, where COBRA coverage arises either: • Because the Employee ceases to be eligible because of a reduction of hours; or • Because the Employee's Dependent ceases to satisfy the eligibility requirements for coverage. For all other individuals (for example, Employees who cease to be eligible because of retirement, termination of employment, or layoff), Contributions for COBRA coverage for Health FSA Benefits shall be paid on an after-tax basis, unless permitted otherwise by the Plan Administrator, in its discretion and on a uniform and consistent basis, but may not be prepaid from Contributions in one Plan Year to provide coverage that extends into a subsequent Plan Year. B.10 Qualifed Reservist Distribution If a Participant meets all of the following conditions, the Participant may elect to receive a qualified reservist distribution from the Health FSA: • The Participant's Contributions to the Health FSA for the Plan Year as of the date the qualified reservist distribution is requested exceeds the reimbursements the Participant has received from the Health FSA for the Plan Year as of that date. • The Participant is ordered or called to active military duty for a period of at least 180 days or for an indefinite period by reason of being a member of the Army National Guard of the United States, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard of the United States, the Air Force Reserve, the Coast Guard Reserve, or the Reserve Corps of the Public Health Service. • The Participant has provided the Plan Administrator with a copy of the order or call to active duty. An order or call to active duty of less than 180 days' duration must be supplemented by subsequent calls or orders to reach a total of 180 or more days. 51 • The Participant is ordered or called to active military duty on or after April 1, 2009, or the Participant's period of active duty begins before April 1, 2009 and continues on or after the date. • During the period beginning on the date of the Participant's order or call to active duty and ending on the last day of the Plan Year during which the order or call occurred, the Participant submits a qualified reservist distribution election form to the Plan Administrator. Amount of Qualified Reservist Distribution. If the above conditions are met,the Participant will receive a distribution from the Health FSA equal to his or her Contributions to the Health FSA for the Plan Year as of the date of the distribution request, minus any reimbursements received for the Plan Year as of that date. No Reimbursement for Expenses Incurred After Distribution Request. Once a Participant requests a qualified reservist distribution, the Participant forfeits the right to receive reimbursements for Health Care Expenses incurred during the period that begins on the date of the distribution request and ends on the last day of the Plan Year. The Participant may, however, continue to submit claims for Health Care Expenses that were incurred before the date of the distribution request (even if the claims are submitted after the date of the qualified reservist distribution), so long as the total dollar amount of the claims does not exceed the amount of the Health FSA election for the Plan Year, minus the sum of the qualified reservist distribution and the prior Health FSA reimbursements for the Plan Year. Tax Treatment of a Qualified Reservist Distribution. If the Participant receives a qualified reservist distribution, it will be included in his or her gross income and will be reported as wages on the Participant's Form W-2 for the year in which it is paid. B.11 Named Fiduciary The Plan Administrator is the Named Fiduciary for the Health FSA. B.12 Coordination of Benefits Health FSAs are intended to pay Benefits solely for Health Care Expenses not previously reimbursed or reimbursable elsewhere. Accordingly, the Health FSA shall not be considered a group health plan for coordination of benefits purposes, and the Health FSA shall not be taken into account when determining benefits payable under any other plan. 52 Schedule C Limited Scope Health Flexible Spending Account Unless otherwise specified, terms capitalized in this Schedule C shall have the same meaning as the defined terms in the Plan Document to which this Schedule is attached. C.1 Benefits An Employee, not enrolled in the Health FSA, can elect to participate in the Limited Scope Health FSA by electing to receive Benefits in the form of reimbursements for Limited Scope Health Care Expenses. If elected, the Benefit Option will be funded by Participant Contributions as provided in the Benefits Offered and Method of Funding section in the Plan Document. Unless an exception applies as described in the Irrevocability of Elections and Exceptions section above, such election is irrevocable for the duration of the Period of Coverage to which it relates. C.2 Benefit Contributions The annual Contribution for a Participant's Limited Scope Health FSA is equal to the annual Benefit amount elected by the Participant. C.3 Eligible Health Care Expenses Under the Limited Scope Health FSA, a Participant may receive reimbursement for Limited Scope Health Care Expenses incurred during the Period of Coverage for which an election is in force. • Incurred. A Limited Scope Health Care Expense is incurred at the time the health care or service giving rise to the expense is provided, and not when the Participant is formally billed for, is charged for, or pays for the health care. • Limited Scope Health Care Expense. Limited Scope Health Care Expense means an expense incurred by a Participant, Spouse or Dependent within the meaning of "health care" as defined in Section 213 of the Code, provided, however, that such expense is for vision, dental, or preventative care only. This term does not include expenses that are excluded under Appendix A to this Plan, nor any expenses for which the Participant or other person incurring the expense is reimbursed for the expense through the Insurance Plan(s), other insurance, or any other accident or health plan. If only a portion of a Health Care Expense has been reimbursed elsewhere, then the Limited Scope Health FSA can reimburse the remaining portion of such Expense if it otherwise meets the requirements of this Section. • Expenses That Are Not Reimbursable. A Participant may not be reimbursed for dental, vision or preventive care of the type covered under any other health plan including an HDHP. In addition, a Participant may not be reimbursed for the cost of other dental or vision coverage such as premiums paid under plans maintained by the employer of the Participant's Spouse or individual policies maintained by the Participant, Spouse or Dependent. Other expenses that are not reimbursable are listed in Appendix A to the Plan Document. 53 C.4 Maximum and Minimum Benefits • Maximum Reimbursement Available; Uniform Coverage Rule. The maximum dollar amount elected by the Participant for reimbursement of Limited Scope Health Care Expenses incurred during a Period of Coverage (reduced by prior reimbursements during the Period of Coverage) shall be available at all times during the Period of Coverage, regardless of the actual amounts credited to the Participant's Limited Scope Health FSA. Notwithstanding the foregoing, no reimbursements will be available for Limited Scope Health Care Expenses incurred after coverage under this Plan has terminated, unless the Participant is eligible for COBRA Benefits, or is entitled to submit expenses incurred during a Grace Period as defined below. • Payment shall be made to the Participant in cash as reimbursement for Limited Scope Health Care Expenses incurred during the Period of Coverage for which the Participant's election is effective, or during a Grace Period as defined below, provided that the other requirements of this Section have been satisfied. • Maximum Dollar Limits. The maximum annual Benefit amount that a Participant may elect to receive under the Limited Scope Health FSA in the form of reimbursements for Limited Scope Health Care Expenses incurred in any Period of Coverage shall be no greater than the federally allowed maximum. There is no minimum dollar limit. Reimbursements due for Limited Scope Health Care Expenses incurred by the Participant's Spouse or Dependent(s) shall be charged against the Participant's Limited Scope Health FSA. • Changes. For subsequent Plan Years, the maximum and minimum dollar limit may be changed by the Plan Administrator and shall be communicated to Employees through the Salary Reduction Agreement or another document. • No Proration. If a Participant enters the Plan mid-year or wishes to increase his or her election mid-year as permitted under this Plan, then the Participant may elect coverage or increase coverage respectively, up to the maximum annual benefit amount stated above. The maximum annual benefit amount will not be prorated. • Effect on Maximum Benefits If Election Change Permitted. Any change in an election affecting annual Contributions to the Participant's Limited Scope Health FSA Benefit Option will also change the maximum reimbursement benefits for the balance of the Period of Coverage commencing with the election change effective date. Such maximum reimbursement Benefits for the balance of the Period of Coverage shall be calculated by adding: o The aggregate Contribution for the period prior to such election change;to o The total Contribution for the remainder of such Period of Coverage to the Limited Scope Health FSA; reduced by o All reimbursements made during the entire Period of Coverage. • FMLA Leave. Any change in an election for FMLA leave will change the maximum reimbursement benefits in accordance with FMLA or the regulations governing cafeteria plan. 54 C.5 Establishment of Account The Plan Administrator will establish and maintain a Limited Scope Health FSA with respect to each Participant who has elected to participate in the Limited Scope Health FSA, but will not create a separate fund or otherwise segregate assets for this purpose. The account established hereto will merely be a record keeping account with the purpose of keeping track of Contributions and determining forfeitures. • Crediting of Accounts. A Participant's Limited Scope Health FSA will be credited following each Salary Reduction actually made during each Period of Coverage with an amount equal to the Salary Reduction actually made. • Debiting of Accounts. A Participant's Limited Scope Health FSA will be debited during each Period of Coverage for any reimbursement of Health Care Expenses incurred during the Period of Coverage, or during a Grace Period as provided below. • Available Amount Not Based on Credited Amount. The amount available for reimbursement of Limited Scope Health Care Expenses is the amount as calculated according to the Maximum Reimbursement Available paragraph above. It is not based on the amount credited to the Limited Scope Health FSA at a particular point in time. C.6 Use It or Lose It Rule; Forfeiture of Account Balance • Use It or Lose It Rule. Except for expenses incurred in an applicable Grace Period, if any balance remains in the Participant's Limited Scope Health FSA after all reimbursements have been made for the Period of Coverage, it shall not be carried over to reimburse the Participant for Limited Scope Health Care Expenses incurred during a subsequent Plan Year. The Participant shall forfeit all rights with respect to such balance. • Use of Forfeiture. All forfeitures under this Plan shall be used as follows: o First,to offset any losses experienced by Employer during the Plan Year as a result of making reimbursements with respect to any Participant in excess of the Contributions paid by such Participant through Salary Reductions; and o Second, to reduce the cost of administering the Limited Scope Health FSA during the Plan Year or the subsequent Plan Year (all such administrative costs shall be documented by the Plan Administrator). • Unclaimed Benefits. Any Limited Scope Health FSA Benefit payments that are unclaimed by the close of the Plan Year following the Period of Coverage in which the Limited Scope Health Care Expense was incurred shall be forfeited and applied as described above. C.7 Grace Period • Special Rules for Claims Incurred During a Grace Period. The Employer has the discretion to establish a grace period following the end of the Plan Year, as follows. 55 o An individual may be reimbursed for Limited Scope Health Care Expenses incurred during a Grace Period from amounts remaining in his or her Limited Scope Health FSA at the end of the Plan Year to which that Grace Period relates ("Prior Plan Year Limited Scope Health FSA Amounts") if the individual is either: ■ A Participant with Limited Scope Health FSA coverage that is in effect on the last day of that Plan Year; or ■ A qualified beneficiary, as defined under COBRA, who has COBRA coverage under the Limited Scope Health FSA Benefit Option on the last day of that Plan Year. o Prior Plan Year Limited Scope Health FSA Amounts may not be cashed out or converted to any other taxable or non-taxable Benefit. For example, Prior Plan Year Limited Scope Health FSA Amounts may not be used to reimburse Dependent Care Expenses. o Limited Scope Health Care Expenses incurred during a Grace Period and approved for reimbursement will be reimbursed first from any available Prior Plan Year Limited Scope Health FSA Amounts and then from any amounts that are available to reimburse expenses that are incurred during the current Plan Year. Limited Scope Health Care Expenses incurred during the Grace Period may need to be submitted manually in order to be reimbursed from Prior Plan Year Limited Scope Health FSA Amounts if the debit card is unavailable for such reimbursement. An individual's Prior Plan Year Health FSA Amounts will be debited for any reimbursement of Limited Scope Health Care Expenses incurred during the Grace Period that is made from such Prior Plan Year Limited Scope Health FSA Amounts. o Claims for reimbursement of Limited Scope Health Care Expenses incurred during a Grace Period must be submitted no later than May 15 of the year following the close of the Plan Year to which the Grace Period relates in order to be reimbursed from Prior Plan Year Limited Scope Health FSA Amounts. Any Prior Plan Year Limited Scope Health FSA Amounts that remain after all reimbursements have been made for the Plan Year and its related Grace Period shall not be carried over to reimburse the Participant for expenses incurred in any subsequent period. The Participant will forfeit all rights with respect to these amounts, which will be subject to the Plan's provisions regarding forfeitures. C.8 Reimbursement Procedure Timing. Within 30 days after receipt by the Plan Administrator of a reimbursement claim from a Participant, the Employer will reimburse the Participant for the Participant's Limited Scope Health Care Expenses or the Plan Administrator will notify the Participant that a claim has been denied. This time period may be extended for an additional 15 days for matters beyond the control of the Plan Administrator, including in cases where a reimbursement claim is incomplete. The Plan Administrator will provide written notice of any extension, including the reasons for the extension, and will allow the Participant 45 days from receipt of the written notice in which to complete an incomplete reimbursement claim. Claims Substantiation. A Participant who has elected to receive Limited Scope Health FSA Benefits for a Period of Coverage may apply for reimbursement by submitting an application to the Plan Administrator by no later than the date set by the Plan Administrator each year, setting forth: 56 • The person or persons on whose behalf the Limited Scope Health Care Expenses have been incurred; • The nature and date of the expenses incurred; • The amount of the requested reimbursement; • A statement that such expenses have not otherwise been reimbursed and that the Participant will not seek reimbursement through any other source; and • Other such details about the expenses that may be requested by the Plan Administrator in the reimbursement request form or otherwise . The application shall be accompanied by bills, invoices, or other statements from an independent third party showing that the Limited Scope Health Care Expenses have been incurred and the amounts of such expenses,together with any additional documentation that the Plan Administrator may request. Except for the final reimbursement claim for a Participant's Limited Scope Health FSA for a Plan Year or other Period of Coverage, no claim for reimbursement may be made unless and until the aggregate claim for reimbursement is at least $25. If the Limited Scope Health FSA is accessible by an electronic payment card a Participant will be required to comply with substantiation procedures established by the Plan Administrator in accordance with the most current IRS guidance. Claims Denied. For appeals of claims that are denied, see the Appeals Procedure in the Plan Document. Claims Ordering; No Reprocessing. All claims for reimbursement under the Health Limited Scope FSA Benefit Option will be paid in the order in which they are approved. Once paid, a claim will not be reprocessed or otherwise recharacterized solely for the purpose of paying it from amounts attributable to a different Plan Year or Period of Coverage. C.9 Reimbursements After Termination; Limited COBRA Continuation The Participant will not be able to receive reimbursements for Limited Scope Health Care Expenses incurred after participation terminates. However, except for expenses incurred during an applicable Grace Period, such Participant, or the Participant's estate, may claim reimbursement for any Limited Scope Health Care Expenses incurred during the Period of Coverage prior to termination, provided that the Participant, or the Participant's estate, files a claim by the date established in the Reimbursement Procedure paragraph above following the close of the Plan Year in which the Limited Scope Health Care Expense was incurred. Notwithstanding any provision to the contrary in this Plan, to the extent required by COBRA, a Participant and such Participant's Spouse and Dependent(s), whose coverage terminates under the Limited Scope Health FSA because of a COBRA qualifying event, shall be given the opportunity to continue the same coverage that the Participant had under the Limited Scope Health FSA the day before the qualifying event subject to all conditions and limitations under COBRA. The Contributions for such continuation coverage will be equal to the cost of providing the same coverage to an active employee taking into account all costs incurred by the Employee and the Employer plus a 2% administration fee. Specifically, an individual will be eligible for COBRA continuation coverage only if the Participant's remaining available amount is greater than the Participant's remaining Contributions at the 57 time of the qualifying event, taking into account all claims submitted before the date of the qualifying event. Such individual will be notified if the individual is eligible for COBRA continuation coverage. If COBRA is elected, COBRA coverage will be subject to the most recent COBRA rules. COBRA will be available only for the remainder of the Plan Year in which the qualifying event occurs; such COBRA coverage for the Limited Scope Health FSA will cease at the end of the Plan Year and cannot be continued for the next Plan Year except for expenses incurred during an applicable Grace Period. Coverage may terminate sooner if the Contributions for a Period of Coverage are not received by the due date established by the Plan Administrator for that Period of Coverage. Continuation coverage is only granted after the Plan Administrator has received the Contributions for that period of coverage. Contributions for coverage for Limited Scope Health FSA Benefits may be paid on a pre-tax basis for current Employees receiving taxable compensation, as may be permitted by the Plan Administrator on a uniform and consistent basis, but may not be prepaid from Contributions in one Plan Year to provide coverage that extends into a subsequent Plan Year, where COBRA coverage arises either: • Because the Employee ceases to be eligible because of a reduction of hours; or • Because the Employee's Dependent ceases to satisfy the eligibility requirements for coverage. For all other individuals (for example, Employees who cease to be eligible because of retirement, termination of employment, or layoff), Contributions for COBRA coverage for Limited Scope Health FSA Benefits shall be paid on an after-tax basis, unless permitted otherwise by the Plan Administrator in its sole discretion on a uniform and consistent basis, but may not be prepaid from Contributions in one Plan Year to provide coverage that extends into a subsequent Plan Year. C.10 Qualifed Reservist Distribution If a Participant meets all of the following conditions, the Participant may elect to receive a qualified reservist distribution from the Limited Scope Health FSA: • The Participant's Contributions to the Limited Scope Health FSA for the Plan Year as of the date the qualified reservist distribution is requested exceeds the reimbursements the Participant has received from the Limited Scope Health FSA for the Plan Year as of that date. • The Participant is ordered or called to active military duty for a period of at least 180 days or for an indefinite period by reason of being a member of the Army National Guard of the United States, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard of the United States, the Air Force Reserve, the Coast Guard Reserve, or the Reserve Corps of the Public Health Service. • The Participant has provided the Plan Administrator with a copy of the order or call to active duty. An order or call to active duty of less than 180 days' duration must be supplemented by subsequent calls or orders to reach a total of 180 or more days. • The Participant is ordered or called to active military duty on or after April 1, 2009, or the Participant's period of active duty begins before April 1, 2009 and continues on or after the date. 58 • During the period beginning on the date of the Participant's order or call to active duty and ending on the last day of the Plan Year during which the order or call occurred, the Participant submits a qualified reservist distribution election form to the Plan Administrator. Amount of Qualified Reservist Distribution. If the above conditions are met,the Participant will receive a distribution from the Limited Scope Health FSA equal to his or her Contributions to the Limited Scope Health FSA for the Plan Year as of the date of the distribution request, minus any reimbursements received for the Plan Year as of that date. No Reimbursement for Expenses Incurred After Distribution Request. Once a Participant requests a qualified reservist distribution, the Participant forfeits the right to receive reimbursements for Health Care Expenses incurred during the period that begins on the date of the distribution request and ends on the last day of the Plan Year. The Participant may, however, continue to submit claims for Health Care Expenses that were incurred before the date of the distribution request (even if the claims are submitted after the date of the qualified reservist distribution), so long as the total dollar amount of the claims does not exceed the amount of the Limited Scope Health FSA election for the Plan Year, minus the sum of the qualified reservist distribution and the prior Limited Scope Health FSA reimbursements for the Plan Year. Tax Treatment of a Qualified Reservist Distribution. If the Participant receives a qualified reservist distribution, it will be included in his or her gross income and will be reported as wages on the Participant's Form W-2 for the year in which it is paid. C.11 Named Fiduciary The Plan Administrator is the Named Fiduciary. C.12 Coordination of Benefits The Limited Scope Health FSA is intended to pay Benefits solely for Limited Scope Health Care Expenses not previously reimbursed or reimbursable elsewhere. Accordingly, the Limited Scope Health FSA shall not be considered a group health plan for coordination of benefits purposes, and the Limited Scope Health FSA shall not be taken into account when determining benefits payable under any other plan. 59 Schedule D Dependent Care Assistance Program Unless otherwise specified, terms capitalized in this Schedule D shall have the same meaning as the defined terms in the Plan Document to which this Schedule is attached. D.1 Benefits An Employee can elect to participate in the DCAP to receive Benefits in the form of reimbursements for Dependent Care Expenses. If elected, the Benefit Option will be funded by the Participant on a pre-tax Salary Reduction basis. Unless an exception applies, as described in the Irrevocability of Elections and Exceptions section above, such election is irrevocable for the duration of the Period of Coverage to which it relates. D.2 Benefit Contributions The annual Contribution for a Participant's DCAP Benefits is equal to the annual Benefit amount elected by the Participant, subject to the Maximum Benefits paragraph below. D.3 Eligible Dependent Care Expenses Under the DCAP, a Participant may receive reimbursement for Dependent Care Expenses incurred during the Period of Coverage or Grace Period for which an election is in force. • Incurred. A Dependent Care Expense is "incurred" at the time the Qualifying Dependent Care Service giving rise to the expense is provided, and not when the Participant is formally billed for, is charged for, or pays for the Qualifying Dependent Care Services. • Dependent Care Expenses. Dependent Care Expenses means expenses that are considered to be: o Employment-related expenses under Code §21(b)(2) relating to expenses for the care of a Qualifying Individual necessary for gainful employment of the Employee and Spouse; and o Expenses for incidental household services, if incurred by the Employee to obtain Qualifying Dependent Care Services, but only to the extent that the Participant or other person incurring the expense is not reimbursed for the expense through any other Plan. If only a portion of a Dependent Care Expense has been reimbursed elsewhere, the DCAP can reimburse the remaining portion of such Expense if it otherwise meets the requirements of this Schedule. • Qualifying Individual. A Qualifying Individual is: o A tax dependent of the Participant as defined in Code §152 who is under the age of 13 and who is the Participant's qualifying child as defined in Code §152(a)(1); 60 o A tax dependent of the Participant as defined in Code §152, who is physically or mentally incapable of self-care and who has the same principal place of abode as the Participant for more than half of the year; or o A Participant's Spouse, as defined in Code §152, who is physically or mentally incapable of self-care, and who has the same principal place of abode as the Participant for more than half of the year. In the case of divorced or separated parents, a child shall be treated as a Qualifying Individual of the custodial parent within the meaning of Code §152(e). • Qualifying Dependent Care Services. Qualifying Dependent Care Services means services that both: o Relate to the care of a Qualifying Individual that enable the Participant and Spouse to remain gainfully employed after the date of participation in the DCAP and during the Period of Coverage; and o Are performed: ■ In the Participant's home; or ■ Outside the Participant's home for: ➢ The care of a Participant's Dependent who is under age 13; or ➢ The care of any other Qualifying Individual who regularly spends at least 8 hours per day in the Participant's household. In addition, if the expenses are incurred for services provided by a facility that provides care for more than six individuals not residing at the facility and that receives a fee, payment or grant for such services, then the facility must comply with all applicable state and local laws and regulations. • Exclusions. Dependent Care Expenses do not include amounts paid to or for: o An individual with respect to whom a personal exemption is allowable under Code §151(c) to a Participant or Participant's Spouse; o A Participant's Spouse; o A Participant's child, as defined in Code §152(f)(I), who is under 19 years of age at the end of the year in which the expenses were incurred; and o A Participant's Spouse's child, as defined in Code §152 (a)(i), who is under 19 years of age at the end of the year in which the expenses were incurred. 61 D.4 Maximum And Minimum Benefits • Maximum Reimbursement Available and Statutory Limits. The maximum dollar amount elected by the Participant for reimbursement of Dependent Care Expenses incurred during a Period of Coverage shall only be available during the Period of Coverage to the extent of the actual amounts credited to the Participant's DCAP less amounts debited to the Participant's DCAP pursuant to the Maximum Contribution paragraph below. Payment shall be made to the Participant as reimbursement for Dependent Care Expenses incurred during the Period of Coverage for which the Participant's election is effective, provided that the other requirements of this Section have been satisfied. No reimbursement otherwise due to a Participant hereunder shall be made to the extent that such reimbursement, when combined with the total amount of reimbursements made to date for the Plan Year, would exceed the year to date amount of Participant Contributions to the DCAP for the Period of Coverage or applicable statutory limit. • Maximum Dollar Limits. The maximum dollar limit for a Participant is the smallest of the following amounts: o The Participant's Earned Income for the calendar year; o The Earned Income for the calendar year of the Participant's Spouse who: ■ Is not employed during a month in which the Participant incurs a Dependent Care Expense; and ■ Is either physically or mentally incapable of self-care or a full-time Student shall be deemed to have Earned Income in the amount of $250 per month per Qualifying Individual for whom the Participant incurs Dependent Care Expenses, up to a maximum amount of$500 per month); or o $5,000 for the calendar year, if: ■ The Participant is married and files a joint federal income tax return; or ■ The Participant is married, files a separate federal income tax return, and meets the following conditions: ➢ The Participant maintains as his or her home a household that constitutes, for more than half of the taxable year, the principal abode of a Qualifying Individual; ➢ The Participant furnishes over half of the cost of maintaining such household during the taxable year; and ➢ During the last six months of the taxable year, the Participant's Spouse is not a member of such household; or ■ The Participant is single or is the head of the household for federal income tax purposes. 62 o $2,500 for the calendar year if the Participant is married and resides with the Spouse, but files a separate federal income tax return. • Changes. For subsequent Plan Years, the maximum and minimum dollar limit may be changed by the Plan Administrator and shall be communicated to Employees through the Salary Reduction Agreement or another document. • No Proration. If a Participant enters the Plan mid-year or wishes to increase his or her election mid-year as permitted under this Plan, then the Participant may elect coverage or increase coverage respectively, up to the maximum annual benefit amount stated above. The maximum annual benefit amount will not be prorated. • Effect on Maximum Benefits If Election Change Permitted. Any change in an election affecting annual Contributions to the DCAP component will also change the maximum reimbursement Benefits for the balance of the Period of Coverage commencing with the election change effective date. Such maximum reimbursement Benefits for the balance of the Period of Coverage shall be calculated by adding: o The aggregate Contribution for the period prior to such election change;to o The total Contribution for the remainder of such Period of Coverage to the DCAP; reduced by o All reimbursements made during the entire Period of Coverage. D.5 Establishment of Account The Plan Administrator will establish and maintain a DCAP with respect to each Participant who has elected to participate in the DCAP, but will not create a separate fund or otherwise segregate assets for this purpose. The account so established will merely be a record keeping account with the purpose of keeping track of Contributions and determining forfeitures. • Crediting of Accounts. A Participant's DCAP will be credited following each Salary Reduction actually made during each Period of Coverage with an amount equal to the Salary Reduction actually made. • Debiting of Accounts. A Participant's DCAP will be debited during each Period of Coverage for any reimbursement of Dependent Care Expenses incurred during the Period of Coverage. • Available Amount is Based on Credited Amount. The amount available for reimbursement of Dependent Care Expenses may not exceed the year-to-date amount credited to the Participant's DCAP, less any prior reimbursements. A Participant's DCAP may not have a negative balance during a Period of Coverage. D.6 Grace Period and Unused Year End Balance • Grace Period. The Employer has the discretion to establish a grace period following the end of the Plan Year as follows. If a Participant has unused funds in his or her DCAP at the end of the Plan Year, such Participant is allowed to carry over the unused balance for reimbursement of 63 Dependent Care Expenses incurred during the Grace Period. Unused funds in a Participant's DCAP may not be used to reimburse another Benefit Option the Participant may have elected. The Grace Period shall begin immediately following the end of the Plan Year and terminate on the 15th day of the third calendar month after the end of the Plan Year. • Use It or Lose It Rule. Except for expenses incurred in an applicable Grace Period, if any balance remains in the Participant's DCAP after all reimbursements have been made for the Period of Coverage, it shall not be carried over to reimburse the Participant for Dependent Care Expenses incurred during the subsequent Plan Year. The Participant shall forfeit all rights with respect to such balance. • Use of Forfeiture. All forfeitures shall be used by the Plan in the following ways: o To offset any losses experienced by the Employer during the Plan Year as a result of making reimbursements with respect to all Participants in excess of the Contributions paid by such Participant through Salary Reduction; and o To reduce the cost of administering the DCAP during the Plan Year or the subsequent Plan Year(all such administrative costs shall be documented by the Plan Administrator). • Unclaimed Benefits. Any DCAP Benefit payments that are unclaimed by the close of the Plan Year following the Period of Coverage or Grace Period in which the Dependent Care Expense was incurred shall be forfeited and applied as described above. D.7 Reimbursement Procedure • Timing. Within 30 days after receipt by the Plan Administrator of a reimbursement claim from a Participant, the Employer will reimburse the Participant for the Participant's Dependent Care Expenses or the Plan Administrator will notify the Participant that a claim has been denied. This time period may be extended an additional 15 days for matters beyond the control of the Plan Administrator, including in cases where a reimbursement claim is incomplete. The Plan Administrator will provide written notice of any extension, including the reasons for the extension, and will allow the Participant 45 days from receipt of the written notice in which to complete an incomplete reimbursement claim. • Claims Substantiation. A Participant who has elected to receive DCAP Benefits for a Period of Coverage may apply for reimbursement by completing, signing, and returning an application to the Plan Administrator by no later than the date set by the Plan Administrator each year, setting forth: o The person or persons on whose behalf Dependent Care Expenses have been incurred; o The nature and date of the expenses incurred; o The amount of the requested reimbursement; o The name of the person, organization or entity to whom the expense was or is to be paid; 64 o A statement that such expenses have not otherwise been reimbursed and the Participant will not seek reimbursement through any other source; o The Participant's certification that he or she has no reason to believe that the reimbursement refunded, added to other reimbursements to date will exceed the limit herein; and o Other such details about the expenses that may be requested by the Plan Administrator. The Participant shall include bills, invoices, or other statements from an independent third party showing that the Dependent Care Expenses have been incurred and the amounts of such expenses, together with any additional documentation that the Plan Administrator may request. Except for the final reimbursement claim for a Period of Coverage, no claims for reimbursement may be made when the aggregate claim for reimbursement is at least$25. • Claims Denied. For appeals of claims that are denied, see the Appeals Procedure in the Plan Document. D.8 Reimbursements After Termination If a Participant's employment terminates, the Participant may submit for reimbursement Dependent Care Expenses incurred after the date of termination through the end of the plan year up to the amount of the Participant's remaining DCAP Benefits. D.9 DCAP Participant vs. Claiming the Dependent Care Tax Credit Employees often have the choice between participating in their employer's DCAP on a Salary Reduction basis or taking a Dependent Care Tax Credit under Code §21. Employees cannot take advantage of both tax benefit options. Employees with questions regarding which option is best should consult with an accountant. 65 EXHIBIT B Commuter Plan for the Employees of the County of Fresno Plan Document Commuter Plan Originally Established January 1, 2003 Plan Document Effective January 1, 2016 Commuter Plan for the Employees of the County of Fresno Plan Document Table of Contents Section Title Page Section1 Introduction........................................................................................................................3 Section 2 General Information ...........................................................................................................4 Section 3 Benefit Options and Method of Funding............................................................................6 Section 4 Eligibility and Participation .................................................................................................8 Section 5 Commuter Benefit Options............................................................................................... 10 Section 6 Claims and Appeals...........................................................................................................12 Section 7 Plan Administration ..........................................................................................................15 Section 8 Amendment or Termination of the Plan...........................................................................17 Section 9 General Provisions............................................................................................................ 18 Glossary ..........................................................................................................................................21 Appendix A Exclusions—Commuter Expenses That Are Not Reimbursable........................................23 2 1 P a g e Section 1 Introduction 1.1 Establishment of the Plan County of resno the "Employer") originally established the County of resno Commuter Plan the "Plan") on January 1, 200S County of resno hereby creates an official Ian document for the Plan effective January 1, 2016 (the "Effective Date"). 1.2 Purpose of the Plan This Plan allows an Employee to participate in the following Benefit Options: • Van Pooling; • Mass Transit; and • Parking. 1.3 Legal Status This Plan is intended to qualify as a "commuter plan" under the Code §132 and regulations issued thereunder and shall be interpreted to accomplish that objective. 1.4 Capitalized Terms Many of the terms used in this document begin with a capital letter. These terms have special meaning under the Plan and are defined in the Glossary at the end of this document or in other relevant Sections. When reading the provisions of the Plan, please refer to the Glossary at the end of this document. Becoming familiar with the terms defined there will provide a better understanding of the procedures and Benefits described. 3 1 P a g e Section 2 General Information Name of the Plan County of Fresno Commuter Plan Name of Employer County of Fresno Address of Plan 2220 Tulare Street, 141h Floor, Fresno, CA 93721 Plan Administrator County of Fresno Plan Sponsor and its IRS County of Fresno Employer Identification 94-6000512 Number Named Fiduciary&Agent for County of Fresno Service of Legal Process Type of Administration The Plan is administered by the Plan Administrator with Benefits provided in accordance with the provisions of the County of Fresno Commuter Plan. It is not financed by an insurance company and Benefits are not guaranteed by a contract of insurance. The County of Fresno may hire a third party to perform some of its administrative duties such as claim payments and enrollment. Plan Effective Date Commuter Plan Document created effective January 1, 2016 Originally established January 1, 2003. Internal Revenue Code and It is intended that this Plan meet all applicable requirements of the Other Federal Compliance Internal Revenue Code of 1986 (the "Code") and other federal regulations. In the event of any conflict between this Plan and the Code or other federal regulations, the provisions of the Code and the federal regulations shall be deemed controlling, and any conflicting part of this Plan shall be deemed superseded to the extent of the conflict. Discretionary Authority The Plan Administrator shall perform its duties as the Plan Administrator and in its sole discretion, shall determine the appropriate courses of action in light of the reason and purpose for which this Plan is established and maintained. In particular, the Plan Administrator shall have full and sole discretionary authority to interpret all Plan documents, and make all interpretive and factual determinations as to whether any individual is entitled to receive any Benefit under the terms of this Plan. Any construction of the terms of any Plan document and any determination of fact adopted by the Plan Administrator shall be final and legally binding on all parties. Any interpretation shall be subject to review only 4 1 P a g e if it is arbitrary, capricious, or otherwise an abuse of discretion. Any review of a final decision or action of the Plan Administrator shall be based only on such evidence presented to or considered by the Plan Administrator at the time it made the decision that is the subject of review. Accepting any Benefits or making any claim for Benefits under this Plan constitutes agreement with and consent to any decisions that the Plan Administrator makes in its sole discretion and further constitutes agreement to the limited standard and scope of review described by this Section. Claims Administrator As of January 1, 2015, the Claims Administrator is Application Software Inc. The Claims Administrator is subject to change as determined by the Employer. 5 1 P a g e Section 3 Benefit Options and Method of Funding 3.1 Benefits Offered Each Employee may elect to participate in one or more of the following Benefits: • Van Pooling; • Mass Transit; and/or • Parking. Benefits under the Plan shall not be provided in the form of deferred Compensation. 3.2 Employer and Participant Contributions • Employer Contributions. The Employer may, but is not required to, contribute to any of the Benefit Options. • Participant Contributions. The Employer shall withhold from a Participant's Compensation by Salary Reduction on a pre-tax basis, an amount equal to the Contributions required for the Benefits elected by the Participant under the Salary Reduction Agreement. The maximum amount of Salary Reductions shall not exceed the aggregate cost of the Benefits elected. 3.3 Computing Salary Reduction Contributions • Salary Reductions per Pay Period. The Participant's Salary Reduction is an amount equal to: o The monthly election for such Benefits payable on a per pay period basis; o An amount otherwise agreed upon between the Employer and the Participant; or o An amount deemed appropriate by the Plan Administrator. (Example: in the event of a shortage of reducible Compensation, amounts withheld and the Benefits to which Salary Reductions are applied may fluctuate.) • Salary Reductions Considered Employer Contributions for Certain Purposes. Salary Reductions to pay for the Participant's share of the Contributions for Benefit Options elected for purposes of this Plan and the Code are considered Employer Contributions. 3.4 Funding This Plan • Benefits Paid from General Assets. All of the amounts payable under this Plan shall be paid from the general assets of the Employer. Nothing herein will be construed to require the Employer nor the Plan Administrator to maintain any fund or to segregate any amount for the Participant's benefit. Neither the Participant, nor any other person, shall have any claim against, right to, or security or other interest in any fund, account or asset of the Employer from which any payment under this Plan may be made. There is no trust or other fund from which Benefits 6 1 P a g e are paid. While the Employer has complete responsibility for the payment of Benefits out of its general assets, it may hire a third party administrator to perform some of its administrative duties such as claims payments and enrollment. • Participant Bookkeeping Account. While all Benefits are to be paid from the general assets of the Employer, the third party administrator will keep a bookkeeping account in the name of each Participant on behalf of the Employer. The bookkeeping account is used to track allocation and payment of Plan Benefits. On behalf of the Plan Administrator, the third party administrator will establish and maintain under each Participant's bookkeeping account a subaccount for each Benefit Option elected by each Participant. Maximum Contributions. The maximum Contributions that may be made under this Plan for the Participant are the total of the maximums that may be elected for the benefits offered under the Plan as determined by the County of Fresno. Additionally, the maximum contributions can not exceed the maximum contribution determined by the federal government. The current maximum contribution is $250.00 per month for parking, and there is no minimum contribution limit. The current maximum contribution is $130.00 per month for van pooling and mass transit (separate or combined), and there is no minimum contribution limit. 7 1 P a g e Section 4 Eligibility and Participation 4.1 Eligibility to Participate An individual is eligible to participate in this Plan if such individual meets the definition of Employee as set forth in the Glossary. Eligibility requirements to participate in the individual Benefit Options may vary from the eligibility requirements to participate in this Plan. 4.2 Required Salary Reduction Agreement To participate in the Commuter Plan, an Employee must complete, sign and return to the Plan Administrator a Salary Reduction Agreement designated by the Plan Administrator. If an Employee fails to return a Salary Reduction Agreement,the Employee is deemed to have elected cash. The Employee may begin participation on the 1st of the month following the date on which the Employee has met the Plan's eligibility requirements and submitted a Salary Reduction Agreement. The date an Employee's coverage begins depends on the date the Salary Reduction Agreement is received: • If the Salary Reduction Agreement is received on or before the 151h of the month, the Employee's Coverage Period will begin on the 1st of the month following receipt of the agreement. (Example: Agreement is received on March 151h, the Employee's coverage period will begin April 1" ) • If the Salary Reduction Agreement is received after the 15th of the month, the Employee's Coverage Period will begin on the 1st of the second month following receipt of the agreement. (Example: Agreement is received on March 16th, the Employee's coverage period will begin May V.) 4.3 Termination of Participation A Participant will terminate participation in this Plan upon the earlier of: • The end of the month in which the Employee's coverage period terminates due to the Employee's change of election to $0 (Changes of Election are addressed in further detail in Section 4.4). • The termination of this Plan; or • The date on which the Employee ceases to be an Employee because of retirement, termination of employment, layoff, reduction in hours, or any other reason. 8 1 P a g e False or Fraudulent Claims. If the Claims Administrator believes that false or fraudulent claims have been submitted, the Claims Administrator will investigate the submitted claims and forward, with all investigational findings, to the County of Fresno for further investigation. In the interim, the Claims Administrator will deny your claim and notify you that your account has been placed on hold until the situation has been resolved. The County of Fresno will make a decision as to whether your participation will be terminated in Pre-Tax Commuter plan. The County of Fresno has the authority to deny claims found to be false or fraudulent and to terminate your participation in the Pre-Tax Commuter plan in accordance with its discretionary duty as the Plan Administrator. The County of Fresno may take legal or disciplinary action against a member found to have committed fraud. Termination of participation in this Plan will automatically revoke the Participant's participation in the elected Benefit Options, according to the terms thereof. 4.4 Change of Election A Participant's election under the Plan may be changed on a monthly basis. Effective Date of New Election. Participation will begin on the 1st of the month following the date on which the Employee has met the Plan's eligibility requirements and submitted a Salary Reduction Agreement. The date an Employee's coverage begins depends on the date the Salary Reduction Agreement is received: • If the Salary Reduction Agreement is received on or before the 15t" of the month, the Employee's Coverage Period will begin on the 15t of the month following receipt of the agreement. (Example: Agreement is received on March 15t", the Employee's coverage period will begin April V ) • If the Salary Reduction Agreement is received after the 151" of the month, the Employee's Coverage Period will begin on the Vt of the second month following receipt of the agreement. (Example: Agreement is received on March 16t", the Employee's coverage period will begin May V ) Changes. For subsequent Plan Years, the maximum and minimum dollar limit may be changed by the Plan Administrator or the federal government and shall be communicated to Employees through the Salary Reduction Agreement, Summary Plan Description, or other document. 4.5 Failure To Elect If an Employee fails to complete, sign and return a Salary Reduction Agreement or fails to complete an election using the electronic system (if any) provided by the Employer within the time described in the Elections paragraphs as discussed immediately above, then the Employee will be deemed to have elected to receive his or her entire Compensation in cash. FQ 9 1 P a g e Section 5 Commuter Benefit Options 5.1 Maximum Benefit for Van Pooling and Mass Transit Categories An employee can enroll in both the Van Pooling program and the mass transit portion of the Commuter Plan. However, the maximum combined benefit cannot currently exceed $130.00 per month and cannot exceed the federal maximum. 5.2 Van Pooling An Employee can enroll in the Van Pooling program and currently set aside up to $130.00 per month. The funds will be deducted from each paycheck. If the Employee's expenses change at any time, the Employee may change the deduction amount at any time by using the Claim Administrator's website to increase or decrease the deduction amount. 5.3 Mass Transit An Employee can enroll in the mass transit portion of the Commuter Plan and currently set aside up to $130.00 per month. This benefit option will cause the Employee to receive a monthly voucher in the requested preferred denomination for expenses incurred. The Claims Administrator will mail the voucher to the Employee's home each month. If the voucher program is not readily available for the mass transit system that the Employee uses, the Employee may use a restricted debit card program for the Employee's transit expenses. Such debit card will be provided to the Employee by the Claims Administrator. The Employee will only be reimbursed up to the amount deducted from the Employee's paycheck. Any requests above available funds will be carried forward until the Employer takes Employee's next contribution and will then be reimbursed automatically. 5.4 Parking The Employee may currently set aside up to $250.00 per month to pay for parking expenses incurred while the Employee is working. The maximum benefit cannot exceed the federal maximum. The Claims Administrator will provide details about how reimbursement is received if the Employee uses a garage that participates in the County of Fresno's Parking Program. If a garage that the Employee is using is not a participating garage, the Employee must submit a reimbursement request form and appropriate documentation in order to receive reimbursement. The Claims Administrator processes claims within one business day of receipt and issues payments the same day that claims are processed. 101 Page The Employee will only be reimbursed up to the amount deducted from the Employee's paycheck. Any requests above available funds will be carried forward until the Employer takes your next contribution and will then be reimbursed automatically. 111 Page Section 6 Claims and Appeals 6.1 Claims Under the Plan If a claim for reimbursement is wholly or partially denied, or if the Participant is denied a Benefit under the Plan regarding the Participant's coverage under the Plan,then the claims procedure described below will apply. 6.2 Notice from the Claims Administrator If a claim is denied in whole or in part, the Claims Administrator will notify the Participant in writing within 30 days of the date that the Claims Administrator received the claim. This time may be extended for an additional 15 days for matters beyond the control of the Claims Administrator, including cases where a claim is incomplete. The Claims Administrator will provide written notice of any extension, including the reason(s)for the extension and the date a decision by the Claims Administrator is expected to be made. When a claim is incomplete,the extension notice will also specifically describe the required information, and will allow the Participant at least 45 days from receipt of the notice to provide the specified information, and will have the effect of suspending the time for a decision on the claim until the specified information is provided. Notification of a denied claim will include: • The specific reasons for the denial; • The specific Plan provisions on which the denial is based; • A description of any additional material or information necessary to validate the claim and an explanation of why such material or information is necessary; and • Appropriate information on the steps to take to appeal the Claims Administrator's adverse benefits determination, including the right to submit written comments and have them considered, and the right to review, upon request and at no charge, relevant documents and other information, and the right to file suit, where applicable, with respect to any adverse benefits determination after the final appeal of the claim. 6.3 First Level Appeal to the Claims Administrator If a claim is denied in whole or in part, the Participant, or the Participant's authorized representative, may request a review of the adverse benefits determination upon written application to the Claims Administrator. The Participant, or the Participant's authorized representative, may request access to all relevant documents in order to evaluate whether to request review of an adverse benefits determination and, if review is requested,to prepare for such review. An appeal of an adverse benefits determination must be made in writing within 30 days upon receipt of the notice that the claim was denied. If an appeal is not made within the above referenced timeframe all rights to appeal the adverse benefits determination and to file suit in court will be forfeited. A written appeal should include: additional documents, written comments, and any other information in support of the appeal. The review of the adverse benefits determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. 121Page 6.4 The Claims Administrator Action on Appeal The Claims Administrator, within a reasonable time, but no later than 60 days after receipt of the request for review, will decide the appeal. The Claims Administrator may, in its discretion, hold a hearing on the denied claim. If the decision on review affirms the initial denial of the claim, a notice will be provided which sets forth: • The specific reasons for the decision on review; • The specific Plan provisions on which the decision is based; • A statement regarding the right to review, upon request and at no charge, relevant documents and other information. If an "internal rule, guideline, protocol, or other similar criterion" is relied on in making the decision on review, a description of the specific rule, guideline, protocol, or other similar criterion or a statement that such a rule, guideline, protocol, or other similar criterion was relied on and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge upon request; and • Appropriate information on the steps to take to appeal the Claims Administrator's adverse benefits determination, including the right to submit written comments and have them considered, and the right to review, upon request and at no charge, relevant documents and other information, and the right to file suit, where applicable, with respect to any adverse benefits determination after the final appeal of the claim. 6.5 Second and Final Level Appeal to the Plan Administrator Participant may file an appeal of the denial in writing to the Plan Administrator within 20 days of the postmark date of the notice of denial of the first level appeal. Appeal must contain how the employee may be contacted (mailing address, telephone number, etc.), a written summary of events, applicable claims, and any additional documentation participant desires to provide to support his/her position. The Plan Administrator will conduct an internal review of the appeal and provide a written notice of the decision to the participant and the third party administrator within 30 days of receiving the appeal. 6.6 Appeal Procedure for Eligibility or Salary Reduction Issues If the Participant is denied a Benefit under the Plan due to questions regarding the Participant's eligibility or entitlement for coverage under the Plan or regarding the amount the Participant owes, the Participant may request a review upon written application to the Plan Administrator. The Participant, or the Participant's authorized representative, may request access to all relevant documents in order to evaluate whether to request review of an adverse benefits determination and if review is requested,to prepare for such review. An appeal of an adverse benefits determination must be made in writing within 20 days upon receipt of the notice that the claim was denied. If an appeal is not made within the above referenced timeframe all rights to appeal the adverse benefits determination and to file suit in court will be forfeited. A 131Page written appeal should include: additional documents, written comments, and any other information in support of the appeal. The review of the adverse benefits determination will take into account all new information, whether or not presented or available at the initial determination. No deference will be afforded to the initial determination. If the decision on review affirms the Plan Administrator's initial denial, the Participant may request a review of the adverse appeal determination upon written application to the Plan Administrator. The Final Level of Appeals Procedures described above will apply. 141 Page Section 7 Plan Administration 7.1 Plan Administrator The administration of this Plan shall be under the supervision of the Plan Administrator. It is the principal duty of the Plan Administrator to see that this Plan is carried out in accordance with the terms of the Plan document and for the exclusive benefit of persons entitled to participate in this Plan and without discrimination among them. 7.2 Powers of the Plan Administrator The Plan Administrator shall have such powers and duties as may be necessary or appropriate to discharge its functions hereunder. The Plan Administrator shall have final discretionary authority to make such decisions and all such determinations shall be final, conclusive and binding. The Plan Administrator shall have the exclusive right to interpret the Plan and to decide all matters hereunder. The Plan Administrator shall have the following discretionary authority: • To construe and interpret this Plan, including all possible ambiguities, inconsistencies and omissions in the Plan and related documents, and to decide all questions of fact, questions relating to eligibility and participation, and questions of Benefits under this Plan (provided that the Committee shall exercise such exclusive power with respect to an appeal of a claim); • To prescribe procedures to be followed and the forms to be used by Employees and Participants to make elections pursuant to this Plan; • To prepare and distribute information explaining this Plan and the Benefits under this Plan in such manner as the Plan Administrator determines to be appropriate; • To request and receive from all Employees and Participants such information as the Plan Administrator shall from time to time determine to be necessary for the proper administration of this Plan; • To furnish each Employee and Participant with such reports in relation to the administration of this Plan as the Plan Administrator determines to be reasonable and appropriate, including appropriate statements setting forth the amounts by which a Participant's Compensation has been reduced in order to provide Benefits under this Plan; • To receive, review and keep on file such reports and information concerning the Benefits covered by this Plan as the Plan Administrator determines from time to time to be necessary and proper; • To appoint and employ such individuals or entities to assist in the administration of this Plan as it determines to be necessary or advisable, including legal counsel and Benefit consultants; • To sign documents for the purposes of administering this Plan, or to designate an individual or individuals to sign documents for the purposes of administering this Plan; • To require such evidence as deemed necessary to decide any claim or appeal; and 15 • To maintain the books of accounts, records, and other data in the manner necessary for proper administration of this Plan and to meet any applicable disclosure and reporting requirements. 7.3 Reliance on Participant,Tables,etc. The Plan Administrator may rely upon the Participant's direction, information or election as being proper under the Plan and shall not be responsible for any act or failure to act because of a direction or lack of direction by the Participant. The Plan Administrator will also be entitled, to the extent permitted by law, to rely conclusively on all tables, valuations, certificates, opinions and reports that are furnished by accountants, attorneys, or other experts employed or engaged by the Plan Administrator. 7.4 Outside Assistance The Plan Administrator may employ such counsel, accountants, claims administrators, consultants, actuaries and other person or persons as the Plan Administrator shall deem advisable. The Plan shall pay the compensation of such counsel, accountants, and other person or persons and any other reasonable expenses incurred by the Plan Administrator in the administration of the Plan. Unless otherwise provided in the service agreement, obligations under this Plan shall remain the obligations of the Employer and the Plan Administrator. 7.5 Fiduciary Liability To the extent permitted by law, the Plan Administrator shall not incur any liability for any acts or for failure to act except for its own gross negligence, misconduct or willful breach of this Plan. 7.6 Compensation of Plan Administrator Unless otherwise determined by the Employer and permitted by law, any Plan Administrator that is also an employee of the Employer shall serve without compensation for services rendered in such capacity, but all reasonable expenses incurred in the performance of their duties shall be paid by the Employer. 7.7 Inability to Locate Payee If the Plan Administrator is unable to make payment to the Participant or another person to whom a payment is due under the Plan because it cannot ascertain the identity or whereabouts of the Participant or such other person after reasonable efforts have been made to identify or locate such person,then such payment and all subsequent payments otherwise due to the Participant or such other person shall be forfeited one year after the date any such payment first became due. 7.8 Effect of Mistake In the event of a mistake as to the eligibility or participation of an Employee, or the allocations made to the Participant's account, or the amount of Benefits paid or to be paid to the Participant or another person, the Plan Administrator shall, to the extent administratively possible and otherwise permissible under Code §132 or the regulations issued thereunder, correct by making the appropriate adjustments of such amounts as necessary to credit the Participant's account or such other person's account or withhold any amount due to the Plan or the Employer from Compensation paid by the Employer. 161 Page Section 8 Amendment or Termination of the Plan 8.1 Permanency While the Employer fully expects that this Plan will continue indefinitely, due to unforeseen, future business contingencies, permanency of the Plan will be subject to the Employer's right to amend or terminate the Plan, as provided in the paragraphs below. 8.2 Right to Amend The Employer reserves the right to merge or consolidate the Plan and to make any amendment or restatement to the Plan from time-to-time, including those which are retroactive in effect. Such amendments may be applicable to any Participant. Any amendment or restatement shall be deemed to be duly executed by the Employer when signed by the Chair of the Board of Supervisors, and attested by its Clerk to the Board of Supervisors. 8.3 Right to Terminate The Employer reserves the right to discontinue or terminate the Plan in whole or in part at any time without prejudice. This Plan may be terminated by the Employer. This Plan also shall terminate automatically if the Employer is legally dissolved, makes a general assignment for the benefit of its creditors, files for liquidation under the Bankruptcy Code, merges or consolidates with any other entity and it is not the surviving entity, or if it sells or transfers substantially all of its assets, unless the Employer's successor in interest agrees to assume the liabilities under this Plan as to the Participant and Dependents. 171 Page Section 9 General Provisions 9.1 Expenses All reasonable expenses incurred in administering the Plan are currently paid by forfeitures and then by the Employer. 9.2 No Contract of Employment Nothing contained in the Plan shall be construed as a contract of employment with the Employer or as a right of any Employee to be continued in the employment of the Employer, or as a limitation of the right of the Employer to discharge any Employee,with or without cause. 9.3 Compliance with Federal Mandates To the extent applicable for each Benefit Option, the Plan will provide Benefits in accordance with the requirements of all federal mandates. This Plan shall be construed, operated and administered accordingly, and in the event of any conflict between any part, clause or provision of this Plan and the Code, the provisions of the Code shall be deemed controlling, and any conflicting part, clause or provision of this Plan shall be deemed superseded to the extent of the conflict. 9.4 Verification The Plan Administrator shall be entitled to require reasonable information to verify any claim or the status of any person as an Employee. If the Participant does not supply the requested information within the applicable time limits or provide a release for such information, the Participant will not be entitled to Benefits under the Plan. 9.5 Limitation of Rights Nothing appearing in or done pursuant to the Plan shall be held or construed: • To give any person any legal or equitable right against the Employer, any of its employees, or persons connected therewith, except as provided by law; or • To give any person any legal or equitable right to any assets of the Plan or any related trust, except as expressly provide herein or as provided by law. 9.6 Non-Assignability of Rights The right of any Participant to receive any reimbursement under this Plan shall not be alienable by the participant by assignment or any other method and shall not be subject to claims by the Participant's creditors by any process whatsoever. Any attempt to cause such right to be so subjected will not be recognized, except to the extent required by law. 181 Page 9.7 Governing Law This Plan is intended to be construed, and all rights and duties hereunder are governed, in accordance with the laws of the State of California, except to the extent such laws are preempted by any federal law. 9.8 Severability If any provision of the Plan is held invalid or unenforceable, its validity or unenforceability shall not affect any other provision of the Plan, and the Plan shall be construed and enforced as if such provision had not been included herein. 9.9 Captions The captions contained herein are inserted only as a matter of convenience and for reference and in no way define, limit, enlarge or describe the scope or intent of the Plan nor in any way shall affect the Plan or the construction of any provision thereof. 9.10 Federal Tax Disclaimer To ensure compliance with requirements imposed by the IRS to the extent this Plan Document or any Schedule contains advice relating to a federal tax issue, it is not intended or written to be used, and it may not be used, for the purpose of avoiding any penalties that may be imposed on the Participant or any other person or entity under the Internal Revenue Code or promoting, marketing or recommending to another party any transaction or matter addressed herein. 9.11 No Guarantee of Tax Consequences Neither the Plan Administrator nor the Employer make any commitment or guarantee that any amounts paid to the Participant or for the Participant's benefit under this Plan will be excludable from the Participant's gross income for federal, state or local income tax purposes. It shall be the Participant's obligation to determine whether each payment under this Plan is excludable from the Participant's gross income for federal, state and local income tax purposes, and to notify the Plan Administrator if the Participant has any reason to believe that such payment is not so excludable. 9.12 Indemnification of Employer If the Participant receives one or more payments or reimbursements under this Plan on a pre-tax Salary Reduction basis, and such payments do not qualify for such treatment under the Code, the Participant shall indemnify and reimburse the Employer for any liability the Employer may incur for failure to withhold federal income taxes, Social Security taxes, or other taxes from such payments or reimbursements. 191 Page IN WITNESS WHEREOF, and as conclusive evidence of the adoption of the foregoing instrument comprising the County of Fresno Commuter Plan, the County of Fresno has caused this Plan to be executed in its name and on its behalf, on this day of , 2015. The County of Fresno By: Its: Attest: Its: 201Page Glossary Capitalized terms used in the Plan have the following meanings: Benefit or Benefits means the Benefit Options offered under the Plan. Benefit Option means a qualified transportation benefit under Code §132 that is offered under this Plan. Commuter Plan means the County of Fresno Commuter Plan as set forth herein and as amended from time to time. Code means the Internal Revenue Code of 1986, as amended. Compensation means the wages or salary paid to an Employee by the Employer, determined prior to: any Salary Reduction election under this Plan; any Salary Reduction election under any other cafeteria plan; any compensation reduction under any Code §132(f)(4) plan; and any salary deferral elections under any Code §§401(k),408(k) or 457(b) Plan or arrangement. Contribution means the amount contributed to pay for the cost of Benefits as calculated under the Benefit Options. Effective Date of this Plan Document shall be January 1, 2016. Employee means an individual who is benefit eligible; and has been employed by the Employer for 90 or more days, counting the Participant's employment commencement date as the first day. The following classes of employees cannot participate in the County of Fresno Commuter Plan: • Leased employees (as defined by§414(n) of the Code); • Contract workers and independent contractors; • Temporary employees, casual employees, and employees hired short-term to meet specific needs of the Employer whether or not such persons are on the Employer's W-2 payroll; • Individuals paid by a temporary or other employment or staffing agency; • Self-employed individuals; and • Any more than 2%shareholders of S corporations. Employer means the County of Fresno. Participant means a person who is an Employee and who is participating in this Plan in accordance with the provisions of the Eligibility and Participation Section. Participants include: (a) those that elect to receive Benefits under this Plan, and enroll for Salary Reductions to pay for such Benefits; and (b) those that elect instead to receive their full salary in cash and have not elected to participate in the Commuter Plan. 211 Page Period of Coverage means the consecutive months during which the Employee participates in the Commuter Plan contributes through a salary reduction. Plan means the County of Fresno Commuter Plan, as set forth herein and as amended from time to time. Plan Administrator means the County of Fresno. Salary Reduction means the amount by which the Participant's Compensation is reduced and applied by the Employer under this Plan to pay for one or more of the Benefit Options. Salary Reduction Agreement means the agreement, form(s) or Internet web site, which Employees use to elect one or more Benefit Options. The agreement and/or forms spell out the procedures used for allowing an Employee to participate in this Plan and will allow the Employee to elect Salary Reductions to pay for any Benefit Options offered under this Plan. 221Page Appendix A Exclusions—Expenses That Are Not Reimbursable The Plan Document contains the general rules governing what expenses are reimbursable under the Commuter Plan. This Appendix A, as referenced in the Plan Document, specifies certain expenses that are excluded under this Plan with respect to reimbursement from the Commuter Plan -- that is, expenses that are not reimbursable. • Any expenses that are not related to transportation used by the Employee to travel to the Employee's work location or mass transit location. • Any expenses that are not supported by third-party receipts. 231Page EXHIBIT C Flexible Spending Account Statistics Eligible Employees: 6,863 Total Participants: 1,724 Health and/or Dependent Care: 1,691 Parking and/or Transit: 33 2016 Claims Paid: 34,419 Debit Card: 28,263 Manual: 5,886 2016 Claim Payments: $1,709,000 2016 Administrative Fees: $49,501 EXHIBIT D AGT. # 14-616 1 FLEXIBLE SPENDING AND MASS TRANSIT ARID PARKING PLAN ADMINISTRATION 2 AGREEMENT 3 4 THIS AGREEMENT is made and entered into this 7th day of October, 2014, by and 5 between the COUNTY OF FRESNO, a Political Subdivision of the State of California, hereinafter 6 referred to as "COUNTY", and Application Software, Inc. dba ASIFlex whose address is 201 West 7 Broadway, Bldg. 4C, Columbia, Missouri, 65203, hereinafter referred to as "CONTRACTOR". 8 WITNESSETH: 9 WHEREAS, the COUNTY intends to maintain an employee benefit plan that includes 10 an "Employee Flexible Spending Account" as defined by Intemal Revenue Code Section 125, and 11 a "Mass Transit and Parking Plan", as defined by Internal Revenue Code section 132, hereinafter 12 called the "Plan", under which benefits may be acquired using pre-tax dollars by employees; and 13 WHEREAS, the COUNTY issued a request for proposal for the purpose of securing 14 said services; and 15 WHEREAS, the CONTRACTOR is engaged in the business of performing such 16 administrative services and responded to the request for proposal, 17 NOW, THEREFORE, it is agreed by both parties as follows: 18 COUNTY hereby engages CONTRACTOR, and CONTRACTOR hereby accepts 19 such engagement, to perform those services specified in this Agreement required in connection 20 with the operation of the Plan under the terms and subject to conditions provided in this 21 Agreement. In the performance of this Agreement, CONTRACTOR will utilize systems, practices 22 and procedures which recognize the specific features of the Plan. 23 1. OBLIGATIONS OF THE CONTRACTOR 24 A. CONTRACTOR shall provide the administrative system, to operate the 25 Plan, as described in this Agreement, in COUNTY's Request for Proposal No. 964-5279 26 attached hereto as Exhibit A and incorporated herein by reference, in CONTRACTOR's response 27 to COUNTY's Request for Proposal No. 964-5279, attached hereto as Exhibit B and incorporated 28 herein by reference. 1 B. CONTRACTOR shall provide the County with a "Plan Document" (the 2 formal document detailing requirements governing the COUNTY's Plan) and Summary Plan 3 Description (summarizes the Plan Document) compliant with all relevant Internal Revenue Service 4 regulations and other applicable laws. The initial Plan Document and Summary Plan Description 5 will be complete prior to January 1, 2015. Final document approval shall be made by the 6 COUNTY. 7 C. The CONTRACTOR shall receive requests for reimbursement; evaluate 8 them under the terms of the Plan, and issue reimbursement subject to availability of funds in each 9 participant's account, pursuant to a defined schedule on a daily basis. Interpretations of benefits 10 shall be governed by the Plan Document. The Plan Document may be amended only upon the 11 written approval of COUNTY. CONTRACTOR may not vary from Plan Document language 12 without the prior written approval of COUNTY, unless otherwise required by law. CONTRACTOR 13 shall provide immediate written notice to COUNTY of any legally required changes to the Plan 14 Document. 15 D. CONTRACTOR shall provide consulting services in regard to the design of 16 the Plan as well as advising COUNTY as reflected in paragraph H. 17 E. CONTRACTOR shall be responsible for enrollment of employees based 18 upon eligibility information supplied by COUNTY, the annual reenrollment, as well as enrollment of 19 new hires in the Flex Spending Accounts and Mass Transit and Parking Plan. New hires will be 20 initially enrolled by COUNTY and enrollment documents forwarded via electronic files to 21 CONTRACTOR on a biweekly basis. 22 F. CONTRACTOR shall maintain records of claims entered and claims paid 23 for each COUNTY participating employee and covered dependent. CONTRACTOR's obligation 24 to reimburse outstanding claims for the last Plan year of this Agreement shall survive the 25 expiration date of this Agreement for a period until all such claims are paid, not to exceed one- 26 hundred eighty (180) days. 27 G. CONTRACTOR shall provide monthly or other periodic reports as follows: 28 1) Participant: CONTRACTOR shall prepare and distribute the following -2- 1 to each participating COUNTY employee: 2 a. Quarterly Employee Statements, detailing quarterly account activity. 3 2) COUNTY: CONTRACTOR shall prepare and provide to COUNTY: 4 a. The fund account statements including monthly reconciliation 5 statements detailing the receipts and disbursements of the Plan; 6 b. Daily check listing, detailing the disbursements made by check 7 number; 8 c. Daily listing of reimbursements made by electronic funds transfer; and 9 d. The Participant Summary Report, detailing the current balance in 10 each participating employee's account. 11 Reports will be available no later than the first week of the month following the 12 end of the report period. 13 H. CONTRACTOR shall upon request consult with COUNTY regarding 14 management of the Plan and Improvements in benefit definition to facilitate Plan administration. 15 I. CONTRACTOR shall maintain duplicate data processing media in a 16 building separate from the building in which claims processing and data processing are performed 17 to provide continuity of operation in the event of fire or other casualty. 18 J. CONTRACTOR shall respond to all questions from COUNTY participating 19 employees concerning claims and the methods and procedures used to evaluate and pay claims 20 within seven (7) business days from receipt of the question. 21 K. All materials distributed to participants shall be reviewed and approved in 22 writing in advance by COUNTY, which approval shall not be unreasonably withheld. 23 L. CONTRACTOR shall furnish all forms and supplies required for the 24 processing of claims and enrollment and re-enrollment of COUNTY participating employees into 25 the Plan and shall pay all costs of such forms and supplies. Should the COUNTY provide any 26 such materials on behalf of the CONTRACTOR, the CONTRACTOR shall pay for all costs 27 associated therewith. 28 M. CONTRACTOR shall, consistent with industry standards, monitor and keep -3- 1 COUNTY informed of any pending or enacted legislation potentially impacting the Plan. 2 N. CONTRACTOR agrees to keep full and accurate records and shall follow 3 generally accepted industry accounting methods and practices. The COUNTY or its duly 4 authorized representatives shall have full and free access to said records during normal working 5 hours. 6 O. CONTRACTOR shall assist COUNTY by providing discrimination testing 7 as required by Internal Revenue Service Code Sections 125 and 129. Such assistance will be 8 provided as needed consistent with Internal Revenue Service requirements. 9 P. CONTRACTOR shall establish a Plan Deposit Account in trust for 10 COUNTY with COUNTY'S assistance. This account shall be used as a depository for funds to be 11 used only for CONTRACTOR's payments pursuant to the Plan and this Agreement. This account 12 shall be funded solely by COUNTY. COUNTY shall submit to CONTRACTOR for deposit, all plan 13 contributions into the Plan Deposit Account. COUNTY authorizes CONTRACTOR to make 14 withdrawals and other types of banking transactions from and to the Plan Deposit Account on 15 behalf of COUNTY but only for purposes stated in this Agreement. It shall be COUNTY'S 16 responsibility to maintain funds in the Plan Deposit Account sufficient to cover checks and 17 electronic funds transfer payments validly issued. All funds deposited by or on behalf of COUNTY 18 and any interest earnings from this account shall remain the property of COUNTY, subject to the 19 control and handling thereof by CONTRACTOR in accordance with the terms of this Agreement. 20 Q. CONTRACTOR shall administer medical spending accounts in accordance 21 with Internal Revenue Service Code Sections 125 and 162 for those individuals electing COBRA. 22 R. CONTRACTOR shall administer mass transit and parking accounts in 23 accordance with Internal Revenue Service Code Section 132. 24 S. CONTRACTOR shall develop the systems and procedures, including the 25 necessary personnel training, to begin payment of claims on the effective date of this Agreement. 26 T. CONTRACTOR shall abide by the terms of the Business Associate 27 Agreement, attached hereto as Exhibit D and incorporated herein by reference. 28 2. OBLIGATIONS OF THE COUNTY -4- 1 A. COUNTY shall provide timely notification of employee new hires and 2 terminations, and shall ensure that the Plan will be funded. COUNTY will provide all information 3 reasonably necessary for CONTRACTOR to properly administer the Plan to the best of its ability. 4 B. COUNTY shall abide by the terms of the Business Associate Agreement, 5 attached hereto as Exhibit D and incorporated herein by reference. 6 3. TERM 7 This Agreement shall become effective on the 1 st day of January, 2015 and 8 shall terminate on the 31st day of December, 2017. 9 4. RENEWAL 10 This Agreement shall automatically renew for an additional one (1) year period 11 except when written notice is delivered by either party to the other expressing intent not to renew. 12 Such notice must be delivered a minimum of sixty (60) days prior to the next expiration date of this 13 agreement. The maximum number of automatic one (1) year renewal periods under this 14 Agreement is two (2). 15 5. TERMINATION 16 A. Non-Allocation of Funds -The terms of this Agreement, and the services to 17 be provided thereunder, are contingent on the approval of funds by the appropriating government 18 agency. Should sufficient funds not be allocated, the services provided may be modified, or this 19 Agreement terminated, at any time by giving the CONTRACTOR thirty (30) days advance written 20 notice. 21 B. Breach of Contract-The COUNTY may immediately suspend or terminate 22 this Agreement in whole or in part, where in the determination of the COUNTY there is: 23 1) An illegal or improper use of funds; 24 2) A failure to comply with any term of this Agreement; 25 3) A substantially incorrect or incomplete report submitted to the 26 COUNTY; 27 4) Improperly performed service. 28 In no event shall any payment by the COUNTY constitute a waiver by the COUNTY -5- 1 of any breach of this Agreement or any default which may then exist on the part of the 2 CONTRACTOR. Neither shall such payment impair or prejudice any remedy available to the 3 COUNTY with respect to the breach or default. The COUNTY shall have the right to demand of 4 the CONTRACTOR the repayment to the COUNTY of any funds disbursed to the CONTRACTOR 5 under this Agreement, which in the judgment of the COUNTY were not expended in accordance 6 with the terms of this Agreement. The CONTRACTOR shall promptly refund any such funds upon 7 demand. 8 C. Without Cause - Under circumstances other than those set forth above, 9 this Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written 10 notice of an intention to terminate to CONTRACTOR. 11 6. COMPENSATION/INVOICING: COUNTY agrees to pay CONTRACTOR and 12 CONTRACTOR agrees to receive compensation as follows: COUNTY shall pay CONTRACTOR 13 administrative fees of one dollar and twenty-nine ($1.29) cents per participating employee enrolled 14 in the Dependent Care and/or Health Care Spending Account and one dollar and twenty-nine 15 ($1.29) cents per participating employee enrolled in the Mass Transit and Parking Plan, on a bi- 16 weekly basis, based on participants' bi-weekly election deduction. 17 In no event shall services performed under this Agreement be in excess of 18 $415,000 during the term of this Agreement, including renewal periods. It is understood that all 19 expenses incidental to CONTRACTOR'S performance of services under this Agreement shall be 20 borne by CONTRACTOR. 21 7. INDEPENDENT CONTRACTOR: In performance of the work, duties and 22 obligations assumed by CONTRACTOR under this Agreement, it is mutually understood and 23 agreed that CONTRACTOR, including any and all of the CONTRACTOR'S officers, agents, and 24 employees will at all times be acting and performing as an independent contractor, and shall act in 25 an independent capacity and not as an officer, agent, servant, employee, joint venturer, partner, or 26 associate of the COUNTY. Furthermore, COUNTY shall have no right to control or supervise or 27 direct the manner or method by which CONTRACTOR shall perform its work and function. 28 However, COUNTY shall retain the right to administer this Agreement so as to verify that -6- 1 CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof. 2 CONTRACTOR and COUNTY shall comply with all applicable provisions of 3 law and the rules and regulations, if any, of governmental authorities having jurisdiction over 4 matters the subject thereof. 5 Because of its status as an independent contractor, CONTRACTOR shall have 6 absolutely no right to employment rights and benefits available to COUNTY employees. 7 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its 8 employees all legally-required employee benefits. In addition, CONTRACTOR shall be solely 9 responsible and save COUNTY harmless from all matters relating to payment of 10 CONTRACTOR'S employees, including compliance with Social Security withholding and all other 11 regulations governing such matters. It is acknowledged that during the term of this Agreement, 12 CONTRACTOR may be providing services to others unrelated to the COUNTY or to this 13 Agreement. 14 8. MODIFICATION: Any matters of this Agreement may be modified from time 15 to time by the written consent of all the parties without, in any way, affecting the remainder. 16 9. NON-ASSIGNMENT: Neither party shall assign, transfer or sub-contract this 17 Agreement nor their rights or duties under this Agreement without the prior written consent of the 18 other party. 19 10. HOLD HARMLESS: CONTRACTOR agrees to indemnify, save, hold 20 harmless, and at COUNTY'S request, defend the COUNTY, its officers, agents, and employees 21 from any and all costs and expenses, damages, liabilities, claims, and losses occurring or 22 resulting to COUNTY in connection with the performance, or failure to perform, by 23 CONTRACTOR, its officers, agents, or employees under this Agreement, and from any and all 24 costs and expenses, damages, liabilities, claims, and losses occurring or resulting to any person, 25 firm, or corporation who may be injured or damaged by the performance, or failure to perform, 26 of CONTRACTOR, its officers, agents, or employees under this Agreement. 27 11. INSURANCE 28 Without limiting the COUNTY's right to obtain indemnification from -7- I CONTRACTOR or any third parties, CONTRACTOR, at its sole expense, shall maintain in full 2 force and effect, the following insurance policies or a program of self-insurance, including but not 3 limited to, an insurance pooling arrangement or Joint Powers Agreement (JPA) throughout the 4 term of the Agreement: 5 A. Commercial General Liability 6 Commercial General Liability Insurance with limits of not less than One 7 Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars 8 ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require 9 specific coverages including completed operations, products liability, contractual liability, 10 Explosion-Collapse-Underground, fire legal liability or any other liability insurance deemed 11 necessary because of the nature of this contract. 12 B. Automobile Liability 13 Comprehensive Automobile Liability Insurance with limits for bodily injury of 14 not less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred 15 Thousand Dollars ($500,000.00) per accident and for property damages of not less than Fifty 16 Thousand Dollars ($50,000.00), or such coverage with a combined single limit of Five Hundred 17 Thousand Dollars ($500,000.00). Coverage should include owned and non-owned vehicles used 18 in connection with this Agreement. 19 C. Professional Liability 20 If CONTRACTOR employs licensed professional staff, (e.g., Ph,D., R.N., 21 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less 22 than One Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) 23 annual aggregate. 24 D. Worker's Compensation 25 A policy of Worker's Compensation insurance as may be required by the 26 California Labor Code. 27 CONTRACTOR shall obtain endorsements to the Commercial General Liability 28 insurance naming the County of Fresno, its officers, agents, and employees, individually and -s- 1 collectively, as additional insured, but only insofar as the operations under this Agreement are 2 concerned. Such coverage for additional insured shall apply as primary insurance and any other 3 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be 4 excess only and not contributing with insurance provided under CONTRACTOR's policies herein. 5 This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance 6 written notice given to COUNTY. 7 Within Thirty (30) days from the date CONTRACTOR signs and executes this 8 Agreement, CONTRACTOR shall provide certificates of insurance and endorsement as stated 9 above for all of the foregoing policies, as required herein, to the County of Fresno, Paul Nerland, 10 2220 Tulare Street, 14th Floor, Fresno, CA 93721, stating that such insurance coverage have 11 been obtained and are in full force; that the County of Fresno, its officers, agents and employees 12 will not be responsible for any premiums on the policies; that such Commercial General Liability 13 insurance names the County of Fresno, its officers, agents and employees, individually and 14 collectively, as additional insured, but only insofar as the operations under this Agreement are 15 concerned; that such coverage for additional insured shall apply as primary insurance and any 16 other insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, 17 shall be excess only and not contributing with insurance provided under CONTRACTOR's policies 18 herein; and that this insurance shall not be cancelled or changed without a minimum of thirty (30) 19 days advance, written notice given to COUNTY. 20 In the event CONTRACTOR fails to keep in effect at all times insurance 21 coverage as herein provided, the COUNTY may, in addition to other remedies it may have, 22 suspend or terminate this Agreement upon the occurrence of such event. 23 All policies shall be issued by admitted insurers licensed to do business in the 24 State of California, and such insurance shall be purchased from companies possessing a current 25 A.M. Best, Inc. rating of A FSC VII or better. 26 12. AUDITS AND INSPECTIONS: The CONTRACTOR shall at any time during 27 business hours, and as often as the COUNTY may deem necessary, make available to the 28 COUNTY for examination all of its records and data with respect to the matters covered by this -9- 1 Agreement. The CONTRACTOR shall, upon request by the COUNTY, permit the COUNTY to 2 audit and inspect all of such records and data necessary to ensure CONTRACTOR'S compliance 3 with the terms of this Agreement. 4 If this Agreement exceeds ten thousand dollars ($10,000,00), CONTRACTOR 5 shall be subject to the examination and audit of the Auditor General for a period of three (3) years 6 after final payment under contract (Government Code Section 8546.7). 7 13. NOTICES: The persons and their addresses having authority to give and 8 receive notices under this Agreement include the following: 9 COUNTY CONTRACTOR 10 Paul Nerland John M. Riddick COUNTY OF FRESNO Application Software, Inc. dba ASIFlex 11 2220 Tulare Street, 14th Floor 201 West Broadwav, Bldq. 4C Fresno, CA 93721 Columbia, MO 65203 12 Any and all notices between the COUNTY and the CONTRACTOR provided 13 for or permitted under this Agreement or by law shall be in writing and shall be deemed duly 14 served when personally delivered to one of the parties, or in lieu of such personal services, when 15 deposited in the United States Mail, postage prepaid, addressed to such party. 16 14. GOVERNING LAW: Venue for any action arising out of or related to this 17 Agreement shall only be in Fresno County, California. 18 The rights and obligations of the parties and all interpretation and performance 19 of this Agreement shall be governed in all respects by the laws of the State of California. 20 15, DISCLOSURE OF SELF-DEALING TRANSACTIONS 21 This provision is only applicable if the CONTRACTOR is operating as a 22 corporation (a for-profit or non-profit corporation) or if during the term of the agreement, the 23 CONTRACTOR changes its status to operate as a corporation. 24 Members of the CONTRACTOR' Board of Directors shall disclose any self- 25 dealing transactions that they are a party to while CONTRACTOR is providing goods or 26 performing services under this agreement. A self-dealing transaction shall mean a transaction 27 to which the CONTRACTOR is a party and in which one or more of its directors has a material 28 financial interest. Members of the Board of Directors shall disclose any self-dealing -10- 1 transactions that they are a party to by completing and signing a Self-Dealing Transaction 2 Disclosure Form, attached hereto as Exhibit C and incorporated herein by reference, and 3 submitting it to the COUNTY prior to commencing with the self-dealing transaction or 4 immediately thereafter. 5 16. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement 6 between the CONTRACTOR and COUNTY with respect to the subject matter hereof and 7 supersedes all previous Agreement negotiations, proposals, commitments, writings, 8 advertisements, publications, and understanding of any nature whatsoever unless expressly 9 included in this Agreement. In the event of any inconsistency in interpreting the documents which 10 constitute this Agreement, the inconsistency shall be resolved by giving precedence in the 11 following order of priority: (1) the text of this Agreement (excluding Exhibits A, B, C and D); (2) the 12 COUNTY'S Request for Proposal No. 964-5279 (Exhibit A); and (3) the CONTRACTOR'S 13 proposal made in response to COUNTY'S Request for Proposal No. 964-5279 (Exhibit B). 14 15 16 17 18 19 2© 21 22 23 24 25 26 27 28 -11- 1 2 3 4 IN WITNESS WHEREOF, the parties hereto have executed this Agreement 5 as of the day and year first hereinabove written. 6 CON;tOw COUNTY OF FRESfVO 7 �~'v uthorized Signature) Chairman, of Supervisors 8 Q hri M. I _ 5 ATTEST: Print Name &Title BERNICE E.SEIDEL,Clerk 10 ffi L j 16 Board of Supervisors 11 U52,03 By ut p Y 12 Mailing Address F 13 DATE: DATE: I 14 REVIEWED & RECOMMENDED FOR APPROVAL 15 ep rtment Head' ignatur 16 17 APPROVED AS TO LEGAL FO APPROVED AS TO ACCOUNTING FORM 18C--- Courf.y Counsel Auditor-Controller s er-Tax Collector 19 20 FOR ACCOUNTING USE ONLY: 21 ORG No.: Various Orgs Account No.: 6600 22 Requisition No.: 8921400158 23 FCMC 06/11 DOCUMENT6 24 25 26 27 28 -12- EXHIBIT E 1 AGREEMENT 2 3 THIS AGREEMENT is made and entered into this day of [Month] , [Year] , by 4 and between the COUNTY OF FRESNO, a Political Subdivision of the State of California, 5 hereinafter referred to as "COUNTY", and [Contractor] , a (Type of business) (Note to County 6 staff: Type of business the contractor is; such as a corporation — including the state in which they 7 are incorporated, e.g., a California corporation; a partnership; a private, non-profit corporation; or a 8 sole proprietorship), whose address is "[Contractor's Address]" , hereinafter referred to as 9 "CONTRACTOR". 10 WITNESSETH: 11 (Add WHEREAS Clauses) (Note to County staff: explains the need/purpose for the contract and 12 the process by which the Contractor was chosen) 13 NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions herein 14 contained, the parties hereto agree as follows: 15 1. OBLIGATIONS OF THE CONTRACTOR 16 A. 17 B. (etc.) 18 2. OBLIGATIONS OF THE COUNTY 19 A. 20 B. (etc.) 21 3. TERM 22 The term of this Agreement shall be for a period of three (3) years, 23 commencing on (Effective Date) through and including (Last day of three year period) . This 24 Agreement may be extended for two (2) additional consecutive twelve (12) month periods upon 25 written approval of both parties no later than thirty (30) days prior to the first day of the next twelve 26 (12) month extension period. The (Title of department head) or his or her designee is authorized 27 to execute such written approval on behalf of COUNTY based on CONTRACTOR'S satisfactory 28 performance. -1- 1 4. TERMINATION 2 A. Non-Allocation of Funds - The terms of this Agreement, and the services to 3 be provided hereunder, are contingent on the approval of funds by the appropriating government 4 agency. Should sufficient funds not be allocated, the services provided may be modified, or this 5 Agreement terminated, at any time by giving the CONTRACTOR thirty (30) days advance written 6 notice. 7 B. Breach of Contract - The COUNTY may immediately suspend or terminate 8 this Agreement in whole or in part, where in the determination of the COUNTY there is: 9 1) An illegal or improper use of funds; 10 2) A failure to comply with any term of this Agreement; 11 3) A substantially incorrect or incomplete report submitted to the 12 COUNTY; 13 4) Improperly performed service. 14 In no event shall any payment by the COUNTY constitute a waiver by the COUNTY 15 of any breach of this Agreement or any default which may then exist on the part of the 16 CONTRACTOR. Neither shall such payment impair or prejudice any remedy available to the 17 COUNTY with respect to the breach or default. The COUNTY shall have the right to demand of 18 the CONTRACTOR the repayment to the COUNTY of any funds disbursed to the CONTRACTOR 19 under this Agreement, which in the judgment of the COUNTY were not expended in accordance 20 with the terms of this Agreement. The CONTRACTOR shall promptly refund any such funds upon 21 demand. 22 C. Without Cause - Under circumstances other than those set forth above, 23 this Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written 24 notice of an intention to terminate to CONTRACTOR. 25 5. COMPENSATION/INVOICING: (Note to County staff: If sales taxis 26 applicable and to be paid to an out-of-state vendor, it must be separated from the total 27 compensation and the vendor must have a California Sales Tax Permit Number.) COUNTY 28 agrees to pay CONTRACTOR and CONTRACTOR agrees to receive compensation as follows- -2- 1 "[Enter compensation]" . CONTRACTOR shall submit monthly invoices in triplicate to the County 2 of Fresno "[Enter Department Name]" . 3 In no event shall services performed under this Agreement be in excess of 4 "[Enter maximum contract amount]" during the term of this Agreement. It is understood that all 5 expenses incidental to CONTRACTOR'S performance of services under this Agreement shall be 6 borne by CONTRACTOR. (Note to County staff: If the number of days within which payment 7 must be made is specified, this paragraph must provide for payment after a minimum of forty-five 8 (45) days from date of receipt of invoice by the COUNTY.) 9 6. INDEPENDENT CONTRACTOR: In performance of the work, duties and 10 obligations assumed by CONTRACTOR under this Agreement, it is mutually understood and 11 agreed that CONTRACTOR, including any and all of the CONTRACTOR'S officers, agents, and 12 employees will at all times be acting and performing as an independent contractor, and shall act in 13 an independent capacity and not as an officer, agent, servant, employee, joint venturer, partner, or 14 associate of the COUNTY. Furthermore, COUNTY shall have no right to control or supervise or 15 direct the manner or method by which CONTRACTOR shall perform its work and function. 16 However, COUNTY shall retain the right to administer this Agreement so as to verify that 17 CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof. 18 CONTRACTOR and COUNTY shall comply with all applicable provisions of 19 law and the rules and regulations, if any, of governmental authorities having jurisdiction over 20 matters the subject thereof. 21 Because of its status as an independent contractor, CONTRACTOR shall have 22 absolutely no right to employment rights and benefits available to COUNTY employees. 23 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its 24 employees all legally-required employee benefits. In addition, CONTRACTOR shall be solely 25 responsible and save COUNTY harmless from all matters relating to payment of 26 CONTRACTOR'S employees, including compliance with Social Security withholding and all other 27 regulations governing such matters. It is acknowledged that during the term of this Agreement, 28 CONTRACTOR may be providing services to others unrelated to the COUNTY or to this -3- 1 Agreement. 2 7. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 3 A. The parties to this Agreement shall be in strict conformance with all 4 applicable Federal and State of California laws and regulations, including but not limited to 5 Sections 5328, 10850, and 14100.2 et seq. of the Welfare and Institutions Code, Sections 6 2.1 and431.300 et seq. of Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the 7 California Civil Code, Sections 11977 and 11812 of Title 22 of the California Code of Regulations, 8 and the Health Insurance Portability and Accountability Act (HIPAA), including but not limited to 9 Section 1320 D et seq. of Title 42, United States Code (USC) and its implementing regulations, 10 including, but not limited to Title 45, CFR, Sections 142, 160, 162, and 164, The Health 11 Information Technology for Economic and Clinical Health Act (HITECH) regarding the 12 confidentiality and security of patient information, and the Genetic Information Nondiscrimination 13 Act (GINA) of 2008 regarding the confidentiality of genetic information. 14 Except as otherwise provided in this Agreement, CONTRACTOR, as a 15 Business Associate of COUNTY, may use or disclose Protected Health Information (PHI) to 16 perform functions, activities or services for or on behalf of COUNTY, as specified in this 17 Agreement, provided that such use or disclosure shall not violate the Health Insurance Portability 18 and Accountability Act (HIP AA), USC 1320d et seq. The uses and disclosures of PHI may not be 19 more expansive than those applicable to COUNTY, as the "Covered Entity" under the HIP AA 20 Privacy Rule ( 45 CFR 164.500 et seq.), except as authorized for management, administrative or 21 legal responsibilities of the Business Associate. 22 B. CONTRACTOR, including its subcontractors and employees, shall protect, 23 from unauthorized access, use, or disclosure of names and other identifying information, including 24 genetic information, concerning persons receiving services pursuant to this Agreement, except 25 where permitted in order to carry out data aggregation purposes for health care operations [45 26 CFR Sections 164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)] This pertains to any 27 and all persons receiving services pursuant to a COUNTY funded program. This requirement 28 applies to electronic PHI. CONTRACTOR shall not use such identifying information or genetic -4- 1 information for any purpose other than carrying out CONTRACTOR' s obligations under this 2 Agreement. 3 C. CONTRACTOR, including its subcontractors and employees, shall not 4 disclose any such identifying information or genetic information to any person or entity, except as 5 otherwise specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164 6 or other law, required by the Secretary, or authorized by the client/patient in writing. In using or 7 disclosing PHI that is permitted by this Agreement or authorized by law, CONTRACTOR shall 8 make reasonable efforts to limit PHI to the minimum necessary to accomplish intended purpose of 9 use, disclosure or request. 10 D. For purposes of the above sections, identifying information shall include, 11 but not be limited to name, identifying number, symbol, or other identifying particular assigned to 12 the individual, such as finger or voice print, or photograph. 13 E. For purposes of the above sections, genetic information shall include 14 genetic tests of family members of an individual or individual, manifestation of disease or disorder 15 of family members of an individual, or any request for or receipt of, genetic services by individual 16 or family members. Family member means a dependent or any person who is first, second, third, 17 or fourth degree relative. 18 F. CONTRACTOR shall provide access, at the request of COUNTY, and in 19 the time and manner designated by COUNTY, to PHI in a designated record set (as defined in 45 20 CFR Section 164.501), to an individual or to COUNTY in order to meet the requirements of 45 21 CFR Section 164.524 regarding access by individuals to their PHI. With respect to individual 22 requests, access shall be provided within thirty (30) days from request. Access may be extended if 23 CONTRACTOR cannot provide access and provides individual with the reasons for the delay and 24 the date when access may be granted. PHI shall be provided in the form and format requested by 25 the individual or COUNTY. 26 CONTRACTOR shall make any amendment(s) to PHI in a designated record 27 set at the request of COUNTY or individual, and in the time and manner designated by COUNTY 28 in accordance with 45 CFR Section 164.526. -5- 1 CONTRACTOR shall provide to COUNTY or to an individual, in a time and 2 manner designated by COUNTY, information collected in accordance with 45 CFR Section 3 164.528, to permit COUNTY to respond to a request by the individual for an accounting of 4 disclosures of PHI in accordance with 45 CFR Section 164.528. 5 G. CONTRACTOR shall report to COUNTY, in writing, any knowledge or 6 reasonable belief that there has been unauthorized access, viewing, use, disclosure, security 7 incident, or breach of unsecured PHI not permitted by this Agreement of which it becomes aware, 8 immediately and without reasonable delay and in no case later than two (2) business days of 9 discovery. Immediate notification shall be made to COUNTY's Information Security Officer and 10 Privacy Officer and COUNTY's DPH HIPAA Representative, within two (2) business days of 11 discovery. The notification shall include, to the extent possible, the identification of each individual 12 whose unsecured PHI has been, or is reasonably believed to have been, accessed, acquired, 13 used, disclosed, or breached. CONTRACTOR shall take prompt corrective action to cure any 14 deficiencies and any action pertaining to such unauthorized disclosure required by applicable 15 Federal and State Laws and regulations. CONTRACTOR shall investigate such breach and is 16 responsible for all notifications required by law and regulation or deemed necessary by COUNTY 17 and shall provide a written report of the investigation and reporting required to COUNTY's 18 Information Security Officer and Privacy Officer and COUNTY's DPH HIPAA Representative. This 19 written investigation and description of any reporting necessary shall be postmarked within the 20 thirty (30) working days of the discovery of the breach to the addresses below: 21 County of Fresno County of Fresno County of Fresno 22 Dept. of Public Health Dept. of Public Health Dept. of Internal Services 23 HIP AA Representative Privacy Officer Information Security Officer 24 (559) 600-6439 (559) 600-6405 (559) 600-5800 25 P.O. Box 11867 P.O. Box 11867 2048 N. Fine Street 26 Fresno, CA 93775 Fresno, CA 93775 Fresno, CA 93727 27 H. CONTRACTOR shall make its internal practices, books, and records 28 relating to the use and disclosure of PHI received from COUNTY, or created or received by the -6- 1 CONTRACTOR on behalf of COUNTY, in compliance with HIPAA's Privacy Rule, including, but 2 not limited to the requirements set forth in Title 45, CFR, Sections 160 and 164. CONTRACTOR 3 shall make its internal practices, books, and records relating to the use and disclosure of PHI 4 received from COUNTY, or created or received by the CONTRACTOR on behalf of COUNTY, 5 available to the United States Department of Health and Human Services (Secretary) upon 6 demand. 7 CONTRACTOR shall cooperate with the compliance and investigation reviews 8 conducted by the Secretary. PHI access to the Secretary must be provided during the 9 CONTRACTOR's normal business hours, however, upon exigent circumstances access at any 10 time must be granted. Upon the Secretary's compliance or investigation review, if PHI is 11 unavailable to CONTRACTOR and in possession of a Subcontractor, it must certify efforts to 12 obtain the information to the Secretary. 13 I. Safeguards 14 CONTRACTOR shall implement administrative, physical, and technical 15 safeguards as required by the HIP AA Security Rule, Subpart C of 45 CFR 164, that reasonably 16 and appropriately protect the confidentiality, integrity, and availability of PHI, including electronic 17 PHI, that it creates, receives, maintains or transmits on behalf of COUNTY and to prevent 18 unauthorized access, viewing, use, disclosure, or breach of PHI other than as provided for by this 19 Agreement. CONTRACTOR shall conduct an accurate and thorough assessment of the potential 20 risks and vulnerabilities to the confidential, integrity and availability of electronic PHI. 21 CONTRACTOR shall develop and maintain a written information privacy and security program 22 that includes administrative, technical and physical safeguards appropriate to the size and 23 complexity of CONTRACTOR's operations and the nature and scope of its activities. Upon 24 COUNTY' s request, CONTRACTOR shall provide COUNTY with information concerning such 25 safeguards. 26 CONTRACTOR shall implement strong access controls and other security 27 safeguards and precautions in order to restrict logical and physical access to confidential, 28 personal (e.g., PHI) or sensitive data to authorized users only. Said safeguards and precautions -7- 1 shall include the following administrative and technical password controls for all systems used to 2 process or store confidential, personal, or sensitive data: 3 1) Passwords must not be: 4 a. Shared or written down where they are accessible or recognizable by anyone else; 5 such as taped to computer screens, stored under keyboards, or visible in a work 6 area; 7 b. A dictionary word; or 8 c. Stored in clear text 9 2) Passwords must be: 10 a. Eight (8) characters or more in length; 11 b. Changed every ninety (90) days; 12 c. Changed immediately if revealed or compromised; and 13 d. Composed of characters from at least three (3) of the following four (4) groups from 14 the standard keyboard: 15 (1) Upper case letters (A-Z); 16 (2) Lowercase letters (a-z); 17 (3) Arabic numerals (0 through 9); and 18 (4) Non-alphanumeric characters (punctuation symbols). 19 CONTRACTOR shall implement the following security controls on each 20 workstation or portable computing device (e.g., laptop computer) containing confidential, personal, 21 or sensitive data: 22 1) Network-based firewall and/or personal firewall; 23 2) Continuously updated anti-virus software; and 24 3) Patch management process including installation of all operating 25 system/software vendor security patches. 26 CONTRACTOR shall utilize a commercial encryption solution that has received 27 FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable 28 electronic media (including, but not limited to, compact disks and thumb drives) and on portable -8- 1 computing devices (including, but not limited to, laptop and notebook computers). 2 CONTRACTOR shall not transmit confidential, personal, or sensitive data via 3 e-mail or other internet transport protocol unless the data is encrypted by a solution that has been 4 validated by the National Institute of Standards and Technology (NIST) as conforming to the 5 Advanced Encryption Standard (AES) Algorithm. CONTRACTOR must apply appropriate 6 sanctions against its employees who fail to comply with these safeguards. CONTRACTOR must 7 adopt procedures for terminating access to PHI when employment of employee ends. 8 J. Mitigation of Harmful Effects 9 CONTRACTOR shall mitigate, to the extent practicable, any harmful effect that 10 is suspected or known to CONTRACTOR of an unauthorized access, viewing, use, disclosure, or 11 breach of PHI by CONTRACTOR or its subcontractors in violation of the requirements of these 12 provisions. CONTRACTOR must document suspected or known harmful effects and the outcome. 13 K. CONTRACTOR' s Subcontractors 14 CONTRACTOR shall ensure that any of its contractors, including 15 subcontractors, if applicable, to whom CONTRACTOR provides PHI received from or created or 16 received by CONTRACTOR on behalf of COUNTY, agree to the same restrictions, safeguards, 17 and conditions that apply to CONTRACTOR with respect to such PHI and to incorporate, when 18 applicable, the relevant provisions of these provisions into each subcontract or sub-award to such 19 agents or subcontractors. 20 L. Employee Training and Discipline 21 CONTRACTOR shall train and use reasonable measures to ensure 22 compliance with the requirements of these provisions by employees who assist in the 23 performance of functions or activities on behalf of COUNTY under this Agreement and use or 24 disclose PHI and discipline such employees who intentionally violate any provisions of these 25 provisions, including termination of employment. 26 M. Termination for Cause 27 Upon COUNTY' s knowledge of a material breach of these provisions by 28 CONTRACTOR, COUNTY shall either: -9- 1 1) Provide an opportunity for CONTRACTOR to cure the breach or end 2 the violation and terminate this Agreement if CONTRACTOR does not cure the breach or end the 3 violation within the time specified by COUNTY; or 4 2) Immediately terminate this Agreement if CONTRACTOR has 5 breached a material term of these provisions and cure is not possible. 6 3) If neither cure nor termination is feasible, the COUNTY's Privacy 7 Officer shall report the violation to the Secretary of the U.S. Department of Health and Human 8 Services. 9 N. Judicial or Administrative Proceedings 10 COUNTY may terminate this Agreement in accordance with the terms and 11 conditions of this Agreement as written hereinabove, if: (1) CONTRACTOR is found guilty in a 12 criminal proceeding for a violation of the HIP AA Privacy or Security Laws or the HITECH Act; or 13 (2) a finding or stipulation that the CONTRACTOR has violated a privacy or security standard or 14 requirement of the HITECH Act, HIP AA or other security or privacy laws in an administrative or 15 civil proceeding in which the CONTRACTOR is a party. 16 O. Effect of Termination 17 Upon termination or expiration of this Agreement for any reason, 18 CONTRACTOR shall return or destroy all PHI received from COUNTY (or created or received by 19 CONTRACTOR on behalf of COUNTY) that CONTRACTOR still maintains in any form, and shall 20 retain no copies of such PHI. If return or destruction of PHI is not feasible, it shall continue to 21 extend the protections of these provisions to such information, and limit further use of such PHI to 22 those purposes that make the return or destruction of such PHI infeasible. This provision shall 23 apply to PHI that is in the possession of subcontractors or agents, if applicable, of 24 CONTRACTOR. If CONTRACTOR destroys the PHI data, a certification of date and time of 25 destruction shall be provided to the COUNTY by CONTRACTOR. 26 P. Disclaimer 27 COUNTY makes no warranty or representation that compliance by 28 CONTRACTOR with these provisions, the HITECH Act, HIP AA or the HIP AA regulations will be -10- 1 adequate or satisfactory for CONTRACTOR's own purposes or that any information in 2 CONTRACTOR's possession or control, or transmitted or received by CONTRACTOR, is or will 3 be secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR is solely 4 responsible for all decisions made by CONTRACTOR regarding the safeguarding of PHI. 5 Q. Amendment 6 The parties acknowledge that Federal and State laws relating to electronic data 7 security and privacy are rapidly evolving and that amendment of these provisions may be required 8 to provide for procedures to ensure compliance with such developments. The parties specifically 9 agree to take such action as is necessary to amend this agreement in order to implement the 10 standards and requirements of HIP AA, the HIP AA regulations, the HITECH Act and other 11 applicable laws relating to the security or privacy of PHI. COUNTY may terminate this Agreement 12 upon thirty (30) days written notice in the event that CONTRACTOR does nor enter into an 13 amendment providing assurances regarding the safeguarding of PHI that COUNTY in its sole 14 discretion, deems sufficient to satisfy the standards and requirements of HIP AA, the HIP AA 15 regulations and the HITECH Act. 16 R. No Third-Party Beneficiaries 17 Nothing express or implied in the terms and conditions of these provisions is 18 intended to confer, nor shall anything herein confer, upon any person other than COUNTY or 19 CONTRACTOR and their respective successors or assignees, any rights, remedies, obligations or 20 liabilities whatsoever. 21 S. Interpretation 22 The terms and conditions in these provisions shall be interpreted as broadly as 23 necessary to implement and comply with HIP AA, the HIP AA regulations and applicable State 24 laws. The parties agree that any ambiguity in the terms and conditions of these provisions shall be 25 resolved in favor of a meaning that complies and is consistent with HIP AA and the HIP AA 26 regulations. 27 T. Regulatory References 28 A reference in the terms and conditions of these provisions to a section in the -11- 1 HIPAA regulations means the section as in effect or as amended. 2 U. Survival 3 The respective rights and obligations of CONTRACTOR as stated in this 4 Section shall survive the termination or expiration of this Agreement. 5 V. No Waiver of Obligations 6 No change, waiver or discharge of any liability or obligation hereunder on any 7 one or more occasions shall be deemed a waiver of performance of any continuing or other 8 obligation, or shall prohibit enforcement of any obligation on any other occasion. 9 8. MODIFICATION: Any matters of this Agreement maybe modified from time 10 to time by the written consent of all the parties without, in any way, affecting the remainder. 11 9. NON-ASSIGNMENT: Neither party shall assign, transfer or sub-contract this 12 Agreement nor their rights or duties under this Agreement without the prior written consent of the 13 other party. 14 10. HOLD HARMLESS: CONTRACTOR agrees to indemnify, save, hold 15 harmless, and at COUNTY'S request, defend the COUNTY, its officers, agents, and employees 16 from any and all costs and expenses, damages, liabilities, claims, and losses occurring or 17 resulting to COUNTY in connection with the performance, or failure to perform, by 18 CONTRACTOR, its officers, agents, or employees under this Agreement, and from any and all 19 costs and expenses, damages, liabilities, claims, and losses occurring or resulting to any person, 20 firm, or corporation who may be injured or damaged by the performance, or failure to perform, 21 of CONTRACTOR, its officers, agents, or employees under this Agreement. 22 11. INSURANCE 23 Without limiting the COUNTY's right to obtain indemnification from 24 CONTRACTOR or any third parties, CONTRACTOR, at its sole expense, shall maintain in full 25 force and effect, the following insurance policies or a program of self-insurance, including but not 26 limited to, an insurance pooling arrangement or Joint Powers Agreement (JPA) throughout the 27 term of the Agreement: 28 -12- 1 A. Commercial General Liability 2 Commercial General Liability Insurance with limits of not less than One 3 Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars 4 ($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require 5 specific coverages including completed operations, products liability, contractual liability, 6 Explosion-Collapse-Underground, fire legal liability or any other liability insurance deemed 7 necessary because of the nature of this contract. 8 B. Automobile Liability 9 Comprehensive Automobile Liability Insurance with limits for bodily injury of 10 not less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred 11 Thousand Dollars ($500,000.00) per accident and for property damages of not less than Fifty 12 Thousand Dollars ($50,000.00), or such coverage with a combined single limit of Five Hundred 13 Thousand Dollars ($500,000.00). Coverage should include owned and non-owned vehicles used 14 in connection with this Agreement. 15 C. Professional Liability 16 If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., 17 L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less 18 than One Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) 19 annual aggregate. 20 D. Worker's Compensation 21 A policy of Worker's Compensation insurance as may be required by the 22 California Labor Code. 23 CONTRACTOR shall obtain endorsements to the Commercial General Liability 24 insurance naming the County of Fresno, its officers, agents, and employees, individually and 25 collectively, as additional insured, but only insofar as the operations under this Agreement are 26 concerned. Such coverage for additional insured shall apply as primary insurance and any other 27 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be 28 excess only and not contributing with insurance provided under CONTRACTOR's policies herein. -13- 1 This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance 2 written notice given to COUNTY. 3 Within Thirty (30) days from the date CONTRACTOR signs and executes this 4 Agreement, CONTRACTOR shall provide certificates of insurance and endorsement as stated 5 above for all of the foregoing policies, as required herein, to the County of Fresno, (Name and 6 Address of the official who will administer this contract), stating that such insurance coverage have 7 been obtained and are in full force; that the County of Fresno, its officers, agents and employees 8 will not be responsible for any premiums on the policies; that such Commercial General Liability 9 insurance names the County of Fresno, its officers, agents and employees, individually and 10 collectively, as additional insured, but only insofar as the operations under this Agreement are 11 concerned; that such coverage for additional insured shall apply as primary insurance and any 12 other insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees, 13 shall be excess only and not contributing with insurance provided under CONTRACTOR's policies 14 herein; and that this insurance shall not be cancelled or changed without a minimum of thirty (30) 15 days advance, written notice given to COUNTY. 16 In the event CONTRACTOR fails to keep in effect at all times insurance 17 coverage as herein provided, the COUNTY may, in addition to other remedies it may have, 18 suspend or terminate this Agreement upon the occurrence of such event. 19 All policies shall be issued by admitted insurers licensed to do business in the 20 State of California, and such insurance shall be purchased from companies possessing a current 21 A.M. Best, Inc. rating of A FSC VI or better. 22 12. AUDITS AND INSPECTIONS: The CONTRACTOR shall at any time during 23 business hours, and as often as the COUNTY may deem necessary, make available to the 24 COUNTY for examination all of its records and data with respect to the matters covered by this 25 Agreement. The CONTRACTOR shall, upon request by the COUNTY, permit the COUNTY to 26 audit and inspect all of such records and data necessary to ensure CONTRACTOR'S compliance 27 with the terms of this Agreement. 28 If this Agreement exceeds ten thousand dollars ($10,000.00), CONTRACTOR -14- 1 shall be subject to the examination and audit of the Auditor General for a period of three (3) years 2 after final payment under contract (Government Code Section 8546.7). 3 13. NOTICES: The persons and their addresses having authority to give and 4 receive notices under this Agreement include the following: 5 COUNTY CONTRACTOR COUNTY OF FRESNO (click here to enter Contractor] 6 (click here to enter Countv Address] (click here to enter Contractor Address] (click here to enter Countv Address] (click here to enter Contractor Address]7 [click here to enter County City/State] [click here to enter Contractor City/State] 8 All notices between the COUNTY and CONTRACTOR provided for or 9 permitted under this Agreement must be in writing and delivered either by personal service, by 10 first-class United States mail, by an overnight commercial courier service, or by telephonic 11 facsimile transmission. A notice delivered by personal service is effective upon service to the 12 recipient. A notice delivered by first-class United States mail is effective three COUNTY business 13 days after deposit in the United States mail, postage prepaid, addressed to the recipient. A notice 14 delivered by an overnight commercial courier service is effective one COUNTY business day after 15 deposit with the overnight commercial courier service, delivery fees prepaid, with delivery 16 instructions given for next day delivery, addressed to the recipient. A notice delivered by 17 telephonic facsimile is effective when transmission to the recipient is completed (but, if such 18 transmission is completed outside of COUNTY business hours, then such delivery shall be 19 deemed to be effective at the next beginning of a COUNTY business day), provided that the 20 sender maintains a machine record of the completed transmission. For all claims arising out of or 21 related to this Agreement, nothing in this section establishes, waives, or modifies any claims 22 presentation requirements or procedures provided by law, including but not limited to the 23 Government Claims Act (Division 3.6 of Title 1 of the Government Code, beginning with section 24 810). 25 14. GOVERNING LAW: Venue for any action arising out of or related to this 26 Agreement shall only be in Fresno County, California. 27 The rights and obligations of the parties and all interpretation and performance 28 of this Agreement shall be governed in all respects by the laws of the State of California. -15- 1 15. DISCLOSURE OF SELF-DEALING TRANSACTIONS 2 This provision is only applicable if the CONTRACTOR is operating as a 3 corporation (a for-profit or non-profit corporation) or if during the term of the agreement, the 4 CONTRACTOR changes its status to operate as a corporation. 5 Members of the CONTRACTOR' Board of Directors shall disclose any self- 6 dealing transactions that they are a party to while CONTRACTOR is providing goods or 7 performing services under this agreement. A self-dealing transaction shall mean a transaction 8 to which the CONTRACTOR is a party and in which one or more of its directors has a material 9 financial interest. Members of the Board of Directors shall disclose any self-dealing 10 transactions that they are a party to by completing and signing a Self-Dealing Transaction 11 Disclosure Form, attached hereto as Exhibit A and incorporated herein by reference, and 12 submitting it to the COUNTY prior to commencing with the self-dealing transaction or 13 immediately thereafter. 14 16. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement 15 between the CONTRACTOR and COUNTY with respect to the subject matter hereof and 16 supersedes all previous Agreement negotiations, proposals, commitments, writings, 17 advertisements, publications, and understanding of any nature whatsoever unless expressly 18 included in this Agreement. [If applicable, add the following In the event of any inconsistency in 19 interpreting the documents which constitute this Agreement, the inconsistency shall be resolved 20 by giving precedence in the following order of priority: (1) the text of this Agreement (excluding 21 Attachment "A" the COUNTY'S Request for Quotation/Proposal No. "[Enter RFQ/RFP No.]" and 22 the CONTRACTOR'S Quote/Proposal in response thereto), (2) Attachment "A"; (3) the 23 COLINTY'S Request for Quotation/Proposal No. "[Enter RFQ/RFP No.]"; and (4) the 24 CONTRACTOR'S quotation/proposal made in response to COUNTY'S Request for 25 Quotation/Proposal No. "[Enter RFQ/RFP No.]".] 26 27 28 -16- 1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as 2 of the day and year first hereinabove written. 3 CONTRACTOR COUNTY OFFRESNO 4 (Authorized Signature) Gary E. Cornuelle 5 Purchasing Manager 6 Print Name &Title 7 8 9 Mailing Address 10 DATE: DATE: 11 REVIEWED & RECOMMENDED FOR APPROVAL 12 Department Head's Signature 13 14 APPROVED AS TO LEGAL FORM APPROVED AS TO ACCOUNTING FORM 15 County Counsel Auditor-Controller/Treasurer-Tax Collector 16 17 FOR ACCOUNTING USE ONLY: 18 ORG No.: [click to type type org] Account No.: [click to type type account] 19 Requisition No.: [click to type requisition number] 20 FCMC 10/12 21 GAEB\OTHER BENEFITS\FLEX SPENDING ACCOUNTS\RFPS\FSA RFP 2017\EXHIBITS\EXHIBIT E-MODEL COUNTY CONTRACT.DOCX 22 23 24 25 26 27 28 -17- 1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement 2 as of the day and year first hereinabove written. 3 CONTRACTOR COUNTY OFFRESNO 4 (Authorized Signature) Chairman, Board of Supervisors 5 6 Print Name &Title 7 8 9 Mailing Address 10 DATE: DATE: 11 REVIEWED & RECOMMENDED FOR APPROVAL 12 Department Head's Signature 13 14 APPROVED AS TO LEGAL FORM APPROVED AS TO ACCOUNTING FORM 15 County Counsel Auditor-Controller/Treasurer-Tax Collector 16 17 FOR ACCOUNTING USE ONLY: 18 ORG No.: [click to type type org] Account No.: [click to type type account] 19 Requisition No.: [click to type requisition number] 20 FCMC 06/11 GAEB\OTHER BENEFITS\FLEX SPENDING ACCOUNTS\RFPS\FSA RFP 2017\EXHIBITS\EXHIBIT E-MODEL COUNTY CONTRACT.DOCX 21 22 23 24 25 26 27 28 -18- Exhibit F co U Eff Date: FLEXIBLE SPENDING ACCOUNTS RcvdBy: O 1856 O FRES5 2017 Plan Year Health & Dependent Care Election Agreement Health and Dependent Care Flexible Spending Account elections are for expenses incurred between Ianuar,�1, 2017 and March 15, 2018 (including the grace period). Claims must be submitted to ASIFIex, the Flexible Benefits Program Administrator, by May 15, 2018 or monies will be forfeited. Please note that this Agreement is for the 2017 Plan Year alone,and will not carry over-you must re-enroll each new plan year. Please return completed forms and supporting documentation,if applicable,to the Human Resources-Employee Benefits Office via the methods below. If you have any questions,please call us at (559) 600-1810. Email: HRBenefits@co.fresno.ca.us I Standard USPS Mail: 2220 Tulare Street,14th Floor,Fresno,CA 93721 Fax: (559)455-4787 1 Interoffice Mail: Stop#188 1 Hand-Delivery: 14th floor of the County Plaza Building EMPLOYEE INFORMATION Name: Employee ID: SSN: Date of Birth: Address: City/State/Zip: Work Phone: SPENDING ACCOUNT ELECTIONS (Please note that election change requests require a separate change form.) Account Type $ Per Pay Period Pay Periods Total$for Plan Year Max. Annual Election Health Care: $ x = $ $2,600 for Plan Year 2017 Dependent Care: $ x = $ $5,000 for Plan Year 2017* * If you are married and you and your spouse file a separate tax return, IRS regulations limit you each to a $2,500 annual election to the Dependent Care Spending Account. BENEFICIARY INFORMATION In the event of the participant's death, the assigned beneficiary may continue to submit claims for qualified expenses through the remainder of the plan year until the funds are exhausted. These may be for previously unclaimed qualified expenses incurred by the participant and his/her dependents or new qualified expenses incurred by the dependents. Beneficiary Name: Relationship: Beneficiary Address: Phone: ACCOUNT COMMUNICATIONS (Previously-submitted information will carry over unless changed or cancelled.) By providing your email address,cell phone number and cell phone company,you consent to receive all communications from ASIFIex, including, but not limited to statements, confirmations, account alerts, and requests for information in connection with your flexible spending account via email and/or text message. E-mail: Cell#/ Company: / Page 1 of 2 CO U� r fl> Flexible Spending Accounts Election Agreement - 2017 Plan Year r; O � s60 FRElio Employee Name: DEBIT CARD AGREEMENT You must complete this section if you are EITHER:1) A current or previous participant with existing cards and wish to use your cards in the 2017 plan year;OR 2)You are a new participant and are requesting debit cards to be issued. By signing below,you agree to all of the following: 1. The card is optional and I can choose at each point-of-sale if I want to use the card,or file a traditional claim. 2. 1 may be required to provide supporting documentation to substantiate certain card transactions. The third party administrator, ASIFIex,will notify me if documentation is required and I must submit correct and appropriate documentation upon request. 3. 1 must review my secure message center at www.asiflex.com to understand the documentation that may be required. 4. It is my responsibility to request appropriate documentation from health care providers in order to substantiate card transactions. 5. If I do not supply the requested documentation in the timeframe requested,my card will be temporarily deactivated as required by Internal Revenue Service regulations,and I may be required to repay any such unsubstantiated or ineligible purchases. 6. Debit cards are issued with a 5-year expiration date and my future plan year elections will be loaded to my existing cards. 7. I will be issued two(2)cards;one for me and the other for a qualified dependent. 8. If I request additional cards for eligible dependents,or if my card is lost or stolen,or if I dispose of or destroy the cards prior to the expiration date,I must complete a separate debit card request form. I understand that I will be charged a$5.00 fee for each request for additional cards and the$5.00 fee will be deducted from my flex account. 9. Debit cards will be cancelled upon separation from service,failing to make my regular contributions or for misuse of the card. Signature Date AUTHORIZATION FOR DIRECT DEPOSIT By signing below, I authorize ASIFIex to deposit expense reimbursements for my qualified health and/or dependent care expenses directly to my bank account indicated on the attached voided check(deposit slips are not acceptable). Please note that previously-submitted information will carry over each year unless changed or cancelled. Signature Date AGREEMENT FOR SPENDING ACCOUNTS By signing below,you agree to all of the following: 1. My annual election,as stated in the"Spending Account Elections'will be deducted from my biweekly pay on a pre-tax basis. 2. This Agreement cancels any prior election agreement I have made under the Plan and cannot be changed or terminated unless I experience a qualified change in status as allowed under the Plan. 3. My election and this Agreement will cease upon termination of employment. 4. My election and this Agreement are for the 2017 Plan year alone,and will not carry over to subsequent Plan Years. 5. Complete claims with correct supporting documentation must be submitted timely as described in the Plan in order to be considered for reimbursement. 6. I may continue participation while on an unpaid leave of absence,as allowed under the Plan. 7. My employer may change my election if necessary in order to satisfy certain provisions of the Internal Revenue Code. 8. Pretax deductions reduce my compensation for tax purposes which reduces my Social Security benefits. 9. Expenses for which I claim a tax deduction under my income tax return cannot also be reimbursed under this Plan. 10. Unused funds are forfeited at the end of the Plan Year as defined in the Plan. Signature Date Employer use only Entry date: Entered by: Dedn.date: Health Code: Page 2 of 2 co U� to �� Qualified Parking / Transportation Fringe Benefit Enrollment / Change Form O� 56 O ❑ Change ❑ New Enrollment Employee Information Employee Name ID Number DOB Address City State Zip Date of Hire ❑Male ❑Female Home Phone Work Phone Job Title Employment Status: ❑Full time ❑Part time ❑On Leave Other: Benefit Elections I request the following amounts be deducted from my pay with pretax dollars: Qualified Parking Expenses: $ Per Pay Period ($250 Monthly Maximum) Qualified Transit or Van Pooling: $ Per Pay Period ($130 Monthly Maximum) Agreement By signing below, I agree to the following: • The amount I have elected will be taken from my pay in equal installments. • My election will continue throughout my employment or until I notify the County by completing a change form. • I understand I must request reimbursement no later than 180 days after the expense is incurred. • I understand I will forfeit any remaining balance not claimed within 180 days after termination. Signature: Date: Authorization for Direct Deposit By signing below I authorize ASIFlex to deposit expense reimbursements for my qualified transportation expenses directly to my bank account indicated on the attached voided check. (Please attach a voided check; deposit slips not accepted.) Prior information rolls over each year unless cancelled. I wish to: ❑Cancel my direct deposit ❑Change my direct deposit information Signature: Date: Employers use only Effective date: Payroll deduction date: [ ] Termination Plan Administrator's signature: Date: Parking/Transportation Enrollment/Change Form(Revised 07/15) CO Flexible Spending Account Off, g6 Unpaid Leave of Absence Election Form Employee Name: ID Number: (Please Print) Home/Cell Phone: FSA Plan Year: Employees on an unpaid leave of absence (LOA) who participate in a Health Care Flexible Spending Account have the option to either continue or revoke their account during their LOA. Specify which of the following options you wish to elect and return this form to Human Resources-Employee Benefits via email to HRBenefits(a-co.fresno.ca.us, fax to (559) 455-4787, or mail to 2220 Tulare Street, 14th Floor, Fresno, CA 93721. Please contact Employee Benefits at (559) 600-1810 if you have any questions. Select one of the options by placing a ✓ in the box: ❑ Option 1 — Continue By electing this option, I understand I am able to continue my participation in Health Care Spending while I am on an unpaid LOA. I understand that I am responsible for my contribution payments while on an LOA and elect the payment option below: ❑ Pre-pay. I elect to pre-pay all or a portion of the contributions for the expected duration of my LOA with pre-tax dollars from taxable compensation received prior to my LOA. Please note that this election must be submitted to Employee Benefits at least thirty (30) days prior to the start of your LOA, regardless of paid/unpaid status. ❑ Pay as you go. I elect to make after-tax contributions during my unpaid LOA. I understand that by electing this option, the County's third party administrator, Administrative Solutions, Inc., will collect contributions on a biweekly basis during my LOA. I understand that if I fail to remit these contributions, my coverage will be revoked during my LOA and I will not be eligible to submit claims or utilize my ASIFIex Debit Card for expenses incurred during my LOA. ❑ Option 2 — Revoke I agree to revoke my participation during my unpaid LOA. I understand that I will not be eligible to participate in the Health Care Spending during my LOA and am not eligible to submit claims for reimbursement or utilize my ASIFIex Debit Card for expenses incurred during the period I am on LOA. Please note the following: • Failure to return this form will result in your FSA account defaulting to Option 2 — Revoke status. • If your coverage is revoked — either by choice or by failing to pay your contributions while on LOA — you may choose to lower your annual election or maintain your current annual election by increasing your biweekly contribution. You must complete the Flexible Spending Account: Return from Leave of Absence Election Form and return it to Employee Benefits within thirty (30) days from the date that you return to work. Signature: Date: Employer's Use Only Leave Begin Dt: Scheduled Return Dt: Collect for Pay Period(s): to Plan Administrator's signature: Date: Revised 611712016 CO Flexible Spending Account Return from Leave of Absence Election Form Employee Name: Phone: (Please Print) ID Number: Effective Date of Return: FSA Plan Year: Employees who return to work from an unpaid leave of absence (LOA) with a revoked Health Care Flexible Spending Account have two options available for the reinstatement of their account upon their return. Please complete the form and return it to Human Resources-Employee Benefits within thirty (30) days from the date that you return to work: Email: HRBenefits(a)-co.fresno.ca.us Fax: (559) 455-4787 Mail: 2220 Tulare Street, 14th Floor, Fresno, CA 93721 Phone: (559) 600-1810 Select one of the options by placing a ✓ in the box: ❑ Option 1 — Reduced Annual I elect to reduce my annual election to the greater of: 1. My original election, minus the number of contributions missed; OR 2. The total amount I have been reimbursed for the current plan year, including approved claims and debit card transactions. ❑ Option 2 — Original Annual I elect to resume coverage at the annual election in effect before my LOA by increasing all remaining biweekly contributions for the plan year to account for the contributions missed while on LOA. Please note that under either option, expenses incurred during the pay periods that the Health Care Flexible Spending Account was revoked, either due to the employee's choice not to participate or by failing to make contribution payments, are not eligible for reimbursement. Signature: Date: Employer's Use Only Effective Date: Payroll Deduction Date: Annual Election: $ Biweekly Contribution: Plan Administrator's Signature: Date: Revised 6/13/2016 EXHIBIT G 2016 Open Enrollment Fair Schedule Date Location Address October 26 Main Health Fair 2220 Tulare St. Fresno, CA 93721 October 27 American Ave. Disposal Site 18950 W American Ave.Kerman, CA 93630 Kerman Regional Center 15180 West Whitesbridge October 28 Kerman, CA 93630 Coalinga Regional Center 311 Coalinga Plaza Dr. Coalinga, CA 93210 Air Fresno 2719 N. Air Fresno Dr. November 1 Fresno, CA 93726 Heritage Center 3151N. Millbrook Fresno, CA 93703 UMC Main Building 4455 E. Kings Canyon November 2 Fresno, CA 93702 Brix Mercer 1221 Fulton Mall Fresno, CA 93721 Selma Regional Center 3800 McCall Ave. November 3 Selma, CA 93662 Reedley Regional Center 1680 E. Manning Reedle , CA 93654 November 4 Senior Resource Center 2025 E. Dakota Fresno, CA 93726 EXHIBIT H Current Biweekly Census File Specifications Max. Data Deck Justifi- Description length Type mals cation Comments Employee ID Number 15 AN Left Employee SSN Number 11 N Left Format may be with or without hyphens Employee name 30 AN Left Last name, First name Middle Street 30 AN Left 1st line of employee's address Street 30 AN Left Second line of employee's address - if applicable City 20 AN Left Employee's city State 2 AN Left Employee's state Zip code in either 5-4 format or 54 (without Zip 10 AN Left hyphen) 5 digit zip code is acceptable Per pay period H.C. F.S.A. deduction 7 N 2 Right Decimal is explicit Per pay period D.C.F.S.A. deduction 7 N 2 Right Decimal is explicit Annual H.C. F.S.A. election 7 N 2 Right Decimal is explicit Annual D.C.F.S.A. election 7 N 2 Right Decimal is explicit H.C. F.S.A.Coverage start date 8 Health care FSA coverage start date H.C. F.S.A. Coverage end date 8 Health care FSA coverage end date D.C.F.S.A. Coverage start date 8 Dependent care FSA coverage start date D.C.F.S.A.Coverage end date 8 Dependent care FSA coverage end date Employee's pay cycle - e.g. 12, 24, 52--Please note this is not the number of pays remaining in Pay cycle 2 N 0 Right the year L=leave T=term F=FMLA E=event N=New Change flag 1 participant etc... Issue Date 6 Payroll issue date Date Format 1 1 = yymmdd, 2 = mmddyy Data is in a tab delimited file. Column A above indicate file headers. Each row should contain one employee record. See examples. DATA TYPE LEGEND: DESCRIPTION LEGEND: N = Numeric H.C.F.S.A. = Health Care FSA AN = Alpha/Numeric D.C.F.S.A. = Dependent Care FSA EXAMPLE #1 - Text File EmployeeID EmployeeSSNEmployeeName Streetl Street2 City StateZip PP_HCFSA PP_DPFSA PP_PARK PP_TRAN Annual_HCFSA Annual_DCFSA Annual_PARK Annual_TRAN HCFSA_StartDt HCFSA_EndDt DCFSA_StartDt DCFSA_EndDt Park_StartDt Park_EndDt MTransit_StartDt MTransit_EndDt PayCycle Birthdate DebitCardFlagFSA_Flag Insurance PlanIssueDt DateFormat Beneficiary 00000469 SSNSSNSSN Bricks,Round L. 1234 Fairroad Avenue Clovis CA 93619 00070.00 00000.00 00000.00 00000.00 01820.00 00000.00 00000.00 00000.00 01/01/17 26 02/13/1957 Y BSUCFX 2 Name Lastname 00000479 SSNSSNSSN Hanger,Copter L 1234 Mana Clovis CA 93611 00046.16 00000.00 00000.00 00000.00 01200.00 00000.00 00000.00 00000.00 01/01/17 26 06/03/1961 Y BLUEFX 2 Name2 Lastname2 00000717 SSNSSNSSN Laughter,Jokiel23 N Clearplace Fresno CA 93727 00060.00 00000.00 00000.00 00000.00 01560.00 00000.00 00000.00 00000.00 01/01/17 26 04/18/1958 Y BLUEFX 2 Name3 Middle3 Lastname3 asiflex_COF_03-26-2017_ThreeLineSample.txt[4/11/2017 8:29:46 AM] EXAMPLE #2: Excel File EmployeelD EmployeeSSN EmployeeName Streetl Street2 City State Zip PP_HCFSA 00000469 SSNSSNSSN Bricks,Round L. 1234 Fairroad Avenue Clovis CA 93619 70.00 00000479 SSNSSNSSN Hanger,Copter L 1234 Mana Clovis CA 93611 46.16 00000717 SSNSSNSSN Laughter,Jokie 123 N Clearplace Fresno CA 93727 60.00 PP_DPFSA PP—PARK PP_TRAN Annual_HCFSA Annual_DCFSA Annual—PARK Annual_TRAN HCFSA_StartDt HCFSA_EndDt 0.00 0.00 0.00 1820.00 0.00 0.00 0.00 01/01/17 0.00 0.00 0.00 1200.00 0.00 0.00 0.00 01/01/17 0.00 0.00 0.00 1560.00 0.00 0.00 0.00 01/01/17 DCFSA_StartDt DCFSA_EndDt Park_StartDt Park_EnclDt MTransit_StartDt MTransit_EndDt PayCycle Birthdate DebitCardFlag 26 02/13/1957 Y 26 06/03/1961 Y 26 04/18/1958 Y FSA_Flag Insurance Plan IssueDt DateFormat Beneficiary BSUCFX 2 Name Lastname BLUEFX 2 Name2 Lastname2 BLUEFX 2 Name3 Lastname3 COUNTY OF FRESNO co O 13 0 FRBli� ADDENDUM NUMBER: ONE (1 ) RFP NUMBER: 17-073 COUNTY FLEXIBLE SPENDING ACCOUNT ADMINISTRATOR Issue Date: May 1, 2017 Closing Date: May 15, 2017 at 2:00 PM All Question and Proposals must be electronically submitted to the Bid Page on Public Purchase. For assistance, contact Nick Chin at (559) 600-7110. NOTE THE FOLLOWING AND ATTACHED ADDITIONS, DELETIONS AND/OR CHANGES TO THE REQUIREMENTS OF REQUEST FOR PROPOSAL NUMBER: 17-073 AND INCLUDE THEM IN YOUR RESPONSE. PLEASE SIGN AND RETURN THIS ADDENDUM WITH YOUR PROPOSAL. Questions and Answers ➢ Replace Scope of Work and Scope of Work Proposal Requirements with attached Revised Scope of Work and Scope of Work Proposal Requirements. ACKNOWLEDGMENT OF ADDENDUM NUMBER-0 NE (1) TO RFP 17-M COMPANY NAME: (PRINT) SIGNATURE: NAME & TITLE: (PRINT) Purchasing Use:NC:st ORG/Requisition:89250200/8921700171 G:\PUBLIC\RFP\FY2016-17\17-073 COUNTY FLEXIBLE SPENDING ACCOUNT ADM INISTRATOR\17-073 ADDENDUM 1.DOC (3/28/17) Addendum No. ONE (1) Page 2 Request for Proposal Number: 17-073 May 1, 2017 QUESTIONS AND ANSWERS Q1. On Page #3, under Plan Basics, it says "Approximately 1,797 employees pay on a pre-tax basis for parking on County-owned parking lots near their work locations". However, on the Cost Proposal form on Page #18 it says 33 participants for transit and/or parking. Can you please clarify if the 1,797 employees mentioned on page #3 are participants in parking and transit? We want to ensure we have the proper number for our cost proposal. A1. These employees are not participants in the County of Fresno Parking Flexible Spending Account (FSA) program and are not part of this RFP. Q2. In the scope of work on page #11, requirement#11 says, "Provide the County of Fresno with bank account reconciliation reports, at least monthly, in a format approved by the County". Can you please explain what format would be approved by the County? A2. The County would like to provide more information regarding our current claim payment and banking arrangement and clarify what the County is asking for. See the Revised Scope of Work and Scope of Work Proposal Requirements. Scope of Work items #8, 10, and 11 and Scope of Work Proposal Requirements items #18 and 19 have been revised. Q3. Regarding Scope of Work Proposal Requirements, 1.d, what aspects of administration is the FSA administrator expected to assume fiduciary responsibility for? A3. Scope of Work Proposal Requirements 1.d is asking whether the FSA administrator will accept fiduciary responsibility for the duties it assumes pursuant to this RFP. For example, the County expects that the FSA administrator will assume fiduciary responsibility for claims adjudication, claims payment, mandated federal reporting, etc. (please note that this is not intended to be an exhaustive list). The County does not expect the FSA administrator to accept responsibility for anything that is in the exclusive purview of the County, unless the County relies on information provided by the FSA administrator to execute said responsibility. Q4. Regarding Scope of Work Proposal Requirements, 13.b, what does "Technical Support" mean? A4. The County needs to know whether staff should contact the Account Manager or some other dedicated person if participants or County staff are experiencing technical difficulties with the FSA administrator's website, smart phone application, etc. Q5. Regarding Scope of Work #12 and Scope of Work Proposal Requirements #20, are non-discrimination tests done quarterly now? A5. Yes. Q6. On page #3, under Plan Basics, it says "The County pays all costs associated with the plan. The current biweekly, per-participant rates are $1.29 per Health and/or Dependent Care participant, and $1.29 per Parking and/or Transit participant. Individuals enrolled in both Health and Dependent Care are subject to one fee". Can you please tell us who pays the $1.29 fee, is it the County or the Participant? A6. The County. G:APUBUCRFP\FY2016-17\17-073 COi 1NIYFIEX[BLE SPENDING ACCOtJNF ADMNN[STRATOR\17-073 ADDENDUM 1.DOC Addendum No. ONE (1) Page 3 Request for Proposal Number: 17-073 May 1, 2017 Q7. On page #18 in the cost proposal form, we see the number of health and/or dependent care participants provided. Can you please provide; the number of health FSA participants only, the number of dependent care FSA participants only, and the number of participants in both health FSA and dependent care FSA? A7. • 1,558 enrolled in health FSA only • 33 enrolled in dependent care FSA only • 93 enrolled in both dependent care and health care FSA Q8. Regarding Scope of Work#12 and Scope of Work Proposal Requirements #20, what non-discrimination tests does the County want the FSA administrator to run? A8. The County expects the FSA administrator to advise the County on what tests need to be run in order to comply with applicable laws and regulations. Currently, the FSA administrator runs the following tests: i. Health Care FSA Eligibility Test ii. Health Care FSA Plan Benefits Test iii. Dependent Care Eligibility Test iv. Dependent Care FSA Contributions and Benefits Test v. Dependent Care Average Benefits Test vi. Dependent Care FSA Benefits Concentration Test vii. Section 125 Eligibility Test viii. Section 125 Key Employee Concentration Test ix. Section 125 Concentration and Benefits Test G:APUBUCRFP\FY2016-17\17-073 COi 1NIYFIEX[BLE SPENDING ACCOtJNF ADMNN[STRATOR\17-073 ADDENDUM 1.DOC Addendum No. ONE (1) Page 4 Request for Proposal Number: 17-073 May 1, 2017 REVISED SCOPE OF WORK The Scope of Work below is intended to inform bidders of the County's Flexible Spending Program Administration needs. If there are any services that a bidder is not able to provide, this should be noted and explained fully. Bidders must complete the Scope of Work Proposal Requirements(see pg.14) contained in this RFP. Bidders are welcome to provide a detailed proposal for any service that is not addressed in the Scope of Work or Scope of Work Proposal Requirements. The Scope of Work includes providing services through the grace period and claims run-out for each plan year being administered through the end of the agreement at no additional cost. Administration 1. Administer the County's Health Care, Dependent Care, Parking and Transit Flexible Spending Account Programs and ensure that the plan design, plan documents, implementation, communication and reports are in compliance with all applicable laws and regulations. Reference Exhibits A and B for the Plan Documents. 2. Process Flexible Spending Account claims; claims will be processed and reimbursements to employees will be made,via check or direct deposit, at least two(2)times per week; currently, claims processing and reimbursements occur daily. 3. Maintain individual accounts for all participants crediting biweekly contributions to each account and debiting periodic payments against those accounts. This includes coordinating with the County and its third-party billing firm on payments from participants on unpaid leave of absence ("Pay As You Go") and tracking payments and claims of COBRA participants. 4. Accept claim forms online, via fax and by U.S. mail; in addition, claim filing via smart phone app is preferred. 5. Provide participants with quarterly account statements, end-of-plan year forfeiture warning notices and Open Enrollment confirmation statements. Employees will be given the opportunity to sign up for paperless statements/correspondence. 6. Provide a dedicated account manager to assist County staff. 7. Provide an employer portal where County staff can access reports, participant account information, etc. 8. The County maintains a separate bank account for Flexible Spending Account transactions. The current Administrator debits this account as needed to payfor claims reimbursement.The Administrator debits the account separately for each plan type;for example, if there are$25 in claims for each of the four (4) plan types, the Administrator will make four (4) separate $25 debits instead of a single debit of$100. The County prefers to maintain this arrangement. 9. Provide biweekly reports detailing any discrepancies between a participant's expected and actual biweekly contribution and annual election. 10. The County currently receives a daily email reporting the amounts that the administrator will debit from the County-owned bank account on the next business day. Each daily email provides a breakdown of the expense type related to each debit (see the example in #8 above). During the run-out period,we receive two (2)daily emails, if there are claims for both the current and previous plan year. The County would prefer to maintain this reporting structure, except that we would like a single daily email/report, regardless of what plan year the debit is related to. G:APUBLIC\RFP\FY2016-17\17-073 COtNrYFIEX[BLESPENDMACCOUNrADN NSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 5 Request for Proposal Number: 17-073 May 1, 2017 11. Provide the County of Fresno with monthly detailed claim payment reports (i.e. reimbursements per participant per day each month); it is preferred that the Administrator provide one (1) report for all plan years. 12. Perform all non-discrimination tests required under applicable laws and IRS guidance,at least quarterly. 13. Provide notification of changes in regulations affecting the plans and advise the County on any amendments to the Plan Documents necessitated by changes in applicable laws or regulations. 14. Provide guidance to the Countywith regard to interpreting the County's existing Cafeteria Plan Document (IRC Sections 105, 125, 129, and 223) and Commuter Plan Document. 15. Review requests by employees to participate in the Health or Dependent Care plans or make changes to their Health or Dependent Care elections outside of Open Enrollment. Determine whether such Change in Status or Qualifying Event requests, on a uniform and consistent basis, are permissible under IRS regulations and the County of Fresno Cafeteria Plan Document. 16. Provide a detailed plan for transitioning the County plans, including a timeline of key events and communication strategy. 17. All Flex Plan literature for plan year 2018 must be available for Open Enrollment by September 1, 2017. Dates for subsequent plan years will be consistent with the above time frame. Participant Services and Communication 18. Administrator will provide plan participants access to their staff for inquiries and problem resolution,to include but not be limited to,toll free phone number,e-mail,and open enrollment fairs. The toll free phone number will be available, at minimum, from 8:00 am to 5:00 pm Pacific Standard Time. 19. Customer service representatives will provide friendly,efficient service to plan participants with a focus on educating them regarding the various components of the plan when necessary. 20. Provide a website and smart phone application where participants may review their account information and submit claims and substantiating information. 21. Assist the County in educating employees on the benefits of the different plans,with particular emphasis on the Dependent Care and Parking/Commuter plans. 22. Typically,the County has one (1)major health and wellness fair and several satellite fairs over the course of a two-week period during the annual Open Enrollment period. Administrator is required to send, at minimum, one(1)representative to the health and wellness fair as well as all other satellite fairs to assist with plan enrollment (see Exhibit G for the 2016 OE fair schedule). Therefore, your Cost Proposal should account for attendance at all Open Enrollment fairs. Debit Card 23. Offer an optional FSA debit card to all Health Care FSA participants and provide a minimum of two (2) debit cards to each participant who elects this option, at no additional cost to the participant. G:APUBLIC\RFP\FY2016-17\17-073 COtNrYFIEX[BLESPENDMACCOUNrADN NSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 6 Request for Proposal Number: 17-073 May 1, 2017 24. Provide clear communications regarding the features and functionality of the debit card, with particular emphasis on what is required to substantiate debit card transactions and clearly explain all instances when the card may be used (pharmacy, doctor's office, vision provider, etc.). 25. Maintain a fully automated claims adjudication system in compliance with electronic transmission standards and security requirements and all other regulations as required by HIPAA and applicable IRS guidance, including Revenue Ruling 2003-43 and Notice 2006-69. 26. Provide monthly and annual unsubstantiated/improper health flexible spending account claims report, detailing members with active unsubstantiated debit card claims, and assist County with correction procedures for improper health flexible spending account payments pursuant to IRS Memorandum number 201413006. Information Transmission and Security 27. The Administrator must be able to receive a biweekly census and deductions file with specifications approved by the County (see Exhibit H for the current file specifications). 28. The Administrator must provide a public key to allow for information to be encrypted and securely transmitted via SFTP (FTP over SSH) protocol. 29. Provide administrative, technical, and physical safeguards to protect any County information maintained in the contractor's custody, consistent with current HIPAA requirements. 30. Provide a backup system in the event of destruction of the primary system so that administration and accounting for the flex plan would not be disrupted by fire, equipment failure, or other catastrophe. G:APUBLIC\RFP\FY2016-17\17-073 COtNrYFIEX[BLESPENDMACCODNrADNEIJSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 7 Request for Proposal Number: 17-073 May 1, 2017 REVISED SCOPE OF WORK PROPOSAL REQUIREMENTS Pursuant to instructions included in this RFP, Proposal Content Requirements, a bidder's proposal shall include a response to the following: Vendor Information 1. Please provide an organization overview including, but not limited to: a. Length of time processing FSA administration for clients b. Company location, claim office location as well as customer service location which will be responsible for servicing the County. c. Does FSA administration represent a core business unit or strategy or ancillary administrative product line? Please explain. d. Will you accept fiduciary responsibility of the plan? If not please explain. 2. Please provide an organization chart of employees who would be involved in this account along with their duties, titles, years of experience and physical locations. 3. In the table below, indicate the number of Public and Private FSA plans your company has in force as of January 1, 2017, by the number of eligible employees. What is the average tenure and average participation rate(i.e.,the percentage of eligible employees who actually participate) among your current FSA clients? Less than 1,000 1,000 — 5,000 5,001 — 10,000 10,000 + Public Private 4. What steps have you taken over the past two (2) years to improve your products and the experience of your customers? What changes do you plan during the next 12—24 months to enhance your member service and technology capabilities? Administration 5. Confirm your ability to administer the plan design exactly as stated in the Plan Documents in terms of benefit levels, covered services, exclusions, claims processing and claim appeal procedures. If not, please specify which provisions and why you are unable to administer them. 6. How often are claims processed and reimbursements made?Can participants submit claims online, by U.S. Mail, via fax, and by a mobile device/app? Do you require a minimum claim amount for submission and/or reimbursement? 7. What was your average claim turnaround time for reimbursements (number of days from receipt of a clean claim)for 2014, 2015, and 2016? 8. What steps do you take to ensure that a submitted FSA claim is a covered expense under applicable federal and state laws and regulations? 9. Will you require substantiation of a recurring eligible expense each time the expense is submitted or only the first time the expense is submitted? G:APUBLIC\RFP\FY2016-17\17-073 COtNrYFIEX[BLESPENDMACCOUNrADN NSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 8 Request for Proposal Number: 17-073 May 1, 2017 10. Please confirm that you are able to debit the County-owned bank account as needed to pay for claims reimbursement as stated in#8 of the Scope of Work. If you are not able continue this process please describe the alternate process. 11. Please confirm that a dedicated account manager for FSA program administration will be assigned to the County's account no later than thirty (30) days prior to Open Enrollment (scheduled to begin October 23, 2017). 12. Please confirm that it is your expectation that the account manager will respond to emails and phone calls within one (1)business day. If the County is not satisfied with the service or responsiveness of the current dedicated account manager, how will your firm work with the County to improve the performance of that account manager? If improvements are not made, will your firm assign a different manager to the County? 13. For each of the following functions, indicate whether the dedicated account manager will coordinate these functions or if the County will have designated contact people. a. Billing/Accounting b. Technical Support c. Customer Service d. Communications e. Legal/Compliance 14. Will you generate detailed quarterly account statements to participants, end-of-plan-year warning notices regarding forfeitures, and Open Enrollment confirmation statements? Are you able to provide paper statements and correspondence? Is there an additional cost for paper? If so, please note in your Cost Proposal. 15. Describe the capabilities of your employer portal. Does it allow for multiple County staff to have access to view and change information if needed? What dailyfunctions are available? 16. Please attach samples of your standard reports and indicate which reports are available on- demand, monthly, quarterly, and annually at no charge. 17. Please confirm that you are able to provide biweekly reports detailing any discrepancies between a participant's expected and actual biweekly contribution and annual election. 18. Please confirm that you are able to provide daily bank account debit reports, as detailed in Scope of Work#10. 19. Please confirm that you are able to provide monthly detailed claim payment reports, as stated in Scope of Work#11. 20. Please confirm that you are able to perform all non-discrimination tests required under applicable laws and IRS guidance, at least quarterly, at no additional charge to the County. 21. Explain how you will keep the County informed of changes to applicable laws and regulations that affect the County's Plan Documents. Do you suggest changes to specific provisions in the Plan Documents? 22. Please confirm that you will assist the County in interpreting provisions of the County's Plan Documents. 23. Do you provide Change in Status or Qualifying Event request review and determination services (as stated in Scope of Work #15) for clients? Is there an additional cost for this service? If so, please note in your Cost Proposal. G:APUBLIC\RFP\FY2016-17\17-073 COtNrYFIEX[BLESPENDMACCOUNrADN NSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 9 Request for Proposal Number: 17-073 May 1, 2017 24. How do you coordinate and communicate with clients and/or their third-party billing firm to: a. Identify COBRA-eligible participants who have separated from service and maintain a record of COBRA participants' contributions and claims? b. Manage the accounts of participants who are on unpaid leave of absence? 25. Please confirm that you have reviewed the Model County Contract(Exhibit E)and are able to comply with the terms and conditions, including: 4. Termination, 7. Health Insurance Portability and Accountability Act, 10. Hold Harmless, 11. Insurance, and 14. Governing Law. Please note any exceptions and provide a detailed remedy. Account Transition 26. Implementation a. Provide a sample implementation calendar detailing the work plan for implementation of FSA program administration, including the personnel required from vendor and County and what each entity is responsible for; assume a July 1, 2017 selection date and a January 1, 2018 effective date. b. Please provide copies of any informational brochures/guidelines you could provide for eligible employees and confirm that all materials will be available by September 1, 2017. c. Confirm that your implementation manager and account executive would meet with County benefits staff in Fresno for a kickoff meeting. 27. Describe how you would transition accounts, including any black-out periods involved: a. Include your capability to transition account history (contributions, claims, etc.). b. Describe the communication support you would provide. 28. Please explain how you would facilitate claims incurred prior to January 1, 2018 but submitted to you for processing. How would you help with the run out period? 29. Will you be willing to put a dollar amount or percentage of fees at risk if implementation goals are not met? If so, please provide a detailed explanation and note in your Cost Proposal. Participant Services and Communication 30. Describe the structure and staffing of your customer service office: a. What are your member service hours of operation? b. What are your 24-hour customer service capabilities? c. How many CSR's will be assigned to the County of Fresno and what is their average tenure? G:APUBLIC\RFP\FY2016-17\17-073 COLNrYFIEX[BLESPENDMACCOUNrADN NSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 10 Request for Proposal Number: 17-073 May 1, 2017 31. For 2016, provide the following customer service statistics: a. Total number of calls received b. Average hold/wait time c. Average hold/wait time between January and March d. Average phone call abandonment rate e. Percent of telephone inquiries resolved during initial call f. Will the County have access to these statistics for our participants? 32. Provide a complete description of your customer service procedures from receipt of a question or complaint to complete resolution. Do your customer service representatives record each call and are calls monitored for quality? Will you contact and communicate directly with participants as required to resolve problems or to respond to questions? 33. Describe your guidelines and requirements for continuing education among your staff for compliance and regulatory issues, customer service,and client-specific account information. 34. How often do you measure participant satisfaction with your program? Please attach a copy of the most recent survey with results, if available. Are you willing to conduct an annual employee satisfaction survey of County of Fresno participants? Will you be willing to put a dollar amount or percentage of fees at risk if participant satisfaction goals are not met? If so, please provide a detailed explanation and note in your Cost Proposal. 35. Please confirm that you offer a website where participants may check the status of their account, submit a claim, and review requests for additional information for a pending claim. Please list any additional capabilities available and include any hardware or software requirements necessary to access the website. Please provide a sample web page and dummy account for the County to review. 36. Do you provide a smartphone application for participants? If yes, please explain what services are provided through the smartphone application and include any hardware or software requirements necessary to access the application. 37. Please describe your strategy for promoting the programs and educating employees on the benefits of the programs, with particular emphasis on the Dependent Care and Parking/Commuter programs. 38. Briefly describe the printed materials you offer employees regarding Flexible Spending Accounts (flyers, brochures, etc.) and the purpose of each one. Do you have separate communications for the Debit Card that detail the restrictions and responsibilities that come with using the Card, such as when and why substantiating information is needed? Do you provide hard-copy welcome kits,webinars and/or on-site seminars? Please provide sample communications materials and describe any additional cost associated with these services. 39. Please confirm that you are able to provide at least one (1) representative at the annual health and wellness fair as well as all other satellite fairs to assist with plan enrollment as stated in Scope of Work#22. G:APUBLICRFP\FY2016-17\17-073 COLNrYFIEX[BLESPENDMACCODNrADNEIJSTRATOR\17-073 ADDENDUM LDOC Addendum No. ONE (1) Page 11 Request for Proposal Number: 17-073 May 1, 2017 Debit Card 40. Please confirm that you offer an optional debit card to Health Care FSA participants and that each participant will receive at least two (2) cards. Please also confirm that debit card participants are still able to submit manual claims and receive reimbursements. 41. Please confirm that you adhere to the claim substantiation rules contained in IRS Revenue Ruling 2003-43 and IRS Notice 2006-69 and describe how the debit card distinguishes between valid FSA purchases and other goods that are not eligible for reimbursement. 42. How do you ensure the debit card is deactivated when a participant separates from service or fails to make a contribution? 43. Please describe your procedure(s) for assisting clients with correction procedures for improper health flexible spending account payments pursuant to IRS Memorandum number 201413006. a. What parts of the process do you manage, and what is the employer responsible for? b. What is the schedule for deactivating a card if a participant fails to provide substantiating documentation and how do you communicate with the participant that this is happening? What appeals process is in place for a participant whose debit card claim is denied? c. What is the timing and process for reactivating cards once a situation is resolved? Information Transmission, Retention and Security 44. Please confirm that you are able to use the current biweekly census file format(Exhibit H). If not, please provide your file specifications. 45. Please confirm that you are able to accommodate the data encryption and transmission protocols as stated in Scope of Work#28. If not, please explain. 46. How do you ensure client confidentiality consistent with current HIPAA requirements? Is your system HIPAA compliant for data security? Explain how. 47. Describe your information technology infrastructure including back-up,security,and disaster recovery procedures?Are files archived and stored at an off-site location? Have procedures been tested? When did you last perform a full-scale disaster recovery test and what were the results? 48. How long are records retained? In what manner are they retained? G:APUBLICRFP\FY2016-17\17-073 COtNrYFIEX[BLESPENDMACCOUNrADN NSTRATOR\17-073 ADDENDUM LDOC Exhibit B COUNTY OF FRESNO h ti cotrt��, 0� 3 0 ARV!9 REQUEST FOR PROPOSAL NUMBER: 17-073 COUNTY FLEXIBLE SPENDING ACCOUNT ADMINISTRATOR Issue Date: April 13, 2017 Closing Date: May 15, 2017 at 2:00 PM All Questions and Proposals must be electronically submitted on the Bid Page on Public Purchase. For assistance, contact Nick Chin at Phone (559) 600-7110. Undersigned agrees to furnish the commodity or service stipulated in the attached response at the prices and terms stated in this RFP. Bid must be signed and dated by an authorized officer or employee. Navia Benefit Solutions, Inc. COMPANY 1.1400 SE Gth St. Suite 125 ADDRESS T� Bellevue,WA 98004 CITY STATE ZIP CODE 425-452-3500 - sknipp@naviabenefits.com TELEPHONE NUMBER r- !' E-MAIL ADDRESS SIGNATURE Stefan Knipp Sales Executive PRINT NAME TITLE G:TubI4RFPTY 2016-17117-073 County Flexible Spending Account AdministratcO17-073 County Flexible Spending Account Adminlstrator.doc PD-040(03I28117) COUNTY OF FRESNO cotr���. o r S ADDENDUM NUMBER: ONE (1 ) RFP NUMBER: 17-073 COUNTY FLEXIBLE SPENDING ACCOUNT ADMINISTRATOR Issue Date: May 1, 2017 Closing Date: May 15, 2017 at 2:00 PM All Question and Proposals must be electronically submitted to the Bid Page on Public Purchase. For assistance, contact Nick Chin at(559) 600-7110. NOTE THE FOLLOWING AND ATTACHED ADDITIONS, DELETIONS AND/OR CHANGES TO THE REQUIREMENTS OF REQUEST FOR PROPOSAL NUMBER: 17-073 AND INCLUDE THEM IN YOUR RESPONSE. PLEASE SIGN AND RETURN THIS ADDENDUM WITH YOUR PROPOSAL. ➢ Questions and Answers ➢ Replace Scope of Work and Scope of Work Proposal Requirements with attached Revised Scope of Work and Scope of Work Proposal Requirements. ACKNOWLEDGMENT OF ADDENDUM NUMBER ONE (1) TO RFP 17-073 COMPANY NAME: Navia Benefit Solutions, Inc. (PRINT) SIGNATURE: t NAME & TITLE: _Stefan Knipp, Sales Executive (PRINT) Purchasing Use:NC:st ORGIRequisition:8925020018921700171 G:IPUBL1C1RFPIFY 2018-17117-073 COUNTY FLEXIBLE SPENDING ACCOUNT ADMINISTRATOR117-073 ADDENDUM 1.DOC (3128/17) e n 11 avi. a May 11, 2017 Proposal No. 17-073 Nick Chin County of Fresno- Purchasing 4525 E. Hamilton Avenue, 2A Floor Fresno, CA 93702 Mr. Chin, Thank you for the opportunity to bid on the County of Fresno's plans for FSA and Commuter administration. I am very confident that our proposal will be seen favorably based on our pricing and experience in providing administration to large public sector employers. There are a few items that I would like to specifically mention regarding our proposal. • I will be the main contact representing Navia Benefit Solutions, Inc. I can be reached via email at sknipp@naviabenefits.com or via phone at (425)452-3508. 1 can also be reached via fax at (425) 233- 6308. 1 am based out of our headquarters in Bellevue,WA and my address is 11400 SE 6th St.Suite 125, Bellevue, WA 98004. Navia is a Corporation licensed in Washington State. • We are quoting the County a very aggressive rate for the administration of the plans. As enrollment increases,we are also willing to decrease our quoted rate to reflect the growth. • Our proprietary systems give us full flexibility to customize your plan administration to deliver a user experience tailored for your participants. • Navia consistently offers a high level of service to all clients. Our commitment to customer service is evident in our participant-first philosophy and our hiring approach. Every Navia employee is hired as a customer service agent and promoted from within. This gives each employee a unique perspective on the participant experience. No other TPA can make a claim to that commitment. I am committed to bringing the County of Fresno the highest level of customer service and technology and welcome the opportunity to prove why making a switch to Navia is the right choice. Cordially, Stefan C. Knipp Sales Executive (and a former customer service agent) Table of Contents ➢ I . RFP Page and Addendum ➢ 11 . Cover Letter ➢ III . Table of Contents ➢ IV. Conflict of Interest Statement ➢ V. Trade Secret ➢ VI . Certification — Disclosure — Criminal History and Civil Actions ➢ IX. Exceptions ➢ X. Vendor Company Data ➢ XI . Scope of Work ➢ XI I . Cost Proposal ➢ XI I I . Check List ➢ XIV. Supplemental Materials • Proposed Implementation Timeline • FSA Employee Open Enrollment Materials • Sample Letters, Statements, and Notifications • Standard Reports • GoNavia Commuter Materials • FSA Deductions File • FSA Eligibility File • Commuter Eligibility File III. Conflict of Interest Statement: Navia does not have any real or potential conflict of interest with the County. Navia will adhere to any conflict of interest requirements as outlined by the County. IX. EXCEPTIONS: This portion of the proposal will note any exceptions to the requirements and conditions taken by the bidder. If exceptions are not noted, the County will assume that the bidder's proposals meet those requirements. The exceptions shall be noted as follows: A. Exceptions to General Conditions. Navia agrees to all terms outlined in the General Conditions section. B. Exceptions to General Requirements. Navia agrees to all terms outlined in the General Requirements section. C. Exceptions to Specific Terms and Conditions. Navia agrees to all Specific Terms and Conditions. D. Exceptions to Scope of Work and/or Scope of Work Proposal Requirements. Navia agrees to all terms outlined in the Scope of Work and/or Scope of Work Proposal Requirements. E. Exceptions to Proposal Content Requirements. Navia does not have any exceptions to the Proposal Content Requirements. F. Exceptions to any other part of this RFP. Navia does not have exceptions to any other part of this RFP. Proposal No. 17-073 Page 22 TRADE SECRET ACKNOWLEDGEMENT All proposals received by the County shall be considered "Public Record"as defined by Section 6252 of the California Government Code. This definition reads as follows: "...Public records" includes any writing containing information relating to the conduct of the public's business prepared, owned, used or retained by any state or local agency regardless of physical form or characteristics"Public records"in the custody of,or maintained by,the Governor's office means anywriting prepared on or after January 6, 1975." Each proposal submitted is Public record and is therefore subject to inspection by the public per Section 6253 of the California Government Code. This section states that"every person has a right to inspect any public record". The County will not exclude any proposal or portion of a proposal from treatment as a public record except in the instance that it is submitted as a trade secret as defined by the California Government Code. Information submitted as proprietary, confidential or under any other such terms that might suggest restricted public access will not be excluded from treatment as public record. "Trade secrets"as defined by Section 6254.7 of the California Government Code are deemed not to be public record. This section defines trade secrets as: "...Trade secrets,"as used in this section, may include, but are not limited to, any formula, plan, pattern, process, tool, mechanism, compound, procedure, production data or compilation of information that is not patented,which is known only to certain individuals within a commercial concern who are using it to fabricate, produce, or compound an article of trade or a service having commercial value and which gives its user an opportunity to obtain a business advantage over competitors who do not know or use it." Information identified by bidder as "trade secret"will be reviewed by County of Fresno's legal counsel to determine conformance or non-conformance to this definition. Such material should be electronically submitted in separate PDF file named "Trade Secret"and marked as Confidential. Examples of material not considered to be trade secrets are pricing, cover letter, promotional materials, etc. INFORMATION THAT IS PROPERLY IDENTIFIED AS TRADE SECRET AND CONFORMS TO THE ABOVE DEFINITION WILL NOT BECOME PUBLIC RECORD. COUNTY WILL SAFEGUARD THIS INFORMATION IN AN APPROPRIATE MANNER. Information identified by bidder as trade secret and determined not to be in conformance with the California Government Code definition shall be excluded from the proposal. Such information will be returned to the bidder at bidder's expense upon written request. Trade secrets must be electronically submitted in a separate PDF file that is plainly named "Trade Secrets" and marked as Confidential. The County shall not in any way be liable or responsible for the disclosure of any proposals or portions thereof, if they are not(1) electronically submitted in a separate PDF that is named "Trade Secret"and marked as Confidential; and (2)if disclosure is required or allowed under the provision of law or by order of Court. Vendors are advised that the County does not wish to receive trade secrets and that vendors are not to supply trade secrets unless they are absolutely necessary. G:\Public\RFP\FY2016-l7\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Admin;matoe.doc Proposal No. 17-073 Page 23 TRADE SECRET ACKNOWLEDGEMENT I have read and understand the above "Trade Secret Acknowledgement." I understand that the County of Fresno has no responsibility for protecting information electronically submitted as a trade secret if it is not delivered in a separate PDF file named "Trade Secret"and marked as Confidential. I also understand that all information my company submits, except for that information electronically submitted in a separate PDF file named"Trade Secret' and marked as Confidential, are public records subject to inspection by the public. This is true no matter whether my company identified the information as proprietary, confidential or under any other such terms that might suggest restricted public access. Enter company name on appropriate line: Has submitted information identified as Trade Secrets in (Company Name) a separate marked binder." Navia Benefit Solutions,Inc. Has not submitted information identified as Trade (Company Name) Secrets. Information submitted as proprietary confidential or under any other such terms that might suggest restricted public access will not be excluded from treatment as public record. ACKNOWLEDGED BY: 425-452-3508 5ignatur Telephone Ste an Knipp, Sales Executive 05/11/2017 Print Name and Tite Date 11400 SE 6th St. Suite 125 Address Bellevue WA 98004 City State Zip "Bidders brief statement that clearly sets out the reasons for confidentiality in conforming with the California Government Code definition. G:\Public\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Adminis trator.doc Proposal No. 17-073 Page 24 DISCLOSURE - CRIMINAL HISTORY & CIVIL ACTIONS In their proposal, the bidder is required to disclose if any of the following conditions apply to them,their owners, officers, corporate managers and partners(hereinafter collectively referred to as'Bidder"): 1. Within the three-year period preceding the proposal, they have been convicted of, or had a civil judgment rendered against them for: a. fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public(federal, state, or local)transaction or contract under a public transaction; b. violation of a federal or state antitrust statute; c. embezzlement, theft, forgery, bribery, falsification, or destruction of records; or d. false statements or receipt of stolen property 2. Within a three-year period preceding their proposal, they have had a public transaction (federal, state, or local)terminated for cause or default. Disclosure of the above information will not automatically eliminate a Bidder from consideration. The information will be considered as part of the determination of whether to award the contract and any additional information or explanation that a Bidder elects to submit with the disclosed information will be considered. If it is later determined that the Bidder failed to disclose required information, any contract awarded to such Bidder may be immediately voided and terminated for material failure to comply with the terms and conditions of the award. Any Bidder who is awarded a contract must sign an appropriate Certification Regarding Debarment, Suspension, and Other Responsibility Matters. Additionally, the Bidder awarded the contract must immediately advise the County in writing if, during the term of the agreement: (1) Bidder becomes suspended, debarred, excluded or ineligible for participation in federal or state funded programs or from receiving federal funds as listed in the excluded parties list system (http://www.epls.gov); or(2)any of the above listed conditions become applicable to Bidder. The Bidder will indemnify, defend and hold the County harmless for any loss or damage resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed Certification Regarding Debarment, Suspension, and Other Responsibility Matters. G:\Public\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Adminis trator.doc Proposal No. 17-073 Page 25 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER RESPONSIBILITY MATTERS - PRIMARY COVERED TRANSACTIONS INSTRUCTIONS FOR CERTIFICATION 1. By signing and submitting this proposal, the prospective primary participant is providing the certification set out below. 2. The inability of a person to provide the certification required below will not necessarily result in denial of participation in this covered transaction. The prospective participant shall submit an explanation of why it cannot provide the certification set out below. The certification or explanation will be considered in connection with the department or agency's determination whether to enter into this transaction. However, failure of the prospective primary participant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 3. The certification in this clause is a material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the prospective primary participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause or default. 4. The prospective primary participant shall provide immediate written notice to the department or agency to which this proposal is submitted if at anytime the prospective primary participant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 5. The terms covered transaction, debarred, suspended, ineligible, participant, person, primary covered transaction, principal, proposal, and voluntarily excluded,as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this proposal is being submitted for assistance in obtaining a copy of those regulations. 6. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. G:\Public\RFP\FY 201 G-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 26 CERTIFICATION (1)The prospective primary participant certifies to the best of its knowledge and belief, that it, its owners, officers, corporate managers and partners: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public(Federal, State or local)transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery,falsification or destruction of records, making false statements, or receiving stolen property; (c) Have not within a three-year period preceding this application/proposal had one or more public transactions (Federal, State or local)terminated for cause or default. (2)Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective icipant shall attach an explanation to this proposal. Signature: Date: 05/11/2017 Stefan Knipp, Sales Executive Navia Benefit Solutions, Inc. (Printed Name&Title) (Name of Agency or Company) G:\Public\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Fle)Jble Spending Account Administrator.doc Proposal No. 17-073 Page 27 REFERENCE LIST VENDOR MUST COMPLETE AND RETURN WITH REQUEST FOR PROPOSAL Firm: Navia Benefit Solutions, Inc. Provide a list of at least five (5)customers for whom you have recently provided similar services. Be sure to include all requested information. Reference Name: County of Santa Clara Contact: Rhonda Schmidt Address: _70 West Hedding City: San Jose State: _CA_ Zip: 95110 Phone No,: ( ) (408)-299--5867 Project Date: 2017 - Present Service Provided: FSA and COBRA Administration Reference Name: County of Sacramento Contact: Dave Comerchero Address: 700 H Street, Suite 4667 City: Sacramento State: CA Zip: 95814 Phone No.; ( ) (916)-874-4529 Project Date: 2005 - Present Service Provided: FSA Administration Reference Name: _City of Palo Alto _ Contact: Sandra Blanch _ Address: 250 Hamilton Ave. _ City: Palo Alto State: CA Zip: 94301 Phone No.: ( } (650)-329-2294 Project Date: 2006 - Present Service Provided: FSA Administration Reference Name: City of Seattle Contact: Carolyn Trapp Address: P.O. Box 34028 City: Seattle State: WA Zip: 98124 Phone No.: ( ) (206)-684-7832 Project Date: 2013 - Present Service Provided FSA Administration Reference Name: City of Oakland Contact: Denise Carter Address: 150 Frank O ag wa Plaza City: Oakland State: CA Zip: 94612 Phone No.: { ) (510)-238-7446 Project Date: 2017 - Present Service Provided: FSA,COBRA, and Commuter Administration ..- Failure to provide a list of at least five (5) customers may be cause for rejection of this RFP. G:\Public\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc Proposal No. 17-073 Page 28 PARTICIPATION The County of Fresno is a member of the Central Valley Purchasing Group. This group consists of Fresno, Kern, Kings, and Tulare Counties and all governmental,tax supported agencies within these counties. Whenever possible, these and other tax supported agencies co-op (piggyback)on contracts put in place by one of the other agencies. Any agency choosing to avail itself of this opportunity,will make purchases in their own name, make payment directly to the contractor, be liable to the contractor and vice versa, per the terms of the original contract, all the while holding the County of Fresno harmless. If awarded this contract, please indicate whether you would extend the same terms and conditions to all tax supported agencies within this group as you are proposing to extend to Fresno County. Note: This form/information is not rated or ranked for evaluation purposes. Yes, we will extend contract terms and conditions to all qualified agencies within the Central Valley X Purchasing Group and other tax supported agencies. No, we will not extend contras terms to any agency other than the County of Fresno. uthorized Signature) Sales Executive Title G:\Public\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc X. VENDOR COMPANY DATA:This section should include: A. A narrative which demonstrates the vendor's basic familiarity or experience with problems associated with this service/project. We have reviewed the contents of RFP No. 17-073 and confirm that we can meet all of the requirements listed. All of the requirements are services that we currently offer for all of our existing clients. The following provides a brief summary of each benefit proposed and our key personnel assigned to the project. Navia will provide fully outsourced administration of FSA and transportation services for the County of Fresno. With low startup costs and a wide selection of out-of-the box systems,there is an ever- increasing number of vendors for employers to choose from. At Navia,we're not trying to be another TPA, but rather a long-term partner for our clients. Our service model is based on old-fashioned values of providing excellent customer service, expertise, and treating clients the way we wish to be treated. With an average client tenure of over ten (10) years,we back up our claims. FSA Overview The following services would be provided for the County's FSA program: • $500 Carryover • Grace Period claims audit service • 2% month Grace Period • Navia benefits card • Online account access • MyNavia mobile app • Online enrollment for annual • Flexible plan funding options open enrollment • FlexConnect claim submission tool • Custom enrollment and • Recurring dependent care expense contracts communication forms . Enrollment confirmation statements • Attendance at enrollment . Periodic account statements meetings and fairs . Full compliance services • Live open enrollment webinars . Dedicated account management B. Descriptions of any similar or related contracts under which the bidder has provided services. Navia administers plans for over 500 public sector clients. The following is a brief sample of our existing clients. We currently administer plans for over 3,000 employer groups consisting of over 195,000 participants. State of Maine Henrico County Government(VA) Sacramento County(CA) City of Detroit(MI) County of Santa Clara (CA) Seattle School District(WA) City of Portland (ME) Howard County Public Schools(MD) State of Rhode Island City of Seattle(WA) Pierce County(WA) State of Washington C. Descriptions of the qualifications of the individual(s) providing the services. The County will be assigned a dedicated account management team based out of our main headquarters in Bellevue, Washington. The team will consist of an account executive, day- to-day account manager, and Implementation manager. The account executive (AE) maintains overall responsibility of the County's contract and the account team. The account manager(AM) is the day-to-day contact for the plan contacts for all plan related matters (eligibility, compliance, billing, participant issues, etc...). The AM reports to both their department manager and to the AE. The implementation manager(IM)works directly with the AE during the implementation phase and is responsible for the internal set up of the client accounts in our systems,file testing, banking set-up and drafting all forms and documents. The following individuals are assigned to the team: Name Role/Title Years (Industry/Navia) Stefan Knipp AE/Business Development 6/5 Chelsea Allen AM/Account Manager 6/5 David Rothschild IM/Implementation Manager 8/4 Stefan Knipp Stefan is a member of our business development and sales team. He has served various roles within Navia from implementation to account management and has been involved with all operational aspects of Navia and development of our services. He has served as the program manager for the successful implementation and rollout of our commuter platform, COBRA services, mobile app and wellness benefits. Stefan will serve as the account executive and contract manager for the County. As the Account Executive (AE), he maintains overall responsibility for the account and all members of the account management team will report to him. He will also work with David on the internal implementation. Chelsea Allen Chelsea will serve as the Account Manager(AM)for the County. As the AM, she is the day-to-day contact for the County's representatives and manages the day-to-day administration of the plan. Chelsea has held many roles within Navia and has a very broad understanding of all aspects of plan administration from claims management to data uploads to compliance. She has a well-established track record of providing excellent service for our large group accounts. Chelsea serves as the AM for some of our highest profile clients such as the State of Washington, BECU, Infosys, City of Waco, and Henrico County. David Rothschild David will work with Stefan on the internal implementation of the plans. He will work on all of the customized forms and documents, internal set up in our processing system and the file testing for all data files. David has served Navia as a customer service agent, EDI team lead, program manager and account manager. He has worked with Stefan on several of our high-profile clients and served as the implementation manager for the County of Santa Clara,State of Rhode Island, City of Seattle, City of Detroit, Howard County Public School Systems and Infosys Technologies. D. Any material (including letters of support or endorsement)indicative of the bidder's capability. Please see attached for all Navia supporting materials. E. A brief description of the bidder's current operations, and ability to provide the services. We have reviewed the contents of RFP No. 17-073 and confirm that we can meet all of the requirements listed. All of the requirements are services that we currently offer for all of our existing clients. There are some items that we would like to highlight about our firm's ability to meet the County of Fresno's administrative needs. • Navia Benefit Solutions has provided benefits administration services for over 25 years. We have administered plans for many city, county, state and school district clients and are currently administering over 500 public sector plans. Many of these clients have been with Navia through several contract renewals. • Navia can fully meet all of the work outlined in the RFP. These are all current services that are offered as part of our standard administration. • Navia uses our own proprietary software for administration. We believe that the most effective way to administer a plan is to have complete control over systems, data and personnel. Part of our successful administration strategy is to provide the highest level of service and expertise to our clients. Some items to note about our administration: — Navia maintains a dedicated account management team for each public sector client — We do not outsource or offshore any of our services — Navia has a full compliance team managed by our in-house counsel — Navia administers all plans in accordance to the proposed IRS regulations and in the interest of our clients to be fully compliant with the regulations F. Copies of the audited Financial Statements for the last three (3)years for the agency or program that will be providing the service(s) proposed. If audited statements are not available, compiled or reviewed statements will be accepted with copies of three years of corresponding federal tax returns. This information is to be provided after the RFP closes, if requested. Do not provide with your proposal. Navia will provide this information if requested. G. Describe all contracts that have been terminated before completion within the last five (5) years: 1. Agency contract with 2. Date of original contract 3. Reason for termination 4. Contact person and telephone number for agency Navia has not had any contract terminations before the scheduled completion date in the past five (5)years. H. Describe all lawsuit(s)or legal action(s)that are currently pending; and any lawsuit(s)or legal action(s)that have been resolved within the last five(5)years: 1. Location filed, name of court and docket number 2. Nature of the lawsuit or legal action Navia does not have any lawsuit(s) or legal action(s) that are currently pending; or any lawsuit(s) or legal action(s)that have been resolved within the last five (5)years. I. Describe any payment problems that you have had with the County within the past three(3) years: 1. Funding source 2. Date(s)and amount(s) 3. Resolution 4. Impact to financial viability of organization. Navia has not had any funding problems with the County in the past three (3) years. XI. SCOPE OF WORK: A. Bidders are to use this section to describe the essence of their proposal. Navia strives to provide the best customer service,technology, and compliance expertise in the industry for each of our clients. We understand that any TPA can administer FSA and commuter plans and most use the same business logic, computers, and a lot of TPAs even use the same software. Navia utilizes proprietary software for FSA and commuter administration that allows us to have much more flexibility in the management of our systems. If there are customizations that need to be made,we can accommodate and adjust quickly. Navia has also invested heavily on customer service. We spend countless resources to educate and train our staff to deliver the best customer service experience possible. Every one of our customer service representatives is based out of our headquarters in Bellevue, WA and each representative has a direct phone line, direct email address, and direct fax number.This means that your employees can connect with real people on a consultative basis when they call our office. Finally,we have an in-house compliance team led by our legal counsel and senior managers who are all involved in national trade organizations. If there are every compliance questions that come up,we can get you answers very quickly. Navia maintains a 99%client retention rate and almost all of our business (except public sector RFPs) comes exclusively from insurance broker referrals. B. This section should be formatted as follows: 1. A general discussion of your understanding of the project and the Scope of Work proposed, including an explanation of any services that you are notable to provide (if applicable), as well as, a detailed description of services that you are able to provide, but are not addressed in the Scope of Work or Scope of Work Proposal Requirements. We have reviewed the contents of RFP No. 17-073 and confirm that we can meet all of the requirements listed. All of the requirements are services that we currently offer for all of our existing clients.The following provides a brief summary of each benefit proposed and our key personnel assigned to the project. Navia will provide fully outsourced administration of FSA and transportation services for the County of Fresno. With low startup costs and a wide selection of out-of-the box systems,there is an ever- increasing number of vendors for employers to choose from. At Navia,we're not trying to be another TPA, but rather a long-term partner for our clients. Our service model is based on old-fashioned values of providing excellent customer service, expertise, and treating clients the way we wish to be treated. With an average client tenure of over ten (10)years, we back up our claims. FSA Overview The following services would be provided for the County's FSA program: • $500 Carryover • Grace Period claims audit service • 2% month Grace Period • Navia benefits card • Online account access • MyNavia mobile app • Online enrollment for • Flexible plan funding options annual open enrollment • FlexConnect claim submission tool • Custom enrollment and • Recurring dependent care expense contracts communication forms . Enrollment confirmation statements • Attendance at enrollment • Periodic account statements meetings and fairs . Full compliance services • Live open enrollment . Dedicated account management webinars Commuter Overview Our GoNavia commuter benefits platform is the perfect solution for the County's pre- tax transit and parking needs.The program will streamline the administrative process without inconveniencing County employees. Most of the commuter benefit solutions in the marketplace require employees to reload their commuter cards through their website or they will mail transit passes to the employee's home. In these situations, the TPA inserts themselves in the middle of an already existing relationship between the employee and the transit agency. With GoNavia,employees load funds onto their Navia Benefits Card and then purchase their monthly commuter pass or pay for parking like they normally do every day. Instead of using their debit or credit card, they now use the pre-tax money loaded onto their Navia card. The following highlights our GoNavia commuter benefits program: Platform Features GoNavia Implementation time 45 days prior to benefit start Ordering deadline 20th of each month prior Benefit options Transit; Parking; Vanpool; Bicycle Funds availability Funds are loaded 3—5 business days after the 20th Re-loadable card Yes, single Navia Benefits card for all expenses Cash only parking lots or Yes, employees can use the DirectPay option for transit agency lots these types of parking expenses Order limitations Yes, employers can cap the order amount Eligibility reporting options Manual updates through the Navia website EDI files sent from client's HRIS system Integrated eligibility file from 3rd party vendors Change only or full eligibility files Order updates/cancellations Yes, changes to the orders are allowed up to two (2) after the monthly ordering business days after the order deadline deadline? Subsidy arrangements Yes, the GoNavia Commuter platform accommodates all subsidy arrangements 2. A detailed description of your proposal as it relates to each item listed under the"Scope of Work Proposal Requirements"section of this RFP. Bidder's response should be stated in the same order as are the"Scope of Work Proposal Requirements" items. Each description should begin with a restatement of the"Scope of Work Proposal Requirements"item that it is addressing. Bidders must explain their approach and method of satisfying each of the listed items. SCOPE OF WORK PROPOSAL REQUIREMENTS Pursuant to instructions included in this RFP, Proposal Content Requirements, a bidder's proposal shall include a response to the following: Vendor Information 1. Please provide an organization overview including, but not limited to: a. Length of time processing FSA administration for clients Navia has provided FSA administration services since 1988. b. Company location, claim office location as well as customer service location which will be responsible for servicing the County. Navia benefits is headquartered in Bellevue, WA. Our main address is 11400 SE 6th St. Suite 125, Bellevue, WA 98004.All services are performed from our Bellevue, WA office. Navia takes great pride in our customer service team. Our customer service department for the County is based in Bellevue,WA and has over 50 representatives. Every representative has a personal email address, phone number and fax number so that County participants can call or email our representatives directly. We also have a general toll-free number that participants can call. Furthermore, if one of our representatives ever issues a denial for a claim,they will include their individual contact information on the claim denial.This allows County participants to contact our representatives directly to work through the denial on a consultative basis. No other TPA can make that claim. c. Does FSA administration represent a core business unit or strategy or ancillary administrative product line? Please explain. FSA administration is Navia's core product offering. Navia was founded in 1990 by Jim and Stan Aitken as a third-party administrator of FSA's for school districts and other public sector employers. We have since grown from our humble beginnings to be considered one of the premier administrators on the West Coast with a national reach across all 50 states. d. Will you accept fiduciary responsibility of the plan? If not please explain. Yes. Navia will indemnify and hold the County harmless from and against any and all claims made or threatened by any third party and all related losses, expenses, damages, costs and liabilities, including reasonable attorneys' Fees and expenses incurred in investigation or defense ("Damages"),to the extent such Damages arise out of or relate to the following: i. Any negligent act or omission or willful misconduct by an Indemnitor, its Representatives or its Subcontractor; or ii. Any material breach in a representation, covenant, or obligation of the Indemnitor contained in the Agreement. 2. Please provide an organization chart of employees who would be involved in this account along with their duties, titles,years of experience and physical locations. The County will be assigned a dedicated account management team based out of our main headquarters in Bellevue, Washington. The team will consist of an account executive, day-to- day account manager, and Implementation manager. The account executive (AE) maintains overall responsibility of the County's contract and the account team. The account manager(AM) is the day-to-day contact for the plan contacts for all plan related matters (eligibility, compliance, billing, participant issues, etc...). The AM reports to both their department manager and to the AE. The implementation manager(IM) works directly with the AE during the implementation phase and is responsible for the internal set up of the client accounts in our systems,file testing, banking set-up and drafting all forms and documents. The following individuals are assigned to the team: Name Role/Title Years (Industry/Navia) Stefan Knipp AE/Business Development 6/5 Chelsea Allen AM/Account Manager 6/5 David Rothschild IM/Implementation Manager 8/4 Stefan Knipp Stefan is a member of our business development and sales team. He has served various roles within Navia from implementation to account management and has been involved with all operational aspects of Navia and development of our services. He has served as the program manager for the successful implementation and rollout of our commuter platform, COBRA services, mobile app and wellness benefits. Stefan will serve as the account executive and contract manager for the County. As the Account Executive (AE), he maintains overall responsibility for the account and all members of the account management team will report to him. He will also work with David on the internal implementation. Chelsea Allen Chelsea will serve as the Account Manager(AM)for the County. As the AM, she is the day- to-day contact for the County's representatives and manages the day-to-day administration of the plan. Chelsea has held many roles within Navia and has a very broad understanding of all aspects of plan administration from claims management to data uploads to compliance. She has a well-established track record of providing excellent service for our large group accounts. Chelsea serves as the AM for some of our highest profile clients such as the State of Washington, BECU, Infosys, City of Waco, and Henrico County. David Rothschild David will work with Stefan on the internal implementation of the plans. He will work on all of the customized forms and documents, internal set up in our processing system and the file testing for all data files. David has served Navia as a customer service agent, EDI team lead, program manager and account manager. He has worked with Stefan on several of our high-profile clients and served as the implementation manager for the County of Santa Clara, State of Rhode Island, City of Seattle, City of Detroit, Howard County Public School Systems and Infosys Technologies. 3. In the table below,indicate the number of Public and Private FSA plans your company has in force as of January 1, 2017, by the number of eligible employees. What is the average tenure and average participation rate(i.e.,the percentage of eligible employees who actually participate) among your current FSA clients? Please see below for a breakdown of Navia clients across both the public sector and private sector.The average client tenure is over 10 years and average participation in in 23% of eligible employees. Less than 1,000 1,000—5,000 5,001 — 10,000 10,000+ Public 620 11322 52 14 Private 115 1347 27 11 4. What steps have you taken over the past two (2) years to improve your products and the experience of your customers? What changes do you plan during the next 12—24 months to enhance your member service and technology capabilities? Navia faces two primary organizational challenges that are inherent of all service-based organizations, customer service retention and innovation. In a heavily customer service focused industry, it is our goal to hire and retain top talent throughout the organization.Through Navia's hiring methodology and employee focused values, Navia has retained on average over 85%of our customer service staff year over year. Navia continues to face increased demand for top talent in the Seattle market and is focused on providing excellent employee benefits and perks to all employees.This includes competitive pay,401k profit sharing, and unique perks like free workout classes every day of the week for all employees. When Navia employees are happy and fulfilled in their roles, so are the participants that call our organization every day. Technology and innovation continue to be challenges that we must face as the marketplace changes. Participants are becoming more autonomous and mobile friendly and Navia must provide an easy to use product for every type of user.To do this, Navia has redesigned both the employee and employer interfaces and continues to enhance platforms to make services easier to use. Navia has also launched a proprietary mobile application for claim submission, as well as a service called "FlexConnect, allowing employees to automatically link insurance carriers to their FSA accounts for easier claim submission. Over the next 12-24 months, Navia has several strategic initiatives: 1. Navia is expanding our partnership with a number of payroll providers to more closely integrate systems and information flow.This will benefit the County by having data more quickly feed to our system should the County utilize an integrated partner. 2. Navia will continue to enhance all of our benefit platforms. This will help County employees to use systems more easily and have a positive experience with our interface. 3. Navia will expand our overall benefit offering. We are currently exploring the opportunity to offer consolidated billing for clients. This could be a great additional service in the future for the County. Administration 5. Confirm your ability to administer the plan design exactly as stated in the Plan Documents in terms of benefit levels, covered services, exclusions, claims processing and claim appeal procedures. If not, please specify which provisions and why you are unable to administer them. Confirmed. Navia will administer the plan to required County specifications. 6. How often are claims processed and reimbursements made?Can participants submit claims online,by U.S.Mail,via fax,and by mobile device/app? Do you require a minimum claim amount forsubmission and/or reimbursement? Claims are reimbursed on a schedule set by the County. Navia can administer any reimbursement cycle. Participants can submit claims to Navia through a variety of different methods. Claims can be submitted through mail,toll-free fax,email, online submission,through our mobile app (available on Android and iPhone platforms). Regardless of the submission method,the claim must contain documentation that clearly shows the date,type and cost of service per the IRS regulations. Photos for the mobile phone app can come from the stored photos section or can be taken directly through the app. Participants can also view all account information through the app. In addition to the above methods, Navia developed the FlexConnect tool for auto- substantiation of transactions. FlexConnect allows Navia to auto-substantiate card transactions through insurance carrier data. Participants can create a FlexConnect account and link all of their health care related accounts to Navia. EOBs from carriers are automatically posted to the FlexConnect site and automatically submitted to Navia through the online claim submission tool. The EOB data is matched against any outstanding debit card charges before being submitted as a claim. When participants link FlexConnect to their carriers,they never have to submit manual claims again! FlexConnect is one of our technology differentiators in the marketplace and is considered an industry"best practice". Navia does not require a minimum claim amount for submission or reimbursement. 7. What was your average claim turnaround time for reimbursements(number of days from receipt of a clean claim)for 2014, 2015, and 2016? Claims are processed within 2-3 business days of receipt during our peak times (March and December). Claims are processed within 1-2 business days during our non-peak times. A claim submitted through the online interface, mobile app, or FlexConnect is processed slightly faster than a mail/fax/emailed claim. The following table highlights our claim processing times for 2016. Metric 2014 2015 2016 Entered same day as receipt 24% 23% 26% Entered within 1 business day of receipt 67% 72% 74% Entered within 2 business days of receipt 99.9% 99.9% 99.9% Entered within 3 business days of receipt 100% 100% 100% 8. What steps do you take to ensure that a submitted FSA claim is a covered expense under applicable federal and state laws and regulations? Claims are audited for accuracy on both a random sampling basis during our off-peak times in the summer. We randomly sample processed claims on a weekly basis to determine if the claim was adjudicated correctly and entered correctly into our system. If the sampled claims fall within our acceptable error rate (<0.25%),then we pass the audit. If the error rate exceeds the threshold, then a larger sample size is audited. To date, we have never exceeded the threshold when a larger sample size is audited. The claims accuracy audit is performed by our CSR supervisors and department manager. 9. Will you require substantiation of a recurring eligible expense each time the expense is submitted oronly the first time the expense is submitted? There are several methods for claim submission that do not require documentation from participants including the following: Method#1—Copayment Matching Card transactions that match one of the copayment amounts under the group medical plan are automatically cleared by Navia and do not require substantiation. The copayment amounts are gathered during implementation. Method#2—IIAS Matching Card transactions at IIAS-approved merchants do not require substantiation. HAS is an industry standard that transmits an expense's FSA eligibility along with the card transaction amount. Retail merchants are required to use an HAS system in order to accept an FSA debit card. Method#3— Recurring Expense Matching Card transactions matching a previously approved transaction (amount and provider) do not require substantiation. In addition to the above methods,we have developed an additional method for auto- substantiation of debit card transactions. Navia offers our clients use of the FlexConnect technology. The FlexConnect technology allows Navia to auto-substantiate card transactions through insurance carrier data. Method#4—FlexConnect Participants can create a FlexConnect account and link all of their health care related accounts. EOBs from carriers are automatically posted to the FlexConnect site and automatically submitted to Navia through the online claim submission tool. The EOB data is matched against any outstanding debit card charges before being submitted as a claim. Currently,we are averaging an auto-substantiation rate of 84%(2016) using the IIAS,copayment matching and recurring expense matching methods. For clients that use the FlexConnect technology, the auto-substantiation rate is —94% of all card transactions. The following table highlights the auto-substantiation rates for Q4 2016. Method Rate(%) HAS 48 Copayments 31.5 Recurring Expense 1.5 FlexConnect 13 10. Please confirm that you are able to debit the County-owned bank account as needed to pay for claims reimbursement as stated in #8 of the Scope of Work. If you are not able continue this process please describe the alternate process. Confirmed. We offer our clients two (2) different plan funding approaches, Contribution and Disbursement funding. For Contribution funding,the client remits the actual payroll deduction amounts to Navia through check, wire,ACH or an auto-draft. We ask that plan contributions be sent to Navia within two (2)weeks of the pay date for proper bookkeeping. For Disbursement funded clients, the client reimburses Navia for the claims paid out on each scheduled reimbursement date. The funds are remitted through an ACH or auto-draft. There is a deposit requirement for this funding method and the level of deposit will dictate the payment due date. Typically, payments are due within two (2) business days after the reimbursement date, but can be extended to be up to ten (10) business days with a higher deposit amount. 11. Please confirm that a dedicated account manager for FSA program administration will be assigned to the County's account no later than thirty(30)days prior to Open Enrollment(scheduled to begin October23, 2017). Confirmed.The County will be assigned a dedicated account management team as described in question two (2) of the Scope of Work. 12. Please confirm that it is your expectation that the account manager will respond to emails and phone calls within one (1) business day. If the County is not satisfied with the service or responsiveness of the current dedicated account manager,how will yourfirm work with the County to improve the performance of that account manager? If improvements are not made,will your firm assign a different manager to the County? Navia has invested heavily on customer service over the years and we are confident that the County will be satisfied with the proposed account manager. We spend countless resources to educate and train our staff to deliver the best customer service experience possible. Every one of our representatives is based out of our headquarters in Bellevue,WA and each representative has a direct phone line, direct email address, and direct fax number.This means that you can connect with your account manager on a consultative basis. Our representatives adhere to a strict 24 hour turnaround time on email and phone correspondence.Voicemails are tracked for turnaround times and email is logged for outgoing response time. If the county is not satisfied with the account manager, they will let the account executive know.The account executive would then loop in the employer services management team to discuss any issues and develop an immediate action plan for resolution. If improvements are not made,the County would have full flexibility to be assigned to a different account manager. 13. For each of the following functions,indicate whether the dedicated account manager will coordinate these functions or if the County will have designated contact people. a. Billing/Accounting b. Technical Support c. Customer Service d. Communications e. Legal/Compliance The County's dedicated account manager will be the main point of contact for all questions. 14. Will you generate detailed quarterly account statements to participants, end-of-plan-year warning notices regarding forfeitures, and Open Enrollment confirmation statements? Are you able to provide paper statements and correspondence? Is there an additional cost for paper? If so, please note in your Cost Proposal. Confirmed. All employee communications will be provided to participants by email or mail for no additional cost. Please see attached for communication samples. The following materials are included for participants throughout the plan year: Document Frequency Method* Enrollment Kit Prior to Plan Year E/M Welcome Letter After Enrollment into Plan E/M Account Statement Quarterly/Monthly E/M Notification of Claim Activity Whenever a claim is processed E Notification of Whenever a reimbursement is issued E Reimbursement Notice of Claim Denial Whenever a claim portion is denied E/M Enrollment Confirmation After an enrollment form is processed E/M Account Balance Reminder End of Plan Year E/M *Email(E)or Mailed hard copy(M) 15. Describe the capabilities of your employer portal. Does it allow for multiple County staff to have access to view and change information if needed? What daily functions are available? County administrators have full access to all account related information through the online employer portal and have the following access through the system: • Enroll participants • Add benefits • Transmit eligibility • Terminate participants • Terminate benefits • Manage eligibility • Process LOAs • Access reports • Access forms/documents • Access invoices • Perform NDT testing • View plan metrics 16. Please attach samples of your standard reports and indicate which reports are available on- demand, monthly, quarterly,and annually at no charge. Please see attached for Navia's standard reports.The County's dedicated account manager can provide additional custom reports for no additional fees.All reports are available in real- time through our website and can be downloaded into excel format. 17. Please confirm that you are able to provide biweekly reports detailing any discrepancies between a participant's expected and actual biweekly contribution and annual election. Confirmed. Navia will provide discrepancy reports biweekly for the County. 18. Please confirm that you are able to provide daily and monthly claim payment reports. Will these reports include all plan types and plan years in the same report? Confirmed. We provide our clients with two (2) standard reports on each scheduled reimbursement date, a check register report and an YTD balances report. Both of these reports are created and posted to the online employer portal and an email is sent to the appropriate plan contacts with a convenient link to the secure reports. The check register report is a detailed list of all the reimbursements issued by Navia for that day. It will show the participant name, benefit paid from, method of payment and amount. There will be an additional tab on the report with a detailed list of all settled debit card transactions for the prior day. The check register reports are static reports posted to the online site and are also created whenever a special reimbursement processing is done. All plan types are included within one report. Each plan year would have separate reporting. The YTD balances report is a listing of all plan participants and their YTD claims processed, plan contributions and reimbursements issued. The report is created real-time and shows all of the individual liabilities for participants as well as plan aggregate totals for the County. The YTD balances report can also be dynamically generated through the online portal. We can also include customized ad hoc reporting to the County at no cost. All of our systems are proprietary and we have full control of our production database so that we can generate any type of custom data report for our clients. The customized reporting would be generated by the account manager and posted to the online portal for secure storage and transfer. 19. Please confirm that you are able to provide monthly bank account reconciliation reports in a format approved by the County. Confirmed.The County's account manager will provide a monthly bank account reconciliation report in a format approved by the County. 20. Please confirm that you are able to perform all non-discrimination tests required under applicable laws and IRS guidance, at least quarterly, at no additional charge to the County. Confirmed. Navia will provide full non-decimation testing for the County at no additional charge. 21. Explain how you will keep the County informed of changes to applicable laws and regulations that affect the County's Plan Documents. Do you suggest changes to specific provisions in the Plan Documents? Changes in regulations and laws are communicated to our clients through various means. We have an internal compliance department, led by our compliance officer and counsel that subscribes to all of the regulatory updates from the various agencies involved in FSA administration and compliance. We also subscribe to several outside agencies such as ECFC and the EBIA for their news services and compliance updates. When a new regulation is issued or a new law is passed that affects our clients, our compliance department will analyze the guidance and provide a concise analysis of the regulation and its impact on our clients. This is then communicated to our clients through an email communication. For complex guidance or guidance with a significant client impact, we may schedule informational webinars for our clients' benefit. The webinars would be conducted by a member of our compliance team and give an overview of the new guidance, its impact on clients and a live Q/A portion. If any specific changes are required or recommended to plan documents, Navia's compliance team would make the recommendations for our clients. 22. Please confirm that you will assist the County in interpreting provisions of the County's Plan Documents. Confirmed. Navia's compliance team and account management team will provide assistance to the County in the interpretation of the County's Plan Documents. 23. Do you provide Change in Status or Qualifying Event request review and determination services (as stated in Scope of Work#15)for clients? Is there an additional cost for this service? Ifso,please note in your Cost Proposal. No.This is a service that should be facilitated by County administrators as it is an adjustment that must be coordinated through the payroll department for the County. 24. How do you coordinate and communicate with clients and/or their third-party billing firm to: a. Identify COBRA-eligible participants who have separated from service and maintain a record of COBRA participants'contributions and claims? As a standard process, Navia would provide balance information to the County at the time of the employee's separation. It would then be the responsibility of the County to Notify the COBRA administrator of the QB's eligibility. Navia can provide full COBRA administration for the County for all COBRA eligible plans as an additional service. We can also provide COBRA services for the FSA plan only for a flat fee of$50 per month. b. Manage the accounts of participants who are on unpaid leave of absence? It is important to discuss Leave of Absence (LOA) options with the employee before they go on leave.The Family Medical Leave Act (FMLA) provides the rules regarding LOA options. First,the County will need to determine whether the employee wants to continue coverage during leave. If so, expenses incurred during leave are eligible.Then determine how they will fund the benefit.There are three funding options: 1) accelerate contributions out of the last paycheck before leave begins; 2) pay-as-they- go by sending contributions to the employer each pay period (similar to COBRA); and 3) catch-up payments upon return. The County would not record a LOA date with Navia and expenses incurred during leave would be eligible. If the employee revokes FSA coverage, expenses incurred during the LOA are not eligible for reimbursement. Upon return from leave,the employee may resume their original per paycheck deduction (thereby decreasing their annual election by the amount of the missed contributions) or they may increase their per paycheck deduction to meet their annual election.The County must record a LOA start and end date with Navia to ensure ineligible expenses are not reimbursed. 25. Please confirm that you have reviewed the Model County Contract(Exhibit E)and are able to comply with the terms and conditions, including:4.Termination,7. Health Insurance Portability and Accountability Act, 10. Hold Harmless, 11. Insurance, and 14. Governing Law. Please note any exceptions and provide a detailed remedy. Confirmed. Navia would request mutual rights to termination and mutual indemnification for both parties. Account Transition 26. Implementation a. Provide a sample implementation calendar detailing the work plan for implementation of FSA program administration,including the personnel required from vendor and Countyand whateach entity is responsible for; assume a July 1, 2017 selection date and a January 1, 2018 effective date. Please see attached excel exhibit labeled "Navia Proposed Implementation Plan" for a detailed timeline of every step involved throughout the entire implementation process. The attached timeline would be tracked each week to verify that each task has been completed for the County. It is a proposed timeline that can be adjusted to meet the needs of the County. b. Please provide copies of any informational brochures/guidelines you could provide for eligible employees and confirm that all materials will be available by September 1, 2017. Please see attached for all participant communications. Navia takes a consultative approach to all materials and will work with the County's team to make sure all communications meet their standard. The County will have the opportunity to review all correspondence that is sent to employees and we will provide custom communications for no additional charge. Forms will be ready in advance of September 1, 2017. c. Confirm that your implementation manager and account executive would meet with County benefits staff in Fresno for a kickoff meeting. Confirmed.The implementation process is managed by the designated account executive, account manager, and implementation manager. The first step is to complete the online group application. This gives Navia all of the data needed to establish the County within our systems, create all communication materials and begin the file testing. Navia will schedule a kickoff meeting with the County so that all parties can complete the group application together. Once the group application is completed, the implementation manager will set up the client in our system environment.Within a few days all forms and materials are drafted and sent to the County's team for review. 27. Describe how you would transition accounts, including any black-out periods involved: a. Include your capability to transition account history(contributions, claims, etc.). b. Describe the communication support you would provide. The following timeline would apply if the County would like Navia to handle the administration of the claims run-out period and Grace Period for the 2017 plan year. Typically,the run-out period would be handled by the prior TPA, but we want to make sure it is addressed within our implementation timeline if this is something that the County would require of the new TPA. The following tasks are associated with the takeover of a prior claims run-out period. These steps are independent from the timeline for new services. Task Date(s) Party Notify current administrator that County will transfer 9/1/2017 County administration of the 2017 claim run-out (with 2 % month Grace Period or$500 carryover) to Navia Notify current FSA participants that the claim run-out 10/1/2017 County/Navia administration is being transferred to Navia Send reminder notice to current FSA participants regarding 12/1/2017 County/Navia the transfer of administration from current administrator to Navia Link to webinars for current participants Link to any forms County would like to include Receive census file of 2017 plan participants 12/15/2017 County Institute a claims black-out period for participant to allow 12/19/2017— Current any manual claims submitted to be process 12/31/2017 Administrator Receive YTD balances file from County for the transfer of 1/4/2018— Navia plan data 1/5/2018 File tested and uploaded — Confirmation statements,welcome letters and claim forms mailed 2017 Claims run-out services commence 1/9/2018 Navia 28. Please explain how you would facilitate claims incurred prior to January 1,2018 but submitted to you for processing. How would you help with the run out period? Typically the run-out period would be administered by the prior TPA as it allows for a smoother transition for participants. If the County would require Navia to administer the run- out period for the 2017 plan year,there would be a blackout period for participants where they could not submit claims to either the prior TPA or Navia. During this time, participant account balances are transferred over to Navia and accounts are closed with the prior TPA. After Navia receives the takeover data,we will accept claims for any eligible dates within the prior plan year. 29. Will you be willing to put a dollar amount or percentage of fees at risk if implementation goals are not met? If so, please provide a detailed explanation and note in your Cost Proposal. Yes. Please see the Cost Proposal section for all performance guarantees. Participant Services and Communication 30. Describe the structure and staffing of your customer service office: a. What are your member service hours of operation? Navia takes great pride in our customer service team. Our customer service department for the County is based in Bellevue,WA and has over 50 representatives. Every representative has a personal email address, phone number and fax number so that County participants can call or email our representatives directly. We also have a general toll-free number that participants can call between the hours of S:OOam through S:OOpm, Monday through Friday. Furthermore, if one of our representatives ever issues a denial for a claim,they will include their individual contact information on the claim denial.This allows County participants to contact our representatives directly to work through the denial on a consultative basis. No other TPA can make that claim. b. What are your 24-hour customer service capabilities? We provide 24/7 online account access for participants as well as 24/7 access through a mobile app. All of the data is updated in real-time for both types of access. There is an after-hours voicemail for any after-hours calls. Given our location and hours, we do not anticipate that County employees will be unable to reach a live customer service representative. We do not use any type of IVR system for customer service (during or after-hours). Although an IVR system may streamline customer service for the TPA, it often comes at the expense of the customer's experience and satisfaction. An IVR system is not consistent with our philosophy of providing best-in-class customer service.All after- hours voicemails are returned the following business day. c. How many CSR's will be assigned to the County of Fresno and what is their average tenure? Navia generally takes a group approach to customer service to ensure timely support for participants. Every Navia customer service representative would be trained to handle County calls,though we have the capability to assign dedicated representatives if the County would require this.The County would be introduced to customer service staff during the weekly all hands meeting.Any specific naming conventions or special plan parameters would be reviewed with all representatives. Furthermore, any special notes for the County will immediately display on a customer service member's computer screen before they can proceed to a County participant's account.This ensures that each Navia representative is fully briefed on any special plan design parameters prior to fielding a call from a participant.The average tenure for Navia customer service representatives is over two (2)years. 31. For 2016, provide the following customer service statistics: a. Total number of calls received b. Average hold/wait time c. Average hold/wait time between January and March d. Average phone call abandonment rate e. Percent of telephone inquiries resolved during initial call f. Will the County have access to these statistics for our participants? Navia tracks the following metrics for participant inquiries. If there is any custom reporting required, the County's account manager can accommodate alternative reporting specific to the County's plan. Metric 2015 2016 Total Calls 194,832 207,863 Average Speed to Answer 6 seconds 7 seconds Call Abandonment Rate 0.4% 0.5% Average Handle Time 3:28 3:23 One Call Resolution 96% 97% 32. Provide a complete description of your customer service procedures from receipt of a question or complaint to complete resolution. Do your customer service representatives record each call and are calls monitored for quality?Will you contact and communicate directly with participants as required to resolve problems or to respond to questions? All questions are tracked within our system and are reported directly to the customer service supervisors. If there is a complaint,the customer service supervisor will attempt to resolve the issue and if a resolution cannot be met,the County's account manager would be notified.The account manager would assess the individual situation and notify the County of the attempted resolution and results.The County would then have discretion on how to resolve the issue further. We stand by our services and our word and are willing to put our fees on the line through aggressive performance guarantees. Within our performance guarantees, we include metrics for open inquiries and aim to resolve 95%of open inquiries within 5 business days. All calls have the option to be recorded based on the discretion of the CSR.All calls are tracked for resolution and notes are taken and saved by the CSR after each call.This allows our team to know the detailed history of each participant's calls in order to provide the best service possible. Every representative has a personal email address, phone number and fax number so that County participants can call or email our representatives directly. Navia representatives will freely provide their direct contact information to County participants to help resolve any issues quickly. 33. Describe yourguidelines and requirements for continuing education among yourstaff forcompliance and regulatory issues, customer service,and client-specific account information. All new CSRs receive a mandatory month-long training before speaking with participants. During the training, there is a series of quizzes to ensure knowledge retention of the complex benefits offered at Navia.As each CSR moves through their education,they answer mock calls with the customer service training team.After the representative is ready for live phone calls, a customer service supervisor will monitor their progress and listen to calls incase support is needed. Ongoing, each CSR has monthly check-ins with a supervisor to ensure all questions are answered and any updates to systems or processes are communicated. Client specific account information and updates are provided for all Navia team members during weekly briefings. Any new account changes or updates would be provided along with guidance for how to handle. Whenever an IRS regulation, notice or revenue ruling is changed, Navia receives notice of it through our subscriptions to the respective agency's update service. Our compliance department reviews the issued guidance and then prepares an immediate announcement to team members and clients notifying them of the update and that further guidance will be issued. The compliance team and compliance officer will then draft a more concise analysis of the regulation and send out an emailed blast to our clients.The notice will emphasize the importance of the regulation and any immediate action that the client needs to take. In some cases, we will also schedule informational webinars to give clients and their benefit consultants an opportunity to ask further questions and hear a more in-depth analysis of the IRS changes. 34. How often do you measure participant satisfaction with your program? Please attach a copy of the most recent survey with results, if available. Are you willing to conduct an annual employee satisfaction survey of County of Fresno participants?Will you be willing to put a dollar amount or percentage of fees at risk if participant satisfaction goals are not met? If so, please provide a detailed explanation and note in your Cost Proposal. Customer service performance is measured through several metrics outlined in question 31 of this document. While we rely on metrics to ensure timeliness and accuracy of calls,we also rely on the feedback from our client partners and participants.All positive feedback is rewarded through a points system called "Navi Notes".As CSRs receive positive email feedback or call feedback,they are rewarded and can use their"Navi Notes"towards rewards like movie tickets, having their car washed by a supervisor, etc.Any negative feedback is incorporated into the CSRs next review and an action plan is put in place to correct any issues that arise. Navia will be launching a company-wide satisfaction survey in 2017 and would be willing to provide specific survey results for County participants as well as performance guarantees. 35. Please confirm that you offer a website where participants may check the status of their account, submit a claim, and review requests for additional information for a pending claim. Please list any additional capabilities available and include any hardware or software requirements necessary to access the website. Please provide a sample web page and dummy account for the County to review. Confirmed. Navia participants can fully manage their accounts through the online participant portal. Participants are able to perform the following functions through their online account access: • Update address • View account balances • Submit online claims • Enroll in direct deposit • View transaction history • Verify card charges • View claim denials • Transmit carrier EOB data • Access forms/documents • Reset mobile app • Request debit card* The demo participant portal can be accessed by using the following information: Web Address: www.naviabenefits.com Username: clarkkent Password: clarkkent 36. Do you provide a smartphone application for participants? If yes, please explain what services are provided through the smartphone application and include any hardware or software requirements necessary to access the application. Yes. Participants can access their plan information through our mobile app that is available on both iPhone and Android platforms. Participants can perform the following functions through the mobile app: • Update address • View account balances • Submit mobile claims • Enroll in direct deposit 0 View transaction history 0 Verify card charges • View claim denials Request debit card* • Access forms/documents An FSA claim may be submitted to Navia through mail,toll-free fax, email, online, mobile application, or FlexConnect. The participant must submit a completed one-page claim form along with documentation that shows the date, cost and type if service. These are the industry standards for verifying an expense's eligibility. With online and mobile application entry,there is no claim form to complete and submit. The participant enters the claim detail online or through the mobile app interface and either uploads an image of the documentation or takes a photo of the documentation. An email notification is sent confirming receipt of an online or mobile app submission. The claim is routed through our LaserFische document imaging software through its entire lifecycle. This allows us to properly track and archive the claim. All faxed, emailed, online and mobile app claims are routed through LaserFische. Mailed claims are sorted and manually scanned into LaserFische. All of our mailed claims are audited to verify proper scanning before they are stored for one (1) month and then shredded. Navia's FlexConnect tool allows participants to directly link any insurance carrier to our platform.Any time an EOB is posted to the carrier's website,the participant will receive a notification and can submit it to our team for automatic processing.The FlexConnect tool has helped to reduce substantiation requirements for participants and has increased overall participant satisfaction. Please see attached fact sheet for more information about this program. FlexConnect is available to County participants at no additional charge. 37. Please describe your strategy for promoting the programs and educating employees on the benefits of the programs, with particular emphasis on the Dependent Care and Parking/Commuter programs. Navia believes strongly in educating employees right from the start of the plan year. To accomplish this, we approach education from a variety of angles including in-person meetings, webinars, print communications, online communications, social media, and video instruction. There are specific educational handouts and online videos that can be highlighted to increase participation for the commuter and dependent care programs. A typical enrollment meeting takes about 20-30 minutes and we start with the basics of the different plan designs (plan year, reimbursement structure, etc.). Once the education portion of the meeting has concluded, we review the logistics of how the benefit actually works. This includes discussing online account access, the mobile app, how to get a reimbursement and the debit card. We will also review investment options for the HSA and discuss the differences between the FSA and HSA options for employees. Once the presentation portion is over,the meeting is opened up for live Q&A. We follow this format for both live meetings and for our webinars. Navia also understands that not all clients are the same, so we are willing to customize each meeting to meet the County's specific needs or concerns. 38. Briefly describe the printed materials you offer employees regarding Flexible Spending Accounts (flyers, brochures, etc.)and the purpose of each one. Do you have separate communications for the DebitCard that detail the restrictions and responsibilities that come with using the Card, such as when and why substantiating information is needed? Do you provide hard-copy welcome kits, webinars and/or on-site seminars? Please provide sample communications materials and describe any additional cost associated with these services. All employee communications will be provided to participants via email or mail. Please see attached for communication samples. Navia also has many additional communication pieces, including a debit card flyer that can be customized to fit the needs of the County.The following materials are included for participants throughout the plan year: Document Frequency Method* Enrollment Kit Prior to Plan Year E/M Welcome Letter After Enrollment into Plan E/M Account Statement Quarterly/Monthly E/M Notification of Claim Activity Whenever a claim is processed E Notification of Whenever a reimbursement is issued E Reimbursement Notice of Claim Denial Whenever a claim portion is denied E/M Enrollment Confirmation After an enrollment form is processed E/M Account Balance Reminder End of Plan Year E/M *Email(E)or Mailed hard copy(M) 39. Please confirm that you are able to provide at least one (1) representative at the annual health and wellness fair as well as all other satellite fairs to assist with plan enrollment as stated in Scope of Work #22. Confirmed. Navia will provide the necessary resources to attend County health benefit fairs. We can also host a series of webinars and create instructional videos for employees. Debit Card 40. Please confirm that you offer an optional debit card to Health Care FSA participants and that each participant will receive at least two(2)cards. Please also confirm that debit card participants are still able to submit manual claims and receive reimbursements. Confirmed. Navia will mail all debit cards to participants for no additional charge. One debit card will be provided initially and participants can request a second card for a spouse or dependent for no additional fee. Debit card participants are still able to submit claims to Navia through any other available method including the following methods: An FSA claim may be submitted to Navia through mail, toll-free fax, email, online, mobile application, or FlexConnect. The participant must submit a completed one-page claim form along with documentation that shows the date, cost and type if service. These are the industry standards for verifying an expense's eligibility. With online and mobile application entry,there is no claim form to complete and submit. The participant enters the claim detail online or through the mobile app interface and either uploads an image of the documentation or takes a photo of the documentation. An email notification is sent confirming receipt of an online or mobile app submission. The claim is routed through our LaserFische document imaging software through its entire lifecycle. This allows us to properly track and archive the claim. All faxed, emailed, online and mobile app claims are routed through LaserFische. Mailed claims are sorted and manually scanned into LaserFische. All of our mailed claims are audited to verify proper scanning before they are stored for one (1) month and then shredded. Navia's FlexConnect tool allows participants to directly link any insurance carrier to our platform.Any time an EOB is posted to the carrier's website,the participant will receive a notification and can submit it to our team for automatic processing.The FlexConnect tool has helped to reduce substantiation requirements for participants and has increased overall participant satisfaction. Please see attached fact sheet for more information about this program. FlexConnect is available to County participants at no additional charge. 41. Please confirm that you adhere to the claim substantiation rules contained in IRS Revenue Ruling 2003- 43 and IRS Notice 2006-69 and describe how the debit card distinguishes between valid FSA purchases and other goods that are not eligible for reimbursement. Confirmed. Navia adheres to all IRS claim substantiation rules. If a transaction cannot be verified as eligible,the participant must verify each incomplete debit card swipe within 75 days of the transaction. A monthly statement itemizing all outstanding Navia card transactions that require substantiation is sent at the beginning of each month. The participant must submit some type of documentation that clearly indicates the date,type and cost of service. These are the same guidelines required by the IRS to process manual claims for reimbursement. The following methods allow participants to utilize the card without having to provide additional documentation. Method#1—Copayment Matching Card transactions that match one of the copayment amounts under the group medical plan are automatically cleared by Navia and do not require substantiation. The copayment amounts are gathered during implementation. Method#2—IIAS Matching Card transactions at IIAS-approved merchants do not require substantiation. HAS is an industry standard that transmits an expense's FSA eligibility along with the card transaction amount. Retail merchants are required to use an HAS system in order to accept an FSA debit card. Method#3—Recurring Expense Matching Card transactions matching a previously approved transaction (amount and provider) do not require substantiation. In addition to the above methods, we have developed an additional method for auto- substantiation of debit card transactions. Navia offers our clients use of the FlexConnect technology. The FlexConnect technology allows Navia to auto-substantiate card transactions through insurance carrier data. Method#4—FlexConnect Participants can create a FlexConnect account and link all of their health care related accounts. EOBs from carriers are automatically posted to the FlexConnect site and automatically submitted to Navia through the online claim submission tool. The EOB data is matched against any outstanding debit card charges before being submitted as a claim. Currently,we are averaging an auto-substantiation rate of 84%(2016) using the IIAS,copayment matching and recurring expense matching methods. For clients that use the FlexConnect technology, the auto-substantiation rate is —94% of all card transactions. The following table highlights the auto-substantiation rates for Q4 2016. Method Rate(%) IIAS 48 Copayments 31.5 Recurring Expense 1.5 FlexConnect 13 42. How do you ensure the debit card is deactivated when a participant separates from service or fails to make a contribution? This is an automatic function of Navia's processing system. If a card transaction has not been verified within the 75 day timeframe, the card will automatically be pended on the 751h day within Navia's system. A participant would then have to provide required documentation or offset the transaction with an eligible expense. If an employee is terminated, the card will immediately shutoff at the time the termination is reported within the Navia portal. 43. Please describe your procedure(s) for assisting clients with correction procedures for improper health flexible spending account payments pursuant to IRS Memorandum number 201413006. a. What parts of the process do you manage, and what is the employer responsible for? If a claim is deemed to be ineligible after the initial payment was processed,then the first course of action is to cancel the payment. If the payment has already been deposited,then the participant is contacted and Navia will work with the individual to recoup the funds. If the funds cannot be recouped (e.g. a terminated employee),then a 1099 is issued for the amount of the reimbursement. There is no standard communication sent for recovering overpayments as each instance is handled on a case-by-case basis. b. What is the schedule for deactivating a card if a participant fails to provide substantiating documentation and how do you communicate with the participant that this is happening? What appeals process is in place for a participant whose debit card claim is denied? Once the participant logs into their online account, a list of all their unsubstantiated card swipes is listed on their home page with convenient links to initiate the substantiation process. If the participant has opted out of emailed communications or does not have an email address on file,then a letter requesting the substantiation is mailed to the participants. The letter will list all of the card swipes that are pending substantiation. Participants can also verify card transactions through the mobile app at any time. When opening the mobile app, the card transactions requiring substantiation are prominently displayed so that the user can tap the transaction and then upload a picture of the documentation. The participant must submit some type of documentation that clearly indicates the date, type and cost of service. These are the same guidelines required by the IRS to process manual claims for reimbursement. Each card transaction that requires after-the-fact substantiation must be substantiated within 75 days of the card swipe. If a card swipe is not substantiated by the deadline or it is determined that the card transaction was for an ineligible expense, then the card is immediately suspended from further use for that benefit. A standard email notification is sent to the participant when the card is suspended. If the participant has any card transactions that require substantiation, a notification email is sent to them at the beginning of the following month indicating so. The email contains a convenient link to the online account landing page and a reminder to verify the transactions to prevent card suspension. Option#1 -Claims Offset(default) Any future claims are applied automatically against the outstanding card transaction and the card is reactivated. For example, participant A has an outstanding$23.89 deficit. They submit a $50 manual claim. The participant is reimbursed the $26.11 difference and the card is reactivated. If they do find the original receipt for$23.89 and submit it to Navia, then we will reimburse this amount from their original $50 manual claim. Option#2-Plan Reimbursement The participant reimburses the plan for the amount of the card transaction. This will remove the transaction from the account entirely and free the funds up for further use. Participants can send Navia a check for the amount or initiate an ACH payment to Navia through our Web site. If neither of the above options occurs,then the employer is notified as part of the end- of-year reports. A report listing all participants with outstanding card transactions is supplied to the employer with the final audited plan reports. Technically,the outstanding amounts are considered ineligible expenses and must be recouped by the Plan. The employer can require the participant to repay these amounts through a check or payroll deduction. If the employer does not require repayment of these amounts, then the amount should be included as imputed income on the employee's W2. If the claim payment was due to Navia's negligence and cannot be recouped,then Navia bears the liability for that claim payment. c. What is the timing and process for reactivating cards once a situation is resolved? Cards are reactivated immediately after the offset or plan reimbursement is processed within Navia's system. Information Transmission. Retention and Security 44. Please confirm that you are able to use the current biweekly census file format(Exhibit H). If not, please provide your file specifications. Navia recommends the use of our file specification for ease of participant processing. Please see attached. For the commuter benefits program, we recommend sending eligibility information only to Navia. From the current specifications, it appears that the County is sending order information as well. We have outlined both scenarios and pros and cons of each below: 1. Participants place orders through Navia's system: For the commuter plan, typically participants would place orders through the Navia website each month between the 1't and 20th. Orders would then be distributed to them before the Vt of the next month. Administratively, Navia would then post the "payroll deduction report"to the employer portal on the 21't of the month prior.This report lists all orders placed for the upcoming month. We then post the final version on the 23rd and direct debit the County's account for all orders and distribute them to participants. The County then takes the same "payroll deduction report" and uses it to take payroll deductions through their system on the next pay period after the 23rd.This is the standard recommended process because it gives participants the flexibility of our commuter platform and ordering options that an HRIS system will not allow. (Recommended) Options available to participants: • Transit debit card—Participants can have funds loaded to the debit card.They would then use the debit card to purchase any type of transit pass they need. • Vanpool— If participants participate in a vanpool,their election amount will be either sent to them via check or direct deposited to their personal bank account. They would then be able to pay out-of-pocket for their vanpool expenses. • Clipper direct—Participants would be able to order and reload Clipper cards directly through Navia's website. • Parking debit card—Participants can have their parking funds loaded to the debit card.They would then use the debit card to pay for parking directly at the parking garage. • "Pay Me Directly"for parking—If participants use a cash only parking lot, then they can elect to have their funds sent to them via check or direct deposit.They would then be able to pay out-of-pocket for the parking expenses. 2. Participants place orders through the County's system: If the County would prefer to have participants place commuter orders through their HRIS system,the process would be as follows: County would need to send us a report by the 10' each month listing all of the orders for the upcoming month. We would then load the orders into our system and disburse funds to participants before the 15Y of the month. This is not the recommended method because participants lose a lot of ordering flexibility. For example,there are a few different options that participants can choose through our website for commuter—to have funds loaded to the debit card, directly to a clipper card, or vanpool. If they place orders on a third party platform,there is not a way for us to know what type of order the participant wants.All the third party HRIS system would typically be able to tell us is that there has been an order placed for$XX. We would not know whether funds should be loaded to debit cards or Clipper cards unless the HRIS vendor somehow built that as an option on their order platform. (Not Recommended) Options available to participants: • Transit debit card—Participants can have funds loaded to the debit card.They would then use the debit card to purchase any type of transit pass they need. • Parking debit card—Participants can have their parking funds loaded to the debit card. They would then use the debit card to pay for parking directly at the parking garage. 45. Please confirm that you are able to accommodate the data encryption and transmission protocols as stated in Scope of Work#28. If not, please explain. Confirmed. Navia provides SFTP access and secure file sharing through the online employer portal for the County. 46. How do you ensure client confidentiality consistent with current HIPAA requirements? Is your system HIPAA compliant for data security? Explain how. Navia has several security safeguards onsite to protect participant information. Our physical access is controlled with a fob and PIN system which allows logging of all employee access. All entrances are monitored with video cameras. Logical access is controlled with username and password. Access is permission and role-based. Navia is also fully compliant with all HIPPA standards and we act as a business associate for all of our clients. At Navia,we take data security very seriously and have taken several measures to ensure our data security. The following list is a sample of the measures we have taken to protect our client's data. o Automatic log-off from computer o Firewall for Internet access after specified time period o Healthcare data not available to external o Force password change after 90-day network time period o Strong encryption required for Internet and o Role based access profiles Extranet users o Secure server room (locked and log in o Authentication and Digital signatures list) required for Internet and Extranet users o Network security, no external o Mobile access (laptop/handheld) physical network access except email on protection and data encryption portable device o Virus checking all files and electronic mail o Secure backup, storage and retrieval o Run anti-intrusion programs o Emergency data access assured in o Stay up on CERT alerts case of disaster, Data content o Scalable confidentiality and security integrity assured, Operations procedures recoverability—battery backups for o Security/confidentiality group outages, nightly tape backups tapes o Designation of an information security stored offsite. officer in the organization o Policies and procedures in place for o Education and training programs for all Access Monitoring,to detect misuse employees and violations o Sanctions for violation of policies and o Policies and procedures strictly procedures enforced o Participant authorization forms for o Internal security audits disclosure of health information o External security audits o Periodic security reminders and user education o Access to audit logs 47. Describe your information technology infrastructure including back-up, security, and disaster recovery procedures?Are files archived and stored at an off-site location?Have procedures been tested?When did you last perform a full-scale disaster recovery test and what were the results? Navia is committed to maintaining a high level of data security for our clients. As a HIPAA Business Associates, we are bound to strict standards, safeguards and protocols regarding data security and how personal health information is handled. We take the general stance that all data we receive in the course of administration is considered PHI. In addition to the HIPAA guidelines, we have taken additional measures to ensure that our databases are physically secure and that our network is secure. The following is a brief list of the measures we have taken to comply with HIPAA and to maintain data security. — Business Associates agreement in force with all of our clients — Designated Privacy Officer — Documented disaster recovery plan in place — Physical security measures for all of our servers — Technical security safeguards including redundant firewall security for all servers and our main network — Workstation level security — Program level security — Internal and external security audits by a third party on a yearly basis Our disaster recovery process depends on the type of disaster. If one machine fails, other machines with installed software have the data restored to them and brought online. If multiple machines fail and/or our location is uninhabitable, a temporary location is rented. Equipment and software purchased and data restored to those machines. Our data is backed up to a local device which encrypts the data and then stores a copy in the cloud. Quick restores can be done locally and large or bare metal restores can be done with cloud stored data.The system is tested on a quarterly basis. 48. How long are records retained? In what manner are they retained? Records are maintained on Navia's servers for a period of eight(8) years. C. When reports or other documentation are to be a part of the proposal a sample of each must be submitted. Reports should be referenced in this section and submitted in a separate section entitled"REPORTS." Confirmed. Please see attached for all Navia sample reports. D. A complete description of any alternative solutions or approaches to accomplishing the desired results. Navia agrees with and recommends a system set-up as proposed by the County. Proposal No. 17-073 Page 18 COST PROPOSAL A. In the table below, indicate the biweekly per participant cost for each category— Health and/or Dependent Care, Transit and/or Parking,and Participants in both—and the total annual cost based upon the expected number of participants. Please state your proposed fees based on a three (3) year agreement with two (2) optional one-year renewals. Health and/or Transit and/or Participants in both Dependent Care Parking Health/DCAP and (1,691 Participants) (33 Participants) Parking/Transit Biweekly Per $1.20 $1.20 $2.40 Participant Fee Total Annual $52,759 $1,029 $53,788 Administration Cost B. Will your company guarantee pricing during the length the contract term, including renewals? Confirmed. Navia will guarantee rates for the life of the contract until the County chooses to go out to bid again. C. Are fees higher if participants request paper statements? If so, please indicate the difference for each fee category in "A" above and the conditions which would trigger higher fees. No. Printed statements are included for no additional charge. D. Does your per participant rate decrease based on program enrollment milestones? If so, please indicate the difference for each fee category in"A"above. Please also indicate whether any of the proposed rates are tied to a minimum enrollment. Rates are not tied to any minimum enrollment. Navia is willing to decrease rates based on target enrollment numbers. If the County program reaches the following targets,fees will be reduced as outlined below. Number of Participants Cost 2,000 Participants 1.18 per pay period 2,500 Participants 1.16 per pay period E. Please confirm that non-discrimination testing, as requested in the Scope of Work, is included in the administrative fee. If not, please specify the additional cost. Confirmed. Navia will provide all nine (9) non-discrimination tests for no additional charge. F. If applicable, please detail any fees your firm will put at risk for failing to meet stated goals. We stand by our services and our word and are willing to put our fees on the line through aggressive performance guarantees.To date, we have never failed to meet a performance guarantee for any of our clients. These are our suggested performance guarantees and we are willing to work with the County to design additional/replacement guarantees. The proposed performance guarantees place up to 35%of fees at risk for year 1 and 25%of fees at risk for subsequent years for the County. Plan Implementation(First Year Only) Standard ` Guarantee ` Amount Measurements) Timeline Vendor will provide and maintain for the client 5% Timeline a detailed timeline of implementation activities and "key"deliverable dates throughout the implementation process Systems Systems will be ready in advance as follows: 5% The date plan • System ready for testing 45 days prior structure,on-line to plan effective date and ready for live benefit tools and claims on effective date. systems are ready • Ready to answer pre-enrollment calls Customer Service by start of open enrollment and at readiness for least 60 days prior to 15Y plan renewal member inquiries date. throughout the Annual Eligibility system loaded and operational prior Enrollment period to effective date. to the effective date Participation in annual enrollment events,as requested by the client Ongoing Performance Guarantees Standard Guarantee Amount Measurement CUSTOMER SERIVCE Average Speed to 95%of all member service calls will be 5% Semi-Annual Answer(ASA) answered within 30 seconds Reports Standard (continued) Guarantee Amount Measurement Call Abandon Rate The call abandonment rate will be less than 5% Semi-Annual 1.5% Reports Open Inquiries 95%of all open inquiries(callback,claim 5% Semi-Annual (Closure Times) adjustment,etc.) placed by plan participants Reports and providers to the service facility completely resolved within 5 business days Resolution or 98%of all formal complaints and appeals 5% Semi-Annual Response to Written resolved within 30 calendar days Reports Complaints/Appeals Debit Cards • 100%of debit cards mailed at least 10 5% Date debit cards business days prior to plan year are mailed G. Please detail any and all other possible charges/expenses/fees applicable to the administration of the programs. No additional fees will be charged for administration of the plans. Proposal No. 17-073 Page 29 CHECK LIST This Checklist is provided to assist vendors in the preparation of their RFP response. Included are important requirements the bidder is responsible to submit with the RFP package in order to make the RFP compliant. Check off each of the following (if applicable): 1. X Signed cover page of Request for Proposal (RFP). 2. X Check https://www2.co.fresno.ca.us/0440/Bids/BidsHome.aspx for any addenda. 3. X Signed cover page of each Addendum. 4. X Provide a Conflict of Interest Statement. Signed Trade Secret Form as provided with this RFP (Trade Secret Information, if provided, 5. X must be electronically submitted in a separate PDF file and marked as Confidential). 6. X Signed Criminal History Disclosure Form as provided with this RFP. 7. X Signed Participation Form as provided with this RFP. 8. X The completed Reference List as provided with this RFP. 9. X Verification of Department of Industrial Relations Contractor Registration. Verification of Contractor's License and the Department of Consumer Affairs—Contractors' 10. X State License Board Indicate all of bidder exceptions to the County's requirements, conditions and specifications 11. X as stated within this RFP. Bidder's proposal, in PDF format, electronically submitted to the Bid Page on Public 12. X Purchase. Return Checklist with your RFP response G:APublic\RFP\FY 2016-17\17-073 County Flexible Spending Account Administrator\17-073 County Flexible Spending Account Administrator.doc �EGOUN �navla County of Fresno Proposed Implementation Timeline O sb Action Item Responsible Party Due Date Actual Completion Date Completed(Y/N) Comments Ad Award of Contract County 7/1/17 No County to award Contract to successful applicant. Direct Debit Form County 7/10/17 No Date County sends debit form back to Navia. Finalize Contract Navia/County 9/1/17 No J County will sign contract and will return to Navia. FSA Items Initial test file is sent Payroll Vendor 9/18/17 No Payroll Vendor will send test files to Navia. 1st Test file results provided Navia 10/1/17 No Navia will test and provide feedback on file. 2nd test file is provided(if needed) Payroll Vendor 10/7/17 No County will provide updated file. FSA Enrollment Guide sent Navia 10/11/17 No Date Navia sends to County. Health Care FSA flyer sent Navia 10/11/17 No Date Navia sends to County. Limited Health Care FSA flyer sent Navia 10/11/17 No Date Navia sends to County. Day Care FSA flyer sent Navia 10/11/17 No Date Navia sends to County. $500 Carryover FSA flyer sent Navia 10/11/17 No Date Navia sends to County. FSA claim form sent Navia 10/11/17 No Date Navia sends to County. Cool features for FSA document sent Navia 10/11/17 No Date Navia sends to County. Navia Debit Card Employee Overview Navia 10/11/17 No Date Navia sends to County. FlexConnect Fact Sheet Navia 10/11/17 No Date Navia sends to County. Navia feedback given on 2nd test file Navia 10/12/17 No Navia will test and provide feedback on file. Payroll Vendor sends 3rd test file(if needed) Payroll Vendor 10/22/17 No County will provide updated file. County will host FSA OE for employees.Elections will be made in Payroll Vendor's system,by paper form,or through Navia's online system and elections will be sent to Navia at the end of open FSA Open Enrollment held County/Payroll Vendor/Navia 10/23/17 to 11/9/17 No enrollment. FSA Mobile app document sent Navia 10/31/17 No Date Navia sends to County. Test file is approved for production Navia 11/11/17 No Navia will approve file for production. FSA Confirmation statement/communications review County 11/14/17 No County will review and provide feedback on confirm statement. County send any necessary internal FSA announcements to County internal FSA communication is sent County 11/17/17 No employees. FSA OE file sent(if needed) Payroll Vendor 12/2/17 No Payroll Vendor will send file for upload. FSA OE file imported Navia 12/6/17 No Navia will process elections file. FSA Debit cards sent Navia 12/9/17 No Debit cards will be issued within 7-10 business days. FSA Confirmation emails sent Navia 12/10/17 No Confirm statements for newly enrolled participants will be sent out. Payroll Vendor or County will send initial deduction file for first pay FSA deduction live file processed Payroll Vendor/County 1/13/18 No date in January. Send reminder notification to 2017 FSA participants re:transition from Current Vendor County 11/17/17 No This document will be sent by County to FSA employees. Send blackout reminder email County 12/1/17 No This reminder should be posted on County intranet. FSA blackout begins Navia/Current Vendor 12/19/17 No Current Vendor will initiate FSA blackout. ' ,�EGOUN �navla County of Fresno Proposed Implementation Timeline O s6 �r Action Item Responsible Party Due Date Actual Completion Date Completed(Y/N) Comments Debit card suspended from further use Current Vendor 12/19/17 No Debit cards with prior vendor are discontinued. Final 2017 payroll deduction report processed Current Vendor 12/31/17 No This needs to be done before the plan data is transitioned to Navia. Current Vendor provides County with final plan Report should contain all of the data points communicated to YTD report Current Vendor 1/4/18 No Current Vendor during prior call. County forwards the final plan YTD report to Report must be in the Navia file format to ensure timely processing Navia County 1/4/18 No and avoid any delays. Current Vendor report tested and uploaded into Navia will have all transferred participant accounts loaded into our Navia system Navia 1/9/18 No system. YTD report is pulled from Navia system and compared to the Current Reconciliation reports provided to County Navia 1/9/18 No Vendor report. Confirmation of takeover sent to all 2017 participants via email/mail FSA takeover Confirmation emails sent Navia 1/9/18 No along with instructions on how to register online account. Takeover complete and claims processing can Participants can now submit claims via mobile app and online begin Navia 1/9/18 account access. Any pended claims are also processed at this time. GoNavia Commuter I Go Navia Employee Overview Navia 10/11/17 No Date Navia sends to County. GoNavia test eligibility file feed County 10/11/17 County needs to send initial test file for the commuter plan. Navia provides Feedback on test file(if needed) 10/15/17 Navia will provide feedback on test file. Navia approves eligibility file feed Navia 10/20/17 Navia will test file and provide results. County sends any required internal communication announcing County sends Commuter introduction email County 11/17/17 commuter program launch with Navia. County needs to send file for the commuter plan.Final file needs to sent by 11/20/2017 for participants to begin placing orders on GoNavia live eligibility file feed County/Navia 11/20/17 12/1/2017. Send reminder notification to 2017 Commuter participants re:transition from Current Vendor County will send internal takeover communication.This reminder (if needed) County 11/22/17 No should be posted on County intranet. navia co County of Fresno Proposed Implementation Timeline O sb �r Action Item Responsible Party Due Date Actual Completion Date Completed(Y/N) Comments Navia will send a welcome email to all eligible commuter participants.The email will have instructions for placing orders on GoNavia participant welcome emails Navia 12/1/17 No Navia's website. Navia card is requested as backend process once initial order is Participants place GoNavia orders on Navia's placed. If an existing Navia card is on file,order is loaded onto system County Participants 12/1/2017-12/20/2017 No existing card. Last day to place order on GoNavia platform to This deadline only applies to County employees who do not already ensure that cards arrive before 1/1 County Participants 12/10/17 No have a Navia card ordered based on 2017 FSA enrollment. Navia will assist with development of communications for the Send blackout reminder email County or Navia 12/19/17 No County. Last day for any Commuter claims to be submitted to Current Commuter blackout begins Current Vendor 12/19/17 No Vendor. Debit card suspended from further use Current Vendor 12/19/17 No Navia will post the initial payroll deduction report to the County employer portal.This report will list all orders placed in Navia's system for the upcoming month.County has two business days to Initial payroll deduction report posted Navia 12/21/17 No review this report. Navia will post the final payroll deduction report to the County employer portal.This report will list all orders placed in Navia's Final payroll deduction report posted Navia 12/23/17 No system for the upcoming month. Navia will debit County for commuter orders placed through online Funds debited from County for January orders Navia 12/24/17 No system. Final reimbursement processing done for 2017 Commuter plan Current Vendor 12/30/17 No No other claims should be processed after this point. Current Vendor provides County with final plan Report should contain all of the data points communicated to balance report Current Vendor 1/4/18 No Current Vendor during prior call. County forwards the final plan balance report to Report must be in the Navia file format to ensure timely processing Navia County 1/4/18 No and avoid any delays. Current Vendor report tested and uploaded into Navia will have all transferred participant accounts loaded into our Navia system Navia 1/9/18 No system. Navia will draft custom communication for any participants that have Navia transfer of balance email Navia 1/9/18 No balance transferred over to Navia from Current Vendor. Debit cards requested for any new Commuter This is done automatically for anyone who has a 2017 Commuter participants Navia 1/9/18 No rollover balance and who did NOT already receive a Navia card. Employee Materials This document contains samples of our open enrollment materials, employee communications and other employee-facing materials. These materials are designed to educate employees about the FSA program, increase benefit awareness and inform participants about some of the specific plan features and options. Included are the following documents: • Open Enrollment Kit This is the standard open enrollment benefit communication that explains the benefits offered under the client's plan. This packet can be customized however the client sees fit. Included with this is an optional enrollment form. • Claim Submission Tools and Claim Form This is a communication piece informing the participant of the various methods to submit a claim along with a sample claim form. • Flyers These are sample flyers that we have created for some of our clients who were looking for ways to increase benefits awareness and participation. • Cool Features An overview of some of the special features that we offer participants. • FlexConnect Factsheet A detailed piece that covers the benefits of the FlexConnect system where participants can submit their carrier EOBs directly to Navia as health care FSA claims without filling any forms or submitting documentation. Expense Estimation Worksheet A worksheet to help first-time enrollees estimate their expenses for the health and dependent care FSA. • Navia Debit Card Employee Overview An overview of our debit card program that is sent with the debit card. navia benefit • • wholeFlexible Spending Arrangements (FSAs) help you save money on health and day care expenses and allow you to spend it on the things you care about. FSAs will have the cheering! Taxes 101 How much could you save? Annual gross income 000 The federal government takes about Let's look at an example: Employees A Estimated axes0., 30%of each dollar you earn in FICA and and B both earn $55,000 per year.They Annual net income $38,500 federal income taxes,and you take each have$2,550 in out of pocket health • ut-of-pocket health -$2,550 care expenses home the remaining 70%to use for your care expenses. Actual take home pay $35,950 living expenses. When you use an FSA, Employee A and Employee B have the you set aside money before it is taxed, same earnings and tax bracket, but Annual gross income $55,000 Out-of-pocket health -$2,550 so you spend the entire 100%of your Employee B saves$765 per year by care expenses earned income on your health and day contributing to an FSA! Adjusted gross income $52,450 Estimated taxes 0% care expenses. Actual take home pay $36,715 How does it work? • During your open enrollment estimate your expenses for the plan year and enroll in the plan. •Your annual election amount will be evenly deducted pre-tax from your paycheck throughout the plan year. •You cannot change your annual election amount after the plan start unless you have a qualified change in status. For example, birth,death,marriage or divorce. •Check out your Navigate My Benefits and Pre-Tax Solutions pages for more details on how your plan works. Visit or contact us: www.naviabenefits.com Spend less on - • and day care expenses customerservice@naviabenefits.com and more on • you • - Enroll now! (800)669-3539 1 (425)452-3500 I-nlAf Cin I AC'C'Pcc m%./ hpnofitc? Accessing your benefits couldn't be easier,just swipe your Navia Benefit Card to pay for eligible health care expenses. Funds come directly out of your Health FSA and are paid to the provider. Some swipes require us to verify the expense,so hang on to your receipts! If we need to see it,we will send you an email or notification via our smartphone app. You can also submit Health Care FSA and Day Care FSA claims online,through our smartphone app for Android and Phone,email,fax or mail. Claims are processed within a few days and reimbursements are issued according to your employer's reimbursement schedule. Be sure to include documentation that clearly shows the date,type and cost of the service. Submitting claims is easier than ever using FlexConnect The FlexConnect feature connects your FSA to your insurance plans and seamlessly creates a claim with proper documentation direct from your insurance carrier! All you have to do is click"reimburse me"and the claim is expedited for payment. Sign up for FlexConnect today! Get more with the MvNavia mobile aDD The MyNavia app is free to download on both iPhone and Android. You can manage your benefits and view important details right from the convenience of your phone. WIN navia benefit • • navia Show - my pre-taxsolutions: Health Care FSA The Health Care FSA (HCFSA) allows you to pay for out-of-pocket medical expenses with tax-free dollars. Think of the HCFSA as a tool to pay for all your regular medical expenses throughout the plan year. • Expenses for you,your spouse and tax-dependents Common Eligible Expenses are eligible for reimbursement, regardless of if they • Prescription drugs are covered on your medical plan. •Copays and coinsurance • Deductibles •The Health Care FSA is a pre-funded benefit. •Office visits This means you have access to your full annual • Dental work election amount at any time during the plan year. .Orthodontia • Estimating future expenses is an important step as •Glasses you prepare to enroll in an FSA.The more accurate •Contacts you are in estimating your expenses •Chiropractic the better the plan will work for you! • Massage NOTE:Expenses that are cosmetic in nature are not eligible Day Care FSA Child care can be one of the single largest expenses for a family with children.A Day Care FSA (DCFSA) can be used to pay for your qualified day care expenses with pre-tax dollars which can save you up to $1700 per year!! • The DCFSA limit is set by the IRS and is a Common Eligible Expenses calendar year limit of$5,000 per household, •Child Care $2,500 if married and filing separately. • Preschool If your plan year is not on a calendar year,take • Before and after school care extra care in calculating your annual election. • Day Camps NOTE:Expenses for school tuition •Expenses can be for your dependent children and overnight camps are not 12 and under,and in some cases elder care,and eligible must be enabling you to work,actively look for work or be a full-time student. Navigate My B ' 4 16� navia benefit • • Election and Claim Filing Period Open Enrollment period is a great time to look at your benefits and estimate your out-of-pocket expenses. Be sure to only elect an amount that you know you will use during your plan year. At the end of the plan year you will have a claim filing period to turn in any leftover claims for your benefits. Unused Health Care FSA balances up to $500 will be carried over to the subsequent plan year. Any Health Care FSA funds in excess of$500 is subject to the Use-or-Lose rule and cannot be refunded to you. Carryover Your plan offers a carryover feature for your health FSA.This feature allows you to roll over up to $500.00 of unused health FSA funds to the following plan year.The carryover feature does not apply to unused daycare FSA funds. Carryover amounts will be credited after your claim filing period. Navia Benefits Card Rather than filing a claim and waiting for reimbursement,you can use the debit card to pay your provider directly for qualified health care expenses.The card is accepted at participating merchants using the Inventory Information Approval System (IIAS) and at medical care merchants using the Master-Card' system. Be sure to hang on to your receipts in case we need to see them to verify the expense eligibility. If we need to see a receipt,you will notice an alert on your mobile app and we will send you an email reminder. Accessing Your Benefits Navia wants to make accessing your benefits as simple and efficient as possible. • Online Account Access: Order additional debit cards, update bank and address information and see up to date details of your benefits. • Online Claims Submission: Upload your documentation, complete the online wizard,and voila! a reimbursement will be on its way within a few days! • Mobile App: MyNavia allows you to simply snap a photo and submit for reimbursement direct from your mobile device. • Flexconnect: Sync your various medical, dental and vision benefits with your FSA plan for a quick and easy reimbursement. No need to submit documentation, we'll get it from the insurance carrier! ABC ABC Company- Flexible Spending Arrangement Enrollment Form Plan Year: 1/1/2016-12/31/2016 • Last Day to Submit Claims: 3/31/2017 �bnavia Employee Information-Please write legibly to ensure proper enrollment 9 Y p p Last Name, First Name SSN/Employee ID# Home Address(Street,City,State,Zip Code) Date of Birth Phone Number Email Address Effective Date Benefit Elections Section 125 Benefit Yes/No Annual Election #of Paycheck Paychecks Deduction Health Care FSA ❑ Yes $ 26 $ Maximum of$2,550.00 per plan year ❑ NO or Day Care FSA ❑ Yes $ 26 $ Maximum of$5,000.00 per plan year (or$2,500 if you're married and filing taxes separately) ❑ NO _ or Premium Conversion The group insurance premiums you pay through your paycheck are automatically deducted pre-tax. Premium contributions Automatic toward domestic partner coverage will be deducted post-tax unless they qualify as a tax dependent. Debit Card & Direct Deposit Navia Debit Card—You may use the card to pay for expenses directly from the funds in your Health Care FSA.There is no cost for the initial card.The cards are valid for 3 year periods; if you've previously received Automatic the card then it will be reloaded with your new election.You must provide a valid email address to use the card. Direct Deposit—Reimbursements are electronically deposited into your bank account. If you've previously signed up for direct ❑ Yes ❑ Checking Account#: deposit with Navia your information will remain on file and you do not need to complete this section. ❑ No ❑ Savings Routing#: Signature This election form will remain in effect and cannot be revoked or changed during the plan year unless the revocation and new election are on account of and consistent with federal regulations.I understand that Health FSA reimbursements will be available only for qualifying medical care expenses for myself,spouse,and dependents.I also understand that Day Care reimbursements will be available only for qualifying day care expenses.I agree to notify the Employer if I have reason to believe that any expense for which I have obtained reimbursement is not a qualifying expense.I also agree to indemnify and reimburse the Employer on demand for any liability it may incur for failure to withhold federal,state or local income tax or Social Security tax from any reimbursement I receive of a non-qualifying expense,up to the amount of additional tax actually owed by me.I understand the benefits and I have read the reverse page.I hereby authorize and direct my employer to reduce my salary by the amount necessary to pay for the benefits as shown above for the plan year indicated above. ❑ YES, the above benefits have been explained to me and I elect to participate as indicated ❑ NO, the above benefits have been explained to me and I decline participation Employee Signature Date X Completed Enrollment Forms must be returned to Human Resources Please see the reverse side for important information regarding the above benefits Additional Information Premium Conversion • If the enrollment status is marked as'AUTOMATIC',you must notify your employer in writing to decline enrollment in this benefit.Premium Conversion is subject to the change in status rules and is considered an election equal to the amount of your premium deductions. Health Care Flexible Spending Arrangement("Health Care FSA") • Reimbursement will only be available for qualifying medical care expenses as set forth in the Plan Document and Section 213 of the Internal Revenue Code.It is your responsibility to check the eligibility of an expense prior to enrollment. • Group Medical Plan Premiums cannot be reimbursed through the Health Care FSA and will be deducted pre-tax through the Premium Conversion Plan. Therefore,do not include the cost of premiums in your FSA annual election amount. Day Care Flexible Spending Arrangement("Day Care FSA") • Reimbursement will be available only for qualifying day care expenses as described in the Internal Revenue Code Section 129,the Plan document and the Summary Plan Description. • Participation in a Day Care FSA will require you to complete tax form 2441 when filing federal taxes.If your plan includes a Grace Period any amounts carried forward or forfeited during a taxable year should be entered in Line 13 of Form 2441.If you or your spouse is a full-time student,please consult IRS Publication 503. • If the Plan Year is less than twelve(12)months,the plan limit may be prorated to be less than the$5,000 calendar year limit mandated by the IRS. Use-It or Lose-It • You must claim all elected funds by the end of the run-out period.After the run-out period is complete,unused Day Care FSA balances will be forfeited;this is referred to as the Use-it or Lose-it rule.Unused Health Care FSA balances up to$500 will be rolled over to the subsequent plan year.Any Health Care FSA funds in excess of$500 will be forfeited. Claim Runout Period • The claim runout period allows you to submit claims after the end of the plan year.Claims received after this period will be denied. Lost Checks and Reissues • Lost or stale dated FSA checks can be reissued 10 business days after the original check date.There is a$25.00 check reissue fee.The check reissue request will require at least one business day to process. • Any fees associated with presenting a canceled check will be deducted from your FSA as well as the face value of the check. Direct Deposit • All electronic funds transfers(EFT)will be initiated on the same day as the normal check reimbursement date.Deposits may take up to two(2)business days to appear in the designated account. • Returned items due to incorrect banking information will be assessed a$10.00 fee that will be deducted from your FSA balance. Deductions • FSA deductions will be deducted from your paycheck evenly throughout the plan year.You must indicate an annual election and a per paycheck deduction on your enrollment form.If you enroll in the plan after open enrollment then please divide your annual election by the remaining deductions in the plan year. Change in Status • All elections set forth are considered irrevocable for the entire plan year unless there is a qualifying change in status.Please consult the plan document or summary plan description for a list of qualifying events. • In the event of a change in status the change in election must be necessitated by and consistent with the change in status and the change must be acceptable under IRS Regulations. Eligibility • Independent contractors and self-employed individuals are not eligible to participate in the Plan.Self-employed individuals include:Sole Proprietors of their own business;General Partners in a general partnership and General Partners in a limited partnership;Limited Partners of partnerships with guaranteed payments; more than 2%Shareholders of an S corporation as well as the spouse,children,parents and grandparents of a more than 2%Shareholder;and non-employee Members of an LLC.It is your responsibility to determine your eligibility. • Expenses must be incurred during the plan year and while you are an active participant in the plan.Any expense incurred prior to your effective date or after your termination date cannot be reimbursed. Debit Card • If you elect to use the card please keep in mind that you may still need to submit supporting documentation to verify that a charge is eligible.You will be notified via email if you have a charge that requires documentation.You can check your account online to view any outstanding charges or contact customer service. • If you use the card for an ineligible expense or do not substantiate a charge within 75 days of receiving the first request for substantiation your card may be temporarily suspended to prevent further use.The IRS provides the participant with 2 methods for correcting an ineligible or unsubstantiated charge:a)repay the plan for the amount of the expense,or b)request the substitution or offset of future out of pocket expenses.If neither option"a"nor"b"is successful the final option illustrated by the IRS permits the employer to deduct the ineligible expense from the participant's wages or other compensation consistent with federal and state law. • You will receive one card by default but you can request additional cards for a fee of$5/card.This fee also applies for reissues of any lost,stolen,or otherwise misplaced cards.The$5 fee will be deducted from your FSA balance. Electronic Disclosure Notice • By providing your email address you consent to receive email communications from Navia,agents,and subcontractors regarding the Plan. • If you no longer wish to receive information electronically,you may withdraw consent at anytime at no cost.To withdraw consent,please contact Navia. • You have a right to receive a paper version of an electronically furnished document at no cost. • To access documents you must have Adobe Reader.A link to download this software will be provided with all electronic documents provided. • n av i a benefit solutions Claim Submission Tools Navia is excited to offer easy-to-use tools to help participants access their funds,view account activity and submit claims. FlexConnect Available Now FlexConnect allows you to sync your medical, dental and vision benefits to your Healthcare FSA plan to deliver potential claims information to a single platform. FlexConnect is an optional feature. This technology allows you to track spending for you and your family, as well as receive notifications when there is an out-of-pocket expense that could be reimbursed from your FSA. When you enroll in the FSA, and register on www.naviabenefits.com you will see a FlexConnect link under the participant tools platform. MyNavia App Available Now The MyNavia app is a mobile tool for you to manage your Healthcare and Dependent care FSA benefits. With our new app, you have full control over your benefits administered through Navia. Some useful features include: ✓ Submitting claims directly through the app with your phone camera ✓ Verifying debit card charges ✓ Access to real-time account status and balances ✓ Receiving alerts when claims and reimbursements are processed ✓ Viewing your complete account history Online Claims Submission Available Now You can submit claims toward your Healthcare and Dependent care FSA through the Navia online account. The simple-to-use interface makes it a breeze to enter the claim data, attach documentation and submit the claim. The tool also works for verifying outstanding debit card charges. Additional features include: ✓ Submitting a claim for any active plan year ✓ Accepting documentation in various electronic formats ✓ Active filtering so you only seethe debit card charges that require verification ✓ Email verification of submission receipt Claim Form n avi a (Instructions on next page) it benefit solutions Employee Information Last Name, First Name SSN/ Employee ID# Home Address(Street,City,State,Zip Code) ❑Please update my address on file Phone Number Employer Name Email Address Did you know you can submit paperless claims online or via the MyNavia mobile app? Just take a picture and submit! Day Care FSA Expenses Service Date(s) Type of Service Provider's Na SSNTax ID and/or Services For Whom Age Net Cost Total Reimbursement Request $ Day Care Provider Certification:I certify that dependent care services were provided as indicated above. Provider/Facility Name: Provider's Signature X Signer's Name(Printed): Date: Health Care/Limited FSA/HRA Expenses Service Date(s) Type of Service Provider's Name Services For Whom Net Cost Total Reimbursement Request $ Signature To the best of my knowledge my statements on this claim form are complete and true.I understand that I am solely responsible for the sufficiency, accuracy,and veracity of claims and all information related to these claims submitted to my HRA,Health Care("HCFSA')or Day Care Flexible Spending Arrangement("DCFSA"),and that unless an expense for which payment or reimbursement is claimed is a proper expense under the HRA,HCFSA or DCFSA, I may be liable for the payment of all related taxes including federal,state or city income tax on amounts paid from the HRA,HCFSA or DCFSA which relate to such expense.I further understand that no day care tax credit is permitted for amounts for which reimbursement is made.I am claiming health care reimbursement for eligible medical care expenses incurred by myself,spouse and/or dependents.Note:The IRS does not recognize Domestic Partners for purposes of receiving tax-favored health benefits.For further information please contact your employer.I certify that these expenses have not been reimbursed under this plan or by any other source and that they will not be reimbursed by any other source or insurance.By providing an email address,I consent to receive all possible communications from Navia Benefit Solutions,agents,and subcontractors regarding the Plan via email.I may withdraw consent at any time without charge by contacting Navia by phone,email,or mail.To update your email address contact Navia Benefit Solutions by phone, email,or mail.You have the right to receive paper version of an electronic document free of charge.Software requirements will be provided with each electronic document.I hereby authorize my HRA,HCFSA and/or DCFSA to be reduced by the amount(s)shown above. Participant's Signature X Date REV 2/2/2016 Claim Form Instructions 1. Complete employee information section. Be sure to write legibly to ensure proper processing. 2. Itemize your expenses in the table provided and attach copies of your documentation. Documentation must clearly show the date of service,type of service,and final cost of service. Examples of acceptable documentation include itemized bills/invoices,or the Explanation of Benefits(EOB)from your insurance carrier. ❖ If your employer offers an HRA and you are enrolled in a plan that only offers reimbursement for deductible, coinsurance,and/or copays an EOB is required for claim submission. If the expense is a copay amount(multiple of$5 up to$500),a payment receipt is acceptable documentation. Proof of payment is not required in order to reimburse medical/dental/vision services. Prescriptions Examples of acceptable documentation include the Rx label, payment receipt,or mail order statement showing the date filled, Rx name or Rx#,and cost.You may also submit an itemized printout from your pharmacy. OTC Medications&Drugs Per IRS regulations, OTC medications and drugs with an active ingredient must be accompanied by a prescription in order to be reimbursed from your FSA(ex. pain relievers,cold/allergy medication, ointments,Antacids).Once approved, prescriptions will remain on file with Navia for future claim submissions. Prescriptions are valid for one year after the date written. Alternative Treatments Expenses that may be seen as merely beneficial to general health will require a Letter of Medical Necessity(LMN),showing the treatment of a specified medical diagnosis. Examples include vitamins/supplements, herbs,weight loss programs, cosmetic products and procedures. Please have your provider write a letter or complete our Letter of Medical Necessity template. Dependent Care Acceptable documentation includes an itemized bill/invoice,showing the date of service,type of service,and cost of service. If the dependent is age 5 or older,the documentation must show the services are"for care,"and not educational in nature. If you are unable to obtain sufficient documentation,you may have the provider sign the front of this claim form to validate the services being claimed. If you would like to automate your recurring day care expenses,you may do so by completing our Recurring Day care Claim Form, logging onto our Participant Portal, and selecting the My Recurring Claims tool tile. Please DO NOT submit the following types of documentation: ❖ Statements showing estimated/pending insurance ❖ Statements showing the claimed amount as a balance forward/previous balance Statements showing the claimed amount as a prepayment for future services Cancelled checks/copies of cashed checks Personal bank statements 3. Be sure to sign the claim form and submit! Please fax, email or mail a signed claim form, but choose one method only. General Claims Submittal: Email: claims@naviabenefits.com Fax: Local(425)451-7002 or Toll-free(866)535-9227 Mail: Navia Benefit Solutions PO Box 53250 Bellevue,WA 98015 Phone: Local(425)452-3500 or Toll-free(800)669-3539 If your employer offers an HRA, Dental or Wellness plan,submit to: Email: 105@naviabenefits.com Fax: Local(425)709-7125 or Toll-free(866)831-6222 Mail: Navia Benefit Solutions PO Box 53250 Bellevue,WA 98015 Phone: Local(425)452-3421 or Toll-free(866)897-1996 Claims status is available online. Please allow at least two(2)full business days for Navia to process your claim. REV 2/2/2016 • I` ybn via benefit solutions r ` = \ r• j A IL `1 Spend less time managing ime on your se f_ ( ies your benefits and more What is a Health Care FSA? Save money on : A Health Care FSA is an easy way to set aside • Copays pre-tax dollars directly from your paycheck • Deductibles to use towards your out-of-pocket health • Prescriptions care expenses. • Lasik • Orthodontia Using a Health Care FSA allows you save • Dental Expenses money on medical expenses you already • Chiropractic have. Don't let your hard earned dollars • Vision Expenses go to waste! • Massage ...and much more! .f J • i via benefit solutions x 40 enoughThey'll never know you saved buy yourself a new set of -.mA golf What is a Day Care FSA? Save money on : A Day Care FSA allows you to set aside pre- • Day Care tax dollars directly from your paycheck to • Before & After use towards your day care expenses. School Care • Day Camp When contributions to your Day Care FSA • Pre-School are made pre-tax you save money! Money • Nannies you can use to have more fun with the kids, . Elder Care or on that expensive ice cream you eat while they're sleeping... We won't tell. navia b�nenL soluLions Cool Features for Your FSA or H RA MyNavia App Navia released the MyNavia App for iPhone and Android, a mobile tool to manage your benefits! With the app, you can: a�t EmoleY..Eva..Inc. Take photos of your receipts to submit a claim wo directly from your phone or verify Navia Benefit Card charges =p , 0 View real-time account balances Receive alerts for when claims are processed or reimbursed View complete account history Report your Navia Benefit Card as lost/stolen or request additional cards Online Claim Submission & Debit Card Substantiation These features provide you with simple tools for submitting claims and Navia Benefit Card documentation through your Navia online account. Some highlights: Submit claims for any active plan year Upload your claim documentation View all your Navia Benefit Card purchases that require documentation Submit documentation for Navia Benefit Card purchases Email verification of your submitted claim All data is submitted through a secured connection FlexConnect This feature allows you to sync your medical, dental and vision benefits to your FSA. Some highlights: Automatically downloads your insurance claims Identifies expenses that can be reimbursed with your FSA Prepares and submits claims for reimbursement FSA balance tracking- don't lose money at the end of the plan year! navia benefit solutiol�s FLEXCONNECT FACTSHEET FlexConnect makes flexible spending accounts (FSAs) easy to manage, and helps you avoid losing hard-earned money saved in your FSA. FlexConnect makes FSA management easy Is Automatically downloads your insurance claims • Identifies expenses that can be reimbursed with your FSA ■ Prepares and submits claims for reimbursement Is Tracks your FSA balance to make sure you don't lose money at the end of the plan year Cut down on paperwork Make FSAs easy Link to your FlexConnect account through ✓ Avoid losing money at the end www.naviabenefits.com and view insurance claims, of the plan year prescription details, and stored documents - all in ✓ No more hassling with one place. paperwork ✓ Easily identify expenses reimbursable by your FSA Expenses ✓ Save time on preparing claims SERVICE PROVIDER DATE INDIVIDUa "CUNT for reimbursement Mm.EmIs Goonrin Tue,Jan 242012 Bo $24.03 InCuffw Damn Huds20n1 dso;, �sn $31.12 so— Users love it "Had I known about FlexConnect, I would have put so much more Automatically prepares and submits claims into my FSA" Review pending FSA eligible claims that FlexConnect "I'm so glad that I don't have to has automatically prepared for you, and click spend 2 to 4 hours this year "Reimburse me"to submit your claims. dealing with paperwork and submissions." Pending Reimbursements "The smile on my face you just SERVIf..E PROVIDER,DATE INDIVIDUAL AAIDUNT can't believe as I click the A MI..Ja�242012 $2a.os Reimburse Me button." How does it work? Simply provide your login information for your medical, dental and vision insurance accounts. After you have connected the accounts, your insurance claims will be periodically downloaded to the portal. When we notice one that is reimbursable through your FSA, a "Reimburse Me" button will appear next to the item. Click"Reimburse Me," and we automatically prepare and submit your claims with the required documentation. How do I connect my insurance account? Go to the accounts tab, click "Add." Choose the insurance plan you wish to add. Enter the username and password for the insurance plan's website, then click"Connect." Hints are provided to set up an account or retrieve a password. Note, the first time an account is added it will take a few minutes to download all the insurance claims. How do I submit FSA claims? Go to the Dashboard tab. If expenses appear in the Pending Reimbursements list, click "Reimburse Me" on an expense. Review the information to be submitted and click "Send," then smile! In the background your reimbursement claim will be automatically transmitted to Navia for processing. Can my company see my information? No Way! The details in your account are for your eyes only. You are the owner of this account. Is my information secure? Our dedicated security team uses bank-grade security and encryption to safeguard your information. Critical data and documents are always encrypted and stored securely. This service is built by a team with deep experience developing secure, highly reliable transaction processing systems - systems that have processed billions of online and mobile transactions. How much does it cost? $0.00. That's right, nothing. The cost is included in the fee your employer already pays for you to have an FSA. How do I get started? First, login to your participant account at www.naviabenefits.com. From there, you will need to opt in to use "FlexConnect". The feature will be ready for you to setup within 1-2 business days. You must link your FSA and insurance providers to use the tool. Health & Day Care FSA Anavia Expense Estimation Worksheet henetit solutions Estimating your expenses is an important step in enrolling in a Flexible Spending Arrangement.The more accurate you are in estimating your expenses the better the plan will work for you. Here are some tools to help you proceed: Locating your Family's Health Care information: ✓ Insurance Explanation of Benefits ✓ Financial Records and Check Register ✓ Health Care Provider Statements ✓ Old Credit Card Bills After you are able to locate your Health Care Expenses, take into account the health care costs not paid for by insurance for yourself, your spouse, and your eligible dependents. Health Care Expenses Estimated Amount Chiropractic Visits Dental Care (routine checkups, fillings, etc.); Orthodontics Eye Care: Exams, prescription (sun)glasses, contacts, solutions Laser Eye Surgery and procedures Insurance Copays and Deductibles mill Over-the-Counter Medications (need Rx) Prescription drugs Routine Exams Additional Eligible Expenses (see below) Day Care Expenses Estimated Amount Before/After School Care Elder Day Care Pre-School Day Care, including summer day camp fees Additional Eligible Expenses (see below) WHAT'S ELIGIBLE? -1 b. We've assembled a list of common expenses that are eligible for reimbursement. Not all eligible items are on this list.Visit our website for more information: www.naviabenefits.com. ELIGIBLE HEALTH CARE EXPENSES Items marked with an asterisk(*)are considered over-the-counter(OTC)medicines or drugs and require a prescription for reimbursement. Acne treatment* Contraceptives Humidifiers Prenatal vitamins Acupuncture Copays Immunizations Prescription drugs Allergy&Sinus medication* CPAP machine Incontinence supplies Prescription glasses Antacids* Crutches Individual counseling Readingglasses Antibiotic ointment* Deductibles Insect bite treatment* Respiratory Treatments* Anti-diarrheal* Dental services Lab work Saline nasal spray Antifungal foot cream* Diabetic supplies Lactation Consultant Sleep Aids&Sedatives* Anti-gas medication* Diaper rash ointment* Lactose intolerance pills* Sleep deprivation treatment Anti-itch cream/gel* Digestive Aids* Laser eye surgery Smoking cessation Antiseptic* Drug addiction treatment Laxative* products* Asthma treatment* Ear wax removal kits* Lice treatment products* Smoking cessation programs Bandages/gauze Eye drops Massage therapy Speech therapy Birthing classes or Lamaze Feminine Anti-Fungal/Anti- Medical records Sterilization procedures Blood pressure monitor Itch* Motion sickness relief* Stool softener* Braces(knee, ankle,wrist) Fertility monitor Nasal strips Thermometer Breast pump Fertility treatment Naturopathic visits Throat lozenges* Burn cream* First Aid Kit Orthodontia Vision care Chiropractic services Flu shots Orthotic inserts Walker Coinsurance Genetic testing Oxygen and equipment Wart treatment* Cold/hot pack Group therapy Pain relievers* Wheelchair&repair Cold sore treatment* Hearing aids&supplies Parasitic treatment* X-rays Cold/cough medication* Hemorrhoid medication* Physical exams Compression stockings Hormone therapy Physical therapy Contacts&solutions Hospital fees Pregnancy test ADDITIONAL DOCUMENTATION REQUIRED Certain medical expenses are not reimbursable unless a licensed health care practitioner states that the service or product is medically necessary. We will need a Letter of Medical Necessity(LMN)for these items to be reimbursed.The LMN is available on our website. Please note that certain expenses may require additional documentation to be reimbursed. Automobile modifications Cosmetic procedures Lumbar support Vitamins and supplements Braille books Family therapy Mole removal Weight loss programs Breast augmentation Home medical equipment Motorized scooter Breast reduction Learning disability fees Nutritionist expenses INELIGIBLE HEALTH CARE EXPENSES The following expenses are not eligible. Under no circumstances will the following items be reimbursed. Please do not submit claims for these items. Books Funeral expenses Insurance premiums Hair growth products Boutique practice fees Gym membership Late fees Electric toothbrush/picks COBRA premiums Hair transplant Liposuction Teeth whitening College insurance Household help Marijuana Toiletries CPR classes Hygiene products Marriage counseling Veneers Electrolysis/laser hair removal Illegal operations/substances Massage chair Warranties Face lift Imported OTC items Mattress Finance charges Imported prescriptions Missed appointment fee Navia Benefits Card Overview bnavia benefit solutions Your company has included the Navia Benefits Card with your benefit. You will receive your card within 1- 2 weeks after your enrollment has been processed. If you currently have the debit card, Navia will reload your card with your full annual benefit. You will not need anew card until your card expires. Your Navia Benefits Card provides several benefits: ✓ Your expense is paid directly from your plan to the provider.When you use your debit card,you will no longer have to pay out of pocket and wait to be reimbursed. ✓ Best of all,we will automatically clear copays or items purchased at participating Inventory Information Approval System(IIAS) retailers that allow you to purchase only eligible items with your card. The HAS Participating Retailers list can be located at http://apps.sig-is.org/SIGISPublicRpts/IIASMerchantList.aspx under Navia Benefits Card Information. Using your Navia Benefits Card is simple: 1. Use the card at your providerjust like you would any other credit card. Be sure to save a copy of the bill, statement, invoice or receipt. ➢ This documentation must clearly show the date,type and cost of the service or product.(The credit card receipt alone does not contain sufficient information.) ➢ If you would like to request a PIN for your card you can click on My Debit Card from your benefits page online. 2. You will receive an email notification requesting documentation for any charges that require substantiation. ➢ If all of the charges were cleared by the copay matching/IIAS systems,then you will not receive an email notification. 3. Submit documentation to Navia Benefit Solutions via the online substantiation tool,our MyNavia mobile app,email,fax or mail. ➢ Remember, only the charges specifically listed as action required on your online statement require substantiation,any other recent charges have either been cleared by our copay matching system or have not yet been settled and will show up after your next notification. ➢ If you would like to see all current Plan Year debit card charges, including those cleared by the copay matching/IIAS systems,you can view your account by logging into our website, www.naviabenefits.com. 4. Your card will be temporarily suspended if a charge is not substantiated or otherwise cleared within 75 days from the date of swipe. Miscellaneous Items: ✓ Items that are not substantiated may be deducted from your salary. ✓ If you need additional cards, or your card is lost/stolen,you can request a new card through your online account. The$5 reissue fee will be deducted from your account balance. ✓ We recommend that you ALWAYS keep itemized documentation for each charge. You will not be able to purchase Over-the-counter("OTC") medicines and drugs with your Navia Benefits Card. In order to claim these items for reimbursement, please submit an itemized receipt, accompanied by a prescription for the items you are claiming. Sample Letters, Statements and Notifications This document contains samples of our system generated letters, notifications, and account statements. Some of these documents are auto-generated by our FSA system according to a set schedule,triggered event, or based on participant activity. Included are the following documents: • Enrollment Confirmation Email This email is sent to the participant once their enrollment has been processed in our system. The Email contains a password-protected Confirmation of Enrollment Statement that details the name, address, election, important dates and instructions on how to register their online account. • Confirmation of Enrollment Statement This is the above-mentioned attachment that lets the participant know what data we have in our systems based on their enrollment. • Statement of Benefits Email This is the quarterly generated email to participants letting them know that their official account statement is available to view through their online account. The statements are generated at the end of the 3rd 6th 9th and 11 th month of the plan year. • Notice of Benefit Activity for Claims Processing An email notification sent to participants once a submitted claim has been processed by a member of our customer service team. There is a corresponding notification send when a reimbursement has been issued by Navia as well. • Notice of Benefit Activity for Reimbursement An email notification sent to participants once a reimbursement has been issued for an approved claim. • Notification of Claim Denial An email notification sent to participants when any portion of a claim cannot be processed.The denial letter itself is posted to the online account for security and privacy reasons. • Denial Letter A sample of the denial letter sent to participants explaining why a portion of the claim could not be processed. The denial shows the total claim amount,the amount approved, and the amount denied.The denial also has the direct contact information for the customer service agent that processed the claim.The participant can communicate directly with the claim processor for resubmission of the claim. • Notification of Completed Debit Card Substantiation An email notification sent to the participant when a debit card claim substantiation is approved. Enrollment Confirmation Email From: notification @navia benefits.com[mai Ito:notification(Janavia benefits.coml Sent: Friday, January 1, 2016 3:19 PM To: tony.stark@abccompany.com Subject: Welcome to Navia Benefits Welcome to Navia ! Congratulations on your enrollment in the Flexible Spending Arrangement! This email is to confirm that your enrollment information has been successfully received and processed. Navia is here to make sure that you get the most out of this valuable benefit. We've outlined some of the administrative details of how your plan works, along with your plan year election, in the attached password-protected document titled 'Confirmation Letter'. Please take the time to review this letter to make sure your name, address and election information is accurate. The password to open the Confirmation Letter uses a combination of the first four letters of your last name ALL UPPER CASE and your zip code (for example, FLEX98888). If your last name is less than four letters, enter your full last name and zip code. Your plan documents are available on our website, which you may access by clicking here and logging in. First time users will click the Register button in the top right corner of the page. To register for online account access, you will be requested to provide the following information: • Last Name, First Initial • E-mail Address • Employer Code: ABC • Last four digits of your social security number/employeelD • Date of Birth • Choose a User Name • Answer three security questions Do not forget to review and accept the 'Terms and Conditions'. After clicking 'Submit' for online access, you will receive an email confirmation with a temporary link to set your password and complete your registration. Please do not reply to this email. If you have general questions regarding your Flexible Spending Arrangement, please contact us. We look forward to serving you in the coming months. Thank you! Navia Benefit Solutions Itnavia Local:425-452-3500 Toll Free: 1-800-669-3539 www.naviabenefits.com Navia Benefit Solutions Join Our Community About Benefits We Offer News Eligible Expenses f Like us on -... ToolsPrivacy Terms of Use FAQs Follow us on Twitter SubscribeContact Us to us on YouTube IMPORTANT NOTICE:The contents of this email are confidential and may also be privileged. If you are not the intended recipient, please notify the sender immediately and do not disclose the contents to any other person, use it for any purpose,or store or copy the information in any medium. If you do not wish to receive further electronic correspondence from Navia Benefit Solutions,please click here to unsubscribe.To access documents,you must have Adobe Reader.If you do not currently have this program installed,visit http:/iget.adobe.com/reader/to download. Enrollment Confirmation Statement .,bnavia January 1,2016 ABC COMPANY Flexible Spending Arrangement To: Stark,Tony 11400 SE 6th St Ste 125 Bellevue,WA 98004 Welcome to Navia Benefit Solutions!Your enrollment confirmation is outlined below along with other important plan details to help you navigate your benefits. Health Care FSA Day Care FSA Plan Year Election: $2,550.00 Plan Year Election: $5,000.00 Effective Date: 1/1/2016 Effective Date: 1/1/2016 Last Day to Incur Expenses: 12/31/2016 Last Day to Incur Expenses: 12/31/2016 Last Day to Submit Expenses: 3/31/2017 Last Day to Submit Expenses: 3/31/2017 If this information is incorrect, please contact your Human Resources or Payroll Department as soon as possible. No action is required if all information is correct. The dates of service for your eligible expenses must be during the plan year,which is 1/1/2016 through 12/31/2016 and while you are an active participant in the plan.Any expenses incurred prior to your effective date or after your termination date cannot be reimbursed. CLAIM SUBMISSION You may submit claims for reimbursement using one of the following methods(use only one method per submission): • MyNavia (mobile app for iPhone&Android) • Online Claims Submission: log in to the participant portal • Email: claims@naviabenefits.com • Fax:(425)451-7002 or toll-free(866)535-9227 • Mail: Navia Benefit Solutions PO Box 53250 Bellevue,WA 98015 • FlexConnect Tool Find a list of common eligible expenses online or use our Recurring Claim Form for expenses you incur again and again. AVAILABILITY OF NOTICE OF PRIVACY PRACTICES TEST DEMO COMPANY maintains a Notice of Privacy Practices that provides information to individuals whose protected health information will be used or maintained by the Flexible Benefits Plan.If you would like a copy of the Plan's Notice of Privacy Practices,please contact your Human Resources Department. Please allow Navia at least two(2)full business days to process your request for reimbursement.All claims must be submitted prior to the end of the claim filing period. Upon claim submission and approval, reimbursements will be added back to your paychecks. REGISTRATION Plan information and claim forms are available to you online through www.naviabenefits.com.First time users will click'Register'in the upper-right corner of the screen and select"I'm a participant."You will need your 3 character employer code,ABC, in order to register. Shortly after completing the online form you will receive an email confirmation to complete your registration. Additional information and plan related forms can be obtained by contacting Navia Benefit Solutions. We look forward to serving you! Navia Benefit Solutions Customer Service Hours: Monday-Friday 5am-5pm Pacific Time Phone:800-669-3539 or 425-452-3500 Email: customerservice@naviabenefits.com Website:www.naviabenefits.com AVAILABILITY OF NOTICE OF PRIVACY PRACTICES TEST DEMO COMPANY maintains a Notice of Privacy Practices that provides information to individuals whose protected health information will be used or maintained by the Flexible Benefits Plan.If you would like a copy of the Plan's Notice of Privacy Practices,please contact your Human Resources Department. Statement of Benefits Email From: notification anavia benefits.com [mai Ito:notification anavia benefits.com] Sent: Friday, February 26, 2016 3:33 PM To: tony.starkaabccompany.com Subject: Statement of Benefits A Statement of Benefits has been created for your Flexible Spending Arrangement through ABC Company, and is now available for your review on our website. If you are not currently registered on our website, you may do so by clicking here. Your company code, which you will need to complete the registration process, is ABC. If you are not automatically directed to this document after logging in, scroll down to the 'My Benefits' section, click the 'Statements' link to the right of your current plan year, and click on the link corresponding to the date this notice was sent. If you have any questions, please contact us directly and do not reply to this email. Our contact info can be found by clicking the 'Contact Us' link below. Thank you, Navia Benefit Solutions 4bnavia Local: 425-452-3500 Toll Free: 1-800-669-3539 www.naviabenefits.com Navia Benefit Solutions JoinOur • About Benefits We Offer f Like us on Facebook News • - Expenses ToolsPrivacy : Resources Terms of - FAOs Subscribe to us on YouTube • IMPORTANT NOTICE: The contents of this email are confidential and may also be privileged. If you are not the intended recipient, please notify the sender immediately and do not disclose the contents to any other person, use it for any purpose, or store or copy the information in any medium. Unsubscribe Notice of Benefit Activity for Claims Processing From: notification a navia benefits.corn [ma i Ito:notification a navia benefits.corn Sent: Friday, February 26, 2016 3:33 PM To: tony.stark(a)abccompany.com Subject: Navia Benefits Notice of Benefit Activity Dear Navia participant, This email is to notify you that a claim has been received and processed. For more information about the details of your claim, please access your online account or click http://www.naviabenefits.com/contact for contact information. Did you know that you can set up Day Care FSA claims to recur? For more information, log on to our web site and under 'Tools,' click 'My Recurring Claims.' Please do not reply to this email. Sincerely, Navia Benefit Solutions 4bnavia If you do not wish to receive further electronic correspondence from Navia Benefit Solutions, please click here to unsubscribe. To access documents, you must have Adobe Reader. If you do not currently have this program installed, visit http://get.adobe.com/reader/to download. Join Our • Like us on Facebook Follow us on Twitter Subscribe .- Notice of Benefit Activity for Reimbursement From: notification a navia benefits.corn [ma i Ito:notification a navia benefits.corn Sent: Friday, February 26, 2016 3:33 PM To: tony.stark(a)abccompany.com Subject: Navia Benefits Notice of Benefit Activity Dear Navia participant, This email is to notify you that a claim reimbursement has been issued. For more information about the details of your disbursement, please access your online account or click https://www.naviabenefits.com/contact for contact information. Please do not reply to this email. Sincerely, Navia Benefit Solutions tnavia If you do not wish to receive further electronic correspondence from Navia Benefit Solutions, please click here to unsubscribe. To access documents, you must have Adobe Reader. If you do not currently have this program installed, visit http://get.adobe.com/reader/to download. Join Our • fLike us on Facebook Follow us on TwitterSubscribe to us on YouTube Notification of Claim Denial From: notification anavia benefits.com [mai Ito:notification anavia benefits.com] Sent: Friday, February 26, 2016 3:33 PM To: tony.stark(a)abccompany.com Subject: Request for Additional Information and/or Notice of Denial Dear Navia participant, A Request for Additional Information and/or Notice of Denial has been issued for your recent claim(s). This document is available for your review by accessing your online account. If you are not automatically directed to this document after logging in, go to 'My Benefits', open your benefit, and scroll to the bottom of the page where your account activity is shown. Click on the 'Request for More Info' link corresponding to the date this notice was sent. Sincerely, Navia Benefit Solutions 4bnavia If you do not wish to receive further electronic correspondence from Navia Benefit Solutions, please click here to unsubscribe. To access documents, you must have Adobe Reader. If you do not currently have this program installed, visit http://get.adobe.com/reader/to download. Join Our • Like us on Facebook Follow us on TwitterSubscribe to us on YouTube Batch # 1234567 Denial Letter 2/3/2016 REQUEST FOR ADDITIONAL INFORMATION OR NOTICE OF ADVERSE DETERMINATION This document serves as a request for additional information and/or a denial, in whole or in part,for the requested reimbursement as indicated below. Any requested information must be submitted within 45 days of your receipt of this notice. We presume you will receive this notice within five days of the date above. If we do not receive the requested information within the timeframe indicated that portion of your claim shall be considered denied. To: Stark,Tony 11400 SE 6th Street Ste 125 Bellevue, WA 98004 Employer: ABC COMPANY Claimed amount $200.00 We have approved $0.00 We are denying $200.00 Denied item(s): Service date(s): 2/1/2016 Amount: $200.00 Your claim did not include any supporting documentation. All claims submitted must be accompanied by documentation that shows the date,type, and cost of service incurred. Please resubmit your claim with documentation, such as an Explanation of Benefits from your insurance provider or a detailed statement from the service provider, showing the date,type, and cost of service corresponding to the amount being claimed. Cody Cook (425)452-3473 ccook@naviabenefits.com Navia Benefit Solutions PO Box 53250, Bellevue, WA 98015-3250 Website portal.naviabenefits.com Batch # 1234567 2/3/2016 You have a right to appeal a denial by following the appeal procedures described below.This procedure is intended to provide a full and fair review of your claim. LEVEL ONE BENEFIT DENIAL REIVEW TO NAVIA BENEFIT SOLUTIONS You must request an appeal in writing within 180 days of the date you received notice of the denial of benefits.You may submit written comments,documents,records,and any other information relating to the claim.Upon written request and free of charge,you will be provided reasonable access to,and copies of,all documents,records,and other information relevant to the claim.This would include comments, documents,records,and other information that either was not submitted previously or was not considered in the initial benefit decision.The review of your appeal will give no deference to the initial decision.It will be conducted by the Navia Review Committee and not anyone involved in the initial denial decision. You must file your appeal by submitting a written request by email,fax,or mail. • Email all materials to claims@naviabenefits.com with"LEVEL ONE REQUEST FOR REVIEW OF BENEFIT DENIAL"in the subject line. • Fax all materials to 425-452-7002 or 866-535-9227 with"LEVEL ONE REQUEST FOR REVIEW OF BENEFIT DENIAL"on the cover page. • Mail all materials to Navia Benefit Solutions Level One Review,PO Box 53250,Bellevue,WA 98015 TIME PERIODS FOR APPEAL You will be notified of the decision no later than 30 days after Navia receives your appeal.The Plan may extend this period by a reasonable time if necessary. Please carefully review the above information.If you decide to appeal this denial by requesting a review as described above,your appeal should be sent within the prescribed time period to the person named above. Failure to file a timely appeal will bar you from any further review of this benefit denial under these procedures or in a court of law. LEVEL TWO BENEFIT DENIAL REVIEW TO THE EMPLOYER(FINAL APPEAL) You must request an appeal in writing within 60 days of the date you received notice of the Level One Denial of Benefits.You may submit written comments,documents,records,and any other information relating to the claim.Upon written request and free of charge,you will be provided reasonable access to,and copies of,all documents,records,and other information relevant to the claim.The review of your level two appeal will take into account all comments,documents,records,and other information submitted that relates to the claim.This would include comments,documents,records,and other information that either was not submitted previously or was not considered in the initial benefit decision.The review of your appeal will give no deference to the initial decision.It will be conducted by the Employer's Review Committee and not anyone involved in the initial denial decision. You must file your appeal by submitting a written request by email,fax,or mail. • Email all materials to claims@naviabenefits.com with"LEVEL TWO REQUEST FOR REVIEW OF BENEFIT DENIAL"in the subject line. • Fax all materials to 425-452-7002 or 866-535-9227 with"LEVEL TWO REQUEST FOR REVIEW OF BENEFIT DENIAL"on the cover page. • Mail all materials to Navia Benefit Solutions Level Two Review,PO Box 53250,Bellevue,WA 98015 TIME PERIODS FOR APPEAL You will be notified of the decision no later than 30 days after Navia receives your appeal and forwards the appeal to your employer.The Plan may extend this period by a reasonable time if necessary. You have a right to bring a civil action under ERISA§502(a)if applicable if you file a final appeal and your request for benefits is denied following review of the appeal. Please carefully review the above information.If you decide to appeal this denial by requesting a review as described above,your appeal should be sent within the prescribed time period to the person named above. Failure to file a timely appeal will bar you from any further review of this benefit denial under these procedures or in a court of law. The above appeals process does not apply to Wellness Plan denials. Navia Benefit Solutions PO Box 53250, Bellevue, WA 98015-3250 Website portal.naviabenefits.com Notice of Completed Debit Card Substantiation From: notification a navia benefits.corn [ma i Ito:notification a navia benefits.corn Sent: Friday, February 26, 2016 3:33 PM To: tony.stark(a)abccompany.com Subject: Adjudication Notification Dear Navia participant, This email is to notify you that a debit card swipe has been resolved. For more information about the details of your debit card swipe, please access your online account or click http://www.naviabenefits.com/contact for contact information. Please do not reply to this email. Sincerely, Navia Benefit Solutions navia If you do not wish to receive further electronic correspondence from Navia Benefit Solutions, please click here to unsubscribe. To access documents, you must have Adobe Reader. If you do not currently have this program installed, visit httn://get.adobe.com/reader/to download. Join Our • Standard Reports This section contains samples of our standard reports. Included are the following documents: • Disbursement Report A detailed report that shows all of the reimbursements issued by Navia. The report is provided in an Excel format and has three (3)tabs: The Manual Claim Disbursement Worksheet, Debit Card Disbursement Worksheet, and Adjustment Disbursement Worksheet. • Year-To-Date Report A report showing all of the FSA participants and their Year-To-Date balances, contributions, reimbursements issued and their annual election amount. This report can be generated at any time. • Final Year-To-Date Report An end of year report with four(4)tabs showing: participant account information, client level funding transactions, participant disbursement detail, and account adjustments for the benefit plan year. Manual Claim Disbursement Worksheet For: ABC Company For Checks Dated: 6/24/2016 11400 SE 6th St.,Suite 125 Date Printed: 6/24/2016 Bellevue,WA 98004 Batch Number: 9233808 Plan Code 201601 Emp ID# Dept Name Amount Total Health Care FSA Day Care FSA Disbursement 123456789 ABC1 Banner,Bruce $310.72 $0.00 $310.72 Chk#5928953 123456790 ABC1 Grayson,Dick $65.00 $0.00 $65.00 Chk#5928954 123456791 ABC1 Grey,Jean $0.00 $208.33 $208.33 Chk#5928955 123456792 ABC1 Howlett,James $1,020.00 $0.00 $1,020.00 ACH 5928956 123456793 ABC1 Kent,Clark $0.00 $208.33 $208.33 ACH 5928957 123456794 ABC1 Murdock,Matthew $0.00 $208.33 $208.33 ACH 5928958 123456795 ABC1 Norris,Chuck $0.00 $208.33 $208.33 Chk#5928959 123456796 ABC2 Parker,Peter $0.00 $208.33 $208.33 ACH 5928960 123456797 ABC2 Quill,Peter $50.57 $0.00 $50.57 ACH 5928961 123456798 ABC2 Rogers,Steve $17.93 $0.00 $17.93 ACH 5928962 123456799 ABC1 Stark,Tony $0.00 $208.33 $208.33 ACH 5928963 123456800 ABC2 Thor,Mr. $0.00 $208.33 $208.33 ACH 5928964 123456801 ABC1 Wayne,Bruce $0.00 $208.33 $208.33 Chk#5928965 123456802 ABC1 Wilson,Wade $0.00 $2,708.29 $2,708.29 Chk#5928966 123456803 ABC1 Xavier,Charles $0.00 $217.39 $217.39 ACH 5928967 Total Employees Processed: 15 Plan: Disbursements #Employees Health Care FSA $1,464.22 5 Day Care FSA $4,592.32 10 Depts: ABC1 $5,571.38 11 ABC2 $485.16 4 Total Disbursements $6,056.54 Debit Card Disbursement Worksheet For: ABC Company For Disbursements Dated: 6/17/2016-6/24/2016 11400 SE 6th St.,Suite 125 Date Printed: 6/24/2016 Bellevue,WA 98004 Plan Code 201601 Emp ID q Dept Name Transaction Date Amount Total Health Care FSA Day Care FSA Disbursement ABCI Banner,Bruce 6/18/2016 $45.00 $0.00 $45.00 ABCI Banner,Bruce 6/18/2016 $20.00 $0.00 $20.00 ABCI Banner,Bruce 6/18/2016 $6.75 $0.00 $6.75 ABCI Banner,Bruce 6/22/2016 $20.00 $0.00 $20.00 ABCI Banner,Bruce 6/21/2016 $103.30 $0.00 $103.30 ABCI Banner,Bruce 6/22/2016 $10.00 $0.00 $10.00 ABCI Banner,Bruce 6/23/2016 $10.00 $0.00 $10.00 ABCI Grayson,Dick 6/18/2016 $22.57 $0.00 $22.57 ABCI Grayson,Dick 6/17/2016 $150.00 $0.00 $150.00 ABCI Grayson,Dick 6/20/2016 $10.00 $0.00 $10.00 ABCI Grey,Jean 6/22/2016 $20.00 $0.00 $20.00 ABCI Grey,Jean 6/23/2016 $10.00 $0.00 $10.00 ABCI Grey,Jean 6/17/2016 $35.00 $0.00 $35.00 ABCI Grey,Jean 6/17/2016 $39.50 $0.00 $39.50 ABCI Grey,Jean 6/17/2016 $20.00 $0.00 $20.00 ABCI Grey,Jean 6/23/2016 $20.00 $0.00 $20.00 ABCI Grey,Jean 6/17/2016 $70.27 $0.00 $70.27 ABCI Grey,Jean 6/17/2016 $15.00 $0.00 $15.00 ABCI Grey,Jean 6/21/2016 $3.60 $0.00 $3.60 ABCI Howlett,James 6/22/2016 $5.75 $0.00 $5.75 ABC1 Howlett,James 6/23/2016 $20.00 $0.00 $20.00 ABC1 Kent,Clark 6/20/2016 $147.72 $0.00 $147.72 ABCI Kent,Clark 6/17/2016 $13.58 $0.00 $13.58 ABCI Kent,Clark 6/21/2016 $54.60 $0.00 $54.60 ABC1 Kent,Clark 6/18/2016 $20.00 $0.00 $20.00 ABC1 Kent,Clark 6/21/2016 $9.69 $0.00 $9.69 ABC1 Kent,Clark 6/22/2016 $20.00 $0.00 $20.00 ABC1 Kent,Clark 6/22/2016 $20.00 $0.00 $20.00 ABC1 Kent,Clark 6/23/2016 $50.00 $0.00 $50.00 ABC1 Kent,Clark 6/17/2016 $20.00 $0.00 $20.00 ABC1 Kent,Clark 6/22/2016 $120.61 $0.00 $120.61 ABC1 Kent,Clark 6/20/2016 $38.57 $0.00 $38.57 ABC1 Kent,Clark 6/20/2016 $34.51 $0.00 $34.51 ABC1 Kent,Clark 6/23/2016 $20.00 $0.00 $20.00 ABC1 Kent,Clark 6/23/2016 $5.00 $0.00 $5.00 ABC1 Kent,Clark 6/22/2016 $5.10 $0.00 $5.10 ABC1 Stark,Tony 6/18/2016 $265.84 $0.00 $265.84 ABC1 Stark,Tony 6/20/2016 $136.19 $0.00 $136.19 ABC1 Stark,Tony 6/22/2016 $12.79 $0.00 $12.79 ABC1 Wayne,Bruce 6/21/2016 $25.00 $0.00 $25.00 ABC1 Wayne,Bruce 6/23/2016 $25.00 $0.00 $25.00 ABC1 Wayne,Bruce 6/17/2016 $30.44 $0.00 $30.44 ABC1 Wayne,Bruce 6/20/2016 $92.80 $0.00 $92.80 ABC1 Wayne,Bruce 6/17/2016 $189.38 $0.00 $189.38 ABC1 Wayne,Bruce 6/22/2016 $20.00 $0.00 $20.00 ABC1 Wayne,Bruce 6/21/2016 $20.00 $0.00 $20.00 ABC1 Wayne,Bruce 6/22/2016 $10.00 $0.00 $10.00 ABC1 Wayne,Bruce 6/22/2016 $20.00 $0.00 $20.00 ABC1 Wayne,Bruce 6/18/2016 $75.00 $0.00 $75.00 ABC1 Wayne,Bruce 6/17/2016 $100.00 $0.00 $100.00 ABC1 Wayne,Bruce 6/17/2016 $20.00 $0.00 $20.00 ABC1 Wayne,Bruce 6/17/2016 $10.00 $0.00 $10.00 ABC1 Wayne,Bruce 6/18/2016 $7.50 $0.00 $7.50 ABC1 Wayne,Bruce 6/18/2016 $4.04 $0.00 $4.04 ABC1 Wilson,Wade 6/23/2016 $40.00 $0.00 $40.00 ABC1 Wilson,Wade 6/18/2016 $20.00 $0.00 $20.00 ABC1 Wilson,Wade 6/22/2016 $20.00 $0.00 $20.00 ABC1 Wilson,Wade 6/23/2016 $91.75 $0.00 $91.75 ABC1 Wilson,Wade 6/17/2016 $180.00 $0.00 $180.00 Total Employees Processed: 8 Plan: Disbursements #Employees Health Care FSA $2,651.85 8 Day Care FSA $0.00 0 Depts: ABC1 $2,651.85 8 ABC2 $0.00 0 Total Debit Card Disbursements $2,651.85 Adjustment Disbursement Worksheet For: ABC Company For Adjustments Dated: 6/17/2016-6/24/2016 11400 SE 6th St.,Suite 125 Date Printed: 6/24/2016 Bellevue,WA 98004 Plan Code 201601 Emp ID# Dept Name Transaction Date Amount Total Adjustment Health Care FSA Day Care FSA Disbursement Description ABC1 Banner,Bruce 6/21/2016 -$65.50 $0.00 -$65.50 Debit Card Credit ABC1 Kent,Clark 6/18/2016 -$30.44 $0.00 -$30.44 Debit Card Credit ABC1 Stark,Tony 6/19/2016 -$38.00 $0.00 -$38.00 Debit Card Credit Total Employees Processed: 3 Plan: Disbursements #Employees Health Care FSA -$133.94 3 Day Care FSA $0.00 0 Depts: ABC1 -$133.94 3 ABC2 $0.00 0 Total Adjustments -$133.94 Report:Year-to-Date Prepared by:Navia Benefit Solutions 6/24/2016 11:24:53 AM Company Name:ABC Company Coverage Period:01/01/16 to 12/31/16 Plan:201601-Section 12S Benefit:Health Care FSA Department I Employee Name IAnnual Election IBenefit Effective Date I Total Contributions IDisbursements IBaiance ITerm Date ITermination Type ABC1 Banner,Bruce $500.00 01/01/2016 $500.00 $0.00 $500.00 ABC1 Grayson,Dick $480.00 01/01/2016 $240.00 $0.00 $240.00 ABC1 Grey,Jean $300.00 01/01/2016 $150.00 $0.00 $150.00 ABC1 Howlett,James $500.00 01/01/2016 $249.96 $402.67 ($152.71) ABC1 Kent,Clark $500.00 01/01/2016 $249.96 $0.00 $249.96 ABC1 Murdock,Matthew $500.00 02/22/2016 $166.68 $289.44 ($122.76) ABC1 Norris,Chuck $1,275.00 05/16/2016 $255.00 $310.72 ($55.72) ABC2 Parker,Peter $120.00 01/01/2016 $60.00 $120.00 ($60.00) ABC2 Quill,Peter $135.38 01/01/2016 $135.38 $0.00 $135.38 ABC2 Rogers,Steve $100.00 01/01/2016 $100.00 $0.00 $100.00 ABC1 Stark,Tony $1,500.00 04/18/2016 $375.00 $0.00 $375.00 ABC2 Thor,Mr. $600.00 01/01/2016 $300.00 $189.12 $110.88 ABC1 Wayne,Bruce $600.00 01/01/2016 $300.00 $0.00 $300.00 ABC1 Wilson,Wade $600.00 01/01/2016 $349.96 $0.00 $349.96 ABC1 Xavier,Charles $800.00 01/01/2016 $133.32 $38.39 $94.93 7/1/2016 Cease participation ABC1 $7,555.00 $2,969.88 $1,041.22 $1,928.66 ABC2 $955.38 $595.38 $309.12 $286.26 Totals: $8,510.38 $3,565.26 $1,350.34 $2,214.92 Total Participants: 15 Benefit:Day Care FSA Department I Employee Name Annual Election Benefit Effective Date I Total Contributions Disbursements Balance ITerm Date Termination Type ABC1 Banner,Bruce $480.00 01/01/2016 $240.00 $0.00 $240.00 ABC1 Grayson,Dick $5,000.00 01/01/2016 $2,499.96 $0.00 $2,499.96 ABC1 Grey,Jean $2,000.00 02/01/2016 $800.00 $0.00 $800.00 ABC1 Howlett,James $5,000.00 01/01/2016 $2,499.96 $0.00 $2,499.96 ABC1 Kent,Clark $5,000.00 01/01/2016 $2,499.96 $2,499.96 $0.00 ABC1 Stark,Tony $300.00 06/01/2016 $23.08 $0.00 $23.08 ABC2 Thor,Mr. $5,000.00 01/01/2016 $2,499.96 $0.00 $2,499.96 ABC1 Wilson,Wade $1,000.00 06/01/2016 $76.92 $0.00 $76.92 ABC1 $18,780.00 $8,639.88 $2,499.96 $6,139.92 ABC2 $5,000.00 $2,499.96 $0.00 $2,499.96 Totals: $23,780.00 $11,139.84 $2,499.96 $8,639.88 Total Participants: 8 Summary Annual Ele ITotal Contributions IDisbursements lBalance ABC1 $26,335.00 $11,609.76 $3,541.18 $8,068.58 ABC2 $5,955.38 $3,095.34 $309.12 $2,786.22 $32,290.38 $14,705.10 $3,850.30 $10,854.80 Total Participant 15 00 00 V O O m O O o0 0 a O N O O N O O 0 0 0 0 O O u P O 1l� O lD O ^j al O Il� n O n a O O O N O c-I ^ M to T a0 Go , m O N N u1 N 00 u C N rl rl m vt .n om 00 O O ul ul n O O ul M O O O1 0 O ti N N ul O 00 N O O m O Cl Cl O ul Ol .--I O O M u1 O O (7l cl O a of of N O cl of O O al C 00 w O ul O 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O 0 0 r-I ri r-I ri L- tw O O O O O O O O O N N N O O O O C N N N N N N N N N \ \ \ N N N N 0000 -4 0 -4 0 -4 -1 o m om m -4 m -4 o m N M m M m m m m \ \ \ m N M m 3 \ \ \ \ \ \ \ \ \ O ri N \ \ \ \ d LL ri N m :T Ln w I" 00 cn ri ri ri ri N m Checks Disbursed Check Number Check Date Type Disburse Type Employee Company Amount Cleared ACH Void Plan Year Department Emp ID 5304804 1/23/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5571704 9/11/2015 Disbursement Standard Banner,Bruce ABC 3,533.77 Yes Yes 201501 3343 55093857 9/15/2015 Disbursement Debit Card Banner,Bruce ABC 25.25 Yes 201501 3343 55098940 9/16/2015 Disbursement Debit Card Banner,Bruce ABC 183.73 Yes 201501 3343 5589590 9/28/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5602967 30/9/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5617133 10/23/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5634370 11/6/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5642504 11/13/2015 Disbursement Standard Banner,Bruce ABC 30.44 Yes Yes 201501 3343 5650661 11/20/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5660550 11/30/2015 Disbursement Standard Banner,Bruce ABC 49.07 Yes Yes 201501 3343 5671676 12/4/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 5692297 12/18/2015 Disbursement Standard Banner,Bruce ABC 208.33 Yes Yes 201501 3343 53922166 1/17/2015 Disbursement Debit Card Grayson,Dick ABC 1,568.31 Yes 201501 3630 5420329 4/24/2015 Disbursement Standard Grayson,Dick ABC 208.33 Yes Yes 201501 3630 5437345 5/8/2015 Disbursement Standard Grayson,Dick ABC 208.33 Yes Yes 201501 3630 5451466 5/22/2015 Disbursement Standard Grayson,Dick ABC 208.33 Yes Yes 201501 3630 5466391 6/5/2015 Disbursement Standard Grayson,Dick ABC 208.33 Yes Yes 201501 3630 54703227 6/17/2015 Disbursement Debit Card Grayson,Dick ABC 54.00 Yes 201501 3630 5712281 1/4/2016 Disbursement Standard Grayson,Dick ABC 2,881.19 Yes Yes 201501 3630 5642505 11/13/2015 Disbursement Standard Grey,Jean ABC 625.00 Yes 201501 4818 5676134 12/8/2015 Disbursement Reissue Grey,Jean ABC 375.00 Yes 201501 4818 54050976 2/11/2015 Disbursement Debit Card Howlett,James ABC 118.28 Yes 201501 2427 54381580 4/11/2015 Disbursement Debit Card Howlett,James ABC 627.60 Yes 201501 2427 54393325 4/14/2015 Disbursement Debit Card Howlett,James ABC 177.42 Yes 201501 2427 55247523 10/24/2015 Disbursement Debit Card Howlett,James ABC 1,132.25 Yes 201501 2427 54254818 3/19/2015 Disbursement Debit Card Kent,Clark ABC 158.20 Yes 201501 4699 54273274 3/23/2015 Disbursement Debit Card Kent,Clark ABC 10.00 Yes 201501 4699 54299400 3/27/2015 Disbursement Debit Card Kent,Clark ABC 7.00 Yes 201501 4699 54339112 4/3/2015 Disbursement Debit Card Kent,Clark ABC 1,202.03 Yes 201501 4699 54078963 2/16/2015 Disbursement Debit Card Murdock,Matthew ABC 10.00 Yes 201501 4262 54141244 2/27/2015 Disbursement Debit Card Murdock,Matthew ABC 30.00 Yes 201501 4262 55203718 10/13/2015 Disbursement Debit Card Murdock,Matthew ABC 88.41 Yes 201501 4262 55203719 10/13/2015 Disbursement Debit Card Murdock,Matthew ABC 1,002.32 Yes 201501 4262 5819280 3/25/2016 Disbursement Standard Murdock,Matthew ABC 472.22 Yes Yes 201501 4262 5831024 4/1/2016 Disbursement Standard Murdock,Matthew ABC 39.22 Yes Yes 201501 4262 53882477 1/9/2015 Disbursement Debit Card Quill,Peter ABC 25.00 Yes 201501 1017 53892995 1/12/2015 Disbursement Debit Card Quill,Peter ABC 25.00 Yes 201501 1017 53956830 1/24/2015 Disbursement Debit Card Quill,Peter ABC 112.00 Yes 201501 1017 53962818 1/26/2015 Disbursement Debit Card Quill,Peter ABC 22.00 Yes 201501 1017 54025808 2/6/2015 Disbursement Debit Card Quill,Peter ABC 2,751.60 Yes 201501 1017 54676817 6/11/2015 Disbursement Debit Card Rogers,Steve ABC 164.20 Yes 201501 4691 55130119 9/24/2015 Disbursement Debit Card Rogers,Steve ABC 25.00 Yes 201501 4691 55134803 9/25/2015 Disbursement Debit Card Rogers,Steve ABC 43.34 Yes 201501 4691 55412954 12/7/2015 Disbursement Debit Card Rogers,Steve ABC 39.99 Yes 201501 4691 5299019 1/16/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5312978 1/30/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5331763 2/13/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5350501 2/27/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5368229 3/13/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5386434 3/27/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5404566 4/10/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5420330 4/24/2015 Disbursement Standard Stark,Tony ABC 208.33 Yes Yes 201501 2983 5692299 12/18/2015 Disbursement Standard Stark,Tony ABC 3,333.28 Yes Yes 201501 2983 54134288 2/26/2015 Disbursement Debit Card Thor,Mr. ABC 25.00 Yes 201501 1030 54141253 2/28/2015 Disbursement Debit Card Thor,Mr. ABC 10.75 Yes 201501 1030 54209644 3/11/2015 Disbursement Debit Card Thor,Mr. ABC 50.19 Yes 201501 1030 54286129 3/25/2015 Disbursement Debit Card Thor,Mr. ABC 25.00 Yes 201501 1030 5395531 4/3/2015 Disbursement Standard Thor,Mr. ABC 1,249.98 Yes 201501 3707 54363300 4/8/2015 Disbursement Debit Card Thor,Mr. ABC 25.00 Yes 201501 1030 5404567 4/10/2015 Disbursement Standard Thor,Mr. ABC 208.33 Yes 201501 3707 54435462 4/22/2015 Disbursement Debit Card Thor,Mr. ABC 451.50 Yes 201501 1030 5420331 4/24/2015 Disbursement Standard Thor,Mr. ABC 2,203.23 Yes 201501 3707 54025805 2/6/2015 Disbursement Debit Card Wayne,Bruce ABC 25.00 Yes 201501 4030 54078960 2/16/2015 Disbursement Debit Card Wayne,Bruce ABC 63.19 Yes 201501 4030 54160799 3/3/2015 Disbursement Debit Card Wayne,Bruce ABC 25.00 Yes 201501 4030 54202317 3/10/2015 Disbursement Debit Card Wayne,Bruce ABC 100.00 Yes 201501 4030 54273277 3/23/2015 Disbursement Debit Card Wayne,Bruce ABC 138.58 Yes 201501 4030 54412550 4/17/2015 Disbursement Debit Card Wayne,Bruce ABC 610.22 Yes 201501 4030 5304805 1/23/2015 Disbursement Standard Wilson,Wade ABC 125.00 Yes Yes 201501 4058 53975339 1/29/2015 Disbursement Debit Card Wilson,Wade ABC 960.00 Yes 201501 4266 5350502 2/27/2015 Disbursement Standard Wilson,Wade ABC 57.00 Yes Yes 201501 4058 54183419 3/7/2015 Disbursement Debit Card Wilson,Wade ABC 1,964.99 Yes 201501 4266 54267469 3/21/2015 Disbursement Debit Card Wilson,Wade ABC 50.00 Yes 201501 4058 5386435 3/27/2015 Disbursement Standard Wilson,Wade ABC 1,943.00 Yes Yes 201501 4058 53876683 1/8/2015 Disbursement Debit Card Xavier,Charles ABC 60.00 Yes 201501 3919 53876684 1/8/2015 Disbursement Debit Card Xavier,Charles ABC 16.23 Yes 201501 3919 53882469 1/9/2015 Disbursement Debit Card Xavier,Charles ABC 482.00 Yes 201501 3919 53993465 1/31/2015 Disbursement Debit Card Xavier,Charles ABC 190.00 Yes 201501 3919 5701185 12/28/2015 Disbursement Standard Xavier,Charles ABC 1.77 201501 3919 Checks Written 36,169.68 Adjustments (174.72) Plan Disbursements 35,994.96 k _ 3 & _ \ \ ƒ \ y & » ƒ $\ \ � f \ \ � \ �« # % \ \ « \ \ \ s \ ik7 § erg \ ƒ 7 � \ \ f � - 3 ƒ } # - \ ƒ � _ # a k % 77 ƒ k ` % k ell � $ 2 � \ � GoNavia Commuter Materials This section contains samples of Navia's standard materials for the GoNavia commuter program. Included are the following documents: • GoNavia Employee Outreach Email An email notification sent to all eligible employees.The email provides a brief highlight of the program and instructions for placing commuter orders through Navia's website. • GoNavia Employee Benefit Overview This document provides a detailed description of each of the benefits available to employees. The document highlights important deadlines and also provides a brief FAQ for participants. • GoNavia Sign-up Instructions This document provides detailed instructions for placing orders through Navia's website. • Agency Direct Flyer This document provides detailed instructions for placing direct transit agency orders through Navia's website. Knipp, Stefan Subject: GoNavia Commuter Now Available! Welcome to Navia ! The GoNavia program is a commuter benefit that enables you to load a benefit card with pre-tax dollars to pay for work related commuting expenses. You can now order commuter benefits online with the GoNavia Program! You must place your order by the 20th of the month to receive your order for the following month. For example, if you would like to order commuter funds for the benefit month of May, you must place your order by April 20th. Sign up instructions and general information about the program can be found in the attached documents. Your company code, ABC, will be required for online registration. The pre-tax maximum for transit is $130 per month and the pre-tax maximum for parking is $255 per month. These limits are always subject to change. It is important to note that the GoNavia Program is available year-round as long as you're eligible for commuter benefits. Thank you, Navia Benefit Solutions tnavia Local:425-452-3500 Toll Free: 1-800-669-3539 www.naviabenefits.com Navia Benefit Solutions JoinOur • About Benefits We Offer News Eligible Expenses f Like us on -••• ToolsPrivacy • Terms of A• Contact Subscribe to us on • •- 1 tnavia benefit solutions GoNavia Transit Benefit The GoNavia Transit Benefit allows employees who commute to and from work to receive pre-tax funds to pay for their work-related mass transit expenses. Eligible expenses include: • Transit passes 0 Fare cards • Ticket books • Vanpool costs How it works: Simply log in at the Navia website (www.naviabenefits.com), select the"GoNavia Commuter Benefits"link follow the prompts to place your order. Your transit order will be loaded onto your Navia Benefits Card before the 15t of the order month.The card may be used at any transit vendor that accepts MasterCard TM. If you have a benefits card with your current employer, you already have the card you need! If you have not been issued one before,we will mail one to you with your first order. Future orders will be loaded onto the same card.Any unused funds may be used in subsequent months. All orders and changes must be completed by 11:59 pm PST on the 201" day of the month prior to the month you would like to receive your benefit. For example, if you are planning on utilizing the benefit for the month of February,you would need to place your order by January 20tn If you have placed a recurring order,you will receive a friendly email on the 101" of each month to remind you to check your order settings and make changes as necessary before your order deadline. Here are some FAQ's about the program: Q:When will my Navia Benefits Card be sent to me? A: If you already have a Navia Benefits Card your transit funds will be loaded to your current card—there's no need to wait for a new one. If you don't have a card one will be mailed to you once you submit your first order. Remember, this card will be the same card if you are enrolled in other benefits with Navia. Q: Do I have to log in to place my order each month? A: No.The GoNavia Benefit allows you to place a one-time order or to set your order to recur for the months of your choice. If you have selected recurring orders,you will receive a friendly email on the 10th of each month to remind you to check your order settings and make changes as necessary before your order deadline. Q:What happens to the transit balance on my Navia Benefits Card at the end of the benefit month? A:The balance will roll over from month-to-month as long as you are an active employee and remain eligible for this benefit. Keep in mind that these funds may only be used to pay for transit related expenses.They may not be used to pay for expenses covered by another benefit. Upon termination,your Navia Benefits Card will be shut off and any unused balance on the cards will be forfeited. Q: Can I reload my transit smart card? A: Most existing smart cards can be reloaded by using the Navia Benefits Card as a funding source. Be sure to verify any specific timing requirements or additional processing fees that may be associated with your particular smart card. All fees assessed by your smart card should be incorporated into your order total Still have questions on how the GoNavia Transit Benefit works? Visit Us Online Call Us Email Us www.naviabenefits.com (800)669-3539 customerservice@naviabenefits.com Monday-Friday(6AM-6PM PST) ibnavia benefit solutions GoNavia Parking Benefit The GoNavia Parking Benefit allows employees who commute to and from work to utilize pre-tax funds to pay for their work-related parking expenses. Eligible expenses include: • Parking costs associated with a lot at or near the place of business. • Parking costs from a lot that is at or near the place of commute(i.e. rideshare, carpool, vanpool) How it works: Simply log in at the Navia website (www.naviabenefits.com), select the"GoNavia Commuter Benefits"link, and follow the prompts to place your order. Your parking order will be loaded onto your Navia Benefits Card before the 15t of the order month.The card may be used at any parking vendor that accepts MasterCard TM. If you have a Navia Benefits Card with your current employer,you already have the card you need! If you have not been issued one before,we will mail one to you with your first order. Future orders will be loaded onto the same card.Any unused funds may be used in subsequent months. If you selected the"Pay Me Directly"option while ordering, a paper check will be mailed to you. If you elected direct deposit with Navia, a deposit will be initiated to your designated account instead. All orders and changes must be completed by 11:59 pm PST on the 20th day of the month prior to the month you would like to receive your benefit. For example, if you are planning on utilizing the benefit for the month of February,you would need to place your order by January 20tn If you have placed a recurring order,you will receive a friendly email on the 101" of each month to remind you to check your order settings and make changes as necessary before your order deadline. Here are some FAQ'S about the program: Q:When will my Navia Benefits Card be sent to me? A: If you already have a Navia Benefits Card your parking funds will be loaded to your current card—there's no need to wait for a new one. If you don't have a card one will be mailed to you once you submit your first order. Remember,this card will be the same card if you are enrolled in other benefits with Navia. Q: Do I have to log in to place my order each month? A: No.The GoNavia Benefit allows you to place a one-time order or to set your order to recur for the months of your choice. If you have selected recurring orders,you will receive a friendly email on the 10th of each month to remind you to check your order settings and make changes as necessary before your order deadline. Q:What happens to the parking balance on my Navia Benefits Card at the end of the benefit month? A:The balance will roll over from month-to-month as long as you are an active employee and remain eligible for this benefit. Keep in mind that these funds may only be used to pay for parking related expenses.They may not be used to pay for expenses covered by another benefit. Upon termination,your Navia Benefits Card will be shut off and any unused balance on the cards will be forfeited. Still have questions on how the GoNavia Parking Benefit works? Visit Us Online Call Us Email Us www.naviabenefits.com (800)669-FLEX(3539) customerservice@naviabenefits.com Monday-Friday(6AM -6PM PST) tnavia benefit solutions GoNavia Bicycle Benefit The GoNavia Bicycle Benefit allows employees who use a bicycle as their primary means of commuting to work to receive a subsidy of up to$20 per month from their employer. The $20 per month subsidy can then be used toward expenses related to your bicycle maintenance and commute. Eligible expenses include: • Bicycle Improvements • Purchase of a New Bicycle • Maintenance& Repair • Helmets&other Protective Gear • Bicycle Storage How it works: Simply log in at the Navia website (www.naviabenefits.com), select the"GoNavia Commuter Benefits"link, and follow the prompts to place your order. Your order will be processed on or around the 25th of the month prior and a paper check will be mailed to you. If you signed up for direct deposit with Navia, a deposit will be initiated to your designated account instead. You may then use those funds to pay for your eligible bicycle costs. The bicycle benefit does not have any purchase limitations.Your subsidies can be accumulated over several months to pay for larger purchases. All orders and changes must be completed by 11:59 pm PST on the 20th day of the month prior to the month you would like to receive your benefit. For example, if you are planning on utilizing the benefit for the month of February,you would need to place your order by January 20tn You will not be eligible for a bicycle subsidy if you are receiving any other type of transportation benefit from your employer during the same month. If you have placed a recurring order,you will receive a friendly email on the 101" of each month to remind you to check your order settings and make changes as necessary before your order deadline. Here are some FAQ'S about the program: Q:What if I do not receive my check? A: First, double-check you do not have direct deposit set-up for your orders. Then, contact Customer Service to notify them of the missing check. Please be prepared to verify your mailing address. Customer Service can be reached 6:OOam-6:OOpm Pacific Time by calling(425)452-3500 or toll-free (800) 669-3539. Q: Do I have to log in to place my order each month? A: No.The GoNavia Benefit allows you to place a one-time order or to set your order to recur for the months of your choice. If you have selected recurring orders,you will receive a friendly email on the 10th of each month to remind you to check your order settings and make changes as necessary before your order deadline. Q: How do I sign-up to have my bicycle order amount deposited directly into my bank account? A: Login at the Navia website (www.naviabenefits.com) and select"Update My Information"in the"My Tools" box. This will open your"Personal Information"page where you can then select"Update Direct Deposit Information." Just complete the form fields and click Submit!A pre-note should be initiated within 2 business days to ensure that the bank account information was entered correctly before it becomes active. Still have questions on how the GoNavia Bicycle Benefit works? Visit Us Online call Us Email Us www.naviabenefits.com (800)669-3539 customerservice@naviabenefits.com Monday-Friday(6AM-6PM PST) ibnavia benefit solutions GoNavia Sign-Up Instructions Commuting to Work is Easier with the GoNavia Program Learn how to register online and place monthly orders. The GoNavia Program allows you to pay for work Step 1: Login as a participant to related transportation costs with pre-tax dollars. www.naviabenefits.com If To place your first order, you will need to log in to you have not registered yet, your online account at www.naviabenefits.com. If you will need to complete the you have already registered, you will see a new link to registration process. GoNavia Commuter Benefits after login. Step 2: Once logged in, select the link to GoNavia Commuter Benefits. Registering Your Account Step 3: Select your benefit. If you are new to Navia Benefit Solutions visit Step 4: Enter the dollar amount for www.naviabenefits.com, click the Register in the your order. upper-right corner of the screen and select "I'm a participant." Step 5: Select the months you would like to have your order recur You will need your 3 character employer code. This and click "continue." code can be found in your original "GoNavia Now Step 6: Confirm your order then click Available" email notification or by simply calling "submit." Customer Service. Shortly after completing the online form you will You're finished! You will receive a receive an email confirmation to complete your confirmation email once your order registration. has been submitted. **THE DEADLINE TO PLACE YOUR MONTHLY ORDER IS THE 20TH OF EACH MONTH** Need help signing up for GoNavia? Visit Us Online Call Us Email Us www.naviabenefits.com (800)669-3539 customerservice@naviabenefits.com Monday- Friday(5AM-5PM PST) How to Place a GoNavia Direct Agency Order navia benefit • • LoginStep 1 .. Step 2 M Tools Under the"My Tools"section,click"GoNavia Clicc k on an icon Commuter • •' to access and maintain your Submit a Claim GoNaviaCommuter Access MyHSA plan. orders Step 3 Click"Place an Order forFir— GoNavia Transit/vanpool Be:n*'m rder Step 4 fill m the information below to piece an order Navla TrenarWanpool•en•fit Remember.the last day to place or change an der for November is 10/20/2016. On the ordering page,select the option to Mo yvu piatmj Jr,order fu.vau(xxJ • • - • •' • • •. Yet •No • card. Maxlmum we Tat Carw emourst 1255.00• •Any amounes m exCe55 of 1?55.00 WIII be dedyour paycnetk psi wa up m Youremploye providesa 1CRNosubsidycuttttetion of your Transt Benehr orderHow would yuu like us to process this order? toad dus amvuM to my Navu Benefits[habit•NEMLoadthisamounttoatranszaguntypa Stepagency: agency,Select the transit •• your �o ycn,have an e>nsong rar0 or bass from inn vawt agency' product,and provide your agency card/pass •vas EJrier your cardrpua nunor 11erP .o Select if this is a one-time order,or recur- ring • • f•�r.,.,­aily for Pxh OroQuR Lai S4,00 Place your order! Order T t3t S40.00 2mmxeu 5utniay amount:Sao 00 SSN/EMPID Full Name BeneCode Deduction Amount Annual Election Paycycle Dept. 123456789 Bedrock, Betty HCFSA 100.00 2400.00 SEMI-MONTHLY HOME 123456789 Bedrock, Betty DCFSA 208.33 5000.00 SEMI-MONTHLY HOME 9876543521 Flintstone, Fred LHCFSA 100.00 2400.00 SEMI-MONTHLY HOME Column -• -• to contain Character limit Description Format Requirements data SSN/EmplD Y 9 Unique employee ID used by employer If using SSN, must be 9 digits with no formatting or dashes. If either name is longer than 32 characters, name may be truncated Full name Y 64 Employee Last Name, Employee First Name on debit card General Health Care FSA=HCFSA, Day Care FSA=DCFSA, BeneCode Y 6 Unique benefits code. Limited Health Care FSA=LHCFSA Deduction Amount Y 7 The per pay check deduction amount. Annual Election I Y 7 IThe annual election (plan year goal)amount. IShould not exceed benefit maximum SSN/EMPID First Name Middle Name Last Name Address#1 Address#2 city State 123456789 Betty B. Bedrock 1 Main Street Bellevue WA 123456789 Betty B. Bedrock 1 Main Street Bellevue WA 987654321 George Jetson 2 Main Street Bellevue WA Zip DOB Email Phone Number Paycycle Dept. BeneCode Deduction Amount 98888 11/13/1066 bbedrock@flinstones.com SEMI-MONTHLY HOME HCFSA 100.00 98888 11/13/1066 bbedrock@flinstones.com SEMI-MONTHLY HOME DCFSA 208.33 98888 9/01/1066 gjetson@spacelysprockets.com SEMI-MONTHLY HOME HCFSA 50.00 Annual Election Benefit Effective Date Benefit Term Date Debit card Direct Deposit Bank Routing# Bank Account# Checking/Savings 2400.00 1/1/2016 Y Y 125000024 55555555 C 5000.00 1/1/2016 N Y 125000024 55555555 C 1200.00 1/1/2016 Y Y 125000024 99999999 C Column Required to contain Description Format Requirements SSN/EmpID Y Unique employee ID used by employer If using SSN, must be 9 digits with no formatting or dashes. First Name Y Employee First Name If longer than 15 characters, name may be truncated on Debit card Middle Name N Employee Middle Name or Initial Last Name Y Employee Last Name If longer than 15 characters, name may be truncated on Debit card Address#1 Y Employee Street Address Should be no longer than 75 characters Apartment/Suite number(include here only if not in Address#2 N Address1 column) Should be no longer than 75 characters City Y Employee City Should be no longer than 75 characters State Y Employee State Abbreviation Zip Y Employee Zip Code Must be 5 digits exactly DOB Y Employee Date of Birth MM/DD/YYYY Employee Email Address(required for Debit card&online Email Y access) Must include Area Code; 10 digits only, no spaces or special Phone Number N Employee Phone Number(work, home or mobile) characters The pay cycle of the employees; BI-WEEKLY, SEMI- MONTHLY, MONTHLY,WEEKLY or, BI-WEEKLY(24). Should be the same for all employees who are paid in the MONTHLY, SEMI-MONTHLY, BI-WEEKLY, BI-WEEKLY(24), Paycycle Y same pay cycle regardless of benefit effective date. WEEKLY,QUARTERLY,ANNUALLY Include only if you need Navia to separate these in Dept. Y, if applicable administration Codes will be provided if departments need to be reported on file. General Health Care FSA= HCFSA, Day Care FSA=DCFSA, Limited BeneCode Y Unique benefits code. Health Care FSA=LHCFSA Deduction Amount Y The per pay check deduction amount. Annual Election Y The yearly goal amount. Can not exceed benefit maximum Benefit Effective Date Y Employee Benefit Effective for the Current Plan Year MM/DD/YYYY; Must be within current plan year MM/DD/YYYY; Must be within current plan year. Only send end of the plan year termination dates for employees not eligible to receive carry Benefit Term Date Y, if applicable Employee Benefit Termination Date over funds. Debit card Y Indicate if employee elects to use the Debit card. Y for Yes or N for No, blank value if card is not offered Direct Deposit N Indicate if employee requests direct deposit Y for Yes or N for No Bank Routing# N Employee Bank Routing#for direct deposit. Must be 9 digits. Bank Account# N Employee Bank Account Number for direct deposit. Should only contain digits Checking/Savings N Type of account "C"for Checking or"S"for Savings SSN/Employee ID Custom ID # First Name Last Name Address#1 Address#2 City 123456789 123456789 Betty Bedrock 555 Test Street Bedrock 123456789 123456789 Betty Bedrock 555 Test Street Bedrock State Zip Email Phone Number Date of Birth Benefit Effective Date Dept WA 98888 bbedrock(cD-msn.com 4154154415 5/24/1978 6/2/2006 WA 98888 bbedrock(o)msn.com 4154154415 5/24/1978 6/2/2006 Pay Code Benefit Code Activate Commuter Link Term Date LOA Start date LOA END date Subsidy(Y/N) SEMI-MONTHLY TRANS Y Y SEMI-MONTHLY PARK Y N Subsidy Type (P/PA/A) Subsidy$ Subsidy% Subsidy Applies to (PRE/POST/PREPOST) A 100.00 PRE Column Required Character limit Description SSN/Employee ID Yes 9 An alphanumeric field that uniquely identifies the employee within our system. Must use the same number for any other benefits that are offered and feed over on files. Custom ID# Yes 9 An alphanumeric field that uniquely identifies the employee within employer system.Will show up on the commuter monthly report. First Name Yes 32 Employee First Name Last Name Yes 32 Employee Last Name Streetl Yes 75 Employee Home Address Line 1 Street2 No 75 Employee Home Address Line 2 City Yes 75 Employee City State Yes 2 Employee State Abbreviation Zip Yes 10 Employee Postal Code Email Yes 64 Employee Email Address Phone No 10 Employee Phone Number, 10 digits only, no spaces or special characters Birth Date Yes 10 Employee Birth Date; MM/DD/YYYY Benefit Effective date Yes 10 Employee Benefit Effective date; MM/DD/YYYY Department Only if applicable 30 Description of the company division of the participant. Pay Code Yes 13 The pay cycle of the employees; BI-WEEKLY,SEMI- MONTHLY, MONTHLY,WEEKLY or, BI-WEEKLY (24).Should be the same for all employees who are paid in the same pay cycle regardless of benefit effective date. Benefit Code Yes 5 "TRANS"for transit "PARK"for parking, "BIKE"for bicycle Activate Commuter Link Yes 1 "Y"for all active records"N"for terminated records. Term Date Only if applicable 10 Employee Termination Date, MM/DD/YYYY,can be removed and the benefit reactivated by sending blank. Please note this will reactivate any recurring orders for the month.Any balances on the debit card will be refunded after the next cycle. LOA Start Date Only if applicable 10 Employee LOA start date, MM/DD/YYYY,can be removed by sending blank. Please note this will reactivate any recurring orders for the month. The LOA start date will cause any future orders to be ignored until it is removed. LOA End Date Only if applicable 10 Employee LOA end date, MM/DD/YYYY,sending an end date will reactivate any recurring orders for the month. Subsidy(Y/N) Yes, if applicable 1 If no subsidies are offered to any employees this can blank as well as all following fields. If subsidy is offered to individual employees"Y" must pass in this field and "N"for all records that do not receive a subsidy or are to have subsidy amounts removed. Subsidy Type(P/PA/A) Yes, if applicable 2 "P"= Percentage, "A"=amount, "PA"_ Percentage up to amount. "PA"subsidy type will require values to be in both the Subsidy$and Subsidy%columns. Subsidy$ Yes, if applicable 6 Monthly subsidy amount paid by Employer, expressed as a specific dollar amount in the form XXXXX.XX, up to the pre-tax maximum.Subsidy information passed on this file will override company level settings. Subsidy% Yes, if applicable 6 Monthly subsidy paid by Employer,expressed as a decimal of the total purchase up to the then current pre-tax maximum. In the form .xx only. Subsidy information passed on this file will override company level settings. Subsidy Applies to Yes, if applicable 7 "PRE"applies subsidy to only pre-tax amount, (PRE/POST/PREPOST) "POST'applies subsidy to only post tax amount, "PREPOST"applies subsidy to both pre-and post- tax amounts. File Name should include the 3-character Company Code, Date and File Type File •- Example Naming Conventions For Test Commuter Census Files: XXX05.25.2012ComCen-Test Company Code, Creation Date and File Type For Production Commuter Census Files: XXX05.25.2012ComCen Company Code, Creation Date and File Type Other File Requirements: All data should be on one workbook All data should be left-justified Data cannot be in the form of an equation or formula Only benefit eligibe employees can pass over on the file. Employees terminated prior to the start of the plan year cannot be on the file. The commuter census file is changes only, terminated employees should pass over once and then drop off the file. Exhibit C SELF-DEALING TRANSACTION DISCLOSURE FORM In order to conduct business with the County of Fresno (hereinafter referred to as "County"), members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must disclose any self-dealing transactions that they are a party to while providing goods, performing services, or both for the County. A self-dealing transaction is defined below: "A self-dealing transaction means a transaction to which the corporation is a party and in which one or more of its directors has a material financial interest" The definition above will be utilized for purposes of completing this disclosure form. INSTRUCTIONS (1) Enter board member's name,job title (if applicable), and date this disclosure is being made. (2) Enter the board member's company/agency name and address. (3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the County. At a minimum, include a description of the following: a. The name of the agency/company with which the corporation has the transaction; and b. The nature of the material financial interest in the Corporation's transaction that the board member has. (4) Describe in detail why the self-dealing transaction is appropriate based on applicable provisions of the Corporations Code. (5) Form must be signed by the board member that is involved in the self-dealing transaction described in Sections (3) and (4). (1)Company Board Member Information: Name: Date: Job Title: (2)Company/Agency Name and Address: (3)Disclosure(Please describe the nature of the self-dealing transaction you are a party to): (4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233(a): (5)Authorized Signature Signature: Date: