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OptumHealth Financial Services - Health Reimbursement Arrangement 2010 t , HEALTH REIMBURSEMENT ARRANGEMENT BASIC PLAN DOCUMENT • ©Hitesman&Associates,PA 2008 Non-ERISA Basic Plan Document TABLE OF CONTENTS ARTICLE I. INTRODUCTION 1 ARTICLE II. DEFINITIONS 3 ARTICLE III. ADOPTING EMPLOYER 6 ARTICLE IV. ELIGIBILITY AND PARTICIPATION OF EMPLOYEES 7 ARTICLE V. BENEFITS UNDER THE PLAN 9 ARTICLE VI. CONTRIBUTIONS 13 ARTICLE VII. CLAIMS DETERMINATIONS AND REVIEW OF DENIED CLAIM 14 ARTICLE VIII. HIPAA PRIVACY AND SECURITY PROVISIONS 18 ARTICLE IX. PLAN ADMINISTRATION 22 ARTICLE X. PLAN AMENDMENT AND TERMINATION 24 ARTICLE XI. GENERAL PROVISIONS 25 ARTICLE XII. COBRA CONTINUATION 28 ©Hitesman&Associates,PA 2008 i Non-ERISA Basic Plan Document 1 ARTICLE I. INTRODUCTION 1.1 Establishment. An executed Adoption Agreement plus this Basic Plan Document constitute the "Plan" for an Adopting Employer. The effective date of the Plan is set forth in the Adoption Agreement. 1.2 Purpose. The purpose of the Plan is to provide certain Employees with an opportunity to receive reimbursement for certain Health Care Expenses as provided in this Plan. It is the intention of the Adopting Employer that the benefits provided and payable under this Plan be eligible for exclusion from the gross income of Participants as provided by Sections 105(b) and 106 of the Code. In addition, it is the intention of the Adopting Employer that the Plan qualify as a Health Reimbursement Arrangement ("HRA") under IRS Revenue Ruling 2002-41 (June 26, 2002) and IRS Notice 2002-45(June 26, 2002). 1.3 HIPAA Privacy and Security Rules. This Plan is a"covered entity"for purposes of the Privacy Rules and Security Rules as described in greater detail in Article VIII below. 1.4 Not ERISA Plan. This Plan is not an employee welfare benefit plan for purposes of ERISA. 1.5 Trust. This Plan is intended to be funded through a Trust, reflected in a separate document. 1.6 Coverage Options. The Plan consists of one or more of the following coverage options as described below. (a) The following coverage options indicated in the Adoption Agreement are available under the Plan: (i) Full Scope Option. Participants may receive reimbursement for Health Care Expenses incurred by themselves and their Spouses and Dependents. (ii) Limited Scope Option. Participants may receive reimbursement for only Limited Scope Health Care Expenses incurred by themselves and their Spouses and Dependents. If provided in the Adoption Agreement, Participants enrolled in a high deductible health plan (as defined in Section 223 of the Code) sponsored by the Adopting Employer shall automatically be enrolled in this coverage option. (iii) Suspended Account Option. Participants may receive no reimbursements from their HC Accounts. However, the balance of the Participant's HC Account will be preserved for use in subsequent Plan Years. (iv) Other. Such other coverage option as described in the Adoption Agreement. (b) Except as otherwise provided above, Participants will be covered under the "Full Scope Option" unless the Participant elects in writing and in a manner specified by the Plan Administrator to participate in another available coverage option for a particular Plan Year. Such an election shall be made prior to the beginning of the Plan Year and shall be irrevocable during the Plan Year. The election will automatically renew for subsequent Plan Years unless the Participant makes an election (in the manner specified above) to participate in a different coverage option for such subsequent Plan Year. (c) If a Participant changes coverage options,the following rules apply with respect to claims for reimbursement under the Plan unless provided otherwise in the Adoption Agreement: ©Hitesman&Associates,PA 2008 1 Non-ERISA Basic Plan Document (i) Expenses incurred during a particular Plan Year will be eligible for reimbursement under the Plan in accordance with the coverage option in which the Participant is enrolled for that Plan Year. For example, if a Participant who is enrolled in the "Limited Scope Option" for a Plan Year incurs an expense for something other than a Limited Scope Health Care Expense during that Plan Year, that expense cannot be reimbursed under the Plan at any time in the future (e.g., if the Participant enrolls in the "Full Scope Option" for the following Plan Year and submits the expense for reimbursement during that Plan Year). Also, if a Participant who is enrolled in the "Suspended Account Option" for a Plan Year incurs a Health Care Expense during that Plan Year, that expense cannot be reimbursed under the Plan at any time in the future (e.g., if the Participant enrolls in the "Full Scope Option" for the following Plan Year and submits the expense for reimbursement during that Plan Year). (ii) During a Plan Year in which a Participant participates in the "Limited Scope Option," the Plan will not reimburse Health Care Expenses that are not Limited Scope Health Care Expenses regardless of when the expense was incurred. For example, if a Participant incurs an expense for something other than a Limited Scope Health Care Expense in a Plan Year, that expense cannot be reimbursed during a subsequent Plan Year in which the Participant is enrolled in the"Limited Scope Option." (iii) During a Plan Year in which a Participant participates in the"Suspended Account Option," the Plan will not reimburse any Health Care Expenses regardless of when the expense was incurred. For example, if a Participant incurs a Health Care Expense in a Plan Year, that expense cannot be reimbursed during a subsequent Plan Year in which the Participant is enrolled in the "Suspended Account Option." ©Hitesman&Associates,PA 2008 2 Non-ERISA Basic Plan Document ARTICLE II. DEFINITIONS The following words and phrases are used in this Plan and shall have the meanings set forth in this Article unless a different meaning is clearly required by the context or is defined within an Article. 2.1 Adopting Employer means a state or political subdivision thereof that adopts this Plan by completing and executing an Adoption Agreement. 2.2 Adoption Agreement means the separate agreement, or portions thereof, completed and executed by an Adopting Employer setting forth the Adopting Employer's selection of options under the Plan. 2.3 Authorized Representative means, for the claims and appeal procedures, the person entitled to act on behalf of the claimant with respect to a benefit claim or appeal. In order for the Plan to recognize a person as an Authorized Representative, written notification to that affect signed by the claimant and notarized must be received by the Plan. An assignment for purposes of payment is not designation of an"Authorized Representative." 2.4 Basic Plan Document means this document, which together with an executed Adoption Agreement constitutes the Plan for an Adopting Employer. 2.5 Code means the Internal Revenue Code of 1986, as amended from time to time. 2.6 Covered Individual means a Participant, Dependent of a Participant and the Spouse of a Participant,and any other person appropriately covered under the Plan. 2.7 Dependent means as defined in the Adoption Agreement. Notwithstanding the foregoing, Dependent shall not include an individual who is not a "dependent"for purposes of Section 105 of the Code. 2.8 Designated Representative means the entity, if any, designated by and under contract with the Plan Administrator to perform certain administrative functions with respect to the Plan, including, but not limited to, claims administration and recordkeeping. If no such entity is designated by the Plan Administrator, the Plan Administrator shall serve as the Designated Representative. 2.9 Employee means any person employed by the Adopting Employer on or after the Effective Date, except that it shall not include: (a) Any employee included within a unit of employees covered by a collective bargaining unit unless such agreement provides, whether specifically or generally, for coverage of the employee under this Plan; (b) Any employee who is a nonresident alien and receives no earned income from the Adopting Employer from sources within the United States; and (c) Any employee who is a leased employee as defined in Section 414(n)(2)of the Code. 2.10 Employer Contribution means a nonelective contribution made by the Adopting Employer on behalf of each Participant in the Plan. The Employer Contribution is an amount that has not been actually or constructively received by the Participant, and it is made available to the Participant exclusively for reimbursement under the Plan. ©Hitesman&Associates,PA 2008 3 Non-ERISA Basic Plan Document 1 2.11 Entry Date means the date as of which an Employee becomes a Participant in this Plan as set forth in the Adoption Agreement. 2.12 ePHI means PHI maintained or transmitted in electronic media, including, but not limited to, electronic storage media (i.e., hard drives, digital memory medium) and transmission media used to exchange information in electronic storage media (i.e., internet, extranet, and other networks). PHI transmitted via facsimile and telephone is not considered to be transmissions via electronic media. 2.13 ERISA means the Employee Retirement Income Security Act of 1974 and regulations thereunder, as amended from time to time. Plans sponsored by public sector entities are not subject to ERISA. 2.14 HC Account means "health care account" and is the record keeping account established under the Plan for each Participant. 2.15 Health Care Expense means as defined in the Adoption Agreement. Notwithstanding the foregoing, Health Care Expense shall not include any expense not described as an eligible HRA expense in IRS Revenue Ruling 2002-41 and IRS Notice 2002-45. If Health Care Expense is defined to include health insurance premiums and the Adopting Employer sponsors a cafeteria plan, Health Care Expense shall not include premiums that may be paid on a pre-tax basis in accordance with the terms of such cafeteria plan,which may include premiums for major medical coverage provided by the Employer and premiums for coverage under an insurance contract, health maintenance organization agreement, or other benefit agreement providing coverage issued on a non-group, individual basis. If Health Care Expense is defined in the Adoption Agreement to include premiums for qualified long-term care insurance, the amount of such premium that will qualify as a Health Care Expense shall be limited to the portion that constitutes "eligible long-term care premiums"as defined in Section 213(d)(10)of the Code. 2.16 HIPAA means the Health Insurance Portability and Accountability Act of 1996 and regulations thereunder, as amended from time to time. 2.17 Health Reimbursement Arrangement ("HRA") means an employer funded medical reimbursement program within the meaning of IRS Revenue Ruling 2002-41 (June 26, 2002) and IRS Notice 2002-45 (June 26, 2002). 2.18 Highly Compensated Individual means an individual who is among the highest paid twenty- five (25) percent of all "non-excludable Employees" based upon compensation received during the preceding Plan Year. "Non-excludable Employees" include all Employees except those Employees who are not Participants and who fall within one of the following categories: (a) Employees who have not completed three (3) years of service, (b) Employees who have not attained age twenty-five (25), (c) part-time or seasonal Employees, (d) Employees who are included a unit of Employees covered under a collective bargaining agreement, and (e) Employees who are nonresident aliens and who receive no earned income from a source within the United States. 2.19 Limited Scope Health Care Expense means, unless provided otherwise in the Adoption Agreement,a Health Care Expense for dental or vision care. 2.20 Managing Body means the person or persons with authority to make decisions for the Adopting Employer. 2.21 Participant means an Employee who has become and not ceased to be a Participant pursuant ©Hitesman&Associates,PA 2008 4 Non-ERISA Basic Plan Document to Article IV. In addition, Participant includes persons "deemed" to be Participants under a specific provision of this Plan. 2.22 PHI means health information that: (a) Is created or received by a health care provider, health plan, public health authority, employer, life insurer,school or university, or health care clearinghouse; (b) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (c) Either identifies the individual or reasonably could be used to identify the individual. PHI includes ePHI. 2.23 Plan means the Adopting Employer's Plan as may be amended from time to time. It consists of a completed Adoption Agreement plus the Basic Plan Document. The name of the Plan is reflected in the Adoption Agreement. 2.24 Plan Administrator means the entity, person or persons determined under Section 9.1. 2.25 Plan Year means the twelve (12) month period beginning and ending as indicated in the Adoption Agreement. The initial Plan Year may be a "short" Plan Year beginning and ending as indicated in the Adoption Agreement. The records of the Plan will be kept based upon the Plan Year. 2.26 Privacy Rules means the Standards of Privacy of Individually Identifiable Health Information at 45 C.F.R. part 160 and part 164 at subparts A and E. 2.27 Security Incident means "security incident" as defined in 45 C.F.R. Section 164.304, which generally defines"security incident"to include attempted or successful unauthorized access, use, disclosure, modification,or destruction of ePHI. 2.28 Security Rules means the Security Standards and Implementation Specifications at 45 C.F.R. part 160 and part 164 at subparts A and C. 2.29 Spouse means"Spouse"as defined in the Adoption Agreement. 2.30 Trust means the trust identified in the Adoption Agreement,created for the purpose of accepting and holding Employer Contributions,and limited other contributions, made under the Plan. 2.31 Trustee means the person or persons identified as a "Trustee"under the Trust. ©Hitesman&Associates,PA 2008 5 Non-ERISA Basic Plan Document ti ARTICLE III. ADOPTING EMPLOYER 3.1 Adoption of Plan. An Adopting Employer may adopt the Plan by resolution duly adopted by its Managing Body, as represented and warranted in the Adoption Agreement, and upon execution of an Adoption Agreement. 3.2 Cessation of Employer Participation. An Adopting Employer may cease to be an Adopting Employer in accordance with Article X. 3.3 Recordkeeping and Reporting. An Adopting Employer shall furnish, or arrange for the furnishing, to the Designated Representative the information with respect to each Covered Individual necessary to enable the Designated Representative to maintain records sufficient to determine the benefits due to or which may become due and to prepare and provide any reports required by law. ©Hitesman&Associates,PA 2008 6 Non-ERISA Basic Plan Document ARTICLE IV. ELIGIBILITY AND PARTICIPATION OF EMPLOYEES 4.1 Eligibility Requirements. Each Employee shall be eligible to participate in this Plan upon meeting the eligibility requirements set forth in the Adoption Agreement. 4.2 Participant Status. An Employee who has met the eligibility requirements described in Section 4.1 shall be a Participant as of the Employee's Entry Date. 4.3 Conditions of Participation. As a condition of participation and receipt of benefits under this Plan,the Participant agrees to: (a) Observe all Plan rules and regulations; (b) Consent to inquiries by the Designated Representative and Plan Administrator with respect to any provider of services involved in a claim under this Plan; (c) Submit to the Plan Administrator all notifications, reports, bills, and other information required by the Plan or which the Designated Representative and Plan Administrator may reasonably require; and (d) Cooperate with all reasonable requests of the Designated Representative and Plan Administrator that may by necessary for the proper administration of the Plan. Failure to do so relieves the Plan, Plan Administrator, Designated Representative, and Adopting Employer of any obligations under this Plan with respect to that Participant and any others claiming entitlement to benefits under this Plan through that Participant and shall result in the termination of the Participant's participation in the Plan. 4.4 Termination of Contributions. Unless provided otherwise in the Adoption Agreement, a Participant shall cease to be eligible to receive contributions under this Plan at midnight of the earliest of the following dates: (a) The date of the death of the Participant; (b) The date of termination of the Participant's employment with the Adopting Employer; (c) The date of the Participant's failure to meet the eligibility requirements of Section 4.1, as may be amended from time to time in accordance with Article X; or (d) The date of termination of the Plan in accordance with Article X. Termination of contributions under this Plan shall not prevent a former Participant from receiving continuation coverage required by applicable law. 4.5 Termination of Participation. Unless provided otherwise in the Adoption Agreement, a Participant shall cease to be a Participant at midnight of the earliest of the following dates: (a) The date of the termination of the Participant's employment with the Adopting Employer; (b) The date of the death of the Participant; (c) The date the balance of the Participant's HC Account reaches zero, if no further ©Hitesman&Associates,PA 2008 7 Non-ERISA Basic Plan Document a contributions will be made to said account under Article VI; or (d) The date of termination of the Plan in accordance with Article X. Termination of participation in this Plan shall not prevent a former Participant from receiving continuation coverage required by applicable law. 4.6 Deemed Participants. For certain purposes, persons that were not Employees are deemed to be Participants as required by law. ©Hitesman&Associates,PA 2008 8 Non-ERISA Basic Plan Document ARTICLE V. BENEFITS UNDER THE PLAN 5.1 Health Care("HC")Account. The HC Account will be credited with the Employer Contribution. A Participant's HC Account will be decreased from time to time in the amount of payments made to the Participant for Health Care Expenses. 5.2 Claims for Reimbursement. Claims for reimbursement under this Plan shall be made by completing a claim form and submitting such form to the Designated Representative. The Designated Representative is entitled to rely on the information provided on the claim form in processing claims under this Plan. A claim must be submitted for payment within the time period indicated in the Adoption Agreement. Where circumstances beyond the Participant's control prevent submission within the described time frame, notice of a claim with an explanation of the circumstances may be accepted by the Designated Representative as a timely filing. Claims shall be determined in accordance with Article VII. 5.3 Incurred Expenses. To be reimbursable, the Participant must have incurred a Health Care Expense after his/her Entry Date. An expense is"incurred"when the Participant is provided with the care giving rise to the Health Care Expense, not when the service is billed or paid. Reimbursement shall not be made for future projected expenses. 5.4 Timing of Reimbursement. Reimbursements shall be made pursuant to a schedule established by the Designated Representative and communicated to the Participants, provided reimbursements shall be made no less frequently than monthly. 5.5 Maximum Reimbursement. The maximum reimbursement a Participant may receive at any time shall be the amount of the Participant's HC Account balance at the time the reimbursement request is processed. The maximum reimbursement requirements apply to the Participant, Spouse, and Dependents on an aggregate basis, not an individual basis. If a Participant's claim is for an amount that is more than the Participant's current HC Account balance, the excess, unreimbursed part of the claim will be carried into the subsequent month(s), to be paid as the balance of the Participant's HC Account becomes adequate. Notwithstanding the foregoing, the excess, unreimbursed portion of a claim will not be carried over into the subsequent month(s) if no further contributions will be made to the Participant's HC Account under Article VI. 5.6 Termination of Participation. (a) Termination of Employment. Notwithstanding anything herein to the contrary, unless specifically provided otherwise in the Adoption Agreement, the former Participant may continue to access the HC Account following termination of employment for purposes of obtaining reimbursement of Health Care Expenses. Such access shall continue until the earliest to occur of the events identified in Section 4.5(b), (c) or (d). Such access shall also be provided to those individuals, if any, who at the time of the termination of the Participant's participation were the Participant's Spouse or Dependents. Such access to the Participant's HC Account by a Spouse and Dependents shall cease upon the earlier of the date of termination of the Participant's access or the date the Spouse ceases to be a Spouse or the Dependent ceases to be a Dependent,as the case may be. If continuation coverage is required by applicable law, the access described in this Section 5.6(a) shall be provided only if offered as and selected in lieu of such continuation coverage. (b) Death. Notwithstanding anything herein to the contrary, unless specifically provided ©Hitesman&Associates,PA 2008 9 Non-ERISA Basic Plan Document s otherwise in the Adoption Agreement, in the event a Participant's participation in the Plan terminates because of the Participant's death, the Participant has no surviving Spouse or Dependents, and the former Participant incurred a Health Care Expense prior to the Participant's death that would have been reimbursable out of the Participant's HC Account but that has not been submitted for reimbursement, the deceased Participant's estate may submit such Health Care Expense for reimbursement in accordance with Section 5.2. A certified copy of the deceased Participant's death certificate and proof that the person acting upon behalf of such Participant's estate has authority to do so must be submitted with such claims. ii. Notwithstanding anything herein to the contrary, unless specifically provided otherwise in the Adoption Agreement, the deceased Participant's surviving Spouse, if any, may continue to access the Participant's HC Account for purposes of obtaining reimbursement of Health Care Expenses until the earlier of: (1) the date on which the HC Account balance reaches zero; or (2) the date on which the surviving Spouse dies. No claim shall be paid to a surviving Spouse pursuant to this subsection (ii) unless a certified copy of the deceased Participant's death certificate has been provided to the Designated Representative. If continuation coverage is required by applicable law, the access described in this Section 5.6(b)(ii) shall be provided only if offered as and selected in lieu of such continuation coverage. iii. Notwithstanding anything herein to the contrary, unless specifically provided otherwise in the Adoption Agreement, the deceased Participant's surviving Dependents, if any, may continue to access the Participant's HC Account for purposes of obtaining reimbursement of Health Care Expenses until the earlier of: (1) the date on which the HC Account balance reaches zero; or (2) the date the last surviving Dependent dies. No claim shall be paid to a surviving Dependent pursuant to this subsection (iii) unless a certified copy of the deceased Participant's death certificate has been provided to the Designated Representative. If continuation coverage is required by applicable law, the access described in this Section 5.6(b)(iii) shall be provided only if offered as and selected in lieu of such continuation coverage. iv. No one other than the Participant's Spouse and Dependents may have access to the Participant's HC Account following the Participant's death. 5.7 Nondiscrimination. This Plan is intended to be nondiscriminatory and to meet the requirements under applicable sections of the Code. If the Plan Administrator determines before or during any Plan Year, that the Plan may fail to satisfy any nondiscrimination requirement imposed by the Code or any limitation on benefits provided to Highly Compensated Individuals, the Plan Administrator shall take such action as the Plan Administrator deems appropriate, under rules uniformly applicable to similarly situated Participants, to assure compliance with such requirements or limitation. ©Hitesman&Associates,PA 2008 10 Non-ERISA Basic Plan Document 5.8 HC Account Forfeitures. Unless provided otherwise in the Adoption Agreement, any amount remaining in a Participant's HC Account shall be forfeited following the later to occur of: (1) the termination of Participant's participation in the Plan, (2) the termination of any continuation coverage provided by the Plan under applicable law, or (3) the termination of any coverage provided by the Plan in lieu of continuation coverage required by applicable law; provided that where participation or coverage is terminated because of the death of the Participant, forfeiture shall not occur until the expiration of the time period contained in Section 5.2 for the submission of claims. Notwithstanding the forgoing, unless provided otherwise in the Adoption Agreement, a Participant's HC Account shall also be forfeited if no further contributions shall be made to the HC Account and either: (i) the balance of the HC account is less than $5 and no claim has been submitted by the Participant for a period of six (6) months, or (ii) the balance of the HC account is less than $25 and no claim has been submitted by the Participant for a period of twelve (12) months. Amounts forfeited hereunder shall be used for the purposes described in the Adoption Agreement. If the Adoption Agreement indicates that forfeitures shall be contributed to the HC Accounts of other Participants, the following rules shall apply. Forfeitures occurring during a Plan Year shall be held in a separate subaccount until the close of the Plan Year. Immediately following the close of the Plan Year, the balance of such forfeiture subaccount (including any earnings that have accrued on the forfeitures) shall be allocated to the HC Accounts of the Participants identified in the Adoption Agreement who were employed by the Adopting Employer on the last day of such Plan Year in the manner provided in the Adoption Agreement. To the extent the full balance of the forfeiture subaccount cannot be allocated as provided in the Adoption Agreement (e.g., because the balance does not divide evenly among the number of Participants), any balance remaining shall be held in the forfeiture subaccount until the end of the subsequent Plan Year and allocated at that time. 5.9 Medical Support Orders. Notwithstanding any provision of this Plan to the contrary this Plan shall recognize medical child support orders as required under applicable state law or under the Child Support Performance and Incentive Act of 1998. Participants involved in a divorce or child custody matter should be directed to have their legal counsel contact the Plan Administrator. 5.10 Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"). Continued coverage shall be provided only if and as required under the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), as amended. To the extent not contained in Article XII, the Plan Administrator shall, within the parameters of the law, establish uniform policies by which to provide such continuation coverage, including but not limited to providing alternative coverage in lieu of COBRA as provided in the regulations. There shall also be compliance with any state laws concerning continuation of health insurance coverage to the extent applicable and not preempted by federal law. 5.11 Coordination with Cafeteria Plan. To the extent the Adopting Employer also sponsors a medical reimbursement program as part of its cafeteria plan within the meaning of Section 125 of the Code,a Participant participates in the medical reimbursement program, and the Participant or a Covered Individual covered through such a Participant incurs an eligible Health Care Expense that is also eligible for reimbursement under the medical reimbursement program, which program pays first is described in the Adoption Agreement. 5.12 Further Limitations on Benefits. (a) This Plan does not cover expenses incurred for any loss caused by or resulting from injury or disease for which benefits are payable under any worker's compensation law or other employer, union, association or governmental sponsored group insurance plan. (b) This Plan does not cover expenses incurred for any loss caused by or resulting from ©Hitesman&Associates,PA 2008 11 Non-ERISA Basic Plan Document r injury or disease for which benefits are received by the Participant, the Participant's Spouse or the Participant's Dependent under any health and accident insurance policy or program, whether or not premiums are paid by the Adopting Employer or by the Participant,the Participant's Spouse or the Participant's Dependent child. (c) Amounts reimbursed under a dependent care assistance program described in Section 129 of the Code shall not be reimbursed under this Plan. ©Hitesman&Associates,PA 2008 12 Non-ERISA Basic Plan Document ARTICLE VI. CONTRIBUTIONS 6.1 Employer Contributions. The Adopting Employer shall make a fixed contribution per Participant as set forth in the Adoption Agreement. Such Employer Contributions may include mandatory salary reduction contributions. The amount of the Employer Contribution, and any restrictions on the use thereof, shall be identified in the Adoption Agreement and communicated to the Participants. The amount of the Employer Contribution may change from time to time as reflected in the Adoption Agreement. Contributions shall be available for reimbursement as described in the Adoption Agreement. 6.2 No Employee Contributions. Except for contributions required for continuation coverage as described in Section 5.10, no contributions other than Employer Contributions (including mandatory salary reduction contributions) are required nor will they be accepted. 6.3 Trust. All contributions shall be held in the Trust. The investment of the assets of the Trust shall be directed as provided in the Adoption Agreement. Notwithstanding the foregoing, the investment of any assets of the Trust that constitute forfeitures shall be directed by the Plan Administrator until such time, if any, that such forfeitures are allocated to the HC Accounts of other Participants. ©Hitesman&Associates,PA 2008 13 Non-ERISA Basic Plan Document ARTICLE VII. CLAIMS DETERMINATIONS AND REVIEW OF DENIED CLAIM The following procedures apply: 7.1 Initial Claim Determination. (a) Time Frame for Decision. The decision maker must determine the claim within thirty (30)days of receipt of the claim. (b) Extension of Time. If the decision maker is not able to determine the claim within this time period due to matters beyond its control, the decision maker may take an additional period(s) of up to fifteen (15) days to determine the claim. If this additional time will be needed, the decision maker must notify the claimant or the claimant's Authorized Representative prior to the expiration of the then current time period for determining the claim. Notification: The notification of the need for the extension must include a description of the "matters beyond the Plan's control" that justify the extension and the date by which a decision is expected. (c) Incomplete Claims. If the reason for the extension described in paragraph (b) above is the failure to provide necessary information and the claimant is appropriately notified, the decision maker's period of time to make a decision is"tolled." Tolling: The period of time in which the decision maker must determine a claim is suspended from the date upon which notification of the missing necessary information is sent until the date upon which the claimant responds. Notification: For this purpose, notification can be made orally to the claimant or the health care professional, unless the claimant requests written notice. The notification will include a time frame in which the necessary information must be provided. Once the necessary information has been provided, the decision maker must decide the claim within the extension described above. If the requested information is not provided within the time specified, the claim may be decided without that information. 7.2 Decision. (a) Notification of Decision. Written (or electronic) notification of the decision maker's determination must be provided to the claimant or the claimant's Authorized Representative. Such notification must be provided only where the decision is adverse. "Adverse"means: • A denial, reduction, or termination of,or • A failure to provide or make payment(in whole or in part)for a benefit. ©Hitesman&Associates,PA 2008 14 Non-ERISA Basic Plan Document (b) Adverse Decision. For adverse claim determinations, the notification shall reflect at least the following: • State the specific reason(s) for determination; • Reference specific Plan provision(s) upon which the determination is based; • Describe additional material or information necessary to complete the claim and why such information is necessary; • Describe Plan procedures and time limits for appeal of the determination and the right to obtain information about those procedures; • Disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request); and • Where the decision involves scientific or clinical judgment, disclose either (1) an explanation of the scientific or clinical judgment applying the terms of the Plan to claimant's medical circumstances, or (2) a statement that such explanation will be provided at no charge upon request. Notice of the adverse determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with applicable legal requirements. (c) Not Adverse Decision. For claim determinations that are not adverse, notice will be provided that informs the claimant or the claimant's Authorized Representative the claim has been accepted. 7.3 Access to Relevant Documents. In order(1)to evaluate whether to request review of an adverse determination, and (2) if review is requested,to prepare for such review,the claimant or the claimant's Authorized Representative will have access to all relevant documents. Relevant: A document, record or other information is"relevant"if it was relied upon in making the determination, or was submitted to the Plan, considered by the Plan, or generated in the course of making the benefit determination without regard to whether it was relied upon. 7.4 Appeal a Denied Claim. If a claim is denied, in whole or part, the claimant or the claimant's Authorized Representative may request the denied claim be reviewed. (a) Requesting Review. The claimant or the claimant's Authorized Representative has a period of 180 days to appeal the claim determination. The appeal request must be in writing and should be sent to the address specified in the notification of adverse decision described above. ©Hitesman&Associates,PA 2008 15 Non-ERISA Basic Plan Document (b) Submission & Consideration of Comments. The claimant or the claimant's Authorized Representative will have the opportunity to submit documents, written comments, or other information in support of the appeal. The review of the adverse benefit determinations 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. (c) Consultation with Independent Medical Expert. In the case of a claim denied on the grounds of a medical judgment, a health professional with appropriate training and experience will be consulted. The health care professional who is consulted on appeal will not be the individual who was consulted, if any, during the initial determination or a subordinate of that individual. Disclosure: If the advice of a medical or vocational expert was obtained by the Plan in connection with the claim denial, the names of each such expert shall be provided, regardless of whether the advice was relied upon. (d) Time Frame for Decision. If claimant or the claimant's Authorized Representative requests a review of a denied claim within the time frame described above, the decision maker shall review of claim and make a determination no later than 60 days from the date the review request was received. (e) Decision. The review of the claim will be conducted by the Plan Administrator. It will be made by a person different from the person who made the initial determination and such person will not be a subordinate of the original decision maker. The information in the administrative record shall be reviewed. Additional information submitted shall be considered. The decision shall be based upon that information plus the terms of the Plan and past interpretations of the same and similar Plan provisions. The decision maker may rely upon protocols, guidelines, or other criterion. CO Notification of Decision. Written (or electronic) notification of the decision maker's determination must be provided to the claimant or the claimant's Authorized Representative. Such notification must be provided whether the decision is adverse or not adverse. "Adverse"means: • A denial, reduction, or termination of,or • A failure to provide or make payment (in whole or in part)for a benefit. (g) Adverse Decision. For adverse appeal determinations, the notification shall reflect at least the following: • State the specific reason(s) for determination; • Reference specific Plan provision(s) upon which the determination is based; • Disclose any internal rules, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request); • A statement indicating entitlement to receive upon request, and without charge, reasonable access to or copies of all documents, records or other information relevant to the determination; and ©Hitesman&Associates,PA 2008 16 Non-ERISA Basic Plan Document r • Where the decision involves scientific or clinical judgment, disclose either (1) an explanation of the scientific or clinical judgment applying the terms of the Plan to claimant's medical circumstances, or (2) a statement that such explanation will be provided at no charge upon request. Notice of the adverse determination may be provided in written or electronic form. Electronic notices will be provided in a form that complies with applicable legal requirements. (h) Not Adverse Decision. For claim determinations that are not adverse, notice will be provided that informs the claimant or the claimant's Authorized Representative the decision has been reversed, and the claim accepted. ©Hitesman&Associates,PA 2008 17 Non-ERISA Basic Plan Document 4 ARTICLE VIII. HIPAA PRIVACY AND SECURITY PROVISIONS The Privacy Rules and Security Rules apply to this Plan. 8.1 Use and Disclosure of PHI. The Plan will use PHI to the extent of and in accordance with the uses and disclosures permitted by HIPAA. Specifically, the Plan will use and disclose PHI for purposes related to health care treatment, payment for health care and health care operations. The Plan will also use and disclose PHI as permitted by authorization of the subject of PHI. (a) Payment includes activities undertaken by the Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of Plan benefits that relate to an individual to whom health care is provided. These activities include, but are not limited to,the following: (1) Determination of eligibility, coverage and cost sharing amounts (for example, cost of a benefit, plan maximums and co-payments as determined for an individual's claim); (2) Coordination of benefits; (3) Adjudication of health benefits claims (including appeals and other payment disputes); (4) Subrogation of health benefit claims; (5) Establishing employee contributions; (6) Risk adjusting amounts due based on enrollee health status and demographic characteristics; (7) Billing, collection activities and related health care data processing; (8) Claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to participant inquiries about payments; (9) Obtaining payment under a contract for reinsurance (including stop-loss and excess of loss insurance); (10) Medical necessity reviews or reviews of appropriateness of care or justification of charges; (11) Utilization review, including pre-certification, preauthorization, concurrent review and retrospective review; (12) Disclosure to consumer reporting agencies related to the collection of premiums or reimbursement (the following PHI may be disclosed for payment purposes: name and address, date of birth, Social Security number, payment history, account number and name and address of provider and/or health Plan); and (13) Reimbursement to the Plan. ©Hitesman&Associates,PA 2008 18 Non-ERISA Basic Plan Document (b) Health care operations include, but are not limited to,the following activities: (1) Quality assessment; (2) Population-based activities relating to improving health or reduction health care costs, protocol development, case management and care coordination, disease management, contacting health care providers and patients with information about treatment alternatives and related functions; (3) Rating provider and Plan performance, including accreditation, certification, licensing or credentialing activities; (4) Underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to health care claims(including stop-loss insurance and excess of loss insurance); (5) Conducting or arranging for medical review, legal services and auditing function, including fraud and abuse detection and compliance programs; (6) Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the Plan, including formulary development and administration, development or improvement of payment methods or coverage policies; (7) Business management and general administration activities of the Plan, including, but not limited to: a. Management activities relating to the implementation of and compliance with HIPAA's administrative simplification requirements; b. Customer service, including data analyses for policyholders; (8) Resolution of internal grievances; (9) Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor in interest is a covered entity under HIPAA or following completion of the sale or transfer, will become a covered entity. 8.2 Adopting Employer's Obligations under Privacy Rules. Under HIPAA, the Plan may not disclose PHI to the Adopting Employer (as defined by the Privacy Rules under HIPAA) unless the Adopting Employer agrees to certain conditions. The Adopting Employer agrees to the following conditions, thereby allowing the Plan to disclose PHI to the Adopting Employer. The Adopting Employer will: (a) Not use or further disclose PHI other than as permitted or required by the Plan document or as required by law; (b) Ensure that any agents, including a subcontractor, to whom the Plan provides PHI received from the Plan agree to the same restrictions and conditions that apply to the Adopting Employer with respect to such PHI; ©Hitesman&Associates,PA 2008 19 Non-ERISA Basic Plan Document (c) Not use or disclose PHI for employment related actions and decision unless authorized by an individual; (d) Not use or disclose PHI in connection with any other benefit or employee benefit plan of the Adopting Employer unless authorized by an individual; (e) Report to the Plan any PHI use or disclosure, that is inconsistent with the uses or disclosures provided for,of which it becomes aware; CO Make available to an individual for inspection and copying PHI about the individual as allowed by and in accordance with HIPAA; (g) Make PHI available for amendment and incorporate any amendments to PHI in accordance with HIPAA; (h) Make available the information required to provide an accounting of disclosures; (i) Make internal practices, books and records relating to the use and disclosure of PHI received from Plan available to the HHS Secretary for the purposes of determining the Plan's compliance with HIPAA; and, (1) If feasible, return or destroy all PHI received for the Plan that the Adopting Employer still maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible). 8.3 Adopting Employer's Obligations under Security Rules. If the Adopting Employer creates, receives, maintains, or transmits ePHI,the Adopting Employer will: (a) Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity,and availability of ePHI; (b) Ensure that any agents, including subcontractors, to whom the Adopting Employer provides ePHI or to whom ePHI is provided on behalf of Adopting Employer implement reasonable and appropriate security measures to protect the ePHI; (c) Report to the Plan any Security Incident of which it becomes aware; and (d) Implement reasonable and appropriate security measures to ensure that only those persons identified in Section 8.4 have access to ePHI and that such access is limited to the purposes identified in Section 8.5. 8.4 Adequate separation between the Plan and the Adopting Employer must be maintained. In accordance with HIPAA, only the following employees or classes of employees may be given access to PHI and ePHI: (1) The benefit manager; and, (2) Staff designated by the benefit manager. The Adopting Employer shall identify, by name, these persons in writing to the Designated Representative. ©Hitesman&Associates,PA 2008 20 Non-ERISA Basic Plan Document i 8.5 Limitation of PHI and ePHI Access and Disclosure. The persons described in Section 8.4 above may only have access to, and use and disclose, PHI and ePHI for Plan administration functions that the Adopting Employer performs for the Plan. 8.6 Noncompliance Issues. If the person described in Section 8.4 above does not comply with this Plan document, the Adopting Employer shall provide a mechanism for resolving issues of noncompliance, including, but not limited to,disciplinary action against such person. ©Hitesman&Associates,PA 2008 21 Non-ERISA Basic Plan Document ARTICLE IX. PLAN ADMIN ISTRATIO N 9.1 Plan Administrator. (a) The Plan Administrator shall be responsible for the general supervision of the Plan and shall have authority to control and manage the operation and administration of the Plan. The Plan Administrator shall perform any and all acts necessary or appropriate for the proper management and administration of the Plan. (b) The Adopting Employer shall be the Plan Administrator unless its Managing Body designates a person or persons other than the Adopting Employer to be the Plan Administrator. The Adopting Employer shall also be the Plan Administrator if the person or persons so designated cease to be the Plan Administrator. (c) The Plan Administrator may designate an individual or entity to act on its behalf with respect to certain powers, duties, and/or responsibilities regarding the operation and administration of this Plan. 9.2 Agent for Service of Legal Process. The agent for service of legal process for the Plan is the Plan Administrator. 9.3 Allocation of Responsibility for Administration. The Plan Administrator shall have the sole responsibility for the administration of this Plan as is specifically described in this Plan. The designated representatives of the Plan Administrator shall have only those specific powers, duties, responsibilities, and obligations as are specifically given to them under this Plan. The Plan Administrator warrants that any directions given, information furnished, or action taken by it shall be in accordance with the provisions of the Plan authorizing or providing for such direction, information or action. It is intended under this Plan that the Plan Administrator shall be responsible for the proper exercise of its own powers, duties, responsibilities, and obligations under this Plan and shall not be responsible for any act or failure to act of another Employee of the Adopting Employer. Neither the Plan Administrator, nor the Adopting Employer makes any guarantee to any Participant in any manner for any loss or other event because of the Participant's participation in this Plan. 9.4 Rules and Decisions. Except as otherwise specifically provided in the Plan, the Plan Administrator may adopt such rules and procedures as it deems necessary, desirable, or appropriate. All rules and decisions of the Plan Administrator shall be uniformly and consistently applied to all Participants in similar circumstances. When making a determination or calculation, the Plan Administrator shall be entitled to rely upon information furnished by a Participant, the Adopting Employer, or legal counsel, or other entity acting on behalf of the Adopting Employer or Plan Administrator. 9.5 Records and Reports. The Plan Administrator shall be responsible for, complying with all reporting, filing and disclosure requirements for the Plan. 9.6 Authorization of Benefit Payments. The Plan Administrator (or its designee) shall issue directions to the Trustee concerning all benefits which are to be paid from the Trust, pursuant to the provisions of the Plan, and warrants that all such directions are in accordance with the Plan. 9.7 Other Powers and Duties of the Administrator. The Plan Administrator shall also have such other duties and powers as may be necessary to discharge its duties under the Plan including, but not limited to,the following: ©Hitesman&Associates,PA 2008 22 Non-ERISA Basic Plan Document (a) Discretion to construe and interpret the Plan in a non-discriminatory manner, to decide all questions of eligibility and to determine all questions arising in the administration and application of the Plan; (b) To receive from the Adopting Employer and from Participants such information as shall be necessary for the proper administration of the Plan; (c) To furnish the Adopting Employer, upon request, such annual reports with respect to the administration of the Plan as are reasonable and appropriate; and (d) To appoint individuals to assist in the administration of the Plan and any other agents the Plan Administrator deems advisable including legal and actuarial counsel. The Plan Administrator shall not have the power to add to, subtract from, or modify any of the terms of the Plan, to change or add to any benefits provided by the Plan, or to waive or fail to apply any requirements of eligibility for a benefit under this Plan. ©Hitesman&Associates,PA 2008 23 Non-ERISA Basic Plan Document ARTICLE X. PLAN AMENDMENT AND TERMINATION 10.1 Amendment by Adopting Employer. The Adopting Employer reserves the right to amend, alter, or wholly revise this Plan or the Adoption Agreement, prospectively or retrospectively, at any time by the action of its Managing Body, and the interest of each Participant is subject to the powers so reserved. The Adopting Employer expressly may amend, alter or wholly revise this Plan or the Adoption Agreement if it determines it necessary or desirable, with or without retroactive effect, to comply with the law. Such changes shall not affect any right to benefits that accrued prior to such amendments. Such amendment shall be made in writing and shall be delivered promptly to the Designated Representative, Plan Administrator,and Trustee. 10.2 Adopting Employer's Right to Terminate. Although the Adopting Employer expects the Plan to be maintained for an indefinite time, the Adopting Employer reserves the right to terminate the Plan or any portion of the Plan at any time. In the event of the dissolution, merger, consolidation, or reorganization of the Adopting Employer, the Plan shall terminate unless the Plan is continued by a successor to the Adopting Employer in accordance with the resolution of such successor's Managing Body. Such termination shall not affect any right to benefits that accrued prior to such termination. Such action shall be made in writing and shall be delivered to the Designated Representative, Plan Administrator, and Trustee at least ninety (90) days prior to the effective date of the termination. • ©Hitesman&Associates,PA 2008 24 Non-ERISA Basic Plan Document ARTICLE XI. GENERAL PROVISIONS 11.1 No Reversion to the Plan Administrator or Adopting Employer. Unless specifically permitted by applicable law, no part of the corpus or income of the Trust shall revert to the Adopting Employer or be used for or diverted to, purposes other than the exclusive benefit of participants and other persons entitled to benefits under the Plan. 11.2 Persons Dealing With Trust. No person dealing with the Trust shall be required to see to the application of any money paid or property delivered to the Trust, or to determine whether or not the Trust is acting pursuant to any authority granted to them under the Trust. 11.3 Non-Alienation of Benefits. Benefits payable under this Plan shall not be subject to anticipation, alienation, sale, transfer, execution, or levy of any kind either voluntary or involuntary, including any such liability which is for alimony or other payments for the support of a spouse or former spouse, or for any other relative of the Participant, prior to actually being received by the person entitled to the benefit under the terms of the Plan, and any attempt to anticipate, alienate, sell, transfer, assign, pledge, encumber, charge or otherwise dispose of any right to benefits payable under the Plan shall be void. The Adopting Employer, Plan Administrator and/or Designated Representative shall not in any manner be made liable for, or subject to,the debts,contracts, liabilities, engagements or torts of any person entitled to benefits under the Plan. 11.4 Action by Employer. Whenever the Adopting Employer, under the terms of this Plan, is permitted or required to do or perform any act or matter or thing, it shall be done and performed by the Managing Body of the Adopting Employer or such representatives of the Adopting Employer as the Managing Body may designate. 11.5 No Guarantee of Tax Consequences. Notwithstanding any provision in this Plan to the contrary, this Plan makes no commitment or guarantee that any amounts paid to or on behalf of a Participant under this Plan will be excludable from the Participant's gross income for federal or state income tax purposes. It shall be the obligation of each Participant to determine whether each payment is excludable from the Participant's gross income for federal and state income tax purposes, and to notify the Plan Administrator if the Participant has reason to believe that any such payment is not so excludable. 11.6 Compensation and Expenses. The Designated Representative shall be entitled to reasonable fees for its services hereunder, which shall be described in an administrative services agreement between the Designated Representative and the Plan Administrator. Such fees and any expenses incurred by the Designated Representative in connection with the Plan (including expenses and fees of persons hired or employed by them) shall be paid as described in the Adoption Agreement. The compensation of the Trustee, as provided for in the Trust document, shall also be paid as described in the Adoption Agreement. 11.7 Governing Law. This Plan shall be construed and enforced according to the laws of the State identified in the Adoption Agreement, except to the extent preempted by federal law. 11.8 Family and Medical Leave Act of 1993 ("FMLA"). Notwithstanding any provision of this Plan to the contrary, this Plan shall be operated and maintained in a manner consistent with FMLA,to the extent the Adopting Employer is subject to such law. ©Hitesman&Associates,PA 2008 25 Non-ERISA Basic Plan Document 11.9 Newborns' and Mothers' Health Protection Act ("NMHPA"). Notwithstanding any provision of this Plan to the contrary, this Plan shall be operated and maintained in a manner consistent with NMHPA. Federal law requires the following statement be included in the Plan document,verbatim: Under federal law, group health plans and health insurance issuers offering group health insurance generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the plan or issuer may pay for a shorter stay if the attending physician (e.g., your physician, nurse, or midwife, or a physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on pre-certification,contact your Plan Administrator. 11.10 Women's Health and Cancer Rights Act of 1998 ("WHCRA"). Notwithstanding any provision of this Plan to the contrary, this Plan shall be operated and maintained in a manner consistent with WHCRA. 11.11 Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA"). Notwithstanding any provision of this Plan to the contrary, this Plan shall be operated and maintained in a manner consistent with USERRA. The Plan Administrator shall, within the parameters of the law, establish uniform policies by which to provide such continuation coverage required by USERRA. 11.12 Plan Not a Contract of Employment. The Plan is not an employment agreement and does not assure the continued employment of any Employee or Participant for any period of time. Nothing contained in the Plan shall interfere with the Adopting Employer's right to discharge an Employee at any time, regardless of the effect such discharge may have upon the individual as a Participant in this Plan. 11.13 Erroneous Payments. If the Plan makes a payment for benefits in excess of the benefits required by the Plan or makes a payment to or on behalf of an individual who is not currently covered by the Plan, the Plan shall be entitled to recover such erroneous payment from the recipient thereof. 11.14 Medicare Secondary Payer. The Plan shall comply with the Medicare secondary payer rules found in 42 U.S.C. § 1395y. In general, the Plan shall pay benefits primary to Medicare if any one of the following conditions is satisfied: (a) the Employer employed twenty (20) or more employees for each working day in at least twenty (20) weeks in either the calendar year in which the claim is made or the preceding calendar year, the Participant is employed by the Employer, and the Participant is actually covered by Medicare by reason of obtaining the age of 65; (b) the Employer employed 100 or more employees on at least 50% of its regular business days during the calendar year preceding the year in which the claim was made, the Participant is employed by the Employer, and the Participant is actually covered by Medicare by reason of disability; and (c) the Participant is entitled to Medicare by reason of end stage renal disease and the claim is made during the twelve (12) month period beginning in the first month in which such ©Hitesman&Associates,PA 2008 26 Non-ERISA Basic Plan Document r Participant is entitled to benefits under Medicare (regardless of whether he/she applies for such benefits). In all other cases,the Plan shall pay benefits secondary to Medicare. 11.15 Medicare Part D. The Plan shall cooperate with Medicare Part D prescription drug plans (and Covered Individuals who are enrolled in such plans) with respect to coordination of benefits between the Plan and the Medicare Part D plan, including the provision of information to the Medicare Part D plan (or the Covered Individuals) regarding the benefits provided under the Plan for costs covered by the Medicare Part D plan. Covered Individuals enrolled in Medicare Part D plans shall cooperate with the Plan so that the Plan may perform its obligations under this subsection. 11.16 Certificates of Creditable Coverage. When coverage terminates, or upon request by a Covered Individual during coverage or within two (2) years of termination of coverage under this Plan, Covered Individuals will be provided with a certification of creditable coverage by the Plan Administrator (or its designee). A request for a certification of creditable coverage should be directed to the Plan Administrator. Upon request, the Plan Administrator (or its designee) will issue the certification of creditable coverage as soon as reasonably possible. ©Hitesman&Associates,PA 2008 27 Non-ERISA Basic Plan Document ARTICLE XII. COBRA CONTINUATION 12.1 Compliance with COBRA. Continued coverage for the Plan shall be provided only if and as required under the Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), as amended, as it applies to group health plans sponsored by public sector employers through the Public Health Services Act ("PHSA"). 12.2 COBRA Policies and Procedures. To the extent not provided herein, the Plan Administrator shall, within the parameters of the law, establish uniform policies by which to provide such continuation coverage. 12.3 Notification Procedures. The Plan requires the notifications described below with respect to continuation coverage under COBRA: (a) Notice of qualifying event. Under the law, a Covered Individual (or a representative acting on behalf of the Covered Individual) has the responsibility to inform the Plan of a divorce, legal separation, or a child losing dependent status under the Plan (the "qualifying event") within sixty (60) days of the latest of: (i) the date of the qualifying event; (ii) the date coverage would be lost because of the qualifying event; or (iii) the date on which the Covered Individual was informed of the responsibility to provide notice and the procedures for doing so. The notification must be provided in writing and be mailed, emailed, or faxed to the Plan. Oral notification, including notification by telephone and/or voice messaging, is not acceptable. The notification must be dated (e.g., postmarked, electronically dated, etc.) no later than the last day of the sixty (60) day notice period described above. The notification must: (1) state the name of the Plan; (2) state the name and address of the employee or former employee who is or was covered under the Plan; (3) state the name(s) and address(es) of all Covered Individuals who lost coverage due to the qualifying event; (4) include a detailed description of the event; (5) identify the effective date of the event; and (6) be accompanied by any documentation providing proof of the event (i.e., the divorce decree). If no notification is received within the required time period, no continuation coverage will be provided. If the notification is incomplete, it will be deemed timely if the Plan is able to determine the plan to which it applies, the identity of the employee and the Covered Individuals, the qualifying event, and the date on which the qualifying event occurred, provided that the missing information is provided within thirty(30)days. If the missing information is not provided within that time, the notification will be ineffective and no continuation coverage will be provided. (b) Notice of second qualifying event. A Covered Individual (or a representative acting on behalf of the Covered Individual) must notify the Plan of the death of the employee, divorce or separation from the employee, or a dependent child's ceasing to be eligible for coverage as a dependent under the Plan, if that event occurs within the eighteen (18) month continuation period (or an extension of that period for disability or for pre- termination Medicare entitlement). The notification must be provided within sixty (60) days after such a second qualifying event occurs in order to be entitled to an extension ©Hitesman&Associates,PA 2008 28 Non-ERISA Basic Plan Document of the continuation period. The notification must be provided in writing and be mailed, emailed, or faxed to the Plan. Oral notification, including notification by telephone and/or voice messaging, is not acceptable. The notification must be dated (e.g., postmarked, electronically dated, etc.) no later than the last day of the sixty (60) day notice period described above. The notification must: (1) state the name of the Plan; (2) state the name and address of the employee or former employee who is or was covered under the Plan; (3) state the name(s) and address(es) of all Covered Individuals who lost coverage due to the initial qualifying event and who are receiving COBRA coverage at the time of the notice; (4) identify the nature and date of the initial qualifying event that entitled the Covered Individuals to COBRA coverage; (5) include a detailed description of the event; (6) identify the effective date of the event; and (7) be accompanied by any documentation providing proof of the event (i.e., the divorce decree). If no notification is received within the required time period, no extension of the continuation period will be provided. If the notification is incomplete, it will be deemed timely if the Plan is able to determine the plan to which it applies, the identity of the employee and the Covered Individuals, the qualifying event, and the date on which the qualifying event occurred, provided that the missing information is provided within thirty (30)days. If the missing information is not provided within that time,the notification will be ineffective and no extension of the continuation period will be provided. (c) Notice of disability. A Covered Individual (or a representative acting on behalf of the Covered Individual) must notify the Plan when a Covered Individual has been determined to be disabled under the Social Security Act within sixty(60) days of the latest of: (i) the date of the disability determination; (ii) the date of the qualifying event; (iii) the date coverage would be lost because of the qualifying event; or (iv) the date on which the Covered Individual was informed of the responsibility to provide notice and the procedures for doing so. Notwithstanding the foregoing, notification must be provided before the end of the first eighteen (18) months of continuation coverage. The notification must be provided in writing and be mailed, emailed, or faxed to the Plan. Oral notification, including notification by telephone and/or voice messaging, is not acceptable. The notification must be dated (e.g., postmarked, electronically dated, etc.) no later than the last day of the sixty (60) day notice period described above. The notification must: (1) state the name of the Plan; (2) state the name and address of the employee or former employee who is or was covered under the Plan; (3) state the name(s) and address(es) of all Covered Individuals who lost coverage due to the initial qualifying event and who are receiving COBRA coverage at the time of the notice; (4) identify the nature and date of the initial qualifying event that entitled the qualified beneficiaries to COBRA coverage; (5) state the name of the disabled Covered Individual; (6) identify the date upon which the disabled Covered Individual became disabled; (7) identify the date upon which the Social Security Administration made its determination of disability; and ©Hitesman&Associates,PA 2008 29 Non-ERISA Basic Plan Document f (8) include a copy of the determination of the Social Security Administration. If no notification is received within the required time period, no extension of the continuation period will be provided. If the notification is incomplete, it will be deemed timely if the Plan is able to determine the plan to which it applies, the identity of the employee and the Covered Individuals, the qualifying event, and the date on which the qualifying event occurred, provided that the missing information is provided within thirty (30)days. If the missing information is not provided within that time, the notification will be ineffective and no extension of the continuation period will be provided. If such person has been determined under the Social Security Act to no longer be disabled, the person must notify the Plan of that determination within thirty (30) days of the later of: (i) the date of such determination; or (ii) the date on which the Covered. Individual was informed of the responsibility to provide notice and the procedures for doing so. The notification must be in writing and be mailed to the Plan. Regardless of when the notification is provided, continuation coverage will terminate retroactively on the first day of the month that begins thirty (30) days after the date of the determination, or the end of the initial coverage period, if later. If the notification is not provided within the required time, the Plan reserve the right to seek reimbursement of any benefits provided by the Plan between the date coverage terminates and the date the notification is provided. (d) Notice of Coverage Under Another Group Health Plan or Medicare. A Covered Individual must notify the Plan immediately if any Covered Individuals receiving continuation coverage actually become covered by another group health plan or Medicare. Regardless of when such notification is provided, coverage will terminate retroactively to the date of the coverage under the other group health plan or Medicare. If, for whatever reason, a Covered Individual on continuation coverage receives any benefits under the Plan after coverage is to cease under the foregoing rule, the Plan reserves the right to seek reimbursement from such Covered Individual. ©Hitesman&Associates,PA 2008 30 Non-ERISA Basic Plan Document