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OptumHealth Financial Services - Basic Plan Adoption Agreement 2010 * • •-- BASIC PLAN DOCUMENT ADOPTION AGREEMENT FOR CITY OF RANCHO PALOS VERDES This is the Adoption Agreement referred to in the Basic Plan Document ("Basic Plan Document"). This Adoption Agreement plus the Basic Plan Document, as amended from time to time, constitutes the Plan for the Adopting Employer. ADOPTING EMPLOYER INFORMATION: Employer Name: City of Rancho Palos Verdes Address: 30940 Hawthorne Blvd City, State Zip: Rancho Palos Verdes,CA 90275 Phone/Fax Number: 310-544-5204 Contact Person: Name: Eric Mausser Title: Human Resources Manager Address: 30940 Hawthorne Blvd City, State Zip Rancho Palos Verdes, CA 90275 Phone/Fax No.: 310-544-5204 Email Address: ericm@rpv.com Addendum(s)Attached: ❑Yes El No Note: Any addendum attached should be labeled as an"Addendum to the Adoption Agreement" and indude a reference to the name of the Plan. ARTICLE I: INTRODUCTION 1.1 Original effective date: January 1, 2010 (month,day,year) Effective date of amendment/restatement: January 1, 2010 (month,day,year) 1.6(a) Coverage options available under the Plan include: ® Full Scope Option. ❑ Limited Scope Option. ❑ Suspended Account Option. LI Other: 1.6(a)(ii) Limited Scope Option is: ® N/A LI Available only for Participants enrolled in the Adopting Employer's high deductible health plan on an automatic basis. ❑ Available for all Participants on an elective basis. O Available for all Participants on an automatic basis for Participants enrolled in the Adopting Employer's high deductible health plan and on an elective basis for other Participants. ©Hitesman&Associates,PA 2008 Page 1 Basic Plan Adoption Agreement • 1.6(c) Reimbursement rules are modified as follows: ® N/A ❑ Describe: ARTICLE II: DEFINITIONS 2.7 Dependent means: [S] "Dependent"for purposes of Section 152 of the Code determined without regard to subsections(b)(1), (b)(2), and (d)(1)(B). ❑ Other: 2.11 Entry Date means: ❑ Date Employee becomes eligible to participate. EX1 Other: The first pay period following the Employee's completion of his or her probationary period. 2.15 Health Care Expense means: O Maximum permitted by law(i.e., Section 213(d) medical expenses). ❑ An expense which,bu t for the deductible, co-insurance,and co-pay requirements under a specific group medical coverage sponsored by the Adopting Employer,would have been paid by that group medical coverage. Specified group medical coverage: ® Other: Because all reimbursements are provided after a Participant's employment terminates,see below for the applicable definition of Health Care Expense. For Participants who have chosen to spend down their accounts in lieu of COBRA once they terminate employment, Health Care Expense means: O N/A—no such access provided O Same as while employed ® Maximum permitted by law(i.e., Section 213(d) medical expenses) O Other: 2.19 Limited Scope Health Care Expense means: ® N/A o Health Care Expense for dental or vision care. O Health Care Expense for dental,vision,or preventive care. 2.23 Name of Plan: City of Rancho Palos Verdes Retirement Health Savings Plan 2.25 Plan Year is: July 1 through June 30 (month,day,year) 2.25 The initial"short"Plan Year is: January 1, 2010 through June 30, 2010 (month,day,year) ©Hitesman&Associates,PA 2008 Page 2 Basic Plan Adoption Agreement l _ 1 • 2.29 Spouse means: [X] An individual who is legally married to a Participant and who is treated as a "spouse" under the Code. O Other: 2.30 Name of Trust: City of Rancho Palos Verdes Retirement Health Savings Trust ARTICLE IV: ELIGIBILITY AND PARTICIPATION OF EMPLOYEES 4.1 To be eligible,an Employee must satisfy each of the following requirements: O Age: o Length of service: El Employment classification: Full-time Employees who(1) have completed the new hire probationary period and(2)work an 80 hour bi-weekly schedule. O Coverage under a specified group medical plan: O Other: 4.4 Termination of Employer Contributions: ® As provided in the Basic Plan Document O Other: 4.5 Termination of participation: ® As provided in the Basic Plan Document ❑ Other: ARTICLE V: BENEFITS UNDER THE PLAN 5.2 Time period for submitting claims: ® Within 365 days from the date the claim was incurred O Other: 5.6(a) Post-termination access: ® As provided in the Basic Plan Document O Other: 5.6(b) Post-death access by Spouse&Dependents: [S] As provided in the Basic Plan Document O Other: ©Hitesman&Associates,PA 2008 Page 3 Basic Plan Adoption Agreement 5.8 When forfeitures occur generally: ® As provided in the Basic Plan Document El Other: 5.8 Forfeitures of small HC Account balances occur: ® As provided in the Basic Plan Document EJ Other: 5.8 Use of forfeitures: U Pay administrative costs that would otherwise be paid from the Trust(i.e., Participants'HC Account balances) and that are incurred during current and future Plan Years ❑ Pay administrative costs that would otherwise be paid from the Trust(i.e., Participants'HC Account balances) and that are incurred during the current Plan Year(i.e., the Plan Year in which the forfeiture occurs). If forfeitures remain,they shall be: El Contributed to the HC Accounts of all Participants on a per capita basis ❑ Contributed on a per capita basis to the HC Accounts of: (1) if the Participant to whom the forfeiture is attributable was part of a bargaining unit, all other Participants in such Participant's bargaining unit, or(2) if the Participant to whom the forfeiture is attributable was not part of a bargaining unit, all non- bargained Participants ❑ Other: ® Contributed to the HC Accounts of all Participants on a per capita basis El Contributed on a per capita basis to the HC Accounts of: (1) if the Participant to whom the forfeiture is attributable was part of a bargaining unit, all other Participants in such Participant's bargaining unit, or(2) if the Participant to whom the forfeiture is attributable was not part of a bargaining unit,all non-bargained Participants El Other: 5.11 Which plan pays first: ❑ This Plan El Medical expense reimbursement plan under a cafeteria plan sponsored by the Adopting Employer El Other: ©Hitesman&Associates,PA 2008 Page 4 Basic Plan Adoption Agreement . L • 0 ARTICLE VI: CONTRIBUTIONS 6.1 Employer Contribution amount,timing, restrictions: One Time Contribution: El N/A- no such contribution is available. El Fixed dollar amount: ® Fixed formula: A retroactive contribution as determined by the City Council. El Restrictions, if any: Contributed: Recurring Contributions: El N/A- no such contributions are available. El Fixed dollar amount: El Per calendar month on or about the first of the month El Per year on or about the first day of the Plan Year El Other: El Fixed formula: (1)$51.65,as a nonelective employer contribution, plus (2) 1% of gross compensation, as a mandatory salary reduction contribution. El Per calendar month on or about the first of the month El Per year on or about the first day of the Plan Year El Other: Per pay period. [X] Restrictions: The nonelective employer contribution shall be adjusted annually each March based upon CPI. ©Hitesman&Associates,PA 2008 Page 5 Basic Plan Adoption Agreement 110 • Conversion Contributions: ❑Annual contribution of accumulated vacation or sick leave: El N/A—no such contribution is available ❑ Describe: ❑ Contribution of accumulated vacation or sick leave upon termination of employment: [E] N/A—no such contribution is available ❑ Describe: 6.1 Availability for reimbursement of HC Account balance: ❑ As soon as deposited ❑ Upon termination of employment ❑ Other: 6.3 Direction of Investments: ❑ Plan Administrator IZ Participant ❑ Other: ARTICLE XI: GENERAL PROVISIONS 11.6 Reasonable fees of Plan Supervisor shall be paid as follows: ❑ Fixed fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer); asset-based fees shall be charged to the Participant and paid from the Participant's HC Account [X] All fees shall.be charged to the Plan and paid from the general assets of the Adopting Employer(billed to the Adopting Employer) ❑ All fees shall be charged to the Participant and paid from the Participant's HC Account ❑ Other: For Participants who have chosen to spend down their accounts in lieu of COBRA, once they terminate employment, reasonable fees of Plan Supervisor shall be paid as follows: ❑ N/A—no such access provided ❑ Fixed fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer); asset-based fees shall be charged to the Participant and paid from the Participant's HC Account ❑ All fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer) El All fees shall be charged to the Participant and paid from the Participant's HC Account ❑ Other: ©Hitesman&Associates,PA 2008 Page 6 Basic Plan Adoption Agreement 0 • . 11.6 Reasonable fees of Trustee shall be paid as follows: D Fixed fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer); asset-based fees shall be charged to the Participant and paid from the Participant's HC Account IZ All fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(billed to the Adopting Employer) 0 All fees shall be charged to the Participant and paid from the Participant's HC Account 0 Other: 11.7 Governing law—State of California (only list one state) ACKNOWLEDGEMENTS 1. Pursuant to Section 2.8(a), any collectively bargained Employees participating in this Plan participate because the collective bargaining agreement provides for coverage under this Plan. 2. This Plan has been duly adopted or authorized to be adopted by the Adopting Employer's Managing Body. 3. This Plan is a"covered entity"for purposes of the Privacy Rules and Security Rules under the Health Insurance Portability and Accountability Act(HIPAA). ADOPTING EMPLOYER: CITY OF RANCHO ALOS VERDES Date: I S- /n By: tit". , Its: AW4V0A ©Hitesman&Associates,PA 2008 Page 7 Basic Plan Adoption Agreement BASIC PLAN DOCUMENT ADOPTION AGREEMENT FOR CITY OF RANCHO PALOS VERDES This is the Adoption Agreement referred to in the Basic Plan Document ("Basic Plan Document"). This Adoption Agreement plus the Basic Plan Document, as amended from time to time, constitutes the Plan for the Adopting Employer. ADOPTING EMPLOYER INFORMATION: Employer Name: City of Rancho Palos Verdes Address: 30940 Hawthorne Blvd City, State Zip: Rancho Palos Verdes,CA 90275 Phone/Fax Number: 310-544-5204 Contact Person: Name: Eric Mausser Title: Human Resources Manager Address: 30940 Hawthorne Blvd City, State Zip Rancho Palos Verdes,CA 90275 Phone/Fax No.: 310-544-5204 Email Address: ericm@rpv.com Addendum(s)Attached: LI Yes El No Note: Any addendum attached should be labeled as an "Addendum to the Adoption Agreement" and include a reference to the name of the Plan. ARTICLE I: INTRODUCTION 1.1 Original effective date: January 1, 2010 (month,day,year) Effective date of amendment/restatement: N/A (month,day,year) 1.6(a) Coverage options available under the Plan include: ® Full Scope Option. LI Limited Scope Option. LI Suspended Account Option. LI Other: 1.6(a)(ii) Limited Scope Option is: El N/A LI Available only for Participants enrolled in the Adopting Employer's high deductible health plan on an automatic basis. LI Available for all Participants on an elective basis. LI Available for all Participants on an automatic basis for Participants enrolled in the Adopting Employer's high deductible health plan and on an elective basis for other Participants. ©Hitesman&Associates,PA 2008 Page 1 Basic Plan Adoption Agreement 1.6(c) Reimbursement rules are modified as follows: ® N/A LJ Describe: ARTICLE II: DEFINITIONS 2.7 Dependent means: El "Dependent"for purposes of Section 152 of the Code determined without regard to subsections(b)(1), (b)(2), and (d)(1)(B). E Other: 2.11 Entry Date means: EJ Date Employee becomes eligible to participate. IZI Other: The first pay period following the Employee's completion of his or her probationary period. 2.15 Health Care Expense means: ❑ Maximum permitted by law (i.e., Section 213(d) medical expenses). E An expense which, but for the deductible, co-insurance,and co-pay requirements under a specific group medical coverage sponsored by the Adopting Employer,would have been paid by that group medical coverage. Specified group medical coverage: ® Other: Because all reimbursements are provided after a Participant's employment terminates,see below for the applicable definition of Health Care Expense. For Participants who have chosen to spend down their accounts in lieu of COBRA once they terminate employment, Health Care Expense means: E N/A— no such access provided E Same as while employed IZ Maximum permitted by law(i.e., Section 213(d) medical expenses) fl Other: 2.19 Limited Scope Health Care Expense means: ® N/A El Health Care Expense for dental or vision care. fl Health Care Expense for dental,vision,or preventive care. 2.23 Name of Plan: City of Rancho Palos Verdes Retirement Health Savings Plan 2.25 Plan Year is: July 1 through June 30 (month,day,year) 2.25 The initial"short"Plan Year is: January 1, 2010 through June 30, 2010 (month,day,year) ©Hitesman&Associates,PA 2008 Page 2 Basic Plan Adoption Agreement 1 2.29 Spouse means: ® An individual who is legally married to a Participant and who is treated as a"spouse" under the Code. ❑ Other: 2.30 Name of Trust: City of Rancho Palos Verdes Retirement Health Savings Trust ARTICLE IV: ELIGIBILITY AND PARTICIPATION OF EMPLOYEES 4.1 To be eligible,an Employee must satisfy each of the following requirements: ❑ Age: ❑ Length of service: Z Employment classification: Full-time Employees who(1) have completed the new hire probationary period and(2) work an 80 hour bi-weekly schedule. ❑ Coverage under a specified group medical plan: ❑ Other: 4.4 Termination of Employer Contributions: ® As provided in the Basic Plan Document ❑ Other: 4.5 Termination of participation: ® As provided in the Basic Plan Document ❑ Other: ARTICLE V: BENEFITS UNDER THE PLAN 5.2 Time period for submitting claims: ® Within 365 days from the date the claim was incurred ❑ Other: 5.6(a) Post-termination access: ® As provided in the Basic Plan Document ❑ Other: 5.6(b) Post-death access by Spouse&Dependents: [S] As provided in the Basic Plan Document ❑ Other: ©Hitesman&Associates,PA 2008 Page 3 Basic Plan Adoption Agreement 5.8 When forfeitures occur generally: IZ As provided in the Basic Plan Document El Other: 5.8 Forfeitures of small HC Account balances occur: ® As provided in the Basic Plan Document i:i Other: 5.8 Use of forfeitures: El Pay administrative costs that would otherwise be paid from the Trust(i.e., Participants'HC Account balances) and that are incurred during current and future Plan Years El Pay administrative costs that would otherwise be paid from the Trust(i.e., Participants'HC Account balances) and that are incurred during the current Plan Year(i.e., the Plan Year in which the forfeiture occurs). If forfeitures remain,they shall be: El Contributed to the HC Accounts of all Participants on a per capita basis El Contributed on a per capita basis to the HC Accounts of: (1) if the Participant to whom the forfeiture is attributable was part of a bargaining unit, all other Participants in such Participant's bargaining unit,or(2) if the Participant to whom the forfeiture is attributable was not part of a bargaining unit, all non- bargained Participants El Other: Z Contributed to the HC Accounts of all Participants on a per capita basis El Contributed on a per capita basis to the HC Accounts of: (1) if the Participant to whom the forfeiture is attributable was part of a bargaining unit, all other Participants in such Participant's bargaining unit, or(2) if the Participant to whom the forfeiture is attributable was not part of a bargaining unit,all non-bargained Participants ❑ Other: 5.11 Which plan pays first: El This Plan El Medical expense reimbursement plan under a cafeteria plan sponsored by the Adopting Employer ❑ Other: ©Hitesman&Associates,PA 2008 Page 4 Basic Plan Adoption Agreement 1 • ARTICLE VI: CONTRIBUTIONS 6.1 Employer Contribution amount,timing, restrictions: One Time Contribution: ❑ N/A- no such contribution is available. ❑ Fixed dollar amount: [s] Fixed formula: A retroactive contribution as determined by the City Council. fl Restrictions, if any: Contributed: Recurring Contributions: ❑ N/A - no such contributions are available. ❑ Fixed dollar amount: ❑ Per calendar month on or about the first of the month ❑ Per year on or about the first day of the Plan Year E Other: [X] Fixed formula: (1) $51.65,as a nonelective employer contribution, plus (2) 1%of gross compensation,as a mandatory salary reduction contribution. ❑ Per calendar month on or about the first of the month El Per year on or about the first day of the Plan Year ® Other: Per pay period. IZ Restrictions: The nonelective employer contribution shall be adjusted annually each March based upon CPI. ©Hitesman&Associates,PA 2008 Page 5 Basic Plan Adoption Agreement A t , P Conversion Contributions: El Annual contribution of accumulated vacation or sick leave: El N/A— no such contribution is available E Describe: fl Contribution of accumulated vacation or sick leave upon termination of employment: IZ N/A—no such contribution is available El Describe: 6.1 Availability for reimbursement of HC Account balance: D As soon as deposited El Upon termination of employment ❑ Other: 6.3 Direction of Investments: E Plan Administrator IZ Participant El Other: ARTICLE XI: GENERAL PROVISIONS 11.6 Reasonable fees of Plan Supervisor shall be paid as follows: El Fixed fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer); asset-based fees shall be charged to the Participant and paid from the Participant's HC Account fl All fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(billed to the Adopting Employer) IZI All fees shall be charged to the Participant and paid from the Participant's HC Account El Other: For Participants who have chosen to spend down their accounts in lieu of COBRA, once they terminate employment, reasonable fees of Plan Supervisor shall be paid as follows: El N/A—no such access provided El Fixed fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer); asset-based fees shall be charged to the Participant and paid from the Participant's HC Account El All fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer) IZ All fees shall be charged to the Participant and paid from the Participant's HC Account El Other: ©Hitesman&Associates,PA 2008 Page 6 Basic Plan Adoption Agreement 4 , • 11.6 Reasonable fees of Trustee shall be paid as follows: ❑ Fixed fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(i.e., billed to the Adopting Employer); asset-based fees shall be charged to the Participant and paid from the Participant's HC Account ® All fees shall be charged to the Plan and paid from the general assets of the Adopting Employer(billed to the Adopting Employer) ❑ All fees shall be charged to the Participant and paid from the Participant's HC Account ❑ Other: 11.7 Governing law—State of California (only Ilst one state) ACKNOWLEDGEMENTS 1. Pursuant to Section 2.8(a), any collectively bargained Employees participating in this Plan participate because the collective bargaining agreement provides for coverage under this Plan. 2. This Plan has been duly adopted or authorized to be adopted by the Adopting Employer's Managing Body. 3. This Plan is a"covered entity"for purposes of the Privacy Rules and Security Rules under the Health Insurance Portability and Accountability Act(HIPAA). ADOPTING EMPLOYER: CITY OF RANCHO PALOS VERDES Date: /x•ia'-09 By: 4111P e 4 Its: - .n W* •wicz, Ma or ©Hitesman&Associates,PA 2008 Page 7 Basic Plan Adoption Agreement