Agenda - Wednesday, November 19, 2014 · Vendor Invoice No. Invoice Description Status Held Reason...

KANE COUNTY CASTRO, Davoust, Kenyon, Molina, Smith, Taylor, Vazquez

HUMAN SERVICES COMMITTEE

WEDNESDAY, NOVEMBER 19, 2014

County Board Room Agenda 9:00 AM

Kane County Government Center, 719 S. Batavia Ave., Bldg. A, Geneva, IL 60134

Kane County Page 1

1. Call to Order

2. Approval of Minutes: October 22, 2014

3. Monthly Financial Reports

A. October Human Services Committee Financial Reports (attached)

4. Veteran's Assistance Commission

A. VAC Report (attached)

B. Veteran Events (attached)

5. Department of Human Resource Management

A. Monthly EEO graphs and reports (attached)

B. Health Insurance Changes and Collections (attached)

6. Old Business

7. New Business

A. Resolution: Approving Contract for Employee Assistance Provider (Metropolitan Family Services)

B. Resolution: Amending Personnel Policy Handbook (Insurance Benefits)

C. Resolution: Amending and Restating County of Kane Flexible Benefits Plan

8. Reports Placed On File

9. Executive Session

10. Resolution: Establishing Annual Salary for Executive Director of Human Resource Management (Sheila D. McCraven) (not included) 11. Adjournment

Current Month Transactions

Total Amended Budget

YTD Actual Transactions

Total % Received

660 Veterans' Commission 10,854 340,976 301,663 88.47%380 Veterans' Commission 10,854 340,976 301,663 88.47%

Grand Total 10,854 340,976 301,663 88.47%

Human Services Committee Revenue Report - SummaryThrough October 31, 2014 (91.7% YTD)

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YTD Encumbrances

Total % Used

120 Human Resource Management 130,975 2,431,141 2,642,144 1,178 108.73%001 General Fund 9,832 414,210 321,106 256 77.58%010 Insurance Liability 121,142 2,016,931 2,321,038 922 115.12%

660 Veterans' Commission 14,064 340,976 247,917 55 72.72%380 Veterans' Commission 14,064 340,976 247,917 55 72.72%

Grand Total 145,039 2,772,117 2,890,062 1,233 104.30%

Human Services Committee Expenditure Report - SummaryThrough October 31, 2014 (91.7% YTD, 92.31% Payroll)

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YTD Encumbrances

Total % Used

120 Human Resource Management 130,975 2,431,141 2,642,144 1,178 108.73%001 General Fund 9,832 414,210 321,106 256 77.58%

Personnel Services- Salaries & Wages 8,158 295,731 247,230 0 83.60%Personnel Services- Employee Benefits 1,674 77,118 44,147 0 57.25%Commodities 0 4,662 4,705 256 106.41%Contractual Services 0 36,699 25,024 0 68.19%

010 Insurance Liability 121,142 2,016,931 2,321,038 922 115.12%Personnel Services- Salaries & Wages 5,274 138,183 110,145 0 79.71%Personnel Services- Employee Benefits 1,566 45,215 31,384 0 69.41%Commodities 0 600 282 0 47.03%Contractual Services 114,303 1,827,270 2,179,227 922 119.31%Contingency and Other 0 5,663 0 0 0.00%

660 Veterans' Commission 14,064 340,976 247,917 55 72.72%380 Veterans' Commission 14,064 340,976 247,917 55 72.72%

Personnel Services- Salaries & Wages 6,558 176,606 150,175 0 85.03%Personnel Services- Employee Benefits 2,882 78,703 62,961 0 80.00%Commodities 54 11,890 2,279 55 19.63%Contractual Services 4,570 72,703 32,502 0 44.70%Capital 0 1,074 0 0 0.00%

Grand Total 145,039 2,772,117 2,890,062 1,233 104.30%

Human Services Committee Expenditure Report - DetailThrough October 31, 2014 (91.7% YTD, 92.31% Payroll)

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Vendor Invoice No. Invoice Description Status Held Reason Invoice Date Due Date G/L Date Received Date Payment Date Invoice AmountFund 001 - General Fund

Department 120 - Human Resource ManagementSub-Department 120 - Human Resource Management

Account 52130 - Repairs and Maint- Computers3854 - Identisys 227786 ID equipment supplied Paid by Check

# 34100809/24/2014 09/29/2014 09/29/2014 10/06/2014 101.70

Account 52130 - Repairs and Maint- Computers Totals Invoice Transactions 1 $101.70Account 55000 - Miscellaneous Contractual Exp

1299 - Kane County Regional Office of Education

0000008636 fingerprinting August 2014

Paid by Check # 341127

09/09/2014 09/29/2014 09/29/2014 10/06/2014 280.00

Account 55000 - Miscellaneous Contractual Exp Totals Invoice Transactions 1 $280.00Account 60010 - Operating Supplies

2291 - Chicago Office Technology Group (COTG)

347155 Quarterly Maintenance 6/19-9/19/14

Paid by EFT # 24674

09/19/2014 09/18/2014 09/18/2014 10/06/2014 128.92

Account 60010 - Operating Supplies Totals Invoice Transactions 1 $128.92Account 60020 - Computer Related Supplies

8771 - Smartgroup Systems 26328 HP inkjet cartridge Paid by EFT # 24809

09/10/2014 09/29/2014 09/29/2014 10/06/2014 48.00

Account 60020 - Computer Related Supplies Totals Invoice Transactions 1 $48.00Account 60050 - Books and Subscriptions

6441 - Emergency Closing Center 3097-09/2014 emergency closing Paid by Check # 340979

09/29/2014 09/29/2014 09/29/2014 10/06/2014 25.00

Account 60050 - Books and Subscriptions Totals Invoice Transactions 1 $25.00Sub-Department 120 - Human Resource Management Totals Invoice Transactions 5 $583.62

Department 120 - Human Resource Management Totals Invoice Transactions 5 $583.62Fund 001 - General Fund Totals Invoice Transactions 5 $583.62

Fund 010 - Insurance LiabilityDepartment 120 - Human Resource Management

Sub-Department 130 - Insurance Liability- HRMAccount 50000 - Project Administration Services

8258 - CCMSI 0083703-IN claims and admin fee - September 2014


09/23/2014 09/29/2014 09/29/2014 10/06/2014 6,291.67

Account 50000 - Project Administration Services Totals Invoice Transactions 1 $6,291.67Account 50150 - Contractual/Consulting Services

1248 - Kinnally Flaherty Krentz & Loran PC 5301-00/16 (PMK) Special Asst State's Attny


09/30/2014 10/07/2014 10/07/2014 10/20/2014 2,327.50

Account 50150 - Contractual/Consulting Services Totals Invoice Transactions 1 $2,327.50Account 53000 - Liability Insurance

8258 - CCMSI 2014-00001228 Workers Comp Claims Paid by EFT # 25286

10/07/2014 10/07/2014 10/07/2014 10/07/2014 72,797.03

3171 - Strypes Plus More, Inc. 12602 Vehicle and Auto Repair-Squad 61

Paid by EFT # 25028

09/12/2014 10/08/2014 10/08/2014 10/20/2014 140.00

3171 - Strypes Plus More, Inc. 12601 Auto Repair-squad 95 Paid by EFT # 25028

09/12/2014 10/08/2014 10/08/2014 10/20/2014 100.00

Run by Finance Reports on 11/04/2014 10:04:08 AM Page 1 of 3

Human Services Accounts Payable by GL Distribution

Payment Date Range 10/01/14 - 10/31/14

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Vendor Invoice No. Invoice Description Status Held Reason Invoice Date Due Date G/L Date Received Date Payment Date Invoice AmountFund 010 - Insurance Liability

Department 120 - Human Resource ManagementSub-Department 130 - Insurance Liability- HRM

Account 53000 - Liability Insurance1016 - Wine Sergi & Co LLC 68329 Notary Bond -Katie

HellerPaid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

1016 - Wine Sergi & Co LLC 68330 Notary Bond-Elena Fuentes

Paid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

1016 - Wine Sergi & Co LLC 68331 Notary Bond-Jennifer Vazquez

Paid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

1016 - Wine Sergi & Co LLC 68332 Notary Bond-Janet Halsey

Paid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

1016 - Wine Sergi & Co LLC 68333 Notary Bond-Angela Knorr

Paid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

1016 - Wine Sergi & Co LLC 68334 Notary Bond-Janice Gabreleski

Paid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

1016 - Wine Sergi & Co LLC 68335 Notary Bond-Btittany Hankes

Paid by EFT # 25049

10/01/2014 10/08/2014 10/08/2014 10/20/2014 25.00

Account 53000 - Liability Insurance Totals Invoice Transactions 10 $73,212.03Account 53010 - Workers Compensation

8258 - CCMSI 2014-00001229 Workers Comp Payment

Paid by EFT # 25287

10/15/2014 10/15/2014 10/15/2014 10/15/2014 17,394.50

Account 53010 - Workers Compensation Totals Invoice Transactions 1 $17,394.50Account 53020 - Unemployment Claims

3594 - Illinois Department of Employment Security

91914 Illinois Unemployment Underpayment


09/19/2014 09/25/2014 09/25/2014 10/06/2014 1,811.16

Account 53020 - Unemployment Claims Totals Invoice Transactions 1 $1,811.16Sub-Department 130 - Insurance Liability- HRM Totals Invoice Transactions 14 $101,036.86

Department 120 - Human Resource Management Totals Invoice Transactions 14 $101,036.86Fund 010 - Insurance Liability Totals Invoice Transactions 14 $101,036.86

Fund 380 - Veterans' CommissionDepartment 660 - Veterans' Commission

Sub-Department 660 - Veterans' CommissionAccount 52140 - Repairs and Maint- Copiers

8930 - Impact Networking, LLC 412806 Copy Overage 09/2014 Paid by EFT # 24731

09/19/2014 09/19/2014 09/19/2014 10/09/2014 10/06/2014 8.76

Account 52140 - Repairs and Maint- Copiers Totals Invoice Transactions 1 $8.76Account 53100 - Conferences and Meetings

9019 - Jacob Zimmerman 91214 Conference Paid by Check # 341119

09/12/2014 09/19/2014 09/19/2014 10/06/2014 15.00

Account 53100 - Conferences and Meetings Totals Invoice Transactions 1 $15.00




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Vendor Invoice No. Invoice Description Status Held Reason Invoice Date Due Date G/L Date Received Date Payment Date Invoice AmountFund 380 - Veterans' Commission

Department 660 - Veterans' CommissionSub-Department 660 - Veterans' Commission

Account 53110 - Employee Training4526 - Fifth Third Bank 8705 JZ - 09/14 Credit Card Payment Paid by EFT #

2469409/04/2014 09/25/2014 09/25/2014 09/26/2014 10/06/2014 35.00

Account 53110 - Employee Training Totals Invoice Transactions 1 $35.00Account 53120 - Employee Mileage Expense

9019 - Jacob Zimmerman 91214 Conference Paid by Check # 341119

09/12/2014 09/19/2014 09/19/2014 10/06/2014 198.24

Account 53120 - Employee Mileage Expense Totals Invoice Transactions 1 $198.24Account 55000 - Miscellaneous Contractual Exp

9346 - 212 Healy St Properties, LLC M3742-0914 Rent Assistance (T.M.) Paid by EFT # 24645

09/18/2014 10/02/2014 09/19/2014 09/22/2014 10/06/2014 400.00

1054 - ComEd 6423230046 09/14

Electric Assistance (T.B.)


09/19/2014 10/13/2014 09/29/2014 09/25/2014 10/06/2014 19.13

9502 - Alejondra Hurtado H3212-0914 Rent Assistance (J.H.) Paid by EFT # 24722

09/11/2014 09/25/2014 09/19/2014 09/19/2014 10/06/2014 580.00

9408 - KP Ventures LLC M3751-0914 Rent Assistance (R.M.) Paid by EFT # 24743

09/11/2014 09/26/2014 09/19/2014 09/19/2014 10/06/2014 400.00

1054 - ComEd 5586551078-0914

Electric Bill (M.C.) Paid by Check # 341184

09/19/2014 10/13/2014 10/02/2014 10/02/2014 10/20/2014 32.64

5228 - Harbor Village Apartments C4052-1014 Rent Assistance (M.C.) Paid by Check # 341249

10/02/2014 10/23/2014 10/02/2014 10/09/2014 10/20/2014 137.00

9408 - KP Ventures LLC M3751-1014 Rent Assistance (R.M.) Paid by EFT # 24958

10/09/2014 10/23/2014 10/14/2014 10/14/2014 10/20/2014 400.00

Account 55000 - Miscellaneous Contractual Exp Totals Invoice Transactions 7 $1,968.77Account 60000 - Office Supplies

4526 - Fifth Third Bank 8705 JZ - 09/14 Credit Card Payment Paid by EFT # 24694

09/04/2014 09/25/2014 09/25/2014 09/26/2014 10/06/2014 28.13

1024 - Ice Mountain Direct 14I8106647400 September Water Service

Paid by EFT # 24937

10/02/2014 10/22/2014 10/02/2014 10/06/2014 10/20/2014 10.55

3578 - Warehouse Direct Office Products 2460003-0 Office Supplies Paid by EFT # 25046

10/02/2014 11/02/2014 10/02/2014 10/03/2014 10/20/2014 43.31

Account 60000 - Office Supplies Totals Invoice Transactions 3 $81.99Sub-Department 660 - Veterans' Commission Totals Invoice Transactions 14 $2,307.76

Department 660 - Veterans' Commission Totals Invoice Transactions 14 $2,307.76Fund 380 - Veterans' Commission Totals Invoice Transactions 14 $2,307.76

Grand Totals Invoice Transactions 33 $103,928.24




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Vendor Invoice No. Invoice Description Status Held Reason Invoice Date Due Date G/L Date Received Date Payment Date Invoice AmountFund 120 - Grand Victoria Casino Elgin

Department 010 - County BoardSub-Department 020 - Riverboat

Account 45420 - Tuition Reimbursement4326 - Keith Berkhout 11142013 tuition reimbursement

Self-study for Realtor License-4 courses


11/14/2013 11/19/2013 11/19/2013 12/02/2013 80.00

4648 - Daniel Eder 11142013 tuition reimbursement: Marketing of healthcare svcs.


11/14/2013 11/19/2013 11/19/2013 12/02/2013 2,360.00

5321 - Michelle Halbesma 11142013 tuition reimbursement: Criminal Justice Administration


11/14/2013 11/19/2013 11/19/2013 12/02/2013 2,560.00

9018 - Suzanna Lindsey 11192013 tuition reimbursement: Statistical Literacy


11/19/2013 11/19/2013 11/19/2013 12/02/2013 1,735.00

1863 - Matthew Nelson 11142013 tuition reimbursement: Learn More Spanish


11/14/2013 11/19/2013 11/19/2013 12/02/2013 129.00

8081 - AMANDA K PATRICOSKI 11142013 tuition reimbursement: Research Methods/Theories of Human Develo


11/14/2013 11/19/2013 11/19/2013 12/02/2013 3,450.00

8828 - Ayesha Tague 11142013 tuition reimbursement: Learn More Spanish


11/14/2013 11/19/2013 11/19/2013 12/02/2013 129.00

8040 - Kelly R. Wiggins 11142013 tuition reimbursement: Learn More Spanish

Paid by EFT # 20564

11/14/2013 11/19/2013 11/19/2013 12/02/2013 129.00

9261 - Vanessa Aguirre 01022014 reimburse tuition Paid by Check # 335636

01/02/2014 01/02/2014 11/30/2013 01/13/2014 1,960.00

5321 - Michelle Halbesma 01022014 reimburse tuition Paid by Check # 335739

01/02/2014 01/02/2014 11/30/2013 01/13/2014 1,920.00

8795 - Marisa Hanczar 01022014 reimburse tuition Paid by Check # 335740

01/02/2014 01/02/2014 11/30/2013 01/13/2014 3,840.00

4290 - LaTanya Hill 01022014 reimburse tuition Paid by EFT # 21008

01/02/2014 01/02/2014 11/30/2013 01/13/2014 1,725.00

9020 - Christopher Janovsky 01022014 reimburse tuition Paid by Check # 335774

01/02/2014 01/02/2014 11/30/2013 01/13/2014 1,026.99

4856 - Tim Mescher 01022014 reimburse tuition Paid by Check # 335801

01/02/2014 01/02/2014 11/30/2013 01/13/2014 360.00

9007 - Michael Roehr 01022014 reimburse tuition Paid by Check # 335837

01/02/2014 01/02/2014 11/30/2013 01/13/2014 3,486.00

5395 - Arlene Ryndak 01022014 reimburse tuition Paid by EFT # 21055

01/02/2014 01/02/2014 11/30/2013 01/13/2014 849.00

4463 - Julie Wiegel 01022014 reimburse tuition Paid by Check # 335883

01/02/2014 01/02/2014 11/30/2013 01/13/2014 2,360.00

4789 - Rosio Mendez 01212014 tuition reimbursement - Ethics & Integrity


01/21/2014 01/13/2014 11/30/2013 01/27/2014 2,220.00


Tuition Reimbursement YTDPayment Date Range 12/01/13 - 10/31/14

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Account 45420 - Tuition Reimbursement8315 - Isabel Ocon 01212014 tuition reimbursement -

Policy PaperPaid by Check # 336133

01/21/2014 01/13/2014 11/30/2013 01/27/2014 1,920.00

8081 - AMANDA K PATRICOSKI 01162014 reimburse tuition 2 classes Practice I & Practice II


01/16/2014 01/13/2014 11/30/2013 01/27/2014 3,450.00

7091 - LISA TARQUINIO 01162014 tuition reimbursement - Criminology

Paid by EFT # 21229

01/16/2014 01/13/2014 11/30/2013 01/27/2014 2,220.00

9021 - KRYSTA M KAUS 01272014 tuition reimbursement - 2 classes


01/27/2014 01/30/2014 11/30/2013 02/10/2014 1,900.00

5053 - Salvador Rodriguez 01272014 tuition reimbursement/Criminal Justice in America


01/27/2014 01/30/2014 11/30/2013 02/10/2014 2,160.00

8634 - CRAIG K CAMPBELL 02142014 tuition reimbursement Paid by EFT # 21447

02/14/2014 02/10/2014 02/10/2014 02/24/2014 2,360.00

9018 - Suzanna Lindsey 1407-01 LAS-105 Intro to Sociology


03/05/2014 03/06/2014 03/06/2014 03/24/2014 1,735.00

8081 - AMANDA K PATRICOSKI 1401-01 SWK-6382 Practice II: Community


03/12/2014 03/06/2014 03/06/2014 03/24/2014 1,458.34

8634 - CRAIG K CAMPBELL 1303-01 MBA500-Financial Accounting

Paid by EFT # 22017

03/28/2014 03/31/2014 03/31/2014 04/07/2014 2,360.00

4648 - Daniel Eder 1406-01 MPH 657 Disater Management in Public Health


03/24/2014 03/31/2014 03/31/2014 04/07/2014 2,360.00

7194 - THOMAS F ROSEBUSH 1302-01 PSF5600-Public Safety Leadership


03/18/2014 03/31/2014 03/31/2014 04/07/2014 1,892.00

9020 - Christopher Janovsky 1405-01 CAHC 500 Professional Identity and Ethics in Counseling


05/12/2014 06/10/2014 06/10/2014 06/16/2014 1,026.99

4463 - Julie Wiegel 1404-01 MPH 611 Public Health Biology


05/12/2014 06/10/2014 06/10/2014 06/16/2014 2,360.00

4565 - Anthony Franklin Sr. 1304-01 SEC-592 IT Governance

Paid by EFT # 23247

06/18/2014 06/24/2014 06/24/2014 06/30/2014 2,298.00

8315 - Isabel Ocon 1409-01 CRJ 5070-Criminal Justice Administration


05/24/2014 06/24/2014 06/24/2014 06/30/2014 2,400.00

9007 - Michael Roehr 1403-01 PP8060-Group Psychotherapy


06/09/2014 06/24/2014 06/24/2014 06/30/2014 2,400.00

8634 - CRAIG K CAMPBELL 1303-4 MGMT 612 -Methods of Org Research

Paid by EFT # 23431

05/23/2014 07/07/2014 07/07/2014 07/14/2014 2,360.00

5321 - Michelle Halbesma 1412-01 CRJ-6950 CBSA;Thesis Prep


06/23/2014 07/07/2014 07/07/2014 07/14/2014 1,920.00



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Account 45420 - Tuition Reimbursement5053 - Salvador Rodriguez 1305-01 CRJ-5030

Design/Analysis CJ Research


06/24/2014 07/07/2014 07/07/2014 07/14/2014 2,160.00

5053 - Salvador Rodriguez 1411-01 CRJ-5050 Crime Causation Theory


06/24/2014 07/07/2014 07/07/2014 07/14/2014 2,160.00

4835 - Ryne McGill 1410-01 CRIMJ-2240-025 Juvenile Delinquency


06/22/2014 07/22/2014 07/22/2014 07/28/2014 420.00

8634 - CRAIG K CAMPBELL 1303-05 MBA671-Strategic Management

Paid by EFT # 23838

08/01/2014 08/05/2014 08/05/2014 08/11/2014 2,360.00

4565 - Anthony Franklin Sr. 1408-01 SEC-591 Disaster Recovery/Forensics & Security

Paid by EFT # 23877

08/01/2014 08/05/2014 08/05/2014 08/11/2014 2,298.00

7194 - THOMAS F ROSEBUSH 1413-02 PSF5602 Leadership & Human Resource Management


07/28/2014 08/05/2014 08/05/2014 08/11/2014 1,892.00

6021 - Richard A. Grenda 1418-01 EDU6505 The Teacher Leader's Role in Pro. Dev.


08/11/2014 08/19/2014 08/19/2014 08/25/2014 1,410.00

8795 - Marisa Hanczar 1414-01 CRJ3610WI-01 Research Methods


08/08/2014 08/19/2014 08/19/2014 08/25/2014 1,960.00

4504 - Karen Ann Miller 1415-01 2014 Planning Law Review

Paid by EFT # 24114

08/11/2014 08/19/2014 08/19/2014 08/25/2014 175.00

6258 - Steven Jones 1422-01 CRJ6300 Proactive Police Administration


08/25/2014 08/29/2014 08/29/2014 09/08/2014 1,695.00

9021 - KRYSTA M KAUS 1423-01 EDUC5140 Comparative & International Education


08/15/2014 08/29/2014 08/29/2014 09/08/2014 2,850.00

4835 - Ryne McGill 1410-02 CRIMJ-1152-060 Criminal Law


08/11/2014 08/29/2014 08/29/2014 09/08/2014 840.00

8081 - AMANDA K PATRICOSKI 1401-02 SWK 6801-01 Professional Writing


08/22/2014 08/29/2014 08/29/2014 09/08/2014 941.66

4364 - Judith Bland 1417-01 40th NOVA Conference Paid by EFT # 24427

09/10/2014 09/11/2014 09/11/2014 09/22/2014 245.00

8634 - CRAIG K CAMPBELL 1421-02 MGMT581 & MGMT582 Paid by EFT # 24873

10/10/2014 10/14/2014 10/14/2014 10/20/2014 2,360.00

Account 45420 - Tuition Reimbursement Totals Invoice Transactions 51 $92,665.98Sub-Department 020 - Riverboat Totals Invoice Transactions 51 $92,665.98Department 010 - County Board Totals Invoice Transactions 51 $92,665.98

Fund 120 - Grand Victoria Casino Elgin Totals Invoice Transactions 51 $92,665.98Grand Totals Invoice Transactions 51 $92,665.98



Packet Pg. 10

Kane County Purchasing Card Information

Human Services Committee

October 2014 Statement

Transaction Date Merchant Name Additional Information Transaction Amount

Department Total

Committee Total

Page 1 of 111/5/2014 Packet Pg. 11

Veterans Assistance Commission Claims Synopsis

Table 1: Disability Claims Processing Times

Table 2: Number of Disability Claims Pending at Chicago VA Regional Office

370

304.9 302.2 261 241.7 276.2

298.4 293.5

289.7

289.3 290.2

273.5 261.2 247.5 239.2 226 220.9

216.1 209.3

182

165.6

158.3

0

50

100

150

200

250

300

350

400

VA Processing Time

VAC Processing Time

VA's Goal

12,613

12,822

9,601

8,884

8,924 8,845

10,239 10,465 11,346

12,469 12,090

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

Claims Pending

Packet Pg. 12

VETERANS ASSISTANCE COMMISSION CLAIM REPORT

Category December January February March April May June July August September October November FY 2014 Total

Service Connected Disability Claims 16 17 19 17 28 18 17 20 21 13 17 203

Non-Service Connected Disability Claims 5 6 12 9 4 16 13 10 6 5 7 93

Dependent's Compensation Claims 1 0 1 6 0 1 0 0 1 0 1 11

Widow's Pension Claims 0 4 2 6 4 5 5 4 2 3 2 37

VA Monetary Awards 92,730.39$ 102,257.04$ 97,204.74$ 95,955.07$ 174,766.52$ 207,109.19$ $1,853,064.88

VCAA Response / Follow up 9 6 7 8 13 8 17 7 10 2 6 93

Total Forms Completed 109 160 148 158 207 154 140 132 145 89 146 1,588

Claims Decision Reviews 11 19 10 19 22 11 12 15 17 19 22 177

Total Claims Pending 196 217 236 240 210 228 206 219 226 213 227

Appeals Filed 1 1 1 0 1 0 1 3 0 0 2 10

Dependent Ancilliary Benefit Claims 0 4 0 5 1 0 0 0 1 0 11

Burial Benefits Applications 0 3 3 0 3 3 3 0 5 0 3 23

VA Home Loan / Insurance Applications 0 0 0 0 3 0 0 0 3 0 2 8

DD-214 / Military Records Request 5 18 9 20 22 8 9 7 25 15 11 149

Discharges Entered into VAC Database 8 17 18 2 22 15 1 1 11 33 5 133

Correction / Upgrade of Military Records 0 1 0 2 0 1 0 1 0 1 1 7

Federal Veterans Education Applications 0 1 1 0 0 1 0 0 0 0 1 4

State Veterans Education Applications 0 1 3 0 1 1 0 0 0 0 0 6

Veterans Health Care Applications 3 9 2 9 8 4 1 3 3 1 0 43

State War Bonus Applications 3 6 5 0 4 3 0 0 1 0 1 23

VAC Outreach Events 9 7 4 10 6 12 5 11 6 14 7 91

THROUGH APRIL $1,083,041.93

Packet Pg. 13

VETERANS ASSISTANCE COMMISSION FAP REPORT

Category Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Year Totals

Shelter $980 $1,864 $1,048 $1,725 $1,600 $1,200 $1,780 $1,200 $1,805 $1,405 $1,142 $15,748

Gas Utility $36 $0 $64 $0 $193 $0 $46 $0 $0 $0 $17 $356

Electrical Utility $17 $41 $106 $0 $116 $117 $54 $0 $51 $19 $109 $630

Water/Waste Water/Garbage $0 $0 $32 $0 $0 $0 $78 $47 $0 $0 $0 $157

Heat $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Food $50 $75 $200 $0 $0 $50 $0 $125 $175 $125 $275 $1,075

Personal Needs $25 $50 $125 $0 $50 $25 $25 $125 $150 $25 $200 $800

Telephone $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Medical $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Emergency Aid $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Transportation $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Burial $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $900 $900

FAP Applications Issued 10 9 16 11 4 5 9 7 6 6 4 87

FAP Applications Received 5 3 7 9 5 0 3 3 1 2 7 45

FAP Approved 0 3 1 3 1 2 2 2 3 0 1 18

FAP Renewed (Assessments) 3 2 3 1 4 3 3 3 5 5 5 37

FAP Denied 3 2 1 7 5 7 2 2 1 3 8 41

Dependents Assisted 2 4 3 0 0 0 2 3 5 3 7 29

Referrals to Other Agencies 35 17 16 19 22 35 27 26 6 19 39 261

VAC Correspondence 17 16 13 37 104 175 54 40 92 37 84 669

Veterans Transported 6 12 16 21 19 19 21 1 0 1 7 123

Monthly Mileage 379 439 626 886 742 888 633 74 0 51 146 4,864

Packet Pg. 14

Join us for monthly programs to provide information on a varying range of topics dealing with Veterans and to meet and discuss with other Veterans. Co�ee and hot tea will be served.No registration.

MedicareThursday, November 20South Elgin Room7 - 8:30 pm

veterans information networking session

www.gailborden.info

Dependent BenefitsThursday, December 18South Elgin Room7 - 8:30 pm

Packet Pg. 15

Packet Pg. 16

Edward Hines, Jr. VA HospitalVeterans Food Pantry

The Greater Chicago Food Depository in partnership with Hines VA Hospital and AmeriCorps, is providing food for those who served.

What:

Who:

When:

Where:

On-site food pantry that provides nutritious and healthy food for Veterans.

Veterans Veterans will be asked to provide identification (examples include: VA ID card, DD214 & photo ID, VA appointment slip & photo ID).

Every Thursday from 11 a.m. to 1 p.m. (Starting November 6)Veterans can access the food pantry once per month.

Hines VA HospitalAuditorium LobbyBuilding 9

For more information, please contact the Food Pantry Coordinator Mark Eaglebarger at [email protected] or Hines VA Social Worker Kerry Thomas at 708-202-4487.

Greater Chicago Food Depository chicagosfoodbank.org 773-247-FOOD

Packet Pg. 17

November 2014 - Number of Job Applicants by Position

Department Position

Date Position

Posted

No. of

Applicants

During Report

Month

Total No. of

Applicants to

Date**

Position

Filled Date FilledBuilding Management Maintenance Worker 10/20/14 8 8 Open Open

Court Services Aurora Adult Probation Officer 8/4/14 0 44 Closed 10/19/14

Court Services Elgin Adult Probation Officer 9/9/14 0 37 Closed Interviewing

Court Services Support Staff Tri Cities 9/9/14 0 24 Closed 12/1/14

Court Services Supervisor 4/10/14 0 17 Closed 8/31/14

Employment & Education KCDEE Employment Training Represenative 10/20/14 2 2 Open Open

Health Department Assistant Director Communicable Disease 7/25/14 0 10 Closed Interviewing

Health Department Division Director of Disease Prevention 10/7/14 12 12 Open Intervewing

Health Department CHSII Community Health Practitioner 8/14/14 0 5 Closed Interviewing

Health Department CHSII Environmental Health Practitioner 9/16/14 4 14 Open OpenHealth Department Clinical Nursing Supervisor 7/21/14 0 2 Closed Interviewing

Information Technologies Desktop Specialist 9/8/14 4 8 Open Open

Judiciary/Court Services Juvenile Drug Court Coordinator 9/2/14 0 5 Closed Interviewing

KDOT Civil Engineer Co-Op Intern 2-Openings Jan-Aug 2015 6/16/14 0 0 Open Open

KDOT Project Manager Civil Engineer 4/9/14 0 6 Open Open

KDOT Seasonal Maintainer/Snowbird 10/1/14 6 6 Closed 12/1/14

KDOT Traffic Safety Engineer (hiring 2 one filled) 10/6/14 4 4 Closed 10/14/14

State's Attorney Office Juvenile Justice Council Coordinator 10/1/14 1 1 Open Open

NA * General Application NA* NA* 2 2 NA NA

* NA - No Position posted

Packet Pg. 18

EEO Report for November 04, 201410/01/2014 10/31/2014-

Job Seekers Submitting County Job Applications

Males 29

14 Females

Female 32.6%

Male 67.4%

Total: 100.0%

Gender

43 Total

4

23

Black

White

Race

American Indian/

Alaskan Native 0

Hispanic 4

Other 0

MultiRacial 0

Pacific Islander/

Hawaiian 3

43 Total

No Race Entered 9

20.9%

Black 9.3%

Hispanic/Latino 9.3%

Pacif ic Islander/Hawaiian 7.0%

White 53.5%

Total: 100.0%

Handicapped

0

0

Veteran

Vietnam Veteran

Disabled Veteran

Special DisabledVet

0

0

0

Packet Pg. 19

Kane County New Hires EEO Report10/1/2014 - 10/31/2014

2Administrative Support

6Professionals

1Technicians

Administrative Support 22.2%2

Professionals 66.7%6Technicians 11.1%1

Total: 100.0%9

EEOC Category

8Female

1Male

Female 88.9%8

Male 11.1%1

Total: 100.0%9

Gender

1Hispanic or Latino

8White

Hispanic or Latino 11.1%1

White 88.9%8

Total: 100.0%9

Race

Page 1 of 2

Packet Pg. 20

Kane County New Hires EEO Report10/1/2014 - 10/31/2014

1Circuit Clerk

1

CourtServices/Court

ServicesAdministration

1

CourtServices/Juvenile

Justice Center

1Finance

2Health

1

Regional Office ofEducation

1State's Attorney

1Transportation

Circuit Clerk 11.1%1Court Services/Court Services Administration 11.1%1Court Services/Juvenile Justice Center 11.1%1Finance 11.1%1Health 22.2%2Regional Office of Education 11.1%1State's Attorney 11.1%1Transportation 11.1%1

Total: 100.0%9

Department

Page 2 of 2

Packet Pg. 21

Kane County New Hire Report

10/1/2014 - 10/31/2014

Department Employee Name HireDateStatusJobTitle

BOENZI, AMANDA MCircuit Clerk 10/20/2014ACTIVEDeputy Clerk

VEGA, ZULAY CCourt Services/Court Services Administration 10/20/2014ACTIVEHybrid Juvenile Probation Ofcr

JACOBS, SARAH ACourt Services/Juvenile Justice Center 10/14/2014ACTIVEYouth Counselor JJC

DOBERSZTYN, THERESA FFinance 10/01/2014ACTIVEAsst Director of Purchasing

COOK, EMMA EHealth 10/07/2014ACTIVECHS II Comm Health Practitioner

SLIVKA, ALEXIS MHealth 10/14/2014ACTIVECHS III Comm Health Practitioner

WEIL, STEFFANIE ARegional Office of Education 10/27/2014ACTIVEParaprofessional

GERDING, JULIANNE MState's Attorney 10/20/2014ACTIVELaw Intern

ZULKOWSKI, STEPHEN DTransportation 10/14/2014ACTIVETraffic Permit Engineer

9 New Hire Employees

Page 1 of 111/12/2014

Packet Pg. 22

Kane County Terminations EEO Report10/1/2014 - 10/31/2014

5Full Time

Full Time 100.0%5

Total: 100.0%5

EEOC Category

4Female

1Male

Female 80.0%4

Male 20.0%1

Total: 100.0%5

Gender

5White

White 100.0%5

Total: 100.0%5

Race

Page 1 of 2

Packet Pg. 23

Kane County Terminations EEO Report10/1/2014 - 10/31/2014

1

BuildingManagement

1Circuit Clerk

1

CourtServices/Court

ServicesAdministration

1KCDEE

1State's Attorney

Building Management 20.0%1Circuit Clerk 20.0%1

Court Services/Court Services Administration 20.0%1KCDEE 20.0%1State's Attorney 20.0%1

Total: 100.0%5

Department

Page 2 of 2

Packet Pg. 24

Kane County Termination Report

10/1/2014 - 10/31/2014

Department Employee Name Termination Date

ANDERSON, KENNETH GBuilding Management 10/17/2014

PEARSON, JESSICACircuit Clerk 10/21/2014

MCCADAM, KATHLEEN SCourt Services/Court Services Administration 10/24/2014

RITCHEY, CRYSTAL MKCDEE 10/16/2014

KOWALCZYK, KARINAState's Attorney 10/17/2014

5 Terminated Employees

Page 1 of 111/12/2014

Packet Pg. 25

PPO 4

HMOIL 1

HMOBA 2

Dependents 3

TOTAL 10

PPO 2

HMOIL 1

HMOBA 1

TOTAL 4

Add Cancel

PPO 1 0

HMOIL 1 1

HMOBA 0 1

TOTAL 2 2

PPO 0

HMOIL 0

HMOBA 1

TOTAL 1

IMRF DeductionsAmount Checks Amount TOTALS

PPO 36 25,017.47$ 6 5,681.61$

HMOIL 3 1,802.89$ 0 -$ HMOBA 14 6,953.41$ 4 3,102.57$

Dental Only 6 321.34$ 0

TOTAL 59 34,095.11$ 10 8,784.18$ 42,879.29$

IMRF DeductionsAmount Checks Amount

PPO 2 1,947.14$ 3 2,325.39$

HMOIL 0 -$ 0 -$

HMOBA 1 454.72$ 2 938.03$

Dental 0 -$ 2 105.59$

TOTAL 3 2,401.86$ 7 3,369.01$ 5,770.87$

Checks Amount

PPO 1 314.68$

HMOIL 0 -$

HMOBA 1 110.20$

TOTAL 2 424.88$ 424.88$

COBRA ENROLLED: 10

ON UNPAID LOA: 2

October 2014 Monthly SummaryNEW HIRE

EMPLOYEE TERMINATIONS

EMPLOYEES ADDING/CANCEL SELF/ DEPENDENTS (Q.E.)

EMPLOYEES ADDED DUE TO QUALIFYING EVENT (Q.E.)

RETIREES ENROLLED: 69

Packet Pg. 26

RESOLUTION/ORDINANCE EXECUTIVE SUMMARY

Resolution No.

Approving Contract for Employee Assistance Provider (Metropolitan Family Services)

Committee Flow: Human Services Committee, Executive Committee, County Board Contact: Sheila McCraven, 630.232.5932

Budget Information:

Was this item budgeted? Yes Appropriation Amount: $15,741

If not budgeted, explain funding source:

Summary:

This resolution approves the continuation of employee assistance services for Kane County employees. The contract is being awarded to the incumbent, Metropolitan Family Services.

Packet Pg. 27

STATE OF ILLINOIS

COUNTY OF KANE

RESOLUTION NO.

APPROVING CONTRACT FOR EMPLOYEE ASSISTANCE PROVIDER (METROPOLITAN FAMILY SERVICES)

WHEREAS, the Kane County Board wishes to continue its Employee Assistance Program

for employees; and

WHEREAS, Global Group received quotes from seven (7) providers, including the

incumbent Metropolitan Family Services; and

WHEREAS, Metropolitan Family Services continues to offer competitive pricing for this

service which includes 65 hours of wellness training and on-site crisis response service;

WHEREAS, the Human Services Committee has recommended that Metropolitan Family

Services continue as the County’s provider, at a cost of $15,741 based upon its ability to provide a

full range of services, 24/7 access and professional staff.

NOW, THEREFORE, BE IT RESOLVED NOW by the Kane County Board that the Chairman

is authorized to enter into a contract with Metropolitan Family Services, for the provision of

professional employee assistance services, at a cost not to exceed fifteen thousand seven hundred

and forty-one dollars (15,741).

Line Item Line Item Description Was Personnel/Item/Service approved

in original budget or a subsequent

budget revision?

Are funds currently available for this

Personnel/Item/Service in the specific

line item?

If funds are not currently available

in the specified line item, where

are the funds available?

001.120.120.50000 Project Administration Yes Yes

Passed by the Kane County Board on December 9, 2014.

________________________________ _____________________________ John A. Cunningham Christopher J. Lauzen Clerk, County Board Chairman, County Board Kane County, Illinois Kane County, Illinois

Vote:

14-12 EAP

Packet Pg. 28

County of Kane 2015 Employee Benefits Renewal September 11, 2014

Comprehensive strateg ies. Individual attention.

County of Kane Marketing Summary Employee Assistance

Carrier:Plan:Flexible Spending Account Fees:Toll‐free Access 24 hours Person to Person VisitOn‐Site Crisis Response ServiceWellness Training/ManagerLegalFinancialElder CareCommunication MaterialsProvide Quarterly Reports

Additional Fees (optional):

additional services Estimated Eligible

Current RenewalMonthly Cost per Employee $1.10 $0.99Estimated Annual Cost $17,490 $15,741Change from Current Costs ($1,749)Percentage Change from Current ‐10%

5 year rate guarantee 3 year rate guarantee 5 Year Rate Guarantee 2 year Rate Guarantee‐10% ‐3% 51% 35%

5 year rate guarantee264%

(1,749.00) (477.00) $8,904.00 6,042.00 $46,110.00$15,741 $17,013 $26,394 $23,532 $63,600$0.99 $1.07 $1.66 $1.48 $4.00

1325 1325 1325 1325 1325 1325$225 per staff hour $300 per staff hour $300 per staff hour $225 per staff hour $500 per staff hour $250 ‐$275 per staff hour

Health Advocacy included/not available on a stand alone

Included Quarterly Quarterly Included Annual Annual Included Included Included Included Included Includedincluded Included/telephonic Included/telephonic Included/telephonic Included/telephonic Included/telephonicincluded Included/telephonic Included/telephonic Included/telephonic Included/telephonic Included/telephonicincluded Included/telephonic Included/telephonic Included/telephonic Included/telephonic Included/telephonic

65 hours combined 10 hours 20 hours combined 65 hours combined 24 hours/combined 65 hours combined65 hours combined 20 hours 20 hours combined 65 hours combined 24 hours/combined 65 hours combined

3 per year per problem area 3 per year per problem area 3 per year per problem area 3 per year per problem area 5 per year per problem area 3 per year per problem areaIncluded Included Included Included Included IncludedCurrent Option Option Option Option Option

Metropolitan Family Services Ceridian Perspectives ComPsych Workplace Solutions Health AdvocateEmployee Assistance Program Employee Assistance Program Employee Assistance Program Employee Assistance Program Employee Assistance Program Employee Assistance Program

Packet P

g. 29


Resolution No.

Amending Personnel Policy Handbook (Insurance Benefits)


Budget Information:

Was this item budgeted? Appropriation Amount:


Summary:

The Insurance Benefits Policy is being amended to bring the policy in compliance with the Patient Protection and Affordable Care Act which requires a large employer to make health insurance available to all employees working an average of 30 hours per week based upon the applicable measurement period. The policy is also amended to specify eligibility requirements for vision insurance.

Packet Pg. 30

STATE OF ILLINOIS

COUNTY OF KANE

RESOLUTION NO.

AMENDING PERSONNEL POLICY HANDBOOK (INSURANCE BENEFITS)

WHEREAS, from time to time, the Human Services Committee recommends that certain amendments are made to the policies contained in the Kane County Personnel Policy Handbook and

WHEREAS, the Human Services Committee recommends that the Insurance Benefits Policy

contained in the Personnel Policy Handbook be amended to comply with the provisions of the Patient Protection and Affordable Care Act; and to make other eligibility clarifications; and

NOW, THEREFORE, BE IT RESOLVED by the Kane County Board that the Insurance

Benefits policy contained in the Kane County Personnel Policy Handbook is amended as set forth

below.

INSURANCE BENEFITS

All regular full-time and regular part-time employees who work a minimum of 21 hours per

week are eligible to enroll in the County's comprehensive group medical, dental, vision, life and

supplemental insurance plans.

Eligibility for coverage will go into effect after 60 days of continuous employment are

completed. Thereafter, employees have 30 days to enroll; otherwise, the employee will be

considered a late enrollee.

Employee participation in each plan is voluntary and optional.

A. Premiums - Premium costs for health and dental insurance are shared by the

employee and the County through payroll deduction. Vision insurance is provided

without cost to active employees and to retired subsidy employees who are enrolled

in any of the County’s health plans.

B. Part-time employees who regularly work less than 30 hours per week as determined

by a measurement period analysis will pay the full premium for all plans for

coverage. Employees who regularly work 30 or more hours per week as

determined by a measurement period analysis, will pay the same employee

Packet Pg. 31

contribution rate as full-time employees. The applicable measurement period is

defined by the Patient Protection and Affordable Care Act and its implementing

regulations.

C. A pre-tax deduction Section 125 plan is available at the time of enrollment which

that allows employees to pay their share of the insurance premiums with before tax

dollars. The amount of each employee’s contribution is linked to participation in the

County’s Employee Wellness Plan.

D. Dependent Eligibility - From time to time, Kane County may require employees

enrolled the County’s health plans to participate in a dependent audit to verify the

eligibility of their enrolled dependents. Employees who refuse to cooperate and

dependents who fail to meet eligibility requirements shall be removed from Kane

County’s health plans. If it is discovered that an employee has provided false

information about their enrolled dependents or fails to timely notify Human

Resources about a change of status that could affect the eligibility of their enrolled

dependents, the Human Services Committee has discretion to take additional action

that may result in the both the employee and the ineligible dependents losing the

County’s health coverage and reimbursing the County for paid claims.

E. Continuation Coverage - There are certain situations where coverage under a

medical plan would otherwise end, such as termination, retirement or divorce. A

continuation option is available where eligible employees may elect to purchase

continued health coverage at the group rate under the plans for a restricted period.

applicable retiree or COBRA rate for an allowable period as set by statute. Neither

vision nor dental insurance is available for retired or Medicare-eligible employees

who reach age 65. Human Resources has information on this continued coverage.

F. Patient Protection and Affordable Care Act - Beginning in 2013 2015, there will be a

$2,500 $2,550 limit on the amount participants can contribute to their healthcare

FSA. This limit is subject to change in subsequent years by the Internal Revenue

Service. See the Kane County Flexible Benefits Plan Summary Document for the

currently allowable limit that has been adopted by Kane County.

G. Optional Death Benefit - Employees who have health insurance elsewhere or do not

Packet Pg. 32

wish to participate under the health plan offered by Kane County, may waive their

health insurance with Kane County and gain a supplemental death benefit. This

option provides that should the employee die while employed by Kane County, six

(6) months salary would be paid to the beneficiary. This is in addition to the IMRF

death benefits. The option of re-enrolling in the medical insurance plan is only

available during the annual open enrollment period or in certain extraordinary non-

medical situations. Health insurance coverage may be waived for the death benefit

anytime throughout the year.

The employee is responsible for notifying the Human Resources Department of any status

change which that could affect insurance coverage such as marriage, civil union, divorce, birth of a

baby. Specific information about health, dental, vision, life or supplemental insurance benefits, pre-

tax plan or the optional death benefit can be obtained from the Human Resources Department.



Vote:

14-12 Insurance Benefits

Packet Pg. 33


Resolution No.

Amending and Restating County of Kane Flexible Benefits Plan


Budget Information:

Was this item budgeted? NA Appropriation Amount:


Summary:

The Flexible Spending Plan document and summary are being amended as follows: 1) a shortened run-out period for terminating employees (reduced from 90 to 30 days); 2)new election change events as permitted under the Affordable Care Act (ACA); 3)revised FSA maximum amount to $2,550 as permitted pursuant to the ACA; 4)revised to reflect use of debit cards; 5)revised to indicate new TPA (Flexible Benefits); 6)revised claims procedures to shorten FSA appeal period from 180 days to 60 days; 7)added some additional legal protections and clarifications, including protection in the event of fraud and/or improper reimbursements.

Packet Pg. 34

STATE OF ILLINOIS

COUNTY OF KANE

RESOLUTION NO.

AMENDING AND RESTATING COUNTY OF KANE FLEXIBLE BENEFITS PLAN

WHEREAS, by Resolution 91-22 dated February 12, 1991 the County heretofore established the County of Kane Pre-Tax Deduction Plan (the “Plan”) to provide for the payment of the portion of the group medical insurance premium payable by the employees of the County on a pre-tax basis; and

WHEREAS, by Resolution 05-446 dated December 13, 2005, the County amended and

restated the Plan to allow participation in flexible spending accounts for health and dependent care; and

WHEREAS, by Resolution 12-357 dated October 25, 2012, the County amended and

restated the Plan to permit participation by qualified Kane County employees who are enrolled in the Teamsters Health and Welfare plan; and

WHEREAS, by Resolution 13-382, dated December 13, 2013, the County amended and

restated the Plan to permit the rollover up to $500 of unused funds at the end of the 2013 plan year and for each year thereafter; and

WHEREAS, County desires to amend and restate the Plan for the benefit of its eligible employees as follows: 1)to shorten the run-out period for terminating employees (reduced from 90 to 30 days); 2)to add new election change events as permitted under the Affordable Care Act (ACA); 3)to revise the FSA maximum amount to $2,550 as permitted pursuant to the ACA; 4)to reflect the use of debit cards; 5)to indicate new TPA (Flexible Benefits); 6) to revise claims procedures to shorten FSA appeal period from 180 days to 60 days; 7) to add some additional legal protections and clarifications, including protection in the event of fraud and/or improper reimbursements.

NOW, THEREFORE, BE IT RESOLVED that the County does hereby adopt the County of

Kane Flexible Benefits Plan as amended, and authorizes the Chairman to execute any necessary documents for the implementation of the plan that is attached.

Line Item Line Item Description Was Personnel/Item/Service approved

in original budget or a subsequent

budget revision?

Are funds currently available for this

Personnel/Item/Service in the specific

line item?

If funds are not currently available

in the specified line item, where

are the funds available?



Vote:

14-12 Amending FSA Plan

Packet Pg. 35

COUNTY OF KANE

FLEXIBLE BENEFITS PLAN

(Effective as of January December 31, 20153)

Packet Pg. 36

i

TABLE OF CONTENTS

Page

ARTICLE 1 - INTRODUCTION .................................................................................................. 1

1.1 Purpose .................................................................................................................... 1

1.2 Effective Date and Plan Year .................................................................................. 1

1.3 Administration ........................................................................................................ 1

ARTICLE 2 - ELIGIBILITY AND PARTICIPATION................................................................ 2

2.1 Eligibility ................................................................................................................ 2

2.2 Cessation of Participation ....................................................................................... 2

2.3 Reinstatement of Former Participant ...................................................................... 3

2.4 Death ....................................................................................................................... 3

ARTICLE 3 - CONTRIBUTIONS ................................................................................................ 5

3.1 Contributions by Participants .................................................................................. 5

3.2 Irrevocability of Election by the Participant During the Plan Year ........................ 6

3.3 Continuation of Coverage ..................................................................................... 10

ARTICLE 4 - PAYMENT OF BENEFITS ................................................................................. 12

4.1 Covered Benefits ................................................................................................... 12

4.2 Insurance Benefits ................................................................................................. 12

ARTICLE 5 - GENERAL PROVISIONS ................................................................................... 13

5.1 Information to be Furnished by Participants ......................................................... 13

5.2 Uniform Rules ....................................................................................................... 13

5.3 Changes by County ............................................................................................... 13

5.4 Plan Administrator/County Decision Final ........................................................... 13

5.5 Gender and Number .............................................................................................. 14

5.6 Severability of Provisions ..................................................................................... 14

5.7 Binding Effect ....................................................................................................... 14

5.8 Headings of Articles and Sections ........................................................................ 14

5.9 Controlling Law .................................................................................................... 14

5.10 Employment Rights .............................................................................................. 14

5.11 Indemnification of Plan Administrator ................................................................. 15

5.12 Cost of Plan Administration.................................................................................. 15

Packet Pg. 37

ii

5.13 Evidence ................................................................................................................ 15

5.14 Interests Not Transferable ..................................................................................... 15

5.15 Facility of Payment ............................................................................................... 15

5.16 No Guarantee of Tax Consequences ..................................................................... 15

5.17 Indemnification of Employer ................................................................................ 16

5.18 Delegation of Authority ........................................................................................ 16

ARTICLE 6 - AMENDMENT AND TERMINATION .............................................................. 17

6.1 Amendment ........................................................................................................... 17

6.2 Termination ........................................................................................................... 17

6.3 Benefits on Termination ....................................................................................... 17

ARTICLE 7 - COMPLIANCE WITH THE HIPAA PRIVACY AND SECURITY RULE....... 18

7.1 Purpose .................................................................................................................. 18

7.2 Disclosure of PHI to County ................................................................................. 19

7.3 Plan Sponsor Certification .................................................................................... 20

ARTICLE 8 - EXECUTION OF PLAN ...................................................................................... 23

SUPPLEMENT A PRE-TAX PREMIUM ACCOUNT ............................................................ A-1

SUPPLEMENT B FLEXIBLE SPENDING ACCOUNT ........................................................ B-1

SUPPLEMENT C DEPENDENT CARE REIMBURSEMENT ACCOUNT ......................... C-1

Packet Pg. 38

1

ARTICLE 1 - INTRODUCTION

1.1 Purpose. The County of Kane Flexible Benefits Plan (the "Plan") has been

established by the County of Kane (the "County") to provide its eligible employees a choice

between certain non taxable and taxable benefits. The Plan is maintained for the exclusive

benefit of eligible employees of the County and is intended to meet the requirements of, and to

constitute, a cafeteria plan under Section 125 of the Internal Revenue Code of 1986, as amended

(the "Code"), and any comparable section or sections of any future legislation that amends,

supplements or supersedes said section of the Code.

1.2 Effective Date and Plan Year. The "Effective Date" of the Plan as set forth herein

is January 1, 2011, or as otherwise provided in the Plan with respect to individual provisions, and

this restatement of the Plan is effective January 1, 20153. A "Plan Year" is the 12-consecutive

month period beginning on each January 1 and ending on the next following December 31.

1.3 Administration. The Plan will be administered by the County or any person,

persons or entity so designated by the County to serve as Plan Administrator. If no Plan

Administrator is designated by the County, the County, itself, is deemed to be the Plan

Administrator. Any notice or document required to be given to or filed with the County will be

properly given or filed if delivered or mailed by registered mail, postage prepaid, to the County

Board Chairman at Kane County Government Center, 719 Batavia, Geneva, Illinois 60134.

Packet Pg. 39

2

ARTICLE 2 - ELIGIBILITY AND PARTICIPATION

2.1 Eligibility. Each employee of the County who is eligible to participate and enrolls

in either the County's group medical or group dental plan shall be eligible to become a

Participant in the Plan as of the later of (i) the Effective Date, or (ii) the first day that the

employee becomes eligible to participate in the County's group health plan (medical or dental),

with actual enrollment to occur as soon as practicable following the employee’s submission of a

completed election form. Also, an employee of the County’s Department of Transportation who

is eligible to participate in the Suburban Teamsters of Northern Illinois Welfare Fund (the

“Teamsters Plan”) shall be eligible to become a participant in the Plan on the first day that the

employee becomes eligible to participate in the Teamsters Plan, with actual enrollment to occur

as soon as practicable following the employee’s submission of a completed election form. If an

employee of the County also provides services to the County as an independent contractor or

director, the employee is eligible to participate in the Plan solely in his capacity as an employee.

2.2 Cessation of Participation. A Participant will cease to be a Participant as of the

earlier of (i) the date on which the Plan terminates, (ii) the date on which the Participant ceases

to be an employee eligible to participate under Section 2.1, (iii) the date of the Participant's

death, subject to Section 2.4, or (iv) the date the Participant ceases to make any contributions to

the Plan. Notwithstanding the preceding sentence, a Participant, his spouse and dependents may

be entitled to continue participation under the Plan with respect to the Flexible Spending

Account as described in Supplement B pursuant to Section 3.3 of this Plan and the requirements

of Code Section 4980B and regulations issued thereunder (“COBRA”). Additionally, a

Participant who becomes eligible for COBRA continuation coverage under the County’s group

health plan or the Teamsters Plan and who continues to receive income from employment by the

County (for example, if the Participant experiences a reduction in hours but continues to be an

employee or if the Participant receives severance pay), may pay for any group health coverage

provided pursuant to COBRA with pre-tax dollars through payroll withholding pursuant to

Supplement A.

If a Participant terminates employment, the Participant’s pre-tax group welfare insurance

(such as group medical or dental) contributions under the Plan (if any) will cease (unless, as

described above, the Participant receives some form of salary continuation, such as severance

pay, and is entitled and elects to continue group health insurance (e.g., group medical or dental)).

Packet Pg. 40

3

Additionally, the Participant’s contributions (if any) to the Dependent Care Reimbursement

Account, and the Flexible Spending Account will cease (unless he is entitled to and elects

COBRA continuation coverage with respect to the Flexible Spending Account).

2.3 Reinstatement of Former Participant. If the Participant terminates employment

and then is rehired during the same Plan Year, the Participant’s pre-tax welfare insurance

elections (if any) in the Plan and his elections with respect to contributions to the Dependent

Care Reimbursement Account and the Flexible Spending Account (if any) will be reinstated

automatically for the remainder of the Plan Year. However, if the Participant is rehired more

than thirty days after his termination, he shall be eligible to make new elections for the remainder

of such Plan Year. If such reinstatement occurs after the end of the Plan Year in which the

Participant’s termination occurred, the Participant shall be eligible to participate in the Plan after

he has satisfied the eligibility requirements of Section 2.1 of the Plan subsequent to his date of

rehire.

2.4 Death. If a Participant dies, his participation in the Plan shall cease. However, a

representative of the Participant's estate may submit claims for expenses or benefits incurred

during the portion of the Plan Year preceding the Participant's date of death. Additionally, the

Participant’s spouse and dependents may be entitled to continue coverage under the Flexible

Spending Account pursuant to Section 3.3.

Packet Pg. 41

4

ARTICLE 3 - CONTRIBUTIONS

3.1 Contributions by Participants. Each Participant may elect in writing to reduce his

future annual compensation from the County in such amount as the Participant designates (not to

exceed the maximum amounts specified in the Supplements attached hereto) for any or all of the

benefits available under the Plan. Any compensation reduction election shall be made in

accordance with the policies and procedures established from time to time by the County. A

compensation reduction election must be in writing and filed with the County prior to the later of

(i) the first day of the Plan Year for which it is to be effective (or such earlier date established by

the County in order to allow adequate time for processing), or (ii) for the first year of eligibility,

the thirtieth (30th) day after a Participant's date of eligibility (with the election to be retroactively

applicable, but the compensation reductions to apply only to compensation not yet currently

available on the date of the election). If the cost of participation in one of the County’s

contributory welfare plans (e.g., medical or dental insurance) or the Teamsters Plan increases or

decreases during any Plan Year, and, under the terms of the respective plan, the Participant is

required to make a corresponding change in payments, the County may, on a reasonable and

consistent basis, automatically make a prospective increase or decrease in the contributions to the

Plan of affected Participants. In addition, if the cost of participation in one of the County’s

contributory welfare plans (e.g., medical or dental insurance) or the Teamsters Plan increased

during the Plan Year, or any prior Plan Year, and, under the terms of the respective plan, the

Participant was required to make a corresponding change in payments, but the County

inadvertently failed to implement such change, the County may, on a reasonable and consistent

basis, require the Participant to pay the difference. One (but not the only) means for doing so

would be to enter into a payment plan whereby any past-due payments that were required to be

paid by the Participant are withheld from the Participant's pay over a reasonable period of time.

3.2 Irrevocability of Election by the Participant During the Plan Year. An election of

benefits made under the Plan, shall be irrevocable by the Participant during the Plan Year for

which made, except as provided herein. A Participant may revoke a benefit election for the

balance of a Plan Year and file a new election only in the following circumstances:

(a) HIPAA Special Enrollment: A Participant may revoke an existing election

and make a new election that corresponds with special enrollment rights

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under the Health Insurance Portability and Accountability Act of 1996

(“HIPAA”) as amended.

(b) Changes in Status: A Participant may revoke a benefit election for the

balance of a Plan Year and file a new election if both the revocation and

the new election are on account of and consistent with a change in status

that affects eligibility of the Participant, his spouse or dependent for

coverage under an employer’s cafeteria plan or other employee welfare

benefit plan in which the individual is a participant. A change in status for

this purpose includes:

(1) a change in legal marital status, including the Participant’s

marriage, death of the Participant’s spouse, divorce, legal

separation or annulment;

(2) an event that changes an employee’s number of dependents,

including birth, death, adoption and placement for adoption, or an

event that otherwise results in an increase or decrease in the

number of a Participant’s family members or dependents who may

benefit from coverage under the Plan;

(3) a change in employment status of the Participant or the

Participant’s spouse or dependent including the termination or

commencement of employment, a strike or lockout, a

commencement of or return from an unpaid leave of absence, a

change in worksite, a reduction or increase in hours of

employment, including a switch from part-time to full-time

employment status or vice versa, or a switch from hourly to

salaried employment or vice versa;

(4) an event causing the Participant’s dependent to satisfy or cease to

satisfy the requirements for coverage due to attainment of age,

student status, or any similar circumstance as provided in the

welfare plan under which the Participant receives coverage for that

dependent;

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(5) a change in the place of residence of the Participant, the

Participant’s spouse or dependent that affects eligibility; and

(6) such other events as the Plan Administrator determines qualify as a

change in status, consistent with regulations and rulings of the

Internal Revenue Service.

(c) Reduction of weekly hours of employment below 30: A Participant may

revoke an existing election and make a new election if he experiences a

reduction in hours of employment such that (1) the Participant reasonably

is expected to work an average of less than 30 hours per week after

reasonably having been expected to average at least 30 hours per week

(even if the reduction in hours of employment does not result in the

Participant’s ceasing to be eligible under the County’s group health plan);

and (2) the revocation of a benefit election under the Plan corresponds to

the intended enrollment of the Participant and the Participant’s spouse or

dependent, who cease coverage due to the revocation in another plan that

provides minimum essential coverage, where such new coverage is

effective no later than the first day of the second month following the

month that includes the date the benefit election is revoked;

(d) Enrollment in a Qualified Health Plan: A Participant may revoke an

existing election and make a new election that corresponds with his

enrollment in a “Qualified Health Plan” (as purchased through a

marketplace established pursuant to Section 1131 of the Patient Protection

and Affordable Care Act of 2010 (a “Marketplace”)), if (1) the Participant

is eligible for a “special enrolment period” to enroll in a Qualified Health

Plan pursuant to guidance issued by the Department of Health and Human

Services and any other applicable guidance, or the Participant seeks to

enroll in a Marketplace during the Marketplace’s annual open enrollment

period; and (2) the revocation of a benefit election under the Plan

corresponds to the intended enrollment of the Participant and the

Participant’s spouse or dependent, who cease coverage due to the

revocation, in a Qualified Health Plan through a Marketplace for new

coverage that is effective beginning no later than the day immediately

following the last day of the revoked coverage.

(c)(e) COBRA Eligibility: In the event a Participant, a Participant’s spouse or

dependent becomes eligible for continuation coverage under the County’s

group health plan or the Teamsters Plan, the Participant may elect to

modify payments under the Plan as appropriate in order to pay for the

continuation coverage elected.

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(d)(f) Court Order: Upon the entry of a judgment, decree or court order

(including a qualified medical child support order under Section 609 of the

Employee Retirement Income Security Act of 1974) resulting from a

divorce, legal separation, annulment or change in legal custody requiring

the Participant or the Participant’s former spouse to provide, or cancel,

health coverage for a Participant’s child or for a foster child who is a

dependent of the Participant, a Participant may make a corresponding

change in election (cancellation to be permitted only if the order also

requires another person to provide coverage for the child and such

coverage actually is provided).

(e)(g) Entitlement to Medicare/Medicaid: In the event the Participant or the

Participant’s spouse or dependent who is enrolled in the County’s group

health plan or the Teamsters Plan becomes entitled to or loses eligibility

for coverage under Medicare or Medicaid, then the Participant may cancel,

reduce, commence or increase coverage for himself, his spouse or his

dependent accordingly.

(f)(h) Significant Change in Cost or Coverage: Other than with respect to the

Flexible Spending Account provided for in Supplement B,

(1) if the cost to the Participant (if any) for a benefit package option

(e.g., a welfare benefit offered through this Plan, or an option for

coverage under an underlying health plan, such as an indemnity

option, an HMO option, or a PPO option) significantly increases or

decreases (whether that increase or decrease results from an action

taken by the employee or from an action taken by the County), or,

with respect to the Dependent Care Reimbursement Account

election, a significant cost change is imposed by a dependent care

provider who is not a relative of the Participant, a Participant may

make a corresponding election change for the balance of the Plan

Year;

(2) if coverage under one of the County’s welfare plans (e.g., medical

or dental coverage), the Teamsters Plan, or a welfare plan of an

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employee’s spouse or dependent, is significantly curtailed or

ceases (for example, there is a significant increase in the

deductible, copay or out-of-pocket cost sharing limit under a health

plan) during such Plan Year, but there is not a loss of coverage as

defined in (3) below, an affected Participant may revoke his

election for that coverage and, in lieu thereof, elect to receive on a

prospective basis coverage under another benefit package option

providing similar coverage, provided such changes are permitted

under the terms of the applicable welfare benefit plan;

(3) if a Participant or his spouse or dependent has a significant

curtailment of coverage that is a loss of coverage (that is, a

complete loss of coverage under the benefit package option or

other coverage option (including the elimination of a benefits

package option, an HMO ceasing to be available in the area where

the individual resides, or the individual losing all coverage under

the option by reason of an overall lifetime or annual limitation)),

the affected Participant may revoke his election under the Plan

and, in lieu thereof, elect either to receive on a prospective basis

coverage under another benefit package option providing similar

coverage or to drop coverage if no similar benefit package option

is available, provided such changes are permitted under the terms

of the applicable welfare benefit plan;

(4) if a new benefit package option or other coverage option is added

or if coverage under an existing benefit package option or other

coverage option is significantly improved, a Participant may

revoke his election, and, in lieu thereof, make an election on a

prospective basis for coverage under the new or improved benefit

package option, provided such changes are permitted under the

terms of the applicable welfare benefit plan; or

(5) a Participant may make an election change on account of and

corresponding with a change made under the plan of the spouse’s,

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former spouse’s or dependent’s employer provided the election

under the spouse’s or dependent’s plan satisfies both that plan’s

election change rules and IRS regulations regarding election

changes, or the spouse’s or dependent’s plan has a different period

of coverage.

(g)(i) FMLA: Family Medical Leave Act.

With respect to a Participant on a paid leave of absence under the Family

Medical Leave Act (“FMLA”), the Participant’s existing election will

remain in effect and the Participant’s share of premiums to the Pre-Tax

Premium Account and/or contributions to a Flexible Spending Account

will be paid in the same manner as prior to the leave. Additionally, the

Participant may make an election change with respect to a Dependent Care

Reimbursement Account, provided the change is on account of and

consistent with the leave. The Participant will not be entitled to

reimbursement of Dependent Care claims incurred during an FMLA leave.

With respect to a Participant on an unpaid FMLA leave of absence, the

Participant may revoke an existing election or continue coverage during

the leave with respect to health benefits (such as medical or dental) under

the County’s health plans or the Teamsters Plan, or with respect to the

Flexible Spending Account.

If the Participant elects to continue coverage, the Participant has two

payment options: (i) pre-pay or (ii) pay-as-you-go. Under the pre-pay

option, the Participant may pay the premiums and contributions due

during the FMLA leave period (but only with respect to benefits through

the end of the current plan year) on a pre-tax salary reduction basis from

any taxable compensation or on an after-tax basis prior to commencement

of the leave. If the Participant’s FMLA leave period spans two Plan

Years, the amount due for the FMLA leave period that extends into the

new Plan Year must be paid on or after the first day of the new Plan Year,

for example, upon the Participant's return to work. Alternatively, the

amount due for that period may be pre-paid on an after-tax basis. Under

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the pay-as-you-go option, the Participant may pay his share of premium

payments and contributions on a monthly basis on the first of every month

(the same schedule as COBRA payments). These payments typically

would be made on an after-tax basis, unless the Participant receives

taxable compensation during the leave period (e.g., as a result of unused

sick days or vacation days). The County may cancel the Participant’s

coverage retroactive to the beginning of the period for which a payment

was due if a Participant fails to make any payment before the end of the

grace period for payment, provided that with respect to Participants on an

FMLA leave, the County notifies such Participants of the overdue

payment at least 15 days before the end of such grace period.

Alternatively, the County, at its option, may continue his coverage during

the leave and then recoup the Participant’s share of premiums and

contributions from available taxable compensation upon the Participant’s

return from leave.

If the Participant does not elect to continue coverage while on FMLA

leave, the Participant will be entitled to reinstatement upon return to

employment on the same terms as prior to taking FMLA leave, subject to

any changes in benefit levels that may have taken place during the leave.

Upon reinstatement in the Flexible Spending Account, the Participant may

resume coverage at the level in effect before the FMLA leave and make up

the unpaid premium payments, or the Participant may resume coverage at

a level that is reduced and resume premium payments at the level in effect

before the FMLA leave. If the Participant does not elect to continue

coverage during the FMLA leave under the Flexible Spending Account

while on FMLA leave, the Participant will not be entitled to

reimbursement for claims incurred during the FMLA leave.

Any election change (other than those made in connection with a court order or as an

exercise of rights pursuant to a statute that provides for a specific election period such as HIPAA

or COBRA) must be requested within thirty (30) days from the date of the change event (or

within such other reasonable period as established by the Plan). Any new election shall be

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effective not earlier than the first pay period covered by the new salary reduction election, unless

an earlier effective date is required by HIPAA or other applicable law. Additionally, a

Participant may not make any change that would reduce the Participant's level of Flexible

Spending Account coverage under Supplement B to an amount that would be less than the

amount of benefits claimed under such coverage as of the date the change would become

effective.

3.3 Continuation of Coverage. A Participant shall be entitled to continue

participation for such benefits under the Plan as required pursuant to and consistent with the

continuation coverage requirements of Code Section 4980B (“COBRA”) and regulations issued

thereunder. In particular, COBRA requires that Participants with positive Flexible Spending

Account balances be permitted to continue participation with respect to the Flexible Spending

Account component of the Plan described in Supplement B through the remainder of the Plan

Year in which a qualifying event that otherwise would result in a loss of coverage has occurred.

(a) A “qualifying event” in the case of a Participant is a reduction in hours of

employment or the termination of employment (for reasons other than

gross misconduct).

(b) A “qualifying event” in the case of a spouse of a Participant is the death of

the Participant, divorce or legal separation from the Participant, or the

reduction in the Participant’s hours of employment or the termination of

the Participant’s employment (for reasons other than gross misconduct).

(c) A “qualifying event” in the case of the Participant’s dependent child is the

death of the Participant, the divorce of the dependent’s parents, the

reduction in the Participant’s hours of employment, the termination of the

Participant’s employment (for reasons other than gross misconduct), or the

dependent ceasing to be eligible as a “dependent” under the County’s

group health plan or the Teamsters Plan.

(d) Under COBRA, the Participant, his spouse or dependent has 60 days from

the later of the date the person would lose coverage as a result of the

qualifying event and the date that the Plan provides notice to the family of

their COBRA rights in which to elect to continue coverage. COBRA

coverage under the Flexible Spending Account may be continued until the

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end of the Plan Year in which the qualifying event occurred. Continuation

coverage may end if the cost of the continuation coverage is not paid in a

timely fashion or if the Flexible Spending Account component of the Plan

is discontinued with respect to all employees. Additional information

about COBRA will be provided to Participants and their families in the

notices that are distributed when the Participant first becomes eligible to

participate in the Plan and again upon the occurrence of a qualifying

event.

(e) A Participant who elects to continue coverage under the Flexible Spending

Account or who elects to continue coverage under the County’s group

health (e.g., medical or dental) plan or the Teamsters Plan pursuant to

COBRA voluntarily may elect to have any payments due for such benefits

withheld on a pre-tax basis from any remaining compensation payable to

the Participant by the County. Alternatively, a Participant may make

after-tax contributions for such benefits. All such payments shall be made

in accordance with the written policies and procedures as may be

established by the County from time to time.

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ARTICLE 4 - PAYMENT OF BENEFITS

4.1 Covered Benefits. An account will be established for each Participant (with

separate sub-accounts established for each benefit elected by the Participant) to which is credited

the Participant's contributions for such benefit and from which is charged disbursements for the

benefit. To the extent of the credited balance in the applicable sub-account, the County shall pay

the covered expenses of each benefit selected by a Participant as such expenses are incurred

during such Plan Year. The covered expenses, when paid, shall be charged against such

Participant's sub-account and shall reduce the balance thereof. Notwithstanding the preceding, a

Participant shall be entitled to receive reimbursement up to the entire amount the Participant has

elected under the Flexible Spending Account for the Plan Year, plus any amounts carried over from

the preceding Plan Year (in accordance with Section B-8). This amount shall be available as of the

first day of the Plan Year. Only substantiated covered expenses incurred on or after the later of

the (i) Plan’s Effective Date and (ii) the date the Participant is enrolled in the Plan, shall be paid

or reimbursed.

4.2 Insurance Benefits. The rights and conditions with respect to any benefits

payable from group welfare insurance contracts selected by the County, or by the Teamsters

Plan, shall be determined solely with respect to such insurance contracts. The County shall not

be responsible for the validity of any insurance contract issued hereunder or for the failure on the

part of any insurer issuing such insurance contract to make any payments thereunder or for the

action of any person which may delay or render null and void or unenforceable, in whole or in

part, any insurance contract. The rights and conditions with respect to any benefits payable from

any self-insured group welfare plan shall be determined solely pursuant to the provisions of thate

plan’s documents.

ARTICLE 5 - GENERAL PROVISIONS

5.1 Information to be Furnished by Participants. Participants shall furnish to the

County such documents, receipts, expense reports, evidence, data or information as the County

considers necessary or desirable for the purpose of administering the Plan. In order to receive

benefits under the Plan, a Participant must furnish full, true and complete evidence satisfactory to

the County and must promptly sign any document related to the Plan requested by the County.

5.2 Uniform Rules. The County shall administer the Plan on a reasonable and

nondiscriminatory basis and shall apply uniform rules to all Participants similarly situated.

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5.3 Changes by County. If the County determines, before or during any Plan Year,

that the Plan may fail to satisfy for such Plan Year any nondiscrimination requirement imposed

by the Code or any limitation on benefits provided to "highly compensated” employees or "key

employees" as defined under the Code, the County shall take such action as it deems appropriate,

under rules uniformly applicable to similarly situated Participants, to assure compliance with

such requirements or limitations. Such action may include, without limitation, a modification of

elections by highly compensated employees or key employees to reduce the amount of their

salary reductions with or without the consent of such Participants.

5.4 Plan Administrator/County Decision Final. The County or its designated Plan

Administrator has discretionary authority to determine eligibility for benefits, to decide claims,

and to determine all other matters under the Plan. Benefits under this Plan will be paid only if

the County or the designated Plan Administrator decides in its discretion that the applicant is

entitled to them. Any interpretation of the provisions of the Plan by the County or the Plan

Administrator and any decision made by the County or Plan Administrator on any matter within

its respective discretion shall be binding on all persons. A misstatement or other mistake of fact

shall be corrected when it becomes known and the County or Plan Administrator shall make such

adjustment or account thereof as it considers equitable and practicable. Neither the County nor

the Plan Administrator shall be liable in any manner for any determination of fact made in good

faith.

5.5 Gender and Number. Where the context permits, words in the masculine gender

shall include the feminine and neuter genders, the singular shall include the plural, and the plural

shall include the singular.

5.6 Severability of Provisions. In the event that any provision of the Plan shall be

held to be illegal or invalid for any reason, said illegality or invalidity shall not affect the

remaining provisions but shall be fully severable, and the Plan shall be construed and enforced as

if said illegal invalid provision had never been inserted therein.

5.7 Binding Effect. The Plan and all actions and decisions hereunder, shall be

binding upon the heirs, executors, administrators, successors and assigns from any and all parties

hereto and Participants, present and future.

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5.8 Headings of Articles and Sections. The headings of Articles and Sections are

included solely for the convenience of reference, and if there is any conflict between such

headings and the text of the Plan, the text shall control.

5.9 Controlling Law. Except to the extent preempted by the laws of the United

States, the laws of the State of Illinois shall be controlling in all matters relating to the Plan.

5.10 Employment Rights. The Plan does not constitute a contract of employment, and

participation in the Plan will not give any employee the right to be retained in the employ of the

County, nor any right or claim to any benefit under the Plan, unless such right or claim has

specifically accrued under the terms of the Plan.

5.11 Indemnification of Plan Administrator. The County agrees to indemnify and to

defend to the fullest extent permitted by law any employee serving as the Administrator or as a

member of a committee designated as Plan Administrator (including any employee or former

employee who formerly served as Plan Administrator or as a member of such committee) against

all liabilities, damages, costs and expenses (including attorney’s fees and amounts paid in

settlement of any claims approved by the County) occasioned by any act or omission to act in

connection with the Plan, if such act or omission is in good faith.

5.12 Cost of Plan Administration. The cost and expenses incurred by the County in

administering the Plan shall be paid by the County.

5.13 Evidence. Any evidence required of anyone under the Plan may be by certificate,

affidavit, document or other information that the person acting on it considers pertinent and

reliable, and signed, made or presented by the proper party or parties, or in such other form as

the County may prescribe or deem satisfactory.

5.14 Interests Not Transferable. The interests of Participants under the Plan are not

subject to the claims of their creditors and may not be transferred or encumbered.

5.15 Facility of Payment. When, in the County's opinion, a Participant is under a legal

disability or is incapacitated in any way so as to be unable to manage his financial affairs, the

County may (but need not) make payments reimbursing such Participant's expenses to the

Participant's legal representative, or to his spouse, or the County may apply the payment for the

benefit of the Participant in any way the County considers advisable.

5.16 No Guarantee of Tax Consequences. Neither the Plan Administrator nor the

County makes any commitment or guarantee that any amounts paid to or for the benefit of a

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Participant under this Plan will be excludable from the Participant’s gross income for federal,

state, or local income tax purposes. It shall be the obligation of each Participant 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.

5.17 Indemnification of Employer. If any Participant receives one or more payments

or reimbursements under this Plan on a tax-free basis and if such payments do not qualify for

such treatment under the Code, then such Participant shall indemnify and reimburse the County

for any liability that it may incur for failure to withhold federal income taxes, Social Security

taxes, or other taxes from such payments or reimbursements.

5.18 Delegation of Authority. Whenever the County under the terms of this document

is permitted or required to perform any action or service, such action or service shall be done and

performed by any officer or individual representative of the County who is duly authorized by

the County or another individual to whom the County has properly assigned or delegated such

duties.

5.19 Misrepresentations or Fraud. If a Participant deliberately defrauds or misleads the

Plan Administrator about the eligibility or entitlement to benefits of himself or another person,

the Plan Administrator has the right to terminate Plan coverage for that Participant and/or any

family members immediately and retroactively. The Plan shall be entitled to recover (including

by means of offset against future benefits or by withholding from future compensation, to the

extent permitted by law) from the Participant and/or his family members any claims mistakenly

paid due to mistake, fraud or a wrongful attempt to procure coverage, and to recover any costs

and expenses arising from such fraud or misrepresentation, including, but not limited to, costs

and expenses recoverable in actions at law and in equity. Additionally, fraud on the part of the

Participant shall be grounds for disciplinary action up to and including termination of

employment.

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ARTICLE 6 - AMENDMENT AND TERMINATION

6.1 Amendment. While the County expects and intends to continue the Plan, the

County expressly reserves the right, in its sole and unrestricted discretion, to amend the Plan at

any time, except that any amount which had become payable under the Plan prior to the date an

amendment is effective shall be paid or payable in accordance with the terms of the Plan as in

effect immediately prior to the date of the amendment. Unless otherwise provided under the

Plan, all amendments to the Plan must be in writing and shall be prospective in nature.

6.2 Termination. The Plan may be terminated at any time by the County.

6.3 Benefits on Termination. On termination of the Plan, any amounts that became

payable under the terms of the Plan prior to the date of termination shall be paid in accordance

with the terms of the Plan as in effect prior to the date of such termination.

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ARTICLE 7 - COMPLIANCE WITH THE HIPAA PRIVACY AND SECURITY RULE

7.1 Purpose. This Section, in compliance with the Privacy Rule and the Security Rule

contained in the Administrative Simplification requirements of the Health Insurance Portability

and Accountability Act of 1996 and the regulations thereunder found at 45 C.F.R. Parts 160, 162

and 164 ("HIPAA"), is intended to allow disclosure of Protected Health Information ("PHI")

including electronic PHI as defined under HIPAA, to County (the "Plan Sponsor") for the

purposes specified below.

Generally, PHI, as defined under HIPAA, includes all individually identifiable

information related to an individual’s past, present or future physical or mental health condition

or to payment for health care. PHI includes information maintained by the Plan in oral, written,

or electronic form. PHI does not include information that has been de-identified. De-identified

information is information that does not identify the individual and with respect to which there is

no reasonable basis to believe that the information can be used to identify the individual.

Electronic PHI (“ePHI”) refers to PHI that is transmitted by or maintained in electronic

media including electronic storage media (such as hard drives, magnetic tapes or disks, optical

disks, and digital memory cards) and electronic transmission media (such as the Internet,

extranets, leased lines, dial-up lines, private networks, telephone voice response systems and

faxback systems, but not paper-to-paper faxes or voicemail messages).

This Section applies only to the “health care components” of the Plan as that term is

defined in 164 CFR §504 of the Privacy Rule contained in the Administrative Simplification

Provisions of HIPAA. In other words, only the Flexible Spending Account benefits provided

pursuant to Supplement B are designated as health care components of the Plan.

To the extent that there is any conflict between this Section and any other Plan

provisions, the terms of this Section as set forth below control. The Plan Administrator and its

duly authorized representatives retain full discretion in interpreting and applying these rules.

7.2 Disclosure of PHI to County. Plan may disclose PHI to the County in the

following circumstances:

Plan receives an authorization from the individual to disclose PHI to the

County.

Plan discloses information to the County on whether an individual is

participating in the Plan.

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Plan also may provide summary health information to the County so that

the County may modify, amend or terminate the Plan. Summary health

information is information that summarizes the claims history, claims

expenses, or type of claims experienced by the individuals for whom the

County has provided health benefits under the Plan, from which individual

identifiers (other than certain limited geographical information), such as

names and social security numbers, have been removed.

Otherwise, Plan shall disclose PHI to the County only to the extent necessary for the

County to perform administrative functions on behalf of the Plan. (If the County does not

perform such functions, Plan will not disclose PHI to the County other than as indicated above.)

Administrative functions include activities that would meet the definition under the HIPAA

Privacy Rule of treatment, payment, and health care operations activities. Such activities

include, but are not limited to, the following:

Review and resolution of claims for benefits and appeals

Determinations with respect to eligibility and coverage

Determining employee contribution rates

Quality assessment

Auditing, monitoring, and fraud detection and investigation programs

Cost management

Solicitation of proposals for services to be provided to or on behalf of the

Plan

Related computer and systems programming and development.

Notwithstanding anything to the contrary, in no event shall the County be permitted to

use or disclose PHI in a manner that is inconsistent with HIPAA.

7.3 Plan Sponsor Certification. The Plan agrees that it will disclose PHI to the

County only upon receipt of a certification that this Plan document incorporates the following

provisions and that the County agrees to abide by such provisions:

(a) Prohibition on Unauthorized Use or Disclosure of PHI. The County will

not use or disclose any PHI received from the Plan, except as permitted in

the Plan documents or as required by law.

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(b) Agents (Including Subcontractors). The County will require each of its

agents, including subcontractors, to whom the County provides PHI that it

received from the Plan, to agree to the same restrictions and conditions

that apply to the County with respect to such information.

(c) Impermissible Purposes. The County will not use or disclose PHI for

employment-related actions and decisions or in connection with any other

of the County's benefits or employee benefit plans.

(d) Reporting. The County will report to the Plan any use or disclosure of

PHI, of which it becomes aware, that is inconsistent with the uses and

disclosures permitted by the Plan. Specifically, the Plan Sponsor will

report to the Plan any Breach occurring on or after September 23, 2009, as

defined by 45 CFR § 164.402.

(e) Access to PHI by Participants. The County will make PHI available to the

Plan to permit Participants upon request to inspect and copy their PHI to

the extent provided by 45 CFR § 164.524.

(f) Amendment of PHI. The County will make PHI available to Participants

who request to amend or correct PHI that is inaccurate or incomplete and

will incorporate any amendments to PHI to the extent required and/or

permitted by 45 CFR § 164.526.

(g) Accounting of PHI. The County will make available the information

required to provide an accounting of disclosures in accordance with 45

CFR § 164.528.

(h) Disclosure to the Secretary. The County will make its internal practices,

books and records relating to the use and disclosure of PHI received from

the Plan available to the Secretary of the Department of Health and

Human Services or its designee for the purpose of determining the Plan's

compliance with HIPAA.

(i) Breach Notification. The Plan Sponsor will cooperate with the Plan’s

efforts to comply with the Breach notification regulations set forth in 45

CFR §§ 164.404, 164.406 and 164.408.

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21

(j) Return or Destruction of PHI. When the PHI is no longer needed for the

purpose for which disclosure was made, the County must, if feasible,

return to the Plan or destroy all PHI that the County received from the

Plan, and retain no copies in any form. If return or destruction is not

feasible, the County agrees to limit further uses and disclosures to the

purposes that make the return or destruction infeasible.

(k) Adequate Separation. The County must ensure that adequate separation

exists between the Plan and the County so that PHI will be used only for

plan administration. The following employees, classes of employees or

persons under the control of the County may have access to and may use

PHI, but only to the extent necessary to perform the administration

functions that (i) are to be performed by the County as set forth under (b)

above and (ii) are assigned to such employees as a part of their job duties:

An officer or employee or committee thereof that serves as Plan

Administrator;

An officer or employee who serves as a Plan fiduciary;

An officer or employee who serves as the Privacy or Security

Officer under HIPAA;

An employee of the Human Resources, Payroll, Accounting,

Finance, Information Technology, or Legal Departments.

In the event that any such persons do not comply with the requirements set

forth herein, such persons shall be subject to disciplinary action by the

County for noncompliance, pursuant to the County’s discipline and

termination or removal procedures. The County shall take whatever

actions necessary to resolve such noncompliance. Regardless of whether a

person is disciplined, terminated or removed pursuant to this paragraph,

the Plan reserves the right to direct that the County modify or revoke any

person’s access to or use of PHI, and the County shall take such action as

warranted. Anyone who suspects an improper use or disclosure of PHI

may report the occurrence to the Plan's Privacy Officer at the telephone

number and address provided in the Plan’s notice of privacy practices.

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22

(l) Protection of Electronic PHI. If electronic PHI is created, received,

maintained, or transmitted to or by the Plan Sponsor on behalf of the Plan,

the Plan Sponsor will do the following:

Ensure that the “adequate separation” described in subparagraph

(10) above is supported by reasonable and appropriate security

measures;

Implement administrative, physical, and technical safeguards that

reasonably and appropriately protect the confidentiality, integrity,

and availability of such electronic PHI;

Ensure that any agent (including a subcontractor) to whom it

provides such electronic PHI agrees to implement reasonable and

appropriate security measures to protect the information; and

Report to the Plan any security incident of which it becomes

aware. For purposes of this provision, “security incident” is

defined as the attempted or successful unauthorized access, use,

disclosure, modification, or destruction of information or

interference with system operations in an information system.

Notwithstanding the above, if the only ePHI that is disclosed to the Plan

Sponsor is disclosed pursuant to a HIPAA-compliant authorization or is

limited to Summary Health Information (as defined in the Privacy Rule)

disclosed for the purpose either of obtaining premium bids for providing

health insurance coverage under the Plan, or modifying, amending or

terminating the plan, and information regarding an individual’s

participation, enrollment or disenrollment, the requirements of this

subparagraph do not apply.

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ARTICLE 8 - EXECUTION OF PLAN

IN WITNESS WHEREOF, the Plan and Supplements A, B and C are hereby executed

effective as of the _______________ day of _______________, 20143.

1. ATTEST: 2. COUNTY OF KANE

3. By:

4. By:

5. Its:

6. Its:

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A-1

SUPPLEMENT A

PRE-TAX PREMIUM ACCOUNT

A-1 Purpose. Each Plan Year, each Participant will be entitled to pay his share (if

any) of the premium cost for the elected group welfare insurance coverage (such as group

medical or dental) for that year with pre-tax dollars through payroll withholding. Salary

reduction amounts from the last month of one Plan Year may be applied to pay group health

insurance premiums for insurance during the first month of the immediately following Plan Year.

A-2 Election of Coverage. In order to elect coverage under the Pre-Tax Premium

Account, a Participant must file the necessary election form provided by the County within the

applicable period pursuant to Section 3.1 of the Plan. The form must specify the type of

coverage elected and whether pre-tax dollars are to be applied for premium payments. If pre-tax

dollars are to be used for either medical or dental insurance, then both types of insurance must be

paid for pre-tax. If, for succeeding Plan Years, a Participant does not submit a new election

form, he will be deemed to have elected the type and level of coverage under the Pre-Tax

Premium Account in effect on the last day of the preceding Plan Year.

A-3 Incorporated Plans. The County's group welfare insurance plans, as adopted by

the County, and the Teamsters Plan, to which employees may make pre-tax contributions are

hereby incorporated by reference into the Plan.

A-4 Irrevocable Elections. Any coverage elected under Section A-2 shall be

irrevocable for the duration of the Plan Year except in the event of a change in status, or as

otherwise provided pursuant to Section 3.2 of the Plan.

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B-1

SUPPLEMENT B

FLEXIBLE SPENDING ACCOUNT

B-1 Purpose. Each Participant will be entitled to choose between (a) reimbursement

for "Medical Care Expenses" (as defined below) not reimbursed by any other plan or taken as an

income tax deduction, and (b) cash compensation. It is intended that this Flexible Spending

Account (the "Health Care Account") qualify as a nondiscriminatory cafeteria plan benefit under

Code Section 125 and as an accident and health care plan within the meaning of Code Section

105(e) and that reimbursements paid hereunder be eligible for exclusion from the Participant's

income under Code Section 105(b).

B-2 Election of Coverage. In order to elect coverage under the Health Care Account,

Participants must file the appropriate election form provided by the County within the applicable

period pursuant to Section 3.1 of the Plan. Each Participant may designate no less than $120 and

no more than $2,5500 (as indexed for inflation) of coverage under the Health Care Account (the

"elected coverage"), and his compensation from the County shall be reduced, by the amount of

the elected coverage, and shall be credited to the Participant's Health Care Account.

B-3 Allowable Benefits Under Health Care Account. Reimbursements to a Participant

shall be permitted hereunder only with respect to “Medical Care Expenses,” that is, amounts

expended (and not reimbursed by any other plan or taken as an income tax deduction) for

"medical care" (within the meaning of Code Section 213(d)) of the Participant or the

Participant’s tax qualified dependents under Code Section 105(b).

(a) For purposes of a Health Care Account, examples of Medical Care Expenses are

set forth below:

1. Deductibles and co-payments under the County's health plans or the

Teamsters Plan (including dental and vision plans) or under personal

accident and health insurance carried by the Participant, his spouse, or

covered dependents;

2. Prescription drugs;

3. Over-the-counter drugs and products such as antacids, allergy medicines,

pain relievers and cold medicines will not be reimbursed unless the

individual has a prescription for such over-the-counter drugs and

medicines, except that a prescription is not needed for insulin;

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B-2

4. Eye care, including vision checkups, eyeglasses and contact lenses;

5. Hearing care, including hearing examinations and hearing aids;

6. Routine physical examinations;

7. Any other medical care item that constitutes medical care within the

meaning of Code Section 213(d).

B-4 Substantiation/Correcting Improper Reimbursements. A Participant must provide

third-party substantiation of any Medical Care Expenses incurred for which reimbursement is

sought by the Participant.

In the event that a Medical Care Expense is improperly reimbursed due to insufficient or

improper substantiation, overpayment, fraud or otherwise, the Plan Administrator shall, to the

extent that it deems administratively possible and otherwise permissible under applicable law,

seek repayment of such improper reimbursement by (1) requesting the Participant direct payment

to the Plan, (2) withholding the corresponding amount from the Participant’s compensation on an

after-tax basis (where such withholding is permissible under applicable law), or (3) offsetting the

improper reimbursement against other valid Medical Care Expense claims.

B-5 Limitations. For each Plan Year, the Participant may be reimbursed for Medical

Care Expenses up to the full amount of elected coverage the Participant has elected for the Plan Year

plus any amounts carried over from a prior Pplan Yyear (in accordance with Section B-8), less any

prior reimbursements for this period. The amount of elected coverage by a Participant for a Plan Year

is only available to reimburse expenses that are incurred during the Plan Year during which an

election is in effect hereunder, unless such amount is carried over to a subsequent Plan Year (in

accordance with Section B-8). Participants shall have ninety daysthree months following the end

of the Plan Year to submit claims for such expenses, except that terminated employees will have

thirty days from the date of their termination to submit claims. An expense is incurred during the

Plan Year if the services giving rise to the expenses are performed during the Plan Year. An

expense shall not be deemed to be incurred during the Plan Year merely because a Participant

receives a bill for the expense during the Plan Year or pays for the expense during the Plan Year.

B-6 Nondiscrimination Requirements. It is intended that contributions and benefits

under the Flexible Spending Account not be discriminatory under the provisions of the Code. In

that regard, notwithstanding anything contained herein to the contrary, the Plan Administrator

may limit the amounts reimbursed or paid to any Participant who is considered a highly

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B-3

compensated individual under Code Sections 105(h)(5) or 125(e) or to any Participant who is

considered a key employee under Code Section 125(b)(2) to the extent the Plan Administrator

deems such limitation advisable to comply with any restrictions contained in the Code.

B-7 Forfeiture. Unless as otherwise provided in Section B-11, if a Participant incurs

during the Plan Year a Participant incurs aggregate expenses qualifying for reimbursement less than

the dollar amount of coverage the Participant elects for such Plan Year, any remaining amount in

excess of $500 in the Participant’s Health Care Account as of the end of that Plan Year (and after

application of Section B-10) shall be forfeited. Any amount of coverage in excess of $500 for a Plan

Year that is unused due to the Participant’s failure to submit proper claims for reimbursements in

conformity with the procedure prescribed by the Plan also shall be forfeited. Subject to the

requirements of applicable law, forfeitures will be paid to the County to defray Plan administrative

expenses, reduce required salary reduction amounts for the next Plan Year on a reasonable and

uniform basis, or be allocated to participating employees on a reasonable and uniform basis.

B-8 Carry-over. Up to $500 of the amount remaining in the Participant’s Health Care

Account as of the end of the Plan Year (and after application of Section B-10) shall be carried

over for use by the Participant during the next following Plan Year.

B-9 Irrevocable Elections. Any coverage elected under Section B-2 shall be



B-10 Run-Out Period. A Run-Out Period is a period after the end of the Plan Year

during which a Participant can submit a claim for reimbursement for a qualified benefit incurred

during the Plan Year. Notwithstanding any provision in the Plan to the contrary, the Plan shall

reimburse the expenses of any Participant submitted during the applicable Run-Out Period, to the

extent they are otherwise eligible for reimbursement under the terms of the Plan. For this

purpose, the term “Run-Out Period” shall mean the 3-month period immediately following the

close of each Plan Year.

B-11 Qualified Reservist Distributions. This Section contains special provisions that

are intended to incorporate qualified reservist distributions permitted by the Heroes Earnings

Assistance and Relief Tax Act of 2008, P.L. 110-245 (the “HEART Act”). The provisions of

this Section shall operate in conjunction with other Plan provisions. In case of conflict or

ambiguity between this section and other provisions of the Plan, the Plan shall be administered in

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B-4

accordance with the intention of this Section, as stated above, to the extent permitted under

applicable law, regulatory requirement, or published tax guidance.

Notwithstanding any provision in the Plan to the contrary, the Plan shall distribute to a

Participant all or a portion of the balance in the Participant’s Health Care Account if:

(a) such Participant is a member of a reserve component ordered or called to active duty

for a period of 180 days or more or for an indefinite period, and

(b) such distribution is made during the period beginning on the date of such order or call

and ending on the last date that reimbursements could otherwise be made for the Plan Year

which includes the date of such order or call.

No qualified reservist distributions shall be paid on behalf of anyone other than a

Participant who is ordered or called to active duty. The Participant ordered or called to active

duty must provide the County with a copy of the order or call to active duty before an amount

may be distributed. The request for a qualified reservist distribution must be made on or after the

date of the order or call to active duty, and before the last day of the Plan Year during which the

order or call to active duty occurred. Qualified reservist distributions shall be paid no later than

sixty days after the date of the request for a qualified reservist distribution.

For purposes of making a qualified reservist distribution, the Participant’s Health Care

Account balance available for such a distribution will be the amount contributed to the Health

Care Account as of the date of the qualified reservist distribution request minus Health Care

Account reimbursements received as of the date of the qualified reservist distribution request.

A qualified reservist distribution will not be made with respect to amounts (1) attributable

to a prior plan year (including a plan year ending on or before June 18, 2008), or (2) attributable

to non-Health Care Accounts.

With respect to medical expenses incurred after the date a qualified reservist distribution

is requested, the Plan will terminate the Participant’s right to submit claims.

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C-1

SUPPLEMENT C

DEPENDENT CARE REIMBURSEMENT ACCOUNT

C-1 Purpose. Each eligible Participant will be entitled to choose between (a)

reimbursement for "Dependent Care Expenses" (as defined below) for which a dependent care

tax credit is not taken, and (b) cash compensation. It is intended that the Dependent Care

Reimbursement Account (the "Dependent Care Account") qualify as a nondiscriminatory

cafeteria plan benefit under Code Section 125 and as a dependent care reimbursement plan

within the meaning of Code Section 129 and that reimbursements paid hereunder be eligible for

exclusion from Participants' income under Code Section 129(a).

C-2 Election of Coverage. In order to elect coverage under the Dependent Care

Account, Participants must file the appropriate election form provided by the County within the

applicable period pursuant to Section 3.1 of the Plan. Each Participant may designate no less

than $120 and no more than up to $5,000 ($2,500 where the Participant is married and files a

separate return) of coverage (the "elected coverage"), provided however, that each Participant's

elected coverage under the Dependent Care Account shall be limited to the lesser of (a) the

Participant's Earned Income for the Plan Year, or (b) the Participant's spouse's Earned Income for

the Plan Year. For purposes of this Supplement C, Earned Income means the individual's

compensation from the individual’s employer plus the amount of the individual's net earnings

from self-employment during the Plan Year, computed without regard to any community

property laws, without taking into account any amount received as a pension or annuity, and

without taking into account any amounts paid under the Plan or under a dependent care

reimbursement plan of any other employer. If the Participant's spouse is a Qualifying Individual

or is a full-time student (as defined in Code Section 21(d)(2)), such spouse will be deemed to

have Earned Income for purposes of this Supplement for each month during the Plan Year in

which the spouse has such status, equal to either (1) $200, if there is one Qualifying Individual

with respect to the Participant; or (2) $400, if there is more than one Qualifying Individual with

respect to the Participant. The $5,000 limit shall be reduced by the amount of dependent care

assistance received under a plan of the employer of the Participant's spouse. The Participant's

compensation from the County shall be reduced, by the amount of the elected coverage, in equal

amounts each payroll period and shall be credited each payroll period to the Participant's

Dependent Care Account.

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C-2

C-3 Allowable Benefits Under The Dependent Care Account. Reimbursements to a

Participant shall be permitted hereunder only with respect to Dependent Care Expenses which

are incurred while an election is in effect either during the Plan Year, or, if shorter, during the

Participant's period of employment within the Plan Year, for which a dependent care tax credit is

not taken on the Participant's income tax return, up to the amount of coverage elected by the

Participant for the Plan Year. Dependent Care Expenses shall include only amounts paid which

constitute "employment related expenses" within the meaning of Code Section 21. Dependent

Care Expenses must be incurred for the care of a Qualifying Individual ((i) a child of a

Participant who is under the age of thirteen (13) and with respect to whom the Participant is

entitled to the deduction under Code Section 151(c), or, (ii) a “Dependent” (as defined in Code

Section 152, except if the Participant is divorced then as defined in Code Section 21(e)(5)) or the

Participant's spouse who is physically or mentally incapable of caring for himself) and to enable

the Participant to be gainfully employed. Dependent Care Expenses shall be limited to: (a)

amounts paid for services rendered in the Participant's home; or (b) amounts paid for services

rendered outside of the Participant's home only if such services are provided for the care of a

Qualified Individual who is under age thirteen (13), or who is age thirteen (13) or older and who

regularly spends at least eight (8) hours a day in the Participant's home provided that services

rendered in a dependent care center (as defined in Code Section 21) must satisfy the

requirements of Code Section 21 and the regulations promulgated thereunder.

C-4 Limitations. For each Plan Year, the Participant may be reimbursed for

Dependent Care Expenses up to the dollar amount of elected coverage the Participant has

accumulated in his Dependent Care Account through contributions to that date less any prior

reimbursements for this period. If the Participant's expenses exceed the accumulated amount to

date, the Participant will receive additional reimbursements hereunder as the Participant

accumulates additional funds in his Dependent Care Account. The amount of elected coverage

by a Participant for a Plan Year is only available to reimburse expenses that are incurred during

the Plan Year during which an election is in effect hereunder. Participants shall have ninety

daysthree months following the end of the Plan Year to submit claims for these expenses, except

that terminated employees will have thirty days from the date of their termination to submit

claims. An expense is incurred during the Plan Year if the services giving rise to the expense are

performed during the Plan Year. An expense shall not be deemed to be incurred during the Plan

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C-3

Year merely because a Participant receives a bill for the expense during the Plan Year or pays for

the expense during the Plan Year.

C-5 Nondiscrimination Requirements. It is intended that contributions and benefits

under the Dependent Care Reimbursement Account not be discriminatory as prohibited by Code

Section 129(d). FurtherAccordingly, the average benefits provided to non-highly compensated

employees (excluding, in the Plan Administrator’s discretion, employees earning less than

$25,000) must be at least 55% of the average benefits provided to highly compensated

employees (as defined in Code Section 414(q)). If the Plan Administrator believes that this limit

may be exceeded, it may, in its own discretion and notwithstanding anything herein to the

contrary, limit the amount of benefits paid with respect to such individuals to the extent the Plan

Administrator deems such limitation advisable in order to comply with the restrictions contained

herein or any other nondiscrimination provision contained in the Code.

C-6 Forfeiture. If a Participant incurs during the Plan Year aggregate expenses

qualifying for reimbursement less than the amount of elected coverage for a Plan Year, any

remaining amount in his Dependent Care Account as of the end of the Plan Year shall be

forfeited. Any amount of elected coverage for a Plan Year unused due to the Participant's failure

to submit proper claims for reimbursements in conformity with the procedures prescribed by the

Plan shall also be forfeited. Subject to requirements of applicable law, forfeitures will be paid to

the County.

C-7 Irrevocable Elections. Any coverage elected under Section C-2 shall be



C-8 Spend Down for Terminated Employees. Expenses incurred within ninety (90)

days after the date an employee ceases participation in the Plan (for example, after termination)

may be reimbursed from unused benefits.

C-9 Run-Out Period. A Run-Out Period is a period after the end of the Plan Year

during which a Participant can submit a claim for reimbursement for a qualified benefit incurred

during the Plan Year. Notwithstanding any provision in the Plan to the contrary, the Plan shall

reimburse the expenses of any Participant submitted during the applicable Run-Out Period, to the

extent they are otherwise eligible for reimbursement under the terms of the Plan. For this

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C-4

purpose, the term “Run-Out Period” shall mean the 3-month period immediately following the

close of each Plan Year.

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SUMMARY OF THE

COUNTY OF KANE

FLEXIBLE BENEFITS PLAN

EFFECTIVE JANUARY 1, 2015DECEMBER 31, 2013

This booklet describes the Plan provisions that currently affect your benefits under the

Plan. If, in the future, the provisions described herein should change for any reason, you will be

provided with a summary of the changes.

IF FOR ANY REASON THERE IS AN OMISSION OR MISSTATEMENT IN

THIS BOOKLET, OR ANY DIFFERENCE BETWEEN THIS BOOKLET AND THE

LEGAL PLAN DOCUMENTS, THE LEGAL PLAN DOCUMENTS WILL IN ALL

RESPECTS CONTROL AND GOVERN.

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-i-

TABLE OF CONTENTS

Page

SUMMARY OF THE ..................................................................................................................... 1

COUNTY OF KANE ...................................................................................................................... 1

FLEXIBLE BENEFITS PLAN....................................................................................................... 1

PREAMBLE ................................................................................................................................... 1

GENERAL INFORMATION ......................................................................................................... 2

WHICH TWELVE (12) MONTH PERIOD DOES THE PLAN USE FOR

RECORDKEEPING PURPOSES? ......................................................................................... 3

WHO PAYS FOR THE BENEFITS UNDER THE PLAN? .......................................................... 3

WHEN WILL I BE ELIGIBLE TO PARTICIPATE IN THE PLAN? .......................................... 3

HOW DO I ELECT TO PARTICIPATE IN THE BENEFITS AVAILABLE THROUGH

THE PLAN? ............................................................................................................................ 4

WHEN AND UNDER WHAT CIRCUMSTANCES MAY I CHANGE MY

ELECTION? ............................................................................................................................ 4

ELECTION CHANGES IMPOSED BY THE PLAN .................................................................. 10

WHAT BENEFITS ARE AVAILABLE UNDER THE PLAN? ................................................. 10

WHAT HAPPENS IF I DON’T USE UP ALL OF THE ELECTED BENEFITS PRIOR

TO THE END OF THE PLAN YEAR? ................................................................................ 14

WHAT HAPPENS IF I RECEIVE REIMBURSEMENTS TO WHICH I AM NOT

ENTITLED UNDER THE PLAN? ....................................................................................... 14

WHAT HAPPENS IF I TERMINATE EMPLOYMENT? .......................................................... 15

AM I ENTITLED TO CONTINUE COVERAGE UNDER THE PLAN? .................................. 15

WHAT HAPPENS IF THIS PLAN IS DISCONTINUED OR AMENDED? ............................. 21

ADMINISTRATION .................................................................................................................... 21

PROCEDURES FOR MAKING A CLAIM AND AN APPEAL FOR BENEFITS ................... 22

FULL DETAILS IN LEGAL PLAN DOCUMENTS .................................................................. 26

GENERAL PLAN INFORMATION ........................................................................................... 27

PREAMBLE ................................................................................................................................... 1

GENERAL INFORMATION ......................................................................................................... 2

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RECORDKEEPING PURPOSES? ......................................................................................... 3

WHO PAYS FOR THE BENEFITS UNDER THE PLAN? .......................................................... 3

WHEN WILL I BE ELIGIBLE TO PARTICIPATE IN THE PLAN? .......................................... 3


THE PLAN? ............................................................................................................................ 3

WHEN AND UNDER WHAT CIRCUMSTANCES MAY I CHANGE MY

ELECTION? ............................................................................................................................ 3

ELECTION CHANGES IMPOSED BY THE PLAN .................................................................... 7

WHAT BENEFITS ARE AVAILABLE UNDER THE PLAN? ................................................... 8

WHAT HAPPENS IF I DON’T USE UP ALL OF THE ELECTED BENEFITS PRIOR

TO THE END OF THE PLAN YEAR? ................................................................................ 10

WHAT HAPPENS IF I TERMINATE EMPLOYMENT? .......................................................... 10

AM I ENTITLED TO CONTINUE COVERAGE UNDER THE PLAN? .................................. 10

WHAT HAPPENS IF THIS PLAN IS DISCONTINUED OR AMENDED? ............................. 16

ADMINISTRATION .................................................................................................................... 16

PROCEDURES FOR MAKING A CLAIM AND AN APPEAL FOR BENEFITS ................... 16

FULL DETAILS IN LEGAL PLAN DOCUMENTS .................................................................. 19

GENERAL PLAN INFORMATION ........................................................................................... 21

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PREAMBLE

The County of Kane (the “County”) is pleased to sponsor a cafeteria plan for the eligible

employees of the County effective as of January 1, 2006. The Plan is named the County of Kane

Flexible Benefits Plan (hereinafter sometimes referred to as the “Plan”).

This Summary of the Plan is effective January 1, 2015December 31, 2013, and is

intended to provide you with a general description of its highlights. If you have any questions

after reading the Summary, please contact the Plan Administrator, at the Department of Human

Resources Management.

IF FOR ANY REASON THERE IS AN OMISSION OR MISSTATEMENT IN

THIS BOOKLET, OR ANY DIFFERENCE BETWEEN THIS BOOKLET AND THE

LEGAL PLAN DOCUMENTS, THE LEGAL PLAN DOCUMENTS WILL IN ALL

RESPECTS CONTROL AND GOVERN.

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-2-

GENERAL INFORMATION

Through the Plan you can elect to participate in the following benefits:

(a) Pre-Tax Premium Account.

(b) Flexible Spending Account.

(c) Dependent Care Reimbursement Account.

These are separate benefits. Your election to be covered under one benefit will not

obligate you to participate in the other benefits.

Participation in the Plan allows you to make contributions (that are withheld from your

paychecks) to a Pre-Tax Premium Account to pay for your share of the cost of your participation

in the County’s group welfare plans (such as group medical or dental) or the Teamsters Plan on a

pre-tax basis. Participation also allows you to make contributions (also via paycheck

withholding) that go into the reimbursement accounts for reimbursement of eligible health care

and dependent care expenses on a pre-tax basis. The contributions withheld from your

paychecks are excluded from your taxable income and, as a result, your taxable income is

reduced.

This can be illustrated by the following example:

With Without

Your Plan Your Plan

-------- --------

Gross Taxable Wages $25,000. $25,000.

Pre-tax Contribution $1,800. N/A

-------- --------

Taxable Wages $23,200. $25,000.

Estimated Taxes* $3,480. $3,750.

After-tax Expenditure N/A $1,800.

-------- --------

Take-home Pay $19,720. $19,450.

* Joint Return, 15% marginal tax rate

By paying for benefits before taxes are calculated, estimated taxes are reduced by $270, which is

$22.50 per month more in take-home pay for the example person. In other words, paying for

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-3-

benefits without participating in the Plan costs this person $22.50 more per month.

Because participation in the Plan reduces your gross taxable income, it may affect your

entitlement to Social Security benefits. In most instances, the benefit of the current tax savings

(as illustrated above) will outweigh the slight impact on future Social Security benefits.

Please consult your tax advisor for a more accurate estimate for your situation.


RECORDKEEPING PURPOSES?

Records for the Plan are maintained on a twelve-consecutive month period beginning on

January 1 and ending on December 31. This is called the Plan Year.

WHO PAYS FOR THE BENEFITS UNDER THE PLAN?

All contributions to the Plan will be made by you from income withheld from your

paychecks that you elect to have diverted to the Plan.

WHEN WILL I BE ELIGIBLE TO PARTICIPATE IN THE PLAN?

All employees of the County who are eligible to participate in the County’s group

medical plan and group dental plan are eligible to contribute to the Pre-Tax Premium Account,

Flexible Spending Account and the Dependent Care Reimbursement Account on the later of

January 1, 2006, or on the date that the employee becomes eligible for and enrolls in the

County’s group medical or dental plan. Also, an employee of the County’s Department of

Transportation who is eligible to participate in the Suburban Teamsters of Northern Illinois

Welfare Fund (the “Teamsters Plan”) shall be eligible to become a participant in the Plan on the

first day that the employee becomes eligible to participate in the Teamsters Plan, with actual

enrollment to occur as soon as practicable following the employee’s submission of a completed

election form. If an employee of the County also provides services to the County as an

independent contractor or director, the employee is eligible to participate in the Plan solely in his

capacity as an employee.

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-4-


THE PLAN?

Prior to meeting the eligibility requirements, you will be given a Section 125 Plan

Enrollment form and a Health/Dependent Care Flexible Spending Accounts-FSA Enrollment

form. The forms must be completed and returned to the Department of Human Resource

Management within thirty (30) days from your date of eligibility. Your election will be effective

beginning with the first day of the payroll period coincident with or next following the date you

submit a completed Compensation Reduction Agreement form, provided that the form is

received by the Department of Human Resource Management within thirty (30) days from your

date of eligibility. In order to continue coverage with respect to the Flexible Spending Account,

however, you must submit a new Health/Dependent Care Flexible Spending Accounts-FSA

Enrollment form each year.

WHEN AND UNDER WHAT CIRCUMSTANCES MAY I CHANGE MY ELECTION?

You will be notified once each year, during the 45-day period prior to each January 1, of

your right to change your election and provided with a new Health/Dependent Care Flexible

Spending Accounts-FSA Enrollment form. The form must be returned to the Department of

Human Resource Management at least 30 days prior to January 1 of each Plan Year or such other

time as determined by the County and set forth in a written policy to be communicated to all

eligible employees.

Additionally, if the cost of participation in one of the County’s welfare plans (e.g.,

medical or dental coverage) or the Teamsters Plan increases or decreases during a period of

coverage, and, under the terms of the respective plan, you are required to make a corresponding

change in payments, the Plan may, on a reasonable and consistent basis, automatically make a

prospective increase or decrease in your elective contributions to the Plan. In addition, if the cost

of participation in one of the County’s contributory welfare plans (e.g., medical or dental

insurance) increased during the Plan Year, or any prior Plan Year, and, under the terms of the

respective plan, you were required to make a corresponding change in payments, but the County

inadvertently failed to implement such change, the County may, on a reasonable and consistent

basis, require you to pay the difference. One (but not the only) means for doing so would be to

enter into a payment plan whereby any past-due payments that were required to be paid by you

are withheld from your pay over a reasonable period of time.

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Once an election is made, it cannot be changed by you during the Plan Year except under

the following circumstances:

1. HIPAA Special Enrollment: You may revoke an existing election and make a new

election that corresponds with special enrollment rights under the Health

Insurance Portability and Accountability Act of 1996 (“HIPAA”).

2. Change in Status: If you have a change in status you may revoke or change a

benefit election provided the election change is on account of and consistent with

the change in status, and the change in status affects the eligibility of yourself,

your spouse or dependeant under an employer’s cafeteria plan or other employee

welfare benefit plan in which any of you are a participant. A change in status

includes:

(a) your marriage, the death of your spouse, your divorce, legal separation or

annulment;

(b) the death of your dependent, or the birth, adoption or placement for

adoption of your child, or an event that otherwise results in an increase or

decrease in the number of your family members or dependents who may

benefit from coverage under the Plan;

(c) a change in employment status of your spouse or dependent or yourself

including the termination or commencement of employment, a strike or

lockout, a commencement of or return from an unpaid leave of absence, a

change in worksite, a reduction or increase in hours of employment,

including a switch from part-time to full-time employment status or vice

versa, or a switch from hourly to salaried employment or vice versa;

(d) an event causing your dependent to satisfy or cease to satisfy the

requirements for coverage due to attainment of age, student status, or any

similar circumstance as provided in the health plan under which you

receive coverage;

(e) a change in the place of residence of yourself or your spouse or dependent;

and

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(f) such other events as the Plan Administrator determines qualify as a change

in status, consistent with regulations and rulings of the Internal Revenue

Service.

3. Reduction of weekly hours of employment below 30: You may revoke an existing

election and make a new election if you experience a reduction in hours of

employment such that (1) you reasonably are expected to work an average of less

than 30 hours per week after reasonably having been expected to average at least

30 hours per week (even if the reduction in hours of employment does not result

in you ceasing to be eligible under the County’s group health plan); and (2) the

revocation of a benefit election under the Plan corresponds to the intended

enrollment of yourself and, as applicable, your spouse or dependent, who cease

coverage due to the revocation in another plan that provides minimum essential

coverage, where such new coverage is effective no later than the first day of the

second month following the month that includes the date the benefit election is

revoked;

4. Enrollment in a Qualified Health Plan: You may revoke an existing election and

make a new election that corresponds with your enrollment in a “Qualified Health

Plan” (as purchased through a marketplace established pursuant to Section 1131

of the Patient Protection and Affordable Care Act of 2010 (a “Marketplace”)), if

(1) you are eligible for a “special enrolment period” to enroll in such Qualified

Health Plan pursuant to guidance issued by the Department of Health and Human

Services and any other applicable guidance, or you seek to enroll in a Marketplace

during the Marketplace’s annual open enrollment period; and (2) the revocation of

your benefit election under the Plan corresponds to the intended enrollment of

yourself and, if applicable, your spouse or dependent, who cease coverage due to

the revocation, in a Qualified Health Plan through a Marketplace for new

coverage that is effective beginning no later than the day immediately following

the last day of the revoked coverage;[LMDBLT1]

3.5. COBRA Eligibility: In the event you, your spouse or your dependent becomes

eligible for continuation coverage under your County’s group medical or dental

plan or the Teamsters Plan pursuant to federal law known as “COBRA,” you may

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elect to modify payments under the Plan as appropriate in order to pay for the

continuation coverage;

4.6. Court Order: Upon the entry of a judgment, decree or court order (including a

qualified medical child support order under Section 609 of the Employee

Retirement Income Security Act of 1974) resulting from a divorce, legal

separation, annulment or change in legal custody requiring you or your former

spouse to provide or cancel health coverage with respect to a child (cancellation

to be permitted only if the order also requires another person to provide coverage

for the child and such coverage actually is provided);

5.7. Entitlement to Medicare/Medicaid: In the event you, your spouse or your

dependent who isare enrolled in the County’s group health plan or the Teamsters

Plan becomes entitled to or loses eligibility for coverage under Medicare or

Medicaid, then you may cancel, reduce, add, or increase coverage for yourself,

your spouse or your dependent accordingly.

6.8. Significant change in Cost or Coverage (not applicable to the Flexible Spending

Account election): You may revoke an election and file a new election for the

balance of the Plan Year under the following circumstances:

(a) if the cost to you (if any) for a benefit package option (e.g., a welfare

benefit offered through this Plan, or an option for coverage under an

underlying health plan, such as an indemnity option, an HMO option, or a

PPO option) significantly increases or decreases (whether that increase or

decrease results from an action taken by you or from an action taken by

the County), or, with respect to the Dependent Care Reimbursement

Account election, a significant cost change is imposed by a dependent care

provider who is not your relative, you may make a corresponding election

change for the balance of the Plan Year;

(b) if coverage under one of the County’s welfare plans (e.g., medical or

dental coverage) or the Teamsters Plan or a welfare plan of your spouse or

dependent, is significantly curtailed or ceases (for example, there is a

significant increase in the deductible, copay or out-of-pocket cost sharing

limit under a health plan) during such Plan Year, but there is not a loss of

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coverage as defined in (c) below, you may revoke your election for that

coverage and, in lieu thereof, elect to receive on a prospective basis

coverage under another benefit package option providing similar

coverage, provided such changes are permitted under the terms of the

applicable welfare benefit plan;

(c) if you or your spouse or dependent has a significant curtailment of

coverage that is a loss of coverage (that is, a complete loss of coverage

under the benefit package option or other coverage option (including the

elimination of a benefits package option, an HMO ceasing to be available

in the area where you reside, or your losing all coverage under the option

by reason of an overall lifetime or annual limitation)), you may revoke

your election under the Plan and, in lieu thereof, elect either to receive on

a prospective basis coverage under another benefit package option

providing similar coverage or to drop coverage if no similar benefit

package option is available, provided such changes are permitted under

the terms of the applicable welfare benefit plan;

(d) if a new benefit package option or other coverage option is added or if

coverage under an existing benefit package option or other coverage

option is significantly improved, you may revoke your election, and, in

lieu thereof, make an election on a prospective basis for coverage under

the new or improved benefit package option, provided such changes are

permitted under the terms of the applicable welfare benefit plan; or

(e) you may make an election change on account of and corresponding with a

change made under the plan of your spouse’s, former spouse’s or

dependent’s employer provided the election under your spouse’s or

dependent’s plan satisfies both that plan’s election change rules and IRS

regulations regarding election changes, or your spouse’s or dependent’s

plan has a different period of coverage.

7.9. FMLA: In the event that you take a paid leave of absence under the Family

Medical Leave Act (“FMLA”), your elections under the Plan with respect to the

Pre-Tax Premium Account and the Flexible Spending Account will remain the

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same, and you will continue to make contributions in the same way that you made

them prior to taking the leave of absence. You may make an election change with

respect to a Dependent Care Reimbursement Account, provided the change is on

account of and consistent with the leave. You will not be entitled to

reimbursement of Dependent Care claims incurred during an FMLA leave.

If you take an unpaid leave of absence under the FMLA, you may revoke an

existing election or continue health coverage (such as medical or dental coverage)

under the County’s health plans or the Teamsters Plan (to the extent permitted by

that plan), or coverage under the Flexible Spending Account.

If you elect to continue coverage, you have two payment options: (i) pre-pay or

(ii) pay-as-you-go. Under the pre-pay option, you may pay the premiums and

contributions due during the FMLA leave period on a pre-tax salary reduction

basis from any taxable compensation or on an after-tax basis prior to

commencement of the leave. (Certain restrictions apply, however, if your FMLA

leave spans two Plan Years.) Under the pay-as-you-go option, you may pay your

share of premium payments and contributions on a monthly basis on the first of

every month (the same schedule as COBRA payments). These payments

typically would be made on an after-tax basis, unless you receive taxable

compensation during the leave period (e.g., as a result of unused sick days or

vacation days). If you fail to make payments when due, the County may

discontinue your coverage during the leave. The County, at its option, may

continue your coverage during the leave and then recoup your share of premiums

and contributions from available taxable compensation upon your return from

leave.

If you do not elect to continue coverage while on FMLA leave, you are entitled to

reinstatement upon your return to employment on the same terms as prior to

taking FMLA leave, subject to any changes in benefit levels that may have taken

place during the leave.

Upon reinstatement in the Flexible Spending Account, you may resume coverage

at the level in effect before the FMLA leave and make up the unpaid premium

payments, or you may resume coverage at a level that is reduced and resume

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premium payments at the level in effect before the FMLA leave. If you do not

elect to continue coverage during the FMLA leave under the Flexible Spending

Account while on FMLA leave, you will not be entitled to reimbursement for

claims incurred during the FMLA leave.

Any election change (other than those made in connection with a court order or as an

exercise of rights pursuant to a statute that provides for a specific election period such as HIPAA

or COBRA) must be requested in writing within thirty (30) days from the date of the change

event. Any new election shall be effective not earlier than the first day of the next pay period

covered by the new Health/Dependent Care Flexible Spending Accounts-FSA Enrollment form.

You may not make an election change that would reduce your Flexible Spending Account

coverage to an amount that would be less than the amount of benefits claimed under such

coverage as of the date the change would become effective.

ELECTION CHANGES IMPOSED BY THE PLAN

Although it is unlikely that your elections and benefits under the Plan will be affected by

the numerous discrimination tests that apply to them under the Internal Revenue Code, you

should know that there are a number of legal limitations that apply to the Plan. The Plan

Administrator reserves the right to modify any benefit elections by the amount necessary to

allow the Plan to satisfy any applicable nondiscrimination requirements. If these discrimination

tests ever apply to you, the Plan Administrator will inform you of the effect on your Plan

elections and benefits.

Additionally, if the cost of participation in one of the County’s welfare insurance plans

(e.g., medical or dental coverage) or the Teamsters Plan increases or decreases during a period of

coverage, and, under the terms of the respective plan, you are required to make a corresponding

change in payments, the Plan may, on a reasonable and consistent basis, automatically make a

prospective increase or decrease in your elective contributions to the Plan.

WHAT BENEFITS ARE AVAILABLE UNDER THE PLAN?

(a) PRE-TAX PREMIUM ACCOUNT

You may elect to pay your share for coverage under the County’s group welfare plans

(e.g. group medical or dental insurance) or the Teamsters Plan with pre-tax dollars. If you do not

complete and return a new election form each plan year, you will be treated as having elected to

continue your coverage option as in effect on the last day of the preceding plan year. If pre-tax

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dollars are to be used for either medical or dental insurance, then both types of insurance must be

paid for pre-tax.

(b) FLEXIBLE SPENDING ACCOUNT

You may elect to put a minimum of $120 and a maximum of up to $2,5500 (as indexed

for inflation) of your compensation per year into a Flexible Spending Account to pay your

unreimbursed medical expenses with pre-tax dollars. If you do not use the entire amount you

have elected to put into the account during the Plan Year for unreimbursed health care expenses

incurred during the Plan Year, you may carry over up to $500 of the unused balance to the next

Plan Year. Subject to the active military duty exception described below, you will lose any

unused balance above the $500 that may be carried over to the next Plan Year. It is therefore

important to estimate conservatively the amount of your prospective unreimbursed medical

expenses for the Plan Year before electing the amount to contribute since your election cannot be

changed except under certain narrow circumstances.

The eligible expenses are those permitted by Section 213 of the Internal Revenue Code

and include out-of-pocket medical, dental and vision expenses incurred by you, your spouse and

your dependents. There is no reimbursement for the cost (e.g. premiums) of other health care

coverage maintained outside of the Plan. Examples of eligible expenses are set forth below:

Deductibles and co-payments under the County's health plans (including

dental and vision plans) or the Teamsters Plan or under personal accident

and health insurance carried by you, your spouse, or covered dependents;

Prescription drugs;

Over-the-counter drugs and products such as antacids, allergy medicines,

pain relievers and cold medicines if you have a prescription, except that no

prescription is needed for over-the-counter insulin;

Eye care, including vision checkups, eyeglasses and contact lenses;

Hearing care, including hearing examinations and hearing aids;

Routine physical examinations;

Any other medical care item that constitutes medical care within the

meaning of Code Section 213(d).

The County has delegated responsibility for claims administration to a third party

administrator as set forth in the section entitled “General Plan Information” (hereinafter referred

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to as the “Claims Administrator”). In order to be reimbursed for an eligible health care expense,

you must submit to the Claim Administrator a completed claim form and itemized bill from the

service provider. You have ninety90 days following the end of the Plan Year to submit claims

for reimbursement with respect to eligible expenses incurred during the immediately preceding

Plan Year, except that terminated employees will have thirty days from the date of their

termination to submit claims.

If there is not enough money in your Flexible Spending Account at any time during the

year to cover the claim you have submitted, the Claims Administrator will pay your claim, up to

the total amount you have elected to contribute to this account for the Plan Year plus any

amounts up to $500 carried over from the previous Plan Year. For example, assume that you

have elected to establish a Flexible Spending Account of $600 for the Plan Year by contributing

$50 each month. Further, assume that during the first month when there is only $50 in your

account, you have qualified medical expenses of $300. The Plan must reimburse you the full

$300 and take the risk that you might terminate employment before you have contributed $300.

That said, if you are a reservist called to active duty for a period of at least 180 days or for an

indefinite period, the Plan may distribute to you all or a portion of the balance in your Flexible

Spending Account. The balance available for such a distribution will be the entire amount

elected for the Flexible Spending Account for the Plan Year plus any carryover from the

previous Plan Year, minus Flexible Spending Account reimbursements received as of the date of

the qualified reservist distribution request. In order to receive this money, you must request it on

or after the date of the order or call to active duty, and before the last day of the Plan Year during

which the order or call to active duty occurred. Before the Plan issues such a distribution, you

must provide the County with a copy of the order or call to active duty. Distributions will be

made no later than 60 days after the date of the request.

(c) DEPENDENT CARE REIMBURSEMENT ACCOUNT

You may elect to put a minimum of $120 and a maximum of $5,000 of your

compensation per year, if you are single, into the Dependent Care Reimbursement Account in

order to pay with pre-tax dollars for child care expenses and other dependent care costs to enable

you to work. If you are married, filing a joint federal income tax return with your spouse, you

and your spouse may together put up to $5,000 per year (but no more than the lower of your two

incomes except that if your spouse is a full-time student or is disabled she is considered to have a

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monthly income of $200 for one dependent or $400 for two dependents) into the Dependent Care

Reimbursement Account. If you are married, filing separately, your limit is $2,500. If you are

married and your spouse does not work (and she is not a full-time student or disabled), then you

may not participate. The limits above apply to the total amount of dependent care assistance you

may receive during the Plan Year. Therefore, if you receive any such benefits under a plan of

your spouse’s company, these amounts must be offset against the amount you may contribute to

this Plan. If you do not use the entire amount you have elected to put into the account for the

Plan Year for dependent care expenses incurred during either the Plan Year, you will lose the

unused balance.

The eligible expenses that may be reimbursed are those incurred for eligible dependents

in certain qualifying dependent care arrangements. Eligible dependents include your children up

to age 13 and your other dependents (for federal tax purposes) who are physically or mentally

unable to care for themselves and reside in your home at least eight hours per day. Qualifying

dependent care arrangements include a day care center, provided that if care is provided by the

facility for more than six individuals, it must comply with applicable state and local laws; an

educational institution for pre-school children (for older children, only expenses for non-school

care are eligible for reimbursement); and care provided inside or outside your home by an

individual who is not your child under age 19 or your dependent (for federal tax purposes).

In order to be reimbursed for an eligible dependent care expense, you must submit to the

Plan Administrator a completed claim form and evidence of the qualifying expense (including

the service provider’s federal company identification number or social security number). If there

is not enough money in your Dependent Care Reimbursement Account at any time during the

year to cover the claim you have submitted, the Claims Administrator will pay your claim up to

the balance in your account and will hold your claim until additional money is deposited into

your account. You have ninety days following the end of the Plan Year to submit claims for

reimbursement with respect to eligible expenses incurred during the immediately preceding Plan

Year, except that terminated employees will have thirty days from the date of their termination to

submit claims.

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WHAT HAPPENS IF I DON’T USE UP ALL OF THE ELECTED BENEFITS PRIOR TO

THE END OF THE PLAN YEAR?

As indicated above, except with respect to up to $500 that may be carried over to a

subsequent Plan Year under the Flexible Spending Account, you must use the entire amount that

you have put into the account during a particular Plan Year for health care and dependent care

expenses incurred during that Plan Year; otherwise, you will lose the unused balance. Following

the end of the Plan Year, you have three months in which to submit claims for reimbursement for

expenses incurred during the Plan Year. This is called the “Run-Out Period.”

For example, assume that $600 remains in your Flexible Spending Account at the end of

the 2015 Plan Year and that you have elected $2,400 of Flexible Spending Account coverage for

2016. Because the carryover is limited to $500, you will lose $100 from your account at the end

of the 2015 Plan Year, and the remaining $500 will carry over for use during the 2016 Plan Year.

This means that you will have a total of $2,900 (i.e., $2,400 election + $500 carryover) available

in your Flexible Spending Account for 2016.

WHAT HAPPENS IF I RECEIVE REIMBURSEMENTS TO WHICH I AM NOT

ENTITLED UNDER THE PLAN?

If any over-payments are made to you under the Plan, you will be responsible for

reimbursing the Plan for such amounts. Reimbursement may be made by any reasonable means

available, including, but not limited to, offset against future benefits at the Plan’s discretion,

direct payment by you to the County or withholding from your future paychecks at the County’s

discretion. By participating in the Plan, you specifically authorize such withholding if needed to

correct overpayments.

Moreover, if you deliberately defraud or mislead the Plan Administrator about the

eligibility or entitlement to benefits of yourself or another person, the Plan Administrator has the

right to terminate Plan coverage for you and/or any family members immediately and

retroactively. The Plan shall be entitled to recover (as described above) from the you and/or

your family members any claims mistakenly paid due to mistake, fraud or a wrongful attempt to

procure coverage, and to recover any costs and expenses arising from such fraud or

misrepresentation, including, but not limited to, costs and expenses recoverable in actions at law

and in equity. Additionally, fraud on your part shall be grounds for disciplinary action up to and

including termination of employment.

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WHAT HAPPENS IF I TERMINATE EMPLOYMENT?

If you terminate employment, your pre-tax contributions to the Pre-Tax Premium

Account and the Dependent Care Reimbursement Account will cease. You may be entitled to

continue your Flexible Spending Account pursuant to the COBRA coverage continuation rules as

described in the next section. If you terminate employment and are rehired during the same Plan

Year, your election in the Plan automatically will be reinstated for the remainder of the Plan

Year. If you incur dependent care expenses after you terminate employment or otherwise cease

participation in the Plan, you may be reimbursed from the unused balance of your Dependent

Care Reimbursement Account for expenses incurred during the Plan Year. However, you may

not be reimbursed for amounts beyond your unused account balance, and you may not contribute

additional amounts to the account.

If you terminate employment and are rehired during the same Plan Year, your election in

the Plan automatically will be reinstated for the remainder of the Plan Year. However, if you are

rehired more than 30 days after your termination, you will be eligible to make new elections for

the remainder of the Plan Year.

AM I ENTITLED TO CONTINUE COVERAGE UNDER THE PLAN?

Continuation of coverage under the County’s group medical and dental plans or the

Teamsters Plan will be governed by the terms of those plans in compliance with the federal

COBRA law. COBRA does not apply to Dependent Care Account benefits.

Dependent care expenses incurred after you cease participation in the Plan (for example,

after termination) and on or prior to the last day of that Plan Year may be reimbursed from

unused benefits remaining in your Dependent Care Account. However, you may not be

reimbursed for amounts beyond your unused account balance, and you may not contribute

additional amounts to the account.

Under certain circumstances (described as “qualifying events”) that otherwise would

cause you to lose coverage under the Plan (such as a termination or reduction in hours of

employment), you may be entitled under federal law (known as “COBRA”) to continue

participation in your Flexible Spending Account for the remainder of the Plan Year if you have a

positive account balance. This section generally explains COBRA continuation coverage, when

it may become available to you and your family, and what you need to do to protect the right to

receive it. COBRA (and the description of COBRA continuation coverage contained here)

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applies only to the group health benefits offered under the Flexible Spending Account and not to

the Dependent Care Reimbursement Account.

For additional information about your rights and obligations under the Plan and under

federal law, you should contact the Department of Human Resource Management. The Plan

provides no greater COBRA rights than what COBRA itself requires, and nothing in this section

is intended to expand your rights beyond COBRA’s requirements.

(a) What Is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when coverage would

otherwise end because of a life event known as a “qualifying event.” Specific qualifying events

are listed later in this section. After a qualifying event occurs and any required notice of that

event properly is provided to the Plan Administrator, COBRA continuation coverage must be

offered to each person losing coverage who is a “qualified beneficiary.” You and your

dependents could become qualified beneficiaries and be entitled to elect COBRA if coverage

under the Plan is lost because of the qualifying event.

COBRA continuation coverage is the same coverage that the Plan gives to other similarly

situated persons under the Plan who are not receiving continuation coverage. Each qualified

beneficiary who elects COBRA continuation coverage will have the same rights under the Plan

as other persons covered under the Plan.

(b) Who Is Entitled to Elect COBRA?

If you are an employee, you will be entitled to elect COBRA if you lose your group

health coverage under the Plan because either one of the following qualifying events happens:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will be entitled to elect COBRA if you lose

your group health coverage under the Plan because any of the following qualifying events

happens:

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross

misconduct;

Your spouse dies; or

You become divorced or legally separated from your spouse.

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Your children who are dependents will be entitled to elect COBRA if they lose group

health coverage under the Plan because any of the following qualifying events happens:

The parent-employee’s hours of employment are reduced;

The parent-employee’s employment ends for any reason other than his or her

gross misconduct;

The parent-employee dies;

The parents become divorced or legally separated; or

The child stops being eligible for coverage under the Plan as a “dependent” as

defined by the Plan.

However, COBRA coverage is provided subject to your eligibility for such coverage. In

particular, you must have been both eligible for coverage and actually covered by the Plan on the

day prior to the date of the qualifying event. The Plan Administrator reserves the right to

terminate your COBRA coverage retroactively if you are determined to have been ineligible.

(c) When is COBRA Coverage Available?

COBRA continuation coverage is available under the Flexible Spending Account only if

there is a positive account balance at the time of the qualifying event that otherwise would cause

a loss of coverage. The Plan will offer COBRA continuation coverage to qualified beneficiaries

only after the Plan Administrator has been notified that a qualifying event has occurred. When

the qualifying event is the end of employment or reduction of hours of employment, or the death

of the employee, the employer must notify the Plan Administrator of the qualifying event.

(d) You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce or legal separation of the employee and spouse or

a dependent child’s losing eligibility for coverage as a dependent child), you will not be entitled

to COBRA unless you notify the Plan Administrator in writing within 60 days after the later of

(i) the date of the qualifying event, and (ii) the date on which the qualified beneficiary would

lose coverage under the terms of the Plan as result of the qualifying event. You must provide

this notice to the Plan Administrator.

The notice must be mailed or hand-delivered. Oral notice, including notice by telephone,

is not acceptable. If mailed, the notice must be postmarked no later than the deadline. If hand-

delivered, the notice must be received no later than the deadline. Electronic notice, including

notice that is sent via e-mail or facsimile, is not acceptable. The notice may be provided by the

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covered employee (i.e., the employee or former employee who is or was covered under the Plan),

another qualified beneficiary who lost coverage to the covered employee’s termination or

reduction in hours and is still receiving COBRA coverage, or a representative acting on behalf of

either one.

The notice must contain the Plan name, the employee’s name, address, birth date, and

social security (or other identification) number, the name and address of any impacted spouse or

dependent, a description of the qualifying event, the date of the event, and adequate

documentation of the event (such as a divorce decree or decree of legal separation, or a copy of

the dependent’s birth certificate, as applicable). A form for providing this notice may be

available from the Plan Administrator, but need not be used so long as all the relevant

information is included in the written notice.

If you provide a written notice that does not contain all of the information and

documentation required, such a notice will nevertheless be considered timely if all of the

following conditions are met:

the notice is mailed or hand-delivered to the individual and address specified;

the notice is provided by the deadline;

from the written notice provided, the Plan Administrator is able to determine that

the notice relates to the Plan;

from the written notice provided, the Plan Administrator is able to identify the

covered employee and qualified beneficiary(ies), the qualifying event (the

divorce, legal separation, or child’s loss of dependent status), and the date on

which the qualifying event occurred; and

the notice is supplemented in writing with the additional information and

documentation necessary to meet the Plan’s requirements within 15 business days

after a written or oral request from the Plan Administrator for more information

(or, if later, by the deadline for this notice).

If any of these conditions is not met, the incomplete notice will be rejected and COBRA

will not be offered. If all of these conditions are met, the Plan Administrator will treat the notice

as having been provided on the date that the Plan Administrator receives all of the required

information and documentation but will accept the notice as timely.

(e) Electing COBRA Continuation Coverage

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Once the Plan Administrator receives notice that a qualifying event has occurred,

COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each

qualified beneficiary will have an independent right to elect COBRA continuation coverage.

Covered employees (and Spouses if the Spouse is a qualified beneficiary) may elect COBRA

continuation coverage on behalf of all of the qualified beneficiaries, and parents may elect

COBRA continuation coverage on behalf of their children.

Any qualified beneficiary for whom COBRA is not elected within the 60-day election

period described in the Plan’s COBRA Election Notice will lose his or her right to elect COBRA

continuation coverage.

Your election must be provided to the Plan Administrator via hand-delivery, U.S. Mail,

or some form of express mail delivery.

(f) Special Second Election Period under the Trade Act

Under the Trade Act of 2002, special COBRA rights apply to certain employees and

former employees who are eligible for federal trade adjustment assistance (TAA) or alternative

trade adjustment assistance (ATAA). The process for determining individual eligibility for trade

adjustment assistance begins when employees (or their representatives) petition the Department

of Labor to recognize their employer as being adversely affected by trade.

Eligible individuals are entitled to a second opportunity to elect COBRA for themselves

and certain family members (if they did not already elect COBRA) during a special second

election period. This special second election period lasts for 60 days or less. It is the 60-day

period beginning on the first day of the month in which an eligible employee or former employee

becomes eligible for TAA or ATAA, but only if the election is made within the six months

immediately after the individual’s group health plan coverage ended. If you are an employee or

former employee and you qualify or may qualify for TAA or ATAA, please contact the Plan

Administrator. Contact the Plan Administrator promptly after qualifying for TAA or ATAA or

you will lose the right to elect COBRA during a special second election period.

(g)(f) How Much Does COBRA Continuation Coverage Cost?

Generally, each qualified beneficiary is required to pay the entire cost of COBRA

continuation coverage, plus a two percent administrative fee. All COBRA premiums must be

paid by personal check or money order (unless arrangements are made to deduct premiums from

remaining paychecks).

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(h)(g) When must payment for COBRA continuation coverage be made?

First payment for COBRA continuation coverage

If you elect COBRA continuation coverage, you do not have to send any payment with

your election. However, you must make your first payment for continuation coverage not later

than 45 days after the date of your election. (This is the date your election is post-marked, if

mailed, or the date your election is received by the Plan Administrator, if hand-delivered.) If you

do not make your first payment for COBRA continuation coverage in full within 45 days of the

date of your election, you will lose all continuation coverage rights under the Plan.

Your first premium payment must include payment for the period from the date that you

lost (or otherwise would have lost) coverage until the date of your election, and each regularly

scheduled monthly premium that became due during the period between your election and the

first payment. You are responsible for making sure that the amount of your first payment is

correct. You may contact the Plan Administrator to confirm the correct amount of your first

payment.

Claims for reimbursement may not be processed and paid until you have elected COBRA

and made the first payment.

Monthly payments for COBRA continuation coverage

After you make your first payment for COBRA continuation coverage, you will be

required to make monthly payments for each subsequent month of coverage. Under the Plan,

each of these monthly payments for continuation coverage is due on the first of the month for

that month’s COBRA continuation coverage. If you make a monthly payment on or before the

first day of the month to which it applies, your coverage under the Plan will continue for that

coverage period without any break. If you do not make a monthly payment on or before the first

day of the month, your coverage may be suspended pending payment. The Plan is not required

to send monthly notices of payments due for these coverage periods. It is your responsibility to

pay your COBRA premiums on time, regardless of whether you receive a monthly bill.

Grace periods for monthly payments

Although monthly payments are due on the first day of each month of COBRA

continuation coverage, you will be given a grace period of 30 days to make each monthly

payment. Your COBRA continuation coverage will be provided for each month as long as

payment for that month is made before the end of the grace period for that payment. If you fail

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to make a monthly payment before the end of the grace period for that coverage period, you will

lose all rights to COBRA continuation coverage under the Plan.

(i)(h) How Long Does COBRA Continuation Coverage Last?

COBRA continuation coverage with respect to your Flexible Spending Account is a

temporary continuation of coverage that generally lasts until the end of the Plan Year in which

the qualifying event occurs.

(j)(i) If You Have Questions

Questions concerning your Plan or your COBRA continuation coverage rights should be

addressed to the Department of Human Resource Management.

For more information about your rights under COBRA, the Health Insurance Portability

and Accountability Act (“HIPAA”), and other laws affecting group health plans, contact the

nearest Regional or District Office of the U.S. Department of Labor’s employee Benefits

Security Administration (“EBSA”) in your area or visit the EBSA website at www.dol.gov/ebsa.

(Addresses and phone numbers of Regional and District EBSA Offices are available through

EBSA’s website.)

For more information regarding your COBRA continuation coverage rights, please

consult the General Notice of COBRA Continuation Coverage Rights that is provided to you at

the time that you become eligible to enroll in this Plan. You also will receive a full explanation

of your COBRA rights when you become entitled to continuation coverage.

WHAT HAPPENS IF THIS PLAN IS DISCONTINUED OR AMENDED?

While this Plan is intended to be a permanent and continuing program, the County

reserves the right to terminate the Plan at any time. On termination of the Plan, any amounts that

become payable under the terms of the Plan prior to the date of termination shall be paid in

accordance with the terms of the Plan as in effect prior to the date of such termination.

The County also reserves the right to amend or modify the Plan at any time. Any amount

that had become payable under the Plan prior to the effective date of any such amendment shall

be paid or payable in accordance with the terms of the Plan as in effect immediately prior to the

date of the amendment.

ADMINISTRATION

The Plan Administrator has discretionary authority to determine eligibility for benefits, to

decide claims, to interpret and construe plan provisions and to determine all other matters under

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the Plan. Benefits under this Plan will be paid only if the Plan Administrator decides in its

discretion that the applicant is entitled to them. Any interpretation of the provisions of the Plan

by the Plan Administrator and any decision made by it on any matter within its discretion shall

be binding on all persons. A misstatement or other mistake of fact shall be corrected when it

becomes known and the Plan Administrator shall make such adjustment or account thereof as it

considers equitable and practicable. The Plan Administrator shall not be liable in any manner for

any determination of fact made in good faith.

PROCEDURES FOR MAKING A CLAIM AND AN APPEAL FOR BENEFITS

Any claim for benefits under the underlying group welfare plans of the County (such as

group medical or dental insurance benefits) or the Teamsters Plan shall be reviewed in

accordance with the claims procedures contained in the applicable insurance policies and plan

documents. You should refer to the plan description of the group welfare plan (if any) for a

description of the claims procedures. Otherwise, please follow the claims procedures outlined

below for claims with respect to benefits under this Plan.

You must follow the procedures below for filing a claim and requesting review of a

denied claim before bringing any legal action. If you fail to raise an issue during the initial claim

or as part of your request for review, you will be precluded from raising such issue in any further

proceedings. If a claim is denied upon appeal, any legal action with respect to that claim must be

brought within one year of the date of the decision upon appeal.

Claims for Benefits with respect to your Pre-Tax Premium Account

Any claim for benefits under the Plan with respect to benefits from your Pre-Tax

Premium Account should be made in writing by you or your authorized representative by filing it

with the Claims Administrator along with such evidence as reasonably may be required to

support your claim. If your claim is denied in whole or in part, you will be informed in writing.

Claims for Benefits with respect to your Dependent Care Account

Any claim for benefits under the Plan with respect to your Dependent Care Account

should be made in writing by you or your authorized representative by filing it with the Claims

Administrator along with such evidence as reasonably may be required. Claims must be filed no

later than the end of the Run-out Period (in other words, within three (3) months following the

end of the Plan Year with respect to eligible expenses incurred during the immediately preceding

Plan Year). Any amounts remaining in your account will be forfeited.

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In order to be reimbursed for an eligible dependent care expense, you must submit to the

Plan Administrator a completed claim form and evidence of the qualifying expense (including

the service provider’s federal company identification number or social security number and the

date, description and cost of the service). Dependent care expenses may not be reimbursed before

the care is provided. If there is not enough money in your Dependent Care Reimbursement

Account at any time during the year to cover the claim you have submitted, the Plan

Administrator will pay your claim up to the balance in your account and will hold your claim

until additional money is deposited into your account.

If your claim is denied in whole or in part, you will be informed in writing within a

reasonable timeframe and given the following information:

1. The specific reason or reasons why the claim is denied;

2. Reference to the specific Plan provisions on which the denial is based;

3. A description of any additional material or information necessary to enable you to

perfect your claim and an explanation of why such material or information is

necessary;

4. An explanation of the Plan’s review procedure, including a statement that any

appeal of the denial must be made in writing to the Claims Administrator within

60 days after receipt of the notice of denial and must include a full description of

the pertinent issues and the basis of the appeal; and

5. A statement describing any other rights you might have after you have exhausted

these administrative claims procedures.

The procedure for obtaining a review of a denied claim is as follows:

1. Your request for a review of the decision denying your claim or part of it must be

made in writing by you or your authorized representative not later than 60 days

after you receive notice of the denial.

2. Your request should be sent to the Claims Administrator.

3. Your request for review may include any issues, comments, documents, records,

or additional information or material relating to the claim, and the Claims

Administrator’s review will take into account all such information provided that it

is submitted in writing.

Packet Pg. 96

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4. On review, you will be afforded reasonable access to all documents relevant to

your claim.

5. The Claims Administrator may hold a hearing or otherwise ascertain such facts as

it deems necessary.

6. The Claims Administrator will give you a decision in writing within a reasonable

timeframe after receiving your request for review. You will be given the reasons

for the Claims Administrator’s decision and will be referred to the Plan provisions

on which the decision is based.

Claim for Benefits with respect to your Flexible Spending Account

Any claim for benefits under the Plan with respect to benefits from your Flexible

Spending Account should be made by you or your authorized representative in writing by filing

it with the Claims Administrator along with such evidence as reasonably may be required by the

end of the Run-out Period (in other words, within three (3) months following the end of the Plan

Year).

In order to be reimbursed for an eligible health care expense, you must submit to the Plan

Administrator a completed claim form and itemized bill from the service provider. You must

provide adequate substantiationdocumentation (i.e., an Explanation of Benefits statement, paid

receipt, or as otherwise determined by the Plan) of the expenses you incur in order to be

reimbursed. Further instructions will be provided on the claim form. Only expenses incurred on

or after you are enrolled in the Plan will be reimbursed.

Alternatively, you may pay for eligible health care expenses with your Plan debit card

provided that you comply with applicable substantiation procedures. Some expenses may be

validated automatically at the time the expense is incurred (like co-pays for medical care). For

other expenses, the card payment is only conditional and you will still have to submit supporting

documents. You will receive more information from the Claims Administrator about what you

must do to obtain reimbursement.

To the extent that the Claims Administrator, in its discretion, determines that you have

failed to properly substantiate your claim for reimbursement or there has otherwise been an

overpayment, the Claims Administrator shall, to the extent that it deems administratively

possible and otherwise permissible under applicable law, seek repayment of any such excess

reimbursement by (1) requesting you directly reimburse the Plan, (2) withholding the

Packet Pg. 97

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corresponding amount from your compensation on an after-tax basis (where such withholding is

permissible under applicable law), or (3) offsetting the improper reimbursement against other

eligible Flexible Spending Account claims.

You have until the end of the Run-out Period to submit claims for reimbursement with

respect to eligible expenses incurred during the immediately preceding Plan Year. If there is not

enough money in your Flexible Spending Account at any time during the year to cover the claim

you have submitted, the Claims Plan Administrator will pay your claim, up to the total amount

you have elected to contribute to this account for the Plan Year plus any carryover amounts. For

example, assume that you have elected to establish a Flexible Spending Account of $600 for the

Plan Year by contributing $50 each month. Further, assume that during the first month when

there is only $50 in your account, you have qualified medical expenses of $300. The Plan must

reimburse you the full $300 and take the risk that you might terminate employment before you

have contributed $300.

If your claim is denied in whole or in part, you will be informed in writing within a

reasonable timeframe and given the following information:

(a) The specific reason or reasons why the claim is denied;

(b) Reference to the specific Plan provisions on which the denial is based;

(c) A description of any additional material or information necessary to enable you to

perfect your claim and an explanation of why such material or information is

necessary; and

(d) An explanation of the Plan’s review procedure, including a statement that any

appeal of the denial must be made in writing to the Kane County Human Services

Committee within 60 days after receipt of the notice of denial and must include a

full description of the pertinent issues and the basis of the appeal.

The procedure for obtaining a review of a denied claim is as follows:

(a) Your request for a review of the decision denying your claim or part of it must be

made in writing by you or your authorized representative not later 60180 days

after you receive notice of the denial.

(b) Your request should be sent to the Kane County Human Services Committee (the

“Committee”).

Packet Pg. 98

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(c) Your request for review may include any issues, comments, documents, records,

or additional information or material relating to the claim, and the review will

take into account all such information provided that it is submitted in writing.

(d) On review, you will be afforded reasonable access to all documents relevant to

your claim.

(e) The Committeelaims Administrator may hold a hearing or otherwise ascertain

such facts as it deems necessary.

(f) The Committeelaims Administrator will give you a decision in writing within a

reasonable timeframe after receiving your request for review. You will be given

the reasons for the Committeelaims Administrator’s decision and will be referred

to the Plan provisions on which the decision is based. [LMDBLT2]

FULL DETAILS IN LEGAL PLAN DOCUMENTS

THE COUNTY RESERVES THE RIGHT TO CONSTRUE AND INTERPRET THE

TERMS OF THE PLAN.

THIS SUMMARY ATTEMPTS TO DESCRIBE THE PLAN IN EASY TO

UNDERSTAND LANGUAGE AND TO DO SO AS ACCURATELY AS POSSIBLE.

HOWEVER, THE COMPLETE PROVISIONS OF THE PLAN ARE CONTAINED IN THE

LEGAL PLAN DOCUMENTS. IF FOR ANY REASON THERE IS AN OMISSION OR

MISSTATEMENT IN THIS SUMMARY, OR ANY DIFFERENCE BETWEEN THIS

SUMMARY AND THE LEGAL PLAN DOCUMENTS, THE LEGAL PLAN DOCUMENTS

WILL IN ALL RESPECTS CONTROL AND GOVERN. THESE LEGAL PLAN

DOCUMENTS ARE AVAILABLE FOR YOUR EXAMINATION DURING NORMAL

BUSINESS HOURS AT THE ADDRESS LISTED ON THE LAST PAGE OF THIS

SUMMARY.

Packet Pg. 99

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GENERAL PLAN INFORMATION

The following describes information, which is of prime importance to you as a Plan

Participant.

Plan Name: County of Kane Flexible Benefits Plan

Type of Plan: Section 125 Cafeteria Plan

Plan Sponsor: County of Kane

Plan Administrator: County of Kane, Department of Human Resource Management

Business Address: Kane County Government Center

719 Batavia

Geneva, IL 60134

Business Telephone No.: (630) 232-3560

Federal Employer

Identification No.:

36-6006585

Plan Number: 502

Effective Date of Plan: January 1, 2006

Plan Year: January 1 to December 31

Agent for Service of

Legal Process:

County Board Chairman

Kane County Government Center

719 Batavia

Geneva, IL 60134

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Claims Administrator: Flexible Benefit Service Corporation

10275 West Higgins Road

Suite 500

Rosemont, Illinois 60018

866-472-5351

www.myflexlogin.com

PayFlex Systems USA, Inc.

1802 Farnam Drive, Suite 100

Omaha, Nebraska 68154

(402) 884-7030

Packet Pg. 101

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