proposal for larimer county · larimer county proposal number: p18-06 fsa/hsa/cobra tpa flexible...

Larimer County Proposal Number: P18-06 FSA/HSA/COBRA TPA Flexible Spending Accounts (Health and Dependent Care), Health Savings Account Plan, and COBRA Plan Administration Services

Proposal for

Shawn Smith Relationship Manager

262-236-3056 [email protected]

WageWorks, Inc. 1100 Park Place, 4th Floor

San Mateo, CA 94403

Larimer County Purchasing Director 200 W. Oak Street, Suite 4000 PO Box 1190 Fort Collins, Colorado 80522

Contact: Les Brown Purchasing Agent 970-498-5954 [email protected]

April 11, 2018 by 2P.M. (MDT)

WageWorks, Inc.

Signature Page

WageWorks, Inc.

Table of Contents

Signature Page ........................................................................................................................ 1

Table of Contents .................................................................................................................... 3

Limitations of Liability ............................................................................................................. 4

Executive Summary................................................................................................................. 5

Qualifications ........................................................................................................................... 6

Attachment A – FSA HSA COBRA RFP Questionnaire ........................................................ 7

References ............................................................................................................................. 15

Exhibits List ........................................................................................................................... 16 COBRA Client Admin Guide ............................................................................................................................ 17 Exceptions/Deviations ..................................................................................................................................... 63 FSA HSA Reports Summary ........................................................................................................................... 64 HSA Fees and Interest Schedule .................................................................................................................... 67

Sample WageWorks’ Agreements ................................................................................................................... 68 WageWorks Evidence of Insurance.................................................................................................................102

WageWorks, Inc.

Limitations of Liability Limitations of Liability: Larimer County does not accept any Limitation of Liability provisions within the final agreement. In this section, you must specifically address your firm’s position on this topic, including acceptance of this.

Notwithstanding anything contained in the RFP including, but not limited to, (i) Scope of Work, (ii) Insurance Requirements, (iii) Limitation of Liability Provisions, and (iv) Sample Professional Services Agreement (“County Documents”), this proposal is submitted with the understanding that the services offered and any contract entered into between the parties will be based upon the following documents, all of which are attached to this Proposal. WageWorks, however, welcomes the opportunity to negotiate the specific terms and conditions, and include certain provisions contained in the County Documents as may be relevant and mutually acceptable to both parties.

Standard Contract Documents:

o V5 WageWorks Terms and Conditions of Service and BAAo Funding Agreement Sample – ACH Credito Funding Agreement Sample – ACH Debito Order Form Sampleo Non Discrimination Services Descriptiono Form 5500 Service Descriptiono FSA Services Descriptiono HSA Service Descriptiono COBRA Service Descriptiono Debit Card Service Description

WageWorks’ Certificate of Insurance Liability

WageWorks, Inc.

Executive Summary WageWorks is pleased to present its Flexible Spending Accounts (FSA), Health Savings Accounts (HSA) and COBRA administration in response to Larimer County’s (the County) Request for Proposal. WageWorks is the incumbent of the FSA and COBRA administration. We look forward to the continuation and expansion of a partnership.

We are also confirming that we meet the County’s minimum qualifications below:

1. The TPA must provide no-commission services.

2. The TPA must provide banking in Colorado.

Please note that WageWorks has no requirements on where the County’s maintains its banking arrangements for the funding of claims.

WageWorks is the leading on-demand provider of consumer-directed benefit programs. We administer and operate a broad array of benefit plans, including spending account management programs, such as health and dependent care Flexible Spending Accounts, Health Reimbursement Arrangements, Health Savings Accounts, Commuter Transit and Parking Benefits, COBRA and Direct Bill Administrative Services.

Our stock is publicly-traded on the NYSE: (WAGE), and our corporate headquarters are located at 1100 Park Place, 4th Floor, in San Mateo, California 94403. We provide call center, claims, administrative and information technology services at servicing centers located in San Mateo, California; Tempe, Arizona; Mequon, Wisconsin; Williston Center, Vermont; Louisville, Kentucky; Alpharetta, Georgia, and Irving, Texas.

WageWorks provides benefits administration services to 100,000 employers, including hundreds of small, medium, and large public sector entities comprised of federal agencies, states, municipalities, counties, public universities and colleges, and public school systems across the nation. We support the consumer-directed benefit needs for many of the nation’s largest and most innovative companies including: 71% of the nation’s Fortune 100 companies and 67% of Fortune 500 companies.

Our employees deliver our Consumer-Directed Benefit programs to more than 6.5 million participants through a highly scalable Benefits-as-a-Service delivery model. Employer clients and their participating employees may access these programs through a standard web browser on any internet enabled device, including computers, smart phones, and other devices.

As an advantage to our continued partnership, no implementation activities will be required for the FSA and COBRA administration. Additionally, your contacts for FSA and COBRA administration will remain the same. The FSA relationship manager, Shawn Smith, will expand his current role to include the administration of the Health Savings Account program.

Pricing for all programs has been provided in the Questionnaire document, tabs FSA Pricing Grid, COBRA Pricing Grid, and HSA Pricing Grid.

Exceptions and deviations to terms and conditions and insurance provisions have been provided as a separate attachment.

Our proposal presents the WageWorks solution in detail. This information will demonstrate how WageWorks’ leadership in the marketplace and commitment to customer service combine to offer Larimer County compelling advantages over other options. We truly appreciate your consideration and look forward to exceeding your service level expectations.

WageWorks, Inc.

Qualifications Explicitly describe/explain how your firm meets each item under QUALIFICATIONS.

WageWorks confirms that we meet the County’s minimum qualifications below:

1. The TPA must provide no-commission services.

WageWorks will provide no-commission services.

2. The TPA must provide banking in Colorado.

Please note that WageWorks has no requirements on where the County’s maintains its bankingarrangements for the funding of claims.

WageWorks, Inc.

Attachment A – FSA HSA COBRA RFP Questionnaire Submit “Attachment A - FSA HSA COBRA RFP Questionnaire“, document must be COMPLETED IN FULL and in both print and Excel format. Completion of the following:

A. Attachment A - FSA HSA COBRA RFP Questionnaire.

Tabs within to be completed include:

I. FSA Pricing Grid

II. COBRA Pricing Grid

III. HSA Pricing Grid

IV. FSA_HSA_COBRA Questionnaire

WageWorks has provided our responses in Attachment A.

Attachment A is provided in the follow pages.

WageWorks (The County was with ADP before WageWorks acquired them)See census, must be requested from the County

FSA Proposal Pricing Grid WageWorks, Inc.

WageWorks is the incumbent

$0, included in monthly compliance fee

Healthcare FSA only PPPM (per participant per month) fee

$3.95 PPPM

Dependent care only PPPM fee $3.95 PPPM

If applicable, PPPM for an employee with both the healthcare FSA and dependent care FSA

$3.95 PPPM, if they have multiple benefits it is just $3.95 PPPM for that ppt.

Limited purpose (dental & vision) FSA only PPPM fee (The County does not currently offer but may if they offer an HSA-eligible HDHP in 2019)

$3.95 PPPM

If applicable, monthly debit card fee N/A

No

$50 monthly compliance fee

No

No

N/A

Rate Guarantee (years)

Plan Document Included

Summary Plan Description Included

Amendments Included

Enrollment materials (summaries, flyers, etc.) Included

Enrollment meeting attendance $500 per half day plus travel & expenses

Direct deposit capability Yes, included with rate

Automatic & daily claim adjudication Claims paid daily

Annual discrimination testing Included

Replacement debit cards Included

Online access for members Included

Toll-free call center (& indicate hours) Included

Other Included

Initial fees

Services (confirm if included or an additional cost and what that cost is)

Flexible Spending Accounts

Initial set-up fees (one-time)

Describe any other costs that would or could be charged to The County

Initial plan document fee

Is there a monthly minimum for total PPPM fees?

Any other monthly fees?

Is there a monthly base fee in addition to the PPPM?

Any annual fees upon renewal?

Proposers - Enter your pricing and response in the tan cells, indicate N/A if not applicableVERY IMPORTANT: YOU MUST COMPLETE OUR PRICING GRIDS COMPLETELY. YOUR PROPOSAL MAY NOT BE REVIEWED IF THE PRICING GRID IS NOT COMPLETED IN ITS ENTIRETY FOR THE PRODUCTS YOU ARE QUOTING. THE PLAN SPONSOR WILL NOT BE LIABLE FOR ANY CHARGES NOT SPECIFICALLY DETAILED IN YOUR PROPOSAL.

FSA Administration Current ProgramCurrent FSA Administrator:Current Participation:

Ongoing fees

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PEPM - COBRA Proposal Pricing Grid WageWorks, Inc. Per Event - COBRA Proposal Pricing Grid WageWorks, Inc.

Implementation fee N/A Implementation fee N/AParticipant takeover fee per primary qualified beneficiary (QB) N/A Participant takeover fee per primary qualified beneficiary (QB) N/A

Annual/renewal fee 500 Annual/renewal fee 500

Monthly base fee See monthly min. Monthly base fee 250 (monthly min.)

Monthly PEPM fee (# eligible)$.45 Per benefit eligible (predicated on

minimum 1,000 BE's) Initial general notice (new hires) fee 4.5

Monthly minimum 250 Qualifying event election notice to QBs fee 20Client requested/approved change

requests Monthly service fee per QB electing COBRA Included in the per QE notice fee

1Client requested/approved change

requests

1Initial general notice (blanket for all existing employees) 4.5

Initial general notice (new hires) 4.5 Initial general notice (blanket for all existing employees) 4.5

Qualifying event election notice to QBs Included Participant online services Available, no additional charge

Participant online services Available, no additional charge Participant toll-free call center (indicate hours) Provided, 8am-8pm Mon-Fri

Participant toll-free call center (& indicate hours) Provided, 8am-8pm Mon-Fri Real-time & monthly reportingReal-time as per data received, no

additional charge

Real-time & monthly reportingReal-time as per data received, no

additional charge Notice of unavailability of COBRAAvailable for clients to download/send from COBRA Site, no additional charge

Notice of unavailability of COBRAAvailable for clients to download/send from COBRA Site, no additional charge Monthly statements (not bills) to QBs N/A

Monthly statements (not bills) to QBs N/A Notice of COBRA premiums short by insignificant amount N/A

Notice of COBRA premiums short by insignificant amount N/A Notice of late premium payment notice to QBs N/A

Notice of late premium payment notice to QBs N/A Notice of early termination to QBs N/ANotice of early termination to QBs N/A Carrier notifications and method (electronic file feed, paper, etc.) Both Available, no additional chargeCarrier notifications and method (electronic file feed, paper?) Both Available, No additional charge Per insured carrier premium remittance Available, no additional charge

Per insured carrier premium remittance Available, no additional charge Annual enrollment services and fees Covered in the Annual/Renewal fee

Annual enrollment services and fees $27.00 per O/E packet Other Postage is a pass-throughOther Postage is a pass-through Does your firm retain the 2% administration charge Yes

Does your firm retain the 2% administration charge Yes

COBRA Administration

Proposers - Enter your pricing and response in the tan cells, indicate N/A if not applicable. We are requesting both PEPM and Per Event Pricing.VERY IMPORTANT: YOU MUST COMPLETE OUR PRICING GRIDS COMPLETELY. YOUR PROPOSAL MAY NOT BE REVIEWED IF THE PRICING GRID IS NOT COMPLETED IN ITS ENTIRETY FOR THE PRODUCTS YOU ARE QUOTING. THE PLAN SPONSOR WILL NOT BE LIABLE FOR ANY CHARGES NOT SPECIFICALLY DETAILED IN YOUR PROPOSAL.

COBRA Administration Current Program

Estimated Number of New Hires per Year:

Number of Current Benefit Eligible Employees:

Number of Employees Currently Under the Medical Plan:

Number of Current COBRA Participants:

COBRA Eligible Benefit Plans and Carrier/TPA:

Estimated Number of Qualifying Events per Year:

265

WageWorks (was ADP before the acquisition)

~1,800See Medical census, must be requested from the County

See Medical census, must be requested from the County

259

Medical (self-funded UMR), Dental (self-funded Delta Dental), Vision (insured VSP) and Flexible Spending Account (WageWorks)

Current COBRA Administrator:



Ongoing Fees Ongoing Fees

Initial FeesInitial Fees





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WageWorks, Inc.

www.takecarewageworks.com

www.takecarewageworks.com

Waived

N/A

$0.00

N/A

N/A

$3.95 PPPM billed to Larimer County

Debit card Included

Checkbook N/A

Online account access Included

Toll free HSA dedicated customer support IncludedToll free HSA dedicated employer and broker support IncludedPaper account statements (monthly or quarterly?) $0.75 quarterly, waived if signed up for E-StatementElectronic account statements (monthly or quarterly?) IncludedIRS tax forms Included

Included

N/A

$4 Duplicate paper statement request, $25 returned deposited check, $30 NSF, $4 manual withdraw, $25 wire transfer, $25 account closing

YesYes, tiered based on balance (please refer to the attached HSA Fees

and Interest Schedule)No minimum balance to invest

TD Ameritrade or DEVENIR self directed

Yes, dependent on trades and investment option

*Investments are not FDIC insured and are not bank guaranteed.

Health Savings Accounts

Proposers - Enter your pricing and response in the tan cells, indicate N/A if not applicableVERY IMPORTANT: YOU MUST COMPLETE OUR PRICING GRIDS COMPLETELY. YOUR PROPOSAL MAY NOT BE REVIEWED IF THE PRICING GRID IS NOT COMPLETED IN ITS ENTIRETY FOR THE PRODUCTS YOU ARE QUOTING. THE PLAN SPONSOR WILL NOT BE LIABLE FOR ANY CHARGES NOT SPECIFICALLY DETAILED IN YOUR PROPOSAL.Bank Name:

Website for account enrollment

Employer implementation/set-up fees

Accountholder application/set-up fees

Website

Ongoing Fees

Implementation

Minimum Account BalanceAccount monthly maintenance fees & at what balance are they waived?Who pays the account monthly maintenance fees? Employer or accountholder?

Investment fees

Other Event Fees. Note the costs for services such as: wire transfers, stop payment requests, insufficient funds, account closure, etc.

Investment options available

Replacement debit card fee

Detail any additional monthly costs separate from the monthly maintenance fee.

Replacement checkbook fee

FDIC insured*

Interest rates

Minimum balance to invest


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WageWorks, Inc. 1

WageWorks has been providing third party administration services since 2000 (18 years)

2WageWorks is headquartered in San Mateo, California with additional offices in Tempe, Arizona; Mequon, Wisconsin; Williston Center, Vermont; Louisville, Kentucky; Irving, Texas, Alpharetta, Georgia and New York, NY.

3WageWorks is a publicly-traded company (NYSE: WAGE).

4WageWorks has not been acquired or merged with any other organization in the past 12 months. We have acquired the assets or stock of the following companies since 2015:• Ceridian Corporation’s COBRA and Direct Bill Services portfolios in September 2015• Automatic Data Processing, Inc.’s Consumer Health Spending Account and COBRA portfolios in November 2016

5As part of our stated growth strategy, we are always looking at potential acquisitions but any specific plans or details are confidential until publicly released.

6 As the incumbent, the County currently partners with Shawn Smith for FSA administration. Shawn is the assigned relationship manager. Should the County award WageWorks the HSA business, Shawn will expand his role to include management of the HSA program.

WageWorks is also the incumbent of the COBRA administration. The COBRA administration is managed by a team of COBRA experts managed under Mike Harbison, Director, Client Services.

As an advantage to our continued partnership, no implementation activities will be required and the current team and relationship manager assignments will remain.

7 No. WageWorks does not currently have an office in Colorado. Our locations are provided below: • San Mateo, California (HQ)• Tempe, Arizona• Mequon, Wisconsin• Williston Center, Vermont• Louisville, Kentucky• Irving, Texas• Alpharetta, Georgia • New York, New York

a If not, from which location will you service this account? Our locations are provided below: • San Mateo, California (HQ)• Tempe, Arizona• Mequon, Wisconsin• Williston Center, Vermont• Louisville, Kentucky• Irving, Texas• Alpharetta, Georgia • New York, New York

8 Corporate offices are segmented from the production network using the Cisco Firewall Services Modules (FWSMs). High-risk security patches are applied monthly to critical systems. Vulnerability management solutions are run on a weekly basis. Intrusion Detection/Prevention Systems is at the edge with Host Based Intrusion Prevention on all devices commonly affected by malware. The WageWorks’ Information Security team conducts daily threat updates briefings in order to discuss new vulnerabilities. The information security team is subscribed to and actively monitors multiple industry periodicals, reviews and vendor specific bulletins. Sources include, but are not limited to the following: US-CERT, CERT, NIST, Microsoft Security Bulletin, Cisco, SANS, CISCO Coalition, Infragard and Security Week. WageWorks maintains a hot-site located in San Jose, CA which includes near-real time replication of our production data using VMWare’s vCenter Site Recovery Manager. Finally, for non-production data and data from ancillary systems, information is encrypted with 256-bit AES encryption, written to tape, and sent offsite for storage. WageWorks is a PCI-compliant level 1 service provider. WageWorks’ PCI compliance has been certified by the Visa CISP program, and is renewed annually. WageWorks also maintains a SSAE 16 SOC1 Type II (SAS 70 Type II) service audit program and is audited annually.

9 Yes. WageWorks has Cyber Security Insurance. Our Cyber Security Insurance is through Lloyd's/Beazley Syndicates.

FSA, COBRA & HSA General Customer ServiceWill you provide a dedicated account manager for The County?

Does your organization have service offices in Colorado?

What is the company's ownership: parent/subsidiary/affiliate relationships. Is the company public or privately held?

Has your organization been acquired or merged with any other organization in the past 12 months?

Do you anticipate merging or buying another carrier vendor in the next 12 months?

FSA, COBRA & HSA General Cyber SecurityOutline your Cyber Security processes and practices to protect your networks, computers and programs from an attack.

Do you have Cyber Security Insurance? If yes, who is the insurance through?

Provide the location of your business.

FSA, COBRA & HSA Administration Questionnaire

Proposers - Enter your response in the tan cells, indicate N/A if not applicableVERY IMPORTANT: YOU MUST COMPLETE OUR QUESTIONNAIRE COMPLETELY. YOUR PROPOSAL MAY NOT BE REVIEWED IF IT IS NOT COMPLETED IN ITS ENTIRETY FOR THE PRODUCTS YOU ARE QUOTING. THE PLAN SPONSOR WILL NOT BE LIABLE FOR ANY CHARGES NOT SPECIFICALLY DETAILED IN YOUR PROPOSAL.

FSA, COBRA & HSA General OrganizationHow long has your business been in existence?

4



WageWorks, Inc.10

WageWorks has been administering flexible spending accounts since 2002 (16 years). 11

This information is considered proprietary and confidential. We administer benefits for over 100,000 clients, including 67% of the Fortune 500 and 71% of the Fortune 100 companies with approximately 6.5 million participants.

12 This information is considered proprietary and confidential. We administer benefits for over 100,000 clients, including 67% of the Fortune 500 and 71% of the Fortune 100 companies with approximately 6.5 million participants.

13 Forest City Realty Trust, Inc. Alicia Dougherty, Benefits [email protected]

Due to the number of reference requests we receive and out of respect for our clients’ privacy and confidentiality, WageWorks will be happy to provide additional references upon being named a finalist for Larimer County. Please note that WageWorks is the incumbent.

14 Standard reporting is available online to Larimer County and custom reports available on request. Details are provided in the attached Report Summary.

1599% of claims are processed within two (2) business days.

16WageWorks tracks claims flow and processing. We have met or exceeded our SLA of 99% of claims processed within two (2) business days since 2007.

17Yes

18This is not applicable. WageWorks is the incumbent.


20

This is not applicable. WageWorks is the incumbent.

21

Check, ACH, or Wirea When are invoices released and when is payment due? Is there a grace period?

Invoices are generated on the 15th and due in 30 days. Please note, the Aflac agent currently pays for FSA administration fees.

22Multiple funding models are available. For government entities the two main funding models are contribution based funding or claim based funding with funds sent by check, wire, or ACH credit.

b Do you offer claim based funding, contribution based funding, or both?Both. The County is currently set up with contribution based funding but can change to claim based funding if preferred.

c Can The County use its own bank? A funding model that is available however, not recommended, we can issue checks off of the bank however public entities are generally not allowed to give access to their bank information.

d Is a minimum deposit required?4% of annual contribution prefund required. With current funding method the first payroll of the year takes care of this requirement.

e When do you request funds and for what claims period? Currently funds are required each pay date as funding is based on contributions. If we switch to claim funding model the funding would be weekly for the previous weeks disbursements.

23Yes

2499% of claims are processed within two (2) business days.

25 Letters mailed to participants. The participant also can view online or set up text or email alerts.

26It is an option however the plan currently offers the card.

27 Unlike other vendors that utilize a split administrator and card provider model, WageWorks fully owns its debit card, and provides all benefit administration associated therewith. WageWorks issues both Visa- and MasterCard-branded cards.

FSA Debit CardIs a debit card an option, or is it mandatory?

Is your debit card outsourced, or is it a wholly-owned card?

Please describe the banking options to submit payment for FSA Administration. (Example, Check and/or ACH)

Please describe the banking options that are available for claims funding

Do you utilize an imaging system to record claims documents?

What is the turnaround on completed claim forms?

For how many clients do you provide FSA administration services?

What is the average size of your FSA clients? What is the largest? The smallest?

Provide three current FSA client references similar in size and industry. Include contact name, title and phone number.

What types of standard FSA reports do you provide for clients?

FSA Financial Information

FSA Member ServiceWhat is your claims turnaround time?

How do you assure turnaround times are meeting your commitment?

Is claims verification (receipts) required?

FSA ImplementationProvided a detailed description of your implementation process, with takeover procedures.

What is the lead time for implementation of FSA administration? (Please provide a tentative timeline.)Are you willing to work with the incumbent administrator to transfer data electronically?

How are incomplete or denied claims communicated?

FSAHow long has your business been administering flexible spending accounts?

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28WageWorks has two systems in place for auto-substantiation. If the merchant is an IIAS-merchant, their inventory is marked FSA-eligible and the authorization only comes for FSA-eligible expenses. We also pre-load the County's co-payment amounts and if the authorization matches the co-pay it will auto-substantiate. For the remaining transactions and email requesting documentation is sent to the participant.

29If there are multiple plans, FSA, LPFSA, HSA, and dependent care, we will determine which plan will pay first based on the merchant category code sent with authorization.

30

Yes, there is a website and a mobile app available to participants.31

WageWorks has two systems in place for auto-substantiation. If the merchant is an IIAS-merchant, their inventory is marked FSA-eligible and the authorization only comes for FSA-eligible expenses. We also pre-load the County's co-payment amounts and if the authorization matches the co-pay it will auto-substantiate. For the remaining transactions and email requesting documentation is sent to the participant.

32Toll free phone number or cards can be requested online.

33No maximum card limit

WageWorks, Inc.34

WageWorks has been administering COBRA services since 2005 (13 years). However, through strategic acquisition, we have more than 30 years of experience.

35This information is considered proprietary and confidential. We administer benefits for over 100,000 clients, including 67% of the Fortune 500 and 71% of the Fortune 100 companies with approximately 6.5 million participants.

36 This information is considered proprietary and confidential. We administer benefits for over 100,000 clients, including 67% of the Fortune 500 and 71% of the Fortune 100 companies with approximately 6.5 million participants.

37 Macy’s Alison Payne 513-573-8657 [email protected]

Aramark Uniform Jan HartDirector, Health Benefits(Uniform Services)818-973-3738 [email protected]

Aramark Services Patricia LeinheiserGlobal Benefits215-238-5930 [email protected]

Rite Aid Allison FullerDirector, Benefits717-730-8296 [email protected]

38Please see accompanying document, 'COBRA_Client_Admin_Guide', page 23 for available standard reports/descriptions.



41

This is not applicable. WageWorks is the incumbent.

42Clients have the choice of either ACH or check payments.

a When are invoices released and when is payment due? Is there a grace period?For COBRA, invoices are due on the 15th of each month. There is a 10 day grace period.

43

WageWorks can do either for Larimer County.

How do participants request a debit card?

What is the maximum number of debit cards per account holder?

How do you ensure the amounts debited to the FSA are for "qualified benefits" under Code section 125?

Describe how your debit card features can be customized for different plan designs.

Does your organization have the technology to view information online (i.e. account history, balance, etc.)? Do you have an app?

How do you verify card transactions?

COBRA Carrier NotificationDescribe the methods in which you can notify carriers? Electronic or Paper?

Please describe the banking options to submit payment for COBRA Administration. (Example, Check and/or ACH)

Provide three current COBRA client references similar in size and industry. Include contact name, title and phone number.

What types of standard COBRA reports do you provide for clients?

What is the average size of your COBRA clients? What is the largest? The smallest?

COBRA ImplementationProvided a detailed description of your implementation process, with takeover procedures. What is the lead time for implementation of COBRA administration? (Please provide a tentative timeline.)Are you willing to work with the incumbent administrator to transfer data electronically?

COBRA Financial Information

How long has your business been administering COBRA?

For how many clients do you provide COBRA administration services?

COBRA

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44Notification is weekly, haste enrollments can be made as emergencies come up.

45WageWorks has a quality control team that monitors/reviews segments of all daily processing, with proper notification to the appropriate teams of any issues.

46Participants can pay by check, or as a one-time ACH debit each month.

47Larimer County currently receives premiums via check, but the ACH option does exist.

48

Monthly49

Consolidated standard report exists (Premium Distribution Report) which is available for clients to retrieve from the COBRA client website. Option also exists to have the report sent via paper if the client is receiving premiums via check monthly.

50

Typically clients send to us a QE file from their Benefits system of record. Additionally the option exists for clients to enter events directly into our COBRA system.

51

Standard processing time is 7-10 days from receipt of an error-free file.

What is the turn around time to process events? (Example, Daily, Weekly, Bi-weekly, Monthly)

How often will you notify carriers? Daily, Weekly?

Describe the controls in place to ensure COBRA elections and terminations processed correctly?

COBRA Premium CollectionOutline payment options COBRA participants have when submitting premium. (Example, Check or Credit Card)How would the premiums collected be remitted back to The County? (Example, Check or ACH)How often are the premiums remitted to client? (Example: Weekly, Bi-weekly, Monthly)

Outline your premium collection reporting available to client.

COBRA Event ProcessingOutline the various options in which you can receive COBRA events. (Example, eligibility file, paper, fax, phone call, excel file)

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WageWorks, Inc.

References Provide at least five (5), but not more than ten (10), references for similar services that you have provided in the past five (5) years; please limit this section to a maximum of ten (10) pages in length.

I. Include: company name, contact name, role/responsibilities and title of contact, contact phone number and email address.

WageWorks has provided references as part of our response to the Questionnaire, tab FSA_HSA_COBRA Questionnaire and also below.

1. Forest City Realty Trust, Inc.

Alicia Dougherty, Benefits Manager

216-416-3971

[email protected]

2. Macy’s

Alison Payne 513-573-8657

[email protected]

3. Aramark Uniform Jan Hart

Director, Health Benefits

(Uniform Services)

818-973-3738

[email protected]

4. Aramark Services Patricia Leinheiser

Global Benefits

215-238-5930

Leinheiser-

[email protected]

5. Rite Aid Allison Fuller

Director, Benefits

717-730-8296 [email protected]

rvizcarra

Highlight

WageWorks, Inc.

Exhibits List

COBRA Client Admin Guide

Exceptions/Deviations

FSA HSA Reports Summary

HSA Fees and Interest Schedule

Sample WageWorks’ Agreements

WageWorks Evidence of Insurance

COBRA and Direct Bill Services

Administrative Processes Guide Client Guide for COBRA and Direct Bill Benefits Continuation

WageWorks® Copyright Information Copyright © 2017 by WageWorks All rights reserved. The information contained in this document is proprietary and confidential to WageWorks. No part of this document may be reproduced or transmitted in any form or by any means, mechanical or electronic, including photography and recording, for any purpose without the expressed written permission of WageWorks. WageWorks and the WageWorks Logo are registered trademarks of WageWorks. Microsoft and Excel are registered trademarks of Microsoft Corporation. Printed in the United States Version 17.3.7

Client Guide: COBRA/Direct Bill Administrative Processes

Table of Contents About This Guide

Introduction ....................................................................................................................................... 6 Audience for This Guide ................................................................................................................... 6 What’s in This Guide ......................................................................................................................... 7 Related Documentation .................................................................................................................... 7 Documentation Conventions ............................................................................................................ 8 Providing Comments ........................................................................................................................ 9

Understanding WageWorks’ Interaction with You

Introduction ..................................................................................................................................... 11 Using BeneDirect Client View ......................................................................................................... 12

Accessing the Website............................................................................................................. 12 Performing Tasks ..................................................................................................................... 12 Contacting WageWorks ........................................................................................................... 13

Providing Qualifying Event Data to WageWorks ............................................................................ 13 When to Provide Qualifying Event Data to WageWorks ......................................................... 14 Reviewing Life Status Change Requests ................................................................................ 15 How to Provide Qualifying Event Data to WageWorks ........................................................... 16 How WageWorks Administers a Severance Agreement ......................................................... 16

Concurrent Severance Period .......................................................................................... 17 Consecutive Severance Period ........................................................................................ 18

How WageWorks Administers a Subsidy Agreement ............................................................. 19 How WageWorks Administers a Flexible Spending Account .................................................. 20 How WageWorks Administers a Health Reimbursement Arrangement (HRA) ………..……..20

Providing Plan or Rate Updates to WageWorks ............................................................................ 20 Updating Plan Administrator Information ........................................................................................ 21

Updating Your Contact Information ........................................................................................ 22 Reviewing WageWorks’ Reports .................................................................................................... 23 Understanding the COBRA Review/Appeals Process ................................................................... 24 Understanding the Request for Refund Process ............................................................................ 26 Understanding the Returned Mail Process ..................................................................................... 27

Understanding Your Options for Additional COBRA Services

Introduction ..................................................................................................................................... 29 Understanding Your Configuration Options .................................................................................... 29 Understanding the General Notice Service .................................................................................... 30

Active Population General Notice ............................................................................................ 31 Catch Up General Notice ......................................................................................................... 31

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Understanding WageWorks’ Interaction with Your COBRA Qualified Beneficiary

Introduction ..................................................................................................................................... 33 WageWorks and Qualified Beneficiary Interaction Diagram .......................................................... 33 WageWorks Mails Election Notice to Qualified Beneficiary ........................................................... 35

Election Notice ......................................................................................................................... 35 Qualified Beneficiary Elects COBRA? ............................................................................................ 36 WageWorks Mails Coupon to Qualified Beneficiary ....................................................................... 37 Qualified Beneficiary Pays? ............................................................................................................ 37 Coverage Continues? ..................................................................................................................... 39

Coverage Continues ................................................................................................................ 38 Coverage Is Terminated .......................................................................................................... 40

Early Termination of Coverage Letter ............................................................................... 40 End of COBRA Period Letter ............................................................................................ 40

Qualified Beneficiary Requests a Change of Coverage ................................................................. 40 Life Status Changes ................................................................................................................. 41 Requests for COBRA Period Extensions ................................................................................ 42

Social Security Disability ................................................................................................... 42 Second Qualifying Event .................................................................................................. 42

Qualified Beneficiary Appeals? …………………………………………………………………………43 How a Qualified Beneficiary Can Contact WageWorks ............................... ……………………….46

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About This Guide

Page Topic 6 Introduction

6 Audience for This Guide

7 What’s in This Guide 7 Related Documentation

8 Documentation Conventions 9 Providing Comments

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Introduction

The WageWorks COBRA Client Guide provides general information on the processes and procedures to be used in the administration of Consolidated Omnibus Budget Reconciliation Act (COBRA) services and describes how WageWorks COBRA Services (also referred to as “WageWorks” in this guide) administers these processes and procedures on behalf of our clients. It is not intended as a description of the COBRA regulations. Specific information on COBRA regulations can be found at either http://www.dol.gov/dol/topic/health-plans/cobra.htm or http://www.irs.gov/. WageWorks provides a comprehensive team of professionals to support your COBRA administration needs. Included in this team are Operations, Client Services, and Qualified beneficiary Services. Additionally, WageWorks COBRA Services provides operational support, including an interactive voice response system, qualified beneficiary and client web access, and electronic submission of files from WageWorks’ Benefits Enrollment Services platforms.

Note: If you have an existing file interface with WageWorks, your current submission methods will not impacted.

This guide provides information concerning the WageWorks COBRA service offerings. Some of these offerings are optional and are not provided to all WageWorks clients. Any information provided in this guide is not intended to be and may not be used as legal advice. WageWorks does not engage in rendering legal services. The purpose of this document is to provide a general understanding of WageWorks’ COBRA administrative processes and is not intended to interpret or instruct clients on legal matters. If legal advice is desired or required, the services of legal counsel are recommended. In addition, WageWorks may modify this guide from time to time as needed. Therefore, this document should not be interpreted as an indefinite promise or guarantee that WageWorks will not modify or otherwise change this guide or its’ processes in the future as needed.

Audience for this Guide

This guide is intended for use by client benefits administrators (also referred to as “clients” and “plan administrators” in this guide) who are responsible for working with WageWorks COBRA Services regarding the administrative aspects of COBRA plans for their company. This guide does not include procedures for using specific applications and is not intended to be a tutorial or “user guide.”

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http://www.dol.gov/dol/topic/health-plans/cobra.htm

http://www.irs.gov/


What’s in This Guide

This guide covers the following topics: “Understanding WageWorks’ Interaction with You” describes your responsibilities as client and plan administrator for COBRA services. “Understanding Your Options for Additional COBRA Services” describes your options for additional COBRA services. “Understanding WageWorks’ Interaction with Your COBRA Qualified Beneficiary” describes a COBRA qualified beneficiary’s experience with WageWorks.

Related Documentation

This guide, available on BeneDirect Client View, addresses the administrative tasks related to the services provided by WageWorks COBRA Services. The WageWorks COBRA Client Web Guide, also available on the website, provides detailed instructions for using the website.

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https://www.benedirect.adp.com/


Documentation Conventions

Table 1 describes the documentation conventions used in this guide.

Table 1. Documentation Conventions

Documentation Convention Description

Bold In procedures, user interface items that you select, click, or enter information for are shown in bold. For instance, tab names, buttons, and field names.

Command Indicates that you should type the command on your computer.

Signifies important additional information.

Signifies very important additional information.

Identifies helpful—but not necessary—information.

Signifies that a failure to follow the recommended procedure could result in a loss of data or could result in the product not performing properly.

Used to indicate either of the following: • You can find additional information

in the online Help

• You can find additional information on interface shortcuts and tips in the user’s guide.

Company Definitions ~ Organization Definitions

At the beginning of a procedure, shows the path or navigation to a process or task.

People ~ Personnel Actions ~ Change Employee’s Job/Position ~ Change Job Position

Within text, shows the path or navigation to a process, task, or tab.

What’s next

Indicates that you have reached the end of one step in a multiple-step process. Instructions are given after this convention to help you find the next step in the process and other related information.

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Table 1. Documentation Conventions (cont.)

Documentation Convention Description

End of procedure

Indicates that you have reached the end of a procedure. If additional information is available, it is noted after this convention.

More info

For a description of the fields on this tab, press F1.

Indicates where you can find a complete description of every field on a tab. This convention is placed either to the left or, less often, to the right of a screen illustration.

Tasks

MULTI-STEP PROCESS First step in process Second step in process Third step in process

Lists each step in a multi-step process, and indicates which step the current section is documenting. In this example, the third step is currently being documented. Note that this step is highlighted in bold and is preceded by a check mark. If you are viewing an online manual, click the highlighted text to jump to the desired section.

Providing Comments

We welcome your comments and suggestions about this guide. You can provide comments by giving feedback to your WageWorks Client Service Team.

Understanding WageWorks’

STOP

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Understanding WageWorks’ Interaction with You

Page Topic 11 Introduction

12 Using BeneDirect Client View 13 Providing Qualifying Event Data to WageWorks

20 Providing Plan or Rate Updates to WageWorks

21 Updating Plan Administrator Information 22 Updating Your Contact Information

23 Reviewing WageWorks Reports 24 Understanding the COBRA Review/Appeals Process

26 Understanding the Request for Refund Process

27 Understanding the Returned Mail Process

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Introduction

This chapter describes your role as your plan’s COBRA plan administrator and WageWorks’ interaction with you. It contains the following sections:

• Using BeneDirect Client View

• Providing Qualifying Event Data to WageWorks COBRA Services

• Reviewing Life Status Change Requests

• Providing Plan or Rate Updates to WageWorks COBRA Services

• Updating Plan Administrator Information

• Updating Your Contact Information

• Reviewing WageWorks Reports

• Understanding the COBRA Review Process

• Understanding the Request for Refund Process

• Understanding the Returned Mail Process

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Using BeneDirect Client View

BeneDirect Client View is a WageWorks website that you can use to complete many of the tasks you need to perform as a COBRA plan administrator. This section contains the following topics: • Accessing the Website • Performing Tasks • Contacting WageWorks

Accessing the Website

To access the website, click BeneDirect Client View and enter the user ID and password provided to you by WageWorks. Your password will be active for 180 days. Upon password expiration, the COBRA website will automatically prompt you to change/update your password for continued access to the system.

If you didn’t receive a user ID and password or if you’ve forgotten it, please contact WageWorks Client Service Team.

Performing Tasks

Depending on your BeneDirect security settings established by your account’s Master User, you may be able to perform the following tasks on BeneDirect Client View: • Providing Qualifying Event Data to WageWorks COBRA Services • Providing Plan or Rate Updates to WageWorks COBRA Services • Reviewing WageWorks Reports • Accessing tools, forms, and information any time • Accessing print and mail dates for COBRA-related correspondence • Viewing qualified beneficiary information, including current status, health plan elections,

and paid through date • Requesting an additional General Notice • Requesting urgent coverage updates (if this feature is included in your Client Service

Agreement) • Assigning and maintaining website access for other people in the organization, if you

are a Master User for your account.

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Contacting WageWorks COBRA Services

You can contact WageWorks by:

• Entering a request on BeneDirect Client View

• Emailing your designated WageWorks Client Service team

• Calling WageWorks COBRA Services during normal business hours

Providing Qualifying Events Data to WageWorks COBRA Services

This section describes how and when to provide qualifying event data to WageWorks for your qualified beneficiaries. For information on what WageWorks does with the information you provide, see “WageWorks Mails Election Notice to Qualified Beneficiary” on page 34.


A qualifying event (QE) is any of a set of specified events that occurs and causes a covered employee — or the covered spouse or dependent child of the covered employee — to lose coverage under a group health plan. The following are COBRA-specified qualifying events: • Termination of employment • Reduction in work hours • Death of employee • Divorce or legal separation • Loss of dependent status • Medicare entitlement for the covered employee • Bankruptcy A qualified beneficiary (QB) is an individual (employee, spouse, or dependent child) who was covered under a group health plan the day before a qualifying event occurred.

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This section contains the following topics: • When to Provide Qualifying Event Data to WageWorks COBRA Services • Reviewing Life Status Change Requests • How to Provide Qualifying Event Data to WageWorks COBRA Services • How WageWorks Administers a Severance Agreement • How WageWorks Administers a Subsidy Agreement • How WageWorks Administers a Flexible Spending Account • How WageWorks Administers a Health Reimbursement Arrangement (HRA)

When to Provide Qualifying Event Data to WageWorks

When the employer and plan administrator are one entity, notice of a qualified beneficiary's COBRA rights must be provided within 44 days. When the employer and plan administrator are separate entities, the employer is obligated to notify the plan administrator when a qualifying event has occurred within 30 days of the event, and the plan administrator must provide a qualified beneficiary with notice of his or her COBRA rights within 14 days. It is important to note that WageWorks COBRA Services is not the plan administrator but acts as a third-party processor, facilitating services on your behalf. A qualified beneficiary must provide notification to the plan administrator of loss of dependent status, divorce, or legal separation within 60 days of the date of the qualifying event or the date on which the qualified beneficiary would lose coverage because of the qualifying event, whichever comes last. It is the employer/plan administrator’s responsibility to provide WageWorks COBRA Services with the qualifying event data in a timely manner. This information may be provided via an electronic feed from WageWorks’ Health & Welfare Services or another third party benefits vendor, direct input to BeneDirect, or another data transmission channel. However, WageWorks COBRA Services cannot initiate the qualifying event notification without all relevant data elements. Processing qualifying events may differ based on the suite of services purchased by your employer. Please contact your WageWorks Client Service team for specifics of how your data should be reported to WageWorks COBRA Services.

For Annual Enrollment, WageWorks COBRA Services may support a default process based on the client’s business rules.

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Reviewing Life Status Change Requests

A qualified beneficiary can request a change of coverage by notifying WageWorks and providing documentation for any of the following life status changes:

• Marriage – valid marriage certificate

• Birth – valid birth certificate

• Adoption – valid adoption paperwork

• Divorce/Legal Separation – upon notification from the covered employee. A copy of divorce decree is no longer required.

Table 2 describes two possible life status change request scenarios.

Table 2. Life Status Change Request Scenarios

Scenario Description Example

Qualified beneficiary notifies WageWorks within 30 days of the date of the event

WageWorks processes the request and adds the new spouse or child to the COBRA account.

• A qualified beneficiary is married on January 2 and notifies WageWorks to add the new spouse to their COBRA coverage on January 31.

• A qualified beneficiary has a new baby on April 17 and notifies WageWorks to add the child to their COBRA coverage on May 5.

Qualified beneficiary notifies WageWorks beyond 30 days after the date of the event

WageWorks requests guidance from the client.

• A qualified beneficiary is married on January 2 and notifies WageWorks to add the new spouse to their COBRA coverage on February 28.

• A qualified beneficiary adopts a child effective April 17 and notifies WageWorks to add the new child to their COBRA coverage on 6/30.

What’s Next

You have finished reviewing life status change requests. The next section describes how to provide qualifying event data to WageWorks.

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How to Provide Qualifying Event Data to WageWorks

You can provide qualifying event data to WageWorks for one or more qualified beneficiaries using any of the following methods.

Table 3 describes the methods for providing data to WageWorks.

Table 3. Methods for Providing Data

Method Description

BeneDirect Client View

The fastest way to provide QE data to WageWorks is by accessing BeneDirect Client View and clicking the Client Transmittal link.

COBRA/Direct Bill Transmittal Form (CTF)

If, for any reason, you can’t use the website, you can provide QE data by obtaining a COBRA/Direct Bill Transmittal Form (CTF) from WageWorks COBRA Services, filling it out, and returning the completed form to WageWorks via email at [email protected] (preferred method) or by faxing it to the number indicated on the form.

Electronic Data Interchange File (If Configured)

If you are configured for Electronic Data Interchange (EDI), you can submit QE data to WageWorks through an EDI file.

You can also use a combination of EDI and the website to submit your data (for example, routine transmission by EDI and case-by-case entries through the website).

How WageWorks Administers a Severance Agreement

Your plan may include an agreement whereby a qualified beneficiary does not lose coverage until some specified duration of time after the qualifying event. Although the loss of coverage does not occur at the time of the qualifying event, generally the plan administrator is still responsible for providing a COBRA Election Notice to all qualified beneficiaries. Because these types of agreements are commonly part of a Severance agreement, WageWorks refers to this type of arrangement generically as severance. WageWorks can process a severance period that runs concurrently with the COBRA period or a severance period that runs consecutively in addition to the COBRA period. Note: WageWorks manages the concurrent severance period by sending the COBRA qualified election notice at the end of the severance period. For consecutive severance processing, the applicable QE date must be reported to WageWorks by the client.

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mailto:[email protected]


Concurrent Severance Period Qualified beneficiaries must be notified of their COBRA eligibility based on the date of the Qualifying Event (QE). When submitting a QE to WageWorks where a Severance period is to run concurrently with the COBRA period, you will need to report the following data to WageWorks: • Date of qualifying event • Date Active coverage will end • Date severance period begins (usually the day after the QE) • Date severance period ends Figure 1 illustrates the concurrent severance period. Figure 1. Concurrent Severance Period

You should be aware of the following information as it applies to a severance that runs concurrent with the COBRA period: • Notifying WageWorks - You should provide notice of the QE to WageWorks within 30

days of the QE to ensure a COBRA election is mailed within the required 44 day notification period.

• Continuation of Coverage – As stipulated by your agreement, qualified beneficiaries remain covered for the same benefit plans in effect prior to the qualifying event for a specified period of time (severance period), regardless of whether or not they ever elect COBRA

• Duration of Continuation Coverage - The continuation of coverage during the severance period is not in addition to the maximum COBRA period. The two periods run concurrently. For example, when the active coverage is continued during a 6-month severance period, coverage could be continued under COBRA for up to 12 months (assuming an 18-month COBRA period).Election Period – The COBRA election period generally extends 60 days past the Election Notice mail date or the loss of coverage date, whichever comes last. Should a qualified beneficiary wish to continue the same or a lesser coverage level beyond the severance period, the qualified beneficiary must elect COBRA before the election period expires. The lesser coverage will begin the first day following the severance period expiration.

• Eligibility Reporting – Because the qualified beneficiary is covered under the active employee benefit plan during the severance period and still administered by the active benefits provider, WageWorks does not report eligibility to the carrier or employer during the severance period, as applicable. WageWorks reports eligibility only when the

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qualified beneficiary elects and pays for COBRA coverage within the COBRA grace dates.

• Qualified Beneficiary Billing – Because the qualified beneficiary is covered under the active employee benefit plan during the period of severance and still administered by the active benefits provider, WageWorks does not generate qualified beneficiary billing during the severance period. WageWorks only generates qualified beneficiary billing for COBRA coverage.

Consecutive Severance Period When submitting a QE to WageWorks where a severance period is meant to be in addition to the COBRA period, you will need to report the date of the QE to WageWorks. Figure 2 illustrates the additional severance period. Figure 2. Consecutive Severance Period

You should also be aware of the following information as it applies to a severance you wish to be in addition to the COBRA period: • Notifying WageWorks – You should provide notice of the QE to WageWorks within 30

days of date you reported as the QE date to ensure compliant and timely processing of the event.

• Continuation of Coverage – As stipulated by your agreement, qualified beneficiaries remain covered under active employee benefits after the qualifying event for a specified period of time (or severance period), regardless of whether or not they ever elect COBRA.

• Duration of Continuation Coverage – The continuation of coverage during the severance period is in addition to the maximum COBRA period. For example, when the active coverage is continued during a 6-month severance period, coverage could be continued under COBRA for up to 18 months (assuming an 18-month COBRA period).

• Election Period – The COBRA election period is typically 60 days, measured from when notice of COBRA rights is provided or the date of loss of coverage under the active plan, whichever comes last.

• Eligibility Reporting – Because the qualified beneficiary is covered under the active employee benefit plan during the severance period and still administered by active benefits provider, WageWorks COBRA Services does not report eligibility during the severance period. WageWorks COBRA Services reports eligibility only when the qualified beneficiary elects and pays for COBRA coverage within the COBRA grace dates.

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• Qualified Beneficiary Billing – Because the qualified beneficiary is covered under the active employee benefit plan during the period of severance and still administered by the active benefits provider, WageWorks COBRA Services does not generate qualified beneficiary billing during the severance period. WageWorks COBRA Services only generates qualified beneficiary billing for COBRA coverage.

How WageWorks Administers a Subsidy Agreement

Your plan may include an agreement to reduce all or a portion of the COBRA premiums for a specified duration of time. WageWorks refers to this type of arrangement as a subsidy. When submitting a QE to WageWorks where a subsidy is included, you will need to report the items below in addition to the “standard” QE data: • Amount of COBRA subsidy (this can be a percentage or dollar amount). A percentage

will be calculated on premium increases during new plan years or special enrollment periods where rates may change. Flat dollar amounts will remain in force until modified by the client.

• Date subsidy begins and ends (concurrent with COBRA coverage) • Plans and/or coverage to be subsidized You should also be aware of the following information as it applies to subsidies: • Continuation of Coverage – If a qualified beneficiary wishes to continue coverage, he or

she must elect or have COBRA coverage elected on their behalf. In the event the subsidy does not cover the full cost of elected coverage, the qualified beneficiary must remit full payment for the balance of premiums within the grace period (no later than 30 days from the coverage due date) in order for COBRA coverage to be effective.

o Note: WageWorks COBRA Services does not recognize separate payments for each of the elected COBRA coverages. If a qualified beneficiary desires to drop any of the elected coverages during the subsidy continuation period, the qualified beneficiary must contact WageWorks COBRA Services to request termination of the specific benefit in order to avoid potential termination of all COBRA continuation coverage.

• Eligibility Reporting – WageWorks reports eligibility during the subsidy period if COBRA is elected.

• Qualified Beneficiary Billing – WageWorks generates qualified beneficiary billing during the subsidy period. Depending on the client's configuration, qualified beneficiaries may or may not be mailed coupons reflecting $0.00 balances. If all plans are not subsidized (ex. Medical is subsidized, but Dental is not) the full payment must be received by the grace date or all coverage will be terminated.

• Election Period – The COBRA election period extends 60 days past the election package mail date or the loss of coverage date, whichever comes last.

• Subsidized rates are displayed on the Election Notice as well as the qualified beneficiary billing.

• WageWorks retains the administrative fee from the premium disbursement even when rates are subsidized by the client (refer to your contractual agreement for more details).

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How WageWorks Administers a Flexible Spending Account

In situations involving loss of coverage under a health care Flexible Spending Account (FSA), the employer is responsible for notifying WageWorks of the following information: • Qualifying events, including Divorce and Loss of Dependent status events • Names of qualified beneficiaries • Length of coverage (not available on BeneDirect, EDI file and manual submission only).

In most instances, FSA COBRA continuation is only offered through the end of the plan year in which the QE occurs so WageWorks will run a default process to control this provision if the end date is not provided by the client.

• Amount of monthly premium to be charged

How WageWorks Administers a Health Reimbursement Arrangement (HRA)

In situations involving loss of coverage under a Health Reimbursement Arrangement (HRA), the employer is responsible for notifying WageWorks of the following information: • Qualifying events, including Divorce and Loss of Dependent status events • Names of qualified beneficiaries • Length of coverage (not available on BeneDirect, EDI file and manual submission

only). • Amount of monthly premium to be charged

What’s Next

You have finished providing QE data to WageWorks. The next section describes how to provide plan or rate updates to WageWorks.

Providing Plan or Rate Updates to WageWorks COBRA Services

At some point during the calendar year, you may experience changes to your group health plans that need to be communicated to WageWorks COBRA Services. Changes such as dropping, adding, or modifying plans or rate changes can impact your active employee base and COBRA qualified beneficiaries. You are responsible for submitting any plan or rate

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change to WageWorks COBRA Services at least 60 days prior to the effective date of the change. WageWorks COBRA Services does not process retroactive rate changes. Any rate changes that are not prospective will cause administrative issues for the qualified beneficiary billing cycle. Failure to submit plan-related adjustments in a timely manner can result in additional late fees. If you need to update plans or rates for annual enrollment after the effective date of the new plan year, a late fee of $250.00 per plan will be assessed and the rates will be applied prospectively. Your COBRA plan or rates are initially set up by WageWorks during implementation. However, if you need to change your plan or rates during the twelve-month determination period, you should communicate those changes to WageWorks in a timely manner through BeneDirect Client View or provide them to your WageWorks Benefits Enrollment Services client services representative. We encourage you to confirm your company’s plans and rates for both active and COBRA populations at least annually and in advance of the next plan year. Changes that you may need to communicate to WageWorks include: • Plan eligibility rules (zip-code based, dependencies with other plans, and so on) • Adding or continuing plans for the new plan year • Rates for the new plan year • Tier changes, if applicable • Updating plan contacts for new and existing plans • Updating payment and reporting schedules and payees • Updates to carriers • Effective date of change • Extend-to-end or per diem - WageWorks can accommodate situations where loss of

coverage is effective either on the day following a qualifying event (per diem) or the month following a qualifying event (extend-to-end)

What’s Next

You have finished providing plan or rate updates to WageWorks. The next section describes how to update ERISA plan administrator information.

Updating Plan Administrator Information

During implementation, you provided plan administrator information for WageWorks to include on qualified beneficiary communications. It’s important to communicate any changes to the following information to WageWorks:

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• Name and Plan Number, if one has been assigned, of your company’s group health plan(s). This information should match the ERISA plan information filed on the company’s IRS Form 5500. Even if you do not file a Form 5500, for instance in the case of healthcare Flexible Spending Accounts, you may have assigned a plan number for other administrative reasons.

• If you maintain multiple group health plans for purposes of continuation of coverage, please contact your WageWorks COBRA Services representative for additional instructions.

• Name, address, e-mail information and telephone number of plan administrator WageWorks COBRA Services uses this data to create the Election Notices and General Notices that we mail to your covered employees and COBRA qualified beneficiaries.

What’s Next

You have finished updating Plan Administrator information. The next section describes how to update your Contact information.

Updating Your Contact Information

Unless specified differently in your contract, access to WageWorks’ Client Services and return communication from WageWorks must be through a single point of contact at the client, either an individual or defined group of individuals, who is authorized on behalf of the client to give plan administrative direction. For clients who use the multiple division capabilities of our CASPro system, these individual groupings are for outgoing reporting purposes only and do not constitute individual points of contact for purposes of engaging WageWorks for plan administrative changes, transaction processing, or information requests. You are responsible for ensuring that WageWorks COBRA Services has the correct and current contact period. WageWorks relies on this information to communicate with you regarding WageWorks COBRA Services. You can view your current contact information on BeneDirect Client View.

What’s Next

You have finished updating your Contact information. The next section describes how to review WageWorks reports.

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Reviewing WageWorks’ Reports

WageWorks generates various reports on a standard schedule as defined at implementation to aid in the administration of COBRA continuation. You are responsible for reviewing the reports for accuracy and immediately notifying WageWorks is you identify a problem. WageWorks COBRA Services assumes the accuracy of the information unless otherwise instructed noted. You can download any of the following reports from the Reports tab on BeneDirect Client View:

Current Status Report Identifies qualified beneficiaries who are currently active on COBRA, currently in their election period, or who have terminated coverage.

New Election Report Lists qualified beneficiaries who have elected COBRA and made their first payment.

Termination Report Lists active qualified beneficiaries who have terminated coverage for any reason. Use this report as the basis for updating your carrier for eligibility and enrollment.

Activity Report Identifies qualified beneficiaries with changes during the last biweekly reporting cycle. Changes may include address update, name changes, plan transfers, status changes, and/or corrections as requested by the client or qualified beneficiary.

Premium Distribution Report

Lists the premium amount received for a specified period by qualified beneficiary and plan. The information contained on a PDR is generated from premium amounts received and applied during the previous period.

Invoice Detail Report Available only upon client request. Lists client and covered employee service activity for any given time period.

WageWorks Health Compliance

Monthly data file (.txt format) with a year-to-date list of COBRA/Direct Bill participants and dependents. The information contained in this data file is to aid the employer with their annual ACA reporting.

What’s Next

You have finished reviewing WageWorks reports. The next section describes the COBRA Review/Appeals process.

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Understanding the COBRA Review/Appeals Process

WageWorks receives an initial request for reinstatement of COBRA coverage and completes an administrative review (also referred to as a first level review) of the qualified beneficiary’s record to verify administratively that the termination of coverage was appropriate. The initial request for reinstatement is typically denied if there is no evidence of administrative error and a letter referencing the pertinent guidelines or provisions is mailed to the qualified beneficiary. As the plan administrator, you are responsible for making decisions on all COBRA appeals that are referred for review. For those reviews, WageWorks COBRA Services will gather all information and documents pertinent to the denial or termination. Once all information and pertinent documents have been gathered, WageWorks COBRA Services will provide a written summary of the factual findings. For second level reviews, or when the qualified beneficiary expresses extenuating circumstances in the initial request (e.g. death of an immediate family member, medical incapacitation, hospitalization, natural disasters, house fire, catastrophic sudden illness/injury), WageWorks COBRA Services will send a summary to you, as the Plan Administrator, for approval or denial within thirty (30) days of receipt by WageWorks COBRA Services of the appeal request. You must respond in writing to WageWorks COBRA Services following the complete review of the pertinent material approving or denying the request. Upon receipt of your decision, WageWorks COBRA Services provides written notice to the qualified beneficiary unless you otherwise direct WageWorks COBRA Services that you will notify the qualified beneficiary directly. If the initial review is denied or termination is confirmed in the second review, the notice will advise of the denial and reference any pertinent guidelines or provisions on which such denial was based. If you decide to reinstate continuation coverage for the qualified beneficiary, the notice instructs the qualified beneficiary to send the applicable premium to WageWorks COBRA Services within the standard billing grace dates. You may specify that a different payment grace date be provided when approving the reinstatement. If you do not respond to WageWorks’ inquiry on a second-level appeal, WageWorks will direct the qualified beneficiary who submitted the appeal to contact you directly.

Appeals related to electing COBRA that include circumstances that may require a tolling period will be sent to the client for review and, if reinstatement is approved, the client will be asked to provide direction to WageWorks COBRA Services regarding the time frame for the qualified beneficiary to make a COBRA election.

In addition to the appeals outlined above, requests for review of 11-month extension denials as well as Annual Enrollments are also processed.

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A qualified beneficiary may request a review of a denial issued for the 11-month extension due to disability. Under COBRA regulations, an extension of 11-months is available for those Qualified Beneficiaries deemed disabled by the Social Security Administration due to disability (under Title XIV or XVI of the Social Security Act). The provisions set-forth by COBRA, the 18 month COBRA period may be extended for up to eleven months, if:

• the qualified beneficiary is determined under the Social Security Act to have been

disabled at any time during the first 60 days of COBRA coverage and

• notification is provided to the Plan Administrator of the disability determination prior to the last day of the initial 18 month COBRA coverage period and

• is within 60 days if the latest occurring event listed:

o the date on which the qualifying event occurred; o the date coverage was lost; or o the date the qualified beneficiary was informed of the responsibility and

procedures for informing the plan of the disability determination. When 11-month extensions are denied based upon either not meeting one or more of the above provisions or perhaps not receiving the necessary information required to make a determination for eligibility, can be appealed by the qualified beneficiary. This type of review request is referred to you for your review and decision by providing them with the documentation received, as well as advising them of the reason for the extension denial. Annual Enrollment (AE) requests for reviews are referred to you when an active AE period has occurred, in which the selection for the next plan year’s benefits was either not received or was received after the deadline for selection of benefits. In addition, it may include requests to change the AE selection after the deadline. In any case, these types of requests for review are also referred to you for review and a decision. Documentation received along with the appeal correspondence is sent to you. Requests for review of denials of the 11-month extension and issues related to Annual Enrollment are automatically referred to you for determination. Upon receipt of your decision, notice is sent to the qualified beneficiary advising of whether the appeal was approved or denied and any necessary changes to the qualified beneficiary’s account are made.

What’s Next

You have finished understanding the COBRA review process. The next section describes the request for refund process.

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Understanding the Request for Refund Process

When COBRA coverage for a qualified beneficiary has been terminated for any reason (including failure to pay on time, insufficient payment, or a specific request for termination), WageWorks will provide a refund of the associated balance based on the following criteria. Table 4 describes WageWorks’ criteria for issuing a refund. Table 4. Refund Criteria

Criteria Example Refund

When a request for a refund for a previously paid COBRA premium is received prior to commencement of coverage due to the termination of an individual’s COBRA coverage, a refund would be issued.

If a qualified beneficiary paid for the month beginning October 1st and requests a refund on September 25th (which is prior to the commencement of the October coverage), a refund would be issued.

Approved

When a qualified beneficiary requests a refund for a COBRA premium paid for a month of coverage that has already begun, the request for a premium refund would be denied.

If a qualified beneficiary paid for the month beginning October 1st and requests a refund on October 5th, a refund would be denied.

Denied

If a qualified beneficiary requests a review of the denial, the requested review is forwarded to you for review and decision. If you approve the qualified beneficiary's request, WageWorks issues a refund of the COBRA premium as directed.

When a COBRA premium is refunded, coverage is terminated in WageWorks’ records as of the first day of the coverage period (month) for which the refunded COBRA premium was originally submitted by the qualified beneficiary.

Refund Request Referred to You

What’s Next You have finished understanding the request for refund process. The next section describes the WageWorks COBRA returned mail process.

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Understanding the Returned Mail Process

General Notices In the event that a general notice is not deliverable by the post office, any undeliverable mail will be routed back to the client, who is then responsible for following up to ensure delivery of the general notice as required by law. Election Notices Currently, when COBRA correspondence is sent to a qualified beneficiary with an undeliverable address, it is returned to WageWorks. WageWorks will then send you a notification stating that the notice was undeliverable and will request the qualified beneficiary’s correct address. This notification is sent to the Primary Client Contact noted in CASPro. However, if the Primary Contact is not the correct contact, you may choose to designate a contact, other than the Primary contact, with specific instructions in writing. The notifications will be sent via e-mail to the person you designate.

What’s Next

You have finished understanding the returned mail process. You have finished understanding your responsibilities as a plan administrator.

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Understanding Your Options for Additional COBRA Services

Chapter 2 Page Topic

29 Introduction

29 Understanding Your Configuration Options

30 Understanding the General Notice Service

Chapter 2

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Introduction

This chapter describes your options for obtaining additional COBRA services in the following sections: • Understanding Your Configuration Options • Understanding the General Notice Service

Understanding Your Configuration Options

WageWorks COBRA Services can set up the following configuration options for you at any time. Table 5 describes your configuration options. Table 5. Configuration Options

Options Description

Termination Based on Medicare

When a COBRA qualified beneficiary reaches age 65 after the date of their COBRA election, WageWorks terminates the COBRA coverage unless otherwise directed by you. Generally, the COBRA qualified beneficiary becomes eligible for Medicare due to age, at which time WageWorks notifies the qualified beneficiary through an Early Termination Letter that their COBRA benefits will be terminated due to Medicare Entitlement.

If the qualified beneficiary notifies WageWorks that he or she has not become entitled to Medicare, WageWorks reinstates COBRA coverage retroactively to the termination date. You may decide to offer dental, vision, and/or prescription coverage to Medicare-eligible qualified beneficiaries until the end of the COBRA coverage period. Additionally, an employer may choose to allow a qualified beneficiary to remain on COBRA while covered under Medicare.

Social Security Disability Admin Fees

This premium amount is charged when a qualified beneficiary has been deemed disabled by the Social Security Administration within the first 60 days of their COBRA period. WageWorks can configure our COBRA billing system for any percentage up to 150%. For employers who elect to bill up to150% of the premium amount during the 19th through 29th month of COBRA, WageWorks distributes the balance as directed by you and retains the 2% administration fee.

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Table 5. Configuration Options (cont.)

Options Description

Multiple Coupons

WageWorks can provide coupons in groups of 3 months, 6 months, or 12 months at one time to your qualified beneficiaries at your request.

No Mailing of Zero Coupons

WageWorks can configure our COBRA billing system to not mail zero balance coupons at your request.

Viewing Social Security Numbers

WageWorks’ Global Security protocols require our COBRA billing system to mask Social Security Numbers. In certain circumstances, WageWorks may allow SSN un-masking for specific users or reports.

Per Diem Versus Extend-to-End

WageWorks can configure our COBRA billing system to initiate the COBRA period on the day following a qualifying event (per diem) or on the first of the month following a qualifying event (extend-to- end).

What’s Next

You have finished understanding your configuration options. The next section describes the General Notice service.

Understanding the General Notice Service

A General Notice (often referred to as a New Hire Notification or an Initial Rights Notice) must be provided to a covered employee and his or her spouse at the time each first becomes covered under a group health plan (not at the time of hire). You are responsible for notifying WageWorks that a General Notice needs to be sent through BeneDirect Client View or by Electronic Data Interchange (EDI). WageWorks provides two optional services for General Notice of COBRA Rights for an additional fee: • Active Population General Notice (when covered)

• Catch Up General Notice (by blanket mailing)

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The General Notice is a standard template format based on the DOL model notice and is not subject to client customization. It will include all eligible group health plans maintained in WageWorks COBRA Services system. Unless instructed by you, WageWorks will not send out a second notice when the covered employee and their spouse elect a different group health plan at a later date. Note: Currently, all COBRA communications are produced in English only.

Active Population General Notice Once WageWorks is notified that a newly eligible employee or spouse has become covered under your COBRA plan, WageWorks mails a General Notice to the covered employee and/or spouse at the address(es) you provide. A separate letter is provided to the spouse if he or she lives at a separate address or first becomes covered at a different time from the employee.

Catch Up General Notice WageWorks offers you the opportunity to have the General Notice mailed to each covered employee and covered spouse who is already enrolled in the client’s plan(s). WageWorks offers this service to assist you in satisfying the requirement to provide qualified beneficiaries with a General Notice of COBRA Rights. Notices can be mailed at the time the organization becomes a WageWorks COBRA Services client or on an as-needed basis.

What’s Next

You have finished understanding the General Notice service.

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Understanding WageWorks’ Interaction with Your COBRA Qualified Beneficiary

Page Topic 33 Introduction 33 WageWorks and Qualified Beneficiary Interaction Diagram

35 WageWorks Mails Election Notice to Qualified Beneficiary

36 Qualified Beneficiary Elects COBRA? 37 WageWorks Mails Coupon to Qualified Beneficiary

37 Qualified Beneficiary Pays?

39 Coverage Continues? 40 Qualified Beneficiary Requests a Change of Coverage

43 Qualified Beneficiary Appeals? 46 How a Qualified Beneficiary Can Contact WageWorks

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Introduction

This chapter describes a COBRA qualified beneficiary’s experience with WageWorks in the following sections: • WageWorks and Qualified Beneficiary Interaction Diagram • WageWorks Mails Election Notice to Qualified Beneficiary • Qualified Beneficiary Elects COBRA? • WageWorks Mails Coupon to Qualified Beneficiary • Qualified Beneficiary Pays? • Coverage Continues? • Qualified Beneficiary Requests a Change of Coverage • Qualified Beneficiary Appeals? • How a Qualified Beneficiary Can Contact WageWorks

WageWorks and Qualified Beneficiary Interaction Diagram

The following diagram illustrates WageWorks’ interaction with your COBRA qualified beneficiary. Steps that require a qualified beneficiary’s decision or action appear in red Figure 3 illustrates WageWorks’ interaction with your COBRA qualified beneficiary.

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Figure 3. WageWorks and Qualified Beneficiary Interaction Diagram

WageWorks Receives

Qualifying Event Data from Client

WageWorks Mails Election

Notice to Qualified

Beneficiary

Qualified Beneficiary

Elects?

WageWorks Mails Coupon to



Pays?

WageWorks Processes Payment

WageWorks Terminates Qualified

Beneficiary Record

Coverage Continues?

Qualified Beneficiary Requests Review?

No Further Action Required


Review Process

Yes

No

Yes

Yes

Yes

Yes

No

No

No

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WageWorks Mails Election Notice to Qualified Beneficiary

After receiving QE data from a COBRA client, WageWorks sends an Election Notice to a qualified beneficiary. The Election Notice is a standard template format based on the DOL model notice and is not subject to client customization. WageWorks COBRA Services does allow “Employer Notes” to be set up that will display in a designated section of the Election Notice template. Note: Currently, all COBRA communications are produced in English only.

Election Notice WageWorks mails an Election Notice based on the Department of Labor Model Notice that informs the qualified beneficiary of his or her rights under COBRA as required. The Election Notice is sent by first class mail and WageWorks obtains proof of mailing. An election notice has the following characteristics: • Lists all qualified beneficiaries • Lists all plans and coverage and the corresponding rates for each applicable tier • Provides subsidy amounts and durations (if data was provided by you) • Provides the date of the qualifying event • Provides the date coverage ends under the plan • Provides the date by which the qualifying beneficiary must elect COBRA • Provides plan administrator information

Note: If COBRA continuation is offered for a Flexible Spending Account (FSA) plan, two notices will be sent if the FSA COBRA coverage start dates differ from the other plans offered.

What’s Next

You have finished learning about WageWorks’ process for mailing an Election Notice. The next section describes how a qualified beneficiary elects COBRA.

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Qualified Beneficiary Elects COBRA?

To elect COBRA, a qualified beneficiary or other party must complete the Election Notice and return it to WageWorks in a timely manner. Table 6 describes the three most common election scenarios. Table 6. COBRA Election Scenarios.

Scenario Description

Qualified beneficiary elects timely

WageWorks reports the election to you and sends a coupon to the qualified beneficiary.

Qualified beneficiary sends an election that’s postmarked after the election period end date or attempt to elect through the website after midnight ET

• WageWorks returns the election and a copy of the envelope to the qualified beneficiary.

• WageWorks maintains a copy of the election and the postmark.

• WageWorks notifies the qualified beneficiary that the election has been denied.

Qualified beneficiary never sends an election

• WageWorks terminates the record in our system. • WageWorks reports the non-election to you. • WageWorks does not notify the qualified beneficiary that the

election period has passed.

What’s Next

You have finished learning how a qualified beneficiary elects COBRA. The next section describes WageWorks’ process of mailing a coupon to a qualified beneficiary.

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WageWorks Mails Coupon to Qualified Beneficiary

If a qualified beneficiary elects COBRA on time, WageWorks (as a courtesy) mails a billing coupon packet to the qualified beneficiary that contains the following information: • Payment due • Coverage period • Grace date • Plan and/or coverage • Amount due by plan and/or coverage • Subsidy amount (if applicable, this is displayed on the Election Notice and the coupons) • Credit balances • Total due

Qualified beneficiaries have the option of receiving email reminders in lieu of paper coupons by selecting that feature through BeneDirect Qualified Beneficiary View.

What’s Next

You have finished learning about WageWorks’ process for mailing a coupon to a qualified beneficiary. The next section describes how a qualified beneficiary makes a payment.

Qualified Beneficiary Pays?

Qualified beneficiaries can make payments by check, money order, or certified check mailed to WageWorks’ lockbox service. Money is deposited into a single WageWorks account. ePayments can be made on BeneDirect Qualified Beneficiary View through a one-time ACH draft on a checking or savings account that must be set up every month. For proper accounting and to reduce the need for refunds, a qualified beneficiary should not remit money for premiums that have not yet been billed. If a refund to a qualified beneficiary is necessary, WageWorks does not return the qualified beneficiary’s original check (which has already been deposited) but creates and disburses a new check to the qualified beneficiary for the refund amount. If WageWorks’ lockbox service attempts to deposit a qualified beneficiary’s check and receives an insufficient funds (NSF) notice, WageWorks will notify the qualified beneficiary by mail. Table 7 describes three possible payment scenarios.

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Table 7. COBRA Payment Scenarios


Qualified beneficiary pays full amount due on or before the grace date

WageWorks posts the payment and updates the paid through date. If a qualified beneficiary pays several months in advance, WageWorks will apply the overpayment as credit balance one month at a time until the balance is exhausted. During this time, the coupons will reflect the credit balance and the amount due as $0.00.

Qualified beneficiary pays a partial amount due on or before the grace date

If a partial COBRA payment is received that is short by the lesser of $50.00 or 10% of the full premium amount due (considered an “insignificant shortfall”), WageWorks sends a letter advising the qualified beneficiary of the amount due and the date full payment is due for the shortfall (an additional period of 30 days is allowed from the day the insignificant shortfall letter is sent). If a qualified beneficiary fails to make full payment by that date, coverage is terminated and a refund is issued (as applicable). NOTE: A qualified beneficiary wishing to cancel some portion of COBRA coverage must contact WageWorks COBRA Services. Partial payment is not an acceptable means to cancel any portion of COBRA coverage.

Qualified beneficiary has a subsidy for one coverage and pays a partial amount due on or before the grace date

If a qualified beneficiary is offered a subsidy for medical, for example, and sends in a partial premium for dental coverage continuation, WageWorks sends a letter advising the qualified beneficiary of the amount due and the date full payment is due for the shortfall (an additional period of 30 days is allowed from the day the insignificant shortfall letter is sent). If a qualified beneficiary fails to make full payment for all enrolled coverages by that date, all coverage, including an coverage eligible for a subsidy, is terminated and a refund is issued (as applicable). WageWorks sends an early termination letter to the qualified beneficiary and reports the termination to you. The qualified beneficiary should contact WageWorks COBRA Services prior to the month in which he or she wishes to cancel coverage to confirm cancellation of any coverages for which they do not expect to send payment. Once this action has been completed, WageWorks COBRA Services will know how to apply any remitted funds to the remainder of the enrolled coverage.

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Table 7. COBRA Payment Scenarios (cont.)


Qualified beneficiary sends a payment that’s postmarked after the grace date

WageWorks posts the payment and tracks the postmark date, sends an early termination letter to the qualified beneficiary, and reports to you. BeneDirect Qualified Beneficiary View website will not allow payment after 12 midnight ET on the grace date.

If an untimely payment is received, WageWorks sends a refund check to the qualified beneficiary. WageWorks does not return the qualified beneficiary’s original check.

Qualified beneficiary doesn’t send a payment

WageWorks terminates the qualified beneficiary, sends an early termination letter to the qualified beneficiary, and reports the termination to you.

What’s Next You have finished learning about how a qualified beneficiary makes a payment. The next section describes WageWorks’ process when a qualified beneficiary’s coverage is continued or terminated.

Coverage Continues? A qualified beneficiary’s COBRA coverage can be continued or terminated based on a wide variety of factors. This section describes what WageWorks does when: • Coverage Continues • Coverage Is Terminated

Coverage Continues When COBRA coverage continues, WageWorks mails a new coupon to the qualified beneficiary. For more information, see “WageWorks Mails Coupon to Qualified Beneficiary.”

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Coverage Is Terminated When COBRA coverage is terminated, WageWorks sends one of two letters to the qualified beneficiary.

Early Termination of Coverage Letter An early termination of coverage letter is sent to a qualified beneficiary when COBRA is terminated for any reason before the end of the COBRA period. The letter is sent by first class mail and contains the following information:

• Date of termination • Plan name • Qualified beneficiaries • Reason for termination • How to request a review End of COBRA Period Letter An end of COBRA period letter is sent to a qualified beneficiary 45 days prior to the end of the coverage period and contains the following information: • Date of expiration • Reason for expiration • Conversion option ( if available)

What’s Next

You have finished learning about WageWorks’ process for terminating coverage. The next section describes a qualified beneficiary’s options for requesting a change in coverage.

Qualified Beneficiary Requests a Change of Coverage

Qualified beneficiaries can request a change of coverage outside the annual enrollment period for the following reasons: • Life Status Changes • Requests for COBRA Period Extensions

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Life Status Changes A qualified beneficiary can request a change of coverage by notifying WageWorks and providing documentation for any of the following life status changes: • Marriage • Birth • Adoption

Table 8 describes two possible life status change request scenarios.

Table 8. Life Status Change Request Scenarios

Scenario Description Example

Qualified beneficiary notifies WageWorks within 30 days of the date of the event

WageWorks processes the request and adds the new spouse or child to the COBRA account.

• A qualified beneficiary is married on January 2 and notifies WageWorks to add the new spouse to their COBRA coverage on January 31.

• A qualified beneficiary has a new baby on April 17 and notifies WageWorks to add the child to their COBRA coverage on May 5.

Qualified beneficiary notifies WageWorks beyond 30 days after the date of the event

WageWorks requests guidance from the client.

• A qualified beneficiary is married on January 2 and notifies WageWorks to add the new spouse to their COBRA coverage on February 28.

• A qualified beneficiary adopts a child effective April 17 and notifies WageWorks to add the new child to their COBRA coverage on 6/30.

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Requests for COBRA Period Extensions A qualified beneficiary may be eligible for an extension to the COBRA period for the following reasons: • Social Security Disability • Second Qualifying Event

If a request is deemed invalid, WageWorks mails a Notice of Unavailability of COBRA Coverage to the qualified beneficiary within 14 days of the request explaining why the extension is denied and how the qualified beneficiary can appeal.

Social Security Disability An 11-month extension of coverage may be available if any of the qualified beneficiaries covered under the qualified beneficiary’s COBRA plan is determined by the Social Security Administration (SSA) to be disabled (and the appropriate documentation is provided). The disability has to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. The qualified beneficiary must notify WageWorks COBRA Services of the disability determination prior to the last day of the initial 18-month COBRA continuation coverage period and within 60 days of the latest of: • The date the qualified beneficiary was informed (through the Summary Plan Description

or Initial General Notice of COBRA Rights) of the responsibility and procedures for informing the plan administrator of the disability determination

• The date on which the qualifying event occurred • The date coverage was lost (or would be lost), or • The date the SSA made the determination (the date of determination notice of award) If the qualified beneficiary is determined by SSA to no longer be disabled, the qualified beneficiary must notify WageWorks COBRA Services of that fact within 30 days of SSA’s determination. Second Qualifying Event WageWorks COBRA Services can support processing of a second qualifying event. If a second qualifying event occurs, a qualified beneficiary may be entitled to an additional 18-month extension of coverage. This may also be available to covered spouses and dependent children who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage (and the appropriate documentation is provided). The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months.

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COBRA regulations do not require WageWorks to request or collect documentation in most cases. The only exception is with respect to a disability extension request where we need to have the notice of award (NOA) from the Social Security Administration in order to properly make a determination on the disability extension and Medicare Entitlement. We are no longer required to provide documentation for the following MQE’s. Second qualifying event includes: • Birth – Birth certificate not required -30 days from the date of birth. We do not require a copy

of the birth certificate to add the new born. If no details about plan details are provided on the request, the new born child is only added to the medical plan.

• Death – Death certificate is not required. • Marriage: WageWorks must be notified 30 days from date of marriage. We do not require a

copy of the marriage certificate. • Adoption: WageWorks must be notified 30 days from the final adoption date. We do not

require a copy of the adoption certificate add the newly adopted child. If no details about plan details are provided on the request, the adopted child is only added to the medical plan.

• Divorce/ Legal Separation WageWorks must be notified by the covered employee as premium remains on the original record. A copy of the divorce decree is no longer required. Qualified beneficiaries can contact WageWorks’ Solution Center and provide the date of Divorce and the spouse will be converted to their own account and receive 36 months of coverage from the original QE date.

o Documentation is required when a qualified beneficiary experiences a multiple Qualifying Event for Loss of Dependent Status, Social Security Disability, and Medicare entitlement of the covered Employee:

o Loss of dependent status for a child – currently we receive direction from you or the qualified beneficiary that the covered dependent is no longer eligible.

o Medicare entitlement of the covered employee - WageWorks requires a copy of the Medicare Card to drop coverage for the covered qualified beneficiary.

Medicare entitlement rarely causes a loss of coverage under a group health plan. Typically, when a former employee on COBRA becomes entitled for Medicare, the spouse and any dependent children currently covered under COBRA are allowed to complete the remainder of the 18-month COBRA coverage period, assuming that all required premiums are paid on time.

What’s Next

You have finished learning about a qualified beneficiary’s options for requesting a change of coverage. The next section describes a qualified beneficiary’s options for appealing a decision.

Qualified Beneficiary Appeals?

WageWorks receives an initial request for reinstatement of COBRA coverage and completes an administrative review (also referred to as a first level review) of the qualified beneficiary’s record to verify administratively that the termination of coverage was appropriate. The initial request for reinstatement is typically denied if there is no evidence of administrative error

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and a letter referencing the pertinent guidelines or provisions is mailed to the qualified beneficiary. Simultaneously, the matter is referred to you for review. As the plan administrator, you are responsible for making decisions on all COBRA appeals that are referred for review. For those reviews, WageWorks COBRA Services will gather all information and documents pertinent to the denial or termination. Once all information and pertinent documents have been gathered, WageWorks COBRA Services will provide a written summary of the factual findings. For second level reviews, or when the qualified beneficiary expresses extenuating circumstances in the initial request (e.g. death of an immediate family member, medical incapacitation, hospitalization, natural disasters, house fire, catastrophic sudden illness/injury), WageWorks COBRA Services will send a summary to you, as the Plan Administrator, for approval or denial within thirty (30) days of receipt by WageWorks COBRA Services of the appeal request. You must respond in writing to WageWorks COBRA Services following the complete review of the pertinent material approving or denying the request. Upon receipt of your decision, WageWorks COBRA Services provides written notice to the qualified beneficiary unless you otherwise direct WageWorks COBRA Services that you will notify the qualified beneficiary directly. If the initial review is denied or termination is confirmed in the second review, the notice will advise of the denial and reference any pertinent guidelines or provisions on which such denial was based. If you decide to reinstate continuation coverage for the qualified beneficiary, the notice instructs the qualified beneficiary to send the applicable premium to WageWorks COBRA Services within the standard billing grace dates. You may specify that a different payment grace date be provided when approving the reinstatement. If you do not respond to WageWorks’ inquiry on a second-level appeal, WageWorks will direct the qualified beneficiary who submitted the appeal to contact you directly.

Appeals related to electing COBRA that include circumstances that may require a tolling period will be sent to the client for review and, if reinstatement is approved, the client will be asked to provide direction to WageWorks COBRA Services regarding the time frame for the qualified beneficiary to make a COBRA election.

In addition to the appeals outlined above, requests for review of 11-month extension denials as well as Annual Enrollments are also processed.

A qualified beneficiary may request a review of a denial issued for the 11-month extension due to disability. Under COBRA regulations, an extension of 11-months is available for those Qualified Beneficiaries deemed disabled by the Social Security Administration due to disability (under Title XIV or XVI of the Social Security Act). The provisions set-forth by COBRA, the 18 month COBRA period may be extended for up to eleven months, if:

• the qualified beneficiary is determined under the Social Security Act to have been

disabled at any time during the first 60 days of COBRA coverage and

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• notification is provided to the Plan Administrator of the disability determination prior to the last day of the initial 18 month COBRA coverage period and

• is within 60 days if the latest occurring event listed: o the date on which the qualifying event occurred; o the date coverage was lost; or o the date the qualified beneficiary was informed of the responsibility and procedures

for informing the plan of the disability determination. When 11-month extensions are denied based upon either not meeting one or more of the above provisions or perhaps not receiving the necessary information required to make a determination for eligibility, can be appealed by the qualified beneficiary. This type of review request is referred to you for your review and decision by providing them with the documentation received, as well as advising them of the reason for the extension denial. Annual Enrollment (AE) requests for reviews are referred to you when an active AE period has occurred, in which the selection for the next plan year’s benefits was either not received or was received after the deadline for selection of benefits. In addition, it may include requests to change the AE selection after the deadline. In any case, these types of requests for review are also referred to you for review and a decision. Documentation received along with the appeal correspondence is sent to you. Requests for review of denials of the 11-month extension and issues related to Annual Enrollment are automatically referred to you for determination. Upon receipt of your decision, notice is sent to the qualified beneficiary advising of whether the appeal was approved or denied and any necessary changes to the qualified beneficiary’s account are made.

What’s Next You have finished learning about qualified beneficiaries’ options for appealing a decision. The next section describes how a qualified beneficiary can contact WageWorks.

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How a Qualified Beneficiary Can Contact WageWorks

A qualified beneficiary can contact WageWorks COBRA Services by:

• Entering a request on BeneDirect Qualified Beneficiary View• Calling WageWorks COBRA Services during normal business hours• Mailing or faxing WageWorks

Correspondence to WageWorks that is mailed, faxed, or emailed should include the full name and BL# of the qualified beneficiary. Qualified beneficiaries who contact WageWorks must submit their correspondence in English in order for WageWorks to respond.

What’s Next

You have finished understanding WageWorks’ interaction with your qualified beneficiary.

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Exceptions/Deviations Notwithstanding anything contained in the RFP including, but not limited to, (i) Scope of Work, (ii) Insurance Requirements, (iii) Limitation of Liability Provisions, and (iv) Sample Professional Services Agreement (“County Documents”), this proposal is submitted with the understanding that the services offered and any contract entered into between the parties will be based upon the following documents, all of which are attached to this Proposal. WageWorks, however, welcomes the opportunity to negotiate the specific terms and conditions, and include certain provisions contained in the County Documents as may be relevant and mutually acceptable to both parties.

• Standard Contract Documents:

o V5 WageWorks Terms and Conditions of Service and BAAo Funding Agreement Sample – ACH Credito Funding Agreement Sample – ACH Debito Order Form Sampleo Non Discrimination Services Descriptiono Form 5500 Service Descriptiono FSA Services Descriptiono HSA Service Descriptiono COBRA Service Descriptiono Debit Card Service Description

• WageWorks’ Certificate of Insurance Liability

Year to DateDescription: Lists each participant’s Cash Balance (contributions less disbursements) and Benefit Balance (for a prefunded benefit, it is the annual election less disbursements; and for a non-prefunded benefit, it is the contributions less disbursements). The report will list activity based on today’s date or a user defined date range.

Use: The report is used to view year to date contributions, payments and remaining balances by participant. It also provides company totals (cash balance), which enables employers to reconcile total plan transactions to the general ledger. For more participant level detail, the year to date report can be run to include reconciliation fields and exported to a flat file.

Company Eligibility ReportDescription: Lists all eligible participants in each benefit plan (excluding Health Savings Accounts).

Use: This report is used to identify eligible parti-cipants in all benefits offered by an employer. The balance displays the total amount available to participants to pay future manual claims or debit card purchases.

Bank ReconciliationDescription: Displays the financial account activity for a user defined date range (excluding Health Savings Accounts). The maximum range of this report is 93 days. Participant detail is available for a 31-day period.

Use: This report is used by employers to re-concile their plan transaction activity to their periodic bank statement.

Standard ContributionDescription: Displays per paycheck deduction for each participant per benefit.

Use: This report should be reviewed before each pay period to ensure it reconciles to the next expected payroll deduction amount.

Check RegisterDescription: Displays checks and ACHs disbursed to participants by benefit for a user-defined date range in a detailed or summary view. It also includes voided checks.

Use: This report should be used to enter dis-bursements as general ledger entries and/or to balance cash (if an employer’s bank account is used for disbursements).

Enrollment Payroll DeductionDescription: This report is used during open enrollment to display the per paycheck deduction amount for each employee for a New Plan Year.

Use: During open enrollment this report can be run to identify per paycheck contribution amounts for posted enrollments.

Company Purchased Debit CardsDescription: Displays all debit cards ordered within a user defined date range.

Use: This report should be used to identify debit cards ordered for billing purposes.

Participants with Balance DueDescription: Shows all participants with a debit card swipe deemed as a non-qualified expense or an incorrect payment from the plan.

Use: This report should be used to identify which participants owe funds to the plan.

NQE Amounts Repaid OnlineDescription: Displays non-qualified expenses repaid online (by credit card or e-check) by participants. Non-qualified expenses can occur in the following circumstances:1. When a paid debit card claim is adjusted as a

result of a card swipe for an ineligible expense.2. When a manual claim is paid out in error

due to a duplicate submission or another adjustment.

Use: This report is used for general ledger entries or cash reconciliation when the employer’s bank account is used for disbursements.

Directory of Reports

e F l ex O n l i n e

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Debit Card SettlementDescription: Displays debit card settlement transactions for a user defined date range.

Use: This report is used to reconcile the employer’s bank account when the employer’s bank is used to fund debit card activity.

Statement of AccountsDescription: Displays a participant’s statement with detailed transaction activity for plan years (current and/or previous). This report does not disclose merchants or service providers.

Use: This report is used to view a PDF of a participant’s statement. This is the same PDF that a participant sees when they run a statement from MyFlexOnline.

Contribution BatchDescription: Displays participant contribution amounts by selected contribution batch.

Use: This report is used to verify the per pay period contributions that were posted to a participant’s account. The user selects a date range and identifies the contribution batches they wish to view.

HSA Contribution BatchDescription: Displays participant HSA contri-bution amounts which were created and posted by your plan service provider. The report displays activity by contribution batch.

Use: This report is used to view/verify the per pay period HSA contributions that your plan service provider posted to participant accounts. The user selects a date range and identifies the contribution batch they wish to view. It does not display contributions made by participants or employers that are directly posted at the HSA Bank website.

Debit Card Listing DetailDescription: Displays a listing of all cards ordered for an employer. This report also displays each participant’s debit card status, expiration date and extra card information (secondary cards).

Use: This report is used to see detailed debit card information for an entire participant population of an employer.

ExceptionDescription: For a terminated participant, this report lists payments made after the Termination Date or payments made after Grace Days After Termination.

Use: The report is used to identify payments that occur after a participant’s Termination Date or Grace Days After Termination.

Contribution DefinitionDescription: Displays a listing of all the Contri-bution Definitions (Contribution Criteria) for an employer. The report includes the Contribution Definition Name, Election Patterns, Recurrences, and Exceptions.

Use: The report is used to review and audit Contribution Definitions (Contribution Criteria) for an employer.

Contribution DatesDescription: Displays a listing of Contribution Dates assigned to the employer for the selected date range. When setting the date range, the Contribution Dates report can look either 12-months forward or backward from the current day.

Use: The report is used to review and audit Contribution Dates. This can be used as a tool to identify if any contribution dates are missing or to determine when the next contribution cycle is scheduled to run.

Post Disbursement Funding TransactionsDescription: Displays a list of disbursement transactions, including Claims (Check and ACH), Debit Card Settlements, Invoices issued, and Payments received. The Funding Transactions report includes the options to display trans-actions processed for a user assigned number of days, specific date range, invoice number, or all transactions.

Use: The report is used to review and audit Post Disbursement Funding Transactions.

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© 2014 WageWorks, Inc. 3165 (10/2014)

Post Disbursement Funding BalancesDescription: Displays the total balance for cash funding. To calculate the companies balance, the report subtracts the total amount disbursed from the total amount received.

Use: The report is used to view the company’s disbursement funding balance.

Post Disbursement Funding Invoice DetailDescription: Displays the disbursement details that were included in each emailed invoice. The report includes the Invoice Number, Invoice Date, Invoice Amount, and Balance Due. Additionally, it displays the summary amount of all transaction types for each invoice, including the Transaction Date, Transaction Type, Batch Number, and Amount.

Use: The report can be used to verify the disbursement detail for a single invoice or multiple invoices.

Post Disbursement Funding Invoice Employee Detail

Description: Displays disbursement transactions by employee for the Post Disbursement Funding invoices. The transactions are grouped by Company Code, then Invoice Number, and then Transaction Date. The report also displays the following fields: Transaction Type, Batch Number, Employee Name, Employee Number, Date Paid, Check or ACH, Check/ACH Number, Plan Year, Benefit, Department, and Amount (of the transaction).

Use: The report can be used to verify employee disbursement detail for a single invoice or multiple invoices based on a specific number of days, a date range, or invoice number.

Post Disbursement Funding Invoice Summary

Description: The Invoice Summary report displays a list of Post Disbursement Funding invoices for your plan. The report displays the Invoice Number, Date, Amount Invoiced, Amount Received, Amount Refunded, and Balance.

Use: This report is used to reconcile the amount invoiced to the amount received by your administrator (for each invoice).

Post Disbursement Funding Invoice AgingDescription: Displays a summary of outstanding invoices for your company. The report includes the option to view the invoice aging information in summary or detail. The invoice information is displayed in columns by the age of the invoices: 30, 60, 90, or 91 plus days.

Use: Allows employers to review and report on any outstanding invoice that are unpaid and aging.


Health Savings Account Fee and Interest Schedule Effective as of July 24, 2013

Fees_Custom_C6_082214_GOE.docx

HSA Bank wants you to understand the fees associated with your Health Savings Account (HSA). For details regarding the general terms and conditions that

apply to your HSA, see the Deposit Account Agreement and Disclosures for Health Saving Accounts.

Standard Fee

Monthly Account Maintenance* No charge to your account.

*If your employment status changes, your monthly account fee may change.

Service Fees Description Amount How to Avoid Fee

Paper Account Statement $0.75 Elect to receive free e-statements through Internet Banking.

Duplicate Copy of Paper Account Statement $4.00 View and print prior 18 months of statements through Internet Banking.

Copy of Check $4.00 Keep records of the checks written from your HSA.

Returned Deposited Check $25.00 Verify funds are available to cover the amount you deposit into your HSA.

Stop Payment $25.00 You will only incur this fee if you request HSA Bank to stop payment on a check or an

electronic payment.

Non-Sufficient Funds (NSF) $30.00 Check your available account balance online before you withdraw funds.

Manual Withdrawal $4.00 Use online transfers, through Internet Banking, to access your funds.

Excess Contribution $25.00 Contribute no more than the annual IRS limits.

Wire Transfer (sent and received) $25.00 Use online transfers, through Internet Banking, to access and contribute HSA funds.

Duplicate Copy of Tax Document $4.00 View or print copies of your tax documents through Internet Banking.

Transaction Correction $25.00 You will incur this fee if you request a change to the contribution type (Pretax or Post tax

or Employer). You will incur this fee if you request a correction to the tax year of a

contribution and/or distribution. You will incur this fee if you request a change in the

dollar amount of a processed contribution or distribution. Any related amendments to

an IRS filing as a result of this change will be included in this fee charge.

Account Closing

(within 24 months of account opening)

$25.00 If you lose your HDHP coverage, you can continue to use your HSA funds for eligible

expenses.

Minimum Account Balance and How We Determine the Interest Rate There is no minimum account balance required to open a health savings account or to obtain the annual percentage yield disclosed. We use the daily

balance method to calculate the interest on your account. The daily balance method applies a daily periodic rate to the principal in the account each day.

Interest is compounded monthly and credited monthly. Interest begins to accrue no later than the business day that we receive credit for the deposit of

non-cash items (for example, checks). The interest rate and annual percentage yield (APY) is based on the balance in your account. The interest rate and

annual percentage yield available on your account is as follows, effective as of

September 1, 2014.

Daily Balance Interest Rate* APY

$25,000 or more 1.49% 1.50%

$15,000.00 - $24,999.99 1.49% 1.50%

$10,000.00 - $14,999.99 1.49% 1.50%

$5,000.00 - $9,999.99 0.20% 0.20%

$2,500.00 - $4,999.99 0.10% 0.10%

Less Than $2,500 0.05% 0.05%

*This interest rate is subject to change at our discretion at any time. Fees may reduce your earnings.

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WageWorks, Inc. General Terms & Conditions of Service V.1/8/18

WageWorks, Inc. General Terms and Conditions of Service

These General Terms and Conditions of Service govern WageWorks’ provision of services to you, the client, and shall be read in conjunction with each Order Form, which identifies the services (“Services”) purchased by you, as well as each Funding Agreement (if applicable). Some of these terms and conditions may not be applicable to you or the purchased Services. 1. Plan Administrator; Fiduciary You acknowledge and agree that you are the “plan administrator” and “fiduciary” within the meaning of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”) (to the extent such law applies) of any and all employee benefit plans or programs (each a “Plan” or, collectively, the “Plans”) sponsored by you, and that WageWorks is an independent contractor engaged to perform the agreed upon Services. 2. Term The term of the provision of each Service is set forth on the applicable Order Form. These General Terms and Conditions of Service shall remain in effect for so long as WageWorks provides Services pursuant to any Order Form. The term of each Service shall automatically renew for successive one (1) year periods, unless earlier terminated by either party as set forth below. 3. Fees; Payment You shall pay WageWorks the fees (“Fees”) listed in the relevant Order Form pursuant to the payment method set forth therein (unless otherwise specified). All undisputed Fees shall be paid net thirty (30) days from the invoice date (unless otherwise specified). You must submit written notice to WageWorks and provide supporting documentation as to any Fees you dispute within thirty (30) days from the date of the invoice. WageWorks shall provide a written response within thirty (30) days of receipt of the notice. Upon resolution, you shall pay any and all outstanding amounts due and owing within five (5) business days of such resolution. WageWorks shall have the right to increase Fees after the first year of Service on an annual basis by three percent (3%) . The new Fees shall take effect on the first day of second year of Service and each annual date thereafter. All services not set forth in the Order Form may be subject to additional fees (e.g. additional services required as a result of legislative changes, correction services, customization, etc.). Any payments received that do not include the information necessary to identify the invoice to which the payment is to be applied will be applied at WageWorks’ discretion. WageWorks is not responsible for reconciling such payments against information you may be maintaining separately. The Fees described herein represent only those fees charged by WageWorks to you. They do not include or cover fees and/or charges that a third party service provider, including a Health Savings Account (“HSA") custodian bank, may directly charge your employee participants for services they receive from such third parties. Any and all such fees and charges that may be charged to an individual, including deductions made from an individual’s account (e.g., an HSA) or otherwise, by such third party service provider are detailed in the individual agreement(s) entered into by and between the third party service provider, including an HSA custodian bank, and each individual employee participant, which may include but are not limited to Accountholder Agreements, Participant Terms and Conditions and other ancillary agreements. 4. Taxes; Regulatory Fees


You shall be responsible for, and shall promptly pay or reimburse WageWorks for any taxes, as well as any benefit or plan-related charge, surcharge or assessment, imposed as a result of the provision of Services by WageWorks. 5. Benefit Claims Funding You shall timely provide to WageWorks all benefit claims funding amounts (“Funding”). You acknowledge and agree that any Funding submitted by you to WageWorks: (i) shall be comprised of general assets; (ii) does not consist of Plan assets or participant/employee contributions, whether made by salary reduction or otherwise, within the meaning of ERISA, without regard to whether ERISA applies, and is not otherwise subject to any restrictions; and (iii) shall not be segregated or set aside in a trust or escrow account by WageWorks. You agree to pay WageWorks the entire amount delivered, or deliverable, to participants in any Plan, regardless of whether you collect sufficient payroll deductions from your participants. 6. Maintenance WageWorks reserves the right to perform routine system (both web and IVR) maintenance during off-hours (normally between 9 PM and 5 AM ET). Any longer maintenance period will be posted on WageWorks’ website. 7. Termination

a. Termination for Convenience. Either party may terminate a Service without cause after completion of the first year of the initial term of that Service upon at least thirty (30) days’ prior written notice to the other party.

b. Termination for Material Breach. Either party may terminate a Service with cause upon thirty (30) days’

prior written notice to the defaulting party if such material breach is not cured within that period, if curable.

c. Termination for Bankruptcy, Insolvency, or Business Wind Down. Either party may terminate a Service immediately if either party (i) voluntarily files for bankruptcy; (ii) declares insolvency; (iii) takes action to commence winding down its business; or (iv) is named as a defendant in any involuntary bankruptcy or insolvency proceeding.

d. Termination Due to Legislative and/or Regulatory Changes. Either party shall have the right to terminate

a Service if a material change to such Service is required as a result of a legislative and/or regulatory change. Upon receipt of written notice of such change, the parties shall meet and confer in good faith. If the parties do not reach agreement on any such modification of the Service, then either party shall have the right to terminate the Service thereafter upon thirty (30) days’ prior written notice to the other party.

e. Effect of Termination. Upon termination of a Service, all rights and licenses granted to you with respect to

that Service shall immediately terminate. You shall be responsible to pay all amounts due and owing upon termination. You shall have the ability to access and download your records and reports via WageWorks’ website up through the date of termination.

8. Intellectual Property

a. Ownership. WageWorks owns and shall retain all right, title and interest (including, without limitation, all intellectual property rights) in and to all software, web pages, documents, processes, and other information, equipment and materials used in connection with the provision of Services hereunder, including, without limitation, those developed by WageWorks for use by you, participants and beneficiaries (the “WageWorks System”).


b. Grant of License. WageWorks grants you, as well as the participants and beneficiaries, a limited, non-exclusive, non-transferable license to access and use the WageWorks System during the applicable term, solely and exclusively: (i) in accordance with these General Terms and Conditions of Service and any instructions, user guides, and policies made available by WageWorks; and (ii) for the purpose of receiving the Services provided by WageWorks. Without limiting the generality of the foregoing, you shall not, (i) without WageWorks’ prior written consent, disclose or provide access to the WageWorks System to any unauthorized third parties, or (ii) duplicate the WageWorks System (or any associated materials) or use the same in connection with any other benefits program (including your programs).

c. Exclusion. All other rights, license and title in and to the WageWorks System not expressly granted

hereunder shall remain the property of WageWorks.

9. Exclusive Warranty WageWorks warrants that the Services will be performed in accordance with generally accepted industry practices and with reasonable skill and care. THE WAGEWORKS SYSTEM AND SERVICES ARE PROVIDED “AS IS” WITHOUT ANY FURTHER WARRANTY OF ANY KIND (EXPRESS OR IMPLIED) INCLUDING, WITHOUT LIMITATION, THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, WHICH WARRANTIES ARE HEREBY EXPRESSLY DISCLAIMED. 10. Indemnification Each party shall indemnify, defend and hold harmless the other party and its officers, directors, shareholders, employees and agents (“Indemnified Parties”) from and against claims and proceedings for actual damages or losses (including legal fees and expenses) arising out of any actual or alleged: (i) breach by such party of its obligations hereunder; (ii) negligence or willful misconduct of such party or its employees, officers or agents; (iii) failure of such party to comply with applicable law (except, with respect to WageWorks, if such act or omission taken by WageWorks is pursuant to your instructions); or (iv) claims in which one party is named or joined with the other party when such party has not engaged in any wrongful acts. In addition, you shall indemnify, defend and hold harmless WageWorks Indemnified Parties for any act or omission taken by WageWorks pursuant to your instructions. The Indemnified Parties will promptly notify the indemnifying party of any claim. The indemnifying party shall assume and have sole control of the defense of such claim; provided, however, that neither party may settle any claim without the prior written consent of the other party if such settlement exposes the other party to any liability. 11. Limitation of Liability IN NO EVENT SHALL EITHER PARTY BE LIABLE TO THE OTHER FOR ANY INCIDENTAL, CONSEQUENTIAL, SPECIAL, OR PUNITIVE DAMAGES (INCLUDING, WITHOUT LIMITATION, LOST PROFITS, LOST BUSINESS, LOSS OF DATA OR COST OF SUBSTITUTE SERVICES) ARISING OUT OF OR IN CONNECTION WITH ANY AGREEMENT BETWEEN THE PARTIES, THE WAGEWORKS SYSTEM OR THE SERVICES PERFORMED THEREUNDER UNDER ANY THEORY OF LIABILITY (WHETHER IN CONTRACT, TORT, STRICT LIABILITY OR OTHERWISE). IN ADDITION, EXCEPT FOR BREACHES OF CONFIDENTIALITY OR PRIVACY, WAGEWORKS SHALL ONLY BE LIABLE TO YOU FOR ANY DIRECT DAMAGES IN AMOUNT EQUAL TO (A) ACTUAL DAMAGES OR (B) THE FEES PAYABLE TO WAGEWORKS FOR THE SERVICE(S) GIVING RISE TO THE CLAIM DURING THE PLAN YEAR IN WHICH THE EVENT OCCURS, WHICHEVER IS LESS.


12. Confidentiality

a. Confidential Information. Each party acknowledges that performance of Services may involve access to and disclosure of Confidential Information that belongs to the other party. “Confidential Information” means any non-public confidential or proprietary information, including, without limitation, business and financial information; policies and procedures; operations; customer and potential customer names; suppliers and vendor names; trade secrets; trade dress; patent applications; inventions disclosures; and, with respect to Plan participants and beneficiaries, personal identification information. Confidential Information does not, however, include any information that: (i) was publicly available or released to the public domain at any time prior to disclosure by one party, (ii) becomes publicly known or generally available after disclosure by one party through no wrongful action or inaction of the other party, (iii) information that is in the party’s possession or known by the party at any time prior to the time of disclosure; (iv) is rightfully disclosed to the party by a third party that is not subject to any restrictions; or (v) a party can demonstrate was independently developed by that party without use of the other party’s Confidential Information.

b. Restricted Use. No Confidential Information shall be disclosed to any third party other than representatives

of such party who have a “need to know” such Confidential Information, provided that such representatives are informed of the confidentiality provisions hereof and agree to abide by them.

c. Disclosure. In the event a party is required by law to disclose Confidential Information, the disclosing party

shall immediately notify the other party in writing, describing the circumstances of and extent of the disclosure.

d. Return or Destruction. Upon termination of all Order Forms, each party, upon the request of the other, will

return or destroy all copies of all of the other's Confidential Information in its possession or control (unless impracticable), except to the extent such Confidential Information must be retained pursuant to applicable law or a party’s document retention policy.

e. Remedies. The parties acknowledge that compliance with the provisions of the foregoing paragraphs are

necessary to protect their businesses and goodwill and that any actual or prospective breach will irreparably cause damage to them, for which money damages may not be adequate. Therefore, the parties agree that if one of them breaches, or attempts to breach, the confidentiality obligations set forth herein, the other party shall be entitled to obtain temporary, preliminary and/or permanent equitable relief, without bond, to restrain such breach, together with any and all other legal and equitable remedies available under applicable law or as set forth herein.

13. Privacy In addition to any confidentiality obligations set forth herein, any personally identifiable information (e.g., name, address, age, and social security number) collected or obtained by WageWorks in the course of performing Services (the “Privacy Restricted Data”) will be collected, stored, maintained, accessed, used and disclosed in accordance with any applicable federal, state and local privacy laws that govern the collection, storage, maintenance, access, use or disclosure of such Privacy Restricted Data (the “Privacy Laws”). WageWorks shall, at all times, perform Services so as not to cause you to be in violation of the Privacy Laws. WageWorks shall be fully responsible for any collection, access, use and disclosure of Privacy Restricted Data that is based on its actions or inactions that are in violation of any Privacy Laws. WageWorks shall notify you as soon as administratively practicable of any breaches of security that may result or may have resulted in the unauthorized collection, access, use or disclosure of Privacy Restricted Data that is, or may be, in violation of any Privacy Laws. WageWorks shall make all reasonable efforts to assist you in relation to the investigation and remedy of any such breach of security and any resulting claim, allegation, action, suit, proceeding or litigation with respect to WageWorks’ unauthorized


collection, access, use or disclosure of Privacy Restricted Data that is in violation of any Privacy Laws. WageWorks shall be responsible for the cost of its violation of any Privacy Laws with respect to the Privacy Restricted Data, including, without limitation, remedial activity, notification of Plan participants and beneficiaries, and fines and/or penalties. 14. Miscellaneous

a. Publicity. With your prior consent, WageWorks shall be permitted to use your name and logo in sales presentations and in any filings with the Securities and Exchange Commission, and shall be permitted to reference your name in any of its earnings calls.

b. Subcontractors. WageWorks utilizes subcontractors to perform certain Services. WageWorks shall be liable for the acts or omissions of its subcontractors. For clarification, HSA custodian banks and/or trustees are not subcontractors of WageWorks and any agreement(s), including an Accountholder Agreement, entered into between the custodian bank and each individual HSA accountholder controls the terms under which the HSA is maintained by the custodian bank, including the rights of the custodian bank to charge fees or other amounts to individual HSA accountholders for services.

c. Massachusetts Data Security Regulations (201 CMR 17.00). WageWorks certifies that it has in place and

shall maintain during the provision of Services, a written comprehensive security program that is in compliance with the provisions of 201 CMR 17.00, et seq., at http://www.mass.gov/ocabr/docs/idtheft/201cmr1700reg.pdf.

d. Tennessee Insurance Code, Sections 56-6-403 through 56-6-409. WageWorks certifies that it shall provide

Services in compliance with the provisions of Sections 56-6-403 through 56-6-409 of the Tennessee Insurance Code at http://www.lexisnexis.com/hottopics/tncode/, as applicable.

e. Third Party Sender. As a Third Party Sender under National Automated Clearing House Association

(“NACHA”) rules and regulations, you acknowledge and agree that WageWorks must perform a certain level of due diligence on you and that part of such diligence requires that you make certain representations and warranties in order for WageWorks to be able to originate ACH transactions on your behalf. Accordingly, you (i) authorize WageWorks to originate transactions on your behalf, (ii) agree to be bound by applicable NACHA rules, (iii) agree not to originate transactions that violate U.S. laws, and (iv) agree to provide written notice to WageWorks if there are any restrictions on the type of transactions that may be originated and, if there are, to describe such restrictions. You further acknowledge and agree that in addition to other termination rights outlined herein, that WageWorks has the right to terminate or suspend the Services if you violate any applicable NACHA rules. You additionally acknowledge and agree that WageWorks and the originating depository financial institution have the right to audit your compliance with the NACHA Rules and the terms of this provision with reasonable notice, during normal business hours.

f. Records Maintenance and Disposition. WageWorks shall keep and archive records of information and data regarding you and your Plan(s) that it obtains in connection with the provision of Services hereunder (collectively “Service Records”) for the longer of seven (7) years or the period required by applicable law.

g. Escheatment. You shall be solely responsible for compliance with all escheatment obligations.

h. Assignment. Neither of us may assign any of our rights and obligations in connection with the provision of

Services without the prior written consent of the other, which consent shall not be unreasonably withheld. These General Terms and Conditions of Service shall be binding upon and shall inure to the benefit of a party’s authorized successors and assigns.


i. Notices. All notices shall be made in writing and delivered (i) in person, (ii) by certified mail, return receipt

requested, (iii) by traceable overnight delivery or (iv) by electronically confirmed facsimile or electronic mail, followed immediately by U.S. Mail to WageWorks at 1100 Park Place, 4th Floor, San Mateo, CA 94403, Attn: General Counsel, or to you at the address listed on the Order Form. A signed receipt shall be obtained where a notice is delivered in person. Notice will be effective upon delivery.

j. Force Majeure. Neither party shall be liable in any way for any delay or any failure of performance of a

Service, or for any loss or damage related thereto, due to any cause beyond its reasonable control, including, without limitation, acts of nature, terrorism, civil unrest, war (whether declared or not) or the Government, earthquakes, fire, floods, degradation or disruption of any communication service not under a party’s control, loss of electrical power, congestion, failure or other inability to access the Internet or disruption in the financial markets or the banking system.

k. Amendments.

These General Terms and Conditions, as well as any Order Form or Funding Agreement, may only be amended in a writing signed by both parties. Notwithstanding the foregoing, WageWorks may make non-material change to these General Terms and Conditions of Service at any time by posting revised General Terms and Conditions of Service at https://www.wageworks.com/employer/terms_conditions.htm. A non-material change is any modification that does not have an adverse impact on you or the Services provided hereunder. You are responsible for regularly reviewing this site to obtain timely notice of such amendments. You shall be deemed to accept the amended General Terms and Conditions of Service by your continued receipt of Services if you do not notify WageWorks of your good faith objection within thirty (30) days after such amended terms and conditions have been posted. If WageWorks does not agree to waive the amended terms and conditions to which you object, either party shall have the right to immediately terminate Services without penalty.

l. Waiver. Any waiver of any provision set forth herein, or any Order Form and/or Funding Agreement,

shall be effective only if in writing and signed by both parties. Failure of either party to insist on performance of any term or condition, or to exercise any right or privilege, shall not be construed as a continuing or future waiver of such term, condition, right or privilege.

m. Governing Law. Any claims arising under or related to the provision of Services shall be governed by the

laws of the State of California, without regard to its conflicts of laws principles.

n. Severability. If any provision in these General Terms and Conditions of Service, an Order Form and/or Funding Agreement is held to be invalid or unenforceable, such provision shall be deemed deleted and the remaining provisions shall continue in full force and effect.

o. Entire Agreement. These General Terms and Conditions of Service and any related Order Form and/or

Funding Agreement (if applicable) constitute the full and complete understanding and agreement of the parties relating to the subject matter hereof and supersede all prior understandings and agreements relating to such subject matter. In case of a conflict between these General Terms and Conditions of Service and an Order Form or Funding Agreement, the Order Form or Funding Agreement shall prevail. Any conflict between an Order Form and a Funding Agreement, the Funding Agreement shall prevail. In addition to the foregoing, these General Terms and Conditions of Service, and any Order Form and/or Funding Agreement, shall prevail over any additional or different provisions in any purchase order, acceptance notice, or other similar document issued by you, which provisions shall be of no force or effect.


p. Survival. The following Sections shall survive the termination of all Order Forms: Effect of Termination, Intellectual Property, Warranty, Indemnification, Limitation of Liability, Confidentiality, Privacy, Records Maintenance and Disposition, Escheatment, Notices, Governing Law, Disputes, Entire Agreement and Survival.

[V.1/8/18]


Business Associate Agreement This Business Associate Agreement ("Agreement") is made and entered into by and between you, as our client, and WageWorks, Inc. (and its subsidiaries), as your service provider, pursuant to the Service Agreement entered into by and between us on even date herewith. This Agreement is incorporated by reference into the Service Agreement, supersedes any prior Business Associate Agreement we have been party to and reflects the Omnibus HITECH Act Final Regulations as of January 25, 2013. 1. Definitions Unless otherwise defined, terms used in this Agreement have the same meaning as those terms in the Standards for Privacy of Individually Identifiable Health Information or the HIPAA Security Standards ("HIPAA Privacy & Security Rules"), found at 45 CFR Parts 160-164.

a. “Agreement” means this Business Associate Agreement.

b. “Business Associate” means WageWorks, Inc. and its subsidiaries.

c. “Covered Entity” means you.

d. “HITECH Act” means the HITECH Act of the American Recovery and Reinvestment Act of 2009 (Title XIII, Subtitle D of P.L. 111-5), enacted February 17, 2009 (codified at 42 USC § 17921 et seq.).

e. “Service Agreement” means the Order Form(s) and General Terms and Conditions of Service. 2. Obligations and Activities of Business Associate

a. Use or Disclosure of Protected Health Information. Business Associate agrees not to use or disclose Protected Health Information, other than as permitted or required by this Agreement or as required by Law. All data transmissions shall be encrypted.

b. Safeguards. Business Associate agrees to use appropriate safeguards to prevent use or disclosure of the Protected Health Information other than as provided for by this Agreement.

c. Duty to Mitigate. Business Associate agrees to mitigate, to the extent practicable, any harmful effect that is known to Business Associate of a use or disclosure of Protected Health Information by Business Associate in violation of the requirements of this Agreement.

d. Duty to Report Violations. Business Associate agrees to report to Covered Entity any use or disclosure of the Protected Health Information not provided for by this Agreement of which it becomes aware, including, where there is a breach of Protected Health Information, the identities of any individual whose Protected Health Information was breached and the data elements disclosed.

e. Agents. In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), Business Associate agrees to ensure that any subcontractors that create, receive, maintain, or transmit Protected Health Information on behalf of Business Associate agree to the same restrictions, conditions, and requirements that apply to Business Associate with respect to such information.

f. Access to Secretary. Business Associate agrees to make internal practices, books, and records, including policies and procedures and Protected Health Information, relating to the use and disclosure of Protected


Health Information received from, or created or received by Business Associate on behalf of, Covered Entity available to the Secretary of Health and Human Services, for purposes of the Secretary determining Covered Entity's compliance with the HIPAA Privacy & Security Rules.

g. Access to Individuals. Business Associate agrees to provide individuals with access to their Protected Health Information, as held in a Designated Record Set by Business Associate, in order to meet the requirements under 45 CFR 164.524.

h. Amendment of Protected Health Information. Business Associate agrees to make any amendment(s) to Protected Health Information it holds in a Designated Record Set, as directed by the Covered Entity pursuant to 45 CFR 164.526.

i. Accounting of Disclosures. Business Associate agrees to document and provide a description of any disclosures of Protected Health Information and information related to such disclosures as would be required for Covered Entity to respond to a request by an Individual for an accounting of disclosures of Protected Health Information in accordance with 45 CFR 164.528. Business Associate agrees to provide such information to Covered Entity, or to an Individual at the direction of the Covered Entity, in order for Covered Entity to comply with the accounting requirements in 45 CFR 164.528.

j. Covered Entity's Right to Restrict. Business Associate agrees to comply, upon communication by Covered Entity, with any restrictions to the use or disclosure of Protected Health Information that Covered Entity has agreed to in accordance with 45 CFR 164.522.

k. HIPAA Security Standards. i. Business Associate agrees to comply with the HIPAA Privacy & Security Rules with respect to any

Electronic Protected Health Information that Business Associate holds on behalf of the Plan.

ii. Business Associate agrees to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with respect to Electronic Protected Health Information to prevent use or disclosure of Protected Health Information other than as provided for by the Agreement.

iii. Business Associate agrees to implement administrative, physical, and technical safeguards that

reasonably and appropriately protect the confidentiality, integrity, and availability of the Electronic Protected Health Information that it creates, receives, maintains, or transmits on behalf of Covered Entity, as required in the HIPAA Privacy & Security Rules.

iv. Business Associate agrees to ensure that any agent, including a subcontractor, to whom it provides

Electronic Protected Health Information agrees to implement reasonable and appropriate safeguards to protect such information.

v. Business Associate agrees to report to Covered Entity any security incident under the HIPAA Privacy

& Security Rules of which it becomes aware, including the identities of any individual whose Electronic Protected Health Information was breached.

3. Responsibilities If Security Breach.

Business Associate shall notify Covered Entity immediately if there is a breach by either Business Associate or one of its agents of unsecured protected health information, as defined in, and consistent with, the HITECH Act and any regulations or guidance issued thereunder, including 45 CFR Part 164, Subpart D. Such notification shall:


a. Be made in writing to the Covered Entity's Privacy Officer. b. Be made within ten (10) days of discovery. c. Include the names of the individuals whose information was breached, the circumstances surrounding the

breach, the date of the breach and date of discovery, the information breached, any steps the individuals should take to protect themselves, the steps Business Associate (or its agent) is taking to investigate the breach, mitigate losses, and protect against future breaches, and a contact person for more information.

If requested by Business Associate, Covered Entity shall allow Business Associate to approve the content of any notification in advance.

If requested by Covered Entity, Business Associate shall notify the individuals involved, or the media or the US Department of Health and Human Services, as applicable, in accordance with the HITECH Act, and regulations or guidance issued thereunder, including 45 CFR Part 164, Subpart D. For purposes of this provision, Business Associate is considered an independent contractor of Covered Entity. 4. Permitted Uses and Disclosures by Business Associate

a. Disclosures Generally. Except as otherwise provided in this Agreement, Business Associate may use or

disclose Protected Health Information to perform functions, activities, or services for, or on behalf of, Covered Entity as specified in the Service Agreement, provided that such use or disclosure would not violate the HIPAA Privacy & Security Rules if done by Covered Entity or the minimum necessary policies and procedures of the Covered Entity.

b. To Carry Out Covered Entity Obligations. To the extent Business Associate is to carry out one or more of Covered Entity’s obligations under Subpart E of 45 CFR Part 164, Business Associate agrees to comply with the requirements of Subpart E that apply to the Covered Entity in the performance of such obligations.

c. Management & Administration. i. Business Associate may use Protected Health Information for the proper management and

administration of Business Associate or to carry out the legal responsibilities of Business Associate.

ii. Business Associate may disclose Protected Health Information for the proper management and administration of Business Associate, provided that disclosures are: (a) required by law or (b) Business Associate obtains reasonable assurances from the person to whom the information is disclosed that it will remain confidential and used or further disclosed only as required by law or for the purpose for which it is disclosed to the person, and the person notifies Business Associate of any instances of which it is aware in which the confidentiality of the information has been breached.

d. Data Aggregation & De-Identification. Except as otherwise limited in this Agreement, Business Associate

may use Protected Health Information to provide Data Aggregation services to Covered Entity or to de-identify Protected Health Information. Once information is de-identified this Business Associate Agreement shall not apply.

e. Required By Law. Business Associate may use or disclose Protected Health Information as required by law.


5. Term and Termination

a. Term. This Agreement shall remain in effect for the term of the applicable Service Agreement. Upon termination of the Service Agreement, Business Associate will retain no copies of the Protected Health Information and will return or destroy the same. If such return or destruction is not feasible, Business Associate will continue to extend the protections afforded to Protected Health Information hereunder. This provision also applies to Protected Health Information that is in the possession of subcontractors or agents of Business Associate.

b. Termination for Cause. Upon Covered Entity's knowledge of a material breach of this Agreement by Business Associate, Covered Entity is authorized to terminate this Agreement and the Service Agreement.

c. Survival. The rights and obligations of Business Associate under this Agreement will survive the termination of this Agreement.

6. Miscellaneous

a. Compliance with Laws and Regulations. The HITECH Act requires federal agencies to establish rules and

regulations regarding the privacy and security of Protected Health Information. Business Associate will ensure that its privacy and security procedures are compliant with the HITECH Act and any rules and regulations issued thereunder with respect to Covered Entity's Protected Health Information. The parties agree to amend this Agreement to comply with applicable requirements of the HITECH Act, where necessary.

b. Relationship of Parties. The parties intend that Business Associate is an independent contractor and not an agent of Covered Entity.

[BAA –V.06/23/15]

Order Form (SAMPLE)

Client: Client Name: [NAME] Client Address: [ADDRESS]

Effective Date*: [XX/XX/XXXX] Payment Method: [ACH Debit / Check / Wire/ACH Credit]

End Date: [XX/XX/XXXX] Payment Terms: Net 30 days Service Charge on Overdue Amounts: 2% Per Month

Products: (Products May Vary) Product Name Fee Type Fee Description Commuter Flat Admin Fee PPPM Commuter Tier Details Below Commuter Monthly Minimum $0.00 Commuter Implementation Fee $0.00 FSA Admin Fee $0.00 PPPM Per Participant Per Month FSA Monthly Minimum $0.00 FSA Implementation Fee $0.00 HSA Admin Fee $0.00 PAPM Per Account Per Month HSA Monthly Minimum $0.00 HSA Implementation Fee $0.00 Gym Reimbursement

Admin Fee $0.00 PEPM Per Eligible Per Month

Gym Reimbursement

Monthly Minimum $0.00

Gym Reimbursement

Implementation Fee $0.00

Adoption Assistance Admin Fee $0.00 PEPM Per Eligible Per Month Adoption Assistance Monthly Minimum $0.00 Adoption Assistance Implementation Fee $0.00 COBRA Admin Fee $0.00 PEPM Per Eligible Per Month COBRA Monthly Minimum $0.00 COBRA Implementation Fee $0.00 COBRA Open Enrollment - Full Service

Additional Service Fee

$0.00 Includes WageWorks standard Open Enrollment letter, WageWorks standard rate change notification, WageWorks standard Open Enrollment Change Form, Employer provided enclosures. NOTE: Postage will be billed to Client for USPS First Class Mail along with print and/or copying charges.

Bike Admin Fee $0.00 PPPM Per Participant Per Month

Terms and Conditions: • This Order Form is subject to WageWorks’ General Terms and Conditions of Service that may be viewed at

https://www.wageworks.com/employers/terms-and-conditions.aspx, and all terms defined therein shall have the same meaning in this Order Form unless otherwise specified herein.

• *This Order Form shall be effective as of [Effective Date], unless this Order Form is rejected by WageWorks (e.g., the Order Form is incomplete or does not match our records). Billing shall commence upon start of Service(s).

• COBRA Eligible Count: You shall provide a good faith estimate of the total number of COBRA eligibles, which is equivalent to covered lives, during each plan year’s open enrollment period and shall, prior to commencement of each plan year, submit a copy of the health insurance invoices (e.g., medical, dental, vision and/or EAP, if applicable) to substantiate the COBRA eligible (covered lives) count. If you do not substantiate the COBRA eligible count prior to the commencement of a plan year, the COBRA eligible count shall be increased by 20% over the prior plan year. If the COBRA eligible count changes by more than 20% during a plan year, you shall promptly notify WageWorks and provide documentation necessary to substantiate such change. WageWorks shall adjust the COBRA eligible count as of the first benefit month following receipt of substantiation of the change in COBRA eligible count for calculation of fees.

• 2% COBRA Surcharge: WageWorks Retains 2% Surcharge

• Commuter Reimbursement Claims for Undelivered Transit Media: Reimbursements for timely filed participant claims for undelivered transit media will be made as follows: (a) if delivery addresses are provided by your participants and WageWorks mailed the transit media to the designated address with sufficient postage, you shall be responsible for reimbursement costs of such undelivered transit media up to the first 1% of the value of all transit media elections made under your plan during the applicable month (and WageWorks shall be responsible for any excess amounts); (b) if delivery addresses are provided by you and WageWorks mailed the transit media to the designated address with sufficient postage, you shall be responsible for 100% of the reimbursement costs of such undelivered transit media; or (c) if WageWorks either failed to mail the transit media to the delivery address provided by you or your participant, as applicable, or affixed insufficient postage, then WageWorks will be responsible for 100% of the reimbursement costs.

• Address Control: If you have elected to be solely responsible for providing participant mailing addresses to WageWorks for the fulfillment of participant commuter orders, WageWorks will only accept mailing address information (and any changes thereto) provided by you.

Client ACH Debit Authorization (Applies only if ACH Debit Payment Option is Selected)

Bank Name: {{*fees_bank_name }}

Bank Address: {{*fees_bank_address }}

ABA Routing No. (9 digits): {{*fees_routing_num }}

Direct Deposit Account No: {{*fees_account_number }}

Finance Contact Email: {{*finance_email }}

https://www.wageworks.com/employers/terms-and-conditions.aspx

FSA Services V. 102315

1100 Park Place, 4th Floor, San Mateo, CA 94403 | www.wageworks.com

WageWorks Flexible Spending Account (FSA) Services

I. CLIENT’S RESPONSIBILITIES

You are the plan administrator and the claims fiduciary as described under ERISA and the Internal Revenue Code. As such, only you have the power to waive, alter, breach or modify any of the terms and conditions of the flexible spending account plan (“Plan”), and you exercise all discretion, control or authority with respect to the disposition of the available benefits. As such, you shall:

a. Ensure that the summary plan descriptions, plan documents and any other documentation relating to the Plan are appropriately completed, are in compliance with FSA requirements and all applicable law, and are appropriately and timely adopted.

b. Provide us with a complete copy of all summary plan descriptions and plan documents for our reference in connection with the provision of Services.

c. Distribute summary plan descriptions, summaries of material modifications and any other plan documentation to participants on a timely basis.

d. Determine which individuals are eligible to participate in your Plan and provide us with accurate and complete initial enrollment and eligibility data in the prescribed electronic data file format.

e. Provide accurate and timely changes to participant enrollment and eligibility data, including, but not limited to, information that modifies a participant’s eligibility, status or election under the Plan, leaves of absence and terminations, in the prescribed electronic data file format.

f. Ensure that your medical plan carriers and/or payroll data processor provide timely, accurate and complete data files in the prescribed electronic data file format and method specified by us.

g. Correct all errors in any data, files or other materials provided to us by you or on your behalf by your third party service providers (e.g., carriers). We do not audit data, files or other information provided by you or your third party service providers.

h. Execute a Funding Agreement and provide all funding required to cover all payments (e.g., FSA claim reimbursements, payment requests and card transactions) made under the Plan in accordance with the Funding Agreement. We shall not be obligated to issue any payments in the absence of an executed Funding Agreement. You have the sole responsibility and obligation to provide us with all required funding.

i. Timely pay all service fees.

j. Provide participants with any required information if you elect to offer Grace Period under your Plan. “Grace Period” is the amount of time (but no more than 2-1/2 months) following the close of a Plan year during which a participant may incur eligible expenses that may be applied against any balance that remains in the participant’s account for the immediately preceding Plan year before any expenses are applied to the participant’s account for the current Plan year (i.e., the Plan year in which the expense is incurred), if the participant has enrolled for the current Plan year.

http://www.wageworks.com/



k. Provide participants with any required information if you elect to offer Carryover under your Plan.

l. Provide participants with any required information if you elect to offer Run-Out under your Plan. “Run-Out” is the period after the close of a Plan year during which a participant may submit claims for eligible expenses incurred during the immediately preceding Plan year.

m. As claims fiduciary, process the second level and/or any final appeal of any claim for benefits.

n. Manage access to the employer portal of our website by your personnel based upon your internal confidentiality and HIPAA privacy policies and procedures.

o. Comply with all applicable laws (e.g., HIPAA, COBRA and ERISA) with respect to your Plan and make any required filings with the appropriate governmental agencies, including the DOL and the IRS.

II. WAGEWORKS’ RESPONSIBILITIES

We have been engaged by you to provide certain administration services in connection with your Plan(s). Accordingly, you have authorized us to use our standard procedures for the provision of services that have been designed to ensure that the administration of your Plan is in compliance with ERISA and all other applicable regulations. We shall provide our services in accordance with the framework of policies, interpretations, rules, practices and procedures as set forth in the Plan documents, and as otherwise mutually agreed upon or as directed by you. We shall:

a. If applicable, provide template summary plan descriptions and plan documents for your review, completion and adoption.

b. Provide you with a set of electronic file specifications for the delivery of data to us.

c. Process initial and ongoing enrollment and eligibility data files submitted by you in the prescribed electronic data file format.

d. Process enrollment data and benefit elections submitted by participants directly through proper methods (e.g., our website).

e. Process data files received from your medical plan carriers and/or payroll data processor in the format and method specified by us.

f. Administer all funding provided you pursuant to the terms of the Funding Agreement.

g. Process claims received from participants.

h. Process the first appeal of a claim.

i. Issue payments via the following methods:

• Bill Payments Services - We issue payments for FSA-eligible expenses on behalf of a participant through either check or other electronic fund transfer directly to the health care or dependent care provider.




• Reimbursement Services - We issue a reimbursement payment for FSA-eligible expenses through either check or direct deposit to the participant.

• Card Payment Processing – We process debit card transactions and authorize payments made directly to approved payees (e.g., health care providers, drugstores or qualifying merchants) via the debit card.

j. Administer Grace Period, if applicable, subject to ongoing payment of service fees.

k. Administer Carryover, if applicable, subject to ongoing payment of service fees.

l. Administer Run-Out, if applicable, subject to ongoing payment of service fees.

m. Provide you with access to our website where you may:

• View and download standard reports (e.g., summary of expenditures claimed by participants, the total number of participants in the Plan, the total amount of benefits paid or reimbursed for each FSA)

• View individual participant FSA transactions

• Access to our online communications gateway and download standard electronic communication material at no additional charge. Customized items may be provided for an additional fee, plus charges for applicable bulk sales, taxes, shipping and handling.

n. Provide you with a client services representative to answer phone or email inquiries by your staff regarding any service matters during the period of 8:00 a.m. (ET) to 8:00 p.m. (ET), Monday through Friday, excluding holidays and other non-business days.

o. Provide customer service representatives who are available to answer participant phone calls during the period of 8:00 AM ET to 8:00 PM ET, Monday through Friday, excluding holidays and other non-business days.

p. Provide participants with 24/7 access (excluding scheduled maintenance) to our website and our interactive voice response phone system, where participants can access information regarding their FSAs.

q. Participate in enrollment meetings and benefits fairs for an additional charge.

r. Add your logo and/or name on the participant website upon request.


HSA Services V. 031016


WageWorks Health Savings Account (HSA) Services

You have established a high deductible health plan (“HDHP”), which is paired with a health savings account (“HSA”) plan, for the benefit of your eligible employees who are participating in the HDHP. Each such eligible employee who participates in your HSA plan offering will be required to enter into an Accountholder Agreement as well as other agreements including, but not necessarily limited to, an HSA Adoption Agreement, Custodial Account Agreement, Disclosure Statement, and HSA Deposit Account Terms, Conditions and Disclosures, directly with the third party custodian bank that you have selected to hold the employees’ HSA funds. The custodian bank has the right to charge fees and other amounts to each individual HSA accountholder and, with appropriate notice to such individual HSA accountholder, to make changes to the custodian bank’s accountholder fee schedule and any other terms and conditions contained in any of their documents if and when the custodian bank deems it appropriate. For clarification, HSA custodian banks are not subcontractors of WageWorks and the Accountholder Agreement between a custodian bank and each individual HSA accountholder controls the terms under which the HSA is maintained by the custodian bank, including the rights of the custodian bank to charge fees or other amounts to individual HSA accountholders for managing the HSAs.


As the plan sponsor, you are liable for the design, funding and operation of your Plan (“Plan”) including compliance with IRS Code Section 223. You shall:

a. Select a custodian for your Plan from our list of approved custodians.

b. Require your employees to complete enrollment procedures to open an HSA.

c. Determine if an employee is eligible to contribute to an HSA.

d. Electronically identify salary reductions and employer contributions for each individual.

e. Limit salary reduction HSA contributions to the maximum specified annually by the IRS.

f. Provide accountholders with all applicable notices, forms and disclosures, including those provided by the custodian or us.

g. For batch-file enrollment, execute a hosting agreement with the custodian and post terms and conditions on your benefits portal, if applicable.

h. Provide us with information that we request with respect to each accountholder.

i. Provide us with completed forms and notices needed to transfer accountholders with existing HSAs from their current custodian to a new one.

j. Represent and guarantee that accountholder information and enrollments are accurate and complete.

k. Remit to us the funds to be deposited into each HSA accompanied by data that accurately indicates the credit amount to be applied to each account.



l. Provide benefits funding pursuant to the terms of the Funding Agreement.

m. Accept full liability for any funds not received by us, or for any errors in crediting an HSA based on false or incorrect data provided by you or an accountholder.

n. Assume full responsibilities for HSA accountholder information that you have provided to us to administer the HSAs, including costs and expenses for error correction.

o. Provide no further limitations beyond the restrictions imposed by the IRS Code for beneficiaries moving or using their HSA funds.

p. Timely pay all service fees.

q. Represent:

Your employee data has been positively identified either by IRS I-9 forms or upon your review of your beneficiaries’ government-issued documentation as evidence of nationality or residence; and

Your employees have certified their authorization to work in the United States and provided social security numbers or taxpayer ID numbers, which you will provide us for the purpose of establishing HSAs.


We have been engaged by you to perform certain recordkeeping and administrative services in connection with your Plan. We shall:

a. Provide data and file integration with your HSA custodian.

b. Provide a set of electronic file specifications for you to use in delivering data to us.

c. Provide standard HSA materials and forms, including HSA applications and information brochures, required by the HSA custodian for viewing and download via an accessible website.

d. Upload and post contribution files after your payroll contributions are completed.

e. Allocate contributions to pay applicable administrative and account maintenance fees for the HSAs.

f. Work with you to correct inaccurate and mistaken HSA contributions to the extent practicable under IRS Code Section 223 and all other applicable regulations.

g. Provide accountholders with access to their HSA balance through our Card Services, Bill Payment Services, and online withdrawal requests via the website.

h. Make rollover distributions to a new trustee or custodian.

i. Provide for viewing and download the following reports: enrollment report, invoice report, HSA contribution funding report, HSA pending and expired contribution report, and HSA termination report.

j. Close an HSA upon the instructions of the accountholder.



III. CUSTODIAN’S RESPONSIBILITIES

a. Determine if an HSA is in an open status and if contributions can be posted to the HSA.

b. Provide individual participants with Accountholder Agreements as well as other agreements including, but not necessarily limited to, an HSA Adoption Agreement, Custodial Account Agreement, Disclosure Statement, and HSA Deposit Account Terms, Conditions and Disclosures, outlining the fees and charges that the custodian may charge such individuals directly for administering their accounts or otherwise and advising such individuals that such fees are subject to change as outlined in their individual Accountholder Agreements and other agreements provided directly to the participant.

c. Provide confirmations for funds remitted by you.

d. Deposit funds remitted by you into the HSAs.

e. Invest the funds in the HSAs, pursuant to the allocations designated by the accountholders.

f. Provide account statements to accountholders.

g. Ensure accuracy, completeness, legality, timeliness or other compliant status of any data provided to us.

h. File any Form 1099-SA (or equivalents) with the IRS and distribute Forms 1099-SA and 5498-SA to accountholders.

Debit Card Services V. 101713


WAGEWORKS® DEBIT CARD PROGRAM

If you have elected to offer a card program in connection with your Plan, we will administer the WageWorks debit card program as follows:

1. Provision of Cards. We will provide one (1) WageWorks debit card (“Card”) to each participant.

Additional Cards may be provided upon request for use by the participant’s spouse and/or dependents who are over 18 years of age. Cards, including additional and replacement cards, are provided at no charge.

2. Use. Cardholders may use the Card at approved locations, facilities, merchants and/or vendors to

pay for eligible expenses.

3. Card Services. We will update participant records, maintain accurate account balances and

deposit information, activate and deactivate Cards, respond to participant inquiries and provide appropriate notices of actions taken with respect to the Card.

4. Payments. Card transactions will be withdrawn against a participant’s account and you shall

reimburse us according to terms of your Funding Agreement.

5. Improper Card Usage/Fraud. You shall notify us immediately if you suspect or confirm any

inappropriate or fraudulent Card usage. We will take reasonable action to investigate and resolve improper Card transactions that we become aware of in accordance with applicable law and regulations (e.g., by offsetting the ineligible expense against a proper expense). We may elect to suspend a participant’s Card until such issue is resolved. If we cannot correct the improper use, we will notify you and you shall be responsible to correct the transaction by adopting such measures as are required by applicable law and regulations (e.g., deducting the amount from the participant’s wages).

6. Lost or Stolen Cards. We agree to cancel, as soon as is administratively practicable, a

participant's Card when the Card is reported as lost or stolen. We are not responsible for any transactions that occur prior to cancellation.

7. Termination or Ineligibility. We will deactivate a participant’s Card as soon as is

administratively practicable after receipt of notice from you that a participant has been terminated or is no longer eligible to participate under the Plan. We are not responsible for any transactions that occur prior to cancellation.

8. Card Use Information. We will make information regarding proper Card usage available to you

for your distribution to participants.

9. Data Hosting; Right to Use Data. All Card data resides on servers owned by or operated on

behalf of our service providers. You grant us and our service providers the right to receive, process and use such data to administer the Card program and provide related services to you and your participants, as well as the right to derive and use aggregate and statistical de-identified data obtained therefrom.


Debit Card Services V. 101713


10. Grant of License. You grant us and our service providers a non-exclusive, non-transferable,

royalty-free license to use your trademarks in connection with the Card program, in the forms and formats approved by you in connection with (i) the Card, (ii) periodic statements and (iii) participant communications regarding their accounts. The name of the financial institution that issues the Card, a website Uniform Resource Locator and a customer service phone number will be printed on each Card.

11. Treatment of Card Transactions. One or more Card transactions, or groups or categories of

Card transactions, may be treated differently pursuant to our provision of Services in accordance with the terms and conditions of our service agreement with you, and such treatment shall be determined by WageWorks, in its sole discretion.


Form 5500 Services V. 101713


WageWorks Form 5500 Services

I. CLIENT RESPONSIBILITIES

You offer an FSA/HRA or Health & Welfare plan (i.e., small or large funded plan, or a large combination insured/unfunded plan) (“Plan”) that consists of 100 or more participants on the first day of the Plan year. As the plan administrator and the plan fiduciary of an ERISA plan, you are responsible for complying with annual Form 5500 reporting and disclosure requirements in an accurate and timely manner, and as imposed under ERISA Title I. If you have elected to have WageWorks provide Form 5500 services, you shall:

a. Determine whether your Plan requires a Form 5500 filing. WageWorks recommends that you consult with your tax and/or legal advisor regarding this determination.

b. Provide accurate and complete information to WageWorks in the prescribed electronic data file format.

c. Timely reply to all correspondence from WageWorks, including the “authorization” email you receive from WageWorks to provide your consent for WageWorks to complete the Form 5500 on your behalf, and provide the name and email address of your designated authorized signatory for the Form 5500.

d. Go to the Department of Labor’s website, and complete the online registration process, following the detailed instructions provided with the authorization email.

e. Complete the questionnaire provided by WageWorks, and submit the questionnaire and your Schedule A information, if applicable, to WageWorks to initiate the Form 5500 preparation process.

f. Access the online portal via the link provided by WageWorks, review your Form 5500 and confirm that it is accurate and complete.

g. E-sign your completed Form 5500 and electronically submit the form to the Department of Labor using your User ID and Password.

h. Print a hard copy of your Form 5500 and have your designated authorized signatory place a “wet” signature on the form. Retain the original document for your records, as required by the Department of Labor.



Form 5500 Services V. 101713



We have been engaged by you to provide certain services in connection with your Plan(s). Accordingly, you have authorized us to use our standard procedures for the provision of services that have been designed to ensure that the administration of your plan is in compliance with ERISA Title I. We shall:

a. Send you an email notification to your designated email address to inform you of the applicable deadline for filing your Form 5500.

b. Provide you with a questionnaire to complete, along with instructions on how to electronically file your Form 5500 with the Department of Labor.


WageWorks Funding Services

1100 Park Place, San Mateo, CA 94403

FUNDING AGREEMENT (ACH CREDIT SAMPLE)

Client:

Client Name:

Client Address:

This Funding Agreement is entered into as of Start Date by and between Client’s Name (“Client”) and WageWorks, Inc. (“WageWorks”) in connection with the provision of Services as set forth in the Order Form. Capitalized terms used herein shall have the same meaning as set forth in the General Terms and Conditions of Service that may be viewed at https://www.wageworks.com/employers/terms-and-conditions.aspx, unless otherwise provided herein. Client acknowledges and agrees that any Funding submitted by Client to WageWorks under this Funding Agreement: (i) shall be comprised of Client’s general assets; (ii) does not consist of Plan assets or Participant/ Employee contributions, whether made by salary reduction or otherwise, within the meaning of the Employee Retirement Income Security Act of 1974, as amended (ERISA), without regard to whether ERISA applies, and is not otherwise subject to any restrictions; and (iii) shall not be segregated or set aside in a trust or escrow account by WageWorks. Client further agrees to pay WageWorks the entire amount delivered or deliverable to Participants in any Plan, regardless of whether Client collects sufficient payroll deductions from the Participants. 1. Funding Method. Client has elected to pay all Funding via Wire / ACH Credit. If notified by WageWorks of

insufficient Funding, Client shall provide additional Funding to WageWorks within one (1) business day via electronic funds transfer.

2. Payment Information.

WAGEWORKS ACH CREDIT ACCOUNT INFORMATION

FSA, HRA Account Information (*Do not send Fees to Account*): MUFG Union Bank, N.A. 350 California Street, 10th Floor San Francisco, CA 94104 Account Name: WageWorks FSA/HRA Deposits Account Account Number: 3120004394 ABA Routing #: 122000496 HSA Account Information (*Do not send Fees to Account*): MUFG Union Bank, N.A. 350 California Street, 10th Floor San Francisco, CA 94104 Account Name: WageWorks HSA Account Account Number: 3120005129 ABA Routing Number: 122000496 Commuter (Order Model) Account Information: MUFG Union Bank, N.A. 350 California Street, 10th Floor San Francisco, CA 94104 Account Name: WageWorks Main Account Account Number: 3120004386 ABA Routing Number: 122000496

3. FSA, HRA Funding Arrangement



a. Required Funding Amount. Client shall initially provide and, thereafter, maintain Funding in an

amount equal to 6% of estimated benefit claims for the applicable Plan year. If WageWorks commences the provision of Services after the start of a Plan year, this amount shall, instead, be equal to 6% of estimated benefit claims for the remainder of that Plan year.

b. Initial Funding. Client shall initiate an ACH credit, electronic funds transfer or wire for the payment

of the initial Funding to WageWorks' designated account so that the amount due is received prior to the first day of the Plan year. WageWorks will roll over the prior Plan year’s initial Funding amount, less 6% of the unspent benefit elections for the prior Plan year, and apply that amount to the required initial Funding amount for the current Plan year. Any Service Delivery Standards shall be waived during the period of time that payment of Funding is delayed.

c. Ongoing Funding. On the first business day of each week, WageWorks shall notify Client via email

that an on-line report that contains the prior week’s Plan transaction history is available for download via WageWorks’ Web site. The report shall indicate the additional amount Client must provide to maintain the required amount of Funding. Client shall initiate an ACH credit, electronic funds transfer or wire to WageWorks’ designated account so that the amount due is received no later than Tuesday of each week (or the following business day thereafter if either the invoice or payment due date falls on a bank holiday).

d. Reconciliation. At the completion of each Plan year, the remaining Funding shall be reconciled and

returned to Client (less any amounts owed to WageWorks) as soon as administratively practicable, but in no event later than ninety (90) days after the completion of any Run-out Period and any ancillary manual claims settlement.

4. HSA Funding Arrangement

a. Required Funding Amount. WageWorks shall notify Client via email that an HSA Contribution Funding report is available for download via WageWorks’ Web site. The report shall indicate the required Funding amount Client must provide to WageWorks.

b. Funding. Client shall initiate an ACH credit, electronic funds transfer or wire of the required Funding

amounts directly to WageWorks’ designated account, and notify WageWorks of the transfer. Funding is due within one (1) business day after the HSA Contribution Funding report is made available for download via WageWorks’ Web site. Any Service Delivery Standards shall be waived during the period of time that payment of Funding is delayed.

5. Commuter Funding Arrangement (Order) Model

a. Initial Funding. Client shall provide an initial Funding amount equal to $0.00. This amount is determined by multiplying the estimated number of Participants who may elect qualified transit and/or parking benefits for the first benefit month by $0.00. Client shall initiate an ACH credit, electronic funds transfer or wire for the payment of the initial Funding to WageWorks' designated account so that the amount due is received on or before the first day of the month prior to the initial benefit enrollment deadline.

b. Ongoing Funding. Client has elected to receive a combined invoice for Fees and Funding for

Commuter Services. If Client has selected different methods of payment for Fees (per the Order Form) and Funding (per this Funding Agreement), this Funding Agreement shall govern both the timing and method of payment for Commuter Fees and Funding. Each month, WageWorks shall provide an invoice to Client via email for the following amounts: (i) commuter benefits delivered or paid by WageWorks to or on behalf of Participants for the prior benefit period (excluding reimbursements provided directly via Client’s payroll), (ii) the aggregate cost of estimated Participant commuter benefit elections for the next benefit period (which is equal to the prior benefit period’s commuter benefit elections, less a credit for the payment of the prior month’s estimated commuter benefit



election), (iii) Fees and (iv) any other additional costs or expenses related to optional services elected by Client. Client shall initiate an ACH credit, electronic funds transfer or wire to WageWorks’ designated account so that the amount due is received by WageWorks no later than the 5th day of the month (or the next business day if the 5th is a bank holiday).



FUNDING AGREEMENT (ACH DEBIT SAMPLE)

Client:

Client’s Name:

Client’s Address:

This Funding Agreement is entered into as of Start Date by and between Client’s Name (“Client”) and WageWorks, Inc. (“WageWorks”) in connection with the provision of Services as set forth in the Order Form. Capitalized terms used herein shall have the same meaning as set forth in the General Terms and Conditions of Service that may be viewed at https://www.wageworks.com/employers/terms-and-conditions.aspx, unless otherwise provided herein. Client acknowledges and agrees that any Funding submitted by Client to WageWorks under this Funding Agreement: (i) shall be comprised of Client’s general assets; (ii) does not consist of Plan assets or Participant/ Employee contributions, whether made by salary reduction or otherwise, within the meaning of the Employee Retirement Income Security Act of 1974, as amended (ERISA), without regard to whether ERISA applies, and is not otherwise subject to any restrictions; and (iii) shall not be segregated or set aside in a trust or escrow account by WageWorks. Client further agrees to pay WageWorks the entire amount delivered or deliverable to Participants in any Plan, regardless of whether Client collects sufficient payroll deductions from the Participants. 1. Funding Method. Client has elected to pay all Funding via ACH Debit. If notified by WageWorks of

insufficient Funding, Client shall provide additional Funding to WageWorks within one (1) business day via electronic funds transfer.

2. Payment Information.

CLIENT ACH DEBIT ACCOUNT INFORMATION

Bank Name: {{*_es_funding_bank_name}}

Bank Address: {{*_es_funding_bank_address}}

ABA Routing No. (9 digits): {{*_es_funding_routing_num}}

Direct Deposit Account No: {{*_es_funding_account_number}}

Finance Contact Email: {{*_es_finance_email}}

{{

3. FSA, HRA Funding Arrangement

a. Required Funding Amount. Client shall initially provide and, thereafter, maintain Funding in an amount equal to 4% of estimated benefit claims for the applicable Plan year. If WageWorks commences the provision of Services after the start of a Plan year, this amount shall, instead, be equal to 4% of estimated benefit claims for the remainder of that Plan year.

b. Initial Funding. Prior to the first day of the Plan year, Client hereby authorizes WageWorks (or its

delegate bank) to initiate an ACH debit against Client’s designated direct deposit account for the payment of the initial Funding. WageWorks will roll over the prior Plan year’s initial Funding amount, less 4% of the unspent benefit elections for the prior Plan year, and apply that amount to the required initial Funding amount for the current Plan year. Any Service Delivery Standards shall be waived during the period of time that payment of Funding is delayed.



c. Ongoing Funding. On the first business day of each week, WageWorks shall notify Client via email that an on-line report that contains the prior week’s Plan transaction history is available for download via WageWorks’ Web site. The report shall indicate the additional amount Client must provide to maintain the required amount of Funding. Client hereby authorizes WageWorks (or its delegate bank) to initiate an ACH debit against the Client’s direct deposit account so that the amount due is received by WageWorks no later than Tuesday of each week (or the following business day thereafter if either the invoice or payment due date falls on a bank holiday).

d. Reconciliation. At the completion of each Plan year, the remaining Funding shall be reconciled and

returned to Client (less any amounts owed to WageWorks) as soon as administratively practicable, but in no event later than ninety (90) days after the completion of any Run-out Period and any ancillary manual claims settlement.

4. HSA Funding Arrangement

a. Required Funding Amount. WageWorks shall notify Client via email that an HSA Contribution Funding report is available for download via WageWorks’ Web site. The report shall indicate the required Funding amount Client must provide to WageWorks.

b. Funding. Client hereby authorizes WageWorks (or its delegate bank) to initiate an ACH debit against

Client’s direct deposit account to ensure that WageWorks receives the required Funding amount no later than the next business day. Funding is due within one (1) business day after the HSA Contribution Funding report is made available for download via WageWorks’ Web site. Any Service Delivery Standards shall be waived during the period of time that payment of Funding is delayed.

5. Commuter Funding Arrangement (Order) Model

a. Initial Funding. Client shall provide an initial Funding amount equal to $0.00. This amount is determined by multiplying the estimated number of Participants who may elect qualified transit and/or parking benefits for the first benefit month by $0.00. Client hereby authorizes WageWorks (or its delegate bank) to initiate an ACH debit against Client’s designated direct deposit account for the payment of the initial Funding on the first day of the month prior to the initial benefit enrollment deadline.

b. Ongoing Funding. Client has elected to receive a combined invoice for Fees and Funding for

Commuter Services. If Client has selected different methods of payment for Fees (per the Order Form) and Funding (per this Funding Agreement), this Funding Agreement shall govern both the timing and method of payment for Commuter Fees and Funding. Each month, WageWorks shall provide an invoice to Client via email for the following amounts: (i) commuter benefits delivered or paid by WageWorks to or on behalf of Participants for the prior benefit period (excluding reimbursements provided directly via Client’s payroll), (ii) the aggregate cost of estimated Participant commuter benefit elections for the next benefit period (which is equal to the prior benefit period’s commuter benefit elections, less a credit for the payment of the prior month’s estimated commuter benefit election), (iii) Fees and (iv) any other additional costs or expenses related to optional services elected by Client. Client hereby authorizes WageWorks (or its delegate bank) to initiate an ACH debit against Client’s designated direct deposit account so that the amount due is received by WageWorks no later than the 5th day of the month (or the next business day if the 5th is a bank holiday).

Non Discrimination Services V. 101713


WageWorks Nondiscrimination Testing Services


You are the plan administrator and the claims fiduciary as described under ERISA and the Internal Revenue Code. As such, only you have the power to waive, alter, breach or modify any of the terms and conditions of the cafeteria plan (“Plan”), and you exercise all discretion, control or authority with respect to the disposition of the available benefits. The IRS requires that the Plan be nondiscriminatory, such that it does not discriminate in favor of highly compensated individuals or key employees, as those terms are defined by the IRS. If you have elected to have WageWorks provide nondiscrimination testing services, you shall:

a. Login to the testing portal website via the link and login credentials provided by WageWorks.

b. Provide accurate and complete information in the prescribed electronic data file format.

c. Upload the data to the testing portal website to initiate the test(s).

d. Log back into the website to review your test results after receipt of email notification from WageWorks that your test results are available.

e. Make necessary election adjustments in the prescribed electronic data file format (or other method specified by WageWorks) and timely provide that information to WageWorks.

f. Update your payroll records to reflect election adjustments, if any.

g. Notify affected participants of any election adjustments made to their accounts.

h. Correct all errors in any data, files or other materials provided to us by you or on your behalf. We do not audit data, files or other information provided by you or on your behalf by third party service providers.


j. Manage access to the testing portal website by your personnel based upon your internal confidentiality and HIPAA privacy policies and procedures.

k. Comply with all applicable laws (e.g., HIPAA, COBRA and ERISA) with respect to your Plan and make any required filings, if any.


We have been engaged by you to provide certain services in connection with your Plan(s). Accordingly, you have authorized us to use our standard procedures for the provision of such services. We shall:


Non Discrimination Services V. 101713


a. Provide you with a set of electronic file specifications for the delivery of data to us.

b. Process data files submitted by you in the prescribed electronic data file format.

c. Provide you with a link to the security testing portal website and login credentials via email.

d. Perform nondiscrimination testing for your Plan(s) upon receipt of all required testing data.

e. Provide you with email notification that your test results are available for your review.

f. Have personnel available to answer phone or email inquiries by your staff regarding any election adjustments that may be necessary.

g. Provide a sample communication you may send to affected participants regarding election adjustments made to their accounts.


COBRA Services V. 052314


WageWorks COBRA Services


You are the plan administrator and fiduciary as described under ERISA and the Internal Revenue Code. As such, only you have the power to waive, alter, breach or modify any of the terms and conditions of your Plan(s), and you exercise all discretion, control or authority with respect to the disposition of the available benefits. As such, you shall: a. Provide WageWorks with a complete copy of all carrier and rate information, for our reference in

connection with the provision of services.

b. Eligibility and Enrollment—Qualifying Event. Determine whether a Qualified Beneficiary has had a Qualifying Event and timely provide us with accurate and complete data regarding the Qualifying Event in the electronic data file format prescribed by WageWorks.

c. Eligibility and Enrollment—Open Enrollment.

Notify WageWorks of the annual Open Enrollment Period.

Determine which individuals are eligible to participate in your Plan(s) and provide us with accurate and complete eligibility data in the prescribed electronic data file format.

d. Provide accurate and timely changes to Participant enrollment and eligibility data, including, but not

limited to, information that modifies a Participant’s eligibility, status or election under a Plan, in the electronic data file format prescribed by WageWorks.

e. Notify WageWorks in writing of any changes in carriers and/or Plan(s) at least sixty (60) days prior to the effective date of the change.

f. Notify WageWorks in writing of any changes in premiums that shall apply at least sixty (60) days prior to the effective billing date of the new premium.

g. On a monthly basis, reconcile all carrier invoices and Participant reports, and notify both WageWorks and

the carrier of any discrepancies.

h. Ensure that your Plan carriers and payroll/pension data processors provide timely, accurate and complete data files in the electronic data file format and method prescribed by WageWorks.

i. Obtain all required Participant consents necessary to disclose Participant PHI to WageWorks for the

provision of services.

j. Correct all errors in any data, files or other materials provided to WageWorks by you or on your behalf by your third party service providers (e.g., carriers, payroll/pension data providers). WageWorks does not audit data, files or other information provided by you or your third party service providers.

k. Timely pay all fees.

l. Timely pay all costs, including postage (billed at then-current USPS First Class Mail rates), print, copying

and travel charges.

m. Manage access to the employer portal of our website by your personnel based upon your internal confidentiality and HIPAA privacy policies and procedures.




n. Comply with all applicable laws (e.g., HIPAA, COBRA and ERISA) with respect to your Plan(s) and make

any required filings with the appropriate governmental agencies, including the DOL and the IRS.


WageWorks has been engaged by you to provide certain COBRA administration services in connection with your Plan(s). Accordingly, you have authorized us to use our standard procedures for the provision of services that have been designed to ensure that the administration of your Plan(s) are in compliance with COBRA, ERISA and all other applicable regulations. We shall provide our services in accordance with the framework of policies, interpretations, rules, practices and procedures as set forth in the Plan documents, and as otherwise mutually agreed upon or as directed by you. We shall provide the following services:

a. Provide you with a set of electronic file specifications for the delivery of data to WageWorks.

b. Process data files submitted by you in the electronic data file format prescribed by WageWorks.

c. Provide each Qualified Beneficiary with a COBRA Qualification Event notice and enrollment form packet

after receipt of notification from you that a Qualifying Event has occurred.

d. Based on your election of full or partial open enrollment services, WageWorks will:

Full Service Partial Service

Send WageWorks’ standard Open Enrollment Letter to all Qualified Beneficiaries and Participants.

Send WageWorks’ standard Rate Change Notification to all Qualified Beneficiaries and Participants.

Send WageWorks’ standard Open Enrollment Change Form to all Qualified Beneficiaries and Participants.

Include client-provided inserts in standard mailings (subject to size limitation)

Provide you with WageWorks’ standard Open Enrollment Change Form to provide to Qualified Beneficiaries and Participants.

e. Process COBRA enrollment and change forms submitted directly by Qualified Beneficiaries and/or

Participants through proper methods (e.g., WageWorks’ website). Enrollment and elections will be considered timely made if the form is postmarked by the U.S. Postal Service or express delivery service within the applicable statutory period or Open Enrollment Period.

f. Provide monthly premium payment coupons to Participants.

g. Collect premium payments (and administrative surcharges) via a WageWorks-owned lockbox and deposit those funds in a WageWorks-owned bank account. Premiums shall be considered timely paid if postmarked by the U.S. Postal Service or express delivery service within thirty (30) days of the due date.

h. Remit premium payments received, less a 2% surcharge retained by WageWorks, to you by the 20th

business day of each month.

i. Process data files received from and/or prepare data files for submission to your medical plan carriers and/or payroll data processor in the format and method prescribed by WageWorks.

j. Provide a notice of termination of COBRA coverage to Participants upon termination of coverage.




k. Provide compliance management services, including processing disability extensions, Medicare entitlement and all second Qualifying Events and changes, upon receipt of proper and timely notification from you or the Participant in the format and method prescribed by WageWorks.

l. Provide you with access to our website where you may:

View and download standard reports

View individual account information

Access to our online communications gateway and download standard electronic communication material at no additional charge. Customized items may be provided for an additional fee, plus charges for applicable bulk sales, taxes, shipping and handling.

m. Provide you with a client services representative to answer phone or email inquiries by your staff regarding any service matters during the period of 8:00 a.m. (ET) to 8:00 p.m. (ET), Monday through Friday, excluding holidays and other non-business days.

n. Provide customer service representatives who are available to answer Eligible, Qualified Beneficiary and Participant phone calls during the period of 8:00 AM ET to 8:00 PM ET, Monday through Friday, excluding holidays and other non-business days.

o. Provide Qualified Beneficiaries and Participants with 24/7 access (excluding scheduled maintenance) to our website where Participants can access information regarding their COBRA coverage.

p. Provide eligibility reporting to carriers in the electronic data file format prescribed by WageWorks.

III. ADDITIONAL SERVICES In addition to the services set forth above, WageWorks may also provide you with the following optional services, as elected and subject to the payment of additional fees. Optional services may include the following:

a. On-site Meetings. Participate in enrollment meetings and benefits fairs.

b. DOL Initial Notification of Rights. Provide DOL Initial Notification of Rights to all Eligibles.

c. Customization Services. Provide customization services for non-standard files and/or communications.

d. Carrier Reconciliation and Remittance Services. Reconcile carrier files against eligibility and enrollment information maintained by WageWorks and remit premiums directly to carrier.

e. Post-termination Transition Services. Provide mutually agreed upon post-termination transition services. WageWorks shall not be obligated to provide post-termination transition services if services are terminated due to your failure to pay amounts due.

IV. DISCLAIMER Notwithstanding anything to the contrary, WageWorks shall not be responsible to receive or review claims for benefits under any Plan(s), or be liable for the payment of any claims for benefits under, or in connection with, any Plan(s).

V. DEFINITIONS

“Eligible” means an employee who is eligible to receive COBRA continuation coverage.




“COBRA” means the Consolidated Omnibus Budget Reconciliation Act of 1985.

“Open Enrollment Period” means the period during which a Qualified Beneficiary may elect COBRA continuation coverage and enroll in or change coverage under a Plan.

“Participant” means any Qualified Beneficiary who elects COBRA continuation coverage under a Plan.

“PEPM” means per Eligible, per month.

“Plan” means any healthcare plan established by you.

“Qualified Beneficiary” means an Eligible or an Eligible’s dependent with individual rights to COBRA continuation coverage, including a surviving spouse.

“Qualifying Event” means:

a. (i) the death of an Eligible, if such event results in the loss of coverage by a Qualified Beneficiary underyour Plan(s); (ii) termination of employment or reduction in hours of an Eligible, (iii) divorce/legalseparation from an Eligible; (iv) the filing for bankruptcy by you (provided that if you file for bankruptcyunder Title 11, U.S.C., you shall advise WageWorks of any loss or substantial elimination of coverageunder your Plan(s) with respect to any Qualified Beneficiaries); and (v) any other event resulting in aQualified Beneficiary losing coverage under your Plan(s);

b. a determination under Title II or XVI of the Social Security Act that a Qualified Beneficiary was disabled atthe time of a Qualifying Event described in (a) above, or a determination that a Qualified Beneficiary is nolonger disabled; or

c. the termination of any Plan(s).


SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:CONTACT

(A/C, No):FAX

E-MAILADDRESS:

PRODUCER

(A/C, No, Ext):PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement onthis certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZEDREPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

OTHER:

(Per accident)

(Ea accident)

$

$

N / A

SUBRWVD

ADDLINSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$

$

$

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLYNON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?(Mandatory in NH)

DESCRIPTION OF OPERATIONS belowIf yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

$

$

$

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

EROTH-

STATUTEPER

LIMITS(MM/DD/YYYY)POLICY EXP

(MM/DD/YYYY)POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTRINSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

$

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCEDAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICYPRO-JECT LOC

CERTIFICATE OF LIABILITY INSURANCEDATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIREDAUTOS ONLY

3/22/2018

ABD Insurance & Financial Services3 Waters Park Drive, Suite 100San Mateo, CA 94403 650-488-8565

www.theabdteam.com

Rod Sockolov

Cert Request

[email protected]

WageWorks, Inc.1100 Park Place 4th FloorSan Mateo CA 94403

40939960

Evidence of Insurance

Re: Evidence of Insurance.

1,000,000

1,000,000

10,000

1,000,0002,000,000

2,000,000

1,000,000

2,000,000

2,000,000

1,000,000

1,000,0001,000,000

A 630 6G606444 3/24/2018 3/24/2019✓

✓

✓

B BA 7K175518 3/24/2018 3/24/2019

✓ ✓

A CUP 2J905167 3/24/2018 3/24/2019✓✓

A UB 9G195724 3/24/2018 3/24/2019 ✓

D Errors & Omissions/Cyber Liability W12341180701 3/24/2018 3/24/2019 $10,000,000 Each Claim/AggregateC Crime/Third Party 8246-3273 3/24/2018 3/24/2019 $10,000,000 Limit

Travelers Property Casualty Co of Amer 25674

Travelers Indemnity Company of CT 25682

Federal Insurance Company 20281

Lloyd's/Beazley Syndicates

40939960 | 18-19 All Lines/E&O $10M/CR $10M | Alison Smaalders | 3/22/2018 8:56:41 AM (PDT) | Page 1 of 1

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