Los Angeles County Municipal Code Ch. 5.30 County of Los Angeles Health Care Reimbursement Plan

Effective January 1, 1985, there is established the County of Los Angeles Health Care Reimbursement Plan (hereinafter called the "Plan"). The Plan is established for the purpose of providing a Benefit pursuant to Section 5.27.050 of Subdivision 1 of the County of Los Angeles Flexible Benefit Plan ("Flexible Benefit Plan"), Section 5.27.250 of Subdivision 2 of the County of Los Angeles Flexible Benefit Plan ("MegaFlex Benefit Plan"), Section 5.28.050 of Subdivision 1 of the County of Los Angeles Nonpensionable Flexible Benefit Plan ("Nonpensionable Flexible Benefit Plan") and Section 5.28.250 of Subdivision 2 of the County of Los Angeles Nonpensionable Flexible Benefit Plan ("Nonpensionable MegaFlex Benefit Plan").

(Ord. 2004-0020 § 1, 2004: Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1 (b) (Ch. 5.29 § 1) 1984.)

As used herein, the following words and phrases shall have the following meanings respectively, unless the context otherwise requires:

A.

"Dependent" means the Participant's spouse to whom he or she is legally married and a Participant's tax dependent (as defined in Code Section 152, determined without regard to Section 152(b)(1), (b)(2), and (d)(1)(B)). Dependent shall also mean a Participant's child (as defined in Code section 152(f)(1)) who has not attained age 26 as of the end of the taxable year). A child of a divorced or separated Employee to whom Code Section 152(e) applies shall be considered a Dependent of both parents in accordance with Revenue Procedure 2008-48 or subsequent guidance. Domestic partners, children or other relatives who are not Dependents as defined herein are not covered by the Health Care Reimbursement Account.

B.

"Election Information" means the information and rules relating to the general administration of the Health Care Spending Account, which may include, but is not limited to, rules relating to election procedures and deadlines, rules relating to the administration of benefits for Participants during a Plan Year, or who experience an interruption of active service, and rules necessary to maintain the tax-favored status of the Health Care Spending Account. Such Election Information shall be developed by the Chief Executive Officer except as otherwise provided by the Board.

C.

"Health Care Reimbursement Account" means an individual account established and maintained for a Participant to which Contributions are periodically credited pursuant to Section 5.27.060F of the Flexible Benefit Plan, Section 5.27.260F of the MegaFlex Benefit Plan, Section 5.28.060F of the Nonpensionable Flexible Benefit Plan, or Section 5.28.260F of the Nonpensionable MegaFlex Benefit Plan, and from which Medical Expenses are paid.

D.

"Maximum Amount" means the Contribution amount selected by a Participant (on an election form furnished by the County) for credit to his Health Care Reimbursement Account for a Plan Year; provided, however, that such amount shall not be less than $10.00 per month nor more than $400.00 per month. Effective January 1, 2013, as required by the Patient Protection

and Affordable Care Act, the maximum allowable employee contribution for the Health Care Spending Account is reduced from $400 to $200 per month. Effective January 1, 2023, the maximum allowable employee contribution shall not be less than $10.00 per month nor more than the annual contribution limit, as established by the Internal Revenue Service under Code section 125(i), divided by 12. If the IRS annual contribution limit divided by 12 is not a whole number, the monthly maximum allowable employee contribution for the Health Care Spending Account will be rounded down to the nearest whole number.

E.

"Medical Care" means amounts paid (1) for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body; or (2) for transportation primarily for and essential to medical care referred to in (1) above. This definition is to be construed in accordance with Section 213(d)(1) of the Code.

F.

"Medical Expenses" means all expenses incurred during a Plan Year by a Participant for the Medical Care of himself and/or his Dependents, irrespective of whether such expenses were incurred in connection with such Participant's employment, provided that such expenses (i) are not reimbursed or paid for by any other plan, (ii) include a medicine or drug only if it is a prescribed drug (determined without regard to whether such drug is available without a prescription) or is insulin, and (iii) do not include insurance premiums or long-term care benefits. Medical Expenses are incurred on the date the medical care or supply is provided, not on the date charged, billed, or paid.

G.

"Participant" means an Eligible Employee who is actively participating in the Health Care Reimbursement Account in accordance with Section 5.30.025.

H.

"Run-Out Period" means the period during which expenses or claims incurred during a Plan Year must be submitted to be eligible for payment or reimbursement. The Run-Out Period ends six (6) months after the end of the Plan Year.

I.

The following terms shall have the same definitions as are specified in Section 5.27.020 of the Flexible Benefit Plan, Section 5.27.220 of the MegaFlex Benefit Plan, Section 5.28.020 of the Nonpensionable Flexible Benefit Plan, and Section 5.28.220 of the Nonpensionable Megaflex Benefit Plan, as applicable.

"Benefits"

"Board"

"CAO"

"Code"

"Contributions"

"County"

"Election Information"

"Eligible Employee"

"Materials"

"Plan Year"

(Ord. 2022-0046 § 4, 2022; Ord. 2014-0008 § 13, 2014; Ord. 2012-0036 § 1, 2012: Ord. 2004-0020 § 2, 2004; Ord. 94-0079 § 7 (part), 1994; Ord. 89-0123P § 4, 1989; Ord. 84-0220 § 1 (b) (Ch. 5.29 § 2), 1984.)

A.

Commencement of Participation. When an individual first becomes an Eligible Employee, he or she may enroll as provided in the Election Information and Materials. Assuming he or she timely enrolls, his or her participation in the Health Care Reimbursement Account commences in accordance with the following chart:

Except as provided in Section 5.30.030E, an Eligible Employee must reenroll during open enrollment as provided in the Election Information and Materials to participate in the following Plan Year. If the Eligible Employee enrolls during open enrollment, participation in the Health Care Reimbursement Account will commence on the first day of the next following Plan Year.

B.

Termination and Suspension of Participation. Participation in the Health Care Reimbursement Account shall terminate or be suspended as provided in the Election Information and Materials.

(Ord. 2022-0046 § 5, 2022; Ord. 2014-0008 § 14, 2014.)

The County shall from time to time, upon request of a Participant made in writing not later than the end of the Run-Out Period, reimburse all or part of the Medical Expenses incurred by the Participant during such Plan Year; provided, however, that:

A.

All such payments during or in respect of a particular Plan Year to the Participant's Health Care Spending Account shall be limited in the aggregate to (a) his Maximum Amount; plus (b) the Carryover Amount described in Section 5.30.030B and C, as applicable, subject to the rules in Section 5.30.030D.

B.

Subject to the rules in Section 5.30.030D below, amounts up to $500 that remain unused, (increased to $550 of unused amounts beginning in the 2022 Plan Year), under the Health Care Reimbursement Account with respect to one Plan Year are carried over to the next Plan Year. The carryover amount is the lesser of (a) any unused amounts from the immediately preceding Plan Year, or (b) $500 (increased to $550 beginning in the 2022 Plan Year) (the "Carryover Amount"). Any unused amount in the Health Care Reimbursement Account in excess of the Carryover Amount that remains unused as of the last day of the Run-Out Period shall be forfeited. Notwithstanding the foregoing limits on the Carryover Amount, in the case of a Participant who has a balance credited to his Health Care Spending Account as of the end of the 2020 Plan Year and/or 2021 Plan Year, the entire unused balance from such Plan Year (after the processing of all claims for such Plan Year) shall be the Carryover Amount from such Plan Year to the next Plan Year.

C.

Effective with the 2023 Plan Year, subject to the rules in Section 5.30.030D below, the unused balance that remains under the Health Care Reimbursement Account with respect to one Plan Year are carried over to the next Plan Year, up to the maximum carryover limit as established by the Internal Revenue Service under Code section 125(i). The carryover amount is the lesser of (a) any unused amounts from the immediately preceding Plan Year, or (b) the maximum carryover limit as established by the Internal Revenue Service under Code section 125(i) (the "Carryover Amount"). Any unused amount in the Health Care Reimbursement Account in excess of the Carryover Amount that remains unused as of the last day of the Run-Out Period shall be forfeited.

D.

A Participant's unused balance under the Health Care Reimbursement Account at the end of the prior Plan Year will be used either: (a) to reimburse expenses incurred during the prior Plan Year and submitted during the Run-Out Period that begins at the end of the prior Plan Year (thus retroactively reducing the unused amount as of the end of the prior Plan Year), or (b) to the extent of the Carryover Amount, for expenses that are incurred at any time during the current Plan Year. Any Carryover Amount used to reimburse a prior Plan Year's expense during the Run-Out Period will reduce the Carryover Amount that may be used for current Plan Year expenses, and any of the Carryover Amount used for current Plan Year expenses will reduce the amount available to reimburse the prior Plan Year's expenses during the applicable Run-Out Period. The Health Care Reimbursement Account treats claims for Medical Expenses as reimbursed first from unused amounts credited for the current Plan Year and, only after exhausting such amounts, as reimbursed from the Carryover Amount. Any unused amounts from the prior Plan Year that are used to reimburse a current Plan Year expense: (a) reduce the amounts available to pay prior Plan Year expenses during the Run-Out Period; (b) are counted against the Carryover Amount; and (c) cannot exceed the Carryover Amount.

E.

Notwithstanding Section 5.30.025, a Participant in a Health Care Reimbursement Account during one Plan Year who fails to enroll in the Health Care Reimbursement Account for the following Plan Year on a timely basis will nevertheless have a Health Care Reimbursement Account established for him for that following Plan Year to the extent of any Carryover Amount provided for in this Section 5.30.030.

F.

Payments hereunder may be made only upon such proof of the Medical Expenses in question as the County shall in its discretion require. It is not necessary that such Medical Expenses have been already paid by the Participant, his spouse or his dependents, but merely that, if not yet paid, there exists an obligation to pay them.

G.

Medical Expenses reimbursed by the Plan for a Plan Year must have been incurred during a period when the Participant (and Dependents) are covered by the Health Care Reimbursement Account, as described in the Election Information and Materials, and submitted for reimbursement, with all required substantiation, before the end of the Run-Out Period.

Accordingly, with regard to each Plan Year, the Health Care Reimbursement Account will not reimburse any expenses incurred: (i) before the start of the Plan Year or, if later, before the date the Eligible Employee first becomes a Participant under Section 5.30.025; (ii) after the end of the Plan Year; (iii) after coverage terminates or while coverage is suspended as described in the Election Information and Materials, or (iv) that are not adequately substantiated before the end of the Run- Out Period.

(Ord. 2022-0046 § 6, 2022; Ord. 2021-0020U § 9, 2021; Ord. 2020-0036U § 6, 2020; Ord. 2014-0008 § 15, 2014; Ord. 98- 0076 § 12, 1998; Ord. 94-0079 § 7 (part), 1994; Ord. 90-0164 § 4(a), 1990; Ord. 84-0220 § 1(b)(Ch. 5.29 § 3) 1984.)

All of the amounts payable under the Plan shall be paid from Contributions credited to the Health Care Reimbursement Account established by the County for such Participants as elect this Benefit under the Flexible Benefit Plan for a Plan Year.

(Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1 (b) (Ch. 5.29 § 4), 1984.)

The County intends to administer the Plan under the direction of the Board so that benefits payable hereunder will qualify for exclusion from the gross income of Participants, as provided in Section 105 of the Code. The County may contract with one or more private firms for services related to the administration of the Plan.

(Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1 (b) (Ch. 5.29 § 5), 1984.)

The Plan may be amended from time to time hereafter or terminated at any time by the County without the advice or consent of any Participant, but such action shall not adversely affect the rights of any Participant hereunder with respect to any balance remaining in his Health Care Reimbursement Account at the time of termination.

(Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1(b) (Ch. 5.29 § 6), 1984.)

To the extent permitted by law and except as otherwise provided in the Plan, no right or interest of any kind of a Participant hereunder shall be transferable or assignable by him, nor shall any such right or interest be subject to alienation, anticipation, encumbrance, garnishment, attachment, execution or levy of any kind, voluntary or involuntary.

(Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1 (b) (Ch. 5.29 § 7), 1984.)

Except to the extent that federal law applies, the Plan shall be construed in accordance with the laws of the state of California. The CAO may interpret any ambiguous provisions of the Plan, correct any defect, supply any omission, or reconcile any inconsistency, in such manner and to such extent as the CAO in his discretion may determine; and any such action of the CAO shall be binding and conclusive upon all Participants. Wherever appropriate in the Plan, the masculine gender shall include the feminine, and the feminine gender the masculine, unless the context clearly indicates otherwise.

(Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1(b) (Ch. 5.29 § 8) 1984.)

Nothing herein contained is intended to be, or shall be construed as constituting, a contract or other arrangement between any Participant and the County to the effect that he will be employed for any specific period of time.

(Ord. 94-0079 § 7 (part), 1994; Ord. 84-0220 § 1(b) (Ch. 5.29 § 9), 1984.)

Any Eligible Employee or Participant who fails to submit the election form on or before the due date shall be subject to the deemed election rules specified in Subdivision 1 or 2 of Chapter 5.27, or in Subdivision 1 or 2 of Chapter 5.28.

(Ord. 2004-0020 § 3, 2004: Ord. 94-0079 § 7 (part), 1994; Ord. 90-0164 § 4(b), 1990.)

This section contains the Plan provisions required by the Standards for Privacy of Individually Identifiable Health Information and for the security of Electronic Protected Health Information 45 CFR § 164.102 et seq., as amended from time to time, and any successor thereto (the "Privacy Rules") promulgated under Title II of the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA"), relating to the permitted disclosure of Protected Health Information by the Plan to the County. The provisions of this section shall apply to the Plan for so long as such portion of the Plan constitutes a "health plan" under HIPAA and, as such, is subject to the HIPAA Privacy Rules.

Except as otherwise provided in this section, the provisions of the Plan, including any definitions therein, shall apply to this section; provided, however, that the provisions of this section shall supercede any conflicting or inconsistent provision of the Plan.

A.

Definitions. The following terms, when capitalized, will have the meanings set forth below for purposes of this section, unless otherwise specified herein:

"Covered Person" means any eligible employee or former employee of the County or an eligible spouse or dependent thereof who participates in the Plan.

"Electronic Protected Health Information" means Protected Health Information that is maintained in, or transmitted by, electronic media (as defined in 45 CFR § 160.103).

"Health Information" means any information, whether oral or recorded in any form or medium, that is created or received by the Plan and relates to the past, present or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual.

"Individually Identifiable Health Information" means Health Information, including demographic information collected from an individual, that identifies an individual; or with respect to which there is a reasonable basis to believe the information can be used to identify an individual.

"Notice" means the notice of privacy practices for Protected Health Information required to be provided by the Plan to a Covered Person pursuant to the Privacy Rules.

"Plan Administration Functions" means administration functions performed by the County on behalf of the Plan, but excluding functions performed by the County in connection with any other benefit or benefit plan of the County.

"Policies and Procedures" means those Comprehensive Privacy Policies and Procedures with respect to Protected Health Information established and maintained by the Plan pursuant to the Privacy Rules.

"Privacy Official" means that person designated by the County in the Policies and Procedures to implement and enforce the Policies and Procedures.

"Protected Health Information" means Individually Identifiable Health Information that is transmitted by electronic media, maintained in any medium described in the definition of electronic media at 45 CFR § 160.103, or transmitted or maintained in any other form or medium; provided, however, that Protected Health Information does not include Individually Identifiable Health Information in education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. § 1232g, records described at 20 U.S.C. § 1232g(a)(4)(B)(iv), and employment records held by a health plan in its role as employer.

"Required by Law" means a mandate contained in law that is enforceable in a court of law and includes, but is not limited to:

a.

Court orders and court-ordered warrants;

b.

Subpoenas or summons issued by a court, grand jury, governmental or tribal inspector general, or administrative body authorized to require the production of information;

c.

Civil or an authorized investigative demand;

d.

Medicare conditions of participation with respect to health care providers participating in the program; and

e.

Statutes or regulations that require the production of information.

"Summary Health Information" means information that may be Individually Identifiable Health Information, and:

a.

That summarizes the claims history, claims expenses or type of claims experienced by individuals for whom the County had provided health benefits under the Plan; and

b.

From which the information described at 45 CFR § 164.514(b)(2)(i) has been deleted, except that the geographic information described in 45 CFR § 164.514(b)(2)(i)(B) need only be aggregated to the level of a five-digit zip code.

B.

Identity of Plan Sponsor.

The County shall be the plan sponsor for purposes of the Privacy Rules when using or disclosing Protected Health Information in accordance with subsection C of this section and when otherwise acting on behalf of the Plan with respect to the Plan's obligations under the Privacy Rules.

The Privacy Official shall act for the plan sponsor, and shall be entitled to delegate its powers and responsibilities in accordance with its usual practices.

Individuals and classes of individuals identified in subsection F of this section shall assist the Privacy Official.

C.

Permitted Uses and Disclosure of Protected Health Information.

Subject to obtaining written certification from the County as described in subsection E of this section, and except as provided in subsection C2 of this section, the Plan may disclose Protected Health Information to the County only for the purpose of performing Plan Administration Functions. Only those individuals identified in subsection F of this section will be permitted to access and use Protected Health Information disclosed under this subsection C1, and may access and use it solely for the purposes of performing Plan Administration Functions, consistent with any conditions or restrictions imposed on, or otherwise agreed to by, the County pursuant to this Section.

In addition, the Plan may disclose to the County information on whether an individual is participating in the Plan and may disclose Summary Health Information to the County, provided the County requests Summary Health Information for the purpose of:

a.

Obtaining premium bids from health plans for providing health insurance coverage under or on behalf of the Plan; or

b.

Modifying, amending or terminating the Plan.

The Plan shall not disclose Protected Health Information to the County unless the Notice contains the statement required by 45 CFR § 164.520(b)(1)(iii)(C).

Notwithstanding any provisions of the Plan to the contrary, in no event will the County be permitted to use or disclose Protected Health Information in a manner that is inconsistent with 45 CFR § 164.504(f).

The Plan may otherwise use and disclose Protected Health Information in accordance with the Privacy Rules and the Plan's Policies and Procedures.

D.

Protected Health Information Disclosure Conditions. The Plan will disclose Protected Health Information to the County as provided in subsection C1 of this section only if the County furnishes the certification set forth in subsection E of this section, and the County agrees that with respect to any Protected Health Information disclosed to it by the Plan, the County will:

Not use or further disclose the Protected Health Information other than as permitted or required by the Plan or as Required by Law;

Ensure that any agents, including a subcontractor, to whom it provides Protected Health Information received from the Plan agree to the same restrictions and conditions that apply to the County with respect to such Protected Health Information;

Not use or disclose the Protected Health Information for employment-related actions and decisions or in connection with any other benefit or employee benefit plan of the County, (except to the extent such other benefit plan, program or arrangement is part of an organized health care arrangement of which the Plan also is a part);

Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware;

Make Protected Health Information available to an individual who requests access to his or her Health Information in accordance with 45 CFR § 164.524;

Make Protected Health Information available for amendment and incorporate any amendments to Protected Health Information in accordance with 45 CFR § 164.526;

Maintain and make available information required to provide an accounting of disclosures in accordance with 45 CFR § 164.528;

Make its internal practices, books and records relating to the use and disclosure of Protected Health Information received from the Plan available to the Secretary of the Department of Health and Human Services for the purposes of determining compliance by the Plan with Subpart E of 45 CFR § 164;

If feasible, return or destroy all Protected Health Information received from the Plan that the County still maintains in any form, and retain no copies of such information, when no longer needed for the purpose for which the disclosure was made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information infeasible; and

Ensure that the adequate separation between the Plan and the County, required in 45 CFR § 164.504(f)(2)(iii), is established.

E.

County Certification. The Plan will disclose Protected Health Information to the County as provided in subsection C1 of this section only upon the receipt of a certification from the County that the Plan has been amended to incorporate the provisions of 45 CFR § 164.504(f)(2)(ii), and that the County agrees to the conditions set forth in subsection D of this section.

F.

Adequate Separation between the Plan and the County for Plan Administration Functions. Only the following employees or classes of employees or other persons under the County's control will be permitted to access and use Protected Health Information for Plan Administration Functions in accordance with subsection C of this section:

Director of Personnel

Department of Human Resources, Employee Benefits Division—Senior Human Resources Manager and all Human Resources Analysts

Department of Human Resources, Administrative Services

Division, Fiscal Services Section—Senior Human Resources

Manager and all Human Resources Analysts

Office of the County Counsel—Designated Deputies

Chief Administrative Office—Compensation Policy Division—Division Chief,

Assistant Division Chief, all Principal Analysts, CAO

County Privacy Official and Assistant Privacy Official

Protected Health Information disclosed to these individuals under subsection C1 of this section may be accessed and used only for purposes of performing Plan Administration Functions.

G.

Disciplinary Sanctions and Mitigation of Harm. In the event that any employee specified in subsection F of this section does not comply with the provisions set forth in this section, that employee will be subject to disciplinary action by the County (which may include termination) for such non-compliance, as set forth in the Policies and Procedures. In addition, the Plan will take all necessary action to mitigate any harm caused by an employee's failure to comply with these provisions.

H.

Compliance with Health Privacy Laws. To the extent applicable, the Plan will comply with Subpart E of 45 CFR § 164 and any other applicable federal, state and local laws governing the safeguarding of health privacy matters.

I.

Interpretation of HIPAA Privacy Rules. The provisions of this section are meant to comply with (and not expand upon) the requirements of the HIPAA Privacy Rules and shall be interpreted accordingly. In the event that any of the provisions of this section are not applicable, are superceded, or are no longer required under HIPAA, they shall be deemed to be deleted from the Plan and shall have no further force or affect.

J.

Security Standards for Electronic Protected Health Information. Beginning no later than April 20, 2006, in order to safeguard any Electronic Protected Health Information created, received, maintained, or transmitted to or by the County on behalf of the Plan, the County shall:

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 the Plan;

Ensure that the adequate separation between the Plan and the County required by subsection F and 45 CFR § 164.504(f)(2) (iii) is supported by reasonable and appropriate security measures;

Ensure that any agent, including a subcontractor, to whom it provides Electronic Protected Health Information agrees to implement reasonable and appropriate security measures to protect that Information; and

Report to the Plan any security incident of which it becomes aware.

(Ord. 2006-0026 § 1, 2006: Ord. 2004-0020 § 4, 2004.)