HomeMy WebLinkAboutA7115 - PACE TPA - ADMIN SVCS AGMT PACET PA
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ADMINISTRATIVE SERVICES AGREEMENT
This agreement specifies the services to be provided by PACE TPA, "PACE TPA" to the"Employer' identified in
Attachment A of this Agreement regarding the administration of the Employer's Flexible Benefit System. Your
Flexible Benefit System includes a—
Section 125 Flexible Spending Account(FSA) Plan
Administrator
The Employer shall be the Plan Administrator and PACE TPA shall be engaged as a subcontractor in the
performance of administrative services for the Plan. The Employer remains responsible for maintaining the Plan,
including the establishment of eligibility and paying all benefits owed or established under the Plan to its
Participants; PACE TPA is to provide the agreed upon services to the Plan, without assuming any liability beyond
the performance of services as set forth below.
Services to be provided by PACE TPA
1. Plan Update Service. This service includes a plan review and amendment documents if needed.
2. Employee Enrollment Assistance. This service includes educational materials such as brochures and
enrollment fors. Enrollment packets including claim forms and instructions for filing are provided to all
participants.
3. Employee Eligibility Changes. PACE TPA will make eligibility changes based on information provided to
us by the Employer in the prescribed manner.
4. Employee Account Mana eq ment. Employee contributions to the Employer's Plan are added by PACE
TPA to employee's account balances at the end of each payroll date. Services also include account
balance tracking, qualifying expense and other claims adjudication, as provided for with Employer's Plan,
and monthly reports on year to date activity. Employee account management services are available in
one of two methods. Rapid Claims or Weekly Accounting Services.
The Rapid Claims Service, claim reimbursement funds are administered through the PACE TPA Flex
Trust. Claim funds are withdrawn from an employer-specified bank account via EFT, or, a contribution
check is sent to PACE TPA on each payroll date. Reimbursements to participants are processed daily,
checks are signed by PACE TPA, and reimbursement checks are then mailed directly to participants or
deposited to a participant-specified bank account through ACH.
Year-to-date reports are mailed to the employer monthly and participants receive statements via the Web
site, on reimbursement check stubs, and 60 days prior to the plan year-end.
5. Participant Assistance. Employees have 24-hour access to their accounts via the Internet and daytime
access to our benefit administrators. Employee account balance information is included on claim
reimbursement checks stubs and provided 60 days prior to plan year-end.
6. Annual Plan Compliance. Services include reconciliation and reporting of employee account balances,
plus compliance with discrimination testing requirements. We will also provide a completed IRS Form
5500 as needed.
7. Unpaid Benefit Funds. In compliance with your Plan document and any applicable state or federal law
requirements, any unclaimed fund amounts remaining unpaid more than 365 days after the close of the
plan year and any applicable grace and appeal periods in which the claim is incurred are forfeited and
returned to the Employer, minus any necessary fees and expenses that are owning to PACE TPA
pursuant to this Agreement.
8. Account Arrears : PACETPA may at any time reserve the right to collect account arrears to make the
account whole.
Responsibilities of the Employer
1. General Compliance. Although PACE TPA serves as Employer's agent for services rendered pursuant to
this Agreement, the Employer remains responsible for all Plan activities, including general compliance with
ERISA, HIPAA, the Internal Revenue Code, or other applicable laws or regulations. The Employer should
seek legal counsel to review the Section 125 Plan Document, as amended and Summary Plan Description,
as amended to determine the types of expenses that are allowed to be paid as qualified expenses under
this Agreement, as well as to ensure the Employer is meeting it's general compliance obligations in the
sponsorship of its Plan.
2. Enrollment. Employer remains responsible for determining the eligibility of all Plan participants. As part of
that process, Employer shall complete new plan enrollment procedures on a timely basis.
ENROLLMENT CHART
If we receive your election information by: Processing of contributions, claims,and
disbursements will begin on the later of,the first day
of the plan year or:
December 15 January 1
January 15 February 1
February 15 March 1
March 15 April 1
April 15 May 1
May 15 June 1
June 15 July 1
July 15 August 1
August 15 September 1
September 15 October 1
October 15 November 1
November 15 December 1
3. Eliaibility Changes. Employer shall notify PACE TPA of changes in employee eligibility(e.g., addition,
termination, Change in Family Status, etc.)at lease 5 business days prior to the first payroll date affected.
PACE TPA must be notified in the prescribed manner via fax or e-mail.
Late notification of Plan eligibility may result in an erroneous payment to an employee. In this event, the
risk of loss will be the burden of the Employer and the Employer will then be responsible for collecting any
erroneous payments from the employee.
4. Discriminatory Plans. Initiate any corrective action required in the event the plan(s) become discriminatory.
5. Ownership of Account Assets. All amounts deposited by the Employer under any of the Flexible Benefit
System Plan(s), described herein, remain the Employer's assets and shall remain available for the
employer's general use or removal. PACE TPA or its representatives, shall only be responsible for
administering the Employer's funds in accordance with the terms of this Agreement. Amounts deposited
by Employer shall only be disbursed by PACE TPA, or its designees, if it is an allowable expense as
determined by the Employer or its representative, or as otherwise required by a Court of appropriate
jurisdiction.
6. Employee Fraud. In the event of Employee fraud against the Plan, it is the Employer's responsibility to
make the Plan whole and pursue appropriate remedies from the Employee
7.
Account Arrears_: PACETPA may request at anytime the right to collect account arrears to make the
account whole.
8. Debit Card Holders
As an alternative to the method of Benefit payment, if you agree to the terms and conditions of any
applicable cardholder agreement(that is also agreed to by your Employer and the Administrator,
with any additional provisions or requirements)that provides for the payment of qualifying Benefit
expenses through use of a debit or credit card, stored value card or other similar electronic media
(generally referred to as the"Debit Card"), payment of qualifying Benefit expenses may be made
directly to the service provider, authorized merchant, or other independent third party using claim
substantiation procedures and policies in accordance with existing IRS guidelines and other
applicable law as set forth below:
If the Benefit reimbursement request being submitted for any non-qualifying Benefit expense in a
manner other than as specified under any of the methods allowable under existing IRS guidelines,
the Administrator will make a conditional payment of an allowable Benefit item to the authorized
service provider, merchant, or approved independent third party, but will also require additional
third-party information, such as merchant or service provider receipts, describing the service or
product; the date of service or sale; and the amount, which will be subject to further review and
substantiation;
If any conditional payment or other Benefit payment has been made but is not deemed to be a
qualifying expense reimbursement, the Administrator will ensure that proper correction procedures
are maintained with respect to the improper payment(s):
(1) Upon identification of any improper payment, the Administrator will require employee to
pay back to the Plan an amount equal to the improper payment;
(2) If employee does not immediately repay the Plan, the Administrator will ensure that the
proper amount is withheld from your wages or other compensation (with such amounts
then being immediately remitted to the Plan by your Employer)to the extent consistent
with applicable law;
(3) To the extent that neither(1)or(2)above are allowable or effective, the Administrator
shall have the authority to utilize a claim substitution or offset approach to resolve the
improper claim amount(s), with such methodology being clearly explained to you as part of
your cardholder agreement;
(4) The Administrator may also take any further steps or actions as deemed necessary,
including denial or cancellation of access to the Debit Card until the indebtedness is repaid
by you. The Administrator may also pursue any other methods of collection as would be
consistent with its usual business practices to ensure the improper payment amounts are
adequately remitted to the Plan as required by the Plan or your cardholder agreement.
Fees for Services
In consideration for PACE TPA's performance of services under this Agreement, Employer shall agree to be
responsible for payment of the fees set forth in Attachment A of the Agreement, Service and Fee Schedule.
1. Invoicing and Collection. The total quarterly fees for administration will be based on the number of
participants enrolled at the beginning of each plan year and invoiced quarterly along with 114 of the Annual
Compliance Fee. The monthly fee will remain constant for the year unless there is a 10% or greater
increase in the number of participants, but the monthly fee will not decrease with for any reason. Invoice
will be prepared each quarter and collected PACE TPA via invoice.
If administrative fees are not kept current, PACE TPA has the right to make immediate demand for the payment of
all balances owed and suspend or terminate services for this Employer(see"Termination' section below). PACE
TPA's obligations to provide the services described in this Agreement are expressly conditioned upon timely
payment of its fees by the Employer or the plan. If any fees remain unpaid for more than thirty(30)days after the
statement date, PACE TPA shall have the right, in its sole and absolute discretion and without liability of any kind
under this Agreement or otherwise, to refuse to perform any further services relating to the Employer's Plan.
Unpaid fees and charges will bear a service charge at the rate of one and one-half percent (1.5%) per month from
the date of default. All fees and charges shall be due when billed and will be considered in default if not paid within
thirty(30)days of the statement date. Full prepayment is required for all plan documents; PACE TPA reserves the
right to require full pre-payment for other services as well
Reports and Data
All reports and data remain the property of the Employer. PACE TPA will provide the Employer all data, upon
request, in the electronic or printed format used by PACE TPA in its administrative procedure to assist Employer in
preparing any necessary financial reports and other information.
Term of Agreement
The term of this Agreement shall be from the Administrative Service Start Date in Attachment A and continue for a
period of twelve months. This agreement automatically renews every twelve months if is has not be terminated.
Fees and service elections may be adjusted at each renewal.
Termination
This agreement will terminate upon the occurrence of the earliest of the following events:
1. At PACE TPA's discretion, the date on which Employer either: (1)fails to pay fees and expenses owing to
PACE TPA under this Agreement, or(2)fails to immediately transfer or fund necessary amounts needed
by PACE TPA to pay approved expense amounts.
2. Any other date that is mutually agreed upon in writing between PACE TPA and Employer provided at least
thirty (30) days notice of intent to terminate and otherwise not renew this Agreement is given by either
party.
When this Agreement is terminated, PACE TPA will immediately cease the performance of any further services
under this Agreement. PACE TPA will invoice and collect a"run-out fee' equal to three (3) months of
administrative service fees.
Upon receipt of the"run-out fee', PACE TPA will continue the processing of qualifying expense reimbursements
and general plan administration.
Upon the completion of the 90 day"run-out period", PACE TPA will cease the processing of any expense
reimbursement requests that are in its possession and return to the Employer any unpaid or other pending
payment requests and/or any subsequent reimbursement requests that are received after the date of the specified
"run-out period". A copy of all records pertaining to Employer's account shall also be returned at the end of the
run-out period, including a detailed reporting of all reimbursement activities performed on behalf of the Employer
through the date of the run-out period. From the date of the run-out period forward, the Employer shall be
responsible for all aspects of its Plan, including the processing of other qualifying expense reimbursements, annual
reporting and general plan administration. PACE TPA shall also return any undistributed funds that had been
previously deposited by the Employer, subject to the completion of a final accounting of all account activities, as
well as after deduction of applicable fees and other expenses. If necessary, PACE TPA shall have the immediate
right to demand and pursue collection of any fees, reimbursements or other amounts that are due and owing to
PACE TPA as of the date of termination pursuant to the terms of this Agreement.
Miscellaneous
1. The laws of the State of California shall govern this Agreement, to the extent they are not inconsistent with
or preempted by ERISA, the Internal Revenue Code, or any other applicable federal law.
2. This Agreement, including its Exhibits attached, constitutes the entire contract between PACE TPA and
employer and no modification or amendment shall be valid unless agreed to in writing by both parties.
3. Employer has total control and discretionary authority over the Plan(s)and the manner in which it is
operated. The amounts deposited by the Employer with PACE TPA under any of the Flexible benefit
System Plans remain the assets of the Employer. PACE TPA, and its representatives, is only an agent of
the Employer for processing of qualifying expense requests, as provided under this Agreement.
4. Employer agrees that PACE TPA is not the plan administrator and is not a plan fiduciary under the Plan(s).
Likewise, PACE TPA shall have no power or authority to waive, alter, breach or modify any terms and
conditions of the Plan(s). However, PACE TPA will not undertake any duties or responsibilities, regardless
of whether they are set forth in the Plan(s), if such actions are in violation of any applicable laws or
regulations.
This Agreement, including the attached Exhibits and Attachments, is accepted and agreed to by the parties as
of this date.
City of Palm Springs November 13, 2018
Signaturg.� D e
AP?ROVcP py rrry C DuNC I L
APPROVED AS TO FORM ATTEST:
Em to tt rwus A'4115
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ATTACHMENT A
Administrative Service Agreement
Services and Fee Option Schedule
November 13, 2018
Kim Peacher
City of Palm Springs
3200 E. Tahnquitz Canyon Way
Palm Springs, CA 92262
Plan Year: 01/01 —112/31/2019
Contact Name: :l^ rPti(heil E-Mail Address: *1 5e120nq ScAt
Your Flexible Benefit System includes the following plan(s):
Flexible Spending Account(FSA)
Service Options:
0 Rapid Claims Service
0 FSA Healthcare Carryover(up to$500)
0 Debit Cards
Please select the method contributions will be transmitted to PACE TPA:
Check one
❑ Via EFT(electronic funds transfer) 13/ Via client check sent on each payroll date
Authorization form completed and enclosed
Participant Based Fees
Service Monthly Numberof Estimated
Rate/Part ici ant Participants Qtl . Fee
Participant Service Fee. Includes changes to employee
eligibility,employee account management,plan reimbursements
and participant assistance. A. $5.00 B. y'-�;(` C. $ L25
A minimum monthly fee of$75.00 is charged for accounts that fall (AxB) x 3 mos or
below 11 participants. The rate is$7.00 per participant per month $75.00 whichever
or$75.00 whichever is greater is greater
Annual Debit Card Fees check one: First Quarter If employer paid
❑ Employee paid E. ',.A%V?at
El Employer paid D. $ 12.00 F. Vj �6A
Quarterly Compliance Fees
Standard Quarterly Compliance Fee. This fee includes the plan document update G. $0.00
service, if required, employee enrollment and account set-up, account reports,
discrimination testing, and annual compliance services.
Total Estimated Quarterly Fees H. $ ZS6
C+F+G
7
November 13,2018
Kim Peacher
of Pal
City of Palm Springs
3200 E.Tahnquitz Canyon Way
Palm Springs,CA 92262
Dear Kim,
lTJ RE: Section 125 Flexible Spending Plan year commencing 01/01/2019
V It's getting near the end of your cafeteria plan year and I look forward to servicing your employees in
D the new plan year.
To ensure that your employees receive the maximum benefit from this year's plan,please consider the
following.
7I n1n :;trn[Ic 1. It is the time for your employees to turn in claims for the 2018 plan year ending
Conii;i:,;nce
December 31,2018 and think about their new election for the 2019 plan year.
Ed uCiiliur 2. Please keep in mind that 2018 contributions are reimbursed to pay for services provided in
the 2018 plan year. Any 2018 funding that remains in the plan after the end of your run out
period(March 31,2019)will be carried over and combined with the 2019 medical account.
The Maximum FSA medical carryover is$500.00.
Debit Cards:Please have participants checked the expiration date;cards are valid for three years;all
expiration dates are based on the actual request date. If a participant needs to request an additional
card they may do so at myfiexonline.com>Card Center>Flex Benefits Card or contact the Claims
department(May)or myself and we can easily order additional cards.All new cards require activation
prior to first use(phone number will be affixed). Contact mavCaloacetaa.com to request additional
cards.
www.mvflexonline.com. We encourage each participant to go online and verify their annual
election for the new plan year. Also participants can access a variety of useful items online
such as claim forms,activity statements, and eligible items for reimbursement as well as
calculating their tax savings plus order additional debit cards.
2019 Annual Maximums
The annual maximum for Medical Reimbursement annual maximum for 2018 is
2650.00; no increase for 2019
Annual maximum for Dependent day care has remained unchanged at$5000.00.
Eligible expenses
Keep in mind that all eligible expenses are based on date of service; we cannot accept
debit card payments for past expenses incurred in the previous plan year unless there
a) still an available balance and b) still in the run out period or 90 days after the end of
the plan year. Debit cards will not work at collection agencies.
Best Regards,
r��t¢r..re c7�2ar�
PACETPA.COM
Date Requested: November 13, 2018
Census Data Request
Non-Discrimination Testing
IRC Section 129— Dependent Care
Highly Compensated Employees— IRC 414(q)
Company Name: City of Palm Springs Plan Year End: 01/01 — 12/3112019
List all employees who fit into one or more of the following categories. An employee may be classified as highly
compensated on the basis of more than one category. When listing highly compensated employees, list each
employee only once.
List all employees with more than 5% ownership during the prior or current plan year.
List all employees who are a spouse or relative of any individual listed above.
n/A
List the employees earning more than $120,000 in the prior plan year.'*
**An employer may elect to treat as highly compensated under the$120,000 compensation test only those employees who are also
in the top-paid 20%group.
Once we have received this information, we will perform the tests and advise if the Flexible Benefit
Plan has failed the discrimination testing. No notice will be returned if your Plan is found to be
nondiscriminatory. If we do not receive the requested information, PACE TPA will have no liability for any
sanctions arising from any audit by any regulatory agency.
PACE TPA
1645 Shaw Avenue, Suite 101- Clovis, CA 93611 - 559-436-6606 - Fax 559-436-4679
Last Name First Name
Ready David
Fuller Marcus
Kotkin Edward
Reyes Bryan
Nolan Thomas
Nalder John
Beverly Ronald
Fagg Flinn
Madison Perry
Desmarais Melissa
Wright Robert
Virata Whitlan
Kovaleff Michael
Loya Jason
Brown Arron
Oltean Vicki
Araiza Gustavo
Browning Frank
Kays Regina
King Peter
Montalvo Joel
Mejia Anthony
Pendleton Marla
Villegas Mike
Mozzillo Richard
Paden Glenn
Barrier Ryan
Smith Michael
Robertson Edward
Aguirre Ulises
Hutchinson William
Larson Owen
Schafer Staci
Fernandez Guillermo
Gorospe Cory
Harandi Ali
MacLean Matthew
Seacrist Wayne
Skyberg Ronald
Case Adam
Duenas Paul
Gunkel Nathan
Lyle Gregory
Beard Matthew
Cabrera Jonathan
Casavan Michael
Fieux Kelly
Flinn Shawn
Galvan Arnold
Guarino Frank
Hackbarth Isaac
Stjerne Kyle
Bowser Harold
Kelsheimer Jeffrey
Myers Damien
Ferguson Rande
Perotti Robert
Clardy Nathan
Fite Todd
Smith George
Van Lierop Jeffrey
Date Requested: November 13, 2018
Census Data Request
Non-Discrimination Testing
IRC Section 125— Cafeteria Plan
Key Employees — IRC 416(i)(1)(A)
Company Name: City of Palm Springs Plan Year End: 01/01 — 12/31/2019
Total number of employees as of 12/31/2018 `1(0L-
List all employees who, at any time during the current plan year or preceding plan year, fit into one or more of
the following three categories. An employee may be classified as a key employee on the basis of more than
one category. When listing key employees, list each employee only once.
Officer and had annual compensation greater than $175,000:
Y6J
Employees with more than 5% ownership:
Employees with more than 1% ownership and annual compensation greater than $120,000:
Once we have received this information, we will perform the tests and advise if the Flexible Benefit Plan
has failed the discrimination testing. No notice will be returned if your Plan is found to be
nondiscriminatory. If we do not receive the requested information, PACE TPA will
have no liability for any sanctions arising from any audit by any regulatory agency.
PACE TPA
1645 Shaw Avenue,Suite 101•Clovis,CA 93611• 559-436-6606• Fax 559-436-4679
ORIGINALPALCETPA
Plan Design, Administration, Compliance. Education
ai
,.uL+^I0R AGREEMENT ADMINISTRATIVE SERVICES AGREEMENT
This agreement specifies the services to be provided by PACE TPA,"PACE TPA"to the"Employer"identified in Attachment A
of this Agreement regarding the administration of the Employer's Flexible Benefit System. Your Flexible Benefit System
includes a—
Section 125 Flexible Spending Account(FSA)Plan
Administrator
The Employer shall be the Plan Administrator and PACE TPA shall be engaged as a subcontractor in the performance of
administrative services for the Plan. The Employer remains responsible for maintaining the Plan,including the establishment of
eligibility and paying all benefits owed or established under the Plan to its Participants; PACE TPA is to provide the agreed
upon services to the Plan,without assuming any liability beyond the performance of services as set forth below.
Services to be provided by PACE TPA
1. Plan Update Service. This service includes a plan review and amendment documents if needed.
2. Employee Enrollment Assistance. This service includes educational materials such as brochures and enrollment
forms. Enrollment packets including claim forms and instructions for filing are provided to all participants.
3. Employee Eligibility Changes. PACE TPA will make eligibility changes based on information provided to us by the
Employer in the prescribed manner.
4. Emolovee Account Management. Employee contributions to the Employer's Plan are added by PACE TPA to
employee's account balances at the end of each payroll date. Services also include account balance tracking,
qualifying expense and other claims adjudication,as provided for with Employer's Plan,and monthly reports on year
to date activity. Employee account management services are available in one of two methods. Rapid Claims or
Weekly Accounting Services.
The Rapid Claims Service,claim reimbursement funds are administered through the PACE TPA Flex Trust. Claim
funds are withdrawn from an employer-specified bank account via EFT,or,a contribution check is sent to PACE TPA
on each payroll date. Reimbursements to participants are processed daily, checks are signed by PACE TPA,and
reimbursement checks are then mailed directly to participants or deposited to a participant-specified bank account
through ACH.
Year-to-date reports are mailed to the employer monthly and participants receive statements via the Web site,on
reimbursement check stubs,and 60 days prior to the plan year-end.
5. Participant Assistance. Employees have 24-hour access to their accounts via the Internet and daytime access to our
benefit administrators. Employee account balance information is included on claim reimbursement checks stubs and
provided 60 days prior to plan year-end.
6. Annual Plan Compliance. Services include reconciliation and reporting of employee account balances, plus
compliance with discrimination testing requirements. We will also provide a completed IRS Form 5500 as needed.
7. Unpaid Benefit Funds. In compliance with your Plan document and any applicable state or federal law requirements,
any unclaimed fund amounts remaining unpaid more than 365 days after the close of the plan year and any applicable
grace and appeal periods in which the claim is incurred are forfeited and returned to the Employer, minus any
necessary fees and expenses that are owning to PACE TPA pursuant to this Agreement.
Responsibilities of the Employer
1. General Compliance. Although PACE TPA serves as Employers agent for services rendered pursuant to this
Agreement,the Employer remains responsible for all Plan activities, including general compliance with ERISA, HIPAA,
the Internal Revenue Code,or other applicable laws or regulations. The Employer should seek legal counsel to review
the Section 125 Plan Document,as amended and Summary Plan Description,as amended to determine the types of
expenses that are allowed to be paid as qualified expenses under this Agreement,as well as to ensure the Employer is
meeting it's general compliance obligations in the sponsorship of its Plan.
2. Enrollment. Employer remains responsible for determining the eligibility of all Plan participants. As part of that
process, Employer shall complete new plan enrollment procedures on a timely basis.
3. Eligibility Changes. Employer shall notify PACE TPA of changes in employee eligibility(e.g.,addition,termination,
Change in Family Status,etc.)at lease 5 business days prior to the first payroll date affected. PACE TPA must be
notified in the prescribed manner via fax or e-mail.
Late notification of Plan eligibility may result in an erroneous payment to an employee. In this event,the risk of loss will
be the burden of the Employer and the Employer will then be responsible for collecting any erroneous payments from
the employee.
4. Discriminatory Plans. Initiate any corrective action required in the event the plan(s)become discriminatory.
5. Ownershio of Account Assets. All amounts deposited by the Employer under any of the Flexible Benefit System
Plan(s),described herein,remain the Employers assets and shall remain available for the employer's general use or
removal. PACE TPA or its representatives,shall only be responsible for administering the Employer's funds in
accordance with the terms of this Agreement. Amounts deposited by Employer shall only be disbursed by PACE TPA,
or its designees, if it is an allowable expense as determined by the Employer or its representative,or as otherwise
required by a Court of appropriate jurisdiction.
& Employee Fraud. In the event of Employee fraud against the Plan,it is the Employer's responsibility to make the Plan
whole and pursue appropriate remedies from the Employee.
7. Debit Card Holders
As an alternative to the method of Benefit payment, if you agree to the terms and conditions of any applicable
cardholder agreement(that is also agreed to by your Employer and the Administrator,with any additional
provisions or requirements)that provides for the payment of qualifying Benefit expenses through use of a
debit or credit card,stored value card or other similar electronic media(generally referred to as the"Debit
Card"), payment of qualifying Benefit expenses may be made directly to the service provider,authorized
merchant,or other independent third party using claim substantiation procedures and policies in accordance
with existing IRS guidelines and other applicable law as set forth below:
If the Benefit reimbursement request being submitted for any non-qualifying Benefit expense in a manner
other than as specified under any of the methods allowable under existing IRS guidelines,the Administrator
will make a conditional payment of an allowable Benefit item to the authorized service provider,merchant,or
approved independent third party,but will also require additional third-party information,such as merchant or
service provider receipts,describing the service or product;the date of service or sale;and the amount,which
will be subject to further review and substantiation;
If any conditional payment or other Benefit payment has been made but is not deemed to be a qualifying
expense reimbursement,the Administrator will ensure that proper correction procedures are maintained with
respect to the improper payment(s):
(1) Upon identification of any improper payment,the Administrator will require employee to pay back to
the Plan an amount equal to the improper payment;
(2) If employee does not immediately repay the Plan,the Administrator will ensure that the proper
amount is withheld from your wages or other compensation(with such amounts then being
immediately remitted to the Plan by your Employer)to the extent consistent with applicable law;
(3) To the extent that neither(1)or(2)above are allowable or effective,the Administrator shall have the
authority to utilize a claim substitution or offset approach to resolve the improper claim amount(s),
with such methodology being clearly explained to you as part of your cardholder agreement;
(4) The Administrator may also take any further steps or actions as deemed necessary,including denial
or cancellation of access to the Debit Card until the indebtedness is repaid by you.The
Administrator may also pursue any other methods of collection as would be consistent with its usual
business practices to ensure the improper payment amounts are adequately remitted to the Plan as
required by the Plan or your cardholder agreement.
Fees for Services
In consideration for PACE TPA's performance of services under this Agreement, Employer shall agree to be responsible for
payment of the fees set forth in Attachment A of the Agreement,Service and Fee Schedule.
1. Invoicing and Collection. The total quarterly fees for administration will be based on the number of participants
enrolled at the beginning of each plan year and invoiced quarterly along with 114 of the Annual Compliance,Fee. The
monthly fee will remain constant for the year unless there is a 10%or greater increase in the number of participants,
but the monthly fee will not decrease with for any reason. Invoice will be prepared each quarter and collected PACE
TPA via invoice.
If administrative fess are not kept current,PACE TPA has the right to make immediate demand for the payment of all balances
owed and suspend or terminate services for this Employer(see"Termination"section below). PACE TPA's obligations to
provide the services described in this Agreement are expressly conditioned upon timely payment of its fees by the Employer or
the plan. If any fees remain unpaid for more than thirty(30)days after the statement date, PACE TPA shall have the right, in its
sole and absolute discretion and without liability of any kind under this Agreement or otherwise,to refuse to perform any further
services relating to the Employer's Plan. Unpaid fees and charges will bear a service charge at the rate of one and one-half
percent(1.5%)per month from the date of default. All fees and charges shall be due when billed and will be considered in
default if not paid within thirty(30)days of the statement date. Full prepayment is required for all plan documents;PACE TPA
reserves the right to require full pre-payment for other services as well
Reports and Data
All reports and data remain the property of the Employer. PACE TPA will provide the Employer all data, upon request, in the
electronic or printed format used by PACE TPA in its administrative procedure to assist Employer in preparing any necessary
financial reports and other information.
Term of Agreement
The term of this Agreement shall be from the Administrative Service Start Date in Attachment A and continue for a period of
twelve months. This agreement automatically renews every twelve months if is has not be terminated. Fees and service
elections may be adjusted at each renewal.
Termination
This agreement will terminate upon the occurrence of the earliest of the following events:
1. At PACE TPA's discretion,the date on which Employer either:(1)fails to pay fees and expenses owing to PACE TPA
under this Agreement; or(2)fails to immediately transfer or fund necessary amounts needed by PACE TPA to pay
approved expense amounts.
2. Any other date that is mutually agreed upon in writing between PACE TPA and Employer provided at least thirty(30)
days notice of intent to terminate and otherwise not renew this Agreement is given by either party.
When this Agreement is terminated, PACE TPA will immediately cease the performance of any further services under this
Agreement. PACE TPA will invoice and collect a"run-out fee"equal to three(3)months of administrative service fees.
Upon receipt of the"run-out fee", PACE TPA will continue the processing of qualifying expense reimbursements and general
plan administration.
Upon the completion of the 90 day"run-out period", PACE TPA will cease the processing of any expense reimbursement
requests that are in its possession and return to the Employer any unpaid or other pending payment requests and/or any
subsequent reimbursement requests that are received after the date of the specified"run-out period". A copy of all records
pertaining to Employer's account shall also be returned at the end of the run-out period,including a detailed reporting of all
reimbursement activities performed on behalf of the Employer through the date of the run-out period. From the date of the run-
out period forward,the Employer shall be responsible for all aspects of its Plan, including the processing of other qualifying
expense reimbursements,annual reporting and general plan administration. PACE TPA shall also return any undistributed
funds that had been previously deposited by the Employer,subject to the completion of a final accounting of all account
activities,as well as after deduction of applicable fees and other expenses. If necessary, PACE TPA shall have the immediate
right to demand and pursue collection of any fees,reimbursements or other amounts that are due and owing to PACE TPA as
of the date of termination pursuant to the terms of this Agreement.
Miscellaneous
1. The laws of the State of California shall govern this Agreement,to the extent they are not inconsistent with or
preempted by ERISA,the Internal Revenue Code,or any other applicable federal law.
2. This Agreement, including its Exhibits attached,constitutes the entire contract between PACE TPA and employer and
no modification or amendment shall be valid unless agreed to in writing by both parties.
3. Employer has total control and discretionary authority over the Plan(s)and the manner in which it is operated. The
amounts deposited by the Employer with PACE TPA under any of the Flexible benefit System Plans remain the assets
of the Employer. PACE TPA,and its representatives,are only an agent of the Employer for processing of qualifying
expense requests,as provided under this Agreement.
4. Employer agrees that PACE TPA is not the plan administrator and is not a plan fiduciary under the Plan(s). Likewise,
PACE TPA shall have no power or authority to waive,alter, breach or modify any terms and conditions of the Plan(s).
However, PACE TPA will not undertake any duties or responsibilities, regardless of whether they are set forth in the
Plan(s),if such actions are in violation of any applicable laws or regulations.
This Agreement, including the attached Exhibits and Attachments,is accepted and agreed to by the parties as of this date.
City of Palm Springs Feb ru ry 12, 2018
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ATTACHMENT A
Administrative Service Agreement
Services and Fee Option Schedule
February 12, 2018
Kim Peacher
City of Palm Springs
3200 E. Tahnquitz Canyon Way
Palm Springs, CA 92262
Plan Year: 01/01 — 12/31/2018
Contact Name: Mnng_ 6600nzp1eZ E-Mail Address: ViQnnGy.gonza�z@Dd�r'�s�'nrt�5(U �Dt
Your Flexible Benefit System includes the following plan(s):
Flexible Spending Account(FSA)
Service Options:
Q Rapid Claims Service
Q FSA Healthcare Carryover(up to$500)
Q Debit Cards
Please select the method contributions will be transmitted to PACE TPA:
Check one
Ef Via EFT(electronic funds transfer) ❑ Via client check sent on each payroll date
Authorization form completed and enclosed
Participant Based Fees
Service Monthly Number of Estimated
Rate/Participant Participants Qtl . Fee
Participant Service Fee. Includes changes to employee
eligibility,employee account management,plan reimbursements
and participant assistance. A. $5.00 B. 138 C. $ 2 r 0-7 O
A minimum monthly fee of$75.00 is charged for accounts that fall (AxB)x 3 mos or
below 11 participants. The rate is$7.00 per participant per month $75.00 whichever
or$75.00 whichever is greater Is greater
Annual Debit Card Fees check one First Quarter If employer paid
❑ Employee paid E. waived
❑ Employer paid D .$ 12.00 — F.waived
Quarterly Compliance Fees
Standard Quarterly Compliance Fee. This fee includes the plan document update G. $0.00
service, if required, employee enrollment and account set-up, account reports,
discrimination testing, and annual compliance services.
Total Estimated Quarterly Fees H. $ 210-70
C+F+G
David Ready
Marcus Fuller
Edward Kotkin
Bryan Reyes
Thomas Nolan
John Nalder
Ronald Beverly
Geoffrey Kiehl
Flinn Fagg
Thomas Garcia
Perry Madison
Robert Wright
Henricus Peeters
Whitlan Virata
Jason Loya
Michael Kovaleff
Arron Brown
Vicki Oltean
Gustavo Araiza
Frank Browning
Regina Kays
Melissa Desmarais
Richard Mozzillo
Glenn Paden
Edward Robertson
Ryan Barrier
Michael Smith
Anthony Mejia
James Zicaro
Ulises Aguirre
Marla Pendleton
Paul Abshire
Cory Gorospe
Matthew MacLean
Wayne Seacrist
Mike Villegas
Ronald Skyberg
Adam Case
Paul Duenas
Nathan Gunkel
Gianfranco Laurie
Staci Schafer
Ali Harandi
Gregory Lyle
Craig Gladders
Matthew Beard
Jonathan Cabrera
Kelly Fieux
Shawn Flinn
Arnold Galvan
Frank Guarino
Isaac Hackbarth
William Hutchinson
Owen Larson
Kyle Stjerne
Jeffrey Kelsheimer
Damien Myers
Rande Ferguson
Nathan Clardy
Todd Fite
Robert Perotti
George Smith
Jeffrey Van Lierop
Harold Bowser
Date Requested: February 12, 2018
Census Data Request
Non-Discrimination Testing
IRC Section 129 — Dependent Care
Highly Compensated Employees—IRC 414(q)
Company Name: City of Palm Springs Plan Year End: 12/3112018
List all employees who fit into one or more of the following categories. An employee may be classified
as highly compensated on the basis of more than one category. When listing highly compensated
employees, list each employee only once.
List all employees with more than 5% ownership during the prior or current plan year.
List all employees who are a spouse or relative of any individual listed above.
List the employees earning more than $120,000 in the prior plan year.**
**An employer may elect to treat as highly compensated under the$120,000 compensation test only those employees who are
also
in the top-paid 20%group.
Once we have received this information, we will perform the tests and advise if your Flexible
Benefit Plan has failed the discrimination testing. No notice will be returned if your Plan is
found to be nondiscriminatory. If we do not receive the requested information, PACE TPA will
have no liability for any sanctions arising from any audit by any regulatory agency.
PACE TPA
1645 Shaw Avenue,Suite 101• Clovis,CA 93611• 559-436-6606- Fax 559-436-4850
Date Requested: February 12, 2018
Census Data Request
Non-Discrimination Testing
IRC Section 125— Cafeteria Plan
Key Employees—IRC 416(i)(1)(A)
Company Name: City of Palm Springs Plan Year End: 12/31/2018
Total number of employees as of 12/31/17 �
List all employees who, at any time during the current plan year or preceding plan year, fit into one or
more of
the following three categories. An employee may be classified as a key employee on the basis of more
than
one category. When listing key employees, list each employee only once.
Officer and had annual compensation greater than $175,000:
/VA _
Employees with more than 5% ownership:
NM-7 ---
Employees with more than 1% ownership and annual compensation greater than $120,000:
NA
Once we have received this information, we will perform the tests and advise if your Flexible
Benefit Plan has failed the discrimination testing. No notice will be returned if your Plan is
found to be nondiscriminatory. If we do not receive the requested information, PACE TPA will
have no liability for any sanctions arising from any audit by any regulatory agency.
PACE TPA
1645 Shaw Avenue,Suite 101•Clovis,CA 93611• 559-436-6606• Fax 559-436-4850