CAA FSA Amendment Coronavirus Response and Relief Supplemental Appropriations Act of 2021 FLEXIBLE SPENDING ACCOUNT PLAN AMENDMENT The Employer adopts this Amendment to the Flexible Spending Account (“Plan”) to implement certain temporary relief due to the COVID-19 national emergency as authorized by the Consolidated Appropriations Act of 2020 and IRS Notice 2021-15. The Employer has reserved the right to amend the Plan under Article X of the Plan Document. The Plan is amended, as selected below, and the Amendment is effective retroactively, to the plan year beginning on or after January 1, 2020, unless indicated otherwise: TEMPORARY RELIEF RELATED TO THE COVID-19 EMERGENCY The Health Flexible Spending Account (Health FSA), including a Limited Purpose FSA (as applicable) and/or Dependent Care Flexible Spending Account (DCFSA) components of the Plan are amended as follows (Select all that apply): Select the plan design below that matches your current setup or the setup you would like to adopt under the temporary relief.Medical FSA/Limited FSA with Carryover Yes No Medical FSA/Limited FSA with Grace Period Yes No Dependent Care FSA with Carryover Yes No Dependent Care FSA with Grace Period Yes No Health FSA Carryover: For the plan year ending in 2020, a participant may carryover [ % or flat dollar] of the 2020 unused balance into the 2021 plan year. Elect Health FSA Carryover for plan year ending in 2020 Yes No % or flat dollar Health FSA Carryover: For the plan year ending in 2021, a participant may carryover [ % or flat dollar] of the 2021 unused balance into the 2022 plan year.Elect Health FSA Carryover for plan year ending in 2021 Yes No % or flat dollar DCFSA Carryover: For the plan year ending in 2020, a participant may carryover 100% of the 2020 unused balance into the 2021 plan year.Elect DCFSA Carryover for plan year ending in 2020 Yes No DCFSA Carryover: For the plan year ending in 2021, a participant may carryover 100% of the 2021 unused balance into the 2022 plan year.Elect DCFSA Carryover for plan year ending in 2021 Yes No Health FSA Grace Period: For the Health FSA plan year ending in 2020, the grace period is extended to [ ] months after end of the Plan Year, not to exceed 12 months.Elect Health FSA Grace Period for plan year ending in 2020 Yes No Months of extension not to exceed 12 months Health FSA Grace Period: For the Health FSA plan year ending in 2021, the grace period is extended to [ ] months after end of the Plan Year, not to exceed 12 months. Elect Health FSA Grace Period for plan year ending in 2021 Yes No Months of extension not to exceed 12 months DCFSA Grace Period: For the plan year ending in 2020, the grace period is extended to [ ] months after end of the Plan Year, not to exceed 12 months. Elect DCFSA Grace Period for plan year ending in 2020 Yes No Months of extension not to exceed 12 months DCFSA Grace Period: For the plan year ending in 2021, the grace period is extended to [ ] months after end of the Plan Year, not to exceed 12 months. Elect DCFSA Grace Period for plan year ending in 2021 Yes No Months of extension not to exceed 12 months Health FSA Post Termination Reimbursements: A Health FSA Participant who ceases participation in 2020 is permitted to continue to receive reimbursement from unused benefits in the Health FSA through the end of the Plan Year in which such participation ceased, including any grace periods.Elect Health FSA Post Termination Reimbursements for participation ceasing in 2020 Yes No Health FSA Post Termination Reimbursements: A Health FSA Participant who ceases participation in 2021 is permitted to continue to receive reimbursement from unused benefits in the Health FSA through the end of the Plan Year in which such participation ceased, including any grace periods. Elect Health FSA Post Termination Reimbursements for participation ceasing in 2021 Yes No Health FSA Mid-Year Election Changes: (a) During the Plan Year ending 2021, a Health FSA Participant may make the following prospective changes, subject to any conditions provided in subparagraph (b), to salary reduction contributions under the Plan without a corresponding qualifying life event: Elect Health FSA Mid-Year Election Changes Yes No Select All That Apply revoke an election make a new election decrease an election increase an election (b) The following conditions apply to mid-year election changes permitted above: Indicate conditions for subparagraph (b) here if applicable (c) Participants who revoke their election pursuant to 11(a)(i) will be able to submit claims incurred through the effective date of their election revocation and in accordance with the Plan’s existing run-out period. DCFSA Mid-Year Election Changes: (a) During the Plan Year ending 2021, a Dependent Care FSA Participant may make the following prospective changes, subject to any conditions provided in subparagraph (b), to salary reduction contributions under the Plan without a corresponding qualifying life event:Elect DCFSA Mid-Year Election Changes Yes No Untitled revoke an election make a new election decrease an election increase an election (b) The following conditions apply to mid-year changes permitted above: Indicate conditions for subparagraph (b) here if applicable DCFSA Special Rule for Aged Out Dependents: a) A Dependent Care FSA participant may be reimbursed for eligible dependent care expenses for a qualifying dependent who i) reached the limiting age of 13 during the 2020 plan year through the end of the 2020 plan year or ii) reached the limiting age of 13 during the 2020 or 2021 plan year and there were unused funds in the 2020 plan year. b) Reimbursements under paragraph 13(a)(ii) during the 2021 plan year can only be made from the unused funds from the 2020 plan year.Elect DCFSA Special Rule for Aged Out Dependents Yes No Mid-Year Election Changes for Health Care Coverage: a) Pursuant to the relief provided by IRS Notice 2021-15 due to the COVID-19 national emergency, a Participant may make the following prospective mid-year election changes to elections for employer-sponsored health coverage, including medical, dental and vision coverage, as applicable, and subject to the terms of this section:Elect Mid-Year Election Changes for Health Care Coverage Yes No Select all that apply Make a new election for employer-sponsored health coverage on a prospective basis, if the participant initially declined to elect employer-sponsored health coverage; Revoke an existing election for employer-sponsored health coverage and make a new election to enroll in different health coverage sponsored by the Employer; Revoke an existing election for employer-sponsored health coverage on a prospective basis, provided that the Participant attests in writing that the Participant is enrolled, or immediately will enroll, in other health coverage not sponsored by the Employer; (b) Election changes made under this subsection can only be made during the 2021 plan year and must be prospective, retroactive election changes are prohibited. (c) The following conditions apply to mid-year election changes permitted above:Indicate conditions for subparagraph (c) here if applicable This Amendment has been executed on this day* MM slash DD slash YYYY Company Name* Signed By* First Last Title* Email* By clicking on submit, I am submitting my typed signature in place of a handwritten signature. It will have the same legal representation as my legal signature.CAPTCHA
