CITY OF ELKHORN

COMMON COUNCIL MEETING AGENDA February 18, 2019 ~ 5:30 p.m.

Council Chambers, City Hall, 9 S. Broad St., Elkhorn, Wisconsin 1) Call to Order 2) Pledge of Allegiance 3) Roll Call 4) Public Comment Although the public may speak on any item that is not included on this agenda as a

“Public Hearing or Forum”, the Council may not respond or discuss the issue brought forward at this time. In accordance with open meeting laws the Council must notice an item on the agenda to allow discussion on that matter. Your comments will be considered and may be placed on a future agenda for further discussion.

5) Consent Agenda (One motion & a second will approve all of the following items listed. Any item may be pulled from the list and handled separately.) a) Minutes of February 4, 2019 Council Meeting b) Minutes of Committee Meetings: February 11, 2019 Financial & Judicial Regular and Closed

Session 6) Bills Payable

i) Consideration and recommendation to pay 7) Report of City Officers

a) Mayor i) Appointment of Lacey Reynolds to Deputy Clerk

b) City Administrator i) Request to engage Special Counsel

8) Liaison Committee Meeting Reports a) Fire Advisory Board b) Library Board c) Recreation Advisory Board d) Chamber

9) Committee Reports a) Financial & Judicial

i) Recommendation to create a segregated Agency/Trust Fund (employee post-employment benefits) and transfer existing Post Employment Account funds to new Fund.

10) Plan Commission a) Conditional Use Permit No. 19-03 for America’s Liquor/Jesus Sandoval – 9 N. Lincoln St. for a

Liquor Store b) Ordinance No. 19-02 An Ordinance to Rezone 101 & 107 W. Walworth St. and 10 S. Broad St.

from T-1 Transition District to B-1 Downtown Business District (First Reading) 11) Unfinished Business

a) Resolution No. 19-01 A Resolution for Amendments to Employee Health Reimbursement Plan 12) Adjourn DATED at Elkhorn, Wisconsin, this 15th day of February 2019

Cairie L. Virrueta, City Clerk Should you have any questions or comments regarding any items on this agenda, please contact the City Clerk’s office at 723-2219. Upon reasonable notice to the City Clerk, efforts will be made to accommodate the needs of disabled individuals through appropriate aids and services.

CITY OF ELKHORN COMMON COUNCIL

MEETING MINUTES February 4, 2019

COUNCIL CHAMBERS, 9 S. BROAD ST., ELKHORN, WI 53121 The Common Council meeting was called to order by Mayor Reynolds at 5:30 p.m. in the Council Chambers followed by the Pledge of Allegiance. ROLL CALL Present: Mayor Howie Reynolds, Aldermen Tim Shiroda, Ron Dunwiddie, Frank Boggs, Karel Young, Scott McClory, Tom Myrin; Junior Council Members Absent: Alex Johnson, Megan Degner Others present: City Administrator Sam Tapson, Attorney Ward Phillips, Finance Director James Heilman, City Clerk Cairie Virrueta, Police Chief Joel Christensen, DPW Manager Matthew Lindstrom, Fire Chief Rod Smith, Rec Director Karl Sorvick, City Engineer Greg Calhoun, Doug Snyder, Lee Brown, other persons PUBLIC COMMENT None. CONSENT AGENDA Motion (McClory/Young) to approve the minutes of the January 21, 2019 Common Council meeting. Voice vote, all approved, motion carried. Motion (Shiroda/Boggs) to approve the minutes of the January 21, 2019 Human Resources, January 24, 2019 Legislative & Regulatory and January 28, 2019 Committee of the Whole meetings. Voice vote, all approved, motion carried. REPORT OF CITY OFFICERS MAYOR’S REPORT Oath of Office for New Patrolman Officer David Aranda was welcomed as the new patrol officer. Mayor Reynolds said an arsenic letter was sent to residents and he asked Doug Snyder from Baxter and Woodman to explain what happened. Snyder said he received a letter from the DNR in January regarding samples taken in October. He said procedures were followed and there was no harm to the public. He said the results were based on the first set of data that was part of the start up process and should have been marked “investigative”. The DNR has a system to follow which includes requiring the City send out the notice. He said the plant is currently removing arsenic to below federal levels. Alderman McClory would like to see the notice; it was sent out with utility bills. Mayor Reynolds let the Council know to contact Snyder should they have any questions. CITY ADMINISTRATOR’S REPORT Babe Mann Park Improvement Plan Presentation – Teska Associates Lee Brown and associate presented improvement plan for Babe Mann Park. It separated the improvements into six stages. Mayor Reynolds said the City can start this in 2020 and Phase One needs to be done before starting fundraising as no one will donate with nothing there. Administrator Tapson said it may not be feasible to jump around the phases; the total overall is 1.6 million dollars. He said it will need to go back to capital planning so that it will flow with the other projects the City is doing. Alderman McClory suggested engaging a corporate partner to help with the improvements and perhaps naming the park after them. He knew of two organizations that may be interested and felt now was the time to reach out to them as the City now has concrete plan. He didn’t want to wait until the 2020 budget cycle and wanted staff to reach out now. COMMITTEE REPORTS HUMAN RESOURCES

City of Elkhorn Common Council Meeting, Page 2

Recommendation and possible action to approve modifications to Employee Health Reimbursement Plan Administrator Tapson said the HRA works by employees drawing from the current base, then HRA bank, then the supplemental. The Plan adds supplemental amounts to the base, at $250 for individuals and $500 for families. The legacy benefit applies if an employee retires according to WRS and is prorated based on years of service and only applies to employees employed prior to February 1, 2019. There is a maximum carry-over of $2,500 however any employees with more than $2,500 at this time can keep it. Motion (Myrin/Shiroda) to approve modifications to the Employee Health Reimbursement Plan. Voice vote, all approved, motion carried. LEGISLATIVE AND REGULATORY Recommendation to deny Class A Combination License Application from Gurfateh Enterprises LLC, Manjit Singh, Agent Police Chief Christensen said the committee recommended denying the applicant’s Class A liquor/beer license. City Attorney Phillips said the applicant failed to reveal several violations on the application. Motion (Dunwiddie/Young) to deny the Class A Combination License Application from Gurfateh Enterprises, LLC. Voice vote, all approved, motion carried. COMMITTEE OF THE WHOLE Recommendation to consider repairing flow meters for $6,000, purchasing a rain gauge/logging system for $2,100 and executing Phase One with Strand for $18,000; approximately This item was discussed at the Committee of the Whole and all members were present. Motion (McClory/Shiroda) to approve the purchases. Roll call vote: McClory, yes; Shiroda, yes; Boggs, yes; Dunwiddie, yes; Myrin, yes; Young, yes. Motion carried. Recommendation to approve a budget adjustment in the amount of $29,000 to install EVPs at IH 43 and STH 67 and immediately outfit all vehicles with EVP apparatus Alderman McClory said EVPs automatically turn the signals greens for emergency vehicles equipped to change them. Motion (Dunwiddie/Boggs) to approve the budget adjustment in the amount of $29,000 to install EVPs at IH 43 and STH 67 and to get the amount to install in City emergency vehicles. Roll call vote: McClory, yes; Shiroda, yes; Boggs, yes; Dunwiddie, yes; Myrin, yes; Young, yes. Motion carried. Recommendation to send out City Hall RFPs Motion (Myrin/Shiroda) to send out RFPs for a new City Hall. Voice vote, all approved, motion carried. UNFINISHED BUSINESS Ordinance No. 19-01 An Ordinance to Rezone a Property on East Side of Wisconsin St. Between Harvest Way and Market Street (Second Reading) Mayor Reynolds said this was approved unanimously by the Plan Commission. Motion (Shiroda/Young) to approve Ordinance No. 19-01. Voice vote, all approved, motion carried. NEW BUSINESS TID 4 Improvements Project Change Order No. 1 from Payne & Dolan City Engineer Calhoun said this is a comprehensive Change Order and the project is currently on a hiatus due to winter. The changes include extending the pour in cold weather, utility conflicts, needed additions and the cost to complete in 2020 rather than 2019. Motion (McClory/Shiroda) to approve Payne & Dolan Change Order in the amount of $91,585.83. Roll call vote: McClory, yes; Shiroda, yes; Boggs, yes; Dunwiddie, yes; Myrin, yes; Young, yes. Motion carried. ADJOURN Motion (Dunwiddie/Boggs) to adjourn at 6:14 p.m. Voice vote, all approved, motion carried.

City of Elkhorn Common Council Meeting, Page 3

Cairie L. Virrueta City Clerk

CITY OF ELKHORN Finance & Judicial Committee Minutes

First Floor Conference Room, 9 S. Broad Street, Elkhorn, Wisconsin

February 11, 2019 The Finance and Judicial Committee was called to order at 4:30 p.m. by Alderman McClory, followed by roll call. Roll Call Present: Aldermen Scott McClory, Tom Myrin, Tim Shiroda; Absent: Junior Council Members Megan Degner and Alex Johnson Also present: City Administrator Sam Tapson, City Clerk Cairie Virrueta, Finance Director James Heilman, Police Captain Al Brandl, Fire Chief Rod Smith, DPW Manager Matthew Lindstrom Police Squad Upfitting Purchase Captain Brandl said this is for funding the outfitting of a recently purchased police vehicle. It is budgeted. Alderman McClory asked if this needed to be considered if it was already approved as part of the budget. After brief discussion, the committee supported not having to approve budgeted items as long as they do not go over the budgeted amount. Public Works Procurement of Trailer Mounted Pump This item was budgeted for 2019. Employee Post-Employment Benefits Account Administrator Tapson suggested moving these funds to an agency account as the City is holding the funds on the employee’s behalf. It would no longer come through the home fund and affect levy limits or ERP. This would clean it up and make it easier to manage. Motion (Shiroda/Myrin) to recommend creating a segregated agency employee post-employment benefits account and transfer the funds to it. Voice vote, all approved, motion carried. Adjournment Motion (Myrin/Shiroda) to adjourn into Close Session Pursuant to Wisconsin Statute 19.85(1)(e) “Deliberating or negotiating the purchasing of public properties, the investing of public funds, or conducting other specified public business, whenever competitive or bargaining reasons require a closed session” regarding sale of City property. Adjourned at 4:35 p.m. Cairie L. Virrueta City Clerk

To: Mayor & Council

From: City Administrator

Re: Special Counsel Engagement

Date: February 15, 2019

Most of you are familiar the proposed New Beginnings’ women shelter, which is to be located at the former Aurora doctors’ clinic on Church Street. As you probably also aware, this proposed use met with significant neighborhood opposition at the public hearing held by the Plan Commission. In light of the controversy that has accompanied the proposed conditional use; I believe it prudent to engage outside counsel to represent the interest of the City/Plan Commission when this matter returns for final consideration in March or April in order to ensure compliance with the requirements of Act 67. Engagement of outside counsel is essential since City Atty. Phillips cannot represent the City or Plan Commission in this matter because of his involvement with the project itself. In the past, the city engaged the services of Atty. Dan O’Callaghan as special counsel in matters related to land use and zoning. Atty. O’Callaghan’ s resume includes 5 years as planner with City of Madison and 13 years with MBF where his practice specialized in land use, urban planning/zoning, and real estate. Dan along with several former MBF attorneys formed the Carson Black firm in 2018.

In anticipation of the need for special counsel, I reached out to Dan and he is willing accept an engagement as special counsel for the City. Dan bills at $350 per hour and I estimate a four (4) to five (5) commitment for this engagement depending on whether or not additional meetings of Plan Commission or Common Council are required.

PLAN COMMISSION – FINDING OF FACT DATE: February 12, 2019 PROJECT: Americas Liquor/Jesus Sandoval – 9 N. LINCOLN ST. PC ID: E19.01.002 ACTION: Conditional Use Permit The City of Elkhorn Plan Commission officially convened on February 7, 2019 to consider the Conditional Use Permit submitted by Jesus Sandoval for a Liquor Store. After considering the Conditional Use Permit application, the staff report, oral and written testimony, the Elkhorn 2040 Comprehensive Development Plan, the Zoning on the subject property, and other materials presented at the meeting, the Plan Commission does hereby make the following “finding of fact”: FINDING OF FACT 1) The construction, maintenance and operation of Liquor Store on the subject

property, as conditioned, is in accordance with the intent and purpose of Chapter 17 (Zoning) of the City of Elkhorn Municipal Code.

2) The construction, maintenance and operation of Liquor Store on the subject property, as conditioned, is compatible with other uses permitted in the same zone of vicinity.

3) The construction, maintenance and operation of Liquor Store on the subject property, as conditioned, will not be hazardous, harmful, offensive or otherwise adverse to the environment.

4) The construction, maintenance and operation of Liquor Store on the subject property, as conditioned, will not be detrimental to the value of the neighborhood or community.

Based upon the “Findings of Fact”, the Plan Commission motioned, seconded and voted to recommend APPROVAL of the Conditional Use Permit application to the Common Council.

CITY OF ELKHORN CONDITIONAL USE PERMIT No. 19-03

AMERICAS LIQUOR/JESUS SANDOVAL – 9 N. LINCOLN ST. Pursuant to Section 17.5-1 of the City of Elkhorn Municipal Code, “Liquor Store” located at 9 N. Lincoln St, Tax Key Parcel YRW 00022B shall be permitted as a Conditional Use. The operation at said location shall be subject to the following conditions:

1. Applicant shall meet all City Ordinance requirements regarding the distance between a liquor store and any school,

hospital, day care center or church.

Failure to fully comply with the above stated conditions shall be considered grounds for revocation of this permit.

Common Council of the City of Elkhorn

By: ________________________________ Attest: ________________________________ Howie Reynolds, Mayor Cairie Virrueta, City Clerk

State of Wisconsin State of Wisconsin County of Walworth County of Walworth Subscribed and sworn/affirmed to before me Subscribed and sworn/affirmed to before me this__________ day of ________________ 20__, this_______ day of ________________ 20__, Notary Public Notary Public My Commission Expires: ________________ My Commission Expires: _________________ By: ________________________________

Owner ________________________________

Printed Name State of Wisconsin County of Walworth Subscribed and sworn/affirmed to before me this__________ day of ________________ 20__, This instrument was drafted by: Bonnie Schaeffer Notary Public Zoning Administrator My Commission Expires: _________________

PLAN COMMISSION – FINDING OF FACT DATE: February 12, 2019 PROJECT: St. Patrick Rezone PC ID: E19.01.001 ACTION: Rezone Approval The City of Elkhorn Plan Commission officially convened on February 7, 2019 to consider the Rezone Application, submitted by the City of Elkhorn, for T-1 to B-1. After considering the site plan, the staff report, oral and written testimony, the Elkhorn 2040 Comprehensive Development Plan, the Zoning on the subject property, and other materials presented at the meeting, the Plan Commission does hereby make the following “finding of fact”: FINDING OF FACT

1. The rezone is consistent with the intent and purpose of the City of Elkhorn Zoning Code and the goals, objectives and policies of the Comprehensive Land Use Plan.

Based upon the “Findings of Fact”, the Plan Commission motioned, seconded and voted to recommend APPROVAL of the Rezone Application for T-1 to B-1 to the Common Council.

CITY OF ELKHORN ORDINANCE NO: 19-02

AN ORDINANCE TO REZONE PART OF A PROPERTY LOCATED WITHIN THE BOUNDARIES OF THE CITY OF ELKHORN:

101 & 107 W. WALWORTH ST & 10 S. BROAD ST WHEREAS, City of Elkhorn proposes to rezone Tax Key Parcel: YOP00243 and YOP00245, within the City of Elkhorn, and;

WHEREAS, the Plan Commission did convene a public hearing on the matter of proposed re-zone, and;

WHEREAS, the Plan Commission recommended approval of the proposed rezone.

BE IT ORDAINED by the Common Council of the City of Elkhorn as follows:

1. The zoning classification shall be changed from T-1 Transition District to B-1

Downtown Business District for Tax Key Parcel: YOP00243 and YP00245 de-scribed as:

N 112' OF E 68' LOT 1 BLK 27 ORIGINAL PLAT CITY OF ELKHORN. ALSO, LOTS 1-5 BLK 27 EXC PT LOT 1 DESC AS COM NE COR BLK 27; W 68'; S112'; E 68'; N 112' TO POB. ORIGINAL PLAT OF ELKHORN

2. The Zoning Map of the City of Elkhorn shall be amended in accordance with the above classification of properties.

3. This ordinance shall be in force from and after its introduction and publication as

provided by statutes.

APPROVED AND ADOPTED this _______ day of _______________________________2019.

_____________________ Howie Reynolds, Mayor

ATTEST: Cairie Virrueta, City Clerk

1stReading: _____________ 2nd Reading: ____________ Adopted: _______________

Published: ______________

CITY OF ELKHORN RESOLUTION 19-01

RESOLUTION FOR AMENDMENTS TO EMPLOYEE HEALTH REIMBURSEMENT

PLAN

WHEREAS, the Common Council implemented an Employer-sponsored Health Reimbursement Plan (HRA) for the benefit of employees in 2009; and WHEREAS, the benefits offered under the original Plan no longer meet the design objectives of the Plan; and WHEREAS, upon a review of the existing Plan benefit schedule, the Council Human Resources Committee recommends Plan revisions so as to meet the stated objectives of the original Plan, THEREFORE, BE IT RESOLVED by the Common Council of the City of Elkhorn that the revised Health Reimbursement Plan, as attached hereto, is hereby adopted. Resolved this 18th day of February 2019. CITY OF ELKHORN BY: __________________________________ Howie S. Reynolds, Mayor ATTEST: ________________________________ Cairie Virrueta, City Clerk Adopted: ________________ Approved: ______________

HEALTH REIMBURSEMENT ACCOUNT (HRA)

DESCRIPTION OF BENEFITS & TERMS OF REIMBURSEMENT PLAN: CITY OF ELKHORN, WISCONSIN PLAN YEAR: January 1 through December 31

Original Effective Date: January 1, 2008 Revised: February 18, 2019

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TABLE OF CONTENTS

I. INTRODUCTION II. ELIGIBILITY, FUNDING, EFFECTIVE DATE, &

TERMINATION III. SCHEDULE OF BENEFITS IV. COVERED CHARGES V. DEFINED TERMS VI. PLAN EXCLUSIONS VII. CLAIM PROVISIONS VIII. FRAUD IX. YEAR-END CARRYOVER OF UNUSED BENEFITS X. C.O.B.R.A. CONTINUATION XI. ERISA INFORMATION

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I. INTRODUCTION This document is a description of CITY OF ELKHORN “Employer” Health Reimbursement Account (HRA). It describes the benefit set up by the Employer, and the terms and conditions of reimbursement of expenses to the employees, and eligible dependents of employees. Coverage takes effect when the employee is eligible to participate in the medical plan provided by CITY OF ELKHORN. Coverage extends to all people eligible for and electing coverage under the medical plan. An employee who waives coverage is not eligible to participate in the HRA. If an employee drops coverage under the medical plan, the employee is dropped from the HRA. The Employer intends to maintain this benefit indefinitely. Any modifications to the HRA Plan; including termination, shall be subject to mutual agreement between the Employer and its several collective bargaining units. The Employer will reimburse expenses incurred only while this HRA and the corresponding medical insurance coverage are in force. No benefits are payable for expenses incurred before this coverage began or after coverage is terminated. If the plan is terminated, the rights and benefits of covered persons are limited to covered charges incurred before termination. This document summarizes the plan rights and benefits for covered Employees and covered Dependents. II. ELIGIBILITY, FUNDING, EFFECTIVE DATE, AND TERMINATION ELIGIBILITY 1. All employees of the Employer, who are eligible for and elect to participate in

the Employer sponsored Medical Insurance Plan are eligible to participate in the HRA program.

2. All Dependents of the employee who are eligible for and elect to participate as

dependents of the employee in the Employer sponsored medical insurance program are eligible to participate in the HRA program.

FUNDING 1. The Employer shall be responsible to fund the benefits provided under the terms

of the Plan. Employee contributions are not allowed under this program.

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2. The Employer intends to make contributions to this Plan at the time of claim demand. The Employer will maintain a segregated account for HRA expenses.

3. The Employer intends to make future annual commitments to this HRA plan. The

Employer will not reduce the annual benefit during the plan year. EMPLOYER CONTRIBUITONS 1. Base Annual Contribution. The Employer shall make a base annual contribution of $250 (employee only insured) and $500 (family insured). 2. Supplemental Contribution. The Employer shall contribute an additional $250 (employee only insured) and $500 (family insured) each Plan Year. The carry forward benefit established under Section III of the Plan document does not apply to the Supplemental contribution. EFFECTIVE DATE OF COVERAGE 1. The effective date of coverage under the HRA program will always be the

same as the effective date of coverage under the Employer sponsored medical insurance plan. This effective date rule will extend to employees and dependents.

TERMINATION 1. Coverage under the HRA program will terminate on the date coverage

terminates under the Employer sponsored Medical Insurance Plan. Claims incurred before the date of termination will be eligible for reimbursement. Claims incurred on or after the date of termination will not be eligible for reimbursement.

Coverage under the HRA Plan will be extended to include eligible claims incurred on or after the date of termination, if the Employee elects continuation of insurance coverage under COBRA

III. SCHEDULE OF BENEFITS MAXIMUM PLAN BENEFIT ANNUALLY 1. The Maximum Annual Benefit shall be $500 for any covered Person who has

employee only coverage. The Maximum Annual Benefit shall be $1000 for

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any covered Person who has employee and Dependent coverage under the Medical Insurance Plan. The Annual Benefit will be prorated, except in the first year of the Plan, accordingly for employees who elect coverage sometime throughout the plan year. The Medical Insurance Plan has a $1,000 deductible for individuals and a $2,000 deductible for employee and dependent. The HRA program will reimburse a portion of the deductible expense an employee could incur within a calendar year.

2. Benefits, for which the Employee was eligible but did not use within the year,

may be added to the new base contribution of the Employer for the next Plan Year. The amount added will be 75% of the unused base benefit from the previous year. The Employee can therefore, accumulate unused benefits under this Plan for future health care expenses. The sum of the Maximum Annual Benefit and unused funds carried from one year to another is the Accumulated Benefit, which shall not exceed $2,500. If the employer continues the HRA Plan for another year, any excess funds beyond the rollover amounts are used to fund plan cost for the new plan year.

3. The unused funds will be segregated into Employee accounts, and interest will

be applied to the unused balance on December 31 of each year. Interest shall be at the average rate paid by the Local Government Investment Pool (LGIP) during the Plan Year.

4. Upon termination of the HRA Plan, the Employer shall be responsible for

paying claims incurred up to the date of termination. Upon HRA Plan termination any unused benefits will be retained by the Employer and used to fund the current health insurance plan.

IV. COVERED CHARGES Medical Expenses covered by the program: 1. This program provides reimbursement of medical expenses that are

determined to be covered expenses under the Employer Medical Insurance Plan. If the insurance plan covers charges for a certain procedure, the HRA program will consider those charges to be eligible expenses. The HRA Plan will not duplicate benefits paid under an insurance plan.

2. This program shall consider any expense credited as a deductible and/or co-

insurance expense under the Medical Insurance Plan to be a covered expense. The Plan will make a direct payment of qualified expenses to the Provider or reimburse the Employee for qualified out-of-pocket expenses.

3. Expenses covered under the CITY OF ELKHORN medical insurance plan not

covered under this HRA plan are prescription drug co-payments and medical services co-payment.

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Extent of Coverage: 1. The use of preferred medical providers will not affect the reimbursement level

made under this Plan. This program will reimburse a covered person the full amount of qualified expense they have incurred to a medical care provider. It is recommended that participants submit all bills to Cornerstone Benefits in order to receive all possible discounts prior to paying the bill. Any bill that is not discounted will be reimbursed to the extent allowed by the HRA and the Health Insurance Plans.

2. The Plan shall reimburse claims at fifty-percent (50%) of eligible expenses

subject to the limits of the Maximum Annual Benefit.

The total amount of reimbursement for any given plan year will not however, exceed the total amount of Accumulated Benefit. The total reimbursement will never exceed the amount of the claim loss.

Coverage for Expenses not covered by Medical Insurance: 1. The program will not reimburse expenses incurred for services other than

those covered by the Medical Insurance Plan of the Employer. Prescription Drugs and co-pays are not eligible expenses under this HRA Plan.

V. DEFINED TERMS 1) ACCUMULATED BENEFIT The sum of the Maximum Annul benefit and any

unused funds carried-over from another year. 2) COBRA Consolidated Omnibus Budget Reconciliation Act 3) COBRA ADMINISTRATOR The party designated by the Employer to

administer COBRA benefits for their Medical Insurance Plan.

4) CLAIM REVIEW (PROCEDURE) The process outlined in the Certificate of

Coverage or SPD to dispute a claim that has been denied.

5) COVERED PERSON A person who is an active employee, eligible

retiree or COBRA recipients of the employer who is eligible for employee coverage, and has elected coverage under a Non-Indemnity Employer Medical Insurance Plan. This would include an employee, a covered employee’s spouse, or a covered employee’s dependent child.

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6) DEPENDENT A covered employee’s spouse under the laws of

the state where the covered employee lives, and the covered employee’s unmarried children from birth until the limiting age of 19 until the limiting age of 25 provided they are a full-time student at an accredited school, unmarried and are primarily dependent upon the covered employee for support and maintenance.

7) EFFECTIVE DATE The date an employee/dependent is eligible for

coverage under the CITY OF ELKHORN Health Plan

8) EMPLOYEE All active employees, eligible retirees, or COBRA

recipients of the employer that are eligible for coverage as defined under the CITY OF ELKHORN Health Plan.

9) EMPLOYER CITY OF ELKHORN 10) MAXIMUM ANNUAL BENEFIT The amount of money the Employer agrees to

contributes annually under this Plan for a Plan Year.

11) MEDICAL INSURANCE PLAN The self-funded group health plan that is provided

by the Employer. 12) PLAN Refers to this Health Reimbursement Account

(HRA). 13) PLAN SUPERVISOR The insurance company, or third party

administrator designated by the Employer to handle the day to day claim adjudication and payment duties of the Plan.

14) PLAN YEAR The time period under which the Medical

Insurance Plan and this HRA plan operate. (See cover page) The plan year is maintained on a twelve-month period of time, except for the first Plan Year which began on February 1, 2008.

15) SPD The legal document governing medical insurance coverage under a self-funded plan.

16) SWEEP The Employer right to take back Accumulated

Benefits or set Accumulated benefits back to $0 at the end of the plan year.

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V. PLAN EXCLUSIONS EXCLUDED CHARGES: 1. Refer to the “Exclusions and Limitations section of the Medical Insurance

Summary Plan Description. The HRA Plan does not cover any charges incurred for a service not covered under the medical insurance plan. In the event of a change in the Health Insurance Plan coverage resulting in a charge not being covered by the medical plan, then the HRA will not consider the charge to be a covered charge.

2. If the only reason a charge is excluded from coverage is that the annual

deductible has not been satisfied by the Person and not reimbursed by an insurance plan, then the HRA program will reimburse the charge.

VI. CLAIM PROVISIONS 1. The Employee may file a claim for reimbursement under this program when

the Employee or a Covered Person of an employee has incurred a health related expense.

2. All claims shall be filed first with the Plan Supervisor of the medical insurance

plan, or insurance company; who is responsible for determining whether an expense is eligible for coverage under the medical plan, or is not eligible for coverage. The Plan Supervisor will provide an Explanation of Payments/Benefits (EOB), which illustrates the coverage for a particular expense. The Employer shall reimburse the cost of that expense under this HRA program, under the terms and conditions outlined in this document.

3. The employee shall submit an “HRA Reimbursement Claim” with required

documentation to the Finance Director and shall indicate whether the required HRA distribution is a direct payout to the Provider or a reimbursement to the Employee.

4. Any expense determined to be ineligible under the Health Insurance Plan is

not eligible for reimbursement under the HRA account. If approved by the medical plan but the claim is denied, it will only be denied because the employee’s individual HRA account will have been exhausted for the year or the employee’s accumulated benefit will have been exhausted, If a claim is denied, the employee may file a written request for review of the claim with the Employer. Upon the employee’s written request for Claim Review, the procedures outlined in the medical insurance plan Summary Plan Description (SPD), under “Claim Review Procedure”, will be enacted.

5. The HRA will require the employee to file a claim for reimbursement from this

program. The plan supervisor will provide periodic reports outlining all

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information necessary to make the appropriate reimbursement to the medical provider.

VII. FRAUD DEFINED 1. Fraud is considered making a claim against this program for a medical, or

health related expense where the services were not actually provided, or changing a charge or bill that was actually incurred by an Employee, or Covered Person.

2. If an Employee or Covered Person identifies a case of provider fraud, the

Person should report this immediately to the Employer, or the Plan Supervisor. Fraud is a very serious offense, and the medical insurance plan, and HRA program will take appropriate action when fraud is discovered.

3. If an Employee or Covered Person commits fraud that shall be considered a

very serious offense. Any case of fraud discovered under this program shall be immediately reported to the Employer, for appropriate action.

VIII. YEAR END CARRYOVER OF UNUSED BENEFITS YEAR END MEANS: 1. The last day of the Plan Year as listed on the cover of this document.

Employees should file claims as soon as possible after a incurring eligible expenses. Claims submitted more than one-year (1) after the date incurred by the Employee, or Covered Person will not be eligible for reimbursement under this Plan.

REMAINING FUNDS AT YEAR-END 1. The Employer will add 75% of the remaining amount of unused benefit to the

new benefit contributed by the employer at the beginning of each Plan Year, 2. An Employee cannot use subsequent Plan Year contributions to pay for prior

year expenses. The Employee can use the current year maximum benefit, plus the accumulated benefit for the current Plan Year.

3. If the employee terminates medical insurance coverage with the Employer,

the Employee will also lose any current year and carryover accumulated benefits under this Plan. Only claims incurred through the date of termination will be paid under this Plan.

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4. The Employee cannot take possession of the funds in this Plan. The funds used to pay benefits under this Plan are the property of the Employer and shall be maintained in an HRA segregated account designated by the Employer. The Employee will not earn interest on any funds designated as eligible for reimbursement, eligible for reimbursement, or carried-over from one year to a subsequent year.

5. The Employer may terminate this Plan at the end of the plan year and Sweep

the accounts by retaining any unused balances. IX. POST EMPLOYMENT BENEFIT

1. Upon retirement from City employment under the Wisconsin Retirement System (WRS) or separation due to disability, funds remaining in the individuals HRA Account shall be available for post-employment payment of eligible expenses for employees hired on or before February 1, 2019. Employee hired after February 1, 2019 are not eligible to receive the Post-Employment Benefit contained herein.

2. The amount of funds available for post-employment use shall be subject to

the following vesting schedule:

Less than 5 Years of Service - 0% of accumulated balance 5 – 9 Years of Service - 40% of accumulated balance 10-14 Years of Service - 60% of accumulated balance 15-19 Years of Service - 80% of accumulated balance 20 Years of Service - 100% of accumulated balance

3. An employee cannot receive a cash “take out” of unused funds from the

employee’s HRA Account. X. C.O.B.R.A CONTINUATION COBRA RIGHT TO CONTINUE COVERAGE: 1. If you should terminate employment, you and your qualified beneficiaries may

be eligible to continue coverage under the medical insurance plan, based on applicable federal or state laws.

2. Your continuation rights are outlined in the medical insurance plan SPD, under “COBRA Continuation Options”. The same COBRA rights and obligations of the Medical Insurance Plan apply to this Plan. The COBRA administrator has the sole authority to determine whether a Covered Person has met the COBRA election and qualification provisions under federal statute.

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3. If you elect to continue coverage under COBRA, you will continue to have this HRA benefit. The COBRA rates you are assessed will include the applicable rates for the medical insurance plan, and the rates of this program combined. No Employee may participate in this Plan independent of the Employer medical insurance plan. No Employee can participate in the Medical Insurance Plan without participating in this Plan. The Employee may only accept or reject coverage of both Plans.

The Employer also has the right to assess an additional 2% administrative charge to determine COBRA premium rates. If you qualify for an eleven-month extension, the Employer may charge more. (Federal Law permits this fee to be charged by the Plan Supervisor).

At the time of your qualifying event, you will be provided rates that include the medical insurance rates, and the HRA benefits. It is the terminated employee’s responsibility to make the appropriate COBRA election.

XI. ERISA INFORMATION 1. This program is a Health Reimbursement Account (HRA), for health-related

expenses that are covered expenses under the CITY OF ELKHORN medical insurance plan.

2. Plan Name is CITY OF ELKHORN. Health Reimbursement Account (HRA). 3. Tax ID number is 39-6005442 4. Plan Effective Date is January 1, 2008. 5. Plan Year Ends on December 31 of each year. 6. Employer Information: CITY OF ELKHORN

9 South Broad St. Elkhorn, WI 53121

9. Plan Administrator: CITY OF ELKHORN 9 South Broad St. Elkhorn, WI 53121 10. Named Fiduciary: City Treasurer CITY OF ELKHORN 9 South Broad St. Elkhorn, WI 53121

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11. Agent For Service of Legal Process: City Clerk

CITY OF ELKHORN 9 South Broad St. Elkhorn, WI 53121 12. Plan Supervisor: CITY OF ELKHORN 9 South Broad St. Elkhorn, WI 53121