PLAN DOCUMENT AMENDMENT #1
FOR
ARIZONA LOCAL GOVERNMENT EMPLOYEE BENEFIT TRUST
HEALTH SAVINGS ACCOUNT
EFFECTIVE JULY 1, 2015
NOTICE IS HEREBY GIVEN that the Arizona Local Government Employee Benefit Trust Health
Savings Account document is amended effective July 1, 2015.
CHANGE 1.
The second paragraph, which appears in the subsection “May I transfer
existing funds to my health savings account?” in the section entitled “FUNDING,” is hereby deleted in
its entirety.
Copies of the Plan document and this Plan document amendment are maintained on file by the Plan
Administrator and by the Benefit Services Manager.
This Health Savings Account document amendment is hereby adopted in its entirety.
GILSBARDM-#2705600-v1-HSA_Amendment01_eff_20150701.doc
Reserved.
Copyright © 2015 Gilsbar, L.L.C. All Rights
ARIZONA LOCAL GOVERNMENT EMPLOYEE BENEFIT TRUST
HEALTH SAVINGS ACCOUNT
Plan Document and Summary Plan Description
Effective: July 1, 2014
DOCUMENT CONTAINS CONFIDENTIAL PROPRIETARY
OR TRADE SECRET INFORMATION
Copyright © 2014 Gilsbar, L.L.C. All Rights Reserved.
TABLE OF CONTENTS
Page
PURPOSE OF PLAN; ADOPTION OF THE PLAN DOCUMENT .................................................................................... 1
GENERAL PLAN INFORMATION ....................................................................................................................................... 2
ELIGIBILITY FOR PARTICIPATION ................................................................................................................................. 3
BENEFITS ................................................................................................................................................................................. 4
FUNDING................................................................................................................................................................................... 7
TERMINATION OF PARTICIPATION ................................................................................................................................ 9
PAYMENT PROCEDURES ................................................................................................................................................... 10
DEFINITIONS ......................................................................................................................................................................... 11
PLAN ADMINISTRATION ................................................................................................................................................... 14
MISCELLANEOUS INFORMATION .................................................................................................................................. 15
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PURPOSE OF PLAN; ADOPTION OF THE PLAN DOCUMENT
Purpose of the Plan
Arizona Local Government Employee Benefit Trust (the “Plan Sponsor”) has adopted this health savings account (the
“Plan”) as set forth herein and as amended from time to time for the exclusive benefit of eligible employees. The purpose of
this Plan is to assist employees in establishing a trust or custodial account and to allow employees, who are eligible, to pay for
their current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis out of that
account. This Plan is not an employee welfare benefit plan and is not established pursuant to, or governed by, the Employee
Retirement Income Security Act of 1974, as amended.
This Plan is established pursuant to Code §§ 125 and 223 and is intended to allow expenses, which are eligible under Code §
213(d), including medical, vision, dental, prescription drug and non-prescription drug expenses, to be paid on a tax-free basis.
The tax implications of this Plan are subject to rulings, regulations and the application of the tax laws of the state and federal
government. Although it may anticipate certain tax consequences as being likely, the Plan Sponsor does not represent or
warrant to any participant that any particular tax consequence will result from participation in this Plan. By participating in
this Plan, each participant understands and agrees that, in the event the Internal Revenue Service, or any state or political
subdivision thereof, should ever assess or impose any taxes, charges and/or penalties upon any benefits received under the
Plan, the recipient of the benefit will be responsible for those amounts, without contribution from the Plan Sponsor.
Effective date
This summary plan description is effective as of the date first set forth above, and each amendment is effective as of the date
set forth therein (the “effective date”).
Adoption of the Plan Document
The Plan Sponsor, as the settlor of the Plan, hereby adopts this summary plan description as the written description of the
Plan. This summary plan description amends and replaces any prior statement of the health care participation contained in
the Plan or any predecessor to the Plan.
IN WITNESS WHEREOF, the Plan Sponsor has caused this summary plan description to be executed.
GILSBARDM-#2471334-v2-HSA_Plan_eff_20140701
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v.01.14
GENERAL PLAN INFORMATION
Name of Plan:
Arizona Local Government Employee Benefit Trust Health
Savings Account
Plan Sponsor:
Arizona Local Government Employee Benefit Trust
1115 Stockton Hill Road, Suite 101
Kingman, Arizona 86401
(928) 753-4700
Plan Administrator:
Arizona Local Government Employee Benefit Trust
1115 Stockton Hill Road, Suite 101
Kingman, Arizona 86401
(928) 753-4700
Plan Sponsor ID No. (EIN):
86-0765362
Plan Type:
Health Savings Account under Code § 223
Trustee:
Healthcare Bank
3100 13th Avenue South
Fargo, North Dakota 58103
(866) 442-2472
Participating employer(s):
Arizona Local Government Employee Benefit Trust
Graham County
Greenlee County
Santa Cruz County
La Paz County
Apache County
Gila County
Arizona Association of Counties (AACo)
County Supervisors Association (CSA)
Arizona Counties’ Insurance Pools (ACIP)
Agent for Service of Process:
Arizona Local Government Employee Benefit Trust
Plan Administrator
1115 Stockton Hill Road, Suite 101
Kingman, Arizona 86401
(928) 753-4700
The Plan shall take effect for each participating employer on the effective date shown on the cover, unless a different date is
set forth above.
The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan Administrator.
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Plan Document and Summary Plan Description
v.01.14
ELIGIBILITY FOR PARTICIPATION
Am I eligible to participate in the Plan?
You are eligible to participate in the Plan if you are an employee of a participating employer and you meet the following
requirements:

You are a participant in a high deductible health plan sponsored by the employer;

You are not covered by any other insurance, aside from specific injury, specific disease, accident, disability, dental
care, vision care or long-term care insurance;

You are not enrolled in Medicare; and

You cannot be claimed as a dependent on someone else’s tax return.
What if I meet the eligibility requirements above, but I remain eligible under my former health flexible spending
arrangement during a grace period?
You will be treated as having disqualified coverage which will reduce your health savings account contribution for the plan
year unless:

The balance in your health flexible spending arrangement is zero at the end of the plan year and prior to
commencement of the grace period; or

You transfer the balance remaining in the health flexible spending arrangement directly into your health savings
account (please refer to the section, “May I transfer existing funds to my health savings account?” for rules
regarding transfers).
What if I meet the eligibility requirements above, but I am eligible to receive medical benefits through the
Department of Veterans Affairs?
If you have not received medical benefits through the Department of Veterans Affairs, you are eligible to participate in this
Plan. You cannot make contributions to your health savings account in any month if you have received benefits from the
Department of Veterans Affairs in the previous three months.
How do I establish my health savings account?
You must obtain coverage under a high deductible health plan in order to establish a health savings account. Your employer
may sponsor a high deductible health plan or you may select one of your own choosing. There are very specific
requirements for a plan to qualify as a high deductible health plan. Please refer to the “Definitions” section of this summary
plan description for these requirements.
You must satisfy the eligibility requirements stated above.
You must establish a “trustee” or “custodian” for your health savings account. Your trustee may be a bank, a credit union or
an insurance company. It must be a financial institution as defined in Treasury Reg. 408(n), and any person or institution
already approved by the IRS to be a trustee or custodian of an IRA or Archer medical savings account is automatically
approved to be a trustee or custodian of your health savings account. You are not required to use the institution through
which you are being offered the high deductible health plan.
When will I become a participant in the Plan?
You must enroll in the Plan within 31 days following the date of eligibility. Participation will become effective on the first
day of the month following the date you are eligible provided you have enrolled for participation on a form satisfactory to the
Plan Administrator.
What if I do not enroll during my original eligibility period and later decide to enroll?
You may enroll during the Plan’s annual open enrollment period, which is during the month of May in each calendar year.
If you enroll during an open enrollment period, your participation will be effective at 12:01 A.M. on the first day of July
following the open enrollment period.
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BENEFITS
This section is provided as a convenience only and is not all-inclusive. Important information is contained in other sections.
You may find the “Definitions” section helpful in understanding some of the italicized terms used throughout this summary
plan description. In addition, the Plan has other requirements and provisions that may affect benefits, and it is strongly
recommended that you read the entire summary plan description to ensure a complete understanding of the Plan provisions.
You may also contact the Plan Administrator for assistance.
Qualified Medical Expenses
You may use the funds in your health savings account on a tax-free basis for qualified medical expenses incurred by you,
your spouse or your dependents only to the extent that those expenses are not covered by insurance or otherwise. The
reimbursement under this Plan is limited only by the amount available in your health savings account.
It is up to you to determine whether the expenses you incur are qualified medical expenses. Reimbursement under this Plan
is not available on a tax-free basis for expenses for which you took a deduction pursuant to Code § 213 in any prior taxable
year. It is recommended that you keep receipts for all qualified medical expenses for which you use the funds in your health
savings account.
What are Qualified Medical Expenses?
Qualified medical expenses are health care expenses, which are excludable as income according to Code § 213(d). Qualified
medical expenses may not be otherwise reimbursable under the high deductible health plan or other plan or by any other
entity, and they may not be claimed as a tax deduction. In order to be considered a qualified medical expense, the expense
must be incurred after your health savings account has been established.
Non-Qualified Distributions
If you use any of your account balance for expenses other than qualified medical expenses, the expenditure will be taxed and,
for individuals who are not disabled (as defined by the IRS) or over age 65, you will pay ordinary income tax and be subject
to a 20% tax penalty.
What are examples of Qualified and non-Qualified Medical Expenses?
The examples listed in this section are intended only to give you a convenient reference to the types of expenses that may be
eligible for reimbursement. Determination of eligible expenses will be in accordance with Code § 213(d) as stated at the time
the expense is incurred.
Examples of qualified medical expenses include:

Acupuncture;

Alcoholism treatment;

Allergy tests and shots;

Ambulance;

Artificial limbs;

Automobile modifications required by medical conditions;

Birth control pills;

Birth prevention surgery;

Braille materials (books and magazines);

Chiropractic services;

Christian Science practitioner fees;
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BENEFITS (Continued)

COBRA health care continuation coverage premiums;

Co-payments;

Contact lenses and supplies;

Crutches;

Deductibles on your and your spouse’s group plan;

Dental services (not cosmetic);

Dentures;

Eyeglasses, including examination fees;

Healing services;

Hearing aids and batteries;

Hospital costs not covered by a group health plan;

Insulin;

Insurance premiums for health care coverage while the individual is receiving unemployment compensation;

Laboratory fees;

Laetrile by prescription;

Long-term care insurance premiums;

Medicare Part A or B, or Medicare HMO premiums;

Mental health care and fees;

Nurses’ fees;

Obstetrical expenses;

Orthodontic services if medically necessary;

Orthopedic shoes prescribed by a physician;

Osteopaths’ fees;

Over-the-counter drugs and medicines with a prescription from a physician that are health care expenses;

Oxygen;

Physicians’ fees not covered by medical plan;

Podiatrists’ fees;

Prescription drugs;

Qualified long term care insurance premiums;

Radial keratotomy;

Ramps required by medical conditions;

Rental of medical equipment;
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BENEFITS (Continued)

Routine physical examinations;

Seeing eye dogs and their upkeep;

Smoking cessation programs, only if monitored by a licensed practitioner;

Special communications equipment for the deaf;

Therapeutic care for substance abuse (drug or alcohol);

Weight loss programs prescribed by physicians for specific health problems; and

Wheelchairs.
Examples of non-qualified medical expenses include:

Condoms;

Cosmetic surgery;

Funeral expenses;

Hormone therapy relative to gender identity disorders;

All Insurance premiums, other than those specifically listed as qualified medical expenses. Premiums for Medigap
policies are not qualified medical expenses;

Massage therapy;

Maternity clothes;

Nursing home expenses;

Over-the-counter drugs and medicines without a prescription;

Sexual reassignment surgery, including all related expenses;

Weight loss programs prescribed by physicians for general health improvement; and

Vitamins.
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FUNDING
How is my health savings account funded?
Your health savings account will be owned by you, not by your employer. It is your decision how the funds are invested.
Because you own the health savings account, you will have control over the assets.
You and/or your employer may make contributions to your health savings account on a pre-tax basis. On your enrollment
form, you must indicate the amount that you would like to contribute to your health savings account for each month in which
you are eligible. Unless you indicate otherwise, your entire contribution for the calendar year will be apportioned pro rata
for each pay period, and taken out of your salary on a pre-tax basis.
Additionally, contributions to your health savings account may be made by you or others on a basis other than salary
reduction basis. If contributions to your health savings account are made in this manner, you may take an above-the-line
deduction on your federal income tax return for the calendar year. Generally, contributions may be made to your health
savings account until April 15 in the year following the year for which the contributions are made.
The Plan Sponsor may elect to contribute to each participant’s account. If the employer contributions are made, the
contribution amount must be comparable for each employee.
The Plan is intended not to discriminate in favor of highly compensated individuals as to the contributions of the Plan
Sponsor, and is intended to comply in this respect with the requirements of the Code. If, in the judgment of the Plan
Administrator, the operation of the Plan in any calendar year would result in such discrimination, then the Plan
Administrator shall select and exclude employer contributions under the Plan to such highly compensated individuals who
are participants, and/or reduce contributions under the Plan to the health savings accounts of highly compensated individuals
who are participants, to the extent necessary to assure that, in the judgment of the Plan Administrator, the Plan does not
discriminate.
The Plan Administrator will have the full authority to reduce the employer contributions who are members of prohibited
groups under Code § 125 to the extent necessary to prevent the Plan from discriminating in favor of such prohibited group(s).
How much can be contributed to my health savings account during each calendar year?
This amount is subject to change and can be obtained from your Plan Administrator. The maximum amount for all combined
contributions to your health savings account is established by the IRS, and depends upon the type of coverage you have in
the high deductible health plan. Assuming you participate in the Plan for the entire calendar year, and if you have coverage
for yourself only in a high deductible health plan, then you may contribute up to the maximum allowed by the IRS for selfonly coverage for that calendar year. Assuming you participate in the Plan for the entire calendar year, and if you have
coverage for your family under a high deductible health plan, then you may contribute up to up to the maximum allowed by
the IRS for family coverage for that calendar year.
However, if you are eligible to participate in this Plan for less than the entire calendar year, you may still make the
maximum annual contribution for that calendar year based upon your high deductible health plan coverage in effect during
the last month of the calendar year. Thereafter, you must continue to maintain coverage under a high deductible health plan
during the subsequent testing period. If you do not satisfy the requirements for coverage under the high deductible health
plan at any time during the testing period (unless due to your death or disability), the aggregate amount contributed to your
health savings account made through this provision will become taxable as gross income in the first month of the testing
period in which you were not an eligible participant, and you may also be required to pay an additional tax of 10% on the
contribution amount.
Maximum contribution amounts are expected to be adjusted for each subsequent calendar year.
May I transfer existing funds to my health savings account?
You may roll amounts in a currently-existing health savings account or an Archer medical savings account into this health
savings account without regard to the yearly contribution limitations. You may make only one roll-over contribution in a
calendar year.
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FUNDING (Continued)
If you are terminating a currently-existing health reimbursement arrangement (“HRA”) or a health flexible spending
arrangement (“FSA”), you also may roll over balances from those accounts into this health savings account without regard to
the yearly contribution limitations. You may make only one roll-over contribution with respect to each FSA or HRA, and the
contribution must be made during a tax year prior to the first day of the new plan year. The maximum amount that you may
roll over is the lesser of the balance in the FSA or the HRA as of September 21, 2006, or the balance as of the date of the
transfer. If, however, you do not satisfy the requirements for coverage under the high deductible health plan at any time
during the testing period (unless due to your death or disability), the transferred contributions to your health savings account
for that calendar year will become taxable as gross income, and you may also be required to pay an additional tax of 10% on
the contribution amount.
Additionally, you may transfer funds, tax-free, from an individual retirement plan other than a simplified employee pension
plan or a simple retirement account, as those are defined under Code section 408, to your health savings account. The
contribution must be made directly from trustee to trustee, and is subject to the maximum health savings account yearly
contribution amount. If, at the time of the transfer, you are covered for yourself only under the high deductible health plan
and later during the year switch to family coverage, you may make an additional contribution during that year provided that
all contributions do not exceed the yearly maximum permitted. Any such contributions are irrevocable and may not be
claimed as a deduction. If you do not satisfy the requirements for coverage under the high deductible health plan at any time
during the testing period (unless due to your death or disability), the full amount of the transferred funds contributed to your
health savings account for that calendar year will become taxable as gross income, and you may also be required to pay an
additional tax of 10% on the contribution amount.
Other than amounts that are transferred from these sources, all contributions to your health savings account must be made in
cash. Contributions may not be made in the form of stock or other property.
How much can be contributed to my health savings account if both my spouse and I have family coverage under
different high deductible health plans?
If you or your spouse has family coverage in a high deductible health plan, then both spouses are treated as having family
coverage. If you and your spouse have family coverage under different health plans, both spouses are treated as having only
that family coverage. Thus if both spouses are health savings account eligible, the contribution limit for each spouse is
divided equally among the spouses, unless you and your spouse agree otherwise. However, if you have high deductible
health plan family coverage, and your spouse has non-high deductible health plan self-only coverage, your spouse is not an
eligible individual and may not contribute to a health savings account.
How much can I be reimbursed for qualified medical expenses?
Qualified medical expenses shall be payable to the extent that funds are available in your health savings account, so long as
the expense was incurred after the health savings account was established.
If I or my spouse is 55 or older, am I able to make “catch up” contributions to my health savings account?
If you are, or your spouse is, between the ages 55 and 65, the contribution limit set forth above will be increased by $1,000
for the calendar years on and after 2009.
Rollover Amounts
All balances in your health savings account will be rolled over from calendar year to calendar year.
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TERMINATION OF PARTICIPATION
When does my participation end?
Your participation will end at midnight on the earliest of the following dates:

The date the Plan terminates;

The last day of the month in which you request that your coverage be terminated, provided your request is made on
or before that date;

The last day of the month immediately preceding the month in which you enroll in Medicare;

The last day of the month immediately preceding the month in which you may be claimed as a dependent on
someone else’s tax return;

The last day of the month immediately preceding the month in which you otherwise cease to be eligible for coverage
under the Plan;

The last day of the month immediately preceding the month in which your coverage in a high deductible health plan
ceases;

On the first date that you are covered by a separate prescription drug plan that is not a high deductible health plan;
or

On the first date that the plan under which you are covered under fails to be considered a high deductible health
plan.
Will my participation continue if I take Family and Medical Leave?
During any leave taken under the Family Medical Leave Act, you may maintain participation under this Plan on the same
conditions as if you had been continuously employed during the entire leave period.
Will my participation continue if I am absent under USERRA?
If you are absent from employment with a participating employer on account of being in uniformed services, you may elect
to continue participation in the Plan. During any leave taken under USERRA, you may maintain participation under this Plan
on the same terms and conditions as if you had been continuously employed during the entire leave period.
What will happen to my health savings account if my participation in this Plan terminates?
Your health savings account will continue to exist after the termination of your participation in this Plan. You may continue
to make requests for disbursement from your health savings account. Additionally, you may roll any amounts in your health
savings account into another health savings account.
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PAYMENT PROCEDURES
How do I submit a withdrawal request?
You can submit a request for a withdrawal from your health savings account to the trustee at:
Healthcare Bank
3100 13th Avenue South
Fargo, North Dakota 58103
(866) 442-2472
Upon receipt of such request, the trustee will disburse the funds from your health savings account to you.
Who is responsible for ensuring that the amounts paid out of my health savings account are for qualified medical
expenses?
It is your responsibility to ensure that amounts taken from your health savings account are used for qualified medical
expenses. It is recommended that you maintain records of your medical expenses sufficient to show that the distributions
have been made for qualified medical expenses and, therefore, are excludable from gross income.
What happens if I use amounts in my health savings account for expenses, which are not qualified medical expenses?
If you use any amount in your health savings account to pay for costs that do not qualify as qualified medical expenses, such
disbursements will be treated as gross income and will be subject to any applicable taxes and penalties.
What if I withdraw funds for expenses which I mistakenly believe are qualified medical expenses, but in actuality are
not?
If there is clear and convincing evidence that amounts were distributed from your health savings account due to reasonable
cause, you may repay the mistaken distribution no later than April 15, following the first year in which you knew or should
have known that the distribution was a mistake.
Can I appoint an authorized representative?
You are permitted to appoint an authorized representative to act on your behalf with respect to requests for disbursement
from your health savings account. To appoint such a representative, you must complete a form, which can be obtained from
the trustee.
How will benefits be paid?
All benefits under this Plan are payable, in U.S. Dollars, to you. In the event of your death, any balance remaining in your
health savings account becomes the property of the individual named in the enrollment form as the beneficiary of the
account. If your surviving spouse is the named beneficiary of your health savings account, the health savings account
becomes the health savings account of your surviving spouse. Your surviving spouse will be subject to income tax only to
the extent distributions from the health savings account are not used for qualified medical expenses.
If, by reason of your death, your health savings account passes to a person other than your surviving spouse, your health
savings account ceases to be a health savings account as of the date of your death, and that person is required to include in
gross income the fair market value of the health savings account assets as of the date of death. The includable amount should
be reduced by any payments from the health savings account for your qualified medical expenses, if paid within one year
after your death.
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DEFINITIONS
In this section you will find the definitions for the italicized words found throughout this summary plan description. There
may be additional words or terms that have a meaning that pertains to a specific section, and those definitions will be found
in that section.
“Actively at work” or “Active employment” means performance by the employee of all the regular duties of his or her
occupation at an established business location of the participating employer, or at another location to which he or she may be
required to travel to perform the duties of his or her employment.
“Calendar year” means the period commencing on January 1 and continuing until the next succeeding anniversary.
“Code” means the Internal Revenue Code of 1986, as amended.
“Company” means one of the following: Graham County, Greenlee County, Santa Cruz County, La Paz County, Apache
County, Gila County, Arizona Association of Counties (AACo), County Supervisors Association (CSA), and Arizona
Counties’ Insurance Pools (ACIP).
“Dependent” means any of the following individuals who reside in the employee’s household, who qualify as a dependent
pursuant to Code § 152, and over half of whose support the employee provides:

Children and grandchildren of the participant;

Stepchildren of the participant;

Siblings of the participant; and

Parents and grandparents of the participant.
Children whose parents are divorced, legally separated, separated under a written separation agreement, or whose parents
have lived apart at all times during the last six months of the calendar year, will be considered a dependent so long as they
receive over one-half of their support from their parents and are in the custody of one or both parents for more than one-half
of the calendar year.
“Disabled” means an individual is unable to engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment which can be expected to result in death or to be of long-continued and
indefinite duration.
“Effective date” means, July 1, 2014, the original effective date of the Plan.
“Employee” means a person who is regularly scheduled to work for the participating employer in an employer-employee
relationship or is an elected official, and who is eligible under the terms of the underlying group employee benefit plan. An
employee is not a part-time, seasonal, temporary or leased employee, or an independent contractor.
“GINA” means the Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110-233), which prohibits group
health plans, issuers of individual health care policies, and employers from discriminating on the basis of genetic information.
The term “genetic information” means, with respect to any individual, information about:

Such individual’s genetic tests;

The genetic tests of family members of such individual; and
 The manifestation of a disease or disorder in family members of such individual.
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DEFINITIONS (Continued)
The term “genetic information” includes participating in clinical research involving genetic services.
Genetic tests would include analysis of human DNA, RNA, chromosomes, proteins, or metabolite that detect genotypes,
mutations, or chromosomal changes.
Therefore, this Plan will not discriminate in any manner with its participants on the basis of such genetic information.
“Health care expense” means an expense incurred for the diagnosis, cure, mitigation, treatment or prevention of disease, or
for the purpose of affecting any structure or function of the body. A health care expense is not one that is merely beneficial
to the general health of an individual.
“Health savings account” means the individual tax-exempt trust or custodial account established exclusively for the purpose
of paying the qualified medical expenses under the terms of this summary plan description.
“High deductible health plan” means a health plan that satisfies certain requirements with respect to deductibles and out-ofpocket expenses. These requirements are subject to change and can be obtained from your Plan Administrator. These
requirements include limits on the amounts of the deductible and out-of-pocket expenses required to be paid (deductibles, copayments, and other amounts, but not premiums). These amounts change annually and are established by the IRS. The
dollar amounts for self-only coverage are different than for family coverage. In the case of family coverage, a plan is a high
deductible heath plan only if, under the terms of the plan and without regard to which family member or members incur
expenses, no amounts are payable from the plan until the family has incurred annual covered medical expenses in excess of
the minimum annual deductible. A plan does not fail to be a high deductible health plan merely because it does not have a
deductible for preventive care, but except for preventive care, a plan may not provide benefits for any year until the
deductible for that year is met.
For any coverage period of twelve months or less beginning before the first day of the plan year, a health plan that does not
meet the above definition for high deductible health plan, solely due to compliance with state mandated requirements (in
effect on January 1, 2004) to provide certain benefits without regard to a deductible or with a deductible below the minimum
annual deductible specified above shall be considered to fall within the definition of high deductible health plan for the
purposes of this plan document.
“Incurred” means the date the service is rendered or the supply is obtained. With respect to a course of treatment or
procedure that includes several steps or phases of treatment, expenses are incurred for the various steps or phases as the
services related to each step are rendered and not when services relating to the initial step or phase are rendered. More
specifically, covered expenses for the entire procedure or course of treatment are not incurred upon commencement of the
first stage of the procedure or course of treatment.
“Participant” means an eligible employee who has enrolled in the Plan.
“Participating employer(s)” means Graham County, Greenlee County, Santa Cruz County, La Paz County, Apache County,
Gila County, Arizona Association of Counties (AACo), County Supervisors Association (CSA), and Arizona Counties’
Insurance Pools (ACIP).
“Plan Administrator” means Arizona Local Government Employee Benefit Trust.
“Plan Sponsor” means Arizona Local Government Employee Benefit Trust.
“Plan” means this health savings account.
“Prescription” means a written or electronic order for a medicine or drug that meets the legal requirements of a prescription
in the state in which the health care expense is incurred and that is issued by an individual who is legally authorized to issue
a prescription in that state.
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DEFINITIONS (Continued)
“Preventive care” includes but is not limited to: periodic health evaluations, including tests and diagnostic procedures
ordered in connection with routine examinations, such as annual physicals; routine prenatal and well-child care; child and
adult immunizations; tobacco cessation programs; obesity weight-loss programs; and screening services.
“Qualified medical expense” means those expenses defined in Code § 213(d) that are incurred by a participant or his or her
spouse or dependent after the participant has enrolled in this Plan, and which are not otherwise reimbursable under the high
deductible health plan or by any other health care plan.
“Spouse” means an individual who is legally married to a participant, but shall not include an individual legally separated
from a participant under a decree of legal separation. For purposes of this section, “marriage or married” means a union that
is legally recognized as a marriage under the constitution of the state of Arizona.
“Summary plan description” means this plan document and summary plan description.
“Testing period” means the period beginning with the last month of the calendar year in which a participant enrolls in the
Plan, and ending on the last day of the 12th month following such month.
“Trustee” means Healthcare Bank.
“Uniformed services” means the Armed Forces, the Army National Guard and the Air National Guard, when engaged in
active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health
Service, and any other category of persons designated by the President of the United States in time of war or emergency.
“USERRA” means the Uniformed Services Employment and Re-employment Rights Act of 1994, as amended.
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PLAN ADMINISTRATION
May changes be made to the Plan?
The Plan Sponsor expects to maintain this Plan indefinitely; however, the Plan Sponsor may, in its sole discretion, at any
time, amend, suspend, or terminate the Plan in whole or in part. This includes amending the benefits under the Plan.
However, even if this plan is terminated, your health savings account will continue to exist.
Any such amendment, suspension or termination shall be enacted by resolution of the participating employer’s board of
supervisors, board of directors, or equivalent and in accordance with applicable federal and state law.
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MISCELLANEOUS INFORMATION
Will the Plan conform to applicable laws?
This Plan shall be deemed automatically to be amended to conform as required by any applicable law, regulation or the order
or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not limited to, stated
maximums, exclusions or limitations. In the event that any law, regulation or the order or judgment of a court of competent
jurisdiction causes the Plan Administrator to pay claims that are otherwise limited or excluded under this Plan, such
payments will be considered as being in accordance with the terms of this summary plan description.
Rescission
This Plan will rescind coverage only due to fraud or an intentional misrepresentation of a material act. Rescission is a
cancellation or discontinuance of coverage that has a retroactive effect. A cancellation or discontinuance is not a rescission if
the cancellation or discontinuance of coverage has only a prospective effect or the cancellation or discontinuance of coverage
is effective retroactively, to the extent it is attributable to a failure to timely pay premiums or costs of coverage.
How will this document be interpreted?
The use of masculine pronouns in this summary plan description shall apply to persons of both sexes unless the context
clearly indicates otherwise. The headings used in this summary plan description are used for convenience of reference only.
Participants are advised not to rely on any provision because of the heading.
The use of the words, “you” and “your” throughout this summary plan description applies to eligible employees or
participants.
How may a Plan provision be waived?
No term, condition, or provision of this Plan shall be deemed to have been waived, and there shall be no estoppel against the
enforcement of any provision of this Plan, except by written instrument of the party charged with such waiver or estoppel.
No such written waiver shall be deemed a continuing waiver unless specifically stated therein, and each such waiver shall
operate only as to the specific term or condition waived and shall not constitute a waiver of such term or condition for the
future or as to any act other than the one specifically waived.
Is this summary plan description a contract between the company and participants?
This summary plan description and any amendments constitute the terms and provisions of participation under this Plan.
The summary plan description shall not be deemed to constitute a contract of any type between the participating employer
and any participant or to be consideration for, or an inducement or condition of, the employment of any employee. Nothing
in this summary plan description shall be deemed to give any employee the right to be retained in the service of the
participating employer or to interfere with the right of the participating employer to discharge any employee at any time.
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