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STATION CASINOS LLCTEAM MEMBER BENEFIT PLANMEDICAL, DENTAL, VISION AND OTHER BENEFITS
SUMMARY PLAN DESCRIPTION
It is intended that this Summary Plan Description along with the Evidence of Coverage or Certificate of Coverage (“certificate booklet”) will serve to describe your health, prescription, dental, vision, and other benefits under the Employee Benefit Plan (the Plan). The Plan shall conform to the requirements found in the Employee Retirement Income Security Act of 1974 (ERISA), as amended from time to time, as the act applies to employee welfare benefit plans. If any portion of The Plan, now or in the future, conflicts with ERISA or Federal regulations, ERISA or such Federal regulations will govern. If any provision in this SPD conflicts with an Evidence of Coverage or Certificate of Coverage, the applicable certificate booklet will govern.
Este folleto contiene un resumen del plan en inglés. Si usted tiene dificultad entendiendo este resumen, una versión en español está disponible.
Usted puede obtener ayuda adicional comunicándose con la oficina de Recursos Humanos de su propiedad.
STATION CASINOS LLCEMPLOYEE BENEFIT PLAN
Medical, Dental, Vision and Other Benefits
Summary Plan Description
January 1, 2015
TABLE OF CONTENTS
INTRODUCTION .............................................................................................................1
ELIGIBILITY REQUIREMENTS ....................................................................................2
HEALTH BENEFITS ...................................................................................................... 11
DENTAL BENEFITS ..................................................................................................... 14
OTHER BENEFITS .......................................................................................................22
CAFETERIA PLAN ......................................................................................................22
CONTINUATION OF BENEFITS (COBRA) .............................................................23
HIPAA PRIVACY RULE .............................................................................................. 26
ANNUAL FEDERAL NOTICES ................................................................................. 29
ERISA RIGHTS ............................................................................................................37
IMPORTANT INFORMATION ................................................................................... 39
DEFINITIONS .............................................................................................................. 45
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INTRODUCTIONThis Summary Plan Description (SPD) is a summary of some of the principal features of the Health Maintenance Organization (HMO) option(s) and Preferred Provider Organization (PPO) option(s) available to you as part of your medical and prescription benefits. It also provides a description of your dental, vision, and other benefits under the Employee Benefit Plan (The Plan). NOTE: Throughout this document, any references to the terms “he,” “him,” or “his” shall also mean “she,” “her,” or “hers,” or vice versa.
Plan Documents
This document, together with the Benefit Schedule, Prescription Drug Benefit Rider, applicable certificate booklets, endorsements and any other documents distributed by Health Plan of Nevada (HPN) or Sierra Health and Life, a United Healthcare Company (SHL), Davis Vision, or any third party administrator or insurer, as applicable, constitutes the SPD of the Plan. This SPD is meant to summarize the Plan in easy to understand language. However, in the event of uncertainty or an inconsistency between this SPD and the Evidence of Coverage (EOC) or Certificate of Coverage (COC), or insurance certificate, as applicable, the EOC, COC, or insurance certificate will control.
Eligibility
To be eligible to participate in the Plan, you and your dependents must meet the eligibility requirements set forth in the section of this SPD entitled “Eligibility Requirements” and any additional requirements outlined in the EOC/COC.
The Employer intends to maintain the Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue or amend the Plan at any time and for any reason. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, Deductibles, Maximums, Co-pays, Exclusions, Limitations, Definitions, Eligibility and the like.
If the Plan is terminated, amended, or benefits are eliminated, the rights of Covered Persons are limited to covered charges Incurred before termination, amendment or elimination.
We urge you to read this SPD carefully. If you have any questions concerning the Plan, please contact your property’s Human Resources Department or applicable carrier/administrator.
ELIGIBILITY REQUIREMENTS
A. TEAM MEMBER ELIGIBILITY REQUIREMENTS
For the purposes of Section 1 “Eligibility, Enrollment and Effective Date,” in the applicable certificate booklet or any other materials, the following Eligibility Requirements shall apply for determining eligibility for coverage under The Plan for benefits under the Medical, Dental, Vision, Life Insurance, and Disability Options.
1. Team Members classified as Full-time (i.e. those Team Members expected as of date of hire to work an average of 30 hours or more per week) are eligible to participate in The Plan on the 1st day of the month following 60 calendar days of regular full-time employment.
2. Full-time regular front of the house Team Members, who work in a specialty restaurant that is open for dinner service only and who are expected to work an average of 25 hours per week shall be classified as “Full-Time” and shall be eligible to participate in The Plan on the 1st day of the month following 60 calendar days of active continuous employment.
3. Team Members whose employment status changes from temporary, part-time, or on-call to Full-Time, who have been employed with The Employer, or a Joint Venture, for at least 60 calendar days in active continuous employment in temporary, part-time, on-call capacity, are eligible to participate in The Plan on the 1st day of the month following the effective date of the change in job status.
4. On-going variable status Team Members (temporary, part-time or on-call) are eligible to participate in the medical portion of The Plan if they work an average of 30 or more hours per week in a Standard Measurement Period. For purposes of group medical coverage as required under the Affordable Care Act, Station Casinos has adopted a Standard Measurement Period of 6 months for measuring the number of hours that a Team Member has worked. If a Team Member works an average of 30 hours per week during a Standard Measurement Period, he or she will be eligible for medical group (but not other benefits coverage otherwise available to Full-Time Team Members only) during a Stability Period. For 2015, the Standard Measurement Periods are (1) April 14, 2014 to October 13, 2014 for medical coverage under the Plan effective for the Stability Period from January 1, 2015 through June 30, 2015, and (2) October 14, 2014 to April 13, 2015 for medical coverage under the Plan effective for the Stability Period from July 1, 2015 to December 31, 2015.
5. Newly hired variable status Team Members (temporary, part-time or on-call) will also be measured using an Individual Measurement Period starting with their first pay period worked through the 6 month anniversary of such pay period. Newly hired Team Members in variable status are also measured under the Standard Measurement Period(s) that begin after the Team Member’s date of hire.
6. Full-Time Team Members who transfer from Full-Time to a variable status (temporary, part-time or on-call) will be eligible to continue their medical coverage under the Plan during the applicable Stability Period and may continue such coverage if during the applicable Standard or Initial Measurement, the Team Member worked an average of 30 hours or more per week. A Team Member’s change from Full-Time to variable status (i.e. a reduction in hours) does not constitute a Qualifying Life Event, however a Team Member who experiences such a change may change medical plans or may obtain coverage through the Nevada Exchange.
7. A Team Member must be actively at work on his scheduled Effective Date of Coverage (see Section C) to begin coverage. Refer to the “Actively at Work” definition.
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Part Time, On Call and Temporary Team Members
Part-time, on-call and temporary Team Members are not eligible to participate in the dental, vision and other non-medical benefits of the Plan. Such Team Members are eligible to participate in the medical portion of the Plan as set forth above.
Transferring Properties
Covered benefits may change in transferring from one property to another. For this reason, it is important to contact the property Human Resources department at the new property within 31 days of your transfer to verify coverage and receive applicable information. Covered Team Members and covered Spouses and Dependents who were previously participating or otherwise eligible to participate in a plan sponsored by a Joint Venture will be immediately eligible to participate in the Plan (an additional 60-day waiting period is not required).
Collective Bargaining
If a Team Member is covered by a collective bargaining agreement where health benefits were the subject of full good faith collective bargaining, she will not be eligible to participate in the Plan unless such participation has been specifically agreed to within the collective bargaining agreement.
Miscellaneous Provisions
Any decision as to eligibility hereunder made by The Plan Administrator in good faith shall be binding on all persons regardless of any reclassification or redesignation by an applicable court or other judicial determination. Denial of eligibility for benefits cannot be based on Health Status-Related Factors.
A Team Member who transfers from an affiliate (as determined by the Plan Administrator) to The Employer will be credited with prior service for purposes of eligibility under the Plan.
B. DEPENDENT ELIGIBILITY REQUIREMENTS
An eligible Dependent includes the eligible Team Member’s Non-Working Spouse (as defined by the Plan) unless divorced or legally separated and all Children (as defined by the Plan) under 26 years of age. Effective January 1, 2014, only Non-Working Spouses are eligible for the Plan. A Non-working Spouse means a Spouse who is either unemployed or who is employed but ineligible for coverage through his or her own employer.
Dependent Documentation
The Team Member is responsible for providing documentation proving a legal Spouse or a Child is an eligible Dependent. Effective June 1st, 2012 a copy of a certified marriage certificate (for Spouse coverage) or a copy of a certified birth certificate (for Child coverage) must be submitted within 60 days of a Team Member becoming eligible for benefits or having a qualifying change in status event. Dependents will not be eligible for coverage if such documentation is not submitted within the allowed time. If documentation is not submitted within 60 days the Team Member must wait until they experience a qualifying change in status event or until the next Open Enrollment period to add the Dependent with the appropriate documentation. Effective January 1, 2014, a Team Member must complete all forms requested by the Plan Administrator regarding a Spouse’s eligibility to participate in the Plan.
It is the responsibility of the Team Member to remove Dependents from the Plan who no longer meet the Dependent eligibility requirements within 60 days of the event.
Mental or Physical Impairments
An unmarried tax-dependent Child who is incapable of self-sustaining employment by reason of mental or physical impairment upon attaining an age limit under the Plan may be considered as an eligible Dependent while remaining incapacitated and continuously covered under the Plan. To continue a Child’s coverage under this provision, proof of incapacity must be submitted within 60 days of the Child’s attainment of the age limit. Proof of continuing incapacity may be required periodically by the Claims Administrator.
Dependent Coverage
A person who is enrolled as an eligible Team Member shall not also be considered an eligible Dependent of another Team Member under the Plan. If both parents of a Dependent Child are employed by The Employer, coverage will be under one parent only. A Team Member must be covered under The Plan in order to cover any eligible Dependents under the Plan. Dependents must elect the same coverage as the Team Member.
Removal of Dependents
It is the responsibility of the Team Member to remove Dependents from The Plan who cease to meet the Dependent eligibility requirements (e.g. due to divorce or a spouse becoming eligible for group health plan coverage through his/her own employer). The Dependent must be removed within 60 days of the event that causes eligibility to cease. The Plan Sponsor retains the right to request documentation to confirm that a Dependent meets the Plan’s Dependent eligibility requirements.
If the Plan is not made aware of a qualifying change in status event affecting dependent eligibility within 60 days of that event, COBRA will not be offered to that dependent. If timely notice is not provided, all claims will be the responsibility of the Team Member as of the qualifying Change in Status event date and the Team Member will forfeit contributions paid.
If it is discovered that information is withheld or false information has been provided regarding eligibility, this will be considered fraud or intentional misrepresentation, benefits will be terminated immediately, coverage will be rescinded, and the Team Member will be required to reimburse Claims that were paid on behalf of the ineligible Dependent.
Ineligible Dependents
An eligible Spouseor Dependent does not include:
a Spouse following legal separation or a final decree of dissolution or divorce, or a common law Spouse;
any Child who has been legally adopted by another person (coverage ends on the date custody is assumed by the adoptive parents);
any Child who is covered as a Dependent of another Team Member under any Plan to which The Employer makes financial contributions on behalf of the Team Member; or
other individuals living in the Covered Team Member’s home, but who are not Dependents.
If the Plan is not made aware of a qualifying change in status event affecting dependent eligibility within 60 days of that event, COBRA will not be offered to that Dependent.
At any time, The Plan may require proof that a Spouse or a Child qualifies or continues to qualify under the terms of the Plan. Enrolling an unqualified Spouse or Dependent by withholding information or presenting false information regarding eligibility will constitute fraud or an intentional misrepresentation that triggers rescission of coverage and such persons will be immediately ineligible and any benefits paid on behalf of such persons must be reimbursed to the Plan by the covered Team Member.
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C. EFFECTIVE DATE OF COVERAGE
Team Member
A Team Member’s coverage will not become effective until all of the following are met:
1. the Eligibility Requirements; and
2. the Enrollment Requirements of the Plan.
Spousal and Dependent Coverage
A Spouse and/or Dependent’s coverage will not become effective until all of the following are met:
1. the Team Member is covered under the Plan;
2. the Eligibility Requirements; and
3. the Enrollment Requirements of the Plan.
Rehired or Reinstated Team Members
1. For the purpose of coverage under the Plan, if a previously covered Team Member, who was
terminated for a reason other than an Employer initiated reduction-in-force, is rehired within 30
days of his termination date, the Team Member’s coverage will be effective on his rehire date,
provided he otherwise meets the eligibility requirements under the Plan on his rehire date. If a
Team Member is rehired more than 30 days from his termination date, he will be considered the
same as a new Team Member and must meet the eligibility requirements listed in Section A.
2. If a previously covered Team Member, who was terminated due to an Employer initiated
reduction-in-force, is rehired within 90 days (or within 13 weeks for purposes of the medical
portion of the Plan only), the Team Member’s coverage will be effective on his rehire date
provided he otherwise meets the eligibility requirements under the Plan on his rehire date. If the
Team Member who was terminated due to an Employer initiated reduction in force is rehired
more than 90 days (or at least 13 weeks for purposes of the medical portion of the Plan only)
following the termination date, he will be considered the same as a new Team Member and must
meet the eligibility requirements listedn Section A.
3. Any Team Member returning in a variable status position with a break in service of less than 13
weeks may continue applicable Stability or Measurement periods, according to the guidelines
of the Affordable Care Act, to determine if she is eligible for medical coverage based on hours
worked.
Transferred Team Members
If a Team Member transfers with no break in service from one Station Casinos’ property to another
or any of its Joint Ventures, the Team Member will be treated as if the transfer never occurred as far
as coverage under the Plan is concerned, including, but not limited to, the waiting period, applicable
Deductibles, and Out-of-Pocket Maximum. The Effective Date of the change will be the first of the
month following or coinciding with the transfer to the new property with no break in coverage. If as
the result of the transfer the Team Member becomes eligible for different options under The Plan,
the Team Member will be allowed to change the corresponding election as of the Effective Date.
D. ENROLLMENT REQUIREMENTS FOR TEAM MEMBERS AND DEPENDENTS
Initial Enrollment
An eligible Team Member may enroll himself and/or any eligible Dependents within 60 consecutive days after satisfying the waiting period. In order to enroll, a Team Member must complete the enrollment process within the later of 60 days of eligibility or 60 days after notification of eligibility was mailed to the Team Member’s address on record. Coverage of an eligible Dependent enrolled after the Effective Date of the Plan becomes effective on the later of (1) the date coverage for the Team Member becomes effective, if the eligible Dependent is listed as a Dependent; or (2) the date the Dependent is enrolled. If an eligible Team Member fails to enroll within 60 consecutive days after satisfying the waiting period, Enrollment for himself and/or any eligible Dependents may be requested only during Open Enrollment or within a specified period following a Change in Status event as described below.
Open Enrollment
During Open Enrollment all eligible Team Members may enroll themselves and/or any eligible Dependents or make changes to coverage by adding, deleting, or changing coverage for themselves or their eligible Dependents. The period for Open Enrollment shall be as determined by Station Casinos.
Change in Status Enrollment
An eligible Team Member may enroll himself and/or any eligible Dependent or make changes to enrollment elections (including electing a new plan option) following a Change in Status. A Change in Status means any of the following events (which include Special Enrollment events under HIPAA):
1. change in a Team Member’s legal marital status including marriage, death of Spouse, divorce, legal separation, or annulment, including issuance of QMCSO that requires a Team Member to provide health coverage for a Child;
2. change in a Team Member’s number of Dependents, including a Child’s birth, adoption, placement for adoption, or death;
3. change in Team Member’s Spouse’s eligibility for or coverage under a group health plan because of a change in employment status (includes gain or loss of such eligibility or coverage);
4. change in eligibility for other health coverage due to change in employment (including exhaustion of COBRA coverage);
5. a strike or lockout, an FMLA Leave (as required by FMLA), or absence on account of being in uniformed service (as defined under USERRA);
6. a Dependent satisfying or ceasing to satisfy the Dependent eligibility requirements;
7. a transfer between a large property and the Wildfire Gaming divisions;
8. a change in place of residence or work of a Team Member and/or Dependent that affects eligibility status;
If the loss of eligibility for other health coverage was a result of an individual’s failure to pay premiums or for cause (like making a fraudulent Claim), then that individual has no Special Enrollment rights due to loss of other health coverage.
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9. entitlement to or termination of entitlement to Medicare, Medicaid (other than coverage consisting solely of benefits under Section 1928 of the Social Security Act that provides for the distribution of pediatric vaccines), and, effective April 1, 2009, a State Children’s Health Insurance Program (“CHIP”) under Title XXI of the Social Security Act; or, effective April 1, 2009, becoming eligible for assistance with respect to group health coverage under The Plan, under a Medicaid plan or State CHIP (including under any waiver or demonstration project conducted under or in relation to such a plan).
If a Change in Status event occurs, Enrollment or a change in Enrollment elections may be requested within 60 consecutive days after the Change in Status event. If these requirements are met, coverage becomes effective on the date of the Change in Status event. For Enrollment provisions specific to a newborn or adopted Child, refer to “Enrollment Requirements for Newborn or Adopted Children” below.
E. ENROLLMENT REQUIREMENTS FOR NEWBORN OR ADOPTED CHILDREN
A newborn or adopted Child of a covered Team Member will automatically be covered under the medical plan for 31 days from the date of birth or the date the Child is placed with the Team Member pending final adoption if the Team Member has medical coverage under The Plan at the time of the Child’s birth or date of placement for legal adoption.
In order to continue the Child’s coverage beyond the 31-day period, the Child must be enrolled and documentation must be submitted no later than 60 days after the date of birth or date of adoption or placement for legal adoption and any required premium contributions must be made.
If coverage for the Child is not requested within the 60-day period, the Child may only be enrolled as provided in “Enrollment Requirements for Team Members and Dependents.”
If the Team Member does not have medical coverage under The Plan at the time coverage for the Child is requested, the Team Member and Child may enroll as provided in “Enrollment Requirements for Team Members and Dependents.”
F. ENROLLMENT REQUIREMENT RELATED TO MARRIAGE
Newly eligible dependents will be effective immediately as of the date of the marriage provided all enrollment requirements are met. Notice of marriage must be provided within 60 days of the marriage.
G. ENROLLMENT RELATED TO A LOSS OF OTHER HEALTH COVERAGE
If a Team Member or his or her Dependent enrolls due to the loss of other health coverage, the effective date will be the first day following the loss of coverage provided proper notice is given. The Change must be requested within 60 days of the qualifying change in status event or the Team Member must wait until the next open enrollment period.
H. TIMELY OR LATE ENROLLMENT
Enrollment will be considered timely if the enrollment is completed no later than 60 days after the person either becomes eligible for coverage or is notified of their eligibility, either initially or under a Special Enrollment period.
I. CONTINUATION OF COVERAGE DURING LEAVE OF ABSENCE
Family and Medical Leave Act of 1993 (FMLA)
This Plan shall at all times comply with the Family and Medical Leave Act of 1993 and regulations thereunder issued by the Department of Labor. Contact the Plan Administrator for more information.
Uniformed Services Employment and Re-employment Rights Act (USERRA)
If a Team Member must take a leave of absence from employment to perform uniformed service, certain rights with respect to The Plan pursuant to the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) may be available. Contact the Plan Administrator for more information.
Company Approved Leave of Absence (other than FMLA or USERRA)
The Plan Administrator may agree to continue Plan coverage while a Team Member is on a Company-approved leave of absence, provided the leave is in accordance with The Employer’s Leave of Absence Policy and the required contributions applicable to active Team Members are paid when due. In addition, special service crediting rules apply (as required by the Affordable Care Act) while a Team Member is on a Company-approved leave of absence for purposes of the medical portion of The Plan. Please contact the Plan Administrator for more information.
J. TERMINATION OF COVERAGE
Termination with Respect to Team Members
A Team Member’s coverage under The Plan shall terminate on the last day of the month on the earliest of the following dates:
1. the date of termination of The Plan;
2. the date employment terminates;
3. the date on which an Employer initiated lay-off occurs;
4. the date a Team Member ceases to meet The Plan’s eligibility requirements for Team Members;
5. the date all coverage or certain benefits are terminated for a particular class by modification of The Plan;
6. the date an eligible Team Member becomes a full-time member of the Armed Forces, except as required by USERRA.
The Plan Administrator reserves the right to terminate a Team Member’s coverage in the event of non-payment of premiums when due from the Team Member. Coverage may be continued under COBRA. Refer to the “CONTINUATION OF BENEFITS (COBRA)” section for coverage continuation options.
Termination with Respect to Dependents
A Dependent’s coverage shall terminate under The Plan on the last day of the month on the earliest of the following dates:
1. the date of termination of The Plan;
2. the date of termination of all coverage under The Plan with respect to Dependents;
3. the date the Team Member’s coverage terminates for any reason;
The Plan Sponsor may administratively define other changes in circumstances as a Change in Status as long as any such definition is consistent with applicable laws, regulations, rulings and announcements of the Internal Revenue Service and is applicable to Covered Persons on a uniform, non-discriminatory basis.
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4. the date the Dependent becomes covered under The Plan as a Team Member;
5. the date the Dependent becomes a full-time member of the Armed Forces, except as required by USERRA;
6. the day a Dependent who ceases to meet the eligibility requirements due to age, as described in “DEPENDENT ELIGIBILITY REQUIREMENTS”.
The Plan Administrator reserves the right to terminate a Team Member’s Dependent’s coverage in the event of non-payment of premiums when due from the Team Member. Coverage may be continued under COBRA. Refer to the “CONTINUATION OF BENEFITS (COBRA)” section for coverage continuation options.
K. QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO)
Health coverage shall be provided to the Child of an eligible Team Member or eligible Spouse who is the subject of a Qualified Child Medical Support Order (QMCSO) in accordance with applicable law, or who is the subject of a National Medical Support Notice (NMSN) that is deemed to operate as a QMCSO.
A QMCSO is a court order issued pursuant to divorce proceedings requiring Child support or healthcare coverage for an Alternate Recipient. The court order creates or recognizes the existence of the Alternate Recipient’s right to, or assigns to the Alternate Recipient the right to, receive benefits for which the Team Member or Spouse is eligible under the Plan. The term “Alternate Recipient” means any Child of an eligible Team Member or eligible Spouse who is recognized under a QMCSO as having a right to Enrollment under a group health plan.
The QMCSO must specify:
1. the name and last known mailing address of the Team Member or designated parent required to pay for the coverage and the name and mailing address of each Alternate Recipient;
2. a reasonable description of the type of coverage to be provided by The Plan to each Alternate Recipient or the manner in which such coverage is to be determined;
3. each Plan to which the order applies; and
4. the period for which coverage must be provided and the Team Member will not be able to end coverage except as otherwise permitted by court order.
The court order may not require a plan to provide any type or form of benefit, or any option, not otherwise available under the Plan. An Alternate Recipient will be enrolled in the same option elected by the Team Member unless otherwise directed by the Team Member or pursuant to the order.
When The Plan Administrator receives a Medical Child Support Order, the following steps must be taken. The Plan Administrator must:
1. promptly notify both the eligible Team Member or designated parent and each Alternate Recipient of receipt of the order;
2. promptly furnish an explanation of The Plan’s procedures for determining whether the order is a QMCSO;
3. within a reasonable period after receipt of the Medical Child Support Order, determine if it is qualified; and
4. notify the eligible Team Member or designated parent and each Alternate Recipient of the determination and, if the order is determined to be qualified, provide the Alternate Recipient with a full explanation of the benefits hereunder.
QMCSO Enrollment
The Team Member must request enrollment for the Child within 31 days of the judgment decree or order. If coverage is requested within 31 days of the judgment, decree or order that qualifies as a QMCSO, coverage under the Plan will become effective on the date of the judgment, decree or order.
If it is determined that the QMCSO order is valid and the Team Member is not enrolled for coverage, The Plan Sponsor retains the right to automatically enroll the Team Member to the extent necessary to provide the specified coverage to the Alternate Recipient. If not otherwise specified, the participant will be enrolled in the same option elected by the Team Member unless otherwise directed by the Team Member or pursuant to the order. Appropriate payroll deductions will be made regardless of a signed authorization by the Team Member. Once enrolled, all benefits for the Alternate Recipient will be according to the standard terms of The Plan.
In any case in which an appropriately completed NMSN is issued in the case of a Child of a Team Member or eligible Spouse who is not the Custodial Parent of the Child, and the NMSN is deemed to be a QMCSO, within 40 business days after the date of the NMSN the Plan Administrator will:
1. notify the state agency issuing the NMSN with respect to such Child whether coverage of the Child is available under the terms of The Plan and, if so, whether such Child is covered under The Plan and either the Effective Date of the coverage or, if necessary, any steps to be taken by the Custodial Parent (or by the official of a state or political subdivision substituted for the name of such Child) to begin the coverage; and
2. provide to the Custodial Parent (or such substituted official) a description of the coverage available and any forms or documents necessary to begin the coverage.
The NMSN may not require the Plan to provide benefits (or eligibility for such benefits) that are not otherwise available under the terms of the Plan.
The Plan Administrator is responsible for deciding whether the court order satisfies the conditions of a QMCSO. A Team Member, a Dependent of a Team Member or an Alternate Recipient can obtain from the Plan Administrator, without charge, a copy of the procedures used by the Plan Administrator for determining whether an order is a QMCSO.
L. MISCELLANEOUS PROVISIONS
Failure to follow the Eligibility or Enrollment requirements of The Plan may result in delay of coverage, or no coverage at all.
Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as Coordination of Benefits, Subrogation, Exclusions, and timeliness of COBRA elections, utilization review or other cost management requirements, lack of Medical Necessity, lack of timely filing of Claims or lack of coverage.
The Plan will pay benefits only for the expenses Incurred while this coverage is in force. No benefits are payable for expenses incurred before coverage began or after coverage is terminated, even if the expenses were incurred as a result of an accident, injury or disease that occurred, began or existed while coverage was in force. An expense for a service or supply is incurred on the date the service or supply is furnished.
If a Team Member falsely certifies eligibility for Plan participation or does not inform the Plan Administrator of termination of eligibility, The Employer reserves the right to take disciplinary action, as appropriate, including termination of employment, legal actions and request for reimbursement of inappropriate benefit payments.
At any time, the Plan may require proof that a Spouse or Child qualifies or continues to qualify under the terms of the Plan. Enrolling an unqualified Spouse or Dependent by withholding
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information or presenting false information regarding eligibility will constitute fraud or an intentional misrepresentation that triggers rescission of coverage and such persons will be immediately ineligible and any benefits paid on behalf of such persons must be reimbursed to the Plan by the covered Team Member.
An employee who transfers from an Affiliate (as determined by the Plan Administrator) to The Employer will be credited with prior service for purposes of eligibility under the Plan.
The Plan Administrator reserves the right to terminate a Team Member’s coverage in the event of non-payment of premiums when due from the Team Member.
HEALTH BENEFITS
A. HEALTH PLANS OFFERED
PLAN DESCRIPTION
HMO Option(s) Benefits are available only for those Team Members who either live or work in the HMO service area.
The benefits provided under the HMO option(s) are fully insured by Health Plan of Nevada, a United Healthcare Company (“HPN”) and include a comprehensive healthcare plan and prescription drug benefits.
A full description of the benefits under the HMO option(s) can be found in the certificate booklet(s) (also referred to as the EOC(s)) and the Benefits Decision Guide.
PPO Option(s) The benefits provided under the PPO option(s) are fully-insured by Sierra Health & Life, a United Healthcare Company (“SHL”) and include a comprehensive health care plan and prescription drug benefits.
The benefits under the PPO options include a high deductible health plan with a health savings account.
A full description of the benefits under the PPO option(s) can be found in the certificate booklet(s) (also referred to as the COC(s)) and the Benefits Decision Guide.
Dental The benefits provided under the Dental option are self-funded and are fully described in this SPD and the Benefits Decision Guide.
Vision The benefits provided under the Vision option are fully-insured by Davis Vision.
A full description of the benefits under the Vision option can be found in the insurance certificate booklet (also referred to as the COC) and the Benefits Decision Guide.
The HMO, PPO, Dental and Vision options were designed to give you the most benefits for the least Out-of-Pocket costs by using a Network of Providers and services. You should be selective in your use of healthcare services and choice of providers.
Claim Filing, Denials and Appeals
The following procedures apply with respect to claims regarding the HMO and PPO Options (Medical Plans) and Vision Option. Claims procedures with respect to the Dental Option is set forth in the DENTAL BENEFITS section of this SPD.
The EOC and COC contain explicit rules regarding the Claim Provisions related to the medical benefits available under the HMO and PPO options of the Plan and Vision option.
Claims for MEDICAL BENEFITS and VISION BENEFITS must be made in accordance with the claims filing provisions of the applicable EOC or COC. You should review the descriptions in the EOC or COC for more information. If the EOC or COC does not provide its own claims and appeals provisions, the following will apply.
If a claim is wholly or partially denied, notice of the decision will be given within 90 days after receipt of the claim. If special circumstances require an extension of time for processing the claim, written notice of the extension will be furnished before the end of the initial 90 day period. An extension will not exceed 90 days from the end of the initial period. The extension notice will indicate the special circumstances requiring an extension of time and the date by which a final decision is expected.
The following information will be provided in a written notice denying a claim for benefits:
specific reason(s) for the denial;
specific reference to the provisions of the EOC or COC on which the denial is based;
a description of any additional material or information necessary to perfect the claim and an explanation of why such material or information is necessary;
a description of the Plan’s appeal procedures and the applicable time limits. Under the appeal procedures, you or your authorized representative may:
o make an appeal by written application to the Plan Administrator (or other fiduciary responsible for hearing claims appeals) within 60 days after receipt of the notice of claim denial;
o upon written request and free of charge, be provided with reasonable access to and copies of all plan documents, records and other information relevant to your appeal; and
o submit written comments, documents, records and other information relating to the claim.
The decision on the appeal will be made within 60 days after receipt of the written appeal, unless special circumstances require an extension of time for processing, in which case you will be notified of the extension and a decision will be rendered as soon as possible, but not later than 120 days after receipt of the appeal. The decision on the appeal will be in writing and include specific reasons for the decision, written in a manner calculated to be understood by you. The decision will include specific references to the EOC or COC provisions on which the decision is based and such other information, if any, as required by regulations under ERISA Section 503 and the Patient Protection and Affordable Care Act (as applicable), including a statement of your right to bring a civil action under ERISA Section 502. The decision on the appeal will be final and binding on all parties. All of the time limits set forth above will be modified as required to comply with regulations under ERISA Section 503 and the Patient Protection and Affordable Care Act, as applicable.
An authorized representative may file a claim or appeal a denial for you. To name an authorized representative, you must file a Designation of Authorized Representative form with the Plan Administrator.
The Plan Administrator (or its designee including an applicable insurance carrier) has the discretionary authority to determine eligibility for benefits, to interpret any provision of EOC or COC and this Summary Plan Description, and to determine any facts which are relevant to a claim or the appeal of a claim denial. Medical Benefits will be paid only if the Plan Administrator decides in its discretion that you are entitled to the benefits. The decision of the Plan Administrator (or its designee) on an appeal is final and binding on all parties. Any claim or appeal not timely filed will be barred. Similarly, failure to follow the prescribed procedures set forth in the COC, EOC, any notices, and/or this SPD in a timely manner will also cause you to lose your right to sue regarding any adverse benefit determination.
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Note: You must exhaust the Plan’s administrative claims and appeals procedures before bringing suit in either state or federal court. In addition, any claim must be filed within 12 months after the date Covered Services (as defined in the EOC/COC) were provided.
If the terms of the EOC or COC designate a different person or entity to decide claims appeals, then the person or entity so designated will decide claims appeals instead of the Plan Administrator. In that event, the powers and discretionary authority of the Plan Administrator as described above are also granted to the designated person or entity, in addition to any powers and authority granted by the EOC or COC.
Medical Coordination of Benefits
Coordination of Benefits (COB) applies to you if you are covered by more than one health benefits plan, including any one of the following:
another employer sponsored health benefits plan;
a medical component of a group long-term care plan, such as skilled nursing care;
no-fault or traditional “fault” type medical payment benefits or personal injury protection benefits under an auto insurance policy;
medical payment benefits under any premises liability or other types of liability coverage; or
Medicare or other governmental health benefit.
If coverage is provided under two or more plans, COB determines which plan is primary and which plan is secondary. The plan considered primary pays its benefits first, without regard to the possibility that another plan may cover some expenses. Any remaining expenses may be paid under the other plan, which is considered secondary. The secondary plan may determine its benefits based on the benefits paid by the primary plan.
Please refer to the applicable COC or EOC for details and information regarding COB coverage.
B. PROVIDER NETWORK/DIRECTORIES
PLAN NETWORK NAME HOW TO OBTAIN A DIRECTORY
HMO Health Plan of Nevada By visiting www.healthplanofnevada.com.
PPO Sierra Health & Life By visiting www.sierrahealthandlife.com.
Dental Sierra Health-Care Options
By visiting www.uhcnevada.com and then clicking on Sierra Health-Care Options (SHO General Dentists/ SHO Dental Specialists).
Vision Davis Vision Available by visiting www.davisvision.com
Provider’s status can frequently change due to forces beyond the Plan’s control.
Prior to obtaining services, always verify your Provider’s continued participation in the Network.
Protect yourself from fraud!
Be wary of giving your plan identification (ID) number or your Social Security number to anyone you don’t know, except to your provider, or an authorized plan representative.
Do not let others use your insurance card.
Let only appropriate medical professionals review your medical records or recommend services.
Avoid using healthcare Providers who say that an item or service is not usually covered, but they know how to bill The Plan or insurance carrier to get it paid.
Carefully review all Explanation of Benefits (EOB) you receive from The Plan. If you suspect that a Provider has charged you for services you did not receive or billed you for the same service twice, contact the Provider for an explanation. There may have been a billing error.
DENTAL BENEFITS
Dental benefits are administered by the Dental Claims Administrator. The Plan will provide benefits up to the amounts shown (not to exceed the actual charges) for services and supplies listed below. Claims, inquiries and appeals must be submitted directly to the Dental Claims Administrator listed in the “IMPORTANT INFORMATION” section.
SCHEDULE OF DENTAL BENEFITSA network of providers is available under the dental benefits of The Plan. Please see previous page regarding how to access a list of network providers. Use of In-Network Providers is optional to the Covered Person. However, charges for services performed by In-Network Providers will be discounted, resulting in reduced costs to the Covered Person. Charges for Out-of-Network Providers will be reimbursed according to the network fee schedule.
CALENDAR YEAR MAXIMUM BENEFIT
The Maximum Benefit applies to all dental services except for Orthodontia.
$1,500
DEDUCTIBLE
Individual $50
Family $150
BENEFIT PERCENTAGE (payable by The Plan)
Preventative and Diagnostic Services 100% after Deductible
Basic and Restorative Services 100% after Deductible*
Major Services 75% after Deductible*
*Charges for Out-of-Network Providers will be reimbursed according to the network fee schedule, which may be less than the amount charged by the Provider.
ORTHODONTIA BENEFITOrthodontia benefits are available for Dependent Children only. Bands must be placed after age 6 and before age 19.
CALENDAR YEAR MAXIMUM BENEFIT $750
MAXIMUM LIFETIME BENEFIT $1,500
DEDUCTIBLE $0
BENEFIT PERCENTAGE (payable by The Plan) 50%
The Plan will provide benefits for orthodontic treatment on Dependent Children if bands are placed after age 6 and under age 19, subject to any limitations specified in the “SCHEDULE OF DENTAL BENEFITS” section.
Orthodontia benefits will begin upon submission of proof that the orthodontia treatment program has begun.
Payments will be divided into equal installments, based upon the estimated number of months of treatment, and will be paid over the treatment period as proof of continuing treatment is submitted.
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A. COVERED DENTAL EXPENSES
Dental coverage under the Plan is limited to the In-Network allowable, subject to the application of maximum benefit, Deductible, and benefits percentage provisions as stated in the “SCHEDULE OF DENTAL BENEFITS” section.
PREVENTATIVE AND DIAGNOSTIC SERVICESTYPE OF SERVICE BENEFIT
Routine Oral Examination limited to 2 examinations per Calendar Year
Prophylaxis treatment (scaling and polishing of teeth)
limited to 2 treatments per Calendar Year
Periodontal Prophylaxis limited to 2 treatments per Calendar Year
Topical application of sodium or stannous fluoride up to age 18
limited to 2 applications per Calendar Year
Topical application of a sealant on each permanent posterior tooth
up to age 16
Dental x-rays, including panoramic view or full mouth series
limited to 1 series during any period of 36 consecutive months
bitewing x-ray series limited to 1 series per Calendar Year
periapical x-rays other x-rays as needed for diagnosis (except x-rays taken in connection with orthodontic treatment)
as medically necessary
BASIC AND RESTORATIVE SERVICES Office Visits - office visits and consultations, office visits during regular office hours for
treatment and observation of injuries to teeth and supporting structure
Professional visits after hours and special consultation by a dental specialist upon referral by the Covered Person’s attending Dentist
Emergency or palliative visits for relief of pain
Endodontics (including root canal therapy)
Oral surgery
Extractions
Biopsy and examination of oral tissue
Study models
Local anesthetics and antibiotic drugs injected by the attending Dentist
Anesthesia in conjunction with surgical procedures
Fillings - amalgam, silicate, acrylic or plastic fillings
Stainless steel crowns (primary teeth)
Repair of crowns, inlays, bridgework or dentures
Pins to retain filling restorations
Space maintainers up to age 16
Subgingival curettage, alveolar and gingival reconstruction, periodontal scaling and root planning, gingivectomy, osseous surgery, or other treatment of periodontal abscess and periodontitis (refer to “Preventive and Diagnostic Services” for periodontal prophylaxis benefits)
MAJOR SERVICES
Inlays, onlays, gold fillings, crowns, and gold dowel pins;
Recementing of crowns, inlays, or bridgework, or relining of dentures (limited to 1 reline in any 6-month period);
Initial installation of partial or full removable dentures or fixed bridgework (including the accompanying inlays and crowns to form abutments) to replace one or more natural teeth which were extracted while covered under this plan; and
Replacement of existing partial or full removable dentures, crowns, or fixed bridgework, or the addition of teeth to an existing partial removable denture or to bridgework to replace extracted natural teeth, but only if:
the existing denture, crown or bridgework was installed at least 5 years prior to its replacement and cannot be made serviceable; or
the existing denture is an immediate temporary denture, and replacement by a permanent denture is required and takes place within 12 months from the date of installation of the immediate temporary denture.
Note that stainless steel crowns for adults are considered temporary. A temporary stainless steel crown that is not replaced with a permanent crown within 12 months is considered permanent and subject to the 5 year replacement clause. If a temporary stainless steel crown is replaced within 12 months, the benefit previously considered for the stainless steel crown is reduced from the benefits currently considered on the permanent crown.
ORTHODONTIC TREATMENT Oral examinations and diagnosis;
Initial (and subsequent, if any) installation of orthodontic appliances and adjustment of orthodontic appliances;
Comprehensive full-banded treatment; and
All other orthodontic treatment required by accepted orthodontic practice, including tooth extraction and dental x-rays.
B. DENTAL LIMITATIONS AND EXCLUSIONS
No benefits will be paid under the Plan for:
1. for expenses payable under a medical plan sponsored by The Employer;
2. treatment performed by anyone other than a Dentist, except that scaling or cleaning of teeth may be performed by a licensed dental hygienist if treatment is rendered under a Dentist’s supervision and direction;
3. implants, surgical removal of implants, replacement of implants and all related implant services;
4. prosthetic devices (including bridges and crowns) and the fitting thereof which were ordered before, or while, the person was covered under the dental benefits portion of The Plan, but installed or delivered after termination of his dental coverage under The Plan; replacement of a lost or stolen prosthetic device;
5. cosmetic surgery or dentistry for cosmetic reasons; treatment for congenital (hereditary) or
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developmental malformations; cleft palate; maxillary or mandibular (upper and lower jaw) degeneration; enamel hypoplasia (lack of development); fluorosis;
6. a veneer or facing (i.e., a tooth-colored exterior) on a crown or pontic is not covered on a tooth posterior to the second bicuspid but will be considered cosmetic; the maximum allowance for restoration or replacement of such a tooth will be the allowance for a gold crown or pontic;
7. crowns placed for the purpose of periodontal splinting;
8. appliances and restorations for splinting teeth;
9. any treatment to remove or lessen discoloration except in connection with endodontics;
10. personalization or characterization of dentures;
11. myofunctional therapy, muscle training therapy or training to correct or control harmful habits;
12. occlusal restoration, procedures, appliances or restorations that are performed to alter, restore or maintain occlusion (i.e., the way the teeth mesh), including:
increasing the vertical dimension;
replacing or stabilizing tooth structure lost by attrition;
realignment of teeth;
gnathological recording or bite registration or bite analysis;
occlusal equilibration; and
occlusal guards (night guards);
13. plaque control or oral hygiene; or
14. localized delivery of antimicrobial agent to include but not limited to Arestin, Atridex and/or Periochip;
15. items intended for sport or home use, such as athletic mouth guards or habit-breaking appliances;
16. items or services which are not Medically Necessary for the diagnosis and treatment of an Illness or Injury, unless stated otherwise as covered in The Plan;
17. for which the patient or Covered Person has no legal obligation to pay;
18. rendered by a member of the Covered Person’s Immediate Family or anyone who customarily lives in the Covered Person’s household;
19. which exceed The Plan allowable for In-Network and Out-of-Network Providers;
20. which are furnished in a government owned or operated facility or any other hospital where care is provided at government expense, unless it is non-service related;
21. for Accidental Injury or Illness arising out of or in the course of any employment for wage or profit or which is covered by Workers’ Compensation or Occupational Disease Policy, or any expenses payable under compromise settlement agreements arising from a Workers’ Compensation Claim;
22. for Injury resulting from or sustained as a result of being engaged in an illegal occupation, commission of an assault or felonious act, unless such Injury results from a medical condition (physical or mental health condition) or domestic violence;
23. resulting from or sustained as a result of participation in a riot or insurrection;
24. which are not generally accepted in the United States as being necessary and appropriate for the treatment of the Covered Person’s Illness or Injury;
25. which are still considered Experimental or Investigational (as defined by The Plan), whether or not such treatment, services or supplies are generally accepted by the medical profession;
26. which are considered as Over-Utilization, as determined by the Claims Administrator;
27. for Orthognathic conditions (including associated diagnostic procedures) and for Orthognathic surgery due to an Orthognathic condition or any other condition, whether or not Medically Necessary;
28. for preparing medical reports or itemized bills;
29. for broken or missed appointments;
30. for services, supplies, or accommodations provided in connection with holistic or homeopathic treatment, including drugs;
31. for charges made for the completion of Claim forms or for providing supplemental information; for postage, shipping or handling charges which may occur in the transmittal if information to the Claims Administrator; or for interest or financing charges;
32. for treatment or services rendered outside the United States or its territories except for an Accidental Injury or a Medical Emergency;
33. for Claims not filed within 6 months of the date the service or supply was Incurred, however, Coordination of Benefits Claims will be accepted after the 6 month filing time limit if received within 3 months of the date of the primary insurance Explanation of Benefits. NOTE: In-Network Providers are required by contract to submit Claims within the time limit, denied charges due to timely filing cannot be billed to the Covered Person;
34. for services rendered as a result of a complication of a non-covered service or procedure including any reversal procedure.
C. GENERAL DENTAL PROVISIONS
Pre-Determination Procedures (Optional)
If charges which would be payable for a proposed course of dental care will exceed a total of $300.00, written notice outlining such course and including charges should be forwarded to the Claims Administrator for assessment and certification prior to the commencement of any work or treatment. The Claims Administrator will determine and certify in writing the maximum amount of work or treatment and charges for which payment will be made. This certification is not required and is not a guarantee of payment. A pre-determination of charges may not be valid after 60 days, or after a person’s coverage terminates under the Plan. Although not required, this process helps participants understand what out-of-pocket costs to expect particularly when using Non-Network providers.
Services Incurred and Services Performed
Charges shall be allocated to a particular Calendar Year and to the Deductible or maximum applicable to such year, in accordance with the date such charge is deemed Incurred under this contract. All charges which are incurred with respect to any Treatment Plan shall be deemed Incurred on the date the service is actually performed
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Dental Claim Filing
Original bills for expenses Incurred (whether In-Network or Out-of-Network) must be submitted to the Dental Claims Administrator within 6 months after the date the service(s) were rendered. Coordination of Benefits Claims will be accepted after the 6 month filing time limit if received within 3 months of the date of the primary insurance explanation of benefits. Note: In-Network Providers are required by contract to submit Claims within the time limit; denied Claims cannot be billed to the Covered Person.
In the case of requests for information by the Dental Claims Administrator, the requested information must be submitted within 6 months of the date of the initial request in order for the Claim to be considered.
Dental Claim Denials and Appeals
If the Claims Administrator determines that a claim should be wholly or partially denied, the member will be sent written notification of such denial. This notice will include:
the reason for the denial; and
specific reference to the plan provisions on which the denial is based.
If the member believes a claim was improperly settled, the following process is available:
Within 60 days of receipt of the claim, the member may request, in writing or verbally, that the plan conduct a review of the processed claim. The Claim Administrator will review the processed claim and inform the member whether or not an error was made. Any errors will be corrected promptly.
All requests for a review of denied benefits should include a copy of the initial denial notification and any other pertinent information. Send all information to the Dental Claims Administrator listed in the Important Information section.
Coordination (Maintenance) of Benefits
The Coordination of Benefits provision is intended to eliminate duplicate payments and to provide the sequence in which coverage will apply when a Covered Person is covered by one or more plans. “Plan” means any group insurance, group-type coverage, a Health Maintenance Organization (HMO), Government programs (including Medicare), and No-Fault Insurance coverage (homeowners insurance, automobile insurance, personal Injury protection, or medical payment coverage). Coordination of Benefits provisions do not apply to individual insurance policies, school accident-type coverage, Champus or Medicaid.
The benefit payable under The Plan shall be integrated with the benefit payable to a person under all other plans.
If The Plan is Primary (see Order of Benefit Determination), benefits will be paid as if The Plan was the person’s only coverage.
If The Plan is Secondary, The Plan will pay the amount it would have paid had it been the person’s only coverage, less any amounts paid by all Primary Plans. If the plans that determine benefits first pay as much or more than the amount the Plan would have paid, had the Plan been the person’s only coverage, the Plan will not pay any benefits.
Order of Benefit Determination
The rules for determining the Primary Plan are:
1. The benefits of a plan that has no rules for coordination with other benefits are determined before The Plan’s benefits (No-Fault Insurance).
The Plan will pay the amount it would have paid had it been the person’s only coverage, less any amounts paid by all Primary Plans.
a. The benefits of a plan that covers the person as a Team Member, member or subscriber, that is, other than a Dependent, are determined before those of the plan that covers the person as a Dependent.
b. Except as stated in paragraph “c” below, when The Plan and another plan cover the same Child as a Dependent of different persons, called “parents”:
i. the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year (Birthday Rule);
ii. but if both parents have the same birthday, the benefits of the plan which covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time; however, if the other plan does not have the rule described in “1”, but instead has a rule based upon the gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits.
c. If two or more plans cover a person as a Dependent Child of divorced, never married, or separated parents, benefits for the Child are determined in this order:
i. first, the plan of the parent with custody of the Child;
ii. then, the plan of the Spouse of the parent with the custody of the Child; and
iii. finally, the plan of the parent not having custody of the Child.
iv. However, if a court decree states that one of the parents is financially responsible for the health care expenses, the benefits of that plan are determined first.The benefits of a plan which covers a person as a Team Member who is neither laid-off nor retired (or as that Team Member’s Dependent) are determined before those of a plan which covers that person as a laid-off or retired Team Member (or as that Team Member’s Dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply.
d. If a person whose coverage is provided under a right of continuation pursuant to Federal or state law is also covered under another plan, benefits for such person are determined in this order:
i. first, the benefits of the plan covering the person as a Team Member, member or subscriber (or as that person’s Dependent);
ii. second, the benefits under the continuation coverage.
e. If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply.
f. If none of the above rules determine the order of benefits, the benefits of the plan which has covered a Covered Person longer are determined before those of the plan which has covered that person for the shorter time.
Right to Receive and Release Necessary Information
The Claims Administrator may release or obtain any information if it is deemed necessary to implement this section or if it is deemed necessary for similar sections of other plans. Such information does not require prior notice or consent. Any person who Claims benefits under The Plan shall give the Claims Administrator any necessary information required.
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Dental Right of Reimbursement
If any Plan benefit paid to or on behalf of a Covered Person should not have been paid or should have been paid in a lesser amount, and the Team Member or any other appropriate party fails to repay the amount promptly, the overpayment may be recovered by The Plan Administrator from the Team Member, such party, or from any monies then payable by the Plan. Any such amounts that are not repaid when due may be deducted, at the direction of The Plan Administrator, from other benefits payable under this Plan with respect to the Dependent himself, the Team Member under whom the Dependent was covered, or any covered Dependent of the Team Member.
The Plan Administrator also reserves the right to recover any such overpayment by appropriate legal action. The Team Member must pay all costs of The Plan, including without limitation, attorneys’ fees, should The Plan pursue any means available under the law to recover any amount owed to The Plan by the Team Member or on behalf of his or her Dependent.
PAYMENT OF BENEFITS
All benefits under The Plan are payable to the covered Team Member whose Illness or Injury or whose covered Dependent’s Illness or Injury is the basis of a Claim. In the event of incapacity of a covered Team Member and in the absence of written evidence to The Plan of the qualification of a guardian (or person acting under durable power of attorney) for the covered Team Member’s estate, The Plan may, at its sole discretion, make any and all such payments to the individual or institution which, in the opinion of The Plan Administrator, is or was providing the care and support of such Team Member. In the event of death, the personal representative of the estate will act on behalf of the covered Team Member.
Benefits for expenses covered under The Plan may be assigned by a covered Team Member to the individual or institution rendering the services for which the expenses were incurred. No such assignment will bind The Plan Administrator unless it is in writing and unless it has been received and accepted by the Claims Administrator prior to the payment of the benefit assigned.
The Claims Administrator will not be responsible for determining whether any such assignment is valid. Payment of benefits which have been assigned will be made directly to the assignee unless a written request not to honor the assignment, signed by the covered Team Member and the assignee, has been received by the Claims Administrator before the proof of loss is submitted. Payment of benefits will be made by The Plan in accordance with any assignment of rights made by or on behalf of a Covered Person if required by a Qualified Medical Child Support Order (QMCSO), the Plan will not take Medicaid eligibility into account and will pay benefits in accordance with any assignment of rights under a state Medicaid law.
RECOVERY OF OVERPAYMENTS
If an overpayment is made under The Plan, The Plan Administrator reserves the right to determine and exercise one or all of the following options that it deems necessary to recover the overpayment to The Plan. The Plan Administrator may:
request the overpayment from any Covered Person to whom such overpayment was made;
request the overpayment from any Provider to whom such overpayment was made;
deduct the overpayment of benefits from subsequent benefits payable to the Covered Person; and/or
deduct the overpayment of benefits from subsequent benefits payable to the Provider to whom the overpayment was made.
Each Covered Person is deemed, through participation in The Plan, to authorize recovery of overpayments as described above.
LEGAL ACTIONS
The Plan’s procedures for filing and appealing Claims must be followed before the claimant can file any litigation with respect to an Adverse Benefit Determination.
OTHER BENEFITS
LIFE INSURANCE AND SHORT TERM DISABILITY
Eligible Team Members (as defined in the Eligibility Requirements section above) shall be entitled to certain life insurance and short term disability benefits. These company paid benefits are described in separate materials provided to you when you become initially eligible for benefits. Please refer to these materials regarding specific payments and benefits under these plans. Additional information is also available in the applicable Group Booklet – Certificate of Coverage which may be requested from the Plan Administrator and your Benefits Decision Guide.
WELLNESS PROGRAM
The Plan may include wellness programs to better your health. Please refer to separate materials and information regarding wellness programs, if any.
CAFETERIA PLAN
Each Team Member may pay their share for benefits under The Plan with pretax contributions pursuant to a “Cafeteria Plan.” Each Team Member who is eligible to participate in The Plan will be eligible to participate in this Cafeteria Plan. Team Members may only pay for the coverage of yourself and your tax dependents as defined in Code Section 152 generally (except as otherwise defined in Code Section 105(b) and the regulations issued under Code Section 106) under this Plan and as set forth in the SPD.
Team Members become a participant in the Cafeteria Plan once they become eligible for benefits. Unless the Team Member affirmatively waives participation, an election to participate in the Plan will constitute an election under this Cafeteria Plan.
Team Members may be required to complete a salary reduction agreement via telephone or voice response technology, electronic communication, or any other method prescribed by the Plan Administrator. In order to utilize a telephone system or other electronic means, Team Members may be required to sign an authorization form authorizing issuance of personal identification number (“PIN”) and allowing such PIN to serve as your electronic signature when utilizing the telephone system or electronic means. The Plan Administrator and all parties involved with Plan administration will be entitled to rely on your directions through use of the PIN as if such directions were issued in writing and signed by you.
Coverage under the Cafeteria Plan ends on the earliest of the following to occur:
a. The date that you make an election not to participate in the Plan;
b. The date you no longer satisfy the Eligibility Requirements of the Plan;
c. The date that you terminate employment; or
d. The date that the Cafeteria Plan is either terminated or amended to exclude you or the class of employees of which you are a member.
If a Team Member’s employment is terminated during the Plan Year or otherwise ceases to be eligible, the Team Member’s active participation in the Cafeteria Plan will automatically cease, and the Team Member will not be able to make any more pretax contributions under the Cafeteria Plan
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except as otherwise provided pursuant to Employer policy or individual arrangement.
Team Members save both federal income tax and FICA (Social Security) taxes by participating in the Cafeteria Plan. Cafeteria Plan participation will reduce the amount of the Team Member’s taxable compensation. Accordingly, there could be a decrease in Social Security benefits and/or other benefits (e.g., pension, disability, and life insurance) that are based on taxable compensation.
When a Team Member elects to participate both in the Plan and this Cafeteria Plan, applicable premiums are deducted from his paycheck each month that he is enrolled. The deduction is made before any applicable federal and/or state taxes are withheld.
If a Team Member begins a qualifying leave under the Family and Medical Leave Act of 1993 (FMLA), the Employer will continue to maintain the Team Member’s benefit options that provide health coverage on the same terms and conditions as though the Team Member was still active to the extent required by FMLA (e.g., the Employer will continue to pay its share of the contribution to the extent you opt to continue coverage).
Team Member’s health coverage will continue while on a Company approved leave. The Team Member will continue to be responsible for their portion of the cost to maintain coverage during their leave.
Team Member contributions for coverage during a Company approved leave of absence may be made in one of the following ways:
1. You may pre-pay all or a portion of your share of the contribution for the expected duration of the leave by personal check or money order payable to Station Casinos LLC.
2. If you do not pre-pay for coverage during a leave of absence, the amount owed but not paid will be withheld from your compensation upon your return from leave.
The payment options provided by the Employer will be established in accordance with Code Section 125, FMLA and the Employer’s internal policies and procedures regarding leaves of absence and will be applied uniformly to all Participants.
CONTINUATION OF BENEFITS (COBRA)
This section has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan and constitutes your initial COBRA notice. This section explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the other sections of this SPD or contact the Plan Administrator.
You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
What is COBRA continuation coverage?COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end
because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.
If you’re an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
You worked less than an average of 30 hours per week in an applicable Standard Measurement Period or
Your employment ends for any reason other than your gross misconduct.
If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:
Your spouse dies;
Your spouse works less than an average of 30 hours per week in an applicable Standard Measurement Period;
Your spouse’s employment ends for any reason other than his or her gross misconduct;
Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
You become divorced or legally separated from your spouse.
Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:
The parent-employee dies;
The parent-employee works less than an average of 30 hours per week in an applicable Standard Measurement Period;
The parent-employee’s employment ends for any reason other than his or her gross misconduct;
The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
The parents become divorced or legally separated; or
The child stops being eligible for coverage under the Plan as a “dependent child.”
When is COBRA continuation coverage available?
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:
The end of employment or employee works less than an average of 30 hours per week in an applicable Standard Measurement Period;
Death of the employee;
Commencement of a proceeding in bankruptcy with respect to the employer;]; or
The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).
For all other qualifying events (divorce or legal separation of the employee and spouse or a
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dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. The Plan Administrator contact information is in the IMPORTANT INFORMATION section of this SPD. Documentation of your qualifying event may be required.
How is COBRA continuation coverage provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.
COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or employee works less than an average of 30 hours per week in an applicable Standard Measurement Period. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.
There are also ways in which this 18-month period of COBRA continuation coverage can be extended:
Disability extension of 18-month period of COBRA continuation coverage
If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Your Social Security Disability Award Notice must be submitted to the COBRA Administrator within 60 days of the date you receive notice of the award and before the end of the initial 18 month COBRA period.
Second qualifying event extension of 18-month period of continuation coverage
If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
If you have questions:
Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified in the IMPORTANT INFORMATION section of this SPD that includes the Plan Administrator and COBRA administrator contact information. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the
Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
PLEASE Keep your Plan Administrator informed of any address changes.
To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.
HIPAA PRIVACY RULE
A. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
The Plan Sponsor will only use and disclose protected health information (“PHI”) to the extent of and in accordance with the uses and disclosures required and permitted by 45 C.F.R. Parts 160 and 164 of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). This includes the right to use or disclose PHI for treatment and health care operations. The Plan will disclose PHI to The Plan Sponsor only in accordance with 45 C.F.R. § 164.504(f) and this section.
B. DEFINITIONS OF PHI
Whenever used in this section, the following terms shall have the respective meanings set forth below.
a. Health Care Operations include, but are not limited to, the following activities:
i. conducting quality assessment and improvement activities;
ii. population-based activities relating to improving health or reducing health care costs, protocol development, Case Management and/or coordination, Disease Management, contacting health care Providers and patients with information about treatment alternatives and related functions;
iii. rating Provider and Plan performance, including accreditation, certification, licensing or credentialing activities;
iv. underwriting, premium rating and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing or placing a contract for reinsurance of risk relating to health care Claims (including stop-loss insurance and excess loss insurance);
v. conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance programs;
vi. business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating The Plan, including Formulary development and administration, development or improvement of payment methods or coverage policies; and,
vii. business management and general administrative activities of The Plan, including, but not limited to:
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management activities relating to the implementation of and compliance with HIPAA’s administrative simplification requirements;
customer service, including the provision of data analyses for policyholders, plan sponsors or other customers provided that PHI is not disclosed to such policyholder, plan sponsor or customer;
resolution of internal grievances;
the sale, transfer, merger or consolidation of all or part of The Plan with another covered entity (as defined in 45 C.F.R. § 160.103) or an entity that following such activity will become a covered entity and due diligence related to such activity;
creating de-identified health information in a limited data set, in accordance with 45 C.F.R. § 1640.514; and
fundraising for the benefit of The Plan.
b. Individually Identifiable Health Information means information that is a subset of health information, including demographic information collected from an individual, and:
i. is created or received by a health care Provider, health plan, employer, or health care clearinghouse; and
ii. relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or
iii. the past, present, or future payment for the provision of the health care to an individual; and
that identifies the individual; or
with respect to which there is a reasonable basis to believe the information can be used to identify the individual.
c. Payment includes activities undertaken by The Plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of benefits under The Plan. These activities include, but are not limited to, the following:
i. determination of eligibility or coverage (including Coordination of Benefits and cost sharing amounts);
ii. adjudication or Subrogation of health benefit Claims (including appeals and other payment disputes);
iii. risk adjusting amounts due based on enrollee health status and demographic characteristics;
iv. billing, Claims management, collection activities, obtaining payment under a contract for reinsurance (including stop-loss insurance and excess loss insurance) and related health care data processing;
v. review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care or justification of charges;
vi. utilization review, including pre-certification and prior authorization of services, concurrent and retrospective review of services; and,
vii. disclosure to consumer reporting agencies related to the collection of premiums or reimbursement (the following PHI may be disclosed: name and address, date of birth, social security number, payment history, account number and name and address of the Provider and/or health plan).
d. Plan Administrative Functions means administrative functions performed by The Plan Sponsor on behalf of The Plan, which are limited to those functions listed under the definition of “Payment” and “Health Care Operations.” Plan administrative functions do not include functions performed by The Plan Sponsor in connection with any other benefit or benefit plan of The Plan Sponsor.
e. PHI means Individually Identifiable Health Information that is transmitted or maintained electronically, or any other form or medium.
f. Privacy Official shall mean the individual appointed by The Plan Sponsor pursuant to 45 C.F.R. § 164.530(a)(1)(i) who is responsible for the development and implementation of The Plan Sponsor’s privacy policies and procedures.
C. DISCLOSURES OF PHI TO THE PLAN SPONSOR
The Plan hereby incorporates the provisions listed in Section D below to enable it to disclose PHI to The Plan Sponsor and acknowledges receipt of written certification from The Plan Sponsor that The Plan has been so amended.
D. PLAN SPONSOR COMPLIANCE WITH PRIVACY CONDITIONS
Pursuant to 45 C.F.R. § 164.504(f)(2)(ii), The Plan Sponsor agrees to:
a. not use or further disclose PHI other than as permitted or required by the Plan documents or as required by law;
b. ensure that any agents, including subcontractors, to whom it provides PHI received by the Plan agree to the same restrictions and conditions that apply to The Plan Sponsor with respect to such PHI;
c. not use or disclose PHI for employment-related actions and decisions unless authorized by an individual;
d. not use or disclose PHI in connection with any other benefit or Team Member benefit plan of The Plan Sponsor, unless authorized by an individual;
e. report to the Plan any use or disclosure of PHI that is inconsistent with the uses or permitted disclosures which The Plan Sponsor becomes aware;
f. make PHI available to an individual in accordance with the access requirements, as described in 45 C.F.R. § 164.524;
g. make PHI available for amendment and incorporate any amendments to PHI in accordance with 45 C.F.R. § 164.526;
h. make available the information required to provide an accounting of disclosures in accordance with 45 C.F.R. § 164.528;
i. make internal practices, books and records relating to the use and disclosure of PHI received from The Plan available to the DHHS Secretary for the purposes of determining The Plan’s compliance with HIPAA; and
j. if feasible, return or destroy all PHI received from the Plan that The Plan Sponsor still maintains in any form, and retain no copies of such PHI when no longer needed for the purpose for which disclosure was made (or if return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction infeasible).
E. PLAN SPONSOR COMPLIANCE WITH SECURITY CONDITIONS
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Pursuant to 45 C.F.R. § 164.314(b)(1), as of April 21, 2005, The Plan Sponsor agrees to:
a. implement administrative, physical and technical safeguards that reasonably and appropriately protect the confidentiality, integrity and availability of electronic PHI that it creates, receives, maintains or transmits on behalf of the Plan;
b. ensure that adequate separation required by 45 C.F.R. § 164.502(f)(2)(iii) is supported by reasonable and appropriate security measures;
c. ensure that any agent or subcontractor to whom it provides PHI agrees to implement reasonable and appropriate security measures to protect the information; and
d. report to the Plan any security incident of which it becomes aware.
F. SEPARATION BETWEEN THE PLAN AND THE PLAN SPONSOR
The Plan will only disclose PHI to the following classes of Team Members:
Sr. Vice President of Human Resources
Corporate Director of Benefits
Corporate Benefits Manager
Benefits Professionals
G. LIMITATIONS ON PHI AND ACCESS AND DISCLOSURE
The persons described in Section F may only have access to and use and disclose PHI for Plan Administrative Functions and as required by law. Such access or use shall be permitted only to the extent necessary for these individuals to perform their respective duties for the Plan.
H. NON-COMPLIANCE ISSUES
If The Plan Sponsor becomes aware of a violation of this section, The Plan Sponsor shall inform the Privacy Official, who shall cause the violation to be investigated and determine in accordance with the Plan’s privacy policies and procedures what sanctions, if any, shall be imposed.
The Privacy Official is the Senior Vice President of Human Resources.
ANNUAL FEDERAL NOTICES
Compliance with Applicable Laws
The Plan Sponsor will administer the Benefit Plans in compliance with federal and state laws. Any interpretation of this document or the Benefit Plan Description incorporated by reference that is prohibited by federal or state law is void and will not be relied on for the administration of this Plan. The Plan Sponsor will administer the Benefit Plans in compliance with:
(1) The Mental Health Parity Act (MHPA) and The Mental Health Parity and Addiction Equity Act (MHPABA) ERISA § 712, requiring parity in certain mental health and substance use disorder benefits;
(2) The Women’s Health and Cancer Rights Act of 1998 (WHCRA) ERISA § 713(a), imposing requirements for coverage of reconstructive surgery and other complications in connection with mastectomy;
(3) ERISA § 609(c) coverage for adopted children:
(4) ERISA § 609(d) coverage of costs of pediatric vaccines;
(5) The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA);
(6) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (applies to any group health plan sponsored by the Plan Sponsor);
(7) The Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA);
(8) The Genetic Information Nondiscrimination Act (GINA):
(9) The Health Information Technology for Economic and Clinical Health Act (HITECH);
(10) Michelle’s Law; and,
(11) The Family and Medical Leave Act of 1993 (FMLA).
Newborns’ Act Disclosure
This Plan does not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Additional information including State Rights required are described in detail in the applicable Benefit Plan Descriptions.
Notice of Rights Under the Women’s Health and Cancer Rights Act (WHCRA)
If you have had or are going to have a mastectomy you may be entitled to certain benefits, under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomyrelated benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:
(1) All stages of reconstruction of the breast on which the mastectomy was performed;
(2) Surgery and reconstruction of the other breast to produce a symmetrical appearance;
(3) Prostheses; and,
(4) Treatment of physical complications of the mastectomy, including lymphedemas.
These benefits will be provided subject to the same deductible and coinsurance particulars that are applicable to other medical and surgical benefits provided under this Plan. For more information or to get a copy of the Certificate of Coverage or Evidence of Coverage containing these details contact your Plan Sponsor Representative.
The Genetic Nondiscrimination Act of 2008 (GINA)
GINA prohibits a group health plan from adjusting group premium or contribution amounts for a group of similarly situated individuals based on the genetic information of members of the group. GINA prohibits a group health plan from requesting or requiring an individual or a family member of an individual to undergo genetic tests. Genetic information means information about an individual’s genetic tests, the genetic tests of family members of the individual, the manifestation of a disease or disorder in family members of the individual or any request for or receipt of genetic services, or participation in clinical research that includes genetic services by the individual or a family member of the individual. The term genetic information includes, with respect to a pregnant woman (or a family member of a pregnant woman) genetic information about the fetus and with respect to an individual using assisted reproductive technology, genetic information about the embryo. Genetic information does not include information about the sex or age of any individual.
HIPAA PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
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DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your Employee Benefit Plan (the “Plan”) is required by law to give you this privacy notice (“Notice”) about our duties and privacy practices with respect to your medical information. The Plan provides health, dental, vision, prescription and/or employee assistance program benefits to you as described in your summary plan description(s).
This Notice describes how the Plan sponsored by your Employer (the “Plan Sponsor”) may use and disclose your health information to carry out treatment, payment and health care operations and for other uses and disclosures that are required or permitted by law. Additionally, this Notice explains the rights you have with respect to your health information, and certain obligations the Health Plans must abide by in accordance with the law. The Plan hires business associates to help it provide these benefits to you. These business associates also receive and maintain your medical information in the course of assisting the Plan.
Nothing contained in this Notice should be construed to supersede or limit any additional rights you may be entitled to under other applicable law. Therefore, if any applicable law affords you greater rights or more protections other than as described herein, we will comply with the law that gives you greater rights and/or protections.
Purposes for which the Plan May Use or Disclose Your Medical Information Without Your Consent or Authorization
The Plan may use and disclose your medical information for the following purposes:
For Treatment Purposes. For example, the Plan may disclose your medical information to your doctor, at the doctor’s request, for your treatment by him.
For Payment. For example, the Plan may use or disclose your medical information to pay claims for covered health care services or to provide eligibility information to your doctor when you receive treatment.
For Health Care Operations. For example, the Plan may use or disclose your medical information (i) to conduct quality assessment and improvement activities, (ii) for underwriting, premium rating, or other activities relating to the creation, renewal or replacement of a contract of health insurance, (iii) to authorize business associates to perform data aggregation services, (iv) to engage in care coordination or case management, and (v) to manage, plan or develop the Plan’s business.
For Treatment and Health Services. The Plan may use your medical information to contact you to give you information about treatment alternatives or other health-related benefits and services that may be of interest to you. The Plan may disclose your medical information to its business associates to assist the Plan in these activities.
As required by law. For example, the Plan must allow the U.S. Department of Health and Human Services to audit Plan records. The Plan may also disclose your medical information as authorized by and to the extent necessary to comply with workers’ compensation or other similar laws.
To Business Associates. The Plan may disclose your medical information to business associates the Plan hires to assist the Plan. Each business associate of the Plan must agree in writing to ensure the continuing confidentiality and security of your medical information.
To Plan Sponsor. The Plan may disclose to the Plan Sponsor, in summary form, claims history and other similar information. Such summary information does not disclose your name or other distinguishing characteristics. The Plan may also disclose to the Plan Sponsor that fact that you are enrolled in, or disenrolled from the Plan. The Plan may disclose your medical information to the Plan Sponsor for Plan administrative functions that the Plan Sponsor provides to the Plan if the Plan Sponsor agrees in writing to ensure the continuing confidentiality and security of
your medical information. The Plan Sponsor must also agree not to use or disclose your medical information for employment-related activities or for any other benefit or benefit plans of the Plan Sponsor.
To Family Members, Relatives or Close Friends. Unless you object to such disclosure, we may disclose your health information to your family members, relatives or close personal friends, or any other persons identified by you as being involved in your treatment or payment for your medical care. If you are present, we will ask if you would like us to share your health information with a family member, relative or a friend before we disclose such information. If, however, you are not present to agree or object to our disclosure of your health information to a family member, relative or friend, we may exercise our professional judgment to determine whether the disclosure is in your best interest. If we decide to disclose your health information to your family member, relative or other individual identified by you, we will only disclose the health information that is relevant to your treatment or payment.
The Plan may also use and disclose your medical information as follows:
To comply with legal proceedings, such as a court or administrative order or subpoena.
To law enforcement officials for limited law enforcement purposes.
To your personal representatives appointed by you or designated by applicable law.
For research purposes in limited circumstances.
To a coroner, medical examiner, or funeral director about a deceased person.
To an organ procurement organization in limited circumstances.
To avert a serious threat to your health or safety or the health or safety of others.
To a governmental agency authorized to oversee the health care system or government programs.
To federal officials for lawful intelligence, counterintelligence and other national security purposes.
To public health authorities for public health purposes.
To appropriate military authorities, if you are a member of the armed forces.
To the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law that provide benefits for work-related injuries or illness without regard to fault.
Other Uses of Confidential Information
For purposes not described above, including uses and disclosures of PHI for marketing purposes and disclosures that would constitute a sale of PHI, we will ask for your written authorization before using or disclosing PHI. If you provide us permission to use or disclose confidential information about you, you may revoke that permission, in writing to the Benefits Department, at any time. If you revoke your permission, we will no longer use or disclose confidential information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records.
To the extent required by law, when using or disclosing your confidential information or when requesting confidential information from another covered entity, we will make reasonable efforts not to use, disclose or request more than the minimum amount of confidential information necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations.
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Genetic Information. We are not permitted to use or share your genetic information for underwriting purposes, to adjust premiums, or to make enrollment/eligibility determinations based on your predisposition to a genetic condition. We are also prohibited from requesting, requiring, or purchasing genetic information about you prior to enrollment.
Uses and Disclosures with Your Authorization
The Plan will not use or disclose your medical information for any other purposes unless you give the Plan your written authorization to do so. If you give the Plan written authorization to use or disclose your medical information for a purpose that is not described in this notice, then, in most cases, you may revoke it in writing at any time. Your revocation will be effective for all your medical information the Plan maintains, unless the Plan has taken action in reliance on your authorization.
Information Breach Notification
We are required to notify you if we discover a breach of unsecured PHI unless there is a demonstration, based on a risk assessment, that there is a low probability that the PHI has been compromised. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what can be done to mitigate any harm.
Your Rights
You may make a written request to the Plan to do one or more of the following concerning your medical information that the Plan maintains:
• To put additional restrictions on the Plan’s use and disclosure of your medical information. The Plan does not have to agree to your request.
• To communicate with you in confidence about your medical information by a different means or at a different location than the Plan is currently doing. The Plan does not have to agree to your request unless such confidential communications are necessary to avoid endangering you and your request continues to allow the Plan to collect premiums and pay claims. Your request must specify the alternative means or location to communicate with you in confidence. Even though you requested that we communicate with you in confidence, the Plan may give subscribers cost information.
• To see and get copies of your medical information. In limited cases, the Plan does not have to agree to your request.
• To correct or amend your medical information. In some cases, the Plan does not have to agree to your request.
• To receive a list of disclosures of your medical information that the Plan and its business associates made for certain purposes for the last 6 years (subject to certain exceptions).
• To provide you with a paper copy of this notice, even if you received this notice by e-mail or on the internet.
If you want to exercise any of these rights described in this notice, please contact the Privacy Compliance Office listed below. The Plan will give you the necessary information and forms for you to complete and return to the Privacy Compliance Office. In some cases, the Plan may charge you a nominal, cost-based fee to carry out your request.
Complaints
If you believe your privacy rights have been violated by the Plan, you have the right to complain to the Plan or to the Secretary of the U.S. Department of Health and Human Services. You may file a complaint with the Plan at our Privacy Compliance Office (below). We will not retaliate against you if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human Services.
Effective Date/Changes
The Plan is required to follow the terms of this notice until it is replaced. The Plan reserves the right to change the terms of this notice at any time. If the Plan makes changes to this notice, the Plan will revise it and send a new notice to all subscribers covered by the Plan. The Plan reserves the right to make the new changes apply to all your medical information maintained by the Plan before and after the effective date of the new notice.
Contact Office
To request additional copies of this notice or to receive more information about our privacy practices or your rights, please contact us at the following Contact Office:
Station Casinos LLC Employee Benefit Plan
Privacy Compliance Office
1505 S. Pavilion Center Drive
Las Vegas, NV 89135
Telephone: 702-495-3000
Fax: 866-254-8758
E-mail: [email protected]
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1877KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer
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health plan premiums. The following list of states is current as of January 31, 2015. Contact your State for more information on eligibility –
ALABAMA – Medicaid GEORGIA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-692-5447
Website: http://dch.georgia.gov/
- Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP)
Phone: 1-800-869-1150
ALASKA – Medicaid INDIANA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
COLORADO – Medicaid IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
FLORIDA – Medicaid KANSAS – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
Website: http://www.kdheks.gov/hcf/
Phone: 1-800-792-4884
KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
MAINE – Medicaid NEW YORK – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 1-800-977-6740
TTY 1-800-977-6741
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
MINNESOTA – Medicaid NORTH DAKOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3739
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573-751-2005
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
MONTANA – Medicaid OREGON – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 1-800-694-3084
Website: http://www.oregonhealthykids.gov
http://www.hijossaludablesoregon.gov Phone: 1-800-699-9075
NEBRASKA – Medicaid PENNSYLVANIA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
NEVADA – Medicaid RHODE ISLAND – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
Website: www.ohhs.ri.gov
Phone: 401-462-5300
SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm
Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 1-855-242-8282
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ index.aspx
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Website:
Medicaid: http://health.utah.gov/medicaid
CHIP: http://health.utah.gov/chip
Phone: 1-866-435-7414
Website:
https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm
Phone: 1-800-362-3002
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2015, or for
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more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Serviceswww.dol.gov/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565
ERISA RIGHTS
A. RECEIVING INFORMATION ABOUT THE PLAN AND ITS BENEFITS
As a participant in the Station Casinos LLC Employee Benefit Plan, a Team Member is entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all Covered Persons shall be entitled to:
examine, without charge, at The Plan Administrator’s office and at other specified locations, such as worksites and union halls, all documents governing The Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by The Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration;
obtain, upon written request to The Plan Administrator, copies of documents governing the operation of The Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may impose a reasonable charge for the copies; and
receive a summary of The Plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report (“SAR”).
B. CONTINUING GROUP HEALTH PLAN COVERAGE
A participant shall be entitled to continue health care coverage for himself, his Spouse or Dependents if there is a loss of coverage under The Plan as a result of a Qualifying Event. The participant or his Dependents may have to pay for such coverage. Participants should review this Summary Plan Description and the documents governing The Plan for the rules governing COBRA continuation coverage rights.
.
C. PRUDENT ACTIONS BY FIDUCIARIES
In addition to creating rights for Covered Persons, ERISA imposes obligations upon the individuals who are responsible for the operation of The Plan. The individuals who operate this Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of Covered Persons and their beneficiaries. No one, including The Employer, or any other person, may fire a Team Member or otherwise discriminate against a participant in any way to prevent him from obtaining a welfare benefit or exercising his rights under ERISA.
D. ENFORCING RIGHTS AS A PARTICIPANT
If a Claim for a welfare benefit is denied or ignored, in whole or in part, the participant has a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
Under ERISA, there are steps a participant can take to enforce the above rights:
For instance, if the participant requests a copy of plan documents or the latest annual report from The Plan and does not receive the materials within 30 days, he may file suit in a Federal court. In such a case, the court may require The Plan Administrator to provide the materials and pay the participant up to $110.00 a day until he receives the materials, unless the materials were not sent because of reasons beyond the control of The Plan Administrator.
If a participant has a Claim for benefits, which is denied or ignored, in whole, or in part, he may file suit in a state or Federal court, provided he has exhausted the administrative remedies available under The Plan.
In addition, if a participant disagrees with The Plan’s decision or lack thereof concerning the qualified status of a medical Child support order, he may file suit in Federal court.
If it should happen that Plan fiduciaries misuse The Plan’s money, or if a participant is discriminated against for asserting his rights, he may seek assistance from the U.S. Department of Labor, or he may file suit in Federal court.
The court will decide who should pay court costs and legal fees. If the participant is successful, the court may order the person he has sued to pay these costs and fees. If the participant loses, the court may order him to pay these costs and fees, for example, if the court finds his Claim is frivolous.
E. ASSISTANCE WITH QUESTIONS
If the participant has any questions about The Plan, he should contact The Plan Administrator. If he has any questions about this statement or about his rights under ERISA, or if he needs assistance in obtaining documents from The Plan Administrator, he should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in his telephone directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C., 20210.
A participant may also obtain certain publications about his rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
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IMPORTANT INFORMATION
A. GENERAL INFORMATION
ABOUT THE PLAN
Type of Plan: The Plan is considered a welfare benefit plan under ERISA providing group health benefits.
Type of Plan Administration: The PPO Option(s) and the HMO Option(s) provide reimbursement for certain hospital, surgical, and medical expenses through fully insured contracts with SHL and HPN, respectively. SHL and HPN administer the payment of claims and the appeal of denied claims under the PPO Option(s) and the HMO Option(s), respectively. The Vision Option provides for certain vision expenses through a fully insured contract issued by Davis Vision. The Dental Option is self-funded and provides reimbursement for certain dental benefits.
Plan Name: Station Casinos LLC Employee Benefit Plan
Plan Number: 501
Employer Tax Identification Number:
27-3312261
End of Plan Year: December 31
Plan Sponsor: Station Casinos LLC
Plan Administrator/Agent for Service of Legal Process:
Station Casinos LLC
Address: 1505 S. Pavilion Center Drive Las Vegas, NV 89135
Telephone Number: (702) 495-3000
Fiduciary for Adverse Benefit Determinations:
Station Casinos LLC
CLAIMS ADMINISTRATOR/INSURANCE CARRIERS:
HMO(s) Health Plan of Nevada, Inc.P.O. Box 15645, Las Vegas, NV 89114-5645(702) 562-8013 or (877) 559-4511
PPO(s) Sierra Health and Life InsuranceP.O. Box 15645, Las Vegas, NV 89114-5645(702) 562-8013 or (877) 559-4511
Dental Boon-ChapmanP.O. Box 9201, Austin, TX 78766(800) 936-7670
Vision Davis VisionP.O. Box 1525, Latham, NY 12110(877) 923-2847
Third Party Administrator Custom Benefit Consultants (CBC)300 S. 4th St. Suite 704 Las Vegas, NV 89101Phone: (866) 254-8758
COBRA Control Source, Inc300 S. 4th St. Suite 704 Las Vegas, NV 89101Phone: (877) 652-7872 Fax: (877) 652-7872Email: [email protected]
Life Insurance and Short-Term Disability
Principal Financial Group7711 High Street Des Moines, IA 50392(800) 245-1522
PARTICIPATING EMPLOYERS
Team Members are eligible to participate in the Dental and Vision options and the applicable medical plans as listed.
Station Casinos LLC (HMO & PPO) 1505 S Pavilion Center Dr, Las Vegas NV 89135
(EIN 27-3312261)
NP Palace LLC (HMO & PPO)
(dba) Palace Station Hotel & Casino
2411 W Sahara Ave, Las Vegas NV 89102
(EIN 27-3312372)
NP Boulder LLC (HMO & PPO)
(dba) Boulder Station Hotel & Casino
4111 Boulder Hwy, Las Vegas NV 89121
(EIN 27-3312313)
NP Texas LLC (HMO & PPO)
(dba) Texas Station Gambling Hall & Hotel
2101 Texas Star Lane, North Las Vegas NV 89032
(EIN 27-3484110)
NP Sunset LLC (HMO & PPO)
(dba) Sunset Station Hotel & Casino
1301 W Sunset Rd, Henderson NV 89014
(EIN 27-3312450)
NP Lake Mead LLC (HMO & PPO)
(dba) Fiesta Henderson Casino & Hotel
777 W Lake Mead Pkwy, Henderson NV 89015
(EIN 27-3483890)
Station GVR Acquisition LLC (HMO & PPO)
(dba) Green Valley Ranch Resort Spa Casino
2300 Paseo Verde Pkwy, Henderson NV 89052
(EIN 27-4440679)
NP Santa Fe LLC (HMO & PPO)
(dba) Santa Fe Station Hotel & Casino
4949 N Rancho Dr, Las Vegas NV 89130
(EIN 27-3484083)
NP Fiesta LLC (HMO & PPO)
(dba) Fiesta Casino & Hotel
2400 N Rancho Dr, Las Vegas NV 89130
(EIN 27-3483838)
NP Durango LLC (HMO & PPO)
(dba) Durango Station Hotel & Casino
1505 S Pavilion Center Dr, Las Vegas NV 89135
(EIN 27-4348250)
NP Red Rock LLC (HMO & PPO)
(dba) Red Rock Casino Resort & Spa
11011 W Charleston Blvd, Las Vegas NV 89135
(EIN 27-3312418)
SC Sonoma Management
(dba) Sonoma Management
1505 S. Pavilion Center Drive, Las Vegas, NV 89135
(EIN 74-3090768)
Team Members at the following six properties are not eligible to participate in the Sierra Health & Life PPO Medical Plans, and may only participate in the Health Plan of Nevada HMO Plus Medical Plan.
NP Gold Rush LLC
(dba) Wildfire Sunset
1195 W Sunset Rd, Henderson NV 89014
(EIN 27-3483949)
NP Rancho LLC
(dba) Wildfire Casino
1901 N. Rancho Drive Las Vegas, NV 89106
(EIN 27-3483980)
NP Magic Star LLC
(dba) Wildfire Boulder
2000 S Boulder Hwy, Henderson NV 89015
(EIN 27-3484005)
SC SP 2 LLC
(dba) Wildfire Valley View
3045 S. Valley View Blvd, Las Vegas, NV 89102
(EIN 46-1109329)
SC SP 4 LLC
(dba) Wildfire Anthem
2551 Anthem Village Drive, Henderson, NV 89014
(EIN 46-1123185)
NP LML LLC
(dba) Wildfire Lake Mead
846 E. Lake Mead Parkway, Henderson, NV 89015
(EIN 27-3484201)
B. FUNDING THE PLAN AND PAYMENT OF BENEFITS
Team Members contribute to the cost of The Plan. The Employer contributes the difference between the cost of benefits coverage and the amount the Team Members contribute. From time to time, The
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Plan Sponsor will evaluate the costs of The Plan and determine the amount to be contributed by The Employer as well as the amount to be contributed by each Team Member, if any.
Team Member contributions are held in The Employer’s general assets. A current summary of these premium amounts may be obtained from The Employer at any time upon request. Additional cost-sharing provisions for which the Covered Person may be responsible include, but are not limited to, Deductibles, Co-pays, out-of-pocket expenses, penalties for non-compliance with The Plan’s pre-approval or certification requirements, and non-covered expenses. The premium amount to be paid by each Team Member may be increased during the Plan Year by The Employer.
C. CHANGES TO PLAN/TERMINATION OF PLAN
The Plan may be changed and/or benefits may be reduced or eliminated by The Plan Sponsor. The Plan Sponsor shall have the right to amend The Plan, at any time and from time to time, to any extent deemed advisable in its discretion, without prior notice to or consent of any Covered Person or of any person entitled to receive payment of benefits under The Plan. The Plan Sponsor can amend or replace the administrative services or other contracts and agreements through which benefit Claims are paid under The Plan. The Plan Sponsor’s decision to amend or replace any contract or to amend The Plan is not a Fiduciary decision, but is a business decision that can be made solely in The Plan Sponsor’s interest.
All changes to The Plan shall become effective as of a date established by The Plan Sponsor, and thereupon all Covered Persons, whether or not they became Covered Persons prior to such amendment, shall be bound thereby. However, no amendment shall be effective with respect to any covered expense Incurred prior to the date a change was adopted by The Plan Sponsor, regardless of the Effective Date of the change.
The Plan shall continue in full force and effect unless and until The Plan Sponsor terminates The Plan. Although The Plan Sponsor has the intention and expectation that The Plan will be maintained indefinitely, The Plan Sponsor is not and shall not be under any obligation or liability whatsoever to continue or maintain The Plan for any given length of time. The Plan Sponsor, in its sole and absolute discretion, may discontinue or terminate The Plan at any time by providing written notice to the covered Team Members. Such termination will become effective on the date set forth in such written notice.
The terms of The Plan cannot be modified by written or oral statements made by The Plan Administrator or other personnel. The Senior Vice President of Human Resources or any other person with properly delegated authority are authorized to amend, modify or terminate The Plan.
D. CIRCUMSTANCES RESULTING IN LOSS OR REDUCTION OF BENEFITS
There are circumstances, which may result in ineligibility or in denial, loss, suspension, offset, reduction or recovery of benefits that a Covered Person might reasonably expect The Plan to provide. These circumstances include, but are not limited to:
1. Subrogation, reimbursement and third party recovery rights of The Plan;
2. Coordination of Benefits when a Covered Person is enrolled in more than one plan and The Plan is not the Primary Plan;
3. possible reductions when private Hospital rooms are used and for certain Multiple Surgical Procedures;
4. reductions due to charges that exceed The Plan allowable;
5. reductions or denials due to services that are not generally accepted as appropriate, and/or which are not Medically Necessary, and/or which are considered as Over-Utilization;
6. treatment, services and supplies that are excluded from coverage by The Plan, whether or not Medically Necessary;
7. non-compliance with The Plan’s Prior Authorization requirements; or
8. non-compliance with The Plan’s Claims filing deadline.
These provisions are described in greater detail throughout this document and the applicable EOCs and COCs.
E. OBTAINING COVERAGE INFORMATION
A Covered Person may obtain information at no cost on whether, and under what circumstances, existing and/or new drugs, tests, devices, procedures and other services are covered, as well as obtain specific benefit information, by contacting the appropriate Claims Administrator.
F. CERTIFICATES OF CREDITABLE COVERAGE
The Plan Administrator shall issue Certificates of Creditable Coverage to a Covered Person whose coverage terminates, as well as to such individuals upon their written request within 24 months of the date of coverage termination, as required by Federal law.
G. WRITTEN NOTICE
Any written notice required under The Plan shall be deemed received by a covered Team Member if sent by regular mail, postage prepaid, to the last address of such covered Team Member on the records of The Employer.
H. CLERICAL ERROR/DELAY
Clerical error made on the records of The Employer and delays in making entries on such records shall not invalidate coverage or cause coverage to be in force or to continue in force. The Effective Dates of coverage shall be determined solely in accordance with the provisions of The Plan regardless of whether any contributions with respect to Covered Persons have been made or have failed to be made because of such errors or delays. Upon discovery of any such error or delay, an equitable adjustment of any such contributions will be made. Errors cannot provide a benefit to which a Covered Person is not otherwise entitled.
I. ACCEPTANCE/COOPERATION
Accepting benefits under The Plan means that the Covered Person has accepted its terms and is obligated to cooperate with The Plan Sponsor in doing what The Plan Sponsor may ask to help protect The Plan’s rights and carry out its provisions.
J. NOT A CONTRACT OF EMPLOYMENT
Nothing contained in The Plan shall be construed as:
a contract of employment between The Employer and any Team Member;
a right of any Team Member to be continued in the employment of The Employer;
43 44
consideration or inducement for employment with The Employer;
a condition of employment between The Employer and any Team Member; or
a limitation of the right of The Employer to discharge any Team Member, with or without cause, at any time.
All Team Members shall be subject to discharge to the same extent as if The Plan had never been adopted.
K. AUTHORITY OF PLAN ADMINISTRATOR
The Plan Administrator is responsible for the administration of this Plan. Should you need to see any records or have any questions regarding any Benefit Plan, contact the Plan Administrator. The Plan Administrator has final discretionary authority to interpret the Plan and make factual determinations as to whether any individual is eligible for coverage and entitled to receive any benefits under the Plan. CBC has been appointed to assist you in answering questions and providing information to you regarding your benefits and elections. The Plan Administrator may delegate any of the responsibilities to an insurance company or an administrator identified in the Benefit Plan Table.
The Plan Administrator will have the following rights, duties and powers to:
(1) Interpret the terms of any Benefit Plan, to determine the amount, manner and time for payment of any benefits, and to construe or remedy any ambiguities, inconsistencies or omissions, and correct any administrative errors or omissions;
(2) Adopt and apply any rules or procedures to insure the orderly and efficient administration of any Benefit Plan;
(3) Determine the rights of any participant, spouse, dependent or beneficiary to benefits under any Benefit Plan;
(4) Develop appellate and review procedures for any participant, spouse, dependent or beneficiary to benefits under any Benefit Plan;
(5) Provide the Plan Sponsor with such tax or other information it may require in connection with any Benefit Plan;
(6) Employ any agents, attorneys, accountants or other panics (who may also be employed by the Plan Sponsor) and to allocate or delegate to them such powers or duties as is necessary to assist in the proper and efficient administration of any Benefit Plan, provided that such allocation or delegation and the acceptance thereof is in writing; and,
(7) Report to the Plan Sponsor, or any party designated by the Plan Sponsor, after the end of each Plan year regarding the administration of the Plan, and to report any significant problems as to the administration of any Benefit Plan and to make recommendations for modifications as to procedures and benefits, or any other change which might insure the efficient administration of any Benefit Plan.
Subject to applicable State or Federal law, any interpretation of any provision of this Plan made in good faith by the Plan Administrator and any determination by the Plan Administrator as to any Participant’s rights or benefits under this Plan is final, shall be binding upon the parties and shall be upheld on review, unless it is shown that such interpretation or determination was an abuse of discretion (i.e., arbitrary and capricious).
The Plan Administrator (and its delegates) has full discretion to administer, construe and interpret The Plan in all respects, and to decide all matters arising under The Plan, including eligibility for participation and benefits. The determinations of The Plan Administrator (and its delegates) are final and binding on all parties, except as otherwise provided by law.
Failure to enforce a provision does not waive other provisions or the enforcement of that provision in other instances. Enforceability of any single provision shall not affect enforceability of other provisions.
L. FRAUD AND ABUSE
The Plan is subject to federal laws, which provide that criminal penalties may be imposed against those who receive or attempt to receive health care plan benefits by committing fraud or abuse against The Plan. State fraud and abuse laws may also apply.
Any person who commits a fraudulent act against The Plan may be subject to criminal prosecution, fine or imprisonment as provided by law, including but not limited to:
falsifying, withholding, omitting or concealing information to obtain or retain coverage;
misrepresenting eligibility criteria for Dependents (marital status, age, Full-Time Student status, Dependent Child or the right to Claim a Dependent for Federal income tax purposes) to obtain or continue coverage for a person who would not otherwise meet the Dependent eligibility criteria, as defined in The Plan, and qualify for coverage;
withholding, omitting, concealing, or failing to disclose any medical history or health status where required to calculate benefit payments or determine Pre-Existing Conditions for which there is no Creditable Coverage;
making or using any false writing or document in connection with obtaining coverage or payment for health benefits, including falsifying or altering (a) a Certificate of Creditable Coverage to reduce or eliminate Waiting Periods or Pre-Existing Conditions Limitations under The Plan, (b) a Claim or (c) medical records;
permitting a person who is not covered under The Plan to use a Plan identification card or other Plan identifying information to obtain Covered Services or payment under The Plan; or
making false or fraudulent representations in connection with delivery of or payment for health benefits, or being untruthful to obtain reimbursement under The Plan; or obtaining, or attempting to obtain, medical care or Covered Services under The Plan by false or fraudulent pretenses.
If a Team Member falsely certifies eligibility for Plan participation or does not inform the Plan Administrator of termination of eligibility, The Employer reserves the right to take disciplinary action, as appropriate, up to and including termination of benefits and employment, legal actions and request for reimbursement of inappropriate benefit payments as permitted by applicable law.
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DEFINITIONSNOTE: Throughout this document, any references to the terms “he,” “him,” or “his” shall also mean “she,” “her,” or “hers”.
Capitalized terms used in the SPD are defined in this section unless otherwise defined in the applicable certificate or evidence of coverage.
Accidental Injury: An unforeseen bodily Injury caused by unexpected external means, resulting, directly and independently of all other causes, in necessary care rendered by a Physician. Sprains and strains resulting from over-exertion, excessive use or over-stretching will not be considered Accidental Injury for purposes of benefit determination.
Actively at Work: A Team Member will be considered Actively at Work on a day that he is performing the normal duties of a regular job for The Employer on any of the following days:
a regular paid holiday or day of vacation;
a regular or scheduled non-working day; or
a day on which the Team Member is on an approved FMLA Leave, USERRA Leave or a personal leave of absence provided the Team Member was actively working on the last preceding regular workday.
A day on which the Team Member is absent from work due to any health factor.
Adverse Benefit Determination: Any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Covered Person’s or Beneficiary’s eligibility to participate in The Plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental or Investigational or not Medically Necessary or not appropriate.
Allowable Expense: Charges for services rendered or supplies furnished by a healthcare Provider that would qualify as covered expenses and for which The Plan will pay in whole or in part, subject to any Copay, Deductible, or Coinsurance. The allowable amount for services rendered by In-Network and Out-of-Network Providers is the In-Network Provider Fee Schedule.
Appeal of Adverse Benefit Determination: The Covered Person or the Provider has the right to request reconsideration following an Adverse Benefit Determination. A written appeal must be filed within 180 days after the receipt of the original Claim determination. Refer to the “CLAIM PROVISIONS” section.
Benefit Percentage: The portion of eligible expenses payable by The Plan in accordance with the coverage provisions as stated in The Plan.
Birthday Rule: Coordination of Benefits provision for dependent Children in which the plan of the parent with the earliest birth month and day is the Primary Plan for Claim payment purposes.
Calendar Year: January 1 through December 31 of the same year. For new Team Members and Dependents, a Calendar Year begins on the person’s Effective Date and runs through December 31 of the same year.
Calendar Year Maximum Benefit: The total amount of benefits payable by The Plan on behalf of a Covered Person during any Calendar Year (unless specified otherwise).
Change in Status: An event in which the Team Member receives Special Enrollment rights. Refer to the “ELIGIBILITY REQUIREMENTS” section.
Child or Children: A Team Member’s natural Children, legally adopted Children (including Children placed for adoption for whom legal proceedings have been started), stepchildren (the stepchild’s parent must be the Team Member’s legal Spouse), Alternative Recipients under Qualified Medical Child Support Orders (QMSCO), and any other Child for whom the eligible Team Member or his Spouse has obtained legal guardianship. Foster children are not considered eligible Children under the Plan.
Claim: A request made to The Plan for payment of healthcare services. A Pre-service Claim is a request for benefits prior to receipt of treatment or a Prior Authorization. A Post-service Claim is a request for benefits after the services have already been rendered.
Claims Administrator: The person or organization hired by The Plan Sponsor in connection with the operation of The Plan and performing functions such as processing and payment of Claims, and any other task as may be delegated to it. Refer to the “IMPORTANT INFORMATION” section.
COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. Refer to the “COBRA” section.
Coordination of Benefits: A group health plan provision designed to eliminate duplicate payments and provide the sequence in which coverage will apply (primary and secondary) when a person is covered by two group health plans.
Copay or Coinsurance: A dollar amount that must be paid by the Covered Person in order to receive a Covered Service, supply or treatment, such as for a Physician’s office visit with an In-Network Provider or a prescription. The Plan’s Copay amounts are specified in the “SCHEDULE OF DENTAL BENEFITS” and “SCHEDULE OF VISION BENEFITS” sections.
Cosmetic Procedures: Procedures performed solely to improve appearance.
Covered Person: Any Team Member or Dependent who is covered under The Plan.
Deductible: The amount of covered expenses which must be paid by a Covered Person each Calendar Year before benefits are payable under The Plan for certain services. A separate Deductible applies to a covered Team Member and each of the Team Member’s Dependents, subject to the Family Deductible Limit. Medical and dental services are subject to separate Deductibles.
Dentist: A currently licensed Dentist practicing within the scope of the license or any other Physician furnishing dental services which the Physician is licensed to perform.
Dependent: Refer to the “ELIGIBILITY REQUIREMENTS” section.
Effective Date: The first day of the person’s coverage. The person’s Effective Date may or may not be the same as the person’s Enrollment Date. Refer to the “Enrollment Date” definition.
Employer: Station Casinos LLC and the employers participating in The Plan as stated in the “IMPORTANT INFORMATION” section.
Enrollment: The process by which a Team Member and Dependents become Covered Persons of The Plan. Coverage does not become effective until the eligible Team Member completes an enrollment form and submits appropriate supporting documentation.
ERISA: “ERISA” means Employee Retirement Income Security Act of 1974, as amended, including regulations implementing the Act.
Exclusion: An item or service, which is not a Covered Expense under The Plan. Refer to the “EXCLUSIONS” section.
Experimental or Investigational: A treatment, procedure, device, drug or medicine where one or more of the following is true:
it cannot be lawfully marketed without U.S. Food and Drug Administration approval, and
47 48
approval for marketing for the condition treated has not been given at the time the device, drug or medicine is furnished; or
reliable evidence shows that to determine its maximum tolerated dose, toxicity, safety, and/or efficacy (or efficacy as compared with the standard means of treatment or diagnosis): (1) it is undergoing phase I, II, or III clinical trials or is under study; or (2) further clinical trials or studies are needed, according to expert consensus of opinion. Reliable evidence means only published reports and articles in the authoritative medical and scientific literature; or the written protocol or written informed consent used by the treating facility (or by another facility studying substantially the same treatment, procedure, device, drug or medicine).
Explanation of Benefits (EOB): A statement issued by the Claims Administrator after services have been rendered explaining how benefits were paid by The Plan and showing the Covered Person’s financial responsibility.
Family Deductible Limit: Applies collectively to all Covered Persons in the same family. When the Family Deductible Limit is satisfied, no further Deductibles need to be satisfied in the Calendar Year.
Fee Schedule: Amounts that In-Network Providers or participating pharmacies have contracted to accept as payment in full for covered expenses of The Plan. See also the “Allowable Expense” definition.
Fiduciary: The person or organization that has the authority to control and manage the operation and administration of The Plan. The Fiduciary has discretionary authority to determine the eligibility for benefits or to construe the terms of The Plan. The named Fiduciary for The Plan is The Employer.
FMLA: The Family and Medical Leave Act of 1993.
FMLA Leave: A leave of absence taken by a Team Member in accordance with the Family and Medical Leave Act of 1993.
Health Status-Related Factors: Includes these 8 categories: health status, medical condition (both physical and mental), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability.
HIPAA: The Health Insurance Portability and Accountability Act of 1996, as amended. Refer to the “HIPAA” section.
Illness: A bodily disorder, disease, physical or mental impairment, functional nervous disorder, pregnancy or complication of pregnancy. The term Illness when used in connection with a newborn Child includes, but is not limited to, congenital defects and birth abnormalities, including premature birth.
Immediate Family: A person who is related to a Covered Person, whether the relationship is by blood or exists in law, limited to a Spouse, parent, grandparent, Child, brother or sister.
In-Network Provider: Health care Providers, medical groups, plan hospitals or other Plan Providers who are under a contract with the Network(s) affiliated with The Plan. In-Network Providers are required to comply with all terms and conditions of the Provider’s contract.
Incurred: The date a treatment, service or supply is provided to a Covered Person.
Initial Enrollment: The period of time when a Team Member is first eligible to participate in The Plan. Refer to the “ELIGIBILITY REQUIREMENTS” section.
Injury: Physical damage to the body, which is not caused by disease or bodily infirmity.
Joint Venture: An entity designated by the Plan Sponsor including Town Center Amusements, Inc., a Limited Liability Company (dba Barley’s Casino & Brewing Company), Greens Café, LLC (dba The Greens Café), Sunset GV, LLC (dba Wildfire Casino & Lanes), and any other entities so designated by The Plan Sponsor.
Med-Pay: A payment made by an insurer intended specifically to pay for medical expenses without regard to the fault of any party to the accident. Med-Pay is a form of automobile no-fault/personal Injury protection insurance and is covered by the “No-Fault Insurance” definition.
Medically Necessary: The expense Incurred upon the recommendation and approval of a Physician for the medical services and supplies generally furnished for cases of comparable nature and severity in the particular geographical area concerned. Any agreement as to fees or charges made between the patient and the Physician shall not bind The Plan in determining its liability with respect to necessary expenses. These Incurred expenses must be:
consistent with the symptoms of diagnosis and treatment of the condition, Illness, or Injury;
appropriate with regard to standards of good medical practice;
not primarily for the convenience of the patient, the Physician or other Provider;
the most appropriate level of services which can safely be provided to the patient; and
when applied to Inpatient services, it means that the patient’s medical symptoms or conditions require that the services or supplies cannot be safely provided to the patient as an Outpatient.
The fact that a Physician might prescribe, order, recommend, or approve a service or supply does not, in itself, make it Medically Necessary or make the charge an Allowable Expense under The Plan, even though it is not specifically listed as an Exclusion. The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary.
Medicare: The program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.
Negotiated Fees: Refer to the “Fee Schedule” definition.
Network: A group of providers who offer healthcare services according to a contract agreement.
No-Fault Insurance: Insurance that pays for medical expenses for injuries sustained on the property or premises of the insured, or in the use, occupancy, or operation of an automobile, regardless of who may have been responsible for causing the accident. Examples of No-Fault Insurance include automobile No-Fault Insurance, often referred to as personal Injury protection, homeowner’s insurance and Med-Pay coverage. Refer also to the “Med-Pay” definition.
Open Enrollment: The period of time in which all benefits eligible Team Members may make changes to their coverage by adding, deleting or changing coverage for themselves or their Dependents. Refer also to “Special Enrollment” and “Late Enrollment” definitions.
Orthognathic: Deformities of the jaw and associated with malocclusion.
Out-of-Network Provider: Health care Providers, medical groups, Plan hospitals or other Plan Providers who are not under a contract with the Network or Networks affiliated with The Plan. Out-of-Network Providers are not obligated to follow the same terms and conditions as the In-Network Providers.
Over-Utilization: Refers to any of the following:
the practice of applying more than what is necessary to evaluate and treat the problem at hand; or
a redundancy in treatment options; or
that which most practitioners in the discipline would consider to be in excess of sufficient measures.
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Personal Injury Protection (PIP): Refer to the “No Fault Insurance” definition.
Plan Administrator: The Plan Sponsor
Plan Sponsor: Station Casinos LLC
PPO (Preferred Provider Organization) Plan: A healthcare plan that utilizes a network of Physicians, Hospitals or other healthcare Providers who have contracted to provide health care services at specified rates and to follow the terms and provisions of the Provider contract.
Pre-Determination: A review prior to services to determine eligibility by The Plan.
Primary Plan: In Coordination of Benefits, The Plan that provides benefits or benefit payments without considering any other plan is the Primary Plan. Refer to the “COORDINATION OF BENEFITS” section.
Provider: A Hospital, Physician, Dentist or any other practitioner who is licensed to provide healthcare services.
QMCSO: A Qualified Medical Child Support Order in accordance with applicable law. Refer to the “ELIGIBILITY REQUIREMENTS” section.
Qualified Beneficiary: A Team Member, former Team Member or Dependent of a Team Member or former Team Member who is eligible for continuation of benefits (COBRA) covered under The Plan. Refer to the “CONTINUATION OF BENEFITS (COBRA)” section.
Qualifying Event: Refer to the “COBRA” section.
Secondary Plan: In Coordination of Benefits, the Secondary Plan may reduce its benefits or benefit payments by the amount paid by the Primary Plan. Refer to the “COORDINATION OF BENEFITS” section.
Special Enrollment: The opportunity for the Team Member to add, delete or change coverage for himself and/or Dependents outside The Plan’s Open Enrollment period when a Change in Status occurs, or an Enrollment period at the discretion of The Plan Sponsor. Refer to the “ELIGIBILITY REQUIREMENTS” section.
Specialist: A Physician who practices in a particular specialty of medicine, based on license and qualifications.
Spouse: The person who is recognized as the Team Member’s husband or wife under the laws of the state where the Team Member lives. Documentation proving a legal marital relationship will be required. Common law marriages and common law Spouses are not eligible under The Plan.
Subrogation: The provision in which The Plan has the right to take direct legal action against a responsible third party and, therefore, The Plan could force the Covered Person to pursue legal remedies, although he or she may not have intended to do so.
Team Member: A person who is directly employed by The Employer. Refer to the “ELIGIBILITY REQUIREMENTS” section.
The Plan: Whenever used herein without qualification, means the Station Casinos LLC. Employee Benefit Plan as described in this Summary Plan Description.
Treatment Plan (Dental): A program of dental care and treatment planned in written outline by a Dentist upon examination of a Covered Person.
USERRA: The Uniformed Services Employment and Reemployment Rights Act of 1994, as amended.
USERRA Leave: A leave of absence taken by a Team Member for a call to military duty that is protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended. Refer to the “ELIGIBILITY” section
