Station Casinos LLC Team Member Benefit Plan

Station Casinos LLC
Team Member Benefit Plan
Medical, Dental, Vision and Other Benefits
SUMMARY PLAN DESCRIPTION
STATION CASINOS LLC EMPLOYEE BENEFIT PLAN Medical, Dental, Vision and Other Benefits Summary Plan Description January 1, 2013 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.
TABLE OF CONTENTS Introduction ................................................................................................................................................................1 Eligibility Requirements .............................................................................................................................................1 Health Benefits Generally ...................................................................................................................................... 11 Dental Benefits ....................................................................................................................................................... 14 Other Benefits ......................................................................................................................................................... 23 Cafeteria Plan ......................................................................................................................................................... 24 Continuation of Benefits (COBRA) ......................................................................................................................... 25 HIPAA Privacy Rule .................................................................................................................................................. 27 ERISA Rights............................................................................................................................................................ 31 Important Information ............................................................................................................................................ 33 Definitions ............................................................................................................................................................... 39 Index ........................................................................................................................................................................ 46 i
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INTRODUCTION
This 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 Docum ents
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, ENROLLM ENT 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
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1. Full-time Team Members working an average of 32 hours per week (including any hours attributed to a
management initiated “early out” for any scheduled shifts or a Company approved Leave of Absence) are
eligible to participate in The Plan on the 1st day of the month coinciding with or following 180 calendar
days of regular full-time employment.
2. 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 180 calendar days in active
continuous employment in temporary, part-time, on-call, or full-time capacity, are eligible to participate in
The Plan on the 1st day of the month coinciding with or following the effective date of the change in job
status.
3. Full-time regular front of the house Team Members, who work in a specialty restaurant (as defined by the
Plan Administrator) an average of 25 hours per week (including any hours attributed to a management
initiated “early out” for any scheduled shifts or a Company approved Leave of Absence) are eligible to
participate in The Plan on the 1st day of the month coinciding with or following 180 calendar days of
active continuous employment.
4. 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.
Part Tim e, On Call and Tem porary Team M em bers
Part-time, on-call and temporary Team Members are not eligible to participate in the Plan.
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 180-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.
M iscellaneous Provisions
Notwithstanding the provisions of eligibility as stated above, or any other provision of the Plan to the
contrary, The Plan Administrator may at any time, in its sole and absolute discretion, designate as eligible to
participate a Team Member not otherwise eligible under the terms of the Plan. Similarly, the Plan
Administrator may at any time elect to terminate such a Team Member’s eligibility, in its sole and absolute
discretion, giving the Team Member prior written notice of the termination of eligibility and the Effective Date
of such termination, subject to applicable law.
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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. 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 Spouse (as defined by the Plan) unless divorced
or legally separated and all Children (as defined by the Plan) under 26 years of age.
Dependent Docum entation
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.
M ental or Physical Im pairm ents
An unmarried 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.
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ualifying change in status
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ependent eligibility within
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OBRA will not bewill not offered
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Dependent Coverage
A person who is covered as an eligible Team Member shall not also be
considered an eligible Dependent under any of the Plan or a benefit plan of
a Joint Venture. If both parents of a Dependent Child are employed by The
Employer or a Joint Venture, 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.
Rem oval 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). 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.
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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.
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 and coverage
will be rescinded, and the Team Member will be required to reimburse
Claims that were paid on behalf of the ineligible Dependent.
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the Team MMember
ember to to remove
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remove Dependents from from
the
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meet the meet
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within
within 31 days of the 60 daysevent. of the event.
Ineligible Dependents
An eligible Spouse or 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.
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.
C. EFFECTIVE DATE OF COVERAGE
Team M em ber
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.
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Rehired or Reinstated Team M em bers
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-inforce, is rehired within 90 days, 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 following the termination date, he will be considered the same as a new Team Member and must
meet the eligibility requirements listed in Section A.
3. If a previously covered Team Member, whose employment status changes from full-time to temporary,
part-time, or on-call due to an Employer initiated reduction-in-force and is reinstated to full-time status
within 90 days, he will be eligible on the first day of the Change in Status.
4. If a previously covered Team Member, whose employment status changes from full-time to temporary,
part-time, or on-call due to an Employer initiated reduction-in-force and is reinstated to full-time status
after 90 days, he will be eligible on the first day of the month following the Change in Status.
Transferred Team M em bers
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, Pre-Existing Condition Exclusion
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.
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Open Enrollm ent
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. loss of eligibility for other health coverage (including exhaustion of COBRA coverage),
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.
4. a strike or lockout, an FMLA Leave (as required by FMLA), or absence on account of being in uniformed
service (as defined under USERRA);
5. a Dependent satisfying or ceasing to satisfy the Dependent eligibility requirements;
6. a transfer between a large property and the Wildfire Gaming divisions;
7. a change in place of residence or work of a Team Member and/or Dependent that affects eligibility
status;
8. 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 “ENROLLM ENT REQUIREMENTS FOR NEW BORN OR ADOPTED CHILDREN”
below.
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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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 “ENROLLM ENT REQUIREMENTS FOR TEAM MEM BERS 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 “ENROLLM ENT REQUIREMENTS FOR
TEAM M EM BERS 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.
G. ENROLLMENT RELATED TO A LOSS OF OTHER HEALTH COVERAGE
If a Team Member 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
Fam ily and M edical 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.
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Uniform ed Services Em ploym ent and Re-em ploym ent 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 Companyapproved 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.
J. TERMINATION OF COVERAGE
Term ination with Respect to Team M em bers
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 nonpayment of premiums when due from the Team Member. Coverage may be continued under COBRA. Refer to
the “CONTINUATION OF BEN EFITS (COBRA)” section for coverage continuation options.
Term ination 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;
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 BEN EFITS (COBRA)” section for coverage continuation options.
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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.
QM CSO Enrollm ent
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
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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,
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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 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 nonpayment of premiums when due from the Team Member.
HEALTH BENEFITS GENERALLY
A. HEALTH PLANS OFFERED
PLAN
DESCRIPTION
§
HMO Option(s)
§
§
§
PPO Option(s)
Dental
Vision
§
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)).
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.
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)).
§
The benefits provided under the Dental option are self-funded and are fully
described in this SPD.
§
§
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).
The HMO, PPO, Dental and Vision options were designed to give you the most benefits for the least Out-ofPocket costs by using a Network of Providers and services. You should be selective in your use of healthcare
services and choice of providers.
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Claim Filing, Denials and Appeals
•
HMO and PPO Options (Medical Plans) and Vision Option
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, your 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.
Page 12 of 48
12
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.
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.
M edical 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.
Page 13 of 48
13
B. PROVIDER NETWORK/DIRECTORIES
PLAN
NETW ORK NAM E
HOW TO OBTAIN A DIRECTORY
HMO
Health Plan of Nevada
Available in your property’s HR office or by visiting
www.healthplanofnevada.com.
PPO
Sierra Health & Life
Available in your property’s HR office or by visiting
www.sierrahealthandlife.com.
Dental
Sierra Health-Care Options
Available in your property’s HR office or 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 “IM PORTANT
INFORMATION” section.
Page 14 of 48
14
SCHEDULE OF DENTAL BENEFITS
A 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 BENEFIT
Orthodontia 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.
Page 15 of 48
15
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 SERVICES
TYPE 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
limited to 2 applications per Calendar Year
to age 18
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
Page 16 of 48
16
BASIC AND RESTORATIVE SERVICES
AND RESTORATIVE
SERVICES
Office Visits - office visits and BASIC
consultations,
office visits during
regular office hours for treatment and
observation of injuries to teeth and supporting structure
Office
Visits - visits
officeafter
visitshours
and BASIC
consultations,
office visitsby
during
regular
office hours
for treatment
AND consultation
RESTORATIVE
Professional
and special
aSERVICES
dental
specialist
upon referral
by theand
observation
of
injuries
to
teeth
and
supporting
structure
Covered
Person’s
Office
Visits
- visits
officeattending
visitshours
andDentist
consultations,
office visitsby
during
regular
office hours
for treatment
Professional
after
and
special
consultation
a dental
specialist
upon referral
by theand
Emergency
or
palliative
visits
for
relief
of pain
observation
of
injuries
to
teeth
and
supporting
structure
Covered Person’s
attending
Dentist
Endodontics
canal
therapy)
Professionalor(including
visits
afterroot
hours
and
special
consultation by a dental specialist upon referral by the
Emergency
palliative
visits
for
relief
of pain
Oral
surgery
Covered
Person’s
attending
Dentist
Endodontics
(including root canal therapy)
Extractions
Emergency
or palliative visits for relief of pain
Oral
surgery
Biopsy
and examination
of oral
tissue
Endodontics
(including root
canal
therapy)
Extractions
Study
models
Oral
surgery
Biopsyanesthetics
and examination
of oral tissue
Local
and antibiotic
drugs injected by the attending Dentist
Extractions
Study
models
Anesthesia
in
conjunction
with
surgical
procedures
Biopsyanesthetics
and examination
of oral tissue
Local
and
antibiotic
drugs
injected
by the attending Dentist
Fillings
amalgam,
silicate,
acrylic
or
plastic
fillings
Study models
Anesthesia
in
conjunction
with
surgical
procedures
Stainless
steel crowns
(primary teeth)
Local
anesthetics
and
antibiotic
drugs
injected
by the attending Dentist
Fillings
amalgam,
silicate,
acrylic
oror
plastic
fillings
Repair of crowns,
inlays, bridgework
dentures
Anesthesia
in
conjunction
with
surgical
procedures
Stainless
steelfilling
crowns
(primary teeth)
Pins to -retain
restorations
Fillings
amalgam,
silicate,
acrylic oror
plastic
fillings
Repair
of
crowns,
inlays,
bridgework
dentures
Space maintainers
up to
age 16teeth)
Stainless
steel
crowns
(primary
Pins
to retain
filling restorations
Subgingival
curettage,
alveolar
and gingival
reconstruction, periodontal scaling and root planing,
Repair
of crowns,
inlays,
bridgework
or dentures
Space
maintainers
up to
age 16or other
gingivectomy,
osseous
surgery,
treatment
of periodontal abscess and periodontitis (refer to
Pins
to retain
filling restorations
Subgingival
curettage,
alveolar
and gingival
reconstruction,
periodontal
scaling and root planing,
“Preventive
and
Diagnostic
Services”
for
periodontal
benefits)
Space maintainers
up to
age 16or other treatment of prophylaxis
gingivectomy,
osseous
surgery,
periodontal abscess and periodontitis (refer to
Subgingival curettage,
alveolar
and gingival
reconstruction,
periodontal
scaling and root planing,
“Preventive
and Diagnostic
Services”
for periodontal
prophylaxis
benefits)
gingivectomy, osseous surgery, or other treatment of periodontal abscess and periodontitis (refer to
“Preventive and Diagnostic Services” for periodontal prophylaxis benefits)
MAJOR SERVICES
•
•
•
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
Inlays,
dowel
pins;
MAJOR
SERVICES
period);onlays, gold fillings, crowns and gold
Recementing
of
crowns,
inlays,
or
bridgework
,
or
relining
dentures
(limited
to 1 reline
any 6 - month
Initial installation
offillings,
partial or
full removable
dentures
or of
fixed
bridgework
(including
the in
accompanying
Inlays,
onlays, gold
crowns
and gold dowel
pins;
period);
inlays and crowns
to forminlays,
abutments)
to replace
one or more
natural(limited
teeth which
were extracted
while
Recementing
of crowns,
orremovable
bridgework
,dentures
or relining
dentures
to 1 reline
any 6 - month
Initial
installation
ofplan;
partial
or full
or of
fixed
bridgework (including
the in
accompanying
covered
under
this
and
period);
inlays
and crowns
to form
abutments)
to replace
one or more
natural
teeth
which werethe
extracted
Replacement
of existing
partial
or full
removable
dentures,
or fixed
bridgework,
additionwhile
of
Initial
installation
ofplan;
partial
or full
removable
dentures
or crowns,
fixed bridgework
(including or
the accompanying
covered
under
this
and
teeth
to
an
existing
partial
removable
denture
or
to
bridgework
to
replace
extracted
natural
teeth,
but
only
if:
inlays
and crowns
to form
abutments)
to replace
one or more
natural
teeth
which were
extracted
while
Replacement
of existing
partial
or fullorremovable
dentures,
crowns,
orleast
fixed
bridgework,
ortothe
addition
of
1.
the
existing
denture,
crown
bridgework
was
installed
at
5
years
prior
its
replacement
covered
under
this partial
plan; and
teeth to and
an
existing
removable
denture
bridgework to replace extracted natural teeth, but only if:
cannot
be made
serviceable;
or or to
Replacement
of
existing
partialcrown
or fullorremovable
dentures,
crowns,atorleast
fixed5bridgework,
or the
of
1.
the
existing
denture,
bridgework
was installed
years prior
its addition
replacement
the
existingpartial
denture
is an immediate
temporary
denture,
and replacement
by to
a teeth,
permanent
teeth2.to and
an existing
removable
denture
or
to
bridgework
to
replace
extracted
natural
but
only
if:
cannot
be madeand
serviceable;
or within 12 months from the date ofinstallation of the
denture
is required
takes
place
1.
the
existing
denture,
crown
or
bridgework
was
installed
at
least
5
years
prior
to
its
replacement
2. the
existingtemporary
denture isdenture.
an immediate temporary denture, and replacement by a permanent
immediate
and
cannot
be madeand
serviceable;
or within 12 months from the date ofinstallation of the
denture
is required
takes place
Note2.that
stainless
steel
crowns
for
adults are
considered
temporary.
A temporaryby
stainless
steel crown that is not
the
existing
denture
is
an
immediate
temporary
denture,
and replacement
a permanent
immediate temporary denture.
replaceddenture
with a permanent
crown
within
12
months
is
considered
permanent
and
subject
to
the
5
year
replacement
is required and takes place within 12 months from the date ofinstallation of the
Note
that
steel
crownssteel
for adults are considered temporary. A temporary stainless steel crown that is not
clause.
If astainless
temporary
stainless
immediate
temporary
denture.crown is replaced within 12 months, the benefit previously considered for the
replaced
with
a
permanent
crown
within
12the
months
is considered
andon
subject
to the 5 year
replacement
stainless
steel crown
is reduced
from
benefits
currentlypermanent
considered
the permanent
crown.
Note
that
steel
crownssteel
for adults
considered
temporary.
A temporary
stainless
steelconsidered
crown thatfor
is not
clause.
If astainless
temporary
stainless
crownare
is replaced
within
12 months,
the benefit
previously
the
replaced
with
a
permanent
crown
within
12
months
is
considered
permanent
and
subject
to
the
5
year
replacement
stainless steel crown is reduced from the benefits currently considered on the permanent crown.
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; ORTHODONTIC TREATMENT
Initial (and subsequent, if any) installation of orthodontic appliances and adjustment of orthodontic
ORTHODONTIC TREATMENT
appliances;
Comprehensive full-banded treatment; and
Page 17 oforthodontic
48
All other orthodontic treatment required by accepted
practice, including tooth extraction and
dental x-rays.
Page 17 of 48
Page 17 of 48
17 B. DENTAL LIMITATIONS AND EXCLUSIONS
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
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. items intended for sport or home use, such as athletic mouth guards or habit-breaking appliances;
15. 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;
16. for which the patient or Covered Person has no legal obligation to pay;
17. rendered by a member of the Covered Person’s Immediate Family or anyone who customarily lives in
the Covered Person’s household;
18. which exceed The Plan allowable for In-Network and Out-of-Network Providers;
19. 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;
Page 18 of 48
18
20. 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;
21. 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;
22. resulting from or sustained as a result of participation in a riot or insurrection;
23. 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;
24. 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;
25. which are considered as Over-Utilization, as determined by the Claims Administrator;
26. 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;
27. for preparing medical reports or itemized bills;
28. for broken or missed appointments;
29. for services, supplies, or accommodations provided in connection with holistic or homeopathic
treatment, including drugs;
30. 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;
31. for treatment or services rendered outside the United States or its territories except for an Accidental
Injury or a Medical Emergency;
32. 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;
33. 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 predetermination 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.
Page 19 of 48
19
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.
Dental Claim Filing
Original bills for expenses Incurred (whether In-Network or Out-of-Network) m ust
be submitted to the Dental Claims Administrator within 6 m onths 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.
The Plan will pay
the amount it would
The ill pay the havePlan paidwhad
it been
amount it would only
have the person’s
paid h
ad i
t b
een the coverage, less any
person’s o
nly amounts paid by all
coverage, any Primaryless Plans.
amounts paid by all Primary Plans. 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.
Page 20 of 48
20
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 Determ ination
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).
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; and 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.
d. 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.
e. 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:
Page 21 of 48
21
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.
f. 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.
g. 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 Inform ation
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.
Dental Right of Reim bursem ent
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.
PAYM ENT 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
Page 22 of 48
22
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 OVERPAYM ENTS
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 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.
Page 23 of 48
23
CAFETERIA PLAN
Each Team Members 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.
b.
c.
d.
The date that you make an election not to participate in the Plan;
The date you no longer satisfy the Eligibility Requirements of the Plan;
The date that you terminate employment; or
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 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 your paycheck each month that you are enrolled. The deduction is made before any
applicable federal and/or state taxes are withheld.
Page 24 of 48
24
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)
A. WHO IS ELIGIBLE FOR COBRA CONTINUATION COVERAGE
1. Team Members who lose health coverage because of termination of employment (other than for gross
misconduct) or reduction of hours may continue coverage for 18 months or 29 months if disabled (as
discussed below).
2. Team Member’s Dependent Child, Spouse or former Spouse, may continue health coverage for:
a. up to 18 months if health coverage is lost because the Team Member’s employment ends (other
than for gross misconduct) or the Team Member’s hours are reduced;
b. up to 36 months, if health coverage is lost because of the Team Member’s death, divorce, legal
separation, entitlement to Medicare; or
c. up to 36 months, if the Team Member’s Dependent Child loses health coverage because he no
longer meets the Eligibility Requirements of a Dependent.
3. A Team Member or his Dependent Child, Spouse or former Spouse (the “Qualified Beneficiary”) may be
entitled to 29 months of COBRA coverage instead of 18 months if the Qualified Beneficiary is disabled
during the first 60 days of the 18-month COBRA period.
The Team Member or Qualified Beneficiary must notify The Plan Administrator before the end of the 18month COBRA period. Non-disabled family members are also entitled to this extension. A higher premium
may be charged for the additional months.
Page 25 of 48
25
COBRA periods are measured from the date of the event which causes a loss of health coverage
(termination
employment,
COBRA
periodsofare
measured divorce,
from thedeath,
date ofetc).
the event which causes a loss of health coverage
Special Rule for Multiple Qualifying Events If the Qualified Beneficiary is receiving 18 months of COBRA coverage because of the Team Member’s termination OR reduction in hours, and health coverage is lost again because of the Team Member’s death, divorce, legal separation, Medicare entitlement, or loss of Dependent Child status, the maximum COBRA period may increase from 18 to 36 months, measured from the Team Member’s termination or reduction in hours. (termination of employment, divorce, death, etc).
B. CAN COBRA CONTINUATION COVERAGE END EARLY?
B.
CANcoverage
COBRAcan
CONTINUATION
COVERAGE
END EARLY?
COBRA
end early for several
reasons, including:
§ coverage
the required
COBRA
premium
is not
paid onincluding:
time;
COBRA
can end
early
for several
reasons,
§ the Covered Person becomes covered under another group health plan that does not contain any
§ the
requiredorCOBRA
premium
is not paid
on time;
Exclusion
limitation
which applies
to any
Pre-Existing Condition;
§§ the
Covered
Person
becomes
covered
under
another group health plan that does not contain any
the Covered Person becomes entitled to Medicare;
or limitation
which
applies
to any
Pre-Existing
§ Exclusion
the Employer
no longer
provides
group
health
coverageCondition;
to any of its Team Members; or
§§ the
Covered
Person
becomes
entitled
to Medicare;
if the
Covered
Person
is receiving
extended
coverage due to a disability and the individual is no
§ the
Employer
no longer provides group health coverage to any of its Team Members; or
longer
disabled.
§ if the Covered Person is receiving extended coverage due to a disability and the individual is no
longer disabled.
C. NOTICE OF COBRA CONTINUATION COVERAGE
C.TheNOTICE
OF COBRA
CONTINUATION
COVERAGE
Covered Person
or a family
member must inform
the COBRA administrator within 60 days of a divorce,
legal separation, or Child losing Dependent status. If such notice is not provided timely, COBRA continuation
The
Covered
a family or
member
the COBRA administrator within 60 days of a divorce,
coverage
willPerson
not beoravailable
offeredmust
to theinform
Dependent.
legal separation, or Child losing Dependent status. If such notice is not provided timely, COBRA continuation
The Employer
must
inform the
within 30 days of a death, termination of employment,
coverage
will not
be available
orCOBRA
offeredadministrator
to the Dependent.
reduction in hours, or Medicare entitlement. The COBRA administrator must then send notification of COBRA
The
Employer
must
inform the COBRA administrator within 30 days of a death, termination of employment,
rights
within 14
days.
reduction in hours, or Medicare entitlement. The COBRA administrator must then send notification of COBRA
rights within 14 days.
D. ELECTING AND PAYING FOR COBRA CONTINUATION COVERAGE
D.
ELECTING
COVERAGE
COBRA
coverageAND
must PAYING
be electedFOR
withinCOBRA
60 daysCONTINUATION
after the date of notification
of COBRA rights (or, if later,
the date health coverage would otherwise end). The first monthly payment is due within 45 days after
COBRA
be elected
within
60 days
aftercover
the date
of notification
COBRA
rights
(or, if later,
COBRAcoverage
coveragemust
is elected.
The first
payment
must
the months
from theofdate
health
coverage
would
the
date health
coverage
end). Subsequent
The first monthly
payment
is dueare
within
days
after
otherwise
end to
the timewould
of theotherwise
first payment.
monthly
payments
due 45
by the
first
day of
COBRA coverage is elected. The first payment must cover the months from the date health coverage would
otherwise end to the time of the first payment. Subsequent monthly payments are due by the first day of
Page 26 of 48
Page 26 of 48
26
each month. If the COBRA administrator receives COBRA premiums more than 30 days late, coverage will
end.
E. CERTIFICATE OF CREDITABLE COVERAGE
If health coverage is lost, the COBRA administrator or insurer automatically issues a Certificate of Creditable
Coverage showing the dates of coverage under The Plan. The Covered Person also may request a certificate,
either before loss of group health coverage or within 24 months of losing coverage.
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,
Page 27 of 48
27
vii.
business management and general administrative activities of The Plan, including, but not
limited to:
§ 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
Page 28 of 48
28
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).
Page 29 of 48
29
E. PLAN SPONSOR COMPLIANCE WITH SECURITY CONDITIONS
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.
Page 30 of 48
30
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. PRE-EXISTING CONDITIONS
A participant shall also be entitled to reduction or elimination of exclusionary periods of coverage for PreExisting Conditions under the group health plan if he has Creditable Coverage from another plan. The
participant should be provided a certificate of Creditable Coverage, free of charge, from his group health
plan or health insurance issuer when his coverage is lost, if he becomes entitled to elect COBRA
continuation coverage, or when his COBRA continuation coverage ceases, provided that he requests the
certificate before losing coverage or up to 24 months after losing coverage. Without evidence of Creditable
Coverage, a participant and/or his beneficiaries may be subject to a Pre-Existing Condition Exclusion for 12
months (up to 18 months for late enrollees) after the participant’s or beneficiary’s Enrollment Date for
coverage.
Page 31 of 48
31
D. 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.
E. 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.
F. 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.
Page 32 of 48
32
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.
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 selffunded 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 Insurance
P.O. Box 15645, Las Vegas, NV 89114-5645
(702) 562-8013 or (877) 559-4511
Dental
Boon-Chapman
P.O. Box 9201, Austin, TX 78766
(800) 936-7670
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Vision
Davis Vision
P.O. Box 1525, Latham, NY 12110
(877) 923-2847
COBRA
Control Source, Inc.
7660 W. Cheyenne Ave Ste 109, Las Vegas, NV 89129
(877) 652-7872
Principal Financial Group
7711 High Street
Des Moines, IA 50392
(800) 245-1522
Life Insurance and Short-Term Disability
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
(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)
Team Members at the following 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) Gold Rush Casino
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)
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34
NP Tropicana LLC
(dba) Days Inn Las Vegas at Wild Wild West
3330 W Tropicana Ave, Las Vegas NV 89103
(EIN 27-3312489)
NP Magic Star LLC
(dba) Wildfire Casino – Boulder
2000 S Boulder Hwy, Henderson NV 89015
(EIN 27-3484005)
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 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, Copays, 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.
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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. WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998
The Plan Administrator shall provide each eligible Team Member applicable notice describing The Plan’s
benefits for a person who has a mastectomy with respect to: reconstruction of the breast on which the
mastectomy was performed; surgery and reconstruction of the other breast to produce a symmetrical
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36
appearance; and prosthesis and physical complications in all stages of mastectomy, including
lymphedemas; in a manner determined in consultation with the attending Physician and the Covered Person.
H. 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.
I. 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.
J. 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.
K. 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;
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.
L. AUTHORITY OF PLAN ADMINISTRATOR
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
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37
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.
M. 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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DEFINITIONS
NOTE: 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 W ork: 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 Determ ination: 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 Determ ination: 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.
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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.
Creditable Coverage: Prior continuous health coverage, which includes prior coverage under:
§
§
§
§
§
another group health plan;
group or individual health insurance coverage issued by a state regulated insurer or an HMO;
COBRA;
Medicaid;
Medicare;
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§
§
§
§
§
§
§
§
CHIP (Children’s Health Insurance Program);
the Active Military Health Program;
Tricare/CHAMPUS;
American Indian Health Care Programs;
a State health benefits risk pool;
the Federal Employees Health Plan;
the Peace Corp Health Program; or
a public health plan (U.S. government or foreign government).
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 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
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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.
Fam ily Deductible Lim it: 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.
FM LA: The Family and Medical Leave Act of 1993.
FM LA 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.
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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.
M ed-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.
M edically 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.
M edicare: 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 NoFault Insurance, often referred to as personal Injury protection, homeowner’s insurance and Med-Pay
coverage. Refer also to the “Med-Pay” definition.
Open Enrollm ent: 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.
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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.
Personal Injury Protection (PIP): Refer to the “No Fault Insurance” definition.
Plan Adm inistrator: 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.
Prim ary 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.
QM CSO: 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.
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Spouse: The person of the opposite sex 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 M em ber: 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.
Treatm ent 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.
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INDEX
A Accidental Injury ·∙ 19, 39 Actively at Work ·∙ 2, 39 Adverse Benefit Determination ·∙ 39 Allowable Expense ·∙ 39, 42, 43 Alternate Recipient ·∙ See QMCSO Appeal ·∙ 39 B Baby ·∙ See Newborn or Adopted Children Benefit Percentage ·∙ 39 Birthday Rule ·∙ 21, 39 C Cafeteria Plan ·∙ 24 Calendar Year ·∙ 16, 20, 40 Calendar Year Maximum Benefit ·∙ 40 Certificate of Creditable Coverage ·∙ 27, 31, 38 Certificates of Creditable Coverage ·∙ 36 Change in Status ·∙ 4, 5, 6, 40 Child ·∙ 40 Children ·∙ 3, 40 CHIP ·∙ 6 Claim ·∙ 40 Claims Administrator ·∙ 3, 14, 19, 20, 33, 40 COBRA ·∙ 4, 6, 8, 10, 25, 26, 27, 31, 40, 44 Continuation of Benefits ·∙ See COBRA Coordination of Benefits ·∙ 10, 13, 19, 20, 28, 36, 39, 40, 44 Copay ·∙ 40 Cosmetic Procedures ·∙ 40 Covered Person ·∙ 15, 18, 19, 20, 22, 31, 36, 37, 40 Creditable Coverage ·∙ 31, 40 D Deductible ·∙ 41 Dental ·∙ 14, 16, 18, 19, 20, 22, 33 Basic and Restorative Services ·∙ 15, 17 Major Services ·∙ 15, 17 Orthodontia ·∙ 15, 17 Dental Exclusions ·∙ 18 Dentist ·∙ 41 Dependent ·∙ 3, 4, 41 Dependent Eligibility ·∙ 3 disability ·∙ 26 E Effective Date of Coverage ·∙ 4, 41 Eligibility ·∙ 1 Employee Retirement Income Security Act ·∙ See ERISA Employer ·∙ 41 Enrollment ·∙ 41 Change In Status ·∙ 6 Initial Enrollment ·∙ 5, 42 Open Enrollment ·∙ 6, 43 Requirements ·∙ 5, 7 Special ·∙ 44 EOB ·∙ 14, 42 ERISA ·∙ 0, 30, 33, 41 Exclusions ·∙ 18, 41 Experimental or Investigational ·∙ 19, 41 Explanation of Benefits ·∙ See EOB F Family and Medical Leave Act of 1993 ·∙ See FMLA Family Deductible Limit ·∙ 42 Fee Schedule ·∙ 42 Fiduciary ·∙ 42 FMLA ·∙ 6, 7, 8, 25, 42 FMLA Leave ·∙ 42 Fraud ·∙ 38 H HEALTH Benefits GENERALLY ·∙ 11 Health Plan of Nevada ·∙ See HPN Health Status-­‐Related Factors ·∙ 3, 42 HIPAA ·∙ 6, 27, 42 Page 46 of 48
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HMO ·∙ 1, 11, 14, 20, 33 HPN ·∙ 1, 11, 33 I Illness ·∙ 42 Immediate Family ·∙ 42 incurred ·∙ 10 Incurred ·∙ 42 Initial Enrollment ·∙ 5, 42 Injury ·∙ 42 In-­‐Network Provider ·∙ 42 J Joint Venture ·∙ 2, 43 Joint Ventures ·∙ 5 L Orthognathic ·∙ 43 Other Benefits ·∙ 23 Out-­‐of-­‐Network Provider ·∙ 44 Over-­‐Utilization ·∙ 44 P Participating EmPloyers ·∙ 34 Personal Injury Protection (PIP) ·∙ 44 PHI ·∙ See HIPAA Plan Administrator ·∙ 2, 37, 44 Plan Sponsor ·∙ 33, 44 PPO ·∙ 1, 11, 14, 33, 44 Pre-­‐Determination ·∙ 44 Pre-­‐Determination Procedures ·∙ 19 Pre-­‐Existing Conditions ·∙ 31 Primary Plan ·∙ 21, 44 Privacy ·∙ See HIPAA Protected Health Information ·∙ See PHI Provider ·∙ 44 Provider Directory ·∙ 14 Leave of Absence ·∙ 7, 8 Limitations and Exclusions Dental ·∙ 18 Q M QMCSO ·∙ 6, 9, 44 Qualified Beneficiary ·∙ 44 Qualified Medical Child Support Order ·∙ See QMCSO Qualifying Event ·∙ 44 Major Services ·∙ See Dental Marriage ·∙ 7 Medical Child Support Order ·∙ See QMCSO Medically Necessary ·∙ 43 Medicare ·∙ 6, 13, 20, 25, 26, 40, 43 Med-­‐Pay ·∙ 43 R Recission of Coverage ·∙ 4 Rehired or Reinstated Team Members ·∙ 5 N S National Medical Support Notice ·∙ See QMCSO Negotiated Fees ·∙ 43 Network ·∙ 14, 43, See Provider Directory Newborn or Adopted Children ·∙ 7 No-­‐Fault Insurance ·∙ 43 Secondary Plan ·∙ 44 SHL ·∙ 1, 11, 33 Sierra Health & Life ·∙ See SHL Specialist ·∙ 44 Spouse ·∙ 3, 4, 45 State Children’s Health Insurance Program ·∙ See CHIP Subrogation ·∙ 10, 36, 45 O Open Enrollment ·∙ 6, 43 Orthodontia ·∙ 15 Page 47 of 48
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T Team Member ·∙ 1, 45 Termination of Coverage ·∙ 8 The Plan ·∙ 45 Transferred Team Members ·∙ 5, 6 Treatment Plan (Dental) ·∙ 45 U Uniformed Services Employment and Re-­‐employment Rights Act ·∙ See USERRA UnitedHealthcare Vision ·∙ 33 USERRA ·∙ 6, 8, 45 USERRA Leave ·∙ 45 V Vision ·∙ 11, 14, 33 W Women’s Health and Cancer Rights Act of 1998 ·∙ 36 Page 48 of 48
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