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, 2015
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...... 2 HEALTH BENEFITS...... 11 DENTAL BENEFITS...... 14 OTHER BENEFITS...... 22 CAFETERIA PLAN...... 22 CONTINUATION OF BENEFITS (COBRA)...... 23 HIPAA PRIVACY RULE...... 26 ANNUAL FEDERAL NOTICES...... 29 ERISA RIGHTS ...... 37 IMPORTANT INFORMATION...... 39 DEFINITIONS...... 45 INTRODUCTION ELIGIBILITY REQUIREMENTS 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) A. TEAM MEMBER ELIGIBILITY REQUIREMENTS 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: For the purposes of Section 1 “Eligibility, Enrollment and Effective Date,” in the applicable certificate Throughout this document, any references to the terms “he,” “him,” or “his” shall also mean “she,” booklet or any other materials, the following Eligibility Requirements shall apply for determining “her,” or “hers,” or vice versa. eligibility for coverage under The Plan for benefits under the Medical, Dental, Vision, Life Insurance, and Disability Options. Plan Documents 1. Team Members classified as Full-time (i.e. those Team Members expected as of date of hire to This document, together with the Benefit Schedule, Prescription Drug Benefit Rider, applicable work an average of 30 hours or more per week) are eligible to participate in The Plan on the 1st certificate booklets, endorsements and any other documents distributed by Health Plan of Nevada day of the month following 60 calendar days of regular full-time employment. (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 2. Full-time regular front of the house Team Members, who work in a specialty restaurant that is to summarize the Plan in easy to understand language. However, in the event of uncertainty or an open for dinner service only and who are expected to work an average of 25 hours per week inconsistency between this SPD and the Evidence of Coverage (EOC) or Certificate of Coverage shall be classified as “Full-Time” and shall be eligible to participate in The Plan on the 1st day of (COC), or insurance certificate, as applicable, the EOC, COC, or insurance certificate will control. the month following 60 calendar days of active continuous employment.
Eligibility 3. Team Members whose employment status changes from temporary, part-time, or on-call to Full- Time, who have been employed with The Employer, or a Joint Venture, for at least 60 calendar To be eligible to participate in the Plan, you and your dependents must meet the eligibility days in active continuous employment in temporary, part-time, on-call capacity, are eligible to requirements set forth in the section of this SPD entitled “Eligibility Requirements” and any participate in The Plan on the 1st day of the month following the effective date of the change in additional requirements outlined in the EOC/COC. job status. The Employer intends to maintain the Plan indefinitely. However, it reserves the right to terminate, 4. On-going variable status Team Members (temporary, part-time or on-call) are eligible to suspend, discontinue or amend the Plan at any time and for any reason. Changes in the Plan may participate in the medical portion of The Plan if they work an average of 30 or more hours per occur in any or all parts of the Plan including benefit coverage, Deductibles, Maximums, Co-pays, week in a Standard Measurement Period. For purposes of group medical coverage as required Exclusions, Limitations, Definitions, Eligibility and the like. under the Affordable Care Act, Station Casinos has adopted a Standard Measurement Period If the Plan is terminated, amended, or benefits are eliminated, the rights of Covered Persons are of 6 months for measuring the number of hours that a Team Member has worked. If a Team limited to covered charges Incurred before termination, amendment or elimination. Member works an average of 30 hours per week during a Standard Measurement Period, he or she will be eligible for medical group (but not other benefits coverage otherwise available to We urge you to read this SPD carefully. If you have any questions concerning the Plan, please Full-Time Team Members only) during a Stability Period. For 2015, the Standard Measurement contact your property’s Human Resources Department or applicable carrier/administrator. Periods are (1) April 14, 2014 to October 13, 2014 for medical coverage under the Plan effective for the Stability Period from January 1, 2015 through June 30, 2015, and (2) October 14, 2014 to April 13, 2015 for medical coverage under the Plan effective for the Stability Period from July 1, 2015 to December 31, 2015.
5. Newly hired variable status Team Members (temporary, part-time or on-call) will also be measured using an Individual Measurement Period starting with their first pay period worked through the 6 month anniversary of such pay period. Newly hired Team Members in variable status are also measured under the Standard Measurement Period(s) that begin after the Team Member’s date of hire.
6. Full-Time Team Members who transfer from Full-Time to a variable status (temporary, part- time or on-call) will be eligible to continue their medical coverage under the Plan during the applicable Stability Period and may continue such coverage if during the applicable Standard or Initial Measurement, the Team Member worked an average of 30 hours or more per week. A Team Member’s change from Full-Time to variable status (i.e. a reduction in hours) does not constitute a Qualifying Life Event, however a Team Member who experiences such a change may change medical plans or may obtain coverage through the Nevada Exchange.
7. A Team Member must be actively at work on his scheduled Effective Date of Coverage (see Section C) to begin coverage. Refer to the “Actively at Work” definition.
1 2 Part Time, On Call and Temporary Team Members Mental or Physical Impairments
Part-time, on-call and temporary Team Members are not eligible to participate in the dental, vision An unmarried tax-dependent Child who is incapable of self-sustaining employment by reason of and other non-medical benefits of the Plan. Such Team Members are eligible to participate in the mental or physical impairment upon attaining an age limit under the Plan may be considered as an medical portion of the Plan as set forth above. 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 Transferring Properties days of the Child’s attainment of the age limit. Proof of continuing incapacity may be required periodically by the Claims Administrator. Covered benefits may change in transferring from one property It is the responsibility Dependent Coverage to another. For this reason, it is important to contact the property of the Team Member Human Resources department at the new property within 31 days of to remove Dependents A person who is enrolled as an eligible Team Member shall not also be considered an eligible your transfer to verify coverage and receive applicable information. from the Plan who Dependent of another Team Member under the Plan. If both parents of a Dependent Child are Covered Team Members and covered Spouses and Dependents who no longer meet the employed by The Employer, coverage will be under one parent only. A Team Member must be were previously participating or otherwise eligible to participate in Dependent eligibility covered under The Plan in order to cover any eligible Dependents under the Plan. Dependents must a plan sponsored by a Joint Venture will be immediately eligible to requirements within elect the same coverage as the Team Member. participate in the Plan (an additional 60-day waiting period is not 60 days of the event. required). Removal of Dependents
Collective Bargaining It is the responsibility of the Team Member to remove Dependents from The Plan who cease to meet the Dependent eligibility requirements (e.g. due to divorce or a spouse becoming eligible for If a Team Member is covered by a collective bargaining agreement where health benefits were the group health plan coverage through his/her own employer). The Dependent must be removed within subject of full good faith collective bargaining, she will not be eligible to participate in the Plan 60 days of the event that causes eligibility to cease. The Plan Sponsor retains the right to request unless such participation has been specifically agreed to within the collective bargaining agreement. documentation to confirm that a Dependent meets the Plan’s Dependent eligibility requirements.
Miscellaneous Provisions If the Plan is not made aware of a qualifying change in status event affecting dependent eligibility within 60 days of that event, COBRA Any decision as to eligibility hereunder made by The Plan Administrator in good faith shall be will not be offered to that dependent. If timely notice is not provided, If the Plan is not made aware of a qualifying binding on all persons regardless of any reclassification or redesignation by an applicable court all claims will be the responsibility of the Team Member as of the change in status event or other judicial determination. Denial of eligibility for benefits cannot be based on Health Status- qualifying Change in Status event date and the Team Member will forfeit contributions paid. affecting dependent Related Factors. eligibility within 60 days If it is discovered that information is withheld or false information has A Team Member who transfers from an affiliate (as determined by the Plan Administrator) to The of that event, COBRA been provided regarding eligibility, this will be considered fraud or will not be offered to Employer will be credited with prior service for purposes of eligibility under the Plan. intentional misrepresentation, benefits will be terminated immediately, that Dependent. coverage will be rescinded, and the Team Member will be required to reimburse Claims that were paid on behalf of the ineligible Dependent. B. DEPENDENT ELIGIBILITY REQUIREMENTS Ineligible Dependents An eligible Dependent includes the eligible Team Member’s Non-Working Spouse (as defined by the An eligible Spouseor Dependent does not include: Plan) unless divorced or legally separated and all Children (as defined by the Plan) under 26 years of age. Effective January 1, 2014, only Non-Working Spouses are eligible for the Plan. A Non-working . a Spouse following legal separation or a final decree of dissolution or divorce, or a common law Spouse means a Spouse who is either unemployed or who is employed but ineligible for coverage Spouse; through his or her own employer. . any Child who has been legally adopted by another person (coverage ends on the date custody Dependent Documentation is assumed by the adoptive parents);
The Team Member is responsible for providing documentation proving a legal Spouse or a Child is . any Child who is covered as a Dependent of another Team Member under any Plan to which The an eligible Dependent. Effective June 1st, 2012 a copy of a certified marriage certificate (for Spouse Employer makes financial contributions on behalf of the Team Member; or coverage) or a copy of a certified birth certificate (for Child coverage) must be submitted within 60 . other individuals living in the Covered Team Member’s home, but who are not Dependents. 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 At any time, The Plan may require proof that a Spouse or a Child qualifies or continues they experience a qualifying change in status event or until the next Open Enrollment period to add to qualify under the terms of the Plan. Enrolling an unqualified Spouse or Dependent by the Dependent with the appropriate documentation. Effective January 1, 2014, a Team Member must withholding information or presenting false information regarding eligibility will constitute complete all forms requested by the Plan Administrator regarding a Spouse’s eligibility to participate fraud or an intentional misrepresentation that triggers rescission of coverage and such in the Plan. 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.
3 4 C. EFFECTIVE DATE OF COVERAGE D. ENROLLMENT REQUIREMENTS FOR TEAM MEMBERS AND DEPENDENTS
Team Member Initial Enrollment
A Team Member’s coverage will not become effective until all of the following are met: 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 1. the Eligibility Requirements; and 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 2. the Enrollment Requirements of the Plan. 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 Spousal and Dependent Coverage 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 A Spouse and/or Dependent’s coverage will not become effective until all of the following are met: requested only during Open Enrollment or within a specified period following a Change in Status event as described below. 1. the Team Member is covered under the Plan; Open Enrollment 2. the Eligibility Requirements; and During Open Enrollment all eligible Team Members may enroll themselves and/or any eligible 3. the Enrollment Requirements of the Plan. 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 Rehired or Reinstated Team Members Casinos.
1. For the purpose of coverage under the Plan, if a previously covered Team Member, who was Change in Status Enrollment 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, 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 provided he otherwise meets the eligibility requirements under the Plan on his rehire date. If a in Status means any of the following events (which include Special Enrollment events under HIPAA): 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. 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 2. If a previously covered Team Member, who was terminated due to an Employer initiated provide health coverage for a Child; reduction-in-force, is rehired within 90 days (or within 13 weeks for purposes of the medical 2. change in a Team Member’s number of Dependents, including a Child’s birth, adoption, portion of the Plan only), the Team Member’s coverage will be effective on his rehire date placement for adoption, or death; 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 3. change in Team Member’s Spouse’s eligibility for or coverage under a group health plan because more than 90 days (or at least 13 weeks for purposes of the medical portion of the Plan only) of a change in employment status (includes gain or loss of such eligibility or coverage); following the termination date, he will be considered the same as a new Team Member and must 4. change in eligibility for other health coverage due to change in employment (including meet the eligibility requirements listedn Section A. exhaustion of COBRA coverage);
3. Any Team Member returning in a variable status position with a break in service of less than 13 If the loss of eligibility for other health coverage was a result of an individual’s failure to weeks may continue applicable Stability or Measurement periods, according to the guidelines pay premiums or for cause (like making a fraudulent Claim), then that individual has no of the Affordable Care Act, to determine if she is eligible for medical coverage based on hours Special Enrollment rights due to loss of other health coverage. worked. 5. a strike or lockout, an FMLA Leave (as required by FMLA), or absence on account of being in Transferred Team Members uniformed service (as defined under USERRA);
If a Team Member transfers with no break in service from one Station Casinos’ property to another 6. a Dependent satisfying or ceasing to satisfy the Dependent eligibility requirements; or any of its Joint Ventures, the Team Member will be treated as if the transfer never occurred as far 7. a transfer between a large property and the Wildfire Gaming divisions; as coverage under the Plan is concerned, including, but not limited to, the waiting period, applicable Deductibles, and Out-of-Pocket Maximum. The Effective Date of the change will be the first of the 8. a change in place of residence or work of a Team Member and/or Dependent that affects month following or coinciding with the transfer to the new property with no break in coverage. If as eligibility status; 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.
5 6 9. entitlement to or termination of entitlement to Medicare, Medicaid (other than coverage consisting I. CONTINUATION OF COVERAGE DURING LEAVE OF ABSENCE 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”) Family and Medical Leave Act of 1993 (FMLA) 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 This Plan shall at all times comply with the Family and Medical Leave Act of 1993 and regulations under any waiver or demonstration project conducted under or in relation to such a plan). thereunder issued by the Department of Labor. Contact the Plan Administrator for more information.
If a Change in Status event occurs, Enrollment or a change in Enrollment elections may be requested Uniformed Services Employment and Re-employment Rights Act (USERRA) within 60 consecutive days after the Change in Status event. If these requirements are met, If a Team Member must take a leave of absence from employment to perform uniformed service, coverage becomes effective on the date of the Change in Status event. For Enrollment provisions certain rights with respect to The Plan pursuant to the Uniformed Services Employment and specific to a newborn or adopted Child, refer to “Enrollment Requirements for Newborn or Reemployment Rights Act of 1994 (USERRA) may be available. Contact the Plan Administrator for Adopted Children” below. more information.
Company Approved Leave of Absence (other than FMLA or USERRA) 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, The Plan Administrator may agree to continue Plan coverage while a Team Member is on a rulings and announcements of the Internal Revenue Service and is applicable to Covered Company-approved leave of absence, provided the leave is in accordance with The Employer’s Persons on a uniform, non-discriminatory basis. Leave of Absence Policy and the required contributions applicable to active Team Members are paid when due. In addition, special service crediting rules apply (as required by the Affordable Care Act) while a Team Member is on a Company-approved leave of absence for purposes of the medical portion of The Plan. Please contact the Plan Administrator for more information. E. ENROLLMENT REQUIREMENTS FOR NEWBORN OR ADOPTED CHILDREN J. TERMINATION OF COVERAGE 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 Termination with Respect to Team Members 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. A Team Member’s coverage under The Plan shall terminate on the last day of the month on the earliest of the following dates: 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 1. the date of termination of The Plan; or placement for legal adoption and any required premium contributions must be made. 2. the date employment terminates; If coverage for the Child is not requested within the 60-day period, the Child may only be enrolled 3. the date on which an Employer initiated lay-off occurs; as provided in “Enrollment Requirements for Team Members and Dependents.”
If the Team Member does not have medical coverage under The Plan at the time coverage 4. the date a Team Member ceases to meet The Plan’s eligibility requirements for Team for the Child is requested, the Team Member and Child may enroll as provided in “Enrollment Members; Requirements for Team Members and Dependents.” 5. the date all coverage or certain benefits are terminated for a particular class by modification F. ENROLLMENT REQUIREMENT RELATED TO MARRIAGE of The Plan;
Newly eligible dependents will be effective immediately as of the date of the marriage provided 6. the date an eligible Team Member becomes a full-time member of the Armed Forces, except all enrollment requirements are met. Notice of marriage must be provided within 60 days of the as required by USERRA. marriage. The Plan Administrator reserves the right to terminate a Team Member’s coverage in the event of non-payment of premiums when due from the Team Member. Coverage may be continued under COBRA. Refer to the “CONTINUATION OF BENEFITS (COBRA)” section for coverage continuation G. ENROLLMENT RELATED TO A LOSS OF OTHER HEALTH COVERAGE options. If a Team Member or his or her Dependent enrolls due to the loss of other health coverage, the effective date will be the first day following the loss of coverage provided proper notice is given. The Change must be requested within 60 days of the qualifying change in status event or the Team Termination with Respect to Dependents Member must wait until the next open enrollment period. A Dependent’s coverage shall terminate under The Plan on the last day of the month on the earliest of the following dates:
H. TIMELY OR LATE ENROLLMENT 1. the date of termination of The Plan;
Enrollment will be considered timely if the enrollment is completed no later than 60 days after the 2. the date of termination of all coverage under The Plan with respect to Dependents; person either becomes eligible for coverage or is notified of their eligibility, either initially or under a Special Enrollment period. 3. the date the Team Member’s coverage terminates for any reason;
7 8 4. the date the Dependent becomes covered under The Plan as a Team Member; QMCSO Enrollment
5. the date the Dependent becomes a full-time member of the Armed Forces, except as The Team Member must request enrollment for the Child within 31 days of the judgment decree required by USERRA; 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 6. the day a Dependent who ceases to meet the eligibility requirements due to age, as order. described in “DEPENDENT ELIGIBILITY REQUIREMENTS”. If it is determined that the QMCSO order is valid and the Team Member is not enrolled for The Plan Administrator reserves the right to terminate a Team Member’s Dependent’s coverage coverage, The Plan Sponsor retains the right to automatically enroll the Team Member to the extent in the event of non-payment of premiums when due from the Team Member. Coverage may be necessary to provide the specified coverage to the Alternate Recipient. If not otherwise specified, continued under COBRA. Refer to the “CONTINUATION OF BENEFITS (COBRA)” section for the participant will be enrolled in the same option elected by the Team Member unless otherwise coverage continuation options. 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. K. QUALIFIED MEDICAL CHILD SUPPORT ORDER (QMCSO) In any case in which an appropriately completed NMSN is issued in the case of a Child of a Team Health coverage shall be provided to the Child of an eligible Team Member or eligible Spouse who is Member or eligible Spouse who is not the Custodial Parent of the Child, and the NMSN is deemed to the subject of a Qualified Child Medical Support Order (QMCSO) in accordance with applicable law, be a QMCSO, within 40 business days after the date of the NMSN the Plan Administrator will: or who is the subject of a National Medical Support Notice (NMSN) that is deemed to operate as a QMCSO. 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 A QMCSO is a court order issued pursuant to divorce proceedings requiring Child support or The Plan and either the Effective Date of the coverage or, if necessary, any steps to be taken healthcare coverage for an Alternate Recipient. The court order creates or recognizes the existence by the Custodial Parent (or by the official of a state or political subdivision substituted for the of the Alternate Recipient’s right to, or assigns to the Alternate Recipient the right to, receive name of such Child) to begin the coverage; and 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 2. provide to the Custodial Parent (or such substituted official) a description of the coverage a QMCSO as having a right to Enrollment under a group health plan. available and any forms or documents necessary to begin the coverage.
The QMCSO must specify: 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. 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; 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 2. a reasonable description of the type of coverage to be provided by The Plan to each obtain from the Plan Administrator, without charge, a copy of the procedures used by the Plan Alternate Recipient or the manner in which such coverage is to be determined; Administrator for determining whether an order is a QMCSO.
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 L. MISCELLANEOUS PROVISIONS end coverage except as otherwise permitted by court order. Failure to follow the Eligibility or Enrollment requirements of The Plan may result in delay of The court order may not require a plan to provide any type or form of benefit, or any option, not coverage, or no coverage at all. otherwise available under the Plan. An Alternate Recipient will be enrolled in the same option Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, elected by the Team Member unless otherwise directed by the Team Member or pursuant to the such as Coordination of Benefits, Subrogation, Exclusions, and timeliness of COBRA elections, order. utilization review or other cost management requirements, lack of Medical Necessity, lack of timely When The Plan Administrator receives a Medical Child Support Order, the following steps must be filing of Claims or lack of coverage. taken. The Plan Administrator must: The Plan will pay benefits only for the expenses Incurred while this coverage is in force. No benefits 1. promptly notify both the eligible Team Member or designated parent and each Alternate are payable for expenses incurred before coverage began or after coverage is terminated, even Recipient of receipt of the order; 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 2. promptly furnish an explanation of The Plan’s procedures for determining whether the order service or supply is furnished. is a QMCSO; If a Team Member falsely certifies eligibility for Plan participation or does not inform the Plan 3. within a reasonable period after receipt of the Medical Child Support Order, determine if it is Administrator of termination of eligibility, The Employer reserves the right to take disciplinary action, qualified; and as appropriate, including termination of employment, legal actions and request for reimbursement of inappropriate benefit payments. 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 At any time, the Plan may require proof that a Spouse or Child qualifies or continues to qualify with a full explanation of the benefits hereunder. under the terms of the Plan. Enrolling an unqualified Spouse or Dependent by withholding
9 10 information or presenting false information regarding eligibility will constitute fraud or an intentional Claims for MEDICAL BENEFITS and VISION BENEFITS must be made in accordance with the misrepresentation that triggers rescission of coverage and such persons will be immediately claims filing provisions of the applicable EOC or COC. You should review the descriptions in the ineligible and any benefits paid on behalf of such persons must be reimbursed to the Plan by the EOC or COC for more information. If the EOC or COC does not provide its own claims and appeals covered Team Member. provisions, the following will apply.
An employee who transfers from an Affiliate (as determined by the Plan Administrator) to The If a claim is wholly or partially denied, notice of the decision will be given within 90 days after receipt Employer will be credited with prior service for purposes of eligibility under the Plan. of the claim. If special circumstances require an extension of time for processing the claim, written The Plan Administrator reserves the right to terminate a Team Member’s coverage in the event of notice of the extension will be furnished before the end of the initial 90 day period. An extension will non-payment of premiums when due from the Team Member. 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. HEALTH BENEFITS The following information will be provided in a written notice denying a claim for benefits: . specific reason(s) for the denial; A. HEALTH PLANS OFFERED . specific reference to the provisions of the EOC or COC on which the denial is based; PLAN DESCRIPTION . a description of any additional material or information necessary to perfect the claim and an HMO Option(s) Benefits are available only for those Team Members who either live or work . explanation of why such material or information is necessary; in the HMO service area. . a description of the Plan’s appeal procedures and the applicable time limits. Under the appeal . The benefits provided under the HMO option(s) are fully insured by Health procedures, you or your authorized representative may: Plan of Nevada, a United Healthcare Company (“HPN”) and include a comprehensive healthcare plan and prescription drug benefits. make an appeal by written application to the Plan Administrator (or other fiduciary o responsible for hearing claims appeals) within 60 days after receipt of the notice of . A full description of the benefits under the HMO option(s) can be found in claim denial; the certificate booklet(s) (also referred to as the EOC(s)) and the Benefits Decision Guide. upon written request and free of charge, be provided with reasonable access to and o PPO Option(s) . The benefits provided under the PPO option(s) are fully-insured by copies of all plan documents, records and other information relevant to your appeal; Sierra Health & Life, a United Healthcare Company (“SHL”) and include a and comprehensive health care plan and prescription drug benefits. submit written comments, documents, records and other information relating to the o . The benefits under the PPO options include a high deductible health plan claim. with a health savings account. The decision on the appeal will be made within 60 days after receipt of the written appeal, unless . A full description of the benefits under the PPO option(s) can be found in special circumstances require an extension of time for processing, in which case you will be notified the certificate booklet(s) (also referred to as the COC(s)) and the Benefits of the extension and a decision will be rendered as soon as possible, but not later than 120 days Decision Guide. after receipt of the appeal. The decision on the appeal will be in writing and include specific reasons Dental . The benefits provided under the Dental option are self-funded and are fully for the decision, written in a manner calculated to be understood by you. The decision will include described in this SPD and the Benefits Decision Guide. specific references to the EOC or COC provisions on which the decision is based and such other Vision . The benefits provided under the Vision option are fully-insured by Davis information, if any, as required by regulations under ERISA Section 503 and the Patient Protection Vision. 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 . A full description of the benefits under the Vision option can be found in the the time limits set forth above will be modified as required to comply with regulations under ERISA insurance certificate booklet (also referred to as the COC) and the Benefits Section 503 and the Patient Protection and Affordable Care Act, as applicable. Decision Guide. An authorized representative may file a claim or appeal a denial for you. To name an authorized The HMO, PPO, Dental and Vision options were designed to give you the most benefits for the least representative, you must file a Designation of Authorized Representative form with the Plan Out-of-Pocket costs by using a Network of Providers and services. You should be selective in your Administrator. use of healthcare services and choice of providers. The Plan Administrator (or its designee including an applicable insurance carrier) has the Claim Filing, Denials and Appeals 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 The following procedures apply with respect to claims regarding the HMO and PPO Options or the appeal of a claim denial. Medical Benefits will be paid only if the Plan Administrator decides (Medical Plans) and Vision Option. Claims procedures with respect to the Dental Option is set forth in the DENTAL BENEFITS section of this SPD. 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 The EOC and COC contain explicit rules regarding the Claim Provisions related to the medical barred. Similarly, failure to follow the prescribed procedures set forth in the COC, EOC, any notices, benefits available under the HMO and PPO options of the Plan and Vision option. and/or this SPD in a timely manner will also cause you to lose your right to sue regarding any adverse benefit determination.
11 12 Note: You must exhaust the Plan’s administrative claims and appeals procedures before bringing suit . Carefully review all Explanation of Benefits (EOB) you receive from The Plan. If you suspect that in either state or federal court. In addition, any claim must be filed within 12 months after the date a Provider has charged you for services you did not receive or billed you for the same service Covered Services (as defined in the EOC/COC) were provided. twice, contact the Provider for an explanation. There may have been a billing error.
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 DENTAL BENEFITS 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 Dental benefits are administered by the Dental Claims Administrator. The Plan will provide benefits the EOC or COC. 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 Medical Coordination of Benefits the “IMPORTANT INFORMATION” section.
Coordination of Benefits (COB) applies to you if you are covered by more than one health benefits SCHEDULE OF DENTAL BENEFITS plan, including any one of the following: A network of providers is available under the dental benefits of The Plan. Please see previous . another employer sponsored health benefits plan; 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 . a medical component of a group long-term care plan, such as skilled nursing care; 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. . no-fault or traditional “fault” type medical payment benefits or personal injury protection benefits under an auto insurance policy; CALENDAR YEAR MAXIMUM BENEFIT $1,500
. medical payment benefits under any premises liability or other types of liability coverage; or The Maximum Benefit applies to all dental services except for Orthodontia. . Medicare or other governmental health benefit. DEDUCTIBLE If coverage is provided under two or more plans, COB determines which plan is primary and Individual $50 which plan is secondary. The plan considered primary pays its benefits first, without regard to the Family $150 possibility that another plan may cover some expenses. Any remaining expenses may be paid under BENEFIT PERCENTAGE (payable by The Plan) the other plan, which is considered secondary. The secondary plan may determine its benefits based Preventative and Diagnostic Services 100% after Deductible on the benefits paid by the primary plan. Basic and Restorative Services 100% after Deductible* Please refer to the applicable COC or EOC for details and information regarding COB coverage. 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. B. PROVIDER NETWORK/DIRECTORIES
PLAN NETWORK NAME HOW TO OBTAIN A DIRECTORY HMO Health Plan of Nevada By visiting www.healthplanofnevada.com. ORTHODONTIA BENEFIT PPO Sierra Health & Life By visiting www.sierrahealthandlife.com. Orthodontia benefits are available for Dependent Children only. Bands must be placed after age 6 Dental Sierra Health-Care By visiting www.uhcnevada.com and then clicking on Sierra and before age 19. Options Health-Care Options (SHO General Dentists/ SHO Dental CALENDAR YEAR MAXIMUM BENEFIT $750 Specialists). MAXIMUM LIFETIME BENEFIT $1,500 Vision Davis Vision Available by visiting www.davisvision.com DEDUCTIBLE $0 . Provider’s status can frequently change due to forces beyond the Plan’s control. BENEFIT PERCENTAGE (payable by The Plan) 50% . Prior to obtaining services, always verify your Provider’s continued participation in the Network. . 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 Protect yourself from fraud! DENTAL BENEFITS” section.
. Be wary of giving your plan identification (ID) number or your Social Security number to anyone . Orthodontia benefits will begin upon submission of proof that the orthodontia treatment you don’t know, except to your provider, or an authorized plan representative. program has begun.
. Do not let others use your insurance card. . 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 . Let only appropriate medical professionals review your medical records or recommend services. submitted.
. 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.
13 14 A. COVERED DENTAL EXPENSES MAJOR SERVICES Dental coverage under the Plan is limited to the In-Network allowable, subject to the application of . Inlays, onlays, gold fillings, crowns, and gold dowel pins; maximum benefit, Deductible, and benefits percentage provisions as stated in the “SCHEDULE OF DENTAL BENEFITS” section. . Recementing of crowns, inlays, or bridgework, or relining of dentures (limited to 1 reline in any 6-month period);
PREVENTATIVE AND DIAGNOSTIC SERVICES . Initial installation of partial or full removable dentures or fixed bridgework (including the TYPE OF SERVICE BENEFIT accompanying inlays and crowns to form abutments) to replace one or more natural teeth Routine Oral Examination limited to 2 examinations per Calendar Year which were extracted while covered under this plan; and Prophylaxis treatment limited to 2 treatments per Calendar Year . Replacement of existing partial or full removable dentures, crowns, or fixed bridgework, or (scaling and polishing of teeth) the addition of teeth to an existing partial removable denture or to bridgework to replace Periodontal Prophylaxis limited to 2 treatments per Calendar Year extracted natural teeth, but only if: Topical application of sodium or stannous limited to 2 applications per Calendar Year . the existing denture, crown or bridgework was installed at least 5 years prior to its replacement fluoride up to age 18 and cannot be made serviceable; or Topical application of a sealant on each up to age 16 permanent posterior tooth . the existing denture is an immediate temporary denture, and replacement by a permanent Dental x-rays, including panoramic view or limited to 1 series during any period of 36 denture is required and takes place within 12 months from the date of installation of the full mouth series consecutive months immediate temporary denture. bitewing x-ray series limited to 1 series per Calendar Year . Note that stainless steel crowns for adults are considered temporary. A temporary stainless periapical x-rays as medically necessary steel crown that is not replaced with a permanent crown within 12 months is considered other x-rays as needed for diagnosis (except permanent and subject to the 5 year replacement clause. If a temporary stainless steel crown x-rays taken in connection with orthodontic is replaced within 12 months, the benefit previously considered for the stainless steel crown is treatment) reduced from the benefits currently considered on the permanent crown.
BASIC AND RESTORATIVE SERVICES ORTHODONTIC TREATMENT . Office Visits - office visits and consultations, office visits during regular office hours for . Oral examinations and diagnosis; treatment and observation of injuries to teeth and supporting structure . Initial (and subsequent, if any) installation of orthodontic appliances and adjustment of . Professional visits after hours and special consultation by a dental specialist upon referral by orthodontic appliances; the Covered Person’s attending Dentist . Comprehensive full-banded treatment; and . Emergency or palliative visits for relief of pain . Endodontics (including root canal therapy) . All other orthodontic treatment required by accepted orthodontic practice, including tooth extraction and dental x-rays. . Oral surgery . Extractions . Biopsy and examination of oral tissue B. DENTAL LIMITATIONS AND EXCLUSIONS
. Study models No benefits will be paid under the Plan for: . Local anesthetics and antibiotic drugs injected by the attending Dentist 1. for expenses payable under a medical plan sponsored by The Employer; . Anesthesia in conjunction with surgical procedures . Fillings - amalgam, silicate, acrylic or plastic fillings 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 . Stainless steel crowns (primary teeth) supervision and direction; . Repair of crowns, inlays, bridgework or dentures 3. implants, surgical removal of implants, replacement of implants and all related implant . Pins to retain filling restorations services; . Space maintainers up to age 16 4. prosthetic devices (including bridges and crowns) and the fitting thereof which were ordered . Subgingival curettage, alveolar and gingival reconstruction, periodontal scaling and root before, or while, the person was covered under the dental benefits portion of The Plan, but planning, gingivectomy, osseous surgery, or other treatment of periodontal abscess and installed or delivered after termination of his dental coverage under The Plan; replacement of periodontitis (refer to “Preventive and Diagnostic Services” for periodontal prophylaxis a lost or stolen prosthetic device; benefits) 5. cosmetic surgery or dentistry for cosmetic reasons; treatment for congenital (hereditary) or 15 16 developmental malformations; cleft palate; maxillary or mandibular (upper and lower jaw) 23. resulting from or sustained as a result of participation in a riot or insurrection; degeneration; enamel hypoplasia (lack of development); fluorosis; 24. which are not generally accepted in the United States as being necessary and appropriate for 6. a veneer or facing (i.e., a tooth-colored exterior) on a crown or pontic is not covered on the treatment of the Covered Person’s Illness or Injury; 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 25. which are still considered Experimental or Investigational (as defined by The Plan), whether crown or pontic; or not such treatment, services or supplies are generally accepted by the medical profession;
7. crowns placed for the purpose of periodontal splinting; 26. which are considered as Over-Utilization, as determined by the Claims Administrator;
8. appliances and restorations for splinting teeth; 27. for Orthognathic conditions (including associated diagnostic procedures) and for Orthognathic surgery due to an Orthognathic condition or any other condition, whether or 9. any treatment to remove or lessen discoloration except in connection with endodontics; not Medically Necessary; 10. personalization or characterization of dentures; 28. for preparing medical reports or itemized bills; 11. myofunctional therapy, muscle training therapy or training to correct or control harmful habits; 29. for broken or missed appointments;
12. occlusal restoration, procedures, appliances or restorations that are performed to alter, 30. for services, supplies, or accommodations provided in connection with holistic or restore or maintain occlusion (i.e., the way the teeth mesh), including: homeopathic treatment, including drugs;
. increasing the vertical dimension; 31. for charges made for the completion of Claim forms or for providing supplemental information; for postage, shipping or handling charges which may occur in the transmittal if . replacing or stabilizing tooth structure lost by attrition; information to the Claims Administrator; or for interest or financing charges;
. realignment of teeth; 32. for treatment or services rendered outside the United States or its territories except for an . gnathological recording or bite registration or bite analysis; Accidental Injury or a Medical Emergency;
. occlusal equilibration; and 33. for Claims not filed within 6 months of the date the service or supply was Incurred, however, Coordination of Benefits Claims will be accepted after the 6 month filing time limit if received . occlusal guards (night guards); 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 13. plaque control or oral hygiene; or charges due to timely filing cannot be billed to the Covered Person; 14. localized delivery of antimicrobial agent to include but not limited to Arestin, Atridex and/or Periochip; 34. for services rendered as a result of a complication of a non-covered service or procedure including any reversal procedure. 15. items intended for sport or home use, such as athletic mouth guards or habit-breaking appliances;
16. items or services which are not Medically Necessary for the diagnosis and treatment of an C. GENERAL DENTAL PROVISIONS Illness or Injury, unless stated otherwise as covered in The Plan; Pre-Determination Procedures (Optional) 17. for which the patient or Covered Person has no legal obligation to pay; If charges which would be payable for a proposed course of dental care will exceed a total of 18. rendered by a member of the Covered Person’s Immediate Family or anyone who customarily $300.00, written notice outlining such course and including charges should be forwarded to the lives in the Covered Person’s household; 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 19. which exceed The Plan allowable for In-Network and Out-of-Network Providers; work or treatment and charges for which payment will be made. This certification is not required and is not a guarantee of payment. A pre-determination of charges may not be valid after 60 days, 20. which are furnished in a government owned or operated facility or any other hospital where care is provided at government expense, unless it is non-service related; 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 21. for Accidental Injury or Illness arising out of or in the course of any employment for wage providers. 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’ Services Incurred and Services Performed Compensation Claim; Charges shall be allocated to a particular Calendar Year and to the Deductible or maximum 22. for Injury resulting from or sustained as a result of being engaged in an illegal occupation, applicable to such year, in accordance with the date such charge is deemed Incurred under this commission of an assault or felonious act, unless such Injury results from a medical condition contract. All charges which are incurred with respect to any Treatment Plan shall be deemed (physical or mental health condition) or domestic violence; Incurred on the date the service is actually performed
17 18 Dental Claim Filing 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 Original bills for expenses Incurred (whether In-Network or Out-of-Network) must be submitted that covers the person as a Dependent. to the Dental Claims Administrator within 6 months after the date the service(s) were rendered. Coordination of Benefits Claims will be accepted after the 6 month filing time limit if received within b. Except as stated in paragraph “c” below, when The Plan and another plan cover the 3 months of the date of the primary insurance explanation of benefits. Note: In-Network Providers same Child as a Dependent of different persons, called “parents”: are required by contract to submit Claims within the time limit; denied Claims cannot be billed to the Covered Person. 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 In the case of requests for information by the Dental Claims Administrator, the requested that year (Birthday Rule); information must be submitted within 6 months of the date of the initial request in order for the Claim to be considered. 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 Dental Claim Denials and Appeals covered the other parent for a shorter period of time; however, if the other The Plan will pay the amount plan does not have the rule described in “1”, but instead has a rule based upon If the Claims Administrator determines that a claim should be it would have paid had it been the gender of the parent, and if, as a result, the plans do not agree on the order wholly or partially denied, the member will be sent written the person’s only coverage, of benefits, the rule in the other plan will determine the order of benefits. notification of such denial. This notice will include: less any amounts paid by all Primary Plans. c. If two or more plans cover a person as a Dependent Child of divorced, never married, . the reason for the denial; and or separated parents, benefits for the Child are determined in this order:
. specific reference to the plan provisions on which the denial is based. i. first, the plan of the parent with custody of the Child;
If the member believes a claim was improperly settled, the following process is available: ii. then, the plan of the Spouse of the parent with the custody of the Child; and
Within 60 days of receipt of the claim, the member may request, in writing or verbally, that the plan iii. finally, the plan of the parent not having custody of the Child. 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. 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 All requests for a review of denied benefits should include a copy of the initial denial notification determined first.The benefits of a plan which covers a person as a Team and any other pertinent information. Send all information to the Dental Claims Administrator listed Member who is neither laid-off nor retired (or as that Team Member’s in the Important Information section. 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 Coordination (Maintenance) of Benefits the other plan does not have this rule, and if, as a result, the plans do not agree The Coordination of Benefits provision is intended to eliminate duplicate payments and to provide on the order of benefits, this rule does not apply. the sequence in which coverage will apply when a Covered Person is covered by one or more plans. d. If a person whose coverage is provided under a right of continuation pursuant to “Plan” means any group insurance, group-type coverage, a Health Maintenance Organization (HMO), Federal or state law is also covered under another plan, benefits for such person are Government programs (including Medicare), and No-Fault Insurance coverage (homeowners determined in this order: insurance, automobile insurance, personal Injury protection, or medical payment coverage). Coordination of Benefits provisions do not apply to individual insurance policies, i. first, the benefits of the plan covering the person as a Team Member, member school accident-type coverage, Champus or Medicaid. or subscriber (or as that person’s Dependent);
The benefit payable under The Plan shall be integrated with the benefit payable to a person under all ii. second, the benefits under the continuation coverage. other plans. e. If the other plan does not have this rule, and if, as a result, the plans do not agree on If The Plan is Primary (see Order of Benefit Determination), benefits will be paid as if The Plan was the order of benefits, this rule does not apply. the person’s only coverage. f. If none of the above rules determine the order of benefits, the benefits of the plan If The Plan is Secondary, The Plan will pay the amount it would have paid had it been the person’s which has covered a Covered Person longer are determined before those of the plan only coverage, less any amounts paid by all Primary Plans. If the plans that determine benefits first which has covered that person for the shorter time. 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. Right to Receive and Release Necessary Information
Order of Benefit Determination 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 The rules for determining the Primary Plan are: 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. 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).
19 20 Dental Right of Reimbursement LEGAL ACTIONS
If any Plan benefit paid to or on behalf of a Covered Person should not have been paid or should The Plan’s procedures for filing and appealing Claims must be followed before the claimant can file have been paid in a lesser amount, and the Team Member or any other appropriate party fails to any litigation with respect to an Adverse Benefit Determination. 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 OTHER BENEFITS 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 LIFE INSURANCE AND SHORT TERM DISABILITY whom the Dependent was covered, or any covered Dependent of the Team Member. Eligible Team Members (as defined in the Eligibility Requirements section above) shall be entitled to The Plan Administrator also reserves the right to recover any such overpayment by appropriate legal certain life insurance and short term disability benefits. These company paid benefits are described action. The Team Member must pay all costs of The Plan, including without limitation, attorneys’ in separate materials provided to you when you become initially eligible for benefits. Please refer to fees, should The Plan pursue any means available under the law to recover any amount owed to The these materials regarding specific payments and benefits under these plans. Additional information Plan by the Team Member or on behalf of his or her Dependent. is also available in the applicable Group Booklet – Certificate of Coverage which may be requested from the Plan Administrator and your Benefits Decision Guide. PAYMENT OF BENEFITS
All benefits under The Plan are payable to the covered Team Member whose Illness or Injury or whose covered Dependent’s Illness or Injury is the basis of a Claim. In the event of incapacity of a WELLNESS PROGRAM 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 include wellness programs to better your health. Please refer to separate materials and The Plan may, at its sole discretion, make any and all such payments to the individual or institution information regarding wellness programs, if any. 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 CAFETERIA PLAN the covered Team Member. Each Team Member may pay their share for benefits under The Plan with pretax contributions Benefits for expenses covered under The Plan may be assigned by a covered Team Member to pursuant to a “Cafeteria Plan.” Each Team Member who is eligible to participate in The Plan will the individual or institution rendering the services for which the expenses were incurred. No such be eligible to participate in this Cafeteria Plan. Team Members may only pay for the coverage of assignment will bind The Plan Administrator unless it is in writing and unless it has been received yourself and your tax dependents as defined in Code Section 152 generally (except as otherwise and accepted by the Claims Administrator prior to the payment of the benefit assigned. defined in Code Section 105(b) and the regulations issued under Code Section 106) under this Plan The Claims Administrator will not be responsible for determining whether any such assignment is and as set forth in the SPD. valid. Payment of benefits which have been assigned will be made directly to the assignee unless a Team Members become a participant in the Cafeteria Plan once they become eligible for benefits. written request not to honor the assignment, signed by the covered Team Member and the assignee, Unless the Team Member affirmatively waives participation, an election to participate in the Plan will has been received by the Claims Administrator before the proof of loss is submitted. Payment of constitute an election under this Cafeteria Plan. 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 Team Members may be required to complete a salary reduction agreement via telephone or voice not take Medicaid eligibility into account and will pay benefits in accordance with any assignment of response technology, electronic communication, or any other method prescribed by the Plan rights under a state Medicaid law. 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 RECOVERY OF OVERPAYMENTS (“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 If an overpayment is made under The Plan, The Plan Administrator reserves the right to determine will be entitled to rely on your directions through use of the PIN as if such directions were issued in and exercise one or all of the following options that it deems necessary to recover the overpayment writing and signed by you. to The Plan. The Plan Administrator may: Coverage under the Cafeteria Plan ends on the earliest of the following to occur: request the overpayment from any Covered Person to whom such overpayment was made; a. The date that you make an election not to participate in the Plan;
request the overpayment from any Provider to whom such overpayment was made; b. The date you no longer satisfy the Eligibility Requirements of the Plan;
deduct the overpayment of benefits from subsequent benefits payable to the Covered c. The date that you terminate employment; or Person; and/or d. The date that the Cafeteria Plan is either terminated or amended to exclude you or the class deduct the overpayment of benefits from subsequent benefits payable to the Provider of employees of which you are a member. to whom the overpayment was made. If a Team Member’s employment is terminated during the Plan Year or otherwise ceases to be Each Covered Person is deemed, through participation in The Plan, to authorize recovery of eligible, the Team Member’s active participation in the Cafeteria Plan will automatically cease, and overpayments as described above. the Team Member will not be able to make any more pretax contributions under the Cafeteria Plan
21 22 except as otherwise provided pursuant to Employer policy or individual arrangement. because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to Team Members save both federal income tax and FICA (Social Security) taxes by participating in the each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could Cafeteria Plan. Cafeteria Plan participation will reduce the amount of the Team Member’s taxable become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. compensation. Accordingly, there could be a decrease in Social Security benefits and/or other Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for benefits (e.g., pension, disability, and life insurance) that are based on taxable compensation. COBRA continuation coverage.
When a Team Member elects to participate both in the Plan and this Cafeteria Plan, applicable If you’re an employee, you will become a qualified beneficiary if you lose your coverage under the Plan premiums are deducted from his paycheck each month that he is enrolled. The deduction is made because of the following qualifying events: before any applicable federal and/or state taxes are withheld. . You worked less than an average of 30 hours per week in an applicable Standard Measurement If a Team Member begins a qualifying leave under the Family and Medical Leave Act of 1993 (FMLA), Period or 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 . Your employment ends for any reason other than your gross misconduct. 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). If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: 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 . Your spouse dies; their leave. . Your spouse works less than an average of 30 hours per week in an applicable Standard Team Member contributions for coverage during a Company approved leave of absence may be Measurement Period; made in one of the following ways: . Your spouse’s employment ends for any reason other than his or her gross misconduct; 1. You may pre-pay all or a portion of your share of the contribution for the expected duration . Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or of the leave by personal check or money order payable to Station Casinos LLC. . You become divorced or legally separated from your spouse. 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. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: 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 . The parent-employee dies; be applied uniformly to all Participants. . The parent-employee works less than an average of 30 hours per week in an applicable Standard CONTINUATION OF BENEFITS (COBRA) Measurement Period; . The parent-employee’s employment ends for any reason other than his or her gross misconduct; This section has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan and constitutes your initial COBRA notice. This . The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); section explains COBRA continuation coverage, when it may become available to you and your . The parents become divorced or legally separated; or family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA . The child stops being eligible for coverage under the Plan as a “dependent child.” continuation coverage.
The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to When is COBRA continuation coverage available? you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan the other sections of this SPD or contact the Plan Administrator. Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling . The end of employment or employee works less than an average of 30 hours per week in an in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums applicable Standard Measurement Period; and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period . Death of the employee; for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. . Commencement of a proceeding in bankruptcy with respect to the employer;]; or
What is COBRA continuation coverage? . The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end For all other qualifying events (divorce or legal separation of the employee and spouse or a
23 24 dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact Administrator within 60 days after the qualifying event occurs. The Plan Administrator contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security information is in the IMPORTANT INFORMATION section of this SPD. Documentation of your Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of qualifying event may be required. Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.
How is COBRA continuation coverage provided? PLEASE Keep your Plan Administrator informed of any address changes. Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage To protect your family’s rights, let the Plan Administrator know about any changes in the addresses on behalf of their children. of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or employee works less than an average of 30 hours per week in an applicable Standard Measurement Period. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of HIPAA PRIVACY RULE coverage. A. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION There are also ways in which this 18-month period of COBRA continuation coverage can be extended: The Plan Sponsor will only use and disclose protected health information (“PHI”) to the extent of Disability extension of 18-month period of COBRA continuation coverage 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 If you or anyone in your family covered under the Plan is determined by Social Security to be disabled right to use or disclose PHI for treatment and health care operations. The Plan will disclose PHI to and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled The Plan Sponsor only in accordance with 45 C.F.R. § 164.504(f) and this section. to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. B. DEFINITIONS OF PHI Your Social Security Disability Award Notice must be submitted to the COBRA Administrator within 60 days of the date you receive notice of the award and before the end of the initial 18 month COBRA Whenever used in this section, the following terms shall have the respective meanings set forth below. period. a. Health Care Operations include, but are not limited to, the following activities: Second qualifying event extension of 18-month period of continuation coverage i. conducting quality assessment and improvement activities; If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of ii. population-based activities relating to improving health or reducing health care costs, COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the protocol development, Case Management and/or coordination, Disease Management, second qualifying event. This extension may be available to the spouse and any dependent children contacting health care Providers and patients with information about treatment getting COBRA continuation coverage if the employee or former employee dies; becomes entitled alternatives and related functions; to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only iii. rating Provider and Plan performance, including accreditation, certification, licensing or available if the second qualifying event would have caused the spouse or dependent child to lose credentialing activities; coverage under the Plan had the first qualifying event not occurred. iv. underwriting, premium rating and other activities relating to the creation, renewal or Are there other coverage options besides COBRA Continuation Coverage? 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- Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for loss insurance and excess loss insurance); you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some v. conducting or arranging for medical review, legal services and auditing functions, of these options may cost less than COBRA continuation coverage. You can learn more about many including fraud and abuse detection and compliance programs; of these options at www.healthcare.gov. vi. business planning and development, such as conducting cost-management and planning- If you have questions: related analyses related to managing and operating The Plan, including Formulary development and administration, development or improvement of payment methods or Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to coverage policies; and, the contact or contacts identified in the IMPORTANT INFORMATION section of this SPD that includes the Plan Administrator and COBRA administrator contact information. For more information about vii. business management and general administrative activities of The Plan, including, but not your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the limited to:
25 26 . management activities relating to the implementation of and compliance with HIPAA’s d. Plan Administrative Functions means administrative functions performed by The Plan Sponsor on administrative simplification requirements; behalf of The Plan, which are limited to those functions listed under the definition of “Payment” and “Health Care Operations.” Plan administrative functions do not include functions performed . customer service, including the provision of data analyses for policyholders, plan sponsors by The Plan Sponsor in connection with any other benefit or benefit plan of The Plan Sponsor. or other customers provided that PHI is not disclosed to such policyholder, plan sponsor or customer; e. PHI means Individually Identifiable Health Information that is transmitted or maintained electronically, or any other form or medium. . resolution of internal grievances; f. Privacy Official shall mean the individual appointed by The Plan Sponsor pursuant to 45 C.F.R. . the sale, transfer, merger or consolidation of all or part of The Plan with another covered entity § 164.530(a)(1)(i) who is responsible for the development and implementation of The Plan (as defined in 45 C.F.R. § 160.103) or an entity that following such activity will become a covered Sponsor’s privacy policies and procedures. 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 C. DISCLOSURES OF PHI TO THE PLAN SPONSOR
. fundraising for the benefit of The Plan. 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 b. Individually Identifiable Health Information means information that is a subset of health Plan has been so amended. 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 D. PLAN SPONSOR COMPLIANCE WITH PRIVACY CONDITIONS clearinghouse; and Pursuant to 45 C.F.R. § 164.504(f)(2)(ii), The Plan Sponsor agrees to: 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 a. not use or further disclose PHI other than as permitted or required by the Plan documents or as required by law; iii. the past, present, or future payment for the provision of the health care to an individual; and 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 . that identifies the individual; or respect to such PHI; . with respect to which there is a reasonable basis to believe the information can be used to c. not use or disclose PHI for employment-related actions and decisions unless authorized by an identify the individual. individual; c. Payment includes activities undertaken by The Plan to obtain premiums or determine or fulfill its d. not use or disclose PHI in connection with any other benefit or Team Member benefit plan of responsibility for coverage and provision of benefits under The Plan. These activities include, but The Plan Sponsor, unless authorized by an individual; are not limited to, the following: e. report to the Plan any use or disclosure of PHI that is inconsistent with the uses or permitted i. determination of eligibility or coverage (including Coordination of Benefits and cost disclosures which The Plan Sponsor becomes aware; sharing amounts); f. make PHI available to an individual in accordance with the access requirements, as described ii. adjudication or Subrogation of health benefit Claims (including appeals and other in 45 C.F.R. § 164.524; payment disputes); g. make PHI available for amendment and incorporate any amendments to PHI in accordance iii. risk adjusting amounts due based on enrollee health status and demographic with 45 C.F.R. § 164.526; characteristics; h. make available the information required to provide an accounting of disclosures in iv. billing, Claims management, collection activities, obtaining payment under a contract for accordance with 45 C.F.R. § 164.528; reinsurance (including stop-loss insurance and excess loss insurance) and related health care data processing; 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 v. review of health care services with respect to medical necessity, coverage under a health compliance with HIPAA; and plan, appropriateness of care or justification of charges; j. if feasible, return or destroy all PHI received from the Plan that The Plan Sponsor still vi. utilization review, including pre-certification and prior authorization of services, maintains in any form, and retain no copies of such PHI when no longer needed for the concurrent and retrospective review of services; and, purpose for which disclosure was made (or if return or destruction is not feasible, limit further vii. disclosure to consumer reporting agencies related to the collection of premiums or uses and disclosures to those purposes that make the return or destruction infeasible). 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). E. PLAN SPONSOR COMPLIANCE WITH SECURITY CONDITIONS
27 28 Pursuant to 45 C.F.R. § 164.314(b)(1), as of April 21, 2005, The Plan Sponsor agrees to: (4) ERISA § 609(d) coverage of costs of pediatric vaccines;
a. implement administrative, physical and technical safeguards that reasonably and (5) The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA); appropriately protect the confidentiality, integrity and availability of electronic PHI that it (6) The Health Insurance Portability and Accountability Act of 1996 (HIPAA) (applies to creates, receives, maintains or transmits on behalf of the Plan; any group health plan sponsored by the Plan Sponsor);
b. ensure that adequate separation required by 45 C.F.R. § 164.502(f)(2)(iii) is supported by (7) The Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA); reasonable and appropriate security measures; (8) The Genetic Information Nondiscrimination Act (GINA):
c. ensure that any agent or subcontractor to whom it provides PHI agrees to implement (9) The Health Information Technology for Economic and Clinical Health Act (HITECH); reasonable and appropriate security measures to protect the information; and (10) Michelle’s Law; and,
d. report to the Plan any security incident of which it becomes aware. (11) The Family and Medical Leave Act of 1993 (FMLA). Newborns’ Act Disclosure F. SEPARATION BETWEEN THE PLAN AND THE PLAN SPONSOR This Plan does not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours The Plan will only disclose PHI to the following classes of Team Members: following a cesarean section. Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn . Sr. Vice President of Human Resources earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for . Corporate Director of Benefits prescribing a length of stay not in excess of 48 hours (or 96 hours). Additional information including . Corporate Benefits Manager State Rights required are described in detail in the applicable Benefit Plan Descriptions.
. Benefits Professionals Notice of Rights Under the Women’s Health and Cancer Rights Act (WHCRA) If you have had or are going to have a mastectomy you may be entitled to certain benefits, under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving G. LIMITATIONS ON PHI AND ACCESS AND DISCLOSURE mastectomyrelated benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: 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 (1) All stages of reconstruction of the breast on which the mastectomy was performed; extent necessary for these individuals to perform their respective duties for the Plan. (2) Surgery and reconstruction of the other breast to produce a symmetrical appearance;
(3) Prostheses; and, H. NON-COMPLIANCE ISSUES (4) Treatment of physical complications of the mastectomy, including lymphedemas. 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 These benefits will be provided subject to the same deductible and coinsurance particulars that are the Plan’s privacy policies and procedures what sanctions, if any, shall be imposed. applicable to other medical and surgical benefits provided under this Plan. For more information The Privacy Official is the Senior Vice President of Human Resources. or to get a copy of the Certificate of Coverage or Evidence of Coverage containing these details contact your Plan Sponsor Representative. ANNUAL FEDERAL NOTICES The Genetic Nondiscrimination Act of 2008 (GINA)
Compliance with Applicable Laws GINA prohibits a group health plan from adjusting group premium or contribution amounts for a group of similarly situated individuals based on the genetic information of members of the group. The Plan Sponsor will administer the Benefit Plans in compliance with federal and state laws. Any GINA prohibits a group health plan from requesting or requiring an individual or a family member of interpretation of this document or the Benefit Plan Description incorporated by reference that is an individual to undergo genetic tests. Genetic information means information about an individual’s prohibited by federal or state law is void and will not be relied on for the administration of this Plan. genetic tests, the genetic tests of family members of the individual, the manifestation of a disease The Plan Sponsor will administer the Benefit Plans in compliance with: or disorder in family members of the individual or any request for or receipt of genetic services, or participation in clinical research that includes genetic services by the individual or a family member (1) The Mental Health Parity Act (MHPA) and The Mental Health Parity and Addiction of the individual. The term genetic information includes, with respect to a pregnant woman (or a Equity Act (MHPABA) ERISA § 712, requiring parity in certain mental health and family member of a pregnant woman) genetic information about the fetus and with respect to an substance use disorder benefits; individual using assisted reproductive technology, genetic information about the embryo. Genetic (2) The Women’s Health and Cancer Rights Act of 1998 (WHCRA) ERISA § 713(a), information does not include information about the sex or age of any individual. imposing requirements for coverage of reconstructive surgery and other complications in connection with mastectomy; HIPAA PRIVACY NOTICE (3) ERISA § 609(c) coverage for adopted children: THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
29 30 DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT your medical information. The Plan Sponsor must also agree not to use or disclose your medical CAREFULLY. information for employment-related activities or for any other benefit or benefit plans of the Plan Sponsor. Your Employee Benefit Plan (the “Plan”) is required by law to give you this privacy notice (“Notice”) about our duties and privacy practices with respect to your medical information. The Plan provides . To Family Members, Relatives or Close Friends. Unless you object to such disclosure, we may health, dental, vision, prescription and/or employee assistance program benefits to you as described disclose your health information to your family members, relatives or close personal friends, or in your summary plan description(s). any other persons identified by you as being involved in your treatment or payment for your medical care. If you are present, we will ask if you would like us to share your health information This Notice describes how the Plan sponsored by your Employer (the “Plan Sponsor”) may use and with a family member, relative or a friend before we disclose such information. If, however, disclose your health information to carry out treatment, payment and health care operations and for you are not present to agree or object to our disclosure of your health information to a family other uses and disclosures that are required or permitted by law. Additionally, this Notice explains member, relative or friend, we may exercise our professional judgment to determine whether the the rights you have with respect to your health information, and certain obligations the Health Plans disclosure is in your best interest. If we decide to disclose your health information to your family must abide by in accordance with the law. The Plan hires business associates to help it provide member, relative or other individual identified by you, we will only disclose the health information these benefits to you. These business associates also receive and maintain your medical information that is relevant to your treatment or payment. in the course of assisting the Plan. The Plan may also use and disclose your medical information as follows: Nothing contained in this Notice should be construed to supersede or limit any additional rights you may be entitled to under other applicable law. Therefore, if any applicable law affords you greater . To comply with legal proceedings, such as a court or administrative order or subpoena. rights or more protections other than as described herein, we will comply with the law that gives you greater rights and/or protections. . To law enforcement officials for limited law enforcement purposes.
Purposes for which the Plan May Use or Disclose Your Medical Information . To your personal representatives appointed by you or designated by applicable law. Without Your Consent or Authorization . For research purposes in limited circumstances. The Plan may use and disclose your medical information for the following purposes: . To a coroner, medical examiner, or funeral director about a deceased person. . For Treatment Purposes. For example, the Plan may disclose your medical information to your doctor, at the doctor’s request, for your treatment by him. . To an organ procurement organization in limited circumstances.
. For Payment. For example, the Plan may use or disclose your medical information to pay claims . To avert a serious threat to your health or safety or the health or safety of others. for covered health care services or to provide eligibility information to your doctor when you To a governmental agency authorized to oversee the health care system or government receive treatment. . programs. . For Health Care Operations. For example, the Plan may use or disclose your medical information (i) to conduct quality assessment and improvement activities, (ii) for underwriting, premium . To federal officials for lawful intelligence, counterintelligence and other national security rating, or other activities relating to the creation, renewal or replacement of a contract of health purposes. insurance, (iii) to authorize business associates to perform data aggregation services, (iv) to . To public health authorities for public health purposes. engage in care coordination or case management, and (v) to manage, plan or develop the Plan’s business. . To appropriate military authorities, if you are a member of the armed forces.
. For Treatment and Health Services. The Plan may use your medical information to contact you to . To the extent necessary to comply with laws relating to workers’ compensation or other similar give you information about treatment alternatives or other health-related benefits and services programs established by law that provide benefits for work-related injuries or illness without regard that may be of interest to you. The Plan may disclose your medical information to its business to fault. associates to assist the Plan in these activities. Other Uses of Confidential Information . As required by law. For example, the Plan must allow the U.S. Department of Health and Human Services to audit Plan records. The Plan may also disclose your medical information For purposes not described above, including uses and disclosures of PHI for marketing purposes as authorized by and to the extent necessary to comply with workers’ compensation or other and disclosures that would constitute a sale of PHI, we will ask for your written authorization before similar laws. using or disclosing PHI. If you provide us permission to use or disclose confidential information about you, you may revoke that permission, in writing to the Benefits Department, at any time. If . To Business Associates. The Plan may disclose your medical information to business associates you revoke your permission, we will no longer use or disclose confidential information about you for the Plan hires to assist the Plan. Each business associate of the Plan must agree in writing to the reasons covered by your written authorization. You understand that we are unable to take back any ensure the continuing confidentiality and security of your medical information. disclosures we have already made with your permission, and that we are required to retain our records. . To Plan Sponsor. The Plan may disclose to the Plan Sponsor, in summary form, claims history and other similar information. Such summary information does not disclose your name or other To the extent required by law, when using or disclosing your confidential information or when distinguishing characteristics. The Plan may also disclose to the Plan Sponsor that fact that you requesting confidential information from another covered entity, we will make reasonable efforts not are enrolled in, or disenrolled from the Plan. The Plan may disclose your medical information to to use, disclose or request more than the minimum amount of confidential information necessary the Plan Sponsor for Plan administrative functions that the Plan Sponsor provides to the Plan to accomplish the intended purpose of the use, disclosure or request, taking into consideration if the Plan Sponsor agrees in writing to ensure the continuing confidentiality and security of practical and technological limitations.
31 32 Genetic Information. Complaints We are not permitted to use or share your genetic information for underwriting purposes, to adjust premiums, or to make enrollment/eligibility determinations based on your predisposition If you believe your privacy rights have been violated by the Plan, you have the right to complain to to a genetic condition. We are also prohibited from requesting, requiring, or purchasing genetic the Plan or to the Secretary of the U.S. Department of Health and Human Services. You may file a information about you prior to enrollment. complaint with the Plan at our Privacy Compliance Office (below). We will not retaliate against you if you choose to file a complaint with the Plan or with the U.S. Department of Health and Human Uses and Disclosures with Your Authorization Services.
The Plan will not use or disclose your medical information for any other purposes unless you give the Effective Date/Changes Plan your written authorization to do so. If you give the Plan written authorization to use or disclose your medical information for a purpose that is not described in this notice, then, in most cases, you The Plan is required to follow the terms of this notice until it is replaced. The Plan reserves the right may revoke it in writing at any time. Your revocation will be effective for all your medical information to change the terms of this notice at any time. If the Plan makes changes to this notice, the Plan will the Plan maintains, unless the Plan has taken action in reliance on your authorization. revise it and send a new notice to all subscribers covered by the Plan. The Plan reserves the right to make the new changes apply to all your medical information maintained by the Plan before and after Information Breach Notification the effective date of the new notice.
We are required to notify you if we discover a breach of unsecured PHI unless there is a Contact Office demonstration, based on a risk assessment, that there is a low probability that the PHI has been compromised. You will be notified without unreasonable delay and no later than 60 days after To request additional copies of this notice or to receive more information about our privacy discovery of the breach. Such notification will include information about what happened and what practices or your rights, please contact us at the following Contact Office: can be done to mitigate any harm. Station Casinos LLC Employee Benefit Plan Your Rights Privacy Compliance Office You may make a written request to the Plan to do one or more of the following concerning your 1505 S. Pavilion Center Drive medical information that the Plan maintains: Las Vegas, NV 89135 • To put additional restrictions on the Plan’s use and disclosure of your medical information. The Plan does not have to agree to your request. Telephone: 702-495-3000 • To communicate with you in confidence about your medical information by a different means or Fax: 866-254-8758 at a different location than the Plan is currently doing. The Plan does not have to agree to your request unless such confidential communications are necessary to avoid endangering you and E-mail: [email protected] your request continues to allow the Plan to collect premiums and pay claims. Your request must specify the alternative means or location to communicate with you in confidence. Even though Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) you requested that we communicate with you in confidence, the Plan may give subscribers cost information. If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, • To see and get copies of your medical information. In limited cases, the Plan does not have to using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid agree to your request. or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy • To correct or amend your medical information. In some cases, the Plan does not have to agree to individual insurance coverage through the Health Insurance Marketplace. For more information, visit your request. www.healthcare.gov. • To receive a list of disclosures of your medical information that the Plan and its business If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed associates made for certain purposes for the last 6 years (subject to certain exceptions). below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
• To provide you with a paper copy of this notice, even if you received this notice by e-mail or on If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any the internet. of your dependents might be eligible for either of these programs, contact your State Medicaid If you want to exercise any of these rights described in this notice, please contact the Privacy or CHIP office or dial 1877KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you Compliance Office listed below. The Plan will give you the necessary information and forms for you qualify, ask your state if it has a program that might help you pay the premiums for an employer- to complete and return to the Privacy Compliance Office. In some cases, the Plan may charge you a sponsored plan. nominal, cost-based fee to carry out your request. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa. dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer
33 34 MINNESOTA – Medicaid NORTH DAKOTA – Medicaid health plan premiums. The following list of states is current as of January 31, 2015. Contact your Website: http://www.dhs.state.mn.us/ State for more information on eligibility – id_006254 Website: http://www.nd.gov/dhs/services/ medicalserv/medicaid/ Click on Health Care, then Medical Assistance ALABAMA – Medicaid GEORGIA – Medicaid Phone: 1-800-755-2604 Phone: 1-800-657-3739 Website: http://dch.georgia.gov/ MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP Website: www.myalhipp.com - Click on Programs, then Medicaid, then Health Website: http://www.dss.mo.gov/mhd/ Phone: 1-855-692-5447 Insurance Premium Payment (HIPP) Website: http://www.insureoklahoma.org participants/pages/hipp.htm Phone: 1-800-869-1150 Phone: 1-888-365-3742 Phone: 573-751-2005 ALASKA – Medicaid INDIANA – Medicaid MONTANA – Medicaid OREGON – Medicaid Website: http://health.hss.state.ak.us/dpa/ Website: http://www.oregonhealthykids.gov programs/medicaid/ Website: http://www.in.gov/fssa Website: http://medicaid.mt.gov/member http://www.hijossaludablesoregon.gov Phone (Outside of Anchorage): Phone: 1-800-694-3084 1-888-318-8890 Phone: 1-800-889-9949 Phone: 1-800-699-9075 Phone (Anchorage): 907-269-6529 NEBRASKA – Medicaid PENNSYLVANIA – Medicaid COLORADO – Medicaid IOWA – Medicaid Website: www.ACCESSNebraska.ne.gov Website: http://www.dpw.state.pa.us/hipp Medicaid Website: http://www.colorado.gov/hcpf Website: www.dhs.state.ia.us/hipp/ Phone: 1-800-692-7462 Medicaid Customer Contact Center: Phone: 1-855-632-7633 Phone: 1-888-346-9562 1-800-221-3943 NEVADA – Medicaid RHODE ISLAND – Medicaid FLORIDA – Medicaid KANSAS – Medicaid Medicaid Website: http://dwss.nv.gov/ Website: www.ohhs.ri.gov Website: Website: http://www.kdheks.gov/hcf/ Medicaid Phone: 1-800-992-0900 Phone: 401-462-5300 https://www.flmedicaidtplrecovery.com/ Phone: 1-800-792-4884 Phone: 1-877-357-3268 SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP Website: http://www.scdhhs.gov Medicaid Website: http://www.coverva.org/ KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Phone: 1-888-549-0820 programs_premium_assistance.cfm Website: http://www.dhhs.nh.gov/oii/ Website: http://chfs.ky.gov/dms/default.htm Medicaid Phone: 1-800-432-5924 documents/hippapp.pdf Phone: 1-800-635-2570 CHIP Website: http://www.coverva.org/ Phone: 603-271-5218 programs_premium_assistance.cfm LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP CHIP Phone: 1-855-242-8282 Medicaid Website: http://www.state.nj.us/humanservices/dmahs/ SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Website: http://www.hca.wa.gov/medicaid/ Website: clients/medicaid/ premiumpymt/pages/ index.aspx http://www.lahipp.dhh.louisiana.gov Medicaid Phone: 609-631-2392 Phone: 1-888-828-0059 Phone: 1-800-562-3022 ext. 15473 Phone: 1-888-695-2447 CHIP Website: http://www.njfamilycare.org/index.html TEXAS – Medicaid WEST VIRGINIA – Medicaid CHIP Phone: 1-800-701-0710 Website: https://www.gethipptexas.com/ Website: www.dhhr.wv.gov/bms/ MAINE – Medicaid NEW YORK – Medicaid Phone: 1-800-440-0493 Phone: 1-877-598-5820, HMS Third Party Liability Website: UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP http://www.maine.gov/dhhs/ofi/public- Website: http://www.nyhealth.gov/health_care/ Website: Website: assistance/index.html medicaid/ Medicaid: http://health.utah.gov/medicaid https://www.dhs.wisconsin.gov/ Phone: 1-800-977-6740 Phone: 1-800-541-2831 CHIP: http://health.utah.gov/chip badgercareplus/p-10095.htm TTY 1-800-977-6741 Phone: 1-866-435-7414 Phone: 1-800-362-3002 MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid Website: http://www.mass.gov/MassHealth Website: http://www.ncdhhs.gov/dma VERMONT– Medicaid WYOMING – Medicaid Phone: 1-800-462-1120 Phone: 919-855-4100 Website: http://www.greenmountaincare.org/ Website: http://health.wyo.gov/healthcarefin/ Phone: 1-800-250-8427 equalitycare Phone: 307-777-7531 To see if any other states have added a premium assistance program since January 31, 2015, or for 35 36 more information on special enrollment rights, contact either: D. ENFORCING RIGHTS AS A PARTICIPANT
U.S. Department of Labor U.S. Department of Health and Human Services If a Claim for a welfare benefit is denied or ignored, in whole or in part, the participant has a right to Employee Benefits Security Administration Centers for Medicare & Medicaid Services know why this was done, to obtain copies of documents relating to the decision without charge, and www.dol.gov/ebsa www.cms.hhs.gov to appeal any denial, all within certain time schedules. 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565 Under ERISA, there are steps a participant can take to enforce the above rights:
ERISA 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 A. RECEIVING INFORMATION ABOUT THE PLAN AND ITS BENEFITS 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. 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 . If a participant has a Claim for benefits, which is denied or ignored, in whole, or in part, he may (“ERISA”). ERISA provides that all Covered Persons shall be entitled to: file suit in a state or Federal court, provided he has exhausted the administrative remedies available under The Plan. . 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 . In addition, if a participant disagrees with The Plan’s decision or lack thereof concerning the and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) qualified status of a medical Child support order, he may file suit in Federal court. filed by The Plan with the U.S. Department of Labor and available at the Public Disclosure Room . If it should happen that Plan fiduciaries misuse The Plan’s money, or if a participant is of the Employee Benefits Security Administration; discriminated against for asserting his rights, he may seek assistance from the U.S. Department . obtain, upon written request to The Plan Administrator, copies of documents governing the of Labor, or he may file suit in Federal court. operation of The Plan, including insurance contracts and collective bargaining agreements, and . The court will decide who should pay court costs and legal fees. If the participant is successful, copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. the court may order the person he has sued to pay these costs and fees. If the participant loses, The Plan Administrator may impose a reasonable charge for the copies; and the court may order him to pay these costs and fees, for example, if the court finds his Claim is . receive a summary of The Plan’s annual financial report. The Plan Administrator is required by frivolous. law to furnish each participant with a copy of this summary annual report (“SAR”).
E. ASSISTANCE WITH QUESTIONS B. CONTINUING GROUP HEALTH PLAN COVERAGE If the participant has any questions about The Plan, he should contact The Plan Administrator. If he A participant shall be entitled to continue health care coverage for himself, his Spouse or has any questions about this statement or about his rights under ERISA, or if he needs assistance Dependents if there is a loss of coverage under The Plan as a result of a Qualifying Event. The in obtaining documents from The Plan Administrator, he should contact the nearest office of the participant or his Dependents may have to pay for such coverage. Participants should review this Employee Benefits Security Administration, U.S. Department of Labor, listed in his telephone Summary Plan Description and the documents governing The Plan for the rules governing COBRA directory, or the Division of Technical Assistance and Inquiries, Employee Benefits Security continuation coverage rights. Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C., 20210.
. A participant may also obtain certain publications about his rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.
C. PRUDENT ACTIONS BY FIDUCIARIES
In addition to creating rights for Covered Persons, ERISA imposes obligations upon the individuals who are responsible for the operation of The Plan. The individuals who operate this Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of Covered Persons and their beneficiaries. No one, including The Employer, or any other person, may fire a Team Member or otherwise discriminate against a participant in any way to prevent him from obtaining a welfare benefit or exercising his rights under ERISA.
37 38 IMPORTANT INFORMATION PARTICIPATING EMPLOYERS A. GENERAL INFORMATION Team Members are eligible to participate in the Dental and Vision options and the applicable medical plans as listed. ABOUT THE PLAN Station Casinos LLC (HMO & PPO) 1505 S Pavilion Center Dr, Las Vegas NV 89135 Type of Plan: The Plan is considered a welfare benefit plan under ERISA providing (EIN 27-3312261) group health benefits. NP Palace LLC (HMO & PPO) 2411 W Sahara Ave, Las Vegas NV 89102 Type of Plan Administration: The PPO Option(s) and the HMO Option(s) provide reimbursement (dba) Palace Station Hotel & Casino (EIN 27-3312372) for certain hospital, surgical, and medical expenses through fully NP Boulder LLC (HMO & PPO) 4111 Boulder Hwy, Las Vegas NV 89121 insured contracts with SHL and HPN, respectively. SHL and HPN (dba) Boulder Station Hotel & Casino (EIN 27-3312313) administer the payment of claims and the appeal of denied claims under the PPO Option(s) and the HMO Option(s), respectively. The NP Texas LLC (HMO & PPO) 2101 Texas Star Lane, North Las Vegas NV 89032 Vision Option provides for certain vision expenses through a fully (dba) Texas Station Gambling Hall & Hotel (EIN 27-3484110) insured contract issued by Davis Vision. The Dental Option is self- NP Sunset LLC (HMO & PPO) 1301 W Sunset Rd, Henderson NV 89014 funded and provides reimbursement for certain dental benefits. (dba) Sunset Station Hotel & Casino (EIN 27-3312450) Plan Name: Station Casinos LLC Employee Benefit Plan NP Lake Mead LLC (HMO & PPO) 777 W Lake Mead Pkwy, Henderson NV 89015 Plan Number: 501 (dba) Fiesta Henderson Casino & Hotel (EIN 27-3483890) Employer Tax Identification 27-3312261 Station GVR Acquisition LLC (HMO & PPO) 2300 Paseo Verde Pkwy, Henderson NV 89052 Number: (dba) Green Valley Ranch Resort Spa Casino (EIN 27-4440679) End of Plan Year: December 31 NP Santa Fe LLC (HMO & PPO) 4949 N Rancho Dr, Las Vegas NV 89130 Plan Sponsor: Station Casinos LLC (dba) Santa Fe Station Hotel & Casino (EIN 27-3484083) Plan Administrator/ Station Casinos LLC NP Fiesta LLC (HMO & PPO) 2400 N Rancho Dr, Las Vegas NV 89130 Agent for Service of Legal (dba) Fiesta Casino & Hotel (EIN 27-3483838) Process: NP Durango LLC (HMO & PPO) 1505 S Pavilion Center Dr, Las Vegas NV 89135 Address: 1505 S. Pavilion Center Drive Las Vegas, NV 89135 (dba) Durango Station Hotel & Casino (EIN 27-4348250) Telephone Number: (702) 495-3000 NP Red Rock LLC (HMO & PPO) 11011 W Charleston Blvd, Las Vegas NV 89135 Fiduciary for Adverse Station Casinos LLC Benefit Determinations: (dba) Red Rock Casino Resort & Spa (EIN 27-3312418) CLAIMS ADMINISTRATOR/INSURANCE CARRIERS: SC Sonoma Management 1505 S. Pavilion Center Drive, Las Vegas, NV 89135 (dba) Sonoma Management (EIN 74-3090768) HMO(s) Health Plan of Nevada, Inc. P.O. Box 15645, Las Vegas, NV 89114-5645 Team Members at the following six properties are not eligible to participate in the Sierra Health & Life (702) 562-8013 or (877) 559-4511 PPO Medical Plans, and may only participate in the Health Plan of Nevada HMO Plus Medical Plan. PPO(s) Sierra Health and Life Insurance NP Gold Rush LLC 1195 W Sunset Rd, Henderson NV 89014 P.O. Box 15645, Las Vegas, NV 89114-5645 (dba) Wildfire Sunset (EIN 27-3483949) (702) 562-8013 or (877) 559-4511 NP Rancho LLC 1901 N. Rancho Drive Las Vegas, NV 89106 Dental Boon-Chapman (dba) Wildfire Casino (EIN 27-3483980) P.O. Box 9201, Austin, TX 78766 NP Magic Star LLC 2000 S Boulder Hwy, Henderson NV 89015 (800) 936-7670 (dba) Wildfire Boulder (EIN 27-3484005) Vision Davis Vision SC SP 2 LLC 3045 S. Valley View Blvd, Las Vegas, NV 89102 P.O. Box 1525, Latham, NY 12110 (877) 923-2847 (dba) Wildfire Valley View (EIN 46-1109329) Third Party Administrator Custom Benefit Consultants (CBC) SC SP 4 LLC 2551 Anthem Village Drive, Henderson, NV 89014 300 S. 4th St. Suite 704 Las Vegas, NV 89101 (dba) Wildfire Anthem (EIN 46-1123185) Phone: (866) 254-8758 NP LML LLC 846 E. Lake Mead Parkway, Henderson, NV 89015 COBRA Control Source, Inc (dba) Wildfire Lake Mead (EIN 27-3484201) 300 S. 4th St. Suite 704 Las Vegas, NV 89101 Phone: (877) 652-7872 Fax: (877) 652-7872 Email: [email protected] B. FUNDING THE PLAN AND PAYMENT OF BENEFITS Life Insurance and Short- Principal Financial Group Term Disability 7711 High Street Des Moines, IA 50392 Team Members contribute to the cost of The Plan. The Employer contributes the difference between (800) 245-1522 the cost of benefits coverage and the amount the Team Members contribute. From time to time, The
39 40 Plan Sponsor will evaluate the costs of The Plan and determine the amount to be contributed by The 6. treatment, services and supplies that are excluded from coverage by The Plan, whether or Employer as well as the amount to be contributed by each Team Member, if any. not Medically Necessary;
Team Member contributions are held in The Employer’s general assets. A current summary of these 7. non-compliance with The Plan’s Prior Authorization requirements; or 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, 8. non-compliance with The Plan’s Claims filing deadline. Deductibles, Co-pays, out-of-pocket expenses, penalties for non-compliance with The Plan’s pre- These provisions are described in greater detail throughout this document and the applicable EOCs approval or certification requirements, and non-covered expenses. The premium amount to be paid and COCs. by each Team Member may be increased during the Plan Year by The Employer.
C. CHANGES TO PLAN/TERMINATION OF PLAN E. OBTAINING COVERAGE INFORMATION A Covered Person may obtain information at no cost on whether, and under what circumstances, The Plan may be changed and/or benefits may be reduced or eliminated by The Plan Sponsor. existing and/or new drugs, tests, devices, procedures and other services are covered, as well as The Plan Sponsor shall have the right to amend The Plan, at any time and from time to time, to obtain specific benefit information, by contacting the appropriate Claims Administrator. 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 F. CERTIFICATES OF CREDITABLE COVERAGE contract or to amend The Plan is not a Fiduciary decision, but is a business decision that can be The Plan Administrator shall issue Certificates of Creditable Coverage to a Covered Person whose made solely in The Plan Sponsor’s interest. coverage terminates, as well as to such individuals upon their written request within 24 months of All changes to The Plan shall become effective as of a date established by The Plan Sponsor, the date of coverage termination, as required by Federal law. 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 G. WRITTEN NOTICE of the Effective Date of the change. Any written notice required under The Plan shall be deemed received by a covered Team Member The Plan shall continue in full force and effect unless and until The Plan Sponsor terminates The if sent by regular mail, postage prepaid, to the last address of such covered Team Member on the Plan. Although The Plan Sponsor has the intention and expectation that The Plan will be maintained records of The Employer. 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 H. CLERICAL ERROR/DELAY covered Team Members. Such termination will become effective on the date set forth in such written notice. 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 The terms of The Plan cannot be modified by written or oral statements made by The Plan Dates of coverage shall be determined solely in accordance with the provisions of The Plan Administrator or other personnel. The Senior Vice President of Human Resources or any other regardless of whether any contributions with respect to Covered Persons have been made or have person with properly delegated authority are authorized to amend, modify or terminate The Plan. 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. D. CIRCUMSTANCES RESULTING IN LOSS OR REDUCTION OF BENEFITS
There are circumstances, which may result in ineligibility or in denial, loss, suspension, offset, I. ACCEPTANCE/COOPERATION reduction or recovery of benefits that a Covered Person might reasonably expect The Plan to provide. These circumstances include, but are not limited to: 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 1. Subrogation, reimbursement and third party recovery rights of The Plan; protect The Plan’s rights and carry out its provisions. 2. Coordination of Benefits when a Covered Person is enrolled in more than one plan and The Plan is not the Primary Plan; J. NOT A CONTRACT OF EMPLOYMENT 3. possible reductions when private Hospital rooms are used and for certain Multiple Surgical Procedures; Nothing contained in The Plan shall be construed as:
4. reductions due to charges that exceed The Plan allowable; . a contract of employment between The Employer and any Team Member;
5. reductions or denials due to services that are not generally accepted as appropriate, and/or . a right of any Team Member to be continued in the employment of The Employer; which are not Medically Necessary, and/or which are considered as Over-Utilization;
41 42 . consideration or inducement for employment with The Employer; 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 . a condition of employment between The Employer and any Team Member; or provisions. . a limitation of the right of The Employer to discharge any Team Member, with or without cause, at any time. L. FRAUD AND ABUSE All Team Members shall be subject to discharge to the same extent as if The Plan had never been adopted. 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.
K. AUTHORITY OF PLAN ADMINISTRATOR 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: The Plan Administrator is responsible for the administration of this Plan. Should you need to see any records or have any questions regarding any Benefit Plan, contact the Plan Administrator. The Plan . falsifying, withholding, omitting or concealing information to obtain or retain coverage; Administrator has final discretionary authority to interpret the Plan and make factual determinations as to whether any individual is eligible for coverage and entitled to receive any benefits under . misrepresenting eligibility criteria for Dependents (marital status, age, Full-Time Student status, the Plan. CBC has been appointed to assist you in answering questions and providing information Dependent Child or the right to Claim a Dependent for Federal income tax purposes) to obtain to you regarding your benefits and elections. The Plan Administrator may delegate any of the or continue coverage for a person who would not otherwise meet the Dependent eligibility responsibilities to an insurance company or an administrator identified in the Benefit Plan Table. criteria, as defined in The Plan, and qualify for coverage;
The Plan Administrator will have the following rights, duties and powers to: . 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 (1) Interpret the terms of any Benefit Plan, to determine the amount, manner and time for there is no Creditable Coverage; payment of any benefits, and to construe or remedy any ambiguities, inconsistencies or omissions, and correct any administrative errors or omissions; . 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 (2) Adopt and apply any rules or procedures to insure the orderly and efficient administration of Coverage to reduce or eliminate Waiting Periods or Pre-Existing Conditions Limitations under any Benefit Plan; The Plan, (b) a Claim or (c) medical records;
(3) Determine the rights of any participant, spouse, dependent or beneficiary to benefits under . permitting a person who is not covered under The Plan to use a Plan identification card or other any Benefit Plan; Plan identifying information to obtain Covered Services or payment under The Plan; or
(4) Develop appellate and review procedures for any participant, spouse, dependent or . making false or fraudulent representations in connection with delivery of or payment for beneficiary to benefits under any Benefit Plan; 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 (5) Provide the Plan Sponsor with such tax or other information it may require in connection with pretenses. any Benefit Plan; If a Team Member falsely certifies eligibility for Plan participation or does not inform the Plan (6) Employ any agents, attorneys, accountants or other panics (who may also be employed Administrator of termination of eligibility, The Employer reserves the right to take disciplinary action, by the Plan Sponsor) and to allocate or delegate to them such powers or duties as is necessary to as appropriate, up to and including termination of benefits and employment, legal actions and assist in the proper and efficient administration of any Benefit Plan, provided that such allocation or request for reimbursement of inappropriate benefit payments as permitted by applicable law. delegation and the acceptance thereof is in writing; and,
(7) Report to the Plan Sponsor, or any party designated by the Plan Sponsor, after the end of each Plan year regarding the administration of the Plan, and to report any significant problems as to the administration of any Benefit Plan and to make recommendations for modifications as to procedures and benefits, or any other change which might insure the efficient administration of any Benefit Plan.
Subject to applicable State or Federal law, any interpretation of any provision of this Plan made in good faith by the Plan Administrator and any determination by the Plan Administrator as to any Participant’s rights or benefits under this Plan is final, shall be binding upon the parties and shall be upheld on review, unless it is shown that such interpretation or determination was an abuse of discretion (i.e., arbitrary and capricious).
The Plan Administrator (and its delegates) has full discretion to administer, construe and interpret The Plan in all respects, and to decide all matters arising under The Plan, including eligibility for participation and benefits. The determinations of The Plan Administrator (and its delegates) are final and binding on all parties, except as otherwise provided by law.
43 44 DEFINITIONS 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 NOTE: Throughout this document, any references to the terms “he,” “him,” or “his” shall also mean parent must be the Team Member’s legal Spouse), Alternative Recipients under Qualified Medical “she,” “her,” or “hers”. 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 Capitalized terms used in the SPD are defined in this section unless otherwise defined in the the Plan. applicable certificate or evidence of coverage. Claim: A request made to The Plan for payment of healthcare services. A Pre-service Claim is a Accidental Injury: An unforeseen bodily Injury caused by unexpected external means, resulting, request for benefits prior to receipt of treatment or a Prior Authorization. A Post-service Claim is a directly and independently of all other causes, in necessary care rendered by a Physician. Sprains request for benefits after the services have already been rendered. and strains resulting from over-exertion, excessive use or over-stretching will not be considered Accidental Injury for purposes of benefit determination. 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 Actively at Work: A Team Member will be considered Actively at Work on a day that he is other task as may be delegated to it. Refer to the “IMPORTANT INFORMATION” section. performing the normal duties of a regular job for The Employer on any of the following days: COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. Refer to the . a regular paid holiday or day of vacation; “COBRA” section. . a regular or scheduled non-working day; or Coordination of Benefits: A group health plan provision designed to eliminate duplicate payments . a day on which the Team Member is on an approved FMLA Leave, USERRA Leave or a personal and provide the sequence in which coverage will apply (primary and secondary) when a person is leave of absence provided the Team Member was actively working on the last preceding regular covered by two group health plans. workday. Copay or Coinsurance: A dollar amount that must be paid by the Covered Person in order to receive . A day on which the Team Member is absent from work due to any health factor. 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 Adverse Benefit Determination: Any of the following: a denial, reduction, or termination of, or a BENEFITS” and “SCHEDULE OF VISION BENEFITS” sections. 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 Cosmetic Procedures: Procedures performed solely to improve appearance. Covered Person’s or Beneficiary’s eligibility to participate in The Plan, and including, with respect to Covered Person: Any Team Member or Dependent who is covered under The Plan. 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 Deductible: The amount of covered expenses which must be paid by a Covered Person each as a failure to cover an item or service for which benefits are otherwise provided because it is Calendar Year before benefits are payable under The Plan for certain services. A separate determined to be Experimental or Investigational or not Medically Necessary or not appropriate. 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. 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 Dentist: A currently licensed Dentist practicing within the scope of the license or any other Physician to any Copay, Deductible, or Coinsurance. The allowable amount for services rendered by In- furnishing dental services which the Physician is licensed to perform. Network and Out-of-Network Providers is the In-Network Provider Fee Schedule. Dependent: Refer to the “ELIGIBILITY REQUIREMENTS” section. Appeal of Adverse Benefit Determination: The Covered Person or the Provider has the right to request reconsideration following an Adverse Benefit Determination. A written appeal must be Effective Date: The first day of the person’s coverage. The person’s Effective Date may or may not filed within 180 days after the receipt of the original Claim determination. Refer to the “CLAIM be the same as the person’s Enrollment Date. Refer to the “Enrollment Date” definition. PROVISIONS” section. Employer: Station Casinos LLC and the employers participating in The Plan as stated in the Benefit Percentage: The portion of eligible expenses payable by The Plan in accordance with the “IMPORTANT INFORMATION” section. coverage provisions as stated in The Plan. Enrollment: The process by which a Team Member and Dependents become Covered Persons Birthday Rule: Coordination of Benefits provision for dependent Children in which the plan of the of The Plan. Coverage does not become effective until the eligible Team Member completes an parent with the earliest birth month and day is the Primary Plan for Claim payment purposes. enrollment form and submits appropriate supporting documentation.
Calendar Year: January 1 through December 31 of the same year. For new Team Members and ERISA: “ERISA” means Employee Retirement Income Security Act of 1974, as amended, including Dependents, a Calendar Year begins on the person’s Effective Date and runs through December 31 regulations implementing the Act. of the same year. Exclusion: An item or service, which is not a Covered Expense under The Plan. Refer to the Calendar Year Maximum Benefit: The total amount of benefits payable by The Plan on behalf of a “EXCLUSIONS” section. Covered Person during any Calendar Year (unless specified otherwise). Experimental or Investigational: A treatment, procedure, device, drug or medicine where one or Change in Status: An event in which the Team Member receives Special Enrollment rights. Refer to more of the following is true: the “ELIGIBILITY REQUIREMENTS” section. . it cannot be lawfully marketed without U.S. Food and Drug Administration approval, and
45 46 approval for marketing for the condition treated has not been given at the time the device, drug Med-Pay: A payment made by an insurer intended specifically to pay for medical expenses without or medicine is furnished; or 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. . 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) Medically Necessary: The expense Incurred upon the recommendation and approval of a Physician it is undergoing phase I, II, or III clinical trials or is under study; or (2) further clinical trials or for the medical services and supplies generally furnished for cases of comparable nature and studies are needed, according to expert consensus of opinion. Reliable evidence means only severity in the particular geographical area concerned. Any agreement as to fees or charges made published reports and articles in the authoritative medical and scientific literature; or the written between the patient and the Physician shall not bind The Plan in determining its liability with respect protocol or written informed consent used by the treating facility (or by another facility studying to necessary expenses. These Incurred expenses must be: substantially the same treatment, procedure, device, drug or medicine). . consistent with the symptoms of diagnosis and treatment of the condition, Illness, or Injury; 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 . appropriate with regard to standards of good medical practice; financial responsibility. . not primarily for the convenience of the patient, the Physician or other Provider; Family Deductible Limit: Applies collectively to all Covered Persons in the same family. When the . the most appropriate level of services which can safely be provided to the patient; and Family Deductible Limit is satisfied, no further Deductibles need to be satisfied in the Calendar Year. . when applied to Inpatient services, it means that the patient’s medical symptoms or Fee Schedule: Amounts that In-Network Providers or participating pharmacies have contracted conditions require that the services or supplies cannot be safely provided to the patient as an to accept as payment in full for covered expenses of The Plan. See also the “Allowable Expense” Outpatient. definition. The fact that a Physician might prescribe, order, recommend, or approve a service or supply does Fiduciary: The person or organization that has the authority to control and manage the operation not, in itself, make it Medically Necessary or make the charge an Allowable Expense under The Plan, and administration of The Plan. The Fiduciary has discretionary authority to determine the eligibility even though it is not specifically listed as an Exclusion. The Plan Administrator has the discretionary for benefits or to construe the terms of The Plan. The named Fiduciary for The Plan is The Employer. authority to decide whether care or treatment is Medically Necessary. FMLA: The Family and Medical Leave Act of 1993. Medicare: The program of medical care benefits provided under Title XVIII of the Social Security Act FMLA Leave: A leave of absence taken by a Team Member in accordance with the Family and of 1965 as amended. Medical Leave Act of 1993. Negotiated Fees: Refer to the “Fee Schedule” definition. Health Status-Related Factors: Includes these 8 categories: health status, medical condition (both Network: A group of providers who offer healthcare services according to a contract agreement. physical and mental), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability. 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 HIPAA: The Health Insurance Portability and Accountability Act of 1996, as amended. Refer to the who may have been responsible for causing the accident. Examples of No-Fault Insurance include “HIPAA” section. automobile No-Fault Insurance, often referred to as personal Injury protection, homeowner’s Illness: A bodily disorder, disease, physical or mental impairment, functional nervous disorder, insurance and Med-Pay coverage. Refer also to the “Med-Pay” definition. pregnancy or complication of pregnancy. The term Illness when used in connection with a newborn Open Enrollment: The period of time in which all benefits eligible Team Members may make Child includes, but is not limited to, congenital defects and birth abnormalities, including premature changes to their coverage by adding, deleting or changing coverage for themselves or their birth. Dependents. Refer also to “Special Enrollment” and “Late Enrollment” definitions. Immediate Family: A person who is related to a Covered Person, whether the relationship is by Orthognathic: Deformities of the jaw and associated with malocclusion. blood or exists in law, limited to a Spouse, parent, grandparent, Child, brother or sister. Out-of-Network Provider: Health care Providers, medical groups, Plan hospitals or other Plan In-Network Provider: Health care Providers, medical groups, plan hospitals or other Plan Providers Providers who are not under a contract with the Network or Networks affiliated with The Plan. Out- who are under a contract with the Network(s) affiliated with The Plan. In-Network Providers are of-Network Providers are not obligated to follow the same terms and conditions as the In-Network required to comply with all terms and conditions of the Provider’s contract. Providers. Incurred: The date a treatment, service or supply is provided to a Covered Person. Over-Utilization: Refers to any of the following: Initial Enrollment: The period of time when a Team Member is first eligible to participate in The . the practice of applying more than what is necessary to evaluate and treat the problem at hand; or Plan. Refer to the “ELIGIBILITY REQUIREMENTS” section. . a redundancy in treatment options; or Injury: Physical damage to the body, which is not caused by disease or bodily infirmity. . that which most practitioners in the discipline would consider to be in excess of sufficient Joint Venture: An entity designated by the Plan Sponsor including Town Center Amusements, Inc., measures. 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.
47 48 Personal Injury Protection (PIP): Refer to the “No Fault Insurance” definition.
Plan Administrator: The Plan Sponsor
Plan Sponsor: Station Casinos LLC
PPO (Preferred Provider Organization) Plan: A healthcare plan that utilizes a network of Physicians, Hospitals or other healthcare Providers who have contracted to provide health care services at specified rates and to follow the terms and provisions of the Provider contract.
Pre-Determination: A review prior to services to determine eligibility by The Plan.
Primary Plan: In Coordination of Benefits, The Plan that provides benefits or benefit payments without considering any other plan is the Primary Plan. Refer to the “COORDINATION OF BENEFITS” section.
Provider: A Hospital, Physician, Dentist or any other practitioner who is licensed to provide healthcare services.
QMCSO: A Qualified Medical Child Support Order in accordance with applicable law. Refer to the “ELIGIBILITY REQUIREMENTS” section.
Qualified Beneficiary: A Team Member, former Team Member or Dependent of a Team Member or former Team Member who is eligible for continuation of benefits (COBRA) covered under The Plan. Refer to the “CONTINUATION OF BENEFITS (COBRA)” section.
Qualifying Event: Refer to the “COBRA” section.
Secondary Plan: In Coordination of Benefits, the Secondary Plan may reduce its benefits or benefit payments by the amount paid by the Primary Plan. Refer to the “COORDINATION OF BENEFITS” section.
Special Enrollment: The opportunity for the Team Member to add, delete or change coverage for himself and/or Dependents outside The Plan’s Open Enrollment period when a Change in Status occurs, or an Enrollment period at the discretion of The Plan Sponsor. Refer to the “ELIGIBILITY REQUIREMENTS” section.
Specialist: A Physician who practices in a particular specialty of medicine, based on license and qualifications.
Spouse: The person who is recognized as the Team Member’s husband or wife under the laws of the state where the Team Member lives. Documentation proving a legal marital relationship will be required. Common law marriages and common law Spouses are not eligible under The Plan.
Subrogation: The provision in which The Plan has the right to take direct legal action against a responsible third party and, therefore, The Plan could force the Covered Person to pursue legal remedies, although he or she may not have intended to do so.
Team Member: A person who is directly employed by The Employer. Refer to the “ELIGIBILITY REQUIREMENTS” section.
The Plan: Whenever used herein without qualification, means the Station Casinos LLC. Employee Benefit Plan as described in this Summary Plan Description.
Treatment Plan (Dental): A program of dental care and treatment planned in written outline by a Dentist upon examination of a Covered Person.
USERRA: The Uniformed Services Employment and Reemployment Rights Act of 1994, as amended.
USERRA Leave: A leave of absence taken by a Team Member for a call to military duty that is protected by the Uniformed Services Employment and Reemployment Rights Act of 1994, as amended. Refer to the “ELIGIBILITY” section
49 50