Eligibility and Enrolling

Different Eligibility for Different Plans

Eligibility rules differ for the different benefits for a variety of reasons. In some cases, such as the 401(k) Plan, Internal Revenue Code requirements determine who is eligible.

You are eligible to enroll for and participate in MPTN health care coverage if:

• you are employed by an MPTN division that participates in the applicable plan.
• you are a regular full-time team member actively at work.
• you are a regular part-time team member actively at work.
• you have been employed continuously for 60 days.

If your regularly scheduled work week or your average hours worked per week changes, your eligibility to participate in MPTN benefits may change.

The plan does not include coverage for temporary or seasonal team members, nor does it cover team members who work less than the required minimum hours per week.

The Mashantucket Pequot Tribal Nation (MPTN) offers a variety of health care benefits for team members, including:

• medical coverage,
• prescription drug coverage,
• vision coverage,
• dental coverage,
• mental health and alcohol/substance abuse coverage.

Individuals no longer eligible for health care coverage may be able to continue coverage at their own expense through MPTN COBRA.

If you are not eligible for benefits but later change to an eligible status — for example, if you change from a seasonal to a full-time team member — you must be employed continuously for 60 days in the new status before you become eligible for benefits. If you enroll for benefits, in most cases coverage begins on the first of the month following the day you complete 60 days of service in the new status.

Active Team Member

The health care benefit plan described in this Plan Document and SPD is designed primarily for active team members and their eligible family members. For benefits eligibility purposes, you are considered an active team member if you are receiving a regular paycheck to pay wages for services you are currently providing to MPTN.

Although you may be able to continue participating in some of the plans if your active employment ends (for example, if you go on an approved, unpaid leave of absence), to begin participating you must be considered an active team member.

For information on your eligibility to continue participating in the health care plan when you are not an active team member, see the separate descriptions of the plans and “Coverage in Special Situations” within this section.

Family Eligibility

If you are eligible, you may enroll your spouse and eligible dependent children for health care coverage under the MPTN Medical Plan.

The plans that offer coverage for family members generally enable you, as an eligible team member, to cover:

• your spouse, if he or she is your legal spouse, (Common law marriages, civil unions and domestic partnerships are not recognized under the plan.),
• your children up to their 26th birthday,
• your children of any age who are incapable of self-support because of a mental or physical handicap that existed before they reached age 26, and were covered under the plan up to age 26.
  

Coverage Levels

You can choose separate coverage levels for your medical and dental coverage. You must select from the following three coverage levels:

• Single (team member only)
• Single + 1 (team member + one family member)
• Family (team member + two or more family members)

Dependent Children

Eligible dependent children include children:

• by birth,
• by adoption (effective as of the date the child is placed for adoption),
• by marriage (that is, stepchildren),
• for whom you are legally responsible, and
• children who are specified under legal guardianship documents.

Your eligible dependent children (as defined above) include your children who:

• are under age 26, and
• depend on you to pay medical expenses under a divorce decree or support order, such as a Qualified Medical Child Support Order (QMCSO) or a Qualified Domestic Relations Order (QDRO).

If your child is removed from your home — for example, your child becomes a ward of the state — health care coverage ends as of the date the child is no longer legally your dependent.

If a QMCSO affects you, notify Human Resources so that the order can be handled properly. If Human Resources receives a QMCSO or a QDRO affecting you, you will be notified. Human Resources will comply with all valid QMCSOs and QDROs. For more information, see “Court Orders” in the Rules and Regulations section.

Disabled Dependent Children

If your child becomes totally and permanently disabled before age 26, that child is eligible for coverage as your dependent as long as the child remains disabled.

To cover disabled dependent children, you must verify in writing that the disability occurred before age 26.

Enrolling and Changing Coverage

If you are eligible, you can enroll yourself and any eligible dependents in health care coverage, which includes medical, dental vision coverage and prescription drug coverage.  When you enroll, you must select a coverage level:

• Single (team member only),
• Single + 1 (team member + one family member), or
• Family (team member + two or more family members).

Please note that you may elect a different level for dental coverage than you do for medical coverage. See the Dental Coverage section for more information.

If both you and your spouse are eligible team members, the following rules apply:

• If there are no eligible children within the family, only one spouse may elect Single + one family member coverage.
• If there are eligible children within the family, only one spouse may elect Family coverage.
• The spouse who is not the primary carrier is required to waive coverage.

Benefit Cards

When you enroll for Health coverage, you receive a card that identifies you as a plan participant. Carry your card with you, as health care providers will ask to see it when you receive care.

If you lose your card, call the plan administrator at 1-888-779-6872 to get a new one. You can also request additional cards for covered family members.

When First Eligible

If you want to enroll in MPTN health care coverage, you will need to complete an enrollment form and return it to Human Resources before your 60th day of employment. (Generally, you become eligible after you have been employed by MPTN for 60 days, and the coverage you elect begins on the first of the month after that 60-day period.) If you are absent from work due to illness or injury on the date your coverage would normally begin, your coverage will begin on the date you return to active employment.

In most cases, if you do not enroll you will not have an opportunity to change your health care coverage until the next annual enrollment period, unless:

• you have a qualified change in status, as explained below in “After Qualified Changes in Status,” or
• you decline health care coverage from MPTN because you have other employer-provided coverage and you lose that other coverage, as explained in “After Losing Other Coverage” on the following page.

During Annual Enrollment

Each year, MPTN holds an annual enrollment period. During this time, you have the opportunity to change your participation in MPTN health care coverage. Any health care coverage changes that you make during annual enrollment take effect on January 1 for the coming plan year.

Network Provider Changes Are Not Status Changes

The enrollment choices you make are in effect for the entire plan year for which you enroll. If the Plan’s network coverage changes — for example, if your physician is no longer available through the network — you cannot change your coverage until the next annual enrollment period. A network provider change is not a qualified change in status.

After Qualified Changes in Status

The health care plan enrollment choices you make when you first become eligible or during annual enrollment are usually in effect for the entire plan year for which you enroll. However, because your needs for benefits typically change when you experience certain family events, such as getting married or having a baby, the health care plans, in accordance with Internal Revenue Service rules, allow you to make changes in some situations. The change must be made within 30 days after the event.

Generally, the qualified change in status must affect eligibility for coverage (for you or your dependents) under MPTN’s or another employer’s plan. Examples of qualified changes in status include:

• a change in your legal marital status, such as your marriage, divorce, or legal separation;
• a change in the number of your eligible dependents, including:
  • the birth or placement for adoption of a child, or
  • the death of your spouse or other benefit-eligible family member;
• a change in an eligible dependent’s employment status (such as starting a new job, terminating employment, going on leave, etc.);
• a change in an eligible dependent’s eligibility for coverage (for example, when your dependent child reaches the eligibility age limit or when your position changes from full-time to part-time status);
• your eligible dependent’s loss of health care coverage from another source;
• a change in your or an eligible family member’s entitlement to Medicare coverage; or
• a change in your or an eligible family member’s residence, if it changes the health care options from which that person can choose.

How to Make Changes

You have 30 days from the date of a qualified change in status to change your coverage. To make a change, you must notify Human Resources.

After Losing Other Coverage

Some eligible team members may choose not to enroll for MPTN health care coverage because they have coverage available from another source, such as from a spouse’s employer’s plan.

If you do not enroll for MPTN health care coverage because you have other coverage, and if that coverage ends, you may enroll for an MPTN plan within 30 days of the date your other coverage ends.

If you do not enroll within 30 days, you must wait until the next annual enrollment.

Reinstatement of Coverage (for the medical plan)

An employee who is terminated and rehired will be treated as an employee upon rehire only if the employee was not credited with an hour of service, as defined under the ACA, with the Employer (or any member of the controlled or affiliated group) for a period of at least 13 consecutive weeks immediately preceding the date of rehire.

Upon return, coverage will be effective on the first of the month following the date of rehire, so long as all other eligibility criteria are satisfied.