Administrative Details

Plan Year

For all plans, the Plan Year is January 1 to December 31.

The Mashantucket Pequot Tribal Nation employer identification number is 06-0995554.

In addition to the employer identification number, an official name and number are assigned to all benefit plans subject to TERISA. The plans listed within this section under “Other Plan Details” show the names, numbers, insurance companies or trustees, and sources of funding of the plans subject to TERISA.

Hospital Stays—Childbirth

Group health plans and health insurance issuers generally may not restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, the law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Women’s Health and Cancer Rights Act

The Women’s Health and Cancer Rights Act requires group health plans that provide coverage for mastectomies to also cover:

• reconstruction of the breast on which the mastectomy was performed;
• surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• prostheses and treatment of physical complications of the mastectomy, including lymphedemas.

This coverage will be subject to the same annual deductibles and coinsurance provisions that apply for the mastectomy.

Your Rights for Health Care Coverage

Tribal law adopts the substantive law of the Health Insurance Portability and Accountability Act (HIPAA), a part of TERISA. This was enacted to provide improved portability and continuity of health insurance coverage for dependents. The law restricts the ability of group health plans to exclude coverage for pre-existing conditions.

About Your Privacy

We are committed to maintaining the confidentiality of medical information about you and that can be identified with you. Tribal laws, which include the substantive law of HIPAA, also impose numerous requirements on employer health plans concerning the use and disclosure of individual health information. This information, known as “protected health information,” includes virtually all individually identifiable health information held by any health plan, including health care flexible spending accounts — whether received in writing, in an electronic medium, or as an oral communication. It includes demographic information and information that relates to your physical or mental health, the treatment you received or the payment for your care. Your protected health information is contained in the enrollment, payment, claims adjudication, case or medical management record systems and other documents maintained by the health plans in order to provide you with insurance coverage.

The plan has implemented policies and practices to appropriately protect the privacy of your protected health information. Protected health information that you provide will be handled in accordance with the MPTN Notice of Privacy Practices. The “Notice of Privacy Practices” (the “Notice”) describes how we may use and disclose your protected health information.

We are required to protect the confidentiality of your protected health information, to notify you of our legal obligations and your rights with respect to your protected health information, and to abide by the terms of the Notice, as currently in effect. To obtain a copy of the Notice, contact Human Resources toll-free at 1-888-287-4369.

Court Orders

In certain situations, courts may issue orders that benefits be provided for a certain individual or individuals, typically a family member of an employee. Examples of these court orders include:

• Qualified Medical Child Support Orders, also known as QMCSOs, and
• Qualified Domestic Relations Orders, also known as QDROs.

If a QMCSO ,QDRO or other court order affects you, you should notify Human Resources so that the order can be handled properly. You will be notified if MPTN receives a QMCSO, QDRO  or other court order affecting you. MPTN will comply with all valid QMCSOs, QDROs and other court orders. You may receive, without charge, a copy of the procedures applicable to QMSCOs, QDROs and other court orders.

Other Plan Details

An official name and number are assigned to all benefit plans subject to TERISA. The list below provides the names, numbers, insurance companies or trustees, and sources of funding of MPTN’s plans subject to TERISA. (The Dependent Care Flexible Spending Account is not a TERISA plan and is not listed below.)

For some benefits, the MPTN Plan is either an insured plan or a self-insured plan. For self-insured plans, MPTN is liable for any benefits payable. However, the claims administrator has the authority to determine first-level administrative claims and appeals for all welfare plans, subject to TERISA. For insured plans, the plan insurer listed is liable for any benefits payable and is authorized to determine claims and appeals.

To learn more about MPTN’s benefit plans or to arrange to see the official plan documents, call Human Resources toll-free at 1-888-287-4369. Contact information for the plans is shown below.

MPTN Contributions to Other Benefit Plans

In addition to those plans listed here, MPTN contributes on your behalf to other governmental benefit plans, such as Social Security and Medicare.

Mashantucket Pequot Health Benefits Plan

This plan includes the MPTN Medical Plan, Vision Plan and Dental Plan.

• Plan Type — Self-insured welfare benefit plan
• Plan Number — 501
• Claim Administrator — Pequot Plus Health Benefit Services
• Source of Contributions — Mashantucket Pequot Tribal Nation and team members
• Source of Benefit Payments — Mashantucket Pequot Tribal Nation

Health Care Flexible Spending Account and Dependent Care Flexible Spending Account

• Plan Type — Welfare benefit plan
• Plan Number — 501
• Claim Administrator — Pequot Plus Health Benefit Services
• Source of Contributions — Team members
• Source of Benefit Payments — Mashantucket Pequot Tribal Nation

Group Short-Term Disability Plan

(“Short-Term Disability Plan”)

• Plan Type — Insured welfare benefit plan
• Plan Number — 501
• Plan Insurer — Life Insurance Co of North America
• Claim Administrator — Cigna Group Insurance
• Source of Contributions —Team members
• Source of Benefit Payments — Plan insurer

Group Long-Term Disability Plan

(“Long-Term Disability Plan”)

• Plan Type — Insured welfare benefit plan
• Plan Number — 501
• Plan Insurer — Life Insurance Co of North America
• Claim Administrator — Cigna Group Insurance
• Source of Contributions — Mashantucket Pequot Tribal Nation and team members
• Source of Benefit Payments — Plan insurer

Group Term Life and Accidental Death and Dismemberment Insurance Plan  

(“Life and AD&D Insurance Plan”) 

This plan includes team member Basic Life and AD&D insurance and Supplemental Life insurance coverage as well as optional Spousal and Dependent Child Life insurance.

• Plan Type — Insured welfare benefit plan
• Plan Number — 501
• Plan Insurer — Life Insurance Co of North America
• Claim Administrator — Cigna Group Insurance
• Source of Contributions — Mashantucket Pequot Tribal Nation and team members
• Source of Benefit Payments — Plan insurer

Mashantucket Pequot Tribe 401(k) Retirement Plan

(“The 401(k) Plan”)

This type of plan is not subject to or insured by the Pension Benefit Guaranty Corporation (PBGC).

• Plan Type — Defined contribution plan
• Plan Number — 001
• Trustee and Record Keeper — Bank of America, N.A.
• Source of Contributions — Mashantucket Pequot Tribal Nation and participants